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HEALTH 
SCIENCES 
LIBRARY 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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Modern  Surgery 

GENERAL  AND  OPERATIVE 


BY 

JOHN  CHALMERS  DA  COSTA,  M.D,  LL.D.,  F.  A.  C.  S. 

SAinTEL  D.    GROSS    PROFESSOR  OF  SURGERY,  JEFFERSON  MEDICAL  COLLEGE,  PHTLADELPHLA; 
SURGEON  TO  THE  JEFFERSON  MEDICAL  COLLEGE  HOSPITAL;  CONSULTING  SURGEON  TO 
PHILADELPHIA    GENERAL   HOSPITAL,    ST.    JOSEPH 's   HOSPITAL,   AND    MISERICORDIA 
HOSPITAL,  PHILADELPHIA;    CONSULTING   SURGEON  TO  THE  HOSPITAL  FOR  THE 
INSANE,  EASTERN  DISTRICT  OF  PENNSYLVANIA  AT  NORRISTOWN;  FELLOW 
OF     THE     AMERICAN     SURGICAL     ASSOCIATION  ;      MEMBER     OF     THE 
SOCIETY    OF   CLINICAL   SURGERY;     MEMBER    OF    THE   AMERICAN 
PHILOSOPHICAL  SOCIETY;     MEMBRE   DB   LA  SOCIETE   INTER- 
NATIONAL    DE     CHIRURGIE;      COMMANDER,     MEDICAL 
CORPS,  U.  S.  N.  R.  F.,  ETC.,  ETC. 


Eighth   Edition,    Revised,    Enlarged,   and  Reset 
With  1177  Illustrations,  Some  of  Them  in  Colors 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1920 


F^Vf 


Copyright,  1894,  By  W.  B.  Saunders.     Reprinted  March,  1895,  and  August,  1896.    Revised,  entirely  reset, 
reprinte-^,  and  recopyrighted  June,  189S.     Reprinted  October,  1898,  and  June,  1899.      Revised,  re- 
printed, and  recopyrighted  August;  1900.    Reprinted  August,  1901;  August,  1902,  and  November,, 
1902.     Revised,  entirely  reset,  reprinted,  and  recopyrighted  August,  1903.     Reprinted  July, 
1904;  October,  1905;  September,  1906,  and  October,  1906.  Revised,  reprinted,  and  recopy- 
righted January,  1907.     Reprinted  April,  1907;  March,  1908,  and  July,  1909.    Re- 
vised, reprinted,  and  recopyrighted  January,  1910.    Reprinted  September,  1910; 
May,  1911;  August,  1912,  and  August,  1913.      Revised,  entirely  reset,  re- 
printed, and  recopyrighted  April,  1914.     Reprinted  January  and 
September,     1915;    September.    1917;    January,    May, 
and   November,  igiS.     Revised,  entirely   reset, 
reprinted,   and   recopyrighted 
September,  1919. 


Copyright,  1919,  by  W.  B.  Saunders  Company 


Reprinted  September.  1920 


AMERICA 


05 
Of 

a. 


'  Yet   each   man ,   following  his   sympathies, 
Unto  himself  assimilating   all, 

Using  men's  thoughts  and  forms  as  steps  to   rise. 
Who   speaks   at  last  his  individual   word, 
The  free  result  of  all  things  seen  and  heard, 
Is   in   the  noblest   sense  original. 

Each   to  himself  must  be  his   final   rule,  •  •     . 

Supreme   dictator,   to   reject  or  use, 
Employing  what  he   takes  but  as   his  tool. 
But  he  who,   self-sufficient,    dares  refuse 
All  aid  of  men,  must  be  a  god  or  fool." 

W.  W.  Story   ("A  Contemporary  Criticism""). 


THIS   BOOK   IS   DEDICATED   TO   THE   CHIEF    SURGEON   AND   INSPIRA- 
TION   OE    ONE    OE    THE    GREATEST,    MOST    PROGRESSIVE,    AND 
MOST   INFLUENTIAL-   SURGICAL    CLINICS   IN  THE   WORLD. 
A    CLINIC    FROM    WHICH    COME    IMPORTANT    FACTS, 
REAL    IDEAS,    AND    BRILLIANT    MEN. 

TO   THE   OPERATOR,    THE   TEACHER,    THE   INVESTIGATOR,   AND   THE 
SURGICAL    PHILOSOPHER.       TO 

DR.   WILLIAM   STEWART   HALSTED, 

THE   DISTINGUISHED   PROFESSOR   OF   SURGERY   IN 

JOHNS    HOPKINS    UNIVERSITY. 


PREFACE  TO  THE  EIGHTH  EDITION 


In  presenting  to  medical  readers  this,  the  eighth  edition  of  "A  Manual  of 
Modern  Surgery, "  I  Uke  to  believe  that  there  is  a  real  demand  for  it,  but  I  feel 
some  apprehension  that  I  may  be  one  of  those  of  whom  Coleridge  spoke  when  he 
said  they  "do  not  believe  but  only  beheve  they  believe."  ^  I  hope  that  previous 
complimentary  criticisms  are  to  be  regarded  as  constituting  an  encore,  and  not 
merely  as  courteous  acknowledgments.  Perhaps  the  long  tried  medical  public 
will  say  of  me  as  Mr.  F.'s  aunt  said  of  Clennam  "Drat  him!  If  he  aint  come 
back  again." 

In  completing  a  task  which  has  occupied  me  for  a  weary  time,  I  realize  that 
the  revision  was  made  under  extreme  difficulties.  Parts  of  it  were  written  at 
odd  times  and  in  strange  places.  The  war  was  raging  and  all  the  forces  of  the 
world  seemed  devoted  to  slaughter.  The  routine  of  peace  times  was  but  a 
faded  memory.  Millions  were  dead  and  it  seemed  as  though  more  millions  were 
to  die.  Civilization  trembled  in  the  balance.  Mercy,  Christianity,  Liberty, 
Law,  Humanity  were  threatened  with  annihilation.  In  the  words  of  Sir  Thomas 
Browne,  all  of  us  were  looking  in  "the  furious  face  of  things."  All  of  these 
elements  conspired  to  settle  upon  me  as  a  vast  obsession,  full  of  sorrow  and  of 
heartbreak,  paralyzing  thought  of  other  things.  It  was  a  dreadfully  hard 
task  under  such  circumstances  to  sit  at  a  desk  and  try  to  revise  a  book.  It 
was  an  utterly  impossible  thing  to  do  it  as  it  should  be  done. 

I  did  not  have  continuous  access  to  some  very  important  sources  of  informa- 
tion, for  instance,  to  the  British  Journal  of  Surgery.  Until  the  reading  of  the 
proof  I  had  not  my  usual  help.  Lt.  Col.  Nassau,  the  Assistant  Professor  of 
Surgery,  who  has  formerly  aided  me  in  the  section  on  Local  Anesthesia  was  with 
a  hospital  unit  in  France.  My  valued  personal  assistant.  Captain  Thomas  A. 
Shallow,  was  in  France  with  the  American  Expeditionary  Force.  My  assistant, 
Captain  Owen,  was  in  a  base  hospital  in  France.  My  assistant.  Lieutenant 
John  F.  X.  Jones,  U.  S.  Navy,  who  in  literary  work  has  been  as  my  right  hand, 
was  in  the  Breton  Patrol,  at  the  base  hospital  in  Brest  and  for  a  time  with  an 
operating  team  at  the  fighting  front.  My  assistant,  Captain  Warren  B.  Davis, 
was  Director  of  a  School  of  Plastic  and  Oral  Surgery,  U.  S.  A.  Major  Stellwagen, 
who  has  formerly  aided  me  in  the  section  on  Geni to-urinary"  Surgery,  had  an 
operating  team  at  the  front  in  France.  Lt.  Col.  Manges,  the  eminent  x-ray 
expert,  who  has  always  revised  the  section  upon  Roentgenology,  was  on  active 
service  with  the  army.  Two  others  of  my  assistants.  Doctor  Righter  and 
Doctor  Lipshutz,  v/ere  on  active  service  with  the  navy.  I  was  also  on  active 
service  in  the  navy,  and  this  very  preface  is  being  written  on  board  a  United 
States  naval  transport. 

Difficulties  of  a  revision  under  such  circumstances  must  be  evident  to  all.  I 
have  done  the  best  I  could.  The  war  has  developed  an  immense  amount  of 
literature  which  has  not  yet  been  sorted,  analyzed,  and  weighed  with  accuracy. 

The  newer  methods  for  preventing  tetanus  and  for  treating  infections,  com- 
pound fractures,  head  injuries  and  chest  injuries  are  of  the  very  first  importance. 
There  seems  to  have  been  no  radical  change  in  our  views  as  to  injuries  of  the 
abdomen.  It  is  difiicult  or  impossible  for  one,  without  large  personal  experience, 
to  determine  the  real  position  of  the  guillotine  amputation.  Of  course  claims 
are  made  by  some  writers  which  do  not  seem  to  rest  on  sound  surgical  principles. 
I  still  believe  that  the  pus  of  an  empyema  like  pus  anywhere  else  should  be  evacu- 


12  Preface    to  the  Eighth  Edition 

ated  with  the  utmost  promptitude.  When  I  have  read  some  articles  I  feel  the  way 
Huckleberry  Finn  felt  when  he  had  read  part  of  The  Pilgrim's  Progress — "The 
statements  was  interesting  but  tough. "  Every  now  and  then  we  see  a  claim  to  a 
discovery  of  a  new  thing  which  turns  out  to  be  only  a  scientific  egg  from  cold  storage 
being  offered  for  sale  as  new. 

I  have  tried  to  exclude  the  non-essential,  to  omit  nothing  which  is  vital,  but 
I  fear  the  effort  has  been  but  a  trial.  The  loom  of  truth  sometimes  spins  webs 
of  fancy,  and  the  statistical  long  bow  sends  arrows  to  a  great  distance.  I  am 
like  the  children,  of  whom  Pope  speaks,  who 

"Birds  pursue 
Still  out  of  reach 
But  never  out  of  view." 

After  setting  forth  new  things  which  seem  to  me  to  be  true  things,  I  often  feel 
in  the  frame  of  mind  of  James  Anthony  Froude,  who  wrote  the  biography  of 
Saint  Neot.  We  learn  from  Lytton  Strachey  that,  at  the  conclusion  of  the  biog- 
raphy of  this  saint,  Froude  wrote  the  following:  "This  is  all  and  indeed  more 
than  all  that  is  known  to  man  of  the  blessed  Saint  Neot,  but  not  more  than  is 
known  to  the  angels  in  Heaven." 

I  express  my  warmest  thanks  to  some  gentlemen  who  have  aided  me. 

Dr.  John  F.  X.  Jones  has  assisted  me  to  read  the  proof.  Major  George  M. 
Dorrance  aided  me  in  the  section  on  Transfusion  of  Blood.  My  distinguished 
colleague,  Dr.  Chevalier  Jackson,  wrote  for  me  the  section  on  Bronchoscopy 
and  Esophagoscopy.  My  friend  and  colleague,  Dr.  J.  T.  Rugh,  aided  in  the 
revision  of  the  section  on  Orthopedic  Surgery.  My  friend  and  colleague,  Dr. 
S.  Mac  Cuen  Smith,  wrote  for  me  the  description  of  the  Barany  Test. 

Dr.  William  S.  Wadsworth,  the  eminent  authority  on  legal  medicine,  coroner's 
physician  of  Philadelphia,  revised  for  me  the  section  on  Electrical  Injuries. 

Dr.  George  E.  Pf abler,  the  distinguished  Roentgenologist,  undertook  on 
short  notice  to  revise  the  section  on  the  A'-rays. 

Dr.  Benjamin  A.  Thomas  revised  for  me  the  section  on  Venereal  Diseases. 
Violating  the  habits  of  a  life  time  I  put  his  manuscript  away  and  so  carefully 
that  I  have  never  been  able  to  find  it  since.  This  goes  to  prove  that  the  apho- 
rism of  Hippocrates  is  the  truth,  and  that  no  one  should  abandon  suddenly  a  life- 
long habit. 

I  cannot  put  in  everything  pertaining  to  surgery'.  I  must  leave  out  many 
things,  but  I  follow  the  sound  advice  of  Sydney  Smith  and  "have  the  courage 
to  be  ignorant  of  a  great  number  of  things  in  order  that "  I  "  may  avoid  the 
calamity  of  being  ignorant  of  everything." 

John  Chalmers  DaCosta. 
204S  Walnut  Street,  Philadelphia 


CONTENTS 


I. 
II. 
III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XL 

xn. 

XIII. 

XIV. 

XV. 

XVI. 

xvn. 

xvni. 

xix. 


XX. 


XXI. 

XXII. 
XXIII. 


XXIV. 


XXV 
XXVI 


XXVII 


Page 

Bacteriology ■'■7 

Asepsis  and  Antisepsis "4 

Intlammation 9 

Repair '^^^ 

Surgical  Fevers ■'•39 

Suppuration  and  Abscess ^'♦^ 

Ulceration  and  Fistula , ^°3 

Mortification,  Gangrene,  or  Sphacelus i75 

Thrombosis  and  Embolism 2°3 

Focal  Sepsis.     Septicemia  and  Pyemia 213 

Erysipelas  (St.  Anthony's  Fire) 219 

Tetanus  or  Lockjaw 224 

Tuberculosis ^35 

Rachitis  or  Rickets ^7 

Contusions  and  Wounds ^°^ 

Burns  and  Scalds;  Effects  of  Cold 3^0 

Syphilis 3  5 

Tumors,  or  Morbid  Growths 397 

Diseases  and  Injuries  of  the  Heart  and  Vessels 4.';9 

Hemorrhage  or  Loss  of  Blood 497 

Operations  on  the  Vascular  System 523 

Ligation  of  Arteries  in  Continuity 539 

Diseases  and  Injuries  of  Bon-es  ant)  Joints 5^4 

Diseases  of  the  Bones 5^4 

Fractures 5 

Diseases  of  the  Joints. .  .• 702 

Luxations  or  Dislocations 745 

Operations  upon  Bones  and  Joints 777 

Diseases  and  Injuries  of  Muscles,  Tendons,  and  Burs^ 801 

Operations  upon  Muscles  and  Tendons 823 

Orthopedic  Surgery ^^" 

Diseases  and  Injuries  of  Nerves 838 

Diseases  of  Nerves 3° 

Wounds  and  Injuries  of  Nerves 840 

Operations  upon  Nerves 851 

Diseases  and  Injuries  of  the  Head 863 

Diseases  of  the  Head ^^3 

Injuries  of  the  Head ^74 

Surgery  of  the  Spine 94i 

Surgery  of  the  Respiratory  Organs 973 

Diseases  and  Injuries  of  the  Nose  and  Antrum 9^8 

Diseases  and  Injuries  of  the  Larynx  and  Trachea 99 1 

Operations  on  the  Larynx  and  Trachea 993 

Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs ioi4 

Operations  on  Pleura  and  Lungs ^°32 

Diseases  and  Injuries  of  the  Upper  Digestr^  Tract 1040 

13 


14 


Contents 


XXVIII.     Diseases  and  Injuries  of  the  Abdomen 

Stomach  and  Intestines 

The  Peritoneum 

The  Liver,  Gall-bladder,  and  Bile-ducts 

The  Pancreas 

The  Spleen 

Operations  upon  the  Abdomen 

Diseases  and  Injckiks  of  the  Rectim  and  Anus 

Anesthesia  and  Axesthetics 

Diseases  of  the  Skin  antj  Nails 

Diseases  and  Injuries  of  the  Thyroid  Gland 

The  Carotid  Gland;  the  Thymus  Gland 

Diseases  and  Injuries  of  the  Lymphatics 

Bandages 

Plastic  Surgery 

Diseases  and  Injuries  or  the  Genito-urinary  Organs 

Diseases  and  Injuries  of  the  Kidney  and  Ureter 

Diseases  and  Injuries  of  the  Bladder 

Diseases  and  Injuries  of  the  Urethra,  Penis,  Testicles,  Prostate,  Seminal 

Vesicles,  Sperm.atic  Cord,  and  Tunica  Vaginahs 

Amputations 

Special  Amputations 

Diseases  of  the  Mammary  Gland 

The  X-Rays  in  Surgery.     Rontgenography;  Rontgenoscopy;  Ront- 

gentherapy;  Radium  and  Radiotherapy;  Electrocoagulation.  . 
XLI.     Injuries  by  Electricity 


XXIX. 

XXX. 

XXXI. 

XXXII. 

XXXIII. 

xxxrv'. 

XXXV. 

XXX  VI. 

XXXVII. 


XXXVIII. 

XXXIX. 
XL. 


Page 

1073 
1088 

"59 
II 70 
1192 
1 201 
1204 
1304 
1331 
1367 
1369 
1389 
1391 
1396 
1404 
1410 
1417 
1458 


1550 
1557 
1573 

1600 
1643 


INDEX 


1651 


MODERN  SURGERY 


MODERN  SURGERY 


I.  BACTERIOLOGY 


Bacteriology  is  the  science  of  micro-organisms.  Though  a  science  in 
the  youth  of  its  years,  bacteriology  has  not  only  profoundly  altered,  but  it 
has  also  revolutionized  pathology,  and  our  views  of  surgery  would  be  incom- 
plete, misleading,  and  erroneous  without  its  aid. 

Micro=organisms,  or  microbes,  are  minute,  non-nucleated,  vegetable 
cells  closely  connected  with  fungi  and  algffi,  many  of  them  being  visible  only 
by  means  of  a  highly  powerful  microscope  and  after  they  have  been  brightly 
stained.  These  vegetable  cells  contain  water,  protoplasm  and  nuclear  chromatin 
enclosed  by  an  albuminous  structure  which  is  not  cellulose  but  is  in  many  microbes 
a  similar  carbohydrate  called  hemicellulose.  In  all  the  lower  fungi  cellulose  is 
absent.  The  ash  of  bacteria  contains  calcium,  potassium,  chlorine,  magnesium 
and  perhaps  iron  and  sulphur.  Some  bacteria  obtained  from  sewage  contain 
granules  of  sulphur.  There  is  considerable  evidence  that  certain  diseases  are 
caused  by  micro-organisms  so  minute  as  to  escape  detection  even  by  aid  of  the 
most  powerful  microscope.  They  are  known  as  submicroscopic  parasites. 
Some  are  bacterial,  some  are  protozoal.  They  form  filterable  viruses.  In  1898 
loffler  and  Frosch  asserted  ("Centralb.  f.  Bakt.  Orig.,"  1898,  23)  that  some 
micro-organisms  which  cause  disease  in  man  are  so  minute  as  to  pass  through  a 
filter  of  porcelain  or  of  infusorial  earth  (the  Pasteur-Chamberland  filter  is  made 
■of  baked  clay.  The  Berkefeld  filter  is  made  of  infusorial  earth).  Reed  and 
Carroll  (''Am.  Med.,"  Feb.  22,  1902)  stated  that  the  blood  of  a  victim  of  yel- 
low fever  may  be  passed  through  a  Berkefeld  filter  yet  still  retain  its  infec- 
tive element  and  be  able  to  reproduce  the  disease  in  a  predisposed  individual. 
Rosenau,  Beyer  and  others  proved  that  the  blood  can  be  passed  through  a 
Pasteur-Chamberland  filter  without  losing  its  infective  properties  ("Bulletin  of 
U.  S.  Public  Health  and  Marine  Hosp.  Service,"  No.  14,  May,  1904).  The 
French  Yellow  Fever  Commission  asserted  that  the  yellow  fever  micro-organ- 
ism (which  is  perhaps  protozoal)  passes  through  a  porcelain  filter  ("Annals 
of  the  Pasteur  Institute,"  Nov.,  1903).  The  micro-organism  of  rabies  prob- 
ably does  the  same  thing. 

Simon  Flexner  believes  that  many  diseases  are  due  to  submicroscopical 
parasites  (Ether  Day  Address,  191 1).  Some  organisms  which  pass  a  filter 
can  be  seen  in  the  filtrate  by  sunlight  illumination  in  the  ultra-microscope. 
This  is  said  to  be  the  case  of  the  micro-organisms  of  acute  poliomyelitis  and  of 
pleuro-pneumonia  of  cattle.  The  following  filterable  viruses  are  pathogenic 
to  man:  "Hydrophobia,  vaccinia- variola,  molluscum  contagiosum,  pappataci 
fever,  yellow  fever,  dengue  fever,  trachoma,  poliomyelitis,  scarlet  fever, 
measles,  the  excitant  of  warts,  spotted  typhus.  Rocky  Mountain  fever,  the 
virus  of  parotitis  epidemica  and  alastrin"  ("Filterable  Agents  of  Infection"  by 
Dr.  B.  Lipschutz  in  "Handbook  of  Pathogenic  Micro-organisms,"  edited 
by  KoUe  and  Wassermann,  Jena,  191 3). 

Even  in  the  most  remote  times  some  have  believed  that  "the  mysterious 
cause  of  contagious  and  epidemic  diseases  must  be  sought  in  living  entities" 
(Monti  on  "Modern  Pathology"),  but  all  such  beliefs  were  ingenious  guesses 
2  17  . 


i8  Bacteriology 

or  unproved  theories,  unsustained  by  a  scrap  of  experimental  demonstration. 
Frascatorius  of  Verona  in  1546  published  a  treatise  on  contagion  in  which  he 
put  forth  the  view  that  the  cause  resided  in  living  elements.  In  1658  a  Jesuit 
priest,  Athanasius  Kircher,  of  Fulda,  the  first  microscopist,  published  some 
experiments  upon  putrefaction.  He  believed  in  the  existence  of  a  "contagium 
animatum  "  and  may  even  have  seen  large  micro-organisms  but  he  mistook  blood 
corpuscles  for  httle  worms.  Kircher  in  1658  hazarded  the  guess  that  a  living 
contagium  was  responsible  for  many  diseases.  Bacteria  were  discovered  in  1683 
by  the  Dutch  optician  Leeuwenhoek,  of  Delft.  In  his  researches  he  used  the 
simple  microscope,  that  is,  single  lenses  of  short  focal  length.  By  means  of  this 
primitive  instrument  he  saw  spermatozoids,  capillaries,  blood-corpuscles,  the 
structure  of  the  crystalline  lens,  yeast-cells,  and  certain  large  bacteria.  This 
Dutch  observer  regarded  bacteria  as  animalculae.  He  wrote  a  description  of 
the  "animalcule"  found  in  the  tartar  of  the  teeth  and  sent  it  to  the  Roval 
Society  in  the  fall  of  1683. 

In  1762  Marcus  Anton  von  Plenciz,  of  Vienna,  impressed  by  the  publications 
of  Leeuwenhoek,  asserted  that  each  disease  was  caused  by  a  special  organism, 
that  decomposition  was  caused  by  micro-organisms,  and  that  bacteria  could  grow 
in  living  tissue. 

In  1786  O.  F.  Miiller,  of  Copenhagen,  learned  to  identify  certain  bacteria 
by  their  structure.  In  1832  Ehrenberg,  of  Prussia,  described'  certain  groups  of 
bacteria  and  invented  the  names  bacterium  and  spirillum.  These  names  have 
now  a  diflferent  significance  from  what  they  had  then. 

In  1836  the  Italian  Agostino  Bassi  claimed  that  a  certain  disease  of  silk- 
worms was  due  to  a  fungus.  In  1839  Schonlein  discovered  the  vegetable 
parasite  causative  of  favus. 

In  1840  Jacob  Henle,  the  great  German  anatomist  and  histologist,  came  to 
the  conclusion  that  fungi  caused  all  infectious  diseases.  In  1843  Ohver  Wendell 
Holrnes  pubhshed  his  famous  essay  on  the  Contagiousness  of  Puerperal  Fever, 
and  in  1847  Semmelweiss,  of  Vienna,  strongly  maintained  the  same  thesis. 
In  1846  Herman  Klencke  showed  that  tuberculosis  could  be  transmitted 
by  the  milk  of  tuberculous  cows. 

In_  1849  Professor  John  K.  Mitchell,  of  Phila.,  put  forth  the  theory  that 
malarial  and  epidemic  fevers  had  a  "  cr\'ptogamous  origin."  In  1849  Malmsten 
pointed  to  a  fungus  as  the  cause  of  ringworm. 

Ferdinand  Cohn,  of  Breslau,  who  for  over  twenty  years  subsequent  to  1850, 
contributed  actively  to  science,  described  round  bacteria  (cocci),  rod-shaped 
bacteria  (bacilli),  and  in  1872  admitted  disease-producing  bacteria  to  his 
classification. 

In  1863  Casimir  Davaine,  of  France,  found  bacilli  in  the  blood  of  victims 
of  splenic  fever  and  in  1865  made  a  strong  argument  to  prove  that  the  bacilli 
caused  the  disease.  Robert  Koch  proved  it  in  1876.  In  1868  Villemin,  of  Paris, 
showed  that  tuberculous  virus  was  inoculable.  Absolute  proof  was  furnished  by 
Koch,  of  Berlin.  In  1882  he  discovered  the  bacillus  of  tuberculosis,  inoculated 
animals  with  pure  cultures  of  the  bacilli  and  produced  the  disease  ("Bacteria 
and  Their  Products,"  by  Sims  Woodhead). 

The  first  definite  knowledge  of  bacteria  and  their  products  came  from  a 
chemist  and  not  a  physician,  and  dates  from  the  study  of  fermentation  by  the 
illustrious  Frenchman,  Pasteur. 

Before  his  day  "bacteria  were  known,  theories  of  infection  had  been  elabo- 
rated, and  vaccination  practised,"  but  he  "definitely  established  the  impor- 
tance of  bacteria  in  putrefaction,  fermentation,  and  disease,  and  gave  to  vac- 
cination a  scientific  basis"  ("Research  in  Medicine,"  by  Prof.  Richard  M. 
Pearce,  in  "Popular  Science  Monthly,"  July,  191 2). 

In  1858  Pasteur  asserted  that  every  fermentation  had  invariably  its  specific 
ferment;  that  a  ferment  consisted  of  living  cells;  that  cells  produced  fermentation 


Molds,  or  Filamentous  Fungi  19 

by  absorbing  the  oxygen  of  the  substance  acted  upon;  that  putrefaction  was 
caused  by  an  organized  ferment;  that  all  organized  ferments  were  carried 
about  in  the  air;  and  that  the  entire  exclusion  of  air  prevented  putrefaction 
or  fermentation. 

In  i860  Pasteur  published  the  observation  that  sterile  liquids  would  not  be 
contaminated  by  air  if  the  air  gained  entry  through  a  long  curved  tube,  the 
only  reason  being  that  dust  and  growths  would  fall  from  the  entering  air  by 
gravity  ("Comptes  rendus,"  i860). 

In  1863  Pasteur  published  experiments  which  proved  that  beer  could  not 
ferment  without  yeast  and  that  wine  received  in  sterile  vessels  and  defended 
from  external  contamination  would  not  undergo  ammoniacal  change. 

Most  of  the  subsequent  life  of  Pasteur  was  passed  in  seeking  the  causes,  the 
prevention,  and  the  cure  of  infectious  diseases  in  man  and  animals. 

The  views  of  Pasteur,  which  were  radical  departures  from  accepted  belief, 
inaugurated  a  bitter  controversy,  and  in  that  controversy  were  born  the  microbic 
theory  of  disease,  the  doctrine  of  preventive  inoculation,  antiseptic  sur- 
gery, and  serum-therapy.  Pasteur's  jubilee  was  held  in  1892.  Lord  Lister 
wrote:  "Your  researches  on  fermentation  have  thrown  a  powerful  beam, 
which  has  lightened  the  baleful  darkness  of  surgery,  and  has  transformed  the 
treatment  of  wounds  from  a  matter  of  uncertain  and  too  often  disastrous 
empiricism  into  a  scientific  art  of  sure  beneficence.  Thanks  to  you,  surgery 
has  undergone  a  complete  revolution,  which  has  deprived  it  of  its  terrors  and  has 
extended  almost  without  limit  its  efficacious  power"  ("A  Text-book  of  General 
Bacteriology,"  by  Edwin  O.  Jordan). 

The  word  microbe,  which  signifies  a  small  ■  living  being,  was  introduced 
in  1878  by  Professor  Sedillot,  of  Paris.  At  that  time  the  nature  of  these  bodies 
was  in  doubt:  some  thought  them  animal,  and  called  them  microzoaria;  others 
thought  them  vegetable,  and  called  them  microphyta;  the  designation  "microbe" 
does  not  commit  us  to  either  view.  We  now  believe  them  to  be  vegetable, 
but  the  term  "microbe"  has  remained  in  use. 

The  micro-organisms  connected  with  disease  in  man  are  divided  into: 

1.  Yeasts,  Saccharomyces,  or  Blastomycetes; 

2.  Molds,  or  Hyphomycetes; 

3.  Bacteria,  or  Schizom.ycetes. 

Yeasts,  or  budding  fungi,  include  most  of  those  fungi  which  can  cause 
alcoholic  fermentation  in  saccharine  matter.  They  consist  of  small  round  or 
oval  cells,  which  are  devoid  of  chlorophyl,  which  can  live  without  free  oxygen, 
and  which  multiply  by  gemmation  or  budding.  Definite  nuclei  are  not  demon- 
strable in  the  cells.  When  a  cell  multiplies  a  small  bud  of  protoplasm  projects 
from  or  near  the  end,  or  buds  project  from  or  near  both  ends  of  the  cell.  Buds 
increase  progressively  in  size  and  a 'constriction  appears  between  each  bud 
and  the  parent-cell.  A  constriction  deepens  as  the  corresponding  projection 
enlarges,  until  the  bud  attains  a  considerable  size  and  is  cast  off  as  a  daughter- 
cell.  In  some  cases  buds  are  not  cast  off,  but  remain  attached,  a  chain  or 
series  of  rounded  yeast-cells  being  formed.  Yeast-cells  contain  spores  when 
nourishment  is  insufficient.  Under  certain  conditions  yeast  fungi  can  form 
interwoven  threads  called  mycelial  threads. 

Molds,  or  filamentous  fungi,  consist  of  filaments,  each  filament  being  com- 
posed of  a  single  row  of  cells  arranged  end  to  end,  and  all  filaments  springing 
from  a  germinal  tube  which  grows  from  a  germinating  spore.  A  thread  grows 
by  increase  at  the  apex,  and  this  area  eventually  gives  origin  to  new  spores. 
The  yeast  fungi  are  the  common,  but  not  the  only  cause  of  fermentation. 
Mold  fungi  are  connected  with  processes  of  decomposition.  Putrefaction  is 
due  to  bacteria  and  retards  the  growth  of  yeasts  and  molds. 

Most  yeasts  and  molds  grow  best  upon  dead  organic  matter,  some  attack 
plants,  a  few  the  lower  animals,  and  a  very  few  grow  upon  or  in  the  tissues 


20  Bacteriology 

of  the  human  body.     The  term  jnycosis  means  an  infection  with  budding  fungi 
or  with  filamentous  fungi. 

The  o'idium  albicans  is  a  fungus  which  b}'  growing  in  the  mucous  membrane 
produces  the  disease  known  as  thntsh.  Some  observers  believe  that  the  thrush 
fungus  is  a  mold.  Others  maintain  that  it  is  a  budding  fungus  which  may 
develop  filaments.  Thrush  attacks  especially  the  mucous  membrane  of  the 
tongue,  lips,  cheeks,  gums,  and  pharynx,  but  occasionally  the  growth  takes 
place  upon  the  esophagus,  the  vocal  cords,  the  stomach,  the  vagina  of  a  preg- 
nant woman,  the  respiratory  tract,  and  the  areola  of  the  breast  of  a  nursing 
woman.  The  fungus  has  been  found  in  areas  of  bronchopneumonia.  The 
proliferating  fungus  presents  the  appearance  of  milky  white  spots  which  by 
thickening  and  coalescing  form  curd-like  masses,  the  superficial  layer  of  epi- 
thelium being  raised  and  cast  off.  Thrush  is  particularly  common  in  infants 
during  the  second  week  of  life,  and  in  infants  suffering  from  marasmus,  but  it 
may  occur  in  older  children  and  even  in  adults  who  have  been  weakened  by 
some  exhausting  disease  like  typhoid  fever  or  tuberculosis. 

Blastomycetes  dermatitis  is  an  inflammation  of  the  skin  due  to  yeast  fungi 
and  bearing  a  resemblance  to  tuberculosis  or  syphilis.  Pharyngomycoses, 
keratomycoses,  otomycoses,  pneumomycoses,  and  mycoses  of  the  liver,  kidney, 
etc.,  have  been  reported.  Sanfelice  and  others  maintain  that  pathogenic 
yeasts  are  responsible  for  the  growth  of  malignant  tumors.     It  is  certain  that 

yeasts  may  exist  in  a  carcinoma  and  can  be  culti- 
vated, but  proof  is  entirely  lacking  that  they  are 
anything  but  a  contamination.  Many  skin  dis- 
eases are  due  to  fungi;  among  them  should  be 
mentioned  favus,  pityriasis  versicolor,  herpes  ton- 
surans, parasitic  sycosis,  and  eczema  marginatum. 
The  sporotrichoses  constitute  a  group  among 
X  the    mycoses.     They   are  introduced  into  the  body 

Fig.  I.— Actinomyces  (Ziegler).    through     a     wound    or    in    the    food    and    cause 

Sporotrichosis.  This  may  manifest  itself  as  in- 
flammation of  periosteum,  bone,  joint,  lymph  gland,  tendon  sheath  muscle, 
skin,  mucous  membrane  or  viscera.  If  the  skin  or  mucous  membrane  is 
attacked  nodules  form  and  ulcerate.  In  deeper  seated  lesions  abscess  forma- 
tion takes  place.  The  diagnosis  is  made  by  finding  the  organism.  Large 
doses  of  iodide  of  potassium  will  often  effect  a  cure. 

Actinomycosis  (streptotrichosis)  •  is  a  disease  due  to  infection  with  some 
variety  of  streptothrix.  Usually  the  streptothrices  are  regarded  as  molds,  but 
they  possibly  constitute  a  transition  stage  between  filamentous  fungi  and 
bacteria. 

It  was  long  believed  that  the  ray  fungus  (Fig.  i)  was  the  only  cause  of 
actinomycosis.  We  now  know  that  other  members  of  the  streptothrix  group 
may  be  responsible  (see  page  356). 

Madura-foot,  or  mycetoma,  is  due  to  the  Streptothrix  madura  (see  page  359). 
Schizomycetes,  or  bacteria,  chiefly  claim  our  attention.  It  is  important 
to  remember  that  the  term  "bacteria,"  though  applied  to  the  class  schizomycetes, 
has  also  a  more  restricted  application — that  is,  to  a  division  of  the  class;  it 
may  mean  either  schizomycetes  in  general,  or  rod-shaped  schizomycetes,  whose 
length  is  not  more  than  twice  their  breadth.  In  this  work  it  is  employed  to 
designate  schizo?nycetes  as  a  class. 

Bacteria  are  minute,  unbranched,  non-nucleated,  vegetable  cells,  free 
from  chlorophyl,  varying  in  shape  and  occasionally  presenting  locomotive 
flagella.  Though  devoid  of  chlorophyl  (leaf  coloring-matter),  many  of  them 
produce  pigment.  Most  observers  beheve  that  they  are  low  forms  of  vege- 
table life  but  Vaughan  maintains  that  they  contain  no  cellulose  and  that  they 
are  more  closely  related  to  low  forms  of  animal  life  than  to  vegetables.     The 


Schizomycetes,  or  Bacteria  21 

cell  consists  of  a  cell  membrane,  a  layer  of  protoplasm,  and  some  central  fluid. 
No  true  nucleus  has  yet  been  demonstrated,  but  granules  are  found  within  the 
cells  which  some  call  metachromatic  bodies  (Babes)  and  others  nuclei  (Ernst). 
The  cell  membrane  varies  greatly  in  thickness,  and  when  it  is  very  thick  the 
cell  is  said  to  have  a  capside.  The  round  cells  have  a  smooth  outer  surface, 
but  some  of  the  rod-shaped  cells  show  many  flagella  or  at  the  end  a  single 
fiagellum  (Fig.  2).  Flagella  enable  some  bacteria  to  move  {motile  bacteria), 
but  all  organisms  which  possess  them  are  not  motile,  and  under  certain  condi- 
tions bacteria  without  flagella  may  develop  them,  or  organisms  which  normally 
possess  flagella  may  lose  the  power  to  develop  them. 

Some  bacteria,  known  as  non- pathogenic,  cannot  grow  and  produce  poison 
either  in  the  tissues,  in  wound-fluid,  or  in  the  fluid  moistening  a  mucous  surface. 
Others  grow  upon  dead  organic  matter,  but  are  not  able  to  invade  living 
tissues.  They  can  live  and  multiply  in  dead  material,  as  the  discharge  from  a 
wound  or  in  the  fluid  covering  a  mucous  surface,  and  are  called  saprophytes, 
saprophytic  microbes,  or  putrefactive  bacteria.  Obligate  saprophytes  only  live 
in  dead  matter  and  never  become  parasites.  Facultative  saprophytes  can 
become  parasites  under  certain  circumstances,  but  normally  grow  in  dead 
organic  matter.  Bacteria,  known  as  the  pathogenic,  under  certain  conditions 
invade  living  tissue  and  cause  various  diseases.  Harmless  bacteria  are  called 
non-pathogenic.     Jordan  says  ("General  Bacteriology"),  "the  conception  of  a 


/5 


^^^\J 


a  b  c 

Fig.  2. — Types  of  flagella:  a,  Vibrio  cholerse,  one  flagellum  at  the  end — monotrichia  type; 
b,  Bact.  syncyaneum,  tuft  of  flagella  at  the  end,  rarely  at  the  side — Lopotrichia 
type;  c,  Bact.     vulgare,  flagella  arranged  all  about — Peritrichia  type  (Lehmann  and  Neumann). 

pathogenic  micro-organism  is  a  relative,  not  an  absolute  one."  A  bacterium 
may  be  pathogenic  to  man  and  non-pathogenic  to  animals  or  pathogenic  to 
animals  and  not  to  man,  or  pathogenic  to  mammals  and  not  to  cold  blooded 
animals.  Whether  a  microbe  is  or  is  not  pathogenic  depends  "primarily, 
upon  the  nature  of  the  host"  (Jordan,  Ibid.).  Parasitic  bacteria  can  grow  on 
or  in  the  tissues  of  the  body.  Obligate  parasites  are  those  which  have  not  been 
cultivated  outside  of  the  body  (as  the  spirilla  of  relapsing  fever).  Facultative 
parasites  usually  live  outside  the  body,  but  may  enter  into  the  body  and  pro- 
duce disease.  The  schizomycetes  vary  much  in  shape,  size,  color,  arrange- 
ment, mode  of  growth,  and  action  upon  the  body.  The  protoplasm  of  these 
cells  can  be  stained  with  anilin  colors,  and  the  cell-wall  is  more  readily  detected 
after  treating  it  with  water,  which  causes  it  to  swell.  One  form  cannot  be 
transformed  into  another,  but  each  maintains  its  specific  identity.  Every 
organism  comes  from  a  pre-existing  organism,  this  being  true  of  all  forms. 
Pasteur  proved  that  spontaneous  generation  of  bacteria  is  impossible.  Although 
numerous  attempts  have  been  made  to  overthrow  this  view  it  still  stands 
unshaken.  Some  find  an  analogy  in  parthogenesis,  that  is  the  development 
of  a  living  being  without  a  father.  Parthogenesis  occurs  among  ants,  bees, 
wasps  and  certain  butterflies.  The  formation  of  dermoid  cysts  is  as  remark- 
able as  parthogenesis.  Washington  Irving  stated  that  where  a  maiden  of 
today  claims  that  her  pregnancy  was  not  due  to  sexual  intercourse,  she  could 
hardly  overcome  the  prejudice  of  scientists.  Jacques  Loeb  has  succeeded 
in   causing  unfertilized  eggs   to   develop  and  has  obtained  a  fatherless  frog 


22  iSacteriology 

and  a  fatherless  sea  urchin.  He  claims  that  the  stimulus  is  physical.  He 
places  the  eggs  in  fluid  with  an  increase  of  osmotic  pressure.  This  causes 
loss  of  water  from  the  eggs,  membrane  formation  and  cell  division  (Artificial 
Parthenogenesis  and  Fertilization,  1913).  But  even  so  Loeb  did  not  create 
the  egg  nor  claim  to.  He  did  not  create  life.  Though  sugar  and  many  other 
organic  substances  can  be  made  synthetically,  yet  no  one  can  dare  advance 
as  more  than  a  bare  possibiUty  "that  the  thing  we  call  life  may  some  day  be 
produced  by  a  daring  chemist"  ("The  Nation").  Yet,  as  Talbot  remarks 
("Degeneracy"  by  Eugene  S.  Talbot) — "If  startling  and  apparently  miraculous 
nature  as  a  virgin  generation  of  a  living  child  be  regarded  as  the  sole  objec- 
tion to  receiving  such  a  fact,  its  defender  might  urge  that  the  virgin  genera- 
tion of  a  dermoid  cyst  with  all  the  traces,  however  aborted,  of  vertebrate 
organization,  is  only  a  shade  less  startling  and  miraculous." 

Many  bacteria  are  colored;  others  are  colorless.  Some  move  {motile 
bacteria);  others  do  not  move  {amotile  bacteria).  The  bacilli  of  anthrax  and 
tuberculosis  and  all  cocci  are  amotile.  Most  bacteria  can  change  from  motile 
to  amotile,  or  from  amotile  to  motile,  when  subjected  to  certain  changes  of 
soil  and  environment.  The  oscillations  of  cocci  are  physical  in  nature,  not 
vital;  they  are  Brtmonian  or  Brownian  movements,  movements  due  to  altera- 
tions in  equilibrium  because  of  currents  or  changes  of  level  in  the  fluid  in  which 
the  micro-organisms  are  contained.  Bacteria  seem  to  possess  the  power  of 
attracting  elements  necessary  for  their  nutrition  {positive  chemiotaxis  or  chemo- 
taxis)  and  of  repelling  harmful  elements  {negative  chemiotaxis  or  chemotaxis). 

Bacterial  Products. — Bacteria  when  active  form  many  different  prod- 
ucts. Among  them  are  gases  (H,  H2S,  CO2,  NH3),  water,  alcohols,  fatty  acids, 
carbohydrates,  phenol,  coloring-matter,  toxins,  enzymes,  etc.  Some  of  these 
materials  are  given  off  from  the  living  cell,  some  are  found  only  when  the  cell 
is  dead.  Some  of  them  are  excretions,  some  of  them  secretions.  Some  are 
formed  within  the  cell  (intracellular),  others  are  excreted  by  the  bacteria  into 
the  material  in  which  the  cell  Hes  (extracellular). 

Forms  of  Bacteria. — The  three  chief  forms  of  bacteria  are: 

1.  The  Coccus  or  Micrococcus— Xhe  berry-shaped,  oval,  or  round  bacterium 

(Fig.  3) ; 

2.  The  Bacillus — the  rod- shaped  bacterium  (Fig.  4); 

3.  The  Spirillum  or  Vibrio — the  corkscrew-shaped  or  spiral  bacterium 
(Fig.  5).  A  short  spiral  organism  is  called  a  comma  bacillus.  Spirochetes  are 
sharply  bent  curved  rods  twisted  like  the  thread  of  a  screw. 


Fig.  3.— Micrococci.  Fig.  4.— Bacilli.  Fig.  5.— Spirilla. 

De  Bary  compares  these  forms,  respectively,  to  the  billiard-ball,  the  lead- 
pencil,  and  the  corkscrew. 

Besides  these  three  fundamental  forms  there  are  certain  filamentous  forms 
known  as  trichomyceles.  They  should  probably  be  placed  between  bacteria 
and  higher  fungi.  . 

Cocci  and  Bacilli. — As  surgeons  we  have  to  do  chiefly  with  f off z  and  bacilli. 
Cocci  may  be  designated  according  to  their  arrangement  with  one  another; 
namely,  when  existing  singly  they  are  called  monococci  (Fig.  3);  in  pairs  they 
are  called  diplococci  (Fig.  8,  a);  arranged  end  to  end  in  a  chain  they  are  called 
streptococci  (Fig.  8,  c);  in  group  side  by  side  clustered  like  a  bunch  of  grapes 
they  are  called  staphylococci  (Fig.  8,  b)  ;  in  groups  of  four  they  are  called  plate 


Multiplication  of  Bacteria 


23 


■cocci  or  tetracocci;  in  cubic  groups  they  are  called  sarcincB  or  wool-sack  cocci 
(Fig.  6).  Irregular  masses,  resembling  frog-spawn,  constitute  zooglea  masses 
(Fig.  9).  The  gelatinous  matter  in  such  a  mass  is  formed  by  a  transformation 
in  the  walls  of  the  bacteria.  The  term  ascococci  is  applied  to  a  group  of  cocci 
-enclosed  in  a  capsule  (G.  S.  Woodhead)  (Fig.  7).  " 


Fig.  6. — Sarcinae  forming  bales  of  packets. 
Single  packets  regularly  grouped  together 
(Lehmann  and  Neumann). 


Fig. 


7. — Ascococcus  Billrothii  Cohn  (after 
F.  Cohn). 


The  cocci  are  often  named  according  to  their  function,  as,  for  example, 
'' pyogenic,''''  or  pus-forming.  Cocci  may  be  named  according  to  the  color  of 
the  culture.  The  name  may  embody  the  form,  arrangement,  color  of  culture, 
and  function;  for  instance.  Staphylococcus  pyogenes  aureus  signifies  a  round 
micro-organism,  which  arranges  itself  with  its  fellows  in  the  form  of  a  bunch 
of  grapes,  which  produces  pus,  and  which  gives  golden-yellow  cultures. 


r:^ 


^ 


t  / 

/ 
% 

3  I* 


Fig.  9.— Zooglea  (Ball). 


Tig.  8. — Forms  of  cocci: — A,  Diplococci; 
B,  staphylococci;  C,  streptococci. 

The  bacilli  are  long,  staff-shaped  organisms.  Long,  delicate,  unbranched, 
jointed  bacilli  having  wavy  outlines  are  known  as  leptothrix  forms.  Chain-like 
bacilli  are  called  streptohacilli.     Bacilli  give  origin  to  many  surgical  diseases. 

Dichotomy  or  Branching. — It  is  very  seldom  that  a  side  bud  appears  upon 
bacteria  except  in  the  bacteria  of  tuberculosis  and  diphtheria. 


I  a 


^ 


CO 
Q 


oaf 

s 

Q 


a  h 

Fig.  ^10.— Pseudodichotomy:  a,  In    bacilli;  b,  in    streptococci    (Lehmann    and    Neumann). 

Pseudodichotomy  is  by  no  means  unusual.  It  occurs  when  one  end  of  a 
bacillus  grows  by  the  end  of  the  adjacent  bacillus  or  when  a  bacillus  in  a  chain 
divides  in  a  line  parallel  to  the  chain  and  thus  begins  another  chain  (Fig.  10). 

Multiplication  of  Bacteria.^ — Bacteria  multiply  with  great  rapidity 
when  placed  under  suitable  conditions.     They  can  multiply  by  transverse 


24 


Bacteriology 


fission  or  by  spore-formation.  Some  bacteria  multiply  by  both  methods.  In 
fission,  or  segmenlalion,  a  bacillus  undergoes  an  increase  in  size  and  length; 
a  coccus  does  not  increase  in  size,  but  may  elongate  slightly.  In  either  case  about 
the  middle  of  the  cell  a  transverse  constriction  begins,  which  deepens  until  the 
cell  has  divided  into  two  parts,  each  of  which  soon  grows  as  large  as  its  parent 
(Figs.  11,12).  As  a  rule,  the  micro-organisms  separate  after  division  of  the  cell; 
but   they   may  not   do  so;   and  if   they  do  not   separate,  a  special   grouping 

,,--.       ,.----,        — ^^        ,'-■-.■ — ,  receives     a     particular     name 

' /'^^'^^^^^^  "'  (diplococci,   streptococci,   etc.). 

i^         )  ]    \  \}.^^^  }         If   the   division  is  invariably  in 

'-— -'      - -' ...-''       --..-•.-..--'  the   same  direction,  and  if  the 

1-iG.  II.— Divisions  of  a  micrococcus  (after  Mace).        ^^^^    cells    remain    in    contact, 

streptococci     or     streptobacilli 
.'- -..  .---■----•■•■■,        are    formed.      Tetracocci    and 

€T  '  ^^""^'^^\      sarcinae  are  formed  when  a  num- 
.,   ix^i^:£ii»ii^^ji^/'       ber   of  cocci  "divide  in  two  or 
'  three    successively  vertical   di- 

^'^|^^;^^^|^^^\  /'p^^^^^^^\  rections"     ("CUnical     Bacteri- 

\  t..^_'v__^/'  '^^\-LSyk.^}  ology,"byLevyandKlemperer), 

^"— "'"        '  "^        '         "  forming   four  quadrants   {tetra- 

FiG.  12.— Di\-isions  of  a  bacillus  (after  Mace).  COCci)  or  eight  octants  {sarcina). 

All  cocci  and  most  bacilli  mul- 
tiply by  fission.  Hence  the  common  term  of  ^^55/ow /z^/zg/.  The  time  required 
for  the  multiplication  of  a  bacterium  varies.  It  is  always  rapid  and  young  ceDs 
quickly  reach  maturity.  Some  varieties,  when  placed  under  favorable  con- 
ditions, undergo  fission  in  two  hours.  The  cholera  bacillus  requires  only 
twenty  minutes  to  di\ade.  The  tubercle  bacillus  requires  several  days.  If 
segmentation  of  a  single  cell  and  the  growth  to  maturity  of  its  products  require 
one  hour,  a  single  cell  in  a  single  day,  if  the  conditions  for  increase  were  ideally 
favorable,  would  have  16,000,000  descendants,  and  in  three  days  the  mass  of 
new  cells  would  weigh  7500  tons  (Cohn).  In  order,  however,  for  such  enormous 
multiplication  to  occur  conditions  would  have  to  be  absolutely  favorable  for 
the  cells,  and  conditions  are  never  absolutely 
favorable.     Were  it  otherwise,  all  other  forms  ^  © 

of  life  would  be  destroyed.     During  growth  in  ^H   W       M     (§    ^' 

a  culture-medium  acids  and  other  inhibitory  0    (^^  \Q     t\    rl 

substances  are  formed,  and  these  substances  ^^  '' 

are  detrimental    to    the  bacteria  themselves        ^    IS   ®     /-/      vo 
and   to  all  bacteria  of  the  same  t\q3e.     Such        ^    M  ^ 
substances  are  kno^\•n  as  autotoxins  (Conradi  "     ^ 

and     Kurpjuweweit,    in    "Muenchen.    med. 
Woch.,"  No.  32,  September  12,  1905).     In  a      B  (^    M    ^ 
culture  of  cholera  V^acilli  the  number  of  living      ^cC^    (f     ^  ^ 

microbes  begins  to  lessen  after  twenty-four  ^  ^ 

hours,  and  after  forty-eight  hours  the  diminu-  ^iis-,      ,     ^-^ 

tion  is  distinct.  ^  ^        ,    .      ,  , 

o  \         .  •  J  •  riG.  i^. — bporulation  (after 

Spores. — A    spore    is    a    germ,    and  cor-  -^  De  Bar^O 

responds   with    the  seed  of  a   plant.     Some 

bacilli,  a  few  spirilla,  and  it  may  be  sarcinae,  multiply  by  spore-formation. 
Cocci  do  not  undergo  spore-formation  after  the  manner  of  bacilli,  though  some 
observers  maintain  that  cocci  occasionally  undergo  an  alteration  that  makes 
them  very  resistant  to  any  destructive  influences.  To  quote  Jordan  ("  General 
Bacteriology'')  "Saving  certain  anaerobic  bacilli  (bacillus  of  tetanus,  bacillus  of 
malignant  edema  and  a  few  others)  only  one  spore-forming  bacterium,  the  an- 
thrax bacillus,  is  known  to  be  pathogenic  for  man."  When  spore-formation  is 
about  to  occur  in  a  bacillus,  a  point  of  cloudiness  or  an  area  of  bright  refraction 


Life-conditions  of  Bacteria  25 

appears  in  the  protoplasm  and  the  cell  generally  elongates.  When  a  row  of  cells 
sporulate,  the  segments,  each  of  which  contains  a  lustrous  area  or  a  region  of 
cloudiness,  look  like  parts  of  a  necklace  of  beads  (Fig.  13).  The  spor^  enlarges, 
the  cell  membrane  bursts,  and  the  young  bacillus  emerges  through  the  opening. 
A  cell  usually  contains  but  one  spore,  which  may  be  situated  at  the  end  of  the 
cell  (ciui  spore)  or  in  the  middle  of  the  cell  {end  as  pore).  Sometimes  a  single  cell 
contains  several  spores.  If  an  endspore  exists,  the  end  of  the  cell  containing 
the  spore  is  swollen  or  club  shaped  {drumstick  bacterium).  If  an  endospore 
exists,  the  cell  becomes  spindle  shaped  {Clostridium).  When  multiplication 
is  by  a  single  endospore,  the  bacillus  does  not  elongate.  When  multiplication 
takes  place  by  a  process  of  combined  spore-formation  and  fission,  the  mother- 
cell  divides  into  a  number  of  daughter-cells,  which  are  called  arihrospores. 
Organisms  which  when  active  multiply  by  fission  take  on  spore-formation 
when  subjected  to  certain  conditions. 

Spore-formation  tends  to  occur  when  bacilli  have  to  resist  unfavorable 
circumstances.  Free  oxygen  causes  some  bacteria  to  form  spores,  x\bsence 
of  oxygen  causes  others  to  do  so.  Inhibitory  products,  improper  temperature 
or  unsuitable  food  may  be  responsible.  Jordan  says  (,"  General  Bacteriology") 
"The  spore  is  a  resting  stage.  It  serves  to  tide  the  organism  over  a  period 
of  dr\Tiess,  famine,  or  unsuitable  temperature  and  to  preserve  alive  in  a  hostile 
environment  a  sufficient  number  of  individuals  until  such  time  as  favorable 
circumstances  recur,"  He  compares  the  spore  stage  to  hibernation  higher 
in  the  scale  of  life.  The  spore  has  a  dense  envelope  or  covering  which  is  very 
resistant  to  staining  agents,  poisons  and  high  temperature.  So  resistant 
is  the  covering  that  twice  the  amount  of  heat  is  necessary  to  kill  a  spore  as  to 
kill  an  active  adult  cell.  Spores  when  placed  under  conditions  unfavorable 
for  development  may  remain  inactive  for  an  indefinite  period,  just  as  seeds 
remain  inactive  when  unplanted.  Drying,  even  dr}-ing  for  years,  may  not 
destroy  them.  A  dry  temperature  of  nearly  300°  F.  destroys  the  spores  of 
anthrax,  but  only  after  acting  for  three  hours.  Steam  or  boiling  water  kills 
most  spores  in  a  few  minutes.  Some  spores  are  able  to  withstand  the  actioa 
of  live  steam  for  several  or  perhaps  for  many  hours.  Direct  sunhght  in  the 
presence  of  free  oxygen  destroys  spores.  When  spores  encounter  favorable 
conditions,  they  develop  very  rapidly  into  adult  cells,  just  as  seeds  develop 
when  planted.  It  seems  probable  that  spores  occasionally  remain  dormant  in 
the  human  body  for  long  periods,  and  finally  awaken  into  activity  because  of 
injury  or  disease  of  the  tissue  in  which  they  lie. 

Chemical  Composition  of  Bacteria. — The  protoplasm  of  bacteria  consists 
of  water,  salts,  albuminous  material,  extractives  soluble  in  alcohol,  and  extrac- 
tives soluble  in  ether. 

Life=conditions  of  Bacteria. — In  order  to  grow  and  to  multiply,  bacteria, 
require  a  suitable  soil  and  the  favoring  influences  of  heat  and  moisture.  The 
soil  demanded  consists  of  highly  organized  compounds  rather  than  crude 
substances,  and  shght  modifications  in  it  may  prove  fatal  to  some  forms  of 
bacterial  life,  but  highly  advantageous  to  others.  Some  organisms  require 
albuminous  matter,  others  need  carbohydrates;  they  all  require  water,  carbon, 
nitrogen,  oxygen,  hydrogen,  and  certain  inorganic  materials,  especially  hme 
and  potassium  (Woodhead).  All  organisms  require  water.  If  dried,  nO' 
micro-organisms  will  multiply,  and  many  forms  will  die.  The  fluids  and 
tissues  of  the  individual  may  or  may  not  afford  a  favorable  soil  for  the  germs 
of  a  disease,  or,  in  the  same  person,  may  afford  it  at  one  time  and  not  at 
another.  Some  individuals  seem  to  possess  indestructible  immunity  for,  and 
others  are  especially  prone  to,  certain  bacterial  diseases,  and  these  immunities  and 
predispositions  may  be  hereditary.  The  Japanese  are  predisposed  to  measles 
but  show  high  immunity  to  scarlet  fever.  Negroes  if  full  blooded  are  practically 
immune  to  yellow  fever.     ISIulattoes  possess  far  less  exemption.     Drunkards  are 


26  Bacteriology 

predisposed  to  pneumonia.  Some  families  exhibit  high  susceptibility  to  scarlet 
fever.  Negroes  are  very  susceptible  to  small-pox.  The  tropical  negro,  if  re- 
moved to  another  limate,  is  highly  susceptible  to  tuberculosis.  The  Irish  are 
predisposed  to  the  same  disease.  Among  Jews  the  death  rate  from  consumption 
is  low.  In  1 55 1  it  was  noted  that  foreigners  in  England  escaped  the  sweating 
sickness  and  that  the  disease  followed  Englishmen  into  foreign  parts.  Impair- 
ment of  health,  by  altering  some  subtle  condition  of  the  soil,  may  make  a  person 
liable  who  previously  was  exempt.  The  insane  are  predisposed  to  infections. 
Injury  or  disease  of  a  tissue  may  increase  local  liability. 

Again,  some  bacteria  which  under  normal  conditions  are  harmless  may 
become  virulent  under  altered  conditions.  Colon  bacilli,  which  under  nor- 
mal conditions  seem  to  be  putrefactive  organisms  inhabiting  the  intestine,  may 
attack  a  point  of  least  resistance  in  the  intestine  itself:  this  point  is  established 
by  congestion,  strangulation,  inflammation,  or  injury,  and  descendants  of  the 
bacteria  which  attacked  the  point  of  least  resistance  may  become  so  virulent 
that  they  can  live  and  develop  in  tissues  distant  and  apparently  normal  and 
cause  disease  in  them.  That  epidemics  of  a  disease,  for  instance  influenza, 
vary  greatly  in  virulence  is  well  known.  This  is  explained  by  alteration  in  the 
virulence  of  bacteria  due  to  atmospheric  and  also  perhaps  to  other  influences. 

The  presence  of  oxygen  influences  microbic  growth.  Most  organisms  thrive 
best  when  exposed  to  the  oxygen  of  the  air,  and  they  are  known  as  aerobic. 
The  term  anaerobic  is  employed  to  designate  organisms  that  can  grow  and 
multiply  and  produce  particular  products  only  when  air  is  absent,  free  oxygen 
being  fatal  to  them.  They  may  need  oxygen;  but  if  they  do,  they  are  able  to 
obtain  it  from  the  tissues  when  air  is  excluded.  Tetanus  bacilli  and  the  bacilli 
of  malignant  edema  are  anaerobic.  The  obligate  aerobes  cannot  live  without 
free  oxygen.  The  obligate  anaerobes  cannot  grow  unless  free  oxygen  is  absent 
or  almost  absent.  The  facultative  anaerobes  can  live  and  multiply  whether  free 
oxygen  is  present  or  not.  Diphtheria  and  cholera  are  due  to  obligate  aerobes. 
Most  microbic  diseases  in  man  are  due  to  facultative-anaerobic  bacteria. 

Effect  of  Motion,  Sunlight,  the  X=rays,  Radium,  Cold,  and  Heat. — 
The  majority  of  fungi  grow  best  when  at  rest;  violent  agitation  retards  the 
growth  of  some.  Sunlight  antagonizes  the  growth  of  certain  bacteria,  especially 
tubercle  bacilli  and  the  bacilli  of  typhoid  fever.  Direct  sunlight  even  destroys 
spores.  Ordinary  daylight  is  very  slowly  germicidal  to  bacteria.  Direct  sun- 
light is  more  quickly  fatal  to  them.  In  the  presence  of  plenty  of  oxygen  direct 
sunlight  kills  tubercle  bacilli  from  cultures  in  a  few  minutes  to  two  or  three 
hours,  bacilli  in  sputum  are  killed  in  thirty  or  more  hours  (Jordan,  "General 
Bacteriology").  Sunlight  is  bactericidal  even  when  heat  rays  are  intercepted. 
The  active  agent  is  the  light.  The  blue  and  violet  rays  are  the  most  active,  while 
the  rays  of  the  red  end  of  the  spectrum  are  devoid  of  power  to  kill  bacteria. 
The  electric  arc-light  acts  on  bacteria  like  sunlight.  It  is  claimed  by  some 
that  the  x-rays  retard  bacterial  growth  but  they  cannot  be  used  to  destroy 
bacteria  in  the  tissues  without  employing  them  in  such  intensity  as  gravely  to 
damage  the  tissues.  Radium  rays  are  bactericidal.  In  some  cases  radium 
rays  destroy  bacteria  in  the  tissues,  in  other  cases  the  rays  modify  the  bacteria, 
and  in  still  other  cases  destroy  the  tissue  cells  which  produce  bactericidal 
substances.  Sunlight,  the  arc-light,  radium  emanations,  and  .v-rays  whatever 
else  they  may  do,  stimulate  tissue  activities,  and  so  aid  the  tissues  to  rid  themselves 
of  bacteria.  Temperature  influences  bacterial  growth.  Some  organisms  will 
grow  within  narrow  temperature  limits  only,  while  others  can  sustain  sweeping 
alterations,  but  most  grow  best  between  the  limits  of  from  86°  to  104°  F.  Freezing 
renders  bacteria  motionless  and  incapable  of  multiplication,  but  it  does  not  kill 
them ;  they  again  become  active  when  the  temperature  is  raised.  Prudden  showed 
that  typhoid  bacilli  can  live  in  ice  one  hundred  and  three  days.  The  absurdity 
of  employing  cold  as  a  germicide  is  evident  when  the  fact  is  knowTi  that  a 


Latent  Bacteria  27 

temperature  of  200°  F.  below  zero  is  not  fatal  to  germ-life,  cell-activities  by- 
such  a  temperature  being  rendered  dormant  only.  Bacteria  have  been  placed 
in  hermetically  sealed  tubes  and  the  tubes  immersed  in  liquid  air  for  seven 
days.  The  germs  were  thus  subjected  to  a  temperature  of — 190°  C,  but  there 
was  no  change  produced  in  their  virulence  (A.  MacFayden  and  S.  Roland,  in 
^'Lancet,"  March  24,  1900),  High  temperatures  are  fatal  to  bacteria;  moist 
heat  is  more  destructive  than  dry  heat,  and  adult  cells  are  more  easily  killed 
than  spores.  A  temperature  less  than  212°  F.  will  kill  many  organisms,  and 
boiling  will  kill  every  pathogenic  organism  that  does  not  form  spores.  Some 
spores  are  not  destroyed  after  prolonged  boiling,  and  some  will  withstand  a 
temperature  of  120°  C.  As  a  practical  fact,  however,  boiling  water  kills  in  a 
few  minutes  all  cocci,  most  bacilli,  and  all  pathogenic  spores;  though  the  spores 
of  anthrax,  tetanus,  and  malignant  edema  are  killed  with  more  difficulty  than 
are  the  spores  of  other  bacteria. 

Effect  of  Bacteria  Upon  Bacteria. — Some  bacteria  are  antagonistic  to 
others,  some  are  synergistic  to  others.  When  certain  bacteria  favor  the  growth 
•of  other  bacteria  the  process  is  called  symbiosis.  When  certain  bacteria  retard 
the  growth  of  other  bacteria  the  process  is  known  as  antibiosis.  Such  synergy 
or  antagonism  is  due  to  the  nature  of  the  bacterial  products.  The  strepto- 
coccus of  erysipelas  is  antagonistic  to  the  bacillus  of  anthrax  and  also  to  syphilis 
and  tuberculosis.  The  Bacillus  prodigiosus  makes  the  streptococcus  of  ery- 
sipelas more  active,  and  the  bacillus  of  anthrax  less  active.  The  growth  of 
some  microbes  in  culture-media  makes  a  soil  favorable  or  unfavorable  for  other 
microbes,  and  the  same  process  may  occur  in  the  human  body.  Influenza 
renders  the  lungs  prone  to  infection  with  pneumococci  and  streptococci.  Aerobic 
organisms  prepare  a  wound  for  tetanus  bacilli.  Saprophytes  on  mucous  sur- 
faces are  antagonistic  to  certain  pathogenic  bacteria.  Typhoid  bacteria  are 
destroyed  by  the  common  organisms  of  water.  When  tetanus  bacilli  lodge  in 
the  tissues  with  organisms  that  consume  quantities  of  oxygen  the  latter  organ- 
isms favor  the  growth  of  the  former.  Nitrifying  bacteria  eventually  destroy 
fecal  bacteria.  The  organisms  productive  of  lactic  acid  fermentation  are  de- 
structive to  many  injurious  intestinal  bacteria,  hence  the  repute  of  buttermilk 
diet  and  of  treatment  by  milk-souring  bacteria.  The  Bacillus  pyocyaneus 
hinders  the  growth  of  the  bacillus  of  anthrax  and,  as  Kitasato  has  pointed  out 
antagonizes  the  growth  of  the  cholera  bacillus.  We  are  not  yet  able  to  cure  a 
microbic  disease  by  inoculating  the  sufferer  with  antagonistic  microbes,  on  the 
principle  of  sending  a  thief  to  catch  a  thief,  although  Hankin  ("British  Medical 
Journal,"  August  14,  1897)  suggests  purifying  water  infected  with  colon  or 
typhoid  bacilH  by  means  of  the  Micrococcus  Ghadiallii,  which  is  fatal  to  them. 

Latent  Bacteria. — Sometimes  pathogenic  organisms  remain  latent  in  the 
body  for  a  considerable  time.  They  are  not  destroyed,  but  produce  no  symp- 
toms, or  only  local  symptoms,  possibly  because  the  individual  is  immune  for 
the  time  being.  Pneumococci,  staphylococci,  and  typhoid  bacilli  may  become 
latent.  Tubercle  bacilli  may  remain  long  latent  in  a  lymph-gland  or  in  any  old 
area  of  caseation.     Syphilis  may  remain  latent  for  a  long  time. 

Latent  bacteria  may  take  on  active  growth  when  the  tissue  containiiig 
them  is  damaged  by  injury  or  disease.  I  have  seen  active  disease  arise  in 
an  apparently  cured  and  stiff  tuberculous  joint  as  a  result  of  forcibly  breaking 
up  adhesions.  An  attack  of  bronchitis  may  light  up  an  old  and  latent  area  of 
pulmonary  tuberculosis.  The  administration  of  ether  or  chloroform  by  in- 
halation may  render  active  a  previously  inactive  tuberculous  focus  in  the  lung. 
A  partial  or  incomplete  operation  on  a  quiescent  tuberculous  lesion  is  apt  to  be 
followed  by  active  spread  and  may  result  in  wide  dissemination  of  disease. 
It  has  been  shown  by  Rosenow  that  strains  of  streptococci  may  inhabit  the 
tonsils,  the  gall-bladder,  the  appendix,  the  tooth  sockets  and  gums^  and  other 
tissues  and  that  at  any  time  these  streptococci  may  inaugurate  disease  in  a 


28  Bacteriology 

distant  tissue  or  organ.  Billings,  in  his  work  upon  focal  infections  refers  to- 
Rosenow's  demonstration  of  streptococci  which  inhabit  the  gall-bladder  be- 
coming the  cause  of  acute  myocarditis.  It  is  a  fact  that  dilatation  of  the  heart 
with  acute  myocarditis  may  follow  an  abdominal  operation,  the  shock  and 
trauma. of  the  operation  being  apparently  responsible  for  the  transportation 
of  the  bacteria  (E.  A.  Vander  Veer,  '"Annals  of  Surgery,"  Sept.,  191 7). 

Mixed  Infection. — A  fact  of  practical  importance  to  the  surgeon  is  that 
an  area  infected  by  one  form  of  micro-organism  may  be  invaded  by  another 
form.  This  is  known  as  a  mixed  infection,  and  consists  in  a  primary  infection 
with  one  variety  of  organism,  and  a  secondary  infection  with  another,  or  in  an 
infection  at  the  same  time  with  different  micro-organisms.  Mixed  infection 
is  especially  common  on  surfaces  exposed  to  air  and  wound  infection  is  usually 
mixed.  Koch  found  both  bacilli  and  micrococci  in  the  same  lesion  of  tuber- 
culosis. A  soil  filled  with  pneumococci  favors  the  growth  of  pus  cocci  and 
tubercle  bacilli.  Tuberculous  or  s}'philitic  lesions  may  be  attacked  by  erysipelas. 
Chancre  and  chancroid  can  exist  together.  A  syphilitic  ulcer  is  a  good  culture- 
soil  for  tubercle  bacilli  (Schnitzler).  Suppuration  in  lesions  of  tuberculosis- 
is  due  to  secondary  infection  with  pus  organisms.  Diphtheria  may  be  associated 
with  streptococcic  infection.  Diphtheria  and  scarlatina  may  exist  at  the  same 
time.  So  may  pneumococcic  pneumonia  and  t\^hoid  fever.  Occasionally 
in  empyema  and  other  conditions  due  to  pus  organisms  the  diseased  process 
ceases  to  be  active,  the  pyogenic  bacteria  having  lost  much  of  their  virulence, 
but  a  mixed  infection  with  some  germ  usually  harmless  may  break  dowm  sur- 
rounding barriers,  intensify  the  virulence  of  bacteria,  and  aggravate  the  disease 
into  an  acute  outburst.  The  French  call  the  germs  of  such  a  secondary  in- 
fection accomplices.  When  secondary  infection  occurs  the  primary  infection 
may  remain  as  before,  may  be  aggravated,  may  be  mitigated  in  intensity, 
may  be  destroyed,  or  may  be  disseminated. 

Intra=uterine  or  Placental  Infection. — The  infection  of  the  embryo 
from  the  diseased  ovum  or  the  diseased  sperm-cell  occurs,  if  it  occurs  at  all, 
in  syphilis  and  tuberculosis  only.  Bacteriologists  regard  seminal  transmission 
as  extremely  improbable  in  tuberculosis.  If  seminal  transmission  should  take 
place  the  embryo  would  be  diseased  at  the  first  moment  of  life.  The  direct 
transmission  of  bacteria  from  parent  to  fetus  is  a  problem  still  in  course  of 
solution.  Certain  it  is  that  some  diseases  may  follow  the  transmission  of  the 
micro-organism  through  the  septum  of  separation  between  the  circulations 
of  the  mother  and  child.  Placental  transmission  may  occur  in  syphilis,  scar- 
latina, pneumonia,  anthrax,  measles,  pyogenic  conditions,  and  tuberculosis 
(Hektoen).  A  child  born  of  a  woman  recently  the  subject  of  pneumonia  may 
be  born  with  that  disease,  and  a  child  may  be  born  with  pneumonia  when  the 
mother  has  never  had  it.  Mothers  free  from  infectious  disease  may  give  birth 
to  infected  children.  It  is  stated  that  Francois  Mauriceau  (a  noted  Parisian 
obstetrician  of  the  17th  century)  was  born  with  small-pox,  though  his  mother 
had  never  had  a  sign  of  the  disease.  Few  cases  of  congenital  tuberculosis 
have  been  reported,  but  Rosenberger  claims  to  have  found  the  bacilli  in  the 
umbilical  vein  from  the  placenta  of  a  tuberculous  mother.  A  child  of  a 
tuberculous  parent  may  not  be  born  tuberculous,  but  may  have  weakened 
tissue-cells  that  easily  fall  a  prey  to  the  tubercle  bacillus  when  it  reaches  them 
by  any  avenue.  Placental  transmission  of  bacteria  is  favored  by  disease  or 
injury  of  the  placenta. 

Chemical  Antiseptics  and  Germicides  and  Aseptic  Agents. — It  is 
necessary  to  make  a  distinction  between  deodorizers,  antiseptics,  and  germi- 
cides, although  the  two  latter  terms  are  usually  regarded  as  being  interchang- 
able.     In  the  methods  of  antiseptic  surgery  we  use  germicides. 

A  deodorizer  is  an  agent  which  destroys  an  offensive  odor.  It  is  true  that 
an  offensive  odor  may  be  due  to  microbic  growth.     It  is  also  true  that  nasty 


Corrosive  Sublimate  29 

odors  may  prove  injurious  to  those  who  inhale  them.  But,  nevertheless,  the 
odor  is  the  result  of  microbic  action,  and  destroying  an  odor  does  not 
render  harmless  the  bacteria  which  caused  it.  Charcoal  is  a  well-known 
•deodorizer. 

An  antiseptic  is  an  agent  which  retards  or  prevents  putrefaction.  It  acts 
by  weakening  or  killing  saprophytic  organisms,  but  is  not  fatal  to  spores. 

A  germicide  or  disinfectant  is  an  agent  which  is  fatal  to  adult  bacteria 
and  spores.  The  destruction  of  the  germs  of  disease  on  the  skin,  in  clothing, 
in  excreta,  in  a  wound,  etc.,  is  known  as  disinfection.  Disinfection  of  the  skin, 
■of  a  wound,  of  dressings,  or  of  instruments  is  called  also  sterilization. 

Antiseptics  and  germicides  should  not  be  used  in  surgically  clean  wounds. 
Repair  will  occur  more  quickly  if  they  are  not  used.  Tillmanns  has  pointed 
out  that  when  antiseptics  are  used  cell-division  begins  late  and  progresses 
rslowly.  Germicides  are  not  efi&cient  in  fatty  tissue,  as  bacteria  surrounded 
with  oil  cannot  be  reached  by  the  drug,  and  the  chemical  is  irritant  and  apt 
to  induce  fat  necrosis  (Haenel,  in  "Deutsch.  med.  Woch.,"  1895,  No.  8). 

There  is  no  known  germicide  not  sufficiently  strong  to  destroy  tissue  which 
can  produce  immediate  sterilization  of  an  extensive  area  of  infected  tissue 
(see  Makins  in  "Lancet,"  Feb.  17,  1917).  The  chemical  can  sterilize  the  sur- 
iaces  of  the  wound  and  the  tissue  cavity  only.  It  cannot  enter  deeply  into  the 
infected  tissues.  It  may  destroy  contamination  but  cannot  abolish  infection. 
Chemical  germicides  are  of  great  use  in  contaminated  wounds  and  are  of  value 
in  infected  wounds.  They  wash  away  many  bacteria,  lessen  the  danger  of  toxin 
absorption  under  pressure  and  save  prolonged  suppuration  (Makins,  "Ibid."). 
The  enormous  experience  gained  in  the  war  proves  anew  what  was  well  known 
to  LordLister,  that  immediate  and  complete  disinfection  of  a  wound  is  impossible. 
That  eminent  surgeon  is  quoted  by  Makins  ("Lancet,  Ibid.")  from  Virchow's 
Festschrift  (i8gi,  II)  as  follows:  "If,  for  example,  a  pair  of  forceps  is  handed  to 
the  operator  with  the  intervals  between  the  teeth  occupied  by  dry  septic  pus, 
and  a  portion  of  this  dirt  becomes  detached  and  left  in  the  wound,  the  evil 
cannot  be  corrected  by  any  antiseptic  wash  that  is  now  at  our  disposal  or 
that  the  world  is  ever  likely  to  see."  The  vital  resistance  and  the  vital  re- 
sistance alone  can  save  the  deeper  tissues,- even  if  the  bacteria  are  being  gradually 
■destroyed  by  keeping  the  wound  full  of  Dakin's  fluid.  Furthermore  it  has  been 
pointed  out  that  "  the  power  of  an  antiseptic  to  kill  organisms  is  not  the  same  for 
.all  organisms"  (comment  in  "Lancet,"  Feb.  24,  191 7,  on  the  observations  of 
Kenneth  Taylor).  Taylor  made  his  studies  on  chronically  infected  wounds  and 
•concludes  that  eventually  a  specific  dressing  will  be  used  for  each  form  of  in- 
fection. In  mixed  infections  one  variety  of  bacteria  and  then  another  could  be 
gradually  destroyed. 

Taylor  cited  the  action  of  quinin  solution  used  for  dressing  in  causing  the 
disappearance  of  gas  bacilli  (it  being  the  only  agent  that  seemed  to  do  so)  yet 
quinin  has  very  slight  effect  upon  staphylococcus.  The  experience  of  Carrel  and 
Dakin,  experience  which  has  been  confirmed  by  numerous  surgeons,  shows  that 
by  keeping  a  wound  open  and  constantly  full  of  a  germicidal  fluid  it  is  possible 
to  sterilize  a  wound  or  a  suppurating  focus  in  the  course  of  several  or  many 
days.  The  bacteria  are  estimated  at  intervals  by  a  study  of  smears.  When 
the  bacteria  have  almost  entirely  disappeared  the  wound  may  be  closed  by 
:sutures  (see  Dakin's  fluid,  page  334). 

Corrosive  Sublimate. — Many  chemical  agents  will  kill  bacteria,  one  of 
the  most  popular  of  them  all  being  corrosive  sublimate.  Koch  showed  that 
corrosive  sublimate  is  an  efficient  test-tube  germicide  when  present  in  the 
proportion  of  only  i  part  to  50,000.  It  is  used  in  surgery  in  strengths  of  i  part 
of  the  salt  to  1000,  2000,  3000,  or  more  parts  of  water.  It  used  to  be  a 
■custom  to  irrigate  badly  infected  wounds  with  solutions  of  a  strength  of  i  :  500. 
•Contact  with  albumin  precipitates  from  a  solution  of  corrosive  sublimate  an 


30  Bacteriology 

insoluble  albuminate  of  mercury  which  forms  a  white  layer  upon  the  surface 
of  the  wound,  is  not  a  germicide,  and  prevents  deep  diffusion  of  the  mercurial 
fluid.  In  surgical  operations  by  the  antiseptic  method  the  mercurial  salt 
should  be  combined  with  tartaric  acid  in  the  proportion  of  i  to  5,  which  com- 
bination prevents  the  formation  of  the  insoluble  albuminate  of  mercury. 

But  though  corrosive  sublimate  under  certain  conditions  is  extremely  pow- 
erful, it  is  not  absolutely  reliable.  Many  spores  are  very  resistant  to  its 
action.  Even  a  i  per  cent,  solution  of  bichlorid  of  mercury  is  not  certainly 
destructive  to  the  spores  of  anthrax.  Geppert  tells  us  that  anthrax  spores 
may  be  active  after  a  twenty-five-hour  immersion  in  a  i  :  100  solution  of  sub- 
limate (Schimmelbusch).  In  the  presence  of  hydrogen  sulphid  corrosive  sub- 
limate is  useless,  inert  insoluble  sulphid  of  mercury  being  precipitated;  hence 
corrosive  sublimate  is  without  value  as  a  rectal  antiseptic;  in  fact,  Gerloczy 
has  proved  that  a  concentrated  aqueous  solution  of  sublimate  will  not  disinfect 
an  equal  quantity  of  feces.  Corrosive  sublimate  contained  in  dressings  after 
a  time  undergoes  decomposition  and  ceases  to  be  a  germicide.  It  is  not  germi- 
cidal in  fatty  tissues  because  it  is  unable  to  attack  bacteria  which  are  coated 
with  oil.  Corrosive  sublimate  is  very  irritating  to  the  tissues  and  causes 
copious  exudation.  Hence,  if  an  extensive  wound  has  been  irrigated  with  this 
agent,  drainage  must  be  employed  to  secure  exit  for  the  wound  fluid.  In 
some  wounds  which  have  been  irritated  by  corrosive  sublimate  the  tissues 
seem  to  lose  to  a  great  extent  their  power  of  resistance  to  bacteria  and  infection 
may  be  actually  facilitated  by  irrigation  with  bichlorid  of  mercury.  In  rare 
instances  corrosive  subhmate  is  absorbed  and  produces  poisoning.  In  spite  of 
these  shortcomings  and  drawbacks  it  is  a  valuable  aid  to  the  surgeon  and  is 
very  frequently  used,  especially  upon  the  skin  of  the  patient  and  the  hands  of 
the  operator  and  his  assistants.  It  should  be  dissolved  in  distilled  water. 
Ordinary  water  causes  a  precipitate  to  form  (common  salt  prevents  the  forma- 
tion of  this  precipitate). 

Because  of  the  fact  that  corrosive  sublimate  is  poisonous  and  very  irritant, 
it  should  not  be  used  upon  serous  membranes.  It  is  absorbed  quickly  from 
serous  membranes  and  destroys  the  endotheHal  cells  and  should  not  be  in- 
troduced into  the  pleural  sac,  into  joints,  or  into  the  peritoneal  cavity.  It 
should  never  be  put  within  the  dura,  and  should  not  be  applied,  in  strong  solu- 
tion at  least,  to  mucous  membranes.  It  should  not  be  introduced  into  the 
rectum  for  three  reasons:  First,  it  is  intensely  irritant  and  causes  pain  and 
inflammation.  Second,  it  is  useless,  being  largely  and  promptly  converted  into 
insoluble  and  inert  sulphid  of  mercury.  Third,  a  poisonous  dose  may  be 
absorbed.  Instruments  cannot  be  placed  in  corrosive  subhmate  without  being 
dulled,  stained,  and  corroded.  It  is  better  to  make  the  solution  at  the  time  it  is 
needed,  so  as  to  have  it  fresh,  for  in  old  solutions  much  of  the  soluble  corrosive 
subhmate  has  been  converted  into  insoluble  oxychlorid  of  mercury,  and  the  fluid 
has  ceased  to  be  germicidal.  In  order  to  make  up  fresh  solutions  use  tablets, 
each  of  which  contains  about  7H  grains  of  the  drug— one  of  these  tablets  added 
to  a  pint  of  water  makes  a  solution  of  a  strength  of  i  :  1000.  Tablets  which 
also  contain  ammonium  chlorid  are  more  soluble  than  those  which  contain 
corrosive  sublimate  only.  Hot  solutions  of  the  drug  are  more  powerfully 
germicidal  than  cold  solutions.  As  corrosive  sublimate  is  irritant,  leads  to 
profuse  exudation,  and  may  produce  tissue  necrosis,  it  should  never  be  in- 
troduced into  an  aseptic  wound.  In  such  a  wound  it  can  do  no  good  and  may 
do  much  harm. 

Griffin,  in  Foster's  "Practical  Therapeutics,"  sets  forth  the  strengths  of 
solutions  applicable  to  different  regions: 

For  disinfection  of  the  surgeon's  hands  and  the  patient's  skin,  i  :  1000; 
for  irrigating  trivial  wounds,  i  :  2000;  for  irrigating  larger  wounds  and  cavi- 
ties,  I  :  10,000  to  I  :  5000;  for  irrigating  vagina,   i  :  10,000  to   i  :  5000;  for 


Carbolic  Acid  31 

irrigating  urethra,  i  :  40,000  to  i  :  20,000;  for  irrigating  conjunctiva,  i  :  5000; 
for  gargling,  I  :  10,000  to  i  :  5000. 

Corrosive  Sublimate  Poisoning. — Corrosive  sublimate  may  be  absorbed 
from  a  wound,  a  serous  surface,  or  a  mucous  membrane,  ptyalism  and  diar- 
rhea resulting.  The  absorption  of  bichlorid  of  mercury  may  be  followed  by 
cramp  in  the  limbs  and  belly,  feeble  pulse,  cold  skin,  extreme  restlessness,  and 
even  collapse  and  death.  At  the  first  sign  of  trouble  withdraw  the  drug  and 
treat  the  ptyalism  (see  page  389). 

Lithiomercuric  lodid. — This  material  was  prepared  and  tested  by  Dr. 
Rosenberger  and  Mr.  England  ("American  Medicine,"  1904,  page  102 1).  It  is 
asserted  that  the  iodid  of  mercury  with  lithium  is  more  powerfully  germicidal 
than  corrosive  sublimate,  does  not  form  inert  albuminate  when  placed  in  a 
wound,  and  is  not  precipitated  by  alkalis.  It  is  not  nearly  so  irritant  nor  is 
it  so  poisonous  as  corrosive  sublimate.  I  have  given  it  an  extensive  trial  in 
my  clinic  and  am  satisfied  that  it  is  superior  to  corrosive  sublimate  as  a  germi- 
cide, is  less  irritant,  and  is  less  poisonous.  Its  only  objection  is  that  it  is 
more  expensive. 

Harrington's  Solution. — Harrington  utilized  the  known  fact  that  an  alcoholic 
solution  of  mercury  is  more  powerfully  germicidal  than  an  aqueous  solution  and 
pointed  out  that  the  solution  by  acidulation  becomes  still  more  powerful.  His 
solution  consists  of  0.8  grams  of  corrosive  sublimate — 60  grams  of  hydrochloric 
acid — 300  grams  of  distilled  water  and  640  grams  of  alcohol. 

Carbolic  acid  is  a  valuable  germicide  in  the  strength  of  from  i  :  40  to  i  :  20. 
It  is  certainly  fatal  to  pus-organisms,  but  weak  solutions  fail  to  kill  most  bac- 
teria and  do  not  destroy  spores.  Unfortunately,  this  acid  attacks  the  hands  of 
the  surgeon;  consequently  in  the  United  States  dilute  carbolic  acid  is  chiefly 
employed  as  a  solution  in  which  to  place  the  sterilized  operating  instruments, 
or  as  a  germicide  to  prepare  the  skin  of  the  patient  before  the  operation  is  per- 
formed. 

Carbolic  acid  is  very  irritant  to  tissues,  and  carbolized  dressings  may  be 
responsible  for  sloughing  of  the  wound  or  dry  gangrene  (see  page  200).  Because 
of  its  irritant  properties  wounds  which  have  been  irrigated  with  it  should  be 
well  drained.     Carbolic  acid,  like  corrosive  sublimate,  is  inert  in  fatty  tissues. 

Pure  carbolic  acid  is  a  very  useful  disinfectant  for  certain  conditions.  It  is 
used  to  destroy  chancroids;  in  attempts  to  disinfect  infected  wounds,  abscess 
cavities,  medullary  cavities  attacked  by  osteomyelitis,  sloughing  burns  and 
ulcerated  areas;  and  to  stimulate  the  formation  of  granulations  after  the  per- 
formance of  the  open  operation  for  hydrocele.  Even  pure  carbolic  acid  fails 
to  disinfect  extensive  wounds  from  shrapnel  or  shell  fragments.  The  pure  acid 
rarely  produces  constitutional  symptoms,  but  it  occasionally  causes  sloughing. 
Its  application  causes  pain  for  a  moment  only,  and  then  analgesia  ensues. 
Even  dilute  solutions  of  carbolic  acid  greatly  relieve  pain  when  applied  to  raw 
surfaces.  The  local  action  of  carbolic  acid  can  be  at  once  antidoted  by  the 
application  of  alcohol  (Seneca  D.  Powell).  When  carbolic  acid  is  applied 
to  a  wound,  the  area  about  the  wound  should  first  be  moistened  with  alcohol. 
After  the  application  of  pure  carbolic  acid  to  the  interior  of  a  joint,  a  wound, 
the  medullary  canal,  or  an  infected  area  the  surgeon  should  wait  about  one 
minute  and  then  apply  alcohol. 

Dilute  carbolic  acid  acts  more  slowly  and  less  certainly  than  corrosive  sub- 
limate. It  requires  twenty-four  hours  for  a  5  per  cent,  solution  to  kill  anthrax 
spores.  Pus  or  blood  (albuminous  matter)  greatly  weakens  the  germicidal 
power  of  carbolic  acid,  and  fatty  tissue  cannot  be  disinfected  by  it.  It  is  not 
even  the  best  of  agents  in  which  to  place  instruments,  as  it  dulls  them.  After 
operation  upon  the  mouth  it  may  be  used  as  a  wash  or  gargle,  i  to  2  per  cent, 
being  a  suitable  strength.  It  is  used  sometimes  to  irrigate  the  bladder  and 
often   to  cleanse  sinuses,  but  is  not  employed  in  the  peritoneal  cavity,  the 


32  Bacteriology 

pleural  sac,  the  rectum,  or  the  brain.  It  is  occasionally  injected  into  tubercu- 
lous joints.     Carbolic  solution  should  never  be  used  in  clean  wounds. 

Carbolic  Acid  Poisoning. — Carbolic  acid  is  readily  absorbed,  and  may  thus 
produce  toxic  symptoms.  Absorption  is  not  uncommon  when  the  weaker 
solutions  are  used,  but  seldom  occurs  when  a  wound  has  been  brushed  over 
with  pure  acid,  because  the  pure  acid  at  once  forms  an  extensive  zone  of  coagu- 
lated albumin,  which  acts  as  a  barrier  to  absorption.  One  of  the  early  indi- 
cations of  the  absorption  of  carbolic  acid  is  the  assumption  by  the  urine  of  a 
smoky,  greenish,  or  blackish  hue.  This  hue  appears  a  little  time  after  the  urine 
has  been  voided,  whereas  the  smoky  hue  of  hematuria  is  noted  in  urine  at  once 
after  it  has  been  passed.  The  condition  produced  by  carbolic  acid  is  known  as 
carboluria,  and  examination  of  such  urine  shows  a  great  diminution  or  entire 
absence  of  sulphates  when  the  acidulated  urine  is  heated  with  chlorid  of  barium. 
The  diminution  of  precipitable  sulphates  is  explained  by  the  fact  that  these 
salts  are  combined  with  carbolic  acid,  forming  soluble  sulphocarbolates.  Such 
urine  is  apt  to  contain  albumin.  If  during  the  use  of  carbolized  dressing 
or  the  employment  of  carbolic  solutions  the  urine  becomes  smoky,  the  use  of 
the  drug  in  any  form  must  be  at  once  discontinued,  otherwise  dangerous  symp- 
toms will  soon  appear.  These  symptoms  are  subnormal  temperature,  feeble 
pulse  and  respiration,  muscular  weakness,  and  vertigo.  If  death  occurs, 
it  is  due,  as  a  rule,  to  respiratory  failure.  The  treatment  of  slow  poisoning 
by  carbolic  acid  consists  in  at  once  withdrawing  the  drug,  giving  stimulants 
and  nourishing  food,  administering  sulphate  of  sodium  several  times  a  day, 
and  atropin  in  the  morning  and  evening.  (For  Carbolic  Acid  Gangrene,  see 
page  200.) 

Boric  Acid. — This  drug  is  a  very  mild  antiseptic.  It  is  used  to  dust  wounds. 
A  solution  of  it  is  used  to  irrigate  wounds  and  as  the  fluid  for  hot  antiseptic 
fomentations.     The  solution  should  be  concentrated. 

Acetate  of  Aluminum. — This  is  a  mild  antiseptic,  useful  as  a  constituent 
of  irrigating  fluids  and  of  hot  fomentations.  Its  prolonged  use  hardens  the 
tissues.     A  strength  of  i  or  2  per  cent,  is  employed. 

Saline  Solution. — Sodium  chlorid  solution  of  normal  strength  (0.9  of  i 
per  cent.)  does  not  damage  the  cells  of  serous  surfaces  or  of  a  wound,  hence 
it  is  used  as  an  irrigating  fluid,  and  it  is  the  best  fluid  for  such  a  purpose.  In 
intravenous  infusion,  in  shock,  or  hemorrhage  it  is  very  valuable.  It  does  not 
damage  the  blood-corpuscles  as  plain  water  does.  It  is,  however,  irritant  to 
the  kidneys  when  used  by  hx-podermoclysis  or  intravenous  infusion;  hence 
if  the  kidneys  are  diseased  saline  fluid  of  one-half  normal  strength  should  be 
used  for  either  of  the  latter  purposes.  Normal  salt  solution  is  prepared  as 
follows:  A  quart  of  water  is  filtered  and  sterilized  and  in  this  2  teaspoonfuls 
of  table  salt  are  dissolved,  and  the  fluid  is  again  boiled  fsee  pages  536  and  537). 

Thiersch's  Fluid. — This  fluid  is  used  upon  mucous  and  serous  surfaces 
and  is  employed  to  irrigate  wounds.  It  is  non-toxic  and  non-irritant.  It 
consists  of  I  gr.  of  salicylic  acid  and  6  gr.  of  boric  acid  to  i  oz.  of  sterile  water. 

Alcohol  is  a  germicidal  agent,  which  is  most  powerful  when  of  the  strength 
of  70  per  cent.  It  may  be  used  on  the  hands  of  the  surgeon  or  the  skin  of  the 
patient  in  a  strength  of  70  per  cent,  and  may  be  used  plain  or  mixed  with  cor- 
rosive sublimate,  of  the  strength  of  i  part  of  corrosive  to  1000  parts  of  alcohol. 
Pure  alcohol  is  used  to  arrest  the  local  action  of  pure  carbolic  acid. 

Boiled  water  is  used  to  dissolve  antiseptic  materials;  to  inject  by  h^-po- 
dermoclysis;  to  irrigate  wounds,  mucous  cavities  or  serous  surfaces,  and  as  a 
fluid  in  which  to  keep  instruments  during  the  operation.  It  damages  somewhat 
the  tissue-cells  of  the  surface  of  a  wound  and  injures  the  cells  of  serous  surfaces, 
hence  for  irrigation  and  h\-podermoclysis  salt  solution  is  to  be  preferred. 

Creolin,  which  is  a  preparation  made  by  the  dry  distillation  of  English  coal, 
is  a  germicide  wathout  irritant  or  powerful  toxic  effects.     It  is  less  powerful 


Iodoform  33 

than  carbolic  acid,  but  acts  similarly.  It  is  not  soluble  in  water,  but  is  used 
in  emulsion  of  a  strength  of  from  i  to  5  per  cent.  It  does  not  irritate  the  skin 
like  carbolic  acid. 

Peroxid  or  dioxid  of  hydrogen  is  an  excellent  agent  for  cleansing  a  purulent 
or  putrid  area,  but  it  is  never  appUed  to  a  sterile  wound.  It  is  prepared  in  a 
ID-volume  solution,  which  should,  be  diluted  one-half  to  two-thirds  before  using. 
A  30  per  cent,  solution  is  known  as  perhydrol.  It  probably  destroys  the  al- 
buminous element  upon  which  bacteria  live,  and  thus  starves  the  fungi.  When 
peroxid  of  hydrogen  is  applied  to  a  purulent  area  ebulHtion  occurs,  liberated 
oxygen  bubbling  up  through  the  fluid  and  the  pus  being  oxidized.  The  per- 
oxid reaches  every  cranny  and  diverticulum  containing  pus.  The  peroxid 
of  hydrogen  is  not  fatal  to  tetanus  bacilU;  in  fact,  tetanus  bacilli  can  be  culti- 
vated in  a  strong  solution  of  it.  It  is  very  valuable  as  a  mouth- wash  to  cleanse 
the  mouth  before  and  after  operations  in  the  oral  cavity.  Some  surgeons  use 
it  to  wash  out  appendicular  abscesses  (R.  T.  Morris).  It  must  not  be  injected 
into  a  deep  abscess  in  any  region  unless  a  large  opening  exists,  as  otherwise  the 
evolved  gas  may  tear  apart  structures,  dissect  up  the  cellular  tissue,  and  spread 
infection.  The  use  of  peroxid  should  not  be  too  long  continued,  for  if  used  for 
a  considerable  period  it  makes  the  granulations  edematous  and  retards  healing. 
In  fact,  its  daily  use  for  some  time  may  actually  prevent  a  sinus  closing. 

Iodoform  is  largely  used  by  surgeons  in  spite  of  the  fact  that  laboratory 
workers  have  assured  us  it  is  not  truly  a  germicide,  as  bacteria  will  grow  upon 
it.  Clinical  evidence,  however,  is  in  its  favor  and  surgeons  long  ago  concluded 
that  it  at  least  hinders  the  development  of  bacteria,  directly  antagonizes  the 
action  of  the  toxic  products  of  germ-life,  and  stimulates  the  production  of 
connective  tissue.  It  is  of  the  greatest  value  when  applied  to  putrid  foci, 
suppurating  areas,  and  tuberculous  processes.  In  putrid  foci  it  probably 
combines  with  toxins  and  renders  them  less  poisonous  or  even  inert. 

It  attenuates  the  virulence  of  pus  cocci  and  organisms  of  putrefaction.  It 
renders  its  greatest  service  in  tuberculous  processes  and  is  infinitely  more 
powerful  when  oxygen  is  excluded  than  when  it  is  present.  The  laboratory 
workers  who  condemn  it  have  in  many  cases  used  nutrient  material  in  which 
it  does  not  dissolve  (P.  F.  Lomry,  "Archiv  fiir  klin.  Chir.,"  1896).  D.  B. 
Heile  ("Proceedings  of  the  German  Surgical  Congress  of  1903")  insists  that 
iodoform  is  a  valuable  germicide  if  oxygen  is  excluded.  He  says,  if  iodoform 
is  mixed  with  tissue  juice,  oxygen  being  excluded,  the  mixture,  in  from  three  to 
five  days,  becomes  powerfully  germicidal,  even  to  streptococci,  although,  as  he 
maintains,  neither  constituent  of  the  mixture  when  alone  is  germicidal.  Tissue 
juice  decomposes  iodoform,  liver  juice  decomposing  it  most  rapidly,  brain  and 
fat  decomposing  it  slowly.  Granulation  tissue  decomposes  it  and  tuberculous 
granulation  tissue  acts  upon  it  most  rapidly. 

The  conclusion  of  Heile  is  that  this  study  confirms  the  clinical  observation 
that  iodoform  is  valuable  in  cavities,  but  not  on  free  surfaces.  My  own  belief 
is  that  it  is  more  valuable  in  cavities  than  upon  free  surfaces,  but  when  we  are 
dealing  with  putrefactive  areas,  even  on  free  surfaces,  it  is  of  real  value. 
When  iodoform  decomposes  on  a  free  surface  it  sets  free  I,  which  we  now  know 
is  a  powerful  germicide.  When  it  decomposes  in  tissue  juice  Heile  says  it 
forms  a  powerful  germicide  which  is  rendered  inert  by  oxygen.  Clinically, 
no  real  substitute  for  iodoform  has  yet  been  found.  It  can  be  rendered  sterile 
by  several  washings  with  a  solution  of  corrosive  sublimate.  It  need  not  be 
applied  to  clean  wounds,  but  the  powder  is  very  useful  when  dusted  into  infected 
wounds.  It  prevents  wound  discharges  from  decomposing  and  distinctly  allays 
pain.  Gauze  impregnated  with  iodoform  is  used  to  keep  abscesses  open  after 
evacuation,  to  drain  the  belly  after  certain  operations,  to  pack  aside  the  intes- 
tines and  prevent  their  infection  during  some  abdominal  operations,  and  as 
packing  to  arrest  intracranial  hemorrhage.     Iodoform  gauze  will  drain  serum 


34  Bacteriology 

well,  but  will  not  drain  pus.  In  fact,  it  blocks  up  a  pus-cavity,  and  if  long  re- 
tained leads  to  the  collection  of  purulent  matter  behind  and  about  the  supposed 
drain.  If  used  in  an  abscess,  it  must  be  replaced  in  twenty-four  or  thirty-six 
hours.  Tuberculous  joints  and  cold  abscesses  are  injected  with  iodoform  emul- 
sion, which  is  made  by  adding  the  drug  to  sterile  glycerin  or  oliv^e  oil.  The 
emulsion  contains  from  4  to  lo  per  cent,  of  iodoform.  Dunham's  iodoform 
emulsion  is  valuable  in  suppurating  cavities  ("Annals  of  Surgery,"  May,  1909). 
In  order  to  prepare  it  he  adds  to  100  c.c.  of  glycerin,  i  gm.  of  iodin,  and  i  gm.  of 
iodid  of  potassium,  sets  the  mixture  in  an  Arnold  sterilizer,  and  boils  the  fluid 
in  the  sterilizer.  By  shaking  the  mixture  the  iodin  goes  into  solution  in  the 
glycerin.  When  the  mbcture  cools,  10  gm.  of  iodoform  are  added  and  ground 
into  the  mixture  by  use  of  a  sterile  mortar.  A  solution  of  iodoform  in  ether  of  a 
strength  of  10  per  cent,  may  be  used  to  inject  the  cavity  of  a  cold  abscess,  but  it 
is  dangerous,  may  rupture  the  wall,  and  is  more  apt  to  produce  poisoning  than  is. 
the  emulsion.     Iodoform  wax  is  used  to  fill  cavities  in  bone  (see  page  574). 

lodoform-poisoning. — The  drug  must  be  used  with  some  caution.  Ab- 
sorption from  a  wound  sometimes  happens,  producing  toxic  symptoms.  These 
symptoms  are  frequently  misinterpreted,  being  usually  attributed  to  infec- 
tion. R.  T.  Morris  has  pointed  out  that  in  iodoform-poisoning  the  wound 
seems  to  be  in  excellent  condition,  whereas  in  sepsis  the  wound  appears  un- 
healthy. The  symptoms  in  some  cases  are  acute  and  arise  suddenly,  and  con- 
sist of  hallucinatory  delirium,  nausea,  fever,  watery  eyes,  contracted  pupils, 
metallic  taste  in  the  mouth,  yellowness  of  the  skin  and  eyes,  an  odor  of  iodoform 
upon  the  breath,  the  presence  of  the  drug  in  the  urine,  the  outbreak  of  a  skin 
eruption  resembling  measles  or  which  is  erythematous,  vesicular,  bullous, 
or  petechial.  There  is  often  nephritis  and  always  excessive  loss  of  flesh  and 
strength.  Patients  with  such  acute  symptoms  usually  pass  into  coma  and  die 
within  a  week.  Such  attacks  are  most  apt  to  arise  in  those  beyond  middle  life 
(see  Gerster  and  Lilienthal,  in  Foster's  "Practical  Therapeutics")-  Iodin  can 
be  recognized  in  urine  by  adding  a  few  drops  of  commercial  nitric  acid  and  a 
little  chloroform.  When  the  mixture  is  shaken  the  chloroform  will  take  up  the 
free  iodin  and  become  purple,  and  on  standing  the  purple  layer  will  settle  to  the 
bottom  of  the  tube.  Another  method  is  as  follows:  Put  a  small  amount  of  urine 
into  a  saucer,  add  a  little  calomel,  and  stir.  If  the  urine  contains  iodoform  a 
brown  color  will  be  noted  (R.  T.  Morris).  The  finding  of  iodin  in  the  urine, 
however,  is  not  proof  that  the  patient  is  poisoned.  We  may  find  it  when  no 
sign  of  poisoning  exists.  But  it  calls  for  the  removal  of  all  iodoform  gauze  as 
otherwise  symptoms  of  poisoning  will  probably  arise.  In  chronic  cases  of  iodo- 
form-poisoning the  first  symptoms  usually  observed  are  moroseness,  bewilder- 
ment, and  irritability,  followed  by  depression,  with  unsystematized  persecutory 
delusions,  delirium,  coma,  and  even  death. 

In  systematic  poisoning  by  iodoform,  discontinue  the  use  of  the  drug,  sus- 
tain the  strength  of  the  patient,  and  favor  the  elimination  of  the  poison. 

Iodoform  sometimes  produces  great  local  irritation  of  the  cutaneous  sur- 
face, the  dermatitis  being  eczematous  or  else  being  manifested  by  crops  of 
vesicles  filled  with  turbid  yellow  serum  or  even  bloody  serum.  These  vesicles 
rupture  and  expose  a  raw,  oozing  surface,  looking  not  unlike  a  burn.  The 
dermatitis  usually  exists  only  in  the  region  with  which  iodoform  was  in  con- 
tact, but  in  some  cases  it  spreads  widely.  The  use  of  the  drug  should  be 
abandoned  at  once.  To  continue  its  employment  would  not  only  increase  the 
dermatitis,  but  might  produce  constitutional  symptoms.  The  vesiculated  area 
should  be  washed  with  a  stream  of  normal  salt  solution  to  remove  iodoform,  each 
vesicle  should  be  opened,  and  the  part  should  be  dressed  for  several  days  with 
gauze  wet  with  normal  salt  solution.  After  acute  inflammation  has  ceased 
zinc  ointment  or  cosmolin  should  be  applied. 

Aristol  (thymol  iodid)  is  an  odorless  iodin  compound  used  by  some  as  an 


Silver  35 

antiseptic  dusting-powder.  It  is  less  toxic  but  less  powerful  than  iodoform. 
It  should  not  be  used  on  a  wound  or  ulcer  with  free  discharge  because  it  will 
increase  the  flow. 

Lbretin,  a  compound  of  cresol  and  iodin,  is  an  antiseptic  powder  which  is 
odorless,  germicidal,  non-irritant,  and  is  said  to  be  non-toxic. 

Euphoren  is  a  powder  containing  28  per  cent,  of  iodin,  and  the  iodin  separates 
from  it  slowly  when  the  powder  is  applied  to  wounds  or  burns.  It  does  not 
produce  toxic  symptoms  readily,  if  at  all,  and  is  a  valuable  substitute  for  iodo- 
form.    It  is  used  especially  in  the  treatment  of  ulcers  and  burns. 

Nosophen  is  a  pale-yellow  powder  containing  60  per  cent,  of  iodin.  It  is 
an  iodin  compound  of  phenolphthalein.  Its  sodium  salt  is  known  as  antinosin. 
Nosophen  is  not  toxic,  is  free  from  odor,  and  is  one  of  the  best  of  the  substi- 
tutes for  iodoform. 

Acetanilid  is  frequently  used  as  a  substitute  for  iodoform.  It  is  of  value 
when  applied  to  suppurating,  ulcerating,  or  sloughing  areas,  but  it  does  not 
benefit  tuberculous  conditions.  Sometimes  absorption  takes  place  to  a 
sufficient  extent  to  cause  cyanosis,  sweating,  and  weakness  of  the  pulse  and 
respiration.  If  cyanosis  arises,  suspend  the  administration  of  the  drug  and 
administer  stimulants  by  the  stomach. 

Dermatol  (subgallate  of  bismuth)  is  an  astringent  drying  powder.  Because 
of  its  astringency  it  must  not  be  used  on  an  indolent  wound  or  ulcer.  It  is  less 
toxic  and  less  powerful  than  iodoform  and  is  without  value  in  tuberculous 
processes. 

Airol  is  a  compound  of  bismuth  iodin  and  gallic  acid. 

Among  other  powders  we  may  mention  iodol,  amyloform,  and  subiodid  of 
bismuth. 

Silver  is  a  valuable  antiseptic.  Halsted  and  Bolton  have  shown  that 
metallic  silver  exerts  an  inhibitive  action  upon  the  growth  of  micro-organisms 
and  does  not  irritate  the  tissues.  Crede  has  also  demonstrated  the  same  facts. 
These  statements  indicate  one  great  reason  why  silver  wire  is  such  a  useful 
suture  material  (see  page  85).  Halsted  is  accustomed  to  place  silver  leaf  over 
wounds  after  they  have  been  sutured,  and  Crede  employs  as  a  dressing  a 
fabric  in  which  metallic  silver  is  intimately  incorporated. 

Silver  leaf  lessens  wound  secretion,  retards  exuberant  granulation  in  an  open 
wound,  hurries  cicatrization  and  minimizes  the  scar  (see  Lexer,  Abstracted  in 
"Surgery,  Gynecology  and  Obstetrics,"  Sept.,  1915). 

Dilute  solutions  of  nitrate  of  silver  are  used  in  cases  of  urethritis  and  cystitis 
for  their  germicidal  effects.  If  a  child  has  passed  through  an  infected  birth 
canal,  nitrate  of  silver  should  be  used  in  the  eyes.  Crede  uses  in  each  eye  two 
drops  of  a  2  per  cent,  solution.  This  is  dangerously  strong  and  may  cause  vio- 
lent conjunctivitis  (silver  catarrh),  bleeding  from  the  conjunctiva  and  haziness 
of  the  cornea.  A  strength  of  i  per  cent,  is  sufficient.  If  ophthalmia  neonatorum 
develops,  2  per  cent,  solutions  must  be  used. 

Crede  considers  silver  lactate  (actol)  an  admirable  antiseptic.  It  does 
not  form  an  insoluble  albuminate  when  introduced  into  the  tissues  and  is 
not  an  irritant.  Silver  citrate  (itrol)  is  said  to  be  even  a  better  preparation 
than  silver  lactate,  and  it  is  a  useful  dusting-powder.  A  preparation  of  metallic 
silver,  known  as  colloidal  silver-  or  collargolum,  is  made.  This  preparation 
is  soluble  in  water  and  in  albuminous  fluids.  It  is  said  to  remain  as  metallic 
silver  when  in  solution  and  to  be  powerfully  germicidal.  It  certainly  seems  to 
cause  temporary  leukocytosis,  but  so  do  some  other  drugs  which  are  not  an- 
tagonistic to  infections.  In  severe  cases  of  sepsis  some  advocate  injecting  this 
solution  into  a  vein.  I  have  never  seen  it  do  the  slightest  good  and  I  believe 
that  intravenous  injections  are  dangerous.  Some  have  given  it  subcutaneously, 
some  by  the  mouth,  others  by  enema.  Subcutaneous  injections  are  often  very 
irritant  and  it  is  doubtful  if  the  drug  is  absorbed  from  either  the  stomach  or 


36  Bacteriolofj;y 

rectum.  The  most  extraordinary  claims  have  been  put  forth  regarding  the  thera- 
peutic value  of  coUargolum.  Its  use  has  been  advocated  in  the  most  diverse 
general  infections.  I  believe  it  is  of  no  real  value.  Its  claims,  in  my  opinion, 
have  been  shattered  by  the  majority  report  of  the  committee  of  the  American 
Medical  Association  ("Jour.  Am.  Med.  Assoc,"  March  13,  1909).  Crede's 
ointment  of  silver,  I  believe,  is  of  use  in  infections  of  the  skin  and  lymphatic 
vessels.  I  have  used  it  repeatedly  in  such  cases.  In  a  child,  15  gr.,  in  an  adult, 
45  gr.  of  the  ointment  are  rubbed  into  the  skin  at  one  time,  and  the  rubbing 
should  be  kept  up  from  ten  to  thirty  minutes.  There  is  said  to  be  no  risk  of 
argyria.  Protargol  is  a  silver  salt  much  used  in  gonorrhea.  A  solution  in  water 
is  made.  The  drug  is  not  precipitated  by  albumin,  alkalis,  nor  acids.  In 
gonorrhea  a  i  to  5  per  cent,  solution  is  used.  To  prevent  ophthalmia  neonatorum 
a  10  per  cent,  solution  is  used.  Argyrol  is  a  new  and  valuable  preparation  of 
silver  which  I  have  used  frequently  with  much  satisfaction.  It  is  known  as 
silver  vitelline,  is  not  irritant,  and  contains  30  per  cent,  of  metallic  silver. 
It  is  not  precipitated  by  albumin.  In  a  strength  of  5  per  cent,  it  is  a  very 
useful  injection  for  gonorrhea,  as  it  has  powerful  gonococcidal  properties.  In 
some  types  of  chronic  cystitis  several  drams  of  a  3  per  cent,  solution  may  be 
injected  into  the  bladder  from  time  to  time,  and  much  stronger  solutions  can 
be  used  with  safety.  Inflamed  mucous  membranes  may  be  painted  with  a 
solution  of  a  strength  of  from  20  to  50  per  cent.  A  sinus  or  a  sluggish  area 
of  granulation  may  be  stimulated  by  touching  with  a  solution  of  a  strength  of 
from  25  to  50  per  cent.  I  have  found  it  of  much  service  in  sinuses.  Argyrol 
(10-25  pc^  cent.)  is  used  in  conjunctivitis.  A  25  per  cent,  solution  is  instilled 
in  the  eyes  of  a  child  which  has  passed  through  an  infected  canal  and  is  in 
danger  of  ophthalmia  neonatorum. 

Formaldehyd,  or  formic  aldehyd,  has  valuable  antiseptic  properties.  For- 
malin (liquor  formaldehydi)  is  a  37  per  cent,  solution  of  the  gas  in  water.  Solu- 
tions of  this  strength  cauterize  the  tissues,  but  i  per  cent,  solutions  can  be 
used  to  disinfect  wounds.  A  solution  of  a  strength  of  0.5  per  cent,  is  used  to 
irrigate  sinuses,  tuberculous  areas,  abscess  cavities,  and  suppurating  joints. 
A  strong  solution  is  used  to  asepticize  chancroids  and  other  ulcers.  A  2  per 
cent,  solution  disinfects  instruments.  The  vapor  of  formalin  has  been  tried  for 
the  disinfection  of  wounds.  Formic  aldehyd  gas  thoroughly  disinfects  catheters. 
Morestin  uses  equal  parts  of  formalin,  alcohol  and  glycerin  to  disinfect  infected 
wounds.  He  claims  that  it  is  of  value  in  gas  infection  and  gas  gangrene.  It 
causes  severe  pain  ("Bull,  et  mem.  Soc.  de  Chil.  de  Par.,  1915,  xli). 

Formalin-gelatin  was  introduced  by  Schleich  as  an  antiseptic  powder. 
The  commercial  preparation  is  known  as  glutol.  When  applied  to  a  clean 
wound  it  gives  off  formalin  and  keeps  the  wound  aseptic.  When  it  is  applied 
to  a  sloughing  surface  it  will  not  give  off  formalin  unless  it  is  mixed  with  pepsin 
and  hydrochloric  acid.     Formalin-gelatin  has  been  used  to  fill  bone  cavities. 

Hypochlorous  acid  is  a  powerful  wound  disinfectant.  Lorraine  Smith  and 
others  use  it  in  solution  of  a  strength  of  0.5  per  cent.,  and  in  a  powder  consisting 
of  equal  parts  of  bleaching  powder  and  boric  acid.  The  solution  is  called 
Eusol,  the  powder  Eupad. 

Lysol  is  a  clear,  brownish,  oily  fluid  with  an  odor  like  creasote.  It  is  a 
valuable  germicidal  agent.  It  is  saponified  phenol  and  is  used  in  a  solution 
of  a  strength  of  from  i  to  3  per  cent.  It  does  not  attack  the  hands  like  carbolic 
acid  and  is  much  less  poisonous. 

Mustard  is  an  excellent  emergency  germicide.  Its  value  was  demon- 
strated by  Roswell  Park,  who  used  a  mixture  of  soap,  cornmeal,  and  mus- 
tard flour  to  scrub  the  surgeon's  hands  or  the  patient's  skin.  I  have  used 
it  repeatedly  with  entire  satisfaction.  Mustard  removes  the  odor  of  decay  at 
once. 

Picric  acid  is  useful  in  suppurating  wounds.     T.  F.  Brown  ("Lancet,"  Sept.  2, 


D akin- Carrel-Dehelly-DeP age  Method  37 

1 91 6)  advocates  its  use  in  certain  cases.  He  syringes  suppurating  wounds  with 
0.5  to  I  per  cent,  solution.  When  granulations  reach  the  level  of  the  skin  use 
0.2  per  cent,  to  0.5  per  cent,  solution  as  the  skin  will  not  stand  the  i  per  cent, 
solution.  Gauze  containing  i  per  cent,  is  used  for  dressing.  This  drug  when 
so  used  is  not  toxic.  Brown  has  also  employed  it  in  erysipelas  using  a  0.2  per 
cent,  solution  in  alcohol  and  water  (i  part  alcohol  to  9  parts  water). 

Permanganate  of  Potassium.^ — This  chemical  is  a  powerful  oxidizer  and  is 
largely  used  as  an  antiseptic  and  deodorant.  It  is  used  to  irrigate  foul 
wounds,  ulcers,  putrid  purulent  areas,  and  to  disinfect  the  surgeon's  hands 
before  performance  of  an  operation.  A  saturated  solution  (i :  16)  is  used  upon 
the  hands  (page  72).  It  is  also  employed  for  irrigation  in  gonorrhea.  The 
usual  strength  being  1:4000  to  1:500.  To  disinfect  foul  ulcers  and  putrid 
areas  the  strength  should  be  from  i  to  5  grains  to  the  ounce  of  water. 

Whiting's  Solution. — Whiting  and  Slocum  ("Annals  of  Surgery,"  May,  1916) 
recommend  for  the  preparation  of  the  field  of  operation  a  solution  which  is  but 
slightly  irritant,  does  not  stain  the  skin  and  can  be  used  on  wet  or  dry  skin. 
It  consists  of  3  5  per  cent,  of  acetone,  2  per  cent,  of  phenoco  (a  coal  tar  disinfect- 
ant), and  enough  alcohol  to  make  100  per  cent.  The  skin  is  given  a  wet  or  dry 
shave  and  is  rubbed  for  two  minutes  with  gauze  saturated  in  the  solution.  I 
have  used  it  repeatedly  and  with  great  satisfaction. 

Acriflavine  and  Proflavine.^ — These  are  benzol  derivatives.  It  is  claimed 
that  blood  serum  does  not  destroy  the  bactericidal  power  of  these 
agents  but  increases  it  immensely.  At  first  the  materials  simply  inhibit 
bacterial  growth,  but  as  time  goes  on  they  become  more  and  more  bactericidal. 
These  qualities  make  frequent  change  of  dressings  unnecessary.  Two  applica- 
tions of  the  antiseptics  suffice.     Their  power  is  enhanced  by  blood  serum. 

Brilliant  Green. — This  benzol  derivative  in  the  presence  of  serum  soon  ceases 
to  be  germicidal,  hence  it  must  be  frequently  renewed.  It  is  not  poisonous  to 
the  body,  does  little  or  no  harm  to  the  tissues,  does  not  impair  phagocytosis 
and  is  a  powerful  germicide.     Hull  advocates  it. 

Commercial  gasolene,  used  by  Riordan  and  others  to  clean  wounds  and 
ulcers,  and  to  prepare  the  field  of  operation.  It  is  a  valuable  material.  It  cleans 
out  clot  and  removes  dirt  and  fragments  of  contaminated  fat.  Its  vapor  is  so 
inflammable  that  the  fluid  must  not  be  used  when  gas  or  lamp  light  is  necessary. 
It  is  used  only  in  the  daytime  or  in  a  room  lighted  by  electricity,  and  on  free 
surfaces  where  evaporation  is  rapid.  It  is  sterile,  non-irritant,  and  on  evapora- 
tion leaves  a  dry,  clean  surface.  The  surface  must  be  allowed  to  dry  before 
dressings  are  applied,  otherwise  blisters  will  form.  Gasolene  has  been  used  in 
this  war  to  cleanse  wounds.  It  removes  dirt,  blood  clot  and  portions  of  loose 
and  contaminated  fat. 

lodin. — This  drug  was  strongly  endorsed  by  the  late  Prof.  Nicholas  Senn 
("Surgery,  Gynecology,  and  Obstetrics,"  July,  1905).  Dressings  must  not  be 
applied  until  the  surface  is  dry  or  blisters  will  follow.  He  regarded  it  as  the 
most  powerful  and  the  safest  of  antiseptics,  and  claimed  that  in  solutions  of  a 
strength  of  only  i  per  cent,  it  is  non-irritant  and  causes  a  protective  phagocy- 
tosis. It  may  be  used  in  great  dilution  or  the  tincture  may  be  applied  to  an 
infected  wound  in  the  same  manner  as  is  pure  carbolic  acid ;  a  method  advocated 
by  Carl  Beck.  In  dilute  solution  it  is  used  to  irrigate  sinuses.  The  proper 
dilution  for  irrigation  of  a  sinus  is  obtained  when  the  tincture  is  diluted  to  the 
color  of  sherry  wine.  Its  employment  for  sterilizing  the  skin  is  described  on 
page  77.  lodin  and  many  other  germicides  have  been  tried  upon  enormous 
numbers  of  cases  during  the  existing  war.  They  all  failed  to  produce  immediate 
sterilization  of  extensive  wounds. 

The  Dakin-Carrel-Dehelly-DePage  Method. — Dakin  and  Carrel  after 
experimenting  with  over  two  hundred  antiseptics  finally  selected  a  solution 
^Browning,  Gulbrausen  and  Thornton  in  "Brit.  Med.  Jour.,"  July  21,  1917. 


38  Bacteriology 

which  is  very  powerfully  germicidal,  non-toxic  and  non-irritant.  If  this  fluid 
is  used  early  in  a  wound  it  may  prevent  suppuration;  if  used  after  suppuration 
has  begun  it  gradually  frees  the  wound  from  infection  and  j)uts  it  in  such  a 
condition  that  it  can  be  closed  by  sutures.  The  technical  details  of  its  employ- 
ment are  set  forth  in  the  chapter  on  gunshot  wounds  (Page  329). 

It  is  a  solution  of  sodium  hypochlorite  free  from  all  caustic  alkali.  In  contact 
with  wound  exudate  the  solution  gives  ofif  nascent  chlorine  which  forms  highly 
germicidal  chloramin  (NCI).  The  solution  must  contain  from  0.45  to  0.50  of 
I  per  cent,  of  hypochlorite  of  sodium.  If  used  in  a  strength  of  less  than  0.45 
of  I  per  cent,  it  is  too  weak  to  be  efficient.  Is  used  in  a  strength  of  over  0.50 
of  I  per  cent,  it  will  be  so  strong  as  to  irritate  the  wound  and  also  the  skin,  and 
necessitate  the  keeping  of  the  skin  greased  with  yellow  vaseHne.  ("Lyle,  Jour. 
Amer.  Med.  Assoc,"  Jan.  13,  '17).  Whatever  strength  solution  is  used  it  is 
wise  to  protect  the  skin  by  vaselin  on  strips  of  sterile  gauze. 

The  original  solution  was  made  by  adding  chlorinated  lime  and  boric  acid 
to  a  solution  of  carbonate  of  sodium.  This  solution  is  made  more  easily  than 
the  new  solution  and  is  still  used  where  laboratory  facilities  are  unsatisfactory. 

Dakins  Original  Formula. — Dissolve  140  gm.  dry  sodium  carbonate  or  400 
gm.  crystallized  carbonate  in  1 2  liters  of  tap  water.  To  this  solution  add  200 
gm.  of  chlorinated  lime.  Shake  the  mixture  vigorously,  let  it  stand  for  an  hour. 
Siphon  off  the  clear  liquid  and  filter  it  through  cotton  wool.  This  solution  is 
alkaline  and  it  is  necessary  to  dissolve  in  it  40  gm.  of  boric  acid.  If  this  amount 
is  not  enough  to  render  the  solution  neutral  more  boric  acid  must  be  added  until 
all  free  alkali  disappears. 

Daufresne^s  Formula. — Daufresne  uses  no  boric  acid.  His  solution  is  more 
stable  and  can  be  kept  for  a  much  longer  time  than  the  original  solution  which 
has  to  be  made  just  before  using.  Daufresne's  modification  of  the  original 
solution  should  be  made  fresh,  if  possible,  but  it  is  efficient  even  when  several 
weeks  old  if  it  has  been  kept  in  a  dark  and  cool  place.  The  bleaching  pow- 
der must  contain  25  per  cent,  of  active  chlorin,  and  the  exact  percentage  of 
chlorine  is  determined  by  titration.  If  the  powder  is  found  to  contain  more 
than  the  required  amount  of  chlorin  the  amounts  of  the  other  ingredients 
must  be  increased  correspondingly.  If  it  is  found  to  contain  less  than  25 
per  cent,  of  chlorin  the  amounts  of  the  other  ingredients  must  be  diminished 
correspondingly. 

Place  200  gm.  of  bleaching  pov/der  in  a  12  Uter  flask  and  add  5  liters  of  tap 
water.  Shake  the  solution  vigorously  for  some  little  time  and  permit  it  to  stand 
for  six  hours.  This  long  period  of  standing  can  be  obviated  if  the  solution  is 
shaken  for  half  an  hour  by  a  mechanical  shaker.  Another  flask  is  taken  con- 
taining 5  liters  of  cold  water,  and  in  this  water  are  to  be  dissolved  100  gm.  of 
dry  sodium  carbonate  and  80  gm.  of  sodium  bicarbonate  (some  prefer  to  use 
90  gm.  of  sodium  bicarbonate).  The  mixture  is  shaken  actively  and  allowed  to 
stand  while  the  precipitate  settles  out.  In  half  an  hour  the  clear  fluid  is  re- 
moved by  a  siphon  through  filter  paper.  The  test  is  then  made  to  find  if  the 
solution  is  neutral. 

If  we  attempt  to  use  an  alkaUne  solution  it  will  irritate  the  skin.  Alkalinity 
may  be  corrected  by  passing  CO2  through  the  solution  or  by  adding  boric  acid, 
but  if  the  solution  is  alkaUne  it  is  best  to  make  a  new  solution  containing  less 
of  the  carbonate  and  more  of  the  bicarbonate.  The  wound  must  be  widely 
opened  and  every  recess  in  the  wound  must  be  opened ;  all  foreign  bodies  and  all 
dead  tissue  must  be  removed. 

Dakin's  solution  is  introduced  into  the  wound  every  two  hours  and  tubes  are 
so  arranged  as  to  lead  the  fluid  into  each  diverticulum  of  the  wound. 

The  object  is  not  to  irrigate  the  wound  with  the  fluid  but  to  keep  the  wound 
constantlv  full  of  the  fluid.  There  has  been  much  dispute  about  the  value  of 
Dakin's  Fluid.     For  instance,  Delbet  ("Bull,  et  mem.  Soc.  de  chir.  de  Par.," 


Dichloramin-T  39 

1916,  xliii,  1977)  believes  that  the  good  results  are  largely  due  to  the  thorough 
excision  and  cutting  away  of  the  edges  and  walls  of  the  wound,  but  numerous 
reports  seem  to  prove  the  very  great  value  of  this  method  of  treatment  in  wounds 
of  war  and  in  various  wound  infections  in  civil  hospitals. 

Depage  ("Bull,  et  mem.  Soc.  de  chir.  de  Par,,"  1916,  xlii,  1987)  insists,  as  a 
necessary  addition  to  the  Carrel  method,  upon  a  definite  knowledgeof  the  bacteri- 
ology of  the  wound.  In  the  early  days  of  the  treatment  smears  swarm  with  mul- 
titudes of  bacteria  and  polynuclear  cells.  About  the  sixth  day  the  polynuclears 
begin  to  give  way  to  mononuclears  and  the  bacteria  begin  to  diminish  in  number. 
After  several  examinations  made  on  successive  days  when  only  one  or  two  bac- 
teria can  be  found  in  several  fields,  the  wound  is  regarded  as  fit  to  suture. 

The  necessity  of  frequently  instilling  this  fluid  into  the  wound  depends  on 
the  fact  that  when  in  contact  with  wound  fluid,  the  solution  loses  its  chlorin  in 
an  hour  or  so,  hence  the  chlorin  must  be  replaced  promptly.  Of  course  the  ne- 
cessity of  keeping  the  wound  full  of  the  fluid  is  an  obstacle  to  dependent  drainage. 
If  a  dependent  opening  exists  or  is  made  a  special  technic  is  necessary  (Fig.  151). 

Dakin's  fluid  dissolves  dead  tissue,  a  most  important  function.  It  might 
therefore  be  assumed  that  it  must  dissolve  blood  clot,  but  it  does  not  do  so. 
Great  care  is  taken  in  the  arrest  of  hemorrhage  and  every  oozing  point  is  tied. 
This  rule  was  laid  down  when  we  feared  Dakin's  fluid  might  dissolve  clot. 
As  catgut  is  dead  tissue  one  would  assume  that  it  would  attack  this  material, 
which  is  a  fact.  Carrel  says  that  it  destroys  plain  catgut  in  forty-eight  hours; 
and  we  cannot  substitute  silk  for  sutures  as  it  dissolves  silk;  but  chromic  gut  is 
not  affected  at  all  by  it.     Hence  chromic  gut  is  the  suture  material  to  be  used. 

Carrel  says  that  it  bleaches  but  does  not  destroy  linen,  cotton  and  wool,  and 
has  a  very  slight  action  on  silkworm  gut;  that  it  does  not  injure  rubber;  that  it 
attacks  metals  actively,  and  that  it  is  rapidly  rendered  inert  by  hydrogen 
peroxid.  (Communication  of  notes  of  Captain  Robert  B.  Pratt,  U.  S.  A.  M.  R.  C, 
taken  at  the  Rockefeller  Institute.) 

Dichloramin-T  (Toluene-parasulpho-chloramin).^ — As  previously  stated, 
when  hypochlorites  react  with  proteins  the  free  chlorin  is  changed  into  germi- 
cidal and  non-irritating  substances  of  the  group  of  chloramins. 

Chloramins  can  be  prepared  synthetically  and  the  sodium  salt  has  been  used 
largely  as  a  germicide  under  the  name  of  chlorazene.  It  can  be  used  in  a  2 
per  cent,  aqueous  solution  and  exhibits  no  irritant  effects  on  the  skin.  This  is 
at  least  four  times  the  permissible  strength  of  Dakin's  fluid.  Unfortunately 
chloramins  disappear  rapidly  from  the  wound  exudate  and  the  fluid  must  be 
renewed  every  two  hours.     (Dakin-Lee,  etc.  Ibid.). 

The  method  used  to  overcome  this  objection  was  to  dissolve  the  material 
in  an  oily  agent  which  would  take  up  enough  to  make  a  strongly  germicidal 
solution,  and  would  allow  the  germicide  to  diffuse  so  slowly  into  the  wound 
exudate  that  the  application  would  not  require  renewal  for  many  hours.  Such 
a  fluid  is  called  Dakin's  oil. 

The  dichloramin-T  is  dissolved  in  a  chlorinated  oil,  the  strength  of  the  solu- 
tion is  from  5  to  10  per  cent.  The  germicide  will  be  liberated  in  the  wound 
"  over  a  period  of  from  eighteen  to  twenty-four  hours"  ("  Jour.  Am.  Med.  Assoc." 
June  7,  17).  Chlorinated  eucalyptol  can  be  used  as  a  solvent,  with  or  without 
chlorinated  liquid  paraffin.  The  solution  is  irritant  to  mucous  membrane  and 
somewhat  irritant  to  very  thin  skin. 

The  following  solution  is  used  in  the  Pennsylvania  Hospital  and  the  Jefferson 
Hospital: 

Dichloramin-T  powder gr.  156 

Chlorinated  parafi&n  oil i  oz. 

Chlorinated  eucalyptol 3  oz. 

Making  a  7.5  per  cent,  solution. 

1  Dakin-Lee-Sweet-Hendrix-LeConte  in  "Jr.  Am.  Med.  Assoc,"  June  7,  1917. 


40  Bacteriology 

It  is  sprayed  or  injecied  into  a  wound  or  purulent  area  after  foreign  bodies 
and  dead  tissues  have  been  removed.  It  may  be  introduced  by  a  medicine 
dropper  or  by  a  glass  syringe.  The  solution  is  not  to  be  applied  through  a 
metal  nozzle  as  metal  decomposes  it.  It  is  not  to  be  brought  into  contact  with 
alcohol  for  the  same  reason.  Dependent  drainage  is  desirable.  The  method  is 
cheap,  easy  of  application  and  very  useful.  I  have  used  it  with  much  satisfaction 
in  infected  wounds,  burns  and  various  pyogenic  processes.  It  is  an  excellent 
germicide  for  primary  sterilization  and  may  replace  iodin.  It  is  inferior  to 
Dakin's  fluid  because  it  does  not  dissolve  necrotic  tissue.  It  is  safer  in  the 
brain.  The  dressings  must  be  very  thin.  In  many  cases  it  is  advantageous 
to  lay  a  paraffined  silk  net  upon  the  wound  as  it  facilitates  removal  and  prevents 
destruction  of  new  cells  when  dressings  are  taken  off. 

What  is  known  as  chlorcosane  is  a  new  solvent  for  dichloramin-T,  intro- 
duced by  Dakin  and  Dunham.  It  is  produced  by  taking  hard  paraffin  wa.x  with 
a  melting  point  of  50°  C.  or  more,  melting  it  and  passing  chlorin  gas  through  the 
melted  wax  at  a  temperature  of  120°  to  140°  C.  The  wax  absorbs  4 5  to  55  per  cent, 
of  chlorin.  A  straw-colored  liquid  is  formed  which  will  absorb  8  per  cent,  of 
dichloramin-T.  A  5  per  cent,  solution  is  used.  It  is  applied  to  a  wound  by 
means  of  a  spray,  a  s\Tinge,  a  medicine  dropper  or  a  cotton  swab. 

Nucleins,  especially  protonuclein,  possess  germicidal  powers.  Nuclein  is 
composed  of  nucleinic  acid  and  protein  material.  When  injected  hypodermat- 
ically  and  to  a  less  degree  when  taken  by  the  mouth  it  increases  the  germicidal 
power  of  the  blood-serum,  causes  leukocytosis  and  increased  phagocytosis, 
and  thus  prevents  or  opposes  infection.  Mikulicz  used  nucleinic  acid  to  in- 
crease vital  resistance  as  a  preliminary  to  operation  (see  page  49).  A  i  per 
cent,  solution  of  nucleinic  acid  is  on  the  market.  This  acid  is  made  from 
yeast.  The  dose  of  the  preparation  is  from  10  to  60  minims  hvpodermatically, 
once  or  several  times  a  day.  Protonuclein  probably  contains  nucleinic  acid 
and  is  of  some  value  when  applied  locally  to  areas  of  infection,  particularly 
when  sloughing  exists. 

Heat. — The  best  germicide  is  heat,  and  the  best  form  in  which  to  apply 
heat  is  by  means  of  boiling  water  (which  is  even  better  than  steam).  One  can 
use  boiling  water  upon  instruments  and  dressings,  but  seldom  upon  a  patient. 
Jeannel,  of  Toulouse,  uses  boiling  salt  solution  in  abscess  cavities,  and  some 
other  surgeons  employ  steam  or  boiUng  water  to  disinfect  the  medullary  canal 
in  osteomyelitis.  Nevertheless,  boiling  water  is  seldom  applied  to  a  patient, 
and  in  many  cases  a  chemical  germicide  must  be  used. 

Among  other  antiseptics  and  germicides  of  more  or  less  value  we  may 
mention  ether,  trichlorid  of  iodin,  chlorid  of  zinc  (10  per  cent,  solution),  chlorid 
of  iron,  salol,  tri-brom  beta-naphthol  (i  per  cent,  solution),  oxycyanid  of  mer- 
cury, fluorid  of  sodium,  argonin,  sugar,  lannaiol,  bichlorid  of  palladium  (in  very 
dilute  solution),  thymol,  potash  soap,  salicylic  acid,  sulphate  of  copper,  arsenite 
of  copper,  camphor,  eucah-ptol,  cinnamon,  bromin,  chlorin  (as  gas  or  as  chlorin- 
water),  cinnamic  acid,  permanganate  of  calcium,  chlorate  of  potassium,  and 
oxalic  acid.  The  surgeon  before  operating  should  always  scrub  his  hands  in  a 
germicidal  solution. 

Distribution  of  Bacteria. — Microbes  are  very  widely  distributed  in 
nature.  They  are  found  in  all  water  except  that  which  comes  from  very 
deep  springs;  in  all  soil  to  the  depth  of  3  ft.;  and  in  air,  except  that  oyer  the 
desert,  over  the  open  sea,  and  that  about  lofty  mountains.  Dust-free  air  does 
not  contain  them;  the  more  dust,  the  more  microbes,  hence  they  are  present 
in  greatest  number  in  the  air  of  towns  (see  page  64).  There  are  more  in  narrow 
courts  than  in  broad  highways,  more  in  crowded  attics  than  in  roomy  apart- 
ments. Bacteria  are  present  on  and  in  the  skin,  in  the  alimentary  canal,  in  the 
nose,  mouth,  and  pharvnix,  and  in  the  blood  and  lymph.  As  Adami  points  out, 
under  normal  conditions  the  bacteria  which  enter  the  blood  are  very  quickly  killed. 


Distribution  of  Bacteria  41 

Microbes  may  be  useful.  Some  of  them  are  scavengers,  and  clean  the 
surface  of  the  earth  of  its  dead  by  the  process  known  as  "putrefaction,'''  in 
which  complex  organic  matter  is  reduced  to  harmless  gases  and  to  a  mineral 
condition.  The  gases  are  taken  up  from  the  air  by  vegetables,  and  the  mineral 
matter  is  dissolved  in  rain-water  and  passes  into  the  soil  from  which  it  came, 
there  again  to  be  food  for  plants,  which  plants  will  become  food  for  animals. 
Other  organisms  purify  rivers;  others  cause  bread  to  rise;  still  others  give  rise 
to  fermentation  in  liquors.  Microbes  may  be  harmful.  They  may  poison 
rivers  and  soils;  they  may  be  parasites  on  vegetable  life;  they  cause  diseases  of 
the  growing  vine,  and  also  of  wine;  they  produce  the  mold  on  stale,  damp 
bread;  they  occasionally  form  poisonous  matter  in  sausages,  in  milk,  in  meat,  in 
fish,  in  ice-cream,  and  in  canned  goods;  and  they  produce  many  diseases  among 
men  and  the  lower  animals. 

With  so  universal  a  distribution  of  these  fungi,  man  must  constantly  take 
them  into  his  organism.  They  are  upon  the  surface  of  his  body,  he  inhales 
them  with  every  breath,  and  he  swallows  them  with  his  food  and  drink.  Flies, 
-lice,  mosquitoes,  fleas  and  other  insects  may  be  microbe  bearers.  One  hundred 
thousand  fecal  bacteria  have  been  found  on  a  single  fiy  and  the  average  fly 
carries  at  least  a  million  bacteria  of  various  kinds.  Mosquitoes  carry  filariasis, 
yellow  fever,  malaria  and  dengue.  Tsetse  flies  carry  sleeping  sickness.  Rat 
fleas  carry  plague.  The  domestic  fly  carries  t}-phoid.  Lice  carry  tjqphus  and 
relapsing  fever.  Ticks  are  responsible  for  Montana  spotted  fever.  Bed  bugs 
are  held  responsible  by  many  for  kala-azar.  Some  other  diseases  are  known 
to  be  insect  born.  Some  are  supposed  to  be.  Many  diseases  of  animals  are 
thus  carried.  Fortunately  most  microbes  are  entirely  harmless;  others  cannot 
act  on  the  living  tissues;  but  some  are  virulent,  and  these  are  generally, 
but  not  always,  destroyed  by  the  cells  of  the  human  body.  The  alimentary 
canal  always  contains  bacteria  of  putrefaction,  which  act  only  upon  the  dead 
food,  and  not  upon  the  living  body;  but  w^hen  a  man  dies  these  organisms  at 
once  attack  the  tissues,  and  postmortem  putrefaction  begins  in  the  abdomen. 
Even  pathogenic  bacteria  may  exist  for  long  periods  in  the  tissues  without  causing 
illness  in  the  host,  but  when  such  bacteria  do  persist,  they  may  at  any  time 
and  from  a  variety  of  causes  become  active  in  producing  disease  in  the  carrier, 
or  when  they  pass  from  the  host  they  may  perhaps  infect  other  people  (see 
T\"phoid  Carriers,  page  44).  Active  diphtheria  organisms  may  remain  in  the 
cr\-pts  of  the  tonsil  long  after  the  attack.  After  scarlet  fever  the  discharge  from 
an  infected  middle  ear  may  disseminate  the  disease.  After  some  cases  of 
t\^hoid,  bacilli  remain  in  the  bile  for  months  or  even  years.  There  are  many 
chronic  carriers  of  entamoeba  histolytica.  Some  are  known  as  convalescent 
carriers,  some  as  contact  carriers  (editorial  in^'Brit.  Med.  Jour.,"  Nov.  4, 1916). 
The  intestinal  discharges  contain  amoebae.  After  an  attack  of  pneumonia  one  may 
become  a  pneumonia  carrier  and  be  responsible  for  infecting  others.  Sternberg 
found  pneumococci  in  healthy  sputum.  In  fact,  pneumococci  can  be  found  in 
the  mouths  of  25  per  cent,  of  people  free  from  pneumonia.  Pneumococci 
obtained  from  the  mouth  of  an  individual  free  from  pneumonia  "are  just  as 
pathogenic  as  the  diplococci  obtained  from  a  ciflture  from  the  sputum  of  a 
pneumonic  patient''  (Sir  Thomas  Oliver,  in  "British  Medical  Journal,"  April 
30,  1910).  If  the  lungs  become  irritated,  insufiflation  of  diplococci  from  the 
mouth  may  be  followed  by  pneumonia.  Every  infection  is  at  first  local.  Some 
infections  remain  local,  but  others  become  general.  In  a  general  infection  the 
micro-organisms  are  in  the  blood,  though  often  we  cannot  find  them  because 
of  imperfect  methods   (Ball,  in  "Lancet,"  June  8,  1912). 

Welch  long  ago  pointed  out  that  the  human  skin  normally  contains  the 
Staphylococcus  epidermidis  albus,  even  after  the  most  careful  surgical  cleans- 
ing. Dudgeon,  in  the  Horace  DobeU  Lecture  for  igo8  ("Lancet,"  Dec.  5,  1908, 
"Latent  Persistence  and  the  Reactivation  of  Pathogenic  Bacteria  in  the  Body"), 


42  Bacteriology 

says  that  healthy  organs  may  contain  various  bacteria,  that  the  tissues  of  the 
fetus  are  sterile,  but  in  childhood  and  adult  life  "bacteria  are  found  in  various 
parts  of  the  human  body;  Staphylococcus  albus  can  be  cultivated  from  the 
human  omentum  in  cases  in  which  the  peritoneal  cavity  is  apparently  healthy;" 
that  pus  cocci  may  persist  for  long  periods  in  a  scar;  that  virulent  dij^htheria 
bacilli  may  be  "found  in  the  throats  of  persons  who  have  come  in  contact  with 
diphtheria  patients,  but  show  no  signs  of  the  disease;"  that  the  Bacillus  proteus 
is  frequently  found  in  the  urine;  that  colon  bacilli  normally  inhabit  the  in- 
testinal tract  and  appendix  and  frequently  exist  in  the  urinary  tract  without 
giving  rise  to  inflammation  or  symptoms  of  disease,  and  that  typhoid  bacilli 
tend  notably  to  persist  (see  page  44).  As  previously  stated,  the  organisms  of 
tuberculosis  and  of  syphilis  may  long  rest  latent. 

Koch's  Circuit. — To  prove  that  a  microbe  is  the  cause  of  a  disease  it 
must  fulfil  Koch's  circuit.  It  must  always  be  found  associated  with  the  disease; 
it  must  be  capable  of  forming  pure  cultures  outside  the  body;  these  cultures 
must  be  capable  of  reproducing  the  disease;  and  the  microbe  must  again  be 
found  associated  with  the  artificially  produced  morbid  process. 

Infection  or  Disease  Production  by  Micro=organisms. — Most  infec- 
tions are  caused  by  bacteria,  some  result  from  molds,  a  few  from  protozoa. 
Pathogenic  organisms  cannot  enter  through  the  sound  and  unbroken  skin 
without  causing  the  formation  of  lesions  at  the  point  of  entrance.  The 
sound  skin  is  the  very  best  antiseptic  covering  for  tissue,  as  ordinary  bacteria 
cannot  pass  it  at  all.  Some  bacteria  by  entering  the  ducts  of  cutaneous  glands 
may  cause  disease.  Disease-producing  organisms  which  enter  the  body  may 
reach  the  focus  in  which  they  act  from  outside  of  the  body,  entering  by  inocu- 
lation, inhalation,  or  ingestion.  In  most  instances  organisms  which  enter  the 
body  from  without  are  rapidly  destroyed.  When  they  enter  in  large  numbers, 
or  when  they  are  very  virulent,  or  when  the  vital  resistance  of  the  individual 
is  at  a  low  ebb  they  cause  disease.  Bacteria  may  reach  the  region  in  which 
they  become  active  from  some  other  part  of  the  body.  Bacteria  may  dwell 
in  the  body  long  without  inducing  disease,  and  spores  can  lie  dormant  in  the 
system  for  years.  When  bacteria  or  spores  from  some  other  part  of  the  body 
reach  a  region  of  injury  or  disease  they  may  become  active;  this  area  is  a  dam- 
aged and  weakened  part,  in  it  the  circulation  is  abnormal,  it  is  a  so-called  point 
of  least  resistance  (a  loctis  minoris  resistentice)  which  affords  them  a  nest  in  which 
germs  may  lodge,  develop  and  multiply,  the  cellular  activities  of  the  weakened 
part  being  unable  to  cope  with  the  activities  of  the  germs.  Even  large  numbers 
of  pathogenic  organisms  may  induce  no  trouble  in  a  healthy  man;  but  let  them 
reach  a  damaged  spot,  and  mischief  is  apt  to  arise.  Kocher  established  subcu- 
taneous bone  injuries  in  dogs,  and  these  injuries  pursued  a  healthy  course  until 
the  animal  was  fed  upon  putrid  meat,  whereupon  suppuration  took  place.  This 
experiment  proves  that  micro-organisms  can  reach  a  damaged  area  by  means 
of  the  blood,  and  it  enables  us  to  understand  how  a  knee-joint  can  suppurate 
when  we  merely  break  up  adhesions,  and  how  osteomyelitis  can  follow  trauma 
when  the  skin  is  intact.  A  given  number  of  organisms  might  produce  no  effect 
on  a  healthy  man,  whereas  the  same  number  might  produce  disease  in  an  indi- 
vidual who  was  weak  or  ill-nourished,  suffering  from  depression  or  fear,  or 
debilitated  by  the  habitual  use  of  alcohol.  The  personal  equation  plays  a  great 
part  in  disease  production.  Some  individuals  seem  to  be  immune  to  certain 
diseases;  and  these  immunities  and  liabilities  may  be  hereditary  or  acquired, 
temporary  or  permanent. 

The  local  infection  may  be  violent  and  yet  never  be  generalized.  Sometimes 
the  local  reaction  at  the  point  of  bacterial  entry  is  so  trivial  as  to  be  overlooked, 
or  by  the  time  general  infection  occurs  the  initial  point  of  local  infection  may 
have  healed. 

It  is  not  at  all  unusual  to  observe  lymphangitis  or  lymphadenitis  "above  a 


Toxins  43 

healed  focus"  (J.  C.  Bloodgood,  in  "Progressive  Medicine,"  Dec,  191 1).  A 
few  infections  generalize  primarily  by  way  of  the  blood — most  do  so  by  the 
lymphatics.  From  the  moment  there  is  lymphangitis  or  lymphadenitis  the 
infection  is  to  be  regarded  as  general,  and  the  blood  contains  toxins  or  bacteria, 
the  lymph-glands  filtering  out  and  holding  comparatively  few  micro-organisms. 
(See  J.  C.  Bloodgood,  in  "Progressive  Medicine,"  Dec,  1911,  and  Noetzel,  in 
"Beitr.  z.  khn.  Chir.,"  1909,  Ixv). 

A  general  infection  in  which  the  blood  contains  toxins  but  not  bacteria  is 
called  a  toxemia.  A  general  infection  in  which  the  blood  contains  bacteria  is 
called  a  bacteremia. 

The  intensity  of  an  infection  may  often  be  estimated  by  the  degree  of 
leukocytosis  and  anemia  (see  page  48). 

Enzymes. — Bacteria  contain  and  excrete  ferments,  and  these  ferments 
are  known  as  enzymes.  Bacterial  ferments  resemble  pepsin  and  trypsin,  the 
digestive  ferments.  The  digestive  ferments  convert  albumin  into  peptone, 
starch  into  sugar,  and  break  up  fat.  Some  enzymes  are  proteolytic  (dissolve 
albumin);  some  are  diastatic  (change  starch  into  sugar);  some  convert  cane- 
sugar  into  grape-sugar;  some  coagulate  milk.  When  microbic  infection  of  the 
tissues  occurs  the  enzymes  of  the  bacteria  act  upon  the  tissues  just  as  the  digest- 
ive ferments  act  upon  the  food,  and  form  microbic  albumoses.  The  enzymes 
are  the  weapons  of  micro-organisms.  By  means  of  these  ferments  bacteria 
not  only  prepare  substances  for  assimilation,  but  seek  to  destroy  antagonists 
and  cell  enemies.  It  is  probable  that  enzymes  when  absorbed  are  frequently 
productive  of  toxemia. 

Toxins  are  poisons  produced  by  microbic  action.  The  action  of  patho- 
genic bacteria  upon  the  tissues  is  of  great  importance.  In  the  first  place,  they 
invade  the  tissue,  the  capacity  for  invasion  varying  greatly  and  depending  on 
their  power  to  sweep  aside  the  defenses  of  the  body.  When  they  invade  the 
tissues  they  abstract  from  the  blood,  the  lymph,  and  the  cells  certain  elements 
.necessary  to  the  body — as  water,  oxygen,  albumins,  carbohydrates,  etc. — 
and  thus  cause  body  wasting  and  exhaustion  from  want  of  food.  In  the  second 
place,  bacteria  produce  a  vast  number  of  compounds,  some  harmless  and  others 
highly  poisonous.  The  symptoms  of  a  microbic  disease  are  largely  due  to  the 
absorption  of  poisonous  materials  from  the  area  of  infection.  These  poisons 
may  be  formed  from  the  tissues  by  the  action  upon  them  of  the  bacterial  fer- 
ments (see  above),  may  be  excreted  by  the  bacteria  {extracellular  toxins),  or 
may  be  liberated  from  the  bodies  of  degenerating  microbes  {bacterial  protein, 
intracelhdar  toxins,  or  endotoxins).  Intracellular  toxins  are  very  insoluble. 
Bacteria  contain  and  secrete  ferments;  and  as  albumoses  are  formed  in  the 
alimentary  canal  by  the  action  of  digestive  ferments  upon  proteins,  sugars, 
and  starches,  so  microbic  albumoses  are  formed  by  the  action  of  microbic 
ferments  upon  tissues.  Just  as  the  albumoses  formed  in  digestion  are  poisonous 
when  injected,  so  the  albumoses  of  microbic  action  are  poisonous  when  ab- 
sorbed. The  albumoses  of  microbic  action  are  called  toxalbumins,  and  these 
albumoses  often  operate  as  virulent  poisons  to  the  body-cells. 

A  number  of  compounds  formed  during  the  microbic  destruction  of  tissue  are 
alkaloidal  in  nature.  These  poisonous  alkaloids  are  readily  diffusible  and, 
many  of  them,  very  virulent.  It  is  probable  that  every  pathogenic  organism 
has  its  own  special  toxin  which  produces  its  characteristic  effects,  although 
the  effects  are  modified  by  the  nature  of  the  soil — that  is  to  say,  by  the  condi- 
tion of  the  tissues.  Again,  one  micro-organism  may  produce  several  toxins. 
The  absorption  of  toxins  may  be  very  rapid;  for  instance,  the  toxins  of  cholera 
may  kill  a  man  before  the  bacilli  have  migrated  from  the  intestine.  Brieger 
uses  the  term  toxin  to  designate  all  of  the  poisonous  products  of  bacterial  action. 
He  divides  toxins  into  alkaloidal  or  crystallizable  and  amorphous,  the  latter 
being  called  toxalbumins. 


44  '  Bacteriology 

Ptomains. — By  many  writers  the  term  "ptomain"  is  used  to  designate 
these  toxins,  but,  in  reality,  a  ptomain  is  a  form  of  toxin  produced  by  the  action 
of  saprophytic  bacteria.  A  ptomain  is  a  putrefactive  alkaloid  and  a  toxin 
is  any  poison  of  microbic  origin.  Among  these  putrefactive  alkaloids  may 
be  mentioned  tetanin,  typhotoxin,  sepsin,  putrescin,  tyrotoxicon,  muscarin, 
and  spasmotoxin.  The  poison  which  occasionally  forms  in  meat,  fish,  milk, 
cheese,  ice-cream,  sausage,  and  canned  goods  is  composed  of  ptomains.  Poison- 
ing by  any  putrid  food  is  called  ptomain-poisoning. 

Leukomains  must  not  be  confounded  with  the  above-mentioned  bodies. 
Leukomains  are  alkaloidal  substances  existing  normally  in  the  tissues  and 
not  produced  by  bacteria,  but  arising  from  physiologic  fermentations  or  ret- 
rograde chemical  changes.  They  are  natural  body  constituents,  in  contrast 
to  toxins,  which  are  morbid  constituents.  Leukomains  are  found  in  expired 
air,  saliva,  urine,  feces,  tissues,  and  the  venom  of  serpents.  If  not  excreted, 
these  bodies  may  induce  illness,  and  when  injected  may  act  as  poisons.  Ordi- 
nary colds  and  some  fevers  result  from  leukomains;  they  play  a  great  part  in 
uremia,  and  when  excretion  is  deficient  the  retained  leukomains  make  the  system 
a  hospitable  host  for  pathogenic  bacteria.  Sickness  due  to  the  retention  and 
absorption  of  leukomains  is  known  as  aiito-intoxkation.  Among  leukomains 
may  be  mentioned  adenin,  h\T3oxanthin,  and  xanthin,  allied  to  uric  acid,  and 
other  substances  allied  to  creatin  and  creatinin.  The  surgeon  should  never 
forget  the  possibility  of  harm  being  done  by  retained  leukomains,  and  should 
endeavor  to  prevent  auto-intoxication  in  all  cases  by  keeping  the  skin,  the  bowels, 
and  the  kidne}  s  active. 

Immunity. — Resistance  is  the  fight  of  the  body  against  bacteria.  Even  a 
person  with  high  resistance  may  be  infected,  but  even  though  infected  the  body 
still  fights  the  bacteria.  If  a  person  cannot  be  infected  with  a  certain  disease, 
he  is  said  to  be  immune  to  it.  Some  persons  seem  naturally  immune  to  certain 
diseases  {natural  immunity).  Immunity  to  some  diseases  may  be  produced 
artificially.  WTien  the  body  itself  produces  the  materials  which  render  it 
immune  the  immunity  is  called  active.  When  immunity  is  produced  by  the 
introduction  of  substances  artificially  produced  the  immunity  is  called  passive 
or  artificial.  It  has  long  been  known  that  when  a  person  recovers  from  certain 
diseases  he  has  become  immune  to  the  disease  from  which  he  suffered  (acquired 
immunity).  Immunity  may  be  transitory,  prolonged,  or  permanent.  Acquired 
immunity  may  be  compared  to  fermentation.  When  fermentation  ceases,  the 
addition  of  more  ferment  is  without  result.  When  a  person  recovers  from 
certain  diseases,  the  addition  to  his  blood  of  more  of  the  causative  bacteria  is 
also  void  of  result. 

Immunity  was  long  believed  to  arise  from  the  exhaustion  of  some  unknown 
constituent  of  tissue  necessary  to  the  life  of  the  bacteria.  This  theory  was 
advanced  by  Pasteur.  It  has  been  abandoned  because  of  the  demonstration 
that  though  an  animal  may  become  immune  to  a  disease  caused  by  certain 
bacteria,  these  bacteria  may  continue  to  live  in  the  host.  It  is  true  that  when 
recovery  ensues  upon  infections,  as  a  rule,  the  causative  bacteria  disappear, 
but  there  are  enough  exceptions  to  this  rule  to  invalidate  the  theory  of  Pasteur. 
It  is  well  known  that  even  for  years  after  an  attack  of  tv^^hoid  fever  the  bacilli 
may  exist  in  the  gall-bladder  or  the  bone-marrow,  or  be  passed  in  the  urine  or 
feces.  A  person  apparently  well,  yet  holding,  for  instance,  in  his  gall-bladder 
infectious  bacteria,  is  called  a  "bacteria  carrier."  From  i  to  2  per  cent,  of  per- 
sons who  have  had  tj'phoid  fever  years  ago  pass  baciUi  in  the  stools,  and  such 
carriers  are  often  responsible  for  the  spread  of  the  disease.  Hutchinson  ("  Brit- 
ish Medical  Journal,"  March  26,  1910)  reports  a  ''carrier"  whose  attack  had 
been  fifteen  years  before.  Gregg  ("Boston  Med.  and  Surg.  Jour.,"  July 
16,  1908)  reported  the  case  of  a  typhoid  carrier  fifty-two  years  after  recovery 
from  typhoid.     Some  carriers  never  knew  they  had  had  typhoid,  the  attack 


Agglutinins  and  Precipitins  45 

having  been  very  mild.  Some  have  never  had  it,  but  have  been  in  contact  with 
it.  Such  people  were  immune.  A  carrier  may  give  the  disease  to  others,  but 
is  practically  immune.  "  Certain  protective  immune  bodies,  such  as  opsonins 
and  stimulins,  are  augmented  by  the  attack;  others,  such  as  the  bactericidins 
and  bacteriolysins,  are  not  augmented  to  the  point  of  destruction  of  the  bacilli" 
(Willard  J.  Stone,  in  ''American  Journal  of  Medical  Sciences,"  April,  1912). 
Fromme  operated  upon  4  typhoid  carriers.  In  each  case  he  removed  the  gall- 
bladder. In  the  bile  of  each  he  found  bacilli.  After  operation  the  bacilli 
disappeared  from  the  feces  of  each  ("Deutsch  Zeitsch.  f.  Chir.,"  Nov., 
19 10).  In  a  case  of  my  own  the  bacilli  disappeared  after  draining  the  gall- 
bladder and  administering  urotropin.  A  theory  proposed  by  Chauveau  is 
known  as  the  "retention  theory,"  and  is  the  opposite  of  Pasteur's  "exhaustion 
theory."  According  to  Chauveau,  bacteria  growing  within  the  body  leave  as 
a  legacy  excrementitious  material,  and  the  accumulation  and  retention  of 
excrementitious  products  produce  immunity. 

Until  very  recently  one  set  of  investigators  maintained  that  immunity 
depended  entirely  upon  the  activity  of  certain  body  cells  which  attacked,  con- 
sumed, and  destroyed  bacteria.  This  is  the  theory  of  phagocytosis  (see  page  48). 
Another  set  asserted  the  claims  of  Nuttal  and  Buchner,  that  normal  fresh 
blood-serum  was  germicidal,  the  power  varying  for  different  bacteria  and  being 
limited.  A  fixed  amount  of  serum  is  capable  of  destroying  a  fbced  number  of 
bacteria  of  a  certain  variety.  Vaughan  and  others  state  that  the  germicidal 
agent  is  probably  a  nuclein  furnished  chiefly  by  the  white  cells  and  held  in 
solution  by  the  alkaline  serum.  This  germicidal  agent  of  normal  serum  Buchner 
called  ''alexin''  or  defensive  protein.,  and  explained  immunity  by  its  presence. 
This  theory  is  known  as  the  '' Jnimoral  theory.'"  According  to  this  theory  as 
originally  maintained,  when  an  animal  is  naturally  immune  to  a  bacterial  dis- 
ease it  is  assumed  that  the  blood-serum  and  body  fluids  contain  enough  of  this 
alexin  to  dissolve  or  destroy  the  bacteria.  Neither  method  of  defense  is  the 
only  one.  In  aU  probability  both  phagocytosis  and  bacterial  solution  are  occur- 
ring in  the  same  patient  at  the  same  time,  phagocytosis  being  impossible  but 
for  the  serum  and  bacteriolysis  being  impossible  without  leukocytes. 

Since  the  above  theories  were  set  forth  it  has  been  found  that  when  an  ani- 
mal recovers  from  some  bacterial  diseases  the  blood-serum  and  body  fluids 
•contain  new  protective  materials  called,  in  general,  antibodies.  The  toxins  of 
bacteria  stimulate  body  cells  to  the  production  of  antibodies,  and  antibodies 
bring  the  disease  to  an  end  and  secure  immunity.  It  is  thus  seen  that  the  very 
poisons  produced  by  bacteria  cause  the  body  cells  to  produce  poison  antidotes. 
The  bacteria  may  be  so  virulent  or  the  patient  so  susceptible  that  poison  over- 
whelms the  cells,  antibodies  are  not  formed  in  sufficient  quantity,  and  death 
ensues.  The  cells  may  be  badly  poisoned  and  the  patient  may  become  very  ill, 
and  yet  after  a  time  the  cells  may  regain  enough  vitality  to  furnish  antibodies  in 
•sufficient  quantity  to  bring  about  cure  and  to  secure  immunity.  The  bacteria 
may  be  so  few  in  number  or  so  attenuated  in  \drulence  or  the  cells  of  the  patient 
may  be  so  active  that  quantities  of  antibodies  are  quickly  formed  under  mild 
:stimulation,  and  the  indi\ddual  does  not  take  the  disease  at  aU  or  takes  it  very 
mildly. 

The  l3rtic  or  bacteriolytic  antibodies  or  lysins  destroy  and  dissolve  bacteria. 
All  bacteria  are  not  susceptible  to  lysis,  for  instance,  streptococci,  tubercle 
baciUi,  and  pneumococci.  WTien  recovery  ensues  the  causative  bacteria  usu- 
ally but  not  always  disappear  (see  page  44).  These  lytic  bodies  are  formed 
by  the  leukocytes,  bone-marrow,  spleen,  and  lymph-glands  (Wassermann,  in 
"Berlin,  klin.  Woch.,"  No.  4,  1898,  and  Levaditi,  in  "Annales  de  ITnst.  Pas- 
teur," 1904). 

Agglutinins  and  precipitins  gather  in  the  blood-serum  of  an  animal  when 
.the  animal  has  been  injected  with  bacteria  or  certain  cells.     When  these  anti- 


46  Bacteriology 

bodies  appear  in  blood  after  an  animal  has  been  injected  with  bacteria  they 
agglutinate  and  precipitate  the  bacteria  injected.  It  is  probable  that  agglu- 
tinins and  precipitins  are  formed  by  the  endothelium  of  vessels'  walls  (Kraus 
and"  Schiffman,  in  "Annales  de  I'lnst.  Pasteur,"  1906).  These  materials 
appear  after  certain  infections  only.  * 

Opsonins  are  materials  which  by  attaching  themselves  to  certain  bacteria 
so  alter  the  bacteria  that  they  easily  become  the  victims  of  phagocytosis  (see 
Phagocytosis,  page  48). 

Antitoxins  are  specific  bodies  secreted,  as  Roux  says,  by  the  body  cells. 
They  pass  into  the  serum  and  body  fluids.  They  fix  and  neutralize  the  bac- 
terial toxin  by  combining  with  it,  but  do  not  dissolve,  kill,  precipitate,  or  agglu- 
tinate the  bacteria.  The  first  antitoxin  to  be  discovered  was  that  of  diphtheria. 
The  discovery  was  made  by  Behring  in  1890.^  He  found  that  if  an  animal 
were  injected  with  gradually  increasing  amounts  of  diphtheria  toxin  the  serum 
then  contained  an  antitoxic  material.  Very  soon  after  this  discovery  was 
announced  Behring  and  Kitasato  made  a  like  discovery  in  regard  to  tetanus 
toxin.  It  was  pointed  out  by  Kitasato  and  Behring  that  animals  can  be  ren- 
dered immune  to  tetanus  by  artificial  means  and  that  the  blood-serum  of  im- 
mune animals  will,  if  injected  into  other  animals,  render  them  immune,  or 
perhaps  cure  the  disease  if  injected  into  animals  suffering  from  tetanus.  The 
same  statements  were  also  proved  to  be  true  of  diphtheria.  Now  many  experi- 
menters are  endeavoring  to  find  the  antitoxin  of  each  microbic  disease  for  the 
purpose  of  using  it  therapeutically  and  also  as  a  preventive  agent. 

In  some  infections  soluble  toxins  are  not  formed  and  the  body  resistance 
depends  largely  on  the  formation  by  the  bacteria  of  substances  which  finally, 
when  present  in  sufficient  amounts,  destroy  bacteria. 

Surely  one  of  the  most  important  of  modern  discoveries  is  that  certain  sub- 
stances introduced  into  the  body  cause  a  reaction  which  results  in  the  formation 
of  antibodies.  Any  material  which  causes  antibodies  to  form  is  called  an  anti- 
gen. In  the  preceding  section  we  have  spoken  of  bacterial  products  as  the 
antigens.  But  other  antigens  exist,  for  instance,  blood-corpuscles  and  other 
cells,  blood-serum,  some  vegetable  poisons,  and  some  animal  poisons.  Thought 
is  now  directed  to  treating  bacterial  diseases  by  the  introduction  of  the  proper 
antigen  to  produce  lysins,  opsonins,  antitoxins,  as  the  case  may  be.  Strepto- 
cocci produce  no  antigen  which  leads  to  lysin  formation,  but  do  produce  antigens 
which  lead  to  antitoxin  and  opsonin  formation. 

The  subject  is  of  enormous  importance  and  is  vastly  complicated. 

Ehrlich's  Theory  of  the  Mechanism  of  Immunity  hy  Antitoxins. — Ehrlich's 
theory  was  advanced  in  1898  and  is  generally  accepted  at  the  present  time. 
"Ehrlich's  theory  of  the  mechanism  of  immunity  is  based  upon  Weigert's 
teaching  of  the  process  of  tissue  repair.  It  is  a  matter  of  universal  observation 
that  nature  is  prodigal  in  her  attempts  to  repair  an  injury.  This  is  shown  in 
the  healing  process  in  an  ordinary  wound.  A  much  larger  amount  of  material 
is  thrown  out  to  bridge  the  chasm  than  is  really  utilized  in  the  formation  of 
new  tissue.  The  presence  of  an  excessive  amount  of  new  material  is  shown  by 
the  fact  that  the  part  is  raised  above  the  level  of  the  surrounding  sound  tissue, 
and  this  excess  is  removed  gradually  as  the  new-formed  tissue  becomes  stronger 
and  stronger,  until  finally  the  wound  is  marked  by  a  line  of  white  scar-tissue, 
the  excess  gradually  passing  into  the  blood-current. 

"Ehrlich  believed  that  the  mechanism  of  immunity  was  explainable  on  a 
similar  basis.  It  had  become  evident  from  the  experiments  of  Wassermann 
with  the  tetanus  bacillus  that  its  toxin  had  an  especial  afl&nity  for  the  cells  of 
the  central  nervous  system.  Ex-periments  with  other  bacteria  pointed  to  the 
fact  that  the  toxins  of  different  species  of  bacteria  had  an  especial  affinity  for 
the  cells  of  different  organs  of  the  body.  When  the  amount  of  poison  entering 
^"  Deutsche  Med.  Wbchenschrift,"  1890,  Nos.  49  and  50. 


Phagocytes  47 

the  body  is  not  sulficient  to  destroy  the  cells  which  have  an  especial  affinity 
for  it,  these  cells  may  be  injured  only  to  such  an  extent  as  to  permit  subsequent 
repair.  In  order  to  comprehend  Ehrlich's  hypothesis  it  is  necessary  to  con- 
ceive the  cells  of  the  body  as  having  a  complex  structure  which  may  be  stated 
diagrammatically  as  consisting  of  a  central  mass  or  nucleus  from  which  radiate 
a  number  of  'lateral  chains/  or  bonds,  each  of  which  serves  to  bind  the  cell  to 
other  substances.  In  the  case  of  the  cells  of  the  central  nervous  system  one 
of  these  lateral  bonds  has  an  especial  affinity  for  tetanus  toxin  and  suffers 
destruction.  The  cell  now  finds  itself  in  unstable  equilibrium,  and  at  once 
proceeds  to  repair  the  damage  wrought.  As  in- the  case  of  tissue  repair,  the 
new  material  produced  is  far  in  excess  of  the  required  amount.  The  excess 
finds  its  wa}^  into  the  blood-current.  This  material  now  circulating  in  the 
blood-current  has  the  same  affinity  for  tetanus  toxin  as  when-  united  with  the 
central  mass  of  a  cell  as  its  lateral  bond,  and  can,  therefore,  combine  with  tetanus 
toxin  floating  in  the  blood-current,  thus  preserving  other  cells  from  injury. 
The  union  formed  between  the  lateral  bond  of  the  cell  (which  is  really  the  anti- 
toxin) and  the  tetanus  toxin  results  in  the  formation  of  a  compound  which  is 
physiologically  inert.  According  to  Ehrlich's  idea,  therefore,  the  antitoxin  is 
simply  the  excess  of  lateral  bonds  floating  in  the  blood-current.  This  substance 
can  neutralize  the  effect  of  the  tetanus  toxin,  in  a  test-tube  just  as  readily  as  it 
does  within  the  body"  (D.  H.  Bergey,  "American  Medicine,"  October  11,  1902). 
Phagocytes. — It  was  generally  believed  after  Metchnikoff's  important 
discoveries  that  leukocytes  were  the  agents  which  protected  the  body  from 
infection.  When  other  observers  found  that  in  blood-serum  is  material  that 
damages  or  destroys  bacteria,  opinion  swung  to  the  view  that  the  blood-serum 
contains  the  protective  element,  and  that  the  leukocytes  are  simply  scavengers 
and  remove  dead  bacteria,  but  do  not  destroy  living  ones.  It  has  recently  been 
shown  that  under  some  circumstances  leukocytes  destroy  living  bacteria  and 
under  other  circumstances  they  do  not,  and  that  the  presence  or  absence  of 
this  property  depends  in  most  instances  upon  the  presence  or  absence  in  the 
blood-serum  of  substances  which  act  upon  bacteria  and  render  them  susceptible 
to  the  phagocytic  action  of  leukocytes.  We  say  in  most  instances,  not  in  all 
instances,  because  certain  bacteria,  for  instance,  influenza  bacilli,  are  phago- 
cytable  without  the  presence  of  opsonic  serum  (Ludvig  Hektoen,  address  in 
"  Section  of  Physiology  and  Experimental  Medicine,  American  Assoc,  for  Ad- 
vancement of  Science,"  1908;  "Science,"  Feb.  12,  1909).  The  existence  in  the 
serum  of  substances  provocative  of  phagocytosis  was  demonstrated  by  Wright  • 
and  Douglas  in  1903,  and  they  named  them  opsonins.  If  opsonins  are  present, 
the}^  act  upon  bacteria,  and  render  the  bacteria  susceptible  to  phagocytosis. 
(See  Ludvig  Hektoen,  in  "Jour.  Am.  Med.  Assoc,"  May  12,  1906.)  Opsonins- 
act  upon  bacteria  and  alter  them,  and  the  altered  bacteria  are  easily  eaten  up 
by  leukocytes.  Very  virulent  bacteria  resist  phagocytosis  because  they  have 
little  affinity  for  opsonin,  and  such  virulent  bacteria  may  grow  in  opsonic  serum. 
The  source  of  opsonins  is  not  known,  but  serum  normally  contains  "  opsonins 
for  many  different  bacteria"  (Hektoen,  in  "Jour.  Am.  Med.  Assoc,"  May  12, 
1906).  When  experiment  determines  the  fact  that  an  individual's  leukocytes 
are  highly  phagocytic  toward  particular  bacteria,  we  believe  that  a  quantity  of 
opsonin  for  that  variety  of  bacteria  is  present,  and  we  may  say  the  indi-vidual 
has  a  high  opsonic  index  as  regards  them.  Under  opposite  conditions  we  say 
he  has  a  low  opsonic  index.  "The  opsonic  index  of  Wright  with  respect  to  a 
given  bacterium  is  obtained  by  comparing  the  number  of  the  bacteria  taken 
up  under  the  influence  of  the  serum  of  the  person  or  animal  in  question  with  the 
number  taken  up  under  the  influence  of  the  corresponding  standard  of  normal 
serum  under  conditions  that  are  as  comparable  as  they  possibly  can  be  made" 
(Ludvig  Hektoen,  address  in  "Section  of  Advancement  and  Physiology  and  Ex- 
perimental Medicine  in  Am.  Assoc,  for  Science,"  1909;  "Science,"  Feb.  12, 1909). 


48 


Bacteriology 


The  Process  of  Phagocytosis. — We  have  just  seen  how  opsonins  stimulate 
phagocytosis.  The  process  of  destruction  of  bacteria  by  cells  is  known  as 
phagocytosis,  and  the  destroying  cells  are  called  phagocytes.  The  cells  active  in 
phagocytosis  are  the  endothelial  cells  of  the  blood-vessels,  lymph-channels  and 
IvmjSh-spaces,  and  particularly  the  leukocytes.  When  infection  occurs,  the 
white  blood-cells  gather  in  enormous  numbers  at  the  seat  of  disease,  encompass 
and  surround  the  bacteria,  and  build  a  barrier  to  prevent  dissemination  of  the 
microbes  and  general  infection  of  the  victim.  The  force  which  draws  leuko- 
cytes to  a  region  of  infection  also  tends  to  draw  them  to  an  area  where  there  is 
cellular  degeneration  or  death.  This  force  is  called  positive  chemiotaxis  and  is 
greatly  stimulated  by  opsonins.  In  very  virulent  infections  the  leukocytes 
may  fail  to  collect  and  may  actually  be  repelled  and  scattered  under  the  influ- 
ence of  what  has  been  called  negative  chemiotaxis.  Phagocytes  at  the  seat  of 
infection  try  to  eat  up,  carry  away  to  a  gland,  and  there  digest  and  destroy 
bacteria.  A  battle  royal  occurs,  the  microbes  fighting  the  body  cells  with  most 
active  ferments  and  destroying  the  opsonic  power  of  the  blood-liquor;  the 
body  cells  endeavoring  to  devour  and  destroy  the  bacteria  (Fig.  14),  in  which 
effort  opsonins   give  them  aid.     In  some  cases  the  bacteria  win  absolutely 

and  the  patient  dies.  In  other 
cases  they  win  for  a  time  and 
overwhelm  the  sytem;  but  pres- 
ently the  body  cells,  whose  move- 
ments were  inhibited  by  the 
poison,  regain  their  activity  and 
are  then  immune  to  the  bacterial 
poison.  It  is  probable  that  the 
materials  thro\\'n  out  by  the  white 
cells  during  the  combat  with  the 
microbes  tend  to  destroy  bacterial 
products  and  to  neutralize  toxic 
productsof  tissue  destruction.  The 
materials,  which  neutralize  toxic 
products,  are  known  as  antitoxius 
(see  page  46).  After  the  attack 
of  disease  has  passed  away  the 
body  cells  have  been  educated  to  withstand  this  poison,  and  new  cells  in  the 
future  retain  this  capacity;  the  weak  cells  were  killed,  the  fittest  survived, 
and  the  body  fluids  contain  antitoxin.  The  new  cells  formed  in  the  body 
are  insusceptible  to  the  poison  and  the  indi\ddual  is  said  to  be  insusceptible  or 
immune.  The  theory  of  phagocytosis  immunity  assumes  an  educated  white 
corpuscle  and  body  cell.  This  view  originated  with  Surgeon  General  George 
M.  Sternberg,  U.  S.  A.,  but  it  is  usually  accredited  to  Elie  INIetchnikoflf  of 
Russia.     Sir  Edwin  Ray  Lankester  gave  us  the  term  ''educated  corpuscle." 

Leukocytosis. — In  a  number  of  infectious  and  inflammatory  diseases  leuko- 
cytosis occurs.  By  this  term  we  mean  a  notable  increase  of  leukocytes  in  the  blood, 
the  polynuclear  neutrophiles  being  increased  relatively  and  absolutely.  Leuko- 
cytosis in  an  infection  indicates  that  the  body  is  trying  to  protect  itself  against 
poisons  by  furnishing  more  phagocytes  to  attack  bacteria.  The  degree  of 
the  leukocytosis  is  a  sort  of  gauge  of  the  virulence  of  the  infection  and  of  the 
reacting  or  resisting  powers  of  the  individual.  In  a  very  trivial  infection  there 
may  be  a  slight  leukocytosis  or  no  leukocytosis  at  all.  A  violent  infection,  if 
resistance  is  high,  is  accompanied  by  a  high  degree  of  leukocytosis;  if  resist- 
ance is  low,  there  is  a  low  degree  or  no  leukocytosis  at  all. 

In  a  virulent  infection  absence  of  leukocytosis  is  of  unfavorable  import. 
It  means  that  tissue  resistance  is  at  an  end  and  that  the  body  cells  have  ceased 
to  fight  the  bacteria. 


:<'.'•.•") 


Fig.  14. 


'if;' 

-Phagocytosis:  A,  Successful;  B,  un- 
successful (Senn). 


\  ital  Resistance  4q 

Normally,  the  blood  of  an  adult  should  contain  about  7500  leukocytes  per 
c.mm.  From  50  to  60  per  cent,  of  the  cells  are  polynuclear  neutrophiles.  If 
the  cells  number  well  above  10,000,  and  if  the  percentage  of  polynuclear 
neutrophiles  is  increased,  the  condition  is  regarded  as  leukocytosis. 

In  most  cases  the  leukocyte  count  is  below  20,000.  Over  20,000  is  high 
leukocytosis.  It  is  very  seldom  that  a  count  of  over  30,000  is  obtained  (see 
page  103).  During  the  first  year  of  life  the  normal  blood  contains  from  15,000 
to  20,000  leukocytes  to  the  c.mm.  At  ten  years  of  age  it  should  contain  10,000. 
In  an  infant  or  a  young  child  a  high  count  of  leukocytes  is  without  signifi- 
cance unless  it  is  very  high  or  unless  a  differential  count  shows  a  decided 
proportional  excess  of  polymorphonuclear  cells.  In  tuberculous  lesions  the 
blood  picture  exhibits  lymphocytosis  instead  of  predominance  of  polymorpho- 
nuclear cells  as  occurs  in  pyogenic  processes. 

Artificial  Stimulation  of  Phagocytosis. — When  active  h}'peremia  is  induced 
by  heat,  when' irritants  are  appUed  to  an  inflamed  surface,  or  when  an  inflamed 
joint  is  treated  by  Bier's  method  of  passive  hyperemia,  local  leukoc^losis  is 
stimulated  and  phagocytosis  becomes  more  active.  A  few  years  ago  Issaeff 
aflBjmed  that  the  introduction  of  certain  materials,  as  salt  solution,  into  the 
peritoneal  cavity,  lead,  for  a  time,  to  great  increase  in  the  resistance  to  abdom 
inal  infection.  This  period  of  increased  resistance  he  caUed  the  resistance  period. 
It  begins  a  few  hours  after  the  injection  and  terminates  by  the  end  of  the  fifth 
day.  During  this  period  the  great  increase  in  intraperitoneal  leukocytes  saves 
the  animal  from  infection  ^\'ith  bacteria,  which  would  other\\dse  cause  a  dan- 
gerous or  even  fatal  inflammation.  Mikulicz  believed  it  possible  to  estabhsh 
this  resistance  period  before  undertaking  abdominal  operations  and  was  working 
on  the  problem  just  before  his  lamented  death.  Mikulicz  used  diluted  nucleinic 
acid  injected  twenty-four  to  forty-eight  hours  previous  to  operation  (Mikulicz, 
'"Verhandl.  d.  ^t,.  Congress  d.  Deutsch.  Ges.  f.  Chir.,"  1904).  Graf's  studies  of 
nucleinic  acid  used  to  secure  immunity  from  puerperal  sepsis  were  inconclusive 
C'Zentralblatt  fiir  G}Tiakologie,"  1910,  No.  27).  Injections  of  nucleinic  acid 
cause  a  particular  rise  in  polymorphonuclear  ceUs.  At  the  height  of  the  process 
polymorphonuclear  cells  may  constitute  95  per  cent,  of  all  the  white  cells  seen  in 
the  count  (Fox  and  Lynch  in  "Am.  Jour.  Med.  Sci,"  1917,  cliii).  Some  surgeons 
have  injected  fresh  warm  horse-serum  for  the  same  piirpose  (Petie,  Jayle,  and 
Federmann;  see  "Le  Presse  Medicale,"  1905),  others  protein,  others  isotonic 
sugar  (Andain  Marmonteil  in  "Presse  Medicale,"  19 17,  xxv).  The  agents  used 
must  not  be  of  a  nature  to  damage  opsonins,  for  leukocytosis  without  plenty 
of  opsonins  would  not  favor  phagocytosis  and  w^ould  do  no  good.  A  true  in- 
fectious or  inflammatory  leukocytosis  is  much  more  protective  than  an  artificial 
leukocytosis,  however  induced.  In  fact  leukocytosis  induced,  for  instance,  by 
injecting  such  a  material  as  nuclein  is  of  very  little  use  against  an  estabhshed 
infection.  It  is  probably  of  more  value  as  a  protective  against  infection.  How 
slight  or  how  great  this  value  may  be  is  not  yet  certainly  determined.  We  do 
know  that  leukocytosis  due  to  injections  of  nucleinic  acid  cannot  be  maintained 
by  repeated  small  doses  (Fox  and  Lynch,  Ibid.).  It  is  a  transitory  leukocvtosis 
and  can  only  be  maintained  by  advancing  doses  (Neymann,  Bull,  of  Johns 
Hopkins  Hospital,  191 7,  xxxiii). 

Vital  Resistance. — ^Local  resistance  is  lowered  by  injury  or  disease  of  the  skin 
or  mucous  membrane.  Sound  skin  and  mucous  membrane  are  most  important 
elements  in  resistance.  For  instance,  disease  of  the  intestinal  mucosa  may  permit 
colon  baciUi  or  other  micro-organisms  to  be  taken  through  the  damaged  mucous 
membrane  and  to  be  carried  to  distant  regions  where  disease  may  arise. 

In  the  same  manner  pulmonary  tuberculosis  may  develop  subsequent  to 
disease  of  the  bronchial  mucous  membrane.  The  general  vital  resistance 
to  infection  depends  in  part  upon  germicidal  and  opsonic  blood-liquor  and  in 
part  upon  active  leukocytes. 


5©  Bacteriology 

Vital  resistance  is  increased  by  agents  which  cause  active  phagocytosis 
without  destruction  of  opsonins. 

Anything  that  lessens  the  germicidal  and  opsonic  power  of  blood-serum  or 
the  phagocytic  activity  of  corpuscles  lessens  general  vital  resistance.  Among 
these  causes  are  ill  health,  worry,  unhygienic  life,  chronic  drug  intoxications, 
alcoholism,  chronic  visceral  diseases,  diabetes,  Bright's  disease,  gout,  rheuma- 
tism, violent  and  sudden  fluctuations  of  temperature,  bodily  or  mental  over- 
work, improper  food,  insufficient  food,  too  little  sleep,  fear,  antecedent  illness, 
exposure  to  cold,  and  the  creation  of  points  of  least  resistance  (see  page  42). 
The  general  vital  resistance  to  infection  is  also  lowered  by  inordinate  prolonga- 
tion of  a  surgical  operation,  by  shock,  by  hemorrhage,  and  by  protraction  of  the 
anesthetic  state  %vith  ether  or  chloroform.  Exham  ("  Brit.  Med.  Jour.,"  Jan.  27, 
191 2)  points  out  that  inflammation  is  a  factor  in  resistance  (this  is  seen  by 
pus  limitation  in  appendiceal  abscess),  and  so  is  fever.  Elevated  temperature 
means  that  the  body  is  fighting  the  infection  (see  page  139). 

Diff'erent  tissues  in  the  same  individual  show  great  differences  in  resistance. 
We  know  that  certain  bacteria  have  a  predisposition  to  attack  certain  tissues. 
This  is  notably  true  of  tubercle  bacilli.  The  resistance  of  an  individual  varies 
at  different  times.  Heredity  often  plays  a  part  in  predisposition  and  resist- 
ance and  sex  has  some  influence  upon  it.  Race  is  influential  regarding  some 
diseases  (see  page  25).  Resistance  varies  at  different  ages.  Exham  ("Brit. 
Med.  Jour.,"  Jan.  27,  191 2)  points  out  that  children  are  particularly  prone  to 
acute  infections,  but  are  less  apt  to  die  of  them  than  are  adults. 

Protective  and  Preventive  Inoculations. — Our  knowledge  of  pro- 
tective inoculations  for  contagious  diseases  dates  from  Jenner's  discovery 
of  vaccination  against  small-pox  in  1798.  Preventive  inoculations  with  attenu- 
ated virus  are  due  to  the  ex-periments  of  Pasteur.  This  observer  discovered 
the  cause  of  chicken-cholera,  and  cultivated  the  micro-organism  of  the  disease 
outside  the  body.  He  found  that  by  keeping  his  cultures  for  some  time  they 
became  attenuated  in  virulence,  and  that  these  attenuated  cultures,  inoculated 
in  fowls,  caused  a  mild  attack  of  the  disease,  which  attack  was  protective,  and 
rendered  the  fowl  immune  to  the  most  virulent  cultures.  Cultures  can  be 
attenuated  by  keeping  them  for  some  time,  by  exposing  them  for  a  short  period 
to  a  temperature  just  below  that  necessary  to  kill  the  organisms,  or  by  treating 
them  with  certain  antiseptics.  It  has  further  been  shown  that  injection  of  the 
blood-serum  of  an  animal  rendered  immune  by  inoculation  is  capable  of  making 
a  susceptible  animal  also  immune.  Animals  may  be  protected  against  anthrax 
by  the  injection  of  attenuated  cultures  or  of  the  blood-serum  of  actively  mini- 
mized animals.  Promising  results  have  been  obtained  in  the  prevention  of 
cholera.  Some  have  used  attenuated  cultures,  some  the  blood-serum  of 
immunized  animals,  some  dead  bacteria.  The  serum  of  immunized  animals  is 
used  to  protect  man  from  tetanus  and  diphtheria. 

A  most  important  fact  is  that  animals  may  be  rendered  immune  to  certain 
diseases  by  inoculating  them  with  filtered  cultures  of  the  microbes  of  the  dis- 
ease, the  filtrate  containing  microbic  products,  but  not  living  microbes.  By 
this  method  animals  can  be  rendered  immune  to  tetanus  and  diphtheria.  The 
serum  of  such  an  immunized  animal  if  injected  into  a  man  will  render  him  also 
immune.  An  antitoxin  for  the  prevention  of  gas  gangrene  is  now  on  trial. 
Pasteur's  protective  inoculations  against  hydrophobia  owe  their  power  to  mi- 
crobic products,  and  Koch's  lymph  contains  them  as  its  active  ingredients. 
Injections  of  dead  bacteria  are  the  basis  of  inoculation  against  typhoid  fever. 
Inoculation  with  dead  bacteria  is  called  vaccination  and  the  dead  bacteria  con- 
stitute the  vaccine  (see  page  54).  Protective  vaccination  has  been  highly  suc- 
cessful in  preventing  typhoid  fever.  Three  injections  of  the  vaccine  are  given 
at  ten-day  intervals.  The  first  dose  is  five  hundred  million  dead  bacteria. 
The  second  and  third  doses  each  contain  one  billion  dead  bacteria. 


Orrhotherapy,  or  Serum-therapy  51 

In  the  U.  S.  Navy  in  1900  the  total  strength  of  personnel  was  23,756.  That 
year  there  were  175  cases  and  25  deaths  from  typhoid.  In  191 1  injections 
were  made  optional  and,  with  a  personnel  of  61,399  there  were  222  cases  and 
15  deaths  from  typhoid.  In  191 2  injections  were  made  obligatory.  In  a 
personnel  of  61,897  there  were  57  cases  of  typhoid  and  2  deaths.  In  1913 
there  were  22  cases  and  4  deaths.  In  1914,  13  cases  and  no  deaths.  In  191 5, 
in  a  personnel  of  68,075  there  were  18  cases  and  i  death.  In  1916  there  were 
17  cases  and  no  deaths.  In  191 7,  with  an  enormously  increased  personnel  there 
were  66  cases  and  i  death. 

In  1916  there  was  not  one  death  from  typhoid.  For  191 5  Admiral  Wm.  S. 
Braisted  calculated  that  in  the  Navy  the  incidence  of  typhoid  is  7  per  100,000 
against  8.65  per  hundred  thousand  in  our  large  cities  (Annual  Report  of  the 
Surgeon- General,  U.  S.  Navy,  1916). 

In  1 913,  12,000  troops  were  assembled  on  the  Mexican  border  and  500  of 
them  remained  for  two  years.    There  was  not  a  single  case  of  typhoid  among  them. 

In  1 91 6,  130,000  militia  (including  civilians  serving  with  the  army)  and 
43,500  regulars  were  assembled  along  the  Mexican  border.  Thirteen  thousand 
of  these  were  sent  into  Mexico.  Many  arrived  before  the  full  course  of 
inoculations  had  been  completed.  There  were  37  cases  of  typhoid  fever. 
Eight  of  these  had  never  been  vaccinated  against  typhoid  fever  (six  civilians, 
one  regular  and  one  militiaman.  In  two  regulars,  three  years  had  expired 
since  vaccination  and  two  militiamen  had  been  given  but  two  doses  each). 

Official  figures  are  not  yet  obtainable  from  the  Surgeon-General  of  the  Army. 
Some  of  the  supposed  cases  have  not  yet  been  confirmed  as  having  been  typhoid. 

The  above  information  as  to  the  Army  was  sent  me  by  Dr.  A.  W.  Williams, 
Major,  Medical  Corps,  U.  S.  A.  Admiral  Wm.  S.  Braisted,  Surgeon-General 
of  the  U.  S.  Navy,  wrote  me  as  to  the  naval  figures. 

The  chief  feature  in  acquired  immunity  is  the  presense  in  the  blood  and 
tissues  of  elements  which  can  neutralize  the  toxic  products  of  bacteria.  These 
elements  are  "antitoxins"  (see  page  46).  Microbic  products  are  dead  and 
cannot  multiply  as  can  living  bacteria,  hence  the  human  organism  is  not  over- 
whelmed unless  the  dose  is  too  large,  but  the  microbic  products  cause  the 
development  of  antitoxin  as  certainly  as  do  the  living  microbes.  The  above 
facts  are  of  immense  importance,  for  on  these  lines  may  be  solved  the  problems 
of  the  prevention  and  treatment  of  microbic  maladies. 

The  horse  is  naturally  immune  to  diphtheria.  In  order  to  increase  the 
antitoxic  powers  of  his  serum,  toxin  is  obtained  from  cultures  of  the  germs  of 
diphtheria  and  is  injected  into  his  blood.  Serum  so  treated  has  become  able,  if 
injected  into  a  person  to  render  him  temporarily  immune  to  the  disease  and  if 
injected  into  a  person  with  diphtheria  to  cure  or  ameliorate  the  disease. 

Orrhotherapy,  or  serum=therapy,  is  an  attempt  to  utilize  therapeu- 
tically the  germicidal  properties  of  blood-serum.  It  is  believed  that  when 
a  person  recovers  from  an  infectious  disease  the  alkaline  blood-serum  is  satu- 
rated with  protective  material,  particularly  with  antitoxin.  If  this  belief  is 
true,  a  proper  deduction  is,  that  blood-serum  containing  protective  material 
should  cure  the  disease  if  injected  into  a  patient  suffering  from  an  attack. 
Some  sera  used  therapeutically  are  antitoxic,  that  is,  they  do  not  kill  bacteria, 
•but  merely  neutralize  the  toxin.  Others  are  bacteriolytic,  destroying  and 
dissolving  bacteria.  An  antitoxic  serum  is  made  by  injecting  a  horse  with 
toxin.  The  horse-serum  comes  to  contain  antitoxin.  Antibacterial  serum 
is  obtained  by  injecting  an  animal  first  with  the  dead  and  then  with  the 
living  bacteria.  The  serum  contains  the  bacteriolytic  material.  Instead  of 
using  the  blood-serum  itself,  some  observers  have  precipitated  the  supposed 
curative  material  from  the  serum,  have  dissolved  this  material,  and  have 
administered  the  solution  in  fixed  amounts.     Instead  of  using  the  serum  of 


52  Bacteriology- 

persons  rendered  immune  by  an  attack  of  the  disease,  many  physicians  have 
employed  the  serum  of  animals  rendered  artificially  immune  by  injections  of 
attenuated  cultures  of  the  bacteria  or  injections  of  bacterial  products.  Some 
experimenters  have  even  employed  the  serum  of  animals  naturally  immune 
to  the  disease.  In  some  cases  the  serum  is  given  hypodermatically,  in  some 
intravenously,  in  some  by  lumbar  puncture,  in  some  by  intracerebral,  and 
in  others  by  intraneural,  injection.  Claims  have  been  made  that  serums  are 
eflacient  when  given  by  the  mouth  or  by  the  rectum.  Paten  of  Melbourne, 
claimed  in  1906  that  the  oral  administration  of  immune  serum  raised  the  opsonic 
index  ("Med.  Press  and  Circular,"  Jan.  31  and  Feb.  7,  1906). 

Latham  ("Lancet,"  Feb.  15,  1908)  and  others  claim  that  clinical  and  bac- 
teriologic  evidences  are  in  favor  of  the  view  that  serums  are  efficient  when  given 
by  the  mouth.  If  these  views  are  proved  to  be  true  serum- therapy  will  receive 
an  enormous  impetus,  but  as  yet  they  are  not  proved  and  the  way  of  wisdom  is 
to  give  serum  subcutaneously,  intraspinally  or  by  the  blood.  Calmette  has 
perfected  an  antivenomous  serum  (antivenene)  for  use  after  cobra  bites.  Pasteur 
devised  a  method  which  will  usually  prevent  hydrophobia  (see  page  353).  That 
Murri,  of  Bologna,  has  apparently  cured  a  case  of  hydrophobia  seems  proved 
(see  page  354).  There  is  no  doubt  of  the  utiHty  of  diphtheria  antitoxin  as  a 
prophylactic  agent  and  as  a  therapeutic  agent.  In  1895  the  deaths  from  diph- 
theria in  the  registration  area  of  the  United  States  were  80  per  100,000.  In 
1907  they  were  17  per  100,000  (T.  Stuart  Chapin,  "Pop.  Science  Monthly," 
Feb.,  1917). 

Tetanus  antitoxin  has  high  value  as  a  preventive  of  the  disease  and  many 
are  convinced  of  its  therapeutic  value.  The  earlier  in  the  disease  the  injection 
of  an  antitoxic  serum  is  practised  and  the  larger  the  dose,  the  more  apt  it  is  to 
prove  curative.  When  the  toxin  has  not  yet  combined  with  cells,  antitoxin 
may  keep  it  from  doing  so,  and  when  it  has  recently  combined  and  the  com- 
bination is  still  unstable,  antitoxin  may  cause  dissociation  of  the  combination. 
When  the  disease  is  well  established  and  the  cell  combination  of  toxin  is  firm, 
antitoxin  will,  in  all  probability,  fail  to  cure.  If  we  decide  to  give  serum  in 
an  acute  infection,  give  it  early  and  as  advised  by  Ball  ("Lancet,"  June  8,  1912). 

A  rapid  effect  will  be  obtained  by  mixing  the  serum  with  normal  salt  solu- 
tion and  throwing  100  c.c.  of  the  mixture  into  a  vein.  Each  day  after  this 
50  to  100  c.c.  are  given  subcutaneously. 

Ball  advises  that  we  obtain  the  serum  which  is  most  nearly  autogenous. 
The  best  is  obtained  from  the  blood  of  one  who  has  recently  recovered  from  the 
identical  infection.  The  next  best  is  obtained  from  a  person  who  has  been  arti- 
ficially immunized.  Make  a  vaccine  at  once,  and  as  soon  as  it  is  made,  sub- 
stitute it  for  the  serum  injections. 

It  is  very  important  to  remember  that  the  water  of  the  salt  solution  must 
have  been  recently  distilled.  Otherwise  an  intravenous  injection  of  serum  and 
salt  solution  will  be  followed  by  a  chill  in  from  one-half  to  two  hours  after  the 
injection  (Ball,  in  "Lancet,"  June  8,  191 2).  In  order  to  make  diphtheria 
antitoxin  a  horse  is  immunized  to  diphtheria  toxin  by  injecting  subcutaneously 
increasing  doses  of  diphtheria  toxin.  It  requires  two  or  three  months  for  the 
blood  of  the  animal  to  acquire  sufficient  potency.  The  blood  containing  anti- 
toxin is  withdrawn  by  bleeding,  the  serum  is  separated  from  the  clot,  and  its 
antitoxic  potency  is  determined  by  complicated  methods.  We  signify  the  de- 
gree of  potency  of  a  serum  by  saying  that  it  is  of  so  many  "immunizing  units," 
a  unit  being  an  arbitrary  standard.  The  average  dose  for  a  child  is  1000  units 
and  for  an  adult  2000  units.  (Tetanus  Antitoxin  is  considered  on  page  232; 
Antivenene  is  considered  on  page  346.) 

Anthrax  in  animals  and  human  beings  has  been  treated  with  success  by 
Sclavo's  serum  (the  serum  of  an  actively  immunized  animal).  The  antimenin- 
gococcus  serum  of  Flexner  and  Jobling  seems  to  possess  distinct  power  in  the 


Anaphylaxis,  or  Untoward  Effects  of  Serum  Injections  53 

treatment  of  epidemic  cerebrospinal  meningitis.  It  is  given  by  lumbar  puncture. 
It  has  reduced  child  mortality  from  this  disease  at  least  50  per  cent.  Cholera 
serum  has  not  as  yet  proved  of  avail  therapeutically.  Shiga's  antidysenteric 
serum  is  of  value.  Claims  are  made  for  plague  serum.  A  serum  against  gas 
gangrene  is  on  trial.  Inconclusive  experiments  have  been  made  in  the  treat- 
ment of  sx-philis  by  the  serum  of  dog's  blood  and  by  the  blood-serum  of  men 
laboring  under  tertiary  syphilis;  in  the  treatment  of  pneumonia  by  the  blood- 
serum  of  persons  convalescent  from  pneumonia;  and  in  the  treatment  of  sufferers 
from  septic  diseases  by  antistreptococcic  serum — blood-serum  of  horses  rendered 
immune  to  virulent  streptococci.  The  serum  treatment  of  pneumonia  may 
with  justice  be  called  a  failure.  The  real  value  of  antistreptococcic  serum  is. 
yet  uncertain.  Occasionally  it  seems  to  do  great  good;  at  other  times  it  appears 
to  produce  no  benefit  whatever.  Some  observers  claim  remarkable  results  in 
erysipelas.  In  several  cases  of  phlegmonous  erysipelas  and  in  2  cases  of  malig- 
nant endocarditis  I  thought  it  was  of  benefit.  In  some  cases  we  seem  to  obtain 
brilliant  results,  but  in  others  no  results.  We  cannot  explain  this  variability 
of  action.  Antistreptococcic  serum  often  fails  completely.  This  is  supposed 
to  be  due  to  the  fact  that  there  are  many  different  families  of  streptococci. 
It  was  hoped  that  a  polwalent  serum  would  prove  efl&cient,  but  the  hope  is 
still  only  a  hope.  It  has  been  proved  that  some  antistreptococcic  sera  have  not 
as  high  an  opsonic  index  for  streptococci  as  has  normal  horse-serum,  and  ''the 
opsonin  content  of  an  antistreptococcic  serum  seems  to  be  the  factor  that  gives 
the  serum  whatever"  value  it  possesses  (Jordan's  "General  Bacteriology"). 
Tavel  and  Moser,  believing  that  scarlatina  is  a  streptococcic  malady,  prepare 
serum  by  using  cultures  of  streptococci  obtained  from  a  number  of  cases  of 
scarlet  fever.  Van  de  Velde  uses  cultures  of  streptococci  obtained  from  various 
streptococci  infections.  Acocrding  to  Burkard  antistreptococcic  serum  destroys 
neutrophiles  in  the  blood.  This  destruction  is  not  harmful  if  leukocytosis 
follows  the  injections,  and  it  does  follow  them  in  all  cases  when  the  body  is 
able  to  react  to  the  serum  ("Archiv.  f.  Gjmak.,"  Ixxx,  No.  3).  Before  remov- 
ing a  tongue,  an  upper  jaw  or  a  lower  jaw,  it  is  my  custom  to  give  antistrepto- 
coccic serum,  and  I  beheve  that  it  lessens  the  tendency  to  toxemia  and  to  septic 
bronchopneumonia.  Malignant  tumors  (both  sarcomata  and  carcinomata)  have 
been  treated  with  the  blood-serum  of  dogs,  which  animals  have  been  injected 
T\ith  fluid  expressed  from  malignant  growths  (Richet  and  Hericourt) .  Von  Ley- 
den  and  Blumenthal  obtained  a  serum  by  compression  of  a  recent  cancerous 
growth  and  treated  human  victims  of  cancer  with  it.  They  claimed  that  the 
results  were  encouraging  ("Deutsche  medicinische  Wochenschrift,"  Sept.  4, 
1902).  It  is  certain  that  diphtheria  antitoxin  has  reduced  enormously  the  death 
rate  from  diphtheria.  It  is  claimed  that  antimeningitis  serum  has  reduced  child 
mortahty  from  this  disease  50  per  cent.  Many  claims  made  for  serum-therapy  in 
surgical  diseases  are  exaggerated,  sensational,  and  unscientific.  It  does  not 
seem  possible  to  obtain  an  antitoxin  for  each  bacterial  malady,  and  the  bacteria 
of  most  specific  diseases  are  potent  for  harm  for  more  reasons  than  because  they 
form  crystalloidal  toxic  matter.  That  there  is  truth  in  the  method  seems  highly 
probable,  but  how  much  truth  there  is,  is  not  yet  definitely  ascertained.  It  is 
our  duty  to  study,  experiment,  and  observe,  and  to  reach  a  conclusion  only  after 
honest,  careful,  and  thorough  investigation.  A  little  skepticism  is  as  yet  a  safe 
rule.  A  writer  of  a  book  finds  himself  in  doubt  about  many  of  the  claims  made 
for  serum  therapv.  He  should  follow  the  rule  set  forth  by  Mark  Twain,  viz : 
"When  in  doubt  tell  the  truth." 

Anaphylaxis,  or  Untoward  Effects  of  Serum  Injections. — Anaphylaxis  is  a 
term  introduced  by  Richet  in  1904  to  designate  a  state  of  h\^ersusceptibility 
(congenital  or  acquired)  "to  a  strange  protein  or  antigen  with  a  reaction  body 
formed  in  the  body  of  the  organism  undergoing  immunity"  (St.  George  T. 
Grinnan,  in  "Jour.  Amer.  Med.  Assoc,"  Jan.  20,  191 2).     It  has  been  knowm 


54  Bacteriology 

for  a  considerable  time  that  guinea-pigs  which  had  been  injected  with  anti- 
toxin frequently  died  when  given  another  injection  some  time  later.  The 
curious  fact  is  that  the  first  dose  does  no  harm,  but  the  second  dose,  given 
days  after,  produces  the  trouble.  The  reinjection  is  the  dangerous  act. 
By  reinjection  we  mean  an  injection  given  fourteen  days  or  longer  after  a 
previous  injection.  At  between  eight  and  twelve  days  after  an  injection  of 
serum  all  antitoxin  should  disappear  from  the  system.  In  man  unpleasant  or 
even  dangerous  effects  may  follow  the  injection  of  any  serum.  They  occur  in 
certain  h}^ersensitive  individuals.  They  may  occur  from  a  first  dose,  but  are 
far  more  apt  to  arise  from  the  second,  the  third,  or  some  later  injection.  They 
are  most  apt  to  occur  when  there  has  been  an  interval  of  two  or  three  weeks  be- 
tween injections.  In  some  cases  where  death  followed  a  first  injection  an  enlarged 
thymus  existed.     In  a  recent  case  in  Philadelphia  this  was  proved  by  autopsy. 

The  symptoms  may  be  trivial  and  not  arise  for  several  hours.  The  most 
common  ones  are  joint  pains,  weakness,  depression,  dyspnea,  urticaria  or 
erythema,  cough,  itching,  sneezing,  edema  of  the  face,  and  swelling  of  the 
tongue  ("Progressive  Medicine,"  Dec.  i,  1908).  There  is  moderate  elevation 
of  temperature  for  a  few  hours. 

The  symptoms  may  be  serious  and  arise  in  a  few  minutes.  In  such  a  con- 
dition any  of  the  previously  mentioned  symptoms  may  exist,  but  the  dysp- 
nea is  urgent,  the  face  is  often  cyanosed,  and  collapse  occurs.  In  some  cases 
death  occurs  in  a  few  minutes  after  an  injection.  When  untoward  results 
follow  a  first  injection  the  condition  is  regarded  as  hypersusceptibility  to  serum. 
When  it  follows  a  later  injection  it  is  called  serum  disease.  We  fear  fatality 
from  an  initial  dose  when  there  is  hypersusceptibility.  Serum  disease  is 
usually  made  manifest  by  minor  symptoms  developing  from  eight  to  thirteen 
days  after  a  first  injection  or  almost  at  once  after  an  injection  given  from  four- 
teen days  to  four  months  after  the  first  one.  There  is  no  way  of  knowing 
beforehand  that  a  person  is  hypersensitive  or  that  he  is  liable  to  serum  disease 
although  we  may  suspect  it.  Asthma  is  ominous  and  makes  us  fear  some 
untoward  effect.  Those  who  get  hay  fever  or  urticaria,  who  have  purpura 
or  tuberculosis  or  who  are  much  "affected  by  various  scents  (smell  of  horses)" 
are  viewed  with  suspicion.  If  an  injection  is  given,  give  it  very  slowly  and 
be  ready  to  stop  at  the  first  sign  of  trouble  (see  MacConkey  and  Homer  in 
"Brit.  Med.  Jour.,"  Feb.  17,  1917.  They  quote  the  Committee  of  Societe 
Medicale  des  Hopitaux  de  Paris,  Ibid.).  The  dyspnea  in  some  cases  may  have 
been  due  to  enlarged  thymus.  In  using  diphtheria  antitoxin  or  tetanus  anti- 
toxin the  serum  should  be  given  at  close  intervals  and  not  at  intervals  of  several 
days.  In  this  war  there  have  been  cases  of  tetanus  arising  after  the  protection 
from  a  prophylactic  dose  of  antitetanic  serum  has  run  out.  Because  of 
such  cases  it  is  now  the  custom  after  a  wound  to  give  several  doses  of  serum 
repeated  at  intervals  of  seven  or  eight  days  and  in  some  few  of  these  cases 
serum  disease  has  developed  (Committee  Societe  Medicale  des  Hopitaux  de 
Paris.  Report  published  in  "Bull.  Societe,"  Nov.  19,  1915).  Longcope 
discussed  The  Susceptibility  of  Man  to  Foreign  Proteids  in  the  "American 
Journal  of  Medical  Sciences,"  1916,  clii. 

There  is  no  danger  of  bacterial  vaccines  causing  proteid  poisoning  if  a  person 
has  not  been  sensitized  by  serum.  The  doses  are  too  small.  If  a  person  had 
been  sensitized  by  serum  it  is  possible  that  bacterial  vaccines  might  cause 
anaphylaxis.  To  avoid  this  Sherman  advises  giving  small  doses  after  brief 
intervals  (G.  H.  Sherman,  in  "Internat.  Jour,  of  Surg.,"  1914,  xxvii). 

Vaccine  Therapy,  or  Treatment  of  Infections  by  Bacterial  Vac= 
cines  {Bacterines,  as  S.  Solis  Cohen  calls  them).^ — The  studies  of  Wright  and 

1  In  this  connection  see  particularly  article  by  Roger  J.  Lee  and  article  by  H.  F.  Hartwell 
and  Roger  J.  Lee  in  "Publications  of  Mass.  General  Hosp.,"  October,  1908;  also  article  by 
Ball,  in  "Lancet,"  June  8,  1912.     I  have  used  these  articles  freely. 


Vaccine  Therapy,  or  Treatment  of  Infections  by  Bacterial  Vaccines 


:>:> 


Douglas  upon  opsonins  led  to  the  adoption  of  this  plan  of  treating  certain 
infections. 

By  the  injection  of  an  antitoxic  scrum  we  seek  to  neutralize  directly  toxic 
products.  By  the  injection  of  the  bacterial  vaccines  we  seek  to  stimulate  the 
body  cells  to  produce  antibodies  and  particularly  opsonin.  An  injection  of 
antitoxic  serum  has  only  a  temporary  eflfect.  Injections  of  bacterial  vaccine 
cause  a  much  more  enduring  effect.  After  such  an  injection  the  opsonic  index 
usually  begins  to  rise  in  from  twelve  to  twenty-four  hours.  Additional  doses 
gain  more  pronounced  response.  The  injections  appear  to  be  free  from  all 
danger.  Bacterial  vaccine  consists  of  dead  bacteria  and  their  endotoxins 
made  into  emulsion  in  normal  salt  solution.  Each  individual  has  his  own  re- 
sponse to  such  an  injection,  but  this  response  varies  at  different  times.  An 
antitoxic  serum  contains'  other  antibodies  besides  antitoxin.  Bacterial  vac- 
cine is  made  up  with  salt  solution  and  is  truly  specific.  A  vaccine  made 
up  from  a  certain  variety  of  organism  is  valuable  only  in  infection  from 
that  variety  of  organism.  In  some  cases  stock  cultures  are  used,  but  it  is 
better  w^henever  possible  to  obtain  the  bacteria  from  the  infected  person  and 
obtain  our  cultures  from  them  (autogenous  vaccine).  In  some  cases,  how- 
ever, we  cannot  wait  for  the  development  of  a  culture  and  must  then  use 
stock  vaccines.  In  er^-sipelas  we  cannot  use  autogenous  vaccine.  In  a  mixed 
infection  it  is  sometimes  uncertain  which  organism  is  the  main  factor  in  causing 
the  trouble  and  danger,  and  yet  it  is  the  main  factor  against  which  the  vaccine 
must  be  leveled.  Until  recently  it  was  beheved  that  the  dose  must  be  deter- 
mined by  the  opsonic  index.  This  plan  is  now  seldom  followed.  Each  cubic 
centimeter  of  Wright's  stock  vaccine  contains  600,000,000  dead  bacteria. 
The  first  dose  is  y^  c.c.  and  the  second  dose  is  i  c.c.  Hartwell  and  Lee  repeat 
the  fuU  dose  every  fourth  or  fifth  day  until  the  lesions  are  cleared  up  ("Pub- 
lications of  Mass.  General  Hosp.,"  Oct.,  1908).  Each  injection  is  made  in  the 
subcutaneous  tissue,  the  skin  having  been  previously  scrubbed  with  soap  and 
water  and  washed  with  alcohol.  In  many  cases  there  is  a  trivial  reaction  after 
injection.  This  reaction  is  not  febrile,  is  of  brief  duration,  and  is  manifested 
by  headache,  backache,  and  languor.  It  might  well  be  asked,  "  Why  inject  dead 
bacteria  to  stimulate  resistance  when  live  bacteria  in  the  individual  have  failed 
to  do  it?"  The  theory  is  that  the  bacteria  causing  the  disease  have  died  too 
quickly  in  the  blood  or,  for  some  other  reason,  have  failed  to  produce  enough 
stimulation  to  result  in  the  copious  production  of  antibodies. 

There  is  much  testimony  as  to  the  value  of  this  plan  of  treatment.  It  is 
said  that  the  temperature  of  some  cases  of  streptococcic  infection  may  be 
lowered  rapidly  by  vaccine  treatment,  pus  formation  ma}^  be  lessened,  and 
delirium  aboHshed.  It  is  considered  particularly  serviceable  in  superficial 
infections  from  the  Staphylococcus  aureus  (boils  and  carbuncles).  In  many 
cases  pain  and  tenderness  begin  to  abate  a  few  hours  after  the  first  injection, 
a  profuse  discharge  flows  from  the  lesion  if  it  is  open,  and  gathers  in  the  tissues 
if  there  is  no  opening.  If  the  focus  of  infection  is  closed  it  should  be  incised, 
but  Wright  insists  that  antiseptics  must  not  be  used,  as  they  destroy  the 
activity  of  opsonins.  It  has  been  thought  to  do  good  in  pyeHtis  and  in 
osteomyelitis.  In  some  cases  it  seems  to  mitigate  the  virulence  of  infection 
so  that  drugs  previously  impotent  become  active  for  good.  The  treat- 
ment is  of  little  or  no  value  in  abscess,  pyemia,  septicemia,  and  mixed 
infections.  It  seems  certain  that  in  an  overwhelming  infection  a  vaccine  can 
do  no  possible  good.  In  such  a  condition  it  cannot  possibly  cause  the  patient's 
tissues  to  produce  antibodies.  We  may  lay  it  down  as  a  rule  that  vaccines  are 
particularly  indicated  for  chronic  and  for  local  infections,  and  serums  for  general 
infections.  In  an  acute  infection  give  serum  at  once  and  autogenous  vaccine 
as  soon  as  it  can  be  made  (Ball's  rule).  My  own  experience  with  the  thera- 
peutic  use    of   vaccines   has   been   rich   in   disappointments.     The   greatest 


56  Bacteriology 

claims  made  for  them  have  been  in  the  treatment  of  staphylococcic  lesions  of 
the  skin,  but  most  dermatologists  have  lost  all  the  confidence  of  ten  years  ago. 

In  the  sepsis  encountered  in  the  war  the  treatment  has  proved  futile. 

Sir  Almroth  Wright  admits  that  vaccine  therapy  practically  takes  a 
secondary  place  when  compared  with  preventive  vaccination. 

H.  G.  Adamson  has,  in  a  recent  number  of  "The  Lancet"  (August  10,  1918), 
set  forth  some  of  the  disappointments  of  vaccine  therapy. 

Tuberculin. — (See  page  243.) 

Special  Surgical  Microbes. — Suppuration  (see  page  143)  is  caused  by 
microbes.  Does  it  ever  exist  without  them?  The  answer  is,  "  Practically  no." 
Injection  of  a  sterile  fluid  containing  dead  organisms,  or  the  injection  of  the 
sterile  products  of  the  growth  of  pyogenic  cocci,  will  form  a  limited  amount  of 
pus.  Injection  of  an  irritant  causes  the  formation  of  a  thin  fluid  which  may 
resemble  pus,  but  is  not  pus.  In  surgery  pus  very  seldom  forms  without  the 
actual  presence  of  living  micro-organisms  (see  page  144),  and  the  presence  of 
pus  is  regarded  as  proving  the  presence  of  living  micro-organisms. 

Pyogenic  Bacteria. — Pus  microbes,  or  pyogenic  microbes,  are  strongly  pro- 
teolytic, that  is,  they  possess  the  property  of  peptonizing  albumin,  and  thus 
forming  pus.  The  peptonizing  action  is  brought  about  by  bacterial  prod- 
ucts. Some  believe  that  pus  is  not  formed  by  a  peptonizing  action  of  the 
bacteria,  but  that  the  bacteria  furnish  a  poison  (leukolysin)  which  breaks 
up  the  leukocytes,  and  that  the  breaking  up  of  leukocytes  liberates  an  enzyme 
which  dissolves  albumin.  The  inflammation  which  surrounds  an  area  of 
pyogenic  infection  is  caused  by  the  irritant  products  of  bacterial  action  (tox- 
albumins,  ammonia,  etc.).  In  the  presence  of  the  pyogenic  peptones  the 
coagulation  of  inflammatory  exudate  is  retarded  or  prevented.  Bacteria 
which  ordinarily  cause  suppuration  may  fail  to  cause  it,  producing  instead 
a  non-suppurative  inflammation.  Non-suppurating  inflammation  may  arise 
if  bacteria  are  present  in  small  numbers  or  if  the  tissue  resistance  is  at  a  high 
level,  or  if  the  virulence  of  the  bacteria  has  been  modified  by  adverse  antecedent 
conditions.  Bacteria  which  ordinarily  do  not  cause  suppuration  may  do  so 
under  certain  conditions  of  increased  bacterial  virulence  or  lessened  tissue 
resistance.  The  typhoid  bacillus  is  at  times  pyogenic,  but,  as  a  rule,  it  is  not 
pyogenic.     The  usual  causes  of  suppuration  are  the  following  micro-organisms. 

The  term  Micrococcus  pyogenes  (Fig.  15)  includes  the  Staphylococcus 
aureus,  the  Staphylococcus  albus,  and  the  Staphylococcus  citreus.  These 
forms  are  deviations  from  one  form  and  are  not  specifically  different.  The 
albus  and  citreus  may  be  grown  from  the  aureus,  and  they  may  remain  white 
and  yellow  or  may  revert  in  part  to  the  aureus  form  ("Atlas  of  Bacteriology," 
by  Lehmann  and  Neumann).  Some  observers  maintain  that  these  forms  vary 
greatly  in  virulence  and  hence  are  specifically  different,  but  the  varying  virulence 
has  been  disputed,  and  it  seems  to  have  been  proved  that  virulence  may  be 
lessened  greatly  even  when  the  color  does  not  change.  Eighty  per  cent,  of 
acute  abscesses  are  due  to  staphylococci.  Staphylococci  are  found  also  in 
osteomyelitis,  in  carbuncle,  in  boil,  in  acne,  in  pemphigus,  in  periostitis,  in 
septicemia,  and  in  pyemia,  and  in  some  cases  of  empyema  and  peritonitis. 
Some  toxic  products  of  staphylococci  destroy  leukocytes.  All  of  the  sta- 
phylococci are  non-motile. 

Staphylococcus  pyogenes  aureus  (Plate  i,  Figs,  i  and  15),  is  the  golden- 
yellow  coccus.  When  grown  in  the  air  it  produces  orange-yellow  pigment. 
This  is  the  most  usual  cause  of  abscesses  (circumscribed  suppurations).  The 
Staphylococcus  pyogenes  aureus  growsbest  in  air,  but  can  grow  when  air  is  ex- 
cluded. As  it  can  thus  grow  it  is  a  facultative  anaerobic  parasite.  It  is 
widely  distributed  in  nature,  and  is  found  in  the  soil,  the  dust  of  air,  water,  the 
alimentary  canal,  under  the  nafls,  on  and  in  the  superficial  layers  of  skin, 
especially  in  the  axilla  and  perineum,  in  the  mouth,  the  nasal  cavities,  the 


BACTERIOLOGY. 


Plate  i. 


1.  Staphylococcus  pyogenes  aureus. 

2.  Staphylococcus  pyogenes  albus. 

3.  Bacillus  tuberculosis  on  glycerin-agar. 

(Warren's  Surgical  Pathology. ) 


Pyogenic  Bacteria 


.■>/ 


vagina,  and  human  milk.  It  forms  the  characteristic  color  only  when  it  grows 
in  air  (Plate  i,  Fig.  i).  It  is  killed  in  ten  minutes  by  a  moist  temperature  of 
58°  C.  and  is  instantly  killed  by  boiling  water.  Carbolic  acid  (1:40)  and 
corrosive  sublimate  (1:2000)  are  quickly  fatal  to  this  coccus. 

Staphylococcus  pyogenes  albus  (Plate  i,  Fig.  2),  the  white  staphylococcus, 
acts  like  the  aureus,  but  is  usually  more  feeble  in  power.  When  this  organism 
is  found  upon  and  in  the  skin  it  is  called  the  Staphylococcus  epidermidis  albus, 
an  organism  which  Welch  proved  to  be  the  usual  cause  of  stitch-abscesses. 

Staphylococcus  pyogenes  citreus,  the  lemon-yellow  coccus,  is  found  occa- 
sionally in  acute  circumscribed  suppurations,  but  less  often  than  are  the  other 
two  forms.     Its  pyogenic  power  is  even  weaker  than  that  of  the  albus. 

The  Staphylococcus  cereus  albus  and  the  Staphylococcus  cereus  flavus  are 
found  occasionally  in  acute  abscesses,  but  these  forms  cannot  be  sharply  dif- 
ferentiated from  the  Micrococcus  pyogenes  and  the  names  should  be  abandoned. 

Staphylococcus  flavescens  is  occasionally  found  in  abscesses.  It  is  inter- 
mediate between  the  aureus  and  albus. 

Micrococcus  pyogenes  tenuis  rarely  takes  the  form  of  a  bunch  of  grapes. 
It  is  occasionally  found  in  the  pus  of  acute  abscesses. 


Fig.  15. — Micrococcus  pyogenes  aureus  Fig.  16. — Streptococcus  pyogenes  (X  700) 

(X  1000)  (Lehmann  and  Neumann).  Lehmann  and  Neumann.) 

The  Micrococcus  tetragenus  is  thought  to  be  the  bacterium  chiefly  respon- 
sible for  the  suppuration  of  tuberculous  pulmonary  lesions. 

Streptococcus  pyogenes  (Fig.  16). — This  coccus,  known  as  the  chain  coccus, 
grows  best  in  air  and  can  also  grow  when  air  is  excluded.  It  is  non-motile  and 
does  not  bear  spores.  It  is  found  in  the  healthy  human  body  in  the  nasal 
cavities,  urethra,  mouth,  vagina,  and  on  the  skin.  It  has  been  found  in  spread- 
ing inflammation  and  suppuration,  erysipelas,  pneumonia,  otitis,  puerperal 
fever,  pyemia,  septicemia,  lymphangitis,  some  very  acute  abscesses,  and  some 
cases  of  meningitis,  empyema,  peritonitis,  ulcerative  endocarditis,  pericarditis, 
osteomyelitis,  diarrhea,  and  in  certain  sore  throats.  It  varies  very  greatly 
in  virulence  and  the  intensity  of  its  action  is  strongly  influenced  by  the  nature 
of  the  soil  in  which  it  is  implanted.  Streptococci  are  apt  to  cause  serious  local 
lesions,  violent  constitutional  involvement,  and  frequently  death.  Not  only  do 
streptococci  produce  virulent  toxins,  but  they  also  produce  a  non-toxic  material 
called  hemolysin,  which  dissolves  red  corpuscles.  Some  bacteria  always  get 
in  the  blood  during  the  existence  of  a  streptococcic  infection.  In  a  mild  case 
those  which  enter  the  blood  are  soon  killed.  Even  in  a  very  severe  case  we  may 
be  unable  to  demonstrate  them,  but  they  are  surely  there.  Woodhead  tells 
us  (Treves's  "System  of  Surgery")  that  six  organisms,  each  of  which  bears  a 
separate  name,  are  discussed  under  this  designation.  Three  of  these  organ- 
isms he  places  in  one  group,  two  in  another,  and  says  the  sLxth  may  be  a  sepa- 
rate species. 

ist  Group. — Streptococcus  pyogenes  (Fig.  16),  found  especially  in  spreading 
suppuration.  Such  suppurations  spread  because  streptococci  only  feebly  attract 
leukocytes  and  also  because  they  prevent  the  coagulation  of  encompassing 


58  Bacteriology 

exudate.  Streptococci  are  also  found  in  very  acute  abscesses.  About  15  per 
cent,  of  acute  abscesses  contain  streptococci.  The  Streptococcus  pyogenes  is 
easily  killed  by  boiling,  and  can  be  destroyed  by  carbolic  acid  and  corrosive 
sublimate.  These  organisms  are  normally  present  in  the  nasal  passages, 
vagina,  mouth,  and  urethra. 

Streptococcus  pyogenes  malignus,  an  uncommon  organism  found  in  splenic 
abscess. 

Streptococcus  septicus  has  a  strong  tendency  to  break  up  into  diplococci. 

2d  Group. — Streptococcus  of  erysipelas  is  found  in  the  capillary  lymph- 
spaces  in  erysipelas.  Many  bacteriologists  believe  it  to  be  identical  with  the 
Streptococcus  pyogenes.  These  bacteria  tend  particularly  to  gather  in  the 
lymph-spaces.  They  rarely  produce  pus  and  when  they  do  it  is  usually  watery. 
When  ordinary  thick  pus  forms  there  is  a  mixed  infection  with  staphylococci. 

Streptococcus  of  Septicemia  and  Pyemia. — Most  observers  maintain  that 
it  is  identical  with  the  Streptococcus  pyogenes  and  the  streptococcus  of 
erysipelas. 

3d  Group. — Streptococcus  articular um,  found  in  the  false  membrane  of 
diphtheria  (see  the  article  by  Woodhead  in  the  "System  of  Surgery,"  by  Sir 
Frederick  Treves). 

Other  Pyogenic  Organisms. — The  various  forms  of  colon  bacillus,  the 
typhoid  bacillus,  the  Streptococcus  intracellularis,  the  Micrococcus  tetragenus, 
and  the  pneumococcus,  are  at  times  pyogenic.  Pneumococci  may  produce  ar- 
thritis (see  page  725),  peritonitis  (see  page  1168),  cholecystitis,  empyema,  necro- 
sis of  bone,  or  wound  infection.  A  case  of  wound  infection  due  to  pneumococci 
was  reported  by  J.  H.  Beaty  ("Northwestern  Lancet,"  July  i,  1907).  In  so 
many  healthy  persons  pneumococci  exist  in  the  mouth  that  it  is  difficult  to  accept 
unreservedly  the  autogenic  infection  theory.  In  all  probability  pneumonia  is 
due  to  contact  with  a  person  suffering  from  the  disease  or  from  contact  with  a 
healthy  carrier  of  pneumococci.  A  common  form  of  colon  bacillus  is  the  Bacillus 
pyogenes  fetidus:  it  is  found  in  stinking  peritoneal  pus  and  in  the  pus  of  ischio- 
rectal abscesses.     The  gonococcus  is  also  pyogenic. 

The  Bacillus  pyocyaneus  may  be  the  sole  cause  of  a  suppuration,  but  usually 
when  it  appears  it  constitutes  a  secondary  infection  in  a  suppurating  area.     It 
causes  a  blue  or  blue-green  hue  in  pus  and  wound  dis- 
^  charges.     Blue  pus  appears  suddenly  and  disappears  with 

^^  equal  suddenness.     It   quickly  disappears  if  antiseptics 

i0&  ^"^^    used    in    the   wound.     Its   presence    is    not  an  evil 

CS   %W  augury  in  fact  wounds  infected  by  it  seem  to  heal  sooner 

Fig.  17.— Micrococci     than  would  be  the  case  in  plain  pyogenic  infection, 
gonorrhoeje,      highly  j|.  -g  normally  found  in  water  and  exists  in  the  mouth, 

magnined,       schematic      •    ,      ^-  ^    ^  ■ 

(Lehmann    and    Xeu-     mtestme,  and  skm. 

mann).  Other    Surgical    Microbes. — Streptococcus   oj   ery- 

sipelas (Fehleisen's  coccus),  as  stated  before,  is  thought 
by  many  to  be  identical  with  the  Streptococcus  pyogenes.  Their  difference  in 
action  is  believed  by  Sternberg  to  be  due  to  difference  in  virulence  induced  by 
external  conditions  and  by  the  state  of  the  tissues  of  the  host.  The  coccus 
of  erysipelas  is  somewhat  larger  than  the  ordinary  form  of  Streptococcus 
pyogenes.  Infection  takes  place  by  a  wound,  often  a  very  trivial  wound  of 
the  skin  or  mucous  membrane.  The  cocci  multiply  in  the  small  lymph- 
channels.  This  coccus  will  cause  puerperal  fever  in  a  woman  in  childbed  when 
it  gains  access  to  any  area  in  the  genital  tract  from  which  absorption  can 
occur.  The  streptococcus  seldom  causes  suppuration  in  erysipelas;  when  it 
does  so  the  pus  is  usually  watery.     Thick  pus  means  mixed  infection. 

The  gonococcus,  or  the  Micrococcus  gonorrhoscB  (the  bacillus  of  Neisser)  (Fig. 
18),  is  the  diplococcus  which  causes  gonorrhea.  Neisser,  in  1879,  observed  this 
bacillus  in  pus  from  gonorrheal  ophthalmia  and  urethral  gonorrhea.     Bumm, 


Other  Surgical  Microbes  59 

in  1887,  proved  the  causative  influence  of  the  gonococcus.  He  reproduced  the 
disease  in  a  healthy  female  urethra  by  inoculation  with  the  twentieth  genera- 
tion in  descent  from  a  pure  culture.  These  micrococci  are  in  pairs,  and  each 
member  of  a  pair  is  kidney  shaped  (Fig.  17).  Gonococci  grow  best  in  air, 
but  can  grow  when  air  is  excluded.  Diplococci  are  found  often  in  the  secretions 
of  apparently  healthy  mucous  membranes,  and  simulate  very  closely  gonococci, 
but  genuine  gonococci  are  not  so  found.  The  gonococcus  is  a  pure  parasite 
and  is  not  found  outside  of  the  organism  except  upon  articles  contaminated 
with  gonorrheal  discharge.  In  male  gonorrhea  the  gonococci  are  in  the  urethra 
and  prostate;  in  female  gonorrhea  they  are  in  the  urethra,  glands  of  Bartholin, 
and  cervix  uteri.  These  cocci  may  cause  gonorrheal  conjunctivitis,  lymphan- 
gitis, lyrnphadenitis,  rhinitis,  otitis,  proctitis,  endometritis,  salpingitis,  oophori- 
tis, cystitis,  peritonitis,  bursitis,  thecitis,  pleuritis,  malignant  endocarditis, 
arthritis,  periostitis,  abscess,  and  parotitis.  In  chronic  urethral  gonorrhea  the 
gonococci  may  at  times  be  absent  from  the  discharge,  returning  when  there  has 
been  sexual  or  alcoholic  excess,  traumatism,  or  contact  with  an  irritant  secre- 
tion. In  such  a  case  there  could  have  been  but  a  very  few  gonococci  in  the 
urethra  before  the  irritation  was  applied,  and  the  discharge  was  kept  up,  in 
part  at  least,  by  irritant  toxins.  If  a  part  in  such  a  condition  is  irritated,  active 
multiplication  begins  and  the  cocci 
reappear  in  the  discharge.  Gonococci 
cannot  be  cultivated  upon  ordinary 
media,  but  grow  best  upon  human  blood 
or  human  blood-serum.  In  gonorrhea 
the  organisms  are  found  both  within 
and  outside  of  pus-cells  and  on  mucous 
cells  (Fig.  18).  The  gonococci  infect  a 
surface  covered  with  cylindrical  epithe- 
lium much  more  readily  than  a  surface 

covered    with    pavement     epithelium.  ''-" 

They  pass   into   the  submucous  tissue,    Fig.  18.— Gonococci  from  gonorrheal  pus. 
cause  inflammation,  and  spread  by  way 

of  the  lymph-paths.  It  seems  certain  that  the  gonococcus  is  pyogenic,  although 
mixed  infection  with  other  pyogenic  organisms  may  exist  in  this  disease.  The 
presence  of  gonococci  inside  of  pus-cells  means  phagocytosis.  Gonococci  stain 
easily  by  methylene-blue  and  are  readily  decolorized  by  Gram's  method. 

In  noma  streptococci  are  found.  No  specific  organism  has  been  isolated 
for  hospital  gangrene. 

The  hacillus  of  tetanus  or  the  Bacillus  tetani  (Nicolaier's  bacillus)  (Fig. 
19)  was  discovered  by  Nicolaier  in  1884.  In  1889  Kitasato  obtained  a  pure 
culture.  It  is  an  obligate  anaerobic  organism.  In  recent  cultures  at  least 
it  ceases  to  grow  in  the  presence  of  free  oxygen.  It  grows  within  the  tissues 
of  the  animal  body.  In  a  wound  to  which  air  has  access  the  bacilli  may  lie 
so  surrounded  by  fluid  that  air  cannot  reach  the  bacteria.  Pyogenic  or  sapro- 
phytic bacteria  may  consume  the  air  or  the  bacilli  may  lie  in  a  laceration 
of  the  tissue  the  outlet  of  which  is  sealed  by  exudate  or  blood.  The  bacillus 
of  tetanus  is  a  facultative  saprophyte,  that  is,  under  certain  conditions  it  can 
grow  in  dead  organic  material.  It  is  possible  to  develop  by-  cultivation  bacilli 
which  will  live  in  air,  but  such  bacilli  have  lost  their  virulence. 

The  bacilli  of  tetanus  are  widely  distributed.  They  are  found  particularly 
in  hay,  in  the  soil  of  gardens,  in  the  dust  of  old  buildings,  in  street  dust  and 
dirt,  and  in  the  sweepings  of  stables.  The  feces  of  healthy  horses,  cattle,  and 
men  may  contain  the  bacilli.  Tetanus  develops  after  a  wound  and  the  bacilli 
remain  in  the  wound  and  do  not  enter  the  blood.  They  furnish  deadly  toxins 
which  are  absorbed.  The  symptoms  are  due  to  intoxication,  not  to  infection. 
The  toxin  of  tetanus  is  alkaloidal,  not  albuminoidal.     These  bacilli  stain  by 


•• 

• 

fi          » 

ffSPf*^''  *  •  ■■^'  ■■ 

-.>."»^--*   ^     ♦ 

.*■«««,      ■»  ♦ 

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,«.  •*,•         « 

nv»» 

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Vi» 

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Bacteriology 


Fig.  19. — Bacillus  of  tetanus,  with  spores. 


Gram's  method.  Cultures  are  made  in  agar-agar  punctures,  the  air  being 
excluded,  or  on  gelatin-containing  glucose  and  in  an  atmosphere  of  hydrogen. 
These  bacilli  when  placed  under  somewhat  unfavorable  conditions  sporulate 
with  great  rapidity,  and  the  spores  are  seen  at  the  ends  (Fig.  19).  The  spores 
are  far  more  resistant  than  the  adult  bacilli,  and  it  is  difficult  to  kill  them  in  a 
wound.     A  drug  which  is  very  fatal  to  tetanus  bacilli  is  bromin. 

The  Bacillus  tuberculosis  (Koch's 
bacillus)  (Fig.  20).  This  bacillus  is 
the  cause  of  all  tuberculous  pro- 
cesses. It  was  discovered  and  cul- 
tivated by  Koch  in  1882. 

It  is  non-motile  and  requires 
oxygen  in  order  to  grow,  but  may 
obtain  this  from  the  body  cells  or 
fluids.  It  stains  by  Gram's  method 
and  by  fuchsin.  These  bacilli  are 
cultivated  upon  glycerin-agar  or  solid 
blood-serum  (Plate  i,  Fig.  3). 

They  are  found  in  dust  contain- 
ing the  dried  sputum  of  victims  of 
phthisis  and  dried  discharges  and 
secretions  of  tuberculous  patients. 
This  infected  dusty  air  is  influential 
in  conveying  infection  (inhalation 
tuberculosis).  Infection  can  also  be 
conveyed  by  inoculation  of  bacilli 
(inoculation  tuberculosis)  and  by  eating  the  meat  and  drinking  the  milk  of 
tuberculous  animals  (ingestion  tuberculosis).  Tuberculin  is  discussed  on 
page  243. 

Koch  maintains  that  the  human  type  of  bacilli  is  almost  altogether  re- 
sponsible for  tuberculosis  in  human  beings.  Behring  and  many  other  ob- 
servers dispute  this  statement,  and  assert  that  bovine  bacilli  are  frequently 
responsible  for  tuberculosis  in  human  beings.  It  seems  certain  that  in  children 
many  cases  of  glandular  tuberculosis  and  abdominal  tuberculosis  are  due  to 
bovine  bacilli.     The  bacilli  of  cattle  are 

not  so  long  or  thick  and  are  straighter  '^  ^^ 

than   human   bacilli.     It  is  not  yet  quite        \ 
certain   that   the   bovine  bacilli  are  iden- 
tical  with   human    bacilli.     They   are   at 
least  very  clos3  blood  relations. 

Bacillus   anthracis,   or    the  bacillus  of 
aw//?ra.v  (Fig.  21),  is  the  cause  of  malignant  ^-^  '^  1^ 

pustule,  anthrax,  or   splenic  fever.     This  ^C    \,^/  --        ' 

bacillus  was   first  observed  by  Pollender      .'   ^        K         \ 
in  1849,  and  its  causal  influence  was  first      /^  \i         ^   \ 

strongly    asserted    by  Davaine   in    1863. 
Davaine's     contention     was    proved    by      Fig. 
Koch  in   1876.     It  is  nonmotile.     Tissue 
containing     it     is     stained     by     Gram's 

method.  Cover-glass  preparations  are  stained  by  a  watery  solution  of  an 
anahne  dye.  It  will  grow  without  oxygen,  but  can  grow  also  in  air.  In  the 
presence  of  air  sporulation  occurs,  but  it  does  not  occur  in  the  infected  animal. 
It  grows  upon  or  in  gelatin  or  agar.  Only  outside  of  the  diseased  body  are 
spores  found,  and  they  exist  in  the  hides  and  hair  of  infected  animals  and  in 
stalls  and  pastures  in  which  diseased  animals  have  been  kept. 

Bacillus  mallei,  or  the  bacillus  of  glanders,  is  the  cause  of  glanders.     It  was 


V 


V      V 


\ 


\ 


..N. 


/^ 


V 


\N 


A 


20. — Tubercle  bacilli  in  sputum 
(Ziegler). 


Other  Surgical  Microbes 


6i 


discovered  by  Lofifler  and  Schiitz  in  1882.  It  is  non-motile  and  grows  best  in 
air,  growing  with  great  difficulty  when  air  is  excluded.  It  grows  well  upon 
glycerin-agar  and  does  not  stain  by  Gram's  method.  It  is  never  found  except  in 
the  body  of  a  diseased  man  or  other  animal.  It  is  best  cultivated  in  solid  blood- 
serum.     Under  certain  circumstances  some  few  of  the  bacilli  contain  spores. 

The  pnetimococcus ,  called  also  the  Diplococcus  pneumonia,  FrdnkeVs  bacillus, 
and  the  Streptococcus  lanceolatus,  was  discovered  by  Sternberg  in  1880.  It  is 
often  found  in  the  saliva  of  healthy  individuals.     It  is  not  found  outside  of  the 


Fig. 


21. — Bacillus    anthracis     (X 
(Lehmann  and  Neumann). 


Fig.     22.— Bacillus    of    malignant 
(Lehmann  and  Neumann). 


edema 


^^ 


y'^- 


X 


body.  It  varies  greatly  in  virulence,  but  when  virulent  can  establish  inflamma- 
tion and  even  suppuration,  particularly  of  mucous  and  serous  surfaces.  It  is 
especially  apt  to  lodge  and  multiply  in  the  lung,  but  it  may  lodge  in  a  joint, 
in  the  brain  membranes,  in  the  peritoneum,  or  in  other  parts.  It  may  cause 
croupous  pneumonia,  catarrhal  pneumonia,  pleuritis,  meningitis,  conjunctivitis, 
arthritis,  peritonitis,  periostitis,  osteomyelitis,  parotitis,  salpingitis,  wound  infec- 
tion, empyema,  cholecystitis,  perinephric  and  other  abscesses,  nephritis,  tonsil- 
litis, mastoiditis,  and  septicemia.  In  any  of  these  conditions  it  may  appear  in 
the  blood.    Pneumococci  in  the  blood  % 

constitute  pneumococcemia.    In  fact,  ^^i^  ^ 

it   may  appear   in   the  blood  when  "'       /"* 

the  lungs   have  not  been  diseased. 
Pneumococcic    arthritis,    peritonitis,  "^  ^   Zr 

cholecystitis,  or  empyema  may  arise 
without  coexisting  or  antecedent 
pneumonia.  The  pneumococcus 
grows  best  in  bouillon  cultures,  in 
blood-serum  and  in  glycerin-agar. 
Sir  Thomas  Oliver  ("Brit.  Med. 
Jour.,"  April  30,  1910)  points  out  _  ^  ^ 
the  interesting  fact  that  in  pneumo-  // 

coccic    meningitis,    although   symp-  •->' 

toms    are  largely    cerebral,   the  pa- 
tient  looks  like  one  suffering  from  Fig.  23. 
pneumonia. 

The  Bacillus  coli  communis,  called  also  the  Bacterium  coli  commune,  the 
colon  bacillus,  or  the  bacillus  of  Escherich  (Fig.  23),  was  discovered  m  feces  by 
Emmerich  in  1885.  Under  ordinary  conditions  this  is  a  putrefactive  bacillus 
inhabiting  the  intestinal  canal  and  feces  invariably  contain  it.  It  is  found  in 
the  mouth,  nose,  and  vagina,  on  the  skin,  and  under  the  nails.  The  bacillus  is 
normally  found  in  water,  even  in  water  regarded  by  the  users  as  pure.  It  has 
already  been  stated  that  this  ordinarily  harmless  micro-organism  m.ay,  under 
certain  conditions,  acquire  pathogenic  power  and  enter  the  circulation.  This 
bacterium  grows  best  in  air,  but  it  can  also  grow  when  air  is  excluded.     It  is  not 


}^ 


K 


—Bacillus  coli  communis 


<€ 


62  Bacteriology 

stained  by  Gram's  method  and  it  has  pyogenic  power.  It  stains  with  anilin  dyes 
and  is  decolorized  by  iodin  solution.  There  are  numerous  forms  of  colon  bacilli, 
and  some  of  them  are  motile,  some  are  amotile.  This  bacillus  may  be  respon- 
sible for  appendicitis,  peritonitis,  inflammation  of  the  genito-urinary  tract, 
pneumonia,  inflammation  of  the  intestine,  leptomeningitis,  perineal  abscess, 
cholangitis,  cholecystitis,  myelitis,  puerperal  fever,  wound  infection,  and 
septicemia.  It  is  the  cause  of  many  abscesses  about  the  intestine,  and  is 
responsible  for  many  ischiorectal  abscesses.  From  the  pus  of  an  appendiceal 
abscess  we  may  perhaps  obtain  a  pure  culture  of  Escherich's  bacillus,  but  usu- 
ally find  also  streptococci  or  staphylococci,  and  sometimes  pneumococci. 
Colon  baciUi  introduced  into  the  system  by  tainted  food  may  be  responsible 
for  epidemic  pneumonia.  A  few  years  ago  there  was  such  an  epidemic  in 
Middlesbrough,  England  (Oliver,  in  "Brit.  Med.  Jour.,"  April  30,  1910). 

Lehmann  and  Neumann  point  out  that  there  are  occasionaUy  encountered 
"gaseous  phlegmons  and  similar  diseases  of  internal  organs,  in  which  are  found 
the  bacterium  coli  alone  or  usually  in  combination  with  other  varieties,  but 
without  any  anaerobes  being  present"  ("Atlas  and  Principles  of  Bacteriology," 
vol.  ii,  edited  by  Geo.  H.  Weaver). 

The  BacUlus  cedemafis  maligni,  the  bacillus  of  malignant  edema,  or  the 
vibrion  septique  of  Pasteur  (Fig.  22),  was  discovered  by  Pasteur  in  1875. 
This  bacillus  is  found  especially  in  stagnant  water  and  certain  varieties  of  soil 
and  exists  in  putrefying  material.  It  is  sometimes  motile,  but  is  often  amotile, 
and  multiplies  by  spore  formation.  It  is  anaerobic  and  in  its  growth  produces 
bubbles  of  gas.  In  the  disease  known  as  malignant  edema  there  is  usually  a 
mixed  infection  with  the  baciUi  of  malignant  edema  and  saprophytic  organisms, 
and  the  latter  also  form  considerable  quantities  of  gas  in  the  tissues.  The 
bacilli  of  malignant  edema  may  cause  either  spreading  bloody  edema  contain- 
ing gas-bubbles  or  spreading  emphysematous  gangrene.  This  bacilli  is  one  of 
the  causes  of  the  dreaded  gas  gangrene  of  the  trenches.  The  bacilli  enter  the 
blood  and  produce  septicemia.  The  bacillus  is  grown  in  the  interior  of  a  stab 
in  gelatin  agar-agar  or  solid  blood-serum  when  the  mouth  of  the  stab  has  been 
sealed  up. 

The  Bacillus  aerogenes  capsidatus  of  Welch  {Bacillus  welchii)  was  described 
by  Welch  and  Nuttall  in  the  Bulletin  of  the  Johns  Hopkins  Hospital,  July  and 
August,  1892.  It  is  probably  identical  with  the  Bacillus  perfringens.  It  is 
amotile  and  is  found  particularly  in  soil.  It  may  form  very  resistant  spores. 
It  has  a  capsule,  grows  well  upon  blood-serum  and  may  be  stained  by  Gram's 
method.  It  enters  the  tissues  through  a  wound,  sets  free  quantities  of  gas  and 
causes  emphysema  and  gangrene.  This  purely  anaerobic  baciUus  is  found 
sometimes  in'  closed  abscesses  containing  gas.  It  is  causative  of  mpst  cases  of 
gangrenous  cellulitis,  which  is  a  spreading  gangrene  with  gas  formation  (the  gas 
gangrene  of  the  present  war). 

The  Bacillus  botidiniis  is  one  of  the  pathogenic  anaerobes.  WTien  it  acts 
on  raw  meat  and  some  other  foods  it  forms  a  highly  dangerous  toxin.  The  meat 
may  look  good  and  be  without  odor  yet  nitrogenous  putrefaction  may  exist. 
Sausage  is  the  most  common  source  of  meat  poisoning.  The  toxin  is  irregularly 
distributed  through  meat,  hence  some  who  eat  may  escape,  others  may  suffer. 

Botulism  is  the  name  given  to  poisoning  caused  by  eating  meat  infected 
with  the  baciUus  botulinus  (Lat.  botulus — a  sausage).  The  symptoms  do  not 
arise  for  twelve  hours  or  more  after  eating  and  they  come  on  gradually.  The 
ordinary  symptoms  are  nausea  and  vomiting,  constipation,  double  vision, 
difficulty  in  swaflowing,  impaired  speech,  dryness  of  the  mouth,  dreadful 
prostration,  absence  of  knee-jerks,  widely  dilated  pupils  and  paralysis  of  accom- 
modation, paralysis  of  the  muscles  of  the  palate  and  pharynx.  It  is  a  very 
fatal  condition  and  death  is  due  to  bulbar  palsy  (see  Schede  in  "  Medizinische 
Klinik,"  Dec.  10,  1916). 


Infection  by  Protozoa      '  63 

The  Bacterium  typhi,  the  typhoid  bacillus,  or  Eberth's  bacillus,  was  discovered 
by  Eberth  in  1880.  It  is  sometimes  found  in  water  or  soil  contaminated  by 
typhoid  fecal  matter.  It  never  exists  in  the  healthy  human  body  (except  in 
typhoid  carriers).  It  causes  typhoid  fever.  Typhoid  fever  is  a  very  common 
and  a  very  fatal  malady.  There  are  180,000  cases  of  typhoid  and  18,000  deaths 
a  year  in  the  United  States.  It  can  be  prevented  almost  certainly  by  anti- 
typhoid vaccination  (pages  50,  51).  In  considering  the  spread  of  the  disease  a 
study  must  be  made  of  water  supply,  milk  supply,  food  supply,  sewage  disposal, 
and  all  possible  agents  of  contamination,  especially  flies  and  typhoid  carriers. 
In  typhoid  fever  the  bacilli  can  be  obtained  and  cultivated,  particularly  from 
the  spleen  and  lymphatic  glands  and  frequently  from  the  blood.  It  has  been 
found  in  the  urine,  kidney,  bone-marrow,  and  bile.  It  is  difficult  to  cultivate 
typhoid  bacilli  from  feces  because  of  the  presence  of  multitudes  of  other  bacteria. 
The  bacillus  of  typhoid  is  motile,  does  not  stain  by  Gram's  method,  and  grows 
best  in  air,  but  can  grow  when  air  is  excluded.  It  grows  upon  all  the  ordinary 
nutrient  media.  This  bacillus  is  particularly  apt  to  be  confounded  with  the 
colon  bacillus,  and  it  is  even  possible  that  the  former  develops  from  the  latter. 
Besides  typhoid  fever  the  typhoid  bacillus  may  cause  peritonitis,  chronic  osteo- 
myelitis, epididymitis,  orchitis,  gangrene,  cholecystitis,  thrombosis,  embolism, 
synovitis,  arthritis,  and  pulmonary  inflammation.  If  pneumonia  is  caused 
by  the  typhoid  bacillus,  there  are  the  ordinary  physical  signs  of  pneumonia 
and  there  are  no  abdominal  symptoms,  but  the  appearance  of  the  patient  and 
the  duration  of  the  disease  are  suggestive  of  typhoid  fever.  It  is  interesting 
to  note  that  relapse  may  occur  (Oliver,  in  "Brit.  Med.  Jour.,"  April  30,  1910). 
This  bacillus,  under  certain  conditions,  is  pyogenic.  Typhoid  bacilli  are  agglu- 
tinated and  lose  motion  by  contact  with  a  i  to  50  dilution  of  the  blood-serum  of 
a  patient  with  typhoid  fever  or  convalescent  from  typhoid  fever  (the  Widal 
reaction).  Typhoid  fever  is  a  widespread  and  very  fatal  malady.  Contamina- 
tion of  water  supply,  milk  and  other  foods  is  responsible  for  the  diffusion  of 
the  disease.  Water  is  contaminated  by  stupid  criminal  methods  of  sewage 
disposal.     The  domestic  fly  plays  a  great  part  in  spreading  the  disease. 

Putrefactive  Bacteria. — By  putrefaction  we  mean  the  decomposition 
of  albuminous  matter  with  the  production  of  materials  possessed  of  a  foul  odor 
and  containing  putrefactive  alkaloids.  The  bacilli  of  putrefaction  act  upon 
dead  tissue  exposed  to  air  and  are  most  active  when  the  supply  of  air  is  some- 
what limited.  The  surgeon  encounters  these  bacteria  in  areas  of  necrosis  or 
in  tissues  previously  destroyed  by  other  microbes.  In  the  latter  case  they 
cause  a  mixed  infection.  An  instance  of  such  a  mixed  infection  is  putrid  pus. 
Putrefactive  bacteria  may  cause  gas  gangrene.  Some  of  the  products  of  putre- 
factive bacteria  are  highly  poisonous  (ptomains) .  Absorption  of  a  small  amount 
of  putrid  toxin  causes  surgical  fever  and  absorption  of  a  large  amount  causes 
putrid  intoxication. 

The  chief  putrefactive  bacteria  are:  The  colon  bacillus  (when  under  normal 
conditions) ;  the  bacillus  of  malignant  edema ;  the  Proteus  vulgaris ;  the  Proteus 
mirabilis;  the  three  forms  of  the  Bacillus  saprog'enes;  and  the  Proteus  zenkeri. 

We  may  mention,  in  conclusion,  as  of  occasional  surgical  importance  the 
bacillus  of  influenza,  bacillus  of  diphtheria,  bacillus  of  bubonic  plague,  bacillus 
of  leprosy,  bacillus  of  rhinoscleroma,  bacillus  of  fetid  ozena,  bacillus  of  hemor- 
rhagic septicemia  and  the  Bacillus  lactis  aerogenes,  which  is  an  unusual  cause 
of  peritonitis. 

Infections  by  Protozoa. — Protozoa  is  the  name  given  to  the  lowest 
forms  of  animal  life.  This  group  of  organisms  shows  transitions  from  forms 
certainly  animal  toward  forms  certainly  vegetable.  The  protozoa  are  minute 
unicellular  organisms.  The  cell  has  a  definite  nucleus  and  is  composed  of 
protoplasm  and  a  more  or  less  dense  cell  wall.  Many  species  have  organs  of 
locomotion   (cilia  or  flagella).     Most  parasitic  protozoa  are  sporozoa.     The 


64  '      Asepsis  and  Antisepsis 

sporozoa  multiply  by  spore  formation,  feed  by  osmosis,  and,  when  freely  formed, 
possess  neither  cilia  nor  flagella.  Pebrine  or  silkworm  disease  is  due  to  protozoa, 
so  is  trypanosomiasis.  Protozoa  are  known  to  cause  malaria  (the  j^lasmodium 
malariae),  tropical  dysentery  (the  Entameba  histolytica),  and  syphilis.  Some 
observers  maintain  that  they  cause  cancer,  others  assert  that  they  are  respon- 
sible for  hydrophobia;  and  it  is  thought  proljable  that  they  may  produce 
measles,  small-pox,  yellow  fever,  scarlatina,  and  spotted  fever. 

The  SpirochcBta  Pallida  (the  Treponema  Pallidum). — A  bacterial  cause  of 
syphilis  has  long  been  sought.  Lustgarten  thought  he  had  found  it  in  a 
bacillus  resembling  the  tubercle  bacillus,  but  this  view  has  been  disproved. 
Schaudinn  and  Hoffmann  have  described  an  organism  constantly  present  in  the 
initial  lesion  of  syphilis  and  in  secondary  lesions  and  which  they  call  the  Spiro- 
chaeta  pallida  (^'Arbeiten  aus  dem  Kaiserlichen  gesundheitsamte,"  Berlin, 
April  lo,  Heft  2).  The  studies  of  Schaudinn  and  Hoffmann  were  confirmed  by 
Metchnikoff  ("  Bull.  Acad,  de  med.  de  Paris,"  May  16,  1905).  These  organisms 
are  found  in  great  numbers  in  the  juice  of  syphilitic  glands,  in  condylomata,  and 
in  chancres.  They  are  motile,  are  without  flagella,  curve  from  three  to  twelve 
times,  are  stained  with  difificulty,  and  are  transported  by  the  lymph  and  blood 
(Blaschko,  in  "Berlin  klin.  Woch.,"  No.  11,  1907).  The  organism  is  thought 
by  many  to  be  a  protozoon.  The  fact  that  the  cell  divides  longitudinally  and 
not  transversely  suggests  that  it  is  not  a  bacterium  (Noguchi).  Many  ob- 
servers place  the  organism  with  bacteria.  The  matter  is  still  in  doubt.  The 
spirochetes  were  originally  discovered  by  Bordet  and  Gengou  in  1903.  These 
observers  found  them  in  chancres,  but  thought  their  presence  was  inconstant. 
Schaudinn  and  Hoffmann  show  that  it  is  constant.  It  seems  certain  that 
syphilis  is  a  chronic  spirillosis.  The  micro-organism  is  present  in  primary 
syphilis  and  all  early  secondary  lesions  and  in  congenital  syphilis.  It  has  been 
found  in  the  blood  of  syphilitics.  The  organisms  are  found  in  tertiary  lesions 
although  in  far  less  numbers  than  exist  in  secondary  lesions.  In  view  of  their 
discovery  in  tertiary  lesions  we  must  abandon  the  old  view  that  tertiary  lesions 
are  not  infectious.  We  now  know  that  such  lesions  are  infectious  but  not 
nearly  so  powerfully  as  secondary  lesions.  Noguchi  obtained  pure  cultures  of 
the  spirochete,  and  inoculation  of  monkeys  with  the  cultures  caused  the  devel- 
opment of  sores  resembling  chancres.  These  experiments  furnish  final  proof 
that  treponema  pallidum  causes  syphilis. 

II.  ASEPSIS  AND  ANTISEPSIS 

The  effort  in  all  operations  is  to  secure  and  maintain  scrupulous  surgical 
cleanliness.  What  is  known  as  the  antiseptic  method  we  owe  to  the  splendid 
labors  of  Lord  Lister,  and  the  aseptic  method  is  but  a  natural  evolution  of 
the  antiseptic  method.  It  is  true  that  Agostino  Bassi,  much  over  half  a  century 
ago,  convinced  that  various  maladies  were  due  to  parasites,  treated  wounds  with 
a  solution  of  corrosive  sublimate.  It  is  true  that  Oliver  Wendell  Holmes  in 
1843  insisted  on  the  contagiousness  of  puerperal  fever.  It  is  also  true  that 
Semmelweiss  in  1847  demonstrated  the  infectiousness  of  puerperal  fever  and  the 
method  of  preventing  it;  that  Jules  Lemaire  in  1863  published  a  treatise  on  car- 
bolic acid  and  advocated  the  use  of  this  drug  in  the  treatment  of  wounds  in  order 
to  destroy  living  germs;  and  that  Bottini  in  1866  employed  carbolic  acid  in  the 
treatment  of  putrid  and  suppurating  wounds  because  he  believed  germs  to  be 
responsible  for  such  conditions  (Monti,  on  "Modern  Pathology").  In  spite  of 
the  above  facts.  Lister  is  the  real  father  of  asepsis  and  taught  all  nations  how  to 
prevent  infection.  Monti  says:  "But  Lister,  with  that  practical  spirit  which 
forms  one  of  the  best  characteristics  of  English  genius,  from  the  scientific 
Studies  of  Pasteur  deduced  the  general  laws  of  antisepsis  and  the  rules  for 


Asepsis  and  Antisepsis  6 


their  methodical  application  to  practical  surgery."  Lister  called  the  attention 
of  the  profession  to  a  new  method  of  treating  wounds,  compound  fractures, 
and  abscesses  in  1867.^  The  processes  first  employed  were  extremely  com- 
plicated, but  have  been  made  in  the  last  few  years  simple  and  easy  of  per- 
formance. Lister  believed  the  chief  danger  to  be  from  air.  It  is  now  believed 
that  the  chief  danger  is  from  actual  contact  of  hands,  instruments,  dressings, 
or  foreign  bodies  with  a  wound.  Air  carries  but  few  micro-organisms  unless 
it  is  filled  with  dust.  Infection  through  air  is  most  apt  to  occur  if  the  air  is 
dusty,  and  is  more  common  after  an  aseptic  than  an  antiseptic  operation.  Of 
course  all  air  where  man  dwells  contains  some  dust.  In  a  dusty  street  or  work- 
room there  are  vast  numbers  of  bacteria.  Students  by  walking  into  an  ill-kept 
clinic  room  just  before  operation  may  stir  up  much  dust  which  had  settled. 
Dust  can  be  carried  very  great  distances.  In  1883  the  volcano  of  Krakatoa, 
which  is  on  a  small  island  in  the  Strait  of  Sunda,  burst  into  eruption  and  the 
volcanic  dust  of  pumice  surrounded  the  earth  and  remained  in  our  atmosphere 
for  several  years  (Prof.  Frederic  S.  Lee,  in  "The  Popular  Science  Monthly," 
April,  1914).  "The  number  of  dust  particles  found  by  different  observers 
in  a  single  cubic  centimeter  of  air  have  varied  from  157  at  the  summit  of  the 
Swiss  Bieshorn  to  more  than  200,000  in  a  Parisian  garden"  (see,  Ibid.). 

Of  course,  some  bacteria  from  the  air  must  settle  in  every  wound,  but 
the  majority  of  the  air  fungi  are  harmless.  Comparatively  few  reach  the  wound 
unless  the  air  is  dusty,  and  these  few  the  tissues  are  usually  able  to  destrov. 
Schimmelbusch  made  experiments  in  v.  Bergmann's  clinic  when  the  stu- 
dents were  present.  He  found  that  "  the  number  of  bacteria  which  settle  upon 
the  surface  of  a  wound  a  square  decimeter  in  extent,  in  the  course  of  half  an 
hour,  is  about  60  or  70,"  and  thousands  are  usually  required  to  produce  infection. 

There  is  no  danger  of  infection  being  produced  by  the  breath  of  spectators. 
Air  which  comes  from  the  lungs  (simple  expired  air)  is  germ  free,  and  even  a 
large  class  will  not  infect  the  air  by  breathing,  but  will  rather  help  to  free  it 
from  bacteria,  for  the  lungs  are  filters  for  air  laden  with  micro-organisms.  If 
a  surgeon  talks  forcibly  while  he  is  operating,  he  may  spray  droplets  of  saliva 
into  the  wound  and  thus  produce  infection.  He  may  do  so  also  by  coughing, 
sneezing  or  laughing.  In  order  to  obviate  this  danger  some  surgeons  wear 
masks  of  gauze  before  the  nose  and  mouth.  A  conversational  assistant  is  a 
danger,  and  a  surgeon  should  direct  his  remarks  away  from  the  wound  and 
not  toward  it.  The  surgeon  and  his  assistant  should  wear  caps  to  keep  hair 
from  falling  in  the  wound.  The  clean  shaven  face  is  not  a  peril  to  the  patient, 
the  face  "bearded  like  the  pard"  may  be.  A  bearded  man  should  wear  a 
mask. 

The  more  simple  the  operative  technic,  the  better  and  the  more  certain  is 
it  to  be  carefully  carried  out.  Desault  said,  "The  simplicity  of  an  operation 
is  the  measure  of  its  perfection."  This  is  as  true  to-day  as  when  the  great 
French  surgeon  said  it.  The  fewer  assistants  that  are  used  the  better,  and  no 
hands  but  the  surgeons  should  enter  the  wound  unless  others  are  absolutely 
required. 

In  performing  any  surgical  operation  cutting  is  better  than  tearing  by 
blunt  dissection.  The  former  method  makes  an  incised  wound,  the  latter  a 
lacerated  wound.  In  an  incised  wound  there  is  a  minimum  amount  of  dam- 
age and  there  will  be  rapid  repair.  In  a  lacerated  wound  some  necrosis  occurs 
and  there  is  great  lowering  of  tissue  resistance,  hence  a  lacerated  woimd  is  much 
more  apt  to  become  infected  than  an  incised  wound. 

Surgical  cleanliness  may  be  obtained  by  either  the  aseptic  or  the  antiseptic 

method.     In  the  aseptic  method,  heat,  chemical  germicides,  or  both  are  used 

to  cleanse  the  instruments,  the  field  of  operation,  and  the  hands  of  the  surgeon 

and  his  assistants,  the  surface  being  freed  from  the  chemical  germicide  by 

1  "Lancet."  March  16,  1867;  "Brit.  Med.  Jour.,"  August  9,  1867. 

5 


66  Asepsis  and  Antisepsis 

washing  with  boiled  water  or  with  saline  solution.  After  the  incision  has  been 
made  no  chemical  germicide  is  used,  the  wound  being  simply  sponged  with 
gauze  sterilized  by  heat;  if  irrigation  is  necessary,  boiled  water  or  normal  salt 
solution  (at  iio°  F.)  is  used,  and  the  wound  is  dressed  with  gauze  which  has  been 
rendered  sterile  by  heat.  The  effort  of  the  surgeon  is  simply  to  prevent  the 
entrance  of  micro-organisms  into  the  tissues.  Some  micro-organisms  must 
enter,  but  the  number  will  be  so  small  that  they  will  be  destroyed  by  healthy 
tissues.  The  aseptic  method  should  be  used  in  non-infected  areas  only.  If 
chemical  germicides  are  not  used  in  the  wound,  there  will  be  a  minimum  amount 
of  irritation,  few  cells  will  be  destroyed,  the  amount  of  wound-fluid  will  be 
small,  the  surgeon  can  often  dispense  with  drainage,  and  repair  will  be  rapid. 
If  a  wound  is  to  be  closed  without  drainage,  every  point  of  bleeding  must 
be  ligated.  Many  wounds  are  closed  by  interrupted  through-and-through 
sutures  of  silkworm-gut.  Some  wounds  are  closed  in  layers  by  catgut  sutures. 
If  a  wound  is  closed  in  layers,  muscle  being  against  muscle,  fascia  against  fascia, 
etc.,  the  skin  may  be  closed  by  interrupted  sutures  or  by  Halsted's  subcuticular 
or  intradermal  stitch  (Fig.  119).  If  this  stitch  is  employed,  the  skin  staphylo- 
coccus does  not  obtain  access  to  stitch-holes,  and  stitch-abscesses  do  not  form. 
The  intradermal  suture  may  consist  of  catgut,  silk,  or,  preferably,  silver  wire,  this 
latter  agent  being  capable  of  certain  sterilization  by  heat  and  of  exercising  a  defi- 
nite inhibitorv  action  on  micro-organisms.  If  a  wound  is  closed  without  drain- 
age, firm  compression  is  applied  over  the  wound  to  obliterate  any  cavity  which 
may  exist.  Such  a  cavity  is  called  a  dead  space.  If  a  dead  space  is  allowed  to 
rernain  wound-fluid  will  gather,  tissue  resistance  will  be  lowered,  and  the 
wound-fluid,  the  tissue,  or  both  may  become  infected.  Drainage  must  be 
used  if  the  wound  is  very  large,  if  its  shape  or  structure  prevents  the  obliteration 
of  the  cavity  by  pressure,  if  there  is  any  doubt  as  to  the  perfect  cleanliness  of 
the  part,  if  the  patient  is  very  fat  (for  in  such  individuals  fat  necrosis  pre- 
disposes to  sepsis  and  to  fat  embolism),  or  if  the  skin  is  so  thin  that  we  fear 
pressure  will  produce  sloughing  ("A  Manual  of  Surgical  Treatment,"  by  Cheyne 
and  Burghard).  In  some  regions  of  the  body  wounds  are  sealed  with  collodion 
or  iodoform-collodion.  If  irrigation  is  not  practised  and  the  wound  is  dressed 
with  dry  sterile  gauze,  the  procedure  is  said  to  be  by  the  ''dry"  aseptic  method. 
It  has  been  proved  in  the  present  war  that  the  aseptic  method  is  not  sufficient 
for  wounds  in  war.  In  the  antiseptic  metJiod  the  same  preparations  are  made 
for  the  operation  as  in  the  aseptic  method,  but  during  the  operation  gauze 
sponges  impregnated  with  a  chemical  germicide  are  used,  and  the  wound  is 
dressed  with  gauze  containing  corrosive  sublimate  or  some  other  chemical 
germicide.  If  the  wound  is  not  flushed  with  a  chemical  germicide,  and  is 
dressed  with  dry  antiseptic  gauze,  the  operation  is  said  to  be  by  the  '"dry" 
antiseptic  method.  The  antiseptic  method  is  preferred  in  infected  areas.  Dry 
dressings  are  usually  preferable  to  moist  dressings  in  treating  aseptic  wounds, 
because  they  are  more  absorbent  and  do  not  act  as  poultices,  and  dry  dressings 
may  be  used,  even  when  the  wound  has  been  flushed.  Some  surgeons  question 
the  value  of  antiseptic  irrigation  in  a  septic  wound.  Delbet  ("Bull.  Soc.  de 
Chir.,"  1916,  xlii)  believes  that  disinfectants  frequently  interfere  with  phago- 
cytosis and  other  methods  exercised  by  the  tissues  in  their  protection;  that 
bacteria  in  a  wound  may  become  tolerant  to  germicides  and  that  the  action  of 
chemical  agents  in  pus  may  lead  to  the  formation  of  substances  which  encourage 
the  growth  of  microbes.  In  other  words,  Delbet  is  of  the  opinion  that  germicides 
may,  under  certain  circumstances,  actually  favor  the  growth  of  bacteria  in 
wounds. 

Certain  it  is  that  a  germicidal  solution  which  damages  the  tissues  may  do 
actual  harm  (Cuneo  in  "Bull.  Soc.  de  Chir.,"  1916,  xlii).  Clinically  I  have 
come  to  believe  that  antiseptic  irrigation  can  remove  many  bacteria  and  much 
poisonous  matter  and  also  antidote  toxic  material.     In  civil  practice  an  accidental 


Preparation  for  an  Operation  67 

wound  is  to  be  regarded  as  infected,  mechanical  cleansing  of  the  wound  and  the 
surface  about  it  should  be  accorhplished  by  shaving  the  part,  scrubbing  with  a 
brush  wet  with  tincture  of  green  soap  and  water.  The  part  should  then  be 
well  rubbed  with  the  A.  P.  A.  mixture  (see  Whiting's  fluid,  page  73).  If  iodin  is 
to  be  used  the  part  should  be  dry  shaved  but  not  scrubbed.  In  suppurating 
areas  it  is  often  best  to  use  moist  dressings  in  the  form  of  antiseptic  fomentations. 
Year  by  year  the  aseptic  method  becomes  more  popular  in  civil  practice.  Sur- 
geons have  learned  that  the  most  important  factor  in  asepsis  is  mechanical 
cleansing  by  means  of  soap  and  water.  The  chemical  germicide  plays  a 
secondary  rather  than  a  vital  part.  By  mechanical  cleansing  of  the  skin  great 
numbers  of  micro-organisms  are  removed  along  with  dirt,  grease,  and  epi- 
thelium. Many  bacteria  remain,  but  vast  hordes  are  washed  away,  and  the 
danger  of  infection  is  greatly  lessened  by  thus  diminishing  the  number  of  bacteria. 
If  a  chemical  germicide  is  used  without  preliminary  mechanical  cleansing  it  is 
useless,  because  it  cannot  destroy  bacteria  iij  the  epithelium  and  in  masses  of 
oily  matter.  When  iodin  is  used  the  part  is  first  cleansed  by  a  dry  shave,  or 
in  a  case  in  which  there  is  no  hurry,  by  scrubbing  and  shaving  the  day  before. 
After  mechanical  cleansing  the  germicide  is  active  in  destroying  the  compara- 
tively few  bacteria  which  are  naked  on  the  surface.  In  many  regions  a  strong 
chemical  germicide  must  not  be  used  (in  the  abdomen,  in  the  brain,  in  joints, 
in  the  pleural  sac,  and  in  the  bladder),  and  in  other  regions  (mucous  surfaces 
and  fatty  tissue)  it  is  productive  of  serious  harm  rather  than  good. 

Preparation  for  an  Operation. — If  the  operation  is  to  be  performed 
in  a  hospital  there  is,  of  course,  an  operating  room  always  ready.  If  it  is  to 
be  done  in  a  private  house,  much  careful  preparation  is  desirable.  The  opera- 
ting room  should  be  warm,  but  not  too  warm.  The  desirable  temperature 
is  78°  to  80°  F.  Over  80°  F.  is  too  warm,  it  causes  vascular  relaxation  in  the 
patient,  and  makes  the  surgeon  perspire  and  wear  out.  The  patient  is  kept 
warm  by  certain  special  methods.  He  may  be  placed  on  a  table  heated  by  hot 
water  or  electricity  or  he  may  be  surrounded  by  hot- water  bags.  Any  large 
raw  surface  is  kept  covered  as  far  as  possible  with  pads  of  gauze  wrung  out  of 
hot  salt  solution  and  frequently  changed.  Protruding  intestines  are  treated  in 
the  same  way.  Every  effort  is  made  to  avoid  soaking  the  patient's  skin  with 
fluids,  because  as  they  cool  they  will  chill  him.  A  room  in  which  an  operation 
is  to'  be  performed  should  be  well  lighted  and  well  ventilated.  In  northern 
latitudes  the  northern  light  is  the  best.  It  is  advantageous  to  have  an  open 
grate  in  the  room,  for  then  a  wood  fire  can  be  quickly  made  to  take  a  chill  off  the 
air  and  ventilation  is  improved.  The  morning  before  the  operation  the  furni- 
ture should  be  removed,  the  carpet  taken  up,  and  the  curtains  and  hangings 
taken  down.  If  the  ceiling  and  walls  are  papered,  they  must  be  thoroughly 
brushed.  If  they  are  painted,  they  must  be  washed  with  soap  and  water.  Dust 
is  thus  removed  and  the  danger  of  dust  falling  into  the  wound  is  averted.  The 
floor  is  scrubbed  with  soap  and  water.  The  windows  should  be  opened  for 
many  hours  to  thoroughly  dry  and  freshen  the  room.  On  the  morning  of  the 
operation  the  windows  are  closed  and  newspapers  are  tacked  up  so  as  to  cover 
the  lower  half  of  each  window.  Plenty  of  light  is  admitted  and  the  curiosity 
of  neighbors  across  the  street  cannot  be  satisfied.  The  patient's  bed  is  brought 
into  the  room  and  placed  in  a  position  where  there  will  be  plenty  of  light  for 
future  dressings,  and  where  the  surgeon  will  have  access  from  either  side.  In 
order  that  there  may  be  access  from  each  side,  the  bed  must  not  be  in  a  corner 
or  against  the  wall.  Never  use  a  big  broad  bed;  use  a  narrow  bed.  Never 
have  a  feather  bed,  but  insist  on  Treves 's  advice  being  followed,  and  employ 
a  metal  bed  with  a  wire  netting  and  hair  mattress. 

A  piece  of  carpet  or  rug  is  spread  upon  a  portion  of  the  floor  and  the  table 
is  set  upon  it.  The  table  should  be  so  placed  that  there  will  be  a  good  light 
on  the  field  of  operation.     There  are  several  tables  which  are  very  satisfac- 


68 


Asepsis  and  Antisepsis 


tory.  The  best  for  a  private  house  operation  is  LiUenthal's  (Figs.  24  and 
25).  This  table  can  be  folded  into  a  small  compass,  can  be  carried  in  a  case 
with  a  handle,  and  is  comparatively  light  and  easily  transportable.     It  can  be 


Fig.   24. — LiUenthal's  portable  operating  table. 

rapidly  set  up,  is  firm,  and  it  enables  the  surgeon  to  obtain  the  Trendelenburg 
position  at  any  moment.  A  kitchen  table  does  very  well.  If  a  kitchen  table  is 
used  and  the  abdomen  is  to  be  opened  a  frame  should  be  at  hand  which,  when 


Fig.  25. — Lilienthal's  portable  operating  table,  folded. 


slipped  under  the  patient,  enables  the  surgeon  to  obtain  the  Trendelenburg 
position.  Dr.  Joseph  Price  was  accustomed  to  use  two  trestles  and  a  board 
like  an  ironing  board.     In  hospital  work  T  use  Boldt's  table  (Figs.  26   and 


Preparation  for  an  Operation 


69 


27).     On  the  table  or  board  is  placed  a  folded  comfortable  or  several  folded 
blankets.     A  rolled  blanket  is  placed  under  the  hollow  of  the  back  to  prevent 


Fig.  26. — Boldt's  operating  table. 

strain  of  the  sacro-iliac  joints  and  postoperative  backache.     Kelly's  pad  to 
catch  fluids  is  laid  up  on  the  blankets  and  is  so  placed  that  fluid  used  in  ir- 


r-"'iG.   27. — Boldt's  operating  table. 

rigation    will    flow   into    it   and    will    be    conducted    by   it   to   a  suitable 
receptacle. 


70 


Asepsis  and  Antisepsis 


Around  the  operating  table  at  proper  distances  are  to  be  arranged  a  table  for 
instruments,  ligatures  and  sutures,  a  table  for  dressings,  a  table  for  pads,  packs, 
gauze  sponges,  and  a  basin  of  bichlorid  or  alcohol,  and  a  table  for  soap  and  a  basin 
of  water.  Ordinary  wooden  tables  may  be  used  if  they  are  covered  with  towels 
wet  in  corrosive  sublimate  solution.  In  a  hospital  special  tables  are  used. 
They  are  of  iron  with  glass  tops  and  the  tops  are  sterilized.  Ordinary  basins 
may  be  used,  but  enameled  or  glass  basins  in  stands  (Figs.  28  and  29)  are  the 
most  satisfactory.     A  couple  of  buckets  should  be  placed  on  the  floor  near  at 

hand.  Enameled  buckets  are  the  best 
ones  to  use.  The  nurses  and  assistants 
should  have  ready  the  ether  cone, 
wTapped  in  a  clean  towel,  sterile  sheets, 
sterile  gowns,  sterile  towels,  sterile  gauze 


Revol\-ing  wash- 


FiG.  29. —  Plain  double  wabh-stand. 


for  sponges,  pads  and  dressings,  trays  for  instruments  (Figs.  30  and  31), 
iodoform  gauze,  catgut,  silk,  silkworm-gut,  hot  normal  salt  solution,  etc., 
according  to  the  nature  of  the  operation.  The  surgeon  should  pick  out  the 
instruments  required.  The  anesthetist  should  lay  out  a  mouth-gag,  tongue- 
forceps,  h}q3odermatic  syringe  in  working  order,  ether  or  chloroform,  brandy, 
camphorated  oil,  tablets  of  strychnin  and  also  of  atropin,  and  a  cylinder  of 
oxygen. 

Most  surgeons  have  the  operation  field  sterilized  the  day  before  the  opera- 
tion, except  in  an  emergency  case.     For  several  years  I  have  been  doing  it  in 


Fig.  30. — i'orcelain  surgical  tray. 


Fig.  31. — Glass  surgical  traj'. 


most  cases  after  the  patient  has  been  anesthetized,  and  find  this  plan  more 
comfortable  for  the  patient,  less  troublesome,  and  equally  effective. 

When  the  time  for  the  operation  arrives,  the  surgeon  and  his  assistants 
remove  their  clothing  and  put  on  duck  trousers  and  thin,  short-sleeved  shirts  of 
white  muslin.  After  sterilizing  the  hands  and  forearms  they  envelop  themselves 
in  aseptic  or  antiseptic  sheets  or  gowns,  to  protect  the  patient  and  themselves. 
The  gowns  should  have  sleeves  long  enough  to  cover  the  forearms  and  wrists. 
Sterile  muslin  caps  should  always  be  worn.  The  caps  prevent  hair,  dandruff, 
and  sweat  from  falling  into  the  wound.  Many  operators  wear  over  the  mouth 
and  nose  a  respirator  or  piece  of  gauze  in  order  to  prevent  saliva  or  mucus  being 
projected  into  the  wound  while  the  surgeon  talks. 


Mechanical  Cleansing  of  the  Hands  and  Forearms  71 

Danger  from  the  Hands. — It  is  a  difficult  or  impossible  matter  to  abso- 
lutely sterilize  the  hands,  but  it  is  fortunate,  as  Mikulicz  and  Flligge  say,  that 
most  of  the  bacteria  of  the  skin  are  harmless.  The  Staphylococcus  epidermidis 
albus,  however,  is  constantly  present  in  the  epidermis.  The  hands  of  some 
persons  are  more  easily  sterilized  than  those  of  others.  For  instance,  a  hairy, 
creased  hand  is  more  difficult  to  sterilize  than  a  smooth  and  almost  hair- 
less one;  a  hand  grossly  neglected,  than  one  reasonably  clean.  Germs  abound 
in  the  epidermis,  in  the  fissures  and  creases,  under  and  around  the  nails,  on 
hairs,  and  in  ducts  of  glands.  The  surface  of  the  hands  may  be  thoroughly 
sterile  at  the  beginning  of  an  operation  and  become  infected  later,  because 
germs  in  gland  ducts  are  forced  to  the  surface.  Hence,  in  a  prolonged  opera- 
tion the  surgeon,  if  he  does  not  wear  gloves,  should  from  time  to  time  stop 
operating  and  wash  his  hands,  first  in  alcohol  and  then  in  corrosive  sublimate 
solution  (Leonard  Freeman), 

In  view  of  the  difficulty  of  cleansing  the  hands,  every  student  must  be 
taught  how  to  do  it,  and  he  must  become  impressed  with  the  fact  that  the 
surgical  hand  is  to  be  regarded  as  reaching  to  the  elbow.  The  more  the  finger§ 
enter  a  wound,  the  greater  is  the  danger  of  infection  of  the  wound.  The 
surgeon  uses  retractors  and  forceps  whenever  possible,  but  in  most  cases  his 
fingers  must  at  times  enter  the  wound.  The  fingers  of  no  other  person  should 
enter  unless  absolutely  necessary.  The  basis  of  all  plans  of  sterilization  and  the 
most  important  part  of  any  plan  is  mechanical  cleansing  by  scrubbing  with  soap 
and  water.  By  this  means  a  quantity  of  loose  epidermis  is  removed  and  with 
it  great  numbers  of  bacteria. 

Mechanical  Cleansing  of  the  Hands  and  Forearms. — The  hands  and 
forearms  may  be  sterilized  in  several  ways.  Any  method  is  preceded  by 
mechanical  cleansing,  which  is  carried  out  as 
follows :  Scrub  for  five  minutes  with  soap  and 
hot  running  water,  giving  special  attention  to 
the  nails  and  creases  in  the  skin.  Scrubbing 
for  ten  minutes  loosens  many  epithelial  cells 
which  may  fall  into  the  wound  and  if  repeated 

frequently,  as  must  be  the  case  with  a  busy      ^       .  ^  kv  ^ 

surgeon,  causes  the  hands  to  crack  and  be-   1  -^    .  |iL--J     tBTTHR      ^flm 
come  sore.     I  believe  five  minutes  of  careful      \Ir  ^fm      l||fc™W       *»  «" 

scrubbing  is  sufficient.     The  water  should  be       ^^^ ,„       — '      '     " — *" 

as  hot  as  can  be  borne  with  comfort,  as  hot 

water  stimulates   the  sweat  glands  and  the   Fig.  s^.-Glass  brush-box  with  cover. 

flow  of  sweat  washes  out  the  ducts.     If  the 

ducts  are  washed  out  before  the  operation  by  copious  sweating,  during 
the  operation  the  secretion  will  be  slight.  The  brush  is  rubbed  both  in 
the  long  axis  of  the  extremity  and  transversely.  The  creases  on  the  back  of 
the  hands  and  fingers  will  be  partially  opened  by  flexing  the  fingers,  and 
transverse  scrubbing  will  clean  the  furrows.  The  furrows  on  the  palmar 
surface  will  be  opened  by  extending  the  fingers,  and  will  be  best  cleaned  by 
transverse  scrubbing  (George  Ben  Johnston).  An  excellent  soap  is  ethereal 
soap,  which  is  a  solution  of  castile  soap  in  ether.  Castile  soap  can  be  used.  I 
am  accustomed  to  use  green  soap.  Some  surgeons  prefer  to  use  green  soap  in 
the  form  of  a  tincture.  Synol  soap  has  advocates.  There  is  no  particular 
advantage  in  using  soap  containing  a  germicide,  as  such  soap  is  practically 
without  germicidal  power.  The  brush  employed  should  be  kept  in  a  i  :  1000 
solution  of  corrosive  sublimate  or  should  have  been  recently  sterilized  with 
steam  and  kept  in  a  sterile  glass  box  (Fig.  32).  The  nails  are  cut  short,  are 
cleansed  with  an  orange-wood  stick,  which  does  not  scratch  them,  and  the 
hands  are  again  scrubbed.  Very  prolonged  or  very  rough  scrubbing,  especially 
with  harsh  agents  like  marble  dust  or  sand,  is  actually  harmful,  as  it  tends  to 


7 2  Asepsis  and  Antisepsis 

crack  the  hands  and  make  them  rough  and  it  extensively  loosens  epidermis 
which  may  drop  into  the  wound.  Epidermis  may  contain  bacteria  within  it 
and  may  infect  the  wound. 

The  Use  of  Germicides  upon  the  Hands  and  Forearms. — After  mechanical 
cleansing  a  germicide  is  employed.  It  is  thought  to  be  impossible  to  sterilize 
the  hands  but  the  number  of  bacteria  upon  them  can  be  lessened  greatly. 
Whatever  method  is  adopted  it  is  desirable  that  it  shall  not  unduly  irritate  the 
skin.  An  occasional  operator  may  use  without  injury  tolerably  strong  chem- 
icals, but  the  busy  hospital  surgeon,  who  operates  perhaps  several  times  or  many 
times  a  day,  cannot  use  them.  Any  method  which  inllames,  cracks,  or  roughens 
the  skin  makes  future  sterilization  difficult  or  impossible,  hence  such  a  method  is 
undesirable.     Five  methods  are  described  here: 

Fiirbringer's  Method. — After  washing  off  the  soap  in  sterile  water  the  hands 
are  dipped  in  95  per  cent,  alcohol  and  held  there  for  two  or  three  minutes  while 
the  forearms,  hands,  fingers,  and  nails  are  being  rubbed  with  alcohol.  Alcohol 
removes  the  soap  which  has  entered  into  follicles  and  creases,  removes  desqua- 
mated epithelium,  enters  under  and  about  the  nails,  is  germicidal,  and  favors 
the  diffusion  of  the  corrosive  sublimate  under  the  nails  and  into  the  follicles, 
when  the  hands  are  placed  later  in  the  mercurial  solution.  Alcohol  also  hardens 
epithelium  and  keeps  it  from  desquamating  into  the  wound.  After  using  the 
alcohol  the  hands  and  forearms  are  dipped  in  a  hot  solution  of  corrosive  sub- 
limate (i  :  1000),  and  both  are  scrubbed  for  at  least  a  minute,  the  nails  receiving 
especial  care. 

The  Welch-Kelly  Method. — After  the  hands  and  forearms  have  been  cleansed 
mechanically  and  have  been  rinsed  in  sterile  water  they  are  immersed  for 
two  minutes  in  a  warm  solution  of  permanganate  of  potassium  (a  saturated 
solution  in  distilled  water).  This  solution  causes  the  cutaneous  surface  to 
assume  a  very  dark  brown  color.  The  hands  and  forearms  are  then  immersed 
in  a  warm  saturated  solution  of  oxalic  acid  and  are  held  there  until  decolor- 
ized. They  are  then  well  washed  in  sterile  water,  are  next  immersed  for 
two  minutes  in  a  i  :  500  solution  of  corrosive  sublimate,  and  finally  are  rinsed 
in  sterile  water  and  dried  on  a  sterile  towel.  The  solutions  for  use  in  the  above 
method  should  be  contained  in  jars  of  the  shape  of  a  druggist's  percolator, 
so  that  both  the  hands  and  forearms  can  be  immersed  at  the  same  time.  In 
this  method  the  permanganate  of  potash  is  merely  an  oxidizer  and  the  oxalic 
acid  is  the  active  germicide.  Some  persons  find  that  the  skin  tolerates  the  plan 
very  well,  others,  among  whom  is  the  author,  find  the  oxalic  acid  decidedly 
irritant  when  used  several  times  in  a  day. 

The  W eir-Stimson  Method. — This  method  was  suggested  by  Mr.  Rausch- 
enberg,  the  pharmacist  of  the  New  York  Hospital,  and  it  was  applied  prac- 
tically by  Doctors  Weir  and  Stimson.  The  process  is  as  follows:  The  hands 
should  be  cleansed  mechanically  as  previously  directed.  Place  about  a  table- 
spoonful  of  chlorinated  lime  in  the  palm  of  the  hand,  place  upon  the  lime  a 
piece  of  crystalline  carbonate  of  soda  (washing  soda)  i  inch  square  and  '  '9  ir^ch 
thick,  add  a  little  water,  and  rub  the  creamy  mixture  over  the  arms  and  hands 
until  the  rough  granules  of  sodium  carbonate  are  no  longer  felt.  This  requires 
from  three  to  five  minutes.  At  first  there  is  a  sensation  of  heat  usually  fol- 
lowed by  a  sensation  of  coolness.  Place  the  paste  under  and  around  the  nails 
by  means  of  a  bit  of  sterile  orange  wood.  Wash  the  arms  and  hands  in  hot 
sterile  water. ^  Remove  the  odor  of  chlorin  by  washing  the  hands  and  arms 
in  sterile  ammonia  water  of  a  strength  of  from  ^^  to  i  per  cent.  (McBurney, 
Collins,  and  Oastler,  in  "International  Text-Book  of  Surgery").  The  com- 
bination of  carbonate  of  sodium  and  chlorinated  lime  is  said  to  set  free  nascent 
chlorin,  a  most  efficient  germicide.  I  used  this  method  for  several  years  in 
the  clinic  of  the  Jefferson  Medical  College  Hospital  and  found  it  efficient. 
'  "Medical  Record,"  April  3,  1897. 


The  Use  of  Gloves  y. 

When  employed  several  times  a  day  it  may  prove  decidedly  irritant.  It  is 
important  that  crystalline  washing-soda  be  employed.  If  the  bicarbonate 
is  used,  nascent  chlorin  will  not  be  produced,  but  hydrochloric  acid  gas  will 
be  formed,  and  the  latter  gas  irritates  the  skin  and  is  not  a  satisfactory  germicide. 

The  Method  of  Whiting  and  Slocum  ("Annals  of  Surgery,"  May,  191 6). — 
Hamilton  studied  various  coal-tar  disinfectants  ("American  Jour,  of  Phar.," 
July,  1 91 5).  McDonald  suggested  the  employment  of  acetone,  denatured 
alcohol  and  pyxol,  acetone  being  merely  a  solvent  and  not  a  germicide.  Whit- 
ing and  Slocum  employ  a  solution  containing  35  per  cent,  of  acetone,  2  per  cent, 
of  phenoco,  alcohol  to  100  per  cent,  (page  37).  Scrub  with  hot  running  water. 
Wash  with  the  solution  for  two  minutes,  using  a  piece  of  sterile  gauze  to  rub  the 
fluid  into  the  skin.  Rinse  with  sterile  water.  This  method  gives  admirable 
results  tested  by  bacteriologic  study.  When  a  busy  surgeon  uses  this  fluid  it 
causes  some  irritation  of  the  hands. 

The  Sublimate-alcohol  Method. — This  is  the  method  I  personally  prefer. 
It  is  rapid,  efhcient,  and  reasonably  non-irritant.  It  is  as  follows:  Cleanse 
the  hands  with  soap  and  water  as  previously  directed.  Use  95  per  cent,  alco- 
hol as  in  Flirbringer's  method  (see  p.  72).     Dip  the  hands  in  70  per  cent. 


Fig.  33. — Showing  rubber  glove  applied. 

alcohol  containing  i  part  to  1000  of  corrosive  sublimate,  and  rub  the  hands, 
forearms,  and  nails  with  a  piece  of  sterile  gauze  wet  with  this  fluid  for  three 
minutes.     Rinse  these  parts  in  the  fluid  and  then  rinse  in  sterile  water. 

The  Use  of  Gloves. — Most  surgeons  are  so  impressed  with  the  impos- 
sibility of  sterilizing  the  hands  that  they  wear  gloves  in  operations.  Over 
sixty  years  ago,  at  King's  College,  Sir  Thomas  Watson  in  a  lecture  on  puer- 
peral fever  suggested  that  obstetricians  wear  gloves.  He  said:  "In  these  days 
of  ready  invention,  a  glove,  I  think,  might  be  devised  which  should  be  im- 
pervious to  fluids,  and  yet  so  thin  and  pliant  as  not  to  interfere  materially 
with  the  delicate  sense  of  touch  required  in  these  manipulations.  One  such 
glove,  if  such  shall  ever  be  fabricated  and  adopted,  might  well  be  sacrificed 
to  the  safety  of  the  mother  in  every  labor"  ("Watson's  Lectures  on  Physic"). 
Professor  Hals  ted  was  a  pioneer.  He  began  to  use  rubber  gloves  in  1889. 
Some  surgeons  used  cotton  and  others  silk  gloves,  but  it  has  been  proved 
that  cotton  and  silk  are  not  impervious  to  micro-organisms,  and  that  rubber 
is.  The  thin,  seamless  rubber  gloves  which  are  now  made  are  very  satisfactory. 
They  are  sterilized  by  boiling,  are  then  dried,  and  are  wrapped  in  a  sterile 
towel.  In  order  to  insert  the  hand  in  them  the  hand  should  be  dried,  the 
interior  of  the  glove  should  be  dusted  with  sterile  starch  or  talc  powder,  and 
then  the  nurse  should  fold  forward  the  wrist  part  and  hold  the  glove  open 


74 


Asepsis  and  Antisepsis 


while  the  surgeon  inserts  his  lingers  into  the  proper  compartments  and  pushes 
the  hand  in.  The  custom  of  filling  the  glove  with  sterile  fluid  and  then  in- 
serting the  hand  is  troublesome  and  objectionable,  because  the  fingers  soon 
become  sodden  like  those  of  a  washwoman,  the  sense  of  touch  is  impaired, 
considerable  discomfort  is  occasioned,  and  the  skin  is  apt  to  crack. 

If,  during  an  operation,  a  glove  becomes  infected,  a  clean  one  can  be  sub- 
stituted for  it.  Gloves  somewhat  impair  the  sense  of  touch,  but  a  surgeon  soon 
learns  to  work  with  them.  If  they  are  to  be  used,  the  hands  should  be  sterilized 
just  as  carefully  as  when  they  are  not  to  be  used,  because,  during  the  opera- 
tion, the  gloves  may  tear  or  be  punctured  by  a  needle.     I  always  wear  gloves, 

but  that  it  is  absolutely  necessary  to  wear 
gloves  in  all  cases  has  not  been  proved.  Their 
use  does  contribute  to  success  in  brain  opera- 
tions, abdominal  operations,  and  joint  operations. 
They  are  of  great  value  in  military  surgery, 
for  the  military  surgeon  may  not  have  time  to 
prepare  his  hands,  and  sterile  gloves  always  can  be 
kept  ready. 
When  a  surgeon  is  obliged  to  place  his  fingers  in  an  area  of  virulent  infec- 
tion he  may  be  poisoned.  Gloves  will  save  him  from  this  danger.  Again, 
a  surgeon  should  try  to  avoid  bringing  his  hands  unnecessarily  in  contact 
with  putrid  or  purulent  matter.  Though  it  may  not  poison  him,  it  grossly 
infects  the  surface,  renders  subsequent  cleansing  difficult,  and  endangers 
other  patients.  Gloves  will  prevent  this  danger.  A  surgeon  should  wear 
gloves  if  he  is  making  an  examination  or  performing  an  operation  which  is  sure 
to  infect  the  bare  hands,  and  he  should  wear  gloves  in  an  operation  if  in  a 

previous  operation  his  hands  were  in- 
fected. A  surgeon  whose  hands  are 
very  hairy  or  sweat  much  will  con- 
tribute to  the  patient's  safety  by  wear- 
ing gloves. 

Gloves  should  be  worn  if  the  surgeon 


Fig.  34. — Half-long  rubber 
glove. 


la-i^^- 


YiG.  35.— a,  Schimmelbuscli's  gas-heated  apparatus  for  sterilizing  instruments;  b,  wire  basket. 


has  a  wound  or  sore  upon  his  hand  or  chapped  hands.  When  using  gloves  in 
a  prolonged  operation  dip  the  covered  hands  now  and  then  in  corrosive  sub- 
limate solution,  because  the  glove  may  have  been  punctured  or  dust  may  have 
settled  upon  it  from  the  air. 

Gloves  make  the  hands  sweat,  and  if  one  should  be  punctured  considerable 
sweat  may  emerge  from  the  puncture  and  enter  the  wound,  and  sweat  contains 
bacteria.  The  entry  of  any  considerable  amount  of  sweat  is  more  dangerous 
to  the  patient  than^are  well  cleaned  naked  hands,  hence  gloves  may  actually 
favor  the  infection  they  are  meant  to  prevent.  When  they  are  used  the  sur- 
geon must  take  scrupulous  care  not  to  puncture  them  with  a  needle,  clip  them 
with  forceps,  or  tear  them  with  a  ligature  or  suture. 

The  closer  they  fit  the  less  the  danger  of  puncture,  and  one  should  know 
accurately  what  size  he  requires  to  fit  closely  and  smoothly  without  being  so 
tight  as  to  make  the  fingers  numb. 

Preparation  of  Gloves. — Wash  with  soap  and  water  containing  a  little  am- 
monia, rinse  in  sterile  water,  boil  for  thirty  minutes  in  a  i  per  cent,  solution 


Preparation  of  the  Patient  75 

of  carbonate  of  soda.  Dry  the  glove  and  wrap  in  a  dry  sterile  towel  and  keep 
until  it  is  heeded.  A  glove  should  stand  about  twenty  boilings.  The  surgeon 
should  carry  a  number  of  pairs  of  prepared  gloves  in  his  bag,  for  the  use  of 
himself  and  assistants  in  private  house  operations. 

Metal  instruments  are  disinfected  by  subjecting  them  to  the  action  of 
steam  in  a  special  sterilizer,  or,  better,  by  boiling  them  for  fifteen  minutes  in  a 

1  per  cent,  solution  of  carbonate  of  sodium.  They  are  wrapped  into  a  bundle 
by  means  of  a  towel  or  piece  of  gauze  and  are  dropped  into  the  solution.  The 
blades  of  knives  should  first  be  wrapped  in  cotton  to  prevent  scratching  and 
duUing.  After  boiling,  the  instruments  should  be  rinsed  in  hot  sterile  water 
or  in  a  5  per  cent,  solution  of  carbolic  acid  and  be  kept  until  needed  in  pans 
of  sterile  water.  The  carbonate  of  sodium  prevents  rusting.  In  a  clinic  the 
boiling  is  carried  out  in  a  Schimmelbusch  sterilizer  (Fig.  35).  In  a  private 
house  it  can  be  done  in  a  sterilizer 

such  as  that  shown  in  Fig.  36,  or 
in  a  pan,  a  kettle,  or  a  wash-boiler. 
A  sterilizer  with  a  tray  is  better 
than  an  ordinary  pan  or  kettle, 
because,  when  the  latter  is  used, 
the  metal  instruments  lie  in  the 
bottom  of  the  vessel,  w^here  the 
heat  is  very  great  and  the  temper  Fig.  36.  —Portable  sterilizer. 

may  be  impaired.  Boiling,  unfor- 
tunately, destroys  to  some  extent  the  keenness  of  cutting  instruments,  the 
ebullition  throwing  them  about.  After  the  completion  of  the  operation  the  in- 
struments should  be  scrubbed  with  soap  and  water,  boiled  in  soda  solution, 
dried,  and  placed  in  a  closet  with  glass  shelves  so  that  they  will  be  protected 
from  moisture  and  dust.  Instruments  can  be  partially  disinfected  by  keeping 
them  for  thirty  minutes  in  a  5  per  cent,  solution  of  carbolic  acid  or,  better,  in  a 

2  per  cent,  solution  of  formalin.  Instruments  with  handles  of  wood^  bone, 
ivory,  or  tortoise  shell  must  not  be  boiled.  Such  instruments  should  not 
be  used.  If  such  instruments  are  used,  they  can  be  partially  disinfected  by 
the  use  of  carbolic  acid  or  formalin.  Metal  instruments,  whenever  possible, 
should  consist  of  one  smooth  piece.  Grooves  and  letters  are  objectionable,  as 
dirt  gathers  in  such  depressions. 

Preparation  of  the  Patient. — Whenever  possible  give  the  patient  some 
days'  rest  in  bed  before  a  severe  operation.  This  is  not  possible  in  an  emer- 
gency. It  is  seldom  desirable  in  the  case  of  a  highly  nervous  and  excitable 
woman.  Such  a  patient  is  sleepless  and  frightened  and  loses  ground  by  delay. 
In  most  cases  this  preliminary  rest  is  advisable.  It  is  particularly  desirable  in 
a  strong,  active  working  man  suddenly  translated  from  labor  to  bed.  We  wish 
to  prepare  him  to  meet  operative  shock.  During  the  wait  the  patient  is  apt  to 
adjust  himself  to  his  surroundings,  he  becomes  accustomed  to  diminished 
activity  and  to  sick-room  routine,  forms  an  acquaintance  with  his  nurses  and 
physicians,  and,  as  a  rule,  becomes  less  nervous  and  more  calmly  confident  of 
the  result.  He  also  learns  to  use  the  bed-pan  and  to  micturate  while  recumbent. 
A  patient  while  waiting  is  to  have  a  general  bath  several  times.  Some  weak 
and  emaciated  patients  are  treated  and  built  up  for  weeks  before  the  operation 
is  attempted.  During  this  preliminary  rest  the  surgeon  should  study  the 
disease,  and  study  the  individual  in  order  to  learn  his  tendencies,  peculiarities, 
etc.  The  condition  of  the  lungs,  the  heart,  the  blood,  and  the  kidneys  should  be 
accurately  determined.  The  amount  of  urine  passed  in  twenty-four  hours 
should  be  ascertained,  and  the  percentage  of  urea  should  be  estimated  from  a 
sample  of  the  twenty-four-hour  urine.  The  urine  is  carefully  examined  for 
sugar,  albumin,  casts,  acetone,  diacetic  acid,  indican,  etc.  By  the  above  exami- 
nations the  surgeon  may  be  able  to  anticipate  and  provide  against  certain  calami- 


y6  Asepsis  and  Antisepsis 

ties.     Sometimes  such  a  study  leads  us  to  postpone  or  abandon  an  operation. 
Furthermore,  such  a  study  gives  the  information  which  is  necessary  in  order  to 
intelligently  select  the  proper  anesthetic.     The  presence  in  the  urine  of  acetone 
and  diacetic  acid  forbids  any  but  an  emergency  operation.     These  substances 
are  common  in  the  urine  of  those  who  have  been  long  ill-nourished  or  have  been 
all  but  starved  in  the  preparation  for  operation.     They  may  also  be  found  in 
diabetics.     In  order  to  correct  acidosis  give  large  doses  of  bicarbonate  of  sodium 
and  add  carbohydrates  to  the  diet  (see  page  193).     Sugar  or  granular  and  fatty 
casts  in  the  urine,  or  a  considerable  quantity  of  albumin,  make  us  hesitate  to 
operate. "^     In  patients  with  obstructive  jaundice  and  in  those  in  whom  we  sus- 
pect pancreatic  disease  or  hemophilia  the  coagulation  time  of  the  blood  should  be 
taken.     If  the  blood  fails  to  coagulate  in  three  minutes  there  is  delay  in  coagula- 
tion.   In  jaundice  cases  coagulation  may  require  eight  or  nine  minutes.    In  a  case 
ot  hemophilia  reported  by  Wright  coagulation  required  over  one  hour.    A  hemo- 
globin percentage  of  under  50  makes  us  seek  to  avoid  operation  in  most  cases  not 
associated  with  bleeding,  and  in  all  cases  of  malignant  disease.     The  anesthetist 
should,  during  this  preliminary  period,  examine  the  heart,  pulse,  and  blood- 
pressure,  so  as  to  know  the  natural  character  of  each  when  the  patient  is  free 
from  excitement.     Without  this  preliminary  knowledge  he  cannot  accurately 
appreciate  or  intelligently  interpret  some  changes  induced  by  the  anesthetic. 
The  anxiety  preliminary  to  an  operation  raises  blood  pressure  and  the  pressure 
may  vary  greatly  in  the  same  individual.     In  arteriosclerosis  there  will  be  high 
blood  pressure  but  so  there  may  be  in  a  vasomotor  neurosis.    Low  blood  pressure 
is  seldom  of  ominous  significance  except  in  acute  illness  or  states  of  exhaustion 
(see  G.  V.  Dearborn  in  "Med.  Record,"   1916,  xc).     In  spite  of  some  recent 
articles  I  still  believe  that  constipation  should  be  amended  by  mild  laxatives  or 
enemas,  and  all  fermented  matter  should  be  removed  from  the  alimentary  canal. 
I  do  not  believe  in  drastic  purgatives.     Of  course,  purgatives  are  forbidden  in 
strangulated  hernia,  appendicitis,  etc.     Constipation  increases  the  probability 
of    wound    infection    and    greatly    impairs    the  comfort  of  the  patient.     As 
previously  shown,   the  putrefactive   bacteria  in   the  intestinal  canal,  which 
are  usually  harmless   and   are  what  Adami  calls  "potential  parasites,"  may 
escape  into  the  tissues.     The  retention  of  fermented  matter  causes  catarrhal 
inflammation  and  bacteria  escape  more  easily.     If  they  escape  they  may  lead 
to  damage  in  the  wound,  and  even  if  wound  infection  from  within  does  not  occur, 
constipation  lessens  vital  resistance  and  increases  the  liability  to  wound  infection 
from  without.     Purgatives  must  not  be  violent,  as  anything  which  greatly 
depresses  a  person  lessens  vital  resistance,  and  powerful  purgatives  are  powerful 
depressants.     It  is  only  fair  to  state  the  opposite  view  on  these  points.     It  is 
set  forth  by  W.  C.  Alvarez  in  Surgery,  Gynecology  and  Obstetrics,  June,  1918. 
He  claims  that  preliminary  purgation  will  not  make  an  anesthetic  safer  or  its 
administration  easier,  will  not  lessen  the  danger  of  auto-intoxication,  gas  pains 
or  peritonitis  and  in  fact  actually  increases  such  danger  by  disturbing  the 
mesenteric  circulation.     He  believes  that  purgation  interferes  with  intestinal 
absorption,  upsets  the  balance  of  salts,  causes  bodily  weakness,  flatulence,  dis- 
tention and  increased  growth  of  bacteria,  puts  the  bowels  in  such  a  condition 
that  they  react  poorly  to  drugs,  and  is  responsible  for  some  postoperative 
nausea  and  vomiting.     This  is  a  heavy  and  a  comprehensive  indictment  which  it 
seems  to  me  might  lodge  against  a  drastic  purgative  but  scarcely  against  a  mild 
laxative.     The  diet  should  be  bland  and  nutritious,  but  not  bulky.     The  night 
before  the  operation  give  a  laxative  dose  of  a  saline  cathartic,  and  the  morning  of 
the  operation  employ  an  enema.     Not  only  do  we  empty  the  bowel  to  lessen  the 
liability  to  wound  infection,  but  we  wish  the  rectum  empty  at  the  time  of  opera- 
tion for  another  reason.     It  is  desirable  that  the  rectum  be  empty  because  in 
shock  the  absorbing  power  of  the  stomach  is  greatly  diminished  or  is  even 
1  The  question  of  operation  on  diabetics  is  discussed  on  p.  78. 


Preparation  of  the  Patient  yy 

abolished  for  the  time,  and  it  may  be  necessary  to  utilize  the  absorbing  power  of 
the  rectum  to  take  up  stimulants  given  by  enema.  When  a  patient  is  under 
the  influence  of  an  anesthetic  or  when  he  is  profoundly  shocked,  of  course  no 
attempt  is  made  to  give  stimulants  by  the  mouth.  Whenever  possible  give  a 
general  warm  bath  the  day  before  the  operation.  It  is  a  common  custom  the 
evening  before  the  operation  to  shave  the  region  if  hairy,  scrub  the  entire 
field  of  operation,  as  well  as  the  adjoining  regions,  with  soap  and  water;  wash 
with  alcohol;  scrub  with  hot  corrosive  sublimate  solution  (i  :  looo);' apply 
a  layer  of  moist  corrosive  sublimate  gauze,  and  place  over  this  dry  antiseptic 
gauze,  a  rubber  dam,  and  a  bandage.  Many  surgeons  apply  a  poultice  of  green 
soap  for  many  hours  before  applying  a  chemical  germicide,  in  order  to  separate 
masses  of  epithelium  and  with  them  many  germs.  This  method  is  particularly 
useful  in  cleansing  the  scalp.  On  removing  the  dressings  to  perform  the  opera- 
tion, the  part  is  scrubbed  with  soap  and  water,  washed  with  sterile  water,  then 
with  alcohol,  and  then  with  corrosive  sublimate  solution.  I  have  become  con- 
vinced that  the  teachers  in  Johns  Hopkins  Hospital  are  right,  and  that  cleansing 
the  day  before  operation  is  not  necessary  except  for  a  brain  case.  Neither  is  it 
desirable,  as  it  often  gives  the  patient  a  restless  night.  It  is  my  custom  to  have 
a  hairy  region  shaved  the  day  before  operation.  In  all  cases  the  field  of  opera- 
tion is  disinfected  the  morning  of  the  operation.  Disinfection  is  again  practised 
when  the  patient  is  on  the  operating  table,  after  anesthetization.  In  emergency 
cases  disinfection  can  only  be  practised  just  previous  to  the  operation.  In 
emergency  operations  iodin  should  be  used  (see  below)  or  Whiting's  solution  (page 
73).  When  the  field  of  operation  has  been  prepared,  surround  it  with  dry  sterile 
sheets  and  towels.  In  a  head  operation  I  stitch  the  towels  to  the  skin  to  keep 
them  in  place  and  at  the  termination  of  the  operation  remove  these  stitches. 
Murphy  prevented  infection  from  the  cutaneous  surface  by  spreading  a  specially 
prepared  sterile  solution  of  rubber  over  the  sterilized  operation  area.  The 
rubber  is  dissolved  in  acetone.  The  incisions  are  made  through  the  artificial 
skin  of  rubber  and  the  rubber  is  removed  when  the  surgeon  is  ready  to  introduce 
the  sutures.  Thus  infection  of  the  wound  with  contaminated  secretion  of  the 
skin  glands  is  prevented.  If  iodin  has  been  used  upon  the  abdomen,  the  surgeon 
must  be  scrupulously  careful  not  to  bring  intestine  in  contact  with  the  skin. 
If  iodin  comes  in  contact  with  intestine,  it  irritates  the  gut  and  becomes  respon- 
sible for  subsequent  adhesions. 

If  disinfecting  an  emergency  case  in  which  a  wound  exists,  tincture  of 
iodin,  unless  well  diluted,  should  not  be  put  in  the  wound.  Hindenburg  had  a 
case  in  which  local  gangrene  followed  such  an  application  ("Miinchener  medi- 
zinische  Wochen.,"  July  5,  1911).  It  is  not  probable  that  the  very  dilute 
alcoholic  solution  of  iodin  used  by  many  to  prepare  the  skin  would  ever  endanger 
a  wound. 

Of  recent  years  iodin  has  been  largely  used  and  warmly  praised  as  a  disinfec- 
tant for  the  skin.  It  was  recommended  by  Senn  in  1905  and  was  strongly  advo- 
cated by  Grossich  in  1908.  If  iodin  is  to  be  used  the  skin  may  be  scrubbed  with 
soap  and  water  and  shaved  the  night  before,  but  must  never  be  scrubbed  with 
soap  and  water  within  several  hours  of  the  impending  operation.  Were  it  done,  it 
would  swell  the  surface  epithelium  and  keep  the  iodin  from  entering  into  the  skin. 
Two  hours  before  operation  give  the  parts  a  dry  shave,  apply  a  3  per  cent,  solu- 
tion of  iodin  and  apply  it  again  when  the  patient  is  on  the  table.  In  an  emer- 
gency case  the  skin  is  dry  shaved,  the  field  of  operation  is  painted  with  pure 
tincture  of  iodin  (which  is  allowed  to  dry  and  is  not  wiped  away),  and  covered 
with  sterile  towels  or  gauze.  When  the  patient  is  placed  upon  the  table  the  field 
is  again  painted  with  iodin.  This  method  is  of  great  value  in  emergency  cases, 
especially  in  out-patient  and  accident  work.  I  have  abandoned  it  in  the  axilla  and 
perineum  because  the  constant  moisture  of  those  regions  makes  iodin  inefficient. 
The  method  is  less  efficient  in  summer  than  in  winter,  because  in  summer  the 


yS  Asepsis  and  Antisepsis 

skin  is  apt  to  be  wet  with  sweat.  Corrosive  sublimate  solution  must  not  be 
put  upon  skin  containing  iodin.  To  do  so  will  cause  violent  irritation.  If  iodin 
has  been  used  upon  the  abdomen  the  field  of  operation  should  be  wiped  with 
alcohol  just  before  making  the  incision  and  every  effort  should  be  made  to  keep 
any  intraabdominal  structure  from  touching  the  iodized  skin.  A  mere  touch 
will  result  in  severe  irritation  of  the  peritoneum  and  will  lead  to  the  formation 
of  adhesions. 

During  an  operation  the  patient  must  be  carefully  protected  from  cold 
by  wrapping  him  in  blankets,  and  often  by  having  him  wear  specially  pre- 
pared drawers  with  feet.  In  operations  of  great  severity  the  blood  pressure 
should  be  frequently  noted.  A  sudden  fall  gives  notice  of  impending  dangerous 
shock.  This  is  true  particularly  of  operations  upon  the  head  and  neck.  After 
the  completion  of  an  operation  and  the  application  of  the  dressings  the  patient 
is  returned  to  his  room  or  the  ward,  care  being  taken  to  protect  him  from  cold 
and  drafts  while  in  transit. 

Disinfection  of  Mucous  Membranes. — It  is  impossible  to  disinfect  thor- 
oughly mucous  membranes.  We  must  not  scrub  forcibly  and  we  must  not 
use  powerful  germicides,  because  they  are  irritant  and  also  because  they  may 
be  absorbed.  The  best  that  can  be  done  in  the  vagina  is  to  rub  lightly,  when 
possible,  with  a  bit  of  moist  absorbent  cotton  and  irrigate  with  a  solution 
of  boric  acid  or  with  normal  salt  solution.  Another  method  is  to  sponge  the 
vagina  with  creolin  and  ethereal  soap  (i  and  i6)  and  irrigate  with  hot  saline 
fluid  or  boric  acid. 

The  rectum  is  prepared  by  washing  out  all  retained  feces  oy  the  use  of 
copious  high  injections  and  by  irrigating  \^dth  salt  solution  or  boric  acid. 

The  mouth  is  prepared  by  having  snags  of  teeth  and  tartar  removed  and 
decayed  teeth  removed  or  plugged.  For  several  days  before  the  operation 
scrub  the  teeth  twice  a  day  with  a  soft  brush  and  castile  soap;  and  every  three 
hours,  when  the  patient  is  awake,  rinse  the  mouth  with  peroxid  of  hydrogen 
and  spray  the  nares  and  nasopharynx  with  a  saturated  solution  of  boric  acid. 

The  urethra  is  prepared  by  administering  by  the  mouth  for  several  days 
salol  or  urotropin  and  by  frequent  irrigation  of  the  urethra  wath  boric  acid 
solution,  normal  salt  solution,  a  solution  of  permanganate  of  potash  (i:6ooo), 
or  a  1 :  5000  solution  of  silver  nitrate. 

Preparation  of  a  Patient  for  An  Operation  Upon  the  Stomach. — (Seep.  12 18.) 

The  Time  of  Day  to  Operate. — A  hard-and-fast  rule  cannot  be  set  as  to  the 
time  of  day  when  operations  should  be  done.  Emergency  operations  must  be 
performed  at  once  without  any  consideration  as  to  time.  It  is  often  necessary, 
because  of  other  professional  obligations,  to  set  an  afternoon  hour  for  an  opera- 
tion. Whenever  possible,  however,  if  the  nature  of  the  case  admits  of  it,  operate 
in  the  morning  and,  preferably,  in  the  early  morning.  By  doing  this  the  patient 
is  saved  some  hours  of  dread  and  worry  and  the  surgeon  is  enabled  to  operate 
when  he  is  fresh,  active,  and  alert;  in  other  words,  when  he  is  at  his  best.  A 
tired  mind,  like  a  tired  hand,  tends  tp  become  shaky,  and  a  tired  mind  may 
mean  incorrect  observation,  careless  technic,  impaired  judgment,  disastrous 
timidity,  or  calamitous  recklessness. 

Operations  on  Diabetics. — Surgical  operations  upon  diabetics  are  regarded 
as  very  dangerous  and  are  employed  by  most  surgeons  in  emergencies  only. 
In  operations  upon  such  subjects  gangrene  may  arise  in  the  wound  or  diabetic 
coma  may  develop  (page  191).  It  is  important  to  remember  that  glycosuria 
may  result  from  a  surgical  condition  (head  injury,  sepsis,  etc.),  and  this  tempo- 
rary diabetes  may  be  relieved  by  operation.  I  have  seen  it  in  appendicitis,  and 
in  such  cases  operation  is  not  contra-indicated,  but  is  imperative.  Llewellyn 
Phillips  ("Lancet,"  May  10  and  17,  1902)  refers  to  the  temporary  glycosuria 
produced  by  injury  and  sepsis.  He  thinks  that  diabetes  may  directly  cause 
cataract  and  balanoposthitis,   but  produces   gangrene  indirectly  by  causing 


The  Time  of  Day  To  Operate  yg 

nerve  degeneration  and  arteriosclerosis.  Phillips  points  out  that  a  surgical 
condition  and  glycosuria  may  exist  independent  of  and  uninfluenced  by  each 
other,  and  many  such  cases  can  be  operated  upon,  although  operation  should 
be  avoided  if  there  is  serious  disease  of  some  important  organ  (the  liver,  for 
instance).  Phillips,  in  the  valuable  article  referred  to,  insists  that  the  percent- 
age of  sugar  is  not  a  measure  of  the  degree  of  danger;  that  albuminuria  adds 
greatly  to  the  danger;  that  the  presence  of  acetone  in  the  urine,  and  also  the 
presence  of  ammonia,  gives  a  bad  prognosis.  Phillips's  conclusions  as  to 
when  to  operate  and  when  to  refuse  operation  are  as  follows  ("Lancet,"  May 
lo  and  17,  1902):  An  operation  for  malignant  disease  in  a  diabetic  can  be 
performed  if  the  operation  would  be  proper  on  a  non-diabetic  individual. 
Large  abdominal  tumors  can  be  removed.  Cosmetic  operations  are  justi- 
fiable if  the  general  health  is  good  and  there  is  not  marked  arterial  disease  or 
nerve  degeneration.  Operation  is  justifiable  in  all  emergencies  without  regard 
to  the  condition  of  the  urine.  In  a  diabetic  with  a  surgical  malady  it  is  often 
possible  to  lessen  danger  by  preliminary  treatment.  Only  an  operation  of  the 
greatest  urgency  should  be  performed  if  over  i  gm.  of  ammonia  is  excreted 
during  twenty-four  hours;  and  if  aceto-acetic  acid  or  much  albumin  is  present, 
every  case  but  the  most  urgent  should  be  postponed  and  subjected  to  medical 
treatment.  The  plan  of  preparation  employed  in  the  clinic  of  the  Mayo's  has 
given  excellent  results  (see  DavidM.  Berkman  in  "Collected  Papers  of  the  Mayo 
Clinic,"  1915).  The  urine  is  freed  from  sugar  by  Allen's  plan.  The  patient  is 
starved  for  from  forty-eight  to  seventy-two  hours,  being  given  all  the  water  he 
desires  and  some  black  coffee  and  whiskey  three  or  four  times  a  day.  Then  he 
is  put  upon  a  strict  diet  of  meat,  eggs,  meats  of  nuts  and  a  small  amount  of  cream. 
This  diet  is  continued  until  the  urine  is  free  of  sugar  and  remains  so  for  two  days. 
Ordinary  green  vegetables  are  then  added  gradually,  sugars,  starches,  and  all  food 
rich  in  carbohydrates  being  still  avoided.  Should  sugar  reappear  the  strict 
diet  is  again  enforced.  Berkman  does  not  believe  that  simply  removing  sugar 
from  the  urine  abolishes  the  risk  of  operation.  Our  object  should  be  to 
increase  tolerance  so  that  the  patient  may  utilize  more  carbohydrate  and  lay  up 
a  reserve  store  of  glycogen.  A  strict  carbohydrate-free  diet  up  to  operation 
increases  the  risk  of  coma  by  permitting  acidosis.  Slight  acidosis  does  not  forbid 
operation,  marked  acidosis  does.  If  over  a  gram  of  ammonia  is  excreted  in 
twenty-four  hours,  operation  is  contra-indicated.  Severe  nephritis  is  a  positive 
contra-indication.  Transitory  (physiological)  glycosuria  is  a  rare  condition. 
Riesman  points  out  that  it  exists  in  10  per  cent,  of  pregnant  women.  The 
Mayo's  in  order  to  antagonize  acidosis  give,  for  three  or  four  days  before  opera- 
tion I  dram  of  sodium  bicarbonate  by  mouth  six  to  eight  times  a  day.  Soon 
after  operation  the  administration  of  this  drug  is  resumed.  If  it  cannot  be 
taken  by  the  mouth  give  it  by  rectum  or  intravenously  in  0.5  per  cent, 
solution. 

I  would  add  to  the  above  conclusions  that  the  anesthetic  is  a  danger  to  the 
kidneys  irritated  by  the  secretion  of  sugar  and  may  induce  acidosis  (page  1348) 
and  it  is  desirable,  when  possible,  to  use  local  anesthesia,  or,  as  Robt.  T.  Morris 
advises,  nitrous  oxid  and  oxygen  ("Medical  News,"  June  29,  1901),  or  spinal 
anesthesia,  or  to  block  the  nerves  with  cocain.  In  4  cases  I  used  spinal  anes- 
thesia, but  in  I  of  them  the  patient  died  in  coma.  Opium  and  codein  wiU  dimin- 
ish sugar  in  the  urine.  If  sugar  diminishes  in  the  urine  but  increases  in  the 
blood,  the  condition  is  one  of  danger.  As  a  matter  of  fact  the  amount  of  sugar 
in  the  urine  is  no  real  measure  of  the  amount  in  the  blood  and  it  is  the  sugar  in 
the  blood  which  counts.  It  is  to  be  hoped  that  soon  examination  of  the  blood 
will  become  a  routine  procedure. 

In  acidosis  dextrose  is  of  value.  Alkalies  neutralize  acids  but  carbohydrates 
aid  in  stopping  acid  formation.  Dextrose  is  valuable  for  this  purpose.  It  may 
be  given  by  the  mouth,  by  hypodermoclysis,  intravenously  or  by  rectum.     We 


8o  Asepsis  and  Antisepsis 

do  not  give  ordinary  sugars  (disaccharidsj  by  hypodermoclysis,  intravenously 
or  by  the  rectum.  They  require  the  digestive  juices  to  disintegate  them.  We 
use  levulose  or  dextrose  (monosaccharids).  A  lo  per  cent,  solution  of  dextrose 
in  salt  solution  is  used  for  intravenous  or  subcutaneous  injection.  In  proc- 
toclvsis  a  lo  per  cent. solution  in  plain  water  is  used. 

irrigation  is  often  practised  in  septic  wounds,  but  is  not  required  in  aseptic 
wounds.  In  a  septic  wound  gentle  irrigation  is  often  desirable.  Irrigation 
removes  many  bacteria  and  much  toxin  and  antiseptic  irrigation  perhaps 
antidotes  retained  toxins.  Irrigation  must  never  be  forcible  for  fear  it  may  dis- 
seminate infection.  Among  irrigating  fluids  we  may  mention  corrosive  sub- 
limate, carbolic  acid,  peroxid  of  hydrogen,  boric  acid  solution,  acetate  of 
aluminum,  and  normal  salt  solution.  Hot  normal  salt  solution  is  the  best 
agent  with  which  to  irrigate  the  peritoneal  cavity,  the  pleural  sac,  the 
interior  of  joints,  and  the  surface  of  the  brain.  This  solution  contains  0.9 
per  cent,  of  sodium  chlorid. 

The  Dry  Method. — Many  surgeons  employ  Landerer's  dry  method  in  opera- 
ting aseptically,  no  fluid  being  applied  to  the  wound.  As  the  wound  is  en- 
larged gauze  sponges  are  packed  in  to  arrest  hemorrhage.  On  the  completion  of 
the  operation  the  sponges  are  removed,  bleeding  points  are  ligated,  and  the 
wound  is  often  closed  without  drainage. 

Ligatures  and  Sutures. — In  using  sutures  always  remember  that  they 
must  be  tied  firmly,  but  never  tightly.  A  tight  suture  will  cut  when  the  wound 
sweUs  and  will  thus  fail  of  its  purpose;  further,  it  produces  an  area  of  tissue 
necrosis,  which  is  a  point  of  least  resistance  in  and  about  which  infection  is 
prone  to  occur.  We  had  far  better  use  many  very  fine  sutures  than  a  less 
number  of  thick  ones.  The  individual  fine  suture  is  weak,  but  in  numbers  they 
give  firm  support.  A  fine  suture  cannot  be  tied  too  tightly.  If  we  try  to  make 
it  very  tight  the  attempt  is  frustrated  by  the  breaking  of  the  suture. 

Catgut. — The  favorite  ligature  material  is  catgut.  The  name  catgut  was 
not  given  to  the  material  because  it  was  made  from  cat's  intestine.  It  is  supposed 
to  be  a  conversion  or  perversion  of  kitgut  or  kit  string  that  is,  fiddle  string,  kit 
being  an  old  term  for  a  dancing  master's  fiddle.  Catgut  undergoes  absorption 
in  the  tissues.  Years  ago  attempts  were  made  by  Scarpa,  Crampton,  and 
Physick  to  use  absorbable  ligatures.  Sir  Astley  Cooper  tried  catgut.  These 
attempts  failed  because  the  material  employed  was  septic,  suppuration  ensued, 
the  wound  gaped,  and  the  ligature  was  cast  off  prematurely.  Surgeons  re- 
mained content  with  non-absorbable  ligatures  of  sflk  or  linen.  These  liga- 
tures were  not  cut  short,  but  a  long  end  was  left  to  each  one,  and  the  ends 
were  allowed  to  hang  out  of  the  wound.  The  ligatures  were  slightly  pulled 
upon  from  time  to  time,  and  when  they  loosened  or  cut  through  were  removed. 
Catgut  is  the  submucous  coat  of  the  intestine  of  the  sheep,  and  is  the  material 
from  which  violin  strings  are  made.  It  was  reintroduced  into  surgery  by 
Lister.  It  is  usually  obtained  in  the  following  manner:  The  small  intestine, 
after  separation  from  the  mesentery,  is  washed  in  water,  laid  upon  a  board, 
and  scraped  by  a  metal  instrument.  Thus  the  mucous  coat  and  the  muscular 
coat  are  scraped  away,  and  the  submucous  coat  only  remains.  The  submu- 
cous coat  is  cut  into  strips,  and  each  strip  is  twisted  into  a  coil.  Raw  catgut  is 
an  infected  material.  It  is  difficult  to  sterilize,  because  in  the  twisting  many 
bacteria  get  into  the  interior  of  the  strand,  where  it  is  impossible  for  anti- 
septics to  reach  them.  Raw  catgut  obtained  from  animals  dead  of  splenic  fever 
contains  spores  of  anthrax.  If  not  thoroughly  disinfected  catgut  is  dan- 
gerous, and  some  surgeons  consider  its  cleanliness  always  a  matter  of  grave 
question  and  will  not  use  it.  Cases  of  tetanus  after  operation  have  been  traced 
directly  to  infected  catgut.  Repin  is  so  convinced  that  catgut  is  of  uncertain 
cleanliness  and  that  at  any  time  the  surgeon  may  get  an  infected  strand  that  he 
advises  keeping  the  sterilized  material  in  sealed  tubes  of  bouillon.     The  slightest 


Ligatures  and  Sutures  8i 

evidence  of  grovvtii  proves  contamination  and  tlie  tube  is  thrown  away.  The 
safest  raw  catgut  is  obtained  from  fresh  intestines  (as  advised  Ijy  Kuhn),  is  not 
twisted,  16  made  into  strands  in  sterile  machines  so  as  to  prevent  handling,  and 
is  put  up  in  aseptic  bundles.  The  commission  of  the  Paris  Academy  of  Medicine 
("Bull.  Acad,  de  med.,"  1916,  Ixxv)  maintains  that  no  catgut  is  safe  unless  it 
has  been  treated  from  the  beginning  of  its  preparation  with  the  conviction  clear 
in  mind  that  the  material  is  to  be  used  surgically.  No  method  of  chemical 
treatment  will  sterilize  gut  certainly  and  always.  When  the  animal  has  been 
killed  the  intestine  should  be  removed  immediately,  be  examined  with  care 
washed,  put  in  a  refrigerator  and  transported  in  the  refrigerator  to  the  factory 
within  fifteen  hours  after  the  death  of  the  animal.  In  the  factory  the  intestine 
should  be  placed  in  oxygenated  water  and  cut  into  strands  which  are  to  be 
sterilized.  Surgeon's  catgut  is  usually  obtained  from  the  dealer  in  skeins  con- 
taining 30  yards.  It  should  be  rough  and  yellow.  The  smooth  white  variety 
should  not  be  purchased.  It  has  been  rubbed  smooth  with  a  piece  of  glass  and 
bleached  with  a  chemical,  and  in  consequence  is  weak  and  unreliable.  The 
smallest  size  is  known  as  double  zero,  then  come  single  zero.  No.  i.  No.  2,  No.  3, 
and  No.  4.  The  usual  ligature  size  is  No.  2.  Nos.  3  and  4  are  only  used  for 
tying  thick  pedicles.  Nos.  i  and  2  are  used  for  suturing  the  dura  and  perito- 
neum and  zero  and  No.  i  for  tying  small  vessels  in  the  brain.  When  catgut  is 
used  to  tie  delicate  tissue  (omental  masses,  intestinal  surfaces,  etc.)  it  must  first 
be  softened  by  immersing  for  half  a  minute  in  normal  salt  solution.  If  this 
precaution  is  neglected  and  wiry  catgut  is  used,  the  ligature  or  suture  will  cut 
and  hemorrhage  will  occur.  The  greater  the  diameter  of  the  gut,  the  more 
uncertain  is  the  sterilization.  Nos.  3  and  4  are  of  doubtful  cleanliness,  no 
matter  what  method  of  sterilization  is  employed,  and  a  strand  though  clean 
upon  the  surface  'may  be  infected  in  its  interior.  When  a  strand  which  is 
infected  within  is  used  by  the  surgeon  the  tissues  are  not  infected  promptly, 
but  after  some  days  when  the  catgut  has  been  partially  absorbed  and  the  spores 
or  bacteria  within  the  strand  have  been  set  free.  Many  late  infections  are 
due  to  catgut  infected  in  the  interior  of  the  strand.  The  smaller  sizes  I  believe 
can  usually  be  satisfactorily  sterilized.  I  am  very  uncertain  as  to  the  invariable 
surgical  cleanliness  of  the  larger  sizes. 

If  catgut  is  thoroughly  freed  from  bacteria  and  the  wound  in  which  it  is 
used  is  aseptic,  it  is  a  most  satisfactory  ligature  material,  is  absorbed  in  the 
wound  after  being  cut  off  short,  and  produces  no  trouble,  although  it  does 
increase  wound  secretion  slightly.  The  smaller  sizes  are  absorbed  in  four  or 
five  days.  No.  2  lasts  from  nine  to  ten  days,  Nos.  3  and  4  from  ten  days  to 
three  weeks.     Chromicized  catgut  is  absorbed  far  less  rapidly  than  plain  gut. 

One  of  the  following  methods  of  preparation  may  be  used: 

Boiling  in  Alcohol. — The  catgut  is  soaked  in  ether  for  twenty -four  hours 
to  remove  fat.  It  is  then  wound  on  glass  spools,  transferred  to  alcohol,  and 
boiled  under  pressure.  The  boiling  is  conducted  in  a  hea\y  metal  jar  with 
a  well-fitting  screw-top.  The  jar  is  half  filled  with  alcohol.  The  spools  of 
catgut  are  placed  in  the  jar,  the  lid  of  the  jar  is  screwed  down,  and  the  ap- 
paratus is  immersed  in  boiling  water  for  half  an  hour.  The  gut  is  kept  in 
this  jar  until  needed.  Fowler's  catgut  is  prepared  by  boiling  in  alcohol.  It 
is  placed  in  hermetically  sealed  U-shaped  glass  tubes.  Each  tube  contains 
alcohol  and  twelve  ligatures.  The  alcohol  is  boiled  by  immersing  the  tube  in 
boiling  water. 

The  cumol  method  is  employed  by  Kelly  in  the  Johns  Hopkins  Hospital, 
and  is  known  as  Kronig's  method.  Cumol  is  a  fluid  hydrocarbon  which  boils 
at  179°  C.  Catgut  is  wound  upon  spools  of  glass,  and  these  are  placed  in  a 
beaker  glass,  the  bottom  of  which  is  covered  with  cotton.  A  bit  of  cardboard 
is  placed  on  top  of  the  beaker,  and  through  a  small  perforation  in  the  card- 
board a  thermometer  is  introduced.  The  beaker  is  placed  in  a  sand-bath 
6 


82  Asepsis  and  Antisepsis 

and  the  bath  is  heated  by  means  of  a  Bunsen  burner.  The  temperature  is 
gradually  raised  to  80°  C,  and  is  kept  at  this  point  for  one  hour,  in  order 
to  remove  entirely  moisture  from  the  gut.  Cumol,  at  a  temperature  of  100°  C, 
is  poured  into  the  glass,  and  the  heat  is  increased  until  the  temperature  of  the 
cumol  is  165°  C,  which  is  a  few  degrees  below  its  boiling-point.  For  one  hour 
this  temperature  is  maintained.  Then  the  cumol  is  poured  off  and  the  beaker 
containing  the  catgut  is  allowed  to  remain  for  a  time  in  the  sand-bath,  at  a 
temperature  of  100°  C,  in  order  that  the  gut  may  dry.  The  gut  is  transferred 
for  keeping  into  sterile  glass  jars  or  test-tubes.^ 

The  Claudius  Method. — The  iodin  catgut  is  prepared  by  the  Claudius 
method.  Sir  Berkley  Moynihan,  of  Leeds,  makes  Claudius  catgut  as  follows: 
In  10  oz.  of  sterile  water  dissolve  i  oz.  of  crystals  of  iodid  of  potassium.  When 
all  the  crystals  are  dissolved  add  10  oz.  of  sterile  water,  and  then  add  i  oz. 
of  iodin  in  crystalline  form.  Dilute  the  mixture  with  4  pints  of  sterile  water. 
The  result  is  a  i  per  cent,  solution  of  iodin  and  potassium  iodid.  After  the 
usual  preliminary  preparation,  place  the  gut  in  the  mixture  and  keep  it  in  it  for 
at  least  eight  days  before  using.  It  can  be  kept  in  it  without  harm  for  a. 
number  of  months.  Salkindsohn  has  modified  the  Claudius  method  as  follows: 
Use  I  part  of  tincture  of  iodin  and  15  parts  of  proof  spirits  and  immerse  the  cat- 
gut for  eight  days  (J.  S.  Riddell,  in  "Brit.  Med.  Jour.,"  April  6,  1907). 

Siherized  Catgut. — Blake  advocates  this  form  of  gut  ("Annals  of  Surgery," 
January,  1907).  He  prepares  it  as  follows:  He  winds  four  coils  of  gut  on  four 
glass  plates,  places  the  plates  in  a  jar  containing  a  2  per  cent,  solution  of  col- 
largolum  and  keeps  them  immersed  for  a  week,  the  jar  being  shaken  once 
or  twice  during  the  period  of  immersion.  At  the  end  of  a  week  the  plates  are 
removed  from  the  silver  solution  and  are  placed  for  from  fifteen  to  thirty 
minutes  in  95  per  cent,  alcohol,  then  the  gut  is  wound  with  aseptic  care  on 
glass  spools  and  is  kept  until  wanted  in  95  per  cent,  alcohol. 

The  formalin  method  was  advocated  by  the  late  Prof.  Senn.  The  catgut 
is  wound  on  glass  test-tubes  and  is  immersed  in  an  aqueous  solution  of  formalin 
(2-4  per  cent.)  for  twenty-four  to  forty-eight  hours.  It  is  placed  in  running 
water  for  twelve  hours  to  get  rid  of  the  formalin.  It  is  boiled  in  water  for 
fifteen  minutes,  is  cut  in  pieces  and  tied  in  bundles,  is  placed  in  a  glass-stop- 
pered jar,  and  is  kept  ready  for  use  in  the  following  mixture:  950  parts  of 
absolute  alcohol,  50  parts  of  glycerin,  and  100  parts  of  pulverized  iodoform. 
Every  few  days  the  mixture  should  be  shaken. 

Senn's  process  is  a  modification  of  Hoffmeister's.  Even  sterile  catgut 
contains  a  toxic  substance,  which  increases  wound  secretion,  has  a  poisonous 
effect  on  body  cells,  and  favors  to  some  extent  limited  suppuration.  Senn 
maintains  that  to  counteract  this  influence  gut  should  not  only  be  sterile, 
but  should  be  antiseptic,  to  inhibit  the  growth  of  pyogenic  organisms  which 
reach  the  wound  from  without  during  operation  or  subsequently  by  the  blood. 

Dry  Heat  Method. — Boeckman  wraps  catgut  in  paraffin  paper,  seals  it  in  a 
paper  envelope,  puts  it  in  the  sterilizer,  and  subjects  it  to  dry  heat.  For  three 
hours  it  is  heated  to  a  temperature  of  284°  F.,  and  for  four  hours  to  a  tempera- 
ture of  290°  F.  The  envelope  can  be  carried  in  the  pocket  or  the  instrument 
bag.  WTien  the  gut  is  wanted  the  end  of  the  envelope  is  torn  off,  an  assistant 
with  sterilized  hands  unwraps  the  paraffin  paper,  and  the  gut  is  dipped  for  a 
moment  in  sterile  water  to  make  it  pliable. ^ 

Corrosive  Sublimate  Method. — A  method  which  has  been  largely  used  is 
to  take  raw  catgut,  keep  it  in  ether  for  twenty-four  hours,  soak  it  for  twenty- 
four  hours  in  an  alcoholic  solution  of  corrosive  sublimate  (1:500),  wind  it  on 
sterihzed  glass  rods,  and  place  it  for  keeping  in  ether  or  in  alcohol. 

^  See  McBurney  and  Collins,  in  "International  Text-Book  of  Surgery,"  and  Clark,  in 
"Johns  Hopkins  Hospital  Bulletin,"  March,  1896. 

2  James  E.  Moore,  in  "Phila.  Med.  Jour.,"  June  22,  1898. 


Ligatures  and  Sutures  83 

Johnstons  quick  method  of  preparing  catgut  is  as  follows:  Place  it  for 
twenty-four  hours  in  ether;  at  the  end  of  this  period  place  it  in  a  solution 
containing  20  gr.  of  corrosive  sublimate,  100  gr.  of  tartaric  acid,  and  6  oz. 
of  alcohol.  The  small  gut  is  kept  in  this  for  ten  or  fifteen  minutes,  the  larger 
gut  from  twenty  to  thirty  minutes,  but  never  longer.  It  is  placed  for  keeping 
in  a  mLxtvue  containing  i  drop  of  chlorid  of  palladium  to  8  oz.  of  alcohol. 
This  gut  is  strong  and  reliable.  At  the  time  of  operation  the  gut  is  placed 
in  a  solution  one-third  of  which  is  5  per  cent,  carbolic  acid  solution  and  two- 
thirds  of  which  is  alcohol. 

Preparation  of  Chromicized  Catgut. — Chromicized  catgut  is  absorbed  less 
rapidly  by  the  tissues  than  ordinary  catgut.  It  is  used  to  tie  thick  pedicles 
and  large  arteries,  to  suture  nerves  and  tendons,  and  as  a  suture  material  in 
the  radical  cure  of  hernia.  Chromicized  gut.  No.  3  and  No.  4,  will  remain 
unabsorbed  in  the  tissues  from  four  to  six  weeks.  The  gut  should  be  soaked  in 
ether  for  twenty-four  hours,  and  be  immersed  for  twenty-four  hours  in  a  4  per 
cent,  solution  of  chromic  acid  in  water.  The  gut  is  then  dried  in  a  hot-air 
sterilizer  and  is  disinfected  by  one  of  the  several  methods.  The  cumol  method 
is  satisfactory. 

How  to  Tie  Catgut. — Catgut  is  tied  in  a  reef  knot  (square  knot)  and  dis- 
tinct ends  are  left  on  cutting.  The  second  knot,  if  pulled  too  tightly,  may 
break  the  ligature.  Moist  catgut  is  slippery  and  is  hard  to  tie.  If  a  large 
vessel  is  tied  by  catgut,  a  third  knot  should  be  used  and  the  ends  cut  close  to 
the  knot.  In  tying  a  vessel  in  the  brain  or  omentum  be  sure  the  gut  is  not 
wiry;  if  it  is  it  will  tear  the  vessel  and  permit  renewed  bleeding.  Wiry  gut 
must  be  dipped  in  salt  solution  for  a  moment  just  before  using.  Really  strong 
catgut  can  be  tied  in  a  surgeon's  knot. 

Kangaroo-tendon  and  Its  Preparation. — This  material  is  said  to  be  obtained 
from  the  tail  of  the  great  kangaroo.  It  is  hard  to  believe  that  kangaroos  are 
sufficiently  cheap  and  plentiful  to  furnish  us  with  it  in  quantity.  It  is  cer- 
tainly a  tendinous  material.  It  is  especially  useful  for  buried  sutures  in 
hernia  operations;  it  will  be  absorbed  in  the  tissues,  but  only  after  a  long  time 
(sixty  to  seventy  days).  Kangaroo-tendon  is  not  grossly  infected  as  is  catgut. 
The  material  is  obtained  from  a  recently  killed  animal  and  is  promptly  dried 
in  the  sun.  This  suture  material  was  introduced  by  Dr.  Henry  O.  Marcy. 
It  can  be  prepared  in  the  same  manner  as  the  chromicized  catgut,  and  it  ought 
always  to  be  chromicized. 

The  following  method  of  preparation  is  recommended  by  Charles  Truax 
("Mechanics  of  Surgery"):  Soak  the  dried  tendon  until  it  becomes  supple 
in  a  1 :  1000  solution  of  corrosive  sublimate.  Separate  the  material  into  in- 
dividual tendons,  place  them  lengthwise  between  two  towels;  dry  them;  make 
them  aseptic  by  soaking  in  a  solution  of  formalin,  as  we  w^ould  do  with  cat- 
gut (see  above).  After  washing  out  the  formalin  chromicize  the  tendon 
by  placing  it  in  a  fresh  5  per  cent,  solution  of  carbolic  acid  containing  i :  4000 
parts  of  chromic  acid.  When  the  tendons  become  "dark  golden  bro^^Ti"  in 
color,  they  are  removed  from  the  chromic  acid  solution,  dried  between  sterile 
towels,  and  placed  for  keeping  in  10  per  cent,  carbolized  oil.  WTien  wanted, 
they  are  removed  from  the  oil,  and  wiped  with  a  sterile  towel  saturated  with 
bichlorid  solution  (i:  1000).  Kangaroo- tendon  is  tied  in  a  reef  knot.  It  must 
be  tied  firmly,  else  the  knot  will  slip. 

Silk. — This  material  can  be  used  for  both  ligatures  and  sutures;  many 
sizes  should  be  kept  on  hand.  Silk  is  very  strong,  soft,  extremely  supple, 
and  does  not  swell  or  irritate  the  tissue.  It  can  be  tied  into  very  firm  knots. 
Ordinary  surgical  silk  is  a  form  of  twisted  silk — that  is,  several  or  many  strands 
are  t\\dsted  into  one.  Cable  twist  or  Tait's  silk  is  very  strong  and  is  used  for 
tjdng  large  pedicles.  Braided  silk  is  extremely  strong  and  is  made  by  plaiting 
together  several  strands  of  twisted  silk.     Floss  silk  is  "a  straight  fiber  slightly 


84 


Asepsis  and  Antisepsis 


twisted"  (Truax).  Silk  is  usually  tied  in  a  reef  knot,  but  occasionally  in  a  sur- 
geon's knot.  White  silk  ma>-  be  used,  or  black  silk,  which  is  more  easily  visible. 
Silk  becomes  encapsulated  in  the  tissues.  It  is  not  absorbed  at  all  or  only  after 
a  very  long  time.  Stout  silk  is  not  a  good  material  for  buried  sutures,  as  in 
the  long  run  it  may  form  a  sinus.     Fine  silk  ligatures  do  not  cause  sinuses. 

Preparation  of  Silk. — Before  using,  sutures  of  silk  should  be  boiled  for  half 
an  hour  in  a  i  per  cent,  solution  of  carbonate  of  sodium.  Some  surgeons  keep 
the  silk  after  boiling  in  sublimated  alcohol  (i:iooo)  or  carbolic  solution  (5 
per  cent.),  but  it  is  better  to  prepare  it  just  before  using.  A  convenient  method 
of  preparation  is  to  wind  the  silk  on  a  glass  spool,  place  the  spool  in  a  large 
test-tube,  close  the  mouth  of  the  tube  with  jeweler's  cotton,  introduce  the  tube 
into  a  steam  sterilizer,  and  subject  it  to  a  pressure  of  10  pounds  for  twenty 
minutes,  repeating  the  process  the  next  day.  These  tubes  are  carried  in 
wooden  boxes  sealed  wath  rubber  corks. 

Horsehair  and  Its  Preparation.— This  material  is  used  for  effecting  very  neat 
approximation  when  only  light  sutures  are  required;  for  instance,  in  wounds 

of  the  face.  Its  chief  use  is  for  capillary 
drainage.  It  is  prepared  by  washing  and 
then  boiling  for  fifteen  minutes  in  a  4  per 
cent,  solution  of  carbonate  of  sodium.  It 
is  kept  until  needed  in  sublimated  alcohol 
(i:  1000). 

Silkworni-giit  and  Its  Preparation. — This 
material  contains  fewer  bacteria  than  catgut 
and  does  not  swell  when  introduced  into  a 
wound.  It  is  strong,  solid,  smooth,  non- 
irritating,  can  be  drawn  through  the  tissues 
with  slight  force,  and  does  not  tend  to  cut 
the  tissue  as  does  a  metallic  suture.  The 
designation  silkworm-gut  is  a  misnomer; 
the  material  is  not  gut  at  all,  but  is  ob- 
tained from  the  silk-producing  glands. 
Italy  supplies  most  of  the  gut  used  by 
fishermen,  but  the  gut  used  by  the  surgeon 
comes  chiefly  from  Murcia  in  Spain.  When 
the  silkworms  are  just  ready  to  spin  they 
are  placed  in  vinegar  and  water  for  a  num- 
ber of  hours  and  are  thus  killed.  Each  worm 
is  opened  and  the  silk-producing  glands  are 
clearly  exposed  and  each  gland  is  drawn 
by  its  ends  into  a 
threads  are  dried  in 
reddish  color  (M.  J. 
des 
No, 


fiG.  37. — Small  steam-pressure  steril- 
izer and  instrument  boiler  (Fowler). 


Sciences     Pharmacologiques," 
5.    Quoted  in  ''Lancet,"  Feb.  3, 


single  thread.  The 
the  air  and  assume  a 
Triollet,  in  "Bulletin 

1905. 
1906). 


This  crude  silkworm-gut  is  sold  to  the 
manufacturer  and  further  treated.  It  is 
first  boiled  in  alkaline  water  to  remove  fat  and  blood  and  is  then  dried  in  the 
sun,  being  protected  from  dust.  It  is  next  polished  by  means  of  slightly  oiled 
pumice  stone.  The  gut  is  then  bleached  with  sulphurous  acid  and  rubbed  vig- 
orously with  chamois  leather  to  remove  dust  and  sulphur"  ("Lancet,"  Feb. 
3,  1906).  It  is  a  very  valuable  material,  but  is  not  used  for  ligatures,  as  it 
cannot  be  tied  as  firmly  as  catgut  and  because  when  left  buried  in  the  tissues 
the  sharp  ends  may  stick  and  irritate  and  a  point  of  least  resistance  may  be 
created.  Silkworm-gut  is  prepared  by  placing  it  in  ether  for  forty-eight  hours 
and  in  a  solution  of  corrosive  sublimate  (i  :iooo)  for  one  hour,  or  it  can  be 


Dressings 


85 


boiled  in  plain  water  for  half  an  hour.  It  is  carried  in  a  long  tube  filled  with 
alcohol.  A  few  minutes  before  using  the  gut  is  placed  in  carbolic  acid  and 
alcohol  (one-third  of  the  solution  is  a  3  per  cent,  solution  of  acid,  two-thirds  of 
it  is  alcohol).     Silkworm-gut  is  tied  either  in  a  reef  or  a  surgeon's  knot. 

Celluloid  Thread  and  Its  Preparation. — This  material  is  warmly  advocated  by 
Pagenstecher.  He  calls  it  celluloid  yarn,  and  prepares  it  from  English  gray 
lineii  thread.  I  have  used  it  with  much  satisfaction.  It  is  strong,  smooth, 
flexible,  and  the  knot  holds  firmly;  it  can  be  sterilized  by  any  method  used  for 
raw  silk,  and  sterilization  by  dry  heat  actually  increases  its  strength.  Its  one 
disadvantage  is  that  it  absorbs  about  40  per  cent,  of  fluid,  but  it  does  not  soften. 
The  celluloid  is  added  in  a  iper  cent,  solution  of  carbonate  of  soda  after  the 
thread  has  been  boiled.  The  thread  is  wiped  off  or  wrapped  in  a  sterile  towel, 
and  dried  in  hot  air  or  steam.  It  is  then  dipped  in  a  solution  of  celluloid  heated 
in  a  hot-air  sterilizer,  and  is  packed  in  sterile  boxes  (Schlutius,  in  "Pacific 
Med.  Journal,"  Jan.,  1900;  Keen  and  Rosenberger,  in  "Phila.  Med.  Journal," 
May  10,  1900).     Celluloid  thread  can  be  used  for  sutures  or  ligatures. 

Silver  wire  is  prepared  by  boiling.  It  is  a  very  useful  suture  material,  as  it 
can  be  thoroughly  sterilized  and  has  a  mild  inhibitory  effect  on  the  growth  of 


Fig.  38. — Lautenschlager's  steam  sterilizer  for  dressings:  A,  Exterior  view;  5,  cross-section. 

bacteria.  Some  surgeons  use  it  for  buried  sutures,  but  many  are  opposed 
to  using  it  thus  on  the  ground  that  it  is  apt  to  lead  to  sinus  formation.  Copper, 
brass,  and  bronze  have  a  very  distinct  inhibitory  effect  on  bacteria  (C.  L.  Green, 
in  the  "Practitioner,"  March,  1907),  and  wire  made  of  any  one  of  these  metals 
is  useful.  Gold,  tin,  platinum,  magnesium,  aluminum,  and  nickel  are  devoid 
of  inhibitory  power.  If  iron  oxidizes  freely  it  has  decided  inhibitory  power; 
if  it  is  so  coated  that  it  cannot  oxidize  it  has  no  inhibitory  power.  Copper  is 
more  powerfully  inhibitory  than  any  other  metal  (C.  L.  Green,  in  the  "  Prac- 
titioner," March,  1907).  I  have  used  copper  wire  and  brass  screws  in  bone 
and  have  used  wire  of  aluminum  bronze  for  various  purposes.  After  many 
months  wire  of  aluminum  bronze  may  be  absorbed. 

Most  wounds  are  closed  by  interrupted  sutures  of  silkworm-gut,  but  silk, 
catgut,  chromic  catgut,  or  silver  wire  can  be  used.  The  old  continuous  suture 
(glovers'  stitch)  is  rarely  used  except  as  a  buried  suture.  An  admirable  closure 
can  be  effected  by  Halsted's  subcuticular  stitch,  and  scarcely  any  scar  results 
(see  page  66).  Marcy's  buried  tendon  sutures  are  much  used,  especially  in 
hernia  operations  and  in  various  other  operations  upon  the  abdomen. 

Dressings  are  made  of  cheese-cloth.  In  order  to  make  antiseptic  gauze 
the  cheese-cloth  is  boiled  in  a  solution  of  carbonate  of  sodium,  rinsed  out, 


86  Asepsis  and  Antisepsis 

and  dried;  it  is  then  soaked  for  twenty-four  hours  in  a  solution  containing  i 
part  of  corrosive  sublimate,  2  parts  of  table  salt,  and  500  parts  of  water.  It 
is  placed  in  clean  jars  with  glass  lids,  and  it  may  be  kept  moist  or  dry. 

Sterilized  or  aseptic  gauze  is  prepared  by  boiling  in  carbonate  of  sodium 
solution,  etc.,  as  described  under  Antiseptic  Gauze.  The  gauze  is  then  wrapped 
in  a  towel  and  is  placed  in  a  steam  sterilizer  (Figs.  37  and  38)  for  an  hour.  It 
is  kept  until  wanted  in  sterile  glass  jars  with  glass  lids. 

Sterile  absorbent  cotton  is  prepared  in  the  same  manner  as  gauze.  Cotton 
is  useful  as  a  dressing  to  supplement  gauze,  being  placed  on  the  outside  of  the 
gauze.     It  absorbs  quantities  of  serum,  but  will  take  up  very  little  pus. 

Iodoform  gauze  is  very  useful  for  packing  in- the  brain  and  abdomen,  for 
packing  abscesses  and  tuberculous  areas,  and  for  dressing  foul  wounds.  It 
is  prepared  as  follows:  Make  an  emulsion  composed  of  equal  parts  by  weight 
of  iodoform,  glycerin,  and  alcohol,  and  add  corrosive  sublimate  in  the  pro- 
portion of  I  part  to  1000  of  the  mixture.  This  mixture  stands  for  three  days. 
Take  moist  bichlorid  gauze,  saturate  it  with  the  emulsion,  let  it  drip  for  a  time, 
and  keep  it  in  sterilized  and  covered  glass  jars  (Johnston). 

Lister's  cyanid  gauze  (double  cyanid  of  zinc  and  mercury)  is  not  certainly 
antiseptic,  and  must  be  dipped  into  a  corrosive  sublimate  solution  (i  12000) 
before  using.    All  forms  of  gauze  can  be  bought  ready  prepared  from  reliable  firms. 

It  is  an  excellent  plan  to  place  silver  leaf  upon  a  wound  before  applying  the 
gauze  (Halsted,  page  35).  It  hurries  healing,  inhibits  the  growth  of  bacteria, 
lessens  wound  discharge  and  minimizes  scar  formation.  Very  sm.all  wounds  in 
which  drainage  is  not  employed  may  be  dressed  by  laying  a  film  of  aseptic 
absorbent  cotton  over  the  wound  and  applying,  by  means  of  a  clean  camel's- 
hair  brush,  iodoform  collodion  (48  gr.  of  iodoform  to  i  oz.  of  collodion).  Among 
other  materials  sometimes  used  for  dressing  wounds  the  following  should  be 
mentioned:  Wood  wool,  absorbent  wool,  moose  pappe,  oakum,  jute,  peat,  ab- 
sorbent paper,  and  sawdust. 

Protectives. — A  protective  is  a  material  placed  directly  upon  wounds  to 
shield  them  from  irritation  and  infection.     The  commonly  used  protectives  are 
Lister's  oiled  silk  protective,  gutta-percha  tissue,  rubber  dam,  waxed  paper, 
A  paraffin  paper,  mackintosh,   Cargile 
membrane,     and    silver    leaf.      Un- 
doubtedly,   many   antiseptic  agents 
destroy  young  cells  and  in  this  way 
hinder  repair.     The  same  is  true  of 
certain  rough  dressings. 
R.    T.    Morris    showed    us    that 

Fig.  39.-Drainage-tubes:^,  Glass;  5,  rubber,      gauze     and    particularly    cotton    are 

injurious  to  a  healing  wound.  A 
non-irritant  protective  laid  directly  upon  a  wound  may  be  useful  by  saving 
new  cells  from  injury  by  an  irritant  germicide  and  from  being  pulled  away  at 
each  change  of  dressings. 

Among  the  best  protectives  in  common  use  are  Lister's  protective,  gutta- 
percha tissue,  silver  leaf,  and  Cargile  membrane.  Morris  condemns  gutta- 
percha tissue  as  irritant.  He  uses .  thin  gold-beaters'  skin  made  from  the 
peritoneum  of  the  ox,  which  material  he  calls  Cargile  membrane,  after  an  Arkan- 
sas physician  who  introduced  it  into  practice.  The  advantage  of  this  material 
is  that  moisture  cannot  penetrate  and  new  cells  do  not  adhere.  I  have 
used  it  with  satisfaction  in  many  cases,  but  in  wounds  and  ulcers  prefer  silver 
leaf. 

Silver  leaf.  Lister's  protective,  or  gutta-percha  tissue  is  laid  directly  upon 
a  wound,  the  dressing  being  placed  above  it.  Silver  leaf  comes  in  books  and 
is  sterilized  by  dry  heat.  Gutta-percha  tissue  should  be  sterilized  by  wash- 
ing with  soap  and  water,  rinsing  in  sterile  water,  and  soaking  in  a  solution  of 


E 


Pads  and  Packs 


87 


•corrosive  sublimate.     Lister's  protective  is  employed  to  save  the  wound  from 
the  irritation  of  carbolized  dressings. 

Impermeable  Material  Over  Dressings. — In  the  United  States,  if  it  is  desired 
to  place  an  impermeable  material  over  a  dressing,  a  rubber  dam  is  usually  em- 
ployed. A  rubber  dam  before  being  used  should  be  washed  with  soap  and 
water  and  soaked  in  a  solution  of  corrosive  sublimate. 

The  use  of  an  impermeable  material  on  the  outside  of  the  gauze  dressing 
is  not  nearly  so  common  as  formerly.  In  an  aseptic  wound  dry  dressing  un- 
covered by  rubber  is  the  most  useful  plan.  When  a  dressing  is  covered  by  an 
impermeable  material  it  becomes  moist,  acts  as  a  poultice,  and  the  discharges 
on  the  dressing  may  undergo  decomposition. 

Drainage  is  used  in  all  infected  wounds,  in  most  very  large  wounds,  in 
wounds  to  which  irritant  antiseptics  have  been  applied,  in  cases  in  which  large 
abnormal  cavities  exist,  in  very  fat  people,  and  in  individuals  whose  skin  is  so 
thin  that  we  dare  not  apply  firm  pressure  (see  page  66).  Drainage,  when  needed, 
is  obtained  by  rubber  or  glass 
tubes  (Fig.  39),  by  strands  of 
horsehair,    silkworm-gut    or 

catgut,  by  pieces  of  gauze,  'MB^MffllHinii'^'  "1  '"•"'"" "  lltBlliillir''^r  '^ " '  •■•  -^ 
and  occasionally  in  the  ab- 
domen by  Mikulicz's  bag  or 
tampon  by  which  we  obtain 
pressure  to  arrest  hemor- 
rhage and  also  secure  drain-  Fig.  40.— Smith's  dressing  basin. 
age  (Fig.  42).  Gauze  drain- 
age is  satisfactory  for  the  removal  of  serum,  but  not  pus.  An  objection  to 
the  gauze  drain  is  the  suffering  caused  by  its  removal.  Before  removal  it  should 
be  thoroughly  moistened  and  carefully  separated  from  the  wound  edges  to 
which  it  is  apt  to  adhere.  Sometimes  it  is  removed  a  Httle  at  a  time.  If  pus 
is  plentiful,  especially  if  it  is  thick,  rubber  tubes  should  be  used.  The  caliber 
of  the  tube  must  be  sufficient  to  permit  the  pus  to  flow  freely.  Rubber  drainage- 
tubes  (Fig.  39,  B)  are  rendered  sterile  by  boiling  in  plain  water.  They  are 
kept  in  a  mercurial  solution  until  wanted.  This  solution  should  be  changed 
every  few  days,  because  the  mercury  is  apt  to  be  precipitated  as  sulphid. 
'Glass  tubes  are  sterilized  by  boiling.     A  bit  of  rubber  tissue  is  sometimes  used 

for  drainage.  The  cigarette  drain  is 
useful  in  many  cases.  It  drains  serum 
well  and  is  easily  removed.  It  is  made  by 
folding  up  a  piece  of  gauze  and  surround- 
ing it,  except  at  each  extremity,  with 
guttapercha  tissue.  Gauze,  catgut,  etc., 
are  known  as  capillary  drains.  When 
moist  they  drain  serum  excellently,  but 
pus  very  badly  or  not  at  aU.  Pus  requires 
tubular  drainage.  Drainage-tubes  or  strands  are  brought  out  at  a  portion  of 
the  wound  which  will  be  dependent  when  the  patient  is  recumbent. 

Sponges. — Marine  sponges  are  never  used  to-day;  instead  we  use  gauze 
rolled  into  balls,  the  edges  and  ends  being  turned  in. 

Pads  and  Packs. — Ashton's  gauze  pads  are  very  useful  to  push  away  struc- 
tures during  an  abdominal  operation  and  to  pack  a  wound  temporarily.  ^  Several 
layers  of  sterile  gauze  are  taken.  Each  piece  is  about  6  in.  long  and  4  in.  wide. 
A  stitch  is  run  round  the  margins.  A  piece  of  tape  is  sewed  in  one  corner. 
During  the  operation  the  tape  protrudes  from  the  wound  and  is  clamped  with 
forceps.  This  plan  saves  the  pad  from  being  lost  or  forgotten  in  the  abdomen. 
Long  narrow  pieces  of  gauze  make  the  safest  and  best  packs  (Halsted's  packs), 
as  then  a  long  end  always  protrudes  from  the  wound  during  the  operation. 


Fig.  41. — Plain  dressing  basin. 


^8 


Asepsis  and   Antisepsis 


Fig.  42. — Mikulicz's  bag:  a, 
Abdominal  sutures;  b,  gauze 
bag;  c,  abdominal  wound;  d, 
loops  in  the  abdominal  wall;  c, 
gauze  strip. 


Fig.  43. — Method  of 
extraction  of  a  suture 
(Esmarch    and    Kowal- 


Change  of  Dressing. — Dressing  should  not  be  changed  unless  indications 
call  for  change.  To  meddle  unnecessarily  with  a  wound  is  stupid  and  harmful. 
In  many  cases  dressings  are  not  renewed  until  the  wound  has  healed.  When  a 
change  of  dressings  is  determined  upon  the  surgeon  should  carefully  sterilize 
his  hands  and  forearms  and  should  have  at  hand  a  warm  solution  of  corrosive 
sublimate,  normal  salt  solution,  an  irrigator,  iodoform  gauze,  scissors, 
forceps,  basins  (Figs.  40  and  41),  etc.  Dressings  should  be  moistened  before 
removal  with  salt  solution  or  corrosive  sublimate  solution.  If  they  stick  to 
the  part,  a  spray  of  hydrogen  dioxid  projected  from  an  atomizer  between  the 
skin  and  dressings  will  soon  loosen  them.     Dressings  must  be  changed  as  soon 

as  soaking  with  blood  or  wound-fluid  is  apparent. 
If  the  wound  becomes  uneasy  and  painful,  or  if 
constitutional  symptoms  of  wound  infection  arise, 
the  dressings  must  be  removed  to  permit  of  inspec- 
tion of  the  wound.  A  change  of  dressings  must  be 
effected  with  all  of  the  aseptic  care  employed  in  a 
surgical  operation.  Dressings  are  not  dispensed 
with  until  the  wound  is  soundly  healed. 

Removal     of    Stitches. — 
Buried    stitches    of    animal 
material  are  not  removed  by 
the    surgeon,   but  are  grad- 
ually absorbed  in  the  tissues. 
Buried    stitches    of   silk    or 
silver   wire,  which  are   used 
by  some  surgeons,  although 
they    are    not   absorbed    in 
the    tissues,    may  never    re-     zig). 
quire  removal,  but   in  some 
cases   cause  sinuses   to  form,  and   a  sinus  from  a  suture  or  ligature  will  not 
heal  until  the  suture  or  ligature  is  cast  out  or  removed.     Sutures  of  aluminum- 
bronze  wire  are  absorbed  after  a  long  stay  in  the  tissues. 

If  a  catgut  stitch  is  passed  through  the  skin  and  tied  externally  the  loop 
in  the  tissue  is  absorbed,  but  the  knot  and  remainder  of  the  loop  is  on  the 
surface  and  is  not  absorbed,  but  remains  adherent  to  the  wound  and  the  sur- 
geon needs  only  to  lift  it  off  with  forceps.  Catgut  is  used  as  a  material  for 
cutaneous  suturing  in  the  operation  of  circumcision.  When  a  skin  wound  is 
closed  by  unabsorbable  sutures,  as  it  usually  is,  the  surgeon  at  the  proper  time 
takes  forceps  and  scissors  and  removes  the  stitches.  There  is  no  day  after  an 
operation  immutably  fixed  as  the  proper  day  to  remove  stitches.  Stitches  may 
usually  come  out  from  the  sixth  to  the  eighth  day,  although  if  there  is  much 
tension  on  the  edges  of  the  wound  they  are  allowed  to  remain  several  days 
longer.  In  large  wounds  half  of  the  stitches  are  taken  out  at  one  time,  the 
remainder  being  allowed  to  remain  for  a  couple  of  days  longer.  When  a  stitch 
begins  to  cut,  it  is  doing  no  good,  and  it  should  be  removed,  no  matter  how 
short  a  time  it  has  been  in  place.  If  it  is  allowed  to  remain  it  will  cut  into  the 
wound,  make  a  stitch-abscess,  and  cause  an  irregular  suture-line.  In  order  to 
remove  a  stitch  pick  up  an  end  distal  from  the  knot  with  forceps,  lift  it  lightly, 
cut  one  side  of  the  suture  close  to  the  skin  by  scissors,  and  remove  it  by  pulling 
in  the  direction  of  the  side  on  which  the  suture  was  cut  (Fig.  43). 

Bandages. — For  retaining  dressings  upon  wounds  unbleached  muslin  band- 
ages may  be  used,  but  in  most  cases  gauze  bandages  are  employed.  Gauze 
bandages  may  be  applied  when  dry  or  wet;  normally,  they  are  applied  when 
dry.  Gauze  bandages  soaked  in  corrosive  sublimate  solution  are  antiseptic, 
do  not  seal  the  dressing,  hence  do  not  act  like  rubber  dam;  can  be  applied 
firmly,  evenly  and  rapidly,  and  are  very  comfortable. 


89 

III.  INFLAMMATION 

Definition. — When  the  tissues  are  injured  they  react  or  respond,  and 
this  reaction  or  response  is  known  as  inflammation.  The  process  of  inflam- 
mation was  defined  by  the  late  Sir  John  Burdon-Sanderson  as  "  the  succession 
of  changes  which  occur  in  a  Hving  tissue  when  it  is  injured,  provided  that  the 
injury  is  not  of  such  a  degree  as  at  once  to  destroy  its  structure  and  vitality," 
Professor  Adami,  in  his  article  upon  inflammation  in  Allbutt's  "System  of 
Medicine,"  points  out  that  this  definition  really  includes  too  much.  He  alludes 
to  the  hemorrhage  which  occurs  in  the  liver  after  a  traumatism,  and  the  sub- 
sequent changes  in  the  extravasated  corpuscles,  and  points  out  that  these 
changes  are  not  inflammatory  phenomena.  This  definition,  however,  includes 
all  inflammatory  conditions,  is  largely  employed,  is  very  useful,  indicates  the 


Fig. 


44. — Normal  vessels  and  blood- 
stream. 


Fig.  45. — Dilatation  of  the  vessels  in 
inflammation. 


cause,  and,  as  Burdon-Sanderson  says,  makes  clear  that  inflammation  is  a 
process  and  not  a  state  (Adami).  Adami's  definition  is  as  follows:  "The  series 
of  changes  constituting  the  local  manifestation  of  the  attempt  at  repair  of 
actual  or  referred  injury  to  a  part,  or,  briefly,  the  local  attempt  at  repair  of 
actual  or  referred  injury."  The  changes  alluded  to  in  Burdon-Sanderson's 
definition  comprise  (i)  changes  in  the  vessels  and  the  circulation,  (2)  departure 
of  fluids  and  solids  from  the  vessels,  and  (3)  changes  in  the  perivascular  tissues. 

Vascular  and  circulatory  changes  were  formerly  thought  to  be  abso- 
lutely essential  to  inflammation  in  both  vascular  and  non-vascular  tissues.  In 
the  former  they  occur  in  the  inflamed  tissues;  in  the  latter  (cornea  and  cartilage) 
they  are  manifest  in  neighboring  tissues  from  which  the  non-vascular  area  de- 
rives its  nutritive  material.  As  a  matter  of  fact,  in  inflammation  vascular 
changes  are  almost  always  present;  but  in  a  rather  trivial  corneal  inflammation 
the  episcleral  vessels  may  not  dilate,  and  the  only  white  corpuscles  which  gather 
in  the  damaged  area  are  those  which  come  from  the  lymph-spaces  of  the  cornea. 
Inflammation  in  any  tissue  will  not  be  accompanied  by  vascular  dilatation  unless 
the  process  reaches  a  certain  stage  of  severity. 

Active  Hyperemia. — When  an  irritant  is  applied  to  tissue  there  may  be  a 
momentary  arterial  contraction  due  to  irritation  of  the  nerves,  but  this  con- 


90 


Inflammation 


traction  is  transitory,  and  is  not  an  inflammatory  phenomenon.  The  first 
vascular  phenomenon  is  dilatation  of  all  the  vessels — capiUaries,  venules,  and 
arterioles — appearing  first  and  being  most  pronounced  in  the  small  arteries. 
As  a  result  of  the  dilatation  there  are  increased  rapidity  of  circulation  and 
increased  determination  of  blood  to  the  part,  and  the  area  of  hyperemia  becomes 
warmer  than  is  normal.  This  condition  of  increased  circulatory  activity  is 
known  as  "active  hyperemia"  (Fig.  45). 

Active  hyperemia  is  an  increase  in  the  amount  of  moving  blood  in  a  part. 
Passive  hyperemia  is  an  increase  in  the  amount  of  blood  in  a  part,  but  not  of 
moving  blood,  as  passive  hyperemia  or  congestion  is  due  to  venous  obstruction, 
and  the  blood  is  stagnated.  Diminution  in  the  amount  of  blood  in  a  part  is 
ischemia.  Local  anemia  is  the  complete  cutting  off  of  the  blood-supply  of  a 
part. 

In  active  hyperemia  more  blood  goes  to  the  part  and  more  blood  passes 
through  it,  an  increased  amount  of  venous  blood  comes  from  the  hyperemic 

area,  the  venous  tension  is  increased,  and 
the  veins  may  even  pulsate.  The  capillaries, 
which  under  ordinary  circumstances  con- 
tain but  few  blood-cells  (Fig.  44),  become 
filled  with  corpuscles  (Fig.  45),  and  even 
the  smallest  capillaries  pulsate.  The  blood 
in  the  veins  adjacent  to  the  area  of  in- 
flammation is  of  a  much  lighter  red  than 
in  health.  Many  capillaries  which  were 
invisible  under  normal  conditions  become 
visible  when  active  hyperemia  exists.  The 
capillaries  contain  no  muscle-fiber,  and 
hence  these  tubes  cannot  actively  con- 
tract, except  so  far  as  the  caliber  of  the 
tubes  is  altered  by  the  contraction  or 
expansion  of  the  endothelial  cells  of  the 
capillary  wall.  Contraction  and  dilatation 
of  the  capillaries  depend  chiefly  on  the 
amount  of  blood  sent  to  or  retained  in 
them.  In  active  hyperemia  the  increased 
amount  of  blood  sent  to  the  part  causes 
capillary  dilatation.  As  a  result  of  the 
dilatation  the  endothelial  ceUs  become 
thinner  than  before,  the  cells  in  conse- 
quence of  irritation  lose  some  of  their  power 
to  restrain  exudation,  and  some  observers  assert  that  openings  are  formed  be- 
tween the  ceUs  or  that  previously  existing  openings  enlarge  (page  93).  Fluid 
elements  rarely  leave  the  blood-vessels  during  active  hyperemia,  but  they 
occasionally  do.  The  wheals  of  urticaria  are  thus  formed  (Warren).  Active 
hvperemia'is  often  the  first  stage  of  an  inflammation,  but  it  is  not  of  necessity 
followed  by  other  inflammatory  changes,  and  it  can  be  caused  by  nerve  section 
or  nerve  stimulation. 

The  duration  of  active  hyperemia  is  variable.  If  the  irritation  has  been 
brief,  the  hyperemia  is  very  transitory.  In  some  cases  dilatation  with  accelerated 
circulation  is  scarcely  more  than  momentary,  giving  way  almost  immediately  to 
dilatation  with  retardation.  If  the  irritation  is  prolonged,  hyperemia  may  last 
some  time  before  giving  way  to  retardation.  In  the  web  of  a  frog's  foot,  if  an 
irritant  is  applied,  hyperemia  lasts  from  one-half  hour  to  two  hours  before  it  is 
replaced  bv  retardation. 

Clinical  Signs  of  Active  Hyperemia.— A  hyperemic  part,  if  on  or  near  the 
surface,  is  red  in  color,  imparts  a  sense  of  heat  to  the  examining  hand,    the 


Fig.  46. — Retardation  of  blood  and 
migration  of  white  corpuscles  in  in- 
flammation. 


Resume  of  the  Vascular  Changes  of  Inflammation  91 

color  quickly  disappearing  on  pressure  and  quickly  returning  when  pressure 
is  released.  In  a  congested  part  the  temperature  is  diminished,  the  surface  is 
purple,  the  congested  veins  are  visible,  there  are  edema  and  a  sensation  of 
coldness  and  numbness.  When  congestion  is  purely  local  the  lividity  dis- 
appears quickly  when  pressure  is  appHed  and  returns  quickly  when  pressure 
is  removed.  When  due  to  disease  of  the  heart  or  lungs,  lividity  disappears  and 
returns  slowly.  When  a  local  congestion  is  about  to  give  way  to  gangrene 
the  lividity  disappears  very  slowly  on  pressure  and  crawls  back  very  slowly 
when  pressure  is  released. 

Retardation. — After  active  hyperemia  has  existed  for  a  variable  time  the 
blood-current  begins  to  lessen  in  velocity,  until  it  becomes  more  tardy  than 
in  health.  This  is  known  as  "retardation  of  the  circulation."  Retardation 
is  first  noted  in  the  venules,  next  in  the  capillaries,  and  last  in  the  arterioles; 
but  arterial  pulsation  continues.  The  red  cells  take  the  center  of  the  blood- 
stream, which  is  known  as  the  axial  current.  The  white  corpuscles  settle  out 
of  the  central  stream,  separate  from  the  red  cells,  and  float  lazily  along  near  the 
vessel  wall  (margination),  and  they  are  accompanied  by  many  third  corpuscles. 
The  white  cells  show  a  strong  tendency  to  adhere  to  the  venule  walls,  and,  as  a 
result,  accumulate  against  the  inside  of,  and  stick  to,  these  walls  and  to  one 
another,  until  the  venules  are  entirely  lined  with  layers  of  leukocytes  (Fig.  46). 
The  third  corpuscles  act  in  a  similar  manner  and  take  the  peripheral  current.  In 
the  capillaries  some  leukocytes  gather,  but  not  so  many.  In  the  arterioles  they 
adhere  during  cardiac  dilatations,  but  are  swept  away  by  the  force  of  the 
heart's  contractions.  Retardation  is  believed  to  be  chiefly  due  to  paresis  of 
the  muscular  walls  of  the  arterioles.  This  causation  seems  probable  when 
we  recall  Lord  Lister's  experiments  upon  the  pigment-cells  of  the  frog's  foot. 
Lister  proved  that  inflammation  paralyzes  the  pigment-cells,  and  concluded 
that  dilatation  at  the  focus  of  an  inflammation  is  due  to  the  paralyzing  action 
of  an  irritant.  Dilatation  at  a  distance  from  the  focus  is  a  reflex  phenomenon 
(Sir  Watson  Cheyne).  When  the  vessels  are  weakened  or  paralyzed  the 
contractions  of  the  arterioles  are  feeble  or  absent,  and  the  blood  is  no  longer 
urged  forward  by  arterial  power.  The  endothelial  cells  of  the  small  vessels 
enlarge  distinctly  during  retardation  and  develop  a  condition  of  stickiness,  which 
leads  the  white  cells  to  adhere  to  them,  and  thus  increases  resistance  to  the 
current  of  blood  and  adds  to  retardation.  Fluids  pass  through  the  wall  of  a 
vessel  in  this  condition  more  readily  than  through  a  healthy  vessel,  and  white 
corpuscles  leave  the  vessel  in  large  numbers. 

Oscillation  and  Stagnation. — By  the  accumulation  of  leukocytes  the  blood- 
stream is  progressively  narrowed  and  the  axial  current  is  impeded.  The  red 
blood-cells  begin  to  stick  to  one  another,  forming  aggregations  like  rouleaux 
of  coin,  which  increase  the  difficulty  the  axial  current  has  to  contend 
with,  until  progressive  movement  ceases  and  the  contents  of  the  vessels  sway 
to  and  fro  with  each  heart-beat.  This  is  the  stage  of  oscillation.  In  a  short 
time  oscillation  ceases  and  the  vessels  are  filled  with  blood  which  does  not 
move,  and  the  vessel  walls  become  irregular  in  outline  or  even  pouched.  This 
stage  is  known  as  '' stasis"  or  "stagnation."  Stasis  is  chiefly  due  to  paralysis 
and  damage  of  the  vessel  walls.  Migration  ceases  when  stasis  takes  place. 
If  stasis  persists,  coagulation  occurs,  because  the  vessel  walls  have  been  so 
injured  by  the  irritant  as  to  be  practically  dead  material,  and  they  are  no  longer 
able  to  prevent  clotting  of  their  contents.  Finally,  in  persisting  stasis  the 
•vessel  walls  rupture  or  are  entirely  destroyed. 

Resume  of  the  Vascular  Changes  of  Inflammation. — We  can  sum  up  the 
vascular  changes  of  inflammation  by  stating  that  they  consist  in  a  dilatation 
of  the  small  vessels  and  a  primary  acceleration,  a  secondary  retardation,  and  a 
subsequent  stagnation  of  the  blood-current,  exudation  of  blood-liquor,  adhe- 
sion of  leukocytes  to  the  walls  of  veins  and  capillaries,  migration  of  leukocytes, 


92  Inflammation 

the  aggregation  of   the  blood-cells   into   intravascular   masses,   and  coagula- 
tion of  the  material  remaining  in  the  vessel. 

Exudation  of  Fluids. — It  is  to  be  remembered  that  in  the  process  of 
nutrition  blood-liquor  and  also  white  cells  pass  into  the  tissues  through  the 
walls  of  veins  and  capillaries,  and  during  this  process  certain  other  materials 
are  passing  from  the  tissues  into  the  vessels.  Hence,  a  diffusible  irritant  in 
the  vessels  may  pass  into  the  tissues  and  a  diffusible  irritant  in  the  tissues  may 
pass  into  the  vessels.  Whenever  retardation  of  the  circulation  arises  there 
is  an  increase  in  the  amount  of  plasma  which  passes  out  of  the  vessels,  but  in 
inflammation  the  exudation  into  the  lymph-spaces  is  vastly  greater  in  amount 
and  is  different  in  composition.  In  a  slight  inflammation,  and  in  the  early 
stage  of  any  inflammation,  there  is  an  increase  in  the  fluid  exudate,  and  we 
speak  of  the  condition  as  ''serous  inflammation."  This  fluid  is  really  not  serum, 
but  is  liquor  sanguinis.  We  find  true  serum  in  passive  congestion,  not  in  active 
inflammation.  The  fluid  of  a  serous  exudation  contains  very  few  white  cells, 
and  hence  little  or  no  fibrin  can  form  in  it,  and  coagulation  does  not  take  place 
in  the  perivascular  tissues;  and  if  the  inflammation  goes  no  further,  the  exudate 
is  absorbed  by  the  lymphatics.  A  blister  is  an  example  of  ^serous  inflamma- 
tion. If  the  inflammation  continues  to  intensify,  the  exudation  is  altered 
in  character — it  becomes  thicker,  turbid  and  very  coagulable,  and  exhibits 
a  greatly  increased  bactericidal  power.  It  contains  many  white  cells  and 
fibrin  elements,  and  coagulates  in  the  tissues,  because  some  of  the  leukocytes 
break  up  and  set  free  fibrin  ferment,  and  fibrin  ferment  causes  the  union  of 
calcium  and  fibrinogen  and  the  formation  of  fibrin.  This  fluid  exudate  is 
known  as  "lymph,''  or  plastic  exudation,  and  when  it  is  present  we  speak  of  the 
condition  as  "plastic  inflammation.''  Lymph  can  be  seen  in  the  anterior 
chamber  of  the  eye  in  cases  of  plastic  iritis.  Coagulated  fibrin  in  a  recent 
wound  causes  the  edges  to  adhere  or  glazes  the  raw  surface.  In  inflammation 
of  a  mucous  surface  it  may  appear  as  a  false  membrane.  In  inflammation  of 
serous  surfaces  it  may  glue  the  surfaces  together  and  lessen  motion,  the  fibrin- 
ous masses  which' elTect  the  gluing  being  called  fibrinous  or  plastic  adhesions. 
Such  adhesions  within  the  abdomen  may  seal  a  perforation,  may  cover  a  raw 
spot,  or  may  encompass  an  area  of  infection  and  prevent  fatal  diffusion. 
Further,  fibrin  surrounds  and  entangles  bacteria  and  retards  their  diffusion. 
Pyogenic  cocci  lessen,  retard,  or  prevent  fibrin  formation  or  destroy  fibrin  pre- 
viously formed.  Fibrinous  adhesions  may,  of  course,  do  harm.  They  may 
retard  or  prevent  the  absorption  of  exudate;  they  may  narrow  and  obstruct 
important  structures  (bowel,  urethra,  larynx);  they  may  bind  up  and  cripple  an 
important  viscus  (liver,  heart,  or  brain).  Fibrinous  adhesions  may  be  succeeded 
by  dense  contracting  and  constricting  bands  of  fibrous  tissue.  The  lymphatics 
endeavor  to  absorb  the  fluid  exudate  in  inflammation,  but  become  occluded 
by  coagulation,  and  the  area  they  drain  becomes  swollen,  hard,  and  "brawny." 
The  slighter  the  inflammation,  the  less  albuminous  is  the  fluid;  the  more  in- 
tense the  inflafnmation,  the  more  albuminous  is  the  fluid.  The  focus  of  a 
severe  inflammation  feels  brawny  because  of  coagulation  of  a  highly  albumin- 
ous exudate;  the  periphery  of  an  inflammation  is  soft  and  edematous  because 
of  the  presence  there  of  thin  and  non-coagulated  exudate.  Inflammatory 
lymph  contains  proteins  and  other  substances.  "  Of  these  the  more  important 
are  ferments,  the  results  of  proteolysis  (notably  fibrin  and  its  precursors  and 
peptones),  and  in  many  cases  mucin,  together  with  bactericidal  substances,  and, 
where  bacteria  are  present,  the  products  of  their  growth."^  The  amount  of 
the  exudation  varies  with  the  violence  of  the  irritation,  the  nature  of  the  irri- 
tant, the  general  condition  of  the  organism,  and  the  state  of  the  tissues  which  are 
involved.  In  dense  tissue  (bone,  periosteum,  etc.)  the  exudation  is  scanty. 
In  loose  tissue  (subcutaneous  tissue)  it  is  profuse.  Profuse  exudation  may 
^  Adami,  in  Allbutt's  "System  of  Medicine." 


Migration  and  Diapedesis 


93 


take  place  into  a  joint,  the  pleural  sac,  the  peritoneal  cavity,  or  the  peri- 
cardium. In  such  cases  the  exudation  is  profuse  because  the  serous  mem- 
brane has  a  thin  covering  of  endothelium,  contains  quantities  of  vessels,  and 
the  vessels  own  but  a  thin  covering  and  obtain  but  a  scant  support  on  the 
side  of  the  cavity. 

Does  the  plasma  leave  the  vessels  as  a  simple  filtrate?     Some  maintain 
that  it  does.     Heidenhain  and  others  claim  that  it  does  not,  and  believe  that 


Fig.  47. — Stages  of  the  migration  of  a  single  white  blood-corpuscle  through  the  wall  of  a  vein 

(Caton). 

the  endothelial  cells  play  an  active  part  in  the  process.  Heidenhain  likens 
exudation  to  secretion,  because  some  materials  from  the  plasma  pass  out 
and  others  do  not.  Adami  is  inclined  to  agree  with  Heidenhain,  that  the 
endothelium  plays  "not  a  passive  but  an  active  role."  Are  there  spaces  between 
the  endothehal  cells  of  the  capillary?  It  was  long  taught  positively  that  there 
were  no  open  spaces  between  the 
endothelial  cells  of  the  vessel  wall 
and  that  these  cells  were  held 
close  together  by  a  cement  sub- 
stance. It  is  now  believed  by 
some  observers  that  spaces  exist 
between  the  protoplasmic  strands 
which  hold  the  cells  together,  these 
spaces  being  closed  when  the  vessel 
is  contracted  and  open  when  the 
vessel  is  dilated.  When  these 
spaces  are  open  fluid  passes,  and 
through  these  doorways  leukocytes 
emerge. 

Migration  and  Diapedesis. — 
Even  early  in  an  inflammation  a 

number  of  white  corpuscles  pass  through  the  vessel  walls;  but  when  the  in- 
flammation is  well  established,  large  numbers,  and  when  it  is  severe  vast  hordes, 
pass  into  the  perivascular  tissues.  This  process  is  known  as  "migration" 
(Figs.  46  and  47).  The  leukocytes  throw  out  protoplasmic  arms,  insert  them- 
selves between  the  cells  of  the  walls  of  the  vessel,  and  pull  themselves  through 
by  their  power  of  ameboid  movement  (Fig.  48).  Some  observers  claim  that 
they  do  not  pass  through  existing  open  doors,  but  force  openings  which  close 
after  them.  This  is  readily  accomplished,  because  the  vessel  wall  is  itself  dam- 
aged, weakened,  and  convoluted.  Others  claim  that  stomata  exist  between  the 
endothelial  cells,  the  vessel  wall  being  porous  like  a  filter  (see  above).  The 
escape  of  leukocytes  takes  place  chiefly  from  the  venules,  though  some  migrate 
through  the  capillaries  and  even  the  arterioles  (Fig.  46). 


Fig.  48. — Ameboid  movements  of  a  leukocyte 
(Warner) . 


94  Inflammation 

The  leukocytes  are  influenced  to  move  toward  the  damaged  tissue  by  the 
attractive  force  known  as  positive  '"c/iemiotaxis,''  a  force  which  draws  them  to- 
ward invading  bacteria,  to  regions  of  irritation,  and  to  areas  of  tissue  death. 
Leukocytes  may  move  from  very  virulent  organisms,  influenced  by  what  is 
known  as  negative  '^chemiotaxis."  The  migration  of  a  leukocyte  requires 
but  a  short  time.  Figure  47  shows  the  migration  of  a  white  blood-cell  through 
a  vein  wall,  the  process  requiring  one  hour  and  fifty  minutes.  In  very  acute 
inflammations  red  corpuscles  also  pass  into  the  tissues.  Red  corpuscles  are  not 
capable  of  ameboid  movements,  and  if  they  do  escape  from  the  vessels  the 
process  is  passive  on  their  part  and  not  active.  This  passive  escape  happens 
because  the  capillary  walls  have  been  destroyed  or  because  stomata  have  been 
greatly  enlarged  by  vascular  dilatation.  If  red  corpuscles  do  pass  into  the 
exudate,  as  happens  in  pneumonia,  the  inflammation  is  a  very  severe  one,  and 
is  called  a  hemorrhagic  inflammation.  The  escape  of  corpuscles  by  a  passive 
process  is  known  as  "diapedesis,"  in  contradistinction  to  the  escape  of  leuko- 
cytes by  active  ameboid  movements,  a  process  known  as  "migration."  The 
white  corpuscles  usually  greatly  increase  in  number  in  the  blood  of  a  person 
who  has  an  acute  inflammation,  and  the  blood-making  organs,  such  as  the 
spleen  and  lymphatic  glands,  are  often  enlarged.  An  increase  of  white  cor- 
puscles in  the  blood  of  an  individual  is  called  leukocytosis  (see  page  103). 

Blood=pIaques. — Blood- plates,  blood-plaques,  or  third  corpuscles,  may  be 
discovered  in  freshly  drawn  blood,  but  unless  they  are  present  in  unusual  num- 
bers they  will  rarely  be  seen  in  specimens  prepared  in  the  usual  way.  The 
third  corpuscles  can  be  seen  by  a  high-power  microscope  in  the  moving  blood 
of  the  web  of  a  frog's  foot.  In  blood  outside  of  the  body  they  are  destroyed  as 
soon  as  coagulation  begins,  and  in  order  to  see  them  coagulation  must  be 
prevented.  Some  observers  maintain  that  the  third  corpuscles  are  the  real 
fibrin-formers.  The  blood-plaques,  or  third  corpuscles,  are  found  to  be  present 
in  increased  numbers  in  inflammation.  In  health  their  usual  proportion  to 
red  cells  is  as  i  to  20.  They  are  especially  numerous  at  the  height  of  fever 
processes  and  during  convalescence  from  an  extensive  abscess. 

Changes  in  the  Perivascular  Tissues. — The  cells  of  the  perivascu- 
lar tissue  are  phagocytes,  and  when  stimulated  they  enlarge,  become  more 
actively  phagocytic,  and  undergo  reproduction.  The  liquor  sanguinis  which 
exudes  during  an  acute  inflammation  coagulates  unless  prevented  by  virulent 
bacteria.  It  has  often  been  asserted  that  exudation  is  Nature's  method  of 
supplying  nutriment  to  the  cells  of  the  damaged  region.  Adami  points  out  the 
apparently  contradictory  observation  that  the  amount  of  exudate  is  in  direct 
proportion  to  the  rapidity  of  cell  destruction,  but,  nevertheless,  concludes  that 
exudation  stands  in  close  relation  to  cefl  proliferation. ^  From  whatever  cause, 
tissue-cells  multiply.     This  process  is  known  as  ''cell  proliferation.'' 

When  a  tissue  is  injured  it  inflames,  and,  as  Adami  points  out,  the  reaction 
we  call  inflammation  is  an  attempt  to  repair  injury. 

Irritation  may  lead  to  degeneration  and  death  of  cells;  it  may  lead  to  growth 
and  multiplication.  In  many  cases  both  processes  are  active  in  the  acute 
stage,  the  cells  at  the  focus  of  the  inflammation  undergoing  degeneration  and 
destruction,  and  those  at  the  boundary  undergoing  growth  and  proliferation. 

If  tissue-ceUs  have  been  seriously  damaged  they  perish,  and  new  cells  are 
required  to  replace  them.  The  inflammatory  process  has  led  to  exudation 
of  plasma  and  migration  of  leukocytes  into  the  perivascular  tissues.  The 
connective-tissue  cells  multiply  and  produce  young  cells,  which  are  known 
as  "fibroblasts,"  and  which  eat  up  many  leukocytes.  Early  in  an  inflammation 
polynuclear  leukocytes  preponderate,  later  mononuclear  phagocytic  cells 
predominate  (Opie).  The  leukocytes  contain  two  enzymes.  One  is  derived 
from  bone-marrow  and  digests  protein  in  an  alkaline  medium;  the  other  is  de- 
1  Adami,  in  Allbutt's  "System  of  Medicine." 


Inflammation  in  Non-vascular  Tissue  95 

rived  from  lymph-glands  and  digests  protein  in  an  acid  medium  (Opie),  The 
migrated  leukocytes  in  part  surround  the  inflamed  region  and  retard  diffusion 
of  the  process.  Many  enter  the  diseased  area  and  attack  bacteria.  Some 
undergo  degenerative  changes  and  liberate  fibrin  ferment  which  makes  the 
exudate  clot.  Some  move  out  of  the  inflamed  area,  each  one  carrying  within 
it  tissue  debris  or  a  dead  bacterium,  and  many  are  eaten  up  by  the  fibroblasts. 
There  is  no  real  proof  that  leukocytes  proliferate  and  help  directly  to  form  new 
tissue.  This  mass  of  young  cells,  taking  origin  from  the  fixed  cells,  has  been 
called  embryonic  tissue,  because  of  a  fancied  resemblance  to  the  cells  of  the 
embryo.  John  Hunter  called  \t  juvenile  tissue.  It  has  also  been  called  indiffer- 
ent tissue,  because  of  the  belief  that  it  could  be  converted  indifferently  into  vari- 
ous tissue  according  to  circumstances.  It  is  also  spoken  of  as  inflammatory 
new  formation.  The  cells  of  embryonic  tissue  are  called  fibroblasts  because 
they  form  fibrous  tissue. 

An  exudation  may  be  absorbed  by  the  lymphatics.  It  may  be  converted 
into  pus  if  infected  with  pyogenic  bacteria,  or  be  replaced  by  cells  from  the 
proliferation  of  fixed  tissue-cells,  the  cellular  mass  being  subsequently  vascu- 
larized by  the  extension  into  it  of  capillary  loops  derived  from  adjacent  capil- 
laries. When  embryonic  tissue  is  filled  with  blood-vessels — that  is  to  say, 
when  it  is  vascularized — it  is  called  granulation  tissue.  Granulation  tissue  is 
finally  converted  into  fibrous  tissue.  The  above  complicated  processes,  vascular 
and  perivascular,  are  not  accidents  nor  haphazard  freaks,  but  are  Nature's  efforts 
to  bring  about  a  cure. 

Dilatation  is  due  to  the  direct  effect  of  the  irritant  upon  the  muscle  or  its 
nerve-elements.  Retardation  and  stasis  are  due  to  paralysis  of  the  vessel 
wall,  which  causes  resistance  to  the  passage  of  the  blood-stream  and  adhesion  of 
the  leukocytes  to  the  vessel  wall.  The  blood-liquor  exudes  and  the  leukocytes 
migrate.  Often  these  efforts  of  Nature  succeed.  Acceleration  of  the  circula- 
tion may  succeed  in  washing  away  an  irritant  from  the  vessel  wall.  By  bringing 
quantities  of  blood  to  the  part  copious  exudation  of  plasma  is  rendered  certain. 
The  exudation  may  wash  and  remove  irritants  from  the  tissues,  and  the  germici- 
dal blood-liquor  may  destroy  bacteria  in  the  damaged  area.  The  migration  of 
corpuscles  may  prove  of  great  service.  The  leukocytes  surround  an  area  of 
infection  and  tend  to  limit  its  spread.  Leukocytes  have  phagocytic  properties, 
and  energetically  attack  and  often  destroy  bacteria,  and  they  furnish  enzymes 
which  may  digest  proteins  and  antitoxins,  which  antagonize  and  may  neutralize 
the  poisons  produced  by  micro-organisms.  Leukocytes  aid  in  forming  fibrin. 
Fibrin  formation  is  of  service  by  helping  immobilization  and  by  hindering  the 
spread  of  bacteria.  Leukocytes  also  aid  in  separating  dead  tissue  from  living, 
and  they  remove  tissue  debris  from  the  area  of  inflammation.  The  multiplica- 
tion of  the  fixed  connective-tissue  cells  leads  to  the  formation  of  fibroblasts,  and 
fibroblasts  are  converted  into  fibrous  tissue;  which  effects  permanent  repair 
(these  changes  will  be  alluded  to  again  in  the  section  on  Repair). 

Nature  may  fail  in  her  efforts.  For  instance,  an  enormous  exudate  increases 
stasis  and  may  cause  such  tension  that  gangrene  results. 

Inflammation  in  Non=vascular  Tissue. — A  type  of  non- vascular 
tissue  is  the  cornea,  and  the  cornea  can  inflame.  The  healthy  cornea  contains 
no  blood-vessels.  It  is  formed  of  many  layers  of  fibers,  each  layer  running 
in  general  parallel  with  the  corneal  surface  but  at  places  forming  angles  with 
the  fibers  of  the  adjacent  layers.  Between  the  layers  are  communicating  lymph- 
spaces  containing  connective-tissue  cells  known  as  corneal  corpuscles.  It  obtains 
its  nourishment  in  part  from  the  vessels  of  the  conjunctiva,  but  chiefly  from  the 
vessels  of  the  ciliary  body  and  sclera.  When  the  cornea  inflames  definitely 
the  episcleral,  conjunctival,  and  ciliary  vessels  usually  dflate  and  pour  out 
exudate,  and  the  fluid  exudate  and  the  leukocytes  enter  into  the  corneal  lymph- 
spaces.     The  exudate  coagulates  and  cell  multiplication  ensues  as  in  inflam- 


96  Inflammation 

mation  in  a  vascular  structure.  In  mild  inflammations  the  vessels  about  the 
cornea  may  not  dilate.  Leukocytes,  from  the  lymph-spaces,  reach  the  seat  of 
injury  in  small  numbers,  and  the  fixed  cells  multiply.  De  Nancrede  points  out 
that  in  trivial  inflammation,  which  injures  but  does  not  destroy  the  epithelium, 
leukocytes  may  not  go  to  the  seat  of  inflammation,  the  only  change  being  en- 
largement and  multiplication  of  corneal  corpuscles.  If  new  formation  takes 
place,  a  permanent  opacity  mars  the  cornea  as  a  consequence. 

Cartilage  has  no  blood-vessels  except  in  regions  where  growth  is  very  active 
or  where  ossification  is  taking  place.  Cartilage  has  no  spaces,  like  the  cornea, 
for  a  free  circulation  of  lymph.  In  man  canals  have  not  been  demonstrated 
and  it  is  thought  that  fibrils  conduct  nutritive  fluids,  the  nutritive  plasma  flow- 
ing between  the  cells,  but  there  is  no  direct  connection  with  blood-vessels.  The 
plasma  is  furnished  by  the  vessels  at  the  margin  of  the  perichondrium.  Carti- 
lage can  inflame,  and  an  inflammation  of  this  structure  is  of  slow  evolution  and 
of  long  duration.  When  inflammation  occurs  the  cartilage  cells  enlarge  and 
their  nuclei  proliferate,  the  intercellular  substance  softens  and  cartilage  cells 
may  be  cast  off.  After  a  long  time  vessels  may  invade  the  inflamed  cartilage 
and  fibrous  tissue  may  form  from  the  perichondrium,  but  in  some  cases  a  loss 
of  substance  is  not  repaired. 

Inflammation  of  Mucous  Membrane. — It  may  be  catarrhal,  suppura- 
tive, croupous,  or  diphtheritic.  In  a  catarrhal  inflammation  the  increased 
blood-supply  causes  an  excessive  flow  of  mucus.  The  submucous  tissues 
present  the  ordinary  changes  of  inflammation  and  quantities  of  epithelial 
cells  are  cast  off  from  the  surface.  Fibrous  tissues  may.  form  in  the  submucous 
tissue  and  thus  cause  permanent  thickening  (strictures,  etc.). 

Suppurative  infla?nmation  is  usually  preceded  by  catarrhal  inflammation. 
In  this  condition  there  is  a  discharge  of  mucopurulent  fluid  and  ulcers  are  apt 
to  form.  A  trivial  loss  of  substance  permits  of  regeneration,  but  a  considerable 
loss  is  repaired  by  fibrous  tissue,  which  by  its  bulk  and  by  contracting  may 
interfere  greatly  with  the  functional  usefulness  of  an  organ  or  a  canal. 

A  croupous  inflammation  is  one  in  which  quantities  of  epithelial  cells  are 
cast  off  the  surface  and  there  forms  upon  the  surface  a  highly  fibrinous 
exudate  (false  membrane). 

In  diphtheritic  inflammation  the  mucous  membrane  is  destroyed  and  the 
false  membrane  invades  the  submucous  tissue.  Diphtheritic  inflammation 
is  due  to  a  specific  bacillus. 

Classification  of  Inflammations. — The  various  forms  of  inflamma- 
tions are — (i)  Simple  or  common,  that  which  is  due  to  any  ordinary  traumatic, 
chemical,  thermal,  or  actinic  cause,  and  not  to  bacteria.  An  instance  of  simple 
inflammation  is  traumatic  periostitis  or  sun  dermatitis.  It  does  not  tend  par- 
ticularly to  spread.  Often  the  cause  of  a  simple  inflammation  is  momentary 
in  action;  (2)  infective  or  sped  fie,. t\\d,t  which  is  due  to  micro-organisms,  as  the 
streptococcus  of  erysipelas.  An  unsuccessful  attempt  has  been  made  to  charge 
all  inflammations  to  bacteria.  It  is  true  that  bacteria  can  generally  be  found 
in  inflammatory  areas,  but  that  they  are  the  only  causes  of  inflammation  is 
accepted  by  few.  Infective  inflammations  often  tend  to  spread  widely;  (3) 
traumatic,  which  is  due  to  a  blow  or  an  injury;  (4)  idiopathic,  which  is  without 
an  ascertainable  cause.  There  is  certainly  a  cause,  even  if  it  cannot  be  pointed 
out,  and  the  term  "idiopathic"  means  that  we  do  not  know  the  cause;  (5) 
acute,  which  is  rapid  in  course  and  violent  in  action;  (6)  chronic,  which  follows  a 
prolonged  course;  (7)  subacute,  which  is  intermediate  in  violence  and  dura- 
tion between  acute  and  chronic;  (8)  sthenic,  characterized  by  high  action; 
it  occurs  in  strong  young  subjects;  (9)  asthenic  or  adynamic,  occurring  in  the 
old,  the  debilitated,  and  the  broken  down.  In  such  an  inflammation  there 
is  no  certain  limitation  of  the  inflammation  by  leukocytes,  and  there  is  an 
indisposition  on  the  part  of  the  tissue-ceUs  to  form  fibroblasts;   (10)  paren- 


Causes  of  Inflammation  97 

chymatous,  affecting  the  "parenchyma,"  or  active  cells  of  an  organ;  (11)  intersti- 
tial, affecting  the  connective-tissue  stroma  of  an  organ;  (12)  serous,  characterized 
by  profuse  non-coagulating  exudation  (as  in  pleuritis)  or  by  marked  inflamma- 
tory edema;  (13)  plastic,  adhesive,  or  fibrinous,  characterized  by  an  exudation 
which  glues  together  adjacent  surfaces,  as  in  peritonitis;  (14)  purulent,  phleg- 
monous, or  suppurative,  when  pyogenic  cocci  are  present  and  multiply;  (15)  hem- 
orrhagic, when  the  exudate  contains  many  red  blood-cells,  as  in  strangulated 
hernia  and  in  the  pustules  of  black  small-pox;  (16)  croupous,  when  an  inflamma- 
tion produces  upon  the  surface  of  a  tissue  a  fibrinous  exudate  which  cannot  be 
organized  into  tissue,  and  which  is  due  to  the  action  of  micro-organisms.  An 
exudate  of  this  character  was  called  by  the  older  surgeons  ^'aplastic  lymph." 
It  occurs  most  usually  on  mucous  membrane;  (17)  diphtheritic,  which  differs 
from  croupous  in  the  fact  that  the  false  membrane  is  in  the  tissue  rather  than 
upon  it;  (18)  gangrenous,  an  inflammation  resulting  in  death  of  the  part,  the 
gangrene  being  due  to  the  .tension  of  the  exudate  or  the  virulence  of  the  poison; 
(19)  healthy,  when  the  tendency  is  to  repair;  (20)  unhealthy,  when  the  tendency 
is  to  destruction;  (21)  latent,  an  inflammation  which  for  some  time  does  not  an- 
nounce itself  by  any  obvious  symptoms,  as  the  inflammation  of  Peyer's  patches 
in  typhoid  fever;  (22)  contagious,  when  its  own  secretions  can  propagate  it; 
(23)  dry,  without  exudation;  (24)  hypostatic,  arising  in  a  region  of  passive  conges- 
tion (as  a  bed-sore);  (25)  malignant,  due  to  a  malignant  growth;  (26)  catarrhal, 
aft'ecting  a  mucous  membrane;  (27)  neuropathic,  due  to  impairment  of  the 
trophic  functions  of  the  nervous  system,  as  in  perforating  ulcer;  and  (28) 
sympathetic  or  reflex,  due  to  disease  or  injury  of  a  distant  part,  as  when  orchitis 
follows  mumps. 

Extension  of  Inflammation. — Inflammation  extends  by  continuity 
of  structure,  by  contiguity  of  structure,  by  the  blood,  and  by  the  lymphatics. 
Extension  by  continuity  is  seen  in  phlebitis.  Extension  by  contiguity  is 
seen  when  a  cutaneous  inflammation  advances  and  attacks  deeper  structures. 
Extension  by  the  blood  is  seen  in  the  formation  of  the  small-pox  exanthem. 
Extension  by  the  lymphatics  is  witnessed  in  a  bubo  following  chancroid. 

Terminations  01  Inflammation. — Inflammation  may  be  f  oho  wed  by 
a  return  of  the  tissues  to  health,  and  this  return  may  take  place  by  delitescence, 
by  resolution,  or  by  new  growth.  By  delitescence  is  meant  abrupt  termination 
at  an  early  stage,  as  when  quinsy  is  aborted  by  the  administration  of  quinin 
and  morphin,  and  the  production  of  a  sweat;  resolution  means  the  gradual 
disappearance  of  the  symptoms  when  inflammation  has  passed  through  its 
regular  stages;  and  new  growth  means  that  an  inflammation  has  lasted  a  consider- 
able time,  with  ample  blood-supply  and  without  suppuration,  and  has  gone  on 
to  the  formation  of  fibroblasts,  granulation  tissue,  and  fibrous  tissue.  Inflam- 
mation may  be  followed  by  death  of  the  inflamed  part  or  necrosis.  Death 
of  the  part  may  be  due  to  suppuration,  ulceration,  or  gangrene. 

The  causes  of  inflammation  are — predisposing,  or  those  residing  in 
the  tissues,  and  rendering  them  liable  to  inflame;  and  exciting,  or  those  which 
directly  awake  the  process  into  activity.  The  first  may  be  thought  of  as 
making  material  inflammable;  the  second  may  be  regarded  as  sparks  of  fire. 

Predisposing  causes  are  those  which  impair  the  general  vigor,  injure  the 
blood,  weaken  the  tissues,  or  lower  nutritive  activities.  Among  these  causes 
are  shock,  hemorrhage,  nervous  irritation,  gout,  rheumatism,  diabetes,  Bright's 
disease,  alcoholism,  and  s\^hilis.  Plethora  renders  a  person  Hable  to  sthenic 
inflammations  (those  characterized  by  high  action).  Tissue  debihty  renders 
one  prone  to  ad^mamic  or  asthenic  inflammations.  Nerve  injury  predisposes 
to  inflammation,'  either  from  damage  to  trophic  nerves  and  consequent  failure 
in  tissue  nutrition  and  resistance  or  because  analgesia  exists  and  irritants 
which  reach  the  region  are  not  recognized  and  are  aflow^ed  to  remain.  For 
mstance,  if  the  conjunctiva  is  in  a  condition  of  analgesia,  the  presence  of  foreign 


gS  Inflammation 

bodies  is  not  noticed  and  destructive  inflammation  may  result  from  their  non- 
removal. 

After  removal  of  the  Gasserian  ganglion  the  cornea  is  devoid  of  sensation, 
the  flow  of  tears  is  lessened,  dust  gathers  in  the  eye,  and  if  not  removed  by 
irrigation  or  kept  out  by  a  shield,  inflammation  and  disastrous  ulceration  will 
ensue. 

Exciting  Causes. — The  exciting  causes  of  inflammation  are — traumatic^ 
as  blows  and  mechanical  irritation;  chemical,  as  the  stings  of  insects,  the  rube- 
facient effects  of  mustard,  venom  of  serpents,  products  of  bacteria,  ivy  poison, 
etc.;  thermal,  heat  and  cold;  actinic,  certain  solar  and  electric  rays;  specific,  the 
micro-organisms,  causing,  for  instance,  tuberculous  peritonitis  or  erysipelas;  and 
nervous,  nerve  stimulation  certainly  being  capable  of  producing  hyperemia  and 
sometimes  even  inflammation.  Inflammation  due  to  nerve  stimulation  is  seen 
in  herpes  zoster  and  in  the  swoUen  and  discolored  skin  over  an  inflamed  joint 
(Adami).  Inflammation  may  also  be  induced  by  electric  currents,  by  the  x-rays, 
and  by  radium  rays. 

Some  writers  insist  that  every  inflammation  is  due  to  the  action  of  micro- 
organisms, but  this  statement  lacks  proof.  They  maintain  that  inflammation 
is  a  destructive  microbic  process  which  cannot  bring  about  repair,  and  that 
repair  begins  only  when  inflammation  ends.  As  Adami  points  out,  the  advo- 
cates of  this  view  argue  that  swelling,  pain,  and  discoloration  point  to  the 
existence  of  inflammation;  that  repair  can  take  place  when  these  phenomena 
are  absent,  hence  inflammation  is  not  present  when  repair  begins.  As  a  matter 
of  fact,  swelling,  discoloration,  and  pain  are  phenomena  often  but  not  invariably 
associated  with  inflammation;  and  in  inflammation  one  or  all  of  these  phe- 
nomena may  be  absent.  Because  these  signs  are  not  discovered  is  no  proof 
that  inflammation  does  not  exist.  I  believe  that  inflammation  is  not  always  due 
to  microbes  and  is  not  always  a  destructive  process,  but  may  be  from  the  start 
conservative  and  reparative.  It  is  always  the  reaction  of  the  tissue  to  injury  and 
however  caused  is  the  first  step  on  the  road  to  repair.^ 

Symptoms  of  Acute  Inflammation. — Inflammation,  if  at  all  severe, 
announces  its  presence  by  symptoms  which  are  both  local  and  constitutional. 

Local  Symptoms  of  Acute  Inflammation. — The  most  prominent  local 
symptoms  were  known  in  the  first  century  A.  D.  to  the  famous  Roman,  Celsus, 
who  stated  them  as  ^^rubor,  color  cum  tumorc  et  dolore'" — redness  and  heat  with 
swelling  and  pain.  As  set  forth  to-day,  the  local  symptoms  are:  (i)  heat; 
(2)  pain;  (3)  discoloration;  (4)  sweUing  ;  (5)  disordered  function;  and  (6)  muscular 
rigidity,  which  is  noted  in  inflammation  of  certain  regions  and  structures. 

Heat  is  due  to  the  passage  of  an  increased  quantity  of  blood  through  the 
damaged  area  and  to  the  arrival  at  the  surface  of  the  body  of  warm  blood 
from  internal  parts.  Although  an  inflamed  part  may  be,  and  usually  is,  warmer 
than  the  surrounding  parts,  its  temperature  is  never  greater  than  the  tempera- 
ture of  the  blood.  This  increase  of  heat  is  especially  noticeable  when  we, 
for  instance,  touch  an  arm  affected  with  erysipelas  and  contrast  the  sensa- 
tion obtained  with  that  obtained  by  placing  the  hand  on  the  sound  arm.  The 
diseased  arm  feels  much  warmer  to  the  examining  hand  than  does  the  sound 
arm,  but  its  temperature  is  not  above  the  general  body  temperature.  An  ex- 
tremity in  health,  as  is  well  known,  shows  on  the  surface  a  temperature  below 
that  of  the  blood;  in  an  inflamed  state  the  temperature  may  nearly  equal 
that  of  the  blood.  Heat  is  always  present  in  inflammation  of  a  superficial 
part.  The  surgeon  examines  for  heat  by  placing  his  hand  upon  the  suspected 
area  and  then  placing  the  same  hand  upon  a  corresponding  portion  of  the  op- 
posite side  of  the  patient  in  order  to  note  the  contrast.  If  great  accuracy  is 
desired,  a  surface  thermometer  is  used. 

Pain  is  a  constant  and  conspicuous  symptom.     It  is  due  to  stretching 
1  See  Adami's  masterly  article  in  Allbutt's  "System  of  Medicine." 


Local  Symptoms  of  Acute  Inflammation 


99 


of  or  pressure  upon  nerves  from  exudate;  to  irritation  of  nerves;  or  to  inflam- 
mation of  the  nerves  themselves,  producing  cellular  changes.  Pain  is  asso- 
ciated witli  tenderness  (pain  on  pressure),  it  is  aggravated  by  motion  and  by 
a  dependent  position  of  the  part,  and  it  varies  in  degree  and  in  character.  In 
serous  membranes  it  is  acute  and  lancinating,  like  dagger- thrusts;  in  connect- 
ive tissue  it  is  acute  and  throbbing;  in  large  organs  it  is  dull  and  heavy;  in 
the  bone  it  is  gnawing  or  boring;  in  the  skin  and  mucous  membrane  it  is  itch- 
ing, burning,  smarting,  or  stinging;  in  the  urethra  it  is  scalding;  in  the  testicle 
it  is  sickening  or  nauseating;  in  the  teeth  it  is  throbbing;  and  in  inflammation 
under  dense  fascia  it  is  pulsatile.  Pain  in  inflammation  after  presenting  itself 
in  one  form  may  change  in  character.  If  a  pain  becomes  markedly  throbbing, 
suppuration  may  be  anticipated.  Pain  does  not  always  occur  at  the  seat  of 
trouble  only,  but  may  be  felt  also  at  some  distant  point.  Usually  there  is  also 
pain  at  the  seat  of  disease.  Sometimes  no  pain  is  complained  of  in  this  region. 
I  have  seen  pain  in  the  right  sciatic  region  dependent  upon  a  chronically  in- 
flamed, posteriorly  placed  appendix,  no  complaint  having  been  made  of  pain 
in  the  abdomen.  This  is  known  as  a  ^^ sympathetic'^  or  referred  pain,  and  is 
due  to  the  fact  that  the  area  to  which  pain  is  referred  receives  its  nerve- 
supply  from  the  same  spinal  segment  as  does  the  inflamed  area;  in  other 
words,  there  is  a  nervous  communication  between  the  inflamed  part  and  a  distant 
area.  When  appendicitis  causes  sciatic  pain  the  appendix  has  caused  trouble  in 
the  sciatic  plexus  or  sciatic  nerve.  In  many  cases  of  sympathetic  pain  a  nerve- 
trunk  refers  the  sense  of  pain  to  its  peripheral  distribution,  but  sometimes 
pain  is  referred  to  an  adjacent  nerve,  a  distant  nerve,  or  even,  perhaps,  to  a 
nerve  on  the  opposite  side  of  the  body.  Tenderness,  however,  is  detected  at 
the  seat  of  trouble,  whether  or  not  it  exists  at  the  seat  of  referred  pain. 

Pain  of  hepatitis  is  often  felt  in  the  right  shoulder.  Pain  at  the  point  of  the 
right  shoulder  or  in  the  shoulder-blade  is  felt  also  in  gall-stones,  cholecystitis, 
and  in  cancer  of  the  liver.  It  is  held  by  some  that  pain  arises  in  filaments  of 
the  pneumogastric  from  the  hepatic  plexus.  Others  maintain  that  it  is  referred 
from  the  phrenic  nerve  to  the  cervical  nerves  by  the  sympathetic  (Mackenzie). 
Pain  in  the  shoulder  (see  Ldffelmann  Abstract  in  "Surgery,  Gynecology,  and 
Obstetrics,"  Sept.,  1915)  as  a  result  of  acute  abdominal  conditions  may  be 
above  the  clavicle,  at  the  point  of  the  shoulder,  in  the  nape  of  the  neck  or  in 
the  upper  part  of  the  arm.  It  is  due  to  irritation  of  the  diaphragm.  If  the  right 
side  of  the  diaphragm  is  irritated  the  pain  is  felt  in  the  right  shoulder,  if  the  left 
side  it  is  felt  in  the  left  shoulder.  In  splenic  injuries  and  inflammations  the  pain  is 
in  the  left  shoulder.  Pain  in  the  right  shoulder  is  a  common  but  not  invariable 
symptom  after  perforation  of  the  stomach,  in  appendicitis  with  a  high  appendix, 
in  abscess  of  the  dome  of  the  liver,  in  subphrenic  abscess  and  in  hepatitis. 

Pain  of  coxalgia  is  often  felt  on  the  inside  of  the  knee,  because  the  obturator 
nerve,  which  sends  a  branch  to  the  ligamentum  teres,  also  sends  a  branch  to  the 
interior  and  to  the  inner  side  of  the  knee-joint. 

Inflammation  of  an  eye  with  increased  tension  causes  browache.  Inflam- 
mation of  the  anus,  uterus,  tubes,  or  ovaries  may  cause  sacral  backache.  Pain 
of  rectal  inflammation  may  be  referred  to  the  back  of  the  sacrum,  down  the 
thighs,  to  the  penis  and  to  the  perineum.  I  have  seen  pain  in  the  heel  as  a 
symptom  of  rectal  cancer.  Pain  of  inflammation  of  the  sacro-iliac  joint  may  be 
referred  to  the  sciatic  nerve  and  its  branches.  Inflammation  of  the  prostate 
and  neck  of  the  bladder  causes  pain  in  the  head  of  the  penis,  and  often  pain  in 
the  lower  abdomen  and  loin.  Inflammation  of  a  testicle  or  epididymis  causes 
pain  in  the  groin,  and  often  also  in  the  abdomen,  back,  and  thighs.  Renal 
calculus  and  pyelitis  cause  pain  in  and  retraction  of  the  testicle,  and  pain  in  the 
loin,  groin,  or  thigh.  Pain  is  sometimes  felt  in  the  renal  region  of  the  opposite 
side. 

If  the  covering  of  an  organ  is  involved,  pain  becomes  more  violent;  for 


lOo  Inflammation 

instance,  hepatitis  becomes  much  more  painful  when  the  perihepatic  structures 
are  attacked.  Inflammation  without  pain  is  known  as  "latent"  (as  the 
inflammation  of  Peyer's  patches  in  typhoid).  The  sudden  disappearance  of 
inflammatory  pain,  when  not  due  to  the  administration  of  opiates,  suggests 
the  possibility  of  gangrene,  because  analgesia  exists  in  gangrene.  The  char- 
acteristics of  inflammatory  pain  are  that  it  comes  on  gradually,  has  a  fixed 
seat,  is  continuous,  is  attended  by  other  inflammatory  symptoms,  and  is  in- 
creased by  motion,  by  pressure,  and  by  a  dependent  position  of  the  part.  If 
there  be  no  tenderness  in  a  part,  the  source  of  the  pain  is  not  local  inflam- 
mation; but  tenderness  may  exist  when  there  is  no  local  inflammation,  as  in 
an  area  to  which  pain  is  referred  from  a  distant  part.  Pain  of  an  inflammation 
which  does  not  involve  a  nerve  does  not  correspond  to  an  exact  nervous  dis- 
tribution. If  pain  corresponds  exactly  to  the  area  of  a  nerve's  distribution,  the 
cause  of  it  is  acting  on  the  nerve-trunk  or  on  its  roots.  If  the  cutaneous  sur- 
face is  involved,  the  lightest  touch  causes  pain.  The  surface  may  be  extremely 
hyperesthetic  even  when  it  is  not  inflamed,  the  condition  resulting  from  deep- 
seated  or  distant  inflammation.  Areas  of  h>peresthesia  (hyperalgesia)  of  the 
skin  of  the  abdomen  are  noted  in  various  visceral  inflammations.  Such 
hyperesthesia  is  due  to  referred  impressions.  Sir  James  Mackenzie  set  forth 
the  significance  of  this  symptom.  Ligat  ("Practitioner,"  1916,  xcvii)  tests  for 
hyperesthesia  by  taking  a  portion  of  skin  between  the  thumb  and  index  finger 
and  lifting  it  away  from  the  deeper  parts.  He  finds  that  in  gastric  ulcer  and 
duodenal  ulcer  the  maximum  point  of  sensitiveness  is  in  the  midline  and  midway 
between  the  umbilicus  and  the  ensiform.  If  a  line  is  drawn  from  the  middle  of 
Poupart's  ligament  to  the  umbilicus  the  j  unction  of  the  middle  and  lower  thirds  of 
this  hne  is  the  Fallopian  tube  point.  The  appendix  point  is  at  the  meeting 
place  of  the  upper  and  middle  thirds  of  a  Une  drawn  to  the  anterior  superior  spine 
from  the  right  side  of  the  umbiHcus.  The  gall-bladder  point  is  found  at  the 
junction  of  a  line  drawn  horizontally  from  the  tip  of  the  tenth  rib  and  a  vertical 
line  drawn  midway  between  the  middle  of  the  abdomen  and  the  nipple  line. 
If  touching  the  skin  produces  no  pain,  but  deep  pressure  does  produce  it,  the 
deeper  structures  are  the  source.  Pain  in  muscle  and  ligament  is  developed 
by  motion;  in  muscle,  by  contraction,  but  not  by  passive  movements  with  the 
muscle  relaxed;  in  ligament  pain  is  developed  by  active  or  passive  movernents 
which  stretch  the  ligament.  If,  for  example,  a  man  with  a  stiff  neck  has  pain  on 
the  right  side  of  the  back  of  his  neck  on  voluntarily  turning  his  face  toward  the 
left  shoulder,  but  is  without  pain  when  his  face  is  turned  by  the  surgeon,  who, 
conversely,  induces  pain  by  turning  the  patient's  face  far  to  the  right,  this  condi- 
tion indicates  the  trouble  to  be  muscular.  If,  however,  no  pain  arises  on  turn- 
ing the  face  to  the  right,  but  it  is  manifest  on  turning  the  face  actively  or 
passively  to  the  left,  the  pain  is  in  those  ligaments  which  stretch  when  the 
face  is  turned  to  the  left.^  In  inflammation  of  the  synovial  membrane  even 
gentle  passive  motion  in  any  direction  causes  pain. 

The  pain  of  colic  differs  from  that  of  inflammation.  It  is  sudden  in  onset, 
intermits,  recurs  in  paroxysms,  and  is  relieved  by  pressure.  The  pain  of  in- 
flammation is  gradual  in  onset,  is  continuous,  and  is  made  worse  by  pressure. 
The  pain  of  neuralgia  is  often  preceded  by  cutaneous  anesthesia  of  the  skin 
of  the  part,  is  very  paroxysmal,  comes  on  suddenly,  darts  through  recognized 
nerve-areas,  the  attack  lasts  some  hours,  and  is  apt  to  recur  at  a  certain  hour. 
It  presents  no  general  tenderness,  as  does  inflammation,  but  there  may  be 
several  points  which  are  acutely  sensitive  to  pressure  (Valleix's  points  dou- 
loureux). The  tender  spots  of  Valleix  are  met  with  in  inveterate  neuralgia,  and 
occur  at  points  where  nerves  "pass  from  a  deeper  to  a  more  superficial  level, 
and  particularly  where  they  emerge  from  bony  canals  or  pierce  fibrous  fasciae."'^ 

1  "Surgical  Diagnosis,"  by  A.  Pearce  Gould. 

''Anstie,  "Neuralgia  and  Diseases  which  Resemble  It." 


Local  Symptoms  of  Acute  Inflammation  loi 

Pain  is  often  of  great  value  by  calling  attention  to  parts  diseased;  but  it 
may  be  a  terrible  evil,  racking  the  organism  and  even  causing  death.  If  pain 
continues  long,  it  becomes  in  itself  formidable:  it  prevents  sleep,  it  destroys 
appetite,  and  it  deteriorates  the  mind,  and  one  of  the  surgeon's  highest  duties 
is  to  relieve  it.  The  physiognomy  or  expression  of  persistent  physical  pain 
presents  the  following  characteristics:  Heavy  fulness  about  the  eyes,  drooping 
of  the  angles  of  the  mouth,  contraction  of  the  brows,  and  the  aspect  of  fatigue. 
The  victim  of  pain  may  be  restless,  but  in  severe  inflammation  he  is  apt  to 
assume  some  fixed  posture.  He  may  be  anemic.  There  may  be  widespread 
tremor,  muscular  twitches,  or  muscular  rigidity.  Agony  is  made  evident  by 
various  signs  and  is  often  associated  with  fear.  The  absence  of  the  physiognomy 
of  pain  in  a  person  who  complains  of  great  pain  is  a  strong  indication  that 
the  patient  exaggerates  the  gravity  of  his  sufferings  or  deliberately  deceives. 
Spartans  are  few. 

Discoloration  arises  from  determination  of  blood  to  the  part;  hence  the 
more  vascular  the  tissue,  the  greater  the  discoloration.  A  non-vascular  tissue 
presents  no  discoloration,  though  we  usually  find  discoloration  adjacent  in  the 
zone  of  blood-vessels  which  furnish  the  tissue  with  nutriment.  Discoloration  in 
vascular  tissue  is  most  intense  at  the  focus  or  center  of  the  inflammation.  Dis- 
coloration varies  in  tint  and  in  character  according  to  the  tissue  implicated  and 
the  nature  of  the  inflammation.  It  may  be  circumscribed  or  diffuse.  Arbores- 
cent redness  means  a  distribution  in  dendritic  lines.  Linear  discoloration  signi- 
fies redness  running  in  straight  lines,  as  in  phlebitis.  Punctiform  discoloration 
occurs  in  points,  and  is  due  to  vascular  rupture.  Maculiform.  redness  re- 
sembles an  ecchymosis  or  blotch.     Dusky  discoloration  points  to  suppuration. 

Inflammation  of  the  throat  and  skin  produces  scarlet  discoloration;  in- 
flammation of  the  sclerotic  coat  of  the  eye  and  of  the  fibrous  coat  of  muscle 
produces  lilac  or  bluish  discoloration;  inflammation  of  the  iris  produces  brick- 
dust,  grayish,  or  brown  discoloration;  erysipelas  causes  a  yellowish-red  dis- 
coloration; secondary  syphilis  causes  a  copper-hued  discoloration;  and  ton- 
sillitis causes  a  livid  discoloration.  A  tuberculous  ulcer  is  of  a  purple  color 
on  the  edge.  Gangrene  is  shown  by  a  black  discoloration.  A  scorbutic  ulcer 
is  surrounded  by  an  area  of  violet  color. 

Redness  as  a  sign  of  inflammation  must  be  permanent  and  joined  with 
other  symptoms.  Redness  due  to  inflammation  disappears  on  pressure,  but 
returns  when  the  pressure  has  been  removed.  If  redness  is  due  to  staining  of 
the  surface  by  dye,  pigmentation,  or  extravasation  of  blood,  pressure  will  not 
blanch  the  spot.  If  on  taking  off  pressure  the  redness  of  inflammation  rapidly 
returns,  the  circulation  is  active;  if,  on  the  contrary,  it  very  slowly  reappears, 
the  circulation  is  very  sluggish  and  gangrene  is  threatened.  Subcutaneous 
hemorrhage  gives  rise  to  a  purple-red  color  which  does  not  fade  when  sub- 
jected to  pressure.  Stains  of  the  surface  by  dyes  fail  to  disappear  on  pressure, 
are  distributed  over  a  considerable  surface,  show  a  hue  which  is  uniform  through- 
out, are  obviously  superficial,  are  not  associated  with  other  signs  of  inflamma- 
tion, and  can  be  washed  away. 

A.  Pearce  Gould,  in  his  excellent  little  work  upon  ''Surgical  Diagnosis," 
tells  us  that  the  color  of  a  h,yperemic  surface  may  furnish  important  informa- 
tion. Lividity  may  mean  failure  of  the  heart  and  lungs,  or  simply  venous 
congestion  in  the  part.  In  lividity  from  obstruction  of  the  lungs  or  heart  the 
color  slowly  returns  after  pressure  has  driven  it  out.  In  lividity  due  to  local 
congestion  the  color  quickly  returns  when  pressure  is  released  and  the  dilated 
veins  are  often  distinctly  visible.  Of  course,  in  a  local  trouble,  when  the 
circulation  becomes  impaired  to  such  a  degree  that  gangrene  is  threatened, 
the  lividity  fades  very  slowly  on  pressure  and  reappears  very  slowly  on  the 
release  of  pressure. 

Swelling  or  tumefaction  is  due  in  small  part  to  vascular  distention,  but 
chiefly  to   effusion  and  cell  multiplication.     The  more  loose  cellular  mate- 


I02  Inflammation 

rial  a  part  contains,  the  more  it  swells;  hence  the  eyelids,  scrotum,  vulva, 
tonsils,  glottis,  and  conjunctivie  swell  very  greatly  when  inflamed.  A  swelling 
is  soft  or  edematous  when  due  to  uncoagulated  effusion;  is  brawny  and  doughy 
when  due  to  coagulated  effusion;  is  hard  and  elastic  when  produced  by  pro- 
liferating cells.  Swelling  may  do  good  by  unloading  the  vessels  and  acting 
like  a  blister  or  local  bleeding,  or  it  may  do  great  harm  by  pressing  upon  the 
vessels  and  cutting  off  the  blood-supply.  Swelling  of  the  conjunctiva,  or 
chemosis,  may  cause  sloughing  of  the  cornea,  and  swelling  of  the  prepuce 
may  cause  gangrene.  A  swelling  may  do  harm  by  obstructing  an  aperture, 
as  in  edema  of  the  glottis,  when  the  larynx  becomes  blocked;  or  by  compression 
of  a  normal  channel,  as  in  the  swelling  of  the  perineum  when  the  urethra  is 
compressed.  The  cutaneous  surface  over  a  swollen  area  may  become  covered 
with  blisters  or  blebs.  This  condition  is  noted  particularly  after  burns  and 
fractures. 

Disordered  function  is  always  present  in  inflammation.  It  may  be  mani- 
fested by  increased  tenderness  or  sensibility;  a  slight  touch,  it  may  be,  pro- 
ducing torturing  pain.  This  condition  is  called  hyperesthesia.  Healthy  parts 
almost  or  entirely  destitute  of  feeling  (as  tendons,  ligaments,  and  bones) 
become  highly  sensitive  when  inflamed.  It  may  be  manifested  by  increased 
irritabiUty.  In  dysentery  the  colon  repeatedly  contracts  and  expels  its  con- 
tents; the  stomach  does  likewise  in  gastritis;  and  the  bladder  acts  similarly  in 
cystitis.  Spasmodic  twitching  of  the  eyehds  occurs  in  conjunctivitis,  and 
twitching  of  the  muscles  of  a  limb  after  fracture  and  amputation. 

Impairment  of  Special  Function. — In  inflammation  of  the  eye,  when  an  at- 
tempt is  made  to  look  at  objects  the  lids  close  spasmodically,  and  even  a  little 
light  causes  great  pain  and  lacrimation  (photophobia).  In  inflammation  of 
the  ear  noises  cause  great  suffering,  and  even  when  in  a  quiet  room  the  patient 
has  subjective  buzzing  and  roaring  in  his  ears  (tinnitus  aurium).  In  coryza  the 
sense  of  smell,  in  glossitis  the  sense  of  taste,  in  dermatitis  the  sense  of  touch, 
and  in  laryngitis  the  voice  may  be  lost.  In  inflammation  of  the  brain  the  mind 
is  disordered;  in  arthritis  the  joints  can  scarcely  be  moved;  and  in  myositis  it 
is  difficult  and  painful  to  employ  the  muscles. 

Derangement  of  Secretions. — In  dermatitis  the  sweat  is  not  thrown  off;  in 
hepatitis  bile  is  not  properly  secreted;  and  in  nephritis  nitrogenous  elements 
are  not  satisfactorily  removed.  The  secretions  may  undergo  important 
changes  of  composition.  The  sputum  in  pneumonia  is  rusty,  and  dysentery 
causes  a  discharge  of  bloody  mucus. 

Derangement  of  Absorbents. — In  the  heigth  of  an  inflammation  the  absorb- 
ents are  blocked  and  clogged  by  coagulated  exudate,  and  they  cannot  perform 
their  offices. 

Muscular  rigidity  is  sometimes  an  important  sign  of  inflammation.  If 
a  joint  is  inflamed,  the  muscles  which  move  the  joint  are  rigid  and  the  joint 
is  more  or  less  immobile.  In  inflammation  of  the  peritoneum  the  abdominal 
muscles  are  rigid,  and  the  respirations  become  shallow,  frequent,  and  thoracic. 
In  pleuritis  the  intercostal  muscles  of  the  inflamed  side  become  rigid  and  the 
respiratory  excursion  of  the  chest  is  limited.  Rigidity  serves  to  lessen  motion, 
prevent  pain,  protect  the  part,  and  so  gives  physiological  rest. 

Constitutional  Symptoms  of  Acute  Inflammation. — The  chief  constitutional 
symptoms  of  acute  inflammation  are  elevated  temperature  and  leukocytosis. 
Constitutional  symptoms  may  be  absent,  and  often  are  in  moderate  or  limited 
inflammations;  iDut  in  severe,  extensive,  or  infective  inflammations  the  symp- 
tom group  known  as  fever  is  certain  to  exist.  This  is  known  as  symptomatic, 
or  inflammatory  fever,  and  it  arises  in  non-septic  cases  from  the  absorption  of 
aseptic  pyrogenous  exudate,  and  in  microbic  inflammations  from  the  absorption 
of  pyrogenous  toxic  products  of  bacterial  action.  In  young  and  robust  indi- 
viduals an  acute  non-microbic  inflammation  causes  a  fever  characterized  by 


Local  Bleeding  103 

full,  strong  pulse,  flushed  face,  coated  tongue,  dry  skin,  nausea,  constipation, 
and  possible  acute  delirium  (the  sthenic  type  of  the  older  authors).  In  broken- 
down  and  exhausted  individuals  an  ordinary  inflammation,  and  in  any  individ- 
ual a  bacterial  inflammation,  may  cause  a  fever  with  typhoid  symptoms  (the 
typhoid,  asthenic,  or  adynamic  type).  Fibrin  ferment  is  obtained  from  the 
white  corpuscles;  it  is  liberated  as  the  corpuscles  break  up  in  the  exudate,  and 
acting  on  the  liquor  sanguinis  causes  the  union  of  calcium  and  fibrinogen  and  the 
formation  of  fibrin.  The  absorption  of  fibrin  ferment  many  believe  causes 
aseptic  fever  (see  page  139).  Inflammatory  blood  contains  an  increased  amount 
of  albumin  and  salts.  If  a  person  with  inflammatory  fever  is  bled,  the  blood  co- 
agulates rapidly,  the  clot  sinks,  and  there  is  found  on  the  surface  a  cup-shaped 
coat,  made  up  of  liquor  sanguinis  and  white  cells,  known  as  the  ^^ huffy  coat;''' 
but  this  is  not  really  proof  of  inflammation,  and  occurs  normaUy  in  the  blood  of 
the  horse.  The  buffy  coat  forms  when  blood  contains  a  great  number  of  leu- 
kocytes, because  these  leukocytes  sink  more  slowly  than  do  the  red  corpuscles. 
Cupping  occurs  because  the  white  corpuscles  sink  more  slowly  at  the  wall 
of  the  tube  than  in  the  center. 

Leukocytosis. — In  many  inflammatory  and  infectious  diseases  leukocy- 
tosis is  noted.  It  probably  indicates  an  attempt  on  the  part  of  the  organism 
to  protect  itself  from  noxious  materials.  Leukocytosis  is  usually  much  more 
marked  if  pus  exists  than  if  the  exudation  is  serous  or  fibrinous. 

"The  degree  of  leukocytosis  may  be  considered  a  general  index  to  the  in- 
tensity of  the  infection  and  to  the  strength  of  the  individual's  resisting  powers 
in  reacting  against  it.  It  follows,  therefore,  that  intense  infections  occurring 
in  individuals  whose  resisting  powers  are  strong,  produce  a  decided  increase; 
but  the  presence  of  an  infection  of  like  intensity  in  one  whose  resisting  powers 
are  greatly  crippled  fails  to  cause  leukocytosis,  for  in  such  an  instance  the  organ- 
ism is  so  overpowered  by  the  effects  of  the  morbid  process  that  it  is  incapable 
of  reacting"  ("Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.).  We  see  from 
the  above  that  gangrene  or  any  other  virulent  infection  may  be  accompanied 
by  a  low  leukocyte  count,  and  when  pus  is  surrounded  by  a  thick  wall  the  leu- 
kocytes may  be  normal  or  nearly  normal  in  number.  An  increased  proportion 
of  polymorphonuclear  leukocytes  strongly  suggests  body  reaction  against  in- 
fection, and  an  increase  of  eosinophiles  aids  us  in  recognizing  deep-seated  pus 
when  the  leukocyte  count  is  normal  or  but  slightly  increased. 

The  introduction  of  salt  solution  into  the  peritoneal  cavity  leads  to  the 
gathering  of  numbers  of  white  cells,  and  the  resistance  of  the  serous  mem- 
brane to  infection  is  increased.  Horse-serum  that  has  been  boiled  is  said  by 
Petit  to  be  a  valuable  material  to  draw  polynuclear  leukocytes  to  a  part 
("Med.  Record,"  June  22,  1907).  It  has  been  injected  into  the  peritoneal 
■cavity  the  evening  before  an  operation  (30  c.c);  it  has  been  poured  into  the 
cavity  at  the  termination  of  an  operation;  the  gauze  used  for  drainage  after 
an  appendicitis  operation  has  been  soaked  in  it. 

There  is  no  fixed  number  of  leukocytes  which  causes  us  to  affirm  the  pres- 
ence or  absence  of  gangrene  or  pus.  A  normal  count  shows  from  50  to  60  per 
cent,  of  polymorphonuclear  leukocytes  and  from  2  5  to  40  per  cent,  of  lymphocytes. 
Most  serious  inflammations  show  marked  inflammatory  leukocytosis  and  an  in- 
crease in  the  relative  proportion  of  polynuclear  cells.  Typhoid  and  tuberculosis 
show  no  inflammatory  leukocytosis  and  even  a  mixed  infection  may  cause 
•comparatively  little  increase  of  polynuclear  cells.  In  tuberculosis  the  propor- 
tion of  lymphocytes  is  increased.  The  same  man  should  make  all  the  counts 
on  one  patient;  at  least  five  hundred  cells  should  be  counted  at  each  examina- 
tion and  several  examinations  ought  to  be  made. 

Chronic  Inflammation, — This  condition  results  from  the  action  on  the 
tissues  of  some  mfld  but  long-acting  irritant.  It  progresses  slowly  and  does  not 
produce  symptoms  of  severity  either  in  the  part  or  the  body  at  large. 


104  Inflammation 

Causes. — Elood  diseases,  as  rheumatism  and  gout;  infective  diseases,  as 
tuberculosis  and  syphilis;  retained  pus  in  an  ill-drained  abscess;  blocking 
of  the  duct  of  a  gland;  the  retention  of  a  foreign  body  in  a  part;  the  flow  of  an 
irritant  secretion  (as  saliva  from  a  fistula);  repeated  identical  traumatisms 
of  an  occupation,  etc.  Sir  Watson  Cheyne  tells  us  that  chronic  inflammation 
is  not  due  to  the  ordinary  pyogenic  organisms  (see  Cb^yne':  article  in  Treves's 
"System  of  Surgery"). 

Tissue  Changes. — These  changes  are  practically  the  same  as  in  acute  in- 
flammation, but  tnke  place  far  less  rapidly.  Vascular  dilatation,  exudation, 
r.nd  leukocytic  migration  arc  often  tri\aal.  Cell  proliferation  is  always  con- 
sp  cuiusly  i';arked.  It  is  maintained  by  Cheyne  and  others  that  typical  granu- 
lation tiiSUc  does  not  form,  the  tissues  of  the  part  being  replaced  directly  by 
nb.ous  ..issue.  The  amount  of  fibrous  tissue  produced  is  relatively  very  great: 
Th':  tissue  may  ( ause  permanent  thickening,  or  may  contract  and  thus  dimin- 
:'j'i  the  size  of  a  part.  Contraction  is  very  considerable  in  cirrhosis  of  the  liver 
and  in  interstitial  nephritis. 

Symptoms. — Pain  varying  in  intensity  and  character;  tenderness;  great 
swelling,  which  in  some  cases  is  followed  by  shrinking,  and  is  usually  indurated 
or  brawny.  As  a  matter  of  fact,  great  swelling  is  the  most  usual  symptom. 
Sometimes  there  is  a  trivial  amount  of  heat.  There  is  rarely  discoloration 
unless  the  skin  is  itself  inflamed,  but  usually  the  surface  veins  are  distinctly, 
and  sometimes  they  are  greatly,  distended.  There  are  no  constitutional 
symptoms  attributable  purely  to  the  inflammation.  If  there  are  such  symp- 
toms, they  are  due  to  the  disease  which  induced  the  inflammation  or  to  inter- 
ference with  the  function  of  an  organ  because  of  the  fibrous  mass.  (For  the 
treatment  of  chronic  inflammation  see  articles  upon  special  regions  and  par- 
ticular structures.) 

Treatment  of  Acute  Inflammation. — The  first  rule  in  treat'ng  an 
inflammation  must  be  to  remove  the  exciting  cause.  If  this  cause  is  a  spUnter 
in  the  part,  take  out  the  spHnter;  if  it  is  a  foreign  body  in  the  eye,  remc  /e  the 
foreign  body;  if  urine  is  extra vasated,  open  and  drain;  take  off  pressure  from 
a  corn;  pull  out  an  ingrown  nail;  and  remove  microbes  from  an  infected  area 
by  draining,  irrigating,  and  perhaps  by  applying  antiseptics.  The  rule,  remove 
the  cause,  applies  to  a  chronic  as  well  as  to  an  acute  inflammation.  If  the  cause 
of  an  inflammation  was  momentary  in  action  (as  a  blow),  we  cannot  remove  it,, 
for  it  has  already  ceased  to  exist.  After  removing  the  cause,  endea\  zr  to  bring 
about  a  cure  by  local  and  constitutional  treatment. 

Local  Treatment  of  Inflammation. — It  must  be  remembered  that  the  division 
of  inflammation  into  stages  is  natural,  and  not  artificial,  and  that  a  remedy 
which  does  good  in  one  stage  may  do  harm  in  another.  Certain  agents  are 
suited  to  all  stages  of  an  acute  inflammation,  namely,  rest  and  elevation.  In 
many  inflammatory  conditions  nature  seeks  to  immobilize,  protect,  and  rest 
the  part  by  increasing  the  tension  of  adjacent  muscles.  By  this  muscular 
rigidity  inflamed  joints  are  fixed  and  rested.  Rigidity  of  the  intercostal  mus- 
cles in  pleuritis  limits  chest  motion  and  pain;  rigidity  of  the  abdominal  mus- 
cles in  peritonitis  limits  abdominal  movements  and  lessens  suffering. 

Rest. — Physiological  rest  is  of  infinite  importance,  and  is  always  indicated 
in  acute  inflammation.  In  the  exercise  of  function  blood  is  taken  to  a  part 
and  an  existing  inflammation  is  aggravated.  Further,  as  Billroth  has  pointed 
out,  rest  prevents  the  dissemination  of  infection,  because  motion  exposes 
fresh  surfaces  to  inoculation  and  breaks  down  protective  barriers  of  leuko-' 
cytes.  Its  principles  were  first  thoroughly  studied  by  Hilton.  ^  Baron  Larrey, 
the  celebrated  mflitary  surgeon  of  the  Napoleonic  Empire,  anticipated  many 
modern  views  on  this  subject.  He  insisted  on  the  necessity  of  rest  in  the 
treatment  of  wounds;  he  believed  that  rest  permitted  Nature  to  perform 
1  "Lectures  upon  Rest  and  Pain." 


Local  Bleeding  105 

her  work  unhampered;  he  was  accustomed  to  leave  a  "first  dressing,"  if  prop- 
erly applied,  undisturbed  for  several  or  even  for  many  days.  He  believed  it 
advisable  to  associate  with  rest  well  adjusted  and  judicious  compression  made 
by  bandages,  especially  flannel  bandages.  (The  author,  on  Baron  Larrey, 
in  "Johns  Hopkins  Hospital  Bulletin,"  July,  1906.)  The  means  of  securing 
rest  differ  with  the  structure  or  the  part  diseased.  When  rest  is  used,  do  not 
employ  it  too  long.  Rest  in  bed  diminishes  the  amount  of  blood  sent  to  an 
inflamed  part  and  lessens  the  force  of  the  circulation;  hence  it  antagonizes 
stasis.  It  has  been  shown  that  the  heart  beats  at  least  fifteen  times  per  minute 
less  when  the  patient  is  recumbent  than  when  he  is  erect.  The  saving  of 
strength  and  the  benefit  of  the  local  condition  are  thus  seen  to  be  enormous.  In 
fact,  the  heart  saves  at  least  twenty-one  thousand  beats  a  day.  In  every 
severe  inflammation  insist  on  the  patient  going  to  bed. 

In  cerebral  concussion  rest  must  be  secured  by  quiet,  by  darkness,  by  the 
avoidance  of  stimulants  and  meat,  by  the  application  of  ice  to  the  head,  and 
by  the  use  of  purgatives  to  prevent  reflex  disturbance  and  the  circulation  of 
poisons  in  the  blood.  In  inflamed  joints  rest  must  be  obtained  by  proper 
position,  associated  in  many  cases  with  the  adjustment  of  splints  or  plaster 
of  Paris,  or  the  employment  of  extension. 

In  pleuritis  partial  rest  can  be  secured  by  strapping  the  affected  side  with, 
adhesive  plaster,  or  by  using  a  bandage  or  a  binder  to  limit  respiratory  move- 
ments. In  fractures  Nature  procures  rest  by  her  splints — the  callus — and 
the  surgeon  procures  rest  by  his  splints — firm  dressings  or  extension.  In 
cancer  of  the  rectum  and  intractable  rectitis  a  colostomy  secures  rest  for  the 
inflamed  and  damaged  bowel.  In  enteritis  opium  gives  rest  to  the  bowel  by 
stopping  peristalsis.  In  cystitis  rest  is  obtained  by  the  administration  of  opium 
and  belladonna,  which  paralyze  the  muscular  fibers  of  the  bladder.  The  use 
of  the  catheter  gives  rest  to  the  bladder  by  removing  urine.  A  cystostomy 
allows  complete  rest  by  permitting  the  bladder  to  suspend  its  function  as  a 
reservoir  of  urine.  In  cystitis  from  vesical  calculus  rest  is  obtained  by  incising 
the  bladder,  removing  the  stone,  and  draining,  or  by  crushing  and  evacuating 
the  stone.  In  inflamed  mucous  membrane  rest  from  the  contact  of  irritants  is 
secured  by  touching  the  membrane  with  silver  nitrate,  which  forms  a  protective 
coat  of  coagulated  albumin.  Opening  an  abscess  gives  its  walls  rest  from  ten- 
sion. In  inflammation  of  the  eye  light  must  be  excluded  to  obtain  complete 
rest,  but  tolerably  satisfactory  rest  is  given  in  some  cases  by  the  use  of  glasses 
of  a  peacock-blue  tint.  In  aneurysm  the  operation  of  ligation  cuts  off  the  blood- 
current  and  gives  rest  to  the  sac.  In  hernia  the  operation  gives  rest  from  pres- 
sure.    Instances  of  the  value  of  rest  could  be  multiplied  indefinitely. 

Relaxation  is  in  reality  a  form  of  rest,  and  consists  in  placing  the  part  in  an 
easy  position.  In  synovitis  of  the  knee  semiflexion  of  the  knee-joint  lessens 
the  pain.     In  muscular  inflammation  relaxation  relieves  the  pain. 

Elevation  partly  restores  circulatory  equilibrium.  A  felon  is  less  painful 
when  the  hand  is  held  up  in  a  sling  than  when  it  is  dependent.  A  congestive 
headache  is  worse  during  recumbency.  A  gouty  inflammation  in  the  great  toe 
is  more  painful  with  the  foot  lowered  than  when  it  is  raised.  A  toothache 
becomes  worse  on  lying  down. 

Certain  agents  are  suited  to  the  stage  of  vascular  engorgement,  increased 
arterial  tension,  and  beginning  effusion.  These  agents  are — (i)  local  bleed- 
ing or  depletion;  (2)  cold. 

Local  Bleeding. — Local  bleeding,  or  depletion,  is  the  abstraction  of  blood 
from  the  inflamed  area.  This  abstraction  relieves  circulatory  retardation 
and  causes  the  blood  to  move  rapidly  onward.  The  corpuscles  clinging  to  the 
vessel  walls  are  washed  away,  the  capillaries  shrink  to  their  natural  size,  and 
the  exudate  is  absorbed.  In  other  words,  local  blood-letting  increases  the 
rate  of  the  circulation,  though  not  its  force. 


io6  Inflammation 

The  methods  of  bleeding  locally  are — (a)  puncture;  {b)  scarification;  {c) 
leeching;  {d)  cupping. 

Puncture  is  recommended  in  inflammation,  not  only  because  it  abstracts 
blood  locally,  but  also  because  it  gives  an  exit  to  effusion  under  fibrous  mem- 
branes. It  is  very  useful  in  relieving  tension — for  instance,  in  epididymitis. 
It  is  performed  with  a  tenotome  and  with  aseptic  precautions.  If  numerous 
punctures  are  made,  the  procedure  is  termed  "multiple  puncture."  This  is 
very  useful  when  applied  to  the  inflamed  area  around  a  leg  ulcer.  The  late 
Prof.  Joseph  Pancoast  was  very  fond  of  employing  multiple  punctures, 
designating  the  operation  "the  antiphlogistic  touch  of  the  therapeutic 
knife." 

Scarification  or  Incision. — By  means  of  scarification  we  bleed  locally, 
evacuate  exudate,  and  relieve  tension.  One  cut  or  many  cuts  may  be  made, 
and  these  cuts  may  be  deep  or  may  not  go  entirely  through  the  skin,  according 
to  circumstances.  Multiple  incisions  are  useful  when  applied  to  inflamed 
ulcers,  tissues  in  danger  of  gangrene,  and  to  almost  any  condition  of  great  ten- 
sion. Scarification  is  of  notable  value  when  edema  of  the  glottis  exists.  Free 
incision  is  of  great  benefit  in  periostitis  and  in  threatened  gangrene.  In  osteo- 
myelitis the  medullary  canal  must  be  promptly  opened. 

Leeching. — ^Leeches  must  not  be  applied  to  a  region  plentifully  endowed 
with  loose  cellular  tissue,  as  great  swelling  and  discoloration  are  sure  to  ensue. 
These  regions  are  the  prepuce,  labia  majora,  scrotum,  and  eyelids.  Leeches 
should  never  be  applied  to  the  face  (because  of  the  scar),  near  specific  sores 
or  inflammations,  nor  over  a  superficial  artery,  vein,  or  nerve.  A  leech  is  best 
applied  at  the  periphery  of  an  inflammation  and  between  an  inflammation 
and  the  heart.  To  leech  at  the  inflammatory  focus  only  aggravates  the  trouble. 
Before  apphdng  leeches,  wash  the  part  and  shave  it  if  hairy.  Place  the  leech 
in  a  test-tube  or  an  inverted  wine-glass,  inserting  the  tail  or  thick  end  first, 
and  invert  the  tube  so  that  the  leech's  head  will  come  in  contact  with  the  pre- 
pared skin.  The  leech  is  restrained  in  the  tube  until  it  "takes  hold"  and 
begins  to  feed,  when  the  tube  is  removed.  If  the  leech  will  not  bite,  smear 
the  part  with  milk  or  a  little  blood.  Never  pull  off  a  leech;  let  it  drop  off. 
It  will  usually  drop  off  when  fufl,  but  if  it  refuses  to  do  so,  sprinkle  it  with  salt. 
After  removing  a  leech,  employ  warm  fomentations  if  continued  bleeding  is 
desired.  Sometimes  the  bleeding  persists  or  recurs.  Weill  and  Mouriquand 
("Press.  Medicale,"  Paris,  No.  i,  191 1)  report  6  cases  of  severe  bleeding.  Bleed- 
ing can  usually  be  arrested  by  styptic  cotton  and  pressure.  In  some  rare  cases 
the  bleeding  continues  in  spite  of  pressure.  This  is  due  to  the  fact  that  the 
tissue  contains  a  considerable  quantity  of  a  material  secreted  from  the  throat 
of  the  leech,  which  material  prevents  coagulation  of  blood.  In  such  a  case 
excise  the  bite  and  the  area  of  tissue  adjacent  to  it,  and  suture  the  wound. 
Leeching  leaves  permanent  triangular  scars.  The  Swedish  leech,  which  is 
preferred  to  the  American,  draws  from  2  to  4  drams  of  blood.  After  a  leech  has 
been  removed,  if  we  desire  to  use  it  again,  place  it  in  salt  water.  This  causes  it 
to  vomit  the  blood  which  it  has  taken  up.  Leeching  has  both  a  constitutional 
and  a  local  effect.  It  is  at  present  used  comparatively  rarely,  but  it  is  employed 
by  some  practitioners  over  the  spermatic  cord  in  epididymitis,  on  the  temple  in 
ocular  inflammation,  and  over  the  right  iliac  region  to  relieve  pain  in  mild  cases 
of  appendicitis. 

Cupping. — Dry  cups  deviate  blood  from  a  deeply  placed  inflamed  area  to 
the  surface.     Wet  cups  actually  remove  blood. 

Dry  cups  are  applied  without  first  incising  the  skin.  One  or  more  may  be 
applied.  A  special  instrument  is  sold  in  the  shops  for  the  performance  of  dry 
cupping.  It  consists  of  a  glass  bell,  with  a  globular  and  hollow  top  of  rubber 
(Fig.  49).  The  rubber  is  emptied  of  air  by  squeezing.  The  glass  bulb,  the 
edges  of  which  have  been  greased,  is  pushed  upon  the  skin,  and  the  compression 


Cold  in  Treatment  of  Inflammation  107 

is  relaxed  upon  the  rubber  bulb.     A  partial  vacuum  is  created,  and  an  area  of 
skin  and  subcutaneous  tissue  full  of  blood  rises  into  the  glass  bell. 

Cupping  can  be  easily  performed  by  means  of  a  tumbler.  The  edge  of  the 
glass  is  greased;  a  bit  of  blotting-paper  wet  with  alcohol  is  placed  in  the  bottom 
of  the  tumbler  and  lighted.  After  a  brief  period  the  glass  is  inverted  and  placed 
upon  the  skin,  which  has  been  dampened  with  warm  water.  As  the  air  in  the 
glass  cools  the  tissues  rise  into  the  partial  vacuum. 

Wet  cups  draw  blood,  and  the  skin  should  be  cleansed  before  they  are 
appHed.  In  wet  cupping  apply  a  dry  cup  for  a  moment,  remove  it,  incise  or  punc- 
ture the  skin,  and  replace  the  cup  to  draw  the  requisite  amount  of  blood.  In- 
cisions may  be  made  by  an  ordinary  scalpel,  a  lancet,  or  a  scarificator,  a  cup 
being  then  applied.  An  excellent  scarificator  is  shown  in  Fig.  50.  In  this 
instrument  concealed  blades  are  thrown  out  by  touching  a  spring.  Baron 
Heurteloup  devised  an  instrument  (Fig.  51)  in  which  the  incision  is  marie  by  a 
scarificator.  The  blood  is  drawn  out  by  a  pump,  the 
tube  being  placed  upon  the  cut  area  and  the  withdrawal  of 
the  piston  creating  a  vacuum.  This  instrument  is  known 
as  the  "artificial  leech."  After  scarification  and  the  appli- 
cation of  the  cup,  the  partial  vacuum  draws  blood  into  the 
cup;  when  the  wounds  cease  to  bleed  the  cup  is  removed, 
and  if  further  bleeding  is  thought  desirable,  the  clots  are 
wiped  away  and  the  cup  is  again  applied,  and  after  its 
removal  warm  fomentations  are  used.  Wet  cupping  is  of 
value  in  pleuritis,  pericarditis,  and  nephritis. 

Cold    is    a    very    powerful    and    useful   agent   if    used 
judiciously  and  applied  at  the  proper  time.     It  is  valuable 
because  of  its  reflex  effect  upon  the  vessels  of  the  inflamed     Fig.  49. — Rubber 
area  rather  than  because  of  direct  action  upon  the  cells  of         t»ulb  cupper. 
a  part.     It  should  only  be  used  early  in  the  case,  that  is, 
before  stasis  occurs.     It  is  not  to  be  used  in  the  later  stages  of  inflammation, 
for  it  will  then  only  aggravate  the  existing  state;  in  fact,  when  there  is  con- 
siderable exudation  cold  does  actual  harm. 

Cold  acts  by  constricting  the  vessels  of  a  hyperemic  area,  thus  lessening 
the  amount  of  blood  sent  to  the  part,  and  preventing  the  evolution  of  the  proc- 
ess into  the  stage  of  stasis  and  exudation.  Further,  it  prevents  the  migra- 
tion of  leukocytes,  retards  cell-proliferation,  relieves  pain  and  tension,  and 
lowers  temperature.  If  cold  is  too  intense,  if  it  is  kept  too  long  applied,  if  it 
is  used  too  late  in  an  inflammation,  if  it  is  used  upon  an  old  or  feeble  patient,  or 
if  it  is  employed  when  there  is  much  exudation  or  a  condition  of  tissue  strangu- 
lation, it  does  actual  harm.  It  lessens  the  nutritive  activity  of  cells,  constricts 
the  lymph-spaces  and  channels,  increases  existing  stasis,  hence  lowers  the  vital- 
ity of  the  tissues,  and  may  cause  gangrene.  If  the  parts  are  constricted,  as  in 
strangulated  hernia,  or  if  they  are  compressed  by  a  large  exudate  or  fed  by  dis- 
eased blood-vessels,  or  if  the  patient  is  old  or  exhausted,  cold  is  particularly 
apt  to  cause  gangrene.  Cold  should  not  be  used  in  a  bacterial  inflammation. 
In  such  an  inflammation  it  is  desirable  that  quantities  of  active  leukocytes 
should  come  to  the  part.  These  phagocytes  destroy  bacteria  and  circumscribe 
the  inflammatory  focus.  Cold  keeps  much  blood  and  hence  many  leukocytes 
out  of  the  part,  lessens  the  ameboid  activity,  and  prevents  migration  of  the 
leukocytes  which  do  succeed  in  arriving.  Hence,  cold  actually  favors  the 
spread  of  a  microbic  process.  Furthermore,  it  lessens  leukocytosis  and  thus 
lessens  the  protective  reaction  of  the  tissues.  DeNancrede,  in  his  "Principles 
of  Surgery,"  points  out  that  in  an  inflammation  stasis  soon  arises  at  the  focus 
of  the  inflammation,  and  there  is  an  area  of  stasis  surrounded  by  a  zone  of 
hyperemia.  Cold  benefits  the  hyperemic  zone,  but  aggravates  the  stasis. 
DeNancrede  cautions  us  as  follows:  "Judgment  is,  therefore,  requisite  to  decide 


io8 


Inflammation 


whether  the  evil  at  the  focus  will  not  outweigh  the  good  exerted  at  the  periph- 
ery."^ DeNancrede  further  points  out  that  cold  must  not  be  used  intermit- 
tently; but  if  employed  at  all,  must  be  continuously  appHed.  If  cold  is  apjilied 
intermittently,  there  will  be  a  reaction  whenever  it  is  removed,  and  this  reac- 
tion causes  increased  hyperemia.  Hence,  cold  must  be  "continued  in  action  to 
prevent  reaction."  If  during  the  employment  of  cold  the  skin  becomes  purple 
and  congested  and  the  circulation  feeble,  at  once  discontinue  the  use  of  it,  as 
its  continuance  will  be  dangerous. 

Cold  may  be  used  as  wet  cold  or  as  dry  cold. 

Wet  cold  is  easily  applied,  but  it  is  much  more  depressing  than  dry  cold, 
is  likely  to  produce  discomfort,  macerates  the  skin,  and  may  lead  to  the  forma- 
tion of  excoriations,  etc.  A  part  can  be  subjected  to  wet  cold  by  the  applica- 
tion of  evaporating  fluids  or  the  use  of  a  siphon.  When  wet  cold  is  used  inspect 
the  part  at  frequent  intervals,  and  discontinue  the  treatment  if  evidences  of 
stasis  become  positive.  Evaporating  fluids  are  extensively  employed.  If 
such  a  fluid  is  used,  never  cover  the  part  with  a  thick  dressing.  If  this  should 
be  done,  the  fluid  will  not  evaporate  with  sufficient  rapidity  to  produce  cold. 


Fig.  50. — Scarificator. 


Hcurteloup's  artificial  leech. 


A  piece  of  thin  muslin  or  flannel  should  be  moistened  with  the  fluid  and  laid 
upon  the  part,  and  be  kept  constantly  moist  by  the  application  from  time  to  time 
of  small  quantities  of  the  liquid.  Lead-water  and  laudanum  is  used  extensively, 
and  probably  owes  its  chief  value  to  the  fact  that  it  produces  cold  on  evaporation. 
Lead-water  and  laudanum  is  composed  of  i  oz.  of  laudanum,  i  oz.  of  liquor 
plumbi  subacetatis,  i  pint  of  water.  Liquor  plumbi  subacetatis  dilutus  may 
be  used  without  laudanum.  It  is  thought  that  the  addition  of  laudanum  tends 
to  allay  pain.  Coplin  demonstrated  by  a  series  of  laboratory  experiments 
that  lead-water  and  laudanum  is  a  germicide.  A  solution  of  ammonium 
chlorid  may  be  used  in  the  strength  of  i  oz.  of  the  drug  to  2  quarts  of  water. 
If  ammonium  chlorid  is  used  for  more  than  a  short  period  of  time,  it  is  prone 
to  cause  the  formation  of  blisters,  which  are  irritable  and  painful.  Cheyne 
and  Burghard  use  the  following  formula:  3  2  o^-  of  ammonium  chlorid,  i  oz. 
of  alcohol,  and  7  oz.  of  water.  Plain  spring-water,  iced  water,  or  a  mixture  of 
alcohol  and  water  may  be  used.  The  sip/ion  is  occasionally  used.  If  there  is 
a  wound,  the  fluid  which  comes  in  contact  with  it  must  be  aseptic  or  antiseptic. 
We  may  use  sterfle  water,  sterile  salt  solution,  a  solution  of  boric  acid,  or  a 
solution  of  acetate  of  aluminum.  In  conjunctivitis,  cold  is  applied  to  the  eye 
by  means  of  linen  or  muslin  soaked  in  iced  water,  laid  upon  the  closed  lids,  and 
changed  frequently. 

To  apply  wet  cold  by  means  of  a  siphon,  the  part  is  covered  with  one  layer 
of  wet  linen  or  muslin,  and  is  laid  upon  a  rubber  sheet  folded  like  a  trough  and 
emptying  into  a  bucket.  A  vessel  fiUed  with  cold  water  is  placed  upon  a- 
higher  level  than  the  bed.     A  wet  lamp-wick  is  now  taken,  one  end  is  inserted 

1  "Principles  of  Surgery.'' 


Cold  in  Treatment  of  Inflammation 


109 


into  the  water  of  the  vessel,  and  the  other  end  is  laid  ui)on  the  part.  Capillary 
action  and  gravity  combine  to  keep  the  part  moist.  A  rubber  tube  may  be 
used  instead  of  a  wick.  If  a  tube  is  employed,  tie  it  in  a  knot  or  clamp  "it  so 
that  the  fluid  is  delivered  drop  by  drop  (Fig.  52).  Ordinary  water  or  iced 
water  can  be  used.  If  the  water  be  too  warm,  it  can  be  reduced  to  about  45°  F. 
by  adding  i  part  of  alcohol  to  every  4  parts  of  water,  but  such  a  degree  of 
moist  cold  is  too  intense  for  safety.  A  mixture  of  5  parts  of  nitrate  of  potassium, 
5  parts  of  chlorid  of  ammonium,  and  16  parts  of  water  produces  great  cold, 
but  such  a  degree  of  cold  is  not  useful  surgically,  in  fact  it  is  dangerous. 

Dry  cold  is  more  manageable  and  more  generally  useful  than  wet  cold.  It  is 
applied  by  means  of  a  rubber  bag  or  a  bladder  filled  with  ground  or  finely  cracked 
ice,  several  folds  of  flannel  being  first  laid  over  the  part.  The  flannel  collects 
the  moisture  from  the  "sweating"  bag  and  thus  prevents  maceration  of  the  skin. 
Further,  it  saves  the  tissue 
from  being  subjected  to 
too  much  direct  cold  and 
enables  us  to  obtain  the 
beneficial  reflex  e  fl"  e  c  t. 
The  ice-bag  of  India- 
rubber  is  widely  used.  We 
can  venture  to  apply  by 
means  of  the  ice-bag  a 
greater  degree  of  cold  than 
it  is  proper  to  apply  by  the 
nse  of  fluids,  as  dry  cold  is 
not  so  likely  to  induce 
gangrene  as  is  moist  cold. 
If  there  is  much  tender- 
ness, the  weight  of  an  ice- 
bag  causes  pain,  and  it  is 
best  to  suspend  it  from  a 
frame,  so  that  it  lightly 
touches  the  part.  The 
frame  is  the  same  as  is 
used  to  keep  the  bedclothes 
from  contact  with  a  frac- 
tured leg,  and  can  be  easily 
made  from  barrel-hoops. 
During  the  time  an  ice- 
bag  is  being  used  the  part 
must  be  inspected  at  brief 

intervals  to  see  that  the  circulation  is  not  unduly  depressed.  The  ice-bag 
is  frequently  used  in  joint  inflammation,  in  intracerebral  inflammation,  in 
epididymitis,  in  acute  myelitis,  and  by  many  in  the  earliest  stage  of  appendicitis 
(see  page  1153,  where  the  author  expresses  his  disapproval  of  such  a  method 
of  treatment).  If  a  joint  is  sprained,  the  immediate  application  of  an  ice-bag 
is  of  great  service.  A  part  can  be  encircled  with  a  rubber  tube  through 
which  iced  water  is  made  to  flow  (Fig.  54).  Even  when  this  apparatus  is  used 
the  part  should  first  be  wrapped  in  flannel.  Leiter's  tubes,  which  are  tubes  of 
lead  made  to  fit  various  regions  and  which  carry  a  stream  of  cold  water,  can 
also  be  used.  A  piece  of  flannel  must  be  placed  between  the  tube  and  the 
skin.  The  temperature  of  these  tubes  can  be  lowered  to  any  desired  degree  by 
lowering  the  temperature  of  the  circulating  fluid.  Che^me  and  Burghard 
vvdsely  caution  us  to  use  a  fluid  at  a  temperature  not  under  50°  or  60°  F.,  to 
inspect  the  part  every  three  or  four  hours,  and  not  to  employ  the  tubes  longer 
than  t went v-f our  hours. 


Siphon  (Esmarch). 


no 


Inflammation 


Fig.  S3- — Ice-bag  (W.  E.  Ashton). 


Heat  is  employed  by  some  early  in  an  inflammation.  It  is  rarely  beneficial 
at  this  stage,  except  when  applied  by  a  hot-air  apparatus  for  the  treatment  of 
an  injured  joint.  It  is  true  that  a  degree  of  heat  which  does  not  actually 
destroy  the  tissues  will  contract  the  vessels  as  does  cold;  but  this  degree  of  heat 
will  not  be  borne  by  the  patient  unless  but  a  limited  portion  of  a  superficial 
part  is  involved. 

Certain  agents  are  suited  to  the  stage  of  fully  developed  inflammation, 
when  there  is  a  great  deal  of  swelling  due  to  effusion  and  cell-proliferation. 

The  indication  in  this  stage  is  to 
abate  swelling  by  promoting  absorp- 
tion. This  is  accomplished  by  (i) 
compression;  (2)  local  use  of  astringents 
and  sorbefacients;  (.3)  the  douche;  (4) 
massage;  (5)  heat. 

Compression  is  especially  beneficial 
in  fully  developed  or  in  chronic  in- 
flammation, but  it  will  do  good  even 
in  the  early  stages.  Compression  is 
of  great  usefulness;  it  supports  the  vessels  and  causes  them  to  drink  up 
effusion,  and  it  strongly  rouses  the  absorbents.  This  agent  is  valuable  in  most 
external  inflammations  with  marked  swelling,  and  is  particularly  beneficial 
in  chronic  inflammation.  In  erysipelas  of  an  extremity  the  part  should  be 
elevated  and  the  extremity  bandaged  from  the  periphery  to  the  body.  In 
ulcers,  especially  those  with  hard  and  blue  edges,  the  use  of  Martin's  elastic 
bandage  or  of  straps  of  adhesive  plaster  gives  decided  relief.  In  chronic  in- 
flammation of  a  joint  elastic  compression  is  of  great  value.  In  epididymitis, 
after  the  acute  stage,  the  testicle  may  be  strapped  with  adhesive  plaster.  In 
Ivmphadenitis  compression  by  a 
weight  or  by  a  bandage  is  very 
generaUy  employed.  In  frac- 
tures compression  not  only  an- 
tagonizes spasm,  but  also  com- 
bats the  swelling  and  pain  of 
inflammation.  Compression 
must  be  judicious;  it  must  never 
be  forcible,  and  it  must  not  be 
applied  to  a  limb  without  in- 
cluding the  distal  portion  of 
the  extremity  (never,  for  in- 
stance, strongly  compress  the 
elbow  without  including  the 
hand,  nor  the  palm  without 
bandaging  the  fingers).  In- 
judicious compression  causes 
severe  pain  and  great  edema, 
and  may  produce  gangrene. 

Astringents  and  Sorbefaci- 
ents.— Astringents  may  have 
direct    value   in    inflammation  _ 

of  the  skin,  but  it  is  not  Ukely  that  they  have  any  ettect  on  deep-seated 
inflammation.  When  used  in  evaporating  lotions  in  an  earlier  stage  of  m- 
flammation  the  cold  does  good  rather  than  the  drug.  Lead-water  and 
laudanum  is  extensively  emploved  and  it  is  thought  to  allay  somewhat  mflam- 
matorv  pain.  The  mixture  certainlv  gives  comfort  in  cutaneous  erysipelas. 
It  is  very  doubtful  if  lead-water  is  of  any  service  at  any  stage  of  a  deep-seated 
inflammation  or  in  any  fully  developed  inflammation.     If  used  after  the  first 


Fig.   ^4.. — The  Esmarch  cooling  coil. 


Douche  in  Treatment  of  Inflammation  iir 

stage  it  must  not  be  applied  as  an  evaporating  lotion,  because  cold  will  do 
harm.  Pieces  of  lint  are  soaked  in  the  fluid  and  placed  upon  the  part,  and  a 
bandage  is  apphed.  The  wet  lint  which  has  been  placed  upon  the  part  is  cov- 
ered with  oiled  silk  or  a  rubber-dam  before  the  bandage  is  applied.  If  used  in 
the  latter  manner,  the  body-heat  is  retained  in  the  part.  If  greater  heat  is 
required,  a  hot-water  bag  can  be  placed  outside  of  the  bandage.  Lead-water, 
though  germicidal,  is  seldom  used  in  treating  wounds,  and  hot  lead-water 
should  not  be  applied  to  an  area  of  cutaneous  inflammation,  as  heat  increases 
congestion  and  does  harm  to  a  cutaneous  inflammation. 

Saturated  watery  solution  of  Epsom  salt  is  of  real  value  in  inflammation. 
It  is  applied  as  a  wet  compress  covered  with  rubber-dam.  It  is  moistened 
every  two  or  three  hours  and  renewed  in  twenty-four  hours,  the  skin  being 
washed  at  the  time  of  renewal.  In  many  cases  it  allays  pain  and  abates  swell- 
ing. Its  use  was  suggested  by  Tucker  ("Jour.  Experimental  Med.,"  May  25, 
1907). 

Tincture  of  iodin  is  astringent,  sorbefacient,  counterirritant,  and  germicidal. 
It  must  not  be  used  pure.  For  application  to  adults  it  should  be  diluted  with 
an  equal  amount  of  alcohol,  and  for  children  with  3  parts  of  alcohol.  In  using 
iodin,  paint  it  upon  the  part  with  a  camels'-hair  brush  and  fan  it  dry,  applying 
one  or  more  coats.  The  repeated  application  of  iodin  to  the  skin  is  of  great 
benefit  in  inflammation  of  the  glands,  muscles,  tendons,  joints,  and  perios- 
teum, iodin  is  apt,  after  a  time,  to  vesicate,  and  must  not  be  used  in  full 
strength,  because  it  is  irritant.  It  is  of  special  value  in  chronic  inflammation. 
In  deep-seated  inflammation  it  acts  as  a  counterirritant. 

Nitrate  of  silver  is  a  non-irritating  astringent  of  considerable  value  in  inflam- 
mation of  mucous  membranes.  It  forms  a  protective  coat  of  coagulated  albu- 
min, and  is  much  used  in  treating  the  throat,  mouth,  and  genital  organs.  In 
urethral  inflammation  a  protein  compound  of  silver  known  as  protargol  may  be 
used. 

Ichthyol  is  a  drug  of  decided  efficiency  in  reducing  inflammatory  swelling. 
It  is  usually  employed  in  ointments,  the  strength  being  from  25  to  50  per  cent. 
It  is  best  exhibited  with  lanoHn.  When  rubbed  in  over  inflamed  glands, 
joints,  and  lymphatic  enlargements,  it  is  of  great  value.  In  children  a  25  per 
cent.,  and  in  adults  a  50  per  cent.,  ointment  should  be  rubbed  in  thoroughly 
twice  a  day.  In  inflammatory  skin  disease,  synovitis,  thecitis,  frost-bite, 
bubo,  chilblain,  and  in  many  other  conditions,  acute  or  chronic,  the  use  of 
ichthyol  is  indicated.  The  odor  of  ichthyol  is  highly  disagreeable,  and  when 
ordered  for  a  refined  person  it  had  better  be  deodorized.  For  this  purpose 
Hare  uses  oil  of  citronella,  20  minims  to  i  oz.  of  ointment. 

Mercurials. — Blue  ointment,  pure  or  dfluted  to  various  strengths,  is  ex- 
tremely valuable.  It  is  spread  upon  lint  and  kept  apphed  over  areas  of  fully 
developed  inflammation.  It  is  especially  useful  in  periostitis  and  in  acutely 
or  chronicahy  inflamed  joints,  glands,  tendons,  etc.  Blue  ointment  is  strongly 
irritant,  and  will  soon  blister  or  excoriate  a  tender  skin. 

The  douche  consists  of  a  stream  of  water  falling  upon  a  part  from  a  height. 
The  water  may  be  poured  from  a  receptacle  or  may  run  through  a  tube,  and 
may  be  either  hot  or  cold.  Alternating  hot  and  cold  streams  are  very  popular 
in  inflammations  of  joints  and  tendons,  especially  in  chronic  inflammation. 
This  mode  of  application  is  known  as  the  "Scotch  douche."  It  restores  the 
tone  of  the  blood-vessels  and  plasma-channels  and  promotes  the  absorption  of 
inflammatory  exudate.  If  the  part  is  very  tender,  the  water  should  be  squeezed 
upon  it  from  sponges.  In  a  sprain  of  a  joint,  after  a  time,  when  thickening 
has  occurred,  pour  upon  the  part  daily  from  a  height,  first  a  pitcherful  of  very 
warm  water,  then  a  pitcherful  of  very  cold  water;  then  dry  the  part  and  use 
friction  with  a  hand  greased  with  cosmolin.  Hot  vaginal  douches  are  generahy 
employed  in  pelvic  inflammations  of  women. 


112  Inflammation 

Massage  is  a  procedure  not  employed  frequently  enough.  It  is  very  useful 
in  some  acute  inflammations,  though  in  these  it  must  be  gentle.  It  is  of  great 
service  in  the  treatment  of  sprains  of  joints  and  fractures  of  bones.  It  is  in- 
fluential for  good  in  chronic  inflammations  at  the  period  when  rest  is  aban- 
doned. It  acts  by  promoting  the  movements  of  tissue-fluids  (blood,  Ivmph, 
and  areolar  fluid),  stimulating  the  absorbents,  strengthening  local  nervous 
control,  and  thus  improving  nutrition.  Passive  motion  in  joints  acts  as 
massage. 

Heat  may  be  used  continuously  or  intermittently,  and  may  be  either 
moist  or  dry.  A  considerable  degree  of  heat  will  act  like  cold  and  contract 
the  vessels.  The  degree  necessary  to  cause  vascular  contraction  would  not 
destroy  the  tissue,  but  would  produce  discomfort,  which  would  become  un- 
bearable discomfort  during  the  continuance  of  the  application.  Therefore, 
heat  is  rarely  used  in  the  earliest  stage  of  an  acute  inflammation.  It  is  hard 
to  state  exactly  when  heat  should  be  substituted  for  cold.  Certainly  when 
retardation  and  stasis  are  manifest  it  is  to  be  preferred.  Heat  should  be 
used  when  inflammation  is  not  very  superficial.  In  a  cutaneous  inflammation 
heat  usually  does  harm,  because  it  increases  the  congestion  of  an  inflamed 
superficial  part.  In  deep-seated  inflammations  heat  to  the  surface  acts  a.s 
a  revulsive  or  counterirritant.  Thus  a  poultice  to  the  chest  may  do  good 
in  the  first  stage  of  pneumonia  and  cauterization  of  the  skin  near  a  joint  may 
benefit  an  acute  synovitis.  The  use  of  heat  for  purposes  of  counterirrita- 
tion  will  be  discussed  under  the  head  of  Counterirritants.  A  moderate  de- 
gree of  heat  applied  over  a  fully  developed  and  not  too  superficial,  inflamed 
area  dilates  the  vessels,  especially  the  veins,  of  the  skin  and  superficial  tissues. 
Thus  circulation  is  re-established  in  an  area  filled  with  stagnant  blood  or 
blood  which  is  scarcely  moving  and  the  inflamed  region  is  drained,  fluid  exu- 
date is  absorbed,  tension  is  lessened,  the  lymph-spaces  and  vessels  distend, 
and  lymphatic  absorption  becomes  active.  The  application  of  heat  increases 
the  ameboid  activity  and  the  migratory  tendency  of  the  leukocytes,  phago- 
cytes gather  in  great  numbers  and  surround  an  area  of  infection,  and  those 
which  have  taken  up  bacteria  or  tissue  debris  hurry  away.  Heat  also,  in  all 
probability,  causes  antibodies  to  escape  from  the  leukocytes  and  enter  the 
blood-serum.  Furthermore,  heat  favors  leukocytosis.  Thus,  we  see,  that  heat 
tends  to  help  the  building  of  protective  barriers  about  an  area  of  infection  and 
aids  the  protective  reactions  of  the  body.  Heat  notably  lessens  the  pain  of 
inflammation.     It  is  often  used  purely  to  relieve  pain. 

The  forms  of  heat  are — (i)  fomentations;  (2)  poultices;  (3)  water-bath; 
(4)  dry  heat. 

Fomentation  is  the  application  to  the  skin  of  a  piece  of  flannel  containing 
a  hot  liquid.  A  basin  is  warmed  and  over  the  top  of  the  basin  a  towel  is  placed. 
A  piece  of  flannel  folded  in  two  or  three  thicknesses  is  laid  upon  the  towel  and 
boiling  water  is  poured  upon  it.  By  twisting  the  towel  the  water  is  squeezed 
out  of  the  flannel.  Great  care  must  be  taken  to  squeeze  the  water  thoroughly 
out  of  the  flannel,  otherwise  the  skin  may  be  scalded.  The  hot  flannel  is  laid 
upon  the  skin  over  the  disordered  part.  A  rubber-dam  larger  than  the  flannel 
is  placed  over  it,  a  mass  of  cotton  is  laid  upon  the  rubber-dam,  and  a  bandage 
is  applied.  The  fomentation  must  be  changed  within  an  hour  unless  a  hot- 
water  bag  has  been  placed  outside  the  bandage,  in  which  case  it  need  not  be 
changed  for  two  hours  or  more.  The  flannel  which  is  dipped  into  the  hot 
liquid  is  known  as  a  "stupe."  The  turpentine  stupe  is  made  by  wringing  out 
the  flannel  as  above  and  then  putting  upon  it  from  10  to  20  drops  of  turpentine. 
Instead  of  fomenting  the  part,  steam  may  be  thrown  upon  it.  Fomentations 
are  used  chiefly  for  their  reflex  influence  over  deep  congestions  or  inflamma- 
tions. The  liquid  of  a  fomentation  may,  if  desired,  contain  corrosive  sublimate, 
carbolic  acid-,   or  other  agents.     A  fomentation   containing  an  antiseptic   is 


Heat  in  Treatment  of  Inflammation  113 

known  as  an  antiseptic  fomentation.  An  antiseptic  fomentation  or,  as  it  is  often 
called,  an  antiseptic  poultice  is  made  and  applied  as  follows:  Sterile  gauze  is 
used  instead  of  flannel,  and  is  laid  upon  the  towel  over  the  basin  as  previously 
described.  A  very  warm  solution  of  corrosive  sublimate  (i  :  1000),  of  concen- 
trated boric  acid  solution,  or  a  2  per  cent,  solution  of  acetate  of  aluminum,  is 
poured  upon  the  gauze,  the  material  is  partly  wrung  out,  placed  upon  the  part, 
covered  with  a  rubber-dam,  and  upon  it  a  hot-water  bag  is  placed.  Fomenta- 
tions are  very  useful  in  relieving  pain  in  any  stage  of  an  inflammation  and  act 
also  as  counterirritants.  Fomentations  are  used  in  preference  to  ordinary 
poultices  if  there  is  any  probability  of  a  surgical  operation  becoming  neces- 
sary, because  skin  to  which  an  old-fashioned  poultice  has  been  applied  cannot 
be  satisfactorily  sterilized.  The  antiseptic  fomentation  is  of  great  service  in 
removing  sloughs  from  foul  wounds  and  ulcers.  It  is  the  only  form  of  poultice 
which  is  admissible  when  the  skin  is  broken. 

Poultice  or  Cataplasm. — A  poultice  is  a  soft  mass  applied  to  a  part  to  bring 
heat  and  moisture  to  bear  upon  it.  Poultices  can  be  made  of  ground  flaxseed, 
of  shppery-elm  bark,  of  arrowroot,  starch,  bread  and  milk,  potatoes,  turnips, 
etc.  The  poultice  should  be  placed  upon  the  part  and  be  covered  outside  with 
oiled  silk,  a  rubber-dam,  or  waxed  paper.  A  mass  of  cotton  is  applied  outside 
of  the  rubber  and  the  poultice  is  held  in  place  by  a  bandage  or  binder.  It  can 
be  kept  very  warm  for  a  considerable  period  by  placing  upon  it  a  bag  filled 
with  hot  water.  If  a  hot-water  bag  is  not  employed,  a  poultice  should  be 
changed  every  two  hours.  Spongiopilin,  when  moistened  with  hot  water,  is  a 
good  substitute  poultice.  Lint  soaked  with  hot  water  and  covered  with  some 
impermeable  material  does  very  well.  A  poultice  containing  opium  is  known  as 
a  "sedative"  poultice.  About  2  gr,  of  opium  to  the  ounce  of  poultice-mass 
may  relieve  pain.  Flaxseed  is  a  vegetable  material,  adheres  to  the  skin,  enters 
the  mouths  of  glands  and  follicles,  undergoes  decay,  can  be  removed  only  with 
great  difficulty,  and  is  a  very  objectionable  material  to  use  if  there  is  any 
breach  of  surface  continuity  or  if  it  is  possible  that  an  incision  will  be  required. 
The  preparation  of  an  antiseptic  potdtice  or  fomentation  is  described  above. 
Poultices  m.ust  not  be  kept  on  the  part  too  long,  as  they  will  cause  vesication, 
especially  in  adynamic  conditions.  If  a  poultice  is  causing  vesication,  remove 
it  and  do  not  replace  it,  or  replace  it  after  sprinkling  the  part  and  the  poultice 
with  powdered  oxid  of  zinc.  If  suppuration  exists  or  is  seriously  threatened, 
do  not  waste  time  by  using  poultices,  but  incise  at  once.  Incision  may  prevent 
suppuration  by  relieving  tension,  affording  drainage,  and  permitting  the  local 
use  of  antiseptics.  If  pus  exists,  it  cannot  be  evacuated  too  soon.  To  use 
poultices  and  delay  incision  is  often  productive  of  irreparable  harm.  After 
incision  of  a  purulent  focus  it  is  common  practice  to  apply  an  antiseptic  fomen- 
tation in  order  to  draw  quantities  of  leukocytes  to  the  part  and  thus  limit  the 
spread  of  infection  and  stimulate  granulation. 

Hot-water  Bath. — The  immersion  of  a  part  in  a  continuous  warm  bath  is  now 
rarely  advised  except  in  burns  and  cases  of  phagedena.  In  such  cases  it  often 
proves  curative.  An  antiseptic  agent  may  be  dissolved  in  the  water.  Con- 
tinuous immersion  in  a  warm  bath  is  regarded  favorably  by  some  surgeons  for 
the  treatment  of  sloughing  wounds  and  large  purulent  areas.  The  immersion 
of  a  part  from  time  to  time  in  water  as  hot  as  can  be  tolerated  is  useful  in  fully 
developed  and  in  chronic  inflammation.  Such  immersion  benefits  an  inflamed 
joint,  lessening  the  pain,  swelling,  and  stiffness. 

Dry  heat' is  applied  by  a  metallic  object  dipped  in  hot  water  and  laid  upon 
the  part;  by  Leiter's  tubes,  through  which  hot  water  flows;  by  the  hot-water 
bag  or  by  the  hot-air  apparatus.  Some  surgeons  use  the  hot-water  bag  in 
cases  of  mild  appendicitis  in  order  to  favor  the  limitation  of  the  area  of  infec- 
tion. The  hot-water  bag  is  often  soothing  and  beneficial  when  laid  upon  an 
inflamed  joint,  or  on  the  perineum  or  the  hypogastric  region  in  cystitis.     A 


114  Inflammation 

bag  of  hot  sand,  a  hot  brick,  or  a  bottle  or  can  of  hot  water  may  be  used  instead 
of  the  water-bag.  The  hot-air  apparatus  is  of  very  great  service  in  the  treat- 
ment of  chronic  inflammation,  and  particularly  of  inflamed  joints  (vide  dry  hot- 
air  apparatus). 

Treatment  When  Suppuration  is  Threatened. — When  suppuration  is  threat- 
ened, ordinarily  hot  fomentations  or  antiseptic  fomentations  must  be  used,  and 
the  part  must  be  kept  at  rest.  As  previously  explained,  the  flaxseed  poultice 
is  inadmissible.  When  suppuration  is  threatened,  the  use  of  heat  causes  the  col- 
lection of  multitudes  of  leukocytes,  which  tend  to  limit  the  area  of  infection 
and  destroy  bacteria.  Even  when  suppuration  is  not  prevented,  heat  aids  in 
the  rapid  breaking  down  of  the  diseased  tissue  at  the  focus  of  the  inflammation 
and  causes  hordes  of  leukocytes  to  gather  and  encompass  the  suppurating  tissue, 
and  these  leukocytes  prevent  the  spread  of  the  infection. 

In  most  cases,  when  suppuration  is  obviously  inevitable  or  seriously  threat- 
ened, a  free  incision  will  be  of  greatest  benefit. 

Irritants  and  Counterirritants  in  Inflammation. — Irritants  attract  an  in- 
creased supply  of  blood  to  the  part  whereon  they  are  applied,  and  are  used 
for  their  local  effects.  Counterirritants  are  used  to  affect  by  reflex  influence 
some  distant  part.  In  chronic  inflammation  irritants  may  do  good  by  pro- 
moting the  blood-supply,  thus  favoring  the  removal  of  exudates  (nitrate  of 
silver  for  indolent  ulcers).  Counterirritants  are  powerful  pain-relievers 
when  used  over  an  inflamed  structure;  they  bring  blood  to  the  surface,  and 
are  thought  by  many  writers  to  cause  anemia  of  internal  parts,  the  site 
and  area  of  anemia  depending  on  the  site,  the  area,  and  the  duration  of  the 
surface  irritation.  Some  recent  studies  seem  to  suggest  that  counterirrita- 
tion  produces  hyperemia  of  the  superficial  part,  compensatory  anemia 
of  surrounding  regions,  and  anemic  edema  of  the  subcutaneous  tissue  and 
muscles  _(W.  Wecksberg,  "Zeit.  f.  klin.  Med.,"  Bd.  xxxvii,  H.  3  u.  4). 
Nancrede  dissents  from  the  statement  that  counterirritants  cause  anemia  of 
internal  parts;  and  he  maintains  that  they  irritate  deeper  parts  and  cause  more 
external  blood  to  be  taken  to  them.  He  claims  that  a  blister  applied  to  the 
chest  produces  a  hyperemic  area  in  the  pleura,  and  refers  to  Furneaux  Jordan's 
opinion  that  direct  irritation  to  the  surface  over  a  joint  adds  to  synovial  hypere- 
mia, and  that  consequently  in  joint  inflammation  counterirritants  should  be 
applied  above  and  below  a  joint,  but  not  directly  over  it.  As  a  matter  of  fact, 
we  know  clinically  that  powerful  counterirritation  directly  over  an  inflamed 
superficial  joint  is  occasionally  followed  by  an  aggravation  of  the  trouble,  and 
that  in  pericarditis  blistering  directly  over  the  pericardium  may,  as  pointed 
out  by  Sir  Lauder  Brunton,  make  the  condition  worse.  Counterirritants  not 
only  relieve  pain  in  the  earlier  stages  of  inflammation,  but  they  also  promote 
absorption  of  exudate  in  the  later  stages,  and  are  particularly  valuable  in 
chronic  inflammations.  Great  benefit  is  obtained  by  bUstering  old  thickened 
ulcers,  and  by  painting  the  chest  with  iodin  to  relieve  pleuritic  effusion. 
Frictions,  besides  their  pressure  effects,  act  as  counterirritants.  Frictions  may 
relieve  skin  pain,  and  are  associated  with  the  appHcation  of  stimulating  liniments 
in  the  treatment  of  stiff  joints.  A  mustard  plaster  is  a  valuable  counterirritant 
in  an  acute  deeply  seated  inflammation.  Tincture  of  iodin  is  extensively  used 
in  chronic  inflammation. 

There  is  no  more  efficient  nonoperative  method  of  reUeving  pleural  effusion 
than  by  the  application  of  a  succession  of  bhsters.  Blisters  are  also  used  in  the 
treatment  of  inflamed  joints,  pericarditis,  pneumonic  consolidation  of  the  lung, 
acute  and  chronic  rheumatism,  etc. ;  and  are  applied  back  of  the  ears  or  at  the 
nape  of  the  neck  in  congestive  coma  or  meningitis.  A  blister  can  be  produced  in 
a  few  minutes  by  soaking  a  bit  of  lint  in  chloroform,  and  after  applying  it  to  the 
surface,  covering  it  with  ofled  silk  or  with  a  watch-glass.  Equal  parts  of  lard 
and  ammonia  will  bUster  in  five  minutes.     It  is  easier  to  blister  with  cantharidal 


General  Bleeding,  Venesection,  or  Phlebotomy  115 

collodion  or  blistering  paper.  Before  applying  a  blister,  shave  the  part  if  it 
be  hairy;  then  grease  the  plaster  with  olive  oil  and  apply  it.  Blistering  plaster 
is  left  in  place  six  hours  in  the  case  of  an  adult,  but  only  two  hours  in  the  case 
of  an  old  person  or  a  child;  the  plaster  is  then  removed,  and  if  a  blister  has  not 
formed,  the  part  must  be  poulticed  for  a  few  hours.  When  a  blister  is  obtained, 
open  it  with  a  needle  which  has  been  dipped  in  boiling  water.  If  the  surgeon 
wishes  the  blister  to  heal,  it  should  be  covered  with  a  piece  of  lint  smeared  with 
cosmolin  or  with  zinc  ointment.  If  it  is  to  be  kept  open  for  a  time,  cut  away 
the  stratum  corneum  and  dress  with  cosmolin,  each  ounce  of  which  contains 
6  drops  of  nitric  acid. 

Pustulation  can  be  effected  with  tartar-emetic  ointment  or  with  Vienna 
paste.  Tartar-emetic  ointment  was  formerly  used  on  the  scalp  in  meningitis. 
It  consists  of  I  part  of  tartar  emetic  to  5  parts  of  simple  ointment.  Vienna 
paste  consists  of  5  parts  of  caustic  potash  and  6  parts  of  lime  made  into 
a  paste  with  alcohol.  It  is  applied  for  five  minutes,  and  is  then  washed  off 
with  vinegar. 

The  actual  cautery  is  the  most  powerful  of  counterirritants.  It  is  chiefly 
used  in  chronic  inflammation  of  joints,  bones,  nerves,  and  the  spinal  cord.  The 
application  is,  of  course,  very  painful,  and  it  is  best  to  give  an  anesthetic  before 
using  the  cautery.  The  Paquelin  cautery  is  the  instrument  used.  This  is  a 
hollow  platinum  point  which,  after  being  heated  in  the  flame  of  an  alcohol  lamp, 
is  kept  hot  by  forcing  through  it  the  vapor  of  gasolene  (Fig.  257).  The  point 
is  used  at  a  white  heat.  One  area  or  several  may  be  seared.  The  cautery  is 
drawn  lightly  two  or  three  times  over  each  spot  we  wish  to  burn.  The  object 
is  to  destroy  only  the  superficial  layers  of  the  skin.  After  the  cauterization  is 
completed,  lint  wet  with  iced  water  is  applied  for  several  hours  to  allay  pain, 
and  then  hot  antiseptic  fomentations  are  used  until  the  slough  separates. 

If  the  wish  is  to  prevent  healing  after  separation  of  the  slough,  dress  the  sore 
with  cosmolin,  each  ounce  of  which  contains  6  drops  of  nitric  acid.  It  is  not 
wise  to  cauterize  deeply  directly  over  a  superficial  joint. 

Constitutional  Treatment  of  Inflammation. — Certain  remedies  are  used  in 
inflammation  for  their  general  or  constitutional  effects;  these  remedies  are — (i) 
general  bleeding;  (2)  arterial  sedatives;  (3)  cathartics;  (4)  diaphoretics;  (5) 
diuretics;  (6)  anodynes;  (7)  antipyretics;  (8)  emetics;  (9)  mercury  and  iodids; 
(10)  stimulants;  (11)  tonics. 

General  Bleeding,  Venesection,  or  Phlebotomy. — Venesection  is  suited  to 
the  early  stages  of  an  acute  inflammation  in  a  young  and  robust  subject.  The 
indication  for  its  employment  is  increased  arterial  tension,  as  shown  by  a  strong, 
full,  rapid,  and  incompressible  pulse  in  a  vigorous  young  patient.  General 
blood-letting  diminishes  blood-pressure  and  increases  the  speed  of  the  blood- 
current,  thus  amends  stasis,  causes  the  absorption  of  exudate,  and  the  washing 
of  adherent  white  corpuscles  from  the  vessel  wall;  furthermore,  it  reduces  the 
whole  amount  of  body  blood  and  thus  forces  a  greater  rapidity  of  circulation, 
decreases  the  amount  of  fibrin  and  albumin,  lowers  the  temperature,  arrests 
cell-proliferation,  and  stops  effusion. 

This  procedure  was  in  former  days  so  highly  esteemed  that  it  settled  mto 
a  routine  formula  to  be  applied  to  every  condition  from  yellow  fever  to  dislo- 
cation. The  terrible  mortahty  of  the  cholera  epidemics  from  1830  to  1835  led 
practitioners  to  question  the  behef  that  bleeding  was  a  general  panacea,  and 
from  this  doubt  there  was  born  in  the  next  generation  violent  opposition  to 
blood-letting  in  any  disease.  Like  most  reactions,  opposition  has  gone  too  far, 
the  pendulum  of  condemnation  has  swung  beyond  the  line  of  truth  and  sense, 
and  thus  a  powerful  and  valuable  resource  is  neglected  universally  and  condemned 
unsparingly.  Many  physicians  of  long  experience  have  never  seen  a  person 
bled;  its  performance  is  not  demonstrated  in  most  schools,  and  few  patients 
and  families  will  permit  it  to  be  done;  but  when  properly  used  it  may  be  very 


ii6  Inflammation 

beneficial.  It  is  applicable,  however,  only  to  the  young,  strong,  and  robust, 
and  not  to  the  old,  weak,  or  feeble.  It  is  used  for  violent  acute  inflammations 
of  important  organs  or  tissues,  and  not  for  low  inflammations  or  for  slight 
affections  of  unimportant  parts.  It  is  used  in  the  early,  but  not  in  the  late, 
stages  of  an  inflammation.  It  is  used  when  the  pulse  is  frequent,  full,  hard, 
and  incompressible,  but  not  when  it  is  slow,  small,  soft,  compressible,  and 
irregular.  It  is  used  when  the  face  is  flushed,  but  not  when  it  is  pallid.  It  is 
not  used  in  fat  persons,  drunkards,  very  nervous  people,  or  the  sufferers  from 
ad>Tiamic,  septic,  or  epidemic  diseases.  It  is  of  value  in  some  few  cases  of 
congestion  of  the  lungs,  pneumonitis,  pleuritis,  meningitis,  nephritis,  prostatitis, 
cystitis,  and  other  acute  inflammatory  conditions.  It  is  particularly  valuable 
in  any  subject  when  uremia  exists,  or  when  there  is  distention  of  the  right  side 
of  the  heart.     The  method  of  bleeding  is  described  on  page  528. 

After  bleeding  the  patient  should  be  put  on  arterial  sedatives,  diuretics, 
diaphoretics,  anod\Ties,  and,  if  necessary,  purgatives.  A  favorite  mixture  of 
Prof.  S.  D.  Gross  was  the  antimonial  and  saline,  40  gr.  of  Epsom  salt,  3-1 0  gr. 
of  tartar  emetic,  2  drops  of  tincture  of  aconite,  and  i  dram  of  sweet  spirits  of 
niter,  in  enough  ginger  syrup  and  water  to  make  3^  oz.;  given  every  four  hours. 

Arterial  Sedatives.'- — Drugs  of  this  character  are  of  great  use  before  stasis 
is  pronounced;  but  if  used  after  stasis  is  established  they  will  increase  it.  If 
stasis  exists  it  may  be  relieved  by  blood-letting,  local  or  general,  and  then 
arterial  sedatives  can  be  given.  Either  local  bleeding  or  venesection  abolishes 
stasis  and  lowers  tension,  and  arterial  sedatives  maintain  the  effect  and  hold 
the  ground  which  is  gained.  The  arterial  sedatives  employed  are  aconite, 
veratrum  \aride,  gelsemium,  and  tartar  emetic.  These  sedatives  lessen  the 
force  and  the  frequency  of  the  heart-beats,  and  thus  slow  and  soften  the  pulse, 
and  are  suited  to  a  robust  person  with  an  acute  inflammation,  but  are  not 
suited  to  a  weak  individual  in  an  ad\Tiamic  state. 

Aconite  is  given  in  small  doses,  never  in  large  amounts.  One  drop  of  the 
tincture  in  a  little  water  is  given  every  half  hour  until  its  effect  is  manifest  on 
the  pulse,  when  it  may  be  given  every  two  or  three  hours.  Large  doses  of 
aconite  produce  pronounced  depression,  and  are  dangerous.  Aconite  lowers 
the  temperature,  slows  the  pulse,  and  produces  diaphoresis. 

Veratrum  viride  is  a  powerful  agent  to  slow  the  pulse  and  to  lower  blood- 
pressure;  it  produces  moisture  of  the  skin,  and  often  nausea.  It  is  given  in 
i-drop  doses  of  the  tincture  every  half  hour  until  its  physiologic  effects  are 
manifested,  when  the  period  between  doses  is  extended  to  two  or  three  hours. 
Ten  drops  of  laudanum  given  a  quarter  of  an  hour  before  each  dose  of  veratrum 
viride  will  prevent  nausea. 

Gelsemium  is  an  arterial  sedative.  It  is  given  in  doses  of  5  to  10  drops  of 
the  tincture  every  three  or  four  hours. 

Tartar  emetic  lowers  arterial  tension  and  lessens  the  pulse-rate.  This  drug 
is  not  generaUy  employed;  if  it  is  used  with  the  greatest  care  it  is  no  better 
than  some  other  agents,  and  if  it  is  not  so  used  it  will  cause  dangerous  depres- 
sion. The  dose  is  from  }y4o  to  If  0  gr-,  given  in  water  every  three  hours  until 
the  physiological  effects  are  manifest. 

Cathartics. — Purgation  is  of  great  value  in  inflammation.  By  it  putrid 
material  is  removed  from  the  intestine,  fluid  containing  poisonous  elements 
is  drawn  from  the  blood,  and  the  liabiHty  to  infection  of  the  tissues  is  lessened. 
Purgation  is  a  powerful  aid  in  removing  serous  efl'usions  and  other  exudates. 
The  administration  of  purgatives  is,  of  course,  not  to  be  a  routine  procedure 
in  inflammatory  states.  The  bowels  may  be  acting  so  freely  that  no  cathartic 
is  required.  Treatment  in  an  inflammation  should  be  inaugurated,  if_  consti- 
pation exists,  by  giving  a  cathartic.  The  tongue  affords  important  indications 
as  to  the  necessity  for  purgation.  Castor  oil  can  be  given  in  capsules,  or  in  the 
froth  of  beer,  or  the  juice  of  half  a  lemon  is  squeezed  into  a  tumbler,  i  oz.  of  oil 


Anodynes  and  Hypnotics  117 

poured  in,  and  the  rest  of  the  lemon  is  squeezed  on  top,  thus  making  a  not 
unpalatable  mixture.  Aloin,  podophyllum,  the  salines,  and  calomel  in  3- 
or  5-gr.  doses,  followed  by  a  saline,  have  their  advocates.  In  threatened 
peritonitis  the  salines  are  used  by  some  surgeons,  a  teaspoonful  of  Epsom 
salt  and  a  teaspoonful  of  Rochelle  salt  being  given  hourly  until  a  movement 
occurs.  In  this  condition,  however,  purging  may  prove  disastrous.  In  the 
course  of  inflammation,  from  time  to  time,  if  there  be  constipation,  a  coated 
tongue,  and  foulness  of  the  breath,  there  should  be  ordered  i  gr.  of  calomel 
with  24  gr.  of  bicarbonate  of  sodium,  made  into  twelve  powders,  one  being  given 
every  hour;  if  the  bowels  are  not  moved  by  the  time  the  powders  are  all  taken, 
a  saline  should  be  given.  If  a  violent  purgative  effect  is  desired,  as  in  menin- 
gitis, croton  oil  or  elaterium  may  be  ordered.  If  constipation  is  persistent,  give 
fluidextract  of  cascara  sagrada  daily  (20  to  40  drops),  or  a  pill  at  night  contain- 
*  ing  3^4  gr.  of  extract  of  belladonna,  3^^  gr.  of  extract  of  nux  vomica,  ^^^q  gr.  of 
aloin,  3^4  gr.  of  extract  of  physostigma,  and  3^-^  drop  of  oil  of  cajuput.  Enemas 
or  clysters  may  be  used  in  some  cases.  A  very  useful  enema  is  composed  of  i 
fl.oz.  of  oil  of  turpentine,  13^^  fl.oz.  of  olive  oil,  )--^  fl.oz.  of  mucilage  of  acacia,  in 
10  fl.oz.  of  water.  Soap  and  turpentine  is  very  satisfactory.  Soapsuds  and 
vinegar  in  equal  parts  make  a  serviceable  clyster.  A  combination  of  oil  of 
turpentine,  castor  oil,  the  yolk  of  an  egg,  and  water  can  be  used.  Asafetida, 
30  gr.  to  the  yolk  of  i  egg,  makes  a  good  enema  to  abate  gas  pains  in  the 
abdomen.  An  ounce  of  alum  in  i  quart  of  water  is  valuable  for  the  same 
purpose. 

Diaphoretics. — These  agents  are  very  useful.  A  profuse  sweat  removes 
much  toxic  material  from  the  blood  and  in  the  beginning  of  an  acute  inflam- 
mation, such  as  tonsillitis,  may  abort  the  disease.  Dover's  powder  is  commonly 
used,  but  pilocarpin  is  preferred  by  some.  Camphor  in  doses  of  from  i  to 
5  gr.  is  diaphoretic,  and  so  are  antimony  and  ipecac.  Acetate  and  citrate 
of  ammonium,  opium,  alcohol,  hot  drinks,  heat  to  the  surface  (baths,  hot  bricks, 
hot-water  bags),  serpentaria,  and  guaiac  are  diaphoretic  agents. 

Diuretics  are  useful  in  fevers  when  the  urine  is  scanty  and  high-colored, 
and  are  valuable  aids  in  removing  serous  effusions  and  other  exudates.  Among 
the  diuretics  may  be  mentioned  calomel  in  repeated  large  doses,  cocain,  alcohol, 
infusion  of  digitalis,  the  nitrites,  squill,  turpentine,  copaiba,  and  cantharides. 
The  liquor  potassae  and  the  acetate  of  potassium  are  the  best  agents  to  in- 
crease the  solids  in  the  urine.  The  liquor  potassii  citratis  in  doses  of  i  to  4 
fl.dr.  is  efficient.  Large  drafts  of  water  wash  out  the  kidneys.  If  the  heart 
is  weak,  citrate  of  caflein  is  a  good  stimulant  diuretic,  and  hot  coffee  is  very 
serviceable  in  promoting  the  secretion  of  urine.  The  injection  of  hot  salt 
solution  into  the  rectum  and  under  the  skin  favors  diuresis,  and  the  intra- 
venous infusion  of  salt  solution  is  a  very  powerful  diuretic  if  the  kidneys  are 
not  seriously  damaged  (see  page  536).  The  application  of  heat  to  the  loins 
promotes  the  secretion  of  urine.  Sodio-theobromin  salicylate  (diuretin)  is  an 
uncertain  but  often  valuable  diuretic,  in  doses  of  10  gr.,  every  two  or  three  hours. 

Anodynes  and  Hypnotics. — Drugs  may  be  required  to  allay  pain  or  procure 
sleep.  Dover's  powder,  besides  being  diaphoretic,  is  anodyne.  Opium  acts  well 
after  bleeding  or  purgation.  If  it  causes  nausea,  it  should  be  preceded  one  hour 
by  the  administration  of  30  gr.  of  bromid  of  potassium.  Opium  is  given  by 
the  mouth  or  by  the  rectum,  Morphin  is  given  by  the  mouth  or  hypodermatic- 
ally.  Opium  is  used  when  there  is  pain,  but  its  use  is  not  to  be  long  persisted 
in  if  it  can  be  avoided.  It  is  given  in  doses  measured  purely  by  the  necessities 
of  the  case.  If  opium  disagrees,  try  the  combination  of  morphin  with  atropin. 
After  an  operation  antipyrin  or  phenacetin  will  often  quiet  pain  and  secure  sleep. 
When  a  person  feels  "so  tired  he  can't  sleep,"  alcohol  in  the  form  of  whisky 
or  brandy  must  be  given.  Sleeplessness  not  due  to  pain  is  met  by  chloral, 
trional,  veronal,  the  bromids,  chlorotone,  chloramid,  paraldehyd,  or  sulphonal. 


ii8  Inflammation 

Chloral  is  dangerous  in  conditions  of  weak  heart  or  exhaustion.  Bromids  must 
be  o^iven  in  large  doses  to  be  efficient.  Sulphonal  must  be  given  about  four  or 
five  hours  before  sleep  is  expected,  in  doses  of  from  lo  to  20  gr.  in  hot  milk  or 
hot  mint-water.  Trional  is  safe  and  very  satisfactory.  It  is  given  in  doses  of 
15  to  25  gr.  in  hot  water. 

Antipyretics. — Arterial  sedatives,  diaphoretics,  and  purgatives  lower  tem- 
perature, and  have  previously  been  alluded  to  (see  page  116).  There  are  two 
great  classes  of  febrifuges — those  which  lessen  heat-production  and  those 
which  increase  heat-elimination.  In  the  first  group  we  find  quinin,  salicylic 
acid  and  the  salicylates,  kairin,  alcohol,  antimony,  aconite,  digitalis,  cupping, 
and  bleeding.  In  the  second  group  we  find  alcohol,  nitrous  ether,  antipyrin, 
acetanilid,  phenacetin,  opium,  ipecac,  cold  to  the  surface,  and  cold  drinks. 
In  surgical  inflammations  it  is  rarely  necessary  to  employ  heroic  means  to 
lower  temperature.  Quinin  is  but  a  feeble  antipyretic  for  non-malarial  fevers, 
and  that  it  shall  be  one  at  all  requires  a  dose  of  20  gr.  or  more.  Salicylic  acid 
is  not  advisable  unless  there  is  hyperpyrexia  or  unless  the  patient  has  acute 
rheumatism.  If  30  or  40  minims  of  guaiacol  are  painted  on  the  skin  of  the  ab- 
domen, it  will  cause  a  notable  but  brief  drop  in  a  febrile  temperature.  After 
a  short  period  of  lowered  temperature  has  been  obtained  by  guaiacol  there  is 
commonly  a  chill  and  a  rapid  rise.  Cardiac  depression  may  arise  after  giving  an 
antipyretic,  and  such  an  agent  as  antipyrin  is  dangerous  to  the  weak  and 
adynamic.  In  truth,  all  of  the  coal-tar  derivatives  are  dangerous  when  used  as 
antipyretics.  As  a  matter  of  fact,  fever  is  a  condition  in  which  the  animal 
organism  is  endeavoring  to  oxidize  and  render  inert  certain  poisonous  materials, 
and  antipyretic  drugs  lessen  oxidation  and  actually  make  the  patient  worse.  It 
is  a  suggestive  fact  that  bacteria  are  said  to  multiply  more  rapidly  when  kept  at 
about  the  normal  body  temperature  than  when  kept  at  fever  heat  (102°  F.  or 
more).  The  mere  discomfort  of  fever  may  be  much  mitigated  by  antipyretic 
drugs,  but  the  fever  process  is  not  benefited  by  them.  No  attempt  should  be 
made 'to  lower  temperature  by  cold  or  antipyretic  drugs,  unless  with  the  high 
temperature  there  are  the  nervous  phenomena  of  hyperpyrexia. 

Emetics  may  do  good  when  the  patient  suffers  from  a  parched,  coated 
tongue,  a  dry  and  hot  skin,  nausea,  and  gastric  oppression,  but  it  is  very  rarely 
in  these  days  that  we  employ  them. 

Mercury  and  the  lodids. — Mercury  is  an  alterative,  that  is,  an  agent 
which  favorably  affects  body  nutrition  without  causing  any  recognizable 
change  in  the  fluids  or  the  solids  of  the  body.  Mercury  lessens  blood  plas- 
ticity, hinders  the  exudation  of  liquor  sanguinis — thus  furnishing  less  food  to 
the  cells  in  the  perivascular  tissues — and  retards  cell-proliferation.  Further, 
by  a  stimulant  action  on  the  absorbents  it  promotes  the  breaking  up  of  an 
existing  inflammatory  exudation,  and  hence  limits  damage  from  excess  of 
new  formation.  The  time  at  which  mercury  is  best  given  is  when  violent 
symptoms  have  abated,  the  guides  being  a  reduced  temperature  and  a  moist 
skin.  Mercury  is  often  given  in  conjunction  with  the  local  use  of  sorbefacients 
(ichthyol  or  'mercurial  ointment).  When  possible,  the  administration  of 
mercury  is  associated  with  compression  of  the  inflamed  part.  Mercury  is 
sometimes  given  until  the  gums  are  slightly  touched,  but  it  is  not  given  to  the 
point  of  saHvation.  When  the  breath  becomes  offensive  and  the  gums  tender  on 
snapping  the  teeth,  or  when  griping  and  diarrhea  begin,  the  dose  should  be 
reduced  or  the  drug  should  be  stopped  (see  Ptyahsm).  In  iritis  mercury  is 
used  to  get  rid  of  the  plastic  effusion  which  is  causing  pupillary  fixation  and 
opacity.  In  keratitis  the  gums  should  be  touched  slightly.  In  orchitis,  after 
the  subsidence  of  the  acute  symptoms,  mercury  should  be  employed.  In 
pericarditis,  meningitis,  and  in  many  chronic  and  lingering,  and  in  all  syphi- 
litic inflammations,  this  drug  can  be  used. 

Some  persons  will  be  saHvated  by  very  min  ^te  doses  of  mercury,  either 


Remedies  Directed  Against  Special  Morbid  States  iig 

because  of  idiosyncrasy  or  previous  saturation.  Others  can  take  enormous 
doses  without  any  appreciable  constitutional  effect.  The  action  of  mercurials 
can  be  favored  by  a  combination  with  ipecac  or  with  tartar  emetic. 

In  giving  mercury,  if  a  prompt  effect  is  desired,  give  3  gr.  of  calomel  every 
three  hours  until  a  metallic  taste  is  noted  in  the  mouth.  If  the  case  is  not  so 
urgent,  mercury  and  chalk  (gray  powder")  is  a  good  combination.  Children  are 
given  calomel  and  sugar  or  mercury  and  chalk.  If  it  is  desired  to  give  the  drug 
for  some  time,  corrosive  sublimate  is  a  suitable  form,  and  small  doses  will  actually 
increase  the  number  of  red  blood-corpuscles.  Corrosive  sublimate  is  to  be  given 
alone  or  combined  only  with  iodid  of  potassium.  The  green  iodid  of  mercury  is  a 
drug  suitable  for  prolonged  administration.  During  a  prolonged  course  of  mer- 
cury it  will  often  be  necessary  to  give  at  the  same  time  a  little  opium  to  preverit 
diarrhea  and  griping.  A  rapid  effect  can  be  obtained  by  rubbing  daily  with 
a  gloved  hand  i  dr.  of  the  oleate  of  mercury  or  3-^  dr.  of  the  ointment  into  the 
groins,  the  axillae,  or  the  inside  of  the  thighs.  Suppositories  of  mercurial 
ointment  induce  rapid  ptyalism.  Hypodermatic  injections  of  corrosive  sub- 
limate or  gray  oil,  etc.,  may  be  used,  and  must  be  thrown  deeply  into  the  muscles 
of  the  buttock  or  back.  Old  people,  those  who  are  exhausted,  anemic,  and 
broken  down,  and  the  tuberculous  bear  mercury  badly.  If  it  be  given  to  them 
at  aU,  it  must  only  be  in  small  amounts  and  for  a  brief  time. 

Alkaline  iodids  are  useful  in  removing  the  products  of  inflammation;  they 
can  be  given  for  a  long  time,  and  admirably  supplement  mercurials.  Iodid 
of  potassium  can  be  prescribed  in  combination  with  corrosive  sublimate  as 
follows: 

R.     Hydrarg.  chlor.  corros gr-  ij; 

Potass,  iodidi 3v  et  9j; 

Syr.  sarsaparillfe  comp q.  s.  ad  foviij. — M. 

Sig. — Two  fluidrams  in  water,  after  meals. 

Iodid  of  potassium,  well  diluted,  is  given  on  a  full  stomach;  it  is  never 
given  concentrated  or  before  meals.  A  convenient  mode  of  administration 
is  to  procure  a  concentrated  solution  of  the  iodid  of  potassium,  remembering 
that  every  drop  equals  about  i-  gr.  of  the  drug,  and  give  as  many  drops  as  may 
be  desired  in  half  a  glass  of  water  after  meals.  If  the  medicine  causes  nausea, 
add  to  each  dose,  after  it  is  put  in  water,  i  dr.  of  the  aromatic  spirit  of  am- 
monia. Extract  of  licorice  is  a  good  vehicle  for  the  iodid.  If  the  mixture 
in  water  causes  nausea,  the  drug  should  be  given  in  milk.  Capsules  are 
satisfactory,  but  a  drink  of  water  should  be  taken  just  before  and  again  just 
after  taking  a  capsule,  to  protect  the  stomach  from  the  concentrated  drug. 
Iodid  of  sodium  may  agree  when  iodid  of  potassium  does  not.  When  the  iodids 
disagree  systemically  they  produce  iodism.  The  first  indications  of  iodism  are 
a  bad  taste  in  the  mouth,  running  of  the  eyes  and  nose  and  sneezing,  followed 
by  a  feeling  of  exhaustion,  absolute  loss  of  appetite,  nausea,  tremor,  and  skin 
eruptions  (acne,  hemorrhages,  blebs,  hydroa,  etc.).  If  iodism  occurs,  stop  the 
drug  and  give  the  patient  Fowler's  solution  in  increasing  doses,  laxatives, 
diuretic  waters  and  also  nutritious  food,  and  stimulants  if  depression  is  great. 
Sometimes  belladonna  does  good  in  obstinate  cutaneous  disorders  induced  by 
the  iodids. 

Remedies  Directed  Against  Special  Morbid  States. — If  inflammation 
is  associated  with  rheumatism,  gout,  scurvy,  syphilis,  tuberculosis,  or  any 
other  constitutional  disease  or  predisposition,  appropriate  treatment  should  be 
instituted  to  control  the  disease  or  combat  the  predisposition,  and  at  the  same 
time  the  area  of  inflammation  should  be  locally  treated.  Syphilis  is  treated  by 
the  internal  use  of  mercury  and  perhaps  an  occasional  injection  of  salvarsan;  in 
some  cases  the  iodids  are  also  given;  scurvy,  by  fresh  vegetable  juices;  rheuma- 
tism, by  the  alkalis  or  salicylates;  gout,  by  colchicum  or  piperazin;  tuberculosis, 
by  fats,  tonics,  and  open-air  life. 


I20  Inllammation 

Stimulants. — The  chief  stimulants  used  are  hot  black  coffee  by  the  stomach 
or  bowel;  hot  normal  salt  solution  by  the  bowel,  beneath  the  skin,  or  in  a  vein, 
alcohol  by  the  mouth  or  rectum;  and  strychnin  or  atropin  hyjjodermatically. 
The  use  of  alcoholic  stimulants  is  called  for  by  conditions  rather  than  by  dis- 
eases, being  indicated  by  the  state  of  (he  patient  rather  than  by  the  name 
of  the  malady.  For  a  brief  acute  inllammation  in  a  robust  young  person 
alcohol  is  not  needed;  but  all  who  are  weak  or  exhausted,  be  they  young  or 
old,  all  who  are  aged,  those  who  are  accustomed  to  alcoholic  beverages,  those 
who  have  high  temperature  or  failure  of  circulation,  and  those  who  labor 
under  septic  inflammations  or  adynamic  processes  require  alcohol,  and  it 
should  be  given  with  a  free  hand.  In  an  acute  malady,  a  feeble,  compressible, 
rapid,  or  irregular  pulse,  and  great  weakness  of  the  first  sound  of  the  heart  are 
indications  that  alcohol  is  required.  Low,  muttering  delirium  is  a  strong  in- 
dication for  stimulation.  There  is  no  dose  of  alcohol  for  these  states;  it  is  given 
for  its  effect.  Two  ounces  of  brandy  or  whisky  may  be  needed  in  a  day,  or 
perhaps  many  ounces.  If  the  breath  of  the  patient  smells  strongly  of  the 
alcohol,  he  is  getting  too  much.  If  delirium  increases  after  each  dose,  alcohol 
is  doing  harm.  Alcohol  is  contra-indicated  in  acute  meningitis.  In  acute  illness 
use  whisky,  brandy,  champagne,  or  alcohol  and  water.  During  convalescence 
there  may  be  used  a  little  port,  claret,  or  sherry  wine,  or  malt  liquor.  These 
agents  will  promote  appetite,  digestion,  and  sleep. 

Strychnin  is  a  very  valuable  stimulant.  It  can  be  given  by  the  mouth  in 
doses  of  \^Q  to  3^2  0  gi*-  three  times  a  day,  but  after  a  few  days  seems  to  lose  its 
stimulant  effect. 

Atropin  is  one  of  the  best  remedies  for  exhaustion  of  the  vasomotor  sys- 
tem.    The  dose  is  }f  oo  gr.  hypodermatically. 

Tonics. — The  use  of  tonics  is  indicated  during  convalescence  from  acute 
and  throughout  the  course  of  chronic  inflammations.  There  may  be  used 
iron,  quinin,  and  strychnin  in  the  form  of  elixir;  iron  alone,  as  in  the  tincture 
of  the  chlorid;  quinin  in  tonic  doses  (6  to  8  gr.  daily");  or  Fowler's  solution 
of  arsenic.     An  excellent  pill  consists  of — 

R.     Acid,  arsenos gr.  j ; 

Strychnini gr.  ss; 

Quinini gr.  xlviij ; 

Ferri  reduct gr.  vj. — M. 

Ft.  in  pil.  No.  xxiv. 

Sig. — One  after  each  meal. 

Bitter  tonics  before  meals  improve  the  appetite.  One  of  the  best  tonics  is 
tincture  of  nux  vomica  in  gradually  increasing  doses. 

Antiphlogistic  Regimen. — rThis  term  comprises  the  necessary  directions 
relating  to  diet,  ventilation,  cleanliness,  etc. 

Diet. — When,  in  the  early  stages  of  an  acute  inflammation,  the  patient 
cannot  eat,  there  must  be  administered  a  cathartic  before  food  is  given.  Nausea 
is  combated  by  calomel  and  soda,  drop-doses  of  a  6  per  cent,  solution  of  cocain, 
iced  champagne,  iced  brandy,  chloroform-water,  hot  water,  and  counter- 
irritation  of  the  epigastric  region.  Sucking  ice  may  check  nausea,  but  it 
often  makes  the  patient  uncomfortable,  because  he  sucks  in  air  with  the  melted 
ice.  Sucking  ice  does  not  quench  thirst.  When  the  process  is  depressive  from 
the  start,  and  in  any  case  after  the  earliest  stage,  feeding  is  of  vital  moment. 
The  great  tissue  waste  calls  for  large  quantities  of  nutritive  material,  but  the 
impaired  digestion  demands  that  the  food  shall  be  easily  assimilable;  hence 
it  is  taken  in  liquid  form,  small  quantities  being  frequently  given.  Albumin- 
water  is  an  agreeable  beverage  of  some  nutritive  value.  Milk  contains  all  the 
elements  required  by  the  body,  and  is  the  food  of  foods.  It  contains  carbo- 
hydrates (milk  sugar),  protein  (casein  and  albumin),  fat  and  mineral  salts. 
Carbohydrate  and  fat  are  fuel  to  furnish  body  heat  and  protein  repairs  and 


Antiphlogistic  Regimen  121 

reconstitutes  destroyed  tissue.  If  it  disagrees,  it  should  be  mixed  with  lime- 
water,  or  to  each  dose  an  equal  amount  of  Vichy  or  sodawater  may  be  added. 
Peptonized  milk  is  a  valuable  agent.  Some  people  can  take  boiled  milk 
who  cannot  take  cold  unboiled  milk.  Some  patients,  however,  digest  raw 
better  than  boiled  milk.  Peptonized  milk  has  been  to  a  great  extent  super- 
seded by  pancreatinized  milk.  It  is  given  cold,  either  alone  or  mixed  with  a 
carbonated  water.  Koumiss  is  retained  in  some  cases  when  the  stomach 
rejects  all  other  foods.  This  fermented  milk  is  nutritious,  stimulant,  and 
very  useful.  One  part  of  milk,  2  parts  of  cream,  and  2  parts  of  lime-water 
make  a  nutritious  and  digestible  mixture.  Milk  punch  is  largely  used.  Whey 
may  be  used  when  plain  milk  cannot  be  taken.  Eggs  are  highly  nutritious,  but 
are  apt  to  disturb  the  stomach;  they  may  be  given  as  egg-nog,  or  simply  soft- 
boiled,  or  the  yolk  can  be  beaten  up  in  a  cup  of  tea,  or  raw  eggs  may  be  given  in 
sherry  or  brandy.  When  considerable  nausea  exists  the  yolk  of  an  egg  may  be 
added  to  i  oz.  of  lemon-juice  and  2  dr.  of  sugar,  the  glass  being  filled  with 
carbonated  water.  Beef-tea  is  certainly  a  stimulant,  but  it  is  not  a  food.  It 
contains  the  excrementitous  elements  of  the  beef.  It  is  prepared  by  cutting 
up  I  pound  of  lean  beef,  adding  to  it  a  quart  of  water,  and  then  simmering, 
but  not  boiling,  down  to  a  pint,  finally  filtering  and  skimming  the  liquid.  The 
dose  is  a  wineglassful  seasoned  to  taste.  Beef  juice  is  nutritious.  It  is  pre- 
pared as  follows:  A  thick  and  tender  beefsteak  is  partly  broiled  over  a  hot  fire, 
the  outside  is  browned  and  the  juice  is  retained  within  the  meat.  The  steak 
is  cut  into  pieces  to  fit  a  lemon  squeezer  or  meat-press  (the  instrument  having 
been  warmed  by  previously  dipping  it  in  hot  water) .  The  juice  is  expressed  into 
a  warmed  glass  by  squeezing  and  may  be  given  warm,  seasoned  with  salt  and 
pepper.  Some  patients  prefer  it  frozen.  Fresh  meat  juice  may  be  used  plain  or 
pancreatinized.  The  meat  juices  obtained  in  the  shops  have  little  nutritive  value. 
Bouillon  and  beef  extracts  have  slight  nutritive  value.  Meat  jellies  (calf's  foot 
being  the  one  commonly  used)  have  some  though  little  nutritive  value  by  pro- 
ducing a  certain  amount  of  energy  which,  were  they  not  given,  would  of  neces- 
sity be  furnished  by  protein.  Hence,  meat  jelly  saves  or  spares  protein  (Bauer). 
Clam-juice  and  clam-broth  are  palatable  and  slightly  nutritious.  They  are 
retained  in  many  cases  when  any  other  food  would  be  rejected.  The  broth  is 
to  be  given  hot  and  the  juice  either  hot  or  cold.  Coffee  is  a  valuable  stimulant  in 
febrile  conditions.  When  the  stomach  entirely  rejects  food  day  after  day,  nutri- 
tive enemata  are  given.  There  is  dispute  as  to  their  value,  because  it  is  certain 
that  the  large  intestine  does  not  digest  by  juices  of  its  own  manufacture,  and 
no  protein  matter  can  be  absorbed  without  previous  digestion.  If  undigested 
protein  matter  is  introduced  it  undergoes  putrefaction,  causes  irritation,  and 
liberates  toxins  which  are  absorbed.  It  seems  equally  certain,  however,  that 
the  large  bowel  does  absorb  water  as  part  of  its  physiological  duty  and  that  it 
can  absorb  alcohol,  saline  fluid,  glucose,  certain  drugs,  and  perhaps  digested 
albumin  and  fat.  Undigested  albumin  and  fat  should  never  be  given  by  enema. 
These  materials  should  be  pancreatinized  before  injection  or  should  be  mixed 
with  pancreas  and  then  injected,  thS  peptones  being  formed  in  the  bowel.  Nutri- 
tive enemata  are  given  at  a  temperature  of  90°  to  95°  F.  They  should  not  be 
bulky  (not  over  7  or  8  oz.),  because  a  large  enema  is  usually  quickly  expelled. 
They  should  not  be  given  oftener  than  three  or  perhaps  four  times  a  day,  be- 
cause too  frequent  administration  irritates  the  rectum  and  enemas  will  not  be 
retained  by  an  irritated  rectum.  During  the  period  that  rectal  enemata  con- 
stitute the  method  of  feeding  the  rectum  should  be  washed  out  once  a  day  by 
a  high  enema  of  warm  salt  solution;  this  cleansing  enema  is  given  one  hour  be- 
fore a  nutritive  enema.  A  useful  enema  is  Leube's  meat  and  pancreas— 3  oz.  of 
pancreas  and  8  oz.  of  meat  are  rubbed  together  in  a  mortar  by  a  pestle,  tepid  water 
is  added,  and  the  mixture  is  injected.  It  undergoes  digestion  in  the  large  bowel. 
Bidwell's  formula  is  as  follows :  2  oz.  of  milk,  2  oz.  of  strong  beef-tea,  yolk  of  i 


122  Inflammation 

egg,  I  dr.  of  pancreatic  solution,  prepared  one  hour  before  using  and  kept  during 
the  interim  at  a  temperature  of  ioo°  F.  Brandy  can  be  added  just  before  using. 
Enemata  of  salt  solution  greatly  relieve  thirst.  When  the  sufferer  feels  able 
to  eat  a  little,  any  good  soup,  strained  and  skimmed,  should  be  ordered.  As 
the  patient  gets  better  he  may  be  fed  on  scraped  meat,  broth  containing  crumbs, 
tapioca  with  cream,  custard,  milk-toast,  sweetbreads,  chops,  oysters,  chicken, 
etc.,  until  he  gradually  reaches  ordinary  diet. 

The  temperature  should  be  taken  at  regular  intervals,  and  the  condition  of 
the  gastro-intestinal  tract  should  be  observed.  The  urine  must  be  examined 
at  intervals,  and  the  daily  amount  passed  must  be  known.  If  insufficient 
urine  is  being  passed,  increase  the  amount  of  fluid,  particularly  of  water,  given 
by  the  mouth.  If  the  urine  is  scanty  and  the  patient  is  nauseated  by  drinking 
water,  give  enemata  of  hot  saline  fluid  or  employ  h}qpodermoclysis.  The 
ptdse  and  heart  must  be  frequently  observed,  and  cardiac  weakness  must  be 
combated  by  suitable  stimulants. 

Ventilation  and  Cleanliness. — The  ventilation  of  the  apartment  is  of  the 
greatest  importance.  Every  day  the  windows  should  be  opened  widely  for  a 
time,  the  patient,  of  course,  being  protected  from  chilling  and  kept  out  of  a 
draft.  When  the  windows  are  open  the  air  of  a  room  can  be  quickly  changed 
by  swinging  the  door  to  and  fro.  A  constant  access  of  fresh  air  must  be  secured, 
and  the  temperature  kept  as  near  as  possible  to  68°  F.  If  high  fever  exists,  the 
sick  man  must  be  cleaned  and  be  sponged  off  with  alcohol  and  water  every 
day.  It  is  important  that  the  bed-clothing  be  clean  and  that  the  sheet  be  un- 
wTinkled,  as  otherwise  bed-sores  may  form. 

Treatment  of  Chronic  Inflammation. — The  subject  of  chronic  inflam- 
mation has  been  referred  to  previously.  The  local  treatment  comprises  rest, 
relaxation,  elevation,  counterirritation,  massage,  ■  passive  movements,  the 
douche,  the  application  of  sorbefacients,  the  use  of  compression,  incision,  and, 
perhaps,  certain  special  methods,  as  the  induction  of  passive  hyperemia  by 
Bier's  method,  or  baking  the  part  in  a  hot-air  oven.  The  patient  should  be 
placed  under  proper  hygienic  and  climatic  conditions;  the  diet  must  be  judi- 
ciously regulated;  drugs  are  given  symptomatically  or  to  combat  some  con- 
stitutional tendency  or  disease  (see  articles  upon  Special  Regions  and  Diseases). 

Bier's  Hyperemic  Treatment  of  Inflammation. — Years  ago  Laennec 
asserted  that  cyanosis  was  antagonistic  to  tubercle.  Rokitansky  emphatically 
supported  the  contention  that  people  with  marked  valvular  disease  of  the  heart 
w^ere  seldom  attacked  by  pulmonary  tuberculosis.  Such  lesions,  of  course,  dam 
back  the  blood  in  the  lungs.  Farre  and  Travers  pointed  out  the  great  liability 
to  pulmonary  tuberculosis  of  patients  with  anemic  lungs  because  of  stenosis  of 
the  pulmonary  artery  (Edward  Adams,  in  "N.  Y.  Med.  Jour.,"  February  26, 
1910).  The  discovery  of  how  to  utilize  this  knowledge  in  treatment  was  made 
by  Professor  Bier,  of  Berlin.  Bier  believes  that  hyperemia  in  inflammation  is 
a  reaction  on  the  part  of  the  organism;  that  it  is  Nature's  effort  to  remove  an 
irritant  and  to  supply  increased  nutritive  material,  hence  that  it  is  desirable 
and  should  not  be  combated  by  cold,  but 'should  be  favored  by  every  means 
in  our  power.  Bier  endeavors  to  increase  the  hyperemia  of  an  inflamed  region, 
or  to  produce  hyperemia  in  an  area  of  disease.  He  regards  hyperemia  as 
beneficial,  stasis  as  harmful;  hence  he  causes  or  increases  hyperemia  and  com- 
bats stasis.  Stasis  lowers  tissue  resistance  and  may  cause  gangrene.  The 
increase  in  the  amount  of  moving  blood  in  a  part  means  an  increase  in  the 
number  of  phagocytes  and  the  amount  of  germicidal  blood  liquor.  By  the 
method  of  treatment  recommended  by  Bier  the  surgeon  induces  venous,  pas- 
sive, or  obstructive  hyperemia  by  means  of  an  elastic  band  or  a  cupping  glass, 
active  or  arterial  hyperemia  by  means  of  hot  air. 

Obstructive  Hyperemia  by  Means  of  the  Elastic  Bandage. — The  constrictor 
should  be  the  soft  broad  bandage  of  an  Esmarch  apparatus.     Figure  55  shows 


Obstructive  Hyperemia  by  Means  of  the  Cupping  Glass        123 

it  applied  around  the  arm.  The  bandage  must  not  be  so  tight  as  to  cut  ofi  the 
pulse  at  the  wrist  or  to  cause  unpleasant  sensations,  pain,  or  very  rapid  dis- 
tention of  the  subcutaneous  veins  (Meyer  and  Schmieden).  When  edematous 
swelling  arises  we  may  be  unable  to  feel  the  pulse.  Then  our  guide  must  be 
the  sensations  of  the  patient.  If  the  treatment  causes  pain  or  increases  existing 
pain,  at  once  discontinue  it  (Waterhouse,  "Brit.  Med.  Jour.,"  December  16, 
191 1).  The  part  below  the  band  should  become  bluish  red  and  warm,  but 
never  white  under  the  influence  of  the  constriction.  When  the  bandage  is  in 
place  an  area  of  inflammation 
shows  an  increase  of  redness,  heat 
and  swelling,  and  a  diminution  of 
pain.  If  pain  was  not  present  be- 
fore, the  bandage  must  not  produce 
it.  Should  it  do  so  it  is  too  tight. 
In  chronic  conditions  the  bandage 
is  usually  employed  daily  and  for 
two,  three,  or  four  hours  at  a 
seance.  When  used  for  three 
hours  or  longer  temporary  edema 
may  arise.  In  acute  cases  it  is 
used  for  twelve,  fifteen,  or  twenty 
hours  a  day.  Prolonged  applica- 
tion may  make  the  skin  sore  un- 
less a  flannel  bandage  is  applied 
before  the  band  is  used,  unless  the 
site  of  application  is  shifted  daily, 
and  unless  the  skin  during  each 
intermission  is  well  rubbed  with 
alcohol.  The  bandage  is  always 
applied  well  above  the  inflamed 
region,  and  that  region  is  exposed 
free  from  dressings  in  order  that 
its  condition  during  treatment  may 
be  observed.  If  edema  occurs, 
the-  band  must  be  removed  and 
the  edema  relieved  by  elevation 
and  massage.  If  the  inflammation 
is  accompanied  by  marked  edema, 
incisions  are  required.  Treatment 
by  the  bandage  may  prevent  pus 
formation.  If  pus  forms  it  must, 
of  course,  be  evacuated. 

Obstructive  Hyperemia  by 
Means  of  the  Cupping  Glass. — 
Endeavor  to  make  the  skin  bluish 
red,     but    not    white.      Cupping 

glasses  are  used  not  only  to  treat  areas  of  inflammation,  but  to  aid  in  empty- 
ing sinuses  and  abscesses  which  have  ruptured  or  have  been  incised.  Figures 
56-59  show  cupping  glasses. 

I  am  satisfied  from  personal  experience  that  Bier's  method  of  treatment 
is  of  great  value  in  acute  inflammation  as  weU  as  in  chronic  inflammation, 
and  that  it  is  not  used  as  often  as  it  should  be.  I  have  used  it  with  success  in 
several  cases  of  ununited  fracture.  It  is  an  improvement  on  the  method  of 
Thomas,  of  Liverpool,  for  inducing  hyperemia  about  the  ends  of  the  fragments. 
He  did  it  by  repeated  percussion  with  a  mallet.  Barker  has  recently  advocated 
Bier's  treatment  for  ununited  fracture.     I  have  never  used  it  for  purulent 


Fig.  55. — Shows  elastic  bandage  in  place  around 
the  arm,  its  ends  tied  with  tapes  which  are  at- 
tached to  the  bandage.  This  is  the  style  of 
bandage  usually  found  upon  the  market.  If  the 
bandage  is  to  remain  on  for  a  number  of  hours,  it  is 
advisable  to  apply  a  strip  of  adhesive  plaster,  to 
guard  against  the  tapes  becoming  undone.  Note 
the  engorgement  of  the  subcutaneous  veins  of  the 
forearm,  showing  the  effect  it  is  desired  to  produce 
by  the  ijandage  (Meyer  and  Schmieden). 


124 


Inflammation 


affections  of  large  joints,  a  condition  in  which  Bier  claims  it  highly  useful  (Bier 
and  Baetzner,  in  "Practitioner,"  Jan.,  191 2).  He  empties  the  joint  with  a 
trocar,  washes  it  with  carbolic  solution,  puts  on  dressing,  but  does  not  immobilize. 


Fig.  56. — The  simplest 
form  of  suction  glass.  The 
rubber  bulb  is  attached  di- 
rectly to  the  glass.  This 
glass  is  used  in  the  treat- 
ment of  furuncles  of  smaller 
size  and  sinuses  (Meyer  and 
Schmieden). 


Fig.  57. — Illustrating  an  ordinary  suc- 
tion apparatus  for  the  finger  (felon,  etc.) 
with  a  convexity  at  the  lower  surface, 
designed  to  receive  the  pus  (Meyer  and 
Schmieden). 


Bier  retains  the  band  from  twenty  to  twenty-two  hours  a  day.  As  soon  as  acute 
symptoms  subside  he  uses  hot  air.  The  reduction  of  the  daily  period  of  hyper- 
emia is  brought  about  gradually  before  substituting  hot  air.  I  have  seen  very 
gratifying  results  from   the  Bier  treatment  of  gonorrheal  joints.     I  believe 


'"^Wpprc^^ 


Fig.  58. — Shows  glass  of  simpler  configuration;  a  rubber  tube  connects  glass  with  bulb; 
the  same  can  be  readily  detached,  thus  rendering  easy  the  sterilization  of  the  glass  by  boiling. 
In  the  tube  a  three-way  stop-cock  is  inserted.  This  cup  is  used  for  treating  furuncles  of  larger 
dimensions,  etc.  (Meyer  and  Schmieden). 

that  this  treatment  gives  the  best  chance  of  cure  without  deformity  and  with 
retained  function.  It  is  valuable  for  joint  tuberculosis,  although  very  numer- 
ous brief  applications  are  necessary.     It  is  beneficial  for  thecitis,  areas  of  sup- 


Repair  1 2  ^ 

puration  after  incision,  and  chilblains.  Waterhouse  suggests  its  use  to  prevent 
suppuration  in  a  crushed  Hmb.  The  treatment  is  contra-indicated  in  spreading 
inflammation — for  instance,  erysipelas. 

Bier  claims  that  arterial  hyperemia  induced  by  hot  air  is  particularly 
useful  in  chronic  inflammation,  as  it  favors  the  absorption  of  exudates  and  of 
adhesions.  It  will  hasten  the  separation  of  sequestra.  Venous  hyperemia 
produced  by  the  elastic  band  or  the  cupping  glass  is  claimed  to  be  of  great 
value  in  infections.  It  may  abolish  the  infection,  prevent  suppuration,  and 
hasten  the  process  to  a  conclusion.  It  does  certainly  lessen  pain  and  favor 
absorption.  The  elastic  band  may  be  used  upon  an  extremity,  a  testicle,  the 
scrotum,  and  the  head.  In  other  regions  cupping  glasses  are  used,  a  partial 
vacuum  being  established  in  the  glass  by  means  of  a  pump  or  a  rubber  bulb. 


Fig.  59. — Constructed  for  the  treatment  of  the  hand.     A  soft-rubber  band  wound  around  the 
cuff  makes  it  fit  air-tight  around  the  arm  (Meyer  and  Schmieden). 

Sir  Almroth  Wright's  Views  Upon  Inflammation  and  Its  Treat= 
ment. — Wright  maintains  that  a  free  supply  of  blood  and  lymph  is  necessary 
for  repair,  that  both  the  blood  and  lymph  should  contain  a  sufficiency  of  pro- 
tective materials,  and  that  it  is  essential  that  numerous  active  leukocytes  enter 
the  area  of  disease. 

When  there  is  a  large  serous  effusion  and  few  leukocytes,  a  condition  met 
with  often  in  tuberculous  pleurisy,  repair  does  not  take  place. 

In  abscess  the  leukocytes  are  dead  and  the  material  obtained  from  dead 
leukocytes  retards  healing.  If  the  fluid  exudate  does  not  contain  protective 
material  the  process  extends. 

Repair  is  retarded  by  induration,  or  by  the  formation  of  a  fistula  or  a  sinus. 

If  there  is  a  small  amount  of  fluid  exudate,  there  is  little  protective  sub- 
stance thrown  into  the  inflamed  part  and  repair  is  retarded. 

If  there  be  a  large  effusion  and  few  leukocytes,  cure  is  favored  by  removing 
the  fluid.  This  is  done  in  abscess  and  in  serous  effusion.  If  there  is  too 
Uttle  lymph  in  the  part  salt  solution  and  citric  acid  should  be  used  locally, 
and  citric  acid  should  be  administered  internally.  The  administration  of 
proper  bacterial  vaccines  will  increase  the  protective  qualities  of  the  lymph. 
(See  Wright,  "The  Pathology  of  Inflammation,"  and  the  resume  of  his  views 
in  "Progressive  Medicine,"  Sept.  i,  1908,  p.  31,) 


IV.  REPAIR 

A  damaged  tissue  reacts  to  the  injury  and  Nature  attempts  to  effect  re- 
pair. It  is  held  by  many  that  inflammation  is  a  destructive  process  and 
repair  is  a  constructive  process;  that  repair  is  constantly  effected  in  an  aseptic 
wound  without  many  of  the  evidences  of  inflammation;  that  repair  does  not 
proceed  from  inflammation,  but  is  retarded  or  prevented  if  inflammation 
occurs.  As  before  stated,  we  agree  with  Adami,  that  inflammation  is  reaction 
to  injury  and  the  effort  of  Nature  to  repair  the  injury.  As  Adami  points  out, 
the  attempt  to  repair  may  fail,  the  reaction  to  injury  being  excessive  or  not 


126  Repair 

powerful  enough;  but  even  should  ihe  attempt  fail,  the  conservative  intention 
exists.  "What  is  the  development  of  cicatricial  tissue  but  an  attempt  at 
repair?  What  other  meaning  can  be  ascribed  to  the  increased  bactericidal 
power  of  the  inflammatory  exudate  as  compared  with  that  of  ordinary  lymph 
and  blood-serum?  Why  do  leukocytes  accumulate  in  a  region  of  injury? 
Why  do  some  of  them  incorporate  bacteria  and  irritant  particles,  and  others 
bring  about  the  destruction  of  these  without  necessarily  ingesting  them? 
All  these  are  means  whereby  irritants  are  antagonized  or  removed,  and  repara- 
tion and  return  to  the  normal  sought  after.'" 

Repair  is  favored  by  good  general  health,  asepsis  of  the  wound,  coaptation  of 
wound  edges,  and  rest.  It  is  retarded  or  prevented  by  infection,  gaping  of  the 
wound,  frequent  or  forcible  motion,  and  impairment  of  the  general  health. 

Albuminuria  and  diabetes  particularly  obstruct  repair.  R.  T.  Morris 
points  out  that  sugar  in  the  blood  is  hygroscopic,  removes  water  from  the 
tissues,  and  thus  obstructs  repair;  and  also  that  the  wound  fluids  contain 
sugar  and  are  good  culture-media  ("Med.  News,"  June  29,  1901). 

Healing  by  First  Intention. — A  wound  may  "heal  by  first  intention." 
This  mode  of  healing,  which  is  known  as  "primary  union,"  occurs  without 
suppuration,  and  is  observed  in  the  healing  of  an  aseptic  wound.  If  infection 
occurs,  primary  union  will  not  take  place.  The  phrase  "by  first  intention" 
_  comes  down  to  us  from  the  past.     It  was  properly 

V-,  .■ri''^^:^-'^\7^  f'-i^  thought  that    Nature   intends   to  repair  a  wound, 

\V:^x!<??-:   ,,■  •     ;  ■ -y  xj         and  first  intention  signifies  the  first,  best,  the  most 

^•;;:;    !.     •'-      :    -■      V       desirable  way  in  which  it  can  be  accomplished.     In 

'/•;:'•  ..  '       •       .'         a  small  aseptic  incision,  in  which  no  considerable 

•i^-;-  ,.  ,  ,.,.'.''    .  J^^         vessels  are  cut,  repair  will  take  place  very  rapidly 

^^^^^0/Mj /i^  -^o^-^       after  the  edges  have  been  approximated  and  the 

^^^.^ftM/""^^ ^  wound  dressed.     In  fact,  the  wound  edges  may  be 

£^    •^^-/     ;••■  held  firmly  together  in  twenty-four  hours.     In  such 

Fig.    60. — Cells    developing      a  wound  a  small  amount  of  blood  flows  from  the 

into  fibers  (Bennett).  capillaries  between  the  edges  of  the  wound,  and  this 

blood  clots.  A  trivial  amount  of  exudate  and  some 
few  migrated  corpuscles  pass  into  the  clot  and  into  the  tissues.  The  fixed 
connective-tissue  cells  and  the  endothelial  cells  of  the  vessels  multiply,  and 
form  embryonic  or  juvenile  tissue.  The  cells  are  epithelioid  cells  and  are 
known  as  fibroblasts.  The  fibroblasts  eat  up  many  of  the  leukocytes  and 
multiply,  so  that  the  new  cells  from  one  side  of  the  wound  finally  interlace 
with  the  new  cells  from  the  other  side.  Nearby  capillaries  become  irregular 
in  outline;  at  certain  points  bulging  occurs,  and  at  these  points  new  capillaries 
develop,  extend  into  the  mass  of  fibroblasts,  and  join  new  capillaries  of  the 
opposite  side.  The  reparative  material  is  now  said  to  be  organized;  it  has 
become  granulation  tissue.  The  fibroblasts  become  spindle  shaped  and 
develop  into  interlacing  fibers  (Fig.  60).  The  tissue  is  now  fibrous  tissue;  it 
contracts  strongly,  and  finally  most  of  the  capillaries  are  obliterated  by  pressure. 
In  such  a  slight  wound  the  reaction  to  injury  is  chiefly  noted  in  the  cells  of 
the  part,  and  the  vessels  and  leukocytes  play  but  a  small  part  in  repair.  The 
exudation  is  so  scanty  that  there  is  practically  no  swelling  unless  it  arises 
from  venous  obstruction.  The  vessels  are  so  slightly  affected  that  there 
is  no  redness.  The  final  step  in  heaUng  is  contraction  of  the  fibrous  tissue  and 
the  covering  of  the  surface  with  epithelium,  which  springs  from  the  epithelial 
cells  upon  the  edges.  This  final  process  is  called  ''■cicatrization,'''  and  con- 
sists in  the  formation  from  fibroblasts  of  new  fibrous  tissue  and  the  contraction 
of  the  new  tissue.  The  "immediate  union "  of  some  writers  never  occurs.  This 
term  means  the  union  of  microscopic  parts  to  their  counterparts  without  any 
effort  at  repair.  A  first  union  is  effected  always  by  clotted  blood  and  coagulated 
1  Adami,  in  AUbutt's  "System  of  Medicine." 


Healing  by  First  Intention  127 

exudate,  next  by  proliferating  cells,  and  finally  by  fibrous  tissue.  A  wound 
healing  by  first  intention  exhibits  no  evidence  of  inflammation.  There  is  some 
slight  tenderness,  but  no  actual  pain.  A  certain  amount  of  swelling  arises  be- 
cause of  exudation  of  fluid  from  the  blood,  and  the  coagulation  of  this  fluid 
makes  the  wound  edges  hard.  Venous  obstruction  leads  in  some  cases  to  a  con- 
siderable fluid  swelling.  A  wound  may  heal  by  first  intention  even  though  some 
bacteria  are  present,  if  the  part  has  a  good  blood-supply  and  the  patient  is  in 
good  health.  Active  leukocytes  and  germicidal  blood  liquor  may  prevent 
infection.  In  a  more  extensive  incised  wound  many  vessels  are  cut.  After 
oozing  ceases  the  vessels  are  closed  by  clots  continuous  with  the  clot  between  the 
sides  of  the  wound.  An  exudation  of  plasma  from  the  blood-vessels  and  of 
lymph  from  the  lymph-spaces  takes  place.  Leukocytes  in  great  numbers  in- 
vade the  wound  edges  and  the  exudate,  and  the  exudate  clots.  Thus,  an  infec- 
tion may  be  surrounded  and  limited.  This  mass  of  blood-clot,  plasma-clot,  and 
leukocytes  used  to  be  known  as  "coagulable  lymph."  The  leukocytes  actively 
eat  up  the  clot,  and  by  the  end  of  the  third  day  occupy  the  space  formerly 
occupied  by  the  clot.  Embryonic  tissue  is  formed  by  multiplication  of  the 
fixed  connective-tissue  cells  and  endathelial  cells.  These  '^eUs  are  calle^ 
fibroblasts.  They  multiply  and  grow  into  the  mass  of  leukocytes,  eating  up 
many  of  the  leukocytes,  and  finally  join  the  fibroblasts  of  the  other  side  of  the 
wound.  Some  leukocytes  enter  into  the  lymph-spaces.  New  capillaries  form 
from  the  capillaries  at  the  wound  margins.  By  the  end  of  the  first  week  the 
fibroblasts  begin  to  assume  various  outlines,  sending  out  poles  or  branches  or 
becoming  spindle  shaped.  These  spindle-shaped  cells  become  fibers,  and  the 
fibers  of  the  new  tissue  interlace  and  strongly  contract.  Thus  the  edges  are 
pulled  firmly  together.  Finally,  new  epithelium,  derived  from  epithelium  at 
the  wound  edges,  forms  and  grows  over  the  wound  (Figs.  61-63).  ^^  order  to 
obtain  primary  union  the  surgeon  ought  to  cleanse  the  wound,  and  all  his  pro- 
cedures must  be  thoroughly  aseptic  and  bleeding  should  be  carefully  arrested. 
The  parts  are  then  accurately  coaptated  by  sutures,  aseptic  or  antiseptic  dress- 
ings are  applied,  and  special  care  is  taken  to  secure  rest.  In  a  large  wound  spe- 
cial methods  to  secure  drainage  are  required  (page  87).  In  a  small  wound 
the  spaces  between  the  stitches  give  exit  to  the  tri\dal  quantity  of  wound  fluid. 
The  use  of  irritant  germicides  in  a  wound  greatly  increases  the  amount  of 
discharge  and  renders  necessary  the  introduction  of  material  for  drainage.  Even 
a  comparatively  small  wound  so  treated  requires  drainage  for  the  first  twenty- 
four  hours.  During  the  first  twenty-four  hours  after  a  large  wound  begins  to 
heal  by  first  intention  the  discharge  of  bloody  serum  is  most  plentiful,  but  after 
this  period  it  becomes  very  scanty  and  soon  ceases  entirely,  and  can  be  much 
diminished  in  quantity  on  the  first  day  by  the  application  of  pressure.  Warren 
says  that  after  a  hip-joint  amputation  over  a  pint  of  bloody  serum  flows  out 
during  the  first  twenty-four  hours.  In  an  aseptic  wound,  as  a  rule,  one-half  of 
the  stitches  are  removed  on  the  sixth  or  seventh  day  and  the  remainder  on  the 
eighth  day,  but  for  two  weeks  more  the  wound  should  be  rested  and  supported, 
as  the  new  tissue  is  not  very  resistant  to  infection.  Aseptic  fever  always  arises 
when  much  exudation  is  poured  out  and  is  slowly  and  imperfectly  drained. 
Aseptic  fever  is  due  to  the  absorption  of  aseptic  pyrogenous  material  (see  page 
139).  If  an  incised  wound  becomes  infected,  the  pyogenic  organisms,  by  lique- 
fying the  intercellular  substance,  destroy  the  bond  of  union  which  is  forming 
between  the  w^ound  edges.  As  a  consequence,  the  wound  edges  are  soon  -widely 
separated  by  pus. 

What  used  to  be  kno^Ti  as  "healing  by  blood-clot''  is  healing  by  first  in- 
tention. If  there  is  a  considerable  gap  between  the  edges  of  an  aseptic  wound, 
and  the  gap  is  filled  with  a  blood-clot,  healing  goes  on  in  the  same  manner  as 
when  the  gap  is  narrow,  although  more  corpuscles,  more  exudate,  and  more 
fibroblasts  are  required  to  effect  repair. 


12^ 


Repair 


Healing  by  Second  Intention.— Healing  of  a  wound  in  which  there  is  a 
large  cavity  in  the  tissue  or  in  which  the  edges  have  gaped  a})art  is  known  as 
heahng  by  granulation,  or  "healing  by  second  intention."  It  is  called  healing 
by  granulation  because   the  granulations   (areas  of  vascularized  embryonic 


Fig.  6i. 


Fig.  62. 


Fig.  63. 

Figs.  61-63. — Healing  by  first  intention:  a,  Skin;  b,  fibroblasts;  c,  d,  c,  capillaries.  Fig.  61, 
Clot  in  the  vessels  continuous  with  clot  between  the  edges  of  the  wound.  Fig.  62,  Migration 
of  leukocytes  into  the  perivascular  tissues  and  into  the  clot  between  the  edges  of  the  wound. 
Fig.  63,  Formation  of  new  capillaries  (after  Pick). 

tissue)  are  visible.  It  is  effected  in  the  same  manner  as  "healing  by  first 
intention,"  the  processes  in  the  two  cases  being  practically  identical  if  pus  is 
absent.  As  a  matter  of  fact,  in  healing  by  granulation  there  is  usually  wound 
infection.  As  a  result  of  infection  intercellular  substance  is  peptonized,  many 
reparative  cells  are  cast  off,  and  repair  can  be  effected  only  after  the  formation 


Healing  by  Second  Intention 


i2g 


of  enormous  numbers  of  fibroblasts  and  the  expenditure  of  considerable  time. 
It  requires  much  longer  for  an  infected  wound  to  heal  than  for  an  incised  wound 
to  be  repaired,  and  an  infected  wound  can  heal  by  granulation  only.  A  short 
time  after  the  infliction  of  a  wound  the  oozing  ceases,  because  thrombi  form  in 
the  vessels  and  clot  gathers  in  tissue-gaps  and  interstices.  Exudation  begins 
and  leukocytes  migrate  into  the  exudate  and  into  the  walls  of  the  wound.  In 
an  hour  or  two  the  surface  of  the  wound  becomes  distinctly  glazed  or  gUstening, 
because  of  the  formation  and  coagulation  of  fibrin.  The  exudation  is  at  first 
thin  and  red,  and  it  soon  becomes  so  profuse  as  to  wash  away  the  discolored 
fibrin  coat.  Usually,  in  a  few  days  the  discharge  becomes  purulent.  The 
connective-tissue  cells,  especially  the  endothelial  cells  of  the  vessels,  pro- 
liferate and  form  fibroblasts,  and  the  fibroblasts  multiply  to  close  the  wound. 
From  adjacent  capillaries  new  capillaries  form.  This  formation  takes  place  as 
follows:  A  portion  of  a  capillary  thickens  and  a  whip-like  process  comes  off 
from  the  thickened  part.     This  process  fuses  with  a  second  filament  budded 


Fig.  64. — Development  of  a  blood-vessel  in  mesentery  of  an  embryo  (Warren). 


from  another  or  from  the  same  capillary,  or  runs  straight  out  as  a  terminal  ves- 
sel. The  filaments  after  a  time  are  hollowed  out  from  within,  protoplasmic 
tubes  are  formed,  and  endothelial  cells  develop  from  the  protoplasm.  In 
some  cases  a  tubular  prolongation  comes  off  from  a  capillary  directly.  Figures 
63  and  64  show  the  formation  of  a  capillary.  In  a  wound  healing  by  granula- 
tion these  newly  formed  capillaries  run  among  the  fibroblasts,  and  some  of 
them  run  perpendicularly  to  the  surface,  or  a  loop  forms  and  reaches  the  sur- 
face. The  surface  of  a  granulating  wound  is  covered  with  migrated  leukecytes, 
and  directly  under  these  are  fibroblasts  covering  the  new  vascular  strings  or 
loops.  Vascular  strings  or  loops  coated  with  fibroblasts  are  called  granulations 
(Fig.  65  shows  a  granulating  surface).  When  the  discharge  becomes  purulent, 
many  leukocytes  and  fibroblasts  are  destroyed,  inflammation  increases,  exuda- 
tion becomes  profuse,  and  cellular  multiplication  widespread  and  rapid  in  order 
to  make  up  for  the  cells  lost  by  microbic  action.  Gradually  the  gap  is  filled. 
As  it  is  being  filled  the  older  fibroblasts  in  the  deeper  layers  of  the  edges  and  base 
of  the  wound  are  converted  into  cicatricial,  fibrous,  or  scar  tissue  (Fig.  66). 


I30 


Repair 


As  the  granulations  rise  to  a  higher  level  at  the  surface  the  area  of  fibrous  tissue 
becomes  broader  at  the  base  and  margins,  and  this  young  fibrous  tissue  con- 
tracts. By  contracting  it  draws  the  edges  of  the  wound  into  closer  approxima- 
tion, and  thus  lessens  the  area  of  the  surface  which  must  be  covered  with 
epithelium.  When  the  granulations  reach  the  level  of  the  cutaneous  surface  the 
epithelial  cells  at  the  margin  of  the  wound  proliferate,  and  young  epithelial  cells, 
constituting  a  bluish  or  opalescent  film,  grow  over  the  granulations.  Epi- 
thelium comes  only  from  epithelium.  Granulations  are  never  converted  into 
epithelium.  The  epithelial  covering  comes  only  from  the  epithelium  at  the 
wound  margins,  unless  there  be  epithelial  remains  in  the  wound;  for  instance,  an 
undestroyed  papilla,  sweat-duct,  or  hair-follicle.  The  process  of  covering  the 
surface  with  epithelium  is  known  as  epidermization.  The  epidermization  of 
a  large  area  always  consumes  considerable  time  and  sometimes  Nature  fails 
to  accompHsh  it.  In  such  cases  skin-grafting  is  employed  {q.  v.).  Before,  dur- 
ing, and  for  a  time  after  epi- 
dermization the  fibrous  tissue  ^  ^ 
of     the    walls    and   base    of    the          ^      -  r  ^^  '  .'  I  I      I  f  fl  ^ 


Fig.  65. — Blood-vessels  in  granulation 
(Gross). 


Fig.  66. — Cicatricial  tissue;  X  670  (Fowler). 


wound  contracts.  Thus  the  wound  margins  are  pulled  and  held  nearer 
together,  the  gap  to  be  bridged  is  diminished  in  size,  the  danger  of  tear- 
ing apart  of  the  epithelial  layer  is  lessened,  many  capillaries  are  destroyed 
by  pressure,  and  the  scar  becomes  firm,  white,  and  puckered.  Cicatrization 
consists  in  the  conversion  of  immature  connective  tissue  into  mature  fibrous 
tissue  and  in  the  contraction  of  the  new  fibrous  tissue.  The  rate  of  cicatrization 
is  more  rapid  early  in  repair  than  it  is  later  in  the  process.  Carrel  says  the 
rate  is  even  more  dependent  upon  the  area  of  the  wound  than  upon  its  age 
(Carrel  and  Hartmann  in  "Jour,  of  Exper.  Med.,"  1916,  xxiv).  The  larger 
the  wound  the  more  rapid  the  cicatrization.  It  is  sought  by  these  experi- 
menters and  others  (Du  Nouy,  "Jour.  Exper.  Med.,"  1916,  xxiv)  to  measure 
accurately  wounds  to  obtain  a  mathematical  formula  as  to  the  time  for  ideal 
healing  of  a  given  wound.  Cicatrization  is  hurried  in  a  healthy  granulating 
wound  by  the  application  of  an  8  per  cent,  ointment  of  scarlet  red.  It  is 
kept  in  place  only  twenty-four  hours.  To  keep  it  longer  will  irritate  the 
wound  edges.  If  infection  is  severe,  destruction  will  exceed  repair  and  healing 
will  not  occur.  In  such  a  case  there  is  coagulation  necrosis  of  granulation 
tissue,  and  the  wound  becomes  covered  with  tissue  remains  (aplastic  lymph). 
If  granulations  rise  above  the  cutaneous  level,  healing  will  not  take  place, 
because  the  epithelium  cannot  then  grow  over  the  raw  surface.  A  wound  in 
this  condition  is  said  to  possess  exuberant  granulations,  or  proud  flesh.  In 
some  cases  the  granulations  are  pale  from  insufficient  blood-supply,  and  in 
others  edematous  from  venous  congestion.  Contraction  of  the  fibrous  tissue 
may  be  insufficient  because  there  is  adhesion  to  deep  unyielding  fascia  or  to 
periosteum.  Excessive  contraction  is  frequent  after  burns  and  often  produces 
terrible  deformity.     The  scars   or  cicatrices   of  burns   contain   much   elastic 


Cicatrices,  or  Scars  131 

tissue  derived  from  cell  protoplasm.  Infected  wounds  and  ulcers  heal  by 
second  intention. 

Healing  by  Third  Intention.— This  consists  in  the  union  of  two  granu- 
lating surfaces,  the  granulations  of  one  side  fusing  with  the  granulations  of 
the  other  side.  It  is  seen  in  the  union  of  collapsed  abscess-walls.  The  sur- 
geon may  seek  to  obtain  union  of  a  wound  several  days  old  by  third  in- 
tention by  approximating  two  granulating  surfaces.  If  the  surfaces  are 
aseptic,  he  will  often  succeed.  Wounds  may  be  rendered  aseptic  preparatory 
to  secondary  suturing  by  the  use  of  Dakin's  fluid  (page  329).  The  procedure 
of  approximation  is  known  as  secondary  suturing.  It  is  not  unusual  to  pack  a 
wound  with  iodoform  gauze  to  control  oozing.  When  this  is  done  it  is  cus- 
tomary to  pass  the  sutures,  but  not  to  tie  them.  After  a  few  days  the  gauze 
is  removed  and  the  sutures  are  tied.  This  plan  renders  healing  much  more 
rapid^than  would  be  possible  by  the  process  of  healing  by  second  intention. 

Cicatrices,  or  Scars. — The  newly  formed  connective  tissue  which  con- 
stitutes a  scar  will  be  present  in  large  amount  if  more  granulations  were  formed 
than  were  really  necessary  for  repair  or  if  a  considerable  defect  was  repaired. 

A  recent  scar  contains  fibrous  tissue,  many  fibroblasts,  and  numerous 
blood-vessels,  but  no  nerves,  lymphatics,  or  elastic  fibers.  The  skin  above 
recent  scars  is  usually  red  because  of  the  numerous  vessels  beneath  it  and  the 
layer  of  epidermis  is  well  developed.  In  old  scars  fibroblasts  have  disappeared 
and  fibrous  tissue  really  constitutes  the  cicatrix.  Some  blood-vessels  disappear 
and  the  diameters  of  those  remaining  are  much  reduced.  These  vascular 
changes  result  from  contraction  of  the  cicatrix.  Delicate  elastic  fibers  appear 
in  old  scars.  They  appear  at  the  end  of  the  second  month  in  wounds  healed 
by  first  intention,  at  the  end  of  the  third  or  fourth  month  in  wounds  healed  by 
second  intention,  and  they  take  origin  directly  from  cell  protoplasm  and  not 
from  fibrous  tissue  (Minervini,  in  "Virchow's  Archiv,"  vol.  clxxv,  No.  2).  No 
genuine  lymphatics  exist  in  old  scars,  but  occasionally  nerve  filaments  are 
present.  Some  dermal  papillae  are  found  after  a  time,  but  skin  glands,  skin 
muscle,  and  hair-follicles  remain  absent. 

An  old  scar  is  smooth,  whiter  than  the  surrounding  skin,  somewhat  creased 
or  wrinkled  and  deficient  in  tactile  sense.  The  scar  of  a  healed  tuberculous 
ulcer  is  irregular,  livid,  and  often  actually  corrugated.  The  scar  of  a  healed 
syphilitic  ulcer  is  at  first  coppery  red  and  then  glistening  white  and  depressed. 
The  scar  of  an  old  ulcer  of  the  leg  and  of  the  skin  about  it  is  often  darkened 
by  pigmentation. 

A  cicatrix  may  be  discolored  by  retained  foreign  bodies,  for  instance, 
grains  of  gunpowder. 

During  scar  formation  shreds  of  epidermis  may  be  displaced  and  included 
in  granulation  tissue.  Subsequently  they  are  included  in  fibrous  tissue,  and 
may  then  give  rise  to  transplantation  {implantation)  dermoids  or  to  epithelial 
tumors  (see  page  432).  A  scar  may  be  deformed,  for  instance,  may  be  greatly 
depressed  and  adherent  to  underlying  bone,  and  in  certain  situations  such  a 
scar  will  fix  the  jaws  or  any  other  joint.  The  vicious  cicatrix  is  a  great  excess  of 
scar  tissue  and  results  from  delayed  healing  by  second  intention.  Such  cica- 
trices are  particularly  common  after  burns  and  tuberculous  ulcerations.  In 
some  cases  the  scar  is  irregular  and  lumpy,  in  other  cases  it  is  thickened  at 
certain  parts  and  discolored  and  resembles  keloid. 

A  cicatrix  may  block  a  natural  orifice,  as  the  mouth  or  nostril;  may  pro- 
duce great  deformity,  for  instance,  the  head  may  be  drawn  upon  the  chest 
or  shoulder  by  a  contracting  scar  in  the  neck,  fingers  may  have  grown  together 
after  a  burn,  or  a  hideous  depression  may  exist  on  the  forehead  after  an  injury, 
or  the  face  may  be  fearfully  contorted  by  contracting  cicatrices.  A  scar  may 
produce  great  disability  by  blocking  the  jaws,  obstructing  the  rectum  or  ure- 
thra, or  fixing  a  joint  or  certain  muscles  of  an  extremity. 


13- 


Repair 


Most  scars  are  insensitive,  some  are  hypersensitive.  The  hypersensitive 
scars  are  usually  thin  and  pale.  The  itching,  burning,  or  tingling  appreciated 
in  a  sensitive  scar  is  located,  as  a  rule,  at  the  junction  of  sound  skin  and  newly 
formed  epidermis.  Sometimes  acute  neuralgic  pain  in  and  about  a  scar  is  due 
to  pressure  upon  nerve  filaments. 

A  scar  may  inflame  or  ulcerate,  warts  may  spring  from  its  cutaneous  sur- 
face, keloid  may  arise  from  the  fibrous  tissue,  carcinoma  may  come  from  the 
epithelial  elements  (Marjolin's  ulcer),  sarcoma  from  the  connective-tissue 
elements. 

Healing  of  Subcutaneous  Wounds. — Blood  fills  the  tissue  gap  and  the 
blood  clots.  Plasma  exudes  and  corpuscles  migrate  into  the  clot  and  the 
tissue  about  it.  The  clot  is  eaten  up  by  the  leukocytes.  The  connective-tissue 
cells  and  the  endothelial  cells  of  the  adjacent  tissue  proliferate  and  form  fibro- 
blasts, and  fibroblasts  multiply  and  replace  the  clot.  The  area  of  fibroblasts 
is  vascularized  by  the  formation  of  new  capillaries,  fibrous  tissue  forms  and 
strongly  contracts. 

Healing  of  Wounds  in  the  Non=vascular  Tissues. — After  a  trivial 
injury  of  the  cornea  a  few  leukocytes  gather  from  the  lymph-spaces  and  a  few  of 
the  fixed  cells  proliferate.  When  the  cornea  is  more  severely  wounded,  an 
increased  flow  of  lymph  occurs.  The  nerves  are  irritated,  vessels  adjacent  to 
the  cornea  distend,  and  many  leukocytes  invade  the  lymph-spaces.  The  cor- 
neal corpuscles  multiply  and  alter  in  shape.  The  product  of  the  process  may  be 
transparent  if  fibrin  is  absorbed  and  leukocytes  pass  away,  because  proliferating 
corneal  corpuscles  form  transparent  tissue.  The  surface  epithelium  is  re- 
placed by  proliferation  of  the  deep  layer  of  corneal  epithehum.  If  the  wound 
has  penetrated  the  posterior  portion  of  the  cornea,  it  becomes  filled  by  prolifer- 
ating epithelium  from  the 
membrane  of  Descemet. 
In  a  severe  injury  of  the 
cornea  endothelial  cells  and 
corneal  corpuscles  prolifer- 
ate, vessels  grow  in  from  the 
corneal  margins  toward  the 
seat  of  inflammation,  fibrous 
tissue  forms,  and  permanent 
opacity  results. 

Repair  in  cartilage,  when  it 
occurs  at  all,  is  very  slow  and 
is  accomplished  in  the  same 
way  as  repair  in  the  cornea. 
Any  severe  injury  is  repaired 
by  white  fibrous  tissue,  fur- 
nished by  the  cells  of  the  perichondrium,  and  the  scar  is  permanent. 

Cell=division.— The  multiplication  of  connective-tissue  cells  in  repair 
may  be  by  direct,  but  usually  is  by  indirect,  cell-di\dsion.  Direct  cell-division 
consists  in  division  of  the  nucleus  foUowed  by  division  of  the  entire  cell. 

Indirect  cell-division,  or  karyokinesis,  takes  place  after  remarkable  changes 
in  the  nucleus.  The  membrane  of  the  nucleus  disappears;  the  nuclear  net- 
work becomes  first  close  and  then  more  open;  and  the  cell  becomes  round,  if 
not  so  before.  The  network  of  the  nucleus,  now  consisting  of  one  long  fiber, 
takes  the  shape  of  a  rosette;  next  it  takes  a  star  form — the  aster  stage;  two  V's 
next  form — the  equatorial  stage;  an  equatorial  fine  appears  and  widens,^  and 
each  one  of  the  V's  retreats  toward  a  pole.  Thus  two  new  nuclei  are 
formed,  each  polar  V  passing  in  inverse  order  through  the  previous  changes 
of  shape,  and  protoplasm  of  the  original  cell  collecting  about  each  nucleus 
(Fig.  67). 


Fig.  67. — Forms  assumed  by  a  nucleus  dividing  (Green, 
from  Flemming). 


Repair  of  Nerves 


^0.5 


Repair  of  Nerves. — A  nerve-fiber  consists  of  a  core  known  as  the  axis- 
cylinder,  which  is  the  essential  element  in  function.  About  the  axis-cyhnder 
is  an -almost  liquid  material,  known  as  the  medullary  sheath  or  white  substance 
of  Schwann,  or  myelin.  The  myelin  is  surrounded  by  a  firm  sheath  known 
as  the  neurilemma  (sheath  of  Schwann,  primitive  sheath,  neurilemma).  On 
the  inner  surface  of  the  sheath  of  Schwann,  or  between  it  and  the  white  sub- 
stance of  Schwann,  are  nuclei  which  are  supposed  by  some  to  be  peripheral 
nerve-cells  (neuroblasts).  The  neurilemma  is  absent  in  the  brain  and  cord. 
The  continuity  of  the  white  substance  of  Schwann  is  interrupted  at  frequent 
intervals,  and  these  breaks  in  the  myelin  are  called  nodes  of  Ranvier.  Num- 
bers of  fibers  of  the  kind  just  described,  bound  in  bundles  by  connective  tissue 
and  surrounded  by  a  fibrous  sheath,  constitute  a  nerve.  It  is  known  that  a 
nerve  may  regenerate  and  completely  regain  function  after  division;  that  regen- 
eration is  strongly  favored  by  suturing  the  ends  together;  and  that  if  the  ends 
of  a  divided  nerve  are  more  than  i  inch  apart,  regeneration  will  rarely  take  place 
unless  they  are  sutured  together.  The  method  by  which  regeneration  is  effected 
has  been  much  disputed  and  is  still  involved  in  uncertainty.  If  a  nerve  is 
divided,  the  peripheral  segment  at  once  loses  its  function  and  then  undergoes 
degeneration  (^Wallerian  degeneration).  The  degeneration  begins  within 
twenty-four  to  forty-eight  hours  and  affects  the  entire  peripheral  segment. 
The  axis-cylinder  perishes,  the  myelin  runs  into  globules  and  is  absorbed, 
lea^-ing  an  almost  empty  sheath;  the  nuclei  of  the. inner  surface  of  the  neuri- 
lemma prohferate  for  a  time,  but  cease  to  do  so  before  the  myelin  is  completely 
absorbed.  The  sheath  shrinks  and  looks  empty,  but  here  and  there  are  col- 
lected masses  of  proliferated  nuclei  and  protoplasm.  Degeneration  takes 
place  in  days,  but  regeneration  requires  months.  Regeneration  takes  place 
by  the  multiplication  of  pre-existing  nerve-fibers,  and  not  by  the  transforma- 
tion of  connective  tissue  into  nerve  structure.  The  ends  of  a  divided  nerve,  it 
is  true,  become  united  by  connective  tissue  formed  by  the  proliferation  of  fibro- 
blasts, but  this  connective  tissue  is  onty  a  bridge  to  carry  nerve  elements  across 
the  gap  between  the  proximal  and  peripheral  segments.  The  common  view 
is  that  regeneration  takes  place  as  follows:  The  new  axis-cylinder  of  the  per- 
ipheral segment  is  a  prolongation  of  the  old  axis-cylinder  of  the  proximal  seg- 
ment, projected  in  the  follo-\^-ing  manner:  A  fiber,  which  is  at  first  devoid  of 
myelin,  is  prolonged  from  a  proximal  axis-cylinder:  it  di^ddes  into  many  cylin- 
ders, which  pierce  the  granulation  tissue  between  the  separated  ends  and  enter 
into  the  empty  sheaths  of  Schwann  of  the  distal  segment  or  insinuate  themselves 
between  these  sheaths  (Ranvier,  Reclus,  Senn).  Verga  (quoted  in  "Journal  de 
Chirurgie,"  April,  1910)  opposes  the  notion  that  the  peripheral  end  plays 
any  part  in  regeneration  and  advocates  the  view  that  all  regeneration  comes 
from  the  centralend.  The  above  is  the  viev:  entertained  by  those  who  teach 
that  the  new  axis-cylinders  come  entirely  and  only  from  the  prolongation 
of  old  axis-cylinders  of  the  proximal  segment,  that  the  distal  segment  is 
passive  in  the  process  until  "neurotised"  (Vanlair),  and  that  regeneration 
is  impossible  in  the  distal  segment  unless  it  is  in  approximation  with  the 
proximal  segment  or  within  easy  reach  of  the  prolongations  of  the  axis- 
cylinders  from  above.  Another  \dew  is  that  the  axis-cylinders,  myelin,  and 
neinrilemma  are  formed  from  cells  which  exist  in  the  distal  segment,  and 
that  juvenile  axis-cylinders  and  medullary  sheaths  are  formed  in  the  peripheral 
portion  and  then  effect  a  junction  with  like  structures  of  the  central  segment. 
The  last-mentioned  ^iew  is  advocated  by  jNIayer  and  Eichhorst,  Tizzoni, 
Cattani,  and  others,  and  Ballance  and  Stewart  have  pubHshed  a  most  valuable 
monograph  advocating  it  ("The  HeaHng  of  Nerves")-  The  nuclei  prohferate 
and  form  a  mass  of  protoplasm  within  the  old  sheath,  and  this  protoplasm  sub- 
sequently joins  the  proximal  segment.  Such  a  protoplasmic  fiber  has  '"con- 
duction and  irritability"  (Raymond's  "Human  Physiology"),  but  there  is  as 


134  Repair 

yet  neither  myelin  nor  axis-cylinder.  "The  fiber  is  responsive  to  mechanical 
stimuli,  but  not  to  induction  shocks,  which  latter  property  returns  only  after 
the  axis-cyUnder  is  developed.  The  medullary  substance  later  appears  and 
forms  a  tube;  and  still  later  the  axis-cylinder  is  formed,  having  its  origin  in 
the  central  end  of  the  nerve"  (Ibid.).  The  views  of  Ballance  and  Stewart 
may  be  set  forth  as  follows:  When  a  nerve-trunk  is  divided,  the  peripheral 
segment  degenerates  whether  it  has  been  sutured  to  the  proximal  segment 
or  not,  and  the  portion  of  the  proximal  segment  near  the  wound  also  degen- 
erates. The  injury  produces  at  once  an  effusion  of  blood,  migration  of  leuko- 
cytes takes  place  into  and  about  the  wound  at  the  proximal  segment,  but 
leukocytic  invasion  of  the  entire  distal  segment  is  noted.  After  three  days 
connective-tissue  cells  begin  to  replace  the  leukocytes,  and  after  two  weeks 
the  excess  of  leukocytes  is  no  longer  observed,  proHferated  connective-tissue 
cells  having  taken  their  place  (Ballance  and  Stewart,  "Heahng  of  Nerves," 
page  94).  The  proximal  segment  in  the  neighborhood  of  the  wound  and 
the  entire  distal  segment  are  invaded  by  proliferating  connective-tissue  cells. 
The  connective-tissue  cells  completely  absorb  the  fatty  myeUn  and  axis- 
cylinders.  The  cells  of  the  neurilemma  actively  multiply,  and  connective- 
tissue  cells  lying  among  chains  of  neurilemma  cells  become  spindle-shaped 
and  "the  degenerated  nerve-trunk  therefore  becomes  hard,  fibrous,  and  cir- 
rhosed"  (Ibid.). 

In  the  proximal  end  of  a  divided  nerve  an  ''end-bulb^'  is  formed.  This 
was  long  supposed  to  be  due  to  the  prolongation  of  nerve-fibers  from  the  cen- 
tral fibers  and  a  turning  backward  because  they  could  not  cross  the  gap.  As 
a  matter  of  fact,  the  ends  of  the  divided  fibers  curl  up;  on  and  in  this  scaffold- 
like arrangement  new  fibers  are  placed,  they  having  been  produced  by  the 
neurilemma  cells  which  have  taken  on  " neuroblastic  function"  (Ballance  and 
Stewart).  When  a  nerve  has  been  sutured,  the  earUest  signs  of  regeneration 
"occur  at  the  end  of  three  weeks"  (Ibid.).  Short  lengths  of  new  fibers  are 
laid  down  within  old  neurilemma  sheaths.  The  new  axis-cyhnder  "is  seen  to 
consist  in  the  deposition  along  one  side  of  a  spindle-shaped  neurilemma  cell,  of 
a  thin  thread  which  grows  in  length  until  it  projects  beyond  the  limits  of  the 
parent  cell  and  stretches  on  toward  its  next  neighbor  in  the  same  longitudinal 
row"  (Ibid.).  The  new  medullary  sheath  is  "laid  down  by  a  process  of  secre- 
tion" (Ibid.)  along  the  sides  of  the  neurilemma  cells. 

Ballance  and  Stewart  go  on  to  point  out  that  if  the  central  theory  of  regen- 
eration is  true,  not  a  trace  of  regeneration  could  occur  in  the  distal  segment 
when  the  two  segments  have  not  been  united  by  sutures,  and  yet  such  regen- 
eration does  occur,  although  slowly,  the  new  axis-cylinders  and  medullary 
sheaths  not  attaining  full  size.  "Evidently  some  stimulus  afforded  by  the 
conduction  of  impulses  is  necessary  in  order  to  permit  of  their  full  develop- 
ment" (Ibid.).  In  the  notable  study  quoted  at  such  length  are  some  ex- 
periments on  the  "conduct  and  fate  of  '  transplanted  nerve."  When  the 
gap  is  wide  between  the  two  ends,  a  portion  of  fresh  nerve-trunk  may  be  in- 
serted to  bridge  it.  The  transplanted  piece  degenerates;  it  is  invaded  by 
leukocytes,  and  prohferating  connective-tissue  cells,  medullary  sheaths,  and 
axis-cylinders  are  destroyed,  but  regeneration  may  subsequently  occur;  "but 
when  it  does  occur,  it  is  not  from  the  activity  of  the  cells  of  the  graft  itself." 
Blood-vessels  enter  the  degenerated  graft  at  each  end  and  they  are  accom- 
panied by  chains  of  neurilemma  cells,  which  form  axis-cylinders  and  medul- 
lary sheaths.     The  graft  is  merely  a  scaffold. 

The  studies  of  Ballance  and  Stewart  persuade  us  that  regeneration  does 
occur  in  the  distal  part  independently  of  the  proximal  part,  although  full  de- 
velopment does  not  take  place  unless  there  is  a  junction  with  the  central 
part.  As  to  the  exact  method  of  regeneration  we  still  feel  somewhat  un- 
certain.    When   we  remember   that   the   nerve-fibers  of   the  spinal  cord  are 


Repair  of  Muscles  135 

devoid  of  neurilemma  and  that  the  cord  can,  to  some  extent  at  least,  regenerate, 
we  must  conclude  that  regeneration  can  take  place  in  the  cord  without  the  aid  of 
neurilemma  cells,  and  must  infer  that  the  same  may  be  true  in  a  nerve. 

Repair  of  the  Spinal  Cord  and  Brain. — Can  the  spinal  cord  regenerate? 
Many  observers  have  doubted  it.  But  there  is  no  doubt  of  the  fact  that  some- 
times, after  the  subsidence  of  an  acute  myelitis  or  after  the  relief  of  a  pressure 
which  produced  complete  and  prolonged  paralysis,  there  is  a  return  of  func- 
tional power.  It  is  usually  assumed  that  restoration  is  possible  in  fibers  which 
have  not  been  hopelessly  damaged,  but  is  not  possible  in  those  which  have  been 
destroyed;  but,  as  Gowers  says,  there  are  cases  in  which  "we  can  scarcely 
beHeve  that  the  axis-cylinders  retain  their  continuity,  although  conducting 
capacity  is  ultimately  restored."  Chnical  evidence  indicates  strongly  that 
the  pyramidal  fibers  may  regenerate.  Mills  ("The  Nervous  System  and  Its 
Diseases")  says:  "Nerve-tracts  in  the  spinal  cord  and  brain  have  power  to 
regenerate,  but  this  is  not  so  great  as  in  the  peripheral  nerves,  and  yet  even  old 
cases  of  compression  of  the  spinal  cord  may  make  great  improvement  after  a 
long  time,  largely  through  the  regeneration  of  the  columns  of  the  cord."  Mills 
affirms  that  although  nerve-cells  sometimes  appear  to  regenerate,  the  de- 
struction in  these  cases  was  not  complete.  Some  years  ago  I  showed  in  my  clinic 
a  man  who  had  had  complete  paraplegia  with  .paralysis  of  the  bladder  and 
rectum  for  nineteen  years.  The  condition  was  due  to  a  bullet  lodged  within 
the  spinal  canal.  Removal  of  the  bullet  was  followed  in  a  few  weeks  by  restora- 
tion of  control  over  the  bladder  and  rectum.  In  a  few  months  spastic  paraplegia 
was  substituted  for  flaccid  paralysis. 

When  axis-cylinders  have  been  destroyed  in  the  cord  and  yet  some  power 
returns,  we  ask  ourselves:  Does  this  occur  because  new  fibers  have  grown  down 
from  above?  Gow^ers  says  that  such  a  growth  has  been  proved  to  occur  in  the 
lower  animals,  but  has  not  as  yet  been  demonstrated  in  man;  although  speci- 
mens have  been  described  which  strongly  suggest  such  an  occurrence  in  the 
human  subject.  That  the  cord  can  regenerate  to  some  extent  seems  highly 
probable  from  the  report  of  a  case  operated  upon  by  my  colleague.  Professor 
Francis  T.  Stewart,  of  Philadelphia.  He  sutured  a  completely  divided  spinal 
cord  and  extraordinary  restoration  of  function  took  place  (Francis  T.  Stewart 
and  Richard  H.  Harte,  in  "Phila.  Med.  Journal,"  June  7,  1902).  This  case  is 
commented  on  at  some  length  in  the  section  on  Injuries  of  the  Spinal  Cord. 
Another  somewhat  similar  case  was  reported  by  George  Ryerson  Fowler  in  the 
"Annals  of  Surgery,"  Oct.,  1905. 

Many  claim  that  a  brain  injury  cannot  be  followed  by  repair  with  restora- 
tion of  function;  some  think  that  complete  regeneration  can  take  place;  others, 
that  partial  regeneration  may  occur.  Vitzon  and  Tedeschi  even  believe  that 
nerve-cells  in  the  brain  can  regenerate.  It  seems  probable  that  extensive 
injuries  are  not  repaired,  but  slighter  ones  may  be,  new  gangUon-cells  and 
neurogha  being  formed.  Tedeschi  describes  the  process  of  repair  after  a 
wound  of  the  brain  as  follows:  Degeneration  occurs  and  a  limited  focus  of 
necrosis  forms  and  then  the  adjacent  tissue  shows  evidences  of  repair.  Capil- 
laries form  from  the  endothelial  cells,  glia  tissue  from  the  neuroglia,  ganghon- 
cells  present  karyokinetic  changes,  and  some  nerve-fibers  appear  in  the  scar 
(Senn's  "Principles  of  Surgery"). 

Repair  of  Muscles. — It  has  long  been  taught  that  the  repair  of  muscle 
by  muscle  is  impossible,  and,  as  a  matter  of  fact,  it  does  not  take  place  if  the 
ends  of  a  divided  muscle  are  separated  to  the  extent  of  an  inch  or  more.  WTien 
a  muscle  is  divided  transversely  by  a  cut  of  considerable  extent,  the  ends  of 
the  divided  fibers  retract  and  a  wide  space  is  left  between  them.  Blood  flows 
into  the  space  between  the  ends,  and  also  between  individual  fibers  of  the  in- 
jured muscle  and  the  blood-clots.  Exudation  of  plasma  occurs  and  migration 
of  corpuscles  takes  place.     Fibroblasts  are  produced  by  proliferation  of  con- 


136  Repair 

nective-tissue  cells  and  a  mass  of  fibroblasts  soon  replaces  the  blood-clot. 
Granulation  tissue  is  formed  by  vascularization  of  the  mass  of  fibroblasts,  and 
granulation  tissue  is  converted  into  scar  tissue,  but  not  at  all  into  muscle. 
After  slight  injuries  a  trivial  amount  of  muscular  regeneration  does  occur  by  the 
multiplication  of  living  muscle-cells,  but  not  by  metamorphosis  of  fibroblasts. 
Fibroblasts  are  incapable  of  transformation  into  muscular  tissue.  When  the 
ends  of  a  divided  muscle  are  separated  to  a  very  slight  degree  or  when  they 
have  been  brought  together  and  sutured,  some  muscular  regeneration  occurs. 
After  an  injury  a  number  of  the  muscular  fibers  always  wither,  perish,  and  are 
absorbed.  The  process  of  regeneration  arises  from  the  remaining  fibers.  The 
nuclei  of  the  muscle-fiber  proliferate  and  so  do  the  nuclei  of  the  perimysium. 
The  muscle-cells  are  called  myoblasts,  and  the  nuclei  of  the  perimysium  are 
called  sarcoblasts.  About  the  juvenile  muscle-cells  a  deposit  of  protoplasm 
takes  place  (Weber).  The  embryonal  cells  gradually  become  spindle-shaped, 
and  muscular  fiber  is  formed  by  cellular  fusion  or  by  elongation  of  individual 
cells. 

The  above  remarks  refer  to  striated  muscle.  Unstriated  muscle-fibers 
are  repaired  solely  by  "indirect  multiplication  of  their  nuclei"  (Senn). 

If  a  muscle  has  been  divided,  it  should  be  sutured.  This  process  insures 
more  rapid  repair  and  secures  a  better  functional  result,  and  is  followed  by  a 
much  greater  amount  of  muscular  regeneration. 

Repair  of  Tendon. — When  a  tendon  is  divided,  the  ends  retract,  and  the 
sheath,  as  a  rule,  becomes  filled  with  blood-clot.  The  blood-clot  is  rapidly 
removed,  fibroblasts  replacing  it.  This  new  tissue  arises  from  the  sheath, 
the  cut  ends  of  the  tendon  not  participating  in  its  formation.  Granulation 
tissue  is  formed;  this  is  converted  into  fibrous  tissue,  and  after  a  time  the 
fibrous  tissue  becomes  true  tendon.  If  no  blood-clot  forms  in  the  sheath,  the 
walls  of  this  structure  collapse  and  adhere,  and  the  separated  tendon-ends 
are  held  together  by  a  flat  fibrous  band  formed  from  the  collapsed  sheath 
(Warren's  "Surgical  Pathology"). 

Repair  of  Bone. — When  a  bone  is  broken  a  blood-clot  quickly  forms  in 
the  medullary  cavity,  between  the  broken  ends  and  under  and  outside  the  peri- 
osteum. Leukocytes  invade  and  destroy  the  clot.  The  cells  outside  the  peri- 
osteum, the  cells  of  the  periosteum  and  of  the  medullary  tissue,  particularly 
the  endothelial  cells,  proliferate  and  produce  cells  which  are  practically  fibro- 
blasts. The  osteoblasts  in  the  medullary  tissue,  and  perhaps  in  the  deeper 
layers  of  the  periosteum,  multiply  and  are  distributed  through  the  mass  of 
fibroblasts.  The  osteoblasts  may  form  bone  directly  or  may  form  cartilage 
first.  Some  teach  that  fibroblasts  can  be  converted  into  bone;  others  positively 
deny  such  a  conversion.  The  point  is  not  settled,  but  it  is  well  to  remember 
that  in  myositis  ossificans  a  muscle  is  converted  into  bone,  and  hence  that  it  is 
probable  that  fibroblasts,  which  are  formed  from  periosteum  and  medullary 
tissue,  are  more  prone  to  undergo  such  a  development.  During  regeneration 
the  bone  ends  soften  and  are  partially  absorbed  by  osteoclasts.  Osteoclasts  are 
large  osteoblasts  which  have  lost  the  power  of  bone  production  and  furnish  a 
secretion  which  dissolves  osseous  matter.  The  excess  of  callus  is  finally  ab- 
sorbed by  osteoclasts.  (For  a  more  extended  description  see  Repair  of  Frac- 
tures). Sir  Wilham  Macewen  has  denied  emphatically  that  the  periosteum 
plays  a  leading  role  in  bone  production  ("  Brit.  Med.  Jour.,"  June  22, 1907).  He 
believes  that  the  periosteum  is  a  membrane  to  limit  and  control  the  osteoblasts 
and  that  new  bone  is  formed  purely  from  bone  cells.  There  is  much  experimen- 
tal evidence  to  confirm  Sir  William's  assertion.  If  he  is  correct,  a  considerable 
osseous  defect  could  not  be  filled  up  by  new  bone  even  if  the  periosteum  were 
intact.  As  a  clinical  fact,  we  see  this  very  thing  occur.  In  a  more  recent 
article  ("Lancet,"  August  3,  191 2)  Sir  William  claims  that  osteoblasts  are  the 
essential  elements  in  repair,  that  they  come  from  cartilage  cells,  that  when 


Repair  of  Bone 


^37 


growing  bone  is  stripped  of  periosteum  growth  continues,  that  when  bone 
is  removed  and  periosteum  is  left  no  growth  occurs,  and  that  transplantation 
of  spicules  offers  the  best  chance  of  repair  Ijecause  each  fragment  furnishes 
peripheral  growth.  During  the  last  few  years  many  surgeons  have  utiUzed  bone 
transplantation,  for  instance,  transplanting  a  portion  of  a  rib  or  the  crest  of 
the  tibia  of  the  same  individual  to  fix  an  ununited  fracture,  to  fill  a  bone  gap  the 
result  of  osteomyelitis,  or  to  anchor  vertebrae  as  in  Albee's  operation  for  verte- 
bral caries.  Davis  and  Hunnicult  ("  Annals  of  Surgery,"  191 5,  Ixi)  assert  that  a 
transplanted  bit  of  periosteum  and  a  flap  of  periosteum  do  not  produce  new 
bone  unless  shavings  of  bone  have  been  attached,  and  that  removal  of  periosteum 
has  little  effect  in  bone  nutrition.  The  late  Professor  John  B.  Murphy  in  many 
respects  disagreed  with  Macewen.     (See  "Practical  Med.  Series,"  vol.  ii,  19 12.) 


Fig.  68. — Fracture  one  week: 
blood-clot  containing  fragment 
of  bone  (Warren) . 


Fig.  69. — Callus  of  fracture 
(dog),  four  weeks:  commencing 
ossification  of  external  callus. 
(Warren) . 


Fig.  70. — Femur  of  a 
child  fifth  week  after 
fracture  (Warren). 


He  believed  that  a  bit  of  periosteum  completely  detached  from  the  bone  of  a 
young  individual  and  placed  in  the  fat  or  muscle  of  the  same  ^individual  did 
make  new  permanent  bone.  If  one  end  of  the  strip  were  allowed  to  retain  at- 
tachment to  the  bone,  the  transplanted  end  practically  always  made  new 
bone.  Bone  with  or  without  periosteum  transplanted  in  the  same  individual 
and  placed  in  contact  with  growing  bone  united  to  the  living  bone,  acting  as  a 
scaffold  for  blood-vessels  and  osteogenetic  cells,  and  was  eventually  absorbed. 
Many  cases  studied  during  this  war  indicate  the  frequent  high  value  of  bone 
fragments  in  aiding  repair.  Fragments  covered  with  periosteum  seem  to  have 
been  of  particular  use.  Only  fragments  devoid  of  periosteum,  those  seriously 
infected  and  those  distant  from  the  bone  injury  should  be  removed  by  the 


138  Repair 

surgeon.  If  these  statements  are  confirmed  we  must  accept  Mur[)hy's  view  as 
to  the  value  of  {)eriosteum. 

Repair  of  Blood=vessels. — If  an  artery  is  cut  across  and  Ugated,  a  clot 
forms  within  its  lumen  and  about  its  divided  end,  and  the  circulation  in  the 
vessel  at  this  point  is  permanently  arrested.  The  proximal  clot,  it  used  to  be 
thought,  always  reaches  the  first  collateral  branch.  This  statement  was  true 
before  the  days  of  asepsis;  it  is  not  always  true  now.  Often  a  clot  stops  far 
short  of  the  branch  above.  Exudation  of  plasma  and  migration  of  corpuscles 
take  place  from  the  vasa  vasorum;  The  clot  becomes  filled  with  leukocytes, 
which  gradually  destroy  it,  and  it  plays  no  active  part  in  repair.  Fibroblasts 
form  by  the  multiplication  of  the  cells  of  the  vessel  wall  and  the  clot  is  soon 
replaced  by  fibroblasts.  The  fibroblasts  are  converted  into  granulation  tissue, 
granulation  tissue  becomes  fibrous  tissue,  the  fibrous  tissue  contracts,  and  the 
artery  is  transformed  into  a  fibrous  cord.  Warren  insists  that  the  muscle- 
cells  of  the  middle  coat  play  an  active  part  in  repair.  Usually,  when  a  liga- 
ture is  applied  to  an  artery  in  continuity,  a  deliberate  attempt  is  made  to 
rupture  the  internal  and  middle  coats,  in  order  to  permit  of  contraction  and 
retraction  above  and  below  the  seat  of  ligature,  and  a  turning  inward  of  the 
inner  coat.  Such  a  sequence  of  events  happens  when  an  artery  is  completely 
divided  across  and  not  tied,  and  favors  the  rapid  formation  of  a  clot. 

Ballance  and  Edmunds  ("Ligation  in  Continuity")  maintain  that  repair 
is  obtained  most  rapidly  when  the  artery  is  tied  with  two  ligatures,  the  vessel 
at  this  point  being  deprived  of  blood,  but  the  internal  and  middle  coats  being 
kept  intact.  Cell-proliferation  forms  a  spindle-shaped  mass  of  new  cells  and 
the  lumen  is  obliterated  at  the  seat  of  ligation  by  fibroblasts  obtained  from 
the  fixed  cells  of  the  wall  of  the  artery.  Halsted's  studies  seem  to  disprove 
these  views.  Senn  advocates  the  employment  of  two  ligatures,  not  placed 
side  by  side  as  in  the  method  of  Ballance  and  Edmunds,  but  so  applied  as  to 
include  "a  bloodless  space  about  l^  inch  in  length"  ("Principles  of  Surgery"). 
Professor  Halsted  ("Surgery,  Gynecology  and  Obstetrics,"  Dec,  19 18)  shows 
that  an  aluminum  band,  no  matter  how  tightly  rolled  does  not  rupture  the 
intima;  that  intimal  surfaces  however  lightly  brought  together  do  not  unite 
by  first  intention  but  necrosis  always  ensues;  that  a  gradual  substitution  of 
the  necrotic  tissue  takes  place,  new  vessels  entering  from  both  ends,  and 
finally  a  fibrous  cord  forms.  Sutures  lightly  approximating  intimal  surfaces 
act  like  a  band. 

When  a  lateral  ligature  is  applied  to  a  vein  or  when  a  small  wound  in  a 
vein  or  artery  is  sutured,  the  circulation  in  the  vessel  is  not  completely  cut  ofif, 
a  thrombus  of  small  size  is  formed  on  the  vessel  walls,  the  fixed  cells  of  the 
vessel  wall  proliferate,  and  a  scar  of  fibrous  tissue  eflfects  repair.  A  com- 
pletely divided  vein  heals  as  does  a  completely  divided  artery.  The  clot 
after  the  aseptic  application  of  a  ligature  to  a  vein  may  be  of  sHght  extent, 
but  in  some  cases  the  proximal  clot  reaches  the  first  collateral  branch  and  in 
others  goes  far  above  it. 

Repair  of  Skin. — The  fibrous  structure  is  repaired  by  fibrous  tissue.  Hair- 
follicles,  sweat-glands,  and  sebaceous  glands  are  not  re-formed.  The  epithelial 
layer  is  regenerated  by  the  proliferation  of  adjacent  epithelial  cells. 

Repair  of  Lymphatic  Tissue. — Lymphatic  tissue  may  be  formed  from 
the  fatty  tissue,  or  the  divided  ends  of  the  lymph-ducts.  When  a  gland  has 
been  removed  a  new  gland  may  be  formed.  When  a  gland  has  been  partially 
removed  it  heals  by  scar  tissue  but  does  not  regenerate. 

Repair  of  the  Kidney  and  Testicle, — These  organs  when  damaged  can  undergo 
some  regeneration. 

Repair  of  the  Liver  and  Spleen. — Each  of  these  organs,  after  injury,  is  capable 
of  considerable  regeneration. 


Aseptic  Traumatic  Fever  139 


V.  SURGICAL  FEVERS 

The  surgeon  encounters  fever  as  a  result  of  an  inflammation  or  an  aseptic 
wound,  in  consequence  of  infection,  as  a  result  of  poisoning  by  certain  drugs, 
and  in  several  maladies  of  the  nervous  system.  It  is  important  to  remember 
that,  while  elevated  temperature  is  generally  taken  as  a  gauge  of  the  intensity 
of  fever,  it  is  not  a  certain  index.  There  -may  be  fever  with  subnormal  tem- 
perature (as  in  collapse  of  t>'phoid  or  pneumonia),  and  there  may  be  elevated 
temperature  without  true  fever  (as  in  certain  diseases  of  the  nervous 
system).  It  is  true,  however,  that  elevation  of  temperature  is  almost 
always  noted,  and  is  usually  accepted  as  the  measure  of  the  severity  of  the 
fever. 

Elevated  temperature  is  only  a  symptom.  The  elevated  temperature  of  an 
infection  may  be  regarded  as  evidence  that  the  body  is  fighting  the  infection. 
An  acute  infection  with  a  low  or  subnormal  temperature  is  a  far  graver  condi- 
tion than  an  acute  infection  with  a  high  temperature.  The  low  temperature 
shows  that  the  body  is  abandoning  the  contest;  the  subnormal  temperature 
shows  that  it  has  abandoned  it.  Exham  ("Brit.  Med.  Jour.,"  January  27, 
191 2)  points  out  that  the  worst  cases  of  pneumonia,  peritonitis,  and  diph- 
theria are  those  with  subnormal  temperature,  and  that  in  some  of  the  most 
malignant  cases  of  scarlet  fever  the  temperature  does  not  rise  much  above 
ioo°F.  As  Exham  says:  elevated  temperature  is  a  defence  and  subnormal 
temperature  means  that  body  resistance  is  at  an  end  (see  page  50).  If  in 
doubt  as  to  the  cause  of  fever,  count  the  leukocytes;  make  a  blood-culture,  a 
Widal  test,  and  a  Wassermann  test. 

The  essential  phenomena  of  fever,  according  to  T.  J.  Maclagan  ("Fever,  A 
Clinical  Study")  are — (i)  wasting  of  nitrogenous  tissue;  (2)  increased  consump- 
tion of  water;  (3)  increased  elimination  of  urea;  (4)  increased  rapidity  of  circula- 
tion; (5)  preternatural  heat. 

Traumatic  fevers  follow  traumatism  and  attend  the  healing  or  infection 
of  a  wound.  The  forms  are — (i)  benign  traumatic  fever;  (2)  malignant  trau- 
matic fever. 

Benign  traumatic  fever  is  divided  into  two  forms — the  aseptic  and  the 
septic.  There  is  but  one  form  of  aseptic  fever,  the  postoperation  rise._  The 
septic  benign  fevers  are  surgical  fever  and  suppurative  fever.  The  malignant 
traumatic  fevers  are  sapremia,  septic  infection,  and  pyemia.  In  this  section  we 
discuss  the  benign  fevers  only. 

Aseptic  traumatic  fever,  or  the  postoperation  rise,  often,  but  not  always, 
appears  after  a  thoroughlv  aseptic  operation  and  after  a  simple  fracture  or  a 
contusion.  It  is  not  preceded  by  a  chill,  by  chilliness,  or  by  a  feeling  of  illness. 
It  may  appear  during  the  evening  of  the  day  of  operation  or  not  until  the  next 
day,  and  reaches  its  highest  point  by  the  evening  of  the  second  day  (ioo°-io3° 
F.).  This  elevation  is  spoken  of  as  the  "postoperation  rise"  because  it  is 
usually  encountered  after  an  operation.  Besides  the  elevated  temperature 
there  are  no  obvious  symptoms;  the  patient  feels  well,  seeps  well,  and  often 
wants  to  sit  up;  there' are  no  rigors  and  there  is  no  dehrium.  The  wound  is 
free  from  pain  and  appears  entirelv  normal.  Blood  examination  may  show 
moderate  leukocytosis.  This  fever  is  due  to  absorption  of  pyrogenous  material 
from  the  wound' area,  the  material  being  obtained  from  clot  or  inflammatory 
exudate,  or  from  both.  Many  observers  beheve  that  the  pyrogenous  element 
is  fibrin  ferment,  which  is  absorbed  from  disintegrating  blood-clot  and  coagu- 
lating exudate.  Warren  thinks  the  fever  is  due  to  fibrin  ferment,  and  "also 
to  other  substances  slightly  altered  from  their  original  composition  durmg  life.  ' 
Some  have  asserted  that  t'he  fever  is  due  to  nervous  shock. 


I40  Surgical  Fevers 

Schnitzler  and  Ewald  have  studied  aseptic  fever.'  These  observers  main- 
tain that  aseptic  fever  can  exist  when  no  fibrin  ferment  is  free  in  the  blood,  that 
fibrin  ferment  can  be  free  in  the  blood  when  there  is  no  fever,  and,  in  conse- 
quence, that  fibrin  ferment  is  not  the  cause  of  the  elevation  of  temperature. 
They  rule  out  of  consideration  nervous  shock  as  a  cause,  and  assert  that  a 
combination  of  several  factors  is  responsible,  nucleins  and  albumoses  which 
are  set  free  by  traumatism  being  looked  upon  as  the  most  active  causative 
agents.  The  presence  of  nuclein  in  the  blood  in  aseptic  fever  is  indicated  by 
leukocytosis  and  by  the  increase  of  the  alloxur  bodies  (including  uric  acid)  in 
the  urine.  The  capacity  of  nucleins  and  albumoses  to  cause  elevated  tempera- 
ture is  greater  in  the  tuberculous  than  in  the  non-tuberculous,  and  we  know 
clinically  that  a  tuberculous  patient  is  apt  to  exhibit  a  more  violent  postopera- 
tion  rise  than  is  a  non-tuberculous  subject.  The  diagnosis  of  aseptic  traumatic 
fever  is  only  to  be  made  after  a  careful  examination  has  assured  the  surgeon 
that  there  is  no  obscure  or  hidden  area  of  infection. 

In  some  cases  aseptic  fever  may  appear  after  an  operation,  and  later  be 
replaced  by  a  septic  fever.  If  the  temperature  remains  elevated  more  than  a 
day  or  so,  if  other  symptoms  appear,  or  if  after  the  temperature  has  become 
normal  it  again  rises,  the  wound  should  be  examined  at  once,  as  trouble  almost 
certainly  exists. 

True  traumatic,  or  genuine  surgical  fever,  is  seen  as  a  result  of  infected 
wounds  in  which  there  is  decided  inflammation,  but  no  pus.  The  real  cause 
is  the  presence  of  fermentative  bacteria  in  the  wound  and  the  absorption  of  a 
moderate  amount  of  their  toxic  products.  The  most  active  and  commonly 
present  organisms  are  those  of  putrefaction.  Surgical  fever  ceases  as  soon  as 
free  discharge  occurs,  and  the  appearance  of  such  a  fever  is  an  indication  for 
instant  drainage.  The  condition  is  ushered  in  two  or  three  days  after  the 
operation  by  chilly  sensations  and  general  discomfort.  The  temperature  rises 
pretty  sharply,  ascends  with  evening  exacerbations  and  morning  remissions, 
and  reaches  its  height  about  the  third  or  fourth  day,  when  suppuration  sets  in; 
the  temperature  begins  to  drop  when  pus  forms,  if  the  pus  has  free  exit,  and 
reaches  normal  at  the  end  of  a  week.  (See  Suppurative  Fever.)  The  tempera- 
ture may  reach  104°  F.  or  more,  but  rarely  rises  above  103°  F.  The  patient  has 
the  general  phenomena  of  fever,  that  is  to  say,  thirst,  anorexia,  nausea,  dry  and 
coated  tongue,  constipation,  pain  in  the  back  and  legs,  and  headache.  The 
urine  is  scanty  and  high  colored.  Blood  examination  usually  shows  decided 
leukocytosis.  The  wound  is  painful,  tender,  swollen,  discolored,  and  often 
foul,  and  stitch-abscesses  may  form.  Some  or  all  of  the  stitches  must  be  cut, 
the  area  should  be  asepticized,  the  wound  edges  separated  by  iodoform  gauze, 
or  the  wound  drained  by  a  tube.  The  fact  that  this  fever  is  apt  to  cease  when 
discharge  of  pus  begins  led  the  older  surgeons  to  hope  for  pus  and  to  endeavor 
to  cause  it  to  form.  A  severe  grade  of  surgical  fever,  such  as  arises  when  there 
is  putrefaction  in  a  large  and  ill-drained  wound,  is  due  to  the  absorption  of  a 
large  quantity  of  the  toxic  products  of  putrefactive  bacteria,  and  is  known  as 
sapremia  (see  page  214). 

Suppurative  Fever. — This  fever,  which  is  due  to  the  absorption  of  the 
toxins  of  pyogenic  organisms,  occurs  after  suppuration  has  begun,  is  found 
when  the  pus  has  not  free  exit,  and  is  an  intoxication  rather  than  an  infection, 
that  is  to  say,  toxins  enter  the  blood,  but  no  bacteria.  It  can  follow  or  be 
associated  with  surgical  fever,  or  may  arise  in  cases  in  which  surgical  fever  has 
not  existed.  Suppuration  in  a  wound  is  indicated  by  a  rapid  rise  of  tempera- 
ture— possibly  by  a  chill.  The  temperature  rises  to  a  considerable  height, 
shows  morning  remissions  and  evening  exacerbations,  and  as  it  begins  to  fall 
toward  morning  sweating  occurs.     The  patient  is  much  exhausted  and  presents 

1  See  "Archiv  fiir  klinische  Medicin,"  Bd.  liii,  H.  3,  1896;  also  statement  of  their  views 
in  "Medical  Record,"  Dec.  19,  1896. 


Neurotic  or  Hysterical  Fever  141 

the  phenomena  of  fever  previously  described.  The  skin  about  the  wound  be- 
comes swollen,  dusky  in  color,  and  edematous,  pain  becomes  pulsatile,  and  much 
tenderness  develops.  Blood  examination  shows  \-cry  marked  leukocytosis.  The 
wound  must  at  once  be  drained  and  antisepticized.  In  a  chronic  suppuration, 
such  as  occurs  when  there  is  pyogenic  infection  of  a  tuberculous  area,  there 
exists  a  fever  with  marked  morning  remissions  and  vesperal  exacerbations, 
attended  with  drenching  night-sweats,  emaciation,  diarrhea,  and  exhaustion. 
This  is  known  as  hectic  fever;  it  is  really  a  chronic  suppurative  fever.  The  treat- 
ment of  hectic  fever  consists  in  the  drainage  and  disinfection,  if  possible,  the 
excision  of  the  infected  area,  the  employment  of  a  nutritious  diet,  stimulants, 
tonics,  remedies  for  the  exhausting  sweats,  and  free  access  of  fresh  air. 

Some  Other  Forms  of  Fever  Seen  by  the  Surgeon. — Fever  of  Ten- 
sion.— When  there  is  great  tension  upon  the  stitches,  the  spots  where  the 
stitches  perforate  ulcerate  and  some  fever  arises.  To  relieve  the  fever  of 
tension  cut  one  or  several  stitches.  This  fever  is  in  some  cases  surgical,  and 
in  some  suppurative,  according  as  to  whether  the  infective  organisms  cause 
fermentation  or  suppuration. 

Fever  of  Iodoform  Absorption. — (See  page  34.) 
Fever  of  Ptyalism,  or  Mercurial  Fever. — (See  page  389.) 
Fever  Due  to  Awakening  of  an  Area  of  Pulmonary  Tuberculosis. — A  quiet, 
jion-progressive  area  of  pulmonary  tuberculosis  may  burst  into  activity  after  an 
operation,  and  is  particularly  apt  to  if  ether  has  been  administered.  The  surgeon 
must  be  watchful  of  this  condition.  Several  times  I  have  seen  a  person  with 
signs  suggesting  bronchitis  at  the  base  of  one  lung  develop  a  moderate  and 
prolonged  fever.  Such  a  condition  is  not  bronchitis  because  it  is  unilateral. 
The  sputum  shows  pus  cocci,  but  no  tubercle  bacilli.  I  formerly  regarded 
it  as  tuberculosis,  but  it  is  always  recovered  from  and  is  probably  broncho- 
pneumonia of  one  lobe  of  one  lung. 

Fever  of  Morphinism. — Sometimes  a  morphin  habitue  suffers  from  severe 
chills  and  intermittent  fever  of  the  quotidian  or  tertian  t}qDe.  The  condition 
is  usually  thought  to  be  malarial,  a  view  which  is  strengthened  by  the  common 
association  with  neuralgia;  but  quinin  proves  futile  as  a  remedy  and  blood 
examination  gives  a  negative  result.  If  we  have  reason  to  suspect  that  the 
patient  is  using  morphin,  examine  the  urine  for  the  drug  and  wash  out  the 
stomach  and  examine  the  washing.  The  latter  test  is  of  value  even  when 
morphin  is  used  h\'podermatically,  because  some  of  the  drug  is  excreted  into 
the  stomach. 

Fever  of  Cocain-poisoning.— (See  Local  Anesthesia.) 
Hepatic  Fever. — (See  section  on  Liver  and  Gall-bladder.) 
Neurotic  or  Hysterical  Fever. — This  remarkable  condition  is  occasionally, 
though  seldom,  encountered.  It  is  unusual  for  the  temperature  to  rise  above 
101°  F.  Most  of  the  reported  cases  of  great  h}^erpyrexia  are  instances  of 
simulation  and  fraud.  That  very  great  elevation  can  occur  is  shown  by  the 
case  seen  by  jSIr.  J.  W.  Teale,  which  case  was  also  observed  by  Sk  Chfford 
Allbutt.  The  temperature  rose  again  and  again  to  118°  F.  In  such  cases  the 
temperature  rises  very  rapidly,  remains  at  its  height  but  a  short  time,  and  then 
falls  as  rapidly  as  it  'arose.  It  may  happen  that  elevated  temperature  is  the 
sole  evidence  of  illness,  there  being  no  wasting,  thirst,  or  other  febrile  symp- 
toms. Cold  sponging  rapidly  lowers  the  temperature.  Such  elevated  tempera- 
ture may  occur  irregularly  or  be  attained  daily  for  months.  As  a  rule,  hys- 
terical stigmata  can  be  detected.  Osier  points  out  that  cases  of  hysterical 
fever  "with  spurious  local  manifestations"  are  very  deceptive.  The  case  may 
resemble  meningitis,  peritonitis,  or  some  other  acute  inflammatory  condition; 
but  the  course  of  the  supposed  malady  is  found  to  be  at\'pical  and  the  symptoms 
are  observed  to  be  variable  and  often  anomalous.  There  is  no  leukocytosis; 
frequently  there  is  an  apparent  increase  in  red  cells,  because  of  vasomotor 


142  Surgical  Fevers 

disturbance,  a  fall  in  hemoglobin,  and  an  increased  proportion  of  lymphocytes 
and  eosinophiles  ("Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.).  It  is 
dangerous  to  make  a  diagnosis  of  neurotic  fever;  it  must  not  be  done  unless 
all  other  possible  causes  have  been  excluded.  Some  supposed  cases  depend 
upon  unrecognized  tuberculosis,  some  on  visceral  syphilis,  some  on  undiscov- 
ered malignant  disease,  some  on  toxin  absorption  from  the  alimentary  canal. 

An  emotional  fever  sometimes  occurs  after  accidents  or  operations.  The 
patient  may  have  a  chill,  and  then  develop  violent  headache,  photophobia,  and 
hysterical  excitement,  with  elevated  temperature.  Inexplicable  elevations  of 
temperature  may  occur  in  neurasthenia. 

Malaria. — It  is  wise  to  examine  the  blood  in  supposed  septic  fevers,  for 
only  by  this  means  can  malaria  be  excluded.  It  is  more  common  to  mistake 
sepsis  for  malaria  than  malaria  for  sepsis.  In  malaria  the  spleen  is  enlarged, 
the  febrile  attacks  exhibit  periodicity,  neuralgias  are  common  associates,  and 
quinin  cures  the  condition. 

Surgical  Scarlet  Fever. — It  is  maintained  by  some  writers  (notably  Sir  Victor 
Horsley  and  Sir  James  Paget)  that  a  child  is  rendered  especially  susceptible  to 
scarlet  fever  by  the  shock  of  a  surgical  operation.  Scarlet  fever  which  develops 
after  a  wound,  a  burn,  or  an  operation  is  spoken  of  as  surgical  scarlet 
fever.  Warren  quotes  Thomas  Smith  as  having  had  lo  cases  of  scarlet 
fever  in  43  operations  of  lithotomy  in  children.  The  puerperal  state  is  sup- 
posed also  to  predispose  to  scarlet  fever.  It  is  not  certain  whether  the  poison 
enters  by  the  wound,  or  whether  shock  and  exhaustion  predispose  to  ordinary 
scarlatina,  or  whether  ordinary  scarlatina  was  incubating  before  the  accident 
or  operation.  Some  surgeons  hold  that  an  attack  of  scarlet  fever  after  an 
operation  is  a  mere  coincidence.  Others  maintain,  and  with  great  show  of 
reason,  that  a  red  scarlatiniform  eruption  appearing  after  an  operation  rarely 
indicates  genuine  scarlet  fever,  but  usually  points  to  infection,  as  such  eruptions 
are  known  occasionally  to  arise  in  septicemia.  It  rarely  indicates  scarlet  fever, 
and  yet  it  sometimes  does.  There  is  such  a  condition  as  surgical  scarlet  fever, 
as  is  proved  by  the  facts  that  victims  of  the  disease  have  been  known  to  com- 
municate it,  and  that  it  is  often  followed  by  "nephritis  and  usually  by  des- 
quamation" (Holt's  "Diseases  of  Infancy  and  Childhood"). 

Hoffa  has  discussed  this  subject  elaborately.  He  concludes  that  four  types 
of  eruption  can  follow  operation:  (i)  a  vasomotor  disturbance  due  to  irrita- 
tion of  sensory  nerves,  and  manifested  by  a  transient  urticaria  or  erythema; 
(2)  a  toxic  erythema  due  to  absorption  of  aseptic  pyrogenous  material  from 
the  injured  area— the  absorption  of  carbolic  acid,  iodoform,  of  corrosive  sub- 
limate, or  the  effect  of  ether;  (3)  an  infectious  rash,  which  is  sometimes  found 
in  septicemia  or  pyemia,  and  is  due  to  minute  emboli  composed  of  bacteria, 
which  emboH  lodge  in  the  capillaries;  (4)  true  scarlet  fever,  with  the  usual 
symptoms  and  complications,  the  micro-organisms  having  entered  by  way  of 
the  wound  and  the  eruption  often  beginning  at  the  wound  edges  (quoted  in 
Warren's  "  Surgical  Pathology").  Surgical  scarlatina  is  aberrant.  It  develops 
rapidly,  the  period  of  incubation  is  extremely  brief,  and  the  throat  may  or  may 
not  be  involved.  Holt  tells  us  that  the  rash  is  usually  atypical  and  that  "the 
general  symptoms,  particularly  those  relating  to  the  nervous  system,"  are 
"especially  severe"  ("Diseases  of  Infancy  and  Childhood").  The  infection 
is  believed  to  be  due  to  a  specific  germ,  but  it  has  not  been  certainly  identi- 
fied. Streptococci  have  been  found  in  the  throat,  skin,  and  the  pus  from 
secondary  otitis  media. 

If  surgical  scarlet  fever  develops  the  wound  should  be  drained  and  asepti- 
cized, and,  if  the  situation  admits  of  it,  dressed  with  hot  antiseptic  fomentations. 
The  general  treatment  is  the  same  as  for  ordinary  scarlatina. 

Fever  of  Malignant  Disease. — Elevation  of  temperature  may  occur  during 
the  course  of  sarcoma  or  carcinoma.     It  is  particularly  apt  to  if  growth  is  very 


Suppuration  and  Abscess  143 

rapid  or  if  ulceration  exists.     Malignant  growths  of  the  liver  are  especially  apt 
to  cause  elevation  of  temperature  and  leukocytosis. 

Fever  of  malignant  disease  usually  appears  as  irregular  elevations  of  tem- 
perature of  short  duration.  In  some  cases  there  is  a  continuous  or  remittent 
fever;  in  some  an  intermittent  fever.     Even  the  hectic  type  is  met  with. 

Urinary  Fever  and   Urethral  Fever. — (See  section  on   Disease  of   Genito- 
urinary Organs.) 

Syphilitic  Fever. — (See  page  372.) 

Thyroid  Fever. — (See  section  on  Thyroid  Gland.) 

Postoperative  Thermic  Fever  (Insolation  Sunstroke). — In  the  heat  of 
summer  I  have  seen  several  patients  after  operation  present  rises  of  temperature 
apparently  due  to  heat  stroke.  In  one  case  of  appendicitis  the  temperature 
rose  to  107°  and  the  other  symptoms  of  thermic  fever  developed  during  an 
operation  for  appendicitis.  One  case  of  appendicitis  died  after  operation  from 
what  was  believed  to  be  heat  stroke.  There  are  12  cases  reported  (Alexis  V. 
Moschcowitz  in  "Surgery,  Gynecology,  and  Obstetrics,"  Oct.,  1916). 

I  do  not  believe  that  heat  stroke  can  arise  only  in  one  who  has  been  exposed 
to  the  direct  rays  of  the  sun.  If  we  believe  direct  exposure  the  requisite,  we 
must  disbeheve  in  postoperative  insolation.  Brouardel  says — "it  is  not  the 
solar  radiation  which  kills.  People  are  found  dead  in  the  shade  of  a  wood  or 
under  a  tent,  while  the  thermometer  registers  97°  F.  in  the  shade"  ("Death  and 
Sudden  Death"). 

The  ice-bag  to  the  head,  cold  sponging  and  proctoclysis  with  iced  water 
constitute  the  best  treatment. 


VI.  SUPPURATION  AND  ABSCESS 

Suppuration  is  a  process  in  which  damaged  living  tissues  and  inflamma- 
tory exudates  are  liquefied  by  the  action  of  pyogenic  organisms,  and  it  is  a  com- 
mon result  of  microbic  inflammation.  The  organisms  which  are  responsible 
are  referred  to  on  page  56.  Staphylococci  tend  to  produce  local  suppuration; 
streptococci  tend  to  cause  spreading  suppuration.  It  is  generally  taught  that 
pyogenic  bacteria  liquefy  damaged  tissues  and  exudates  by  peptonizing  them, 
the  active  agent  in  effecting  the  chemical  change  being  poison  furnished  by 
the  bacteria.  There  is  some  evidence  that  white  corpuscles  by  disintegration 
set  free  enzymes,  which  dissolve  or  aid  in  dissolving  albumin.  Streptococci 
and  staphylococci  vary  greatly  in  virulence,  and  the  intensity  and  diffusion  of 
a  pyogenic  infection  depends  upon  the  virulence  and  number  of  the  bacteria 
and  the  level  of  vital  resistance.  Streptococci  and  staphylococci  may  both  be 
present  in  one  focus,  and  there  may  be  secondary  infection  with  bacteria  of 
putrefaction  or  other  bacteria.  The  pyogenic  infection  may  be  primary  or  it 
may  be  secondarily  implanted  in  a  disease  area  containing  other  micro-organ- 
isms. The  pyogenic  organisms  are  very  irritant,  and  when  deposited  cause  in- 
flammation; inflammation  leads  to  exudation,  but  the  exudate  cannot  coagu- 
late or  coagulates  but  imperfectly,  because  it  is  peptonized  by  the  ferment  of 
the  micro-organisms  and  also  perhaps  because  albumin  is  dissolved  by  leukoly- 
sin  from  the  white  corpuscles.  If  an  area  of  embryonic  tissue  is  invaded  by 
many  pyogenic  micro-organisms,  it  is  promptly  peptonized.  The  peptonizing 
action  is  upon  the  fibrinous  elements  of  an  exudate  and  upon  the  intercellular 
substance  of  embryonic  or  granulation  tissue.  Cells  are  separated  from  inter- 
cellular substance,  and  in  consequence  degenerate  and  die.  Peptonized  exu- 
date or  peptonized  embryonic  tissue  is  called  pus.  In  suppurations  induced  by 
staphylococci  a  barrier  of  leukocytes  is  first  formed  around  the  region  of  irrita- 
tion; this  barrier  is  reinforced  by  fibroblasts,  the  pus  is  imprisoned,  and  rapid 
spreading  and  wide  diffusion  are  prevented.     In  inflammations  induced  by 


144  Suppuration  and  Abscess 

streptococci  the  peptonizing  action  of  the  organisms  is  so  great  that  no  barrier 
of  white  blood-cells  or  of  proliferating  connective-tissue  cells  forms  in  time  to 
imprison  the  micro-organisms,  hence  the  suppuration  spreads  rapidly  and 
widely.  During  the  existence  of  a  streptococcic  infection  some  bacteria  always 
enter  the  blood.  Suppuration  can  be  induced  by  the  injection  of  pyogenic 
bacteria,  by  their  entry  through  a  wound,  and  by  rubbing  them  into  the  skin. 
In  some  rare  instances,  especially  when  the  diet  has  been  putrid,  they  may 
enter  through  the  blood  and  lodge  at  a  point  of  least  resistance.  When  a 
medullary  canal  suppurates  after  a  chill  to  the  surface  or  after  a  blow  that  does 
not  cause  a  wound,  we  know  that  the  bacteria  must  have  arrived  by  means  of 
the  blood.  Bacteria  which  reach  a  point  of  least  resistance  through  the  blood 
come  from  some  atrium  of  infection  which  may  be  discoverable  or  which  may 
not  be  found.  The  entry  of  pyogenic  bacteria  does  not  necessarily  cause  sup- 
puration, as  the  healthy  human  body  can  destroy  a  considerable  number,  even 
if  given  in  one  "  dose;"  but  a  large  number  in  a  healthy,  or  even  a  small  number 
in  an  unhealthy  body  almost  certainly  leads  to  pus  formation.  The  pus  of  all 
acute  abscesses  contains  bacteria  of  suppuration,  but  the  pus  of  tuberculous 
abscesses  does  not,  unless  there  be  a  mixed  infection;  in  other  words,  pure 
tuberculous  pus  is  not  pus  at  all. 

Can  suppuration  be  induced  without  the  actual  presence  of  bacteria?  It  is 
true  that  the  injection  of  irritants  can  cause  the  formation  of  a  thin  fluid  which 
contains  no  bacteria,  but  this  non-bacterial  fluid  is  not  pus.  A  purulent  fluid 
may  be  formed  by  injecting  cultures  of  pus  cocci  which  have  been  rendered 
sterile  by  heat,  the  bacteria  having  been  killed,  a  ferment  contained  in  the 
bacterial  cells  being  the  active  agent.  Purulent  material  also  results  from  the 
injection  simply  of  the  sterile  products  of  the  growth  of  pyogenic  cocci.  This 
purulent  or  sterile  fluid  is  known  as  spurious  or  aseptic  pus.  An  area  of  such 
aseptic  suppuration  does  not  tend  to  spread  and  the  process  concerns  us  but 
little  as  surgeons,  except  in  cases  of  pyemia,  in  which  thrombi  containing  toxins 
alone  may  occasionally  induce  limited  secondary  abscesses. 

Impaired  health  or  an  area  of  lowered  vitahty  predisposes  to  suppuration. 
Diabetes  and  albuminuria  are  common  and  influential  predisposing  causes, 
because  in  these  diseases  tissue  resistance  is  always  at  a  low  ebb.  In 
amyloid  disease  resistance  to  pus  cocci  is  greatly  impaired.  It  is  lessened  in 
lithemia  and  in  any  condition  of  ill  health.  The  lymphatic  glands,  medulla 
of  bones,  serous  membranes,  and  connective  tissue  are  especially  prone  to 
suppurate. 

Pus  may  form  within  twenty-four  hours  after  bacteria  have  been  deposited, 
or  it  may  not  form  for  days.  The  older  surgeons  claimed  that  pus  could  do 
good  by  protecting  granulations  and  separating  disorganized  tissue.  It  is  now 
held  that  it  is  absolutely  harmful  by  melting  down  sound  tissue  and  poisoning 
the  entire  organism.     Modern  surgery  has  to  a  great  degree  abolished  pus. 

If  pus  stands  for  a  time,  it  separates  into  two  portions — (i)  a  watery  por- 
tion, the  liquor  puris  or  pus-serum,  containing  peptone,  fat,  microbic  products, 
osmazone,  and  salts,  and  not  tending  to  coagulate;  (2)  a  solid  portion,  or  sedi- 
ment composed  of  dead  and  living  micro-organisms  of  suppuration,  connective- 
tissue  cells,  often  epithehal  cells,  perhaps  red  blood-cells,  lymphocytes,  pus- 
corpuscles  (Fig.  71),  debris  of  tissue,  and  shreds  of  dead  tissue.  The  pus- 
corpuscles  are  either  polynuclear  white  blood-cells  or  altered  connective-tissue 
cells  containing  many  nuclei.  Most  of  them  are  dead,  some  have  ameboid 
movements  and  are  still  capable  of  phagocytosis  under  favorable  circumstances 
(C.  J.  Bond,  "  Brit.  Med.  Jour.,"  June  3,  1916).  Some  of  the  pus-cells  are  fatty, 
others  are  granular  and  contain  more  than  one  nucleus,  and  all  are  degener- 
ating. A  pus-cell  is  waste  matter,  and  it  cannot  aid  in  repair.  Very  excep- 
tionally pus  disappears  by  absorption,  by  caseation,  or  by  calcification. 

Pus  in  General. — The  color  of  pus  is  variable  and  depends  upon  the  nature 


Forms  of  Pus 


145 


of  the  bacteria;  the  presence  or  absence  of  blood,  fibrin,  body  secretions  or 
body  excretions  (bile,  urine,  mucus,  feces,  etc.);  and  the  existence  or  non- 
existence of  putrefaction. 

Its  consistence  varies.  In  some  cases  it  is  scarcely  thicker  than  water,  in 
others  it  is  like  cream,  and  in  still  others  it  is  cheesy.  Thick  pus  is  opaque  and 
of  a  greenish-yellow  color,  and  thin  pus  has  a  distinct  reddish  or  yellowish 
tinge.  When  freshly  evacuated  many  varieties  are  almost  or  quite  odorless, 
and  are  alkaline  or  slightly  acid  in  reaction. 

Some  varieties  possess  a  very  offensive  odor.  Pus  contaminated  by  the 
bacteria  of  putrefaction  is  certain  to  have  a  foul  odor.  Pus  which  forms  in  the 
tonsil,  in  the  brain,  about  the  vermiform  appendix,  or  around  the  rectum  usu- 
ally possesses  an  offensive  odor. 

Forms  of  Pus.— Laudable,  or  healthy  pus,  a  name  long  in  vogue,  is  a  con- 
tradiction, no  pus  being  healthy.     In  former  days  free  suppuration  after  an 


ijiiiiigpiii? 


<^; 


Fig.  71. — Fragmentation  of    nucleus   in   leukocytes    undergoing    transformation   into    pus- 
corpuscles  (Senn). 


operation  was  regarded  as  a  favorable  indication,  and  when  it  occurred  the 
surgeon  congratulated  himself  that  surgical  fever  was  at  an  end.  At  the  present 
day  suppuration  after  an  operation  is  an  evidence  of  previous  infection,  of  lack 
of  care,  failure  in  our  precautions,  or  of  infection  by  the  blood.  The  so-called 
laudable  pus  is  seen  coming  from  a  healing  ulcer,  and  is  an  opaque,  yellowish- 
white,  or  a  greenish  fluid  of  the  consistence  of  cream,  without  odor  or  with  a 
very  slight  odor  if  it  is  not  putrid,  and  having  a  specific  gravity  of  about  1030. 

Malignant,  watery,  or  ichorous  pus  is  a  thin,  watery,  putrid  fluid.  It  is 
pus  filled  with  the  organisms  of  putrefaction. 

Stinking  pus  may  be  ichorous.  Its  odor  may  be  due  to  the  Bacterium  coli 
commune.  If  this  bacterium  is  the  cause  the  pus  is  very  foul,  but  not  thin. 
Pus  of  this  nature  is  met  with  in  ischiorectal  abscess  and  appendiceal  abscess. 
The  odor  of  stinking  pus  may  be  due  to  ordinary  bacteria  of  putrefaction,  in 
which  case  the  pus  is  usually  thin. 

Sanious  pus  is  a  form  of  ichorous  pus  containing  blood  coloring-matter  or 
Mood.  It  is  thin,  of  a  reddish  color,  and  very  acrid,  corroding  the  parts  with 
which  it  comes  in  contact.     It  is  found  notably  in  caries  and  carcinoma. 

Concrete  ox  fibrinous  pus,  which  contains  flakes  of  fibrin  or  coagulated  fibro- 


146  Suppuration  and  Abscess 

purulent  masses,  is  met  witii  in  serous  cavities  (joints,  j)leura,  etc.).  These 
masses  also  form  in  infective  endocarditis. 

Red  pus  signifies  the  presence  of  the  Bacillus  prodigiosus. 

Blue  Pus. — The  color  of  blue  pus  is  due  to  the  Bacillus  pyocyaneus. 

Orange  Pus. — The  color  of  orange  pus  is  due  either  to  the  action  of  Sarcina 
aurantiaca,  or  to  the  formation  of  crystals  of  hematoidin  from  the  coloring- 
matter  of  red  blood-cells  which  have  been  mingled  with  the  pus.  Pus  of  this 
color  appears  only  in  violent  inflammations. 

Serous  pus  is  a  thin,  serous  fluid,  containing  few  flakes. 

So-called  tuberculous,  scrofulous,  or  curdy  pus  is  not  pus  at  all,  unless  the 
tuberculous  area  has  undergone  pyogenic  infection. 

So-called  gummy  pus  arises  from  the  breaking  down  of  a  gumma  which  has 
outgrown  its  own  blood-supply.     It  is  not  pus. 

Mucopus  is  found  in  purulent  catarrh — that  is,  in  suppurative  inflammation 
of  an  epithelial  structure.     It  contains  pus  elements  and  epithelial  cells. 

Caseous  pus  comes  from  the  fatty  degeneration  of  pus-corpuscles  or  inflam- 
matory exudations.  It  occurs  especially  in  tuberculous  processes.  A  caseous 
mass  may  calcify. 

Signs  and  Symptoms  of  Suppuration. — Suppuration  is  announced  by  the 
intensification  of  all  local  inflammatory  signs.  The  heat  becomes  more  marked, 
the  discoloration  dusky,  the  swelling  augments,  the  pain  becomes  throbbing  or 
pulsatile,  and  the  sense  of  tension  is  greatly  increased.  The  skin  at  the  focus 
of  the  inflammation  after  a  time  becomes  adherent  to  the  parts  beneath,  and 
fluctuation  soon  appears.  This  adhesion  of  the  skin  is  a  preparation  for  a 
natural  opening,  and  is  known  as  pointing.  An  important  sign  of  pus  beneath 
is  edema  of  the  skin.  This  is  always  observed  in  a  superficial  abscess,  and  is 
sometimes  noticeable  in  empyema  or  pyothorax,  in  appendiceal  abscess,  and 
in  perirenal  suppuration.  The  above  symptoms  can  be  reinforced  and  their 
significance  proved  by  the  introduction  of  an  aseptic  tubular  exploring  needle 
and  the  discovery  of  pus.  Irregular  chills,  high  fever,  drenching  sweats,  weak- 
ness, and  a  feeling  of  serious  sickness  are  very  significant  of  suppuration  in  an 
important  structure  or  of  a  large  area.  It  must  always  be  remembered  that  in 
some  virulent  pyogenic  infections  the  human  organism  is  so  overwhelmed  with 
toxins  that,  though  the  patient  is  desperately  ill,  the  temperature  is  normal  or 
even  subnormal.  This  means  that  body  resistance  has  abandoned  the  conflict. 
In  abscess  of  the  brain  the  temperature,  after  an  initial  rise,  often  becomes 
normal  or  subnormal  because  of  stimulation  of  the  heat  inhibitory  center  by 
toxins  or  by  irritation. 

Diffuse  Cellulitis  or  Phlegmonous  Suppuration  (Purulent  Infiltration). — 
This  process  may  involve  a  small  area  or  an  entire  limb,  and  is  due  to  infection 
by  the  Streptococcus  pyogenes  (streptococcus  of  erysipelas),  usually  associated 
with  mixed  infection  with  other  bacteria,  particularly  the  bacteria  of  putre- 
faction. The  streptococci  are  intensely  virulent.  Barriers  of  white  corpuscles 
do  not  form  early  enough  to  restrain  them,  and  tissues  break  down  before 
cellular  multiplication  is  able  to  encompass  the  bacteria.  The  bacteria  dis- 
seminate through  the  lymph-spaces  and  lymph-vessels.  The  disease  in  severe 
cases  produces  enormous  swelling,  areas  which  feel  boggy,  a  dusky  red  discolora- 
tion, and  great  burning  pain.  Gangrene  of  superficial  areas  is  not  unusual, 
due  to  thrombosis  of  vessels  or  coagulation  necrosis  from  toxins.  The  dis- 
charges of  the  wound,  if  a  wound  exists,  are  apt  to  dry  up,  and  the  wound  be- 
comes foul,  dry,  and  brown.  The  adjacent  lymphatic  glands  are  much  en- 
larged. The  disease  is  ushered  in  by  a  chill,  which  is  followed  by  high  oscillating 
temperature,  due  to  suppurative  fever,  sapremia,  or  even  septic  infection  or 
pyemia.  Sweats  are  noted  during  periods  of  falling  temperature.  Diffuse  sup- 
puration tends  to  arise  in  an  infected  compound  fracture,  after  extravasation 
of  urine  and  after  the  infliction  of  a  wound  upon  a  person  broken  down  in  health. 


Wooden,  Woody,  or  Ligneous  Phlegmon 


147 


It  is  not  unusual  after  typhoid  or  scarlet  fever,  and  is  typical  of  phlegmonous 
erysipelas.  The  pus  is  sanious  and  offensive,  and  burrows  widely  in  the  sub- 
cutaneous tissue  and  intermuscular  planes.  Diffuse  suppuration  may  widely 
separate  muscles  and  even  lay  bare  the  bones.  It  is  a  very  grave  condition, 
and  may  cause  death  by  exhaustion,  septic  intoxication,  septic  infection, 
pyemia,  or  hemorrhage  from  a  large  vessel  which  has  been  corroded. 
Cdlulitis  of  a  mild  degree  is  due  to  attenuated  streptococci  or  to  staphylococci. 
An  area  of  cellulitis  may  surround  an  infected  wound  or  a  stitch-abscess.  Its 
spread  is  manifested  by  red  lines  of  lymphangitis  running  up  to  the  adjacent 
lymphatic  glands.  Light  cases  may  not  suppurate,  the  lymphatics  carrying 
off  the  poison.  Any  case  of  cellulitis  is,  however,  a  menace,  and  any  severe 
case  is  highly  dangerous.     (See  Erysipelas.) 

Wooden,  Woody,  or  Ligneous  Phlegmon. — This  condition  was  fully  de- 
scribed by  Reclus  in  1893.  It  is  chronic  inflammation  of  the  cellular  tissue  and 
fascia,  and  is  characterized  by  the  pro- 
duction of  quantities  of  fibrous  tissue. 
It  occurs  in  those  over  fifty  years  of 
age.  The  neck  is  the  region  usually 
involved.  It  begins  with  hard  swelling 
of  one  side  or  of  the  front  of  the  neck 
and  for  weeks  is  unaccompanied  by  any 
other  sign.  The  swelling  may  be  at  first 
localized,  but  it  spreads  slowly  and 
widely  and  finally  comes  to  involve 
an  extensive  area,  even  perhaps  the 
front  of  the  neck  and  both  sides  from 
the  jaw  to  the  collar-bone.  It  may 
involve  the  cervical  muscles  and  thus 
create  rigidity,  and  it  may  compress 
the  larynx  and  trachea  and  thus  inter- 
fere with  breathing.  In  most  cases  there 
is  difficulty  in  swallowing.  After  weeks, 
or  perhaps  a  month  or  two,  the  skin  be- 
comes edematous  and  red  or  rather  of  a 
violet  hue.  There  is  no  fever  and  rarely 
pain.  The  significant  facts  are  the 
gradually  advancing  hard  swelling  long  unaccompanied  by  fever,  pain,  discolor- 
ation, or  cutaneous  edema.  The  condition  is  said  to  be  due  to  the  deposition  and 
multiplication  of  bacteria,  which  reach  the  tissues  from  the  lymph-glands  and 
reach  the  glands  from  an  area  of  infection  in  the  pharynx,  a  salivary  gland,  or 
the  mouth.  Pus  does  not  form  at  all  or  only  minute  encapsulated  foci  form, 
probably  because  the  bacteria  are  of  greatly  attenuated  virulence  or  because 
the  local  vital  resistance  to  these  bacteria  is  at  a  high  level.  Inflammation 
occurs,  there  is  copious  exudation,  and  enormous  amounts  of  fibrous  tissue  form. 
If  pus  forms,  it  may  discharge  spontaneously  in  six  or  seven  weeks.  The  causa- 
tive bacteria  are  often  attenuated  pyogenic  microbes.  In  one  of  Reclus's  cases 
diphtheria  bacilli  were  found,  and  this  case  got  better  after  having  been  given 
antitoxin.     Cases  have  been  reported  which  were  caused  by  pneumococci. 

Wooden  phlegmon  is  occasionally  found  in  s\^hilitics,  but  it  is  not  a  syphil- 
itic condition.  Neither  Bright's  disease  nor  diabetes  has  anything  to  do  with 
its  origin.  It  may  be  mistaken  for  actinomycosis  or  tuberculosis.  It  is  fre- 
quently mistaken  for  sarcoma  or  carcinoma,  in  fact,  Lange  believes  it  to  be 
cancer.  I  know  that  it  may  be  sarcomatous.  In  two  of  my  cases  excision  of 
a  portion  of  tissue  furnished  the  proof.  There  are  two  forms  of  the  condition, 
a  pyogenic  and  a  malignant  and  the  microscope  alone  can  prove  which  exists. 
Clinically  my  cases  of  sarcoma  were  identical  with  ordinary  wooden  phlegmon. 


< 


Fig.  71J. — Wooden  phlegmon. 


148  Suppuration  and  Abscess 

Of  course,  phlegmon  is  not  the  proper  term  for  a  hgneous  cancer  or  sarcoma. 
Wooden  phlegmon  arises  in  those  who  are  in  ill  health  rather  than  in 
the  vigorous  or  robust.  It  is  always  dangerous  and  is  frequently  fatal.  Cne 
of  Reclus's  cases  died  of  edema  of  the  glottis.  We  have  spoken  of  woody 
phlegmon  as  though  it  could  involve  the  neck  only;  as  a  matter  of  fact  it  can 
involve  other  parts.  Reclus  maintains  that  it  can  occur  in  the  right  iliac  fossa, 
and  that  perinephric  sclerosis  is  in  reality  due  to  it  (Powers,  in  "Jour.  Amer. 
Med.  x^ssoc,"  July  20,  191 1).  A  case  has  been  reported  by  Todd  in  which  the 
abdominal  wall  was  involved  ("Jour.  Missouri  State  Med.  Assoc,"  February  8, 
191 2).  Duse  also  reported  such  a  case  ("  Gazz.  d.  Osped.,"  1910,  xxxi).  W\  W. 
Grant,  of  Denver,  has  reported  ligneous  phlegmon  of  the  abdominal  wall  ("Jour. 
Amer.  Med.  Assoc,"  April  5,  1913).  A  similar  condition  may  arise  in  the  peri- 
neum, after  urinary  extravasation  or  fistula  formation.  Charles  A.  Powers,  of 
Denver,  has  reviewed  this  subject  and  presented  the  report  of  an  admirably 
studied  case  (Ibid.,  July  20,  1911). 

Treatment. — Extirpation,  if  feasible,  is  the  best  plan.  It  is  seldom  feasible, 
and  the  surgeon  instead  makes  numerous  incisions  and  usually  dresses  with 
antiseptic  poultices.  In  these  cases  free  suppuration  occasionally  occurs  after 
a  long  delay,  and  when  it  does  occur  a  cure  may  promptly  follow  evacuation. 
An  autogenous  vaccine  should  be  made  and  injected  into  the  indurated  area. 
The  surgeon  must  be  prepared  to  do  tracheotomy  should  an  emergency  arise. 
For  a  malignant  case  use  .v-ray  or  radium. 

Furuncle,  or  boil,  is  an  acute  and  circumscribed  inflammation  of  the 
deep  layer  of  the  true  skin  and  the  subcutaneous  cellular  tissue  following 
bacterial  infection  of  a  hair-follicle  or  a  sebaceous  gland  and  resulting  in  local 
necrosis  of  the  dermis.  The  infecting  organism  is  the  Staphylococcus  pyogenes 
aureus  which  gains  entrance  through  a  slight  wound  or  a  trivial  invasion. 
Shaving  or  scratching  may  be  causal.  If  hair  is  cut  very  short  it  may  grow 
beneath  the  skin  solely,  and  such  an  ingrowing  hair  is  a  common  cause  of 
furuncle.  Boils  are  very  common  in  individuals  with  Bright's  disease,  dia- 
betes, gout,  lithemia,  tuberculosis,  and  disorders  of  menstruation  and  digestion; 
and  crops  of  boils  are  apt  to  appear  during  convalescence  from  typhoid  fever. 
Some  persons  develop  boils  after  eating  sweets,  others  after  eating  eggs  (Francis, 
"Brit.  Med.  Jour.,"  Aug.  17,  1912).  A  rough  collar  may  be  responsible  for  a 
boil  on  the  neck.  Rowing  men  are  liable  to  boils  on  the  buttocks.  Boils  are 
commonest  in  the  spring,  and  sometimes  an  epidemic  of  furunculosis  appears 
in  a  hospital,  a  jail,  or  an  asylum. 

The  symptoms  of  a  boil  are  as  follows:  a  red  elevation  appears,  which  stings 
and  itches;  this  elevation  enlarges  and  becomes  dusky  in  color;  a  pustule  forms 
that  ruptures  and  gives  exit  to  a  very  little  discharge  which  forms  a  crust.  In- 
flammatory infiltration  of  adjacent  connective  tissue  advances  rapidly,  and  the 
boil  in  about  three  days  consists  of  a  large,  red,  tender,  and  painful  base  capped 
by  a  pustule  and  a  little  crusted  discharge.  In  rare  instances,  at  this  stage, 
absorption  occurs,  but  in  most  cases  the  swelling  increases,  the  discoloration 
becomes  darker,  the  skin  becomes  edematous,  the  pain  becomes  severe  and 
pulsatile,  and  the  center  of  the  boil  becomes  raised.  About  the  seventh  day 
rupture  occurs,  pus  flows  out,  and  a  "core"  of  necrosed  tissue  is  found  in  the 
center  of  a  ragged  opening.  This  core  consists  of  the  sebaceous  gland  and 
hair-follicle,  which  have  undergone  coagulation  necrosis  (Warren).  In  a  day 
or  two  more  the  core  will  be  discharged,  and  healing  by  granulation  will  begin. 
A  blind  boil  lasts  only  three  or  four  days  and  has  no  core.  The  constitution 
often  shows  reaction  during  the  progress  of  a  boil.  Boils  may  be  either  single 
or  multiple.  The  development  of  one  boil  after  another,  or  the  formation  of 
several  boils  at  once,  is  known  as  ''furunadosis.'''  Boils  are  commonest  upon 
the  neck  and  the  back. 

Lymphangitis  is  very  rare.     In  unusual  cases  a  boil  leads  to  abscess  forma- 


Carbuncle 


149 


tion.  Distant  abscess  may  arise  long  after  a  boil  has  healed  and  metastasis 
may  be  fatal.  Bone,  kidney,  perirenal  tissue,  brain,  or  other  parts  may  be 
involved  in  secondary  abscess.  A  boil  endangers  life  if  it  involves  a  vein,  hence 
furuncles  of  the  face  and  of  the  neck  are  dangerous.  The  lesion  which  may 
arise  is  suppurative  thrombophlebitis,  a  clot  propagating  perhaps  to  an  intra- 
cranial sinus.  Thrombophlebitis  of  the  facial  vein  is  usually  rapidly  fatal, 
causing  sinus- thrombosis  of  the  cavernous  sinus  (see  Reidel  in  "Deutsche  med. 
Woch.,"  1915,  Nos.  4  and  5). 

Treatment. — In  a  superficial  boil  early  in  the  case  when  the  area  is  hard  do 
not  incise.  Paint  the  boil  and  the  region  about  it  with  iodin,  freeze  the  parts 
with  ethyl  chlorid,  and,  with  a  very  sharp  knife,  remove  a  small  circular  piece 
of  skin  from  the  top  of  the  boil.  This  permits  fluid  to  escape  and  favors  the 
subsequent  evacuation  of  the  core.  Do  not  squeeze  the  inflamed  area.  The 
parts  about  the  boil  are  to  be  dressed  daily  with  Crede's  silver  ointment  (to 
prevent  infection  of  other  hair  follicles).  Dress  the  boil  with  hot  antiseptic 
fomentations.  Every  day  try  the  core  with  forceps  to  aid  its  removal.  In 
later  cases  when  fluctuation  exists  the  treatment  consists  in  excision  or  in  crucial 
incision,  removal  of  necrotic  tissue,  irriga- 
tion with  peroxid  of  hydrogen,  touching 
with  pure  carbolic  acid,  the  site  of  the  boil 
being  dressed  with  hot  antiseptic  fomenta- 
tions and  the  adjacent  skin  with  Crede's 
silver  ointment.  When  the  sore  becomes 
a  granulating  surface  employ  dry  dressings. 
A  boil  which  involves  or  threatens  to  in- 
volve a  vein  should  be  excised  at  once. 
The  vein  should  be  divided  if  possible 
above  any  clot  which  it  may  contain  and 
the  ends  of  the  cut  vein  should  be  ligated. 
If  there  are  many  boils  or  crops  of  boils 
(furunculosis)  seek  for  the  provocative 
disease  and  treat  it.  The  commonest 
causes  are  diabetes  and  Bright's  disease. 
Brewer's  yeast  is  given  by  some.  Others 
give  nuclein  itself.  Sulphurous  acid  has 
been  advised. 

Aleppo     Boil     {Endemic    Boil    of  the 
Tropics;  Delhi  Boil;  Oriental  Sore,  houton 
de   Baghdad,    etc.). — It  is  not  a  pyogenic 
process     but     an    infectious     ulceration. 

Papules,  which  are  granulomata,  appear  upon  the  exposed  parts  of  the  body. 
These  papules  ulcerate,  the  ulcers  crust,  are  superficial,  do  not  furnish  purulent 
discharge,  do  not  cicatrize  for  at  least  a  year,  and  leave  ineradicable  scars. 
This  condition  is  due  to  a  protozoon.  Man  is  infected  by  means  of  flies, 
lice,  or  other  insects.  The  Aleppo  boil  was  once  apparently  confined  to  India, 
Arabia,  Persia,  Egypt,  Algeria,-  etc.  Of  late  it  is  said  to  have  appeared  in 
Panama,  the  Philippine  Islands,  and  Hawaii. 

Treatment. — Excision  of  ulcers  has  been  advocated;  so  has  cauterization. 
A  useful  treatment  is  to  dress  the  areas  with  copper  sulphate  solution,  gradually 
increasing  the  strength  from  i  per  cent,  to  5  per  cent. 

Carbuncle  {benign  anthrax)  is  a  circumscribed  infectious  inflammation  of  the 
deeper  layer  of  the  true  skin  and  of  the  subcutaneous  tissue,  with  fibrinous  exuda- 
tion, multiple  foci  of  necrosis  arising,  and  the  tissue  adjacent  to  each  necrotic 
plug  becoming  gangrenous.  The  infection  takes  place  through  a  hair-foUicle. 
It  is  really  a  multiple  boil  with  extensive  infiltration  of  adjacent  tissues.  A 
boil  may  become  a  carbuncle,  and  pus  from  a  carbuncle  inoculated  into  a 


Fig.  72. — Columna  adiposa  (Warren). 


I^O 


Suppuration  and  Abscess 


healthy  person  may  cause  either  a  boil  or  a  carbuncle.  The  causative  organism 
seems  to  be  the  Staphylococcus  pyogenes  aureus.  Carbuncle  is  most  common 
in  the  upper  part  of  the  back  and  on  the  back  of  the  neck.  In  this  region  the 
skin  is  very  thick;  each  hair-follicle  holds  only  a  downy  hair,  is  shallow,  and 
projects  but  a  short  distance  into  the  cutis  vera.  Columns  of  fatty  tissue  run 
from  the  subcutaneous  tissue  in  an  oblique  direction  to  join  the  point  and  sides 


Fig.  73. — Infiltration  of  columna  adiposa  and  subcutaneous  tissue  with  pus  in    carbuncle 

(Warren). 

of  the  hair-follicle.  These  columns  are  known  as  columncB  adiposes,  and  each 
one  contains  a  sweat-gland  (Fig.  72).  When  pus  runs  down  one  of  these  col- 
umns, it  seeks  an  outlet;  it  cannot  spread  easily  to  the  sides,  so  it  slowly  works 
its  way  to  deeper  tissue  and  from  one  to  another  interspace  and  finds  its  way 
to  the  surface  through  other  fatty  columns  (Warren's  "Surgical  Pathology") 
(Fig.  73).     When  pus  finds  its  way  to  the  surface,  an  opening  forms,  hence  the 


Fig.  74. — Diagram  of  a  carbuncle  (Warren). 


Carbuncles 
diabetes  and 


numerous  foci  of  pointing;  finally  a  large  opening  forms  (Fig.  74) 
are  most  common  in  the  spring  of  the  year.  In  persons  with 
Bright's  disease  carbuncles  not  unusually  occur. 

The  local  symptoms  in  the  beginning  resemble  those  of  a  boil,  but  the  con- 
stitution sympathizes  from  the  very  start  (perhaps  a  chill  and  always  a  septic 
fever)  and"  the  pain  is  usually  severe.  The  inflammatory  area  begins  as  a 
papule  with  an  indurated  base,  it  enlarges  enormously,  is  boggy  to  the  touch, 


Treatment  of  Carbuncle 


151 


is  dusky  in  color,  is  edematous,  a'nd  the  skin  is  not  freely  movable  over  the 
deeper  parts.  In  a  few  days  many  pustules  appear,  each  pustule  marking  the 
site  of  a  focus  of  necrosis.  Large  vesicles  lilled  with  bloody  serum  very  fre- 
quently form.  In  some  cases  about  the  tenth  day  the  pustules  rupture,  the 
necrotic  plugs  are  discharged,  and  the  case  slowly  progresses  toward  cure;  but 
in  many  cases  the  carbuncle  spreads  at  the  periphery  while  pustules  are  rup- 
turing near  the  center  of  inflammation,  and  pus  forms  in  the  deeper  tissues, 
reaching  the  surface  through  many  small  openings,  each  of  which  is  partly 
blocked  by  a  plug  of  dead  tissue.  A  carbuncle  in  this  stage  resembles  a  honey- 
comb (Fig._  74),  discharges  bloody  pus,  and  large  masses  of  skin  and  sub- 
cutaneous tissue  are  destroyed.  The  entire  carbuncular  mass  may  become  gan- 
grenous, and  a  sudden  and  almost  complete  cessation  of  pain  points  to  this 
complication.  An  ordinary  carbuncle  remains  acute  for  about  three  weeks, 
but  healing  requires  a  month  or  more.  The  most  dangerous  situations  in  which 
to  have  a  carbuncle  are  the  face  and  neck  (tends  to  produce  septic  phlebitis, 
septic  clots  in  the  facial,  jugular,  or  ophthalmic  veins,  or  in  the  cerebral  sinuses, 


Fig.  75. — Infiltration  of  connective  tissue  of  cutis  (X  500)  with  beginning  suppuration  in^the 

center  (Senn). 

or  infective  emboli).  The  mortality  of  facial  carbuncle  is  at  least  50  per  cent. 
The  most  usual  positions  for  carbuncle  are  the  neck,  the  back,  and  the  buttocks. 
The  diagnosis  of  carbuncle  is  made  by  noting  the  multiple  foci  of  necrosis  and 
the  profound  constitutional  involvement.  A  carbuncle  may  produce  death  by 
causing  septicemia,  pyemia,  septic  thrombosis  of  a  cerebral  sinus,  or  profuse 
hemorrhage. 

Treatment. — Some  have  suggested  the  treatment  of  a  carbuncle  in  an  early 
stage  by  injecting  5  to  30  drops  of  carbolic  acid  (80  per  cent.)  into  and  around 
the  inflammatory  mass.  Such  a  method  does  not  promise  success  and  necessi- 
tates dangerous  delay.  The  best  treatment  if  the  case  is  seen  sufficiently  early 
is  thorough  extirpation  while  the  patient  is  anesthetized.  The  entire  area  of 
the  infection  is  thus  removed,  and  the  large  wound  heals  by  granulation  and 
is  to  be  subsequently  skin-grafted.  When  the  condition  is  too  far  advanced  to 
admit  of  complete  extirpation,  the  following  useful  plan  should  be  employed. 

Give  ether,  make  free  crucial  incisions,  remove  dead  and  necrosing  tissue 
and  also  the  points  of  the  skin-flaps  with  the  scissors  and  forceps,  curet  pockets, 
arrest  hemorrhage  by  pressure  and  hot  water,  cauterize  with  pure  carbohc  acid, 
dust  with  iodoform,  pack  with  iodoform  gauze,  and  dress  with  hot  antiseptic 
fomentations.  Cover  the  gauze  with  a  piece  of  some  impermeable  material 
and  lay  a  hot-water  bag  upon  the  dressing.     Every  day,  or  several  times  a  day, 


1^2 


Suppuration  and  Abscess 


remove  the  dressings,  wash  with  peroxid  of  hydrogen,  irrigate  with  corrosive 
subUmate  solution,  dust  with  iodoform,  and  reapply  the  iodoform  gauze  and 
antiseptic  fomentation.  Keep  up  this  treatment  until  sloughs  are  separated, 
then  dress  with  dry  antiseptic  gauze.  Secure  sleep  by  morphin,  give  quinin,  milk- 
punch,  and  nourishing  diet,  and  maintain  the  action  of  the  bowels  and  kidneys. 
Acute  Abscesses. — An  acute  abscess  is  a  circumscribed  cavity  of  new  for- 
mation containing  pus.  We  emphasize  the  fact  that  it  is  a  circumscribed  cavity 
— circumscribed  by  a  mass  of  leukocytes  and  j^roliferating  fibroblasts.  A  puru- 
lent infiltration  is  not  circumscribed,  hence  it  does  not  constitute  an  abscess. 
An  essential  part  of  the  definition  is  the  assertion  that  the  pus  is  in  a  cavity  of 
new  formation,  in  an  abnormal  cavity;  hence  pus  in  a  natural  cavity  (pleural, 
pericardial,  synovial,  or  peritoneal)  constitutes  a  purulent  effusion,  and  not  an 
abscess,  unless  it  is  encysted  in  these  localities  by  walls  formed  of  inflammatory 
tissue. 

An  acute  abscess  is  due  to  the  deposition  and  multiplication  of  pyogenic 
bacteria  in  the  tissues  or  in  inflammatory  exudates.     These  bacteria  attack 

exudates  or  tissues,  form  irritants  which  cause 
inflammation  or  intensify  existing  inflamma- 
tion, and  by  exerting  a  peptonizing  action  on 
intercellular  substance  and  the  fibrin  of  the 
exudate,  liquefy  tissue  and  the  products  of 
inflammation,  and  form  pus.  As  a  rule,  within 
twenty-four  hours  after  lodgment  of  the  bac- 
teria the  exudation  increases  in  amount,  the 
migrated  leukocytes  gather  in  enormous  num- 
bers, the  fibers  of  tissues  swell,  and  the  con- 
nective tissue  spaces  distend  with  cells  and 
fluid.  The  connective-tissue  cells,  acted  on 
by  pus  cocci,  multiply  by  karyokinesis,  de- 
velop many  nuclei,  lose  their  stellate  projec- 
tions, degenerate,  and  constitute  one  form  of 
pus-corpuscle,  leukocytes  forming  the  other. 
All  the  small  vessels  are  choked  with  leu- 
kocytes, this  blocking  serving  to  cut  off 
nourishment  and  tending  to  produce  anemic 
necrosis.  Liquefaction  occurs  at  many  foci  of  the  inflammation,  drops  of  pus 
being  formed,  the  amount  of  each  being  progressively  added  to  and  many  foci 
coalescing  (Fig.  75).  The  pus-cavity  is  circumscribed,  not  by  a  secreting  pyo- 
genic membrane,  but  by  a  mass  of  fibroblasts,  whose  cells  and  intercellular 
material  have  not  as  yet  broken  down;  such  a  mass  of  fibroblasts  is  often  called 
embryonic  tissue,  and  it  is  circumscribed  by  a  zone  of  inflammation  in  which 
there  are  hordes  of  migrated  leukocytes  (Fig.  76).  As  an  abscess  increases  in 
size,  the  embryonic  tissue  from  within  outward  liquefies  into  pus,  and  ihe 
zone  of  inflammation  beyond  continually  enlarges  and  forms  more  embryonic 
tissue.  After  a  time  the  inflammation  reaches  the  surface,  the  embryonic  tis- 
sue glues  the  superficial  to  the  deeper  parts,  the  superficial  parts  inflame  and 
become  embryonic  tissue,  and  the  intercellular  substance  is  liquefied.  When 
pus  has  all  but  reached  the  surface,  a  thin  layer  of  tissue  only  being  undestroyed, 
an  elevation  or  tit  of  thin  tissue  is  formed,  due  to  the  fluid  pressure.  This 
process  is  known  as  pointing.  The  elevation  or  point  thins  from  tension  and 
liquefaction,  and  finally  gives  way  and  spontaneous  evacuation  occurs.  When 
an  abscess  forms  in  an  internal  organ  or  in  some  structure  which  is  not  loose, 
like  connective  tissue — for  instance,  in  a  lymphatic  gland — a  mass  of  pyogenic 
bacteria,  floating  in  the  blood  or  lymph,  lodges,  and  these  bacteria  by  means 
of  irritant  products  cause  coagulation  necrosis  of  the  adjacent  tissue  and  in- 
flammatory exudation  around  it.     The  area  of  coagulation  necrosis  becomes 


Fig.  76. — Diagram  of  an  abscess: 
A,  Pus;  B,  layer  of  fibroblasts;  C, 
tissue  infiltrated  with  leukocytes;  D, 
zone  of  stasis;  E,  zone  of  active  hy- 
peremia; F,  healthy  tissue. 


Local  Symptoms  of  Acute  Abscesses  153 

filled  with  white  blood-cells,  and  the  dry  necrosed  part  is  liquefied  by  the  cocci. 
Suppuration  in  dense  structures  causes  considerable  masses  of  tissue  to  die  and 
to  be  cast  ofT,  and  these  masses  float  in  the  pus.  Death  of  a  mass  with  dissolu- 
tion of  its  elements  is  necrosis,  or  inflammatory  gangrene.  Pus  travels  in  the 
line  of  least  resistance.  It  may  reach  a  free  surface,  or  may  break  into  a  cavity 
or  joint,  may  invade  bone  or  destroy  a  vessel.  When  an  abscess  ceases  to 
spread  or  is  evacuated,  the  fibroblastic  layer  forming  the  walls  becomes  vas- 
cularized and  is  converted  into  gra^iulation  tissue.  An  abscess  heals  by  the 
collapse  of  its  walls  and  fusion  of  the  granulations  (union  by  third  intention), 
or  by  granulation  (union  by  second  intention).  In  either  case  granulation 
tissue  is  ultimately  converted  into  fibrous  or  scar  tissue. 

Forms  of  Abscesses. — The  following  are  the  various  forms  of  abscesses: 
Acute,  which  follows  an  acute  inflammation.  Strumous,  cold,  lymphatic,  tuber- 
culous, or  chronic  abscess  is  due  to  the  bacilli  of  tuberculosis,  and  does  not  con- 
tain true  pus  unless  there  is  secondary  pyogenic  infection.  It  presents  no  signs 
of  inflammation.  Such  an  abscess  occasionally  forms  in  a  week  or  two,  and  hence 
is  not  necessarily  chronic.  Caseous  or  cheesy  abscess,  a  cavity  containing  thick 
cheesy  masses,  is  due  perhaps  to  the  fatty  degeneration  of  inflammatory  exu- 
date and  pus-corpuscles,  but  most  commonly  results  from  the  caseation  of  a 
tuberculous  focus.  Circtimscribed  abscess  is  one  limited  by  a  layer  of  fibro- 
blasts. Diffused  abscess  is  an  unlimited  collection  of  pus,  in  reality  not  an 
abscess,  but  either  a  purulent  effusion  or  a  purulent  infiltration.  Congestive, 
gravitative,  wandering,  or  hypostatic  abscess  is  a  collection  of  pus  or  tuberculous 
matter  which  travels  from  its  formation  point  and  appears  at  some  distant 
spot  (as  a  psoas  abscess).  Critical  or  consecutive  abscess  is  one  which  arises 
during  an  acute  disease.  Diathetic  abscess  finds  its  predisposing  cause  in  a 
diathesis.  Embolic  abscess  is  due  to  an  infected  embolus.  Tympanitic  or  em- 
physematous abscess  is  one  which  contains  air  or  the  gases  of  putrefaction. 
Encysted  abscess,  in  which  pus  is  circumscribed  in  a  serous  cavity.  Fecal  or 
stercoraceous  abscess  is  one  containing  feces  in  consequence  of  a  communication 
with  the  bowel.  Follicular  abscess  is  one  arising  in  a  follicle;  hematic  abscess, 
one  arising  around  a  blood-clot,  as  a  suppurating  hematoma;  marginal  abscess, 
which  appears  upon  the  margin  of  the  anus.  Pyemic  or  metastatic  abscess  is  the 
embolic  abscess  of  pyemia.  Milk  abscess  is  an  abscess  in  the  breast  of  a  nursing 
woman.  Ossifluent  abscess  arises  from  diseased  bone.  Psoas  abscess  is  a  tuber- 
culous abscess  arising  from  vertebral  caries,  the  matter  following  the  psoas  mus- 
cle, and  usually  pointing  in  the  groin  (see  page  267).  A  sympathetic  abscess, 
arising  some  distance  from  the  exciting  cause,  such  as  a  suppurating  bubo 
from  chancroid,  is  not  in  reality  sympathetic,  because  infective  material  has 
been  carried  from  the  primary  focus.  Thecal  abscess  is  a  purulent  effusion  in  a 
tendon-sheath.  Tropical  abscess  is  an  abscess  of  the  liver,  so  named  because 
it  occurs  chiefly  in  those  dwelling  in  tropical  countries:  it  usually  follows  dysen- 
tery. Urinary  abscess,  caused  by  extravasated  urine.  A  verminous  abscess  is 
one  which  contains  intestinal  worms  and  communicates  with  the  bowel.  A 
syphilitic  abscess  occurs  in  the  bones  during  tertiary  syphiHs,  and  is  gummatous 
and  not  primarily  pyogenic.  Brodie's  abscess  is  a  chronic  abscess  of  the  head 
of  a  long  bone,  most  common  in  the  head  of  the  tibia  (see  page  569).  A  super- 
ficial abscess  occurs  above  the  deep  fascia;  a  deep  abscess  occurs  below  the 
deep  fascia,  A  residiial  or  Paget's  abscess  is  a  recurrence  of  active  changes 
around  the  residue  of  a  former  tuberculous  abscess  (see  page  263), 

Symptoms  of  Acute  Abscesses.^In  an  acute  abscess,  as  before  stated,  a 
part  becomes  inflamed  and  a  quantity  of  fibroblasts  are  formed;  fibroblastic 
tissue  is  liquefied  (as  above  noted)  and  pus  is  produced.  An  acute  abscess  can 
occur  in  a  person  of  any  constitution. 

Local  Symptoms, — ^Locally,  there  is  intensification  of  inflammatory  signs 
and  enormous  increase  of  the  swelling.     At  first  the  area  is  hard,  but  after- 


154  Suppuration  and  Abscess 

ward  becomes  soft,  and  it  finally  fluctuates.  The  discoloration  becomes  dusky. 
The  pain  becomes  throbbing  and  the  sense  of  tension  increases.  The  pain  is 
greater  the  denser  the  implicated  tissue  and  the  greater  the  number  of  nerves 
it  contains.  At  every  pulse-beat  the  tension  in  the  abscess  increases  tempo- 
rarily, and  hence  the  pain  momentarily  increases.  Pain  is  increased  by  a  de- 
pendent position  of  the  part.  There  is  great  tenderness.  The  pain  may  be  felt 
at  the  seat  of  suppuration  or  may  be  referred  to  some  distant  point.  Tender- 
ness is  located  at  the  focus  of  disease.  The  cutaneous  surface,  if  the  abscess  is 
adjacent,  is  seen  to  be  polished  and  edematous,  after  a  time  fluctuation  can  be 
detected,  and  eventually  pointing  is  observed.  If  pus  is  deeply  situated  the  skin 
may  not  be  reddened,  and  perhaps  the  area  of  induration  cannot  be  palpated.  In 
such  a  case  there  is  often  rigidity  of  the  muscles  overlying  the  abscess  (as  in 
abdominal  suppurations),  the  skin  may  be  edematous  (as  in  deep  abscess  of 
the  neck),  and  besides  local  pain  there  may  be  pain  due  to  pressure  upon  a  nerve- 
trunk,  the  pain  perhaps  being  referred  to  a  distant  point. 

Constitutional  Symptoms. — If  there  is  a  small  collection  of  pus  in  an  un- 
important structure,  there  may  be  no  obvious  constitutional  disturbance. 
If  the  abscess  contains  much  pus  or  affects  an  important  part,  disturbances 
are  certain  to  appear,  from  slight  rigors  or  moderate  fever  to  chills,  high  tempera- 
ture, and  drenching  sweats.  The  constitutional  condition  t\'pical  of  an  abscess 
is  due  to  the  absorption  of  retained  toxins,  and  is  known  as  "suppurative 
fever."  WHien  an  abscess  is  open  but  ill-drained,  or  when  it  is  unopened  and 
deep-seated,  long-continued  suppuration  causes  a  fever  which  is  markedly 
periodic:  the  temperature  rises  in  the  evening,  attaining  its  highest  point 
usually  between  4  and  8  p.  m.,  and  sinks  to  normal  or  nearly  normal  in  the 
earlv  morning  (from  4  to  8  A.  M.).  When  the  tefnperature  begins  to  fall, 
profuse  sweating  takes  place.  This  fever  is  known  as  hectic.  As  previously 
stated,  the  temperature  may  be  normal  or  subnormal  in  abscess  of  the 
brain.  Prolonged  suppuration  causes  albuminoid  changes  in  various  organs, 
notably  in  the  Hver,  spleen,  and  kidneys.  Albuminoid  changes  are  especially 
common  when  there  has  been  mixed  infection  of  a  tuberculous  area  and  long- 
continued  suppuration.  It  also  occurs  as  a  result  of  protracted  suppuration  of 
old  svphilitic  lesions. 

J.'  C.  DaCosta,  Jr.  ("Clinical  Hematology")  tells  us  that  "in  both  trivial 
and  extensive  pus  foci  the  number  of  leukocytes  may  be  normal  or  even  sub- 
normal; in  the  former  instance  because  systemic  reaction  is  not  provoked, 
and  in  the  latter  because  it  is  overpowered.  Leukocytosis  may  also  be  absent 
in  case  toxic  absorption  is  impossible,  owing  to  the  complete  waUing  off  of 
the  abscess.  In  all  other  instances  save  these  a  definite  and  usually  well- 
marked  leukocytosis  occurs,  amounting  on  the  average  to  a  count  of  about 
twice  the  mean  normal  standard,  but  frequently  greatly  exceeding  this  figure 
in  the  individual  case." 

The  signs  and  symptoms  of  an  abscess  are  somewhat  modified  by  location, 
and  it  would  seem  wise  to  discuss  acute  abscesses  in  different  situations. 

Acute  Abscesses  in  Various  Regions.— .4 i^r^^^  of  the  brain  may  follow 
cerebral  concussion  or  fracture  of  the  skull,  may  result  from  a  wound,  may  arise 
during  a  general  infection,  but  in  about  50  per  cent,  of  cases  results  from  chronic 
suppurative  disease  of  the  middle  ear.  In  abscess  of  a  silent  region  of  the  brain 
symptoms  may  long  be  entirely  absent.  The  usual  symptoms  are  a  temporary 
initial  rise  of  temperature,  which  soon  gives  place  to  a  normal  and  in  one-half  of 
the  cases  to  a  subnormal  temperature,  headache,  vomiting,  delirium,  drowsiness, 
and  choked  disk.  Localizing  symptoms,  spasmodic  or  paralytic,  may  be  present. 
There  is  usually  but  not  always  leukocytosis.  In  but  few  uncomplicated  cases 
are  there  elevated  temperature  and  sweats  at  the  height  of  the  process.  _  Toward 
the  end  of  the  case  there  may  be  elevated  temperature  and  delirium.  In 
extradural  abscess  there  is  fever  from  beginning  to  end  (see  page  906). 


Acute  Abscesses  in  Various  Regions  155 

Appendiceal  or  appendicular  abscess  results  from  inflammation,  usually 
but  not  always  with  perforation  of  the  vermiform  appendix,  plastic  peritonitis 
leading  to  agglutination  of  the  mesentery  and  omentum,  adhesion  of  the  bowels 
and  mesentery,  and  the  formation  of  a  barrier  of  leukocytes  and  a  mass  of  fibro- 
blasts. This  process  circumscribes  the  pus.  If  the  pus  in  suppurative  ap- 
pendicitis has  been  formed  by  colon  bacilli  or  staphylococci,  it  will  probably 
be  circumscribed  and  limited.  If  the  pus  has  been  formed  by  streptococci, 
it  will  probably  not  be  limited,  and  the  peritoneum  will  be  attacked  by  diff'use 
septic  peritonitis.  The  signs  of  appendicular  abscess  are  pain,  tenderness, 
muscular  rigidity,  and  the  existence  of  a  mass  in  the  right  iliac  fossa.  The  mass 
may  be  palpated  through  the  abdominal  wall  or  perhaps  the  rectum  and  is 
dull  on  percussion.  There  may  be  vomiting,  and  sometimes  constipation  and 
sometimes  diarrhea.  Very  seldom  is  there  skin  edema  and  fluctuation.  The 
patient  lies  upon  his  back,  usually  with  one  or  both  thighs  flexed.  In  appen- 
dicular abscess  there  is  fever,  usually  higher  at  night  than  in  the  morning,  pro- 
fuse sweating  occurring  during  the  fail.  In  some  cases  the  temperature  is  per- 
sistently high;  in  some  the  elevation  is  trivial;  in  some  chills  occur.  A  sud- 
den fall  of  temperature  with  shock  is  produced  by  rupture  of  the  abscess  wall. 
If  this  accident  happens,  general  peritonitis  quickly  arises.  In  appendicular 
abscess  there  is  marked  leukocytosis,  unless  the  walls  are  very  thick  or  unless 
the  process  has  diffused  and  general  peritonitis  has  taken  place,  in  which 
conditions  it  may  be  absent.  Appendiceal  abscess  may  be  assumed  to  exist 
when  the  s\Tnptoms  of  appendicitis  persist  after  the  fifth  or  sixth  day,  or 
when,  after  the  symptoms  have  subsided,  they  reappear  a  day  or  two  later 
(see  page  1141). 

Abscess  of  the  live)'  may  not  be  announced  by  s}Tnptoms  until  rupture. 
It  may  follow  dysentery,  may  be  a  result  of  the  lodgment  of  infected  clots  from 
the  hemorrhoid  veins,  may  follow  upon  the  infective  phlebitis  of  appendicitis, 
may  result  from  septic  cholangitis  or  suppuration  of  a  hydatid  cyst.  Abscess 
from  dysentery  is  apt  to  be  solitary.  Portal  infection  induces  multiple  ab- 
scesses. We  speak  now  of  solitary  abscess.  The  bacterial  origin  of  this  is  in 
doubt.  Amebae  are  usually  present.  We  usually  find  fever  of  an  intermittent 
type,  profuse  sweats,  pain  in  the  back,  the  right  shoulder,  or  the  right  hypo- 
chondriac region,  enlargement  of  the  area  of  liver-dulness,  and  hepatic  tender- 
ness. Sometimes  there  are  fluctuation  and  skin  edema  over  the  liver,  and  the 
general  cutaneous  surface  may  be  a  little  jaundiced.  The  s}Tnptoms  vary  as 
the  pus  invades  adjacent  organs.  WTien  there  are  pain  on  respiration  and 
e\ddences  of  diaphragmatic  pleuritis,  the  pus  is  probably  breaking  into  the 
pleural  sac.     There  may  or  may  not  be  leukocytosis  (see  page  11 73). 

Deep  Abscess  of  the  Neck. — The  majority  of  these  abscesses  are  due  to 
suppuration  of  lymph-glands,  bacteria  having  reached  the  glands  from  an  ad- 
jacent area  of  infection,  cutaneous,  mucous,  or  osseous.  Suppuration  beneath 
the  deep  fascia  induces  dusky  discoloration  of  the  surface,  great  pain,  extensive 
edematous  swelling,  and  often  interference  with  respiration.  The  constitu- 
tional evidences  of  suppuration  are  noted.  Acute  suppuration  under  the  deep 
fascia  of  the  submaxillary  region  causes  extensive  inflammatory  edema,  inter- 
ference with  respiration  and  deglutition,  violent  constitutional  symptoms,  and 
often  sloughing  of  tissues  (see  Ludwig's  Angina).  A  deep  abscess  over  the 
carotid  artery  is  lifted  by  each  arterial  beat  and  may  be  mistaken  for  aneurysm, 
but  the  pulsation  is  not  expansile.  The  pus  of  a  deep  cervical  abscess  may  track 
its  way  into  the  mediastinum  or  axilla,  or  the  abscess  may  break  into  a  large 
blood-vessel,  the  pharynx,  the  wind-pipe,  or  the  gullet. 

Axillary  Abscess. — Superficial  abscesses  are  usually  multiple,  are  in  reality 
furuncles,  and  result  from  infection  of  the  sweat-glands  and  hair-follicles. 

Deep  abscesses  are  in  most  instances  due  to  suppuration  of  the  axillary 
lymph-glands.     The  most  common  cause  is  an  infected  wound  or  a  focus  of 


156  Suppuration  and  Abscess 

suppuration  about  the  hand,  forearm,  arm,  or  chest,  but  they  may  result  from 
caries  of  a  rib  or  may  follow  a  deep  cervical  abscess.  An  axillary  abscess  may 
be  lifted  at  each  beat  of  the  artery  and  to  this  extent  it  resembles  an  aneurysm, 
but  the  pulsation  is  not  expansile. 

.'Uute  retropharyngeal  abscess  is  due  to  pyogenic  infection  of  the  retro- 
pharyngeal tissues.  The  abscess  usually  forms  upon  one  of  the  lateral  halves 
of  the  pharynx.  The  retropharyngeal  lymph-glands  are  on  each  side,  between 
the  wall  of  the  pharynx  and  the  rectus  capitis  anticus  major  muscle  in  front  of  the 
first  and  second  cervical  vertebrae  (Cunningham's  "Anatomy").  An  abscess  may 
be  due  to  traumatism,  to  acute  infectious  diseases,  to  infective  processes  of  the 
mucous  membrane  of  the  mouth,  ear,  and  nasopharynx,  to  pyogenic  infection 
of  a  tuberculous  abscess,  to  vertebral  or  occipital  osteomyelitis.  In  the  great 
majority  of  cases  the  disease  is  due  to  suppuration  of  the  deep  cervical  glands. 
Lymphadenitis  need  not  of  necessity  eventuate  in  abscess.  Pus  may  find  its 
way  into  the  mediastinum  and  may  break  into  a  bronchus,  the  esophagus  or 
a  great  vessel.  If  an  abscess  breaks  into  the  wind-pipe  or  a  bronchus  it  will 
cause,  probably,  death  by  asphyxia.  Edema  of  the  glottis  is  to  be  apprehended 
in  all  cases.  There  is  pain,  difhculty  in  swallowing,  dyspnea,  nasal  voice, 
bulging  into  the  pharynx,  which  is  detected  by  inspection  and  palpation, 
enlargement  of  the  deep  cervical  glands,  fever,  sweats,  and  great  weakness. 
Tuberculous  Retropharyngeal  Abscess  is  considered  on  page  266. 

Subphrenic  or  subdiaphragmatic  abscess  is  apt  to  begin  beneath  the  dia- 
phragm, though  in  some  few  instances  the  pus  forms  above  this  muscle,  and  sub- 
sequentlv  gains  access  to  the  region  beneath.  Such  an  abscess  may  contain 
not  only  pus,  but  gas,  and  in  some  cases  also  fluid  from  the  stomach  or  intestine. 
The  gas  of  a  subphrenic  abscess  may  have  entered  from  a  perforation  of  a  hol- 
low viscus  or  may  have  been  made  by  gas-forming  bacteria.  Subphrenic 
abscess  may  arise  after  perforation  of  the  bowel  or  stomach,  or  it  may  result 
from  infected  spinal  abscess,  perinephric  abscess,  traumatism,  abscess  of  liver, 
kidney,  spleen  or  pancreas,  empyema,  or  pneumonia  (Greig  Smith's  "Abdominal 
Surgery").  Inflammation  of  the  gall-bladder  or  appendicitis  may  cause  it.  The 
symptoms  are  pain,  fever,  sweats,  dyspnea,  cough,  and  the  physical  signs  of  a 
collection  of  fluid  beneath  the  diaphragm  and  often  of  gas  in  the  cavity  of  the 
abscess.     There  is  usually  leukocytosis  (see  page  154). 

Abscess  of  the  Jung  gives  the  physical  signs  of  a  cavity;  the  expectoration  is 
offensive  and  contains  fragments  of  lung-tissue.  An  abscess  may  usually  be 
located  by  the  use  of  the  .r-rays.  Pyemic  abscesses  may  exist  and  yet  escape 
discovery.     (See  Surgery  of  Respiratory  Organs.) 

Abscess  of  the  mediastinum  may  arise  secondarily  to  deep  abscess  of  the  neck 
or  vertebral  suppuration;  suppuration  of  the  mediastinal  glands,  lung,  or  pleura; 
caries  of  a  rib  or  of  the  sternum,  ulceration  of  the  esophagus  or  pericarditis.  It 
causes  throbbing  retrosternal  pain,  pain  in  the  back,  chills,  fever,  sweats,  irregular 
pulse,  and  often  dyspnea.  A  lump  may  appear  which  pulsates  and  fluctuates, 
but  the  pulsation  is  not  expansile. 

Perinephric  abscess  usually  causes  tenderness  and  pain  in  the  lumbar  region 
or  about  the  hip-joint,  this  pain  running  down  the  thigh  and  being  accom- 
panied by  pain  in  and  retraction  of  the  testicle.  Induration,  or  edema  of  the 
skin  may  be  observed  in  the  lumbar  region.  If  fluctuation  occurs  at  alMt  is  a 
very  late  sign.  The  constitutional  symptoms  of  suppuration  usually  exist  (see 
page  154).     There  is  a  high  leukocytosis. 

Abscess  or  empyema  of  the  antrum  of  Highmore  is  a  collection  of  pus  within 
the  maxillary  antrum.  It  results  from  inflammation  of  the  jaw,  the  teeth,  or 
the  mucous  membrane  of  the  nose.  It  causes  pain,  edematous  s\yelling  of  the 
overlying  soft  parts,  and  crepitation  on  pressure  upon  the  superior  maxfllary 
bone.  Pus  mav  escape  from  the  nostril  of  the  diseased  side  when  the  head 
is  bent  in  the  direction  of  the  healthy  side.     A  rhinoscopic  examination  dis- 


Acute  Abscesses  in  Various  Regions  157 

closes  the  fluid  passing  into  the  nares.  The  antrum  on  the  side  of  the  abscess 
cannot  be  transilluminated  by  an  electric  light  in  the  mouth  (Garel's  sign). 
The  constitutional  symptoms  of  suppuration  usually  arise. 

Alveolar  abscess  is  suppurative  dental  periostitis  due  to  diseased  teeth.  The 
simplest  form  is  a  gum-boil,  a  collection  of  pus  between  the  gum  and  the 
bone  external  to  the  inflamed  root  of  a  tooth.  In  more  severe  cases  the  suppu- 
ration begins  within  the  tooth  socket  and  the  pus  escapes  around  the  neck  of 
the  tooth;  a  distinct  and  local  abscess  may  be  situated  at  the  end  of  the  root, 
absorption  of  bone  having  occurred,  or  a  considerable  cavity  may  form  in  the 
bone,  the  external  maxillary  plate  being  perforated.  In  the  very  severe  cases 
the  cheek  is  involved.  An  alveolar  abscess  may  break  through  the  gum  into 
the  mouth  or  it  may  break  externally  through  the  cheek.  Acute  alveolar 
abscess  causes  intense  pulsatile  pain,  marked  swelling  of  the  gum  and  cheek, 
and  sometimes  very  great  edematous  and  dusky  swelling  of  the  face.  A  sinus 
may  follow  its  evacuation.  Dead  bone  may  form.  A  chronic  apical  abscess 
may  give  rise  to  no  definite  symptoms  and  yet  be  a  focus  of  infection  leading  to 
distant  infection  of  bone,  gland,  joint,  pleura,  etc. 

Abscess  of  the  larynx  invariably  causes  laryngeal  edema,  which  obstructs 
respiration  and  puts  life  in  jeopardy.  Such  an  abscess  is  most  apt  to  appear 
upon  the  oral  surface  of  the  epiglottis,  but  may  arise  within  the  larynx.  It  in- 
duces violent  cough,  pain,  interference  with  the  voice,  swallowing,  and  breath- 
ing, and  the  swelling  can  often  be  felt  with  a  finger  and  can  always  be  seen  by 
the  aid  of  a  laryngoscope. 

An  ischiorectal  abscess  is  situated  in  the  areolar  tissue  of  the  ischiorectal 
fossa.  The  pyogenic  organisms  usually  gain  entrance  to  the  lymphatics  by 
way  of  an  abrasion,  fissure,  or  ulceration  of  the  rectum  or  anus.  A  perfora- 
tion made  by  a  foreign  body  may  inaugurate  the  condition.  In  rare  cases 
bacteria  reach  the  fossa  in  the  blood-stream.  The  condition  may  be  due  to 
pyogenic  infection  of  a  tuberculous  focus.  The  pain  is  severe  and  throbbing; 
there  are  great  tenderness,  redness  and  edema  of  skin,  induration,  and  usually 
the  constitutional  symptoms  of  pus  formation.  Fluctuation  is  a  very  late 
sign  because  of  the  density  of  the  fascia. 

Prostatic  abscess  may  result  from  catheter  infection,  from  infection  of  the 
bladder  or  urethra,  or  from  traumatism,  but  the  commonest  cause  is  gonorrhea. 
There  may  be  one  abscess,  several  abscesses,  or  many  abscesses.  Pus  may 
break  into  the  rectum,  the  bladder,  or  the  urethra,  or  may  break  externally. 
A  prostatic  abscess  is  manifested  by  chills,  fever,  sweats,  frequent  and  painful 
micturition,  tenderness  of  the  perineum  and  rectum,  and  agonizing  pain, 
developing  during  an  attack  of  acute  prostitis.  A  finger  in  the  rectum  can 
palpate  the  swollen  gland. 

Abscess  of  the  breast  follows  absorption  of  pyogenic  bacteria  from  a  fissure 
or  abrasion  of  the  nipple.  Some  surgeons  maintain  that  the  bacteria  enter 
along  the  milk-ducts,  while  others  assert  that  they  gain  entrance  by  the  lym- 
phatics. It  is  most  common  in  nursing  women.  Its  symptoms  are  swelling, 
tenderness,  pulsatile  pain,  dusky  discoloration,  skin  edema,  fluctuation,  and 
usually  constitutional  disorder.     (See  Mastitis.) 

Orbital  abscess  is  a  diffuse  suppuration,  due  to  cellulitis  or  a  collection  of 
pus  due  to  caries  or  necrosis  of  the  orbital  wall,  suppuration  of  the  accessory 
nasal  sinus,  facial  erysipelas,  or  dental  caries.  A  wound  may  cause  it.  In 
severe  orbital  cellulitis  the  movements  of  the  eye  are  limited,  the  Hds  are  very 
red  and  edematous,  the  conjunctiva  is  red  and  swollen  (chemosis),  and,  if  the 
case  is  not  promptly  reHeved,  optic  neuritis  may  arise  and  sloughing  of  the  cornea 
occur. 

Von  Bezold's  Abscess. — In  this  condition  the  pus  of  a  suppurating  mastoid 
process  breaks  through  the  mastoid  near  the  tip  and  enters  into  the  sheath  of 
the  digastric  muscle  or  the  sheath  of  the  sternocleidomastoid.     There  exist  ex- 


158  Suppuration  and  Abscess 

tensive  inflammatory  swelling  of  the  neck,  a  history  of  mastoid  trouble,  usually 
a  lessened  amount  of  pus  from  the  ear,  pain  in  the  neck,  and  constitutional 
symptoms.  The  condition  suggests  thrombosis  of  the  lateral  sinus,  but  the 
symptoms  are  not  so  violent  and  are  not  pyemic  as  they  are  in  that  disease. 

Abscess  of  the  Groin  or  Pyogenic  Bubo. — Such  an  abscess  may  have  mounted 
up  from  the  pelvis,  tracked  forward  from  the  sacro-iliac  joint,  or  descended  in 
the  psoas  sheath  from  the  vertebrae,  but  in  a  very  great  majority  of  cases  it  is 
due  to  suppuration  of  the  lymphatic  glands.  A  bubo  may  be  tuberculous, 
venereal,  or  pyogenic.  A  pyogenic  bubo  results  from  an  area  of  infection  in 
the  trajectory  drained  by  the  lymph-vessels  of  the  inguinal  or  femoral  glands. 
The  glands  involved  may  be  superficial  or  deep.  The  symptoms  are  those 
ordinarily  linked  with  suppuration.  Occasionally,  the  pulsations  of  the  great 
vessels  may  lift  the  mass. 

Abscess  of  the  Popliteal  Space. — This  results  from  traumatism,  mixed  in- 
fection of  a  tuberculous  or  syphilitic  area,  suppuration  of  the  contained  lymph- 
glands,  of  one  of  the  adjacent  bursae,  or  of  the  neighboring  bone.  In  rare 
cases  it  arises  as  a  result  of  suppuration  of  the  sac  of  an  aneurysm.  The  symp- 
toms are  severe  pain,  swelling,  flexion  of  the  knee,  and  edema  of  the  leg.  The 
pulsations  of  the  popliteal  artery  may  be  transmitted  to  the  abscess.  These 
pulsations  are  not  expansile,  as  in  aneurysm.  Pus  may  pass  under  the  deep 
fascia,  up  or  down  the  extremity,  or  may  break  into  the  knee-joint. 

Suppurative  thecitis  or  felon  is  a  form  of  diffuse  suppuration.     (See  Felon.) 

Palmar  abscess  is  a  purulent  effusion  (see  page  812). 

Furuncle  and  carbuncle  are  discussed  on  pages  148  and  149. 

Empyema  is  a  purulent  effusion  into  the  pleural  sac  (see  page  1015).  It  is 
technically  an  abscess  if  it  becomes  encapsuled. 

Diagnosis. — The  diagnosis  of  an  abscess  rests  upon — (i)  its  history;  (2) 
fluctuation;  (3)  pointing;  (4)  surface  edema;  (5)  the  use  of  the  tubular  ex- 
ploring needle;  (6)  leukocytosis. 

Fluctuation  is  the  sensation  imparted  to  a  finger  held  against  a  sac  con- 
taining fluid  when  a  wave  is  started  in  the  fluid  by  striking  the  mass  with  a 
finger  of  the  other  hand.  Fluctuation  cannot  be  obtained  if  the  amount  of 
fluid  is  small.  It  should  never  be  sought  for  across  a  limb,  but  rather  along  it, 
because  a  false  sense  of  fluctuation  can  always  be  obtained  across  the  muscles 
of  the  limb.     Pointing  and  surface  edema  have  been  discussed. 

A  suspected  abscess  in  a  part  containing  large  blood-vessels  under  no  cir- 
cumstance should  be  opened  by  a  bistoury  without  knowing  that  the  diagnosis 
is  certainly  correct.  This  knowledge  is  obtained  in  some  cases  by  inserting 
a  small  aspirating  needle  and  observing  the  nature  of  the  fluid  which  exudes. 
This  operation  must  be  performed  with  aseptic  care;  otherwise,  if  there  is  no 
abscess,  infection  may  be  inaugurated;  if  there  is  an  abscess,  mixed  infection 
may  occur.  The  older  operators  used  a  grooved  ex-ploring  needle,  but  many 
able  surgeons  object  to  its  use,  on  the  ground  that  when  plunged  into  an  in- 
fected area  pus  bathes  the  track  of  puncture  and  may  cause  infection  of  other 
tissues  and  diff'usion  of  the  pyogenic  process.  The  tubular  e\-ploring  needle 
is  the  proper  instrument. 

An  abscess  which  moves  with  the  pulse  because  it  rests  upon  an  artery 
may  be  confounded  with  an  aneurysm.  The  pulse  movements  of  such  an 
abscess  are  in  one  direction  only;  the  abscess  is  lifted  with  each  pulse-beat, 
but  does  not  enlarge,  and  if  a  finger  is  laid  upon  either  side  of  it  the  fingers 
will  be  Hfted,  but  not  separated.  The  pulse  movements  of  an  aneurysm  are 
in  all  directions;  they  are  expansile,  the  sac  grows  larger,  and  the  fingers  will 
not  only  be  lifted,  but  will  also  be  separated.  The  small  tubular  exploring 
needle  may  be  used  in  doubtful  cases;  if  aseptic,  it  will  do  no  harm  even  to  an 
aneurysm.  A  rapidly  growing,  small-cell  sarcoma  feels  not  unlike  an  abscess, 
but  the  exploring  needle  discovers  blood  and  not  pus.     A  cystic  tumor  is 


Treatment  of  Abscess 


159 


separated  from  an  abscess  by  the  absence  of  inflammation,  or,  if  it  inflames, 
by  the  nature  of  the  contained  fluid.  Ordinary  caution  will  prevent  one  con- 
founding an  abscess  with  strangulated  hernia.  A  tuberculous  abscess  is  sepa- 
rated from  an  acute  abscess  by  the  absence  of  inflammatory  signs  in  the  former. 
The  contents  of  the  acute  abscess  dil^er  from  those  of  the  tuberculous  abscess. 
When  an  abscess  exists  in  an  important  region  (brain,  appendix,  liver,  etc.) 
cultures  of  the  pus  should  be  taken  after  incision.  Such  studies  often  give 
valuable  information  as  to  the  probable  course  of  the  condition,  and  an  accumu- 
lation of  many  accurate  observations  will  add  greatly  to  scientific  information. 
Figure  77  shows  a  convenient  case  for  carrying  culture-tubes. 

Prognosis. — The  prognosis  varies  according  to  the  number  of  abscesses, 
their  location  and  size,  the  vital  resistance  of  the  patient,  and  the  virulence 
of  the  causative  bacteria. 

Treatment. — In  the  treatment  of  an  abscess  there  is  one  absolute  rule 
which  knows  no  exception,  namely,  that  whenever  and  wherever  pus  is  found 
the  abscess  should  be  evacuated  at  once,  and,  after  evacuation,  thorough 
drainage  must  be  provided  for.  It  should  be  opened  up  early,  if  possible, 
even  before  fluctuation  and  positively  before  pointing,  to  prevent  tissue  destruc- 


FiG.   77. — Vischer's  case  for  carrying  culture-tubes  for  inoculation. 

tion,  subfascial  burrowing,  and  general  contamination.  Drainage  is  continued 
until  the  discharge  becomes  scanty,  thin,  and  seropurulent. 

Alveolar  abscess  requires  prompt  incision  through  the  gum,  extraction  of 
the  diseased  tooth  in  most  cases,  and  the  rinsing  of  the  mouth  at  frequent 
intervals  with  hot  fluid.  Heat  should  not  be  applied  to  the  cheek  or  jaw  exter- 
nally, as  it  would  favor  external  rupture.  If  spontaneous  rupture  externally 
is  inevitable,  then  an  incision  must  be  made  at  the  point  where  the  abscess 
is  nearest  the  surface.  The  cut  will  leave  less  scar  than  will  spontaneous 
evacuation.  It  is  sometimes  necessary  to  gouge  through  the  external  table 
of  the  bone,  pus  being  lodged  within  the  two  osseous  plates. 

Abscess  of  the  liver,  if  the  liver  is  adherent  to  the  parietal  peritoneum,  is 
opened  at  one  operation;  if  the  liver  is  not  adherent,  some  surgeons  operate 
in  two  stages.  In  the  two-stage  operation  an  incision  is  made  along  the  edge 
of  the  ribs  down  to  the  liver,  which  organ  is  then  stitched  to  the  edges  of  the 
wound.  In  a  day  or  two  after  the  first  operation  the  two  layers  of  peritoneum 
are  firmly  adherent,  and  the  abscess  can  be  opened  without  danger  of  the 
passage  of  pus  into  the  peritoneal  cavity.  The  abscess,  located  by  an  aspirat- 
ing needle,  is  opened  by  the  Paquelin  cautery,  is  washed  out  with  salt  solution, 
and  a  tube  is  inserted.  If  care  is  taken,  the  operation  can  be  safely  completed 
in  one  seance  even  if  the  liver  is  not  adherent  to  the  parietal  peritoneum. 
If  this  course  is  determined  on,  after  the  liver  is  exposed  by  incision,  the  ex- 


i6o  Suppuration  and  Abscess 

posed  surface  of  the  organ  is  surrounded  with  iodoform  gauze,  the  abscess  is 
located  by  an  aspirating  needle,  is  opened  by  the  cautery,  is  irrigated  and 
drained  as  directed  above.  Some  physicians  try  to  locate  an  abscess  by  plung- 
ing an  aspirating  needle  into  the  liver  before  making  an  abdominal  incision. 
This  procedure  seems  to  me  uncertain  and  dangerous.  An  abscess  of  the  dome 
of  the  right  lobe  of  the  liver  (the  commonest  seat)  may  be  reached  by  resecting 
a  rib,  incising  the  pleura,  and  opening  through  the  diaphragm  (transthoracic 
hepatotomy). 

Abscess  of  the  mediastimmi,  like  all  other  abscesses,  requires  incision  and 
drainage.  This  is  effected,  if  the  abscess  can  be  reached  in  front,  by  cutting 
between  the  rib  cartilages  or  by  trephining  the  sternum.  Abscess  of  the 
posterior  mediastinum  can  be  reached  only  by  resecting  portions  of  se\-eral  ribs 
near  their  vertebral  ends. 

In  abscess  of  the  lung  an  incision  is  made  and  the  pleura  is  exposed.  The 
incision  is  usually  through  an  intercostal  space;  but  if  the  spaces  are  narrow,  it 
will  be  necessary  to  resect  a  rib.  If  the  two  layers  of  pleura  are  found  adherent, 
the  operation  is  proceeded  with.  If  they  are  not  adherent,  they  are  stitched  to 
each  other  and  to  the  lung  with  catgut  sutures,  and  the  surgeon  waits  forty-eight 
hours  before  continuing.  This  precaution  is  taken  in  order  to  prevent  collapse 
of  the  lung  from  acute  traumatic  pneumothorax,  and  to  save  the  pleura  from 
receiving  pus  during  operation.  The  operation  is  completed  by  locating  the 
pus  by  means  of  an  aspirating  needle,  evacuating  it  by  the  cautery  at  a  dull- 
red  heat,  and  inserting  a  drainage-tube  into  the  abscess-cavity. 

A  subphrenic  abscess  requires  operation  at  once.  Immediately  before  oper- 
ating, if  in  doubt,  it  may  be  justifiable  to  endeavor  to  locate  pus  with  an  aspi- 
rating needle.  Incise  the  abscess  and  open  any  secondary  abscesses.  Many 
abscesses  point  below  the  diaphragm,  and  are  easily  reached  by  an  incision  in  the 
loin  or  in  the  epigastric  region.  Lannelonge  resects  the  eleventh  and  twelfth 
ribs  and  raises  the  pleura  out  of  the  way.  Some  surgeons  prefer  to  practise 
rib  resection  and  incise  the  adherent  pleural  layers  and  the  diaphragm.  After 
drainage  has  been  continued  for  a  time  it  may  be  necessary  to  do  a  secondary 
operation  in  order  to  cure  the  lesion  causative  of  the  abscess,  for  instance,  it 
may  be  necessary  to  close  a  chronic  gastric  perforation. 

In  abscess  of  the  antrum  of  Highmore  bore  a  gimlet-hole  through  the  supe- 
rior m'axillary  bone,  above  the  canine  tooth,  or  perforate  the  bone  by  means  of 
a  trocar.  Irrigate  daily  with  boiled  water  or  normal  salt  solution.  Prevent 
contraction  of  the  opening  by  inserting  a  small  piece  of  rubber  tissue  fastened 
externally  to  keep  it  from  slipping  in.  In  persistent  cases  it  may  be  necessary 
to  draw  a  tooth,  break  through  the  socket  of  the  first  or  second  bicuspid  into 
the  antrum,  and  insert  a  silver  or  hard-rubber  tube,  and  also  to  perforate 
the  antrum  from  the  inferior  meatus  and  keep  the  opening  patent.  In  very 
persistent  cases  osteoplastic  resection  of  a  portion  of  the  upper  jaw  will  be 
demanded. 

In  appendicular  abscess  incise,  support  the  abscess  walls  with  gauze,  remove 
the  appendix  in  most  cases,  but  not  in  all,  and  insert  a  drainage-tube  and  strands 
of  gauze  (see  page  1155). 

An  ischiorectal  abscess  must  be  opened  early.  The  surgeon  never  waits 
for  fluctuation.  Fluctuation  is  a  very  late  symptom.  To  wait  for  it  entails 
great  destruction  of  tissue  and  serves  no  useful  purpose.  Place  the  patient 
on  his  side,  with  the  legs  drawn  up.  Insert  a  finger  in  the  rectum,  lift  the 
abscess  toward  the  surface,  and  incise  it  from  the  surface.  The  incision  runs 
from  the  anal  margin  like  a  spoke  from  the  hub  of  a  wheel.  Irrigate  with 
salt  solution,  inject  iodoform  emulsion,  insert  a  drainage-tube,  dress,  and  later 
let  the  patient  know  he  is  in  danger  of  developing  a  fistula. 

A  retropharyngeal  abscess  must  be  opened  early,  because  delay  may  lead 


Treatment  of  Abscess  i6i 

to  fatal  obstruction  and  because  if  spontaneous  evacuation  occurs  the  patient 
may  be  suffocated.  Some  surgeons  open  it  from  within  the  mouth,  but  this 
exposes  the  patient  to  the  danger  of  septic  bronchopneumonia  from  inhalation 
of  purulent  elements  and  to  serious  gastro-intestinal  disorder  from  swallowing 
quantities  of  pus.  Again,  if  opened  through  the  mouth,  the  abscess  is  liable 
to  become  putrid.  It  is  better  to  open  it  from  the  neck  by  Hilton's  method, 
the  incision  being  carried  through  the  sternocleidomastoid  muscle  or  posterior 
to  it.  Drainage  is  inserted  and  the  abscess  is  treated  in  the  usual  way.  The 
operation  is  performed  with  the  aid  of  infiltration  anesthesia. 

In  abscess  of  the  breast  make  an  incision  radiating  from  the  nipple,  or,  what 
is  better,  incise  under  the  breast  by  means  of  a  cut  at  the  inferior  thoracic 
mammary  junction  and  enter  the  abscess  from  beneath. 

In  abscess  of  the  brain  the  skull  should  be  trephined,  the  membranes  incised, 
and  the  abscess  sought  for,  opened,  and  drained  (see  page  904). 

In  suppuration  within  the  orbit  due  to  cellulitis,  incise  the  conjunctiva 
and  drain.  In  suppuration  due  to  caries  or  necrosis  of  the  upper  orbital  wall 
make  a  transverse  incision  through  the  upper  lid,  reach  the  pus  by  Hilton's 
method  (see  page  162),  remove  carious  or  loose  necrotic  bone,  and  drain. 

A  perinephric  abscess  requires  an  incision  in  the  lumbar  region  and  free 
drainage. 

An  abscess  of  the  larynx  requires  immediate  incision,  scarification  and  in- 
halation of  steam  to  abate  swelling.  In  a  severe  case  the  surgeon  should  at 
once  performi  tracheotomy. 

Bezold's  abscess  requires  one  or  more  incisions  in  the  neck  for  drainage. 
Then  the  mastoid  is  exposed,  its  tip,  including  the  osseous  fistula,  is  removed, 
and  its  interior  is  cleared  out  by  a  complete  operation. 

A  prostatic  abscess  should  be  opened  promptly  by  a  perineal  incision. 

In  an  ordinary  superficial  abscess,  after  cleansing  the  parts,  make  the  skin 
tense,  locate  the  superficial  vessels  and  nerves,  and  plan  the  incision  to  avoid 
them.  Incise  with  a  sharp-pointed  curved  bistoury  at  the  most  dependent 
part  of  the  abscess  or  tlirough  the  region  of  pointing.  If  the  abscess  is  upon 
the  face  or  neck,  make  the  incision  in  the  line  of  the  skin  creases  so  as  to  limit 
the  scar.  The  incision  must  not  be  made  suddenly  and  fiercely,  neither  should 
it  be  made  with  hesitation  and  uncertainty.  Thomas  Bryant  says:  "It 
should  be  done,  as  ought  every  other  act  of  surgery,  with  confidence  and  de- 
cision, boldness  and  rapidity  of  action  being  governed  by  caution  and  made  sub- 
servient to  safety"  ("Practice  of  Surgery").  Permit  the  pus  to  run  out  spon- 
taneously; pressure,  as  a  rule,  is  undesirable  because  it  may  damage  the  abscess 
wall  and  cause  diffusion  of  the  infection.  If  tissue  shreds  block  the  opening, 
they  must  be  picked  out  with  forceps.  If  the  atmospheric  pressure  will  not 
cause  the  pus  to  flow  out,  make  light  pressure  with  warm,  moist,  aseptic  gauze 
pads.  After  the  pus  has  come  away,  gently  wash  the  cavity  with  normal 
salt  solution  or  boiled  water,  and  drain  with  a  tube  for  two  or  three  days  when 
the  discharge  becomes  serous.  It  is  not  desirable  to  overdistend  the  abscess- 
cavity  with  fluid,  because  the  hydrostatic  pressure  may  break  down  the  wall 
of  young  cells  and  infection  be  diffused.  Do  not  irrigate  with  powerful  disin- 
fectants. They  cannot  be  used  strong  enough  to  really  disinfect,  but  may 
easily  be  used  strong  enough  to  cause  necrosis  of  an  abscess  wall.  Peroxid 
of  hydrogen  is  not  to  be  used  unless  the  incision  is  large,  because  the  gas  it 
generates  may  tear  the  abscess  wall  and  diffuse  the  infection.  Peroxid  of  hydro- 
gen is  a  dangerous  agent  to  inject  into  the  cavity  of  a  deep  abscess  of  the 
neck,  as  the  liberated  gas  may  not  escape  from  the  opening,  but  may  pass 
widely  into  the  tissues  and  cause  great  distention.  The  author  saw  a  child 
who  narrowly  escaped  death  after  such  an  injection.  In  this  patient  the  gas 
passed  beneath  the  pharyngeal  mucous  membrane  and  the  swelling  almost 
occluded   the   air-passages.     If   an   abscess   contains   putrid  pus   the  incision 


i62  Suppuration  and  Abscess 

should  be  free,  and  after  evacuation  it  should  be  irrigated  with  hot  salt  solution 
or  peroxid  of  hydrogen  and  injected  with  iodoform  emulsion.  Pursue  rigid 
antisepsis  in  dealing  with  purulent  areas.  It  is  true  we  already  have  infection 
with  pyogenic  bacteria,  but  infection  can  also  take  place  with  organisms  of 
putrefaction,  causing  pus  to  become  putrid,  or  with  other  bacteria,  for  instance, 
those  of  tetanus.  If  a  tube  is  not  used  and  the  cavity  is  filled  with  iodoform 
gauze,  remember  that  gauze  will  not  drain  pus  and  requires  to  be  changed 
once  a  day  or  oftener.  An  abscess  should  be  dressed  with  hot,  moist,  antiseptic 
dressings  (antiseptic  fomentation)  and  the  part  must  be  put  at  rest.  When 
the  discharge  becomes  thin  and  scanty,  dry  aseptic  or  antiseptic  dressings  are 
used. 

In  a  deep  abscess  or  an  abscess  situated  near  important  vessels  do  not  boldly 
plunge  in  a  knife.  Hilton  says  to  "plunge  in  a  knife  is  not  courageous,  as 
it  is  without  danger  to  the  surgeon,  but  may  be  fatal  to  the  patient."  Re- 
member also  that  a  large  amount  of  pus  displaces  normal  anatomical  relations. 
Hilton's  method  of  opening  a  deep  abscess  (as  in  the  axilla  or  neck)  is  to  cut 
to  the  deep  fascia,  nick  the  fascia  with  a  knife,  and  then  push  into  the  abscess 
a  grooved  director  until  pus  shows  in  the  groove;  along  the  groove  push  a  pair 
of  closed  dressing  forceps;  after  they  reach  the  depths  take  out  the  director, 
open  the  forceps,  and  withdraw  them  while  open,  and  so  dilate  the  opening; 
then  insert  a  tube  and  gently  irrigate  with  warm  salt  solution. 

Always  endeavor  to  open  an  abscess  at  its  most  dependent  part,  remem- 
bering that  the  situation  of  this  part 
may  depend  upon  whether  the  patient 
is  to  be  erect  or  recumbent.  If  we  do 
not  make  the  opening  at  the  lowest 
point,  all  the  pus  will  not  run  out  and 
the  walls  will  not  completely  collapse. 
A  deep  abscess  must  be  drained  thor- 
oughly until  the  discharge  becomes 
seropurulent.  WTien  the  tube  is  re- 
FiG.  78. — Drainage-tubes  for  abscess  re-  moved  it  is  wise  to  insert  a  piece  of 
quiring  irrigation.  rubber   tissue  just  through  the  outlet 

of  the  abscess.  This  tent  prevents 
the  skin  from  closing  over  the  channel.  It  is  removed  and  a  new  one  inserted 
every  day  until  it  is  clear  that  there  is  no  longer  danger  of  fluid  becoming 
blocked  and  retained.  When  an  abscess  contains  diverticula  or  pouches  they 
should  be  slit  up  or  a  counteropening  ought  to  be  made.  A  counteropening 
is  made  by  entering  the  dressing  forceps  at  the  first  incision,  pushing  them 
through  the  abscess  to  the  point  where  we  wish  to  make  our  counteropening, 
opening  the  blades,  and  cutting  between  them  from  without  inward.  The 
blades  are  then  closed  and  projected  through  the  incision;  they  are  opened  in 
order  to  dilate  the  new  door,  and  are  closed  again  upon  a  drainage-tube, 
which  is  pulled  through  from  opening  to  opening  as  the  instrument  is  with- 
drawn. WTien  pus  burrows,  insert  a  grooved  director  in  each  channel  and  slit 
the  sinus  with  a  knife.  An  abscess  may  make  an  opening  through  dense  fascia, 
the  opening  being  small  like  the  neck  of  an  hour-glass  {shirt-stud  abscess). 
Always  examine  to  see  if  such  a  condition  exists,  and  if  it  is  found,  incise  the 
fascia. 

In  a  deep  abscess  containing  putrid  pus  frequent  irrigation  is  desirable. 
In  such  a  case  two  tubes  may  be  employed  (Fig.  78).  The  tubes  are  prevented 
from  slipping  in  by  the  use  of  a  safety-pin  (c).  The  irrigating  fluid  is  passed 
into  the  cavity  {d)  through  the  tube  6,  which  is  without  fenestra,  and  most 
of  it  runs  out  through  the  tube  c,  which  possesses  fenestra. 

Rest  is  of  the  first  importance  in  the  healing  of  an  abscess,  and  we  try  to 
obtain  it  by  bandages,  spUnts,  and  pressure,  which  will  immobilize  adjacent 


Classification  of  Ulcers  163 

muscles  and  approximate  the  abscess  walls.  If  an  abscess  is  slow  to  heal,  use 
as  a  daily  injection  a  solution  of  corrosive  sublimate  of  the  strength  of  i:  1000, 
or  3  drops  of  nitric  acid  to  i  oz.  of  water,  or  3  gr.  of  zinc  sulphate  to  i  oz.  of 
water,  or  a  5  per  cent,  solution  of  carbolic  acid,  or  a  2  per  cent,  aqueous  solu- 
tion of  pyoktanin,  or  20  drops  of  tincture  of  iodin  to  i  oz.  of  water,  or  a  2  per 
cent,  solution  of  acetate  of  aluminum.  The  constitutional  treatment  of  an 
abscess  depends  upon  the  severity  of  the  morbid  process  and  the  importance 
of  the  structures  involved.  In  a  serious  case  the  patient  should  be  put  to 
bed,  opiates  should  be  given  with  a  free  hand,  the  bowels  be  kept  active  by 
calomel  and  salines,  skin  activity  be  maintained,  the  taking  of  nutritious  food 
insisted  on,  and  stimulants  liberally  employed. 

Purulent   Effusions. — (See    Suppurative    Thecitis,    Palmar    Abscess,    Sup- 
purative S}Tiovitis,  Purulent  Peritonitis,  Empyema,  etc.) 


VII.  ULCERATION  AND  FISTULA 

An  ulcer  is  a  loss  of  substance  due  to  molecular  death  of  a  superficial 
structure.  The  molecular  death  is  brought  about  by  bacteria.  Ordinary 
ulcers  are  caused  by  pus  organisms.  The  action  of  the  pus  organisms  is  the 
same  as  in  an  abscess.  A  broken  abscess  becomes  an  ulcer,  and  an  ulcer  is 
in  structure  a  half-section  of  an  abscess.  The  floor  of  an  ulcer  consists  of 
granulation'  tissue  and  corresponds  to  the  abscess  wall.  An  abscess  arises 
from  molecular  death  within  the  tissues;  an  ulcer,  from  molecular  death  of 
a  free  surface.  An  ulcer  may  increase  in  size  by  molecular  death  of  adjacent 
structures  or  by  sloughing,  that  is  to  say,  by  death  of  visible  masses  of  tissue. 
A  wound  healing  by  granulation  is  often  wrongly  called  an  ulcer.  An  ulcer 
must  not  be  confounded  with  an  excoriation.  In  an  ulcer  the  corium  is  always, 
and  the  subcutaneous  tissue  is  generally,  destroyed,  and  a  scar  is  left  after 
healing.  In  an  excoriation  the  mucous  layer  of  epithelium  is  exposed,  or 
this  is  destroyed  and  the  corium  is  exposed.  In  an  excoriation  the  corium  is 
never  destroyed,  and  no  scar  remains  after  healing.  An  ulcer  heals  by  granula- 
tion (see  page  128).  Embryonic  tissue  by  vascularization  becomes  granulation 
tissue,  granulation  tissue  is  converted  into  fibrous  tissue,  the  fibrous  tissue 
contracts,  and,  by  pulHng  strongly  the  edges  of  the  ulcer  together,  lessens  the 
size  of  the  cavity.  When  the  granulations  reach  the  level  of  the  skin  the 
epithelium  at  the  edges  of  the  ulcer  proliferates  and  the  sore  is  soon  covered 
over  mth  new  epithehum. 

Necrosis  of  a  superficial  part  may  arise  from — (i)  Inflammation.  The 
pressure  of  the  exudate  can  cut  ofi  the  circulation,  or  bacteria  may  directly 
destroy  tissue.  Suppuration  occurs.  (2)  The  action  of  pus  bacteria,  causing 
primary  ceU-necrosis.  (3)  Bacteria  of  putrefaction  and  organisms  of  suppura- 
tion acting  upon  a  wound.  (4)  Traumatism  or  irritants,  producing  at  once 
stasis,  which  is  added  to  by  secondary  inflammation,  the  exudate  undergoing 
purulent  liquefaction.  (5)  Prolonged  pressure.  (6)  Deficient  blood-supply. 
(7)  Faulty  venous  return.  (8)  Degeneration  of  a  neoplastic  infiltration  (gum- 
matous, malignant,  or  tuberciilous) .  (9)  Trophic  disturbance.  (10)  Nutri- 
tional disturbances  (as  scurvy).  Most  ulcers  are  due  directly  to  pus  organ- 
isms, and  areas  of  necrosis  of  superficial  parts  that  arise  from  something  else 
(as  gum^matous  degeneration)  usually  suppurate. 

Classification. — Ulcers  are  classified  into  groups  according  to  the  con- 
dition of  the  ulcer  and  the  associated  constitutional  state.  In  the  first  group 
we  find  the  varicose,  hemorrhagic,  acute,  chronic,  irritable,  neuralgic,  etc. 
In  the  second  group  are  placed  the  tuberculous,  syphihtic,  senile,  scorbutic, 
etc.  All  ulcers,  whatever  their  origin,  are  either  acute  or  chronic,  and  such 
conditions  as  great  pain,  hemorrhage,  edema,  exuberant  granulations,  phage- 


164  Ulceration  and  Fistula 

dena,  sloughing,  eczema,  gout,  syphilis,  scurvy,  etc.,  are  to  be  looked  upon 
as  complications.  The  leg  is  so  common  a  site  for  ulcers  as  to  warrant  a  special 
description  of  ulcers  of  this  part.  In  describing  an  ulcer  state  the  patient's 
previous  history  and  his  occupation;  the  supposed  cause;  the  situation;  the  out- 
line; the  duration,  and  the  mode  of  onset  of  the  ulcer.  A  knowledge  of  the 
victim's  occupation  may  furnish  the  key  to  the  cause  (for  instance,  the  ulcers 
ot  tanners  which  are  due  to  chrome  salts).  See  the  author  and  Dr.  John  F.  X. 
Jones  in  "Annals  of  Surgery,"  Feb.,  1916.  State  if  the  ulcer  is  single  or  if 
multiple  sores  exist,  and  if  there  is  or  is  not  pain;  whether  or  not  any  healing  has 
ever  occurred,  and  the  patient's  constitutional  condition.  Set  forth  the  com- 
plications; the  state  of  anatomically  related  glands;  the  condition  of  the  edge, 
the  floor,  and  the  parts  about  the  ulcer,  and  the  nature  and  quantity  of  the 
discharge. 

Acute  or  inflamed  ulcer  of  the  leg  may  follow  an  acute  inflammation 
and  may  be  acute  from  the  start,  or  may  be  first  chronic  and  then  become  acute. 
It  is  especially  common  in  drunkards,  and  among,  those  of  dilapidated  con- 
stitutions. It  is  characterized  by  rapid  progress  and  intense  inflammation. 
There  is  rarely  more  than  one  ulcer.  In  outline  these  ulcers  are  usually  oval, 
but  may  be  irregular.  The  floor  of  an  acute  ulcer  contains  no  granulations, 
but  is  composed  of  the  raw  and  inflamed  tissues,  or  is  covered  by  a  mass  of 
gray  aplastic  lymph,  or  it  may  have  upon  it  large  greenish  sloughs.  The 
edges  are  thin  and  undermined.  The  discharge  is  very  profuse  and  ichorous, 
excoriating  the  surrounding  parts.  The  adjacent  cutaneous  surface  is  in- 
flamed and  edematous,  and  there  is  much  burning  pain.  In  some  cases  the 
glands  in  the  groin  enlarge.  Constitutionally,  there  is  gastro-intestinal  de- 
rangement, but  rarely  fever.  When  the  ulcer  spreads  with  great  rapidity 
and  becomes  deeper  as  well  as  larger  in  surface  area,  it  is  called  '-'phagedenic." 
The  formation  of  sloughs  indicates  that  tissue  death  is  going  on  so  rapidly  that 
the  dead  portions  have  not  time  to  break  down  and  be  cast  off.  Limited  stasis 
produces  molecular  death;  more  extensive  stasis,  a  slough.  If  a  chronic  ulcer 
becomes  acute,  existing  granulations  are  destroyed. 

Treatment. — In  treating  an  acute  ulcer  of  the  leg,  give  a  dose  of  blue  mass 
or  calomel,  followed  in  eight  or  ten  hours  by  a  saline  (2  dr.  each  of  Rochelle 
and  Epsom  salts),  and  order  light  diet.  Deny  stimulants  except  in  a  case 
of  diphtheritic  ulcer  or  if  the  patient  is  a  hard  or  a  regular  drinker.  Administer 
opium  if  pain  is  severe.  Spray  the  ulcer  with  hydrogen  peroxid,  use  the  scissors 
and  forceps  to  get  rid  of  sloughs,  and  after  sloughs  are  removed  wash  the  ulcer 
with  corrosive  sublimate  solution  (i:  1000)  or  paint  it  with  pure  carbolic  acid. 
Paint  the  skin  adjacent  to  the  ulcer  with  equal  parts  of  tincture  of  iodin  and 
alcohol.  Dress  with  hot  antiseptic  formations.  Apply  a  bandage  from  the  toes 
to  well  above  the  ulcer.  Insist  on  the  patient  remaining  in  bed  with  the  leg 
slightly  elevated.  Change  the  dressings  before  they  become  cool  and  always 
as  soon  as  they  are  saturated  with  discharge.  Every  day  or  two  paint  the  parts 
about  the  ulcer  with  equal  parts  of  iodin  and  alcohol. 

Many  cases  do  very  well  after  antiseptization  and  dusting  the  ulcer  with 
iodoform,  lead-water  and  laudanum  being  applied  to  the  inflamed  parts  around 
the  ulcer;  but  in  a  bad  case  hot  antiseptic  fomentations,  compression,  and 
elevation  are  more  useful  until  sloughs  separate.  Dichloramin-T  is  a  valuable 
drug  in  the  treatment  of  acute  ulcer.  If  the  discharge  is  offensive,  apply 
acetanilid,  aristol,  or  iodoform,  or  use  3  gr.  of  chloral  to  i  oz.  of  water  before 
applying  hot  fomentations  or  ordinary  antiseptic  dressings.  A  25  per  cent, 
ointment  of  ichthyol  is  very  useful  when  applied  to  parts  around  the  ulcer. 
If  sloughs  continue  to  form,  touch  the  sloughing  area  with  a  1:8  solution 
of  acid  nitrate  of  mercury  or  with  a  solution  of  pure  carbolic  acid,  and 
reapply  antiseptic  fomentations.  If  an  ulcer  continues  to  spread,  cleanse 
with  peroxid  of  hydrogen,  dry  with  absorbent  cotton,  touch  with  nitrate  of 


Treatment   of  Chronic  Ulcer  of  Leg  165 

mercury  solution  (1:8),  and  apply  antiseptic  fomentations.  Repeat  the  api)li- 
cation  of  nitrate  of  mercury  every  day  until  the  ulcer  ceases  to  extend  and 
granulations  begin  to  form.  When  granulations  begin  to  form  freely,  moist 
hot  dressings  are  no  longer  desirable,  and  dry  aseptic  or  antiseptic  dressings 
can  be  used. 

If  an  ulcer  is  covered  with  a  great  mass  of  aplastic  lymph,  touch  daily  with  a 
solution  of  silver  nitrate  (40  gr.  to  i  oz.)  or  with  acid  nitrate  of  mercury  (1:15), 
and  dress  with  iodoform  and  antiseptic  fomentations.  Give  internally  tonics^ 
stimulants,  and  nutritious  liquid  food.  In  any  case,  when  granulations  form' 
dress  antiseptically  with  dry  dressings,  moisten  daily  with  dichloramin-T,  or 
employ  a  non-irritant  ointment,  such  as  cosmolin.  If  granulations  form  slowly 
touch  them  every  day  with  a  solution  of  silver  nitrate  (10  gr.  to  the  oz.)  and  dress 
antiseptically,  or  apply  a  stimulating  ointment  (resin  cerate  or  i  dr.  of  ung. 
hydrarg.  nitratis  to  7  dr.  of  ung.  petrolii,  or 
an  ointment  of  copper  sulphate,  3  gr.  to  the 
oz.),  or  dress  with  gauze  soaked  in  a  solution 
of  3  drops  of  nitric  acid  to  i  oz.  of  gum 
arable.  When  the  granulations  are  healthy 
cicatrization  can  be  greatly  hastened  by  an 
application  of  scarlet  red  ointment  (8  per 
cent.).  This  is  kept  in  place  for  twenty-four 
hours  at  a  time.     It  is  used  intermittently.  Fig.  79.  Fig.  80. 

Chronic  ulcer  of  the  leg  is  characterized         Figs.  79  and  80.— incisions  for 
by  low  action  and  slow  progress.     It  may  adherent  ulcer. 

be  chronic  from  the  start,  or  it  may  result 

from  acute  ulcer.  Usually  it  is  found  as  a  solitary  ulcer  2  inches  above  the 
internal  malleolus.  Syphilitic  ulcers  often  occur  in  a  group,  are  usually 
crescentic,  and  are  frequent  upon  the  front  of  knee.  A  tuberculous  ulcer  may 
have  no  granulations,  but  is  usually  covered  with  pale  edematous  granulations, 
which  signify  the  existence  of  a  tendency  to  venous  stasis.  The  edges  of  the 
tuberculous  ulcer  are  undermined  and  irregular,  the  parts  about  it  are  livid 
and  tender,  and  the  discharge  is  thin  and  scanty  (see  page  272).  An  ordinary 
chronic  ulcer  is  circular  or  oval,  and  is  surrounded  by  congested,  discolored,  and 
indurated  skin,  this  induration  being  due  to  fibrous  tissue,  and  there  is  often 
eczema  or  a  brown  pigmentation  of  the  neighboring  skin.  The  floor  of  the  ulcer 
is  uneven,  and  usually  is  covered  with  granulations,  each  of  which  is  red  and 
the  size  of  a  pin-point,  but  which  may  be  exuberant  or  edematous.  If  gran- 
ulations are  absent,  the  ulcer  has  the  appearance  of  a  piece  of  liver,  oris  smooth 
and  glazed.  The  edges  are  thick,  turned  out,  and  not  sensitive  to  the  touch. 
Occasionally,  but  rarely,  they  are  thin  and  undermined.  Some  ulcers  are  in- 
durated and  adherent;  this  adhesion  to  the  deeper  structures  prevents  healing 
by  antagonizing  contraction.  An  ulcer  may  fail  to  heal  because  of  severe 
infection;  because  of  want  of  rest;  because  of  absence  of  granulations 
resulting  from  deficient  blood-supply;  because  of  edematous  granulations; 
because  of  exuberant  granulations;  because  of  adhesion  to  deep  structures,  or 
because  of  some  constitutional  disease. 

Treatment. — In  treating  a  chronic  ulcer,  give  a  saline  cathartic  every  day  or 
so.  Treat  any  existing  diathesis.  Insist  on  rest  and,  if  possible,  elevation. 
Asepticize  the  ulcer.  Draw  blood  by  shallow  scarifications  of  the  bottom  and 
edges  of  the  ulcer  and  the  skin  about  it.  If  the  ulcer  is  adherent  to  deeper 
structures,  make  incisions  like  those  shown  in  Figs.  79  and  80,  each  cut 
going  through  the  deep  fascia.  These  incisions,  besides  permitting  contrac- 
tion, allow  granulations  to  sprout  in  the  cuts  and  absorb  exudate.  Nussbaum 
advocated  encircling  the  ulcer  with  an  incision  about  3^-^  or  %  inch  away  from 
the  edge  of  the  ulcer,  the  incision  passing  through  the  skin.  After  incision 
keep   the   part   elevated   and   dressed   antiseptically  for   two   days.     In   two 


i66  Ulceration  and  Fistula 

days  after  scarification  or  incision  scrape  the  ulcer  with  a  curet  until  sound 
tissue  is  reached.  Use  hot  antiseptic  fomentations  for  two  days  more,  then 
paint  the  parts  adjacent  to  the  ulcer  with  tincture  of  iodin  and  alcohol  (1:3), 
dress  the  parts  about  the  ulcer  with  ichthyol  ointment,  and  dress  the  ulcer 
antiseptically  or  with  sterile  gauze.  In  a  day  or  so  the  use  of  ichthyol  should 
be  discontinued  and  the  ulcer  be  dressed  with  sterile  gauze,  normal  salt  solution, 
boric  acid,  solution  of  acetate  of  aluminum,  chlorin-water,  a  solution  of  per- 
manganate of  potassium,  sulphur,  glutol,  or  protonuclein.  Glutol  (formalin- 
gelatin)  is  very  useful  in  some  cases  and  so  is  protonuclein.  When  healing  begins, 
treat  as  outlined  for  heaUng  acute  ulcer  (see  page  164).  Baking  two  or  three 
times  a  week  allays  pain  and  stirs  an  indolent  ulcer  to  reparative  efforts.  The 
temperature  employed  should  be  2 50° -300°  F.  (page  703  and  Fig.  439).  A 
baking  should  last  from  half  an  hour  to  an  hour.  During  the  intervals  between 
the  bakings  the  ulcer  should  be  dressed  with  scarlet  red  (Sonnenschein,  in 
"N.  Y.  Med.  Jour.,"  Dec.  19,  1914). 

Unna's  dressing  is  satisfactory  in  many  cases.  It  is  applied  as  a  fluid, 
painted  on  when  hot.  It  solidifies  on  cooling  and  resembles  rubber.  The 
paint  is  made  as  follows:  Dissolve  4  parts  of  the  best  gelatin  in  10  parts  of 
water  by  means  of  a  hot-water  bath.  While  the  fluid  is  hot  add  10  parts  of 
glycerin,  and  then  4  parts  of  powdered  white  oxid  of  zinc  and  stir  energetically 
until  the  mixture  is  cold.  Melt  the  paint  before  using  by  placing  the  receptacle 
in  a  hot-water  bath.  The  extremity  must  be  clean  and  thoroughly  dry.  Apply 
the  paint  from  just  above  the  roots  of  the  toes  to  just  below  the  knee.  Cover 
the  layer  of  paint  with  a  gauze  bandage;  put  over  this  another  layer  of  paint, 
then  another  bandage,  and  so  on  until  three,  four,  or  five  bandages  have  been 
applied.  To  prevent  wrinkling  apply  the  gauze  in  short  pieces.  The 
outer  layer  of  the  dressing  is  a  coat  of  the  paint.  This  dressing  is  worn  from 
four  to  eight  weeks  unless  it  loosens  sooner.  When  it  loosens,  it  is  changed. 
If  the  ulcer  discharges  freely  and  stains  the  dressing,  cut  a  trap-door  in  the  dress- 
ing and  through  this  cleanse  the  ulcer  and  apply  dressings  and  a  bandage 
as  often  as  necessary  (Michel,  in  '' Chicago  Clinic,"  No.  8,  1900). 

An  excellent  treatment  if  the  patient  must  walk  about  is  camphor,  first 
recommended  by  Schulze  ("Miinchener  medicinische  Wochenschrift,"  March 
19,  1901).  It  is  most  conveniently  used,  as  Walbaum  shows,  in  the  form  of 
spirits  of  camphor  (Ibid.,  June  25,  1901).  He  applies  the  dressing  in  the 
following  manner:  Clean  the  ulcer  with  green  soap  and  dress  it  daily  with 
dressings  wet  with  a  2  per  cent,  solution  of  the  acetate  of  aluminum.  In 
about  three  days  the  discharge  will  become  scanty  and  free  from  odor.  It 
is  at  this  period  that  camphor  should  be  used.  A  small  piece  of  gauze  wet 
with  spirits  of  camphor  is  applied  directly  upon  and  only  to  the  ulcer.  Over  this 
is  applied  a  large  piece  of  dry  sterile  gauze,  a  rubber-dam,  a  large  piece  of 
absorbent  cotton,  and  a  bandage  from  the  toes  up.  Every  other  day  the 
dressings  are  removed,  the  ulcer  is  washed  with  a  2  per  cent,  solution  of  carbolic 
acid,  and  the  dressings  are  reapplied.     Usually  the  ulcer  is  healed  in  three  weeks. 

Complications. — Remove  by  scissors  and  forceps  any  badly  damaged 
tissue.  Take  out  dead  bone;  slit  sinuses;  trim  overhanging  edges.  T^-eat 
eczema  locally  by  washing  with  ethereal  soap  and  applying  powdered  oxid 
of  zinc  or  borated  talcum,  the  leg  then  being  wrapped  in  cotton.  Unna's 
paint  is  very  useful  in  chronic  eczema.  If  the  part  is  crusted,  the  crusts  should 
be  removed  by  applying  some  oily  materials  and  washing  with  ethereal  soap 
and  water.  Ordinary  soap  should  not  be  used.  In  an  acute  case  soap  and 
water  always  do  harm  and  the  part  is  to  be  cleaned  by  "gently  wiping  with 
cold  cream  or  petrolatum  "  (Stelwagon,  on  "  Diseases  of  the  Skin  ") .  If  crusting 
is  very  marked  it  may  be  necessary  to  remove  it  by  means  of  an  ordinary  poul- 
tice or,  better,  a  starch  poultice  made  with  a  2  per  cent,  solution  of  boric  acid. 
When  scales  or  crusts  are  slight  or  absent  or  when  they  have  been  removed,  the 


Varicose  Veins 


167 


remedial  agent  should  be  applied.  The  remedies  for  eczema  are  legion.  Among 
them  are  a  solution  of  lead  acetate;  lead- water  and  laudanum;  a  powder  com- 
posed of  30  gr.  of  powdered  boric  acid  and  Yi  oz.  each  of  talc  and  zinc  oxid; 
ung.  picis  liquidae,  i  dr.,  with  sufficient  ung.  zinci  oxidi  to  make  i  oz.;  Yi  oz.  of 
liquor  carbonis  detergens  to  i  pint  of  water.  In  every  case  of  eczema  place 
the  patient  upon  a  plain  and  nutritious  diet;  order  hirn  to  avoid  wines  and 
liquors;  give  an  occasional  saline  laxative;  keep  the  skin  and  kidneys  active, 
and  if  the  patient  is  gouty  or  rheumatic,  give  appropriate  remedies.  The  value 
of  arsenic  in  eczema  has  been  much  overrated. 

Varicose  veins  may  demand  either  ligation  at  several  points,  excision, 
Trendelenburg's  operation  (see  page  527),  or  the  continued  use  of  a  flannel  roller 
or  a  Martin  rubber  bandage.  Never  operate  on  varicose  veins  if  phlebitis  exists 
unless  a  clot  has  formed,  in  which  case  it  may  be  proper  to  apply  a  ligature  above 
the  clot.  Never  operate  on  the  veins  for  varicose  ulcer  unless  the  ulcer  is  in  an 
aseptic  state.  Inflammation  of  the  ulcer  is  met  by  rest,  elevation,  painting  the 
neighboring  parts  with  dilute  _..,.^" 
tincture  of  iodin,  and  applying  [ 
about  the  ulcer  ichthyol  oint- 
ment. For  calloused  edges, 
blister,  employ  radiating  in-  > 
cisions,  or  cut  the  edges  away. 
Ordinary  thick  edges  should  be 
strapped.  In  strapping  use  zinc 
oxid  adhesive  plaster  and  do 
not  completely  encircle  the  limb 
(Fig.  81).  When  the  parts  are 
adherent  the  ulcer  is  immovable, 
being  firmly  anchored  to  struc- 
tures beneath  it.  In  such  a  con- 
dition completely  or  partly 
surround  the  sore  with  a  cut 
through  the  deep  fascia  (see 
Figs.  79,  80).  This  cut  sets  the 
ulcer  free  from  its  anchorage  ; 
and  permits  it  to  contract. 
Edematous  granulations  require 
dry  dressings  and  pressure  by  a 
flannel  bandage,  a  rubber 
bandage,  or  adhesive  plaster. 
If  the  bottom  of  the  ulcer  is  foul, 
dry  it  and  touch  with  a  solution 

of  acidnitrateof  mercury  (1:8)  or  with  crystals  of  pure  carbolic  acid.  Repeat  this 
every  third  day  and  dress  with  hot  antiseptic  fomentations  until  granulations 
appear.  Superfluous  granulations  (proud  flesh)  should  be  cut  away  with  scissors, 
scraped  away,  or  burned  down  with  a  strong  solution  of  silver  nitrate,  with 
the  soHd  stick  of  lunar  caustic  or,  better,  with  pure  carbolic  acid,  which  causes 
much  less  pain  than  does  silver.  Absence  of  granulations  or  scantiness  of 
_granulations  means  deficiency  of  blood-supply.  The  surgeon  endeavors  to 
bring  more  blood  to  the  part,  and  to  do  this  induces  inflammation.  The 
usual  method  of  procedure  is  to  apply  daily  to  the  sore  a  solution  of  nitrate 
■of  silver  (10  or  15  gr.  to  the  ounce).  Argyrol  of  a  strength  of  25  per  cent,  is  not 
painful  and  is  as  efficient.  In  obstinate  cases  blister  the  ulcer  or  scrape  it,  or 
paint  it  with  tincture  of  iodin,  or  apply  pure  carbolic  acid,  or  touch  it  with  the 
actual  cautery.  In  many  cases  granulation  is  greatly  stimulated  by  a  twenty- 
four-hour  application  of  an  8  per  cent,  ointment  of  scarlet  red.  If  it  causes  irri- 
tation its  use  is  suspended  for  a  day  or  two,  and  then  the  ointment  is  reapplied; 


Fig.  81. — Strapping  an  ulcer  of  leg  ("Keen's 
Surgery"). 


1 68  Ulceration  and  Fistula 

If  an  ulcer  of  the  leg  becomes  painful  at  one  point  (see  page  169),  touch  with 
pure  carbolic  acid  after  curetting,  or  find  the  painful  spot  with  a  probe  and 
divide  the  exposed  nerve  filament  with  a  tenotome. 

If  healing  entirely  fails,  skin-graft.  Among  the  methods  of  skin-grafting 
are — (i)  Reverdin's,  (2)  Thiersch's,  and  (3)  Wolfe's.     (See  Plastic  Surgery.) 

When  a  man  having  an  ulcer  must  go  out  and  about,  the  camphor  treatment 
can  be  employed  (see  page  166),  Unna's  dressing  may  be  applied  (see  page  166), 
the  patient  can  use  a  firmly  applied  roller  or,  better  still,  a  Martin  bandage. 
Martin's  bandage,  which  is  made  of  red  rubber,  limits  the  amount  of  arterial 
blood  going  to  the  ulcer  and  favors  venous  flow  from  the  sore  and  its  neigh- 
borhood. The  bandage  should  be  used  as  follows:  Before  getting  out  of  bed 
spray  the  sore  with  hydrogen  peroxid  by  means  of  an  atomizer,  remove  the  froth 
with  absorbent  cotton,  wash  the  leg  with  alcohol,  dry  it  with  a  towel,  dust  the 
skin  with  borated  talcum  powder,  and  apply  the  bandage  from  the  toes  up. 
All  of  these  things  should  be  done  before  putting  the  foot  to  the  floor.  At  night, 
after  getting  on  the  bed,  remove  the  bandage,  wash  it  with  soap  and  water,  dry 
it  with  a  towel,  hang  it  unrolled  over  the  back  of  a  chair  to  air,  and  again  cleanse 
the  leg  and  ulcer.  If  these  rules  are  not  strictly  observed,  the  Martin  bandage 
will  produce  pain,  increase  suppuration  of  the  ulcer,  and  intensify  eczema  of 
the  leg. 

Tuberculous  Ulcers. — (See  page  272,) 

Syphilitic  Ulcers. — (See  page  378.) 

A  healthy  ulcer  is  covered  with  small,  bright-red  granulations  which  do 
not  bleed  on  touching,  are  painless,  and  grow  rapidly.  The  edges  of  the  sore 
are  soft  and  show  the  opalescent  blue  line  of  proliferating  epithelium.  The 
sore  is  movable,  the  discharge  is  purulent  and  yellow,  and  the  parts  about 
are  not  inflamed. 

Various  Ulcers. — The  fungous  or  exuberant  ulcer  of  the  leg  is  produced 
by  interference  with  the  return  of  venous  blood  from  the  part,  and  it  is  specially 
common  after  burns  and  other  injuries  when  cicatricial  contraction  causes 
venous  obstruction.  The  granulations  are  large,  deep  red  in  color,  bleed 
when  touched,  form  rapidly,  and  mount  above  the  level  of  the  skin.  The 
discharge  from  a  fungous  ulcer  is  profuse,  thin,  and  bloody.  In  the  treatment 
of  such  an  ulcer  venous  return  must  be  favored  by  bandaging  and  by  elevation 
of  the  part.  If  the  edges  are  very  thick,  divide  them  in  a  number  of  places. 
The  superfluous  granulations  should  be  burnt  down  with  lunar  caustic  or 
pure  carbolic  acid  or  should  be  cut  off.  Strapping  with  adhesive  plaster  or 
the  use  of  a  rubber  bandage  does  good.  The  sore  can  be  dressed  with  europhen, 
aristol,  dichloramin-T,  or  dry  aseptic  gauze. 

A  varicose  ulcer  of  the  leg  is  an  ulcer  dependent  upon  varicose  veins- 
Varicosity  of  veins  of  the  leg  causes  stasis  of  blood,  stasis  impairs  nutrition,, 
a  slight  traumatism  in  an  area  of  impaired  nutrition  becomes  infected,  and  the 
area  of  chronic  infection  is  an  ulcer.  Varicose  ulcers  are  found  particularly 
in  those  victims  of  venous  varicosity  who  lead  laborious  lives,  who  lift  and 
strain,  who  stand  long  in  one  position,  who  are  subjected  to  slight  and  frequent 
traumatisms  of  the  legs,  and  who  are  careless  as  to  cleanliness  and  the  care  of 
sores.     There  are  two  distinct  types: 

I.  The  ulcer  of  superficial  varix  is  the  common  form.  It  may  follow 
repeated  brief  ulcerations,  it  is  above  visible  varicose  veins  and  is  said  to 
"  ride  "  the  vein  (J.  Roman's,  in  ''Surg.,  Gynec.  and  Obst.,"  March,  1917),  in  old 
cases  there  is  much  pigment  about  the  veins  and  pigmentation  may  have 
existed  before  ulceration.  Ulceration  of  this  type  is  usually  single  but  may  be 
multiple.  The  usual  situation  is  above  the  inner  malleolus  but  may  be  any- 
where in  the  lower  half  of  the  leg.  The  sore  is  oval,  round,  or  irregular  in 
outline.  Its  edges  are  thick,  everted,  and  swollen.  The  swelling  is  largely 
due  to  edema,  and  is  found  to  pit  on  pressure.     The  edges  are  not  undermined,. 


Indolent  Ulcer  of  the  Leg  169 

but  slope  gently  to  the  floor  of  the  ulcer.  The  floor  is  usually  covered 
with  rather  large  granulations  which  bleed  freely  on  touching.  In  a  varicose 
ulcer  the  destruction  of  tissue  often  begins  at  the  margin  of  a  congested  area 
and  advances  toward  the  center.  Such  an  ulcer  is  usually  surrounded  by 
eczema  and  an  area  of  pigmentation.  To  aid  the  healing  of  a  varicose  ulcer 
it  is  first  of  all  necessary  to  favor  the  return  of  venous  blood  from  the  part  by 
position  and  bandaging.  Martin's  bandage  is  very  useful  and  the  daily  use 
of  the  hot-air  apparatus  is  of  value.  It  may  be  necessary  to  operate  on  the 
veins  and  perhaps  to  excise  the  ulcer.  Excision  of  a  large  ulcer  should  be 
followed  by  skin-grafting 

2.  The  other  type  of  varicose  ulcer  follows  in  from  six  months  to  two  years 
blocking  of  the  iliacs  (milk-leg).  This  blocking  may  have  occurred  during 
pregnancy  or  a  fever  or  after  an  abdominal  operation.  The  lumen  of  the  veins 
becomes  restored,  but  the  internal  saphenous  remains  rigid  and  its  valves  are 
incompetent,  the  perforating  veins  are  dilated,  blood  flows  from  the  deep  veins 
to  the  superficial  veins,  the  lymph  current  is  interfered  with,  the  deep  fascia 
is  thickened,  but  is  fibrous,  areas  of  edema  and  scar-like  formation  are  common 
(Roman's,  Ibid.). 

In  tissue  of  such  impaired  vitality  ulcers  are  prone  to  form.  There  may  be 
one,  several  or  a  number  of  ulcers.  There  is  great  induration  around  and  beneath 
the  ulcer,  the  skin  about  it  is  red  and  irritable,  and  no  varicosities  are  visible,  but 
the  surgeon  can  feel  small,  hard  veins  in  the  calf  and  thigh.  The  ulcer  will  not 
heal  from  rest  in  bed  or  medical  treatment.  Excision  is  necessary.  On  excision  a 
very  much  enlarged  perforating  vein  will,  be  seen  just  beneath  the  base  of  the 
ulcer  and  it  must  be  hgated.     The  wound  should  be  skin-grafted. 

Erethistic,  irritable,  or  painful  ulcer  is  very  sensitive  ulcer,  a  condition  due 
to  the  exposure  of  nerve-filaments  and  destruction  of  nerve-sheaths.  Irritable 
ulcers  are  especially  found  near  the  ankle,  over  the  tibia,  in  the  anus  (fissure), 
or  in  the  matrix  of  the  nail  (ingrowing  nail).  Fissure  of  the  anus  is  considered 
on  page  13 15.  An  ingrowing  nail  is  sometimes  encountered  on  the  finger,  but 
far  more  commonly  affects  the  toe.  The  great  toe  is  especially  apt  to  suffer. 
We  call  it  ingrowing  nail,  but  the  condition  is  really  overgrowing  skin.  As  a 
result  of  wearing  ill-fitting  boots  or  stockings,  especially  shoes  which  are  too 
short  or  are  pointed,  the  toes  are  forced  together  and  the  skin  at  the  edge  of  the 
nail  is  squeezed.     After  a  time  an  ulcer  forms. 

When  a  nail  begins  to  ingrow  the  condition  can  usually  be  arrested  by 
wearing  well-fitting  shoes  and  stockings,  allowing  the  nail  to  grow  somewhat 
long  and  cutting  it  square  across  instead  of  cutting  away  the  troublesome 
corner.  Daily  a  Httle  absorbent  cotton  should  be  packed  under  the  imbedded 
corner.  In  more  severe  cases,  under  local  anesthesia  cut  away  the  overlapping 
skin  and. a  portion  of  the  flesh  on  the  side  of  the  toe,  split  the  nail  longitudinally, 
and  remove  the  ingrown  portion  of  nail  and  a  corresponding  part  of  the  matrix. 

An  erethistic  ulcer  of  the  cutaneous  surface  is  treated  as  follows:  Curet 
and  touch  with  pure  carbolic  acid  or  with  the  solid  stick  of  silver  nitrate. 
Chloral,  20  gr.  to  the  ounce,  allays  the  pain;  so  do  cocain  and  eucain  for  a 
time.  In  some  cases  the  painful  spot  can  be  located  definitely  by  a  probe  and 
the  nerve-filament  divided  by  a  tenotome. 

The  indolent  ulcer  of  the  leg  shows  no  tendency  to  heal.  In  such  an  ulcer 
there  is  usually  venous  congestion  from  varicose  veins  or  from  cardiac  weak- 
ness. A  great  mass  of  scar-tissue  forms  at  the  base  and  edges,  which  fastens 
the  ulcer  to  bone  or  fascia,  so  that  the  edges  cannot  contract.  Healthy  granula- 
tions cease  to  form.  The  edges  of  such  an  ulcer  are  thick,  smooth,  immovable, 
and  free  from  tenderness.  Granulations  are  entirely  absent  or  there  are  seen 
here  and  there  a  few  unhealthy  granulations.  The  discharge  is  thin,  sero- 
purulent,  and  offensive.  The  parts  about  the  ulcer  are  congested  and  pig- 
mented.    The  pigmentation  is  due  to  the  fact  that  in  the  area  of  chronic  con- 


lyo 


Ulceration  and  Fistula 


gestion  numbers  of  red  blood-cells  have  been  disintegrated.  Such  an  ulcer 
is  treated  by  making  incisions  to  loosen  the  base  and  edges,  so  that  contrac- 
tion can  take  place.     Venous  congestion  is  corrected  by  means  of  position,  the 


Fig.  82. — -Marjolin's  ulcer  (epithelioma)  in  a  man  twenty  years  of  a£;e,  arising  in  the 

cicatrix  of  a  burn. 

use  of  compression,  and  in  some  cases  the  administration  of  cardiac  stimu- 
lants.    In  all  cases  the  surgeon  employs  stimulating  applications  to  the  ulcer  in 


Fig.  83. — Same  case  as  Fig.  82,  after  excision  and  skin-grafting  by  the  Thiersch  method. 

order  to  increase  the  supply  of  arterial  blood.     Scarlet  red  ointment  (8  per  cent.) 
strongly  stimulates  granulation. 

The  callous  ulcer  of  the  leg  is  the  most  chronic  form  of  indolent  ulcer  and  is 


_^.-v 


Marjolin's  Ulcer  171 

sunken  deeply  below  the  level  of  the  skin.  Its  border  is  hard  and  knobby.  Its 
floor  shows  no  granulations,  and  is  either  smooth  and  glistening  or  foul  and 
liver  colored.  The  discharge  is  thin  and  scanty,  and  the  ulcer  varies  little  in 
appearance  from  week  to  week  or  even  from  month  to  month.  The  treatment 
consists  in  scraping  and  cauterizing  the  ulcer;  making  radiating  incisions 
through  the  margins  and  floor  or  elliptical  incisions  about  the  ulcer;  applying 
antiseptic  dressings  and  firm  bandages.  In  some  cases  the  ulcer  should  be 
strapped.  A  daily  baking  in  the  hot-air  oven  is  often  of  great  benefit. 
In  severe  cases  it  is  necessary  to  extirpate  the  ulcer  and  apply  skin-grafts. 

Hemorrhagic  ulcers  bleed  easily  and  profusely.  Pressure  must  be  applied; 
it  is  sometimes  necessary  to  cut  or  burn  away  the  granulations. 

Phagedenic    Ulcers. — The    phagedenic    ulcer    results    from    the    profound 
microbic  infection  of  tissues  debihtated  by  local  or  constitutional  disease,  and 
is  commonly  venereal.     This  ulcer  has  no  granulations  and  is  covered  with 
sloughs;  its  edges  are  thin  and  undermined, 
and  it  spreads   rapidly  in  all   directions. 
Such    an    ulcer    should    be    touched  with 
strong  caustics  or  Paquelin's  cautery,  and 
dressed  with  iodoform  gauze  and  antiseptic 
fomentations.       Tonics     and     stimulants 
should  always  be  administered. 

The  edematous  vdcer  may  result  from 
impediment  to  the  venous  return  or,  as 
De  Na,ncrede  points  out,  may  be  produced 
by  the  persistent  use  of  poultices  or  wet 
dressings  upon  any  ulcer. ^  It  is  most 
often  met  with  in  tuberculous  processes 
and  is  occasionally  seen  in  the  leg  when 
varicose  veins  exist.  The  granulations 
are  large  and  pale,  and  are  apt  to  bend  over 
like  unsupported  vines.  The  discharge  is 
profuse  and  seropurulent.  The  edges  are 
softened  and  desquamating.  An  edematous 
ulcer  requires  dry  dressings,  stimulation, 
and  compression. 

A  rodent  or  Jacob's  ulcer,  noli  me 
tangere,  or  cancroid  ulcer,  is  a  super- 
ficial epithelioma  developing  usually  from 
sebaceous  glands,  sweat-glands,  or  hair- 
follicles.  It  requires  scraping  and  cauter- 
ization, the  application  of  the  ^-rays,  or, 
what  is  better,  excision  (see  page  449). 

Marjolin's  vdcer  (Figs.  82-86)  is  an  epithelioma  arising  from  a  chronic 
ulcer  or  an  old  cicatrix.  The  mahgnant  change  begins  at  some  point  of  the 
edge  of  the  ulcer,  and  its  first  evidence  is  induration.  The  induration  spreads 
slowly  and  comes  to  involve  a  considerable  part  of  or  even  the  entire  ulcer. 
Marjolin's  ulcer  is  the  seat  of  scalding,  darting  pain;  the  discharge  is  profuse, 
ichorous,  and  foul,  and  the  floor  of  the  ulcer  is  uneven,  warty,  or  cauliflower- 
Hke.  The  anatomically  related  lymph-glands  eventually  become  involved. 
This  involvement  is  seldom  early  because  induration  has  blocked  lymph- 
channels.  In  order  to  confirm  the  diagnosis  a  bit  of  tissue  should  be  removed, 
and  the  removed  piece  must  include  a  portion  of  the  edge  of  the  ulcer  and 
of  some  apparently  sound  tissue  beyond  it.  If  a  microscopic  examination 
shows  epithelial  infiltration  of  the  apparently  sound  tissue,  a  diagnosis  of 
malignant  disease  must  be  made.     In   an  early  stage  of  such   an  ulcer  the 

1  "Principles  of  Surgery." 


Fig.  84. — Marjolin's  ulcer  (epithelioma) 
from  the  scar  of  a  burn. 


17- 


Ulceration  and  Fistula 


x-rays  or  electric  desiccation  may  be  successful.  If  these  fail  free  extirpa- 
tion and  removal  of  the  anatomically  related  glands  may  cure  the  patient. 
In  a  more  advanced  case,  even  if  an  extremity  is  involved,  try  the  .r-ray  or 
electric  desiccation.  If  this  treatment  does  not  cause  rapid  and  decided 
improvement,  amputate  and  clear  out  the  related  lymphatic  area.     In  a  very 


Fig.  85. — K[)ithelioma  arising  in  the  scar  01  a  burn  i^A^iirJolin's  ulcer). 

advanced  case  use  the  .v-rays  or  radium.  Fig.  82  shows  a  Marjolin  ulcer  in  a, 
man  twenty  years  of  age.  It  arose  in  the  cicatrix  of  a  bum.  I  removed  it  and 
applied  Thiersch  grafts  to  the  raw  surface.  Figs.  84,  85,  and  86  show  Marjolin's 
ulcers. 

Decubitus,  or  bed-sore,  is  due  to  pressure  upon  an  area  of  feeble  circu- 
lation (see  page  198).     It  is  in  most  instances  a  condition  of  gangrene. 


Fig.  86. — Marjolin's  ulcer  arising  from  a  chronic  ulcer  of  the  leg. 

Neuroparalytic  or  trophic  ulcer  is  due  to  impairment  of  the  trophic  nerve- 
fibers  or  of  the  trophic  centers  in  the  cord. 

The  perforating  ulcer,  as  it  was  named  by  Vesigne,  is  believed  to  result 
from  peripheral  neuritis.     It  is  certain,  however,  that  in  some  of  these  cases 


Curling's  Ulcer  17:5 

there  is  arteriosclerosis,  and  it  has  been  held  that  the  vascular  sclerosis  is  the 
real  cause  and  that  the  nerve  changes  are  secondary  to  the  vascular  changes. 
My  own  belief  is  that  perforating  ulcer  is  a  condition  dependent  upon  both  ar- 
teriosclerosis and  peripheral  neuritis,  traumatism  usually  being  the  exciting 
cause  of  the  ulcer.  It  is  met  with  most  frequently  in  diabetics,  but  may  be  en- 
countered in  the  victims  of  chronic  alcoholism,  injuries  and  diseases"  of  the 
spinal  cord,  injuries  and  diseases  of  nerves,  Bright's  disease,  and  syphilis.  I 
have  seen  this  ulcer  in  an  individual  with  a  fractured  spine,  in  several  tabetics, 
and  in  not  a  few  diabetics.  The  perforating  ulcer  commonly  affects  the  plantar 
surface  of  the  metatarsophalangeal  joint  or  the  pulp  of  the  great  toe  or  little 
toe  about  a  callosity  or  corn.  It  may  arise  on  the  heel  or  the  sole  or  the  side 
of  the  foot.  It  is  usually  unilateral,  but  sometimes  both  feet  are  affected. 
In  ver}'  rare  cases  more  than  one  ulcer  is  present  on  the  foot.  Very  rarely  it 
affects  the  palm  of  the  hand.  The  parts  about  the  corn  inflame,  and  pus  forms 
and  reaches  into  the  bone.  A  sinus  evacuates  the  pus  by  the  side  of  the  corn 
or  callosity  or  the  center  of  the  callosity  exhibits  a  blister  containing  seropus. 
A  portion  of  the  callous  mass  is  cast  off  and  a  shallow  ulcer  is  often  exposed. 
This  ulcer  is  small,  has  a  punched-out  appearance,  and  is  surrounded  by 
calloused  margins.  The  ulcer  penetrates  deeply  and  after  a  time  the  bone 
is  laid  bare  or  the  joint  opened.  The  margins  of  the  ulcer  or  sinus  exhibit 
sprouting  granulations  and  these  are  encircled  by  an  area  of  markedly  thick- 
ened epidermis.  The  discharge  from  a  perforating  ulcer  is  thin  and  scanty,  and 
the  ulcer,  which  slowly  advances,  is  very  chronic.  It  is  not  painful  and  is 
slightly,  if  at  all,  tender.  The  foot  is  cold  and  often  edematous  and  the  parts 
about  the  ulcer  may  be  anesthetic.  The  iilcer  may  heal  when  the  patient  is 
kept  in  bed  and  open  again  when  he  gets  out.  The  disease  is  far  more  common 
among  males  than  among  females  and  is  most  often  met  with  in  the  fifth  or 
sixth  decades  of  life.  As  this  ulcer  may  be  present  in  anesthetic  leprosy,  in 
diabetes,  peripheral  neuritis,  syphilis,  in  a  paralyzed  limb,  and  tabes  dorsalis, 
and  as  the  part  on  which  it  occurs  is  apt  to  be  sweaty,  cold,  and  more  or  less 
anesthetic,  and  as  the  sore  may  be  hereditary,  it  is  usually  set  dowoi  as  trophic 
in  origin.  In  the  treatment  of  a  perforating  ulcer  I  follow  the  plan  suggested 
by  Treves.  This  consists  in  putting  the  patient  to  bed  and  applying  fomenta- 
tions to  the  sore.  Every  time  a  fomentation  is  removed  the  raised  epithelium 
around  the  ulcer  is  cut  away  and  then  the  fomentation  is  reapplied.  In  about 
two  weeks  an  ulcer  remains  surrounded  by  healthy  tissue.  Treves  treats  this 
sore  with  glycerin  made  to  a  creamy  consistency  with  salicylic  acid,  to  each 
ounce  of  which  mixture  10  min.  of  carbolic  acid  have  been  added.  He  directs 
the  patient  to  wear  during  the  rest  of  his  life  some  form  of  bunion-plaster  to  keep 
off  pressure.  If  in  a  perforating  ulcer  the  bone  is  diseased,  it  must  be  re- 
moved. If  the  patient  is  diabetic  he  must  be  placed  on  antidiabetic  diet  and 
drugs.  Nerve-stretching  has  been  recommended  as  the  proper  treatment  for 
perforating  ulcer,  but  I  have  never  tried  it.  No  matter  what  treatment  is 
employed,  the  sore  is  apt  to  reappear  in  the  old  situation  or  an  adjacent  region 
when  the  part  is  subjected  to  pressure.  In  order  to  prevent  pressure  upon 
the  region  of  ulceration  some  advise  the  use  of  an  artificial  leg,  the  knee  being 
kept  bent.     It  may  be  necessary  to  amputate  the  toe  or  the  foot. 

The  scorbutic  ulcer  is  covered  with  a  dark-brown  crust,  beneath  which 
are  pale  and  bleeding  granulations.     The  parts  adjacent  are  of  a  violet  color. 

Epitheliomatous,  sarcomatous,  tuberculous,  and  syphilitic  ulcers  and  ulcers 
of  the  stomach  and  duodenum  are  considered  under  these  respective  diseases. 

Curling's  Ulcer. — This  is  an  ulcer  of  the  first  portion  of  the  duodenum 
which  in  very  rare  cases  follows  an  extensive  burn  or  scald  of  the  cutaneous 
surface.  Curling  described  this  condition  in  1841,  but  Sir  Berkeley  Moynihan 
points  out  in  his  book  upon  "Duodenal  Ulcer"  that  Long,  of  Liverpool,  de- 
scribed it  in  1840.     It  is  small,  clean  cut,  and  deep.     It  may  be  due  to  toxic 


174  Ulceration  and  Fistula 

material  in  the  bile,  the  toxic  material  being  due  to  the  burn,  but  against  this 
is  the  occurrence  of  the  ulcer  well  above  the  opening  of  the  bile-duct.  Sir 
Berkeley  !Mo>Tiihan  regards  it  as  a  toxic  ulcer  and  points  out  that  the  ulcer 
practically  never  occurs  unless  there  were  septic  changes  in  the  burnt  area. 
Septic  emboli  may  be  the  cause.  So  far  no  case  of  Curling's  ulcer  seems  to 
have  been  treated  surgically.  As  Sir  Berkeley  Moynihan  says,  ''there  is  no 
reason  why  it  should  not  prove  successful  if  the  condition  of  the  patient  were 
not  too  exhausted  by  the  extent  or  severity  of  the  original  injur>'."  If  per- 
foration occurs  the  treatment  is  as  for  any  other  perforating  duodenal  ulcer. 

A  fistula  is  an  abnormal  communication  between  the  surface  and  an  in- 
ternal part  of  the  body,  or  between  two  natural  cavities  or  canals.  The  first 
form  is  seen  in  a  rectal  fistula,  a  urethral  fistula,  or  a  biliary  fistula;  and  the 
second  form  is  seen  in  a  vesicovaginal  fistula.  Fistulae  may  result  from  con- 
genital defect,  as  when  there  is  failure  in  the  closure  of  the  branchial  clefts, 
and  can  arise  from  sloughing,  traumatism,  and  suppuration.  Fistulae  are 
named  from  their  situation  and  communications.  For  instance,  a  pleural 
fistula,  an  intestinal  or  fecal  fistula,  a  rectal  fistula,  an  anal  fistula,  a  gastric 
fistula,  a  bronchial  fistula,  a  vesical  fistula,  a  biliar}-  fistula,  etc.  Many  fis- 
tulae are  tuberculous  and  lead  to  some  deeply  placed  tuberculous  focus.  A 
fistula  in  communication  with  a  \dscus  (for  instance,  the  gall-bladder)  may  be 
maintained  by  an  obstruction  of  the  duct  of  that  \'iscus;  the  removal  of  such 
an  obstruction  cures  the  fistula. 

A  sinus  is  a  tortuous  track  opening  usually  upon  a  free  surface  and  leading 
down  into  the  cavity  of  an  imperfectly  healed  abscess.  A  sinus  may  be  an 
unhealed  portion  of  a  wound.  Many  sinuses  are  due  to  pus  burrowing  sub- 
cutaneously.  A  sinus  fails  to  heal  because  of  the  presence  of  some  irritant 
fluid,  as  saliva,  urine,  or  bile;  because  of  the  existence  of  a  foreign  body,  as 
dead  bone,  a  bit  of  wood,  a  bullet,  a  septic  ligature,  etc. ;  or  because  of  rigidity 
of  the  sinus  walls,  which  rigidity  will  not  permit  collapse.  Sinuses  may  be 
maintained  by  want  of  rest  (muscular  movements)  and  general  ill  health. 
The  walls  of  a  tuberculous  sinus  are  lined  with  a  material  identical  with  the 
Volkmann's  membrane  of  a  cold  abscess. 

Treatment. — In  treating  a  fistula  or  a  sinus,  remove  any  causative  ob- 
struction and  any  foreign  body,  lay  the  channel  open,  curet,  brush  with  pure 
carbolic  acid,  and  pack  with  iodoform  gauze.  To  stimulate  a  sinus  to 
granulation  it  is  sometimes  necessary  to  touch  it  throughout  with  the  actual 
cautery,  nitric  acid,  pure  carbolic  acid,  nitrate  of  silver  fused  on  a  metallic 
probe,  or  in  a  solution  of  a  strength  of  40  gr.  to  the  ounce,  or  argyrol  of  a  strength 
of  50  per  cent.  Fresh  air  is  a  necessity  to  the  patient,  and  nutritious  food 
and  tonics  must  be  ordered.  There  is  some  testimony,  although  scarcely 
as  yet  evidence,  that  the  use  of  bacterial  vaccines  may  at  times  be  of  value 
in  the  treatment  of  certain  sinuses  (see  page  54).  Sometimes  cure  of  a  tuber- 
culous sinus  may  be  secured  by  repeated  injections  of  iodoform  emulsion 
or  by  injecting  a  paste  of  subnitrate  of  bismuth  and  vaselin  (see  page  708). 
The  mixture  remains  in  the  sinus  and  serves  as  a  framework  for  granulations. 
WTien  a  sinus  closes  after  injections  of  bismuth  paste,  bismuth  concretions 
sometimes  form  and  lead  to  reopening  after  weeks  or  months.  In  obstinate 
cases  of  fistula  or  sinus  entirely  extirpate  the  fibrous  walls,  sew  the  deeper 
parts  of  the  wound  with  buried  catgut  sutures,  and  approximate  the  skin 
surfaces  with  interrupted  sutures  of  silkworm-gut. 


Microbic  Gangrene  175 

VIII.  MORTIFICATION,  GANGRENE,  OR  SPHACELUS 

Mortification,  Or  gangrene,  is  death  in  mass  of  a  portion  of  the  living  body 
— the  dead  portions  being  large  enough  to  be  visible — in  contrast  to  ulcera- 
tion, or  molecular  death,  in  which  the  dead  particles  have  been  liquefied,  cannot 
be  seen,  and  are  cast  away.  When  all  the  tissues  of  a  part  are  dead,  the  proc- 
ess is  spoken  of  as  sphacelus.  Gangrene  is,  in  reality,  a  form  of  necrosis,  but 
clinically  the  term  "necrosis"  is  restricted  to  molar  death  of  bone  or  to  death 
of  parts  below  the  surface  en  masse.  In  gangrene  a  portion  of  tissue  dies 
because  of  anemia,  and  the  dead  portions  may  either  desiccate  or  putrefy. 
Gangrene  may  be  due  to  tissue  injury,  either  chemical  or  mechanical,  to  heat 
or  cold,  to  failure  of  the  general  health,  to  circulatory  obstruction,  to  nerve 
disorder,  the  nerves  involved  being  the  vasomotor  or  possibly  the  trophic,  or 
to  microbic  infection.  A  microbic  poison  can  directly  destroy  tissues.  It 
can  indirectly  destroy  them  by  causing  such  inflammation  that  the  products 
obstruct  the  circulation,  but  gangrene  can  occur  when  no  bacteria  are  present. 
The  essential  cause  of  gangrene  is  that  the  tissues  are  cut  off  from  a  due  supply 
of  nourishment,  and  cell-nutrition  is  no  longer  possible.  In  other  words, 
the  essential  cause  of  gangrene  is  the  cutting  off  of  arterial  blood.  De  Nancrede 
says:  "Indeed,  except  when  the  traumatism  physically  disintegrates  tissues, 
as  a  stone  is  reduced  to  powder,  heat  or  strong  acids  physically  destroy  struc- 
ture, or  cold  suspends  cellular  nutrition  so  long  that  when  this  nutrition  be- 
comes a  physical  possibility  vital  metabolism  cannot  be  resumed,  gangrene 
always  results  from  total  deprivation  of  pabulum  ("Principles  of  Surgery"). 
Classification. — Gangrene  is  divided  into  the  following  three  great  groups: 
(i)  Dry  gangrene,  which  is  due  to  circulatory  interference,  the  arterial 
supply  being  decreased  or  cut  off.     The  tissues  dry  and  mummify. 

(2)  Moist  gangrene,  which  is  due  to  interference  not  only  with  arterial 
ingress,  but  also  with  venous  return  or  capillary  circulation,  the  dead  parts 
remaining  moist. 

(3)  Microbic  gangrene,  arising  from  virulent  bacteria.  In  this  form 
the  bacterial  process  causes  the  gangrene,  and  is  not  merely  associated  with  it. 

The  above  classification,  if  unqualified,  suggests  erroneous  ideas.  It  in- 
dicates that  there  is  an  essential  difference  between  dry  gangrene  and  moist 
gangrene,  which  is  not  the  case.  If,  when  gangrene  begins,  the  tissues  are 
free  from  fluid,  the  patient  develops  dry  gangrene;  if  they  are  full  of  fluid,  he 
develops  moist  gangrene.  If  the  arterial  supply  is  gradually  cut  off,  the  tissues 
are  sure  to  be  free  from  fluid,  and  the  gangrene  will  certainly  be  of  the  dry 
form.  If  arterial  blood  is  suddenly  cut  off,  the  gangrene  may  be  dry  or  moist, 
according  as  to  whether  the  tissues  are  or  are  not  drained  of  fluid.  When 
gangrene  results  from  inflammation,  strangulation,  and  infection  it  is  certain 
to  be  of  the  moist  variety,  because  the  tissues  are  sure  to  be  filled  with  fluid. 

De  Nancrede  says,  in  his  very  valuable  work  on  the  "Principles  of  Sur- 
gery:" "Yet,  let  accidental  inflammation  have  preceded  the  final  blocking  of  an 
artery,  or  let  ligation  of  the  main  artery  cause  gangrene  because  the  collateral 
circulation  cannot  become  developed,  and  if  an  aneurysmal  sac  is  so  situated 
as  to  interfere  with  a  free  return  of  venous  blood  and  lymph,  this  anemic 
gangrene  will  in  both  instances  prove  moist  and  not  dry." 

There  are  many  gangrenous  processes  which  belong  under  one  or  other 
of  the  above  heads,  namely:  congenital  gangrene,  a  rare  form  existing  at  birth; 
constitutional  gangrene,  arising  from  a  constitutional  cause,  as  diabetes; 
cutaneous  gangrene,  which  is  limited  to  skin  and  subcutaneous  tissue,  as  in 
phlegmonous  erysipelas;  gaseous  or  emphysematous  gangrene,  in  which  the 
tissues  becomes  distended  with  putrefactive  gases  and  crackle  on  pressure; 
hospital  gangrene,  which  is  defined  by  Foster  as  specific  serpiginous  necrosis, 


176  Mortilication,  Gangrene,  or  Sphacelus 

the  tissues  being  pulpefied:  some  consider  it  a  traumatic  diphtheria;  cold 
gangrene,  a  form  in  which  the  parts  are  entirely  dead  (sphacelus);  hot  gan- 
grene, which  is  associated  with  inflammation,  as  shown  by  heat;  dermatitis 
gangrcenosa  infantum,  or  the  multiple  cachectic  gangrene  of  Simon;  idiopathic 
gangrene,  which  has  no  ascertainable  cause;  mixed,  which  is  partly  dry  and 
partly  moist;  primary,  in  which  the  death  of  the  part  is  direct,  as  from  a  burn; 
secofidary,  which  follows  an  acute  inflammation;  multiple,  as  gangrenous 
herpes  zoster;  diabetic  or  glycemic  gangrene,  which  arises  during  the  existence 
of  diabetes;  gangrenous  ecthyma,  a  gangrenous  condition  of  ecthyma  ulcers; 
pressure,  which  is  due  to  long  compression;  piirpuric  or  scorbutic,  which  is 
due  to  scurvy;  Raynaud's  or  idiopathic  symmetrical,  which  is  due  to  vascular 
blocking,  perhaps  from  nerve  disorder;  senile,  the  dr\'  gangrene  of  the  aged; 
venous  or  static,  which  is  due  to  obstruction  of  circulation  as  in  a  strangulated 
hernia;  trophic,  which  is  due  to  nutritive  failure  by  reason  of  disorder  of  the 
trophic  nerves  or  centers;  thrombotic,  which  is  due  to  thrombus;  embolic,  which  is 
due  to  embolus;  and  decubitus,  decubital  gangrene,  or  bed-sores  due  to  pressure. 

Dry  gangrene  arises  from  deficiency  of  arterial  blood.  For  this  reason 
De  Nancrede  calls  it  anemic  gangrene. 

This  form  of  gangrene  is  far  more  apt  to  result  from  the  gradual  than  from 
the  sudden  cutting  off  of  the  supply  of  arterial  blood,  and  is  more  common  if 
the  blood-vessels  are  atheromatous  than  if  they  are  healthy;  but  even  in  a 
person  with  healthy  arteries  gangrene  will  ensue  upon  blocking  of  the  main 
artery,  if  the  collaterals  fail  to  supply  the  part  with  blood.  This  form  of 
gangrene  can  occur  after  laceration,  ligation,  or  the  lodgment  of  an  embolus 
in  the  main  artery  of  a  limb;  but  in  such  accidents  considerable  fluid  usually 
remains  in  the  tissues  and  the  gangrene  is  apt  to  be  moist  rather  than  dry. 

Gangrene  Due  to  Embolism  or  Thrombosis. — An  embolus  may  cause  gan- 
grene in  rare  instances,  hence  the  cause  of  emboHsm  is  responsible  for  the  gan- 
grene. There  may  be  vascular  disease.  There  may  be  or  there  may  have  been 
an  infectious  process  (typhoid  fever,  pneumonia,  influenza,  diphtheria,  etc.). 
If  an  embolus  causes  gangrene,  it  is  probable  that  the  blocking  was  not  at  once 
complete.  Why  an  embolus  in  a  young  person  causes  gangrene  is  perplexing, 
because  in  such  a  person  we  can  tie  a  large  artery  with  comparatively  little 
fear  of  gangrene.  It  must  be  that  a  clot  forms  proximally  to  the  embolus, 
fills  a  considerable  extent  of  the  vessel,  and  cuts  off  the  collaterals.  When  an 
embolus  lodges  in  an  artery  and  causes  dry  gangrene,  the  case  runs  the  follow- 
ing course:  sudden  severe  pain  at  the  seat  of  impaction,  and  also  tenderness; 
pulsation  above,  but  not  below,  this  point,  after  obstruction  has  become  com- 
plete; the  Hmb  below  the  obstruction  is  blanched,  cold,  and  anesthetic;  within 
forty-eight  hours,  as  a  rule,  the  area  of  gangrene  is  widespread  and  clearly  evi- 
dent; the  Hmb  becomes  reddish,  greenish,  blue,  and  then  black;  the  skin  be- 
comes shriveled  and  its  outer  layer  stony  or  hke  horn  because  of  evaporation. 
The  entire  part  may  become  dry;  but  usually  there  are  spots  where  some  fluid 
remains,  and  these  spots  are  soft  and  moist,  and  the  dead  tissue,  where  it  joins 
the  living,  is  sure  to  be  moist.  The  moist  areas  become  foul  and  putrid,  but  the 
dry  spots  do  not.  In  dry  gangrene,  at  the  point  of  contact  of  the  dead  and 
living  tissues,  inflammation  arises  in  the  latter  structures,  a  bright-red  line 
forms,  exudation  occurs,  and  ulceration  takes  place.  This  hne  of  ulceration  in 
the  sound  tissues  is  called  the  litie  of  demarcation.  It  is  Nature's  effort  at 
amputation,  and  in  time  may  get  rid  of  a  large  portion  of  a  limb,  and  then 
heal  as  any  other  ulcer.  A  Hne  of  demarcation  rarely  causes  hemorrhage, 
because  it  enters  a  vessel  only  after  inflammation  has  caused  occlusion  by  throm- 
bosis. In  dry  gangrene  from  arterial  obstruction  there  is  gastro-intestinal  de- 
rangement and  also  some  fever.  The  gangrene  does  not  extend  up  to  the  point 
of  obstruction,  but  only  to  a  region  in  which  the  anastomotic  circulation  is  suffi- 
ciently active  to  permit  of  the  formation  of  a  Hne  of  demarcation.     Below  this 


Presenile  Spontaneous  Gangrene 


177 


point  inflammatory  stasis  arises,  but  before  this  can  go  on  to  ulceration  the  parts 
die.  In  cases  in  which  the  arterial  obstruction  is  sudden  and  complete  the  limb 
swells  decidedly.  This  is  due  to  the  sudden  loss  of  vis  a  tergo  in  the  arterial 
system,  venous  reflux  occurring  and  fluids  transuding.  In  such  a  case  the 
tissues  contain  fluid  and  putrefy,  and  the  process,  though  due  to  the  cutting  off 
of  the  arterial  circulation,  is  moist  gangrene.  Embolic  gangrene  attacks  the 
leg  more  often  than  the  arm.  A  thrombus  in  an  artery  rarely  causes  gangrene 
except  in  the  aged,  as  the  collateral  circulation  has  time  to  adjust  itself;  but 
gangrene  may  follow  thrombus  formation,  and  when  it  does  it  comes  on  more 
slowly  than  does  gangrene  from  embolus,  and  is  certain  to  be  of  the  dry  form. 

Treatment  of  Thrombotic  and  Embolic  Gangrene. — When  injury  or  blocking 
of  a  healthy  artery  causes  us  to  fear  the  onset  of  gangrene,  the  patient  should 
be  placed  in  bed,  the  extremity  should  be  elevated  a  little,  kept  wrapped  in  cot- 
ton-wool, and  surrounded  with  bottles  filled  with  warm  water.  Baking  in 
the  hot  air  oven  is  very  useful  (Willy  Meyer,  De  Witt  Stetten).  It  is  useless 
when  an  artery  is  extensively  diseased  to  incise  it  and  remove  a  clot,  because 
another  clot  will  form  at  once.  If  a  clot  forms  in  a  limited  area  of  disease,  it 
may  be  possible  to  excise  the  diseased  section  of  the  artery  and  do  end-to-end 
anastomosis,  or  insert  by  implantation  a  section  taken  from  a  distant  vein.  In 
cases  of  thrombosis,  however, 
some  surgeons  prefer  arterio- 
venous anastomosis  (see  page 
179).  In  embolism  it  is  a  logical 
procedure  to  make  a  longitudi- 
nal incision  in  the  artery,  re- 
move the  embolus,  and  suture 
the  wound  in  the  vessel.  So 
far  arteriotomy  for  embolism 
has  not  been  as  successful  as 
Carrel's  experiments  lead  us  to 
infer  it  should  be;  the  probable 
reason  is  that  most  reported 
operations  were  upon  elderly 
people,  in  whom,  because  of 
diseased  arteries,  extensive  clots 
existed.  Lejars  believes  that  in 
the  young  results  are  sure  to 
be  better^  Mosny  and  Du- 
mont  report  a  successful 
arteriotomy  for  embolism  of  the 

femoral  artery  in  a  case  of  mitral  stenosis  (quoted  in  "Lancet,"  March  9,  1912). 
If  in  spite  of  our  efforts  gangrene  begins  and  progresses,  wait  for  a  line  of 
demarcation,  and  while  waiting  dress  the  dying  and  dead  parts  antiseptically, 
wrap  the  extremity  in  cotton  and  keep  it  warm,  and  see  to  it  that  the 
patient  gets  plenty  of  sleep  and  nourishment.  It  is  also  advisable  to  give 
tonics  and  stimulants.  When  a  line  of  demarcation  forms,  amputate  well 
above  it. 

Presenile  Spontaneous  Gangrene. — I  have  adopted  Buerger's  suggested 
name  for  this  condition.  The  vascular  disease  responsible  for  the  gangrene 
is  in  dispute.  Winiwarter  and  others  beheve  it  is  obhterative  endarteritis  of 
all  the  arteries  of  a  leg.  Buerger  regards  the  condition  as  thrombo-angiitis 
obhterans,  appearing  in  the  larger  arteries  and  also  in  the  deep  veins  of  the  leg 
("  Amer.  Jour.  Med.  Sciences,"  Oct.,  1908).  In  some  cases  migrating  phlebitis 
develops  in  the  superficial  veins.  The  clots  become  canaHzed,  vascularized 
connective  tissue.  In  this  condition  there  is  always  an  absence  of  elastic 
fibers  save  a  few  around  the  large  canalizing  vessels.     Here  we  have  a  definite 


n 

^H^F''^-: 

S 

■ 

-iJ^^^^H 

1 

Fig.  87.- 


-Gangrene  from  thrombo-angiitis 
obliterans. 


178  Mortification,  Gangrene,  or  Sphacelus 

and  positive  organization  of  a  thrombus  with  httle  participation  of  the  elastica 
(J.  Parsons  Schaeflfer,  in  "The  Anatomical  Record,"  Jan.,  191;).  L.  Buerger 
has  seen  over  300  cases.  He  believes  that  the  start  of  the  condition  is  an 
acute  inflammation  with  occluding  thrombosis  and  the  formation  of  areas  of 
giant  cells.  As  healing  advances  giant  cells  and  inflammatory  material  disappear 
and  the  clot  becomes  organized  and  canalized.  Finally  fibrous  tissue  forms  in 
the  adventitia,  causing  artery,  vein  and  nerves  to  adhere,  hence  the  pain  (Am. 
Jour.  Med.  Sciences,  Sept.,  1917). 

In  this  condition  perivascular  inflammation  comes  to  exist.  In  cases  which 
have  lasted  for  years  there  is  arteriosclerosis.  Some  hold  that  this  form  of  gan- 
grene is  most  apt  to  occur  in  sclerotic  vessels.  Buerger  regards  infection  as  the 
cause.  Some  think  ovarian  secretion  protects  females.  The  points  at  which 
an  occluding  clot  is  most  apt  to  form  are  the  tibials  and  the  bifurcation  of  the 
pophteal.  If  this  clot  forms  slowly  and  the  collaterals  are  in  good  condition 
gangrene  will  not  occur,  if  the  clot  forms  rapidly  and  the  collaterals  are  not 
in  good  condition  gangrene  will  occur. 

Mayesima  of  Japan  has  pointed  out  that  in  presenile  gangrene  there  is  an 
increase  in  the  viscosity  of  the  blood  (quoted  by  Willy  Meyer,  in  "Annals  of 
Surgery,"  March,  1916). 

It  occurs  among  young  adults  (from  twenty  to  forty,  I  have  never  seen  a 
case  in  a  man  over  fifty)  and  is  especially  noticed  among  the  Russian,  Galhcan 
and  PoUsh  Jews  in  our  large  cities.  It  is  not  limited  to  Jews.  Five  of  my 
eight  cases  belonged  to  that  race.  Three  were  Americans.  Cases  have  been 
reported  among  Chinamen,  Japanese  and  Swedes.  It  is  said  not  to  occur 
at  all  in  women.  I  have  seen  one  Jewish  woman  with  what  I  believe  to  be 
thrombo-angiitis  obliterans.  This  form  of  gangrene  is  said  to  be  apt  to  arise 
after  typhus  fever  (Goodman,  in  Med.  Record,  August  18,  1917).  Occupation 
does  not  seem  to  have  a  causal  influence.  Many  but  not  all  of  the  victims  smoke 
quantities  of  cigarettes.  A  diet  containing  too  much  salt  meat  has  been  blamed, 
but  the  disease  can  arise  in  those  on  ample  diet.  Occupations  requiring  pro- 
longed standing  have  been  thought  to  predispose.  It  usually,  but  not  always, 
begins  in  the  left  leg.  It  may  start  almost  simultaneously  in  both  legs.  If  it 
begins  in  one  leg,  the  other  tends  to  become  affected  sooner  or  later.  It  comes 
on  with  attacks  of  severe  pain  in  the  toes,  foot,  or  leg,  the  extremity  feels  cold 
and  looks  bloodless,  and  no  pulse  can  be  detected  in  the  dorsaUs  pedis  and 
posterior  tibial  arteries.  Such  attacks  are  at  first  brought  on  by  cold,  later 
they  appear  to  arise  spontaneously. 

When  the  foot  is  warmed  some  color  returns  and  feeble  pulse  may  be  ap- 
preciated. Many  of  these  patients  get  so  that  any  attempt  at  walking  causes 
violent  pains  in  the  calf  muscles,  pain  so  violent  as  to  make  the  victim  limp  in 
torture  or  at  once  stop  walking  {intermittent  claudication). 

After  a  case  has  lasted  a  number  of  months  erythromelalgia  may  develop.  In 
this  condition  when  the  foot  is  hung  dowoi  the  toes  and  dorsum  of  foot  rather 
rapidly  grow  bright  red. 

After  a  case  has  lasted  for  many  months  it  will  be  impossible  at  any  time 
to  detect  a  pulse  in  the  dorsahs  pedis  or  posterior  tibial.  The  patient  is  wear- 
ing out  with  violent  pain  and  cannot  walk.  Whenever  the  foot  hangs  down  it 
becomes  red  or  cyanotic.  A  bleb  or  ulcer  may  form  upon  the  foot  or  great  toe; 
it  is  sure  to  be  intensely  painful,  and  finally  dry  gangrene  occurs.  Gangrene 
may  occur  in  a  few  months  after  the  onset  of  the  disease  but  it  seldom  occurs 
until  after  years. 

I  have  seen  8  such  cases  of  gangrene  and  in  5  of  them  I  performed  ampu- 
tation. In  one  case,  a  man  in  the  early  forties,  I  amputated  the  leg  above  the 
knee,  at  a  later  period  the  other  leg  at  a  corresponding  point,  and  later  still 
re-amputated  the  extremity  first  operated  upon,  gangrene  from  thrombosis 
having  arisen  in  the  stump.     A  few  weeks  later  the  man  died  with  evidences 


Fig.  SS. — Senile  gangrene  of  the  feet  (Gross). 


Treatment  of  Gangrene  170 

of  beginning  gangrene  in  the  hands.  Autopsy  was  refused.  The  examination 
of  the  vessels  in  all  the  amputated  legs  accorded  with  Buerger's  view  that  the 
condition  is  one  of  thrombo-angiitis  obliterans,  the  veins  often  suffering  as 
well  as  the  arteries.  The  clot  often  fills  the  vessels  of  the  toes,  the  dorsahs 
pedis,  the  plantar,  and  may  extend  up  both  tibials  to  the  popliteal.  Before 
gangrene  arises  various  diagnoses  are  apt  to  be  made  (Raynaud's  disease, 
intermittent  claudication,  erythromelalgia). 

The  characteristic  combination  is  violent  pain,  with  absent  pulse  in  the 
dorsalis  pedis  and  posterior  tibial  arteries. 

Treatment. — All  sorts  of  treatment  has  been  tried  from  injections  of  sodium 
citrate  to  hyperemia  suction;  from  a  diet  free  from  meat  and  salt,  to  salt  solution 
by  hypodermoclysis;  from  reflected  light  upon  the  extremity  to  the  .r-ravs  and 
ail  of  them  have  failed  totally 
or  proved  only  palliative.  I 
have  seen  notable  relief  of 
pain  and  apparent  checking 
of  beginning  gangrene  by  the 
use  of  Ringer's  solution  given 
by  h^-podermoclysis.  This 
plan  was  introduced  by  Ito 
and  Koga  of  Japan  and  has 
been  endorsed  by  Willy 
Meyer  ("  Annals  of  Surgery," 
March,  1916).  It  acts  by 
reducing  the  viscosity  of 
the  blood.  Meyer  advises  us 
to  dissolve  one  of  the  tabloids 

used  for  Ringer's  solution  in  500  c.c.  of  distilled  water  and  inject  it  daily  or 
every  other  day.    Use  it  15  or  20  times.     A  series  of  injections  can  be  repeated. 

In  one  of  my  cases  the  pain  disappeared  after  ten  injections.  Later  the 
symptoms  may  return,  in  which  case  the  injections  should  be  given  again. 
Meyer  suggests  a  trial  of  intravenous  injection  of  a  2  per  cent,  aqueous  solution 
of  sodium  citrate.  With  this  treatment  Meyer  associates  baking  of  the  limb 
and  advises  a  trial  of  organo therapeutic  preparations  ("Annals  of  Surgery," 
March,  191 6). 

In  these  cases  it  is  not  possible  to  remove  tlie  thrombus  surgically  because 
the  vein  is  involved  and  the  blocking  material  in  the  vessels  is  organized  ma- 
terial attached  to  the  walls  (B.  M.  Bernheim,  "Southern  Med.  Jour.,"  1915, 
viii). 

Since  1902  when  Carrel  made  his  report  on  vascular  anastomosis  surgeons 
have  tried  to  arrest  this  and  other  forms  of  gangrene  by  reversal  of  the  circula- 
tion. The  plan  is  to  anastomose  the  femoral  vein  to  the  femoral  artery,  end- 
to-end  as  Carrel  and  Guthrie  ad\dse  or  laterally  as  Murphy,  Bernheim  and 
Weiting  advocate  (J.  S.  Horsley  and  R.  H.  Whitehead,  in  "Jour.  Am.  Med. 
Assoc,"  1915,  Ixiv). 

Horsley,  Stetten,  and  others  strongly  oppose  the  operation.  Carrel,  Bern- 
heim, Goodman,  and  others  advocate  it.  Stetten  collected  136  operations  for 
different  forms  of  gangrene  and  found  a  direct  mortality  of  more  than  30  per 
cent,  and  complete  failure  of  the  operation  in  more  than  '^2  per  cent.  ("Surg., 
G>Ti.,  and  Obst.,"  1915,  xx). 

Early  in  a  case  when  gangrene  threatens  or  when  it  is  recent  and  limited, 
we  may  assume  that  the  veins  are  free  from  clot  and  the  operation  is  justifiable 
and  may  perhaps  prove  successful.  Bloodgood  has  had  success  in  a  case 
which  seems  to  have  been  of  this  t}^e  (Bernheim,  in  "Amer.  Jour.  Med. 
Sciences,"  Feb.,  191 2).  Meyer  has  reported  a  successful  case  ("Annals  of 
Surgery,"  March,  1916).     I  do  not  beMeve  that  such  an  operation  causes  the 


i8o  Mortification,  Gangrene,  or  Sphacelus 

blood  to  move  toward  the  body  in  the  arteries  and  from  the  body  in  the  large 
veins.  The  valves  in  the  veins  prevent  such  a  happening  in  those  vessels 
(Horsley  and  Whitehead,  in  "Jour.  Am.  Med.  Assoc,"  March  13,  191 5). 
Willy  Meyer  ("Annals  of  Surgery,"  March,  1916)  says  that  what  occurs  is  as 
follows:  The  arterial  blood  stream  deflected  into  the  vein  is  obstructed  by  the 
valves  and  is  deflected  into  branches  of  the  femoral  vein  devoid  of  valves. 
These  smaller,  thin- walled  veins  enlarge.  Some  of  the  blood  runs  back  through 
collaterals  to  "the  proximal  end  of  the  ligated  femoral  vein.  A  good  deal  of 
the  arterial  blood  does  reach  the  foot  and  toes  in  a  non-spurting,  venously  even 
flow"  and  this  blood  returns  "through  such  branches  of  the  venous  system 
as  have  not  been  seized  upon  by  arterial  blood;"  If  Meyer's  theory  is  correct 
the  term  "reversal  of  circulation"  is  a  misnomer.  Bernheim  believes  reversal 
does  occur  and  cites  a  case  in  which  amputation  of  the  foot  was  required  after 
arteriovenous  anastomosis.  One  vein  bled  bright  blood  in  a  constant  stream 
from  the  proximal  end.  Another  vein  bled  bright  blood  in  spurts  from  the 
proximal  end  ("Interstate  Med.  Jour.,"  191 5,  xxii). 

Another  operation,  suggested  by  von  Oppel  for  threatened  senile  gangrene, 
is  ligation  of  the  popliteal  vein.  Lessening  the  carrying  ability  of  the  vein  puts 
it  in  accord  with  the  lessened  carrying  ability  of  the  artery.  Consequently 
the  blood  pressure  and  the  rate  of  the  circulation  in  the  two  more  nearly  accord 
and  the  scanty  arterial  supply  ceases  to  be  removed  too  rapidly  by  the  large 
vein.  In  this  form  of  gangrene  ligation  of  the  femoral  vein  below  the  long  saph- 
enous should  be  preferred  to  ligation  of  the  popliteal.  Both  operations  are  of 
very  doubtful  value.     As  Meyer  says,  they  are  as  yet  on  trial. 

Sooner  or  later  these  cases  come  to  amputation.  In  some  cases  violent 
pain  compels  amputation  even  before  gangrene  begins.  Gangrene,  if  involving 
more  than  a  small  area,  calls  for  it  imperatively.  Not  unusually,  weeks  or 
months  after  amputation  of  one  leg,  the  other  leg  has  to  be  sacrificed. 

The  amputation  should  always  be  above  the  knee  in  order  to  be  well  above 
the  thrombi  in  the  vessels.  Surgeons  have  used  Moschcowitz's  test  to  deter- 
mine where  to  amputate.     (See  Senile  Gangrene,  page  182.) 

Senile  gangrene,  chronic  gangrene,  Pott's  gangrene  (Fig.  88),  which  was  first 
described  by  Percival  Pott  of  London  as  mortification  of  "the  toes  and  feet," 
(Pott's  works)  is  a  form  of  gangrene  due  to  feeble  action  of  the  heart  plus 
obliterating  endarteritis  or  atheroma  of  peripheral  vessels.  The  vessels  do  not 
carry  a  normal  amount  of  blood,  and  may  at  any  time  be  occluded  by  throm- 
bosis. If  the  process  is  uncomplicated  by  thrombosis  an  abundance  of  elastic 
fibers  aid  in  the  obliteration  of  the  vessel.  It  is  much  more  common  in  men 
than  in  women  and  is  most  common  after  60  years  of  age.  In  a  drunkard  or 
in  a  victim  of  syphilis,  Bright's  disease,  tubercle  or  lead  poisoning  the  arterio- 
sclerotic condition  supposed  to  characterize  old  age  may  appear  while  a  man 
is  young  in  years.  It  was  long  ago  said,  with  truth,  "a  man  is  as  old  as  his 
arteries."     Senile  gangrene  most  often  occurs  in  a  toe,  in  toes,  or  in  the  foot. 

Symptoms. — A  man  whose  vessels  are  in  the  state  above  indicated  is  gener- 
ally in  feeble  health  and  has  a  fatty  heart  and  an  arcus  senilis  (a  red  or  white 
line  of  fatty  degeneration  around  the  cornea).  His  toes  and  feet  are  cold  and  feel 
numb,  they  "go  to  sleep"  easily,  and  he  suffers  from  cramp  and  often  pains  in  the 
legs  and  feet.  He  is  dyspeptic  and  short  of  breath,  and  his  urine  is  frequently 
albuminous.  The  arteries  are  felt  as  rigid  tubes,  Hke  pipe-stems.  He  is  in 
danger  of  edema  of  the  lungs  and  of  dry  gangrene  of  the  toes,  A  slight  injury 
or  inflammation  of  a  toe — for  instance,  a  hang  nail,  stubbing  a  toe,  or  cutting 
a  corn  too  close — will  produce  extensive  inflammatory  stasis  followed  by  throm- 
.bosis,  which  completely  cuts  off  the  blood-supply  and  causes  gangrene  of  the  part. 
Gangrene  is  usually  announced  by  the  appearance  of  a  purple  and  anesthetic 
spot  followed  by  a  vesicle  which  ruptures  and  liberates  a  small  amount  of  bloody 
serum  and  exposes  a  dry  floor.     In  the  parts  about  the  gangrenous  area  there  is 


Senile  Gangrene,   C'hronic  Gangrene,  Pott's  Gangrene  i8i 


often  burning  pain.     The  circulation  in  the  tissues  immediately  adjacent  to  the 
dead  spot  is  retarded  or  stagnated,  the  parts  being  purple  and  the  color  not  disap- 
pearing or  disappearing  slowly  under  pressure.     If  the  color  fades  under  pressure 
it  returns  slowly  when  pressure  is  removed.     The  parts  a  little  further  removed 
are  hyperemic,  the  color  disappearing  rapidly  on  pressure,  and  returning  rapidly 
when  pressure  is  removed.     The  dead  parts  do  not  putrefy  at  all  or  do  so  but 
slightly,  hence  the  odor  is  never  very  offensive  and  is  usually  trivial.     The  dead 
parts  are  anesthetic,  hard,  leathery  and  wrinkled,  and  resemble  a  varnished  ana- 
tomical specimen  or  the  extremity  of  a  mummy  (hence  the  term  mnmmijkatlon). 
Before  the  line  of  demarcation  forms  there  is  burning  pain;  after  it  forms  pain  is 
rarely  present,     li  an  embolus  or  thrombus  in  a  diseased  vessel  of  some  size  causes 
gangrene,  the  pain  is  severe  at  the  point  of  impaction.     In  senile  gangrene  the  dis- 
tal portion  of  the  dead  area  is  always  dry,  the  part  nearer  the  body  being  generally 
somewhat  moist.     The  process  may  be  very  limited  or  it  mav  spread  up  along 
the  dorsum  of  the  foot  and  the  leg,  even  to  the  knee.     As  it  spreads  the  area  of 
hyperemia  advances  at  the  margin,  the  area  of  stasis  follows,  and  the  zone  of 
gangrene  becomes  more  extensive. 
When    tissues    are    reached,    the 
blood-supply    of    which    is    suffi- 
ciently good  to  permit  of  inflam- 
mation going  beyond  the  stage  of 
stasis  and  to  allow  of  stasis  with- 
out extensive  thrombosis,  Nature 
tries  to  limit  the  gangrene  by  the 
formation  of  a  line  of  demarcation. 
A  line  of  demarcation  may  begin, 
but  prove  abortive,  the  tissue  mor- 
tifying above  it.     This  proves  that 
tissue  near  the  line  is  in  a  state  of 
low  vitality.     The  line  of  demar- 
cation may  prove  durable  and  in 
some  few  cases  spontaneous  am- 
putation   takes  place    (Fig.    89). 
When  a  limited  area  is  gangrenous, 
constitutional  symptoms  are  trivial 
or  absent;  but  when  a  large  area 
is   involved,    the   fever   of   septic 
absorption    exists.      Death    may 
ensue  from  exhaustion  caused  by 
sleeplessness    and    pain,    from  septic  absorption,  from  embolism  of  internal 
organs,    or.    from    some    complication    (renal,    pulmonary,    or    cardiac).     In 
many   cases    of  senile  gangrene  clots  are  formed   in  the  superficial  femoral 
artery  or  its  branches,  an  observation  it  is  important  to  bear  in  mind  when 
amputating. 

Prevention  of  Senile  Gangrene  in  the  Predisposed. — Such  a  patient  must 
avoid  injuring  the  toes  and  feet.  Cutting  corns  carelessly  is  highly  dan- 
gerous, and  any  wound,  however  slight,  requires  rest  and  antiseptic  dressing. 
The  victim  of  general  atheroma  must  wear  woolen  stockings,  put  a  rubber 
bag  containing  warm  water  to  his  feet  on  cold  nights,  and  attend  to  his  general 
health.  He  must  avoid  overeating  and  is  to  be  particularly  moderate  in  the 
use  of  meats,  should  have  a  daily  bowel  movement,  and  should  drink  water 
in  plenty  between  meals.  He  should  avoid  as  far  as  may  be  work  and  worry, 
and  enough  sleep  is  imperative.  A  little  whisky  after  each  meal  is  indicated, 
and  occasional  courses  of  nitroglycerin  are  desirable.  Courses  of  iodid  of  potas- 
sium, given  in  small  doses,  may  retard  the  progress  of  the  sclerosis.     If  gan- 


FiG.  89. — Dr.  Keller's  case  of  spontaneous  ampu- 
tation of  a  foot  and  part  of  a  leg  in  a  condition  of 
senile  gangrene. 


i82  Mortification,  Gangrene,  or  Sphacelus 

grene  is  impending  use  superheated  air  and  hypodermoclysis  with  Ringer's 
solution  (page  179).  If  the  subject  is  syphilitic,  also,  give  salvarsan  and  courses 
of  mercury  and  the  iodids. 

Treatment  of  Senile  Gangrene. — When  gangrene  occurs,  if  it  is  limited  to 
one  toe  or  a  portion  of  several  toes,  if  it  is  a  first  attack,  if  there  is  no  fever  or 
exhausting  diarrhea,  if  there  is  no  tendency  to  pulmonary  congestion,  if  the 
appetite  is  fair  and  sleep  refreshing,  it  is  best  to  avoid  radical  interference 
and  to  await  the  formation  of  a  line  of  demarcation.  While  awaiting  the  line 
of  demarcation  dress  the  part  antiseptically,  raise  the  foot  several  inches 
from  the  bed,  and  surround  the  part  with  bottles  of  moderately  warm  water. 
Very  warm  water  may  do  harm.  Give  the  patient  nourishing  diet,  stimulants, 
and  tonics;  see  to  it  that  he  sleeps,  and  during  the  spread  of  the  gangrene  watch 
for  fever,  diarrhea,  pulmonary  congestion,  and  kidney  failure.  Percival  Pott 
pointed  out  a  century  and  a  half  ago  that  opium  in  moderate  doses  is  very  use- 
ful. It  should  be  given  in  the  form  of  laudanum  or  the  deodorized  tincture. 
Dr.  George  W.  Gay  warmly  advocates  its  use.  He  finds  that  it  relieves  pain, 
quiets  restlessness,  and  is  a  cardiac  and  vascular  tonic  which  increases  the  nu- 
trition of  peripheral  parts  (Med.  and  Surg.  Reports  of  Boston  City  Hospital, 
sixteenth  series).  I  believe  this  praise  of  opium  is  well  merited.  When  a  line  of 
demarcation  forms,  dress  with  warm  antiseptic  fomentations  and  iodoform,  and 
every  day  pick  away  dead  bits  with  the  scissors  and  forceps.  A  tendon  or  liga- 
ment should  be  cut  through  and  a  protruding  phalanx  should  be  divided  with  a 
Gigli  saw.  If,  after  separation,  an  ulcer  forms,  skin-grafts  may  be  applied.  In 
many  cases  healing  will  occur;  but  even  when  the  parts  heal  the  patient  will 
always  be  in  deadly  peril  of  another  attack.  If  the  gangrene  shows  a  tendency 
to  spread,  if  it  involves  more  than  a  portion  of  several  toes,  if  it  is  not  a  first 
attack,  if  there  is  sleeplessness,  fever,  exhausting  diarrhea,  anorexia,  or  a  strong 
tendency  to  pulmonary  congestion,  do  not  delay,  but  at  once  amputate  high  up. 
If  the  gangrene  shows  no  tendency  to  hmit  itself,  or  if  the  patient  develops  sepsis 
or  exhaustion,  at  once  amputate  high  up.  The  best  point  at  which  to  amputate 
is  above  the  knee,  so  that  the  deep  femoral  artery,  which  rarely  becomes 
atheromatous,  can  nourish  the  flap  and  gangrene  will  not  occur.  It  has  been 
pointed  out  that  the  superficial  femoral  artery  and  its  branches  often  contain 
a  clot.  Never  amputate  below  the  tubercle  of  the  tibia.  Some  operators 
disarticulate  at  the  knee-joint.  Heidenhain  affirms  that  so  long  as  the  gangrene 
is  limited  to  one  or  two  toes  we  should  merely  treat  it  antiseptically,  elevate 
the  limb,  and  wait  for  the  dead  part  to  be  cast  off  spontaneously;  if,  however,  it 
extends  to  the  dorsum  or  sole  of  the  foot,  we  should  amputate  at  once  above 
the  knee.  He  further  states  that  gangrene  of  the  flaps  almost  always  occurs 
in  amputations  below  the  knee,  and  high  amputation  is  indicated  in  advancing 
gangrene  with  or  without  fever. ^  Personally,  I  still  follow  Heidenhain's 
rule.  Many  surgeons  dissent  from  it  and  believe  that  in  certain  cases  we  can 
amputate  lower  down.  Our  right  to  do  so  depends  on  collateral  efficiency. 
Many  tests  to  determine  the  activity  of  the  collaterals  have  been  suggested. 
Matas  considers  them  as  preliminaries  to  operations  for  aneurysm  (Matas,  in 
''Am.  Jour.  Med.  Sciences,"  1914,  Ixiii).  Moschcowitz  suggested  a  method 
of  determining  the  viable  area.  {Moschcowitz^ s  test  for  collateral  adequacy.) 
He  applies  an  elastic  bandage  from  the  toes  to  high  up  the  thigh,  puts  in  place 
the  tourniquet  band,  and  removes  the  bandage.  In  five  or  ten  minutes  he  re- 
moves the  band  and  notes  the  color  of  the  limb  as  it  is  invaded  by  reaction- 
ary hyperemia.  This  wave  of  color  travels  toward  the  periphery.  High  up 
the  extremity  the  reactionary  blush  appears  quickly.  The  nearer  the  area  of 
vascular  obstruction,  the  slower  the  manifestation  of  color.  In  doubtful  areas 
the  blush  comes  slowly  and  imperfectly,  and  patches  of  white  show  here  and 
there  in  the  color.  In  a  region  of  total  ischemia  no  reactionary  blush  occurs. 
1  "Deutsche  medicinische  Wochenschrift,"  1891,  p.  1087. 


]Moist  Gangrene  of  a  Limb  183 

Operation  must  be  performed  in  the  region  where  there  was  a  complete  red 
reaction,  and  never  through  an  area  where  anemic  patches  were  noted.  This 
very  ingenious  test  of  Moschcowitz  has  not  seemed  to  me  conclusive,  and  I  have 
fancied  in  cases  of  threatened  gangrene  that  it  helped  to  bring  about  the  very 
condition  we  feared.  It  is  only  just  to  say  that  in  other  hands  the  test  seems 
to  have  proved  successful.  Matas  uses  it  to  test  the  collaterals  before  operating 
for  aneurysm.  When  amputation  has  been  performed  and  the  Esmarch 
band  has  been  removed  and  no  arterial  bleeding  takes  place  from  the  superficial 
femoral  artery,  a  clot  is  lodged  in  that  vessel.  If  such  a  condition  e.xists, 
insert  into  the  artery  a  fine  rubber  catheter  or  a  filiform  bougie  and  break  up 
the  clot.     WTien  blood  flows  we  are  sure  that  the  clot  has  been  washed  out.^ 

Some  surgeons  have  practised  arteriovenous  anastomosis  between  the 
femoral  vein  and  common  femoral  artery  in  hope  of  establishing  sufl5cient 
circulation  to  prevent  impending  or  to  cure  existing  gangrene.  The  results 
are  as  yet  inconclusive,  but  some  apparent  successes  have  been  reported  (see 
page  179).  Oppel  suggested  ligation  of  the  popliteal  vein.  Others  would  tie 
the  femoral  vein. 

In  moist  or  acute  gangrene 
(Fig.  90)  the  dead  part  re- 
mains moist  and  putrefies.  As 
De  Nancrede  points  out,  there 
are  two  forms  of  moist  gan- 
grene: '"that  limited  to  the 
areas  actually  killed  by  a 
traumatism,    with    some    sur-  i'-iti-  go-— Acute  gangrene  (Gross), 

rounding   tissue   which   dies," 

and  "that  which  tends  to  spread  widely,  this  latter  being  usually  caused  by 
specific  micro-organisms,  an  intense,  widespread,  pyogenic  inflammation 
resulting,  involving  the  subcutaneous  and  intermuscular  cellular  planes,  by 
strangulation  of  the  vessels  by  which  all  blood-supply  to  the  remaining  soft 
parts  is  destroyed."-  In  a  case  of  moist  gangrene  the  parts  remain  moist, 
either  because  the  main  artery  has  become  suddenly  blocked,  and  the  tissue 
fluids  are  not  urged  by  sufiacient  vis  a  tergo  to  cause  them  to  flow  out  of  the 
limb,  or  because  the  main  vein  is  blocked.  It  may  arise  in  a  limb  after  ligation, 
obstruction,  or  destruction  of  its  main  artery,  main  vein,  or  both;  after  long 
constriction,  as  by  a  tight  bandage;  after  crushes  and  lacerated  wounds,  and 
after  thrombosis  of  the  vein.  Moist  gangrene  may  follow  severe  pyogenic 
infection  or  may  be  due  to  local  constriction  (strangulated  hernia),  crushing, 
chemical  irritants,  heat,  and  cold. 

Moist  gangrene  of  a  limb  may  be  seen  t\'pically  in  certain  cases  in  which 
the  main  vein  or  artery  or  both  vein  and  artery  are  constricted,  damaged, 
or  destroyed.  The  leg  swells  greatly  and  is  pulseless  below  the  obstruction; 
the  skin,' at  first  pale,  :old,  and  anesthetic,  becomes  li\dd,  mottled,  purple, 
or  greenish.  A  greenish  color  signifies  putrefaction.  Blebs  are  formed  which 
contain  a  reddish  or  browm  fluid.  ''These  blebs,  being  caused  by  the  accumu- 
lation of  serum  beneath  epithelium  w^hich  has  lost  its  \dtal  connection  with  the 
derm,  can  be  slipped  around  upon  the  surrounding  true  skin,  the  epithelium 
readily  separating  for  long  distances  around,  as  in  a  cadaver"  (De  Nancrede). 
The  extremity  swells  enormously,  there  may  be  pain  at  the  seat  of  obstruction, 
but  there  is  no  pain  in  the  gangrenous  area,  and  sapremic  s}-mptoms  quickly  de- 
velop. The  bullae  break  and  disclose  the  browm  derm  and  sometimes  the  deeper 
structures,  which  are  swollen  and  edematous.  The  fetor  is  horrible.^  SHght 
or  moderate  fever  usuaUy  exists.  In  mfld  cases  a  line  of  demarcation  soon 
forms.  In  severe  cases  in  which  virulent  anerobic  bacteria  are  present  the 
1  Severeano.  See  T^Iancozet's  report  before  the  Second  Pan-American  Medical  Congress. 
^De  Nancrede's  "Principles  of  Surgery." 


i84  Mortification,  Gangrene,  or  Sphacelus 

process  spreads  with  great  rapidity,  neighboring  glands  enlarge,  the  tempera- 
ture is  much  elevated,  no  line  of  demarcation  forms,  there  is  profound  ex- 
haustion, and  gases  of  decomposition  accumulate  in  and  distend  the  tissues 
and  cause  crackling  when  the  parts  are  pressed  upon.  Such  severe  cases  are^ 
in  reality,  examples  of  foudroyant  or  emphysematous  gangrene. 

Moist  gangrene  from  inflammation  is  due  to  pressure  of  the  exudate, 
cutting  off  the  blood-supply,  or  to  loss  of  blood-circulation  because  of  microbic 
involvement  of  vessels  and  clotting  of  blood.  It  occurs  typically  in  phleg- 
monous erysipelas.  When  an  infiammation  is  about  to  terminate  in  gangrene 
all  the  signs  of  inflammation,  local  and  constitutional,  increase;  swelling  be- 
comes very  great  and  may  be  due  partly  to  fluid  and  partly  to  gas.  If  gas 
is  present  pressure  will  cause  crackling.  The  color  becomes  livid  or  purple. 
The  anatomically  related  glands  are  enlarged  and  the  symptoms  of  sapremia 
or  suppurative  fever  exist.  When  gangrene  is  actually  present  the  signs  of 
inflammation  have  passed  away,  bullse  and  emphysema  are  noted,  with  great 
swelling  and  all  the  other  symptoms  of  molar  death.  The  sudden  cessation 
of  pain  is  very  suggestive  of  gangrene.  The  constitutional  symptoms  are 
those  of  suppurative  fever  and  sapremia,  or  possibly  of  septic  infection. 

When  a  wound  becomes  gangrenous  the  surface  looks  like  yellow  or  gray 
tow,  the  discharge  becomes  profuse  and  very  fetid,  and  the  parts  about  swell 
enormously  and  gradually  become  gangrenous. 

Treatment  of  Moist  Gangrene. — In  extensive  moist  gangrene  of  a  limb,  if 
the  condition  is  of  the  form  described  as  mild,  in  which  there  are  not  severe 
symptoms  of  sepsis  and  in  which  the  gangrene  is  not  rapidly  progressive, 
wait  for  a  lin.  of  demarcation,  and  amputate  clear  of  and  above  it.  While 
waiting  for  the  line  to  form,  dress  the  dead  parts  antiseptically,  wrap  the  ex- 
tremity in  cotton,  apply  warmth,  and  slightly  elevate  the  limb.  Give  opium, 
tonics,  nourishing  food,  and  stimulants.  In  the  severe  form  of  moist  gangrene 
(really  foudroyant  gangrene)  amputate  at  once  high  above  the  gangrenous 
process  (page  193).  In  inflammatory  gangrene,  such  as  is  sometimes  associated 
with  phlegmonous  erysipelas,  relieve  tension  by  incisions,  cut  away  the  dead 
parts,  brush  the  raw  surface  with  pure  carbolic  acid,  dust  with  iodoform,  and 
dress  with  hot  antiseptic  fomentations.  Stimulate  freely,  administer  nourish- 
ment at  frequent  intervals,  and  treat  the  patient  in  general  as  we  would  a 
case  of  sapremia  or  suppurative  fever.  A  gangrenous  wound  is  treated  as 
pointed  out  in  the  section  on  Sloughing. 

Gas  Infection  and  Gas  Gangrene, — Virulent  infection  of  a  wound  with 
certain  micro-organisms  may  produce  a  violent  spreading  process  or  even 
gangrene.  The  gangrene  was  first  described  in  1853  by  Maisonneuve  under 
the  name  of  gangrene  foudroyantc.  In  1864  Pirogoff  called  it  acute  gangrenous- 
edema.  It  has  also  been  called  acute  mortification,  fulminating  gangrene, 
emphysematous  gangrene,  gangrenous  emphysema,  gaseous  phlegmon,  and  trau- 
matic spreading  gangrene.  It  is  occasionally  though  seldom  seen  in  civil  Ufe 
particularly  after  crushes  of  the  legs.  I  have  seen  it  several  times  in  run-over 
accidents,  compound  fractures  having  occurred  and  the  wounds  having  been 
contaminated  with  street  dirt.  We  were  accustomed  to  call  it  acute  mortifi- 
cation or  traumatic  spreading  gangrene  and  knew  that  gas  gathered  in  the 
tissues.  Sir  Anthony  Bowlby  says  "  it  is  practically  unknown  in  Great  Britain  " 
("  The  Treatment  of  War  Wounds,"  by  W.  W.  Keen).  It  must  have  been  very 
rare  in  the  war  between  the  States  as  my  old  master  Prof.  Keen  never  saw  a 
case.  It  has  been  demonstrated  in  a  case  of  gangrenous  cholecystitis  (G.  G. 
Cottam,  Surgery,  Gynecology,  and  Obstetrics,  August,  191 7). 

In  the  present  war  it  has  proved  a  frightful  scourge.  Great  numbers  of 
those  wounded  in  trench  warfare  develop  gas  infection  and  many  of  the 
wounded  die. 

The  condition  results  from  infection  with  various  anerobic  micro-organisms, 


Gas  Infection  and  Gas  Gangrene  •  185 

particularly  bacteria  which  belong  to  the  intestinal  flora.  The  soil  of  Belgium 
has  for  centuries  supported  a  teeming  population  and  abounds  with  all  sorts  of 
fecal  bacteria.  Trench  warfare  means  dust  in  dry  weather  and  mud  in  wet 
weather.  The  soldiers'  skin  is  smeared  with  bacteria  and  his  clothes  contain 
multitudes  of  them.  The  organism  responsible  in  most  cases  is  the  Bacillus 
aerogenes  capsulatus  (the  Bacillus  of  Welch).  It  is  found  in  70  per  cent,  of 
cases  of  gas  infection  although  very  seldom  in  pure  culture.  Usually  the 
infection  is  a  mixed  one.  Very  seldom  is  the  Welch  bacillus  found  alone.  The 
streptococcus  is  the  organism  most  often  found  with  the  Bacillus  of  Welch. 
We  may  find  the  diplococcus,  the  bacillus  sporogens,  the  bacillus  perfringens, 
the  bacillus  proteus  or  other  micro-organisms.  There  are  various  strains  of 
the  Welch  bacillus.  The  Bacillus  aerogenes  capsulatus  and  the  Bacillus  per- 
fringens belong  to  different  strains  of  the  same  organism.  The  Bacillus  per- 
fringens and  the  Bacillus  aerogenes  capsulatus  proliferate  much  more  rapidly 
when  grown  in  symbiosis  with  Bacillus  proteus,  Bacillus  pyocyaneus,  strepto- 
coccus, staphylococcus,  and  diphtheroid  bacilli  (Douglas,  Fleming  and  Cole- 
brook,  in  Lancet,  April  21,  1917).  Legros  (.Presse  Med.,  Feb.  19,  1917)  found 
the  Bacillus  perfringens  with  the  Bacillus  edematiens  in  a  case  of  gas  gan- 
grene with  edema. 

In  4  per  cent,  of  cases  the  bacillus  of  malignant  edema  is  the  cause  (Wein- 
berg, in  "Glasgow  Med.  Jour.,"  1916,  Ixxxv).  The  various  organisms  named 
above  may  be  found  in  certain  soils,  in  animal  and  human  feces,  in  street  dirt  and 
in  the  dust  of  floors.  Three  classes  of  wounds  are  especially  predisposed: 
crushes  with  breach  of  surface  continuity,  punctures  with  much  blood  extra- 
vasation and  lacerations  with  much  hopelessly  damaged  tissue.  The  condition 
sometimes  follows  slight  wounds  but  the  wounds  are  usually  extensive. 
Lacerations  of  muscle  are  especially  dangerous.  Wallace  (Brit.  Med.  Jour., 
June  2,  191 7)  and  others  assert  that  gas  gangrene  is  first  of  all  and  chiefly  a 
disease  of  muscle.  Great  numbers  of  the  sufferers  from  compound  fractures 
have  fallen  victims  to  the  infection.  Lodged  foreign  bodies  are  often  actively 
causal,  a  rifle  bullet  much  less  powerfully  so  than  a  piece  of  shrapnel  case.  A 
shell  fragment  is  most  dangerous.  A  portion  of  clothing  carried  into  the  tissues 
is  highly  dangerous. 

In  most  of  the  wounded  from  the  trenches  the  discharge  contains  the 
causal  bacteria  although  in  many  there  may  be  no  clinical  evidence  of  the 
infection  and  in  many  of  these  cases  prompt  treatment  prevents  disastrous 
consequences.  Taylor  says  that  the  gas  bacillus  is  found  in  70  per  cent,  of 
the  wounded  ("Treatment  of  War  Wounds,"  by  W.  W.  Keen)  and  Fleming 
found  it  in  103  wounds  out  of  127  ("Lancet,"  Sept.  18,  1915).  In  trench 
warfare  every  wound  is  to  be  regarded  as  containing  it  and  the  surgeon  acts 
in  accordance  with  this  belief. 

The  bacteria  of  gas  infection  grow  with  frightful  activity.  Sir  Anthony 
Bowlby  saw  gas  five  hours  after  the  infliction  of  the  wound  and  saw  gangrene 
of  an  entire  lower  extremity  and  death  in  sixteen  hours.  I  have  seen  gangrene 
of  an  entire  lower  extremity  and  death  in  thirty-six  hours.  But  such  great 
rapidity  of  progress  is  not  the  rule.  Signs  of  infection  are  not  met  with  in 
most  cases  until  between  ten  and  thirty  hours  after  the  wounding.  The  .r-rays 
will  show  bubbles  of  gas  in  the  tissues  even  before  infection  is  made  manifest 
by  clinical  signs.  Savill  maintains  that  the  appearance  of  the  radiograph 
not  only  indicates  gas  in  the  tissues,  its  situation  and  diffusion,  but  also  the 
variety  of  infection,  viz.,  pure  Bacillus  perfringens,  or  Bacillus  perfringens 
and  sporogenes,  etc.  (Quoted  in  Brit.  Med.  Jour.,  March  3,  191 7,  from  Archiv. 
Radiol,  and  Elec).  Infection  without  gas  bubbles  will  not  show  on  the  plate. 
Between  thirty-six  and  forty-eight  hours  the  clinical  signs  become  marked  and 
positive.  The  infection  does  not  seem  to  start  in  the  subcutaneous  tissue.  It 
starts  in  the  muscular  tissue.     If  gas  appears  in  the  subcutaneous  tissue  it 


i86 


Mortification,  Gangrene,  or  Sphacelus 


does  not  form  there  but  reaches  there  from  the  muscle  (Frankan,  Drummoncl, 
and  Neligan  in  Brit.  Med.  Jour.,  June  2,  1917).  The  infection  spreads  within 
muscle  sheaths  and  along  fascial  planes  with  very  great  rapidity,  and  muscles 
tend  particularly  to  become  gangrenous.  The  rapidity  of  spread  is  explained 
by  the  structure  of  the  muscles.  The  sheaths  of  individual  fibers  are  easily 
detached  and  when  detached  form  spaces  along  which  toxic  matter  passes  to 
cause  necrosis  of  the  fibers  (Wallace,  in  Brit.  Med.  Jour.,  June  2,  191 7.     (The 


Fig.  91. — Showing  a  gas-bacillus  infection  of  a  mutilating  shoulder  wound,  due  to  a  high- 
explosive  shell  fragment  and  accompanied  by  necrotic  infiltration  of  a  large  part  of  the  chest 
wall,  which  proved  fatal.  The  patient  was  received  5  days  after  injury  and  the  necrotic 
material  was  removed,  followed  by  a  continuous  irrigation.  (By  courtesy  of  the  Harvard 
unit)  (Fauntleroy,  Report  on  the  Medico- Military  Aspect  of  the  European  War). 

process  ascends  and  descends  the  damaged  muscle.  A  muscle  or  a  group  of 
muscles  becomes  involved.  Infection  is  not  apt  to  spread  to  adjacent 
muscles.  In  a  great  majority  of  cases  the  infection  is  in  the  lower  extremity. 
The  region  most  liable  is  the  buttock  and  then,  in  order,  come  the  thigh,  the 
leg,  the  arm,  the  forearm  and  the  foot.     The  hand  is  seldom,  the  face,  neck, 


Fig.  92. — Fatal  case  of  gas-bacillus  infection  of  the  arm  and  forearm,  following  a  high 
explosive  shell  wound  of  upper  arm.  Patient  received  five  days  after  injury  and  an  immediate 
amputation  performed  at  shoulder  joint  (Fauntleroy,  Ibid.). 

chest,  abdomen  and  scalp  are  very  seldom  attacked  (see  "  Report  of  the  Medico- 
MiHtary  Aspects  of  the  European  War,"  by  Surgeon  A.  M.  Fauntleroy, 
U.  S.  N.).  Bowlby  never  saw  it  in  the  head.  The  apparent  immunity  of  cer- 
tain regions  is  thought  to  be  due  to  their  excellent  blood  supply.  The  blood 
maintains  tissue  resistance  and  by  its  ox}'gen  inhibits  the  growth  of  anaerobic 
micro-organisms.  Mixed  infection  by  aerobes  (staphylococci,  streptococci, 
etc.)  adds  greatly  to  the  danger  because  these  bacilli  appropriate  oxygen  and 
anaerobes  grow  without  restraint.     In  a  wound  dead  tissue  and  foreign  bodies, 


Gas  Infection  and  Gas  Gangrene  187 

especially  bits  of  clothing,  are  great  dangers  (Tissier,  "Ann.  Inst.  Pas- 
teur," Dec,  1916).  Lacerated  wounds  with  much  hopelessly  damaged  tissue 
and  punctured  wounds  with  great  blood  extravasation  are  the  most  usual  seats 
of  infection. 

Weinberg  ("Glasgow  Med.  Jour.,"  1916,  Ixxxv)  is  so  impressed  with  the 
value  of  good  blood  supply  in  antagonizing  the  growth  of  anaerobes  that  he 
asserts  gangrene  does  not  occur  unless  the  main  vessel  or  vessels  of  the  limb 
are  occluded.  Few  agree  with  this  contention  although  all  would  admit  that 
if  the  vessels  are  occluded  gangrene  will  appear  early  and  be  most  rapid  in 
progress. 

Infections  were  always  more  numerous  in  rainy  weather  because  the  soldiers 
when  struck  were  covered  with  the  mud  of  the  trenches. 

As  the  bacilU  grow  in  the  tissues  they  form  gas  and  also  poisons  of  enormous 
potency  and  these  poisons  ^\ith  gas  enter  the  blood.  Two  poisons  are  formed, 
one  a  hemolysin  causing  blood  destruction,  the  other  acting  locally  and  causing 
edema  and  necrosis  (Bull  and  Pritchett,  in  "Jour,  of  Exper.  Med.,"  July,  1917). 
Until  late  in  the  case  the  blood  does  not  contain  the  bacteria  but  in  what  we 
call  the  septicemic  state  does  contain  them.  They  are  found  in  the  wound 
discharge  in  the  first  few  hours  of  the  infection,  can  be  found  before  there  are 
any  clinical  signs  of  infection,  and  have  been  found  in  many  cases  which  never 
developed  clinical  signs  of  the  infection  because  the  treatment  was  efl&cient. 

Gas  enters  the  blood  and  it  is  probable  that  the  presence  of  gas  in  the 
blood  explains  the  sudden  deaths  which  are  not  uncommon  in  gas  infections. 

In  from  ten  to  twenty  hours  after  the  injury  the  pulse  begins  to  rise,  the 
temperature  mounts  a  degree  or  two.  As  yet  there  is  little  swelling  and  prac- 
tically no  pain.  The  skin  about  the  wound  shows  a  light  coppery  hue.  The 
wound  discharge  is  brownish  in  color,  contains  the  causal  bacteria,  and  is 
somewhat  foul  in  odor.  Gas  formation  is  already  taking  place,  bubbles  may  be 
seen  in  the  discharge  and  will  be  seen  certainly  in  the  wound  if  free  incisions 
are  made.  If  the  infection  is  not  arrested  promptly  it  will  develop  rapidly, 
and  all  the  symptoms  will  be  intensified.  By  the  period  of  forty-eight  hours 
from  the  accident  great  changes  in  the  tissues  have  begun.  The  pulse  becomes 
very  rapid.  The  temperature  rises  but  not  at  first  to  a  degree  which  would 
correspond  to  the  pulse.  In  a  day  or  two,  however,  the  temperature  becomes 
io4°-io5°.  The  discharge  now  stinks.  Great  swelling  occurs,  partly  edema- 
tous, partly  gaseous.  The  gas  causes  the  parts  to  crepitate  on  pressure.  In 
some  cases  edema  is  so  great  as  to  mask  crepitation. 

Around  the  wound  is  an  area  of  induration  and  the  skin  about  the  wound 
becomes  coppery,  brown,  or  purple.  There  is  usually  violent  pain  in  the  wound 
and  backache  and  headache  are  often  prominent  symptoms.  The  expression 
is  dull  and  listless  and  there  is  commonly  wandering  delirium.  Vesicles  soon 
crop  up  on  the  skin  near  the  wound.  The  fluid  of  the  bHsters  may  or  may 
not  contain  the  bacteria. 

After  one,  two  or  three  days  of  this  state  septicemia  develops.  The  bac- 
teria have  now  entered  the  blood  and  the  case  is  hopeless.  The  pulse  rises 
and  the  temperature  falls.  The  pulse  is  rapid  and  weak,  the  respirations  are 
shallow,  stupor  deepens  into  coma,  if  sudden  death  does  not  occur  from  gas 
embolism  the  comatose  patient  \\ill  pass  into  collapse  with  subnormal  tem- 
perature and  thus  will  the  tragedy  terminate. 

Treatment. — Early  and  radical  treatment  is  imperative.  If  the  discharge 
contains  the  bacilli  but  there  are  no  clinical  symptoms  removal  of  foreign 
bodies  and  dead  tissue,  free  incision,  sterilization  of  the  wound  mth  iodin  or 
solution  of  h>^ochlorous  acid  (0.5  per  cent.),  drainage  or  the  use  of  Dakin's  fluid 
will  almost  certainly  prevent  the  development  of  the  disease.  During  the  first 
twenty-four  hours  after  the  injury  when  symptoms  have  just  begun,  free  in- 
cision" extirpation  of  every  muscle  the  fibers  of  which  do  not  respond  to  external 
stimulus  (Debridement),  opening  up  of  every  pocket,  removal  of  foreign  bodies 


i88  Mortification,  Gangrene,  or  Sphacelus 

and  the  use  of  the  Carrcl-Dakin  tcchnic  will  save  most  cases.  During  the 
first  forty-eight  hours  this  plan  will  save  many  cases.  The  widest  extirpation 
of  infected  muscle  and  damaged  muscle  is  imperative. 

In  more  advanced  cases  if  free  incisions,  extirpations  of  necrotic  muscles  and 
other  tissues,  the  Carrel-Dakin  treatment  fail,  amputation  will  be  necessary. 
In  rapidly  advancing  cases  amputation  is  the  only  chance.  When  amputation 
has  been  performed,  if  not  a  guillotine  amputation,  suture  the  llaps  back  to 
sound  skin  so  as  to  keep  them  wide  open  and  leave  the  wound  exposed  to  the 
air.  Injecting  peroxid  of  hydrogen  into  the  tissue  about  an  area  of  gas  in- 
fection has  been  tried  but  is  not  to  be  commended.  Inhalations  of  oxygen 
are  thought  to  be  of  service. 

Weinberg  (Ibid.)  believes  that  the  polyvalent  serum  of  Leclainche-Vallee  is 
valuable  in  treatment  especially  if  streptococci  are  present,  and  that  an  auto- 
vaccine  should  be  made  of  all  the  organisms  found  in  the  wound.  An 
antitoxic  serum  to  prevent  and  treat  gas  gangrene  is  prepared  by  Bull  and 
Pritchett  ("Jour.  Exper.  Med.,"  July,  191 7).  They  suggest  that  a  preventive 
dose  be  given  to  all  wounded  men  at  the  first  dressing  station.  In  the  early 
days  of  the  war  the  mortality  from  gas  gangrene  was  frightful.  The  importance 
of  early  treatment  and  the  necessity  for  radical  action  were  not  fully  appre- 
ciated. Many  cases  were  not  radically  treated  until  they  reached  base 
hospitals,  which  often  meant  a  delay  of  five  or  six  days.  The  improvement  in 
transport  now  gets  them  to  a  base  much  sooner.  The  earlier  and  the  more 
radical  the  treatment  the  better  the  prognosis.  The  mortality  in  cases  in 
which  gangrene  appeared  within  the  first  twenty-four  hours  after  injury  has 
been  at  least  50  per  cent.,  in  those  in  which  it  appeared  in  from  twenty-four 
to  seventy-two  hours,  ^t,  per  cent.  (Chalier,  in  Presse  Med.,  March  22,  191 7). 

Hospital  gangrene  or  sloughing  phagedena  is  a  disease  that  has  practically 
disappeared  from  civilized  communities.  The  last  case  seen  in  Guy's  Hos- 
pital was  in  1849  (Bryant's  Practice  of  Surgery).  It  formerly  occurred  with 
dreadful  frequency  among  the  wounded  in  crowded,  ill-ventilated  hospitals,  in 
camps  and  on  war  vessels.  There  were  many  cases  during  the  Arherican  Civil 
war.  At  times  it  would  sweep  through  a  hospital  with  a  frightful  toll  of  deaths. 
Such  outbreaks  lead  Ponteau  to  wonder  if  hospitals  were  not  a  curse.  The  first 
distinct  description  of  it  will  be  found  in  the  posthumous  works  of  Ponteau  of 
Lyons,  published  in  1783.  He  christened  the  condition  hospital  gangrene. 
Some  consider  it  traumatic  diphtheria.  Koch  thinks  it  is  due  to  streptococci. 
Jonathan  Hutchinson  says:  "Hospital  gangrene  is  set  up  by  admitting  to  the 
wards  a  case  of  syphilitic  phagedena."  It  may  show  itself  as  a  diphtheritic 
condition  of  a  wound,  as  a  process  in  which  sloughs  which  look  like  masses  of 
tow  form,  or  as  a  phagedenic  ulceration.  The  surrounding  parts  are  inflamed 
and  painful,  and  buboes  form  in  adjacent  lymphatic  glands.  The  system  passes 
into  a  low  septic  state.  Unlike  gas  gangrene,  the  muscles  resist  infection. 
Delirium  is  common.  There  is  no  formation  of  gas.  The  prognosis  is  most 
grave.  Surgeon  General  Sir  G.  H.  Makins  says  that  in  the  present  war  "hos- 
pital gangrene  of  the  classical  types  has  been  conspicuous  only  by  its  absence; 
during  a  period  of  two  and  a  half  years  I  have  only  seen  one  or  two  cases 
which  seemed  to  resemble  the  spongy  form,  although  the  membranous  type  has 
been  occasionally  seen"  ("Lancet,"  Feb.  17,  1917). 

Treatment. — In  treating  hospital  gangrene  ether  should  be  given,  the  large 
sloughs  removed  with  scissors  and  forceps,  the  parts  dried  with  gauze  and 
cauterized  with  fuming  nitric  acid  or  bromin.  The  wound  should  be  plenti- 
fully sprinkled  with  iodoform  and  dressed  with  hot  antiseptic  fomentations. 
When  the  sloughs  separate  the  sore  can  be  treated  as  an  ordinary  ulcer.  The 
constitutional  treatment  is  that  employed  for  sepsis.  In  many  cases  amputa- 
tion is  indicated. 

Special  Forms  of  Gangrene. — Raynaud's  disease  may  be  responsible  for 
symmetrical    gangrene.     Raynaud's  disease   (Fig.   93)   was  first   described  as. 


Rg-ynaud's  Disease  "  189 

a  distinct  malady  by  Maurice  Raynaud  in  1862  (L'Asphyxie  locale,  Paris,  1862). 
It  is  usually  regarded  as  a  vasomotor  neurosis,  is  seen  particularly  in  children 
and  young  female  adults,  but  is  sometimes  met  with  in  men.  Chlorotic  and 
hysterical  women  seem  more  apt  than  others  to  suffer  from  it.  The  condition 
is  much  commoner  in  winter  than  in  summer,  and  cold  seems  to  be  an  exciting 
cause.  The  well-known  chilblain  is  an  area  of  local  asphyxia.  The  essential 
cause  of  Raynaud's  disease  is  uncertain.  In  some  acute  cases  associated  with 
fever,  albuminuria,  and  splenic  enlargement  it  seems  to  be  a  part  of  an  acute 
infectious  disease.  It  can  occur  in  a  variety  of  toxic  conditions  and  in  a  num- 
ber of  infectious  diseases  (typhoid  fever,  for  instance).  It  may  develop  in  the 
course  of  gout  and  also  of  diabetes.  In  many  cases  neuritis  exists;  in  some 
there  is  either  obliterative  endarteritis  or  angiothrombosis  of  the  larger 
peripheral  vessels.  Some  cases  seem  to  be  purely  hysterical.  The  fact  that 
attacks  of  Raynaud's  disease  are  sometimes  accompanied  by  hemoglobinuria 
has  suggested  malaria  as  a  possible  cause.  Raynaud's  disease  is  characterized 
by  attacks  of  cold,  dead  bloodlessness  in  the  fingers  or  toes  as  a  result  of 
exposure  to  cold  or  of  emotional  excitement  {local  syncope).    In   the  more 


Fig.  93- — Ra5aiaud's  disease  (Horwitz). 

severe  cases  there .  are  capillary  congestion  and  mottled,  livid  swelling  {local 
asphyxia).  A  case  may  begin  with  attacks  of  local  syncope,  and  after  a 
longer  or  shorter  time  get  instead  attacks  of  local  asphyxia.  Attacks  may  be 
occasional  and  far  apart,  may  be  frequent,  or  the  condition  of  "dead"  blood- 
lessness or  asphyxia  may  be  almost  continuous.  In  some  cases  they  only  occur 
in  winter;  in  others  the  slightest  chill  develops  them.  The  patient  complains 
of  pain,  tingling,  numbness,  coldness,  and  stiffness  in  the  affected  parts.  In  some 
few  cases  the  skin  of  the  face  or  trunk  is  attacked.  Local  syncope  is  thought 
to  be  due  to  vascular  spasm,  and  local  asphyxia  to  some  contraction  of  the 
arterioles,  with  dilatation  of  the  capillaries  and  venules.  It  is  after  local 
asphyxia  that  gangrene  may  appear.  Attacks  of  Raynaud's  disease  occur 
again  and  again,  and  may  never  eventuate  in  gangrene. 

Raynaud's  disease  is  seldom  fatal  and  is  often  recovered  from. 

Ever  since  Raynaud's  day  it  has  been  generally  maintained  that  the  attacks 
are  always  symmetrical  and  that  the  blood-vessels  are  not  diseased.  We  now 
know  that  many  cases  are  successive  but  not  symmetrical  in  the  beginning, 
and  that  some  never  become  symmetrical.  This  is  especially  true  in  the  lower 
extremities.     It  has  been  shown  of  recent  years  that  cases  of  thrombotic  block- 


igo 


Mortification,  Gangrene,  or  Sphacelus 


ing  of  the  larger  arteries  of  the  legs  exhibit  symptoms  of  Raynaud's  disease 
before  gangrene  occurs,  and  that  cases  of  Raynaud's  disease  of  the  feet  and  of 
erythromelalgia  are  apt  to  suffer  from  vascular  thrombosis  and  gangrene  from 
this  cause. 

Raynaud's  gangrene  (Fig.  94)  is  a  dry  gangrene  and  is  most  commonly  met 
with  upon  the  ends  of  the  lingers  or  the  toes,  but  it  may  attack  the  lobes  of  the 
ears,  the  tip  of  the  nose,  or  the  skin  of  the  arms  or  the  legs.  Sometimes  the 
disease  is  seen  upon  the  trunk.  The  gangrene  may  be  symmetrical  from  the 
beginning,  may  be  successive,  or  may  remain  asymmetrical.  Certain  it  is  that 
many  cases  which  we  formerly  regarded  as  clear  cases  of  Raynaud's  disease  of 
the  lower  extremities  develop  gangrene,  due  either  to  obliterative  endarteritis 
or  angiothrombosis  (see  page  177).     In  such  cases  there  is  usually  violent  pain 

for  weeks  or  months  before  gangrene 
begins,  and  in  large  arteries  well  above 
the  lesion  the  pulse  is  not  detectable. 
When  genuine  Raynaud's  gangrene  is 
about  to  occur  the  local  asphyxia  at 
that  point  deepens,  anesthesia  be- 
comes complete,  and  the  part  black- 
ens and  feels  cold  to  the  touch.  The 
epidermis  adjacent  to  the  gangrene 
may  be  raised  into  blebs  which  rup- 
ture and  expose  dry  surfaces.  A  line 
of  demarcation  forms,  and  the  ne- 
crosed area  is  removed  as  a  slough. 
During  all  of  this  process  the  pulse 
is  still  detectable  above  the  lesion. 
Widespread  gangrene  from  pure  Ray- 
naud's disease  is  rare;  there  is  not 
often  an  extensive  area  involved — 
rather  a  small  superficial  spot. 

Treatment  of  Raynaud's  Disease 
and  of  Raynaud's  Gangrene. — If  an 
individual  suffers  from  attacks  of 
Raynaud's  disease,  every  effort 
should  be  made  to  improve  the 
general  health  and  to  avoid  chilling 
the  surface  of  the  body.  During 
ihe  attack  employ  gentle  massage, 
place  the  extremity  in  warm  water, 
and,  if  pain  is  severe,  give  morphin 
hypodermatically.  Amyl  nitrite  is 
without  value  in  this  condition. 
When  attacks  of  Raynaud's  disease 
are  so  severe  as  to  threaten  gan- 
grene, put  the  patient  to  bed;  if  the  feet  are  attacked,  elevate  the  legs 
slightly,  wrap  the  affected  extremities  in  cotton-wool,  and  apply  warmth. 
If  the  hands  are  affected,  wrap  them  in  cotton-wool,  elevate  them  slightly, 
and  apply  warmth.  Massage  is  useful.  Arteriovenous  anastomosis  has  been 
employed  for  threatened  gangrene,  and  several  apparent  successes  have  been 
reported  (see  page  179).  When  gangrene  occurs,  dress  the  part  antiseptically 
until  a  line  of  demarcation  forms,  and  then  remove  the  dead  parts  by  scissors, 
forceps,  and  antiseptic  fomentations.  If  amputation  becomes  necessary,  wait 
for  a  line  of  demarcation.  In  gangrene  of  a  toe,  toes,  or  foot  due  to  angio- 
thrombosis or  obliterative  endarteritis,  amputation  is  always  necessary.  The 
terrible  pain  calls  for  it,  and  even  if  the  gangrenous  area  is  very  small  it  is  cer- 


FiG.  94. — Raynaud's  gangrene.  Patient  has 
lost  most  of  the  terminal  phalanges  of  the  fingers 
and  also  the  left  leg.  Right  leg  was  ampu- 
tated soon  after  this  picture  was  taken.  (Patient 
of  Dr.  T.  E.  Wannamaker,  Jr.,  of  Cheraw,  S.  C.) 


Diabetic  Gangrene  and  Diabetic  Coma  igi 

tain  to  spread  or  new  areas  are  sure  to  arise.  This  form  of  gangrene  has  been 
treated  by  several  surgeons  by  anastomosing  the  femoral  vein  to  the  femoral 
artery.  Several  times  this  operation  seems  to  have  proved  successful.  In  an 
advanced  case  with  thrombosed  veins  it  cannot  succeed  (see  page  179). 

Diabetic  gangrene  often  resembles  strongly  senile  gangrene,  but  in  many 
cases  the  dead  portions  remain  somewhat  moist  and  putrefy.  Some  surgeons 
attribute  it  directly  to  the  sugar  in  the  blood.  Some  think  diabetes  causes 
gangrene  indirectly  by  rendering  the  tissues  less  resistant  to  infection  and  less 
capable  than  normally  of  repair.  We  know  that  sugar  in  blood  removes  fluid 
from  the  tissues  and  causes  wound  fluids  to  contain  sugar.  Hence  wound  fluids 
become  excellent  culture-media  and  body  cells  lose  resisting  power  (see  Morris, 
page  126).  There  is  a  great  deficiency  of  oxygen  in  the  tissues,  which  probably 
predisposes  to  infection  (Lockwood,  in  "Lancet,"  February  10,  191 2).  The 
frequency  in  diabetes  of  boils,  carbuncles,  and  spreading  suppuration  indicates 
lessened  resistance  to  infection,  and  any  infected  area  may  become  gangrenous. 
If  phthisis  exists  or  arises  in  a  diabetic  it  develops  with  fearful  speed  toward 
a  fatal  issue.  J.  C.  DaCosta,  Jr.,  and  Beardsley  demonstrated  that  diabetic 
blood-serum  shows  a  lowered  opsonic  index  for  tubercle  bacilli,  staphylococci, 
and  streptococci.  It'  is  an  interesting  fact  in  this  connection  that  the  blood- 
serum  of  a  pancreatectomized  dog  has  a  very  low  bactericidal  power.  Some 
hold  that  diabetic  gangrene  is  of  neurotic  origin,  being  the  result  of  nerve  de- 
generation. Certain  it  is  that  some  few  cases  present  symptoms  resembling 
those  of  Raynaud's  disease.  Heidenhain  believes  that  it  is  due  to  arterial 
sclerosis.  That  most  of  the  victims  of  diabetic  gangrene  suffer  from  arterio- 
sclerosis is  certain.  It  seems  probable  that  the  gangrene  is  due  to  infection  of 
tissue  predisposed  to  infection  by  the  presence  of  sugar  and  lessened  amount 
of  oxygen,  and  weakened  by  changes  in  the  nerves  and  blood-vessels.  Diabetic 
gangrene  is  most  usually  met  with  upon  the  feet  and  legs  of  elderly  people,  but 
it  may  arise  at  any  age  and  may  attack  the  genital  organs,  thigh,  lung,  buttock, 
eye,  back,  finger,  or  neck.  It  may  affect  only  a  single  area,  may  attack  several 
areas,  or  may  be  symmetrical.  It  may  arise  in  any  stage  of  diabetes,  from  the 
earliest  to  the  latest.  It  may  begin  as  a  perforating  ulcer.  It  may  attack  a 
wound.  It  is  much  more  common  in  men  than  in  women.  There  are  clearly 
two  forms  of  this  condition.  In  one  there  is  a  slowly  progressive,  fairly  dry 
gangrene,  probably  due  chiefly  to  arterial  sclerosis.  In  such  a  case  a  small, 
dry,  dead  patch  sometimes  lasts  months  before  spreading  begins.  As  in  senile 
gangrene,  a  trivial  injury  is  apt  to  be  the  exciting  cause.  In  such  a  case  the 
urine  contains  sugar  and  perhaps  albumin,  but  seldom  either  acetone  or  diacetic 
acid.  In  the  other  form  an  injury,  perhaps  a  trivial  one,  is  followed  by  a 
rapidly  spreading  cellulitis,  which  seldom  forms  pus  and  which  eventuates  in 
moist  gangrene.  In  such  a  case  the  urine  is  apt  to  contain  acetone  and 
diacetic  acid  and  there  is  grave  danger  of  coma.  When  the  gangrene  follows- 
a  traumatism  there  are  no  prodromal  symptoms.  When  it  arises  sponta- 
neously in  the  skin,  it  is  often  preceded  by  pain  of  a  neuralgic  nature  and 
attacks  of  "livid  or  violaceous  discoloration  of  the  skin,  with  lowered  surface 
temperature  and  sometimes  loss  of  sensation"  (EUiot).  In  diabetic  gan.grene 
of  an  extremity  the  pain  is  often  most  violent,  due  probably  to  neuritis  In 
fact,  neuritis  may  precede  the  gangrene.  Diabetic  gangrene  is  often  superficial, 
but  may  become  deep  if  it  follows  an  injury  or  ulceration.  Many  of  these 
patients  are  cyanosed  (Lockwood,  in  "Lancet,"  February  10,  1912).  A  suf- 
ferer from  diabetic  gangrene  is  Hable  to  cardiac  failure,  collapse,  and  coma. 

Diabetic  coma  (Kussmaurs  coma)  is  an  acid  intoxication  due  to  accumula- 
tion  in  the  blood  of  acids  which  do  not  belong  there.  It  has  been  generally 
stated  that  the  chief  agent  is  beta-oxybutyric  acid,  that  acid  gathers  in  the  blood, 
because  of  lack  of  proper  oxidation^  that  diacetic  acid  is  formed  from  beta-oxy- 
butyric acid,  and  that  the  breaking  up  of  diacetic  acid  in  the  urine  forms  acetone 


192  [Mortification,  Gangrene,  or  Sphacelus 

and  carbon  dioxid.  Hence,  acetonuria  means  acidosis.  Some  blame  the 
ketone  bodies,  others  the  acid  phosphates  for  acidosis.  Among  the  theories 
of  acidosis  the  most  striking  is  that  of  Crile  ("Annals  of  Surgery,"  September, 
191 5).  It  is  founded  upon  a  series  of  brilliantly  conceived  and  carefully  con- 
ducted experiments.  Crile  points  out  that  acidity  is  fatal  to  the  life  of  a  plant. 
The  blood  of  animals  is  alkaline  and  even  a  trivial  diminution  in  its  alkalinity, 
if  persistent,  is  fatal.  Alkalis  and  bases  must  be  broken  down  to  furnish  the 
energy  for  muscular  action  and  heat,  and  when  they  break  down  acids  must  be 
set  free.  How  are  these  acids  eliminated?  Carbon  dioxid  is  eliminated  by  the 
lungs.  An  increase  of  carbon  dioxid  causes  an  increased  output  of  adrenin 
(which  dilates  the  alae  nasi,  bronchioles  and  air  vesicles),  and  increased  activity 
of  the  respiratory  center  (which  controls  the  "rate  and  amplitude"  of  respira- 
tion). An  increased  output  of  adrenin  is  caused  by  emotion,  overexertion 
anesthesia,  injury,  surgical  shock,  auto-intoxication.  Graves'  disease,  infection, 
strychnin  poisoning,  injections  of  indol,  amido-acids  and  foreign  proteins  and 
by  certain  other  things.  (Cannon,  Crile,  Magnus,  Elliot).  These  elements  are 
called  activators,  and  when  they  act  they  cause  an  increased  formation  of  acid 
by-products,  gaseous  and  in  solution. 

The  brain  controls  the  adrenals.  If  the  path  between  the  brain  and  adre- 
nals is  severed  or  if  the  brain  function  is  depressed  or  suspended  by  morphia, 
activation  of  the  adrenals  causes  no  increase  in  the  output  of  adrenin.  The 
respiratory  center  is  governed  by  the  hydrogen  ion  concentration  of  the 
blood. 

Crile  states  that  it  thus  becomes  evident  that  the  mechanism  for  the  elimina- 
tion of  acid  by-products  that  are  gaseous  consists  of  the  brain,  the  adrenals  and 
the  lungs,  and  the  carbon  dioxid  is  the  stimulant  of  this  mechanism.  It  is 
known  that  when  carbon  dioxid  is  injected  into  a  normal  man  there  is  an  in- 
crease in  the  output  of  adrenin  and  an  increase  of  respiratory  activity.  Acid 
by-products  which  are  in  solution  in  the  body  fluids  should  be  eliminated  by  the 
kidneys  and  the  sweat-glands.  Crile  points  out  that  when  these  by-products 
are  first  formed  they  are  not  in  forms  permitting  elimination.  They  must  first 
be  transformed  into  salts  which  do  not  damage  the  kidneys  (phosphates,  chlo- 
rids,  sulphates,  urea,  creatin  and  creatinin) ;  that  the  brain,  the  adrenals  and  the 
liver  are  especially  concerned  in  effecting  this  transformation,  and  the  brain  is 
the  governor  of  the  mechanism  which  accomplishes  neutralization  of  acid  by- 
products in  the  body  fluid.  When  these  acid  by-products  are  not  transformed, 
in  other  words,  are  not  put  in  proper  form  for  solution,  the  condition  of  acidosis 
exists.  Acetone  is  found  in  the  urine  when  carbohydrates  are  not  taken  in  suffi- 
cient quantity  or  are  not  assimilated  by  the  tissues.  Diabetic  coma  may  be  seen 
at  any  age  but  is  most  often  seen  in  young  diabetics.  It  may  arise  after  shock, 
excitement,  general  anesthesia  by  ether  or  chloroform  (page  1348),  or  exhaustion. 
After  many  surgical  operations  some  acetone  can  be  detected  in  the  urine 
(Brodner  and  Reimann,  "Am.  Jour.  Med.  Sciences,"  1915,  cl).  Coma  in  acid 
intoxication  commonly  comes  on  rapidly,  with  vomiting,  abdominal  pain,  weak- 
ness, restlessness,  and  drowsiness,  which  soon  passes  into  coma.  In  some  cases 
it  is  ushered  in  by  collapse,  in  others  by  confusion  of  thought  and  speech,  in  still 
others  by  delirium  or  even  mania.  In  coma  the  respiration  is  usually  deep, 
rapid  and  may  be  sighing.  The  pulse  is  small,  of  low  tension,  and  very  rapid 
and  weak.  The  face  is  pale  until  the  patient  is  near  death  when  it  may  become 
cyanotic.  The  urine  is  scanty  and  albuminous.  Urinary  suppression  may 
occur.  The  temperature  becomes  subnormal,  although  during  the  onset  it  may 
be  elevated  and  it  may  rise  before  death.  The  breath  smells  of  acetone.  The 
odor  of  acetone  on  the  breath  has  been  compared,  according  to  the  taste  and 
fancy  of  the  comparer,  to  all  sorts  of  odors  from  that  of  rotten  apples  to  that  of 
new  mown  hay.  Some  compare  it  to  sour  beer,  some  to  chloroform,  some  to 
violets.     In  truth  acetone  on  the  breath  has  the  smell  of  acetone,  a  fact  which  we 


Diabetic  Gangrene  and  Diabetic  Coma  193 

might  infer.  The  patient  Ues  quietly  in  bed,  and  the  pupils  are  dilated.  In 
from  twenty-four  to  forty-eight  hours,  as  a  rule,  the  patient  dies.  Death  may 
be  preceded  by  convulsions. 

Never  fail  to  examine  carefully  the  urine  in  every  surgical  case  and  espe- 
cially in  every  case  of  gangrene,  because  diabetes  or  acidosis  may  exist  when 
least  suspected.  If  albumin  is  present  in  the  urine  of  a  diabetic  it  means 
increased  peril;  if  casts  are  found  the  prognosis  is  still  worse.  In  such  a  case 
uremic  coma  may  occur  and  be  mistaken  for  diabetic  coma.  The  treatment 
before  and  after  operation  if  acidosis  exists  is  indicated  on  page  79. 

Treatment  of  Diabetic  Coma. — Diabetic  coma  is  treated  by  purgation. 
Purgatives  may  be  given  by  the  mouth  if  the  patient  can  swallow  (and  swallow- 
ing is  usually  possible)  or  enemata  may  be  given.  It  is  usually  difficult  to 
move  the  bowels.  An  enema  of  sodium  bicarbonate  should  be  given  every 
hour  (half  an  ounce  of  sodium  bicarbonate  in  half  a  pint  of  warm  water).  The 
sodium  bicarbonate  should  also  be  given  by  the  stomach  (if  swallowing  is 
possible),  by  hypodermoclysis  or  by  hypodermatic  injection.  For  intravenous 
use  employ  an  aqueous  solution  containing  5  j  or  5ij  of  sodium  bicarbonate  to  the 
pint  of  water.  The  same  solution  may  be  used  for  hypodermoclysis.  Austin 
points  out  ("Penna.  Med.  Jour.,"  Feb.,  1917)  that  the  acid  bodies  are  not  the 
same  in  all  cases.  "In  starvation,  on  a  protein-fat  diet,  in  diabetes  melhtus 
and  in  surgical  anesthesia,  they  are  chiefly  the  ketone  bodies,  the  same  is 
probably  true  of  most  of  the  severe  intoxications  of  childhood. "  Austin  is  of 
the  opinion  that  in  nephritis  and  the  severe  diarrheas  of  children,  acid  phos- 
phates are  mainly  responsible. 

Treatment  of  Diabetic  Gangrene  of  Foot. — When  a  part  is  threatened  wdth 
diabetic  gangrene  superheated  air  should  be  tried  and  it  may  be  tried  even  when 
gangrene  begins  if  the  process  is  slow  in  development  and  occupies  but  a  limited 
area.  Treatment  must  be  adopted  to  remove  sugar  from  the  blood.  This  treat- 
ment is  by  diet  and  by  drugs. 

When  gangrene  arises  rigid  treatment  by  drugs  and  diet  is  of  immense  im- 
portance, may  arrest  the  process,  may  at  least  retard  it  and  will  add  to  the 
prospect  of  success  offered  by  a  surgical  operation.  Most  surgeons  had  grown 
very  shy  of  amputating  for  diabetic  gangrene  until  Kiister,  of  BerHn,  warmly 
advocated  amputating  above  the  knee  without  waiting  for  a  Hne  of  demarca- 
tion. He  showed  that  if  amputation  is  performed  below  the  knee,  the  flaps 
will  become  gangrenous,  and  that  after  high  amputation  sugar  may  disappear 
from  the  urine.  Of  11  amputations  by  Kiister,  6  recovered  and  5  died;  and  of 
these  5,  3  had  albumin  in  the  urine  as  well  as  sugar. 

Heidenhain  warmly  advocated  early  high  amputation,  with  the  making  of 
short  flaps,  and,  in  the  United  States,  Powers,  of  Denver,  defended  the  views  of 
Kuster  ("Amer.  Jour,  of  Med.  Sciences,"  Nov.  11,  1892).  Most  writers  now 
advocate  high  operation  without  waiting  for  a  line  of  demarcation  if  the  gangrene 
is  moist  and  due  to  bacteria  attacking  tissue  weakened  by  diabetes.  The  same 
practitioners,  if  dry  gangrene  due  to  arterial  changes  exists,  advocate  awaiting 
the  formation  of  a  line  of  demarcation  before  amputating.  I  agree  with  Klemp- 
erer  ("Therapie  der  Gegenwart,"  Jan.,  1907)  that  we  should  reach  a  conclusion 
as  to  the  proper  course  to  pursue  more  from  the  character  of  the  diabetes  than 
from  the  nature  of  the  gangrene.  If  neither  diacetic  acid  nor  acetone  is  in  the 
urine,  the  glycosuria  can  be  much  improved  and  the  general  health  vastly 
benefited  by  restricting  the  carbohydrates  and  administering  codein  or  opium. 
In  many  cases  sugar  rapidly  disappears.  In  such  a  case  during  the  improvement 
of  the  glycosuria  we  await  the  formation  of  a  line  of  demarcation,  and  while 
waiting  the  gangrenous  Hmb  is  treated  with  superheated  air  and  in  the  intervals 
of  the  baking  is  wrapt  in  cotton  wool,  slightly  elevated  and  kept  warm  by  a 
hot-water  bag.  When  a  Hne  of  demarcation  forms  and  only  a  toe  or  toes  are 
involved,  the  dead  parts  are  removed  surgically  and  spontaneous  heahng  will 
13 


194  Mortification,  Gangrene,  or  Sphacelus 

perhaps  occur.     If  it  does  not  occur,  or,  if  the  gangrene  involves  the  dorsum 
or  sole  of  the  foot,  amputate  above  the  knee. 

If  acetone  and  diacetic  acid  persist  in  the  urine  in  spite  of  treatment  (page  79) 
and  if  that  excretion  contains  not  only  sugar,  but  also  quantities  of  albumin,  we 
cannot  dare  to  wait  for  a  line  of  demarcation  because  of  the  high  probability 
that  during  the  wait  the  patient  will  perish  of  septicemia  (Klemperer,  ''Therapie 
der  Gegenwart,"  Jan.,  1907).  In  such  a  case  perform  an  immediate  high 
amputation. 

If  the  urine  contains  acetone  and  diacetic  acid  a  line  of  demarcation  will 
almost  never  form,  and  high  amputation  must  be  performed  at  once.  Intense 
pain  unchecked  by  baking  is  a  strong  indication  for  operation.  So  is  positive 
infection. 

In  operating,  ether  and  chloroform  (especially  chloroform)  are  to  be  avoided, 
because  either  is  liable  to  induce  acid  intoxication.  The  operation  may  be 
performed  under  nitrous  oxid  and  oxygen  anesthesia  or  under  spinal  anesthesia, 
although  I  case  in  which  I  amputated  under  spinal  anesthesia  died  of  coma. 
In  a  recent  successful  case  I  infiltrated  all  the  nerves  with  cocain  and  ampu- 
tated.    There  was  no  pain  and  apparently  nc'  shock. 

My  experience  of  amputation  in  diabetic  gangrene  of  the  leg  comprises 
6  cases.  In  4  cases  the  urine  contained  sugar,  acetone,  and  diacetic  acid,  and  in 
2  of  these  cases  albumin  was  also  present.  In  2  cases  sugar  was  in  the  urine,  but 
no  albumin,  acetone,  or  diacetic  acid.  In  each  case  a  high  amputation  was 
performed — i  case  (one  of  those  with  albumin)  died  of  shock;  2  cases  died  in 
coma;  i  case  died  of  sepsis;  2  cases  recovered. 

Treatment  of  Diabetic  Gangrene  in  General. — In  gangrene  of  some  region 
other  than  an  extremity,  place  the  patient  on  antidiabetic  treatment,  treat 
locally  \\ath  hot  antiseptic  fomentations,  remove  tissue  which  is  completely 
dead  with  scissors  and  forceps,  and  sustain  the  strength. 

Gangrene  from  Ergotism. — Ergot  gangrene  was  first  described  by 
Dodard  in  the  Journal  des  Savans  for  1676  (Aitken's,  "Science  and 
Practice  of  Medicine").  Ergotism  is  a  diseased  condition  resulting  from 
eating  bread  made  from  rye  which  has  been  attacked  by  a  fungus  {Claviceps 
purpura).  In  former  days  it  was  not  unusual  to  have  epidemics  of  ergotism 
from  time  to  time,  but  at  present  the  disease  is  found  in  individuals  or,  at 
most,  in  a  few  of  a  community.  Ergotism  is  very  rare  in  the  United  States, 
but  is  not  uncommon  in  southern  Russia.  It  has  occurred  during  the  ad- 
ministration of  ergot  as  a  drug.  Billroth  reported  such  a  case.  It  is  never  seen 
in  unweaned  children.  The  eating  of  bread  made  of  diseased  rye  provokes 
gastro-enteritis,  the  evidences  of  which  are  abdominal  pain  of  a  crampy  char- 
acter, vomiting,  diarrhea,  and  exhaustion.  The  patient  complains  of  formi- 
cation and  itching  of  the  skin  of  the  extremities;  severe,  cramp-like,  and  ting- 
ling pains  in  the  limbs,  and  disorders  of  vision.  The  pulse  becomes  small  and 
slow.  In  some  cases  very  painful  spasms  attack  the  muscles  of  the  extremities 
and,  finally,  tonic  spasm  is  noted,  and  the  patient  probably  perishes  from  ex- 
haustion after  developing  general  convulsions  and  passing  into  coma.  In 
other  cases  certain  areas  exhibit  "gradual  blood-stasis"  (Osier),  anesthesia,  and 
finally,  gangrene.  The  gangrene  is  dry  and  peripheral.  It  usually  affects  the  fin- 
gers or  toes,  but  may  involve  an  entire  limb  and  may  be  symmetrical.  Chronic 
ergotism  is  usually  recovered  from,  but  acute  cases  die  in  from  seven  to 
ten  days.^  The  ingestion  of  ergot  in  quantity  sufficient  to  produce  chronic 
poisoning  causes  tonic  contraction  of  the  peripheral  blood-vessels,  degeneration 
of  the  inner  coats,  and  thrombosis  of  some  arterioles.  It  is  also  maintained  that 
degeneration  of  the  posterior  columns  of  the  spinal  cord  takes  place. 

Treatment. — Ergotism  is  treated  by  forbidding  the  eating  of  the  poison- 
ous  bread,   allaying   gastro-enteric   inflammation,   favoring   elimination,   and 
iPick,  in  Heath's  "Surgical  Dictionary." 


Gangrene  from  Frost-bite 


195 


administering  nourishment  and  stimulants.  If  gangrene  is  threatened,  en- 
deavor to  prevent  it  by  gentle  massage  and  the  application  of  warmth.  If 
superficial  gangrene  occurs,  dress  with  warm  antiseptic  fomentations  and  ele- 
vate the  part,  and  every  day  take  scissors  and  forceps  and  remove  the  loose 
crusts.  If  deeper  and  more  extensive  gangrene  arises  in  an  extremity  wait 
for  a  line  of  demarcation  and  amputate  above  it. 

Gangrene  from  Frost-bite. — Frost-bite  is  most  common  in  the  fingers, 
toes,  nose,  and  ears,  but  the  genital  organs,  the  cheeks,  the  chin,  the  feet  and 
legs,  and  the  hands  and  arms  may  be  attacked.  Cold  causes  a  primary  con- 
traction of  the  vessels  and  pallor  and  numbness  of  the  part.  After  reaction 
the  vessels  dilate,  the  part  reddens  and  swells,  and  a  burning  sensation  or 
actual  pain  is  experienced.  In  a  trivial  frost-bite  the  swelling  and  redness 
usually  disappear  after  a  few  days,  but  in  some  cases  the  redness  is  permanent, 
and  in  many  cases  the  redness,  in  the  form  of  local  asphyxia,  returns  under 
the  influence  of  slight  cold.     (See  Chilblains.) 


Fig.  95. — Showing  different  degrees  of  frost-bite  (Fauntleroy,  Ibid.)- 


In  a  more  severe  frost-bite  the  affected  part  becomes  purple  and  covered 
with  vesicles,  and  gangrene  may  or  may  not  follow.  When  a  part  has  been 
badly  frozen  it  is  whiter  than  normal,  painless,  anesthetic,  and  the  peripheral 
portion  dries.  The  part  is  deprived  of  all  blood  because  of  contraction  of  the 
vessels  and  because  plasma  coagulates  at  a  few  degrees  above  freezing.  Cold 
disorganizes  the  blood,  breaking  up  white  corpuscles  mth  the  liberation  of 
fibrin  ferment.  Coagulation  of  plasma  and  destruction  of  red  corpuscles  with 
the  liberation  of  hemoglobin  subsequently  take  place.  The  thrombosis  which 
is  established  prevents  circulation,  and  the  tissue-cells  are  damaged  beyond 
repair.  The  part  is  bloodless  and  anesthetic,  and  a  line  of  demarcation  forms; 
hence  we  note  that  severe  frost-bite  causes  dry  gangrene.  Areas  of  superficial 
gangrene  are  not  so  uncommon.  If  a  part  w'hich  is  not  so  badly  frozen  is  brought 
suddenly  into  a  warm  atmosphere,  hj'peremia  takes  place  when  the  blood  runs 
into  the  frosted  tissues,  blebs  form,  and  moist  gangrene  may  result.  Baron 
Larrey  ("Surgical  Memoirs"),  in  speaking  of  the  retreat  from  Russia,  tells  a 
dreadful  story  of  the  suffering  from  cold.  He  says:  "Persons  were  seen  to  fall 
dead  at  the  fires  of  the  bivouacs.  Those  who  approached  them  sufficiently  near 
to  warm  their  frozen  feet  and  hands  were  attacked  by  gangrene." 


196 


Mortification,  Gangrene,  or  Sphacelus 


Treatment  of  Frost-bite  and  of  Gangrene  from  Frost-bite. — A  frost-bite  in 
which  the  skin  is  Hvid  and  not  as  yet  gangrenous  should  be  treated  by  frictions 
with  snow  or  rubbing  with  towels  soaked  in  iced  water.  Larrey  says  that  if 
frictions  with  snow  or  ice  fail  the  part  should  "be  plunged  in  cold  water,  in 
which  it  should  be  bathed  until  bubbles  of  air  are  seen  to  disengage  themselves 
from  the  congealed  part.  This  is  the  process  adopted  by  the  Russians  for 
thawing  a  fish"  (''Surgical  Memoirs").  Whatever  method  is  used,  as  the  skin 
becomes  warmer  and  congestion  disappears  the  part  should  be  subjected  to 
dry  friction  and  wrapped  in  cotton-wool.  As  previously  stated,  a  sufferer  from 
frost-bite  should  not  be  brought  suddenly  into  a  warm  room.  When  gangrene 
follows  frost-bite,  if  only  small  areas  are  involved,  allow  the  dead  parts  to  come 
away  spontaneously,  applying  in  the  meanwhile  hot  antiseptic  fomentations. 
If  separation  be  delayed  by  cartilage,  ligament,  or  bone,  cut  through  the  re- 


FiG.  96. — Noma.  Seven  days  after  first  appearance  of  measles  child  showed  gangrenous 
condition  of  mouth.  Now,  three  days  later,  it  involves  both  cheeks  and  under  surface  of 
upper  and  lower  lips.  Left  cheek  perforated.  Two  days  before  death  a  septic  diarrhea  de- 
veloped which  was  uncontrollable  (Crandon,  Place,  and  Brown). 

straining  structure.  If  amputation  becomes  necessary,  await  a  line  of  demar- 
cation, as  it  is  not  possible  otherwise  to  be  certain  how  high  tissue  damage 
extends,  and  to  amputate  through  devitalized  parts  would  mean  renewed 
gangrene. 

Noma  is  a  rapidly  spreading  gangrenous  process  which  is  most  apt  to  be- 
gin upon  the  mucous  membrane  of  the  gums  or  cheeks.  Noma  of  this  region 
is  known  as  cancrum  oris  or  gangrenous  stomatitis.  Occasionally  it  begins  in 
the  ears,  the  genitals,  or  the  rectum.  When  it  attacks  the  vulva  it  is  called 
noma  pudendi  or  noma  vulva.  It  may  originate  in  the  mouth  and  subsequently 
attack  other  regions.  Noma  is  a  very  rare  disease,  is  chiefly  met  with  in 
children  between  the  ages  of  three  and  ten,  but  it  may  attack  older  persons. 
O.  Zusch^  reports  a  case  in  a  man  sixty-six  years  of  age.  King  reports  a  case 
in  a  woman  of  fifty-nine.^     It  occurs  in  girls  oftener  than  in  boys.     The  disease 

^"Munchener  medicinische  Wochenschrift,"  May  14,  1901. 
^"Jour.  Amer.  Med.  Assoc,"  1911,  vol.  Ivi. 


Noma 


197 


is  most  frequently  encountered  in  children  recovering  from  an  acute  disease. 
It  is  seen  after  scarlatina,,  typhoid,  pneumonia,  erysipelas,  nephritis,  dysentery, 
and  especially  after  measles;  in  fact,  Osier  says  that  over  one-half  the  cases 
follow  measles.  Children  of  tuberculous  tendencies  seem  more  liable  than 
others.  Young  children  who  live  amidst  filth  and  squalor,  in  damp  and  ill- 
lighted  apartments  are  most  prone  to  suffer,  but  that  such  conditions  are  not 
essential  to  the  genesis  of  the  disease  is  shown  by  the  report  of  an  epidemic  of 
noma  in  the  Albany  Orphan  Asylum..  In  this  excellefitly  situated,  well-lighted, 
and  well-ventilated  building  the  children  are  carefully  fed  and  cared  for,  and 
yet  16  cases  of  noma  occurred  after  an  epidemic  of  measles.  (See  "An  Epidemic 
of  Noma,"  by  Geo.  Blumer  and  Andrew  MacFarlane,  in  "Amer.  Jour,  of  Med. 
Sciences,"  Nov.,  1901.)  The  disease  is  thought  by  many  to  be  due  to  pus 
organisms.  Lingard  describes  a  bacillus  which  he  considers  causative.  Blumer 
and  MacFarlane  conclude  that  the  disease  begins  as  a  simple  infection  and  a 
mixed  infection  takes  place  later.  The  mixed  infection  is 
not  always  due  to  the  same  organism,  but  is  usually  due  to 
a  long  organism  of  a  leptothrix  type  (Ibid.).  Some  think 
that  cases  of  noma  are  due  to  a  variety  of  spirochetes,  and  it  is 
an  interesting  observation  that  in  noma  the  Wassermann 
serum  reaction  may  be  obtained. 

In  1908  Crandon,  Place,  and  Brown  studied  an  outbreak  of 
noma.  Measles  had  been  through  the  ward,  46  children  had 
had  gangrenous  stomatitis,  and  6  of  them  developed  gangrene 
of  the  lip  and  cheek.  A  seventh  case  of  gangrene  appeared 
from  another  source  ('' Boston  Med.  and  Surg.  Jour.,  "April  15, 
1909),  They  decided  that  the  lesion  was  necrosis  due  to 
fusiform  bacilli  which  invade  living  tissue,  but  rapidly  die  in 
necrotic  tissue.  Of  these  7  cases,  2  recovered.  The  writers 
state  that  the  duration  of  the  disease  is  from  four  to  ten 
days.  They  do  not  regard  it  as  proved  that  noma  is  con- 
tagious and  do  not  advise  isolation.  Noma  vulvae  is  a  very 
fatal  lesion  most  common  in  young  children.  It  is  called  also 
cancer  Aquaticus. 

Symptoms. — The    disease    begins    as    a    sloughing    ulcer; 
thrombosis   and  gangrene  are  soon  observed.     The  edges  of 
the  ulcer  are  dark  red  and  indurated.     The  gangrene  usually 
spreads  with  very  great  rapidity,  but  in  some  cases  it  remains 
apparently  stationary  for  days  at  a  time.     There  is  little  or  no 
pain.     The  odor   is   horrible.     The  disease  is  frightfully  de- 
structive, and  if  the  mouth  is  involved  is  apt  to  destroy  the 
cheeks,  lips,  eyelids,  and  large  portions  of  the  jaws.     There 
is  usually  fever,  but  the  temperature  may  be  normal  or  even 
subnormal.     The  pulse  is  rapid,  and  exhaustion  appears  early 
and  deepens  rapidly.     The  mortality  is  large:  Bruns  says  70 
per    cent.;    Rilliet    and    Barthez    say    95   per  cent.    ("Amer.   Jour,  of  Med. 
Sciences,"  Nov.,  1901).     Out  of  Nicoll's  11  cases,  9  died  ("Progressive  Med.," 
March,  191 2),     The  cause  of  death  is  exhaustion,  pyemia,  or  septic  broncho- 
pneumonia. 

Treatment. — Administer  an  anesthetic  and  destroy  the  gangrenous  area  with 
the  Paquelin  cautery.  In  noma  of  the  mouth  chloroform  is  used  as  an 
anesthetic  instead  of  ether  because  the  hot  iron  is  to  be  applied  in  a  region 
surrounded  with  anesthetic  vapor,  and  ether  vapor  is  inflammable.  In  noma 
in  some  other  regions  ether  can  be  given.  After  cauterization  directions  are 
given  to  wash  the  part  every  few  hours  with  peroxid  of  hydrogen,  irrigate  it 
with  hot  salt  solution  or  boric  acid  solution,  and  dress  it  with  compresses 
soaked  in  Labarraque's  solution  (Blumer  and  MacFarlane,  in  "Amer.  Jour. 


Fig.  97. — Im- 
provised appara- 
tus for  the  irriga- 
tion of  a  wound. 


198  Mortification.  Gangrene,  or  Sphacelus 

of  Med.  Sciences,"  Nov.,  1901).  Nourishing  food  is  given  at  frequent  intervals, 
alcohol  is  administered,  and  strychnin  is  used  to  combat  weakness.  Rumple 
and  NicoU  have  each  employed  salvarsan  and  they  believe  with  benefit.  In 
one  of  NicoU's  successful  cases  two  doses  were  given  intravenously  at  an 
interval  of  three  days.  Each  injection  produced  a  great  local  reaction  in  the 
cheeks.  If  the  surgeon  succeeds  in  arresting  the  gangrene  it  will  probably  be 
necessary  later  to  perform  a  plastic  operation  in  order  to  replace  loss  of 
substance. 

Sloughing  is  a  septic  process  by  which  visible  portions  of  dead  tissue  are 
separated.  These  visible  portions  are  called  "sloughs;"  if  they  were  large  they 
would  be  called  "gangrenous  masses."  A  large  septic  slough  is  a  gangrenous 
mass;  a  small  gangrenous  mass  is  a  slough;  there  is  no  difference  in  the  process, 
which  corresponds  to  the  formation  of  a  line  of  demarcation. 

Treatment. — Sloughing  requires  thorough  and  frequent  irrigation  by  an 
antiseptic  fluid,  removal  of  the  sloughs,  and  antiseptic  treatment.  An  irriga- 
tor can  be  improvised  from  an  ordinary  bottle  (Fig.  97).  Warm  antiseptic 
fomentations  are  applied  until  granulation  is  well  advanced.  In  most  cases 
Dakin's  fluid  is  the  best  remedy.  Continuous  irrigation  with  a  hot  antiseptic 
fluid  is  useful;  in  other  cases  continued  immersion  in  a  hot  antiseptic  solution 
is  employed. 

Phagedena  is  a  process  of  ulceration  and  gangrene  (most  common  in 
venereal  sores)  in  which  the  surrounding  tissues  are  rapidly  eaten  up,  the  sore 
becoming  jagged  and  irregular,  with  a  sloughy  floor  and  thin  edges.  The  dis- 
charge is  thin  and  reddish,  and  the  encircling  tissues  are  deeply  congested. 
This  ulcer  has  no  tendency  to  heal.  Phagedena  may  attack  wounds,  but  in 
this  age  is  almost  never  seen  except  in  venereal  sores.  When  it  attacks  a 
wound  the  discharge  is  arrested,  the  parts  about  the  wound  become  dark  red  and 
swollen,  a  black  slough  forms  upon  the  wound,  and  the  process  spreads  rapidly 
in  all  directions.  The  process  when  it  attacks  a  wound  is  similar  to  or  identical 
with  a  mild  case  of  hospital  gangrene,  differing  from  the  gangrene  in  the  fact 
that  in  most  cases  a  line  of  demarcation  forms  and  the  constitutional  depres- 
sion is  not  so  great.  Phagedena  is  probably  due  to  mixed  infection  with  pus 
organisms. 

The  treatment  of  phagedena  consists  in  repeated  touching  with  tincture 
of  chlorid  of  iron  and  the  local  use  of  iodoform,  the  employment  of  continued 
irrigation,  immersion  in  hot  antiseptic  fluids,  the  use  of  Dakin's  fluid  or  the 
application  of  the  cautery,  chemical  or  actual.  After  using  the  cautery  the 
part  is  dressed  with  hot  antiseptic  fomentations.  Whatever  else  is  done,  tonics, 
stimulants,  and  nutritious  diet  must  be  given  and  opium  is  often  required. 

Decubitus,  Decubital  Gangrene,  or  Bed=sore.^A  bed-sore  is  the 
result  of  local  failure  of  nutrition  in  a  person  whose  tissues  are  in  a  state  of 
low  vitality  from  age,  disease,  or  injury.  The  arterial  condition  of  the  aged 
favors  the  development  of  bed-sores.  Such  sores  are  due  to  pressure,  aided 
it  may  be  by  some  slight  injury  or  by  the  irritation  produced  by  urine,  feces, 
sweat,  crumbs  or  other  foreign  bodies  in  the  bed,  or  by  wrinkling  of  the  sheets. 
The  pressure  destroys  vascular  tone,  stasis  results,  thrombosis  occurs,  and  gan- 
grene follows.  Sores  occur  over  the  heel,  elbow,  scapula,  trochanter,  buttock, 
sacrum,  and  nucha.  In  some  cases  after  pressure  is  removed  there  are  stasis, 
vesication,  suppuration,  and  the  formation  of  an  ugly  ulcer,  surrounded  by 
a  zone  of  swelling  and  hyperemia.  These  ordinary  pressure-sores  arise  like  a 
splint-sore  due  to  the  pressure  of  a  splint  upon  the  tissues  over  a  bony  promi- 
nence. The  pressure  interferes  with  the  blood-supply,  the  weakened  tissues 
inflame,  vesication  occurs,  sloughs  form,  and  an  ugly  ulcer  is  exposed.  When 
a  bed-sore  is  about  to  form  the  skin  becomes  red  and  edematous.  Pressure 
with  the  finger  drives  the  color  out  rather  slowly.  The  color  becomes  purple 
or  black,  a   slough  forms  and  separates,  and  a  large,  irregular,  foul   cav-ity 


I    Ludwig's  Angina  199 

is  exposed.  The  discharge  is  profuse  and  oiTensive.  The  parts  about  are 
swollen  and  red.  If  the  sore  is  not  upon  an  anesthetic  part,  much  suffering 
is  produced  by  it.  Bed-sores  are  most  common  in  paralyzed  parts;  such  parts 
are  anesthetic,  and  injurious  pressure  is  not  painful  and  does  not  attract 
attention,  and  in  such  parts  there  is  vasomotor  paresis. 

The  acute  bed-sores  of  Charcot  are  seen  during  certain  diseases  and  after 
some  injuries  of  the  nervous  system.  These  sores  are  usual  over  the  sacrum  in 
acute  myelitis,  and  may  appear  in  four  or  five  days  after  the  beginning  of  that 
disease  or  the  infliction  of  an  injury  upon  the  spinal  cord.  The  surgeon  sees 
acute  bed-sores  upon  the  buttock  of  the  paralyzed  side  after  brain-injuries, 
and  over  the  sacrum  and  other  bony  points  after  spinal  injuries.  Some  believe 
these  sores  are  due  to  vasomotor  disorder;  but  others,  notably  Charcot,  at- 
tribute them  to  disturbance  of  the  trophic  nerves  or  centers. 

Treatment  of  Bed-sores. — The  "ounce  of  prevention"  is  here  invaluable. 
From  time  to  time,  if  possible,  alter  the  position  of  the  patient,  keep  him  clean, 
maintain  the  blood-distribution  to  the  skin  by  frequent  rubbing  with  alcohol 
and  a  towel,  keep  the  sheet  clean  and  smooth,  and  in  some  situations  use  a  ring- 
shaped  air-cushion  to  keep  pressure  from  the  part.  When  congestion  appears 
(paratrimma,  or  beginning  sore),  at  once  use  an  air-cushion  or  a  water-bed 
and  redouble  the  care  to  change  frequently  the  position  of  the  patient.  Not 
only  protect,  but  also  harden,  the  skin.  Wash  the  part  twice  daily  and  apply 
spirits  of  camphor  or  glycerol  of  tannin;  or  rub  with  salt  and  whisky  (2  dr.  to 
I  pint);  or  apply  a  mixture  of  3^  oz.  of  powdered  alum,  2  fl.oz.  of  tincture  of 
camphor,  and  the  whites  of  four  eggs;  or  paint  with  corrosive  sublimate  and 
alcohol  (2  gr.  to  i  oz.) ;  or  apply  tannate  of  lead  or  equal  parts  of  oil  of  copaiba 
and  castor  oil;  or  paint  upon  the  part  a  protective  coat  of  flexible  collodion. 

When  the  skin  seems  on  the  verge  of  breaking,  paint  it  with  a  solution  of 
nitrate  of  silver  (20  gr.  to  i  oz.).  When  the  skin  breaks,  a  good  plan  of  treat- 
ment is  to  touch  once  a  day  with  a  solution  of  silver  nitrate  (10  gr.  to  i  oz.)  and 
cover  with  zinc-ichthyol  gelatin.  We  can  wash  the  sores  daily  with  1:2000 
■corrosive  sublimate  solution,  dust  with  iodoform,  and  cover  with  soap  plaster, 
with  lint  spread  with  zinc  ointment,  or  with  dry  aseptic  gauze.  When  sloughs 
form,  cut  most  of  them  off  with  scissors  after  cleansing  the  parts,  slit  up  sinuses, 
and  use  antiseptic  fomentations.  In  sloughing  Dupuytren  employed  pieces  of 
lint  wet  with  lime-juice  and  dusted  the  sore  with  cinchona  and  charcoal.  In 
obstinate  cases  use  the  continuous  hot  bath.  When  the  sloughs  separate, 
dress  antiseptically  or  with  equal  parts  of  resin  cerate  and  balsam  of  Peru. 
If  healing  is  slow,  touch  occasionally  with  a  solution  of  silver  nitrate  (10  gr.  to 
I  oz.).  Bed-sores,  being  expressive  of  lowered  vitality,  demand  that  the  patient 
shall  be  stimulated,  shall  be  well  nourished,  and  shall  obtain  sound  sleep. 

Ludwig's  Angina  (Angina  Ludovici). — This  disease,  which  was  first  de- 
scribed by  Ludwig,  of  Stuttgart,  in  1836,  is  an  acute  septic  infection  about  the 
submaxillary  salivary  gland  and  in  the  cellular  tissue  beneath  the  mucous  mem- 
brane of  the  floor  of  the  mouth  and  of  the  upper  portion  of  the  neck.  Ludwig 
called  it  "  gangrenous  induration  of  the  neck  "  (D.  Ludwig,  "Med.  Correspondenz 
Blatt,"  p.  21,  Feb.,  1836,  Stuttgart).  The  disease  may  arise  in  an  apparently 
healthy  man  or  during  or  after  an  infectious  fever.  It  can  arise  at  any  age. 
The  bacteria  enter  from  the  mouth  by  way  of  abrasions,  wounds,  ulcerations, 
or  dental  caries.  It  may  be  caused  by  delayed  development  of  the  third  molar, 
necrosis  of  the  tooth  and  alveolar  process  taking  place  and  an  abscess  forming 
(G.  G.  Ross,  "Annals  of  Surgery,"  June,  1901).  In  most  cases  the  condition 
is  a  pure  streptococcic  infection  or  a  streptococcic  infection  associated  with 
infection  by  some  other  organism,  for  instance,  staphylococci,  pneumococci, 
or  bacilli.  In  one  of  Davis's  cases  it  was  due  to  pneumococci  alone;  in  another, 
to  staphylococci  alone  (Gwillym  W.  Davis,  "Annals  of  Surgery,"  August,  1906). 
In    a    case    reported    by   Lockwood   the  bacillus  of   malignant   edema   was 


200  Mortification,   Ciangrenc,  or  Sphacelus 

found.  The  condition  is  essentially  an  acute  spreading  cellulitis  about  the 
submaxillary  gland.  It  usually  begins  about  that  gland,  but  in  some  cases 
seems  to  arise  about  the  sublingual  gland.  It  is  usually  a  violent  process  from 
the  start,  but  sometimes  it  is  first  an  indolent  swelling  in  the  submaxillary 
region  and  becomes  violent  and  begins  to  spread  rapidly  after  a  few  days.  It 
spreads  along  planes  of  connective  tissue  to  the  sublingual  region  of  the  mouth 
and  to  the  pharynx. 

The  bacteria  reach  the  submaxillary  region  in  the  lymph.  A  lymph-gland 
or  perhaps  several  glands  enlarge  and  are  rapidly  destroyed,  the  peri-glandular 
cellular  tissue  becomes  involved,  and  after  this  spread  takes  place  along 
connective-tissue  planes  rather  than  by  lymph-paths,  and  other  lymph-glands 
seldom  enlarge. 

The  localization  in  the  submaxillary  region,  the  violence  of  the  inflamma- 
tion, the  rapidity  of  the  spreading,  and  the  subsequent  involvement  of  the 
pharynx  and  floor  of  the  mouth  are  the  characteristic  features  of  Ludwig's 
angina  (T.  Turner  Thomas,  "Annals  of  Surgery,"  February  and  March,  1908). 
Thomas,  in  the  article  just  referred  to,  proves  by  anatomical  studies  that  the 
connective  tissue  in  the  submaxillary  fossa  is  directly  continuous  with  that  in 
the  floor  of  the  mouth.  The  disease  begins  as  a  painful  indurated  swelling  be- 
neath the  body  of  the  jaw,  the  swelling  rapidly  increases  in  the  neck,  and  may 
even  pass  to  the  level  of  the  sternum.  A  board-like  feel  of  this  swelling  is  dis- 
tinctive. The  skin  may  be  pale  or  dusky  red.  There  may  or  may  not  be 
marked  tenderness. 

After  a  few  hours  or  a  day  or  two  the  floor  of  the  mouth  becomes  involved; 
as  a  result  of  this  the  tongue  is  raised  and  pushed  back,  the  mouth  is  kept  from 
closing,  swallowing  becomes  difficult,  speech  is  impaired,  the  saliva  dribbles 
constantly,  and  dyspnea  becomes  an  alarming  feature  of  the  case. 

In  some  cases  the  temperature  is  much  elevated,  but  in  most  it  is  moder- 
ately or  only  slightly  elevated. I 

If  a  spontaneous  opening  should  occur  it  will  be  within  the  mouth.  Free 
suppuration  may  occur  or  only  a  little  watery  pus  may  form  and  the  pus  may 
be  brown-  and  putrid.  In  many  cases  the  cellular  tissue  becomes  gangrenous, 
the  gangrene  resembling  that  of  noma.  The  mortality  is  high.  In  Thomas's 
collection  of  106  cases  it  is  seen  that  43  died  (Ibid.),  though  with  the  prompt 
intervention  which  is  now  advised  the  mortality  should  be  much  below  this 
figure  at  the  present  time.     I  have  had  4  cases  and  2  of  them  died. 

Death  may  take  place  suddenly.  Death  is  seldom  due  to  septic  intoxica- 
tion or  pyemia,  but  may  be.  It  is  usually  due  to  edema  of  the  glottis  or  to 
bronchopneumonia. 

Treatment. — Operate  promptly  and  incise  freely.  If  there  is  an  infective 
focus  within  the  mouth,  remove  it.  Make  an  incision  through  the  swelling  in 
the  submaxillary  region,  carry  the  incision  forward  to  the  median  line  and 
divide  the  mylohyoid  muscle.  "The  finger  should  be  passed  upward  in  the 
wound  until  only  mucous  membrane  intervenes  between  it  and  the  mouth. 
Gangrenous  tissue  is  cut  away,  the  wound  is  painted  with  pure  carbolic  acid, 
and  dusted  with  iodoform"  (T.  Turner  Thomas,  Ibid.).  Drainage-tubes  are 
inserted  and  the  part  is  dressed  by  antiseptic  fomentations.  If  edema  of 
the  glottis  exists,  tracheotomy  should  be  performed  promptly.  Stimulants 
are  given  with  a  free  hand  in  Ludwig's  angina. 

Carbolic  Acid  Gangrene. — Dressings  moistened  with  a  solution  of 
carbolic  acid  of  a  strength  of  from  3  to  5  per  cent,  if  wrapped  for  a  number 
of  hours  around  a  finger  or  toe,  a  hand  or  a  foot,  may  cause  dry  gangrene. 
There  is  but  little  danger  when  such  dressings  are  applied  to  the  tissues  of  the 
trunk,  because  these  thicker  tissues  are  better  nourished  and  cannot  be  com- 
pletely surrounded  by  the  wet  dressings.  When  a  dressing  wet  with  a  watery 
solution  of  carbolic  acid  is  wrapped  about  the  part  the  water  evaporates,  and 


Postfebrile  Gan<!;rene  201 

as  it  does  so  the  carbolic  acid  becomes  more  and  more  concentrated.  A  well 
mixed  solution  seldom  causes  gangrene.  A  recent  aqueous  solution  often  con- 
tains free  globules  of  acid  and  is  particularly  apt  to  cause  gangrene  (Murphy). 
It  is  claimed  that  a  solution  of  carbolic  acid  in  glycerin  never  causes  gangrene 
(Pautrier,  in  "Presse  Medicale,"  March  2,  1907).  Gangrene  of  a  toe  has  oc- 
curred from  the  application  of  carbolized  vaselin  (Buckmaster's  case,  "Jour. 
Amer.  Med.  Assoc,"  January  13,  191 2).  Two  cases  have  been  reported  in 
which  gangrene  of  a  linger  was  caused  by  carbolized  ointment  (Brown,  "Jour. 
Amer.  Med.  Assoc,"  November  11,  1911;  Schussler,  "Jour.  Amer.  Med. 
Assoc,"  August  19,  191 1).  In  one  case  reported  by  DeWitt  gangrene  of 
the  thumb  resulted  from  injecting  a  ganglion  of  the  thumb  with  equal  parts 
of  camphor  and  pure  carbolic  acid  ("Southern  Med.  Jour.,'*  June,  1909). 
The  application  of  strong  acid  rarely  causes  gangrene,  but  Levan  found  14 
reported  cases  in  which  it  did  (J.  Levan,  in  "Centralbl.  f.  Chir.,"  August  14, 
1897),  and  Wallace  has  reported  several  more  ("Brit.  Med.  Jour.,"  May  11, 
1907).  A  solution  as  mild  as  i  per  cent,  has  caused  gangrene.  The  con- 
tinuous application  of  a  solution  of  a  strength  of  3  per  cent,  or  over  is  very 
dangerous  and  ought  never  to  be  practised.  The  author  has  seen  8  cases. 
Harrington  saw  r8  cases  of  gangrene  in  five  years  in  the  Massachusetts  General 
Hospital,  and  collected  132  cases  from  Uterature  ("Boston  Med.  and  Surg. 
Jour.,"  May  2,  1901).  Carbolic  acid  gangrene  is  due  to  great  exudation 
into  the  cellular  tissue,  blocking  the  circulation  (Housell),  and  the  produc- 
tion of  arterial  thrombi,  a  condition  to  which  the  patient  is  predisposed  by 
the  injury  and  often  by  tight  bandaging.  The  dressing  is  frequently  ap- 
plied by  a  druggist;  it  produces  anesthesia  of  the  part,  and  the  dressing  may 
not  be  removed  for  days,  gangrene  perhaps  progressing  beneath.  In  the 
author's  8  cases  pain  was  absent  and  there  was  no  smokiness  of  the  urine  or 
any  other  evidence  of  absorption  of  the  drug.  Dressing  of  lysol  and  alcohol 
may  produce  gangrene,  but  the  necrosis  is  more  superficial  than  that  due  to 
carbolic  acid. 

Treatment. — If  the  gangrene  is  very  superficial,  recovery  may  be  obtained 
by  using  hot  fomentations  and  picking  the  dead  parts  gradually  away.  In 
most  cases  the  finger  or  toe  is  completely  destroyed,  a  line  of  demarcation 
forms,  and  amputation  is  required. 

Postfebrile  Gangrene. — Dry  or  moist  gangrene  may  follow  any  fever, 
but  is  most  frequent  after  typhoid  (may  follow  typhus,  influenza,  measles, 
diphtheria,  scarlet  fever,  etc.).  Keen  tells  us  that  the  gangrene  resulting  from 
arterial  obstruction  is  apt  to  be  dry,  and  that  from  venous  obstruction  is 
usually  moist.  The  same  observer  has  collected  203  cases. ^  It  is  most  usual  in 
the  low^er  extremities,  but  may  appear  in  the  upper  extremities,  cheeks,  ears, 
nose,  genitals,  lungs,  etc.  Some  wTiters  have  assigned  as  the  cause  w^eakness  of 
cardiac  action,  but  most  observers  believe  an  obstructing  clot  is  the  usual 
cause.  This  clot  may  come  from  the  heart  as  an  embolus,  but  in  most 
cases  it  is  a  local  thrombus  secondary  to  endarteritis  due  to  the  action  of  the 
toxins  of  the  bacilli  of  the  specific  fever.  Keen  shows  that  in  some  cases 
gangrene  is  due  to  obstruction  of  peripheral  vessels  and  not  of  a  main  trunk. 
In  rare  cases  gangrene  arises  after  thrombophlebitis.  Gangrene  may  begin  as 
early  as  the  fourteenth  day  of  t}'phoid,  but  usually  appears  late  in  the  disease 
and  may  arise  far  into  convalescence.  In  the  course  of  a  continued  fever 
frequent  examinations  should  be  made  to  see  that  gangrene  is  not  arising. 
Particular  examination  from  time  to  time  should  be  made  of  the  lower 
extremities  and,  in  young  girls,  of  the  genitals.  If  gangrene  arises  in  an 
extremity,  apply  antiseptic  dressings,  wait  for  a  line  of  demarcation,  and  then 
amputate.  If  gangrene  occurs  in  other  regions,  remove  the  dead  tissue  and 
employ  hot  antiseptic  fomentations. 

1  Keen  on  the  "Surgical  Complications  and  Sequels  of  Typhoid  Fever." 


202  Mortification,  Gangrene,  or  Sphacelus 

Puerperal  Gangrene  of  the  Limbs. — Stein  collected  74  cases  and  re- 
ported two  of  his  own  ("Surgery,  Gynecology,  and  Obstetrics,"  1916,  xxiii). 
Most  of  the  cases  occurred  after  abortion.  The  condition  may  occur  during 
pregnancy.  Infection  is  the  cause  of  most  cases,  but  the  condition  may  resuU 
from  embolism,  and  Ra\niaud's  gangrene  may  occur.  Puerperal  gangrene 
may  be  dry  or  moist  according  to  the  actual  causal  lesion. 

Rules  When  to  Amputate  for  Gangrene; — In  dry  gangrene,  due  to 
obstruction  of  a  non-diseased  arter>',  wait  for  a  line  of  demarcation.  In  senile 
gangrene,  if  it  affect  only  one  or  two  toes,  let  the  dead  parts  be  cast  off  spon- 
taneously. If  a  greater  area  is  involved  or  the  process  spreads,  amputate 
above  the  knee  without  waiting  for  the  line.  In  ordinary  moist  gangrene,  if 
there  are  not  severe  symptoms  of  sepsis,  and  if  the  gangrene  is  not  rapidly 
progressive,  wait  for  a  line  of  demarcation.  In  the  severer  cases  amputate 
at  once  high  up.  In  many  cases  of  traumatic  spreading  gangrene  amputate  at 
once  high  up.  In  some  cases  of  diabetic  gangrene  amputate  at  once  high 
up;  in  other  cases  await  the  formation  of  a  line  of  demarcation  (see  page 
193).  In  ergot  gangrene,  in  carbolic  acid  gangrene,  in  postfebrile  gangrene,  in 
Raynaud's  gangrene,  and  in  frost  gangrene  wait  for  a  line  of  demarcation. 

Arteriovenous  Anastomosis  for  the  Prevention  or  Treatment  of  Gan- 
grene of  an  Extremity. — This  operation  took  origin  from  Carrel's  famous 
demonstration  of  the  reversal  of  the  circulation  in  a  dog's  leg.  The  axil- 
lary artery  has  been  anastomosed  to  the  axillary  vein;  the  femoral  artery  has 
been  anastomosed  to  the  femoral  vein.  We  know  that  by  an  anastomosis 
we  can  send  arterial  blood  into  a  vein,  but  usually  a  clot  soon  forms  at  the 
junction.  Those  who  advocate  the  operation  assert  that  the  force  of  the  arterial 
blood-current  overcomes  the  valves  of  the  vein,  and  that  arterial  blood  goes 
toward,  even  if  it  does  not  reach,  the  periphery.  Further,  that  even  if  a  clot 
does  form,  it  forms  slowly,  circulation  is  arrested  gradually,  and  collaterals 
distend  during  clotting. 

Horsley,  Stetten  and  others  oppose  the  operation.  The  opponents  of  the 
operation  assert  that  the  valves  cannot  be  overcome,  that  the  blood  flows  off 
into  venous  branches  and  returns  to  the  heart.  Though  it  is  doubtful  how  far 
toward  the  periphery  the  blood  goes,  we  believe  that  the  repeated  impact  of  the 
arterial  blood  must  finally  overcome  the  valves;  and  in  spite  of  great  un- 
certainty as  to  the  return  of  blood  to  the  heart,  we  know  that  successful  rever- 
sal seems  to  have  been  accomplished  (see  Meyer's  explanation  on  page  180). 

Bernheim  ("Annals  of  Surgery,"  February,  191 2)  has  collected  46  cases 
from  literature  and  has  added  6  operations,  2  of  which  were  performed  on 
the  same  individual  (Halsted's  case,  Finney's  case,  Bloodgood's  4  cases). 
In  the  52  operations  gathered  in  Bernheim's  table  the  ages  of  the  subjects 
varied  from  twenty  to  eighty  years.  There  w^ere  13  deaths.  He  considers 
15  of  the  ca^es  successful,  that  is,  "cases  in  which  reversal,  as  far  as  one  can 
judge,  actuaUy  saved  the  limb  from  real  or  threatened  gangrene."  H.  Mor- 
riston  Davies  recently  reported  a  successful  operation  for  gangrene.  The 
artery  and  vein  were  completely  divided  and  anastomosed  in  Hunter's  canal 
("Annals  of  Surgery,"  191 2).     The  mortahty  is  large  (see  Stetten  on  page  179). 

The  best  plan  is  lateral  anastomosis  with  proximal  Hgation  of  the  vein,  to 
prevent  the  deviated  blood  from  returning  at  once  to  the  heart.  Bernheim 
and  Stone  devised  this  method  (Ibid.)  and  Murphy  advocates  it.  Only  one- 
third  of  the  circumference  of  the  artery  is  used  for  the  anastomosis  and  some 
blood  continues  to  flow  in  the  artery  toward  the  periphery.  The  artery  carries 
blood  to  where  the  block  is;  the  vein  is  supposed  to  carry  blood  much  further. 
Bernheim  points  out  that  if  a  thrombus  forms  it  will  do  so  on  the  side  of  the 
artery  and  the  limb  will  be  no  worse  off.  Carrel  and  others  advise  end-to-end 
anastomosis. 

The  operation  is  yet  on  trial.     In  suitable  cases  the  operation  is  justifiable 


Causes  of  Thrombosis 


203 


and  age  is  no  bar.  It  is  useless  if  veins  are  occluded  as  well  as  arteries,  hence 
it  is  useless  in  advanced  cases  of  gangrene  from  thrombo-angiitis  obliterans. 
If  any  considerable  area  of  gangrene  exists  veins  are  involved  and  the  opera- 
tion is  useless. 


IX.  THROMBOSIS  AND  EMBOLISM 

Thrombosis  is  the  antemortem  coagulation  of  blood  in  the  heart  or  in  a 
vessel,  the  coagulum  remaining  at  its  point  of  origin  and  plugging  up  the 
vessel  partially  or  completely.  The  process,  and  also  the  condition  significant 
of  the  process,  is  kno^Yn  as  thrombosis;  the  clot  is  called  the  thrombus.  This 
process  is  an  essential  part  in  the  arrest  of  hemorrhage;  it  occurs  in  phlebitis 
and  arteritis,  and  affords  a  frequent  basis  for  embolism.  The  thrombus  is  com- 
posed of  red  corpuscles,  white  corpuscles,  fibrin,  and  platelets  in  varying  pro- 
portions. Thrombi  may  form  in  the  veins,  in  the  arteries,  in  the  capillaries, 
•or  in  the  heart.  Clotting  is  due  to  destruction  of  white  blood-cells,  fibrin 
ferment  being  set  free,  causing  the  union  of  calcium  and 
fibrinogen  and  thus  forming  fibrin.  Thrombosis  is  more 
common  in  the  veins  than  in  the  arteries,  the  slow  blood- 
current  and  the  existence  of  valves  favoring  the  deposit, 
though  not  causing  it.  A  thrombus  forms  gradually, 
being  deposited  layer  by  layer;  hence  it  is  stratified  or 
laminated.  Figure  98  shows  a  thrombus  in  a  vein.  All 
thrombi  are  either  infectious  or  simple,  the  latter  being 
also  called  aseptic  or  bland.  Thrombi  are  also  spoken  of 
as  fibrinous,  red,  hemostatic,  leukocytic,  etc. 

Causes  of  Thrombosis. — In  the  formation  of  a  throm- 
bus four  conditions  are  to  be  considered,  viz.,  chemical 
alterations  in  the  blood,  a  bacterial  attack  on  the  intima, 
tissue  changes  in  the  inner  coat  of  the  vessel,  and  slow- 
ing of  the  circulation.  One,  several,  or  all  of  these  con- 
ditions may  exist  in  a  case  of  thrombosis.  In  arteries 
the  chief  causes  are  disease  of  the  coats  and  embolism.  In 
veins  the  chief  causes  are  injury  and  infectious  phlebitis, 
may  be  due  to  propagation  from  veins  or  arteries  or  may  form  in  the  capillaries. 
The  latter  condition  is  seldom  seen.  The  essential  cause  of  all  intravascular 
thrombi  is  damage  to  the  endothelial  coat  and  in  most  instances  the  damage 
is  effected  by  bacteria,  hence  most  cases  of  thrombosis  seen  by  the  surgeon  are 
infectious.  Any  condition  which  causes  the  blood  to  contain  an  excess  of 
fibrin-forming  elements  favors  thrombosis,  in  the  sense  that  a  sKght  injury  of 
the  vascular  endothelium  will  be  followed  by  clot  formation.  Among  conditions 
favoring  thrombosis  we  must  note  particularly  slowing  of  circulation,  however 
caused.  A  special  predisposing  condition  is  the  retarded  circulation  in  tuber- 
culosis, influenza,  and  fevers,  the  blood-clotting  behind  the  vein-valves  after 
the  endothelium  has  been  damaged  by  toxins.  Among  other  inciting  states 
are  inflammations ;  wounds ;  fractures ;  the  pressure  of  a  bandage  or  of  a  splint ; 
varicose  veins;  ligation  of  a  vessel;  injury  of  a  vessel;  foreign  bodies  in  a  vessel; 
hematoma;  atheroma  in  arteries;  sutures  in  a  vessel;  pregnancy;  certain  diseases, 
such  as  gout,  t>'phoid  fever,  and  septic  processes;  phlebitis  or  arteritis  arising 
in  the  vessel  or  from  extension  of  surrounding  inflammation,  and  the  entrance 
of  specific  organisms. 

It  has  been  asserted  that  so  long  as  the  endothelium  of  a  vessel  is  unin- 
jured a  clot  does  not  form.  Slowing  of  the  blood-current  in  aseptic  conditions, 
it  is  now  taught,  will  not  cause  thrombosis.  One  of  the  functions  of  the  endo- 
thelial coat  is  to  keep  the  blood  fluid  by  preventing  corpuscular  disintegration. 
A  thrombus  can  form  only  when  fibrin  ferment  is  set  free,  and  fibrin  ferment 


Fig.  98.— Throm- 
bus in  the  saphenous 
vein  (Green). 

Capillary  thrombi 


204  Thrombosis  and  Embolism 

can  be  set  free  only  when  white  corpuscles  disintegrate.  When  moving  blood 
coagulates,  the  third  corpuscles  or  platelets  first  settle  out  and  foim  a  nucleus 
about  which  the  leukocytes  gather.  This  is  known  as  the  white  or  '' ante- 
mortem''  thrombus — the  clot  of  moving  blood.  Thrombi  from  moving  blood 
are  rarely  pure  white;  they  contain  some  red  corpuscles,  forming  mixed  thrombi. 
White  thrombi  and  mixed  thrombi  are  stratified  and  are  at  first  soft,  but  harden 
as  they  age.  The  red  thrombus  plugs  vessels  which  are  cut  across  or  ligated;  it 
also  occurs  in  septic  processes  and  is  the  thrombus  formed  after  death.  A 
primary  thrombus  remains  in  the  original  region  of  thrombosis.  A  secondary 
fhrombus  forms  about  an  embolism.  A  propagating  or  spreading  thrombus  ex- 
tends a  considerable  distance  from  the  seat  of  initial  disturbance.  A  thrombus 
soon  undergoes  a  change.  An  aseptic  clot  usually  "organizes" — that  is,  the  clot 
is  absorbed  and  is  replaced  by  fibrous  tissue.  The  walls  of  the  injured  vessel 
become  filled  with  leukocytes,  leukocytes  invade  the  clot,  the  vascular  endo- 
thelium proliferates,  and  the  young  cells  follow  the  colonies  of  leukocytes  into 
the  thrombus.  The  thrombus  is  gradually  removed  by  leukocytes  and  replaced 
by  fibroblasts,  the  new  tissue  is  vascularized  and  becomes  granulation  tissue, 
the  granulation  tissue  is  converted  into  fibrous  tissue,  and  the  fibrous  tissue 
contracts.  In  some  instances  a  thrombus  is  implanted  on  the  wall  of  the  vessel 
and  the  tube  is  not  permanently  occluded.  Such  a  condition  may  be  obtained 
by  the  application  of  a  lateral  ligature  about  a  small  tear  in  a  large  vein.  In 
most  instances,  after  the  formation  of  an  intravascular  thrombus,  the  vessel  is 
converted  into  a  narrow  cord  of  fibrous  tissue.  A  thrombus 
may  degenerate  and  break  down  (fatty  degeneration),  giving 
rise  to  emboli,  or  a  thrombus  may  undergo  calcification.  A 
calcified  thrombus  in  a  vein  is  known  as  a  phlebolith.  An 
infected  thrombus  may  undergo  liquefaction,  infective 
emboli  being  set  free  (Fig.  99). 

A  clot  may  propagate  in  both  directions,  that  is,  toward 
the  periphery  and  toward  the  heart.  It  was  taught  for 
many  years  that  when  an  artery  had  been  ligated  a  thrombus 
quickly  formed  and  reached  to  the  first  collateral  branch 
above.     This  view  was  formulated  in  pre-antiseptic  days. 

YiG.  99. In-     It  is  now  known  that  when  aseptic  ligation  is  performed  the 

fected  thrombus  of  thrombus  is  small  and  rarely  reaches  the  first  collateral 
a  vein  (schematic).  branch;  and  is' of  ten  actually  absent,  vascular  obliteration 
being  obtained  by  proliferation  of  connective-tissue  cells 
and  of  cells  from  the  endothelial  coat.  If  an  infection  takes  place  the  clot 
may  reach  the  first  collateral  branch.  The  old  rule  of  surgery  was  as  follows: 
If  an  artery  is  cut  near  a  large  branch,  tie  the  branch  as  well  as  the  artery,  in 
order  to  permit  of  the  formation  of  a  lengthy  clot.  This  rule  is  no  longer  fol- 
lowed unless  infection  exists  or  is  anticipated. 

A  clot  in  a  vein  often  extends  a  long  distance.  The  author  has  seen  in  a, 
postmortem  examination  a  venous  thrombus  reaching  from  the  ankle  to  the 
vena  cava.  A  common  example  of  thrombus  in  a  vein  is  the  clot  formed 
in  the  uterine  sinuses  in  a  condition  of  puerperal  sepsis,  a  clot  which  tends  to 
extend  into  the  iliac  and  femoral  veins.  Infectious  thrombosis  of  the  lateral 
sinus  causes  clot  formation  and  the  clot  tends  to  extend  up  to  the  torcular, 
into  other  sinuses  and  down  into  the  jugular.  Phlegmasia  alba  dolens  or 
milk-leg  is  a  condition  in  which  the  leg  or  the  leg  and  thigh  are  swollen 
and  painful  because  of  venous  thrombosis  or  sometimes  lymphatic  thrombosis 
(see  page  203). 

Lymphatic  thrombosis  occasionally  occurs  in  the  thoracic  duct,  axillary  lym- 
phatics, or  inguinal  lymphatics.  It  is  most  common  in  the  uterine  lymphat- 
ics during  puerperal  fever.  Lymphatic  thrombosis  may  be  due  to  infection,, 
to  cancer,  to  tuberculosis,  or  to  change  in  the  lymph  itself. 


General  Symptoms  of  Thrombosis  205 

General  Symptoms. — The  symptoms  are  dependent  on  the  seat  of  the 
obstruction  and  the  presence  or  absence  of  infection.  An  organ  or  a  i)art 
of  an  organ  may  exhibit  functional  aberration.  The  local  signs  in  a  vessel 
accessible  to  touch  or  sight  are  the  presence  of  a  clot;  if  it  be  in  an  artery, 
anemia  and  the  absence  of  pulse  below  the  clot;  if  it  be  a  vein,  swelling  and 
edema  below  it.  There  is  usually  pain  at  the  seat  of  trouble,  and  anesthesia 
below  it.  Moist  gangrene  may  follow  venous  thrombosis,  and  dry  gangrene, 
arterial  thrombosis.  Thrombosis  of  the  mesenteric  vein  is  followed  by  gan- 
grene of  the  bowel.  Infective  thrombophlebitis  is  a  spreading  inflammation 
of  a  vein.  A  septic  thrombus  forms  and  the  condition  is  an  early  step  in 
pyemia.  We  see  this  condition  sometimes  in  the  lateral  sinus  of  the  brain  as  a 
result  of  suppuration  in  the  middle  ear;  in  any  of  the  cerebral  sinuses  after  in- 
fected compound  fracture  of  the  skull;  and  in  the  uterine  veins  during  puerperal 
-sepsis.  Portal  pyemia  results  from  thrombophlebitis  of  branches  of  origin  of 
the  portal  system_  (see  page  11 74).  Thrombo-arteritis  is  a  spreading  inflamma- 
tion of  an  artery  in  which  a  septic  thrombus  forms  or  in  which  a  septic  embolus 
lodges.  It  occasionally  attacks  an  aneurysmal  sac.  In  infective  thrombo- 
phlebitis and  in  arterial  pyemia  the  symptoms  are,  of  course,  those  of  pyemia. 
A  great  danger  of  venous  thrombosis  is  pulmonary  embohsm;  pulrnonary 
embolism  if  the  clot  is  in  a  systemic  vein,  portal  embolism  if  it  be  in  a  vein  of 
the  portal  system. 

Infective  Thrombosis  of  the  Lateral  Sinus. — (See  page  906.) 

Thrombosis  of  the  Jugular  Vein. — This  condition  is  usually  infectious  and 
secondary  to  infectious  thrombosis  of  the  lateral  sinus  or  sometimes  of  the 
petrosal  sinus.  It  is  occasionally  due  to  cancer,  tuberculosis,  acute  rheu- 
matism, or  pyemia,  taking  origin  from  a  distant  focus.  If  it  is  infectious,  the 
chills,  the  high  and  fluctuating  temperature,  and  the  great  exhaustion  pro- 
claim the  existence  of  pyemia.  Locally  the  vein  feels  hard,  the  adjacent  tissues 
are  edematous,  the  branches  of  the  jugular  are  visibly  distended,  there  may 
be  linear  discoloration  over  the  course  of  the  jugular,  and  the  head  is  held 
stiffly  ^^'ith  an  inclination  to  the  diseased  side. 

Thrombosis  of  the  Mesenteric  Vessels  (see  page  1122). — The  arteries  are 
affected  much  more  commonly  than  the  veins,  and  the  superior  mesenteric 
artery  far  more  often  than  the  inferior.  Vascular  disease  is  the  cause  of  arte- 
rial thrombosis,  and  arterial  thrombosis  occurs  chiefly  in  those  beyond  middle 
life.  Venous  thrombosis  may  be  primar}-  and  has  been  observed  after  splen- 
ectomy, the  clot  ha\'ing  propagated  to  the  mesenteric  veins.  It  may  occur 
as  a  result  of  any  gastro-intestinal  or  general  infection  (pyemia,  appendicitis, 
t\"phoid  fever).  Secondary  venous  thrombosis  is  due  to  portal  obstruction  or 
accompanies  arterial  mesenteric  thrombosis. 

Mesenteric  thrombosis  usually  produces  sooner  or  later  gangrene  of  the 
gut,  but  does  not  always  do  so. 

The  period  at  which  gangrene  develops  after  blocking  is  uncertain;  it 
may  arise  in  thirty-six  hours,  it  may  not  arise  for  two  weeks  or  more.  The  gut 
becomes  distended,  bloody  serum  exudes  into  the  peritoneal  cavity,  and  in 
most  cases  into  the  lumen  of  the  bowel.  The  mucous  membrane  undergoes 
necrosis  and  perforation  occurs.  The  area  involved  varies  greatly  in  differ- 
ent cases.  In  some  cases  it  is  very  limited,  and  is  rather  apt  to  be  in  the  large 
intestine.  In  other  cases  it  is  very  extensive,  and  is  apt  to  be  in  the  small 
intestine.  In  a  case  of  .the  author's  in  the  Jefferson  College  Hospital  prac- 
tically the  entire  ileum  was  gangrenous  and  numerous  perforations  existed. 

In  mesenteric  thrombosis  pain  arises  rather  suddenly  and  rapidly  becomes 
severe.  It  is  a  persistent  pain  with  paroxysmal  exacerbations  and  is  usually 
generalized,  though  in  many  cases  it  has  an  area  of  peculiar  intensity.  The 
pain  is  accompanied  by  rapid  pulse,  growing  exhaustion,  distention,  subnormal 
temperature,  tenderness,  a  mass  appreciable  by  palpation  in  the  region  of  the 


2o6  Thrombosis  and  Embolism 

mesentery,  free  fluid  in  the  peritoneal  cavity,  nausea,  and  vomiting.  The 
condition  suggests  intestinal  obstruction.  The  vomited  matter  consists  first 
of  the  contents  of  the  stomach,  then  of  bile,  finally  becomes  stercoraceous, 
and  sometimes  contains  blood. 

In  nearly  one-half  of  all  cases  blood  in  considerable  quantity  passes  from 
the  rectum. 

Ballance  points  out  that  cardiac  disease  or  arterial  degeneration  suggests 
the  artery  as  the  seat  of  thrombosis. 

The  only  chance  for  recovery  without  operation  is  the  establishment  of 
the  collateral  circulation,  and  as  the  superior  mesenteric  vessels  are  terminal 
vessels  this  seldom  occurs  (in  only  about  5  per  cent,  of  cases).  (See  Intestinal 
Obstruction  from  Mesenteric  Thrombosis.) 

Postoperative  Thrombosis. — This  complication  is  occasionally  encountered, 
may  involve  the  iliac,  the  femoral  or  the  saphenous  vein,  and  is  most  often  met 
with  in  the  left  side,  even  when  the  operation  has  been  in  the  middle  line  or 
the  right  side.  It  is  a  rare  complication,  occurring,  according  to  Professor 
Clark,  35  times  in  a  series  of  3000  operations.  In  5835  operations  performed  in 
the  Mayo  Clinic,  Beckman  states  there  were  16  cases  of  phlebitis  ("Annals  of 
Surgery,"  May,  1913).  In  three-fourths  of  the  cases  the  left  femoral  or  left 
internal  saphenous  was  involved.  In  one-fourth  the  lesion  was  on  the  right 
side.     Both  sides  may  be  involved. 

Many  explanations  have  been  given  to  account  for  it.  A  great  many  sur- 
geons regard  it  the  result  of  infection,  but  many  cases  certainly  are  not.  The 
most  common  cause  is  sepsis  but  clotting  can  occur  without  sepsis.  Clark 
believes  it  is  due  to  injury  of  the  deep  epigastric  vein,  forcible  and'prolonged 
separation  of  the  wound  edges  by  retractors  being  a  common  cause.  The 
free  anastomosis  between  the  epigastric  veins  of  the  two  sides  accounts  for 
the  appearance  of  thrombosis  on  one  side  after  operation  on  the  other.  It  is 
most  common  after  gall-bladder  and  pelvic  operations.  It  is  believed  that 
after  gall-bladder  operations  there  is  particular  risk  of  toxic  destruction  of 
blood  corpuscles.  It  is  held  by  McCann  ("Brit.  Med.  Jour.,"  March  9,  1918) 
that  transfixion  of  a  vascular  area  is  an  influential  cause  of  thrombosis  and 
embolism.  "By  transfixion  vessels  are  liable  to  be  punctured  and  bleed 
either  externally  or  into  the  tissues ;  the  transfixing  ligature  is  tied  to  arrest 
the  bleeding,  and  the  result  may  be  that  the  ligature  remains  in  the  lumen 
of  the  vessel.  Now,  if  this  ligature  is  of  doubtful  asepticity  or  becomes  subse- 
quently infected,  the  natural  process  of  clotting  in  the  vessel  may  be  arrested' 
the  clot  liquefying  and  becoming  detached  in  portions  or  in  its  entirety', 
(McCann,  Ibid.).  It  is  probable  that  in  many  slight  cases  the  condition  is  not 
recognized,  and  it  will  not  be  recognized  unless  the  clot  reaches  the  femoral 
vein,  and  it  requires  one  or  two  weeks  to  reach  this  vein  if  it  does  reach  it  at 
all.  When  a  clot  forms  in  the  femoral  vein  a  milk-leg  develops.  The  entire 
extremity  swells  below  the  seat  of  thrombus,  the  part  is  painful,  the  tem- 
perature is  usually  normal,  but  may  be  distinctly  elevated.  Embolism  may 
follow.     Embolism  may  be  pulmonary,  cerebral  or  coronar}^ 

Thrombosis  in  General  Infections. — In  typhoid  fever  a  thrombus  may  form 
in  the  heart,  the  veins,  or  the  arteries.  Thrombosis  may  occur  in  pneumonia, 
in  influenza  and  in  other  fevers,  and  in  tuberculosis.  The  vessels  of  a 
limb,  a  lung,  the  brain,  or  the  mesenteric  zone  may  suffer.  The  condition 
foUows  bacterial  infection,  the  veins  are  most  prone  to  suffer  and  gangrene  may 
ensue. 

Thrombosis  in  Appendicitis. — In  about  2  per  cent,  of  cases,  according  to 
Sonnenberg,  this  complication  is  noted.  It  may  affect  the  femoral  or  saphenous 
vein  of  either  side  or  of  both  sides,  the  portal  vein  or  the  vena  cava,  and  may 
occur  during  an  acute  attack,  but  is  more  often  noted  in  an  interval. 

It  is  not  very  unusual  to  find  liver  abscess  follow  appendicitis,  the  in- 


Embolism  207 

fection  being  carried  by  the  portal  vein  and  the  condition  being  known  as 
septic  pylephlebitis  (see  page  1174). 

Treatment — If  an  aseptic  thrombus  forms  in  a  large  vessel  of  a  limb,  raise 
the  limb  a  few  inches  from  the  bed,  keep  it  perfectly  quiet  to  avoid  detachment 
of  fragments  (em boh),  apply  a  bandage  lightly  from  the  toes  up,  and  place  Ijags 
of  warm  water  about  the  extremity.  Maintain  rest  for  four  or  five  weeks.  The 
great  danger  is  the  formation  of  emboli,  hence  movements  and  rough  handling 
are  to  be  avoided.  Gangrene  is  another  danger,  hence  it  is  wise  to  favor  venous 
return  and  the  development  of  the  collateral  circulation  by  warmth,  elevation, 
and  bandaging.  In  infective  thrombophlebitis,  if  the  vessel  is  accessible,  tie 
it  above  and  below  the  clot,  open  the  vessel,  remove  the  clot,  irrigate,  and  pack 
the  wound  with  iodoform  gauze.  The  general  treatment  for  a  septic  condi- 
tion should  be  stimulating  and  supporting.  Massage  is  unsafe  in  any  con- 
dition of  thrombosis,  and  is  particularly  dangerous  in  septic  thrombosis.  In 
■  a  man  with  a  large  hematoma  of  the  loin  massage  caused  fatal  pulmonary 
embolism.  In  thrombo-arteritis  treat  as  in  the  thrombophlebitis.  If  gangrene 
of  an  extremity  follows  thrombosis,  treat  as  previously  directed  (see  page  177). 
Gangrene  of  the  intestine  in  mesenteric  thrombosis  if  not  too  extensive  is 
treated  by  resection. 

The  treatment  of  infective  thrombosis  of  the  lateral  sinus  is  set  forth  on 
page  908, 

Embolism  signifies  vascular  plugging  by  a  foreign  body  (usually  a  blood- 
clot)  which  has  been  brought  from  a  distance.  The  foreign  body  is  called  an 
embolus.  An  embolus  usually  consists  of  a  separated  or  ruptured  portion  of  a 
thrombus,  atheromatous  material  from  a  diseased  artery,  or  a  bit  of  fibrin 
from  a  diseased  heart-valve.  In  some  cases  an  embolus  consists  of  bacteria, 
of  air,  of  fat,  of  a  fragment  of  a  tumor,  or  of  parasites.  In  severe  burns  the  blood 
undergoes  changes  and  jelly-like  matter  is  often  precipitated  and  may  cause 
embolism,  Emboli  vary  in  shape,  in  size,  and  in  consistency.  Emboli  are 
divided  into  simple,  bland  or  aseptic  and  infective,  toxic  or  septic.  Emboli  may 
arise  either  in  the  venous  or  in  the  arterial  system,  but  are  particularly  prone  to 
arise  in  the  veins;  they  lodge  in  an  artery,  in  capillaries,  or  in  the  veins  of  the 
liver.  An  embolus  taking  origin  in  one  of  the  systemic  veins  passes  through 
the  right  heart  and  lodges  in  a  terminal  branch  of  the  pulmonary  artery.  If 
at  this  point  it  disintegrates,  smaller  emboli  pass  to  the  left  heart  and  enter 
the  arterial  circulation  to  be  deposited,  as  are  emboli  originating  in  the  heart 
or  arteries,  in  the  arteries  of  an  extremity,  the  kidneys,  spleen,  or  brain.  Em- 
boli of  the  portal  circulation  lodge  in  the  liver  or  perhaps  pass  through  that 
organ  and  reach  the  lungs.  An  embolus  is  arrested  when  it  reaches  a  vessel  the 
diameter  of  which  is  less  than  its  own.  It  is  usually  caught  just  above  a  bifur- 
cation. When  an  embolus  lodges,  it  at  once  partially  or  entirely  obstructs  the 
circulation  and  increases  in  size  by  thrombosis.  Figure  100  shows  an  impacted 
embolus.  A  non-septic  embolus  when  lodged  usually  "organizes,"  as  does  a 
thrombus,  and,  as  described  on  page  204,  is  replaced  ultimately  by  fibrous 
tissue,  A  soft  embolus  may  disintegrate  and  permit  the  re-establishment  of 
the  circulation.  An  embolus  may  cause  an  aneurysm.  A  septic  embolus  breaks 
down,  forms  a  metastatic  abscess,  and  sends  other  emboli  onward  in  the  blood- 
stream.    It  may  arise  in  typhoid  fever. 

An  embolus  is  more  serious  than  a  thrombus:  it  causes  sudden  plugging, 
which  makes  dangerous  anemia  inevitable,  and  it  will  produce  gangrene  if 
the  collateral  circulation  fails.  EmboHsm  of  the  mesenteric  artery  causes 
necrosis  of  the  intestine.  In  organs  with  terminal  arteries  (spleen,  kidney, 
brain,  and  lung)  there  is  no  collateral  circulation  and  embolism  causes  in- 
Jarction.  For  instance,  if  an  embolus  lodges  in  the  lung  it  produces  an  area 
of  ischemia;  the  removal  of  all  propulsion  upon  the  venous  blood  causes  it  to 
flow  back  and  stagnate,  and  vascular  elements  exude  and  form  a  wedge-shaped 


208 


Thrombosis  and  Embolism 


area  of  red  tissue,  the  embolus  being  the  apex  of  the  wedge.  This  is  known  as 
hjemorrhugic  or  red  infarction^  and  is  often  seen  in  the  lung  (Fig.  loi).  The 
white  infarction,  seen  in  the  brain  and  kidney,  is  not  due  to  retrogression  of 
venous  blood,  but  is  due  to  ischemia  resulting  in  coagulation-necrosis.  A 
septic  embolus  causes  septic  thrombosis  and  a  septic  infarction,  and  a  septic 
infarction  is  followed  by  suppuration  and  the  production  of  a  pyemic  abscess. 
That  emboli  of  the  systemic  venous  circulation  usually  lodge  in  the  lungs  ex- 
plains the  occurrence  of  pulmonary  embolism  after  certain  operations  upon 
and  during  certain  diseases  of  the  regions  drained  by  the  systemic  veins.  Emboli 
formed  in  vessels  of  the  systemic  circulation  lodge  most  often  in  the  lungs, 
brain,  kidney,  or  spleen.  It  is  because  emboli  which  pass  into  the  portal 
vein  lodge  in  the  liver  that  operations  upon  the  rectum  may  be  followed  by 
hepatic  embolism  and  abscess  of  the  liver. 

General  Symptoms. — The  symptoms  depend  upon  the  organ  involved 
and  the  presence  or  absence  of  infection.  They  are  sudden  in  onset,  and 
are  due  to  loss  of  function,  which  may  be  permanent  or  which  may  be  fol- 
lowed by  inflammation,  softening,  or  gangrene.  In  a  septic  embolus  there 
are  symptoms  of  infection  and  abscess  forms  at  the  seat  of  lodgment.     In 


^=^ 


Fig.   ICO. — Embolus  impacted  at  bifurca-  Fig.     ioi. — Diagram    of    a    hemorrhagic 

tion  of  a  branch  of  the  pulmonarj'  artery  infarct:  a,  Artery  obliterated  by  an  embo- 
(Green).  lus  (e);  v,  vein  filled  with  a  secondary- throm- 

bus (///);  I,  center  of  infarct,  which  is  be- 
coming disintegrated;  2,  area  of  extravasa- 
tion; 3,  area  of  collateral  hyperemia  (O. 
Weber). 

the  course  of  pyemia  a  chill  usually  means  the  occurrence  of  embolism.  Em- 
bolism of  the  cerebral  arteries  may  cause  aphasia,  paralysis,  or  coma.  Embo- 
lism of  the  pulmonary  artery  may  cause  almost  instant  death.  EmboHsm  of 
a  large  artery  of  a  limb  produces  symptoms  similar  to  those  of  thrombus,  ex- 
cept more  sudden  and  decided.  Below  the  obstruction  the  pulse  is  absent  and 
the  limb  is  swollen  with  edema,  is  cold,  and  is  discolored.  There  is  pain  at 
the  seat  of  obstruction.  This  condition  is  frequently  followed  by  gangrene. 
Embolism  of  the  superior  mesenteric  artery  produces  symptoms  similar  to 
those  caused  by*  acute  intestinal  obstruction,  and  results  in  gangrene  of  a 
portion  of  the  intestine. 

Postof)erative  Embolism. — It  may  result  from  clotting  in  varicose  veins, 
in  veins  of  a  uterine  fibroid,  from  pelvic  veins  when  an  ovarian  cyst  exists, 
and  from  clot  in  a  cerebral  sinus.  It  may  occur  from  cancer  or  tuberculosis. 
Cases  of  pulmonary  embolism  have  resulted  from  mammary  cancer,  uterine 
cancer  and  prostatic  cancer.  It  may  follow  a  facial  infection,  a  fracture,  a 
dislocation  and  gonorrhoea  in  the  female.  It  may  result  from  any  operation 
but  is  especially  apt  to  follow  operations  on  the  gall-bladder  and  the  female 
genitalia.  In  most  cases  but  not  in  all,  there  is  sepsis.  In  the  Mayo  Clinic 
during  the  years  1899-1911  inclusive,  there  were  63,573  major  operations  and 


Treatment  of  Embolism  209 

47  fatal  cases  of  embolism  (L.  B.  Wilson,  in  "Annals  of  Surgery,"  Dec., 
1912).  There  were  2  deaths  after  operations  on  blood-vessels,  2  after 
operations  on  the  thyroid,  i  after  an  operation  on  the  mouth,  3  after  opera- 
tions on  the  stomach  or  duodenum,  9  after  operations  on  the  gall-bladder,  i 
after  operation  on  the  small  intestine,  4  after  operations  on  the  ai)pendix,  5 
after  operations  on  the  colon  and  rectum,  5  after  operations  for  hernia,  i  after 
a  kidney  operation,  4  after  operations  on  the  prostate,  10  after  operations  on 
the  uterus,  tubes  and  ovaries.  In  36  cases  the  emboUsm  was  pulmonary, 
in  10  cerebral  and  in  i  coronary.  A  large  hematoma  is  a  danger  as 
embolism  may  result.  Hence  a  large  hematoma  should  be  evacuated. 
Careless  hemostasis  in  an  abdominal  or  pelvic  operation  leads  to  the  forma- 
tion of  a  large  blood  lake.  A  thrombus  forms  and  emboli  may  result.  Trans- 
fixion of  a  vascular  area  may  lead  to  embolism  (page  206). 

Pulmonary  Embolism. — This  condition  occasionally  follows  operations 
and  injuries  and  sometimes  develops  during  certain  diseases.  I  have  seen  a 
case  after  an  operation  for  appendicitis,  a  case  after  an  operation  for  varicocele, 
a  case  after  an  operation  for  hydrocele,  a  case  after  operation  for  perforated 
duodenal  ulcer,  a  case  after  gastrostomy,  and  a  case  in  a  man  with  a  large 
lumbar  contusion  to  which  massage  was  injudiciously  applied.  It  arises  in 
most  cases  from  ten  to  twenty  days  after  the  operation.  In  one  of  Mayo's  cases  it 
arose  on  the  sixty-fourth  day.  The  patient  is  thought  well  or  almost  well.  If  the 
wound  is  examined  postmortem  it  will  be  found  to  contain  some  liquefied 
blood-clots.  Absorption  of  these  altered  clots  is  probably  the  cause  of  the 
condition.  Vvelcker  puts  forth  this  view  and  maintains  that  failure  to  ligate 
aU  the  veins  leads  to  bleeding  after  the  wound  has  been  closed  and  disintegration 
of  the  blood-clots  causes  embolism  ("Deutsche  Gesellsch.  f.  Chir.,"  1914). 
McCann  regards  transfixion  of  a  muscular  area  as  causal  ("Brit.  Med.  Jour.," 
March  9,  1918).  It  is  not  very  common.  Albanus  ("Beitrage  klin.  Chir.," 
xl)  in  1 140  abdominal  operations  found  23  cases.  The  emboli  may  be  aseptic  or 
■septic.  The  condition  is  most  common  as  a  result  of  thrombosis  of  the  veins 
of  the  lower  extremities,  appendicitis,  gall-bladder  operations,  operations  on  the 
female  pelvic  organs,  and  strangulated  hernia.  Certain  postoperative  pneu- 
monias are  embolic.  Very  small  aseptic  emboli  may  cause  no  symptoms  or 
slight  symptoms.  WTien  aseptic  hemorrhagic  infarction  occurs  there  are 
s\Tnptoms.  These  symptoms  are  a  chill  or  chilly  sensations,  moderate  fever 
which  may  be  transitory,  dyspnea,  rapid  pulse,  pain  in  the  chest,  sometimes 
rapidly  advancing  signs  of  consolidation,  often  a  pleural  friction-  sound,  and 
bloody  expectoration.  If  the  embolus  is  large  (occluding  embolus)  there  may 
be  immediate  or  very  rapid  death.  The  mortality  is  always  large  (80  per 
cent.).  I  am  satisfied  that  it  is  a  much  more  common  condition  than  we 
formerly  supposed,  and  that  some  cases  in  which  the  emboli  are  very  small  are 
not  diagnosticated  and  recover. 

A  septic  embolism  causes  metastatic  abscess  and  usually  suppurating 
pleuritis,  the  condition  being  known  as  septic  emboHc  pneumonia.  Recovery 
is  rare,  but  occasionally  occurs.  The  symptoms  are  those  of  pyemia  with  the 
physical  signs  of  consolidation  and  of  pleuritis. 

Embolism  of  the  Mesenteric  Arteries. — The  superior  mesenteric  is  the 
vessel  usually  affected.  It  may  arise  in  pyemia,  septicemia,  arterial  or  cardiac 
•disease.  The  symptoms  are  practically  identical  with  thrombosis  of  the 
mesenteric  vessels,  except  they  arise  suddenly.  There  is  usually  endocardial 
disease  (see  page  11 17). 

Treatment. — iSIurphy  removed  an  embolus  from  the  femoral  and  iliac  arte- 
ries through  an  incision  in  the  femoral,  and  then  sutured  the  incision  ("Jour. 
Amer.  Med.  Assoc,"  May  22,  1909).  The  operation  was  too  late  to  prevent 
gangrene,  but  it  emphasizes  the  truth  that  an  aseptic  embolism  of  a  large 
artery  can  be  treated  by  incision  of  the  artery,  removal  of  the  clot,  and  suture 
14 


2IO 


Thrombosis  and  Embolism 


of  the  vessel.  This  plan  has  been  followed  by  others.  It  is  suitable  to  early 
cases.  If  gangrene  is  threatened,  consider  arteriovenous  anastomosis  (page 
179).  The  treatment  long  in  vogue  was  as  follows:  In  a  limb,  keep  the  part 
warm  in  order  to  stimulate  the  collateral  circulation,  elevate  the  extremity 
several  inches  from  the  bed,  apply  a  bandage  lightly  from  the  periphery,  and 
insist  on  perfect  quiet.  Massage  is  unsafe.  If  gangrene  ensues,  await  a 
line  of  demarcation  and,  when  it  forms,  amputate.  In  septic  embolic  arteritis 
in  an  accessible  region  it  would  be  good  surgery  to  act  as  in  septic  thrombo- 
phlebitis. After  an  operation  upon  veins  (as  the  operation  for  varicocele,  for 
varix  of  the  leg,  or  for  hemorrhoids),  after  any  cutting  operation,  and  after 
the  infliction  of  a  fracture,  avoid  as  much  as  possible  and  for  some  time  move- 
ments or  handling,  as  fragments  of  thrombus  may  be  detached. 

In  mesenteric  embolism  exploratory  laparotomy  may  disclose  a  perfora- 
tion which  can  be  closed  or  a  portion  of  gangrenous  gut  which  can  be  resected. 

In  aseptic  pulmonary  embolism  enforce  absolute  rest,  give  strychnin  and 
morphin  hypodermatically,  and  inhalations  of  oxygen.  Trendelenburg  has 
suggested  operation  for  occluding  pulmonary  embolism  (see  page  1028). 

In  septic  embolic  pneumonia  pursue  the  conservative  plan  of  treatment 
unless  a  large  pulmonary  abscess  forms  or  an  empyema  arises.  In  either  case 
operate  to  remove  pus. 

Fat=emboIism  in  the  human  being  was  first  noted  by  MacGibbon,  of  New 
Orleans,  in  1856,  and  was  first  thoroughly  described  by  von  Recklinghausen  in 
although  Magendie,  in  1827,  and  Virchow,  in  1856,  developed  it  experi- 


mentally in  animals.     It  is  a  process 
capillaries  of  liquid  fat  after  injury 


which  leads  to  an  accumulation  in  the 
to  adipose  tissue,  high  tension  having 
forced  the  fat  into  the  open  mouths  of 
veins.  Fat  may  be  forced  into  open 
veins  by  muscular  action,  by  efforts  at 
repair,  or  by  concealed  bleeding.  Fat 
may  get  into  the  blood  by  means  of  the 
lymphatics  and  it  can  also  enter  by  way 
of  the  synovial  membrane.  Wilms  be- 
lieves that  fat  reaches  the  veins  by  way 
of  the  lymphatics  and  the  thoracic  duct. 
Fat  in  the  blood  is  quite  a  common 
condition,  but  seldom  produces  serious 
trouble,  although  it  is  occasionally  fatal 
and  is  responsible  for  some  otherwise  in- 
explicable sudden  deaths  after  fractures. 
Fat-embolism  may  arise  during  osteo- 
myelitis, after  extensive  bruises,  crushes, 
lacerations,  amputations,  fractures,  re- 
sections, or  rupture  of  the  liver.  ^  In  a 
fatal  case  of  mine  it  developed  as  a  result  of  manipulation  of  a  fracture  of 
the  neck  of  the  femur.  In  another  fatal  case  it  followed  amputation  for  cancer 
of  the  breast  of  a  very  fat  woman.  This  fluid  fat  accumulates  especially  in 
the  capillaries  of  the  lungs  and  brain.  It  may  plug  systemic  capillaries.  If 
the  patient  recovers,  he  does  so  because  the  fat  has  been  forced  through  the 
vessels;  if  he  dies,  the  death  results  from  mechanical  hindrance  to  function 
and  nutrition.  When  the  emboli  are  widely  scattered  and  not  large,  and 
when  they  do  not  lodge  in  vital  parts  of  the  brain  or  cord  they  may  produce  no 
symptoms  and  do  no  real  harm.  Normal  blood  contains  a  small  amount 
of  finely  emulsified  fat  (from  i  to  3  parts  per  1000).  In  a  number  of  ph}-sio- 
logical  and  .pathological  conditions  the  circulating  blood  contains  considerable 
free  fat.  It  may  be  found  in  a  pregnant  woman,  a  nursing  baby,  a  fat  individual, 
1  G.  H.  Makins,  in  "Heath's  Dictionarj'." 


Fig.  102. — Fat-embolism  of  the  lung  after 
fracture  of  the  femur.  The  fat-globules  and 
masses,  stained  black  with  osmic  acid,  lie  in 
the  capillaries  of  the  lung;  X  150  (Hektoen). 


Symptoms  of  Fat  Embolism  211 

or  in  anyone  during  digestion.  "It  has  been  noted  in  tlic  following  conditions: 
chronic  alcoholism;  diabetes  mellitus;  certain  diseases  of  the  liver,  heart,  and 
pancreas;  chronic  nephritis;  splenitis,  tuberculosis;  malarial  fever,  typhus 
fever;  Asiatic  cholera,  and  poisoning  by  phosphorus  and  by  carbon  monoxid. 
Lipemia  commonly  occurs  as  the  result  of  lacerated  wounds  of  the  blood- 
vessels situated  in  fatty  tissue,  and  after  fractures  of  long  bones  involving 
injury  of  the  fatty  matter"  (''Clinical  Hematology,,"  by  John  C.  DaCosta, 
Jr.).  In  many  cases  of  fracture  in  adults  fat  is  found  in  the  urine.  I  have 
had  this  demonstrated  by  repeated  observations.  When  we  recall  how  rarely 
simple  fracture  causes  death  it  becomes  evident  that  a  moderate  amount  of 
fat  in  the  blood  is  not  dangerous  or  only  becomes  dangerous  if  it  fails  to  flow 
out.  In  lipemia  fatty  embolism  may  occur  if  the  amount  of  fat  becomes 
excessive  or  if  vascular  damage  favors  plugging.  At  my  suggestion.  Dr.  Wm. 
Carrington  conducted  an  investigation  to  determine  the  frequency  of  lipuria 
after  fractures  (Essay  Awarded  the  Surgical  Prize  in  Jefferson  Medical  College 
in  1908).  He  determined  that  fracture  of  a  long  bone  invariably  causes  lipuria, 
fracture  of  a  small  bone  seldom  does;  that  after  fracture  of  a  long  bone  fat 
appears  in  the  urine  "on  different  days,  in  different  amounts,  and  in  different 
forms"  (this  curious  periodicity  was  first  observed  by  Scriba  in  1878);  that 
when  fat  is  present  albumin  is  almost  always  present  and  blood  is  occasionally 
found;  that  the  urea  percentage  falls  as  the  fat  content  rises  and  rises  as  the  fat 
content  falls;  that  the  condition  is  rare  in  young  children  and  that  fat-embolism, 
as  a  rule,  is  a  benign  process;  that  about  the  fifteenth  day  after  a  fracture  fat 
usually  disappears  from  the  urine.  Carrington,  in  1908,  found  in  literature 
276  reported  cases  of  fat-embolism.  Buerger  thinks  that  fat  emboU  are  much 
more  common  than  we  have  suspected  ("Progressive  Medicine,"  Dec,  1916. 
Article  on  "Shock"). 

Symptoms  arise  only  when  many  emboH  block  a  multitude  of  the  capillaries 
of  an  organ,  when  a  large  embolism  lodges,  or  when  the  capillaries  of  a  vital 
region  of  the  brain  are  blocked  (the  medullary  centers) .  Emboli  are  most  apt  to 
form  after  or  during  handling  of  the  wound  or  seat  of  injury  or  exhausting 
movement  of  the  patient.  Hence  one  peril  of  transportation  after  an  accident, 
of  early  massage,  of  frequent  changes  of  dressings,  and  of  getting  up  too  early 
after  operation  (Groendahl,  "Deut.  Zeitsch.  f.  Chir.,"  1911,  cxi).  The  symp- 
toms are  those  of  edema  of  the  lungs  and  exhaustion,  often  with  coma  or  delir- 
ium, and  sometimes,  in  the  beginning,  are  wrongly  thought  to  be  due  to  shock. 
There  are  restlessness,  dyspnea,  rapid  and  weakening  pulse  and  rapid  respira- 
tion, contracted  pupils,  and  pallor  followed  by  cyanosis.  The  temperature 
may  be  elevated,  normal,  or  subnormal.  Many  coarse  rales  are  heard  in  the 
chest,  but  percussion  gives  a  clear  note.  If  pulmonary  edema  becomes  marked, 
the  patient  spits  up  a  bloody  froth.  If  life  is  prolonged  a  day  or  two,  oil  is 
found  in  the  urine.  Small  amounts  of  oil  may  be  found  in  the  urine  after 
serious  injuries  or  operations  when  no  symptoms  of  embolism  exist.  Never- 
theless, the  presence  of  the  oil  is  always  a  cause  of  anxiety  and  is  often  a  warn- 
ing. It  is  maintained  by  Groube  that  the  amount  of  fat  in  the  urine  is  in  inverse 
ratio  to  the  amount  in  the  blood;  the  greater  the  amount  excreted  in  the  urine, 
the  less  the  amount  retained  in  the  blood.  Hence,  fat  in  the  urine  makes  the 
surgeon  anxious,  and  a  sudden  diminution  of  the  amount  in  the  urine  is  a  sign 
of  grave  danger  if  there  develops  increasing  difficulty  in  respiration  ("Rev.  de 
Chir.,"  Juty,  1895).  The  inverse  ratio  said  to  be  maintained  between  fat  in  the 
blood  and  fat  in  the  urine,  if  it  really  exists,  is  similar  to  a  finding  of  Lepine  in 
diabetes,  that  is,  if  a  diabetic  is  given  diuretics,  the  sugar  in  the  urine  increases 
and  the  sugar  in  the  blood  decreases.  Fat-embolism  is  one  of  the  possible  causes 
of  symptoms  of  shock  after  injury.  Cases  of  fat-embolism  may  preset  symp- 
toms like  those  of  shock  (Bissell,  "Jour.  Am.  Med.  Assoc,"  Dec.  23,  1916). 
The  symptoms  of  fat-embolism  seldom  occur  until  at  least  twelve  hours  after 


212  Thrombosis  and  Embolism 

an  accident,  and  rarely  before  the  third  day,  but  may  occur  much  earlier.  In 
a  case  of  mine  it  occurred  during  the  manipulation  of  a  fracture  of  the  femur 
and  the  condition  was  first  thought  to  be  due  to  ether.  The  man  never  re- 
gained consciousness  and  died  in  a  couple  of  hours.  As  a  matter  of  fact  fat- 
embolism  very  seldom  arises  until  at  least  three  hours  after  an  injury,  the 
symptoms  occurring  at  a  later  period  than  those  of  shock  and  at  an  earlier 
period  than  those  of  ordinary  embolism  of  the  lung.  The  imi)ortant  point 
emphasized  by  Carrington  is  that  after  the  reaction  from  shock,  if  there  has  been 
shock,  and  for  hours  or  days  after  the  injury  in  any  case,  there  is  a  period  of 
freedom  from  all  alarming  symptoms,  and  that  the  symptoms  of  fat-embolism 
come  on  suddenly  and  without  warning.  If  some  of  the  oil  is  forced  through 
the  vessels  of  the  lung,  it  will  lodge  in  other  regions  and  produce  other  symptoms. 
Oil  may  appear  in  the  urine  as  above  stated.  Urinary  suppression  may  occur. 
DeUrium  may  arise,  there  may  be  twitching,  convulsions  or  paralysis,  or  the 
patient  may  pass  into  coma.  Cases  with  delirium  are  sometimes  diagnosticated 
delirium  tremens.  The  eye-ground  may  show  choked  disk,  hemorrhage,  and 
fat  in  the  vessels  (Connel's  case  and  Czerny's  case).  Cases  of  fat-embolism 
with  severe  symptoms  are  commonly  fatal;  milder  cases  are  often  recovered 
from.  In  mild  cases  the  symptoms  last  but  a  few  days,  in  severe  cases  the 
condition  may  prove  fatal  in  from  a  few  hours  to  seven  days  after  the  injury, 
and  in  from  a  few  to  forty-eight  hours  after  the  appearance  of  symptoms.  A 
patient  may  have  two  or  three  attacks.  Connel's  patient  had  three  attacks, 
there  being  an  interval  of  a  week  between  the  first  and  second  and  between  the 
second  and  third  attacks. 

Treatment. — It  will  aid  in  the  prevention  of  fat-embolism  if  transportation 
be  accomplished  as  gently  and  rapidly  as  possible.  In  a  case  like  a  crush  or  a 
compound  fracture  the  application  of  an  Esmarch  band  favors  clotting  and 
clots  tend  to  prevent  the  entrance  of  fat  into  the  vessels.  Early  and  free 
incision  of  a  crushed  area  or  amputation  of  the  extremity  will  probably  prevent 
fat-embolism.  (See  Buerger's  views  and  Bloodgood's  comments,  in  "Pro- 
gressive Med.,"  Dec,  1916.) 

Wilms,  acting  on  his  belief  that  fat  enters  the  lymphatic  duct  and  from 
there  gets  into  the  venous  circulation,  treated  one  ca^^e  of  fat-emboUsm  suc- 
cessfully by  making  a  fistula  in  the  thoracic  duct.  This  operation  might 
be  justifiable  when  dangerous  brain  symptoms  are  known  to  be  due  to  fat- 
emboli.  The  usual  treatment  consists  in  absolute  rest  of  the  diseased  or  injured 
part  and  the  administration  of  stimulants,  such  as  strychnin,  alcohol,  and 
carbonate  of  ammonium,  the  use  of  external  heat;  the  employment  of  oxygen 
by  inhalation,  and  the  administration  of  diuretics  and  of  nitroglycerin  hypo- 
dermatically.  Artificial  respiration  may  tide  a  patient  over  a  crisis.  If  an  exter- 
nal wound  exists,  free  drainage  must  be  established,  and  the  diseased  or  damaged 
part  should  be  thoroughly  immobilized  if  possible.  In  order  to  prevent  fat- 
embolism  after  a  severe  injury  insist  on  rest.  Massage  used  early  after  some 
injuries  is  dangerous,  as  it  may  force  fluid  fat  into  the  vessels.  Getting  up 
very  early  after  operation  is  not  safe.  Frequent  changes  of  dressings  are  un- 
desirable. When  severe  contusion  causes  the  formation  of  a  large  cavity  filled 
with  blood,  Groube  wisely  advises  incision  to  lessen  the  danger  of  fat-embolism.^ 

Air=embolism. — Air  may  enter  a  vein  during  a  surgical  operation  or  it 
may  be  injected  accidentally  while  giving  a  "hypodermatic  injection,  hypo- 
dermoclysis,  or  a  saline  infusion  into  a  vein.  It  has  followed  irrigation  of  the 
pleura  with  hydrogen  peroxid.  In  caisson  disease  it  is  taught  by  some  that 
nitrogen  is  set  free  in  the  blood.  It  may  occur  when  a  cerebral  sinus  is  opened, 
and  some  say  in  the  uterine  veins,  if  the  uterus  does  not  remain  contracted 
after  delivery.  Brouardel  denies  emphatically  that  air  enters  the  uterine 
sinuses  ("Death  and  Sudden  Death").     Dupuytren  and  Berard  claimed  that 

^  "Rev.  de  Chir.,"  July,  1895. 


Focal  Sepsis  213 

in  wounds  of  the  neck  air  could  enter  the  veins  and  if  it  did  so  instant  death 
would  follow.  It  is  very  seldom  that  any  symptoms  follow.  It  was  long 
thought  that  such  an  accident  must  be  always  extremely  dangerous.  The 
experiments  of  my  colleague,  Professor  Hare,  indicate  that  quantities  of  air 
may  be  injected  into  the  veins  of  a  dog  without  apparent  harm.  The  entry 
of  a  small  amount  of  air  into  the  veins  of  a  human  being  will  not  be  apt 
to  induce  dangerous  symptoms,  but  it  may  cause  dangerous  symptoms  and 
even  death.  The  more  rapidly  it  is  introduced  and  the  greater  the  amount, 
the  greater  is  the  danger.  The  manner  in  which  it  can  induce  death  is 
doubtful.  Some  maintain  that  it  causes  blood  in  the  right  side  of  the  heart 
to  froth,  and  thus  prevents  normal  action  of  the  valves,  the  heart  becoming 
unable  to  propel  blood  through  the  lungs.  Others  maintain  that  air  reaches 
the  cerebral  capillaries  and  so  causes  cerebral  anemia.  Some  believe  cardiac 
failure  results  from  the  presence  of  air  in  the  pulmonary  capillaries.  The 
first  view  is  the  most  probable.  If  a  surgeon  divides  a  large  vein,  air  may 
be  sucked  in,  and  there  is  particular  danger  in  such  an  accident  if  a  vein  at 
the  root  of  the  neck  or  a  cerebral  sinus  is  torn  or  incised,  or  if  the  damaged 
vessel  lies  in  scar  tissue  and  cannot  collapse. 

Symptoms. — When  during  an  operation  air  enters  a  large  vein  there  is 
a  sucking  sound,  air-bubbles  may  be  noted  in  the  wound,  and  serious  symp- 
toms may  or  may  not  follow.  Twice  I  have  wounded  the  subclavian  vein  and 
have  heard  this  sound,  but  no  alarming  symptoms  developed.  If  serious 
symptoms  are  produced,  they  arise  suddenly,  and  consist  of  extreme  failure 
of  circulation,  a  curious  whirring  or  churning  sound  synchronous  with  cardiac 
systole  and  audible  even  without  a  stethoscope,  deadly  pallor  or  cyanosis, 
gasping  for  air,  convulsions,  and  possibly  death. 

Treatment, — Compress  the  vein  with  the  finger  and  clamp  the  venous 
wound  quickly.  Suspend  the  anesthetic,  lower  the  head,  employ  artificial 
respiration,  give  inhalations  of  oxygen,  hypodermatic  injections  of  strychnin, 
and  intravenous  infusion  of  normal  salt  and  adrenalin. 


X.  FOCAL  SEPSIS.    SEPTICEMIA  AND  PYEMIA 

Focal  Sepsis. — By  focal  sepsis  we  mean  an  area  of  infection  which  is  or 
may  become  responsible  for  some  distant  or  general  disease.  If  on  examining 
a  sufferer  from  some  form  of  arthritis,  the  surgeon  discovers  a  running  sinus 
or  a  suppurating  gland  he  at  once  suspects  that  the  joint  trouble  may  have 
resulted  from  the  suppuration.  But  if,  in  a  like  case  of  joint  disease  he  sees  no 
discharging  pus  he  must  not  conclude  that  pus  has  no  hand  in  causing  the  con- 
dition, as  there  may  be  concealed  suppuration.  Our  habit  has  been  to  regard 
the  secondary  disease  as  the  disease,  but,  as  Daland  says,  "Concealed  pus  is 
the  danger"  (Judson  Daland,  "Dental  Cosmos,"  May,  1916).  Bacteria  taken 
up  from  a  region  of  concealed  suppuration  may  cause  various  diseases — for 
instance,  septicemia,  pyemia,  arthritic  inflammation,  chorea,  purpura,  abscess 
of  the  liver,  endocarditis,  nephritis,  pancreatitis,  abscess  of  the  brain,  chole- 
cystitis or  rheumatoid  arthritis.  Again,  a  concealed  suppuration  may  under- 
mine the  general  health,  may  produce  anemia,  may  cause  certain  nervous 
maladies  and  may  be  responsible  for  grave  disease  of  the  eye,  middle  ear  or 
internal  ear. 

Nearly  ten  years  ago  Rosenau  pointed  out  that  streptococci  increase  in 
virulence  as  oxygen  is  diminished  so  that  a  mild  streptococcus  may  become 
very  virulent.  In  further  studies  he  has  shown  that  a  certain  variety  of 
streptococcus,  wherever  lodged  has  an  affinity  for  certain  tissues.  Some 
varieties  have  an  affinity  for  joints,  some  for  the  pericardium,  some  for  muscles, 
some  for  the  endocardium,  etc.     This  fact  explains  the  diverse  maladies  which 


214  Focal  Sepsis.     Septicemia  and  Pyemia 

may  arise  from  a  focal  infection.  (See  Rosenau,  in  "Jour.  Am.  Med.  Assoc," 
Nov.  7,  1908,  and  Nov.  29,  1913.  Rosenau  and  Davis,  "Jour.  Am.  Med, 
Assoc,"  April  15,  1915  and  Frank  Billings,  "Jour.  Am.  Med.  Assoc,"  Sept. 
12,  1914). 

Focal  infections  may  exist  in  the  genito-urinary  tract,  the  gastro-intestinal 
tract,  the  mastoid  and  middle  ear,  the  nasopharynx,  and  the  sinuses.  Intes- 
tinal stasis  is  thought  to  be  a  not  uncommon  cause  of  distant  trouble.  So  is 
chronic  appendicitis. 

The  tonsil,  the  prostate,  the  sinuses  and  the  mouth  are  the  commonest 
regions  involved.  Beyond  doubt  oral  sepsis  is  the  chief  cause  of  focal  infection. 
In  1859  Chassaignac  claimed  that  a  putrid  condition  of  the  gums  could  cause 
septicemia.  In  1889  Miller  of  Germany,  pointed  out  that  oral  sepsis  can 
cause  distant  disease.  There  may  be  pyorrhea  alveolaris,  decay  of  teeth, 
disease  of  pulp,  exposure  of  bone  between  the  teeth,  exposure  of  a  root  to  the 
tip,  abscess  about  the  apex  of  the  root,  apical  granuloma,  accumulation  of  foul 
matter  in  bridge-work  or  a  deficient  crown  to  a  dead  tooth.  The  .r-rays  are  of 
enormous  service  in  finding  abscesses  about  tooth  roots.  In  every  case  of 
disease  in  which  focal  sepsis  might  be  the  cause,  .v-ray  pictures  of  the  teeth 
should  be  taken,  a  skilled  dentist  should  examine  the  teeth  and  gums,  and  every 
region  in  the  body  in  which  a  cause  might  reside  must  be  investigated  carefully 
by  surgeon  and  specialist.  Only  thus  can  we  reach  the  cause  of  many  obscure 
cases  of  arthritis,  empyema,  nephritis,  pericarditis,  endocarditis,  cholecystitis, 
brain  abscess,  etc. 

Septicemia,  or  sepsis,  is  a  febrile  malady  due  to  the  introduction  into 
the  blood  of  pyogenic  organisms  or  the  products  of  saprophytic  bacteria. 
There  is  no  one  special  causative  organism,  and  any  microbe  which  produces 
inflammatory  and  febrile  products  may  cause  it.  Either  streptococci  or 
staphylococci  may  be  present.  Pneumococci  are  a  not  very  unusual  cause. 
Septicemia  arises  by  absorption  of  septic  matter  by  the  lymphatics.  Clin- 
ically, we  distinguish  two  forms  of  septicemia:  (i)  sapremia,  septic  or  putrid 
intoxication,  and  (2)  septic  infection,  true  or  progressive  septicemia.  In 
these  conditions  the  area  of  infection  is  usually  discovered  by  the  surgeon; 
but  when  it  cannot  be  located,  the  disease  is  called  by  the  Germans  cr>T3to- 
genetic  septicemia. 

Sapremia,  Septic  or  Putrid  Intoxication. — This  condition  is  due  to  the 
absorption  of  poisonous  ptomains  from  a  putrefying  area.  The  bacteria 
do  not  enter  the  blood,  but  their  toxins  do,  and  as  these  toxins  are  active 
poisons  the  condition  is  comparable  to  poisoning  by  successive  alkaloidal 
injections,  the  symptoms  and  prognosis  depending  upon  the  dose.  Not 
unusually  there  is  absorption  not  only  of  the  toxins  of  saprophytic  bacteria, 
but  also  of  the  toxins  of  pyogeilJQ^micro-organisms.  Even  if  some  of  the  bacteria 
enter  the  blood,  they  do  ncrt  rm^tiply  in  this  fluid.  Slight  symptoms  and 
recovery  follow  a  small  dose;  api'N'^symptoms,  even  death  follow  a  large  one. 
The  poison  does  not  multiply  m  the  blood,  and  a  drop  of  the  blood  of  a  per- 
son laboring  under  putrid  intoxication  will  not  produce  the  disease '  when 
introduced  into  the  blood  of  a  well  person;  in  other  words,  the  disease  is  not 
infective.  Considerable  putrid  material  must  be  absorbed  to  cause  sapremia. 
What  is  known  as  surgical  fever  is  due  to  the  absorption  of  a  small  amount 
of  putrid  or  fermented  wound  fluid,  and  is,  in  reality,  a  mild  form  of  sapremia. 
If  sapremia  arises,  it  does  so  soon  after  the  infliction  of  a  wound,  and  after  a 
large  rather  than  small  wound  when  a  considerable  amount  of  wound  fluid  is 
pent  up  under  pressure.  It  may  follow  labor  where  putrid  fluid  is  retained  in 
the  womb,  may  follow  an  injury  of  or  an  operation  upon  a  joint,  may  follow 
amputation  where  decomposing  blood-clot  or  wound  fluid  is  locked  up  within 
the  flaps,  or  may  ensue  upon  an  abdominal  operation  or  injury.  In  sapremia 
there  always  exist  a  considerable  absorbing  surface  and  a  large  amount  of 


Sapremia,  Septic  or  Putrid  Intoxication  215 

dead  matter  which  has  become  putrid.  Roswell  Park'  pointed  out  that  sapre- 
mia arises  from  putrefaction  of  a  blood-clot  or  wound  fluids  which  are  retained 
like  foreign  bodies  in  the  tissues,  and  does  not  arise  from  putrefaction  of  the 
tissues  themselves.  He  speaks  of  the  condition  as  due  to  the  absorption  of 
poison  from  a  ''putrid  suppository."  Sapremia  will  not  occur  after  granu- 
lations form.  The  term  "putrefaction"  is  used  because  this  is  , the  usual 
change,  but  any  fermentative  organism  may  cause  the  disorder.  '  Sapremia 
is  a  malignant  form  of  surgical  fever,  and  its  existence  means  an  ill-drained 
wound,  and  a  fermenting  and  probably  putrid  collection  of  blood-clot  or 
wound  fluid. 

In  sapremia  there  is  congestion  of  the  stomach,  intestines,  and  other  ab- 
dominal viscera,  particularly  the  kidneys,  and  also  of  the  brain,  and  numbers 
of  red  blood-cells  disintegrate. 

Symptoms. — The  patient  often  seems  to  react  incompletely  from  the  in- 
jury; he  feels  miserable,  complains  of  headache,  nausea,  and  pain  in  the  back 
and  limbs;  or,  he  may  react  and  in  a  day  or  two  develop  this  condition  of 
malaise.  In  some  cases  an  aseptic  fever  is  directly  succeeded  by  sapremia. 
In  most  cases  of  sapremia,  between  twenty-four  hours  and  two  or  three  days 
after  labor,  after  an  injury,  or  after  an  operation,  there  is  usually  a  chiU  or  a 
chiUy  sensation,  though  in  some  cases  this  is  wanting.  The  temperature 
rapidly  rises  to  103°  F.  or  even  more.  There  are  severe  headache,  dry  and 
coated  tongue,  rapid  and  weak  pulse,  nausea  and  often  vomiting,  diarrhea, 
great  prostration,  restlessness,  muscular  twitching,  and  active  delirium.  The 
wound  is  found  to  be  foul,  and  sometimes  there  is  drying  up  of  wound  discharge. 
There  is  diminution  or  suppression  of  urine,  and  a  strong  tendency  to  conges- 
tion of  various  organs.  Jaundice  is  not  unusual.  Petechial  spots  are  frequently 
noticed  upon  the  skin.  They  occur  also  upon  mucous  membranes  and  serous 
surfaces,  and  result  from  the  plugging  of  small  vessels  with  detritus  of  broken- 
down  red  corpuscles  and  consequent  vascular  rupture.  Great  elevation  of 
temperature  often  precedes  death.  In  some  cases  the  dose  of  poison  is  so 
large  that  the  patient  passes  into  rapid  collapse  without  preliminary  fever. 
Some  cases  recover  if  the  initial  dose  is  not  overwhelming  and  if  additional 
•doses  are  not  absorbed.  Many  cases  die  of  exhaustion.  Some  become  linked 
with  fatal  pyemia  or  septicemia.  Hemoglobin  and  red  blood-corpuscles  are 
rapidly  and  notably  diminished.  Distinct  leukocytosis  exists,  except  in 
those  cases  in  which  the  organism  is  overwhelmed  with  the  poison  and  is 
unable  to  react.  Cover-glass  preparations  do  not  show  organisms  in  the 
blood,  and  cultures  from  the  blood  are  sterile. 

Treatment  consists  in  at  once  draining  and  asepticizing  the  putrid  area 
and  administering  very  large  doses  of  alcohol  and  large  medicinal  doses  of 
strychnin  and  digitalis.  The  patient  should  be  purged  and  diaphoresis  favored. 
The  hot  bath  is  valuable  to  cause  sweating.  The  action  of  the  kidneys  must 
be  maintained  if  possible.  Purgatives,  diuretics,  and  diaphoretics  are  given 
to  aid  in  removing  the  toxin,  and  stimulants  are  used  to  sustain  the  strength 
of  the  patient  during  the  elimination  of  the  poison.  Vomiting  is  allayed  by 
champagne,  cracked  ice,  calomel,  cocain,  or  carbolic  acid  with  bismuth.  Food 
should  be  administered  every  three  hours.  The  patient  is  fed  on  milk,  milk  and 
lime-water,  milk  punch,  beef- juice,  and  other  concentrated  foods.  Quinin  in 
stimulant  doses  is  of  value.  Antipyretics  are  useless.  The  use  of  saline  fluid 
by  hypodermoclysis  or  intravenous  infusion  dilutes  the  poison  and  stimulates 
the  heart,  skin,  and  kidneys  to  activity.  Visceral  complications  must  be 
watched  for  and  should  be  promptly  treated  if  discovered.  Among  the  possible 
visceral  complications  are  nephritis,  cholecystitis,  enteritis,  hepatitis,  peritonitis, 
pleuritis,  empyema,  bronchopneumonia,  pericarditis,  and  endocarditis.  Anti- 
streptococcic serum  is  useless  in  sapremia. 

^  "Treatise  on  Surgery  by  American  Authors." 


2i6  Focal  Sepsis.     Septicemia  and  Pyemia 

Septic  Infection,  or  True  Septicemia. — This  condition  is  a  true  infective 
process.  In  sapremia  the  blood  contains  toxins  of  putrefactive  bacteria, 
but  not  the  bacteria  themselves.  In  septic  infection  the  blood  contains  both 
pyogenic  toxins  and  multiplying  pyogenic  bacteria,  the  bacteria  perhaps 
being  free  in  the  blood  or  in  white  cells.  In  sapremia  the  causative  con- 
dition is  putrid  material  lodged  like  a  foreign  body  in  the  tissues.  In  septic 
infection  the  tissues  themselves  are  suppurating,  and  both  bacteria  and  toxins 
are  being  absorbed  by  the  lymphatics.  Of  course,  septic  infection  may  be 
associated  with  septic  intoxication  or  may  follow  it.  In  suppurative  fever 
the  tissues  suppurate,  but  only  the  pyogenic  toxins  are  absorbed,  and  not 
the  pyogenic  bacteria.  In  septic  infection  both  the  pyogenic  bacteria  and 
toxins  enter  the  blood,  and  the  bacteria  multiply  in  the  blood  and  produce 
continually  increasing  amounts  of  poison.  The  symptoms  of  sapremia  de- 
pend on  the  dose.  In  septic  infection  only  a  small  number  of  organisms 
may  get  into  the  blood,  but  they  multiply  enormously.  The  pus  microbes 
cause  true  septicemia,  and  reach  the  blood  chiefly  through  the  lymphatics, 
but  to  some  degree  by  penetrating  the  walls  of  vessels.  A  drop  of  blood  from 
a  man  with  septic  infection  will  reproduce  the  disease  when  injected  into  the 
blood  of  an  animal;  hence  the  disease  is  truly  infective.  The  wound  in  such 
cases  is  often  small,  but  may  be  large,  and  is  commonly  punctured  or  lacerated, 
and  the  disease  begins  later  after  the  infliction  of  a  wound  than  does  sapre- 
mia. No  wound  may  be  discoverable,  the  infection  having  arisen  from  an 
unrecognized  focus  of  suppuration — for  instance,  gonorrhea,  middle-ear  dis- 
ease, dental  caries,  apical  dental  abscesses,  tonsillar  suppuration,  appendicitis, 
etc.     The  initial  atrium  of  infection  may  or  may  not  be  discovered. 

The  bacteria  which  exist  in  the  blood  and  organs  in  septicemia  are  usually 
staphylococci  or  streptococci,  often  both.  Pneumococci  or  colon  bacilli  in  some 
cases  are  causative.  The  blood  is  found  to  have  lost  much  of  its  coagulating 
power;  it  remains  fluid  for  some  time  after  death,  quantities  of  red  corpuscles 
are  destroyed,  and  minute  hemorrhages  take  place  in  the  brain,  mucous  mem- 
branes, skin,  serous  membranes,  muscles,  and  various  viscera.  There  may 
be  inflammation  of  synovial  and  serous  membranes.  There  is  congestion  of 
the  gastro-intestinal  tube  and  of  the  abdominal  viscera.  The  lymph-glands 
are  larger  than  normal  and  the  spleen  is  notably  enlarged.  The  wound  con- 
tains numbers  of  bacteria. 

Symptoms. — The  t\^e  of  this  condition  is  met  with  in  puerperal  septicemia 
or  in  septicemia  from  an  infected  wound.  When  septicemia  arises  from  an 
infected  wound,  red  lines  due  to  lymphangitis  are  usually  seen  about  the 
wound,  and  there  is  enlargement  of  related  lymphatic  glands.  In  some  cases, 
however,  the  wound  and  the  parts  about  it  look  normal.  A  supposed  aseptic 
fever  after  an  injury  may  continue  for  an  undue  time  and  the  surgeon  may 
find  that  septicemia  has  developed.  Septicemia  may  arise  during  the  exist- 
ence or  after  the  abatement  of  sapremia,  or  may  arise  when  the  aseptic  fever 
has  passed  away  and  when  there  has  been  no  putrid  intoxication.  It  begins 
in  from  four  to  seven  days  after  labor  or  an  injury,  usually  with  a  chill,  which 
is  followed  by  fever,  at  first  moderate,  but  soon  becoming  high.  In  some 
cases  there  is  a  chilly  sensation,  but  no  distinct  chill.  There  is  always  great 
prostration  even  before  the  chill.  The  fever  presents  morning  remissions  and 
evening  exacerbations,  and  may  occasionally  show  an  intermission.  When 
the  remission  begins  there  is  a  copious  sweat.  As  the  case  progresses  the 
temperature  may  fluctuate,  and  it  often  rises  very  high  before  death.  The 
pulse  is  small,  weak,  very  frequent,  and  compressible.  The  tongue  is  dry 
and  brown,  with  a  red  tip.  Sordes  gather  on  the  teeth  and  gums.  Vomiting 
is  frequent,  and,  as  a  rule,  there  is  diarrhea.  Low  delirium  alternates  \\\ih 
stupor,  and  coma  is  usual  before  death.  The  great  prostration  is  a  noticeable 
and  characteristic  feature  of  the  sufferer  from  septicemia.  There  are  siib- 
sultus  tendimim  (twitching  of  the  muscles  of  the  hands  and  feet)  and  carpho- 


Pyemia  217 

logia  (picking  at  the  bedclothing),  and  often  hiccough.  Toward  the  end  the 
face  often  becomes  Ilippocratic  (hollow  temples,  pinched  nose,  sunken  eyes 
livid  skin,  lead-colored  and  cold  ears,  and  relaxed  lips).  Visceral  congestions 
occur.^  The  spleen  is  enlarged,  ecchymoses  and  petechia?  are  noted,  urinary 
secretion  becomes  scanty  or  is  suppressed,  and  the  wound  becomes  dry  and 
brown.  Blood  examination  detects  a  rapid  and  great  diminution  in  red  cor- 
puscles and  hemoglobin.  The  anemia  is  in  many  cases  profound.  There  is 
marked  leukocytosis  except  when  the  system  is  overwhelmed  by  the  poison. 
What  is  known  as  pyoculture  (Delbet's  method)  is  the  cultivation  of  bacteria 
from  wound  secretion.  In  septicemia  it  should  be  practised.  It  is  of  great  value 
in  the  diagnosis  of  pyogenic  processes.  Cover-glass  preparations  made  from 
blood  may  show  bacteria,  but  often  fail  to  do  so.  Cultures  from  the  blood  are 
sterile  in  most  cases,  but  not  in  all.  Of  67  patients  with  marked  infections  only 
21  were  positive  (Loygue "and  Abrami,  in  "La  Presse  medicale,"  April  16, 1917). 
A  negative  finding  does  not  disprove  the  existence  of  septic  infection;  a  posi- 
tive finding  is  of  conclusive  diagnostic  and  of  high  prognostic  value.  Colon 
bacilli  may  be  found.  Bacillus  perfringens  has  been  reported.  Pneumococcic 
septicemia  is  extremely  violent  in  manifestation.  In  some  cases  death  ensues 
before  the  lung  has  consolidated.  If  it  is  not  so  rapid,  endocarditis,  arthritis, 
peritonitis,  parotitis,  meningitis,  or  osteomyehtis  may  develop.  A  septicema 
may  become  chronic  and  linger  indefinitely.  It  is  particularly  apt  to  in  bone 
disease.     It  may  be  chronic  from  the  start. 

The  prognosis  of  true  septicemia  is  very  unfavorable,  and  in  some  malig- 
nant cases  death  occurs  within  twenty-four  hours,  but  mild  cases  often  recover. 
Welch  points  out  that  finding  the  Staphylococcus  pyogenes  albus  in  the  blood 
is  not  particularly  ominous,  but  the  presence  of  other  pyogenic  cocci,  especially 
streptococci,  is  exceedingly  threatening.  Pyoculture  is  of  prognostic  value. 
Endocarditis,  pericarditis,  peritonitis,  pleuritis,  bronchopneumonia,  empyema, 
nephritis,  arthritis,  cholecystitis,  hepatitis,  meningitis,  and  pyelitis  are  among 
the  complications  which  may  arise. 

Treatment  in  general  is  the  same  as  for  septic  intoxication.  Antistrepto- 
coccic serum  is  employed  by  some  surgeons,  but  the  value  of  this  method  is 
as  yet  doubtful.  It  does  not  do  any  harm.  It  may  do  good.  It  is  proper  to 
use  it,  but  not  to  the  exclusion  of  other  remedies.  The  usual  dose  is  10  c.c. 
injected  into  the  abdominal  wall.  The  injection  may  be  repeated  two,  three, 
or  even  six  times  a  day,  and  may  be  used  for  a  number  of  days.  Because 
of  uncertainty  as  to  the  causative  organisms  polyvalent  serum  is  used  by  some. 
Some  use  bacterial  vaccines.  Petre  has  injected  fresh  warm  horse-serum  to 
stimulate  leukocytosis.  Jayle  ("La  Presse  medicale,"  1905,  p.  722)  and 
Federman  have  also  used  it.  All  sera  and  vaccines  are  as  yet  of  undetermined 
value  in  septic  infection.  Depage  and  Nolf  inject  peptones.  The  subcuta- 
neous is  safer  than  the  intravenous  route.  The  preparation  is  described  by 
Potel  ("La  Presse  medicale,"  Nov.,  1917).  The  dose  is  10  c.c.  In  chronic 
septicemia  some  surgeons  use  transfusion  of  immunized  blood  (Hooker  in  Annals 
of  Surgery,  Nov.,  1917).  Washing  the  blood  by  the  intravenous  infusion  of 
salt  solution  often  produces  distinct  improvement,  which,  unfortunately, 
is  usually  temporary.  Dr.  C.  C.  Barrows  commends  formalin  used  intra- 
venously. The  strength  of  the  solution  is  i  part  of  formalin  to  5000  parts  of 
salt  solution.  The  dose  is  500  c.c.  I  have  had  no  experience  with  formalin 
in  septicemia,  but  do  not  believe  that  any  reagent  which  would  rapidly  and 
directly  kill  the  bacteria  can  be  introduced  safely.  Even  if  such  an  agent  could 
be  found,  the  attempt  to  use  it  would  be  dangerous,  as  dead  bacteria  liberate 
a  poison,  and  the  rapid  death  of  immense  numbers  of  bacteria  would  mean  the 
entrance  into  the  blood  of  an  enormous  amount  of  toxic  matter.^ 

Pyemia  is  a  condition  in  which  metastatic  abscesses  arise  as  a  result  of 

^Litchfield  gives  glucose  intravenously  in  a  25  per  cent,  solution.     From  250  to  500  c.c. 
are  given  and  the  dose  may  be  given  two  or  three  times  in  48  hours. 


2i8  Focal  Sepsis.     Septicemia  anfl  Pyemia 

the  existence  of  septic  thrombo])hlebitis,  the  disease  being  characterized  by 
fever  of  an  intermittent  t>pe  and  by  recurring  chills.  It  is  not  actually  due 
to  free  pus  in  the  blood,  but  to  the  passage  into  the  blood  of  the  clots  filled 
with  toxins  or,  far  oftener,  of  clots  infected  by  streptococci,  staphylococci, 
or  both.  After  a  wound  is  inflicted  blood  clots  in  the  divided  veins.  If  sup- 
puration occurs,  the  clots  may  become  filled  with  the  toxins  of  pyogenic  bacteria 
or  be  invaded  by  the  bacteria  themselves.  Thus  it  becomes  evident  that 
pyemia  may  develop  with  septicemia.  It  may  also  develop  when  there  is 
suppuration  in  a  wound,  but  not  septicemia,  no  h-mphatic  absorption  of 
bacteria  or  toxins  having  occurred.  A  suppurating  focus  about  a  vein  may 
cause  thrombophlebitis  and  clot-formation  even  when  no  wound  exists.  This 
is  seen  in  thrombophlebitis  of  the  lateral  sinus  secondary  to  suppuration  of  the 
middle  ear. 

A  vessel  thrombus  runs  up  in  the  lumen  of  a  vein,  and  the  apex  of  the 
clot  softens,  a  portion  of  it  is  broken  off  by  the  blood-stream  and  carried  as 
an  embolus  into  the  circulation.  Many  of  these  poisonous  emboli  enter  into 
the  blood  and  lodge  in  some  vessels  which  are  too  small  to  transmit  them,  and 
at  their  points  of  lodgment  form  embolic,  secondary,  or  metastatic  abscesses. 
If  the  embolus  contains  only  pyogenic  toxins  the  danger  is  infinitely  less  than 
if  it  contains  bacteria.  The  secondary  abscess  if  caused  by  a  clot  containing 
toxins  only  may  not  lead  to  further  dissemination  of  disease.  If  the  embolus 
contains  bacteria,  thrombophlebitis  occurs  about  it,  and  new  infected  emboli 
form  and  are  sent  throughout  the  system.  Wounds  of  the  superficial  parts 
and  bones  produce  pyemic  infarctions  and  metastatic  abscesses  of  the  lungs. 
When  these  infarctions  break  into  fragments  particles  may  return  to  the  heart 
and  lodge,  or  may  be  sent  out  through  the  arterial  system  to  form  other  foci 
in  distant  organs.  Infected  areas  connected  with  the  portal  circulation  (in- 
testinal injuries,  appendicitis,  or  suppurating  piles)  may  produce  portal  pyemia 
and  multiple  abscesses  of  the  liver  (see  page  1174).  Wounds  of  bones  which 
open  the  medullary  cavity  or  diploic  structure  are  particularly  apt  to  be  followed 
by  pyemia,  and  the  disease  may  follow  labor,  phlegmonous  erysipelas,  and 
other  conditions.  Mahgnant  endocarditis  is  called  ''arterial  pyemia,''  and 
is  due  to  endocardial  embolic  infection.  In  this  disorder  infected  emboU  lodge 
in  the  kidneys,  the  spleen,  the  alimentary  tract,  the  brain,  and  the  skin  (Osier). 
Idiopathic  pyemia  is  a  misnomer.  Some  primary  focus  of  infection  must  exist, 
as  was  pointed  out  when  discussing  septicemia. 

Symptoms. — The  wound  often  becomes  dry  and  brown,  and  sometimes 
also  offensive.  A  severe  and  prolonged  chill  or  a  succession  of  chills  ushers 
in  the  disease;  high  fever  follows,  and  drenching  sweats  occur.  The  chills 
recur  every  other  day,  every  day,  or  oftener.  A  chill  arises  from  the  libera- 
tion and  lodgment  of  emboli.  During  the  sweat  the  temperature  falls  and 
may  become  nearly  normal,  normal,  or  actually  subnormal.  The  tempera- 
ture often  oscillates  violently.  The  general  symptoms  of  vomiting,  wasting, 
etc.,  resemble  those  of  septicemia.  In  some  cases  the  mind  remains  clear,  in 
many  the  delirium  is  purely  nocturnal.  The  skin  frequently  becomes  jaun- 
diced and  a  profound  ad\Tiamic  state  is  rapidly  established.  The  blood 
changes  are  like  those  of  septicemia.  The  spleen  is  enlarged.  The  lodgment 
of  emboli  produces  s>Tnptoms  whose  nature  depends  upon  the  organ  involved. 
Lodgment  in  the  lungs  causes  shortness  of  breath  and  cough,  with  slight  physi- 
cal signs.  Lodgment  in  the  pleura  or  pericardium  gives  pronounced  physical 
evidence.  Lodgment  in  the  spleen  produces  severe  pain  and  great  enlarge- 
ment.    The  parotid  gland  not  unusually  suppurates. 

In  a  suspected  case  of  pyemia  always  examine  an  existing  wound,  and  if 
there  is  no  wound,  remember  that  the  infection  may  arise  from  gonorrhea, 
osteomyelitis,  suppuration  in  the  middle  ear,  appendicitis,  dental  caries,  ton- 
sillar suppuration,  abscess  of  the  prostate,  etc.     Chronic  pyemia  may  last 


Erysipelas  219 

for  months;  acute  pyemia  may  prove  fatal  in  three  days.  The  chief  com- 
plications are  joint-suppuration,  bronchopneumonia,  pleuritis,  empyema, 
endocarditis,  pericarditis,  peritonitis,  nephritis,  cholecystitis,  pyelitis,  parotitis, 
venous  thrombosis,  and  abscesses. 

Treatment  is  the  same  as  for  septicemia.  Open,  drain,  and  asepticize 
any  wound  and  any  accessible  secondary  abscess.  The  remarks  made  as  to 
the  use  of  sera  and  bacterial  vaccines  in  septicemia  apply  also  to  pyemia. 

Erysipeloid  (^reticular  lymphangitis,  crab  cellulitis)  was  described  by  Rosen- 
bach  in  1S87,  although  like  cases  were  reported  nearly  fifteen  years  before 
by  Morrant  Baker 'under  the  name  of  erythema  serpens.  Gilchrist,  in  1904, 
reported  329  Baltimore  cases.  I  have  seen  a  number  of  cases  in  the  Jefferson 
Hospital.  The  condition  is  due  to  infection  from  handhng  putrid  animal 
matter,  especially  fish;  bites  of  crabs,  and  sticks  of  fish  fins.  Rosen  bach 
claimed  to  find  a  special  organism  resembling  but  larger  than  a  staphylococcus, 
but  other  observers  fail  to  find  it.  The  period  of  incubation  is  from  a  few 
hours  to  two  days.  Jopson  describes  the  disease  as  follows  ("Amer.  Jour. 
Med.  Sciences,"  May,  1908):  "It  appears  as  a  swelling  with  elevated,  sharply 
defined  edges,  which  soon  affects  the  entire  circumference  of  the  finger;  and  is 
commonly  described  as  of  a  dark-red  color,  with  purplish  or  even  livid  edges. 
The  finger  is  tense  and  only  moderately  painful,  but  itching  and  burning  are 
prominent  s-ymptoms.  Sections  of  tissue  excised  show  an  inflammation  of  the 
entire  corium  and,  to  a  slight  extent,  of  the  subcutaneous  tissue,  with  infiltra- 
tion of  polynuclear  leukocytes  and  small  lymph-cells;  edema  of  the  epithelial 
cells  of  the  epiderm,  and  inflammatory  changes,  especially  marked  around  the 
sweat-glands  and  blood-vessels  (Gilchrist).  It  has  a  characteristic  tendency 
to  spread  from  its  usual  point  of  origin,  near  the  end  of  the  finger,  toward  the 
palm,  the  primarfly  affected  area  fading  from  red  to  yellow,  and  thence  to 
normal.  Reaching  the  palm,  it  may  spread  over  it;  but  commonly,  it  soon 
affects  the  neighboring  finger;  and,  when  untreated,  it  may  gradually  spread 
to  all  the  fingers  and  to  the  back  of  the  hand.  There  is  no  fever  or  other 
constitutional  disturbance,  and  the  lymph-glands  are  almost  never  involved. 
It  is  more  or  less  self-limited,  commonly  lasting  from  ten  days  to  three  weeks ; 
and  during  this  time  there  is  a  well-marked  tendency  to  relapse.  There  is  no 
suppuration,  pustulation  or  vesiculation,  and  no  scaling  follows." 

It  is  treated  by  applications  of  lead- water  and  laudanum,  ichthyol  or  com- 
presses soaked  in  a  saturated  solution  of  Epsom  salt.  Jopson  applies  tincture 
of  iodin,  and  Gilchrist,  25  per  cent,  salicylic  acid  plaster. 

XI.  ERYSIPELAS  (ST.  ANTHONY'S  FIRE) 

Erysipelas  is  an  acute,  contagious,  spreading  capillary  lymphangitis 
due  to  the  streptococci  of  erysipelas,  which  grow  and  multiply  in  the  smaller 
lymph-channels  of  the  skin  and  the  subcutaneous  cellular  layers  and  also  in 
'the  lymph-channels  of  serous  and  mucous  membranes.  Erysipelas,  though 
contagious,  is,  as  a  matter  of  fact,  seldom  conveyed  as  such  from  one  patient  to 
another.  Pantou  and  Adams  ("Lancet,"  Oct.  9,  1909)  present  this  truth  con- 
vincingly. In  St.  Thomas's  Hospital  from  1896  to  1905  erysipelas  cases  were 
kept  with  other  cases  in  the  septic  wards.  In  1906  isolation  was  begun.  The 
records  of  1907  show  that  isolation  had  no  effect  in  diminishing  the  number 
of  cases  of  erysipelas  arising  in  the  septic  wards.  Cutaneous  erysipelas  \& 
characterized  by  a  rapidly  spreading,  acutely  beginning  dermatitis,  by  a  remit- 
tent fever  due  to  absorption  of  toxins,  and  by  a  tendency  to  recurrence.  It 
is  always  preceded  by  a  wound,  a  scratch,  or  an  abrasion,  which  may  have  been 
trivial  and  may  never  have  been  noticed.  The  so-called  idiopathic  erysipelas 
is  preceded  by  a  breach  of  surface  continuity  so  small  as  to  escape  notice.     The 


220  Erysipelas 

initial  point  of  infection  may  be  in  the  mouth,  the  nostril,  the  pharynx,  the 
auditory  meatus,  between  the  fingers  or  toes,  at  the  margin  of  a  nail,  or  in  a 
cutaneous  furrow.  The  involved  area  in  cutaneous  erysipelas  seldom  sup- 
purates, but  sometimes  does,  very  thin,  watery  })us  being  formed.  If  thick 
pus  forms  it  means  mixed  infection  with  staphylococci,  but  the  formation  of 
thin  pus  does  not  require  a  mixed  infection,  as  the  streptococcus  is  identical 
with  the  Streptococcus  pyogenes.  In  some  cases  of  erysipelas,  staphylococcus 
infection  follows  and  even  actually  replaces  streptococcus  infection.  The 
rapid  spread  of  erysipelas  is  due  to  the  fact  that  the  streptococci  prevent  coagu- 
lation of  exudate  and  are  not  actively  attacked  by  leukocytes.  Erysipelas 
is  most  common  in  the  spring  and  fall,  and  is  most  usually  met  with  among 
those  who  are  crowded  into  dark,  dirty,  and  ill- ventilated  quarters;  it  attacks 
by  preference  the  debilitated  and  broken-down  (as  alcoholics  and  sufferers 
from  Bright's  disease).  The  disease  may  become  endemic  in  special  places 
or  localities.  The  poison  of  erysipelas  will  produce  puerperal  fever  in  a  lying- 
in  woman.  The  streptococcus  was  first  obtained  in  pure  cultures  by  Feh- 
leisen.  This  organism  is  widely  diffused.  The  question  of  identity  with  the 
Streptococcus  pyogenes  is  discussed  on  page  58. 

Forms  of  Erysipelas. — Ambulant,  erratic,  migratory,  or  wandering  erysipe- 
las is  a  form  which  tends  to  spread  widely  over  the  body,  leaving  one  part  and 
going  to  another.  Bullous  erysipelas  is  attended  by  the  formation  of  bullae. 
In  diffused  erysipelas  the  borders  of  the  inflammation  gradually  merge  into 
healthy  skin.  Erythematous  erysipelas  involves  the  skin  superficially.  Meta- 
static erysipelas  appears  successively  in  various  parts  of  the  body.  Puer- 
peral erysipelas  begins  in  the  genitals  of  lying-in  women,  producing  puerperal 
fever.  Erysipelas  simplex  is  the  ordinary  cutaneous  form.  Erysipelas  neo- 
natorum begins  in  the  unhealed  navel  of  a  newborn  child  and  spreads  from 
that  point.  Typhoid  erysipelas  occurs  with  profound  adynamia.  Univer- 
sal erysipelas  involves  the  entire  body.  CeUulitis  is  often  erysipelas  of  the 
subcutaneous  layers.  Phlegmonous  erysipelas  involves  the  skin  and  the  cellular 
tissues,  and  causes  suppuration,  and  often  gangrene.  Edematous  erysipelas 
is  a  variety  of  phlegmonous  erysipelas  with  enormous  subcutaneous  edema. 
Lymphatic  erysipelas  is  characterized  by  rose-red  lines  due  to  lymphangitis. 
Venous  erysipelas  is  marked  by  the  dark  color  of  venous  congestion.  Mucous 
erysipelas  involves  a  mucous  membrane.  Erysipelas  may  attack  the  fauces, 
producing  the  very  grave  condition  known  as  faucial  erysipelas. 

Clinical  Forms. — The  clinical  forms  are  cutaneous  erysipelas,  cellulocuta- 
neous  or  phlegmonous  erysipelas;  cellulitis,  and  mucous  erysipelas. 

Cutaneous  erysipelas  most  frequently  attacks  the  face.  A  fever  sud- 
denly appears,  rises  rapidly,  reaches  a  considerable  height,  is  remittent  in 
type  and  sometimes  distinctly  fluctuating,  and  usually  terminates  in  four  or  five 
days  by  crisis.  At  the  time  of  febrile  onset  spots  of  redness  appear  on  the 
skin.  These  spots  run  together,  and  soon  a  large  extent  of  surface  is  found 
to  be  red  and  a  little  elevated.  Any  wound,  ulcer,  or  abrasion  which  exists 
becomes  dry  and  unhealthy,  and  its  edges  redden  and  swell.  The  erysipe- 
latous area  of  redness  and  swelHng  extends  either  in  spots  with  intervening 
healthy  skin  or  in  an  uninterrupted  line.  The  margin  is  usually  sharply 
defined  from  the  healthy  skin,  and  the  color  fades  at  the  original  focus  as  the 
disease  advances  at  the  periphery  of  the  red  area.  The  border  shows  the  most 
intense  redness,  the  most  marked  inflammatory  swelling  (if  there  is  swelling), 
and  the  greatest  pain.  The  point  of  origin  shows  the  least  redness,  the  least 
swelling,  and  the  least  pain.  Thus  erysipelas  reverses  the  rule  of  an  ordinary 
inflammatory  process.  Milian  calls  this  tendency  of  erysipelas  "the  law  of 
centrifugal  maximum"  ("La  Presse  medicale,"  Nov.  5,  1910).  The  color  fades 
at  once  on  pressure  and  returns  at  once  when  pressure  is  removed.  There  is 
burning  pain,  which  is  most  intense  at  the  border  and    which  is  increased  by 


Cutaneous  Erysipelas  221 

pressure.  In  the  hyperemic  area  vesicles  or  jjulkc  form,  containing  first  serum 
and  later  it  may  be  seropus,  but  there  is  rarely  genuine  suppuration  in  cuta- 
neous erysipelas.  Edema  affects  the  subcutaneous  tissues,  producing  great 
swelling  in  regions  where  there  is  much  loose  cellular  tissue  (as  in  the  eyelids). 
Anatomically  related  lymphatic  glands  may  become  large  and  tender.  If  they 
do  so  it  means  that  pus  has  formed.  In  an  ordinarily  strong  person  the  color 
of  an  erysipelatous  area  is  bright  red  or,  more  rarely,  dark  red.  A  dusky  color 
precedes  suppuration.  A  blue  color  precedes  gangrene  or  indicates  i)rofound 
cardiac  or  pulmonary  involvement.  Erysipelas  spreads  now  in  one  direction, 
now  in  another,  influenced,  according  to  Pfleger,  by  the  furrows  of  the  skin.  As 
facial  erysipelas  spreads  it  involves  the  ear.  All  subcutaneous  inflammations 
stop  short  at  the  ear  and  cannot  invade  it  because  of  the  close  adhesion  of  the 
.skin  to  the  cartilage.  Milian  calls  this  the  "ear  sign."  When  the  disease 
ceases  to  spread,  the  sweUing  and  redness  gradually  abate,  and  after  they  dis- 
appear desquamation  takes  place,  and  the  blebs  become  dry  and  crusted. 

In  strong  subjects  the  constitutional  symptoms  of  cutaneous  erysipelas  are 
•often  slight.  In  the  old  and  debihtated  the  symptoms  are  typhoidal,  there 
is  a  dry  tongue,  dyspnea  and  hebetude,  delirium  comes  on,  and  death  is  usual. 
Possible  complications  are  meningitis,  pneumonia,  septicemia,  pleuritis,  pyemia, 
myocarditis,  endocarditis,  arthritis,  and  albuminuria.  Erysipelas  neonatorum 
is  very  fatal.  The  mortality  in  infants  is  certainly  50  per  cent.  (Sir  Watson 
Cheyne's  "Weightman  Lecture  for  1908").  In  some  instances  an  attack  of 
erysipelas  will  cure  an  old  skin  eruption,  a  new  growth,  an  ulcer,  or  an  area  of 
lupus.     This  is  the  erysipele  salutaire  of  our  French  confreres. 

Treatment. — It  is  the  cystom  to  isolate  the  patient.  Asepticize  the  wound,  if 
there  be  a  wound.  Examine  to  determine  if  there  is  diabetes  or  Bright's  disease. 
Administer  a  purge.  Cases  of  cutaneous  erysipelas  occurring  in  a  fairly  healthy, 
young  or  middle-aged  subject,  tend  to  get  well  without  treatment.  The  late 
J.  M.  DaCosta  advocated  the  administration  of  )-^  to  3^^  gr.  of  pilocarpin.  Debility 
.absolutely  contra-indicates  this  drug.  If  a  person  is  debilitated,  free  stimula- 
tion is  necessary.  Tincture  of  chlorid  of  iron  is  usually  administered  in  doses 
of  from  20  to  40  min.  well  diluted,  and  given  three  or  four  times  a  day.  Tonic 
doses  of  quinin  are  also  given.  Nutritious  food  is  given  at  intervals  of  three 
or  four  hours.  For  sleeplessness  or  delirium  use  chloral  or  the  bromids;  for 
very  high  temperature  cold  sponging  is  required.  Early  in  an  attack,  when  the 
area  is  limited,  the  application  of  Bier's  cup  may  do  good.  To  prevent  spread- 
ing some  have  advised  injection  of  the  healthy  skin  near  the  blush  with  a  2 
per  cent,  carbolic  solution  or  with  fluid  containing  3'f  6  gr-  of  corrosive  subli- 
mate. A  band  of  iodin  painted  on  the  skin  may  arrest  the  progress  of  the 
disease,  and  so  may  a  ring  streaked  around  a  limb  or  about  an  erysipelatous 
area  by  lunar  caustic.  Kraske  has  suggested  a  method  of  preventing  the 
spread  of  cutaneous  erysipelas  which  is  often  effective.  The  patient  is  anes- 
thetized. At  about  2  inches  from  the  margin  of  the  redness  a  series  of  cuts 
are  made  into  the  skin,  to  a  sufhcient  depth  to  cause  free  oozing.  Each  cut 
is  crossed  by  another  cut  and  a  ring  of  scarifications  is  made  to  surround  the 
region  of  the  erysipelas.  After  the  oozing  ceases  the  scarified  area  is  soaked 
for  one  hour  with  a  solution  of  carbolic  acid  (i  :  20)  or  corrosive  sublimate 
(i  :  2000).  The  part  is  dressed  with  pads  wet  with  carbolic  acid  (i  :  40)  or 
corrosive  sublimate  (i  :  2000).  This  operation  causes  the  formation  of  a  pro- 
tective barrier  of  leukocytes.  For  a  number  of  years  I  have  used  with  satis- 
faction a  treatment  taught  me  by  my  old  master.  Prof.  S.  W.  Gross.  It  is  as 
follows:  Paint  the  part  and  well  around  the  part  several  times  a  day  with  a 
mixture  of  equal  parts  of  tincture  of  iodin  and  alcohol.  If  a  wound  exists, 
keep  it  open  and  disinfect  it  with  the  iodin  once  a  day.  Cover  the  part  with 
lint  wet  with  lead-water  and  laudanum,  and,  if  it  be  an  extremity,  bandage  it 
from  the  toes  or  fingers  to  well  above  the  erysipelatous  area.     The  iodin  is 


2  22  Erysipelas 

germicidal  and  quickly  enters  the  lymph-spaces.  The  lead-water  and  lauda- 
num allays  the  burning  pain.  Saturated  solution  of  Epsom  salt  is  a  useful 
preparation.  It  is  applied  on  gauze  which  is  kept  constantly  moist.  It  quickly 
allays  the  burning  pain  and  seems  to  limit  the  spread  of  the  infection.  Some 
advocate,  a  daily  inunction  of  Crede's  soluble  silver.  A  good  application  is  a 
50  per  cent,  ichthyol  ointment  with  lanolin.  A  very  useful  method  is  von 
Nussbaum's.  The  author  applies  it  somewhat  modified,  as  follows:  wash  the 
part  with  ethereal  soap,  irrigate  with  a  solution  of  corrosive  sublimate  (i  :  1000), 
dry  with  a  sterile  towel,  apply  an  ointment  of  ichthyol  and  lanolin  (50  per  pent.), 
and  dress  with  antiseptic  gauze.  Some  use  iced-water  cloths,  but  cold  is  in- 
jurious. Hot  fomentations  are  harmful  in  cutaneous  erysipelas.  Some  apply 
borated  talc  or  salicylated  starch.  Ringer  advised  painting  every  three  hours 
with  a  mixture  composed  of  30  gr.  of  tannic  acid,  30  gr.  of  camphor,  and  4  dr. 
of  ether.  Antistreptococcic  serum  has  been  used  in  erysipelas,  and  most  bene- 
ficial results  have  been  claimed  for  it.  It  is  asserted  that  under  its  influence 
the  temperature  soon  becomes  normal.  My  personal  experience  with  the  serum 
treatment  has  not  convinced  me  of  its  value,  although  some  cases  seemed  to 
have  been  benefited.  Antidiphtheritic  serum  is  praised  by  Polak.  Schorer 
studied  100  cases  of  erysipelas  in  Bellevue  Hospital  and  determined  the 
opsonic  index  and  its  relation  to  treatment  by  inoculation  of  dead  streptococci. 
He  concluded  that  a  vaccine  does  not  prevent  migration  or  recurrence,  but 
seems  to  shorten  the  duration  of  the  disease  ("Amer.  Jour.  Med.  Sciences," 
Nov.,  1907).  Ross  and  Johnson  regard  treatment  by  a  specific  vaccine  as  very 
efficient  ("Jour.  Amer.  Med.  Assoc,"  March  6,  1909). 

Cellulocutaneous  or  phlegmonous  erysipelas  is  characterized  by  high  tem- 
perature (104°- 1 06°  F.),  the  rapid  onset  of  grave  prostration,  irregular  chills, 
sweat,  and  a  strong  tendency  to  delirium.  The  constitutional  condition  may 
be  one  of  suppurative  fever,  sapremia,  septicemia,  or  pyemia.  The  parts  are 
red,  as  in  cutaneous  erysipelas,  and  the  tumefaction  is  vastly  greater.  The 
swelling  is  brawny,  comes  on  early,  increases  with  exceeding  rapidity,  induces 
a  high  degree  of  tension,  and  frequently  becomes  associated  with  sloughing 
or  even  cutaneous  gangrene.  The  lymphatic  glands  are  swollen,  but  the  in- 
flamed lymphatic  vessels  are  hidden  by  the  tumefaction.  In  most  cases  sup- 
puration occurs,  and  when  this  happens  the  parts  become  boggy  and  the  pus 
is  widely  disseminated  in  the  subcutaneous  and  intramuscular  tissues,  and 
even  into  muscle-sheaths  and  tendon-sheaths  {purulent  infiltration).  When 
the  disease  abates  sloughs  form,  which  leave  ulcers  upon  being  cast  off.  In 
bad  cases  muscles,  vessels,  tendons,  and  fascia  may  slough  away.  The  com- 
monest complications  are  suppression  of  urine,  bronchopneumonia,  congestion 
and  edema  of  the  lungs,  meningitis,  congestion  of  the  kidneys,  and  acute 
pleurisy.  Septicemia  or  pyemia  may  occur.  We  sometimes  meet  with  this 
form  of  erysipelas  after  extravasation  of  urine.  It  is  not  a  pure  streptococcic 
infection.  There  is  a  mixed  infection  with  other  pyogenic  cocci,  and  often  with 
organisms  of  putrefaction. 

Treatment. — At  once  asepticize  and  drain  any  existing  wound,  and  dress 
such  a  wound  with  hot  antiseptic  fomentations.  If  there  are  inflamed  lymph- 
vessels  or  glands  above  the  area  of  cellulocutaneous  infection,  paint  the  skin 
above  them  with  iodin  and  smear  it  with  blue  ointment  or  rub  in  Crede's 
ointment  of  soluble  silver.  Make  numerous  incisions  into  the  inflamed  tissues. 
These  incisions  should  be  near  together,  and  each  cut  should  be  2  or  3  inches 
long.  Spray  the  wounds  with  hydrogen  peroxid  by  means  of  an  atomizer,  wash 
with  a  solution  of  acetate  of  aluminum  (2  per  cent.),  and  pack  each  wound 
with  iodoform  gauze.  Dress  with  many  layers  of  gauze  wet  with  a  hot  solu- 
tion of  acetate  of  aluminum  (2  per  cent.).  The  gauze  is  covered  with  a  rubber- 
dam  and  a  hot-water  bag  is  laid  upon  the  dressing.  If  sloughs  form,  cut  them 
away  and  employ  hot  antiseptic  fomentations.     Change  the  dressings  often. 


Treatment  of  Cellulitis  223 

In  some  cases  it  may  be  necessary  to  employ  continuous  irrigation  with  warm 
antiseptic  fluid,  or  continuous  immersion  in  a  hot  aseptic  or  antiseptic  bath. 
Probably  the  Dakin-Carrel  treatment  will  give  the  best  results.  Sometimes  it 
is  necessary  to  operate  for  the  removal  of  enlarged  lymphatic  glands.  The 
Bier  treatment  is  a  valuable  addition  to  our  resources.  In  rare  cases  ampu- 
tation is  demanded.  When  granulations  begin  to  form,  treat  as  a  healing 
wound.  The  constitutional  treatment  is  that  previously  set  forth  as  applicable 
to  septicemia,  viz.,  purgation,  the  use  of  diuretics  and  diaphoretics,  the  admin- 
istration of  strychnin,  quinin,  digitalis,  alcoholic  stimulants,  and  nourishing 
food.  In  severe  cases  employ  hypodermoclysis  or  saline  infusion  into  a  vein. 
Antistreptococcic  serum  may  be  employed. 

Cellulitis  (Fig.  103)  is  a  microbic  inflammation  of  the  cellular  tissue. 
It  may  be  due  to  staphylococci,  to  streptococci,  to  other  pyogenic  bacteria, 
or  to  mixed  infection  with  two  varieties  of  pyogenic  organisms.  The  com- 
monest form  is  streptococcic  infection,  and  this  is  a  variety  of  erysipelas.  A 
streptococcic  infection  may  be  followed  and  replaced  by  a  staphylococcic  in- 
fection.    Infection  with  the  Bacillus  aerogenes  capsulatus  may  cause  muscle 


Fig.   103. — Acute  cellulitis  of  palm  and  forearm  following  a  slight  wound. 

infection  and  gangrene  followed  by  gangrenous  cellulitis.  Cellulitis  is  prone 
to  arise  in  damaged  tissues,  for  instance,  in  a  crushed  part,  a  limb  the  seat 
of  a  compound  fracture,  or  tissue  containing  extravasated  urine.  In  tissue 
the  resistance  of  which  has  been  lessened  by  diabetes,  Bright's  disease, 
irritating  discharges,  or  trophic  lesions,  cellulitis  is  rather  apt  to  develop. 
In  celluHtis  of  the  subcutaneous  tissue  the  micro-organisms  find  entrance 
by  means  of  a  wound.  Swelling  precedes  redness.  The  swelling  is  not  so 
marked  as  in  phlegmonous  erysipelas,  and  the  redness  is  darker  and  is  less  dis- 
tinct than  in  cutaneous  erysipelas.  The  redness  of  cellulitis  is  about  the 
wound;  it  spreads,  but  does  not  fade  at  the  center  as  does  ordinary  erysipelas; 
red  lines  due  to  lymphangitis  ascend  the  limb  from  the  infected  wound,  and 
the  anatomically  associated  lymphatic  glands  enlarge.  In  the  wound  and  its 
neighborhood  there  is  severe  throbbing  pain.  The  constitutional  symptoms 
of  infection  develop  rapidly.  In  trivial  cases  the  lymphatics  dispose  of  the 
poison  and  suppuration  does  not  occur.  In  severe  cases  pus  forms  about  the 
wound  and  lymphatic  glands  may  suppurate.  In  staphylococcic  infection  pus 
is  thick,  in  pure  streptococcic  infection  it  is  thin.  Phlegmonous  erysipelas  may 
develop,  and  septicemia  or  pyemia  may  arise. 

Treatment. — Open,  disinfect,  and  drain  the  wound.     Pamt  iodin  upon  the 
skin  over  inflamed  lymphatic  vessels  and  glands  and  cover  with  ichthyol  oint- 


22/\.  Tetanus,  or  Lockjaw 

ment,  or  rub  Crede's  soluble  silver  ointment  into  the  skin  over  the  inflamed 
lymph-glands  and  vessels.  Dress  the  wound  and  the  adjacent  inflamed  area 
with  hot  antiseptic  fomentations.  The  Dakin-Carrel  treatment  may  be  used. 
Secure  rest  of  the  part.  It  may  be  necessary  to  make  incisions  as  in  phleg- 
monous erysipelas.  In  some  cases  it  is  necessary  to  remove  breaking-down 
glands.     The  constitutional  treatment  is  that  employed  for  septicemia. 

XII.  TETANUS,  OR  LOCKJAW 

Tetanus  is  a  microbic  disease  invariably  preceded  by  some  injury  or  focus 
of  infection  and  characterized  by  spasm  of  the  voluntary  muscles.  The  wound 
may  have  been  severe,  it  may  have  been  so  slight  as  to  have  attracted  no  atten- 
tion, it  may  have  been  inflicted  upon  the  alimentary  canal  by  a  fish-bone  or 
other  foreign  body,  or  may  have  been  situated  in  the  nose,  urethra,  rectum, 
vagina,  or  ear.  Infection  can  occur  through  a  mere  abrasion  of  a  mucous 
membrane  or  skin.  Excoriations  in  the  nasopharynx,  infection  of  the  tonsil, 
infection  of  the  middle  ear,  ulcer  of  the  leg,  suppuration  at  a  tooth  root,  ab- 
scesses in  various  regions,  a  frost-bite  or  a  burn  may  be  responsible  (Post- 
operative Tetanus,  Kellogg,  Speed  in  "Surgery,  Gynecology,  and  Obstetrics," 
April,  1916).  Sir  David  Semple  has  recently  sought  to  demonstrate  that 
tetanus  does  not  of  necessity  depend  on  spores  or  bacilli  introduced  at  the 
time  of  the  injury.  He  believes  that  spores  may  be  taken  up  from  the  intes- 
tine and  deposited  from  the  blood  in  the  anaerobic  area  created  by  a  wound 
or  contusion  ("Lancet,"  May  20,  1911,  March  9,  1912).  As  yet  this  view  lacks 
general  acceptance.  It  has  long  been  taught  that  so-called  idiopathic  tetanus  is 
either  not  tetanus  at  all,  or  the  term  expresses  the  fact  that  we  have  not  found 
the  traces  of  an  injury  which  did  exist.  Sir  David  Semple  maintains  that 
spores  may  enter  into  trivial  wounds  and  remain  in  the  healed  area  for  months, 
possibly  to  become  active  as  a  result  of  exposure  to  great  heat  or  cold,  to  fatigue, 
or  to  bruising  of  the  part.  Semple's  view  would  explain  so-called  idiopathic 
tetanus  (see  "Lancet,"  May  20,  191 1).  They  may  also  explain  some  of  the 
■cases  of  tetanus  which  develop  late  after  a  wound  and  in  spite  of  a  prophylactic 
■dose  of  antitetanic  serum,  the  serum  protection  having  worn  out.  Tetanus 
arises  most  frequently  after  punctured  and  particularly  after  lacerated  wounds 
of  the  hands  or  feet.  In  a  surgical  experience  of  thirty  years  in  connection 
with  the  Philadelphia  Fire  Department  I  have  known  hundreds  of  firemen  to 
injure  their  feet  by  stepping  on  nails  and  not  one  developed  tetanus.  In  fact, 
the  only  case  of  tetanus  among  them  since  1871  arose  in  a  man  who  lacerated 
his  hand  with  glass.  Morowitz  (Med.  Record,  March  31,  191 7)  points  out 
that  wounds  nearest  the  ground  are  most  liable  to  infection.  In  106  cases  of 
tetanus,  27  followed  wound  of  the  foot,  26  wound  of  the  leg  and  21  wound  of 
the  thigh.-  Before  tetanus  appears  a  wound  is  apt  to  suppurate  or  slough;  but 
in  some  instances  the  wound  is  found  soundly  healed  when  the  tetanus  be- 
gins. The  toy  pistol  produces  a  peculiarly  dangerous  wound.  In  the  United 
States  many  cases  of  tetanus  have  followed  the  celebration  of  the  Fourth  of 
July,  a  large  percentage  of  the  causative  wounds  having  been  from  the  toy 
pistol.  In  Philadelphia  in  1880  there  were  30  deaths  from  Fourth  of  July 
tetanus  and  in  Baltimore  in  the  same  year  there  were  20  deaths  (S.  D.  Gross, 
"A  System  of  Surgery").  The  Fourth  of  July,  1903,  was  responsible  for  466 
reported  and  no  one  knows  for  how  many  unreported  cases  in  the  United  States. 
Since  that  date  the  prophylactic  use  of  antitetanic  serum  has  become  the  rule 
of  practice  in  suspected  injuries  and  there  has  been  a  notable  diminution  in 
the  number  of  cases.  In  1909  there  were  150  cases;  in  1910  there  were  72 
cases;  in  191 1  there  were  18  cases;  in  191 2  there  were  only  7  cases  ("Jour. 
Amer.  Med.  Assoc,"  Sept.  7,  191 2).     Of  the  7  cases,  6  died  (86  per  cent.). 


Tetanus,  or  Lockjaw  225 

The  fact  that  the  bacillus  of  tetanus  is  anaerobic  explains  the  compara- 
tive frequency  with  which  punctured  and  lacerated  wounds  are  attacked, 
for  in  such  wounds  the  bacilli  are  deeply  lodged  in  recesses  or  cavities  into 
which  air  does  not  penetrate  or  are  covered  with  discharges  which  exclude 
air.  Suppuration  favors  the  growth  of  tetanus  bacilli  because  the  pyo- 
genic organisms  consume  oxygen.  Occasionally,  though  fortunately  very 
rarely,  tetanus  follows  vaccination.  It  is  essential  that  vaccine  virus  should 
be  carefully  selected  and  prepared.  When  care  is  taken,  the  operation  is  ab- 
solutely safe.  When  tetanus  follows  vaccination,  it  arises  from  infection  of 
the  wound  either  at  the  time  of  vaccination  or,  as  is  far  more  common,  at  a 
later  period  from  scratching  or  some  other  fouling.  The  tetanus  organism  is 
not  introduced  in  the  vaccine,  but  obtains  entrance  during  or  subsequent  to  the 
operation  of  vaccination,  because  of  utter  neglect  of  the  vaccine  lesion  and  in 
consequence  of  the  accumulation  of  filth  upon  and  about  it.  In  no  reported 
case  have  the  symptoms  of  tetanus  appeared  earlier  than  two  weeks  after 
vaccination  (Wm.  N.  Welch,  "N.  Y.  Med.  Jour.,"  Jan.  16,  1909).  The  organ- 
isms or  their  spores  have  never  been  discovered  in  tubes  or  in  points,  and,  as 
Rosenau  points  out,  the  organism  cannot  grow  and  cannot  form  toxins  on  dry 
points  or  in  glycerinated  virus.  The  most  scrupulous  care  is  taken  to  prevent 
contamination  of  vaccine  virus,  and  it  is  examined  for  tetanus  toxin  and  tetanus 
bacilli  before  it  is  placed  on  the  market.  Tetanus  has  followed  the  injection 
of  gelatin.  Commercial  gelatin  often  contains  the  bacilli  and  should  never  be 
used  without  careful  fractional  sterilization  (see  page  480).  Roberts  reports  a 
case  of  fatal  tetanus  in  a  patient  with  chronic  ulcer  of  the  leg  ("Lancet,"  vol.  i, 
1912).  Evler  infected  himself  while  operating  on  a  case  of  tetanus  ("Berliner 
klin.  Wochenschr.,"  Sept.  12,  1910).  Tetanus  has  followed  a  burn,  a  frost-bite, 
child-birth,  abortion,  and  the  use  in  a  wound  of  contaminated  catgut.  Most 
cases  of  postoperative  tetanus  depend  upon  infected  catgut.  The  disease  some- 
times arises  when  no  catgut  was  used  (J.  B.  Smith's  case,  "Brit.  Med.  Jour.," 
May  6, 191 1).  Cases  have  arisen  from  such  trivial  operations  as  ligation  of  piles 
and  hypodermatic  injection  of  quinin.  Peterson  ("Jour.  Am.  Med.  Assoc," 
Jan.  8,  1 910)  collected  49  cases  of  postoperative  tetanus  reported  since  1890. 
In  40  the  peritoneal  cavity  had  been  opened.  In  only  18  cases  suture  material 
was  named  (catgut,  3 ;  catgut  and  kangaroo-tendon,  2 ;  catgut  with  other  mate- 
rial, 7;  silk,  4;  silk  and  silk-worm-gut,  i;  silk  and  silver  wire,  i).  No  case 
appeared  before  the  fourth  day,  most  began  on  the  ninth  day.  Drainage  should 
tend  to  prevent  it.  In  1909  Matas  pointed  out  that  tetanus  was  most  apt  to  fol- 
low operations  in  regions  exposed  to  the  danger  of  fecal  contamination  ("Tr. 
Am.  Surg.  Assoc,"  xxvii).  Speed  says  that  man  may  be  a  tetanus  carrier.  He 
believes  that  bacilli  and  spores  may  at  times  enter  the  blood.  He  would  thus 
account  for  some  cases  of  postoperative  tetanus  ("Surg.,  Gynec,and  Obst.," 
April,  1 91 6).  Colombino  believes  there  are  tetanus  carriers.  He  has  examined 
many  wounds  in  men  who  had  received  prophylactic  injections  of  antitoxin 
and  who  had  never  showed  signs  of  tetanus.  A  number  of  times  he  found 
spores  of  tetanus  (as  Berard  and  Lumiere  had  done  before)  and  also  bacilh 
(Presse  medicale,  August  2,  1917).  If  any  operation  were  done  on  such  a  man, 
for  instance  appendicitis,  the  lowering  of  resistance  would  be  apt  to  lead  to  the 
development  of  tetanus  unless  antitoxin  was  given  before  operation.  Tetanus 
may  appear  within  twenty-four  hours  after  an  accident,  but  it  may  not  arise 
until  many  days  or  even  several  weeks  have  elapsed.  Rose  reported  a 
case  which  began  within  twenty-four  hours.  Kuhn  ("Berliner  klinische 
Wochensch.,"  1901)  reports  a  fatal  case  of  tetanus  beginning  twelve  hours  after 
an  injection  of  gelatin.  Such  a  rapid  case  could  only  be  due  to  the  gelatin  hav- 
ing contained  a  large  quantity  of  tetanus  toxin  (Schuckmann).  Jacobson  and 
Pease  are  of  the  opinion  that  "such  cases  as  have  been  recorded  with  periods  of 
incubation  under  three  days  must  be  accepted  with  considerable  reserve" 
15 


226  Tetanus,  or  Lockjaw 

("Annals  of  Surgery,"  Sept.,  1906J.  Samuel  D.  Gross,  in  his  "System  of 
Surgery,"  speaks  of  i  case  occurring  in  a  man  five  weeks  after  injury,  and 
another  in  a  girl  four  weeks  after  injury.  Late  cases  are  due  to  modifica- 
tion by  one  dose  of  protective  serum,  or  arise  when  dormant  bacteria  or 
spores  hang  in  the  wound  or  in  the  tissues  are  roused  into  action  by  a  trau- 
matism, which  may  be  very  trivial  (see  Sir  David  Semple's  views  on  page  224). 
It  seems  certain  that  tetanus  bacilli  or  at  least  spores,  may  live  in  uncontami- 
nated  tissue,  for  instance  a  healed  wound,  for  months  without  propagating  and 
without  inducing  symptoms.  Were  these  same  bacteria  lodged  in  devitalized 
tissue  tetanus  would  arise.  One  case  of  tetanus  is  recorded  as  arising  on  the 
fifty-third  day  after  the  injury  (Bowling,  "Brit.  Med.  Jour.,"  March  4,  1916)- 
Antitetanic  serum  may  greatly  delay  but  not  prevent  the  onset  of  tetanus. 
In  order  to  prevent  these  late  cases  three  injections  of  serum  are  now  given,  an 
interval  of  seven  or  eight  days  intervening  between  doses.  Any  muscular 
contraction  after  a  wound  however  late  it  appears  should  excite  apprehensions  of 
tetanus.  Many  such  late  cases  are  now  on  record.  Tetanus  is  more  common 
in  the  tropics  than  in  the  temperate  zone;  it  prevails  more  in  certain  localities 
than  in  others,  but  it  is  met  with  all  over  the  world  from  the  Arctic  Zone  to  the 
Tropics,  and  may  arise  in  either  sex,  in  any  race,  and  at  any  age.  Colored  people 
are  very  susceptible,  and  the  disease  may  exist  endemically ,  and  does  so  in  certain 
portions  of  New  Jersey  and  of  Cuba.  In  our  country  the  greatest  prevalence^ 
according  to  Anders,  is  in  Pennsylvania,  northern  New  York,  Long  Island, 
Virginia,  Georgia,  and  Louisiana.  Anders  collected  1201  cases  and  Pennsyl- 
vania stands  first  on  his  list  with  224  cases  ("Jour.  Am.  Med.  Assoc,"  July  29, 
1905).  It  is  stated  that  in  certain  districts  of  Nigeria  the  soil  contains  so  many 
tetanus  spores  that  the  natives  poison  their  arrows  by  sticking  them  into  the 
ground  (Allan  C.  Parsons,  in  "Brit.  Med.  Jour.,"  Jan.  23,  1909).  The  soil  of 
Belgium  contains  multitudes  of  tetanus  spores.  In  the  Civil  War  one  case  of 
tetanus  arose  among  every  450  wounded  men  ("Agnew's  Surgery").  The  pro- 
portion in  the  Crimea  was  about  the  same.  During  the  early  months  of  the 
present  war  tetanus  was  a  disastrous  scourge.  It  has  been  stated  that  during 
those  months  7  per  cent,  of  the  wounded  developed  tetanus.  In  the  British 
army  in  October,  1914,  "the  ratio  of  cases  of  tetanus  to  wounded  men  was  32  per 
thousand.  Thorough  prophylaxis  has  brought  about  an  immense  improvement 
in  the  ratio  (page  232),  many  observers  have  agreed  with  Larrey  that  sudden 
changes  of  temperature  favor  the  development  of  tetanus.  After  the  battle  of 
Bantzen  the  wounded  lay  exposed  to  a  cold  storm.  The  day  after  the  battle 
Larrey  found  100  cases  of  tetanus.  Tetanus  is  due  to  the  growth  in  a  wound 
of  a  bacillus  which  was  first  described  by  Nicolaier  and  was  first  cultivated  by 
Katasato.  It  is  the  most  widely  distributed  of  all  the  pathogenic  bacteria.  It 
is  very  difiicult  to  cultivate  and  cannot  be  cultivated  at  all  unless  air  is  abso- 
lutely excluded.  Tetanus  bacilli  or  their  spores  are  found  particularly  in  garden 
soil,  in  the  dust  of  walls,  walks  and  cellars,  in  street  dirt,  and  in  the  refuse  of 
stables.  There  is  much  suggestive  evidence  that  \-irulent  tetanus  bacilli  come 
from  the  intestinal  canal  of  animals;  that  the  bacteria  lose  their  virulence  when 
they  have  been  long  outside  of  the  intestinal  canal;  and  that  the  highest  degree  of 
virulence  is  obtained  by  those  which  have  passed  frequently  through  intestinal 
canals.  The  above  view  is  known  as  the  fecal  theory  and  is  strongly  advocated 
by  Somani.^ 

It  is  taught  that  in  tetanus  the  bacilli  do  not  enter  into  the  blood,  and  toxic 
products  produced  by  them  are  not  directly  absorbed  by  the  blood  or  lymph. 
Porter  and  Richardson  ("Boston  Med.  and  Surg.  Jour.,"  Dec.  23,  1909)  in  2 
cases  obtained  cultures  of  the  baciUi  from  h-mph-glands  which  received  drain- 
age from  the  wound  region.  This  is  a  highly  important  observation.  The 
toxic  products  alone  \\dthout  any  bacteria  enter  the  muscular  end  organs  of 
1  "Verhandl.  d.  X  internat.  med.  Cong.,"  Berlin,  1890,  Bd.  v,  Abth  15,  p.  152. 


Tetanus  Dolorosa  227 

motor  nerves,  ascend  along  the  perineural  lymph  sheaths,  and  reach  the  spinal 
cord  and  medulla  (Brunner,  Marie),  become  fixed  in  the  nerve-cells  of  the  spinal 
cord  and  medulla,  and  produce  the  symptoms  of  the  disease.  Metchnikoff 
found  tetanus  toxin  in  the  cord.  Emulsion  made  from  the  region  of  the  mas- 
ticatory nuclei  of  the  floor  of  the  fourth  ventricle  is  peculiarly  rich  in  highly 
potent  toxin  (Trosier  and  Georges  Roux,  quoted  in  "Lancet,"  Jan.  15,  1910). 
Tetanus  is  an  intoxication  and  not  an  infection,  and  a  drop  of  blood  of  an  animal 
w-ith  tetanus,  if  injected  into  another  animal,  wdll  not  produce  the  disease. 
Tetanus  toxin  poisons  the  nervous  system  as  would  strychnin  or  some  other 
vegetable  alkaloid.  It  is  probably  the  most  powerful  of  known  poisons.  It 
has  been  estimated  that  }  275  gr.  is  sufficient  to  kill  an  adult  weighing  165  lb. 
(''American  Medicine,"  Nov.  30,  1901).  The  great  power  of  the  poison  is 
shown  by  the  report  of  Dr.  Nicholas's  case  ("Comptes  rendu  de  la  Societe  de 
Biologic,"  1S93).  Dr.  Nicholas,  had  been  using  a  syringe  to  inject  filtered  cul- 
tures of  the  bacilli  of  tetanus  and  he  accidentally  pricked  his  finger  with  the 
needle.  In  four  days  tetanus  began,  and  he  barely  escaped  with  his  life  in 
spite  of  the  fact  that  the  fluid  was  free  of  bacteria  and  the  dose  of  toxin  was 
extremely  minute.  The  nature  of  the  virulent  poison  which  is  produced  at 
the  seat  of  inoculation  is  uncertain.  Some  believe  it  to  be  alkaloidal,  like  the 
vegetable  alkaloids;  some,  that  it  is  a  toxalbumin;  others  maintain  that  it  is  an 
enz^Tne  or  ferment  (Nocard,  Courmont,  and  others).  In  a  very  few  instances 
the  injection  of  perfectly  sterile  antidiphtheritic  serum  into  human  beings  has 
caused  death  \yiih  all  the  symptoms  of  tetanus.  The  serum  must  have  been 
obtained  from  horses  in  whom  tetanus  was  incubating,  and  the  blood-serum 
injected  must  have  contained  a  fatal  dose  of  tetanus  toxin.  In  tetanus  an 
ascending  neuritis  occasionally,  though  seldom,  exists  in  the  peripheral  nerve 
near  the  lesion.  The  toxin  is  carried  to  the  cord  by  the  motor  nerves  only,  and 
it  is  not  only  absorbed  by  the  lymph-channels  of  the  nerve,  but  ascends  along 
the  axis-cylinders  of  the  nerve  itself  and  reaches  the  motor  cells  of  the  spinal 
cord  (Meyer  and  Ransom,  in  ''Arch,  exper.  Path.  u.  Pharmakol.,"  1903).  On 
reaching  the  cord  it  attacks  the  motor  nerve-cells,  producing  changes  similar 
to  those  produced  by  certain  infections,  and  ascends  in  the  motor  tracts  of  the 
cord  to  the  medullary  nerve-centers.  WTiile  toxin  is  ascending  the  axis-cylin- 
ders a  certain  amount  is  taken  up  by  the  honphatics,  enters  the  blood,  and 
reaches  the  spinal  cord  by  other  nerve-fibers  (Jacobson  and  Pease,  in  "Annals 
of  Surgery,"  Sept.,  1906).  The  essential  basis  of  tetanus  is  spreading  irritation 
of  the  motor  portion  of  the  spinal  cord  accompanied  by  extreme  reflex  excita- 
bility which  is  due  to  poisoning  of  sensory  neiurones  (Meyer  and  Ransom). 
The  irritation  of  the  motor  cord  produces  tonic  contraction  of  the  muscles ; 
the  excitation  of  the  sensory  neurons  is  responsible  for  clonic  con\nilsions. 
Lumiere  (La  Presse  medicale,  March  29,  191 7)  reports  the  case  of  a  man 
wounded  with  shrapnel  and  given  antitoxin  who  developed  tetanus  on  the  six- 
teenth day.  In  spite  of  various  doses  of  antitoxin  he  got  another  attack  on 
the  sixty-seventh  day  and  died  on  the  seventy-fourth  day.  If  this  were  a 
real  second  attack  of  tetanus,  it  is  a  surgical  rarity,  as  second  attacks  are 
extremely  unusual,  but  it  is  not  believed  that  one  attack  confers  any  prolonged 
immunitv. 

Trismus  neonatorum  {trismus  nascentium)  is  the  lockjaw  of  the  newborn. 
It  is  due  to  infection  of  the  stump  of  the  umbilical  cord  and  practically  is 
invariably  fatal. 

Cerebral  tetanus  has  only  been  seen  as  a  result  of  animal  experiments.  It 
is  caused  by  injecting  tetanus  toxin  into  the  brain  and  is  characterized  by  men- 
tal s}Tnptoms  (Roux  and  Borrell  in  '' .Annals  Inst.  Pasteur,"  July,  1897). 

Tetanus  dolorosa  is  experimental  tetanus  produced  by  injecting  toxin  into 
the  posterior  roots  of  the  spinal  nerves.  It  is  characterized  by  \dolent  spasms 
of  pain  and  absence  of  motor  s}Tnptoms. 


2  28  Tetanus,  or  Lockjaw 

Local  Tetanus. — In  some  cases  local  sym{)toms  precede  widespread  evi- 
dences of  tetanus.  There  may  be  local  spasm  in  a  limb  for  two  or  three  days 
before  general  symptoms  arise.  In  some  cases  the  symptoms  remain  local. 
These  last  cases  constitute  local  tetanus.  Experimental  tetanus  in  animals 
"exhibits  almost  without  exception  as  its  earliest  manifestations  those  of  a 
purely  local  character  and  which  are  at  first  restricted  to  the  neighborhood  of 
the  inoculation.  This  is  now  understood  to  be  due  to  the  absorption  of  the 
toxin  by  the  perineural  lymphatics  of  the  motor  nerve  of  the  part.  Local 
tetanus  is  a  modified  genuine  tetanus.  A  number  of  cases  have  been  seen  in 
this  war,  in  which  a  single  preventive  dose  of  antitoxin  greatly  modified,  but 
did  not  entirely  prevent  the  disease.     There  are  three  forms  of  it. 

1.  Cephalic,  Hydrophobic  or  Head  Tetanus. — In  this  condition  the  contrac- 
tions are  confined  chiefly  to  the  face,  neck  and  pharynx,  although  the  abdominal 
muscles  may  also  be  rigid.  There  may  be  no  paralysis  but  paralysis  may  in- 
volve the  facial  nerve,  the  oculomotor  nerve  or  the  hypoglossal  nerve  (Burrows 
in  "Lancet,"  Jan.  27,  191 7).     Cephalic  tetanus  follows  head  injury. 

2.  Splanchnic  Tetanus. — This  occurs  after  thoracic  or  abdominal  wounds. 
The  muscles  of  deglutition  and  respiration  are  those  which  are  involved.  Gen- 
eral spasms  are  absent. 

3.  Local  Tetanus  of  the  Extremities. — A  single  group  of  muscles,  one  limb, 
two  corresponding  limbs  may  suffer.  The  condition  follows  injury  of  an  ex- 
tremity or  of  extremities. 

4.  Abdominodorsal  Tetanus. — In  this  condition  rigidity  is  limited  to  the 
abdomen  and  back.     It  follows  injury  of  the  chest  or  back. 

Prof.  Osier  has  seen  nine  cases  of  local  tetanus  and  he  cautions  us  that  every 
muscular  spasm  arising  after  a  wound  is  not  of  necessity  tetanus  because  reflex 
spasm  and  neurotic  spasm  ma}'  occur.  In  local  tetanus  the  condition  is  apt  to 
arise  late  after  the  infliction  of  the  wound  (over  seven  days)  and  in  those  who 
were  given  one  prophylactic  injection  of  antitetanic  serum  soon  after  the  inflic- 
tion of  the  wound.  Widalspeaks  of  it  as  the  tetanus  of  incomplete  immunization. 
The  serum  after  injection  of  an  ordinary  dose  reaches  its  highest  antitoxic 
power  in  two  to  three  days,  remains  at  high  power  until  about  the  fifth  day  and 
then  the  power  begins  to  decline.  Between  the  eighth  and  twelfth  day  all  the 
antitoxin  will  disappear.  If  while  the  antitoxin  is  disappearing  tetanus  toxin  is 
still  being  absorbed  modified  tetanus  will  occur.  If  toxin  pours  in  when  anti- 
toxin is  all  gone,  general  tetanus  may  occur. 

We  might  prolong  the  immunity  by  giving  a  much  larger  dose  than  500 
units,  but,  as  MacConkey  and  Homer  say  ("Lancet,"  Feb.  17,  1917)  it  is  "quite 
impracticable  to  use  for  man  doses  corresponding  to  some  of  those  we  have 
given  to  guinea-pigs,  and  we  must  content  ourselves  with  smaller  doses,  even 
though  the  protection  does  not  last  as  long  as  we  would  wish." 

Many  surgeons  now  recommend  repeating  the  dose  of  protective  serum 
once,  twice,  or  even  three  times  at  intervals  of  seven  or  eight  days.  There  may 
perhaps  be  some  danger  of  anaphylaxis  but  care  in  giving  the  injection  will  lessen 
the  danger  and  we  had  better  run  the  small  risk  of  anaphylaxis  arising  than  let 
the  patient  have  the  dreadful  risk  of  tetanus.  (See  Berard  in  "Bull,  de  Acad, 
de  Med.,"  1915,  Ixxiv.  Vaillard,  "BuU.  de  Acad,  de  Med.,"  Sept.  5,  1916. 
Report  on  injections  of  serum,  made  by  Committee  of  Societe  Medicale  des 
Hopitaux  de  Paris.  Published  in  "BuH.  Societe,"  Nov.  19,  191 5,  MacConkey 
and  Homer  in  "Lancet,"  Feb.  17,  1917;  Burrows  in  "Lancet,"  Jan.  27,  1917.) 
The  conditions  favoring  the  local  appearance  of  tetanus  are  a  short  motor 
nerve,  as  in  head  injuries;  an  injury  to  a  nerve-trunk  permitting  the  rapid 
absorption  of  a  large  amount  of  toxin;  the  production  of  a  meager  amount  of 
toxin  or  the  presence  of  something  which  prevents  the  admission  of  a  large 
amount  of  toxin  into  the  circulation  (Nathan  Jacobson  and  Herbert  D.  Pease, 


Symptoms  of  Tetanus  229 

Ibid.).  Cases  with  local  symptoms  in  the  beginning  are  apt  to  have  had  long 
periods  of  incubation,  are  apt  to  be  cured,  and  usually  endure  a  considerable 
time. 

Mortality.— It  is  a  very  fatal  disease.  Acute  tetanus  has  a  mortality  of 
from  75  to  90  per  cent.;  chronic  tetanus,  from  40  to  50  per  cent.;  postoperative 
tetanus,  of  over  85  per  cent.  (Peterson's  estimate  in  "Jour.  Am.  Med.  Assoc," 
Jan.  8,  1910). 

Local  tetanus  is  apt  to  terminate  in  recovery.  Tetanus  produces  death 
by  overwhelming  the  patient  with  toxin  by  exhaustion  resulting  from  repeated 
convulsions,  by  spasm  of  the  glottis,  or  fixation  of  the  respiratory  muscles. 

Symptoms.— Acute  tetanus  begins  within  ten  or  twelve  days  of  an  accident. 
The  usual  period  of  incubation  is  from  three  to  five  days.  Evler  had  the  rare 
and  dreadful  experience  of  contracting  the  disease  from  a  victim  of  tetanus  on 
whom  he  was  operating,  and  the  extreme  good  fortune  to  recover.  He  reports 
his  own  case  and  says  that  various  short  and  transient  early  symptoms  occur 
which  the  patient  is  apt  to  attribute  to  the  heahng  wound.  Among  these  he 
mentions  restlessness,  sleeplessness,  bad  dreams,  oppression  of  breathing,  fre- 
quent and  difficult  micturition,  headache,  fatigue,  vertigo,  chilliness,  darting 
pains  in  various  regions,  and  perhaps  pains  about  the  injured  part.  If  an  ex- 
tremity is  the  seat  of  wound,  it  may  swell  and  remain  swollen  even  when  ele- 
vated, and  it  feels  hot,  but  is  not  discolored.  Before  long  the  wound  becomes 
tender  and  glands  often  swell.  There  may  be  painless  contractions  and  tremors 
of  the  injured  extremity.  Single  groups  of  muscles  may  undergo  tonic  contrac- 
tion ("  Berliner  klin.  Wochensch.,"  Sept.  12, 1910).  In  most  cases  of  tetanus  the 
first  symptom  noted  by  the  patient  is  stiffness  of  the  jaw  on  opening  the  mouth. 
In  some  cases  the  first  symptom  is  stiffness  of  the  neck,  and  the  patient  be- 
lieves he  has  "  caught  cold."  In  other  cases  the  stiffness  begins  in  the  abdomen. 
In  any  case  the  jaw  and  neck  soon  become  stiff,  and  finally  both  the  neck  and 
jaw  become  as  rigid  almost  as  iron.  The  fixation  of  the  jaw  is  called  trismus. 
The  muscles  of  deglutition  become  rigid  on  attempts  at  swallowing.  The  mus- 
cles of  the  back,  legs,  and  abdomen  are  thrown  into  tonic  spasm,  but  the  arms 
rarely  suffer.  If  the  infected  injury  is  on  the  hand  or  foot,  that  extremity 
usually  is  found  to  be  rigid.  Spasm  of  the  face  muscles  causes  the  risus  sar- 
donicus,  or  sardonic  smile  (contraction  particularly  of  the  musculus  sardonicus 
of  Santorini).  The  contraction  of  the  muscles  of  the  back  is  often  so  powerful 
as  to  bend  the  patient  into  a  curve  like  a  bow  and  allow  him  to  rest  only  on  his 
occiput  and  heels.  This  condition  is  known  as  opisthotonos.  If  he  is  bent  for- 
ward, so  that  the  face  is  drawn  to  the  legs,  it  is  called  emprosthotonos.  If  his 
body  is  curved  sideways,  it  is  designated  pleurosthotonos.  An  upright  position 
is  orthotonos.     The  spasm  may  be  so  violent  as  to  cause  muscular  rupture. 

The  characteristic  condition  in  tetanus  is  one  of  widely  diffused  tonic  spasm, 
aggravated  frequently  by  clonic  spasms  arising  from  peripheral  irritations. 
These  irritations  may  be  drafts,  sounds,  lights,  shaking  of  the  bed*  attempts 
at  swallowing,  contact  of  the  bed-clothing,  the  presence  of  urine  in  the  bladder 
or  of  feces  in  the  rectum,  or  various  visceral  actions.  The  clonic  spasms  begin 
early  in  the  case  and  become  more  frequent  and  more  violent  as  the  disease 
progresses.  The  muscles  become  more  rigid  and  the  attitude  produced  by  the 
tonic  contraction  of  the  muscles  is  temporarily  exaggerated.  The  forcible  con- 
traction of  the  jaw  may  loosen  or  break  teeth.  The  spasms  of  the  diaphragm, 
of  the  glottis,  and  of  the  muscles  of  respiration  may  produce  death  and  always 
produce  great  dyspnea.  .  Attempts  at  swallowing  produce  spasmodic  contrac- 
tion of  the  muscles  of  deglutition.  The  respirations  are  rapid  and  shallow 
because  of  muscular  rigidity.  Every  now  and  then  the  contracted  thoracic 
muscles  are  thrown  into  clonic  spasm  and  then  cyanosis  occurs.  In  well-devel- 
oped tetanus  when  the  muscles  exhibit  only  tonic  contraction  the  condition  is 
as  follows:  The  jaws  are  rigidly  locked.     The  eyes  are  fixed  and  stare  wildly. 


230  Tetanus,  or  Lockjaw 

The  nostrils  are  distended.  The  angles  of  the  mouth  are  retracted.  The  lips 
are  flattened  and  the  teeth  are  exposed.  All  the  facial  lines  are  accentuated. 
The  expression  is  a  mingling  of  fear  and  pain.  At  this  time  there  is  severe 
thirst,  general  muscular  soreness  and  often  torturing  pain  in  the  precordium. 
When  a  clonic  convulsion  occurs  the  condition  is  suddenly  and  acutely  aggra- 
vated. The  man  laboring  under  a  tetanic  convulsion  presents  a  dreadful  pic- 
ture; he  is  bent  into  some  unnatural  attitude,  the  face  is  cyanotic  and  wet  with 
drops  of  sweat,  the  lips  are  covered  with  froth  which  is  often  bloody,  the  eyes 
bulge  and  are  suffused,  and  the  countenance  expresses  deadly  terror  and  suffer- 
ing. Some  of  the  teeth  may  be  broken  and  the  tongue  lacerated.  The  agon- 
izing "girdle  pain"  or  precordial  pain  so  often  met  with  is  due  to  spasm  of  the 
diaphragm.  Each  clonic  spasm  causes  a  hideous  scream  by  the  constriction 
of  the  chest  forcing  air  through  a  contracted  glottis.  During  the  progress  of 
the  disease  constipation  is  persistent,  and  retention  of  urine  is  the  rule  (because 
of  sphincter  spasm).  The  urinary  secretion  is  scanty.  The  mind  is  almost 
invariably  entirely  clear  until  near  the  end — one  of  the  worst  elements  of  the 
disease.  Delirium  may  arise.  I  have  seen  it  in  three  cases,  due,  I  fancy,  in 
each  case,  to  the  drugs  administered.  It  may,  of  course,  be  due  to  previous 
alcoholism.  There  is  obstinate  insomnia.  Headache  is  common.  Hearing,  at 
first  hyperacute,  is  later  impaired.  Deafness  may  arise.  Pulse  is  seldom  above 
80  or  90  until  shortly  before  death,  when  it  may  become  150  or  more.  Usually 
the  pulse  is  of  high  tension.  Swallowing  in  many  cases  is  impossible.  Talking 
is  very  difhcult  and  usually  it  is  impossible  to  project  the  tongue.  The  muscles 
throughout  the  body  feel  very  sore.  The  temperature  may  be  normal,  but 
may  be  a  little  elevated,  and  always  rises  just  before  death.  Hyperpyrexia 
sometimes  occurs  (io8°-ii2°  F.),  and  the  temperature  may  even  ascend  for  a 
time  after  death.  An  injection  of  serum  raises  the  temperature  several  degrees. 
In  about  85  per  cent,  of  fatal  cases  of  acute  tetanus  death  occurs  within  five 
days,  and  many  of  these  patients  die  within  two  or  three  days.  Very  few  puer- 
peral cases  recover  and  practically  no  cases  which  follow  abortion  recover.  Of 
late  years  the  mortality  in  acute  tetanus  has  slightly  diminished.  If  a  patient 
lives  a  week,  his  chance  of  recovery  is  good.  In  the  Civil  War  the  mortality 
was  89.3  per  cent.  In  the  Franco-Prussian  war  it  was  about  the  same.  Ash- 
hurst  and  John  in  1913  collected  435  cases  with  a  mortality  of  60  per  cent.  ("  Am. 
Jour.  Med.  Sciences,"  June,  1913).  I  beUeve  that  if  modified  cases  and  cases 
of  chronic  tetanus  are  excluded  and  we  count  only  acute  general  tetanus  in 
which  the  incubation  period  was  brief,  the  mortality  is  still  at  least  80  per  cent. 
Early  in  this  war  the  mortality  among  tetanus  cases  who  had  not  received  pro- 
phylactic injections  was  91  per  cent,  when  the  incubation  was  short  and  50  per 
cent,  when  it  was  delayed  (Bruce,  "Brit.  Med.  Jour.,"  Oct.  23,  1915).  Death 
may  be  due  to  exhaustion,  to  respiratory  failure,  to  carbonic-acid  narcosis  from 
spasm  of  the  glottis  or  fixation  of  the  respiratory  muscles  or  to  pneumonia. 

Chronic  tetanus  comes  on  late  after  a  wound  (from  ten  days  to  several 
weeks).  The  symptoms  are  not  so  severe  as  in  acute  tetanus.  The  muscular 
spasm  is  widespread,  but  it  may  not  be  persistent,  intervals  of  relaxation  per- 
mitting sleep  and  the  taking  of  food.  Chronic  tetanus  long  had  a  mortality 
of  40  or  50  per  cent.,  but  modern  methods  of  treatment,  it  has  been  claimed, 
have  considerably  reduced  it.  According  to  the  report  of  Jacobson  and  Pease 
it  is  still  from  35  to  50  per  cent.  ("Annals  of  Surgery,"  Sept.,  1906).  The  dis- 
ease may  last  for  some  weeks. 

Diagnosis. — Tetanus  may  be  confounded  with  strychnin-poisoning,  with 
hysteria,  with  tetany,  or  with  hydrophobia.  Wood's  table  (see  page  231)  makes 
the  diagnosis  clear  between  tetanus,  strychnin-poisoning,  and  hysteria.' 

Tetany  is  distinguished  from  tetanus  by  the  milder  nature  of  the  spasms, 
by  the  greater  limitation  of  the  rigidity,  by  the  fact  that  spasms  begin  in  the 
1  "Nervous  Diseases,"  by  Prof.  H.  C.  Wood. 


Treatment  of  Tetanus 


231 


Hysteric  Tetanus 


Strychnin-poisoning 


Muscular  symptoms 
usually  commence  with 
pain  and  stiffness  in  the 
liack  of  the  neck,  some- 
times with  slight  muscu- 
lar twitching;  comes  on 
gradually.  Jaw  one  of 
the  earliest  parts  affected; 
rigidly  and  f)ersistently 
set. 

Persistent  muscular 
rigidity  very  generally, 
with  a  greater  or  less  de- 
gree of  permanent  opis- 
thotonos, emprosthoto- 
nos,  pleurosthotonos,  or 
orthotonos. 

Consciousness  pre- 
served until  near  death, 
as  in  strychnin-poisoning. 


Drafts,  loud  noises,  etc., 
produce  convulsions,  as  in 
strychnin-poisoning;  may 
•complain  bitterly  of  pain. 


Eyes  open  and  rigidly 
fixed  during  the  convul- 


Commences     with    blind- 
ness and  weakness. 


Muscular  symptoms  com- 
mence with  rigidity  of  the 
neck,  which  creeps  over  the 
body,  affecting  the  e.xtremi- 
ties  last.  Jaws  rigidly  set 
before  a  convulsion,  and  re- 
main so  between  the  paro.x- 
ysms. 


Persistent  opisthotonos 
and  intense  rigidity  between 
the  convulsions  and  after  the 
convulsions  have  ceased,  the 
opisthotonos  and  intense 
rigidity  lasting  for  hours. 


Consciousness  lost  as  the 
second  convulsion  comes  on, 
and  lost  with  every  other 
convulsion,  the  disturbance 
of  consciousness  and  motility 
being  simultaneous. 


Crying   spells    alternating 
with  convulsions. 


Eyes  closed. 


Partial  spasm  in  the  leg, 
producing  in  Wood's  cases 
crossing  of  the  feet  and  in- 
version of  the  toes.  If  all 
the  muscles  were  involved, 
eversion  would  occur,  as  the 
muscles  of  eversion  are  the 
stronger. 


Begins  with  exhilaration  and  rest- 
lessness, the  special  senses  being 
usually  much  sharpened.  Dimness 
of  vision  may  in  some  cases  be  mani- 
fested later,  after  the  development 
of  other  symptoms,  but  even  then 
it  is  rare. 

Muscular  symptoms  develop  very 
rapidly,  commencing  in  the  extremi- 
ties, or  the  convulsion  when  the  dose 
is  large  seizes  the  whole  body  simul- 
taneously. Jaw  the  last  part  of  the 
body  to  be  affected;  its  muscles  re- 
lax first,  and  even  when,  during  a 
severe  convulsion,  it  is  set,  it  drops 
as  soon  as  the  latter  ceases. 

Muscular  relaxation  (rarely  a 
slight  rigidity)  between  the  convul- 
sions, the  patient  being  exhausted 
and  sweating.  If  recovery  occurs, 
the  convulsions  gradually  cease, 
leaving  merely  muscular  soreness, 
and  sometimes  stiffness  Hke  that 
felt  after  violent  exercise. 

Consciousness  always  preserved 
during  convulsions,  except  when  the 
latter  become  so  intense  that  death 
is  imminent  from  suffocation,  in 
which  case  sometimes  the  patient 
becomes  insensible  from  asphyxia, 
which  comes  on  during  the  latter 
part  of  a  convulsion  and  is  almost  a 
certain  precursor  of  death. 

The  "slightest  breath  of  air"  pro- 
duces convulsion.  Patient  may 
scream  with  pain  or  may  express 
great  apprehension,  but  "crying 
spells"  would  appear  to  be  impos- 
sible. 

Eyes  stretched  wide  open. 


Legs  stiffly  extended  with  feet 
everted,  as  the  spasms  affect  all  the 
muscles  of  the  leg. 


hands  or  feet,  not  in  the  jaw  and  neck,  and  in  most  cases  by  periods  of  distinct 
intermittence. 

In  hydrophobia  tonic  spasm  does  not  exist,  and  if  clonic  spasms  occur  they 
are  secondary  to  suffocative  attacks! 

Treatment. — Far  better  even  than  to  treat  tetanus  well  is  to  prevent  it. 
Careful  antisepsis  will  banish  it  as  a  sequence  of  surgical  operations  as  thor- 
oughly as  it  has  banished  septicemia  provided  no  dormant  bacteria  of  tetanus 
and  no  tetanus  spores  are  lodged  in  the  traumatized  tissues.  Every  infected 
wound  must  be  disinfected  with  the  most  scrupulous  care.  Every  punctured 
wound  is  to  be  incised  to  its  depths  and  thoroughly  cleaned  and  drained.  In  a 
very  suspicious  wound,  such  as  a  Fourth  of  July  injury  or  a  wound  from  a  dung 


232  Tetanus,  or  Lockjaw 

fork,  or  the  entrance  into  the  tissues  of  a  splinter  from  a  stable  floor,  after  the 
removal  of  foreign  bodies  and  thorough  antiseptic  cleansing,  give  a  subcutaneous 
injection  of  500  U.  S.  A.  units  (3  cm.  of  horse  serum)  of  tetanus  antitoxin.  It 
is  certain  that  tetanus  antitoxin  has  prophylactic  f)ower;  in  fact,  Jacobson  and 
Pease  say  that  "as  a  prophylactic  measure  it  merits  our  fullest  confidence" 
(Loc.  cit.).  The  procedure  is  not  a  certain  preventive.  Reynier  injected  anti- 
toxin into  a  patient  on  whom  he  was  about  to  operate  because  there  was  a 
case  of  tetanus  in  the  wards,  and  yet  this  man  developed  tetanus  ("Gaz.  des 
Hopiteaux,"  July  16,  1901).  Thirty  Hght  cases  have  been  reported  in  which 
prophylactic  injections  failed  to  prevent  the  disease.  When  in  spite  of  such 
injections  the  disease  does  arise,  it  is  apt  to  be  mitigated  in  violence.  Never- 
theless it  is  sure  that  animals  can  be  rendered  immune  to  tetanus,  and  the  pro- 
phylactic power  of  antitoxin  is  warmly  advocated  by  many  eminent  men.  It  is 
extensively  and  most  successfully  used  by  veterinarians  to  prevent  tetanus 
after  castration  of  horses,  and  this  success  is  a  guide-post  to  us.  The  following 
table  is  most  suggestive  (quoted  by  Heineck  in  "  Surgery,  Gynecology,  and 
Obstetrics,"  Jan.,  1909,  from  Scherck's  article  in  "Jour.  Am.  Med.  Assoc," 
1906,  vol.  xlvii,  p.  500).  It  sets  forth  the  Fourth  of  July  injuries  treated  in 
St.  Louis  dispensaries: 


Antitetanic  serum  as 

Years. 

No, 

.  of  cases. 

a  preventive. 

Deaths  from  tetanus. 

1903 

56 

no 

16 

1904 

37 

yes 

none 

1905 

84 

yes 

none 

1906 

170 

yes 

none 

War  experience  on  an  immense  scale  proves  the  prophylactic  value  of  anti- 
tetanic  serum.  In  the  British  army  since  universal  immunization  was  intro- 
duced the  ratio  of  cases  of  tetanus  to  wounded  men  has  fallen  from  32  per  thou- 
sand to  2  per  thousand  (David  J.  Davis  in  "Scientific  Monthly,"  Nov.,  1917). 

In  this  war  all  wounds  are  regarded  as  infected.  A  wound  of  war  requires 
immediate  incision,  disinfection  and  drainage.  It  may  be  disinfected  with 
iodin  or  some  chlorin  preparation  and  should  be  dressed  antiseptically. 

As  soon  as  the  soldier  comes  from  the  firing  line  he  is  given  a  subcutaneous 
injection  of  500  U.  S.  A.  units  represented  by  3  cm.  of  horse  serum.  In  seven  or 
eight  days  he  is  given  a  second  injection  and  in  seven  or  eight  days  more  a 
third.  The  injection  is  to  be  made  very  slowly  and  if,  in  giving  a  second  or 
third  injection,  the  slightest  sign  of  anaphylaxis  is  noted,  cease  at  once. 

An  admirable  memorandum  on  "  The  Prevention  and  Treatment  of  Tetanus" 
was  issued  by  the  British  War  Office  ("Brit.  Med.  Jour.,"  Nov.  11,  1916): 
Puerperal  tetanus  is  prevented  by  antiseptic  rriidwifery,  and  tetanus  neo- 
natorum by  the  antiseptic  treatment  of  the  stump  of  the  cord.  In  order  to 
obviate  all  danger  of  the  development  of  tetanus  after  vaccination  perform 
the  Httle  operation  with  cleanliness  and  care  properly  for  the  wound  and  for 
the  pustule.  The  skin  should  be  cleansed  with  soap  and  water,  rubbed  with 
alcohol,  and  washed  with  boiled  water.  It  should  be  gently  scraped  with 
a  knife  (which  has  been  boiled)  until  serum  exudes.  The  virus,  taken  from 
a  hermetically  sealed  tube,  is  applied  to  the  raw  surface  and  allowed  to  remain 
exposed  to  the  air  until  dry.  A  piece  of  sterile  gauze  is  laid  over  the  part  and 
is  held  in  place  by  a  bandage.  This  dressing  is  changed  as  may  be  necessary, 
and  is  used  until  granulation  begins,  at  which  time  the  use  of  any  simple  oint- 
ment is  admissible.  Do  not  apply  a  shield.  The  evil  of  shields  is  pointed 
out  by  Robert  N.  Willson  ("American  Medicine,"  Dec.  7,  1901). 

When  tetanus  exists,  always  look  for  a  wound,  and  if  one  is  found,  open 
it  widely  and  to  the  very  depths,  if  there  are  sloughs,  cut  them  away,  paint  the 
wound  with  tincture  of  iodin  and  secure  drainage  by  leaving  the  wound  open. 

Surgeons  of  a  former  day  were  accustomed  to  amputate  for  tetanus  if  the 


Treatment  of  Tetanus  235 

wound  was  upon  an  extremity.  This  treatment  was  overthrown  by  Dupuy- 
tren  and  Sir  Astley  Cooper.  When  we  reflect  that  the  poison-producers  are 
in  the  wound  and  not  in  the  circulation,  it  seems  a  reasonable  treatment.  As 
a  matter  of  fact,  it  never  does  any  good,  because,  when  the  symptoms  begin, 
the  toxin  has  already  entered  into  the  nerve-cells  and  become  fixed.  Kitasato 
has  shown  that  if  a  mouse  is  inoculated  with  tetanus  near  the  root  of  the  tail, 
excision  of  the  tail  and  cauterization  of  the  stump  will  not  prevent  tetanus 
unless  it  is  performed  within  one  hour  of  the  inoculation.  Nocard  inoculated 
sheep  near  the  root  of  the  tail  with  tetanus  spores,  and  although  the  moment 
symptoms  appeared  he  amputated  well  above  the  point  of  inoculation,  the  ani- 
mals died  of  the  disease.  We  must  regard  amputation  as  a  useless  method 
of  treatment.  The  cases  of  Porter  and  Richardson  in  which  bacilli  were  found 
in  adjacent  glands  suggest  the  wisdom  of  removing  any  enlarged  glands 
which  could  have  received  lymph  from  the  wound. 

Keep  the  sufferer  from  tetanus  in  a  darkened,  well-ventilated,  and  quiet 
apartment,  so  as  to  exclude  as  far  as  possible  peripheral  irritation.  Watch  for 
the  occurrence  of  retention  of  urine,  and  use  the  catheter  if  necessary.  Secure 
movements  of  the  bowels  by  administering  salines,  castor  oil,  croton  oil,  or 
enemas.  Stimulate  freely  with  alcohol,  and  give  fluids  by  hypodermoclysis. 
Give  plenty  of  concentrated  liquid  food  unless  swallowing  causes  convulsions,, 
then  feed  by  the  rectum.  If  swallowing  causes  convulsions  some  surgeons 
give  an  inhalation  of  nitrite  of  amyl  before  an  attempt  is  made  to  swallow. 
If  this  treatment  does  not  make  swallowing  possible,  then  partially  anesthetize 
the  patient  and  feed  him  by  means  of  a  pharyngeal  tube  passed  through  the 
nose.  It  may  become  necessary  to  abandon  mouth  feeding.  Large  doses 
of  the  bromid  of  potassium,  or  of  this  drug  with  chloral,  give  the  best  results, 
as  far  as  drug  treatment  is  capable  of  giving  results.  If  bromid  is  used,  give 
about  I  dr.  every  four  to  six  hours.  Chloretone  has  warm  advocates.  It  is 
given  in  large  doses.  It  abates  rigidity  and  diminishes  the  number  and  severity 
of  clonic  convulsions.  Other  drugs  that  have  been  used  with  some  success 
are  gelsemium,  morphin,  curare,  injections  and  fomentations  of  tobacco,  phy- 
sostigmin,  anesthetics,  cocain,  and  cannabis  indica.  An  ice-bag  to  the  spine 
somewhat  relieves  the  girdle  pain.  Hot  baths  have  been  advised.  It  is  said 
that  venesection  followed  by  the  intravenous  infusion  of  saline  fluid  does  good. 
This  procedure  is  followed  by  a  free  flow  of  urine  and  by  lessening  of  the  number 
of  the  paroxysms.  It  may  be  repeated  several  times  during  a  few  days  (E.  J. 
McOscar,  in  "American  Medicine,"  Sept.  14,  1901;  A.  V.  Moschcowitz,  in 
"Med.  News,"  Oct.  13,  1900). 

Years  ago,  Yandell  said,  in  summing  up  Cowling's  report  on  tetanus:^ 
"Recoveries  from  traumatic  tetanus  have  been  usually  in  cases  in  which  the 
disease  occurs  subsequent  to  nine  days  after  the  injury.  When  the  symp- 
toms last  fourteen  days  recovery  is  the  rule,  apparently  independent  of  treat- 
ment. The  true  test  of  a  remedy  is  its  influence  on  the  history  of  the  disease. 
Does  it  cure  cases  in  which  the  disease  has  set  in  previous  to  the  ninth  day? 
Does  it  fail  in  cases  whose  duration  exceeds  fourteen  days?  No  agent  tried 
by  these  tests  has  yet  established  its  claim  as  a  true  remedy  for  tetanus. "^ 
Yandell's  statement  is  true  to-day. 

It  is  now  claimed  by  some  observers  that  we  have  a  remedy  which  fulfils 
the  requirements  of  Yandell  in  the  tetanus  antitoxin  serum.  Behring  and 
Kitasato  succeeded  in  immunizing  animals,  and  Tizzoni  and  Cattani  assert 
that  the  antitoxin  is  an  enzyme.  The  antitoxin  destroys  the  activity  of  the 
toxin  and  is  obtained  from  an  immunized  horse. 

If  injected  subcutaneously  it  is  absorbed  very  slowly,  and  even  twenty- 
four  hours  or  more  after  such  an  injection  a  considerable  amount  remains 

1  "American  Practitioner,"  Sept.,  1870. 

2  Quoted  by  Hammond,  in  his  "Diseases  of  the  Nervous  System." 


234  Tetanus,  or  Lockjaw 

unabsorbecl  in  the  tissues.  It  is  not  absorbed  at  all  by  the  nervous  structures. 
It  is  eliminated  rapidly  and  unaltered  in  the  urine,  feces,  and  sweat.  It  seems 
to  be  harmless  and  its  immunizing  powers  are  certain.  It  saves  a  huge 
majority  but  not  all.  Its  curative  power  is  very  much  less  certain.  Hypo- 
dermatic injections  are  practically  useless  therapeutically.  Intravenous 
injections  are  of  more  service,  but  even  then  the  antitoxin  only  grasps 
the  toxin  in  the  blood  and  fails  to  reach  that  in  the  nerves,  nerve-cells,  and 
nerve-tracts.  Some  practise  intramuscular  injections,  but  7  acute  cases  so 
treated  died,  a  mortality  of  100  per  cent.  (Jacobson  and  Pease,  "Annals  of 
Surgery,"  Sept.,  1906).  Injection  into  the  theca  of  the  cord  (intrathecal  in- 
jection) by  means  of  lumbar  puncture  is  an  attractive  method,  but  the  inability 
of  nerve-elements  to  absorb  antitoxins  when  the  pia  intervenes  is  an  argu- 
ment against  it,  though  in  i  violent  acute  case  of  my  own,  occurring  in  a  boy, 
recovery  followed  this  method.  In  7  acute  cases  treated  by  this  method  the 
mortality  was  57.1  per  cent.  (Jacobson  and  Pease,  Ibid.).  John  Rodgers  in- 
jected antitoxin  into  the  cauda  equina  and  nerves  and  apparently  hopeless 
cases  recovered  ("Med.  Record,"  July  2,  1904).  Injection  into  a  nerve  (in- 
traneural injection)  is  a  more  rational  method,  but  even  this  plan  is  only  of  serv- 
ice in  localized  tetanus,  the  main  nerve  about  the  part  tetanized  being  injected 
(Kiister,  in  German  Surgical  Congress  of  1905).  Some  have  injected  serum 
under  the  cerebral  dura.  Others  have  injected  it  into  the  brain.  These  latter 
plans  have  been  abandoned  by  most  surgeons.  However  antitoxin  is  given, 
the  dose  must  be  large  if  any  good  is  to  be  done. 

The  value  of  the  tetanus  antitoxin  in  acute  tetanus  is  doubtful.  In  the 
Russo-Japanese  War  its  use  was  abandoned,  and  d'Autma  found  it  of  no  value 
in  the  tetanus  cases  which  followed  the  Italian  earthquakes  of  1908.  Recent 
war  reports  do  not  indicate  that  antitoxin  has  any  high  therapeutic  value.  A 
serum  injection  in  tetanus  raises  the  temperature  and  may  cause  depression 
of  the  circulation,  severe  headache,  vomiting,  diarrhea,  perhaps,  in  very  rare 
cases,  death.  Under  its  use  the  mortality  from  acute  tetanus  is  said  to  fall  from 
nearly  90  to  75  per  cent.,  but  this  contention  is  doubtful.  Neither  do  the  figures 
indicate  that  the  mortality  in  chronic  tetanus  has  been  greatly  influenced  by  it. 
If  tetanus  antitoxin  is  of  service  it  can  only  be  when  used  early  and  in  large 
doses.  If  used  subcutaneously  for  a  moderate  case  inject  20  to  30  c.c.  in  the 
abdominal  wall  and  repeat  the  injection  every  sixth  or  eighth  hour  until  there 
are  evidences  of  improvement.  If  signs  of  improvement  become  evident  give 
5  or  10  c.c.  at  the  same  intervals.  As  the  symptoms  abate  lessen  the  dose  and 
lengthen  the  intervals.  In  violent  cases  the  first  dose  should  be  50  to  60  c.c. 
and  it  should  be  repeated  in  four  or  five  hours.  Enormous  doses  have  been 
given.  In  a  patient  of  Mixter's,  who  recovered,  3400  c.c.  were  given  in  the  ag- 
gregate about  285  c.c.  having  been  given  each  day.  In  47  acute  cases  treated 
by  subcutaneous  injection  the  mortality  was  82.6  per  cent.  Intramuscular 
and  intravenous  injections  are  not  more  successful.  The  most  promising 
method  is  injection  of  the  spinal  theca. 

A  lumbar  puncture  is  made,  20  c.c.  of  spinal  fluid  are  permitted  to  flow  away 
and  20  c.c.  of  serum  are  slowly  injected.  The  injection  should  be  repeated  each 
day  for  four  or  five  days  and  during  the  same  period  serum  should  be  given 
subcutaneously  or  intramuscularly,  in  the  doses  previously  directed  (See 
"Memorandum  on  Tetanus"  issued  by  British  War  Office.  "Brit.  Med. 
Jour.,"  Nov.   II,  1916). 

Kitasato  has  shown  that  injections  of  iodoform  render  animals  immune, 
and  Sonnani  has  maintained  that  this  drug  placed  in  a  wound  prevents  the  dis- 
ease. If  antitoxin  is  not  obtainable,  give  hypodermatic  injections  of  iodo- 
form, 3  to  5  gr.  t.  l.  d.  or  use  Bacelli's  treatment. 

BacelWs  treatment  was  introduced  by  Bacelli,  of  Rome,  in  1892.  It  consists 
in  the  hypodermatic  injection  of  carbolic  acid,  which  is  thought  to  grasp  tetanus 


Treatment  of  Tetanus  235 

toxin  and  mitigate  its  virulence  or  even  make  it  inert.  The  drug  is  also  thought 
to  be  sedative  and  to  lower  temperature.  Tetanus  toxin  is  destroyed  by 
carbolic  acid  (shovm  by  Tizzoni  and  Cattani  in  1890).  Kitasato  pointed  out 
in  1891  that  cultures  of  tetanus  bacilli  can  be  rendered  sterile  in  thirty  minutes 
by  a  5  per  cent,  solution  of  carbolic  acid.  The  usual  dose  is  15  minims  of  a 
3  per  cent,  solution  every  two  hours.  Three  times  this  amount  can  be  given  in 
a  day.  ^  To  avoid  irritation  Maragliano  uses  a  5  per  cent,  solution  in  sterile 
olive  oil.  Favorable  results  are  claimed  for  the  plan.  Bacelli  has  collected 
190  cases  (all  severe  or  very  severe).  There  were  94  severe  cases  and  92  re- 
covered (2I  2  per  cent.  mortaUty).  There  were  38  very  severe  cases  and  22 
retovered  (see  BacelH,  in  "  Berliner  klinische  Wochenschrift,"  June  5,  191 1). 
Even  the  occurrence  of  carboluria  does  not  cause  the  surgeon  to  suspend  the 
treatment.  These  results  are  the  best  ever  given  in  tetanus  but  others  have 
not  had  such  fortunate  results.  A  patient  of  mine  with  acute  tetanus  recovered 
under  the  treatment. 

The  "Memorandum  on  Tetanus"  by  the  British  War  Ofhce,  quoted  above 
says :  "  There  is  no  convincing  evidence  that  the  carbolic  acid  treatment  of  tetanus 
has  any  curative  effect  whatever  or  any  action  upon  the  course  of  the  disease." 

The  hypodermatic  injection  of  an  emulsion  of  fresh  brain-matter  has  been 
advocated  on  the  ground  that  brain-matter  and  tetanus  toxin  have  a  mutual 
affinity  (Krokiewicz).     The  results  are  not  conclusive. 

Mathews  reports  cure  in  2  cases  following  the  very  gradual  introduction 
into  a  vein  of  a  solution  containing  sodium  chlorid,  sodium  citrate,  sodium  sul- 
phate, and  chlorid  of  calcium  ("Jour.  Am.  Med.  Assoc,"  August  29,  1903). 
Cure  of  acute  tetanus  hasi  followed  the  intraspinal  injection  of  a  solution  of 
magnesium  sulphate,  which  drug,  Meltzer  has  shown,  strongly  stimulates  in- 
hibition. Blake  has  reported  such  a  case  ("Jour,  of  Surgery,  Gynecology, 
and  Obstetrics,"  May,  1906).  If  magnesium  sulphate  is  used,  5  c.c.  of  a  25 
per  cent,  solution  are  injected  into  the  subarachnoid  space  of  the  cord,  after 
first  removing  an  equal  quantity  of  cerebrospinal  fluid.  Some  hours  after 
such  an  injection  there  is  marked  muscular  relaxation  lasting  a  number  of  hours. 
Not  unusually  there  is  lowering  of  respiratory  rate.  When  the  improve- 
ment ceases  another  dose  is  given.  Heinecke  (Ibid.)  reports  a  successful  case 
and  collects  12  other  cases  so  treated,  7  of  which  died.  Smithson  used  this 
drug  and,  although  the  patient  died,  there  was  not  a  convulsion  after  the  in- 
jection. Kocher  was  of  the  opinion  that  the  treatment  reduced  greatly  the 
mortality.  There  are  grave  dangers  in  the  method.  It  may  arrest  respiration 
by  causing  paralysis  of  the  respiratory  center.  The  "Memorandum  on 
Tetanus"  quoted  above  rejects  the  magnesium  sulphate  treatment,  saying  that 
it  can  only  arrest  spasm  temporarily  and  its  use  is  a  great  risk. 

Murphy  reports  the  recovery  of  a  case  after  spinal  puncture  and  injection 
•of  morphin  and  eucain  into  the  theca  of  the  cord  ("Jour.  Am.  Med.  Assoc," 
August  13,  1904).  I  have  seen  but  four  recoveries  from  acute  tetanus.  Two 
cases  of  acute  tetanus  recovered  after  intraspinal  injection  of  antitoxin.  One 
acute  case  recovered  after  the  subcutaneous  use  of  antitoxin.  One  acute  case 
recovered  after  Bacelli's  treatment.  I  have  known  4  cases  of  chronic  tetanus 
to  recover :  i  was  treated  by  chloral  and  bromid  only,  3  were  treated  by  chloral 
and  bromid  and  antitoxin  subcutaneously. 


XIII.  SURGICAL  TUBERCULOSIS 

Tuberculosis  is  an  infective  disease  due  to  the  deposition  and  multipli- 
cation of  tubercle  bacilli  in  the  tissues  of  the  body.  The  term  surgical  tuber- 
culosis is  applied  to  all  of  those  numerous  tuberculous  lesions  that  may  demand 
surgical  treatment.     Such  lesions  may  exist  in  different  structures,  often  seem 


236 


Surgical  Tuberculosis 


clinically  to  be  strictly  localized  j)rocesses,  and  in  many  instances  may  be  ex- 
tirpated, drained,  or  sterilized.  Among  the  conditions  placed  under  the  head- 
ing of  surgical  tuberculosis  are:  Tuberculosis  of  glands,  of  bones,  of  joints, 
and  of  the  skin.  These  lesions  are  most  common  in  children,  the  majority 
of  cases  are  curable,  and  they  are  not  so  often  associated  with  or  followed  by 
pulmonary  phthisis  as  are  some  other  tuberculous  lesions.  They  tend  in  many 
cases  to  remain  local  and,  beyond  doubt,  a  considerable  numl)er  of  them  are 
due  to  infection  with  bovine  bacilli.  Tuberculosis  is  characterized  either 
by  the  formation  of  tubercles  or  by  widespread  cellular  proliferation  (diffuse 
tubercle)  or  by  fibrinous  exudation,  which  is  very  rich  in  cells.  Tuberculous 
conditions  tend  to  caseation,  sclerosis,  or  ulceration.  • 

A  tubercle  is  a  non-vascular  infective  focus,  appearing  to  the  unaided  vision 
as  a  semitransparent  gray  or  yellowish  mass  the  size  of  a  mustard-seed.  The 
microscopic  tubercle  is  the  most  characteristic  evidence  of  the  disease.  The 
microscope  shows  that  a  gray  tubercle  consists  of  a  number  of  cell-clusters, 
each  cluster  constituting  a  primitive  tubercle.  A  typical  primitive  tubercle 
shows  a  center  consisting  of  one  or  of  several  polynucleated  giant-cells  sur- 
rounded by  a  zone  of  epithelioid  cells  which  are  surrounded  by  an  area  of  leuko- 
cytes.    When  the  bacillus  obtains  a  lodgment  the  liAed  connective-tissue  cells 

multiply  by  karyokinesis,  forming  a  mass  of  nucleated 
polygonal  or  round  cells.  These  cells  are  connective- 
tissue  cells  and  are  derived  particularly  from  endothe- 
lium and  are  called  epithelioid  cells  from  their 
resemblance  to  epithelial  cells.  Early  in  the  de- 
velopment of  a  tubercle  blood  channels  lined  with 
epithelioid  cells  exist,  but  continued  cell  proliferation 
blocks  the  channels  and  at  the  same  time  the  blood- 
supply  of  the  growth  is  further  limited  by  the  pressure 
of  proliferating  perivascular  cells  and  the  pro- 
liferation of  the  endothelial  cells  of  adjacent  vessels. 
Some  of  the  epithelioid  cells  proliferate,  and  others 
attempt  to,  but  fail  for  want  of  blood-supply. 
Those  which  fail  to  multiply  succeed  only  in  dividing 
their  nuclei  and  enormously  increasing  their  bulk 
(giant-cells).  Giant-cells,  which  may  also  form  by 
a  coalescence  of  epithelioid  cells,  are  not  alwaN's 
present.  Giant-cells  are  not  certain  evidence  of 
tuberculosis,  for  they  occur  in  syphilitic  lesions. 
The  presence  of  irritant  bacterial  products  induces 
surrounding  inflammation  and  numbers  of  leukocytes  gather  about  the  epithe- 
lioid cells  (Fig.  104). 

The  bacilli,  when  found,  exist  in  and  about  the  epithelioid  cells,  and  sometimes 
in  the  giant-cells.  When  bacilli  enter  the  tissues  they  are  often  killed.  If  they 
enter  in  large  numbers  or  are  peculiarly  virulent,  or  if  resistance  is  low  they  induce 
chronic  inflammation,  granulation  tissue  forms,  and  the  cells  of  the  focus  often 
have  the  characteristic  arrangement  described  above.  The  bacilli  are  not 
pyogenic  and  suppuration  means  secondary  infection.  If  mixed  infection  of  any 
considerable  area  occurs,  the  patient  is  apt  to  develop  fever  and  to  perish  from  ex- 
haustion, amyloid  disease,  dissemination,  or  a  terminal  infection.  In  rare  cases 
the  tuberculous  area  is  destroyed  and  cure  is  brought  about.  A  tuberculous 
focus  tends  strongly  to  degenerative  changes  because  of  the  local  anemia  and 
the  presence  of  bacilli.  If  numerous  active  bacilli  are  present  caseation  takes 
place.  This  is  coagulation  necrosis  due  to  the  action  of  bacteria  upon  a  non-vas- 
cular area.  It  starts  at  the  center  of  a  tuberculous  focus  and  spreads  toward 
the  periphery  and  finally  forms  masses  like  cheese.  When  caseated  material 
is  mixed  with  serum  tuberculous  pus  is  formed. 


.  ,.„, .mm 


Fig.  104. — Synovial 
membrane,  showing  giant- 
cells  (Bowlby). 


The  Incidence  of  Tuberculosis  237 

A  caseated  focus  may  be  surrounded  or  encapsulated  by  fibrous  tissue. 
When  this  happens  the  tuberculous  process  may  remain  latent  for  months 
or  years,  perhaps  awakening  into  activity  as  the  result  of  a  traumatisn  or 
lowered  general  resistance.  A  caseated  focus  may  be  cured  by  growth  of  fibrous 
tissue  which  replaces  the  tuberculous  focus.  This  is  cure  by  sclerosis.  A 
caseated  area  may  calcify.  Even  when  tuberculous  pus  forms,  encapsulation 
may  occur,  the  fluid  being  absorbed,  and  the  remains  being  surrounded  by 
fibrous  tissue.  Whenever  tubercle  bacilli  consume  all  available  food  they  die  or 
remain  latent.  If  they  die  the  granulations  are  converted  into  fibrous  tissue  and 
the  part  is  healed.  If  they  remain  latent  they  may  at  any  time  become  again 
active.  Infiltrated  tubercle  is  due  to  the  running  together  of  many  minute 
infective  foci,  or  to  widespread  infiltration  without  any  formation  of  foci. 
Infiltrated  tuljercle  tends  strongly  to  caseate.  The  description  of  a  tubercle 
previously  given  relates  to  the  common  reticulated  tubercle.  Two  other  varieties 
exist. 

The  fibrous  tubercle  is  much  richer  in  dense  connective  tissue  than  is  the 
ordinary  tubercle.  It  forms  when  bacilli  are  greatly  weakened  or  killed. 
When  this  happens  embryonal  cells  cease  to  degenerate,  and  ordinary  inflam- 
mation results  in  fibrous  tissue  formation.  Fibrous  tubercle  is  evidence  of 
an  eft'ort  at  cure. 

Hyaline  tubercle  results  from  hyaline  degeneration  of  the  reticulum  of  an 
ordinary  tubercle  and  is  the  early  stage  of  coagulation  necrosis. 

Knowledge  of  recent  years  proves  that  the  bacillus  of  tubercle  may  fail  to 
cause  the  supposed  essential  lesions  outlined  above,  but  may  induce  instead 
tissue  changes  identical  with  those  due  to  various  other  organisms.  Some 
of  these  changes  are  acute,  some  are  chronic.  In  some  there  is  hyperemia, 
in  some  serous  exudation,  in  some  fibrous  exudation,  in  some  cellular  hyper- 
plasia, perhaps  with  parenchymatous  degeneration,  or  perhaps  with  sclerosis 
causing  cirrhosis  (Rudolph  Matas,  in  "Southern  Med.  Jour.,"  Oct.,  1911). 
'Matas  says  that  this  group  is  non-tuberculomatous,  atypical,  and  non- 
specific- 

The  Incidence  of  Tuberculosis. — Tuberculosis  is  the  most  widespread 
of  diseases,  being  particularly  common  in  northern  countries,  in  civilized 
regions,  and  in  great  cities.  Both  men  and  domestic  animals  suffer  from  it,  and 
it  is  occasionally  met  with  in  captive  wild  animals.  It  may  even  occur  in 
cold-blooded  animals.  It  is  rare  in  savage  races  still  spared  to  lead  the  lives  for 
which  they  were  intended,  and  is  extremely  rare  in  wild  animals  dwelling  under 
natural  conditions.  Savage  races  suddenly  subjected  to  the  blighting  influences 
of  material  progress  die  in  hordes  from  tuberculosis.  Wild  animals  placed  in 
captivity  are  prone  to  die  of  it.  The  negro  race  if  removed  from  the  tropics 
or  the  subtropics  to  the  temperate  zone  or  farther  north  is  predisposed  to  tuber- 
culosis. The  Hebrew  race,  has  become  to  a  considerable  extent  immune  to 
tuberculosis.  If  a  Jew  becomes  tuberculous  the  lesion  is  apt  to  be  slow  in  evolu- 
tion, to  be  local  and  to  tend  to  cure. 

Many  people  possess  lesions  of  tuberculosis  who  present  no  clinical  evidence 
of  it.  Careful  necropsies,  with  microscopical  studies  and  observations  wuth  the 
aid  of  tuberculin,  prove  this.  The  greatest  death-rate  of  those  infected  is  in 
childhood  and  early  adult  life  (Burkhardt,  in  1903,  quoted  by  Hamman  and 
Wolman  in  their  book  on  ''Tuberculin"). 

How  many  persons  die  of  tuberculosis  is  a  much  debated  point.  Some 
writers  claim  that  consumption  of  the  lungs  alone  kills  one-third  of  all  that 
die;  and  if  the  deaths  from  various  other  tuberculous  lesions  are  added  to 
this,  it  will  be  seen  what  an  enormous  part  the  disease  plays  in  the  mortahty 
tables.  Many  observers  hold  that  one-third  of  the  human  race  suffer  from 
tuberculosis,  and  that  in  every  country  the  remaining  two-thirds  free  from 
the  disease  are  every  moment  in  danger  of  acquiring  it.     Evans  has  main- 


238  Surgical  Tuberculosis 

tained  that  of  the  35,000,000  deaths  that  occur  yearly  in  the  world,  5,000,000 
are  the  result  of  tuberculosis.  Ptliigge  thinks  that  one-seventh  of  the  race  die  of 
tuberculosis,  Sherman  G.  Bonney,  in  his  work  on  "  Pulmonary  Tuberculosis," 
asserts  that  "from  85  to  95  per  cent,  of  the  human  race  have  been  at  some 
period  of  life  the  subject  of  tuberculous  infection"  and  that  i  person  in  7  dies 
of  the  disease.  In  the  U.  S.  150,000  deaths  a  year  are  due  to  tuberculosis  and 
the  country  contains  at  least  a  million  and  a  half  victims  of  the  disease. 

This  enormous  incidence  of  the  disease,  however,  is  disputed  by  some 
authorities;  notably,  by  G.  Cornet  (Nothnagel's  "Encyclopedia  of  Practical 
Medicine").  This  observer  states  that  apparently  one-seventh  of  all  deaths 
result  from  tuberculosis,  and  that  some  pathologists  have  reported  that  in 
one-third  of  all  necropsies  tuberculous  lesions  are  found;  but  that  these  sta- 
tistics are  obtained  from  institutions  where  only  the  very  poor  are  cared  for, 
and  that  the  percentage  of  tuberculosis  is  vastly  lower  in  the  better  classes  of 
the  community.  The  exact  figures,  however,  are  difficult  to  determine.  It  is 
certain  that  enormous  numbers  of  people  are  affected  with  tuberculosis.  I 
believe  many  affected  ones  recover,  for  Naegeli  points  out  that  almost  all  who 
perish  after  thirty  from  non-tuberculous  conditions  show  healed  lesions  of 
tubercle.  Of  420  adults,  391  (93  per  cent.)  showed  signs  of  tuberculosis. 
Spengler  claims  that  every  human  adult  was  at  some  period  of  life  a  host 
for  tubercle  bacilli.  Bolhnger  stated  that  in  one-fourth  of  all  postmortems 
upon  adults  evidences  of  tuberculous  disease  are  found  at  the  pulmonary  apices. 
Baumgarten  asserts  that  one  corpse  out  of  every  three  showed  a  tuberculous 
focus,  latent  or  healed.  Tuberculin  tests  confirm  the  views  of  Burkhardt  and 
Naegeli  and  contradict  the  opinions  of  Cornet.  Franz  injected  400  recruits 
who  had  passed  their  physical  examination  for  the  army  and  61  per  cent, 
reacted.  Von  Behring  maintains  that  all  of  us  are  "a  little  tuberculous" 
(Jonathan  Wright,  in  "New  York  Med.  Jour.,"  April  2,  1904).  Pfliigge 
maintains  that  from  50  to  70  per  cent,  of  the  human  race  are  predisposed 
to  tuberculous  infection,  and  if  infected  will  die  of  it  unless  an  intercurrent 
malady  destroys  them.  Practically  every  adult  who  has  always  been  a  town 
dweller  has  or  has  had  tuberculous  lesions.  The  lesion  may  have  been  cured 
or  became  latent,  in  fact  it  may  never  have  given  rise  to  any  symptoms.  The 
infection  of  youth  when  it  is  cured  or  becomes  latent  serves  to  protect  from  the 
disease  in  adult  life.  It  is  a  well-known  fact  that  a  child  who  recovers  from  a 
tuberculous  joint  is  not  apt  to  develop  phthisis.  The  same  is  true  of  a  case  of 
cured  Pott's  disease  of  the  spine  and  of  cured  glandular  tuberculosis.  In  the 
European  countries  now  at  war  there  is  a  great  increase  in  tuberculosis,  not 
only  in  the  armies  but  at  home.  In  the  armies  we  blame  exposure,  hardship, 
psychic  tumult,  wounds  and  illness.  In  the  people  at  home  we  blame  improper 
or  insufficient  diet  and  depressing  emotions.  Many  of  the  scheduled  cases 
are  supposed  cured  cases  raised  into  activity. 

The  Bacillus  of  Tuberculosis. — The  tubercle  bacillus  was  discovered  by 
Robert  Koch  in  1882.  It  is  a  little  rod  with  a  length  about  equal  to  one-half  the 
diameter  of  a  red  corpuscle.  It  is  non-motile,  does  not  form  spores,  and  requires 
oxygen  in  order  to  grow,  but  it  may  obtain  oxygen  from  body-cells  or  fluids. 
Tubercle  bacilh  exist  in  all  active  tuberculous  lesions,  and  the  more  active  the 
process  the  greater  their  numbers.  They  may  not  be  found  in  a  tuberculous 
area,  having  once  existed,  but  having  died  for  want  of  nourishment.  For  in- 
stance, in  a  cold  abscess  they  are  frequently  absent.  Bacilli  may  be  destroyed 
by  a  secondary  infection,  for  example,  by  a  pyogenic  infection.  Even  when 
present,  tubercle  bacilli  may  be  overlooked.  Differential  staining  may  exhibit 
the  baciUi.  In  the  material  from  an  active  tuberculous  lesion,  even  if  bacilli  are 
not  found,  injection  of  the  tuberculous  matter  into  a  guinea-pig  will  be  followed 
by  the  production  of  the  disease,  and  in  these  lesions  bacilli  can  be  demonstrated. 
Bacilli  may  be  widely  distributed  throughout  the  body.     It  has  long  been 


The  Bacillus  of  Tuberculosis  239 

taught  that,  in  cases  of  acute  miliary  tuberculosis,  they  may  be  demonstrated 
occasionally,  though  seldom,  in  the  blood.  We  have  discussed  the  tubercle 
bacillus  on  page  60.  The  bacillus  of  leprosy,  the  smegma  bacillus,  and  the 
tubercle  bacillus  are  similar,  but  not  identical.  Each  is  an  acid-fast  bacillus ;  that 
is,  if  stained  with  an  anilin  color,  mineral  acids  will  not  wash  out  the  stain. 
All  acid-fast  bacilli  are  capable  of  producing  lesions  that,  to  some  extent  at 
least,  resemble  tuberculous  lesions;  but  the  lesions  produced  by  all,  except 
the  tubercle  bacillus  and  the  leprosy  bacillus,  tend  to  recovery.  It  is  possible 
that  all  acid-fast  bacilli  are  branches  from  a  common  stem. 

The  tubercle  bacilli  obtained  from  different  animals  differ  considerably, 
both  in  morphology  and  in  virulence.  Koch  asserted,  in  1901,  that  the  bacilli 
of  human  tuberculosis  differ  radically  from  those  of  bovine  tuberculosis,  that 
human  tuberculosis  cannot  be  given  to  cattle  at  all,  and  that  is  it  so  difficult  to 
transfer  bovine  tuberculosis  to  the  human  being  that  the  danger  from  infected 
cattle  is  utterly  trivial  and  may  be  disregarded.  Ravenel  and  others  have 
positively  opposed  this  view  of  Koch's,  and  there  have  been  reported  what 
appear  to  be  undoubted  cases  of  the  transference  of  tuberculosis  from  animals 
to  man.  There  is  still  dispute  upon  this  point,  but  most  writers  beheve  that 
bovine  tuberculosis  and  human  tuberculosis  are  essentially  the  same,  although 
the  bacilli  present  temporary  differences  due  to  altered  environment.  The 
bacilli  of  bovine  tuberculosis  are  certainly  far  less  dangerous  to  man  than  are  the 
baciUi  of  human  tuberculosis,  and  the  baciUi  of  human  tuberculosis  are  vastly 
less  dangerous  to  cattle  than  are  the  baciUi  of  bovine  tuberculosis.  Human 
bacilH  introduced  into  cattle  may  produce  chronic  lesions,  but  they  are  always 
non-progressive.  The  histologic  lesions  seen  in  man  and  cattle  are  identical 
and  so  are  the  degenerative  changes,  and,  as  Baumgarten  showed,  tuberculous 
cattle  react  to  tuberculin  obtained  from  human  bacilH. 

Nocard  reports  2  cases  of  individuals  who  wounded  themselves  while 
cutting  the  flesh  of  tuberculous  cattle.  Both  developed  generahzed  lesions 
and  died.  Ravenel  strongly  opposes  the  view  of  Koch  and  maintains  that 
the  bacillus  of  bovine  tuberculosis  is  highly  pathogenic  for  man  ("University 
of  Penna.  Med.  Bull.,"  xiv,  238,  1901).  The  same  author  has  reported  4  cases 
of  undoubted  inoculation  tuberculosis  in  the  hands  of  veterinarians.  Similar 
cases  have  been  placed  on  record  by  other  observers.  The  entire  question  is 
one  of  immense  importance.  If,  Koch  is  right,  there  is  practically  no  danger 
to  man  in  eating  tuberculous  meat  or  in  drinking  tuberculous  milk.  Most 
observers  endorse  the  words  of  the  report  of  the  British  Commission  of  191 1. 
This  commission  positively  maintained  that  bovine  tuberculosis  can  be  com- 
municated to  man. 

The  bacilH  of  bovine  tuberculosis,  when  they  find  lodgment  in  human  tissues, 
are  apt  to  produce  local  lesions  and  seldom  disseminate,  and  yice_  versa.  It 
has  been  proved  that  many  cases  of  tuberculous  cervical  adenitis  in  children, 
are  due  to  bovine  bacilh.  In  adults  the  bovine  bacilh  are  not  nearly  so  often 
responsible.  Griffith  ("Lancet,"  Feb.  10,  191 7)  shows  that  in  children  under  lo- 
years  of  age  three-fourths  of  all  cases  of  tuberculous  cervical  adenitis  are  due  to 
bovine  baciUi — that  in  persons  between  10  and  20  years  of  age  bovine  bacUh  are 
responsible  for  one-third  of  the  cases— and  for  one-fifth  of  the  cases  in  those  over 
the  age  of  twenty.  Fifty  per  cent,  of  cases  of  abdominal  tuberculosis  in  chUdren 
and  20  per  cent,  in  adults  are  due  to  bovine  bacilli.  Many  bone  cases  and  a 
considerable  number  of  joint  cases  in  chUdren  depend  on  bovine  baciUi,  but  very 
few  in  adults  are  so  caused.  Pulmonary  tuberculosis  very  seldom  depends  upon 
bovine  organisms.  It  is  thus  clear  that  human  infection  with  bovine  bacUh  is 
most  common  in  the  young,  and  that  surgical  tuberculosis  is  far  more  apt  to 
have  such  origin  than  other  forms.  Such  infections  frequently  tend  to  spon- 
taneous cure,  although  in  some  cases  they  become  generahzed  and  cause  death 
by  miliary  tuberculosis. 


240  Surgical  Tuberculosis 

Distribution  of  the  Bacilli. — These  bacilli  are  parasites,  and  not  sapro- 
phytes; and  the  real  source  of  infection  is  a  tuberculous  person  or  animal. 
Wherever  there  are  tuberculous  men  or  animals  the  bacilli  get  into  the  air. 
The  number  that  gets  into  the  air  depends  upon  the  number  of  animals  affected, 
the  seat  of  the  tuberculous  lesion  in  each,  the  care  taken  by  the  victims,  and  the 
control  exercised  by  the  community. 

Tubercle  bacilli  from  an  infected  individual  may  get  into  the  atmosphere 
from  the  urine,  the  sputum,  the  feces,  the  sweat,  the  milk,  or  caseous  or  puru- 
lent material.  The  bacilli  from  dried  sputum  enter  the  dust,  in  which,  for- 
tunately, they  are  usually  destroyed  quickly  by  complete  dryness,  the  fresh  air, 
and  the  sunlight;  but  under  some  circumstances  they  may  retain  their  virulence 
for  weeks  or  even  for  months.  The  infected  area  itself  is  usually  the  direct 
source  of  the  bacteria  from  a  given  case  of  tuberculosis,  but  this  is  not  invariably 
so;  for  a  tuberculous  woman  with  a  healthy  mammary  gland  mav  secrete  milk 
containing  tubercle  bacilli,  a  consumptive  free  from  genito-urinary  tuberculosis 
may  occasionally  pass  urine  containing  bacteria,  a  cow  may  give  tuberculous 
milk  when  the  udder  is  not  diseased,  and  tubercle  bacilli  may  enter  the  bile  of  a 
tuberculous  patient.  The  Third  Interim  Report  of  the  Royal  Commission  on 
Tuberculosis  states  positively  that  the  milk  of  tuberculous  cows  may  contain 
bacilli  even  when  the  udder  is  not  diseased.  It  is  probable  that  flies  and  insects 
may  transmit  infection  (Lord,  in  "Boston  Med.  and  Surg.  Jour.,"  1904,  cli); 
and  it  is  certain  that  putrefaction  does  not  surely  destroy  tubercle  bacilli. 
This  is  proved  by  the  fact  that  living  bacilli  may  be  passed  in  the  feces  of  an  ani- 
mal that  has  been  fed  on  tuberculous  meat,  and  that  they  may  be  found  in  the 
feces  of  an  individual  suffering  from  intestinal  tuberculosis.  We  are  thus  justi- 
fied in  concluding  that  slaughter-house  waste,  if  improperly  disposed  of,  is  a 
danger  to  the  community. 

Routes  of  Infection. — An  individual  may  acquire  tuberculosis  by  inhaling 
tuberculous  material  {inhalation  tuberculosis)  ,hy  swallowing  tuberculous  material 
{ingestion  tuberculosis),  and  by  inoculation  with  tuberculous  material  {inoculation 
tuberculosis).  Infection  of  the  lungs  may  be  brought  about  by  the  inhalation 
of  dried  tuberculous  sputum  or  dust  carrying  tubercle  bacilli.  Ingestion  tuber- 
culosis may  follow  the  eating  of  tuberculous  meat,  the  drinking  of  tuberculous 
milk,  or  the  consumption  of  uncooked  articles  on  which  tubercle  bacilli  have 
gathered.  It  has  been  shown  that  the  lacteals  may  take  up  tubercle  bacilli 
from  the  intestine,  even  if  there  is  no  intestinal  lesion;  and  that  bacilli  can 
pass  through  the  thoracic  duct  and  into  the  blood,  and  lodge  in  some  tissue, 
particularly  the  pulmonary  tissue,  so  inducing  tuberculosis.  They  are  apt  to 
lodge  at  any  point  of  least  resistance;  and  if  not  caught  up  in  the  lungs,  will 
tend  to  be  arrested  in  an  irritated  gland  or  in  some  region  that  has  been  the 
seat  of  a  trifling  injury — for  instance,  in  an  epiphysis  that  has  been  strained. 
It  is  a  peculiar  fact  that  a  trivial  injury  constitutes  a  point  of  least  resistance; 
but  a  severe  injury,  such  as  a  fracture  of  a  bone,  does  not  do  so.  Baumgarten 
was  a  strong  believer  in  the  idea  that  bacilli  enter  the  organism  with  the  food 
and  von  Behring  now  warmly  advocates  the  same  view,  teaching  that  bacilli 
enter  the  organism  of  every  person  in  early  life.  They  may  be  destroyed  by 
tissue  resistance,  but  if  not  destroyed  have  a  period  of  latency  and,  finally, 
perhaps  after  years,  become  active  and  cause  the  disease  (''Deutsche  Med. 
Woch.,"  Sept.  24,  1903).  Calmette  and  Vanstenberg  ("  Annales  de  ITnstitut 
Pasteur,"  1906)  have  long  insisted  that  infection  is  chiefly  by  the  alimentary 
canal  and  that  inhalation  infection  is  rare.  The  great  source  of  bovine  bacilli 
is  infected  milk.  Much  milk  supposed  to  be  uncontaminated  is  infected.  Fraser 
("Jour.  Am.  Med.  Assoc,"  Jan.  2,  1915)  says  that  in  Edinburgh  from  15  to  20 
per  cent,  of  the  milk  samples  contain  tubercle  bacilli.  In  Washington,  D.  C, 
out  of  1538  cows  furnishing  milk  to  the  city,  belonging  to  104 persons,  16. 9 per 
cent,  were  tuberculous  (Waddell  in  "Popular  Science  Monthly,"  Feb.,  1917). 


Routes  of  Infection  241 

Every  now  and  then  from  60  to  80  per  cent,  of  a  herd  will  be  found  infected. 

To  get  good  milk  the  cow  must  be  healthy  and  clean,  the  stable  sanitary,  the 
milking  must  be  done  outside  of  the  stable,  the  milker  as  well  as  his  clothing  must 
be  clean,  the  receptacles  must  be  sterile,  and  the  milk  must  be  kept  cool  and 
protected  from  flies  (Waddell,  Ibid.). 

It  is  certain  that  inoculation  may  be  followed  by  tuberculosis.  The  inocu- 
lation of  tubercle  bacilli  in  the  intestine  may  produce  intestinal  ulceration.  It 
has  been  shown  experimentally  that  rubbing  the  bacilli  into  the  nasal  mucous 
membrane  may  produce  a  local  area  of  disease.  Inoculation  of  the  skin  may 
result  from  a  wound,  the  bacilli  being  carried  into  the  wound  itself.  The  vic- 
tims of  cutaneous  inoculation  are  usually  butchers,  veterinary  surgeons,  phvs- 
icians  who  have  made  postmortem  examinations,  and  workmen  who  handle 
hides.  In  these  cases,  as  a  rule,  an  ulcer  promptly  forms  at  the  point  of  inocula- 
tion; but  in  some  few  cases  the  wound  heals  soundly  and  tuberculous  lesions 
develop  in  several  or  many  weeks  later  in  the  wound  area  or  in  the  neighbor- 
hood. In  still  rarer  instances  no  apparent  inflammation  or  ulceration  occurs  in 
or  around  the  seat  of  inoculation,  but  the  anatomically  related  lymph-glands 
become  tuberculous.  In  other  cases  adjacent  bone  or  an  adjacent  joint  be- 
comes tuberculous.     Disease  of  the  lungs  may  follow  cutaneous  inoculation. 

A  number  of  cases  of  inoculation  tuberculosis  have  been  reported.  Not 
a  few  pathologists  have  developed  anatomic  tubercle  (see  page  272).  Schmidt 
records'  a  case  of  tuberculous  ulcer  on  a  woman's  lip  due  to  a  bite  from  her 
tuberculous  husband.  It  is  recorded  that  a  tuberculous  person  inoculated 
others  while  tattooing  them,  the  needle  having  been  moistened  with  saliva. 
Xetulle's  case  of  inoculation  tuberculosis  was  a  woman,  who,  while  scrubbino- 
the  floor  of  the  room  in  which  her  tuberculous  husband  had  died,  ran  a  splinter 
into  her  hand.  The  wound  became  tuberculous.  Bosanquet  ("Lancet " 
Jan.  13,  191 2)  refers  to  a  laundress  who  infected  a  whitlow  with  tuberculosis 
while  washing  infected  linen.  I  have  treated  a  physician  who  inoculated  his 
finger  while  making  culture  studies  with  tuberculous  material.  In  this  case 
the  axillary  glands  became  tuberculous  and  were  removed.  I  have  also  seen 
■Si  tuberculous  ulcer  of  the  forearm  in  an  attendant  of  a  lunatic  asylum  who  had 
been  bitten  by  a  tuberculous  patient.  Inoculation  tuberculosis  occasionally 
follows  circumcision,  as  practised  by  an  orthodox  rabbi,  the  operator  beino- 
tuberculous.  A  ritual  operator  (as  Bosanquet  calls  him)  stops  bleedino-  either 
by  applying  his  mouth  to  the  wound,  or  by  squirting  wine  from  his  mouth  upon 
the  wound.  There  have  been  reported  apparent  cases  of  direct  inoculation  of 
the  genito-urinary  tract  during  sexual  intercourse.  If  there  has  been  some  defi- 
nite injury  of  the  tissues,  inoculation  may  follow  a  simple  rubbing  of  tubercle 
bacilli  into  a  part. 

When  the  mother's  ovum  is  tuberculous,  the  disease  may  be  directly  trans- 
mitted to  the  fetus,  producing  the  condition  known  as  congenital  tuberculosis. 
Rosenberger  found  bacilli  in  the  blood  from  the  umbilical  cord  of  the  placenta 
of  a  tuberculous  mother.  This  proves  that  congenital  tuberculosis  may  exist 
•even  when  the  ovum  is  not  known  to  be  tuberculous,  and  also  that  a  child 
born  of  a  tuberculous  mother  is,  if  not  immune  to  the  bacteria,  tuberculous 
from  the  moment  circulation  is  established  between  embryo  and  mother. 
Baumgarten  believes  that  bacilli  may  pass  the  placenta,  enter  the  fetus,  and 
remain  latent  for  years.  Latent  bacilli  have  been  found  in  normal  lymph- 
nodes  (Harbitz,  in  "Jour.  Infect.  Diseases,"  vol.  ii,  1904);  this  proves  that 
latency  is  possible.  A  mother  who  presents  no  clinical  sign  of  tuberculosis 
may  be  the  victim  of  placental  tuberculosis  and  placental  tuberculosis  may  be 
responsible  for  fetal,  mfliary  tuberculosis  (C.  V.  Weller  in  "Arch.  Int.  Med.," 
191 6,  xvii).  However  common  the  direct  transmission  of  bacilli  may  be, 
the  direct  transmission  of  the  disease  is  unusual,  but  the  transmission  of  an 
"hereditary  predisposition  to  infection  is  not  unusual.  In  spite  of  recent  asser- 
16 


242  Surgical  Tuberculosis 

tions  to  the  contrary,  I  believe  that  there  is  such  a  thing  as  hereditary  predis- 
position to  tuberculosis.  The  experience  of  the  human  race  uniformly  con- 
firms the  belief  in  predisposition.  In  some  Cases  of  tuberculosis  we  can  satisfy 
ourselves  clinically  as  to  the  cause  of  the  infection.  For  instance,  when  an  in- 
dividual is  injured  with  an  object  known  to  carry  tubercle  bacilli,  if  an  ulcer 
of  the  skin  forms,  and  the  adjacent  lymphatic  glands  enlarge,  the  deduction  is 
obvious.  In  other  cases  it  is  impossible  to  make  up  our  minds  as  to  the  cause 
of  a  tuberculous  lesion.  For  instance,  we  can  only  guess  that  a  person  has 
inhaled  tuberculous  material  or  has  eaten  tuberculous  food.  If  in  inoculation 
tuberculosis  no  lesion  arises  at  the  point  of  entry,  the  opinion  as  to  the  causa- 
tion will  be  founded  merely  upon  guesswork. 

A  tuberculous  individual  is  a  menace  to  the  healthy.  The  more  closely  the 
healthy  are  hoarded  with  the  unhealthy  the  greater  the  danger.  Fresh  air  and 
sunlight  are  enemies  to  infection,  overcrowding,  poor  ventilation,  dark 
rooms,  dust  are  allies  of  infection.  The  sputum  of  a  victim  of  phthisis 
brings  danger  to  the  healthy,  hence  kissing  is  a  peril.  Sputum  which  dries,, 
floats  in  dust,  lodges  on  food,  lips,  and  fingers,  is  inhaled  and  is  taken  into  the 
gastro-intestinal  tract.  The  same  may  be  said  of  discharges  from  a  tuberculous 
ulcer,  gland,  bone,  joint,  or  anal  fistula.  The  above  facts  are  generally  regarded 
as  established.  One  might  then  infer,  without  further  inquiry,  that  the  wife 
of  a  tuberculous  husband  or  the  husband  of  a  tuberculous  wife  would  be  almost 
certain  to  contract  the  disease.  This  has  been  the  view  of  many  clinicians  and 
when  one  partner  develops  the  disease  after  the  other,  the  condition  is  called 
conjugal  tuberculosis.  Fishberg  ('"Am.  Jour.  Med.  Sciences,"  March,  191 7) 
after  a  careful  study  of  many  cases  of  phthisis  contradicts  this  view  and  says 
"the  simultaneous  or  consecutive  occurrence  of  phthisis  in  husband  and  wife 
is  extremely  rare."  In  a  study  of  170  married  couples  in  which  one  of  the  part- 
ners was  tuberculous  and  who  lived  under  conditions  favorable  to  transmission 
of  the  disease  in  only  5  were  both  husband  and  wife  affected.  Fishberg  con- 
siders these  few  cases  as  coincidences,  "analogous  to  cases  of  conjugal  diabetes 
or  cancer  (cancer  a  deux)."  I  believe  these  statements  are  strictly  correct  when 
apphed  to  partners  both  of  whom  are  tow^n  bred  (in  other  words  who  had 
tuberculosis  in  youth,  recovered  from  it,  and  resist  reinfection).  If  the  healthy 
partner  was  country  bred  she  is  prone  to  become  a  victim  of  the  disease.  Sir 
Malcolm  Morris  ("Brit.  Med.  Jour.,"  Nov.  16,  1918)  in  maintaining  the  thesis 
that  our  confidence  in  contagion  as  the  sole  cause  has  lead  us  away  from  a 
study  of  antenatal  and  environmental  iniluences  quotes  Professor  Pearson 
and  Goring  as  follows:  Familial  infection  receives  little  support  from  sta- 
tistics. The  mate  of  a  tuberculous  individual  is  no  more  likely  to  be  tubercu- 
lous than  another  person,  at  least  among  the  poor.  Higher  in  the  social  scale 
a  tuberculous  male  is  more  apt  to  have  a  tuberculous  mate,  probably  because 
sexual  selection  lead  like  to  mate  with  like.  A  tuberculous  father  is  twice  as 
likely  to  have  tuberculous  children  as  to  have  a  tuberculous  wife.  Children 
of  tuberculous  mothers  are  only  slightly  more  liable  to  be  tuberculous  than  the 
children  of  tuberculous  fathers.  As  Professor  Pearson  says:  if  in  tuberculous 
families  the  main  factor  is  infection,  why  should  the  father  and  mother  be 
equally  influential  with  their  children,  and  why  should  the  father  be  twice  as 
influential  as  the  husband. 

Fishberg  says  (Ibid.)  tests  prove  that  "practically  every  person  living  in  a 
large  city  has  been  infected  with  tubercle  baciUi"  during  childhood  though  he 
or  she  may  not  have  been  sick,  and  further,  "  tuberculous  infection  minimizes  the 
individual  against  exogenic  reinfection  or  superinfection  with  the  same  virus." 

It  seems  certain  that  when  the  bacilli  of  tuberculosis  enter  into  the  body, 
if  they  are  not  destroyed  by  the  body-resistance,  they  may  produce  a  local 
lesion  at  the  site  of  inoculation,  or  pass  to  the  nearest  lymphatic  glands  or  to 
some  point  of  least  resistance,  and  there  estabUsh  disease.     The  first  lesion  is 


Products  of  the  Tubercle  Bacilli  245 

knowm  as  the  primary  focus,  and  from  this  focus  disease  may  be  dissemi- 
nated to  the  most  distant  parts.  The  bacilli  enter  readily  if  there  is  a  wound 
or  an  abrasion;  but  in  exceptional  circumstances  they  may  enter  through  un- 
broken skin  and  undamaged  mucous  membrane.  Any  structure  may  become 
tuberculous,  but  some  structures  are  much  more  liable  to  do  so  than  others. 
The  lungs  are  very  liable;  the  conjunctiva  is  very  resistant. 

The  bacilli  are  generally  distributed  by  the  lymph,  but  may  enter  the  blood. 
Those  which  do  enter  the  blood  may  pass  out  in  the  urine  or  feces,  may  produce 
local  lesions,  or  may  induce  advancing  and  widespread  tuberculosis.  Dissemi- 
nation by  the  lymph-stream  is  known  clinically  to. occur,  and  it  means  slowly 
advancing  tuberculosis  with  localization  of  lesions.  In  dissemination  by  the 
lymph-stream,  the  dissemination  is  usually  in  the  normal  direction  of  the 
lymph-current;  but  if  the  lymph-vessels  become  blocked,  lymph-regurgitation 
may  occur,  and  then  the  dissemination  takes  place  in  a  direction  opposite  to 
the  normal  flow  of  the  lymph-current. 

Latent  Lesions. — By  a  latent  lesion  we  mean  a  non-progressive  or  a  healing 
lesion  which  gives  no  clinical  evidence  of  its  progress.  Such  a  lesion  is  most 
apt  to  be  in  a  lung  or  in  a  gland.  It  may  serve  to  furnish  bacilli  to  distant  parts 
and  hence  be  responsible  for  secondary  lesions.  It  may  give  toxin  to  the  blood 
and  thus  induce  distant  trouble.  The  frequency  of  latent  lesions  becomes  evi- 
dent when  we  test  apparently  healthy  adults  with  tuberculin.  Although  we 
state  that  a  latent  lesion  causes  no  symptoms,  we  had  better  say  presents  no 
symptoms  to  suggest  tuberculous  involvement  of  the  part.  Hollos,  of  Hungar\% 
insists  that  such  an  area  contains  toxin-forming  bacilli,  and  that  the  poisons 
taken  up  from  it  by  the  circulation  cause  a  chronic  toxemia  productive  of 
numerous  symptoms.  Such  symptoms  are  usually  thought  to  be  due  to  anemia 
or  neurasthenia.  This  subject  has  been  brilliantly  discussed  by  Matas  in  the 
"  Southern  Med.  Jour.,"  Oct.,  191 1.  A  lesion  long  latent  may  be  awakened  into 
activity  by  traumatism,  by  severe  congestion,  by  over-activity  of  the  part  or 
by  depression  of  the  general  system.  A  latent  focus  in  the  lung  may  become  ac- 
tive after  etherization  or  such  a  focus  in  a  joint  may  be  raised  by  over  use. 
A  large  dose  of  tuberculin  may  lead  to  spread  of  the  process.  An  attack  of 
bronchitis  may  break  down  the  barriers  which  kept  a  tuberculous  gland  from 
breaking  into  lung  tissue.  Numbers  of  examples  could  be  given.  It  has  been 
a  common  experience  in  the  war  to  find  latent  areas  of  tuberculosis  or  areas 
supposed  to  be  cured,  become  violently  active. 

Products  of  the  Tubercle  Bacilli. — A  great  variety  of  products  are  formed 
by  the  tubercle  bacilli,  and  among  them  we  may  mention  alkaloids,  toxal- 
bumins,  fatty  acids,  and  ferments.  Experimental  injection  of  the  toxalbu- 
mins  produces  inflammation;  and  of  the  alkaloids,  fever.  It  has  been  shown 
by  Maragliano  that  injection  of  the  toxalbumins  actually  lowers  the  tempera- 
ture. Bevond  any  doubt,  the  culture  material  in  which  tubercle  bacilli  are 
growing  contains  poison;  and  the  bodies  of  the  bacilli  themselves  contain  poison. 
The  poisons  in  the  culture-medium  are  called  extracellular  poisons,  and  those 
within  the  bacilli  are  called  intracellular  poisons.  It  is  quite  probable  that  the 
former  poisons  are  identical  with  the  latter,  and  have  merely  passed  from  the 
bacilli  into  the  culture-medium. 

Tuberculin. — It  was  proved  some  time  ago  that  dead  bacilli  are  toxic  and, 
if  experimentally  injected,  induce  a  toxic  condition  in  the  animal,  cause  inflam- 
mation of  the  kidneys,  and  sometimes  produce  subsequently  cold  abscess 
at  the  seat  of  injectioii.  In  1890  Koch_  collected  the  poison  from  dead  bacteria 
in  the  form  of  a  liquid,  which  he  called  tuberculin.^  A  number  of  different 
methods  of  extracting  such  poison  have  been  suggested;  hence,  there  are  a  num- 
ber of  different  tuberculins,  not  one  of  which  contains  Hving  bacilli.  Koch  has 
made  several  himself.  His  early  tubercuHn  was  made  by  making  a  glycerin- 
i"Deutsch.  med.  Wochenschr.,"  1891,  svii. 


244  Surgical  Tuberculosis 

bouillon  culture  of  tubercle  bacilli,  evaporating  on  a  water-bath  to  one-tenth 
of  its  volume,  and  filtering  out  the  dead  bacilli.  The  filtrate  contained  tuber- 
culin mixed  with  glycerin.  It  is  now  known  as  original  or  old  tuberculin  or  OT. 
Later  Koch  prepared  tuberculin  from  virulent  cultures  of  bacilli,  dried,  ground 
up,  and  mixed  with  water,  the  fluid  being  centrifuged  for  forty-five  minutes: 
When  centrifuged,  two  layers  separate.  The  upper  layer,  which  is  white 
and  opalescent,  contains  the  elements  soluble  in  glycerin,  is  like  the  old  tubercu- 
lin, and  is  called  TO.  The  lower  layer  contains  an'emulsion  of  insoluljle  elements 
of  high  immunizing  power,  and  is  called  TR.  In  1901  Koch  presented  another 
tuberculin  of  dried  bacilli  in  equal  amounts  of  glycerin  and  water.  It  is  called 
bacillary  emulsion  or  BE.     This  is  really  a  vaccine. 

It  was  discovered  by  Koch  that  tuberculous  animals  are  much  more  strongly 
affected  by  an  injection  of  tuberculin  than  are  healthy  animals.  The  most 
positive  reaction  is  noted  in  the  tuberculous  area;  but,  as  a  rule,  there  is  also 
a  reaction  in  the  area  where  the  injection  is  made.  We  get  no  reaction  from 
the  administration  of  tuberculin  by  the  stomach,^  but  occasionally  can  obtain 
it  by  the  inhalation  of  the  dried  material.  If  a  moderate  dose  of  tuberculin  is 
injected  into  a  non-tuberculous  animal,  there  may  be  a  trivial  redness  at  the 
point  of  injection  and  a  slight  and  temporary  rise  of  temperature;  or  there 
may  'be  no  evidence  of  reaction  whatever.  An  injection  in  a  tuberculous  ani- 
mal, however,  is  followed  by  distinct  inflammation  at  the  seat  of  injection,  and 
a  positive  reaction  in  the  tuberculous  area.  This  area  undergoes  congestion 
or  inflammation,  leukocytes  collect  around  it,  and  the  part  tends  to  necrosis 
and  is  liable  to  break  down.  It  is  not  that  the  bacilli  are  killed,  but,  rather,  the 
tissues  containing  the  bacilli  die. 

In  addition  to  the  changes  already  mentioned  there  is  elevation  of  tempera- 
ture. If  the  dose  has  been  small,  there  may  be  only  a  slight  feeling  of  coldness 
to  usher  in  the  rise  of  temperature;  but  if  the  dose  has  been  large,  there  is 
usually  a  distinct  chill.  This  chill  comes  on  eight  to  twelve  hours  after  the 
injection  and  is  accompanied  and  followed  by  elevated  temperature.  The 
fever  lasts  from  four  to  twenty-four  hours,  and  the  temperature  may  be  ele- 
vated from  2°  to  5°  F.  The  febrile  condition  is  accompanied  by  pain  in  the 
head,  limbs  and  back,  with  increased  rapidity  of  the  circulation,  restlessness, 
weakness,  and  usually  nausea.  As  the  temperature  passes  to  normal  all  the 
symptoms  disappear.  The  slight  elevation  of  temperature  which  may  be  noted 
after  tuberculin  has  been  injected  into  a  non-tuberculous  animal  is  not  ushered 
in  by  a  chill,  and  does  not  exceed  1°  F.  unless  a  very  large  dose  has  been  given. 
We  thus  note  that  the  injection  of  tuberculin  may  be  of  the  greatest  possible 
value  in  diagnosis. 

A  person  with  a  latent  lesion  does,  one  with  a  thoroughly  healed  lesion  does 
not,  and  a  far-advanced  case  may  not,  react  to  tuberculin. 

Much  has  been  written  on  the  reaction  of  non-tuberculous  human  beings  to 
tuberculin.  Such  reaction  is  said  to  occur  in  leprosy,  in  convalescents  from 
acute  illnesses,  in  s>'philis,  and  in  actinomycosis.  Many  supposedly  healthy 
people  react  to  tuberculin.  Some  react  to  a  moderate  dose,  some  only  to  a 
large  one.  We  are  now  convinced  that  the  tuberculin  reaction  is  specific  and 
that  any  one  who  exhibits  it  possesses  a  tuberculous  focus,  active,  latent,  or 
healing.  Reaction  means  infection,  but  not  of  necessity  disease  with  clinical 
evidences.  Very  young  children,  especially  infants,  are  very  refractory  to 
tuberculin  because  young  children  are  seldom  actively  tuberculous. 

A  real,  complete  reaction  to  tuberculin  has  three  elements. 

1.  A  constitutional  reaction  manifested  by  fever. 

2.  A  local  reaction  manifested  by  the  indication  of  swelling  and  redness,  a 

1  Latham  and  S.  Solis-Cohen  claim  results  from  oral  administration.  MoUer  and  Heine- 
mann  seem  to  demonstrate  that  those  clinicians  are  mistaken  "Deutsche  med.  Woch.," 
Oct.  5,  1911. 


Immunity  245 

nodule,  or  an  infiltrating  area  in  the  region  of  jjunclure  (stick  reaction).  Some- 
times adjacent  glands  swelling. 

3.  A  focal  reaction,  that  is,  inflammation  about  the  lesion.  ("Tuberculin," 
by  Hamman  and  Wolman.) 

A  good  many  observers  have  grown  fearful  of  injecting  tuberculin,  believ- 
ing that  it  is  liable  to  cause  the  tuberculous  focus  to  sj)reacl,  or  actually  to  lead 
to  the  development  of  disseminated  tuberculosis.  Virchow  was  of  this  opin- 
ion. That  such  a  condition  may  follow  the  use  of  large  doses  seems  certain, 
but  moderate  or  small  doses  appear  to  be  entirely  safe.  Flick  has  pointed  out 
that  if  a  blister  is  applied  to  a  tuberculous  person  a  distinct  febrile  reaction  ap- 
pears a  number  of  hours  after  the  application.  This  is  due  to  the  absorption 
of  toxic  material,  probably  tuberculin,  from  the  blister.  It  is  known  that  in  a 
tuberculous  animal  certain  excretions  (urine)  and  serous  exudates  contain  tu- 
berculin. Merieux  and  Baillon  show  that  if  a  tuberculous  person  is  blistered 
the  fluid  of  the  blister,  injected  into  a  tuberculous  animal,  produces  a  definite 
reaction.  This  proceeding  is  of  diagnostic  value,  A  fluid  containing  tubercu- 
lin comes  from  the  blister  upon  the  tuberculous  person  and  he  is  proved  to 
be  tuberculous  by  injecting  the  blister  fluid  into  another  tuberculous  animal. 

Resistance  of  Bacilli. — Among  the  antagonistic  elements  we  have  men- 
tioned oxygen,  dryness,  and  sunlight.  Moist  heat,  at  the  temperature  of  boil- 
ing water,  is  rapidly  fatal.  A  5  per  cent,  solution  of  carbolic  acid  is  one  of  the 
most  powerful  of  germicides.  Full-strength  alcohol  is  next  in  point  of  power. 
Corrosive  sublimate  is  not  a  satisfactory  germicide.  Formaldehyd  is  fatal  only 
after  long  exposure.     Iodoform  and  ether  is  a  reasonably  powerful  mixture. 

That  the  virulence  of  tubercle  bacilli  varies  under  different  circumstances 
is  sure.  Under  some  circumstances  they  may  be  extremely  powerful;  under 
others,  nearly  innocuous.  The  liability  to  infection  depends,  probably,  in  part, 
on  individual  predisposition,  and  certainly,  to  a  great  extent,  on  the  number 
and  the  virulence  of  the  bacteria. 

Immunity. — It  seems  likely  that  some  persons  are  immune  to  tuberculo- 
sis. Such  persons  may  come  from  an  ancestral  line  in  which  all  the  predis- 
posed died  of  tuberculosis,  so  that  the  immediate  ancestors  of  the  line  were  non- 
susceptible.  As  a  race  the  Jews  have  a  considerable  degree  of  immunity. 
The  tendency  to  immunity  may  be  strengthened  by  proper  marriages,  and  may 
be  weakened  by  improper  marriages;  or  immunity  in  a  line  may  be  destroyed 
by  the  continuance  of  unfavorable  conditions.  In  health  there  are  no  antibod- 
ies lying  in  wait  for  tubercle  bacilli  and  ready  to  destroy  them.  Antibodies  can 
only  arise  when  bacteria  enter  the  blood  or  lymph,  that  is  when  infection 
already  exists.  It  is  sometimes  noticed  that  during  the  progress  of  a  localized 
tuberculous  infection  a  deep-seated  tuberculosis  (for  instance,  phthisis)  im- 
proves. This  exhibits  a  progressive  development  in  the  powers  of  the  organism 
to  resist  infection  by  stimulation  of  the  apparatus  for  opposing  infection.  That 
numbers  of  people  get  entirely  well  of  tuberculosis  is  certain  and  that  many 
such  people  have  secured  prolonged  immunity  is  probable.  Paretic  dements 
seem  to  possess  a  high  degree  of  immunity  to  tuberculosis  (Rosanoff,  in  "Jour. 
Amer.  Med.  Assoc,"  February  13,  1909).  Of  course,  the  term  "immunity" 
is  only  relative  No  one  can  be  absolutely  immune;  for  when  subjected  to  ex- 
tremely unfavorable  circumstances,  or  when  a  number  of  virulent  bacilli  are 
introduced,  any  one  may  become  tuberculous.  Attempts  to  create  artificial 
immunity  have  been  failures.  Vaccination  with  living  bacteria  and  vaccination 
with  dead  bacteria  are  alike  unsuccessful.  No  method  of  specific  immuniza- 
tion is  known  (Theobald  Smith  in  "Jour.  Am.  Med.  Assoc,"  March  10,  191 7). 

Von  Behring  sought  to  immunize  cattle  by  giving  living  human  bacteria 
by  intravenous  injection.  This  is  called  bovovaccination.  It  increases  re- 
sistance for  a  time  only.  The  human  bacilli  are  relatively  harmless  to  cattle 
and  yet  the  method  is  not  free  from  danger  to  the  animal. 


246  Surgical  Tuberculosis 

Predisposition.— Personally,  I  believe  that  there  is  such  a  thing  as  a  predis- 
position toward  tuberculosis,  just  as  there  is  toward  many  other  diseases.  Such 
a  predisposed  individual  possesses  temporarily  or  permanently  a  condition  of  the 
body-cells,  body-fluids,  or  both,  that  either  makes  easy  the  entrance  of  the 
bacilli  or  prevents  strong  opposition  to  their  multiplication  when  they  have 
entered.  A  person  is  predisposed  to  an  infectious  disease  when  the  opsonic 
index  is  low,  for  this  indicates  lack  of  phagocytic  power  in  the  leukocytes. 
Predisposition  may  be  increased  by  some  extraneous  circumstance,  such  as 
occupation,  residence,  etc.,  that  brings  the  individual  into  frequent  or  pro- 
longed contact  with  virulent  bacteria. 

There  is  certainly  such  a  thing  as  antenatal  tuberculosis,  and  any  tissue 
may  be  involved  in  the  antenatal  trouble.  The  blood  in  the  umbilical  vein 
from  the  placenta  of  a  tuberculous  mother  may  contain  tubercle  bacilli  (page 
241).  Young  children  may  develop  tuberculosis  of  the  acquired  form. 
According  to  Professor  Behring,  all  infection  dates  from  early  life.  Many  chil- 
dren become  infected  with  tuberculosis  in  their  early  years  by  eating  tuberculous 
food;  but  such  a  tuberculosis  often  remains  latent  for  a  considerable  length  of 
time,  and  then  develops.  It  may  not  develop  until  adolescence  or  adult  life. 
This  liability  depends  probably  upon  the  fact  that  the  digestive  organs  of  the 
child  are  not  so  strongly  protective  against  bacteria  as  are  those  of  the  adult. 
It  is  hard  to  understand  why  children,  who  bear  infections  badly,  should  not 
when  infected  develop  a  progressive  and  fatal  .disease.  Why  the  disease  should 
redevelop  in  adults,  w^ho  bear  infections  better  than  children,  is  difficult  to 
understand.  Metchnikoff  believes  that  the  abortive  tuberculosis  of  childhood 
is  due  to  attenuated  strains  of  bacilli  (Sir  Malcolm  Morris,  in  "Brit.  Med. 
Jour.,"  Nov.  16,  1918).  The  theory  "that  all  infection  dates  from  early  life 
should  be  accepted  with  caution  and  reserve"  (Theobald  Smith  in  "Jour. 
Am.  Med.  Assoc,"  March  10,  1917). 

Do  certain  individuals  possess  a  special  predisposition  to  develop  tuber- 
culosis, and  is  this  hereditary?  Hereditary  predisposition  was  once  regarded 
as  practically  the  only  cause  of  the  disease,  but  many  thinkers  now  regard  it 
as  of  slight  importance,  although  I  do  not  see  how  we  can  deny  its  existence. 
To  do  so  is  to  run  counter  to  the  experience  of  the  human  race  in  all  countries 
and  at  all  times.  We  all  see  how  common  tuberculosis  is  in  the  descendants  of 
tuberculous  persons.  Hutley  studied  432  cases  of  tuberculosis.  In  23.8  per 
cent,  one  or  both  parents  had  the  disease  (the  father  alone  in  11.5  per  cent., 
the  mother  alone  in  9.9  per  cent.,  and  both  in  2.4  per  cent.).  Some  maintain 
that  in  30  per  cent,  of  consumptives,  one  parent  or  both  parents  have  been  con- 
sumptives, and  in  60  per  cent,  a  parent  or  a  grandparent  has  suffered  from 
tuberculosis.  Of  course,  the  above  statements  do  not  prove  that  the  cases  in 
a  family  are  due  to  heredity;  but  that  there  must  be  such  a  thing  as  hereditary 
predisposition  is  indicated  by  the  fact  that  there  are  many  families  living  under 
similar  conditions  to  the  tuberculous  families,  without  there  having  occurred, 
through  several  generations,  a  single  case  of  tuberculosis  among  their  members. 
A  feature  that  makes  us  unable  to  reach  a  certain  conclusion  is  that  tubercu- 
losis is  contagious  and  several  members  of  a  family  may  be  infected  from  one 
member,  even  when  there  is  no  predisposition  to  the  trouble  by  heredity.  The 
mere  living  in  one  house  may  account  for  the  infection.  A  fact  strongly  in 
favor  of  the  hereditary  influence  is  that  in  a  family  whose  ancestors  have  been 
tuberculous  and  whose  members  have  not  lived  together,  but  have  been  scat- 
tered widely  over  the  earth,  member  after  member  may  die  of  the  disease. 

Unhealthy  environment  particularly  predisposes  to  tuberculosis;  and  the 
element  of  poverty — leading  as  it  does  to  taking  improper  or  insufficient 
food,  dwelHng  in  an  unhygienic  room  or  in  an  overcrowded  building,  pursuing  an 
exhausting  occupation,  working  for  long  hours  in  a  dust  laden  atmosphere,  and 
obtaining  insufficient  amusement  and  outdoor  exercise — also  has  a  most  power- 


Relation  of  Trauma  to  Tuberculosis  247 

fully  unfavorable  effect.  As  a  class  the  poor  dislike  ventilation,  take  insufficient 
exercise  in  the  open  air,  do  not  get  enough  sunlight,  work  in  a  dusty  atmosphere, 
take  insufficient  nourishment  and  eat  improper  food,  live  in  damp  and  dirty 
rooms,  are  subjected  to  grinding  competition  and  cruel  anxieties,  and  many  of 
them  drink  quantities  of  whisky.  City  life  is  a  predisposing  cause  of  tubercu- 
losis for  many  of  the  foregoing  reasons,  and  particularly  because  many  city 
workers  follow  an  indoor  occupation.  The  enemies  of  tuberculosis  are  sunlight, 
fresh  air,  nourishing  food,  and  outdoor  exercise,  and  the  limiting  of  any  of 
these  factors  favors  the  development  of  the  disease. 

Tuberculosis  may  occur  in  any  region  that  man  inhabits;  although  in  some 
regions  it  is  rare,  and  in  others  it  is  excessively  common.  Its  great  frequency 
in  some  regions  is  probably  due  less  to  climate  than  to  environment,  occupation, 
and  heredity;  and  the  greatest  predisposition  is  found  in  the  town  dweller. 
There  is  much  more  tuberculosis  among  males  than  among  females. 

Many  diseases  and  conditions  predispose  to  tuberculosis.  It  is  very  com- 
mon in  chronic  drunkards,  in  the  insane,  in  the  occupants  of  prisons,  alms- 
houses, and  reformatories;  among  negroes  in  the  North,  particularly  those 
engaged  in  indoor  occupations;  among  American  Indians  subjected  to  the  blight- 
ing influences  of  civilization  by  formula  and  routine;  and  in  the  sufferers  from 
tertiary  s}'philis,  diabetes,  and  Bright's  disease.  Any  exhausting  malady  may 
be  followed  by  tuberculosis. 

Relation  of  Trauma  to  Tuberculosis. — (See  the  author  in  "Annals  of  Surgery" 
(June,  1 914).  (Inoculation  Tuberculosis  is  discussed  on  page  240.)  This  ques- 
tion is  often  in  dispute  and  has  become  of  much  medicolegal  importance. 
Several  times  of  late,  in  the  courts  of  Philadelphia,  it  has  been  the  sub- 
ject of  acrimonious  controversy.  Suitors  affirm  the  relationship,  corpora- 
tions deny  it,  and  experts  wTangle  till  judge  and  jurymen  do  not  know  what  to 
believe. 

There  can  be  no  doubt  that  tuberculosis  often  becomes  manifest  in  a  part 
-after  that  part  has  been  subjected  to  traumatism.  No  one  denies  this.  In 
fact,  in  over  one-sixth  of  all  cases  of  bone  and  joint  tuberculosis  traumatism 
is  set  down  as  causal. 

I  do  not  mean  that  trauma  causes  the  tissue  changes  characteristic  of  tuber- 
culosis. Such  changes  are  always  and  only  produced  by  the  action  of  tubercle 
baciUi.  I  do  mean  that  the  injury  puts  the  part  in  such  a  condition  that  the 
"bacilli  of  tubercle  attack  the  injured  tissue,  having  been  unable  to  attack  it 
when  it  was  in  a  state  of  health.  The  injury  creates  an  area  of  least  resistance. 
In  such  an  area  the  cellular  activities  are  no  longer  able  to  withstand  the  action 
of  bacteria.  Without  an  injury  it  is  highly  improbable  that  tuberculosis  would 
ever  have  arisen  in  the  part.  .  At  least  the  injury  determined  the  localization 
and  multiplication  of  bacilli  and  the  origin  of  an  active  tuberculous  focus,  and 
to  this  extent  the  injury  was  causal. 

Osteomyelitis  is  due  to  pyogenic  cocci.  It  may  arise  in  a  bone  subjected  to 
traumatism.  Traumatism  is  stated  to  be  a  cause.  WTiy  should  a  tuberculous 
process  be  placed  in  a  different  categon,-?  Where  do  the  tubercle  bacilli  come 
from?  Some  maintain  that  if  tuberculosis  follows  traumatism  of  apart,  there 
was  a  latent  and  undiscovered  tuberculous  process  in  the  part  before  the  acci- 
dent, and  that  all  the  accident  did  was  to  light  up  a  latent  focus  into  activity; 
in  other  words,  to  precipitate  an  inevitable  event.  This  contention  is  true  in 
some  few  cases;  we  believe  it  to  be  untrue  in  a  large  majority  of  cases. 

Some  believe  that  though  there  may  have  been  no  local  latent  focus,  there  is, 
at  least,  somewhere  in  the  body  an  area  of  tuberculosis  to  furnish  the  bacilh. 
This  view  is  true  of  many,  but  we  do  not  believe  of  all,  cases.  It  gains  in  proba- 
bility from  the  estabUshed  fact  that  tuberculous  bone  or  joint  disease  is  most 
apt  to  arise  in  those  known  to  have  tuberculous  infection  somewhere  about 
them.     It   is   certain  that  in  many  cases  there  is  no  demonstrable  focus  of 


248  Surgical  Tuberculosis 

tubercle  anywhere  to  be  found  except  in  the  injured  part.  It  is  hard  to  prove 
a  negative,  and  it  is  impossible  in  any  case  to  deny  arbitrarily  that  an  un- 
recognizable distant  latent  focus  may  exist. 

We  know,  however,  that  many  cases  never  give  any  sign  of  distant  tuber- 
culosis before  the  accident,  and  never  give  any  sign  of  it  afterward.  We  do 
know  that  bacilli  can  exist  for  a  considerable  time  in  blood  or  lymph  when  there 
is  no  demonstrable  lesion  of  tuberculosis.  From  such  blood  or  lymph  bacilli 
may  be  deposited  in  the  injured  part  and  become  active  for  harm. 

We  do  know  that  bacilli  may  live  for  a  long  time  in  glands  or  bone-marrow 
without  producing  any  evidence  of  a  lesion  of  bone  or  of  gland  (Petrow,  Lan- 
nelongue).  If  bone-marrow  or  gland  containing  bacilli  is  injured,  these  bacilli 
become  active  and  establish  an  area  of  disease.  Without  the  injury  it  is  im- 
probable that  there  would  have  been  disease. 

Local  tuberculosis  follows  slight  rather  than  severe  injury.  I  have  seen  it 
after  a  strain  of  an  epiphysis,  never  after  a  fracture.  I  have  seen  it  after  a  sprain 
of  a  joint,  never  after  a  dislocation.  After  a  severe  injury  tissue  reaction  is  so 
marked  that  bacilli  are  destroyed.  It  is  particularly  in  bone  and  joint  tubercu- 
losis that  traumatism  is  held  to  be  causal.  Whitman  tells  us  that  out  of  nearly 
3400  cases  occurring  in  the  clinics  of  Bruns,  Koenig,  Mikulicz,  and  Hildebrand 
over  500  were  attributed  to  trauma.  I  have  seen  a  number  of  such  cases,  most 
of  them  involving  the  knee,  foot,  or  wrist.  I  have  seen  tuberculosis  of  the  glands 
of  the  groin  arise  after  a  bruise,  tuberculous  pleuritis  and  tuberculosis  of  the 
chest-wall  follow  a  chest  contusion,  and  sacro-iliac  tuberculosis  follow  a  sprain. 
Tuberculous  meningitis  has  followed  head  injury.  I  have  seen  several  cases  of 
tuberculosis  of  the  testicle  after  contusion.  When  injury  is  followed  by  a  tuber- 
culous lesion,  the  definite  signs  and  symptoms  of  that  lesion  do  not  appear  for 
from  three  to  six  weeks  after  the  accident.  We  may  conclude  that  tuberculosis 
may  arise  at  the  seat  of  an  injury;  that  in  some  cases  there  may  have  been  an 
antecedent  lesion  at  that  point;  in  some  cases  there  is  a  distant  active  lesion; 
in  some  cases  a  distant  latent  lesion;  in  some  the  bacilli  must  have  been  lying 
inactive  in  the  part  or  must  have  lodged  there  from  blood  or  lymph,  after  the 
accident  and  because  of  it.  R.  L.  Dixon  reported  a  number  of  such  cases 
("Physician  and  Surgeon,"  Jan.,  1909).  Hueter  and  Schiiller  insist  on  the 
tendency  of  trauma  to  localize  tuberculosis.  Ribera  Y  Sans  (quoted  in  "  Prac- 
tical Medicine  Series,"  vol.  in  Surgery,  191 2,  edited  by  John  B.  Murphy)  states 
that  in  45  per  cent,  of  cases  of  tuberculosis  of  the  larger  joints  the  condition 
is  preceded  by  trauma.  In  an  appended  note  by  Murphy  we  learn  that  that 
surgeon  believes  that  tubercle  bacilli  tend  to  escape  from  the  circulation  at  the 
site  of  a  slight  trauma  and  to  light  up  disease.  Bosanquet  ("Lancet,"  Jan. 
13,  191 2)  says  that  in  expressing  an  opinion  "as  to  the  probability  of  a  tuber- 
cular lesion  being  due  to  a  preceding  accident,  I  think  we  must  put  disease  of 
joints  in  a  class  by  itself.  There  is  a  considerable  mass  of  evidence,  that  in 
some  way  or  other  injury  does  lead  to  tubercular  arthritis,  and  if  the  occurrence 
of  the  accident  is  clearly  established  and  it  is  followed  at  a  reasonable  interval 
by  the  tuberculosis,  we  may  accept  the  causal  connection  as  probable."  He 
regards  "a  reasonable  period  of  time"  as  not  over  three  months.  During  the 
interval  there  should  have  been  some  pain  in  or  stiffness  of  the  joint. 

The  Term  ''Scrofula." — Many  surgeons  positively  oppose  the  use  of  the 
term  scrofula,  but  I  believe  that  there  is  clinical  value  in  retaining  it.  The  sur- 
geons that  have  entirely  abandoned  it  think  that,  after  all,  it  is  exactly  synony- 
mous with  tuberculosis.  I  use  it  to  designate  the  persons  that  are  predisposed 
to  tuberculosis  through  possessing  a  type  of  tissue  of  low  resisting  power. 
These  tissues  fall  a  ready  prey  to  the  bacteria  of  tuberculosis.  Such  tissue  vul- 
nerability is  usually  hereditary;  and,  as  a  rule,  one,  or  even  both  parents  are 
tuberculous,  are  in  ill  health,  or  are  themselves  predisposed.  Occasionally 
this  type  of  tissue  is  acquired,  a  child  having  at  first  been  apparently  entirely 


Lymphatism,  or  the  Lymphatic  Constitution  (Status  Lymphaticus)     249 

healthy,  and  later,  owing  to  poor  food,  insufficient  fresh  air,  and  bad  hygienic 
surroundings,  developing  scrofula. 

That  scrofula  is  not  simply  osseous,  articular,  or  glandular  tuberculosis  is- 
proved  by  the  fact  that  a  person  that  we  recognize  as  scrofulous  may  never 
throughout  his  life  develop  a  recognizable  tuberculous  lesion.  Some  surgeons 
think,  that  scrofula  is  latent  tuberculosis,  and  will,  under  the  influence  of  an 
exciting  cause,  burst  into  activity.  This  is  possible,  but  unproved.  We  do 
know  that  some  so-called  scrofulous  lesions  are  not  tuberculous;  for  instance 
facial  eczema,  corneal  ulceration,  granular  hds,  and  mucous  catarrh.  These 
lesions  are  rather  expressive  of  poor  health,  improper  food,  and  deprivation 
of  fresh  air. 

The  subjects  of  scrofula,  besides  being  prone  to  the  non-tuberculous  lesions. 
above  mentioned,  are  particularly  prone  to  develop  tuberculous  lesions;  and 
such  a  lesion  may  arise  in  any  part  that  has  been  the  seat  of  a  slight  injury  or 
of  a  non-tuberculous  inflammation  The  parts  most  apt  to  become  tubercu- 
lous are  the  bones,  the  joints,  and  the  glands. 

There  are  two  types  of  the  so-called  scrofulous,  that  is,  two  types  of  those 
that  are  predisposed.  The  common  type  is  known  as  the  phlegmatic,  or  lym- 
phatic; and  it  is  this  type  that  is  particularly  described  by  our  surgical  fore- 
fathers. In  the  phlegmatic  type  the  individual  is  stohd  of  expression,  and 
has  thick,  coarse  skin,  a  muddy  complexion,  dark,  coarse  hair,  a  thick  neck,, 
thick  lips,  a  thick  nose,  and  a  heavy  lumbering  gait.  He  is  dull  of  apprehension^ 
with  feeble  emotional  reaction,  and  but  little  capacity  for  concentration  or 
interest.  The  other  type  is  much  more  seldom  met  with.  It  is  what  is  called 
the  sanguine  type,  or  what  the  elder  Gross  spoke  of  as  the  angelic  type.  Such 
a  child  is  frequently  beautiful  and  graceful  in  its  movements.  Its  skin  is  trans- 
parent and  clear,  and  the  color  comes  and  goes.  The  eyes  are  blue,  the  lashes 
long,  and  the  hair  silky.  The  tendency  is  to  thinness,  rather  than  fat,  the  mind 
is  not  dull,  but  precocious,  and  the  temperament  is  nervous.  In  both  these 
types  of  scrofula  the  condition  of  lymphatism  exists. 

Lymphatism,  or  the  Lymphatic  Constitution  (Status  Lymphati= 
cus). — The  term  was  introduced  by  Potain  to  designate  a  condition  in  child- 
hood in  which  there  is  a  very  strong  disposition  to  the  development  of  disease  of 
the  lymphatic  structures,  or  in  which  at  birth  there  was  excessive  develop- 
ment of  these  structures.  It  is  a  hereditary  condition  particularly  common  in 
tuberculous  families,  characterized  by  "certain  external  peculiarities  of  configu- 
ration by  hypoplasia  of  the  cardiovascular  apparatus,  by  hyperplasia  of  the 
thymus  gland  and  of  the  lymphoid  tissues  in  other  localities,  and,  incidentally, 
by  congenital  structural  defects  in  different  viscera"  (Douglas  Symmers,  in 
"Am.  Jour,  of  Diseases  of  Children,"  Dec,  191 7). 

Most  of  the  cases  we  see  are  infants  or  children  but  a  number  live  to  adult 
life.  Of  1 18  "  straight-forward  "  cases  which  came  to  autopsy  in  Bellevue  Hospi- 
tal, 29  were  between  sixteen  and  forty  years  of  age  (Symmers,  Ibid.).  In  many 
of  the  cases  the  faucial  tonsils,  lingual  tonsil  and  pharyngeal  follicles  are  en- 
larged. In  most  cases  Peyer's  patches  and  the  solitary  follicles  are  enlarged.  In 
about  one-tenth  of  the  frank  cases  the  axillary  glands  are  enlarged,  in  about 
one-tenth  the  inguinal  glands  and  in  about  one-tenth  the  cervical  glands.  (See 
Symmers,  Ibid.) 

Of  the  118  cases  cited  above  the  thymus  gland  was  enlarged  in  every  case  and 
there  were  30  per  cent,  of  them  in  which  splenic  enlargement  existed.  In  85 
per  cent,  of  them  the  malpighian  follicles  showed  hyperplasia. 

In  the  retrogressive  form  of  status  lymphaticus  the  lymphoid  tissue  is  under- 
going retrogression.  This  condition  is  seldom  met  with  in  persons  under  twenty 
years  of  age  (Symmers,  Ibid.).  Of  this  type  89  cases  came  to  autopsy.  In 
19  of  these  the  thymus  was  recognizable  though  small,  in  the  others  it  was 
replaced  by  fat.     In  28  per  cent,  of  the  recessive  cases  the  faucial  tonsils  were 


250  Surgical  Tuberculosis 

enlarged,  in  32  per  cent,  the  lingual  tonsils  were  enlarged  and  21  per  cent,  the 
pharyngeal  tonsils.  In  68.5  per  cent,  of  cases  Peyer's  patches  were  atrophied 
and  there  was  atrophy  of  the  solitary  follicles  in  41  per  cent,  of  cases.  The 
spleen  was  normal  in  size  or  small  in  71  per  cent,  of  the  cases. 

Taking  all  of  the  cases,  that  is  249,  Symmers  (Ibid.)  found  the  heart  small 
in  51  per  cent.  In  71  of  the  cases  measurement  showed  an  aorta  lessened  in 
caliber.  In  31  per  cent,  of  the  cases  there  was  increased  elasticity  of  the  aorta 
and  in  26.5  per  cent,  of  the  cases  the  aorta  was  unnaturally  thin.  In  these 
cases  the  cerebral  vessels,  central  and  meningeal  were  very  thin  and  could  rup- 
ture from  slight  force  or  simply  from  raised  blood-pressure.  The  enlarged  glands 
may  become  tuberculous.  Inflammation  of  a  mucous  membrane  is  very  apt 
to  be  followed  by  enlargement  of  the  anatomically  related  lymphatic  glands. 

Lymphatic  children  frequently  have  rickets  and  are  invariably  anemic, 
yet  there  is  considerable  or  much  subcutaneous  fat  (Escherich).  In  infancv 
it  is  the  bronchial  and  mesenteric  glands  that  are  particularly  apt  to  enlarge; 
in  childhood,  it  is  the  glands  of  the  neck.  The  tonsils  are  enlarged  in  many 
cases  and  the  nasopharynx  in  many  cases  contains  adenoids.  The  spleen  is 
sometimes  palpable.  In  lymphatic  children  there  is  a  persistent,  in  fact  an 
hypertrophied  thymus  gland.  The  gland,  however,  is  not  obvious,  but  rather 
hides  at  the  root  of  the  neck  (Humphrey,  in  "Lancet,"  Dec.  26,  1908),  and  may 
be  missed  at  necropsy.  During  life  the  thymus  is  sometimes  observed  as  a  pul- 
sating mass  at  the  root  of  the  neck.  Even  if  it  cannot  be  seen  its  presence 
can  perhaps  be  determined  by  percussion  and  by  the  x-rays  (Hochsinger)  (see 
page  1390).  In  my  experience  the  x-rays  have  been  of  httle  or  no  service  in 
demonstrating  enlargement  of  the  thymus.  The  Mayos  and  Bloodgood  reached 
this  conclusion  some  time  ago.  In  adult  cases  the  thymus  may  be  persistent 
but  is  usually  replaced  by  fat.  In  about  half  the  cases  a  goiter  is  obvious,  and, 
as  pointed  out  by  Berg,  many  of  those  with  goiter  have  symptoms  of  Graves' 
disease.  As  the  child  increases  in  age,  the  visible  lymphatic  enlargements  are 
likely  to  disappear  unless  tuberculous  infection  has  occurred.  After  a  child  has 
reached  the  age  of  seven  or  eight  years  non-tuberculous  glands  of  the  neck  cease 
to  enlarge,  and  by  the  time  of  puberty  they  have  usually  disappeared.  Buxton 
("Lancet,"  Aug.  6,  1910)  states  that  young  persons  suffering  from  this  condition 
are  tall  and  thin;  possess  clear,  fair,  and  pale  skins;  the  temperament  is  blended, 
there  is  mental  slowness  yet  intelligence,  there  is  shyness  and  strong  self-feeling. 
I  have  seen  victims  of  lymphatism  who  were  not  thin  but  rather  stout,  gela- 
tinous, pasty  and  of  a  peculiar  fish-belly  pallor.  They  cannot  withstand  cold, 
are  very  emotional,  and  yet  may  be  able  to  appear  calm.  The  pulse  is  normally 
50  to  60,  but  is  made  rapid  and  irregular  by  trifling  excitement.  Norris  of  New 
York,  Neusser  of  Vienna,  and  Douglas  Symmers  of  New  York,  have  shown  that 
certain  structural  peculiarities  may  identify  the  victims  of  lymphatism. 

In  a  male  subject  the  bodily  conformation  resembles  that  of  the  female. 
The  beard  in  the  adult  is  scanty  or  absent,  the  same  is  true  of  axillary  hair. 
The  base  of  the  cluster  of  pubic  hairs  is  transverse,  the  waist  is  narrow,  the 
thighs  are  graceful  and  arched,  the  skin  is  smooth  and  soft.  In  the  female  the 
normal  feminine  attributes  are  accentuated  (Symmers,  Ibid.). 

I  am  convinced  that  one  type  of  the  so-called  scrofulous  child  is  the  victim 
of  lymphatism  (see  the  angelic  type  of  Gross,  page  249).  In  some  cases  there 
are  attacks  of  dyspnea  which  are  spoken  of  as  asthmatic  seizures  and  which 
may  be  induced  by  going  about  horses  or  by  taking  an  injection  of  horse  serum. 
I  do  not  believe  that  the  condition  can  be  certainly  diagnosticated  during  Hfe. 
McCardie  regards  hypertrophied  lingual  follicles,  and  the  existence  of  lymphoid 
masses  in  the  wall  of  the  pharynx,  the  pyriform  sinus,  and  in  the  anterior  sur- 
face of  the  epiglottis  as  significant  of  the  existence  of  lymphatism.  Status 
lymphaticus  is  particularly  frequent  in  individuals  with  disorder  of  certain 
internal  secretions  (suprarenal  glands,  pituitary  gland,  thyroid  gland) — in  in- 


The  Diagnosis  of  Tuberculosis  251 

dividuals  called  scrofulous — in  neurasthenics  and  lunatics.     Subjects  of  lympha- 
tism  seem  particularly  prone  to  alcoholic  and  drug  inebriety  and  to  suicide. 

If  an  operation  is  performed  on  the  victim  of  lymphatism  the  wound  is 
very  liable  to  become  infected,  and  the  bleeding  from  the  wound  is  very  trivial. 
In  many  cases  of  status  lymphaticus  there  is  a  distinct  liability  to  sudden  death. 
This  tendency  is  said  not  to  exist  in  recessive  cases.  The  victims  of  lymphatism 
are  more  apt  than  other  persons  to  die  under  a  general  anesthetic,  and  occasion- 
ally one  of  them  dies  during  natural  sleep.  Now  and  then  a  death  occurs  in 
a  bath  or  while  exercising  actively.  Death  may  follow  so  slight  a  procedure  as 
vaccination.  (See  Dr.  Geo.  Blumer,  in  the  "Bulletin  of  the  Johns  Hopkins 
Hospital,''  Oct.,  1903.)  Cases  have  died  from  injection  of  diphtheria  antitoxin 
(see  page  54).  This  disease  accounts  for  most  otherwise  inexplicable  cases 
of  sudden  death  in  children  and  young  persons.  It  is  generally  held  that  such 
deathsarerespiratory  and  not  cardiac  (Humphrey,  in ''Lancet,"  Dec.  26,  1908), 
but  some  observers  regard  them  as  syncopal.  It  is  no  longer  believed  that  the 
enlargement  of  the  thymus  causes  death  by  pressure  on  the  trachea.  It  is  true 
that  in  such  cases  there  is  apt  to  be  an  enlarged  thymus,  but  that  is  only  expres- 
sive of  the  lymphatism  and  is  not  the  cause  of  death. 

One  cause  of  sudden  death  is  rupture  of  a  cerebral  blood-vessel  and  the 
rupture  may  be  traumatic,  or  may  be  spontaneous,  during  an  episode  of  high 
blood-pressure  (Symmers,  Ibid.).  It  may  be  a  central  artery  or  a  meningeal 
vessel.  Very  slight  force  may  cause  it.  Symmers  (Ibid.)  asserts  that  anaphy- 
laxis explains  most  sudden  deaths  among  the  victims  of  lymphatism.  If  sudden 
death  occurs  necrotic  changes  will  be  found  in  lymphoid  structures,  and,  when 
such  changes  exist  we  know  that  nucleoproteins  must  have  been  absorbed  during 
life.     Symmers  (Ibid.)  goes  on  to  say: 

"Previous  to  the  expiration  of  the  so-called  anaphylactic  incubation  period 
the  Ivmph  nodes  are  subjected  to  the  action  of  destructive  substances  which 
serve  to  bring  about  still  further  disintegration  of  germinal  nuclei,  thus  providing 
the  requisite  quantity  of  specific  protein  to  complete  the  anaphylactic  reaction. 
The  destructive  substances  in  question  may  be  introduced  in  the  form  of  anti- 
toxins h\podermically  injected,  or  as  vaccines  applied  by  scarification  or  other- 
wise, or  as  substances  derived  from  intestinal  absorption,  or  manufactured  in  the 
process  of  shock  induced  even  by  such  simple  procedures  as  the  prick  of  a  needle, 
sudden  exposure  to  cold,  and  a  number  of  similar  events.  That  apparently 
trivial  and  negligible  affairs  are  sometimes  attended  by  extraordinary  physical 
or  chemical  revulsions  is  a  recognized  fact  in  medicine,  and  is  illustrated,  among 
other  things,  by  the  almost  instantaneous  jaundice  which  sometimes  is  occa- 
sioned bv  severe  fright,  so  that  the  occurrence  of  equally  remarkable  reactions 
in  status  lymphaticus  is  by  no  means  unprecedented." 

The  Diagnosis  of  Tuberculosis.— "\Mienever  he  sees  a  persistent  area 
of  chronic  inflammation  in  any  structure  of  the  body  the  surgeon  must  think 
of  the  possibiHty  of  its  being  tuberculous.  A  thorough  investigation  must 
be  made  into  the  local  disease  and  the  body  generally;  and  it  is  of  particular 
importance  to  determine  whether  there  is  any  other  diseased  locality,  and 
whether  there  is  any  evidence  of  tuberculous  disease  anywhere  in  the  body. 
The  patient's  history  must  be  investigated,  and  any  possible  tendencies  or  pre- 
dispositions inquired  into.  Tuberculosis  does  not  cause  leukocytosis  except, 
perhaps,  occasionally  and  moderately  in  tuberculosis  of  serous  membrane, 
and  even  in  this  condition  there  is  no  increase  in  polymorphonuclear  cells. 
A   mixed  infection  causes  only  a  trivial  increase  in  polynuclear  leukocytes. 

In  many  cases  of  tuberculosis  the  diagnosis  can  be  made  from  purely  clini- 
cal investigation.  This  is  the  case,  for  instance,  in  many  tuberculous  ulcers, 
abscesses,  and  glands.  In  some  cases  the  diagnosis  can  be  made  only  by  mak- 
ing differential  stains  of  material  obtained  from  the  suspected  focus,  or  by 
removing  a  section  of  the  inflammatory  area  by  MLxter's  cannula,  and  studying 


252  Surgical  Tuberculosis 

it  carefully  under  the  microscope.  Cultures  may  be  taken  from  any  material' 
obtained  from  the  suspected  focus. 

In  unusually  doubtful  cases  animal  inoculation  is  necessary  to  make  a 
diagnosis.  The  material  is  injected  into  a  guinea-i)ig;  and  if  it  be  tuberculous,, 
the  animal  will  develop  miliary  tuberculosis  within  a  few  weeks.  With 
apparently  sterile  fluid  obtained  from  a  tuberculous  focus  the  disease  can  be 
induced  in  guinea-pigs  by  inoculation.  Blistering  a  tuberculous  person  causes 
elevated  temperature  (see  page  245).  If  the  fluid  of  the  blister  be  injected 
into  a  tuberculous  animal  a  distinct  reaction  occurs  (see  page  245). 

In  a  suspected  case  of  tuberculous  meningitis  of  the  brain  or  of  tuberculous 
disease  of  the  membranes  of  the  cord,  the  theca  of  the  cord  should  be  tapped' 
(lumbar  puncture),  and  the  fluid  obtained  should  be  carefully  examined.  Of 
course,  if,  in  a  case  of  tuberculous  cerebral  meningitis  the  foramina  in  the  floor 
of  the  fourth  ventricle  have  been  blocked  by  exudate,  no  characteristic  fluid 
will  be  obtained  by  tapping.  It  is  usually  found,  however,  that  even  in  tuber- 
culous cerebral  meningitis  there  is  increased  tension  of  the  fluid  in  the  sub- 
arachnoid space  of  the  cord,  that  this  fluid  is  present  in  unnaturally  large 
quantity,  and  that  it  is  turbid  through  the  presence  of  pus  and  lymphocytes. 
Sometimes  it  contains  bits  of  fibrin  and  sometimes  blood;  and  in  many  cases 
the  bacilli  of  tuberculosis.  Exploratory  abdominal  incision  is  sometimes  nec- 
essary to  determine  the  existence  of  tuberculous  peritonitis. 

The  .v-rays  are  of  great  aid  in  making  a  diagnosis  of  osseous,  articular,  and,, 
also  of  certain  forms  of  pulmonary  tuberculosis.  The  area  of  tuberculosis  is- 
lighter  than  the  surrounding  healthy  structures  when  seen  in  a  skiagraph. 

The  Tuberculin  Test. — This  test  may  sometimes  be  used  to  advantage 
in  making  an  early  diagnosis  of  recent  lesions.  Some  physicians  will  not 
use  it,  believing  that  it  is  very  dangerous.  However  tuberculin  is  used,  it  is 
much  more  reliable  diagnostically  in  children  than  in  adults.  Apparently 
healthy  infants  never  react.  Apparently  healthy  children  under  six  or  seven 
years  of  age  seldom  react.  In  many  adults  free  from  demonstrable  signs  of 
tuberculosis,  tubercuUn  gives  a  distinct  reaction  because  many  adults  have 
encapsuled,  quiescent,  or  retrogressive  lesions  of  tuberculosis.  I  have  already 
expressed  the  belief  that  if  given  in  moderate  doses  it  is  safe;  that  is,  it  is  safe 
if  the  disease  is  not  too  far  advanced.  "Very  large  doses,  or  the  giving  of  the 
remedy  at  all  in  greatly  advanced  tuberculosis,  would  not  be  safe.  Some  con- 
ditions contra-indicate  its  use,  among  them  are  the  following:  Addison's  disease,, 
recent  pulmonary  hemorrhage,  and  suspected  bilateral  renal  tuberculosis 
(Howes  and  Floyd,  in  "  Publications  of  Mass.  Gen.  Hospital,"  1908).  A  contra- 
indication is  the  finding  of  cocci  in  the  sputum.  It  should  only  be  given  when 
other  diagnostic  methods  fail  to  give  certain  information,  and  is  only  to  be 
used  by  a  man  trained  in  its  use.  Too  large  a  dose  may  cause  a  severe  chill, 
high  fever,  and  great  exhaustion,  may  arouse  a  latent  focus  to  activity,  and 
may  actually  cause  dissemination  of  the  disease. 

The  elements  of  the  reaction  following  a  tuberculin  injection  are: 

1.  Constitutional  (fever,  etc.). 

2.  Local  (redness  or  nodule  at  the  point  of  puncture). 

3.  Focal  (inflammation  at  the  seat  of  lesion). 

If  fever  exists  we  never  seek  to  obtain  the  constitutional  reaction  by  an 
injection  of  tuberculin.  The  result  would  be  misleading.  We  never  inject 
tuberculin  when  there  is  mixed  infection. 

A  temperature  of  99.5°  F.  or  over,  when  the  patient  is  quiet  in  bed,  contra- 
indicates  the  employment  of  the  test.  The  test  should  be  used  as  directed  by 
John  B.  Howes  and  Cleveland  Floyd  (Ibid.).  These  rules  are  as  follows: 
Koch's  old  tuberculin  is  used  and  the  preparation  must  not  be  over  two  months 
old.  One  c.c.  (100  mg.)  of  the  material  is  drawn  up  in  a  pipet  and  is  dropped 
into  10  c.c.  of  a  3^^  per  cent,  solution  of  carbolic  acid.     Each  cubic  centimeter 


Calmette's  Ophthalmo-tuberculin  Reaction  253 

of  this  solution  contains  10  mg.  of  tuberculin;  i  c.c.  of  solution  No.  i  is  mixed 
with  9  c.c.  of  a  }'2  per  cent,  solution  of  carbolic  acid.  Each  cubic  centimeter 
of  solution  No.  2  contains  i  mg.  of  tuberculin. 

One  c.c.  of  solution  No.  2  is  mixed  with  9  c.c.  of  the  very  dilute  carbolic  solu- 
tion.    Each  cubic  centimeter  of  solution  No.  3  contains  o.i  mg.  of  tuberculin. 

The  patient  is  kept  in  bed  for  three  days  before  beginning  the  test,  and  also 
during  the  test,  and  during  all  of  this  time  the  temperature  is  taken  every  two 
hours.  The  injection  is  to  be  made  at  an  indifferent  point.  The  first  dose  is 
0.1  mg.  of  tuberculin  (i  c.c.  of  solution  No.  3).  If  there  is  no  reaction,  wait  for 
three  days  and  then  give  i  mg.  (i  c.c.  of  solution  No.  2).  If  No.  2  gives  no 
reaction,  wait  three  days  and  give  10  mg.  (i  c.c.  of  No.  i  solution);  if  No.  2 
gives  a  slight  reaction,  inject  5  mg.  (I/2  c.c.  of  No.  i  solution). 

We  have  previously  described  the  tuberculin  reaction;  that  is,  the  temporary 
local  congestion  or  inflammation  in  the  tuberculous  area,  and  the  chilly  sensa- 
tion or  chill,  followed  by  marked  elevation  of  temperature  (see  page  245). 
The  constitutional  signs  of  reaction  are  chilly  sensations  or  chills,  sweats,  skin 
■eruptions,  headache,  pain  in  the  back  and  joints,  diarrhea,  nausea,  malaise, 
cardiac  palpitation,  and  dyspnea.  Howes  and  Floyd  regard  even  3^°  F.  of 
fever  as  significant  of  reaction  if  there  are  also  constitutional  symptoms  and 
local  signs.  The  focal  reaction  is  the  most  important.  In  certain  tuberculous 
lesions  we  can  see  the  focal  reaction;  for  instance,  in  lupus.  In  lupus  the  dis- 
eased skin  begins  to  swell  and  redden  a  few  hours  after  the  injection.  The 
reddened  tissue  may  actually  necrose.  The  ulcerated  area  becomes  crusted. 
The  swelling  and  redness  disappear  in  a  few  days.  In  joint  tuberculosis  the 
skin  over  the  joint  becomes  red.  In  a  tuberculous  ulcer  of  the  mouth  we  can 
see  the  changes ;  and  in  a  lesion  of  the  larynx  the  laryngologist  can  observe  them 
with  the  laryngoscope.  By  means  of  a  cystoscope  the  local  reaction  can  be 
seen  in  a  tuberculous  ulcer  of  the  bladder. 

Epstein  in  1891  pointed  out  that  redness  and  swelling  at  the  seat  of  injec- 
tion constitute  a  specific  reaction. 

The  tuberculin  test  should  not  be  used  in  advanced  pulmonary  tuberculosis 
because  it  is  unsafe.  In  advanced  cases  it  fails  to  cause  any  reaction  because 
the  tissues  are  unable  to  produce  antibodies  when  acted  on  by  toxin  (Howes 
and  Floyd,  in  ''Publications  of  the  Mass.  General  Hosp.,"  1908).  As  a  matter 
of  fact,  there  is  never  any  need  of  using  the  test  in  an  advanced  case,  because  the 
diagnosis  is  perfectly  clear  without  it.  We  should  never  give  extremely  large 
doses  in  making  the  tuberculin  test.  If,  after  the  careful  use  of  tuberculin, 
there  is  no  reaction,  it  is  usually  a  safe  conclusion  that  there  is  no  tuberculosis. 
The  tendency  is  more  and  more  to  use  as  a  diagnostic  test  the  local  rather  than 
the  constitutional  reaction. 

Various  methods  have  been  devised  for  obtaining  a  local  reaction  (oph- 
thalmo-tuberculin reaction,  von  Pirquet's  reaction,  Moro's  reaction).  The  local 
reaction  is  obtained  without  danger  of  dissemination  of  infection  and  can  be 
used  even  if  fever  exists. 

Calmette's  Ophthalmo-tuberculin  Reaction. — It  was  pointed  out  that  when 
tuberculin  is  injected  into  a  tuberculous  individual  a  reaction  arises  at  the  seat 
of  injection.  It  has  been  shown  that  if  tubercuhn  is  placed  in  the  conjunctival 
sac  of  a  tuberculous  individual  a  reaction  occurs,  and  this  method  is  valuable 
because  even  a  trivial  reaction  is  easily  observed.  The  introduction  of  tuber- 
culin into  the  conjunctival  sac  is  usually  spoken  of  as  Calmette's  method. 
This  test  can  be  used  even  if  fever  exists  and  even  if  a  skin  eruption  exists. 
It  is  not  as  satisfactory  in  surgical  as  in  medical  cases.  The  old  tuberculin  of 
Koch  is  used.  It  is  carefully  freed  from  irritant  materials,  a  i  per  cent,  solu- 
tion is  made  in  normal  salt  solution,  and  i  drop  of  this  is  placed  in  the  eye. 
Baldwin  regards  i  per  cent,  as  dangerously  strong  and  uses  J-'^  per  cent.  No 
•constitutional  symptoms  develop,  but  in  four  or  five  hours,  if  the  subject  be 


254  Surgical  Tuberculosis 

tuberculous,  the  conjunctiva  of  the  lids  may  become  injected,  the  corneal  vessels 
distend,  lacrimation  arises,  and  the  lids  may  swell  (Howes  and  Floyd,  Ibid.). 
The  reaction  attains  its  height  in  from  twelve  to  twenty-four  hours  and  dis- 
appears in  from  forty-eight  to  seventy-two  hours  after  its  first  appearance. 
In  a  non-tuberculous  person  no  redness,  or  only  a  trivial  and  temporary  red- 
ness, is  noted.  There  is  never  a  constitutional  reaction  even  in  a  case  of 
advanced  tuberculosis.  Of  course,  this  test  is  contra-indicated  if  there  is  a 
tuberculous  lesion  of  the  lids  or  eye,  if  there  is  ulceration  of  the  cornea,  or  if 
conjunctivitis  exists.  I  have  never  become  convinced  that  the  method  is 
entirely  free  from  danger  to  the  eye,  and  I  own  that  I  rather  fear  to  use  it. 
Cases  of  permanent  ocular  injury  are  on  record.  Baldwin  ("Jour.  Am.  Med. 
Assoc,"  February  20,  1909)  made  over  1000  tests.  He  says  that  the  test  has 
some  value  in  diagnosis,  no  value  in  prognosis,  and  as  yet  cannot  distinguish 
"active  latent"  from  healed  tuberculosis.  He  says  danger  to  the  eye  is  slight. 
I  believe  that  a  positive  reaction  indicates  the  probable  existence  of  tuberculosis 
and  a  negative  reaction  indicates  the  probable  absence  of  that  disease. 

Von  Pirquet's  Cutaneous  Tuberculin  Reaction. — After  the  skin  has  been 
cleansed  with  alcohol  2  drops  of  old  tuberculin  are  applied  a  short  distance 
apart.  The  skin  is  then  abraded  or  scarified  between  the  drops  and  through 
each  drop.  The  abrasion  between  the  drop  is  a  control  experiment.  The  tuber- 
culin is  permitted  to  remain  for  ten  minutes  and  is  then  wiped  off.  In  a  tuber- 
culous individual  local  redness  will  appear  in  ten  or  twelve  hours,  and  in  twelve 
hours  more  the  area  will  be  swollen  and  perhaps  edematous.  This  condition 
disappears  in  a  few  days,  leaving,  perhaps,  as  a  legacy  a  trivial  induration. 
There  is  very  seldom  a  febrile  reaction.  This  reaction  is  so  sensitive  that  it 
does  not  indicate,  except  in  children,  w^hether  a  tuberculous  area  is  active 
or  latent.  In  an  adult  a  negative  reaction  is  a  strong  indication,  though  not  a 
proof,  that  the  patient  is  not  tuberculous. 

Moro's  Cutaneous  Tuberculin  Reaction. — The  material  used  is  5  c.c. 
of  old  tuberculin  and  5  gm.  of  lanolin.  It  is  rubbed  into  the  abdominal  skin 
and  if  the  individual  is  tuberculous  red  papules  or  nodules  or  numerous  vesicles 
appear  in  the  area  where  the  inunction  was  made.  A  severe  reaction  or  a 
moderate  reaction  will  be  noted  within  twenty-four  hours.  A  slight  reaction 
appears  in  from  twenty-four  to  forty-eight  hours.  The  eruption  of  a  slight 
or  a  moderate  reaction  disappears  in  a  few  days.  After  a  severe  reaction  the 
skin  may  remain  red  for  several  weeks.  In  suspected  surgical  tuberculosis 
Moro's  reaction  is  generally  used.  There  is  no  febrile  reaction.  A  negative 
reaction  is  strongly  indicative  of  absence  of  tuberculosis. 

Blistering  a  Tuberculous  Person. — (See  page  245.) 

Injecting  a  Tuberculous  Animal  with  Blister  Fluid  from  a  Person  Suspected 
to  be  Tuberculous. — (See  page  245.) 

Massage  of  a  Tuberculous  Focus. — Wright  has  shown  that  gentle  mas- 
sage of  a  tuberculous  focus  may  be  followed  by  a  reaction  like  that  which  fol- 
lows the  diagnostic  use  of  tuberculin.  In  such  a  case  the  massage  drives 
tuberculous  products  into  the  blood  and,  perhaps,  if  the  massage  is  frequently 
repeated,  auto-immunizes  the  individual. 

Animal  Inoculations. — This  method  of  diagnosis  is  so  slow  that  it  is  seldom 
employed  and  only  in  unusually  obscure  cases.  It  is  the  certain  method  and 
it  is  eminently  desirable  that  the  method  be  so  improved  that  results  can  be 
obtained  quickly. 

The  Agglutination  Test. — This  test,  as  applied  to  the  blood-serum  of  a 
tuberculous  individual,  is  decidedly  uncertain. 

Wright's  Opsonin  Estimation. — This  procedure  is  too  difficult  and  too 
technical  to  be  used  in  clinical  work  although  it  has  diagnostic  value. 

Prognosis. — Many  cases  of  tuberculosis  are  cured.  This  is  indicated 
by  the  frequency  with  which  we  find  healed  tuberculous  lesions  in  necropsies 


Treatment  of  Tuberculosis  255 

on  individuals  dead  of  other  diseases.  We  reach  the  same  conclusion  from 
the  clincal  study  of  many  cases.  The  prognosis  of  a  single  tuberculous  focus, 
especially  if  it  can  be  extirpated  or  sterilized,  is  very  good;  provided  that  the 
general  health  is  good,  that  there  is  not  much  anemia,  that  the  digestive  proc- 
esses are  well  performed,  that  mixed  infection  is  absent,  that  there  are  no 
albuminoid  changes  in  the  viscera,  and  that  the  patient  is  able  and  willing  to 
live  the  life  that  is  necessary  for  his  welfare.  Unfavorable  prognostic  indications 
are  inability  to  eat,  disturbance  of  digestion,  deepening  anemia,  progressive 
loss  of  weight,  high  fever,  and  sweats.  Of  course,  the  prognosis  is  influenced 
by  the  patient's  temperament,  his  willingness  to  brook  control,  his  monetary 
status,  and  his  habits.  The  danger  is  greatly  increased  by  multiple  lesions. 
The  dangers  of  mixed  infection  and  of  albuminoid  disease  have  been  previously 
discussed. 

In  very  young  children  the  prognosis  is  most  unfavorable;  but  in  older 
children  it  is  very  much  better;  in  fact,  it  is  better  in  them  than  in  adults. 

Tuberculosis  of  the  skin  gives  a  very  fair  prognosis;  and  glandular,  bony, 
or  articular  tuberculosis  is  frequently  recovered  from;  but,  of  course,  any 
tuberculous  lesion,  however  limited  in  area,  is  a  profound  menace. 

Another  fact  to  be  borne  in  mind  is  that  many  cases  apparently  cured  are 
not  really  cured;  and  that  the  disease  may  tend  to  reappear  in  the  same  region 
or  in  a  nearby  region,  or  to  reappear  later  in  another  part  of  the  body.  We 
should,  further,  remember  that  in  many  cases  in  which  there  is  apparently 
one  lesion  only,  there  are,  in  reality,  distant  lesions  undiscoverable  by  clinical 
methods.  In  any  case  of  tuberculosis  the  higher  the  opsonic  index  the  better 
the  prognosis,  the  lower  the  opsonic  index  the  w^orse  the  prognosis. 

Another  important  fact  is  that  when  an  indi\ddual  has  a  latent  focus  of 
tuberculosis,  especially  if  this  latent  focus  is  in  the  lungs,  should  a  surgical 
operation  be  performed  for  some  other  purpose,  and  the  patient  be  kept  in 
bed  for  a  considerable  length  of  time,  the  latent  focus  may  become  active.  I 
have  always  believed  that  in  latent  pulmonary  tuberculosis  the  administration 
of  ether  or  chloroform  might  awaken  the  disease  into  activity.  It  therefore 
becomes  e\ddent  that  in  such  persons  operations  of  necessity  are  the  only 
ones  that  should  be  undertaken.  Such  an  operation,  if  possible,  should  be 
done  under  nitrous  oxid  or  a  local  anesthetic;  and  the  patient  should  get  up 
and  get  about  again  at  the  earliest  possible  moment. 

Tuberculin  in  Prognosis, — Wolff-Eisner  maintains  that  advanced  and 
rapidly  advancing  cases  fail  to  show  an  ophthalmo-tuberculin  reaction,  hence, 
when  the  existence  of  tuberculosis  is  proved  clinically,  a  negative  ophthalmo- 
tuberculin  reaction  indicates  a  bad  prognosis.'  Most  observers  reject  this  con- 
tention. "  Of  two  indi\dduals  with  moderately  advanced  disease  and  in  equally 
good  general  condition,  tuberculin  cannot  predict  with  more  assurance  than 
other  clinical  methods  t"he  state  of  affairs  a  year  hence"  ("Tuberculin,"  by 
Hamman  and  Wolman). 

Treatment. — One  of  the  first  thoughts  of  the  surgeon  is  to  provide  against 
the  contamination  of  healthy  individuals  by  the  infected.  Any  infected  ex- 
cretion or  suspicious  discharge  from  the  patient  must  be  disinfected  at  once  and 
dressings  that  are  removed  from  the  patient  should  be  burned. 

We  are  not  in  this  section  discussing  the  treatment  of  tuberculosis  of  the 
lungs,  which  belongs  to  the  medical  man,  and  in  which  climate  is  of  great 
importance.  In  cases  of  surgical  tuberculosis,  however,  the  patient  may  do 
better  in  some  climates  than  in  others;  and  the  change,  by  stimulating  the 
appetite  and  causing  sleep  and  gi\dng  renewed  hope,  will  be  beneficial.  In 
surgical  tuberculosis  climate  is  not  the  factor  that  it  is  in  tuberculosis  of  the 
lungs;  but  if  there  is  pure  atmosphere,  an  equable  temperature,  and  plenty  of 
sunlight,  the  climate  will  lure  the  patient  out-of-doors,  and  will  thus  be  greatly 
to  his  advantage. 


256  Surgical  Tuberculosis 

A  life  in  the  open  air  is  the  most  essential  thing  in  the  treatment  of  surgical 
tuberculosis;  but,  as  Professor  Halsted  points  out,  it  is  not  of  much  use  to  tell  a 
great  many  persons  to  live  in  the  fresh  air.  They  will  not  do  it  unless  they  are 
made  to;  and  it  is  hard  to  make  them  unless  they  live  in  quarters  especially 
built  with  this  object  in  view.  Therefore,  others  things  being  equal,  if  patients 
with  surgical  tuberculosis  have  the  means,  it  is  a  good  plan  to  send  them  to 
a  sanatorium  in  the  mountains  or  at  the  seashore,  where  they  can  obtain  the 
persistent,  unbroken  life  in  the  open  air  that  is  the  cure  of  the  disease.  The 
patient  should  spend  his  days  in  the  fresh  air,  and  he  should  sleep  at  night 
directly  exposed  to  the  air;  and  if  the  atmosphere  is  free  from  dust  and  foul 
odors,  so  much  the  better.  The  poorer  patients  must  get  the  fresh  air  at  home, 
if  they  cannot  be  sent  to  some  camp  or  colony.  From  large  cities  adjacent  to  the 
ocean  even  poor  people  can  usually  be  sent  to  the  seaside  for  a  short  time  at 
least.  I  am  a  very  great  believer  in  the  beneficial  effects  of  Atlantic  City  and 
other  seashore  resorts. 

It  is  frequently  necessary  to  do  an  operation  in  a  great  city,  although  we 
operate  much  less  than  formerly  for  these  conditions.  If  an  operation  is  done 
in  a  great  city,  the  patient  is  kept  in  the  fresh  air  as  much  as  possible  during 
his  convalescence.  If  it  is  feasible,  he  is  sent  away  to  a  colony  or  sanatorium 
to  recuperate.  It  would  be  an  excellent  thing  if,  in  many  of  those  cases  in 
which  operation  is  necessary,  the  operation  could  be  performed  at  the  camp  or 
the  sanatorium.  One  advantage  of  the  camp  or  sanatorium  is  that  the  patient  is 
watched  and  regulated  daily,  and  is  led  to  do  things  that  otherwise  he  would  neg- 
lect. Many  patients  endeavor  to  avoid  going  out  when  they  should  go  out 
because  they  are  afraid  of  taking  cold;  many  are  simply  neglectful;  some  are 
lazy  and  do  not  want  to  take  the  trouble  to  do  it. 

It  cannot  be  too  strongly  insisted  upon  that  in  surgical  tuberculosis  fresh  air 
is  of  as  much  importance  as  in  tuberculosis  of  the  lungs.  It  increases  the  vital 
resistance,  it  stimulates  opsonic  power,  and  it  causes  the  patient  to  eat  more 
nourishing  food  and  to  sleep  better  at  night.  Frequently  we  see  children 
that  have  had  sinuses  for  months  get  rapidly  well  when  they  adopt  an  open-air 
life;  and,  although  albuminoid  changes,  when  they  once  exist,  will  never  pass 
away,  further  albuminoid  changes  may  not  take  place  if  the  patient  lives 
properly. 

A  patient  with  surgical  tuberculosis  can  have  no  more  injurious  environ- 
ment than  a  dark,  damp  room,  especially  if  it  is  in  a  crowded  tenement  and  up 
a  narrow  court.  The  value  of  sunshine  in  glandular,  articular,  osseous  and 
cutaneous  tuberculosis  is  beginning  to  be  appreciated  {heliotherapy).  We 
know  that  it  limits  the  growth  of  tubercle  bacilli.  It  is  not  the  heat  that 
benefits  the  person,  but  the  chemical  rays  of  sunlight.  These  rays  have 
some  germicidal  influence,  have  considerable  penetrating  power,  and  seem 
to  influence  decidedly  the  nutritive  processes.  Tuberculous  joints,  even 
when  sinuses  exist,  are  often  much  benefited  by  exposure  to  the  direct  rays  of 
the  sun.  It  is  often  advisable  to  expose  the  entire  body  except  the  head. 
Leysin  begins  with  a  three-minute  exposure  and  gradually  increases  it  up  to 
two  or  three  hours.  During  exposure  traction  is  usually  maintained  on  the 
joint.  This  treatment  is  very  valuable  even  in  Philadelphia  (a  large  city  in 
the  lowlands).  It  is  especially  valuable  when  used  on  the  sea  coast  and  in 
mountain  regions.  Excessive  sunlight  is,  however,  not  beneficial.  In  summer 
it  exhausts  the  patient  and  even  in  winter  it  produces  eye-strain  and  headache. 
Major  Woodruff,  U.  S.  A.  insists  that  excessive  sunhght  is  actually  harmful, 
particularly  to  blondes  ("The  Effects  of  Tropical  Light  on  White  Men"). 
Tuberculosis  is  dreadfully  fatal  in  certain  tropical  countries  and  is  more  fatal 
to  blondes  than  brunettes.  Open-air  treatment  is  more  valuable  in  winter  than 
in  summer,  perhaps  because  cold  stimulates  respiration  and  because  the  winter 
sunlight  is  not  debilitating.     Artificial  heliotherapy  by  the  arc  lamp  is  thought 


Treatment  of  Tuberculosis  257 

by  some  to  be  more  valuable  than  by  the  sun's  rays.     The  entire  body  is  exposed 
for  from  half  an  hour  to  two  hours  and  a  half  every  other  day. 

The  tuberculous  structures  require  rest.  We  have  long  known  how  disas- 
trous it  is  to  confine  a  person  to  bed  in  a  dark,  ill-lighted,  and  improperly 
ventilated  room.  We  can,  however,  confine  a  person  to  bed  with  perfect  safety 
if  there  is  a  free  flow  of  fresh  air.  We  must  confine  certain  cases  to  bed;  for 
instance,  cases  of  tuberculous  peritonitis,  and  some  cases  of  bone  tuberculosis 
and  of  joint  tuberculosis.  A  patient  with  tuberculosis  who  has  fever  ought  to 
be  in  bed.  We  can  put  such  patients  to  bed  without  any  fear  of  the  disease 
becoming  worse  or  spreading  if  the  supply  of  fresh  air  is  plentiful  and  if  the 
patient  is  kept  warmly  covered  and  wears  a  skull-cap.  Of  course,  a  draft  is  to 
be  avoided.  Patients  that  are  confined  to  bed  do  excellently  in  a  tent,  in  a 
cottage  sanatorium,  or  on  a  porch  that  has  been  altered  for  the  purpose. 

At  the  very  first  possible  moment  the  patient  should  be  sent  out-of-doors; 
and  in  many  cases  of  tubercul'ous  disease  (for  instance,  vertebral  disease) 
the  tuberculous  part  is  supported  by  means  of  a  brace  or  a  splint. 

We  thus  see  the  twofold  nature  of  the  modern  treatment  of  surgical  tuber- 
culosis: rest  for  the  tuberculous  part  and  a  life  in  the  open  air.  Exercise  is 
of  importance  also,  although  it  should  never  be  taken  in  excess.  If  the  patient 
is  confined  to  bed,  he  should  be  massaged  and  rubbed  with  alcohol,  the  tuber- 
culous part  being  usually  avoided.  Forcible  manipulation  must  never  be 
applied  to  a  focus  of  tuberculosis  because  it  may  lead  to  dissemination.  Gentle 
massage  of  a  tuberculous  part  may  do  good.  Wright  has  shown  that  it  is  fol- 
lowed by  a  reaction  like  that  produced  by  tuberculin — a  reaction  due  to  the 
absorption  of  tuberculin  from  the  seat  of  disease.  If  a  person  has  fever  he 
must  not  attempt  active  exercise,  but  must  be  Qonfined  to  bed. 

One  should  feed  fully  tuberculous  patients  if  the  stomach  tolerates  it,  but 
not '  on  any  single  article,  or  even  on  any  particular  one.  The  diet  should 
contain  a  sufficiency  of  fats,  proteins,  and  carbohydrates;  and  the  food  should 
be  agreeable  to  the  taste  and  readily  assimilable.  Otherwise,  disgust  will  be 
engendered;  and  with  disgust  come  indigestion  and  loss  of  appetite.  The 
very  life  of  the  patient  may  depend  on  his  remaining  able  to  take  a  sufficiency 
of  nourishing  food.     A  bad  cook  may  be  a  murderer. 

There  is  no  specific  diet  for  tuberculosis,  although  many  have  been  sug- 
gested. One  of  the  most  valuable  foods  is  milk,  taken  raw  or  mixed  with 
other  articles,  such  as  lime-water  or  sodium  bicarbonate,  and  frequently  with 
brandy.  The  use  of  an  exclusive  diet  of  boiled  milk  is  to  be  deprecated,  and  in 
children  it  sometimes  leads  to  the  development  of  scurvy.  Practically  anyone 
can  take  milk  if  proper  efforts  are  made. 

Soft-boiled  eggs  are  useful;  and  bread  or  toast  should  be  eaten  with 
plenty  of  butter,  which  is  an  agreeable  form  of  fat.  Vegetables  and  fruits  are 
desirable. 

If  the  patient  can  take  cod-liver  oil  without  impairing  his  appetite  or  di- 
gestion, it  should  be  given,  provided  the  weather  is  not  tpo  hot.  Cod-liver 
oil  produces  diarrhea  in  very  hot  weather.  Children  learn  to  take  it  very  well. 
To  many  adults,  however,  it  is,  and  remains,  absolutely  abhorrent.  The 
chief  value  of  cod-liver  oil  is  that  it  is  a  fat,  and  it  seems  improbable  that  it 
contains  any  elements  specifically  antagonistic  to  tubercle.  If  used,  large 
doses  should  not  be  given,  as  they  will  not  be  digested.  The  common  dose 
for  an  adult  is  a  teaspoonful  two  or  three  hours  after  meals.  Thirty  drops  three 
times  a  day  is  usually  given  a  child,  and  an  infant  should  receive  15  drops  three 
times  a  day. 

We  know  of  no  drug  or  medicine  that  can  with  safety  be  used  at  the  present 
time  with  any  real  hope  that  it  will  specially  destroy  tubercle.  Drugs  are, 
of  course,  given,  but  they  are  of  secondary  importance. 

Tonics  are  used,  and  in  children  the  syrup  of  the  iodid  of  iron  has  con- 
17 


258  Surgical  Tuberculosis 

siderable  reputation.  Remedies  may  be  needed  to  improve  digestion  or  con- 
trol night-sweats,  etc.  I  do  not  believe  that  beechwood  creosote  or  carl)onate 
of  guaiacol  internally,  or  iodoform  inunctions,  or  painting  the  surface  with 
guaiacol  confers  any  real  benefit  in  tuberculosis. 

Alcohol  is  often  required.  It  is  not  needed  in  all  cases,  but  is  in  many. 
We  should  avoid  it  in  children,  however,  unless  there  is  a  particular  indication 
for  its  use.  *W^hen  a  tuberculous  patient  is  weak,  milk-punch  or  egg-nog  is 
of  service;  and  in  any  case  of  mixed  infection  alcohol  is  required  in  full  doses. 
If  fever  exists,  and  the  administration  of  alcohol  makes  the  pulse  more  rapid 
and  the  delirium  worse,  and  causes  flushing  of  the  face,  the  dose  is  too  large 
and  should  be  diminished.  Any  patient  that  smells  strongly  of  alcohol  is  get- 
ting an  overdose. 

Tuberculin  in  Treatment. — Many  able  investigators  in  many  lands  are 
striving  to  work  out  a  safe  and  satisfactory  specific  treatment  for  tuberculosis. 
Landerer  proved  that  immunity  to  tuberculosis  can  be  produced  in  the  lower 
animals  by  injection  of  living  bacilli.  We  dare  not  practise  this  on  human 
beings.  Injections  of  tuberculin  finally  produce  immunity  to  that  product. 
The  original  plan  of  using  tuberculin  therapeutically  was  to  obtain  definite 
reactions  again  and  again.  This  plan  was  founded  on  the  belief  that  the  reac- 
tion did  the  good  and  that  cure  might  be  obtained  in  this  way  in  a  few  weeks. 
This  utterly  reckless  plan  was  most  disastrous,  produced  many  deaths,  and 
caused  widespread  distrust  and  final  abandonment  of  tuberculin.  Tuberculin 
treatment  was  not  an  error;  the  plan  adopted  was,  as  the  material  was  given  in 
large  doses  to  any  and  all  tuberculous  patients.  Just  at  present  we  are  witness- 
ing a  revival  of  faith  in  tuberculin.  The  object  now  is  to  stop  short  of  obvious 
reaction,  believing  that  reaction  is  unsafe,  as  it  may  at  any  time  get  beyond 
control  and  do  harm.  Treatment  is  begun  with  very  small  doses  which  pro- 
duce no  reaction.  Larger  and  larger  doses  are  very  gradually  attained  until 
immunity  to  tuberculin  is  established. 

When  an  animal  becomes  immune  to  tuberculin  the  body  cells  resist  and 
finally  destroy  the  tubercle  baciUi  (Braun,  in  "Boston  Med.  and  Surg.  Jour.," 
July  23,  1908).  From  six  months  to  a  year  is  required  for  the  treatment. 
The  essence  of  treatment  is  the  very  small  dose  and  the  very  gradual  increase, 
reaction  being  scrupulously  avoided. 

Many  different  tuberculins  have  been  recommended.  The  best  known 
ones  are  Koch's  old  tuberculin  (O.  T.),  Koch's  new  tuberculin  (T.  R.),  Koch's 
bacillary  emulsion  (B.  E.),  the  bouillon  filtrate  of  Denys  (B.  F.),  von  Ruck's 
watery  extract,  and  bovine  tuberculins.  There  seems  to  be  no  sound  clin- 
ical reason  for  insisting  on  the  use  of  any  particular  form  of  tubercuHn.  Bovine 
tuberculin  does  not  seem  more  useful  than  human  tuberculin  in  tuberculosis 
of  the  abdomen,  glands,  and  liver,  structures  so  often  the  seat  of  infection 
with  bovine  bacilli.  WTiate'ver  form  is  chosen  is  given  subcutaneously  in 
the  back  and  near  to  the  skin,  so  that  a  local  reaction  may  be  quickly  recognized. 
If  after  any  dose  there  is  even  a  slight  elevation  of  temperature  or  even  a 
trivial  local  reaction  the  dose  must  not  be  advanced  until  that  dose  can  be 
given  without  reaction.  Loss  of  weight  means  that  doses  are  too  large.  Judi- 
ciously small  doses  are  entirely  safe  even  when  tuberculosis  is  complicated. 
One  or  two  injections  are  given  each  week  until  the  maximum  dose  without 
reaction  is  attained.  The  maximum  dose  when  attained  may  be  given  at 
weekly  intervals  for  months.  Another  plan  is  to  reach  the  maximum  dose, 
stop  the  treatment  for  months,  and  then  start  it  again,  beginning  with  the 
smallest  dose. 

The  initial  dose  and  the  maximum  dose  of  certain  tuberculins  are  given  in 
the  following  table  taken  from  the  valuable  work  of  Hamman  and  Wolman 
on  "Tuberculin."  The  dose  is  expressed  in  cubic  centimeters  instead  of 
grams : 


The  Local  Treatment  of  Tuberculosis  259 


Tuberculin 

Initial  Dose 

Maximum  Dose 

0.  T. 
T.  R. 
B.  E. 

B.  F. 
Beraneck's 

O.CHDO,000,I    to  0.000,001   C.C. 
0.000,001   to  0.000,1   C.C. 

0.000,001  to  0.000,1  C.C. 
0.000,000,01  to  0.000,000,1  C.C. 
Of  A/32,  0.05  C.C. 

1  C.C. 

2  C.C. 
2  C.C. 
I  C.C. 

Of  H  I  C.C. 

Wright  gives  very  small  doses  of  emulsion  of  powdered  bacilli,  not  with  the 
idea  of  causing  directly  body  immunity  to  tuberculin,  but  to  produce  immunity 
by  strengthening  the  phagocytic  power  of  the  leukocytes. 

When  this  plan  is  followed  the  dose  is  determined  by  the  opsonic  index, 
and  the  dose  is  only  raised  to  a  sufficient  degree  to  establish  the  positive  phase 
\\ithout  producing  even  the  most  trivial  subjective  symptoms.  One  dose 
causes  an  increase  of  immunizing  power  in  the  body  for  about  a  fortnight  and 
then  another  dose  is  given.  Many  clinicians  deny  positively  the  need  of  giving 
the  dose  by  the  opsonic  index.  When  tuberculin  is  given  by  either  of  the  above 
plans  it  is  entirely  safe,  and  I  believe,  beyond  doubt,  is  of  value  in  suitable  cases. 
It  is  not  to  be  used  in  advanced  cases  or  in  febrile  conditions.  For  lupus, 
tuberculous  glands,  tuberculous  bones,  or  tuberculous  joints  one  dose  a  week  is 
given.  It  is  of  real  service  in  these  conditions,  but  general  treatment  must  not 
be  discontinued  because  tuberculin  treatment  is  employed.  It  may  be  used 
after  operation  to  prevent  recurrence.  When  given  in  this  way  it  is  safe,  never 
produces  trouble  at  the  site  of  injection,  seems  to  arrest  some  cases  of  tuber- 
culosis, improves  the  local  trouble  in  many,  and  benefits  the  general  conditions 
of  most.  According  to  Trudeau  tuberculin  strengthens  the  individual's 
immunity  to  tuberculosis.  According  to  Wright  it  causes  an  increase  in  opso- 
nins which  were  deficient.  Tuberculin  is  of  unquestionable  value  in  some 
cases  of  lupus,  in  articular  tuberculosis  and  in  glandular  tuberculosis.  It  can 
be  used  in  association  with  open  air,  Bier's  h3q3eremia,  heliotherapy,  etc. 
Many  clinicians  advocate  the  use  of  tuberculin. 

Serum  Treatment. — Various  serums  have  been  prepared  but  only  two 
have  been  used  at  all  extensively. 

1.  Alaragliano's  Serum. — Maragliano  treats  tuberculosis  with  the  serum 
of  immunized  horses.  The  immunization  is  carried  on  for  from  four  to  six 
months  by  a  mixed  toxin.  One  element  of  the  mixture  is  prepared  from  cultures 
a  few  days  old,  filtered  and  concentrated  at  a  temperature  of  30°  C.  while  in  a 
vacuum.  The  other  element  is  extracted  by  water  from  virulent  cultures, 
the  bacteria  having  been  killed.  The  aqueous  extract  is  concentrated  on  a 
water  bath  for  three  or  four  days  at  a  temperature  of  100°  C.  Maragliano 
believes  that  the  serum  contains  quantities  of  antibodies  and  toxins,  and  that 
this  highly  agglutinative  serum,  when  introduced  into  the  human  being,  leads 
to  the  production  of  antibodies  and  toxins.  The  dose  of  the  serum  is  i  c.c. 
injected  subcutaneously  every  other  day  for  six  weeks  (Kolmer,  in  "Infection, 
Immunity  and  Specific  Therapy").  Some  observers  believe  in  this  serum  but 
most  look  upon  its  virtues  as  doubtful. 

2.  Alarmorek's  Serum. — Marmorek  immunizes  horses  with  young  tubercle 
bacilli.  WTien  the  horses  have  become  immune  he  injects  "pure  cultures  of 
streptococci  obtained  from  the  sputum  of  tuberculous  patients"  (Kolmer, 
Ibid.).  The  serum  is  given  once  a  day  subcutaneously  (5-10  c.c.)  or  by  rectum 
(10-20  c.c).     The  value  of  the  treatment  is  uncertain. 

The  Local  Treatment  of  Tuberculosis. — When  certain  drugs  are  directly 
inserted  into  a  tuberculous  focus  they  possess  an  antagonistic  influence.  Iodo- 
form is  the  most  powerful  of  these  drugs;  guaiacol,  balsam  of  Peru  (Lan- 
derer),  bismuth,  and  chlorid  of  zinc  (Lannelongue)  have  a  similar  action.     Some 


26o    •  Surgical  'J'uberculosis 

surgeons  inject  tuberculous  nodules  with  camphorated  naphtol.  Iodoform  has 
little  or  no  influence  when  placed  on  a  free  surface  exposed  to  the  air,  but 
when  in  the  form  of  an  emulsion  it  is  injected  into  a  tuberculous  area,  the  air 
being  excluded  (see  page  i^),  this  drug  is  i)owerfully  antituberculous.  Chlorid 
of  zinc  seems  to  act  by  causing  the  development  of  quantities  of  fibrous  tissue, 
which  encapsulates  or,  perhaps,  replaces  the  tuberculous  focus.  Every  region 
of  tuberculosis  requires  local  rest,  perhaps  by  the  use  of  a  splint  or  a  brace. 

Special  Methods  of  Surgical  Treatment. — The  surgeon  may  endeavor 
to  extirpate  a  tuberculous  focus,  or  to  drain  it  thoroughly  and  to  sterilize  the 
area.  Extirpation  is  sometimes,  although  not  very  frequently,  possible.  Com- 
plete extirpation  is  a  valuable  method,  but  partial  extirpation  is  dangerous. 
If  a  part  only  of  a  tuberculous  focus  is  extirpated,  many  lymph-tracts  and  blood- 
vessels are  opened;  and  the  incomplete  operation  may  lead  to  the  dissemination 
of  the  disease.  The  methods  of  surgical  treatment  suited  to  different  forms 
of  tuberculous  disease  will  be  discussed  in  different  sections  of  this  book. 

Bier's  Method  by  Congestive  Hyperemia  (see  page  122). — Bier  believes  that 
passive  hyperemia  is  of  the  greatest  possible  benefit.  Active  hyperemia  is 
obtained  by  heat,  and  is  especially  valuable  to  induce  the  absorption  of  the  prod- 
ucts of  a  non-tuberculous  chronic  inflammation.  Passive  hyperemia  is  par- 
ticularly useful  in  tuberculosis  of  joints,  tuberculous  ulcers,  cold  abscesses, 
and  tuberculous  disease  of  the  tarsus,  carpus,  and  phalanges.  If  a  limb  is 
affected,  passive  h^'peremia  is  obtained  by  placing  a  rubber  band  around  the 
limb  above  the  part,  the  band  being  applied  with  sufficient  firmness  to  inter- 
fere with  venous  return,  but  not  so  tightly  as  to  block  arterial  entry.  This 
band  should  be  applied  daily,  and  should  be  kept  in  place  for  an  hour  or  so 
at  each  application,  but  pain  should  not  be  produced.  In  the  intervals  between 
the  treatments  the  limb  should  be  at  rest.  Bier  uses  special  apparatuses  for 
obtaining  congestive  hyperemia  in  various  parts  of  the  body. 

I  have  seen  cure  or  very  great  improvement  follow  this  treatment  in  a  num- 
ber of  cases.  It  is  founded  on  the  old  idea  of  Laennec  that  cyanosis  and 
tubercle  are  antagonistic.  Why  this  method  is  beneficial  is  much  debated. 
Some  think  that  the  imprisoned  blood  takes  on  increased  bactericidal  power; 
some,  that  the  number  of  leukocytes  is  greatly  increased;  some,  that  quantities 
of  leukocytes  migrate;  and  some,  that  the  amount  of  bactericidal  blood-serum 
is  increased.  Bier  believes  that  it  depends  upon  phagocytosis.  It  would  seem 
possible  that  the  cells  in  this  locality,  under  the  influence  of  the  congestive 
hyperemia,  may  form  powerful  antitoxins. 

Heliotherapy. — (See  page  256.) 

The  Finsen  Light. — Finsen  pointed  out  that  the  chemical  rays  in  sunlight 
are  powerfully  germicidal,  and  that  this  germicidal  power  can  be  notably  in- 
creased if  the  rays  are  concentrated  on  a  part  by  the  use  of  particular  apparatus. 
He  also  showed  that  enormous  numbers  of  chemical  rays  can  be  obtained  from 
electric  light.  The  Finsen  treatment  to-day  consists  in  applying  the  actinic 
rays  obtained  from  electric  light.  They  act  most  powerfully  on  lupus,  but  re- 
quire a  very  long  time  to  effect  a  cure. 

The  x-rays  are  of  value  in  treating  certain  tuberculous  conditions.  They 
are  of  most  use  in  lupus,  their  effects  in  this  disease  being  nearly  as  power- 
fully curative  as  those  of  the  Finsen  light,  and  much  more  rapid. 

The  tuberculous  abscess  is  called  also  the  cold,  the  lymphatic,  the  con- 
gestive, the  scrofulous,  the  strumous,  the  wandering,  or  the  migrating  abscess; 
and  it  is  very  commonly  called  the  chronic  abscess.  The  Germans  call  it 
Senkungsabscess.  Tuberculous  abscess  is  the  best  designation,  as  this  indicates 
the  cause  of  the  trouble. 

The  term  "cold  abscess "  is  often  used  because  the  cutaneous  surface  over  the 
disease  is  not  warmer  to  the  touch  than  is  the  skin  of  the  corresponding  part  of 
the  opposite  side  of  the  body.     The  term  "lymphatic  abscess"  was  employed 


Contents  of  Tuberculous  Abscess  261 

because  it  was  once  thought  that  such  abscesses  arose  only  from  lymphatic 
structures.  Scrofulous  abscess  was  the  name  given  it  when  scrofula  was  sup- 
posed to  be  a  definite  disease,  the  common  phase  of  which  was  this  form  of 
abscess.  The  term  "  chronic  abscess  "  is  employed  because  the  condition  usually 
develops  slowly,  and  does  not  present  the  evidences  of  acute  inflammation;  an 
acute  pyogenic  abscess  developing,  as  a  rule,  rapidly,  and  presenting  jjositive 
signs  of  inflammation.  I  agree  with  the  late  Professor  Ashhurst  that  the  term 
"chronic, "  in  this  connection,  is  improper,  as  it  tends  to  give  a  wrong  idea.  It 
refers  merely  to  time;  and  we  know  that  a  genuine  pyogenic  abscess  that  is 
deep  seated  may  be  rather  slow  in  developing,  and  that  a  tuberculous  abscess 
that  is  superficial  may  develop  with  considerable  rapidity.  When  used  prop- 
erly, the  term  "chronic  abscess"  means  that  real  pus  exists,  this  pus  having 
arisen  from  the  pyogenic  infection  of  the  granulation  tissue  of  a  lesion  of  syphi- 
lis, tuberculosis,  or  actinomycosis.  In  other  words,  a  genuine  chronic  abscess 
is  secondary  pyogenic  infection  of  an  infective  granuloma.  The  terms  "wan- 
dering," "migrating,"  "gravitating,"  and  "congestive"  have  been  used  because 
the  fluid  products  of  a  tuberculous  inflammation  are  liable  to  wander  a  consid- 
erable distance  away  from  the  primary  focus  of  disease.  For  instance,  a  tuber- 
culous abscess  that  is  discovered  in  the  groin  may  have  arisen  from  tuberculous 
caries  of  the  vertebrae.  This  tendency  to  wander  is  not  due  to  gravity,  as  one 
of  the  names  of  the  condition  would  suggest;  but  the  wandering  always  takes 
place  in  the  line  of  least  resistance. 

It  will  be  seen  from  the  foregoing  that  a  true  tuberculous  abscess  is  not  an 
abscess  at  all,  because  it  does  not  contain  genuine  pus.  It  is  a  collection  of  the 
degenerated  products  of  tuberculous  inflammation;  and  a  tuberculous  abscess 
may  be  defined  as  a  circumscribed  cavity  of  new  formation,  containing  the  de- 
generated products  of  a  tuberculous  inflammation.  These  products  may  have 
been  formed  in  that  region  or  may  have  passed  to  that  point  from  some  adja- 
cent or  distant  focus  of  tuberculous  disease.  If  a  supposed  tuberculous  abscess 
is  found  to  contain  genuine  pus,  there  must  have  been  mixed  infection  with 
pyogenic  bacteria;  and  such  mixed  infection  either  causes  violent  and  danger- 
ous inflammation  or  leads  to  the  formation  of  a  true  chronic  abscess,  in  which 
there  is  no  sign  of  acute  inflammation.  The  tubercle  bacillus  is  not  pyogenic. 
It  can  produce  inflammation,  but  not  pus,  and  pus  can  be  formed  in  a  tuber- 
culous focus  only  by  secondary  infection  with  pus  bacteria. 

Situations  of  Tuberculous  Abscesses. — These  abscesses  are  particularly 
apt  to  form  as  the  result  of  tuberculous  disease  of  bones,  joints,  lymph-glands, 
and  subcutaneous  connective  tissue,  but  the  brain,  any  viscus,  or  any  tissue  in 
the  body  may  present  the  condition. 

Age. — No  age  is  exempt,  but  children  are  most  prone  to  the  trouble;  and 
the  period  of  greatest  liabihty  is  before  the  age  of  twenty  years. 

Contents.— The  usual  terms  for  the  contents  are  scrofulous,  curdy,  or  case- 
ous pus.  As  previously  stated,  it  is  not  true  pus,  but  it  resembles  pus  when 
viewed  by  the  .naked  eye.  Examination  of  this  fluid  by  staining  methods,  by 
cultures,  and  by  inoculations  shows  that  it  contains  no  pyogenic  bacteria.  It 
consists  of  liquefied  and  caseated  tubercle,  masses  of  coagulated  fibrin,  and 
bits  of  necrotic  tissue.  The  tuberculous  material  is  whitish,  yellowish,  or 
yellowish  green,  thick,  and  without  odor.  Floating  in  this  pus  are  portions 
of  caseous  matter,  which,  as  the  elder  Gross  said,  resemble  bits  of  soft-bofled 
rice.  Occasionally  the  tuberculous  material,  especially  if  it  comes  from  disease 
of  a  lymph-gland  or  of  a  bone,  is  almost  watery  and  nearly  colorless,  and  con- 
tains curd-like  masses,  consisting  of  tuberculous  granulations,  coagulated  fibrm, 
and  necrotic  tissue.  It  was  previously  stated  that  tuberculous  pus  is  free  from 
odor.  This  is  not  true  of  tuberculous  pus  from  the  ischiorectal  fossa,  which 
is  highly  putrid;  but  in  an  ischiorectal  abscess,  as  a  matter  of  fact,  there  is 
usually  mixed  infection  with  pyogenic  organisms,  as  well  as  with  the  organisms 


262  Surgical  Tuberculosis 

of  putrefaction.  If  tuberculous  pus  is  permitted  to  stand,  the  curdy  mass 
settles  to  the  bottom,  and  a  thin  serous  fluid  remains  above. 

Formation  of  Tuberculous  Abscess. — The  growth  of  tubercle  bacilli  in 
the  tissues  causes  chronic  inflammation.  The  cells  of  the  tissues,  especially 
the  fixed  cells,  proliferate  and  form  granulation  tissue.  This  granulation 
tissue  consists  of  multitudes  of  cell  clusters,  and  each  cluster  is  called  a  primi- 
tive tubercle  (see  page  236).  Each  individual  tubercle  enlarges;  myriads 
of  new  ones  form,  and  many  of  the  old  ones  fuse.  These  new  cells,  how- 
ever, do  not  become  vascularized.  In  the  earliest  stage  of  their  formation 
there  are  blood-channels,  but  these  become  closed  through  endothelial  prolifera- 
tion and  through  the  pressure  of  cells  external  to  them.  The  tuberculous  area 
then  becomes  absolutely  avascular.  This  avascular  mass  of  cells  is  composed  of 
what  are  known  as  epithelioid  cells,  and  the  cells  obtain  nourishment  by  imbibi- 
tion. The  nourishment  is  very  incomplete.  As  the  nodule  enlarges  the  nour- 
ishment grows  more  and  more  insufficient.  Finally,  the  adjacent  blood-vessels 
that  furnished  the  fluid  for  imbibition  become  occluded,  and  nourishment  is 
no  longer  possible.  The  toxins  of  the  tubercle  bacilli,  acting  upon  this  area 
of  greatly  lowered  nutritional  activity,  produce  coagulation  necrosis,  and 
caseation  follows  this.  The  caseation  begins  at  many  points  near  the  middle 
of  the  tuberculous  nodule.  Each  area  of  caseation  enlarges.  Several  of  them 
fuse,  and  eventually  many  caseated  areas  coalesce.  The  tuberculous  lesion  may 
be  spreading  at  the  periphery  at  the  same  time  that  it  is  undergoing  caseation 
at  the  center.  The  bacilli  in  the  caseated  material  soon  die  for  want  of  nourish- 
ment. When  an  area  of  caseated  tubercle  is  liquefied  by  the  addition  of  serum, 
what  we  call  caseous  or  curdy  pus  is  produced,  and  the  lesion  is  then  known  as 
a  tuberculous  abscess. 

The  wall  of  the  abscess  is  formed  by  compressed  or  solidified  tissues.  In 
a  very  recent  case  the  wall  is  soft  and  will  readily  collapse.  In  an  old  case  it  is 
dense  or  actually  fibrous  and  will  not  collapse.  This  wall  of  compressed  tissue 
is  not,  as  used  to  be  thought,  a  pyogenic  membrane  which  secretes  the  tuber- 
culous material,  but  it  actually  surrounds  the  tuberculous  material  and  hinders 
its  diffusion.  As  Roswell  Park  says,  it  is  not  a  pyogenic  membrane,  but  it  is  a 
prophylactic  membrane.  The  inner  surface  of  the  wall  of  the  compressed  tis- 
sue is  lined  with  tuberculous  granulations,  which  at  different  points  show 
different  stages  of  the  tuberculous  lesion.  This  layer  of  tuberculous  granula- 
tions is  known  as  Volkmanti's  membrane.  The  fluid  in  the  abscess  may  con- 
tain a  few  living  bacteria,  but  often  none  can  be  found;  and  certainly  the  bac- 
teria are  not  multiplying  in  this  fluid,  but  they  exist  in  numbers  and  multiply 
in  Volkmann's  membrane.  When  tuberculous  matter  has  been  long  retained 
and  is  thoroughly  encapsuled  the  bacflli  soon  die  for  want  of  nourishment,  and 
because  a  culture  from  a  supposed  tuberculous  area  fails  to  show  the  baciUi  of 
tuberculosis  we  have  not  obtained  conclusive  evidence  that  the  area  is  not 
tuberculous.  We  know  this  same  fact  to  be  true  of  the  fluid  of  tuberculous 
empyema. 

From  the  abscess  wall  there  may  be  one,  two,  several,  or  many  sinuses 
tracking  out.  These  sinuses  are  lined  with  granulation  tissue  exactly  like 
the  Volkmann's  membrane  in  the  main  abscess;  and  they  may  spread  by  a 
sort  of  crawHng  progression  for  long  distances,  perhaps  passing  through  dense 
fascia,  and  at  their  terminations  may  form  secondary  tuberculous  abscesses. 
The  wall  of  an  abscess  may  contain  expansions  or  loculi.  If  an  abscess  spreads 
to  some  distant  place,  the  tuberculous  infection,  of  course,  goes  with  it,  and  it 
is  the  tuberculous  infection  that  causes  the  spread.  Injury,  breaking,  or 
contusion  of  this  granulation  tissue,  if  unaccompanied  with  the  removal  of 
all  the  tissue  or  the  killing  of  aU  the  germs  it  contains,  may  diffuse  the  in- 
fective matter  and  actually  cause  disseminated  tuberculosis.     We  sometimes 


Signs  and  Symptoms  of  Tuberculous  Abscess  263 

see  such  dissemination  after  spontaneous  opening,  nonaseptic  operation,  or 
forcible  squeezing;  and  particularly  after  an  imperfect  operation  that  removes 
only  a  part  of  the  tuberculous  area. 

Terminations  of  Tuberculous  Abscess. — The  abscess  may  slowly  and 
gradually  enlarge,  and  finally  open  of  itself,  either  on  the  skin  or  on  the  mucous 
surface,  or  into  some  viscus  or  joint.  It  may  become  encapsuled  by  fibrous 
tissue,  there  being  absorption  of  the  fluid  and  shrinking  of  the  entire  focus, 
•the  caseous  part  perhaps  remaining  or  becoming  calcified.  The  tuberculous 
abscess  may  actually  be  replaced  by  fibrous  tissue,  and  this  constitutes  a  per- 
manent cure.  When  the  tuberculous  area  is  merely  encapsuled  by  fibrous 
tissue,  some  living  bacilH  may  remain  latent  in  the  wall;  and  long  afterward, 
as  the  result  of  injury  or  of  some  other  damage,  an  abscess  may  re-form  at  the 
old  site  of  disease.  Sir  James  Paget  called  this  condition  residtml  abscess. 
As  a  rule,  the  abscess,  as  it  shrinks,  tends  toward  cure.  The  bacilli  usually 
die  for  v/ant  of  material  to  nourish  them,  but  occasionally  they  remain  latent 
for  a  long  period  of  time.  When  they  do  die,  the  tuberculous  granulation 
tissue  may  become  healthy  tissue,  be  vascularized  through  the  entrance  of 
blood-vessels,  and  be  converted  into  scar-tissue.  Tuberculous  abscess  may 
also  be  cured  by  a  surgical  operation. 

Secondary  Infection  of  a  Tuberculous  Area  by  the  Bacteria  of  Suppuration. 
— This  is  liable  to  occur  when  the  abscess  undergoes  spontaneous  evacuation, 
and  may  occur  when  it  has  been  opened  by  the  surgeon.  It  occasionally  occurs 
when  the  abscess  has  neither  undergone  spontaneous  evacuation  nor  has 
been  opened  by  the  surgeon,  having  been  infected  apparently  as  a  point  of 
least  resistance.  When  such  infection  does  occur,  there  is,  in  all  probabihty, 
some  area  of  ordinary  suppuration  elsewhere  in  the  person's  body,  and  the 
bacteria  of  suppuration  have  entered  the  body  fluids.  Pyogenic  infection  is 
apt  to  produce  violent  inflammation  and  profuse  suppuration — a  condition  that 
is  extremely  dangerous,  because  septicemia  is  very  liable  to  develop.  In  some 
very  rare  cases  suppuration  destroys  the  tuberculous  area  and  cures  the 
tuberculous  disease.  More  commonly,  however,  it  produces  illness,  and  in 
large  abscesses  it  may  cause  death.  Because  of  this  liability  to  secondary 
infection  surgeons  were  long  opposed  to  operating  on  tuberculous  abscess 
unless  it  was  evidently  going  to  evacuate  itself.  In  some  cases  secondary  in- 
fection produces  a  true  chronic  abscess  (see  page  260).  Infection  by  strep- 
tococci is  much  more  dangerous  than  is  infection  by  staphylococci.  Acute 
inflammation  with  dangerous  constitutional  symptoms  is  particularly  apt 
to  arise  if  the  walls  of  the  abscess  contain  very  little  tuberculous  tissue,  if 
they  have  been  bruised  or  damaged  by  powerful  chemicals,  if  there  is  poor 
drainage  (and  there  is  certain  to  be  poor  drainage  if  loculi  exist,  or  if  the  incision 
is  small  and  blocked  with  plugs  of  fibrin  or  necrotic  tissue),  if  a  partial  or 
imperfect  operation  has  been  performed,  if  a  number  of  virulent  bacteria  have 
been  introduced,  or  if  the  vital  resistance  is  at  a  low  ebb. 

Secondary  Infection  by  the  Bacteria  of  Putrefaction. — This  complica- 
tion is  extremely  grave  and  may  produce  death.  It  is  commonly  associated 
with  pyogenic  infection.  The  wound  fluid  becomes  intensely  putrid,  violent 
acute  inflammation  arises,  and  the  absorption  of  materials  from  the  wound 
induces  the  systemic  condition  known  as  sapremia  or  putrid  intoxication. 

Signs  and  Symptoms  of  Tuberculous  Abscess. — A  purely  tuberculous 
abscess  presents  no  evidence  of  inflammation  except  swelling;  and,  owing 
to  the  absence  of  heat,  it  has  received  its  name  of  cold  abscess.  The  cutane- 
ous surface  looks  and  feels  normal  or  is  paler  than  normal  until  the  struc- 
tures just  beneath  the  skin  or  the  skin  itself  becomes  involved.  When  this 
happens,  livid  discoloration  appears,  but  the  lividity  presents  a  very  different 
appearance  from  the  dusky  discoloration  of  an  acute  abscess.  Neither  is  the 
skin  edematous  or  glossy  as  it  is  in  acute  abscess. 


264  Surgical  Tuberculosis 

There  is  rarely  tenderness  in  the  region  of  the  abscess,  and  still  more  rarely- 
spontaneous  pain.  Pain  and  tenderness,  although  frequently  absent  in  the 
area  of  a  tuberculous  abscess,  may  be  complained  of  at  the  primary  focus  of 
disease.  Tenderness  is  especially  likely  to  be  noted  at  the  primary  focus; 
and  in  cases  of  joint  tuberculosis  and  of  bone  tuberculosis  it  is  nearly  always 
present.  There  may  or  may  not  be  pain  at  the  primary  focus,  but  referred 
pain  is  frequently  complained  of.  For  instance,  in  tuberculous  disease  of  the 
hip-joint  the  pain  may  be  referred  to  the  inner  side  of  the  knee;  and  severe 
bellyache  is  frequently  observed  in  Pott's  disease  of  the  spine.  At  the  point  to 
which  pain  is  referred,  however,  there  is  seldom  tenderness.  For  instance,  in  the 
bellyache,  particularly  of  Pott's  disease  of  the  spine,  the  belly  is  not  tender,  al- 
though the  spine  may  be.  In  sacro-iliac  tuberculosis  the  pain  is  often  referred  to 
the  distribution  of  the  sciatic  nerve,  but  the  nerve  is  seldom  tender  on  pressure. 
In  a  psoas  abscess  we  find  that  pain  in  the  spine  can  be  induced  by  pressing 
on  the  spinous  process  of  the  diseased  vertebra,  by  concussion  to  the  heels  or 
the  head  when  the  spine  is  held  stiff,  and  especially  by  flexion  of  the  spine;  but 
the  spinal  pain  is  lessened  or  completely  aboHshed  by  extension,  fixation,  and 
rest.  The  primary  focus  of  disease,  if  spinal  or  articular,  produces  rigidity 
in  the  adjacent  muscles,  and  rigidity  secures  rest  by  inhibiting  movement, 
but  it  also  impairs  the  function  of  the  part.  In  an  intra-abdominal  tubercu- 
lous abscess  there  is  rigidity  of  the  abdominal  muscles. 

In  a  tuberculous  abscess  fluctuation  is  usually  obtained  readily,  because 
the  fluid  is  not  surrounded  by  a  thick  mass  of  granulation  tissue  and  also  be- 
cause a  considerable  amount  of  fluid  is  usually  present.  A  notable  character- 
istic of  a  tuberculous  abscess  is  the  tendency  to  wander,  and  it  may  appear 
with  suddenness  at  some  distant  point.  Abscesses  of  the  spine  wander  long 
distances,  but  the  wandering  is  not  the  effect  of  gravity,  and  is  due  to  the 
disposition  of  the  tuberculous  matter  to  travel  in  the  line  of  least  resistance. 
The  temperature  of  the  body  may  be  entirely  normal  if  the  infection  is  purely 
tuberculous.  As  a  rule,  however,  there  is  a  slight  evening  elevation;  and  the 
patient  is  weak  and  pale,  grows  tired  readily,  sleeps  poorly,  and  has  a  wretched 
appetite  and  impaired  digestion.  The  blood  examination  sometimes  shows  a 
notable  diminution  in  the  number  of  red  blood-cells,  and  the  hemoglobin  is 
usually  lowered  to  60  or  70  per  cent.  There  is  no  leukocytosis.  In  mul- 
tiple tuberculous  foci,  and  particularly  in  tuberculosis  in  children,  there  is  a 
marked  decrease  in  the  red  blood-cells.  If  secondary  infection  occurs,  there 
is  a  rapid  and  progressive  diminution  in  the  number  of  red  cells  and  usually 
a  trivial  increase  in  polynuclear  leukocytes. 

A  tuberculous  abscess  underneath  the  deeper  fascia  may  break  through 
the  fascia  by  making  a  small  opening,  and  a  large  secondary  abscess  may  arise 
in  the  subcutaneous  tissue.  The  entire  abscess  is  thus  shaped  like  an  hour- 
glass, the  opening  through  the  fascia  being  the  narrowest  point.  Such  art 
abscess  is  called  a  shirt-stiid  abscess.  A  tuberculous  abscess  is  liable  to  form 
one,  several,  or  many  sinuses,  and  the  end  of  each  sinus  may  expand  into  a 
secondary  abscess.  The  surgeon  must  always  make  a  careful  examination 
to  try  to  determine  w^hether  the  abscess  is  the  primary  disease  focus  or  whether 
the  tuberculous  matter  has  wandered  from  a  distant  point.  He  must  also  make 
a  thorough  examination  to  see  whether  anywhere  in  the  body  there  are  other 
regions  of  disease.  He  will  often  find  such  a  region  of  disease;  for  instance, 
in  the  lungs.  In  many  cases,  however,  there  is  no  clinical  evidence  that  other 
areas  of  tuberculous  disease  exist. 

A  tuberculous  abscess  arising  deep  in  the  tissues  usually  requires  weeks  or 
months  to  reach  the  overlying  skin  or  mucous  membrane  and  undergo  spon- 
taneous evacuation.  That  spontaneous  evacuation  is  imminent  is  shown  by 
livid  discoloration  and  thinning  of  the  skin.  Finally,  at  the  area  in  which  the 
skin  is  thinnest  a  little  tit  is  elevated.     This  condition  is  known  as  pointing 


Diagnosis  of  Tuberculous  Abscess  265 

and  a  rupture  occurs  at  this  point,  tuberculous  pus  running  out.  Spontaneous 
evacuation  is  a  peril,  because  it  is  liable  to  be  followed  by  secondary  pyogenic 
or  putrefactive  infection.  After  spontaneous  evacuation  has  occurred,  a 
true  chronic  abscess  may  form;  but,  instead,  there  may  be  violent  acute 'in- 
flammation, manifested  locally,  by  pain,  heat,  and  dusky  discoloration.  If 
acute  inflammation  does  arise  there  develops  a  fever,  which  presents  evening 
exacerbations  and  morning  remissions,  and  is  accompanied  by  an  exhausting 
sweat  during  the  night  or  early  morning.  Fatal  septicemia  or  sapremia  may 
follow  spontaneous  evacuation. 

Results  of  a  Tuberculous  Abscess. — It  may  undergo  spontaneous  cure, 
and  the  cure  may  be  lasting,  but  long  after  an  apparent  cure  a  new  abscess 
may  form  (the  residual  abscess  of  Sir  James  Paget).  A  tuberculous  abscess 
may  remain  stationary  for  a  very  long  time,  and  then  perhaps  diminish  in 
size  and  be  cured,  or  extend  in  size  and  rupture.  After  spontaneous  rupture, 
suppuration  may  cure  the  tuberculous  area  by  annihilating  the  tuberculous 
tissue;  but,  as  a  rule,  after  spontaneous  rupture  there  is  either  an  acute  septic 
process  or  a  chronic  suppuration,  constituting  a  genuine  chronic  abscess. 

Amyloid  Disease. — The  pyogenic  infection  of  an  area  of  chronic  tuberculosis, 
especially  of  a  bony  area,  if  it  induces  long-lasting  suppuration,  may  lead  to  the 
development  of  albuminoid,  amyloid,  waxy  or  lardaceous  disease.  Pyogenic 
infection  of  a  tuberculous  area,  though  by  far  the  commonest,  is  not  the  only 
cause  of  amyloid  disease.  It  may  arise  when  there  has  been  no  pyogenic  infec- 
tion of  the  tuberculous  area.  It  may  arise  after  prolonged  ordinary  suppuration. 
It  may  follow  bone  syphilis,  and  may  be  due  to  cancer,  B right's  disease,  malaria, 
chronic  dysentery,  or  prolonged  lactation.  In  this  condition  a  peculiar  mate- 
rial is  deposited  in  the  middle  coats  of  the  smaller  arteries  and  later  the  inner 
coats  are  involved.  The  albuminoid  substance  resembles  fibrin  and  there  has 
been  much  dispute  as  to  its  nature.  One  theory  is  that  this  deposit  takes 
place  from  blood-serum  which  has  been  dealkalinized  because  the  flow  of  pus 
has  removed  potash  salts  from  the  blood.  Krakow  seems  to  have  demon- 
strated that  the  albuminoid  material  is  a  combination  of  chondroitin-sulphuric 
acid  and  histon.  This  acid,  carried  by  the  blood  or  lymph,  "combines  with  a 
protein  of  the  fixed  tissues"  (W.  Taylor  Cummins,  "Proceedings  of  Patholog. 
Soc.  of  Philadelphia,"  Dec,  1910).   • 

In  rare  cases  this  deposit  is  only  a  local  mass.  The  corpora  amylacea  of  the 
prostate  and  nervous  structure  are  due  to  albuminoid  deposit.  Such  a  deposit 
may  take  place  directly  in  a  tuberculous  focus  or  a  S}q3hilitic  lesion. 

In  the  vast  majority  of  instances  the  disease  is  general,  involving  blood- 
vessels, the  membrana  propria  of  mucous  membranes,  the  liver,  the  kidneys, 
and  especially  the  spleen.  The  lymph-glands,  tonsils,  stomach,  intestines,  heart, 
and  connective  tissues  are  less  often  involved.  The  amyloid  material  is  de- 
posited between  the  cells  and  not  in  them.  The  tissues  of  a  subject  of  amyloid 
disease  are  very  prone  to  suppurate  from  even  slight  infection. 

In  all  or  nearly  all  cases  the  spleen  is  involved.  The  victim  of  general  al- 
buminoid disease  is  pale,  greatly  exhausted,  emaciated,  and  very  anemic; 
suffers  from  diarrhea  and  usually  develops  capillary  hemorrhages  beneath  the 
skin  and  mucous  membranes.  The  albuminoid  material  can  be  detected 
chemically  in  the  urine  if  the  kidneys  are  involved.  Albuminoid  degeneration 
is  incurable  and  is  usually  fatal;  but  if  the  patient  is  subjected  to  proper  treat- 
ment soon  after  it  begins  it  may  be  arrested  and  never  progress. 

Diagnosis  of  Tuberculous  Abscess. — The  fluctuation,  the  absence  of  evi- 
dences of  acute  inflammation,  the  tendency  to  wander,  and,  in  some  cases,  the 
sudden  appearance,  mark  the  diagnosis.  The  surgeon  always  examines  with  care 
to  see  whether  there  is  some  distant  tuberculous  focus  from  which  the  abscess 
may  have  wandered,  or  whether  the  abscess  itself  is  at  the  primary  seat  of 
disease.     The  advancing  impairment  of  the  general  health,  the  lessened  amount 


266  Surgical  Tuberculosis 

of  hemoglobin,  the  normal  or  almost  normal  temperature,  and  the  absence  of 
leukocytosis  are  points  in  the  diagnosis  of  the  condition.  In  a  doubtful  case 
the  aseptic  use  of  the  tubular  exploring  needle  is  important,  the  fluid  that 
emerges  being  studied  by  the  microscope  after  staining,  by  cultures,  and 
perhaps  by  inoculating  it  into  guinea-pigs.  The  fluid  that  is  withdrawn!  may 
contain  no  bacteria  that  can  be  demonstrated;  but  if  it  is  sterile,  one  should 
strongly  suspect  tuberculosis.  Various  diagnostic  tests  for  tuberculosis  will 
be  found  on  pages  251,  252,  253,  254,  and  255. 

Prognosis. — Advanced  albuminoid  degeneration  makes  the  prognosis  of 
tuberculous  abscess  hopeless  and  any  extent  of  albuminoid  degeneration  is 
unfavorable.  Secondary  pyogenic  infection,  as  already  stated,  may  produce 
death  or  a  lingering  suppuration.  The  prognosis  is  worse  in  very  young  chil- 
dren than  in  adults,  but  in  older  children  is  better  than  in  adults;  and  in  any 
case  it  is  unfavorable  if  the  victim  cannot  or  will  not  follow  rigidly  a  proper 
plan  of  open-air  treatment,  if  the  exhaustion  deepens,  if  the  anemia  is  marked, 
if  there  are  tuberculous  lesions  in  distant  parts  or  in  important  organs  or 
structures,  if  the  patient  is  unable  to  take  enough  food  or  if  he  cannot  digest 
what  he  does  take,  and  if  the  regions  of  tuberculosis  cannot  be  extirpated  or 
sterilized.     Under  other  circumstances  the  prognosis  is  favorable. 

Tuberculous  Abscesses  in  Various  Regions. — Tuberculous  abscess 
of  the  head  of  a  bone  (see  Brodie's  Abscess,  page  569)  arises  in  the  cancel- 
lous structure  of  a  long  bone,  most  often  in  the  head  of  the  tibia,  and  is  fre- 
quently noted  as  having  been  preceded  by  a  trivial  traumatism.  The  focus 
of  tuberculosis  seldom  induces  severe  symptoms  unless  secondary'  pyogenic  in- 
fection occurs.  A  tuberculous  nodule  forms  as  a  result  of  tuberculous  osteo- 
myelitis. The  bone  about  the  nodule  is  hyperemic,  the  bony  trabeculae  are 
thickened,  and  the  cancellous  spaces  "are  devoid  of  fat  cells,  and  they  contain 
a  swollen  semifibrous  material"  (Warren's  "Surg.  Pathol.").  The  center  of 
the  nodule  becomes  cheesy,  the  bone  trabeculae  are  absorbed,  and  the  bone 
becomes  cheesy  and  broken  up,  the  cheesy  mass  containing  bone  fragments. 
Finally  the  area  becomes  filled  with  tuberculous  pus,  the  cavity  which  contains 
it  being  lined  with  tuberculous  granulations.  Distinct  sequestra  may  form 
and  the  bone  about  the  diseased  focus  undergoes  sclerosis.  In  tuberculous 
abscess  of  bone  pain  is  continuous,  but  is  not  usually  very  severe,  is  of  a  boring 
character,  and  is  worse  when  the  patient  is  in  bed.  Attacks  of  synovitis  arise 
from  time  to  time  in  the  adjacent  joint.  The  bacteria  of  tuberculosis  obtain 
access  to  the  bone  by  means  of  the  blood,  and  find  in  the  bone  a  point  of  least 
resistance.  There  is  no  such  thing  as  an  acute  abscess  of  bone.  A  pyogenic 
inflammation,  of  such  severity  as  to  cause  an  acute  abscess  in  soft  parts, 
in  bone  causes  acute  necrosis.  A  less  violent  pyogenic  infection  causes  a  very 
chronic  suppuration. 

Retropharyngeal  or  postpharyngeal  abscess  is  often  tuberculous.  Such  an 
abscess  is  usually  due  to  caries  of  the  cervical  vertebra?,  but  can  arise  in  the 
connective  tissue  of  the  parts  or  as  tuberculous  adenitis.  An  abrasion  of  the 
mucous  membrane  may  admit  the  bacilli  to  the  connective  tissue  or  the  glands. 
A  swelling  projects  from  the  posterior  pharyngeal  wall,  and  there  is  great  inter- 
ference with  respiration  and  deglutition.  Caseous  matter  from  caries  of  the 
cervical  vertebrae  may  reach  the  posterior  mediastinum  by  following  the 
esophagus,  or  may  appear  in  front  of  or  behind  the  sternomastoid  muscle 
in  the  neck  (Edmund  Owen).  A  tuberculous  abscess  back  of  the  pharxmx  is 
apt  to  undergo  pyogenic  infection,  in  which  case  the  patient  develops  fever, 
sweats,  pain,  and  prostration. 

Dorsal  Abscess. — The  tuberculous  matter  in  dorsal  abscess  arises  from 
dorsal  caries,  flows  into  the  posterior  mediastinum,  and  reaches  the  surface 
by  passing  between  the  transverse  processes.  The  tuberculous  matter  from 
dorsal  caries  may  run  forward  between  the  intercostal  muscles  or  between 


Tuberculous  Abscess  of  the  Breast 


267 


these  muscles  and  the  pleura,  pointing  in  an  intercostal  space,  at  the  side  of  the 
sternum,  or  by  the  rectus  muscle.  It  may  burst  into  the  gullet,  windpipe, 
])ronchus,  pleural  sac,  or  pericardium.  It  may  descend  to  the  diaphragm  and 
travel  under  the  inner  arcuate  ligament  to  form  a  psoas  abscess,  or  under  the 
outer  arcuate  ligament  to  form  a  lumbar  abscess.  A  psoas  abscess  may  point 
above  Poupart's  ligament  or  in  the  lumbar  region.  If  it  extends  below  Pou- 
part's  ligament  it  usually  points  external  to  the  femoral  vessels  (a  characteristic 
which  is  said  to  distinguish  it  at  once  from  an  ordinary  femoral  hernia),  but 
may  burrow  in  any  direction. 

Iliac  abscess  arises  from  lumbar  caries,  the  swelling  lying  in  the  iliac  fossa 
and  pointing  above  Poupart's  ligament. 

Psoas  abscess  is  usually  due  to  lumbar  caries,  but  may  arise  from  dorsal 
caries.  The  fluid  usually  points  in  Scarpa's  triangle  external  to  the  femoral 
vessels,  but  may  descend  much  lower  (Fig.  105).  A  psoas  or  iliac  abscess,  by 
following  the  lumbosacral  cord  and  great  sciatic 
nerve,  forms  a  gluteal  abscess.  These  abscesses 
may  open  into  the  bowel,  bladder,  ureter,  or 
peritoneal  cavity.  A  hernia  is  almost  never 
mistaken  for  a  psoas  abscess,  but  a  psoas 
abscess  is  sometimes  mistaken  for  a  hernia 
(Fig.  106).  J.  Torrance  Rugh  points  out 
that  without  a  search  for  spinal  kyphosis  or 
muscular  rigidity  the  mistake  may  be  made, 
but  that  the  presence  of  a  mass  in  the  iliac 
fossa  continuous  with  the  external  lump 
eliminates  the  possibility  of  the  condition 
being  hernia. 

Lumbar  Abscess. — In  a  lumbar  abscess 
the  fluid  produced  by  dorsal  caries  descends 
beneath  the  outer  arcuate  ligament,  or  the 
fluid  from  lumbar  caries  which  collected  an- 
terior to  or  in  the  quadratus  lumborum 
muscle  passes  between  the  last  rib  and  iliac 
crest  in  the  triangle  of  Petit,  the  small  space 
"bounded  by  the  crest  of  the  ilium,  the  pos- 
terior edge  of  the  external  oblique  muscle, 
and  the  anterior  edge  of  the  latissimus  dorsi 
muscle.^ 

Tubercvdous  abscess  of  the  neck  results  from  tuberculosis  of  the  cervical 
glands.  It  is  not  often  that  such  an  abscess  attains  any  considerable  size. 
It  tends  strongly  to  spontaneous  rupture,  and,  if  this  is  permitted  to  occur, 
a  livid,  corrugated  scar  results. 

Tuberculous  Abscesses  of  Joints. — (See  Section  XX.) 

Tuberculous  Abscess  of  Rib. — It  is  not  uncommon  to  find  a  tubercu- 
lous abscess  of  moderate  size  about  a  tuberculous  rib.  The  pleura  may  be- 
come involved  secondarily. 

Tuberculous  mediastinal  abscess  may  result  from  the  downward  passage 
of  a  cervical  abscess;  from  tuberculosis  of  the  sternum,  ribs,  vertebrae  or  pleura, 
or  from  tuberculous  mediastinal  glands. 

Tuberculous  abscess  of  the  breast  is  a  caseated  and  liquefied  area  of  tuber- 
culosis of  the  mammary  gland.  A  lump  is  detected,  which  slowly  enlarges 
and  finally  ruptures,  sinuses  being  formed.  The  axillary  glands  are  apt 
to  be  implicated.  The  patient  may  belong  to  a  tuberculous  stock,  as  a 
rule  gives  a  history  of    previous  tuberculous  troubles  of  various  sorts,  and 

^  For  a  lucid  description  of  these  abscesses  see  Owen's  "Manual  of  Anatomy,"  from  which 
much  of  the  above  is  condensed. 


Fig.  105. — Psoas  abscess  (Albert). 


268 


Surgical  Tuberculosis 


has  usually  borne  children.  Tuberculous  abscess  of  the  breast  causes  little  or 
no  pain. 

Treatment  of  Tuberculous  Abscess. — For  many  years  the  majority  of 
surgeons  would  not  o|)en  a  tuberculous  abscess  unless  it  was  on  the  j)oint  of 
rupturing.  With  the  advent  of  antiseptic  surgery  it  was  assumed  that  aseptic 
incision  and  drainage  would  be  the  proper  treatment  for  these  cases;  but 
the  results,  except  in  small  superficial  tuberculous  abscesses,  have  been  ex- 
tremely disappointing.  If  a  large  abscess  is  so  treated,  pyogenic  infection  will, 
in  all  probability,  sooner  or  later  occur,  with  all  its  possibilities  of  disaster. 
Incision  and  drainage  is  the  treatment  for  small  and  superficial  abscesses. 

Treatment  of  Small  Superficial  Tuberculous  Abscesses.— The  surgeon 
must  remember  that  after  one  has  opened  an  apparently  superficial  abscess 
it  is  his  duty  to  make  an  examination  to  see  that  there  is  no  channel  connecting 
the  abscess  with  a  deep  or  a  distant  focus.  If  he  finds  such  a  channel,  he  may  be 
disposed  to  follow  one  of  the  plans  of  treatment  outlined  below  and  on  page  269. 


Fig.   106.- — Case  of  cold  abscess  of  the  abdominal  wall  which  had  been  treated  as  a  hernia. 


It  is  also  his  duty  to  see  whether  there  are  sinuses  tracking  off  from  the  abscess^ 
and  if  these  exist,  he  must  slit  them  up.  If  there  are  loculi  in  the  wall  of  the 
abscess,  he  must  stretch  their  mouths.  He  must  be  particularly  careful  to  see 
that  he  is  not  dealing  with  a  shirt-stud  abscess,  in  which  there  is  a  little  opening 
through  the  deep  fascia  connecting  the  abscess  above  with  the  abscess  below. 
la  a  shirt-stud  abscess  the  deep  fascia  must  be  freely  incised.  After  the  ab- 
scess has  emptied  itself,  its  walls  must  be  thoroughly  scraped  with  a  curet,  and 
the  cavity  must  be  irrigated  with  warm  salt  solution  and  drained  with  a  tube 
or  with  iodoform  gauze.  If  the  skin  above  a  superficial  abscess  is  diseased  and 
discolored,  and  the  abscess  is  on  the  eve  of  spontaneous  rupture  or  has  ruptured, 
the  discolored  skin  must  be  cut  aw-ay  with  scissors.  If  the  discolored  skin  is 
allowed  to  remain,  a  livid  and  jagged  scar  will  inevitably  result.  If  it  is  cut 
away  a  healthy  scar  which  is  not  very  deforming,  will  result. 

Treatment  of  Tuberculous  Abscesses  of  Considerable  Size. — Method 
I.  Aspiration,  Irrigation,  and  the  Introduction  of  Iodoform. — The  operation  is 
carried  out  with  the  most  scrupulous  aseptic  care.  The  trocar  is  passed  through 
the  sound  skin;  is  carried  beneath  the  skin  for  an  inch,  as  Senn  suggests;  and 


Treatment  of  Tuberculous  Abscesses  of  Considerable  Size      269 


is  then  made  to  enter  into  the  cavity  of  the  abscess.  The  stylet  is  pulled 
out,  and  the  flow  of  fluid  is  aided  by  very  delicate  pressure.  Occasionally  the 
tube  will  become  blocked  by  necrosed  tissue  or  plugs  of  fibrin.  It  is  opened 
up  again  by  pushing  in  a  wire  or  forcing  through  it  a  stream  of  sterile  fluid. 
When  tuberculous  matter  ceases  to  run  out  of  the  trocar,  a  very  warm  solution 
of  boric  acid  is  thrown  in  in  order  to  wash  the  abscess  walls.  This  can  be  in- 
jected with  a  fountain  syringe  or  with  the  special  apparatus  of  Senn  (Fig.  107). 
Enough  of  it  is  allowed  to  enter  to  overdistend  the  abscess-cavity,  as  Mr.  Cal- 
lender  long  ago  advised.  The  fluid  is  then  allowed  to  pass  out;  fresh  fluid  is 
passed  in;  and  this  procedure  is  repeated,  perhaps  again  and  again,  until  entirely 
clear  fluid  flows  out.  When  this  takes  place,  an  emulsion  of  iodoform  is  thrown 
in  by  Senn's  syringe.  A  10  per  cent,  emulsion  in  glycerin  is  as  satisfactory 
as  the  more  elaborate  formulas.  Verneuil  used  to  employ  iodoform  and  ether; 
but  this  is  painful,  is  more  Hable  to  cause  iodoform-poisoning,  and  sometimes 
induces  gaseous  distention  and  ruptures  the  wall  of  the  abscess.  In  order  to 
prevent  the  danger  of  iodoform-poison- 
ing the  surgeon  should  not  introduce  at 
one  time  more  than  8  dr.  of  the  emulsion, 
if  dealing  with  an  adult;  or  more  than  4 
dr.,  if  dealing  with  a  child.  After  the 
emulsion  has  been  inserted  into  the 
abscess-cavity  the  wound  in  the  skin  is 
sealed  with  a  bit  of  gauze  and  iodoform 
collodion.  Gauze  is  fluffed  up  and  laid 
on  the  skin  above  the  abscess,  and  the 
walls  of  the  cavity  are  then  forced 
toward  each  other  by  applying  a  roller 
bandage.  The  part  is  put  at  complete 
rest,  and  it  is  usually  necessary  to  put  the 
patient  in  bed.  Sometimes,  although 
very  seldom,  one  injection  will  produce  a 
cure;  but  usually,  after  one  or  two  weeks, 
it  will  be  observed  that  the  cavity  has 
to  some  extent  filled  again.  A  second 
operation  is  then  performed;  and,  if  im- 
provement is  really  taking  place,  it  will 
be  found  that  the  fluid  is  not  nearly  so 
thin  as  it  was  at  the  first  operation.  It  is  needless  to  persist  in  this  method 
after  six  or  seven  attempts  have  failed  to  cure.  If  the  abscess  has  thick  and 
uncollapsed  walls  it  is  not  fitted  for  treatment  by  aspiration  and  injection. 

Method  2.  Incision,  Cleansing,  and  Suture. — If,  owing  to  the  considerable 
size  or  the  rather  rigid  walls  of  the  abscess,  one  believes  that  the  aspiration 
method  would  be  useless;  or  if  the  aspiration  method  has  been  tried  and  has 
failed,  one  may  adopt  the  following  plan.  It  should  not,  however,  be  em- 
ployed if  the  walls  are  very  thick  and  rigid.  An  incision  is  made  at  the  most 
dependent  part  of  the  abscess.  The  walls  are  scraped  carefully  with  Barker's 
sharp-edged  irrigating  curet  (Fig.  108),  and  are  rubbed  smooth  with  bits  of 
gauze.  The  part  is  freely  irrigated  with  hot  boric  acid  solution,  and  pressure 
is  applied  to  arrest  bleeding.  Iodoform  emulsion  is  introduced;  the  skin  is 
sutured;  dressings,  compresses,  and  bandages  are  applied,  and  complete  rest 
is  secured.  This  operation  may  cure  an  abscess,  or  it  may  be  necessary  to 
repeat  the  procedure  two  or  three  or  many  weeks  afterward. 

Method  3.  Incision  and  Removal  of  the  Primary  Focus  oj  Tuberculosis. — If 
the  surgeon  does  not  wish  to  use  the  iodoform  treatment,  or  if  it  has  failed, 
and  if  he  fi'nds  that  the  primary  seat  of  disease  may  be  attacked  and  removed, 
an  operation  should  be  undertaken  to  get  rid  of  Volkmann's  membrane  in  the 


Fig.  107. — Senn's  injection  syringe. 


270  Surgical  Tuberculosis 

last-formed  abscess  and  also  to  remove  the  primary  tuberculous  focus.  An 
incision  is  made,  when  possible,  that  will  lay  open  not  only  the  last-formed 
abscess,  but  the  primary  lesion.  Tuberculous  tissue  is  thoroughly  removed 
by  Barker's  spoon  and  by  rubbing  with  gauze  or,  perhaps,  by  scissors  and 
forceps.  Any  focus  of  bone  disease  is  curetted  and  touched  with  pure  carbolic 
acid,  and  loose  fragments  of  bone  are  removed.  The  part  is  irrigated  with  a 
hot  solution  of  boric  acid;  bleeding  is  arrested  by  pressure,  and  the  wound  is 
nearly,  but  not  quite,  closed,  drainage  being  inserted  at  the  most  appropriate 
spot.  Dressings,  compresses,  and  bandages  are  then  applied.  In  this  opera- 
tion the  entire  tuberculous  area  has  been  removed  and  the  raw  surfaces  have 
been  forced  into  contact,  and  there  is  scarcely  more  danger  of  secondary 
pyogenic  infection  than  there  is  in  any  ordinary  wound. 

General  Treatment. — It  is  never  to  be  lost  sight  of  that  in  every  case  of 
tuberculous  abscess  the  general  treatment  of  tuberculosis  must  be  rigorously 
pursued  (see  page  255).  In  the  treatment  of  a  cold  abscess  give  nutritious 
food,  cod-liver  oil,  quinin,  iron,  and  the  mineral  acids.  Removal  to  the  moun- 
^ins  or  the  seaside  is  often  indicated,  life  in  the  open  air  is  imperative,  and 
mechanical  appliances  may  be  needed  for  diseases  of  the  bones  and  joints. 

Tuberculous  Abscess  of  Bone. — Make  an  incision  to  bare  the  bone.  Open 
the  abscess  with  the  trephine,  the  gouge,  or  the  chisel;  curet  the  interior  of  the 
wall  of  the  cavity  with  a  sharp  spoon  and  rub  it  with  bits  of  gauze;  cut  away 
the  edges  of  the  bone  with  rongeur  forceps;  irrigate  the  cavity  with  hot  normal 
salt  solution,  dry  its  walls  with  gauze,  and  paint  the  cavity  with  pure  car- 


L 


awiiiwV  II  '  Tf  "nil  '-"^f-T^rai 


Fig.  108. — Barker's  sharp-edged  irrigating  curet  ("Keen's  Surgery 


bolic  acid;  pack  with  iodoform  gauze  and  apply  antiseptic  dressings.  It  is 
better  not  to  employ  an  Esmarch  apparatus.  Bleeding  will  not  be  severe, 
and  when  no  apparatus  is  used  to  prevent  bleeding  it  is  possible  to  see  and  thus 
be  sure  that  all  the  diseased  bone  has  been  removed. 

Tuberculous  Abscess  of  Lymphatic  Glands. — In  non-exposed  portions  of  the 
body  the  capsule  of  the  gland  should  be  incised,  the  gland  should  be  dissected 
or  scraped  away  and  the  cavity  swabbed  out  with  pure  carbolic  acid  or  iodin 
and  packed  with  iodoform  gauze,  but  drainage  should  not  be  prolonged.  If  the 
abscess  is  allowed  to  burst,  it  will  cause  an  ugly  scar;  therefore,  in  exposed  por- 
tions of  the  body,  as  the  neck,  special  effort  should  be  made  to  prevent  a  scar  by 
incising  early  before  the  skin  is  involved.  WTien  only  a  little  caseated  matter 
exists  and  the  skin  is  not  discolored,  prepare  the  parts  antiseptically,  incise,  rub 
the  interior  with  gauze,  inject  iodoform  emulsion,  and  suture  the  wound.  It  used 
to  be  a  custom  in  such  cases  to  carry  a  silk  thread  by  means  of  a  needle  through 
the  skin,  through  the  gland,  and  out  at  its  lowest  point,  the  part  being  then 
dressed  with  gauze.  In  three  days  the  thread  w^as  removed  and  a  firm  com- 
press was  applied.  The  plan  is  not  satisfactory  and  incision  is  to  be  preferred. 
When  the  gland  is  almost  entirely  broken  down  and  the  skin  above  it  is  becom- 
ing purple  and  thin,  insert  a  hypodermatic  needle  through  sound  skin  into  the 
abscess,  draw  off  the  fluid  tuberculous  matter,  and  inject  iodoform  emulsion. 
This  procedure  is  to  be  repeated  when  the  fluid  again  accumulates.  By  this 
means  we  can  sometimes  effect  a  cure  in  a  week  or  so.  When  an  abscess 
breaks  or  is  on  the  point  of  breaking,  cut  away  all  purple  skin,  curet  the  abscess 


Dorsal  Abscess  and  Lumbar  Abscess  271 

walls  (the  abscess  having  become  a  tuberculous  ulcer),  remove  the  remains 
of  gland  and  capsule,  swab  the  cavity  with  pure  carbolic  acid,  and  dress  with 
iodoform  and  antiseptic  gauze. 

Tuberculous  glands,  if  not  cured  by  general  treatment  and  the  .v-rays,  ought 
in  many  cases  to  be  extirpated.  They  should  certainly  be  extirpated  before  they 
caseate  and  form  an  abscess.  If  an  abscess  does  form  it  is  treated  as  directed 
above,  and  after  healing  takes  place  the  diseased  glands  may  be  extirpated.  If 
sinuses  exist  they  are  curetted  and  touched  with  iodin  or  carbolic  acid.  After 
healing,  the  glands  are  extirpated.  When  sinuses  exist  there  is  always  mixed 
infection. 

Tuberculous  Abscess  of  a  Rib. — This  lesion  requires  incision  of  the  soft 
parts  and  resection  of  the  diseased  bone.  The  tuberculous  area  should  be 
thoroughly  curetted,  rubbed  with  pure  carbolic  acid,  and  packed  with  iodoform 
gauze. 

Tuberculous  Mediastinal  Abscess. — In  tuberculous  abscess  of  the  me- 
diastinum aspiration  and  injection  of  iodoform  may  prove  efficient.  In  some 
cases  it  will  be  necessary  to  open  and  drain. 

Tuberculous  Abscess  of  the  Mammary  Gland. — Many  operators  simply  in- 
cise, curet,  pack  with  iodoform  gauze,  and  dress  antiseptically.  It  is  wiser  to 
remove  the  entire  gland  and  to  clear  out  the  axilla,  as  in  an  operation  for 
cancer,  in  order  to  prevent  both  recurrence  and  dissemination. 

Large  Tuberculous  Abscesses. — In  view  of  the  facts  that  these  abscesses 
ma\'  cause  no  trouble  for  years  and  that  an  operation  may  be  fatal,  some  emi- 
nent surgeons  are  opposed  to  an  operation  unless  the  abscess  is  moving  toward 
inevitable  rupture  or  is  disturbing  the  function  of  organs  by  pressure.  Most 
practitioners  believe,  however,  and  I  agree  with  them,  that  this  mass  of  tuber- 
culous matter  is  a  source  of  danger  through  being  a  depot  of  infective  organ- 
isms which  may  overwhelm  the  system,  and  that  death  will  seldom  result 
from  an  operation  performed  by  one  who  employs  with  intelligence  strict 
antisepsis.  In  no  other  cases  is  attention  to  every  detail  more  important, 
as  a  mixed  infection  may  easily  take  place,  and  will  probably  mean  death. 
As  W.  Watson  Cheyne  points  out,  over  70  per  cent,  of  cases  of  spinal  abscess 
treated  by  aseptic  methods  recover  completely  and  without  any  real  illness 
after  such  an  operation.  The  recoveries  from  the  old  let-alone  method  must 
be  infinitely  less  than  this,  and  cases  cured  by  operation  usually  remain  well. 
The  surgeon  must  always  remember  that  the  wall  of  the  abscess  and  not  the 
fluid  in  the  cavity  is  the  real  seat  of  disease,  and  this  wall  must  be  actually 
removed  or  completely  sterilized  if  operation  is  to  be  safe  and  curative.  To 
simply  open,  drain,  and  leave  the  wall  to  Nature  to  get  rid  of  as  she  can  is 
fraught  with  the  gravest  peril. 

Psoas  Abscess. — Some  of  these  cases  can  be  treated  by  aspiration  and 
injection  (see  page  268),  others  by  incision  and  subsequent  suture  (see  page 
269),  others  by  the  radical  operation  set  forth  on  page  269. 

Treves's  operation  for  psoas  abscess  is  described  on  page  784. 

An  operation  occasionally  performed  for  psoas  abscess  consists  in  an  in- 
cision in  the  groin,  an  incision  in  the  back,  removal  of  carious  vertebrse,  thorough 
cleansing  of  the  abscess  wall,  and  through-and-through  tubular  drainage. 
It  has  been  found,  however,  that  this  operation  is  uncertain,  and  dangerous. 
It  is  not  advisable  to  remove  carious  vertebrae  unless  the  carious  parts  are 
loose,  and  through-and-through  tubular  drainage  is  rarely  used  unless  mixed 
infection  already  exists.  WTien  a  large  abscess  breaks  spontaneously  it  should 
be  widely  opened  at  once,  scraped  and  irrigated,  rubbed  with  gauze,  and 
packed  -^-ith  iodoform  gauze.  If  secondary-  pyogenic  infection  of  a  large 
tuberculous  abscess  does  occur  the  patient  will  develop  septic  fever  and  will 
probably  die  (q.  v.). 

Dorsal  abscess  and  lumbar  abscess  are  treated  after  the  same  plan  as 


272  Surgicar  Tuberculosis 

psoas  abscess.  One  incision  only  is  usually  necessary  unless  the  fluid  has 
traveled  to  a  distant  point. 

A  postpharyngeal  abscess  should  not  be  opened  through  the  mouth.  To 
open  it  in  this  manner  puts  the  patient  in  danger  of  suffocation  by  fluid  running 
into  the  larynx  during  or  after  the  operation.  Further,  mixed  infection  of  the 
abscess  area  will  be  certain  to  ensue.  Septic  pneumonia  will  be  apt  to  arise 
from  inhaled  infected  particles,  and  profound  gastro-intestinal  disturbance 
will  be  liable  to  develop  because  of  the  inevitable  swallowing  of  purulent, 
putrid,  and  tuberculous  masses.  Incise  the  neck  and  open  into  the  abscess 
by  Hilton's  method,  going  through  the  sternocleidomastoid  muscle  or  behind 
it.  Rub  the  wall  of  the  abscess  with  bits  of  gauze,  remove  any  loose  bone, 
irrigate  with  hot  normal  salt  solution,  inject  iodoform  emulsion,  insert  a  tube 
or  pack  with  iodoform  gauze. 

Tuberculosis  of  the  skin  may  arise  from  inoculation  with  material  de- 
rived from  a  bovine  or  human  source.  It  is  frequently  found  that  some  other 
member  of  the  family  labors  under  tuberculous  disease  or  that  some  family 
predecessor,  direct  or  collateral,  suffered  from  it.  Stelwagon  ('"Diseases 
of  the  Skin")  includes  all  cases  under  five  heads:  (i)  tuberculosis  ulcerosa; 

(2)  tuberculosis  disseminata;  (3)  tuberculosis  verrucosa;  (4)  scrofuloderma; 
(5)  lupus  vulgaris. 

Tuberculosis  Ulcerosa. — The  disease  arises  at  a  mucous  outlet  and  is 
usually  secondary  to  internal  tuberculous  disease.  Small  miliary  tubercles 
form  which  caseate  and  are  converted  into  ulcers.  An  ulcer  is  shallow,  round 
or  oval  in  outline,  with  soft  edges,  the  floor  being  composed  of  sluggish  or 
edematous  granulations  covered  wdth  a  crust.  The  discharge  is  scanty  and 
seropurulent.  In  some  cases  there  is  but  one  ulcer;  in  others  there  are  two 
or  several,  and  the  fusion  of  ulcers  produces  a  serpiginous  outline.  The  ulcers 
do  not  tend  to  heal,  but  gradually  and  steadily  advance.  Such  ulcers  are  met 
with  about  the  mouth,  the  genital  organs,  and  the  anus. 

Tuberculosis  Disseminata. — This  occurs  only  in  children;  it  is  acute  in 
onset  and  widespread.  One  type  is  polymorphic:  spots,  papules,  pustules, 
and  crusted  ulcers  existing,  and  lymphatic  glands  being  enlarged.  Another 
type  arises  after  an  ^attack  of  an  exanthematous  fever  and  presents  ''a  rough 
resemblance  to  flat,. lupus  tubercles,  to  sluggish  acne  papules,  and  to  lichen 
scrofulosum"  (Stelwagon,  "Diseases  of  the  Skin"). 

Tuberculosis  Verrucosa. — Anatomical  tubercle,  the  verruca  necrogenica  of 
Wilks,  is  due  to  local  inoculation  with  tuberculous  matter.  It  may  be  met 
with  in  surgeons,  the  makers  of  postmortems,  leather  workers,  and  butchers, 
usually  upon  the  backs  of  the  hand  and  fingers.  It  consists  of  a  red  mass  of 
granulation  tissue  having  the  appearance  of  a  group  of  inflamed  warts.  Pus- 
tules often  form. 

Scrofulodermata  or  Tuberculous  Gummata. — By  '"scrofulodermata"  we 
mean  chronic  inflammations  of  the  skin,  the  granulation-tissue  product  of 
which  caseates,  mixed  infection  occurs,  and  small  abscesses,  sinuses,  or  ulcers 
form.  A  tuberculous  ulcer  has  a  floor  of  a  pale  color,  and  has  no  granulations 
at  all,  or  is  covered  with  large,  pale,  edematous  granulations.  The  discharge 
is  thin  and  scanty.  The  ulcer  is  surrounded  by  a  considerable  zone  of  purple, 
tender,  and  undermined  skin,  which  is  apt  to  slough.  When  healing  occurs, 
the  skin  puckers  and  usually  inverts. 

Lupus  begins  usually  before  the  age  of  twenty-five,  but  is  met  with  often 
in  individuals  in  middle  life.  It  is  most  common  upon  the  face,  especially  the 
nose.  It  is  a  very  chronic  and  extremely  destructive  disease.  Three  forms  are 
recognized:  (i)  lupus  vulgaris,  in  which  appear  pink  nodules  that  after  a  time 
ulcerate  and  then  cicatrize  partly  or  completely.  These  nodules  resemble 
jelly  in  appearance;  (2)  lupus  exedens,  in  which  ulceration  is  ver>'  great,  and 

(3)  lupus  hypertrophicus,  in  which  large  nodules  or  tubercles  arise.     Lupus 


Tuberculosis  ol    ihc  AlinicnUiry   Canal  273 

may  appear  as  a  pimple,  as  a  group  of  pimples,  or  as  nodules  of  a  larger  size. 
The  ulcer  arises  from  desquamation,  and  is  surrounded  by  inflammatory 
products  which,  by  progressively  breaking  down,  add  to  the  size  of  the  raw 
surface.  The  ulcer  is  usually  superficial,  is  irregular  in  outline,  the  edges 
are  soft  and  neither  sharp  nor  undermined,  the  sore  gives  origin  to  a  small 
amount  of  thin  discharge,  the  parts  about  are  of  a  yellowish-red  color,  the  edges 
are  solid  and  puckered  and  scar-like  and  there  is  no  pain.  The  sore  is  often 
crusted,  the  crusts  being  thin  and  of  a  brown  or  black  color;  it  may  be  pro- 
gressing at  one  point  and  heahng  at  another;  it  is  slow  in  advancing,  but  often 
proves  hideously  destructive.  The  scars  left  by  healing  are  firm  and  corru- 
gated, but  are  apt  to  break  down.  Clinically,  it  is  separated  from  a  rodent 
ulcer  by  several  points.  The  rodent  ulcer  is  deep,  its  edges  are  everted,  and 
the  parts  about  filled  with  visible  vessels.  It  is  not  crusted,  has  not  a  puckered 
edge,  its  edges  and  base  are  hard,  and  it  rarely  shows  any  tendency  to  healing. 
Many  victims  of  lupus  live  twenty  or  thirty  years  and  die  without  the  devel- 
opment of  pulmonary  tuberculosis.  It  is  estimated  that  one-third  of  those 
who  die  show  signs  of  pulmonary  tuberculosis.  Lupus  patients  exhibit  a  strong 
focal  reaction  to  tuberculin  and  also  show  von  Pirquet's  reaction. 

Lupus  may  be  treated  by  the  Finsen  light,  the  .r-rays,  excision,  electro- 
thermic  methods,  curetment  followed  by  cauterization  with  the  Paquelin 
cautery,  chlorid  of  zinc,  pure  carbolic  acid  or  pyrogallic  acid.  Tuberculin  may 
be  of  service. 

Tuberculosis  of  Subcutaneous  Connective  Tissue. — In  this  form 
of  tuberculosis  nodules  form  and  break  down  (tuberculous  abscesses).  In 
the  deeper  tissues  these  abscesses  are  usually  associated  with  bone,  joint, 
or  Ivmphatic  gland  disease  (see  Cold  Abscess,  page  260). 

Tuberculosis  of  the  Mammary  Gland. — (See  page  271.) 

Tuberculosis  of  the  Thyroid  Gland. — It  used  to  be  thought  that  the 
thyroid  was  immune.  Primary  tuberculosis  is  very  rare  but  secondary  tuber- 
culosis is  not  nearly  so  unusual.  It  may  exist  with  or  without  goiter.  The 
condition  may  be  miliary,  abscess,  or  tuberculoma  or  sclerosis.  Mosiman  re- 
ported on  9  cases  from  Prof.  Crile's  clinic  ("Surgery,  Gynecology,  and  Obstet- 
rics," June,  191 7). 

Tuberculosis  of  Blood=vessels. — It  is  certain  that  bacilli  in  the  blood 
or  in  tuberculous  emboli  may  establish  intravascular  tuberculosis. 

Tuberculous  Meningitis. — (See  page  901.) 

Tuberculosis  of  nerves  is  excessively  rare.  Tuberculous  neuritis  may 
arise  in  the  course  of  general  tuberculosis.  A  nerve  lying  in  a  tuberculous 
area  may  itself  become  tuberculous.  It  rarely  does  so,  however.  In  fact, 
nerves  resist  infections  though  in  the  midst  of  them,  and  for  this  reason  have 
been  called  the  "aristocrats  of  the  body." 

Pulmonary  Tuberculosis. — In  adults  the  lungs  are  more  commonly 
affected  than  any  other  structure.  The  lung  affection  may  be  primary  or 
may  be  secondary  to  some  distant  tuberculous  process.  Pulmonary  tubercu- 
losis belongs  to  the  province  of  the  physician  and  requires  no  description  here. 

Tuberculosis  of  the  pleura  is  not  uncommon.  Tuberculous  pleurisy 
may  be  acute  or  chronic.  In  some  instances  mixed  infection  takes  place  and 
suppuration  occurs.  The  tuberculosis  may  be  primary,  but  is  usually  second- 
ary to  pulmonary  tuberculosis,  and  may  be  due  to  direct  extension  or  to  rupture 
of  an  area  of  pulmonary  softening.  A  primary  pleurisy  not  due  to  traumatism 
is  very  apt  to  be  tuberculous.  In  many  cases  of  tuberculous  pleurisy  there  are 
tubercles  present  and  in  some  cases  there  are  none. 

Tuberculosis  of  the  Alimentary  Canal. — A  tuberculous  ulcer  of  the 
lip  occasionally  arises,  and  may  be  mistaken  for  a  cancer  or  a  chancre.  A 
tuberculous  ulcer  of  the  tongue  is  commonly  associated  with  other  foci  of  dis- 
ease, in  fact  primary  cases  are  extremely  rare.     J.  R.  Scott  ("Jour.  Am.  Med. 


2  74  Surgical  Tubi-rculosis 

Assoc,  1916,  clii)  collected  reports  of  231  cases.  It  may  occur  at  any  age  but 
is  most  common  between  forty  and  fifty  years  of  age.  Scott  found  record  of  a 
case  occurring  in  a  child  less  than  six  years  old.  The  disease  is  more  common  in 
males  than  in  females.  Such  ulcers  are  separated  from  cancer  by  their  soft 
I  bases  and  edges  and  by  the  rarity  of  glandular  enlargements,  and  from  syphilitic 
processes  by  the  therapeutic  test.  Confirmation  of  the  diagnosis  is  obtained 
by  examination  of  an  excised  piece,  cultivations  and  inoculations.  In  cases 
secondary  to  laryngeal  or  pulmonary  tuberculosis,  the  sputum  contains  the 
bacilli  of  tubercle.  Tubercle  may  aflfect  the  pharynx,  palate,  tonsils,  and, 
very  rarely,  the  stomach. 

Gastric  Tuberculosis. — It  is  thought  that  the  acid  gastric  juice  must 
protect  the  stomach  from  tubercle,  because  tubercle  bacilli  are  frequently 
introduced  into  the  stomach,  but  the  organisms  very  rarely  lodge  and  multiply 
in  the  stomach  wall.  Furthermore,  bacilli  when  introduced  into  the  stomach 
are  retained  but  a  short  time  and  the  stomach  walls  contain  few  lymph-follicles 
(Barchasch,  in  "Beit.  Z.  klin.  d.  Tuberculose,"  vii,  Part  III,  1907).  It  may 
be  assumed  that  gastric  catarrh  and  motor  impairment  are  predisposing  causes. 
Gastric  tuberculosis  may  be  primary,  but  is  usually  secondary  to  pulmonary 
tuberculosis,  infected  sputum  having  been  repeatedly  swallowed  ("Jour.  Am. 
Med.  Assoc,"  Dec  28,  1907).  Gastric  tuberculosis  may  cause  cicatricial 
stenosis  of  the  pylorus,  ulcer  (of  which  I  reported  an  instance),  a  tumor-like 
thickening,  solitary  tubercle,  and  miliary  tuberculosis  (Barchasch,  Loc  cit.). 

Broders  ("Surgery,  Gynecology,  and  Obstetrics,"  Nov.,  1917)  out  of  all 
cases  in  literature  accepts  49  as  certainly  cases  of  gastric  tuberculosis. 

Intestinal  tuberculosis  may  follow  pulmonary  tuberculosis,  but  it  may 
arise  primarily  in  the  mucous  membrane  of  the  bowel  or  result  from  tubercu- 
lous peritonitis.  Intestinal  tuberculosis  causes  diarrhea  and  fever,  may  re- 
semble appendicitis,  and  may  cause  abscess  and  perforation.  True  tubercu- 
lous disease  of  the  appendix  occasionally  occurs.  Scott  ("Annals  of  Surgery," 
Dec,  1917)  thinks  tuberculous  appendicitis  more  common  than  is  usually 
thought.  He  believes  that  .5  per  cent  of  all  appendices  removed  by  operation 
are  tuberculous.  Tuberculosis  of  the  cecum  is  by  no  means  as  rare  as  we  used 
to  believe  (see  page  1 151).  Fistula  in  ano  is  frequently  tuberculous,  and  when  it 
is,  the  lungs  are  very  often  involved,  the  pulmonary  lesion  being  usually  primary. 

Tuberculosis  of  the  Liver. — Tuberculous  disease  of  the  liver  causes 
cold  abscess  or  cirrhosis.  Tuberculous  abscess  does  not  cause  elevation  of 
temperature  and  does  not  cause  eosinophilia  which  we  would  expect  a  hydatid 
cyst  to  inaugurate.  Typical  cirrhosis  without  tubercles  may  arise,  the  bacilli 
being  present  in  the  tissues.  Many  cases  of  supposed  alcoholic  cirrhosis  are 
probably  tuberculous.  The  hepatic  cirrhosis  which  may  arise  during  peritoneal 
tuberculosis  is  tuberculous. 

Peritoneal  tuberculosis  (see  page  1 165)  may  be  primary,  infection  having 
taken  place  by  way  of  the  blood,  may  be  part  of  a  diffused  process,  or  may  follow 
intestinal  tuberculosis,  the  serous  and  mucous  coats  of  the  bowel  having  been 
at  some  point  in  contact  or  a  follicular  ulcer  having  perforated  (Abbe).  The 
germ  may  have  entered  by  the  Fallopian  tube.  Tuberculous  peritonitis  may  be 
due  to  ovarian  or  Fallopian  tuberculosis,  or  to  ulceration  of  a  tuberculous  ap- 
pendix. In  some  cases  a  caseating  tuberculous  gland  furnishes  the  causative 
bacilli.  Peritoneal  tuberculosis  usually  causes  ascites,  tympany,  and  tumor- 
like formations  composed  of  adherent  bunches  of  bowel  or  omentum  or  dis- 
tended mesenteric  glands  (see  page  1165). 

Tuberculosis  of  the  Pancreas. — Tuberculous  sclerosis  of  this  organ  has 
been  induced  experimentally  by  Carnot. 

Tuberculosis  of  the  spleen  may  occur  with  tubercles  or  as  a  sclerosis. 

The  heart  muscle  is  rarely  attacked  by  tuberculosis.  In  fact,  valvular 
lesions  of  the  left  side  of  the  heart  actually  protect  the  individual  from  pul- 


Tuberculous  Disease  of  the  Joints  275 

monary  tuberculosis.  Non-tuberculous  endocarditis  may  arise  in  the  course 
of  a  tuberculous  process  elsewhere.  Tuberculous  endocarditis  does  occur  but 
very  rarely. 

The  endocardium  may  be  inflamed  and  covered  with  fibrous  exudate  as  a 
result  of  the  toxins  from  some  distant  point  of  tuberculosis. 

The  pericardium  may  be  attacked  with  primary  tuberculosis,  or  the 
process  may  be  secondary  to  pleural  tuberculosis.  There  may  or  may  not  be 
pulmonary  tuberculosis. 

Tuberculosis  of  the  brain  induces  meningitis  and  hydrocephalus  (see 
page  901). 

Tuberculosis  of  the  membranes  of  the  spinal  cord  is  seen  alone 
or  in  association  with  tuberculous  inflammation  of  the  brain. 

Tuberculous  disease  of  fascia  is  common;  in  fact,  fascia  is  peculiarly 
prone  to  infection.  Fascia  may  be  attacked  primarily,  and  when  it  is ,  the 
disease  is  apt  to  spread  rapidly  and  widely  and  to  produce  most  disastrous 
results.  The  elder  Senn  regards  tuberculosis  of  the  intermuscular  septa  of  the 
thigh  as  a  very  grave  condition,  which,  if  extensive,  demands  amputation  of 
the  limb.  Secondary  tuberculosis  of  fascia  is  far  more  common  than  the 
primary  form,  the  original  focus  of  disease  being  in  bone,  joint,  tendon-sheath, 
or  lymph-gland. 

Tuberculosis  of  muscle  is  rare.  Instances  of  primary  tuberculosis 
have  been  reported.  Secondary  tuberculosis  is  more  common,  but  even  this 
condition  is  rare,  muscle  seeming  to  have  a  high  degree  of  resistance. 

Tuberculous  disease  of  bone  (see  page  565)  is  very  common  in  youth, 
and  a  sprain  or  a  contusion,  which  is  oftener  slight  than  severe,  may  precede 
any  signs  of  the  disease.  The  injury  establishes  a  point  of  least  resistance,  and 
in  the  damaged  area  the  bacilli  are  deposited  and  multiply,  or  a  latent  area 
of  tuberculosis  is  roused  into  activity  by  the  traumatism.  The  organisms 
may  be  deposited  directly  from  the  lymph  or  blood,  or  may  arrive  in  an  embolus 
from  a  distant  tuberculous  focus  (lung  or  lymph-gland),  and  this  embolus  is 
caught  in  a  terminal  artery  in  the  end  of  a  long  bone  and  causes  a  wedge-shaped 
infarction. 

Tuberculous  osteomyelitis,  as  a  rule,  begins  just  beneath  the  articular 
cartilage  or  in  the  epiphysis.  There  may  be  one  focus,  several  foci,  or  many 
foci  in  the  same  bone.  The  products  of  the  tuberculous  inflammation  con- 
stitute tuberculous  nodules  which  destroy  the  medullary  tissue  and  hence 
cut  off  the  nutrition  of  adjacent  bone.  Bone  trabeculae  are  destroyed,  and 
tuberculous  granulations  take  their  place,  and  here  and  there  small  dead 
portions  of  bone  trabeculae  lie  as  sequestra  among  the  granulations.  In  some 
bones,  for  instance,  the  vertebrae  and  the  bones  of  the  carpus  and  tarsus,  the 
tuberculous  process  spreads  widely;  in  some,  it  tends  to  remain  locahzed. 
Tuberculous  granulations  may  be  absorbed,  may  be  encapsuled,  may  be 
replaced  by  fibrous  tissue,  or  may  caseate  (see  page  236).  When  an  osseous 
tuberculous  focus  in  the  shaft  of  a  long  or  short  bone  spreads  the  bone  enlarges 
and  becomes  spindle  shaped,  as  is  seen  in  a  phalanx  the  seat  of  tuberculous 
osteomyelitis,  the  condition  known  as  spina  ventosa. 

Tuberculous  diseeise  of  the  joints  (see  page  703)  is  called  white  swelling 
and  also  pulpy  degeneration  of  the  synovial  membrane.  Joints  are  especially 
liable  to  tuberculosis  in  youth,  although  the  wrist  and  shoulder  not  infrequently 
suffer  in  adult  life.  Joint-tuberculosis  is  often  preceded  by  an  injury  (page  565). 
The  tuberculous  process  in  rare  cases  begins  in  the  synovial  membrane.  Nichols 
examined  1 20  joints  (some  at  autopsy,  some  after  resection  or  amputation)  and 
found  one  or  more  live  foci  in  every  case.  Primary  synovial  tuberculosis  is 
most  often  met  with  in  the  knee-joint  and  next  in  the  shoulder.  Usually  the 
disease  begins  in  the  end  of  a  bone,  dry  caries  resulting,  necrosis  ensuing,  or 
an  abscess  forming,  which  may  break  into  the  joint. 


2'j6  Surgical   'I'libcrculosis 

Poncet's  rhmmalism  or  tuberculous  articular  rheumatism  is  a  condition  in 
which  toxic  joint  inflammation  is  evidence  of  latent  tuberculous  infection 
perhaps  at  some  distant  point,  it  being  often  impossible  to  demonstrate  the 
bacillus  in  the  joint  fluid  or  tubercles  at  the  autoj^sy  (see  page  704). 

Tuberculosis  of  lymphatic  glands  is  known  as  tuberculous  adenitis. 
It  is  the  most  typical  lesion  of  scrofula.  Tuberculous  adenitis  is  most  fre- 
quent between  the  third  and  fifteenth  years.  A  person  not  of  the  tuberculous 
type  may  acquire  tuberculosis  of  the  glands,  but  the  disease  is  unquestionably 
of  much  greater  frequency  in  those  who  are  recognized  as  predisposed  to  tuber- 
culosis. Tuberculous  glands  may  get  well,  may  even  calcify,  but  usually 
caseate  if  let  alone.  Long  after  healing  they  may  break  down  and  soften 
{residual  abscess  of  Paget).  They  very  frequently  suppurate  because  of  mixed 
infection.  Though  at  first  a  local  disease,  tuberculous  glands  may  prove  to  be 
a  dangerous  focus  of  infection,  furnishing  bacteria  which  are  carried  by  blood  or 
lymph  to  distant  organs  or  throughout  the  entire  system.  Glandular  enlarge- 
ment is  in  rare  instances  widely  diffused,  but  it  is  far  more  commonly  localized. 
Enlargement  of  the  cervical  glands  is  most  common.  Tuberculous  disease  of 
the  mesenteric  gland  is  known  as  tabes  mesenterica.  Tuberculosis  of  lymph- 
glands  may  be  due  either  to  bovine  bacilli  or  to  haman  bacilli. 

Tuberculosis  of  the  cervical  lymph=glands  is  a  very  common  condi- 
tion. It  is  most  common  in  children  over  two  years  of  age  and  is  often  seen  in 
young  adults.  It  is  rare  in  children  imder  two  and  in  persons  of  middle  age. 
In  the  majority  of  cases  infection  takes  place  from  the  tonsils,  pharynx,  or  pos- 
terior part  of  the  oral  cavity,  and  in  these  cases  the  first  glands  to  enlarge  are 
those  just  below  the  parotid  salivary  glands.  In  a  number  of  cases  enlargement 
begins  in  the  submaxillary  or  submental  glands,  and  in  these  cases  infection 
originates  from  the  teeth,  mouth,  or  face  (Dowd,  in  "Surgery,  G\Tiecology,  and 
Obstetrics,"  March,  1909).  A  tuberculous  lesion  of  the  scalp  may  be  followed 
by  tuberculosis  of  the  parotid  lymph-glands.  Cervical  adenitis  may  be  uni- 
lateral or  bilateral  and  is  a  very  chronic  condition.  It  is  predisposed  to  b}' 
enlargement  of  the  tonsils,  adenoids,  and  nasopharyngeal  catarrh.  In  young 
children  three-fourths  of  all  cases  are  due  to  bovine  bacilli  (page  239).  The 
enlargements  usually  arise  insidiously,  but  sometimes,  especially  after  whoop- 
ing-cough, measles,  or  scarlet  fever,  they  come  on  more  rapidly.  When  first 
observed  the  enlargements  are  small,  round,  firm,  isolated,  painless,  and  some- 
what movable.  As  they  enlarge  they  fuse  into  an  irregular  swelling  which  may 
be  quite  tender  and  is  always  anchored  to  surrounding  parts.  As  the  glands  case- 
ate  the  mass  softens,  the  skin  over  it  becomes  adherent  and  red,  and  finally 
breaks  open.  Cold  abscess  may  form  or  mixed  infection  with  pus  cocci  may 
take  place. 

Cervical  lymphadenitis  may  be  confused  with  lymphadenoma.  The  former, 
as  a  rule,  first  appears  in  the  submaxillary,  submental  or  parotid  lymph  glands, 
the  latter,  in  the  occipital  or  sternomastoid  glands.  The  mass  in  the  former  is 
more  tender,  softer,  and  less  movable  than  in  the  latter.  Tuberculous  glands 
weld  together,  they  are  apt  to  remain  localized  for  a  considerable  time,  and 
they  tend  to  soften.  The  younger  the  patient,  the  greater  the  probability 
of  softening.  In  adults  there  is  comparatively  slight  tendency  to  softening. 
Tuberculous  adenitis  may  be  accompanied  by  other  tuberculous  manifestations. 
Lymphadenoma  from  the  start  affects  many  glands;  it  may  arise  simultaneously 
in  several  regions,  although  in  some  cases  there  is  a  distinct  beginning  in  one 
region.  Lymphadenoma  shows  very  little  tendency  to  suppurate,  and  does  not 
break  down  except  late  in  the  course  of  the  disease,  and  is  accompanied  by 
great  debility  and  anemia.  Tuberculin  tests  may  aid  in  the  diagnosis,  but  a 
difficulty  is  that  Hodgkin's  disease  and  tuberculosis  may  coexist.  Malignant 
gland-tumors  infiltrate  adjacent  glands  and  other  structures,  binding  skin, 
muscles,  and  glands  into  one  hard,  firm  mass. 


Tuberculosis  of  the  Cervical  Lymj)h-<^lan(ls  277 

Tuberculous  cervical  adenitis  is  in  most  instances  a  reasonably  curable 
condition.  In  children  under  two  or  three  years  of  age,  however,  it  is  a  danger- 
ous condition  and  one  apt  to  be  associated  with  severe  pulmonary,  osseous,  or 
other  complications.  Some  cases  of  adenitis  can  be  cured  by  open-air  treat- 
ment, food,  medicine,  tuberculin,  the  .v-rays,  and  hygienic  care.'  In  many,  how- 
ever, operation  is  indicated  in  addition  to  such  treatment,  and  these  operations 
are  usually  successful  if  thoroughly  performed  when  the  disease  is  localized  and 
softening  has  not  occurred.  When  possible  operation  should  be  performed  when 
the  patient  is  at  the  seaside,  or,  at  least,  the  patient  should  convalesce  there  if 
circumstances  permit.  Thorough  extirpation  is  the  proper  operative  treatment 
and  any  diseased  condition  of  scalp,  face,  mouth,  tonsil,  teeth  or  nasopharynx  is 
to  be  corrected.  My  belief  is  that  about  75  per  cent,  of  cases  are  permanently 
cured  by  thorough  operation.  If  a  patient  is  well  five  years  after  operation  the 
cure  may  be  regarded  as  permanent.  Cured  cases  seldom  die  subsequently 
of  any  tuberculous  lesion. 

It  is  not  uncommon  after  removal  of  infected  glands  and  healing  of  the 
wound  to  have  several  or  numerous  small,  hard  nodules  form  beneath  the  skin 
in  the  area  operated  upon.  Dowd  extirpated  some  of  these  nodules  and 
found  they  were  not  tuberculous,  but  were  fibrous.  I  have  been  able  to  con- 
firm Dowd's  statement  in  several  of  my  own  patients. 

Medical  treatment  is  not  nearly  so  valuable  as  surgical  treatment  in  this 
form  of  tuberculosis.  If  medical  treatment  alone  is  relied  on,  many  of  these 
cases  develop  pulmonary  tuberculosis.  Attridge,  quoting  Demme  and  Dowd 
("Surgery,  Gynecology,  and  Obstetrics,"  Dec,  1908),  sets  the  number  which 
develop  it  when  medical  treatment  is  relied  on  at  21  per  cent.,  and  the  number 
developing  other  distant  tuberculous  lesions  at  8.2  per  cent. — a  total  of  29.2 
per  cent.,  and  these  figures  do  not  include  bone  infections  and  late  infections 
of  the  lymph-nodes.  Even  in  cases  supposed  to  have  been  cured  by  medical 
means  it  will  be  found  that  most  of  them  react  to  tuberculin,  showing  that 
lesions  are  latent  rather  than  cured.  Wohlgemuth  shows  that  complete 
removal  cures  75  per  cent,  of  cases;  curetting  and  drainage  cures  63  per  cent.; 
general  treatment,  24  per  cent.  (Attridge,  Ibid.).  In  a  series  of  100  cases  oper- 
ated upon  by  Dowd,  pulmonary  tuberculosis  arose  in  but  i  case  and  bone 
tuberculosis  in  3  cases.  If  miliary  tuberculosis  exists,  if  the  patient  is  much 
exhausted,  if  the  infection  is  not  definitely  localized,  or  if  an  internal  organ  is 
the  seat  of  active  tuberculosis,  operation  is  not  indicated. 

Death  seldom  follows  operation.  The  records  of  the  Victoria  Hospital,  Chel- 
sea, show  four  deaths  in  533  operations,  a  mortality  of  0.75  per  cent.  (Geoffrey 
Jefferson,  in  "Lancet,"  May,  9,  1914).  The  mortality  without  operation  is 
probably  10  per  cent.  Complete  extirpation  of  the  involved  group  of  glands  is 
practised  when  the  disease  is  well  localized.  If  it  is  not  well  localized  I  follow 
Attridge's  plan  (Ibid)  and  wait  until  it  becomes  so,  treating  the  patient  in  the 
interval  by  open-air  life,  nourishing  food,  medicine,  tuberculin,  and  the  .^•-rays. 
If  softening  occurs,  the  area  should  be  incised  and  curetted  and  the  exposed  sur- 
face should  be  treated  by  repeated  applications  of  tincture  of  iodin.  When 
healing  occurs,  extirpation  is  to  be  performed.  If  sinus  formation  exists, 
mixed  infection  has  occurred  or  will  occur  and  the  sinuses  must  be  curetted 
and  treated  with  iodin  until  they  heal,  when  the  glands  may  be  extirpated.  I 
do  not  believe  in  a  bilateral  extirpation  at  one  seance.  The  operation  even 
on  one  side  is  prolonged  and  bloody  and  is  all  the  patient  is  fit  to  stand.  If 
both  sides  of  the. neck  are  involved,  an  interval  of  several  weeks  should  be 
insisted  on  before  the  other  side  is  attacked.  Judd  insists  on  the  necessity  of 
hunting  up  and  removing  all  the  little  glands  external  to  the  sheath  of  the 
carotid  and  in  order  to  accomplish  this  makes  his  incision  in  the  posterior  tri- 
angle and  begins  his  glandular  removal  there  ("Collected  Papers  of  Mayo 
Clinic,"  1910-1911). 


278  Rachitis,  or  Rickets 

In  chronic  cases  of  cervical  lymphadenitis  it  is  invariably  necessary  to 
search  for  intra-oral  and  nasopharyngeal  disease,  and  if  such  disease  exists  it 
must  be  treated  before  the  glands  are  removed.  After  operation  rigid  open-air 
life  is  insisted  on. 

Tuberculosis  of  tendon=sheaths  {tuberculous  tenosynovitis)  is  discussed 
on  page  813. 

Tuberculosis  of  the  Kidney. — (See  page  1436.) 

Tuberculosis  of  adrenals  may  cause  sclerosis. 

Tuberculosis  may  attack  the  Fallopian  tubes,  ovaries,  or  uterus. 

Tuberculosis  of  the  urethra,  prostate  gland,  seminal  vesicles,  and 
bladder  is  considered  in  a  section  on  Regional  Surgery. 

Tuberculosis  of  the  Testicle  (see  page  i54i).^This  disease  is  not  rare. 
It  is  sometimes  primary,  but  is  usually  preceded  by  tuberculosis  of  the  kidney, 
bladder,  or  prostate.  But  one  testicle  is  affected  in  the  beginning,  but  the  other 
gland  is  apt  to  be  attacked  later.  The  tuberculous  mass  softens,  becomes 
adherent  to  the  scrotum,  and  breaks  or  bursts,  exposing  the  damaged  testicle 
{fungus  of  the  testicle).  The  cord  is  apt  to  be  involved  in  tuberculosis  of  the 
testicle. 

Typhobacillosis. — This  condition  was  described  by  Landouzy  in  1883. 
It  is  a  toxemia  in  which  the  localization  of  lesions  is  very  much  deferred 
and  is  preceded  by  a  prolonged  typhoid  or  septic  stage  (Matas,  "Southern 
Med.  Jour.,"  Oct.,  191 1).  Bacilli  of  tubercle  are  widely  distributed  through- 
out the  body,  but  for  a  long  time  there  are  no  tubercles  formed,  and  all  of 
the  symptoms  are  due  to  bacillary  poison.  Matas  describes  the  condition  as. 
"a  continued  fever  with  remissions  and  enlargement  of  the  spleen,  without 
signs  of  visceral  localization"  (Ibid-.).  It  strongly  resembles  typhoid,  but  the 
pulse  is  more  frequent,  the  temperature  is  less  regular,  there  are  no  spots, 
and  no  intestinal  or  bronchial  symptoms  pointing  to  typhoid.  Few  of  these 
cases  die  early.  Most  of  them  make  an  incomplete  recovery  after  several 
weeks,  and  in  periods  varying  from  weeks  to  months  develop  evident  localized 
tuberculosis. 

Acute  Miliary  Tuberculosis. — In  this  condition  an  organ,  several  or- 
gans, or  the  entire  body  is  infected  with  tubercle  bacilli  which  have  caused  the 
formation  of  multitudes  of  tubercles.  The  symptoms  for  a  time  resemble 
typhoid,  but  in  a  short  time  an  organ  or  organs  present  evidences  of  disease. 
Death  occurs  in  from  three  weeks  to  three  months. 


XIV.  RACHITIS,  OR  RICKETS 

Rickets  was  known  by  the  people  and  named  by  them  long  before  any  medi- 
cal man  had  written  of  it.  It  first  appeared  in  the  London  bills  of  mortality  in 
1634.  Glisson,  in  1650,  wrote  the  first  description  of  it  and  renamed  it  rachitis, 
because  of  the  commonly  resulting  spinal  curvature.  Rickets  is  a  chronic  dis- 
order of  nutrition  arising  during  the  early  years  of  life  (the  first  two  or  three) 
as  a  result  of  insufiicient  or  of  improper  diet,  aided  and  abetted  in  many  cases 
by  bad  hygienic  surroundings.  A  deficiency  of  fat  and  protein  and  an  excess  of 
starch  and  sugar  in  the  food  or  the  use  of  a  diet  which,  by  inducing  gastro- 
intestinal catarrh  lessens  and  perverts  assimilation,  causes  rickets.  The  disease 
is  not  common  in  nursing  children  unless  breast-feeding  has  been  unduly  pro- 
longed, and  children  fed  upon  artificial  foods  are  particularly  apt  to  develop 
it.  Holt  says  such  diet  is  very  deficient  in  fat  and  often  in  proteins,  and 
contains  an  excess  of  carbohydrates  ("Diseases  of  Infancy  and  Childhood"). 
Sir  J.  Bland-Sutton  made  some  valuable  experiments  to  indicate  the  injury 
done  animals  by  denying  them  natural  diet.  He  fed  lion  cubs  in  the  London 
Zoological  Gardens  on  raw  horse  meat  only  and  the  animals  developed  rickets. 


Evidences  of  Rickets  279 

The  London  cab  horses  were  not  noted  for  fat  and  the  young  lions  could  not 
crush  the  bones  and  reach  the  marrow.  The  rickety  animals  rapidly  recovered 
on  feeding  them  with  milk  and  powdered  bones  mixed  with  cod-liver  oil.  Some 
think  that  a  deficiency  of  phosphates  is  causal.  The  disease  is  essentially  a 
city  malady,  "being  principally  seen  in  children  living  in  crowded  tenements 
where  the  effects  of  improper  food  are  most  strikingly  shown;  yet  even  here 
the  disease  is  rare  in  those  who  get  a  plentiful  supply  of  good  breast  milk" 
(Holt,  Ibid.).  Rickets  is  characterized  by  incomplete  osteogenesis  and  other 
nutritive  failures,  but  it  must  not  be  regarded  as  a  bone  disease.  It  is  true  the 
bones  are  afTected,  but  so  are  various  other  structures  and  organs,  all  of  the  dis- 
orders being  due  to  an  underlying  nutritive  defect.  Some  maintain  that  lactic 
acid  or  some  other  toxic  material  produced  in  the  intestinal  canal  causes  bone 
inflammation,  but  most  observers  do  not  believe  the  bone  changes  are  inflam- 
matory. Children  are  very  seldom  born  with  rickets,  but  develop  it  later,  the 
period  of  greatest  liability  being  between  the  seventh  month  and  the  fifteenth 
month.  So-called  congenital  rickets  is  usually  sporadic  cretinism.  A  child 
with  rickets  may  become  scorbutic  {scurvy  rickets).  Some  regard  rickets  as 
the  result  of  an  infection.  Glisson,  in  the  seventeenth  century,  thought  it  was 
infectious.  Some  observers  claim  to  have  found  bacteria  in  rickety  bone  and 
in  the  cerebrospinal  fluid  of  rickety  children  (Mirculi,  Sorgente).  Others  think 
it  results  from  thymus  atrophy.  Some  blame  syphilis,  some  malaria,  some  the 
thyroid  gland,  some  the  hypophysis  cerebri,  some  the  nervous  system.  Some 
believe  that  disease  of  the  parathyroids  alters  calcium  metabolism — perhaps 
too  much  calcium  being  cast  out,  perhaps  too  little  being  taken  in  or  assimilated. 
Rickets  may,  perhaps,  be  a  deficiency  disease  due  to  the  absence  of  an  essential 
vitamin. 

Whatever  may  be  the  cause  of  rickets,  the  essential  condition  in  the  bones 
is  an  insufficient  deposit  of  mineral  matter  in  the  new  bone  cells.  The  bone, 
cartilage  and  periosteum  become  hyperemic,  cartilage  cells  grow  rapidly  and 
fail  to  calcify  properly.  The  new  bone  is  soft  and  vascular  and  bone  lamellae 
toward  the  medullary  canal  are  actually  absorbed.  There  is  excessive  pro- 
liferation of  cartilage  which  results  in  enlargement.  The  proliferating  and 
imperfectly  ossified  cells  cause  enlargements  at  the  ends  of  long  bones  and  at  the 
sternal  ends  of  the  ribs,  and  various  bones  bend  and  are  distorted.  The  parietal 
bones  bulge,  the  fontanels  remain  long  open;  there  may  be  unossified  gaps 
in  the  occipital  bone,  membrane  only  filling  them  (craniotabes) .  There  may 
be  pigeon-breast,  bent  long  bones,  curved  spine,  and  distorted  pelvis.  The 
bones  later  may  become  firmly  ossified  in  deformity.  In  rickets  the  spleen 
and  liver  are  enlarged  and  the  thymus  is  atrophied. 

Evidences  of  Rickets. — Rickets  is  apt  to  arise  in  the  spring,  but  may  begin 
any  time  of  the  year.  In  some  few  cases  it  begins  with  fever.  The  condition 
is  one  of  general  ill-health;  the  child  is  ill-nourished,  palHd,  and  flabby;  it  has  a 
tumid  belly  and  suffers  from  attacks  of  diarrhea  and  sick  stomach;  it  is  disin- 
clined to  exertion  and  has  a  capricious  appetite;  it  is  liable  to  sweating  of  the 
head  when  asleep;  the  sleep  is  restless  and  there  may  be  night  terrors;  enlarged 
glands  are  often  noted,  the  teeth  appear  behind  time,  and  the  fontanels  close 
late.  In  health  the  posterior  fontanel  closes  in  the  second  month  and  the  anterior 
fontanel  in  the  eighteenth  month.  In  rickets  the  anterior  fontanel  is  often 
open  when  the  child  is  three  years  of  age.  The  sutures  are  often  open  at  the 
end  of  the  first  year.  In  children  under  six  months  areas  of  softening  may 
be  felt  in  the  cranial  bones  (craniotabes) .  This  condition  is  most  common  if 
the  child  is  syphilitic.  The  head  is  square  in  shape,  the  cranial  bones  are  thick, 
and  areas  of  thickening  known  as  bosses  appear  over  the  parietal  bones.  The 
head  is  large  and  the  forehead  bulges.  The  long  bones  become  much  curved, 
the  upper  part  of  the  chest  sinks  in,  curvature  of  the  spine  appears,  and  the 
pelvis  is  distorted.     The  ligaments  are  relaxed  and  lengthened  and  the  joints 


28o 


Rachitis,  or  Rickets 


are  wobblv.  The  muscles  are  feeble  and  ill-developed.  Infantile  convulsions 
are  common.  The  liver  and  spleen  are  enlarged.  Nocturnal  restlessness 
and  night  terrors  are  the  rule.  Laryngismus  stridulus  and  tetany  may  occur. 
Swelling  appears  in  the  articular  heads  of  long  bones,  by  the  side  of  the  epiphyseal 
cartilages,  and  in  the  sternal  ends  of  the  ribs,  forming  in  the  latter  case  rachitic 
heads  (the  rachitic  rosary).  The  lesions  of  rickets  are  due  to  imperfect  ossifica- 
tion of  the  animal  matter  which  is  prepared  for  bone  formation,  and  the  soft 
bones  gradually  bend.  The  swellings  at  the  articular  heads  are  due  to  pressure 
forcing  out  the  soft  bone  into  rings.  Rachitic  children  rarely  grow  to  full  size, 
and  the  disease  is  responsible  for  many  dwarfs.  Most  cases  recover  without 
distinct  deformity,  but  the  time  lost  during  the  period  when  active  development 
should  have  gone  on  cannot  be  made  up,  and  some  slight  deficiency  is  sure  to 
remain.  Bow-legs,  knock-knees,  and  spinal  curvatures  are  usually  rachitic  in 
origin.  The  disease  may  be  associated  with  scurvy,  inherited  syphilis,  or 
tuberculosis.  In  appearance  the  rickety  child  is  pot-bellied,  pale  and  anemic, 
and  usually  fat  and  flabby,  though  occasionally  thin.  The  spleen  may  be 
enlarged.  There  is  great  liability  to  enlargement  of  the  tonsils,  gastro-intestinal 
catarrh,  and  bronchial  catarrh.     The  blood  is  deficient  in  red  corpuscles  and 

hemoglobin,  and  sometimes 
there  is  leukocytosis.  The 
disease  lasts  for  many 
months  and  is  usually  re- 
covered from.  It  does  not 
directly  produce  death,  but 
is  a  powerful  indirect  cause 
of  infant  mortality  because 
it  lessens  resistance  and 
predisposes  to  many  diseases. 
It  is  almost  always  afebrile, 
rarely  congenital,  and  in  un- 
usual cases,  knowm  as  late 
rickets,  develops  between  the 
fifth  and  tenth  year.  The 
so-called  acute  rickets  is 
practically  always  scur\y 
(Holt).  The  victims  of  ra- 
chitis are  very  liable  to  fracture  the  bones  from  slight  force  and  green-stick 
fractures  are  particularly  prone  to  occur  (Fig.  109).  After  fracture  of  a  rickety 
bone  union  is  usually  delayed. 

Prevention  of  rickets  is  secured  by  seeing  to  it  that  the  pregnant  woman  has 
a  generous  diet  and  that  she  should  nurse  her  o\\xv  child  if  it  thrives  on  her 
breast  milk  (W.  L.  Rost,  in  ''N.  Y.  Med.  Jour.,"  1915,  cii).  Should  artificial 
feeding  become  necessary,  pure,  raw  milk  should  be  used  and  elaborate  formulae 
are  to  be  regarded  as  anathema. 

The  treatment  consists  in  having  the  child  live  as  much  as  possible  in  the 
open  air  and  sunshine.  Salt-water  baths  are  useful.  Sea  air  is  very  beneficial. 
Fresh  food  (milk,  cream,  and  meat-juice)  should  be  ordered.  Prune  juice 
and  orange  juice  are  of  service.  As  the  child  grows  older  it  can  be  given  eggs, 
broths  of  vegetables  and  cereals  (Rost,  Ibid.).  Cod-liver  oil,  syrup  of  the 
iodid  of  iron,  arsenic,  and  some  form  of  phosphorus  are  to  be  administered. 
Some  give  thymus  extract,  others  administer  pituitrin.  It  is  absolutely 
necessary  to  improve  the  primary  assimilation.  During  the  acute  and  pro- 
gressive stage  keep  children  off  their  feet  in  order  to  prevent  deformities. 
Slight  deformities  of  the  extremities  require  no  special  treatment  unless  they 
increase.  If  the  deformity  is  marked  or  is  increasing,  use  braces;  employ  mas- 
sage, manipulation,  and  faradism.     By  the  time  the  child  is  three  years  of  age 


109. — Fracture  of  femur  in  rickets. 


Scorbutus   (Scurvy)  281 

the  bones  are  usually  so  firm  that  the  pressure  of  a  brace  cannot  cure  the  de- 
formity, though  the  real  test  of  brace  efficiency  is  the  degree  of  elasticity 
present  in  the  bones,  as  determined  by  the  surgeon's  hands.  After  the  age 
of  three  braces  are  commonly  useless.  Pronounced  established  deformities 
of  the  extremities  are  usually  treated  surgically.  Kyphosis  is  treated  by  making 
the  patient  lie  upon  a  hard  bed  without  a  pillow.  The  child  sits  up  a  few  hours 
each  day,  the  shoulders  being  held  back  and  support  applied  to  the  body.  In 
bad  cases,  during  the  time  the  child  is  erect  it  should  wear  a  brace  or  plaster- 
of-Paris  jacket.  Daily  manipulation,  the  child  lying  prone,  is  helpful.  Friction 
of  and  electricity  to  the  spinal  muscles  do  good. 

Scorbutus  (Scurvy). — Many  ancient  writers  described  symptoms  which 
must  have  been  due  to  scurvy.  For  instance,  Pliny,  speaking  of  the  army  of 
Germanicus  when  near  the  Rhine,  describes  a  condition  of  illness  characterized 
by  sore  gums,  falling  out  of  teeth,  and  weakness  of  the  legs.  Voyagers  in  the 
fifteenth  century  noted  symptoms  which  we  now  know  were  caused  by  scurvy. 
In  Vasco  da  Gama's  voyage  around  the  Cape  of  Good  Hope  more  than  half  of 
his  crew  perished  of  what  was  certainly  scurvy.  It  seems  to  have  been  first 
specifically  described  early  in  the  sixteenth  century.  A  most  graphic  picture 
of  scurvy  as  it  used  to  occur  at  sea  will  be  found  in  "A  Voyage  Around  the 
World  in  1740,  by  Lord  Anson,"  compiled  by  the  Rev.  R.  Walter,  chaplain 
of  the  "  Centurion."  Scurvy  is  rare  to-day  in  adults,  but  was  at  one  time  very 
common  among  those  who  took  long  voyages,  or  who  engaged  in  campaigns,  or 
were  the  victims  of  sieges,  and  was  quite  common  even  in  cities.  Poupart 
describes  it  as  he  saw  it  in  the  St.  Louis  Hospital  of  Paris  early  in  the  eighteenth 
century.  It  was  common  during  the  siege  of  Paris.  Of  recent  3'ears  it  is  very 
uncommon,  and  has  occurred  chiefly  among  voyagers  in  the  Artie  and  Antarctic 
regions  or  those  who  were  beleaguered.  Hopkins  ("Jour.  Am.  Med.  Assoc," 
191 7,  Ixix)  saw  3000  cases  of  scurvy  in  the  year  191 5  in  the  Island  of  Aruba,  a 
small  island  of  the  West  Indies.  In  this  island  from  April  to  November  no 
fresh  vegetables  are  obtainable  and  bad  well  water  is  used  for  drinking.  It 
can  occur  in  any  part  of  the  world,  on  land  or  sea.  There  has  been  more  or 
less  scurvy  among  soldiers  in  this  war.  It  has  been  noticed  among  those  on 
short  vegetable  rations.  Among  the  British  troops  in  Mesopotamia  scurvy  has 
not  been  common  but  great  numbers  of  Indian  soldiers  were  attacked  (jNIajor 
Turner,  in  "Brit.  Med.  Jour.,"  July  14,  191 7).  Some  years  ago  I  saw  several 
cases  in  the  Philadelphia  almshouse.  It  is  important  to  remember  that  though 
scurvy  is  rare  in  adults,  it  is  by  no  means  uncommon  in  ill-nourished  infants. 

Scurvy  is  a  constitutional  malady  due  to  the  consumption  of  improper  diet, 
and  especially  to  the  employment  of  a  diet  characterized  by  the  absence  of 
vegetables. 

The  use  of  salt  meat  as  a  staple  article  seems  to  favor  the  production  of 
the  disease,  but  scurvy  can  occur  when  there  was  not  a  salty  diet,  and  in- 
crease of  sodium  chlorid  in  the  blood  is  not  characteristic  of  scurvy,  but  occurs 
in  various  forms  of  anemia.  Garrod  considered  absence  of  potassium  salts 
to  be  the  real  cause.  The  diminution  of  potassium  salts  he  supposed  to  be  re- 
sponsible for  diminished  alkalinity  of  the  blood,  but  we  know  that  diminished 
alkalinity  is  common  in  all  forms  of  secondary  anemia.  Some  consider  absence 
of  malat'es  the  cause.  Absence  of  variety  in  diet,  bad  water,  poorly  ventilated 
quarters,  and  insufficient  exercise  favor  the  development  of  the  disease.  Some 
believe  that  an  organic  poison  derived  from  tainted  food  is  responsible  (Torup) . 
A  bacterial  origin  has  been  suggested  by  Berthenson,  Babes,  and  others.  Cer- 
tain studies  made  in  the  Transvaal  suggest  the  bacterial  origin  of  scurvy.  Myer 
Coplans  ("Lancet,"  June  18,  1904)  states  that  it  occurred  in  those  getting 
excellent  rations  and  began  as  inflammation  of  the  gums,  the  constitutional 
symptoms  following.  If  the  gum  condition  was  recognized  early  and  cured  simply 
by  cleanliness  and  antiseptics,  that  is,  by  pure  local  treatment,  constitutional 


2«2 


Rachitis,  or  Rickets 


trouble  did  not  develop.  Goadly  ("Brit.  Med.  Jour.,"  1910)  showed  that  the 
mouth  of  a  scurvy  patient  is  acid  to  litmus,  and  even  though  there  is  no  dental 
caries,  and  in  most  cases  there  is  early  inflammation  of  the  gums.  Hewetson 
examined  400  South  African  males,  varying  in  age  from  fifteen  to  thirty-five. 
He  found  134  with  scorbutic  gums,  although  they  seemed  in  good  health 
("Transvaal  Medical  Journal,"  April,  191 1).  Many  think  scurvy  is  due  to  the 
absence  of  a  vitamin  which  is  contained  in  fresh  meat,  milk  and  certain  vege- 
table juices.  McCollum  and  Pitz  ("Jour.  Biological  Chemistry,"  191 7,  xxxi) 
after  studying  experimental  scurvy  on  guinea-pigs  point  out  that  in  guinea-pigs 
dead  of  scurvy  the  cecum  is  found  distended  with  pasty  feces  and  that  scurvy 
can  be  prevented  if  this  cecal  distention  is  prevented  by  mineral  oil  or  other 
cathartics.     The  authors  do  not  accept  the  vitamin  theory  of  scurvy. 

The  efifect  of  great  depression  of  spirits  in  predisposing  to  scurvy  and  in 
aggravating  cases  of  scurvy  has  often  been  commented  on.  During  the  siege  of 
Breda  in  1625  scurvy  was  rife.  Bad  news  rapidly  increased  the  number  of 
cases.     Good  news  checked  it.     Anson  made  a  similar  observation. 


1  h(_'  u'ums  in  m.  urvv. 


Scurvy  begins  with  sore  gums,  weakness,  drowsiness,  muscular  pains,  and 
great  susceptibility  to  cold.  The  skin  is  pallid  or  dirty  white,  and  is  occasionally 
mottled  and  often  peels  off.  The  patient  is  breathless  on  the  slighest  exer- 
tion. The  pulse  is  excessively  weak  and  slow.  There  is  no  fever  unless  a  com- 
plication arises.  The  gums  are  often  tender  and  inflamed  from  the  start,  but  in 
some  cases  they  are  not.  After  two  or  three  weeks  in  all  cases  usually  the  gums 
are  found  to  be  tender,  painful  and  swollen,  and  bleeding  at  frequent  intervals; 
the  breath  becomes  offensive,  the  teeth  loosen  and  even  drop  out;  subcutaneous 
hemorrhages  take  place,  giving  rise  to  petechiae  or  extensive  extravasations;  the 
vision  becomes  dim;  the  urine  becomes  scanty  and  of  low  specific  gravity; 
cutaneous  vesicles  form,  rupture,  and  give  rise  to  bleeding  ulcers,  and  ulcers 
likewise  arise  from  breaking  down  of  blood  extravasation;  hemorrhages  take 
place  into  and  between  the  muscles,  and  in  severe  cases  beneath  the  periosteum 
and  into  joints,  and  blood  may  flow  from  the  nose,  lungs,  kidneys,  stomach,  and 
intestines.  Deep  hemorrhages  are  palpable  as  hard  lumps.  Bleeding  at  an  epi- 
physeal line  may  separate  the  epiphysis  from  the  shaft.  If  an  inflammation 
or  ulceration  arises  at  any  point,  fever  is  observed.     In  many  cases  blood-clotting 


Infantile  Scurvy  or  Barlow's  Disease  283 

is  retarded.  Wright  maintains  that  there  is  diminished  alkahnity  of  blood  and 
that  scurvy  is  really  acid  intoxication.  Other  observers  dispute  this.  The 
examination  of  corpuscles  and  hemoglobin  gives  a  picture  identical  with  second- 
ary anemia.  As  a  rule  the  red  cells  number  from  3,000,000  to  4,000,000  per 
c.mm.,  but  may  fall  to  1,000,000  or  even  less.  Hemoglobin  loss  is  more  marked 
than  corpuscular  diminution,  hence  the  color-index  is  low.  There  is  usually  an 
increase  in  leukocytes.  Major  Turner  in  describing  scurvy  among  the  British 
troops  in  Mesopotamia  says  that  it  was  sometimes  made  manifest  by  an  other- 
wise inexplicable  hemorrhage,  by  very  slow  healing  of  a  wound  or  ulcer,  and 
in  some  cases  developed  during  an  illness,  the  patient  having  been  fed  for  a  long 
time  on  sterilized  food  ("Brit.  Med.  Jour.,"  July  14,  1917).  It  was  observed 
by  DeHaven,  who  commanded  the  Grinnell  expedition  in  search  of  Sir  John 
Franklin,  that  scurvy  causes  old  and  soundly  healed  wounds  to  ulcerate.  The 
same  observation  was  made  years  before  in  Lord  Anson's  voyage.  A  sailor 
of  the  "Centurion"  had  been  wounded  fifty  years  before  at  the  battle  of  the 
Boyne.  He  developed  scurvy  and  the  old  wound  opened.  In  another  case 
an  old  and  soundly  united  fracture  gave  way  and  felt  like  a  fresh  break. 
Most  cases  of  scurvy  get  well  under  proper  treatment,  but  complete  recovery 
is  not  attained  for  a  long  time.  Sudden  death  is  liable  to  occur  if  any  ex- 
ertion is  made.  The  lightest  exercise  may  be  fatal.  Even  moving  a  man 
while  he  is  lying  down  may  cause  death.  Many  cases  while  quiet  and  re- 
cumbent feel  well,  eat  well,  sleep,  make  no  complaint  of  pain,  and  yet  even 
slight  movement  may  cause  death.  Nansen  is  said  to  attribute  the  loss  of 
the  gallant  Scott  and  his  companions  in  the  Antarctic  to  scurvy,  the  effort 
necessary  to  climb  a  glacier  being,  in  his  opinion,  the  cause  of  death. 

Prevention  and  Treatment. — Captain  Cook  succeeded  in  preventing  scurvy 
among  his  sailors  by  providing  plenty  of  fresh  water;  guarding  them  against 
fatigue,  wet,  and  extremes  of  heat  and  cold;  attending  to  cleanliness  and  ventila- 
tion, and  stimulating  cheerfulness.  This  great  navigator  lost  no  men  from 
scurvy.  Long  before  the  time  of  Captain  Cook,  in  1795,  the  British  Admiralty, 
acting  on  the  suggestions  of  James  Lind  (1757)  and  Sir  Gilbert  Blane  (1785), 
provided  ships  with  lime-juice  or  lemon-juice  with  the  most  beneficial  results 
in  preventing  the  disease.  As  a  matter  of  fact,  lemon-juice  was  suggested  by 
John  Woodhall  long  before  the  time  of  Lind  and  Blane;  Woodhall  proposed  it 
in  1636,  Huxham,  in  1747,  recommended  a  vegetable  diet.  Until  comparatively 
recent  years  sailors  of  the  United  States  Navy  were  accustomed  to  refer  to  sailors 
of  the  British  Navy  as  "lime- juicers."  Scurvy  is  prevented  at  the  present  time 
by  employing  a  proper  diet  and  by  maintaining  cleanliness  and  hygienic 
conditions. 

The  following  agents  are  believed  to  be  especially  useful  as  preventives :  fresh 
meat,  orange  juice,  lemon-juice,  cider,  vinegar,  milk,  eggs,  onions,  cranberries, 
cabbages,  pickles,  potatoes,  juice  squeezed  from  a  partly  cooked  beef  steak,  lime- 
juice,  and  citrate  of  sodium  or  potassium.  When  the  disease  develops,  give 
vinegar,  lemon-juice,  onions,  scraped  apples,  cider,  salts  of  calcium,  citric  acid, 
arsenic  or  iron,  whisky  or  brandy,  and  plenty  of  nourishing  food.  Lind  used, 
with  great  success  in  many  cases,  4^-^  oz.  of  lemon-juice  or  Ume-juice  and  2  oz.  of 
sugar  in  a  pint  of  Malaga  wine.  This  was  taken  during  each  twenty-four  hours. 
In  twenty-four  hours  improvement  was  manifest.  Antiseptic  mouth- washes 
are  necessary  and  strychnin  is  a  valuable  stimulant  to  the  circulation.  Sleep 
must  be  secured  and  ulcers  are  treated  by  antiseptic  dressings  and  compression. 
In  a  very  grave  case  transfusion  of  blood  should  be  practised. 

Infantile  scurvy  or  Barlow's  disease  may  exist  alone  or  with  rickets  (scurvy 
rickets) .  It  occurs  most  often  in  the  children  of  the  well-to-do,  those  who  have 
been  brought  up  on  artificial  foods,  in  fact,  only  children  who  are  fed  on  arti- 
ficial foods  or  on  unsuitable  breast  milk  get  it.  SteriHzed  milk,  condensed  milk, 
boiled  milk,  stale  mijk,  or  other  artificial  food  may  be  responsible.     It  may  occur 


284  Contusions  and  Wounds 

in  a  breast-fed  baby  if  lactation  has  been  inordinately  prolonged.  It  occurs  most 
frequently  between  the  eighth  and  eighteenth  months  of  life.  It  is  noted  that 
the  child  has  lost  its  appetite,  is  losing  weight,  has  perhaps  lost  the  use  of  its 
legs,  lies  quiet  with  the  thighs  flexed  and  abducted,  cries  when  touched  and  when 
it  fears  it  is  going  to  be  touched  (Grasty,  in  "Amer.  Jour.  Obstet.,"  1910). 
The  child  is  anemic,  suffers  from  gastro-intestinal  disorders,  spongy  and  bleeding 
gums  if  teeth  have  erupted,  weakness  of  the  legs,  general  muscular  tenderness, 
night-sweats,  and  often  febrile  attacks  (Rotch),  bleeding  from  the  nose,  bleeding 
beneath  the  skin  (blue  spots),  bloody  urine  and  stools,  bleeding  beneath  the 
periosteum,  into  joints,  viscera,  or  muscles.  In  some  cases  hematuria  is  the 
first  and  perhaps  the  only  symptom  (J.  Lovett  Morse,  ''Jour.  Am.-  Med.  Assoc," 
Dec.  17,  1904).  A  subperiosteal  hemorrhage  is  very  dense  to  palpation,  is  ten- 
der, is  fusiform  in  outline,  and  does  not  fluctuate.  It  is  sometimes  mistaken  for 
sarcoma.  In  i  case  seen  by  the  author  a  hemorrhage  beneath  the  periosteum 
of  the  femur  was  mistaken  for  a  sarcoma.  The  limb  attacked  is  flexed  and  the 
child  will  not  move  it.  In  another  case  hemorrhage  into  the  knee-joint  was 
thought  to  be  inflammatory  effusion  from  traumatism.  Separation  of  an  epiph- 
ysis may  result  from  hemorrhage  between  it  and  the  bone.  Infantile  scurvy 
is  often  unrecognized.  If  promptly  treated,  recovery  is  the  rule,  otherwise 
death  may  occur  from  exhaustion. 

Treatment. — Keep  the  child  quiet  in  bed  and  give  liberal  amounts  of  fresh 
and  raw  cow's  milk  and  beef-juice  squeezed  from  a  partly  cooked  steak.  Ad- 
minister orange-juice,  grape-juice,  scraped  apples,  and  tonics.  To  children 
over  one  year  of  age  give  potatoes.  Antiseptic  mouth-washes  are  necessary. 
In  a  very  grave  case  transfusion  is  indicated. 


XV.  CONTUSIONS  AND  WOUNDS 


Contusions. — A  contusion  or  bruise  is  a  subcutaneous  laceration  due  to 
the  application  of  blunt  force,  the  surrounding  skin  being  uninjured  or  damaged 
without  a  surface-breach  and  blood  being  effused.  Punches,  kicks,  blows 
from  a  blackjack,  etc.,  cause  contusions.  In  intra-abdominal  contusions 
the  skin  of  the  abdomen  is  frequently  not  damaged.  In  contusions  of  struc- 
tures overlying  a  bone  the  skin  suffers  with  the  deeper  structures.  If  a  large 
vessel  is  ruptured  hemorrhage  is  profuse  and  much  blood  gathers  in  the  tis- 
sue. If  only  small  vessels  suffer  hemorrhage  is  moderate.  An  ecchyttwsis 
is  diffuse  hemorrhage  over  a  large  area,  the  Ijlood  lying  in  the  spaces  of  the 
subcutaneous  or  submucous  areolar  tissue.  A  very  small  ecchymosis  is  knoum 
as  a  petechia;  a  very  large  ecchymosis  is  called  a  sufusion  or  extravasation.  A 
hematoma  is  a  blood-tumor  or  a  circumscribed  hemorrhage,  the  blood  lying  in  a 
distinct  cavity  in  the  tissue.  In  extremely  severe  contusions  tissue  vitality 
may  be  destroyed  or  so  seriously  impaired  that  gangrene  follows.  Suppuration 
rarely  occurs,  but  occasionally  does  so,  and  is  most  apt  to  in  a  drunkard  or 
a  person  of  debiUtated  constitution.  A  contusion  may  lead  to  thrombosis 
and  embolism.  When  hemorrhage  arises  in  the  tissues  after  a  contusing 
force  it  soon  ceases  unless  a  very  considerable  vessel  is  ruptured.  The  arrest 
of  hemorrhage  is  brought  about  by  the  resistance  of  the  tissues,  the  con- 
traction and  retraction  of  the  vessels,  coagulation  of  blood,  and  in  some  cases 
of  severe  injury  coagulation  is  favored  by  syncope.  Blood  in  the  tissues,  as 
a  rule,  soon  coagulates,  the  fluid  elements  being  absorbed  and  the  red  cor- 
puscles breaking  up  and  setting  free  pigment,  which  may  be  carried 
away  from  the  seat  of  injury  or  may  crystalUze  and  remain  there  as  hema- 
toidin.  In  some  cases  inflammation  occurs  about  the  extravasated  blood, 
a  capsule  of  fibrous  tissue  being  formed,  and  the  blood  being  slowly  absorbed 


Local  Phenomena  of  Wounds  285 

or  the  fluid  elements  remaining  unabsorbed  (blood-cysf),  or  the  blood  becoming 
thicker  and  thicker,  and  finally  calcifying.  Blood  in  serous  sacs  (joints,  pleura, 
pericardium)  coagulates  very  slowly.  As  blood  is  being  absorbed  it  under- 
goes chemical  changes  and  color  changes  ensue,  the  part  being  at  first  red  and 
then  becoming  purple,  black,  green,  lemon,  and  citron.  The  stain  following 
a  contusion  is  most  marked  in  the  most  dependent  area.  After  a  bruise  of  the 
periosteum  a  blood-clot  forms,  much  tissue-induration  occurs,  and  a  hard  edge 
can  be  detected  by  palpation  at  the  margin  of  the  clot.  Drunkards,  the  obese, 
opium  habitues,  tea  inebriates,  anemic  persons  and  many  neurotic  individuals 
may  develop  extensive  bruising  from  slight  force. 

Symptoms.^ — The  symptoms  are  tenderness,  swelling,  and  numbness, 
followed  by  some  aching  pain  or  a  feeling  of  soreness.  The  pain  rarely  per- 
sists beyond  the  first  twenty-four  hours.  Cutaneous  discoloration  appears 
quickly  in  superficial  contusions,  but  only  after  days  in  deep  ones.  In  some 
regions — the  scalp,  for  instance — it  can  scarcely  be  detected;  in  others,  as  in 
the  eyelid  and  vulva,  discoloration  is  early,  widespread,  and  marked.  Dis- 
coloration and  swelling  are  very  marked  in  regions  where  loose  cellular  tissue 
abounds  (eyelids,  prepuce,  scrotum).  The  swelling  is  primarily  due  to 
blood,  and  is  added  to  by  inflammatory  exudation.  In  a  more  severe 
contusion  a  hematoma  may  form.  A  recent  hematoma  fluctuates,  but 
gradually,  because  of  cell-proliferation,  the  edge  becomes  hard,  but  the  center 
continues  to  fluctuate.  The  mass  gradually  grows  smaller  and  finally  dis- 
appears. A  subperiosteal  hematoma  of  the  scalp  may  be  mistaken  for  depressed 
fracture  of  the  skull.  Any  form  of  hematoma  of  the  scalp  may  be  mistaken 
for  an  abscess,  but  differs  from  it  in  the  absence  of  inflammatory  signs.  It 
occasionally,  though  rarely,  suppurates.  In  a  case  in  which  suppuration  occurs 
an  abrasion,  which  may  be  very  minute,  often  exists  on  the  skin.  In  any 
severe  contusion  there  is  considerable  and  possibly  grave,  or  even  fatal,  shock. 

Treatment. — In  a  severe  injury  bring  about  reaction  from  the  shock. 
Local  treatment  consists  in  rest,  elevation,  and  compression  to  arrest  bleeding, 
antagonize  inflammation,  and  control  swelling.  Cold  is  useful  early  in  most 
cases,  but  it  is  not  suited  to  very  severe  contusions  nor  to  contusions  in  the 
debilitated  or  aged,  as  in  such  cases  it  may  cause  gangrene.  In  very  severe 
contusions  employ  heat  and  stimulation.  When  inflammation  is  subsiding 
after  a  contusion,  compression  and  inunctions  of  ichthyol  should  be  employed. 
If  the  amount  of  blood  is  very  large,  massage  must  not  be  used  because  it  may 
cause  embolism  or  fat-embolism.  If  a  distinct  cavity  exists,  aspiration  or 
incision  lessens  the  danger  of  fat-embolism.  A  contusion  should  never  be 
incised  unless  the  amount  of  blood  is  large  and  a  distinct  cavity  exists,  or 
hemorrhage  continues,  or  infection  takes  place,  or  a  lump  remains  for  some 
weeks,  or  gangrene  is  threatened.  For  persistent  bleeding  freely  lay  open 
the  contused  area,  turn  out  clots,  ligate  vessels,  insert  drainage-strands  or 
a  tube,  and  close  the  wound.  If  gangrene  is  feared,  make  incisions  and  apply 
heat  to  the  part;  If  a  slough  forms,  employ  antiseptic  fomentations.  The 
constitutional  treatment  for  contusion,  after  the  patient  has  reacted  from  shock, 
is  the  same  as  that  for  inflammation.  (See  Abdomen,  etc.)  Massage  and 
passive  motion  are  imperatively  needed  after  contusion  of  a  joint. 

Wounds. — A  wound  is  a  breach  of  surface  continuity  effected  by  a  sudden 
mechanical  force.  Wounds  are  divided  into  open  and  subcutaneous,  septic 
and  aseptic,  incised,  contused,  lacerated,  punctured,  gunshot,  stab,  and  poi- 
soned wounds. 

The  local  phenomena  of  wounds  are  pain,  hemorrhage,  loss  of  func- 
tion, and  gaping  or  retraction  of  edges. 

Pain  is  due  to  the  injury  of  nerves,  and  it  varies  according  to  the  situation 
and  the  nature  of  the  injury.  It. is  influenced  by  temperament,  excitement, 
and  preoccupation.     It  may  not  be  felt  at  all  at  the  time  of  injury.     Early 


286  Contusions  and  Wounds 

it  is  usually  acute,  becoming  later  dull  and  aching.  In  an  aseptic  wound  the 
pain  usually  remains  slight,  but  in  an  infected  wound  it  always  becomes  severe. 

The  nature  and  amount  of  hemorrhage  vary  with  the  state  of  the  system, 
the  vascularity  of  the  part,  and  the  variety  of  injury. 

Loss  of  function  depends  on  the  situation  and  extent  of  the  .injury. 

Gaping  or  retraction  of  edges  is  due  to  tissue  elasticity,  and  varies  according 
to   the  tissues  injured  and  the  direction,  nature,  and  extent  of  the  wound. 

The  constitutional  condition  arising  after  a  severe  injury  is  a  state  known 
as  shock. 

Shock. — The  condition  was  known  to  the  ancients.  The  name  is  compara- 
tively modern.  The  term  "shock"  was  introduced  in  1795  by  James  Latta  to 
designate  the  condition  ensuing  upon  severe  injury.  (See  G.  C.  Kinnaman, 
in  "Annals  of  Surg.,"  Dec,  1903.)  Shock  is  a  general  depression  of  the  vital 
powers  arising  from  an  injury  or  a  profound  emotion.  As  the  elder  Gross  said: 
"Shock  is  a  rude  unhinging  of  the  entire  machinery  of  life."  There  are  many 
theories  as  to  the  cause  and  essential  nature  of  shock.  ^  No  theory  is  entirely 
satisfactory.  Some  attribute  it  to  failure  on  the  part  of  the  adrenals  to  furnish 
sufficient  adrenalin  to  sustain  vascular  tone  (J.  E.  Sweet,  Collective  Review  in 
"International  Abstract  of  Surgery,"  June,  1916).  Henderson  thinks  it  due  to 
a  deficiency  of  carbon  dioxid  in  the  blood  (acapnia).  Boise  claims  that  shock  is 
due  to  cardiac  spasm  followed  by  exhaustion.  Meltzer  looks  upon  shock  as  inhi- 
bition of  the  bodily  functions  in  general.  The  theory  that  shock  is  the  result 
of  vasomotor  failure  was  advocated  by  Keen  and  Mitchell  over  fifty  years  ago. 
The  great  modern  advocate  of  this  view  is  Crile.  Certain  it  is  that  loss  of  blood- 
pressure  is  the  most  obvious  phenomenon  of  shock.  The  vasomotor  theory 
maintains  that  there  is  exhaustion  or  inhibition  of  the  vasomotor  mechanism. 
Exhaustion  is  gradually  induced;  inhibition  is  suddenly  produced.  It  is 
supposed  that  by  overstimulation  of  sensory  nerves  violent  impressions  are 
conveyed  to  the  nerve-centers,  the  vasomotor  center  is  exhausted  or  inhib- 
ited, vasoconstrictor  power  is  lost,  the  peripheral  arteries  and  capillaries  are 
palsied  and  are  depleted  or  nearly  emptied  of  blood,  and  the  blood  is  largely 
transferred  to  the  veins.  The  blood-pressure  is  lowered,  the  cardiac  action  is 
impaired,  the  respiratory  action  is  impeded,  and  quantities  of  dark-colored 
blood  gather  in  the  somatic  veins,  but  especially  in  the  veins  of  the  splanchnic 
area.  (See  the  masterly  study  of  "  Surgical  Shock,"  by  Crile.)  Although  this 
theory  finds  wide  acceptance,  some  able  investigators  do  not  accept  it.  In 
shock  the  abdominal  veins  are  greatly  distended  and  the  other  veins  of  the  body 
may  also  be  overfull,  the  arteries  contain  less  blood  than  normal,  and  an  insuffi- 
cient amount  of  blood  is  sent  to  the  heart  and  to  the  vital  centers  in  the  brain. 
In  other  words,  in  shock  there  is  a  deficiency  in  the  circulating  blood.  In  grave 
shock  so  much  blood  is  imprisoned  in  the  splanchnic  area  that  the  patient  may 
be  regarded  as  bleeding  to  death  in  his  viscera.  The  term  collapse  is  used  by 
some  to  designate  a  severe  condition  of  shock,  and  is  employed  by  others  as  a 
name  for  a  condition  produced  by  functional  depression  of  the  vasomotor  center 
the  result  of  mental  disturbance,  cardiac  failure,  respiratory  failure,  or  vasomo- 
tor insufficiency,  rather  than  of  physical  injury.  Crile  regards  collapse  as  inhibi- 
tion of  the  vasomotor  center,  in  contrast  to  shock,  which  is  exhaustion  of  the 
center.  As  a  matter  of  fact,  shock  and  collapse  are  often  both  present.  That 
the  bombardment  of  the  nerve-centers  by  a  tumult  of  peripheral  impressions 
causes  shock  is  shown  by  the  fact  that  if  the  nerves  from  a  part  are  thoroughly 
cocainized  so  that  they  will  not  transmit  sensation,  operation  upon  the  part 
produces  practically  no  shock.  Crile  calls  such  cocainization  the  introduction 
of  a  physiological  block.  Again,  Crile  insists  that  in  shock  there  are  demon- 
strable changes  in  the  brain  cells.     The  changes  consist  in  shrinking  of  nuclei 

1  See  the  very  able  review  in  "The  Nature  of  Shock,"  by  Major  G.  Seelig,  in  "Internat. 
Abstract  of  Surg.,"  Feb.,  1914. 


Shock  287 

and  dissipation  of  the  granular  matter  of  the  protoplasm.  Such  changes 
mean  that  the  cells  involuntarily  discharged  nerve  force  many  times,  were 
caused  to  discharge  by  impressions  brought  to  them,  and  by  the  discharges  were 
exhausted  of  certain  necessary  chemical  materials;  ])eripheral  impressions 
act  by  suggesting  painful  or  harmful  things  to  the  nerve-cells,  that  is,  by  caus- 
ing subconscious  fear.  Crile  calls  such  automatic  association  philogcnetic 
association.  Shock  may  be  slight  and  transient,  it  may  be  severe  and  prolonged, 
it  is  usually  sudden  in  onset,  but  may  come  on  gradually,  and  it  may  even  pro- 
duce almost  instant  death.  I  agree  with  Bloodgood  that  even  a  violent  injury 
does  not  of  necessity  at  once  produce  it.  Every  now  and  then  we  see  a  man 
with  a  crushed  limb  who  does  not  exhibit  shock,  the  condition  gradually  coming 
on  from  pain,  terror,  etc.,  and  being  aggravated  perhaps  by  hemorrhage.  The 
onset  of  shock  may  be  delayed  for  half  an  hour  or  an  hour.  If  the  victim  of  a 
railroad  accident  is  greatly  excited  he  may  actually  move  about  for  quite  a 
time  before  passing  into  shock.  A  soldier  seriously  wounded  in  battle  may  not 
show  signs  of  shock  at  once.  If  shock  appears  after  a  decided  delay  the  surgeon 
should  always  suspect  and  examine  for  concealed  hemorrhage.  What  surgeons 
used  to  call  secondary  shock,  that  is,  deep  shock  arising  twenty-four  hours  or 
more  after  an  operation  or  injury,  is  probably  due  either  to  acute  sepsis  or  to 
hemorrhage.  Fat  embolism  may  be  mistaken  for  shock.  During  an  opera- 
tion if  shock  arises  it  is  apt  to  do  so  gradually,  but  this  is  not  always  the 
case,  for  sometimes  it  comes  on  with  great  suddenness,  as  when  the  bone  of  the 
thigh  is  sawed  through,  or  when  there  is  a  burst  of  blood  from  a  large  ves- 
sel. Sudden  death  from  what  is  usually  called  shock  is  probably  due  to 
reflex  stimulation  of  the  pneumogastric  nuclei  and  arrest  of  cardiac  action. 
It  is  known  as  death  by  inhibition.  A  blow  over  the  solar  plexus,  upon  the  point 
of  the  chin,  upon  the  testicle,  on  the  larynx,  or  over  the  heart,  may  cause  death 
from  inhibition.  It  may  also  occur  during  intralaryngeal  operations  or 
manipulation,  and  during  general  anesthesia.  Sudden  death  from  terror  or 
from  the  reception  of  ill  news  is  probably  caused  in  the  same  way.  Shock  is 
more  severe  in  women  than  in  men,  in  the  nervous  and  sanguine  than  in  the 
lymphatic,  in  those  weakened  by  suffering  than  in  those  who  are  strangers 
to  illness.  Disease  of  the  kidneys,  diabetes,  chronic  cardiac  disease,  and  al- 
coholism predispose  to  it.  Fear  is  probably  a  great  factor.  Injuries  of 
nerves,  of  the  intra-abdominal  viscera,  of  the  urethra,  or  of  the  testicle  pro- 
duce extreme  shock;  so  do  crushes  and  compound  fractures  of  the  extremities 
and  the  nearer  to  the  body  the  injury  is  the  greater  is  the  shock.  Archibald 
and  McLean  in  "Annals  of  Surgery"  191 7,  Ixvi,  state  that  on  the  battle  front  it 
has  been  found  that  chest  wounds  and  head  wounds  seldom  produce  severe 
shock,  an  observation  not  in  accord  with  older  writings  on  injuries  in  civil  life. 
Anything  which  extracts  the  body-heat  favors  the  development  of  shock  (ex- 
posure to  cold  air,  insufScient  covering,  chilling  the  body  by  solutions  or  wet 
towels).  Those  who  are  cold,  wet,  fatigued  and  hungry  are  predisposed. 
Prolonged  and  rough  transportation  adds  to  the  gravity  of  shock  (Archibald  and 
McLean,  Ibid.).  In  cerebral  concussion  there  is  shock  plus  other  conditions. 
Sudden  and  profuse  hemorrhage  greatly  aggravates,  and  prolonged  anes- 
thetization causes  shock.  Great  shock  may  occur  after  the  removal  of  a  large 
tumor  or  a  quantity  of  fluid  from  the  abdomen.  In  such  a  case  it  is  brought 
about  by  the  sudden  removal  of  pressure  and  the  consequent  rapid  disten- 
tion of  intra-abdominal  veins.  Exposure  of  tissue  and  vital  parts  to  air  ag- 
gravates shock.  Crile  lays  down  as  the  most  important  causes  of  shock: 
fear,  pain  and  traction. 

The  influences  which  cause  cells  to  exhaust  themselves  by  discharge  are 
recognized  by  the  nerve-cells  as  meaning  or  suggesting  harm  to  the  organism. 
Such  influences  cause  impulses  to  escape  and  are  called  by  Crile  nocuous 
or  noci  influences.     Fear  itself   can  cause  shock,  and  fear  is  a  great  factor 


288  Contusions  and  Wounds 

even  when  shock  is  apparently  due  to  pain  or  traction.  Fear,  then,  is  the  ever- 
existing  factor  in  shock  causation.  It  is  often  a  conscious  fear.  It  may  be 
subconscious  fear. 

Crile  maintains  that  an  individual  ma}-  be  anesthetized  by  ether  or  chloro- 
form and  feel  no  pain,  and  yet  noci  influences  may  cause  shock.  The  influences 
then  act  by  suggesting  painful  or  harmful  things  to  the  nerve-cells,  that  is,  by 
causing  subconscious  fear.  Crile  calls  such  automatic  association  philogenetic 
association.  W.  T.  Porter  ("Boston  IMed.  and  Surg.  Jour.,"  1916,  clxxv) 
in  a  very  valuable  study  of  shock  as  seen  in  the  trenches,  makes  the  interest- 
ing statement  that  during  an  ordinary  bombardment,  even  if  prolonged,  the  sol- 
diers exhibited  no  fall  of  blood-pressure.  Under  a  very  violent  bombardment 
with  8-inch  shells  the  blood-pressure  actually  rose.  The  severe  shock  noted 
in  most  of  those  wounded  in  battle  is  due  to  rough  and  prolonged  transporta- 
tion and  delayed  treatment. 

The  symptoms  of  well-developed  ordinary  shock  {torpid  or  apathetic  shock) 
are  subnormal  temperature;  weakness  of  heart  action;  irregular,  small,  weak, 
rapid,  and  compressible  pulse  (very  soon  after  the  beginning  of  shock  the  pulse 
may  be  slow  and  remain  so  for  a  brief  time  but  it  soon  becomes  frequent). 
The  skin  is  cold,  pallid,  bloodless,  and  often  clammy  or  profusely  perspiring. 
Sweating  about  the  head  is  particularly  noticeable.  The  respirations  are 
shallow,  feeble,  irregular,  and  perhaps  sighing  or  gasping.  The  extremi- 
ties are  cold.  The  reflexes  are  diminished  in  activity,  A  sphygmomanometer 
will  indicate  a  notable  fall  in  blood-pressure.  Consciousness  is  usually  main- 
tained, but  there  is  an  absence  of  mental  originating  power,  the  injured  person 
answering  when  spoken  to,  but  volunteering  no  statements  and  lying  with  partly 
closed  lids  and  expressionless  countenance  in  any  position  in  which  he  may  be 
placed.  The  answers  to  questions  though  apparently  intelligent  are  usually 
utterly  unreliable.  Before  death  stupor  may  creep  upon  the  patient.  There 
is  great  motor  weakness  and  muscular  relaxation.  The  pupils  are  dilated  and 
react  but  slowly  to  light.  The  sphincters  are  relaxed.  Pain  is  slightly  or  not 
at  all  appreciated.  Nausea  is  absent  and  vomiting  may,  as  in  concussion, 
presage  reaction.  Gastric  regurgitation,  after  a  considerable  duration  of  shock, 
is  not  unusual,  and  is  a  bad  omen.  It  must  impress  students  of  physiology 
that  certain  of  the  well-known  signs  of  shock  do  not  seem  to  indicate  that  there 
are  paralysis  and  dilatation  of  the  peripheral  vessels,  as  the  popular  theory  of 
shock  supposes.  The  signs  which  do  not  co-ordinate  with  the  theory  are  anemia 
of  the  surface,  lowered  temperature  of  the  surface,  and  small  pulse  (Seelig  and 
Lyon,  in  "Surgery,  Gynecology,  and  Obstetrics,"  Aug.,  1910).  Shock  is  not 
rarely  followed  by  suppression  of  urine.  WTiereas  the  victim  of  shock  is  usually 
stupid  and  indift'erent,  he  may  become  delirious.  If  delirium  arises,  the  condi- 
tion is  very  grave.  Travers  called  shock  with  delirium  crethistic  or  delirious 
shock.  As  a  matter  of  fact,  such  a  state  is  not  genuine  shock,  but  is  either  a 
traumatic  or  a  toxic  delirium  added  to  or  following  upon  shock.  It  is  usually 
due  to  uremia  or  sepsis.  Delirious  shock  may  arise  after  a  person  has  been 
bitten  by  a  poisonous  snake.  Many  years  ago  Travers  described  a  delayed  form 
of  shock,  which  comes  on  several  hours  after  an  injury  or  violent  emotional 
disturbance.  This  form  of  shock  is  seen  not  unusually  in  those  who  have  passed 
through  a  railroad  accident.  It  may  be  a  sign  of  hemorrhage  or  an  evidence 
of  acute  sepsis,  and  is  sometimes  met  with  after  the  administration  of  ether  or 
chloroform.  Fat  embolism  may  be  mistaken  for  it.  The  statements  made 
by  a  person  who  has  recovered  from  a  severe  shock  are  always  unreliable  as 
to  events  which  occurred  while  shock  existed,  and  are  often  doubtful  as  to  the 
details  of  the  accident.  Not  unusually  the  memory  of  the  accident  is  perverted 
or  even  destroyed. 

Diagnosis. — Concealed  hemorrhage  is  difficult  to  differentiate  from  shock. 
The  former  produces  impairment  of  vision  (retinal  anemia),  great  restlessness, 


The  Prevention  of  Shock  in  Operations  289 

frequent  yawning,  extreme  thirst,  nausea,  and  sometimes  convulsions.  In  shock 
the  hemoglobin  is  unaltered;  in  hemorrhage  it  is  enormously  reduced  (Hare 
and  Martin).  In  hemorrhage  recurrent  attacks  of  syncope  are  met  with.  In 
pure  shock  such  attacks  do  not  occur.  In  concealed  hemorrhage  the  abdomen 
may  exhibit  physical  signs  of  a  rapidly  increasing  collection  of  fluid.  Shock 
and  hemorrhage  are  often  associated.  A  usual  characteristic  of  shock  is  rapid 
onset,  which  separates  it  distinctly  from  exhaustion.  It  arises  at  a  much  earlier 
period  after  an  injury  than  does  fat-embolism. 

The  Prevention  of  Shock  in  Operations. — When  possible  examine  the  patient 
with  care  before  operating,  giving  special  attention  to  the  condition  of  the  kidneys. 
The  amount  of  urine  passed  and  the  amount  of  urea  it  contains  should  always 
be  determined  when  possible.  The  amount  of  urea  should  be  estimated  from 
the  twenty-four-hour  urine.  The  normal  amount  of  urine  in  the  twenty-four 
hours  is  about  50  ounces  and  the  normal  amount  of  urea  2  per  cent.  Less  urea  is 
significant  of  danger  from  shock  and  subsequent  kidney  complications.  If 
the  condition  of  the  patient  leads  us  to  fear  that  there  may  be  dangerous  shock, 
do  not  purge  him  at  all  before  operation,  and  just  previous  to  operation 
give  a  rectal  injection  of  hot  saline  fluid  and  a  hypodermatic  injection  of  3^f  00  gr- 
of  atropin.  It  is  also  a  good  plan  in  some  cases  to  give  a  hypodermatic  injection 
of  3^^  gr.  of  morphin  twenty  minutes  before  operation.  It  tranquilizes  the  pa- 
tient and  less  ether  will  be  needed  to  anesthetize  him.  Examine  the  patient  thor- 
oughly and  prepare  him  carefully  beforehand  and  decide  if  he  should  take  a 
general  anesthetic  at  all,  and  if  so,  which  one.  Nitrous  oxid  diminishes  opera- 
tive shock,  Crile  says,  because  cell  activity  is  lessened  by  deficiency  of  oxygen. 

Many  operators  believe  that  ether  and  chloroform  lessen  shock.  Crfle 
disputes  this.  He  holds  that  they  merely  inhibit  conscious  fear  and  muscular 
response  to  peripheral  impressions,  but  do  not  save  the  brain-cells  from  noci 
impressions,  and  hence  do  not  save  the  cells  from  exhausting  discharges. 

It  would  seem  probable  that  a  drugged  brain-cell  could  not  receive  influences 
as  acutely  and  strongly  as  one  untouched  by  ether  or  chloroform.  I  beheve 
that  a  general  anesthetic  given  properly  and  in  proper  amount,  does,  to  some 
extent  at  least,  lessen  the  shock  of  an  operation. 

In  some  cases  (as  in  typhoid  perforation  or  strangulated  bernia)  a  local 
anesthetic  may  be  used.  The  nerves  well  above  the  area  of  operation  should 
be  infiltrated  with  cocain,  even  if  a  general  anesthetic  has  been  given.  This 
prevents  the  ascent  of  peripheral  impressions,  makes  what  Crile  calls  a  "physio- 
logical block,"  and  so  prevents  shock.  After  this  infiltration,  even  if  a  general 
anesthetic  has  not  been  given,  a  limb  can  be  amputated  below  the  infiltrated 
area  without  pain  and  without  great  depression  of  the  vital  powers.  I  have 
performed  a  number  of  amputations  most  satisfactorily  relying  for  anes- 
thesia purely  upon  cocainization  of  the  nerves.  In  these  cases  there  has  been 
very  little  shock.  This  is  a  valuable  procedure  even  when  ether  is  given.  I 
employ  it  frequently  and  am  satisfied  of  its  great  value  in  preventing  shock. 
The  ether  prevents  conscious  fear  during  the  operation,  the  cocainization  of  the 
nerve  intercepts  harmful  impressions  in  their  ascent.  Thus  is  shock  prevented. 
In  some  few  cases  in  which  we  fear  shock  spinal  anesthesia  is  used;  in  others, 
scopolamin  and  morphin.  If  a  general  anesthetic  is  used  it  must  be  skilfully 
given  and  not  a  drop  should  be  given  beyond  the  amount  necessary  to  maintain 
thorough  anesthesia.  Cover  every  part  but  the  field  of  operation  with  hot 
blankets  and  put  cans  of  hot  water  about  the  patient,  or  put  him  on  a  bed  com- 
posed of  hot-water  pipes  covered  with  blankets.  Prevent  bleeding  with  the 
greatest  possible  care.  Operate  as  rapidly  as  is  consistent  with  safety  and  thor- 
oughness. The  blood-pressure  is  of  great  importance  in  estimating  the  degree 
of  shock,  and  any  sudden  fall  of  blood-pressure  is  ominous.  It  is  a  custom  with 
many  operators  to  fix  a  sphygmomanometer  to  the  arm  and  have  an  assistant 
watch  the  scale  constantly  during  an  operation.  If  shock  develops  during  an 
19 


290  Contusions  and  Wounds 

operation  hasten  on  the  work,  lessen  the  amount  of  ether,  and  apply  active  treat- 
ment. Return  the  patient  to  bed  as  soon  as  possible  and  without  exposure  in 
cold  halls  or  a  windy  elevator.  Occasionally  it  becomes  necessary  to  suspend 
an  operation  in  order  to  prevent  death  on  the  table. 

Crile's  anoci  association  operation  is  founded  on  the  prevention  of  shock  by 
the  exclusion  as  far  as  possible  of  all  painful,  terrifying,  and  depressing  influ- 
ences from  a  patient  before,  during,  and  after  operation.  The  patient  is  not 
kept  for  days  or  even  for  hours  waiting  in  fear.  He  is  to  be  reassured,  made 
confident,  dominated  by  his  surgeon.  He  is  anesthetized  by  means  of  nitrous 
oxid  and  nitrogen,  ether  being  added  only  if  necessary.  The  tissues  are  infil- 
trated with  a  local  anesthetic.  During  the  operation  all  noci  impressions 
are  carefully  excluded.  This  method,  in  the  hands  of  Crile,  Bloodgood,  and 
others,  has  given  highly  satisfactory  results. 

Treatment. — In  treating  ordinary  apathetic  shock  raise  the  feet  and  lower 
the  head,  unless  this  position  causes  cyanosis.  At  least  place  the  head  flat  and 
the  body  recumbent.  Wrap  the  patient  in  hot  blankets  and  surround  him  with 
hot  bottles,  hot  bricks,  hot-water  bags,'or  cans  of  hot  water.  Always  wrap  a  can. 
a  bottle,  or  a  bag  in  flannel  or  some  other  material  to  avoid  burning  the  patient. 
Ordinary  stimulants  seem  of  little  or  no  value  and  drugs  given  by  the  stomach 
are  not  absorbed.  Salt  solution  should  be  thrown  into  a  vein  if  blood-pressure 
is  below  80  {intravenous  infusion).  If  blood-pressure  is  higher  it  may  be  given 
by  the  rectum  {proctoclysis),  or  subcutaneously  (hypodermoclysis).  Intraven- 
ous infusion  does  some  good,  but,  unfortunately,  the  benefit  is  very  temporary 
except  in  cases  associated  with  hemorrhage.  In  hemorrhage  it  should  always  be 
given,  and  it  should  be  given  mixed  with  adrenalin  chlorid  (i  teaspoonful  of  the 
1:1000  solution  of  adrenalin  chlorid  is  added  to  i  liter  of  salt  solution).  The 
operation  of  intravenous  infusion  is  described  on  page  536.  The  custom  of  giv- 
ing salt  solution  in  a  vein  has  become  so  common  that  resident  physicians  are  apt 
to  resort  to  it  as  a  routine.  It  is  to  be  remembered  that  if  given  rapidly  or  in 
too  great  quantity  it  may  gather  in  the  chambers  of  a  dilated  right  heart  and 
arrest  a  heart  so  weakened  that  it  has  almost  reached  its  Umit  of  function.  I 
am  satisfied  that  the  rapid  administration  of  salt  solution  intravenously  is 
responsible  for  some  deaths.  Crile  maintains  that  the  only  way  ''to  increase 
and  sustain  the  blood-pressure  when  the  vasomotor  center  is  exhausted"  is  to 
"create  a  peripheral  resistance  either  by  a  drug  acting  on  the  blood-vessels  t  hem- 
selves  or  by  mechanical  pressure."^  In  order  to  accomplish  this  he  uses  adrenahn 
chlorid.  Because  of  the  rapidity  with  which  this  drug  is  oxidized  he  gives  it 
intravenously,  slowly  and  continuously  from  a  buret,  using  a  solution  of  a 
strength  of  from  i :  50,000  to  i :  100,000  in  salt  solution.  The  rate  of  flow  should 
be  "controlled  by  a  screw-cock  attached  to  the  rubber  tube."  Crile  also  places 
the  patient  in  a  rubber  suit  and  distends  the  suit  by  means  of  an  air  pump  and 
thus  obtains  equable  resistance.  The  difficulty  with  giving  the  solution  in  a 
vein  is,  the  drug  first  comes  in  contact  with  "the  vessels  ha\'ing  the  least  power 
of  influencing  blood-pressure,"  and  before  a  notable  rise  can  be  affected  by 
arterial  action  "it  is  necessary  that  the  solution  should  pass  through  the  right 
heart,  the  lungs  on  its  way  to  the  aorta,  then  finally  affecting  the  coronary 
arteries"  (Crile,  in  "Am.  Jour.  Med.  Sciences,"  Jan.,  1909).  The  best  way  to 
use  adrenalin  solution  in  very  dangerously  severe  shock  is  to  introduce  it  as 
Crile  now  advises,  that  is,  into  the  arterial  system  and  toward  the  heart. 
Occasionally,  by  this  means,  resuscitation  from  apparent  death  may  be  ac- 
complished. Crile  calls  this  method  centripetal  arterial  transfusion.  It  is 
applied  as  follows  ("Am.  Jour.  Med.  Sciences,"  April,  1909): 

"In  human  resuscitation  the  technic  is  as  follows:  The  patient  in  the  prone 
posture  is  subjected  at  once  to  rapid  rhythmic  pressure  upon  the  chest,  with 
one  hand  on  each  side  of  the  sternum.  This  pressure  produces  artificial  res- 
1  George  Crile,  in  "Boston  Med.  and  Surg.  Jour.,"  March  s,  1903. 


Treatment  of  Shock 


291 


piration  and  a  moderate  artificial  circulation.  A  cannula  is  inserted  toward 
the  heart  into  an  artery.  Normal  saline,  Ringer's,  or  Locke's  solution,  or,  in 
their  absence,  sterile  water,  or,  in  extremity,  even  tap  water,  is  infused  by  means 
of  a  funnel  and  rubber  tubing.  But  as  soon  as  the  flow  has  begun  the  rubber 
tubing  near  the  cannula  is  pierced  with  the  needle  of  a  hypodermatic  syringe 
loaded  with  i  :  1000  adrenalin  chlorid  and  15  to  30  min.  are  at  once  injected. 
Repeat  the  injection  in  a  minute  if  needed.  Synchronously  with  the  injection 
of  the  adrenalin  the  rhythmic  pressure  upon  the  thorax  is  brought  to  a  maxi- 
mum. The  resulting  artificial  circulation  distributes  the  adrenalin  that  spreads 
its  stimulating  contact  with  the  arteries,  bringing  a  wave  of  powerful  contrac- 
tions and  producing  a  rising  arterial,  hence  coronary,  pressure.     When  the 


Fig.   III. — Subcutaneous  saline  infusion   (Senn). 

coronary  pressure  rises  to,  say,  40  mm.  or  more,  the  heart  is  likely  to  spring 
into  action.  The  first  result  of  such  action  is  to  spread  still  further  the  blood- 
pressure-raising  adrenalin,  causing  a  further  and  vigorous  rise  in  blood-pres- 
sure, possibly  even  doubling  the  normal.  The  excessively  high  pressure  is 
most  favorable  to  the  resuscitation  of  tissue,  especially  of  the  central  nerv^ous 
system  (Stewart).  Just  as  soon  as  the  heart-beat  is  established  the  cannula 
should  be  withdrawn,  first  because  it  is  no  longer  needed,  and  second,  because 
the  rising  blood-pressure  will  drive  a  torrent  of  blood  into  the  tube  and  fun- 
nel. Unless  there  has  been  hemorrhage,  the  only  object  in  the  use  of  saline 
infusion  is  to  serve  as  a  means  of  introducing  the  adrenalin  into  the  arterial 
circulation  toward  the  heart.  Bandaging  the  extremities  and  abdomen  tightly 
over  masses  of  cotton  is  very  useful." 

In    prolonged    shock    and   in   shock   with  persisting   hemorrhage   direct 


292  Contusions  and  Wounds 

transfusion  of  blood  is  indicated  (see  page  528).  The  use  of  hot  and  stimu- 
lating rectal  enemata  is  important.  The  rectum  may  absorb  fluids  when 
the  stomach  refuses  to  do  so.  An  enema  of  hot  coffee  is  decidedly 
stimulating.  Enemata  of  hot  normal  salt  solution  are  beneficial  {procto- 
clysis). The  tube  is  carried  as  high  as  possible  and  the  injection  is  intro- 
duced so  as  to  distend  the  colon.  Hypodermoclysis  is  given  as  follows:  Insert 
an  aspirator  tube  into  the  cellular  tissue  of  the  loin,  scapular  region,  or  under 
the  mamma,  first  disinfecting  the  part  with  tincture  of  iodin.  The  tube  is 
attached  to  a  fountain  syringe,  which  is  filled  with  warm  normal  salt  solution, 
and  is  hung  at  a  height  of  2  or  5  feet  above  the  bed  (Fig.  11 1).  In  an  hour's 
time  a  pintormoreof  fluid  will  enter  the  tissue  and  be  absorbed.  It  is  the  custom 
to  give  h\podermatic  injections  of  ether,  brandy,  strychnin,  digitalis  or  a  tropin. 
Crile  has  demonstrated  experimentaUy  that  strychnin  is  perfectly  futile  in 
pure  shock  and  may  actually  aggravate  the  condition.  In  collapse  it  is  of  some 
value.  We  believe  this  statement  is  true  clinically.  Strychnin  goads  a  heart  to 
increased  action  when  that  organ  has  not  sufficient  blood  passing  into  it  to  enable 
it  to  contract  firmly  and  strongly.  The  use  of  strychnin  in  shock  has  been  com- 
pared by  Hare  to  beating  a  dying  horse  to  make  it  pull.  I  believe  that  atro- 
pin  is  of  great  benefit  in  shock,  especially  if  the  skin  is  very  moist.  This  drug, 
according  to  my  colleague,  Prof.  Hobart  A.  Hare,  is  a  sedative  to  the  vagus; 
but  what  makes  it  particularly  valuable  is  that  it  acts  upon  the  vasomotor 
system,  combats  the  dilatation  of  the  blood-vessels,  maintains  vascular 
tone,  opposes  stagnation  of  blood  in  any  vessels,  and  increases  the  amount  of 
moving  blood.  If  the  skin  is  very  moist,  atropin  is  particularly  indicated. 
Senn  recommends  the  h\TDodermatic  injection  of  sterile  camphorated  oil,  a  hv^po- 
dermatic  syringeful  every  fifteen  minutes,  until  reaction  begins.  Inhalation  of 
oxygen  is  often  of  much  service,  and  artificial  respiration  may  be  necessary.  Opi- 
ates are  contra-indicated  in  shock.  Mustard  plasters  should  be  placed  over  the 
heart,  spine,  and  shins.  A  turpentine  enema  is  useful.  Pituitrin  is  a  valuable 
remedy  to  restore  blood-pressure.  The  dose  for  intramuscular  injection  is 
from  10  to  30  min.  It  is  usually  given  intravenously  in  saline  fluid.  The 
duration  of  its  action  is  brief.  Cannon  suggests  introducing  pituitrin  into  the 
peritoneal  cavity  in  order  to  empty  the  abdominal  vessels  of  their  imprisoned 
blood.  A  stronger  solution  can  be  put  into  the  peritoneal  cavity  than  should  be 
introduced  into  the  blood  (Cannon,"  Boston  Med.  and  Surg.  Jour.,"  June  21, 
191 7).  In  severe  cases  of  shock,  bandage  the  extremities.  Bandaging  for  the 
relief  of  shock  is  called  aiiiotransfnsion.  This  procedure  increases  peripheral  re- 
sistance and  enables  the  body  to  utilize  to  the  best  advantage  the  small  amount  of 
circulating  blood,  and  sends  most  of  it  to  the  brain,  where  it  will  maintain  the 
activitv  of  the  vital  centers  and  keep  up  circulation  and  respiration.  For 
this  purpose  ordinary  muslin  bandages  may  be  used,  or  gauze  bandages,  or 
the  bandages  of  Esmarch.  Crile's  rubber  suit  accomplishes  the  object  more 
satisfactorily  than  does  bandaging  the  extremities.  Abdominal  massage  helps 
drive  out  the  blood  imprisoned  in  the  splanchnic  area,  and  after  massage  has  set 
free  the  abdominal  blood  apply  a  compress  and  binder.  In  serious  cases  artifi- 
cial respiration  and  stimulation  of  the  diaphragm  with  a  galvanic  current  may  be 
used.  At  the  military  front  the  elements  of  treatment  are  gravity,  injection 
of  normal  salt  solution  and  adrenalin  (W.  T.  Porter,  Ibid.).  The  head  is  placed 
30  cm.  low^er  than  the  feet  and  the  position  is  maintained  until  blood-pressure 
becomes  nearly  normal.  Saline  fluid  is  throwm  into  the  veins  if  the  pressure 
is  below  80  and  the  administration  is  stopped  when  the  pressure  reaches  80. 
Should  it  fall  again  adrenalin  is  injected  into  an  ankle  vein.  When  very  low 
blood-pressure  is  associated  with  continued  bleeding  immediate  transfusion  of 
blood  is  indicated.  In  Depage's  hospital  at  La  Panne  and  in  Carrel's  hospital  at 
Compiegne  a  special  table  is  used  to  obtain  the  lowered  position  of  the  head  and 
the  table  is  heated  by  electricity.     Porter  is  disposed  to  believe  that  respiratory 


Treatment  of  Wounds  293 

reaction  may  be  of  service,  the  thoracic  pump  driving  blood  to  heart  and  lungs. 
Should  we  operate  during  shock?  We  should  certainly  do  so  when  death  with- 
out prompt  operation  is  inevitable.  We  must  operate,  if  it  is  necessary  to  do  so, 
to  arrest  hemorrhage,  to  relieve  strangulated  hernia,  intestinal  obstruction,  ob- 
struction of  the  air-passages,  compound  fractures  of  the  skull,  extravasated 
urine,  or  intraperitoneal  extravasations  from  ruptured  viscera.  If  hemorrhage 
can  be  temporarily  controlled  by  pressure  or  a  clamp,  so  much  the  better,  and  the 
permanent  arrest  can  be  efifected  after  the  reaction  from  shock.  It  is  not  judi- 
cious, in  the  author's  opinion,  to  amputate  during  shock  if  it  can  be  avoided. 
A  tourniquet  or  Esmarch  bandage  should  be  applied,  and  attempts  be  made  to 
.bring  about  reaction,  and  when  reaction  is  obtained  the  amputation  should  be 
performed.  If  the  patient  does  not  show  promptly  evidences  of  reaction  and 
particularly  if  the  trend  is  toward  a  worse  condition  do  not  delay  but  operate. 
It  is  only  just  to  say  that  some  eminent  surgeons  oppose  this  rule.  Roswell 
Park  says  that  "shock  is  often  alleviated  by  the  prompt  removal  of  mutilated 
limbs  which,  when  still  adherent  to  the  trunk,  seem  to  perpetuate  the  condition." 
The  same  teacher  beheves  in  operating  at  once  upon  severe  compound  fractures.^ 
After  every  operation  keep  careful  watch  upon  the  amount  of  urine  passed, 
see  to  it  that  the  patient  takes  sufficient  fluid,  and  if  the  urine  becomes  scanty 
put  a  hot-water  bag  to  each  loin,  give  diuretics  by  the  mouth,  secure  cutaneous 
activity,  give  saline  purgatives,  and  administer  hot  saline  enemata.  If  the  con- 
dition is  not  soon  benefited,  the  custom  is  to  infuse  hot  saline  fluid  into  a  vein.  I 
am  doubtful  if  intravenous  infusion  of  saline  fluid  is  beneficial  in  suppression,  and 
I  even  fear  it  may  do  harm  (see  the  studies  of  Widal,  Marie  and  Crouzon, 
Merklen,  and  others).  Rossle  ("Centralbl.  f.  Chir.,"  1907,  xxxiv)  says  that  in 
certain  cardiac  and  renal  conditions  salt  solution  damages  the  capillaries  and 
does  actual  harm.  In  urinary  suppression  following  accident  or  surgical 
operation  {postoperative  suppression^  postoperative  anuria)  the  condition  is  so 
dreadfully  grave  that  it  is  justifiable  to  expose  each  kidney  and  split  the 
capsule  in  order  to  frelieve  tension  and  in  the  hope  of  thus  abating  conges- 
tion. In  fact,  I  believe  this  should  always  be  done.  In  a  case  in  which 
there  had  been  total  suppression  for  three  days  I  did  this  operation. 
During  the  next  thirty-six  hours  the  patient  passed  12  oz.  of  urine,  but  died 
of  complications.  Postoperative  suppression  of  urine  is  almost  invariably 
fatal.  Delayed  'shock  is  treated  in  the  same  manner  as  apathetic  shock 
if  hemorrhage,  sepsis  and  fat  embolism  can  be  excluded.  If  hemorrhage  is 
the  cause,  the  bleeding  must  be  arrested,  and  blood  be  transfused,  or 
saline  fluid  be  infused  into  a  vein.  If  delirious  shock  is  due  to  sepsis,  the 
treatment  is  that  of  sepsis.  If  it  is  nervous  delirium,  give  morphin  and  other 
sedatives.     If  due  to  uremia,  the  treatment  is  obvious. 

Fat=embolism. — (See  page  210.) 

Fever. — (See  Fevers,  page  139.) 

Treatment  of  Wounds.— All  wounds,  other  than  those  made  by  the 
surgeon,  are  regarded  as  infected.  The  rules  for  treating  such  wounds  are: 
(i)  arrest  hemorrhage;  (2)  bring  about  reaction;  (3)  remove  foreign  bodies; 
(4)  antisepticize;  (5)  drain,  coaptate  the  edges,  and  dress;  and  (6)  secure  rest  to 
the  part  and  combat  overaction  of  the  tissues.  Constitutionally,  allay  pain, 
secure  sleep,  maintain  the  nutrition,  and  treat  inflammatory  conditions.  In 
many  cases  give  prophylactic  doses  of  antitetanic  serum. 

Arrest  of  Hemorrhage. — To  arrest  hemorrhage  the  bleeding  must  be  con- 
trolled by  an  Esmarch  band  or  digital  pressure  until  the  bleeding  point  can 
be  grasped  with  forceps ;  it  is  then  caught  up  and  tied  with  catgut  or  aseptic  silk. 
SHght  hemorrhage  ceases  spontaneously  on  exposure  of  the  bleeding  point  to  air, 
and  moderate  hemorrhage  ceases  permanently  after  the  temporary  applica- 
tion of  a  clamp.  An  injured  vessel  when  not  of  the  smallest  size  must  be 
1  Park's  "Surgery  by  American  Authors." 


294  Contusions  and  Wounds 

ligated,  even  if  it  has  ceased  to  bleed.  Capillary  oozing  is  checked  by  hjot 
water  (120°  F.)  and  compression.  If  a  large  artery  is  divided  in  a  limb,  apply  a 
tourniquet  before  ligating.     (See  Wounds  of  Vessels.) 

Bringing  About  of  Reaction. — (See  Shock.) 

Removal  of  Foreign  Bodies. — Remove  all  foreign  bodies  visible  to  the  eye 
(splinters,  bits  of  glass,  portions  of  clothing,  gun-wadding,  grains  of  dirt,  etc.) 
by  forceps  and  a  stream  of  corrosive  sublimate  solution,  sterile  water,  or  normal 
salt  solution.  In  a  lacerated  or  contused  wound  portions  of  tissue  injured  be- 
yond repair  should  be  regarded  as  foreign  bodies  and  be  removed  with  scissors. 

Cleaning  the  Wound. ^ — To  clean  the  wound  shave  the  surrounding  area, 
if  it  is  hairy.  If  we  intend  to  disinfect  with  iodin  the  shaving  must  be  done 
dry.  Rub  the  adjacent  skin  with  alcohol  and  paint  the  wound  and  the  skin 
mth  a  2  to  5  per  cent,  iodin  solution.  Or,  the  skin  may  be  scrubbed  with  castile 
soap,  green  soap  or  with  ethereal  soap  and  water,  shaved  with  the  aid  of  lather, 
and  the  skin  and  wound  disinfected  by  a  mixture  of  alcohol,  phenol  and  acetone 
(page  37).  A  0.5  per  cent,  solution  of  hypochlorous  acid  is  valuable  for  wound 
disinfection.  Disinfection  is  only  relative.  Complete  primary  disinfection 
is  not  possible  if  infection  exists.  It  is  more  nearly  possible  when  there  is 
only  contamination.  In  contamination  microbes  are  free  in  the  wound.  In 
infection  they  have  entered  into  the  tissues  which  surround  the  wound.  Com- 
plete disinfection  of  an  infected  area  can  be  accomplished  by  extirpating  the 
wound.  In  every  wound  in  which  we  have  reason  to  suspect  tetanus  infection 
a  preventive  dose  of  antitoxin  should  be  given.  We  have  particular  occasion 
to  apprehend  tetanus  if  the  wound  is  contaminated  with  feces,  street  dirt,  stable 
dust,  or  stable  refuse,  or  if  it  were  caused  by  a  toy  pistol  such  as  boys  use  to 
celebrate  the  Fourth  of  July.  Lacerated  wounds  and  punctured  wounds  are 
particularly  apt  to  be  followed  by  tetanus.  A  clean  wound  made  by  the  surgeon 
need  not  be  irrigated  or  treated  with  antiseptics;  in  fact,  an  antiseptic  leads 
to  necrosis  of  tissue,  causes  a  profuse  flow  of  serum,  and  necessitates  drain- 
age. If  clots  have  gathered  in  a  wound  they  must  be  removed,  as  their  pres- 
ence will  prevent  accurate  coaptation  of  the  edges.  In  an  infected  wound  they 
are  washed  out  by  a  stream  of  corrosive  sublimate  solution,  or  better  by  a  0.5 
per  cent,  solution  of  hypochlorous  acid.  In  a  clean  wound  they  are  washed  out 
by  hot  salt  solution.  If  dirt  is  ground  into  a  wound,  as  is  often  seen  in  crushes, 
excision  is  desirable.  If  this  is  not  or  cannot  be  done  pour  sweet  oil  or  gasoline 
into  the  wound,  rub  it  into  the  tissues,  and  scrub  the  wound  with  ethereal  soap. 
The  oil  or  gasoline  entangles  the  dirt,  and  the  soap  and  water  remove  both  oil 
and  dirt.  After  the  rough  cleansing  irrigate  with  hypochlorous  acid  (0.5  percent). 
In  some  cases,  especially  in  bone  injuries,  it  is  necessary  to  scrape  the  wound  with 
a  curet.  If  a  fissure  of  the  skull  is  infected,  enlarge  the  fissure  with  a  chisel  in 
order  to  clean  it.  In  a  badly  infected  wound  one  of  the  most  valuable  agents  for 
use  in  producing  disinfection  is  pure  carbolic  acid.  After  cleaning  the  wound,  it  is 
necessary  in  certain  regions  to  examine  in  order  to  determine  if  tendons  or 
important  nerves  have  been  cut.  If  such  structures  have  been  divided,  they 
must  be  sutured  with  fine  silk,  chromic  gut,  or  kangaroo-tendon. 

Drainage,  Closure,  and  Dressing. — Superficial  wounds  require  no  special 
drainage,  as  some  wound-fluid  will  find  exit  between  the  stitches  and  the  rest 
will  be  absorbed.  A  large  or  deep  wound  requires  free  drainage  for  at  least 
twenty-four  hours  by  means  of  a  tube,  strands  of  horsehair,  silk  or  catgut, 
or  bits  of  iodoform  gauze.  An  infected  wound  must  be  drained  invariably. 
Good  drainage  may,  to  a  considerable  extent,  compensate  for  imperfect  anti- 
sepsis. Some  wounds  are  allowed  to  remain  wide  open.  This  is  usually  the 
best  plan  in  infected  wounds  of  the  hand.  Violent  suppuration  may  impair 
the  usefulness  of  the  hand  and  so  destroy  a  man's  ability  to  earn  a  living. 
Spreading  suppuration  seldom  occurs  when  the  wound  is  kept  open.  If  capil- 
1  The  use  of  iodin  as  a  germicide  is  discussed  on  page  77. 


Treatment  of  Wounds  295 

lary  drains  are  employed,  apply  a  moist  dressing.  Otherwise  the  strands  dry  and 
fail  to  act  as  drains.  Approximate  the  wound  edges  with  interrupted  sutures 
of  silk  or  silkworm-gut  if  the  wound  is  deep  and  considerable  tension  is  inevitable. 
Catgut  is  used  for  superficial  wounds  and  for  those  where  tension  is  slight.  If 
there  is  decided  'tension,  silver  wire  may  be  used.  In  very  deep  wounds  buried 
sutures  must  be  used.  These  sutures  may  consist  of  absorbable  material 
(kangaroo-tendon  or  catgut)  or  unabsorbable  material  (silver  wire  or  very 
fine  silk).  Of  late  I  have  been  following  the  Johns  Hopkins  custom  and  have 
closed  all  clean  wounds  with  sutures  of  very  fine  iron  dyed  silk  passed  by  small 
and  very  sharp  sewing  needles.  By  the  use  of  these  fine  sutures  a  minimum 
amount  of  tissue  necrosis  occurs,  the  risk  of  infection  is  greatly  lessened,  and 
the  resulting  scar  is  the  smallest  that  can  be  obtained.  As  is  well  known,  tight 
sutures  cause  tissue  necrosis  and  hence  predispose  to  infection.  It  is  impossi- 
ble to  tie  the  fine  black  silk  very  tightly  because  if  we  try  to  do  so  it  breaks. 
It  requires  considerable  practice  to  learn  to  tie  the  sutures  without  breaking. 
This  fine  silk  can  be  buried  without  fear,  as  it  never  causes  a  sinus,  and  it  is 
used  for  layer  sutures  with  perfect  confidence.  I  learned  this  plan  from  Dr. 
Harvey  Gushing,  and  am  much  pleased  with  it.  If  the  wound  is  infected  it 
has  been  the  custom  to  dress  with  warm,  moist  antiseptic  gauze.  If  it  is 
not  infected,  dress  with  dry  sterile  gauze.  The  custom  once  was  to  cover  even 
dry  gauze  with  a  rubber-dam  to  diffuse  the  fluids,  but  we  now  prefer  to  omit 
the  rubber-dam  and  use  plentiful  dressings.  A  dry  dressing  absorbs  wound- 
fluids  quickly  and  is  less  likely  to  become  infected.  Change  the  dressings  in 
twenty-four  hours  or  sooner  if  they  become  soaked  with  discharge.  Dressings 
are  changed  for  cause,  but  not  according  to  scheduled  time.  They  must,  of 
course,  be  changed  when  they -become  soaked  with  wound-fluid,  and  soaking 
may  occur  in  a  few  hours,  but  may  not  occur  for  days.  As  long  as  the  tem- 
perature remains  normal  and  the  wound  free  from  pain,  if  the  dressing  is  not 
wet  with  discharge,  it  can  be  left  in  place  unless  removal  is  necessary  to  take 
out  a  drainage-tube.  If  pus  forms,  open  the  wound  at  once.  Many  surgeons 
sprinkle  wounds  before  approximation  and  wound  surfaces  after  approximation 
with  a  drying  powder.  These  powders  are  of  great  use  in  infected  wounds, 
but  are  not  necessary  in  clean  wounds.  Among  the  substances  employed  are 
salicylic  acid,  boric  acid,  calomel,  acetanilid,  aristol,  iodoform,  subiodid  of  bis- 
muth, and  glutol.  In  large  wounds  which  cannot  be  approximated  it  is  occasion- 
ally advisable  to  skin-graft  by  Thiersch's  method.  A  small  wound  which  cannot 
be  sutured  is  dusted  with  an  antiseptic  powder  and  dressed.  A  granulating 
wound  is  dressed  as  is  a  healing  ulcer.  In  recent  infected  wounds,  disinfection, 
drainage,  dichloramin-T  and  rest  associated  with  Bier's  treatment  comprise 
the  means  of  local  treatment.  Incision  is  usually  required.  In  later  infections 
or  severe  infections  the  wounds  must  be  opened  widely  and  treated  with  Dakin's 
fluid  or  dichloramin-T.  A  sloughing  wound  is  opened,  is  dusted  with  iodoform 
or  acetanilid,  and  is  dressed  with  hot  antiseptic  fomentations. 

Many  of  the  above  rules  have  been  set  aside  by  the  introduction  of  the  Car- 
rel-Dakin  fluid  or  dichloramin-T.  One  of  these  is  now  generally  used  in  infected 
wounds.  It  gradually  makes  the  wound-fluid  practically  sterile,  at  which  time 
secondary  suturing  can  be  performed  (page  334). 

Rest. — Severe  wounds  require  the  confinement  of  the  patient  to  bed.  Band- 
ages, spHnts,  etc.,  are  used  to  secure  rest.  In  a  closed  wound  rest  need  not 
be  protracted,  in  fact,  our  former  custom  was  to  insist  upon  it  for  too  long  a 
period.  The  slight  irritation  of  moderate  motion  stimulates  repair.  We 
no  longer  feel  it  necessary  to  keep  laparotomy  cases  in  bed  for  three  full  weeks, 
but  we  get  them  up  in  from  ten  to  twelve  days.  By  doing  this  we  secure  just 
as  firm  a  cicatrix,  greatly  lessen  the  annoyance  from  constipation  and  flatulence, 
and  diminish  notably  the  number  of  cases  of  postoperative  pneumonia  and 
phlebitis.     I  do  not,  however,  advocate  getting  such  patients  up  in  twenty- 


296 


Contusions  and  Wounds 


four  to  thirty-six  hours,  as  is  advised  by  some  surgeons.  A  patient  with  an 
infected  wound  or  an  open  or  draining  wound  should  be  confined  to  bed.  The 
methods  of  combating  inflammation  have  previously  been  set  forth.  In  wounds 
of  the  hand  rigid  immobilization  must  not  be  persisted  in  too  long.  To  do  so 
will  mean  adhesion  of  tendons  and  impairment  or  destruction  of  the  usefulness 
of  the  hand.  If  spreading  infection  arises  motion  is  not  permissible  until 
infection  ceases  to  spread  and  granulations  begin  to  form.  If  there  is  no  m- 
fection,  passive  motion  of  wrist  and  fingers  should  be  begun  the  day  after  the 
injury   and  each  dav  the  hand  should  be  dressed  in  a  different  position. 

Constitutional  Treatment.— Bring  about  reaction  from  depression,  but  pre- 
vent undue  reaction.     Feed  the  patient   well,   stimulate  him   if  necessary, 


Fig.  112. — Muscle  suture:  .4,  Transverse  wound  of  biceps  muscle,  sho\ving  marked  retraction 
of  muscle-ends  and  mattress  suture  in  place;  B,  muscle  suture  completed  (Senn). 

attend  to  the  bowels  and  bladder,  secure  sleep  and  allay  pain.  Watch  for 
comphcations,  namely,  inflammation,  suppuration,  gangrene,  tetanus,  ery- 
sipelas, suppression  of  urine,  and  pneumonia.  Observe  the  temperature 
closely;  it  may  be  a  danger-signal  of  urgent  importance. 

Incised  Wounds. — An  incised  wound  is  a  clean  ciU  inflicted  by  an  edged 
instrument.  Only  a  thin  film  of  tissue  is  so  devitalized  that  it  must  die.  Such 
wounds  have  the  best  possible  chance  of  union  by  first  intention. 

The  pain  may  be  very  severe;  but  if  the  instrument,  weapon  or  tool  was 
sharp  and  used  quickly  pain  may  be  trivial.  The  pain  is  less  severe  than  that 
caused  by  some  other  varieties  of  wounds.  The  acute  pain  does  not  last  long, 
and  is  followed  by  smarting.  The  hemorrhage  is  profuse,  varying,  of  course, 
with  the  region  cut.  Bleeding  from  the  scalp  is  violent,  because  there  are  numer- 
ous vessels  which  lie  in  fibrous  tissue  and  they  can  neither  retract  nor  contract. 


Incised  Wounds 


297 


The  edges  of  an  incised  wound  retract  because  of  tissue  elasticity,  and  the  wound 
"gapes."  If  the  skin  or  fascia  is  divided  at  a  right  angle  to  the  muscle  beneath, 
there  is  wide  gaping.  If  the  cut  is  parallel  to  the  muscle-fibers,  the  gaping  is 
slight. 

When  the  skin  is  violently  pulled  upon,  it  tends  to  split  in  a  certain  line. 
Langer  and  Kocher  speak  of  this  as  the  line  of  cleavage,  and  point  out  the 
direction  of  these  lines  in  various  situations.  A  cut  across  the  line  of  cleavage 
is  followed  by  wide  gaping.  A  cut  in  the  direction  of  the  line  of  cleavage  pro- 
duces slight  gaping,  and  is  followed  by  a  trivial  scar. 

When  a  muscle  is  cut  across  the  wound  edges  separate  widely.  When  a 
tendon  is  completely  cut  across  extensive  separation  occurs. 

An  incised  wound  can  be  thoroughly  inspected,  all  divided  structures  can 
be  identified,  foreign  bodies  can  be  easily  removed,  and  disinfection  can  be 
carried  out  satisfactorily. 


Fig.   113.- — Suturing  of  tendons  and  nerves  in  incised  wounds:  a,  Primary  tendon  suture;  h, 

primary  nerve  suture  (Senn). 


Treatment. — According  to  general  principles.  Arrest  hemorrhage,  asep- 
ticize, etc. 

Examine  the  wound  carefully  to  see  if  a  nerve,  a  tendon,  or  a  muscle  is 
divided,  and  if  such  injury  is  discovered,  insert  sutures  at  once  (Figs.  112  and 
113).  If  the  wound  is  extensive  or  deep ;  it  may  be  necessary  to  use  buried  sutures 
in  order  to  keep  the  sides  of  the  wound  in  contact.  If  the  surface  of  a  wound 
is  approximated,  but  the  depths  are  not,  the  dead  space  or  cavity  becomes 
filled  with  wound  fluid,  and  infection  almost  certainly  occurs.  If  buried  sutures 
have  not  been  used,  such  a  cavity  must  be  obhterated  by  the  judicious  apphca- 
tion  of  pressure  upon  the  surface.  This  is  secured  by  the  adaptation  of  a  mass  of 
loose  or  flufied-up  gauze,  and  the  firm  apphcation  of  a  bandage  or  binder.  An 
incised  wound  is  usually  closed  with  interrupted  sutures  (Figs.  114  and  115). 
In  adjusting  the  sutures,  see  that  the  edges  of  the  wound  are  not  inverted,  but 
are  neatly  approximated  with  raw  edge  to  raw  edge.  Tie  the  stitches  firmly 
but  not  tightly.  If  a  stitch  is  tied  too  tightly  it  will  make  a  ridge,  as  shown 
in  Fig.  114,  and  undue  tightness  is  sure  to  cause  necrosis,  and  is  often  produc- 
tive of  a  stitch-abscess.     As  previously  stated,  I  usually  close  wounds  with 


298 


Contusions  and  Wounds 


sutures  of  very  fine  black  silk.  This  will  break  if  we  try  to  tie  it  tightly,  and 
as  it  never  causes  a  sinus  when  retained  in  the  tissues  it  can  be  used  for  buried 
sutures  as  well  as  for  the  skin.  A  silk  suture  and  a  catgut  suture  should  be  tied 
w'ith  the  reef  knot;  a  suture  of  silkworm-gut  may  be  tied  with  either  a  sur- 


The  ri^ht  way. 


%+fV  The  wrong  way. 


Fig.   114. — The  interrupted  suture  (after  Bryant). 


Fig.  1 15-^ Tying  an  interrupted 
suture.  The  knot  is  placed  to  the 
side  of  the  wound  as  shown  in  Fig.  112. 


116. — Continuous  suture. 


geon's  knot  or  a  reef  knot.  If  a  wound  is  on  the  face,  particular  care  must 
be  employed  in  closing  it,  in  order  to  hmit  the  amount  of  disfigurement.  Fine 
sutures  of  silk  or  horsehair  are  passed  with  a  small  sharp  needle  or  a  subcuticular 
stitch  is  used.     In  a  clean  wound  stitches  may,  as  a  rule,  be  removed  in  from 


Fig.  117. — Ford'ssuture:  A  square  knot,  a  Fig.    118. — Ford's    suture:  Showing  two 

single  knot,  a  double  or  friction  knot,  and  the  square  knots,  a  single  knot,  and  the  method 

first  method   of  passing   the  needle  to  tie  a  of  completing  a  square  knot, 
single  knot  immediately. 

six  to  eight  days.  In  a  large  wound  one-half  the  stitches  are  removed  at  one 
sitting,  and  in  a  day  or  two  the  rest  are  removed.  Stitches  are  removed 
promptly  if  they  begin  to  cut  out  or  if  infection  occurs. 

The  old  continued  suture  is  rarely  used  for  skin-wounds  at  the  present 
time.  This  suture  is  employed  to  suture  the  dura  after  division,  to  suture 
the  two  layers  of  pleura  together  before  an  abscess  of  the  lung  is  opened,  to 


Wounds  of  Mucous  Membranes 


299 


suture  the  peritoneum  after  laparotomy,  and  to  suture  the  mucous  membrane 
after  certain  operations  upon  the  stomach.  The  continuous  suture  is  shown  in 
Fig.  116.  _A  continuous  suture  knotted  after  each  emergence  was  devised  by 
Ford.     It  is  very  useful  in  suturing  the  parietal  peritoneum  (Figs.  117  and  118). 

Chassaignac  in  1851  devised  a  method  of  intradermic  suture  which  Kendal 
Franks  revived  some  twenty-five  years  ago. 

Halsted's  subcuticular  sti-tch  (Fig.  119)  makes  a  most  perfect  closure  of 
the  skin-wound,  and  is  followed  by  the  smallest  possible  scar.  In  closing 
a  deep  wound  the  muscles,  fasciae,  and  subcutaneous  structures  are  sutured 
in  layers  by  buried  sutures  before  the  subcuticular  stitch  is  inserted.  It  is  only 
used  in  wounds  which  are  almost  cer- 
tainly clean  (as  those  made  by  the 
surgeon),  and  in  wounds  which  do 
not  require  drainage.  The  suture 
material  should  be  of  fine  silver  wire 
or  horsehair  caught  upon  a  curved 
Hagedorn  needle  or  silkworm-gut 
carried  by  a  long,  straight,  round 
needle.     The  suture  is  passed  through 

the  corium  on  each  side  of  the  wound,  as  shown  in  Fig.  119.  The  curved 
needle  must  be  held  in  the  bite  of  a  needle-holder.  When  the  suture  has  been 
passed  the  ends  are  pulled  upon,  and  the  skin-wound  closes  neatly.  This 
method  secures  a  linear  cicatrix  (see  Arana,  in  ''The  Intradermic  Suture"  in 
Semaine  med.,  1916,  xxiii). 

Halsted's  suture  does  not  penetrate  the  cuticle;  hence,  in  passing  it  the 
white  staphylococcus  is  not  carried  through  stitch-holes  and  into  the  wound, 
an  accident  which  might  be  followed  by  infection  of  a  stitch  hole  or  even  of 
the  wound.  When  it  is  desired  to  withdraw  this  suture,  take  one  end  in  the 
bite  of  the  forceps,  cut  it  off  short  with  scissors,  catch  the  free  end  with  forceps, 


Fig.  119. — Halsted's  subcuticular  suture:  A  is 
j  the  true  skin. 


Fig.  120. — The  quilled  suture. 

and  pull  steadily  upon  it.  During  withdrawal  the  wound  is  supported  by  light 
pressure  on  a  superimposed  piece  of  gauze. 

In  very  deep  wounds  or  wounds  in  which  there  is  much  tension  after  ap- 
proximation the  quilled  suture  (Fig.  120)  or  the  button  suture  (Fig,  121) 
may.be  used.     The  twisted  suture  or  hare-lip  suture  is  shown  in  Fig.  122. 

Problems  of  drainage,  dressing,  etc.,  are  discussed  on  pages  87  and  88. 

If  infection  occurs,  the  wound  becomes  swollen,  tender,  painful  and  dis- 
colored, and  the  temperature  of  the  patient  soon  becomes  elevated.  In  such  a 
condition  cut  the  stitches,  disinfect,  and  drain. 

Wounds  of  Mucous  Membranes. — If  the  surgeon  intends  to  inflict  a  wound 
upon  a  mucous  surface,  he  should  see  to  it  that  the  patient's  general  condition 
is  good.  Thorough  asepsis  is  impossible,  and  a  good  result  depends  largely 
upon  the  vital  resistance  of  the  tissues.  Before  operating,  irrigate  the  part 
frequently  with  boric  acid,  peroxid  of  hydrogen,  or  normal  salt  solution.  When 
ready  to  sew  up  the  wound  be  sure  that  all  irritant  fluids  are  removed  (saliva  in 


300 


Contusions  and  Wounds 


the  mouth,  etc.).  Cleanse  the  wound  with  hot  normal  salt  solution.  The 
stitches  must  include  submucous  tissue  as  well  as  the  mucous  membrane,  and 
consist  of  silver  wire,  catgut,  silk,  chromic  catgut,  or  silkworm-gut.  After 
sewing  up  a  wound  in  the  mouth  wash  the  oral  cavity  at  frequent  intervals 
\vith  salt  solution  or  dilute  alcohol  and  follow  each  washing  with  an  insuf- 
flation of  iodoform. 

In  accidental  wounds  irrigate  with  salt  solution,  dust  with  iodoform,  and 
close  as  directed  above.  Corrosive  sublimate  is  so  irritant  that  it  does  harm 
when  applied  to  a  mucous  membrane.  In  some  wounds  of  the  lij)  and  tongue 
the  sutured  wound  is  covered  with  While/lead's  varnish,  a  material  which 
adheres  tenaciously.  It  is  a  modification  of  the  compound  tincture  of  benzoin, 
a  saturated  solution  of  iodoform  in  ether  being  substituted  for  the  alcohol  and 
one  volume  of  turpentine  to  lo  of  the  mixture  being  added. 

Contused  and  Lacerated  Wounds. — A  contused  wound  results  from  a 
blow  or  a  squeeze  which  bruises  and  crushes  the  tissues  and  splits  or  ruptures 
the  skin.  It  is  a  common  injury  when  force  is  applied  to  tissues  over  a  bone. 
The  blow  of  a  blackjack  upon  the  scalp  may  cause  either  a  contusion  or  a  con- 
tused wound.  A  contused  wound  is  irregular  in  outline,  has  jagged  edges,  and 
is  surrounded  by  a  broad  zone  of  contusion.  The  worst 
form  of  contused  wound  is  a  crush  of  an  extremity  produced 
by  being  run  over.  The  skin  is  often  widely  separated  from 
the  tissues  beneath.  A  crush  is  liable  to  be  followed  by  gan- 
grene, embolism,  or  fat-embolism. 

A  lacerated  wound  results  from  tearing  apart  of  the 
tissues.  It,  too,  is  irregular  and  jagged,  and  is  accompanied 
by  more  or  less  contusion.  A  brush-burn  is  a  contused-lacerated 
wound  due  to  friction.  Both 
lacerated  and  contused  wounds 
contain  masses  of  partly  de- 
tached and  damaged  tissue, 
the  vitality  of  which  is  en- 
dangered. Nerve-trunks,  mus- 
cles, and  great  vessels  may  be 

PiQ_  J2I. Button    to^^    across.      Hence,    such 

suture.  wounds     are     apt     to    slough, 

frequently  suppurate,  and  are 
occasionally  followed  by  cellulitis  or  even  by  gangrene.  There  is  more  danger 
of  tetanus  than  in  incised  wounds.  A  wound  especially  apt  to  be  followed 
by  tetanus  is  made  by  the  toy  pistol.  In  contused  and  lacerated  wounds 
the  edges  are  discolored  and  cold  to  the  touch,  and  there  is  little  primary 
hemorrhage  unless  a  great  vessel  has  been  torn.  There  is  considerable  danger  of 
secondary  hemorrhage  if  large  vessels  have  been  bruised.  In  wounds  of  this 
nature  the  pain  is  often  slight,  but  it  may  be  violent.  Shock  is  very  severe. 
Avulsion  of  a  limb  is  a  dreadful  form  of  lacerated  wound.  The  thumb 
or  a  finger  may  be  torn  off  or  the  arm  may  be  wrenched  from  the  body  with 
or  without  the  scapula.  In  such  cases  the  wound  is  large,  jagged,  and  irreg- 
ular, long  strings  of  muscle  or  tendon  hang  from  the  gap,  the  wound  edges  are 
cold,  but  the  bleeding  is  trivial.     The  shock  is,  of  course,  profound. 

Avulsion  of  the  scalp  may  be  produced  when  the  hair  is  caught  in  machinery. 
The  American  Indian  inflicts  this  injury  when  he  scalps  a  conquered  foe. 
In  some  cases  of  avulsion  of  the  scalp  the  periosteum  is  removed  with  the  flap; 
in  most  it  is  not.  The  flap  usually  consists  of  skin  and  aponeurosis.  In  this 
form  of  laceration  there  is  severe  bleeding. 

Treatment. — The  surgeon  brings  about  reaction  and  endeavors  to  asepticize 
the  wound  and  skin  about  it  (see  page  294),  arrests  hemorrhages,  and  ligates 
any  visible  damaged  vessel  whether  it  bleeds  or  not.     Foreign  bodies  are  removed. 


The  twisted  suture. 


Punctured  Wounds  301 

Hopelessly  damaged  tissue  should  be  cut  away.  In  a  shell  wound  doubtful  tissue 
must  not  be  retained.  In  some  cases  amputation  is  necessary.  Give  an  injection 
of  antitetanic  serum  as  a  preventive.  Repeat  the  dose  twice  at  intervals  of  eight 
days.  Secure  thorough  drainage,  in  some  situations  making  counter-openings 
if  necessary.  In  many  cases  leave  the  wound  open.  In  some  cases  excise 
the  wound.  Tube-drainage  may  be  necessary  or  iodoform  gauze  in  strands 
may  be  used.  In  the  past  contused  wounds  and  lacerated  wounds,  except  when 
on  the  face,  were  seldom  closed  by  sutures.  They  were  rarely  closed,  because 
the  great  damage  to  tissue  and  serious  interference  with  the  blood-supply 
strongly  militate  against  primary  union.  In  the  face  the  blood-supply 
is  so  good  that  primary  union  may  be  obtained  in  part  or  entirely  and  surgeons 
thought  it  worth  while  to  try  to  obtain  it.  A  method  of  treatment  popularized 
by  surgeons  active  in  the  war  is  to  excise  the  wound.  If  this  can  be  done  soon 
after  the  injury  (within  a  few  hours)  close  without  drainage.  Otherwise,  leave 
the  wound  open,  employ  the  Carrel-Dakin  treatment,  and  when  bacteria  prac- 
tically disappear,  perform  secondary  suturing.  Cold  must  not  be  applied  to  a 
region  of  lowered  vitahty  because  it  may  cause  gangrene.  Heat  is  useful. 
Hence,  it  is  a  custom,  even  from  the  start,  in  cases  in  which  excision  has  not 
been  practised,  to  dress  with  hot  antiseptic  fomentations,  and  this  mode  of  dress- 
ing is  regarded  as  imperative  if  sloughing  begins.  An  excellent  fomentation  is 
made  by  soaking  the  gauze  in  a  hot  solution  of  acetate  of  aluminum,  using  i 
fluidram  of  a  j^4  per  cent,  solution  to  an  ounce  of  water  (Waterhouse,  "British 
Med.  Jour.,"  July  9,  1910).  The  best  treatment  for  a  lacerated  wound,  if  extir- 
pation and  immediate  suturing  has  not  been  practised,  is  the  use  of  Dakin's 
fluid  and  the  performance  of  secondary  suturing.  Of  course,  the  part  must  be 
kept  at  rest. 

If  suppuration  occurs,  the  surgeon  sees  to  it  that  the  pus  has  free  exit,  and 
if  necessary  secures  free  exit  by  making  incisions.  Bier's  treatment  and  rest 
are  useful  for  infections. 

After  avulsion  of  a  limb  the  patient  is  brought  out  of  shock,  large  vessels  are 
sought  for  and  tied,  damaged  tissue  is  cut  away,  the  wound  is  drained  by 
gauze  and  is  partly  approximated  by  sutures.  After  avulsion  of  the  scalp 
bleeding  vessels  are  carefully  ligated.  A  portion  of  the  scalp  may  be  torn 
away,  but  a  pedicle  may  connect  it  with  the  balance  of  this  structure.  In  such 
a  case  cleanse  the  parts  thoroughly  and  suture  the  flap  in  place  (W.  T.  Bivings, 
"Phila.  Med.  Jour.,"  June  7,  1902).  If  the  portion  of  scalp  is  entirely  sepa- 
rated, adopt  Gussenbauer's  suggestion  w^hen  possible  and  graft  pieces  of  the 
a\nilsed  scalp  on  the  wound.  In  any  case  the  ulcer  resulting  from  avulsion  must 
be  repeatedly  grafted.  Abbe  obtained  healing  in  a  case  after  four  years  by  the 
use  of  12,000  grafts. 

Punctured  wounds  are  made  by  pointed  objects,  as  needles,  splinters, 
etc.  The  depth  of  a  punctured  wound  greatly  exceeds  its  surface  area.  After 
the  withdrawal  of  the  instrtunent  inflicting  the  injury  the  wound  closes  partly 
at  points,  blood  and  wound-fluid  cannot  find  exit,  and  if,  as  is  probably  the 
case,  bacteria  w^ere  deposited  ui  the  tissues,  infection  by  pus  organisms  is  very 
likely  to  occur,  and  if  it  does  occur  suppuration  spreads  widely.  There  is 
also  danger  of  infection  by  tetanus  bacilli.  Such  a  wound  may  involve  an 
important  blood-vessel,  arid  in  such  a  case  profuse  hemorrhage  may  occur; 
other\\ise  hemorrhage  is  slight.  A  great  ca\ity  of  the  body  may  be  penetrated 
or  an  important  organ  may  be  w^ounded.  Large-sized  foreign  bodies  may  be 
driven  into  the  tissues  or  a  portion  of  the  instrument  may  break  off  and  lodge. 
Pain  is  rarely  severe  unless  a  considerable  nerve  has  been  damaged.  If  both 
a  large  vein  and  artery  are  punctured,  a  varicose-aneurysm  or  an  aneurysmal- 
varix  may  form. 

Treatment. — WTien  possible,  inspect  the  object  which  did  the  damage 
to  see  if  a  piece  has  been  broken  off.     If  there  is  severe  hemorrhage,  enlarge 


302  Contusions  and  Wounds 

the  wound  and  tie  the  bleeding  vessels.  In  a  puncture  not  made  by  the  surgeon 
the  wound  must  be  regarded  as  infected.  If  a  trivial  wound  is  made  by  a  dirty 
instrument  through  skin  known  to  be  unclean,  it  is  proper  that  the  skin  about 
the  puncture  be  sterilized,  that  the  wound  be  enlarged,  that  foreign  bodies  be 
removed,  that  the  wound  be  irrigated  with  an  antiseptic  solution  or  be  painted 
with  pure  carbolic  acid,  and  be  drained  with  a  tube,  a  strip  of  gauze,  or  a  piece  of 
rubber  tissue.  Such  treatment,  though  painful,  and  appearing  unnecessarily 
severe  or  even  cruel  to  the  sufferer  from  a  trivial  puncture,  is  necessary,  and  may . 
save  the  patient  from  serious  illness  or  from  death.  Every  deep  puncture 
inflicted  by  an  instrument  not  surgically  clean,  and  every  puncture  inflicted 
by  a  nail,  a  splinter,  a  meat-hook,  a  rusty  pin,  a  tooth  of  a  cat  or  dog,  etc., 
must  be  regarded  as  grossly  infected  and  must  be  treated  by  free  incision, 
Dakin's  fluid,  and  rest.  If  the  puncture  is  superficial  and  is  made  with  a  smooth- 
pointed  instrument  like  a  needle,  when  the  instrument  was  not  grossly  infected 
the  parts  may  be  dressed  with  hot  antiseptic  fomentations,  but  they  should  be 
inspected  daily  for  evidence  of  infection,  and  at  the  first  sign  of  trouble  an 
incision  must  be  made.  If  a  foreign  body  is  retained  in  the  tissue  it  must  be 
removed. 

If  an  important  cavity  of  the  body  has  been  invaded  by  a  puncture  ex- 
ploratory incision  is  necessary  (see  Brain,  Thorax,  Abdomen).  In  punctures 
with  contaminated  instruments  antitetanic  serum  should  be  given,  at  an 
interval  of  eight  days  another  dose,  and  after  eight  days  more  another  dose 
should  be  administered. 

Stab  Wounds  were  formerly  considered  with  punctured  wounds,  but  Senn 
wisely  placed  them  in  a  class  by  themselves.  Stab;, wounds  are  inflicted  by  the 
penetration  of  the  tissues  by  a  pointed  or  narrow  instrument — for  instance,  a 
dagger,  a  knife,  the  blades  of  scissors,  a  bayonet,  or  a  sword.  Such  wounds 
are  narrow  and  very  deep.  A  stab  wound  may  cause  rapid  death  by  penetra- 
tion of-a  large  blood-vessel.  Some  great  cavity  of  the  body  may  be  penetrated 
and  internal  hemorrhage  will  then  occur.  The  body  may  be  transfixed  b}^  a 
sword  or  bayonet.  Bone  is  rarely  injured  unless  the  skull  is  penetrated  or' 
the  chest  entered.  In  stab  wounds  there  is  usually  great  hemorrhage  and 
shock. 

Treatment. — Whenever  possible,  look  at  the  object  which  did  the  damage 
and  see  if  a  piece  is  broken  off.  If  no  great  cavity  is  entered,  treat  by 
general  rules:  arrest  bleeding,  react  from  shock,  etc.  The  treatment  of  pene- 
trating wounds  of  the  abdomen,  thorax,  and  cranium  is  discussed  in  the  special 
sections.     Stab  wounds  call  for  preventive  doses  of  antitetanic  serum. 

Arrow  wounds  might  be  considered  under  the  head  of  punctured  wounds  or 
stab  wounds.  When  hostilities  with  the  red  men  were  frequent  and  before 
mercenary  traders  had  fitted  out  the  savages  with  rifles,  arrow  wounds  were 
common  among  the  men  of  the  frontier.  They  are  now  very  rare.  Military 
surgeons  still  encounter  them,  especially  in  some  parts  of  Africa  and  in  the 
Philippine  Islands.  An  arrow  wound  may  be  a  trivial  puncture  of  the  skin, 
a  deep  wound  of  the  soft  parts  with  or  without  bone  injury,  a  penetration 
of  a  joint,  or  of  one  of  the  body  cavities.  The  skull  cavity  may  be  entered  by 
an  arrow.  In  some  of  these  cases  there  is  a  puncture  of  the  bone  without 
the  formation  of  fissures,  but  usually  when  bone  is  punctured  there  are  fissure 
formation,  splintering,  or  depression.  A  large  blood-vessel  may  be  divided 
by  an  arrow  and  violent  bleeding  result  or  fatal  concealed  hemorrhage  may 
take  place  from  a  wounded  viscus.  Some  tribes  poison  arrows.  It  is  said  that 
the  Piutes  were  the  only  tribe  of  North  American  Indians  which  did  this. 

Some  tribes  in  South  America  use  curare,  others  use  snake-venom,  others 
used  decomposed  meat.  Certain  tribes  in  Africa  employ  the  venom  of  the 
puff  adder.  In  Northern  Nigeria  some  form  of  strophanthus  plays  a  part 
in  nearly  all  the  poisons  used  (Allan  C.  Parsons,  in  "Brit.  Med.  Jour.,"  Jan. 


Gunshot  Wounds  303 

23,  1909).  The  same  author  points  out  that  the  poison  used  is  generally  complex 
and  contains  also  various  animal  and  vegetable  ingredients,  particularly  de- 
composed organic  matter,  plant  juice  containing  strychnin,  and*  soil  con- 
taminated with  tetanus  organisms. 

Treatment. — An  arrow  is  always  septic  and  should  be  extracted.  Some- 
times when  it  has  been  buried  deeply  in  a  part  it  should  be  pushed  across  and 
extracted  through  a  counteropening  after  the  protruding  shaft  has  been  cut 
off.  An  arrow-head  cannot  be  pulled  out  by  the  shaft.  The  barbs  on  the  head 
catch  and  prevent  extraction  and  the  neck  of  the  shaft  is  apt  to  break.  The 
tissues  should  be  freely  divided  down  to  the  head  of  the  arrow  and  on  each  side 
of  it,  when  it  can  usually  be  withdrawn  by  forceps.  If  imbedded  in  bone,  the 
head  must  be  gently  rocked  from  side  to  side  to  loosen  it,  every  care  being  taken 
to  avoid  breaking  a  stone  or  bending  an  iron  arrow  head.  If  an  arrow  has 
penetrated  the  abdomen,  a  laparotomy  should  be  perform-ed.  If  it  has  entered 
a  joint,  the  joint  should  be  freely  opened.  If  it  has  entered  the  chest,  one  or 
more  ribs  will  require  resection.  If  it  has  entered  the  skull,  trephining  is 
indicated.  Any  bleeding  vessels  are  to  be  caught  and  tied.  The  track  of  the 
arrow  should  be  carefully  disinfected  and  drainage  should  be  secured.  It  is 
particularly  important  to  remove  a  poisoned  arrow  at  once.  After  removing  a 
poisoned  arrow,  if  the  nature  of  the  poison  is  known,  proper  treatment  should 
be  applied  to  antidote  the  poison.  The  French  Colonial  surgeons  fill  wounds 
inflicted  by  poisoned  arrows  with  tannic  acid.  The  same  custom  is  followed  by 
English  surgeons  in  West  Africa  (Allan  C.  Parsons,  in  "Brit.  Med.  Jour.,"  Jan. 
23,  1909). 

Gunshot  wounds  are  contused  or  contused-lacerated  wounds  inflicted 
by  materials  projected  by  explosives.  A  bit  of  rock  or  a  crowbar  hurled  by 
dynamite  inflicts  a  gunshot-wound,  as  does  a  shell-fragment,  a  pistol-ball, 
small  birdshot,  a  rifle  bullet,  pieces  of  a  hand  grenade,  a  flying  cap,  a  piece  of 
wadding,  grains  of  powder,  a  buckshot,  a  fragment  of  metal  broken  off  a  shell, 
grapeshot,  canister  and  shrapnel  or  a  cannon-ball.  Injuries  by  portions  of 
a  bursted  boiler,  pieces  of  masonry  or  wood,  are  either  lacerated  or  punctured 
wounds,  and  need  no  special  consideration  here.  In  this  article  we  treat  of 
injuries  caused  by  bullets,  shot,  shell,  etc.,  that  is,  by  missiles  propelled  from 
firearms. 

Firearms  are  instruments  by  means  of  which  missiles  are  projected  to  a 
distance  by  the  expanding  gases  of  burning  gunpowder.  There  are  many 
different  sorts  of  firearms.  Artillery  includes  various  sizes  of  guns  upon  sup- 
ports, from  the  great  howitzers,  of  a  caliber  of  420  mm.,  and  which  fire  huge 
shells,  to  machine-guns,  which  fire  ordinary  rifle  bullets.  Field  artillery 
frequently  uses  shrapnel-shells.  Such  a  shell  is  a  case  of  steel,  cylindroconoidal 
in  shape,  containing  a  number  of  bullets  and  a  charge  of  explosive,  the  shell 
exploding  by  means  of  a  time-fuse.  Canister  is  an  iron  casing  containing 
bullets  unassociated  with  an  explosive  discharge  within  the  casing.  The 
canister  breaks  when  fired,  and  the  balls  separate  over  a  large  area.  It  is  used 
only  at  close  range — that  is,  300  or  400  yards. 

Among  small  arms  may  be  mentioned  muskets,  revolvers,  shotguns,  and 
rifles.  Wounds  from  the  old-time  musket  ball  are  now  never  met  with  except 
in  warfare  against  barbarous  tribes.  The  musket  has  a  smooth  bore  and  fires 
round  bullets  of  soft  lead.  This  round,  soft  bullet,  being  large,  moving  with 
comparative  slowness,  and  flattening  easily,  is  very  liable  to  glance,  to  deform, 
and  to  lodge.  When  a  musket  is  fired  at  close  range  and  the  bullet  strikes 
the  tissue  at  a  right  angle,  it  produces  a  punched-out  entrance  wound.  If 
the  velocity  is  low  or  the  impact  is  not  at  a  right  angle  to  the  tissues,  the  en- 
trance wound  may  "be  formed  of  triangular  flaps,"  the  corners  of  which  are 
inverted.^  The  entrance  wound  is  surrounded  by  a  bruised  area.  The  track 
^  "Wounds  in  War,"  by  Surgeon  Col.  W.  F.  Stevenson. 


304  Contusions  and  Wounds 

of  the  bullet  is  larger  than  the  bullet,  and  is  so  badly  contused  and  lacerated 
that  some  tissue  is  devitalized;  and  the  shaft  of  a  bone,  if  struck,  is  likely  to 
be  splintered.  If  the  ball  emerges,  the  wound  of  exit  is  larger  than  the  bullet, 
and  forms  triangular  and  everted  flaps.  Healing  by  first  intention  seldom 
occurs  in  such  wounds.  The  old  smooth-bore  musket,  firing  a  round  bullet, 
has  been  displaced  by  the  rifle  propelling  a  pointed  projectile. 

In  the  firearms  of  civilians,  as  a  rule,  the  bullets  are  made  of  lead,  hardened 
and  shaped  by  compression  or  hardened  by  an  admixture  with  tin.  The  cylindro- 
ogival  rifle  bullet  (Fig.  130)  has  much  greater  velocity  and  penetrating  power 
than  the  round  bullet.  Hence,  it  is  more  liable  to  penetrate  and  less  likely 
to  deflect  and  to  lodge.  The  tissues  in  the  track  of  this  bullet  are  less  devital- 
ized than  in  the  track  of  the  round  buUet.  The  cutaneous  surface  is  not  so 
much  contused.  If  the  bullet  strikes  at  a  right  angle  to  the  surface  the  wound 
of  entrance  is  about  the  size  of  the  bullet,  and  is  punched  out  or  inverted;  and 
the  wound  of  exit  is  larger  than  that  of  entrance  and  is  often  everted.     The 


Fig.  123. — Lodged  shot. 

bones  are  more  seriously  comminuted  than  by  the  round  buUet,  and  osseous 
fragments  may  be  driven  widely  into  the  tissues.  In  fact,  "an  explosive  effect " 
may  occur  at  close  range.  Delorme  laid  it  down  as  a  rule  that  comminution 
of  bone  makes  the  wound  of  exit  larger;  and  he  asserts  that  a  wound  of  exit 
larger  in  diameter  than  the  thumb  means  comminution  of  bone  (Fig.  138). 
He  was  not  speaking  of  the  pointed  bullet.  If  the  pointed  bullet  does  not 
strike  at  right  angles  it  wiU  be  deflected  and,  going  through  the  tissues,  side 
on  instead  of  point  ahead  will  leave  a  frightful  gap. 

Gunshot  Wounds  Seen  in  Civil  Life. — Wounds  are  occasionally  inflicted  by 
the  sporting  rifle  or  the  shotgun,  and  frequently  by  blank  cartridges;  but  the  vast 
majority  of  such  wounds  seen  by  the  civilian  surgeon  are  inflicted  by  the 
revolver. 


Wounds  Inflicted  by  the  Revolver  Bullet  305 

Wounds  from  the  Sporting  Rifle. — In  the  sporting  rifle  a  large  charge  of 
powder  is  employed.  Some  sporting  rifle  bullets  have  no  hard  jackets.  Others 
have  an  incomplete  hard  jacket.  In  a  bullet  with  a  partial  hard  jacket  the 
"nose"  of  the  bullet  is  exposed  and  soft.  The  bullets  are  usually  larger  than 
those  used  in  the  military  rifle.  Such  bullets  deform  in  the  tissues,  and  inflict 
dreadful,  tearing  wounds.  If  a  bullet  of  a  sporting  rifle  strikes  a  limb,  ampu- 
tation may  be  required.  If  it  strikes  the  head  or  trunk,  it  will  almost  certainly 
produce  a  fatal  wound. 

Wounds  from  the  Shotgun. — The  degree  of  injury  is  in  direct  relation  to  the 
adjacency  of  the  wounded  individual  to  the  gun,  when  the  discharge  took 
place,  to  the  size  and  number  of  the  shot,  and  to  the  charge  of  powder.  Single 
shot  may  bruise  the  surface  and  fail  to  enter  the  tissues  or  may  enter  the  tissues. 
When  many  shot  enter  together  they  strike  as  a  solid  body.  Single  shot  are 
usually  deflected  from  vessels  and  nerves,  and  seldom  lodge  in  bone,  but, 
rather,  flatten  on  the  bone  surface.  Even  a  single  shot  lodged  in  the  eyeball 
is  apt  to  produce  violent  inflammation  which  may  destroy  the  eye.  Numerous 
shot  entering  together  at  close  range  produce  extensive  contusions  of  the  surface 
and  fearful  lacerations  of  the  tissues,  and  often  inflict  irreparable  damage. 
Bone  may  be  fractured  and  bits  of  clothing  or  other  foreign  bodies  may  be 
carried  into  the  wound  with  the  shot.  At  close  range  toes  or  fingers  may  be 
blown  off,  an  eye  may  be  blown  out,  or  portions  of  tendon  or  muscle  may 
be  shot  away.  At  close  range  dreadful  subcutaneous  lacerations  are  caused  by 
the  gases.  Primary  hemorrhage  is  seldom  severe  because  the  wound  is  lacer- 
ated; but  secondary  hemorrhage  is  to  be  feared,  and  serious  infection  usually 
follows  such  injuries.  Buckshot  at  close  range  inflict  grave  or  dreadful  wounds. 
The  United  States  Army  is  supplied  with  a  cartridge  for  use  in  riots.  This 
cartridge  contains  two  shot,  each  about  the  size  of  a  buckshot. 

The  Treatment  of  Shotgun  Wounds. — If  the  shot  be  scattered  and  lodged 
it  is  seldom  necessary  to  remove  them.  As  a  rule,  such  cases  require  only 
cleansing  of  the  skin  and  aseptic  dressings.  If  shot  lodge  in  a  joint,  they 
impair  function;  if  in  the  face,  they  produce  deformity.  In  both  of  these 
cases  removal  is  necessary.  When  a  shot  lodges  in  the  eye  it  usually,  but  not 
always,  causes  blindness.  If  the  eye  is  gravely  damaged  it  must  be  enucleated. 
In  serious  lacerations  produced  by  shot  at  close  range  the  hopelessly  damaged 
tissue  must  be  cut  away,  hemorrhage  must  be  arrested,  foreign  bodies  must  be 
removed  (though  no  protracted  search  is  either  necessary  or  desirable  to  re- 
move grains  of  shot),  the  wound  must  be  disinfected  as  well  as  possible,  free 
drainage  must  be  employed  or  the  Carrel-Dakin  treatment  should  be  used. 
It  is  wise  to  give  prophylactic  doses  of  antitetanic  serum. 

Blank-cartridge  Injuries. — These  injuries  can  occur  only  at  close  range. 
They  consist  of  burns  and  lacerations,  frequently  a  wad  or  a  bit  of  clothing 
lodges  in  the  tissues,  and  tetanus  is  a  not  unusual  sequence.  The  explosive 
used  in  the  toy  pistol  is  a  fulminate,  and  bits  of  the  envelope  of  the  explosive 
may  be  driven  quite  deeply  into  the  tissues.  There  is  considerable  danger  of 
tetanus  after  injuries  inflicted  by  the  toy  pistol.  What  in  the  United  States 
is  called  "Fourth  of  July  tetanus"  is  tetanus  foflowing  such  an  injury,  the  small 
boy  being  prone  to  employ  a  toy  pistol  to  contribute  noise  to  the  celebration 
of  the  nation's  birthday  (see  page  224). 

Blank-cartridge  wounds  and  toy-pistol  wounds  are  treated  by  cleansing 
the  skin,  enlarging  the  wound,  removing  foreign  bodies,  disinfecting,  and 
draining.     Prophylactic  doses  of  antitetanus  serum  should  always  be  given. 

Wounds  Inflicted  by  the  Revolver  Bullet. — The  revolver  varies  in  caliber 
from  0.22  to  0.45.  Whereas  it  is  true  that  certain  military  revolvers  of  the  auto- 
matic type  fire  a  hard-jacketed  rifle  bullet,  the  revolvers  of  civil  life  propel 
cylindroconoidal  unjacketed  bullets  at  a  velocity  of  about  700  feet  a  second. 
A  revolver  bullet  of  the  civilian's  weapon  never  produces  an  explosive  effect. 


3o6  Contusions  and  Wounds 

It  is  liable  to  deform  in  the  tissues,  is  often  deflected  from  bone  or  tendon,  and 
is  very  apt  to  lodge.  The.  shape  of  the  bullet,  the  velocity  with  which  it  is  pro- 
pelled and  with  which  it  rotates,  and  its  hardness  made  it  unlikely  that  at  any 
near  range  the  bullet  will  merely  contuse,  and  not  enter,  the  skin.  Unless  strik- 
ing at  a  decided  angle  to  the  perpendicular,  it  will  amost  always  enter.  Some- 
times it  perforates,  more  often  it  lodges.  In  some  cases,  however,  a  pistol 
bullet,  like  a  spent  rifle  bullet,  may  fail  to  enter  the  tissues.  It  then  grazes  the 
surface  and  inflicts  a  brush  burn  or  simply  contuses  the  part.  Whereas  it  may 
be  deflected,  it  comparatively  seldom  is;  and  it  often  deforms,  though  it  does 
not  do  so  to  anything  like  the  degree  that  the  soft,  round  bullet  does.  If  a 
bullet  enters  the  tissue,  a  cavity,  or  an  organ,  and  lodges  there,  it  causes  a 
penetrating  wound.  If  it  enters  and  emerges  it  causes  a  perforating  wound. 
The  bullet  may  not  enter  alone,  but  may  carry  with  it  bits  of  clothing  or  other 
foreign  bodies,  though  this  complication  is  much  rarer  in  injury  with  the  conical 
bullet  than  with  the  round  ball.  On  one  occasion  I  removed  a  piece  of  coat 
from  the  interior  of  the  lung,  to  which  it  had  been  carried  by  a  pistol  bullet.  In 
another  instance  I  removed  a  piece  of  shirt  from  the  interior  of  the  abdomen,  to 
which  it  had  been  carried  by  a  similar  bullet.  A  revolver  bullet  may  break 
bone,  though  it  is  not  nearly  so  liable  to  do  so  as  a  rifle  bullet. 

In  studying  a  gunshot  wound  one  must  consider  the  wound  of  entrance, 
the  tissue  track,  and,  if  the  bullet  has  emerged,  the  wound  of  exit.  It  is  usually 
stated  that  if  a  revolver  bullet  fired  from  a  distance  of  lo  feet  or  more  from 
the  person  struck  hits  the  skin  at  a  right  angle,  it  makes  a  wound  of  entrance 
that  is  smaller  than  the  bullet  because  the  skin  is  elastic.  It  is  a  certain  fact 
that  one  cannot  assert  from  a  mere  inspection  of  the  wound  of  entrance  with 
what  size  bullet  a  man  was  struck.  A  0.22  often  leaves  a  most  trivial  opening. 
Careful  separation  of  the  margins  enables  us  to  measure  a  wound  of  entrance,, 
and  if  this  is  done  it  will  be  found  that  a  wound  of  entrance  is  never  smaller 
than  the  bullet.  (See  Wm.  S.  Wadsworth,  in  "International  Clinics,"  Vol.  iv, 
Twentieth  Series.)  The  shape  of  the  wound  is  somewhat,  but  not  regularly, 
circular,  because  a  certain  amount  of  tissue  is  destroyed.  The  margins  are 
also  somewhat  depressed.  It  has  a  punched-out  look,  and  the  edges,  as  Draper 
tells  us,  are  frayed  in  appearance  ("Text-book  of  Legal  Medicine").  The 
edges  of  the  wound  look  thickened  and  are  contused,  this  discoloration  being 
noted  for  a  distance  of  i  inch  or  even  2  inches  from  the  margin  of  the  wound. 
The  skin  surface  is  distinctly  blackened;  but  unless  the  weapon  were  fired 
at  very  close  range  this  is  not  due  to  burning,  but  rather  to  staining  with  a 
mixture  of  burnt  gunpowder  and  the  grease  of  the  outer  surface  of  the  bullet. 
The  appearance  of  the  wound  of  entrance  will  be  very  diff'erent  if  the  bullet 
strikes  the  surface  at  an  acute  instead  of  a  right  angle.  Then  the  wound  will 
not  be  round,  but  oval  or,  perhaps,  linear.  \Vhen  a  bullet  is  fired  very  near  to 
the  surface  of  the  body  the  hair  of  the  skin  will  be  burned,  there  will  be  some 
staining  with  gunpowder  around  the  wound,  and  powder-grains  will  be  found 
lodged  in  the  skin.  The  burning  is  due  to  hot  gases  and  with  the  gases  come 
powder-grains.  Whether  the  weapon  inflicting  the  wound  was  close  or  dis- 
tant there  is  bruising  of  the  skin,  but  when  the  powder  is  found  in  the  tissues 
or  on  the  surface  and  when  the  surface  is  scorched  the  weapon  must  have  been 
close  at  the  time  of  discharge.  Hot  gases  singe  hairs,  clothing,  or  the  skin 
itself.  The  nearer  the  skin  the  weapon  was  held  the  more  severe  the  burning. 
Wadsworth  says,  "  all  gas  phenomena  require  very  close  range,  usually  within 
18  inches."  What  is  called  the  smudge  is  due  to  "  the  debris  and  smoke  from  the 
powder"  and  takes  place  at  a  range  of  less  than  18  inches  (Wadsworth,  in  "  Inter- 
national Clinics,"  Vol.  iv,  Thirtieth  Series).  The  absence  of  embedded  powder, 
however,  does  not  prove  that  the  shot  was  not  close,  because  the  weapon  em- 
ployed might  have  been  one  using  smokeless  powder.  When  smokeless  powder 
has  been  used  the  burn  is  the  same  as  from  black  powder,  the  smudge  is  apt  to 


Wounds  Inflicted  by  the  Revolver  Bullet  307 

be  of  an  orange  color,  tattooing  is  rarer,  and  when  it  does  occur  shows  fewer 
grains.  If  the  smokeless  powder  contains  graphite  it  produces  a  smudge.  If 
the  weapon  were  fired  at  close  range  the  skin  may  have  been  burnt  by  burning 
gases  or  the  clothing  may  have  been  burnt  and  the  skin  scorched  by  the  burning 
clothing.  Staining  of  the  skin  with  powder  can  be  washed  off,  but  when  the  skin 
has  been  burnt  it  is  dry  hke  parchment.  When  unexploded  powder-grains  are 
lodged  in  the  skin  the  resulting  condition  is  spoken  of  as  tattooing,  and  this 
always  means  a  very  short  range.  Powder-grains  may  cause  severe  wounds.  It 
has  been  held  by  some  that  powder-grains  are  never  found  in  the  skin  unless  the 
bullet  has  been  fired  from  a  distance  of  less  than  3  feet,  but  this  is  too  arbitrary 
a  statement  to  make  in  a  court  of  law.  In  any  medicolegal  case  experiments 
should  be  made  with  a  weapon  and  ammunition  of  the  same  size  and  make  as 
those  used  in  inflicting  the  wound  in  order  to  determine  the  real  facts  of  the  case. 
Draper  ("Text-book  of  Legal  Medicine")  makes  the  following  important  state- 
ment relating  to  burns  of  the  skin:  "If  the  weapon  is  held  in  the  hand  in  the 
ordinary  way,  hammer  and  sight  on  the  barrel  directed  upward,  the  wound  in  the 
skin  will  show,  immediately  above  its  orifice,  a  brand  or  scorching  caused  by  a 
slight  recoil  in  the  act  of  firing.  The  location  of  this  brand  will  change  as  the 
position  of  the  hammer  is  changed.  If  the  weapon  is  held  in  a  vise  and  fired  this 
relation  of  the  brand  to  the  wound  is  obliterated.  This  observation,  first 
made  and  published  by  Dr.  D.  B.  N.  Fish  in  1883,  supphes  an  accurate  index 
of  the  position  in  which  the  pistol  was  held  in  firing."  Wadsworth  is  of  the 
opinion  that  the  "flip"  is  usually  but  not  always  toward  the  hammer  side. 
It  is  modified  "by  the  grip  on  the  handle  at  the  instant  of  discharge."  If 
the  muzzle  of  a  pistol  is  pressed  lightly  against  the  skin  gases  enter  with  the 
bullet  and  "burst  the  skin  outward,  giving  a  large  ragged  wound,  which  is 
not  a  wound  of  entrance,  though  always  called  so,  but  a  wound  of  exit  of  the 
gas"  (Wadsworth,  in  "International  Clinics,"  Vol.  IV,  Thirtieth  Series). 
If  the  muzzle  is  held  firmly  against  the  surface  the  gases  cause  a  horrible  wound 
under  the  skin.  This  condition  is  not  the  same  thing  as  the  explosive  effect 
of  a  bullet.  In  passing  through  the  tissues  the  revolver  bullet  makes  a  con- 
tused-lacerated  wound,  and  we  may  find  along  this  wound  powder-grains 
(if  the  bullet  has  been  fired  at  close  range)  and  portions  of  clothing,  pieces 
of  the  bullet  itself,  or  perhaps  of  bone-.  A  bullet  may  pass  directly  through 
both  walls  of  the  skull,  traversing  the  brain  in  its  passage.  It  may  pass  through 
a  wall  of  the  skuU  and  lodge  within  the  cavity  of  the  cranium.  In  some  cases 
it  makes  an  opening  of  entrance  that  is  smallest  on  the  external  surface  of  the 
bone  and  largest  on  the  inner  table.  In  other  cases  it  makes  extensive  com- 
minuted fractures.  When  a  bullet  tears  its  way  through  a  muscle  it  makes 
a  jagged,  contused,  lacerated  wound.  It  does  the  same  in  the  brain.  In 
both  cases  the  track  of  the  bullet  is  larger  than  the  bullet,  and  the  tissue  for 
a  considerable  distance  wide  of  the  track  is  contused  or  actually  destroyed.  In 
passing  through  an  aponeurosis  or  a  serous  membrane  the  bullet  may  make  a 
round  orifice  or  a  slit-like  tear.  Of  course,  the  nature  of  the  wound  in  the  tissues 
will  be  greatly  affected  if  the  bullet  is  deformed  by  having  struck  bone,  or  if 
it  carries  bits  of  bone  along  with  it.  The  deflection  of  a  bullet  from  an  aponeu- 
rosis, fascia,  or  bone  so  alters  its  course  that  the  missile  becomes  very  difficult 
to  locate  and  remove.  In  some  cases  a  bullet  has  entered  near  the  front  of  the 
body  and  passed  around  the  wall  of  the  chest  until  it  has  almost  reached  its 
point  of  entrance,  or  else  has  lodged  or  emerged  at  some  point  of  this  course — 
in  either  case  constituting  what  is  known  as  a  contour  wound.  Contour  wounds 
are  not  infrequently  seen  upon  the  head.  For  instance,  a  bullet  may  strike 
the  frontal  region,  pass  around  under  the  scalp,  and  lodge  in  or  emerge  from 
the  occipital  region. 

When  the  bullet  does  not  lodge,  but  emerges  from  the  body,  the  wound  of 
exit  must  be  studied.     If  an  undeformed  bullet  passes  straight  through  the 


3o8  Contusions  and  Wounds 

body  it  makes  a  wound  of  exit  that  is  somewhat  larger  than  the  bullet.  It  has 
a  torn-out  appearance,  but  without  distinct  destruction  of  tissue,  and  exhibits 
an  irregular  outline  and  eversion  of  the  edges.  The  margins  of  such  a  wound 
are  bruised,  but  are  never  scorched  and  never  show  powder-grains.  If  a  bullet 
has  been  deformed  by  hitting  bone,  or  if  it  has  driven  bone  before  it,  a  very  large 
lacerated  wound  of  exit  may  be  formed  (Fig.  138).  It  is  important  to  remember 
that  the  presence  of  a  number  of  wounds  on  the  surface  of  the  body  does  not 
in  itself  prove  that  a  number  of  different  bullets  have  been  fired,  for  in  certain 
circumstances  one  bullet  may  make  several  wounds.  A  few  years  ago  I  saw 
a  case  in  which  a  bullet  had  penetrated  the  right  hand  and  the  right  thigh, 
and  had  lodged  in  the  left  thigh.  There  were  three  wounds  of  entrance  and 
two  wounds  of  exit.  Many  very  extraordinary  cases  of  this  sort  have  been 
reported. 

Symptoms  of  a  "Wound  Caused  by  a  Pistol  Bullet. — Hemorrhage  is  often  con- 
siderable, but  ceases  spontaneously  unless  a  large  vessel  has  been  divided.  If 
hemorrhage  is  profuse  the  constitutional  symptoms  of  hemorrhage  exist  (see 
page  497).  These  symptoms  are  of  great  importance  in  abdominal  wounds.  A 
pistol  ball  seldom  causes  severe  primary  hemorrhage,  because  it  will  not  often 
penetrate  a  large  artery.  It  is  apt  to  push  aside  a  vessel  and  secondary  hemor- 
hage  is  not  unusual.  Even  if  a  large  vessel  is  wounded  and  a  succession  of  vio- 
lent hemorrhages  occur,  a  man  may  live  for  several  days.  Secondary  hemor- 
rhage may  follow  a  gunshot  wound  because  of  contusion  of  vessels  or  of  infection. 

Pain  is  often  not  noticed  at  first.  The  injured  individual,  if  greatly  pre- 
occupied or  excited,  may  not  know  that  he  has  been  struck  by  a  bullet.  There 
may  be  only  a  feeling  of  numbness,  but  usually  there  is  a  dull  or  stinging  pain. 
If  a  large  nerve  has  been  injured  there  may  be  violent  pain.  Even  trivial 
gunshot  wounds  frequently  produce  profound  shock,  and  yet  it  may  happen  that 
severe  wounds  may  be  accompanied  by  but  slight  shock.  In  most  gunshot 
wounds  of  the  brain,  abdomen,  and  spinal  cord  the  shock  is  very  great. 

General  Considerations  as  to  Treatment  of  Wounds  Caused  by  Pistol  Bul- 
lets.— The  dangers  are  shock,  hemorrhage,  and  infection.  Bullets  are  not 
aseptic  when  they  enter  a  part,  but  a  bullet  usually  carries  but  few  bacteria, 
and  if  bits  of  clothing  are  not  carried  in  by  the  bullet  and  if  infection  is  not  in- 
serted in  the  track  of  the  ball  the  wound  will  in  many  instances  heal  kindly, 
the  tissues  taking  care  of  the  bacteria  lodged  in  them.  A  stationary  bullet, 
when  there  is  no  infection,  is  usually  let  alone.  Careless  examination  of  the 
wound  will  certainly  cause  infection.  "The  fate  of  a  wounded  man  is  in  the 
hands  of  the  surgeon  who  first  attends  him"  (Nussbaum).  If  a  bit  of  clothing 
or  other  foreign  body  is  carried  in  by  the  bullet  infection  is  inevitable.  The 
danger  of  a  wound  depends  upon  the  size  and  velocity  of  the  bullet,  the  part 
struck,  the  intensity  of  infection,  ''and  the  degree  of  asepsis  observed  dur- 
ing the  first  examination  and  dressing"  (De  Nancrede).  The  rules  of  treatment 
are:  bring  about  reaction,  arrest  hemorrhage,  preserve  asepsis,  and,  in  many 
cases,  remove  the  ball.  Always  notice  if  a  wound  of  exit  exists.  It  is  a  good 
plan,  when  endeavoring  to  determine  the  extent  of  injury,  to  put  the  parts  in 
the  position  they  were  in  when  the  injury  was  inflicted.  We  should  try  to  ascer- 
tain the  size  and  nature  of  the  weapon,  and  the  range  at  which  it  was  fired. 
Examine  the  clothing  to  see  if  any  fragments  are  missing  and  could  have  been 
carried  in.  Such  fragments  render  sepsis  inevitable.  The  surgeon  must  not 
feel  it  his  duty  to  probe  in  all  cases.  In  many  cases  it  is  better  not  to  probe 
at  all.  Never  probe  when  there  is  a  wound  of  entrance  and  a  wound  of  exit. 
Explore  for  and  remove  the  ball  when  there  is  infection  or  when  sure  that 
it  has  carried  with  it  foreign  bodies;  or  when  its  presence  at  the  point  of  lodg- 
ment interferes  with  repair;  or  when  it  is  in  or  near  a  vital  region  (as  the  brain) 
and  in  every  case  in  which  it  can  be  reached  with  reasonable  safety.  In 
light  of  recent  observations  a  rule  should  be   to  arrest  serious  hemorrhage, 


Considerations  as  to  Treatment  of  Wounds  Caused  by  Pistol  Bullets     309 

remove  a  bullet  whenever  possible  and  remove  with  it  all  bits  of  clothing  car- 
ried in  (treat  loose  fragments  of  bone  and  hopelessly  damaged  tissue  as  foreign 
bodies),  arrest  bleeding  completely,  disinfect  the  wound  and  either  extirpate 
the  wound  and  suture  without  drainage  or  leave  the  wound  open  and 
treat  with  Dakin's  fluid  or  Dakin's  oil  and  later  perform  secondary  suturing 
(page  334).  We  must  locate  the  ball  when  it  is  necessary  to  know  its  position 
in  order  to  determine  the  question  of  amputation  or  resection.  If  the  wound  is 
large  enough  the  finger  is  the  best  probe.  The  x-rays  render  the  use  of  the  probe 
seldom  necessary. 

Fluhrer's  aluminum  probe  is  a  valuable  instrument  (Fig.   124).     It  is  em- 
ployed especially  in  brain- wounds,  and  is  allowed  to  sink  into  the  track  of 


Fig.   124. — Fluhrer's  aluminum  gravitation  probe  (natural  size,  except  the  length  which  is  12 

inches). 


Fig.  125. — Nelaton's  bullet-probe. 


Senn's  bullet-probe. 


the  ball  by  the  influence  of  gravity  after  the  part  has  been  placed  in  a  proper 
position.  If  a  lead  bullet  is  deeply  embedded  it  is  possible  to  distinguish  the 
hard  projectile  from  a  bone  by  inserting  the  asepticized  stem  of  a  clay  pipe,  a 
bit  of  pine  wood,  or  Nelaton's  porcelain-headed  probe  (Fig.  125).  On  any  one 
of  these  appliances  lead  will  make  a  black  mark.  No  such  test  can  be  ap- 
plied to  a  military  bullet,  for  this  has  a  hard  metal  jacket,  and  will  not  make 
a  black  mark  on  a  white  substance. 

Though  Nelaton's  probe  will  not  show  the  difference  between  a  hard-jack- 
eted projectile  and  bone,  it  is  a  valuable  instrument  to  follow  the  track  of  any 
bullet  wound.  The  porcelain  head  ought  to  be  larger  than  it  is  usually  made;  in 
fact,  it  should  be  nearly  the  size  of  the  bullet  (Senn)  (Fig.  126). 


Fig.  127. — Bullet-forceps. 

In  passing  a  probe  use  no  more  force  than  in  passing  a  catheter. 

The  induction  balance  of  Graham  Bell  has  been  employed  to  determine 
the  situation  of  a  bullet.  The  bullet  rnay  be  located  by  Girdner's  telephonic 
probe.  In  order  to  construct  this  instrument  take  a  telephone  receiver,  fasten 
one  of  the  wires  to  a  metal  plate  and  the  other  one  to  a  metallic  probe.  Mois- 
ten a  portion  of  the  patient's  body  and  place  the  metal  plate  in  contact  with  it. 
The  surgeon  places  the  receiver  to  his  ear  and  inserts  the  probe  into  the  wound. 
If  the  probe  strikes  metal,  a  click  is  heard  with  distinctness.  A  bullet  may 
be  located  by  LilienthaVs  probe.     This  apparatus  consists  of  a  mouth  piece, 


3IO  Contusions  and  Wounds 

two  insulated  copper  wires,  and  a  probe.  The  mouth-piece  is  composed  of 
two  plates,  one  of  copper  and  one  of  zinc,  which  are  applied  to  the  sides  of  the 
tongue.  An  insulated  wire  runs  from  each  plate  and  into  the  metal  probe. 
The  tip  of  the  probe  is  composed  of  two  or  four  pieces  of  metal,  is  separated 
from  the  shank  by  a  washer  of  rubber,  and  is  attached  to  the  wires.  The 
operator  closes  the  teeth  upon  the  mouth-piece  and  inserts  the  probe  into  the 
wound.  If  the  probe  touches  the  bullet  a  distinct  and  continuous  metallic 
taste  will  be  appreciable. 

The  best  means  of  discovering  a  bullet  is  to  use  the  fluoroscope  (see  pp. 
i6ig  to  1628)  or  to  take  a  skiagraph.  In  order  to  locate  it  accurately  view  it 
through  a  series  of  squares,  insert  guide-pins,  or,  better  than  either  of  these 
plans,  employ  Sweet's  apparatus.  Bullets  are  readily  seen  by  the  fluoroscope 
in  the  superficial  soft  parts,  and  are  discovered  in  deeper  structures  (bone, 
abdomen,  lung,  brain,  etc.)  by  taking  skiagraphs. 

In  extracting  the  ball  use  veiy  strong  forceps  (Fig.  127).  The  old  Amer- 
ican bullet-forceps  is  useless  for  the  extraction  of  the  hard-jacketed  ball,  as  the 
points  will  not  penetrate  and  the  instrument  will  not  hold. 

If  hemorrhage  is  severe  in  a  gunshot-wound,  enlarge  the  wound,  find  the 
bleeding  vessel,  and  tie  it.  Before  handling  a  gunshot-wound  asepticize  the 
parts  about  it  and  irrigate  the  wound  with  hot  sterile  salt  solution.  In  most 
situations  excision  is  proper.  In  some  situations  a  wound  should  be  drained 
with  a  short  tube  or  a  bit  of  iodoform  gauze;  in  other  regions  this  is  unnecessary. 
The  dressing  should  be  antiseptic.  Primary  union  rarely  takes  place  after  a 
wound  inflicted  by  a  pistol-ball  or  an  ordinary  rifle-ball  (unless  the  wound  were 
excised),  because  of  the  ine\a table  necrosis  of  damaged  tissue  in  the  track  of 
the  ball,  but  in  some  cases  it  can  be  obtained.  Primary  union  is  frequent  after 
injury  by  the  small  hard-jacketed  modem  army  projectile.  Healing  begins 
in  the  depths  of  the  wound  and  extends  toward  the  wound  of  entrance,  or,  if 
there  be  also  a  wound  of  exit,  toward  both.  Radical  operations  may  be  de- 
manded: laparotomy,  trephining,  rib-resection,  joint-resection,  or  amputation. 

Excision  of  a  joint  may  be  required  when  there  is  great  comminution. 
Amputation  IS,  sovaetirae^  demanded  because  of  severe  injur}'  to  the  soft  parts, 
great  splintering  of  a  bone,  grievous  injury  of  a  joint,  damage  to  the  chief  vessels 
or  nerves,  or  the  destruction  of  a  considerable  part  of  a  limb.  Perform  a  pri- 
mary amputation  if  possible,  and  make  the  flaps  through  tissue  that  will  not 
slough.  In  ci\il  practice,  with  careful  antisepsis,  more  questionable  tissue  can  be 
admitted  into  a  flap  than  in  military  practice,  where  transportation  will  become 
necessary  and  antisepsis  may  be  imperfect  or  wanting.  It  has  been  shown  in 
recent  years  that  even  when  a  large  joint  has  been  perforated  by  a  small  hard- 
jacketed  projectile,  amputation  or  resection  is  rarely  required  if  the  wound  has 
been  treated  aseptically  from  the  beginning,  but  this  is  not  true  of  the  revolver 
bullet. 

Surgery  of  War. — Military  surgery  (including  in  this  term  naval  surgery) 
is  a  specialty.  One  who  would  practice  it  must  have  special  training  different 
from  and  beyond  that  given  in  the  medical  schools  to  civilians.  He  must  be 
much  more  than  a  well-qualified  physician  and  surgeon.  Even  the  best  quali- 
fied civilian  surgeon  is  unfit  to  pass  into  militar}'  service  without  special  train- 
ing, and  no  man  is  fit  to  come  direct  from  civil  life  and  take  charge  of  a  military 
or  naval  hospital. 

The  United  States  insists  that  every  man  appointed  to  the  medical  corps 
of  the  army  or  navy  in  days  of  peace  and  when  time  permits  shall  receive  special 
instruction  in  the  Army  Aledical  School  or  the  Naval  Medical  School  before 
he  goes  to  a  regiment,  a  ship  or  a  hospital.  In  these  war  days  army  men  are 
specially  trained  in  an  army  camp  and  naval  men  in  a  naval  hospital. 

The  surgeons  of  the  army  and  navy  are  protean  specialists.  They  must  be 
able  to  treat  the  sick  and  injured  with  the  greatest  skill  and  on  the  most  modern 


Wounds  in  War  311 

principles.  But  they  rnust  know  much  more  than  this.  They  must  understand 
bacteriology  and  be  able  to  make  various  laboratory  studies  of  blood,  urine, 
feces,  spinal  fluid,  wound-fluid,  etc.  They  must  be  masters  of  hygiene.  They 
must  possess  executive  ability.  They  must  be  able  to  discipline  others  and  to 
command  their  respect  and  must  be  \villing  to  submit  cheerfully  to  disciphne. 
They  must  be  forceful,  self-reKant  and  resourceful.  They  must  be  acquainted 
with  the  regulations  and  instructions  of  the  mihtary  establishment.  They  must 
have  a  special  knowledge  of  the  wounds  inflicted  in  war,  of  the  transport  of  the 
sick  and  wounded,  of  the  establishment  of  hospitals  and  of  epidemic  diseases 
that  might  gain  a  foothold  on  ship-board,  in  camp  or  in  barracks.  The  wounds 
received  in  war  are  peculiar.  The  treatment  appropriate  for  a  wound  inflicted 
by  a  revolver  bullet  of  lead  might  be  entirely  inappropriate  for  or  totaUy  impos- 
sible of  appHcation  to  a  wound  inflicted  by  the  hard-jacketed  projectile  of  a 
military  rifle  or  by  a  shell  fragment. 

In  civil  life  the  patient  has  the  best  of  surroundings.  Every  care  can  be 
given  him.  Numerous  skilled  assistants  are  at  hand  if  needed.  There  is  no 
hurry  unless  it  is  called  for  by  his  condition. 

The  problems  presented  to  the  surgeon  are  purely  surgical  and  the  case  is 
dealt  with  in  exact  accordance  with  its  surgical  necessities.  In  war  there  are 
various  problems  other  than  those  that  are  surgical  and  non-surgical  necessities 
may  dominate  the  surgeon's  actions.  The  war  surgeon  is  first  of  all  a  militar>^ 
man  and  after  that  a  humanitarian.  There  are  problems  of  transport  which 
are  not  present  in  civil  life.  Strategic  necessity  may  compel  hurried  move- 
ment. There  is  inevitable  delay  in  inaugurating  radical  treatment.  Great 
numbers  of  men  may  have  to  wait  for  long  periods  before  they  can  be  attended 
to  at  all.     Time  is  insufficient  and  assistants  are  few. 

Accommodations  may  be  bad.  Shelter  may  be  imperfect.  Climate  and 
meteorologic  conditions  may  be  most  trying.  Food  may  be  scanty  and  inap- 
propriate. Medicines  may  be  scarce.  After  some  engagements  in  South 
Africa  the  British  surgeons  had  to  care  for  numbers  of  men  under  difficulties 
that  were  appalling,  among  which  were  fearful  clouds  of  dust  and  swarms  of 
flies.  In  the  present  war  hospitals  have  again  and  again  been  literally  over- 
whelmed by  the  sudden  arrival  of  immense  numbers  of  men  dreadfully  wounded. 
In  other  words,  the  military  surgeon,  after  a  battle,  is  seldom  able  to  treat  his  cases 
purely  in  accordance  with  surgical  necessities,  but  his  conduct  must  be  influ- 
enced by  other,  often  imperative,  needs.  If  there  are  numerous  wounded, 
he  does  not  have  time  to  do  immediate  laparotomies.  He  will  lose  some  cases 
because  he  has  not  done  laparotomy,  but  he  would  lose  many  other  cases  from 
delay  in  treating  dangerous  but  remedial  conditions  were  he  to  make  many 
simpler  cases  wait  until  his  laparotomies  had  been  performed.  He  may  be  forced 
to  make  the  abdominal  wounds  wait  and  after  long  delay  there  is  seldom  any 
use  in  opening  the  abdomen  at  all.  The  same  is  true  of  head  injuries  and 
chest  injuries.  The  necessity  for  removal  or  the  inability  to  treat  properly  at 
that  time  and  place  may  lead  a  surgeon  to  amputate  a  limb  which  might  be 
saved  in  a  civil  hospital.  He  strives  with  every  pound  of  energy  that  is  in  him 
to  save  those  who  can  be  most  certainly  returned  to  the  fighting  line.  After 
these  have  been  cared  for  comes  the  problem  of  saving  other  cases  and  saving 
men  from  permanent  crippling. 

Wounds  in  War. — We  will  consider  sword  wounds,  bayonet  wounds,  and 
wounds  inflicted  by  rifle  buUets  and  various  forms  of  shells. 

So  many  cases  of  bayonet  wounds,  and  so  many  cranial,  abdominal  and  tho- 
racic cases  never  live  to  reach  the  hospital  but  die  in  transit  or  on  the  field, 
that  hospital  returns  in  no  sense  show  the  relative  frequency  of  such 
injuries.  Again  returns  from  one  region  are  not  representative  of  another 
region.  Trench  warfare  gives  statistics  which  differ  vastly  from  those  which 
.are  obtained  from  fighting  in  the  open,  in  besieged  forts  or  in  beleaguered  cities. 


312  Contusions  and  Wounds 

Marsiglio  from  a  study  of  near  6000  wounded  reached  the  following  conclu- 
sions ("  Riform.  Med.,"  1916,  xxxxv). 

Nearly  58  per  cent,  of  wounds  are  due  to  bullets.  (It  will  be  seen  below 
that  other  observers  claim  that  in  trench  fighting  only  25  per  cent,  of  wounds 
are  due  to  bullets.) 

The  most  common  injuries  are  those  of  the  limbs,  over  65  per  cent. 

Next  come  cranial  injuries,  over  19  per  cent. 

Next  come  thoracic  injuries,  over  8  per  cent. 

Next  come  abdominal  injuries,  over  5  per  cent. 

Sword  Wounds. — These  wounds  require  no  special  description.  They 
are  of  the  same  nature  as  slashes  received  in  civil  life.  The  dull  European  sword 
causes  an  incised  wound  with  contused  edges.  The  keen  sword  of  India  and 
the  East  causes  an  incised  wound  without  contusion.  Sword  wounds  have 
been  extremely  rare  in  this  war,  because  infantry  officers  no  longer  use  them 
in  an  assault  and  until  very  recently  the  part  played  by  cavalry  has  been  small. 

Sword  wounds  are  treated  as  are  similar  wounds  in  civil  life. 

Bayonet  Wounds. — Bayonet  wounds  are  stab-wounds  and  their  danger 
depends  on  the  structures  damaged  and  the  degree  of  infection.  There  have 
been  many  such  wounds  in  this  war.  A  few  years  ago  nations  thought  of  dis- 
carding the  bayonet  on  the  ground  that  modem  weapons  of  warfare  rendered 
hand-to-hand  fighting  impossible.  The  Japanese  in  the  war  with  Russia  gave 
exhibitions  of  bayonet  fighting  and  in  this  war  there  has  been  bayonet  fighting 
whenever  a  trench  has  been  taken.  The  treatment  is  on  general  principles 
(see  Stab  Wounds,  page  302). 

Wounds  by  Rifle  Bullets.— Before  the  present  war  surgeons  had  reached  the 
conclusion  that  over  90  per  cent,  of  wounds  in  war  were  sure  to  be  inflicted  by 
rifle  or  machine  gun  bullets.     This  estimate  was  wrong. 

In  trench  fighting  25  per  cent,  of  wounds  are  from  rifle  or  machine  gun 
bullets  and  75  per  cent,  from  shells. 

During  the  last  few  years  frequent  and  notable  improvements  have  been 
made  in  the  military  rifle.  The  range  and  rapidity  of  firing  have  been  vastly 
increased,  the  velocity  of  the  projectile  and  its  penetrating  power  have  been 
enormously  added  to,  and  the  trajectory  has  been  decidedly  lowered.  Hence, 
the  zone  dangerous  to  an  enemy  has  been  lengthened.  In  order  to  accomplish, 
these  things  changes  have  been  made  in  the  gun,  the  explosive,  and  the  projec- 
tile. It  is  a  far  cry  from  the  old  Brown  Bess,  of  song  and  story,  to  the  modern 
Lee-Enfield  of  the  British  Army,  or  the  Springfield  of  the  United  States  Army. 
All  modern  military  rifles  are  of  small  caliber,  that  is,  less  than  0.35  inch.  The 
Springfield  rifles  of  the  days  of  the  war  between  the  States  had  a  caliber  of  0.45 
inch.  The  old  Springfield  projected  a  bullet  at  an  initial  or  muzzle  velocity 
of  1300  feet  a  second;  whereas  the  modern  rifle  sends  a  projectile  on  its  way  with 
an  initial  velocity  of  2700  feet  a  second,  the  bullet  rotating  on  its  long  axis  more 
than  2500  times  during  the  first  second  of  translation.  At  a  range  of  1000  yards 
it  will  penetrate  nearly  13  inches  of  pine  wood.  At  a  range  of  100  yards  it 
"wUl  penetrate  a  steel  plate  0.3843  inch  thick"  (Borden,  in  "Keen's  Surgery," 
vol.  vi).  Up  to  5000  yards  a  modern  rifle  can  inflict  a  fatal  wound,  and  it  can 
be  used  point-blank  at  a  range  of  from  500  to  over  700  yards.  With  the  Spring- 
field of  the  United  States  Army  the  point-blank  zone  of  danger  is  about  718  yards. 
A  bullet  from  a  modern  military  rifle,  even  after  having  struck  some  solid, 
hard  body,  may  grievously  injure  a  man  by  ricochet.  With  a  magazine  rifle,  at 
2500  yards,  from  5  to  10  per  cent,  of  the  balls  will  ricochet  from  turf.  At 
3000  yards  they  will  bury  in  turf,  but  may  ricochet  from  very  hard 
ground.  The  United  States  Army  magazine  Springfield  rifle  weighs  less  than 
9  pounds.  The  barrel  is  24  inches  in  length  and  the  diameter  of  the  bore 
is  0.30  inch.  The  rifling  makes  one  complete  turn  in  every  10  inches.  With 
this  weapon,  by  magazine  fire,  25  aimed  shots  may  be  fired  in  a  minute;  and 


Wounds  by  Rifle  Bullets 


313 


when  used  as  a  single-loader,  23  aimed  shots  (Surgeon-General  O'Reilly,  U. 
S.  A.,  in  "Keen's  Surgery,"  vol.  iv).  It  should  be  noted  that  military  neces- 
sity compelled  the  U.  S.  Army  to  adopt  a  modified  Enfield.  The  Enfields  could 
be  made  quickly  because  facilities  existed  in  the  U.  S.  for  making  them.  Haste 
^vas  imperative. 


Fig.  128. — Showing  secondary  missile  effect  of  a  rifle  ball  striking  binoculars,  causing- 
loss  of  right  eye  and  multiple  wounds  of  hand  and  face.  The  fragments  shown  were  removed 
from  eyeballs,  face,  and  hand  (Fauntleroy,  Ibid.). 

Old-fashioned  Black  Gunpowder  as  Compared  with  Smokeless  Powder. — 
There  are  many  different  varieties  of  smokeless  powder,  but  each  is  essentially 
a  nitro-powder.  Among  these  smokeless  powders  are  melenite,  used  by  the 
French;  lyddite,  employed  by  the  British;  and  shimose,  adopted  by  the  Japan- 


FiG.  129. — Showing  the  multiple  wounds  from  secondary  missile  effects  of  bullet  passing 
through  binoculars  and  lodging  in  eyeball,  face  and  right  hand.  Photograph  taken  several 
weeks  after  operation  (Fauntleroy,  Ibid.). 

ese.  The  United  States  forces  use  cellulose  nitrate  in  perforated  cylindrical, 
amber-colored  grains.  Nitro-powder  is  very  nearly  smokeless  because  all  the 
products  of  its  combustion  are  gases.     Of  the  products  of  the  combustion  of 


314 


Contusions  and  Wounds 


black  gunpowder,  57  per  cent,  by  weight  settle  out  from  the  atmosphere  in 
solid  form  on  cooling. 

There  are  great  advantages  in  the  use  of  smokeless  powder.  It  is  much 
more  powerful  than  black  gunpowder;  hence,  a  smaller  charge  can  be  em- 
ployed. The  modern  Springfield  requires  a  charge  of  47  gr.;  and  at  the  time 
of  the  discharge  the  pressure  in  the  chamber  is  about  49,000  pounds  to  the 
square  inch.  Smokeless  powder  gives  the  bullet  a  greater  velocity,  causes 
less  recoil,  and  fouls  the  barrel  infinitely  less  than  black  powder;  and  the  ab- 
sence of  smoke  maintains  a  clearer  atmosphere  for  observation,  and  also  fur- 
nishes no  sign  of  location  which  might  prove  of  advantage  to  the  enemy. 

Projectiles-. — The  bullet  of  a  modern  rifle  is  either  cylindroogival  or  pointed, 
has  a  lead  core,  and  is  hardened  by  being  covered  with  a  mantle  or  jacket  of 
copper,  steel,  or  nickel,  or  of  alloys  of  copper  and  nickel,  or  of  copper,  nickel,  and 
zinc.  The  English  bullet  has  in  its  base  a  core  of  lead  and  in  the  point  a  core  of 
aluminum.    The  jacket  is  of  steel.    The  French  bullet  is  composed  of  solid  bronze 


Fig.  130. — I,  Krag-Jorgensen  bullet;  2,  new  Springfield  bullet  (pointed). 


and  is  without  a  steel  jacket.  The  hard  outer  surface  is  absolutely  essential, 
because  the  speed  of  the  projectile  is  so  great  that  no  soft  bullet  would  take  the 
rifling.  Fragments  would  be  torn  off  from  the  bullet  in  the  gun,  and  the  grooves 
of  the  gun  would  soon  be  filled  with  metal,  the  gun  becoming  useless.  The  pro- 
jectile of  a  modern  Springfield  rifle  is  elongated  and  pointed.  The  air-resistance 
is  least  in  a  bullet  of  this  shape.  The  core  is  composed  of  lead  hardened  with 
tin,  and  its  jacket  is  of  nickel  and  copper. 

The  military  surgeon  deals  with  wounds  inflicted  by  these  small,  dense, 
hard,  cylindroogival,  or  pointed  projectiles  impelled  with  great  velocity,  and 
carried  long  distances.  The  old  lead  bullet  was  liable  to  lodge,  was  often  de- 
flected in  the  tissues,  was  flattened  out  on  meeting  with  resistant  structures, 
such  as  bone  or  cartilage,  and,  after  flattening,  became  larger,  tearing  and  lacer- 
ating the  soft  parts  and  comminuting  the  bone  (Fig.  135).  The  modern  hard 
projectile  is  likely  to  penetrate,  is  rarely  deflected,  and  is  so  hard  that  its  shape 
is  often  but  little  altered  on  meeting  with  resistant  structures.  Hence,  it  was 
thought  that  the  new  bullet  would  prove  more  humane  than  the  old  projectile 


Wounds  by  Rifle  Bullets  315 

and  inflict  wounds  that  would  be  more  easily  treated,  because  the  bullet  would 
be  unapt  to  lodge  and  extensive  damage  would  seldom  be  inflicted.  This  view 
has  proved  in  many  respects  correct. 

With  the  modern  rifle  of  small  caliber  and  the  hard  projectfle  propelled 
by  smokeless  powder  the  range  has  been  notably  increased,  the  trajectory 
of  the  bullet's  flight  has  been  greatly  lowered,  and  the  danger-zone  to  an  enemy 
has  been  correspondingly  lengthened. 

Mechanics  of  Projectiles. — If  a  moving  bullet  were  acted  upon  by  no  force 
but  propulsion,  it  would  continue  to  move  in  the  direction  that  it  was  pursuing 
when  it  left  the  muzzle  of  the  gun  and  its  course  would  be  a  straight  line,  but 
it  is  acted  upon  by  other  forces.  Even  in  a  vacuum  its  course  would  not  be 
a  straight,  but  a  curved  line,  because  gravitation  would  draw  it  toward  the 
earth.     Under  ordinary  circumstances  the  air  also  resists  its  forward  progress. 

A  moving  bullet  is  urged  onward  by  the  force  of  the  exploding  powder. 
This  onward  movement  is  called  the  motion  of  translation.  The  rate  of  for- 
ward movement  is  the  velocity,  and  this  is  expressed  in  feet  per  second.  Air- 
resistance  causes  the  velocity  to  lessen  rapidly,  and  the  farther  away  from  the 
gun  the  projectile  is,  the  greater  is  its  loss  of  velocity.  For  instance,  on  leaving 
the  muzzle  of  the  Lee-Enfield  rifle  a  bullet  has  a  velocity  of  2060  feet  a  second 
{muzzle  velocity  or  initial  velocity);  at  700  yards  it  has  a  velocity  of  1039  feet  a 
•second;  at  2000  yards,  571  feet  a  second;  at  3000  yards,  369  feet  a  second  ("  Gun- 
shot-wounds," by  Major  C.  G.  Spencer).  The  muzzle  velocity  of  the  bullet 
of  the  United  States  Army  Springfield  is  2700  feet  a  second.  The  velocity 
of  a  bullet  at  any  particular  portion  of  its  flight  is  called  remaining  velocity. 

A  buflet  fired  from  a  rifle  rotates  on  its  long  axis.  This  rotation  is  cafled 
spin  or  the  movement  of  rotation,  and  is  in  the  direction  of  the  groove  of  the 
rifling.  It  is  this  motion  that  keeps  the  point  of  the  bullet  toward  the  front 
and  prevents  rotation  on  its  short  axis,  which  would  be  responsible  for  increased 
air-resistance,  diminished  striking  force,  and  lessened  range.  If  a  cylindro- 
conoidal  bullet  were  fired  from  a  smooth  bore,  it  would  rotate  on  its  short  axis 
at  even  as  short  a  range  as  9  yards,  and  would  strike  a  target  in  its  length 
(Stevenson's  "Wounds  in  War"). 

■  The  diminution  in  the  transverse  diameter  of  bullets  has  necessitated  an 
increase  in  length  in  order  to  maintain  their  weight  and  sectional  density. 
{Sectional  density  is  the  weight  divided  by  the  area  of  the  cross-section.)  The 
increase  in  length  makes  an  increased  rapidity  of  rotation  indispensable.  The 
higher  the  pitch  of  the  rifling  the  more  rapid  the  rate  of  rotation  imparted 
to  the  bullet.  The  Minie  rifle  had  a  complete  turn  in  78  inches.  The  United 
States  Army  Springfield  has  a  complete  turn  in  10  inches.  The  velocity  of  spin 
as  the  bullet  leaves  the  barrel  of  a  Springfield  is  about  2500  times  a  second. 
The  velocity  of  rotation  changes  as  the  velocity  of  translation  changes;  and 
when  translation  ceases,  because  the  energy  of  propulsion  has  expended  itself, 
rotation  also  ceases.  "But  when  the  motion  of  translation  is  suddenly  and 
completely  arrested  by  contact  wdth  an  obstacle,  then,  if  the  bullet  is  not  broken 
up,  the  motion  of  rotation  continues  untfl  its  energy  is  expended"  ("Wounds 
in  War,"  by  Surgeon-General  W.  F.  Stevenson,  C.  B.,  A.  M.  S.).  A  rifle-bullet 
in  its  flight  deviates  a  httle  laterally,  and  in  the  direction  of  the  groove  of  the 
rifling.  In  the  United  States  Army  rifle  the  groove  of  the  rifling  is  toward  the 
right  when  the  gun  is  held  with  the  butt  toward  the  shoulder;  hence,  the  devia- 
tion of  the  bullet  is  toward  the  right.     This  lateral  deviation  is  called  drift. 

Influence  of  Gravity  and  Air-resistance. — We  have  previously  stated  that, 
even  if  moving  in  a  vacuum,  the  line  of  flight  of  a  bullet  (the  trajectory)  would 
be  a  curved  and  not  a  straight  line,  because  of  the  influence  of  gravity,  which 
puUs  the  bullet  toward  the  earth.  The  buUet  would  faU  16  feet  the  first  second, 
64  feet  in  two  seconds,  144  feet  in  three  seconds,  and  so  on.  A  bullet  moving 
forward  in  a  vacuum  would  advance  through  equal  distances  in  equal  periods 


3i6 


Contusions  and  Wounds 


of  time,  and,  as  gravity  would  draw  it  toward  the  earth  with  increasing  rapidity,, 
the  trajectory  would  be  a  parabola  (Fig.  131,  hne  A-E-F-G). 

Air-resistance  retards  strongly  the  advance  of  a  bullet  and  causes  it  to 
lose  its  velocity  rapidly,  and  a  bullet  fired  in  air  does  not  advance  through  equal 
distances  in  equal  periods  of  time.     Because  of  air-resistance  a  bullet  falls  to 


6     B 


c    d 


Fig.   131. — Trajectories  in  vacuo  and  in  air  (Stevenson). 

the  earth  sooner  than  it  would  under  the  influence  of  gravity  alone.  Hence,, 
the  trajectory  of  a  bullet  in  air  is  not  a  true  parabola,  but  the  line  of  descent  is 
much  nearer  to  the  vertical  than  would  be  the  case  in  a  vacuum  (Fig.  131,  line 
h-e-f-g). 


A'  B'  D 

Fig.  132. — Trajectory,  showing  dangerous  zones:  A-B-D,  Trajectory  of  bullet;  D,  point 
of  termination  of  the  bullet's  flight;  A-B,  point  of  first  catch  for  cavalry;  B,  point  of  first 
catch  for  infantry;  A'-D,  dangerous-  zone  for  cavalry;  B'-D,  dangerous  zone  for 
infantry  (Spencer). 

Air-resistance  depends  upon  the  velocity  of  the  bullet,  the  cross-section  area 
of  the  bullet,  the  shape  of  the  head  of  the  bullet,  the  atmospheric  density,  and 
the  steadiness  of  flight  ("Gunshot  Wounds,"  by  Major  C.  G.  Spencer).     Air- 


Fig.  133. — Trajectories  of  bullets  from  certain  rifles:  i,  Trajectory  of  Lee-Enfield  at 
1500  yards,  action-point,  81  feet;  2,  trajectory  of  Martini-Henry  at  1500  yards,  action-point, 
178  feet;  3,  trajectory  of  Lee-Enfield  at  2000  yards,  action-point,  194  feet;  4,  trajectory  of 
Martini-Henry  at  2000  yards,  action-point,  357  feet;  5,  trajectory  of  Snider  at  2000  yards,. 


action-point,  866  feet;  horizontal  scale. 


(i  inch  =  2000  feet);  vertical  scale. 


(i 


24000  "  '  1 2000 

inch  =  1000  feet).     Vertical  measurements  are  represented  on  twice  as  large  a  scale  as  horizon- 
tal measurements  (Spencer). 

resistance  is  least  in  the  bullet  that  tapers  rapidly.     A  bullet  begins  to  lose  its 
steadiness  of  flight  about  1000  yards  from  the  muzzle  of  the  rifle. 

The  Danger  Zone. — Owing  to  the  fact  that  the  trajectory  is  a  curved  line 


Wounds  by  Rifle  Bullets 


317 


■elevation  must  be  given  to  rifles  except  at  point-blank  range,  and  the  degree  of 
elevation  must  be  increased  according  to  the  range.  Point-blank  range  for  a 
Springfield  is  up  to  718  yards.  By  this  term  is  meant  that  when  a  gun  is  aimed 
horizontally  the  entire  course  of  the  bullet  up  to  718  yards  is  dangerous  for 
infantry.  For  longer  ranges  the  rifle  must  be  elevated  and  the  bullet  "  shot  into 
the  air."  Sighted  at  2000  yards  the  Snider  sent  a  bullet  866  feet  above  the  line 
of  sight;  the  Martini-Henry  sighted  at  the  same  range,  357  feet;  the  Lee-Enfield 
at  the  same  range,  194  feet.  It  becomes  evident  that  when  a  rifle  is  elevated  the 
bullet  rises  far  above  a  man's  head,  and  continues  to  rise  to  what  is  known  as 
the  culminating  point,  when  it  begins  to  descend.  It  does  not  become  dangerous 
to  men  until  it  gets  near  to  the  earth.  The  point  at  which  it  becomes  dangerous 
to  cavalry  is  called  ^^the  point  of  first  catch  for  cavalry"  (Fig.  132).  The  point  at 
which  it  becomes  dangerous  for  infantry  is  called  "the  point  of  first  catch  for 
infantry^'  (Fig.  132).  The  dangerous  zone  (Fig.  132)  is  from  the  point  of  first 
catch  to  the  termination  of  the  bullet's  flight,  because  anywhere  in  this  zone 
men  may  be  struck,  but  between  the  point  of 
first  catch  and  the  man  firing  the  gun  soldiers 
are  perfectly  safe.  The  point  of  first  catch 
for  cavalry  is  about  83^^  feet  and  for  infantry 
about  6  feet  above  the  ground. 

The  more  nearly  vertical  the  line  of  the 
bullet's  descent,  the  shorter  is  the  danger 
zone;  the  less  vertical  the  line  of  descent, 
the  longer  is  the  danger  zone.  The  higher 
the  culminating  point  of  the  trajectory,  the 
more  vertical  is  the  line  of  descent,  hence 
the  shorter  is  the  danger  zone;  the  lower  the 
culminating  point,  the  flatter  is  the  trajectory, 
and  the  less  vertical  the  line  of  descent, 
hence  the  longer  the  danger  zone.  The  chief 
object  of  improvements  in  rifles  is  to  lower 
the  trajectory  (that  is,  make  it  less  curved) 
and  thus  lengthen  the  danger  zone,  render 
marksmanship  more  accurate,  and  insure 
velocity. 

Power  of  the  Bullet  to  Wound. — According 
to  Spencer  (''Gunshot  Wounds"),  this  de- 
pends upon  its  energy  and  the  ease  with  which 
its  energy  is  converted  into  work  on  striking. 
Energy  is  largely  a  matter  of  range.  At  short 
range  energy  is  enormous,  but  it  rapidly  di- 
minishes as  the  range  is  increased.  At  3000  yards  energy  is  only  about  one- 
sixteenth  of  what  it  is  at  300  yards.  The  ease  with  which  a  bullet  converts 
energy  into  work  depends  upon  (see  Spencer  (Ibid.):  (i)  The  area  of  the 
cross-section  of  the  bullet.  The  larger  the  bullet,  the  worse  the  wound. 
(2)  The  deformation  of  the  bullet.  Such  deformation  enlarges  the  area.  A 
bullet  that  expands  on  striking  is  said  to  "mushroom."  The  modern  bullet 
seldom  deforms  much  unless  its  jacket  has  been  more  or  less  torn  off  (Figs. 
136  and  137) ;  and  it  inflicts,  as  a  rule,  a  much  less  grave  injury  than  does  the  soft 
bullet.  It  has  been  found  that  this  very  humanity  of  the  bullet  is  at  times  re- 
garded as  an  objection.  The  buHet  lacks  "stopping  power"  unless  it  strikes  a 
vital  part  or  a  large  bone,  and  a  wounded  man  may  continue  to  fight  and  charge. 
Civilized  men  wifl  usually  stop  when  hit,  but  savages  very  often  wfll  not. 
Hence,  in  warfare  with  barbarous  people,  it  was  until  recently  the  custom  to 
modify  the  buflet.  A  portion  of  the  soft  buflet  at  the  apex  of  the  projectile 
was  left  exposed,  and  such  a  bullet  was  said  to  be  uncovered  or  to  have  a  "soft 


Fig.  134.— Mauser  bullet-wound 
of  chest:  a.  Wound  of  entrance;  b, 
point  where  bullet  was  extracted 
(Major  Charles  F.  Kieffer,  U.  S.  A.). 


3i8  Contusions  and  Wounds 

nose."  It  was  called  a  Dumdum  bullet,  because  such  missiles  were  first  made 
at  Dumdum,  the  ordnance  factory  near  Calcutta.  When  a  Dumdum  bullet 
strikes,  it  spreads  and  expands,  or  "mushrooms,"  and  inflicts  an  extensive  and 
dreadful  wound,  which  stops  the  most  ferocious  savage  or  the  most  fanatical 
tribesman.  These  expanding  or  deformable  bullets  are  often  wrongly  called 
"explosive  bullets."  They  have  been  forbidden  by  The  Hague  Convention, 
although  Stevenson  and  some  other  surgeons  maintain  that  they  are  more 
humane  than  were  the  bullets  of  the  Snider  or  the  Martini-Henry  rifle.  The 
present  bullet  of  the  United  States  Army  is  pointed  and  will  produce  wounds 
"which  will  resemble  the  wounds  made  by  the  'deformable'  bullets  whose  use 
is  forbidden  in  civilized  warfare"  (Borden,  in  ''Keen's  Surgery,"  vol.  vi).  The 
United  States,  England,  Germany,  Turkey  and  France  now  use  pointed  bullets. 

The  Resistance  Encountered. — If  energy  is  great  (as  at  close  range)  and 
a  very  resistant  tissue  is  struck  (bone),  dreadful  injury  may  be  inflicted,  but 
if  a  tissue  with  little  resistance  is  struck  but  little  damage  may  be  done.  At 
a  long  range  the  energy  of  the  bullet  is  so  lessened  that  the  danger  to  resistant 
tissue  will  be  much  less;  whereas  injury  of  soft  parts  may  be  much  the  same 
as  at  closer  range. 

The  Nature  of  the  Wounds  Inflicted  by  the  Small  Projectile. — The  effect  of 
lessening  the  size  of  the  bullet  is  to  decrease  its  wounding  power,  because, 
other  things  being  equal,  the  larger  the  bullet,  the  greater  its  wounding  power. 
In  many  instances  the  modern  bullet  will  make  a  clear  track,  without  lacera- 
tion or  comminution.  It  W8.s  thought,  as  has  been  stated,  that  this  projectile 
would  prove  humane,  that  it  would  kill  comparatively  few,  and  that  the 
wounded  would  receive  injuries  which  would  incapacitate  them,  but  from  which 
most  of  them  would  recover.  Recent  wars  have  indicated  that  at  a  range  of 
over  1500  yards  the  unpointed  bullet,  as  a  rule,  penetrates  cleanly,  making  a 
wound  that  heals  by  first  intention.  Sir  Frederick  Treves  expressed  his  ex- 
perience by  saying,  "the  Mauser  bullet  is  a  very  merciful  one." 

Very  many  studies  have  been  made  of  the  action  of  the  modern  bullet, 
and  numerous  experiments  have  been  carried  out — firing  through  boxes  filled 
with  wet  sand,  firing  into  thick  oak,  firing  at  cadavers  at  fixed  distances  with 
reduced  charges,  and  firing  at  corpses  and  at  live  horses  with  service  charges. 
De  Nancrede,  some  years  ago,  wisely  cautioned  us  to  remember  that  experi- 
ments upon  the  cadaver  employing  reduced  charges  and  standing  at  fixed  dis- 
tances, are  uncertain  in  their  provings.  "  The  difference,"  he  said,  "  between  the 
velocity  of  rotation  and  the  angle  of  incidence  with  reduced  charges  at  fixed 
distances  and  service  charges  at  actual  distances  is  marked.  The  tension  of 
living  muscle  and  fascia,  as  compared  with  dead  tissues,  and  the  physical  change 
of  semiliquid  fat  of  adipose  tissue  and  medulla  to  a  more  solid  condition  by 
the  loss  of  animal  heat,  influence  the  results"  (Ibid.,  "Gunshot-wounds," 
Roswell  Park's  ''Surgery  by  American  Authors"). 

All  the  theoretical  conclusions  derived  from  experiment  and  the  observa- 
tions made  on  the  occasional  victims  of  suicide  or  homicide  have  been  put  to  the 
test  of  war  in  recent  years;  and  we  now  draw  our  deductions  from  a  study  of  the 
wounds  in  the  Greco-Turkish  War,  the  Spanish-American  War,  the  South 
African  War,  the  taking  of  Pekin,  the  Russo-Japanese  War,  the  Balkan  War 
and  particularly  from  the  present  tremendous  and  ferocious  conflict.  Precon- 
ceived opinions  have,  in  many  particulars  at  least,  been  confirmed.  It  has  been 
found  that  many  wounds  are  non-infected  and  are  apt  to  heal  by  first  intention 
unless  inflicted  by  ricochet,  which  deforms  the  bullet  (often  tearing  off  its  jacket 
or  making  it  mushroom)  (Fig.  137),  or  unless  the  bullet  is  deviated  from  the 
straight  path  with  the  point  forward  and  enters  with  its  side  to  the  front.  This 
event  is  apt  to  happen  with  the  pointed  bullet,  not  with  the  unpointed  bullet. 
If  it  does  happen  a  bit  of  clothing  will  be  liable  to  lodge  in  the  tissues,  the 
wound  will  be  lacerated  and  infection  will  be  inevitable.     As  a  matter  of  fact  in 


Wounds  by  Rifle  Bullets  319 

the  trenches  infection  has  been  very  common  after  bullet  injuries  and  surgeons 
have  come  to  regard  all  wounds  as  infected.  The  infection  comes  from  the 
dirt-begrimed  skin  and  clothing  of  the  soldier.  At  a  range  of  1500  yards  or 
more,  if  the  bullet  enters  point  on,  the  wounds  are  commonly  clear  tracts,  with- 
out much  splintering  of  bone  or  laceration  of  tissues.  The  wound  of  entrance 
is  extremely  small  and  could  be  overlooked  by  a  careless  observer.     It  is  usu- 


FiG.  135. — Deformation  of  leaden  bullets  (natural  size)    (Seydel). 

ally  circular,  it  may  be  triangular.  The  bullet  is  far  less  Hable  to  lodge  in  the 
body  than  was  the  older  bullet.  If  it  perforates,  the  wound  of  exit  is  usually 
small,  and  may  be  either  round  or  a  slit.  These  facts  are  true  when  the  bullet 
goes  through  point  on.  Otherwise  it  tears  a  great  laceration.  The  wound  of 
exit  is  large  if  the  injury  has  been  inflicted  at  close  range,  or  if  bone  has  been 
splintered  and  fragments  have  been  driven  along  with  the  bullet  (Fig 


Fig.   136. — Deformation  of  small-caliber  jacketed  bullets  (after  Bruns). 

Theoretically,  the  projectile  does  not  flatten,  but  it  has  been  found  that  in 
many  instances  it  does  flatten  a  little  (Fig.  136).  Its  coat  is  apt  to  be  torn  off 
when  it  strikes  hard  bone  at  a  distance  of  less  than  1800  3^ards.  Treves  has 
pointed  out  that  if  a  bullet  smashes  a  bone  and  lodges,  the  shell,  as  a  rule,  peels 
off  from  the  core.  Then  the  bullet  may  be  distorted  or  broken  into  fragments. 
When  a  hard-jacketed  bullet  is  "travehng  over  2000  feet  per  second"  it  "will 


Fig.  137. — I,  Empty  Krag  jacket  removed  from  thigh  after  penetrating  6  inches  at  340 
yards;  2,  3,  4,  5,  lodged  Krag  bullets  removed  from  wounds  after  deflection  from  frozen  ground. 
Ranges  from  50  to  300  yards. 

hold  together"'  and  penetrate  any  human  structure  "without  breaking  up,  but 
as  the  velocity  drops,  there  comes  a  point  when  the  resistance  is  too  great  for  the 
momentum  of  the  buHet  to  be  overcome  quickly,  and  then  the  bullet  piles  up  on 
itself,  just  as  it  does  when  it  strikes  a  very  hard  object,  and  the  lead  crowds  to 
the  front  part  of  the  bullet  till  the  nose  of  the  jacket  bursts.  When  this  hap- 
pens the  wounds  are  very  serious  and  have  given  rise  to  rumors  of  the  use  of 


320  Contusions  and  Wounds 

'dumdum'  or  soft-nose  bullets  or  of  explosive  bullets"  (Wadsworth,  in  "Inter- 
national Clinics,"  Vol.  IV,  Twentieth  vSeries).  At  lon<];  range  the  bullet  may 
lodge,  or  it  may  also  do  so  if  it  hits  a  man  after  bounding  from  a  stone,  hard 
ground,  or  a  piece  of  metal.  It  may  lodge  in  compact  bone.  In  Cuba  lo  per 
cent,  of  the  wounded  suffered  from  lodged  bullets.  In  the  Russo-Japanese  War 
less  than  lo  per  cent,  of  the  wounded  suffered  from  lodged  bullets.  I  do  not 
know  the  proportion  in  this  war. 

It  is  seldom  that  bits  of  clothing  are  carried  in  with  the  bullet,  but  some- 
times they  are,  and  some  fabrics  are  more  liable  to  be  carried  in  than  others. 
Threads  are  not  unusually  carried  in  on  the  roughened  areas  cut  into  the  bullet 
by  the  grooves  of  the  rifling.  If  the  bullet  ricochets  from  stony  ground,  bits 
of  stone  may  enter  the  tissues. 

Blood-vessels  are  likely  to  be  cut  and  not  pushed  aside,  as  was  often  the 
case  with  the  old-time  bullets.  Cases  of  arterial  contusion  and  subsequent 
secondary  hemorrhage  are,  however,  occasionally  met  with.  If  a  large  vessel 
is  struck  and  cut,  primary  hemorrhage  will  be  profuse  and  may  prove  rapidly 
fatal.  In  many  cases  external  hemorrhage  is  slight  and  the  vascular  injury 
may  not  be  suspected.  In  such  a  case  a  pulsating  hematoma  may  form.  The 
modern  bullet  is  seldom  deflected  in  the  tissues,  but,  as  a  rule,  it  passes  straight 
ahead.  The  skin  is  usually  split  by  it.  Fascia  and  muscle  are  likely  to  be  much 
damaged,  but  in  a  transverse  wound  of  muscle  the  fibers  may  be  separated 
rather  than  destroyed. 

Although  under  most  circumstances  this  bullet  is  humane,  it  has  been 
found  that  in  some  instances  it  pulpifies  structure  for  a  considerable  distance 
around  the  track  of  the  ball,  producing  what  is  known  as  an  explosive  efect. 
The  cause  of  this  condition  has  been  much  debated,  though  it  never  means  that 
the  bullet  has  exploded.  Some  think  that  it  is  always  due  to  comminution  of 
bone  and  the  blowing  of  bone-fragments  ahead  of  and  around  the  ball.  Most 
believe  that  the  sudden  impact  against  the  tissues  engenders  waves  of  force, 
which  cause  explosive  and  distant  damage.  Certain  it  is  that  an  explosive 
•effect  causes  horrible  and  often  irreparable  injury. 

Explosive  effects  are  most  frequently  seen  at  close  range,  when  the  velocity 
of  translation  and  the  frequency  of  rotation  are  most  marked.  Such  injuries 
were  seen  in  the  marines  killed  at  Guantanamo,  in  persons  killed  during  the 
Milan  riots,  and  in  many  instances  in  South  Africa,  China,  Manchuria,  France 
and  Belgium. 

The  bullet  from  the  pistol  usually  employed  in  civil  life  has  no  explosive 
action  at  all;  and  the  old-time  large,  soft  bullet  possessed  it  only  at  a  very 
■close  range.  The  modern  rifle  projectile,  at  300  yards  or  less,  causes  great 
splintering  and  comminution  of  bone.  It  may  produce  explosiv-e  effects  up  to 
500  yards,  but  it  does  not  invariably  do  so.  At  900  yards  and  over  it  causes 
:great  smashing  and  comminution  of  bone  (Posnett,  in  "Lancet,"  Sept.  5,  19 14). 
At  1300  yards  a  single  bullet  may  entirely  destroy  the  cranium.  Explosive 
•effects  may  at  times  occur  at  longer  distances  upon  the  liver,  spleen,  kidneys 
and  lungs,  and  upon  hollow  viscera  containing  fluid.  At  a  distance  of  500  yards 
or  less  a  bone  will  usually  be  shattered  into  many  fragments;  whereas,  at  a  range 
of  1500  or  2000  yards  the  bone  will,  as  a  rule,  be  cleanly  perforated,  usually 
■without  comminution. 

It  is  extraordinary  how  little  trouble  may  follow  a  wound  by  a  modern  pro- 
jectile and  how  quickly  healing  can  occur.  This  is  due  to  the  facts  that  the  tissue 
is  cleanly  perforated,  that  foreign  bodies  are  seldom  carried  in,  and  that  the 
wound  rarely  becomes  infected  unless  the  soldier's  clothing  and  skin  are  very  dirty 
•or  unless  the  bullet  struck  some  object  on  the  ground  before  striking  the  man. 
This  freedom  from  infection  is  not  due  to  the  bullet  being  sterile.  It  is  not 
sterile,  and  when  the  gun  is  fired  the  bullet  does  not  heat  sufficiently  to  destroy 
bacteria  certainly.  The  bullet  is  carried  in  a  dirty  belt  or  pouch,  is  handled  by 
.dirty  hands,  and  is  not  clean  when  put  into  the  rifle,  but  its  sides  may  be  scraped 


Symptoms  321 

cleaner  by  the  rifling  and  the  burning  powder  may  disinfect  it  in  part;.  The 
point,  however,  contains  bacteria  on  its  surface.  They  are  few  in  number 
if  the  bullet  flew  direct  to  its  mark  and  if  the  soldier  and  his  clothing  are  free 
from  mud  and  dust.  If  the  bacteria  are  few  in  number  they  are  scattered  in 
the  tissues;  and,  in  most  instances,  are  overcome  by  tissue  resistance.  The  clean 
track  of  the  bullet  which  is  usual  in  wounds  inflicted  at  ordinary  fighting  ranges 
impairs  tissue  resistance  much  less  than  a  badly  contused  and  lacerated  wound. 
In  some  observed  cases  there  have  been  almost  no  symptoms  after  perforation  of 
the  lung.  In  others,  none  after  perforation  of  the  abdomen,  a  joint,  or  the 
skull.  The  buflet,  if  reasonably  clean,  when  it  has  become  stationary  seldom 
does  harm,  unless  lodged  in  the  brain.  In  most  conflicts  outside  of  Belgium 
and  France  the  modern  rifle  has  proved  to  be  humane  and  its  humanity  is 
largely  a  matter  of  range.  At  a  range  of  1500  yards  or  over  modern  rifles 
in  which  pointed  projectiles  are  not  used  are  humane  weapons.  The  pointed 
bullets  are  not  humane  and  may  inflict  ghastly  wounds. 

What  used  to  be  called  a  wind  contusion  is  a  severe  and  often  a  dreadful 
injury.  The  skin  being  unbroken,  bone  may  be  broken,  viscera  ruptured,  tis- 
sues torn  asunder.  The  older  surgeons  believed  that  such  an  injury  was  pro- 
duced by  the  wind  pressure,  a  projectile  passing  close  to,  but  not  touching  the 
surface.  We  know  now  that  they  result  from  a  projectile's  glancing  along  the 
surface,  the  elasticity  of  the  skin  saving  it  from  immediate  destruction,  although 
in  many  instances  it  sloughs  later. 

A  small  bullet  in  striking  never  gets  hot  enough  to  burn  a  part.  Fragments 
of  high  explosive  shells,  hand  grenades,  shrapnel  and  bombs  are  hot  and  may 
burn  clothing  and  tissues.  A  burn  of  the  tissue  thus  inflicted  complicates  the 
contusions  and  lacerations  (Magnus,  in  "  Medizinische  Klinik,  "  Nov.  5,  1916). 
It  is  needless  to  say  that  bullets  are  never  deliberately  poisoned. 

Symptoms. — Pain  is  seldom  severe  in  wounds  of  the  soft  parts,  but  violent, 
immediate  pain  is  felt  when  a  bone  or  a  nerve  is  injured;  the  pain  is  usually 
stinging  or  burning,  but  is  seldom  of  long  duration,  except  in  bone  injuries, 
spinal  cord  injuries,  and  nerve  injuries.  Sometimes  a  man  does  not  know  he 
has  been  struck.  It  is  common  to  have  anesthesia  or  numbness  and  loss  of 
muscle-function  about  the  wound  for  several  hours  or  days. 

Shock  is  very  variable.  In  some  cases  it  is  scarcely  noticeable,  in  others  it  is 
overwhelming.  It  is  most  marked  in  wounds  of  bone,  the  spine,  the  abdomen, 
and  the  extremities.  It  is  greatly  aggravated  by  hemorrhage.  Hemorrhage 
may  be  great  if  a  large  vessel  is  struck.  Cases  of  vessel  injury  have  increased 
notably  since  the  introduction  of  pointed  bullets.  Many  are  undiagnosticated 
because  of  shght  external  bleeding,  the  small  wound  in  the  vessel  and  the  un- 
equal retraction  of  muscle  layers  keeping  blood  from  the  surface  wound.  Even 
when  a  large  blood-vessel  is  struck  bleeding  may  be  moderate  or  even  scanty; 
yet  when  the  projectile  is  removed  it  will  become  violent.  In  such  a  case  the 
projectile  and  a  clot  about  it  acted  as  a  plug  (Potherat,  in  "Arch,  des  maladies 
du  coeur.,"  Nov.,  191 6).  If  the  vessel  is  in  a  limb  it  is  seldom  that  much  blood 
escapes  externally,  but  a  large  hemorrhage  occurs  in  the  tissues.  Such  cases 
reach  the  hospital  for  treatment,  and  are  spoken  of  as  "traumatic  aneurysm." 
They  were  not  uncommon  in  South  Africa,  and  there  have  been  many  of  them 
in  this  war.  The  condition  is  not  true  aneurysm  but,  as  Auvray  says,  is  a 
hematoma  ("  Bull,  et  mem  de  la  Soc.  ed  Chir.  de  Paris,"  April,  1915).  The  ex- 
ternal opening  may  close,  or  infection  may  creep  in  through  the  opening.  Sec- 
ondary hemorrhage  is  uncommon.  When  it  does  occur  it  is  usually  a  result  of 
infection,  but  it  may  arise,  as  in  a  soft-bullet  injury,  from  contusion  of  a  vessel. 
If  a  great  vessel  is  divided  in  the  chest  or  abdomen,  the  patient  rapidly  bleeds 
to  death  on  the  field,  and  seldom  reaches  the  hospital  at  all.  A  military  bullet 
may  cause  arterioverious  aneurysm.     Many  cases  have  been  reported. 

Primary  infection  is  rare  except  in  wounds  received  during  trench  fighting. 


322  Contusions  and  Wounds 

The  bullet  wound  tends  to  remain  uninfected  unless  bits  of  clothing  or  other 
foreign  bodies  have  been  carried  in,  unless  the  bullet  glanced  from  the  ground 
or  some  object  before  striking  the  man,  unless  it  was  defurmed,  unless  the  wound 
was  at  close  range,  or  unless  unnecessary  and  uncleanly  probing  was  practised. 
If  suppuration  occurs,  it  is  apt  to  remain  locahzed  unless  the  bullet  was  grossly 
infected  in  one  of  the  ways  already  stated.  Pyemia  and  true  septicemia 
are  rare  after  wounds  by  reasonably  clean  bullets.  In  the  Russo-Japanese 
War  suppuration  seems  to  have  been  common.  In  the  Japanese  hospitals  at 
least  60  per  cent,  of  wounds  of  the  soft  parts  by  undeformed  bullets  suppurated. 
At  most  in  only  one  case  out  of  ten  does  the  bullet  lodge.  (Reports  on  Russo- 
Japanese  War,  by  Maj.  Chas.  Lynch,  Medical  Department,  General  Staff, 
U.  S.  A.)  It  is  stated  that  among  the  Russians  suppuration  occurred  in  30  per 
cent,  of  the  cases.  More  wounds  suppurated  in  winter  than  in  summer.  The 
Russians  used  a  larger  bullet  than  the  Japanese,  and  the  wound  inflicted  by  the 
Russian  bullet  was  far  more  liable  to  suppurate  than  was  that  produced  by  the 
Japanese  projectile.  Practically  all  wounds  of  bone  made  by  Russian  bullets 
suppurated.  (Lynch,  Ibid.)  The  above  remarks  upon  the  military  projectile 
do  not  apply  in  all  particulars  to  the  new  bullet  adopted  by  the  United  States 
(model  of  1906).  It  is  of  the  same  caliber  as  its  predecessor,  but  it  is  0.17  inch 
shorter,  70  gr.  lighter,  and  its  point  is  decidedly  sharper.  The  muzzle  velocity 
is  400  yards  per  second  greater.  Point-blank  range  has  been  extended  from  600 
to  718.6  yards.  Because  the  new  bullet  is  short  and  because  the  center  of  gravity 
is  toward  the  base  the  bullet  is  easily  deflected  and  is  prone  to  enter  the  tissues 
sideways,  inflicting  a  frightful  wound,  instead  of  the  usual  small  puncture  of 
the  ogival  headed  bullet  of  1903.  La  Garde  has  pointed  out  that  even  the  skin 
resistance  may  cause  the  bullet  to  turn.  Hence  it  is  evident  that  the  bullet  of 
the  Springfield  now  in  use  is  distinctly  not  a  humane  weapon;  it  will  inflict 
horrible  injury  and  is  very  apt  to  kill  the  victim  outright  (Lt.-Col.  Borden,. 
U.  S.  A.,  in  "Keen's  Surgery,"  vol.  vi). 

The  Machine  or  Rapid-fire  Gun. — From  this  gun  rifle  cartridges  are  fired. 
The  gun  is  automatic  and  can  fire  550  shots  a  minute.  The  wounds  caused  by 
the  projectiles  of  the  machine  gun  are  identical  with  those  produced  by  pro- 
jectiles fired  from  the  rifle.  The  3-inch  quick-firing  field  gun  can  be  fired  from  1 5 
to  25  times  a  minute  (Report  on  the  Medico-Military  Aspects  of  the  European 
War,  by  Surgeon  A.  M.  Fauntleroy,  U.  S.  N.). 

Artillery  Shells. — A  shell  is  a  metallic  case  containing  a  bursting  charge  of 
explosive.  The  shell  may  produce  havoc  by  means  of  its  own  fragments  or  by 
bullets  which  it  holds  being  blown  out  by  the  explosion  within.  Shells  are 
cylindro-conoidal  in  shape  and  are  fired  from  rifled  cannon.  The  high-explosive 
shell,  which  is  usually  made  to  explode  on  impact,  kills  and  maims  by  means  of 
the  numerous  pieces  into  which  it  is  blown  by  the  explosion.  A  high-explosive 
shell  weighs  from  a  few  pounds  to  a  ton.  The  shrapnel  shell  is  a  metal  case 
containing  a  charge  of  explosive  which  is  fired  by  a  time  fuse.  The  case  also 
contains  many  spherical  bullets.  The  bullets  may  be  hard  but  are  usually  of 
soft  lead,  each  about  }  2  an  inch  in  diameter,  and  tend  to  mushroom  on  striking. 
A  3-inch  shrapnel  shell  weighs  18  pounds  and  contains  about  350  bullets.  The 
bursting  charge  does  not  burst  the  shell  but  merely  opens  its  head  or  base  and 
drives  out  the  bullets. 

The  high-explosive  shrapnel  shell  can  be  used  as  shrapnel,  and  is  then  fired 
with  a  time  fuse;  or  can  be  used  as  a  high-explosive  shell,  and  then  detonates 
on  impact. 

Shell  Wounds. — Shell  wounds  are  always  infected.  Shrapnel  wounds  are 
contused  and  lacerated.  Bone  is  smashed.  Extensive  hematomata  form. 
The  deformed  bullets  are  apt  to  carry  in  bits  of  clothing.  Lodged  bullets  are 
common.  Of  course  the  emptied  case  may  kill  or  wound  a  man.  The  high- 
explosive  shell  drives  shell-fragments,  dirt  and  bits  of  clothing  into  the  tissues^ 


Shell  Concussion 


32J 


Shell  Concussion. — Shell  concussion  is  not  shell  shock.  Shell  shock  or,  to 
use  a  better  term,  war  shock,  is  traumatic  neurasthenia  and  hysteria.  A  high- 
explosive  shell  may  cause  instant  death  when  it  explodes  near  a  man,  and  yet 


Fig. 


138. — Showing  a  large  "explosive"  wound  of  exit  resulting  from  a  rifle  ball,  causing  the 
entire  loss  of  the  middle  third  of  the  ulna  (Fauntleroy,  Ibid). 


the  man  may  show  no  sign  of  an  external  wound.  Death  may  have  been  so 
sudden  that  the  dead  retain  in  death  the  last  attitude,  perhaps  even  the  final 
gesture  of  hfe  ("Brit.  Med.  Jour.,"  Aug.  14,  1915).     It  is  quite  common  for 


Fig.  139. — Compound  comminuted  fracture  of  the  lower  third  of  right  leg,  the  result  of 
a  high-explosive  shell  wound,  involving  ankle-joint  and  foot.  Treated  satisfactorily  in  a 
modified  Blake  splint,  \\-ith  extension  from  an  anklet  secured  around  dressing.  The' discolora- 
tion shown  in  the  photograph  is  due  to  the  silver-nitrate  solution  used  to  control  especially  the 
virulent  infection  (Fauntleroy,  Ibid.) 

men  near  such  an  explosion  to  escape  being  struck  but  to  be  hurled  about  or  to  be 
thrown  a  number  of  feet  in  the  air.  A  man  who  is  not  killed  instantly  gets  up, 
although  he  is  terribly  weak  and  shaken,  but  in  a  few  hours  he  is  apt  to  pass  into 


324 


Contusions  and  Wounds 


collapse  and  perish.  Shell  concussion  may  cause  cerebral  or  spinal  bleeding 
(as  indicated  by  bloody  cerebrospinal  fluid),  rupture  of  the  lung  or  rupture  of 
the  hollow  organs  ("Brit.  Med.  Jour.,"  Aug.  14,  igi5).     It  has  been  suggested 


Fig.  140. — Hand-grenade  wounds  of  the  face  and  other  parts  of  the  body  (Fauntleroy,  Ibid.). 

that  either  an  enormous  and  temporary  increase  of  atmospheric  pressure,  or 
the  ensuing  temporary  vacuum  is  responsible  for  the  physical  injury. 


Figs.  141,  142. — Operative   stages  shown  in  a  series  of  two  photographs  of  the  same  case 

(Fauntleroy,  Ibid.). 

Grenades. — These  weapons  are  small,  explosive  shells  which  are  used  largely 
in  trench  fighting.  Some  are  thrown  by  hand,  some  are  projected  by  a  rifle. 
Some  are  exploded  by  a  fuse,  some  by  percussion.     On  explosion  the  shell 


Base  Hospital  (Stationary  Hospital  of  the  English  Army)       325 

breaks  into  numerous  pieces.  Grenade  wounds  are  torn  and  contused,  the 
fragments  of  the  casing  lodge  in  the  tissues  and  are  apt  to  carry  in  dirt  and  often 
particles  of  clothing.     All  such  wounds  are  infected. 

Other  bombs  that  are  used  are  aerial  bombs,  some  of  which  are  incendiary, 
others  of  which  are  explosive — and  trench  mortar  bombs,  each  composed  of  a 
very  thin  metallic  casing  and  containing  a  large  charge  of  high  explosive. 
Trench  mortar  bombs  are  used  at  close  range,  350  yards  or  less. 

Position  and  Functions  in  Battle  of  Hospitals,  Military  OflBcers,  etc. — (See 
Col.  T.  H.  Goodwin,  in  the  "Military  Surgeon,"  June,  191 7).  From  a  quarter 
to  half  a  mile  back  of  the  front  fighting  line  and  within  range  of  rifle  fire  are  the 
regimental  aid  posts. 

1.  Regimental  Aid  Posts. — One,  two,  or  several  of  these  posts  are  placed 
back  of  a  battalion.  When  the  fighting  is  in  the  trenches  an  aid  post  will  prob- 
ably be  in  a  dugout,  when  it  is  in  the  open  it  will  be  placed  at  the  safest  near 
spot.  These  aid  posts  have  medical  ofhcers,  hospital  corps  men  and  stretcher 
bearers.  Aid  posts  move  -with  their  respective  regiments.  The  medical  officers 
belong  to  the  regiments  at  the  front.  The  effort  is  to  gather  up  the  wounded 
and  bring  them  in  as  quickly  as  possible.  The  theory  is  that  when  a  man  is 
wounded,  he,  a  comrade,  a  medical  officer,  a  hospital  corps  man  or  a  stretcher 
bearer,  should  at  once  apply  a  dressing  and.  if  there  is  a  compound  fracture  of 
a  limb,  a  temporary  splint  should  be  applied  before  bringing  the  man  in.  As  a 
matter  of  fact  it  is  seldom  that  anything  at  all  is  done  until  the  wounded  man 
reaches  the  regimental  aid  post.  The  gathering  of  the  wounded  is  usually  a 
dangerous  task,  sometimes  so  dangerous  that  it  must  be  deferred  until  night. 
The  slightly  wounded  walk  back,  those  more  seriously  hurt  are  borne  on  stretch- 
ers. In  the  regimental  aid  post  no  grave  operations  are  performed  and  only 
first  aid  is  given.  It  is  a  busy  place  and  often  full  of  peril  from  bombs  and 
bullets.  After  first  aid  has  been  extended  all  of  the  patients  go  to  the  field 
ambulance,  unless  transport  facilities  are  ample,  in  which  case  those  very  seri- 
ously injured  are  sent  direct  to  the  field  hospital  or  to  the  evacuation  hospital. 
Patients  are  moved  to  the  dressing  station  in  the  most  feasible  manner  (horse 
or  mule  ambulance,  stretchers,  etc.). 

2.  Field  Ambulance  Dressing  Station  (Advanced  Dressing  Station  of  the 
English  Army).^ — This  post  is  farther  back  and  better  protected  than  the  aid 
post.  It  is  in  charge  of  a  medical  unit.  Here  dressings  are  changed,  trivial 
operations  are  performed,  serious  external  bleeding  is  arrested,  etc.  All  sur- 
gical emergencies  are  first  of  all  weeded  out  and  sent  back  quickly  and  directly 
to  the  field  hospital.  Patients  in  general  are  moved  to  the  field  hospital  by 
motor  ambulances. 

3.  Field  Hospital  (Main  Dressing  Station  of  the  British  Army). — From  here 
those  whose  wounds  are  trivial  walk  to  the  hospital  for  the  slightly  wounded 
(Corps  Rest  Station  of  the  English  Army).  Such  men  soon  return  to  the  front. 
Those  who  are  wounded  more  severely  are  gathered  in  motor  ambulances  and 
taken  to  the  field  hospital.  The  field  hospital  is  from  6  to  1 2  miles  to  the  rear 
and  may  have  to  be  moved  over  and  over  again. 

4.  Evacuation  Hospital  (Casualty  Clearing  Station  of  the  EngUsh  Army). — 
In  this  hospital  most  of  the  grave  operations  are  performed.  The  former  idea 
was  to  send  many  or  most  of  the  wounded  requiring  serious  operations  to  a 
base  hospital  but  this  is  now  seldom  practised  except  in  certain  head  injuries  and 
instead  of  a  casualty  clearing  station  the  station  has  become  (as  Bloodgood 
says),  a  casualty  hospital.  Patients,  more  or  less  quickly,  after  operation  are 
moved  by  motor  ambulance  or  ambulance  train  to  the  base  hospital. 

5.  Base  Hospital  (Stationary  Hospital  of  the  EngUsh  Army). — The  base 
hospital  is  far  back  of  the  firing  line.  In  it  certain  operations  are  performed 
and  patients  are  treated  until  convalescent  from  their  injuries.  From  the  base 
hospital  patients  go  to  the  convalescent  hospital. 


326  Contusions  and  Wounds 

6.  Convalescent  Hospital. — This  is  far  away  from  the  zone  of  fighting  and 
may  be  in  another  country  or  across  the  sea.  Transportation  may  be  by  train, 
transport,  or  hospital  shij). 

Treatment  of  Wounds  in  War. — On  a  previous  page  we  set  forth  some 
of  the  conditions  under  which  a  military  surgeon  must  act,  conditions  vastly 
difTcrent  from  those  encountered  by  the  surgeon  in  civil  life  and  which  may 
dictate  a  different  course  of  action. 

The  wound  inflicted  by  the  bullet  of  a  miUtary  rifle  is  very  different  in 
nature  and  in  danger  from  the  wound  inflicted  by  a  revolver  bullet.  In  the 
former,  if  a  large  vessel  is  struck,  it  is  usually  perforated  or  divided,  and  profuse 
bleeding  occurs,  either  into  a  cavity  or  in  the  tissues.  If  the  bleeding  occurs  in  a 
cavity  the  patient  usually  dies  on  the  field,  and  does  not  reach  the  first  dressing- 
station  at  all.  If  it  occurs  in  the  tissues  a  ".traumatic  aneurysm"  forms.  In 
revolver  bullet  wounds  primary  hemorrhage  is  seldom  severe.  Wounds  with 
revolver  bullets  are  very  apt  to  suppurate.  Wounds  with  the  undeformed 
hard-jacketed  projectile  that  has  not  ricocheted  very  commonly  escape  primary 
infection  unless  such  conditions  exist  as  are  found  in  the  trenches. 

Wounds  that  in  cival  life  might  require  only  a  resection,  may  in  military 
practice  require  amputation.     The  promise  of  aseptic  healing  may  lead  the  mili- 

'   :w D---a 

/ 

Fig.  143. — I.  The  fighting  front  of  the  battalion.  There  are  surgeons,  stretcher  bearers  and 
hospital  corps  men.  2.  Regimental  aid  posts.  At  these  points  first  aid  is  given.  3.  Field 
ambulance.  4.  Field  hospital  (6  to  1 2  miles  instead  of  3  miles  back,  and  may  have  to  move  again 
and  again).  5.  Evacuation  hospital.  6.  Base  hospital.  Patients  who  cannot  walk  are  brought 
from  I  to  2  by  stretcher  bearers;  from  2  to  3  by  stretcher  bearers  or  perhaps  horse  or  mule 
ambulance;  from  3  to  4  by  field  ambulance;  from  4  to  5  by  motor  ambulance;  from  5  to  6  by- 
ambulance  train. 

tary  surgeon,  if  conditions  are  favorable,  to  treat  without  operation  many  bullet 
wounds  which  in  civil  life  would  be  operated  upon  at  once,  and  both  surgeons 
would  be  right  in  the  different  courses  pursued  by  them.  In  the  trenches, 
however,  every  wound  is  regarded  as  infected. 

In  civil  Hfe  the  rule  is  absolute  to  open  the  abdomen  for  every  case  of 
gunshot-wound  entering  that  cavity.  The  experience  of  all  military  men  in 
recent  wars  before  the  present  conflict  was  that  in  treating  patients  wounded 
in  the  abdomen  during  open  fighting  by  rifle  bullets  more  cases  get  well 
under  a  policy  of  non-interference  than  with  laparotomy.  In  trench  fighting 
this  is  not  true.  It  is  probably  not  true  in  wounds  from  the  pointed  bullet. 
In  military  surgery  laparotomy  can  be  performed  only  when  there  is  '"time 
to  do  i/;"  and,  even  then,  was  seldom  performed  before  this  war  unless  there 
was  hemorrhage  or  else  certain  evidence  or  a  very  strong  probability  that  an 
organ  or  viscus  had  been  struck  or  perforated.  On  account  of  the  difficulties 
in  the  treatment  of  the  wounded  in  military  life,  as  compared  with  civil  life, 
military  surgery  is  a  pure  specialty;  and  the  details  of  the  treatment  of  wounds 
in  war  must  be  sought  for  in  treatises  by  military  surgeons.  The  watchwords 
of  the  military  surgeon  had  become — preserve  asepsis  and  avoid  meddle- 
some interference. 


Base  Hospital  (Stationary  Hospital  of  the  English  Army)      327 

Trench  warfare  differs  vastly  from  fighting  in  the  open,  and  in  it  to  follow 
the  formula  given  above  would  be  disastrous  folly.  In  trench  warfare  the  surgeon 
regards  practically  all  wounds  as  infected.  Many  of  them  are  huge  and  lacer- 
ated, much  skin  being  lost  and  dreadful  compound,  comminuted  fractures  ex- 
isting (Lt.-Col.  Keefer,  in  "Mihtary  Surgery,"  June,  1916).  Aseptic  surgery 
has  been  abandoned  totally,  and  antiseptic  surgery  has  replaced  it.  Free 
drainage  is  imperative  if  the  wound  was  not  excised.  Many  wounds  are  left 
wide  open  and  plugging  with  gauze  is  condemned  because  it  tends  to  dam  up 
discharge.  The  wounds  are  either  extirpated  and  sutured  or  are  extirpated, 
treated  with  an  antiseptic  fluid  and  sutured  secondarily.  Even  in  the  field 
under  fire  it  is  desirable,  if  possible,  to  apply  an  antiseptic  to  the  wound  and  to 
dress  the  wound.  This  is  usually  impossible.  The  wounded  man  is  lucky  if 
he  can  be  brought  into  his  own  lines.  Many  wounded  men  must  lie  for  hours 
between  the  lines  until  shrouding  night  enables  rescue  parties  to  bring  them  in. 
At  the  earliest  possible  moment  the  clothing  is  cut  away  (if  the  wound  is  under 
the  clothing).  If  possible  the  wound  and  skin  about  it  are  washed  with  alcohol 
and  painted  with  iodin  (tincture,  diluted  one-half  with  alcohol)  and  then  the 
dressings  are  applied.  If  this  cannot  be  done  the  dressings  are  applied  at  once. 
The  dressing  should  be  absorbent  and,  if  possible,  antiseptic  rather  than 
aseptic  gauze.  Absorbent  cotton  should  be  placed  over  the  gauze,  and  a 
bandage  of  linen,  muslin  or  gauze  should  be  applied  to  hold  the  dressing  in 
place. 

It  may  be  said  here  that  for  injury  of  limbs  amputation  is  seldom  necessary. 
It  is  done  when  the  great  vessels  are  injured,  when  the  soft  parts  are  grievously 
lacerated,  when  an  articular  surface  is  badly  comminuted,  and  perhaps  when 
there  is  menacing  infection.  Excision  of  a  joint  is  occasionally  performed 
when  there  is  comminution.  Frequently,  a  wound  of  an  articulation  is 
recovered  from  by  incision,  disinfection  and  free  drainage. 

The  custom  was  to  let  many  lodged  bullets  alone.  If  the  wound  is  infected, 
or  is  known  to  contain  foreign  material  other  than  the  bullet,  the  bullet  and  all 
other  foreign  material  must  be  removed.  A  bullet  in  the  brain  should  be  removed, 
and  at  the  first  minute  possible  when  proper  facilities  are  obtainable.  Serious 
hemorrhage  always  calls  for  operation.  Tie  the  vessel  in  the  wound  if  possible ; 
if  not,  tie  the  main  trunk  above,  and  if  this  fails,  amputate. 

In  warfare  at  the  present  day  an  attempt  is  made  to  limit  the  death-rate 
from  gunshot  wounds  by  protecting  them  from  infection  at  an  early  period 
after  the  accident.  Esmarch  offered  a  suggestion  which  has  been  adopted  in 
the  armies  of  all  civilized  countries.  Every  officer  and  private  soldier  carries 
a  package  which  contains  antiseptic  dressings,  and  at  the  first  opportunity  after 
the  infliction  of  a  wound,  if  possible  on  the  field,  these  dressings  are  applied  by 
the  soldier,  by  a  comrade  (for  even  the  privates  are  instructed  in  the  applica- 
tion), or  by  an  ambulance  man.  If  not  applied  on  the  field,  they  are  applied 
at  the  first  dressing-station  by  a  surgeon  or  a  hospital  steward.  In  the  United 
States  Army  the  first-aid  package  is  carried  in  a  metal  case  to  prevent  contami- 
nation and  damage  by  moisture.  The  case  is  hermetically  sealed,  but  can  be 
easily  opened.  It  is  carried  hooked  to  the  cartridge  belt.  It  contains  two 
bandages,  two  compresses  of  absorbent  corrosive  sublimate  gauze,  and  two  No.  3 
safety-pins,  all  wrapped  in  waxed  paper.  One  compress  is  stitched  to  the  center 
of  each  bandage,  and  the  bandage  is  so  folded  that  the  compress  can  be  opened 
without  touching  its  inner  surface.  Each  private  of  the  hospital  corps  and  the 
orderly  of  each  medical  ofificer  carries  hermetically  sealed  tubes — each  tube 
contains  i  gm.  of  iodin  and  i)^  'gr.  of  iodid  or  potassium.  By  adding  50  c.c. 
of  water  or  alcohol  a  proper  antiseptic  solution  is  obtained.  In  regard  to  the 
procedures  practised  for  wounds  of  special  regions,  see  regional  surgery. 
Wounds  of  Chest,  Wounds  of  Abdomen,  etc.  It  is  now  a  routine  to  give 
antetanic  serum  after  all  wounds  in  war. 


328  Contusions  and  Wounds 

Treatment  of  Shell  Wounds. — Sometimes  a  shell,  failing  to  explode,  acts 
like  a  solid  shot,  kills  a  man  instantly,  tears  off  a  limb,  or  produces  some  other 
fearful  mutilation.  Large  bursting  shells  not  only  wound  and  slay  by  means  of 
fragments  but  may  cause  severe  burns  by  flame,  cause  grave  disturbance  or 
death  by  fumes  or  injure  or  kill  by  concussion  blast. 

The  usual  shell  injury  is  by  splinters  or  fragments,  which  lacerate  and  are 
apt  to  become  imbedded.  The  shell,  by  striking  iron,  stone,  etc.,  makes  a 
multitude  of  small  projectiles.  Fragments  commonly  carry  in  with  them  por- 
tions of  dirt  and  bits  of  clothing  and  shell  wounds  are  always  infected  wounds. 
Large  fragments  may  produce  horrible  mutilation.  A  fragment  or  splinter 
of  a  shell  becomes  a  missile.  On  a  war  boat,  a  shell,  striking  part  of  the  boat 
fills  the  air  with  missiles,  some  being  splinters  from  the  shell,  some  splinters  from 
the  steel  of  the  boat.  Fragments  of  shell  vary  in  size.  One  man  may  be  struck 
by  many  fragments,  wounds  may  be  deep  or  superficial,  may  be  horrible  pul- 
pifications,  grave  lacerations  or  slight  tears.  Fragments  become  imbedded 
and  may  or  may  not  be  deeply  lodged.  Fractures  are  common.  Wounds 
by  shrapnel  are  bullet  wounds.  Of  course  the  emptied  case  may  itself  inflict  a 
wound. 

Treatment. — Depends  considerably  upon  the  nature  of  the  injury.  Such 
wounds  are  lacerated  invariably,  infected  grossly  and  contain  foreign  bodies. 
Amputation  of  a  limb  or  resection  of  a  joint  may  be  necessary.  Lodged  frag- 
ments are  to  be  removed. 

Free  incision  and  removal  of  foreign  bodies  are  the  basic  procedures  in 
most  cases.  Then  the  wound  is  treated  by  extirpation  of  all  injured  tissue  and 
suturing,  or  the  Carrel-Dakin  plan  or  some  other  method  which  aims  to  frus- 
trate the  effects  of  infection  (see  page  329).  Antitetanic  serum  is  always  given 
to  prevent  tetanus. 

Shell  Gases.— (See  Watt  and  Irvine,  "Brit.  Med.  Jour.,"  Aug.  14,  191 5.) 
An  exploding  shell  gives  off  dangerous  gases  from  the  smokeless  powder.  These 
gases  are  oxides  of  nitrogen,  carbon  dioxid  and  carbon  monoxid.  Such  gases 
may  produce  immediate  unconsciousness  and  asphyxia  (poisoning  by  CO 
and  CO2).     Some  of  these  cases  die  rapidly,  others  recover. 

A  man  who  gets  a  dose  of  the  nitrous  gases  may  feel  for  a  time  constric- 
tion of  the  chest  and  headache  and  may  suffer  from  cough.  All  the  symp- 
toms may  pass  away  and  yet  in  six  or  eight  hours  he  may  develop  bloody  ex- 
pectoration and  dyspnea  and  die  rapidly  from  the  pulmonary  edema. 

Treatment. — It  has  been  found  that  an  emetic  given  early,  may  prevent 
symptoms.  It  acts  as  a  purgative  to  the  bronchial  tubes  and  air  cells.  Rest 
in  bed  is  required.  The  development  of  moist  rales  at  the  pulmonary  bases 
calls  for  immediate  venesection,  inhalations  of  oxygen  and  administration  of 
atropin  (Watt  and  Irvine,  Ibid.). 

I  have  long  employed  a  practically  identical  method  for  firemen,  the  victims 
of  nitrous  fumes  and  so  far  Philadelphia  has  not  lost  a  fireman  from  that  cause. 
It  is  also  my  custom  to  bleed  the  patient. 

First  Field  Dressing.— In  many  cases  it  is  impossible  to  give  any  treatment  or 
apply  any  dressing  until  the  wounded  man  reaches  the  regimental  aid  station. 
If  it  is  possible  bleeding  is  arrested  by  a  tourniquet.  The  wound  is  moistened 
with  iodin  and  covered  with  antiseptic  dressings,  and  if  there  is  a  fracture  the 
limb  is  immobilized  on  some  sort  of  emergency  splint  (a  rifle  is  commonly  used). 
A  hypodermatic  injection  of  morphia  brings  great  comfort  and  makes  transpor- 
tation far  easier  to  bear.  A  surgeon  may  at  times  have  an  opportunity  to  arrest 
hemorrhage  by  ligation.  As  Hull  says  (Surgery  in  War)  practically  all  wounds 
are  grossly  infected  to  their  very  depths  with  anaerobic  bacteria  and  no  super- 
ficial painting  with  iodin  can  do  more  than  lessen  the  danger  of  secondary- 
infection. 


The  Carrel-Dakin  Technic 


329 


In  the  regimental  aid  post  the  wounded  man  receives  first  aid  if  he  has  not 
already  obtained  it.  Hemorrhage  is  arrested,  wounds  are  disinfected  and 
dressed,  fractures  splinted,  stimulants  and  morphia  are  given  as  indicated. 
If  possible  he  is  given  an  injection  of  500  units  cf  antitetanic  serum.  From  here 
the  wounded  man  goes  to  the  Field  Ambulance,  the  Field  Hospital  or  the 
Evacuation  Hospital,  according  to  the  nature  of  the  injury,  the  degree  of  shock 
and  the  facihties  for  transportation.  He  has  on  the  first  aid  dressing  and  wears 
a  tag  on  which  is  written  the  nature  of  his 
injury.  Severe  shock  may  cause  the  retention 
of  a  man  for  some  hours  before  it  is  safe  to  move 
him.  If  antitetanic  serum  has  not  been  given 
it  is  at  once  administered  no  matter  how  trivial 
the  wound.  It  used  to  be  the  custom  to  leave 
the  first-aid  dressing  untouched  unless  indica- 
tions called  for  interference.  The  hope  was  to 
get  healing  under  the  first-aid  dressing.  That 
plan  has  been  abandoned.  The  first-aid  dressing 
is  to  be  removed,  as  it  is  invariably  infected  if 
applied  on  the  field  or  in  the  regimental  aid 
post  and  is  often  so  tight  as  to  constrict  the 
part.  For  a  trivial  and  superficial  wound,  the 
wound  and  surrounding  skin  should  be  cleansed 
with  alcohol  to  remove  dirt  and  blood  clot.  A 
2  per  cent,  solution  of  iodin  is  to  be  painted  upon 
the  wound  and  the  skin  about  it.  This  is  the 
time  to  excise  a  severe  wound  or,  at  least  to 
open  it  more  widely,  remove  foreign  bodies, 
remove  hopelessly  damaged  tissue,  disinfect  and 
drain  freely.  Counteropening  may  be  necessary. 
Various  disinfectants  have  been  used. 

If  there  is  a  fracture  the  limb  must  be 
immobilized.  If  the  wound  of  a  limb  is  very 
extensive  the  extremity  should  be  immobilized 
even  when  there   is  no  fracture. 

The  Carrel-DaMn  Technic. — The  principles 
of  the  Carrel-Dakin  treatment  of  wounds  were 
set  forth  on  pages  37-39  and  the  necessary  ma- 
terials are  given  below. 

I  take  from  Dr.  Keen's  book  (Treatment  of 
War  Wounds)  a  description  of  the  method  in 
which  he  quotes  Lyle  (Jour.  Am.  Med.  Assoc, 
Jan.  13,  191 7,  and  others). 

^^ Necessary  Materials. — i.  A  solution  of  0.5 
per  cent,  sodium  hypochlorite  prepared  by  the 
Dakm  and  Daufresne  technic. 

"2.  A  glass  container  with  a  capacity  of  from 
500  to  1000  c.c.  (Fig.  144,  a). 

"3.  Two  yards  of  moderate-sized  rubber 
tubing. 

''4.  An  adjustable  clamp  for  controlling  the  flow  of  the  solution  (Fig.  144,  c)' 

"5.  Rubber  instillation  tubes  about  25  cm.  long,  with  assorted  diameters 
(average  size,  No.  16  French).  These  tubes  are  tied  at  the  extremity  and  per- 
forated with  holes  made  with  a  punch.  The  primary  and  secondary  tubes 
are  7  mm.  in  internal  diameter,  the  final  distributing  tubes  4  mm.,  and  the  little 
holes  in  these  tubes  are  only  i  mm.  (3^5  inch)  in  diameter. 


Fig.  144. — Carrel's  Irrigation 
apparatus:  a,  Reservoir  for  Da- 
kin's  fluid;  b,  the  main  distribut- 
ing tube;  c,  the  metal  pinch-cock; 
d,  glass  tube  with  multiple  open- 
ings; e,  e,  e,  e,  final  distributing 
tubes  closed  at  distal  end,  but 
perforated  with  openings  of  i  mm. 
each  (Carrel  and  Dehelly). 


330  Contusions  and  Wounds 

6.  Ordinary  rubber  tube  drains,  from  25  to  35  cm.  long,  without  lateral 


holes. 


"7.  Glass  connecting  and  distributing  tubes  (Fig.  147). 

"8.  The  dressings  consist  of  cotton  surrounded  by  gauze.     The  cotton  con- 


FiG.  145. — Showing  Carrel's  glass  tube  (Fig.  144,  d)  to  connect  the  main  distributing  tube. 
(Fig.  144,  b)  from  the  reservoir  to  multiple  final  small  distributing  tubes  (Carrel  and  Dehelly). 

sists  of  a  layer  of  absorbent  cotton  with  a  thicker  layer  of  non-absorbent  cotton. 
These  dressings  are  about  3  cm.  thick,  and  of  different  sizes.  Three  different 
^izes  are  sufficient — one  large  enough  to  surround  the  leg  once,  a  second  to 


Fig.   146. — Showing  the  mode  in  which  the  small  distributing  tubes  are  carried  through  the 
dressing  to  the  various  parts  of  the  wound  (Carrel  and  Dehelly). 

surround   the   arm,  the   third  still  smaller.     Webbing  straps  with  buckles  to 
fasten  the  dressing  in  place. 

"g.  Sterilized  pieces  of  gauze  impregnated  with  yellow  petrolatum  to  be 
used  in  the  protection  of  the  skin. 


Fig.   147. — Showing  a  similar  distribution  as  in  Fig.  146,  by  means  of  a  Y-tube,  thus  doubling 
the  number  of  final  distributing  tubes  (Carrel  and  Dehelly). 

"Operative  Technic  to  Prepare  the  Wound  for  the  Introduction  of  the  Anti- 
septic.— The  future  course  of  the  wound  is  directly  dependent  on  the  thorough- 
ness of  the  first  surgical  act.  This  should  be  carried  out  under  the  strictest 
aseptic  precaution  and  at  the  earliest  possible  moment.     It  consists  of  a  thor- 


The  Introduction  of  the  Instillation  Tubes  -      331 

ough,  methodical,  mechanical  disinfection  of  the  wound,  with  the  extraction 
of  all  shell  fragments,  particles  of  clothing,  dirt,  etc.  (For  the  new  stereo- 
liuoroscopic  method  of  extracting  foreign  bodies,  see  pp.  1619  to  1628.) 

"The  operative  field  is  painted  with  tincture  of  iodin,  and  the  bruised  and 
necrotic  skin-edges  of  the  wound  are  trimmed  away  with  a  sharp  knife.  The 
knife  and  forceps  are  then  put  aside.  With  new  instruments  the  wound  is 
laid  open  like  a  book  and  gently  explored  for  shell  fragments,  pieces  of  clothing, 
pockets,  etc.  Everything  that  could  have  been  infected  by  the  traumatism  or 
could  become  the  source  of  infection  is  removed.  All  non-infected  tissues  and 
tissues  unlikely  to  become  infected  are  preserved. 

"  Gentleness  of  manipulation  is  the  keystone  of  the  technic. 
Brutalization  of  the  traumatized  tissue  is  a  technical  crime. 
In  many  of  the  cases  it  will  be  found  that  fibers  of  clothing, 
dirt,   grass,   etc.,   are  encrusted  in   the  muscular  surfaces  of 
the  wounds.     To  avoid  overlooking  this  blood-stained  debris     /'  j|| 
the  track  of  the  projectile  must  be  lightly  but  methodically     lf{\ 
resected.     Great  conservatism  is  exercised  in  the  removal  of     \,\    '  -f 
comminuted  fragments  of  bone.     The  same  minute  and  careful 
mechanical  cleansing  is  carried  out  in  osseous  wounds  as  in 
the  soft  parts.     Before  placing  the  instillation  tubes,  a  careful 
revision  of  the  wound  is  made,  and  particular  attention  paid  to 
securing  a  perfect  hemostasis.     Muscular  tissue  infiltrated  with 
blood  is  difficult  to  disinfect. 

"There  is  another  reason  special  to  the  employment  of 
Dakin's  solution  which  calls  for  a  thorough  hemostasis. 
Owing  to  its  hemolytic  property,  Dakin's  solution  has  the 
power  of  dissolving  recent  blood-clots.  A  poor  hemostasis 
invites  the  danger  of  a  secondary  hemorrhage. 


to 

c  *> 


10^ 


Fig.  i48.-^Showing  Carrel  method  of  irrigating  wound  with  the  Dakin  fluid.  Note  on 
the  main  distributing  tube  the  pinch-cock  below  the  reservoir.  The  wound  is  covered  with 
the  dressing,  which  is  fastened  by  safety-pins.  The  distributing  tube  is  similarly  held  in  place 
by  being  pinned  to  the  plaster  cast  (Carrel  and  Dehelly  modified). 

"  Counteropenings  for  drainage  are  rarely  employed.  If  the  necessity 
for  their  use  should  arise,  one  should  avoid  making  them  at  the  most  dependent 
point,  as  the  goal  of  technic  is  to  keep  the  liquid  in  contact  with  all  the  surface 
of  the  wound. 

"The  Introduction  of  the  Instillation  Tubes. — The  guiding  principle  is  to 
place  the  tubes  so  that  the  liquid  will  come  into  contact  with  every  portion  of 
the  wound.     The  placing  of  the  tubes  will  vary  with  the  nature  of  the  wound. 

"Superficial  Wounds. — A  thin  layer  of  gauze  is  placed  over  the  wound,  and 
on  this  the  requisite  number  of  instillation  tubes.  The  tubes  are  secured  to 
the  wound-edges  by  a  rubber  cuff  and  suture  or  a  two-wav-flow  tube  is  used.     If 


332 


Contusions  and  Wounds 


the  tubes  are  placed  directly  on  the  surface,  they  become  encrusted  and  the 
orifices  are  blocked  with  granulations.  Too  thick  a  layer  of  gauze  should  not 
be  used,  as  it  will  become  clogged  with  the  wound  secretions  and  prevent  the 
solution  from  reaching  the  wound. 

^'Penetrating  Wounds. — In  the  simple  type,  a  tube  without  lateral  perfora- 
tions is  introduced  to  the  depth  of  the  cavity  and  the  solution  allowed  to  well 
up  from  the  bottom  (Fig.  149).     In  a  large  tract  terminating  in  a  cavity  with 

irregular  collapsible  walls  a  little  gauze  is  in- 
troduced to  support  the  walls  of  the  cavity  and 
allow  a  more  thorough  distribution  of  the  fluid. 
Penetrating  wounds  with  the  point  of  entrance 
in  a  dependent  position  (as  the  buttock,  pos- 
terior surface  of  the  extremities,  and  the  back) 
are  treated  with  perforated  tubes  dressed  with 
toweling  (Fig.  151).  These  dressed  tubes  keep 
the  antiseptic  in  contact  with  the  wound.  A 
suitable  non-perforated  tube  can  also  be  used. 
"  Through-and-through  Wounds. — A  perfo- 
rated tube  with  the  tied  extremity  uppermost 
is  passed  from  the  lower  to  the  upper  wound. 
The  liquid,  escaping  through  the  small  lateral 
holes,  flows  back  along  the  tract  to  the  inferior 
orifice,  moistening  the  entire  wound. 

"Wounds  of  the  hand  or  foot,  open  ampu- 
tation stumps,  etc.,  are  immersed  in  Dakin's  solution  for  from  ten  to  fifteen 
minutes  every  two  hours  until  the  wound  is  sterilized.  The  skin  is  protected 
by  smearing  it  with  sterile  yellow  petrolatum. 


Fig.  149. — Showing  Carrel's 
method  of  using  Dakin's  solution 
in  an  anterior  wound  and  keeping 
the  wound  full  of  the  solution  so  as 
constantly  to  attack  the  infecting 
bacteria  (Carrel  and  Dehelly). 


Fig.  150. — Showing  the  method  by  which 
the  distributing  tube  enters  the  wound 
through  the  dressing  without  being  con- 
stricted (Carrel  and  Dehelly). 


Fig.  151. — Mode  of  irrigating  a  wound 
in  a  posterior  position.  Observe  that  the 
distributing  tube  is  here  necessarily  sur-  ■ 
rounded  with  toweling,  otherwise  the  fluid 
would  escape  almost  immediately.  This 
toweling  should  be  firmly  sewed  to  the  dis- 
tributing tube  by  silk  and  not  by  catgut,  so 
that  it  may  not  become  detached  and  be  left 
in  the  wound  (Carrel  and  Dehelly). 

"The  After-care  of  the  Wounds. — The  materials  used  are  described  above. 
In  the  care  of  the  wounds  a  strict  instrumental  technic  is  employed,  the  gloved 
hands  never  coming  in  contact  with  the  wounds  or  dressings. 


Systematic  Bacteriologic  Examination  of  the  Wound 


333 


"Instillations  of  the  fluid  are  made  every  two  hours  (day  and  night)  by 
releasing  the  adjustable  clamp  (for  a  second  or  two)  (Fig.  147)  controlling  the 
flow.  The  amount  of  solution  employed  varies  with  the  nature  and  extent 
of  the  wound;  for  the  average  wound,  10  c.c.  are  sufficient.  This  interrupted 
instillation  is  kept  up  until  the  wound  is  proved  sterile.  The  tubes  are  then 
removed,  and  a  compress  moistened  with  Dakin's  solution  is  applied.  Formerly 
a  continuous  instillation  was  the  method  of  choice:  if  used  at  all,  it  should  be 
discontinued  in  from  twenty-four  to  forty-eight  hours.  The  rate  of  instilla- 
tion is  from  5  to  20  drops  a  minute,  according  to  conditions.  The  object  is  to 
moisten  the  wound  surfaces  and  not  flood  the  bed. 

"Once  a  day — oftener,  if  necessary — the  wound,  the  tubes,  and  the  flow  of 
the  liquid  are  inspected.  Flushing  the  wound  shows  if  the  solution  is  being 
delivered  as  planned,  and  mechanically  washes  away  the  excess  of  wound 
secretion. 

"The  Carrel  method  is  not  a  continuous  irrigation.  It  is  a  mechanical  at- 
tempt to  deliver  an  antiseptic  of  definite  chemical  concentration  to  every  por- 


FiG.  152. — Showing  the  hiiproper  way 
of  placing  the  distributing  tubes.  They  are 
in  contact  with  the  gauze  instead  of  in  con- 
tact with  the  wound  (Carrel  and  Dehelly). 


Fig.  153. — The  correct  way  of  placing  the 
distributing  tubes  so  that  the  Dakin  fluid 
comes  directly  in  contact  with  all  the  surfaces 
of  the  wound  (Carrel  and  Dehelly). 


tion  of  a  surgically  prepared  wound  and  to  insure  its  constant  contact  for  a 
prolonged  period. 

"Systematic  Bacteriologic  Examination  of  the  Wound. — This  consists  in 
a  regular  determination  of  the  number  of  microbes  on  the  wound  surfaces. 
This  is  done  by  transferring  with  a  standard  loop  a  portion  of  the  secretion  to  a 
slide  and  counting  the  number  of  microbes  per  microscopic  field.  This  is  carried 
out  every  second  day,  and  the  results  are  entered  on  a  suitable  chart.  When 
the  microbes  are  absent  from  the  wound  on  three  successive  counts,  the  wound 
is  considered  sterile.  Though  not  absolute,  the  bacteriologic  control  is  of  great 
practical  value  as  a  therapeutic  guide.      .    .    . 

"It  is  better  to  begin  the  bacterial  chart  one  or  two  days  after  the  reception . 
of  the  patient.     As  a  rule,  the  germs  begin  to  appear  after  the  ninth  or  tenth 
hour..    There  is  an  initial  rise  on  the  second  or  third,  day.     This  remains  so  for 
a  few  days,  and  then  the  descent  begins.     Wounds  on  the  soft  parts  are  steril- 
ized in  from  five  to  eight  days.     Greatly  traumatized  wounds  require  a  longer 


334 


Contusions  and  Wounds 


time.  Fractures  can  be  sterilized  in  from  two  to  four  weeks.  If  sequestra  are 
present,  they  must  be  removed  to  obtain  an  asepsis. 

"Wounds  sterilized  by  the  Carrel  method  are  readily  reinfected  if  the  treat- 
ment is  stopped. 

"Reunion  of  Wound. — When,  by  three  successive  tests,  the  bacteriologic 
examination  shows  the  wound  to  be  sterile,  it  is  closed  by  careful  layer  sutures. 


Fig.   154. — The  edges  of  a  wound  being  drawn  together  bv  rubber  clastic  traction  (Carrel  and 

Dehelly). 

In  the  favorable  cases  this  can  be  done  on  the  fifth  day.     The  average  time  for 
the  soft  parts  is  from  seven  to  nine  days. 

"In  cases  in  which  sutures  cannot  be  employed  the  wounds  are  closed  by 
adhesive  straps  passed  in  such  a  way  that,  besides  pulling  the  edges  of  the  wound 
together,  they  make  a  compression  around  the  whole  circumference  of  the  limb, 
or  a  'corset  lacing'  (Fig.  154).  Care  must  be  taken  not  to  have  the  circular 
bandage,  if  this  be  used,  too  tight. 
43q.cnv~ 


ea. 

T 

r 

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12 

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& 

1 

^ 

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c 

^ 

s. 

N 

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2 

^ 

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V 

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/) 

'^^I 

f^ 

^ 

// 


2/ 
Dec. 


29 


6 


ro 


Fig.  155.— On  December  17th  the  area  of  the  wound  was  16.2  sq.  cm.  A  slight  infection 
between  December  27th  and  2gth,  when  one  microorganism  in  two  microscopic  fields  was 
found,  caused  a  slight  deviation  of  the  actual  curve  frorn  the  calculated  curve.  (Kmdness  of 
Carrel  and  du  Nouy  and  the  Jour.  Exp.  Med.,  191 6,  xxiv,  454.) 

"For  extensive  wounds  two  Canton-flannel  bands  are  prepared,  the  length  to 
be  sHghtlv  longer  than  the  wound,  the  breadth  to  be  a  little  less  than  half  the 
circumference  of  the  limb.  On  the  hemmed  edges  shoe-hooks  are  inserted  every 
2  cm.  The  limbs  are  painted  up  to  the  edges  of  the  wound  with  a  resin  varnish 
or  Heusner's  glue  (see  Fig.  1041, page  1555),  and  the  wooly  side  of  the  Canton 


Reunion  of  Wound 


335 


flannel  applied.  One  should  wait  until  the  traction  strips  are  firmly  adherent 
before  lacing  them  with  rubber  bands.  The  tension  of  the  rubber  bands 
rapidly  draws  the  wound  edges  together." 

In  the  entire  treatment  of  these  wounds  even  the  gloved  hands  never  are 
allowed  to  touch  any  dressing  or  the  wound.  Everything  is  handled  by  for- 
ceps, which  can  be  so  much  more  certainly  disinfected  than  hands  or  even- 
gloves. 

When  a  wound  has  filled  up  and  is  in  condition  to  cicatrize,  Carrel  and  Count 
du  Noliy,  a  French  physicist,  by  means  of  a  "planimeter,"  are  able  to  measure 
the  exact  area,  i.e.,  the  number  of  square  centimeters,  in  the  most  irregular 
wound.  The  number  of  square  centimeters  is  entered  on  a  chart  (Figs.  155, 
156,  157,  vertical  numl:)ers)  every  second  day.     The  dates  are  entered  according 


y    6    S  /O /JZ /■^ /6 /3  ZO 2Z2'y  26 
Feb. 

Fig.  156. — Wound  of  the  abdominal  wall.  The  horizontal  part  of  the  curve  from  Febru- 
ary i6th  to  i8th  represents  a  period  of  slight  infection.  As  soon  as  the  wound  was  sterilized 
chemically  the  curve  descended  abruptly.  (Kindness  of  Carrel  and  Hartman  and  the  Jour. 
Exp.  Med.,  1916,  xxiv,  p.  437.) 


to  the  horizontal  numbers.  After  three  or  four  observations  have  been  entered, 
a  "curve  of  healing"  is  established.  By  prolonging  this  curve  they  can  pre- 
dict with  almost  absolute  accuracy  the  day  on  which  a  given  wound  will  be 
completely  healed.  It  is  remarkable  how  nearly  the  "actual"  curve  and  the 
"calculated"  curve  in  a  normal  case  coincide  (Fig.  155).  Any  renewed  in- 
fection, of  course,  disturbs  this  curve,  but,  curiously  enough,  if  the  infection 
is  quickly  overcome,  the  healing  process  undergoes  acceleration  and  the  healing 
will  still  be  brought  about  at  or  very  near  the  predicted  date.  Of  course,  any 
prolonged  infection  would  considerably  delay  the  healing.     Another  curious  fact 


336 


Contusions  and  Wounds 


brought  out  by  these  curves  is  that  large  wounds  heal  much  more  rapidly  than 
small  wounds  (Fig.  157). 

Excision  of  "Wounds. — Excision  of  the  tissues  about  an  infected  wound 
is  advised  by  Carrel  as  a  preliminary  to  treatment  by  Dakin's  fluid.  Moynihan 
and  others  warmly  advocate  excision  of  wounds  (recent  or  of  some  duration) 
and  immediate  suturing,  the  idea  being  to  extirpate  infected  tissues  and  secure 
aseptic  wounds.     The  treatment  was  suggested  by  Col.  Gray  of  the  R.  A.  M.  C. 

Gray's  views  are  set  forth  below  (quoted  by  Major  Hull,  R.  A.  M.  C.,in 
his  book  on  "Surgery  in  War,"  from  Col.  Gray's  article  in  the  Journal  of  the 
Royal  Army  Medical  Corps). 

A  wound  of  any  length  may  be  so  treated.  The  sooner  it  is  done  the  better 
and  it  is  not  necessary  to  wait  until  the  wound  is  clean.  If  a  large  mass  of 
inflammatory  tissue  surrounds  the  wound  excision  is  to  be  deferred,  because 
the  bacteria  are  deep  in  the  tissues  and  will  make  trouble  when  invaded  tissues 

OJrea. 

57 

S-^C 

5J 

55 

3/ 

29 

27 

25 

23 

2/ 

to 

17 
15 
fS 
11 


2 


^    7     9  If  /3  IS  17  /9  2/  Z5Z5Z7Z90r   2    10    6/0 
tlsjt.  Fe-b. 

Fig.  157. — Shell  wounds  with  fracture  of  the  radius  and  ulna.  The  curves  of  both  wounds 
tend  to  unite.  Note  that  the  larger  wound,  n  sq.  cm.,  healed  far  more  rapidly  than  the  smaller 
wound,  which  was  less  than  7  sq.  cm.  on  the  same  date.  (Kindness  of  Carrel  and  Hartman 
and  the  Jour.  Exp.  Med.,  1916,  x.xiv,  p.  442.) 

are  subjected  to  the  pressure  of  sutures.  By  treating  such  a  wound  with  hy- 
pertonic salt  solution  we  can  make  the  parts  ready  for  excision  and  suture  in 
forty-eight  hours.  Other  contra-indications  are  the  existence  of  extensive 
pockets,  the  exposure  of  bone  which  it  is  "inadvisable  or  impossible  to  remove," 
and  the  exposure  of  large  vessels  or  nerve  trunks.  In  any  case  however,  the 
infected  skin  edges,  superficial  connective  tissue  and  muscles  should  be  excised. 
In  some  cases  bony  prominences  are  removed  with  the  infected  muscles 
(tip  of  the  acromion  or  a  vertebral  spine).  The  operation  is  usually  performed 
under  infiltration  anesthesia.  The  parts  are  subjected  to  iodin  disinfection. 
"The  skin  close  to  each  extremity  of  the  wound  is  caught  up  by  tissue  forceps 
in  a  loop  of  thread  and  slight  traction  is  made  in  a  direction  away  from  the  center 
of  the  wound  and  at  an  angle  of  about  forty-five  degrees  with  the  sound  skin. 
The  whole  wound  is  then  cut  away  en  masse  (skin,  flesh,  and,  if  necessary  bone) 


Hypertonic-saline  Treatment  of  Wounds  (Wright's  Method)    337 

at  a  distance  of  about  one-third  to  one-half  an  inch  from  the  raw  surface." 
Pockets  are  cut  out  and  not  broken  into  and  bony  prominences  are  removed  by 
chisels,  bone  cutters  and  rongeurs.  The  wound  is  washed  with  saline  fluid  and 
packed  with  gauze  while  the  surgeon  changes  his  gloves.  "The  wound  should 
be  closed  by  wide  sutures  which  under-run  its  floor  so  that  no  dead  spaces  are 
left.  It  may  be  necessary  to  suture  in  layers.  If  so,  the  suture  of  each  layer 
should  include  some  of  the  tissue  of  the  deeper  layer.  The  skin  should  be  ac- 
curately approximated  by  a  few  fine  sutures."  The  line  of  sutures  and  the 
adjacent  skin  for  several  inches  should  be  painted  with  a  wound  varnish, 
of  which  mastic,  dissolved  in  some  rapidly  evaporating  solvent,  forms  the  im- 
portant part  (40  to  50  per  cent.). 

"When  the  varnish  has  become  sticky  (after  one  and  a  half  to  two  minutes), 
a  covering  of  gauze,  at  least  two  layers  thick,  should  be  stretched  tightly  and 
smoothly  over  the  sticky  area,  gently  patted  down,  and  cotton  wool  and  band- 
ages applied,  fairly  firmly." 

The  varnish  is  never  to  be  painted  on  the  gauze.  If  this  is  done  it  will 
not  be  possible  to  peel  off  the  gauze  when  it  is  desirable. 

Hypertonic-saline  Treatment  of  Wounds  (Sir  Almroth  Wright's  Method). — 
Some  approve  of  this  treatment,  others  consider  it  inefficient. 

Wright  maintains  that  whatever  antiseptic  may  be  used  in  an  infected  wound, 
the  infection  runs  an  almost  definite  course  and  lasts  a  fairly  definite  time, 
unless  it  is  abohshed  by  something  besides  the  antiseptic.  He  takes  these  facts 
as  proofs  that  something  besides  and  more  important  than  the  antiseptic 
is  at  work  in  the  wound. 

"The  tissues  in  the  immediate  vicinity  of  the  wound  are  more  or  less  de- 
^dtalized,  not  only  by  the  severity  of  the  trauma,  but  especially  by  the  condition 
called  by  some  'local  shock,'  peculiar  to  gunshot  wounds.  Antiseptics  will 
tend  to  maintain  this  state  of  lowered  vitality  and  to  favor  microbic  attack. 
Every  efficient  antiseptic  is  more  or  less  toxic  and  irritating,  so  the  less  they  are 
introduced  into  wounds  the  better"  ("Surgery  of  War"  by  Major  Alfred  J. 
Hull,  R.  A.  M.  C).  Hull  goes  on  to  point  out  that  the  patient's  tissues  possess 
far  more  power  to  destroy  invading  organisms  than  any  antiseptic,  therefore, 
the  surgeon  should  aim  to  stimulate  the  forces,  offensive  and  defensive, .  re- 
siding in  the  patient  himself. 

All  know  the  value  of  free  drainage  and  the  removal  of  foreign  matter, 
destroyed  tissue  and  blood-clot.  Sir  Almroth  Wright  adds  to  these  expedients 
the  establishment  of  "free  lavage  of  the  wound  by  lymph  laden  with  antibodies 
which  act  in  the  tissues  lining  the  wound  as  well  as,  but  to  a  less  extent,  than  on 
its  surface. 

"The  lymph  in  the  depth  of  the  wound  becomes  more  inert  as  its  antibodies 
are  used  up  in  the  fight  with  micro-organisms  and  must  be  drained  away, 
otherwise  it  becomes  a  pabulum  for  their  growth"  (Hull,  Ibid.). 

H3^ertonic  solutions  of  sodium  chlorid  are  used  to  cause  lymph  lavage. 
The  salt  may  be  applied  by  continuous  irrigation  through  a  fine  tube,  the  wound 
being  drained  by  gauze,  by  immersion  of  the  part  in  a  continuous  saline  bath, 
by  keeping  gauze  wet  with  salt  solution  in  contact  with  the  raw  surface  or  by 
placing  tablets  of  salt  here  and  there  in  the  wound,  the  serum  of  the  patient 
making  the  necessary  solution. 

For  irrigation  or  immersion  a  5  per  cent,  solution  is  used.  In  very  septic  cases 
a  10  per  cent,  solution  is  used.  When  the  wound  becomes  clean  normal  salt 
solution  is  used.  In  a  short  time  this  is  abandoned  and  the  wound  is  then  merely 
dressed  with  gauze  moistened  in  normal  saline  solution. 

The  treatment  by  solid  salt  was  devised  by  Col.  Gray,  R.  A.  M.  C.  The 
wound  is  irrigated  with  salt  solution  (5  per  cent.),  is  packed  with  gauze  wet 
with  a  solution  of  the  same  strength,  and  "wrapped  in  the  gauze  are  tablets 
of  salt.     Every  portion  of  the  wall  of  the  cavity  must  be  in  contact  with  the 


338  Contusions  and  Wounds 

gauze  or  the  treatment  will  fail.  Into  the  depth  of  the  wound  a  large  drain 
is  placed"  (Hull,  Ibid.). 

One  great  advantage  of  this  method  is  that  transportation  of  the  patient 
does  not  interfere  with  it. 

Rutherford  Morisons  Method. — Many  surgeons  commend  it  highly.  The 
wound  is  enlarged,  every  pocket  is  opened  up,  devitalized  and  necrotic  tissue  is 
removed,  granulation  tissue  is  freely  curetted,  bleeding  is  arrested,  foreign 
bodies  are  removed  and  also  any  loose  pieces  of  bone.  The  wound  is  packed 
with  gauze  while  the  surgeon  changes  his  gloves.  The  wound  is  now  sponged 
out  with  methyl  alcohol.  "Onto  the  raw  wound  surface  a  thin  layer  of  a  prepa- 
ration known  as  "Bipp"  (bismuth  subnitrate  or  carbonate  one  part,  iodoform, 
two  parts,  paraffin  in  quantity  sufficient  to  make  a  soft  paste).  With  a  gauze 
swab  this  paste  is  rubbed  well  into  the  wound,  which  is  then  sutured  from  end 
to  end  without  drainage."  ("American  Addresses"  by  Sir  Berkeley  Moyni- 
han.)  The  wound  is  usually  found  healed  in  ten  days.  Moynihan  believes- 
the  success  of  the  method  is  due  far  more  to  the  careful  mechanical  cleansing, 
of  the  wound  than  to  the  iodoform  and  bismuth. 

Asphyxiating  and  Poisonous  Gases. — We  have  already  stated  that  the 
gases  from  exploding  shells  are  dangerous  and  may  be  fatal.  But  this  elimina- 
tion of  gases  is  an  incident  not  a  design.  High-explosive  shells  are  thrown  for 
other  purposes.  It  was  reserved  for  the  Huns  in  this  war  to  invent  and  delib- 
erately use  irritating,  asphyxiating  and  poisonous  gases.  Long  before  Christ 
the  fumes  of  burning  sulphur  and  the  smoke  from  resinous  wood  were  used  in 
warfare.  The  Chinese  for  ages  employed  the  "stinkpot,"  a  shell  of  earthenware 
filled  with  combustibles  which  in  bursting  gave  out  foul  and  asphyxiating  gases. 
The  Germans  reinvented  gas  warfare,  and  made  of  it  a  science  of  superlative 
cruelty  and  horror. 

Such  gases  were  first  used  in  April,  191 5,  against  the  Canadians  and  Turcos. 
The  effects  upon  men  entirely  unprepared  and  unprotected  were  dreadful  in 
the  extreme. 

There  are  four  different  ways  of  using  gas.  (See  Lt.-Col.  George  W.  Norris, 
M.  C.  N.  A.,  in  "  Jour.  Amer.  Med.  Assoc,"  Nov.  30,  1918.) 

1.  Drift,  Cloud,  or  Cylinder  Gas. — This  gas  plan  was  employed  largely  in  the 
earlier  gas  attacks.  Chlorin  or  phosgen  (carbonyl  chlorid)  was  usually  used. 
The  wind  had  to  be  in  just  the  right  direction  and  blowing  at  the  rate  of  from 
4  to  1 2  miles  an  hour.  The  gas  is  eliminated  from  a  number  of  cylinders,  usually 
at  night  or  early  in  the  morning.  "The  gas  is  heavier  than  air,  sinks  into 
trenches,  dugouts  and  shell  holes,  and  is  unaffected  by  mist,  rain  or  water 
courses.  Such  attacks  have  been  made  on  a  5-mile  front  and  have  produced 
intoxication  at  points  6  miles  behind  the  lines  "  (Lt.-Col.  Norris,  Ibid.) .  A  change 
of  wind  during  a  gas  attack  may  drive  the  gas  back  upon  the  lines  of  those 
who  are  employing  it.  A  knowledge  of  the  direction  and  force  of  the  wind  is 
imperative  to  both  combatants.  "  Various  devices  were  employed  to  serve  as 
wind  vanes.  Anything  that  could  easily  be  seen  by  the  enemy  naturally  drew 
fire.  A  simple  vane  was  then  devised,  consisting  of  a  stick  with  a  thread  about 
a  foot  long  fastened  at  the  upper  end  of  it,  and  with  a  small  piece  of  cotton  wool 
at  the  end  of  the  thread.  The  strength  of  the  wind  was  indicated  by  the  rise 
of  the  cotton  wool  from  a  vertical  position.  Night  was  soon  found  to  be  the 
best  for  chlorin  gas  attacks,  because  the  moving  air  then  has  a  greater  tendency 
to  flow  down  any  slopes,  and  to  keep  the  gas  cloud  near  the  ground.  By  day, 
on  the  other  hand,  the  general  tendency  of  the  air  is  upward,  and  this  is  likely 
to  dissipate  the  gas."  (Prof.  Robert  De  C.  Ward,  in  "The  Scientific 
Monthly,"  June,  1918.) 

2.  Artillery  Shell  Gas. — These  shells  are  used  at  long  range  as  precursors  to 
attacks  of  infantry  and  to  silence  troublesome  batteries.  Each  shell  contains  an 
explosive  charge  and  a  liquid  which  is  liberated  and  gives  out  gas  when  the  shell 


Treatment  of  Gassing  339 

bursts.     A  great  concentration  of  gas  can  be  placed  in  a  given  area,  especially 
if  the  ground  is  "low  or  wooded"  (Lt.-Col.  Norris,  Ibid,), 

3.  Mortar  Gas. — Shells  of  great  size  can  be  hurled  by  mortars  at  least  2000 
yards.  Many  mortars  are  fired  at  once  by  electricity,  an  intense  concentra- 
tion of  gas  being  suddenly  delivered  without  any  warning.  "After  such  attacks 
40  per  cent,  of  casualties  with  15  per  cent.,  of  fatalities  are  not  uncommon. 
When  one  reflects  that  an  8-inch  shell  contains  2!-^  gallons  of  volatile  liquid, 
it  is  not  difiicult  to  understand  why  this  should  be  so"  (Lt.-Col.  Norris,  Ibid.). 

4.  Hand  Grenade  Gas. — Gas  grenades  are  used  to  clear  out  trenches  and 
dugouts.     Lt.-Col.  Norris  (Ibid.)  sets  forth  the  different  types  of  gases,  they  are: 

(i)  Lacrimators  or  tear  gases  (acetone,  xylene  or  bromid  of  benzen).  Tear 
gas  causes  violent  irritation  of  the  eyes,  profuse  lacrimation,  and  the  victim 
becomes  at  least  temporarily  blind. 

(2)  Sternutators  or  sneezing  gas  (diphenylchlorarsin) .  This  gas  causes 
at  once  fierce  cough,  violent  sneezing,  headache,  profuse  flow  of  saliva,  vomiting 
and  retrosternal  pain.  It  keeps  a  man  from  getting  on  a  mask  or  causes 
him  to  take  it  off  if  he  gets  it  on,  hence  sneezing  gas  is  sent  as  a  preliminary 
to  attack  by  another  gas.     The  second  gas  is  toxic,  and  catches  unmasked  men. 

(3)  Suffocating  gases.  These  irritate  the  lungs  and  cause  death  by  pul- 
monary edema.  Among  them  are  phosgen,  diphosgen,  chlorin,  and  oxy- 
chlorcarbon. 

(4)  Vesicating  or  mustard  gases  (dichlorethylsulphid,  dichlormethylether). 
The  skin,  eyes  and  respiratory  tract  are  irritated  and  blistered,  intense  inflam- 
mation and  commonly  sloughing  follow.  Bronchopneumonia  is  the  cause  of 
death. 

(5)  Gases  which  destroy  the  function  of  the  red  corpuscles  of  the  blood. 
Carbon  monoxid  which  causes  asphyxia. 

Arsin  which  produces  hemolysis  followed  by  jaundice,  nephritis,  hemoglo- 
binemia  and  gastro-intestinal  disorder. 

Prevention  of  Gassing. — A  helmet  or  mask  must  be  worn.  It  is  put  on  when 
the  gas  is  seen  approaching.  It  must  fit  snugly  and  cover  the  eyes  as  well  as 
the  nose.  It  must  have  no  holes  in  it  and  in  every  way  be  in  perfect  order. 
If  possible  a  soldier  in  the  trenches  should  carry  two  masks  or  helmets,  because 
one  may  be  put  out  of  function  by  a  bullet  hole.  One  is  carried  so  that  it  can 
be  applied  rapidly.  There  are  many  different  types.  An  excellent  mask  is 
made  of  mackintosh  and  has  a  piece  of  transparent  celluloid  in  front  of  the  eyes. 
In  front  of  the  mouth  and  nose  are  a  number  of  small,  round  openings.  Back 
of  these  and  within  the  mask  is  a  pocket  perforated  by  a  number  of  holes  and 
containing  a  pad.  Air  sucked  in  passes  through  the  pocket  and  pad  into  the 
mask. 

Just  before  the  mask  is  used  the  soldier  removes  from  the  pocket  the  pad 
which  contains  bicarbonate  of  sodium  and  hyposulphite  of  sodium,  pours  some 
water  on  this  pad,  puts  the  pad  in  the  pocket  and  puts  on  the  mask.  The 
soldier  carries  a  little  bottle  of  water  for  this  purpose  and  also  carries  a  tin  box 
of  extra  powders.     These  masks  have  proved  wonderfully  efficient. 

Treatment. — ^A  victim  of  a  suffocating  gas  (diphosgen)  may  have  slight 
symptoms  for  some  or  a  number  of  hours  and  then  develop  pulmonary  edema. 
Death  is  due  to  dilatation  of  the  heart  and  pulmonary  edema. 

A  man  gassed  with  diphosgen  must  not  walk  or  make  an  unnecessary  move- 
ment. Severe  cases  are  kept  in  the  field  hospital  for  several  days.  When  acute 
symptoms  disappear  the  victim  is  sent  to  the  evacuation  hospital.  Lt.-Col. 
Norris  (Ibid.)  sums  up  the  treatment  as  follows:  (i)  Absolute  rest;  (2) 
warmth;  (3)  venesection;  (4)  removal  of  clothing;  (5)  oxygen  inhalations; 
(6)  cardiac  stimulation  (camphor,  digitalin,  spartein,  caffein),  and  (7).  fresh 
air.  He  further  says  that  atropin  is  useless  and  that  opium,  emetin,  depressants 
and  expectorants  are  contraindicated.     A  victim  of  mustard  gas  may  not  begin 


34©  Contusions  and  Wounds 

to  suffer  severely  for  some  hours.  The  entire  body  must  be  washed  with  soap 
and  water  and  the  hair  should  be  clipped  closely.  Lt.-Col.  Norris  (Ibid.)  advises 
that  the  eyes,  nose  and  mouth  be  douched  with  a  i  per  cent,  solution  of  bi- 
carbonate of  sodium,  followed  by  instillations  of  a  bland  oil.  Dichloramin-T 
of  a  strength  of  0.5  is  the  best  treatment  for  the  eyes  as  it  antidotes  most  gas 
by  its  chlorin  and  it  is  an  antiseptic.  (Major  J.  E.  Sweet  introduced  its  use 
for  this  purpose.)  Cocain  is  injurious.  An  eye  shade  is  used,  but  is  lifted 
at  intervals  to  let  fluid  escape.  The  eyes  usually  recover.  Skin  burns  are 
treated  with  paraffin,  petrolatum  or  an  alkalin  dusting  powder  (talc,  zinc 
oxid  or  carbonate  of  magnesium).  It  is  proper  to  prick  a  blister  but  it  is 
not  proper  to  permit  the  fluid  to  flow  upon  adjacent  skin  (Lt.-Col.  Norris, 
Ibid.). 

Steam  inhalations  with  benzoin  are  used  for  cough;  so  are  codein  or  morphia. 
(See  Lt.-Col.  Norris  in  "Jour.  Amer.  Med.  Assoc,"  Nov.  30,  1918.) 

Burns  by  Liquid  Fire, — ^Liquid  fire  is  a  return  to  the  old  idea  of  Greek  fire, 
k  material  which  gradually  disappeared  from  warfare  after  the  introduction  of 
gunpowder.     Shells  containing  combustible  gas  and  incendiary  shells  are  used. 

Liquid  fire  is  used  by  means  of  a  flame  projector.  The  apparatus  is  carried 
on  the  back  like  a  fire  extinguisher  and  it  throws  a  liquid  which  takes  fire  in  the 
air.  It  can  be  used  with  effect  to  a  distance  of  80  or  90  feet.  It  is  employed 
particularly  in  close  range  fighting,  especially  in  the  streets  of  a  town.  Liquid 
fire  produces  horrible  burns.  Inhalation  of  flame  causes  instant  death.  The 
burns  are  treated  with  a  paraffin  preparation. 

War  Shock. — We  use  this  term  in  preference  to  shell  shock  so  that  it  may  not 
be  confused  with  shell  concussion,  which  is  a  condition  in  which  there  are  struc- 
tural injuries  and  in  which  instant  death  may  occur.  War  shock  does  not  differ 
from  the  like  condition  seen  in  civilians.  War  shock  is  a  condition  of  exhaustion 
of  the  nervous  system.  The  man's  "nerve"  has  snapped  under  the  strain  of 
responsibility,  bombardment,  the  constant  sight  of  death  and  mutilation, 
fatigue,  cold,  wet,  hunger,  homesickness,  etc.  All  sorts  of  hysterical  and  psy- 
chical phenomena  arise.  There  may  be  temporary  blindness,  deafness  or 
aphasia,  distressing  insomnia, hideous  dreams,  paralysis,  melancholy  depression, 
vivid  hallucinations  or  maniacal  excitement.  Under  change  of  scene,  rest,  sug- 
gestion, etc.,  the  patients  recover.  The  treatment  should  be  directed  by  a 
neurologist. 

Trench  Foot. — This  condition  has  been  very  common.  It  was  at  first 
thought  to  be  frost-bite,  but  whereas  it  occurs  particularly  in  cold  weather 
it  may  be  seen  when  the  thermometer  is  above  freezing.  It  is  due  to  a  combi- 
nation of  cold,  wet,  tight  shoes  and  circulatory  constriction  by  ill-adjusted 
leggings  or  puttees.  In  severe  cases  there  is  infection  of  the  skin  and  subcu- 
taneous tissues.  In  most  cases  only  one  foot  suffers.  In  ordinary  cases  there 
is  edema  and  areas  of  cutaneous  hyperesthesia  and  anesthesia  in  congested 
zones,  with  pain,  tenderness  of  the  heel  and  ball  of  the  foot  and  of  the  muscles 
of  the  leg.  In  more  severe  cases  discoloration  is  widespread  and  darker,  and 
even  the  toe  nails  darken.  Swelling  is  greater.  Vesicles  form  and  rupture, 
ulcers  being  exposed." 

In  the  worst  cases  gangrene  may  develop.  There  is  some  danger  of  tetanus. 
The  condition  can  be  prevented  by  keeping  the  feet  clean  and  greased,  wearing 
rubber  boots,  and  carefully  avoiding  circulatory  obstruction.  When  it  arises 
the  foot  should  be  slightly  elevated  and  the  parts  dressed  with  a  preparation 
of  camphor  and  borate  of  sodium  in  water.  In  severe  cases  give  antitetanic 
serum.  Amputation  is  seldom  required.  The  average  victim  returns  to  duty 
in  from  three  to  five  weeks  (J.  C.  Bloodgood,  on  "Military  Surgery"  in  Progres- 
sive Medicine,  Dec,  1917). 

Poisoned  Wounds. — A  poisoned  wound  is  a  wound  into  which  some  in- 
jurious substance,  chemical  or  bacterial,  has  been  introduced.  This  poison 
may  be  the  product  of  bacteria  which  are  capable  of  self-multiplication,  or  it 


Symptoms  of  Malignant  Edema  341 

may  be  chemical,  and  hence  incapable  of  multiplication.  There  are  three 
classes  of  poisons:^  (i)  mixed  infection,  as  septic  wounds,  dissection- wounds, 
and  malignant  edema;  (2)  chemical  poison,  such  as  snake-bites  and  insect- 
stings;  and  (3)  infection  with  such  diseases  as  rabies,  glanders,  etc. 

Septic  or  infected  wounds  are  those  which  putrefy,  suppurate,  or  slough. 
Septic  wounds  should  be  opened  freely  to  secure  drainage,  and  hopelessly 
damaged  tissue  should  be  curetted  or  cut  away.  The  wound  and  the  skin 
about  should  be  painted  with  iodin.  In  some  cases  complete  excision  of  the 
wound  is  practised.  In  others  the  wound  is  kept  wide  open  and  is  treated 
with  Dakin's  fluid  or  Dakin's  oil  (pages  37-39  and  329).  If  the  older  plan  of 
attempted  immediate  disinfection,  followed  by  tubular  drainage  or  packing  with 
gauze  is  employed,  the  parts  should  be  subjected  to  heat  applied  by  means  of  hot 
fomentations  Or  by  the  electric  light.  In  many  cases  antitetanic  serum  should 
be  given.  The  part  must  be  kept  at  rest  and  internal  treatment  should  be 
stimulating  and  supporting.  If  lymphangitis  arises,  the  skin  over  the  inflamed 
vessels  and  glands  is  to  be  painted  with  iodin  and  smeared  with  ichthyol, 
and  quinin,  iron,  and  whisky  are  given  internally.  The  temperature  is  watched 
for  evidence  of  general  infection  or  intoxication.  The  patient  must  be  stimu- 
lated freely,  nourishing  food  is  given  at  frequent  intervals,  pain  is  allayed  by 
anodynes  if  necessary,  and  sleep  is  secured.  In  infected  wounds  of  the  extremi- 
ties Bier's  treatment  is  very  useful. 

Dissection=wounds  are  simple  examples  of  infected  wounds,  and  they 
present  nothing  peculiar  except  virulence.  They  affect  butchers,  cooks, 
surgeons  who  cut  themselves  while  operating  on  infected  areas,  those  who 
make  postmortems,  and  those  who  dissect.  A  dissection-wound  inflicted 
while  working  on  a  body  injected  with  chlorid  of  zinc  possesses  but  few  ele- 
ments of  danger  unless  the  health  of  the  student  is  much  broken  down.  If 
a  wound  is  simply  poisoned  by  putrefactive  organisms,  there  is  rarely  serious 
trouble.  Postmortems  are  peculiarly  dangerous  when  the  subject  has  died 
of  some  septic  process.  When  a  wound  is  inflicted  while  dissecting,  wash  it 
under  a  strong  stream  of  water,  squeeze,  and  suck  it  to  make  the  blood  run, 
paint  skin  and  wound  with  iodin,  lay  it  open  if  it  be  a  puncture.  It  should  be 
kept  open  and  be  treated  by  Dakin's  oil.  The  custom  has  been  to  leave  it 
open,  dress  with  moist  gauze,  apply  heat  and  keep  the  part  at  rest.  Trouble, 
of  course,  may  follow,  but  often  it  is  only  local,  and  a  small  abscess  forms.  It 
should  be  treated  by  hot  antiseptic  fomentations  and  early  incision.  Occasion- 
ally lymphangitis  arises,  adjacent  glands  inflame,  and  constitutional  symptoms 
are  present.  It  is  rarely  that  true  septicemia  or  pyemia  arises  unless  the  wound 
was  inflicted  while  making  a  postmortem  upon  a  person  dead  of  septicemia 
or  while  operating  on  a  septic  focus.  If  glands  enlarge  and  soften,  it  may  be 
necessary  to  remove  them  surgically. 

Malignant  edema  or  gangrenous  emphysema  arises  most  commonly 
after  a  puncture.  It  is  due  to  a  specific  bacillus  which  produces  great  edema. 
The  emphysema  which  soon  arises  is  due  to  mixed  infection  with  putrefactive 
organisms.  Pus  does  not  form,  but  gangrene  occurs.  The  disease  is  identical 
with  one  form  of  traumatic  spreading  gangrene  (see  page  184). 

Symptoms. — These  are  identical  with  those  of  traumatic  spreading  gan- 
grene with  emphysema. 

There  is  a  rapidly  spreading  edema,  followed  by  gaseous  distention  of  the 
tissues  and  by  gangrenous  cellulitis.  The  zone  of  edema  is  at  the  margin  of 
the  emphysema,  and  the  process  spreads  rapidly.  The  emphysematous  zone 
crackles  when  pressed  upon.  The  area  of  edema  is  covered  with  blebs  which 
contain  thin,  putrid,  reddish  matter,  and  the  skin  becomes  mottled.  If  a 
wound  exists,  the  discharge  wiU  be  bloody  and  foul.  If  incisions  are  made, 
a  thin,  brown,  offensive  liquid  flows  out.  High  fever  rapidly  develops,  the 
1  "American  Text-Book  of  Surgery." 


342  Contusions  and  Wounds 

patient  becomes  delirious,  and  coma  may  follow.  In  many  cases  death  ensues 
in  from  twenty-four  to  forty-eight  hours. 

Treatment. — If  malignant  edema  affects  a  limb  after  a  severe  injury  ampu- 
tate at  once,  high  up.  If  it  affects  some  other  part  or  begins  in  a  limb  after 
a  trivial  injury,  make  free  incisions,  excise  all  suspicious  tissue,  employ  hot, 
continuous  antiseptic  irrigations  or  the  hot  antiseptic  bath,  or  employ  Dakin's 
fluid  and  stimulate  freely  (see  page  329).  Administer  preventive  doses  of 
antitetanic  serum. 

Stings  and  Bites  of  Insects  and  Reptiles :  Stings  of  Bees  and  Wasps. — 
A  bee's  sting  consists  of  two  long  lances  within  a  sheath  with  which  a  poison- 
bag  is  connected.  The  wound  is  made  first  by  the  sheath,  the  poison  then 
passes  in,  and  the  two  barbed  or  twisted  lances,  moving  up  and  down,  deepen 
the  cut.  The  barbs  on  the  lances  make  it  difficult  to  withdraw  the  sting 
rapidly,  and  it  may  be  broken  off  and  remain  in  the  flesh.  Edematous,  dis- 
colored swelling  quickly  arises.  The  pain  is  severe  and  burning.  Besides  bees, 
hornets,  yellow  jackets,  and  other  wasps  produce  painful  stings  like  bee-stings. 
The  sting  of  a  w^asp  is  rarely  broken  off  in  the  tissues  because  the  beards  on  the 
darts  are  shorter;  hence  the  sting  is  not  so  firmly  fixed  in  the  flesh,  and  also 
because  these  insects  are  more  rapid  and  nimble  in  their  actions.  Stings  of 
bees  and  wasps  seldom  cause  any  trouble  except  pain  and  swelling.  In  rare 
cases  syncope  occurs.  Widespread  urticaria  may  develop.  Erysipelas  or 
phlebitis  may  arise.  In  some  unusual  cases  a  bee-sting  is  fatal;  persons  have 
been  stung  to  death  by  a  great  number  of  these  insects. 

Symptoms. — If  general  symptoms  ensue,  they  appear  rapidly,  and  con- 
sist of  great  prostration,  vomiting,  purging,  and  delirium  or  unconsciousness. 
These  symptoms  may  disappear  in  a  short  time,  or  they  may  end  in  death 
from  heart-failure.     Stings  of  the  mouth  may  cause  edema  of  the  glottis. 

Treatment. — To  treat  a  bee-sting,  extract  the  sting  with  splinter  forceps 
if  it  has  been  broken  off  and  is  visible  in  the  wound.  If  it  is  not  visible,  squeeze 
the  part  lightly  in  order  to  expel  it,  or  at  least  expel  the  poison.  Pressure 
may  be  most  satisfactorily  made  by  means  of  the  barrel  of  a  key.  The  poison 
is  counteracted  by  touching  with  ammonia  or  washing  the  part  in  ammonia- 
water,  touching  with  pure  carbohc  acid,  painting  with  tincture  of  iodin,  or  soak- 
ing in  a  strong  solution  of  common  salt  or  carbonate  of  sodium.  The  part 
may  be  dressed  with  lead-water  and  laudanum,  a  solution  of  washing-soda, 
or  a  solution  of  common  salt.     If  constitutional  symptoms  appear,  stimulate. 

Other  Insect=bites  and  Stings. — If  a  tick  bites  a  person  it  cUngs  to  the 
victim.  If  an  attempt  is  made  to  pull  it  off  the  barb  remains  in  the  tissues 
and  an  abscess  follows.  If  a  little  ammonia  is  dropped  on  a  tick  the  insect 
will  at  once  withdraw  its  barb.  A  tick  bite  never  causes  constitutional  symp- 
toms. The  mandibles  of  a  poisonous  spider  are  terminated  by  a  movable  hook 
which  has  an  opening  for  the  emission  of  poison.  The  bite  of  a  large  spider  is 
productive  of  inflammation,  swelling,  weakness,  and  possibly  death.  The  bite  of 
the  poisonous  spider  of  New  Zealand  produces  a  large  white  swelling  and  great 
prostration;  death  may  ensue,  or  the  victim  may  remain  in  a  depressed,  en- 
feebled state  for  weeks  or  even  for  months.  The  tarantula  is  a  much-dreaded, 
large,  brown,  hairy  spider  of  the  southwestern  part  of  the  United  States.  In 
Europe  the  name  is  given  to  an  entirely  different  kind  of  spider.  The  bite 
of  a  Texas  tarantula  is  very  painful  and  may  be  dangerous.  The  scorpion 
has  in  its  tail  a  sting.  The  sting  of  the  scorpion  produces  great  prostration, 
delirium,  vomiting,  diaphoresis,  vertigo,  headache,  local  swelling  and  burn- 
ing pain,  followed  often  by  fever  and  suppuration,  and  occasionally  even  by 
gangrene,  but  it  is  rarely  fatal.  Centipedes  must  be  of  large  size  to  be  formidable 
to  man,  and  the  symptoms  arising  from  their  stings  are  usually  only  local. 

Treatment. — To  treat  the  bite  of  a  poisonous  spider  or  sting  of  a  scorpion 
tie  a  fillet  above  the  bitten  point;  make  a  crucial  incision,  favor  bleeding,  and 


Snake-bites 


343 


paint  the  wound  with  pure  carbolic  acid  or  some  caustic  or  antiseptic  (if  in 
the  wilds,  burn  with  fire  or  gunpowder);  dress  antiseptically  if  possible,  and 
stimulate  as  constitutional  symptoms  appear.  Slowly  loosen  the  ligature  after 
symptoms  disappear.  Chloroform  stupes  and  ipecac  poultices  are  recom- 
mended; also  puncture  by  a  needle  and  rubbing  in  a  mixture  of  3  parts  of 
alcohol  and  i  part  of  camphor  (Bauer jie).  Antiscorpion  venene  is  recom- 
mended by  Todd  for  scorpion  stings. 

Myiasis. — When  the  larvae  of  dipterous  insects  are  deposited  in  the  tissues 
the  condition  is  called  myiasis.  Certain  varieties  of  flies  sting  with  the  ovi- 
positor and  lay  their  eggs  in  the  skin  or  in  the  mucous  membrane  of  the  nose. 
The  bot-fly  may  do  this,  and  the  larvae  or  maggots  of  bot-flies  are  called  bots. 
Inflammation  arises  in  the  area  containing  the  ova  and  suppuration  may  occur. 
Myiasis  is  most  common  in  tropical  and  subtropical  countries,  but  the  blue- 
bottle fly  may  be  responsible  for  the  condition  in  temperate  climates.  Myiasis 
of  the  genito-urinary  tract  has  been  described. 

Treatment. — Incision  and  application  of  pure  carbolic  acid  to  kill  the  larvae. 
If  in  the  nasal  passages  inhalation  of  chloroform  may  prove  fatal  to  larvae. 

Maggots  in  Wounds. — In  tropical  countries  especially  flies  may  lay  eggs  in 
wounds  and  maggots  form  in  immense  numbers.  Larrey  saw  many  such  cases. 
I  have  seen  maggots  several  times  in  foul  leg  ulcers.  Antiseptic  dressings 
prevent  such  an  occurrence  and  antiseptics  will  destroy  larvae.  lodin  is  very 
successful. 

Chigger. — The  chigger  or  sand  flea  is  common  in  the  tropics  and  subtropics. 
The  female  when  impregnated  may  enter  an  abrasion  or  may  pass  through  "  the 
soft  skin,  especially  in  the  sole  between  the  toes"  or  "around  the  nails"  (Mad- 
den, in  a  "System  of  Surgery,"  edited  by  C.  C.  Choyce). 

Inflammation  occurs  and  the  body  of  the  flea  is  recognizable  as  a  small  black 
spot.  Suppuration  may  occur  and  the  flea  may  be  cast  out  with  the  pus. 
Sinuses  may  arise  and  persist.  There  is  some  danger  of  erysipelas,  tetanus,  and 
gangrene  (Ibid.). 

Treatment. — Apply  a  hot  solution  of  bicarbonate  of  soda  for  some  hours, 
enlarge  the  opening  with  a  knife,  remove  the  insect  without  breaking  it  up,  and 
dress  the  part  antiseptically  (Ibid.). 

Fish  Stings. — The  spines  of  many  fish  inflict  a  poisoned  wound,  as  they  are 
covered  with  an  irritant  material  obtained  from  the  skin.  The  spines  of  the 
catfish  are  known  to  do  this.  Certain  fish  actually  inject  poison  along  a  spine, 
the  poison  coming  from  a  receptacle  or  bag.  Fish  stings  are  very  painful,  are 
septic,  and  are  apt  to  be  followed  by  lymphangitis,  erysipelas,  erysipeloid,  gan- 
grene, or  general  sepsis. 

Treatment. — Incise,  favor  bleeding,  swab  with  pure  carbolic  acid  or  iodin, 
and  apply  hot  antiseptic  fomentations. 

Snake=bites. — The  poisonous  snakes  of  America  comprise  the  copper- 
heads (red  vipers  or  upland  moccasins),  water  moccasins  (rice  snakes  or  cotton- 
mouths),  harlequin  snakes  (coral  snakes),  and  rattlesnakes.  The  King  cobra  of 
India  is  the  most  combative  and  deadly  of  reptiles.  In  some  countries  great 
numbers  of  people  and  the  lower  animals  are  killed  by  poisonous  serpents. 
Consular  reports  show  that  in  India  during  the  years  from  1887-1911  inclusive 
543,991  human  beings  and  187,436  cattle  were  killed  by  poisonous  snakes. 
The  average  human  death  rate  was  21,700  a  year.  The  coral  snake  is  found  in 
the  southeastern  United  States,  and  is  common  in  South  Carolina,  Georgia,  and 
Florida.     It  is  often  discovered  in  sweet  potato  fields. 

The  extremely,  belligerent  water  moccasin,  which  is  semi-aquatic,  infests 
"the  lagoons  and  sluggish  waterways  of  the  southeastern  portion  of  the  United 
States"  ("Reptiles  of  the  World,"  by  Raymond  L.  Ditmars). 

The  copperhead,  which  is  a  variety  of  moccasin,  is  found  east  of  the  Mississ- 
ippi River  from  Florida  to  Massachusetts,  and  west  of    the    Mississippi   in 


344  Contusions  and  Wounds 

Texas.  In  the  South  it  Uves  on  plantations,  in  the  North  in  or  near  forests 
(Ibid.).  In  practically  every  part  of  the  United  States  there  dwells  some 
variety  of  rattlesnake.  Fifteen  species  are  catalogued  as  dwelling  within  our 
borders  (Ibid.).  Some  inhabit  prairie,  some  desert,  some  rocky  land,  some 
timber  regions,  some  dwell  adjacent  to  water.  The  diamond-back  rattlesnake 
is  the  most  poisonous  serpent  of  the  United  States.  A  small  rattler  is  not  nearly 
so  dangerous  to  life  as  a  big  rattler.  Next  to  a  big  rattlesnake  in  poisonous 
power  comes  the  water  moccasin.  Mr.  Ditmars  characterizes  the  coral  snake 
as  "highly  formidable"  and  the  copperhead  as  "highly  venomous."  Statistics 
seem  to  contradict  the  belief  that  the  copperhead  is  very  dangerous.  Prentiss 
Willson  ("Jour.  Am.  Med.  Assoc,"  Aug.  27,  1910)  claims  to  have  established  99 
instances  of  persons  bitten  by  copperheads.  There  were  only  5  deaths.  It 
is  quite  possible  that  some  of  those  bitten  thought  they  were  bitten  by  copper- 
heads when  in  reality  the  assailants  were  non-poisonous  serpents.  Wilson's 
figures  make  the  statistics  of  recovery  highly  favorable.  "Most  snake-bites 
are  from  non-venomous  snakes.  The  colubers  of  the  middle  west  are  very 
belligerent  serpents  and  attack  with  satanic  fury"  (W.  M.  Winton,  in  "Popular 
Science  Alonthly,"  May,  191 6).  It  used  to  be  taught  that  there  is  no  essential 
difference  in  the  action  of  venoms  of  different  varieties  of  snakes,  and  that  the 
venom  of  an  Indian  cobra  is  practically  identical  with  the  venom  of  an  American 
rattler,  any  apparent  difference  in  action  depending  upon  difference  in  toxic  power 
and  the  different  dose  of  poison  introduced.  We  now  know  that  there  are  es- 
sential differences  in  venoms  (Leonard  Rogers,  in  "Lancet,"  Feb.  6,  1904).  The 
natural  toxic  power  of  the  poison  varies  in  different  species  and  also  in  different 
members  of  the  same  species.  The  venom  remains  poisonous  when  dried.  Poi- 
son injected  into  a  vein  may  prove  almost  instantly  fatal.  The  poison  is  not 
absorbed  by  the  sound  mucous  membranes.  Poison  is  harmless  when  given  by 
the  mouth  and  swallowed,  but  if  directly  introduced  into  the  intestines  of  an 
animal  it  is  certainly  fatal.  The  pancreatic  ferment  destroys  the  toxic  power  of 
the  venom  (R.  H.  Elliot,  in  "Brit.  Med.  Jour.,"  May  12,  1900).  The  venom  is 
discharged  through  the  channeled  fangs  of  the  reptile,  having  been  forced  out  by 
contractions  of  the  muscles  of  the  poison-bag.  The  coral  snake,  like  the  cobra, 
has  short  and  rigid  fangs.  Rattlesnakes,  cotton-mouths,  and  copperheads  have 
long  and  movable  fangs.  A  coral  snake  bites  like  a*cobra.  It  grasps  the  object, 
sinks  in  its  fangs,  and  then  advances  its  fangs  by  chewing,  thus  inflicting  several 
wounds.  In  viperine  snakes  the  teeth  lie  along  the  back  of  the  mouth  and  are 
only  erected  when  the  reptile  strikes.  The  maxillary  bones  of  the  rattlesnake  are 
very  short  and  move  with  great  freedom  at  the  prefrontal  articulation.  The 
fangs  are  canahculated,  are  attached  to  the  maxillary  bones,  and  move  with  the 
bones.  Some  mildly  poisonous  snakes  have  grooved  fangs.  The  poison  gland 
drives  the  poison  into  the  canals  of  the  fangs.  The  canal  emerges  from  the 
front  of  each  fang  near  the  tip.  The  fangs,  when  depressed,  are  carried  in  a  fold 
of  mucous  membrane.  When  the  animal  is  ready  to  strike  the  fangs  are  erected 
into  a  vertical  position  and  carried  to  the  front  of  the  mouth.  S.  Weir  Mitchell 
showed  that  the  poison  gland  is  really  the  parotid  gland.  In  amphibia  and  some 
reptiles  the  parotid  is  a  mucous  gland.  In  higher  mammals  it  is  a  serous  gland. 
In  poisonous  snakes  the  gland  partakes  of  the  nature  of  both  varieties  (Noguchi 
in  Carnegie  Inst.  Pub.,  iii).  Cope  describes  the  movement  used  by  the  rattle- 
snake in  biting.  The  body  springs  forward,  but  never  more  than  two-thirds 
of  the  reptile's  length,  the  jaws  seize  the  tissues  and  then  the  fangs  penetrate 
and  move  to  and  fro  as  the  poison  emerges  from  them.  Snake-poison  is  a  thin, 
greenish-yellow,  turbid,  sterile  fluid,  of  acid  reaction  and  of  a  distinctive  odor. 
The  two  chief  poisonous  principles  are  called  venom-peptone  and  venom- 
globulin  (Gustave  Langmann,  "Medical  Record,"  Sept.  15,  1900). 

Symptoms. — Rogers    ("Lancet,"   Feb.   6,    1904)   divides  poisonous  snakes 
into  two  classes:  the  colubrines  (of  which  the  cobra,  ash  and  coral  snake  are 


Treatment  of  Snake-bites  345 

examples)  and  the  viperines,  which  are  not  so  poisonous  (this  class  includes 
rattlesnakes  and  African  pufT  adders).  Moccasin  and  copperhead  venoms  re- 
semble rattlesnake  venom  but  contain  more  of  the  neurotoxic  elements.  Colu- 
brine  venom,  according  to  this  observer,  causes  paralysis  of  the  respiratory 
center  and  of  the  motor  end  organs  of  the  phrenic  nerves,  destruction  of 
red  blood-corpuscles,  lessened  coagulabiHty  of  blood,  and  death  by  respira- 
tory paralysis.  The  violent  and  rapid  action  is  upon  the  nervous  system. 
The  hemolytic  effect,  though  present  is  slower.  Viperine  venom  is  violently 
hemolytic  and  causes  paralysis  of  the  vasomotor  center  and  great  destruc- 
tion of  red  corpuscles.  In  laboratory  experiments  some  viperine  venoms  are 
found  to  cause  thrombosis  but  don't  do  so  in  man.  Death  from  any  one  of 
them  is  due  to  vasomotor  paralysis.  The  mortality  from  snake-bites  varies. 
The  mortality  in  India  from  cobra  bites  is  about  25  per  cent.  (Sir  Joseph 
Fayrer).  The  mortality  in  America  from  rattlesnake  bites  is  about  the  same. 
According  to  Willson  the  mortality  from  copperhead  bites  is  only  5  per  cent. 
("Jour.  Am.  Med.  Assoc,"  Aug  27,  1910).  The  local  symptoms  are:  pain,  soon 
becoming  intense;  mottled  swelling  of  the  bitten  part,  which  may  be  enormous, 
and  which  is  due  to  edema  and  extravasation  of  blood,  and  assumes  a  pur- 
puric discoloration.  The  bite  of  a  cobra  produces  inflammation  and  marked 
spreading  edema.  It  may  be  recovered  from  without  symptoms  or  with  trivial 
symptoms;  it  may  induce  profound  systemic  involvement.  The  general  symp- 
toms begin  in  a  comparatively  few  minutes.  The  coagulating  power  of  the 
blood  is  lost,  and  there  is  great  destruction  of  red  corpuscles.  The  patient 
is  terror-stricken  and  soon  becomes  unable  to  stand  because  of  weakness  of 
the  legs.  Glossopharyngeal  paralysis  arises,  and  talking  and  swallowing 
become  impossible.  There  is  a  profuse  flow  of  saliva,  perhaps  nausea  and 
vomiting.  The  patient  may  be  dull  mentally,  but  is  not  unconscious.  The 
paralysis  becomes  widespread,  and  finally  the  diaphragm  and  respiratory 
center  become  involved,  and  death  occurs  from  respiratory  paralysis.  Arti- 
ficial respiration  may  prolong  life  for  hours  (Sir  Joseph  Fayrer).  Bad  cases 
usually  die  in  three  or  four  hours,  but  life  may  last  for  many  hours.  A  rattle- 
snake bite  produces  severe  pain  and  mottled  swelling  from  blood  extravasation. 
In  some  cases  there  is  enormous  swelling  from  edema  and  blood;  the  discol- 
oration in  such  a  case  is  purpuric.  The  blood  of  the  victim  quickly  undergoes 
hemolysis  and  loses  the  power  of  coagulation.  It  was  previously  stated  that 
in  laboratory  experiments  it  has  been  shown  that  viperine  poison  may  produce 
thrombosis,  but  it  does  not  do  so  in  man,  as  it  contains  a  very  small  amount 
of  the  coagulating  element  (Rogers).  Extravasations  of  blood  occur  in  serous 
and  mucous  membranes  and  in  the  skin,  petechial  spots  frequently  arising 
upon  the  cutaneous  surface.  There  may  be  free  bleeding  from  mucous  sur- 
faces and  great  extravasation  beneath  the  conjunctivae.  These  blood  extrava- 
sations are  due,  according  to  Flexner,  to  destruction  of  vascular  endothelium. 
General  symptoms  begin  in  from  a  few  minutes  to  several  hours.  The  symp- 
toms are  those  of  profound  shock,  possibly  with  delirium,  the  vasomotor  center 
being  exhausted  and  finally  paralyzed.  There  are  usually  muscular  twitching 
and  convulsions,  and  finally  paralyses  are  noted  in  most  cases  (pharyngeal  palsy, 
paraplegia,  and  ascending  paralysis).  There  may  be  complete  consc  ousness, 
or  there  may  be  lethargy,  stupor,  or  coma.  Death  may  occur  in  about  five 
hours,  but,  as  a  rule,  it  is  postponed  for  a  number  of  hours.  If  death  is  deferred 
for  a  day  or  more,  profound  sepsis  comes  upon  the  scene,  with  glandular 
enlargement,  suppuration,  and  sometimes  gangrene. 

Treatment. — Cases  of  snake-bite  must,  as  a  rule,  be  treated  without  proper 
appliances.  The  elder  Gross  was  accustomed  to  relate  in  his  lectures  how 
he  had  seen  an  army  officer  blow  off  his  finger  by  a  pistol  the  moment  after 
it  was  bitten  by  a  rattlesnake,  and  thus  escape  poisoning.  If  the  bite  is 
upon  a  limb,  and  it  usually  is,  twist  several  fillets  at  different  levels  above  the 


346  Contusions  and  Wounds 

bite  to  prevent  the  dissemination  of  the  poison  from  the  Hmb  throughout  the 
body.  If  possible  the  fillets  should  be  elastic,  but  in  an  emergency  any  available 
material  must  be  used.  As  soon  as  fillets  have  been  applied  above  the  bitten  area 
make  crucial  incisions  to  the  depth  of  each  bite.  A  rattlesnake  bite,  a  copper- 
head bite,  and  a  water  moccasin  bite  show  but  two  punctures.  A  coral  snake  bite 
shows  several.  After  incising  suck  or  cup  it  if  possible,  and  cauterize  it  with  pure 
nitric  acid  or  by  a  cautery.  There  is  no  danger  in  sucking  the  wound,  provided 
there  are  no  abrasions  upon  the  lips,  cheeks,  or  tongue.  Before  sucking,  fill 
the  mouth  with  a  dilute  solution  of  permanganate  of  potash,  to  oxidize  and  thus 
destroy  the  poison.  An  expedient  among  hunters  is  to  cauterize  by  pouring 
a  very  little  gunpowder  on  the  excised  area  and  applying  a  spark,  or  by  laying  a 
hot  ember  on  the  wound.  Some  surgeons  inject  in  many  places  about  the 
wound  a  10  per  cent,  watery  solution  of  chlorid  of  calcium  to  neutralize  chemi- 
cally the  poison.  Some  advocate  injecting  the  area  about  the  bite  with  a  strong 
solution  of  chlorid  of  gold.  It  has  been  taught  that  if  a  man  is  bitten  by  a  large 
and  deadlv  snake,  the  surgeon,  if  one  is  at  hand,  should  at  once  amputate 
well  above  the  bite.^  Wynter  Blyth  pointed  out  that  permanganate  of  potas- 
sium mixed  with  an  equal  weight  of  cobra  venom  renders  the  venom  inert.  A 
number  of  surgeons  have  treated  snake-bites  by  injecting  in  and  about  the 
wound  a  i  per  cent,  solution  of  permanganate  of  potassium,  but  this  plan 
is  inefficient.  Rogers  ("Lancet,"  Feb.  6,  1904)  says  we  should  tie  fillets  around 
the  limb  above  the  bitten  part,  take  a  knife  and  enlarge  the  wounds,  and  rub  in 
crystals  of  permanganate.  The  fillets  are  not  to  be  removed  suddenly,  and  they 
had  best  be  kept  on  for  some  time.  Remove  the  highest  constricting  band  first; 
if  no  symptoms  come  on  after  a  time,  remove  the  next,  and  so  on;  if  symptoms 
appear,  reapply  the  fillets.  Permanganate  of  potash  is  not  a  successful  treat- 
ment for  cobra  bites.  In  cobra  poison  the  neurotoxic  element  predominates. 
It  would  seem  to  promise  more  against  rattlesnake  venom  in  which  the  hemolytic 
element  predominates.  Whatever  local  treatment  is  employed,  stimulants  are 
given.  Some  give  strychnin  hypodermatically;  others,  ether;  others,  digitalis. 
Halford,  of  Australia,  advocated  the  intravenous  injection  of  ammonia  (10  min. 
of  strong  ammonia  in  20  min.  of  water).  Adrenalin  as  given  in  shock  is  indi- 
cated if  there  is  a  marked  fall  in  blood-pressure,  and  autotransfusion  and  external 
heat  are  also  indicated.  If  the  respiration  is  failing,  artificial  respiration  and 
oxygen  inhalation  are  required.  Few  beliefs  are  held  more  tenaciously  than  that 
large  amounts  of  whisky  or  brandy  should  be  given  to  the  victim  of  snake 
venom.  And  yet  this  belief  is  false.  In  a  person  badly  poisoned  by  snake 
venom  the  medullary  centers  are  depressed  and  threatened  with  paralysis. 
Large  doses  of  alcohol  increase  this  tendency  and  may  hasten  death.  It  is  well 
known  that  if  a  drunken  man  is  bitten  by  a  large  poisonous  snake  he  is  prac- 
tically certain  to  die,  because  the  depression  produced  by  alcohol  is  enormously 
accentuated  by  the  venom.  Moderate  doses  of  whisky  or  brandy  are  useful  (i 
to  13^-2  ounces  every  half-hour).  The  wounds  made  by  the  incisions  of  the  sur- 
geon are  kept  open  for  a  number  of  days  by  the  insertion  of  bits  of  rubber  tissue, 
and  warm  and  moist  antiseptic  dressings  are  used.  Attempts  are  being  made 
to  obtain  a  curative  serum.  Animals  can  be  rendered  immune  by  giving 
them  at  first  small  doses  of  the  poison  and  gradually  increasing  the  amount 
administered.  It  is  asserted  that  the  serum  of  immune  animals  will  cure  a 
person  bitten  by  a  venomous  snake.  Cures  have  been  reported  after  the  use 
of  Calmette's  antivenene  serum.  Antivenene  is  obtained  by  immunizing  a 
horse  by  injecting  attenuated  venom.  The  mixture  to  be  attenuated  consists 
of  80  parts  of  cobra  venom  and  20  parts  of  viperine  venom.  It  takes  a  number 
of  months  to  obtain  strong  antivenene.  The  dose  is  from  10  to  20  c.c.  hypo- 
dermatically, repeated  if  necessary  in  three  or  four  hours.  It  seems  certain, 
however,  that  no  single  serum  can  antidote  the  venom  of  all  varieties  of  serpents 
1  Charters  James  Symonds,  in  "Heath's  Dictionary  of  Practical  Surgery." 


Anthrax  347 

(A.  T.  F.  Macdonald,  of  Australia),  and  it  has  been  shown  that,  though  Calmette's 
antivenene  is  antagonistic  to  colubrine  venom,  it  is  inert  against  viperine  venom. 
Again,  as  Rogers  says,  it  deteriorates  quickly  in  a  hot  climate  and  is  seldom 
on  hand  when  wanted.  The  horse  can  be  immunized  against  rattlesnake  venom, 
and  antivenene  (anti-crotalus  serum)  obtained  from  the  horse  may  be  used 
against  rattlesnake  poison  but  very  large  doses  are  necessary.  Captains  Acton 
and  Knowles  (''Indian  Journal  of  Medical  Research,"  vol.  in.  No.  2)  treat  poison- 
ing from  a  cobra  bite  or  the  bite  of  Russel's  viper  as  follows:  Place  a  firm  fillet 
around  the  limb  and  above  the  wound.  Infiltrate  the  area  about  the  wound 
with  a  strong  solution  of  chlorid  of  gold.  Inject  subcutaneously  100-200  c.c. 
of  antivenene.  If  symptoms  of  venom  intoxication  arise  give  further  and  larger 
doses. 

The  poisonous  lizard  (Qila  monster),  of  the  southwestern  United  States, 
can  certainly  kill  small  animals,  but  it  is  doubted  by  many  that  its  bite  is  ever 
fatal  to  man.  When  we  recall,  however,  that  small  animals  which  die  of  the 
poison  present  symptoms  identical  with  those  produced  by  serpent  venom,  we 
should  regard  the  Gila  monster  with  careful  respect. 

The  lizard  bites  and  hangs  on.  Each  tooth  of  the  lower  jaw  has  a  conduct- 
ing channel  for  poison  and  there  is  a  poison  gland  for  each  tooth. 

The  treatment  of  a  bite  of  the  Gila  monster  is  practically  the  same  as  for 
a  snake-bite. 

Anthrax  (malignant  pustule,  charbon,  milzbrand,  wool=sorters' 
disease,  or  splenic  fever)  is  a  term  formerly  used  by  some  as  synonymous  with 
ordinary  carbuncle,  but  it  is  not  here  so  employed.  It  is  a  specific  contagious 
disease  resulting  from  infection  with  the  bacillus  of  anthrax.  Cattle  anthrax 
has  long  been  known.  Virgil  refers  to  it  (Ponder,  in  "Lancet,"  Nov.  4,  1911). 
PoUender  showed  more  than  fifty  years  ago  that  a  rod-shaped  organism  is 
present  in  the  blood  of  animals  dying  from  splenic  fever.  Duvaine  insisted 
that  the  organisms  caused  the  disease.  Koch  proved  it  in  1876.  The  spores 
of  this  bacillus  are  highly  resistant.  Animal  anthrax  is  particularly  common  in 
the  East  and  in  Russia,  and  is  frequently  met  with  in  Germany,  Italy,  and  South 
America.  In  Italy  anthrax  is  prevalent.  In  that  country  from  1890  to  1904 
there  were  36,426  cases  with  7308  deaths,  a  mortality  of  20.1  per  cent.  (Schwartz, 
in  "N.  Y.  Med.  Jour.,"  June  22, 19 18).  In  some  regions  so  many  cases  arise  year 
after  year  that  the  district  obtains  an  evil  notoriety.  It  is  stated  that  in  Nov- 
gorod, Russia,  in  four  years  "  56,000  horses,  cattle  and  sheep,  and  528  men  per- 
ished from  anthrax"  (Frank  S.  Billings,  in  "Twentieth  Century  Practice"). 
It  is  a  rare  disease  in  the  United  States,  but  since  the  start  of  the  war  it  has 
increased.  In  Philadelphia  cases  occasionally  occur  in  workers  in  the  woolen 
mills.  The  author  has  seen  7  cases  of  human  anthrax,  6  of  which  occurred  in 
Philadelphia  and  i  in  New  Jersey.  Herbivora  are  most  liable,  next  omnivora, 
but  carnivora  seldom  suffer.  Anthrax,  as  met  with  in  man,  is  a  disease  contracted 
in  some  manner  from  an  animal  with  splenic  fever.  It  may  be  contracted 
by  inoculation  while  working  around  diseased  animals,  while  handling  or  tan- 
ning their  hides,  or  sorting  their  hair  or  wool;  brush-makers,  spinners,  workers 
in  horn  and  combers,  rag  sorters,  verterinary  surgeons,  clippers,  stockmen, 
farmers,  and  butchers  may  become  inoculated.  Infection  may  take  place 
through  the  hair-follicles  of  unbroken  skin.  Menschig  reported  2  such  cases 
("N.  Y.  Med.  Jour.,"  Nov.  18,  1905).  Anthrax  may  be  conveyed  by  eating 
infected  meat  or  by  drinking  infected  milk.  Flies  may  carry  the  poison. 
Inhalation  of  poisoned  dust  may  infect  the  lungs.  Catgut  ligatures  may  be 
contaminated  and  carry  the  poison.  Blood-stained  wools  and  hides  are  a 
particular  peril.  It  is  stated  that  in  England  i  out  of  7000  leather  makers 
dies  of  anthrax  each  year  (Ponder,  in  "Lancet,"  Nov.  4,  191 1).  Ponder  points 
out  that  40  per  cent,  of  English  cases  (arising  among  those  working  in  the  hide, 
skin,  and  leather  industries)  are  due  to  Chinese  or  East  Indian  goods;  that  no 


348 


Contusions  and  Wounds 


anthrax  has  ever  been  traced  to  wet  salted  hides;  that  infection  may  rise  at 
wharf,  dockyard,  or  tannery;  that  the  pulmonary  form  occurs  particularly 
amoni^'  wool'workers;  that  among  those  who  work  with  hides,  skin,  and  leather 
cutaneous  anthrax  is  the  common  form,  and  intestinal  anthrax  is  extremely  rare. 
Brown  and  Simpson  ("Jour.  Am.  Med.  Assoc,"  Feb.  24, 1917)  report  an  outbreak 
of  anthrax  among  Massachusetts  tannery  works.  There  were  25  cases  in  the 
course  of  four  months.  For  a  full  discussion  cf  "Anthrax  as  an  Occupational 
Disease  "  see  John  B.  Andrews,  in  "Bulletin  of  the  U.  S.  Bureau  of  Labor 

Statistics,"  Jan.,  1917. 

In  all  probability  many  slight  cases  are  recovered  from  without  bemg  recog- 
nized. This  would  explain  the  fact  that  it  is  particularly  among  recent  em- 
ployees that  anthrax  seems  tooccur  (Mitchell,  "Brit.  Med.  Jour.,  "  April  4, 1911). 

Many  older  employees  may  be  immune 
because  they  have  had  the  disease. 
Many  attempts  have  been  made  to 
render  animals  immune  (Pasteur,  Wool- 
bridge,  Hankin).  Pasteur's  method  has 
been  used  in  France  with  decided  suc- 
cess, but  with  less  success  in  other 
countries.  Pasteur  devised  a  method 
for  vaccinating  animals  against  anthrax 
by  injecting  attenuated  cultures  be- 
neath the  skin.  First,  a  much-atten- 
uated culture  is  used  and  later  a 
stronger  one.  When  an  animal  has 
been  actively  immunized,  its  blood- 
serum  contains  protective  materials  of 
a  specific  nature  and  may  be  used 
therapeutically.  The  immunity  is  re- 
garded by  some  authorities  as  "a 
phagocytic  immunity"  (Jordan's 
"General  Bacteriology").  Certain  or- 
ganisms are  antagonistic  to  anthrax  (the 
streptococcus  of  erysipelas,  the  pneu- 
mococcus,  the  Micrococcus  prodigio- 
sus,  and  the  Bacillus  pyocyaneus). 

Forms  of  Anthrax. — There  are  two 
forms  of  the  disease — external  and 
internal.  Internal  anthrax  may  be 
intestinal  from  eating  diseased  meat,  laryngeal  or  pulmonary  froni  inhalation 
of  poisoned  dust.  Intestinal  anthrax  arises  only  when  the  bacilli  in  the  meat 
contain  spores.  Koch  and  others  have  pointed  out  that  the  non-sporulating 
bacteria  are  destroyed  by  the  gastric  juice.  Internal  anthrax  is  quick  in  prog- 
ress, and  death  sometimes  takes  place  within  twenty-four  hours  of  the  onset  of 
symptoms.  It  cannot  be  diagnosticated  with  certainty  unless  bacilli  are  found 
in  the  blood. 

External  anthrax  may  be  anthrax  carbuncle  or  anthrax  edema.  Anthrax  car- 
huncle  ox  malignant  pustule  appears  on  an  exposed  portion  of  thebody,  especially 
the  face,  neck,  hand,  or  finger,  in  90  per  cent,  of  cases  of  external  anthrax. 
In  one  of  my  cases  it  was  upon  the  temple  and  in  two  of  them  on  the  neck. 
It  appears  iii  from  twenty-four  hours  to  six  days  after  inoculation,  and  presents 
an  itching,  burning  papule  with  a  purple  center  and  a  red  base;  in  a  few  hours 
the  papule  becomes  a  vesicle  which  contains  bloody  serum,  and  the  tissues  about 
the  papule  become  swollen,  reddened,  and  indurated.  The  vesicular  condition 
does  not  become  pustular  because  the  anthrax  bacillus  is  not  pyogenic  (hence  the 
term  malignant  pustule  is  a  misnomer).     Pus  only  appears  when  sloughmg 


Fig.  159. — Anthrax.  Case  in  author's 
wards  in  Philadelphia  Hospital,  recovered. 
Treated  by  ipecac  both  externally  and 
internally. 


Diagnosis  of  Anthrax 


349 


begins  and  is  due  to  secondary  infection.  The  vesicle  bursts  and  dries,  the 
base  of  it  swells  and  enlarges,  other  vesicles  appear  in  circles  around  it, and 
there  is  developed  an  "anthrax  carbuncle,"  which  shows  a  black  or  purple 
elevation  with  a  central  depression  surrounded  by  one  or  more  rings  of  vesicles. 
The  surrounding  tissues  become  purple,  and  great  edema  may  spread  widely, 
the  vesicles  grow  very  large,  new  vesicles  form,  and  gangrene  may  occur. 
Pain  is  trivial  or  absent.  Lymphatic  enlargements  may  occur,  but  pus  does  not 
form  unless  sloughing  takes  place.  The  constitutional  symptoms  may  rapidly 
follow  the  local  lesion,  but  may  be  deferred  for  a  week  or  more.  The  patient 
feels  depressed,  has  obscure  aches  and  pains,  and  is  feverish,  but  usually  remains 
about  for  a  short  period.  In  some  cases  with  constitutional  symptoms  there  is 
no  elevated  temperature,  and  such  cases  are  frequently  fatal.  After  a  time 
most  patients  develop  rigors,  high 
irregular  fevers,  sweats,  acute  fugi- 
tive pains,  diarrhea,  delirium, 
typhoid  exhaustion,  dyspnea,  cough, 
and  cyanosis.  The  temperature  is 
frequently  markedly  subnormal  for 
some  little  time  before  death.  In 
cutaneous  cases  which  get  well  a 
line  of  demarcation  forms  about  the 
pustule  and  the  gangrenous  area  is 
rather  rapidly  cast  off,  a  granulating 
surface  remaining. 

Anthrax  Edema. — An  area  of 
edema  surrounds  a  malignant  pus- 
tule and  often  spreads  widely,  but 
in  cases  of  external  anthrax  without 
a  pustule  there  is  edema  alone. 
This  lesion  occurs  in  connective 
tissue,  especially  loose  tissue.  It 
is  a  spreading,  livid  edema,  with  an 
ill-defined  margin.  There  is  no 
pain  and  usually  no  vesication  and 
no  fever.  In  severe  cases,  however, 
there  is  fever,  vesicles  form,  and 
gangrene     may     arise.      Anthrax 

edema  differs  from  cellulitis  in  the  absence  of  pus  formation,  and  from  malig- 
nant edema  by  the  less  disposition  to  result  in  gangrene.  Two  of  the  cases 
I  have  seen  were  anthrax  edema.  In  Horwitz's  case  in  the  Philadelphia 
Hospital  the  forearm,  arm,  and  shoulder  were  enormously  edematous.  In 
Keen's  case  in  the  Jefferson  College  Hospital  the  forearm  and  arm  were 
edematous. 

Bacilli  in  the  Blood  in  All  Forms  of  Anthrax. — In  some  cases  they  are  found, 
in  others  they  are  not.  To  find  them  is  extremely  ominous,  as  most  cases  with 
bacilli-laden  blood  die.  Bacilli  are  seldom  found  until  thirty-six  hours  before 
death  (Mitchell,  in  "Brit.  Med.  Jour.,"  April  i,  1911).  In  fatal  cases  the  blood 
always  contains  bacilli. 

As  a  result  of  the  general  infection  the  spleen  usually  and  the  liver  sometimes 
enlarge.     Hemorrhages  occur  into  the  muscles  and  beneath  serous  m.embranes. 

Diagnosis. — The  occupation  of  the  patient  is  highly  significant.  The 
malignant  pustule  is  distinguished  from  an  ordinary  carbuncle  by  the  follow- 
ing points.  The  malignant  pustule  has  a  central  depression;  a  dark,  dry, 
adherent  eschar;  is  surrounded  by  vesicles;  is  painless;  free  from  suppuration 
and  without  tenderness.  In  an  ordinary  carbuncle  the  center  is  elevated; 
there  are  signs  of  inflammation;  multiple  foci  of  suppuration  soon   become 


Fig.  160. — Anthrax.     Fifth  day.     Junk  dealer. 


350  Contusions  and  Wounds 

visible;  sloughing  occurs  and  there  are  usually  severe  pain  and  tenderness. 
Anthrax  bacilli  are  found  in  the  fluid  of  the  pustules  and  if  the  case  progresses 
will  be  found  in  the  blood. 

Prognosis. — If  anthrax  has  a  visible  lesion  and  if  constitutional  symptoms 
are  absent  or  slight,  recovery  is  probable.  When  bacilli  are  found  in  the  blood 
the  prognosis  is  very  bad.  Becker  knows  only  of  3  such  cases  which  survived 
(''Miinchener  medicinische  Wochen.,"  Jan.  23,  1912).  Of  Becker's  44  cases 
which  had  no  bacilli  in  the  blood,  43  recovered.  There  were  11  with  bacilli 
in  the  blood  and  all  died.  A  case  which  is  to  be  fatal  always  shows  bacilli  in 
the  blood,  at  least  within  thirty-six  hours  of  death.  Even  a])parently  bad  cases 
with  negative  blood  findings  are  apt  to  recover  (Becker,  Ibid.).  During  six 
years  the  Board  of  the  Bradford  woolen  industry  reported  that  in  71  cases  of 
anthrax  24  died  (15  internal  and  9  external).  The  former  estimate  of  the  death- 
rate  from  external  anthrax  was  from  25  to  30  per  cent.  If  a  lesion  is  upon  the 
face  the  prognosis  is  much  worse  than  if  it  is  upon  an  extremity,  and  if  upon  the 
upper  extremity  it  is  worse  than  if  it  is  upon  the  lower.  It  is  claimed  that 
the  death-rate  has  been  notably  reduced  by  modern  treatment,  and  under  serum 
treatment  is  said  to  be  but  little  over  6  per  cent.  In  a  series  of  15  cases  of  ex- 
ternal anthrax  reported  by  Royer  and  Holmes  there  were  3  deaths  ("  Therapeutic 
Gazette,"  Jan.,  1908).  Eleven  of  these  cases  received  serum,  and  of  the  11, 
2  died. 

Pulmonary  anthrax  and  intestinal  anthrax  have  been  regarded  as  invariably 
fatal,  but  vastly  better  results  may  be  looked  for  hereafter  if  the  diagnosis  can 
be  made.  The  usually  estimated  mortality  for  pulmonary  anthrax  is  50  to  75  per 
cent.  (Ullman,in  "Surgery,  Gynecology  and  Obstetrics,"  April,  1916). 

Prevention  of  Human  Anthrax. — Spores  are  the  great  danger.  Unfortu- 
nately, there  is  no  known  disinfectant  for  wool  which  will  kill  spores  and  not 
injure  fabric  (London  letter  in  "Jour.  Am.  Med.  Assoc,"  Feb.  17,  191 2).  Blood- 
stained wools  are  the  great  peril.  The  blood  contains  the  spores  and  formalin 
will  not  penetrate  dried  blood.  Wet  salted  hides  are  entirely  safe,  and  govern- 
mental regulation  to  prevent  the  importation  of  any  other  kind  would  prevent 
anthrax  among  those  who  work  in  hide,  skin,  and  leather  industries  (Ponder,  in 
"Lancet,"  Nov.  4,  191 1).  When  a  surgeon  assumes  charge  of  a  case  of  anthrax 
he  must  take  means  to  safeguard  others.  Every  excretion  and  discharge 
from  the  patient  should  be  disinfected  and  incinerated.  Flies  and  other  in- 
sects should  be  kept  out  of  the  room  by  careful  screening.  If  death  occurs  the 
body  should  be  cremated  and  a  necropsy  is  not  admissible. 

Treatment  of  External  Anthrax. — If  a  person  is  wounded  by  an  object  sus- 
pected of  carrying  the  infection,  cauterize  the  wound  by  the  hot  iron  or  fum- 
ing nitric  acid.  A  sufferer  from  anthrax  must  be  isolated  in  a  well-ventilated 
room.  All  dressings  are  to  be  burned,  all  discharges  asepticized,  and  after 
the  removal  of  the  patient  the  bed-clothes  are  burned  and  the  room  disinfected. 
If  there  are  no  bacilli  in  the  blood  a  malignant  pustule  should  be  entirely  excised, 
and  the  wound  mopped  out  with  pure  carbolic  acid  or  burned  with  the  hot 
iron.  If  there  is  an  extensive  area  of  edema,  it  should  be  freely  incised  down 
to  the  deep  fascia  at  several  points.  The  area  about  an  anthrax  edema  or  an 
excised  pustule  should  be  injected  every  sixth  hour  with  a  5  per  cent,  solution 
of  carbolic  acid.  The  wound  and  the  edematous  area  should  be  dressed  with 
hot  antiseptic  fomentations,  and,  if  dealing  with  an  extremity,  a  splint  is  applied. 
Excision  should  be  practised  for  pustule  even  when  glands  are  enlarged.  When 
excision  cannot  be  performed  make  crucial  incisions  through  the  lesions,  mop 
the  wounds  with  pure  carbolic  acid,  and  inject  about  and  in  the  pustule  carbolic 
acid  (1:20)  every  six  hours  until  the  disease  abates  or  toxic  symptoms  appear. 
Dress  the  part  as  directed  above.  In  a  successful  case  the  adherent  eschar  is 
finally  separated  by  the  influence  of  the  fomentations.  Davaine  advised  the 
following  plan:  Inject  the  pustule  and  the  tissues  about  it  at  many  points  every 


Hydrophobia,  Rabies,  or  Lyssa  351 

eight  or  ten  hours  with  i  part  of  tincture  of  iodin  diluted  with  2  parts  of  water 
or  with  a  10  per  cent,  solution  of  carbolic  acid,  or  with  a  o.i  per  cent,  solution 
of  corrosive  sublimate;  dress  with  wet  antiseptic  gauze  and  apply  an  ice-bag. 
Personally  1  would  not  use  an  ice-bag  on  an  area  of  infection,  but  would  prefer 
heat.  In  Keen's  very  severe  case  of  anthrax  edema  multiple  incisions  were 
made,  carbolic  acid  was  injected  into  sound  tissues  above  the  edema,  and  the 
part  was  dressed  with  hot  antiseptic  fomentations.  Recovery  followed.  Con- 
stitutional treatment  in  anthrax  edema,  malignant  pustule,  or  internal  anthrax 
must  be  sustaining  and  stimulating.  Maffucci  gives  carbolic  acid  internally, 
and  also  uses  it  externally.  Davies-Colley  uses  ipecac  locally  and  gives  5  gr. 
by  the  mouth  every  four  hours.  Statistics  indicate  that  the  serum  treatment  is 
of  the  greatest  value.  The  material  is  known  as  Sclavo's  serum;  it  is  obtained 
from  the  immunized  ass,  and  it  was  introduced  into  practice  in  1897.  It  is 
perfectly  harmless  and  may  be  given  in  a  vein  or  subcutaneously.  Sclavo  in- 
jects 40  c.c.  in  different  regions  of  the  wall  of  the  abdomen.  Usually  the  tem- 
perature begins  to  fall  in  an  hour;  if  improvement  is  not  obvious  in  twenty-four 
hours,  the  dose  is  repeated.  Intravenous  injection  is  reserved  for  severe  cases, 
the  dose  being  10  c.c.  into  a  subcutaneous  vein  of  the  dorsal  surface  of  the  hand. 
The  serum  can  do  no  harm  and  should  always  be  given.  If  given  early,  all 
cases  but  very  severe  ones  will  recover  (Legge's  Milray  Lectures,  "Brit.  Med. 
Jour.,"  March  18,  1905).  In  1915  Adolph  Eichhorn  introduced  his  serum. 
He  gave  an  animal  a  serovaccination  by  the  Pasteur  method  and  then  inocu- 
lated it  at  intervals  with  virulent  cultures.  Fourteen  to  sixteen  days  later  he 
used  this  serum  to  treat  anthrax  in  man,  giving  an  intravenous  injection  of 
from  30-60  c.c.  every  sixth  to  tenth  hour  until  three  doses  were  taken  (Schwartz, 
Ibid.).  Becker  ("Miinch.  med.  Woch.,"  Jan.  23,  1912)  has  given  salvarsan, 
and  he  believes  it  saved  the  life  of  a  very  ill  man.  The  persistence  of  anthrax 
infection  in  a  room  was  well  shown  in  the  record  of  Keen's  case.  The  infection 
lingered  on  the  floor  of  the  room  in  which  the  patient  had  been  operated  upon 
for  a  long  time.  Three  disinfections  were  necessary  before  it  became  impossible 
to  obtain  anthrax  bacilli  from  the  contaminated  floor.  This  indicates  that  such 
a  case  should  be  operated  upon  in  a  room  not  regularly  used  for  operations. 
Hydrophobia,  Rabies,  or  Lyssa. — Hydrophobia  is  a  spasmodic  and 
paralytic  disease  due  to  inoculation  with  virus  from  a  rabid  animal.  Inocula- 
tion is  nearly  always  through  a  wound,  but  cases  have  occurred  after  the  licking 
of  the  hand  by  a  diseased  dog.  The  disease  does  not  appear  to  arise  except 
as  the  result  of  inoculation.  It  is  most  common  in  dogs  and  wolves,  but  it 
may  develop  in  cats,  horses,  goats,  foxes,  cattle,  sheep,  and  pigs.  Cats  are 
said  to  cause  6  per  cent,  of  the  cases  (Cumming,  in  "Jour.  Am.  Med.  Assoc," 
May  18,  1912).  Lack  of  water  is  never  a  cause.  It  is  far  more  common  in 
the  carnivora  than  the  herbivora.  In  Russia  wolves  are  responsible  for  many 
cases.  It  is  said  that  poultry  may  suffer  from  it.  Human  hydrophobia  in 
most  instances  follows  dog  bites.  Roux  estimates  that  about  14  per  cent,  of 
the  people  bitten  by  mad  animals  develop  the  disease.  If  the  bite  is  on  an 
exposed  part,  it  is  far  more  apt  to  cause  rabies  than  if  the  rabid  animal's  teeth 
passed  through  clothing.  The  saliva  is  the  usual  vehicle  of  contagion,  but  other 
fluids  and  tissues  contain  the  \drus,  especially  the  brain  and  cord.  The  blood 
and  urine  do  not  contain  it.  Hydrophobia  has  been  known  for  centuries.  It 
is  not  spoken  of  by  Hippocrates,  but  is  described  in  animals  by  Aristotle, 
Pliny,  and  Celsus,  and  is  alluded  to  by  Ovid,  Horace,  Virgil,  and  Plutarch. 
Celsus  first  described  the  disease  in  man  and  first  used  the  term  "hydrophobia." 
Aristotle  thought  that  men  were  not  liable  to  hydrophobia.  The  disease  has  al- 
ways excited  the  greatest  fear  and  horror.  Southey  tells  us  in  his  "  Common- 
place Book"  that  it  was  the  French  custom  to  bleed  to  death  or  to  smother 
dehberately  victims  of  hydrophobia.  Such  murders  were  regarded  as  justifiable 
and  a  man  who  killed  his  brother  pleaded  justification  on  the  ground  that  the 


352  Contusions  and  Wounds 

brother  was  hydrophobic.  At  the  present  day  some  ardent  antivivisectionists 
with  the  audacity  of  ignorance  and  the  acrimony  of  fanaticism  deny  the  existence 
of  the  disease  called  rabies.  The  fact  that  an  infant  bitten  by  a  rabid  animal 
may  develop  rabies  proves  that  the  disease  is  not  due  to  the  imagination.  Trans- 
fer of  the  disease  can  be  certainly  made  from  animal  to  animal,  as  Pasteur  proved. 
Hydrophobia  is  almost  invariably  fatal.  No  causative  micro-organism  has  been 
demonstrated.  One  must  exist,  but  it  probably  escapes  detection  because  of  its 
very  small  size.  ^  Negri  has  discovered  in  the  central  nervous  system  bodies  which 
are  probably  protozoa  and  are  perhaps  the  cause  of  the  disease.  They  are  called 
Negri  bodies.  The  poison  cannot  gain  entrance  through  sound  mucous  mem- 
brane. It  used  to  be  thought  that  the  disease  was  particularly  apt  to  arise 
in  hot  weather,  but  it  is  now  known  that  it  may  occur  any  time  of  the  year. 
There  was  a  veritable  epidemic  of  it  among  the  animals  in  Greenland  in  i860, 
and  at  that  time  the  temperature  averaged  25  degrees  below  zero  (F.  W.  Dudley, 
in  "Jour.  Am.  Med.  Assoc,"  Dec.  19,  1908).  It  is  common  in  Russia.  No 
portion  of  the  world  is  completely  exempt.  No  constant  postmortem  lesions 
have  been  certainly  demonstrated  in  those  dead  of  rabies.  Gowers  beheves 
that  in  the  spinal  cord  there  is  hyperemia,  but  no  infiltration  with  cells,  whereas 
in  the  medulla,  especially  about  the  respiratory  center,  there  are  hyperemia 
and  cellular  infiltration  of  the  perivascular  spaces;  but  such  perivascular 
infiltration  can  occur  in  some  other  acute  conditions  and  hence  is  not  charac- 
teristic. What  is  known  as  the  rabic  tubercle  is  found  in  the  medulla  and  about 
the  motor  cells  of  the  upper  part  of  the  spinal  cord.  Each  tubercle  consists 
of  an  aggregation  of  embryonal  cells,  which  destroy  and  finally  replace  the  nerve- 
cells  which  they  surround.  Babes  thinks  the  tubercle  characteristic.  In- 
filtration of  the  ganglia  with  epithelioid  cells  and  round  cells  has  been  held  by 
some  to  be  characteristic,  but  both  the  rabic  tubercle  and  ganglion  infiltration 
occur  in  other  conditions.  The  disease  is  extremely  rare  in  the  United  States 
and  the  author  has  not  seen  a  single  case. 

If  a  dog  is  poisoned  with  barium  carbonate  the  symptoms  are  similar  to 
those  of  rabies  ("Penna.  Health  Bulletin,"  Aug.,  1909). 

Symptoms. — The  period  of  incubation  of  human  hydrophobia  is  from  a  few 
weeks  to  several  months,  and  it  has  been  alleged  that  it  may  even  be  two 
years,  but  it  is  very  doubtful  if  there  is  ever  a  period  of  incubation  of  over 
six  or  seven  months.  The  average  incubation  period  in  man  is  forty  days 
(Ravenel).  The  initial  symptoms  are  mental  depression,  anxiety,  sleepless- 
ness, restlessness,  headache,  malaise,  and  often  pain  or  even  congestion  in  the 
cicatrix.  The  anxiety  which  is  usually  present  may  be  deepened  into  actual 
fear.  In  dogs  the  condition  of  fear  is  so  evident  that  Cslius  Aurelianus  centuries 
ago  called  the  disease  pantophobia  (fear  of  everything).  The  previously  men- 
tioned symptoms  are  quickly  followed  by  dysphagia.  It  is  not  only  water 
that  is  difficult  to  swallow,  but  everything  the  patient  tries  to  drink  or  eat. 
The  difficulty  in  swallowing  results  apparently  from  apnea  produced  instantly 
when  an  attempt  is  made  to  swallow.  Curtis  points  out  that  the  difficulty 
is  not  spasm  of  the  pharynx  and  larynx,  but  a  sense  of  immediate  suffocation 
due  to  reflex  stimulation  of  respiratory  inhibition.  If  spasms  occur — and  they 
may  occur — they  are  secondary  to  this  suffocative  state,  a  state  in  which  the 
action  of  the  diaphragm  ceases  for  a  time.  The  air-passages  become  congested 
and  the  sufferer  makes  frequent  and  painful  efforts  to  expel  thick  mucus,  and 
the  efforts  produce  paroxysms  of  suffocation.  Between  the  paroxysms  the 
patient  is  evidently  somewhat  breathless,  and  Warren  tells  us  that  his  speech 
is  not  unhke  that  "of  a  child  who  has  recently  been  crying  and  is  endeavoring 
to  control  itself"  ("  Surgical  Pathology  and  Therapeutics").  As  the  condition 
grows  worse,  suffocative  attacks,  which  were  at    first  induced  by  attempts  at 

1  Since  the  above  was  written  Noguchi  has  announced  the  discovery  of  what  he  believes 
to  be  the  causative  protozoon. 


Treatment  of  Hydrophobia  353 

swallowing,  are  caused  also  by  bright  lights,  sudden  or  loud  noises,  irrita- 
tions of  the  skin,  or  even  thinking  of  swallowing.  At  length  suffocative 
paroxysms  occur  spontaneously  and  the  patient  jumps,  or  hurls  himseh  about, 
or  the  muscles  of  the  entire  body  are  thrown  into  clonic  spasm.  Tonic  spasrti 
does  not  occur.  A  condition  of  general  hyperesthesia  exists.  The  mind  is  usu- 
ally clear,  although  during  the  periods  of  excitement  there  may  be  maniacal  furor 
with  hallucinations  which  pass  away  in  the  stage  of  relaxation.  The  tempera- 
ture is  moderately  elevated  (101°  to  103°  F.  or  higher).  The  spasmodic  stage 
lasts  from  one  to  three  days,  and  the  patient  may  die  during  this  stage  from 
exhaustion  or  from  asphyxia.  If  he  lives  through  this  period,  the  convulsions 
gradually  cease,  the  power  of  swallowing  returns,  and  the  patient  succumbs  to 
exhaustion  in  less  than  twenty-four  hours,  or  he  develops  ascending  paralysis 
which  soon  causes  cardiac  and  respiratory  failure.  In  what  is  knowm  as  para- 
lytic rabies,  a  very  rare  form  of  the  disease  in  human  beings,  the  attack  comes 
on  with  the  same  early  symptoms  met  with  in  the  commoner  form,  but  paralysis 
soon  begins  about  the  bitten  part  and  spreads  to  all  the  limbs  and  to  the  trunk. 

In  hydrophobia  death  is  almost  inevitable.  Practically  all  cases  in  which 
it  is  alleged  that  recovery  ensued  were  not  true  hydrophobia,  but  hysteria. 
An  exception  must  be  made  of  Murri's  case.  Wood  says  that  in  hysteria, 
especially  among  boys,  "beast-mimicry"  is  common,  the  sufferer  snarling  like 
a  dog;  and  in  the  form  known  as  ''spurious  hydro  phobia,''  in  which  there  may 
or  may  not  be  convulsions,  there  are  a  dread  of  water,  emotional  excitement, 
snarling,  and  attempts  to  bite  the  bystanders  (in  genuine  hydrophobia  no  at- 
tempts are  made  to  bite,  and  no  sounds  are  uttered  like  those  made  by  a  dog). 

Lyssa  is  separated  from  lockjaw  by  the  paroxysms  of  suffocation  and  the 
absence  of  tonic  spasms  in  the  former,  as  contrasted  with  the  fixation  of  the  jaws 
and  the  tonic  spasms  with  clonic  exacerbations  of  lockjaw. 

Wohl  beheves  that  the  principles  of  the  Abderhalden  reaction  may  be  apphed 
in  the  early  diagnosis  of  rabies.  If  cellular  metabohsm  is  brought  about  by 
the  virus  protective  ferments  should  be  formed.  Wohl  tests  for  the  protective 
ferments  and  in  rabbits  subjected  to  subdural  inoculation  with  rabic  virus, 
finds  them  the  third  day  ("Am.  Jour.  Med.  Sciences,"  1915,  cxlix). 

Treatment. — When  a  person  is  bitten  by  a  supposed  rabid  animal  and  is 
seen  soon  after  the  injury,  constriction  should  be  applied  if  possible  above  the 
wound,  the  wounded  area  should  be  incised,  allowed  to  bleed  freely,  and  should 
then  be  washed  with  a  5  per  cent,  solution  of  formaldehyd  and  dressed  for 
twelve  hours  with  a  hke  solution.  It  is  held  that  formaldehyd  is  a  specific 
disinfectant  of  the  virus  (Gumming,  in  "Jour.  Am.  Med.  Assoc,"  May  8, 1912). 
If  not  seen  for  a  day  or  two,  open  the  wound  and  scrub  with  a  5  per  cent,  so- 
lution of  formaldehyd.  Many  physicians  advocate  excising  the  wounded 
area  and  cauterizing  with  pure  nitric  acid,  a  hot  iron,  or  the  Paquelin  cau- 
tery. Fuming  nitric  acid  is  warmly  commended  by  Paul  Earth olow  and  others. 
Ravenel  believes  it  may  save  a  man  even  after  twenty-four  hours  have  elapsed 
since  the  bite.  After  the  wound  has  been  treated  with  formaldehyd  or  cauter- 
ized it  is  to  be  dressed  antiseptically.  If  the  patient  is  not  seen  for  a  day  or 
two  after  the  injury,  cauterization  is  useless;  it  is  not  only  useless,  but  it  may 
delude  the  patient  and  his  friends  into  a  feeling  of  security.  In  any  case,  early 
or  late,  send  the  patient  at  once  to  a  Pasteur  institute.  If  the  animal  which 
inflicted  the  injury  was  not  hydrophobic,  no  harm  will  result  from  inoculations; 
if  it  was  hydrophobic,  preventive  treatment  may  save  the  patient.  The  method 
known  as  the  preventive  treatment  was  devised  by  Pasteur,  who  discovered  the 
following  remarkable  facts:  If  the  virus  of  a  rabid  dog  (street  rabies)  be 
placed  beneath  the  dura  of  another  dog,  it  always  causes  hydrophobia  in  from 
sixteen  to  twenty  days,  and  invariably  causes  death.  If  the  virus  is  passed 
through  a  series  of  rabbits  it  gets  stronger  (laboratory  virus),  and  if  in- 
serted beneath  the  dura  of  a  dog  it  causes  the  disease  in  from  five  to  six  days, 
23 


354  Contusions  and  Wounds 

and  kills  in  four  or  five  days.  The  virus  can  be  attenuated  by  passing  it  through 
a  series  of  monkeys  or  by  keeping  it  for  a  definite  time.  To  obtain  attenu- 
ated preparations  in  a  convenient  form  Pasteur  made  emulsions  from  the 
spinal  cords  of  hydrophobic  rabbits,  the  animals  having  been  dead  two  or  three 
weeks.  He  found  that  the  emulsion  obtained  from  the  rabbit  longest  dead 
was  the  weakest.  He  injected  a  dog  with  emulsions  of  progressively  increas- 
ing strength  and  made  it  immune  to  hydrophobia.  The  patient  is  injected 
with  an  emulsion  made  from  the  dried  spinal  cords  of  hydrophobic  rabbits.  In 
this  emulsion  the  virus  is  attenuated,  and  day  by  day  the  strength  of  the 
virus  injected  is  increased.  These  emulsions  cause  the  body-cells  to  form  anti- 
toxin, and  either  the  virus  of  street  rabies  does  not  develop  at  all  or  by  the  time 
it  begins  to  develop  a  quantity  of  antitoxin  is  present  to  antagonize  it.  In  the 
New  York  Pasteur  Institute  patients  remain  under  treatment  for  fifteen  days, 
two  inoculations  being  given  daily.  In  cases  in  which  treatment  is  begun  late, 
or  in  which  the  head  or  face  has  been  bitten,  from  four  to  six  inoculations  are 
given  each  day.  The  report  of  the  Parisian  Pasteur  Institute  shows  that  since 
its  foundation  there  has  been  a  mortality  of  0.5  per  cent.  The  lowest  estimated 
number  of  those  attacked  by  hydrophobia  before  this  method  was  used  was  5 
per  cent,  of  those  bitten,  and  all  attacked  died;  hence,  the  Pasteur  treatment  as 
applied  in  the  Parisian  Institute  shows  one-twenty-fifth  of  the  mortality  which 
attends  other  preventive  methods.  In  the  Paris  Pasteur  Institute  during  iqio 
401  patients  were  treated  without  a  death.  Ravenel,  in  1901,  estimated  that 
55,000  persons  have  been  treated  by  the  Pasteur  method  and  that  less  than  i 
per  cent,  have  died.  The  value  of  this  plan  seems  definitely  established.  The 
general  public  believes  that  the  dog  which  did  the  biting  should  be  killed.  The 
dog  should,  if  possible,  be  locked  up  and  watched  rather  than  killed.  It  may 
be  proved  in  this  way  that  it  did  not  have  hydrophobia.  If  it  were  necessary 
to  kill  the  dog,  or  if  the  dog  was  killed  at  once  or  soon  after  having  inflicted  the 
bite,  the  physicians  of  the  New  York  Pasteur  Institute  advise  that  the  dog's  head 
be  cut  from  the  body  with  an  aseptic  knife  and  a  piece  of  the  medulla  oblongata 
be  abstracted.  The  bit  of  medulla  should  be  placed  in  a  mixture  of  equal  parts 
of  glycerin  and  water  which  has  been  previously  sterilized  by  boiling.  The  bottle 
should  be  sealed  and  sent  to  the  institute,  in  order  that  inoculations  may  be  made 
upon  animals  to  prove  the  existence  or  absence  of  hydrophobia.  Babes  tubercles 
and  Negri's  bodies  are  at  once  sought  for  in  the  specimen,  and  if  they  are  found, 
treatment  should  be  started  at  once  upon  the  bitten  patient.  In  the  paroxysm 
of  hydrophobia  the  treatment  in  the  past  was  purely  palliative.  If  we  employ 
only  palliative  methods,  keep  the  patient  in  a  dark,  quiet  room,  relieve  thirst 
by  enemata,  saturate  him  with  morphin,  empty  the  bowels  by  enemata,  attend 
to  the  bladder  by  regular  catheterization,  and  during  the  paroxysms  anesthetize. 
Murri,  of  Bologna,  cured  a  case  of  hydrophobia  by  injecting  emulsions  of 
cords  of  rabbits  dead  six,  five,  four,  and  three  days  respectively.  It  would  be 
proper  to  try  this  remedy  should  hydrophobia  develop.  A  serum  has  been  pre- 
pared by  Tizzoni  and  Centani  which  they  claim  is  successful  in  treating  the 
disease  as  experimentally  induced  in  the  laboratory.  The  remarkable  sug- 
gestion has  come  from  Tizzoni  that  rabies  be  treated  with  rays  of  radium,  it 
having  been  shown  that  rabic  virus  can  be  destroyed  by  radium. 

Glanders,  Malleus,  Farcy,  or  Equinia. — Glanders  is  an  infectious 
eruptive  fever  occurring  in  horses,  mules,  and  asses,  sometimes  noted  in  goats, 
hogs,  dogs,  cats,  and  some  other  animals,  and  communicable  to  man.  Cattle, 
house  mice,  house  rats,  white  mice,  and  white  rats  are  immune.  The  disease 
is  most  common  in  the  horse  and  is  due  to  the  Bacillus  mallei  (see  page  60). 
These  bacilH  are  found  chiefly  in  the  nasal  discharge  and  the  recent  nodules. 
There  are  few  in  older  ulcerations.  They  are  not  found  in  the  blood.  Human 
glanders  is  by  no  means  as  uncommon  as  was  once  thought.  Not  a  few  cases 
die    undiagnosticated.     In    a    recent    study    156    cases    of   chronic    glanders 


Glanders,  Malleus,  Farcy,  or  Equinia  355 

were  discussed  (Robin,  "  Studies  from  the  Royal  Victoria  Hospital  of  Montreal," 
1906).  If  the  nodules  occur  in  the  nares,  the  disease  is  called  "glanders;"  if 
beneath  the  skin,  it  is  termed  "farcy."  The  Bacillus  mallei  is  communicated 
to  man  through  an  abraded  surface  or  a  mucous  membrane.  Bernstein  and 
Carling  reported  6  cases  of  human  glanders.  They  say:  "In  none  of  our  cases 
was  there  definite  evidence  of  the  point  of  inoculation  or  path  of  infection,  and 
the  general  evidence,  clinical  and  experimental,  on  both  of  these  questions  is  so 
conflicting  that  the  time  is  hardly  ripe  for  the  expression  of  decided  opinions. 
The  hvpothetic  paths  are  by  direct  inoculation  through  a  wound  or  by  the 
hair-follicles,  by  inhalation  or  by  ingestion  ("Brit.  Med.  Jour.,"  Feb.  6,  1909). 
The  characteristic  lesions  are  infective  granulomata  in  the  nares,  skin,  lungs, 
and  subcutaneous  tissue.  In  the  nares  granulomata  result  in  ulcers  and  under 
the  skin  break  down  into  abscesses.  In  some  cases  there  is  no  nasal  discharge. 
Multiple  abscesses  anywhere  should  excite  suspicion  of  the  existence  of  glan- 
ders. From  the  site  of  inoculation  the  bacilli  are  disseminated  and  the  cu- 
taneous and  muscular  structures  and  lungs  become  involved.  There  is  usually  a 
remittent  fever.  There  is  no  known  method  of  immunizing  animals  and  mallein 
has  no  immunizing  power.  One  attack  does  not  prevent  another.  Man  may 
be  infected  from  a  diseased  animal,  and  as  the  common  source  of  infection  is 
the  horse,  the  usual  victims  are  those  who  use  or  work  about  horses,  and  yet 
people  who  have  never  been  about  horses  may  develop  the  disease.  The  period 
of  incubation  after  infection  is  four  or  five  days. 

Acute  and  Chronic  Glanders. — In  acute  glanders  there  is  septic  inflam- 
mation at  the  point  of  inoculation;  nodules  may  form  in  the  nose  and  ulcerate; 
there  is  profuse  nasal  discharge;  the  glands  of  the  neck  enlarge;  there  is 
weakness,  frontal  headache,  chilliness,  pain  in  the  back  and  limbs;  often  diar- 
rhea; after  a  time  the  muscles  become  painful;  there  is  fever,  the  evening  tem- 
perature being  100°  F.  or  higher  and  the  morning  temperature  being  lower. 
Chills  may  occur.  There  may  be  chest  pains,  severe  muscular  pain,  bron- 
chitis, and  signs  of  pulmonary  congestion.  The  lungs  may  be  infected  by 
inspiration  of  the  bacilli  in  the  discharge  of  the  ulcers.  It  may  not  be  sus- 
pected that  the  patient  has  glanders  and  the  diagnosis  of  typhoid  may  perhaps 
be  made.  Twelve  to  fourteen  days  after  the  beginning  of  the  trouble  little 
hard  lumps  arise  in  the  muscles  and  just  beneath  the  skin.  In  a  few  days 
the  lumps  soften,  break  down,  and  discharge  a  bloody  fluid  which  contains 
the  bacilli  of  glanders.  In  a  number  of  cases  an  eruption  resembling  small- 
pox appears  on  the  face  and  about  the  joints,  and  this  exanthem  is  usually 
prophetic  of  approaching  death.  It  differs  from  small-pox  in  not  being  um- 
bilicated.  Leukocytosis  may  or  may  not  exist.  In  chronic  glanders  there  are 
like  symptoms  which  last  six  weeks  or  more.  Acute  glanders  is  nearly  always 
fatal.  Chronic  glanders  lasts  for  weeks,  is  rarely  diagnosticated,  being  mis- 
taken for  catarrh,  may  be  recovered  from,  but  if  not  thoroughly  eradicated  will 
sooner  or  later  eventuate  in  a  fatal  acute  condition.  The  mortality  is  about 
90  per  cent. 

Acute  and  Chronic  Farcy. — Acute  farcy  arises  at  the  site  of  a  skin  inocu- 
lation; it  begins  as  an  intense  inflammation,  from  which  emerge  inflamed 
lymphatics  that  present  nodules  or  ''farcy-hnds."  Abscesses  form,  but  the  pus 
differs  in  appearance  from  ordinary  pus,  is  often  gelatinous,  and  may  be  red  in 
color.  There  are  joint-pains  and  the  constitutional  symptoms  of  sepsis,  but  no 
involvement  of  the  nares.  In  it  nodules  occur  upon  the  extremities,  these 
nodules  break  down  into  abscesses  and  eventuate  in  ulcers  resembling  those  of 
tuberculosis  or,  perhaps,  of  syphiHs.     The  ulcers  form  rapidly  and  often  heal. 

Diagnosis  of  Glanders  and  Farcy. — Mallein  is  a  concentration  of  the  glycerin 
broth  in  which  the  bacilli  of  glanders  have  been  grown.  Injection  of  mallein  into 
an  infected  animal  produces  a  significant  reaction  (fever,  malaise,  restlessness, 
perhaps  a  distinct  rigor,  sometimes  vomiting,  marked  swelling  at  the  point  of 


356  Contusions  and  Wounds 

inoculation).  The  dose  used  is  10  to  15  min.  (Bernstein  and  Carling,  in  "Brit. 
Med.  Jour.,"  Feb.  6,  1Q09). 

Mallein  has  proved  of  high  diagnostic  value  in  the  hands  of  veterinarians. 
The  reaction  when  it  is  injected  into  an  animal  with  glanders  is  like  the  re- 
action produced  by  tuberculin  on  a  tuberculous  animal. 

Animal  injection  is  very  valuable  in  diagnosis.  The  highly  susceptible 
guinea-pig  is  used  for  this  purpose.  The  doubtful  material  (nasal  mucus  or  pus 
or  a  tissue  fragment)  is  injected  into  the  peritoneal  sac  of  a  male  guinea-pig. 
Usually  in  three  or  four  days  the  testicles  enlarge  and  later  suppurate. 

The  pig  is  killed  and  the  pus  examined  for  the  bacillus  of  glanders.  Testicu- 
lar enlargement  does  not  always  occur  even  when  the  inoculated  material 
was  from  a  lesion  of  glanders.  In  some  cases  it  occurs  after  weeks.  As  a  rule, 
it  does  occur  in  a  few  days. 

In  the  lesions  of  glanders  the  bacilli  of  the  disease  are  few  in  number  and 
in  many  lesions  are  mingled  with  other  bacteria,  hence  the  bacteriologic  diagnosis 
is  always  difficult  and  is  often  impossible  without  animal  inoculation.  The 
value  of  an  agglutination  test  is  as  yet  undetermined,  but  it  is  regarded  with 
confidence  by  some. 

Treatment.— In  treating  this  disease  the  point  of  infection  should  be  at 
once  incised,  cauterized,  dusted  with  iodoform,  and  dressed  antiseptically. 
The  skin  over  enlarged  glands  and  swollen  lymphatics  is  to  be  painted  with 
iodin  and  smeared  with  ichthyol.  Bandages  are  applied  to  edematous  extremi- 
ties. Ulcers  are  curetted,  touched  with  pure  carbolic  acid,  dusted  with  iodo- 
form, and  dressed  antiseptically.  In  glanders  the  nostrils  should  be  sprayed  at 
frequent  intervals  with  peroxid  of  hydrogen  and  syringed  with  a  solution  of 
sulphurous  acid.  The  mouth  must  be  rinsed  repeatedly  with  solutions  of 
chlorate  of  potassium.  Abscesses  are  to  be  opened,  mopped  with  pure  car- 
bolic acid,  and  dressed  antiseptically.  Stimulants  and  nourishing  diet  are 
demanded  imperatively,  Morphin  is  necessary  for  the  muscular  pain,  restless- 
ness, and  insomnia.  Digitalis  is  given  to  stimulate  the  circulation  and  kid- 
ney secretion.  Sulphur  iodid  and  arsenite  of  strychnin  have  been  used. 
Diseased  horses  ought  at  once  to  be  killed  and  their  stalls  should  be  torn  to 
pieces,  purified,  and  entirely  rebuilt.  A  man  with  chronic  glanders  should 
be  removed  to  the  seaside.  The  nasal  passages  must  be  kept  clean  and  the 
ulcers  must  be  cauterized  and  dressed  with  iodoform  gauze.  Nutritious  foods, 
tonics,  and  stimulants  are  necessary. 

Treatment  of  recent  cases  by  frequent  small  doses  of  mallein  finds  advocates. 
It  has  been  suggested  that  injection  of  the  serum  of  the  blood  of  an  immune 
animal  (the  ox,  for  instance)  might  be  serviceable.  Most  observers  assert  that 
serum  of  naturally  immune  animals  and  the  serum  of  animals  which  have  been 
repeatedly  injected  with  mallein  are  equally  worthless. 

Actinomycosis  (streptotricliosis)  is  a  specific  infectious  disorder  character- 
ized by  chronic  infiltrating,  granulomatous  inflammation,  and  is  due  to  the 
presence  in  the  tissues  of  some  variety  of  streptothrix.  It  was  long  believed 
that  the  actinomyces  bovis  or  ray-fungus  was  the  only  cause  of  the  disease. 
We  now  believe  that  other  members  of  the  streptothrix  group  may  be  respon- 
sible. As  stated  on  page  20  the  streptothrices  are  usually  regarded  as  molds, 
but  they  possibly  constitute  a  transition  stage  between  filamentous  fungi  and 
bacteria.  At  present  many  pathologists  use  the  term  "actinomyces"  as  the 
generic  name  for  the  various  forms  of  these  parasites.  Other  pathologists 
designate  them  as  streptothrix  forms,  of  which  the  actinomyces  bovis  is  one. 
In  1877  Bollinger  recognized  and  described  these  parasites  as  causative  of  dis- 
ease in  cattle.  In  1878  Israel  described  human  actinomycosis.  Acland,  in  1884, 
reported  the  first  English  case  of  human  actinomycosis.  Some  of  the  varieties  of 
the  organism  are  pathogenic,  others  do  not  seem  to  be.  Some  forms  are  anae- 
robic, others  are  aerobic.     They  are  not  killed  at  once  by  drying,  but  months 


ACTINOiMYCOSIS. 


Plate  2. 


Author's  case  of  facial  actinomycosis. 


Actinomycosis  357 

after  may  develop  if  placed  under  favorable  conditions.  When  growing  in 
the  tissues  they  usually  form  numerous  distinct  yellow,  reddish,  black,  or  gray 
aggregations,  each  about  the  size  of  a  sand  grain,  and  called  from  their  color 
sulphur  grains  or  red  pepper  grains.  They  grow  from  mycelia.  Usually  the 
growths  lie  in  thick  and  sticky  purulent  matter.  If  purulent  matter  containing 
growths  is  rubbed  between  the  fingers,  it  will  give  a  gritty  sensation  Hke  sand 
if  the  growth  is  not  very  recent.  The  grit  is  due  to  lime-salts.  The  growth  of 
the  fungi  causes  the  formation  of  an  infective  granuloma,  and  great  masses 
of  granulation  tissues  may  form  with  collections  of  necrotic  or  purulent  matter 
here  and  there,  and  zones  of  fibrous  tissue.  The  fungi  are  easily  discovered 
in  the  sulphur  grains  by  the  microscope,  but  if  the  fungi  are  mycehal  and  are 
scattered  instead  of  being  gathered  into  granules  it  is  difficult  to  discover 
them.  This  disease  occurs  in  cattle  {lumpy  jaw)  and  in  pigs,  and  can  be  trans- 
mitted to  man.  It  is  believed  by  many  that  the  fungi  exist  normally  inside 
the  husks  of  barley  and  other  grasses  and  that  animals  are  inoculated  by  eating 
the  contaminated  grasses,  scratches  on  the  mucous  membrane  of  the  tongue, 
mouth,  or  pharynx  being  inoculated.  In  man  the  fungus  may  be  taken  in  with 
food,  by  chewing  the  mold-bearing  grass  or  straw,  or  by  inhalation  of  contami- 
nated dust.  Its  development  seems  dependent  upon  processes  of  decay.  It 
may  lodge  and  develop  in  a  breach  of  mucous  continuity,  a  crypt  of  the  tonsil, 
or  a  hollow  tooth. 

Lord,  of  Boston,  has  found  the  parasite  in  carious  teeth  of  those  free  from 
actinomycosis,  and  has  produced  actinomycosis  in  guinea-pigs  by  inoculating 
them  with  the  contents  of  carious  teeth  ("  PubHcations  of  the  Massachusetts 
General  Hospital,"  Oct.,  1911).  Lord  reaches  the  conclusion  that  true  actino- 
mycosis (the  disease  due  to  ray-fungi)  arises  from  within  the  individual,  carious 
teeth  being  the  cause. 

The  disease  is  at  first  local;  later  there  may  be  general  blood  infection 
and  abscesses  may  form  in  the  lung,  liver,  kidney,  etc. 

The  fungi  may  pass  into  the  lungs,  causing  pulmonary  actinomycosis;  into 
the  intestines,  causing  intestinal  actinomycosis;  into  the  skin,  the  bones,  the 
subcutaneous  tissues,  the  heart,  the  brain,  the  liver,  the  urinary  organs,  etc. 
Abdominal  actinomycosis  is  the  commonest  form  and  comprises  nearly  50  per 
cent,  of  cases. 

Cutaneous  actinomycosis  may  be  secondary  to  visceral  infection  with  the 
disease,  may  be  a  purely  local  condition  due  to  inoculation  of  a  wound,  or  may 
be  associated  with  some  adjacent  area  of  bone  infection.  The  gummatous  form 
of  actinomycosis  resembles  a  gummatous  syphilitic  area,  and  in  it  many  small 
purulent  pockets  open  by  fistulse.  Cases  of  human  actinomycosis  until  recently 
were  looked  upon  as  sarcomata.  Many  sinuses  form,  ulcers  develop,  but  large 
abscesses  do  not  arise.    ■ 

In  actinomycosis  there  is  no  spread  by  lymphatics  until  very  late  in  the 
case.  In  fact,  the  adjacent  lymph-glands  are  very  seldom  involved  unless  there 
is  secondary  pyogenic  infection,  and  if  metastasis  occurs  it  takes  place  by  the 
veins.  The  condition  causes  but  slight  pain.  A  diagnosis  must  be  made  from 
syphilis,  sarcoma,  carcinoma,  and  tuberculosis.  The  formation  of  a  tumor, 
followed  by  sinuses  and  ulceration,  the  ulcer  having  thin,  non-indurated,  under- 
mined edges  and  edematous  granulations,  and  adjacent  pus  cavities  joining  by 
sinuses,  the  appearance  of  the  pus  and  the  microscopic  study  of  the  discharge 
are  significant.  An  actinomycotic  ulcer  may  partially  heal  here  and  there. 
It  has  been  stated  that  an  individual  with  actinomycosis  may  react  to  tuberculin 
like  a  person  with  tuberculosis  (see  page  252).  The  muscular  and  connective 
tissues  become  infiltrated  and  hard,  as  though  a  coagulating  material  had  been 
injected  into  them  (Poncet  and  Berard,  in  "Lyon  Medicale,"  March  27,  1904). 
Edema  and  induration  extend  wide  of  the  active  focus  of  disease  (Plate  2). 
Actinomycosis  may  last  for  years  or  it  may  prove  fatal. 


35^  Contusions  and  Wounds 

In  the  anthracoid  form  there  are  no  distinct  purulent  collections,  but  many 
fistulas  discharge  pus  at  various  points  (Monestie). 

An  area  of  cutaneous  actinomycosis  is  characterized  by  the  existence  of 
violet,  blue,  gray,  or  black  maculae,  varying  in  size  from  that  of  a  pin's  head 
to  that  of  a  bean,  the  center  of  each  macule  being  white  and  containing  a 
minute  quantity  of  pus  (Derville). 

In  actinomycosis  of  bone  the  bone  enlarges  and  becomes  painful,  the  parts 
adjacent  swell  from  infiltration  and  soften,  pus  forms  and  reaches  the  surface 
through  fistulae,  and  the  skin  becomes  involved  secondarily. 

Abdominal  actinomycosis  takes  origin  from  the  gastro-intestinal  tract, 
an  actinomycotic  nodule  of  the  intesine  having  ulcerated,  adhesions  having 
formed,  and  an  actinomycotic  abscess  having  arisen,  or  actinomycotic  disease 
of  the  intestine  having  spread.  In  over  50  per  cent,  of  cases  of  abdominal 
actinomycosis  the  cecum  is  the  part  attacked.  A  fecal  fistula  may  form  and 
the  liver  may  be  involved.  At  least  1 50  cases  of  actinomycosis  of  the  appendix 
have  been  reported.  A  mass  containing  putrid  pus  develops.  If  not  evacuated 
fistulae  form.  It  is  a  very  chronic  condition,  and  although  fistulae  may  heal, 
they  break  open  again  and  again  (Short,  in  "Lancet,"  Sept.  14,  1907).  The 
fungi  may  be  found  in  the  stools. 

The  mortality  of  actinomycosis  depends  upon  the  site  of  infection,  the 
question  of  secondary  infection,  and  the  plan  of  treatment.  If  pyogenic  in- 
fection occurs,  fatal  pyemia  may  arise.  The  prognosis  is  reasonably  good  in 
many  cases.  The  majority  of  cutaneous  cases  (nearly  90  per  cent.)  and  many 
osseous  cases  can  be  cured.  The  mortality  in  the  abdominal  cases  is  large. 
Grill  says  that  of  77  abdominal  cases  treated  surgically  45  died,  22  recovered, 
and  10  were  improved.  Frazier  ("Keen's  System  of  Surgery")  tells  us  that 
the  mortality  of  the  reported  cases  of  actinomycosis  in  the  United  States  was 
47  per  cent.,  and  quotes  Jiron  as  follows  regarding  the  mortality  of  the  various 
forms:  Face  and  neck,  11  per  cent.;  thorax,  83  per  cent.;  abdomen,  71  per 
cent.;  brain,  100  per  cent.  Actinomycosis  has  a  strong  tendency  to  redevelop 
even  after  apparently  thorough  excision.  A  case  of  cutaneous  actinomycosis 
of  the  arm,  seen  by  the  author,  was  operated  on  twent}-  times.  Ulceration 
took  place  into  the  axillary  artery  and  death  was  narrowly  averted.  Recovery 
finally  ensued.  I  have  seen  4  cases  of  human  actinomycosis:  one  was  the 
patient  just  referred  to;  another  was  a  mattress  stutter  (straw  being  used) 
with  lesions  upon  the  chest  and  jaw  and  recovering  after  operation;  the 
third  was  a  stable  hand,  who  died  from  lesions  of  the  face,  jaw,  and  neck;  the 
fourth  was  a  railroad  watchman  who  had  nothing  to  do  with  horses  (Plate  2). 

Treatment. — Free  excision  if  possible;  otherwise  incision,  scraping,  cau- 
terization with  pure  carbolic  acid  or  silver  nitrate,  and  packing  with  iodoform 
gauze.  If  possible,  remove  the  entire  area;  if  not  possible,  remove  all  that  can 
be  safely  taken  away.  Sinuses  must  be  widely  opened,  each  collection  of  pus 
must  be  drained,  and  granulation  tissue  if  not  extirpated  must  be  scraped 
away  with  a  sharp  spoon.  Give  internally  large  doses  of  iodid  of  potassium. 
This  drug  alone  has  cured  many  cases.  It  is  given  for  a  week  or  two  and  is 
then  discontinued  for  one  week.  The  x-ray  or  radium  may  be  used  in  associa- 
tion with  iodid  treatment.  It  is  curious  that  though  iodid  of  potash  seems 
to  influence  the  disease  favorably,  the  fungus  will  live  unharmed  in  a  2  per 
cent,  solution  of  that  drug  (Harbitz  and  Grandahl,  in  "Amer.  Jour.  Med. 
Sci.,"  Sept.,  191 1).  In  a  fistula  from  intestinal  or  appendical  actinomycosis 
give  potassium  iodid  and  sulphate  of  copper  (Bevan)  and  irrigate  the  sinuses 
with  diluted  tincture  of  iodin.  Cases  of  actinomycosis  should  be  placed  under 
the  best  hygienic  conditions,  should  live  as  much  as  possible  in  the  sunlight 
and  open  air,  and  should  be  given  nutritious  diet,  tonics,  and  often  stimulants. 

Madura  Foot  (Mycetoma). — This  disease,  which  attacks  particularly 
the  foot  and  ankle  and  occasionally  the  hands  and  other  parts  is  common  in 


Blastomycosis  359 

India  and  East  Africa  and  is  occasionally  met  with  in  the  West  Indies  and  some 
other  tropical  regions.  It  is  due  to  streptothrices,  the  filaments  of  which  re- 
semble but  are  not  identical  with  those  of  actinomyces  (streptothrix  madursej. 
Swellings  form,  soften,  and  rupture.  Sinuses  with  indurated  walls  result.  The 
sinuses  finally  reach  and  may  involve  the  bone.  The  disease  is  of  very  slow 
progress,  never  becomes  generalized  and  does  not  seem  to  cause  death  directly. 
Portions  of  streptothrices  can  often  be  discovered  in  the  fluid  from  the  sinuses, 
and  in  the  granules  found  in  this  fluid. 

Treatment. — lodid  of  potassium  is  valueless.  Incision  and  excision  are 
alike  useless.  The  best  plan  is  to  amputate  if  possible  (C.  W.  Daniels,  in 
"A  System  of  Surgery,"  edited  by  C.  C.  Choyce). 

Yaws  (Framboesia  Tropica). — This  disease  is  thought  by  some  to  be  due 
to  a  spirochsete  resembling  nearly  the  spirochsete  of  syphilis.  It  occurs  endemic- 
ally  in  certain  tropical  regions  (Africa,  India,  Islands  of  the  Southern  Seas, 
Ceylon,  Malacca  and  particularly  in  the  West  Indies).  Now  and  then  we 
see  a  case  in  Philadelphia  in  a  man  who  has  come  from  the  West  Indies. 

Caucasians  may  get  it  but  are  not  very  apt  to  if  they  retain  European  dress 
and  customs.  Native  children  are  particularly  liable.  The  disease  spreads 
by  the  discharges  from  a  victim.  In  some  cases  it  is  carried  by  insects.  The 
first  lesion  arises  where  there  is  a  breech  of  continuity  and  in  very  many  cases 
this  happens  to  be  about  the  mouth.  The  first  lesion  is  an  elevated  infective 
granuloma  of  the  subcutaneous  tissue  which  softens  and  forms  a  yeUowish 
crust.  Crops  of  granulomata  soon  form  especially  on  the  face,  neck  and  elbows. 
Finally  granulomata  cease  to  appear.  Any  granuloma  may  ulcerate  and  such 
an  ulceration  is  persistent. 

At  the  onset  of  the  eruption  there  may  be  fever  and  severe  backache,  hence 
the  condition  has  been  mistaken  for  small-pox.  Like  small-pox  it  protects 
from  another  attack.  It  has  been  mistaken  for  syphilis,  but  the  crust  does  not 
resemble  the  blackened  crust  of  rupia  and  when  it  is  pulled  off  it  does  not 
disclose  the  deep  rupial  ulcer,  but,  instead  humped-up  granulation  tissue. 
Again,  as  Daniels  points  out,  the  eruption  is  not  polymorphic  as  syphilitic  erup- 
tions characteristically  are.  The  disease  is  not  fatal  except  perhaps  to  young 
children. 

Treatment. — Isolate  the  patient.  Administer  salvarsan  and  subsequently 
mercury  and  iodid  of  potassium.  Cleanse  and  disinfect  ulcers  and  administer 
tonics  and  nourishing  food.  (See  C.  W.  Daniels,  in  "A  System  of  Surgery," 
edited  by  C.  C.  Choyce.) 

Blastomycosis. — May,  in  1894,  called  attention  to  the  disease.  In  1894 
Busse  described  a  fatal  infection  due  to  a  pathogenic  yeast.  The  very  exist- 
ence of  this  disease  has  been  denied,  but  numerous  cases  have  been  reported 
and  most  observers  regard  it  as  an  entity.  Many  cases  have  been  reported 
from  Chicago  and  its  neighborhood  by  Bevan,  Hektoen,  Hyde,  and  others.  It 
may  be  a  local  infection  (cutaneous  blastomycosis),  but  in  some  cases  the  dis- 
ease is  generalized  (systemic  blastomycosis).  The  disease  is  found  in  North 
America,  South  America,  Europe,  and  the  East.  The  organism  usually  enters 
through  the  skin  and  is  disseminated  by  the  lymph.  The  course  of  the  disease 
is  slow.  Multiple  abscesses  form  (subcutaneous  tissues,  lungs,  liver,  spleen, 
kidneys) .  Anemia  and  emaciation  develop  and  progress  and  the  urine  is  albu- 
minous. In  generalized  blastomycosis  the  lungs  are  usually  the  first  organs 
infected.  Generalized  blastomycosis  is  fatal  as  a  rule.  The  yeasts  when  found 
in  the  tissues  are  in  the  budding  stage  (Powers,  in  "Surgery,  Gynecology  and 
Obstetrics,"  1914,  Ix;  Stoddard  and  Cutler  on  Torula  Infection  in  "Mono- 
graphs of  Rockefeller  Institute  for  Med.  Research,"  Jan.  31,  1916.) 

Cutaneous  blastomycosis  (blastomycetic  dermatitis  or  oidiomycosis)  was 
first  described  by  Gilchrist  in  1894.  It  is  due  to  infection  with  a  variety  of  yeast 
fungus.     In  the  skin  it  begins  as  a  papule  or  an  indurated  pustule,    which 


360  Burns  and  Scalds;  Effects  of  Cold 

becomes  crusted  and  finally  warty,  enlarges  at  the  periphery,  and  becomes 
surrounded  by  more  recently  developed  lesions.  The  area  becomes  studded 
with  minute  abscesses,  crusted  foci,  and  areas  of  bleeding  granulations.  Here 
and  there  healing  may  occur. 

The  disease  may  arise  on  any  portion  of  the  body,  but  the  hands  and  face 
are  most  liable  to  it.  It  is  slow  in  progress  and  lasts  for  many  months.  If 
it  progresses,  it  will  finally  produce  systemic  blastomycosis  or  secondary 
infection  will  produce  fatal  septicemia.  Bevan  (Lexer's  "General  Surgery," 
edited  by  Arthur  Dean  Bevan)  says  the  evidences  of  general  infection  are: 
"irregular  temperature,  loss  of  appetite,  general  weakness,  emaciation,  cough, 
rapid,  feeble  pulse,  acceleration  of  the  respiration,  at  times  albumin  in  the 
urine,  multiple  subcutaneous  nodules  and  abscesses  resulting  in  superficial,  ir- 
regular ulcers,  abnormal  physical  findings  in  the  lungs,  edema  of  the  extremi- 
ties, and  various  grades  of  anemia."  Coccidial  disease  is  caused  by  an  organism 
strongly  resembling  the  yeast  of  blastomycosis.  Bevan  places  the  two  diseases 
in  the  same  group.  Some  observers  regard  them  as  identical.  The  symptoms 
are  indistinguishable.  Montgomery  regards  iodid  of  potassium  as  a  test 
agent — it  is  without  effect  on  coccidial  disease,  but  acts  strongly  and  favorably 
upon  blastomycosis. 

Treatment. — In  some  cases  excision,  in  others  the  x-rays.  Potassium 
iodid  in  very  large  doses  is  given.  It  greatly  benefits  most  cases  and  cures 
many.  Its  employment  in  this  disease  is  due  to  Bevan.  He  also  gives  copper 
sulphate  internally  (}i  gr.  three  times  a  day),  and  applies  a  i  per  cent.  solutiorL 
of  that  chemical  to  local  lesions. 

XVI.  BURNS  AND  SCALDS;  EFFECTS  OF  COLD 

Burns  and  scalds  are  injuries  due  to  the  action  of  caloric.  Scalds  are 
due  to  heated  fluids  or  vapors.  There  is  no  true  pathological  difference  between^ 
burns  and  scalds.  Dupuytren  classified  burns  into  six  degrees,  as  follows: 
(i)  Characterized  by  erythema;  (2)  characterized  by  dermatitis  with  the 
formation  of  vesicles;  (3)  characterized  by  partial  destruction  of  the  skin,, 
which  structure  is  not,  however,  entirely  burned  through;  (4)  characterized 
by  destruction  of  the  skin  to  the  subcutaneous  tissue;  (5)  characterized 
by  destruction  of  all  superficial  structures  and  of  part  of  the  muscular 
layer;  (6)  characterized  by  "carbonization"  of  the  whole  thickness  of  the 
muscles. 

The  symptoms  of  a  severe  burn  are  local  and  constitutional.  Local  symp- 
toms are  pain  and  inflammation,  which  vary  in  nature,  in  intensity,  or  in  degree 
according  to  the  extent  of  tissue  damage.  Constitutional  symptoms  are  very 
weak  pulse,  shallow  respiration,  and  subnormal  temperature — in  other  words, 
the  condition  of  shock  exists.  The  patient  may  die  without  reacting  from 
shock,  but  in  most  cases  there  is  reaction,  foUowed  by  a  severe  reactionary 
fever,  with  a  strong  tendency  to  congestion  of  internal  parts.  _  During  the 
existence  of  fever  there  may  be  vomiting,  diarrhea,  hemoglobinuria,  albuminu- 
ria and  enlargement  of  the  liver,  spleen,  lymph-glands,  and  tonsils.  Marked 
blood  changes  follow  burns  (see  "  Clinical  Hematology,"  by  J.  C.  DaCosta,  Jr.). 
During  the  early  days  there  is  a  marked  and  rapid  increase  in  red  blood-cells 
(polycythemia).  This  is  due  in  part  to  venous  stasis  and  in  part  to  loss  of  blood- 
plasma.  Leukocytosis  is  rapid  and  pronounced  and  there  is  a  notable  increase 
in  blood-plaques. 

The  blood  has  a  marked  disposition  to  clot,  and  clots  may  damage  various 
structures  or  organs.  Further,  the  altered  blood  damages  the  organs  of  ex- 
cretion, and  the  liver  and  kidneys  may  cease  to  perform  their  functions  properly. 
After    a    severe    burn    there    are    imperfect    oxygenation    and    a  tendency 


Treatment  of  Burns  361 

to  universal  fatty  degeneration.  The  symptomatic  stages  are  often  desig- 
nated as  prostration,  reaction,  and  suppuration.  During  the  first  forty-eight 
hours  after  a  burn  there  are  congestion  in  and  about  the  burned  area, 
severe  pain,  and  possibly  internal  congestions.  There  may  be  shock  and 
possibly  toxic  delirium  or  convulsions.  From  the  end  of  the  second  to  the 
end  of  the  eighth  or  ninth  day  there  are  severe  inflammation  of  the  burned  area, 
formation  of  sloughs,  and  a  strong  tendency  to  inflammation  of  the  brain  in 
head  burns,  of  the  lungs  in  chest  burns,  of  the  abdominal  organs  in  abdominal 
burns.  Duodenal  inflammation  may  arise  after  any  burn.  Septic  emboli  in 
very  unusual  cases  cause  Curling's  ulcer  of  the  duodenum  (see  page  173).  Duo- 
denitis and  Curling's  ulcer  are  possibly  due,  as  Wm.  Hunter  suggested,  to  the 
bile  having  become  irritant  by  the  excretion  in  it  of  toxic  matter.  After  the 
eighth  or  ninth  day  the  sloughs  separate  from  the  burned  area  and  healing  be- 
gins. The  raw  surface  is  slow  to  heal,  hemorrhages  may  occur,  the  granulations 
are  apt  to  be  exuberant  and  edematous,  and  the  scars  are  very  contractile  and 
often  produce  hideous  or  disabling  deformity.  If  over  one-half  of  the  body 
surface  is  badly  burned,  death  will  almost  certainly  occur,  and  probably  within 
two  days.  The  danger  of  a  burn  depends  upon  its  extent,  its  depth,  and  its 
situation.  Burning  of  a  large  area  superficially  is  much  more  dangerous 
than  burning  a  small  area  deeply.  Burns  of  the  extremities  are  not  so  danger- 
ous as  are  burns  of  the  head,  chest,  or  abdomen.  Death  after  severe  burns  is 
positively  not  due  to  loss  of  body-heat  in  the  burned  area.  Some  think  it  is 
produced  by  auto-intoxication  with  retained  body  secretions.  High  tempera- 
ture produces  blood  changes — viz.,  disintegration  of  red  corpuscles.  Throm- 
bosis may  occur,  and  irritation  of  the  kidneys  and  other  organs  is  produced  by 
"products  of  corpuscular  degeneration."^ 

The  blood  of  burned  animals  contains  toxins  (Kijanitzen),  and  so  does 
the  urine  (Reis).  It  seems  probable  that  the  constitutional  symptoms  and 
death,  if  it  occurs,  are  due  partly  to  corpuscular  disorganization  and  partly 
to  the  absorption  of  toxic  matter  from  the  seat  of  injury,  this  matter  having 
been  formed  by  the  action  of  heat  on  the  body-cells  and  fluids.  Sepsis  is  not 
infrequent.  Death  may  be  directly  due  to  shock,  to  sepsis,  to  exhaustion,  to 
tetanus,  to  embolism  or  thrombosis,  to  congestion  of  the  brain,  lungs  or  kid- 
neys, or  to  Curling's  ulcer  of  the  duodenum. 

Treatment. — The  local  treatment  of  slight  superficial  burns  is  to  moisten  the 
parts  frequently  with  a  saturated  solution  of  bicarbonate  of  sodium  or  with  nor- 
mal salt  solution. 

If  a  large  surface  is  burned,  remove  the  clothing  with  great  care,  and  before 
applying  dressings  give  a  hypodermatic  injection  of  morphin,  administer  stimu- 
lants, and  if  the  patient  has  a  chill,  place  him  in  a  warm  bath.  Use  all  ordi- 
nary means  to  secure  reaction  from  shock.  Waterhouse  makes  a  recommen- 
dation which  I  have  frequently  used  with  advantage,  viz.,  dress  the  burn  with 
a  I  per  cent,  solution  of  acetate  of  aluminum,  wrap  the  patient  in  blankets, 
hold  up  the  other  bedclothes  with  a  cradle,  and  put  under  the  bedclothes  an 
electric  light  of  32  candlepower.  This  will  make  the  temperature  under  the 
clothes  from  100°  to  105°  F.  ("Brit.  Med.  Jour.,"  July  9,  1910).  The  custom 
in  the  Jefferson  Medical  College  Hospital  has  long  been  to  give  morphin  and 
stimulants,  to  cut  away  the  clothing,  to  wrap  the  unburned  parts  with  blankets, 
and  place  about  them  cans  or  bags  of  hot  water.  The  burned  region  is  sprayed 
with  boric  acid  solution,  and  is  irrigated  with  salt  solution.  Portions  of  epidermis 
which  remain  are  retained.  Any  blisters  are  opened  with  a  sterile  needle,  but  are 
not  cut  away,  and  the  part  is  dressed  with  several  layers  of  sterile  lint  or  tarlatan 
soaked  in  normal  salt  solution,  and  the  dressing  is  kept  moist.  During  the 
second  or  inflammatory  stage  apply  an  ointment  consisting  of  equal  parts  of  zinc 
oxid  and  cold  cream,  use  stimulants  and  concentrated  food,  allay  pain  by  opium 
1  Bardeen,  in  "Johns  Hopkins  Hospital  Bulletin,"  April,  1897. 


362 


Burns  and  Scalds;  Effects  of  Cold 


t.  - 


or  morphin,  favor  elimination  by  the  skin,  bowels  and  kidneys,  and  combat 
any  tendency  to  internal  congestion  or  inflammation.  In  very  extensive  burns 
complete  and  continuous  immersion  of  the  part  in  warm  salt  solution  is  an  ex- 
cellent treatment.  If  a  burn  becomes  septic  it  is  dressed  with  boric  acid  solution. 
If  dressings  stick  they  can  be  removed  easily  after  moistening  with  diluted 
peroxid  of  hydrogen. 

The  picric  acid  treatment,  first  suggested  by  Thiery,  has  many  advocates. 
It  greatly  mitigates  the  pain.  It  is  used  early  only  in  limited  burns  of  the 
first  and  second  degrees,  but  it  can  be  employed  in  late  stages  of  deep  burns 
to  stimulate  the  formation  of  epidermis.  If  used  early  in  a  large  or  a  deep 
burn,  it  may  poison  the  patient.  It  may  poison  a  child  when  used  upon  a 
burn  of  the  second  degree.  A  case  was  reported  by  Dr.  J.  Stuart  Rose  ("Scot- 
tish Med.  and  Surg.  Jour.,"  Dec,  1903),  occurring  in  a  boy  of  nine,  who 
was  treated  with  picric  acid  for  a  scald  of  the  first  degree,  there  being  only 

one  or  two  small  blisters  in  addition  to  the 
redness.  Ointment  of  picric  acid  was  used 
Q^'2  dr.  to  I  oz.  of  vaselin).  Symptoms  were 
noted  three  days  after  beginning  the  treat- 
ment. The  symptoms  of  poisoning  are  dark- 
colored  urine  (carboluria),  albuminuria, 
marked  yellowness  of  the  skin,  yellowness 
perhaps  of  hair  at  the  scalp  margins,  diarrhea, 
and  elevated  temperature.  Picric  acid  when 
absorbed  enters  the  blood  serum  and  cere- 
brospinal fluid.  It  colors  the  skin  yellow  and 
the  urine  pink.  If  much  is  absorbed  it  makes 
the  urine  dark.  It  damages  the  liver  cells 
and  may  cause  genuine  jaundice  the  dis- 
coloration of  which  is  then  added  to  the 
yellow  hue  caused  by  the  drug  ("Jour.  Am. 
Med.  Assoc,"  March  24,  1917).  Rose 
considers  a  i  per  cent,  solution  safe.  It  is 
applied  as  follows:  The  part  should  be 
cleansed,  gauze  saturated  with  a  i  per  cent, 
watery  solution  of  picric  acid  should  be  laid 
upon  the  burned  area,  and  be  covered  with 
absorbent  cotton  and  a  bandage.  If  there  is 
no  odor  picric  acid  dressings  are  not  changed 
for  3  to  5  days.  Odor  is  one  of  the  first  evident 
signs  of  infection  and  calls  for  change  of 
dressing.  Severe  pain  too  calls  for  change  of  dressing.  It  may  mean  blisters 
under  tension  and  if  they  exist  they  should  be  opened.  After  a  picric-acid  dress- 
ing has  been  removed  substitute  ointment.  It  wiU  be  found  more  comfortable. 
(Vaselin  alone  softens  too  much  at  body  temperature  and  boric-acid  ointment 
alone  forms  hardened  masses.  A  mixture  of  the  two  is  excellent.)  D'Arcy 
Power  has  carefully  studied  the  real  status  of  picric  acid  as  a  remedy  for  burns, 
and  some  of  his  conclusions  have  been  set  forth  above. 

Paraffin  Treatment  of  Burns. — In  this  war  paraflin  has  been  found  highly 
valuable  in  the  treatment  of  bur.ns.  Dr.  Barthe  de  Sandfort  of  the  St.  Nicholas 
Hospital,  Issy-les-Moulineaux  devised  a  combination  of  paraffin  and  5  per 
cent,  oil  of  amber  which  he  used  very  successfully  in  treating  burns,  especially 
tar  and  gas  bums.  The  trade  name  is  ambrine.  Unfortunately  the  formula 
is  held  by  a  commercial  company.  It  is  a  great  pity  it  was  not  given  to  his 
countrymen  and  to  the  world  in  accordance  with  the  principles  of  American 
medical  ethics.  Lt.-Col.  Hull  makes  a  paraffin  preparation  which  some  con- 
sider superior  to  ambrine.     It  is  as  follows: 


Fig.   161. — rL'icatri.x  ul  bum. 


Treatment  of  Burns  363 

„          .  Per  cent. 

Resorcin ^ 

Oil  of  eucalyptus    .    ! .    '    .  2 

Olive  oil [    '  e 

Soft   paraiBn 21; 

Hard  paraffin g- 

If  resorcin  is  unobtainable  substitute  0.25  percent,  of  betanaphthol  and  in- 
crease the  hard  paraffin  to  67.75  per  cent.  Melt  the  hard  paraffin,  add  the  soft 
paraffin  and  olive  oil,  dissolve  resorcin  in  absolute  alcohol  and  add,  oil  of  eucalyp- 
tus. The  burn  is  to  be  washed  with  sterile  water  and  dried  by  fanning.  BHsters 
are  not  opened.  The  mixture  is  to  be  heated  to  a  temperature  of  122°  F. 
(at  which  point  the  surface  wax  will  show  a  film  of  soHdification).  A  layer  of 
paraffin  is  applied  to  the  wound  as  a  spray  by  means  of  an  atomizer  or  is  painted 
on  by  a  camel's-hair  brush.  Over  this  is  placed  a  thin  layer  of  cotton  wool. 
Then  another  stratum  of  paraffin  is  appHed.  A  wool  bandage  completes  the 
dressing.'  Dress  the  burn  every  day,  and  later,  every  other  day.  At  the  second 
dressing  blisters  are  opened  and  dead  skin  is  cut  away. 

Sollmann  and  Beitler  (both  in  the  "Jour.  Am.  Med.  Assoc,"  June  i",  191 7) 
call  attention  to  the  severe  pain  caused  by  applying  paraffin  preparations  to 
recent  burns  and  advise  cleansing  the  burn  and  applying  as  a  first  dressing 
liquid  petrolatum.  It  is  sprayed  or  painted  upon  the  part,  the  cotton  wool 
layer  being  applied  and  then  the  paraffin. 

All  agree  that  burns  of  the  surface  heal  more  quickly  under  paraffin  treat- 
ment than  by  any  other  method.  As  to  results  in  deeper  burns  there  is  dis- 
agreement. Some  hold  that  the  scar  which  follows  healing  under  paraffin  is 
soft  and  little  Hable  to  cause  contractures.  Others  maintain  that  the  scar 
acts  like  the  scar  which  follows  healing  under  any  other  treatment. 

The  So-called  Antiseptic  Treatment  of  Burns. — This  treatment  was  found  to  be 
painful  and  highly  irritant.  As  De  Tarnowsky  says  ("Jour.  Cutan.  Dis.,"  1916, 
xxxiv)  the  treatment  of  burns  by  active  antiseptics  has  been  abandoned. 
The  surgeon  now  cleanses  the  surrounding  parts  and  washes  the  burn  with  some 
mild  fluid  (boracic  acid  solution  or  normal  salt  solution).  Only  gross  dirt  is 
removed  from  the  burn. 

Treatment  by  Horse  Serum. — (See  Edward  Percy  Robinson  in  "Annals  of  Sur- 
gery," March,  1917).  The  object  of  this  treatment  is  to  hasten  epidermization 
by  giving  nourishment  to  the  cells  at  the  wound  margins  and  so  to  stimulate  them 
to  proliferate.  The  treatment  is  begun  at  the  stage  of  a  burn  when  epidermi- 
zation should  begin. 

Normal  serum  containing  a  small  percentage  of  tricresol  is  sprayed  upon  the 
cells  at  the  margin,  several  times  a  day  for  ten  days.  After  spraying  the  parts 
are  covered  with  rubber  tissue. 

"Perier  dresses  a  burn  with  a  tarlatan  compress,  folded  six  times  and  soaked 
in  the  following  solution:  boric  acid,  2}^  dr.  antipyrin,  i}i  dr.;  sterile  water, 
-8  oz.  The  following  ointment  is  used  by  Reclus,  iodoform,  15  gr.;  antipyrin, 
75  gr.;  boric  acid,  75  gr.;  vaselin,  i}i  oz. 

Carron  oil  consists  of  equal  parts  of  Hnseed  oil  and  lime-water.  It  allays 
the  pain  of  a  burn,  but  it  is  a  filthy  preparation,  and  its  use  is  followed  by 
much  pus  formation.  It  is  named  from  the  Carron  Iron  works  near  Stirhng, 
Scotland,  where  the  mixture  was  devised.  Cosmolin  gives  comfort  as  a  dress- 
ing, but  should  not  be  used  on  the  face,  lest  it  cause  pigmentation.  If  used 
alone  it  becomes  too  liquid  at  the  body  temperature  and  should  be  mixed  with 
boric  acid  ointment  The  elder  Gross  used  lead  paint.  A  solution  of  nitrate 
of  potassium  allays  the  pain.  Bismuth  p^ste  is  a  satisfactory  dressing.  In 
a  burn  of  the  face  a  mask  is  applied  and  if  there  is  conjunctivitis  it  is  treated  by 
appropriate  methods.  In  every  burn  of  the  fingers  and  toes  keep  the  burnt  digits 
separated  by  gauze,  lint,  or  rubber  tissue  during  healing,  otherwise  adjacent 


364  Burns  dnd  Scalds;  Effects  of  Cold 

fingers  will  adhere  and  "webbing''  will  result.  When  extensive  destruction  of 
tissue  has  taken  place  and  healing  has  begun,  use  splints  and  extension  to  limit 
contractures,  and  skin-graft  as  soon  as  possible.  Amniotic  grafts  are  useful. 
If  granulation  is  slow,  stimulate  with  copper  sulphate  or  mild  silver  nitrate  solu- 
tions. Exuberant  granulations  require  burning  down.  Flabby  granulations 
require  pressure.  If  healing  is  slow,  or  if  the  burn  is  extensive,  skin-graft. 
Skin-grafting  should  be  done  early  in  an  extensive  burn.  If  performed  before 
much  cicatricial  tissue  has  formed,  the  graft  will  be  more  apt  to  adhere,  and  if 
the  graft  does  adhere,  further  formation  of  scar  tissue  will  be  greatly  limited. 
When  an  extremity  has  been  carbonized,  amputation  must  be  performed. 
The  constitut  onal  treatment  of  a  severe  burn  is  to  bring  about  reaction ;  combat 
pain  with  opium,  and  keep  the  bowels  and  kidneys  active.  If  suppuration 
occurs,  give  tonics,  stimulants,  and  concentrated  foods.  Complications  are 
treated  according  to  general  rules. 

Burns  and  Scalds  of  the  Tongue,  Pharynx,  Glottis,  and  Epiglottis. 
— A  child  or  lunatic  may  drink  boiling  fluid  or  inhale  steam  from  a  t-ea-kettle. 
Firemen  occasionally  suffer  from  scalds  of  the  tongue  and  pharynx  after  being 
suddenly  enveloped  in  a  cloud  of  hot  steam,  and  from  burns  by  the  inhalation 
of  hot  vapor  or  flame.  Caustic  may  be  taken  into  the  mouth  or  swallowed. 
The  tongue  and  pharyngeal  mucous  membrane  swell  greatly,  large  vesicles 
form,  there  are  shock,  severe  pain,  dysphagia,  and  dyspnea.  Edema  of  the 
glottis  may  arise. 

Treatment. — Combat  shock;  give  morphin  for  pain;  puncture  vesicles, 
and  have  the  patient  almost  constantly  suck  bits  of  ice.  If  great  swelling 
occurs,  make  multiple  longitudinal  incisions  through  the  mucous  membrane 
of  the  dorsum  of  the  tongue.  If  edema  of  the  glottis  begins,  scarify  it.  If 
this  fails,  perform  intubation  or  tracheotomy. 

Burns  of  the  Esophagus. — The  esophagus  is  seldom  scalded,  as  a  boiling 
fluid  rarely  gets  below  the  pharynx.  The  swallowing  of  an  acid  or  alkali 
produces  severe  burns  at  the  constricted  portions  of  the  gullet  (see  page  1062). 
Such  an  accident  produces  shock,  dyspnea,  violent  pain,  vomiting  of  blood,  and 
thirst.  Death  may  occur  from  shock  of  perforation  of  the  stomach.  In  many 
cases  severe  gastritis  follows  a  burn  of  the  esophagus.  As  the  acute  symptoms 
of  a  burn  of  the  gullet  gradually  abate,  sloughs  are  cast  off,  ulcers  form,  cicatri- 
zation begins,  and  the  signs  of  stricture  develop  (see  page  1062). 

Treatment. — Give  a  remedy  to  neutralize  the  caustic.  Administer  several 
large  drafts  of  water  and  wash  out  the  stomach.  Combat  shock  Give 
morphin  for  pain.  Feed  by  the  rectum  as  long  as  the  patient's  strength  does 
not  begin  to  fail.  On  beginning  mouth-feeding,  use  at  first  milk  and  later 
beef-juice,  jelly,  and  ice-cream.  In  from  two  to  four  weeks  after  the  infliction 
of  the  burn  begin  the  use  of  bougies  to  limit  contraction. 

Effects  of  Cold.  Local  Effects . — Cold  produces  numbness,  pricking, 
a  feeling  of  weight,  redness  of  the  surface  followed  by  stiffness,  local  insensi- 
bihty,  and  mottUng  or  pallor.  Sudden  intense  cold  causes  the  formation  of 
blebs,  the  coagulation  of  blood  in  the  superficial  veins,  and  violent  pain  in  the 
part.  Cold  locally  produces  frost-bite  (see  page  195).  Trench  foot  is  considered 
on  page  340. 

The  constitutional  efects  of  cold  are  at  first  stimulating,  then  depressing, 
and  are  exhibited  by  uneasiness,  pain,  and  an  intense  drowsiness  which,  if 
yielded  to,  is  the  road  to  death  by  way  of  internal  congestion.  Death  from 
prolonged  cold  resembles  in  appearance  death  from  apoplexy.  Death  from 
sudden  and  overwhelming  cold  is  caused  by  anemia  of  the  brain  from  weak 
circulation  and  capillary  embohsm.  To  bring  a  partly  frozen  person  into 
a  warm  room  may  cause  death  by  embolism. 

Treatment. — Frost-bite  is  treated  as  outlined  on  page  196.  When  a  person 
is  nearly  frozen  to  death  place  him  in  a  cool  room,  but  under  no  circumstance 


Definition  of  Syphilis  365 

in  a  cold  bath;  make  artificial  respiration,  rub  him  briskly  with  flannel  soaked 
in  alcohol  or  in  whisky,  and  follow  this  by  rubbing  by  dry  hands.  After  a  time 
wrap  the  patient  in  warm  blankets  and  give  an  enema  of  brandy.  Mustard- 
plasters  are  to  be  apphed  over  the  heart  and  spine.  As  soon  as  swallowing  is 
possible,  brandy  is  administered  by  the  mouth.  As  the  condition  improves 
gradually  raise  the  temperature  of  the  room  and  give  Jwt  drinks. 

Chilblain  or  p)ernio  is  a  secondary  effect  of  cold.  It  is  really  an  area 
of  local  asphyxia  (see  page  189).  It  usually  appears  as  a  local  congestion  upon 
the  toes,  the  ears,  the  fingers,  or  the  nose,  and  now  and  then  inflames  and  ulcer- 
ates. A  chilblain  is  apt  to  become  congested  on  the  victim  approaching  a  fire 
or  on  taking  exercise,  and  when  congested  it  itches,  tingles,  and  stings.  Fre- 
quent attacks  of  congestion  produce  crops  of  vesicles;  these  vesicles  rupture 
and  expose  ulcers,  which  in  rare  instances  slough. 

Treatment. — If  chilblain  affects  the  toes,  prevent  congestion  of  the  legs 
and  feet.  Order  large  shoes  and  woolen  stockings  and  forbid  tight  garters. 
The  patient  with  pernio  must  take  regular  outdoor  exercise  and  must  not 
loiter  around  a  hot  fire.  Every  morning  and  evening  he  should  take  a  gen- 
eral cold  sponge-bath,  foUowed  by  rubbing  wath  alcohol  and  friction  by  a 
coarse  towel,  and  in  winter  he  should  sleep  wearing  warm  stockings  or  with 
his  feet  upon  a  warm-water  bag.  When  a  chilblain  is  only  a  congested  spot, 
it  shovfld  be  washed  twice  a  day  in  cold  salt  water,  rubbed  dry  wdth  flannel, 
and  subjected  to  applications  of  tincture  of  iodin  and  soap  liniment  (i  :  2), 
tincture  of  cantharides  and  soap  liniment  (i  :  6),  or  equal  parts  of  turpentine 
and  olive  oil  (W.  H  A  Jacobson).  Jacobson  says  itching  is  relieved  by 
painting  belladonna  hniment  upon  the  part  and  allowing  it  to  dry.  Tincture 
of  iodin  may  relieve  it,  and  so  may  a  mustard  foot-bath.  A  valuable  prepara- 
tion for  itching  is  composed  of  i  dr.  of  powdered  camphor  and  4  oz.  of  cosmolin. 
A  little  of  this  ointment  is  rubbed  in  twice  a  day.  The  following  prescription, 
the  source  of  which  I  do  not  remember,  is  very  valuable  for  itching:  i  dr.  of 
powdered  camphor,  1^2  dr.  of  ichthyol,  3''2  dr.  of  lanolin,  and  4  oz.  of  cosmohn, 
rubbed  into  the  part  and  covered  with  cotton-wool.  If  vesicles  form,  paint 
with  contractile  collodion;  if  ulcers  form,  dress  antiseptically.  If  ulcers  are 
sluggish,  use  equal  parts  of  resin  cerate  and  spirits  of  turpentine.  A  good 
antiseptic  and  protective  is  the  following:  oxid  of  zinc,  6  gr. ;  chlorid  of  zinc, 
20  gr.;  gelatin,  2  oz.;  distilled  w^ater,  i  oz. 


XVII.  SYPHILIS,  OR  POX 

The  name  comes  from  the  title  of  a  poem  which  was  published  in  Venice 
in  1530,  ''S\'philis  sive  Morbus  Gallicus,"  by  Girolamo  Fracastoro.  For 
centuries  there  has  been  fierce  dispute  as  to  the  origin  of  s>'philis.  Many  assert 
that  Europe  was  free  of  it  until  the  discovery  of  America  and  that  the  sailors  of 
Columbus  brought  it  from  Hayti.  Others  claim  that  the  disease  has  always 
existed  in  Europe  and  the  East.  We  know  there  was  a  violent  outbreak  of  it  in 
1494  among  the  French  soldiers  besieging  Naples. 

Definition. — S>'philis  is  a  chronic  contagious,  and  sometimes  hereditary, 
constitutional  disease.  It  is  one  of  the  most  common  of  diseases  and  were 
facts  known  would  rank  high  as  a  cause  of  death.  Lesser  states  that  in  Ber- 
lin, of  men  over  twenty-five  years  of  age  who  come  to  autopsy,  9  per  cent,  are 
sj'philitic.  ''There  are  at  least  a  million  and  a  hah  syphilitics  in  the  United 
States"  (J.  Howard  Beard,  ''Pop.  Science  Monthy,"  Feb.,  1917).  In  the 
United  States  it  is  t\\'ice  as  frequent  among  negroes  as  compared  with  whites, 
although  in  the  black  race  the  disease  is  apt  to  be  more  curable  and  less  dis- 
astrous. It  was  long  beheved  that  only  members  of  the  human  family  could 
take  syphiHs,  but  JMetchnikoff  and  Roux  have  succeeded  in  inoculating  chim- 


366  Syphilis,  or  Pox  , 

panzees  ("Annals  of  Pasteur  Institute,"  Dec,  1903).  These  two  observers 
have  inoculated  many  animals  and  have  shown  that  the  nearer  the  animal  is  to 
man,  the  more  nearly  the  disease  resembles  human  syphilis.  Anthroj)oid  apes 
can  be  successfully  inoculated,  but  only  in  the  chimpanzee  are  human  symptoms 
accurately  produced.  At  first  the  causative  protozoons  are  localized.  Metch- 
nikoff  in  1906  inoculated  a  student  and  a  monkey  with  syphilitic  virus.  An 
hour  after  inoculating  the  man  the  seat  of  inoculation  was  rubbed  for  five  min- 
utes with  mercurial  ointment  and  the  man  escaped  syphihs.  The  ointment  was 
not  used  on  the  monkey  and  a  chancre  developed.  Its  first  lesion  is  an  infect- 
ing area  or  chancre,  which  is  followed  by  lymphatic  enlargements,  eruptions 
upon  the  skin  and  mucous  membranes,  affections  of  the  appendages  of  the  skin 
(hair  and  nails),  "chronic  inflammation  and  infiltration  of  the  cellulovascular 
tissue,  bones,  and  periosteum"  (WTiite),  and,  later,  often  by  gummata.  The 
disease  is  due  to  a  protozoon,  the  Spirocha^ta  pallida.  This  fact  was  demon- 
strated by  Schaudinn  in  1905  (see  page  64).  The  Spirochaeta  pallida  is  dem- 
onstrated in  recent  scrapings  from  specific  lesions.  The  more  contagious 
the  lesion,  the  more  of  the  organisms  are  found.  The  later  the  lesion,  the  fewer 
the  organisms  found.  Spirochetes  are  always  discoverable  in  the  chancre. 
They  can  usually  be  found  in  the  secondary  lesions  and  sometimes  in  the  blood 
during  the  secondary  stage.  Spirochetes  are  present  in  tertiary  lesions,  al- 
though in  less  number  than  in  secondary  lesions.  The  presence  of  a  great 
number  of  spirochetes  means  a  malignant  case.  They  tend  to  disappear  under 
mercurial  treatment  (see  pp.  386  and  390).  Syphilitic  fever  is  due  to  absorp- 
tion of  toxins.  Skin  eruptions  and  eruptions  on  the  mucous  membranes  in  the 
secondary  stage  arise  from  local  deposit  and  multiplication  of  the  spirochetes. 
The  spirochetes  continue  to  exist  in  the  body  after  the  cessation  of  second- 
ary symptoms,  and  may  die  out  or  may  awaken  into  activity,  producing 
reminders. 

Up  to  about  twelve  days  after  the  appearance  of  a  chancre  a  person  can  still 
be  infected  by  a  fresh  exposure  to  inoculation.  After  twelve  days  he  cannot  be 
unless  inoculated  with  a  very  large  amount  of  virus  (Pinard).  In  other  words, 
after  twelve  days  there  is  immunity  to  fresh  inoculation,  but  the  immunity  is 
not  powerful  enough  to  kill  the  spirochetes  already  in  the  body.  During  the  pri- 
mary stage,  from  the  twelfth  day  after  the  appearance  of  the  chancre,  and  during 
the  secondary  stage  fresh  poison  cannot  infect,  and  this  is  true  for  a  long  time 
after  the  disappearance  of  secondary  symptoms.  As  a  matter  of  fact,  the  im- 
munity generally  lasts  for  life  and  reinfection  is  one  of  the  rarest  of  occurrences. 
Most  supposed  cases  of  reinfection  were  really  instances  of  a  fresh  outbreak  of  an 
old  disease,  but  a  few  undoubted  cases  of  reinfection  have  been  reported. 
Immunity  in  the  primary  stage  is  due  to  products  absorbed  from  the  infected 
area.  CoUes's  immunity  is  that  acquired  by  mothers  who  have  borne  syphilitic 
children,  but  who  themselves  show  no  sign  of  the  disease.  Profeta's  immunity 
is  the  immunity  against  infection  possessed  by  children  born  of  syphilitic 
parents.  Some  of  these  children  have  never  shown  signs  of  disease,  but  never- 
theless they  are  immune.  It  is  claimed  that  a  person  long  free  from  active 
syphilis,  but  still  immune,  can'  transmit  immunity  to  his  children.  Tertiary 
syphilis  is  not  nearly  as  readily  transmissible  as  secondary  syphilis,  but  it 
secures  immunity. 

Transmission  of  Syphilis. — This  disease  can  be  transmitted:  (i)  by 
contact  with  the  virus — acquired  syphilis,  and  (2)  by  hereditary  transmis- 
sion— hereditary  syphihs.  The  poison  cannot  enter  through  an  intact  epi- 
dermis or  epithelial  layer,  and  abrasion  or  solution  of  continuity  is  requisite 
for  infection.  Syphilis  is  usually,  but  not  always,  a  venereal  disease.  It 
may  be  caught  by  infection  of  the  genitals  during  coition,  by  infection  of 
the  tongue  or  hps  in  kissing,  by  smoking  poisoned  pipes,  by  drinking  out 
of  infected  vessels,  or  by  beastly  practices.     Syphihs  not  due  to  sexual  rela- 


Syphilis  and  Tuberculosis  367 

tion  is  called  syphilis  of  the  iiiiwccnf  (syphilis  insonfium) .  The  barber  is  a 
danger,  and  cases  have  been  reported  as  following  razor  cuts  and  particularly 
the  application  of  the  alum  stick  to  arrest  bleeding.  This  stick  is  used  over 
and  over  again  and  dried  blood  is  often  to  be  found  upon  it.  I  was  consulted 
by  a  man  who  had  been  thus  infected.  I  have  treated  two  young  girls  infected 
by  dentists'  instruments,  a  policeman  infected  by  a  pipe,  a  glassblower  infected 
from  the  blowpipe,  a  street  car  driver  who  got  the  disease  from  a  borrowed 
whistle,  a  police  officer  who  got  it  striking  a  prisoner  on  the  mouth  and  cutting 
his  own  knuckle  on  the  teeth,  a  hospital  orderly  who  infected  his  nose  pick- 
ing it  by  a  contaminated  finger,  and  three  physicians  who  caught  it  from 
patients.  Schamberg  makes  a  valuable  contribution  to  the  accumulation  of 
facts  which  demonstrates  the  danger  of  promiscuous  osculations  (''Jour.  Am. 
Med.  Assoc,"  Sept.  2,  191 1).  A  party  of  young  men  and  women  indulged  in 
a  kissing  game.  One  of  the  young  men  had  a  sore  lip.  As  a  result  of  the  party 
I  man  and  6  women  developed  labial  chancres.  A  girl  kissed  at  another 
party  by  the  contaminator  of  the  first  party  got  a  chancre.  The  solitary 
male  victim  of  the  first  party  evidently  got  the  disease  by  kissing  a  girl 
recently  kissed  by  the  syphilitic  man.  Bulkley  (Ibid.,  March  4,  1905)  col- 
lected 1863  cases  following  vaccination;  179  following  circumcision;  82  follow- 
ing tattooing,  and  745  following  cupping  or  venesection.  The  initial  lesion  of 
s\'philis  may  be  found  on  the  finger,  penis,  eyelid,  lip,  tongue,  cheek,  palate, 
tonsil,  labium,  vagina,  anus,  nipple,  etc.  A  person  may  be  a  host  for  syphilis, 
carry  it,  give  it  to  another,  and  yet  escape  it  himself  (a  surgeon  may  carry  it 
under  his  nails  and  a  woman  may  have  it  lodged  in  her  vagina) .  Syphilis  can  be 
transmitted  by  vaccination  with  hum^n  lymph  which  contains  the  pus  of  a 
s\T)hilitic  eruption  or  the  blood  of  a  syphilitic  person.  Vaccine  lymph,  even 
after  passage  through  a  person  with  pox,  will  not  convey  syphilis  if  it  is  free 
from  blood  and  the  pus  of  specific  lesions;  it  is  not  the  lymph  that  poisons, 
but  some  other  substance  which  the  l5miph  may  carry.  When  syphilis  is 
caught  from  one  of  a  difi'erent  race  the  disease  is  apt  to  run  a  peculiarly  severe 
course.  The  apprehensions  of  the  sailor  regarding  " Chinese  pox"  are  probably 
well  founded.  John  Knott  says  ("New  York  Med.  Jour.,"  Oct.  31,  1908): 
"The  Swan  Alley  sore  of  the  days  of  BenjaminTravers  was  immeasurably  more 
severe  and  more  rapidly  destructive  in  its  progress  than  any  average  London 
chancre;  for  it  was  the  fruit  of  the  continuous  patronizing  culture  of  the  for- 
eign sailors  and  refugees  who  were  derived  from  the  veriest  social  and  moral 
dregs  of  the  population  of  all  foreign  countries." 

Effect  of  Syphilis  Upon  Longevity. — This  is  a  difi&cult  matter  to  deter- 
mine. Many  deaths  result  from  diseases  caused  by  syphilis  and  yet  they 
are  not  certified  as  due  to  s\'philis.  My  own  belief  is  that  the  mortality  directly 
due  to  active  s^'philis  is  very  small  indeed  (except  in  cases  of  congenital  syphilis), 
but  that  the  mortality  due  to  the  results  of  syphilis  is  very  large.  I  think 
that  the  life  insurance  companies  are  justified  in  requiring  those  who  have  had 
s\T3hLhs  to  pay  higher  premiums  than  those  who  have  never  had  the  disease. 
J.  Howard  Beard  ("Popular  Science  Monthly,"  Feb.,  1917)  says  that  in 
1913  syphilis  was  directly  responsible  for  7200  deaths  (4600  due  to  paresis  and 
2600  due  to  locomotor  ataxia) — that  syphilis  tends  strongly  to  produce  cardio- 
vascular disease — that  it  kills  many  infants  during  the  first  year  of  life — that 
it  causes  more  than  one-fourth  of  all  still  births — that  it  is  responsible  for  one- 
fifth  of  the  admissions  to  hospitals  for  the  insane — and  that  "there  is  an  in- 
creased mortality  rate  among  syphilitics  of  70  per  cent.,  which  means  a  reduction 
of  the  average  expectancy  of  life  of  five  and  one-half  years." 

Syphilis  and  Tuberculosis. — Syphihs  and  tuberculosis  may  coexist. 
The  syphihs  may  be  severe  and  the  tuberculosis  mild,  or  vice  versa.  In  some 
cases  neither  is  severe  and  in  some  cases  both  are.  As  a  rule,  they  have  an 
unfavorable  influence  on  each  other.     Tuberculosis  is  not  very  unusual  in  the 


368  Syphilis,  or  Pox 

course  of  secondary  syphilis.  It  is  apt  to  run  a  rapid  course  because  of  the 
patient's  debility  and  worry  and  because  of  the  treatment  employed  for  the 
s^^ihilis.  Old  syphilitics  may  develop  tuberculosis,  but  do  not  seem  particularly 
prone  to  do  so.  A  child  born  s}q)hilitic  is  very  apt  to  become  tuberculous, 
more  apt  even  than  is  a  child  born  of  tuberculous  parents.  If  a  patient  who  is 
thought  to  be  well  of  syphilis  becomes  tuberculous  the  syphilis  may  crop  out 
again.  If  a  tuberculous  patient  becomes  syphilitic  the  tuberculosis  usually 
gets  worse.  It  is  well  known  that  syphilitic  ulcers  may  become  tuberculous. 
This  sometimes  occurs  in  the  larynx.  (See  chapter  on  Sx-philis  in  Bonney's 
treatise  on  "Pulmonary  Tuberculosis.") 

Syphilitic  Stages. — Syphilis  was  divided  by  Ricord  into  three  stages: 
(i)  The  primary  stage — chancre  and  indolent  bubo;  (2)  the  secondary  stage 
— disease  of  the  upper  layer  of  the  skin  and  mucous  membranes;  and  (3)  the 
tertiary  stage — affections  of  connective  tissues,  bones,  fibrous  and  serous 
membranes,  and  parenchymatous  organs.  This  division,  which  is  useful 
clinically,  is  still  largely  employed,  but  it  is  not  so  sharp  and  distinct  as  was 
believed  by  Ricord;  it  is  only  artificial.  For  instance,  ozena  may  develop  during 
a  secondary  eruption,  and  bone  disease  may  appear  early  in  the  case. 

Syphilitic  Periods. — WTiite  divides  the  pox  into  the  following  periods: 
(i)  Period  of  primary  incubation — the  time  between  exposure  and  the  appear- 
ance of  the  chancre,  from  ten  to  ninety  days,  the  average  being  twenty-five 
days;  (2)  period  of  primary  symptoms — chancre  and  bubo  of  adjacent  lymph- 
glands;  (3)  period  of  secondary  incubation — the  time  between  the  appear- 
ance of  the  chancre  and  the  advent  of  secondary  symptoms,  about  six  weeks 
as  a  rule;  (4)  period  of  secondary  symptoms — lasting  from  one  to  three  years; 
(5)  intermediate  period — there  may  be  no  symptoms  or  there  may  be  light 
symptoms  which  are  less  symmetrical  and  more  general  than  those  of  the 
secondary  period:  it  lasts  from  two  to  four  years,  and  ends  in  recovery  or 
tertiary  syphilis;  (6)  period  of  tertiary  symptoms — indefinite  in  duration. 
The  fifth  and  sixth  periods  may  never  occur,  the  disease  having  been  cured. 

Primary  Syphilis. — The  primary  stage  comprises  the  chancre  or  infect- 
ing sore  and  bubo.  A  chancre  or  initial  lesion  is  an  infective  granuloma  re- 
sulting from  the  epidermic  reaction  to  the  poison  of  s^T^hilis  and  is  most  usually 
met  wath  upon  the  genital  organs.  In  men  the  genital  chancre  is  most  com- 
monly seen  on  the  inner  layer  of  the  prepuce  in  or  back  of  the  sulcus.  The 
next  most  usual  sites  are  upon  the  glans  penis,  about  the  frenum  or  near  the 
margin  of  the  opening  of  the  foreskin.  "The  primary  sore  is  found  at  times 
at  the  meatus  urinarius,  in  the  skin  of  the  penis,  on  the  groin  or  the  scrotum 
or  in  the  urethra"  (White  and  Martin's  " Genito-urinary  Surgery  and  Venereal 
Disease"). 

In  women  chancres  are  most  common  upon  the  labia  majora  and  labia 
minora,  are  not  unusual  about  the  fourchet  and  clitoris  but  are  seldom  seen 
in  the  vagina.     A  chancre  may  occur  about  the  os  uteri. 

Whereas  chancre  is  particularly  common  in  the  genital  region  it  may  be 
met  with  in  other  regions  and  when  it  is  in  another  region  we  speak  of  it  as  an 
extragenital  chancre. 

Extragenital  chancre  may  be  found  upon  the  lip,  tongue,  tonsil,  the  mucous 
membrane  of  the  mouth  or  pharynx,  anus,  nipple,  finger,  hand,  eyelid  and 
other  regions. 

A  chancre  may  be  derived  from  the  discharges  of  another  chancre,  from 
the  secretion  of  mucous  patches  and  moist  papules,  from  syphilitic  blood,  or 
from  the  pus  or  secretion  of  any  secondary  lesion.  Tertiary  lesions  seldom 
cause  chancre.  A  chancre  appears  at  the  point  of  inoculation,  and  is  the  first 
lesion  of  the  disease.  During  the  three  weeks  or  more  requisite  to  develop  a 
chancre  the  poison  is  continuously  entering  the  system,  and  when  the  chancre 
develops  the  system  already  contains  a  large  amount  of  poison.     A  chancre 


Initial  Lesions  369 

is  not  a  local  lesion  from  which  s\T)hilis  springs,  but  is  a  local  manifestation 
of  an  existing  constitutional  disease,  hence  excision  is  entirely  useless.  If 
twelve  days  or  more  after  the  appearance  of  a  chancre  we  take  some  of  the 
discharge  and  insert  it  at  some  indifferent  point,  into  the  person  from  whom 
we  took  it,  a  new  indurated  chancre  will  not  be  formed.  This  means  that 
the  subject  has  become  immune  to  inoculation,  but  the  immunity  is  not 
a  sufficiently  powerful  factor  to  kill  the  spirochetes  already  in  the  body. 
If  a  syphilitic  is  inoculated  with  the  discharge  of  a  chancre  twelve  days  or 
more  after  the  chancre  began,  no  indurated  sore  develops,  but  if  the  chancre 
furnishing  the  virus  was  irritated,  a  non-indiirated  sore  may  arise  at  the  point  of 
inoculation.  If  we  take  the  discharge  of  a  chancre  and  insert  it  into  a  healthy 
person,  an  indurated  chancre  follows.  Hence  we  say  that  primary  syphilis 
is  not  auto-inoculable,  but  is  hetero-inoculable.  A  soft  sore  can  be  produced 
in  the  lower  animals  by  inoculation  with  the  virus  of  a  chancre,  but  a  hard 
sore  cannot  except  in  monkeys.  Some  observers,  notably  Kaposi,  of  Vienna, 
advocate  the  unity  theory.  This  theory  maintains  that  both  hard  and  soft 
sores  are  due  to  the  same  virus,  the  infective  power  of  the  soft  chancre  simply 
being  less  than  that  of  the  hard  sore  and  the  possibility  of  constitutional  infec- 
tion depending  not  upon  differences  in  the  poison,  but  rather  upon  differences 
in  the  soil  and  in  the  local  processes.  The  unicists  advocate  excision  of  chancres, 
soft  or  hard,  to  prevent,  if  possible,  constitutional  involvement.  Most  syphi- 
lographers  believe  in  the  duality  theory,  which  we  have  previously  set  forth. 
This  theory  took  origin  from  the  classical  investigations  of  Bassereau  and 
RoUet.  The  duahty  theory  maintains  that  the  soft  sore  is  caused  by  a  poison 
different  from  the  one  which  originates  the  hard  sore,  and  that  a  true  soft  sore 
never  infects  the  system.  The  discovery  of  the  micro-organism  causing 
syphilis  proves  the  dualists  to  be  correct. 

Syphilis  without  Chancre.— A  woman  infected  through  the  fetus  has  no 
chancre.  It  is  claimed  that  chancre  may  be  absent  in  a  woman  who  contracts 
s\'philis  by  tainted  intercourse.  In  most  of  these  cases  there  was  probably  a 
concealed  chancre  although  Gaucher  says  there  are  positive  cases  of  sj'philis 
in  women  not  preceded  by  chancres  ("Lancet,"  Feb.  10,  1917).  Fournier 
stated  that  a  deep  puncture  with  an  infected  needle  or  knife  may  be  followed 
by  syphiHs  without  chancre. 

Initial  Lesions. — An  initial  lesion,  hard  chancre,  or  infecting  sore  never 
appears  until  at  least  ten  days  after  exposure;  it  may  not  appear  for  many 
weeks,  but  it  usually  arises  in  about  twenty-five  days.  There  are  three  chief 
forms  of  initial  lesion:  (i)  A  purple  patch  exposed  by  peeling  epidermis,  with- 
out induration  and  ulceration — a  rare  form;  (2)  an  indurated  area  under 
the  epidermis,  mthout  ulceration — a  very  common  form;  and  (3)  a  round, 
indurated,  cartilaginous  area  with  an  elevated  edge,  which  ulcerates,  exposing 
a  velvety  surface  looking  like  raw  ham;  it  bleeds  easily,  rarely  suppurates, 
does  not  spread,  and  the  discharge  is  thin  and  watery.  This  is  the  Himterian 
chancre,  which  is  rarer  than  the  second  variety,  but  commoner  than  the  first, 
and  which  ulcerates  because  of  dirt,  caustic  applications,  or  friction. 

A  chancre  is  rarely  multiple,  but  if  it  is  so,  all  the  sores  usually  appear  to- 
gether as  a  result  of  the  primary  inoculation;  they  seldom  follow  one  another 
because  of  auto-infection,  although  during  the  first  twelve  days  such  a  result 
is  possible.  A  hard  sore  does  not  suppurate  unless  irritated  by  caustics, 
friction,  or  dirt,  or  unless  there  be  mLxed  infection  with  chancroid.  Its  nature 
is  not  to  suppurate.  The  hardness  may  affect  only  the  base  and  margins  of 
an  ulcer  or  it  may  affect  considerable  areas,  but  it  has  well-defined  margins 
and  feels  like  cartilage  encapsuled,  so  that  it  can  be  picked  up  between  the 
fingers.  This  hardness  or  sclerosis  is  due  to  gradual  inflammatory  exudation 
into  "the  tissue  at  the  base  of  the  ulcer  and  to  growth  of  the  nodule"  (von 
24 


370  Syphilis,  or  Pox 

Zeissl).  It  feels  distinct  from  the  surrounding  tissues,  hke  a  foreign  body- 
lying  in  the  part.  The  very  characteristic,  circumscribed  induration  which 
is  so  common  in  the  male  is  seldom  noted  in  women.  In  them  there  is  apt  to  be 
softer  and  less  definitely  circumscribed  induration.  A  chancre  untreated  may- 
last  many  months.  An  untreated  chancre  is  apt  to  heal  more  quickly  in  a. 
woman  than  in  a  man.  The  induration  usually  disappears  soon  after  the 
appearance  of  secondary  symptoms.  A  copper-colored  spot  remains,  and 
does  not  disappear  until  the  disease  is  cured.  Induration  may  again  appear 
before  the  outbreak  of  some  distant  lesion. 

Mixed  Infection  of  Chancre  and  Chancroid. — Von  Zeissl  says :  "If 
syphilitic  contagion  is  mixed  with  pus,  a  chancre  begins  as  a  circumscribed 
area  of  hyperemia  and  swelling,  which  undergoes  ulceration,  and  does  not 
develop  hardness  for  a  period  of  from  ten  days  to  several  weeks,  and  may 
develop  a  nodule  after  the  first  ulcer  has  entirely  healed."  This  condition  is 
seen  when  mixed  infection  occurs,  the  chancroid  poison  being  quick,  and  the 
syphilitic  poison  being  slow.  If  chancroid  poison  is  deposited  some  time 
after  the  syphilitic  poison  has  been  absorbed,  the  induration  may  appear 
in  a  few  days  after  the  chancroid  begins.  A  soft  chancre  may  arise  upon  an 
existing  syphihtic  nodule  and  may  eat  out  the  induration. 

Diagnosis  of  Chancre. — It  is  necessary  to  distinguish  a  chancre  from  a 
chancroid  and  from  ulcerated  herpes.  A  chancroid  appears  in  from  two  to 
five  days  after  contagion  (always  less  than  ten  days) ;  it  may  be  multiple  from 
the  start,  but,  even  if  beginning  as  one  sore,  other  sores  appear  by  auto-inocu- 
lation; it  begins  as  a  pustule,  which  bursts  and  exposes  an  ulcer;  the  ulcer 
is  circular,  has  thin,  sharp-cut,  or  undermined  edges,  a  sloughy,  non-granu- 
lating base,  and  gives  origin  to  a  thin,  purulent,  offensive  discharge  which  is 
both  auto-  and  hetero-inoculable.  These  soft  sores  have  no  true  sclerotic  area, 
do  not  bleed,  produce  no  constitutional  symptoms,  and  are  apt  to  be  followed 
by  acute  inflammatory  buboes  which  tend  to  suppurate.  A  chancroid  causes 
pain,  and  the  original  ulcer  enlarges  greatly.  A  chancre  appears  in  about 
twenty-five  days  after  inoculation  (never  before  ten  days);  it  is  generally  sin- 
gle, but  if  multiple  sores  exist  they  usually  all  appear  together,  for  their  dis- 
charge is  not  auto-inoculable  after  the  twelfth  day  if  the  sore  is  not  irritated;, 
an  auto-inoculation  of  the  products  of  an  irritated  chancre  may  produce  a  soft 
purulent  ulcer.  A  chancre  begins  as  a  desquamating  area,  an  excoriation,  or  a 
nodule;  if  an  ulcer  forms,  its  floor  is  covered  with  granulations  and  it  is  red  and 
smooth;  the  discharge  is  thin  and  scanty  and  not  offensive;  the  edges  are  thick 
and  sloping;  it  is  surrounded  by  an  area  of  induration,  and  bleeds  when  touched; 
there  appear  about  the  same  time  with  the  induration  or  very  soon  after  it 
indolent  multiple,  unfused  enlargements  of  the  adjacent  glands,  which  rarely 
suppurate,  and  it  is  followed  by  secondary  symptoms.  A  chancre  causes  little 
pain,  and  after  it  has  existed  for  a  few  days  rarely  shows  any  tendency  to  spread. 
For  the  first  few  days  after  the  appearance  of  a  chancre  the  Wassermann  reac- 
tion is  negative,  then,  in  nearly  three-fourths  of  the  cases,  it  becomes  positive. 
There  is,  however,  dispute  as  to  the  value  of  the  reaction  in  the  diagnosis  of 
primary  syphihs.  Finding  the  Spirochsta  pallida  in  scrapings  from  or  the 
discharge  of  the  sore  is  proof  that  the  lesion  is  a  chancre.  A  urethral  chancre 
appears  in  accordance  with  the  usual  period  of  incubation;  it  is  situated  near 
the  meatus,  one  Up  of  which  is  usually  indurated;  the  discharge  is  slight,  often 
bloody,  seldom  purulent;  indurated  multiple  buboes  arise;  the  sore  can  be  seen,, 
and  constitutional  symptoms  follow. 

Herpetic  ulceration  has  no  period  of  incubation;  it  may  follow  fever,  but 
usually  arises  from  friction  or  irritation  due  to  dirt  or  acrid  discharges.  It 
appears  as  a  group  of  vesicles,  all  of  which  may  dry  up,  or  some  may  dry  up 
and  others  ulcerate,  or  they  may  run  together  and  ulcerate.  The  edges  of  a 
herpetic  ulcer  are  in  segments  of  circles;  the  ulcer  is  superficial,  has  but  httle 


Syphilitic  Bubo  3yi 

discharge,  and  does  not  have  much  tendency  to  spread;  it  has  no  induration; 
it  is  painful;  it  is  not  accompanied  by  bubo  unless  suppuration  is  marked. 
Herpes  is  not  followed  by  constitutional  involvement. 

A  chancre  may  be  mistaken  for  cancer  of  the  tongue.  "A  chancre  of  this 
region  is  brownish  red,  a  cancer  being  bright  red.  A  chancre  is  soft  .in  the 
center;  a  cancer  presents  uniformity  of  induration.  A  chancre  gives  origin 
to  a  thin,  purulent  discharge,  free  from  blood;  a  cancer  furnishes  a  non-purulent, 
bloody  discharge.  A  chancre  is  soon  followed  by  indolent  lymphatic  enlarge- 
ments under  the  jaw;  a  cancer  is  followed  by  painful  enlargements."  A  cancer 
is  slower  in  evolution,  is  not  followed  by  constitutional  symptoms,  and  the 
lymphatic  enlargements  are  much  later  in  appearing  than  in  chancre. 

Phagedena. — A  chancre  or  a  chancroid  may  be  attacked  by  phagedena,  a 
destructive  form  of  ulceration  which  was  once  common,  but  at  present  is  rare. 
The  ulceration  often  spreads  on  all  sides  and  also  deeply  into  the  tissues.  In 
some  cases  it  spreads  at  the  edge  in  one  direction  {serpiginous  ulceration),  in 
some  cases  sloughing  occurs.  Phagedena  occurs  only  in  the  debilitated  (anemics, 
drunkards,  strumous  subjects,  sufferers  from  diabetes,  Bright's  disease,  etc.; 
salivation  can  cause  it).  The  phagedenic  ulcer  is  irregular,  with  congested 
and  edematous  edges,  and  a  foul,  sloughy  floor. 

Chancre  Redux. — Some  observers  believe  that  reinfection  with  syphiUs 
is  not  very  unusual.  Most  authorities  maintain  that  it  is  very  rare.  The  latter 
school  maintains  that  the  region  once  occupied  by  a  chancre  may,  after  months 
or  several  or  even  many  years,  become  indurated  anew.  Occasionally  such  a 
relapse  occurs  during  full  treatment.  Fournier  pointed  out  this  fact  thirty 
years  ago.     Such  a  reinduration  is  called  chancre  redux,  or  relapsing  chancre. 

If  syphilitic  manifestations  follow  such  an  induration,  we  must  conclude 
that  reinfection  has  truly  occurred.  If  they  do  not  follow,  and  this  is  the  rule, 
the  lesion  is  not  really  a  chancre,  but  is  probably  a  gumma  in  an  early  stage  of 
development.     Mauriac,  in  1896,  pointed  out  this  last  fact.^ 

In  syphilitic  bubo  anatomically  related  lymphatic  glands  enlarge  about 
the  same  time  as  or  at  least  very  soon  after  induration  of  the  initial  lesion 
begins.  In  the  very  beginning  these  glands  may  be  a  little  painful,  but  the 
pain  is  slight  and  of  temporary  duration.  These  enlargements  are  called 
"indolent  buboes;"  they  may  be  as  small  as  peas  or  as  large  as  walnuts,  are 
freely  movable,  and  very  rarely  suppurate.  The  lesion  of  the  glands  is  hyper- 
plasia of  all  the  gland-elements  and  of  their  capsules,  due  to  absorption  of 
the  virus.  If  the  patient  is  tuberculous,  the  bubo  is  apt  to  become  enormous, 
lobulated,  and  persistent.  If  the  chancre  appears  on  the  penis,  the  superficial 
inguinal  and  femoral  glands  enlarge,  usually  on  the  same  side  of  the  body  as  the 
sore.  If  the  sore  is  on  the  frenum,  both  groins  are  involved.  If  a  chancre  ap- 
pears on  the  lip  or  tongue,  the  bubo  is  beneath  the  jaw.  Chancre  above  the 
lower  third  of  the  vagina  does  not  cause  primary  bubo  of  the  inguinal  glands. 
These  buboes  may  remain  for  many  months;  they  do  not  break  down  unless 
the  sore  suppurates  or  unless  the  patient  is  of  the  tuberculous  type;  and  they 
finally  disappear  by  absorption  or  fatty  degeneration.  About  six  weeks  after 
buboes  have  formed  in  the  glands  related  to  the  lesion  all  the  lymphatics  of 
the  body  enlarge.  General  lymphatic  involvement  arises  about  the  time  the 
secondary  eruption  appears.  The  enlargement  of  the  postcervical  and  epi- 
trochlear  glands  is  diagnostically  important.  Glandular  enlargements  persist 
until  after  the  eruptions  have  disappeared. 

Glandular  enlargement  always  occurs  in  syphilis,  but  the  bubo  exists  in 
only  one-third  of  the  chancroid  cases.  The  bubo  of  syphilis  is  multiple,  con- 
sisting of  a  chain  of  movable  glands  (the  glandulae  Pleiades  of  Ricord);  the 
bubo  of  chancroid  is  one  inflamed  and  immovable  mass.  The  bubo  of  s3^h- 
ilis  is  indurated,  painless,  small,  and  slow  in  growth;  the  bubo  of  chancroid 
1  H.  G.  Antony,  in  "Chicago  Meclical  Recorder,"  April,  1899. 


372  Svphilis,  or  Pox 

shows  inflammatory  hardness,  is  painful,  large,  and  rapid  in  growth;  the  first 
rarely  suppurates,  the  second  often  does.  The  skin  over  a  syphiUtic  bubo  is 
normal;  that  over  a  chancroidal  bubo  may  become  red  and  adherent.  A  syph- 
ilitic bubo  is  not  cured  by  local  treatment,  but  is  cured  by  the  internal  use  of 
mercury  and  is  followed  by  secondary  symptoms.  A  chancroidal  bubo  re- 
quires local  treatment,  is  not  cured  by  mercury,  and  is  not  followed  by  seconda- 
ries. Herpes,  balanitis,  and  gonorrhea  rarely  cause  bubo,  but  when  they  do 
the  bubo  in  each  case  is  similar  to  that  caused  by  chancroid.  A  positive 
diagnosis  of  syphilis  can  be  made  when  an  indurated  sore  on  the  penis  is  followed 
by  multiple  indolent  buboes  in  the  groin  and  by  enlargement  of  distant  glands. 

General  Syphilis. — As  the  general  lymphatic  enlargement  becomes 
manifest  a  group  of  symptoms  known  as  syphilitic  fever  may  appear.  In 
many  mild  cases,  however,  fever  is  absent  and  the  eruption  is  the  first  sign 
of  constitutional  involvement.  The  patient  usually  thinks  he  has  a  severe 
cold,  is  feverish  and  restless;  complains  of  headache,  lassitude,  sleeplessness, 
and  anorexia;  his  face  is  pale;  he  has  intermitting  rheumatoid  pains  in  the 
joints  and  muscles,  especially  of  the  shoulders,  arms,  chest,  and  back,  and  these 
pains  change. their  location  constantly  and  prevent  sleep;  night-sweats  occur, 
and  the  pulse  is  quite  frequent.  The  fever  usually  reaches  its  height  in  forty- 
eight  hours,  and  falls  as  the  eruption  develops.  The  eruption  develops  usually 
in  from  forty-eight  to  seventy-two  hours  after  the  onset  of  the  fever,  but  may 
not  do  so  for  one  week  or  even  more.  The  fever  and  the  discomfort  are  worse 
at  night.  In  type  the  fever  may  be  intermittent,  remittent,  or  continued. 
It  is  usually  intermittent.  There  may  or  may  not  be  chills,  and  chills  may 
occur  every  day  or  irregularly.  Prolonged  syphilitic  fever  with  delay  in 
the  appearance  of  the  eruption  gives  rise  sometimes  to  great  errors  in  diagnosis. 
Prolonged  and  irregular  fever  is  apt  to  arise  in  visceral  syphihs,  especially 
syphilis  of  the  liver.  In  syphilitic  fever  there  are  anemia,  trivial  leukocytosis, 
and  a  marked  fall  in  hemoglobin.  S\T3hilitic  fever  may  reappear  during  the 
progress  of  the  disease. 

Secondary  Syphilis. — The  phenomena  of  secondary  syphilis  are  due 
to  poisoned  blood.  They  are  "local  reactions  against  the  spirochetes  which 
have  now  become  disseminated  by  the  blood-stream"  (H.  G.  Adamson,  in  the 
"Lancet,"  April  6,  1912).  During  untreated  active  secondary  syphilis  the 
Wassermann  reaction  is  practically  always  positive.  Scrapings  from  a  lesion 
may  show  the  causal  organisms.  Secondary  syphilis  is  characterized  by  plastic 
inflammation,  by  the  formation  of  fibrous  tissue,  and  by  thickening  of  tissue. 
Superficial  ulcerations  may  occur.  Structural  overgrowths  appear  (for  in- 
stance, warts). 

Syphilitic  Skin  Diseases. — Syphilodermata  {syphilids)  are  due  to  cir- 
cumscribed inflammation,  and  may  be  dry  or  purulent.  There  is  no  one 
eruption  characteristic  of  syphilis.  This  disease  may  counterfeit  any  skin  dis- 
ease, but  it  is  an  imitation  which  is  not  perfect  and  is  never  a  counterpart. 
Syphilitic  eruptions  are  often  circumscribed;  they  terminate  suddenly  at  their 
edges,  and  do  not  gradually  shade  into  the  sound  skin.  In  color  they  are  apt 
to  be  brownish  red,  like  tarnished  copper;  especially  is  this  the  case  in  late 
syphilids.  Hutchinson  cautions  us  to  remember  that  an  ordinary  non-specific 
eruption  may  be  copper  colored,  especially  in  people  with  dark  complexions 
and  when  it  occurs  on  the  legs.  Eruptions  are  apt  to  leave  a  brownish  stain. 
Early  syphihtic  eruptions  are  symmetrical.  Syphilitic  eruptions  have  an 
affection  for  particular  regions,  such  as  the  forehead,  the  abdomen  and  chest, 
the  neck  and  scalp,  about  the  lips  and  the  alae  of  the  nose,  the  navel,  anus, 
groins,  between  the  toes,  and  upon  the  palms  and  soles.  Early  secondary 
eruptions  rarely  appear  on  the  face  or  hands.  Specific  eruptions  are  poly- 
morphous, various  forms  of  eruption  being  often  present  at  the  same  time,  so 
that  roseola  is  seen  here,  papules  there,  etc.     These  syphilids  do  not  cause  as 


Papular  Syphilids  373 

much  itching  as  do  non-specific  eruptions,  except  when  they  occur  upon  the 
scalp,  about  the  anus,  or  between  the  toes.  The  late  secondary  eruptions 
tend  to  an  arrangement  in  curved  lines. 

Forms  of  Eruption. — The  chief  forms  of  eruption  are:  (i)  erythema, 
(2)  papular  syphilids,  (3)  pustular  syphilids,  and  (4)  tubercular  syphilids. 
Besides  these  eruptions  pigmentation  may  occur  (pigmentary  syphilid),  and 
blood  may  extra vasate  (purpuric  sj-philid). 

Prince  A.  ]\Iorrow  does  not  believe  in  erecting  the  vesicular  syphilids  into 
a  special  group.  He  tells  us  that  vesicles  sometimes  form  on  erythemato- 
papular  lesions,  but  their  presence  is  an  accident  and  not  a  regular  phenomenon. 
So,  too,  the  bullous  sj'philid  is  a  rare  accident  in  a  case,  and  even  when  it  occurs 
soon  becomes  pustular.  The  pemphigoid  syphilid  is  found  almost  exclusively 
in  hereditarv^  disease.^ 

1.  Erythema  (MacuIcB,  Roseola,  or  Spots). — This  eruption  usually  cornes  on 
gradually,  crop  after  crop  of  spots  appearing,  and  many  days  passing  before 
an  extensive  area  is  covered.  Occasionally,  however,  it  arises  suddenly 
(after  a  hot  bath,  after  taking  violent  exercise,  or  after  eating  an  indigestible 
meal).  This  eruption  consists  of  circumscribed,  irregularly  round,  h^-peremic 
spots,  about  ^2  inch  in  diameter,  whose  color  does  not  entirely  disappear  on  pres- 
sure in  an  old  eruption,  but  does  in  a  recent  one.  The  color  is  at  first  hght 
pink,  but  it  becomes  red,  purple,  or  even  bro^vn.  In  the  papular  form  of 
erythema  the  spots  are  slightly  elevated.  Erythema  is  rare  upon  the  face  and 
the  dorsum  of  the  hands  and  feet.  It  attacks  especially  the  chest  and  belly, 
but  appears  often  on  the  forehead,  the  bend  of  the  elbow,  and  the  inner  por- 
tion of  the  thigh,  the  neck,  and  the  flexor  surface  of  the  forearms  and  arms. 
It  appears  first  on  the  abdomen  and  last  on  the  legs.  Usually  erythema  fol- 
lows sj'philitic  fever,  about  six  weeks  after  the  chancre  appears,  and  the  number 
and  distinctness  of  the  spots  are  in  proportion  to  the  violence  of  the  fever. 
No  fever  or  slight  fever  means  there  will  be  but  few  spots  and  they  will  soon 
disappear.  In  rare  cases  the  eruption  is  very  transitory,  lasting  but  a  few 
hours,  but  it  usually  continues  for  several  weeks  if  untreated.  It  may  pass 
away  or  may  be  converted  into  a  papular  eruption.  Mercury  will  cause  it 
to  disappear  in  a  couple  of  weeks.  In  examining  for  this  form  of  eruption  in  a 
doubtful  case,  let  cold  air  blow  upon  the  chest  and  belly;  this  blanches  the 
sound  skin  and  makes  clear  any  discoloration.  No  desquamation  attends 
the  macular  eruption,  but  a  brownish  stain  remains  for  a  variable  time  after  the 
eruption  fades.  Erythema  means,  as  a  rule,  a  mild  and  curable  attack.  Maculae 
may  be  combined  with  the  next  form,  constituting  a  maculopapular  eruption. 

The  maculopapular  syphilids  are  evolved  from  the  macular  syphilids. 
They  are  slightly  elevated,  are  situated  upon  hyperemic  bases,  and  the  sum- 
mits of  some  of  them  may  undergo  slight  desquamation.  A  roseolar  area 
may  show  one  or  several  of  these  macular  papules.  They  are  apt  to  arrange 
themselves  in  segments  of  circles  and  are  symmetrically  distributed.  This 
eruption  usually  appears  early,  but  may  appear  late.  It  may  fade  and  reap- 
pear several  times  in  the  same  patient.     The  eruption  lasts  a  few  weeks. 

2.  Papular  syphilids,  which  are  papules  or  elevations  covered  with  dry  skin, 
may  or  may  not  desquamate.  If  they  do  desquamate,  the  process  begins  over 
the  center.  They  usually  appear  from  the  third  to  the  sixth  month  of  the 
disease.  They  may  be  preceded  by  fever,  and  often  reappear  again  and  again. 
They  are  at  first  small  and  red,  but  become  larger  and  brownish.  They  are 
firm  in  feel  and  vary  in  size  from  the  head  of  a  pin  to  a  five-ceiit  piece  or  larger. 
Large,  flat  papules  constitute  nummular  syphilids.  Papules  all  tend  to  scale. 
The  epiderm  becomes  thin,  red,  and  glistening,  sphts  in  the  center  and  des- 
quamates, and  a  fringe  of  epidermis  surrounds  the  desquamated  area.  This 
process  may  be  repeated  once  or  oftener.     When  lenticular  papules  recur  in 

1  Morrow's  "System  of  Genito-urinary  Diseases,  SyphUology,  and  Dermatology." 


374 


Syphilis,  or  Pox 


the  late  secondary  stage  they  are  apt  to  group  themselves  in  circles  limited 
to  particular  regions  (annular  or  circinate  syphiloderm).  They  may  be  present 
as  miliary  papules,  lenticular  papules,  moist  papules,  and  pj^pules  with  marked 
epidermic  proliferation  resembling  psoriasis  (papulosquamous  eruption). 
Papules  on  fading  leave  very  persistent  coppery-looking  stains.  Papules 
upon  the  palms  and  soles  constitute  the  so-called  "  j)almar  and  plantar  psoriasis," 
which  appears  from  three  months  to  one  year  after  the  appearance  of  the 
chancre.  Papules  just  below  the  line  of  the  hair  on  the  forehead  constitute  the 
corona  veneris.  Papular  syphilids  appear  especially  upon  the  forehead,  the 
neck,  the  abdomen,  and  the  extremities.  The  {)apular  or  squamous  syphilid 
of  the  palms  and  soles  begins  as  a  red  spot,  which  becomes  elevated  and  brown- 
ish; the  epidermis  thickens  and  is  cast  off,  and  there  then  remains  a  central 
red  spot  surrounded  by  undermined  skin.  If  papules  are  in  regions  where 
they  are  kept  moist  (as  about  the  anus),  they  become  covered  with  a  sodden 

gray  him,  which  after  a  time  is  cast  off 
and    leaves   the  papule    without  epi- 
lermis.      The     sodden     papules     are 
called     flat     condylomata,     moist    or 
humid   papules   or  plates   (Fig.  162). 
'S    Papules  which  are  at  first  small  may 
^    become  large.     The  small  or  miliary 
papules    constitute    syphilitic    lichen. 
I    The  lenticular  papules  are  most  com- 
mon, and  strongly  tend   to  scale  off. 
The   papular    syphilids   give  a  worse 
prognosis  for  the  constitutional  disease 
than  do  spots.     The  syphilitic  negro 
is    particularly    apt    to    develop    the 
annular  syphiloderm. 

3.  Pustular  syphilids  arise  from 
papules.  The  condition  is  known  as 
acne  when  the  apex  of  the  papule 
softens,  impetigo  when  the  whole 
papule  suppurates,  and  ecthyma  or 
rnpia  when  thfe  corium  is  also  deeply 
involved.  Vesicles  occasionally  pre- 
cede pustules.  The  pustular  eruption 
appears  a  number  of  months  after 
infection  and  later  than  the  papular. 
The  pustular  eruption  gives  a  very 
bad  prognosis  for  the  constitutional 
disease.  Rupia  is  formed  by  a  pus- 
tule rupturing  or  a  papule  ulcerating, 
the  secretion  drying  and  forming  a 
conical  crust  which  continually  increases  in  height  and  diameter,  while  the 
ulceration  extends  at  the  edges.  When  the  crust  is  pulled  off  there  is  seen  a 
foul  ulcer  with  congested,  jagged,  and  undermined  edges.  Rupia  may  be  sec- 
ondary or  tertiary,  and  it  invariably  leaves  scars.  It  appears  only  after  at 
least  six  months  have  passed  since  the  chancre  began.  Secondary  rupia  is  sym- 
metrical.    Tertiary  rupia  is  asymmetrical. 

4.  Tubercular  syphilids  are  greatly  enlarged  papules  intermediate  between 
ordinary  papules  and  gummata. 

Diagnosis  Between  Secondary  and  Tertiary  Syphilids. — A  secondary  eruption 
is  distinguished  from  a  tertiary  eruption  by  the  following:  the  first  tends 
to  disappear,  the  second  tends  to  persist  and  to  spread;  the  first  is  general 
and  symmetrical,  the  second  is  local  and  asymmetrical;  the  first  does  not 


Fig.   162. — Comlyloniala  (Horwitz). 


Affections  of  the  Nails  3y5 

spread  at  its  edge,  the  second  tends  to  spread  at  its  edge,  and  this  tendency, 
which  is  designated  serpiginous,  produces  an  ulcer  shaped  like  a  horseshoe 
(Jonathan  Hutchinson).  Secondary  lesions  appear  within  certain  limits  of 
time,  develop  regularly,  and  are  dispersed  by  mercurial  treatment.  Tertiary 
lesions  appear  at  no  fixed  time,  develop  irregularly,  and  are  not  cleared  up 
by  mercury. 

Affections  of  the  Mucous  Membranes.— The  chief  lesions  in  syph- 
iUtic  affections  of  the  mucous  membranes  are  mucous  patches,  warts,  and 
cond^domata.  The  first  phenomena  of  secondary  syphilis  are,  as  a  rule, 
symmetrical  ulcers  of  the  tonsils,  painless,  of  temporary  duration,  and  super- 
ficial (Hutchinson).  The  borders  of  the  ulcers  are  gray  and  the  areas  are 
reniform  in  shape.  Catarrhal  inflammations  often  occur.  Eruptions  appear 
on  the  mucous  membranes  as  upon  the  skin.  Mucous  patches  are  papules 
deprived  of  epithelium;  they  are  gray  in  color,  are  moist,  and  give  off  an  offen- 
sive and  virulent  discharge.  They  usually  appear  as  areas  of  congestion,  swell- 
ing, and  abrasion  of  the  epidermis  upon  the  lips,  palate,  gums,  tongue,  cheeks, 
vagina,  labia,  vulva,  scrotum,  anus,  and  under  the  prepuce.  A  moist  papule 
of  the  skin  is  really  a  mucous  patch.  These  patches,  which  are  always  circular 
or  oval,  are  among  the  most  constant  lesions  of  the  secondary  stage,  appearing 
from  time  to  time  during  many  months.  If  a  patch  has  the  papillae  destroyed, 
it  is  called  a  bald  patch.  If  the  papules  present  hypertrophied  papillae  fused 
together,  there  appear  enlargements  with  flat  tops,  termed  condylomata  (Fig. 
162);  if  the  papillfe  of  the  papules  hypertrophy  and  do  not  fuse,  the  growths 
are  called  warts.  Mucous  lesions  of  the  mouth  are  commonest  in  smokers 
and  in  those  with  bad  or  neglected  teeth.  Hutchinson  says  that  persistence 
in  smoking  during  syphilis  may  cause  leukomata,  or  persistent  white  patches. 
The  vagina  and  lips  of  the  vulva  during  the  secondary  stage  are  often  covered 
with  mucous  patches.  The  uterus  may  contain  mucous  lesions  which  poison 
the  uterine  discharge.  The  larynx  may  suffer  from  inflammation,  eruptions, 
and  ulceration  (hence  thejioarse  voice  which  is  so  usual).  The  nasal  mucous 
membrane  may  also  suffer.  The  rectal  mucous  membrane  may  be  attacked 
by  patches,  and  so  may  the  glans  penis,  the  inner  surface  of  the  prepuce, 
and  the  urethra.  Early  in  the  secondary  stage  in  some  cases  there  is  a  slight 
mucopurulent  urethral  discharge,  and  examination  with  an  endoscope  shows 
redness  of  the  mucous  membrane  of  the  anterior  urethra.  The  discharge  is 
contagious.  The  condition  may  be  followed  by  constriction  of  the  urethral 
caliber.     Distinct  ulceration  may  take  place. 

Affections  of  the  Hair. — In  syphilis  the  hair  is  usually  shed  to  a  great 
extent.  This  loss  may  be  widespread  (beard,  mustache,  hair  of  head,  eyebrows, 
pubic  hair,  etc.)  or  it  may  be  limited.  Complete  baldness  sometimes  ensues, 
but  it  is  rarely  permanent.  The  hairs  of  the  head  are  first  noticed  to  come  out 
on  the  comb;  on  pulling  them  they  are  found  loose  in  their  sheaths — so  loose 
that  Ricord  has  said  "a  man  would  drown  if  a  rescuer  could  pull  only  upon 
the  hair  of  the  head."  The  falling  out  of  the  hair,  which  is  known  as  alopecia, 
usually  begins  soon  after  the  fever  or  about  the  time  of  the  eruption,  but 
it  may  be  postponed  until  much  later.  The  skin  of  a  syphilitic  bald  spot  is 
never  smooth,  but  is  scaly.  The  hair  may  thin  generally,  baldness  may  appear 
in  twisting  lines,  or  it  may  be  complete  only  in  limited  areas.  Alopecia  results 
from  shrinking  of  the  hair-pulp,  death  of  the  hair,  and  casting  off  of  the 
sheath. 

Affections  of  the  Nails. — Paronychia  is  inflammation  and  ulceration  of 
the  skin  in  contact  with  a  nail  and  extending  to  the  matrix.  The  nail  is  cast 
off  partially  or  entirely.  Onychia  is  inflammation  of  the  matrix,  and  is  mani- 
fested by  white  spots,  brittleness  or  extended  opacity,  twisting,  and  breaking 
off  of  the  nail.  The  parts  around  are  not  affected.  The  damaged  nail  drops 
off  and  another  diseased  nail  appears. 


376  Syphilis,  or  Pox- 

Affections  of  the  Ear. — Temporary  impairment  of  hearing  in  one  or 
both  ears  is  not  uncommon  in  syphilitic  affections  of  the  ear.  Rarelv,  per- 
manent symmetrical  deafness  is  produced.  Meniere's  disease  is  sometimes 
caused  by  syphilis. 

Affections  of  the  Bones  and  Joints. — In  syphilis  there  may  be  slight 
and  temporary  periostitis.  Pain  racks  various  bones,  the  bones  become  tender 
and  the  pain  is  worse  at  night  {osteocopic  pains).  Osteoperiostitis  usually  arises 
with  or  after  the  onset  of  the  secondary  eruption,  but  in  rare  instances  pre- 
cedes the  syphilids.  The  bones  usually  involved  are  the  tibia?,  clavicles,  and 
skull.  Intense  headache  may  be  due  to  periostitis  of  the  inner  surface  of  a 
cranial  bone.  Local  periostitis  may  form  a  soft  node,  which  by  ossification 
becomes  a  hard  node.  Pain  like  that  of  rheumatism  may  affect  the  joints.  It 
is  not  increased  by  motion  and  is  worse  at  night.  Such  pains  are  by  no  means 
uncommon  and  in  some  cases  are  very  severe.  The  joints  are  not  stiff  except 
perhaps  on  rising.  Paton  reminds  us  that  such  arthralgia  is  an  early  symp- 
tom and  may  actually  antedate  the  secondary  eruption  ("Brit.  Med.  Jour.," 
Nov.  28,  1903).  More  common  than  the  above  condition  is  synovitis,  acute  or 
chronic.  It  often  comes  on  rapidly  without  other  symptoms  and  is  announced 
by  swelling,  tenderness,  and  pain.  In  some  cases  the  pain  is  severe,  and  the 
patient  is  feverish  or  actually  ill.  Such  cases  constitute  what  is  called  syphilitic 
rheumatism,  but  the  profuse  sweats  of  acute  rheumatism  are  absent,  the  heart 
is  never  attacked,  the  skin  is  not  red,  the  fever  is  not  high,  and  the  condition  is 
not  migrating  (Ibid.).  Hydrarthrosis  may  arise  in  the  knee  as  a  sequence  of 
either  of  the  above  conditions,  or,  late  in  the  secondary  stage,  it  may  arise 
without  such  an  antecedent  trouble  (Paton).  Symmetrical  synovitis  has  been 
noted.  Secondary  syphilitic  disease  of  bone,  periosteum,  and  joint  lasts  only 
a  short  time  and  is  never  destructive. 

Affections  of  the  Eye. — Iritis  is  the  commonest  eye  trouble  which  may 
arise  during  secondary  syphilis.  It  appears  from  three  to  six  months  after  the 
chancre,  and  begins  in  one  eye,  the  other  eye  soon  becoming  affected.  The 
symptoms  are  a  pink  zone  in  the  sclerotic,  a  congested,  red  or  muddy  iris,  irregu- 
larity of  the  pupil  accentuated  by  atropin,  the  existence  of  pain  and  photo- 
phobia, and  sometimes  hazy  or  even  clouded  pupil.  Rheumatic  iritis  causes 
much  pain  and  photophobia,  s\^hilitic  iritis  comparatively  little;  there  is  less 
swelling  in  the  first  than  in  the  second;  the  former  tends  to  recur,  the  latter 
does  not.  Iritis  is  usually  recovered  from,  good  vision  being  retained.  Diffuse 
retinitis  and  disseminated  choroiditis  never  occur  until  a  number  of  months 
have  passed  since  the  infection.  The  symptoms  are  failure  of  sight,  muscae 
volitantes,  and  very  little  photophobia.  The  diagnosis  of  retinitis  and  cho- 
roiditis is  made  by  the  ophthalmoscope. 

Affections  of  the  Testes. — Syphilitic  Sarcocele. — This  is  a  very  common 
lesion.  It  occurs  in  over  one  third  of  syphilitics.  The  testicle  enlarges  because 
of  plastic  inflammation.  Both  glands  usually  suffer,  but  not  always.  Fluid 
distends  the  tunica  vaginahs.  The  epididymis  escapes.  The  testicle  is  not 
the  seat  of  pain,  is  troublesome  because  of  its  weight,  and  has  very  little  of 
the  proper  sensation  on  squeezing.  The  plastic  exudate  is  generally  largely 
absorbed,  but  it  may  organize  into  fibrous  tissue,  the  organ  passing  into  atrophic 
cirrhosis  (chronic  interstitial  orchitis).  In  some  cases  a  gumma  often  adheres 
to  the  skin,  opens  and  forms  a  sinus.  In  such  a  case  the  testicle  is  destroyed. 
Nervous  System. — Syphilis  of  the  nervous  system  may  arise  as  early  as 
the  sixth  month  after  infection,  although  the  nervous  system-  is  far  more  apt 
to 'suffer  in  the  intermediate  period  or  in  the  tertiary  stage.  Actual  deposits 
in  the  brain  or  cord  do  at  times  take  place  in  the  secondary  stage.  These 
deposits  call  for  prompt  and  active  treatment  or  they  will  cause  permanent 
damage.  Such  lesions  are  particularly  common  in  untreated  cases  and  in  cases 
in  which  secondary  manifestations  were  sHght  or  perhaps  even  unobserved. 


Tertiary  Syphilis  ^yy 

The  Albuminuria  of  Secondary  Syphilis.— It  is  not  very  unusual 
for  nephritis  with  albuminuria  to  develop  early  in  the  secondary  stage.  There 
may  be  the  ordinary  symptoms  of  nephritis,  but  in  many  cases  there  is  albu- 
minuria and  nothing  more.  Large  amounts  of  albumin  run  away  from  the  kid- 
neys and  the  high  percentage  of  albumin  in  the  urine  is  a  notable  feature.  Many 
of  these  cases  recover  completely,  some  become  chronic,  and  in  some  death 
occurs.  It  seems  probable  that  mercurial  treatment  is,  in  part  at  least,  re- 
sponsible for  some  of  these  cases.  The  syphilitic  poison  causes  the  others. 
Those  in  which  there  is  albuminuria  and  nothing  more  are  due  to  syphilis 
rather  than  to  mercury.  Those  in  which  there  is  dropsy  are  aggravated  and 
perhaps  caused  y  mercury  (Fleissinger,  in  "Journal  des  Practicens,"  August 
3,  1907  and  Stokes,  "in  Jour.  Amer.  Med.  Assoc,"  1916,  Ixvi). 

Intermediate  Period. — Secondary  lesions  cease  to  appear  in  from  eighteen 
months  to  three  years.  In  the  intermediate  period  no  symptoms  may  appear, 
yet  the  disease  may  be  still  for  some  time  latent  and  not  cured.  The  Was- 
sernann  reaction  may  be  negative.  Symptoms  may  arise  from  time  to  time. 
These  symptoms,  which  are  called 
reminders,  are  not  so  severe  as 
tertiary  symptoms,  are  apt  to  be 
symmetrical,  and  do  not  close!}-  re- 
semble secondary  lesions.  Among 
the  re  inders  we  may  name  palmar 
psoriasis  and  sarcocele.  Sarcocele  in 
this  stage  is  bilateral  and  rarely  pain- 
ful. Bilateral  indolent  epidid}Tnitis 
occasionally  occurs.  Sores  on  the 
tongue,  a  papular  skin  eruption,  and 
choroiditis  may  arise.  Gummata 
occasionally  occur  in  this  stage,  but 
thev  are  apt  to  be  symmetrical  and 
non-persistent.  Symmetrical  super- 
ficial dactylitis  may  occur.  Arteritis 
may  develop,  beginning  in  the  intima 
or  adventitia,  and  causing,  it  may  be, 
aneurysm,  thrombosis,  or  embolism. 
Obliterative  endarteritis   may  cause 

gangrene.  Vascular  changes  are  notably  common  in  the  vessels  of  the  brain, 
and  thrombosis  may  occur,  in  which  case  paralysis  usually  comes  on  gradually, 
preceded  by  numbness,  although  sudden  paralysis  may  take  place.  The  paral- 
ysis may  be  limited,  extensive,  transitory,  or  permanent.  The  nervous  system 
often  suffers  in  this  stage  (anesthetic  areas  and  retinitis).  The  \dscera  are 
often  congested  and  infiltrated  (liver,  spleen,  kidneys,  and  lungs). 

Tertiary  Syphilis. — This  stage  is  not  often  reached,  the  disease  being 
cured  before  it  has  been  attained.  About  85  per  cent,  of  s\-philitics  escape  it 
entirely.  In  this  stage  there  is  greatly  impaired  nutrition  the  result  of  the 
prolonged  disease.  Until  recently  it  was  generally  thought  that  tertiary  lesions 
were  not  contagious.  This  opinion  is  now  known  to  be  false.  They  are  not  nearly 
so  contagious  as  the  primary  lesion,  as  secondary  lesions,  or  as  blood  of  the 
secondary  stage,  but  they  are  contagious,  though  feebly  so.  A  tertiary  lesion 
contains  spirochetes,  but  not  nearly  so  many  as  a  secondary  lesion.  The  primary 
stage  disappears  without  treatment,  the  secondary  stage  tends  ultimately 
to  spontaneous  disappearance,  but  tertiary  lesions  tend  to  persist  and  to  recur. 
Tertiary  lesions  may  be  single  or  may  be  widely  scattered;  when  multiple  they 
are  not  symmetrical  except  by  accident.  These  lesions  may  attack  any  tissue, 
even  after  many  years  of  apparent  cure;  they  all  tend  to  spread  locally,  they 
all  leave  permanent  atrophy  or  thickening,  they  all  tend  to  relapse,  and  a  local 


Fig.   163. — Serpiginous  ulcers. 


378 


Syphilis,  or  Pox 


influence  is  often  an  exciting  cause.  Tertiary  syphilis  may  cause  marked  anemia 
and  it  is  sometimes  the  cause  of  pernicious  anemia  (Dumas  and  Pirrot,  in  "La 
Presse  Medicale,"  xv,  Nos.  39  and  40). 

Tertiary  skin  eruptions  are  liable  to  ulcerate.  Various  eruptions  may 
occur:  papular  syphilids,  pustular  syphilids,  gummatous  syphilids,  serpiginous 
syphilids,  and  pigmentary  syphilids.  The  characteristic  syphilid  is  ru'pia, 
which  is  formed  by  a  pustule  rupturing  or  a  papule  ulcerating.  A  brown  or 
black  crust  forms  because  of  the  drying  of  the  discharge,  ulceration  continues 
under  the  crust,  new  crusts  form,  and,  as  the  ulcer  is  constantly  increasing 
peripherally,  the  new  crusts  are  larger  in  diameter  than  the  old  ones  and  the 
mass  assumes  the  form  of  a  cone.  An  ulcer  which  has  destroyed  the  deeper 
layers  of  the  skin  is  exposed  by  tearing  off  the  crust.  On  healing,  a  rupial 
ulcer  always  leaves  a  permanent  scar. 

Serpiginous  ulcers  (Fig.  163)  are  common  in  tertiary  syphilis,  and  are 
especially  common  about  the  knees,  nostrils,  forehead,  and  lips.     Serpiginous 

ulceration  is  spoken  of  as  syphilitic 
lupus.  It  is  preceded  by  a  widespread 
brown-colored  nodular  cutaneous  in- 
filtration. The  nodules  suppurate,  run 
together,  crust,  and  produce  an  ulcer 
which  spreads  rapidly  and  assumes  the 
shape  of  a  horseshoe. 

The  gumma  (Fig.  165)  is  the  typical 
tertiary  lesion.  In  some  cases  there  is  a 
solitary  gumma ;  in  others, there  are  two  or 
three  or  even  many  gummata.  A  gumma 
is  a  mass  of  granulation  tissue,  grayish- 
yellow  in  color,  containing  many  cells 
and  few  fibers.  Organization  of  the 
gumma  fails  to  take  place  because  of  a 
want  of  sufficient  blood-supply,  the  cellu- 
lar mass  is  apt  to  undergo  caseation,  and 
when  this  occurs  an  ulcer  forms.  One 
portion  of  the  mass  may  caseate,  another 
portion  may  become  fibrous.  In  some 
cases  the  entire  gumma  becomes  fibrous. 
A  gumma  varies  in  diameter  from  ^ 
inch  to  2  or  3  inches,  presents  a  center 
of  gummy  degeneration,  a  surrounding 
area  of  immature  fibrous  tissue,  and  an 
outer  zone  of  embryonic  tissue  and  leukocytes.  A  gumma,  when  it  is  sponta- 
neously evacuated,  e.xhibits  a  small  opening  or  many  openings  with  very  thin  red 
and  undermined  edges;  the  ulcer  is  slow  to  heal,  and  forms  a  thin  scar,  white 
in  the  center,  but  pigmented  at  the  margins  and  usually  depressed  (Jonathan 
Hutchinson,  Jr.).  The  gummatous  nicer  is  deep,  circular  in  outline,  with  under- 
mined edges  and  an  uneven  floor,  which  is  usually  covered  with  a  thick,  white, 
adherent  slough.  Sometimes  there  is  no  slough,  but  an  extensive  area  is  infil- 
trated. A  gummatous  ulcer  may  coalesce  with  one  or  more  adjacent  ulcers. 
The  discharge  is  scanty  and  tenacious.  These  ulcers  are  often  seen  upon  the 
legs,  and  when  once  healed  rarely  recur.  A  gumma  in  the  internal  organs 
may  become  a  fibrous  mass.  Gummata  form  in  the  skin,  subcutaneous 
tissues,  submucous  structures,  muscles,  tongue,  joints,  bones,  bursae,  testes, 
spinal  cord,  brain,  and  internal  organs.  In  tertiary  syphilis  an  inflammation 
may  not  form  a  circumscribed  gumma,  but,  instead,  may  produce  a  diffuse 
degenerating  mass.  This  tv-pe  of  inflammation,  which  is  seen  in  bones,  is 
called  "gummatous."     In  the  nasal  cavity  a  gumma  is  rapidly  followed  by 


Fig.  1 04. — Healed  syphilitic  ulcers  (case 
of  Dr.  Jos.  J.  Sweeney,  Toledo,  Ohio). 


Tertiary  Syphilis  of  Bones 


379 


an  ulcer  and  there  is  a  strong  tendency  to  necrosis  of  the  vomer  and  sometimes 
of  the  turbinated  bones.  This  condition  produces  a  foul  discharge  and  is 
known  as  syphihtic  ozena.  Advanced  intranasal  necrosis  causes  the  nose  to 
"fall  in,"  which  is  a  hideous  deformity  (Fig.  i66).     The  commonest  laryngeal 


Fig.  165. — Gumma  of  the  clavicle. 

lesion  is  multiple  ulceration  following  minute  gummata.  A  healing  gumma 
in  a  mucous  canal  such  as  the  rectum  or  larynx  causes  thickening  and  stricture. 
Tertiary  syphilis  is  a  common  cause  of  amyloid  degeneration  and  the  most 
frequent  cause  of  arterial  and  nervous  sclerosis. 

Various    Lesions. — Hutchinson     enu- 

merates  the  lesions  of  tertiary  syphilis 
as  follows:  Periostitis,  forming  nodes  or 
causing  sclerotic  h5^ertrophy,  suppura- 
tion, or  necrosis;  gummata  in  various 
parts;  disease  of  the  skin  of  the  type  of 
rupia  or  lupus;  gumma  or  inflammation 
of  the  tongue,  causing  sclerosis;  struc- 
tural changes  in  the  nervous  system, 
causing  ataxia,  ophthalmoplegia  externa 
and  interna,  general  paresis,  optic  atrophy, 
and  paralyses  of  cerebral  nerves;  amyloid 
degenerations;  and  chronic  inflammation 
of  certain  mucous  membranes  (of  the 
mouth,  pharynx,  vagina,  rectum,  etc.), 
with  thickening  and  ulceration.  Smooth- 
ness and  hardening  of  the  base  of  the 
tongue,  due  to  fibrous  changes  in  the 
lymphoid  follicles,  is  a  very  valuable  sign 
of  late  syphilis.  It  was  called  by  Virchow 
indurative  atrophy.  Gummatous  infiltra- 
tion of  the  eyelid  is  sometimes  observed. 
Gummatous  osteoperiostitis  of  the  verte- 
bras may  arise,  and  this  may  be  associated 
with  disease  of  the  membranes  or  cord. 
Syphilitic  inflammation  of  vertebrae  is  called  syphilitic  spondylitis.  Unilateral 
enlargement  of  the  epididymis  is  sometimes  noted,  the  mass  feeling  heavy, 
aching  a  little,  but  not  being  very  tender.  Unilateral  sarcocele  may  be  met  with. 
Gummata  may  arise  in  the  iris,  the  larynx,  the  rectum,  and  the  nose. 

Tertiary  Syphilis  of  Bones. — The  bones  particularly  Hable  to  disease  are 
the  skull,  sternum,  clavicle,  nasal  septum,  and  tibia.     There  may  be  produc- 


Uli 


Fig.    166. — Destruction   of  the   nose   in 
tertiary  syphilis. 


380  Syphilis,  or  Pox 

tive  periostitis.  This  arises  in  the  deeper  layer  of  the  periosteum.  It  may 
be  one  limited  area,  several,  or  many  areas;  may  be  circumferential,  or  may 
involve  the  length  of  the  shaft  of  a  long  bone.  In  most  cases  the  bone  is  also 
involved  (osteoperiostitis).  The  bone  thickens  under  the  periosteum  or  toward 
the  medullary  cavity,  or  in  both  directions.  The  cortical  or  the  spongy  sub- 
stance may  be  the  seat  of  disease.  The  lesion  may  be  small  and  circumscribed 
or  extensive.  The  thick  bone  becomes  dense  (sclerosis).  In  a  protracted  case 
in  a  long  bone  overgrowth  may  occur.  If  growth  occurs  in  the  direction  of  the 
long  axis,  the  bone  will  become  l)ent.  As  a  matter  of  fact,  each  of  the  above 
lesions  is  a  gumma  which  undergoes  resolution  or  organization.  Syphilitic 
periostitis  is  a  superficial  gumma.  Syphilitic  osteitis  is  a  deep  gumma.  Syph- 
ilitic osteomyelitis  is  a  deep  gumma  which  has  not  undergone  resolution  or 
organization.  The  bone  about  a  deep  gumma  is  thickened.  There  is  usually 
but  one  gumma  in  a  bone,  but  there  may  be  two  or  several.  A  large  gumma 
weakens  bone  so  that  fracture  may  take  place  from  slight  force.  Caries  or 
necrosis  may  arise.  A  sequestrum  seldom  forms  unless  there  is  mixed  infection. 
Periostitis  affects  particularly  the  superficial  bones  (tibia,  clavicle,  sternum, 
ulna,  etc.).  It  begins  in  the  deeper  layer  of  the  periosteum,  swelling  arises, 
gummy  changes  occur,  and  the  bone  beneath  is  more  or  less  destroyed.  In 
the  skull  the  bone  may  be  completely  penetrated.  Not  unusually  syphilitic 
periostitis  arises  at  the  seat  of  a  trivial  injury.  S>'philitic  osteomyelitis 
occurs  particularly  in  the  phalanges  and  skull.  Syphilitic  osteitis  of  the  vertebrae 
is  a  source  of  confusion  in  diagnosis.  It  occurs  particularly  in  adults.  It 
causes  pain  and  stiffness  of  the  back,  which,  unUke  what  occurs  in  tuberculosis, 
are  aggravated  by  rest  in  bed.  The  Wassermann  test  may  suggest  the  diagnosis. 
If  an  abscess  forms  and  opens  the  discharge  is  scanty,  either  thick  or  gummy, 
and  contains  spirochetes.  There  are  no  large  sequestra  and  the  sinus  soon 
heals  (Editorial  in  "N.  Y.  Med.  Jour.,"  Sept.  9,  1916).  An  area  of  syphilitic 
bone  disease  may  undergo  repair,  osteosclerosis  usually  and  osteoporosis  some- 
times resulting.  After  perforation  of  the  skull  there  is  no  bony  repair.  S^'philis 
of  the  bones  of  the  nose  is  necrosis  resulting  from  gummatous  ulceration. 
The  -T-ray  picture  is  usually  most  valuable  in  reaching  a  diagnosis  of  tertiary 
syphilis  of  bone.  A  syphilitic  lesion,  if  visible,  usually  has  a  distinct  outline. 
A  pure  periosteal  mass  may  not  show  at  all.  The  bone  lesion  shows  the  deep 
shadow  of  thickening  throughout  or,  as  in  the  gumma,  thickening  around  a 
much  lighter  region.  Tuberculosis  produces  absorption  of  bone  and  light  areas 
in  the  plate.  Sarcoma  of  the  periosteum  always  shows.  Sarcoma  has  not  a 
distinct  margin  like  syphilis. 

Tertiary  Dactylitis  (Fig.  167). — This  condition  is  a  gummatous  formation  in 
a  finger  or  toe.  There  is  a  superficial  form  in  which  the  deposit  begins  in  the 
subcutaneous  tissue  and  subsequently  involves  the  joint  ligaments.  In  a  toe 
the  entire  digit  is  usually  involved,  in  a  finger  the  condition  is  usually  limited  to 
the  proximal  phalanx.  Superficial  dactylitis  is  a  very  early  tertiary  phenome- 
non. A  painless  swelling  gradually  forms  and  it  is  most  distinct  on  the  dorsal 
surface.  The  swelling  becomes  purplish  or  reddish-blue  in  color  and  the  joint 
becomes  preternaturally  mobile.     The  swelling  may  ulcerate. 

Deep  dactylitis  is  a  very  late  tertiary  manifestation  and  is  osteomyelitis  or 
periostitis  of  the  fingers  or  perhaps  of  the  toes.  One  or  more  proximal  pha- 
langes are  apt  to  suffer.  The  skin  seldom  suffers.  Caries  and  necrosis  may 
occur  and  the  joint  may  be  destroyed,  or  the  bone  may  be  partially  absorbed 
and  shortened  from  dry  caries.     Ulceration  of  the  skin  is  rare. 

Tertiary  Syphilis  of  Joints. — (See  the  careful  study  of  E.  Percy  Paton, 
in  "Brit.  Med.  Jour.,"  Nov.  28,  1903.)  The  knee-joint  is  most  commonly 
affected.  Chronic  synovitis  may  arise  with  considerable  or  even  great  swell- 
ing (hydrarthrosis),  trivial  pain,  slight  functional  impairment,  some  thicken- 
ing of  the  synovial  membrane,  and  some  harshness  or  grating  on  movements 


Nervous  Syphilis  381 

Gummatous  synovitis  may  arise,  a  condition  which  sometimes  follows  the 
ordinary  synovitis,  but  more  often  exhibits  very  little  swelling.  The  synovial 
membrane  exhibits  irregular  areas  of  thickening  and  the  symptoms  resemble 
those  of  a  tuberculous  joint  (Paton). 

In  some  syphilitic  joints  the  disease  begins  in  the  bone  and  cartilage. 
In  such  a  condition  there  is  rigidity,  marked  limitation  of  movement,  pains, 
not  often  severe,  and  some  deformity  (Ibid.).  Again,  as  Paton  points  out,  a 
joint  may  be  involved  by  an  adjacent  syphilitic  area,  synovitis  arising,  or,  if 
a  gumma  breaks  into  a  joint,  secondary  pyogenic  infection  may  follow.  Anky- 
losis may  follow  joint  syphilis. 

Visceral  Syphilis. — Amyloid  changes  may  occur  in  any  of  the  viscera  of 
an  individual  with  tertiary  syphilis,  and  such  changes  may  be  found  in  people 
in  whom  suppuration  never  occurred.  The  lungs  may  contain  gummata  or 
may  undergo  fibroid  induration  (syphilitic  phthisis).  The  commonest  condition 
is  unilateral  and  fibroid  in  character.  It  involves  a  portion  of  one  lobe,  or, 
more  rarely,  portions  of  several  lobes  (Landis  and  Lewis  in  "Am.  Jour.  Med. 
Sciences,"  August,  1915).  An  area  of  consolidation  may  arise  at  one  apex, 
but  it  is  rare  in  this  situation. 

This  latent  pulmonary  syphilis  is  readily  mistaken  for  tuberculosis.  There 
may  or  may  not  be  blood-streaked  expectoration.  Syphilitic  phthisis  is  often 
a  non-febrile  malady  but  there  may  be  slight  rises  of  temperature.  The 
expectoration  may  or  may  not  be  blood-streaked  but  it  does  not  contain  the 
bacilli  of  tuberculosis.  Night-sweats  and  diarrhea  are  unusual,  and  emaciation 
and  exhaustion  are  less  decided  than  in  tuberculosis.  Nodes  may  perhaps  be 
found  on  ribs,  clavicle,  or  tibia  or  nodules  in  the  testicles.  Specific  treatment 
cures  the  case.  Gummata  may  form  in  the  heart,  liver,  spleen,  or  kidneys. 
Disease  of  the  aorta  is  quite  common.  It  is  the  rule  in  cardiac  syphilis  to  find  a 
diastolic  murmur  in  the  aortic  area.  The  capsule  and  fibrous  septa  of  the  liver  may 
thicken,  the  organ  being  puckered  by  contraction.  The  liver  may  enlarge  greatly 
and  be  the  seat  of  pain.  In  such  cases  prolonged  elevation  of  temperature 
may  be  noted.  Ascites  is  common  and  jaundice  may  arise.  Albuminuria 
may  occur  in  tertiary  syphilis.  It  may  be  caused  by  fibroid  changes  in  the 
kidneys,  by  the  formation  of  gummata,  or  by  amyloid  degeneration.  Its 
occurrence  should  be  watched  for.  Mercury  and  iodid  of  potassium  have  been 
regarded  as  causative  of  albuminuria  in  some  cases.  When  albuminuria  is 
associated  with  arterial  disease  and  elevated  tension,  the  condition  is  to  be 
regarded  as  parasyphilitic  rather  than  syphilitic.  Nephritis  in  early  life  is 
not  uncommonly  syphilitic. 

Syphilis  may  cause  disease  of  the  stomach,  and  probably  does  so  more 
frequently  than  was  formerly  supposed,  because  it  is  difficult  to  distinguish 
from  more  common  diseases.  The  condition  may  be  gummatous  infiltration 
of  the  wails  of  the  stomach,  multiple  and  minute  gummata,  ulcerations  result- 
ing from  breaking  down  of  gummata,  or  syphilitic  endarteritis  of  the  gastric 
vessels.  When  ulcers  heal,  cicatricial  contraction  results.  Sometimes  a 
large  mass  can  be  palpated.  The  symptoms  last  for  years.  There  is  pain 
after  eating,  but  hemorrhage  does  not  occur  unless  ulcer  forms.  Syphilitic 
ulcers  and  gummata  of  the  stomach  may  be  cured  by  efiicient  antisyphilitic 
treatment.  Like  lesions  may  form  in  the  intestines.  Flexner,  Frankel, 
Fournier,  and  others  have  discussed  this  subject.^ 

Nervous  syphilis  may  be  manifested  by  disorders  of  the  brain,  cord,  or  nerves. 
It  is  rare  after  severe  secondaries,  and  is  most  common  when  secondaries 
were  light  or  so  trivial  as  to  have  escaped  observation.  Severe  secondaries 
seem  to  cast  oflf,  mitigate,  or  exhaust  the  poison.  Nervous  syphihs  may 
result  directly  from  the  specific  disease,  and  such  lesions  are  truly  syphilitic. 

^  See  editorial  in  "Jour.  Amer.  Med.  Assoc,"  March  24,  1900,  and  Roudnitzky,  quoted  in 
"Progressive  Medicine,"  June,  1908,  from  "Prakt.  Vratch,"  August  and  September,  1907. 


382  Syphilis,  or  Pox 

Paresis,  locomotor  ataxia,  myelitis,  meningitis,  neuritis,  arteritis  may  be 
directly  due  to  the  presence  of  spirochetes  causing  the  formation  of  syphilitic 
tissue.  Nervous  syphilis  may  result  indirectly  from  the  specific  disease,  but  not 
be  directly  caused  by  spirochetes  having  formed  syphilitic  tissue.  Such  lesions 
are  called  parasyphilitic.  For  instance,  a  gumma  of  the  brain  is  a  true  syphilitic 
lesion,  but  locomotor  ataxia  following  syphilis  is  often  a  parasyphilitic  lesion. 
As  a  matter  of  fact,  the  spirochetes  may  act  directly  on  nerve  matter  without 
forming  syphilitic  tissue.  Such  a  condition,  though  degenerative,  is  syj)hilitic, 
not  paras\T3hilitic.  S\T^hilitic  lesions  are  improved  or  cured  by  antisyphilitic 
treatment,  parasyphilitic  conditions  are  not.  The  diagnosis  between  syphilitic 
and  parasyphilitic  lesions  is  often  impossible  without  the  therapeutic  test 
(mercury,  salvarsan).  The  former  are  far  more  apt  to  show  positive  Was- 
sermann  reactions  than  the  latter.  We  must  remember  that  brain  syphiUs 
is  usually  a  late  phenomenon  (from  one  to  thirty  years  after  infection).  The 
lesion  may  be  gumma  of  the  membranes  (tumor),  gummatous  meningitis,  ar- 
terial atheroma,  or  obliteralive  endarteritis.  A  gumma  may  eventuate  in  a 
scar,  a  cyst,  or  a  calcareous  mass.  The  symptoms  of  brain  s>philis  depend  on 
the  nature,  seat,  and  rate  of  development  of  the  lesions.  It  is  to  be  noted  that 
syphilitic  palsy  is  apt  to  be  limited,  progressive,  and  incomplete.  Epilepsy 
appearing  after  the  thirtieth  year  is  very  probably  specific  if  alcohol  as  a  cause 
can  be  ruled  out.  Persistent  headache,  tremor,  insomnia  or  somnolence,  transi- 
tory, limited,  and  erratic  palsies,  unnatural  slowness  of  utterance,  amnesia, 
vertigo,  and  epilepsy  are  very  suggestive  of  syphilis.  Sudden  ptosis  is  very 
significant;  so  is  sudden  palsy  of  one  or  more  of  the  extrinsic  eye-muscles.  In 
syphilitic  insomnia  the  patient  cannot  get  to  sleep  at  night  for  a  long  while,  but 
when  he  once  gets  to  sleep  he  reposes  well.  The  type  of  insanity  which  is  most 
apt  to  arise  is  a  likeness  or  counterpart  of  general  paralysis,  and,  like  ordinary 
paresis,  it  is  not  curable.  Most  paretics  have  a  syphilitic  history.  Spinal 
syphihs  may  cause  sclerosis,  a  condition  like  Landry's  paralysis,  softening,  and 
tumor.     Neuritis  is  not  uncommon  in  syphihs. 

Justus's  Test  for  Syphilis. — The  test  described  by  Justus,  in  1894, 
consists  in  first  estimating  the  amount  of  hemoglobin  present,  then  making  a 
single  mercurial  inunction,  and  again  estimating  the  hemoglobin.  It  is  claimed 
that  the  corpuscles  of  an  untreated  syphilitic  are  unduly  sensitive,  and  if  the 
disease  is  present  a  mercurial  inunction  will  cause  a  loss  of  10  to  20  per  cent, 
of  hemoglobin  within  twenty-four  hours,  and  this  fall  persists  a  few  hours  and 
is  then  followed  by  a  rise  to  a  level  above  that  which  existed  when  the  test 
was  applied.  It  is  often  demonstrable  in  secondary,  tertiary,  or  congenital 
syphiUs.  It  usually  fails  in  latent  cases,  when  an  initial  lesion  is  recent,  and 
in  early  secondary  syphihs,  and  in  some  diseases  other  than  syphilis  the  re- 
action can  be  obtained. 

The  Serum  Diagnosis  of  Syphilis  (Wassermann's  Test). — This 
test  can  only  be  employed  in  institutions  possessed  of  the  best  laboratory 
facilities.  It  is  technical  in  the  extreme.  In  order  to  understand  it  certain 
facts  must  be  known. 

Every  normal  serum  contains  an  activating  material  known  as  complement, 
and  complement  is  destroyed  by  heat.  When  bacteria  or  ahen  corpuscles  are 
injected  into  a  living  animal,  the  tissues  of  that  animal  react  and  amboceptor 
is  formed.  Amboceptor  includes  all  antibodies.  Amboceptor  brings  together 
complement  and  the  bacterial  cell  and  it  is  not  destroyed  by  heat.  If  we 
inject  the  corpuscles  of  sheep's  blood  into  a  rabbit,  amboceptor  forms  and  ap- 
pears in  the  rabbit's  serum.  Amboceptor  unites  wdth  the  complement  and  with 
alien  corpuscles  and  the  sheep's  corpuscles  are  dissolved,  and  the  blood  of  the 
rabbit  now  contains  a  distinct  excess  of  amboceptor.  If  some  of  this  blood  is 
drawn  and  the  serum  is  placed  in  a  test-tube,  it  will  dissolve  in  the  tube  cor- 
puscles of  sheep's  blood  if  they  are  added  to  it.     If,  however,  the  rabbit  serum 


The  Serum  Diagnosis  of  Syphilis  (Wassermann's  Test)         _},S^ 

is  heated  for  one-half  hour  to  50°  C.  before  being  placed  in  a  test-tube,  the  heat 
destroys  the  complement,  and  then  the  rabbit  serum  will  be  unable  to  dis- 
solve the  corpuscles  of  sheep's  blood,  if  they  are  added,  because  amboceptor 
without  complement  is  incapable  of  effecting  the  solution. 

If,  however,  after  destroying  the  complement  by  heat,  any  other  serum 
is  added,  the  added  serum  furnishes  the  necessary  complement  and  the  mixture 
is  now  able  to  dissolve  sheep's  corpuscles. 

On  these  facts  the  serum  diagnosis  of  s}^hilis  depends. 

Wassermann  proved  that  if  an  extract  made  of  a  syphilitic  organ  is  placed 
in  the  serum  of  a  syphilitic  individual,  the  amboceptor  or  antibody  will  unite 
with  the  complement  and  the  organ  extract,  although  the  union  cannot  be 
recognized  by  inspection.  In  order  to  be  able  to  identify  the  occurrence  of 
such  a  union  a  process  must  be  gone  through. 

The  serum  of  the  patient  thought  to  be  syphilitic  is  heated  and  comple- 
ment is  thus  destroyed.  It  is  then  mixed  with  the  organ  extract,  which  unites 
with  the  amboceptor  of  the  serum,  one  arm  of  the  amboceptor  being  still 
unsaturated  and  open  for  union.  Guinea-pig  serum  is  now  added  to  furnish 
complement.  If  the  patient  is  s\^hilitic,  the  serum  complement  just  added 
will  unite  with  the  unsaturated  arm  of  the  antibody  or  amboceptor.  To  find 
out  if  this  has  taken  place  we  add  the  heated  serum  of  a  rabbit,  which  will 
destroy  sheep's  corpuscles  if  fresh  serum  is  added  to  it. 

"Sheep's  corpuscles  are  also  added.  If  the  complement  contained  in  the 
guinea-pig  serum  that  was  added  was  taken  up  or  united  with  by  the  syphilitic 
antibody,  there  will  be  none  left  over,  and  consequently  the  added  sheep's 
corpuscles  will  not  be  dissolved.  If,  however,  the  serum  was  not  syphilitic, 
the  complement  will  not  have  been  taken  up,,  but  will  be  left  over  for  union 
with  the  hemolytic  amboceptor  of  the  inactivated  rabbit  serum,  which  latter 
unites  with  the  blood-corpuscles,  and  the  combination  causes  the  solution  of  the 
latter"  (Wm.  J.  Butler,  "N.  Y.  Med.  Journal,"  Jan.  30,  1909). 

The  test  is  usually  made  with  blood  of  the  suspected  individual,  but  may  be 
made  with  cerebrospinal  fluid  withdrawn  by  lumbar  puncture.  The  test  can 
be  made  with  milk  taken  from  the  breast  of  a  lactating  s\philitic. 

Major  Harrison  (quoted  by  D'Arcy  Power,  in  "Brit.  Med.  Jour.,"  Dec.  7, 
1912)  applied  the  test  in  489  cases.  It  was  positive  in  71.8  per  cent,  of  cases  of 
primary  syphilis,  in  90  per  cent,  of  cases  of  secondary  syphilis,  and  in  83.5 
per  cent,  of  cases  of  tertiary  syphilis.  It  was  present  in  50  per  cent,  of  those 
in  a  stage  of  latency.  In  paretics  it  was  found  in  over  80  per  cent,  of  cases ;  in 
tabetics  in  over  50  per  cent,  of  cases. 

If  the  test  indicates  syphilis  we  say  it  is  positive.  If  it  does  not  indicate 
the  disease  we  say  it  is  negative.  We  indicate  the  emphasis  of  the  positive 
reaction  by  saying  it  is  plus  i,  2,  3,  or  4  as  the  case  may  be.  The  test  is  ex- 
tremely valuable  but  is  not  infallible.  A  strong  positive  test  twice  obtained 
indicates  the  existence  of  s\philis  unless  the  patient  has  yaws,  leprosy,  scarla- 
tina, noma,  relapsing  fever,  sleeping  sickness,  diabetes  with  acidosis,  malaria 
in  the  febrile  stage  or  perhaps  pellagra.  In  each  of  the  above-named  conditions 
a  positive  reaction  can  be  obtained.  A  positive  reaction  can  be  obtained  in 
blood  taken  from  a  patient  under  ether  or  chloroform  (Boas).  Early  in  the 
stage  of  initial  lesion  the  test  is  negative.  Sometimes  the  test  is  negative  in 
persons  obviously  and  even  violently  syphilitic.  In  about  one-fifth  of  cases  the 
test  becomes  negative  after  the  secondary  stage.  A  test  may  be  negative  for 
a  time  and  then  become  positive;  hence  one  negative  test  cannot  be  taken  as 
proof  that  syphilis  is  absent.  A  negative  Wassermann  does  not  prove  that 
s\^hihs  is  absent,  unless  it  is  constantly  negative  and  the  patient  is  not 
taking  mercury.  In  latent  stages  of  syphihs  the  reaction  often  becomes 
negative  for  a  considerable  time.  Active  mercurial  treatment  or  injections 
of    salvarsan  should   cause   a  positive    reaction   to   become   negative.     The 


384  Syphilis,  or  Pox 

earlier  mercury  is  given  in  a  case  of  syphilis,  Ihe  sooner  is  a  negative  reaction 
obtained. 

The  serum  test  may  enable  us  to  be  sure  of  the  diagnosis  before  the  appear- 
ance of  secondaries.  A  positive  reaction  indicates  that  the  poison  is  active 
and  calls  upon  the  physician  to  apply  active  treatment.  This  should  be  the 
rule,  no  matter  how  long  it  has  been  since  there  were  any  external  manifesta- 
tions of  the  disease.  Wet  nurses  should  be  tested  by  this  method  before  being 
allowed  to  assume  charge  of  an  infant. 

Noguchi's  Cutaneous  Reaction  ("Jour,  of  Exper.  Med.,"  1911). — 
Noguchi  gives  the  name  luetin  to  an  emulsion  of  dead  cells  of  pure  culture  of 
Spirocha^ta  pallida.  Rubbed  or  injected  into  the  skin  it  produces  a  marked 
reaction  in  tertiary  and  hereditary  syphilis,  but  seldom  gives  a  reaction  in 
primary  or  secondary  syphilis  (Noguchi,  in  "Jour.  Am.  Med.  Assoc,"  191 2, 
vol.  Iviii).  The  reaction  is  manifested  by  the  formation  of  a  pustule.  The 
value  of  the  test  is  not  as  great  as  was  hoped.  It  is  of  use  only  in  late  syphilis — 
positive  results  are  sometimes  obtained  when  syphilis  is  not  present — and 
a  negative  test  does  not  prove  that  syphilis  is  absent  ("The  Third  Great 
Plague,"  by  John  H.  Stokes). 

Diagnosis  by  Finding  the  Spirochaeta  Pallida. — This  method  is  of 
the  greatest  value.  The  organism,  if  carefully  searched  for,  is  found  in  chancre, 
in  all  the  lesions  of  early  secondary  syphilis,  and  in  congenital  syphilis.  Spiro- 
chetes, though  comparatively  few,  are  found  in  tertiary  lesions.  Hence, 
the  old  idea  that  tertiary  lesions  are  not  contagious  must  be  cast  aside.  They 
are  not  found  in  lesions  other  than  syphilis.  Spirochetes  can  be  found  in  a  few 
minutes  in  material  from  a  syphilitic  papule  or  sore.  Williams  ("Archives  of 
Diagnosis,"  Jan.,  1910)  scrapes  the  papule  or  sore  lightly  with  a  scalpel,  drops 
a  little  warm  salt  solution  on  it,  and  examines  the  salt  solution  at  once. 

Prevention  of  Syphilis. — Various  plans  have  been  proposed  for  the 
diminution  or  extinction  of  syphilis  in  communities.  As  yet  no  method  has 
been  decided  upon.  Serious  bars  to  intelligent  action  are  the  criminal  prudery 
of  many  and  the  unnatural  stupidity  of  many  others.  The  facts  about  syphilis 
should  be  known,  not  hidden.  People  should  be  educated  in  order  that  they 
may  employ  proper  safeguards.  The  professional  moralist  would  undertake 
to  club  out  of  existence  ideas,  habits,  occupations  which  seem  to  breed  the 
disease,  but  to  succeed  in  this  he  must  begin  by  abolishing  certain  fundamentals 
of  human  nature.  Desirable  as  it  would  be  to  prevent  syphilis  entirely,  that 
is  at  present  impossible.  Promiscuous  sexual  intercourse  and  prostitution 
are  still  with  us,  and  destined,  for  some  time  at  least,  to  remain.  Compulsory 
notification  and  detention  are  advocated  by  many.  Certainly  the  system 
could  be  applied  only  to  those  in  active  stages  of  the  disease.  To  lock  up 
everybody  with  a  positive  Wassermann  reaction  would  shrink  the  producing 
population  to  a  dangerous  degree.  Mere  notification  could  not  accomplish 
much  good.  The  adoption  of  the  above  suggestions  of  well  meaning  indi- 
viduals would  cause  victims  to  conceal  the  disease  and  go  for  relief  to  quacks 
who  would  destroy  them.  If  a  man  is  formally  registered  as  a  syphilitic  he 
will  all  of  his  life  be  threatened  by  the  trailing  curse  of  blackmail.  Certain 
things  seem  clear.  A  person  who  deliberately  or  by  heartless  indifference 
gives  syphilis  to  another  should  be  punished  as  a  criminal. 

There  should  be  many  free  dispensaries  and  hospitals  for  the  treatment  of 
venereal  diseases  and  there  should  be  special  beds  for  such  sufferers  in  all  general 
hospitals. 

Men  who  persist  in  wickedness  should  learn  that  the  common  results  of 
a  contaminated  intercourse  may  usually  be  prevented  by  the  adoption  of 
certain  precautions.  This  has  been  practised  with  great  success  in  the  army 
and  navy.  Certain  rigid  doctrinaires  insist  that  this  plan  is  merely  conniving 
at  vice.  But  we  should  reflect  if  we  save  a  bad  man  from  getting  syphilis  we 
may  prevent  him  from  spreading  it  through  the  community  and  infecting 


Treatment  of  the  Primary  Stage  385 

the  innocent.  We  try  to  save  the  one  bad  man  in  order  to  protect  the  hundred 
who  are  innocent.  Firemen  could  not  stand  by-  and  let  a  house,  however 
notorious,  burn  to  the  ground.  The  worst  of  evil  houses,  if  in  flames,  might 
burn  a  city.  So  I  believe  not  only  in  all  precautions  to  avoid  coming  in  con- 
tact with  the  virus,  but  I  also  believe  in  teaching  preventive  treatment. 

The  individual  in  endeavoring  to  avoid  syphilis  should  avoid,  as  far  as  pos- 
sible, all  the  acts  spoken  of  on  pages  366  and  367,  which  may  be  responsible  for 
infection.  Metchnikoff  discovered  that  if  within  twenty-four  hours  of  inocula- 
tion calomel  ointment  is  rubbed  in  the  exposed  area  syphilis  can  be  prevented. 
He  used  i  part  of  calomel  and  2  of  lanolin.  This  fact  is  widely  utilized.  In  the 
United  States  Navy  the  custom  was,  when  a  sailor  returned  from  shore  leave 
and  admitted  to  a  suspicious  connection,  to  rub  the  penis  and  foreskin  with  a 
mixture  containing  33  parts  of  calomel,  10  parts  of  vaselin,  and  67  parts  of 
lanolin. 

If  before  connection  the  glans  and  prepuce  are  smeared  with  soap  or  calomel 
ointment,  the  liability  to  tearing  and  abrasion  is  lessened  and  crvpts  and  fol- 
licles are  blocked  up.  If  this  plan  is  followed,  and  if  after  connection  the  parts 
are  washed  and  bathed  with  a  warm  solution  of  corrosive  sublimate  (i  :  2000) 
or  permanganate  of  potash  (i  :  3000),  the  danger  of  infection  is  greatly  lessened. 
To  apply  also  the  calomel  ointment  gives  additional  assurances  of  safetv. 

Abortive  Treatment.- — I  do  not  believe  that  syphilis  can  be  aborted  bv 
cauterization,  by  excision,  or  by  the  administration  of  mercury,  luetin,  or  sal- 
varsan.  Several  observers,  even  during  recent  years,  have  claimed  that  abla- 
tion of  the  chancre  will  sometimes  prevent  the  disease.  In  the  reported  cases 
there  is  some  doubt  as  to  the  diagnosis.  Neisser's  experiments  upon  apes  dem- 
onstrate the  futility  of  excision.  He  found  spirochetes  in  adjacent  glands 
before  the  sore  had  indurated.  Injection  of  another  ape  with  material  from 
these  glands  was  followed  by  the  development  of  s}^hilis.  Excision  causes 
pain  and  diagnostic  uncertainty  and  I  believe  it  to  be  invariably  useless. 

Treatment  of  the  Primary  Stage. — It  has  long  been  taught  that  a 
chancre  should  not  be  excised  because  the  disease  is  constitutional  when  the 
chancre  appears,  and  excision  and  cauterization  inflict  needless  pain  and  do  no 
good.  The  initial  lesion  should  never  be  cauterized  unless  it  is  phagedenic  or 
becoming  so.  Order  the  patient  to  soak  the  penis  for  live  minutes  twice 
daily  in  warm  salt  water  (a  teaspoonful  of  salt  to  a  cupful  of  water),  and  then 
to  spray  the  sore  with  peroxid  of  hydrogen  diluted  with  an  equal  bulk  of  water. 
The  ulcer  is  then  dried  with  absorbent  cotton  and  on  it  is  dusted  a  powder  com- 
posed of  equal  parts  of  bismuth  and  calomel  or,  better,  is  dressed  with  calomel 
ointment.  The  buboes  in  the  groin  require  no  local  treatment  unless  they 
tend  to  suppurate.  If  they  persist  or  become  large,  paint  them  wdth  iodin  or 
rub  ichthyol  ointment  or  mercurial  ointment  into  them,  and  apply  a  spica 
bandage  to  the  groin.  Some  authorities  give  mercury  in  this  stage  in  order  to 
prevent  secondaries.  The  younger  Gross  opposed  this  strongly,  and  affirmed 
a  wish  to  see  the  secondary  eruption — first,  because  it  proves  the  diagnosis;  and, 
second,  because  it  affords  valuable  prognostic  indications  (an  erythematous 
eruption  means  a  light  case,  an  early  pustular  eruption  means  a  grave  case  with 
serious  complications) ;  I  long  followed  the  plan  of  my  old  master,  and  did  not 
order  mercury  until  constitutional  symptoms  developed.  We  now  know  that 
the  development  of  a  positive  Wassermann  reaction  may  be  regarded  as  con- 
firmatory of  the  diagnosis,  the  finding  of  spirochetes  proves  it,  and  early  treat- 
ment may  prevent  disastrous  lesions.  We  make  the  (fiagnosis  early  and  at  once 
begin  constitutional  treatment  (see  page  386).  If  phagedena  arises,  place  the 
patient  promptly  upon  stimulants  and  nutritious  diet,  secure  sleep,  and  destroy 
the  ulcer  by  the  use  of  nitric  acid  or  the  cautery  while  the  patient  is  anesthetized. 
After  cauterization  dust  the  sore  with  iodoform  and  dress  with  wet  antiseptic 
gauze.     Several  times  a  day  change  the  dressings,  and  at  each  change  spray 

25 


386  Syphilis,  or  Pox 

the  sore  with  peroxid  of  hydrogen,  irrigate  with  bichlorid  of  mercury  solution, 
and  dust  with  iodoform.  It  may  be  necessary  to  cauterize  several  times.  In 
some  cases  it  will  be  necessary  to  employ  continuous  irrigation  by  an  anti- 
septic fluid.  These  cases  are  sometimes  fatal  and  usually  produce  great 
destruction  of  tissue.  In  chancre  redux  watch  carefully  for  the  symptoms  in 
order  to  determine  if  the  condition  is  really  one  of  reinfection  or  if  we  are 
dealing  with  a  gumma  which  resembles  a  chancre  in  appearance. 

A  chancre  usually  heals  promptly  after  the  administration  of  salvarsan,  and 
quite  rapidly  when  the  patient  is  placed  on  mercury.  It  is  not  wise  to  give 
iodid  of  potash  during  the  primary  stage  and  it  is  not  probable  that  it  is  helpful 
at  all.  Some  teach  that  iodid  of  potash  helps  the  absorption  of  granulation 
tissue  and  so  lessens  induration  and  promotes  healing.  It  certainly  is  not  as 
elhcient  as  mercury  for  this  purpose;  it  does  not  kill  spirochetes,  the  tissues  of 
the  patient  soon  become  "habituated  to  its  presence  and  excrete  it  as  rapidly  as 
it  is  ingested''  (D'Arcy  Power,  in  "Brit.  Med.  Jour.,"  Dec.  7,  191 2). 

Treatment  of  the  Secondary  Stage. — The  chance  of  cure  in  most  cases 
is  excellent  if  the  patient  follows  advice.  The  prognosis  is  much  worse  if  the 
patient  is  a  hard  drinker  or  is  the  victim  of  Bright's  disease,  diabetes,  tuber- 
culosis, or  other  chronic  exhausting  malady.  In  the  secondary  stage  the  aim  is 
to  cure  the  disease.  That  it  can  be  cured  is  known,  because  reinfection  occurs 
in  some  persons.     The  old  axiom,  "Syphilis  once,  syphihs  ever,"  is  not  true. 

Diet  and  General  Care. — In  the  beginning  of  treatment  the  patient  must 
see  his  physician  every  day  or  two  until  the  proper  dose  of  mercury  has  been 
ascertained.  For  the  following  six  months  he  should  see  his  physician  once 
a  week,  and  during  the  next  six  months  once  every  other  week.  During  the 
second  year  he  needs  to  see  him  once  ever>'  month  Of  course,  if  comphca- 
tions  arise  at  any  period  the  visits  must  be  more  frequent.  At  the  beginning 
of  the  attack  he  must  have  his  teeth  put  in  perfect  order.  Tobacco  is  abso- 
lutely forbidden  because  its  use  favors  the  development  of  mucous  patches  in 
the  mouth.  Alcohol  as  a  beverage  is  prohibited.  It  is  used  only  as  a  medi- 
cine. The  teeth  should  be  gently  scrubbed  -with  a  soft  brush  in  the  morning, 
in  the  evening,  and  after  each  meal,  and  a  mild  astringent  or  antiseptic  mouth- 
wash and  gargle  is  to  be  used  several  times  a  day.  If  the  gums  become  red 
and  tender,  chlorate  of  potash  is  used  as  a  gargle  and  mouth- wash  (i  oz.  of 
the  drug  to  i  pint  of  water).  The  patient  should  wear  flannel  in  winter. 
The  author  believes  Guiteras's  rules  are  sound,  and  in  accordance  with  them 
directs  the  patient  to  refrain  from  kissing  any  one  on  the  lips  and  from  using 
a  common  towel,  wash-rag,  cup,  glass,  pipe,  or  razor.  He  is  told  to  sleep 
alone  in  bed,  to  wash  his  hands  often,  to  wear  gloves,  and  to  keep  his  fingers 
out  of  his  mouth.  Every  morning  he  should  take  a  warm  bath,  being  espe- 
cially careful  to  cleanse  the  anus,  perineum,  axillae,  groins,  and  between  the 
toes ;  and  after  the  bath  these  parts  should  be  dusted  ^\dth  borated  talc  powder. 
A  Turkish  bath  once  a  week  is  ordered  by  Guiteras  when  no  skin  eruption 
exists.  The  patient  must  avoid  drafts,  cold,  and  wet;  must  take  a  moderate 
amount  of  gentle  outdoor  exercise,  and  must  sleep  eight  hours  out  of  the  twenty- 
four.  The  diet  is  of  importance,  and  in  this,  too,  the  author  follows  Guiteras 
and  orders  the  patient  to  avoid  eating  anything  fried,  or  any  meat  or  fish  which 
has  been  canned,  salted,  or  preserved.  Fruits,  pickles,  tea,  condiments,  alco- 
holic beverages,  clams,  pork,  veal,  and  pastry  are  not  to  be  taken.  (See 
article  by  Luke  Beggs,  in  "Phila.  Med.  Jour.,"  June  7,  1901.) 

Medical  Treatment. — Mercury  cures  syphilis.  We  no  longer  give  it  only 
to  remove  symptoms,  we  give  it  to  produce  cure.  It  is  given  in  small  doses 
for  a  long  period.  We  were  taught  this  by  Fournier,  Lang,  and  Sir  Jonathan 
Hutchinson  (D'Arcy  Power,  in  "Brit.  Med.  Jour.,"  Dec.  7,  1912).  Mercury 
kills  the  spirochetes.  This  is  proved  by  the  experiments  upon  apes  made  by 
Metchnikoff  and  Roux.     Iodid  of  potash  is  seldom  used  in  the  secondary  stage 


Medical  Treatment  387 

for  the  same  reasons  that  it  is  avoided  in  the  primary  stage.  Mercury  must  be 
used,  the  form  being  a  matter  of  choice.  Fournier  advocated  intermittent 
treatment.  In  this  plan  give  Vg  gr.  of  protiodid  of  mercury  daily  for  six  months, 
then  stop  for  a  month;  then  give  mercury  for  three  months,  then  stop  two 
months.  During  the  first  year  the  patient  is  under  treatment  nine  months,  and 
during  the  second  year  eight  months.  Some  prefer  the  intermittent  and  others 
the  continuous  plan  of  treatment.  The  author  prefers  the  continuous  plan. 
In  following  the  continuous  plan  find  the  patient's  tolerance  to  mercury,  and 
keep  him  for  two  years  on  daily  doses  below  the  amount  he  will  tolerate.  Gross's 
rule  for  continuous  treatment  is  to  order  pills  of  green  iodid  of  mercurv  each 
pill  containing  }i  gr.  The  patient  is  ordered  one  pill  after  each  meal  to  begin 
with;  the  next  day  the  after-breakfast  dose  is  increased  to  two  pills;  the  follow- 
ing day  the  after-dinner  dose  is  two  pills,  and  so  on,  one  pill  being  added  every 
day.  This  advance  is  continued  until  there  is  slight  diarrhea,  griping,  a 
metallic  taste,  or  tenderness  on  snapping  the  teeth  together,  whereupon  one 
pill  is  taken  off  each  day  until  all  unfavorable  symptoms  disappear.  Then 
the  dose  is  reduced  one-half  and  this  amount  is  called  the  tonic  dose.  This 
experimentation  finds  a  dose  on  which  the  patient  can  be  kept  with  entire 
safety  for  a  long  time;  but  if  it  is  found  that  colic  or  diarrhea  is  apt  to  recur, 
there  must  be  added  to  each  pill  ^2  gr-  of  opium.  The  patient  is  given  mer- 
cury in  this  way  for  two  years.  Every  time  new  symptoms  appear  the  dose 
is  raised,  and  as  soon  as  they  disappear  it  is  lowered  to  the  standard.  If  the 
protiodid  is  not  tolerated,  give  the  bichlorid: 

I^.     Hydrarg.  chlor.  corros.,  gr.  j; 

Syr.  sarsaparillae  comp.,  f5iij- — M. 

Sig. — One  fluidram,  in  water,  after  meals. 

Mercury  with  chalk  in  i-  or  2-gr.  doses  four  times  a  day,  with  or  without 
Dover's  powder  in  i-gr.  doses,  may  be  used.  Mercurial  inunctions  pro- 
duce a  rapid  effect,  but  irritate  the  skin.  The  drug  should  be  rubbed  in  with 
a  gloved  hand.  There  can  be  used  once  a  day  ^-o  dr.  of  oleate  of  mercury 
(10  per  cent.)  or  i  dr.  of  mercurial  ointment,  rubbed  into  the  skin.  The 
first  day  it  is  rubbed  into  the  inside  of  one  thigh;  the  second  day  into  the  inside 
of  the  other  thigh;  the  third  day  into  the  inside  of  one  arm;  the  fourth  day 
into  the  other  arm;  next,  into  one  groin  and  then  into  the  other  groin,  and  then 
inunction  is  again  made  at  the  point  of  original  application,  and  so  on.  After 
the  rubbing  the  patient  puts  on  underclothes  and  goes  to  bed,  and  in  the 
morning  takes  a  bath.  The  ointment  may  be  smeared  on  a  rag,  which  is  then 
worn  between  the  stocking  and  sole  of  the  foot  during  the  day. 

Fumigation  is  performed  by  volatilizing  each  night  i  dr.  of  calomel.  The 
patient  sits  naked  on  a  cane-seat  chair,  and  is  wrapped  up  to  the  neck  in  a 
blanket  which  drops  tent-like  to  the  floor;  the  calomel  is  put  upon  an  iron 
plate  under  the  chair,  and  is  heated  by  an  alcohol  lamp  beneath  the  plate.  . 
The  skin  becomes  coated  with  calomel,  and  the  subject,  after  putting  on 
woolen  drawers  and  an  undershirt,  gets  into  bed.  Hypodermatic  injections 
of  mercury  are  used  by  some  physicians.  They  cause  an  eruption  to'  dis- 
appear rapidly,  but  may  produce  abscesses,  and  relapses  are  prone  to  occur. 
The  injection  method  will  not  abort  the  disease;  should  never  be  a  routine 
treatment;  in  suitable  cases  it  is  very  valuable  for  symptomatic  use,  as 
when  lesions  on  the  face  or  in  important  structures  make  a  rapid  impres- 
sion desirable  or  necessary;  in  Cases  which  obstinately  relapse  under  other 
treatment,  and  in  syphilis  of  the  nervous  system.  J.  WilKam  White,  after 
a  large  experience  with  this  method,  says  that  hj^odermatic  injections  of 
corrosive  sublimate  are  painful  and  are  strongly  objected  to  by  many 
patients;  that  this  method  of  treatment  is  occasionally  dangerous  and  even 


388  Syphilis,  or  Pox 

fatal;  that  it  is  liable  to  be  followed  by  local  complications  (erythema, 
nodosities,  celluUtis,  abscess,  sloughing);  that  it  cannot  be  carried  out  by  the 
patient,  but  requires  the  surgeon's  constant  intervention.  This  syphilographer 
concludes  that  hypodermatic  medication  does  not  offer  advantages  justifying 
its  use  as  a  systematic  method  of  treatment,  and  that  it  encourages  insufficient 
treatment — those  ''short  heroic  courses"  which  Hutchinson  shows  are"  fol- 
lowed by  the  gravest  tertiary  lesions.  "The  claim  that  by  a  few  injections  the 
time  of  treatment  can  be  measured  by  months  or  even  by  weeks,  instead 
of  by  years,  would  seem,  as  Mauriac  has  said,  to  involve  the  idea  that  mercury 
given  hypodermically  acquires  some  new  and  powerful  curative  property 
which,  given  in  other  ways,  it  does  not  possess."^  The  usual  plan  is  to  give 
daily  a  hypodermatic  injection  of  corrosive  sublimate  deep  into  the  back  or 
buttock,  the  dose  being  }y-i  gr.  of  the  drug.  Thirty  such  injections  are  used 
unless  some  contra-indication  demands  their  discontinuance  sooner.  The 
treatment  is  then  stopped.  If  the  symptoms  recur,  however,  the  patient  is 
given  another  course,  the  daily  dosage  being  }4,  gr.,  the  treatment  being  again 
stopped  after  thirty  injections,  but  being  continued  anew  in  ^  s-gr.  doses  if 
the  symptoms  recur.  At  present  the  most  popular  preparation  for  hypo- 
dermatic use  consists  of  salicylate  of  mercury  suspended  in  albolene.  The 
strength  of  the  mixture  is  10  per  cent.  The  early  doses  are  10  minims  each, 
given  every  third  to  seventh  day.  The  dose  may  be  pushed  up  to  30  or  even 
to  40  minims.  After  from  six  to  twelve  doses  the  administration  is  discontinued 
for  several  weeks  or  several  months.  The  following  preparation  is  used  by  some 
syphilographers :  0.5  part  of  corrosive  sublimate,  3  parts  of  guaiacol,  and  97 
parts  of  sterile  olive  oil.  Thirty  minims  contain  3^f  g  gr.  of  corrosive  sublimate. 
This  mixture  should  be  thrown  deeply  into  the  buttock  and  it  causes  no  pain. 
The  use  of  gray  oil  hypodermatically  has  warm  advocates.  It  is  claimed  that  it 
provokes  little  pain  and  irritation,  and  that  it  is  a  very  efficient  remedy.  The 
oil  should  not  be  thick  like  an  ointment,  because  such  a  preparation  could 
not  be  used  without  warming,  and  heat  causes  the  mercury  to  aggregate  in 
lumps.  Olive  oil  should  not  be  used,  as  it  becomes  rancid.  Dumesnil's 
formula  is  the  best  ("Brit.  Med.  Jour.,"  Jan.  18,  1908): 

"The  ingredients  must  be  sterilized  before  they  are  incorporated,  as  it  is 
impossible  to  sterilize  the  product.  If  the  directions  given  below  are  carefully 
followed  no  risk  of  septic  poisoning  is  to  be  apprehended.  The  formula  pro- 
posed by  M.  Dumesnil  has  been  accepted  by  a  committee  especially  appointed 
by  the  Societe  de  Pharmacie  of  Paris,  to  investigate  the  methods  of  preparing 
gray  oil.  Twenty-six  gm.  of  anhydrous  wool-fat  and  60  gm.  of  pure  liquid 
paraffin  (Jiiiile  de  vaselin  niedicinale)  are  sterilized  separately  in  glass  flasks 
at  120°  C.  for  twenty  minutes.  A  pestle  and  mortar  are  sterilized  by  means  of 
burning  alcohol  and  placed  therein  are  40  gm.  of  mercury  and  then  the  wool- 
fat.  The  metallic  particles  are  triturated  until  they  are  sufficiently  minute 
when  examined  under  a  magnification  of  480  diameters,  and  then  the  liquid 
.paraffin  is  added  in  small  portions.  The  product  should  weigh  126  gm.  and 
measure  100  c.c.  and  should  be  transferred  immediately  to  phials  of  2-,  5-,  and 
lo-c.c.  capacity,  previously  sterilized  at  180°  C." 

An  injection  is  given  twice  during  the  first  week,  once  during  the 
second  week,  and  after  this  once  a  week  or  once  every  other  week  for 
an  indefinite  period  of  time.  It  may  be  given  oftener  if  symptoms  arise  or 
persist. 

Taylor  believes  that  gray  oil  may  give  rise  to  unpleasant  and  sometimes 
even  dangerous  symptoms,  and  that  it  should  be  used  with  extreme  care  and 
only  in  selected  cases  in  which  other  remedies  are  contra-indicated.  He  says 
that  in  reading  about  the  hypodermatic  method  he  has  been  struck  with  the 

ij.  William  White,  in  Morrow's  "System  of  Genito-urinary  Diseases,  Syphilology,  and 
Dermatology." 


Acute  Ptyalism,  or  Salivation  389 

fact  that  "the  most  serious  results  have  almost  invariably  followed  injections 
in  which  fatty  matters  have  been  the  vehicle  of  suspension. "^     ■ 

Some  surgeons  employ  intravenous  injections  of  mercury.  Lane  injects, 
at  first  every  other  day  and  later  daily,  20  min.  of  a  i  per  cent,  solution  of  cyanid 
of  mercury.  The  skin  in  front  of  the  elbow  is  rendered  aseptic,  a  fillet  is  tied 
around  tlie  arm,  the  needle  is  inserted  into  a  vein,  the  fillet  is  loosened,  the 
fluid  is  injected,  and  the  needle  is  withdrawn.  This  method  of  using  mercury 
is  painless  and  produces  a  rapid  effect.  It  may  be  used  in  nervous  s^-philis, 
but  shou  d  not  be  used  as  a  routine.  In  whatever  way  mercury  is  given,  do 
not  allow  it  to  produce  salivation  (hydrargyrism  or  ptyalism).  Always  re- 
member that  mercury  may  cause  albuminuria  and  examine  the  urine  at  regular 
intervals  during  a  course  of  the  drug.  In  the  beginning  of  a  case  of  syphilis, 
if  tlie  kidneys  are  found  to  be  diseased,  give  the  mercury  cautiously,  and  never 
fail  to  examine  the  urine  at  regular  intervals.  An  individual  can  take  more 
mercury  in  summer  than  in  winter  because  during  the  warm  weather  perspiration 
favors  elimination. 

Sometimes,  when  a  patient  has  a  secondary  eruption,  the  eruption  grows 
temporarily  worse  when  mercury  is  administered.  This  is  called  the  Jarisch- 
Herxheimer  reaction.  It  is  due,  according  to  Adamson,  to  having  killed  some 
spirochetes  and  thus  caused  the  hberation  of  more  endotoxins,  the  endotoxins 
causing '' a  further  local  defensive  reaction''  (''Lancet,"  April  6,  1912). 

In  order  to  cure  s^'philis  mercury  should  be  given  for  two  years,  and  the 
mercurial  course  must  be  followed  by  at  least  a  six  months'  course  of  iodid  of 
potash.  Reminders  require  both  iodid  of  potash  and  mercury  (mLxed  treat- 
ment). Throughout  the  mercurial  course  the  patient  should  be  weighed  once  a 
week,  and  if  it  is  at  any  time  found  that  the  weight  is  decreasing,  tonics,  con- 
centrated food,  and  cod-liver  oU  are  ordered.  If  the  weight  continues  to 
grow  less  and  the  health  begins  obviously  to  fail,  stop  the  mercury  for  a  time, 
continue  the  cod-liver  oil,  tonics  and  nourishing  food,  and  order  hot  baths, 
fresh  air,  iron,  and  chlorid  of  gold  and  sodium.  If  during  the  mercurial  course 
albumin  appears  in  the  urine  and  some  edema  is  noted,  the  mercury  should  be 
stopped  for  several  or  a  number  of  weeks  and  the  patient  should  be  given  a 
milk  diet.  If  marked  albuminura  is  noted,  but  no  other  s>Tnptoms  exist, 
mercury  need  not  be  discontinued,  but  the  patient  is  watched  most  carefully 
for  the  advent  of  any  other  symptom  (Fiessinger,  in  "Journal  des  Practiciens," 
August  3,  1907). 

Acute  Ptyalism,  or  Salivation. — In  acute  ptyalism  the  sahva  becomes 
thick  and  excessive  in  amount;  the  gums  become  spongy  and  tender  and 
liable  to  bleed.  Tenderness  can  be  detected  early  by  snapping  the  teeth.  A 
metallic  taste  is  complained  of;  the  breath  becomes  fetid;  the  oral  structures 
swell;  the  teeth  loosen;  the  saliva  is  produced  in  great  quantity;  and  there  are 
purging,  colic,  and  exhaustion.  Sometimes  there  are  fever  and  a  diffuse 
scarlatiniform  eruption  upon  the  skin.  A  chronic  hydrargyrism  may  be 
shown  by  salivation,  gastro-intestinal  disorder,  emaciation,  mental  depression, 
weakness,  albuminuria,  and  tremor.  To  avoid  salivation,  advance  the  dose 
with  great  caution  and  instruct  the  patient  as  to  the  first  sign  of  the  trouble. 
He  should  use  a  soft  tooth-brush  and  an  astringent  mouth-wash  (48  gr.  of 
boric  acid  to  4  oz.  each  of  listerine  and  water).  WTien  ptyalism  is  noted,  dis- 
continue, the  administration  of  the  drug.  Employ  the  above  mouth- wash  or 
one  composed  of  a  saturated  solution  of  chlorate  of  potassium.  Order  H20  gr- 
of  atrop.n  twice  a  day,  and  in  bad  cases  spray  the  mouth  -^ith  peroxid  of 
hydrogen  and  use  silver  nitrate  locally  (20  gr.  to  i  oz.).  Give  stimulants  (iron, 
quinin,  and  strychnin)  and  nutritious  food.  A  weekly  Turkish  bath  is  of 
great  ser\dce.  In  chronic  hydrargyrism  stop  the  administration  of  the  drug, 
use  tonics,  stimulants,  open-air  exercise,  Turkish  baths,  and  nutritious  food. 
^  "Venereal  Diseases,"  by  Robert  W.  Taylor. 


39©  Syphilis,  or  Pox 

The  chlorid  of  gold  and  sodium  forms  a  substitute  for  mercury.  The  use  of 
iodid  of  potassium  is  of  questionable  value  in  ptyalism. 

Treatment  of  Complications  in  the  Secondary  Stage. — The  complica- 
tions of  the  secondary  stage  usually  require  local  a{)plications  in  addition 
to  general  remedies.  Mucous  patches  in  the  mouth  should  be  touched  with 
bluestone  every  day,  an  astringent  mouth-wash  being  employed  several  times 
daily.  If  the  patches  ulcerate,  they  should  be  touched  once  a  day  with  lunar 
caustic;  if  these  areas  proliferate,  they  should  be  excised  and  cauterized.  Vege- 
tations or  growing  papules  on  the  skin  must,  if  calomel  powder  fails  to  remove 
them,  be  cut  away  with  scissors  and  be  cauterized  with  chromic  acid  or  with 
the  Paquelin  cautery.  Condylomata  demand  washing  with  ethereal  soap 
several  times  daily,  thorough  drying,  dusting  with  equal  parts  of  calomel  and 
subnitrate  of  bismuth  or  with  borated  talcum,  and  covering  with  dry  bichlorid 
gauze.     If  these  simple  procedures  fail,  excise  and  cauterize. 

For  psoriasis  of  the  palms  and  soles  diachylon  ointment,  mercurial  plaster, 
or  painting  with  tincture  of  iodin  should  be  employed.  Ulcers  of  paronychia 
are  dressed  with  iodoform  and  corrosive  sublimate  gauze.  Deep  cutaneous 
ulcers  are  cleaned  once  a  day  with  ethereal  soap,  sprayed  with  peroxid  of 
hydrogen,  dressed  with  iodoform  and  corrosive  sublimate  gauze,  and  bandaged. 
When  the  process  of  granulation  is  well  established  dress  with  i  part  of  un- 
guent, hydrarg.  nitratis  to  7  parts  of  cosmolin.  In  sarcocele  mercurial  oint- 
ment should  be  rubbed  into  the  skin  of  the  scrotum  or  the  testicle  be  strapped. 
In  alopecia  the  hair  should  be  kept  short,  and  every  night  the  scalp  should  be 
cleaned  with  equal  parts  of  green  soap  and  alcohol  rubbed  into  a  lather  with 
water.  After  the  soap  has  been  washed  out  some  hair  tonic  should  be  rubbed 
into  the  scalp  with  a  sponge.  A  favorite  preparation  of  Erasmus  Wilson's 
consisted  of  the  following  ingredients: 

I^.     01.  amygd.  dil., 

Liq.  ammoniae,  aa  f  5  J; 

Sp.  rosemarini, 

Aquae  mellis,  aa  f  5iij- — M. 

Ft.  lotio. 

One  part  of  tincture  of  cantharides  to  8  parts  of  castor  oil  may  be  rubbed  into 
the  scalp.  Solutions  of  quinin  are  esteemed  by  some.  A  useful  wash  for  the 
scalp  is  the  following:  i  dr.  of  borate  of  sodium,  i  dr.  of  spirits  of  camphor,  2  dr. 
of  glycerin,  and  sufficient  orange-flower  water  to  make  4  fl.  oz. 

In  treating  persistent  skin-lesions,  inunctions,  injections,  fumigations,  or 
mercurial  baths  may  be  used.  Baths  are  suited  to  patients  with  delicate  skins, 
to  those  whose  digestion  fails  when  mercury  is  given  by  the  mouth,  and  to 
those  whose  lungs  will  not  tolerate  fumigations.  Corrosive  subli  ate,  ^-^  oz., 
and  4  scruples  of  sal  ammoniac  are  mixed  in  about  4  oz.  of  water;  this  is  added 
to  a  bath  at  a  temperature  of  95°  F.  The  patient  gets  into  this  bath,  covers 
the  tub  with  a  blanket,  leaving  only  his  head  exposed,  and  remains  in  the  bath 
an  hour  or  so.     Mercurial  baths  may  rapidly  cause  salivation. 

Tertiary  Stage. — If  at  any  time  during  the  case  there  appear  tertiary 
symptoms,  the  patient  should  be  put  on  mixed  treatment,  that  is,  mercury 
and  an  iodid.  In  any  case,  after  two  years  of  mercury  add  iodid  of  potas- 
sium to  the  treatment.  If  any  tertiary  symptoms  appear,  the  rule  is  to 
use  mixed  treatment  and  to  continue  it  for  at  least  sLx  months  after  all 
symptoms  disappear,  the  six  months'  course  dating  from  their  disappear- 
ance. This  emphasizes  the  fact  that  the  iodids  alone  will  not  cure  tertiary 
syphilis.  Iodid  of  potash  does  not  cure,  but  is  very  valuable  in  removing 
s\Tnptoms.  In  late  syphilis  both  iodid  and  mercury  are  given.  It  is  the  mer- 
cury that  cures.  The  mercury  is  given  in  small  or  tonic  doses.  Since  the 
days  of  Ricord  iodid  of  potash  has  been  held  in  high  esteem.  In  obstinate 
tertiary  lesions  and  in  nervous  syphilis  the  iodids  should  be  run    up    to   an 


Tertiary  Stage  391 

enormous  amount  (from  30  to  250  gr.  per  day).  Sometimes  people  can  take 
large  doses  of  iodid  when  small  doses  produce  iodism.  Cyon  explains  this 
curious  fact  as  follows:  small  doses  combine  with  some  products  of  the  thyroid 
gland  and  form  toxic  iodothyrin.  Large  doses  are  diuretic,  form  soluble 
salts,  and  are  rapidly  eliminated.  An  easy  way  to  give  iodid  is  to  order  a 
saturated  solution  each  drop  of  which  equals  about  i  gr.  of  the  drug.  Each 
dose  of  the  iodid  is  given  one  hour  after  meals  and  in  at  least  half  a  glass  of 
water.  If  the  iodid  disagrees,  it  may  be  given  in  water  containing  i  dr.  of 
aromatic  spirit  of  ammonia,  or  5  drops  of  fluidextract  of  ergot,  or  it  may  be 
given  in  milk.  The  iodid  of  sodium  may  be  tolerated  better  than  the  potas- 
sium salt,  as  it  is  less  depressing  to  the  circulation,  or  the  iodids  of  sodium, 
potassium,  and  ammonium  may  be  combined.  Gottheil  sometimes  gives  tinc- 
ture of  iodin  in  lo-drop  doses,  well  diluted.  Iodid  may  be  given  as  an  enema 
in  milk.  In  giving  the  iodids,  begin  with  a  small  dose.  During  a  course  of 
the  iodids  always  give  tonics  and  insist  on  plenty  of  fresh  air.  Arsenic  given 
daily  tends  to  prevent  skin  eruptions.  The  iodids  may  disagree  for  a  time, 
but  tolerance  may  be  established  as  the  administration  is  continued.  The 
value  of  the  newer  organic  iodin  preparations  is  as  yet  uncertain.  Some  of 
them  are  given  h^-podermatically.  An  iodized  oil,  known  as  iodipin,  can  be 
given  by  the  mouth  or  by  intramuscular  injection.  If  given  by  the  stomach  it 
may  be  taken  in  capsules,  in  tablets,  or  in  milk  (Coates,  in  "Brit.  Med.  Jour.," 
May  7,  1910).  The  iodids  when  they  radically  disagree  produce  iodism — 
a  condition  which  is  made  manifest  by  a  flow  of  mucus  from  the  nose,  con- 
junctival irritation,  a  bad  taste  in  the  mouth,  exhaustion,  anorexia,  nausea, 
and  tremor.  In  some  subjects  there  are  outbreaks  of  acne,  vesicular  eruptions, 
or  even  bulls  or  hemorrhages.  Iodism  calls  for  the  abandonment  of  the  drug, 
and  the  administration  of  increasing  doses  of  Fowler's  solution  of  arsenic,  of 
laxatives,  of  diuretic  waters,  or,  if  there  is  great  exhaustion,  of  stimulants.  In 
some  cases  belladonna  is  of  service.  Some  patients  who  cannot  take  the  al- 
kaHne  iodids  may  take  syrup  of  hydriodic  acid.  After  the  patient  has  been 
for  six  months  under  mixed  treatment  without  a  symptom,  stop  all  treatment 
and  await  developments.  If  during  one  year  no  symptoms  recur,  the  patient  is 
probably  cured;  if  symptoms  do  recur,  there  must  be  six  months  more  of  mixed 
treatment  and  another  year  of  watching.  It  would  be  wise  were  every  person 
who  has  had  syphilis  to  take  a  six  weeks'  course  of  mercury  and  iodid  twice  a 
year  for  the  balance  of  life.  It  is  probable  that  such  a  plan  would  save  many 
from  \'isceral  syphilis  and  late  nervous  syphilis.  S>'philitic  ulcers  are  treated 
locally  by  cleanliness,  antiseptic  applications,  and,  if  the  situation  admits  of  it, 
by  the  daily  use  of  the  hot-air  apparatus  or  by  the  induction  of  h>^eremia  by 
means  of  the  rubber  bandage  or  the  cupping-glass.  If  albuminuria  arises 
during  the  tertiary  stage  and  there  is  arterial  disease  with  high  tension,  mercury 
will  do  harm.  In  albuminuria  without  high  tension  it  may  be  given  (see  pages 
377  and  389). _ 

The  Question  of  Marriage. — Fournier  has  insisted  that  it  is  a  great  wTong 
to  tell  a  syphilitic  that  he  can  never  marry.  He  must  not  marry  until  he  is 
cured,  and  he  is  not  cured  until,  after  the  cessation  of  the  use  of  mercury  and 
iodid,  he  goes  one  year  without  treatment  and  without  symptoms. 

Treatment  of  Syphilis  by  Salvarsan  or  ''606"  {Dioxydiamidoarsenobenzol 
DihydrocJdorid) . — Various  arsenic  compounds  have  been  tried  in  syphilis  (atoxyl, 
cacodylate  of  sodium,  arsacetin,  soamin),  but  salvarsan  and  neosalvarsan 
are  the  most  important.  EhrHch  introduced  "606"  (salvarsan)  in  1909  and 
later  he  introduced  neosalvarsan.  It  was  hoped  that  a  single  intravenous  in- 
jection would  kill  all  the  spirochetes  and  immediately  cure  the  disease.  This 
hope  has  not  been  reaUzed,  though  the  remedy  has  great  power  for  good.  It 
kills  multitudes  of  spirochetes  by  directly  poisoning  them,  not  by  causing  the 
tissues  to  form  antibodies.     It  causes  symptoms  to  pass  away  rapidly,  but  if 


392  Syphilis,  or  Pox 

the  administration  is  not  continued  at  intervals  or  if  mercury  is  not  given, 
relapse,  and  probably  disastrous  relapse,  is  almost  certain  to  occur.  In  many 
cases,  but  not  in  all,  the  Wassermann  reaction  becomes  negative  after  the 
injection.  The  test  is  rendered  negative  more  quickly  than  by  mercury, 
but  it  may  soon  become  positive  again.  The  beneficial  effects  of  these  arsenic 
preparations  are  particularly  manifest  in  early  syphilis,  and  are  very  evident 
in  tertiary  syphilis.     The  drugs  are  of  little  or  no  use  in  parasyphilitic  lesions. 

In  some  cases  "a  spirochete  infection  which  has  been  in  abeyance"  can  be 
roused  by  salvarsan  "into  sufficient  activity  to  cause  the  Wassermann  reaction 
to  become  positive,"  when  it  was  before  negative.  Hence,  salvarsan  and  neo- 
salvarsan  may  be  used  as  tests  for  syphilis  and  as  tests  to  determine  if  syphilis 
has  been  cured  (D'Arcy  Power,  in  "Brit.  Med.  Jour.,"  Dec.  7,  191 2).  This 
reaction  is  known  as  the  J arisch-Herxheim&r  reaction.  It  is  marked  by 
edematous  swelling  of  a  local  lesion. 

Salvarsan  is  not  to  be  given  as  routine  treatment  of  syphilis  because  it  does 
not  cure;  and  mercury  does.  It  is  not  a  substitute  for  mercury,  but  is  used  in 
particular  cases  for  particular  reasons.  Even  when  salvarsan  is  given,  mercury 
and  iodid  should  be  given  in  the  same  doses  and  for  the  same  time  as  they  would 
have  been  given  had  salvarsan  not  been  administered.  Salvarsan  should  be 
given  when  the  patient  is  intolerant  to  mercury  or  when  mercury  fails  to  control 
the  disease;  when  an  important  structure  is  threatened  with  damage  or  destruc- 
tion; when  the  sore  becomes  phagedenic;  for  malignant  syphilis;  for  persist- 
ent or  spreading  ulcerations;  for  laryngeal  syphilis;  for  tertiary  syphilis;  for 
glossitis  and  ulceration  of  the  tongue  with  leukoplakia,  and  for  periostitis 
and  osteitis  in  congenital  or  acquired  syphilis.  It  does  no  good  to  syphilitic 
necrosis,  probably  because  pyogenic  organisms  are  active  in  such  cases,  and  it 
is  useless  for  symmetrical  synovitis  of  the  knees,  possibly  because  the  child 
victims  have  also  tuberculosis  (Ibid.). 

A  man  with  persistent  mucous  patches  in  the  mouth  and  every  prostitute 
with  syphilis  should  be  given  salvarsan  because  of  the  danger  to  the  commu- 
nity of  such  syphilitics.  A  characteristic  and  disfiguring  eruption  calls  for  it. 
A  married  man  with  a  chancre  should  receive  it  promptly.  Salvarsan  is 
contra-indicated  when  there  is  advanced  disease  of  the  heart  and  arteries; 
in  degenerative  conditions  of  the  brain  and  cord,  when  there  is  optic  atrophy; 
in  diabetes;  in  diseases  of  the  liver  or  kidneys  (even  if  syphilitic)  and  in  pul- 
monary tuberculosis.  Until  recently  it  was  thought  to  be  contra-indicated  in 
children  before  the  age  of  three,  but  John  Adams  shows  that  "syphilitic 
children  can  be  safely  treated  by  salvarsan  immediately  after  birth"  (Brit. 
Med.  Jour.,  Nov.  16,  1918).  Neither  salvarsan  nor  mercury  seem  to  enter  the 
cerebrospinal  fluid  which  fact  probably  explains  the  failure  of  these  drugs  tO' 
produce  distinct  benefit  in  cerebrospinal  syphilis  (Gilpin  and  Earley,  "Jour. 
Am.  Med.  Assoc,"  1916,  Ixvi). 

It  is  estimated  by  some  that  salvarsan  is  responsible  for  i  death  in  every 
1000  cases  treated.  Others  set  the  rate  at  a  much  higher  figure.  Major 
French  ("Lancet,"  Nov.  18,  191 1)  refers  to  41  deaths  as  having  occurred 
in  less  than  one  year.  Levy-Bing,  of  Paris,  says  that  the  deaths  number  70 
or  80  and  that  death  may  occur  in  a  healthy  person.  Hallopeau,  Gaucher 
and  Ravant  reported  3  deaths  ("Bull,  de  I'Acad.  de  Med.,"  Oct.  and  Nov., 
191 1).  A  man  of  nineteen  developed  arsenical  poisoning  and  died  of  uremia  on 
the  sixth  day  after  the  injection.  A  girl  of  eighteen  died  in  a  similar  manner. 
Geronne,  Finger,  and  others  seem  to  prove  that  the  symptoms  which  may  follow 
the  administration  of  salvarsan  are  manifestations  of  acute  intoxication  by 
arsenic,  and  are  not,  as  Neisser  claims,  produced  by  endotoxins  from  destroyed 
spirochetes.  Finger  had  a  fatal  case  due  to  arsenical  poisoning  ("Brit.  Med. 
Jour.,"  Jan.  27,  191 2).  Auditory  and  ocular  complications  may  occur.  In  9 
per  cent,  of  patients  to  whom  Finger  gave  salvarsan  nerve  complications  de- 


Hereditary  Syphilis  39^ 

veloped.  Most  of  the  deaths  followed  a  second  injection,  hence  the  claim  that 
anaphylaxis  was  the  cause. 

The  drug  may  be  given  by  intramuscular  injection.  It  causes  pain  which 
is  often  severe  and  prolonged  inflammation.  This  method  is  employed  in 
children  from  three  to  seven  years  of  age,  because  the  veins  are  small  and  hard 
to  find.  In  adults  the  intravenous  method  is  always  to  be  preferred.  It  is 
given  in  a  vein  in  front  of  the  elbow.  One  capsule  containing  0.6  gm.  of 
salvarsan  is  opened,  and  the  drug,  which  is  an  acid  salt,  is  dissolved  in  a  hot 
alkaline  solution.  A  pint  of  recently  sterilized  salt  solution  is  used  and  ten 
minutes  are  occupied  in  running  the  fluid  into  the  vein.  The  fluid  is  given 
at  a  temperature  a  little  above  blood  heat.  Neosalvarsan  to  the  amount  of 
0.9  gm.  is  dissolved  in  6  oz.  of  freshly  distilled  water.  It  gives  a  neutral  solution 
and  is  very  soluble.     The  fluid  is  injected  at  a  temperature  of  60  to  70°  F. 

Several  hours  after  the  injection  of  salvarsan  symptoms  may  arise  (chills, 
elevation  of  temperature,  diarrhea,  vomiting,  headache).  In  a  few  hours,  as 
a  rule,  the  symptoms  pass  away.  One  must  be  on  the  watch  for  dangerous 
symptoms  (cardiac  depression,  dyspnea,  great  restlessness,  excitement,  edema 
of  the  face,  cyanosis  of  the  face,  persistent  vomiting,  diarrhea,  albuminuria, 
spasm  of  the  limb  muscles,  and  collapse).  Since  the  discovery  that  fresh  dis- 
tilled sterile  water  should  be  used  as  solvent,  and  if  it  is  used  that  the  chiU, 
vomiting  and  day's  depression  which  used  to  be  expected  need  not  occur,  the 
safety  of  the  method  has  been  much  enhanced.  In  cerebrospinal  s>^hilis  Swift 
and  others  suggested  giving  salvarsan  as  usual,  draining  40  c.c.  of  blood  from 
the  patient's  vein  after  an  hour  or  so,  separating  the  serum,  making  a 
spinal  puncture,  withdrawing  some  of  the  fluid  and  introducing  a  like  amount 
of  the  salvarsanized  serum.  The  serum  is  diluted  with  normal  salt  solution 
and  subjected  to  a  temperature  of  56°  C.  before  being  injected.  It  is  of  little 
avail  in  advanced  tabes  but  may  do  much  good  in  an  early  case  in  which  the 
cerebrospinal  fluid  contains  the  spirochaete.  This  serum  given  by  spinal 
puncture  does  no  good  in  paresis  but  Gordon  claims  it  is  useful  if  injected 
beneath  the  cerebral  dura. 

The  effect  of  salvarsan  on  the  Wassermann  reaction  has  been  much  discussed. 
Theoretically,  it  should  always  make  a  positive  reaction  negative.  Practically, 
it  often  does  not.  It  may  require  a  second  injection  to  do  it.  After  the  admin- 
istration of  salvarsan  the  reaction  may  become  negative,  remain  so  for  several 
months,  and  again  become  positive.  Neisser  claims  that  in  only  10  per  cent, 
of  latent  cases  is  a  negative  reaction  converted  into  a  positive  one.  It  was 
stated  above  that  in  latent  syphilis  with  a  negative  reaction  salvarsan  may 
actually  cause  a  positive  reaction.  Evidently,  a  negative  Wassermann  is  not 
to  be  regarded  as  absolute  and  unassaflable  proof  that  a  patient  is  cured. 

Hereditary  Syphilis. — Transmitted  congenital  syphilis  is  heredi- 
tary syphilis  manifest  at  birth.  Acquired  syphilis  (except  in  the  case  of  a 
woman  who  obtains  the  disease  from  a  fetus)  always  presents  the  chancre  as 
an  initial  lesion;  hereditary  syphilis  never  does.  Hereditary  syphilis  may 
present  itself  at  birth,  and  usually  shows  itself  within,  at  most,  the  first  six 
months  of  extra-uterine  life.  In  rare  cases  (tardy  hereditary  syphilis)  the 
disease  does  not  become  manifest  until  puberty.  A  woman  may  have  syphihs 
when  she  conceived.  She  may  acquire  syphilis  during  pregnancy.  Some 
women  bear  a  syphilitic  child  but  show  no  evidence  of  syphilis.  Such  a 
woman  may  perhaps  exhibit  a  negative  Wassermann  reaction  during  pregnancy 
and  show  a  positive  reaction  afterwards.  Treatment  of  a  pregnant  woman  by 
salvarsan  and  mercury  is  of  great  value  and  may  result  in  the  birth  of  chfld 
free  from  signs  of  syphflis  and  wdth  a  negative  Wassermann  reaction  (See 
Meeting  of  the  Section  of  Obstetrics  and  Gynecology  of  the  Royal  Society  of 
Medicine  in  Brit.  Med.  Jour.,  Nov.  16,  1918).     John  Adams  gives  the  mother 


394  Syphilis,  or  Pox 

a  weekly  dose  of  a  salvarsan  subslitute  intravenously  and  at  the  same  time 
intramuscular  injections  of  grey  oil.  These  injections  can  be  given  up  to  the 
time  of  confinement  (Brit.  Med.  Jour.,  Nov.  i6,  1918). 

Rules  of  Inheritance, — According  to  von  Zeissl/  the  rules  of  inheritance  are 
as  follows: 

1.  If  one  parent  is  syphilitic  at  the  time  of  procreation,  the  child  may  be 
syphilitic. 

2.  Syphilitic  parents  may  bring  forth  healthy  children. 

3.  If  a  mother,  healthy  at  procreation,  bears  a  child  syphilitic  from  the 
father,  the  mother  must  have  latent  pox,  having  become  infected  through  the 
placental  circulation,  or  must  be  immune.  She  often  shows  no  symptoms, 
having  received  the  poison  gradually  in  the  blood,  and  having  thus  received, 
it  may  be  said,  preventive  inoculations.  Certain  it  is  that  mothers  are  almost 
never  infected  by  suckling  their  syphilitic  children  (Colles's  law). 

4.  If  both  parents  were  healthy  at  the  time  of  procreation,  and  the  mother 
afterward  contracts  syphilis,  the  child  may  become  syphilitic,  and  the  earlier 
in  the  pregnancy  the  mother  is  diseased,  the  more  certain  is  the  child  to  be 
tainted.     This  is  known  as  "infection  in  utero.^' 

5.  The  more  recent  the  parental  syphilis,  the  more  certain  is  infection  of 
the  offspring.     The  children  are  often  stillborn. 

6.  When  the  disease  is  latent  in  the  parents  it  is  apt  to  be  tardy  in  the 
children. 

7.  The  longer  the  time  which  has  passed  since  the  disappearance  of  paren- 
tal symptoms,  the  more  improbable  is  infection  of  the  children. 

8.  In  most  instances  parental  syphilis  grows  weaker,  and  after  the  parents 
beget  some  tainted  children  they  bring  forth  healthy  ones. 

Syphilis  in  the  mother  is  more  dangerous  to  the  offspring  than  syphilis  in 
the  father.  The  frequent  immunity  of  the  mother  is  said  to  be  due  to  the  fact 
that  her  tissues  produce  antitoxins  under  the  influence  of  the  slowly  absorbed 
virus.  The  milk  of  a  syphilitic  mother  contains  quantities  of  antibodies  (Bab, 
"Zeitschrift  f.  Geb.  und  Gynakologie,"  vol.  x,  No.  2). 

Of  late  years  grave  doubt  has  been  thrown  upon  some  of  the  long  accepted 
supposed  laws  of  inheritance.  It  does  not  seem  possible  that  the  spermatic 
fluid  can  convey  the  infection.  If  it  cannot  the  mother  must  be  infected 
before  the  child.  When  we  reflect  that  most  stillbirths  are  in  the  later  months 
we  would  assume  that  the  fetus  becomes  infected  by  way  of  the  placenta. 
We  doubt  the  possibility  of  a  truly  healthy  child  being  born  of  a  syphilitic 
mother.  An  apparently  healthy  child  may  have  latent  syphiUs  and  exhibit 
no  lesion  for  some  years  or  for  a  number  of  years. 

Many  women  affected  with  hereditary  syphilis  are  sterile.  Many  syph- 
ilitic women  abort  before  the  eighth  month,  most  commonly  in  the  fifth  or 
sixth  month.  The  fetus  very  often  dies  at  an  early  period  of  gestation.  This 
may  be  due  to  a  gummatous  placenta  or  to  a  degeneration  of  placental  follicles. 
Thirty  per  cent,  of  stillbirths  are  said  to  be  due  to  pox.  Bab  (Ibid.)  reports 
that  out  of  33  infants,  victims  of  congenital  syphilis,  16  were  born  alive  and 
7  of  these  died  within  a  few  days.  Hyde  says  that  about  90  per  cent,  of  those 
bom  living  subsequently  die  of  the  disease. 

Children  born  of  syphilitic  mothers  in  some  cases  exhibit  a  negative  Wasser- 
mann  reaction  which  may  become  positive  after  some  weeks. 

Evidences  of  Hereditary  Syphilis  Manifest  At  or,  Oftener,  Soon  After  Birth. 
— Hutchinson  says  that  at  birth  the  skin  is  almost  invariably  clear.  In  from 
six  to  eight  weeks  "snuffles"  begin,  which  are  soon  followed  by  a  skin  eruption, 
by  body  wasting,  and  by  a  chain  of  secondary  symptoms  (iritis,  mucous  patches, 
pains,  condylomata,  etc.).  The  child  looks  Uke  a  withered-up  old  man.  Erup- 
tions are  met  with  on  the  palms  and  soles.  Intertrigo  is  usual.  Cracks  occur 
1  "Pathology  and  Treatment  of  Syphilis." 


Dactylitis 


395 


Fig.  167. — DactyKtis. 


at  the  angles  of  the  mouth  and  leave  permanent  radiating  scars.  The  abdomen 
is  tumid  and  there  is  apt  to  be  exhausting  diarrhea.  The  secreting  and  absorb- 
ing glands  of  the  intestinal  tract  atrophy.^  It  is  seldom  that  distinct  gumma- 
tous tumors  form  in  hereditary  syphilis.  The  type  of  disease  induced  is  a  diffuse 
interstitial  cellular  change  in  the  viscera,  and  the  viscera  are  much  more  apt 
to  suffer  than  in  accjuired  syphilis.  The  liver,  spleen,  and  pancreas  often  en- 
large from  interstitial  changes,  and  the  lungs  sometimes  are  attacked  in  the  same 
manner.  Synovitis  or  arthritis  may  arise,  the  condition  being  similar  to  that 
met  with  in  acquired  syphihs.  A  form  encountered  between  the  third  month 
and  end  of  the  second  year,  according  to  Paton,  is  characterized  by  growth 
into  the  joint  of  fungating  granu- 
lation tissue,  the  joint  is  useless, 
and  the  parts  about  are  swollen 
and  edematous.  Atrophic  lesions 
may  appear  in  the  bones.  In  the 
skull  tlae  bone  may  be  softened  by 
removal  of  its  lime  salts  or  be 
thinned  by  the  pressure  of  the 
brain.  In  the  long  bones  the  epi- 
physeal lines  suffer,  the  attach- 
ment of  the  epiphysis  to  the  shaft 
is  weak,  and  separation  is  easily 
induced.  Epiphysitis  is  common, 
seldom  causes  pain,  and  rarely 
leads  to  suppuration,  except  in 
children  who  are  old  enough  to 
walk  (Coutts).  Osteophytic 
lesions  of  the  skull  are  shown  by 

symmetrical  spots  of  thickening  upon  the  parietal  and  frontal  bones  (natiform 
skulls).  In  the  long  bones  osteophytes  are  frequently  formed.  In  some  cases 
osteophytes  grow  from  the  epiphysis,  and  in  consequence  deformity  and  im- 
paired function  are  noted  and  a  certain  amount  of  ankylosis  may  occur. 
This  condition  of  osteophytic  growth  from  an  epiphysis  was  called  by  Fournier 
arthropathie  deformant.  A  child  with  precocious  hereditary  syphilis  is  apt  to 
die,  but  if  it  Uves  from  six  months  to  one  year  the  symptoms  for  a  time  disap- 
pear, and  for  years  the  disease  may  be  latent.  Diagnosis  is  difficult  after  the 
third  or  fourth  year,  especially  if  the  disease  be  associated  with  rickets  or 
tuberculosis.     When  later  symptoms  arise  they  may  be  various,  namely:  noises 

in  the  ears,  often  followed  by  deafness;  inter- 
stitial keratitis;  synovitis  in  any  joint,  par- 
ticularly painless  but  marked  symmetrical 
effusion  in  the  knee-joints,  with  trivial  functional 
disturbance;  ■  ossifying  nodes;  developmental 
osseous  defects;  suppurative  periostitis;  ulcer- 
ations; death  of  bone;  falHng  in  of  the  nose; 
nervous  maladies;  occasionally  sarcocele,  dactylitis,  etc.  SyphiUtic  children 
are  rather  prone  to  contract  tuberculosis.  Ricord  used  to  speak  of  the  scrofula 
of  pox.  Bones,  joints  or  viscera  may  become  tuberculous.  The  Wassermann 
test  is  of  great  value  in  diagnosis  and  prognosis. 

Dactylitis  (Fig.  167)  is  common  in  hereditary  syphihs.  There  is  a  super- 
ficial and  a  deep  form  (see  page  380).  Commonly,  a  swelling  gradually  forms. 
It  is  fusiform  in  shape  and  becomes  purple  in  color.  It  lasts  for  months.  One 
or  more  fingers  may  be  involved  and  the  fingers  are  more  apt  to  suffer  than  the 
toes.  The  proximal  phalanx  is  most  liable  to  the  lesion.  The  superficial 
form  is  apt  to  soften  and  ulcerate.  Sinuses  seldom  form.  The  deep  form 
^  Coutts,  in  "Brit.  Med.  Jour.,"  1894,  p.  1643. 


Hutchinson  teeth. 


390  S>'philis,  or  Pox 

not  infrequently  causes  tissue  destruction  and  shortening  of  the  digit  from 
rarefying  osteitis  or  dry  caries.  Some  cases  of  superficial  dactylitis  are  sym- 
metrical and  of  short  duration  and  are  to  be  regarded  as  late  secondary  lesions. 

In  hereditary  syphilis  the  eye  svTnptoms  are  of  great  diagnostic  importance. 
In  212  cases  of  congenital  syphilis  Fournier  found  eye  trouble  in  loi.  Kera- 
titis and  choroiditis  are  the  most  usual  forms.  Bone  trouble  occurs  in  almost 
half  of  the  cases,  but  is  not  often  severe  enough  to  cause  symptoms.  The 
tongue  often  shows  a  smooth  base  (Virchow's  sign).  It  is  due  to  lymphoid 
atrophy  and  fibrosis  (Symmers,  in'' Amer.  Jour.  Med.  Sci.,"'Dec.,  1910).  Hirsch- 
berg  believed  choroiditis  to  be  pathognomonic.  The  descendants  of  syphilitic 
parents  may  exhibit  certain  pathological  conditions  which  are  not  directly 
s^-philitic.  Fournier  calls  such  phenomena  paras\'philitic.  Among  these 
phenomena  are  arrest  of  development  of  the  body  at  large  or  of  special  struc- 
tures, weakness  of  constitution,  and  other  stigmata  of  degeneration. 

In  the  diagnosis  of  hereditary  syphilis  the  condition  of  the  teeth  is  of  con- 
siderable importance:  the  temporary  teeth  decay  soon,  but  present  no  character- 
istic defect.  If  the  upper  permanent  central  incisors  are  examined,  they  are 
often,  but  by  no  means  always,  found  defective.  Other  teeth  may  show  de- 
fects, but  in  these  alone  are  characteristic  defects  likely  to  appear.  In  heredi- 
tary syphilis  they  may  present  an  appearance  of  marked  deviation  from  health, 
and  are  then  called  Hutchinson  teeth  (Fig.  168).  Hutchinson  stated  that  if 
they  are  dwarfed,  too  short  and  too  narrow,  and  if  they  display  a  single  central 
cleft  in  their  free  edge,  then  the  diagnosis  of  s\'philis  is  probable.  If  the  cleft 
is  present  and  the  dwarfing  absent,  or  if  the  peculiar  form  of  dwarfing  be 
present  without  any  conspicuous  cleft,  the  diagnosis  may  still  be  made.  The 
view  that  teeth  of  this  nature  prove  the  existence  of  hereditary  syphilis  and  that 
they  occur  only  in  s\-philis  has  been  abandoned  by  Hutchinson  himself.  In 
fact,  only  one-fifth  of  congenital  s\-philitics  have  these  teeth,  and  one-third 
of  the  cases  of  Hutchinson  teeth  are  in  individuals  free  from  s>-philis.  In 
early  infancy  the  diagnosis  of  s\-philis  is  made  by  the  snuffles,  the  broad  nose^ 
the  skin  eruptions,  the  wasted  appearance,  the  sores  at  the  mouth-angles, 
the  tenderness  over  bones,  condylomata,  and  the  history  of  the  parents.  The 
diagnosis  at  a  later  period  is  made  by  the  existence  of  s>Tnmetrical  intersti- 
tial keratitis,  choroiditis,  the  smooth  base  of  the  tongue,  deafness,  which 
comes  on  without  pain  or  running  from  the  ear,  ossifying  nodes,  white  radiat- 
ing scars  about  the  mouth-angles,  sunken  nose,  natiform  skull,  deformity  of  long 
bones,  painless  inflammation  of  epiphyses,  and  Hutchinson  teeth.  It  must 
be  remembered  that  a  child  born  apparently  healthy  and  presenting 
no  secondary  symptoms  may  show  bone  disease,  keratitis,  or  syphilitic  deaf- 
ness at  puberty.  A  positive  Wassermann  reaction  is  highly  significant.  Find- 
ing the  spirochetes  is  of  immense  importance  in  arriving  at  a  diagnosis.  (See 
article  by  Wm.  S.  Gottheil,  "Progressive  Medicine,"  Sept.,  1908.) 

Treatment. — In  infants  it  has  long  been  the  custom  to  use  mercurial  inunctions 
until  the  symptoms  disappear,  but  mercury  must  not  be  forced  or  be  continued 
too  long  after  the  symptoms  are  gone.  There  must  be  rubbed  into  the  sole  of 
each  foot  or  the  palrn  of  each  hand  5  gr.  of  mercurial  ointment  every  morning  and 
night.  Brodie  advised  spreading  the  oinment  (in  the  strength  of  i  dr.  to  the 
ounce)  upon  flannel  and  fastening  it  around  the  child's  belly.  If  the  skin  is 
so  tender  that  mercury  must  be  administered  by  the  mouth,  order  that  }i2 
to  1^  gr.  of  mercury  with  chalk,  with  i  gr.  of  sugar,  be  taken  three  times  a  day 
after  nursing.  If  tertiary  symptoms  appear,  and  in  any  case  when  the  second- 
aries have  passed  away,  give  }^  to  i  gr.  or  more  of  iodid  of  potassium  several 
times  a  day  in  syrup.  The  mixed  treatment  should  be  continued  intermittently 
until  puberty.  Local  lesions  require  local  treatment,  as  in  the  adult.  A  syphi- 
litic child  should,  if  possible,  be  nursed  by  its  mother,  as  it  will  poison  a  healthy 
nurse,  and  also  because  the  mother's  milk  contains  antibodies.     The  mother 


Virchow's  Law  397 

is  given  salvarsan.  If  the  baby  has  a  sore  mouth,  it  must  be  fed  from  a 
bottle,  and  if  the  mother  cannot  nurse  the  child,  it  must  be  brought  up  on  the 
bottle.  For  the  cachexia  use  cod-liver  oil,  iodid  of  iron,  arsenic,  and  the 
phosphates.  Adams  gives  babies  intramuscular  injections  of  galyl  in  glucose 
("Brit.  Med.  Jour.,"  Nov.  16,  1918)  and  seems  to  prove  that  salvarsan  may  be 
given  safely  immediately  after  birth.  To  a  child  over  seven  salvarsan  may  be 
given  intravenously.  The  dose  for  a  child  of  seven  is  0.2  gm.  If  salvarsan 
is  used  mercury  must  also  be  given. 

XVIII.  TUMORS  OR  MORBID  GROWTHS 

Division. — Morbid  growths  are  divided  into  (i)  neoplasms  and  (2)  cysts. 

Neoplasms. — A  neoplasm  is  a  pathological  new  growth  which  tends  to 
persist  independently  of  the  structures  in  which  it  lies,  and  which  performs  no 
physiological  function.  We  say  that  a  tumor  performs  no  physiological  func- 
tion in  order  to  make  clear  that  it  is  never  a  useful  addition  to  the  economy, 
but  we  must  not  imagine  that  the  cells  of  every  tumor  are  devoid  of  physiolog- 
ical activity.  As  Fiitterer  ("Medicine,"  March,  1902)  has  shown,  the  cells  of  a 
carcinoma  of  the  liver  may  secrete  bile,  and  even  the  cells  of  a  secondary  focus 
developing  in  the  course  of  hepatic  carcinoma  may  also  secrete  bile.  The  cells  of 
a  tumor  may  be  active,  but  this  activity  is  not  useful  and  does  not  constitute 
physiological  function.  A  hypertrophy  is  differentiated  from  a  tumor  by  the 
facts  that  it  is  a  result  of  increased  physiological  demands  or  of  local  nutri- 
tive changes,  and  that  it  tends  to  subside  after  the  withdrawal  of  the  exciting 
stimulus.  Further,  a  hypertrophy  does  not  destroy  the  natural  contour 
of  a  part,  while  a  tumor  does.  Inflammation  has  marked  symptoms:  its 
swelling  does  not  tend  to  persist,  it  terminates  in  resolution,  organization,  or 
"suppuration,  and  examination  of  a  section  of  tissue  under  the  microscope  dif- 
ferentiates it  from  tumor.  Inflammation,  too,  has  an  assignable  exciting 
cause.  A  new  growth  is  a  mass  of  newly  formed  tissue;  hence  it  is  improper 
to  designate  as  tumors  those  swellings  due  to  extravasation  of  blood  (as  in 
hematocele),  or  of  urine  (as  in  ruptured  urethra),  to  displacement  of  parts 
(as  in  hernia,,  floating  kidney,  or  dislocation  of  the  liver),  or  to  fluid  disten- 
tion of  a  natural  cavity  (as  in  hydrocele  or  bursitis). 

Classes  of  Tumors. — There  are  two  classes  of  tumors:  the  first  class 
includes  those  derived  from  or  composed  of  ordinary  connective  tissue  or  of 
higher  structures.  These  all  originate  from  cells  which  are  developed  from 
the  mesoblast.  There  are  two  groups  of  connective-tissue  tumors:  (a)  the 
typical,  innocent,  or  benign,  which  mimic  or  imitate  some  connective  tissue 
of  the  healthy  adult  human  body;  and  (h)  the  atypical  or  malignant,  which 
find  no  counterpart  in  the  healthy  adult  human  body,  but  rather  in  the  im- 
mature connective  tissues  of  the  embryo. 

The  second  class  of  tumors  includes  those  which  are  derived  from  or  com- 
posed of  epithelium:  (a)  the  typical  or  innocent,  composed  of  adult  epithe- 
lium; and  (b)  the  atypical,  or  malignant,  composed  of  embryonic  epithehum. 

Miiller's  law  is  that  the  constituent  elements  of  neoplasms  always  have 
their  types,  counterparts,  or  close  imitations  in  the  tissues,  either  embryonic  or 
mature,  of  the  human  body. 

Virchow's  law  is  that  the  cells  of  a  tumor  spring  from  pre-existing  cells. 
There  is  no  special  tumor-cell  or  cancer-cell. 

The  starting-point  of  a  tumor  is  a  focus  of  embryonal  cells,  which  focus 
may  have  originated  before  the  person  was  born  or  may  have  resulted  after 
birth  from  some  disease  or  injury.  The  nature  of  the  tumor  depends,  first, 
upon  the  embryonal  layer  from  which  it  took  origin.  Connective-tissue  tumors 
spring  from  the  mesoblast;  epithelial  tumors  spring  from  the  epiblast  or  the 


398  Tumors  or  Morbid   Growths 

hypoblast.  The  nature  of  the  tumor  depends  also  upon  the  stage  in  which  the 
growth  of  its  cells  is  arrested.  If  the  cells  remain  embryonal,  the  growth  is  re- 
garded as  malignant;  if  they  become  fully  developed,  it  is  regarded  as  innocent. 

The  term  "heterologous"  is  no  longer  used  to  signify  that  the  cellular 
elements  of  a  tumor  have  no  counterpart  in  the  healthy  organism,  but  is  em- 
ployed to  signify  that  a  tumor  deviates  from  the  type  of  the  structure  from 
which  it  takes  its  origin  (as  a  chondroma  arising  from  the  parotid  gland). 
Tumors  when  once  formed  almost  invariably  increase  and  persist,  though 
occasionally  warts,  exostoses,  and  fatty  tumors  disappear  spontaneously. 
Tumors  may  ulcerate,  inflame,  slough,  be  infiltrated  with  blood,  or  undergo 
mucoid,  calcareous,  or  fatty  degeneration. 

The  causes  of  tumors  are  not  positively  recognized,  those  alleged  being 
but  theories  varying  in  probability  and  ingenuity. 

The  inclusion  theory  of  Cohnhcim  supposes  that  more  embryonic  cells  exist 
than  are  needful  to  construct  the  fetal  tissues,  that  masses  of  them  remain  in 
the  tissues,  and  that  these  embryonic  cells  may,  later  in  life,  be  stimulated 
into  active  growth  perhaps  by  injury  or  irritations  or  hereditary  tendency. 
In  other  words,  Cohnheim  believes  that  all  tumors  arise  from  embryonal 
cells  which  were  included  or  imprisoned  by  adult  cells  during  fetal  life  and 
were  not  used  during  development;  or  from  cells  which  were  "displaced  from 
their  proper  relations  during  the  process  of  cell  differentiation  in  the  embryo" 
(Henry  Morris,  "Lancet,"  Dec.  12,  1903).  The  embryonic  hypothesis  seems 
to  receive  a  certain  force  from  the  facts  that  exostoses  do  sometimes  develop 
from  portions  of  unossified  epiphyseal  cartilage,  and  that  tumors  often  arise 
in  regions  where  there  was  a  suppression  of  a  fetal  part,  closure  of  a  cleft,  or 
an  involution  of  epithelium  (epitheUoma  is  usual  at  mucocutaneous  junctions). 
This  theory  does  not  explain  the  origin  of  malignant  tumors  in  scars  or  recent 
callus  in  parts  subjected  to  injury  or  operation,  etc.  (Ibid.). 

Durante's  addition  to  Cohnheim's  theory  does  explain  them.  Cohn- 
heim taught  that  the  matrix  from  which  a  tumor  springs  is  always  an  ante- 
natal embryonic  area.  Durante  says  a  tumor  may  also  spring  from  a  postnatal 
embryonic  area  resulting  from  injury  of  the  mature  tissues,  lessening  their 
chemical  and  physiological  activities  (Morris)  and  causing  them  to  revert 
to  an  embryonic  condition. 

Objection  has  been  made  to  the  Cohnheim  theory  on  the  ground  that 
an  embryonal  matrix  could  not  remain  quiescent,  but,  as  Henry  Morris  says, 
certain  teeth,  the  female  mammary  gland,  the  larynx,  and  certain  appendages 
of  the  skin  may  not  develop  until  puberty  ("Bradshaw  Lecture,"  in  "Lancet," 
Dec.  12,  1903).  Branchial  cysts  which  are  known  to  have  such  an  origin  are 
seldom  seen  until  after  puberty,  and  the  same  is  true  of  many  dermoids. 

Morris  shows  that  congenital  matrices  have  been  shown  to  exist  in  the  brain, 
tongue,  eye,  testicle,  ovary,  broad  ligament,  line  of  coalescence  in  the  trunk, 
and  other  places,  and  such  matrices  constitute  fetal  rests  or  vestiges.  The 
same  author  shows  that  postnatal  matrices  may  arise  in  the  healing  of  a  wound 
or  ulcer,  fistula,  burns,  etc.  Portions  of  epithelium  are  separated,  get  placed 
deeply  in  the  newly  forming  tissue,  become  surrounded  by  connective  tissue, 
and  may  later  take  on  active  growth.  As  Ribbert  points  out,  any  fragment 
of  isolated  and  imprisoned  tissue  may  become  a  tumor. 

Heredity  is  an  extremely  uncertain  influence,  though  not  an  influence  to 
be  denied.  I  believe  that  there  is  such  a  thing  as  a  more  or  less  complete 
immunity  to  cancer  and  that  there  is  such  a  thing  as  a  predisposition  to  cancer, 
and  the  predisposition  as  well  as  the  immunity  may  be  hereditary  or  acquired. 
Youth  constitutes  an  almost  though  not  quite  certain  immunity.  Cancer  is 
very  rare  in  youth,  and  when  it  does  occur  in  a  young  person  it  is  always  very 
malignant.  Its  occurrence  means  unnatural  lack  of  tissue  resistance  or  unusual 
vigor  of  cancer-cell.     The  retrogressive  changes  of  age  are  predisposing  causes. 


Causes  of  Tumors  399 

S.  W.  Gross  believed  direct  hereditary  influence  to  be  by  no  means  frequent  in 
cancer  of  the  breast.  From  25  to  37  per  cent,  of  cases  of  cancer  of  the  breast 
have  or  had  cancerous  relatives  (see  page  441) .  Heredity  in  cancer  is  afhrmed  by 
some,  denied  by  others,  and  doubted  by  a  number.  At  most,  hereditary  in- 
fluence may  only  predispose.  Nevertheless,  cases  have  occurred  which  cannot 
be  explained  by  the  term  "coincidence."  In  the  celebrated  " Middlesex  Hospi- 
tal case,"  a  woman  and  five  daughters  had  cancer  of  the  left  breast.  A.  Pearce 
Gould  had  charge  of  a  woman  for'  cancer  of  the  left  breast.  The  mother  of  this 
patient,  the  mother's  two  sisters,  and  two  of  the  mother's  cousins  had  died  of 
cancer.  Power  reports  a  remarkable  instance  of  family  predisposition  to  cancer. 
A  patient  had  his  right  breast  removed  for  cancer  in  i8g6.  In  1897  cancerous 
glands  were  removed  from  the  axilla.  In  1898  he  was  seen  again  with  an  irre- 
movable recurrent  growth.  His  father  died  of  cancer  of  the  breast.  He  had 
two  brothers,  one  of  whom  died  of  cancer  of  the  throat  when  sixty-five  years 
"of  age,  the  other  having  died  of  cancer  of  the  axilla  when  he  was  only  twenty- 
four  years  old.  Of  his  eight  sisters,  four  died  of  cancer  of  the  breast,  and  the 
two  who  are  living  both  suffer  from  cancer  of  the  breast.  One  sister  died  when 
an  infant  and  one  died  after  giving  birth  to  a  child.  ^  The  Emperor  Napoleon, 
his  father,  his  brother  Lucien,  and  his  sisters  Pauline  and  Caroline  died  of 
gastric  cancer.  That  there  is  such  a  thing  as  predisposition  is  rendered  probable 
by  the  fact  that  out  of  'many  exposed  under  like  conditions  a  single  one  may 
develop  cancer.  I  believe,  with  Murphy,  that  there  may  be  such  a  thing  as 
absence  of  resistance  to  the  cause  of  cancer  on  the  part  of  certain  tissues  and 
that  such  impairment  of  resistance  may  be  hereditary. 

Injury  and  inflammation  may  undoubtedly  prove  exciting  causes.  A 
blow  is  not  infrequently  followed  by  sarcoma;  the  irritation  of  a  hot  pipe-stem 
may  excite  cancer  of  the  lip;  the  scratching  of  a  jagged  tooth  may  cause  cancer 
of  the  tongue;  chimney-sweeps'  cancer  (which  used  to  be  seen  in  the  old  days 
when  "the  sweep"  was  an  institution)  arose  from  the  irritation  of  dirt  in  the 
scrotal  creases;  and  warts  often  arise  from  constant  contact  with  acrid  materials. 

Physiological  activity  favors  the  development  of  sarcoma,  and  physiological 
decline  favors  the  development  of  carcinoma. 

Parasitic  Influences. — Many  believe  that  parasites  cause  cancer.  This 
theory  does  not  maintain  that  the  tumor  is  the  parasite,  but  that  it  contains 
the  parasite,  although  Pfeiffer  and  Adamkiewicz  did  at  one  time  assert  that  a 
cancer-cell  is  not  a  body-cell,  but  a  parasite  resembling  an  epithelial  cell.  Butlin 
in  1905  asserted  his  belief  that  the  cancer-cells  are  parasites  and  act  independ- 
ently hke  protozoa.  Most  observers  deny  this  contention  because,  were  it 
true,  there  would  be  only  one  variety  of  cancer,  because  cases  could  only  arise  by 
direct  contact,  and  because  it  would  leave  unanswered  how  the  original  growth 
arose,  as  it  could  not  have  come  from  a  pre-existing  cancer-cell  (Brand,  in 
"Lancet,"  Jan.  11,  1908).  Some  facts  render  a  parasitic  origin  of  malignant 
growths  not  improbable;  as,  for  instance,  the  likeness  of  some  tumors  to  infective 
granulomata,  the  tendency  to  secondary  development  in  distant  parts  of  the 
body,  the  resemblance  of  the  secondary  to  the  primary  growths,  and  the  tenacity 
of  their  persistence.  A  parasitic  origin  of  cancer  is  possibly  suggested  by  its 
geographical  distribution,  the  disease  being  very  common  in  low^  and  marshy 
districts,  and  Haviland  ("Lancet,"  April  27,  1894)  and  others  maintain 
that  certain  houses  become  infected,  the  disease  appearing  in  these  houses 
among  successive  families  inhabiting  them.  They  speak  of  such  abodes  as 
cancer  houses. 

Some  surgeons  believe  that  cancer  is  contagious,  but  most  observers  deny 

it.     Hanau  found  a  rat  with  a  cancer  and  inoculated  other  rats  from  it.     Moreau 

in  1894  inoculated  mice  from  a  mouse  with  cancer.     Guelliott,  of  Rheims, 

believes  that  cancer  is  primarily  a  local  infection.     He  believes  this  because 

1  "Brit.  Med.  Jour.,"  July  16,  iSgS. 


400  Tumors  or  Morbid   Cirowths 

Moreau  and  Hanau  have  inoculated  it  from  one  animal  to  anotiier  of  the 
same  species,  and  if  this  can  be  brought  about  experimentally  he  sees  no  reason 
why  it  cannot  happen  accidentally.  This  surgeon  says  that  cancer  is  very 
unequally  distributed,  that  genuine  cancer  centers  and  "cancer  houses" 
exist,  and  that  numerous  cases  of  accidental  infection  have  occurred. ^  Hahn 
apparently  succeeded  in  grafting  cancer  from  one  part  to  another  on  the  same 
individual.  Jensen  and  Borrell  have  inoculated  the  disease  in  white  mice. 
Mayet,  of  Lyons,  holds  that  cancer  can  be  reproduced  by  grafting  or  by  injec- 
tion of  cancer-fluid.  Graf  could  not  find  cancer  houses  after  a  careful 
search.-  Because  several  people,  in  the  course  of  years,  have  died  in  the  same 
house  of  cancer  is  not  proof  that  the  house  was  infected.  If  such  a  thing  proves 
contagion  there  must  be  contagion  in  many  things  now  thought  free  from  it, 
and  there  must  be  broken-leg  houses,  and  delirium-tremens  houses,  and  heart- 
disease  houses.  Geissler  claims  to  have  produced  the  disease  in  a  dog  by  plant- 
ing fragments  of  cancer  in  the  subcutaneous  tissue  and  vaginal  tissue,  but 
Czerny,  Rosenbach,  and  others  dispute  the  claim.  Plimmer  tells  us  that  an 
epidemic  of  cancer  arose  among  the  captive  white  rats  in  the  Freiburg  Patholog- 
ical Institute,  and  in  each  case  the  growth  was  on  the  rear  part  of  the  body. 
Roswell  Park  believes  that  Gaylord  has  really  produced  adenocarcinoma  in  the 
lower  animals.  Hauser  disputes  the  assertion  that  cancer  must  be  an  infectious 
disease  because  it  is  followed  by  secondary  growths.  Secondary  growths  in  an 
infectious  disease  are  caused  by  the  bacterium;  secondary  growths  in  cancer  are 
caused  by  the  transference  o'f  cells  of  primary  growth. ^  Hauser  says  with 
truth  that  the  close  connection  between  innocent  and  malignant  growths  renders 
the  parasite  view  untenable,  because  to  hold  it  we  would  be  forced  to  believe 
that  every  tumor  has  a  special  parasite  or  that  one  parasite  may  cause  many 
kinds  of  tumors. 

There  seems  to  be  no  doubt  that  autotransference  of  cancer  can  occur, 
although  it  rarely  does  so.  Sippel  has  reported  a  case  in  which  vaginal  car- 
cinoma developed  at  the  point  where  the  vagina  was  in  contact  with  a  pre- 
existing cancer  of  the  portio.*  Cornil  has  seen  cancer  transferred  from  one 
of  the  labia  majora  to  the  other,  and  from  one  lip  to  the  other.  Geissler  was 
unable  to  transplant  cancer,  and  Gratia  also  failed  in  his  attempts.  Duplay 
and  Bazin  say  that  transmissibility  is  possible,  but  only  under  conditions  which 
are  not  practically  realized.  The  facts  that  transplantation  can  be  sometimes 
carried  out,  and  that  contagion  is  a  possible  occurrence  under  exceptional 
circumstances,  do  not  prove  that  cancer  is  a  parasitic  disease,  but  simply 
prove  that  it  can  be  transplanted.  It  is  not  that  the  cancer  carries  a  parasite 
which  will  cause  the  disease  in  sound  tissues,  but  rather  that  the  cells  of  the 
cancer  may  themselves  take  root  and  grow  in  sound  tissues.  The  parasitic 
theory  arose  from  observation  of  the  metastasis  which  occurs  during  the  progress 
of  the  disease,  and  received  support  from  the  fact  that  inoculation  of  another 
part  of  an  individual  suffering  from  cancer  may  be  followed  by  the  development 
of  a  tumor  like  the  original  growth.  For  instance,  if  a  cancer  is  growing  upon 
the  lower  lip,  the  upper  lip  may  be  inoculated  {contact  cancer).  The  same  is 
true  of  the  labia.  Mr.  Harrison  Cripps  reported  the  occurrence  of  cancer 
of  the  skin  of  the  arm  from  contact  with  an  ulcerating  scirrhus  of  the  breast. 
It  has  also  been  pointed  out  that  carcinoma  is  especially  common  in  regions 
predisposed  by  their  situation  to  injury  and  infection,  and  that,  "among  the 
lower  animals  at  least,  tumors  resembling  carcinomata  have  been  transplanted 
from  one  to  another"  ("Recent  Studies  upon  the  Etiology  of  Carcinoma," 
by  Joseph  Sailer,  "Phila.  Med.  Jour.,"  June  7,  1902).     But  there  is  great  doubt 

^  "Amer.  Jour,  of  Med.  Sciences,"  June,  1895. 
^"Archiv.  f.  klin.  Chir.,"  1895,  1,  p.  144. 
'  Hauser,  in  "Biolog.  Centralbl.,"  Oct.  2,  1895. 
^"Centralbl.  f.  Gynak.,"  No.  4,  1894. 


Causes  of  Tumors  401 

as  to  the  cancerous  nature  of  some  of  the  tumors  which  have  been  successfully 
transplanted  from  one  animal  to  another. 

A  transplanted  mouse  cancer  may  grow  for  a  time  and  then  completely 
disappear,  and  some  observers  (among  them  Gaylord)  hold  that  when  this 
occurs  the  mouse  has  become  immune. 

In  1908  the  German  Pathological  Society  met  in  Kiel  and  discussed  various 
problems  of  cancer.  In  this  meeting  Sticker  maintained  that  there  is  such  a 
thing  as  natural  immunity  to  tumors.  He  showed  that  a  tumor  arising  spon- 
taneously in  an  animal  can  never  be  transplanted  into  an  animal  of  another 
species,  and  very  seldom  can  a  malignant  tumor  be  transplanted  into  an  animal 
of  the  same  species.  He  quotes  Metchnikoff's  utter  failure  to  transplant 
human  tumors  into  anthropoid  apes  and  reports  his  own  failure  to  transplant 
human  tumors  into  various  domestic  animals.  He  made  over  400  trials  and 
failed  every  time  ("  Jour.  Am.  Med.  Assoc,"  from  Sticker,  "  Zeitschr.  f.  Krebs- 
forschung,"  1908,  vii). 

In  successful  transplantations  there  has  been  but  slight  effort  to  prove  that 
epithelial  cells  were  not  transferred  with  the  supposed  parasites,  and  if  they 
were  transferred  the  success  of  the  experiment  does  not  prove  that  cancer  is  due 
to  parasites,  but  simply  proves  again  what  we  knew  before — that  epithelial 
■cells  can  be  transplanted.  Many  parasites  have  been  regarded  as  causative  by 
different  observers.  Bacteria,  yeast-cells,  and  protozoa  have  been  found  by  dif- 
ferent experimenters.  It  is  not  thought  that  bacteria  are  causative.  Yeasts  are 
regarded  as  causative  by  some.  It  is  certain  that  they  may  exist  in  cancer, 
but  it  is  by  no  means  certain  that  they  cause  the  disease.  They  may  be  only 
:a  contamination.  Gaylord  and  others  regard  protozoa  as  causative,  but 
this  statement  does  not  seem  to  be  proved.  Many  of  the  supposed  parasites 
'of  cancer  have  been  shown  to  be  cell  degenerations  or  contaminations.  Rous 
claims  that  a  filterable  virus,  obtained  from  chicken  sarcoma  reproduces  the 
disease  in  other  chickens  (''Jour.  Exper.  Med.,"  1914,  xix).  We  are  justified 
in  concluding  that  the  parasitic  origin  is  not  as  yet  proved,  and  we  agree  with  the 
.elder  Senn  that  it  is  improbable. 

Tillmanns  elaborately  discussed  the  subject  of  cancer  in  the  Congress  of 
1895.  His  conclusions  are  still  most  sound  and  scientific.  He  says  there  is 
no  evidence  of  a  bacterial  origin  of  cancer.  The  parasitic  origin  has  not  been 
proved,  and  protozoa  have  not  certainly  been  found.  Cancer  can  be  trans- 
ferred from  one  part  to  another  of  the  same  individual,  or  from  one  indi- 
vidual to  another  of  the  same  species,  but  never  to  one  of  a  different  species. 
It  is  possible  that  cancer  can  spread  by  contagion;  this  is  very  rare,  but  can 
happen  (as  when  penile  cancer  is  followed  by  cervix  cancer  in  a  wife).  Be- 
cause it  is  sometimes  possible  to  transfer  cancer,  this  does  not  prove  that  the 
disease  is  parasitic  or  infectious;  it  simply  shows  that  tissue  has  been  success- 
fully transplanted. 

Cancer  a  deux  is  cancer  developing  in  people  who  live  together.  Such 
•cases  suggest,  but  do  not  prove,  contagion.  Behla  collected  19  cases  and 
Guelliot  103  cases.  Conjugal  cancer  is  classified  as  cancer  a  deux.  A  wife, 
for  instance,  may  have  cancer  of  the  womb  and  a  husband  may  develop  can- 
cer of  the  penis,  supposedly  from  contact.  Conjugal  cancer  is  probably  due 
to  irritation  or  implantation  and  not  to  microbic  inoculation. 

Actinomycosis,  long  thought  to  be  a  true  tumor,  is  now  known  to  arise  from 
the  ray-fungus.  Some  think  that  psorosperms  cause  cancer.  There  can 
be  no  doubt  that  changes  in  the  liver  which  practically  constitute  a  new  growth 
can  arise  from  the  growth  of  a  cell  called  by  Darier  the  "psorosperm."  A 
disease  due  to  psorosperms  is  called  a  "psorospermosis."  It  is  affirmed  by  some 
that  molluscum  contagiosum,  follicular  keratosis,  cancer,  and  Paget's  disease 
are  due  to  psorosperms.  Some  claim  to  find  the  parasite  in  all  cases  of  cancer, 
^while  others  can  find  it  in  only  4  or  5  per  cent,  of  the  cases. 
26 


402  Tumors  or  ]\Iorbicl   Growths 

Heneage  Gibbes  affirms^  that  dilatation  of  the  bile-ducts  of  a  rabbit's 
liver  is  caused  by  the  chronic  irritation  arising  from  multiplication  of  the  Coc- 
cidium  oviforme  in  them,  and  not  in  the  columnar  cells  of  the  bile-ducts,  as  has 
been  stated;  and,  further,  that  the  large  majority  of  glandular  cancers  show  noth- 
ing that  can  be  considered  parasitic,  the  suspicious  appearances  noted  in  some 
few  cases  being  due  to  endogenous  cell  formation.  The  Coccidium  oviforme 
is  a  genus  of  the  sporozoa,  class  protozoa,  the  lowest  division  of  the  animal 
kingdom.  To  this  class  belong  the  monera  and  infusoria.  (For  a  further 
discussion  of  this  subject  see  page  63.) 

Malignant  and  Innocent  Tumors. — Malignant  growths  infiltrate 
the  tissues  as  they  grow;  benign  tumors  only  push  the  tissues  away;  hence 
malignant  tumors  are  not  thoroughly  encapsuled,  while  innocent  tumors  are 
encapsuled.  Malignant  tumors  grow  rapidly;  innocent  tumors  grow  slowly. 
Malignant  tumors  become  adherent  to  the  skin  and  cause  ulceration;  innocent 
tumors  rarely  adhere  and  seldom  cause  ulceration.  Many  malignant  tumors 
give  rise  to  secondary  growths  in  adjacent  lymphatic  glands  (cancer,  except 
in  the  esophagus  and  antrum  of  Highmore,  always  does  so;  sarcoma  rarely 
causes  them,  unless  the  growth  be  melanotic  or  lymphosarcoma,  or  unless  it 
arises  in  the  testicle  or  tonsil).  Innocent  tumors  never  cause  secondary  lym- 
phatic involvement;  although  the  glands  near  the  tumor  may  enlarge  from 
accidental  inflammatory  complications.  The  malignant  tumors,  especially  cer- 
tain sarcomata  and  soft  cancers,  may  be  followed  by  secondary  growths 
(metastases)  in  distant  parts  and  various  structures  (bones,  viscera,  brain, 
muscles,  etc.);  innocent  tumors  are  not  followed  by  these  secondary  repro- 
ductions, although  multiple  fatty  tumors  or  multiple  lymphomata  may  exist. 
Malignant  tumors  destroy  the  general  health,  inducing  anemia  and  cachexia; 
innocent  tumors  do  not,  unless  by  the  accident  of  position.  Malignant  tumors 
tend  to  recur  after  removal;  innocent  tumors  do  not  if  operation  has  been 
thorough.  The  special  histological  feature  of  a  malignant  growth  is  the 
possession  by  its  cells  of  a  power  of  reproduction  which  knows  no  limit,  the 
cells  of  the  tumor  living  among  the  body-cells  like  a  parasite  and  invading 
and  destroying  them. 

The  Cachexia  of  Malignant  Disease. — This  condition  arises  sooner  or  later 
in  every  uncured  case  of  sarcoma  and  carcinoma. 

In  sarcoma  there  is  advancing  anemia  and  there  are  often  episodes  of  ele- 
vated temperature  due  to  the  absorption  of  toxic  materials  from  the  tumor. 
The  blood  examination  gives  results  similar  to  those  found  in  cancer,  but  leu- 
kocytosis is  more  frequent.  Pain  is  far  less  prominent  than  in  cancer  unless  a 
nerve  is  involved  or  squeezed.  Ulceration  occurs  much  later  in  sarcoma  than 
in  carcinoma. 

In  carcinoma  (see  page  435)  the  emaciation  is  rapid  and  decided,  the  loss  of 
strength  is  significant  and  notable,  and  the  anemia  is  marked  and  progressive. 
It  is  due  to  pain,  sleeplessness,  ulceration,  impaired  appetite  and  digestion, 
repeated  hemorrhages,  and  the  absorption  from  th£  tumor  of  toxic  products, 
which  are  probably  enzymes  (especially  isohemolysins).  Loss  of  hemoglobin 
is  early  and  is  followed  by  decrease  in  the  number  of  red  cells.  In  many  cases 
considerable  amounts  of  sugar  exist  in  the  blood.  Irregular  fever  may  occur. 
In  both  sarcoma  and  carcinoma  the  development  of  secondary  growths  aggra- 
vates the  anemia. 

Classification. — Tumors  may  be  classified  as  follows: 

I.  Connective-tissue  tumors  (those  derived  from  the  mesoblast). 

I.  Innocent   tumors,   or   those  composed  of  mature  connective  tissue: 

Lipomata,    or    fatty   tumors;  fibromata^   or   fibrous   tumors;   chondro- 

maia,  or  cartilaginous   tumors;  osteomata,  or  bony  tumors;  odonto- 

mata,  or  tooth-tumors;  myxomata,  or  mucous  tumors;  myomata,  or 

1  "Amer.  Jour,  of  Med.  Sciences,"  July,  1893. 


Lipomata 


403 


muscle-tumors;  neuromata,  or  tumors  upon  nerves;  gliomata,  or  tu- 
mors composed  of  neuroglia;  angiomata,  or  tumors  formed  of  blood- 
vessels; lymphangiomata,  or  tumors  formed  of  lymphatic  vessels. 
The  term  lymphoma,  meaning  a  tumor  of  a  lymphatic  gland,  was 
formerly  applied  to  hypertrophy  and  hyperplasia  of  a  lymphatic 
gland,  no  matter  whether  caused  by  syphiHs,  tubercle,  Hodgkin's 
disease,  or  any  other  morbid  impression.  The  term  has  been  largely 
abandoned  except  as  expressing  enlargement  of  a  gland,  and  does 
not  convey  any  suggestion  as  to  the  cause.  It  is  doubtful  if  there 
is  such  a  thing  as  a  true  lymphoma,  understanding  by  the  term  a 
neoplasm  arising  from  and  composed  of  lymphoid  cells  and  resembling 
lymphatic  structure.  In  the  described  cases  the  possibility  of 
infection  as  a  cause  has  not  been  eliminated 

Malignant  tumors,  or  those  composed  of  embryonic  connective  tissue. 

Sarcomata  and  adrenal  tumors ; 


Fig.   i6g. — Lipoma,  wandered  from  axilla. 


Fig.   170. — Diffuse  lipoma. 


Endotheliomata  are  regarded  by  some  as  constituting  an  independent 
group  and  by  others  as  a  variety  of  sarcomata. 

II.  Epithelial    tumors    (those   derived   from    the    epiblast   or   hypoblast). 

1.  Innocent   tumors,   or    those   composed   of   mature   epithelial   tissue: 
Adenomata,  or  tumors  whose  type  is  a  secreting  gland;  and  papillo- 

fnata,  or  tumors  whose  type  is  found  in  the  papillee  of  skin  and 
mucous  membranes. 

2.  Malignant  tumors,  or  those  composed  of  embryonic  epithelial  tissue: 

Carcinomata,  or  cancers. 

III.  Cystomata  are  cystic  tumors,  the  cyst-walls  of  which  are  new  growths 
and  the  contents  of  which  are  produced  by  the  cells  of  the  newly 
formed  cyst  walls. 

IV.  Teratomata  (tumors  containing  epiblastic,  hypoblastic,  and  meso- 
blastic  elements). 

Innocent  Connective=tissue  Tumors. — These  growths  mimic  or  imi- 
tate some  connective  tissue  or  higher  tissue  of  the  mature  and  healthy  organism. 

Lipomata  are  congenital  or  acquired  tumors  composed  of  fat  contained 
in  the  cells  of  connective  tissue,  and  these  cells  are  bound  together  by  fibers.  If 
the  fibers  are  excessively  abundant,  the  growth  is  spoken  of  as  a  fihrofatty 


404 


Tumors  or  Morbid  Growths 


tumor.  A  fatty  tumor  has  a  distinct  capsule,  tightly  adherent  to  surrounding 
parts,  but  loosely  attached  to  the  tumor;  hence  enucleation  is  easy.  Fibrous 
trabecule  run  from  the  capsule  of  a  subcutaneous  lipoma  to  the  skin;  hence 
movement  of  the  integument  over  the  tumor  or  of  the  tumor  itself  causes 
dimpling  of  the  skin.  An  ordinary  circumscribed  lipoma  is  of  doughy  soft- 
ness, is  lobulated,  of  uniform  consistence,  and  on  being  tapped  imparts  to  the 
finger  a  tremor  known  as  pseudofluctuation.  A  fatty  tumor  is  mobile,  although 
it  may  be  attached  to  the  skin  at  points  by  trabeculae.  Sometimes  a  fatty 
tumor  gradually  shifts  its  position  or  wanders  (Fig.  i6g).  This  is  due  to  gravity. 
Lipomata  are  most  frequent  in  middle  life,  and  their  commonest  situa- 
tions are  in  the  subcutaneous  tissues,  especially  of  the  back  or  of  the  dorsal 
surfaces  of  the  limbs;  they  usually  occur 
singly,  but  may  be  multiple  and  some- 
times symmetrical.  Senn  described 
the  case  of  a  woman  who  had  a  fatty 
tumor  in  each  axilla.  A  lipoma  may 
grow  to  an  enormous  size  (in  Rhodius's 
case  the  tumor  weighed  60  pounds),  and 


Fig.  171. — Lipoma  of  submaxillary  region. 


Fig.  172. — Congenital  diffuse  lipoma 
of  foot  and  leg.  Child  seven  years  of  age, 
second  and  third  toes  amputated  at 
thirteen  months  and  large  mass  moved 
from  sole  of  foot.  Later  a  large  fatty 
mass  moved  from  calf  of  leg,  surround- 
ing gastrocnemius  and  soleus  muscles 
and  between  them  (Rugh), 


the  growth  may  be  progressive  or  may  be  at  times  stationary  and  at  other 
times  active.  The  skin  over  a  fatty  tumor  sometimes  atrophies  or  even 
ulcerates;  the  tumor  itself  may  inflame  or  partly  calcify.  When  a  lipoma 
has  once  inflamed,  it  becomes  immovable.  Subcutaneous  lipoma  of  the 
palm  of  the  hand  or  sole  of  the  foot  bears  some  resemblance  clinically  to 
a  compound  ganglion;,  it  is  apt  to  be  congenital.  Lipomata  of  the  head  and 
face  are  rare.  In  the  subcutaneous  tissues  of  the  groins,  neck,  pubes,  axilla?, 
or  scrotum  a  mass  of  fat  may  form,  unlimited  by  a  capsule  and  known  as  a 
diffuse  lipoma  (Figs.  170  and  172).  A  diffuse  lipoma  may  dip  down  among 
the  muscles.  Such  masses  attain  large  size.  The  typical  diffuse  lipoma 
is  occasionally  seen  on  the  neck.  It  begins  back  of  the  mastoid  process  on 
one  side  or  on  both  sides.  When  large,  it  completely  surrounds  the  neck,  a 
huge  double  chin  forming  in  front,  a  great  mass  hanging  on  each  side,  and  the 


Treatment  of  Lipomata  405 

posterior  portion  being  divided  into  two  halves  by  a  median  depression.  A 
nevolipoma  is  a  nevus  with  much  fibrofatty  tissue.  A  very  vascular  fatty  tu- 
mor is  called  lipoma  telangiectodes.  If  the  tumor  stroma  contains  large  veins 
the  growth  is  called  a  cavernous  lipoma.  A  tumor  containing  much  blood  can 
be  diminished  in  size  by  pressure.  Fatty  tumors  may  arise  in  the  subserous 
tissue,  and  when  such  a  growth  arises  in  either  the  femoral  or  inguinal  canal 
or  the  linea  alba  it  resembles  an  omental  hernia  and  is  spoken  of  as  a,  fat  hernia. 
In  the  retroperitoneal  tissues  enormous  fibrofatty  tumors  occasionally  grow, 
and  these  neoplasms  tend  to  become  sarcomatous.  In  other  regions  lipomata 
very  seldom  become  sarcomatous.  Schiller  reports  two  cases  in  which  lipomata 
underwent  sarcomatous  transformation  ("Surgery,  Gynecology  and  Obstetrics," 
August,  191 8).  Lipomata  which  arise  from  beneath  synovial  membranes  pro- 
ject into  the  joints,  being  still  covered  by  synovial  membrane.  Fatty  tumors 
occasionally  arise  in  submucous  tissues,  between  or  in  muscles,  from  periosteum, 
and  from  the  meninges  of  the  spinal  cord  (Sir  J.  Bland-Sutton).  A  fatty  tumor 
may  undercjo  metamorphosis.     The  stroma  may  be  attacked  by  a  myxomatous 


Fig.  173. — Fatty  tumor. 

process  or  a  calcareous  degeneration.  The  fat-cells  themselves  may  become 
calcareous.  Oil-cysts  sometimes  form.  A  xanthoma  is  a  growth  composed  of 
fatty  tissue  in  and  about  which  there  is  marked  infiltration  with  small  cells. 
Such  a  tumor  is  flattened  and  slightly  elevated.  Several  or  many  of  these 
growths  occur  in  the  same  person.  The  eyelids  are  the  most  common  seat  of 
xanthoma.     The  tumor  may  undergo  involution  or  may  become  sarcomatous. 

Diabetics  are  Hable  to  develop  xanthomata. 

Treatment. — A  single  subcutaneous  lipoma  should  be  extirpated.  The 
capsule  must  be  incised,  when  the  tumor  is  torn  out  forcibly  or,  better,  is  enu- 
cleated by  dissection;  drainage  is  always  employed  for  twenty-four  hours, 
as  butyric  fermentation  will  be  apt  to  occur,  and  necrosis  of  small  particles 
of  fat  predisposes  to  infection.  Multiple  subcutaneous  lipomata,  if  very 
numerous,  should  not  be  interfered  with  unless  troublesome  because  of  their 
size  or  situation,  when  the  growth  or  growths  causing  trouble  should  be  re- 
moved. It  is  difficult  to  extirpate  entirely  a  diffuse  lipoma,  and  several  opera- 
tions may  be  needed  to  effect  complete  removal.  Liquor  potassae,  once  recom- 
mended as  possessing  power,  when  taken  internally,  to  limit  the  growth  of 
multiple   lipomata   or    diffuse   lipoma,    seems    to   be   useless.     Subperitoneal 


4o6  Tumors  or  Morbid  (Growths 

lipomata  are  rarely  diagnosticated  until  the  belly  has  been  opened,  sometimes 
not  until  the  growth  has  been  removed. 

Fibromata  are  tumors  comi)osed  of  bundles  of  fibrous  tissue.  There 
are  two  forms,  the  hard  and  the  soft.  A  hard  fibroma  consists  of  wavy  fibrous 
bundles  lying  in  close  contact.  Here  and  there  connective-tissue  corpuscles 
exist  between  the  fibers.  A  hard  fibroma  has  no  distinct  capsule,  though  sur- 
rounding tissues  are  so  compressed  as  to  simulate  a  capsule.  Fibromata  are 
occasionally  congenital,  are  most  usual  in  young  adults,  but  they  may  occur  at 
any  period  of  life,  and  in  any  part  of  the  body  containing  connective  tissue. 
Pure  fibromata,  which  are  rare,  are  generally  solitary,  grow  slowly,  are  of  uni- 
form consistence,  have  not  much  circulation,  and  are  hard  and  movable.  Fibro- 
mata may  form  upon  nerve-sheaths,  may  arise  in  the  mammary  gland,  may 
develop  in  the  lobe  of  the  ear  and  from  the  stomach,  and  may  spring  from  various 
fibrous  membranes,  from  the  periosteum  of  the  base  of  the  skull  {nasopharyn- 
geal fibromata),  and  from  the  gums  {fibrous  epulides).  A  soft  fibroma  contains 
much  areolar  tissue,  the  spaces  of  which  are  filled  with  fluid,  so  that  the  tissue 
seems  edematous.  Soft  fibromata  grow  from  the  skin,  mucous  membrane, 
subcutaneous  tissue,  intermuscular  planes,  and  periosteum.  Soft  fibromata 
possess  distinct  pedicles  and  are  especially  apt  to  arise  from  the  skin  of  the  scro- 
tum, labia,  inner  surface  of  arm  and  thigh,  and  from  the  belly  wall  of  a  pregnant 
woman.  They  are  not  unusually  multiple,  grow  slowly,  but  more  rapidly  than 
the  hard  fibromata,  and  may  become  quite  large.  Fibromata  may  become 
cystic,  calcareous,  osseous,  colloidal,  or  sarcomatous,  and  may  inflame,  ulcerate, 
or  even  become  gangrenous. 

A  painful  subcutaneous  tubercle,  which  is  a  form  of  fibroma  commonest  in 
females,  arises  in  the  subcutaneous  cellular  tissue,  usually  of  the  extremities. 
It  is  firm,  very  tender,  movable,  rarely  larger  than  a  pea,  and  the  skin  over  it 
seem,S  healthy.  Violent  pain  occurs  in  paroxysms  and  radiates  over  a  con- 
siderable area,  of  which  the  tubercle  is  the  center.  These  paroxysms  may 
occur  only  once  in  many  days  or  many  times  in  one  day.  Pain  is  always  de- 
veloped by  pressure,  and  may  be  linked  with  spasm.  Nerve-fibrillas  are  now 
known  to  exist  in  these  tubercles,  a  fact  which  was  long  denied. 

A  mole  is  a  fibroma  of  the  skin  which  is  gongenital  or  appears  in  the  early 
weeks  of  life.  It  is  rounded  or  flat,  is  usually  pigmented  and  of  a  brown  color, 
is  slightly  elevated  above  the  cutaneous  level,  and  has  a  few  hairs  or  an  abun- 
dant crop  of  hair  growing  from  it,  and  varies  in  size  from  a  pin's  head  to 
several  inches  in  diameter,  or  may  even  occupy  an  extensive  area  of  a  limb  or 
of  the  trunk.  The  tumor  rarely  grows  after  the  thirteenth  or  fourteenth  year. 
A  mole  may  become  malignant,  melanotic  carcinoma  may  arise  from  its  epi- 
thelial structures,  or  melanotic  sarcoma  from  its  connective-tissue  elements, 
A  mole  is  an  extremely  vascular  structure;  it  bleeds  freely  when  cut  or  scratched, 
and  it  sometimes  ulcerates.  Occasionally  several  or  many  moles  exist  in  the 
same  individual.  If  a  mole  begins  to  increase  rapidly  in  size,  operation  is  im- 
perative, as  rapid  growth  probably  indicates  malignant  change. 

Fibrous  epidis  is  a  fibroma  arising  from  the  gums  or  periodontal  membrane 
(Sir  J.  Bland-Sutton)  in  connection  with  a  carious  tooth  or  retained  snag;  it 
is  covered  by  mucous  membrane,  grows  slowly,  may  attain  a  large  size,  and 
sometimes  has  a  stem,  but  is  more  often  sessile.  It  may  undergo  myxomatous 
change  or  may  become  sarcomatous. 

Fibrous  tumors  may  arise  from  the  ovary,  the  intestine,  the  larynx,  and 
the  submucous  tissues  of  the  gastro-intestinal  tract.  Pure  fibromata  of  the 
uterus  are  very  rare,  but  fibromyomata  are  very  common  (see  Myomata,  page 
414);  hence  the  term  "uterine  fibroid"  should  be  abandoned. 

Desmoid  tumors  of  the  abdominal  wall  are  cellular  fibromata.  A  desmoid 
tumor  has  a  strong  disposition  to  become  sarcoma.  It  has  no  real  capsule. 
It   takes  origin  from  one  of  the  abdominal  muscles  or  muscular  insertions 


Fibromata 


407 


or  from  fascia,  particularly  from  the  rectus  muscle  or  its  sheath.  In  most 
cases  the  growth  is  slow;  in  some  it  is  rapid  and  the  tumor  may  attain  a  great 
size.  It  may  project  either  anteriorly  or  toward  the  abdomen.  This  form  of 
tumor  is  vastly  more  common  in  women  than  in  men  and  is  especially  com- 
mon in  women  who  have  borne  children.  It  may  occur  at  any  age,  but  is  most 
frequent  in  those  between  twenty-five  and  thirty-five.  It  is  a  very  rare  tumor. 
(See  Harvey  B.  Stone,  "Annals  of  Surgery,"  August,  1908.) 

Mollusc'iim  jibrosnni  is  an  overgrowth  of  the  fibrous  tissue  of  both  the  skin 
and  subcutaneous  structure.  Senn  excludes  this  form  of  growth  from  considera- 
tion with  fibromata  because  of  its  supposed  infective'origin.  It  may  be  limited 
or  widely  extended;  it  may  appear  as  an  infinite  number  of  nodules  scattered 
over  the  entire  body  or  as  hanging  folds  of  fibrous  tissue  in   certain   areas. 

Keloid  (Figs.  174,  175)  is  a  fibroma  of  the  true  skin.  It  is  a  hard  and  fibrous 
vascular  growth,  with  a  broad  base,  arising  in  scar-tissue;  it  is  crossed  by  pink, 
white  or  discolored  ridges,  and  is  named  from  a  fancied  likeness  to  the  crab. 
It  has  rarely  attacked  mucous 
membrane.  It  is  more  common 
in  negroes  than  in  whites,  and  is 
most  frequent  in  the  cicatrices 
of    burns,    though   it   may    arise 


Fig.  174. — Keloid  following  a  burn. 


Fig.  175. — Keloid  (case  of  Dr.  L.  L.  Plill,  Mont- 
gomery, Alabama). 


in  the  scar  of  any  injury,  as  the  scar  from  piercing  the  ears,  and  in  the  scars 
of  syphilitic  lesions,  tuberculous  processes,  smallpox,  or  vaccination.  I  believe 
that  the  scars  of  tuberculous  lesions  and  the  scars  even  of  ordinary  wounds 
in  tuberculous  individuals  are  particularly  apt  to  become  keloidal.  In  negroes 
keloid  is  not  uncommon  in  the  scar  remaining  after  operations  upon  tubercu- 
lous glands  of  the  neck.  It  is  very  common  in  a  person  with  keloid  to  be  able  to 
find  some  near  or  distant  tuberculous  lesion,  or  a  history  of  former  tuberculosis, 
or  the  record  of  the  individual  having  tuberculous  tendencies.  The  victim  of 
keloid  usually  reacts  to  tuberculin.  The  growth  seldom  begins  in  early  child- 
hood or  in  old  age.  It  grows  slowly,  lasts  for  many  years,  and  may  eventually 
undergo  involution  and  disappear.  The  fact  that  keloid  is  especially  common  in 
the  negro  race  (a  race  predisposed  to  tuberculosis)  and  that  it  is  so  frequently 
met  with  in  the  scars  of  known  tuberculous  processes,  suggests  the  possibihty  of 
a  tuberculous  cause  for  the  condition.  The  rapid  return  of  keloid  after  opera- 
tion suggests  a  near  or  distant  infection  which  furnishes  material  to  a  point  of 
least  resistance  which  causes  keloid  to  redevelop.     Some  cases  of  keloid  have 


4o8  Tumors  or  Morbid  Growths 

active  tuberculous  lesions,  others  have  had  them,  in  still  others  latent  or  dis- 
tant lesions  may  be  found  by  careful  search.  In  many  cases  there  is  a  family 
history  of  tuberculosis.  I  am  at  present  investigating  this  important  matter. 
It  is  certain  that  the  keloid  itself  does  not  contain  bacteria.  Repeated  exami- 
nations have  failed  to  find  them.  It  is  quite  possible  that  the  growth  con- 
tains toxins  of  tubercle  bacilli,  the  toxins  being  the  irritant  cause.  I  am  now 
seeking  to  determine  if  material  from  keloid  introduced  into  tuberculous  ani- 
mals will  cause  a  reaction.  Brenizer  ("Annals  of  Surgery,"  1915,  Ixi)^  combats 
the  view  that  tuberculosis  is  in  any  direct  way  causal  of  keloid.  It  is  usually 
believed  that  it  is  practically  useless  to  remove  keloid  by  operation,  as  it  will 
almost  certainly  return;  yet,  a  study  of  the  growth  removed  shows  no  reason 
for  the  inevitable  return.  Charles  A.  Porter  has  reported  a  case  of  massive 
keloid  of  the  face  and  hands  notably  benefited  by  many  operations  and  skin- 
grafting.  In  this  case.  Porter  says,  "there  has  been  a  gradual  but  distinct 
abatement  of  the  tendency  to  form  keloid  tissue"  ("Annals  of  Surgery,"  July, 
1909).  The  fibrous  tissue  of  keloid  springs  from  the  outer  walls  of  the  blood- 
vessels. The  papillae  of  the  skin  above  the  tumor  are  destroyed  or  replaced  by 
fibrous  tissue. 

Morphea,  spontaneous  or  true  keloid,  is  a  name  used  to  designate  a  growth 
of  this  description  which  does  not  arise  from  a  scar;  but  it  seems  certain  that 
scar-tissue  was  present,  though  possibly  in  small  amount  from  trivial  injury. 

Fibrous  and  papillomatous  growths  covered  with  endothelium  my  spring 
from  any  serous  membrane.  Such  a  growth  of  the  choroid  plexus  calcifies  early 
and  constitutes  a  psammoma  or  brain-sand  tumor.  Such  tumors  are  met  with 
not  only  in  the  choroid  plexus,  but  also  in  the  conarium  and  the  dura.  All 
psammomata  are  not  fibrous;  some  are  gliomatous  and  some  are  endothelio- 
matous.  A  cholesteatoma  is  a  fibrous  growth  covered  with  endothehum  and  con- 
taining layers  of  crystalline  fat.  It  occurs  especially  in  the  pia  mater,  but 
may  arise  in  either  of  the  other  rnembranes  or  even  in  the  brain  substance, 
and  is  called  a  pearl  tumor. 

Treatment. — Fibromata  should  not  be  let  alone,  because  any  fibrous  tumor 
may  become  a  sarcoma.  When  in  accessible  regions  they  should  be  enu- 
cleated. If  a  hard  fibroma  of  the  skin  exists,  the  skin  is  incised  and  the  tumor 
is  "shelled  out."  A  soft  fibroma  is  removed  by  an  incision  carried  around  the 
base  of  its  pedicle.  A  painful  subcutaneous  tubercle  should  be  excised.  If 
a  mole  shows  the  slighest  disposition  to  enlarge,  or  if  it  is  subjected  to  pressure 
or  irritation,  it  should  be  removed,  because  if  allowed  to  remain  it_  may 
develop  into  a  malignant  growth.  It  is  often  desirable  to  remove  a  hairy  or 
pigmented  mole,  not  only  because  it  may  become  malignant,  but  also  because 
it  is  unsightly.  A  mole,  if  not  too  large,  may  be  removed  by  a  30-second  appli- 
cation of  soUd  carbonic  acid.  This  destroys  hair  and  often  causes  pigment  to 
disappear.  Many  moles  are  best  treated  by  excision.  Fibrous  epulis  re- 
quires the  cutting  away  of  the  entire  mass,  the  removal  of  the  related  snag  or 
carious  tooth,  and  sometimes  the  biting  away  of  a  portion  of  the  alveolus  with 
rongeur  forceps.  A  nasopharyngeal  fibrous  polyp  often  contains  sarcomatous 
elements  or  develops  into  a  spindle-celled  sarcoma.  If  the  polyp  is  recent  and 
has  a  pedicle  it  may  be  removed  by  the  cautery  loop.  Most  cases  require 
extirpation,  the  surgeon  cutting  wide  of  the  growth.  In  a  severe  case  a  part 
of  the  superior  maxillary  bone  is  removed  by  osteoplastic  resection  to  permit 
of  extirpation.  Keloid  should  rarely  be  operated  upon:  it  will  almost  certainly 
return,  and  will  also  develop  in  the  stitch  holes.  Trust  to  time  for  involution, 
or  use  pressure  with  flexible  collodion,  by  which  method  J.  M.  DaCosta  cured 
a  case  following  small-pox.  It  may  be  necessary  to  operate  because  of  ulcera- 
tion. If  it  is  necessary  to  operate,  remove  the  keloid  and  considerable  ad- 
jacent tissue  and  fill  the  gap  with  Thiersch  grafts.  The  administration  of 
thyroid  extract  may  be  of  benefit  (a  5-gr.  tablet  three  or  four  times  a  day). 


Chondromata 


409 


This  drug  must  be  given  cautiously,  as  it  may  cause  attacks  characterized  by 
fever,  dyspnea,  and  rapid  pulse.  Thiosinamin  hypodermatically  has  been  used, 
it  is  claimed,  with  benefit.  A  10  per  cent,  solution  is  made,  and  from  10  to 
15  min.  can  be  injected  into  the  gluteal  muscles  every  third  day.  I  have  seen 
two  keloids  cured  by  the  use  of  the  .T-rays. 

Chondromata  {enchondromata  or  ecchondroma)  are  tumors  formed  usually 
of  hyaline  cartilage,  but  may  be  formed  of  fibrocartilage,  or  of  both.  Chondro- 
mata are  apt  to  arise  from  certain  glands,  the  long  bones,  the  pelvis,  the  rib  carti- 
lages, and  the  bones  of  the  hands  or  feet,  and  often  spring  from  unossified  por- 
tions of  epiphyseal  cartilage.  It  has  been  held  by  Helmholtz,  Sudler  and  others 
that  chondroma  may  arise  by  the  transformation  of  fibrous  tissue  into  cartilage. 
Chondromata  occur,  as  a  general  rule,  to  which  there  are  many  exceptions, 
between  the  ages  of  twenty  and  forty.  There  is  no  sex  predilection. 
They  may  be  single  or  multiple,  and  are  most  commonly  met  with  in  the 
young.  They  have  distinct  adherent  capsules;  they  grow  slowly,  and,  if  of 
osseous  origin,  progressively  hollow  out  the  bones  by  pressure;  they  cause  no 
pain;  they  impart  a  sensation  of  firmness  to  the  touch,  unless  mucoid  de- 
generation forms  zones  of  softness  or  fluctuation;  they  are  inelastic,  smooth 
or  nodular,  immovable,  and  often  ossify.  A  chondroma  may  grow  to  an 
enormous  size.  A  chondroma  of  the 
parotid  gland  or  testicle  practically  al- 
ways contains  sarcomatous  elements,  and 
any  chondroma  may  become  a  sarcoma. 
Chondromata  are  notably  frequent  in  per- 
sons who  had  rickets  in  early  life.  Ec- 
chondroses,  which  are  "small  local  over- 
growths of  cartilage"  (Sir  J.  Bland- 
Sutton),  arise  from  articular  cartilages, 
especially  of  the  knee-joint,  and  from  the 
cartilages  of  the  larynx  and  nose.  Loose 
or  floating  cartilages  in  the  joints  may  be 
broken-off  ecchondroses  or  portions  of 
hyaline  cartilage  which  are  entirely  loose 
or  are  held  by  a  narrow  stalk,  and  which 
arise  by  chondrification  of  villous  processes 
of  the  synovial  membrane;  only  one  or  vast 
numbers  may  exist;  one  joint  may  be 
involved  or  several;  they  may  produce 
no  symptoms,  but  usually  produce  from 
time  to  time  violent  pain  and  immobility 
by  acting  as  a  joint-wedge.  An  ecchon- 
droma may  arise  within  the  medullary 
canal  of  a  long  bone,  from  foci  of  dormant 

cartilage,  and  may  lead  to  the  development  of  a  solitary  cyst  of  large  size  by 
softening  of  the  tumor.  The  femur  is  the  most  usual  site  of  solitary  cyst.  It 
begins  very  insidiously  and  progresses  gradually.  There  are  slight  lameness, 
trivial  pain,  tenderness  below  the  level  of  the  trochanter,  apparent  shortening, 
and  some  bulging  of  bone.  The  bone  may  bend  or  at  some  spot  may  thin  so 
that  the  cyst  can  be  felt.  Such  a  bone  fractures  from  slight  force,  and  after  a 
fracture,  when  the  effused  blood  and  inflammatory  exudate  have  been  absorbed, 
a  tumor  can  be  detected  distinctly.  A  solitary  cyst  of  a  long  bone  is  apt  to 
be  regarded  clinically  as  a  sarcoma  (Bergmann-Virchow).  In  the  pelvis,  with 
its  numerous  centers  of  ossification,  there  are  many  sites  from  which  chondro- 
mata may  arise,  and  a  pelvic  chondroma  may  so  block  the  pelvis  of  a  pregnant 
woman  as  to  necessitate  caesarean  section  (J.  H.  Wagner,  in  "Surgery,  Gynecology 
and  Obstetrics,"  1916,  xxiii). 


Osteoma  of  femur. 


410 


Tumors  or  Morbid  Growths 


Treatment. — Remove  chondromata  whenever  possible,   for,   if   allowed  to 
remain    undisturbed,   thev  are  apt  to  resent    this    hospitality    by    becoming 

1 


Fig.   177.— Osteoma  of  humerus. 

sarcomatous.     A  chondroma  of  the  testicle  and  of  a  salivary  gland  is  sure  to  be 
sarcomatous.     In   an  ordinary  chondroma  incise  the  capsule  and  take  away 

the  growth,  using  chisels  and  gouges  if 
necessary.  Incomplete  removal  means 
inevitable  recurrence.  Amputation  is 
very  rarely  demanded.  In  chondro- 
sarcoma incision  must  be  outside  of  the 
capsule.  Loose  bodies  in  the  joints,  if 
productive  of  much  annoyance,  are  to  be 
removed,  the  joint  being  opened  with 
the  strictest  antiseptic  care.  Amputation 
is  sometimes  performed  for  a  solitary  cyst 
of  a  long  bone,  the  surgeon  having  looked 
upon  the  growth  as  sarcomatous.  If  a 
correct  diagnosis  is  arrived  at,  an  attempt 
should  be  made  to  remove  the  cyst  with- 
out amputation.  Bergmann  succeeded 
in  extirpating  such  a  mass  from  the  femur. 
Osteomata  are  tumors  which  are 
composed  of  osseous  tissue.  Sir  J. 
Bland-Sutton  says  that  osteomata  are 
ossifying  chondromata.  Osteomata  take  origin  from  bone,  cartilage,  con- 
nective tissue,  especially  tissue  near  the  bone,  serous  membrane,  and  certain 
glands  and  organs.     Compact  osteomata,  which  are  identical  in  structure  with 


Fig.  178. — Osteophyte  of  os  calcis. 


Osteomata 


411 


the  compact  tissue  of  bone,  arise  from  the  frontal  sinus,  mastoid  process,  ex- 
ternal auditory  meatus,  and  other  regions  in  those  beyond  middle  life;  they 
are  small,  smooth,  round,  densely  hard,  with  small  and  occasionally  cartilaginous 
bases. 

Cancellous  osteomata,  which  comprise  the  great  majority  of  bone-tumors, 
are  similar  in  structure  to  cancellous  bone.  They  spring  from,  and  are  crusted 
with,  cartilage;  they  may  have  fibrous  capsules, 
and  are  often  movable  when  recent,  but  soon 
become  fixed;  they  frequently  have  broad  bases, 
are  angled,  nodular,  firm  (but  not  so  hard  as  are 
the  compact  osteomata),  painless  except  when 
pressed,  occur  particularly  at  the  ends  of  long 
bones  (Figs.  176  and  177),  may  grow  to  large  size, 
and  are  commonest  in  youth.  An  osteoma  near  a 
joint  becomes  overlaid  by  a  bursa,  which  in  rare 
instances  communicates  with  an  adjacent  joint. 

Osteomata  do  not  tend  to  become  malignant, 
and  do  not  recur  after  removal.  The  term  exostosis 
or  osteophyte  has  been  used  as  being  synonymous 
with  osteoma,  but  wrongly  so,  as  an  exostosis  is  an 
irregular,  local,  bony  growth  which  does  not  tend  to 
progress  without  limit,  and  which  is,  hence,  not  a 
tumor,  A  true  exostosis  is  seen  in  the  ossification 
of  a  tendon  insertion  (Fig.  178),  in  a  limited 
growth  from  one  of  the  maxillary  bones,  and  in  a 
local  growth  from  the  last  phalanx  of  the  big  toe, 
"which  latter  form  of  growth  is  known  as  a  subungual 


Fig.   179. — Multiple  exostoses. 


Fig.  180. — Multifile  exostoses. 
Hundreds  of  them  throughout  the 
body. 


exostosis.  A  subungual  exostosis  grows  slowly  and  for  six  months  or  more 
seldom  lifts  the  nail  sufficiently  to  cause  much  annoyance.  It  eventually  causes 
severe  pain  and  disability,  the  nail  being  raised  far  from  its  proper  bed.  In 
no  case  which  I  have  seen  has  there  been  a  history  of  infection  or  injury. 
Probably  the  growth  begins  because  of  irritation  induced  by  ill-fitting  shoes. 
Osteophytes  of  the  retrocalcaneal  bursa  occasionally  form  when  this  bursa  is  in- 
flamed. Inflammation  of  this  bursa  is  known  as  Achiilodynia,  or  Albert's  disease. 
The  bony  masses  sometimes  found  in  the  brain,  lungs,  testicles,  various  glands, 
and  tumors  are  not  true  osteomata.  Osteophytes  may  arise  in  a  joint  in' various 
forms  of  arthritis. 


412  Tumors  or  Morbid  Growths 

Multiple  exostoses  (Figs.  lyg,  i8o)  are  rare  and  depend  upon  some  anomaly 
in  and  ossification  of  temporary  cartilage.  The  condition  has  received  various 
names,  viz.:  hereditary  deforming  chondrodysplasia,  multiple  cartilaginous  exos- 
toses, ossified  diathesis,  multiple  cancellous  exostoses,  rachitiform  enchondrosis, 
chondral  dvsplasia,  and  multiple  congenital  osteochondromata  (Ehrenfried,  in 
"Jour.  Amer.  Med.  Assoc,"  1915,  Ixiv).  Multiple  and  usually  symmetrical 
growths  of  cartilage  or  of  bone  and  cartilage  arise  within  or  on  bones,  eventually 
producing  deformity.  The  epiphyseal  hues  may  undergo  unnatural  ossifi- 
cation. Exostoses  arise  during  the  period  of  active  growth  of  bone.  Three- 
fourths  of  the  cases  are  males.  Volkmann  and  others  assigned  rickets  as  the 
cause.  Virchow  looked  upon  the  condition  as  hereditary.  Lippert  traced  the 
condition  through  four  generations,  but  hereditary  influence  is  not  always  evi- 
dent. Tuberculosis  has  nothing  to  do  with  their  development.  One,  several,  or 
many  of  the  growths  may  diminish  in  size  or  even  disappear  (Bruns,  "  Beitrage," 
xxxiv,  1902).  In  Oberndorf's  case  many  tumors  disappeared,  but  none  after 
maturity  ("New  York  Med.  Jour.,"  March  5,  1910).  This  patient  had  syrin- 
gomvelia  and  acromegalic  symptoms,  causing  one  to  think  of  Charcot's  state- 
ment that  the  gray  matter  of  the  cord  contains  the  center  for  the  nutrition  of  the 
bone.  Exostoses  within  the  cranium  or  spinal  canal  may  cause  symptoms 
from  irritation  or  from  pressure.  Ehrenfried  (Ibid.)  has  collected  reports  of  600 
cases  of  multiple  exostoses.  He  beUeves  that  most  of  the  cases  are  hereditary,  a 
mother  free  from  the  disease  but  holding  the  tendency  from  her  father  who  had 
the  disease,  gives  birth  to  a  child  which  develops  the  affection,  or.  a  father  with 
the  disease  procreates  a  child  which  develops  it.  Among  resultant  deformities 
he  mentions  shortness  of  stature  (from  lack  of  growth  in  the  legs),  shortness  of 
the  arms,  dislocation  of  the  upper  end  of  the  ulna  backward  (because  that  bone 
grows  less  rapidly  than  the  radius),  and  distortion  of  the  limbs,  the  pelvis  and 
the  shoulder  blades.  Scoliosis  may  occur.  In  some  cases  growths  become 
malignant. 

Treatment. — Osteomata  which  are  non-productive  of  pain  or  trouble  do  not 
demand  removal.  If  they  produce  pain  by  pressure,  if  they  crowd  upon  impor- 
tant structures,  if  they  cause  annoying  deformities,  or  if  they  grow  rapidly, 
then  remove  them  by  means  of  chisels,  gouges,  or  the  surgical  engine.  If  iii  a. 
case  of  multiple  exostoses,  after  the  skeleton  has  ceased  to  grow,  growths  in- 
crease in  size,  remove  them.  Subungual  exostosis  should  always  be  removed. 
The  nail  may  be  split  and  part  of  it  taken  away,  and  the  bony  mass  be  gouged 
away  or  be  cut  off  with  forceps.  A  better  plan  is  to  make  a  transverse  cut  on 
the  end  of  the  toe  on  a  level  with  the  dorsal  surface  of  the  phalanx,  lift  the  flap, 
remove  the  exostosis  by  chiselUng,  and  restore  the  flap  to  place.  This  opera- 
tion does  not  injure  the  matrix  (A.  Davidson  in  "Am,  Jour.  Orthop.  Surg.," 
March,  1916). 

Odontomata'  are  tumors  composed  of  tooth-tissue.  They  grow_  slowly, 
are  seldom  painful  and  some  of  them  attain  a  large  size.  They  spring  from  the 
germs  of  teeth  or  from  developing  teeth.  Sir.  J.  Bland-Sutton  divides  them 
into  (i)  those  springing  from  the  follicle;  (2)  those  springing  from  the  papilla, 
and  (3)  those  springing  from  the  whole  germ. 

Epithelial  odontomes,  or  multilocular  cystic  tumors,  arise  from  the  enamel 
organ,  occur  oftenest  in  the  lower  jaw,  dilate  the  bone,  have  capsules,  and  are 
made  up  of  masses  of  cysts  which  are  filled  with  brown  fluid.  These  cysts  are 
met  with  most  frequently  before  the  age  of  twenty.  Follicular  odontomes,  or 
dentigerous  cysts  .(Fig.  181),  oftenest  spring  from  the  follicles  of  the  permanent 
molars.     In  a  dentigerous  cyst  there  exists  an  expanded  folUcle  which  dis- 

1  This  section  is  abridged  from  Sir  J.  Bland-Sutton's  striking  chapter  upon  Odontomes  in 
his  work  on  "Tumors."    See  also  Bonney  and  Ellis  in  "Surg.,  Gyn.  and  Obst.,"  April  iQ,  i9i7j. 
Steinfeld,   in   "Ohio    State   Med.    Jour.,"    1914,   and    New,  in  "Surg.,    Gyn.    and    Obst., 
July,  1915- 


Myxomata  413 

tends  the  bone,  the  folHcle  being  filled  with  thick  fluid  and  containing  a  fully 
formed  permanent  tooth  or  a  portion  of  a  permanent  tooth.  Dentigerous 
cysts  are  equally  frequent  in  the  maxilla  and  mandible,  are  usually  in  the 
bicuspid  or  molar  regions  and  are  generally  noted  during  or  soon  after  the  second 
dentition  (New,  in  "Surgery,  Gynecology,  and  Obstetrics,  July,  191 5).  When 
a  follicular  odontome  is  discovered  after  the  time  of  second  dentition  the  patient 
is  short  one  or  more  permanent  teeth.  The  corresponding  milk  teeth  may  be 
retained.  A  cyst  connected  with  the  third  molar  appears  much  later  than  the 
second  dentition.  The  position  of  the  portion  of  the  tooth  is  variable.  It  is 
usually  just  beneath  the  orbit.  In  a  case  operated  on  in  the  Jefferson  Clinic 
the  tooth  was  in  this  situation.  A  fibrous  odontome  is  due  to  thickening  of  the 
tooth-sac,  which  prevents  eruption  of  the  tooth;  fibrous  odontomes  are  usually 
multiple,  and  are  apt  to  occur  in  rickety  children.  A  cementome  is  due  to  en- 
largement, thickening,  and  ossification  of  the  capsule,  the  developing  tooth 
being  encased  in  cement.     A  compound  follicular  odontome  is  due  to  ossification 


.     0     .   _.    S      ,        4  6  8  10  _.  .„  _ia 

Fig.   181. — Dentigerous  cysts  removed  from  upper  jaw  of  a  negro.     Both  in  the  right  side. 
Contained  portions  of  undeveloped  teeth. 

of  portions  only  of  an  enlarged  and  thickened  capsule,  and  the  tumor  con- 
tains bits  of  cementum,  portions  of  dentin,  or  small  misshaped  teeth.  A  radi- 
cular odontome  springs  from  the  papilla  and  arises  after  the  crown  of  the  tooth 
is  formed  and  while  the  roots  are  forming;  hence  it  contains  dentin  and  cement, 
but  no  enamel.  Composite  odontomes  are  formed  of  irregular,  shapeless  masses 
of  dentin,  cement,  and  enamel.  All  the  above  forms  occur  in  man.  They 
present  themselves  as  hard  tumors  associated  with  teeth  or  in  an  area  where 
teeth  have  not  erupted.  Occasionally  an  odontome  simulates  necrosis;  it  is 
surrounded  by  pus,  and  a  sinus  forms. 

Tr«»atment. — The  diagnosis  is  now  usually  possible  by  the  aid  of  the  x-rays. 
Be' '7-  no  haste  to  excise  large  portions  of  bone  for  a  doubtful  growth;  incise 
firs'^.^nd  see  if  it  be  an  odontome,  which  usually  requires  only  the  removal  of 
an  i^hplicated  tooth,  curetting  with  a  sharp  spoon,  and  packing  with  iodoform 
gauze.  The  operation  can  usually  be  done  through  the  mouth.  Recurrence 
is  common  but  malignant  change  is  rare. 

Myxomata  are  tumors  composed  of  mucous  tissue.  They  are  rare  as 
independent  growths,  although  myxomatous  change  is  frequent  in  the  stroma 
of  other  tumors.     The  tissue  type  of  these  tumors  is  found  in  the  vitreous  humor 


414  Tumors  or  Morbid  Growths 

of  the  eye  and  in  the  perivascular  tissues  of  the  umbiUcal  cord  (Wharton's  jelly). 
Bowlby  states  that  myxomata  are,  in  reality,  soft  fibromata  whose  inter- 
cellular substance  has  been  replaced  by  mucin.  The  myxomatous  state  may 
be  a  stage  in  the  formation  of  a  fibroma,  a  stroma  not  having  developed.  Myx- 
oftiata  may  result  from  myxomatous  degeneration  of  cartilage,  of  muscle,  or 
of  fibrous  tissue.  These  tumors  are  soft,  elastic,  if  superficial  usually  peduncu- 
lated, tremulous,  and  vibratory.  The  stroma  is  very  delicate  and  carries 
minute  blood-vessels.  Cutting  into  a  myxoma  causes  a  straw-color<;d,  clear 
jelly  to  exude.  Myxomata  grow  slowly,  are  encapsuled,  have  but  little  cir- 
culation, and  the  diagnosis  may  be  impossible  before  removal  of  the  growth. 
Deeply  placed  myxomata  offer  no  ear  marks  for  diagnosis.  I  operated  on  a 
very  large  one  connected  with  the  subdeltoid  bursa  and  the  diagnosis  was  im- 
possible until  an  incision  had  been  made.  Some  pathologists  place  myxomata 
among  the  malignant  tumors,  but  most  consider  them  as  benign  tumors,  though 
they  tend  strongly  to  become  sarcomatous  (niyxosarcomata) .  A  sarcoma  may 
undergo  myxomatous  degeneration. 

Myxomata  may  arise  from  the  skin;  from  the  mucous  membrane  of  the 
nose,  the  frontal  sinus,  the  maxillary  antrum,  the  womb,  the  auditory  meatus,  and 
the  tympanum  (gelatinous  polypi) ;  from  the  parotid  and  mammary  glands ;  from 
thesubcutaneous  tissue,  the  nerve-sheaths,  the  intermuscular  septa,  the  bursae,  the 
rectum,  and  the  bladder  (polyps).  They  may  be  congenital,  but  occur  most  often 
in  young  adults,  as  a  result  of  inflammation.  A  sudden  increase  of  growth 
indicates  beginning  malignancy  (sarcomatous  change).  When  a  tumor  begins 
to  undergo  myxomatous  transformation  we  give  to  it  a  compound  name;  for 
instance,  a  chondroma  undergoing  myxomatous  change  is  a  chondromyxoma, 
a  fibroma  undergoing  a  like  change  is  a  fibromyxoma,  etc.  Mucous  polypi 
grow  from  the  mucous  membrane  of  the  nose,  particularly  from  the  outer  wall 
near  the  middle  turbinated  bone,  and  often  from  the  roof  of  the  nares.  Mucous 
polypi  are  soft  and  jelly-like,  of  a  grayish  color,  and  have  stems  or  pedicles; 
they  may  be  seen  through  the  anterior  nares,  may  project  behind  the  veil  of 
the  palate,  and  may  bulge  out  from  the  passages  of  the  nose;  they  may  be,  and 
usually  are,  multiple;  they  may  be  present  in  one  nasal  fossa  or  in  both  fossae,  and 
they  occur  most  commonly  in  youths  and  adults  between  the  ages  of  fifteen  and 
thirty-five  years. 

Hydatid  moles  of  pregnancy  are  due  to  myxomatous  changes  in  the  chorion. 
What  is  known  as  pseudomyxoma  of  the  peritoneum  is  a  cystic  condition  of  the 
peritoneum  arising  after  leakage  of  an  ovarian  cyst  or  after  operation  in  which 
cyst  fluid  ran  into  the  peritoneal  cavity.  It  is  thought  by  most  to  result  from 
the  transplantation  of  mucous  cells  but  Goldschmidt  (Abstract  in  "Surgery, 
Gynecology,  and  Obstetrics,"  Nov.,  1914)  believes  it  is  aplastic  peritonitis  due 
to  the  irritation  of  a  foreign  body. 

Treatment. — In  treating  myxomata,  remove  them  promptly  and  thoroughly, 
because  of  the  danger  of  sarcomatous  change.  Myxomata  tend  to  recur  even 
without  sarcomatous  change  and  after  extirpation  the  wound  should  be  cauter- 
ized. Polypi  of  the  bladder  are  removed  by  means  of  cutting  forceps 
after  suprapubic  cystotomy  has  been  performed.  Nasal  polypi  may  usually 
be  twisted  off  or  be  removed  by  the  wire  snare  or  galvanocautery.  Occasion- 
ally when  the  growths  are  numerous  and  recur  rapidly  after  removal,  t^c  in- 
ferior turbinated  bones  should  be  removed  with  a  saw  (Rouge's  oper\yovi). 
This  operation  secures  ready  access  to  the  area  of  disease,  which  can  be  ati'.g^%ed 
radically.  A  very  soft  myxoma  breaks  up  when  removal  is  attempted,  an^^^the 
base  must  be  cauterized.  Electrothermic  methods  are  of  high  value  in  tnese 
cases. 

Myomata  are  tumors  composed  of  unstriped  muscle-fiber  mixed  often 
with  fibrous  tissue.  They  are  called  leiomyomata.  Tumors  composed  of 
striated  muscle-fiber  and  spindle-cells  are  known  as  rhabdomyomata.     They 


Treatment  of  Myomata  415 

are  very  rare  and  are  always  sarcomatous.  Leiomyomata  are  found  in  the 
womb,  in  the  prostate  gland,  in  the  walls  of  the  gullet,  vagina,  stomach,  bladder 
and  bowel,  in  the  broad  ligament,  ovary  and  round  ligament,  in  the  scrotum, 
and  in  the  skin.  Myomata  usually  begin  during  or  after  middle  age;  they  are 
encapsuled,  they  grow  slowly,  they  are  firm  and  hard,  and  produce  annoyance 
by  their  size  and  weight  or  by  obstructing  a  viscus  or  channel.  A  leiomyoma 
of  the  posterior  portion  of  the  middle  of  the  prostate  gland  is  known  as  a  ''mid- 
dle lobe." 

The  so-called  uterine  fibroid  is  a  myoma  or  fibromyoma.  Uterine  myo- 
mata may  originate  within  the  walls  of  the  womb  (intramural  myomata),  from 
the  muscular  structure  of  the  mucous  lining  (submucous  myomata),  or  from 
the  muscular  tissue  of  the  serous  covering  (subserous  myomata).  Intra- 
mural uterine  myomata  may  be  single  or  multiple  and  may  grow  to  an  enor- 
mous size.  Submucous  myomata  project  into  the  cavity  of  the  womb  (fleshy 
polypi),  and  may  project  into  the  vagina.  They  distend  the  uterus  and  are 
often  accompanied  by  menorrhagia  or  metrorrhagia.  In  some  rare  cases  the 
projecting  tumor  is  detached  by  nature  and  the  patient  is  cured;  in  some  cases 
the  myoma  becomes  gangrenous.  A  fleshy  polyp  may  produce  inversion  of 
the  fundus  of  the  womb.  Subserous  uterine  myomata  cause  trouble  only  by 
the  inconvenience  of  weight  or  the  discomfort  of  pressure.  Uterine  myomata 
are  commonest  in  single  women,  and  arise  most  frequently  between  the  ages 
of  twenty-five  and  forty-five.  Negro  women  are  especially  prone  to  develop 
such  tumors.  They  may  never  produce  any  symptoms.  Some  of  these  growths,, 
by  enlarging  until  they  ascend  above  the  pelvic  brim,  produce  abdominal 
distention;  some  become  jammed  or  impacted  in  the  pelvis,  and  produce  by 
pressure  retention  of  urine,  obstruction  to  the  passage  of  feces,  or  hydronephro- 
sis. Impaction  may  occur  temporarily  at  each  menstrual  period.  Many 
myomata  produce  uterine  hemorrhage ;  some  cause  retroversion  of  the  womb ;  some 
protrude  from  the  cervical  canal;  some  are  so  large  that  they  cause  disastrous 
pressure  upon  the  colon  (obstruction),  upon  the  iliac  veins  (great  edema), 
or  upon  the  ureters  (hydronephrosis).  Uterine  myomata  usually  shrink  after 
the  menopause.  Pregnancy  in  a  myomatous  womb  usually  ends  in  abortion. 
Uterine  myomata  may  undergo  fatty,  calcareous,  or  myxomatous  change,  and 
may  be  infected  by  septic  organisms  as  a  result  of  the  use  of  a  uterine  sound  or 
of  infection  of  the  pedicle  after  oophorectomy.  Infection  of  a  uterine  myoma, 
causes  great  enlargement,  elevated  temperature,  sweats,  and  exhaustion.  Sar- 
comatous change  may  take  place.  Virchow  pointed  out  this  fact  in  1863. 
CuUen  found  sarcomatous  change  in  17  cases  out  of  1400.  If  there  be  a  car- 
cinoma in  some  other  part  of  the  body  metastatic  deposit  may  occiir  in  a  uterine 
growth. 

Uterine  fibromyoma,  if  unoperated  upon,  often  causes  death.  Noble  claims 
that  of  cases  denied  operation  or  who  refuse  operation,  2,i  per  cent,  die  and  28. 
per  cent,  become  chronic  invalids. 

The  symptoms  of  myomata  of  the  alimentary  canal  are  similar  to  or  iden- 
tical with  the  symptoms  of  malignant  growths.  Myomata  of  the  skin  are  rare 
growths;  they  are  encapsuled,  firm  or  elastic,  and  painless. 

Treatment. — Cutaneous  myomata  are  removed  in  the  same  manner  as  fib- 
rous tumors.  A  uterine  tumor  which  causes  symptoms  should  be  operated  up 
on.  A  tumor  which  causes  no  symptoms  need  not  be  operated  upon  if  the  patient 
can  lead  an  easy  life  and  can  rest  during  the  menstrual  periods.  Rest  is  an 
essential  of  the  treatment. .  Ergot,  thyroid  extract,  barium  chlorid,  and  dilute 
sulphuric  acid  are  recommended.  In  some  cases  the  tumor  shrinks,  in  some 
it  disappears.  If  operation  is  required  the  form  of  operation  chosen  depends 
upon  the  case.  In  some  cases  the  operation  should  be  vaginal,  and  may  be 
dilatation  and  curetment,  torsion  or  incision  of  the  pedicle,  enucleation  or  hys- 
terectomy.    In  other  cases  the  operation  should  be  by  the  abdominal  route. 


4i6  Tumors  or  Morbid  Growths 

and  may  be  castration,  ligation  of  vessels,  myomectomy  (cutting  through  the 
pedicle  and  closing  with  deep  sutures),  enucleation,  sheUing  out  growths  from 
the  wall,  partial  hysterectomy,  or  complete  hysterectomy.  Castration  aims  to 
create  an  artificial  menopause,  and  so  arrest  hemorrhage  and  cause  the  shrink- 
ing of  the  growth.  Sometimes  it  acts  admirably,  sometimes  it  fails,  and  it 
brings  with  it  its  own  perils,  for  the  sudden  creation  of  the  menopause  is  a  great 
danger  to  the  nervous  system.  For  subserous  myomata  myomectomy  is 
often  the  operation  of  choice.  A  very  large  tumor,  a  tumor  which  continues  to 
enlarge  after  the  menopause,  and  an  infected  tumor  require  partial  or  complete 
hysterectomy.  If  a  myoma  of  the  prostrate  causes  severe  obstruction,  perform 
a  suprapubic  cystotomy  and  remove  the  enlarged  gland;  or  make  both  a  supra- 
pubic and  a  perineal  opening,  push  the  gland  into  the  perineum  and  shell  it 
out  with  the  finger,  or,  if  the  condition  is  desperate,  make  permanent  supra- 
pubic drainage. 

Neuromata. — A  true  neuroma  (ganglioneuroma)  is  due  to  the  hyperplasia 
of  ganglion  cells  and  may  arise  from  the  sympathetic  nervous  system,  or  the 
cerebrospinal  nerves  and  ganglia,  and  when  glia  tissue  is  abundant  it  is  called 
a  glioneuroma  (Behan,  in  "Surgery,  Gynecology,  and  Obstetrics,"  Sept.,  1916). 
New  ganglia  may  be  formed.  The  true  neuroma  contains  many  septa  of  con- 
nective tissue  which  separate  aggregations  of  nervous  elements.  Networks  of 
fibrils  or  actual  nerve  fibers  may  come  from  the  cells.  The  most  usual  site  for 
these  congenital  growths  is  in  or  about  the  suprarenal  gland,  from  the  embryonic 
cells  of  which  they  spring.  Behan  (Ibid.)  points  out  that  ganghoneuroma 
may  spring  from  sympathetic  ganglia,  the  coccygeal  gland,  the  cords  of  the  sym- 
pathetic, the  brain,  the  spinal  cord,  the  dura  mater,  the  Gasserian  ganglion, 
the  optic  nerve  and  the  capsule  of  the  knee.  The  condition  is  most  commonly 
found  in  those  under  the  age  of  twenty,  and  is  usually  solitary,  though  instances 
of  metastasis  have  been  reported.  The  growth  is  smooth  and  hard.  In  most 
cases  the  condition  is  not  diagnosticated  during  life  but  in  some  cases  pressure 
causes  symptoms.  The  tumor  may  attain  large  size.  A  false  neuroma  or  neiiro- 
Jibroma  is  a  fibrous  tumor  growing  from  a  nerve-sheath  or  the  connective 
tissue  of  a  nerve,  and  is  identical  in  structure  with  the  sheath.  False  neuro- 
mata may  be  single,  but  they  are  often  multiple;  they  may  be  as  small  as  peas 
or  as  large  as  oranges;  they  are  smooth  and  movable,  and  may  cause  great  pain 
or  may  be  painful  only  when  pressed  or  struck;  they  may  spring  from  roots, 
trunks,  or  branches,  and  they  may  be  linked  with  the  disease  known  as  mollus- 
cum  fibrostim.  In  plexiform  neuroma  some  branches  of  a  nerve  enlarge  and 
lengthen  like  an  artery  in  a  cirsoid  aneurysm;  the  mass  feels  like  beads  or  like 
a  bag  of  worms;  it  is  mobile,  and  no  pain  is  felt  on  moving  it;  and  it  is  generally 
congenital.  In  plexiform  neuroma  the  nerve-sheath  undergoes  myxomatous 
change.  Malignant  neuroma  is  usually  a  primary  sarcoma  of  a  nerve-sheath, 
though  any  neuroma  containing  fibrous  tissue  may  become  sarcomatous. 

Traumatic  neuromata  are  false  neuromata,  and  are  occasionally  well  ex- 
hibited after  nerve-section  or  amputation.  After  nerve-section  the  distal  end 
shrinks'  and  atrophies,  the  proximal  end  enlarges  and  becomes  bulbous.  A 
traumatic  neuroma  is  composed  of  fibrous  tissue  which  contains  nerve-fibers. 
Such  a  growth  is  usually,  but  not  always,  painful  on  pressure  or  during  damp- 
ness, and  is  most  commonly  seen  in  a  stump  which  did  not  heal  by  first  inten- 
tion. In  performing  an  amputation  cut  the  nerves  high  up,  and  thus  keep 
them  out  of  the  scar,  permit  them  to  remain  mobile  in  their  sheaths,  and  so 
prevent  a  tender  stump.  A  tender  stump  may  be- due  to  anchoring  of  a  nerve 
in  a  scar,  the  nerve  ceasing  to  gUde  when  the  individual  moves  the  extremity. 
The  condition  known  as  painful  subcutaneous  tubercle  was  discussed  on  page 
406. 

Treatment. — The  treatment  for  a  true  neuroma  is  thorough  extirpation  and, 
if  the  tumor  is  large,  the  operation  may  be  very  formidable.     A  false  neuroma 


Angiomata  or  Hemangiomata 


417 


is  to  be  removed,  if  possible,  without  destroying  the  nerve-trunk.  If,  in  re- 
moving a  neuroma,  it  is  necessary  to  exsect  a  portion  of  a  nerv^e-trunk,  always 
proceed  to  suture  the  ends  of  the  divided  nerve  so  as  to  facilitate  restoration 
of  function.  For  multiple  neuromata — at  least  should  the  number  be  large  or 
should  molluscum  fibrosum  exist — surgery  can  do  nothing.  Plexiform  neuro- 
mata may  often  be  removed,  but  amputation  may  be  required.  Painful  neuro- 
mata in  stumps  should  be  excised. 

Qliomata. — These  tumors  develop  from  neuroglia  and  more  often  from 
the  white  substance  than  from  the  gray.  They  are  usually  single,  and  arise 
not  unusually  in  the  brain,  rarely  in  the  cord,  and  very  rarely  in  the  cranial 
nerves.  They  may  take  origin  in  one  of  the  cerebral  hemispheres,  in  the  cere- 
bellum, in  the  pons,  or  in  the  medulla.  Some  gliomata  are  soft  and  bear  a 
close  relationship  to  sarcoma;  others  are  hard  and  resemble  fibroma. 

A  glioma  is  a  circumscribed  growth  in  contrast  to  a  gliosis,  which  is  a  wide- 
spread and  unlimited  h}^erplasia  of  the  neuroglia.  Syringomyelia  is  due  to 
gliosis  of  the  spinal  cord. 


N 


Fig.    1S2. 


-Dr.    Hansell's    case    of 
angioma  of  the  eyelids. 


cavernous 


Fig.  183. 


-Cavernous  angioma  of 
face. 


"A  glioma  consists  of  cells  containing  rounded  or  oval  nuclei  with  very 
little  protoplasm  and  fine  protoplasmic  extensions  which  interlace  and  form 
an  intercellular  reticulum"  (Stengel). 

A  glioma  passes  almost  insensibly  into  surrounding  tissue,  and  there  is  no 
distinct  edge;  hence,  because  of  the  slight  differentiation  from  brain  sub- 
stance, it  may  be  overlooked  during  exploration.  It  is  harder  than  the  sur- 
rounding tissue,  is  vascular  and  of  a  pink  or  red  color,  and  the  normal  shape 
of  the  part  is  often  very  little  altered,  although  the  tumor  may  reach  the  size 
of  a  lemon. 

Hemorrhage  may  take  place  into  a  glioma,  softening  may  occur,  cavities 
may  form,  or  the  growth  may  become  sarcomatous  or  psammomatous.  The 
sjTnptoms  of  a  gUoma  of  the  brain  depend  on  the  situation.  It  is  probable 
that  soft  glioma,  at  least,  belongs  in  the  group  of  maHgnant  tumors. 

Treatment. — When  a  glioma  of  the  brain  can  be  localized  and  is  hard, 
removal  should  be  attempted.  No  attempt  should  be  made  to  remove  a  soft 
ghoma. 

Angiomata  or  Hemangiomata. — An  angioma  is  a  tumor  composed 
largely  of  dilated  blood-vessels.  The  older  surgeons  called  such  growths 
27 


4i8 


Tumors  or  Morbid   Growths 


erectile  tumors.     Some  of  the  so-called  angiomata  are  not  genuine  new  growths, 
but  are  due  to  dilatation  and  elongation  of  blood-vessels. 

Simple  or  capillary  angiomata,  nevi,  telangiectases,  or  "mother's  marks," 
which  affect  the  skin  or  subcutaneous  tissue,  are  composed  of  e»larged  and 
twisted  capillaries  and  of  anastomosing  vessels  surrounded  by  fat.  These 
growths  are  congenital  or  appear  in  the  first  few  weeks  of  life;  they 
are  fiat  and  slightly  raised,  and  are  of  a  bright-pink  color  if  composed 
chiefly  of  arterioles,  and  are  bluish  if  composed  mainly  of  venules;  they 
can  be  almost  completely  emptied  by  pressure;  they  occasionally  pass  away 
spontaneouslv,  but  usually  grow  constantly  and  may  become  cavernous;  they 

may  ulcerate  and  occasion  violent  or 
fatal  hemorrhage.  One  or  several  large 
vessels  connect  a  nevus  to  adjacent 
blood-vessels.  Port -wine  or  claret 
stains  are  pink  or  blue  discolorations 
due  to  superficial  nevi  of  the  skin; 
they  may  be  small  in  extent  or  they 
may  involve  a  very  large  area,  are  not 
elevated,  and  do  not  usually  spread. 
Telangiectasis  is  a  form  of  nevus  in- 
volving the  skin  and  subcutaneous  tis- 
sue in  which  many  arterioles  and  venules 
exist.  Simple  angiomata  are  common 
on  the  forehead,  the  scalp,  the  face,  the 


Fig.   1S4. — Cavernous  angioma:  Subcutane- 
ous tissue  of  lep. 


Fk;.   1S5. — Method  of  applying  Erichsen's 
suture. 


neck,   the  back,    and   the   extremities.     They   may  appear   on  the  labia,  the 
tongue,  or  the  lips. 

Cavernous  angiomata,  or  venous  nevi  (Figs.  182  and  183),  resemble  in  struc- 
ture the  corpora  cavernosa  of  the  penis;  they  consist  of  large  endothelial  lined 
spaces  with  thin  walls  carrying  blood,  and  there  may  be  distinct  vessels  as  well. 
Arteries  send  blood  into  the  spaces,  and  veins  receive  it  from  the  spaces.  These 
channels  and  sinuses  are  enormously  distended  capillaries.  Cavernous  angio- 
mata arise  in  the  skin  and  subcutaneous  tissues;  they  are  usually  congenital, 
but  may  develop  from  simple  angiomata;  they  are  purple  or  blue  in  color;  are 
more  distinctly  elevated  than  the  capillary  nevi;  may  be  either  cutaneous  or 
subcutaneous;  swell  when  the  child  cries,  and  are  apt  to  pulsate;  they  may  be 


Treatment  of  Angiomata  or  Hemangiomata 


419 


emptied  by  pressure,  and  often  look  like  cysts  with  very  thin  walls.  Cavernous 
angiomata  may  arise  in  the  breast,  the  tongue,  the  lip,  the  cheek,  the  gums, 
the  subcutaneous  tissues,  the  liver,  the  spleen,  the  kidney,  or  the  muscles. 
If  an  angioma  contains  an  excess  of  fat,  the  growth  is  called  a  "nevoid  Upoma." 
Plexiform  angiomata  are  known  as  "cirsoid  aneurysms"  or  aneurysms  by 
anastomosis  (see  page  496). 

Angiomata  noticed  soon  after  birth  may  disappear  completely  or  may  en- 
large progressively. 

Treatment. — A  capillary  nevus  can  often  be  quickly  cured  by  touching  it 
with  fuming  nitric  acid.  A  second  application  of  acid  may  be  required.  The 
growth  may  be  destroyed  by  heat — "a  knitting-needle  at  a  dull-red  heat  or  the 

galvanocautery"  (Wharton).  The  ap- 
plication of  ethylate  of  sodium,  electric 
desiccation,  fulguration,  or  electrolysis 
will  destroy  the  growth.  Solid  carbon 
dioxid  is  valuable  to  destroy  capillary 
nevi.  Often  but  one  application  is 
necessary,  but  in  some  cases  two  or 
more  are  required.  Astringent  injections 
are  dangerous  unless  the  base  of  the 
nevus  is  ligated,  because  they  may  lead 


Fig.     186. — Cavernous     angioma     and 
lymphangioma. 


Fig.  187. — Cavernous  angioma,  lymphan- 
gioma, and  lymphaijgiectasis,  also  beginning 
cancer. 


to  the  formation  of  emboli.  Injection  of  boiling  water  was  advised  by  Wyeth. 
It  is  usually  very  satisfactory.  The  surgeon  wears  white  cotton  gloves  under 
his  rubber  gloves,  in  order  that  he  may  handle  the  hot  syringe.  The  needle  is 
introduced  through  sound  skin  and  is  carried  beneath  the  growth,  but  must 
not  approach  too  closely  the  skin  of  the  other  side.  Babcock  ("N.  Y.  Med. 
Jour.,"  March  3,  191 7)  injects  quinin  and  urea  hydrochlorid.  It  causes  no 
coagula  but  does  produce  necrosis.  Considerable  pain  and  edema  follow  the 
injection  and  sometimes  an  ulcer  forms.  For  an  extensive  area  Babcock 
uses  a  33  per  cent,  solution — for  a  limited  area,  a  50  per  cent,  solution.  The 
material  is  supplied  in  ampoules  each  containing  2  c.c. 

Small  port- wine  stains  may  be  removed  by  electrolysis  or  multiple  incisions, 
but  extensive  stains  are  ineffaceable.     Solid  'CO2  may  be  used.     Two  or  three 


420  Tumors  or  Morbid  (Growths 

applications  are  made  in  the  same  place  and  then  another  spot  is  selected.  It 
usually  fails  to  cure.  Small  nevi  may  be  ligated  under  harelip  pins,  larger  nevi 
may  be  strangulated  in  sections  by  the  Erichsen  suture  (Fig.  185),  or  may  be 
completely  excised.  Excision  is  usually  the  best  plan  for  the  cure  of  angio- 
mata  if  it  will  not  produce  serious  disfigurement.  It  is  rapid,  thorough,  and, 
if  the  growth  is  small,  leaves  but  a  trivial  scar.  Excision  should  be  employed 
if  we  feel  sure  that  the  edges  of  the  wound  can  be  subsequently  approximated 
and  that  there  will  not  be  a  dangerous  loss  of  blood.  It  is  sometimes  justifiable 
to  excise  an  angioma  even  when  approximation  of  the  wound  will  obviously  be  im- 
possible.    In  such  acase  the  raw  surface  should  be  covered  with  Thiersch  grafts. 

Most  superficial  nevi  and  some  cavernous  angiomata  can  be  treated  by 
solid  CO2,  and,  if  this  fails,  by  excision.  The  incisions  must  be  beyond  the 
dilated  vessels.  In  large  angiomata  involving  the  skin  and  also  deeper  parts, 
or  involving  a  structure  like  the  lip,  which  it  is  undesirable  to  remove,  electrolysis 
should  be  employed.  The  operation  should  be  carried  out  with  aseptic  care, 
and  if  the  tumor  is  large  an  anesthetic  should  be  given. 

The  positive  pole  produces  a  firm  and  hard  clot.  One  or  more  needles 
connected  with  the  positive  pole  are  inserted  into  the  tumor,  the  needles  being 
insulated  to  within  about  3^  inch  of  their  points.  A  flat  moist  pad  is  placed 
upon  the  skin  near  the  tumor  and  is  attached  to  the  negative  pole,  and  the  pad 
is  moved  from  time  to  time  during  the  operation. 

From  25  to  75  miUiamperes  is  the  proper  strength,  and  the  current  is  passed 
for  ten  minutes.  The  current  is  increased  for  a  moment  before  withdrawing 
the  needles,  otherwise  they  will  stick  to  the  tissue  and  cause  bleeding  when 
torn  loose.  After  the  withdrawal  of  the  needles  the  nevus  will  be  found  to  be 
hard,  but  the  hardness  will  gradually  disappear.  It  may  be  necessary  to 
repeat  the  operation  a  number  of  times  at  intervals  of  ten  days.^ 

When  solid  CO2  is  applied  it  subjects  the  tissue  to  a  temperature  of  79°  F. 
below  zero.  It  is  called  carbonic-acid  snow.  It  is  applied  with  pressure. 
This  drives  out  the  blood.  It  is  held  against  the  part  for  thirty  or  forty  seconds. 
It  drives  the  color  out  of  the  part,  but  a  few  minutes  after  the  cessation  of  the 
action  color  returns,  reaction  occurs,  the  surface  becomes  moist,  and  fibrinous 
inflammation  takes  place  (E.  R.  Morton,  ''Lancet,"  May  7,  1910). 

Necrosis  seldom  arises.  Within  an  hour  a  vesicle  forms,  which  should  be 
opened  aseptically.  A  crust  gathers,  which  drops  off  in  about  two  weeks,  leav- 
ing "a  soft  and  elastic  scar,"  the  color  of  the  normal  skin  (Morton,  Ibid.). 

Radium  is  particularly  powerful  in  removing  angiomata  and  in  many 
cases  it  should  be  the  treatment.     In  some  cases  the  rv-rays  are  preferred. 

I  always  ask  an  experienced  Rontgenologist  to  see  my  angioma  cases  in  order 
that  I  may  learn  which  ones  are  suitable  for  treatment  by  radium  or  .T-rays. 

Lymphangiomata  are  tumors  composed  of  dilated  lymph-vessels  and 
are  often,  though  not  invariably,  congenital  (Fig.  187).  A  lymphatic  nevus 
is  a  colorless  or  faintly  pink  elevation;  if  it  is  punctured  with  a  needle,  lymph 
flows  from  the  puncture.  One  or  several  nevi  may  be  present  in  the  same 
individual.  The  dilatation  is  due  to  blocking  of  the  lymph-channels.  Local 
lymphangioma  of  the  tongue  is  manifested  by  a  cluster  of  papillary  projec- 
tions containing  lymph.  Macroglossia  is  a  congenital  enlargement  of  the 
anterior  portion  of  the  tongue,  which  enlargement  grows  more  and  more  marked, 
until  finally  the  tongue  is  forced  far  out  of  the  mouth.  This  condition  of  tongue 
enlargement  is  due  to  lymphangioma  of  the  mucous  membrane.  Lymph 
scrotum  is  due  to  a  similar  growth.  A  collection  of  these  warty-looking  dila- 
tations is  called  lymphangiectasis.  Just  as  cavernous  angiomata  constitute 
a  variety  of  blood-vessel  tumors,  so  cavernous  lymphangiomata  constitute  a 
variety  of  lymph-vessel  tumors,  and  the  spaces  of  the  latter  are  filled  with 
lymph  instead  of  with  blood  (Figs.  186  and  187).  Areas  affected  with  lymph- 
1  Cheyne  and  Burghard's  "Manual  of  Surgical  Treatment." 


Malignant  Connective-tissue  Tumors,  or  Sarcomata 


421 


angiectasis  are  liable  to  repeated  attacks  of  erysipelas-like  inflammation. 
Whether  this  inflammation  is  causative  or  secondary  is  not  known.  In  trop- 
ical countries  blocking  of  lymph-channels  may  be  brought  about  by  the  Filaria 

sanguinis  hominis,  a  parasite  which 
~"'"  n  lurks  in  the  lym[)h-vessels  during 
the  day  and  is  found  in  the  blood  at 
night  only.  Lymphangiectasis  is 
often  the  first  stage  of  elephantiasis. 


\ 


Fig.  188. — Sarcoma  of  antrum. 


Fig.   i8q. — Sarcoma  of  antrum 


Treatment. — A  lymphatic  nevus  requires  excision.  In  macroglossia  the 
bulk  of  the  mass  should  be  removed  by  a  V-shaped  cut,  the  mucous  mem- 
brane being  sutured  so  as  to  cover  the  stump.  In  conditions  due  to  the  filaria, 
anilin-blue  has  been  given  internally. 


Fig.   190. — Small  round-celled  f ungating  sarcoma  of  neck. 

Malignant  Connective=tissue  Tumors,  or  Sarcomata. — The  sarco- 
mata are  composed  of  embryonic  tissue-ceUs,  the  intercellular  substance  being 
very  scanty,  and  they  resemble  a  process  of  chronic  inflammation.  They 
develop  from  connectivf  tissue,  rarely  have  a  definite  stroma,  and  the  con- 


422 


Tumors  or  Morbid  (irowths 


stituent  cells,  as  a  rule,  proliferate  with  great  rapidity.  If  a  sarcoma  has  a. 
stroma  of  connective  tissue,  this  stroma  contains  lymphatics  and  such  a  sar-' 
coma  infects  adjacent  glands.  In  most  cases  there  is  no  connective-tissue 
stroma  and  no  lymphatics.  In  a  sarcoma  without  a  definite  stroma  the  blood- 
vessels are  not  surrounded  by  lymph-spaces  and  are  quickly  invaded  by  cells 
(B.  H.  Buxton).  The  rapidly  growing  forms  are  very  vascular,  the  blood 
flowing  in  vessels  whose  walls  are  very  thin  or  running  in  canals  lined  by  endo- 
thelium and  bounded  by  sarcomatous  cells.  Such  a  tumor  may  pulsate  and 
have  a  bruit,  and  hemorrhage  often  takes  place  into  its  substance.  A  rapidly 
growing  soft  sarcoma  with  dusky  skin  above  it  (Fig.  190)  may  be  mistaken  for 
an  abscess.  A  slowly-growing  sarcoma  has  but  few  vessels.  Sarcoma  tends 
strongly  to  infiltrate  adjacent  parts.  The  growth  disseminates  by  means  of 
the  blood  and  the  vessel  walls,  particles  of  the  tumor  being  carried  by  the 
venous  blood  to  the  heart,  and  from  this  organ  to  the  lungs,  where  they  lodge 

—^    and     form     secondary    growths.     Emboli 
from    these  secondary  foci  are  sent   out 
!    by    the    arterial    blood    to    various    por- 
tions of  the  bodv,  as  the  bones,  kidneys, 


r 


Fig.  191. — Small  round-celled  sarcoma 
of  neck.  Skin  has  given  way  and  a  bleed- 
ing mass  is  exposed. 


Fig.   192. — Sarcoma  of  neck  (Horwitz). 


brain,  liver,  etc.  This  process  is  known  as  metastasis.  In  some  cases  sarcoma 
is  disseminated  widely  throughout  the  body,  ahnost  all  the  tissues  showing 
minute  white  spots  of  secondary  sarcoma  which  resemble  tubercles.  Such 
widespread  dissemination  is  called  sarcomatosis.  Sarcoma  follows  the  vein 
walls  for  considerable  distances  and  builds  elongated  masses  of  tumor  substance 
inside  the  veins.  The  primary  tumor  may  possess  a  capsule  when  it  is  in  an 
early  stage,  but  soon  loses  this  except  in  very  slow-growing  varieties  or  in  mixed 
forms  growing  by  central  proliferation,  but  secondary  sarcomata  are  often  encap- 
suled.  Sarcomata  may  arise  at  any  age  from  birth  to  extreme  senility,  but 
they  are  commonest  during  youth  and  early  middle  age.  They  are  not  heredi- 
tary. They  often  follow  traumatism  and  inflammation.  A  number  of  observers 
maintain  that  they  are  due  to  parasites  (the  question  of  the  parasitic  origin  of 
malignant  disease  is  discussed  on  page  399).  A  sarcoma  may  be  primary  or 
may  arise  from  malignant  change  in  an  innocent  connective-tissue  growth 
(chondrosarcoma,  fibrosarcoma,  etc.).  A  sarcoma  rarely  afi"ects  adjacent 
lymphatic  glands  unless  it  contains  lymphatics,  and  the  great  majority  of 
sarcomata  do  not  contain  them.     Occasionally  sarcoma  cells  are  carried  to 


]MaliKnant   Connecti\'e-tissue  Tumors,  or  Sarcomata 


423 


.adjacent  glands  by  ihe  vein  walls  rather  than  by  the  lymph-stream.     Sarcoma 
of  the  tonsil,  sarcoma  of  the  testicle,  melanotic  sarcoma,  and  lymphosarcoma 


Fig.  193. — Dr.  W.  R.  Bishop's  case  of  small- 
celled  sarcoma  of  the  antrum. 


Fig.  194. — Osteosarcoma  of  eighteen 
months'  standing  of  right  side  of  superior 
maxilla.  Note  bon\-  lump  on  left  side 
of  lower  jaw. 


do  affect  the  glands.  The  skin  over  the  tumor  may  give  way,  a  bleeding 
fungous  mass  protruding  (fungus  hsmatodes)  (Figs.  190,  191,  and  192),  and 
suDi3uration  may  cause  septic  enlargement  of  adjacent  glands.     In  the  course 

of  growth  of  a  sarcoma  there  may  be  irregular 
episodes  of  elevated  temperature  (see  page 
402).  After  removal  of  a  sarcoma  the  growth 
tends    to    recur,    and   the   recurrent   tumor 


Fig.    195. — Small    round-celled    sar-         Fig.     196. — Spindle-celled    sarcoma    of   sheath  of 
coma  of  the  neck.  flexor  tendon  of  finger. 


may    be    either    more    or    less    malignant    than  its   predecessor,    the  degree 
of  malignancy  beins:  in  direct  ratio  to  the  number  and  smallness  of  the  cells. 


424 


Tumors  or  ^Morbid  Growths 


A  sarcoma  is  malignant  by  local  tissue  infection  and  by  dissemination. 
Sarcomata  rarely  cause  pain  when  they  are  not  ulcerated.  They  are  com- 
monest in  the  skin  and  connective  tissue  of  the  extremities,  but  they  arise  also 
from  neuroglia,  bone,  medulla  of  bone,  periosteum,  the  lymphatic  glands,  fascia, 
the  breast,  the  testicle,  the  eyeball,  the  parotid,  and  other  parts.  A  pigmented 
mole  may  become  sarcomatous.  Hemorrhages  into  a  sarcoma  often  occur, 
with  the  result  of  suddenly  increasing  the  size  of  the  mass  and  formation  of 
blood-cysts.  Sarcomata  are  subject  to  partial  fatty  degeneration,  to  myomatous 
changes  which  produce  cavities  filled  with  f^uid,  to  calcification,  and  occasionally 
to  necrosis  of  large  masses. 

Varieties  of  Sarcomata. — The  following  species  of  sarcomata  are  recognized: 

I,  Ronnd-celled  sarcoma  is  a  tumor  composed  of  round  or  spherical  cells 

and   resembling   a   chronic   inflammatory   area.     The   intercellular   substance 

is  scanty,  the  mass  is  soft  and  vascular,  and  grows  with  great  rapidity.     It 

often  softens,  and  may  become  cystic.     The  cells  may  be  small  or  large.     The 


Fig.  197 


-Melanotic  sarcoma.     Observe  the  pigmentation  of  the  face. 


smaller  the  cells,  the  more  malignant  the  growth.  A  growth  composed  of 
small  round  cells  is  the  most  malignant  form  of  sarcoma  (Fig.  195).  Lym- 
phosarcoma is  a  form  of  round-celled  sarcoma  which  arises  from  honphatic 
glands,  lymphoid  tissues,  the  thymus  gland,  the  spleen,  and  some  other  struc- 
tures. The  structure  of  a  lymphosarcoma  bears  some  resemblance  to  the  structure 
of  a  lymph-gland  in  the  fact  that  it  has  a  reticulum  which  looks  like  that  of 
lymph-adenoid  structure.  Chloroma  is  a  form  of  lymphosarcoma  arising  particu- 
larly from  the  periosteum  of  the  bones  of  the  cranium  and  face,  involving 
lymph-glands  and  usually  associated  with  the  blood  picture  of  leukemia.  The 
cells  resemble  those  of  bone-marrow.  In  a  chloroma  of  the  mammary  gland 
reported  by  Reid,  the  blood  picture  of  leukemia  was  absent.  The  cells  contain 
greenish  pigment,  hence  the  name.  What  is  kno\\Ti  as  glioma  of  the  eyeball  is 
not  a  true  glioma,  but  is  really  a  sarcoma  composed  of  small  round  cells. 

2.  Spindle-celled  sarcoma  is  a  tumor  composed  of  large  or  small  spindle- 
shaped  cells  lying  in  a  matrix,  which  may  be  homogeneous,  but  which  may 
show  some  attempt  at  fiber  formation.  Angular  cells  and  stellate  cells  are 
often  present.  The  cells  may  be  placed  in  columns,  which  are  at  some  places 
nearly  parallel  and  which  at  others  diverge  or  interlace.     Often  there  is  no 


Varieties  of  Sarcomata  425 

orderly  arrangement.  Spindle-celled  sarcomata  are  usually  harder  than  round- 
celled  growths,  but  are  sometimes  quite  soft.  Cystic  changes  may  occur.  If 
there  is  a  large  amount  of  intercellular  substance  the  growth  is  known  as  a 
fibrosarcoma.  A  rhabdomyoma  is  really  a  spindle-cell  sarcoma  containing 
striated  muscle-cells.  The  spindle-cell  sarcomata  often  contain  cartilage. 
Spindle-cell  growths  are  by  no  means  as  malignant  as  round-cell  tumors.  Often 
they  do  not  show  any  tendency  to  metastasis.  The  greater  the  amount  of 
intercellular  substance  and  the  fewer  the  cells,  the  less  the  malignancy.  Blood- 
good  points  out  that  in  one  group  of  cases  (the  least  malignant)  the  spindle 
cells  exhibit  a  disposition  to  form  fibroblasts  {fibro spindle-cell  sarcoma,).  In 
another  group  (the  most  malignant)  there  are  no  fibroblasts  and  round  cells 
are  distributed  among  the  spindle  cells  {mixed  spindle-cell  and  round-cell  sar- 
coma). Spindle-cell  growths  constitute  the  majority  of  sarcomata  met  with 
in  practice. 

3.  Giant-cell  sarcoma  resembles  in  structure  the  red  marrow  of  growing  bone 
and  is  characterized  by  the  presence  of  numerous  very  large  cells  with  many 
nuclei,  looking  exactly  like  the  myeloplaques  of  bone-marrow.  Such  a  growth 
is  maroon  colored  on  section  and  contains  giant  cells  surrounded  by  round 
cells  or  by  spindle  cells.  Bloodgood  says  that  the  tumor  when  fresh  has  a  striking 
"hemorrhagic  mottled  coloring,"  and  further,  the  tumor  is  very  friable  and 
"resembles  hemorrhagic  granulation  tissue"  ("Jour.  Am.  Med.  Assoc,"  Jan. 
I,  1908).  It  arises  usually  from  bone,  especially  from  the  interior  of  the  end  of 
a  long  bone,  hence  is  often  called  medullar  or  myeloid  sarcoma.  As  a  matter  of 
fact  it  is  only  medullary  or  myeloid  when  it  springs  from  bone.  The  term 
osteosarcoma,  should  be  restricted,  as  Bloodgood  suggests,  to  bone  tumor 
with  accompanying  formation  of  new  bone.  It  is  almost  invariably  single, 
but  Rehn  reported  a  case  of  multiple  giant-cell  sarcoma  of  bone,  and  Crile 
and  Hill  reported  another.  Bloodgood  denies  the  occurrence  of  metastasis. 
Epulis  is  a  form  of  giant-cell  sarcoma.  The  tumor  may  arise  from  other 
structures  than  bone.  It  is  the  least  malignant  form  of  sarcoma.  Metastases 
do  not  occur  and  the  growth  often  admits  of  complete  extirpation  and  cure. 
Some  surgeons  do  not  class  these  growths  with  sarcomata.  Bloodgood  re- 
gards their  malignancy  as  very  slight.  Friedlander  looks  upon  them  as  benign 
angeiomata  in  which  giant  cells  have  been  formed  by  endothelial  cells  budding 
into  spaces  lined  with  endothelium.  Growths  of  this  nature  are  most  commoa 
in  those  under  twenty-five  years  of  age.  They  usually  come  on  almost  sud- 
denly after  a  traumatism.  A  giant-cell  sarcoma  within  a  bone  slowly  expands 
it.  Although  tenderness  exists  from  the  start  there  is  seldom  much  pain 
until  expansion  is  considerable.  When  the  bone  becomes  very  thin  it  may 
crackle  on  pressure.  This  is  called  the  ping-pong  bone  (Connell,  in  "Surgery, 
Gynecology,  and  Obstetrics,"  April,  191 5).  The  tumor  develops  slowly  and 
runs  a  long  course.  It  does  not  penetrate  the  bone  as  would  a  malignant 
medullary  sarcoma. 

4.  Alveolar  sarcoma  is  a  tumor  containing  both  round  cells  and  spindle 
cells,  and  characterized  by  the  formation  of  acini,  filled  with  round  cells  of 
large  size  resembling  epithelioid  cells.  The  walls  of  the  acini  are  formed  of 
spindle  cells  and  fibrous  tissue,  and  in  these  trabeculae  are  the  blood-vessels. 
The  collection  of  the  cells  in  the  alveoli  makes  the  structure  resemble  that  of  a 
cancer.  Such  growths  are  often  pigmented.  Alveolar  sarcomata  arise  par- 
ticularly from  moles  of  the  skin,  but  may  arise  from  lymphatic  glands,  serous 
membranes,  the  testicle,  and  other  parts.     Such  growths  are  very  malignant. 

5.  Melanotic  or  Black  Sarcoma  (Fig.  197). — The  color  of  such  a  tumor  is 
due  to  pigment  in  the  cells  or  matrix.  These  growths  are  usually  composed  of 
round  cells,  but  may  consist  of  spindle  cells,  and  they  are  sometimes  alveolar. 
Melanotic  sarcomata  spring  from  parts  which  contain  pigment  (for  instance, 
the  skin  and  the  choroid  coat  of  the  eye,  pigmented  moles,  and  pigmented 


426 


Tumors  or  Morbid   Growths 


nevi) ;  they  are  very  mahgnant;  they  imphcate  related  lymphatic  glands,  undergo 
early  metastasis,  and  during  their  existence  the  urine  contains  pigment. 

Early  metastasis  is  by  lymph-vessels  and  leads  to  secondary  glandular 
tumors.  Later  metastasis  is  by  the  blood-vessels  and  leads  to  secondary  tumors 
in  the  lungs,  liver,  and  other  parts.  The  tumors  occur  usually  in  those  beyond 
middle  life.  They  soon  ulcerate  and  later  fungate.  The  patient  usually 
dies  in  from  one  to  six  years  (see  Hetzler  and  Gibson,  in  "Annals  of  Surgery," 
1914,  Ix). 

Malignant  growth  from  a  congenital  pigmented  mole  used  to  be  regarded 
by  most  observers  as  melanotic  sarcoma,    but   Bloodgood   would  place  these 
growths  in  a  group  by  themselves.     He  says  that  the  weight  of  opinion  is  on 
the  side  of  those  who  maintain   that   the  cells   are  of  epithelial   origin   mis- 
placed early  in  embryonic  life,  and 
that  the  tumor  is  a  cancer.     Many 
surgeons  still  regard  such  a  tumor 
as  sarcoma. 

6.  Hemorrhagic  sarcoma  is  a 
sarcoma  containing  blood-cysts 
which  result  from  parenchymat- 
ous hemorrhages. 

7.  Angeiosarcoma  or  heman- 
geiosarcoma  takes  origin  from  the 
outer  coat  of  a  blood-vessel  and 
in  this  differs  from  endothelioma 
which  arises  from  the  lining  cells 
of  lymph-spaces.  The  growth  is 
often  very  vascular,  and  when  the 
blood-vessels  are  notably  dilated 
the  tumor  is  called  a  telangiectatic 
sarcoma.  The  ordinary  forms  of 
angeiosarcoma  are  only  moder- 
ately malignant,  but  alveolar  and 
melanotic  forms  occur  which  are 
highly  malignant.  Angeiosarcoma 
may  arise  in  the  skin,  in  a  serous 
membrane,  in  intermuscular  struc- 
ture, in  bone,  or  in  a  salivary  gland. 
It  most  frequently  takes  origin 
from  a  nevus. 

Perithelioma  is  a  variety  of  angiosarcoma  which  is  most  often  noted  growing 
from  the  skin,  the  kidney,  or  the  bone.  It  originates  from  the  perithelial  cells, 
which  are  between  the  capillaries  and  the  perivascular  lymph-spaces.  Peri- 
thelioma is  very  malignant. 

8.  Cylindroma,  or  Plexiform  Sarcoma. — In  this  variety  the  sarcoma  cells 
adjacent  to  vessels  have  undergone  hyaline  or  myxomatous  degeneration;  the 
cells  distant  from  vessels  are  unchanged.  Section  shows  the  sarcoma  cells 
apparently  contained  in  spaces  with  hyaline  walls.  These  degenerative  changes 
occur  most  often  in  the  angiosarcomata.  Cylindromata  arise  from  the  brain, 
salivary  glands,  lacrimal  glands,  and  rarely  from  the  subcutaneous  tissue. 
These  growths  are  only  moderately  malignant.^ 

9.  Mixed  timiors  consist  partly  of  mature  and  partly  of  embryonic  tissue, 
the  cellular  elements  exceeding  the  adult  elements  in  amount.  Among  these 
mixed  tumors  are  fibrosarcoma  or  the  recurrent  fibroid  tumor,  myxosarcoma 
(Fig.  198),  chondrosarcoma,  gHosarcoma,  and  osteosarcoma. 

10.  Endotheliomata  are  tumors  springing  from  the  endothelium  of  lymph- 

'  Stengel,  "Text-Book  of  Pathology." 


Fig 


. — Hansen's   case  of  cystic  myxosarcoma 
of  the  orbit. 


Varieties  of  Sarcomata 


427 


spaces,  and  the  name  is  retained  no  matter. what  changes  the  growths  ultimately 
undergo.  Some  writers  have  included  under  the  term  "endothelioma"  psam- 
nioma,  myxosarcoma,  angiosarcoma,  and  plexiform  sarcoma.  Others  consider 
endothelioma  a  special  and  characteristic  form  of  sarcoma.  Some  would  not 
consider  it  with  the  sarcomata  at  all.  The  growth  may  take  origin  from  the 
"endothelium  of  the  perivascular  lymph-spaces,  of  the  lymph-vessels,  and  of 
the  great  serous  cavities  (peritoneum,  pleura,  meninges)."^  The  characteristic 
■cell  is  the  endothelial  cell,  usually  known  as  the  epithelioid  cell.  The  structure 
of  these  tumors  is  very  variable  and  depends  upon  the  origin;  some  tumors 
"recalling  the  original  vascular  network ' '  ("American  Text-Book  of  Pathology ' ') , 
others  being  distinctly  alveolar.  Many  pathologists  consider  a  psammoma  of 
the  dura  to  be  an  endothelioma  with  a  fibrous 
stroma.  A  psammoma  contains  calcareous 
particles.  In  appearance  an  endothelioma 
strongly  resembles  cancer,  and  such  a  growth 
is  often  spoken  of  as  endothelial  cancer.  Such 
growths  can  arise  in  many  different  situations, 


Fig.   199. — Recurrent  sarcoma  of  the  sternum. 


Fig.  200.- 


-Periosteal  sarcoma  of  tfie 
femur. 


but  are  particularly  common  in  the  skin  over  the  parotid  gland,  the  lymph- 
glands,  the  bone,  peritoneum,  pleural  membrane,  membranes  of  the  brain, 
ovary,  and  testicle.  I  have  removed  an  endothelioma  of  the  tonsil,  one  of 
the  mammary  gland,  two  of  the  nasopharynx,  one  of  the  superior  maxillary 
bone,  and  three  of  the  carotid  gland.  The  proliferating  endothelial  cells  lie 
in  lymph-spaces.  Many  endotheliomata  grow  rapidly,  secondary  growths 
form,  and  metastases  are  apt  to  pass  to  the  serous  membranes.  Certain 
endotheliomata  grow  slowly,  do  not  infiltrate  adjacent  structure,  and  do  not 
produce  secondary  growths.  In  the  brain  and  cord  endothelioma  may  produce 
no  symptoms  for  along  time.  It  is  not  as  yet  possible,  clinically,  to  differen- 
tiate distinctly  between  endotheliomata  and  ordinary  sarcomata. 

II.  Mycosis  or  granuloma  fungoides  is  a  disease  which  resembles  sarcoma 
in  many  particulars  and  may  perhaps  be  a  form  of  sarcoma.  It  attacks  the 
skin  and  subcutaneous  tissues.  It  is  preceded  for  months  or  years  by  an 
eczematous  or  urticarial  condition.  The  skin  becomes  red  and  swollen; 
numerous  pinkish  or  reddish  nodules  or  flat  areas  of  induration  form;  the 
nodules  become  distinct  tumors,  soften  at  their  centers,  usually  ulcerate,  and 

^  "An  American  Text-book  of  Pathology,"  edited  by  Hektoen  and  Riesman. 


428 


Tumors  or  ^Morbid  Cirowths 


fungation  takes  place.  When  ulceration  occurs  mushroom-like  growths  form. 
Microscopically,  the  tumor  resembles  a  lymphadenoma.  Mycosis  fungoides 
is  considered  by  some  pathologists  to  be  multiple  cutaneous  sarcoma.  It  is 
very  chronic  and  lasts  for  months  or  even  years.  It  was  first  described  and 
was  named  by  Alibert. 

Treatment  of  Sarcomata. — Remove  a  sarcoma  at  once  if  it  is  in  an  accessible 
spot.  Never  delav  removal,  and  always  cut  well  clear  .of  it.  If  affecting  a  part 
where  amputation  is  impossible,  a  very  rapidly  growing  sarcoma  will  almost  in- 
evitably return,  and  the  very  malignant  variety,  if  uninterfered  with,  may  ter- 


FiG.   20I. — Central  sarcoma  of  humerus. 


minate  life  in  six  months;  but  even  in  such  a  case  operation  may  postpone  the  evil 
day  and  render  it  possible  that  death  will  occur  from  metastatic  growth  in  an 
organ,  and  that  the  patient  will  escape  the  horrors  of  ulceration  and  hemor- 
rhage from  the  original  tumor.  Slowly  growing  and  hard  tumors  offer  better 
prospects  of  cure.  The  mixed  tumor  (as  a  recurrent  fibroid)  may  repeatedly 
recur,  and  yet  the  patient  may  be  cured  at  last  by  a  sixth,  an  eighth,  or  a 
tenth  operation.  In  a  case  of  spindle-cell  sarcoma  of  the  breast  the  younger 
Gross  performed  22  operations  in  the  course  of  four  years,  and  eleven  years 
later  the  woman  was  well.  In  a  case  of  recurrent  fibroid  of  the  neck  the  younger 
Gross  operated  five  times.  Three  years  after  Prof.  Gross's  death  I  operated 
upon  the  same  patient,  and  again  two  years  later.     Nine  years  after  the  last 


Treatment  of  Sarcomata 


429 


operation  she  was  alive  and  well.  In  sarcoma  of  a  long  bone  (though  not  in 
giant-cell  sarcoma)  amputation  should,  as  a  rule,  be  performed.  Blood- 
good  proves  that  in  some  of  these  cases  extensive  excision  is  just  as  useful. 
In  giant-cell  sarcoma  incision  and  curetting  may  be  employed,  or,  if  this  is 
insufhcicnt,  subperiosteal  excision.  Curetting  is  admissible  only  when  there  is 
a  definite  shell  of  bone  beyond  the  tumor.  Bloodgood  has  reported  the  cases  of 
giant-cell  sarcoma  from  Halsted's  clinic.  The  reports  show  that  excellent 
results  follow  this  plan  of  treatment.  If  the  soft  parts  are  involved,  they  must 
be  removed  wide  of  the  growth.  Amputation  is  necessary  only  when  the  re- 
moval of  soft  parts  must  be  so  extensive  as  hopelessly  to  mutilate  the  limb. 
In  sarcoma  of  either  jaw-bone,  excise;  of  the  eye,  enucleate;  of  the  testicle,  cas- 


FiG.   202. — Central  sarcoma  of  the  fibula. 

trate.  Sarcoma  of  the  ovary  in  adults  demands  removal,  but  in  children  the 
operation  is  generally  useless.  Sarcoma  of  the  kidney  in  adults  calls  for  neph- 
rectomy, but  in  children  the  operation  is  usually  of  little  avail.  ^  In  my  experi- 
ence, in  the  cases  of  sarcoma  of  the  kidney  which  survived  operation  the  growth 
always  appeared  in  the  other  kidney.  In  melanotic  sarcoma  extirpate  the 
growth  widely  and  remove  anatomically  related  lymph-nodes,  or  in  some 
cases  amputate  far  away  from  the  tumor  and  remove  lymph-nodes.  The 
probability  of  recurrence  is  very  strong.  In  very  malignant  sarcoma  even 
amputation  does  not  often  cure.  Removal  of  a  sarcoma  when  there  is  no  hope 
of  a  cure  is  often  justifiable  to  prolong  life,  to  relieve  the  patient  of  a  foul, 
ofifensive,  bleeding  mass,  and  to  permit  of  an  easier  road  to  death  by  means  of 
metastasis  to  an  internal  organ.  In  an  inoperable  case  the  Hgation  of  the  vessel 
■of  supply  may  do  good.     In  sarcoma  of  the  tonsil  Dawbarn  advises  the  extirpa- 


430 


Tumors  or  Morbid  Growths 


tion  of  the  external  carotid  artery  and  the  ligation  of  its  branches.  The  opera- 
tion is  performed  first  on  the  side  occupied  by  the  tumor  and  in  a  week  or  so  on 
the  other  side.  I  employed  it  in  7  cases  with  distinct  but  temporary  benefit. 
Occasionally,  though  very  rarely,  suppuration  cures  a  sarcoma.  Wyeth,  of 
New  York,  reported  a  case  of  sarcoma  of  the  abdominal  wall.  It  was  found 
possible  to  remove  only  part  of  the  growth;  suppuration  followed  and  the  tumor 
disappeared,  and  ten  years  later  had  not  returned.  A  study  of  statistics  seems 
to  indicate  that  more  cases  of  sarcoma  are  cured  after  operation  if  the  wound 
suppurates  than  if  it  remains  aseptic,  and  it  has  been  proposed  to  infect  deliber- 
ately the  wound  with  pus  germs  to  lessen  the  danger  of  recurrence.  If  the 
wound  is  large,  it  should  not  be  infected  until  it  is  nearly  healed.  If  it  is  small, 
it  may  be  infected  at  the  time  of  operation  or  soon  after.  After  amputating 
for  sarcoma,  Wyeth  waits  until  the  wound  is  nearly  healed  and  then  infects  it 
by  inserting  a  gauze  drain  saturated  with  cultures  of  pure  Streptococcus  pyo- 
genes (Wyeth's  "Surgery").  After  re- 
moving a  sarcoma  from  any  region  the 
patient  should  be  given  courses  of  injec- 
tions of  Coley's  fluid  (see  below). 

It  has  been  observed  that  an  attack  of 
erysipelas  occasionally  greatly  benefits  a 
sarcoma,  causing  large  masses  of  the  growth 
to  soften  or  to  slough  and  exposing  a 
granulating  surface.  Busch  noticed  this 
in  1866,  but  the  fact  had  been  observed 
in  the  seventeenth  century.  Interest  was 
decidedly  awakened  by  Billroth's  case  of 
sarcoma  of  the  pharynx  which  was  cured 
by  an  attack  of  facial  erysipelas.  It  was 
suggested  that  in  inoperable  cases  of 
sarcoma  erysipelas  might  be  established 
artificially.  Fehleisen  inoculated  tumors 
\\ath  cultures  of  erysipelas.  Lassarin  1891 
employed  the  toxins  (cultures  rendered 
sterile  by  heat  and  filtration).  In  1892 
Coley  began  his  observations.  The  first 
plan  was  as  follows:  a  bouillon  culture 
was  made  of  the  streptococci;  this  cul- 
ture was  filtered  through  porcelain  and 
an  injection  was  given  once  a  day  into 
and  about  the  sarcoma.  The  first  dose 
was  10  min.  and  it  was  progressively 
increased.  The  effect  was  to  cause  a  febrile  reaction,  and  sometimes  the 
injections  were  followed  by  softening  or  suppuration.  Coley's  present  method 
is  as  follows:  Make  cultures  of  erysipelas  cocci  in  cacao  broth;  after  three 
weeks  inoculate  them  with  the  Bacillus  prodigiosus,  and  cultivate  the  mbced 
growth  for  four  weeks.  The  mixed  cultures  are  maintained  at  a  temperature  of 
136°  F.  until  they  become  sterile.  This  sterile  fluid  contains  the  toxins.  The 
usual  dose  for  an  adult  is  from  i  to  8  min.  Coley  has  given  as  high  as  24  min. 
I  have  never  given  over  18  min.  Most  cases  will  show  reaction  at  4  to  6  min. 
The  first  dose  for  an  infant  is  ^io  min.  If  in  an  adult  the  fluid  is  injected 
remote  from  the  tumor  the  initial  dose  should  be  i  min.  If  the  fluid  is  injected 
into  the  tumor  the  intial  dose  is  }i  to  ^^  min.  (Coley,  in  ''Amer.  Jour.  Med. 
Sci.,"  March,  1906).  Some  cases  are  treated  purely  by  distant  injections 
(gluteal  or  pectoral  regions),  others  by  alternately  injecting  the  tumor  and  some 
distant  point.  The  latter  plan  combines  local  action  and  systemic  effect. 
The    dose    should    be    gradually    increased    until  a  chill  occurs  in  from  one- 


FlG.    203 


-Inoperable 
back. 


Treatment  of  Sarcomata 


43  r 


half  an  hour  to  two  hours  after  the  injection,  followed  by  a  temperature  of 
ioi°to  104°  F.  In  some  cases  there  is  so  much  depression  after  reaction  that 
injections  are  given  every  other  day,  but  if  safely  possible  they  should  be 
given  every  day.  The  object  is  to  obtain  a  reaction  with  each  injection. 
The  more  vascular  the  tumor,  the  more  severe  the  reaction  (Coley).  If  an 
area  softens  during  treatment  Coley  advises  us  to  open  and  drain  the  softened 
area.  If  improvement  is  to  occur  it  usually  begins  in  from  one  to  four 
weeks.  If  there  is  no  improvement  within  four  weeks  there  probably  will  not 
be  any.  In  most  cases  as  injection  is  continued  susceptibility  diminishes;  in 
some  few,  it  increases.  It  seems  definitely  proved  that  cases  are  occasionally 
cured  by  Coley 's  fluid.  It  is  generally  stated  that  spindle-cell  sarcomata  are 
influenced  most  favorably  and  that  round-celled  sarcomata  are  very  refractory. 
Harmer  in  a  study  of  91  cases  regards  the  small  round-cell  sarcomata  as  most 
amenable  to  the  treatment,  spindle-cell  sarcomata  as  coming  closely  next,  and 
the  mixed-cell  type  as  decidedly  refractory  ("Boston  Med.  and  Surg.  Jour.," 
Jan.,  1 91 5,  clxxii).  Cancers  are  seldom  benefited.  The  method  is  not  entirely 
free  from  danger,  but  the  danger  is  very  slight  if  treatment  is  begun  with  the 
minimum  dose.  The  toxins  seem  of  value  in  postoperative  cases  to  prevent 
recurrence.     For  this  purpose  the  fluid  is  used  twice  a  week  for  several  months. 


Fig.  204. — Huge  sarcoma  of  buttock  cured  by  partial  extirpation  and  Coley's  fluid. 


and  at  greater  intervals  for  a  long  period  of  time.  During  the  autumn  of  191a 
I  brought  before  my  class  in  the  Jefferson  Hospital  a  colored  woman  (Fig.  204) 
with  an  inoperable  spindle-cell  sarcoma  of  the  thigh  and  groin.  A  portion  of 
the  growth  was  removed  and  the  remainder  completely  disappeared  from  injec- 
tions of  Coley's  fluid.  She  remained  well  over  three  years  after  treatment  was 
suspended  when  I  lost  sight  of  her.  This  patient  had  a  violent  reaction  every 
day  for  weeks.     She  was  given  as  much  as  7  min.  at  a  dose. 

How  the  toxins  act  is  uncertain.  They  produce  some  change  in  the  blood- 
serum,  and  the  valuable  effect  is  systemic.  Nearly  always  they  cause  leuko- 
cytosis. Probably  they  cause  the  formation  of  antibodies  antagonistic  to  the 
sarcoma  cells.  The  treatment,  as  Coley  insists,  is  not  a  substitute  for  operation. 
The  fluid  is  used  in  inoperable  cases,  a  trial  of  it  is  made  in  sarcoma  of  long  bones 
before  advising  operation,  it  is  given  after  all  operations  for  cancer  or  sarcoma  ta 
combat  recurrence,  and  it  may  be  tried  in  inoperable  cancer.  Coley  ("Surg.,. 
Gynec.  and  Obstet.,"  August,  191 1)  has  had  65  cases  of  inoperable  sarcoma  in 
which  the  tumor  disappeared  from  the  treatment:  7  are  alive  and  well  at  the 
end  of  fifteen  to  eighteen  years ;  7  alive  and  well  at  the  end  of  ten  to  fifteen  years ; 
17  alive  and  well  at  the  end  of  five  to  ten  years;  10  alive  and  well  at  the  end  of 
three  to  five  years.     The  others  could  not  be  traced. 

Emmerich  and  Scholl  claim  good  results  in  inoperable  sarcoma  from  the 
injection  of  erysipelas  serum.     A  sheep  is  injected  with  cultures  of  erysipelas. 


432 


Tumors  or  Morbid  Growths 


the  blood  is  drawn,  the  serum  separated,  filtered  to  remove  cocci,  and  injected 
about  the  sarcoma.  Results  are  not  definite.  Among  other  agents  which 
have  been  used  to  inject  inoperable  sarcomata  we  may  mention  alcohol,  chlorid 
of  zinc,  arsenic,  corrosive  sublimate,  thiosinamin,  pepsin,  alkalis,  etc.  The 
injection  of  anilin  products  into  the  sarcoma,  which  once  received  qualified 
commendation  from  some  observers,  has  been  abandoned  by  most  surgeons. 
The  .v-rays  are  sometimes  of  benefit,  but  are  not  so  serviceable  as  in  carcinoma, 
and  possess  a  certain  danger,  for  occasionally  after  using  them  dissemination 
occurs  rapidly.  Abbe  and  others  have  obtained  some  remarkable  results  by 
radium,  but  such  results  are  exceptional  and  not  the  rule. 

Hypernephromata,  or  Adrenal  Tumors. — Some  hypernephromata  bear 
a  strong  resemblance  to  adenomata  and  carcinomata.  Some  adrenal  tumors 
are  benign,  and  among  such  tumors  we  note  fatty  and  fibrous  growths  and 
growths  resembling  glioma.     Another  benign  growth  imitates  the  structure  of 

the  cortex  of  the  adrenal.  Malig- 
nant tumors  occur,  and  many  of 
them  are  identical  or  almost 
identical  with  sarcoma.  One 
form  is  composed  of  epithelioid 
cells  and  resembles  endothelioma. 
An  adrenal  tumor  may  arise  from 
the  adrenal  body  proper  or  from 
"rests"  in  ectopic  portions  of 
adrenal  within  the  kidney,  ovary, 
testicle,  solar  plexus,  renal  plexus, 
liver,  mesentery,  or  some  other 
part.  Some  of  these  tumors  at- 
tain a  large  size.  Metastases  are 
late,  but  tend  to  occur  eventually 
even  in  hypernephromata  which 
seem  benign,  and  may  occur  even 
when  the  primary  growth  has 
given  rise  to  no  symptoms.  The 
metastases  are  lodged  particularly 
in  the  bones,  the  lungs,  and  the 
liver.  In  a  case  from  which  I 
removed  a  goiter  and  death  resulted  from  reactionary  hemorrhage  the  tumor 
(which  I  had  considered  to  be  adenoma)  was  found  to  be  composed  of  adrenal 
tissue.     Unfortunately,  an  autopsy  was  not  permitted. 

Accessory  adrenals  are  common.  They  are  known  as  adrenal  rests.  "  They 
are  found  oftenest  in  the  connective  tissue  about  the  main  adrenals,  but  also 
in  the  kidneys,  the  right  lobe  of  the  liver,  along  the  renal  vessels  and  spermatic 
veins,  in  the  inguinal  canals,  and  in  the  broad  ligaments"  ("American  Text- 
Book  Pathology"). 

Innocent  Epithelial  Tumors.— These  growths  imitate  an  epithelial 
tissue  of  the  mature  and  healthy  organism. 

Papillomata,  or  Warts  (Fig.  205).— Papillomata  are  formed  upon  the 
type  of  cutaneous  and  mucous  papillae.  A  papilloma  consists  of  a  fibrous 
stroma,  which  contains  blood-vessels  and  lymphatics  and  is  covered  by  epithe- 
lium of  the  variety  appertaining  to  the  diseased  part.  Papillomata  grow  from 
the  skin  and  from  mucous  membranes;  they  may  be  single  or  multiple;  many 
may  form  in  one  region  or  various  distant  parts  may  be  affected;  they  may  be 
painless  or  may  be  ulcerated  or  bleeding;  they  vary  in  color  from  light  pink 
to  deep  brown  or  black.  Papillomata  of  the  skin  are  usually  hard;  papillo- 
mata of  mucous  membranes  are  soft.  A  skin-wart  may  be  smooth  and  rounded, 
or  may  look  like  a  small  cauliflower,  the  epidermis  upon  it  being  very  rough. 


Fig.   205. — Keen's  case  of  papilloma  with  angioma. 


Treatment  of  Papillomata  or  Warts 


433 


A  papilloma  of  a  mucous  membrane  looks  like  a  small  cauliflower.  Papilloma- 
tous masses  may  gather  around  the  anus,  the  vagina,  or  the  penis  during  the 
existence  of  a  filthy  discharge  {venereal  warts,  Fig.  206),  and  crops  of  warts 
may  appear  on  the  hands  of  those  who  work  in  irritant  material  (as  petroleum). 
Papillomata  are  apt  to  arise  in  mucous  membranes  about  carcinomata  or 
chronic  ulcerations.  A  large  crop  of  warts  may  disappear  in  a  single  night; 
hence  the  popular  belief  in  the  efficacy  of  charms.  Warts  are  particularly 
common  on  the  skin  of  the  back  of  the  hands  and  fingers,  the  skin  of  the  back, 
and  the  skin  of  the  neck  and  scalp.  A  single  skin- wart  may  reach  the  size 
of  a  walnut  and  become  pigmented.  The  squamous  epithelium  covering 
a  skin- wart  may  become  horny  (a  wart-horn).  Other  cutaneous  horns  arise 
from  the  nails,  from  the  scars  of  burns,  or  from  ruptured  sebaceous  cysts. 

Villous  papillomata  grow  chiefly  from  the  bladder,  but  they  may  also  grow 
from  the  stomach  and  intestine.  A  papilloma  of  mucous  membrane  covered 
with  squamous  epithelium  looks  like  a  wart  of  the  skin.  Papillomata  of  the 
larynx  are  formed  of  squamous  epithelium.     Villous  papillomata  form  tufts 


Fig.   206. — Venereal  warts. 

like  the  villous  processes  of  the  chorion;  they  may  be  single  or  multiple,  and 
may  be  sessile  or  pedunculated;  they  are  very  vascular,  and  are  apt  to  bleed 
freely.  Papillomata  may  arise  in  cysts  of  the  paroophoron,  in  cysts  of  the 
mammary  gland,  from  the  choroid  plexuses  of  the  ventricles  of  the  brain,  and 
from  the  spinal  membranes.  Papillomata  may  give  rise  to  hemorrhage  or  may 
impair  the  function  of  a  part.     Any  papilloma  may  become  a  cancer. 

Treatment. — Venereal  warts  are  treated  by  repeatedly  washing  with  peroxid 
of  hydrogen,  drying  with  cotton,  and  dusting  with  a  powder  composed  of 
borated  talcum  or  of  equal  parts  of  calomel  and  subnitrate  of  bismuth,  or 
of  oxid  of  zinc  and  iodoform.  If  they  do  not  soon  dry  up,  cut  them  off  with 
scissors  and  burn  with  the  Paquelin  cautery.  Ordinary  warts  may  usually 
be  destroyed  in  a.  short  time  by  daily  applications  of  lactic  or  chromic  acid. 
Most  warts  are  easily  destroyed  by  solid  CO2.  It  is  held  in  contact  with  the 
wart  for  thirty  or  forty  seconds.  In  a  few  days  the  warts  drop  off  or  can  be 
easily  picked  off.  In  multiple  warts  of  the  face  Kaposi  applies  daily  for  several 
days  a  portion  of  the  following  combination:  sublimed  sulphur,  5  dr.;  glycerin, 
ij^^  dr.;  acetic  acid,  2l'2  oz.  Keeping  a  wart  constantly  moist  with  castor  oil 
will  usually  cause  it  to  drop  off.  Warts,  and  even  extensive  callosities,  may  be 
28 


434  Tumors  or  Morbid  Growths 

removed  by  painting  once  a  day  for  five  days  with  pure  carbohc  acid  and  cover- 
ing with  lint  kept  wet  with  boric  acid.  A  convenient  plan  is  to  paint  a  wart 
dailv  with  a  solution  containing  i  part  of  corrosive  sublimate  to  50  parts  of 
collodion  (hydrarg.  chlor.  corros.,  V9  dr.,  collodion,  15  dr.).  Large  warts  should 
be  excised  or  destroyed  by  the  electrothermic  method.  Villous  papillomata  of 
the  bladder,  if  not  cured  by  fulguration,  demand  the  performance  of  a  suprapubic 
cystotomy  in  order  to  remove  them.  A  papilloma  of  the  larynx  may  be  removed 
bv  the  cautery  or  may  be  destroyed  by  sparking. 

Adenomata  are  tumors  corresponding  in  structure  to  normal  epithelial 
glands.  They  have  a  framework  of  vascular  connective  tissue,  and  they 
may  contain  acini  and  ducts  like  racemose  glands  or  tublues  like  tubular  glands. 
The  acini  or  tubules  contain  epithelium  of  either  the  cylindrical  or  polyhedral 
variety.  Adenomata  grow  from  secreting  glands ;  either  they  cannot  produce  the 
secretion  of  the  glands  from  which  they  spring,  or  they  do  secrete,  but  the  fluid 
is  retained  and  not  discharged  by  the  gland-ducts.  Adenomata  occur  in  the 
mammary  gland,  the  parotid,  the  ovary,  the  thyroid  gland,  the  liver,  the  sweat- 
glands,  the  sebaceous  glands,  the  kidney,  the  pylorus,  and  the  prostate;  and 
thev  may  spring  as  pedunculate  growths  from  the  mucous  lining  of  the  intestine 
and'  uterus.  They  are  encapsuled,  are  usually  single,  but  may  be  multiple,  are 
of  slow  growth,  but  may  attain  a  great  size;  they  do  not  tend  to  recur  after 
thorough  removal,  do  not  involve  lymph-glands,  and  do  not  disseminate; 
they  are  firm  to  the  touch ;  they  tend  to  become  cystic  (especially  in  the  thyroid 
gland),  the  fluid  which  distends  the  ducts  being  formed  by  mucoid  hquef action 
of  the  proliferating  epithelium.  If  cysts  form,  the  growth  is  spoken  of  as  a 
cystic  adenoma.  If  the  framework  of  an  adenoma  contains  considerable  fibrous 
tissue,  the  tumor  is  named  SLfibro-adenoma.  Adenomata  are  particularly  liable 
to    become    carcinomatous. 

In  the  breast  a  fibro-adenoma  has  a  distinct  capsule;  it  is  elastic  and  movable, 
is  usually  superficial,  and  one  occasionally  exists  in  each  gland.  They  are  most 
common  before  the  age  of  thirty,  and  are  often  painful,  especially  during  men- 
struation. Cystic  adenomata  of  the  breast  attain  a  large  size;  they  are  en- 
capsuled  and  grow  slowly,  are  most  common  after  the  thirtieth  year,  and  are 
rarely  painful.  Both  fibro-adenoma  and  cystic  adenoma  may  arise  in  the  male 
breast.  Young  unmarried  women  not  unusually  develop  in  the  breast  small, 
very  tender,  and  painful  bodies,  most  usually  around  the  edge  of  the  areola, 
which  bodies  increase  in  size  and  become  more  tender  during  menstruation; 
they  are  only  cysts  of  the  mammary  tissue. 

Adenomata'  of  the  thyroid  gland  usually  begin  before  the  fifteenth  year. 
They  may  arise  in  the  prostate  if  that  gland  be  already  the  seat  of  senile  hyper- 
trophy. 'Adenomata  of  mucous  glands  may  arise  in  the  young  or  middle  aged. 
Adenomata  of  mucous  membranes  often  cause  hemorrhage  and  interfere  wdth 
function. 

Treatment. — Adenomata  should  be  extirpated.  To  let  them  alone  ex- 
poses the  patient  to  the  danger  of  cancerous  change.  By  confusing  adeno- 
mata of  the  mammary  gland  with  small  areas  of  -chronic  mastitis  an  erroneous 
belief  has  arisen  that 'the  former  as  well  as  the  latter  may  sometimes  be  cured 
by  the  local  use  of  iodin,  mercury,  ichthyol,  and  the  internal  use  of  iodid  of 
potassium.     The  treatment  in  the  breast,  as  elsewhere,  is  excision. 

Malignant  Epithelial  Tumors,  Carcinomata,  or  Cancers.^— Can- 
cers are  tumors  taking  origin  from  epithelial  structures  and  composed  of  em- 
bryonic epithelial  cells.  The  cells  are  clustered  in  spaces,  nests,  or  alveoli  of 
fibrous  tissue  and  proliferate  enormously,  extending  beyond  normal  anatomical 
boundaries  and  as  an  invading  host  entering  into  connective  tissue  by  way  of 

1  For  most  valuable  statistical  information  about  cancer  consult  that  learned  book  issued 
by  the  Prudential  Insurance  Co.  of  America,  written  by  Frederick  L.  Hoffman  and  entitled 
"The  Mortality  from  Cancer  Throughout  the  World." 


^lalignant  Epithelial  Tumors,  Carcinomata,  or  Cancers         435 


the  lymph-spaces.  Certain  cells  "pass  out  of  somatic  coordination"  with 
the  other  body  cells  and  become  as  parasites  (Walker,  in  "Lancet,"  May  13, 
191 1).  Such  cells  constitute  cancer.  The  unrestrained  and  unlimited  repro- 
duction of  epithelial  cells  and  the  assumption  by  them  of  parasitic  properties 
are  the  characteristics  of  cancer.  The  healthy  epithelium  has  a  strictly  limited 
power  of  reproduction,  as  is  illustrated  by  a  skin-graft.  Cancerous  epithelium 
has  an  unlimited  power  of  reproduction.  The  alveoli  of  cancer  are  distended 
lymph-spaces  filled  with  proliferating  cells.  The  cells  of  a  cluster  are  not 
separated  by  any  stroma,  and  the  walls  of  the  alveoli  carry  blood-vessels  and 
lymphatics.  The  growth  may  have  been  cancerous  from  the  start,  or  may  have 
begun  as  an  innocent  epithelial  tumor  which  became  cancerous.  Cancers  are 
always  derived  from  epithelium  (of  glands,  of  skin,  of  mucous  membrane,  etc.), 
and  if  found  in  a  non-epithelial  tissue  must  be  secondary,  or  must  have  arisen 
from  a  depot  of  embryonal  epithelial  cells  of  prenatal  origin  or  from  a  dermoid 
cyst  lying  in  the  midst  of  a  non-epithelial  tissue,  or  epithelial  cells  must  have 
'been  displaced  by  inflammation  or  injury  so  as  to  be  among  mesoblastic 
elements.  For  instance,  the  bone  does  not 
normally  contain,  epithelial  cells.  If  osteo- 
myelitis arises,  operation  is  performed,  and 
a  lot  of  skin  may  be  buried  in  the  bone 
cavity  or  an  epithelial  graft  may  adhere. 
Such  an  epithelial  area  may  become  cancer- 
ous. Carcinomata  have  no  capsules,  rap- 
idly infiltrate  surrounding  tissues,  and  are 
firmly  anchored  and  immovable.  In  the 
beginning  a  cancer  is  a  local  lesion,  but  it 
soon  attacks  adjacent  tissue  and  related 
lymph-glands,  and  by  means  of  the  lymph- 
ceUs  is  carried  to  other  structures,  producing 
secondary  tumors  and  diseases  and  enlarge- 
ment of  more  distant  lymph-glands.  Finally, 
lymph  containing  cancer-cells  reaches  the 
blood  by  the  lymph-vessels  and  passes  to 
distant  parts,  and  secondary  tumors  or 
metastatic  deposits  form.  When  lymphatic 
vessels  are  obstructed,  lymph  filled  with 
cancer-cells  may  flow  in  a  direction  the  re- 
verse of  that  pursued  in  health.  Wide- 
spread or  general  dissemination  may  be  due 
to  carcinomatous  thrombosis  of  a  vein,  or  perforation  of  the  wall  of  a  vein,  miiltiple 
emboli  forming.  Strange  to  say,  emboli  composed  of  cancer-cells  may  be  sur- 
rounded by  blood-corpuscles  and  move  against  the  blood-current.  A  secondary 
growth  (Fig.  207)  consists  of  cells  identical  in  character  with  and  similar  in 
arrangement  to  those  of  the  parent  growth.  It  may  be  clinically  more  or  less 
malignant  than  the  parent  growth.  The  cells  of  the  secondary  growth  were 
transported  from  the  primary  growth  and  multiply  in  their  new  situation. 
For  instance,  the  cells  of  a  primary  carcinoma  of  the  liver  may  secrete  bile, 
and  the  cells  of  a  metastatic  area  may  do  the  same.  Fiitterer  has  reported  a 
case  of  carcinoma  of  the  thyroid  the  pulmonary  metastases  of  which  secreted 
colloid.  Stewart  reported  a  case  of  cancer  of  the  lungs  and  liver  secondary 
to  cancer  of  the  pancreas.  The  secondary  growths  were  of  a  structure 
similar  to  the  pancreas  and  contained  trypsin.  Metastases  from  a  columnar- 
celled  rectal  cancer  are  composed  of  columnar  cells.  Metastases  from  a 
squamous-celled  epithelioma  are  composed  of  squamous  cells.  In  rare  cases 
metastasis  of  carcinoma  of  th6  stomach  has  occurred  in  the  rectum.  Schnitzler 
reported    11    cases    ("Mitth.   a.    d.    Grenzgeb.    der    Med.   u.    Chir.,"    1908, 


Fig.  207. — Secondary  carcinoma 
of  the  submental  and  submaxillary 
lymphatic  glands  following  carcinoma 
of  the  lip  (Senn). 


43^  Tumors  or  Morbid  Growths 

xix,  No.  2).  Such  a  condition  is  probal:)ly  due  to  implantation.  Contact  cancer 
has  already  been  referred  to  (see  page  400).  We  often  speak  of  lymph-nodes 
enlarging  when  affected  with  cancer.  The  enlargement  certainly  occurs,  but  is 
not  due  to  growth  of  the  cells  of  the  lymph-node.  It  results  from  multiplication 
of  the  carcinoma  cells  deposited  in  the  gland.  As  Henry  Morris  says  ("The 
Bradshaw  Lecture,"  "Lancet,"  Dec.  12,  190,3),  the  parenchyma  of  the  involved 
part  does  not  undergo  transition  into  cancer.  After  the  growth  of  epithelium 
has  lasted  for  a  length  of  time  the  patient  becomes  poisoned  by  materials  ab- 
sorbed from  the  seat  of  disease,  and  finally  dies  from  cachexia  and  exhaustion 
or  some  complication.  These  materials  are  probably  enzymes.  During  the 
progress  of  cancer  irregular  fever  may  arise  from  time  to  lime  (see  page  402). 
Cancer  is  rare  before  the  age  of  forty,  although  occasionally  it  is  met  with  in 
younger  persons.  Over  80  per  cent,  of  cancer  deaths  are  in  those  beyond  the  age 
of  forty-five.  Cancer  of  the  rectum  is  sometimes  met  with  as  early  as  the  twenty- 
fourth  year.  I  have  operated  on  a  woman  of  twenty-six  for  cancer  of  the  breast, 
on  a  man  of  twenty-four  for  cancer  of  the  stomach,  and  on  a  man  of  twenty 
for  epithelioma  arising  in  the  old  scar  of  a  burn  (see  Fig.  82).  Karsner  ("Proc. 
Path.  Soc.  Phila.,"  Feb.,  1910)  reports  10  cases  of  carcinoma  occurring  before 
the  age  of  twenty-four:  i  was  seven;  i,  ten;  i,  eleven;  i,  fourteen;  i,  nineteen; 
I,  twenty-one;  i,  twenty-two,  and  3,  twenty-three.  In  De  la  Camp's  collection 
of  9906  cases  of  cancer  only  19  were  under  twenty  years  of  age.  X-ray  cancer 
is  most  apt  to  occur  in  young  people.  When  xeroderma  pigmentosum  exists  in 
children  cancer  may  arise  in  areas  of  the  disease.  If  cancer  appears  in  a  young 
person,  growth  is  apt  to  be  extremely  rapid  and  after  extirpation  early  recurrence 
is  common.  A  carcinoma  is  often  the  seat  of  pricking  pain;  the  growth  tends 
strongly  to  recur  after  removal ;  is  prone  to  ulcerate,  causing  pain,  hemorrhage,  and 
cachexia;  makes  rapid  progress,  and  is  often  fatal  in  from  one  to  two  and  a  half 
years.  It  is  more  common  in  women  than  in  men,  and  rarely  exists  in  association 
with  tubercle.  After  a  cancer  has  existed  for  a  time  in  an  important  structure, 
or  after  a  superficial  cancer  has  ulcerated  and  become  hemorrhagic,  there  are 
noted  in  the  individual  evidences  of  illness  and  exhaustion.  We  speak  of  this 
condition  as  the  cancerous  cachexia,  and  in  it  the  muscles  are  wasted,  the  body- 
weight  is  constantly  diminishing,  the  complexion  is  sallow,  the  face  is  sunken, 
pearly  white  conjunctivae  contrast  strongly  with  the  yellow  skin,  the  pulse  is 
weak  and  rapid,  and  night-sweats  occur.  The  above  condition  is  due  to  the 
absorption  from  the  diseased  tissues  of  toxic  products,  which  damage  the  blood- 
corpuscles,  and  also  to  pain,  loss  of  sleep,  deprivation  of  exercise,  malassimilation 
of  food,  and  perhaps  bleeding.  It  is  held  that  cancer  cells  contain  an  enzyme 
which  disintegrates  the  body  cells;  hence  the  wasting.  From  the  disintegrating 
body  cells  poisons  also  come,  hence  some  of  the  toxemia.  Perhaps  the  materials 
from  disintegrating  body  cells  favor  the  proliferation  of  cancer  cells.  Mental 
depression  is  not  believed  by  many  surgeons  a  cause  of  recurrence.  As  J.  D. 
Bryant  says,  it  is  simply  expressive  of  a  condition  of  nutritive  failure  which  may 
favor  recurrence.  We  must  remember,  however,  that  the  great  name  of  Paget 
is  associated  with  the  belief  that  not  uncommon  antecedents  of  the  disease  are 
"deep  anxiety,  deferred  hope,  or  disappointment"  ("Lectures  on  Surgical 
Pathology,"  1863).  Victims  of  rheumatoid  arthritis  are  particularly  liable  to 
cancer.  Recurrence  after  operation  is  due  to  the  growth  of  cells  which  were  not 
removed  at  the  operation.  Cancer  may  kill  by  obstructing  a  canal,  by  destroy- 
ing the  functions  of  a  viscus  or  organ,  by  hemorrhage,  by  anemia,  by  sepsis,  or  by 
exhaustion.  The  duration  of  life  varies  in  different  forms  of  cancer  and  in  dif- 
ferent situations  of  the  growth.  After  the  first  symptoms  appear,  cancer  of  the 
gall-bladder,  as  a  rule,  causes  death  in  about  four  months;  cancer  of  the  stomach, 
in  less  than  a  year;  cancer  of  the  face,  in  from  three  to  three  and  one-half  years. 
Billroth's  case  of  carcinoma  mastitoides  killed  the  patient  in  six  weeks. 

Serum  Reaction  in  Cancer. — Kelling  in  1Q06  pointed  out  that  the  blood- 


Some  Theories  as  to  Cause  of  Carcinoma  437 

serum  of  a  cancer  patient  has  a  hemolytic  action  on  the  red  corpuscles  of  the 
lower  animals  and  on  those  of  non-cancerous  human  beings  but  has  only  a 
limited  power  of  destroying  the  red  blood  cells  of  a  cancerous  patient.  It  has 
been  known  for  some  time  that  the  serum  of  persons  affected  with  certain 
diseases  is  able  to  destroy  the  red  blood-corpuscles  of  normal  individuals; 
in  other  words,  such  sera  are  hemolytic  to  the  red  blood-corpuscles  of  healthy 
human  beings.  The  agents  in  a  serum  which  hemolyze  the  red  corpuscles  in  other 
sera  are  called  isohemolysins.  Isohemolysins  are  contained  in  the  sera  of  syphilis, 
tuberculosis,  and  cancer.  Williams  (Med.  Record,  1916,  xc)  after  90  olDserva- 
tions  believes  that  Kelling's  test  is  of  value  in  the  diagnosis  of  carcinoma.  Freund 
and  Kaminer  pointed  out  that  normal  serum  dissolves  carcinoma  cells,  but  the 
serum  of  a  victim  of  carcinoma  does  not,  and  inhibits  the  solvent  action  of  normal 
serum.  They  suggested  that  this  fact  might  be  employed  diagnostically.  It  is 
called  the  cytotoxic  reaction.  In  about  two-thirds  of  cancer  cases  the  reaction 
is  positive,  but  in  one-third  it  is  negative.  The  test  is  not  conclusive  and  is  un- 
reliable. Cobra  poison  contains  hemolysins  and  has  been  used  as  a  test  for  car- 
cinoma (Weil's  reaction).  The  results  are  positive  in  about  80  per  cent,  of 
cancer  cases.  Weil  pointed  out  that  the  serum  of  a  dog  suffering  from  advanced 
lymphosarcoma  destroys  the  red  corpuscles  of  normal  dogs,  but  is  resisted  by 
the  red  corpuscles  of  animals  that  are  victims  of  the  same  disease.  Attempts 
are  being  made  to  utilize  the  serum  reaction  for  diagnostic  purposes.  Different 
observers  employ  different  technic  and  differ  widely  in  their  conclusions. 
Freund  and  Abderhalden  claim  to  find  sero-enzymes  in  the  serum  of  cancer 
patients,  and  that  these  ferments  digest  coagulated  cancer  protein,  just  as  the  fer- 
ments in  the  serum  of  pregnant  women  digest  placental  protein.  Some  claim 
that  the  Abderhalden  test  is  very  valuble  (Levin,  Erpicum,  and  others).  Some 
think  it  of  no  value  or  impracticable  (Leitch,  Fritsch).  The  complement- 
fixation  test,  the  epiphanin  test  and  the  miostagmin  reaction  are  of  very  doubt- 
ful practical  use.  Crile  is  disposed  to  think  highly  of  the  diagnostic  value'of  the 
serum  reaction.  Janeway's  conclusions  are  wisely  cautious.  He  states  that  a 
negative  reaction  is  not  proof  positive  that  cancer  is  absent.  A  positive  reaction 
makes  the  existence  of  malignant  disease  probable,  especially  if  advanced  tuber- 
culosis and  syphilis  are  absent. 

The  fact  that  the  serum  of  a  cancer  patient  contains  agents  destructive  to 
red  corpuscles  explains  the  anemia  and  cachexia  of  cancer.  Janeway  points 
out  that  the  serum  of  sufferers  from  benign  tumors  never  exhibits  the  reaction. 

Some  Theories  as  to  Cause  of  Carcinoma. — Heredity  is  discussed  on  page 

398- 

I.  Contusion  and  Irritation. — As  Dennis  says,  clinical  evidence  points 
strongly  to  the  view  that  inflammatory  changes  following  irritation  are  re- 
sponsible for  cancer.  Individuals  with  phimosis  are  particularly  prone  to 
cancer  of  the  penis.  A  jagged  tooth  or  an  ill-fitting  plate  may  be  responsible 
for  cancer  of  the  tongue;  so  may  the  common  habit  of  lathers  of  carrying  nails 
in  the  mouth.  A  carious  tooth  may  light  up  cancer  of  the  gum.  Repeated 
applications  of  the  x-rays  or  radium  rays  may  be  causal.  Those  who  smoke  a 
short-stemmed  clay  pipe,  which  grows  hot  when  in  use,  are  most  liable  to  cancer 
of  the  lower  lip.  Abbe  also  indicts  cigarettes  and  cigars.  In  the  East  those 
who  chew  buyo  leaves  are  liable  to  cancer  of  the  region  of  the  cheek  against  which 
the  leaf  is  held.  The  chew  is  composed  of  buyo  leaves,  slaked  lime,  betel-nut 
and  tobacco.     Our  own  tobacco  chewers  are  exposed  to  a  like  peril. 

Rubbing  the  tongue  or  gums  with  snuff  favors  the  development  of  the 
disease. 

The  natives  of  Kashmir  are  liable  to  Kangri  disease.  It  is  cancer  of  the  skin 
of  the  abdomen  and  is  due  to  heat.  These  men  in  cold  weather  carry  a  box  of  hot 
embers  strapped  to  the  belly.  In  the  old  days  chimney-sweeps  often  developed 
cancer  of  the  scrotum,  which  was  always  irritated  by  soot  in  the  cutaneous  folds. 


438 


Tumors  or  Morbid  Growths 


Cancer  of  the  gall-bladder  may  arise  if  gall-stones  exist.  Cancer  of  the  skin  of 
the  hands  may  arise  in  .r-ray  workers.  Cancer  of  the  skin  may  be  induced  by 
the  influence  of  light  (James  Nevins  Hyde,  in  "Amer.  Jour.  Med.  Sciences," 
Jan.,  1906).  Aniline  workers  are  rather  liable  to  cancer  of  the  urinary  bladder. 
An  ulcer  may  be  the  irritating  focus  which  leads  to  the  development  of  cancer  at 
its  edge  (see  Marjolin's  Ulcer,  page  171).  So  may  a  scar.  As  is  well  known, 
certain  innocent  tumors  may  become  cancerous.  The  believers  in  the  parasitic 
theory  maintain  that  irritation  and  inflammation  simply  open  the  gates  to  the 
real  cause,  which  they  assert  is  a  parasite. 

In  certain  regions  of  the  body,  notably  the  tongue  and  lip,  we  regard  pro- 
longed chronic  inflammation  as  very  apt  to  eventuate  in  cancer,  and  if  an 
ulcerated  area  is  not  soon  cured  by  ordinary  means  we  advise  operation.  A 
condition  persisting  in  spite  of  ordinary  treatment,  prone  to  eventuate  in 
cancer,  but  not  as  yet  demonstrably  cancerous,  is  called  the  precancerous  sta-ge 

of  cancer.     It  probably  is  already 
'~      '  !    cancer,  although  so  early  as  to  lack 

1     the  positive  signs. 

A    wart    is    the   result    of   in- 
flammation and  a  wart  may  be- 
come  a  cancer.     The  edge  of  a 
-  gastric  ulcer  may  become  cancer- 

ous. Cancer  may  arise  from  a 
scar  (see  Fig.  85)  or  the  edge  of 
an  old  ulcer  of  the  skin,  the  lip, 
the  cheek,  or  the  tongue. 

Certain  benign  tumors  tend  to 
become  cancerous,  especially  if 
irritated  by  injuries,  caustic  ap- 
plications, or  inefhcient  attempts 
to  remove  them  surgically.  Any 
papilloma  and  any  adenoma  may 
become  cancerous.  A  benign 
epithelial  tumor  is  always  a 
menace  and  is  to  be  regarded  as 
a  possible  or  potential  carcinoma. 
Whereas  chronic  inflammation 
or  irritation  of  epithelial  structures 
is  not  infrequently  followed  by 
carcinoma,  a  single  traumatism, 
as  a  blow,  seldom  is.  Neverthe- 
less well-established  cases  are  on 
record  of  cancer  due  to  a  single  trauma  (Coley,  in  "Annals  of  Surgery,"  April 
and  May,  191 1).  A  woman  with  cancer  of  the  breast  is  apt  to  lay  the  blame 
upon  a  blow,  but  very  seldom  can  the  surgeon  regard  the  blow  as  causal.  In 
many  cases  cancer  was  present  when  the  injury  was  received,  and  the  injury 
drew  attention  to  the  tumor. 

2.  The  Inclusion  Theory  of  Cohnheim. — This  theorv  was  set  forth  on  page 
298. 

3.  The  Thiersch  Hypothesis. — This  maintains  that  normal,  healthy  connect- 
ive tissue  has  a  restraining  influence  on  the  growth  of  adjacent  epithelium; 
when  connective  tissue  degenerates  (as  in  advancing  years  or  after  prolonged 
irritation)  its  control  over  epithelium  is  weakened,  and  the  epithelium  grows 
more  rapidly  than  it  does  normally,  and  from  the  moment  it  invades  the 
connective  tissue  cancer  exists.  This  theory  assumes  that  the  connective  tissue 
is  a  police  force  and  the  epithelial  cells  the  criminal  class.  WTien  the  first  is 
weakened  or  corrupted,  the  second  becomes  active  and  uncontrolled. 


Fig.  208. — Epithelioma  of  right  temporal  region. 
Paralysis  of  right  side  of  face.  Papule  noticed  by 
patient  two  years  prior  to  admission. 


Some  Theories  as  to  Cause  of  Carcinoma  439 

4.  The  Parasitic  Theory. — Various  agents  have  been  described  as  causes, 
viz.,  bacteria,  protozoa,  and  yeast  fungi. 

This  theory  was  discussed  on  page  399.  We  do  not  regard  it  as  proved, 
and  even  Plimmer,  warm  advocate  as  he  is  of  the  theory  of  contagion,  admits 
that  as  yet  there  is  no  clearly  demonstrated  case  of  contagion  of  cancer  from 
one  man  to  another.  I  can  find  no  authenticated  case  on  record  of  a  surgeon 
having  been  infected  by  cancer  during  an  operation.  Transplantation  has  been 
carried  out  from  one  animal  to  another  of  the  same  species,  although  attempts 
to  do  so  usually  fail.  Tyzzer,  of  Harvard,  succeeded  in  nearly  46  per  cent,  of  his 
inoculation  experiments  with  the  Jensen  tumor  and  he  has  kept  up  the  tumor 
formation  for  ten  generations.  (See  "Fourth  Report  from  the  Harvard 
Medical  School  of  the  Caroline  Brewer  Croft  Fund  Cancer  Commission.") 
It  is  a  serious  question,  however,  if  mouse  cancer  is  really  cancer  at  all.  Mouse 
cancer  is  far  more  strongly  hereditary  than  human  cancer;  spontaneous  cure  is 
by  no  means  uncommon;  metastasis  is  rare;  the  disease  may  occur  as  an  epi- 
demic in  a  laboratory.  It  has  been  asserted  that  mouse  cancer  may  revert  to 
sarcoma  (Apolant,  in  "  Miinch.  med.  Wochenschr.,"  1907,  liv),  and  it  may  revert 
to  adenoma  (Ibid.).  These  tendencies  separate  mouse  cancer  very  positively 
from  human  cancer.  It  is  said  that  epidemics  of  fish  cancer  may  occur  in  a 
hatchery.  Cancer  has  not  been  transplanted  from  an  animal  of  one  species 
to  an  animal  of  another  species.  If  a  portion  of  human  cancer  is  implanted  in 
the  tissues  of  an  animal,  the  cells  of  the  growth  retain  their  vitality  for  a  very 
few  days  and  then  perish.  If  a  piece  of  mouse  cancer  is  transplanted  into  a  rat 
the  same  thing  happens.  In  any  case,  even  a  successful  transplantation  of  cells 
is  a  very  different  thing  from  contagion.  The  late  Prof.  Nicholas  Senn  delib- 
erately implanted  a  piece  of  cancer  in  the  tissues  of  his  own  forearm  without 
result  ("Jour.  Am.  Med.  Assoc,"  April  28,  1906).  Recently  advocates  of  the 
contagion  theory  claim  that  mouse  cancer  can  be  reproduced  after  transplanta- 
tion even  when  the  cells  in  the  inoculated  matter  have  been  first  killed  by  expo- 
sure to  the  intense  cold  induced  by  liquid  air  (Salim,  Moore,  and  Walker,  in 
"Lancet,"  Jan.  25, 1908).  If  these  observations  should  be  sustained,  they  would 
indicate  that  the  element  responsible  for  growth  of  a  graft  is  not  cellular  and 
might  be  microbic.  Alibert  carried  out  similar  experiments  and  claims  to  have 
obtained  like  results.  Most  observers  believe  that  transplantation  cancer  is  due 
to  cell  transplantation. 

Experiments  on  plant  tumors  are  striking,  important,  and  are  perhaps  appli- 
cable to  human  tumors. 

That  local  overgrowth  known  as  crowngall  is  in  fact  a  tumor.  Erwin  F. 
Smith  (" Mechanism  of  Tumor  Growth  in  Crowngall")  believes  that  the  growth 
is  due  to  the  removal  of  normal  inhibitions,  that  is  to  loosening  of  the  brakes  and 
that  the  lessening  of  inhibitions  is  caused  by  the  metabolism  of  mild,  continu- 
ously acting  intracellular  bacteria  which  develop  substances  having  osmotic 
power  to  draw  water  and  cell  food  into  the  area.  These  substances  are  alcohol, 
aldehyds,  acetone,  acids  and  alkalies. 

5.  The  Biological  Theory. — In  a  unicellular  organism  the  function  of  repro- 
duction is,  of  course,  possessed  by  the  cell.  In  a  multicellular  organism  certain 
cells  are  set  apart  for  the  performance  of  the  function  of  reproduction,  all  the  other 
cells  possess  the  potentiality  for  reproduction,  but  fail  to  exercise  it.  If  cells 
undergo  atavistic  reversion  they  may  again  assume  the  reproductive  function. 
If  they  do  so,  unrestrained  growth  will  result,  and  such  unrestrained  growth  is 
cancer. 

N.  F.  MacHardy  ("Lancet,"  Oct.  24,  1903)  states  that  if  a  unicellular 
organism  has  not  sufiicient  reproductive  energy  it  fuses  with  another  cell  and 
is  thus  stimulated  to  produce  numerous  daughter-cells.  In  multicellular 
organisms  cells  may  also  fuse,  take  on  active  reproductive  power,  and  produce 
hosts  of  new  cells.     When  cells  are  persistently  irritated,  MacHardy  afi&rms 


440  Tumors  or  Morbid  Growths 

that  they  become  worn  out  by  making  repeated  attempts  at  repair,  undergo 
atavistic'  reversion,  and  actively  assume  the  power  of  reproduction.  Accord- 
ing to  this  theory  cancer  is  expressive  of  atavistic  reversion  of  epitheUal  cells. 
The  Prevalence  and  the  Alleged  Increase  of  Carcinoma.' — Crile  states  that 
in  hospital  autopsies  cancer  is  found  in  i  case  out  of  12  ("Med.  Record,"  June 
6,  1908).  In  the  United  States  cancer  causes  5  per  cent,  of  the  annual  deaths. 
Kellogg  ("N.  Y.  Med.  Jour.,"  Sept.  2,  191 1)  claims  that  there  are  ,300,000 
cancerous  people  in  the  United  States,  that  75,000  die  of  it  each  year,  and  that 
in  1909,  of  women  who  died  between  the  ages  of  forty-iive  and  fifty-five,  i  in 
6  died  of  cancer.  Hoffman  ("The  Mortality  from  Cancer")  is  certain  that  in 
the  United  States,  at  least  80,000  deaths  a  year  are  due  to  cancer.  In  England 
in  1909  there  were  over  34,000  deaths  from  cancer.  In  France  in  1908  there 
were  over  30,000  deaths  from  cancer.  In  the  United  States  cancer  stands 
fifth  in  the  mortality  list,  (i)  Tuberculosis.  (2)  Pneumonia.  (3)  Heart 
disease.  (4)  Kidney  disease.  (5)  Cancer,  It  has  been  stated  that  of  persons 
living  above  the  age  of  thirty-five,  that  i  woman  in  8,  and  i  man  in  12,  will 
die  of  cancer  (Copeman,  ciuoted  by  Brand,  in  "Lancet,"  Jan.  11,  1908).     The 

returns  of  the  Registrar-General  for 
gfH^  191 1  show  "the  chance  that  a  man 

y%  ]     over  thirty-five  years  of  age  will  die 

of  cancer  is  one  in  9.7,  and  the  chance 
of  a  woman  above  the  same  age  is  one 
in  7.4."  ("The  Mortality  from 
Cancer"  by  Frederick  L.  HofYman.) 
Is  cancer  increasing?  Of  course,  the 
number  of  cases  increases  with  the 
increase  of  population.  The  appar- 
ent death-rate  from  cancer  increases 
year  by  year.  It  was  pointed  out 
by  W.  Roger  WilHams  that  in  Eng- 
land and  Wales  the  mortality  from 
cancer  increased  from  i  to  5646  in 
Fig!  209. — Carcinomatous  horn.  1840  to  I  to  1306   in    1896,    and   the 

proportion  to  deaths  from  other 
causes  rose  from  i  to  129  in  1840  to  i  to  22  in  1896  ("Lancet,"  Aug.  20,  1898). 
Roswell  Park  commented  on  the  increasing  number  of  deaths  from  cancer  in 
New  York  State,  and  said  if  it  continued  for  the  next  ten  years  the  disease 
would  kill  more  persons  annually  than  phthisis,  small-pox,  and  typhoid  com- 
bined. Kellogg  ("N.  Y.  Med.  Jour.,"  Sept.  2,  1911)  believes  that  the  increase 
is  enormous,  and  claims  that  in  the  United  States  the  disease  has  increased  500 
per  cent,  in  sixty  years.  Bertillon,  of  the  Statistical  Department  of  Paris, 
believes  that  cancer  is  increasing  in  all  countries.  The  increase  is  greater 
among  men  than  women.  In  1913  the  cancer  mortality  in  the  United  States 
was  79  per  100,000  of  population,  in  1900  it  was  63  (J.  Howard  Beard  in  the 
Scientific  Monthly,  Feb.,  1916). 

The  cancer  death  rate  of  Greater  New  York  has  increased  during  the  last 
twenty  years  from  59  to  81  per  100,000  of  population.  In  London  the  death  rate 
is  94,  in  Paris  109,  in  Berlin  107  and  in  Boston  107  per  100,000  of  population 
(John  Chadwick  Oliver  in  "Annals  of  Surgery,"  May,  1916).  In  the  Boroughs 
of  Manhattan  and  the  Bronx,  the  cancer  death  rate  during  the  last  fifty  years 
has  increased  from  24  to  86  per  100,000  of  population — 253  per  cent.  (J,  C. 
Oliver,  Ibid.) 

Hoffman  (Ibid.)  says  the  facts  of  actual  experience  "prove  beyond  a  doubt 
that  the  actual  as  well  as  the  relative  increase  in  the  cancer  death  rate  in  at 

1  In  considering  statistics  for  the  United  States,  remember  that  only  65  per  cent,  of  the 
population  is  in  the  ragistration  area.     Outside  of  this  area  we  rely  on  estimates. 


Distribution  of  Cancer  441 

least  some  of  the  more  important  countries  continues  progressively  at  the 
present  time  and  that  for  most  of  the  civilized  countries  a  maximum  rate  is  far 
from  having  been  reached."  Such  statements  are  truly  alarming,  and  yet  the 
reality  of  all  of  this  apparent  increase  is  doubtful.  A  part  of  the  apparent 
increase  is  due  to  the  greater  frequency  of  exploratory  operations  for  diagnostic 
purposes,  to  the  greater  frequency  of  postmortem  examinations,  to  more  correct 
diagnoses  of  obscure  internal  conditions,  and  to  greater  accuracy  than  was  once 
either  usual  or  expected  in  filling  up  death  certificates.  Neusholme  says  that 
just  as  deaths  certified  as  due  to  old  age  grow  apparently  fewer  every  year,  so 
other  non-specific  certifications  grow  fewer,  and  cancer  gains  as  they  lose.  The 
diminution  in  infant  mortality  also  causes  a  relative  rise  in  the  apparent  cancer 
mortality.  Further,  more  people  than  formerly  live  to  reach  the  cancerous  age, 
and  people  in  general  live  longer  than  formerly,  and  in  the  later  years  of  life  can- 
cer is  common.  In  the  United  States  over  80  per  cent,  of  cancer  deaths  are  in 
those  over  forty-five  years  of  age.  The  above  facts  certainly  account  for  a  por- 
tion of  the  alleged  increase,  but  we  must  also  remember  that  we  are  curing  many 
more  cases  by  operation  than  we  used  to  be  able  to,  and  hence  that  the  death- 
rate  from  cancer  is  not  the  real  and  final  measure  of  the  incidence  of  cancer. 
The  experience  of  most  practical  surgeons  is  that  there  is  a  real  increase  in  can- 
cer, but  the  extent  of  the  increase  cannot  be  ascertained  with  any  accuracy. 

Hereditary  Influence. — This  was  referred  to  on  page  398.  It  can  be  at 
most  only  tissue  predisposition  or  a  diminution  of  tissue  resistance  to  the  real 
cause  of  cancer,  whatever  that  may  be.  Some  previously  quoted  cases  are  too 
impressive  to  be  regarded  as  coincidences.  Williams  ("Brit.  Med.  Jour.," 
May  9,  1908)  points  out  that  24.2  per  cent,  of  women  with  cancer  of  the  breast 
have  or  had  relatives  with  a  history  of  cancer.  Williams  states  that  Butlin's 
estimate  is  37  per  cent.;  Leaf's,  23  per  cent.;  and  Nunn's,  29.3  per  cent. 

Slye  maintains  that  mouse  cancer  can  be  bred  in  and  out  of  strains  as  is  de- 
sired ("Interstate  Med.  Jour.,"  1915,  xxii). 

Immunity. — This  was  referred  to  on  page  398. 

It  is  known  that  mouse  tumors  which  follow  transplantation  in  some  cases 
retrogress  and  undergo  spontaneous  cure,  and  that  animals  in  which  this  has 
occurred  are  found  to  have  become  immune  to  a  re-inoculation  of  a  like  tumor. 
Crile  and  Beebe  present  some  studies  on  this  interesting  subject  in  the  "Journal 
of  Medical  Research,"  June,  1908.  Gaylord  and  Clowes  found  that  the  serum 
of  an  animal  thus  rendered  immune  tends  to  destroy  tumor  cells,  and  experi- 
mented with  the  transfusion  of  the  blood  of  immune  animals  into  animals  with 
active  tumors;  7  animals  out  of  10  were  cured.  The  blood  of  an  animal  natur- 
ally immune  to  tumor  inoculation  is  said  to  act  similarly  to  that  of  an  animaL 
which  has  acquired  immunity,  as  shown  by  retrogression  of  a  tumor. 

Sex. — Cancer  is  more  common  in  women  than  in  men.  If  we  leave  out 
of  consideration  cancer  of  the  uterus  and  breast,  men  suffer  from  cancer  more 
often  than  women.  Men  are  most  apt  to  get  cancer  of  the  lip,  tongue,  and 
digestive  canal. 

Distribution  of  Cancer. — It  occurs  in  all  climates  and  probably  all  races, 
though  it  is  much  less  common  in  primitive  people  living  under  natural 
conditions  than  among  highly  civilized  races,  although  it  has  been  asserted 
that  Eskimos  are  not  liable  to  it.  We  know  that  the  disease  is  very  rare  in  the 
Esquimaux  of  Labrador  and  Alaska.  We  know  it  is  much  more  common  among 
civilized  than  barbarous  people.  It  is  rarer  among  the  black  and  yellow  races  than 
the  white  race.  Before  the  Civil  War  the  negro  in  the  United  States  seldom  got 
cancer.  Since  emancipation  cancer  has  become  more  and  more  common  among 
negroes  in  the  United  States.  At  present  and  according  to  population,  the 
colored  woman  is  more  liable  to  uterine  cancer  than  the  white  woman.  The 
American  Indians  seldom  suffer  from  it.  It  occurs  in  the  lower  animals  far  less 
often  than  in  man,  is  more  common  in  domestic  than  in  wild  animals,  and  in. 


442  Tumors  or  Morbid  Growths 

captive  wild  animals  than  in  those  free  and  at  large.  It  can  even  occur  in  cold- 
blooded animals.  Cancer  is  most  common  in  the  temperate  zone.  It  is  usually 
asserted  that  the  disease  is  rare  in  the  tropics,  but  Dudley  denies  that  this  state- 
ment is  true  of  the  Philippine  Islands  ("Jour.  Am.  Med.  Assoc,"  May  23,  1908). 
Cancer  is  certainly  less  common  in  India  than  in  England,  and  it  is  very  rare  in 
Greenland.  It  is  almost  unknown  among  the  natives  of  Algeria.  The  fre- 
quency of  the  disease  among  the  Jews  has  been  much  debated.  Lombroso  says 
of  Italian  Jews  that  they  suffer  more  often  than  the  rest  of  the  population.  This 
is  not  true  of  most  countries.  The  Jews  are  long  lived,  hence  there  are  many 
of  the  cancerous  age,  yet  in  New  York  and  Philadelphia  cancer  of  the  uterus  is 
rare  among  Jewesses  in  spite  of  their  usual  fecundity  and  cancer  of  the  breast  is 
relatively  rare.  It  would  be  interesting  to  determine  the  incidence  of  cancer 
among  gypsies.  Cancer  is  more  common  in  cities  than  in  the  country.  This 
is  a  general  rule  to  which  there  are  local  exceptions.  It  is  usually  believed 
that  cancer  is  most  prevalent  in  low  and  marshy  districts.  It  is  less  common  at 
high  altitudes  and  among  the  dwellers  on  soils  of  chalk  and  lime.  Returns  seem 
to  show  that  the  larger  the  city  the  higher  the  cancer  death  rate.  There  seems 
to  be  a  blight  in  civilization.  It  generates  poisons  which  threatens  its  own 
destruction.  Material  progress,  its  artificial  conditions,  its  keen-edged  strife,  its 
anxieties  and  harassments,  its  fears  and  hopes,  cast  an  ominous  shadow,  and 
in  that  shadow  is  cancer.     I  know  not  how  or  why,  but  I  am  sure  it  is  the  case. 

Cancer  Regions  and  "Cancer  Houses." — Some  regions  show  a  remark- 
able frequency  of  cancer.  In  Bookfield,  New  York,  during  five  years  nearly 
10  per  cent,  of  the  deaths  were  due  to  cancer. 

Tynes  (Ibid.,  March  21,  1908)  reports  that  in  Fisherville,  Pennsylvania,  in 
265  families  there  were  105  deaths,  and  18  of  them  were  due  to  cancer.  It  is 
maintained  by  Haviland  and  others  that  certain  houses  become  infected  and 
that  cancer  appears  in  such  houses  again  and  again  among  successive  families 
inhabiting  them.  Such  houses  are  called  "cancer  houses,"  and  many  remark- 
able statements  have  been  collected  relating  to  them,  statements  which  to  some 
observers  seem  to  prove  contagion,  but  which  to  others  merely  serve  as 
interesting  examples  of  coincidence. 

Leeson  ("Practitioner,"  Feb.,  1909)  is  of  the  latter  opinion  and  shows  that 
there  was  not  a  cancer  house  in  his  district.  He  studied  248  cases  of  cancer  and 
all  but  4  of  them  were  in  different  houses.  As  this  author  says:  "If  we  are  to 
accept  such  evidence  as  that  on  which  the  belief  in  'cancer  houses'  is  founded, 
we  must  believe  in  'apoplexy  houses,'  'liver  houses,'  etc." 

Statements  about  cancer  houses  are,  to  use  the  words  of  Horace  Greeley, 
"important  if  true."  Imagination  has  run  wild  on  the  mysterious  theme. 
The  buildings  pointed  out  as  being  under  the  curse  are  usually  old,  damp,  dark 
and  mouldy,  just  such  buildings  as  could  be  responsible  for  all  sorts  of  impair- 
ment of  health  in  the  inmates.  Nothing  has  been  developed  in  the  record  of  any 
such  house  to  indicate  whether  or  not  the  successive  victims  were  of  cancer  age, 
followed  provocative  callings,  were  predisposed  by  heredity,  or  had  causal 
habits.     The  thesis  is  unproved,  fanciful,  in  fact,  all  but  incredible. 

Influence  of  Diet. — Some  blame  meat,  some  tomatoes,  etc.,  for  the  de- 
velopment of  cancer.  Vemueil  and  Reclus,  commenting  on  the  fact  that 
carnivora  are  much  more  prone  to  cancer  than  herbivora,  suggested  that  the 
increase  of  cancer  during  recent  years  might  be  due  to  the  increased  consump- 
tion of  meat  by  the  poorer  classes.  There  is  no  proof  of  the  truth  of  the  sug- 
gestion that  a  meat  diet  is  causative.  If  it  were  true  the  recent  increase  in  the 
cost  of  meat  might  be  regarded  as  the  work  of  philanthropists  stri-\Kng  to 
prevent  cancer.  Certainly  of  late  the  poorer  classes  have  been  consuming  far 
less  meat  but  the  increase  in  cancer  goes  on  just  the  same.  In  fact,  Prof.  Serm 
points  out  that  the  Eskimos  seem  immune  to  tumor  formation;  yet  they  hve  on 
an  exclusive  animal  diet  and,  furthermore,  are  the  healthiest  people  in  the  world. 


Dissemination  or  Metastasis  443 

Arsenic  Cancer, — Sir  Jonathan  Hutchinson  pointed  out  in  1887  that  the 
administration  of  arsenic  may  lead  to  cancer.  Dubrcuilh,  of  Bordeaux,  has 
collected  19  cases  ("Annales  de  Dermatoses,"  Feb.,  1910).  It  will  be  highly 
important  to  find  out  if  salvarsan  can  ever  be  responsible  for  malignant 
growth. 

X-ray  Cancer. — A  number  of  rc-ray  operators  who  worked  with  the  rays 
soon  after  Rontgen's  discovery  developed  cancer.  An  ^(c-ray  operator  in  Phila- 
delphia died  of  carcinoma  of  the  hand.  It  led  to  axillary  and  mediastinal 
growths.  I  operated  on  him  twice  in  vain.  Another  Philadelphia  operator 
submitted  to  amputation  of  the  arm  and  subsequently  died.  The  cells  are 
repeatedly  injured  by  the  rays  and,  finally,  normal  repair  becomes  impossible. 

Recurrence  After  Operative  Removal. — This  is  usually  due  to  the  fact  that 
all  of  the  cells  were  not  removed.  It  may  be  due  to  a  new  growth.  Recur- 
rence may  be  due  to  cutting  across  lymph-tracts  and  flooding  the  wound  with 
carcinoma  cells,  which  lodge  and  grow.  The  growth  of  cancerous  nodules  in 
the  abdominal  scar  resulting  from  an  exploratory  operation  for  cancer  of  the 
stomach  is  observed  now  and  then.  It  is  probably  due  to  contact  inva- 
sion of  the  scar  area,  which  has  lessened  vital  resistance  to  cancer  cells. 

Murphy  thinks  that  the  same  explanation  holds  when  the  stitch  cica- 
trices become  cancerous  ("General  Surgery,"  in  "Practical  Medicine  Series  for 

1909"). 

Extension  of  Cancer. — Cancer  is  at  first  a  local  disease  but  sooner  or  later  it 
spreads.  It  remains  local  longer  in  the  aged  than  in  the  young.  It  spreads  by 
the  lymphatics  and  rapidly  involves  the  anatomically  associated  lymph-nodes. 
The  greater  activity  of  the  lymphatic  system  in  youth  than  in  old  age  explains 
the  rapid  spread  of  cancer  in  youth  and  the  slower  spread  in  old  age.  In  the 
nodes  the  migrating  cancer  cells  are  imprisoned  for  a  time,  and  in  this  incarcera- 
tion lies  the  hope  of  surgery.  The  adjacent  glands  are  involved  much  more 
rapidly  than  we  used  to  think.  They  are  usually  involved  within  a  few  weeks 
of  the  start  of  the  growth,  except  in  superficial  epithelioma,  in  which  cases  they 
are  not  involved  at  all. 

In  a  structure  devoid  of  capsule  (as  the  tongue,  the  mammary  gland,  etc.) 
Lockwood  points  out  that  involvement  of  related  lymph-nodes  is  practically 
immediate. 

Lymphatic  involvement  may  result  in  the  formation  of  a  mass  much  larger 
than  the  parent  growth.  The  ducts  between  the  primary  cancer  and  the  in- 
volved glands  are  filled  with  carcinoma  cells  and  their  walls  will  become  infil- 
trated. Hence  in  an  operation  the  ducts  should  not  be  cut  across  or  the  wound 
will  be  flooded  with  fluid  rich  in  cancer  cells.  The  ducts  should  be  extirpated 
as  well  as  the  glands.  To  flood  the  wound  with  fluid  containing  embryonic  cells 
is  very  dangerous,  for  some  of  them  may  adhere,  multiply,  and  reproduce  the 
disease.  After  a  time  the  capsules  of  cancerous  nodes  rupture  and  periglandular 
tissue  becomes  involved.  The  cells  are  held  in  the  first  glandular  stopping- 
place  (the  anatomically  related  glands)  for  a  time,  but  sooner  or  later  other 
and  more  distant  glands  become  involved.  In  certain  abdominal  cancers 
(stomach,  rectum,  and  uterus)  the  thoracic  duct  may  become  obstructed 
by  cancer  cells.  Large  glands  may  cause  much  trouble  by  pressure.  When 
they  soften  and  break  down  the  skin  becomes  involved  and  dreadful  sores 
form,  oozing  foul  matter  and  blood.  Death  may  be  due  to  hemorrhage  from 
a  large  vessel  which  has  become  infiltrated. 

Several  times .  I  have  been  consulted  by  patients  on  account  of  glandular 
enlargements  of  the  neck,  the  patients  never  having  noticed  a  small  primary 
lesion  in  the  mouth,  and  yet  the  entire  glandular  disease  was  secondary  to  the 
limited  oral  trouble. 

Dissemination  or  Metastasis. — These  terms  mean  the  formation  of  second- 
ary growths.     These  growths  are  formed  by  small  fragments  of  cancer  being 


444 


Tumors  or  ]\Iorbid  Growths 


broken  off  and  carried  to  lodgment  in  distant  structures.  Such  small  frag- 
ments are  called  cancer  emboli.  Cancer  emboli  may  be  carried  by  lymph  or 
blood.  When  cancer  emboli  lodge  in  a  region  favorable  to  their  growth  their 
constituent  cells  multiply  and  produce  secondary  growths.  A  secondary 
growth  is  the  histologic  counterpart  of  the  parent  growth,  and  an  examination 
of  a  secondary  growth  gives  us  accurate  information  as  to  the  nature  of  the 
primary  growth.  In  cancer  of  the  rectum  there  may  be  secondary  deposits 
in  the  liver  or  in  bone.  Such  deposits  contain  structure  resembling  rectal 
glands.  In  cancer  of  the  stomach  secondary  nodules  in  the  skin  may  contain 
structure  resembling  the  gastric  glands.  Secondary  deposits  are  by  no  means  as 
common  in  cases  of  squamous-celled  cancer  as  in  glandular  cancer. 

Another  method  of  dissemination  is  observed  in  the  abdomen.  When 
cancer  of  a  viscus  breaks  through  the  peritoneal  coat  the  cells  are  spread  widely 
by  peristaltic  movements  and  j)eritoneal  fluid,  and  the  peritoneum  becomes 

extensively    involved.      This    in- 

P^^^^^H^HIEr  .^.^ — ...1      volvement   is   a  form  of  contact 

cancer.  Any  structure  may  be 
the  seat  of  a  secondary  growth. 
The  lung  is  frequently  affected, 
so  is  the  liver,  so  are  the  bones. 
What  is  known  as  the  Krukenbcrg 
tumor  is  probably  a  carcinoma  of 
the  ovary  secondary  to  cancer  of 
the  gastrointestinal  tract.  The 
tumor  contains  fibrous  ele- 
ments and  Krukenberg  in  1896 
described  it  as  a  fibrosarcoma 
containing  cells  like  cancer  cells 
(Major,  in  "Surgery,  Gynecology, 
and  Obstetrics,"  August,  1918). 
Any  organ  or  tissue  may  become 
the  host  for  secondary  deposits 
of  carcinoma.  Cancer  of  the 
umbilicus  is  usually,  but  not  always,  secondary  to  intra-abdominal  or  pelvic 
cancer. 

Spontaneous  Disappearance  of  Cancer. — This  is  an  excessively  rare  event 
in  human  beings,  but  it  does  occasionally  occur.  Gaylord  has  collected  11 
cases  which  he  considers  authentic,  viz.,  2  epitheliomata  (i  of  the  tongue  and 
I  of  the  lip),  I  scirrhous  cancer  of  the  breast,  i  malignant  adenoma  of  the 
rectum,  and  7  cases  of  chorion  carcinoma  ("Seventh  Annual  Report  of  the 
Cancer  Laboratory  of  New  York  State  Department  of  Health").  The  same 
author  also  notes  the  spontaneous  disappearance  of  two  sarcomata.  Spon- 
taneous disappearance  of  Jensen  tumors  successfully  inoculated  in  mice  is 
quite  common.  It  occurred  in  23  per  cent,  of  Gaylord's  animals.  Whereas 
it  is  common  in  mouse  tumors  resulting  from  inoculation,  it  is  rare  in  spon- 
taneous mouse  tumors.  Bushford  finds  spontaneous  healing  in  less  than  i  per 
cent,  of  the  latter  group.  Spontaneous  disappearance  is  not  due  to  the  fatty 
degeneration  and  necrosis  so  often  found  about  the  center  of  a  carcinoma,  but 
to  deprivation  of  the  epithelial  cell  of  some  or  all  of  its  vitality  by  an  utterly 
unknown  process.  Some  observers  think  spontaneous  cure  is  brought  about 
by  the  stimulation  of  an  immunizing  force.  When  spontaneous  cure  occurs 
cancer  cells  are  gradually  replaced  by  scar  tissue,  and  the  resulting  scar  may 
contain  cancer  cells  immeshed  in  it.  Hence,  after  apparent  retrogression^ 
growth  may  begin  anew. 

Besides  the  apparently  positively  authenticated  cases  reported  by  Gaylord, 
there  are  numerous  cases  on  record  in  which  it  is  highly  probable  cancer  dis- 


FiG.   210. — Carcinoma  of  the  auricle. 


Classification  of  Carcinomata  445 

appeared  spontaneously.  These  cases  are  collected  in  the  appendix  to  the 
previously  cited  report  of  Gaylord. 

Blood  Changes  in  Cancer  Cases. — In  early  cases  there  is  no  notable  change 
in  either  erythrocytes  or  hemoglobin.  In  more  advanced  cases  as  cachexia 
begins  secondary  anemia  develops,  fall  of  hemoglobin  antedating  diminution  in 
erythrocytes. 

The  anemia  may  become  so  profound  that  it  resembles  pernicious  anemia; 
in  fact,  some  observers  have  asserted  that  pernicious  anemia  may  arise.  The 
anemia  of  cancer  is  not  benefited  by  medical  treatment. 

In  gastric  cancer,  because  of  vomiting  and  diarrhea,  blood  concentration 
may  occur,  the  red  corpuscles  being  6,000,000  or  even  7,000,000  per  cmm. 

The  leukocytes  may  be  normal,  but  are  often  increased.  It  has  been 
■claimed  by  Macalister  and  Ross  ("Lancet,"  Jan.  16,  1909)  that  the  blood  of 
a  patient  with  cancer  contains  a  material  in  its  plasma  which  is  an  excitant 
for  the  leukocytes  of  healthy  persons.  As  previously  stated  (see  page  436)  the 
serum  of  the  blood  of  a  person  with  cancer  contains  agents  destructive  to  the 
red  corpuscles  of  healthy  blood. 

Classification  of  Carcinomata. — Carcinomata  are  classified  as  follows:  (i) 
Epithelioma;  (2)  rodent  ulcer,  or  Jacob's  ulcer;  (3)  spheroidal-celled  cancer; 
(a)  scirrhous;  (b)  encephaloid;  (c)  colloid,  and  (4)  cylindrical-celled  cancer. 
Clinically,  we  speak  of  cuirass  cancer,  a  condition  sometimes  arising  when  the 
mammary  gland  is  cancerous  and  due  to  the  infiltration  of  the  cutaneous  lymph- 
atics with  cancer-cells;  chimney-sweeps^  cancer  and  paraffin  worker's  cancer,  if 
either  of  these  occupations  seems  to  have  been  causative;  cancer  a  deux,  a  phrase 
used  in  France  to  signify  that  carcinoma  has  occurred  in  two  persons  of  a  house- 
hold who  are  not  blood  relations,  but  have  been  in  close  contact;  contact  cancer, 
when  cancer  appears  in  an  area  which  was  in  close  contact  with  a  cancerous  area 
in  the  same  or  in  another  individual — for  instance,  when  a  cancer  of  the  upper 
lip  follows  a  malignant  growth  of  the  lower  lip;  when  a  carcinoma  of  the  face 
follows  a  like  growth  of  the  hand;  when  a  cancer  appears  on  the  penis  of  a  husband 
whose  wife  has  cancer  of  cervix  uteri  or  vagina.  A  melanotic  carcinoma  is  a  form 
of  encephaloid  in  which  the  cells  contain  melanin.  Scirrhous  cancer  contains 
much  fibrous  tissue  and  is  densely  hard.  An  encephaloid  is  very  soft  or  brain- 
like. Marjolin's  ulcer  is  an  epithelioma  which  arises  from  the  epithelial  edge 
of  a  chronic  ulcer,  a  scar,  or  a  sinus  (see  page  171,  Figures  82,  83,  84,  and  85). 

Epitheliomata. — An  epithelioma  arises  from  surface  epithelium,  and  may 
arise  from  squamous  cells  or  cylindrical  cells,  according  to  the  location. 

Squamous-celled  epithelioma  (see  Fig.  208)  takes  origin  from  the  skin  or  from 
a  mucous  membrane  covered  with  pavement-epithelium.  It  is  especially  apt 
to  appear  at  the  junction  of  skin  and  mucous  membrane  (as  the  lips)  or  the 
point  of  juxtaposition  of  different  kinds  of  epithelium.  Such  a  growth  may 
arise  in  the  anus  or  vagina;  on  the  penis,  scrotum,  lips,  or  tongue;  in  the  mouth 
or  nose;  on  the  skin,  and  other  situations.  There  is  an  ingrowth  of  surface 
epithelium  into  the  subepithelial  connective  tissue,  colonies  of  cells  growing  inward 
and  forming  epithelial  nests.  It  may  arise  without  discoverable  cause,  it  may 
follow  prolonged  irritation,  or  it  may  arise  in  a  wart  or  fissure.  In  the  nipple  it 
is  not  very  unusually,  and  in  the  scrotum,  glans  penis  and  nose  it  is  occasionally, 
preceded  by  a  persistent  dermatitis  due  possibly  to  psorosperms,  and  known  as 
Paget' s  disease.  Paget's  disease  is  not  true  eczema,  but  is  rather  malignant 
dermatitis.  A  crust  gathers  on  the  part,  and  beneath  this  crust  is  a  raw,  red, 
and  moist  surface,  the  edge  of  which  is  slightly  elevated  and  somewhat  indu- 
rated. In  the  beginning  there  is  a  strong  resemblance  to  eczema.  The  nipple 
is  apt  to  retract.  The  parts  are  the  seat  of  a  constant  itching  and  scalding 
sensation.  The  area  may  become  cancerous  in  a  few  weeks,  but  may  not 
for  years,  I  have  seen  two  cases  of  Paget's  disease  of  the  glans  penis.  Squa- 
mous epithelioma  generally  begins  as  a  warty  protuberance  which  soon  ulcer- 


446  Tumors  or  Morbid  Growths 

ates.  A  malignant  or  true  cancerous  ulcer  (see  Fig.  208)  has  a  hard,  irregular 
base,  uneven  edges,  a  foul,  fungus-like  bottom,  and  gives  off  a  sanious  or  ichor- 
ous discharge.  This  ulcer  is  the  seat  of  sharp,  pricking  pain,  sometimes  bleeds, 
and  extends  over  a  considerable  area,  embracing  and  destroying  every  struc- 
ture. Epithelioma  usually  affects  lymphatic  glands  early,  but  such  infection 
may  be  long  delayed.  Epitheliomatous  glands  break  down  in  ulceration, 
making  frightful  gaps  and  often  causing  fatal  hemorrhage.  Dissemination  is 
not  nearly  so  common  as  in  other  forms  of  cancer,  but  it  does  sometimes  occur. 
Cylituirical-celled  Epithelioma. — This  form  of  growth  takes  origin  from 
structures  covered  with  or  containing  cylindrical  epithelium,  and  it  contains 
cylindrical  or  columnar  cells.  It  is  composed  of  a  stroma  of  fibers  l^etween 
which  lie  tubular  glands  lined  with  columnar  epithelium  and  containing  masses 
of  epithelial  cells.  Such  tumors  are  found  in  the  uterus  and  gastro-in- 
testinal  tract,  and  may  begin  from  the  surface  epithelium  or  from  the  cells 
of  tubular  glands.  In  these  tumors  there  is  an  acinus-like  structure  and  the 
spaces  are  filled  with  proliferating  epithelium.  Cylindrical-celled  cancers  may 
also  arise  from  the  mammary  gland,  liver,  and  kidney.     One  of  the  most  com- 


FiGS.   211,  212. — Rodent  ulcer  (case  of  Dr.  L.  M.  Raring,  Denver,  Colorado). 

mon  seats  of  cyHndrical-celled  cancer  is  the  rectum.  Cancer  of  the  rectum  tends 
in  many  cases  to  occur  at  an  earlier  age  than  cancer  elsewhere,  being  not  un- 
common between  the  ages  of  twenty-eight  and  forty.  Cylindrical-celled  epithelio- 
mata  are  at  first  covered  with  mucous  membrane,  but  they  soon  ulcerate  and 
involve  the  submucous  and  muscular  coats  in  the  growth.  They  may  grow  rather 
slowly,  usually  but  not  always  cause  lymphatic  involvement,  and  finally  dissemi- 
nate widely.  They  require  in  some  regions  from  five  to  six  years  to  cause 
death.  In  the  rectum,  however,  growth  is  much  more  rapid  and  few  victims 
of  cylindrical-celled  carcinoma  of  the  rectum,  if  unoperated  upon,  live  beyond 
two  years,  and  many  of  them  die  long  before  this  period. 

A  rodent  or  Jacob's  ulcer,  epithelioma  excdens  or  cancroid  (Figs.  211,212,  213), 
wascalledby  the  older  surgeons  noli  me  iangere,  because  they  found  that  surgical 
interference  (incomplete  removal  as  we  now  know)  was  sometimes  followed  by 
very  active  growth.  A  rodent  ulcer  is  scarcely  ever  met  with  except  upon  the 
face,  though  Jonathan  Hutchinson  saw  one  upon  the  forearm,  and  James  Berry 
met  with  one  upon  the  arm.  It  is  especially  common  upon  the  nose  and  fore- 
head. It  begins  usually  between  the  ages  of  thirty  and  fifty  as  a  little  warty 
prominence  which  ulcerates  in  the  center,  the  ulceration  progressing  at  a  rate 
equal  to  the  new  growth.  The  ulcer  becomes  deep;  it  is  not  crusted;  its  edges 
are  irregular,  hard,  and  everted;  the  floor  is  smooth  and  of  a  grayish  color;  the 


Classitication  of  Carcinomata 


447 


discharge  is  thin  and  acrid;  and  the  parts  about  the  sore  contain  numbers  of 
visible  vessels.  Jacob's  ulcer  grows  slowly,  may  last  for  years,  does  not  involve 
the  lymphatics,  produces  no  constitutional  cachexia,  and  is  rarely  fatal.  In  some 
cases,  although  growth  is  very  slow,  destruction  eventually  becomes  very  great  be- 
cause of  ulceration,  there  is  great  loss  of  tissue  and  horrible  deformity.  A  ro- 
dent ulcer  is  usually  considered  to  be  a  malignant  epithelial  growth  which 
springs  from  a  sweat-gland,  a  sebaceous  gland,  or  a  hair-follicle,  but  Kanthack 
asserts  that  before  ulceration  the  rete  and  the  sweat-glands  are  normal,  but  the 
sebaceous  glands  are  destroyed.  The  base  and  edges  of  the  ulcer  are  hard,  and  this 
differentiates  it  from  lupus;  and,  further,  the  bacilli  of  tubercle  may  perhaps  be 
cultivated  from  the  discharge  of  an  area  of  lupus  (see  page  272).  Rodent  ulcer 
begins  below  the  skin,  ordinary  epithelioma  begins  in  the  skin,  and  a  rodent 
ulcer  contains  no  cell-nests.  A  rodent  ulcer  very  rarely  undergoes  cicatrization, 
a  fact  which  differentiates  it  from  lupus.  Occasionally,  but  very  rarely,  a 
small  portion  of  the  growth  sloughs  out  and  a  temporary  scar  forms  at  this  point. 

Adenocarcinoma  or  Glandular 
Carcinoma. — Glandular  c  a  r  c  i  n  o- 
matain  structure  resemble  racemose 
glands.  Such  a  cancer  consists  of  a 
stroma  of  connective  tissue  and 
alveoli  filled  with  proliferating  epi- 
thelial cells.  If  the  proportion  be- 
tween the  fibrous  stroma  and  the 
cellular  elements  is  about  the  same 
as  in  a  normal  gland,  the  growth  is 
called  simple.  When  the  cellular 
element  is  in  excess  the  growth  is 
soft  (medullary),  and  when  the 
fibrous  stroma  is  in  excess  the 
growth  is  hard  (scirrhous). 

1 .  Scirrhous  carcinoma  is  a  white 
and  fibrous  mass  which  has  no 
capsule,  which  infiltrates  tissue,  and 
which,  by  the  contraction  of  its 
outlying  fibrous  processes,  draws 
in  toward  it  adjacent  soft  parts, 
thus  producing  dimpling,  or,  as  in 
the  breast,  retraction  of  the  nipple. 
It  is  composed  of  spheroidal  cells 
in  alveoli  formed  of  connective- 
tissue  bands.  The  commonest  seat  of  scirrhus  is  the  female  breast.  It  occurs 
also  in  the  skin,  vagina,  rectum,  prostate,  uterus,  stomach,  and  esophagus. 
It  is  most  frequent  in  women  after  forty.  It  begins  as  a  hard  lump  which  is 
at  first  painless,  but  which  after  a  time  becomes  the  seat  of  an  acute,  localized, 
pricking  pain.  This  lump  grows  and  becomes  irregular  and  adherent,  causing 
puckering  of  the  soft  parts.  After  the  skin  or  mucous  membrane  above  it  has 
become  infiltrated  ulceration  takes  place  and  a  fungous  mass  protrudes  which 
bleeds  and  suppurates.  The  adjacent  lymphatic  glands  usually  become  cancerous 
in  from  six   to  ten  weeks,  and  constitutional  involvement  is  rapid  and  certain. 

2.  Medullary  or  encephaloid  carcinoma  is  a  soft  gray  or  brain-like  mass. 
It  is  a  rare  growth,  it  has  no  capsule  and  it  may  appear  in  the  kidney,  liver, 
ovary,  testicle,  mammary  gland,  stomach,  bladder,  or  maxillary  antrum. 
An  encephaloid  cancer  often  contains  cavities  filled  with  blood,  and  this 
variety  is  known  as  a  "hematoid"  or  a  "telangiectatic"  carcinoma.  These 
growths  are  soft  and  semifluctuating,  they  infiltrate  rapidly  and  soon  fungate, 
and  they  terminate  life  in  from  a  year  to  a  year  and  a  half.     If  the  cells  of 


Fig.  213. — Rodent  ulcer.     Case  in  the  author's 
wards  in  Philadelphia  Hospital. 


448  Tumors  or  Morbid  Growths 

encephaloid  become  filled  with  melanin,  the  condition  is  called  "melanosis'' 
or  ''melanotic  cancer." 

3.  Colloid  cancer  is  extremely  rare.  It  arises  from  either  a  scirrhus  or  an 
encephaloid,  when  the  cells  or  the  stroma  of  such  a  growth  undergo  colloidal 
degeneration.  On  section  there  will  be  seen  in  the  center  of  the  growth  a 
series  of  cavities  filled  with  a  material  resembling  honey  or  jelly;  the  periphery 
is  frequently  an  ordinary  scirrhus  or  encephaloid  cancer.  Colloid  degenera- 
tion is  most  prone  to  attack  carcinomata  of  the  stomach,  mammary  gland, 
and  intestine.  The  name  colloid  cancer  is  often  given  to  glistening,  gelatinous, 
malignant  growths  springing  from  the  ovary,  testicle,  mammary  gland,  or 
gastro-intestinal  tract.  The  condition  is  due  to  mucous  degeneration  of  the 
connective  tissue  or  of  the  epithelial  tissue  of  a  carcinoma.  Only  a  portion 
of  the  tumor  may  degenerate  or  the  entire  mass  may  become  gelatinous. 

Syncytioma  Malignum. — By  this  name  is  meant  a  malignant  epithelial 
growth  arising  from  the  site  of  the  placenta  during  pregnancy  or  the  puerperal 
state.  It  resembles  placenta  in  appearance  and  rapidly  causes  metastases 
by  way  of  the  blood-vessels.     It  is  quickly  fatal. 

Treatment, — Cancer  is  so  prevalent,  is  so  dreadful  in  its  nature  and  in- 
exorable in  its  progress,  tends  so  strongly  to  cause  death  in  from  two  to  five 
years,  people  are  so  afraid  of  it,  and  so  many  physicians  are  hopeless  of  curing 
it  that  multitudes  seek  relief  from  the  obsessed  Christian  scientists  or  from  the 
vulgar  criminal  quacks.  It  cannot  be  too  strongly  insisted  that  in  the  begin- 
ning cancer  is  a  local  disease  curable  by  early  and  radical  operation,  that  early 
diagnosis  should  be  made,  and  that  prompt  operation  is  imperative.  Delay  is 
not  only  disastrous,  it  is  usually  fatal.  Certainly  at  least  50  per  cent,  of  the 
cases  of  cancer  I  see  are  beyond  operation  when  they  are  first  brought  to  the 
hospital,  they  having  sacrificed  the  golden  moments  during  which  cure  was 
possible.  Carcinomata  demand  early  and  wide  excision,  with  removal  of 
implicated  glands.  Anatomically  related  lymph-nodes  must  be  removed  even 
if  they  show  no  evidence  of  involvement.  If  operation  is  early  and  thorough, 
and  if  certain  regions  are  involved,  a  considerable  proportion  of  cases  can  be 
cured.  Carcinomata  of  the  lip,  the  skin,  and  the  mammary  gland  can  often  be 
cured.  The  operation  must  be  radical.  That  the  tumor  is  small  and  recent  is 
no  justification  for  minimizing  the  extent  of  operation.  That  is  the  sort  of  case 
which  may  be  cured  by  radical  removal.  Anything  short  of  radical  removal 
is  bound  to  fail.  Recurrence  almost  certainly  means  that  cancer  cells  have 
been  left  behind.  Unless  a  wide  area  is  removed  cancer  cells  are  sure  to  be  left. 
During  removal  the  parts  should  be  handled  as  little  as  possible  so  as  not  to 
squeeze  malignant  cells  into  the  wound.  Cancer  cells  in  a  wound  soon  become 
fixed  and  multiply.  For  the  same  reason  tumor  and  glands  are  removed  in  one 
piece.  The  surgeon  avoids  cutting  across  lymph-vessels  and  planting  cancer  cells 
in  the  wound.  After  operation  the  .r-rays  should  be  used  in  hope  of  destroying 
cancer  cells  which  may  have  remained  in  the  tissues.  To  use  the  rays  lessens 
the  danger  of  recurrence.  Czerny  ("Deutsche  Med.  Wochen.,"  Nov.  2,  1912) 
is  so  impressed  with  the  necessity  of  special  effort  to  prevent  recurrence  that  he 
leaves  the  operation  wound  open  for  two  or  three  months,  uses  radium,  the 
:c-rays,  or  fulguration  in  the  wound,  and  then,  if  everything  seems  to  be  going 
on  well,  he  closes  the  wound  by  a  plastic  operation.  A  recurrent  growth  may 
be  removed  as  a  palliative  measure  to  lessen  pain  and  to  relieve  the  patient 
from  ulceration  and  hemorrhage,  but  such  an  operation  is  rarely  curative.  If  a 
growth  does  not  recur  within  five  years  after  removal,  a  cure  has  very  probably 
been  attained;  in  fact,  if  there  is  no  recurrence  within  three  years,  the  case  is 
probably  cured.  The  three-year  limit  has  been  usually  accepted  since  Volk- 
mann's  paper  on  the  subject.  A  rodent  ulcer  should  be  excised  or  be  cu- 
retted and  cauterized  with  the  hot  iron  or  the  Paquelin  cautery  or  subjected  to 
electric  desiccation  or  to  electrothermic  coagulation.     In  cancer  of  the  lower 


Treatment  of  Inoperable  Cancer  449 

Up,  remove  the  growth  by  Grant's  operation  {q.  v.),  or,  if  necessary,  cut  away 
the  entire  Up.  In  every  case  remove  the  glands  beneath  the  jaw.  In  cancer 
of  the  tongue,  excise  this  organ  and  also  the  lymph-nodes  from  beneath  the  jaw 
and  in  the  anterior  carotid  triangles.  In  cancer  of  the  breast,  remove  the  breast, 
the  pectoral  fascia  and  the  pectoral  muscles,  and  take  away  the  fat  and  glands 
of  the  axilla.  In  cancer  of  the  rectum,  if  near  the  surface,  excise  the  rectum 
from  below;  if  above  5  inches  from  the  anus,  do  the  sacral  resection  of  Kraske 
and  then  remove  the  growth.  In  cancer  of  the  esophagus,  perform  gastrostomy; 
in  cancer  of  the  pylorus,  perform  pylorectomy  or  gastro-enterostomy;  in  cancer 
of  the  bowel,  do  resection,  side-track  the  diseased  area  by  an  anastomosis,  or 
make  an  artificial  anus;  in  cancer  of  the  penis,  amputate  the  organ  and  remove 
the  glands  of  the  groin. 

Treatment  of  Inoperable  Cancer. — Erysipelas  toxins  are  seldom  of  any 
service  in  carcinoma.  In  very  rare  cases  they  do  good.  It  is  justifiable  to  try 
them.  Claims  have  been  made  that  cancer  can  be  benefited  by  the  intravenous 
injection  of  material  expressed  from  carcinomatous  tumors.  There  are  sug- 
gestions of  the  value  of  such  treatment.  The  late  Dr.  Hodenpyl  had  charge  of 
a  case  in  which  a  cancer  of  the  liver  was  undergoing  spontaneous  retrogression. 
When  a  cancerous  individual  was  injected  vnih  ascitic  fluid  from  this  case  a 
local  reaction  was  observed  in  the  tumor  (swelling,  redness,  diminution  in  size, 
necrosis).  It  was  assumed  that  the  fluid  contained  a  specific  material  which 
might  cure  cancer.  The  results  of  the  study  of  such  fluid  have  been  negative 
(Richard  Weil,  "Jour.  Med.  Research,"  August,  1910).  Serum  from  animals 
suffering  from  cancer  is  without  therapeutic  value.  Pyoktanin,  thiosinamin, 
tr^'psin,  colloidal  silver,  lecithin,  and  many  other  materials  have  come  upon  the 
scene  as  remedies.  They  were  like  plausible  confidence  men,  but  each  was  soon 
exposed.  There  is  no  drug  and  no  serum,  no  globulin,  no  vaccine  and  no  toxin 
at  present  known  to  be  capable  of  curing  cancer.  Honest  investigators  have 
at  times  been  lead  into  error  by  forgetting  that  at  times  the  rate  of  growth 
of  a  cancer  may  temporarily  lessen  or  that  growth  may  for  a  time  actually  cease. 
(See  Lewis  S.  Pilcher's  address  before  the  Surgical  Society  of  Brooklyn  in  Feb., 
1909.) 

Fulguration  has  of  late  excited  much  interest.  By  this  term  we  mean  bom- 
barding a  part  from  a  metal  electrode  with  sparks  flashed  from  a  high-tension 
current.  It  was  introduced  as  a  treatment  for  cancer  by  De  Keating-Hart  in 
1907.  The  sparks  have  no  specific  action  on  cancer  cells.  All  the  surface  cells 
of  an  ulcerated  growth  are  converted  into  an  eschar  and  the  connective  tissue 
under  and  around  the  sore  is  stimulated  to  cicatrize.  Sometimes  after  ful- 
guration healing  occurs  over  cancerous  nodules.  Fulguration  cannot  act 
through  the  unbroken  skin.  It  is  not  a  real  cure,  though  it  may  retard  the 
progress  of  a  case  or  aid  in  preventing  recurrence  after  extirpation  of  a  growth. 
Application  of  sparks  may,  be  followed  by  grave  or  fatal  sepsis.  The  early 
enthusiasm  for  fulguration  in  cancer  has  largely  waned.  No  operable  growth 
should  be  treated  by  it,  as,  at  best,  it  has  only  a  local  effect  and  cannot  act  upon 
the  involved  lymph-nodes.  The  cautery  at  a  cherry  heat  as  used  by  the  late 
Dr.  Byrne  is  a  valuable  agent.     At  this  heat  there  is  no  bleeding. 

Electric  desiccation  finds  some  warm  supporters.  A  monopolar  electric 
current  of  high  tension  is  used  (the  Oudin  current).  It  is  appHed  by  means 
of  a  metal  conductor.  The  tissues  are  dehydrated  but  not  carbonized,  and 
are  removed  later  by  sloughing  or  curetment  (Clark,  in  "Med.  Council,"  July, 
191 5).  This  is  particularly  suited  for  superficial  lesions.  In  electrothermic 
coagulation  heat  generated  in  the  tissues  by  their  resistance  to  the  passage 
of  the  electric  current  causes  coagulation  and  destruction  of  the  cancer.  The 
high-frequency  current  of  the  d'Arsonval  t^-pe  is  used  (Pfahler,  in  "Interstate 
Med.  Jour.,"  191 7,  vol.  xxiv).  I  find  that  in  some  cases,  obviously  irremovable 
by  the  knife  alone,  a  combined  operation  may  be  done  with  great  benefit.  The 
2g 


45©  Tumors  or  Morbid  Growths 

surgeon  uses  the  knife.  The  electrical  expert  applies  desiccation.  In  one  case 
I  tied  the  external  carotid  artery  before  Dr.  Clark  desiccated  the  area.  In 
another  case  I  removed  the  upperjawasaprehminary  to  desiccation.  In  another 
case  I  removed  part  of  the  lower  jaw.  The  results  were  excellent.  This  com- 
bined operation  permits  of  the  removal  of  a  glandular  area.  The  failure  to  do 
this  by  electrical  methods  alone  has  been  a  major  indictment  against  them.  I 
am  convinced  that  a  cancer  removed  by  desiccation  or  by  the  knife  followed  by 
desiccation  is  decidedly  less  apt  to  recur  than  if  the  knife  alone  were  used.  If 
recurrence  does  take  place  it  will  be  later  if  desiccation  has  been  used  than  if 
it  has  not  been  used. 

Electrolysis  destroys  tissue  by  electrolytic  action.  Cataphoresis  or  ionic 
surgery  is  a  modification  of  electrolysis.  Percy  employs  a  method  by  which 
the  tissues  are  cooked  for  a  considerable  time.  The  heat  is  applied  by  an  elec- 
trocautery controlled  by  a  rheostat  and  the  degree  of  penetration  of  the  heat 
can  be  regulated  rigidly  ("Transactions  of  Western  Surgical  Assoc,"  Dec,  1913). 
The  .x--rays  are  of  distinct  value  in  certain  cases  of  carcinoma.  Surface 
growths  may  be  apparently  cured,  although,  unfortunately,  they  are  apt  to  re- 
turn even  after  total  disappearance.  Deeper  growths  are  seldom  lessened  in 
size  and  practically  never  cured,  but  the  rate  of  growth  may  be  diminished  and 
pain  be  abated  or  aboUshed.  The  knife  is  to  be  preferred  to  the  .T-rays,  except  in 
very  superficial  skin  cancer  about  the  eyelid  or  nostril,  and  in  inoperable  cancer. 
The  real  curative  power  of  radium  is  as  yet  undetermined.  The  x-rays  and 
radium  have  a  decided  influence  in  lessening  the  horrible  pain  of  recurrent  or 
inoperable  cancer.  In  lymphatic  recurrence  after  operation  thyroid  extract 
may  perhaps  be  of  some  value.  In  some  cases  of  recurrent  cancer  ligation  of 
the  artery  of  supply  or  extirpation  of  the  artery,  as  suggested  by  Dawbarn, 
notably  retards  growth.  I  have  been  able  to  confirm  this  statement.  In 
cancer  of  the  breast,  oophorectomy  occasionally  produces  great  benefit  (Beat- 
son's  operation,  page  1599).  In  inoperable  cases  palliative  operations  may  be 
justifiable  to  relieve  some  urgent  discomfort  or  get  rid  of  a  foul  or  bleeding  mass. 
Gastro-enterostomy,  gastrostomy,  and  colostomy  are  palliative  operations. 
In  a  malignant  growth  of  the  nasopharynx  tracheotomy  may  be  required, 
and  in  a  malignant  growth  of  the  bladder  it  may  be  advisable  to  perform  su- 
prapubic cystostomy.  In  an  inoperable  case  it  may  be  necessary  to  relieve  the 
pain  by  opium,  gi\dng  as  much  as  may  be  required  to  secure  ease.  Opium  so 
used  seems  not  only  to  relieve  pain,  but  to  retard  the  growth  of  the  tumor  and 
to  favor  the  development  of  fibrous  tissue  in  the  stroma.  Guy  of  Boston  has 
long  believed  in  the  value  of  compound  tincture  of  iodin  in  retarding  cancer 
growth.  In  some  cases  he  gives  also  the  bro mid  of  arsenic  ("Boston  Med.  and 
Surg.  Journal,''  March  11,  1909). 

Chemotherapy  of  Cancer. — Wassermann  has  been  able  to  cause  mouse 
cancer  to  disappear  by  injecting  into  the  veins  of  tlje  animal  negrosin,  and  also 
by  injecting  eosin  and  selenium.  This  proves  that  a  chemical,  as  well  as 
a  parasite,  may  have  an  afl&nity  for  certain  cells.  The  chemicals  used  by 
Wassermann  attacked  the  cells  of  mouse  cancer,  and  did  not  attack  or  only 
slightly  influenced  the  other  cells  of  the  body.  The  world  is  seeking  for  a 
chemical  agent  to  destroy  cancer. 

Wassermann  desired  to  introduce  selenium  into  the  cancer  cells.  He  found 
eosin  (an  aniline  dye)  to  be  the  helping  hand  to  put  selenium  into  the  cells. 
When  the  pink  solution  of  eosin-selenium  is  thrown  into  the  blood  of  a  mouse 
the  skin  at  once  becomes  pink.  The  pink  color  of  the  skin  disappears  in  a 
few  hours;  the  tumor  remains  deeply  stained.  Numerous  injections  will  kill 
the  mouse  or  cause  the  tumor  to  soften  and  slough,  and  the  action  is  just  as 
positive  in  spontaneous  as  in  transplanted  tumor. 

This  material  is  too  dangerous  to  use  in  man,  but  the  investigation  suggests 
splendid  possibiUties  for  the  future  (E.  F.  Bashford,  in  the  "Lancet,"  Jan.  13^ 


Traumatic  Epithelial  Cystomata 


451 


191 2).  Colloidal  solution  of  vanadium  has  been  tried.  It  is  stated  that  copper 
and  tin  have  a  greiater  affinity  for  cancer  cells  than  selenium  (Weil  reviewed  the 
subject,  in  "Jour.  Am  Med.  Assoc,"  1915,  Ixiv). 

Malignant  Growth  from  Congenital  Pigmented  Mole  (Fig.  213c). 
— As  previously  stated,  the  embryonic  origin  of  the  pigment-producing  cells  is 
uncertain.  Some  regard  a  malignant  growth  of  a  congenital  pigmented  mole 
as  epithelioma,  others  as  alveolar  pigmented  sarcoma.  Bloodgood  thinks  it  is 
probably  carcinomatous. 

Malignant  change  seldom  occurs  before  the  fiftieth  year,  the  growth  rarely 
attains  a  large  size,  metastasis  takes  place  very  rapidly  by  the  blood  and  lym- 
phatics, and  the  patient  seldom  lives  more  than  a  year  after  malignant  change 
begins.     (See  Bloodgood,  in  "Progressive  Medicine,"  Dec,  1907.) 

Because  of  the  danger  of  subsequent  malignant  change  it  is  wise  to  remove 
large  pigmented  moles.  Every  pigmented 
mole  which  is  irritated  or  begins  to  enlarge 
must  be  removed,  and  the  associated 
lymph-nodes  should  also  be  removed. 
Bloodgood  knows  of  no  definite  cure  on 
record  of  a  malignant  tumor  arising  in  a 
pigmented  mole.  Prevention  is  easily 
secured  by  extirpation  before  the  onset  of 
malignancy. 

Cystomata. — A  cystoma  is  a  benign 
cystic  tumor  in  which  the  cells  of  the  cyst 
wall  constitute  the  new  growth.  The  cyst 
contents  are  derived  from  the  cells  of  the 
wall.  The  tumor  is  the  cyst  wall;  the 
cells  of  this  wall  are  derived  from  the 
epiblast,  the  hypoblast,  or  the  mesoblast, 
and  are  either  epithelial  or  endothelial. 
The  cells  of  the  cyst  wall  adhere  to  con- 
nective tissue  which  seems  to  constitute 
a  part  of  the  wall.  A  thick  wall  contains 
much  connective  tissue,  a  thin  wall  very 
little.  The  nature  of  the  contents  is 
dependent  on  the  character  of  the  cells 
which  constitute  the  tumor.  Cysts  lined 
by  endothelium  contain  serous  fluid;  a 
cyst  of  the  thyroid  gland  usually  contains 
colloid  material;  a  cyst  lined  by  flat  epithelial  cells  contains  matter  resulting 
from  fatty  degeneration,  etc. 

Cystomata  may  be  congenital  or  acquired,  and  an  acquired  cystoma  may 
arise  after  injury  or  follow  inflammation.  The  cyst  may  increase  in  size  pro- 
gressively or  its  growth  may  be  halted.  The  wall  may  become  calcareous  or 
even  bony.  When  a  cyst  has  one  cavity,  we  call  it  monolocular;  when  there 
are  several  or  many  cavities  it  is  called  multil ocular. 

Varieties  of  Cystomata. — The  chief  varieties  are:  Traumatic  epithelial; 
atheromatous;  mucous;  mesoblastic 

Traumatic  Epithelial  Cystomata. — These  growths  have  been  called  traumatic 
dermoids.  Such  a  growth  may  arise  after  an  injury  which  carries  and  deposits 
epithelial  cells  or  a  bit  of  skin  deep  into  the  connective  tissue.  For  instance  a 
punctured  wound  of  the  hand  ma}^  be  followed  by  an  epithelial  cystoma  (Fig.  215). 
It  may  arise  after  a  scalp  wound,  in  the  scar  of  a  burn,  or  in  the  scar  following  a 
fistifla  operation  or  an  operation  for  osteomyelitis.  The  cyst  grows  only  to  a 
certain  size  and  then  remains  stationary.  It  is  lined  by  pavement-epithelium 
and  it  contains  products  of  the  fatty  degeneration  of  epithelial  cells  (page  454). 


!i3(2. — Melanotic  growth,  second- 
ary to  pigmented  mole. 


452  Tumors  or  Morbid  Growths 

Treatment. — Extirpation  of  the  wall  of  the  cystoma. 

Atheromatous  Cystomata. — These  growths,  according  *to  Senn,  are  met 
with  particularly  in  the  ovaries,  in  the  orbital  region,  and  at  the  base  of  the 
tongue,  but  they  can  arise  almost  anywhere.  They  may  remain  small  or  may 
attain  a  great  size.  Such  a  cystoma  contains  columnar  epithelial  cells  which 
have  undergone  fatty  degeneration  and  sometimes  contains  oil.  An  athero- 
matous cystoma  is  deep  seated  and  is  not  connected  with  the  skin,  in  contrast 
to  a  sebaceous  cyst,  which  is  superficial  and  is  a  part  of  the  skin.  An  athero- 
matous cystoma  is  lined  with  epithelium,  but  not  with  skin.  A  dermoid  cyst  is 
lined  with  skin  or  other  definite  structure.  An  atheroma  is  due  to  the  dis- 
placement of  a  mass  of  epithelial  cells  which  was  the  matrix  of  the  cystoma. 
"The  displacement  of  the  matrix  of  an  atheroma  occurred  at  a  time  prior 
to  the  differentiation  of  the  epiblastic  cells  into  the  organs  representing  the 
appendages  of  the  skin,  while  the  matrix  of  a  dermoid  cyst  points  to  a  later 
displacement  of  the  matrix"  ("Pathology  and  Surgical  Treatment  of  Tumors," 
by  Nicholas  Senn).  Atheromatous  cystomata  may  be  congenital,  but  may 
not  appear  until  puberty  or  even  much  later. 

Treatment. — Extirpation  of  the  wall  of  the  cystoma. 


Fig.  214. — Hydrocele  of  neck  in  boy  nine  weeks  of  age. 

Mucous  Cystomata. — A  mucous  cystoma,  like  an  atheromatous  cystoma, 
is  due  to  the  displacement  of  epithelium,  but  in  the  former  condition  it  is  pave- 
ment-epithelium and  in  the  latter  it  is  columnar  epithelium.  The  latter  is  filled 
with  a  mucoid  material  and  the  former  with  a  fatty  debris.  Such  a  mucous 
cystoma  must  not  be  confused  with  a  retention  cyst  of  a  mucous  membrane. 
Mucous  cystomata  are  found  particularly  about  the  lips,  mouth,  and  pharynx. 
They  rarely  attain  any  considerable  size.  Cystomata  lined  with  ciliated 
epithelium  may  arise  in  the  testicle,  the  liver,  and  the  brain. 

Treatment. — Incise,  cauterize,  and  drain.  The  wall  is  so  delicate  that 
excision  is  rarely  possible. 

Mesoblastic  Cystomata. — They  are  lined  with  endothelial  cells.  They 
contain  serous  fluid,  often  grow  to  a  large  size,  and  sometimes  disappear  spon- 
taneously. Mesoblastic  cystomata  are  probably  distended  lymph-spaces. 
They  are  congenital  and  are  most  common  in  the  neck,  axilla,  and  perineum. 

Hadley  regards  certain  retroperitoneal  cysts  as  having  a  common  origin 
with  hydrocele  of  the  neck  ("Surgery,  Gynecology,  and  Obstetrics,"  xxii),  1916. 
He  says  that  the  embryological  development  of  the  lymph  system  passes  through 
two  stages.  In  the  first  stage  primitive  lymph  sacs  form  from  veins.  In  the 
second  stage  lymphatic  vessels  grow  from  the  endothelial  layer  of  the  sacs. 
There  are  four  primitive  lymph  sacs,  viz.,  the  jugular  sacs  in  the  neck,  a  sac 


Dermoid  Cysts  453 

back  of  the  peritoneum  and  in  front  of  the  lower  dorsal  and  upper  lumbar 
vertebras,  and  a  sac  in  the  pelvis.  If  development  is  arrested  early  a  cyst  will 
form.  In  one  case  seen  by  the  author  such  a  cystoma  of  the  neck  appeared  late 
in  life,  but  it  is  probable  that  it  had  existed  in  childhood,  and  after  disappearing 
for  a  long  time  had  reappeared.  The  most  common  form  of  mesoblastic 
cyst  is  known  as  hygroma  or  hydrocele  of  the  neck  (Fig.  214),  A  hygroma  con- 
tains numerous  pockets.  Some  hygromata  are  very  large,  reaching  from  the 
clavicle  to  the  lower  jaw  and  from  the  middle  line  of  the  neck  to  the  spine. 
Some  pass  into  the  axilla,  others  into  the  anterior  mediastinum. 

Treatment. — Excision  is  very  ditficult.  In  i  case  in  which  I  assisted  Pro- 
fessor Keen  it  was  successfully  accomplished  and  in  another  case  I  succeeded. 
The  cyst  should  be  injected  \nth  methylene-blue  to  make  its  outlines  clear. 
The  usual  treatment  is  to  tap  frequently,  and,  after  each  tapping,  to  wash  out 
\\'ith  carbolic  acid  (2  to  5  per  cent.)  and  to  apply  pressure.  Recently  I  excised 
successfully  a  hygroma  which  passed  down  into  the  axilla. 

Cystomata  of  bone,  of  the  thyroid  gland,  of  the  mammary  gland,  etc.,  are 
considered  in  the  sections  on  Regional  Surgery. 

Teratomata. — The  teratomata  contain  tissues  or  higher  structures  de- 
rived from  two  or  all  of  the  blastodermic  layers.  The  tumors  we  previously 
considered  are  derived  from  only  one  of  these  layers.  The  elder  Senn,  in  his 
work  on  ''Tumors,"  thus  defines  a  teratoma:  "A  teratoma  is  a  tumor  com- 
posed of  various  tissues,  organs,  or  systems  of  organs  which  do  not  normally 
exist  at  the  place  where  the  tumor  grows.  The  highest  t\^e  of  a  teratoma 
is  a  fetus  in  fetu.  In  the  simpler  varieties  the  tumor  is  composed  of  hetero- 
topic tissue,  such  as  bone,  teeth,  skin,  mucous  membrane,  etc.  All  teratoid 
tumors  are  congenital;  that  is,  the  tumor  either  exists  at  the  time  of  birth  or 
the  patient  is  born  with  the  essential  tumor  matrix.  A  teratoma  never  springs 
from  a  matrix  of  postnatal  origin."  Any  human  structure  may  be  found  in 
a  teratoma.  Various  fetal  malformations  belong  to  this  group,  as  do  also 
double  monsters,  in  which  one  of  the  embryos  is  rudimentary.  Teratomata 
are  divided  into  external  and  internal.  To  the  external  teratomata  belong  the 
parasitic  fetus  and  the  suppressed  fetus.  A  parasitic  fetus  is  the  result  of 
fusion  of  two  embryos,  one  ha^dng  gone  on  to  complete  development,  and  the 
other  developing  partially,  and  obtaining  nutrition  from  the  fully  developed 
embryo  to  which  it  is  attached.  A  suppressed  fetus  is  an  irregular  mass  attached 
to  the  posterior  surface  of  the  sacrum,  to  the  chest,  or  to  the  abdomen.  It 
contains  a  conglomeration  of  tissues  and  fragments  of  organs,  for  instance, 
bone,  cartilage,  lung  tissue,  kidne}"  tissue,  a  piece  of  intestine,  or  a  portion  of 
liver.  In  a  case  pictured  by  Sir  J.  Bland-Sutton  a  leg  projects  from  the  sacral 
region. 

An  internal  teratoma  may  be  found  wdthin  the  cranium,  chest,  abdomen,  or 
pehds.  The  internal  teratoma  consists  of  a  conglomeration  of  the  tissues  and 
\dsceral  fragments  of  a  suppressed  fetus,  but,  unlike  the  external  teratoma,  it 
is  surrounded  by  a  cyst  wall.  The  members  of  this  group  most  often  seen  by 
the  surgeon  are  dermoid  cysts. 

Dermoid  Cysts. — These  cysts  were  first  studied  and  described  by  Lebert. 
The  name  "dermoid"  implies  that  the  cyst  contains  skin,  and  it  does  contain 
skin  or  mucous  membrane,  the  chief  mass  of  the  tumor  being  derived  from 
proliferation  of  the  cells  of  a  portion  of  displaced  epiblast  or  h}^oblast,  but  it 
also  contains  mesoblastic  derivatives.  There  are  two  varieties  of  true  dermoid: 
sequestration  dermoid  and  the  tubulodermoid.  In  this  section  we  speak  of  the 
first  form.  The  second  form  is  considered  on  page  457.  A  superficial  der- 
moid is  formed  by  the  inclusion  in  mesoblastic  tissues  of  a  portion  of  the  epi- 
dermis or  mucous  membrane.  Superficial  non-traumatic  dermoids  are  situated 
in  regions  where  the  blastodermic  layers  were  in  contact.  A  deep  dermoid  is 
formed  from  a  collection  of  epithelial  cells  completely  separated  from  the  epi- 


454  Tumors  or  Morbid  Growths 

blastic  tissue  from  which  they  originated.  When  a  cyst  originates  from  epiblastic 
cells  so  immature  that  the  skin  appendages  have  not  as  yet  been  formed,  it  will 
contain  only  atheromatous  material  like  that  found  in  a  sebaceous  cyst.  When 
a  cyst  arises  from  epiblastic  cells  after  they  have  so  matured  that  the  append- 
ages of  the  skin  have  been  formed,  it  will  contain  atheromatous  matter,  sweat, 
sebaceous  matter,  and  hair.  The  first  form  is  known  as  an  atheromatous  cys- 
toma; the  second,  as  a  dermoid.  A  deep-seated  dermoid  may  contain  also  such 
structures  as  prove  it  must  have  taken  origin  from  "a  displaced  matrix  repre- 
senting different  tissues  and  organs"  (Senn).  Such  a  dermoid  may  contain 
portions  of  organs,  bone,  cartilage,  and  teeth.  A  dermoid  cyst  may  be  defined 
as  a  heterotopic  cyst,  the  wall  of  which  is  composed  of  connective  tissue  lined 
with  epithelium  and  containing  material  formed  by  the  proliferation  of  epithe- 
hum  and  often  hair,  teeth,  or  even  bone.  An  injury  may  displace  a  bit  of  epi- 
thelium and  lodge  it  in  connective  tissue  and  from  this  a  traumatic  dermoid  may 
arise  (Fig.  215).  Traumatic  dermoids  are  not  true  dermoids.  Garre  called 
them  traumatic  epithelial  cysts.  They  are  most  often  encountered  in  the  palmar 
surface  of  the  hand  or  fingers.  The  skin  above  such  a  cyst  is  not  adherent  to  it 
and  often  a  scar  is  visible.     The  cyst  wall  is  composed  from  without  inward 


I'lG.    215. — Traumalic  dermoid  cy.st. 

of  connective  tissue  and  epithelial  cells,  the  stratum  corneum  being  the  inner 
layer  (Leo  Buerger,  in  "Annals  of  Surgery,"  August,  1907).  The  cyst  contains 
desquamated  epithelium  and  often  cholesterin.  The  causal  injury  is  usually  a 
puncture,  but  may  be  a  laceration,  a  contused  wound,  or  a  bite.  Sometimes  a 
cyst  arises  in  the  track  of  a  healed  sinus.  Pietzner  collected  reports  of  73  cases 
("Ueber  Traumatische  Epithelcysten.  Dissert.  Rostock.,"  1905). 

True  dermoid  cysts  are  most  commonly  found  in  the  ovary  and  in  regions 
where,  during  bodily  development,  the  blastodermic  layers  come  in  contact; 
for  instance,  in  the  neck,  the  eyelids,  the  orbital  angles,  the  lumbosacral  region, 
the  root  of  the  nose,  and  the  floor  of  the  mouth.  Such  cysts  are  also  found  in 
the  ovary,  testicle,  brain,  eye,  mediastinum,  lung,  omentum,  mesentery,  and 
carotid  sheath. 

A  dermoid  of  the  lumbosacral  region  may  be  mistaken  for  a  spina  bifida. 
Sarcoma  may  form  from  the  connective-tissue  elements  of  the  wall  of  a  der- 
moid cyst.  A  dermoid  cyst  may  become  cancerous,  or  innocent  epithelial 
tumors  may  originate  from  the  cyst  lining.  The  epithelial  cells  may  become 
fatty  and  an  oil-cyst  may  actually  form.  If  the  cyst  epithelium  was  derived 
from  mucous  membrane,  mucus  may  gather  in  the  sac.  A  dermoid  cyst 
may  inflame  or  even  suppurate.     It  is  free  from  pain  unless  it  suppurates, 


Branchial  Cysts  and  Fistulae  455 

inflames,  or  develops  into  a  malignant  tumor;  it  grows  slowly  and  rarely 
attains  any  considerable  size  unless  it  arises  in  the  ovary.  A  subcutaneous 
dermoid  may  or  may  not  fluctuate.  It  is  not  in  the  skin  as  is  a  sebaceous 
cyst,  but  the  skin  can  be  moved  over  it.  A  sebaceous  cyst  moves  with  the 
skin.  Subcutaneous  dermoids  about  the  orbit  are  adherent  to  the  under- 
hdng  periosteum.  The  matrix  of  a  true  dermoid  is  congenital,  but  the  cyst 
often  does  not  appear  until  puberty  or  later.  Teratoids  and  dermoids  con- 
nected with  the  rectum  require  special  consideration  (see  page  1304). 

Treatment. — Complete  extirpation.  If  any  of  the  epithelium  of  the  cyst- 
wall  is  left,  the  cyst  will  re-form.  A  superficial  dermoid  should  be  removed 
in  the  same  manner  as  a  sebaceous  cyst,  and  if  it  is  adherent  to  underlying 
periosteum  the  portion  of  this  membrane  to  which  it  adheres  should  also  be 
removed.  A  deep  dermoid  ought  to  be  removed  as  a  tumor  would  be,  if 
operation  is  feasible. 

Branchial  Cysts  and  Fistvilae. — WTien  a  branchial  cleft  fails  to  become 
completely  obliterated,  a  branchial  cyst  may  form.  The  branchial  clefts  are 
the  analogues  of  the  gill-sUts  of  a  fish.  There  are  four  of  these  clefts  on  each 
side  of  the  neck.  They  are  called  clefts,  but  they  are  really  grooves,  and  each 
groove  on  the  skin  has  its  counterpart  in  the  mucous  membrane  of  the  pharynx. 
Each  phar}Tigeal  groove  is  covered  with  hypoblastic  epithelium;  each  cuta- 
neous "groove  is  covered  with  epiblastic  epithehum,  and  the  two  grooves  are 
separated  by  mesoblastic  structures.  When  the  sides  of  a  cleft  do  not  unite 
and  an  opening  forms  in  the  mucous  membrane,  a  complete  branchial  fistula 
{complete  congenital  lateral  ceroical  fistula)  results.  When  the  sides  of  a  cleft  fail  to 
unite  and,  although  the  mucous  membrane  is  not  perforated,  the  skin  does  not 
cover  the  cleft,  a  branchial  sinus  or  an  incomplete  branchial  fisttda  {incomplete 
congenital  lateral  cervical  fistula)  results.  When  the  sides  of  a  cleft  toward  the 
phar>Tix  fail  to  coalesce,  a  pharyngeal  diverticulum  is  produced.  When  the 
pharyngeal  surface  and  the  cutaneous  surface  both  close,  but  the  deeper  part 
of  a  cleft  remains  open  and  epithelial  cells  are  caught  in  mesoblastic  elements, 
a  branchial  cyst  is  formed.  Sinuses  are  more  common  than  complete  fistulae  or 
cysts. 

The  essential  cellular  element  of  a  branchial  cyst  is  epithelium,  derived  either 
from  the  skin  or  phar\Tix;  hence  the  branchial  cyst  is  not  a  true  dermoid, 
because  its  histologic  elements  are  derived  from  only  one  of  the  blastodermic 
layers.  Branchial  cysts  are  most  common  in  the  triangle  of  election  of  the 
left  side.  They  are  round,  smooth,  often  fluctuating,  and  are  very  deeply 
situated,  being  in  close  relation  with  the  great  vessels.  Some  cysts  contain 
mucus,  others  serous  fluid,  others  fatty  debris.  An  abscess  may  form.  The 
origin  of  a  cyst  or  fistula  is  usually  from  the  second  branchial  cleft,  but  I  have 
operated  on  two  cysts  of  the  first  branchial  cleft,  and  Dr.  Nassau,  also  operated 
on  one  of  like  origin.  There  may  be  one,  two,  or  three  openings  of  a  fistula. 
The  openings  are  seldom  bilateral.  Hereditary  tendency  is  often  manifest. 
The  cutaneous  openings  are  always  along  the  anterior  margin  of  the  sterno- 
cleidomastoid muscle.  At  the  external  orifice  there  is  often  an  irregularly  shaped 
bit  of  skin  and  cartilage,  which  is  called  a  cervical  auricle.  A  branchial  cyst  or 
sinus  or  epithelial  remains  in  a  cleft  may  become  the  seat  of  epithelioma.  Such 
growths  are  rare,  though  more  common  than  I  used  to  think  and  they  are  ex- 
cessively mahgnant.     They  grow  rapidly,  extend  widely  and  soon  ulcerate. 

Treatment. — In  older  children  and  in  adults  it  may  be  possible  to  extirpate  a 
cyst  or  a  fistula,  although  this  is  very  difficult  and  often  impossible.  A  ureteral 
catheter  is  introduced  into  the  fistula,  a  circular  incision  through  the  skin  is 
made  about  it.  This  incision  leaves  a  disc  of  skin.  An  incision  is  then  made 
along  the  anterior  border  of  the  sternomastoid,  the  muscle  is  dra^vn  outward, 
the  tract  is  dissected  sharply  to  the  carotid  bifurcation  but  from  that  point 
blunt  dissection  is  practised.     The  patient's  mouth  is  opened  and  traction  on 


456 


Tumors  or  ]\Iorbid  Growths 


the  tract  will  make  a  dimple  below  the  tonsil  or  in  the  lateral  wall  of  the  i)harynx. 
The  neck  of  the  tract  is  ligated  and  divided  (Dowd,  quoted  by  Tarnowsky  in 
"Internat.  Abstract  of  Surgery,"  Sept.,  1916).  Other  methods  employed  are 
incision,  cauterization  with  the  Pacjuelin  cautery,  and  packing  with  gauze; 
frequent  tapping  and  injection  with  iodin;  incision  and  drainage,  every  anti- 
septic care  being  observed.  In  all  young  children  and  in  some  older  persons 
with  deep  cysts  the  latter  plan  is  the  only  one  advised,  and  it  will  often  fail, 
but  may  sometimes  produce  a  cure. 

Cysts. — -A  cyst  is  a  cavity,  abnormal  or  pathological  in  character,  lined 
by  a  membrane  and  containing  material  usually  fluid  or  semifluid.  It  is 
necessary  tc)  l)ear  in  mind  the  disfinction  between  a  cystoma  and  a  cyst.     Hek- 

toen  and  Riesman,  in  the  "American 
Text-Book  of  Pathology,"  insist  on  this 
distinction.  They  say:  "A  cystoma  ia^ 
a  true  tumor,  arising  from  active  pro- 
liferation of  a  matrix  destined  to  form 
cystic  spaces;  whereas  a  cyst  is  a 
secondary  formation  not  primarily  due 
to  tissue  proliferation."  Cysts  are 
divided  into  the  following  classes: 
Retention-cysts;  cysts  from  softening; 
tubulocysts;  and  parasitic  cysts  (Ibid.). 
Retention=cysts. — A  retention- 
cyst  is  formed  by  blocking  of  the 
duct  of  a  gland  or  by  failure  in  the 
absorption  of  the  proper  amount  of 
the  secretion  of  a  ductless  gland.  A 
few  characteristic  forms  of  retention- 
cysts  will  be  described. 

Sebaceous  Cysts  (Wens).  —  A 
sebaceous  cyst  arises  when  the  ex- 
cretory duct  of  a  sebaceous  gland  is 
blocked  by  dirt  or  occluded  by  in- 
flammation. The  orifice  of  the  duct 
is  often  visible  as  a  black  speck  over 
the  center  of  the  cyst.  They  are  very  common  in  the  scalp,  being  known  as 
wens,  and  upon  the  face,  neck,  shoulders,  and  back.  There  may  be  one,  several, 
or  a  number  (Fig.  216).  Arising  in  the  skin,  and  not  under  it,  the  skin  can- 
not be  freely  moved  over  a  sebaceous  cyst.  A  sebaceous  cyst  is  lined  by 
epithelium  and  is  filled  by  foul-smelling  sebaceous  material.  A  sebaceous  cyst 
may  suppurate.  When  a  cyst  ruptures  and  the  contents  become  hard,  a  Jwm 
is  formed.  Another  form  of  horn  has  been  previously  alluded  to  as  due  to  horny 
transformation  of  a  wart. 

Treatment. — To  treat  a  sebaceous  cyst,  incise  the  portion  of  skin  above  it 
and  dissect  the  sac  entirely  away  by  scissors  or  a  dissector,  trying  not  to  rupture 
the  delicate  wall.  If  even  a  small  particle  of  the  wall  is  left,  the  cyst  will  re-form 
unless  the  clinging  bit  of  lining  is  destroyed  by  a  cauterizing  agent.  If  it  rupture 
during  removal  and  it  be  feared  that  some  portion  may  remain,  cauterize  the 
interior  of  the  wound  by  pure  carbolic  acid.  If  acid  is  not  used,  close  without 
drainage;  but  if  acid  is  used,  drain  for  twenty-four  hours.  If  an  abscess  forms 
in  a  sebaceous  cyst,  open  it,  grasp  the  edges  of  the  cyst  lining  wath  forceps,  dissect 
out  this  lining  by  scissors  curved  on  the  flat,  cauterize  by  pure  carbolic  acid, 
and  drain  for  twenty-four  hours. 

Mucous  Cysts. — A  mucous  cyst  is  due  to  the  blocking  of  a  mucous  gland 
or  a  mucous  crypt.  Mucous  cysts  occur  particularly  in  the  mucous  membrane 
of  the  mouth  and  genito-urinary  organs,  and  are  filled  by  thick,  adhesive  mucus 


Fig. 


I'). —  I)r.  Weatherby's  case  of  multiple 
.baceous  tumors  of  the  scrotum. 


Urachal  Cysts  457 

containing  numerous  epithelial  cells.  Such  a  cyst  is  of  spherical  outline,  and 
the  epithelial  membrane  which  lines  it  is  strongly  adherent  to  tissues  beyond. 

Treatment. — Incision,  curetment,  cauterization  by  pure  carbolic  acid,  and 
packing  or  extirpation  of  a  considerable  part  of  the  cyst,  and  curetment  and 
cauterization  of  the  part  remaining. 

Oil  Cysts, — An  oil  cyst  is  due  to  fatty  degeneration  of  the  epithelial  lining 
of  a  sebaceous  cyst,  or  of  a  milk  cyst  of  the  breast.  As  previously  noted,  a  der- 
moid may  become  an  oil  cyst. 

Treatment. — Extirpation,  as  for  sebaceous  cysts. 

Salivarj'  Cysts. — A  retention-cyst  of  a  salivary  gland  is  known  as  a  ranula 
(q.  v.).     These  cysts  are  most  common  in  the  submaxillary  or  sublingual  gland. 

Lacteal  or  Milk  Cysts  (Galactoceles). — Such  a  cyst  occasionally  arises  in 
the  mammary  gland  during  lactation,  and  is  the  result  of  blocking  of  a  lac- 
tiferous duct  (see  Cysts  of  Mammary  Gland). 

Among  other  forms  of  retention-cysts,  most  of  which  are  discussed  in 
special  sections  of  this  book,  we  mention  hydrosalpinx,  a  cyst  due  to  blocking 
of  a  Fallopian  tube;  cysts  due  to  obstruction  of  the  bile-ducts  (the  most  com- 
mon form  is  known  as  hydrops,  which  is  a  dilated  gall-bladder  the  result  of 
obstruction) ;  cyst  of  the  thyroid  gland;  cyst  of  the  pancreas;  and  hydronephrosis, 
a  condition  produced  by  obstruction  of  the  ureter. 

Cysts  from  Softening. — These  cysts  are  formed  by  the  disintegration 
of  degenerated  tissues.  For  instance,  after  a  hemorrhage  into  the  brain, 
softening  may  follow  and  a  cyst  arise.  Cystic  changes  of  this  sort  are  fre- 
quently observed  in  sarcomata  and  carcinomata.  A  cyst  from  softening  has 
a  wall  of  connective  tissue,  but  there  is  no  endothelial  or  epithelial  layer. 

Tubulocysts. — This  name  was  given  by  Sir  J.  Bland-Sutton  to  cysts 
formed  in  certain  remains  of  embryonal  ducts — vestiges  which  ought  to  have 
been  destroyed  in  the  developed  body.  A  small  cavity  is  left  unobliterated,  and 
in  this  space  fluid  gathers.  The  source  of  the  fluid  is  usually  the  lining  cells 
of  the  cavity.  Branchial  cysts  are  frequently  considered  under  this  head- 
ing. Among  the  commoner  tubulocysts  are  cysts  of  the  vitello-intestinal 
duct,  cysts  of  the  urachus,  and  thyroglossal  cysts.  Thyroglossal  cysts  and 
sinuses  are  considered  on  page  1056. 

Mesenteric  cysts,  not  hydatid  and  not  due  to  carcinoma,  are  embryonic 
developments  from  remains  in  the  mesentery  of  the  vitelline  duct,  the  Wolfiian 
ducts,  the  Wolffian  bodies,  and  the  Miillerian  ducts  (Moynihan). 

What  are  called  "chyle  cysts"  of  the  mesentery  are  embryonal  cysts  placed 
in  such  close  adjacency  to  lacteals  that  chyle  enters  into  them  (E.  P.  Baumann, 
in  "Lancet,"  May  7,  1904). 

Cysts  of  the  Vitello-intestinal  Duct. — Such  a  cyst  presents  itself  as  a  small, 
bright  red,  globular  mass,  which  appears  to  arise  from  the  umbilicus  of  a  baby 
or  a  young  child,  and  which  usually  has  a  distinct  pedicle,  but  may  be  sessile. 
A  cyst  of  this  character  forms  when  the  vitello-intestinal  duct  atrophies  from 
the  gut  toward  the  umbilicus,  but  a  remnant  at  the  umbilicus  escapes  oblitera- 
tion, and  from  this  remnant  a  cyst  forms.  The  wall  of  such  a  cyst  contains 
unstriped  muscular  fiber  and  is  lined  by  mucous  membrane.  Occasionally  the 
duct  in  the  process  of  involution  is  not  destroyed — its  caliber  is  simply 
lessened — and  the  duct  remains  open  in  the  navel  and  feces  come  from  it. 
If  the  duct  closes  at  the  umbilical  end  but  fails  of  obliteration  at  the  intestinal 
end,  a  diverticulum  remains  at  this  point  (Meeker s  diverticulum). 

Treatment. — A  pedunculated  cyst  at  the  navel  is  treated  by  ligating  its  base 
and  dividing  the  stalk  beyond  the  ligature.  A  cyst  with  a  thick  base  is  dis- 
sected out.  The  surgeon  must  be  careful  to  avoid  confounding  an  umbilical 
hernia  with  a  cyst  of  the  navel. 

Urachal  Cysts. — The  urachus  is  the  obliterated  allantois,  and  is  a  cord 
running  from   the  summit  of  the  bladder  to  the  umbilicus.     This  structure 


458  Tumors  or  Morbid  Growths 

is  in  the  middle  Hne  of  the  abdomen  and  in  front  of  the  peritoneum.  A  por- 
tion of  the  allantois  may  not  be  obliterated  at  birth,  and  in  consequence  of 
this  failure  a  cyst  forms.  It  grows  to  a  considerable  size,  may  push  the  perito- 
neum away  and  reach  the  pelvis,  may  communicate  with  the  bladder,  may 
break  through  the  umbilicus,  or  grow  backward  toward  the  spine. 

Treatment.— Extirpation  of  the  lining  membrane,  partial  closure  of  the 
cavity  by  suture,  and  packing  the  unobliterated  part.  Complete  extirpation 
of  the  cvst  is  seldom  attempted.  W.  R.  Weiser  ("Annals  of  Surgery,"  Oct., 
1906)  collected  86  cases  of  cyst  of  the  urachus.  In  8  of  these  complete  extirpa- 
tion was  performed,  and  Macdonald  has  since  reported  a  successful  complete 
extirpation  (Ibid.,  August,  1907), 

Parasitic  cysts  are  due  to  the  development  of  certain  parasites  in  the 
tissues.     The  form  most  often  encountered  is  known  as  the  hydatid  cyst. 

Hydatid  cysts  are  especially  common  in  Iceland,  and  are  frequent  in  Aus- 
tralia and  South  America,  but  are  very  rare  in  the  United  States.  In  the 
United  States  91  per  cent,  of  cases  occur  in  foreigners  (Lyon).  Hydatid  cysts 
are  due  to  echinococci.  The  adult  echinococcus  is  the  tapeworm  of  the  dog 
(Taenia  echinococcus),  and  its  ova  or  larvae  gain  access  to  man's  body  by  ac- 
companving  the  food  he  eats  and  passing  into  the  alimentary  canal,  from 
which  situation  they  are  transported  to  various  organs  by  the  blood.  The 
cat  also  brings  danger  to  man.  Osier  says  the  embryo  (which  has  six  booklets) 
burrows  through  the  wall  of  the  bowel  and  enters  the  peritoneal  ca\aty  or  mus- 
cles; it  may  enter  the  portal  vessels  and  reach  the  liver,  or  may  enter  the  sys- 
temic circulation  and  pass  to  distant  parts.  The  danger  depends  on  two  factors: 
"the  situation  and  the  liability  of  the  cyst  to  suppurate"  (Sidney  Coupland). 
The  organs  most  usually  attacked  are  the  liver  and  lung.  In  60  per  cent,  of 
cases  the  liver  suffers,  and  in  12  per  cent,  the  lung  (Thomas).  Lyon  estimates 
that  the  Hver  is  the  seat  of  disease  in  73  per  cent,  of  cases.  Cysts  sometimes 
arise  in  the  intestine,  kidney,  genito-urinary  passages,  brain,  or  spinal  canal. 
When  the  embryo  lodges,  the  booklets  disappear  and  a  cyst  is  formed.  This 
cyst  is  composed  of  two  layers,  an  outer  capsule  (cuticular  membrane)  and  an 
inner  layer  (endocyst).  The  cyst  contains  clear  sahne  fluid.  As  the  cyst  grows, 
daughter-cysts  bud  out  from  the  wall  of  the  mother-cyst,  the  structure  of  the 
daughter-cysts  being  identical  with  that  of  the  mother-cyst.  From  the  lining 
membrane  of  all  the  cysts,  after  a  time,  growths  arise  known  as  scolices,  which 
represent  the  head  of  the  echinococcus  and  exhibit  four  sucking  disks  and  a 
row  of  booklets  (Osier). 

The  fluid  is  not  albuminous,  is  occasionally  saccharine,  is  thin  and  clear, 
and  may  contain  scolices  or  booklets. 

A  hydatid  cyst  may  calcify,  may  rupture,  or  may  suppurate.  In  very 
rare  cases  spontaneous  absorption  occurs.  If  hydatid  fluid  is  disseminated 
throughout  the  peritoneal  cavity,  it  may  or  may  not  lead  to  the  development  of 
new  cysts,  but  it  is  almost  certain  to  cause  a  febrile  condition  accompanied  by 
urticaria  and  known  as  hydatid  toxemia.  Hydatid  cysts  are  very  firm,  but 
usually  fluctuate.  Palpation  with  one  hand  while  percussion  is  practised  with 
the  other  appreciates  a  persistent  tremor  (hydatid  fremitus).  If  the  cyst  can  be 
safely  reached,  some  fluid  should  be  drawn  and  examined  for  diagnostic  purposes. 
When  a  cyst  suppurates,  positive  constitutional  and  local  symptoms  arise. 
Hydatid  cysts  of  the  brain  and  cord  tend  to  produce  death  in  the  same  manner  as 
do  tumors.  A  cyst  of  the  liver  may  rupture  into  the  pleural  sac,  into  the  belly 
cavity,  into  the  stomach,  or  into  the  bowel,  producing  shock,  hemorrhage,  and 
probably  death.  In  rare  cases  hydatid  cysts  rupture  into  the  pericardium  or 
into  a  great  abdominal  blood-vessel,  or  externally.  Rupture  into  the  bile- 
passages  is  usuaUy  followed  by  suppuration  of  the  cyst.  Suppuration  of  a  cyst 
may  foHow  unclean  tapping.  It  has  been  pointed  out  that  eosinophilia  is  noted 
in  most  persons  suffering  from  hydatid  disease. 


Rupture  of  the  Heart  459 

Treatment. — An  unruptured  hydatid  cyst  of  superficial  structure  should 
be  incised  and  the  sac  wall  should  be  dissected  out.  Hydatids  of  the  brain 
have  been  successfully  removed  in  Australia.  A  cyst  of  the  kidney  is  re- 
moved through  a  lumbar  incision.  Omental  cysts  should  be  radically  re- 
moved if  possible;  if  this  is  not  possible,  open  the  abdomen,  surround  the 
cyst  with  gauze,  evacuate  through  a  trocar,  stitch  the  cyst  wall  to  the  wound, 
incise,  irrigate,  and  drain  by  gauze.  Bond  advocated  evacuating  the  cyst, 
closing  it  by  sutures,  and  dropping  it  back  in  the  abdomen.  Gardner  says 
tapping  is  dangerous,  as  it  may  cause  rupture  of  the  cyst.  In  a  hydatid  of 
the  liver  the  abdomen  should  be  opened,  the  cyst  should  be  surrounded  by 
gauze  pads,  and  tapped  by  a  trocar  and  cannula.  When  the  cyst  is  emptied 
of  fluid  it  is  grasped  by  forceps  and  pulled  to  the  incision  in  the  abdominal 
wall;  it  is  sutured  to  this  incision,  the  trocar  opening  is  enlarged,  and  the  endo- 
cyst  is  removed  by  irrigation.^  This  operation  is  called  marsupialization. 
If  the  cyst  is  on  the  summit  of  the  liver,  it  may  be  reached  by  a  transpleural 
hepatotomy.  If  aspiration  is  performed  to  settle  a  diagnosis,  operate  at  once 
after  doing  it,  because  of  fear  that  the  cyst  may  leak  and  disseminate  the 
disease  throughout  the  peritoneal  cavity.  Brewer  ("Annals  of  Surgery,"  April, 
1908),  in  operating  on  a  case  of  hydatid  cyst  of  the  liver,  wounded  the  portal 
vein  and  was  obliged  to  tie  it.  The  patient  recovered.  That  there  was  no 
failure  of  nutrition  Brewer  attributes  to  the  fact  that  the  vein  had  been  long 
pressed  upon  and  the  collaterals  were  dilated  when  ligation  was  performed. 
Before  operating  Kolbe  gives  an  intravenous  injection  of  salvarsan  or  neosal- 
varsan  and  waits  for  an  elevation  of  temperature  which  should  occur  in  about 
one  week.  A  simple  incision  will  liberate  necrotic  vesicles  and  turbid  fluid  and 
it  is  said  will  cure  the  case. 


XIX.  DISEASES  AND  INJURIES  OF  THE  HEART  AND  VESSELS 

Rupture,  Wounds,  and  Injuries. — Rupture. — A  heart  valve  may 
rupture.  The  aortic  and  mitral  valves  most  often  suffer.  Barie  collected  38 
cases  of  which  10  were  traumatic  (Babcock,  in  "N.  Y.  Med.  Jour.,"  June  10, 
191 6).  In  this  article  rupture  of  the  wall  of  the  heart  is  considered.  The 
heart  may  rupture  and  cause  instant  death,  but  rupture  may  not  be  in- 
stantly fatal.  Curtin  reported  a  case  in  which  death  did  not  occur  for  over 
twenty-four  hours.  Eisner  reported  a  case  of  rupture  in  which  life  was 
prolonged  for  ten  days.  One  case  lived  eleven  days.  In  cases  in  which  death 
does  not  occur  rapidly  the  rupture  must  be  so  small  that  very  little  blood 
escapes.  Rupture  occurs  in  a  damaged  heart,  a  heart  in  which  the  muscular 
fiber  is  fatty,  is  fibroid,  or  is  necrotic  from  suppuration,  or  which  has  softened 
because  of  occlusion  of  branches  of  the  coronary  artery.  Aneurysm  of  the 
coronary  artery  may  rupture.  A  tumor  or  a  hydatid  cyst  of  the  wall  may  be 
responsible  for  rupture.  It  may  be  traumatic,  resulting  from  a  fall  or  a  blow 
upon  the  chest,  or  non-traumatic,  following  a  great  effort  or  strain,  physical  or 
psychical,  which  raises  the  blood  pressure  greatly.  When  congenital  narrow- 
ing of  the  isthmus  of  the  aorta  exists  the  heart  is  particularly  exposed  to  the 
danger  of  rupture  from  elevated  blood  pressure.  A  bullet  which  enters  the  chest 
but  does  not  open  the  pericardium  may  cause  cardiac  rupture.  If  after  rupture 
death  does  not  at  once  take  place  the  pulse  becomes  very  rapid,  there  is  precor- 
dial pain,  dyspnea,  cyanosis,  feeble  heart-sounds,  rapid  respiration,  great 
restlessness,  collapse  and  syncope,  and  the  development  of  a  triangular  area 
of  dulness  on  percussion.  Positive  diagnosis  is  impossible.  Meyer  collected 
36  cases  of  rupture  of  the  heart  reported  since  1870.  Death  occurs  from 
■accumulation  of  blood  in  the  pericardium  making  pressure  upon  the  auricles. 
^  John  O'Conor,  of  Buenos  Ayres,  in  "Annals  of  Surgery,"  May,  1897. 


460  Diseases  and  Injuries  of  the  Heart  and  Vessels 

This  acute  compression  of  the  heart  due  to  blood  escaping  from  the  heart  is 
called  heart  tamponade.  It  is  held  by  Franke,  of  Berlin,  and  others  that  in 
heart  tamponade  the  pressure  within  the  pericardium  comes  to  exceed  the 
pressure  within  the  auricles,  that  the  pressure  within  the  pericardium  causes 
the  symptoms  of  the  injury,  and  finally  death.  Some  would  treat  heart 
tamponade  by  puncture  or  aspiration.  It  would  seem  that  either  must  be 
useless,  as  fresh  blood  is  bound  to  replace  what  is  withdrawn.  Suturing  must 
fail  in  non-traumatic  cases  because  of  the  badly  diseased  myocardium.  In 
traumatic  cases  it  may  possibly  succeed. 

Wounds  of  the  Pericardium  and  Heart. — Severe  wounds  usually, 
though  not  always,  produce  death,  but  shght  wounds  may  not  prove  fatal. 
It  is  a  popular  impression  that  the  expression  "stabbed  to  the  heart"  is  another 
way  of  saying  that  instant  death  has  occurred.  This  view  was  accepted  even 
by  surgeons  during  many  centuries.  During  the  sixteenth  century  sportsmen 
found  now  and  then  bullets  and  arrow-tips  healed  in  the  heart  walls  of  animals 
they  had  slain.  At  this  time  the  famous  case  of  a  duelist  was  published  by 
Pare:  a  man  received  a  sword  thrust  in  the  heart,  but  was  able  to  run  after 
his  opponent  many  hundred  feet  before  falling  down  in  death.  (See  "An  Ex- 
perimental Investigation  of  the  Treatment  of  Wounds  of  the  Heart,"  by  Charles- 
A.  Elsberg,  in  "  The  Journal  of  Experimental  Medicine,"  Sept.  and  Nov.,  1899.) 
From  Fare's  time  until  our  own  it  has  been  recognized  by  surgeons  that  a  wound 
of  the  heart  does  not  of  necessity  produce  immediate  death,  and  may  even  be 
recovered  from.  In  more  recent  years  Rosenthal,  Block,  Del  Vechio,  and 
others  proved  by  animal  experimentation  not  only  that  cardiac  wounds  are  not 
of  necessity  instantly  fatal,  and  that  in  some  cases  they  may  be  recovered  from, 
but  that  the  suturing  of  such  wounds  is  possible  and  greatly  enhances  the  chance 
of  recovery. 

In  1867  G.  Fisher  pubhshed  a  study  of  452  cases  of  wound  of  the  heart,  and 
pointed  out  the  surprising  fact  that  from  7  to  10  per  cent,  of  such  cases  recover. 
L.  L.  Hill  ("Med.  Record,"  Nov.  29,  1902)  shows  that  although  90  per  cent, 
of  heart- wounds  are  penetrating,  only  19  per  cent,  are  immediately  fatal. 
Sudden  death  occurs  always  when  Kronecker's  coordination  center  is  damaged. 
Kronecker  and  Schmey  showed  that  a  needle  may  be  thrust  into  various  parts  of 
the  ventricle  without  causing  instant  death.  At  one  particular  part  of  the 
ventricle  a  needle  thrust  instantaneously  causes  fibrillary  contraction  which  is 
surely  fatal.  This  spot  is  in  the  line  of  the  septum  at  the  lower  border  of  the 
upper  third  (Howell's  "Text  Book  of  Physiology").  Those  who  maintain  the 
neurogenic  theory  of  heart  action  call  this  spot  Kronecker's  coordination  center. 
Several  times  during  postmortem  examinations  on  human  beings  healed  scars 
have  been  found  upon  the  heart.  The  heart  has  been  punctured  a  number  of 
times  accidentally  or  intentionally,  and  death  has  not  ensued,  yet  until  1881  the 
profession  of  the  world  accepted  the  views  of  Billroth  who  scoffed  at  the  very 
possibility  of  operating  upon  the  heart.  John  B.  Roberts,^  of  Philadelphia, 
suggested  in  1881  that  it  would  be  proper  to  try  to  suture  wounds  of  the  heart. 
In  1882,  Block  demonstrated  upon  animals  the  practicabihty  of  operating  upon 
the  heart. 

Rosenthal,  Block,  Del  Vechio  and  others  proved  by  vivisectional  experiments 
that  wounds  of  the  heart  are  not  of  necessity  instantly  fatal,  that  in  some  cases 
they  may  be  recovered  from,  that  the  suturing  of  such  wounds  is  possible  and  that 
suturing  greatly  enhances  the  chance  of  recovery.  In  1887  Dr.  Harvey  Reed 
of  Cincinnati  sutured  a  wounded  pericardium  and  the  patient  recovered.  In 
1 89 1  Dalton  of  St.  Louis  obtained  recovery  in  a  like  case  by  a  similar  operation. 
In  1896  Farina  of  Rome  did  the  first  suturing  operation  upon  the  human  heart. 
The  patient  had  been  stabbed  in  the  right  ventricle  and  he  died  of  pneumonia 
on  the  sixth  day.  In  1896  Rehn  of  Frankfort  performed  the  first  successful 
1  "Annals  of  Anatomy  and  Surgery,  "Dec,  1881. 


Treatment  of  Wounds  of  the  Pericardium  and  Heart  461 

cardiorrhaphy.  After  suturing  he  packed  the  pericardial  cavity  with  iodoform 
gauze. 

Symptoms. — A  wound  of  the  heart  causes  hemorrhage,  which  is  usually 
copious,  but  owing  to  the  interlocking  of  muscular  fibers  the  hemorrhage  may 
be  slight.  There  may  or  may  not  be  serious  external  bleeding.  Fatal  concealed 
hemorrhage  may  occur.  Bleeding  may  take  place  into  the  pericardial  sac  in 
some  cases  where  the  pericardium  has  been  injured  and  the  heart  has  escaped. 
Such  an  injury  is  occasionally  inflicted  by  the  sharp  end  of  a  fractured 
rib.  The  wound  is  rarely  at  or  near  the  apex  of  the  sac.  In  most  heart  wounds 
the  pleural  cavity  is  also  opened  and  severe  hemothorax  occurs.  The  lung 
may  or  may  not  be  injured.  A  wound  of  the  pericardium  or  heart  causes  pro- 
found shock.  The  pulse  if  detectable  is  irregular  and  very  weak.  The  respira- 
tion is  shallow  and  often  sighing.  There  is  severe  cardiac  pain.  In  most  cases 
attacks  of  syncope  occur.  Dyspnea  is  severe.  There  is  usually  vomiting. 
The  face  is  cyanosed.  There  is  a  low  and  usually  rapidly  falling  blood  pressure. 
There  is  an  increase  in  the  area  of  cardiac  dulness  when  blood  gathers  in  the 
pericardium  {hemo pericardium) .  The  heart  sounds  are  feeble  and  there  are 
occasional  splashing  sounds.  In  some  cases  the  sounds  are  clear,  in  other  cases 
they  are  marked.  In  some  no  heart  sounds  are  audible.  The  apex  beat  may 
be  undiscoverable.  If  air  enters  the  pericardial  sac  a  tympanitic  percussion  note 
replaces  normal  cardiac  dulness  {pneumopericardium).  The  position  of  the 
wound  and  the  evidences  of  hemorrhage  may  aid  in  making  the  diagnosis. 
Death  is  apt  to  occur  suddenly  from  shock,  hemorrhage,  inability  of  the  heart 
to  contract  because  of  the  severed  fibers,  or  inability  of  the  heart  to  dilate 
because  of  the  pressure  of  blood  in  the  pericardial  sac.  Blood  in  the  pericar- 
dium if  present  in  large  amount  compresses  the  auricles  and  finally  arrests  the 
circulation  {heart  tamponade).  If  a  wound  of  the  pericardium  or  heart  does  not 
cause  death  during  the  first  day  or  two,  inflammation  follows  (traumatic 
pericarditis  or  carditis)  and  the  patient  may  die  of  suppurative  pericarditis 
or  of  empyema. 

Treatment. — Wounds  of  the  pericardium  and  heart  should  be  sutured. 
In  every  clear  and  in  every  suspected  case  give  at  once  a  hypodermatic  injection 
•of  atropin  in  order  to  lessen  pneumogastric  inhibition.  Do  not  give  stimulants 
until  the  bleeding  has  been  arrested.  To  do  so  would  increase  hemorrhage. 
The  moment  the  sutures  have  been  tied  and  the  bleeding  has  been  arrested  use 
•every  method  to  rouse  from  shock.  We  should  explore  if,  from  the  location  of 
the  wound  and  the  symptoms,  we  suspect  a  cardiac  wound.  I  agree  with 
Vaughan,  that  if  there  is  a  wound  in  the  cardiac  region  and  if  the  symptoms 
threaten  life,  exploration  should  be  performed  at  once.  In  a  doubtful  case 
exploration  should  be  made  by  enlarging  the  wound,  and  this  may  be  done  under 
local  anesthesia.  Every  wound  which  is  on  the  surface  of  the  cardiac  region  does 
not  of  necessity  involve  the  heart.  Murphy  saw  four  cases  in  each  of  which  the 
wound  of  entrance  of  the  bullet  suggested  strongly  that  the  heart  must  have 
been  hit,  yet  in  these  cases  the  only  cardiac  disturbance  was  manifested  by  slow 
pulse  and  in  but  one  of  them  was  there  a  friction  sound  (Leslie,  in  "N.  Y.  Med. 
Jour.,"  i9i6,civ).  In  operating  for  a  heart-wound  the  cutaneous  surface  should 
be  rapidly  disinfected  with  iodin.  It  is  wiser,  in  most  cases,  to  give  a  general 
anesthetic  than  not  to  give  it.  Local  anesthesia  is  slow  and  unsatisfactory. 
Without  an  anesthetic  the  patient  will  probably  struggle,  and  struggling  is  very 
dangerous,  as  it  loosens  clots  and  permits  hemorrhage  to  begin  again  (L.  L.  Hill, 
in  "  Med.  Record,"  Sept.  19, 1908).  Chloroform  is  the  anesthetic  used  by  many. 
I  would  prefer  ether.  If  the  patient  is  unconscious  and  the  corneal  reflex  is 
abolished,  no  anesthetic  should  be  given.  The  heart  is  exposed  by  resecting 
several  ribs.  In  a  knife- wound  of  the  right  pleural  cavity  and  right  side  of  the 
pericardium,  Barth,  of  Danzig,  removed  i  inch  from  each  of  three  right  costal 
cartilages   (fifth,  sixth,  and  seventh),  close  to  the  side  of  the  sternum,  and 


462  Diseases  and  Injuries  of  the  Heart  and  Vessels 

removed  also  the  ensiform  cartilage  and  i  inch  of  the  sternum.  The  same 
surgeon,  in  the  case  of  a  man  stabbed  in  the  fourth  left  intercostal  space,  re- 
moved the  fourth  and  fifth  left  costal  cartilage  and  part  of  the  sternum  ("  Deut- 
sche Zeitschrift  fur  Chirurgie,"  Bd.  Ixix,  No.  i).  Schwerin,  of  Berlin,  in  a 
stab- wound  of  the  chest  exposed  the  heart  by  resecting  the  fourth  and  a  portion 
of  the  fifth  left  ribs  ("Proceedings  of  German  Surgical  Congress,"  1903). 
Wilms  ("  Centralblatt  f.  Chirurgie,"  Leipzig,  vol.  xxxiii.  No.  22),  in  a  case  of 
gunshot-wound,  obtained  access  to  the  anterior  and  posterior  surfaces  of  the 
heart  by  a  simple  intercostal  incision.  Parrozzani  makes  a  trap-door  in  the 
chest,  the  hinges  of  the  door  being  the  rib  cartilages.  In  exposing  the  heart 
Giordono  enters  along  the  wound,  removing  any  obstacles  that  intervene. 
It  is  needless  to  try  to  avoid  opening  the  pleura  if  a  flap  with  an  internal  hinge 
is  used;  it  has  usually  been  opened  by  the  accident,  and  in  any  case  can  very 
seldom  be  avoided.  Matas  advises  Spangaro's  intercostal  incision.  The  mam- 
mary vessels  are  tied  and  the  ^v-idth  of  the  intercostal  space  is  greatly  increased 
by  strongly  retracting  the  ribs  and  cartilages.  If  more  space  is  needed,  the 
incision  is  carried  upward  at  the  junction  of  the  cartilages  and  sternum.  The 
heart  is  exposed,  clots  are  removed  from  the  pericardial  sac,  and  the  sac  is 
irrigated  with  hot  saline  fluid.  The  bleeding  may  be  furious.  A  non-penetrat- 
ing wound  of  the  ventricle  may  bleed  so  profusely  during  systole  as  to  resemble 
a  penetrating  wound  (Sherman).  A  penetrating  wound  may  bleed  most  during 
diastole.  The  motions  of  the  chest  make  manipulation  difficult.  Some 
surgeons  use  traction  sutures  to  lift  the  organ  toward  the  operator.  In  cases 
with  severe  hemorrhage  it  is  better  to  take  the  heart  in  the  palm.  The  bleeding, 
as  pointed  out  by  Rehn  can  be  completely  controlled  temporarily  by  making 
pressure  upon  the  venae  cavae  just  before  they  enter  the  auricle  (Zur  Chirurgie 
des  Herzens  und  Herzbeutels.  Verhandl.  d.  deutsch  Gesellsch.  f.  chir.,  xxx\d, 
2,  1907). 

Babcock  advises  us  to  take  the  heart  in  the  palm  of  the  hand  and  compress 
the  veins  between  the  ring  and  middle  fingers  ("N.  Y.  Med.  Jour.,"  June  10, 
191 6).  This  pressure  can  be  maintained  for  three  minutes  without  destroying 
life  or  causing  damage  to  the  cells  of  the  cerebral  cortex.  How  much  longer  it 
could  be  continued  is  not  knowm.  We  do  know  that  if  the  cortex  is  entirely 
deprived  of  blood  the  cells  perish  in  seven  minutes.  A  wound  in  the  heart  is 
sutured  with  interrupted  sutures  of  China  silk,  which  are  passed  by  means  of  a 
round,  curved  needle,  and  if  a  cavity  of  the  heart  is  open  each  suture  includes  the 
whole  thickness  of  the  heart  wall  except  the  endocardium.  It  has  been  said  that 
the  sutures  should  be  tied  during  diastole,  otherwise  they  are  apt  to  cut  out. 
Profs.  Gibbon  and  Stewart,  and  Drs.  John  F.  X.  Jones  and  Charles  S.  Nassau 
tell  me  that  in  their  cases  such  a  procedure  was  impossible  because  of  the  very 
rapid  action  of  the  heart.  As  few  stitches  are  used  as  \n\\  efficiently  close  the 
wound.  Numerous  stitches  cause  extensive  degeneration  of  muscular  fiber  and 
stitch-holes  may  permit  leaking.  The  pericardium  is  sutured  \\dth  silk  or,  as  was 
done  in  i  successful  case  (Rehn),  the  sac  is  packed  with  iodoform  gauze.  It  is 
better  to  avoid  draining  the  percardial  sac.  Clots  are  removed  from  the 
pleural  sac  by  irrigation  with  hot  saline  solution,  pulmonary  bleeding  is  arrested 
by  the  suture  or  by  packing,  and  a  wound  in  the  lung,  especially  if  it  com- 
municates with  the  air-passages,  is  sutured  if  the  patient's  condition  justifies 
prolonging  the  operation.^  Primary  drainage  of  the  pleural  cavity  is  seldom 
practised.     Later  drainage  may  become  necessary. 

.  After  such  an  operation  the  patient  is  in  great  danger  and  every  effort 
should  be  made  to  save  him  from  shock.  In  performing  operations  upon  the 
heart  the  pleura  is  almost  always  opened,  and  if  it  is  open  there  is  always 
pneumothorax  and  grave  danger  of  pulmonary  collapse  and  overwhelming  shock. 

Frazier  ("Progressive  Medicine,"  March,  1913)  collects  218  cases  of  opera- 
^The  author,  on  "Suture  of  the  Heart,"  in  "Progressive  Medicine,"  1899,  ^'o'-  '• 


Treatment  of  Wounds  of  the  Pericardium  and  Heart  463 

tion  for  heart-wounds.  The  mortaUty  in  the  series  was  55.5  per  cent.  This 
estimated  mortahty  is  probably  much  too  low.  Many  operators  have  reported 
a  single  successful  case  each.  It  is  reasonable  to  believe  that  many  unsuccessful 
cases  have  not  been  reported.  It  is  eminently  desirable  to  have  the  reports  of 
a  number  of  consecutive  cases.  We  have  here  such  a  record.  Hesse  (Bruns's 
''Beitriige,"  1911,  Ixxv)  reports  21  cases  with  a  mortality  of  71  per  cent.  We 
believe  this  represents  about  the  average  mortality  of  heart-wounds  subjected 
to  operation.  So  many  cases  have  been  reported  that  it  is  now  scarcely  possible 
to  report  them  all  with  the  names  of  the  operators.  There  have  been  13  cases 
of  heart  suture  in  Philadelphia  and  6  recoveries.  Stewart  had  5  cases  and  3 
recoveries;  Gibbon,  2  cases  and  i  recovery;  Nassau,  i  case,  which  recovered  and 
John  F.  X.  Jones,  one  case  which  recovered.  I  have  never  operated  for  a  wound 
of  the  heart.  According  to  Hill,  the  right  ventricle  is  most  often,  the  left  auricle 
least  often,  injured;  wound  of  the  auricle  is  generally  considered  to  be  more 
dangerous  than  wound  of  the  ventricle;  and  wound  of  the  apex  is  less  dangerous 
than  either.  Peck  points  out,  however,  that  there  are  11  reported  cases  of 
auricle  wounds  with  4  deaths,  a  mortality  of  36.3  per  cent.,  while  the  general 
mortality  of  heart-wounds  is  about  64  per  cent.  (''Annals  of  Surgery,"  July, 
1909).  Chibolian  and  Marchals  estimate  the  mortality  of  auricle  wounds 
after  operation  as  50  per  cent.  (Progres  Medical,  Jan.  31  and  Feb.  7,  1914). 
Wounds  of  the  left  ventricle  give  a  better  prognosis  than  of  the  right  ventricle;, 
wounds  of  the  right  auricle  a  better  prognosis  than  of  the  left  auricle.  A  needle 
puncture  rarely  causes  serious  bleeding  from  a  ventricle,  but  is  very  apt  to  cause 
severe  bleeding  from  an  auricle.  A  wound  received  during  diastole  is  less 
dangerous  than  one  received  during  systole.  Wounds  of  the  right  heart  bleed 
more  than  w^ounds  of  the  left  heart.  Wolff  points  out  that  ligation  of  one  coro- 
nary artery  can  be  done  and  recovery  follow;  wounds  of  the  left  ventricle  give 
the  best  prognosis  because  the  wound  is  closed  by  thick  edges  of  muscle.  In  37 
operations  for  heart- wounds  the  left  pleura  was  opened,  in  3  the  right  pleura,  and 
in  2  the  pleura  was  uninjured.  In  bullet-wounds  death  usually  occurs  before 
operation  can  be  done  (Wolff,  "  Deutsche  Zeitschrift  flir  Chirurgie,"  Bd.  Ixix,  No. 
i).  Bircher  reports  a  case  of  gunshot- wound  of  the  heart  in  which  there  was  no 
operation,  yet  the  patient  recovered.  He  believes  that  a  gunshot- wound  by  a 
small  bullet  should  not  be  operated  upon,  but  he  would  operate  for  wounds  by 
large  bullets  and  for  stab-wounds  ("Arch.  klin.  Chir.,"  1912,  xcvii).  Manteuf- 
fel  reported  7  cases,  occurring  during  the  war  in  jNIanchuria,  in  which  recovery 
followed  gunshot- wounds  of  the  heart  which  were  treated  expectantly.  With- 
out operation  the  mortality  of  heart- wounds  will  be  at  least  90  per  cent.;, 
■unth  operation  it  will  be  about  60  to  70  per  cent. 

Matas  (''Southern  Med.  Jour.,"  August,  1908)  discussed  160  cases  of  heart- 
wounds  Tvith  43.83  per  cent,  of  recoveries.  In  134  cases  the  wound  was  sutured, 
^-ith  49  recoveries.  In  11  cases  it  was  exposed,  but  was  not  sutured,  and  5 
recovered.     In  5  cases  foreign  bodies  were  removed  with  success. 

In  Peck's  table  ("Annals  of  Surgery,"  July,  1909)  there  are  69  wounds  of 
the  right  ventricle  with  48  deaths  (69.6  per  cent.);  74  of  the  left  ventricle  with 
45  deaths  (60.8  per  cent.);  5  of  the  left  auricle  with  2  deaths  (40  per  cent.); 
6  of  the  right  auricle  -^dth  2  deaths  (33.3  per  cent.);  and  7  miscellaneous  cases 
with  5  deaths  (71.5  per  cent.),  a  total  of  160  cases  ■v\ith,58  recoveries  and  102 
deaths,  a  mortality  of  63.7  per  cent. 

The  immediate  dangers  of  the  operation  are  hemorrhage,  shock,  and  the 
entrance  of  air.  The  late  dangers  are  pericarditis,  empyema,  and  pneumonia 
(Vaughan),  Traumatic  carditis  or  pericarditis  is  treated  in  the  same  way  as 
idiopathic  cases.  Pus  in  the  pericardial  sac  should  be  evacuated  by  resection 
of  the  fourth  left  costal  cartilage  and  incision  of  the  pericardium  (von  Eisels- 
berg's  case).  Pool  reviewed  the  subject  of  heart-wounds  in  the  "Annals  of 
Surgery,"  April,  191 2. 


4^4  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Wounds  in  War. — ^Most  heart-wounds  in  war  are  instantly  or  rapidly  fatal, 
a  comparatively  small  number  reach  the  evacuation  hospital.  Out  of  123 
wounds  of  the  chest  passing  through  an  Evacuation  Hospital  there  was  but  one 
wound  of  the  heart  (Dixon  and  McEwan  in  "Brit.  Med.  Jour.,"  May  27,  1916). 
Fewer  still  reach  the  base  hospital,  although  there  are  a  number  of  astonishing 
records  of  men  going  about  weeks  or  months  after  such  injuries.  Few  bayonet 
wounds  and  few  wounds  by  fragments  of  explosive  shells  survive  to  be  operated 
upon.  The  surgeon  sees  injuries  by  shrapnel,  rifle  bullets,  and  grenade  frag- 
ments. Gunshot  wounds  of  the  heart  are  more  surely  fatal  than  ordinary 
stab  wounds,  but  much  can  be  done  for  cases  which  survive  for  a  time. 

Le  Fort  has  removed  11  foreign  bodies  from  the  heart  by  9  operations,  in 
two  from  a  heart  cavity.     But  one  patient  died  (Lancet,  Sept.  7,  1918). 

A  bullet  may  pass  through  the  body  including  the  heart  in  its  journey. 
It  may  enter  the  body  but  show  no  wound  of  exit,  having  lodged  in  the  anterior 
wall  of  the  pericardium,  the  pericardial  sac,  the  heart  muscle,  a  cav^ity  of  the 
heart,  the  posterior  sac  of  pericardium  or  the  tissues  beyond  or  around.  A  bullet 
may  hit  the  heart  tangentially  without  making  a  wound  in  that  organ.  If  cir- 
cumstances admit  the  military  surgeon  operates  in  the  same  way  as  does  a 
surgeon  in  a  civil  hospital. 

Early  operations  are  performed  usually  for  hemorrhage.  If  the  projectile 
is  seen  it  is  removed  but  there  is  seldom  time  or  opportunity  to  use  the  .v-rays. 

If  a  lodged  projectile  has  not  been  removed  at  the  operation  or  if  the  man  lias 
not  been  operated  upon  but  has  recovered  from  the  hemorrhage  the  problem 
of  extraction  must  be  faced  in  the  Base  Hospital. 

In  such  a  case  there  are  usually  symptoms.  The  patient  complains  of 
dyspnea  in  exertion  and  chest  pain  and  the  pulse  is  rapid  ("British  Jour,  of 
Surgery,"  1916,  iv).  Yet  cases  are  on  record  in  which  lodged  projectiles  caused 
practically  no  symptoms.  In  Silvan's  case  a  projectile  was  lodged  in  the  heart- 
wall  and  penetrated  the  cavity  and  yet  there  were  no  symptoms  ("Riforma 
med.,"  1916,  xxxii).  See  also  case  reported  by  Lobligeois  in  "  Bull.  Acad,  de  med. 
de  Par.,"  1916,  Ixxvi.  In  any  case  the  projectile  is  shown  and  located  by  the  .r- 
rays.  In  one  case  a  man  walked  a  mile  and  a  half  after  being  struck  yet  the 
:i;-rays  showed  a  bullet  in  the  heart-wall  and  moving  ^vith  it  (Leslie,  in  "N.  Y. 
Med.  Jour.,"  1916,  civ). 

WTien  a  surgeon  operates  for  a  lodged  foreign  body  and  not  for  hemor- 
rhage he  takes  the  route  which  would  seem  to  be  the  most  accessible  and  least 
dangerous. 

This  point  of  view  is  set  forth  by  Villeon  ("Bull,  et  mem.  Soe.  de  Chir. 
de  Paris,"  1916,  xlii). 

In  one  case  a  projectile  was  lodged  against  and  behind  the  left  ventricle. 
It  was  extracted  by  a  transpleural  operation.  In  another  case  the  projectile 
was  against  and  below  the  left  ventricle.  It  was  removed  by  the  abdominal  and 
transdiaphragmatic  route.  In  still  another  case  the  projectile  was  against 
the  left  and  anterior  surface  of  the  heart.  It  was  removed  from  in  front,  the 
surgeon  looking  through  the  screen  of  the  fluoroscope. 

In  operating  the  surgeon  asks  himself  in  each  case — "should  I  drain?" 
In  wound  from  a  rifle  bullet  the  answer  is — "no!"  In  wound  from  a  sheU 
fragment  the  right  answer  is  doubtful.  In  view  of  the  fact  that  bacteriologic 
studies  have  shown  gas  bacilli  and  other  dangerous  bacteria  on  shell  fragments 
removed  from  the  chest  I  am  forced  to  feel  that  drainage  is  called  for  in  such 
cases. 

Tolerance  of  Heart  to  Lodged  Foreign  Bodies  in  the  Walls  or  in  a  Cavity. 
— Some  striking  cases  have  been  reported  showing  extraordinary  tolerance  of  a 
foreign  body  lodged  in  the  wall  of  the  heart.  In  some  of  these  cases  the  missile 
had  been  lodged  for  many  months  and  yet  there  were  no  symptoms.  Lobligeois 
reported  a  case  of  a  shrapnel  bullet  in  the  cavity  of  the  left  ventricle  which 


Pericarditis  465 

had  been  there  for  several  months  without  producing  any  symptoms.  He  was 
given  an  .v-ray  examination  to  locate  the  bullet,  as  there  was  no  exit  wound. 
The  liuoroscope  proved  that  the  bullet  was  in  the  cavity  (Presse  Medical,  Nov. 
9,  191 6).  Le  Fort  successfully  removed  from  the  cavity  of  the  left  ventricle  a 
fragment  of  hand  grenade  which  had  been  there  for  nearly  ten  months  (see 
"Lancet,"  Sept.  7,  1918.)  Beaussanat  records  the  following  case:  Four  months 
before  a  fragment  of  a  grenade  entered  the  right  ventricle.  There  was  shortness 
of  breath.  The  patient  suffered  pain  which  was  aggravated  by  movements  and 
by  attempts  to  speak.  The  ventricle  was  incised  and  the  fragment  removed. 
It  weighed  1.5  gm.  The  patient  recovered  (''Bull.  Acad,  de  med.,"  1915,  Ixxiii). 
Gray  removed  a  bullet  from  the  interior  of  the  right  ventricle.  Death  followed 
in  four  days  but  not  from  operation. 

Arthur  Keith  (quoted  in  "Progressive  Med.,"  Sept.,  1917,  from  "British 
Med.  Jour.")  has  seen  records  of  8  cases  of  bullets  lodged  in  the  heart  cavity, 
and  in  each  case  the  foreign  body  was  coated  with  fibrin.  The  bullet  may 
enter  by  means  of  a  heart  wound  or  it  may  enter  the  heart  from  a  venous 
trunk,  the  wound  being,  perhaps,  far  away.  It  was  long  known  that  intra- 
venous emboli  could  migrate.  It  is  something  new  to  find  out  that  bullets 
can.  Migration  may  be  with  the  blood  current,  or  directly  against  it  by  the 
influence  of  gravity.  Keith  knows  of  no  case  of  a  bullet  having  been  swept 
from  the  ventricle  into  the  pulmonary  artery.  In  three  specimens  which  are 
in  the  Royal  College  of  Surgeons  Keith  shows  that  there  is  not  a  heart-wound 
in  any  and  yet  in  every  case  there  is  a  bullet  in  the  heart  cavity. 

A  curious  fact  is  that  a  bullet  may  enter  a  great  vein  and  the  victim  recover 
without  grave  signs  of  hemorrhage. 

Grandgerard's  case  is  very  interesting  and  important  ("Paris  Med.,"  Jan.  13, 
191 7;  quoted  in  "Practical  Medicine  Series,"  Vol.  ii).  The  bullet  was  first 
located  by  .v-rays  in  the  right  auricle,  it  was  next  seen  in  the  right  groin  and 
finally  over  the  base  of  the  sacrum.  Keith  says  this  case  proves  that  a  loose 
bullet  in  the  right  auricle  or  ventricle  may  shift  its  position  and  may  by  gravity 
be  brought  to  a  region  favorable  for  operation. 

In  Lyle's  cases  of  migration  the  shell  fragment  entered  the  right  femoral 
vein.  Death  occurred  on  the  fifth  day  when  the  fragment  was  removed  from  the 
right  auricle  ("iVnnals  of  Surg.,"  Dec,  1916).  Several  other  such  remarkable 
cases  are  on  record  (see  "Practical  Medicine  Series,"  Vol.  ii  edited  by  Paul 
Ochsner). 

Pericarditis  is  an  infectious  condition  that  may  be  traumatic  or  non- 
traumatic. If  pericarditis  follows  an  open  wound,  it  is  obvious  how  the  in- 
fection must  have  entered;  if  it  follows  a  bruise  or  a  contusion,  the  injury 
has  rendered  the  pericardium  a  point  of  least  resistance.  In  some  few  cases, 
which  are  kno^vn  as  primary  pericarditis,  it  is  impossible  to  determine  how 
the  micro-organisms  gained  entrance.  The  ordinary  form  appears  as  a  com- 
plication of  certain  infectious  diseases,  such  as  septicemia,  pneumonia,  rheu- 
matism, and  tuberculosis.  It  may  be  secondary  to  some  adjacent  infection, 
such  as  an  empyema.  A  tuberculous  abscess  may  break  into  the  pericardium, 
and  an  abscess,  even  from  a  considerable  distance,  may  burrow  into  it.  It  may 
arise  secondary  to  a  distant  infection,  as  a  suppurating  wound,  osteomyelitis, 
middle-ear  suppuration,  pyorrhea,  f  urunculosis,  abscess  of  the  mastoid,  tonsillitis, 
abscesses  any^vhere,  peritonitis,  and  gastric  ulcer.  It  sometimes  follows  gastro- 
enterostomy and  may  arise  in  an  indi\ddual  with  Bright's  disease.  In  a  recently 
born  child  infection  of  the  stump  of  the  umbilical  cord  may  cause  pericarditis. 
A  pericardial  effusion  in  a  newborn  child  is  invariably  purulent  and  in  a  young 
■child  it  is  usually  purulent.  In  children  the  condition  is  usually  associated  with 
pulmonary  disease  (Poynton,  in  "Brit.  Med.  Joiir.,"  August  15,  1908).  A 
great  variety  of  bacteria  may  be  responsible  for  pericarditis  (pneumococci, 
staphylococci,  colon  bacilli).  The  exudation  may  be  serofibrinous;  this  is  an 
30 


466  Diseases  and  Injuries  of  the  Heart  and  Vessels 

evidence  of  its  being  a  mild  infection,  and  such  an  exudate  may  undergo  absorp- 
tion. On  the  other  hand,  the  exudate  may  become  purulent,  and  in  such  a  case 
cure  will  never  be  obtained  by  absorption  of  the  pus.  In  pericarditis  there  is 
usually  some  pain  in  the  region  of  the  heart,  and  this  pain  is  apt  to  extend  into 
the  left  arm.  Epigastric  pain  is  a  common  symptom.  The  heart  is  overacting, 
the  heart-sounds  are  indistinct,  the  pulse  is  strong  and  very  rapid,  there  is  an 
increased  area  of  cardiac  dulness,  and  the  patient  complains  of  dyspnea.  The 
temperature  is  elevated  and  a  double  friction-sound  may  be  made  out  upon 
auscultation. 

Treatment. — Ordinary  pericarditis,  without  pus-formation  or  extensive 
effusion,  is  managed  by  the  physician;  but  when  there  is  extensive  effusion 
with  symptoms  of  dangerous  compression  it  is  advisable  to  open  the  pericar- 
dium, and  if  there  is  purulent  effusion  the  pericardium  must  be  opened.  The 
procedure  usually  practised  in  the  past  to  relieve  pericarditis  with  marked 
effusion  was  puncture  or  aspiration.  This,  however,  is  dangerous.  The  heart  is 
not,  as  was  formerly  taught,  pushed  back  and  up  by  the  pericardial  effusion,  but 
is  lifted  upward  and  forward,  and  may  be  pushed  to  the  right  or  left  if  there  are 
adhesions  between  the  pericardium  and  heart;  and  it  is  impossible  to  select 
any  place  for  aspiration  that  assures  us  that  there  will  be  no  danger  of  punc- 
turing the  heart.  A  coronary  vein  may  be  injured,  the  pleural  cavity  may  be 
entered,  and  a  dry  tap  is  usual  from  blocking  of  the  needle.  Brentano  has  shown 
that  tapping  cannot  completely  empty  the  sac.  Many  surgeons,  however,  do 
not  fear  puncture,  and  explore  by  inserting  a  fine  needle  in  the  fourth  or  fifth 
space  of  the  left  side  close  to  the  sternum.  In  cases  of  extensive  pericardial 
effusion,  and  also  in  cases  of  suppuration  within  the  pericardium,  I  believe 
that  pericardiotomy  should  be  performed.  An  inch  or  more  of  the  cartilage 
of  the  fourth  rib  of  the  left  side  should  be  removed  or  2  inches  of  the  fourth 
rib  itself,  and  the  pericardial  sac  should  be  exposed  and,  after  exploratory 
puncture,  formally  incised.  In  this  operation  it  may  be  necessary  to  tie  the 
internal  mammary  artery.  In  pyopericardium  the  pleural  cavity  is  very  seldom 
invaded,  because  the  pleural  space  in  front  of  the  pericardium  has  usually 
been  obliterated  by  the  spread  of  the  inflammation.  The  pericardial  sac  is 
opened  as  directed  above,  is  cleared  of  purulent  material  and  fibrinous  masses 
by  irrigation,  the  edges  of  the  pericardial  wound  are  sutured  to  the  edges  of  the 
superficial  wound,  and  gauze  drainage  is  introduced.  Incision  is  safer  and  more 
certainly  curative  than  aspiration;  for  whereas  aspiration  might  be  curative  in 
pericardial  effusion,  it  cannot  be  so  if  the  effusion  is  purulent.  In  41  cases  of 
purulent  pericarditis  (Roberts's  table  of  35  cases  and  Ljunggren's  6  cases)  oper- 
ated upon,  16  recovered.  Prof.  Ochsner  states  ("Practical  Medicine  Series,"  Vol. 
ii,  1918)  that  out  of  86  operations  41  died  (47.7  per  cent.).  Local  anesthesia  is 
safer  than  general  anesthesia. 

Phlebitis,  or  Inflammation  of  a  Vein. — Acute  Phlebitis. — Phlebi- 
tis may  be  plastic  or  it  may  be  infective.  Plastic  phlebitis,  while  occasion- 
ally due  to  rheumatism,  to  gout,  to  advanced  phthisis,  to  a  febrile  malady, 
or  to  some  other  constitutional  condition,  usually  takes  its  origin  from  a  wound 
or  other  injury,  from  the  extension  to  the  vein  of  a  perivascular  inflammation, 
or,  in  the  portal  region,  from  an  embolus.  Varicose  veins  are  particularly 
liable  to  phlebitis.  When  phlebitis  begins  a  thrombus  usually  forms  (see 
Thrombosis,  page  203)  because  of  the  destruction  of  the  endothelial  coat 
of  the  vessel,  and  this  clot  may  give  rise  to  emboli,  may  be  absorbed,  or  may  be 
organized.  An  aseptic  clot  organizes  and  the  vein  becomes  permanently 
narrowed  or  blocked.  A  septic  clot  is  apt  to  soften  and  break  up.  In  the  lower 
extremities  paraphlebitis  is  common  with  slight  involvement  of  coats,  and  a 
clot  may  not  form.  Clot-formation  causes  edema.  Infective  phlebitis  is  a 
suppurative  inflammation  of  a  vein  arising  by  infection,  perhaps  from  suppu- 
rating perivascular  tissues  {infective  thrombophlebitis) ,  perhaps  from  the  blood- 


Phlebitis  467 

stream  or  in  the  portal  system,  perhaps  from  infective  embolism.  It  is  not 
unusually  met  with  in  cellulitis  or  phlegmonous  erysipelas,  may  arise  in  the 
lateral  sinus  as  a  result  of  mastoid  suppuration,  or  in  the  liver  from  appendi- 
citis or  from  phlebitis  of  the  rectal  veins.  Sometimes  as  the  convalescence  from 
pneumonia  begins,  phlebitis  due  to  pneumococci  arises.  If  a  septic  thrombus 
forms,  the  vein  wall  suppurates,  is  softened  and  in  part  destroyed,  and  the 
infected  clot  softens  and  gives  rise  to  emboli.  No  bleeding  occurs  when  the 
vein  ruptures  or  is  opened,  as  a  barrier  of  clot  keeps  back  the  blood-stream. 
The  clot  of  suppurative  phlebitis  cannot  be  absorbed  and  cannot  organize. 
Septic  phlebitis  causes  pyemia,  and  the  infected  clots  are  disseminated. 

Postoperative  phlebitis  of  the  iliac,  femoral,  or  saphenous  veins  is  not  un- 
commonly the  result  of  a  mild  or  attenuated  infection,  toxins  in  the  blood 
probably  attacking  the  vein.  As  a  rule,  the  toxins  are  non-pyogenic.  It  may 
follow  an  abdominal  operation  when  there  is  no  evidence  of  infection.  Accord- 
ing to  Cordier,  it  occurs  in  2  per  cent,  of  abdominal  operations.  It  is  called, 
as  is  the  like  puerperal  condition,  milk-leg,  or  phlegmasia  alba  dolens.  Nearly 
always  the  femoral  vein  is  the  one  which  suffers.  Strange  to  say,  it  is  most 
apt  to  attack  the  left  iliac,  femoral,  or  saphenous  veins;  it  matters  not  upon 
which  side  the  operation  has  been  performed.  In  over  90  per  cent,  of  cases  the 
left  femoral  or  left  saphenous  veins  are  attacked  (Cordier,  in  "Jour.  Am.  Med. 
Assoc,"  Dec.  9,  1905).  One  theory  regards  the  pressure  of  the  right  common 
iliac  artery  upon  the  left  common  iliac  vein  as  a  predisposing  cause.  Another 
theory  attaches  importance  to  the  pressure  of  a  loaded  sigmoid.  It  is  most 
common  in  anemic  subjects,  especially  when  anemia  results  from  blood  loss. 
It  may  be  due  to  toxins  damaging  the  inner  coat  of  the  vein,  but  feeble  circula- 
tion is  a  powerful  factor  in  its  production.  I  believe,  with  Clark,  that  powerful 
traction  on  the  sides  of  an  abdominal  wound  may  be  responsible  for  it  (see 
Thrombosis  after  Abdominal  Operations,  page  206).  Vanderveer  reported  4 
cases  in  which  sepsis  was  positively  absent  ("American  Medicine,"  July  13, 
1901).  It  occurred  in  the  left  iliac  vein  of  a  woman  on  whom  I  had  oper- 
ated for  carcinoma  of  the  left  breast  six  days  before.  There  was  no  obvious 
infection  of  the  wound,  I  have  seen  it  occur  in  the  left  iliac  vein  after  an  in- 
terval operation  for  appendicitis.  Phlebitis  may  arise  in  the  vein  of  one 
extremity,  a  clot  may  form,  and  this  may  be  absorbed  or  may  organize.  The 
other  extremity  may  be  involved  afterward  or  simultaneously  (horseshoe 
form).  It  may  come  on  seven  or  eight  days  after  operation,  many  days,  or 
several  weeks.  It  usually  is  ushered  in  by  chilly  sensations  or  slight  chiUs 
and  elevated  temperature.  There  is  always  pain  in  the  limb.  The  pain  may 
be  dull  or  acute;  it  is  made  worse  by  motion  and  by  pressure  over  the  involved 
vein.  The  entire  extremity  swells  from  edema.  It  is  probable  that  marked 
edema  signifies  associated  lymphangitis  or  else  an  extensive  clot  running  into 
many  venous  branches.  The  edema  is  seldom  characterized  by  very  distinct 
pitting  on  pressure.  The  skin  is  white  and  looks  stretched  and  shiny.  The 
inguinal  glands  are  usually  enlarged.  Sensation  is  impaired  except  over  the 
vein.  Paresthesia  is  common.  The  involved  veins  feel  like '  cords  to  the 
touch. 

In  mild  cases  the  symptoms  disappear  in  a  few  days.  Severe  cases  continue 
for  several  or  many  weeks  or  even  months.  Involvement  of  the  deep  veins 
causes  prolonged  swelling.     There  is  seldom  any  disposition  to  gangrene. 

In  some  cases  there  is  extensive  muscular  atrophy,  in  some  there  are  trophic 
disturbances,  in  some  muscular  contractures.  Postoperative  phlebitis  is 
sometimes  responsible  for  embolic  pneumonia  and  cerebral  embolism.  Not  a 
few  postoperative  pneumonias  are  due  to  this  cause. 

The  symptoms  of  plastic  phlebitis  are  pain,  tenderness  in  and  around  a 
vein,  discoloration  over  it,  and  edema  below  the  seat  of  the  disease.  Sup- 
purative phlebitis,   besides  these  conditions,  causes  the  constitutional  S5anp- 


468 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


toms  of  pyemia  (see  page  217).  Any  thrombus,  if  it  loosens,  forms  emboli. 
It  is  said  that  the  clot  resulting  from  pneumococcic  phlebitis  forms  so  rapidly 
that  it  adheres  slightly  and  is  peculiarly  apt  to  loosen  and  give  rise  to  emboli 
(Pierre,  in  "Gazette  des  Hopitaux,"  Sept.  3,  1904).  Septic  thrombi  are  apt  to 
cause  septic  pneumonia. 

The  treatment  of  plastic  phlebitis  of  an  extremity  comprises  rest  in  bed  for 
from  four  to  six  weeks,  slight  elevation  of  the  part,  the  use  of  cold  for  the  first 
twenty-four  hours,  and  then  the  application  of  external  heat  and  a  flannel 
bandage.  If  the  patient  is  gouty  or  rheumatic,  appropriate  remedies  should  be 
given.  A  clot  does  not  always  form  in  an  inflamed  vein,  but  if  one  forms  there 
is  danger  of  embolism;  hence  massage  and  both  active  and  passive  movement 

are  dangerous  until  the  clot  becomes  absolutely 
firm.  When  a  vein  is  involved  in  a  sup- 
purative process  and  septic  thrombophlebitis 
exists,  we  should  operate  when  the  situation 
makes  operation  possible.  Ligate  the  vein 
(compress  a  sinus  by  packing)  above  and  below 
the  clot,  open  the  vessel,  and  wash  out  the 
infected  clot,  or,  if  dealing  with  an  accessible 
vein,  extirpate  the  involved  portion.  This 
plan  of  treatment  is  always  to  be  applied 
in  infective  hrombophlebitis  of  the  lateral 
sinus  and  of  the  internal  saphenous  vein. 
The  constitutional  treatment  is  that  of  pyemia. 
Chronic  Phlebitis. — This  rare  condition 
is  known  as  phi  ebo  sclera  sis,  and  it  is  a  chronic 
inflammation  of  the  wall  of  a  vein,  producing 
a  fibrous  change  in  the  vascular  coats.  It  may 
arise  in  a  part  the  seat  of  chronic  venous  en- 
gorgement, but  its  most  frequent  cause  is 
syphilis.  It  is  often  associated  with  arterio- 
sclerosis. 

Varicose  Veins;  Phlebectasis,  Phle= 
bectasia,  or  Varix  (Figs.  217  and  218). — 
Definition  and  Causes. — Varicose  veins  are 
unnatural,  irregular,  and  permanently  dilated 
veins  which  are  elongated  and  pursue  a  tortuous  course.  This  condition  is 
very  common,  and  20  per  cent,  of  adults  exhibit  it  in  some  degree  in  one 
region  or  another.  Some  facts  indicate  hereditary  predisposition.  In  over 
80  per  cent,  of  cases  the  trouble  begins  before  the  age  of  twenty-five.  The 
causes  of  varicose  veins  are  said  to  be  obstruction  to  venous  return  and 
weakness  of  cardiac  action,  which  lessens  the  propulsion  of  the  blood-stream. 
A.  Pearce  Gould  says  obstruction  is  not  a  cause,  because  in  pregnancy  varicose 
veins  may  be  seen  early,  before  the  womb  is  much  enlarged.  The  real  cause  is 
probably  a  predisposition  to  the  growth  of  vein-tissue,  which  leads  to  valve 
failure  and  a  regurgitation  of  blood  from  the  deep  veins  into  the  superficial 
venous  channels  (A.  Pearce  Gould,  in  "Lancet,"  March  i  and  15  and  June  7, 
1Q02).  As  Billroth  said  over  forty  years  ago,  sudden  obstruction  causes 
edema  and  gradual  obstruction  a  free  collateral  circulation.  Neither  sudden  nor 
gradual  obstruction  causes  true  varicosity  unless  the  veins  are  predisposed 
by  a  tendency  hereditary  or  acquired. 

Varicose  veins  may  occur  in  any  portion  of  the  body,  but  are  chiefly  met 
with  on  the  inner  side  of  the  lower  extremity,  in  the  spermatic  cord,  and  in 
the  rectum.  Varix  in  the  leg  is  met  with  most  commonly  during  and  after 
pregnancy  and  in  persons  who  stand  upon  their  feet  for  long  periods  and  in  those 
who  make  great  muscular  effort.     It  can  occur  as  a  result  of  phlebitis.     It  is 


Fig.  217. — Varicose  veins. 


Varicose  Veins;  Phlebectasis,  Phlebectasia,  or  VarLx 


469 


especially  common  in  the  long  saphenous  vein,  which,  being  subcutaneous, 
has  no  muscular  aid  in  supporting  the  blood-column  and  in  urging  it  on.  The 
deep  as  well  as  the  superficial  veins  may  become  varicose.  Verneuil  maintained 
that  varix  of  the  superficial  veins  is  almost  always  secondary  to  varix  of  the 
deep  veins,  a  radical  view  which  seems  improbable.  The  deep  veins  are  seldom 
varicose.  It  is  certain,  however,  that  after  contusions  of  the  leg  it  is  not  very 
unusual  for  the  deep  veins  to  become  filled  with  clot  and  for  the  superficial  veins 
to  dilate  notably.  The  veins  which  join  the  deep  veins  to  the  superficial  veins 
may  become  varicose  and  incompetent,  they  are  particularly  apt  to  after  phle- 
bitis. If  they  do  become  incompetent  blood  will  flow  from  the  deep  veins  into 
the  superficial  veins  instead  of  as  normally  in  the  other  direction.  By  the  term 
^^ caput  medusa''  is  meant  dilated  veins  radiating  from  the  umbilicus.  The 
veins  of  the  esophagus  may  become  varicose,  and  this  malady  is  commonly  un- 
recognized clinically.  Vari- 
cose veins  are  in  rare  in-  |T~ 
stances  congenital,  but  they 
are  most  often  seen  in  the 
aged,  and  usually  are  first 
observed  between  the  ages  of 
twenty  and  forty.  They  are 
more  common  in  women  than 
in  men,  owing,  it  is  believed, 
to  the  influence  of  pregnancy. 
Varix  of  the  spermatic 
cord  is  known  as  varicocele. 
It  is  apt  to  appear  about  the 
time  of  puberty,  and  most 
adult  men  have  at  least  a 
slight  varicocele.  Varix  is 
more  likely  to  appear  in  the 
left  spermatic  vein  than  in 
the  vein  of  the  right  side, 
because  the  left  spermatic 
vein  has  no  valves  (see  page 

1549^- 

Varicose  tumors  of  the 
rectum  constitute  hemor- 
rhoids or  piles.  Piles  are 
caused  by  obstruction  to  the 
upward  flow  in  the  hem- 
orrhoidal veins,  either  by  obstructive  liver  disease,  enlargement  of  the  uterus 
or  prostate,  or  the  presence  in  the  rectum  of  fecal  masses  in  a  person  habituall}' 
constipated  (see  page  13 16). 

K  vein  under  pressure  may  dilate  more  at  one  spot  than  at  another,  the 
distention  being  greatest  back  of  a  valve  or  near  the  mouth  of  a  tributary. 
The  valves  become  incompetent  and  the  dilatation  becomes  still  greater. 
Callender  has  pointed  out  that  varix  of  the  lower  extremity  is  apt  to  begin 
where  the  deep  vessels  join  the  superficial  veins.  At  this  point  Treves  says 
three  forces  meet :  the  blood  column  above,  the  valve  below,  and  the  force  of  the 
blood-current.  At  the  spot  where  the  pressure  is  greatest  the  vein  wall  dilates, 
and  from  this  dilatation  the  blood-current  is  deflected  and  causes  another  dila- 
tation higher  up  and  on  the  opposite  side  of  the  vessel.  The  blood  is  again 
deflected  and  causes  another  dilatation,  and  so  on.  The  vein  waU  may 
become  fibrous,  but  usually  it  is  thin  and  sometimes  it  ruptures.  _  The  veins 
not  only  dilate,  but  they  also  become  longer,  and  hence  do  not  remain  straight, 
but  tvasi  and  assume  a  characteristic  form.     It  seems  probable  that  the  first 


■iG.   21S. — \'aricose  veins. 


470  Diseases  and   Injuries  of  the  Heart  and  Vessels 

step  in  the  process  is  a  growth  of  new  venous  tissue  (A.  Pearce  Gould),  and 
then  follow  lengthening,  tortuosity,  incompetence  of  the  valves,  and  dilatation 
of  the  vessel. 

Delbet^  points  out  that  varicose  veins  of  the  leg,  which  begin  in  the  thigh, 
result  from  valvular  incompetence.  Varicose  ulcers  arise  from  variations  of 
venous  pressure  due  to  valvular  incompetence.  The  incompetence  of  the  valves 
does  harm  by  allowing  the  intravenous  pressure  to  equal  the  pressure  in  the 
arterioles,  a  condition  which  arrests  capillary  circulation,  causes  congestion, 
and  greatly  lowers  tissue  resistance.  Incompetent  valves  also  favor  ulceration 
by  developing  a  vicious  venous  circle,  first  described  by  Trendelenburg.  Blood 
passing  through  this  circle  loses  nutritive  elements.  Trendelenburg  has 
described  the  vicious  circle  as  follows:  Blood  in  the  saphenous  vein  flows 
toward  the  periphery  instead  of  toward  the  center,  because  of  incompetent 
valves — it  passes  into  the  veins  which  connect  the  superficial  veins  with  the 
deep  veins  and  then  enters  the  tibial  and  peroneal  veins.  It  passes  from  the 
tibial  and  peroneal  into  the  popliteal  and  femoral  veins,  and  some  blood  leaves 
the  femoral  vein  and  again  enters  the  saphenous. 

The  skin  over  varicose  veins  in  the  leg  is  often  discolored  by  pigmenta- 
tion due  to  red  blood-cells  having  escaped  from  the  vessel  and  broken  up. 
The  tissues  around  a  varicose  vein  become  atrophied  from  pressure,  and  it 
is  not  unusual  to  meet  with  a  very  large  vein  whose  thin  walls  are  in  close 
contact  with  skin.  In  this  condition  rupture  and  hemorrhage  are  probable. 
When  the  vein  wall  forms  a  pouch-like  dilatation  the  condition  is  spoken  of 
as  a  vein  cyst.  Varicose  veins  are  apt  to  inflame,  and  thrombosis  frequently 
occurs.  When  a  thrombus  forms,  emboli  may  be  broken  ofif  and  carried  into 
the  circulation,  especially  if  the  patient  walks  about.  The  formation  of  emboli 
is  not  nearly  so  common  as  a  result  of  thrombosis  in  a  varicose  vein  as  in  throm- 
bosis in  an  undistended  and  unelongated  vessel.  In  varicose  veins  of  the  thigh, 
however,  the  chance  of  embolism  following  thrombosis  is  much  greater  than 
when  the  veins  of  the  leg  alone  are  involved.  In  some  elderly  people  thrombus 
actually  effects  spontaneous  cure.  When  a  thrombus  organizes,  more  or  less 
calcification  is  apt  to  ensue,  and  a  vein-stone  or  phlebolith  is  formed.  After 
middle  life  many  varicosities  remain  stationary  or  cease  to  give  trouble.  The 
chief  complications  of  varicose  veins  of  an  extremity  are  thrombosis,  edema, 
violent  hemorrhage  from  rupture,  phlebitis,  eczema,  and  chronic  ulceration. 

Treatment  of  Varix  of  the  Lower  Extremity. — The  treatment  of  varix 
of  the  leg  may  be  palliative  or  curative,  but  whichever  plan  is  followed,  the 
surgeon  should  endeavor  first  of  all  to  remove  the  exciting  cause.  An  essen- 
tial part  of  palliative  treatment  is  to  attend  to  the  general  health,  to  keep  up 
the  force  and  activity  of  the  circulation,  and  to  prevent  constipation.  Mas- 
sage is  useful,  especially  alcohol  frictions,  if  eczema  is  absent.  Cold  baths  are 
always  forbidden  (Bennett).  The  patient  should  exercise  regularly  in  the 
open  air  and  should  he  down  for  a  time,  if  possible,  every  afternoon.  Instead 
of  lying  down  for  a  time  during  each  day,  he  may  sit  down  and  elevate  his  legs, 
resting  them  on  a  table,  and  thus  assuming  a  position  supposed  to  be  peculiarly 
American.  If  there  is  no  pain,  distinct  discomfort,  or  edematous  swelling,  a 
support  is  unnecessary,  but  if  these  conditions  exist  it  is  needed.  If  a  support 
is  required  in  varix  of  the  leg,  use  a  flannel  roller  or  a  perforated  rubber  bandage 
applied  over  a  long  stocking.  Such  a  bandage  supports  the  veins  and  drives 
the  blood  into  the  deeper  vessels,  which  have  muscular  support.  The  use  of  a 
rubber  pad  filled  with  glycerin  and  appHed  over  the  saphenous  vein,  so  as  to 
support  the  blood  column  and  act  as  a  valve,  has  been  recommended.  A 
purely  local  varix  should  be  excised,  because  there  is  always  danger  of  injury, 
and  consequently  of  hemorrhage  or  thrombosis.  If  the  superficial  veins  have 
dilated  because  of  thrombosis  of  the  deep  veins  and  edema  exists,  ligation  or 
1  Delbet,  "Sem.  med.,"  Oct.  13,  1807. 


Acute  Arteritis  471 

excision  is  contra-indicated,  as  its  performance  might  lead  to  permanent  edema. 
If  an  elastic  bandage  worn  for  one  week  gives  comfort  we  may  conclude  that  the 
deep  veins  are  competent  (the  Mayo  Clinic).  Very  marked  capillary  dilata- 
tions about  the  inner  malleolus  strongly  suggest  that  the  deep  veins  are  in- 
competent. If  the  disease  involves  the  leg  only,  operative  treatment  is  rarely 
required  and  may  even  do  harm.  Such  cases  are  operated  upon  if  there  are 
cyst-like  dilatations,  if  thrombi  form,  and,  as  Bennett  points  out,  if  a  thin- 
walled  vein  crosses  the  tibia,  and  is  thus  exposed  to  the  danger  of  injury  and 
thrombosis.^ 

If  the  leg  is  involved  in  the  process,  and  the  saphena  in  the  thigh  is  also 
varicose,  operation  should  be  performed. 

If  a  thrombus  forms  in  a  superficial  varicose  vein,  tie  the  vein  above  and 
below  the  clot,  divide  the  vessel  in  two  places,  and  remove  the  vein  and  the 
clot  within  it.  Thrombosis  of  a  varicose  vein  is  not  so  apt  to  lead  to  emboli 
as  thrombosis  in  a  non-varicose  vein,  but  it  may  do  so,  and  the  condition  has 
some  elements  of  danger. 

If  edema  is  marked,  and  increases  in  spite  of  properly  applied  bandages, 
etc.,  it  probably  signifies  clot-formation,  and  the  patient  should  remain  in 
bed  until  this  question  is  determined.  Hemorrhage  from  a  ruptured  varicose 
vein  qf  an  extremity  is  usually  readily  arrested  by  compression  and  elevation. 

The  radical  treatment  of  varix  of  the  leg  often  does  good,  often  relieves 
some  annoying  condition,  but  rarely  absolutely  cures  ( W.  H.  Bennett) .  There 
are  several  methods  of  operation.     (See  Operations  Upon  Vessels.) 

Nevus. — (See  Tumors.) 

Arteritis,  or  inflammation  of  an  artery,  may  be  acute  or  chronic. 

Acute  Arteritis, — Slight  inflammation  is  by  no  means  unusual,  but  severe 
arteritis  is  decidedly  rare.  It  may  follow  direct  injury  or  arise  secondarily 
to  a  perivascular  inflammation.  An  artery  is  very  resistant  to  the  spread 
of  inflammation,  but  we  sometimes  encounter  suppurative  arteritis  in  a  suppu- 
rating area.  Arteritis  may  arise  in  the  course  of  an  infective  malady,  being  pro- 
duced by  bacteria,  but  it  is  also  found  in  intoxications,  and  is  then  due  purely 
to  toxins.  It  may  occur  in  the  eruptive  fevers,  influenza,  typhoid  fever, 
acute  rheumatism,  gout,  syphilis,  diphtheria,  septicemia,  and  septic  intoxica- 
tion. Ford  points  out  that  acute  arteritis  developing  during  acute  or  chronic 
infections  is  particularly  apt  to  arise  in  the  lower  extremities  (Ford,  "These 
de  Paris,"  1901).  Toxins  or  bacteria  usually  reach  the  artery  in  the  main 
blood-stream,  but  may  be  lodged  in  the  vessel  wall  by  the  lymph  or  the  flow 
in  the  Vasa  vasorum.  The  inner  coat  of  a  portion  of  an  artery  becomes  lined 
with  inflammatory  exudate  and  the  coats  are  infiltrated  with  small  cells. 
Often  parietal  thrombi  form.  Sometimes,  though  rarely,  the  vessel  is  com- 
pletely blocked  by  thrombosis.  In  acute  suppurative  arteritis  pus  accumulates 
in  the  arterial  wall,  a  clot  forms  in  the  lumen,  and  the  coats  of  the  vessel  undergo 
necrosis  and  give  way.  Violent  hemorrhage  may  thus  arise,  but  often,  in 
thrombo-arteritis  as  in  thrombophlebitis,  rupture  does  not  cause  hemorrhage. 
Acute  arteritis,  if  non-bacterial  in  origin,  is  usually  recovered  from  with  slight 
structural  change.  Infective  arteritis  is  recovered  from  if  the  causative  germ 
is  not  very  virulent  or  if  the  toxin  is  not  present  in  excessive  quantity.  Acute 
arteritis  may  terminate  in  arterial  obstruction  with  or  without  gangrene, 
permanent  dilatation,  arterial  rupture,  .or  chronic  arteritis. 

The  symptoms  may  be  merged  with  those  of  an  acute  or  chronic  intoxica- 
tion or  infection,  or  with  those  of  a  local  perivascular  inflammation.  In 
arteritis  arising  during  infections  the  symptoms  appear  abruptly  and  the 
onset  is  marked  by  great  pain.  Ford  studied  18  cases  in  influenza.  He 
says  it  attacks  particularly  persons  over  thirty  years  of  age,  occurs  in  one 
leg  or  both,  arises  most  commonly  during  convalescence,  but  may  not  begin 
^W.  H.  Bennett,  "Lancet,"  Oct.  15,  1898. 


472  Diseases  and  Injuries  of  the  Heart  and  Vessels 

until  the  individual  is  apparently  well.  There  arc  pain  and  tenderness  over  the 
vessels,  low  surface  temperature,  paresthesia,  and  mottled  skin  (Ford,  "These 
de  Paris,"  1901).  The  artery  may  be  obstructed,  and  if  a  large  vessel  is  blocked, 
the  pulse  below"  the  clot  is  lost.  The  block  may  be  temporary  or  persistent. 
Gangrene  rnay  follow.  Ford  points  out  that  if  the  artery  only  is  blocked, 
the  gangrene  is  dry;  but  if  the  vein  also  is  occluded  it  may  be  moist.  I  have 
seen  2  cases  of  dry  gangrene  following  influenza. 

Treatment. — Probably  the  wisest  plan  if  a  large  vessel  is  involved  is  to  open 
the  vessel  and  remove  the  clot.  If  this  is  refused  the  surgeon  must  adopt  a 
conservative  plan.  Secure  rest  in  bed;  elevate  the  extremity  slightly,  relax  it, 
smear  the  skin  over  the  inflamed  vessel  with  ichthyol  ointment  or  mercurial 
ointment,  or  follow  Ford's  advice  and  use  methyl  salicylate  or  an  ointment 
of  salicylic  acid,  turpentine,  and  belladonna.  Wrap  the  part  in  cotton  and 
surround  it  with  bottles  or  bags  filled  with  warm  water.  If  a  patient  is  very 
restless,  a  splint  must  be  used.  It  may  be  necessary  to  give  morphin  for  pain, 
and  any  infection  or  toxemia  must  be  combated  with  appropriate  remedies. 

If  gout,  rheumatism,  or  syphilis  is  regarded  as  causative,  proper  remedies 
must  be  given.  It  is  most  important  to  maintain  the  secretion  of  the  kidneys. 
If  abscesses  form  in  a  septic  case,  they  must  be  opened  and  drained.  If  a 
large  artery  of  one  of  the  lower  extremities  becomes  occluded,  raise  the  foot 
about  2  inches  from  the  bed,  wrap  the  foot  and  leg  in  cotton-wool,  apply  a 
flannel  bandage  from  the  toes  up,  and  surround  the  limb  with  bags  of  warm 
- — not  hot — water.  Hot  water  would  take  more  blood  to  the  region  of  the 
block  than  could  be  distributed.     If  gangrene  occurs,  amputation  is  necessary. 

Chronic  Endarteritis  (Arteriosclerosis,  Atheroma,  Arteriocapillary  Fibrosis, 
Cardiovascular  Degeneration). — By  these  terms  we  mean  thickening  of  the 
walls  of  the  arteries,  Hmited  in  area  or  widespread ,  due  to  inflamrnation  or 
degeneration  of  the  middle  coat,  the  media  undergoing  hypertrophy  and  the 
intima  fibrous  hyperplasia  (Wm.  Russell,  "Brit.  Med.  Jour.,"  June  4,  1904). 
Atheroma  is  used  to  designate  the  disease  when  it  attacks  the  large  vessels 
and  is  characterized  by  advanced  degeneration.  Chronic  endarteritis  is  due  to 
increase  of  blood-pressure.  Hypertension  precedes  sclerosis  and  causes  it. 
Hypertension  is  -detected  and  measured  by  the  sphygmomanometer.  Increase 
of  blood-pressue  means  increase  of  arterial  tension,  because  the  lumen  of  the 
vessels  is  lessened  and  the  heart  works  more  strongly  to  urge  the  blood  along, 
and  finally  hypertrophy  of  the  middle  coat  occurs.  The  persistence  of  arterial 
contraction  which  causes  increase  of  blood-pressure  may  be  brought  about  by 
kidney  disease,  hard  work,  violent  strains,  heart  disease,  care  and  anxiety, 
worry  and  mental  strain,  alcoholic  or  venereal  excesses,  habitual  gluttony, 
syphilis,  gout,  rheumatism,  lead-poisoning,  diabetes,  and  acute  infections  like 
typhoid  fever  and  influenza.  It  may  arise  in  an  old  man  who  has  not  suffered 
particularly  from  any  of  the  above-named  causes,  or  may  occur  prematurely 
from  toxemia  or  heredity.  It  is  a  true  saying  of  Cazalis  that  "A  man  is  as  old 
as  his  arteries,"  and  a  young  man  debilitated  by  syphilitic  disease  or  alcohol 
may  have  diseased  arteries,  and  hence  be  really  older  than  a  healthy  man  of 
sixty.  Heredity  may  be  commonly  traced  in  heart  disease  due  to  diseased 
coronary  arteries,  and  cerebral  hemorrhage  due  to  disease  of  the  middle  cerebral 
arteries.  The  aorta,  of  all  vessels,  is  most  prone  to  suffer.  The  large  vessels 
are  more  apt  to  be  diseased  than  the  small,  but  even  the  arterioles  can  be 
involved.  The  arteries  of  the  stomach,  liver,  and  mesentery  are  rarelv  sclerotic. 
In  arteriosclerosis  connective  tissue  is  substituted  for  the  normal  elements 
of  the  vascular  wall,  and  this  tissue  undergoes  hyperplasia  and  subsecjuent 
contraction  and  induration.  If  the  mass  of  proliferating  fibroblasts  undergoes 
fatty  degeneration,  atheroma  is  said  to  exist,  and  an  atheromatous  vessel  may 
be  calcified  by  deposition  of  lime-salts.  When  fatty  degeneration  occurs  the 
endothelium  is  destroyed,  the  vessel  wall  is  damaged,  and  the  blood  may  obtain 


Aneurysm  473. 

access   to   the   deeper  coats.     Atheroma  is  a  frequent  cause  of   thrombosis, 
aneurysm,  senile  gangrene,  and  apoplexy. 

A  sclerosed  artery  is  rigid,  non-contractile,  and  inelastic,  and  the  parts  it 
supphes  are  cold,  congested  and  ill  nourished,  and  often  edematous.  When 
the  caliber  of  arteries  remains  narrowed  because  of  persistent  contraction 
or  of  arteriosclerosis  there  is  marked  accentuation  of  the  second  aortic  sound. 
The  valve  or  door  which  opened  during  systole  is  slammed  shut  during  diastole 
by  the  peripheral  resistance.  The  heart  is  obHged  to  overwork  and  in  conse- 
quence undergoes  hypertrophy.  The  hypertrophied  heart  finally  dilates.  If  a 
hypertrophied  heart  exists  with  diseased  arteries,  apoplexy  or  aneurysm  is 
apt  to  occur  (Nammack,  "Med.  Record,"  Oct.  26,  1901).  SyphiHtic  arteritis 
is  characterized  by  an  enormous  growth  of  granulation  tissue  from  the  inner 
coats  of  arteries  of  small  size  {obliterative  endarteritis).  Calcification  of  an 
artery  may  be  secondary  to  fatty  change,  or  may  occur  primarily  from  de- 
posit of  lime-salts  in  the  middle  coat.  Periarteritis  is  inflammation  of  the 
sheath  and  outer  coat.  An  acute  arteritis  is  always  local,  but  a  chronic  arteritis 
may  be  general.  If  obhterative  endarteritis  exists  in  a  limb,  the  veins  are 
almost  certain  to  be  involved  as  well  as  the  arteries.  For  this  condition  of 
veins  and  arteries,  Buerger  suggests  the  term  "  thrombo-angiitis  obKterans" 
(see  page  177). 

Treatment. — In  treating  chronic  arteritis,  endeavor  to  antagonize  the  dan- 
gers to  which  the  patient  is  obviously  liable.  Forbid  alcohol  as  a  beverage, 
though  a  Uttle  whisky  may  be  taken  at  meals.  Maintain  the  activity  of  the  , 
skin  by  daily  baths,  and  of  the  kidneys  by  diuretic  waters.  A  daily  bowel 
movement  should  be  secured.  The  diet  is  to  be  plain  and  is  to  contain  a 
minimum  of  nitrogen.  If  syphilis  has  existed,  occasional  courses  of  iodid  of 
potassium  are  to  be  given.  If  the  arterial  tension  at  any  time  becomes^  in- 
ordinately high,  administer  nitroglycerin.  One  danger  to  which  the  patient 
is  liable  is  apoplexy,  hence  excitement  and  violent  exercise  are  to  be  avoided. 
Another  danger  is  senile  gangrene;  hence  the  patient  should  wear  woolen 
stockings,  put  a  bottle  or  bag  of  warm  water  to  his  feet  at  night,  and  be  careful 
to  avoid  injuring  his  toes  or  feet,  especially  when  cutting  his  corns.  A  bag 
of  very  warm  water  is  dangerous  and  may  actually  excite  gangrene.  When  a. 
patient  with  atheroma  has  dyspnea  and  is  of  a  livid  color,  or  when  the  arterial 
tension  is  very  high,  a  moderate  blood-letting  (16  to  18  oz.)  does  good,  and 
may  prevent  or  arrest  edema  of  the  lungs.  Still  another  danger  is  aneurysm, 
which  may  appear  suddenly  from  rupture  or  gradually  from  progressive, 
distention. 

It  has  been  suggested  that  endarteritis  threatening  gangrene  of  the  foot 
should  be  treated  by  an  anastomosis  between  the  common  femoral  artery 
and  the  femoral  vein,  in  order  that  the  blood  may  be  directed  from  blocked 
to  open  channels,  and  hence  may  still  nourish  the  extremity.  The  operation 
is  only  to  be  advised  when  pulsation  is  absent  in  the  tibials,  when  the  femoral 
high  up  seems  normal,  and  when  the  deep  veins  are  patent  (see  page  202). 

Buerger  suggests  the  following  test  of  the  patency  of  the  deep  veins  ("Jour. 
Am.  Med.  Assoc,"  April  24,  1909):  "I  allow  the  Hmb  to  hang,  watch  for 
the  advent  of  the  erythema,  and  wait  until  a  fair  degree  of  cyanosis  has  be- 
come estabhshed.  This  may  take  considerable  time- — five  to  ten  minutes. 
The  veins  are  then  obliterated  above  the  knee  by  means  of  a  Martin  bandage 
properly  appHed.  The  limb  is  then  raised  high  and  the  bandage  loosened 
just  enough  so  as  to  remove  pressure  from  the  deep,  but  not  from  the  super- 
ficial, veins.  If  the  cyanosis  is  slow  in  disappearing  or  fails  to  disappear,  it 
may  be  concluded  that  the  function  of  the  deep  veins  is  impaired." 

An  aneurysm  is  a  pulsating  sac  containing  blood  and  communicating 
with  the  cavity  of  an  artery,  and  formed  partly  or  entirely  by  the  arterial 
walls  or  is  a  fusiform  dilatation  of  an  artery.     Some  restrict  the  term  "true 


474  Diseases  and  Injuries  of  the  Heart  and  Vessels 

aneurysm"  to  a  condition  of  dilatation  involving  all  the  coats  of  the  vessel. 
We  shall  consider,  with  Heath,  a  Irue  aneurysm  to  be  one  in  which  the  blood 
is  included  in  one  or  more  of  the  arterial  coats,  and  3.  false  aneurysm  to  be  a  con- 
dition in  which  the  vessel  has  been  wounded,  has  ruptured  or  has  atrophied  and 
the  aneurysmal  wall  is  formed  by  a  condensation  of  the  perivascular  tissues. 
Forms  of  Aneurysm. — The  following  forms  of  aneurysm  are  recognized: 

1.  True  aneurysm — one  whose  sac  is  formed  of  one  or  more  arterial  coats. 

2.  False  aneurysm — one  whose  sac  is  formed  of  condensed  perivascular 
tissues  and  contains  no  arterial  coat. 

5.  Traumatic  diffused  aneurysm — a  false  aneurysm  due  to  a  wound  or 
traumatic  rupture  of  a  blood-vessel.  At  first  the  blood  is  widely  diffused  and 
unlimited  by  any  sac  or  capsule,  later  a  limitation  or  encapsulation  may  occur 
by  the  condensation  of  tissue,  any  wound  being  healed.  A  traumatic  diffuse 
aneurysm  may  follow  a  puncture  or  an  incised  wound  of  an  artery,  the  injury- 
causing  the  aneurysm  directly.  It  may  follow  an  effort  or  a  strain,  the  injury 
indirectly  causing  the  aneurysm  by  acting  on  a  diseased  vessel.  As  Bar  well 
says,  the  term  ''traumatic  diffused  aneurysm"  is  an  extremely  bad  one,  as  the 
term  "aneurysm"  conveys  the  idea  of  some  sort  of  a  sac.  In  this  condition 
there  is  no  true  sac  and  blood  is  either  unlimited  or  limited  by  condensed 
tissue  only. 

4.  Diffused  aneurysm — a  term  used  to  mean  a  ruptured  aneurysm,  the 
blood  being  diffused  in  the  tissues  and  either  unUmited  or  limited  by  condensed 
tissue  only.  The  term  should  be  limited  to  conditions  in  which  the  effusion 
of  blood  is  slow  and  trivial.  If  the  effusion  is  large  and  rapid,  the  term  rup- 
tured aneurysm  is  preferable. 

5.  Consecutive  aneurysm  results  from  the  rapid  growth  of  a  sacculated 
aneurysm.  At  a  certain  portion  of  the  sac  of  a  true  aneurysm  the  arterial  coats 
give  way  completely,  and  at  this  point  blood  is  hmited  only  by  clot  and  by 
condensed  perivascular  tissue.  The  blood  is  not  diffused,  but  is  encapsuled, 
partly  by  the  old  sac,  partly  by  condensed  tissues,  aided  it  may  be  by  bone 
and  fascia. 

6.  Ftisiform  or  tubulated  aneurysm — a  variety  of  true  aneurysm,  the  sac 
being  spindle-shaped  and  formed,  as  Matas  states,  "at  the  expense  of  the 
artery,"  the  artery  dilates,  the  continuity  of  the  parent  artery  is  interrupted 
for  a  variable  length,  and  is  lost  in  the  sac,  to  be  restored  once  more  as  a  normal 
vessel  at  the  outlet  of  the  aneurysm  ("Transactions  of  Am.  Surg.  Assoc," 
1905).  Such  an  aneurysm  has,  of  course,  two  openings.  This  form,  accord- 
ing to  Matas,  comprises  66.6  per  cent,  of  all  aneurysms. 

7.  Sacculated  aneurysm — a  common  form  of  aneurysm,  in  which  the 
dilatation  is  Hke  a  pouch,  arising  from  a  part  of  the  arterial  circumference 
and  joining  the  lumen  of  the  vessel  by  a  single  aperture.  As  Matas  points 
out,  the  parent  artery  is  involved  in  but  a  portion  of  its  circumference,  the  con- 
tinuity of  the  vessel' is  not  lost,  the  arterial  caliber  is  maintained  at  a  nearly 
normal  diameter,  and  "the  sac  is  simply  grafted  or  attached  to  the  arteryby  a 
narrow  neck,  forming  a  sort  of  diverticulum  of  variable  shape  and  dimensions" 
("Proceedings  of  Am.  Surg.  Assoc,"  1905).  Such  a  sac  has  but  one  orifice. 
The  opening  from  the  artery  into  the  sac  is  called  the  motith;  around  and  just 
above  the  mouth  is  the  neck;  the  balance  of  the  sac  is  much  larger  than  the 
neck  and  is  called  the  body.  A  sacculated  aneurysm  may  arise  from  an  artery 
of  normal  size,  from  a- dilated  artery,  or  from  a  fusiform  aneurysm.  A  sac- 
culated aneurysm  of  unknowTi  cause  is  called  a  spontaneous  aneurysm;  one 
which  is  due  to  injury  is  called  a  traumatic  aneurysm.  _  The  first  step  in  the 
formation  of  a  sacculated  aneurysm  is  stretching  or  giving  way  of  an  area 
of  the  middle  coat  (media),  followed  by  a  gradually  advancing  stretching  and 
dilatation  of  corresponding  areas  of  the  outer  coat  (adventitia)  and  the  inner 
coat  fintima). 


Forms  of  Aneurysm  475 

8.  Dissecting  aneurysm  (Shekelton's  aneurysm) — a  pouch-like  dilatation  of 
an'artery  due  to  the  blood-stream,  which  has  gained  access  to  the  middle  coat 
through  an  atheromatous  ulcer  or  a  minute  rupture  of  the  inner  coat.  It  used  to 
be  taught  that  the  blood  flows  between  the  media  and  adventitia;  we  now  know 
that  it  flows  between  the  layers  of  the  middle  coat.  The  outer  wall  of  the  aneu- 
rysm consists  of  adventitia  and  a  portion  of  the  middle  coat.  The  unnatural 
channel  may  or  may  not  join  the  lumen  of  the  artery  at  another  point  by  a 
fresh  aperture  in  the  intima.  Practically,  the  dissecting  aneurysm  is  met  with 
in  the  aorta  only.  It  is  most  common  in  the  thoracic  aorta.  About  80  cases 
have  been  reported.^ 

9.  Arteriovenous  aneurysm,  which  is  divided  into  aneurysmal  varix,  or 
Pott's  aneurysm,  when  there  is  direct  communication  between  a  vein  and  an 
artery;  and  varicose  aneurysm,  when  there  is  communication  between  an  artery 
and  a  vein  by  means  of  an  interposed  sac. 

10.  Acute  aneurysm — a  cavity  in  the  walls  of  the  heart,  which  communicates 
with  the  interior  of  this  organ,  and  which  is  due  to  suppuration  in  the  course 
of  acute  endocarditis  or  myocarditis. 

11.  Aneurysm  by  Anastomosis. — (See  Angiomata.) 

12.  Aneurysm  of  bone — an  inaccurate  clinical  term  used  to  designate  a 
pulsatile  tumor  of  bone. 

13.  Circumscribed  aneurysm — when  the  blood  is  circumscribed  by  distinct 
walls. 

14.  Cirsoid  aneurysm — a  mass  of  dilated  and  elongated  arteries  shaped 
like  varicose  veins  and  pulsating  with  each  heart-beat. 

15.  Cylindrical  aneurysm — a  dilatation  which  maintains  the  same  dimen- 
sions for  a  considerable  space. 

16.  Embolic  or  capillary  aneurysm — dilatation  of  terminal  arteries  due  to 
emboH. 

17.  Spontaneous  aneurysm — non-traumatic  in  origin. 

18.  Miliary  aneurysm — a  minute  dilatation  of  an  arteriole. 

19.  Secondary  aneurysm — one  which,  after  apparent  cure,  again  pulsates, 
the  blood  entering  by  means  of  the  anastomotic  circulation. 

20.  Verminous  aneurysm — one  containing  a  parasite.  This  form  of  aneu- 
rysm is  met  with  in  the  mesenteric  artery  of  the  horse. 

21.  Bilateral  aneurysm — aneurysms  of  two  corresponding  arteries  are  very 
rare.  In  120  subclavian  aneurysms  two-thirds  were  of  the  right  side  and 
"in  only  two  instances  were  the  lesions  bilateral"  (Lothrop,  in  "Boston  Med. 
and  Surg.  Jour.,"  April  10,  1913). 

The  sac  of  a  sacculated  aneurysm  is  at  first  composed  of  at  least  two  of  the 
arterial  coats,  reinforced  by  the  sheath  and  perivascular  tissues.  After  a 
time  the  blood-pressiu-e  distends  the  sac,  and  the  inner  and  middle  coats  either 
stretch  with  interstitial  growth  or — what  is  more  common — are  worn  away 
and  lost.  When  all  the  coats  are  lost  and  the  blood  is  sustained  only  by 
the  sheath  and  surrounding  tissue,  a  true  aneurysm  becomes  a  false  or  con- 
secutive aneurysm,  the  limiting  tissues  and  sheath  being  condensed,  thick- 
ened, and  glued  together.  This  limiting  process  is  deficient  in  the  brain, 
.hence  cerebral  aneurysms  break  soon  after  their  formation.  When  all  the 
arterial  coats  are  lost,  the  blood-pressure,  acting  on  the  tissues,  finds  some 
spots  less  resistant  than  others,  the  blood  follows  the  lines  of  least  resistance, 
the  aneurysm  grows  with  great  rapidity,  and  soon  ruptures  externally  or  into 
a  cavity. 

An  aneurysm  may  rupture  into  a  cavity  (pleural,  pericardial,  or  peritoneal), 

into  the  perivascular  tissues,  or  through  the  skin.     Rupture  into  the  tissues 

may  produce  pressure-gangrene.     When  rupture  occurs  through  the  skin  the 

hemorrhage  is  not  often  instantly  fatal,  but  during  several  days  recurs  again 

1  Coleman,  in  "Dublin  Jour.  Med.  Sciences,"  Aug.,  1898. 


476  Diseases  and  Injuries  of  the  Heart  and  Vessels 

and  again  in  larger  and  larger  amounts.  The  pressure  of  an  aneurysm  causes 
atrophy  of  tissues,  hard  and  soft,  bones  and  cartilages  being  as  easily  destroyed 
as  muscles  and  fat.  Sometimes  the  ])erivascular  tissues  inflame  and  suppurate, 
and  the  sac  is  opened  rapidly  by  sloughing.  An  aneurysm  usually  progresses 
toward  rupture,  the  slowest  in  this  progression  being  the  fusiform  dilatation, 
which  may  exist  for  many  years,  but  which  finally  is  converted  into  the  sac- 
culated variety. 

In  some  rare  instances  there  takes  place  spontaneous  cure,  which  may 
result  from  laminated  fibrin  being  deposited  upon  the  walls  of  the  sac  as  the 
blood  circulates  through  it.  The  laminated  fibrin  is  known  as  an  "active 
clot,"  and  eventually  fiUs  the  sac.  The  weaker  and  slower  the  blood-stream, 
the  greater  is  the  tendency  to  the  formation  of  an  active  clot,  hence  any  agent 
impeding,  but  not  aboUshing,  the  circulation  aids  in  the  deposition.  The 
weakening  and  slowing  of  circulation  may  be  brought  about  by  great  activity 
of  the  collateral  circulation  diverting  most  of  the  blood  from  the  area  of  dis- 
ease. Sometimes  a  clot  breaks  off  from  the  sac  wall  and  plugs  the  artery 
beyond  the  aneurysm,  and  the  anastomotic  vessels,  enlarging,  divert  the 
blood-stream.  A  large  aneurysm,  falling  over  by  its  own  weight  upon  the 
vessel  above  the  mouth  of  the  sac,  may,  in  very  unusual  cases,  diminish  the 
blood-stream.  The  development  of  another  aneurysm  upon  the  same  vessel 
nearer  to  the  heart  weakens  the  circulation  in  and  may  cure  the  older  one. 
Inflammation  occasionally  forms  a  clot.  I  saw  an  aneurysm  of  the  subclavian 
undergo  spontaneous  cure  from  clot  formation  in  the  brachial  which  gradually 
extended  up  until  the  aneurysm  became  blocked.  The  brachial  clot  was  ap- 
parently due  to  embolism.  The  tissues  about  an  aneurysm  tend  to  contract 
when  arterial  force  is  lessened,  hence  tissue-pressure  may  more  than  counteract 
blood-pressui-e  when  the  circulation  is  feeble.  Clotting  of  the  blood  contained 
within  a  sac,  circulation  through  the  aneurysm  having  ceased,  causes  a  "pas- 
sive clot."  A  passive  clot,  which  occasionally  induces  cure,  may  arise  from 
a  twist  of  the  neck  of  the  sac  preventing  the  passage  of  blood,  from  the  lodg- 
ment of  a  clot  in  the  mouth  of  the  sac,  and  from  inflammation.  Spontaneous 
cure  is,  unfortunately,  very  rare. 

Causes  of  Aneurysm. — Gradual  distention  of  arterial  coats  which  are  in 
a  condition  of  arterial  sclerosis,  or  of  coats  whose  resisting  power  is  lowered 
because  of  atheroma,  may  cause  aneurysm.  Hence,  the  causes  of  sclerosis 
and  atheroma  are  also  causes  of  aneurysm.  The  principal  cause  of  aneurysm 
is  increased  blood-pressure.  This  increase  may  be  brought  about  by  severe- 
labor;  by  sudden  strains,  as  in  lifting;  by  violent  efforts,  as  in  rowing  in  a. 
boat-race;  by  chronic  interstitial  nephritis;  by  h>T)ertrophy  of  the  heart; 
bv  alcoholic  excess,  and  by  syphilis.  Arterial  disease  is  commonest  in  the 
larger  vessels,  and  in  the  aged,  but  it  may  occur  in  youth.  When  an  aneurysm 
foUows  a  strain,  it  may  be  due  to  laceration  of  the  media  and  loss  of  resistance 
at  a  narrow  point.  The  intima  may  lacerate,  permitting  the  blood  to  come  in 
contact  with  the  media  or  causing  blood  to  diffuse  between  the  coats  (dis- 
secting aneurysm).  When  an  embolus  lodges  in  an  artery  the  vessels  may 
become  aneurysmal  on  the  proximal  side  of  the  clot.  The  embolus,  if  infective, 
causes  softening,  and  if  calcareous  causes  laceration  (Osier).  Colonies  of 
micrococci  may  cause  aneurysm. ^  The  parasite  Strongylus  armatus  causes 
aneurysm  of  the  mesenteric  arteries  in  horses.  Suppuration  around  a  vessel 
weakens  its  coats  and  tends  to  aneurysm  by  inducing  acute  arteritis  and  soft- 
ening. Sometimes  an  individual  develops  multiple  aneurysms  the  origins  of 
which  are  absolutely  unknown.  A  bruise  of  a  vessel  may  be  followed  by 
aneurysm.  A  cut  or  puncture  of  a  healthy  artery  may  lead,  after  the  surface 
wound  heals,  to  the  development  of  an  aneurysm.  Such  an  aneurysm  does, 
not  differ  in  symptoms  or  treatment  from  the  other  form. 
1  See  Osier  on  "Malignant  Endocarditis." 


Symptoms  of  Aneurysm 


477 


The  constituent  parts  of  an  aneurysm  are:  (i)  the  wall  of  the  sac;  (2)  the 
cavity;  (3)  the  mouth,  and  (4)  the  contents. 

Symptoms  of  Aneurysm. — The  formation  of  an  aneurysm,  when  sudden, 
is  occasionally,  though  rarely,  appreciated  by  the  patient,  and  is  described 
by  him  as  a  feeling  of  something  having  given  way.     In  most  instances  the 


Fig.  219. — Radial  pulse-tracings  in  aneurysm  of  right  brachial  artery:   i,  Left  radial  pulse;  2, 
right  radial  pulse  (after  Mahomed). 

feeling  of  beating  and  the  discovery  of  the  lump  are  the  first  intimations  that 
anything  is  wrong.  An  oval  or  globular,  soft,  elastic,  and  pulsatile  protrusion 
develops  in  the  line  of  an  artery.  It  is  usually  quite  evident  to  the  touch  that 
the  sac  contains  fluid,  but  sometimes  in  old  aneurysms  the  sac  feels  firm  or 


Fig.  220. — X-ray  of  aneurysm  of  thoracic  aorta. 


even  hard,  because  of  the  deposit  of  fibrin  upon  its  inner  surface.  In  a  par- 
tially consolidated  aneurysm  pulsation  may  be  slight  or  even  inappreciable. 
The  protrusion  instantly  ceases  to  pulsate  and  almost  disappears  on  making 
firm  pressure  on  the  artery  above.  On  relaxing  the  pressure  the  pulsatile 
enlargement  at  once  reappears.     Direct  pressure  upon  the  tumor  may  cause 


478  Diseases  and  Injuries  of  the  Heart  and  Vessels 

it  to  almost  disappear.  Pressure  upon  the  artery  below  causes  the  tumor 
to  enlarge.  The  pulsation  is  expansile — that  is,  the  sac  expands  in  all  direc- 
tions during  every  cardiac  contraction — and  if  an  index-finger  be  laid  on  each 
side  of  the  tumor  so  that  the  points  nearly  touch,  each  pulsation  not  only  Ufts 
the  fingers,  but  it  also  separates  them.  It  is  important  to  remember  that  a 
large  intrathoracic  aneurysm  which  is  in  contact  with  the  chest  may  not  exhibit 
expansile  pulsation,  but  simply  transmit  pulsation  from  the  blood-stream 
(Sidney  Lange,  in  ''N.  Y.  Med.  Jour.,"  Nov.  21,  1908).  On  placing  a  stetho- 
scope over  the  aneurysm  or  over  the  vessel  below  the  aneurysm  there  is  im- 
parted to  the  ear  a  distinct  bruit,  which  travels  in  the  direction  of  the  blood- 
stream, is  systoUc  in  time,  and  is  usually  blowing  in  character.  In  some  cases 
bruit  is  absent  (when  a  sacculated  aneurysm  has  a  very  small  mouth,  when  the 
circulation  is  tranquil,  or  when  the  sac  is  full  of  blood  and  clot).  When  bruit  is 
absent,  it  may  sometimes  be  developed  by  muscular  exercise  or  raising  the 
affected  limb  (Halloway).  In  rare  cases  there  may  be  a  double  bruit.  Occa- 
sionally, in  fusiform  aortic  aneurysm  linked  wnth  aortic  regurgitation,  a  diastolic 
bruit  exists.  A  bruit  is  arrested  by  pressing  upon  the  artery  between  the 
aneurysm  and  the  heart.  A  patient  who  has  an  aneurysm  of  an  extremity 
complains  of  a  sensation  of  beating,  of  weakness  or  stiffness  of  the  Hmb,  fre- 
quently of  pain  in  a  nerve,  a  feeling  of  fatigue  in  the  muscles,  and  edema  and 
dilated  veins  are  apt  to  develop  because  of  pressure  upon  large  veins  and  loss  of 
vis  a  tergo  in  the  circulation.  The  skin  over  an  aneurysm  may  be  normal,  may 
be  discolored,  may  ulcerate,  or  even  slough.  The  pulse  below  an  aneurysm  is 
weaker  than  the  pulse  of  a  corresponding  part  of  the  opposite  limb.  This  is 
well  shown  by  sphygmographic  tracings  (Fig.  219).  The  tracings  taken  below 
an  aneurysm  are  rounded  without  a  sudden  rise  or  an  abrupt  fall.  In  inter- 
nal aneurysms  pressure  symptoms  are  marked.  Thoracic  aneurysm  causes  in- 
tercostal pain;  iliac  aneurysm  causes  pain  in  the  thigh.  Abdominal  aneurysm 
is  very  rare.  It  is  most  common  near  the  diaphragm.  It  is  more  apt  to  be 
sacculated  than  fusiform.  As  a  rule,  it  distends  forward;  if  it  distends  back- 
ward it  may  destroy  the  vertebrae  and  press  upon  the  cord.  Pain  practically 
always  occurs,  usually  in  the  back,  sometimes  in  the  abdomen.  Expansile 
pulsation  and  bruit  make  the  diagnosis  clear.  The  .T-rays  may  be  valuable  in 
estabhshing  the  diagnosis.  Aneurysm  of  the  thoracic  aorta  pressing  upon 
the  pneumogastric  nerve  causes  spasmodic  dyspnea,  and  upon  the  recurrent 
laryngeal  causes  hoarseness,  which  may  be  associated  with  loss  of  voice,  cough,^ 
and  laryngeal  spasm,  and  is  due  to  unilateral  abductor  paralysis.  Pressure 
upon  a  bronchus  or  the  trachea  causes  dyspnea  or  dysphagia  from  obstruction, 
and  cough  from  lar^nigeal  spasm.  Pressure  upon  the  cervical  sympathetic 
first  causes  dilatation  and  later  contraction  of  the  pupil  of  the  same  side.  A 
thoracic  aneurysm  may  erode  the  ribs,  sternum,  or  vertebrae.  The  .v-rays  are 
of  great  value  in  diagnosticating  thoracic  aneurysm  (Fig.  220).  An  aneurysm  in 
the  neck  may  interfere  with  the  cerebral  circulation  and  produce  vertigo  and 
even  attacks  of  unconsciousness.  Leaking  of  blood  from  a  ruptured  aneurysm 
into  the  tissues  causes  a  diffuse  aneurysm.  The  evidences  of  a  diffuse 
aneurysm  of  an  extremity  are  loss  of  distinctness  of  outline  and  increase  in 
area  of  the  swelling,  weakening  or  disappearance  of  pulsation  which  may  later 
appear,  weakening  or  alteration  of  bruit,  absence  of  pulse  below  the  aneu- 
rysm, severe  pain,  edema  and  coldness  of  the  surface.  Only  when  the  swelling 
is  rapid  because  the  bleeding  is  profuse  are  there  constitutional  symptoms. 
External  hemorrhage  may  arise;  the  tissues  may  become  extensively  infiltrated 
with  blood;  sloughing  or  gangrene  may  ensue.  Violent  external  hemorrhage 
causes  shock,  syncope  and  probably  death  unless  a  surgeon  is  at  hand.  Only 
in  very  rare  cases  does  spontaneous  cure  take  place.  Rupture  of  a  large  aneu- 
rysm into  a  cavity  causes  intense  pallor,  advancing  weakness,  syncope,  and 
death. 


Treatment  of  Aneurysm  479. 

Diagnosis. — A  cyst  or  abscess  over  a  vessel  may  show  transmitted  pulsa- 
tion which  is  not  expansile,  and  the  swelling  does  not  disappear  when  pressure 
is  made  upon  the  vessel  above  it.  The  pulsation  ceases  when  the  growth  is 
lifted  off  the  vessel.  There  is  no  true  bruit,  and  the  history  is  widely  diiTer- 
ent.  A  growth  under  a  vessel  may  lift  the  vessel  and  simulate  an  aneurysm, 
but  the  pulsation  is  not  noted  in  the  entire  growth,  the  growth  does  not  dis- 
appear on  proximal  pressure,  and  there  is  only  a  false,  and  never  a  true,  bruit. 
The  larger  the  growth  under  a  vessel  the  less  is  the  pulsation,  because  of  pres- 
sure narrowing  the  caliber  of  the  vessel.  A  sarcoma,  especially  a  soft  sarcoma 
attached  to  the  bone,  and  also  a  nevoid  mass,  pulsate  and  often  have  a  bruit; 
the  tumor  never  disappears  from  proximal  pressure,  though  it  may  slowly 
diminish  in  size,  to  enlarge  gradually  again  when  pressure  is  withdrawn. 
These  growths  do  not  feel  fluid,  and  are  rarely  circumscribed.  An  aneurysm 
may  cease  to  pulsate  from  consolidation  leading  to  cure  "or  from  rupture. 
Rupture  of  a  large  aneurysm  into  a  cavity  induces  deadly  pallor,  syncope, 
and  rapid  death.  Rupture  of  an  aneurysm  of  an  extremity  into  the  tissues  is 
made  manifest  by  a  sensation  of  something  breaking,  by  pain,  by  sudden  in- 
crease in  size,  by  diminution  or  absence  of  bruit  and  pulsation,  by  absence  of 
pulse  below  the  aneurysm,  by  swelling  and  coldness  of  the  limb,  and,  if  bleed- 
ing is  rapid,  by  shock.  The  x-rays  are  valuable  in  diagnosticating  thoracic 
aneurysm  and  abdominal  aneurysm. 

Treatment. — (For  the  history  of  the  evolution  of  the  treatment  of  aneurysm, 
see  "Studies  in  Aneurysm,"  by  James  G.  Mumford,  "Cleveland  Med.  Jour.,"' 
Feb.,  1908.)  In  inoperable  aneurysms,  general,  medical,  and  dietetic  treat- 
ment must  be  tried.  A  chief  element  in  treatment  is  rest  in  bed  to  diminish 
the  rapidity  and  force  of  the  circulation  and  favor  fibrinous  deposit.  Valsalva. 
long  ago  suggested  rest,  occasional  bleeding,  and  a  diet  just  above  the  point 
of  starvation.  Tuffnell's  plan  is  to  reduce  the  heart-beats  by  rest  and  mental 
quiet,  and  to  restrict  rigidly  the  diet  so  as  to  diminish  the  total  amount  of 
blood  and  render  it  more  fibrinous.  Liquids  are  restricted  in  amount,  and  the 
patient  lives  through  each  twenty-four  hours  upon  4  oz.  of  bread,  a  very 
little  butter,  8  oz.  of  milk,  and  3  oz.  of  meat.  This  plan  is  pursued  for  several 
months  if  possible,  or  it  is  employed  for  several  weeks,  intermitted  for  a  short 
period,  the  rigid  diet  again  returned  to,  and  so  on,  over  and  over  again.  There 
can  be  no  doubt  that  Tuffnell's  treatment  sometimes  cures  aneurysm  by  de- 
cidedly lowering  the  blood-pressure.  Many  who  suffer  from  aneurysm  may 
be  permitted  to  go  about,  taking  their  time  about  everything  and  avoiding  work, 
worry,  and  excitement.  The  diet  should  be  low  and  non-stimulating,  and  the 
bowels  must  be  maintained  in  a  loose  condition. 

Even  in  an  operable  case  diet  and  rest  are  of  importance.  Often  a  patient 
is  kept  in  bed  for  a  number  of  days  before  operation,  the  daily  diet  consisting 
of  10  or  12  oz.  of  solid  food  with  a  pint  of  milk.  If  the  circulation  is  very 
active,  use  aconite  and  allay  pain  by  morphin. 

lodid  of  potassium  in  doses  of  20  gr.  undoubtedly  does  good  in  aneurysm 
and  even  in  non-syphilitic  cases.  It  seems  to  lower  the  blood-pressure.  Bal- 
four taught  that  it  thickened  the  walls  of  the  sac.  Osier  says  it  relieves  the 
pain.  Iron,  acetate  of  lead,  and  ergotiu  are  prescribed  by  some.  DigitaUs. 
is  contra-indicated,  as  it  raises  the  blood-pressure.  S.  Solis-Cohen  has  used 
with  some  success  the  hydrated  chlorid  of  calcium.  Morphin  and  bromid  of 
potassium  are  occasionally  useful  to  tranquiHze  the  circulation,  allay  pain,  and 
secure  sleep.     Aconite  and  veratrum  viride  have  long  been  employed. 

Lancereaux  and  others  claiin  that  hypodermatic  injections  of  gelatin  at 
some  indifferent  point  may  cure  aortic  and  subclavian  aneurysm.  In  1896 
Dastres  and  Floresco  proved  that  gelatin  injected  into  the  blood  increases 
coagulability.  Later,  Lancereaux  and  Paulesco  showed  that  injections  into 
the    subcutaneous    tissue    act  similarly.    '  Carnot    pointed    out    that    gelatin 


480  Diseases  and  Injuries  of  the  Heart  and  Vessels 

applied  to  a  wound  may  arrest  bleeding.  How  gelatin  acts  is  uncertain,  but 
that  it  does  increase  blood  coagulability  seems  proved.  The  value  of  injec- 
tions of  gelatin  for  aneurysm  is  in  dispute.  Lancereaux  warmly  advocates  its 
use  for  sacculated  aneurysm,  and  says  that  after  the  first  dose  the  aneurysm 
is  seen  to  shrink  and  the  pulsation  is  observed  to  lessen.  He  injects  it  slowly 
and  with  aseptic  care  into  the  subcutaneous  tissue  of  the  thigh,  using  normal 
salt  solution  containing  from  5  to  10  per  cent,  gelatin.  He  never  injects  less 
than  5  gm.  He  gives  an  injection  every  tenth  to  fifteenth  day  and  admin- 
isters from  ten  to  twenty  injections.  But  the  treatment  is  not  free  from 
danger;  several  deaths  have  taken  place,  and  several  persons  have  died  from 
tetanus.  Care  must  be  taken  not  to  inject  gelatin  into  a  vessel,  and  it  must 
never  be  thrown  about  the  aneurysmal  sac.  It  irritates  the  kidneys  and 
its  use  is  contra-indicated  in  renal  disease.  The  injections  cause  much  pain, 
and  it  is  very  doubtful  if  they  do  any  real  good  in  aneurysm.  If  used  it  should 
be  given  at  the  temperature  of  the  body,  and  not  over  3  gm.  should  be  ad- 
ministered at  one  dose.  A  10  per  cent,  solution  is  the  proper  strength  and 
from  10  to  20  c.c.  the  correct  dose.  Gelatin  can  be  given  by  the  mouth. 
When  thus  given  it  is  not  so  powerful,  but  its  coagulating  property  is  not 
destroyed  by  digestion.  Gelatin  in  normal  salt  solution  is  known  as  Car- 
not's  solution.  Carnot's  solution  is  best  prepared  by  Sailer's  formula,  as 
follows  (Joseph  Sailer,  in  "Therapeutic  Gazette,"  August,  1901):  Take  5 
gm.  of  common  salt,  i  liter  of  distilled  water,  and  100  gm.  of  gelatin.  Bring 
the  water  to  a  temperature  of  80°  C.  and  slowly  stir  in  the  gelatin  until  it 
is  all  in  solution.  Remove  the  solution  from  the  stove,  cool  it  to  40°  C,  add 
to  it  the  white  of  one  egg,  and  stir  for  several  minutes,  and  then  put  the  flask 
on  the  stove  and  boil  the  fluid.  The  white  of  egg  coagulates  and  clears  the 
solution.  Filter  through  gauze  and  then  through  paper.  Place  the  fluid  in 
test-tubes,  each  of  which  will  contain  10  c.c,  and  insert  a  cotton  plug  in  the 
mouth  of  each  tube.  Sterilize  by  putting  the  tubes  in  a  steam  sterilizer  for 
fifteen  minutes  on  three  successive  days.  When  wishing  to  use  a  tube,  place 
it  in  a  cup  of  hot  water  until  the  gelatin  liquefies,  pour  the  gelatin  into  a  sterile 
glass,  and  draw  it  up  into  a  sterile  syringe.  When  kept  several  weeks  the  gela- 
tin dries  out. 

Other  expedients  sometimes  used  in  the  treatment  of  aneurysm  are:  the 
kneading  of  the  sac  to  release  a  clot,  in  the  hope  that  it  will  plug  the  mouth 
of  the  sac  or  the  artery  beyond  it — this  is  dangerous;  electricity;  electrolysis; 
the  injection  of  an  astringent  Uquid;  the  insertion  of  a  fine  aspirating  needle 
and  the  pushing  through  it  into  the  sac  of  a  large  quantity  of  silver  wire,  in 
the  hope  that  it  will  aid  in  whipping  out  fibrin.  Some  physicians  have  inserted 
needles  and  others  horsehair. 

Treatment  by  Pressure. — In  a  case  of  subclavian  aneurysm  in  my  ward  spon- 
taneous cure  followed  clotting  distal  to  the  aneurysm.  In  this  patient  a  cervical 
rib  existed.  I  have  never  seen  personally  an  aneurysm  cured  by  any  method  of 
pressure  although  I  have  observed  several  which  by  it  were  diminished  in  size. 
Instrumental  pressure  is  made  by  applying  two  Signorini  tourniquets  or  some 
.  specially  devised  apparatus  to  limit  the  flow  of  blood  through  an  aneurysm 
without  entirely  stopping  it,  the  aneurysmal  sac  being  felt  still  to  pulsate  slightly. 
In  some  situations  Lister's  abdominal  tourniquet  is  applied;  in  other  regions  we 
may  use  Tuffnell's  compress,  which  is  like  a  spring  truss  and  is  strapped  in  place. 
A  heavy  body  suspended  over  the  artery  and  resting  part  of  its  weight  upon  the 
vessel  has  occasionally  brought  about  cure.  Compressing  instruments  can  be 
worn  for  from  twelve  to  sixteen  hours  at  a  time;  usually  they  are  removed  to 
permit  sleep  and  are  reapphed  the  next  day,  and  so  on  for  several  days.  Before 
applying  the  compress  be  sure  the  sac  is  full  of  blood,  and  render  this  certain 
by  applying  for  a  few  minutes  distal  compression.  This  method  rnay  possibly 
cure,  but  it  is  very  painful.     It  aids  in  the  formation  of  an  active  clot.     It 


Treatment  of  Aneurysm  481 

cannot  be  used  successfully  in  treating  aneurysm  of  the  axillary,  subclavian, 
or  carotid  artery. 

Digital  pressure,  made  with  the  thumb  aided  by  a  weight,  and  maintained 
for  many  hours  by  a  relay  of  assistants,  has  cured  some  cases.  This  method 
may  be  used  alone  or  may  be  used  as  an  accessory  to  instrumental  pressure. 
Its  chief  field  is  in  the  treatment  of  aneurysm  for  which  other  methods  are 
inapplicable  (orbit  and  some  aneurysms  at  the  root  of  neck).  It  entirely  cuts 
off  the  blood  and  promotes  the  formation  of  a  passive  clot.  If  cure  does  not 
take  place  in  three  days,  abandon  pressure.  It  must  often  be  abandoned  far 
earlier  because  of  pain. 

Direct  pressure  upon  the  sac  has  been  used  in  aneurysm  of  the  popliteal 
artery,  the  pressure  being  obtained  by  flexing  the  leg;  and  in  aneurysm  of  the 
brachial  artery  pressure  has  been  applied  at  the  bend  of  the  elbow  by  flexing 
the  elbow.  The  pressure  of  a  hollow  rubber  ball  has  been  used  in  aneurysm 
of  the  subclavian. 

Rapid  pressure  completely  arrests  the  passage  of  blood  through  the  sac 
for  a  limited  time,  and  is  applied  while  the  patient  is  under  the  influence  of 
an  anesthetic.  Take,  for  example,  a  case  of  popliteal  aneurysm:  the  patient 
is  placed  under  the  influence  of  ether;  two  Esmarch  bandages  are  used,  one 
being  applied  to  the  limb  from  the  toes  up  to  the  lower  hmit  of  the  aneurysm, 
and  the  other  from  the  groin  down  to  the  upper  Hmit  of  the  sac,  and  the  Es- 
march .band  is  fastened  above  the  aneurysm.  This  procedure  stagnates 
the  blood  both  in  the  veins  and  in  the  arteries,  and  the  sac  remains  full  of 
blood.  Pressure  is  thus  maintained  for  three  or  four  hours,  and  on  removing 
the  Esmarch  apparatus  a  tourniquet  is  put  on  the  artery  above  the  aneurysm 
and  partly  tightened  in  order  to  limit  the  amount  of  blood  passing  through 
and  thus  prevent  the  washing  away  of  clot.  This  method  of  rapid  pressure 
sometimes  cures  by  forming  a  passive  clot,  but  it  sometimes  results  in  gan- 
grene.    It  was  devised  by  John  Reid. 

Operative  Treatment. — In  the  vast  majority  of  cases  of  aneurysm  an  opera- 
tion is  called  for.  When  an  aneurysm  threatens  to  rupture  or  when  there  is 
infection  immediate  operation  is  demanded  imperatively.  Either  condition  is 
a  surgical  emergency.  In  any  operable  case  of  aneurysm  operate  reasonably 
early.  Don't  delay  needlessly.  Early  operation  means  that  we  deal  with  a  thin 
sac.  Before  operating  on  an  aneurysm  of  an  extremity  test  the  activity  of  the 
collaterals.  If  they  are  active,  operate  promptly.  If  they  are  inefficient  take 
means  to  develop  them  (see  Matas'  views  on  page  486).  Before  operating  on  an 
aneurysm  of  the  neck  test  the  brain  circulation  (page  486). 

Operation  by  the  Ligature  and  by  Sutures. — ^Ligation  of  the  main  artery 
was  the  operation  employed  by  most  surgeons  until  the  Matas  operation  was 
introduced.  The  methods  of  ligation  are:  (i)  the  method  of  Antyllus;  (2) 
extirpation  of  the  sac;  (3)  the  method  of  Anel;  (4)  the  method  of  Hunter; 
(5)  the  method  of  Wardrop,  and  (6)  the  method  of  Brasdor. 

Aneurysmotomy,  the  method  of  Antyllus  (Fig.  221),  a  Roman  successor  to 
Galen,  who  Hved  in  the  third  century,  a.  d.,  is  usually  described  as  a  rnethod 
involving  a  direct  attack  upon  the  sac  itself.  The  artery  is  ligated  immediately 
above  and  below  the  sac,  the  sac  is  opened  and  its  contents  turned  out,  or  the 
sac  is  extirpated.  As  a  matter  of  fact,  Antyllus  advocated  applying  a  ligature 
on  each  side  of  the  sac  and  opening  the  sac  in  order  to  evacuate  its  contents, 
but  he  distinctly  opposed  extirpation  because  of  its  danger.  AU  we  know  of 
Antyllus  is  found  in  writings  of  Oribasius,  who  lived  in  the  fourth  century 
and  was  the  physician  of  Julian  the  Apostate.  Syme  maintained  many  years 
ago  that  incision  of  the  sac  was  the  proper  operation  for  aneurysm  of  the  gluteal, 
iUac,  carotid,  and  axillary  arteries,  but  Syme's  method  is  productive  of  fearful 
hemorrhage,  and  the  plan  of  Antyllus  is  vastly  better.  Syme  opened  the  sac, 
inserted  his  finger,  and  plugged  the  artery  toward  the  heart  until  a  Hgature 
31 


482  Diseases  and  Injuries  of  the  Heart  and  Vessels 

was  applied  and  tied.  He  then  packed  the  sac  with  lint.  The  method  of 
Antyllus  may  be  a  good  plan  for  a  false  aneurysm. 

Aneurysmectomy  {extirpation  of  the  sac),  if  practised,  should  be  carried  out 
after  applying  a  ligature  on  each  side  after  the  method  of  Antyllus.  It  was 
originally  practised  by  Philagrius  and  was  reintroduced  by  Purmann  of  Bran- 
denburg in  1699  (Moynihan,  in  "Annals  of  Surgery,"  July,  1898). 

Extirpation  finds  warm  advocates  in  Delbet,  Littlewood,  and  Moynihan. 
Moynihan  claims  that,  as  compared  with  distal  Hgature,  there  is  a  greater 
chance  of  recovery,  no  chance  of  recurrence,  less  risk  of  gangrene,  and  com- 
plete recovery  from  troubles  due  to  nerve  interference  (Ibid.).  Extirpation 
is  regarded  by  some  surgeons  as  the  best  operation  for  traumatic  aneurysm, 
but  if  the  vessel  is  seriously  diseased  near  the  sac  some  other  method  should 
certainly  be  employed.  It  would  seem  that  excision  must  destroy  collaterals 
which  would  be  of  much  value  if  retained  intact.  In  aneurysm  of  the  common 
carotid  after  extirpation  (as  after  ligation)  there  is  grave  risk  of  cerebral  em- 
boHsm,  and  it  has  been  thought  better  by  some  surgeons  to  attempt  a  re- 
establishment  of  the  circulation  by  circular  suture  of  the  two  ends,  or,  as  Lexer 
did  in  the  axillary  artery,  autoplasty  with  a  piece  of  the  internal  saphenous 
vein.     It  seems  certain  that  the  safest  plan  in  carotid  aneurysm  is  to  apply 


Fig.  221. — Old  operation  of  Antyllus  for  aneu-       Fig.    222. — Anel's   operation   for   aneurysm 
rysm  ("Am.  Text-Book  of  Surgery")-  ("Am.  Text-Book  of  Surgery"). 

the  removable  band.  In  the  extremities  there  is  less  danger  of  gangrene 
after  Matas's  operation  than  after  extirpation.  Monod  and  Vanverts  ("Rev. 
de  Chir.,"  1910,  xH  and  xhi)  collected  205  cases  of  excision.  Of  these,  90  per 
cent,  were  cured.  Relapse  occurred  in  i^i  per  cent.  Direct  operative  mor- 
taUty  was  3  per  cent.  Gangrene  occurred  in  4  per  cent.  Extirpation  shows 
a  higher  percentage  of  cures,  a  lower  rate  of  mortality,  fewer  cases  of  gangrene, 
and  fewer  relapses  than  any  operation  except  that  of  Matas.  Monod  and  Van- 
verts collected  138  cases  of  ligation  by  different  methods.  The  mortahty  was 
7  per  cent.  There  were  12  per  cent,  of  relapses  and  6>^  per  cent,  of  gangrene. 
The  cures  numbered  74  per  cent.  Extirpation  requires  a  very  free  incision. 
In  the  limbs  an  Esmarch  band  controls  bleeding.  In  other  regions  the  artery 
is  clamped  on  each  side  of  the  aneurysm.  On  remo\dng  the  sac  ligate  the  veins 
and  arteries  above  and  below.  Nerve  trunks  are  apt  to  be  found  adherent  to 
the  sac. 

The  Method  of  Anel.—AntX,  of  Toulouse,  devised  and  performed  this 
operation  in  17 10.  In  Anel's  method  the  artery  is  Hgated  above  the  sac,  and  so 
close  to  it  that  there  are  no  anastomotic  branches  between  the  sac  and  the 
ligature  (Fig.  222).  It  is  used  chiefly  for  traumatic  aneurysms,  and  is  never 
employed  when  the  vessel  is  diseased  beyond  the  aneurysm.  Either  extirpation 
or  Matas's  operation  is  preferable  to  Anel's  operation. 

The  Method  of  Hunter.— This  operation,  which  is  the  modern  method  of 
hgation,  was  de\dsed  by  the  illustrious  John  Hunter,  and  was  first  employed  by 
him  in  January,  1786.  He  is  said  by  Sir  Everard  Home  to  have  recognized  the 
fact  that  the  vessel  adjacent  to  an  aneurysm  was  apt  to  be  diseased,  and  he 
discovered  the  anastomotic  circulation.  Putting  together  these  two  facts, 
he  devised  the  operation  which  goes  by  his  name.  It  consists  in  applying  a 
Hgature  between  the  heart  and  the  aneurysm,  but  so  far  above  the  sac  that 
collateral  branches  are  given  off  between  it  and  the  point  of  ligation  (Fig.  223). 


Treatment  of  Aneurysm  483 

This  operation,  which  is  done  upon  a  healthy  portion  of  the  artery,  does  not 
permanently  cut  off  all  blood,  but  so  diminishes  the  force  and  frequency  of 
the  circulation  that  an  active  clot  forms  within  the  sac.  Thus  are  lessened  the 
dangers  of  secondary  hemorrhage  and  gangrene.  According  to  Stimson  ("New 
York  Med.  Jour.,"  July,  1884),  Hunter  really  builded  better  than  he  knew, 
for  he  sought  only  to  tie  the  artery  without  opening  the  sac  and  at  a  healthy 
point,  but  said  not  a  word  about  the  necessity  of  having  branches  between 
the  sac  and  the  ligature  or  about  the  desirability  of  diminishing  the  flow  of 
blood  instead  of  cutting  it  off  completely  (Moynihan,  in  "Annals  of  Surgery," 
July,  1898).  Hunter  tied  the  artery  in  the  region  now  known  as  Hunter's 
canal.  Scarpa  introduced  the  custom,  which  we  still  follow,  of  tying  it  in 
Scarpa's  triangle.  The  Hunterian  method  was  for  many  years  regarded 
by  most  surgeons  as  the  proper  operation  for  aneurysm  in  the  majority 
of  cases.  In  some  cases  pulsation  does  not  return  in  the  aneurysm  after 
tightening  the  ligature;  in  most  cases,  however,  it  reappears  for  a  time 
after  about  thirty-six  hours,  but  is  weak  from  the  start,  constantly  diminishes, 
and  finally  disappears  permanently.  Previous  prolonged  compression  by  en- 
larging the  collateral  branches  permits  strong  pulsation  to  recur  soon  after 
ligation,  and  thus  militates  against  cure;  hence,  it  is  a  bad  plan  to  use  pressure 


Fig.  223.^ — Hunter's  method  of  ligating  for  aneurysm:  a,  The  aneurysm;  b,  point  of  liga- 
tion; c,  the  branches  between  the  aneurysm  and  the  ligature.  The  arrow  shows  the  direction 
of  the  blood-current. 

in  cases  admitting  of  Hgation  and  in  which  the  success  of  pressure  is  very  doubt- 
ful. Proximal  ligature  alone  is  now  seldom  regarded  as  the  best  method  for 
false  aneurysm.  If  the  aneurysm  is  at  the  root  of  the  neck  and  is  very  large 
it  may  be  the  necessary  method.  Hunter's  operation  is  best  suited  to  true 
aneurysm.  Occasionally  after  Hunter's  operation  the  sac  suppurates,  pro- 
ducing symptoms  like  those  of  abscess.  Suppuration  may  occur  between  the 
first  and  the  thirty-second  week  after  hgation.^  When  pus  forms,  open  freely,  as 
we  would  open  an  abscess,  and  if  no  blood  flows,  treat  as  an  abscess,  but  have 
a  tourniquet  loosely  applied  for  several  days  ready  to  screw  up  at  the  first 
sign  of  danger.  If  hemorrhage  occurs,  tie  the  vessel  above  and  below  the 
aneurysm,  open  the  sac,  and  pack  with  iodoform  gauze.  If  bleeding  recurs, 
there  is  no  use  reapplying  the  ligature  and  there  is  little  use  tying  higher  up. 
If  dealing  with  the  upper  extremity,  try  the  application  of  a  Hgature  higher 
up;  if  dealing  with  the  lower  extremity,  amputate  at  once. 

Distal  Ligation. — When  an  aneurysm  is  so  near  the  trunk  that  Hunter's 
operation  is  impracticable,  or  when  the  artery  on  the  cardiac  side  of  the  aneurysm 
is  greatly  diseased,  distal  hgation  may  be  employed.  Distal  Hgation  forms 
a  barrier  to  the  onflow  of  blood,  collateral  branches  above  the  aneurysm 
enlarge,  the  blood-current  is  gradually  diverted,  and  a  clot  may  form  within 
the  aneurysm.  Distal  ligation  is  used  in  some  aneurysms  of  the  aorta,  iliac, 
innominate,  carotid,  and  subclavian.  It  occasionaUy  causes  rupture  of  the 
sac  of  the  aneurysm.  I  have  obtained  two  notably  successful  results  in  aneu- 
1  See  the  case  described  by  Sir  Astley  Cooper. 


484 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


rysms  of  the  innominate  artery  by  Ugation  of  the  common  carotid  and  sub- 
clavian of  the  right  side.  In  each  of  these  cases  I  tied  both  vessels  at  one 
seance,  tying  the  carotid  first.  In  one  case  I  tied  the  third  part  of  the  sub- 
clavian and  in  the  other  the  first  part.  The  first  patient  returned  to  his  work 
as  a  blacksmith  and  died  over  a  year  and  a  half  later  from  rupture  of  a  sec- 
ondary aneurysm  of  the  carotid  at  the  point  where  the  ligature  had  been  ap- 
plied. The  second  case  was  living  and  apparently  well  over  five  years  after 
the  operation  (the  author,  in  "  Surg.,  G>'n.,  and  Obst.,"  June,  1910). 

The  operation  of  Brasdor  consists  in  tying  the  main  trunk  some  little  dis- 
tance below  the  aneurysm  (Fig.  224).  It  completely  arrests  circulation  in 
the  sac.     The  operation  was  introduced  in  1760  by  the  French  surgeon  Brasdor. 

The  operation  of  Wardrop  consists  in  tying  one  of  the  branches  of  the 
artery  beyond  the  aneurysm.  James  Wardrop  of  London  originally  advocated 
ligation  at  a  point  where  there  is  no  intervening  branch  between  the  sac  and  the 
ligature.  Later,  he  advocated  ligation  at  a  point  where  there  is  an  intervening 
branch.  In  1 809  Wardrop  ligated  the  carotid  dis tally  and  successfully  for  carotid 
aneurysm.     He  published  his  well-known  article  in  1825.     In  1827  he  ligated 


Fig.   224. — Brasdor's  operation  (Holmes).  Fig.  225. — Wardrop's  operation  (Holmes). 


thus  successfully  for  subclavian  aneurysm  ("Lancet,"  1827,  xii).  It  is  the  custom 
to  consider  Wardrop's  operation  to  be  the  ligation  of  one  branch  beyond  the 
aneurysm,  as  shown  in  Fig.  225.  The  circulation  is  but  partially  arrested  by 
Wardrop's  operation.  An  a;-ray  picture  should  be  taken  in  every  case  of  aortic 
aneurysm.  Such  a  picture  may  aid  us  in  coming  to  a  conclusion  as  to  which 
vessel  or  vessels  to  tie. 

Matas's  Operation  (Aneurysmorrhaphy). — This  procedure  is  the  greatest 
advance  in  the  surgery  of  the  arterial  system  since  the  observations  of  John 
Hunter.  It  was  devised  and  first  practised  by  Rudolph  Matas  of  New  Orleans 
in  1889  on  a  negro  suffering  from  traumatic  aneurysm  of  the  brachial  artery 
in  the  middle  of  the  arm.  The  operation  was  a  complete  success.  In  1900 
he  began  again  to  use  this  method,  and  in  1902  described  it  to  the  profession 
("Trans,  of  Am.  Surg.  Assoc,"  1902;  "Annals  of  Surg./'  Feb.,  1903;  "Trans, 
of  Am.  Surg.  Assoc,"  1905). 

One  procedure,  applicable  to  ordinary  fusiform  aneurysms,  is  called  ob- 
literative  endo-aneurysmorrhap/iy  without  arterioplasty  (Fig.  226).  "No  at- 
tempt is  made  to  reconstruct  the  parent  artery  (arterioplasty),  and  the  arterial 
orifices  are  simply  obliterated  by  suture."  By  sutures  applied  within  the 
incised  sac  the  sac  is  cut  off  from  the  circulation  without  disturbing  adjacent 
collaterals  and  without  interfering  with  the  nutrition  of  the  sac  walls.  After 
this  operation  there  is  very  seldom  secondary  hemorrhage,  gangrene,  or  relapse. 

A  modification  of  the  above  operation  appHed  to  sacculated  aneurysms 
in  which  there  is  one  orifice  of  communication  with  the  arterv  is  called  endo- 


Treatment  of  Aneurysm 
B 


48: 


Fig.  226. — The  radical  cure  of  aneurysm  based  upon  arteriorrhaphy  (Matas):  A,  First  tier 
of  sutures  in  a  fusiform  aneurysm;  B,  second  tier  of  sutures,  some  of  which  are  tied;  C,  sutures 
to  approximate  the  walls  of  the  aneurysm;  D,  suturing  the  opening  in  a  sacculated  aneurysni — 
the  main  artery  is  not  obliterated;  E,  opening  co'mpletely  closed;  F,  diagram  of  cross-section 
of  parts  after  complete  obliteration  of  sac,  but  with  restoration  of  blood-channel;  G,  diagram 
of  cross-section  of  parts  after  complete  obliteration  of  sac  and  blood-vessel;  H,  operation  for 
fusiform  aneurysm  when  we  wish  to  restore  the  blood-channel — sutures  applied  over  a  rubber 
tube,  most  of  the  sutures  tied,  tube  withdrawn,  and  remaining  sutures  tied. 


486  Diseases  and  Injuries  of  the  Heart  and  Vessels 

aneurysmorrhaphy  with  partial  arterioplasty  (Fig.  226).  The  sac  is  opened, 
clots  are  washed  away,  the  opening  of  the  aneurysm  into  the  artery  is  closed  by 
a  continuous  suture  passing  through  all  the  coats  of  the  sac  at  the  edge  of  the 
opening  into  the  artery.  Blood  is  thus  excluded  from  the  sac,  the  lumen  of  the 
artery  is  not,  however,  obliterated,  and  the  blood-supply  of  parts  beyond  is 
not  interfered  with.  After  closing  the  cut  in  the  arterial  wall  the  sac  is  ob- 
literated by  rows  of  sutures  inserted  in  its  walls.  Matas  reports  4  cases  oper- 
ated upon  successfully  by  this  plan.  In  a  fusiform  aneurysm  with  a  firm  and 
resisting  sac  wall,  and  in  which  there  are  two  openings  near  together  on  the 
floor  of  the  sac,  endo-aneiirysmorrhaphy  with  complete  arterioplasty  may  be 
performed  (Fig.  226).  This  operation  restores  arterial  continuity,  a  new 
channel  being  made  out  of  the  sac  walls  "by  simply  holding  these  over  a  rub- 
ber guide  (tube  or  catheter)  and  suturing  them  firmly  together  so  as  to  restore 
the  continuity  of  the  artery  lost  in  the  sac."  The  catheter  is  withdrawn  before 
the  final  sutures  are  tied.  This  operation  has  been  performed  successfully  by 
Morris,  Craig  and  others.  Some  surgeons  are  fearful  that  such  an  operation 
will  be  followed  by  relapse,  and  a  very  few  of  the  reported  cases  did  relapse. 
Matas  says  that  preservation  of  the  arterial  lumen  is  "  only  indicated  positively 
in  the  sacciform  aneurysms  with  a  single  opening  where  the  parent  artery 
already  exists  as  a  formed  vessel,  and  in  which  the  closure  of  the  fistulous 
opening  can  be  accomplished  with  the  greatest  facility  and  simpHcity"  (address 
dehvered  at  the  Medical  Assoc,  of  Alabama,  April  22,  1906).  Some  surgeons 
think  it  improbable  that  the  artery  remains  patent  long,  because  the  seat 
of  aneurysm  is  a  diseased  vessel  and  it  would  seem  reasonable  to  expect  that 
vascular  disease  would  probably  cause  clotting,  but  even  a  temporary  restora- 
tion of  circulation  if  followed  by  gradual  abolition  gives  time  for  the  enlarge- 
ment of  collaterals  and  so  prevents  gangrene.  Matas  maintains  that  after  the 
purely  restorative  operation  the  artery  "remains  pervious  permanently  or  for 
an  indefinite  time."  This  has  been  proved  by  certain  necropsies  on  successful 
cases,  made  after  the  operation,  death  having  been  caused  by  secondary  con- 
ditions. The  Matas  operation  differs  notably  from  the  Antyllus  operation  in  the 
fact  that  it  saves  certain  collaterals  which  the  Antyllus  method  destroys,  and  the 
retention  of  these  collaterals  may  prevent  gangrene  in  the  limb.  It  differs  from 
it  further  in  the  fact  that  it  occludes  certain  small  vessels  which  after  the  Antyllus 
method  continue  to  convey  blood  into  the  sac.  It  is  superior  to  extirpation 
because  it  does  not  destroy  the  vascular  walls  of  the  sac,  the  blood-vessels  of 
which,  if  unblocked,  aid  in  preventing  gangrene  of  the  limb. 

In  every  case  of  aneurysm  of  an  extremity  the  activity  of  the  collateral 
circulation  should  be  tested  before  operating.  Matas  insists  on  this  being 
done.  If  the  collaterals  are  inactive  we  know  that  occlusion  of  a  main  arterial 
trunk  would  probably  cause  gangrene,  and  we  adopt  means  to  develop  the 
collaterals  before  doing  an  operation.  In  most  cases  there  is  time  to  take  means 
and  delay  brings  no  particular  danger.  But  if  a  sac  is  ruptured,  there  is  exten- 
sive infiltration  of  blood,  the  limb  is  cyanotic  and  practically  strangulated,  and 
no  such  test  can  be  undertaken.  Free  incisions  are  made,  clots  are  turned  out, 
the  sac  is  reached  and  opened  and  the  Matas  operation  is  performed.  If  it  is 
found  advisable  to  develop  the  collaterals  hyperemia  is  induced,  blood-pressure 
is  raised  and  compression  of  the  artery  is  practised  at  intervals. 

Matas  says  that  in  those  rare  cases  in  which  the  collaterals  fail  to  respond 
to  treatment  the  main  artery  should  be  gradually  obliterated  near  the  sac  by 
a  Halsted  band.  If  gradual  occlusion  fails  a  restorative  or  reconstructive 
operation  is  indicated. 

Matas  insists  that  in  all  carotid  aneurysms  the  cerebral  circulation  must  be 
tested.  This  is  done  by  an  aluminium  band.  If  serious  cerebral  symptoms 
arise  the  band  is  removed  and  it  can  be  removed  at  any  time  within  three 
days.     Frequently  the  band  alone  cures  the  aneurysm.     If  it  does  not  aneu- 


Treatment  of  Aneurysm  487 

rysmorrhaphy  should  be  performed.  (See  Matas's  paper  before  the  Inter- 
national Congress  of  Medicine,  London,  1913). 

A  subclavian  aneurysm,  an  innominate  aneurysm  and  an  iliofemoral 
aneurysm  should  be  treated  on  the  same  plan. 

If  the  blood  is  found  by  examination  before  operation  to  coagulate  too 
rapidly  the  patient  should  be  given  citric  acid  to  lessen  the  danger  of  thrombosis. 

Matas  points  out  that  suture  of  an  aneurysm  is  indicated  only  when  cer- 
tain essentials  exist. 

1.  The  situation  of  the  aneurysm  must  admit  of  the  control  of  the  circu- 
lation temporarily  on  the  proximal  side  of  the  sac.  In  most  aneurysms  of 
the  extremities  this  is  done  by  the  elastic  band  of  Esmarch.  In  the  neck  and 
abdomen  both  the  cardiac  and  peripheral  sides  of  the  main  vessels  must  be 
secured  by  traction  loops  and  compression. 

2.  The  sac  must  be  freely  opened  in  a  longitudinal  direction.  Its  wall 
must  not  be  dissected  and  must  be  separated  as  little  as  possible  from  sur- 
rounding tissue. 

3.  Every  orifice  opening  into  the  sac  must  be  thoroughly  exposed  so  that 
it  can  be  closed  by  sutures.  The  suture  material  is  chromic  gut,  the  number 
being  i,  2,  or  3,  according  to  the  size  of  the  aneurysm. 

Fig.  226,  A  to  H,  shows  Matas's  various  operations.  For  a  full  description 
of  them  see  the  previously  quoted  articles  of  the  author.  I  believe  that  the 
Matas  operation  is  a  very  notable  advance  in  surgery,  that  it  is  safer  than 
older  methods,  and  much  less  apt  to  be  followed  by  gangrene.  The  idea  seems 
to  be  general  that  Matas  always  seeks  to  restore  arterial  lumen.  This 
is  not  the  case.  He  only  seeks  to  do  this  in  exceptional  cases.  The  essence 
of  his  method  is  to  cure  aneurysm  by  sutures  within  the  sac  and  by  ob- 
literation of  the  sac.  I  have  performed  the  Matas  operation  (obliterative 
endo-aneurysmorrhaphy)  successfully  on  a  case  of  ruptured  fusiform  popliteal 
aneurysm  and  on  a  case  of  ruptured  sacculated  popliteal  aneurysm.  In  the 
latter  case  there  was  profuse  hemorrhage  during  the  operation  from  vessels 
-opening  into  the  sac. 

At  the  London  International  Congress  of  Medicine  in  19 13,  Matas  discussed 
''The  Suture  as  applied  to  the  Surgical  Cure  of  Aneurysm."  He  collected  225 
cases.  There  were  19  deaths  (8.4  per  cent.).  He  eliminated  9  deaths  in 
no  way  due  to  this  particular  operation  (for  instance,  i  death  from  the  anes- 
thetic, I  from  tetanus,  i  from  nephritis,  i  from  pyelonephritis,  r  from  erysipelas, 
I  from  septic  arthritis  of  the  knee,  i  from  pulmonary  embolism,  i  from  a  sup- 
posed air  embolism,  i  from  heart  disease).  This  elimination  and  the  exclu- 
sion of  the  four  aortic  cases  give  a  mortality  of  6  cases  in  221  (2.7  per  cent.). 
In  the  upper  extremities  there  were  23  cases  and  i  death;  in  the  lower  ex- 
tremity, 194  cases  and  12  deaths;  in  the  neck,  4  cases  and  2  deaths;  in  the 
abdominal  aorta,  4  cases  and  4  deaths.  In  150  obliterative  operations  there  were 
16  deaths  (10.6  per  cent.).  The  four  aortic  cases  are  in  this  list.  So  are  2  ac- 
cidental deaths.  There  were  9  cases  of  gangrene  and  i  secondary  hemorrhage. 
There  were  50  total  restorative  operations,  with  i  case  of  gangrene,  i  secondary 
hemorrhage  and  2  deaths  (4  per  cent.).  There  were  25  total  reconstruction 
operations  -vvdth  i  case  of  gangrene,  i  secondary  hemorrhage  and  i  death  (4  per 
cent.).  There  were  no  relapses  after  the  obliterative  and  restorative  operations 
but  there  were  3  after  the  reconstructive  operations. 

Success  is  obtained  in  about  90  per  cent,  of  cases  and  relapse  is  very  rare. 

In  Monod  and  Vanvert's  103  cases  there  were  89  cures.  Relapse  occurred 
in  1.5  per  cent.  Gangrene  occurred  in  from  3  to  5  per  cent,  of  the  cases.  Direct 
operative  mortahty  was  3  per  cent.  ("Rev.  de  Chir.,"  1910,  xli  and  xlii). 

The  operation  has  been  performed  upon  the  abdominal  aorta,  the  external 
iliac,  the  subcla\aan,  the  popliteal,  the  femoral,  the  internal  carotid,  the  axillary, 
the  common  carotid,  and  the  external  carotid,  as  well  as  upon  smaller  vessels. 


488  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Munro,  Martin  and  Parham,  Lilienthal,  Pringle,  and  Lozano  performed  endo- 
aneurysmorrhaphy  for  subclavian  aneurysm  (Eliot,  in  "Annals  of  Surgery," 
July,  191 2). 

The  So-called  Ideal  Operation  (Circular  Angiorrhaphy). — This  operation  was 
first  advocated  by  Goyanes  of  Madrid  and  Lexer  of  Jena.  The  sac  of  the  aneu- 
rysm is  extirpated,  and  vascular  continuity  is  restored  by  circular  suturing  or  by 
the  introduction  and  suturing  of  a  graft  from  a  vein  or  an  artery  to  fill  the  gap. 
Matas  says  of  this  operation  (Ibid.)  that  "it  combines  all  of  the  objections  that 
can  be  brought  against  extirpation,  and,  in  addition  to  its  traumatizing  quality, 
is  complicated  by  the  great  uncertainties  of  a  circular  suture,  or,  what  is  worse, 
the  interposition  of  a  vascular  graft."  Even  in  the  laboratory  experiments  the 
results  have  been  poor.  In  352  end-to-end  anastomoses  by  Carrel's  plan  there 
were  24.92  per  cent,  failures  from  thrombotic  occlusion — in  8.12  per  cent, 
marked  stenosis  of  the  lumen  followed  and  in  only  49.84  per  cent,  was  a  full 
sized  lumen  obtained  and  retained  (Sofoteroff,  in  Centralb.  f.  Chirug.,  Jan.  28, 
1911). 

Matas  says  that  the  "ideal  operation"  is  not  ideal  surgically,  that  it  is  uncer- 
tain and  liable  to  failure  and  that  as  good  results  "-can  be  obtained  by  a  far 
more  simple,  and,  clinically,  a  more  efficient  procedure."  There  is  no  doubt  that 
lateral  suturing  for  a  small  wound  in  an  artery  is  a  valuable  plan  and  that  in 
many  cases  thrombosis  does  not  occur.  The  case  is  different  with  end-to-end 
suturing  or  vascular  grafting.  In  this  war  a  number  of  surgeons  have  employed 
circular  sutures  and  the  results  have  been  scarcely  fair.  The  technic  is  difficult 
and  in  war  thorough  asepsis  may  fail.  Jeger  maintains  that  suture  protects  from 
gangrene.  Von  Eiselsberg  and  Bier  both  use  it.  Delorme  opposes  it.  Tuffier 
uses  suture  for  lateral  wounds  of  the  femoral  and  popliteal  arteries.  Most  sur- 
geons will  not  do  angiorrhaphy  if  there  is  infection. 

Halsted's  Method  by  Partial,  Progressive,  and,  Finally,  Complete  Occlusion 
by  Metal  Band. — This  method  is  applied  only  to  the  aorta  and  other  very  large 
arteries.  A  number  of  surgeons  have  sought  a  method  to  occlude  the  abdom- 
inal aorta  gradually  and  safely  in  order  that  they  may  attempt  to  cure  aneurysm 
of  the  aorta  or  of  the  iliac  arteries.  The  usual  thought  was  to  leave  a  metal 
instrument  fixed  to  the  aorta,  the  handle  projecting  from  the  abdominal  wound, 
and  a  metal  clamp  or  a  snare  of  silk  or  catgut  being  around  the  vessel,  so  that 
by  means  of  a  screw  arrangement  pressure  could  be  gradually  increased. 

Halsted  showed  that  by  this  plan  sepsis  almost  certainly  occurs  along  the 
track  of  the  instrument.  (See  W.  S.  Halsted,  in  "Johns  Hopkins  Bulletin," 
1905,  xvi,  346;  "Jour.  Am.  Med.  Assoc,"  1906,  xlvii;  "Jour.  Experimental 
Medicine,"  1909,  vol.  xi.  No.  2.)  Halsted  sought  for  a  method  "permitting,  in 
each  entre-act,  complete  closure  of  the  wound."  He  uses  a  band  of  aluminum 
curled  in  cylinder  form  about  the  vessel.  This  material  admits  of  easy  readjust- 
ment at  a  future  operation,  and  it  is  tightened  by  the  fingers. 

Halsted's  band,  when  used  to  occlude  partially,  seldom  causes  macroscopic 
alteration  in  the  wall  of  the  vessel;  when  used  to  completely  occlude,  the  vessel 
may  undergo  atrophy.  A  diseased  vessel  may  atrophy  and  rupture.  Ideal 
closure  is  when  the  lumen  has  been  nearly  but  not  quite  occluded,  spontaneous 
obliteration  having  arisen,  the  arterial  wall  embraced  by  the  band  having  under- 
gone conversion  into  "a  solid  cylinder  of  living  tissue."  The  arteries  may  be- 
come mere  fibrous  cords. 

Matas^s  Plan  for  Testing  Collateral  Efficiency. — ("Jour.  Am.  Med.  Assoc.,"' 
Ixiii.) — Matas  considers: 

1.  The  Sign  ofQuenu  and  Muret. — To  obtain  this  the  main  artery  of  the  limb 
is  compressed  and  while  the  compression  is  maintained  a  puncture  is  made  at 
the  periphery.  If  ho  bleeding  follows  the  collaterals  are  regarded  as  inefficient, 
if  bleeding  follows  they  are  regarded  as  efficient.     This  test  Matas   rejects. 

2.  The  Sign  of  Delbet. — When  an  aneurysm  forms  on  a  main  artery  it  is  often 


Treatment  of  Aneurysm  489 

found  that  the  pulse  below  it  disappears  abruptly  or  gradually.  When,  in 
spite  of  absent  pulse  below  the  aneurysm,  the  nutrition  of  the  part  is  well 
preserved,  the  collaterals  are  active.  Matas  regards  this  sign  as  most  valuable. 
5.  The  Sign  of  Hcnlc  and  Coenen. — This  sign  is  only  made  manifest  during 
an  operation.  If  blood  is  seen  to  flow  from  the  peripheral  lumen  of  the  aneurysm 
when  the  proximal  end  is  compressed  the  collaterals  are  active. 

4.  The  Signs  of  Von  Frisch. — These  signs  can  only  be  made  manifest  during 
operation. 

{A)  When  pressure  is  applied  to  the  proximal  side  of  an  aneurysm  the  pe- 
ripheral part  of  the  limb  retains  the  color  of  life. 
{B)  The  sign  of  Henle  and  Coenen. 
(C)  When  the  main  vein  is  compressed  venous  stasis  arises  below. 

5.  Korotkow's  T^est. — This  is  made  by  estimating  blood-pressure  in  the  periph- 
ery while  the  main  arterial  trunk  above  the  aneurysm  is  being  compressed. 

If  the  blood-pressure  is  fairly  high  the  collaterals  are  active. 

6.  Fachon's  Test. — This  is  also  a  blood-pressure  test  made  in  a  different 
manner  from  number  5. 

7.  The  Test  of  Tuffier  and  Hallion. — If  the  main  artery  and  vein  are  com- 
pressed, the  veins  of  the  foot  will  swell  only  if  a  considerable  amount  of  arte- 
rial blood  is  taken  to  the  periphery  by  the  collaterals. 

8.  Stewart's  Test. — In  this  test  the  amount  of  blood  passing  through  a  part 
in  a  definite  time  is  estimated  by  means  of  a  calorimeter. 

9.  Matas  uses  two  methods: 

,  {A)  The  hyperemic  reaction  advised  by  Moschcowitz.  This  test  is  applied 
to  an  extremity  if  the  main  artery  can  be  compressed.  The  limb  is  elevated. 
Esmarch's  bandage  is  applied  from  the  periphery  to  the  lower  border  of  the 
aneurysm.  A  Matas  compressor  is  applied  to  the  main  artery  above  the 
aneurysm  to  cut  off  all  pulse  below.  After  compression  has  been  acting  from  6 
to  ID  minutes  the  elastic  bandage  is  removed.  It  is  removed  while  the  com- 
pressor is  still  in  place.  At  once  a  flush  of  hyperemia  appears  below  the  com- 
pressor and  descends  the  limb  quickly.  Even  when  the  collaterals  are  active 
the  digits  remain  of  a  waxy  hue  for  some  seconds.  The  longer  the  time  required 
for  the  digits  to  become  hyperemic  the  poorer  is  the  collateral  circulation.  When 
the  collaterals  are  impaired  10  minutes  or  more  will  be  required.  In  cases  of 
great  impairment  30  or  40  minutes  may  be  necessary. 

If  collaterals  are  found  inefi&cient  they  may  be  developed  by  making  pres- 
sure upon  the  artery  above  the  aneurysm.  The  pressure  should  not  entirely 
cut  off  the  circulation,  several  seances  a  day  should  be  held  and  each  seance 
should  last  15  or  20  minutes.  The  seances  are  held  until  collateral  cir- 
culation improves  or  it  becomes  evident  that  it  is  not  going  to  do  so.  If 
collaterals  refuse  to  distend,  partly  close  the  artery  by  means  of  an  aluminium 
band  (see  page  486). 

{B)  Preliminary  closure  of  the  main  artery  with  a  removable  aluminium 
band. 

In  a  huge  iliofemoral  aneurysm  Halsted  partially  occluded  the  left  external 
iliac,  using  a  band.  He  cut  off  the  pulse  but  not  the  stream  of  blood.  Sixteen 
days  later  he  excised  the  aneurysm.  The  patient  was  cured  ("Jour.  Am.  Med. 
Assoc,"  1914,  Ixiii).  If  an  aneurysm  of  the  aorta  is  not  cured  by  partial  closure, 
a  secondary  operation  should  be  performed  in  order  to  permit  further  closure, 
complete  closure  or  perhaps  ligation  (Halsted,  in  Arch.  f.  klin.,  Chir.,  1914,  cv). 

The  band  should  eventually  be  removed  from  the  aorta.  On  any  other  large 
artery  if  healthy,  the  band  can  be  left  permanently.  By  being  careful  to 
refrain  from  cutting  off  the  blood  stream  entirely  the  danger  of  gangrene  is 
obviated.  In  constricting  the  aorta  it  does  not  do  to  aboHsh  the  pulse.  In  other 
large  vessels,  if  the  condition  of  the  heart  permits,  the  pulse  may  be  abolished 
but  even  then  a  small  amount  of  blood  continues  to  flow  through  the  constricted 


490 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


area.  In  certain  cases  of  cardiac  disease  even  this  degree  of  occlusion  is  not 
admissible  (Halsted,  Ibid.). 

In  a  more  recent  study  ("Jour.  Exper.  Med.,"  1916,  xxiv)  Halsted  maintains 
that  the  intimal  surfaces  brought  into  gentle  contact  by  a  band  or  ligature  do 
not  unite.  The  arterial  surfaces  under  the  band  atrophy  because  they  are 
deprived  of  blood.  The  arterial  wall  dies,  and  necrotic  tissue  is  organized  or 
substituted,  blood-vessels  entering  both  ends.  Absorption  of  the  necrotic  wall 
is  proceeding  during  the  vascularization. 

If  an  artery  be  occluded  partially  by  a  band  it  may  develop  a  circumscribed 
dilatation  distal  to  the  seat  of  constriction.  This  will  not  happen  if  the  artery 
be  either  very  slightly  or  completely  occluded.  A  like  condition  may  develop 
in  the  subclavian  in  a  case  of  cervical  rib.  Halsted  ("  Jour.  Exper.  Med.," 
Sept.,  1916)  studied  the  reports  of  716  cases  of  cervical  rib  and  found  that  in 
27  or  more  of  them  dilatation  existed.  Animals  tolerate  gradual  occlusion  very 
well  indeed. 

Halsted  has  made  numerous  experiments  on  dogs  and  has  used  the  band  with 
encouraging  results  on  the  human  being  (partial  occlusion  of  the  innominate, 
twice;  common  carotid,  four  times).     In  a  case  of  aneurysm  of  the  abdominal 


Fig.  227. — Halsted's  improved  band  roller:  The  instrument  shown  in  full  length  is  unloaded; 
in  the  abbreviated  cut  the  band  is  about  to  be  expelled  from  the  roller  (Halsted). 


aorta  Halsted  partially  occluded  the  aorta  near  the  diaphragm.  Seven- 
teen days  later  he  placed  another  band  on  the  aorta  below  the  aneurysm. 
The  patient  lived  twenty-four  days  after  the  second  operation.  The  operation 
checked  the  growth  of  the  aneurysm  and  arrested  pain  ("Trans.  Am.  Surg. 
Assoc,"  1909-10).  In  another  case  of  abdominal  aneurysm  Halsted  put  a  band 
on  the  aorta  above  the  renals.  Seventeen  days  later  Finney  inserted  wire  into 
the  aneurysm.     The  patient  lived  forty-five  days  after  the  first  operation  (Ibid.). 

In  preparing  the  band  for  application  it  is  rolled  by  means  of  the  instru- 
ment shown  in  Fig.  227.  It  is  well  to  fasten  the  band  with  a  silver  ligature 
after  application.     The  ligature  prevents  unrolling  (Ibid.). 

Treatment  After  Operation  for  Aneurysm.— After  operating  for  aneurysm 
of  an  extremity  by  excision,  by  the  ligature,  by  sutures  or  by  a  band,  elevate  the 
limb  slightly,  keep  it  warm  by  wrapping  in  cotton  and  surrounding  with  bags 
of  warm  water.  The  old  plan  was  to  give  arterial  sedatives  to  allay  arterial 
excitement  which  was  feared  might  loosen  the  ligature.  To  lower  blood-pres- 
sure lessens  the  activity  of  the  collaterals  and  the  less  active  the  collaterals 
the  greater  the  danger  of  gangrene.  So  arterial  sedatives  are  not  to  be  given. 
When  gangrene  of  a  limb  follows  ligation,  await  a  line  of  demarcation,  and 


Treatment  of  Aneurysm  491 

when  it  forms,  amputate.  Rupture  of  the  sac  after  Ugation  may  produce  gan- 
grene or  be  associated  with  suppuration,  the  first  condition  demanding  amputa- 
tion; the  second,  incision  for  drainage. 

Other  Methods  of  Treatment  of  Aneurysm. — Injection  of  coagulating  agents 
into  the  sac  (ergot,  perchlorid  of  iron,  etc.)  is  very  dangerous  and  is  to  be  utterly 
condemned.     It  may  lead  to  suppuration,  gangrene,  rupture,  or  embolism. 

Manipiilation  to  break  up  the  clot  was  suggested  by  Sir  Wm.  Fergusson 
and  has  been  practised  by  some.  The  object  aimed  at  is  to  have  a  fragment 
of  clot  block  up  the  vessel  upon  the  peripheral  side  of  the  artery  and  act  like 
a  distal  ligature.  The  method  is  dangerous,  especially  in  carotid  aneurysm, 
and  should  never  be  employed. 

Amputation,  instead  of  distal  ligation,  is  performed  in  some  perilous  cases 
of  subclavian  aneurysm. 

Electrolysis. — An  attempt  may  be  made  to  coagulate  at  once  the  blood  in 
the  sac,  or  from  time  to  time  an  endeavor  may  be  made  to  produce  fibrinous 
deposits,  but  the  first  method  is  the  better.  It  is,  however,  seldom  possible  to 
occlude  a  sac  and  pulsation  at  once.  Pulsation  is  for  a  time  abolished  but  usually 
recurs  as  the  gas  present  is  absorbed.  Use  the  constant  current.  Take  from 
three  to  six  cells  which  stand  in  point  of  size  between  those  used  for  the  cautery 
and  those  used  for  ordinary  medical  purposes.  A  platinum  needle  is  attached- 
to  the  positive  pole  and  a  steel  needle  to  the  negative  pole,  each  needle  being 
insulated  by  vulcanite  at  the  spot  where  the  tissues  would  touch  it.  The  asep- 
ticized needles  are  plunged  into  the  sac  where  it  is  thick,  and  they  are  kept  near 
together.  The  current  is  passed  for  a  variable  period  (from  half  an  hour  to 
an  hour  and  a  half).  This  operation  is  not  dangerous.  Pressure  stops  the 
bleeding.  Electrolysis  often  ameliorates  and  sometimes  greatly  improves 
aortic  aneurysms. 

Acupuncture  consists  in  the  introduction  of  a  number  of  ordinary  sewing 
needles  partially  into  an  aneurysmal  sac  and  in  leaving  them  in  it  for  five  or 
six  days  or  more.  Professor  Macewen  introduces  a  needle,  and  with  it  irritates 
the  interior  of  the  sac  of  an  aneurysm,  hoping  thus  to  cause  deposition  of 
leukocytes,  thickening  of  the  sac,  and  clot  formation. 

Introduction  of  Wire. — This  operation  is  performed  by  inserting  into  the  sac 
a  hypodermatic  or  small  aspirating  needle,  and  pushing  in  through  the  needle  or 
cannula  a  considerable  quantity  of  aseptic  gold  or  silver  wire,  which  is  allowed 
to  remain  permanently.  Wiring  is  used  for  aneurysms  otherwise  inoperable. 
Electrolysis  should  be  combined  with  the  introduction  of  wire.  Wiring  was 
first  proposed  by  Moore,  of  London,  in  1864.  The  details  were  improved  by 
Corradi  in  1879.  Loreta  and  Barwell  both  inserted  wire  into  an  aneurysm 
before  Corradi,  but  Corradi  inserted  wire  and  also  used  electricity.  The  first 
American  wiring  operation  was  performed  by  Ransohoff  in  1886.  Corradi's 
operation  can  be  used  when  distal  ligation  cannot  be  carried  out,  and  can  be 
used  even  when  the  vessel  is  extremely  atheromatous.  It  fitids  its  chief  use 
in  aneurysms  of  the  thoracic  aorta  and  innominate.  In  some  cases  of  ab- 
dominal aneurysm  the  belly  has  been  opened  and  the  operation  carried  out. 
It  is  used  for  sacculated,  never  for  fusiform,  aneurysms.  The  operation  has 
not  many  elements  of  danger.  Sepsis  would  inevitably  cause  death.  If  the 
wire  is  carried  on  into  the  aorta  and  heart,  death  will  follow.  A  cause  of  death 
is  embolism.  In  one  of  Finney's  cases  gangrene  of  the  arm  resulted  from  embo- 
lism. Too  strong  a  current  may  cause  sloughing  of  the  aneurysmal  wall. 
The  wall  of  the  aneurysm  may  rupture  because  of  deviation  of  the  strong  blood- 
current  in  another  direction.  Some  cases  have  been  notably  improved.  The 
operation  is  performed  with  aseptic  care.  If  the  thoracic  aorta  is  to  be  oper- 
ated upon,  an  anesthetic  is  not  required.  If  the  abdorninal  aorta  is  to  be  wired, 
the  patient  must  be  anesthetized,  because  the  abdomen  needs  to  be  opened. 
The  wire  used  must  have  been  previously  drawn,  so  that  it  will  easily  pass 


492  Diseases  and  Injuries  of  the  Heart  and  Vessels 

through  a  hypodermatic  needle  and  will  coil  up  spirally  within  the  sac.  The 
best  wire  is  of  silver  or  gold.  A  special  reel  is  used  to  keep  the  wire  from 
getting  kinked.  It  is  a  great  mistake  to  introduce  a  large  quantity.  Stewart 
decided  that  a  globular  sac  3  inches  in  diameter  required  from  3  to  5  feet,  and 
a  sac  5  inches  in  diameter  required  from  8  to  10  feet.  A  hypodermatic  needle, 
insulated  up  to  3^  inch  of  the  point,  is  carried  into  the  interior  of  the  aneurysm 
through  a  fairly  thick  portion  of  the  sac.  The  shoulder  of  the  needle  is  not 
insulated  and  must  not  be  permitted  to  touch  the  skin,  because  if  it  did  so  it 
would  cause  a  burn  by  electrolysis.  The  required  amount  of  wire  is  introduced. 
The  wire  is  attached  to  the  positive  pole  of  the  battery.  The  negative  pole  is 
fastened  to  a  large  flat  piece  of  clay  or  a  pad  of  moistened  absorbent  cotton, 
and  the  negative  electrode  is  placed  upon  the  back  or  abdomen.  The  current  is 
turned  on  gradually  until  the  necessary  strength  is  obtained  (40  to  80  ma.). 
When  ready  to  terminate  the  operation  the  current  is  lowered  gradually  to 
zero,  the  needle  is  withdrawn,  the  wire  is  cut  ofi  close  to  the  skin,  the  end  is 
pushed  under  the  skin,  the  puncture  is  covered  with  iodoform  collodion,  and 
pressure  is  applied  to  keep  blood  from  gathering  in  the  tissue.  Such  a  hema- 
toma might  cause  the  formation  of  a  slough.  The  entire  operation  requires 
from  three-quarters  of  an  hour  to  one  and  a  half  hours.  A  clot  forms  with 
considerable  rapidity  and  expansile  pulsation  may  lessen  or  cease.  It  requires 
from  a  number  of  days  to  several  weeks  for  the  clot  to  become  hard.  The  opera- 
tion can  be  repeated  if  necessary.  Injections  of  gelatin,  made  at  a  distant  point 
after  wiring,  may  be  beneficial.     Rest  is  imperative  for  months  after  wiring. 

Notable  improvement  is  common,  but  genuine  cure  is  not  obtained.  As 
Hare  says,  "adjacent  tissues  of  the  vessel  sooner  or  later  give  way,  because 
the  effort  is  like  an  effort  to  mend  a  rotten  hose;  though  mended  at  one  spot  it 
breaks  at  another."  One  of  Jones's  cases  remained  well  for  six  years  and  then 
pain  recurred.  The  operation  causes  prompt  and  marked  diminution  of  pain, 
an  amelioration  usually  spoken  of  by  the  patient  before  he  leaves  the  operat- 
ing table.  In  2  of  my  cases  pain,  which  had  been  severe,  disappeared  com- 
pletely during  the  operation.  "Dyspnea  is  also  benefited  and  just  as  rapidly" 
(H.  A.  Hare,  in  "Therapeutic  Gazette,"  April,  1908).  Finney  ("Annals  of 
Surgery,"  May,  191 2)  reported  23  cases  (mostly  thoracic,  some  abdominal). 
Of  these  cases  only  2  were  known  to  be  living  at  the  time  of  the  report. 

Treatment  of  Diffuse  Aneurysm  (Ruptured  Aneurysm). — In  the  neck  and 
subclavian  region  extirpation.  In  the  hmbs  Matas's  operation  or  extirpation. 
In  such  a  case  the  surgeon  works  on  a  diseased  artery,  and  an  angiorrhaphy  is 
not  applicable. 

Diffuse  Traumatic  Aneurysm. — This  condition  has  been  called  pulsating 
hematoma.  There  is  no  true  or  complete  sac.  A  diffuse  traumatic  aneurysm 
is  caused  when  a  wound  in  an  artery  permits  blood  to  flow  into  the  tissues. 
Wounds  of  healthy  arteries  causing  diffuse  aneurysm  are  due  to  stabs  or  bullet 
wounds  and  are-particularly  common  in  war.  Vessel  injuries  have  been  com- 
mon in  this  war  and  a  considerable  number  of  cases  of  diffuse  aneurysm  have 
been  operated  upon.  Wounds  from  pointed  bullets  constitute  the  chief  cause. 
Shell  fragments  are  causal  much  less  commonly.  In  these  cases  there  is  no 
true  sac  but  the  false  sac  is  composed  of  blood-clot,  compressed  muscle,  fascia 
and  inflammatory  exudate.  There  may  be  one  small  opening  in  an  artery,  there 
may  be  two,  there  may  be  a  longitudinal  wound,  a  transverse  wound,  or  a  com- 
plete division.  The  vein  may  also  be  wounded  or  destroyed.  Blood  flows 
into  the  tissues  and  separates  them.  In  some  cases  the  flow  is  slight  and  it 
occasionally  though  seldom  happens  that  the  arterial  wound  closes  and  heals. 
In  nearly  all  cases  the  hemorrhage  continues.  In  some  cases  it  is  profuse, 
separating  the  tissues  widely  and  perhaps  even  stripping  up  the  periosteum. 
In  most  cases  the  hemorrhage  from  the  surface  wound  is  moderate  or  even 
trivial.     There  is  much  danger  of  secondary  hemorrhage. 


Arteriovenous  Aneurysm  493 

111  a  typical  case  pain  is  severe — there  is  swelling  and  coldness  of  the  extremity 
below  the  wound — absence  of  pulse  at  the  periphery — an  oblong,  fluctuating  and 
pulsating  swelling  now  forms  and  increases  in  size  progressively.  On  ausculta- 
tion a  bruit  is  detectable. 

The  skin  at  first  is  of  a  natural  color  but  later  becomes  thin  and  purple. 
Blood  may  trickle,  flow,  or  even  pour  from  the  surface  wound.  Many  cases 
reported  in  this  war  have  deviated  far  from  the  above  description.  In  many 
cases  swelling  has  been  very  slow  in  forming  and  pulsation  has  been  a  late  but 
not  an  early  symptom.  Auscultation  may  afford  the  only  sign  of  the  nature  of 
the  injury.  Hence  the  rule  is  imperative  that  auscultation  must  be  used  in 
every  doubtful  case.  In  battle  this  study  is  made  in  the  first  dressing  station 
or  in  the  field  hospital. 

Treatment. — The  operation  is  seldom  one  of  emergency.  It  must  be  if 
bleeding  is  dangerously  severe  and  increasing  or  if  there  is  infection.  Infection 
is  rare  unless  there  is  lodgment  of  a  bullet  or  bit  of  clothing. 

The  limb  must  be  immobilized  for  transportation  to  the  base. 

The  best  period  for  operation  in  most  cases  is  the  end  of  the  third  week.  The 
collaterals  are  then  as  a  rule  at  their  best.  Later,  as  the  aneurysm  increases 
the  collaterals  will  become  less  efficient.  Test  the  collaterals  before  operat- 
ing (page  486).  If  dealing  with  an  extremity  empty  the  limb  of  blood  by 
applying  an  elastic  bandage  up  to  the  lower  border  of  the  aneurysm,  apply 
an  Esmarch  band  above,  make  a  free  incision  into  the  aneurysm  and  turn  out  the 
clots.  It  may  be  possible  to  suture  the  wound  in  the  artery.  If  the  wound  is 
small  it  should  be  done.  If  sutures  greatly  constrict  the  arterial  lumen  they 
should  not  be  used.  Some  military  surgeons  advocate  resection  of  the  damaged 
area  of  the  artery  and  end-to-end  suture,  or,  if  the  space  between  the  ends  is  too 
extensive,  grafting  in  of  a  piece  of  resected  vein  (see  the  Ideal  Operation,  page 
488).  If  lateral  sutures  are  not  applicable  most  American  surgeons  prefer  to  do 
a  Matas  operation,  or,  to  tie  the  artery  on  each  side  of  the  tear,  open  the  sac,  and 
pack  it  (the  operation  of  Antyllus),  but  Matas's  operation  is  the  preferable  pro- 
cedure. Some  surgeons  prefer  to  tie  the  vessel  on  each  side  of  the  rupture  and 
excise  the  intervening  portion.  If  the  main  vein  is  also  ruptured,  suture  the 
vessels  if  possible.  If  suture  is  impossible,  apply  ligatures.  In  some  compli- 
cated cases  of  grave  injury  amputation  is  necessary.  In  a  few  cases  gangrene 
results  and  amputation  becomes  necessary  but  as  the  wounded  artery  is  healthy 
and  the  collaterals  of  youth  are  active  gangrene  among  soldiers  from  this  cause 
has  been  rare. 

If  a  bullet  or  bit  of  clothing  is  lodged  the  foreign  body  must  be  removed  and 
the  wound  treated  as  an  infected  wound.  In  a  diffuse  traumatic  aneurysm  of 
the  iliacs,  the  subclavian  or  the  carotids,  it  seems  probable  that  extirpation  is 
the  preferable  operation. 

Arteriovenous  aneurysm  was  first  described  by  Wm.  Hunter  in  1757. 
By  this  term  we  mean  an  unnatural  passageway  between  a  vein  and  an  artery, 
through  which  passage  blood  circulates.  There  are  two  forms:  (a)  aneurysmal 
■varix,  or  Fott's  anettrysm,  a  vein  and  an  artery  directly  communicating  (Fig. 
229);  and  (b)  varicose  aneurysm,  a  vein  and  an  artery  communicating  through 
an  intervening  sac.  These  conditions  arise  usually  from  punctured,  bullet  or 
stab  wounds,  the  instrument  passing  through  one  vessel  and  into  the  other, 
blood  flowing  into  the  vein,  the  subsequent  inflammation  gluing  the  two  vessels 
together,  and  the  aperture  failing  to  close  (aneurysmal  varix.  Fig.  229).  After 
the  infliction  of  the  wound  the  two  vessels  may  separate;  the  blood  continuing 
to  flow  from  artery  into  vein,  and  the  blood-pressure,  by  consolidating  tissue, 
forming  a  sac  of  junction  (varicose  aneurysm,  Fig.  230).  Wounds  produced 
by  small  pointed  bullets  not  infrequently  result  in  arteriovenous  aneurysm. 
Out  of  102  cases  of  war  aneurysm  reported  by  Bier  56  were  arteriovenous 
{"Internat.  Abstract  of  Surgery,"  Oct.,  1915).     Aneurysmal  varix  is  a  less  grave 


494 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


disorder  than  varicose  aneurysm.  Arteriovenous  aneurysm  used  to  be  most 
frequent  at  the  bend  of  the  elbow,  the  vessels  being  injured  during  venesection. 
The  condition  may  occur  in  the  neck,  the  axilla,  the  extremities,  or  the  groin. 
I  assisted  Professor  Keen  in  an  operation  upon  an  aneurysmal  varix  of  the  com- 
mon carotid  and  internal  jugular  vein,  and  assisted  Professor  Hearn  in  operating 
on  a  varicose  aneurysm  involving  the  external  iliac  vessels.  Qucnu  operated  on 
an  arteriovenous  aneurysm  of  the  common  carotid  artery  and  jugular  vein 
and  collected  17  cases  from  literature.     Sir  Frederick  Treves  operated  on  a 


Fig,  228. — Dilatation  of  veins  in  arteriovenous  aneurj'sm  of  the  femoral  vessels. 

case  involving  the  internal  maxillary  vessels.  Very  rarely  an  arteriovenous 
aneurysm  forms  spontaneously.  Spontaneous  arteriovenous  aneurysm  is 
most  frequent  between  the  aorta  and  vena  cava.  There  is  no  tendency  to 
spontaneous  cure  in  arteriovenous  aneurysm.  Edema  is  the  rule,  muscular 
atrophy  is  common,  ulceration  or  even  gangrene  of  a  hmb  may  occur.  In  ar- 
teriovenous aneurysm  the  artery  on  the  proximal  side  of  the  fistula  dilates.  In 
many  reported  cases  the  condition  of  the  artery  has  not  been  noted.     Halsted  has 


Fig.  229. — Plan  of  aneurysmal  varix. 


Fig.  2.30. — Varicose  aneurysm  (Spence). 


found  proximal  dilatation  noted  in  52  cases.  Matas  has  collected  1 7  cases  of  ar- 
teriovenous aneurysm  of  the  subclavian  vessels  ("Transactions  of  Amer.  Surg. 
Assoc,"  vol.  xix).  In  this  list  is  the  celebrated  case  of  his  own,  a  traumatic  (gun- 
shot) arteriovenous  aneurysm,  in  which  cure  followed  operation;  in  the  operation 
it  was  necessary  to  obliterate  the  artery  by  ligatures,  but  the  venous  orifice  was 
closed  by  sutures  without  obliterating  the  lumen  of  the  vein.  In  the  analysis  of 
Matas's  paper  15  cases  are  used,  2  having  been  noted  too  late  for  incorporation; 
9  of  the  cases  resulted  from  "  stab  or  penetrating  cut  wounds,"  6  from  bullets — 
in  5  of  the  cases  the  brachial  plexus  was  injured.  In  8  out  of  the  1 1  unoperated 
cases  the  time  after  the  injury,  when  symptoms  of  arteriovenous  aneurysm 
were  noted,  is  stated;  in  i  signs  were  definite  within  four  hours,  in  3  they  were 
noted  on  the  second  day,  in  3  on  the  third  day,  in  i  on  the  sixth  day,  in  i  on 


Treatment  of  Arteriovenous  Aneurysm  495 

the  eighth  day,  in  i  on  the  ninth  day,  and  in  i  a  few  days  later.  In  3  of  the 
15  cases  secondary  hemorrhage  followed  the  injury.  Eleven  of  the  15  cases 
were  treated  expectantly;  i  died  from  secondary  hemorrhage  and  sepsis  three 
weeks  after  the  injury  and  10  "survived  the  immediate  effects  of  the  injury, 
their  wounds  healing  after  the  cessation  of  the  primary  hemorrhage." 

In  4  of  the  15  cases  operation  was  performed.  In  3  the  operation  was 
done  soon  after  the  injury  because  of  violent  secondary  hemorrhage.  In 
I  (Matas's  own  case)  operation  was  done  deliberately  to  prevent  complica- 
tions. Three  of  these  cases  recovered  (including  Matas's) ;  i  died  of  renewed 
secondary  hemorrhage  on  the  twenty-fourth  day  after  operation.  Matas 
points  out  the  fact  that  in  stab-wounds  of  the  subclavian  vessels  the  largest 
proportion  of  cases  die  of  primary  hemorrhage  before  assistance  is  obtained, 
but  in  a  considerable  number  of  cases  temporary  hemostasis  occurs,  which  is 
followed  by  secondary  hemorrhages  or  arteriovenous  aneurysm. 

Symptoms  of  Aneurysmal  Varix. — The  arterial  blood  is  cast  forcibly  into 
the  vein,  and  as  a  consequence  the  vein  becomes  enlarged,  tortuous,  and  thick- 
ened. The  scar  of  a  wound  is  almost  invariably  apparent.  At  the  seat  of 
vascular  trouble  the  most  marked  dilatation  exists  and  it  is  of  bluish  color. 
The  swelling  pulsates  markedly,  and  imparts  a  sensation  to  the  finger  like  that 
felt  when  the  hand  is  laid  upon  the  back  of  a  purring  cat.  This  thrill  or  vibra- 
tion is  very  characteristic.  A  sound  of  a  hissing  or  buzzing  nature  can  be  easily 
heard.  The  swelling  at  once  disappears  on  pressure  being  made  upon  it  or  on 
the  artery  between  it  and  the  heart.  It  is  diminished  in  size  by  raising  the 
limb,  is  increased  in  size  by  a  dependent  position  of  the  limb  and  by  com- 
pressing the  vein  between  the  heart  and  the  tumor.  The  adjacent  veins  are 
dilated  and  often  the  dilatation  is  manifested  over  a  wide  area  above  and 
below  (Fig.  228),  and  the  thrill  and  bruit  are  transmitted  a  considerable  dis- 
tance. If  an  extremity  is  involved  it  is  usually  edematous.  The  parts,  as 
a  rule,  are  painful.  The  condition  progresses,  but  very  slowly,  and  sometimes 
years  may  elapse  without  any  notable  aggravation. 

Symptoms  of  Varicose  Aneurysm. — In  this  condition  we  find  many  of 
the  symptoms  of  aneurysmal  varix,  but  in  varicose  aneurysm  pressure  over 
the  artery  of  supply  between  the  heart  and  the  lesion  does  not  cause  the  entire 
disappearance  of  the  swelling;  the  veins  collapse,  it  is  true,  but  a  distinct  sac 
remains,  which  may  be  emptied  by  direct  pressure. 

Treatment. — The  prognosis  after  operation  is  better  than  in  ordinary 
aneurysm,  but  nevertheless  it  is  wisest  to  refrain  from  operating  on  aneu- 
rysmal varix  so  long  as  the  condition  is  not  progressing  obviously,  is  borne 
without  inconvenience,  and  is  not  leading  to  complications.  Varicose  aneu- 
rysm should  be  operated  upon.  If  we  refrain  from  operating  upon  aneurysmal 
varix  the  patient  should  wear  a  support;  but  if  the  part  becomes  painful  or 
if  there  seems  to  be  danger  of  rupture  of  the  vein,  operation  should  be  performed. 
Ligation  of  the  artery  alone  is  not  to  be  practised.  In  half  of  the  cases  in 
which  this  was  done  in  the  South  African  war  gangrene  followed.  In  such  a  case 
blood  from  the  collaterals  does  not  reach  the  periphery  but  soon  returns  to  the 
vein  as  such  a  course  is  the  line  of  least  resistance.  If  the  vein  is  also  ligated 
the  danger  of  gangrene  is  lessened  materially.  Until  recently,  when  operation 
was  indicated,  surgeons  advised  that  each  vessel  should  be  tied  above  and  below 
the  opening  and  a  portion  of  each  vessel  should  be  excised,  the  excised  area 
including  the  opening  (the  quadruple  suture  with  excision).  In  varicose  aneu- 
rysm it  was  the  custom  to  tie  each  vessel  above  and  below  the  sac,  and  excise 
the  sac  with  a  portion  of  vessel.  In  36  cases  of  arteriovenous  aneurysm  Bier 
resected  the  damaged  portion  of  the  artery  and  united  the  ends  of  the  divided 
trunk  by  circular  sutures.  At  the  present  American  surgeons  prefer  the  Matas 
operation  for  both  varicose  aneurysm  and  aneurysmal  varix.  In  some  cases  of 
varicose  aneurysm,  however,  the  sac  is  extirpated  and  the  openings  in  the  vessels 


496  Diseases  and  Injuries  of  the  Heart  and  Vessels 

closed  by  suture,  and  in  some  cases  of  aneurysmal  varix  the  adherent  vessels 
are  separated  and  the  openhag  in  each  is  sutured.  In  a  case  of  aneurysmal 
varix  of  the  popliteal  due  to  a  gunshot  wound,  I  opened  the  vein  and  closed  the 
fistula  in  the  arterial  wall.  In  accomplishing  this  I  gathered  so  much  of  the 
vein  wall  in  the  sutures  as  to  render  it  impossible  to  suture  the  vein  and  retain 
its  lumen.  I  cut  the  vein  across,  a  little  above  and  a  little  below  the  sutured 
fistula,  used  the  trapdoor-like  piece  of  vein  to  reinforce  the  arterial  suture  line, 
and  did  end-to-end  anastomosis  of  the  vein  ends.  The  result  was  a  complete 
success  ("Annals  of  Surgery,"  April,  191 2). 

I  attempted  a  similar  operation  on  a  varicose  aneurysm  of  the  brachial 
in  the  middle  of  the  arm.  I  found  that  the  superior  profunda  also  ran  into 
the  sac,  and  that  a  saccular  aneurysm  had  formed  on  the  brachial  a  little 
below  the  varicose  aneurysm.  I  was  obliged  to  ligate  the  profunda  and  tie  the 
artery  and  vein  above  and  below  before  extirpating  the  aneurysm.  I  feared 
gangrene,  but,  fortunately,  the  patient  escaped  it. 

Cirsoid  aneurysm,  or  aneurysm  by  anastomosis,  consists  in  great 
dilatation  with  pouching  and  lengthening  of  one  or  several  arteries.  The 
disease  progresses  and  after  a  time  involves  the  veins  and  capillaries.  The 
walls  of  the  arteries  become  thin  and  the  vessels  tend  to  rupture.  Cirsoid 
aneurysm  is  most  commonly  met  with  upon  the  forehead  and  scalp  of  young 
people,  where  it  sometimes  takes  origin  from  a  nevus.  It  is  sometimes  seen 
upon  the  back  or  upper  extremity.  The  cause  is  unknown.  Usually  there 
is  no  assignable  cause,  but  occasionally  the  condition  follows  an  injury.  Preg- 
nancy causes  a  cirsoid  aneurysm  to  grow  rapidly,  and  so  usually  does  the  onset 
of  puberty.  Occasionally  some  of  the  enlarged  vessels  fuse  and  form  a  great 
cavity.     If  rupture  occurs,  desperate  hemorrhage  ensues. 

Symptoms. — There  is  a  pulsating  mass,  irregular  in  outline,  composed 
of  dilated,  elongated,  and  tortuous  vessels  that  empty  into  one  another.  The 
mass  is  soft,  can  be  much  reduced  by  direct  pressure,  and  is  diminished  by 
compression  of  the  main  artery  of  supply.     A  thrill  and  a  bruit  exist. 

Treatment. — In  treating  a  cirsoid  aneurysm  the  ligation  of  the  larger 
arteries  of  supply  is  a  wretched  failure.  Subcutaneous  ligation  at  many 
points  of  the  diseased  area  has  affected  cure  in  some  cases,  but  it  has  failed 
in  more.  Direct  pressure  is  also  entirely  useless.  Ligation  in  mass  has  been 
successful.  Destruction  by  caustic  has  had  its  advocates.  Electropuncture 
with  circular  compression  of  the  arteries  of  supply  has  once  or  twice  effected  a 
cure.  Injection  of  astringents  has  been  recommended.  Verneuil  ligated 
the  afferent  arteries,  incised  the  tissues  around  the  tumor,  and  sank  a  con- 
stricting ligature  into  the  cut.  The  proper  method  of  treatment  is  excision 
after  exposure  and  ligation  of  every  accessible  tributary  supply.  In  a  very 
extensive  mass  extirpation  is  impossible;  hence  one  of  the  other  methods 
suggested  must  be  employed.  A  very  considerable  mass  may  be  excised,  and 
the  resulting  wound  should  be  covered  with  Thiersch  skin-grafts. 

Wounds  of  arteries  are  divided  into  contused,  incised,  lacerated,  punc- 
tured and  gunshot-wounds,  and  vascular  ruptures. 

Contused  and  Incised  Wounds, — A  contusion  may  destroy  vitality  and 
be  followed  by  sloughing  and  hemorrhage.  A  contusion  may  rupture  a  blood- 
vessel, and  is  especially  apt  to  do  so  if  the  vessel  is  diseased.  Blood  is  at  once 
effused  at  the  seat  of  rupture.  If  an  artery  is  ruptured,  there  may  or  may  not  be 
pulsation  over  the  seat  of  rupture,  a  bruit  is  usually  heard  over  and  below  the  seat 
of  injury,  pulse  is  absent  below,  and  the  limb  below  the  injury  swells  and  becomes 
cold.  The  rupture  of  a  large  vein  is  followed  by  a  blood  tumor,  which  does  not 
pulsate  and  has  no  bruit,  and  the  limb  below  becomes  intensely  edematous. 
Gangrene  is  apt  to  follow  the  rupture  of  a  main  blood-vessel  of  an  extremity. 
A  contusion  may  rupture  the  internal  and  middle  coats  of  an  artery,  the  external 
coat  remaining  intact.     When  this  happens  the  internal  coat  curls  up  and  the 


Hemorrhage  497 

middle  coat  contracts  and  retracts,  the  blood-stream  is  arrested,  and  a  large  clot 
forms  within  the  artery.  If  the  clot  blocks  up  many  collaterals,  gangrene  may 
follow,  and,  as  has  been  pointed  out,  the  gangrene  will  not  be  preceded  by  swelling 
at  the  seat  of  injury,  which  always  occurs  if  a  vessel  is  ruptured.  A  contused 
wound  may  do  little  damage,  may  produce  gangrene  from  thrombosis,  or  may 
cause  secondary  hemorrhage.  In  an  incised  wound  of  an  artery  there  is  profuse 
hemorrhage.  The  artery  after  a  time  is  apt  to  contract  and  retract,  bleeding 
being  thus  arrested.  A  tranverse  wound  causes  profuse  bleeding,  but  there  is  a 
better  chance  for  natural  arrest  than  in  an  oblique  or  in  a  longitudinal  wound. 
The  clot  which  forms  within  a  cut  artery  is  known  as  the  "  internal  clot."  It  used 
to  be  taught  that  the  internal  clot  always  reaches  as  high  as  the  first  collateral 
branch,  and  subsequently  is  replaced  by  fibrous  tissue,  which  permanently  obliter- 
ates the  vessel,  and  converts  it  into  a  shrunken  fibrous  cord.  As  a  matter  of  fact, 
when  the  parts  are  aseptic  after  a  ligation  the  clot  is  rarely  bulky  and  is  often  very 
scanty,  repair  being  quickly  effected  by  proliferation  of  endothelial  cells.  Be- 
tween the  vessel  and  its  sheath,  over  the  end  of  the  vessel,  and  in  the  surrounding 
perivascular  tissues  is  the  "external  clot"  (Fig.  231). 

A  lacerated  wound  of  an  artery  may  cause  little  primary  hemorrhage.  The 
internal  coat  curls  up,  the  circular  muscular  fibers  of  the  media  contract  up- 
on it,  the  longitudinal  fibers  retract  and  draw  the  vessel  within  the  sheath, 


Fig.  231. — Clots  formed  after  division  of  an  artery:  a,  Sheath;  b,  outer,  middle,  and  inner 
coats';  c,  c,  branches;  d,  d,  internal  clot;  e,  e,  external  clot. 

and  the  external  coat  becomes  a  cap  over  the  orifice  of  the  vessel.  All  of  these 
conditions  favor  clotting.  The  vessel  wall  is  so  damaged  that  secondary 
hemorrhage  is  usual. 

Punctured  "Wounds. — In  punctured  wounds  primary  hemorrhage  is  slight 
unless  a  large  vessel  is  punctured.  Secondary  hemorrhage  is  not  common. 
Traumatic  aneurysm  and  arteriovenous  aneurysm  are  not  unusual  results. 

Gunshot  wounds  of  arteries  by  pistol  balls  and  the  balls  of  large-caliber 
rifles  are  apt  to  be  contusions  which  may  eventuate  in  sloughing  and  sec- 
ondary hemorrhage  or  thrombosis  and .  gangrene.  A  shell-fragment  makes 
a  lacerated  wound.  A  military  rifle-bullet  may  make  a  cut  or  puncture  of  an 
artery  but  if  the  projectile  is  nearly  spent  may  contuse  the  vessel.  Secondary 
hemorrhage  after  gunshot  wounds  is  most  likely  to  occur  during  the  third  week 
after  the  injury.  A  cut  or  perforation  of  an  artery  may  cause  sloughing  and 
secondary  hemorrhage,  thrombosis  and  gangrene,  or  diffuse  traumatic  aneurysm. 
A  complete  rupture  constitutes  a  lacerated  wound,  and  is  a  condition  accompanied 
by  diffuse  hemorrhage  into  the  tissues.     Such  a  hemorrhage  may  be  rapid  or  slow. 

Wounds  of  veins  are  classified  as  are  wounds  of  arteries.  The  symptom 
of  any  vascular  wound  is  hemorrhage. 

Hemorrhage,  or  Loss  of  Blood 

Hemorrhage  may  arise  from  wounds  of  arteries,  veins,  or  capillaries,  or 
from  wounds  of  the  three  combined.     In  arterial  hemorrhage  the  blood  is 
scarlet  and  appears  in  jets  from  the  proximal  end  of  the  vessel,  these  jets  being 
32 


498  Diseases  and  Injuries  of  the  Heart  and  Vessels 

synchronous  with  the  pulse-beats;  the  stream,  however,  never  intermits. 
The  stream  from  the  distal  end  is  darker  and  is  not  pulsatile.  Venous  hemor- 
rhage is  denoted  by  the  dark  hue  of  the  blood  and  by  the  continuous  stream. 
In  capillary  hemorrhage  red  blood  wells  up  like  water  from  a  squeezed  sponge, 
and  the  color  is  between  the  bright  red  of  arterial  blood  and  the  dark  color  of 
venous  blood. 

In  subcutaneous  hemorrhage  from  rupture  of  a  large  blood-vessel  there 
are  great  swelling,  cutaneous  discoloration,  and  systemic  signs  of  hemorrhage. 
If  a  main  artery  ruptures  in  an  extremity,  there  is  no  pulse  below  the  rupture, 
and  the  hmb  becomes  cold  and  swollen.  At  the  seat  of  rupture  a  large  fluc- 
tuating swelling  forms,  and  sometimes  there  are  bruit  and  pulsation.  If  a 
vein  ruptures  in  an  extremity,  a  large,  soft,  non-pulsatile  swelling  arises,  there 
is  no  bruit,  and  intense  edema  occurs  below  the  seat  of  rupture.  Profuse  hem- 
orrhage induces  constitutional  symptoms,  and  death  may  occur  in  a  few  seconds. 
Loss  of  half  of  the  blood  (from  4  to  6  pounds)  will  usually  cause  death,  though 
women  can  stand  the  loss  of  a  greater  relative  proportion  of  blood  than  men. 
Young  children,  old  people,  individuals  exhausted  by  disease,  drunkards, 
sufferers  from  Bright's  disease,  diabetes,  and  sepsis  stand  loss  of  blood  very 
badly.  An  individual  with  obstructive  jaundice  is  apt  to  suffer  from  persistent 
oozing  of  blood  after  operation,  an  oozing  which  is  particularly  persistent  and 
dangerous  in  obstruction  of  the  bile-ducts  due  to  malignant  disease.  It  not 
unusually  causes  death.  After  profuse  bleeding  has  gone  on  for  a  time,  syncope 
usually  occurs.  Syncope  is  Nature's  effort  to  arrest  hemorrhage,  for  during 
this  state  the  feeble  circulation  and  the  increased  coagulability  of  blood  give 
time  for  the  formation  of  an  external  clot.  When  reaction  occurs  the  clot  may 
hold  and  be  reinforced  by  an  internal  clot,  or  it  may  be  washed  away  with  a 
renewal  of  bleeding  and  syncope.  These  episodes  may  be  repeated  until  death 
supervenes.  Nausea  exists  and  there  may  be  regurgitation  from  the  stomach. 
Vertigo  is  present.  The  room  may  seem  to  be  turning  around.  There  is  dim- 
ness of  vision  or  everything  looks  black;  black  specks  float  before  the  eyes 
(muscae  volitantes),  or  the  patient  sees  flashes  of  light  or  colors.  There  is  a 
roaring  sound  in  the  ears  (tinnitus  aurium).  The  patient  yawTis,  is  restless, 
tosses  to  and  fro,  casts  off  the  bedclothes,  and  great  thirst  is  complained  of. 
The-mind  may  be  clear,  but  delirium  is  not  unusual,  and  convulsions  often  occur. 
After  a  very  severe  hemorrhage  an  individual  is  intensely  pale  and  his  skin  has 
a  greenish  tinge;  his  lips  are  blanched,  the  tongue  is  cold  and  white;  the  brow  is 
covered  with  cold  moisture,  the  breath  is  cold;  the  eyes  are  fixed  in  a  glassy 
stare  and  the  pupils  are  widely  dilated,  and  react  slowly  to  light;  the  respirations 
are  shallow  and  sighing;  the  skin  is  covered  with  a  cold  sweat;  the  hands  are 
clammy  and  look  like  wax;  the  legs  and  arms  are  extremely  cold,  and  the  body 
temperature  is  below  normal.  The  pulse  is  very  frequent,  soft,  small,  compress- 
ible, fluttering,  or  often  cannot  be  detected;  the  heart  is  very  weak  and  flutter- 
ing, and  the  arterial  tension  is  almost  abolished.  There  is  muscular  tremor;  the 
patient  tosses  about,  and  asks  often  and  in  a  feeble  voice  for  water.  The  suffer- 
ing from  thirst  is  terrible  and  no  amount  of  water  gives  relief.  There  is  often 
dreadful  dyspnea;  at  each  inspiration  the  nostrils  open  widely  and  the  acces- 
sory muscles  of  respiration  are  all  in  action.  A  man  who  is  bleeding  to  death 
grasps  at  his  chest,  makes  efforts  to  rise,  and  then  falls  back  in  a  dead  faint. 
Usually  reaction  occurs  after  a  faint,  though  the  patient  ip  obviously  weaker 
than  before;  again  a  faint  may  happen,  and  so  there  is  fainting  spell  after  faint- 
ing spell  until  death  ensues.  Convulsions  frequently  precede  death.  In  hemor- 
rhage the  hemoglobin  is  greatly  diminished  in  amount.  In  an  intra-abdominal 
hemorrhage  the  above  symptoms  are  noted,  and,  except  in  splenic  hemor- 
rhage, blood  gathers  in  both  loins,  and  dulness  on  percussion  exists  which  gradu- 
ally rises  and  shifts  as  the  patient's  position  is  shifted.  The  blood  also  gathers 
in  the  rectovesical  pouch  in  the  male,  and  in  the  recto-uterine  pouch  in  the 


Hemostatic  Agents  499 

female,  and  may  be  detected  by  digital  examination.  If  the  spleen  is  wounded 
the  blood  usually  clots  quickly,  and  if  it  does,  an  area  of  dulness,  which  does 
not  shift  and  which  progressively  increases,  is  noted  in  the  splenic  region. 

Treatment. — WTien  serious  hemorrhage  exists  the  surgeon  should,  when 
possible,  arrest  bleeding  temporarily,  and  should  then  bring  about  reaction 
and  arrest  bleeding  permanently.  Temporary  arrest  is  not  possible  in  an 
intra-abdominal  hemorrhage.  In  any  case  of  severe  hemorrhage  lower  the 
head,  and  have  compression  made  upon  the  femorals  and  subclavians,  so  as 
to  divert  more  blood  to  the  brain,  or  bandage  the  extremities  (autotransfusion). 
Apply  artificial  heat.  The  value  of  adrenalin  in  restoring  or  maintaining  arte- 
rial tension  has  been  demonstrated  by  Crile.  We  should  give  the  patient  by 
h>"podermoclysis  i  pint  of  hot  normal  salt  solution  containing  i  dr.  of  the  i  :  1000 
solution  of  adrenalin  chlorid.  The  fluid  is  allowed  to  run  in  the  subcutaneous 
tissue  beneath  the  breast.  The  infusion  of  i  pint  or  more  of  hot  salt  solution 
into  a  vein  is  a  very  valuable  remedy;  it  gives  the  heart  something  to  con- 
tract upon  and  thus  maintains  cardiac  action.  If  the  depression  is  very  severe, 
inject  ether  h^'podermatically,  then  brandy,  and  then  atropin.  Strychnin 
may  be  given  h^^odermatically  in  doses  of  f^o  gr.,  but  atropin  is  of  more  serv- 
ice. Digitalin  is  advised  by  some,  but  it  is  not  sufiiciently  rapid  in  action. 
Give  enemata  of  hot  coffee  and  brandy.  Apply  mustard  over  the  heart  and 
spine.     Lay  a  hot-water  bag  over  the  heart. 

In  hemorrhage  from  a  vessel  of  an  extremity  temporarily  arrest  bleeding 
while  bringing  about  reaction.  Do  so  by  digital  pressure  in  the  wound,  or, 
if  the  bleeding  is  arterial,  by  the  application  of  an  Esmarch  band.  In  some 
cases  force  flexion  is  used.  As  soon  as  reaction  is  established,  permanently 
arrest  bleeding  by  the  ligature.  In  intra-abdominal  or  concealed  hemorrhage 
it  is  not  possible  to  arrest  it  temporarily  and  wait  for  reaction,  but  the  abdomen 
must  be  opened  and  the  work  proceeded  with  in  spite  of  the  patient's  condi- 
tion.    Every  moment  we  wait  he  is  growing  worse. 

A  severe  hemorrhage  is  apt  to  be  followed  by  fever,  due  to  the  aosorption 
of  fibrin  ferment  from  extravasated  blood  and  its  action  upon  a  profoundly 
debilitated  system.  After  a  severe  hemorrhage  leukocytes  are  increased,  not 
only  relatively,  but  absolutely.  Red  corpuscles  are  diminished  both  relatively 
and  absolutely.  Hemoglobin  diminishes;  many  of  the  corpuscles  become 
irregular  and  microcytes  are  noticed. 

In  treating  a  patient  who  has  thoroughly  reacted  after  a  severe  hemor- 
rhage, apply  cold  to  the  head.  Fluids  and  ice  are  grateful.  Frequently  sponge 
the  skin  -with  alcohol  and  water.  Milk-punch,  koumiss,  and  beef-peptonoids 
are  given  at  frequent  intervals. 

Hemostatic  agents  comprise:  (i)  the  ligature  and  suture;  (2)  torsion; 
(3)  acupressure;  (4)  elevation;  (5)  compression;  (6)  styptics;  (7)  the  actual 
cautery;  (8)  forced  flexion  of  a  limb. 

The  ligature  was  known  to  the  ancients,  but  was  rediscovered  by  Ambroise 
Pare.  The  ligature  may  be  made  of  silk,  floss-silk,  or  catgut.  Whatever 
material  is  used  must,  of  course,  be  rendered  aseptic.  A  ligature  should  be 
about  10  inches  long.  The  vessel  to  be  tied  must  be  drawn  out  with  for- 
ceps and  separated  for  a  short  distance  from  its  sheath,  but  must  not  be  sepa- . 
rated  to  any  considerable  extent;  to  do  so  may  lead  to  necrosis  of  the  vessel 
and  secondary  hemorrhage.  The  hemostatic  forceps  (Figs.  232,  233,  234) 
is  in  most  cases  a  better  instrument  than  the  tenaculum  (Fig.  235).  The 
tenaculum  makes  a  hole  in  the  vessel,  and  sometimes  a  slit-like  tear.  A  por- 
tion of  this  opening  may  remain  back  of  the  tied  ligature,  the  vessel  may  re- 
tract a  little,  or  the  ligature  may  slip  slightly,  and  bleeding  may  occur.  When 
the  artery  lies  in  dense  tissues  or  is  retracted  deeply  in  muscle  or  fascia, 
the  tenaculum,  when  carefully  used,  is  the  better  instrument.  The  ligature 
is  tied  in  a  reef-knot  (Fig.  236),  not  in  a  granny-knot  (Fig.  237)  and  not  in  a 


Soo 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


surgeon's  knot  (Fig.  238).     It  is  often  the  purpose  of  the  surgeon  to  divide  the 
internal  and  middle  coats  of  the  vessel,  and  if  such  is  his  desire  the  first  knot 


Fig.   232. — Halsted's  straight  artery  forceps. 

is  firmly  tied.     The  second  knot  must  not  be  tied  too  tightly  or  it  will  cut  the 
ligature.     The  ligature  must  not  be  jerked  as  it  is  being  tied.     If  a  third  knot 


Fig.  2SS- — Curved  hemostatic  forceps. 

overlies  the  first  two,  the  ligature  can  be  cut  off  close  to  the  knot,  otherwise 
it  is  cut  off  so  that  short  ends  are  left.     Both  ends  of  a  divided  vessel  should  be 


Fig.  234. — Straight  hemostatic  forceps. 

ligated.     If  a  vessel  is  atheromatous,  it  is  not  desirable  to  divide  the  internal 
and  middle  coats.     In  this  case  a  hgature  should  be  applied  firmly  rather  than 


Hemostatic  Agents 


501 


tightly,  and  another  ligature  should  be  put  on  above  it,  or  ligation  can  be 
efifected  by  the  stay  knot.  If  an  artery  is  incompletely  divided,  a  ligature 
should  be  applied  on  each  side  of  the  wound  and  the  vessel  divided  between 
the  ligatures. 

When  the  parts  about  an  artery  are  so  thickened  that  the  vessel  cannot 
be  drawn  out,  arm  a  curved   Hagedorn  needle  (Fig.  239)  with  catgut  and  pass 


Fig.  235. — Tenaculum. 

the  latter  around  the  vessel  in  such  a  manner  that  the  catgut  will  include  the 
vessel  mth  some  of  the  surrounding  tissue.  Then  tie  the  ligature  (Fig.  241). 
This  method  is  known  as  the  application  of  a  suture-ligature,  and  is  pursued 
in  necrosis,  atheroma,  scar-tissue,  sloughing,  etc.  Never  include  a  nerve  of  any 
size  in  the  ligature.     If  this  mode  of  ligation  fails,  we  may  try  acupressure. 


Fig.  236.— Method  of  tying  square  or  reef-knot.         Fig.  237. — Method  of  tying  granny-knot. 


Doyen,  when  about  to  tie  a  thick  pedicle,  crushes  it  by  means  of  a  very 
powerful  instrument  and  then  ties  a  ligature  about  the  crushed  and  attenuated 
area.  The  vessels  are  closed  by  laceration  wide  of  the  ligature  and  the  ligature 
does  not  tend  to  slip.  Some  trust  such  a  stump  without  a  ligature,  but  most 
surgeons  prefer  to  ligate.  This  instrument  is  known  as  the  vasotribe  or  angio- 
tribe  and  is  used  particularly  in  hysterectomy.     Figure  242  shows  a  vasotribe. 

Veins  are  ligated  as  are  arteries.  If  a 
large  vein  is  torn,  we  wish,  if  possible,  to 
control  hemorrhage  without  obliterating 
the  lumen  of  the  vein  by  ligation.  If  the 
wound  is  not  greater  in  length  than  the 
measure  of  the  diameter  of  the  lumen,  a 
lateral  ligature  may  be  used.  It  is  prac- 
tically always  used  in  small  transverse 
wounds.  In  order  to  apply  a  lateral  liga- 
ture' the  two  lips  of  the  vein  wound  are 

seized  by  forceps  and  drawn  out  into  a  tit  (Figs.  240  and  258).  A  ligature 
is  placed  around  the  base  of  the  cone  and  tied.  The  pull  in  the  cone  is 
relaxed  while  the  first  knot  is  being  tied  in  order  that  the  ligature  may  constrict 
tightly.  In  a  large  vessel  the  thread  should  be  passed  by  a  needle  through  the 
outer  coats  of  the  vein  before  it  is  used  to  encircle  the  cone.  This  plan  prevents 
slipping.  In  some  cases  when  a  lateral  ligature  or  suture  cannot  be  applied, 
f orcipressure  will  succeed.  One  or  more  clamp  forceps  are  applied  and  are  left 
in  place  for  several  days. 

Angiorrhaphy  is  suturing  of  a  blood-vessel,  either  a  vein  or  an  artery. 
Temporary  hemostasis  is  secured  before  suturing  by  the  use  of  the  elastic  band 


Fig.  238. 


-Method  of  tying  surgeon's 
knot. 


502 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


(seldom),  by  the  employment  of  a  special  clamp  (Dorrance's,  Crile's,  Murphy's, 
or  Herrick's),  or  by  fine  linen  tape,  passed  around  the  vessel  on  each  side  of  the 


Fig.  239. — Hagedorn's  needles. 


Fig.  240. — Method  of  controlling  hem- 
orrhage by  ligature  (after  Esmarch):  a, 
x\rtery  ligated;  b,  lateral  ligature  of  vein. 


wound,  not  tied  but  fastened  by  forceps  after  tightening.  What  ever  plan 
is  employed  must  be  gentle.  The  circulation  is  to  be  controlled  but  on  no 
account  is  the  vessel  to  be  damaged. 

Phleborrhaphy  is  suturing  of  a  vein,  with  pre- 
servation of  the  lumen  of  the  vessel.  It  is  used 
when  complete  ligation  is  undesirable  (as  in  a 
large  vein),  and  when  lateral  ligation  without 
obliteration  of  lumen  is  impossible.  It  is  com- 
monly employed  for  longitudinal  wounds  and 
for  wounds  in  any  direction  when  the  length  of 
the  wound  is  greater  than  the  diameter  of  the 
vessel.  Fine  catgut  or  silk  may  be  used.  An 
intestinal  needle  threaded  with  silk  is  entirely 
satisfactory.  The  thread  is  passed  through  the 
external  coat  and  part  of  the  middle  coat  on  each 
side  of  the  wound.  Interrupted  sutures  are  employed  and  thus  the  two  lips  of 
the  wound  are  approximated.     A  vein  completely  divided  across  can  be  united 


Fig.  241. — Arrest  of  hem 
orrhage  by  passing  a  suture 
ligature. 


Fig.   242. — Vasotribe  of  Doyen. 

by  end-to-end  suturing.     Figure  243  shows  the  operation  of  phleborrhaphy  for 
a  longitudinal  wound. 


Hemostatic  Agents 


503 


By  suturing  I  successfully  closed  a  tear  in  the  innominate  vein  inflicted 
during  the  removal  of  a  retrosternal  goiter,  and  also  a  considerable  longitudinal 
tear  in  the  internal  jugular  vein  inflicted  during  the  removal  of  lymph-nodes. 

Murphy  and  Damar  Harrison  each  succeeded  in  suturing  a  wound  of  the 
inferior  vena  cava.  Bier  successfully  applied  sutures  in  2  cases  of  wound  of 
the  inferior  vena  cava. 

Israel  points  out  how  difficult  it  is  to  suture  in  the  depths  of  a  cavity  full 
of  blood.  This  complication  always  exists  in  wounds  of  the  inferior  cava,  and 
in  them  it  may  be  necessary  to  use  forcipressure.     He  did  this  in  2  cases. 

In  a  case  of  Korte's  the  cava  was  wounded  during  nephrectomy.  Forci- 
pressure and  lateral  sutures  were 
found  impracticable.  The  cava 
was  tied.  Thrombophlebitis 
arose  in  both  legs,  but  the 
patient  eventually  recovered 
("Zentralbl.  fiir  Chir.,"  August 
8,  i9ii)._ 

Arteriorrhaphy. — As  long  ago 
as  1759  Hallo  well  and  Lambert 
closed  a  small  wound  in  the 
brachial  artery  by  the  use  of 
a  harelip  pin  and  suture.  The 
operation  of  arteriorrhaphy  has 
only  recently  begun  to  claim 
surgical  confidence  and  it  has 
been  brought  into  the  realm  of 
practical  surgery  largely  by 
w^ork  in  the  experimental  labo- 
ratory. The  studies  of  Carrel, 
Murphy,  Matas,  Abbe,  and 
others  have  shown  that  wounded 
arteries  can  be  repaired  by  sutur- 
ing; that  a  portion  of  an  artery 
can  be  removed  and  repair  be  ob- 
tained by  end-to-end  suturing, 
implantation,  or  lateral  anasto- 
mosis; that  an  artery  can  be  obliterated  by  suturing  the  intima  from  within; 
that  an  artery  can  be  anastomosed  into  a  vein,  and  that  after  resection  of  a 
portion  of  an  artery  vascular  integrity  may  be  restored  by  suturing  into  the 
gap  a  portion  of  a  vein  or  artery  recently  resected. 

We  now  suture  certain  wounds  in  large  vessels  which  until  very  recently 
woidd  have  caused  us  to  ligate  the  artery.  In  extirpating  malignant  tumors 
it  is  sometimes  necessary  to  remove  large  arteries  or  veins.  This  may  cause 
grave  danger  of  gangrene,  and  we  may  attempt  to  prevent  gangrene  by  the 
restoration  of  vascular  continuity. 

The  wonderful  experiments  of  Carrel  on  the  transplantation  of  organs  and 
the  brilliant  studies  and  operations  of  Matas  and  Murphy  have  been  the  great 
influences  that  have  brought  vessel  suture  into  the  field  of  practical  surgery. 

There  is  yet  much  to  learn.  What  we  do  know  is  really  little,  but  we  are 
probably  at  the  threshold  of  great  events. 

We  know  that  we  can  close  by  suture  a  lateral  wound,  or  a  transverse  wound 
of  less  than  half  the  circumference  of  the  vessel;  that  we  can  perform  end-to- 
end  suturing;  that  we  can  insert  a  piece  of  resected  vein  to  re-establish  vascular 
continuity;  that  an  artery  can  be  anastomosed  to  a  vein  either  by  lateral  anasto- 
mosis or  end-to-end  suturing;  and  that  after  such  an  operation  the  blood-current 
wiU  in  many  cases  be  re-established.     We  do  not  know  how  long  the  circulation 


Fig.  243. — Phleborrhaphy;  Forceps  are  seen 
everting  lip  of  wound  for  passage  of  needle  and 
interrupted  sutures  (Bickham). 


504 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


will  continue  after  re-establishment.  A  sutured  artery  will  certainly  carry 
blood  for  a  time,  but  in  some  cases,  at  least,  only  for  a  time,  the  ultimate  fate 
of  the  vessel  being  obliteration  by  endothelial  proliferation.  If  the  vessel  oper- 
ated upon  is  diseased,  obliteration  by  clot  is  practically  certain  to  ensue.  But 
even  temporary  re-establishment  of  circulation  is  of  the  greatest  value.  Even 
though  the  lumen  is  finaUy  closed,  the  closure  is  gradual.  While  the  vessel 
is  closing  the  collaterals  are  dilating.  By  the  time  one  source  of  supply  for  the 
tissues  is  cut  off,  another  has  come  into  being.     Thus  gangrene  is  prevented. 

There  appears  to  be  a  certain  amount  of 
danger  of  the  development  of  aneurysm 
at  the  seat  of  suturing.  In  a  longitudi- 
nal wound  of  an  artery  or  in  a  transverse 
wound  of  not  over  half  the  circumference 
of  the  vessel,  the  wound  mav  be  closed 


Fig.  244. — Repair  of  longitudinal  wound  of 
artery  by  combination  cobbler's  stitch  through 
all  coats,  and  interrupted  sutures  through  outer 
coats,  as  suggested  by  the  author:  A,  Begin- 
ning of  cobbler's  stitch  through  all  coats;  B,  B, 
needles  in  act  of  passing  through  same  opening 
in  opposite  directions,  in  characteristic  cobbler 
fashion;  C,  C,  C,  three  interrupted  sutures 
through  outer  coats,  ready  to  be  tied;  D,  D,  two 
interrupted  sutures  tied,  passing  through  outer 
coats  (Bickham). 


Fig.  245. — Repair  of  complete  trans- 
verse division  of  artery  by  combination  cob- 
bler's stitch  through  all  coats,  followed  by 
interrupted  sutures  through  outer  coats,  as 
suggested  by  the  author:  A,  A,  Needles  pass- 
ing in  opposite  directions  through  all  coats, 
in  act  of  placing  cobbler's  stitch;  B,  super- 
ficial tier  of  interrupted  stitches  through 
outer  coats,  showing  three  untied  and  two 
tied  (Bickham). 


by  interrupted  sutures,  passing  the  threads  through  the  two  outer  coats  and 
bringing  the  wound  edges  together  without  inversion.  Floss  silk,  Japanese 
silk,  very  fine  Lyons  silk,  the  celluloid  hemp  of  Braun  or  No  i.  Pagenstecher 
thread  should  be  used  as  a  suture  material.  A  very  fine  needle,  straight  or  cu  rved 
and  devoid  of  a  cutting  edge  is  to  be  employed  (intestinal  needle).  The  silk 
should  be  as  large  as  the  eye  of  the  needle  will  carry  so  that  leaking  through  the 
stitch  hole  will  not  occur.  Carrel  has  shown  that  it  is  highly  important  to 
impregnate  the  suture  material  with  sterile  vaselin.     This  prevents  clotting 


Hemostatic  Agents 


505 


upon  the  thread.     The  sheath   must  be  sutured  over  the  stitch  line  ("Bick- 
ham's  Operative  Surgery"). 

Lateral  artcriorrhaphy  for  a  longitudinal,  an  oblique  or  a  transverse  wound 
may  be  employed  if  it  does  not  too  nearly  obliterate  the  arterial  lumen.  Some 
surgeons  pass  sutures  through  the  external  and  middle  coats  but  not  through  the 
intima.     This  is  an  objectionable  method.     The  blood  is  very  liable  to  clot 


Fig.  246. — Artcriorrhaphy  in  complete  circular  division  of  an  artery  (^lurphy's  method). 
A,  Intussusception,  with  sutures  passing  through  outer  and  middle  coats;  B,  intussuscipiens 
(split  to  aid  invagination),  with  sutures  passing  through  all  coats;  C,  showing  all  sutures  tied 
(Bickham). 

and  blood  may  enter  between  the  coats  and  cause  an  aneurysm.  A  better  plan 
is  to  include  all  the  coats  in  the  sutures  and  so  approximate  the  endothelial 
surfaces.  Some  operators  use  interrupted  sutures  but  most  prefer  a  continuous 
suture.  A  suture  which  everts  the  lips  of  the  wound  has  been  used  by  Dorrance, 
Jaboulay     and     Archibald 


Brien, 

Smith, 
duced 


Each  suture  when  intro- 
is  U-shaped.  Bickham 
passes  cobbler's  stitches  through 
all  the  coats  and  interrupted 
stitches  through  the  cut  coat  (Fig. 
244). 

End-to-end  anastomosis  {circular 
arteriorrhaphy)  may  be  used  when 
a  large  vessel  has  been  cut  across 
completely  or  when  a  portion  of  an 
artery  has  been  excised.  The  sheath 
is  pulled  over  the  end  of  the  vessel 
and  cHpped  off.  During  the  opera- 
tion the  structures  are  kept  moist 


J 

Fig.  247. — a,  Simple  suture;  b,  eversion  suture. - 


by  the  application  of  sterile  vaselin  or  by  the  employment  of  salt  solution. 
The  operation  may  be  done  by  Bickham's  plan,  viz.,  a  cobbler's  stitch  through 
all  the  coats  to  bring  the  intima  of  each  lip  together  and  interrupted  sutures 
through  the  outer  coats  (Fig.  245).  Murphy's  plan  is  invagination  of  one  end 
of  the  cut  vessel  into  the  other  end  split  to  receive  it  (Figs.  245  and  246).  If  a 
vessel  is  divided  transversely  through  more  than  half  of  its  circumference  Murphy 
believes  that  the  division  should  be  made  complete  as  a  preliminary  to  suturing. 


5o6 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


Fig.  248.1  shows  the  method  of  Salomoni  and  TomaselH  and  Fig.  248^  shows 
Gluck's  method.  Payr  uses  a  magnesium  ring  which  is  grooved  in  its  outer  sur- 
face. The  central  end  of  the  cut  artery  is  pulled  through  the  ring  so  that  it 
protrudes.  The  protruding  portion  is  turned  back  over  the  ring  as  a  lady  might 
turn  back  a  long  cuff  over  a  bracelet.  A  suture  is  tied  around  so  as  to  fix  the 
parts.  The  ring  is  now  extra  vascular  and  the  free  end  of  the  vessel  is  an  endothe- 
lial surface.  The  central  segment  with  its  ring  is  passed  into  the  lumen  of  the 
peripheral  segment.  The  parts  are  fixed  by  a  ligature.  The  magnesium  ring 
will  be  absorbed  eventually.  The  method  by  the  cobbler's  stitch  and  inter- 
rupted sutures  is  shown  in  Figs.  244-245. 

Venous  implantation  is  an  operation  in  which  a  gap  in  an  artery  is  filled  by 
the  implantation  of  a  segment  of  a  vein. 

The  author  successfully  sutured  a  wound  in  the  axillary  artery  and  closed 
by  suture  the  arterial  opening  of  an  aneurysmal  varix  after  resecting  and  ligat- 
ing  the  vein.     Stewart  removed  a  clot  from  the  femoral  and  sutured  the  vessel. 


Fig.  248. — Circular  arteriorrhaphy  in  complete  division  of  an  artery:  A,  Method  of 
Salomoni  and  TomaselH — interrupted  sutures  through  all  coats;  B,  method  of  Gluck — inter- 
rupted sutures  through  outer  coats,  protected  by  cylinder  of  decalcified  bone,  ivory,  or  rubber 
(Bickham). 


He  also  resected  a  portion  of  the  brachial  and  in  another  case  a  portion  of  the 
femoral,  suturing  by  Murphy's  method  in  the  first  case  and  by  Carrel's  in  the 
second.  Murphy  removed  a  clot  from  the  external  iliac  artery  and  sutured 
the  vessel.  Braun  ("Zentralblatt  fur  Chirurgie,"  August  29,  1908)  resected 
a  portion  of  the  aorta  along  with  a  tumor  and  performed  circular  suture.  The 
patient  was  well  in  four  weeks.  Depage  successfully  sutured  the  common 
carotid  artery.  Pringle  sutured  a  wound  of  the  external  iliac  artery.  The 
wound  was  3^  inch  in  length.  Dejemil  Pasha  sutured  a  lacerated  wound  of 
the  axillary  artery.  Torance  sutured  a  wounded  brachial  artery.  Martin 
sutured  a  lacerated  wound  of  the  femoral  artery  ("Annals  of  Surgery,"  Oct., 
1905).  Henderson  sutured  a  transverse  wound  extending  half  across  the 
femoral  artery  ("American  Medicine,"  Jan.  14,  1905).  A.  E.  Halstead  cut 
two-thirds  through  the  circumference  of  the  axillary  artery  and  sutured  the 
wound  directly  instead  of  making  the  wound  first  of  all  a  complete  division, 
as  advised  by  Murphy.  Two  months  later  the  radial  pulse  was  present. 
Faykiss  made  an  end-to-end  suture  of  a  divided  carotid  artery  ("Centralb. 
fiir  Chirurgie,"  1908,  xxxv).  Braun,  while  removing  an  abdominal  tumor 
tore    the    aorta.     He   resected   and   performed  end-to-end  anastomosis.     The 


Hemostatic  Agents  507 

patient  recovered  (quoted  by  Behan  in  "  Surgery,  Gynecology,  and  Obstetrics, 
Sept.,  1916). 

Lexer  ("Archiv.  fiir  klinische  Chirurgie,"  1907,  No.  2)  resected  the  sac  of  a 
traumatic  arteriovenous  aneurysm  of  the  popliteal  vessels,  removing  at  the 
same  time  5  cm.  of  artery  and  as  much  vein. 

He  performed  end-to-end  anastomosis  of  each  vessel  by  aid  of  thin  magnesium 
tubes  (Payr's  tubes).  The  pulse  was  restored.  Nine  months  after  operation 
the  pulse  was  present  below  the  seat  of  operation,  but  was  weaker  than  it  had 
been  some  months  before.  In  this  paper  Lexer  speaks  of  a  case  of  diffuse 
aneurysm  of  the  axillary  artery.  The  surgeon  resected  the  sac  and  a  portion  of 
the  artery.  The  gap  of  over  3  inches  was  filled  by  a  piece  of  internal  saphenous 
vein  sutured  in  place  (atito plasty).  The  circulation  was  re-established  in  the 
limb,  but  the  patient  died  of  complications.  Postmortem  demonstrated  that 
the  transplanted  vein  was  patent  and  the  sutures  firm.  There  was  a  clot  above 
the  piece  of  vein  due  to  the  action  of  the  clamp  upon  a  sclerotic  artery.  Gan- 
grene began  on  the  fourth  day  after  operation. 

Manteuffel  successfully  sutured  a  wound  of  the  femoral  artery.  This  was 
the  first  case  to  be  recorded  (Bloodgood,  in  "Progressive  Medicine,"  Dec. 
1,1908),  although  Hallowell,  in  1759,  successfully  closed  a  wound  in  the 
brachial  artery  by  means  of  a  harehp  pin  and  a  ligature  (Mumford).  Blood- 
good  in  the  same  article  notes  that  Korte,  in  1904,  performed  lateral  suture 
of  the  popliteal  artery  and  vein,  and  that  Garre  closed  a  wound  in  the  pop- 
liteal artery  by  suture,  and  in  the  vein  of  the  same  patient  by  lateral  ligature. 

Murphy  was  the  first  surgeon  to  succeed  in  resecting  a  portion  of  a  large 
artery  (the  femoral)  and  in  doing  end-to-end  suturing  ("Med.  Record,"  Jan.  16, 
1897). 

Lund  ("Annals  of  Surgery,"  March,  1909)  sutured  a  double  stab-wound  of 
the  femoral  artery  and  vein,  and  six  months  later  there  was  a  pulse  in  the  dor- 
salis  pedis.  Routier  tore  the  aorta  in  removing  a  hypernephroma  of  the  kidney. 
He  sutured  the  wound  with  catgut.  The  patient  died  on  the  fourteenth  day, 
but  not  from  hemorrhage  ("Gaz.  des  Hopitaux,"  1911).  Mantelh  closed  a 
gap  in  the  femoral  artery  by  a  segment  of  a  vein  (autoplastic  graft).  Buchanan 
performed  circular  resection  and  suture  of  the  axillary  artery,  the  vessel  having 
been  lacerated  by  the  bone  fragments  after  fracture-dislocation  of  the  anatom- 
ical neck  of  the  humerus.  Buchanan  has  collected  29  instances  of  end-to-end 
suture  of  divided  arteries  ("Surgery,  Gynecology,  and  Obstetrics,"  Dec,  1912). 

Among  other  surgeons  reporting  successful  cases  of  arterial  suture  are 
Heidenhain,  Orlow,  Pean,  Baum,  Sherman,  Krause,  Payr,  Kummell,  Seggel, 
Martin  Lindner,  and  Brougham.  A  great  many  successful  cases  of  circular 
arteriorrhaphy  have  been  recorded  during  this  war. 

Torsion  was  practised  by  the  ancients,  but  was  reintroduced  in  modern 
times,  particularly  by  Amussat,  Velpeau,  Syme,  and  Bryant,  of  London.  By 
means  of  torsion  the  internal  and  middle  coats  are  ruptured  and  the  external 
coat  is  twisted.  The  middle  coat  retracts  and  contracts,  and  the  inner  coat 
inverts  into  the  lumen  of  the  artery.  It  is  a  safe  procedure,  and  is  practised 
upon  vessels  as  large  as  the  femoral  by  many  surgeons  of  high  standing.  Before 
the  days  of  asepsis  torsion  possessed  the  signal  merit  of  not  introducing  possible 
infection  in  ligatures.  At  the  present  time  it  offers  no  particular  advantage. 
It  is  no  quicker  than  the  ligature,  and  damages  the  vessel  so  much  that  necrosis 
may  occur.  It  cannot  be  used  if  the  vessels  are  diseased.  In  what  is  known 
as  free  torsion  the  vessel  is  grasped,  drawn  out,  and  twisted  until  the  free  end 
of  the  vessel  is  twisted  off.  Limited  torsion  is  more  often  used.  The  vessel  is 
drawn  out  of  its  sheath  by  a  pair  of  forceps  held  horizontally,  and  is  grasped 
a  little  distance  above  its  extremity  by  another  pair  of  forceps  held  vertically 
(Fig.  249).  The  first  instrument  is  used  to  twist  the  artery  six  to  eight 
times. 


^o8 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


Fig.  249. — Method  of  controlling  hem- 
.orrhage  by  torsion. 


Acupressure  is  pressure  applied  by  means  of  a  long  pin.  The  method  of 
hemostasis  by  acupressure  was  devised  by  Sir  James  Y.  Simpson.  A  pin 
is  simply  passed  under  a  vessel  (transfixion),  leaving  a  little  tissue  on  each 
side  between  the  pin  and  vessel.  A  pin  can  be  passed  under  a  vessel,  and 
a  wire  be  thrown  over  the  pin  and  twisted  (circumclusion).  The  pin  can 
be  inserted  upon  one  side,  passed  through  3^2  ii^ch  of  tissues  up  to  the  vessel,  be 
given  a  quarter  twist,  and  be  driven  into  the  tissues  across  the  artery  (torsoclu- 

sion).  Some  tissue  may  be  pricked  up  on 
the  pin,  folded  over  the  vessel  and  pinned 
to  the  other  side  (retroclusion).  Acu- 
pressure is  occasionally  used  to  arrest 
hemorrhage  if  vessels  are  inflamed  or 
atheromatous,  in  sloughing  wounds,  in 
scar-tissue,  and  when  a  ligature  will  not 
hold  firmly. 

Elevation  is  used  as  a  temporary  expe- 
dient  or   in   association  with  some  other 
method.     It   is   of  use  in  a  wound  of  a 
bursa,  in  bleeding  from  a  ruptured  vari- 
cose vein  or  from  bone,  and  its  use  is  frequently  associated  with  compression. 

Compression  is  either  direct  or  indirect — that  is,  in  the  wound  or  upon  its 
artery  of  supply.  After  the  removal  of  the  upper  jaw  arrest  bleeding  by  plugging 
the  cavity.  In  injury  of  a  cerebral  sinus  plug  with  gauze.  Compression  and  hot 
water  (115°-!  20°  F.)  will  stop  capillary  bleeding.  A  graduated  compress  was  for- 
merly recommended  in  hemorrhage  from  the  palmar  arch  (Fig.  251).  A  compress 
will  arrest  bleeding  from  superficial  veins.  The  knotted  bandage  of  the  scalp 
will  arrest  bleeding  from  the  temporal  artery.  Long-continued  pressure  causes 
pain  and  inflammation. 

Indirect  compression  is  used  to  prevent  hemorrhage  or  to  arrest  it  tem- 
porarily.    It  may  be  effected  by  encircling  a  limb  above  a  bleeding  point  with 

an  Esmarch  band  or  by  applying  a  tourniquet 
or  an  improvised  tourniquet  (Fig.  252).  It  may 
also  be  effected  by  a  clamp.  Crile  has  devised 
a  clamp  to  effect  temporary  closure  of  the 
carotid  artery.  In  operations  about  the  head 
one  or  both  carotids  may  be  closed  for  a  con- 
siderable time  and  bleeding  may  thus  be  largely 
prevented.  In  10  cases  Crile  temporarily  closed 
both  carotids.  A  hypodermatic  injection  of 
atropin  is  given  to  prevent  inhibition,  the 
vessels  are  exposed,  and  the  clamps  are  applied 
with  just  sufficient  firmness  to  approximate  the 


Fig.  250. — Tamponade  of  in- 
tercostal arery  (after  Von  Langen- 
beck) . 


Fig. 


251. — Conical  aseptic  tampon  (graduated  compress) 
compressing  an  artery  (Senn). 


vessel  walls.  No  clot  will  form  if  the  walls  are  not  compressed.  The  patient 
is  in  the  Trendelenburg  position.  If  it  is  found  that  respiratory  difficulty 
occurs,  one  clamp  must  be  loosened.  After  the  completion  of  the  operation 
the  patient  must  be  brought  to  the  horizontal  before  the  clamps  are  removed 
(Crile,  in  "Annals  of  Surgery,"  April,  1902). 


Hemostatic  Agents 


509 


Digital  compression  is  a  form  of  indirect  compression.  It  can  be  main- 
tained for  only  a  few  minutes  by  one  person,  but  a  relay  of  assistants  can  carry 
it  out  for  a  considerable  time.  In  compressing  the  subclavian  artery  wrap  a 
key  as  shown  in  Fig.  253,  and  compress  the  artery  against  the  outer  surface  of 
the  first  rib.  The  shoulder  must  be  depressed  and  pressure  applied  in  the  angle 
between  the  posterior  border  of  the  sternocleidomastoid  and  the  upper  border 
of  the  clavicle.  The  direction  of  the 
pressure  should  be  dowmward,  backward, 
and  inward. 

The  brachial  arter}-  can  be  compressed 
against  the  humerus.  In  the  upper  part 
of    the   course   of  the  artery  the  pressure 


Fig.  252. — Impromptu  tourniquet  for  compressing 
an  artery  vnth  a  handkerchief  and  a  stick. 


Fig.  253. — Handle  of  door-ke}-,  padded. 


should  be  from  within  outw^ard  (Fig.  254);  in  the  lower  part,  from  before  back- 
ward (Fig.  255).  The  abdominal  aorta  can  be  compressed  by  Macewen's 
method  (q.  v.).  The  common  iliac  can  be  compressed  through  the  rectum  by 
means  of  a  round  piece  of  w^ood  known  as  Davy's  lever.  The  femoral  artery 
can  be  compressed  just  below  Poupart's  ligament  against  the  psoas  muscle 
and  head  of  the  femur  (Fig.  256).  The  pressure  should  be  directly  backw^ard. 
In  the  middle  third  of  the  thigh  digital  compression  is  unsatisfactory,  and  a 
tourniquet  should  always  be  used  or  an  Esmarch  band  be  employed. 


Fig.  254. — Digital  compression  of  the  brachial  artery. 


Fig.  255. — Digital  compression 
of  the  brachial  arterj'. 


Forced  flexion  is  a  variety  of  indirect  compression  introduced  by  Adelmann. 
It  will  arrest  bleeding  below  the  point  compressed,  but  soon  becomes  intensely 
painful.  Forced  flexion  can  be  maintained  by  bandages.  Brachial  h}^er- 
flexion  is  maintained  by  tying  the  forearm  to  the  arm.  It  is  often  associated 
with  the  use  of  a  pad  in  front  of  the  elbow.  Genuflexion  is  maintained  by  tying 
the  foot  to  the  thigh.  It  is  increased  in  efficiency  by  placing  a  pad  in  the  pop- 
liteal space. 

Styptics. — Chemicals  are  now  rarely  used  to  arrest  hemorrhage.  In  epistaxis 
w^e  may  pack  with  plugs  of  gauze  saturated  wdth  a  10  per  cent,  solution  of  anti- 


5IO 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


pyrin.  In  bleeding  from  a  tooth-socket  freeze  with  chlorid  of  ethyl  spray, 
and  then  pack  with  gauze  soaked  with  lo  per  cent,  solution  of  antipyrin  or 
pack  with  dry  sponge  or  styptic  cotton  (absorbent  cotton  soaked  in  Monsel's 
solution  and  dried).  A  bit  of  cork  may  be  forced  into  the  socket.  In  bleeding 
from  an  incised  urinary  meatus  pack  with  styj)tic  cotton  and  compress  the  lips 
of  the  meatus.  Cold  water,  chlorid  of  ethyl  spray,  and  ice  act  as  styptics  by 
producing  reflex  vascular  contraction.  Hot  water  produces  contraction  and 
coagulates  the  albumin.  The  temperature  should  be  from  115°  to  120°  F.  A 
mixture  of  equal  parts  of  alcohol  and  water  stops  capillary  oozing. 

The  Use  of  Gelatin  in  Controlling  Hemorrhage. — It  seems  very  positively 
proved  that  gelatin  increases  the  coagulability  of  the  blood  if  given  hypo- 

dermatically.  It  has  been  shown  by  Horatio 
C.  Wood,  Jr.  ("American  Medicine,"  May  3, 
1902),  that,  even  when  administered  by  the 
stomach,  digestion  does  not  destroy  its  coagu- 
lating effect  upon  the  blood.  Carnot,  of  Paris, 
used  it  locally  and  with  success  to  control 
epistaxis  in  a  sufferer  from  hemophilia.  He  then 
employed  it  to  arrest  bleeding  from  hemorrhoids, 
tumors,  and  incised  wounds;  and  demonstrated 
in  animals  that  it  will  arrest  oozing  from  the  cut 
surface  of  the  liver.  Carnot  used  a  5  or  10  per 
cent,  solution.  It  has  been  employed  with  success 
to  control  hemorrhage  in  many  situations,  is  of 
value  when  applied  locally,  and  possibly  of  use 
when  injected  subcutaneously. 

Intravenous  injections  are  extremely  dangerous, 
and  are  apt  to  be  followed  by  embolism.  Sub- 
cutaneous injections  are  decidedly  painful  and  are 
not  altogether  safe,  producing  albuminuria  and 
occasionally  embolism.  Another  danger  that  may 
follow  the  subcutaneous  administration  of  gelatin  is  the  development  of 
tetanus,  and  several  cases  have  been  reported.  The  existence  of  disease  of  the 
kidneys  contra-indicates  the  hypodermatic  use  of  gelatin. 

It  has  been  successfully  used  as  an  enema  in  intestinal  hemorrhage,  and 
as  an  injection  in  hemorrhage  from  the  bladder.  I  have  used  it  with  success 
in  arresting  bleeding  from  the  cut  surface  of  the  human  liver;  to  check  bleed- 
ing from  an  incised  wound  in  a  victim  of  leukemia;  to  arrest  postoperative 
oozing  in  sufferers  from  cholemia;  and  in  several  cases  of  severe  epistaxis. 

When  employed  locally  in  solution,  it  should  be  of  a  strength  of  from  2  to 
10  per  cent,  in  normal  salt  solution.  For  hypodermatic  use  some  employ  a 
5  per  cent.,  some  a  2  per  cent.,  and  some  a  i  per  cent,  solution.  In  using 
a  I  or  2  per  cent,  solution  a  very  large  amount  of  fluid  must  be  injected.  This 
causes  pain;  and  Sailer  maintains  that  the  pain  is  slight  or  absent  if  the  solution 
is  not  turbid  and  if  but  10  c.c.  of  a  10  per  cent,  solution  are  injected.  The 
injection  may  be  repeated  until  from  i  to  3  gm.  of  gelatin  have  been  administered. 
It  should  be  injected  into  the  outer  side  of  the  thigh,  under  the  breast,  or  between 
the  shoulder-blades.  If  the  drug  is  given  by  mouth,  100  c.c.  of  a  10  per  cent, 
solution  is  the  dose,  and  this  may  be  repeated  every  two  or  three  hours. 

On  account  of  the  possible  danger  of  the  development  of  lockjaw  after 
infection  great  care  in  sterilizing  must  always  be  exercised.  The  method  of 
preparation  suggested  by  Joseph  Sailer  will  be  found  of  the  greatest  value. 
(For  the  formula  for  this  see  page  480.) 

In  view  of  the  fact  that  gelatin  is  such  an  excellent  culture  material,  whenever 
it  is  used  in  the  rectum,  nose,  pharynx,  vagina,  or  bladder  it  should  be  mixed 
with  some  antiseptic  agent. 


Fig.  256. — Digital  compression 
of  the  femoral  artery. 


Blood-serum  ^n 

The  exact  mode  in  which  gelatin  acts  in  producing  coagulation  is  not  certain. 
Floresco  maintains  that  it  acts  like  an  acid.  Laborde  states  that  undissolved 
particles  of  gelatin  serve  as  centers  for  coagulation.  Other  experimenters 
insist  that  gelatin  destroys  the  leukocytes,  and  thus  liberates  fibrin  ferment. 

Suprarenal  extract  is  a  valuable  agent  to  control  capillary  oozing.  It 
constricts  capillaries,  and  if  applied  to  a  mucous  membrane  will  rapidly  blanch 
it.  It  is  extensively  used  to  check  bleeding  during  operations  on  the  nose, 
throat,  larynx,  and  ear,  and  to  arrest  epistaxis  and  bleeding  from  the  uterus. 
The  solution  to  employ  is  adrenalin  chlorid  of  a  strength  of  from  i:  10,000 
to  1:1000.  A  piece  of  cotton  soaked  in  this  solution  is  pressed  lightly  upon 
the  part  or  it  is  sprayed  upon  the  part  by  an  atomizer. 

Chlorid  of  calcium,  given  internally,  is  said  to  favor  coagulation  of  the  blood 
and  is  used  to  check  oozing  or  to  prevent  hemorrhage.  It  is  used  particularly 
in  jaundice  cases  when  operation  must  be  performed.  If  given  several  times  a 
day  for  two  or  three  days  it  increases  the  coagulability  of  the  blood;  but  if 
given  for  more  than  four  days,  actually  diminishes  it.  The  initial  dose  is  from 
15  to  30  gr.,  then  5  gr.  every  hour  are  given  until  five  or  six  doses  have  been 
taken.  It  is  apt  to  provoke  gastric  irritability,  and  it  is  often  given  by  the 
rectum.     I  have  never  been  convinced  of  the  value  of  the  drug. 

Blood-serum. — In  hemophiliacs  and  in  the  postoperative  oozing  of  jaun- 
diced patients  blood-serum  is  of  great  value.  The  wound  may  be  tamponed 
with  fresh  animal  blood  or  blood-serum.  A  suitable  material  for  local  use 
can  be  made  by  grinding  up  the  fresh  liver  of  an  animal,  soaking  it  in  water, 
filtering  the  mixture  through  gauze,  soaking  gauze  in  the  filtrate,  and  tampon- 
ing the  wound  with  the  wet  gauze.  This  fluid  contains  the  thrombokinase 
necessary  in  coagulation  (Kottmann  andLidsky,  in  "  Deutsch.  medizin.  Wochen," 
1910,  vol.  i).  The  thymus  gland  of  an  animal  may  be  used  instead  of  liver. 
Human  serum  is  efficient  locally.  In  ordinary  cases  of  hemorrhage  serum 
may  be  given  subcutaneously;  in  very  severe  hemorrhage,  intravenously.  In 
jaundice  cases  a  serum  injection  should  precede  operation.  As  a  pro- 
phylactic or  for  therapeutic  effect  human  serum,  horse  serum,  rabbit  serum, 
antistreptococcus  serum,  or  diphtheria  antitoxic  serum  may  be  used.  The  dose 
is  10  to  40  c.c.  subcutaneously. 

Coagulose  is  an  anhydrous  material  obtained  by  precipitating  horse  serum. 
It  is  obtained  on  the  market  in  a  glass  bulb.  The  amount  is  the  equivalent  of 
10  c.c.  of  horse  serum.  Into  this  bulb  are  poured  6-8  c.c.  of  sterile  water  at 
the  temperature  of  the  body.  Solution  is  accomplished  by  shaking.  The  fluid 
is  given  hypodermatically,  and  the  dose  can  be  repeated  in  two  or  three  hours. 
The  powdered  coagulose  may  be  sprinkled  on  a  wound  or  applied  to  a  wound 
upon  gauze.  A  substance  which  strongly  activates  thrombin  is  obtained  by 
making  an  ethereal  extract  of  ox  brain  (Hirschfelder,  "Science,"  Aug.  18,  1916). 
The  residue  when  the  ether  evaporates  or  an  emulsion  of  the  residue  in  salt 
solution  will  quickly  arrest  bleeding  from  gland,  muscle,  or  bone.  The  surgeon 
may  use  it  while  operating  in  order  to  get  a  clear  field. 

The  actual  cautery  is  a  very  ancient  hemostatic.  It  is  still  used  occasion- 
ally after  excising  the  upper  jaw,  in  bleeding  after  the  removal  of  some  malig- 
nant growths,  in  continued  hemorrhage  from  the  prostatic  plexus  of  veins 
after  lateral  lithotomy,  and  to  stop  oozing  after  the  excision  of  venereal  warts. 
We  are  often  driven  to  its  use  in  "bleeders,''  that  is,  those  persons  who  have 
a  hemorrhagic  diathesis,  and  who  may  die  from  having  a  tooth  pulled  or  from 
receiving  a  scratch.  It  will  arrest  hemorrhage,  but  the  necrosed  tissue  sepa- 
rates, and  when  it  separates  secondary  hemorrhage  is  apt  to  set  in.  The  iron 
for  hemostatic  purposes  must  be  at  a  cherry  heat.  The  old-fashioned  iron, 
which  was  heated  in  a  charcoal  furnace,  is  rarely  used.  It  is  large,  clumsy, 
and  cools  quickly  if  the  bleeding  be  profuse.  In  an  emergency  we  may  heat 
a  poker  or  a  coil  of  telegraph  wire.     The  best  instrument  is  the  Paquelin 


512 


Diseases  and  Injuries  of  the  Heart  and  \'essels 


cautery.  The  Paquehn  cautery  consists  of  an  alcohol  lamp,  a  metal  chamber 
containing  benzene,  a  tube  of  entrance  for  air  containing  two  bulbs,  an  exit 
tube,  and  a  wooden-handled  cautery  instrument,  the  tip  of  which  is  hollow 
and  composed  of  platinum  (Fig.  257).  The  tip  can  be  kept  hot  even  when 
bleeding  is  profuse.  If  the  iron  is  very  hot,  it  will  not  stop  bleeding  completely. 
In  order  to  use  the  Paquelin  cautery,  light  the  lamp,  heat  the  cautery-tip  in 
the  flame  until  it  becomes  red,  remove  it  from  the  flame,  and  squeeze  the  bulb 
repeatedly  until  the  tip  becomes  bright  red.  Each  time  the  bulb  which  is  not 
covered  with  netting  is  squeezed  air  is  driven  through  the  metal  chamber 
into  the  tube  and  cautery,  and  this  air  carries  with  it  the  vapor  of  benzene, 
which  passes  to  the  hot  tip  and  takes  lire.  The  degree  of  heat  maintained 
depends  upon  the  rapidity  with  which  the  bulb  is  squeezed. 

Skene  has  devised  a  method  known  as  electrohemostasis.  He  grasps  the 
vessel  or  tissue  with  specially  constructed  forceps,  an  electric  current  generates 

heat,  the  tissue  is  cooked,  and 
the  walls  of  the  vessel  united. 
For  the  small  instrument  Skene 
uses  a  current  of  2  ma.  and  for 
the  larger  instrument  a  current  of 
8  ma.i 

Downes  has  devised  an  instru- 
ment to  apply  electrothermic  hem- 
ostasis  in  abdominal  and  pelvic 
operations.  He  asserts  that  by 
this  method  an  intraabdominal 
operation  can  be  rendered  blood- 
less; that  the  lymph-ducts  are 
sealed  and  the  stump  rendered 
sterile;  that  adhesions  are  less 
apt  to  form;  and  that  there  is  less 
postoperative  pain  than  if  liga- 
tures were  used  ("Boston  Med  and  Surg.  Jour.,"  July  10,  1902). 

Rules  for  Arresting  Primary  Hemorrhage. — i.  In  arterial  hemorrhage 
tie  the  artery  in  the  wound,  enlarging  the  wound  if  necessary  {Guthrie'' s  rule). 
In  tying  the  main  artery  of  the  limb  in  continuity  for  bleeding  from  a  point 
below  we  fail  to  cut  off  the  bleeding  from  the  distal  extremity,  and  hemor- 
rhage is  bound  to  recur.  If  the  surgeon  does  not  look  into  the  wound,  he 
cannot  know  what  is  cut:  it  may  be  only  a  branch  and  not  a  main  trunk. 
The  same  rule  obtains  in  secondary  hemorrhage. - 

2.  We  can  safely  ligate  veins  as  we  w^ould  arteries. 

3.  In  a  wound  of  the  superficial  palmar  arch  tie  both  ends  of  the  divided  vessel. 

4.  In  a  wound  of  the  deep  palmar  arch  enlarge  the  wound,  if  necessary, 
in  the  direction  of  the  flexor  tendons,  at  the  same  time  maintaining  pressure 
upon  the  brachial  artery.  Catch  the  ends  of  the  arch  by  hemostatic  forceps 
and  tie  both  ends.  If  the  artery  can  be  caught  by,  but  cannot  be  tied  over 
the  point  of  the  forceps,  leave  the  instrument  in  place  for  four  days.  If  the 
artery  cannot  be  caught  by  forceps,  use  a  tenaculum.  The  ends  of  the  divided 
vessel  can  be  caught  and  must  be  caught  even  if  large  incisions  are  needed  to 
effect  it.  An  incision  which  will  probably  always  expose  the  vessel  is  as  follows: 
Make  a  cut  on  a  line  with  the  injury  from  the  web  of  the  fingers  to  above  the 
carpus,  separating  the  metacarpal  and  carpal  bones,  until  the  artery  is  reached. 
(This  is  really  Mynter's  incision  for  excision  of  the  wrist.)  In  former  days, 
if  the  surgeon  found  trouble  in  grasping  the  ends  of  the  vessel,  he  applied  a  gradu- 
ated compress  (see  Fig.  251).     This  is  applied  as  follows:  Insert  a  small  piece  of 

*  "New  York  Medical  Journal,"  Feb.  18,  i8g8. 

-  For  observ^ations  on  suture  of  vessels,  see  page  507. 


Fig. 


-Paquelin  cautery. 


Rules  for  Arresting  Hemorrhage  513 

gauze  in  the  depths  of  the  wound,  put  over  this  a  larger  piece,  and  keep  on  add- 
ing bit  after  bit,  each  successive  jiiece  larger  than  its  predecessor,  until  there 
exists  a  conical  pad,  the  apex  of  which  is  at  the  point  of  hemorrhage  and  the 
base  of  which  is  external  to  the  surface  of  the  palm.  Bandage  each  finger  and 
the  thumb,  put  a  piece  of  metal  over  the  pad,  wTap  the  hand  in  gauze,  bandage 
each  finger,  the  thumb,  palm,  and  wrist,  place  the  arm  upon  a  straight  splint, 
apply  firmly  an  ascending  spiral  reverse  bandage  of  the  arm,  starting  as  a 
figure-of-8  of  the  wrist,  and  hang  the  hand  in  a  sling.  Instead  of  applying  a 
splint,  we  may  place  a  pad  in  front  of  the  elbow  and  flex  the  forearm  on  the  arm. 
The  palmar  pad  is  left  in  place  for  six  or  seven  days  unless  bleeding  continues 
or  recurs.  The  graduated  compress  is  unreliable,  hence  it  is  a  dangerous 
method  of  treatment.  It  is  an  evasion.  It  should  be  employed  at  the  present 
time  only  as  a  temporary  expedient  until  hgatures  can  be  applied.  The  old 
rule  of  surgery  was  as  follows:  If  bleeding  is  maintained  or  begins  again  after 
application  of  a  graduated  compress,  ligate  the  radial  and  ulnar  arteries.  If 
this  maneuver  fails,  we  know  that  the  interosseous  artery  is  furnishing  the  blood 
and  that  the  brachial  must  be  tied  at  the  bend  of  the  elbow.  If  this  fails, 
amputate  the  hand.  At  the  present  day  it  is  hard  to  conceive  of  such  radical 
procedures  being  necessary  for  hemorrhage  from  a  palmar  vessel. 

5.  In  primary  hemorrhage,  if  the  bleeding  ceases,  do  not  disturb  the  parts 
to  look  for  the  vessel.  If  the  vessel  is  clearly  seen  in  the  wound,  tie  it;  other- 
wise do  not,  as  the  bleeding  may  not  recur.  This  rule  does  not  hold  good 
when  a  large  artery  is  probably  cut,  when  the  subject  will  require  transportation 
(as  on  the  battlefield),  when  a  man  has  delirium  tremens  or  mania,  or  when  he 
is  a  heavy  drinker.     In  these  cases  always  look  for  the  artery  and  tie  it. 

6.  When  a  person  is  bleeding  to  death  from  a  wound  of  an  extremity, 
arrest  hemorrhage  temporarily  by  digital  pressure  in  the  wound  and  apply 
above  the  wound  a  tourniquet  or  Esmarch  bandage.  Bring  about  reaction 
and  then  ligate,  but  do  not  operate  during  collapse  if  the  bleeding  can  be 
controlled  by  pressure. 

7.  If  a  transverse  cut  incompletely  divides  an  artery,  it  may  be  found 
possible  and  may  be  considered  desirable  to  suture  the  cut.  Longitudinal 
cuts  can  certainly  be  sutured  (see  page  503).  If  suturing  is  impossible,  or  if 
the  surgeon  prefers  not  to  attempt  it,  apply  a  ligature  on  each  side  of  the 
vessel  wound  and  then  sever  the  artery  so  as  to  permit  of  complete  retraction. 

8.  If  a  branch  comes  off  just  below  the  ligature,  tie  the  branch  as  well  as 
the  main  trunk. 

9.  If  a  branch  of  an  artery  is  divided  very  close  to  a  main  trunk,  the  rule 
used  to  be,  tie  the  branch  and  also  the  main  trunk.  It  was  thought  that  if 
the  branch  alone  were  tied  the  internal  clot,  being  very  short,  would  be  washed 
away  by  the  blood-current  of  the  larger  vessel.  We  now  know  that  the  clot  is 
not  required  in  repair,  and  under  aseptic  conditions  it  is  trivial  in  size  and  rarely 
reaches  the  first  collateral  branch.  Repair  is  effected  by  endothelial 
proliferation. 

10.  If  a  large  vein  is  slightly  torn,  put  a  lateral  ligature  upon  its  wall 
(Fig.  258).  Gather  the  rent  and  the  tissue  around  it  in  a  forceps  and  tie  the 
pursed-up  mass  of  vein  wall.  It  is  a  wise  plan  to  pass  the  ligature  through  the 
two  outer  coats  by  means  of  a  needle  and  tie  the  knot  subsequently.  This 
expedient  prevents  sHpping.  If  a  longitudinal  wound  exists  in  a  large  vein, 
take  an  intestinal  needle  and  fine  silk  and  sew  it  up  (see  page  502).  Transverse 
wounds  can  also  be  sutured. 

11.  When  a  branch  of  a  large  vein  is  torn  close  to  the  main  trunk,  tie  the 
branch  and  not  the  main  trunk.     Apply  practically  a  lateral  ligature. 

12.  If,  after  tying  the  cardial  extremity  of  a  cut  artery,  the  distal  extremity 
cannot  be  found,  even  after  enlarging  the  wound  and  making  a  careful  search, 
firmly  pack  the  wound. 


514  Diseases  and  Injuries  of  the  Heart  and  Vessels 

13.  In  bleeding  from  diploe  or  cancellous  bone,  use  Horsley's  antiseptic 
wax,  or  break  in  bony  septa  with  a  chisel,  or  plug  with  threads  of  gauze  or 
scrapings  of  catgut.  If  the  bleeding  is  very  free,  wax  will  not  stick  and  mash- 
ing the  bone  edges  usually  fails.  The  expedient  suggested  by  Vaughan  should 
then  be  employed,  viz.,  a  piece  of  muscle  or  other  tissue  is  cut  off,  and,  by 
means  of  the  fingers  or  a  knife  handle,  forcibly  rubbed  against  the  bleeding 
bone  surface.  Minute  fragments  of  the  soft  tissue  plug  the  open  vessels  and 
arrest  the  bleeding  (George  Tully  Vaughan,  in  "Jour.  Am.  Med.  Assoc," 
Nov.  9,  1907). 

14.  In  bleeding  from  a  vessel  in  a  bony  canal,  plug  the  canal  with  an  anti- 
septic stick  and  break  the  wood,  or  fill  up  the  orifice  of  the  canal  with  antiseptic 
wax  or  a  separated  bit  of  tissue.     If  this  fails,  ligate  the  artery  of  supply. 

15.  In  bleeding  from  the  internal  mammary  artery  the  old  rule  was  to 
pass  a  large  curved  needle  holding  a  piece  of  silk  into  the  chest,  under  the 
vessel  and  out  again,  and  tie  the  thread  tightly;  but  it  is  better  to  make  an 
incision  and  ligate  the  artery. 

16.  In  bleeding  from  an  intercostal  artery  make  pressure  upward  and  out- 
ward by  a  tampon  (see  Fig.  250),  or  throw  a  ligature  by  means  of  a  curved 
needle  entirely  over  a  rib,  tying  it  externally;  or,  what  is  better,  resect  a  rib 
and  tie  the  artery. 

17.  In  collapse  due  to  puncture  of  a  deep  vessel,  the  bleeding  having  ceased, 


Fig.   258. — Application  of  lateral  ligature  to  a  vein. 

do  not  hurry  reaction  by  stimulants.  Give  the  clot  a  chance  to  hold.  Wrap 
the  sufferer  in  hot  blankets.  If  the  condition  is  dangerous,  however,  stimulate 
to  save  life. 

18.  In  punctured  wounds,  as  a  rule,  try  pressure  before  using  ligation. 

19.  After  a  severe  hemorrhage  always  put  the  patient  to  bed  and  elevate 
the  damaged  part  (if  it  be  an  extremity  or  the  head). 

20.  A  clot  which  holds  for  twelve  hours  after  a  primary  hemorrhage  will 
probably  hold  permanently;  but  even  after  twelve  hours  be  watchful  and 
insist  on  rest. 

21.  If  recurrence  of  a  hemorrhage  from  a  limb  is  feared,  mark  with  anilin 
or  iodin  the  spot  over  the  main  artery  where  compression  is  to  be  applied,  apply 
a  tourniquet  loosely,  and  order  the  nurse  to  screw  it  up  and  to  send  for  the 
physician  at  the  first  sign  of  renewed  bleeding.  This  must  be  done  in  many 
gunshot- wounds. 

22.  When  the  femoral  vein  is  divided  high  up,  the  advice  commonly  given 
is  to  Hgate  the  vein  and  also  the  femoral  artery.  Braune  taught  that  because 
of  the  venous  valves  there  is  no  collateral  circulation,  and  to  tie  the  vein  alone 
renders  gangrene  inevitable.  Niebergall  shows  that  the  valves  may  be  over- 
come by  moderate  arterial  pressure,  and  thus  collateral  circulation  be 
established.  Hence,  when  the  femoral  vein  is  divided  tie  the  vein,  but  leave 
the  artery  untied,  so  as  to  furnish  the  necessary  pressure.^ 

23.  In   extradural  hemorrhage,   trephine.     The   side   to   be   trephined   is 

1  Niebergall,  "Deut.  Zeit.  f.  Chir.,"  vol.  xxxvii,  Nos.  3  and  4. 


Rules  for  Arresting  Hemorrhage  515 

determined  by  the  symptoms,  and  not  by  the  situation  of  the  injury.  The 
opening  is  made  on  a  level  with  the  upper  orbital  border  and  i^i  inches  be- 
hind the  external  angular  process.  This  opening  exposes  the  middle  menin- 
geal and  its  anterior  branch.  If  this  does  not  expose  a  clot,  trephine  over 
the  posterior  branch,  on  the  same  level  and  just  below  the  parietal  eminence. 
When  the  clot  is  found,  enlarge  the  opening  with  the  rongeur,  scoop  out  the 
clot,  and  arrest  the  bleeding  by  passing  ligatures  on  each  side  of  the  injury 
in  the  vessel  through  the  dura,  under  the  artery  and  out  again,  and  then  tying 
them.  If  the  artery  lies  in  a  bony  canal,  plug  the  canal  with  Horsley's  wax. 
In  some  cases  packing  must  be  used  to  arrest  bleeding.  In  subdural  hemorrhage 
open  the  dura  and  endeavor  to  ligate.  If  this  procedure  is  impossible,  pack 
with  iodoform  gauze. 

24.  In  hemorrhage  from  a  cerebral  sinus  catch  the  edges  of  the  opening 
with  forceps,  if  possible,  and  apply  a  lateral  hgature,  or  leave  the  forceps  in 
place  for  forty-eight  hours,  or  compress  firmly  with  iodoform  gauze. 

25.  In  extramedullary  spinal  hemorrhage  rapidly  advancing  and  threaten- 
ing life  perform  laminectomy  and  arrest  the  hemorrhage. 

26.  In  bleeding  from  a  tooth-socket  use  chlorid  of  ethyl  spray  or  ice.  If 
this  treatment  fails,  plug  with  gauze  infiltrated  with  tannin  or  soaked  in  anti- 
pyrin  solution  of  a  strength  of  10  per  cent.,  or  in  Carnot's  solution  of  gelatin. 
Close  the  jaws  upon  the  plug,  and  hold  them  with  Barton's  bandage.  If  this 
expedient  fails,  soak  the  plug  in  Monsel's  solution,  or  plug  with  a  bit  of  cork 
or  dry  sponge,  and  if  this  is  futile,  use  the  cautery.  Pressure  on  the  carotid 
and  ice  over  the  jaw  and  neck  are  indicated.  It  may  be  necessary  to  tie  the 
external  carotid  artery. 

27.  In  intra-abdominal  hemorrhage  open  the  belly.  In  intra-abdominal 
hemorrhage  it  is  necessary  to  operate  during  shock.  If  the  blood  accumulates 
so  rapidly  as  to  prevent  the  location  of  the  bleeding  point,  compress  the  aorta 
or  pack  the  abdominal  cavity  with  large  sponges.  In  seeking  for  the  bleeding 
point  remove  the  sponges  one  by  one,  or  have  the  pressure  momentarily  re- 
laxed from  time  to  time.  In  parenchymatous  hemorrhage  from  the  liver, 
suture  the  torn  edge  or  use  the  cautery.  In  some  cases  the  liver  is  sutured 
to  the  abdominal  wall  and  the  wound  is  packed.  The  portal  vein  may  be 
sutured.  It  has  been  ligated  successfully  (Burdenko,  in  "Deutsche  Ztschr.  f. 
Chir.,"  cxxiv).  The  hepatic  artery  may  be  sutured.  There  are  on  record 
20  cases  of  ligature  of  the  hepatic  artery  (Narath,  in  "Deutsche,  Ztschr. f. 

•Chir.,"  1916,  cxxxv).  Ligature  of  the  main  trunk  is  not  followed  by  liver 
necrosis.  Ligature  between  the  origins  of  the  pyloric  and  gastroduodenal 
branches  is  very  apt  to  cause  hepatic  necrosis  and  Ugature  beyond  the  emergence 
of  those  branches  is  certain  to  do  so  (Narath,  Ibid.) ,  Severe  wounds  of  the  spleen 
demand  splenectomy.  In  hemorrhagic  pancreatitis  packing  is  used  (page 
1 1 97).  Wounds  of  the  kidney  may  be  sutured,  but  may  require  partial  or 
complete  nephrectomy.  Wounded  mesenteric  vessels  are  ligated  en  masse 
with  silk  (Senn).  If  a  portion  of  intestine  is  found  to  be  deprived  of  blood  it 
must  be  resected.  Wounds  of  the  stomach  and  intestines  causing  hemorrhage 
require  stitching  of  their  edges.  The  aorta  and  cava  may  be  sutured.  The 
cava  has  been  ligated.  An  aorta  should  not  be  ligated  but  has  been  resected 
and  sutured  successfully.  When  there  are  a  great  many  points  of  bleeding, 
take  a  number  of  gauze  sponges,  tie  a  piece  of  tape  firmly  to  each  one,  pack 
many  places  in  the  belly  with  the  sponges,  bring  the  tapes  out  of  the  wound, 
and  remove  the  sponges  from  below  upward  one  at  a  time,  securing  the  bleeding 
points  as  they  come  into  view. 

28.  In  abdominal  section  for  disease  of  the  female  pelvic  organs  bleeding 
is  limited  by  the  clamp  or  by  pressure-forceps.  Ligation  en  masse  is  often 
practised.  A  large  mass  can  be  transfixed  and  tied  in  sections.  Bleeding  edges 
are  stitched.  Areas  of  oozing  are  treated  by  temporary  pressure  and  hot 
water  or,  if  this  fails,  by  the  cautery.     Packing  can  be  used  as  a  tamponade, 


5i6 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


which  is  a  gauze  pouch,  pieces  of  gauze  being  packed  into  this  jjouch  after 
its  insertion  into  the  belly. 

29.  A  ruptured  varicose  vein  requires  a  compress,  a  bandage  from  the 
periphery  up,  and  elevation. 

30.  Most  cases  of  capillary  bleeding  can  be  controlled  by  compression 
with  gauze  pads  soaked  in  water  at  a  temperature  of  115°  to  120°  F.  This 
contracts  the  vessels  and  seals  them  with  coagulated  albumin.  Keetly  in 
1878  impressed  the  profession  with  the  value  of  hot  water  as  a  styptic.  Cen- 
turies ago  surgeons  used  hot  oil  for  the  same  purpose.  Capillary  bleeding 
can  often  be  controlled  by  the  application  of  gauze  soaked  in  Carnot's  solu- 
tion of  gelatin.  A  solution  of  suprarenal  extract  may  control  capillary  ooz- 
ing. If  other  means  fail  to  control  capillary  hemorrhage,  the  cautery  must 
be  used.  Understand  that  the  term  "capillary  bleeding"  does  not  so  much 
mean  bleeding  from  genuine  capillaries  as  it  does  bleeding  from  arterioles  and 
venules. 

31.  Pressure  above  a  wound  may  arrest  arterial  hemorrhage,  but  aggravate 
venous  bleeding.     Pressure  below  a  wound  may  arrest  venous  hemorrhage,  but 

increase  arterial  bleeding. 

32.  A  moderate  epistaxis, 
or  bleeding  from  the  nose, 
may  be  arrested  by  an  in- 
jection of  peroxid  of  hydro- 
gen, an  injection  of  a  solution 
of  antipyrin,  or  an  injection 
of  Carnot's  solution  of  gela- 
tin. Favorite  domestic  ex- 
pedients are  keeping  the 
arms  raised  above  the  head 
and  applying  ice  to  the  back 
of  the  neck.  In  severe  epis- 
taxis examine  the  nose  by 
means  of  a  head-mirror  and 
a  speculum.  If  a  little  point 
of  ulceration  is  found,  touch 
it  by  a  cautery.  If  the  bleed- 
ing is  a  general  ooze,  if  ;it  is 
high  up,  or  if  the  cautery  does 
not  arrest  it,  pack  the  nares. 
It  may  be  necessary  to  pack 
one  nostril  or  both.  Pass  a 
Bellocq  cannula  (Fig.  259)  along  the  floor  of  one  nostril  into  the  pharynx,  project 
the  stem  into  the  mxouth,  tie  a  plug  of  lint  or  gauze  wet  with  Carnot's  solution 
of  gelatin  to  the  stem,  and  withdraw  it.  Hold  the  double  string  which  emerges 
from  the  nostril  in  the  hand  and  pack  gauze  wet  with  gelatin  solution  from  be- 
fore backward.  Tie  the  strings  together  over  the  plug;  if  both  nostrils  are  plug- 
ged, the  strings  from  one  nostril  are  fastened  to  the  strings  from  the  other.  Do 
not  use  subsulphate  or  iron,  as  it  forms  a  disgusting,  clotty,  adherent  mass.  If 
Bellocq's  cannula  is  not  obtainable,  push  a  soft  catheter  into  the  pharynx,  catch 
it  by  a  finger,  pull  it  forward,  and  tie  the  plug  to  it.  Remove  the  plug  in  two 
or  three  days.  Do  not  leave  it  longer.  It  blocks  up  decomposing  fluids  and 
may  lead  to  blood-poisoning.  Pick  out  the  front  plug  first,  hold  the  string  of 
the  second  plug  in  the  hand,  push  the  plug  back  into  the  pharynx,  catch  it  by  for- 
ceps, and  withdraw  plug  and  string  through  the  mouth. 

S^.  In  gunshot  wounds  the  primary  hemorrhage  is  slight  unless  a  large 
vessel  is  cut.  The  bleeding  may  be  visible  or  may  be  internal  (concealed), 
the  blood  running  into  a  natural  cavitv  or  among  the  muscles.     Capillary  ooz- 


Fio. 


59. — Plugging  the  nares  for  epistaxis  by  the  aid 
of  Bellocq's  cannula  (Guerin). 


Rules  for  Arresting  Hemorrhage  517 

ing  is  arrested  by  very  hot  water  and  compression.  Venous  bleeding  is  usually 
arrested  by  compression.  If  a  large  vessel  is  the  source  of  bleeding,  enlarge  the 
wound  and  tie  the  vessel.  If  the  artery  cannot  be  found  in  the  wound,  tie  the 
main  trunk. 

34.  In  prolonged  bleeding  from  a  leech-bite  try  compression  over  a  plug 
saturated  with  alum  or  with  tannin.  If  this  fails,  pass  under  the  wound  a 
harelip  pin  and  encircle  it  with  a  piece  of  silk.  If  this  fails,  use  the  actual  cautery 
or  excise  the  bite  and  suture  the  incision. 

35.  In  severe  bleeding  from  the  ear  elevate  the  head,  put  an  ice-bag  over 
the  mastoid,  give  opium  and  acetate  of  lead,  and,  if  blood  runs  into  the  mouth, 
plug  the  Eustachian  tube  with  a  piece  of  catheter. 

36.  Umbilical  hemorrhage  in  infants  requires  pressure  over  a  plug  con- 
taining tannin,  alum,  or  gelatin  solution.  If  compression  fails,  pass  harelip 
pins  under  the  navel  and  apply  a  twisted  suture.  If  this  fails,  use  the  actual 
cautery. 

37.  Rectal  bleeding  requires  elevation  of  the  buttocks,  insertion  of  pieces 
of  ice,. ice  to  the  anus  and  perineum,  astringent  injections  (alum),  injections  of 
gelatin,  injections  of  adrenalin,  and  the  internal  use  of  opium  and  acetate  of 
lead.  If  these  means  fail,  insert  and  inflate  a  Peterson  bag  or  a  colpeurynter, 
or  tampon  and  use  a  T-bandage.  If  the  bleeding  persists  or  if  a  considerable 
vessel  is  bleeding,  stretch  the  sphincter,  catch  the  bowel  and  draw  it  down, 
seize  the  vessel,  and  tie  it  if  possible;  if  not,  leave  the  forceps  in  place.  Fail- 
ing in  this,  the  actual  cautery  must  be  used. 

38.  Subcutaneous  hemorrhage,  if  severe  and  persistent,  demands  that  an 
incision  be  made  and  ligatures  be  applied. 

39.  Bleeding  from  a  cut  urethral  meatus  requires  the  insertion  of  styptic 
cotton  and  the  application  of  pressure.  Moderate  bleeding  from  the  deeper 
urethra  can  usually  be  arrested  by  a  very  warm  bougie,  by  very  warm  in- 
jections, or  by  tying  a  condbm  over  a  catheter,  and,  after  inserting  it,  inflat- 
ing the  condom  by  blowing  through  the  catheter  and  plugging  the  orifice  of 
the  instrument,  thus  using  pressure.  Sitting  with  the  perineum  on  a  thickly 
folded  towel  is  useful.  Ice  to  the  perineum  does  good.  The  patient  can  lie 
down,  have  a  folded  towel  applied  to  the  perineum,  and  a  crutch-handle 
pushed  upon  the  towel,  the  lower  end  of  the  crutch  being  jammed  against 
the  foot  of  the  bed.  If  a  solid  bougie  has  been  first  introduced,  firm  pressure 
can  be  made  by  this  method.  If  these  means  are  futile,  perform  external 
urethrotomy  and  reach  the  bleeding  point. 

40.  Hemorrhage  from  the  prostate  requires  hot  injections,  the  introduction 
of  a  large  bougie  first  dipped  in  very  warm  water,  and  the  retention  of  a  catheter 
for  two  days.  Perineal  section  may  be  required,  or  suprapubic  cystotomy  with 
packing  which  does  not  occlude  the  ureteral  orifices. 

41.  Vesical  hemorrhage  usually  ceases  spontaneously,  in  which  case  the 
urine  must  be  drawn  off  and  the  viscus  be  washed  out  frequently  with  a  solu- 
tion of  boric  acid,  to  prevent  septic  cystitis.  If  blood-clots  prevent  the  flow 
of  urine,  break  them  up  with  a  catheter  or  a  lithotrite  and  inject  vinegar  and 
water,  a  2  per  cent,  solution  of  carbolic  acid,  or  a  solution  of  bicarbonate  of 
sodium.  Perfect  quiet  is  to  be  maintained,  cold  acid  drinks  are  given,  ice-bags 
are  put  to  the  perineum  and  hypogastric  region,  and  opium  with  acetate  of 
lead,  or  galhc  acid  is  to  be  given  by  the  mouth.  If  the  hemorrhage  is  severe 
or  persistent,  perform  suprapubic  cystotomy,  wash  out  the  bladder,  and,  if 
necessary,  plug  the  bladder  with  gauze,  leaving  the  ureters  uncovered. 

42.  In  hemorrhage  after  lateral  lithotomy,  ligate  if  possible.  If  the  vessel 
can  be  caught  but  cannot  be  ligated,  leave  the  forceps  in  place.  If  it  is  not 
possible  to  catch  the  vessel  with  forceps,  use  a  tenaculum.  If  the  tenaculum 
fails,  pass  a  threaded  curved  needle  through  the  tissues  around  the  vessel 


5i8 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


and  tie  the  Hgature  (suture  ligature).  Plugs  of  ice  and  injections  of  hot  water 
may  be  tried.  These  means  failing,  pressure  is  indicated.  Take  a  cannula, 
fasten  to  it  a  chemise  (Fig.  260),  empty  clots  from  the  bladder,  insert  the  in- 
strument into  the  viscus,  and  pack  gauze  between  the  sides  of  the  cannula 
and  the  chemise.  The  chemise  is  bulged  out  and  pressure  is  made.  Tie  the 
cannula  by  means  of  tapes  to  a  T-bandage.  Pressure  is  thus  combined  with 
vesical  drainage.  Buckstone  Brown  makes  pressure  by  inflating  a  rubber  bag 
with  air.     The  hot  iron  may  occasionally  be  demanded. 

43.  Renal  bleeding  requires  ice  to  the  loin,  tannic  acid  and  opium,  gallic 
acid  or  sulphuric  acid  internally,  and  perfect  quiet.  The  use  of  a  cystoscope 
will  show  from  which  ureter  blood  is  emerging.  If  the 
bleeding  threatens  life  and  the  diseased  organ  is 
identified,  make  a  lumbar  incision  and  suture  or 
perform  nephrectomy. 

44.  Vaginal  hemorrhage  requires  the  ligature  of 
the  tampon. 

45.  Severe  uterine  hemorrhage  (unconnected  with 
pregnancy)  requires  the  tampon.  Persistent  hem- 
orrhage due  to  morbid  growths  may  require  removal 
of  the  tubes  and  appendages,  ligation  of  the  uterine 
and  ovarian  arteries,  or  hysterectomy. 

46.  Hematemesis,  or  bleeding  from  the  stomach,  is 
treated  by  the  swallowing  of  ice,  giving  tannic  acid 
(dose,  20  or  30  gr.),  or  Monsel's  solution  (3  drops). 
Gelatin  by  the  mouth  is  recommended.  Never  give 
tannic  acid  and  Monsel's  solution  at  the  same  time, 
as  they  mix  and  form  ink.  Opium  is  usually  or- 
dered. Acetate  of  lead  and  opium  and  gallic  acid 
are  favorite  remedies,  and  ergot  is  used  by  many. 
Give  no  food  by  the  stomach.  If  life  is  threatened 
by  bleeding  from  an  ulcer,  open  the  belly  and  excise 
the  ulcer  and  suture  the  wound.     If  severe  hemorrhage 

follows  injury,  perform  an  exploratory  laparotomy.  Always  remember  that 
furious  and  even  fatal  gastro-intestinal  hemorrhage  may  be  due  to  mere  erosions 
or  to  cirrhosis  of  the  liver,  and  a  slight  injury  may  have  been  the  exciting  cause 
of  a  hemorrhage.     In  such  a  condition,  of  course,  operation  is  useless. 

47.  In  bleeding  from  the  small  bowel  give  acetate  of  lead  and  opium,  sul- 
phuric acid,  or  Monsel's  salt  in  pill  form  (3  gr.),  allow  no  food  for  a  time,  and 
insist  on  liquid  diet  for  a  considerable  period.  If  hemorrhage  threatens  life, 
do  a  celiotomy  and  find  the  cause.  If  ulcer  exists,  excise  it  and  suture,  or 
suture  a  perforation  without  previously  excising.  If  violent  hemorrhage 
follows  injury,  explore  to  discover  the  vessel. 

48.  In  bleeding  from  the  large  bowel,  use  styptic  injections  (10  gr.  of  alum 
or  5  gr.  of  bluestone  to  i  oz.  of  water).     If  bleeding  is  low  down,  use  small 
amounts  of  the  solution;  if  high  up,  large  amounts.     Do  not  use  absorbable" 
poisons.     In   dangerous   cases  perform  an  exploratory  operation  to  find  the 
vessel.     (For  rectal  bleeding,  see  page  517.) 

49.  Hemoptysis,  or  bleeding  from  the  lung,  is  treated  by  morphin  hypo- 
dermatically,  by  perfect  rest,  by  dry  cups  or  ice  over  the  affected  spot  if  it  can 
be  located,  and  by  the  administration  of  gallic  acid,  which  aids  coagulation.  ^ 
It  is  said  that  nitrite  of  amyl  by  inhalation  has  given  good  results. 

50.  In  hemorrhage  from  wound  of  the  lung  do  not  open  the  chest  unless 

1  The  use  of  ergot  is  a  general  but  questionable  practice.  Bartholow  and  others  hold 
that  this  drug  does  harm;  it  contracts  all  the  arterioles,  and  hence  more  blood  flows  from  an 
area  where  there  is  damage.  Purgatives  do  good  in  bleeding  from  the  lung  by  taking  blood 
to  the  abdomen  and  lowering  blood-pressure. 


Fig.  260. — Cannula  a 
chemise. 


Treatment  of  Secondary  Hemorrhage  519 

life  is  threatened.  If  life  is  endangered,  resect  a  rib,  allow  the  lung  to  col- 
lapse, and  see  if  this  arrests  bleeding.  If  bleeding  still  continues,  remove 
several  ribs,  find  the  bleeding  point,  ligate,  suture  or  employ  forcipressure.  A 
small  cavity  may  be  packed  with  gauze.  If  a  large  surface  is  bleeding,  fill  the 
pleural  sac  with  gauze  and  pack  more  gauze  against  the  oozing  surface.^ 

Reactionary  or  Recurrent  Hemorrhage  (called  also  Consecutive,  Inter- 
mediate, or  Intercurrent)^ — This  form  of  hemorrhage  comes  on  during  reaction 
from  an  accident  or  an  operation,  that  is,  during  the  first  forty-eight  hours, 
but  in  most  cases  within  twelve  hours.  It  is  usually  bleeding  from  a  vessel 
Or  vessels  which  did  not  bleed  during  the  shock  which  accompanied  opera- 
tion, and  which  were  overlooked  and  not  tied.  It  may  be  due  to  faultily 
applied  ligatures.  It  is  favored  by  vascular  excitement  or  hypertrophied 
heart.  The  bleeding  is  rarely  sudden  and  severe,  but  is  usually  a  gradual 
drop  or  trickle.  The  Esmarch  apparatus  is  not  unusually  the  cause.  The 
constricting  band  paralyzes  the  smaller  arteries,  which  do  not  bleed  during 
shock  and  do  not  contract  as  shock  departs;  hence  bleeding  comes  on  with 
reaction.  To  lessen  the  danger  of  the  Esmarch  apparatus  use  a  broad  con- 
stricting band  rather  than  a  rubber  tube.  After  an  amputation,  when  the 
larger  vessels  have  been  tied,  gauze  pads  wet  with  hot  water  (115°  to  120°  F.) 
should  be  placed  between  the  flaps.  This  not  only  arrests  capillary  oozing, 
but  stimulates  vessels  and  shows  points  of  bleeding  which  were  not  previously 
visible,  and  these  points  are  ligated.  During  reaction  after  an  amputation, 
if  slight  hemorrhage  occurs,  elevate  the  stump  and  compress  the  flaps.  If 
the  hemorrhage  persists  or  at  any  time  becomes  severe,  make  pressure  on 
the  main  artery  of  the  limb,  open  the  flaps,  turn  out  the  clots,  find  the  bleeding 
point,  ligate,  asepticize,  drain,  close,  and  dress.  In  any  severe  reactionary 
hemorrhage  open  the  wound  at  once  and  ligate. 

Secondary  hemorrhage  may  occur  at  any  time  in  the  period  between 
forty-eight  hours  after  the  accident  or  operation  and  the  complete  cicatriza- 
tion of  the  wound.  Secondary  hemorrhage  may  be  due  to  atheroma,  to  slip- 
ping of  a  ligature,  to  inclusion  of  nerve,  fascia,  or  muscle  in  the  ligature,  to 
sloughing,  to  erysipelas,  to  septicemia,  to  pyemia,  to  gangrene,  and  to  over- 
action  of  the  heart.  The  great  majority  of  cases  of  secondary  hemorrhage 
are  due  to  infection,  and  the  application  of  modern  surgical  principles  has 
rendered  secondary  bleeding  a  rare  calamity.  If  during  an  operation  the  ves- 
sels are  found  atheromatous,  a  thread  should  be  passed,  by  means  of  a  curved 
needle,  around  the  vessel,  including  a  cushion  of  tissue  in  the  loop  of  the  liga- 
ture (this  prevents  cutting  through,  see  Fig.  241).  Acupressure  may  be  used 
in  such  a  case.  If  the  surgeon  decides  to  employ  the  ligature,  he  must  not 
tie  tightly,  but  must  endeavor  to  approximate  the  coats  rather  than  to  cut 
them.  Two  ligatures  can  be  applied  or  the  stay-knot  may  be  used.  One  great 
trouble  with  atheromatous  arteries  is  that  their  coats  cannot  contract;  another 
trouble  is  that  the  ligature  is  apt  to  cut  entirely  through  them.  If  after  an 
operation  the  pulse  is  found  to  be  forcible,  rapid,  and  jerking,  give  aconite, 
opium,  and  low  diet.  The  bleeding  may  come  on  suddenly  and  furiously,  but 
is  usually  preceded  by  a  bloody  stain  in  wound-fluids  which  had  become  free 
from  blood. 

Treatment  of  Secondary  Hemorrhage. — Suppose  a  case  of  leg  amputation 
in  which,  several  days  after  the  operation,  a  little  oozing  is  detected:  the  treat- 
ment is  to  elevate  the  stump,  apply  two  compresses  over  the  flaps,  and  carry  a 
firm  bandage  up  the  leg.  If  the  bleeding  is  profuse  or  becomes  so,  make  pres- 
sure on  the  main  artery,  open  and  tear  the  flaps  apart  with  the  fingers,  find 
the  bleeding  vessel  and  tie  it,  turn  out  the  clots,  asepticize,  drain,  close,  and 
dress.  If  the  bleeding  begins  at  a  period  when  the  stump  is  nearly  healed,  cut 
down  on  the  main  artery  just  above  the  stump  and  ligate.  In  secondary 
1  See  author's  case,  "Annals  of  Surgery,"  Jan.,  1898. 


520  Diseases  and  Injuries  of  the  Heart  and  Vessels 

hemorrhage  from  a  blood-vessel  in  nodular  tissue  apply  a  suture-ligature  or 
tie  higher  up,  or,  if  this  fails,  amputate.  When  secondary  hemorrhage  arises 
in  a  sloughing  wound  apply  a  tourniquet  or  an  Esmarch  bandage,  tear  the 
wound  open  to  the  bottom  with  a  grooved  director,  look  for  the  orifice  of  the 
vessel,  dissect  the  artery  up  until  a  healthy  point  is  reached,  cut  it  across,  and 
tie  both  ends.  If  this  fails,  apply  a  suture-ligature  or  use  acupressure.  In 
secondary  hemorrhage  from  atheromatous  vessels  use  the  suture-ligature, 
double  ligature  with  a  stay-knot,  or  employ  acupressure. 

Secondary  hemorrhage  may  occur  after  ligation  in  continuity,  the  blood 
usually  coming  from  the  distal  side.  If  the  dressings  are  slightly  stained 
with  blood,  put  on  a  graduated  compress.  If  the  bleeding  continues  or  is 
severe,  make  pressure  on  the  main  artery  of  the  limb,  open  the  wound  and 
ligate,  wTap  the  part  in  cotton,  elevate,  and  surround  with  hot  bottles.  If 
this  religation  is  done  on  the  femoral  and  fails,  do  not  ligate  higher  up,  as  gan- 
grene will  certainly  occur,  but  amputate  at  once  above  the  point  of  hemor- 
rhage. If  dealing  with  the  brachial  artery,  do  not  amputate,  but  ligate  higher 
up  and  make  compression  in  the  wound.  In  a  secondary  hemorrhage  from 
the  innominate,  tie  the  innominate  again  and  also  tie  the  vertebral. 

Hemorrhage  After  an  Abdominal  Operation.^ — Hemorrhage  may  occur 
after  an  abdominal  operation.  It  may  come  on  gradually  with  reaction. 
If  it  does  so,  it  causes  thirst,  restlessness,  an  increasing  pulse-rate,  pallor, 
increasing  rate  of  respiration,  and  coldness  of  extremities.  The  temperature 
is  normal  or  subnormal.  If  the  hemorrhage  is  small  in  amount  the  condition 
may  be  recovered  from.  If  it  continues  it  produces  the  grave  symptoms  set 
forth  on  page  498.  A  rapid  secondary  or  reactionary  hemorrhage  produces 
those  grave  symptoms  almost  suddenly.  If  a  severe  hemorrhage  is  occurring 
in  the  abdomen  nothing  but  an  operation  can  save  life  (see  page  515). 

Hemophilia,  Hemorrhagic  Disease,  or  Hemorrhagic  Diathesis. 
— The  term  "hemophilia"  expresses  the  existence  in  an  individual  of  a  tend- 
ency to  joint  effusions,  to  serous  hematomata,  and  to  profuse  or  even  uncontrol- 
lable hemorrhage  which  occurs  spontaneously  or  as  a  result  of  some  very  trivial 
injury.  In  this  disease  blood  coagulation  is  slow  and  imperfect  because  of  con- 
genital defect.  SahU  asserts  that  hemophilia  is  due  to  defects  in  certain  cells 
which  defects  are  responsible  for  a  deficiency  of  thrombokinase,  the  coagulating 
agent  ("  Deutsch  Archiv  f ur  klinische  Medizin,"  1910,  vol.  xcix). 

It  may  exist  in  the  robust  as  well  as  the  pale  and  weakly,  the  rich  as  well  as 
the  poor.  It  is  almost  limited  to  males  and  in  those  rarely  recorded  instances 
of  the  defect  in  females  it  was  seldom  provocative  of  dangerous  bleeding.  In 
70  per  cent,  of  all  cases  the  condition  is  noted  before  the  fifth  year  of  hfe  (R.  C. 
Cabot,  in  "International  Text-Book  of  Surgery").  There  is  a  late  or  deferred 
form  which  some  call  acquired  which  does  not  arise  until  the  first  dentition 
or  perhaps  till  puberty.  The  family  history  of  a  bleeder  shows  that  he  comes 
of  a  bleeding  stock,  in  other  words  the  defect  is  hereditary.  The  women  of  a 
family  of  bleeders  almost  never  show  symptoms  of  hemophilia,  seldom  bleed 
seriously  at  menstrual  periods,  but  are  sometimes  predisposed  to  epistaxis,  post- 
partum hemorrhage  and  severe  bleeding  at  the  menopause.  It  has  been  noticed 
that  the  women  of  bleeding  families  are  apt  to  be  excessively  fertile.  In  four  fami- 
lies of  a  single  stock  there  were  1 9  children  each  (Sir  Almroth  E.  Wright,  in  Allbutt 
and  Rolleston's  "  System  of  Medicine").  As  we  have  said  the  bleeders  are  males. 
The  females  are  not  bleeders.  But  a  non-bleeding  mother  imparts  the  hemophiliac 
tendency  to  her  male  child  and  he  does  bleed.  All  the  mothers  of  a  bleeding  family 
may  not  transmit  the  defect  but  more  than  two-thirds  of  them  do.  All  of  the 
sons  may  not  bleed.  Probably  two-thirds  of  them  do.  All  of  the  daughters 
may  not  transmit  the  inheritance  but  most  of  them  do.  A  male  bleeder  seldom 
transmits  the  defect  to  a  son  or  the  tendency  to  a  daughter,  although  he  does 
so  in  rare  instances  (Goodall,  in  "Scottish  Med.  and  Surg.  Jour.,"  Feb.,  1905). 


Symptoms  of  Hemophilia  521 

Wright  (Ibid.)  is  indined  to  believe  that  "in  the  absence  of  a  definitely  hemophilic 
ancestry  the  disease"  may  "originate  de  novo  from  the  conjunction  of  a  male 
and  a  female  both  predisposed  to  bleeding,  whose  blood  has  in  each  case  the 
characters  associated  with  the  hemophilic  predisposition,"  The  pathology 
of  hemophilia  is  still  in  dispute.  Some  urge  that  the  blood  that  oozes  from  a 
wound  in  a  hemophiliac  does  clot  hence  we  cannot  say  that  inability  to  clot 
lies  at  the  base  of  the  trouble.  It  is  true  that  the  blood  clots  but  it  clots  slowly. 
Those  who  disbelieve  in  the  view  that  the  fault  is  in  clotting  of  the  blood  explain 
the  condition  by  assuming  the  existence  of  hypoplasia  of  the  aorta  and  arteries. 
Certainly  in  Agnew's  case  in  which  profuse  bleeding  from  trivial  causes  occurred 
above  the  clavicles  and  not  below  them  there  must  have  been  structural  defect 
in  the  vessels.  But  such  a  case  was  not  an  instance  of  genuine  hemophilia. 
The  same  statement  maybe  made  of  non-traumatic  hemorrhage  from  one  kidney. 
In  a  case  of  hemophilia  in  the  Jefferson  College  Hospital  it  became  necessary 
to  amputate  a  finger.  A  careful  study  of  the  vessels  of  the  amputated  digit 
failed  to  show  any  vascular  defect.  Wright  (Ibid.)  shows  that  if  the  blood  of 
a  bleeder  is  tested  when  he  is  not  in  a  hemorrhagic  crisis  coagulation  will  be 
found  to  be  very  slow.  Instead  of  five  minutes  which  is  normal  it  will  be  ten 
minutes,  twenty  minutes,  even  fifty  or  sixty  minutes.  Great  confusion  has 
arisen  in  reports  because  we  know  that  during  and  for  some  time  after  hemorrhage 
the  blood  becomes  temporarily  more  rapidly  coagulable  than  in  health.  The  real 
test  for  coagulation  is  when  no  hemorrhage  exists  and  no  hemorrhage  has  taken 
place  for  some  time.  Wright  (Ibid.)  sets  forth  the  blood  condition  of  bleeding 
families  "a  diminished  content  in  leukocytes,  a  relatively  diminished  number 
of  polymorphonuclear  leukocytes  and  diminished  blood  coagulability."  The 
deficiency  in  polymorphonuclear  leukocytes  explains  the  slowness  of  coagula- 
tion, for  these  corpuscles  furnish  the  blood  with  an  element  necessary  to  coagu- 
ulation.  This  element  is  thrombokinase.  The  serum  of  circulating  blood 
according  to  Wright  and  Morawitz  contains  fibrinogen  and  a  ferment  called 
thrombogen.  Thrombokinase  in  the  presence  of  calcium  converts  thrombogen 
into  thrombin  and  thrombin  converts  fibrinogen  into  fibrin  (Wood,  in  "Aus- 
tralian Med.  Jour.,"  vol.  xcix). 

Hemorrhage  may  take  place  from  mucous  or  serous  membranes  or  from 
wounds  of  the  cutaneous  surface,  into  tissue,  into  organs,  into  a  joint,  under 
skin,  under  the  scalp,  or  into  the  external  genitals.  In  a  hemophiliac,  if  a  cut  is 
made,  the  hemorrhage  from  the  larger  vessels  is  easily  arrested,  but  capillary 
oozing  continues. 

The  discovery  of  the  existence  of  such  a  condition  may  not  be  made  until 
a  tooth  is  pulled,  and  extraction  is  followed  by  persistent  bleeding.  It  is  alleged 
that  the  tendency  may  disappear  in  middle  life.  The  earlier  in  life  the  condition 
appears  the  worse  the  prognosis.  Coagulability  improves  as  age  advances. 
In  an  adult  spontaneous  hemorrhage  will  usually  cease  eventually  and  in  most 
cases  traumatic  hemorrhage  can  be  controlled.  Recurrent  joint  involvement 
is  a  very  serious  matter  as  it  leads  to  ankylosis. 

A  joint  lesion  in  hemophilia  is  called  hemophilic  arthritis. 

Symptoms. — In  a  child  who  is  a  bleeder  a  subcutaneous  or  a  deeper  effusion 
may  occur  from  very  trivial  causes.  The  condition  is  serous  hematoma.  If  super- 
ficial it  presents  the  appearance  of  a  bruise,  if  deeper  seated  an  extensive  swelling 
forms.  The  condition  is  due  to  transudation  of  blood  liquor  and  red  corpuscles 
into  the  tissues.  This  fluid  may  clot.  The  condition  is  seldom  seen  in  older 
bleeders.  A  serous  hematoma  is  always  the  seat  of  tenderness  and  when  the 
muscular  sheaths  are  involved,  of  severe  pain. 

Joint  effusions  occur  in  all  bleeders  but  are  far  and  away  most  common  in 
children.  They  follow  traumatism  or  active  exercise.  The  efifusion  is  similar 
to  that  of  a  serous  hematoma.  Repeated  attacks  tend  to  cause  stiffness  from 
adhesions  and  perhaps  to  cause  a  condition  resembling  osteoarthritis. 


522  Diseases  and  Injuries  of  the  Heart  and  Vessels 

Bleeding  from  mucous  membranes  occurs  in  nearly  every  case  and  is  often 
spontaneous.  The  most  usual  form  is  epistaxis.  There  may  be  bleeding 
from  the  bowel,  the  stomach,  the  bladder,  or  the  gums.  The  bleeding  lasts 
for  many  hours  or  perhaps  for  days  when  the  blood  begins  to  clot.  A  fatality 
may  result.  Bleeding  usually  ceases  when  the  victim  is  almost  exsanguine. 
The  clots  gather  in  the  nose,  pharynx,  and  mouth  and  undergo  putrefaction. 

Of  course  bleeding  may  be  caused  by  a  wound.  Even  very  trivial  wounds 
which  would  scarcely  be  thought  of  in  a  normal  person  cause  prolonged  hemor- 
rhage. A  wound  resulting  from  accident  or  made  by  the  surgeon  may  result 
in  death.  Pulling  a  tooth  seems  to  be  particularly  dangerous.  Removal  of 
the  tonsils  is  very  dangerous.  There  is  little  peril  in  vaccination  and  appar- 
ently none  at  all  in  making  a  needle  prick  to  get  blood  for  examination,  in  drawing 
blood  from  a  vein  and  in  giving  hypodermatic  injections.  Blood  from  a  wound 
flows  for  hours  or  days.  Sooner  or  later  clots  begin  to  form  but  blood  runs  under 
the  clots.  The  bleeding  is  not  violent.  It  is  not  from  the  large  vessels.  It  is 
a  capillary  ooze  and  may  prove  unarrestable.  Wright  (Ibid.)  points  out  the 
curious  tendency  of  hemorrhage  spontaneous  and  traumatic,  to  begin  at  night 
during  sleep,  a  time  in  which  the  tissue  output  of  CO2  is  at  its  lowest  and  CO2 
in  the  blood  increases  coagulability.  The  oozing  so  common  in  leukemia  is  not 
due  to  hemophilia.  Neither  is  the  oozing  met  with  in  jaundice.  A  child  who 
is  a  bleeder  must  be  watched  and  guarded  unceasingly.  A  surgeon  must  be  ever 
on  the  lookout  for  hemophilia  and  should  inquire  for  it  before  operating.  If 
a  person  is  a  bleeder  he  should  be  operated  upon  only  when  operation  is 
demanded  by  imperative  necessity. 

As  a  rule,  more  than  one  joint  is  involved,  but  only  a  few  joints  suffer. 
In  Rugh's  case  only  one  knee-joint  suffered  ("Annals  of  Surg.,"  May,  1907). 
If  more  than  one  joint  is  attacked,  the  involvement  may  or  may  not  be 
symmetrical. 

The  acute  form  resembles  acute  rheumatism  and  lasts  about  ten  days. 
In  the  subacute  form  the  temperature  is  lower,  the  symptoms  less  intense,  and 
the  duration  shorter.  In  both  forms  joint  function  is  restored  after  a  first 
attack  (Frolich,  "Centralb.  fiir  Chir.,"  1905,  vol,  xxxii).  The  chronic  form 
resembles  tuberculous  arthritis  or  osteomyelitis.  In  this  form  there  is  a  tend- 
ency to  loss  of  function,  but  there  is  no  reaction  to  tuberculin. 

Treatment. — The  oozing  is  difficult  and  often  impossible  to  control,  although 
most  of  these  cases,  in  the  long  run,  recover.  In  the  so-called  acquired  form 
the  prognosis  is  better  than  in  the  congenital  (Weil,  "Centralb.  fiir  Chir.," 
1907,  vol.  xxxiv).  Internal  administration  of  such  drugs  as  ergot,  gallic  acid, 
and  acetate  of  lead  is  useless.  It  is  claimed  that  chlorid  of  calcium  internally  is 
of  service.  Lactate  of  calcium,  15  to  20  gr.,  is  sometimes  given  three  times  a 
day  by  the  mouth.  It  may  also  be  given  by  the  rectum.  Milk  may  be  given 
by  rectum,  in  order  to  obtain  the  combination  of  salts  of  milk  unchanged 
by  gastric  juice  (Solt,  Ibid.).  The  local  use  of  astringents  is  of  no  avail.  Pro- 
longed elevation  may  in  rare  cases  succeed.  In  the  case  in  the  Jefferson  Med- 
ical College  Hospital  the  bleeding  was  arrested,  after  numerous  expedients 
failed,  by  compression  and  hot  water.  Nurses  sat  by  the  bed  for  several  days, 
constantly  compressed  the  wound  with  gauze  pads  soaked  in  hot  water,  and 
changed  the  pads  as  soon  as  they  cooled.  The  local  use  of  Carnot's  solution 
of  gelatin  has  apparently  saved  several  cases  from  death.  A  valuable  plan 
is  to  tampon  the  wound  with  gauze  containing  fresh  animal  or  human  blood 
or  blood-serum  or  coagulose,  or  extract  of  animal  organs.  A  rapid  method  of 
obtaining  thrombokinase  is  to  take  the  Hver  from  a  rabbit  or  other  animal,  chop 
it,  grind  it,  soak  in  water,  and  filter  through  cloth.  Gauze  soaked  in  this  fluid 
is  used  to  tampon  a  wound  (Koltmann,  Ibid.,  June  2,  1910).  Wright  (Ibid.) 
uses  thymus  gland.  The  residue  from  an  ethereal  extract  of  ox  brain  applied 
locally  is  a  valuable  material  to  combat  bleeding  from  bone,  muscle,  glands,  etc. 


Operation  for  Pericardial  Effusion  or  Suppuration  523 

Serum  in  doses  from  5  to  10  c.c.  may  be  given  liypodermatically  or,  if 
bleeding  is  very  severe,  intravenously.  We  may  use  human  serum,  horse  serum, 
rabbit  serum,  diphtheria  serum,  or  antistreptococcus  serum  (see  page  511). 
After  each  injection  of  serum  there  is  leukocytosis,  and  leukocytosis  means 
increase  of  cells  containing  fibrin  ferment  or  thrombokinase.  (See  Tremburg, 
in  "  Medizinische  Klinik,"  Berlin,  Nov.  7,  1910.) 

Witte  applies  locally  an  extract  of  lymphoid  organs  (spleen,  lymph-glands, 
or  thymus)  and  injects  hypodermatically  a  5  per  cent,  solution  of  sterile  peptone 
in  .5  salt  solution.  The  dose  is  3  c.c.  every  other  day  until  three  or  four  doses 
have  been  taken.  Then  the  injections  are  intermitted  for  three  or  four  weeks 
(Nolf  and  Herry,  ''Reme  de  Medecine,"  Feb.,  1910,  and  "Gaz.  des  Hopitaux," 
191 1).  Thyroid  extract  should  be  tried,  as  in  some  cases  it  seems  to  have  been 
of  value.  The  dose  is  5  gr.  after  each  meal.  Eugene  Fuller's  case  of  hemophilia 
("Med.  News,"  Feb.  28,  1903)  was  apparently  cured  by  the  administration  of 
5  gr.  of  thyroid  extract  three  times  a  day.  In  a  case  of  hemophilia  in  the 
Jefferson  Hospital  th}T-oid  extract  apparently  arrested  the  bleeding.  In 
Rugh's  case,  after  excision  of  a  knee-joint,  bleeding  was  profuse  and  continued, 
but  ceased  in  eight  days.  The  patient  was  given  5  gr.  of  thyroid  extract  three 
times  a  da3^  The  cases  are  particularly  interesting  in  connection  with  W.  J. 
Taylor's  observation  that  thyroid  extract  increases  the  rapidity  of  blood 
coagulation  in  jaundice  cases  and  lessens  the  tendency  to  postoperative  oozing 
in  such  cases.  Wright  gives  tablets  of  thymus  extract  to  supply  the  blood 
with  nucleoprotein,  administers  a  mixture  of  calcium  and  magnesium  salts, 
giving  CO2  by  passing  into  the  mouth  a  small  tube  from  a  generator,  and  applies 
to  the  wound  a  physiological  styptic  made  from  the  thymus  gland  of  the  calf 
or  lamb. 

Operations  on  the  Vascular  System 

Paracentesis  auriculi,  or  tapping  the  heart-cavity,  has  been  suggested 
for  the  relief  of  an  overdistended  heart  from  pulmonary  congestion.  The 
right  auricle  or  ventricle  can  be  tapped.  Push  the  aspirator  needle  directly 
backward  at  the  right  edge  of  the  sternum,  in  the  third  interspace.  This  opera- 
tion is  not  recommended,  as  it  is  highly  dangerous  and  is  of  questionable  value. 
It  has  caused  fatal  hemorrhage  in  several  reported  cases. 

Paracentesis  pericardii,  or  tapping  the  pericardial  sac,  is  done  only 
when  life  is  endangered  by  effusion.  The  surgeon  must  avoid  the  pleura, 
lung,  heart  and  internal  mammary  artery.  Introduce  the  needle  in  the  costo- 
xiphoid  space  close  to  the  sternum  or  else  2  inches  to  the  left  of  the  left  edge 
of  the  sternum,  in  the  fifth  interspace,  and  push  it  directly  backward.  By 
puncturing  close  to  the  sternum  or  more  than  an  inch  external  to  it  we  avoid 
the  artery.  The  operation  of  tapping  is  extremely  dangerous.  The  heart 
is  lifted  up  and  pushed  forward  by  an  effusion  and  the  needle  may  enter  it. 
The  puncture  of  a  ventricle  may  do  no  harm,  although  it  is  very  liable  to,  but  the 
puncture  of  an  auricle  is  very  apt  to  be  followed  by  fatal  hemorrhage.  It  is  wiser 
and  safer  to  expose  the  pericardium  and  incise  it,  as  is  done  for  pericardial 
suppuration. 

Operation  for  Pericardial  Effusion  or  Suppuration.— The  opera- 
tion of  tapping  should  be  abandoned  in  favor  of  a  safer  but  more  radical  pro- 
cedure. There  is  no  spot  where  we  can  introduce  the  needle  mth  perfect 
safety,  and  the  heart  or  pleura  may  be  wounded;  further,  as  Brentano  shows, ^ 
tapping  will  not  completely  empty  the  sac.  In  a  purulent  case  tapping  gives 
practically  no  chance  of  cure.  No  general  anesthetic  should  be  used.  An 
incision  should  be  made  in  the  angle  of  the  costoxiphoid  space  and  the  sixth  and 
seventh  cartilages  should  be  removed.  The  exposed  pericardium  is  to  be  punc- 
tured in  order  to  determine  the  nature  of  the  fluid  present.  If  the  fluid  is  serous, 
i"Deut.  Med.  Woch.,"  Feb.  11,  1890. 


524  Diseases  and  Injuries  of  the  Heart  and  Vessels 

it  can  be  drained  away  through  a  small  incision  and  the  pericardium  may  be 
sutured.  If  the  fluid  be  purulent,  the  pericardium  should  be  stitched  to  the 
chest  wall  and  opened.  Clots  should  l)e  remov^ed  by  hot  salt  solution  irriga- 
tion and  a  drainage-tube  should  be  introduced.  The  mortality  is  about  30 
per  cent. 

Operation  for  Wound  of  the  Heart. — At  once  give  atropin  hypoder- 
matically  in  order  to  antagonize  vagus  inhibition.  Stimulants  would  increase 
bleeding  and  stimulants  are  not  to  be  given  until  bleeding  has  been  arrested. 
In  many  cases  it  is  obviously  impossible  to  administer  an  anesthetic,,  but  when 
possible  it  should  be  given  because  the  movements  of  the  patient  while  under 
the  knife  make  operation  difficult  and  increase  bleeding.  Ether  may  be  used 
or  we  may  take  Hill's  advice  and  give  chloroform.  Hill  would  give  an  anesthetic 
unless  the  patient  is  unconscious  and  the  corneal  reflex  is  abolished.  The  peri- 
cardium can  be  exposed  freely  and  Rotter's  incision  gives  excellent  access,  al- 
though it  always  opens  the  pleura.  This  exposure  is  described  by  Hill  in  the 
''Medical  Record,"  November  29,  1902,  and  was  employed  in  his  successful 
case.  Begin  an  incision  over  the  third  rib  ^^^  inch  from  the  left  edge  of  the  ster- 
num and  carry  it  outward  along  the  rib  for  4  inches.  Begin  an  incision  over 
a  corresponding  point  of  the  sixth  rib  and  carry  it  out  for  a  like  distance.  Join 
the  outer  extremities  of  these  cuts.  Cut  through  the  ribs  and  pleura  by  bone 
forceps  and  scissors.  Raise  the  flap  upon  its  hinges  of  cartilages,  and  have  an 
assistant  grasp  the  lung  to  prevent  collapse.  The  pericardium  thus  exposed 
is  opened  widely  if  necessary.  The  pleura  is  packed  off  with  gauze.  If  the 
right  auricle,  left  auricle  or  right  ventricle  is  wounded  the  flow  of  blood  is  con- 
tinuous. If  the  left  ventricle  is  wounded  the  flow  of  blood  is  pulsatile.  An 
auricular  wound  or  a  wound  in  the  right  ventricle  gaps.  A  wound  in  the  left 
ventricle  closes  from  contraction.  Hill  advises  us  to  steady  the  heart  by 
pressing  the  hand  under  it  and  lifting  it.  Parrozzani  did  this  by  inserting 
a  finger  in  the  wound.  Other  surgeons  have  used  traction  sutures  of  silk. 
Rehn  takes  the  organ  in  the  palm  and  arrests  hemorrhage  by  pressure  on  the 
great  veins  (page  462).  For  wound  closure  interrupted  sutures  are  preferred  to 
the  continuous  suture.  China  silk  should  be  used.  They  should  be  inserted  by 
around-edged  needle.  ''As  few  as  possible  should  be  passed  commensurate 
with  safety  against  leakage,  as  they  cause  a  degeneration  of  the  muscular  fiber." 
It  does  no  harm  apparently  if  they  enter  a  heart  chamber,  but  it  is  wiser  not 
to  have  them  do  so.  The  moment  bleeding  has  been  arrested  by  the  sutures 
institute  active  treatment  for  shock.  Ligature  of  one  coronary  artery  may 
be  survived.  Stewart's  patient  Hved  several  years  ("Am.  Jour  of  Surg.,"  Iviii). 
Babcock  ("N.  Y.  Med.  Jour.,"  June  10,  1916)  emphasizes  the  danger  of  air 
being  sucked  into  a  cardiac  cavity  or  into  a  coronary  artery.  He  says  it  is 
more  dangerous  if  air  is  sucked  into  the  left  ventricle  than  if  it  is  drawn  into 
the  right.  Before  closing  the  left  ventricle  he  would  aspirate  it  of  air  and  if 
air  bubbles  are  seen  in  the  coronary  vessels  he  would  aspirate  them  through 
a  hypodermatic  needle.  If  the  heart  fails,  use  heart  massage  (L.  L.  Hill,  Ibid.). 
Inject  into  it  a  small  amount  of  adrenahn.  The  pericardial  and  pleural  sacs 
are  cleansed  by  salt  solution.  The  question  of  drainage  is  still  subjudice.  The 
pleural  sac  is  treated  according  to  indications  in  each  case. 

George  Tully  Vaughan,  in  reporting  his  second  case  of  heart  suture  and  a 
table  of  1 5^0  operations  ("Jour.  Am.  Med.  Assoc,"  Feb.  6,  1909),  mentions  five 
methods  for  exposing  the  heart,  and  states  that  no  single  method  has  yet  been 
agreed  on  as  the  best.  The  kind  of  operation  is  often  determined  by  the  exter- 
nal wound,  and,  begun  as  an  exploration,  the  subsequent  steps  depend  on  the 
necessities  which  arise  during  its  progress.  The  five  methods  mentioned  by 
Vaughan  are:  (c)  Through  an  intercostal  space,  with  or  without  the  division 
of  one  or  two  cartilages;  {h)  resection  of  one  or  more  cartilages,  with  or  with- 
out a  portion  of  rib;   {c)  flap  method  across  the  sternum,  dividing  the  sternum 


Decompression  for  Heart  Hypertrophy  525 

and  cartilages  (this  avoids  opening  the  pleura) ;  (</)  flap  of  cartilages  and  ribs 
with  an  external  hinge;  (e)  flap  of  cartilages  and  ribs  with  an  internal  hinge. 

Vaughan's  table  shows  that  in  46  patients  the  pericardium  was  drained,  with 
25  recoveries  and  21  deaths;  in  44  the  pericardium  was  not  drained,  with  25 
recoveries  and  19  deaths;  in  42  both  the  pericardium  and  p)leura  were  drained, 
with  21  recoveries  and  21  deaths;  in  19  both  pericardium  and  pleura  were  closed 
without  drainage,  with  12  recoveries  and  7  deaths;  in  72  the  pleura  was  drained, 
with  30  recoveries  and  42  deaths;  in  21  the  pleura  was  not  drained,  with  1.3 
recoveries  and  8  deaths.  These  figures  would  indicate  that  drainage  should 
not  be  the  rule.  It  should  be  used  though  if  bleeding  continues  or  if  we  greatly 
fear  infection  Of  course,  drainage  causes  irritation,  prevents  the  lung  expand- 
ing, and  makes  secondary  infection  more  probable  (Vaughan,  in  "Jour.  Am. 
Med.  Assoc,"  Feb.  6,  1909). 

In  Vaughan's  table  of  150  cases  we  find  that  98  died  and  52  recovered,  a 
mortality  of  65  per  cent.;  32  patients  died  in  less  than  twenty  hours  after  the 
operation  for  the  injury  and  15  died  on  the  table  or  just  after  the  operation. 
In  all  but  I  of  these  cases  death  was  due  to  hemorrhage.  In  i  it  was  due 
to  pneumothorax  on  opening  the  pleura.  The  remaining  66  deaths  occurred 
in  from  twenty-four  hours  to  five* months  after  the  operation:  6  died  of  pleurisy, 
5  of  pericarditis,  21  of  combined  pleurisy  and  pericarditis,  3  of  pneumonia,  3  of 
peritonitis,  2  of  pericarditis  and  nephritis,  i  of  pleurisy  and  cerebral  abscess, 
I  of  pleurisy  and  wound  of  the  tricuspid  valve,  i  of  pleurisy  and  double  pneumo- 
nia, I  of  gangrene  of  the  lung,  i  of  two  wounds,  one  of  which  was  not  sutured, 
3  of  bleeding  into  the  pleura,  2  of  bleeding  into  the  pericardium,  i  of  clot  in 
the  tricuspid  opening,  and  15  of  unassigned  causes.  Laotta's  table  ("PolicHnic," 
XX,  1913)  contains  236  cases  of  cardiac  suture.  It  shows  that  44.91  per  cent, 
recovered. 

Cardiolysis. — As  a  result  of  pericarditis  the  heart  may  adhere  to  the 
pericardium  and  the  pericardium  to  the  chest  wall.  Adhesions  may  form  in 
the  mediastinum.  The  muscular  wall  of  the  heart  may  be  involved.  The 
descent  of  the  diaphragm  is  interfered  with.  The  heart  hypertrophies. 
Ascites  and  edema  develop.  This  condition  is  dangerous,  and,  if  unrelieved, 
will  eventually  prove  fatal. 

Delorme  (Gaz.  des  hosp.,  1908,  125)  has  suggested  that  the  pericardial 
sac  be  opened  and  the  adhesions  be  broken  down  with  the  finger,  a  very 
dangerous  procedure,  which  is  almost  certain  to  inflict  serious  injury  upon  the 
heart. 

Brauer's  method,  which  he  suggested  in  1902  (Archiv  f.  Klin.  Chir.,  Ixxi, 
1902),  consists  in  removing  portions  of  the  several  ribs  and  their  cartilages  and 
the  portion  of  the  sternum  to  which  the  pericardium  adheres.  The  fourth, 
fifth,  sixth  and  seventh  ribs  are  the  ones  selected.  The  periosteum  is  to  be 
removed  with  the  bone  to  prevent  the  formation  of  new  bone.  This  is  the  pref- 
erable operation.  The  safest  plan  is  to  remove  the  anterior,  but  not  the  pos- 
terior, periosteum.  The  danger  of  fresh  ossification  is  slight  and  we  avoid 
injuring  the  left  pleura  (Poynton  and  Trotter,  quoted  by  Simon,  in  "Brit. 
Med.  Jour.,"  Dec.  14,  1912).  The  operation  can  be  done  with  the  aid  of  local 
anesthesia.  Brauer's  operation  may  benefit  a  patient  greatly  if  the  inter- 
ference is  with  systole.  It  is  of  no  value  if  the  interference  is  with  diastole. 
In  the  latter  case  only  a  direct  attack  on  the  adhesions  as  practised  by  Delorme 
could  be  of  avail.  Delageniere  ("Archiv  prov.  de  Chir.,"  1913)  collected  t,^ 
cases  of  operation.  One  died  from  operation,  6  were  not  successful,  26  were 
successful. 

Decompression  for  Heart  Hypertrophy. — In  a  case  of  cardiac  hyper- 
trophy from  aortic  valvular  disease,  in  which  the  heart  knocked  violently  against 
the  ribs,  and  in  which  there  were  no  adhesions,  Morrison  performed  thoracot- 
om\^     He  removed  several  inches  of  the  fifth  rib  and  an  equal  length  of  the  sixth 


526  Diseases  and  Injuries  of  the  Heart  and  Vessels 

rib.     The  patient  was  much  improved,  the  capacity  of  the  chest  was  increased, 
and  the  painful  attacks  were  practically  cured  ("Lancet,"  July  4,  iqcS). 

Operation  to  Permit  of  Resuscitation  by  Direct  Cardiac  Massage. — 

This  procedure  was  suggested  by  Schiff  in  1874. 

I.  Abdominal  Route. — Open  the  abdomen,  place  the  hand  between  the 
diaphragm  and  the  left  lobe  of  the  liver,  grasp  the  heart  through  the  diaphragm 
and  squeeze  it  20  or  30  times  a  minute,  at  the  same  time  press  on  the  chest- 
wall  with  the  other  hand.  An  assistant  gives  an  intravascular  injection  of 
adrenalin.  Babcock  claims  that  this  treatment  may  restore  cardiac  action  20 
minutes  ''after  somatic  death  unless  the  patient  is  exsanguinated  or  has  mark- 
edly degenerated  organs"  ("N.  Y.  Med.  Jour."  June  10,  1916).  If  the  cells  of  the 
cerebral  cortex  have  been  entirely  deprived  of  blood  for  7  minutes  they  perish. 
In  a  case  in  which  the  heart  is  restored  to  action  after  having  been  stopped 
for  7  minutes  consciousness  will  not  return  and  the  patient  will  die. 

Transthoracic  Route. — Several  ribs  or  rib  cartilages  are  quickly  resected 
and  the  hand  is  plunged  in  the  chest  and  grasps  the  heart.  Cardiac  massage 
acts  by  emptying  the  distended  chambers  of  the  heart,  maintaining  a  certain 
small  amount  of  circulation,  and  stimulating  the  heart  muscle  to  contraction. 

Operation  for  Varix  of  Leg.^ — Many  cases  do  not  require  operation. 
In  some,  operation  is  positively  harmful.  In  some  selected  cases  operation  is 
very  useful  to  remove  certain  complications  (ulcer,  eczema,  etc.),  and  to  relieve 
the  patient  from  annoyance,  but  the  operation  rarely  absolutely  cures  the 
condition.  As  Blake  points  out,  a  cure  cannot  be  claimed  until  at  least  one 
year  has  passed  after  operation  without  reappearance  of  the  varix  ("Boston 
Med.  and  Surg.  Jour.,"  Sept.  25,  1902).  The  indications andcontra-indications 
are  discussed  on  page  470.  Never  operate  if  phlebitis  exists  except  to  treat 
thrombosis.  After  any  operation  for  varicose  veins  of  the  leg  follow  Bennett's 
advice  and  keep  the  patient  in  bed  for  three  weeks  and  do  not  let  him  resume 
active  work  for  three  weeks  more  ("Lancet,"  Nov.  22,  1902), 

The  superficial  veins  must  not  be  tied  or  excised  if  the  deep  veins  are  in- 
volved (page  470).  In  such  a  case  no  operation  is  justifiable  except  incision  of 
the  fascia  lata,  placing  the  vein  under  the  fascia  (Cecca's  operation).  This 
procedure  enables  tissue  to  give  support  to  the  vein  without  blocking  it. 

Homans  ("Surgery,  Gynecology,  and  Obstetrics,"  Feb.,  1916)  describes 
certain  clinical  tests  to  demonstrate  the  true  nature  of  varicose  veins.  "The 
tests  devised  by  Trendelenburg  are  easily  performed.  The  leg  is  raised  and 
held  above  the  level  of  the  heart  until  the  veins  are  empty.  It  is  then  rapidly 
lowered  when  the  blood  can  be  seen  to  flow  back  into  the  leg  and  suddenly 
distend  the  surface  vessels.  This  test  for  varicosity  may  be  positive  even  when 
the  reflux  cannot  be  seen  to  distend  the  vein  walls,  for  if  the  veins  are  so  sclerosed 
that  no  change  in  the  tension  of  their  walls  can  be  noted  by  the  eye,  it  can  quite 
readily  be  felt  by  the  fingers. 

"By  such  means,  valvular  incompetence  of  the  surface  veins  as  opposed 
to  hypertrophy  or  distention  of  normal  vessels  can  be  diagnosed,  but  still  more 
information  may  be  derived  from  a  variation  of  the  same  simple  procedure. 
Suppose  it  has  already  been  determined  that  the  surface  veins  allow  a  free 
back  flow.  The  leg  is  now  raised  and  the  veins  emptied  of  blood.  If,  before  it 
is  lowered,  a  constriction  only  firm  enough  to  compress  the  surface  vessels,  as 
by  a  piece  of  bandage,  is  made  about  the  upper  thigh,  blood  cannot  flow  from 
above  into  the  varicose  superficial  veins,  and  until  they  are  filled  by  the  natural 
circulation  they  remain  empty. 

"This,  French  writers  have  called  the  contre-epreuve  of  the  Trendelenburg 
test,  and  it  confirms  the  diagnosis,  for  on  releasing  the  constriction,  the  empty 
or  partially  filled  veins  become  distended  with  a  palpable  shock.  But  this 
procedure  tells  even  more.  Suppose  the  perforating  veins  share  the  varicosity 
of  the  surface  vessels.     The  blood  in  the  deep  veins  will  then  be  able,  as  normally 


Operation  for  Varix  of  Leg  527 

it  cannot  do,  to  leak  into  the  surface  vessels,  and  in  applying  the  constriction 
test  it  will  be  found  that  in  spite  of  the  prevention  of  back  How  down  the  super- 
ficial veins,  these  fill  rapidly  below  the  constriction.  That  is  to  say,  blood  is 
finding  its  way  out  from  the  unobstructed  deep  veins  through  incompetent  perfo- 
rating vessels  to  the  surface.  In  varicosity  of  the  surface  veins  alone,  filling 
below  the  constriction  takes  place  in  three-quarters  of  a  minute  or  more  and 
even  then  these  vessels  may  not  be  very  tense,  for  the  perforating  veins  arc  con- 
tinually carrying  off  the  excess  of  blood.  If,  on  the  other  hand,  the  perforating 
veins  are  incompetent,  the  surface  vessels  will  fill  below  the  constriction,  possi- 
bly in  ten,  twenty,  or  thirty  seconds,  according  to  the  importance  of  the  leak." 

"These  two  tests,  which  I  shall  hereafter  call  respectively  the  Trendelenburg 
test  and  the  constriction  test  for  perforating  veins,  serve  to  separate  the  cases 
of  pure  surface  varicosity  from  surface  varicosity  complicated  by  varicosity 
of  the  perforating  veins.  The  tests  ignore  the  possibility  of  varix  of  the  deep 
venous  system,  a  very  rare  condition  if  indeed  it  is  very  fully  developed." 

Trendelenburg's  Operation. — I  have  employed  this  with  much  satis- 
faction in  cases  of  varix  of  the  leg  following  involvement  of  the  saphenous  in 
the  thigh  when  the  perforating  veins  are  competent.  Trendelenburg  believes 
that  in  varix  the  valves  in  the  saphenous  become  incompetent  because  of  high 
central  pressure.  The  veins  of  the  leg  distend,  as  they  are  unable  to  support 
such  a  long  column  of  blood,  and  finally  the  blood  begins  to  flow  in  the  wrong 
direction  in  the  saphenous,  a  "vicious  circle"  being  established.  The  operation 
is  performed  as  follows :  Make  an  incision  about  4  inches  in  length  over  the  internal 
saphenous  vein  at  the  junction  of  the  upper  and  middle  thirds  of  the  thigh.  If 
the  thigh  is  very  fat  make  a  transverse  incision.  Expose  the  vein,  ligate  each 
visible  branch,  ligate  the  saphenous  at  the  lower  end  of  the  wound  and  also  at 
the  upper  end,  and  remove  the  portion  of  vein  included  between  the  ligatures. 
Do  an  exactly  similar  operation  just  above  the  inner  condyle,  and  another 
similar  operation  just  below  the  inner  condyle.  If  painful  varicose  tumors 
exist  they  should  be  excised.  By  this  operation  the  central  pressure  is  inter- 
cepted and  the  dilated  veins  in  consequence  shrink.  Recurrence  is  frequent 
after  Trendelenburg's  operation  but  only  about  half  of  the  recurrences  develop 
symptoms.  The  operation  is  valuable  in  the  old  and  infirm  or  "  to  tide  a  young 
person  over  a  difficult  period,  or  indeed  merely  to  heal  an  ulcer  temporarily" 
(Homans,  Ibid.). 

Madelung's  operation  is  used  for  surface  varix  with  involvement  of  the  per- 
forating veins  (Homans,  Ibid.).  It  consists  of  complete  excision  of  the  great 
saphenous.  Charles  H.  Mayo  excises  the  vein.  He  ties  and  divides  it  just 
below  the  saphenous  opening,  passes  the  end  of  the  vein  through  the  loop  of 
his  dissector  and  thus  separates  the  vein  as  the  dissector  is  passed  down  to  near 
the  knee.  The  end  of  the  dissect  is  cut  upon,  the  loosened  vein  is  pulled  out, 
ligated  in  the  wound  and  excised.  The  surgeon  may  remove  in  like  manner  as 
many  more  veins  as  he  wishes.  Schede  makes  a  circular  cut  (a  circumcision) 
completely  around  the  leg  at  the  junction  of  the  upper  and  middle  thirds,  the 
incision  reaching  to  the  deep  fascia.  All  bleeding  points  are  ligated  and  the  edges 
of  the  incision  are  stitched  together.  This  operation  is  so  often  followed  by  per- 
sistent hard  edema  that  it  is  now  seldom  performed.  A  recent  operation  is  to 
place  the  internal  saphenous  beneath  the  deep  fascia.  Delbet  implants  the  saphe- 
nous into  the  femoral  10  cm.  below  its  normal  point  of  junction.  The  valvular 
arrangement  of  the  femoral  restores  normal  tension  in  the  saphenous.  Fergus- 
son  ties  the  saphenous  vein  near  the  femoral  and  removes  a  section  from  it.  This 
makes  the  varices  clearly  evident.  A  semilunar  incision  is  made  to  surround  the 
varices,  which  incision  reaches  to  the  deep  fascia.  The  flap  is  raised  and  dis- 
sected up,  the  vessels  are  tied,  and  the  flap  is  sutured  in  place.  Keller  removes 
a  vein  by  inversion  ("N.  Y.  Med.  Jour.,"  Aug.  19,  1905).  Phelps  advises^  multi- 
ple ligation.     Katzenstein  places  the  vein  under  the  sartorius  muscle.     Sir  Wm. 


528 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


I'lG.  261. — Incisions 
for  venesection  (Ber- 
nard and  Huette). 


Fig.  262  — Super- 
ficial veins  in  front  of 
elbow  (Bernard  and 
Huette). 


H.  Bennett  thinks  that  in  ordinary  cases  the  best  operation  consists  in  remov- 
ing a  portion  of  the  long  saphenous  in  the  thigh  and  also  in  removing  3  inches 
of  the  vein  from  below  the  knee.  If  there  are  cystic  dilatations  above  the 
knee  he  removes  the  saphenous  from  the  thigh.  Some  local  varices  he  dis- 
sects out  ("Lancet,"  Nov.  22,  1902).  As  a  matter  of  fact,  excision  of  a  short 
piece  of  vein  seems  to  do  as  much  good  as  excision  of  a  long  piece.  Excision 
of  a  piece  at  several  points  is  valuable.  The  object  of  excision  is  to  reduce 
pressure  on  the  vein  walls  by  breaking  up  the  column  of  blood  (Barker,  in 
"Practitioner,"  Oct.,  1910).  Any  of  the  suggested  operations  may  be  followed 
by  relapse. 

Phlebotomy,  or  Venesection. — Operation. — The  patient  sits  on  a  chair 
'"witli  the  arm  abducted,  extended,  and   inclined   outward"  (Barker).     The 

parts  are  ascepticized  and  a  tape  is 
tied  around  the  arm  just  above  the 
elbow.  The  patient  grasps  a  stick 
firmly  and  works  his  fingers  in  order 
to  cause  the  veins  to  distend.  The 
surgeon  stands  to  the  right  of  the 
arm,  holds  the  elbow  with  his  left 
hand,  and  puts  his  thumb  upon  the 
vein  below  the  intended  point  of 
puncture.  Either  the  median  cephalic 
or  the  median  basilic  may  be  opened 
(Figs.  261,  262).  The  median  basilic 
is  the  more  distinct,  and  is  the  vein 
usually  selected.  In  opening  it  do 
not  cut  too  deep,  as  nothing  but  the 
bicipital  fascia  separates  it  from  the 
brachial  artery.  The  median  cephalic  may  be  selected  (we  thus  avoid  en- 
dangering the  brachial  artery) ;  under  this  vein  lies  the  external  cutaneous  nerve 
(Fig.  262).  Steady  the  vein  wdth  the  thumb  and  open  it  by  transfixion, 
making  an  oblique  cut  which  divides  two-thirds  of  it.  Remove  the  thumb  and 
allow  bleeding  to  go  on,  instructing  the  patient  to  work  his  fingers.  When 
faintness  begins,  remove  the  fillet,  put  an  antiseptic  pad  over  the  puncture, 
apply  a  spiral  reversed  bandage  of  the  hand  and  arm  and  a  figure-of-eight 
bandage  of  the  elbow%  and  place  the  arm  in  a  sling  for  several  days. 

Transfusion  of  Blood. — It  is  spoken  of  in  the  "Book  of  the  Wisdom  of 
Solomon  "  and  is  referred  to  in  the  anatomy  of  Herophilus.  Some  ingenious  stu- 
dents interpret  certain  obscure  allusions  of  Roman  poets  to  mean  that  the  opera- 
tion of  transfusion  was  known  and  practised  in  the  time  of  Augustus.  The 
following  line  from  Ovid  has  been  cited:  "Ut  repleam  vacuas  juvenili  sanguine 
venas." 

The  earliest  proved  application  of  transfusion  was  in  the  case  of  Pope  Inno- 
cent the  eighth  in  1492.  The  story  is  told  in  Villaris'  "Life  of  Savonarola."  The 
Pope,  who  was  sixty  years  of  age,  passed  into  a  state  of  such  extreme  weakness 
that  the  courtiers  thought  he  was  dead. 

A  Jewish  physician  proposed  to  transfuse  into  the  veins  of  the  Pontiff  the 
blood  of  youth.  The  operation  was  performed  three  times  from  different  don- 
ors. The  three  donors  died  and  the  Pope  was  not  saved.  It  is  alleged  that 
Libavius  described  transfusion  in  1625  but  according  to  Heister  the  name  of  the 
book  is  not  stated  by  his  sponsors  (Heister 's  "  Surgery  ").  Lower  of  Oxford  and 
Sir  Christopher  Wren  in  1665  experimented  on  transfusion  from  animal  to 
animal  and  on  the  injection  of  drugs  into  veins. 

In  November  of  1666  Dr.  Croone  (after  whom  the  Croonian  Lectures  are 
named)  told  Pepvs  about  "a  pretty  experiment"  made  very  recently  at  Gres- 
ham  College,  the  blood  of  a  little  dog  having  been  "let  out  till  he  died,  into 


Transfusion  of  Blood  ^^29 

the  body  of  another."  Pepys  continues  "This  did  give  occasion  to  manv 
pretty  wishes,  as  of  the  blood  of  a  Quaker  to  be  let  into  an  Archbishop  and  such 
like"  (Wheatley's  Edition  of  "Pepys's  Diary"). 

In  Birch's  "History  of  the  Royal  Society"  this  very  experiment  is  recorded. 
From  that  book  we  learn  that  Mr.  King  (afterward  Sir  Edward  King)  and  Mr. 
Coxe  operated  and  that  the  dog  recovered.  In  June  of  1667  Denys  of  Mont- 
pelier  appHed  the  treatment  to  a  young  man  who  was  weakened  by  repeated 
hemorrhages.  The  blood  of  a  calf  was  injected  and  the  man  recovered.  No- 
vember 23,  1667,  a  Bachelor  of  Divinity,  aged  32  was  transfused  from  a  sheep. 
Pepys  says  he  was  a  "poor  and  debauched  man"  who  was  hired  for  20  shillings 
by  the  Society.  Birch's  "History"  states  that  he  was  the  first  man  in  England  to 
be  transfused.  The  operation  succeeded.  Pepys  saw  the  man  a  week  later  and 
says  he  was  "the  first  sound  man  that  ever  had  it  tried  on  him  in  England,  and 
but  one  that  we  hear  of  in  France,  which  was  a  porter  hired  by  the  virtuosos." 

Great  things  were  expected  of  the  discovery.  It  was  thought  that  it  would 
permit  of  saving  the  weak,  the  aged,  the  diseased,  by  fresh  blood  and  offered 
an  ideal  method  of  administering  drugs.  Dr.  Croone  told  Pepys  it  may  "if 
it  takes,  be  of  mighty  use  to  man's  health,  for  the  amending  of  bad  blood  by 
borrowing  from  a  better  body."  The  artery  of  a  donor  was  opened  and  the 
blood  was  allowed  to  flow  into  the  vein  of  a  recipient.  A  fierce  controversy 
quickly  arose  as  to  the  merits  and  safety  of  the  procedure.  Proof  was  soon  fur- 
nished that  it  was  very  dangerous.  The  Parliament  of  Paris  issued  an  edict  that 
no  transfusion  should  be  made  without  the  consent  of  the  Faculty  of  Medicine 
of  Paris.  The  operation  soon  fell  into  desuetude.  It  was  condemned  in 
1739  by  Laurence  Heister  in  his  "System  of  Surgery."  Now  and  then  an 
attempt  was  made  to  revive  transfusion  but  it  was  not  recognized  as  a  legiti- 
mate procedure  until  Blundell's  studies  in  1824.  For  years  some  of  its  dangers 
were  recognized  and  it  was  used  only  for  hemorrhage  which  gravely  threatened 
life.  Postpartum  hemorrhage  was  the  particular  indication.  Some  used 
immediate  transfusion  from  the  vein  of  the  donor  to  the  vein  of  the  recipient. 
Some  used  mediate  transfusion,  the  blood  of  the  donor  being  drawm  into  a  vessel 
and  injected  into  the  vein  of  the  recipient.  It  was  claimed  by  Panum  that 
the  blood  should  be  defibrinated  before  injection.  Blundell  believed  that  blood 
of  animals  of  the  same  species  was  the  only  kind  admissible,  but  Brown-Sequard 
denied  this.  Gaillard  Thomas  actually  advocated  the  injection  of  milk.  The 
chief  value  of  transfusion  was  found  in  the  fact  that  it  supplied  sufficient  fluid 
to  replace  that  which  was  lost  and  stimulated  the  heart  to  contraction.  The 
great  perils  were  thought  to  be  clotting  and  entrance  of  air  and  various  plans 
were  suggested  to  prevent  them.  It  was  for  this  reason  that  defibrination  was 
employed.  Richardson  added  a  few  drops  of  ammonia  to  each  ounce  of  drawn 
blood,  Braxton-Hicks  used  phosphate  of  sodium.  Heuter  advocated  injecting 
the  blood  into  an  artery  in  order  that  it  might  reach  the  heart  less  rapidly  and  the 
danger  of  air  embolism  might  be  averted.  Infection  was  a  grave  danger  before 
the  days  of  Listerism.  In  1875  Landois  discovered  that  animal  serum  is  hemo- 
lytic to  human  blood.  In  1892  Maragliano  discovered  that  the  serum  of  a 
healthy  man  mil  prove  hemolytic  to  a  serum  alien  to  it.  It  thus  became  evi- 
dent that  human  serum,  alien  to  another  serum,  was  dangerous  and  might  cause 
death. 

Von  Bergmann  maintained  that  after  severe  hemorrhage  there  was  no  need 
of  injecting  nutritive  elements.  The  need  is  to  restore  the  greatly  diminished 
intracardial  and  intravascular  pressure  and  this  can  be  done  by  the  injection 
of  salt  solution.  Senn  insisted  that  the  operation  of  transfusion  had  proved 
an  absolute  failure,  that  it  did  not  prevent  death  from  hemorrhage,  and  that  the 
transferred  blood  elements  did  not  retain  vitaHty.  In  1895,  Sir  A.  Pearce 
writing  in  Treves's  "System  of  Surgery,"  expressed  the  view  of  most  surgeons 
when  he  said:  "Since  such  exceflent  results  have  been  obtained  with  saline  in- 
34 


530  Diseases  and  Injuries  of  the  Heart  and  Vessels 

jections,  both  forms  of  transfusion  have  been  abandoned."  It  was  seldom 
used  except  in  victims  of  poisoning  by  illuminating  gas,  in  which  cases  its  effects 
were  known  to  be  more  powerful  and  prolonged  than  those  of  saline  fluid. 
In  fact  the  operation  was  all  but  extinct  until  Crile  and  Carrel  revived  it,  and 
showed  that  blood  was  superior  to  saline  fluid.  It  has  proved  of  the  greatest 
service  in  the  present  war. 

Transfusion  is  a  method  of  the  very  greatest  value  in  the  treatment  of  the  con- 
dition resulting  from  violent  or  prolonged  hemorrhage.  It  is  used  when  the 
count  of  red  cells  is  below  2,000,000.  It  is  incomparably  the  best  treatment  for 
severe  hemorrhage.  It  can  be  employed  during  the  performance  of  an  exhaust- 
ing operation  and  its  use  will  bring  not  a  few  cases  to  operation  which,  without  its 
aid,  would  be  esteemed  inoperable.  It  should  be  used  for  severe  tj^ahoid  hemor- 
rhage and  in  jaundiced  cases  requiring  operation,  but  showing  very  slow  coagula- 
tion. It  may  be  of  benefit  for  certain  toxemias  and  infections.  It  will  not  save 
a  case  of  deep  and  prolonged  poisoning  by  carbon  monoxid.  In  purpura  hemor- 
rhagica, melena  neonatorum,  and  hemophilia  it  may  be  of  great  service.  It  is 
of  little  value  in  chronic  anemias  and  pernicious  anemia  (Levison,  in  "Military 
Surgeon,"  1916,  xxxLx).  Not  only  does  it  increase  the  power  of  blood  coagu- 
lation but  it  enhances  the  resistance  of  tissues  to  infection  (Primrose  and  Ryerson, 
in  "Brit.  Med.  Jour.,"  Sept.  16,  1916).  Many  observers  believe  that  the  trans- 
fused blood  actively  functionates  for  a  time  (8  or  10  days).  Strange  to  say 
after  transfusion  there  may  be  no  increase  in  the  red  cell  count,  but  even  then 
the  color  is  improved  and  the  blood-pressure  is  restored.  There  are  certain 
dangers  in  it  unless  there  is  time  to  examine  the  blood  of  both  donor  and  re- 
cipient. It  is  known  that  admixture  of  certain  bloods  results  in  hemolysis.  If 
the  corpuscles  of  the  donor  are  not  agglutinated  by  the  serum  of  the  recipient, 
and  vice  versa,  the  operation  is  safe.  If  time  permit  these  tests  should  always 
be  made.  That  lysins  and  agglutinins  may  do  harm  or  even  cause  death  seems 
certain  but  the  danger  has  been  exaggerated  (Primrose  and  Ryerson,  Ibid.). 
In  the  opinion  of  Dr.  A.  E.  Stansfeld  ("Brit.  Med.  Jour.,"  March  3,  1917)  (re- 
port of  meeting  of  Royal  Soc.  of  Med.)  "The  donor  should  be  a  healthy  adult, 
with  a  negative  Wassermann  reaction.  His  serum  should  not  agglutinate  the 
corpuscles  of  the  patient,  and  the  patient's  serum  should  not  agglutinate  the 
donor's  corpuscles.  Agglutinins  should  be  excluded  by  tests  done  immediately 
before  the  transfusion  and  a  single  examination  was  not  sufficient  to  establish 
the  compatibility  of  two  bloods  on  all  future  occasions.  If  agglutinins  were 
absent  hemolysis  would  also  be  absent.  If  there  were  great  urgency,  and  test- 
ing of  the  blood  of  patient  and  donor  were  impracticable,  a  small  preliminary 
transfusion  should  be  done  half  an  hour  before  the  main  mass  of  blood  was  trans- 
fused, so  that  gross  incompatibility  might  be  recognized  in  time.  Febrile  reac- 
tions occurred  after  about  25  per  cent,  of  transfusions,  even  though  the  bloods  of 
donor  and  patient  had  been  shown  to  be  compatible.  Rigors  occurred  in  about 
10  per  cent,  of  the  cases."  Transfusion  may  be  direct  by  vascular  anastomosis 
or  cannula.  It  may  be  indirect  by  means  of  a  syringe  and  cannula  or  by  employ- 
ing a  receiver,  provision  having  been  made  to  prevent  clotting. 

Arteriovenous  Anastomosis  for  Transfusion  of  Blood  (Crile's  Operation). 
— In  Crile's  operation  the  vascular  system  of  the  donor  is  united  to  the  vas- 
cular system  of  the  recipient.  He  places  intima  in  contact  with  intima.  This 
is  accomplished  by  means  of  a  modification  of  Payr's  magnesium  tube  or  by 
Crile's  tube,  which  is  of  German  silver.  The  vein  of  the  recipient  is  drawn 
through  the  tube,  is  everted,  and  is  tied  into  the  second  groove  on  the  tube. 

The  end  of  the  tube  with  the  everted  vessel  over  it  is  passed  into  the  vessel 
of  the  donor  and  fixed  temporarily  by  a  hgature.  The  left  arm  of  each  subject 
is  usually  employed  and  the  radial  artery  of  the  donor  is  anastomosed  to  a 
superficial  vein  of  the  recipient.  Each  patient  should  be  on  a  table  the  head 
of  which  can  be  raised  or  lowered  at  will.     The  region  over  the  radial  artery 


Fauntleroy's  Vein-to-vein  Anastomosis  531 

of  the  donor  is  exposed  under  local  anesthesia.  Every  small  branch  over  the 
artery  is  carefully  tied  in  order  to  prevent  obstruction  by  blood.  The  artery  is 
bared  for  a  distance  of  about  3  cm.,  tied  distally,  lightly  clamped  with  a  screw 
clamp  proximally,  and  divided.  The  vein  of  the  recipient  is  bared,  clamped, 
and  divided,  the  tube  (dipped  in  sterile  olive  oil)  is  inserted  into  the  vein,  the 
cuff  of  everted  vessel  is  formed  over  the  end,  and  the  artery  is  pulled  over  the 
tube  and  the  cuflF  of  vein,  and  held  by  a  ligature  tied  into  the  first  groove  (Be- 
van,  in  ''General  Surgery,"  by  Lexer-Bevan). 

The  flow  is  at  first  slow,  but  after  eight  or  ten  minutes  becomes  more  rapid, 
especially  if  warm  salt  solution  is  run  into  the  wounds.  The  amount  transfused 
depends  on  the  strength  of  the  donor  and  the  needs  of  the  recipient.  From 
250  c.c.  to  1000  c.c.  of  blood  may  be  given. 

I  have  used  Brewer's  tube  in  this  operation  mth  much  satif action.  It 
makes  the  procedure  vastly  easier  of  execution.  Fig.  263  shows  Brewer's 
tubes.     The  coating  of  paraffin  in  the  tube  prevents  clotting. 

I  am  indebted  to  Dr.  George  Emerson  Brewer  for  describing  in  a  note  to 
me  the  technic  of  his  operation.     The  description  follows: 

''After  thorough  sterilization,  the  tubes  are  prepared  by  dipping  them  in 
melted  paraffin,  shaking  them  out,  and  allowing  them  to  cool,  or  immersing 


Fig.   263. — Brewer's  tubes  for  direct  transfusion. 

them  in  a  solution  of  paraffin  in  benzine.  The  radial  artery  of  the  donor  is 
exposed  in  the  usual  manner,  and  also  the  median  basiHc  or  some  other  avail- 
able vein  of  the  donee.  The  proximal  end  of  the  artery  is  next  drawTi  over 
one  extremity  of  the  glass  tube  and  secured  by  a  silk  ligature.  This  is  facili- 
tated by  expanding  the  lumen  of  the  artery  by  means  of  three  mosquito  forceps 
or  artery  clamps.  When  all  is  ready  to  insert  the  free  extremity  of  the  tube 
into  the  vein  of  the  donee,  the  arterial  clamp  is  temporarily  released  and  a 
few  jets  of  blood  allowed  to  pass  through  the  tube,  which  is  then  quickly  placed 
within  the  lumen  of  the  vein  and  secured  by  another  silk  ligature.  If  the 
vein  of  the  donee  is  large,  the  distal  end  of  the  glass  tube  may  be  inserted 
through  a  longitudinal  slit  in  the  vein,  after  the  manner  usually  adopted  when 
introducing  the  cannula  for  salt  infusion.  WTien  sufficient  blood  has  been 
transfused  the  tube  is  removed,  the  vessels  ligated,  and  the  cutaneous  wounds 
closed.  In  certain  rare  instances  where  it  is  ad\'isable  to  transfuse  from  an 
adult  into  an  infant,  the  popliteal  vein  of  the  infant  may  be  employed,  as  the 
subcutaneous  veins  are  generally  too  small  to  admit  of  the  introduction  of  the 
tube.  In  these  cases  a  tube  of  diminishing  caliber  should  be  used,  the  larger 
end  for  the  donor's  artery,  the  smaller  for  the  donee's  vein." 

Fauntleroy's  Vein-to-vein  Anastomosis. — This  is  a  much  simpler  operation 
than  arteriovenous  anastomosis.     I  have  used  it  wdth  great  satisfaction.     A 


532 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


glass  tube  is  fixed  in  a  vein  of  the  donor  and  a  vein  of  the  recipient.  I  use  the 
tubes  devised  by  Dr.  A.  M.  Fauntleroy  of  the  United  States  Navy  ("  Med, 
Rec.,"  Sept.  3,  1910).  The  tube  is  ^  ^  inch  in  diameter  and  each  end  is  flanged 
to  prevent  shpping.  The  veins  in  front  of  the  elbow  are  used.  The  tube  chosen 
may  be  full  curved  or  S-shaped  (Fig.  264).  The  full  curved  tube  is  called  the 
"hand-to-shoulder  tube,"  because  when  it  is  used  the  hand  of  the  donor  is  toward 
the  shoulder  of  the  recipient  and  the  hand  of  the  recipient  is  toward  the  shoulder 

of  the  donor.  The  S-shaped  tube  is  called  the 
"shoulder-to-shoulder  tube."  It  is  used  when 
the  donor  and  recipient  are  placed  side  by  side 
in  the  same  direction,  with  the  shoulders 
together  (Fauntleroy,  Ibid.). 

The    tubes   are  prepared  with  paraffin.     A 
rubber   band   is   placed  around  the  arm  of  the 


tjAou/ctei'  fo    tS>lou/dej-  Tuhe 

Fig.  264. — Tubes  for  trans- 
fusion, one-half  natural  size  (A. 
M.  Fauntleroy,  in  "Medical 
Record"). 


Fig.  265. — Vein-to-vein  transfusion  with  the  shoulder- 
to-shoulder  tube  (A.  M.  Fauntleroy,  in  "Medical 
Record"). 


recipient  in  order  to  make  the  veins  prominent.  The  median  basilic  or  median 
cephalic  vein  is  exposed  and  freed  for  at  least  il^  inches.  A  ligature  is  passed 
under  the  vein  at  the  lower  angle  of  the  wound,  another  under  the  vein  at 
the  upper  angle  oi  the  wound.  The  lower  ligature  is  tied  and  the  rubber  band 
removed. 

The  tourniquet  is  now  applied  to  the  donor  and  the  vein  exposed  as  just  de- 
scribed. The  ligatures  are  placed,  but  only  the  upper  one  is  tied.  The  vein 
below  the  ligature  is  gently  grasped  with  rubber-protected  forceps  and  is  cut 
completely  across.  The  intima  is  grasped  with  fine  forceps  and  one  end  of  the 
tube  is  inserted  1^4  inch  into  the  vein,  and  the  lower  ligature  is  tied  in  order  to 
fix  the  tube  in  the  donor's  vein. 

The  elbows  are  now  brought  together,  a  nick  is  made  in  the  vein  of  the 
recipient,  the  rubber-protected  forceps  are  released  from  the  vein  of  the  donor, 
and,  while  blood  flows,  the  tube  is  inserted  in  the  vein  of  the  recipient, 
and  is  held  by  the  tying  of  the  upper  ligature.  During  the  operation  the  rub- 
ber band  is  kept  on  the  arm  of  the  donor,  sufficiently  tight  "to  secure  well- 
marked  venous  hyperemia  in  the  forearm  and  a  consequent  increased  venous 
pressure."     The  tourniquet  must  not  cause  stoppage  of  the  radial  pulse. 

It  is  well  to  have  a  blood-pressure  apparatus  on  the  free  arm  of  the  donor 
and  one  on  the  free  arm  of  the  recipient.  The  pulse  and  general  condition  of 
donor  and  recipient  are  carefully  watched. 

Angulation  of  the  veins  would  cause  clotting  and  must  not  be  permitted. 
We  can  tell  that  blood  is  passing  by  the  improvement  in  color,  in  pulse,  and 
in  blood-pressure  of  the  recipient  and  by  the  fulness  of  his  vein  near  the  tube. 
Fauntleroy  in  i  case  kept  up  the  flow  for  thirty  minutes.  At  the  termination 
of  the  operation  the  tubes  are  removed,  the  veins  tied,  the  tourniquet  taken 
from  the  arm  of  the  donor,  and  the  wounds  sutured  and  dressed. 

Major  George  Dorrance,  U.  S.  A.  whose  experience  is  very  large  kindly 
wrote  for  me  the  following  descriptions  of  the  Kimpton-Brown  method  and  the 
Lewisohn  citrate  method. 


Kimpton-Brown  Method 


533 


Kimpton-Brown  Method. — The  arms  of  the  patient  (recipient)  and  donor 
are  carefully  scrubbed  and  washed  with  alcohol,  all  surrounding  parts  being 


Fig.  266. — The    Kimpton-Brown    tubes;    two    sizes,   100    c.c.   and    250    c.c.   cautery  bulb 
(Mason,  in  "Surgery,  Gynecology,  and  Obstetrics"). 


Fig.  267. — Donor's    vein    exposed,    ligated    centrally,    and    tube    ready  to    be  introduced 
into  vein,  the  tip  directed  peripherally  (Mason,  in  "Surgery,  Gynecology,  and  Obstetrics")- 

covered  with  sterile  towels  or  sheets.  The  donor  and  the  recipient  are  placed 
on  separate  tables  or  the  recipient  may  remain  in  bed.  A  blood-pressure  cuff 
is  used  as  a  tourniquet  on  the  donor's  arm. 


534 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


The  median  cephalic  or  basilic  veins  of  both  patient  and  donor  are  carefully 
exposed  for  a  distance  of  3  inches  under  proper  aseptic  technic ,  in  the  case 
of  the  donor  the  upper  end  of  the  vein,  i.  e.,  the  portion  nearest  the  heart  may 
be  ligated.  A  second  ligature  is  placed  around  the  lower  end  of  the  exposed 
vein  but  not  tied.     Fine  silk  or  double  00  plain  catgut  may  be  used. 

In  like  manner,  two  ligatures  are  placed  on  the  recipient's  vein  but  in  this 
case  the  lower  ligature  is  tied. 


Fig.  268. 


-Tube  in  donor's  vein,   and  blood  flowing  into  the  tube  (Mason,  in  "Surgery, 
Gynecology,  and  Obstetrics"). 


The  blood-pressure  cuff  is  now  inflated  and  a  dog  ear  cut  made  in  the  vein 
of  the  donor  into  which  is  inserted  the  curved  end  of  the  Kimpton-Brown  tube 
which  has  previously  been  coated  with  Vincent's  wax.  The  blood  will  quickly 
fill  the  tube  which  is  then  withdrawn  and  the  blood-pressure  cuff  allowed  to 
collapse.  An  assistant  pulls  up  on  the  two  free  ends  of  the  untied  ligature 
and  prevents  further  bleeding. 


Fig.  269. — Proper  method  of  holding  the  tube  while  transporting  blood  from  donor  to  recipi- 
ent (Mason  in  "Surgery,  Gynecology,  and  Obstetrics"). 


If  any  oozing  occurs  while  the  tube  is  being  filled,  the  lower  untied  ligature 
may  be  tied  over  the  cannula  with  one  knot. 

The  tube  filled  with  blood  is  carried  over  to  the  recipient  and  inserted  into 
an  opening  similar  to  the  one  made  in  the  vein  of  the  donor,  only  being  placed 
in  opposite  direction. 

In  order  to  permit  the  blood  to  flow  more  rapidly  a  bulb  may  be  attached 


Kimp ton-Brown  Method 


535 


Fig.  270. — Recipient's  vein  exposed,  ligated  distally,  and  tube  filled  with  blood  ready  for 
introduction  into  vein,  the  tip  of  the  tube  directed  centrally  (Mason,  in  "Surgery,  Gyne- 
cology, and  Obstetrics"). 


Fig.  271. — Tube  in  position,  the  bulb  attached,  and  the  blood  being  slowly  forced  into  the 
vein  of  the  recipient  (Mason,  in  "Surgery,  Gynecology,  and  Obstetrics")- 


536  Diseases  and  Injuries  of  the  Heart  and  Vessels 

by  means  of  a  small  tube  to  the  horizontal  glass  cannula  in  the  upper  part 
of  the  tube. 

The  tube  can  only  be  used  once  as  it  will  require  fresh  coating  with  paraffin 
for  each  operation,  hence  several  tubes  should  be  prepared  and  held  in  readiness 
for  each  case. 

Method  of  Preparing  and  Sterilizing  Tubes. — The  tubes  are  carefully  cleansed 
and  a  piece  of  Vincent's  wax  about  the  size  of  a  small  lemon  is  inserted  into  the 
tube.  The  tubes  are  then  sterilized  in  an  autoclave  for  twenty  minutes,  being 
so  placed  as  to  prevent  the  melted  wax  from  running  out.  The  formula  for 
Vincent's  wax  is:  parafhn,  two  parts;  vaselin,  two  parts;  stearin,  one  part. 

After  sterilization,  the  tubes  are  removed  under  aseptic  conditions  with 
gloved  hands  and  the  rubber  stoppers  inserted.  Now  by  means  of  rapid  rotation 
of  the  tubes  with  alternating  up  and  dowm  motion,  the  liquid  wax  can  be  dis- 
tributed over  the  entire  inner  surface  of  the  tube  including  the  lower  curved 
cannula,  care  being  exercised  in  keeping  the  cannula  patulous.  As  a  rule, 
it  will  require  about  fifteen  minutes  to  prepare  a  tube,  as  one  must  keep  it 
constantly  in  motion  until  the  wax  solidifies.  After  a  little  practice,  it  is 
comparatively  easy  to  gauge  the  amount  of  wax  necessary  to  coat  evenly  the 
inner  surface  of  the  tube.  By  wrapping  the  tubes  in  sterile  cotton  and 
covering  with  a  sterile  towel,  it  is  possible  to  keep  them  indefinitely,  if  placed 
in  a  cool  place. 

Technic  of  Lewisohn's  Citrate  Method. — Apply  a  tourniquet  or  blood-pres- 
sure cufT  to  the  arm  of  the  donor.  By  means  of  a  needle  of  large  caliber  or  a 
trocar  and  cannula,  a  puncture  is  made  in  the  median  basilic  or  cephalic  vein 
and  the  blood  collected  in  a  graduate  glass  which  contains  the  2  per  cent,  sodium 
citrate  solution.  If  450  c.c.  of  blood  are  to  be  withdraAVTi,  50  c.c.  of  the  citrate 
are  used  and  the  same  proportion  if  smaller  or  larger  amounts  are  to  be  used. 

Infusion  of  Blood  into  Recipient. — The  vein,  median  cephalic  or  basilic, 
is  exposed  by  a  small  incision.  The  cannula  is  inserted  and  attached  to  a 
salvarsan  apparatus  or  tubing  attached  to  a  glass  funnel,  the  apparatus  having 
been  previously  filled  with  physiological  sodium  chlorid,  as  a  rule  20  to 
30  c.c.  being  used.  The  blood  is  then  poured  into  this  apparatus  and  allowed 
to  flow  into  the  recipient's  vein  by  gravity. 

Regardless  of  the  method  employed,  we  may  look  for  a  slight  rise  in  tempera- 
ture and  occasionally  a  slight  chill  following  the  transfusion.  This  phenomenon 
if  mild,  is  of  no  consequence,  but  if  severe  indicates  that  we  have  not  selected 
the  proper  donor  and  is  likely  to  mean  that  hemolysis  is  occurring. 

The  heart  action  of  the  recipient  following  a  successful  transfusion  becomes 
stronger,  the  pulse  more  regular  and  of  better  volume,  the  mucous  membranes 
regain  their  color  and  the  hemoglobin  and  red  blood-cells  show  a  proportionate 
increase. 

Intravenous  infusion  of  saline  fluid  is  used  after  severe  hemorrhage,  in 
shock,  in  diabetic  coma,  in  postoperative  suppression  of  urine,  and  occa- 
sionally in  sepsis.  After  a  hemorrhage  its  beneficial  effects  are  often  prompt 
and  obvious.  The  saline  fluid  increases  the  arterial  tension,  gives  the  heart 
enough  matter  to  contract  upon,  and  so  restores  the  activity  of  the  circula- 
tion, and  does  not  destroy  the  red  corpuscles  as  plain  water  would  do.  We 
may  use  a  simple  apparatus  consisting  of  a  rubber  tube,  a  funnel,  and  an  aspi- 
rating needle.  Some  employ  an  Aveling  syringe,  and  others  Collin's  apparatus 
(Fig.  273).  The  last-named  instrument  can  be  used  without  any  danger  of  air 
entering  with  the  fluid.  Spencer's  instrument  (Fig.  274)  is  convenient  and 
useful.  Normal  salt  solution  is  the  fluid  usually  employed,  of  a  strength  of 
0.9  per  cent,  (i  heaping  teaspoonful  of  common  salt  to  i  quart  of  warm  boiled 
water).  Some  surgeons  employ  artificial  serum.  Szumann's  solution  consists 
of  6  parts  of  common  salt,  i  part  of  sodium  carbonate,  and  1000  parts  of  water. 
Ringer's  solution  consists  of  0.7  per  cent,  sodium  chlorid,  0.03  per  cent  of  potas- 


Intravenous  Infusion  of  Saline  Fluid 


537 


sium  chlorid,  0.025  per  cent,  of  calcium  chlorid.  The  results  from  artificial  serum 
containing  many  elements  are  no  better  than  from  normal  salt  solution.  Adren- 
alin may  be  added  to  the  normal  salt  solution  (i  dram  of  the  i :  1000  solution  of 
adrenalin  to  i  pint  of  salt  solution).  The  results  of  a  single  dose  of  adrenalin 
are  very  transitory.  What- 
ever fluid  is  used,  it  should 
be  at  a  temperature  of  105° 
F.  or  over  as  it  enters  the 
vein.  The  stimulant  effect 
of  the  heat  is  of  great  value. 
The  fluid  must  not  be  allowed 
to  cool;  and  a  nurse  gives  con- 
stant attention  to  the  tem- 
perature of  the  fluid  in  the 
reservoir.  This  degree  of 
heat  will  not  damage  the 
corpuscles;  in  fact,  Dawbarn 
has  used  saline  fluid  at  a 
temperature  of  11 8°  F.  \\ith- 
out  doing  damage  to  corpus- 
cles and  with  great  benefit 
to  the  patient.  Globulin 
coagulates  at  158°  F.  and 
serum  albumin  at  162°  F. 
From  }-2  pint  to  2  pints  or 
even  more  are  slowly  in- 
jected, the  condition  of  the 

patient  determining  the  amount  given.  In  one  case  of  violent  hemorrhage  the 
author  used  over  2  quarts.  In  order  to  infuse  this  fluid  tie  a  fillet  well  above 
the  elbow,  and  expose  by  dissection  the  median  basilic  vein,  or  the  basilic  vein  in 
the  portion  of  its  course  where  it  is  superficial  to  the  deep  fascia.     Tie  the  vein. 


Fig.    272. — Intravenous    saline    infusion.      Manner    of 
incising  vein  and  inserting  glass  tube  (Senn). 


Fig.  273. 


-Intravenous  injection  of  saline 
fluid. 


Fig.  274. — Spencer's  apparatus  for  the  infu- 
sion of  saline  fluid  into  a  vein.  The  cannula  can 
be  plunged  directly  into  the  vessel  without  pre- 
liminary incision. 

Incise  it  above  the  ligature,  insert  a  fine  cannula  toward  the  heart,  and  hold  the 
cannula  firmly  in  the  lumen  by  tightening  a  second  ligature  (Figs.  272,  273). 
Remove  the  fillet.  Slowly  and  gradually  introduce  the  fluid,  carefully  watching 
the  pulse.  Occupy  at  least  ten  minutes  in  introducing  i  pint,  except  in  a  very 
desperate  case  of  hemorrhage,  when  the  rapidity  of  the  flow  may  be  accelerated. 


538  Diseases  and  Injuries  of  the  Heart  and  Vessels 

When  the  tension  of  the  pulse  returns,  withdraw  the  cannula,  tie  the  second  liga- 
ture tightly,  sew  up  the  wound,  and  dress  it  aseptically.  In  very  severe  opera- 
tions an  assistant  should  conduct  the  infusion  while  the  surgeon  is  operating. 
It  may  be  necessary  to  repeat  the  injection  if  the  circulation  fails  again.  The 
infusion  of  a  very  large  amount  of  saline  fluid  may  do  harm.  It  may  embarrass 
the  heart  and  cause  acute  dilatation,  may  lead  to  edema  of  the  lungs  or  brain, 
and  cause  marked  anemia  which  lasts  for  days.  If  dilatation  of  the  right  heart 
exists  the  intravenous  administration  of  saline  fluid  is  contra-indicated.  The 
giving  of  salt  solution  intravenously  should  never  be  regarded  as  routine  treat- 
ment, judgment  is  required  in  determining  that  it  should  be  used,  when  it 
should  be  used,  and  how  much  is  required,  and  there  is  a  distinct  element  of 
danger  in  the  procedure. 

Arterial  Transfusion  and  Infusion  of  Saline  Fluid  in  Arteries. — Hueter 
preferred  the  arterial  method  of  transfusion,  in  order  to  send  the  blood  more 
gradually  to  the  heart,  and  thus  prevent  sudden  disturbance  of  the  circulation. 
A  little  air  in  an  artery  will  do  no  harm,  and  the  danger  of  venous  embolism 


Fig.  275. — Injection  of  saline  solution  and  adrenalin  into  an  artery  by  the  method  of  Crile. 

is  avoided.  Saline  fluid  can  be  infused  into  an  artery.  The  radial  artery  is 
exposed  and  surrounded  by  three  ligatures,  and  the  thread  toward  the  heart 
is  at  once  tied.  The  distal  ligature  is  slightly  tightened  to  cut  off  anastomotic 
blood-supply.  The  artery  is  cut  transversely  half  through;  the  syringe  is 
inserted,  pointed  toward  the  periphery,  and  fastened  by  the  third  ligature; 
the  second  ligature  is  loosened  and  the  material  is  injected.  On  finishing,  the 
peripheral  thread  is  tied  tightly -and  that  portion  of  the  artery  which  held  the 
cannula  is  excised.  Dawbarn  puts  a  hypodermatic  needle  into  the  radial 
artery  and  injects  saline  fluid. 

Crile  (Crile  and  DoUey,  in  "Jour,  of  Exper.  Med.,"  Dec,  1906)  has  shown 
that  when  a  patient  is  nearly  dead  or  apparently  dead  the  introduction  of 
saUne  fluid  by  a  vein  may  overwhelm  the  heart.  He  gives  it  in  these  cases  by 
an  artery  and  has  succeeded  in  resuscitating  those  apparently  dead.  The  tube 
of  the  apparatus  is  quickly  inserted  into  the  carotid  artery  and  toward  the 
heart.  The  reservoir  is  raised,  and  as  the  saline  fluid  begins  to  flow  the  tube  is 
punctured  with  a  hypodermatic  needle  and  adrenalin  is  added  to  the  saline 
stream.  If  the  heart  starts  to  beat,  blood  will  appear  in  the  tube  and  then  the 
administration  is  discontinued.  By  this  method  we  may  re-establish  blood- 
pressure  in  the  coronary  arteries  (Fig.  275). 


Ligation  of  Arteries  in  Continuity  539 

Ligation  of  Arteries  in  Continuity 

The  instruments  used  in  this  operation  are  two  scalpels  (one  small, 
one  medium),  two  dissecting  forceps,  several  hemostatic  forceps,  blunt  hooks 
or  broad  metal  retractors,  an  AUis  dissector,  an  aneurysm  needle,  for  superfi- 
cial arteries  the  instrument  of  Saviard  (Fig.  276),  for  deep  vessels  the  needle 
of  Dupuytren  (Fig.  277),  ligatures  of  catgut,  of  chromicized  gut,  or  of  silk, 
curved  needles  and  a  needle-holder,  sutures  of  silkworm-gut,  and  the  reflector 
or  electric  forehead-lamp  for  deep  vessels. 

The  position  in  which  the  patient  is  placed  varies  according  to  the  vessel 
to  be  ligated,  though  the  body  is  supine  except  when  ligation  is  to  be  performed 
on  the  gluteal,  sciatic,  or  popliteal  artery.  The  operator,  as  a  rule,  stands 
upon  the  affected  side,  cutting  from  above  downward  on  the  right  side,  and 
from  below  upward  on  the  left  side. 

Operation. — Accurately  determine  the  line  of  the  artery,  and  make  an  in- 
cision at  a  slight  angle  to  this  line,  avoiding  subcutaneous  veins,  and  holding  the 
scalpel  like  a  fiddle-bow  or  a  dinner-knife  while  cutting  the  superficial  parts,  and 
like  a  pen  while  incising  the  deeper  parts.  On  reaching  the  deep  fascia  make 
out  the  required  muscular  gap  by  the  eye  and  finger,  so  moving  the  extremity 
as  to  bring  individual  muscles  into  action.  Treves  ("Operative  Surgery")  cau- 
tions us  not  to  depend  upon  the  yellow  line  of  fat,  which  often  cannot  be  seen  in 
emaciated  people  or  when  an  Esmarch  bandage  is  employed;  nor  upon  the  white 
line  due  to  attachment  to  the  fascia  of  an  intermuscular  septum.  In  opening 
the  deep  portion  of  the  wound  relax  the  bounding  muscles  by  altering  the  pos- 
ture.   Open  a  muscular  interspace  by  a  sharp  knife,  not  by  a  dissector.     Make  the 


Fig.   276. — Aneurysm  needle  of  Saviard. 

depths  of  the  wound  as  long  as  the  superficial  incision.  Do  not  tear  structures 
apart  with  a  grooved  director;  cut  them.  Arrest  hemorrhage  as  it  occurs.  Try 
to  find  the  situation  of  the  artery  with  the  finger.  Pulsation  is  present,  but  it 
may  be  very  feeble  and  hard  to  detect.  The  artery  feels  like  a  very  thin  rubber 
tube;  it  is  compressible,  though  not  so  easily  as  a  vein,  and  when  compressed 
feels  like  a  flat  band  which  is  thinner  in  the  center  than  at  the  edges.  A  nerve' 
feels  like  a  hard,  round  cord.  Veins  are  soft,  larger  than  their  related  arteries, 
and  so  very  compressible  that  they  can  scarcely  be  felt  when  pressed  upon,  and 
compression  causes  distal  distention.  If  the  wound  can  be  seen  into  clearly,  it 
will  be  noted,  as  Treves  (''Operative  Surgery")  asserts,  that  "the  nerves  stand 
out  as  clear,  rounded,  white  cords ;  that  the  veins  are  of  a  purple  color  and  of 
somewhat  uneven  and  wavy  contour;  that  the  artery  is  regular  in  outline  and 
of  a  pale-pink  or  pinkish-yellow  tint,  the  large  vessels  being  of  lighter  color  than 
the  small."  Each  artery  of  the  upper  extremity  and  each  artery  below  the  knee 
is  accompanied  by  two  veins,  known  as  "venae  comites."  The  arteries  of  the 
head  and  neck,  except  the  lingual,  have  each  a  single  attending  vein;  the  lingual 
has  venae  comites.  Most  of  the  smaller  arteries  of  the  trunk  (pudic,  internal 
mammary,  etc.)  have  venae  comites.  These  companion  veins  may  lie  on 
each  side  of  the  artery  or  in  front  and  back  of  it,  and  they  communicate  with 
one  another  by  transverse  branches  crossing  the  artery.  On  reaching  the 
sheath  pick  up  this  structure  with  toothed  forceps  so  as  to  make  a  transverse 
fold,  and  thus  avoid  catching  the  artery  or  vein;  lift  the  fold  to  see  that  it  is 
free,  and  open  the  sheath  by  cutting  toward  the  edge  of  the  forceps  with  a 
scalpel  held  obliquely  with  its  back  toward  the  vessel,  thus  making  a  small 


540 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


longitudinal  incision  (PI.  3,  Figs,  i,  2).  Hold  the  edge  of  the  incised  sheath 
with  the  forceps;  pass  a  metal  dissector  under  the  vessel  and  from  the  forceps; 
this  clears  one-half  of  the  vessel.  Grasp  the  other  edge  of  the  sheath  and  pass 
the  blunt  dissector  all  the  way  around  the  vessel.  Pass  an  aneurysm  needle 
under  the  cleared  vessel,  away  from  the  forceps  holding  the  sheath  and  away 
from  the  vessel's  most  dangerous  neighbor.  Thread  the  needle  and  withdraw 
it.  If  venae  comites  are  in  the  way,  try  to  separate  them;  but  if  this  proves 
difficult,  include  them  in  the  ligature.  In  small  vessels  always  include  them 
if  they  are  in  the  way,  as  this  saves  trouble.  If,  in  passing  the  needle,  a  large 
vein  is  severely  wounded  (such  as  the  femoral),  Jacobson  advises  the  em- 
ployment of  digital  pressure  in  the  lower  portion  of  the  wound  while  the  artery 
is  being  tied  on  a  level  above  or  below  that  of  the  vein  injury,  and  after  ligation 
the  maintenance  of  pressure  on  the  wound  for  a  couple  of  days.  A  slight  puncture 
in  a  vein  merely  requires  a  lateral  ligature.  A  small  wound  can  be  closed  with 
Lembert  sutures  of  fine  silk.  After  getting  a  ligature  under  an  artery  press 
for  a  moment  upon  the  artery  over  the  ligature,  which  is  held  taut;  this  pressure 
will  arrest  pulsation  below  if  the  ligature  is  around  the  main  artery  and  there 

is  not  a  double  vessel.  Tie  the  thread  at 
right  angles  to  the  vessel  with  a  reef-knot 
(Fig.  278),  rupturing  the  internal  and 
middle  coats.  As  the  ligature  is  tightened 
place  the  extended  index-fingers  along  the 
ligature  up  to  the  artery  (PI.  3,  Fig.  3) ,  using 
the  middle  joints  as  the  fulcrum  of  a  lever 
by  placing  them  against  each  other. 


Fig.  277. 


-Dupuytren's  aneurysm 
needles. 


Fig.  278.— Reef-knot. 


Ballance  and  Edmunds  claim,  as  Scarpa  and  Sir  Philip  Crampton  claimed 
long  since,  that  it  is  not  necessary  to  divide  the  internal  and  middle  coats  to 
insure  obliteration.  If  this  claim  be  true,  the  danger  of  secondary  hemorrhage 
can  be  greatly  lessened.  Holmes,  however,  thinks  the  older  method  the  more 
certain  of  the  two.  Ballance  and  Edmunds  use  floss  silk  as  a  ligature  material, 
because  it  is  soft,  broad,  and  flat,  and  they  surround  the  artery  with  a  double 
ligature.  These  surgeons  thus  describe  the  application  of  the  stay-knot: 
"The  best  way  of  tying  two  ligatures  is  to  make  on  each  separately,  and  in 
the  same  way,  the  first  hitch  of  a  reef-knot,  and  to  tighten  each  separately  so 
that  the  loop  lies  in  contact  with  the  vessel  without  constricting  it.  Then 
taking  the  ends  on  one  side  together  in  one  hand  and  the  two  ends  on  the 
other  side  in  the  other  hand,  constrict  the  vessel  sufficiently  to  occlude  it,  and 
finally  complete  the  reef-knot.  The  simplest  way  of  completing  the  knot  is  to 
treat  the  two  ends  in  each  hand  as  a  single  thread  and  to  tie  as  if  completing 
a  single  reef-knot."  This  knot  is  shown  in  PI.  3,  Figs.  5,  6.  The  stay-knot 
appHed  by  this  method  is  of  great  value  if  a  vessel  be  atheromatous. 

The  chief  dangers  after  ligation  are  secondary  hemorrhage  and  gangrene. 
Rigid  asepsis  usually  prevents  the  first;  rest,  elevation,  and  heat  antagonize 
the  second. 

Radial  Artery. — The  line  of  the  radial  artery  is  from  the  middle  of  the 
front  of  elbow- joint  to  the  ulnar  side  of  the  styloid  process  of  the  radius.     The 


LIGATIONS. 


Plate  3. 


I  Opening  the  Sheath  for  Ligation  of  an  Artery  (Guerin).  2.  Sheath  of  Artery  Open  (Guerin). 
3  Tightening  the  Knot  in  Ligation  (Guerin).  4-  Anatomy  of  the  Iliac  Arteries,  and  showing  the 
lines  of  incision  for  their  ligation:  I,  Abernethy's  incision  (Guerin).  5,  6.  Ballance  and  Ed^ 
munds'  Stay-knots. 


Radial  Artery  541 

line  in  the  tabatiere  is  from  the  apex  of  the  styloid  process  to  the  posterior 
angle  of  the  first  interosseous  space  (Fig.  279). 

Anatomy  (PI.  4,  Fig.  5). — The  radial  artery,  though  smaller  than  the 
ulnar,  is  the  direct  continuation  of  the  brachial.  It  arises  from  the  bifurcation 
of  the  brachial  }  2  inch  below  the  bend  of  the  elbow,  runs  down  the  radial 
side  of  the  forearm  to  the  front  of  the  styloid  process  of  the  radius,  passes 
beneath  the  extensor  muscles  of  the  first  metacarpal  bone  and  of  the  first 
phalanx  of  the  thumb,  and  over  the  carpus  to  the  first  interosseous  space. 
It  is  crossed  by  the  tendon  of  the  extensor  secundi  internodii  pollicis,  enters 
into  the  palm  between  the  heads  of  the  first  dorsal  interosseous  muscle,  and 
forms  the  deep  palmar  arch.  The  artery  in  the  upper  two-thirds  of  its  course 
is  somewhat  overlaid  by  the  supinator  longus  muscle;  in  the  lower  one- third 
of  the  forearm  it  is  superficial.  In  the  upper  third  of  the  forearm  it  lies  be- 
tween the  supinator  longus  on  the  outside  and  the  pronator  radii  teres  on 
the  inside;  in  the  lower  two-thirds  of  the  forearm  it  lies  between  the  supinator 
longus  on  the  outside  and  the  flexor  carpi  radialis  on  the  inside.  Two  venae 
comites  attend  the  vessel.  The  radial  nerve  is  to  the  outer,  or  radial,  side 
of  the  artery,  well  removed  from  the  artery  in  the  upper  third,  nearer  to  the 
artery  in  the  middle  third,  far  external  to  the  artery  in  the  lower  third,  the 
nerve  at  this  point  passing  beneath  the  supinator  longus  muscle.  The  radial 
artery  from  above  downward  rests  upon  the  biceps  tendon,  the  supinator 


Pig.  279. — ^Lines  of  incision  for  ligation  of  the  axillary  (third  portion),  brachial,  radial,  and 

ulnar  arteries  (MacCormac). 

brevis,  the  flexor  sublimis,  the  pronator  radii  teres,  the  flexor  longus  pollicis, 
the  pronator  quadratus  muscles,  and  the  radius.  The  best  guide  to  the  radial 
artery  in  the  forearm  is  the  outer  edge  of  the  flexor  carpi  radialis  muscle  or 
the  inner  edge  of  the  supinator  longus  muscle. 

The  tabatiere  anatomique  of  Cloquet,  or  the  anatomical  snuff-box,  is  a  tri- 
angle whose  base  is  the  lower  edge  of  the  posterior  annular  ligament,  the 
ulnar  side  being  formed  by  the  extensor  secundi  internodii  pollicis  tendon, 
the  radial  side  by  the  extensor  ossis  metacarpi  and  the  extensor  primi  internodii 
pollicis  tendons;  the  floor  consists  of  the  trapezium,  scaphoid,  their  dorsal 
ligaments,  and  the  base  of  the  first  metacarpal  bone. 

Operations. — Ligation  in  the  tabatiere  is  a  dissecting-room  operation  of  but 
little  practical  use.  The  patient  is  placed  in  a  recumbent  position,  the  arm 
is  abducted,  and  the  forearm  is  placed  midway  between  pronation  and 
supination  (Barker).  The  surgeon  stands  upon  the  side  operated  upon.  An 
incision  2  inches  in  length  is  made  along  the  radial  border  of  the  extensor  secundi 
internodii  pollicis  muscle.  The  skin  and  superficial  fascia  are  cut  and  some 
T'enous  branches  are  divided.  The  deep  fascia  is  incised,  and  the  vessel  is 
easily  found  and  tied  before  it  passes  between  the  heads  of  the  first  dorsal  inter- 
osseous muscle  (Barker). 

Ligation  of  the  Lower  Third. — In  this  operation  (PI.  4,  Fig.  6,  and  Fig.  279) 
the  patient  is  placed  supine,  the  arm  is  abducted,  the  forearm  is  supinated,  is 
rested  upon  a  table,  and  is  held  by  an  assistant.     The  surgeon  stands  on  the 


542  Diseases  and  Injuries  of  the  Heart  and  Vessels 

side  operated  upon,  and  cuts  from  above  downward  on  the  right  forearm  and 
from  below  upward  on  the  left  forearm.  The  line  of  the  vessel  should  be 
determined,  and  may  be  indicated  with  iodin.  An  incision  i}'2  inches  in  length 
is  made  at  a  slight  angle  to  this  line  and  midway  between  the  supinator  longus 
and  the  flexor  carpi  radialis  muscles,  which  incision  must  not  extend  below  the 
level  of  the  tuberosity  of  the  scaphoid  bone.  In  the  superficial  fascia  watch 
for  the  superficial  radial  vein,  and  if  it  comes  into  view  push  it  aside.  Incise 
the  superficial  fascia  and  locate  each  guide-tendon.  Open  the  deep  fascia  in 
the  length  of  the  first  cut;  try  to  separate  the  veins,  but  if  they  strongly  adhere 
include  them  in  the  ligature.  There  is  no  special  fascial  sheath.  The  radial 
nerve  will  not  be  seen,  but  a  division  of  the  anterior  cutaneous  nerve  is  frequently 
found  in  relation  with  the  vessel.  The  needle  can  be  passed  in  either  direction. 
A  high  origin  of  the  superficialis  volae  artery  is  confusing. 

Ligation  of  the  Middle  Third. — In  this  operation  the  position  of  the  patient 
should  be  the  same  as  in  the  preceding.  A  2-inch  incision  is  made.  Veins 
of  the  subcutaneous  tissues  are  avoided.  Lying  upon  the  deep  fascia  is 
the  anterior  division  of  the  musculocutaneous  nerve.  Open  the  fascia;  find  the 
inner  edge  of  the  supinator  longus  muscle  and  draw  it  outward,  flexing  the 
elbow  partly  if  necessary.  Be  sure  not  to  cut  external  to  this  muscle.  Find 
the  vessel  where  it  is  bound  down  by  connective  tissue  to  the  pronator  radii 
teres  muscle,  separate  the  veins,  and  pass  the  Hgature  from  without  inward. 
The  nerve  is  external. 

Ligation  of  the  Upper  Third  (PI.  4,  Fig.  6,  and  Fig.  279). — For  this  opera- 
tion the  incision  is  as  described  above,  only  higher  up.  The  artery  is  between 
the  supinator  longus  and  the  pronator  radii  teres,  which  are  at  once  differ- 
entiated by  the  different  direction  of  their  fibers.  The  artery  is  usually  covered 
by  the  supinator  longus  muscle,  which  must  be  retracted  externally.  The 
nerve  is  not  seen.     The  ligature  may  be  passed  in  either  direction. 

Ulnar  Artery. — No  one  line  will  overlie  the  entire  ulnar  arter}'.  The 
line  of  the  upper  third  runs  from  the  middle  of  the  front  of  the  elbow-joint 
to  the  point  of  junction  of  the  upper  and  middle  thirds  of  the  ulna.  The 
line  of  the  lower  two-thirds  runs  from  the  tip  of  the  internal  condyle  of  the 
humerus  to  the  radial  side  of  the  pisiform  bone  (PL  4,  Figs.  5,  6;  Fig.  279). 

Anatomy  (PI.  4,  Fig.  5). — The  ulnar  artery  arises  from  the  brachial  bifur- 
cation and  runs  obliquely  inward  under  the  median  nerve  and  a  group  of 
muscles  from  the  internal  condyle;  it  turns  down  the  arm,  being  covered  in 
the  middle  third  of  its  course  by  the  flexor  carpi  ulnaris  muscle.  In  the  lower 
third  it  is  superficial,  between  the  tendons  of  the  flexor  carpi  ulnaris  on  the  inside 
and  the  flexor  sublimis  digitorum  on  the  outside,  the  vessel  being  a  little 
overlapped  by  the  flexor  carpi  ulnaris.  This  vessel  rests  first  upon  the 
brachialis  anticus  muscle,  next  upon  the  flexor  profundus,  to  which  it  is  bound 
by  a  distinct  process  of  fascia,  and  next  upon  the  annular  ligament,  which 
structure  it  crosses  to  become  the  superficial  palmar  arch.  Two  venae  comites 
attend  the  vessel.  In  the  upper  third  the  ulnar  nerve  is  well  internal,  but  in  the 
lower  two-thirds  the  nerve  lies  near  the  artery  and  to  its  ulnar  side.  The  guide 
is  the  outer  edge  of  the  flexor  carpi  ulnaris. 

Operations  (PI.  4,  Fig.  6,  and  Fig.  279). — Ligation  of  the  Lower  Third. — 
The  position  in  this  operation  is  the  same  as  for  ligation  of  the  radial  artery.. 
Make  a  2-inch  incision  to  the  radial  side  of  the  tendon  of  the  flexor  carpi  ulnaris. 
This  incision  should  not  be  taken  lower  than  a  point  i  inch  above  the  pisiform 
bone.  Avoid  the  superficial  ulnar  vein  in  the  subcutaneous  tissue.  Open  the 
deep  fascia,  find  the  tendon  of  the  flexor  carpi  ulnaris,  flex  the  wrist  and  draw 
the  tendon  inward,  open  a  second  layer  of  fascia,  clear  the  vessel,  separate  the 
veins,  and  pass  the  ligature  from  within  outward  to  avoid  the  nerve.  On  the 
artery  is  the  palmar  cutaneous  branch  of  the  ulnar  nerve,  and  this  branch  must 
not  be  included  in  the  ligature. 


LIGATIONS. 


Plate  4. 


Brachial  Artery  545 

Ligation  of  ihe  Middle  Third  (PI.  4,  Fig.  6).— In  this  operation  the  position 
is  the  same  as  in  the  preceding  one,  the  incision  being  3  inches  long.  Avoid 
the  anterior  ulnar  vein  and  the  branches  of  the  internal  cutaneous  nerve  in 
the  superficial  fascia.  Open  the  deep  fascia  a  little  external  to  the  superficial 
cut  (Treves).  Find  the  space  between  the  flexor  carpi  ulnaris  and  the  super- 
ficial flexor,  feeling  with  the  index-finger,  and  when  the  space  is  discovered 
flex  the  wrist,  retract  the  flexor  carpi  ulnaris  inward  and  the  flexor  sublimis 
digitorum  outward,  open  the  fascia,  find  the  ulnar  nerve,  look  external  to  it  for 
the  artery,  clear  the  vessel,  separate  the  venas  comites,  and  pass  the  needle  from 
within  outward.  The  ulnar  artery  should  not  be  ligated  in  continuity  in  the 
upper  third  of  its  course. 

Brachial  Artery.^The  line  of  the  brachial  artery  is  from  the  junction 
of  the  anterior  and  middle  thirds  of  the  outlet  of  the  axilla,  the  arm  being 
abducted  and  the  forearm  supinated,  to  the  middle  of  the  front  of  the  elbow- 
joint  (Fig.  279). 

Anatomy  (PI.  4,  Fig.  i). — The  brachial  artery  is  the  prolongation  of  the 
axillary,  and  extends  from  the  lower  edge  of  the  teres  major  muscle  to  3^-2  inch 
below  the  bend  of  the  elbow,  where  it  divides  into  the  radial  and  ulnar  arteries. 
It  lies  first  to  the  inner  side  of  the  arm,  but  passes  to  the  front  of  the  elbow. 
It  is  crossed  by  no  muscle,  and  is,  in  fact,  superficial,  barring  its  being  somewhat 
overlaid  in  part  of  its  course  by  the  edge  of  the  biceps  muscle.  The  median 
nerve  is  external  above,  crosses  over  the  vessel  about  the  middle  of  the  arm,  and 
reaches  the  inner  side  of  the  artery.  The  coracobrachialis  and  biceps  muscles 
are  external,  and  both  often  overlap  the  vessel.  The  ulnar  nerve  is  internal 
above,  and  the  median  nerve  is  internal  below  the  middle.  The  basilic  vein 
is  to  the  inner  side  of  the  artery,  being  outside  the  deep  fascia  to  near  the  middle 
of  the  arm,  at  which  point  it  pierces  it.  The  artery  above  is  separated  from  the 
long  head  of  the  triceps  by  the  musculospiral  nerve  and  superior  profunda  artery 
and  vein;  it  rests  from  above  down  on  the  inner  head  of  the  triceps,  the  coraco- 
brachialis, and  the  brachialis  anticus  muscles.  The  artery  is  covered  by  skin, 
by  superficial  fascia,  and  by  deep  fascia.  The  internal  cutaneous  nerve  hes 
in  front  of  the  artery,  upon  the  deep  fascia,  until  it  pierces  the  fascia  along  with 
the  basilic  vein.  The  artery  has  venae  comites,  and  in  its  upper  half  has  also 
the  basilic  vein  to  its  inner  side.  The  guide  to  the  brachial  is  the  inner  edge 
of  the  biceps  muscle.  Just  in  front  of  the  elbow- joint  the  artery  lies  in  a 
triangle,  the  base  of  which  is  formed  by  an  imaginary  transverse  line  above 
the  condyles,  and  the  apex  by  the  junction  of  the  pronator  radii  teres  and  the 
supinator  longus  muscles.  The  outer  line  is  the  supinator  longus,  the  inner 
line  is  the  pronator  radii  teres,  and  the  floor  is  formed  by  the  brachiahs  anticus 
and  the  supinator  brevis  muscles.  From  within  outward  the  triangle  contains 
the  median  nerve,  brachial  artery,  tendon  of  the  biceps,  anastomosis  of  the 
superior  profunda  and  radial  recurrent  arteries,  and  the  musculospiral  nerve. 

Operations. — Ligation  at  the  Bend  of  the  Elbow. — In  this  operation  (PI.  4, 
Fig.  2,  and  Fig.  279)  the  patient  is  placed  supine,  the  arm  is  moderately  abducted 
and  extended,  and  is  allowed  to  lie  upon  its  posterior  aspect.  The  forearm  is 
supinated.  The  surgeon  stands  upon  the  side  operated  upon,  and  cuts  from 
above  downward  on  the  right  side  and  from  below  upward  on  the  left  side. 
The  tendon  of  the  biceps  and  the  median  basilic  vein  must  be  accurately  located. 
An  incision  is  made  parallel  to  the  inner  edge  of  the  biceps  tendon  and  2  inches 
in  length,  the  center  of  this  cut  being  in  the  crease  of  the  elbow.  On  exposing 
the  median  basilic  vein,  retract  it  downward  and  inward,  open  the  bicipital 
fascia,  clear  the  artery  of  fat,  separate  the  venae  comites,  and  pass  the  ligature 
from  within  outward  to  avoid  the  median  nerve.  The  above  operation  is  not 
frequently  performed. 

Ligation  in  the  Middle  of  the  Arm  (Fig.  279). — In  this  operation  the  patient 
is  placed  supine,  the  arm  is  abducted,  and  the  forearm  is  supinated.     An 


544  Diseases  and  Injuries  of  the  Heart  and  Vessels 

assistant  holds  the  forearm,  but  the  arm  should  not  rest  upon  the  table,  because, 
if  it  be  allowed  to  do  so,  the  inner  head  of  the  triceps  will  be  forced  forward 
and  may  overlie  the  artery,  and  thus  complicate  the  operation.  Locate  the 
inner  edge  of  the  biceps,  which  is  the  guide.  Make  an  incision  3  inches  in 
length  in  the  line  of  the  artery.  Incise  the  skin  and  fascia,  flex  the  elbow 
slightly,  retract  the  biceps  outward,  feel  for  the  artery,  open  the  sheath,  separate 
its  venae  comites,  and,  having  located  the  median  nerve,  pass  the  ligature  from 
it.  In  the  middle  of  the  arm  the  nerve  is  in  front  of  the  vessel,  above  the 
middle  it  is  external  to  it,  and  below  the  middle  it  is  internal  to  it.  High  up 
the  arm  the  inner  edge  of  the  coracobrachialis  is  the  guide,  rather  than  the 
biceps.  Above  the  middle  of  the  arm  the  basilic  vein  is  beneath  the  deep 
fascia  and  passes  along  by  the  inner  side  of  the  artery;  hence,  high  up  the  artery 
has  three  companion  veins,  the  venae  comites  and  the  basilic  vein,  and  there  is 
seen  the  ulnar  nerve  to  the  inside  of  the  artery. 

Axillary  Artery. — To  determine  the  line  of  the  axillary  artery  place  the 
arm  at  a  right  angle  to  the  body,  with  the  patient  supine,  and  lay  down  a  line 
from  the  middle  of  the  clavicle  to  the  humerus  near  the  inner  border  of  the 
coracobrachialis.  The  line  of  the  third  portion  can  be  approximated  by  pro- 
jecting the  line  of  the  brachial  upward  (Fig.  279). 

Anatomy  (PI.  4,  Fig.  3;  PI.  5,  Fig.  i). — The  axillary  artery  is  the  continuation 
of  the  subclavian,  and  runs  from  the  lower  margin  of  the  first  rib  to  the  inferior 
border  of  the  teres  major  muscle.  It  is  divided  into  three  portions  by  the  pec- 
toralis  minor  muscle.  The  first  portion  is  above,  the  second  portion  is  behind, 
and  the  third  portion  is  below,  the  pectoralis  minor.  The  position  of  the  artery 
varies  with  the  position  of  the  limb.  When  the  arm  is  parallel  with  the  body 
the  artery  is  far  from  the  surface  and  forms  a  curve  whose  convexity  is  upward 
and  outward.  When  the  arm  is  at  a  right  angle  to  the  body  the  vessel  is  nearer 
the  surface  and  straight.  When  the  arm  is  raised  above  a  right  angle  the 
artery  comes  near  the  surface  and  forms  a  curve  with  the  convexity  downward. 

The  first  portion  of  the  axillary  artery  is  occasionally  ligated.  It  lies  upon 
the  first  intercostal  muscle  and  the  first  serration  of  the  great  serratus  muscle, 
and  has  behind  it  the  posterior  thoracic  nerve;  the  brachial  plexus  is  external 
and  posterior  to  the  vessel;  on  its  inner  side  is  the  axillary  vein;  in  front  of  it 
are  the  clavicle,  the  great  pectoral  muscle,  the  subclavius  muscle,  the  costo- 
coracoid  membrane,  the  cephalic  and  acromiothoracic  veins,  and  the  external 
anterior  thoracic  nerve.  The  branches  of  the  first  part  of  the  axillary  artery 
are  the  superior  thoracic  and  the  acromiothoracic.  The  second  part  of  the 
artery  is  not  ligated.  The  brachial  plexus  surrounds  the  second  portion. 
The  third  part  is  covered  in  front,  above,  by  the  great  pectoral,  but  is  covered 
below  by  skin  and  fascia;  behind,  it  has  the  tendon  of  the  subscapularis,  the 
latissimus  dorsi,  and  the  teres  major  muscles;  the  coracobrachiahs  is  on  the 
outer  side;  the  axillary  vein  is  on  the  inner  side.  It  is  important  to  remember 
that  there  may  be  three  veins,  one  external  and  two  internal.  The  axillary 
vein  is  formed  by  the  venae  comites  of  the  brachial  artery  joining,  and  this  new 
vein  effecting  a  junction  with  the  basilic  vein.  The  median  nerve  lies  upon  the 
axillary  artery  in  the  upper  part  of  the  third  portion  of  the  vessel's  course, 
and  passes  to  the  outer  side.  The  musculocutaneous  nerve  is  external,  but  it  is 
only  seen  high  up;  the  ulnar  nerve  is  internal;  the  lesser  internal  and  the  internal 
cutaneous  nerves  are  internal;  the  musculospiral  and  the  circumflex  nerves 
are  behind.  The  branches  of  the  third  portion  of  the  axillary  artery  are  the 
subscapular  and  the  anterior  and  posterior  circumflex. 

Operations. — Ligation  of  the  Third  Portion  (PI.  4,  Fig.  4,  and  Fig.  279). — 
The  position  of  the  patient  should  be  supine,  with  the  shoulders  raised  and  the 
arm  abducted  to  a  right  angle.  The  surgeon  stands  between  the  patient's  arm 
and  side,  with  his  back  toward  the  subject's  feet.  An  incision  is  made  3  inches 
in  length.     It  begins  half-way  up  the  axilla  opposite  to  the  head  of  the  humerus, 


Subclavian  Arterv 


545 


and  is  taken  downward  parallel  to  the  lower  edge  of  the  great  pectoral  muscle 
and  crosses  the  junction  of  the  anterior  and  middle  thirds  of  the  outlet  of  the 
axilla.  The  integuments  and  fascia  are  incised.  The  vein  or  veins  will  be 
prominent  to  the  inner  side  and  may  overlie  the  vessel.  To  the  inner  side 
with  the  veins  are  the  ulnar  and  internal  cutaneous  nerves.  The  median 
nerve  is  upon,  and  the  external  cutaneous  is  to  the  outer  side  of,  the  artery. 
Feel  for  the  pulsations  of  the  artery,  find  the  median  nerve,  and  draw  it  out- 
ward, draw  the  nerves  and  veins  which  lie  to  the  inner  side  inward,  clear  the 
artery  from  the  venae  comites,  and  pass  the  ligature  from  within  outward. 
Apply  the  ligature  well  below  the  circumflex  branches. 

Ligation  of  the  First  Part. — This  operation  (PL  5,  Fig.  2,  and  Fig.  244)  was 
first  performed  in  181 5  by  Chamberlaine,  of  Jamaica.  The  patient  is  placed 
supine,  the  upper  part  of  the  body  being  raised,  a  sand-pillow  being  placed 
between  the  scapula  to  insure  carrying  back  of  the  point  of  the  shoulder, 
and  the  arm  being  brought  down  along  the  side.  In  operating  on  the  left  side 
the  surgeon  stands  on  the  outer  side  of  the  left  arm;  in  operating  on  the  right 
side  he  stands  to  the  right  of  the  subject's  head  and  leans  over  his  shoulder. 
The  incision,  which  is  slightly  curved  downward,  begins  external  to  the  stemo- 
cla\acular  joint  and  ends  internal  to  the  margin  of  the  deltoid,  thus  avoiding  the 
cephalic  vein.  The  incision  is  J-^  inch  below  the  clavicle  (Fig.  281).  Incise 
the  skin,  platysma  myoides  muscle,  and  deep  fascia.  In  the  outer  angle  of  the 
wound  watch  for  the  acromiothoracic  artery  and  the  cephalic  vein.  Incise 
the  pectoralis  major;  draw  the  pectoralis  minor  downward;  retract  the  lower 
margin  of  the  wound,  cut  through  the  costocoracoid  membrane  close  to  the 
coracoid  process  and  the  upper  border  of  the  lesser 
pectoral  muscle.  Bring  the  arm  to  the  side  so  as 
to  relax  the  structures.  Find  the  brachial  plexus, 
feel  for  the  artery  internal  to  it,  clear  the  vessel, 
draw  the  vein  internally,  and  pass  the  needle  from 
within  outward.  This  avoids  the  dangerous  neigh- 
bor, which  is  the  axillary  vein.  This  operation  is 
difi&cult,  dangerous,  and  unusual,  and  in  its  per- 
formance the  axillary  vein,  which  has  a  close 
attachment  to  the  costocoracoid  membrane,  is  apt 
to  be  torn. 

Subclavian  Artery. — The  subclavian  artery 
was  first  successfully  tied  by  Post,  of  New  York, 
who  applied  a  ligature  about  the  third  portion  of 
the  vessel  in  181 7.  In  1809  Sir  Astley  Cooper 
attempted  to  tie  the  first  part  of  the  left  sub- 
clavian, but  abandoned  the  operation  because  he 
feared  he  had  wounded  the  thoracic  duct.  The 
first  part  of  the  subclavian  was  first  tied  by  Colles 
in  1818  (Treves's  "Manual  of  Surgery"),  but  the 
patient  died.  At  the  present  day  the  first  and 
second  portions  are  rarely  ligated..  Professor 
Halsted  in  1892  successfully  tied  the  first  portion 
of  the  left  side  for  aneurysm.     Schumpert  tied  it 

successfully  for  aneurysm.  I  assisted  Dr.  Nassau,  of  St.  Joseph's  Hospital, 
Philadelphia,  in  a  ligation  of  the  first  part  of  the  right  subclavian.  The 
man  suffered  from  a  ruptured  traumatic  aneurysm  of  the  third  portion  of 
the  vessel.  The  operation  was  followed  by  recovery.  Chilton  produced 
a  cure  of  an  aneurysm  of  the  third  portion  of  the  subclavian  of  the  right 
side  by  tying  the  first  portion,  and  twenty-four  hours  later  tying  the  first 
portion  of  the  axillary.  Curtis,  in  1897,  and  Allingham,  in  1899,  ligated  the 
first   part  successfully.     Neff,  of  Spokane,  successfully  ligated  the  first  part 

35 


Fig.  280. — The  triangles  of 
the  neck,  right-sided  view:  i, 
Submaxillary  triangle;  2,  "tri- 
angle of  election,"  or  superior 
carotid  triangle;  3,  submental 
triangle;  4,  "triangle  of  neces- 
sity," or  inferior  carotid  tri- 
angle; 5,  occipital  triangle;  6, 
subclavian  triangle  (after 
Keen) . 


546 


Diseases  and  Injuries  of  the  Heart  and  \'essels 


of  the  left  subclavian  ("Annals  of  Surgery,"  Oct.,  191 1).  I  tied  the  first 
part  of  the  right  subclavian  and  the  first  part  of  the  common  carotid  for  innom- 
inate aneurysm.  The  aneurysm  was  apparently  cured.  I  also  tied  the  third 
part  of  the  right  subclavian  and  the  first  part  of  the  carotid  for  an  innominate 
aneurysm.  The  patient  apparently  recovered,  but  many  months  later  devel- 
oped an  aneurysm  at  the  point  of  carotid  ligation.  There  is  no  line  for  this 
vessel. 

Anatomy  (PI.  5,  Fig.  i). — The  subclavian  artery  of  the  right  side  arises  from 
the  innominate;  that  of  the  left  side,  from  the  arch  of  the  aorta.  The  subclavian 
is  divided  into  three  parts:  the  first  part  runs  from  the  origin  of  the  vessel 

to  the  inner  border  of  the  scalenus 
anticus  muscle;  the  second  part 
lies  behind  the  scalenus  anticus 
muscle,  and  the  third  part  runs 
from  the  outer  edge  of  the  muscle 
to  the  lower  border  of  the  first  rib. 
The  third  portion  is  contained  ia 
the  subclavian  triangle  (Fig.  280), 
and  is  superficial.  It  rises,  as  a 
rule,  to  }y<2,  inch  above  the  clavicle. 
The  subclavian  vein  is  below  the 
artery,  being  separated  from  it 
by  the  scalenus  anticus  muscles. 
The  brachial  plexus  is  above  and 
external  to  the  artery.  The  vessel 
rests  upon  the  first  rib,  and  behind 
it  is  the  scalenus  medius  muscle. 
The  suprascapular  and  trans- 
versalis  colli  arteries  and  veins 
and  branches  of  the  cervical 
plexus  of  nerves  lie  in  front  of 
the  artery,  and  the  external  jug- 
ular vein  crosses  it  at  its  inner 
side.  The  third  portion  gives  off 
no  branches. 

Ligation  of  the  Third  Part  (PI.  5, 
Fig.  2,  and  Fig.  281). — The  patient  is  placed  upon  his  back,  the  shoulders 
are  raised,  the  head  is  extended  and  turned  toward  the  opposite  side,  the 
arm  is  pulled  down  and  held  by  pushing  the  forearm  under  the  patient's 
back  (Treves).  This  pulls  down  the  clavicle,  thus  increasing  the  size  of  the 
subclavian  triangle.  The  operator  stands  facing  the  shoulder,  with  his  back 
toward  the  patient's  feet.  The  skin  over  the  subcla\ian  triangle,  at  a  point  3-^ 
inch  above  the  clavicle,  is  drawn  down  until  it  overlies  the  bone  and  is  incised. 
This  maneuver  enables  the  surgeon  lo  avoid  the  external  jugular  vein  and 
to  make  an  incision  in  the  skin  }4  inch  above  the  collar-bone.  The  incision 
reaches  from  the  anterior  edge  of  the  trapezius  to  the  posterior  border  of  the 
sternocleidomastoid  (PI.  5,  Fig.  2,  and  Fig.  281),  and  is  about  3  inches  long. 
This  incision  divides  the  skin,  superficial  fascia,  the  platysma  myoides,  the  vein 
running  from  the  cephalic  to  the  external  jugular,  and  some  superficial  nerves. 
The  deep  fascia  is  opened.  The  external  jugular  vein  is  drawn  into  the  inner 
angle  of  the  wound,  and  is  not  divided  unnecessarily;  if  forced  to  divide  the  vein, 
tie  with  two  hgatures  and  cut  between  them.  The  surgeon  seeks  to  find  the 
outer  edge  of  the  anterior  scalene  muscle,  and  runs  the  finger  down  along  it  to  the 
tubercle  on  the  first  rib.  The  posterior  belly  of  the  omohyoid  muscle  is  drawn 
upward  by  an  assistant.  The  surgeon,  with  a  finger  on  the  tubercle,  recalls  the 
facts  that  the  vein  is  in  front  of  the  finger  and  the  artery  is  behind  it,  and  that  the 


Fig.  281. — Position  of  the  lines  of  incision  of 
temporal,  facial,  lingual,  common  carotid  (above 
the  omohyoid),  subclavian  axillary  (first  portion), 
and  internal  mammary  arteries  (MacCormac). 


LIGATIONS. 


Plate  5. 


-•^ffni 


Vertebral  Artery  547 

subclavian  vein  is  on  a  lower  plane  tlian  the  artery.  The  artery  is  felt  beating 
as  it  lies  upon  the  rib.  The  artery  is  cleared  and  the  lower  cord  of  the  brachial 
plexus  is  exposed.  The  vein  must  be  guarded  with  the  finger  and  the  needle  is 
passed  from  above  downward,  as  the  plexus,  which  is  in  more  danger  than  the 
vein,  is  to  be  avoided.  In  this  operation  the  transversalis  colli  and  suprascapu- 
lar arteries  must  not  be  cut,  as  they  are  necessary  to  the  future  anastomotic 
circulation.  If  the  field  of  operation  is  too  small,  the  trapezius  or  sternocleido- 
mastoid, or  both  should  be  partly  divided  transversely. 

Results. — Before  the  days  of  antisepsis  ligation  of  the  subclavian  was  a 
■  very  fatal  operation.  Poland  estimated  the  mortality  at  70  per  cent.  In 
most  cases  death  was  due  to  secondary  hemorrhage.  Koenig  collected  20 
cases  of  Hgation  of  the  first  part  of  the  right  subclavian,  with  19  deaths.  Lilien- 
thal  believes  that  the  mortality  after  ligating  the  first  portion  on  the  right  side 
is  now  only  16  per  cent,  (quoted  by  Neff,  in  "Annals  of  Surg.,"  Oct.,  191 1). 
According  to  Joseph  D.  Bryant,  there  have  been  134  deaths  in  250  ligations 
at  various  points  of  the  subclavian  ("Operative  Surgery").  I  have  twice  tied 
this  vessel  with  success.  Gangrene  seldom  follows  ligation  of  the  subclavian. 
In  42  recoveries  after  ligation  of  various  points  there  was  i  case  of  gangrene 
of  the  arm  (Poiret's  statistics,  quoted  by  Neff,  in  "Annals  of  Surg.,"  Oct.,  191 1). 
In  Von  Bergmann's  90  ligations  for  gunshot-wounds  there  was  not  a  case  of 
gangrene  of  the  arm  and  only  3  of  gangrene  of  the  fingers. 

The  vertebral  artery  was  first  successfully  ligated  by  Smythe,  of  New 
Orleans,  in  1864.  He  had  ligated  the  innominate  for  aneurysm  of  the  subclavian 
and  at  the  same  time  tied  the  common  carotid.  Secondary  hemorrhage  oc- 
curred, the  blood  coming  from  the  brain.     He  arrested  it  by  tying  the  vertebral. 

Anatomy — This  vessel  is  the  largest  branch  of  the  subclavian,  and  is 
the  first  branch  coming  from  the  first  portion  of  the  subclavian.  The  verte- 
bral artery  ascends  and  enters  the  foramen  in  the  transverse  process  of  the 
sixth  cervical  vertebra  (in  rare  cases  the  fifth  or  the  seventh),  and  ascends 
through  foramina  in  the  cervical  vertebrae,  passes  behind  the  articular  process 
of  the  atlas  and  over  the  posterior  arch  of  this  first  vertebra,  pierces  the  pos- 
terior occipito-atloid  ligament,  and  enters  the  skull  by  way  of  the  foramen 
magnum  ("Gray's  Anatomy").  It  joins  its  fellow  of  the  opposite  side  to 
form  the  basilar  artery.  At  its  point  of  origin  the  vertebral  artery  has  in  front 
of  it  the  internal  jugular  vein  and  inferior  thyroid  artery.  Near  the  spine  it 
lies  between  the  longus  colli  and  scalenus  anticus  muscles,  and  on  the  left  side 
has  the  thoracic  duct  to  the  left  and  in  front. 

Ligation. — The  position  of  the  patient  is  the  sanie  as  for  ligation  of  the 
carotid  artery.  Alexander  thus  describes  the  operation:  "An  incision  3  or  4 
inches  long  is  made  in  an  upward  and  outward  direction  along  the  hollow 
which  exists  between  the  scalenus  anticus  and  the  sternomastoid  muscles. 
The  incision  should  begin  just  outside  and  on  a  level  with  the  point  where  the 
external  jugular  vein  dips  over  the  edge  of  the  sternomastoid  muscle,  or,  if 
the  vein  is  invisible,  about  3=2  ^^^h  above  the  clavicle.  The  external  jugular 
vein  is  drawn  inward  with  the  sternomastoid  muscle.  The  connective  tis- 
sue now  appearing,  the  wound  is  opened  by  a  blunt  dissector  until  the  Sca- 
lenus anticus  muscle,  the  phrenic  nerve,  and  the  transverse  cervical  artery 
are  seen.  It  cannot  be  too  well  remembered  that  the  pleura  is  at  the  inner 
side  of  the  wound,  while  below  lies  the  subclavian  artery.  It  is  now  only 
necessary  to  separate  the  edges  of  the  scalenus  anticus  and  the  longus  colli 
muscles  to  see  the  vertebral  artery  lying  in  the  space  between  them.  The 
artery  is  generally  completely  covered  by  the  vein,  which  is  dra^^^l  aside^  and 
the  artery  is  then  ligatured"  (quoted  in  Bryant's  "Operative  Surgery"). 
When  the  vessel  is  cleared  and  tied,  branches  of  the  inferior  cervical  ganglion 
are  damaged  and  possibly  included  in  the  ligature,  and  as  a  consequence  the 
pupil  contracts.     Jacobson  tells  us  to  remember  that  the  phrenic  nerve  lies 


548  Diseases  and  Injuries  of  the  Heart  and  Vessels 

on  the  scalene  muscle,  the  pleura  is  internal,  the  internal  jugular,  inferior 
thyroid,  and  vertebral  veins  are  over  the  vessel,  and  the  thoracic  duct  on  the 
left  side  crosses  it  from  within  outward. 

Results. — In  36  ligations  of  the  vertebral  artery  there  were  3  deaths  (Joseph 
D.  Bryant). 

The  Inferior  Thyroid  Artery.  Anatomy.— The  inferior  thyroid  artery 
is  a  branch  of  the  thyroid  axis.  It  ascends  the  neck,  passes  back  of  the  carotid 
sheath  and  the  sympathetic  nerve,  and  reaches  the  thyroid  gland.  The  re- 
current lar^Tigeal  nerve  lies  behind  the- artery.  The  phrenic  nerve  is  external 
to  the  artery  and  near  to  it  in  the  first  part  of  its  course  (up  to  the  point  of 
origin  of  the  ascending  cervical  branch).  The  ascending  cervical  branch 
takes  origin  just  before  the  artery  begins  to  dip  behind  the  carotid.  In  front 
of  the  beginning  of  the  inferior  thyroid  artery  of  the  left  side  the  thoracic 
duct  crosses.  The  artery  is  ligated  in  the  second  part  of  its  course  (between  its 
distribution  and  the  origin  of  the  above-named  branch). 

Ligation. — The  position  of  patient  and  the  incision  are  the  same  as  for 
the  ligation  of  the  common  carotid  artery  in  the  triangle  of  necessity  (see  page 
550).  After  exposing  the  sternocleidomastoid  muscle  retract  it  outward, 
and  then  draw  outward  the  common  carotid  artery  and  also  the  internal  jugular 
vein.  The  inferior  thyroid  artery  will  be  found  a  little  below  the  carotid 
tubercle.  It  is  cleared  and  ligated.  Treves  advises  ligation  close  to  the 
level  of  the  carotid,  so  as  to  avoid  the  recurrent  laryngeal  nerve. 

Innominate  Artery. — The  innominate  artery  was  first  ligated  by  Valen- 
tine Mott,  of  New  York,  in  1818.  It  was  first  successfully  ligated  by  Smyth,  of 
New  Orleans,  in  1864.  Symth's  operation  was  performed  for  subclavian 
aneurysm.  He  tied  the  common  carotid  as  well  as  the  innominate  and  at  a 
later  seance  tied  the  vertebral  artery  because  of  hemorrhage. 

Anatomy. — The  innominate  artery  arises  from  the^  beginning  of  the  trans- 
verse portion  of  the  arch  of  the  aorta,  passes  to  the  back  of  the  right  sterno- 
clavicular joint,  and  divides  into  the  common  carotid  and  subclavian  vessels. 
It  rests  upon  the  trachea.  It  has  upon  its  outer  side  the  pleura,  the  right 
innominate  vein,  and  the  pneumogastric  nerve.  Upon  its  inner  side  are  the 
remnant  of  the  thymus  gland  and  the  beginning  of  the  left  carotid  artery. 
In  front  of  it  are  the  inferior  thyroid  veins  of  the  right  side,  the  left  innomi- 
nate vein.,  the  sternohyoid  and  sternothyroid  muscles,  the  remnant  of  the 
thymus  gland,  and  sometimes  a  branch  from  the  right  pneumogastric  nerve. 

Ligation. — Place  the  patient  supine,  with  the  shoulders  a  little  raised, 
and  the  head  thrown  back.  Carry  an  incision  from  the  upper  margin  of 
the  sternum  for  3  inches  along  the  anterior  margin  of  the  sternomastoid.  Make 
another  cut  of  the  same  length  along  the  upper  border  of  the  clavicle 
to  meet  the  first  cut.  Dissect  up  the  flap  of  skin  and  fascia.  Divide  the 
sternal  origin  and  a  part  of  the  clavicular  portion  of  the  sternocleidomastoid 
muscle,  and  cut  the  sternohyoid  and  sternothyroid  muscles  just  above  their 
sternal  origins  (Joseph  Bell).  Retract  the  inferior  thyroid  veins.  Divide 
the  dense  leaflet  of  cervical  fascia.  Find  the  common  carotid  artery,  and 
trace  back  along  this  vessel  until  the  innominate  comes  into  view.  Retract 
the  left  innominate  vein  downward.  The  needle  is  passed  from  without 
inward  to  avoid  the  right  innominate  vein  and  right  pneumogastric  nerve. 
If  the  needle  is  kept  close  to  the  artery  the  pleura  and  trachea  will  not 
be  injured.^ 

Results. — Burns,  of  Memphis,  collected  45  cases  and  added  i  of  his  own, 
making  46  cases,  with  9  recoveries  ("Jour.  Am.  Med.  Assoc,"  1908).  To  these 
should  be  added  Percy  Sargent's  successful  case  ("Lancet,''  May  6,  1911), 
making  47  cases  and  10  recoveries.     Hamann  ("Annals  of  Surgery,"  1914, 

1  See  the  exceedingly  clear  and  terse  account  in  that  excellent  book,  "  A  Manual  of  Surgical 
Operations,"  by  Joseph  Bell. 


Region  of  the  Neck  549 

lix)  reported  a  successful  case  and  collected  the  records  of  53  ligations,  14  of 
which  were  successful.  There  is  no  note  oi  gangrene  in  any  of  these  cases. 
The  ligation  of  this  vessel,  especially  in  the  elderly  naay  cause  serious  brain 
damage  by  cutting  off  circulation  or  by  embolism.  Brain  changes  are  not 
so  common  as  after  ligation  of  the  common  carotid.  Burrell's  case  in  1895  is 
counted  as  a  success,  although  death  occurred  on  the  one  hundred  and  fourth 
day.  Smyth's  case  lived  ten  years.  Sargent's  case  lived  seventeen  months 
and  then  died  of  pneumonia  and  pericarditis.  He  tied  the  common  carotid 
as  well  as  the  innominate.  The  case  of  Coppinger,  of  Dublin,  was  alive  and 
well  two  years  after  operation.  Mitchell  Banks's  case  lived  over  three  months. 
Dr.  Sinclair's  case  was  well  three  months  after  operation  and  the  pulse  had 
not  returned  to  the  wrist  ("Brit.  Med.  Jour.,  "  March  3,  1917). 

Region  of  the  Neck. — Anatomy. — The  side  of  the  neck  is  that  space 
beween  the  median  line  in  front  and  the  anterior  edge  of  the  trapezius  muscle 
behind,  which  space  is  limited  below  by  the  clavicle  and  above  by  the  body 
of  the  jaw  and  an  imaginary  line  running  from  the  angle  of  the  jaw  to  the 
mastoid  process.  The  sternocleidomastoid  muscle  divides  this  space  into  an 
anterior  and  a  posterior  triangle,  and  each  of  the  triangles  is  subdivided  by 
other  structures,  the  anterior  into  four  spaces  and  the  posterior  into  two  (Fig. 
280). 

The  anterior  triangle  is  bounded  in  front  by  the  median  line  of  the  neck, 
behind  by  the  anterior  margin  of  the  sternocleidomastoid  muscle,  and  above 
by  the  body  of  the  lower  jaw  and  an  imaginary  line  drawn  from  the  angle  of 
the  jaw  to  the  mastoid  process.  This  space  is  subdivided  into  four  smaller 
triangles — namely,  the  inferior  carotid,  the  superior  carotid,  the  submaxillary, 
and  the  submental. 

The  inferior  carotid  triangle  is  called  the  "triangle  of  necessity,"  because  the 
common  carotid  artery  in  this  region  is  ligated,  not  from  choice,  but  through 
force  of  necessity.  It  is  bounded  in  front  by  the  median  line,  above  by  the 
anterior  belly  of  the  omohyoid  muscle  and  the  hyoid  bone,  and  below  by  the 
anterior  edge  of  the  sternomastoid  muscle.  The  floor  of  this  triangle  is  com- 
posed of  the  longus  colli,  the  scalenus  anticus,  the  rectus  capitis  anticus  major, 
the  sternohyoid,  and  sternothyroid  muscles. 

The  superior  carotid  triangle  is  known  as  the  "triangle  of  election,"  be- 
cause, if  the  carotid  artery  must  be  tied,  the  surgeon,  whenever  possible, 
elects  or  chooses  to  tie  it  in  this  triangle.  In  this  region  the  carotid  is  super- 
ficial, and  there  can  be  tied  either  the  external,  the  internal,  or  the  common 
carotid  artery,  as  the  surgeon  elects.  The  triangle  is  bounded  behind  by  the 
anterior  edge  of  the  sternocleidomastoid,  above  by  the  posterior  belly  of  the 
digastric,  and  below  by  the  anterior  belly  of  the  omohyoid  muscles.  Its 
floor  is  composed  of  the  inferior  and  middle  constrictors  of  the  pharynx,  the 
thyrohyoid  and  hyoglossus  muscles. 

The  submaxillary  triangle  is  bounded  above  by  the  body  of  the  jaw  and 
an  imaginary  line  drawn  from  the  angle  of  the  jaw  to  the  mastoid  process, 
behind  by  the  posterior  belly  of  the  digastric  muscle  and  the  stylohyoid  muscle, 
and  in  front  by  the  anterior  belly  of  the  digastric  muscle.  Its  floor  is  composed 
of  the  mylohyoid  and  hyoglossus  muscles. 

The  submental  triangle  is  bounded  on  either  side  by  the  anterior  belly  of  one 
digastric  muscle;  its  base  is  the  hyoid  bone  and  its  floor  is  the  mylohyoid  muscle. 

The  posterior  triangle  is  bounded  in  front  by  the  posterior  border  of  the 
sternocleidomastoid  muscle,  behind  by  the  anterior  edge  of  the  trapezius 
muscle,  and  below  by  the  clavicle.  The  posterior  belly  of  the  omohyoid  muscle 
subdivides  it  into  two  smaller  spaces,  the  occipital  and  subclavian  triangles. 

The  occipital  triangle  is  bounded  in  front  by  the  posterior  edge  of  the  sterno- 
cleidomastoid muscle,  behind  by  the  anterior  border  of  the  trapezius  muscle, 
and  below  by  the  posterior  belly  of  the  omohyoid  muscle. 


550  Diseases  and  Injuries  of  the  Heart  and  Vessels 

The  subclavian  triangle  is  bounded  above  by  the  posterior  belly  of  the 
omohyoid  muscle,  below  by  the  clavicle,  and  in  front  by  the  posterior  border 
of  the  sternocleidomastoid  muscle.  Its  floor  i's  formed  by  the  first  rib  and 
the  first  serration  of  the  serratus  magnus  muscle. 

Common  Carotid  Artery. — The  common  carotid  was  tied  to  arrest 
bleeding  by  Abernethy  in  1798.  The  man  died  in  thirty  hours.  It  is  usually 
said  that  this  was  the  first  case  of  ligation  of  this  vessel,  a  statement  which  Gross 
denies  ("A  System  of  Surgery").  In  1805  Sir  Astley  Cooper  tied  the  vessel 
for  carotid  aneu^^'sm.  The  patient  died  on  the  nineteenth  day.  In  1808 
he  ligated  the  vessel  successfully  for  aneurysm.  The  line  of  the  common  carotid 
artery  is  from  the  sternoclavicular  articulation  to  midway  between  the  angle  of 
the  jaw  and  the  mastoid  process,  the  head  being  turned  toward  the  opposite  side. 

Anatomy  (PL  5,  Fig.  3). — The  right  common  carotid  arises  from  the  in- 
nominate opposite  the  sternoclavicular  joint;  the  left  common  carotid  arises 
from  the  arch  of  the  aorta.  In  the  neck  the  two  carotids  possess  identical 
relations.  The  common  carotid  runs  upward  and  outward  from  behind 
the  sternoclavicular  articulation  to  a  level  with  the  upper  border  of  the  thyroid 
cartilage,  at  which  point  it  divides  into  the  external  and  internal  carotid. 
The  common  carotid  is  contained  in  a  sheath  derived  from  the  cervical  fascia. 
This  sheath  also  contains,  in  separate  compartments,  the  internal  jugular 
vein  on  the  outer  side  of  the  artery  and  the  pneumogastric  nerve  between 
the  vein  and  artery,  but  more  deeply  placed.  The  anterior  edge  of  the  sterno- 
cleidomastoid muscle  lies  over  the  artery  and  is  a  guide.  Low  in  the  neck 
the  common  carotid  is  deep,  being  covered  by  skin,  superficial  fascia,  platysma, 
deep  fascia,  and  the  sternocleidomastoid,  sternohyoid,  and  the  sternothyroid 
muscles.  Above  the  omohyoid  muscle  the  vessel  is  more  superficial,  being 
covered  by  the  skin,  superficial  fascia,  platysma,  deep  fascia,  and  the  anterior 
edge  of  the  sternocleidomastoid  muscle.  Upon  the  sheath  (occasionally  within 
it),  above  the  crossing  of  the  omohyoid  muscle,  lies  the  descendens  noni  nerve 
— the  descending  branch  of  the  ninth  pair  of  Willis  (the  hypoglossal).  This 
nerve  is  a  valuable  guide  to  the  sheath  in  the  triangle  of  election. 

The  sternomastoid  branch  of  the  superior  thyroid  artery  crosses  the  carotid 
artery  a  little  below  its  bifurcation,  and  the  superior  thyroid  vein  also  crosses 
it  in  this  region;  the  middle  thyroid  vein  crosses  the  artery  near  its  middle, 
and  the  anterior  jugular  vein  crosses  low  down.  The  common  carotid  rests 
upon  the  longus  colli  and  rectus  capitis  anticus  major  muscles,  the  sympathetic 
nerve  lying  between  the  last-named  muscle  and  the  vessel,  outside  the  carotid 
sheath.  The  recurrent  laryngeal  nerve  passes  behind  the  carotid  below  the 
omohyoid  muscle,  and  the  inferior  thyroid  artery  passes  behind  the  carotid 
just  above  the  omohyoid  muscle.  The  common  carotid  is  in  relation  internally 
with  the  trachea,  thyroid  gland,  larynx,  and  pharynx.  To  the  outer  side  are 
the  pneumogastric  nerve  (which  is  on  a  posterior  plane)  and  the  internal  jugu- 
lar vein.  On  the  left  side,  low  down  in  the  neck,  the  jugular  vein  often  lies 
in  front,  or  partly  in  front,  of  the  artery. 

Ligation  in  the  Triangle  of  Necessity. — In  this  operation  the  patient  is 
placed  supine,  with  the  shoulders  raised,  a  sand-pillow  under  the  neck,  and 
the  head  turned  to  the  opposite  side,  with  the  chin  raised.  The  operator 
stands  upon  the  side  operated  upon.  The  incision,  3  inches  long,  at  a  slight 
angle  to  the  arterial  line,  runs  from  the  level  of  the  cricoid  cartilage  downward 
and  inward  toward  the  sternoclavicular  joint,  following  the  inner  border  of  the 
sternocleidomastoid  muscle.  The  surgeon  opens  the  deep  fascia,  draws  the 
sternocleidomastoid  outward,  retracts  the  sternohyoid  and  sternothyroid  mus- 
cles inward,  and  feels  for  the  carotid  tubercle  of  Chassaignac.  This  tubercle 
is  the  costal  process  of  the  sixth  cervical  vertebra,  and  lies  directly  under  the 
artery.  The  tubercle  is  found  about  the  point  at  which  the  omohyoid  crosses 
the  carotid.     When  the  tubercle  is  found  we  know  the  situation  of  the  artery, 


External  Carotid  Artery  551 

and  that  the  triangle  of  necessity  is  below,  and  the  triangle  of  election  above, 
the  tubercle.  The  operator  draws  the  omohyoid  muscle  upward,  opens  the 
sheath  of  the  artery  on  its  inner  side,  clears  the  vessel,  and  passes  the  needle  from 
without  inward  to  avoid  the  internal  jugular  vein,  remembering  that  the  pneu- 
mogastric  nerve  is  in  the  same  sheath  as  the  artery  and  vein,  posterior  and  ex- 
ternal to  the  artery.  In  this  operation  the  inferior  th>Toid  veins  are  much  in 
the  way,  the  anterior  jugular  vein  crosses  low  dowTi,  and  on  the  left  side,  at  the 
root  of  the  neck,  the  internal  jugular  vein  may  be  in  front  of  the  carotid  artery. 
If  the  incision  is  not  sufficiently  wide,  partially  divide  the  sternocleidomastoid 
or  the  sternohyoid  and  th\Toid  muscles.  In  the  triangle  of  necessity  the  de- 
scendens  noni  nerve  does  not  serve  as  a  guide  to  the  sheath  of  the  vessels.  (See 
PI.  5,  Fig.  4.) 

Ligation  in  the  Triangle  of  Election  (Fig,  281). — The  position  of  the  patient 
for  this  operation  is  the  same  as  in  the  preceding  one.  An  incision,  3  inches 
in  length,  is  made  along  the  anterior  edge  of  the  sternocleidomastoid  muscle 
in  the  line  of  the  artery,  the  middle  of  this  incision  being  opposite  the  cricoid 
cartilage  (Fig.  281).  In  cutting  the  superficial  fascia  the  surgeon  avoids  the 
external  jugular  vein,  the  course  of  which  should  be  outlined  before  making  the 
incision.  The  line  of  the  external  jugular  is  from  the  angle  of  the  jaw  to  the 
middle  of  the  clavicle.  The  operator  opens  the  deep  fascia,  retracts  the  sterno- 
cleidomastoid muscle  outward,  feels  for  the  carotid  tubercle,  draws  the  omo- 
hyoid muscle  downward,  finds  the  descendens  noni  nerve  upon  the  sheath, 
opens  the  sheath  at  its  inner  side,  and  passes  the  needle  from  without  inward. 
This  incision  permits  ligation  of  either  the  superior  thyroid  or  the  external, 
Internal,  or  common  carotid,  and  if  it  be  extended  up  a  little  there  can  be  tied 
through  it  the  lingual  and  even  the  facial  and  occipital  arteries.  (See  PL  5, 
Fig.  4-) 

Results. — In  from  20  to  25  per  cent,  of  cases  after  ligation  of  the  common 
carotid  artery  there  is  cerebral  softening  or  some  other  intracranial  complica- 
tion. Delbet  says  that  cerebral  complications  follow  in  one-fifth  of  the  cases. 
Jordan  says  in  one-fourth  of  the  cases. '  Crile  does  not  think  they  are  nearly 
so  frequent.  Crile  states  that  of  the  cases  that  develop  cerebral  trouble,  one- 
half  die.  The  direct  operative  mortality,  according  to  Crile,  is  only  3  per  cent. 
Some  modern  operators  regard  the  mortality  as  much  higher  than  this.  I  was 
obliged  to  tie  the  common  carotid  during  an  operation  for  tumor  of  the  carotid 
gland;  the  patient  developed  hemiplegia.  Occlusion  of  the  artery  by  a  re- 
movable metal  band  is  much  safer  than  ligation  (page  488). 

External  Carotid  Artery. — Burke  ligated  the  external  carotid  in  1827 
(Treves,  from  Chelius).  The  line  of  the  external  carotid  artery  is  the  upper 
portion  of  the  common  carotid  line. 

Anatomy  (PI.  5,  Fig.  3). — The  external  carotid  artery,  which  is  one  of  the 
terminal  branches  of  the  common  carotid,  arises  on  a  level  with  the  upper 
border  of  the  thyroid  cartilage  and  runs  to  the  level  of  the  neck  of  the  condyle 
of  the  lower  jaw.  At  its  point  of  origin  it  is  covered  only  by  skin,  platysma 
and  fascia,  and  the  edge  of  the  sternomastoid,  but  as  it  ascends  it  passes  be- 
neath the  digastric  and  stylohyoid  muscles  and  into  the  parotid  gland.  The 
glossopharyngeal  nerve,  styloid  process,  and  stylopharyngeus  muscle  lie  be- 
tween the  external  and  internal  carotid  arteries.  The  hypoglossal  nerve 
crosses  the  vessel  just  below  the  digastric  muscle,  and  the  facial  and  lingual 
veins  cross  it  a  little  below  the  nerve.  The  first  branch  is  the  superior  thyroid, 
which  arises  from  the  very  beginning  of  the  trunk.  The  lingual  arises  on  a 
level  with  the  greater  cornu  of  the  hyoid  bone.  The  facial  and  occipital  take 
origin  above  the  lingual.  Each  of  them  can  be  ligated  through  the  incision 
made  for  ligation  of  the  external  carotid. 

Operation. — Place  the  patient  in  the  same  position  as  for  ligation  of  the 
common  carotid.     The  point  of  election  is  between  the  superior  thyroid  and 


552  Diseases  and  Injuries  of  the  Heart  and  Vessels 

the  lingual  arteries.  Make  an  incision  3  inches  in  length  at  a  slight  angle  to 
the  arterial  line,  from  near  the  angle  of  the  jaw  to  opposite  the  middle  of  the 
thyroid  cartilage.  Cut  through  the  skin,  superficial  fascia,  platysma  and  deep 
fascia,  and  retract  the  sternocleidomastoid  muscle  outward.  Watch  for  the 
digastric  muscle,  find  the  hypoglossal  nerve,  and  feel  for  the  greater  cornu  of 
the  hyoid  bone.  Open  the  sheath  a  little  below  the  hyoid  cornu  and  pass  the 
needle  from  without  inward.  Ligation  of  the  external  carotid  has  been  neg- 
lected because  ligation  of  the  common  carotid  is  easier. 

Results. — Crile  believes  the  operativ'e  mortality  to  be  2  per  cent. 

Internal  Carotid  Artery. — The  internal  carotid  was  tied  by  Keith, 
of  Aberdeen,  in  1851  (  Ashhurst's  "International  Encyclopedia  of  Surgery"), 
The  line  of  the  internal  carotid  is  parallel  with  and  }  2  inch  external  to  the 
line  of  the  external  carotid. 

Anatomy  (PI.  5,  Fig.  3). — The  internal  carotid  artery,  the  other  terminal 
branch  of  the  common  carotid,  arises  on  a  level  with  the  upper  border  of  the 
th>Toid  cartilage  and  enters  the  carotid  canal.  The  first  inch  of  the  artery  is 
the  only  point  where  a  ligature  is  ever  appHed,  this  point  being  covered  only 
by  skin,  platysma,  fascia,  and  the  sternocleidomastoid  muscle;  higher  up  the 
artery  is  more  deeply  placed.  It  rests  upon  the  vertebrae  and  the  rectus  capitis 
anticus  major  muscle.  The  internal  jugular  vein  is  in  the  same  sheath  and 
external  to  the  artery;  the  pneumogastric  is  in  the  same  sheath,  between  the 
artery  and  the  vein,  but  posterior  to  both.  The  superior  cervical  ganglion 
of  the  sympathetic  hes  behind  the  origin  of  the  internal  carotid,  and  between 
the  ganglion  and  the  artery  is  the  superior  laryngeal  nerve. 

Operation. — In  this  operation  the  position  of  the  patient  is  the  same  as  for 
ligation  of  the  external  carotid.  The  incision  is  of  the  same  length  and  direction 
as  that  for  ligation  of  the  external  carotid,  and  is  1^  inch  external.  The  sterno- 
cleidomastoid muscle  is  drawm  outward,  the  external  carotid  artery  is  found 
and  drawn  inward,  the  internal  carotid  is  found  and  cleared,  and  the  needle 
is  passed  from  without  inward.  The  internal  carotid  is  known  by  its  more 
external  position  and  by  the  fact  that  it  gives  off  no  branches. 

Results. — There  is  the  same  danger  of  cerebral  complications  after  this 
operation  as  after  ligation  of  the  common  carotid.  The  operative  mortality 
is  probably  as  great. 

Superior  Thyroid  Artery  (PI.  5,  Fig.  3). — This  branches  off  from  the 
external  carotid  below  the  level  of  the  greater  cornu  of  the  hyoid  bone,  in  the 
triangle  of  election.  It  is  primarily  superficial,  runs  first  upward  and  inward^ 
next  downward  and  forward,  passes  underneath  the  omohyoid,  sternohyoid, 
and  sternothyroid  muscles,  and  reaches  the  thyroid  gland. 

Ligation. — -The  position  of  the  patient  and  of  the  surgeon  is  the  same  as 
for  ligation  of  the  carotid.  The  artery  may  be  reached  through  the  incision 
employed  for  ligation  of  the  external  carotid.  Gross  made  an  incision  be- 
ginning at  the  edge  of  the  hyoid  bone,  and  running  downward  and  outward  to 
the  sternomastoid  muscle.  The  skin  and  superficial  and  deep  fasciae  are 
divided,  and  the  artery  is  found  deeply  placed  in  the  triangle  of  election  between 
the  carotid  sheath  and  the  thyroid  gland. 

Lingual  Artery. — Sir  Charles  Bell  ligated  the  first  part  of  the  lingual  artery 
in  1814.  The  operation  beneath  the  hyoglossus  muscle  was  devised  by  Piro- 
goff  in   1836   (Treves's  "Manual  of  Operative  Surgery"). 

Anatomy  (PI.  5,  Fig.  3). — The  lingual  artery  arises  from  the  external  carotid 
opposite  the  greater  cornu  of  the  hyoid  bone,  passes  beneath  the  digastric 
and  stylohyoid  muscles,  reaches  the  margin  of  the  hyoglossus  muscle,  passes 
under  that  muscle,  and  emerges  from  beneath  it  to  run  along  the  under  surface 
of  the  tongue.  The  place  of  election  for  ligation  is  where  the  artery  is  beneath 
the  hyoglossus  muscle.  Its  guide  is  the  hypoglossal  nerve,  which  lies  upon 
the  muscle,  but  at  a  slightly  higher  level  than  the  artery. 


Occipital  Artery  555 

Operation. — In  this  operation  the  patient  is  placed  recumbent  with  the 
shoulders  raised  and  the  face  turned  away  from  the  side  to  be  operated  upon. 
The  surgeon  stands  upon  the  affected  side.  A  curved  incision  is  made  from 
a  little  external  to  the  symphysis  of  the  lower  jaw,  downward  and  outward, 
to  just  above  the  greater  cornu  of  the  hyoid  bone,  and  upward  and  outward 
to  just  in  front  of  the  facial  artery  at  the  lower  edge  of  the  lower  jaw.  The 
skin,  the  superficial  fascia  and  platysma,  and  the  deep  fascia  are  incised. 
•The  submaxillary  gland  is  cleared  and  retracted  well  upward.  The  fascia 
beneath  the  gland  is  divided  by  a  transverse  incision.  The  posterior  edge  of 
the  mylohyoid  muscle  and  the  bellies  of  the  digastric  muscle  are  sought  for 
and  identilied.  One  of  the  digastric  tendons  is  retracted  down  and  out  (Treves). 
The  hyoglossus  muscle  is  cleared  with  a  dissector;  the  hypoglossal  nerve  and 
ranine  vein  are  found  and  drawn  a  little  upward.  The  hyoglossus  muscle  is- 
divided  transversely  a  little  above  the  hyoid  bone  and  below  the  level  of  the 
hypoglossal  nerve.  The  artery  is  found  under  the  muscle  and  the  needle  is- 
passed  from  above  downward. 

Facial  Artery.  Anatomy  (PI.  5,  Fig.  3). — It  arises  from  the  external 
carotid  a  little  above  the  lingual,  runs  upward  and  forward  beneath  the  body 
of  the  inferior  maxillary  bone,  passes  along  a  groove  in  the  posterior  and  upper 
surface  of  the  submaxillary  gland,  crosses  the  body  of  the  lower  jaw  at  the 
lower  anterior  edge  of  the  masseter  muscle,  and  passes  forward  and  upward 
to  the  angle  of  the  mouth  and  side  of  the  nose. 

Ligation  (PL  5,  Fig.  4). — The  facial  artery  is  rarely  ligated  in  the  cervical 
portion,  but  may  be  reached  through  the  incision  employed  for  ligation  of 
the  external  carotid.  The  vessel  may  be  tied  before  it  crosses  the  submax- 
illary gland,  the  stylohyoid  and  digastric  muscles  being  drawn  aside.  The 
vessel  is  reached  in  the  facial  portion  of  its  course  by  a  i-inch  cut  at  the  anterior 
edge  of  the  masseter  muscle  (Fig.  281).  Branches  of  the  facial  nerve  are  pushed 
aside.     The  needle  is  passed  from  behind  forward  to  avoid  the  vein  (Jacobson). 

Temporal  Artery.- — The  line  of  the  temporal  artery  passes  "upward 
over  the  root  of  the  zygoma,  midway  between  the  condyle  of  the  jaw  and  the 
tragus"  (Jacobson). 

Anatomy. — The  temporal  artery  arises  from  the  external  carotid  behind 
the  condyle  of  the  jaw  and  in  the  parotid  gland,  passes  over  the  zygoma,  and 
divides  into  two  terminal  branches. 

Ligation. — The  patient  is  placed  recumbent  and  the  head  is  turned  to  the 
opposite  side.  An  incision  i  inch  in  length  is  made  (see  Fig.  281),  the  super- 
ficial structures  and  dense  fascia  are  divided,  the  vein  is  retracted  backward,, 
and  the  needle  is  passed  from  behind  forward. 

The  occipital  artery  takes  origin  from  the  posterior  surface  of  the  ex- 
ternal carotid,  below  the  digastric  muscle  and  opposite  the  point  of  origin 
of  the  facial  artery.  It  ascends  beneath  the  digastric  and  stylohyoid  muscles 
and  parotid  gland;  the  hypoglossal  nerve  hooks  around  it  from  behind  for- 
ward. It  crosses  the  internal  carotid  artery,  the  internal  jugular  vein,  the 
pneumogastric  and  spinal  accessory  nerves;  passes  between  the  mastoid  process 
of  the  temporal  bone  and  the  atlas;  grooves  the  temporal  bone;  penetrates 
the  trapezius  muscle,  and  ascends  over  the  occiput. 

Ligation. — This  vessel  can  be  ,  ligated  near  its  origin  through  the  same 
incision  as  is  employed  to  reach  the  external  carotid.  The  hypoglossal  nerve 
is  avoided.  To  tie  back  of  the  mastoid  process,  place  the  patient  in  the  same 
position  as  for  ligation  of  the  carotid.  Carry  an  incision  from  the  tip  of  the 
mastoid  upward  and  backward,  reaching  a  point  midway  between  the  mastoid 
and  the  occipital  protuberance  (Jacobson).  Cut  the  skin,  the  fascia,  the 
sternocleidomastoid,  the  splenius  capitis,  and  possibly  a  portion  of  the  trachelo- 
mastoid  muscles.  Bring  the  head  toward  the  operator  in  order  to  relax  the 
structures,  retract  the  edges  of  the  wound,  and  clear  the  artery  where  it  lies. 


554  Diseases  and  Injuries  of  the  Heart  and  Vessels 

between  the  mastoid  process  and  the  transverse  process  of  the  atlas  (Jacob- 
son).  An  electric  forehead  light  is  of  great  assistance  in  finding  the  vessel. 
Pass  the  needle  away  from  the  vein  or  veins  (there  are  often  several). 

Dorsalis  Pedis  Artery. — The  line  of  the  dorsalis  pedis  artery  is  from 
the  middle  of  the  front  of  the  ankle-joint  to  the  middle  of  the  base  of  the  first 
interosseous  space. 

Anatomy  (PI.  6,  Fig.  i). — The  dorsalis  pedis  is  a  continuation  of  the  an- 
terior tibial  artery,  and  it  runs  from  the  bend  of  the  ankle  to  the  proximal 
extremity  of  the  first  interosseous  space,  where  it  divides  into  the  dorsalis 
hallucis  and  the  communicating  arteries.  The  artery  rests,  from  above  down- 
ward, upon  the  astragalus,  scaphoid,  and  internal  ■  cuneiform  bones,  and  at 
its  point  of  bifurcation  lies  between  the  heads  of  the  first  dorsal  interosseous 
muscle.  It  may  lie  in  some  persons  a  little  external  to  this  course.  It  is  held 
upon  the  bones  by  a  distinct  layer  derived  from  the  deep  fascia.  This  artery 
is  covered  by  skin,  by  superficial  and  deep  fascia,  and  by  the  annular  ligament 
above,  and  is  sometimes  partly  overlaid  by  the  extensor  proprius  pollicis 
muscle,  and  is  crossed,  just  before  its  bifurcation,  by  the  innermost  tendon 
of  the  extensor  brevis  muscle.  The  inner  tendon  of  the  extensor  communis 
digitorum  is  to  the  outer  side  of  the  vessel;  the  tendon  of  the  extensor  proprius 
pollicis  is  to  the  inner  side,  and  is  a  guide.  The  artery  is  ligated  in  the  dorsal 
triangle  of  the  foot — a  space  which  is  bounded  above  by  the  lower  edge  of  the 
annular  ligament,  externally  by  the  inner  tendon  of  the  extensor  brevis,  and 
internally  by  the  tendon  of  the  extensor  proprius  pollicis.  The  artery  has 
venae  comites;  the  anterior  tibial  nerve  lies,  as  a  rule,  to  its  inner  side,  but  may 
be  found  upon  the  artery  or  to  its  outer  side,  and  the  inner  division  of  the 
musculocutaneous  nerve  is  external  to  the  vessel  in  the  superficial  parts. 

Operation  (PI.  6,  Fig.  2). — In  this  operation  the  patient  is  placed  supine 
with  the  leg  and  foot  extended.  Heath  flexes  the  leg  partly  and  rests  the  sole 
of  the  foot  directly  upon  the  table.  The  surgeon  stands  below  the  extremity 
and  cuts  from  above  downward.  Make  an  incision  2  inches  in  length  along 
the  arterial  line,  beginning  opposite  the  lower  edge  of  the  annular  ligament 
and  running  along  by  the  tendon  of  the  extensor  proprius  pollicis ;  cut  through 
the  skin  and  superficial  and  deep  fascia;  have  the  toes  extended;  retract  the 
tendon  of  the  extensor  proprius  pollicis  inward,  and  the  tendon  of  the  extensor 
communis  digitorum  outward;  clear  the  artery,  find  the  nerve,  try  to  separate 
the  venae  comites,  and  pass  the  needle  from  the  nerve. 

Anterior  Tibial  Artery.— To  locate  the  line  of  the  anterior  tibial  mark  a 
point  midway  between  the  head  of  the  fibula  and  the  tuberosity  of  the  tibia, 
drop  I  inch,  and  draw  a  line  from  the  second  point  to  the  middle  of  the  front 
of  the  ankle-joint. 

Anatomy. — The  anterior  tibial  artery  is  one  of  the  terminal  branches  of 
the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  forward  between  the  two  heads  of  the  posterior  tibial  muscle,  comes 
to  the  front  of  the  leg  through  an  opening  in  the  interosseous  membrane,  and 
runs  down  to  the  middle  of  the  front  of  the  ankle-joint.  In  the  upper  two- 
thirds  of  its  course  it  rests  upon  the  interosseous  membrane,  to  which  it  is 
fastened  by  firm  fascia;  in  the  lower  third  it  Hes  first  upon  the  front  of  the  tibia 
and  then  upon  the  anterior  ligament  of  the  ankle-joint.  For  its  upper  two- 
thirds  the  artery  has  the  tibialis  anticus  muscle  just  external  to  it;  at  the  junc- 
tion of  the  middle  and  lower  thirds  the  extensor  proprius  pollicis  comes  from 
the  outside  and  lies  either  upon  the  artery  or  to  its  inner  side  for  the  rest  of  its 
course.  Externally  in  its  upper  third  is  the  extensor  communis  digitorum; 
in  the  middle  third  is  the  extensor  proprius  pollicis;  in  the  lower  third,  the 
proprius  pollicis  having  crossed  to  the  inner  side,  the  extensor  communis  digi- 
torum again  becomes  the  outer  boundary.  The  artery  is  covered  by  skin 
and  by  superficial  and  deep  fascia.     In  its  upper  third  it  is  deeply  placed  between 


LIGATIONS. 


Plate  6,. 


Posterior  Tibial  Artery  555 

the  muscles;  in  its  middle  third  it  is  less  overlaid  by  muscle;  in  its  lower  third 
it  is  superficial  except  where  it  is  crossed  by  the  extensor  proprius  and  where  it 
is  covered  by  the  annular  ligament.  The  artery  has  venae  comites.  In  the 
lower  three-fourths  of  its  course  it  is  accompanied  by  the  anterior  tibial  nerve, 
'which  in  its  course  in  the  upper  third  of  the  leg  is  external  to  the  artery;  in  the 
middle  third  it  is  external  and  a  little  in  front  of  the  artery;  and  in  the  lower 
third  it  is  external  to  or  upon  the  artery  (PI.  5,  Fig.  5). 

Operations. — The  ligations  of  the  anterior  tibial  (PL  5,  Fig.  6)  are:  (i)  of 
the  lower  third;  (2)  of  the  middle  third;  (3)  of  the  upper  third.  In  all  these 
ligations  the  patient  is  placed  recumbent  with  the  leg  extended,  and  the  surgeon 
stands  to  the  outer  side  of  the  extremity,  cutting  from  above  downward  on 
the  right  side  and  from  below  upward  on  the  left  side. 

Ligation  of  the  Lower  Third. — Make  an  incision  3  inches  long  in  the  line 
of  the  artery  and  over  the  annular  hgament.  This  incision  is  external  to  the 
tibialis  anticus  muscle  and  }-2  inch  from  the  outer  border  of  the  tibia  (Barker). 
Divide  the  skin  and  fascia,  retract  the  tendon  of  the  tibiaHs  anticus  inward, 
and  the  tendon  of  the  extensor  proprius  pollicis  outward,  along  with  the  tendons 
of  the  extensor  communis.  Flex  the  ankle-joint  to  relax  the  tendons  and  clear 
the  artery.  Draw  the  nerve  external  and  pass  the  ligature  from  without  inward. 
In  order  to  recognize  the  muscles  in  this  as  in  other  ligations,  rely  largely  upon 
the  finger  while  the  muscles  are  being  moved. 

Ligation  of  the  Middle  Third. — In  this  operation  the  procedure  is  similar 
to  the  above.  Remember  that  the  nerve  lies  in  front  of  the  vessel  and  that 
the  extensor  proprius  pollicis  muscle  is  external.  The  nerve  is  retracted  out- 
ward and  the  needle  is  passed  from  the  nerve.  A  good  rule  for  detecting  the 
artery  is  to  find  the  outer  edge  of  the  tibia  and  by  this  locate  the  interosseous 
membrane,  and  then,  by  passing  out  along  this  membrane,  discover  the  artery. 

Ligation  of  the  Upper  Third. — Make  an  incision  3  inches  long  in  the  arterial 
line.  On  opening  the  deep  fascia,  do  not  rely  on  the  eye  for  finding  the  mus- 
cular interspace,  as  often  the  latter  cannot  be  seen,  and  neither  a  white  nor  a 
yellow  line  is  reliable.  Place  the  index-finger  deep  in  the  wound  and  have  the 
tibialis  anticus  and  extensor  communis  digitorum  muscles  successively  rendered 
tense  by  an  assistant.  In  opening  the  interspace  use  the  handle  of  the  knife. 
Relax  the  muscles,  retract  the  tibialis  anticus  inward  and  draw  the  extensor 
communis  digitorum  outward.  Find  the  interosseous  membrane  where  it  is 
attached  to  the  edge  of  the  tibia,  and  the  artery  will  be  found  upon  this  mem- 
brane, between  the  tibia  and  the  nerve.  Clear  the  vessel  and  pass  the  ligature 
from  without  inward  to  avoid  the  nerve. 

Posterior  Tibial  Artery.— The  line  of  the  posterior  tibial  is  from  the 
middle  of  the  popliteal  space  to  a  point  midway  between  the  tip  of  the  inner 
malleolus  and  the  point  of  the  heel  (PL  6,  Figs.  5,  6). 

Anatomy. — The  posterior  tibial  is  the  larger  of  the  two  terminal  branches 
of  the  popliteal.  It  arises  opposite  the  lower  border  of  the  popliteus  muscle, 
passes  down  between  the  deep  and  superficial  flexor  muscles  to  midway  between 
the  tip  of  the  malleolus  and  the  point  of  the  heel,  and  divides  into  the  external 
and  internal  plantar  vessels.  In  the  upper  third  of  its  course  it  is  very  deeply 
placed  midway  between  the  tibia  and  fibula;  in  its  middle  third  it  is  less  deep, 
'having  passed  inward;  and  in  its  lower  third  it  is  superficial.  At  the  ankle  the 
artery  is  beneath  the  annular  ligament.  From  above  downward  the  posterior 
tibial  artery  rests  upon  the  posterior  tibial  muscle,  the  flexor  longus  digitorum 
muscle,  the  posterior  surface  of  the  tibia,  and  the  internal  lateral  ligament  of  the 
ankle-joint.  For  the  first  inch  or  two  of  the  course  of  the  artery  the  posterior 
tibial  nerve  is  to  the  inner  side;  the  nerve  then  crosses  to  the  outer  side,  and 
remains  in  that  relative  position  throughout  the  rest  of  the  course  of  the  artery. 
When  the  knee  is  partly  flexed  and  the  leg  is  laid  upon  its  outer  surface  the  artery 
is  between  the  operator  and  the  nerve,  and  the  nerve  is  between  the  artery  and 


556 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


the  table.  Back  of  the  malleolus,  in  the  first  compartment,  lies  the  posterior 
tibial  muscle;  in  the  next  compartment  is  the  flexor  longus  digitorum  muscle; 
in  the  next  compartment  are  the  artery  and  nerve;  and  in  the  most  posterior 
is  the  flexor  longus  pollicis  muscle. 

Operations. — Ligation  Back  of  the  Malleolus. — In  this  operation  the  patient' 
is  placed  recumbent,  with  the  thigh  abducted  and  the  leg  flexed  and  resting 
upon  its  outer  surface.  The  surgeon  stands  to  the  outer  side.  Make  a  2-inch 
semilunar  incision  corresponding  in  its  curve  to  the  malleolus  and  }^  inch 
posterior  to  its  margin  (Fig.  282).  Cut  down  to  the  annular  ligament,  incise 
the  ligament,  and  find  the  artery  and  vena;  comites.  Clear  the  vessel  and  pass 
the  needle  from  behind  forward  (to  avoid  the  nerve,  which  is  here  posterior  and 
external).  Do  not  make  the  preliminary  incision  nearer  the  malleolus  than  }^ 
inch,  as  the  sheath  of  the  tibialis  posticus  muscle  will  then  surely  be  opened. 
In  closing  the  wound,  suture  the  ligament  by  buried  sutures  of  catgut  before 
closing  the  superficial  parts  (PI.  6,  Fig.  6). 


Pig.  282. — The  lines  indicate  the  incision  to  be  made  for  the  ligature  of  the  common_ fem- 
oral, of  the  femoral  in  Scarpa's  trians^le  and  in  Hunter's  canal,  and  of  the  posterior  tibial  in 
the  calf  and  behind  the  malleolus  (MacCormac). 

Ligation  in  the  Middle  of  the  Leg. — In  this  operation  the  patient  is  placed 
in  the  same  position  as  for  the  ligation  back  of  the  malleolus.  Feel  for  the  inner 
border  of  the  tibia,  and  make  an  incision  4  inches  long  i  inch  behind  the  osseous 
border,  parallel  with  it,  and  extending  through  skin  and  superficial  and  deep 
fascia  (Fig.  282).  Draw  the  gastrocnemius  muscle  outward.  Incise  the  soleus 
muscle,  but  not  the  fascia  beneath  the  soleus;  cut  this  fascia,  after  dropping 
the  handle  of  the  knife  so  that  the  blade  is  at  right  angles  with  the  plane  of  the 
tibia.     Clear  the  artery;  pass  the  needle  from  without  inward  (PI.  6,  Fig.  6). 

The  popliteal  artery  is  almost  never  ligated  in  continuity.  It  can  be 
tied  at  the  upper  portion  of  the  popliteal  space,  at  the  lower  portion  of  the 
pophteal  space,  or  at  the  inner  side  of  the  thigh. 

Anatomy  (Fig.  283). — The  popliteal  artery  is  the  continuation  of  the  femoral, 
and  runs  from  the  opening  in  the  adductor  magnus  muscle  to  the  lower  margin 
of  the  popliteus  muscle.  This  vessel  runs  downward  and  outward  behind  the 
knee-joint  and  in  the  popliteal  space.  The  ham,  or  popliteal  space,  is  a  lozenge- 
shaped  space,  which  above  the  joint  is  bounded  on  the  outer  side  by  the  biceps 
muscle,  and  on  the  inner  side  by  the  semitendinosus,  semimembranosus,  gracilis, 
and  sartorius  muscles,  while  below  the  joint  it  is  bounded  externally  by  the 


Femoral  Artery 


557 


plantaris  and  outer  head  of  the  gastrocnemius  muscles,  and  internally  by  the 
inner  head  of  the  gastrocnemius  muscle.  The  floor  of  this  space  is  formed  by 
the  surface  of  the  femur,  the  posterior  ligament  of  the  knee-joint,  the  head  of 
the  tibia,  and  the  popliteus  fascia.  The  internal  popliteal  nerve  passes  down 
the  middle  of  the  popliteal  space;  it  is  superficial  to  the  vessels  in  the  upper  half 
of  the  space,  and  is  external  to  them;  it  is  internal  to  the  vessels  in  the  lower 
half  of  the  space.  The  external  pophteal  nerve  is  in  the  outer  side  of  the  space. 
The  popliteal  vein  is  between  the  nerve  and  the  artery.  Above  the  knee- 
joint  it  is  to  the  outer  side  of  the  artery,  but  below  the  knee-joint  it  is  to  the  inner 
side.     The  artery  lies  deeply  in  the  space. 

Ligation  in  tipper  Third. — Place  the  patient  prone.  The  surgeon  stands 
to  the  outer  side  of  the  limb  and  makes  a  vertical  incision  3  inches  in  length 
along  the  outer  margin  of  the  semimembranosus  muscle,  exposes  the  popliteal 
nerve,  retracts  the  muscle  inward  and  the  nerve  outward,  exposes  the  artery, 
separates  it  from  the  other  structures,  and  passes  the  needle  from  without 
inward  (Fig.  284). 

Ligation  in  Lower  Third. — Make  a  3-inch  vertical  incision  between  the  heads 
of  the  gastrocnemius  muscle.     Avoid  the  external  saphenous  vein  and  nerve, 


Fig. 


283. — Anatomy   of    popliteal   artery 
(Bernard  and  Huette). 


Fig.   284. — ^r>igation  of  popliteal  artery  in 
its  upper  third  (Bernard  and  Huette). 


and  retract  them  with  the  popliteal  nerve.  Separate  the  artery  from  the  vein 
and  pass  the  needle  from  within  outward. 

Femoral  Artery. — The  line  of  the  femoral  artery  is  from  midway  be- 
tween the  anterior  superior  spine  of  the  ilium  and  the  symphysis  pubis  to  the 
adductor  tubercle  on  the  inner  condyle  of  the  femur,  the  thigh  being  abducted 
and  resting  upon  its  outer  surface  (PL  6,  Fig.  3). 

Anatomy. — The  femoral  ^artery  is  the  continuation  of  the  external  iliac 
trunk;  it  extends  from  the  lower  border  of  Poupart's  ligament  to  the  opening 
in  the  adductor  magnus  muscle,  and  hence  occupies  the  upper  two-thirds  of 
the  thigh.  The  artery  for  its  first  5  inches  is  superficial,  lying  in  Scarpa's 
triangle,  a  space  which  is  bounded  externally  by  the  sartorius  muscle  and 
internally  by  the  adductor  longus,  its  base  being  Poupart's  ligament  and  its 
iioor  being  composed  of  the  psoas,  iliacus,  pectineus,  and  adductor  longus 
muscles,  and  often  the  adductor  brevis.  The  artery  enters  the  triangle  as  the 
common  femoral,  but  after  a  2-inch  course  it  divides  into  the  profunda  (which 


558  Diseases  and  Injuries  of  the  Heart  and  Vessels 

passes  deeply)  and  the  superficial  femoral.     The  latter  vessel  is  the  one  alluded 
to  in  this  section. 

At  the  base  of  Scarpa's  triangle  the  vein  is  internal,  the  artery  is  between, 
and  the  nerve  is  external  (v.  a.  n.).  At  the  apex  of  the  triangle  the  vein  is 
internal  and  a  little  posterior.  At  the  apex  of  the  triangle  the  superficial 
femoral  passes  under  the  sartorius  muscle  and  enters  into  Hunter's  canal, 
which  occupies  the  middle  third  of  the  thigh  and  which  terminates  at  an  opening 
in  the  adductor  magnus  muscle.  Hunter's  canal  is  bounded  externally  by  the 
vastus  internus  muscle,  internally  by  the  adductors  longus  and  magnus,  and 
its  roof  is  fascia  which  stretches  from  the  adductor  longus  to  the  vastus  internus. 
In  Hunter's  canal  the  vein  is  behind  the  artery  in  the  upper  part,  but  external 
to  it  in  the  lower  part,  and  is  firmly  attached  to  the  artery.  There  may  be  two 
veins.  Inside  Hunter's  canal,  but  outside  the  femoral  sheath,  is  the  long  saph- 
enous nerve,  which  crosses  the  artery  from  without  inward. 

A  way  to  remember  the  relation  of  the  femoral  vein  to  the  femoral  artery 
is  to  recall  the  fact  that  the  relation  of  the  vein  to  the  artery  is  always  contrary 
to  the  relation  of  the  sartorius  muscle  to  the  artery:  when  the  sartorius  muscle 
is  external  to  the  artery  the  vein  is  internal,  as  at  the  base  of  Scarpa's  triangle; 
when  the  sartorius  muscle  is  crossing  in  front  toward  the  inside  of  the  artery, 
the  vein  is  passing  at  the  back  to  the  outside,  as  at  the  apex  of  Scarpa's  triangle; 
when  the  muscle  is  over  the  artery  the  vein  is  back  of  it,  as  in  the  upper  third 
of  Hunter's  canal;  and  when  the  muscle  is  to  the  inside  of  the  artery  the  vein 
is  to  the  outside,  as  in  the  lower  two-thirds  of  Hunter's  canal.  In  a  ligation 
at  the  apex  of  Scarpa's  triangle  the  inner  edge  of  the  sartorius  is  the  guide. 
In  a  ligation  in  Hunter's  canal  the  long  saphenous  nerve  is  the  guide. 

Operations. — Ligation  of  the  Superficial  Femoral  at  the  Apex  of  Scarpa's 
Triangle. — In  this  operation  the  position  of  the  patient  is  supine,  with  the 
thigh  and  leg  partly  flexed,  and  the  thigh  abducted,  everted,  and  rested  upon 
its  outer  surface  on  a  pillow.  The  operator  stands  to  the  outer  side  of  the 
extremity.  From  a  point  corresponding  to  the  middle  of  Scarpa's  triangle, 
and  2I 2  inches  below  Poupart's  ligament,  make  a  3-inch  incision  in  the  arterial 
Hne  (Fig.  282).  Cut  the  skin  and  superficial  fascia.  The  saphenous  vein  will 
not  be  seen  unless  the  incision  is  internal  to  the  arterial  Hne;  if  this  vein  is  seen, 
draw  it  inward.  Open  the  fascia  lata,  find  the  inner  border  of  the  sartorius 
muscle,  and  draw  it  outward.  The  fibers  of  this  muscle  run  downward  and 
inward,  thus  distinguishing  it  from  the  adductor  longus,  whose  fibers  run  down- 
ward and  outward.  Open  the  common  sheath  for  the  artery  and  vein,  and  then 
incise  the  individual  arterial  sheath.  Clear  the  artery  and  pass  the  ligature 
from  within  outward  (PL  6,  Fig.  4). 

Ligation  of  the  Superficial  Femoral  in  Hunter's  Canal. — This  operation 
was  fijst  performed  for  aneurysm  by  John  Hunter  in  1785.  In  this  operation 
the  position  of  the  patient  is  the  same  as  in  the  ligation  at  the  apex  of  Scarpa's 
triangle.  Make  a  3-inch  incision  in  the  middle  third  of  the  thigh,  parallel 
with  the  arterial  line  and  3^^  inchinternal  to  it  (Barker) (Fig.  282).  Incise  the 
skin  and  superficial  fascia,  look  out  for  the  internal  saphenous  vein,  open 
the  fascia  lata,  find  the  sartorius  muscle,  and  retract  it  inward,  thus  exposing 
the  roof  of  Hunter's  canal,  which  is  to  be  opened  for  i  inch  or  more.  Within  the 
canal  is  seen  the  long  saphenous  nerve,  usually  upon  the  sheath.  Open  the 
sheath  of  the  artery,  clear  the  vessel,  and  pass  the  needle  from  without  inward. 
Results:  Ligation  at  the  apex  of  Scarpa's  triangle  is  a  method  for  treat- 
ing popliteal  aneurysm.  It  is  a  very  successful  procedure.  I  have  performed 
it  4  times  with  success  and  have  assisted  other  operators  in  3  successful 
cases.  Syme  successfully  ligated  the  femoral  about  its  middle  23  consecutive 
times,  and  in  Guy's  hospital  the  same  operation  was  done  24  times,  with  i  death 
("Practice  of  Surgery,"  by  Thomas  D.  Bryant).  The  common  femoral  and 
the  deep  femoral  are  seldom  ligated  except  for  hemorrhage. 


Iliac  Arteries  559 

Iliac  Arteries. — The  line  of  the  common  and  external  iliac  arteries  is 
from  a  point  ^  9  inch  below  and  ^  9  inch  to  the  left  of  the  umbilicus  to  midway 
between  the  anterior-superior  spine  of  the  ilium  and  the  pubic  symphysis. 
The  upper  third  of  this  line  represents  the  common  iliac,  and  the  lower  two- 
thirds  the  external  iliac  (PL  3,  Fig.  4). 

Anatomy. — The  common  iliac  arteries  arise  from  the  aorta  opposite  the 
left  side  and  lower  border  of  the  fourth  lumbar  vertebra,  and  extend  to  the 
upper  margin  of  the  right  and  left  sacro-iliac  joints,  where  they  each  bifurcate 
into  an  external  and  an  internal  iliac.  The  common  iliac  arteries  He  upon 
the  fifth  lumbar  vertebra,  are  covered  -^-ith  peritoneum,  and  are  crossed  by 
the  ureters.  In  women  the  ovarian  arteries  cross  the  common  iliacs.  Each 
common  iliac  vein  lies  to  the  right  side  of  its  associated  arter}%  The  right 
common  iliac  artery  has  in  front  of  it,  besides  the  peritoneum  and  ureter  (in 
women  also  the  ovarian  artery),  the  ileum,  branches  of  the  superior  mesenteric 
artery  and  branches  of  the  sympathetic  nerve.  The  left  common  iliac  artery 
has  in  front  of  it,  in  addition  to  structures  common  to  both  sides  (ureter, 
ovarian  artery,  s}"mpathetic  branches),  branches  of  the  inferior  mesenteric 
artery  and  the  sigmoid  flexure  with  its  mesocolon.  The  internal  iliac  arterv' 
runs  from  the  sacro-iliac  joint  to  the  upper  margin  of  the  great  sacrosciatic 
foramen.  It  is  very  rarely  ligated  (only  for  gluteal  aneurysm,  for  uncontrol- 
lable hemorrhage  from  the  gluteal  or  sciatic  arteries,  or  to  produce  atrophy 
of  the  prostate  gland).  The  external  iliac  artery  runs  from  the  sacro-iliac 
joint  along  the  pelvic  brim,  upon  the  inner  edge  of  the  psoas  muscle,  to  Pou- 
part's  ligament.  The  external  iliac  vein  is  internal  to  the  artery.  On  the  right 
side,  high  up,  it  passes  behind  the  artery.  The  external  iliac  artery  has  in  front 
of  it  peritoneum  and  subserous  tissue  (Abernethy's  fascia).  The  ileum  crosses 
the  right,  and  the  sigmoid  flexure  crosses  the  left,  external  iliac  artery.  The 
genital  branch  of  the  genitocrural  nerve  crosses  the  artery  low  down,  and  the 
circumflex  iliac  vein  crosses  it  just  before  it  terminates  in  the  femoral.  The 
spermatic  vessels  and  the  vas  deferens  in  the  male,  and  the  ovarian  vessels  in 
the  female,  lie  upon  the  artery  near  its  termination.  Sometimes  the  ureter 
crosses  the  vessel  near  its  point  of  origin. 

Ligation  of  the  Iliac  Arteries  after  Abdominal  Section. — The  best  method 
for  ligating  the  common,  the  internal,  and  sometimes  the  external  iliac  is  by 
abdominal  section.  The  patient  is  placed  in  the  Trendelenburg  position.  The 
abdomen  is  opened  in  the  midline  below  the  umbilicus  or  in  the  semilunar  line 
of  the  diseased  side.  The  median  incision  is  to  be  preferred  in  order  that  the 
deep  epigastric  artery  may  not  be  injured.  This  arter\'  is  a  very  important 
anastomotic  branch.  The  intestines  are  lifted  toward  the  diaphragm,  and  are 
held  up  by  gauze  pads.  The  edges  of  the  incision  are  retracted.  The  vessel  to 
be  tied  is  located  and  the  point  for  ligation  is  selected.  The  posterior  layer  of 
the  peritoneum  is  opened  over  the  selected  point,  the  vessel  is  cleared,  and  the 
threaded  Dupuytren's  aneurysm  needle  is  passed  in  a  direction  away  from  the 
vein.  In  Hgating  either  common  ihac  pass  the  needle  from  right  to  left.  In 
ligating  the  external  iliac  pass  the  ligature  from  within  outward.  It  is  not 
necessary  to  suture  the  posterior  layer  of  peritoneum.  The  abdomen  is  closed 
without  a  drain.  In  these  operations  be  sure  to  push  the  ureter  out  of  the  way. 
This  operation  has  been  performed  by  Dennis,  Hearn,  Marma duke  Shield,  Tee, 
]\Iitchell  Banks,  the  author,  and  others. 

Results:  Bryant  ('"Operative  Surgery")  alludes  to  5  reported  cases  of 
transperitoneal  Hgation  of  the  common  ihac  artery,  with  i  death. 

Ligation  of  the  Common  Iliac  Artery  by  the  Extraperitoneal  Method. — The 
common  iliac  artery  was  tied  unsuccessfully  by  Dr.  \Vm.  Gibson  in  i Si 2.  It 
was  first  successfully  ligated  by  Valentine  Mott  in  1827.  The  patient  is  placed 
recumbent  or  in  the  Trendelenburg  position.  The  body  is  then  turned  a  Httle 
to  the  opposite  side  and  the  thighs  are  partly  flexed.     Bryant  says  there  are 


;6o 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


two  linear  guides  for  this  artery.  Crampton's  line  is  drawn  from  "the  apex  of 
the  cartilage  of  the  last  rib  downward  and  a  little  forward  nearly  to  the  crest 
of  the  ilium,  then  carried  forward  parallel  with  it  to  a  little  below  the  ante- 
rior-superior spine"  ("Operative  Surgery,"  by  Joseph  D.  Bryant).  McKee's 
line  is  "drawn  from  the  tip  of  the  cartilage  of  the  eleventh  rib  to  a  point  i^^ 
inches  within  the  anterior-superior  spine,  then  curved  downward,  forward, 
and  inward,  and  terminating  abruptlv  above  the  internal  abdominal  ring" 
(Ibid.). 

The  incision  can  be  begun  just  external  to  the  internal  abdominal  ring 
and  be  curved  upward  and  outward  as  in  ligation  of  the  external  iliac,  but 


Fig.  285. — .4,  Nephrotomy:  a,  last  dorsal  n.;  b,  latissimus  dorsal  m.;  c,  serratus  post,  in- 
ferior m.;  d,  middle  layer  of  lumbar  fascia;  e,  outer  layer;/,  ext.  oblique  m.;  g,  int.  oblique  m.; 
h,  perinephritic  (extraperitoneal)  fat;  /,  quadratus  lumborum  m.;  j.  erector  spinas  m.  B, 
Nephrotomy:  a.  first  lumbar  n.;  b,  kidney;  c.  transversalis  fascia.  C,  Ligature  of  the  sciatic 
and  internal  pudic  arteries,  and  exposure  of  the  great  sciatic,  small  sciatic,  and  internal  pudic 
nerves;  a,  gluteus  maximus  m.;  b,  inf.  gluteal  n.;  c,  sciatic  a.;  d,  int.  pudic  a.  and  n.;  e,  great 
sciatic  n. ;  /,  small  sciatic  n.;  g,  pyriformis  m.  D,  Ligature  of  the  gluteal  artery  and  exposure  of 
the  superior  gluteal  nerve:  a,  gluteus  maximus  m.;  6,  gluteal  a.;  c,  superior  gluteal  n.;  d, 
pyriformis  m.;  e,  gluteus  medius  m.  (Kocher). 

Crampton's  incision  gives  more  room.  The  superficial  tissues  are  divided 
down  to  the  transversalis  fascia,  this  structure  is  nicked  and  divided,  and  the 
exposed  and  unopened  peritoneum  is  rolled  upward  and  inward.  The  mus- 
cular guide  is  the  inner  border  of  the  psoas  magnus  muscle.  By  its  side  an 
artery  is  felt.  If  the  sacrovertebral  prominence  is  above  the  vessel  touched, 
the  artery  is  the  external  iliac;  otherwise  it  is  the  common  iliac.     If  the  e.x- 


Gluteal  Artery  561 

ternal  iliac  is  the  vessel  first  exposed,  follow  it  up  to  find  the  common  trunk. 
When  the  common  iliac  is  found,  separate  the  fatty  tissue  about  it  and  pass 
the  hgature  from  the  right  toward  the  left  in  order  to  avoid  the  associated 
vein. 

Results:  Jos.  D.  Bryant  tells  us  that  this  vessel  has  been  ligated  by  the 
extraperitoneal  method  69  times,  with  only  16  recoveries,  but  it  is  to  be  re- 
membered that  many  of  these  operations  were  in  pre-antiseptic  days.  The 
artery  has  been  tied  80  times,  with  56  deaths  (70  per  cent.). 

Twenty-one  of  these  operations  were  done  since  1880;  there  were  10  deaths 
(mortality  of  nearly  48  per  cent.).  In  these  21  cases  gangrene  occurred  7 
times.  (See  Wm.  J.  Gillette,  in  "Annals  of  Surgery,"  July,  1908.)  Halsted 
estimates  the  mortality  of  ligation  at  46  per  cent.  In  the  days  before  asepsis 
it  was  over  80  per  cent.  Tee  ("Lancet-Clinic,"  1915,  cxiii)  says  there  are  only 
on  record  18  cases  in  which  gangrene  did  not  occur,  16  were  performed  for  aneu- 
rysm, 2  for  hemorrhage.  Gradual  occlusion  by  a  metal  band  is  safer  than  liga- 
tion. Halsted  prefers  ligation  of  this  vessel  to  ligation  of  the  external  iliac, 
holding  the  larger  an  artery  and  the  nearer  it  is  to  the  heart  the  less  is  the  danger 
of  gangrene.  Tee  (Ibid.)  reports  a  successful  case.  The  man  was  well  two  years 
after  operation. 

Extraperitoneal  Ligation  of  the  Internal  Iliac  Artery. — This  operation  was 
first  performed  by  Stevens,  of  Vera  Cruz,  in  1812  ("Practice  of  Surgery,"  by 
Thomas  Bryant).  The  incision  and  the  method  of  exposing  the  vessel  are 
identical  with  like  steps  in  the  ligation  of  the  common  iliac. 

Results:  Of  26  ligations  of  this  vessel  recorded,  18  were  fatal,  but  only 
a  few  of  the  cases  were  done  antiseptically  (Joseph  D.  Bryant's  "Operative 
Surgery"). 

Ligation  of  the  External  Iliac  hy  Abernethy^s  Extraperitoneal  Method  (PI. 
3,  Fig.  4). — The  external  iliac  artery  was  first  ligated  by  Abernethy  in  1796. 
The  operation  failed,  but  he  did  the  first  successful  operation  in  1806.  The 
patient  is  placed  recumbent  with  the  thighs  extended  during  the  first  incisions; 
but  in  the  later  stages  of  the  operation  the  thighs  are  flexed  a  little  to  relax 
the  abdominal  structures.  The  operator  stands  to  the  outer  side.  The 
surgeon  will  find  the  artery  by  the  side  of  the  psoas  muscle,  Mark  a  point  i 
inch  above  and  i  inch  external  to  the  middle  of  Poupart's  ligament,  and 
another  point  i  inch  above  and  i  inch  internal  to  the  anterior-superior  ihac 
spine  (Barker).  Join  these  two  points  by  a  curved  incision  4  inches  long  and 
convex  downward.  Cut  the  skin,  the  fat,  the  two  oblique  muscles,  and  the 
transversalis  muscle;  open  the  trans versalis  fascia,  separate  the  peritoneum 
toward  the  vessels,  and  draw  it  inward  by  a  broad  retractor,  and  look  for  the 
artery  along  the  pelvic  brim.  The  anterior  crural  nerve  is  seen  to  the  outer 
side  of  the  artery,  the  external  iliac  vein  is  to  the  inner  side  of  the  artery,  and 
the  genitocrural  nerve  is  upon  the  artery.  Clear  the  artery  near  its  middle 
and  pass  the  ligature  from  within  outward.  In  Sir  Astley  Cooper's  method 
of  ligation  the  inguinal  canal  is  opened;  in  Abernethy's  method  the  inguinal 
canal  is  not  opened. 

The  Gluteal  Artery. — This  vessel  is  a  continuation  of  the  posterior 
division  of  the  internal  iliac.  It  emerges  from  the  great  sacrosciatic  foramen  at 
the  upper  border  of  the  pyriformis  muscle.  It  rests  upon  the  gluteus  minimus, 
divides  into  three  branches,  and  is  covered  by  the  gluteus  maximus  muscle. 
The  superior  gluteal  nerve  lies  inferior  to  the  artery  (Fig.  285).  The  artery  was 
first  ligated  by  John  Bell  of  Edinburgh  (see  his  "Principles  of  Surgery,"  1801.) 

Ligation. — The  patient  should  be  prone.  The  surgeon  stands  to  the  outer 
side.  The  incision  corresponds  to  a  line  drawn  from  the  posterior-superior 
ihac  spine  to  the  upper  border  of  the  great  trochanter  (Fig.  286).  Divide  the 
skin,  fascia,  gluteus  maximus  muscle,  and  the  fascia  over  the  gluteus  medius 
muscle,  and  retract  the  gluteus  medius  upward.  Feel  for  the  great  sacro- 
36 


;62 


Diseases  and  Injuries  of  the  Heart  and  Vessels 


sciatic  foramen,  and  at  this  point  the  artery  is  found  above  the  pyriformis 
muscle.  Clear  the  vessel  and  pass  the  needle  from  below  upward  (Kocher's 
"Operative  Surgery").  There  is  practically  no  mortality  from  this  operation. 
The  Sciatic  Artery. — This  artery  is  the  larger  of  the  terminal  branches 
of  the  anterior  division  of  the  internal  iliac  artery.  It  passes  to  the  lower  por- 
tion of  the  great  sacrosciatic  foramen,  lying  back  of  the  internal  pudic  artery, 

and  resting  upon  the  sacral 
plexus  of  nerves  and  pyriformis 
muscle  (Gray).  It  leaves  the 
pelvis  between  the  pyriformis 
and  coccygeus  muscles,  and 
passes  downward  between  the 
ischial  tuberosity  and  great 
trochanter.  It  is  covered  by 
the  glutaeus  maximus  muscle, 
rests  upon  the  gemelli,  internal 
obturator,  and  quadratus 
femoris  muscles,  has  the  great 
sciatic  nerve  external  to  it,  and 
the  small  sciatic  nerve  external 
and  posterior  (Fig.  285). 

Ligation. — rThe  patient  lies 
prone.  The  surgeon  stands  to 
the  outer  side.  The  incision 
"  corresponds  to  the  middle  two- 
thirds  of  a  line  extending  from 
the  posterior  inferior  iliac  spine 
to  the  base  of  the  great  tro- 
chanter."^ MacCormac  advises 
the  incision  shown  in  Fig.  286. 
Divide  the  skin,  fat,  fascia,  and 
the  glutaeus  maximus  muscle. 
Find  the  artery  at  the  lower 
border  of  the  pyriformis  muscle 
and  trace  it  to  its  point  of 
emergence  from  the  pelvis. 
Pass  the  ligature  from  without 
inward.  There  is  practically  no 
mortality  from  this  operation. 

Internal  Pudic  Artery. — 
This  artery  is  one  of  the  terminal 
branches  of  the  anterior  trunk 
of  the  internal  iliac.  It  passes 
to  the  lower  margin  of  the  great 
sacrosciatic  foramen,  and  leaves 
the  pelvis  between  the  pjTiformis 
and  coccygeus  muscles,  crosses 
the  ischial  spine,  and  again 
enters  the  pelvis  by  the  lesser 
sacrosciatic  foramen.  The 
vessel  is  accompanied  by  the  internal  pudic  nerve  (Fig.  285). 

Ligation. — The  position  of  the  patient  and  the  incision  are  the  same  as 
for  ligation  of  the  sciatic  artery  (Fig.  286).  The  artery  is  found  below  the 
ischial  spine.  Pass  the  needle  from  below  upward  to  avoid  the  nerve.  There 
is  practically  no  mortality  from  this  operation. 

'  Kocher's  "Operative  Surgery,"  by  Stiles. 


Fig.  286. — Position  and  direction  of  the  superficial 
incisions  which  must  be  made  in  order  to  secure  the 
gluteal  artery  and  the  sciatic  and  pudic  arteries:  A, 
Posterior  superior  iliac  spine;  B,  great  trochanter;  C, 
tuberosity  of  the  ischium;  D,  anterior-superior  iliac 
spine;  A-B,  iliotrochanteric  line,  divided  into  thirds. 
This  line  corresponds  in  direction  with  the  fibers  of  the 
gluteus  maximus  muscle.  The  incision  to  reach  the 
gluteal  artery  is  indicated  by  the  darker  portion  of 
the  line.  Its  center  is  at  the  junction  of  the  upper 
and  middle  thirds  of  the  iliotrochanteric  line,  and 
exactly  corresponds  with  the  point  of  emergence  of 
the  gluteal  artery  from  the  great  sciatic  notch.  A-C, 
ilio-ischiatic  line.  The  incision  to  reach  the  sciatic 
artery  and  internal  pudic  is  indicated  by  the  lower 
dark  line.  It  is  also  to  be  made  in  the  direction  of 
the  fibers  of  the  gluteus  maximus  muscle.  The  center 
of  the  wound  corresponds  to  the  junction  of  the  lower 
with  the  middle  third  of  the  ilio-ischiatic  line 
(MacCormac). 


Ligation  of  the  Abdominal  Aorta  563 

Ligation  of  the  Abdominal  Aorta.— This  operation  was  first  performed 
by  Sir  Astley  Cooper  in  1817.  The  patient  Hved  but  a  few  hours.  The  aorta 
has  been  Hgated  twenty  times  and  there  have  been  twenty  deaths.  Nine  of 
these  cases  were  aseptic  operations.  The  patient  of  Monteiro,  of  Rio  Janeiro, 
lived  for  ten  days.  The  circulation  was  entirely  restored  in  the  limbs,  and  the 
man  died  from  hemorrhage  resulting  from  the  ulceration  produced  by  a  septic 
ligature.  Keen's  case  lived  for  forty-eight  days  after  ligation  just  below 
the  diaphragm.  The  urinary  secretion  was  plentiful  and  the  circulation  in  the 
lower  extremities  was  restored,  death  resulting  from  cutting  through  of  the 
ligature.  Robert  T.  Morris  performed  distal  ligation  below  an  aneurysm. 
He  encircled  the  aorta  with  a  soft-rubber  catheter  and  clamped  it  with  forceps. 
Twenty-two  hours  after  operation  the  aneurysm  began  to  shrink,  and  in  three 
hours  more  had  apparently  disappeared.  Twenty-seven  hours  after  operation 
the  clamp  and  catheter  were  removed.  The  patient  died  of  septicemia  fifty- 
three  hours  after  operation.  The  necropsy  disclosed  gangrene  of  a  bit  of  in- 
testine which  had  been  in  contact  with  the  forceps,  but  the  dissecting  aneurysm 
was  filled  with  solid  clot,  the  aorta  was  patent,  and  the  circulation  in  the  extremi- 
ties was  re-established  ("Amer.  Jour,  of  Med.  Sciences,"  Sept.,  1900).  These 
cases  prove  that  under  certain  circumstances  the  operation  is  feasible,  and  in 
desperate  cases  it  must  be  considered  as  a  possible  means  of  treatment.  Halsted 
and  Matas  prefer  a  metal  band  to  the  ligature  (see  page  488).  Gradual  occlu- 
sion and  partial  occlusion  of  the  aorta  are  much  safer  than  sudden  closure. 

Murray'' s  Operation. — -This  procedure  aims  to  avoid  opening  the  peritoneum. 
An  incision  is  made  from  just  below  the  tip  of  the  tenth  rib  to  a  point  i  inch 
internal  to  the  anterior  superior  iliac  spine.  The  peritoneum  is  separated 
from  the  abdominal  wall  until  the  vessel  is  reached.  Cooper's  operation  by 
abdominal  section  is  the  preferable  procedure. 

Operation  by  Abdominal  Section  {Cooper's  Operation);  Inst^-uments  Re- 
quired.— Those  used  in  any  ligation,  with  the  addition  of  an  aneurysm  needle 
with  a  large  curve  and  a  very  long  handle.  With  an  ordinary  instrument  it 
is  extremely  difficult  to  pass  the  ligature.  It  would  be  a  great  advantage  to 
use  an  instrument  which,  after  being  passed  under  the  vessel,  could  have  a 
central  eyed  shaft  projected,  as  is  the  center  shaft  of  a  Bellocq  cannula.  Floss 
silk  is  probably  the  best  ligature  material. 

If  the  patient  is  much  exhausted,  an  assistant  should  infuse  salt  solution 
in  a  vein  during  the  operation.  In  Keen's  case  there  was  profound  shock, 
but  the  moment  the  ligature  was  tightened  it  passed  away. 

The  patient  should  be  placed  upon  his  back.  The  surgeon  stands  to  the 
right  of  the  patient  and  opens  the  abdomen  in  the  median  line,  a  little  above 
the  level  of  the  aneurysm.  The  intestines  are  packed  aside,  the  posterior 
layer  of  the  peritoneum  is  divided,  the  surface  of  the  aorta  over  a  small  area 
is  cleared  of  nerves,  the  plexuses  being  separated  with  a  blunt  dissector. 

The  needle  is  passed  from  right  to  left.  A  double  ligature  of  floss  silk 
should  be  passed  and  the  ends  should  be  tied  with  a  stay-knot.  The  wound  is 
closed  and  dressed. 

It  has  been  suggested — I  think  by  Wyeth — that  it  might  be  wise  to 
tighten  the  ligatm-e  only  partially  at  first,  completing  the  occlusion  of  the 
artery  after  a  day  or  two.  Such  a  procedure  would  certainly  give  a  better 
chance  for  the  collaterals  to  dilate  and  restore  circulation  in  the  legs  (see 
page  488). 

Unfortunately,  in  an  aneurysm,  the  vessel  will  usually  be  extensively 
diseased,  and  ligation  will  be  out  of  the  question.  If,  however,  a  normal 
region  is  found,  the  chance  of  success  in  a  case  of  aneurysm  will  be  greater 
than  in  a  case  of  hemorrhage  from  a  branch  of  the  aorta,  because,  in  a  case 
of  aneurysm,  the  probabilities  are  that  the  collaterals  are  somewhat  distended 
before  a  ligature  is  applied. 


564  Diseases  and  Injuries  of  the  Bones  and  Joints 

Operation  upon  the  Thoracic  Aorta. — TufFier  endeavored  to  suture  the 
sac  of  an  aneurysm  so  as  to  reduce  its  lumen  ("  Bull,  et  mem  de  la  soc.  de  chir.," 
1907,  xiv).  Krummel  operated  upon  a  ruptured  aneurysm  of  the  lower  part 
of  the  thoracic  aorta.  He  sutured  the  sac.  The  circulation  in  the  legs  was 
restored  but  the  patient  died  ("Deutsche  med.  Woch.,"  1914,  xl). 


XX.  DISEASES  AND  INJURIES  OF  BONES  AND  JOINTS 

Diseases  of  the  Bones 

Atrophy  of  bone  is  a  diminution  in  the  amount  of  bony  matter  without 
change  in  osseous  structure.  It  arises  from  want  of  use  (as  seen  in  the  wasting 
of  the  bone  of  a  stump)  or  from  pressure  (as  seen  in  the  destruction  of  the 
sternum  by  an  aneurysm  of  the  aorta).  Eccentric  atrophy  is  the  thinning  of 
a  long  bone  from  within,  the  outer  surface  being  perhaps  unchanged.  It  is 
usually  a  senile  change.  Concentric  atrophy  means  a  thinning  of  the  outer 
surface  of  the  shaft,  causing  a  lessened  diameter.  It  is  usually  linked  with 
eccentric  atrophy. 

Hypertrophy  of  bone  may  be  due  to  increased  blood-supply  (as  seen 
in  chronic  epiphyseal  inflammation),  the  bone  growing  much  more  than  does 
its  fellow.  It  may  arise  from  excessive  use  or  from  strain  (as  seen  in  the  in- 
creased size  of  the  fibula  when  the  tibia  is  congenitally  absent). 

Osteogenesis  Imperfecta  {Idiopathic Fragilitas  Ossium) . — In  this  condition 
fractures  occur  without  known  injury,  and  frequently  unite  with  great  defor- 
mity because  they  escaped  recognition  and  were  not  splinted.  The  long  bones 
are  most  apt  to  sufTer.  The  condition  is  congenital  and  some  cases  are  heredi- 
tary. The  bones  of  the  skull  may  ossify  partly  or  may  remain  membranous. 
The  victims  of  this  defect  seldom  reach  maturity.  It  has  been  thought  by  some 
observers  that  adrenal  disease  is  the  cause. 

Achondroplasia. — This  is  a  congenital  condition  in  which  the  epiphyses 
of  the  long  bones  ossify  prematurely,  the  growth  of  the  limbs  being  interfered 
with  gravely.  A  victim  of  this  condition  has  a  body  of  normal  size  but  very 
short  limbs.  The  skull  is  seldom  involved.  It  is  thought  that  the  state 
bears  some  relation  to  cretinism.  In  the  condition  known  as  hereditary  deform- 
ing chondrodysplasia  irregularly  shaped,  symmetrical,  hyperostoses  form  about 
the  epiphyseal  lines.  The  ankles,  knees,  hips,  wrists,  elbows,  shoulders,  cran- 
ium and  other  bones  may  be  involved  (Ehrenfried,  in  "Jour.  Am.  Med.  Assoc," 
Feb.  17,  191 7).  Growth  becomes  very  much  stunted,  great  joint  disability  may 
be  caused,  pain  may  arise  from  pressure  upon  nerves,  and  lack  of  development  of 
a  bone  (for  instance  the  ulna)  may  cause  marked  deformity  (Ehrenfried,  Ibid.). 

Tumors  of  Bone  {See  Tumors). — Bones  give  origin  to  both  innocent  and 
malignant  tumors.  Myeloid  sarcoma  takes  origin  in  the  endosteum  and  e.x- 
pands  the  bone.  The  fasciculated  sarcoma  is  a  periosteal  growth.  Besides 
these  growths  there  may  develop  an  osteoma,  chondroma,  and  secondacy  de- 
posits of  cancer  and  sarcoma.  A  bone  may  become  cystic.  Gummata  are 
frequently  met  with. 

Cysts  and  Cystomata  of  Bone. — One  variety  of  cyst  is  found  in  the 
jaws  (dentigerous  cysts,  see  page  412).  The  other  variety  occurs  usually  in 
the  medullary  canal  of  long  bones  and  very  seldom  in  short  bones  and  flat 
bones.  "It  differs  from  the  dentigerous  cyst  in  the  absence  of  a  connect- 
ive-tissue capsule.  The  fluid  is  usually  hemorrhagic.  Islands  of  cartilage 
may  be  found  in  the  bone  capsule"  (Bloodgood,  in  "Progressive  Medicine," 
Dec.  I,  1907).  The  condition  known  sls  fibrous  osteitis  is  prone  to  cause  cyst 
formation.  Fibrous  osteitis  is  a  very  chronic  inflammatory  condition 
in  which  medullar  substance  is  replaced  by  connective  tissue.     It  may  lead  to 


Tuberculosis  of  Bone  565 

the  formation  of  a  cyst  or  of  cysts.  It  arises  particularly  in  children  and  is  most 
commonly  found  in  the  femur,  tibia  and  humerus.  It  may  escape  recognition 
until  fracture  occurs.  In  1910  Bloodgood  collected  reports  of  89  cases  of  bone 
cyst  and  69  of  them  were  related  to  fibrous  osteitis. 

Barrie  ("Surgery,  Gynecology,  and  Obstetrics,"  1914,  xix)  has  presented 
strong  evidence  to  prove  that  a  basis  for  various  solitary  lesions  in  the  long 
bones  is  hemorrhagic  osteomyelitis. 

If  the  condition  retains  throughout  its  course  hemorrhagic  granulation 
tissue  he  calls  it  chronic  hemorrhagic  osteomyelitis  and  places  in  this  group 
giant-cell  sarcoma  which  he  regards  as  a  regenerating  inflammation.  If  fibrous 
tissue  appears  and  cystic  formation  begins  he  names  the  condition  chronic 
fibrocystic  osteomyelitis. 

A  bone-cyst  slowly  expands  and  thins  the  shaft  of  the  bone,  and  in  some 
cases  fracture  of  the  bone  is  the  first  evidence  of  the  trouble.  Fracture  may  be 
caused  by  very  trivial  force.  Union  takes  place  after  fracture,  but  the  enlarge- 
ment remains.  The  .r-ray  picture  does  not  enable  us  to  make  the  diagnosis, 
because  it  exactly  resembles  the  picture  of  any  medullary  growth  possessed  of  a 
bony  capsule  and  producing  osseous  absorption. 

Many  bone-cysts  are  produced  by  softening  of  solid  neoplasms  (giant-cell 
sarcoma,  myxoma,  medullary  fibroma,  chondroma).  Occasionally  cysts  form 
in  osteomalacia  and  osteitis  deformans,  the  condition  arising  from  softening. 
Hydatid  cysts  and  dermoid  cysts  are  sometimes  encountered.  A  true  cystoma 
of  bone,  except  in  one  of  the  jaws,  is  a  surgical  rarity.  In  the  jaws  cystomata  are 
not  very  uncommon.  The  diagnosis  of  a  bone  cyst  is  confirmed  by  exploratory 
incision.  A  solitary  cyst  is  treated  by  curetment  and  packing  or  by  filling  the 
curetted  cavity  with  Mosetig-Moorhof  bone- wax  (page  574). 

Multiple  cysts  may  be  treated  by  resection  and  bone-grafting  (Tyler,  in 
"Med.  Herald,"  1914,  xxxiii). 

Syphilis  of  Bone. — Secondary  sjqDhilis  may  attack  the  bones  (see  page 
376).     Tertiary  syphilitic  lesions  are  considered  on  page  379. 

Actinomycosis  of  bone  is  most  usual  in  the  jaw,  but  may  attack  the 
orbit,  ribs,  sternum,  or  limbs  (see  page  356).  Actinomycosis  of  bone  may 
arise  secondarily  after  infection  of  superficial  parts  by  the  streptothrix.  In  the 
jaw  the  fungus  obtains  entrance  to  the  interior  of  the  bone  through  a  tooth 
socket.  In  some  cases  of  bone  actinomycosis  the  fungus  reaches  the  bone  by 
the  blood.  Actinomycosis  leads  to  the  production  of  granulation  tissue,  the 
bone  is  expanded  and  becomes  carious,  and  a  quantity  of  new  bone  is  some- 
times produced.  In  vertebral  actinomycosis,  although  the  condition  resembles 
tuberculosis,  angular  deformity  does  not  occur. 

Tuberculosis  of  bone  {iubercnious  osteomyelitis)  tends  especially  to  ap- 
pear in  the  cancellous  ends  of  long  bones.  In  about  one-fifth  of  the  cases  it 
is  primary,  that  is,  only  one  focus  can  be  found.  In  such  cases  the  point  of 
entry  shows  no  lesion,  or  the  lesion  at  that  point  may  have  healed.  In  some 
cases  the  bacilli  enter  through  the  tissue.  The  blood  or  lymph  carries  the 
bacteria  to  the  region  where  they  lodge  and  develop. 

Healthy  marrow  is  almost  immune  to  infection,  it  has  such  a  high  degree 
of  resistance  (Fraser,  "Jour.  Am.  Med.  Assoc,"  Jan.  2,  1915). 

The  bacilli  grow  readily  in  diseased  marrow.  The  common  disease  which 
precedes  infection  is  gelatinous  degeneration,  the  result  of  endarteritis,  and 
endarteritis  can  be  produced  by  the  toxemia  of  distant  tuberculosis  (Fraser, 
Ibid.).  Such  a  blood-vessel  ruptures  easily  giving  rise  to  hemorrhage  and  in 
that  area  of  extravasation  bacteria  are  prone  to  lodge.  Trauma  may  be  an 
exciting  cause.  It  ruptures  the  diseased  blood-vessels.  Long  after  apparent 
healing  the  disease  process  may  awaken  into  activity  and  trauma  is  often  the 
cause  of  the  awakening.     In  one  of  Konig's  cases  trouble  began  anew  after 


566  Diseases  and  Injuries  of  the  Bones  and  Joints 

sixty  years.  The  disease  is  especially  apt  to  attack  the  epiphysis  and  spread  to 
the  joint,  although  in  some  cases  it  spreads  to  the  shaft.  In  exceptional  cases  it 
begins  on  the  diaphyseal  side  of  the  epiphysis.  Primary  tuberculosis  is  rare  in  the 
shafts  of  long  bones,  but  is  not  uncommon  in  the  shafts  of  short  bones.  When 
the  shaft  of  a  short  bone  is  distended  by  a  tuberculous  process  the  condition  is 
called  spina  ventosa.  In  a  bone  focus  the  original  tubercle  necroses,  other  tuber- 
cles form  and  necrose,  the  separate  areas  unite  and  a  bone  cavity  forms.  This 
cavity  is  surrounded  by  granulation  tissue  and  the  cavity  contains  tuberculous 
granulations,  necrotic  tubercles  and  perhaps  bone  sequestra.  This  cavity  is  the 
result  of  rarefying  osteitis  and  no  new  bone  forms  unless  there  is  a  sequestrum  or 
are  sequestra.  A  sequestrum  causes  irritation  and  irritation  leads  to  bone  forma- 
tion. The  sequestra  in  tuberculous  osteomyelitis  are  not  completely  loose,  but 
are  still  attached  at  some  point.  The  bone  may  sclerose  from  the  action  of 
osteoblasts,  osteoclasts  may  soften  the  bone  by  removing  the  lime  salts  or  the  bone 
may  become ''  worm-eaten. "  Sclerotic  bone  means  a  healing  process.  Softened 
bone  means  a  spreading  process.  A  sequestrum  in  tuberculous  osteomyelitis  is 
usually  wedge  shaped,  the  base  being  toward  the  joint.  A  sequestrum  is  due, 
Konig  thinks,  to  the  obstruction  of  a  terminal  artery  by  a  tuberculous  embolus 
or  by  the  intra-arterial  growth  of  bacilli  ("Die  Tuberculose  der  Menschlichen 
Gelenke,  swiel  der  Brustwand  und  des  Schaedels  ").  In  a  certain  number  of  cases 
tuberculosis  infiltrates  a  spongy  bone  with  great  rapidity  because  of  rapid  casea- 
tion.    This  condition  is  known  as  infiltrating  progressive  bone  tuberculosis. 

The  vertebrae  are  the  most  common  seats  of  bone  tuberculosis.  Next  in 
order  come  the  lower  end  of  the  femur,  the  cranium  and  face,  the  hip,  the  ster- 
num and  ribs,  foot,  humerus,  pelvis,  tibia  and  fibula,  ulna,  radius  and  scapula. 

Primary  tuberculosis  of  the  patella  is  very  seldom  seen.  According  to 
Murphy  this  immunity  is  due  to  the  fact  that  the  patella  is  a  sesamoid  bone 
without  any  epiphyseal  loop  circulation  ("Surgery,  Gynecology,  and  Obstet- 
rics," vi,  1908).     See  tuberculous  arthritis,  page  705. 

Thickening  of  the  periosteum  and  beneath  the  periosteum  is  one  of  the  first 
signs  of  osseous  tuberculosis.  This  results  from  hyperemia  and  connective 
tissue  or  even  new  bone  may  form.  I  do  not  mean  that  the  periosteum  is 
attacked  primarily.  It  is  not.  The  initial  lesion  is  osteomyelitis  and  the 
periosteal  thickening  is  only  a  sign  of  the  deeper  lesion.  If  bone  production 
should  be  marked  we  would  question  the  diagnosis  of  uncomplicated  tuberculosis 
and  would  suspect  tuberculosis  with  syphilis  or  syphilis  alone. 

Caries  sicca  (Volkmann's  caries)  is  a  condition  without  suppuration, 
in  which  the  joint  cavity  is  obliterated  and  in  which  the  articular  extremity 
of  the  bone  undergoes  "sclerosis  and  concentric  atrophy"  (Senn,  in  "Tubercu- 
losis of  Bones  and  Joints").  It  is  most  common  in  the  shoulder-joint  and  is 
a  form  reasonably  curable  by  conservative  means. 

Osteitis,  Periostitis  and  Osteoperiostitis. — It  is  not  wise  to  consider 
alone  acute  inflammation  of  medulla,  bone,  or  periosteum.  Acute  periostitis 
almost  always  is  soon  accompanied  by  at  least  some  degree  of  osteomyelitis 
and  acute  inflammation  about  the  epiphysis  is  soon  followed  by  inflammation  of 
bone,  medulla  and  periosteum,  that  is  by  acute  osteomyelitis.  Osteitis,  or 
inflammation  of  bone,  may  be  due  to  traumatism,  to  a  constitutional  malady 
or  diathesis,  to  the  extension  of  inflammation  from  some  other  structure,  to 
certain  fevers,  to  cold,  to  phosphorus  or  mercury,  to  infection,  or  to  working  in 
pearl  button  factories.  In  inflammation  of  bone  the  exudate  and  leukocytes 
pass  into  the  Haversian  canals,  spaces,  and  canaliculi.  The  bone  corpuscles 
proliferate  and  the  bone  undergoes  thinning  (rarefaction),  not  because  of  pres- 
sure, but  because  of  absorption  by  voracious  leukocytes  and  osteoclasts.  This 
process  of  rarefaction  enlarges  all  the  bony  spaces,  and  by  destroying  septa 
throws  many  of  the  spaces  into  one.  If  the  surface  of  a  bone  inflames,  the 
periosteum  will  be  separated  more  or  less  by  exudation,  and  the  bone  will  be 


Symptoms  of  Osteitis  ami  Osteoperiostitis  567 

covered  with  little  pits  or  erosions  made  by  the  leukocytes.  Inflamed  bone 
is  so  soft  that  it  can  be  readily  cut  with  a  knife. 

Pearl  ivorkers'  osteitis  may  arise  in  those  who  polish  mother  of  pearl.  It 
occurs  particularly  in  youths  before  fusion  of  the  epiphyses.  It  arises  in  the 
diaphysis  near  the  epiphysis.  The  bones  of  the  Hmbs  are  most  apt  to  suffer,  but 
the  bones  of  the  face  or  chest  may  be  attacked.  The  attack  begins  with  pain 
and  moderately  elevated  temperature  and  the  fever  may  persist  for  several 
weeks.  The  condition  may  apparently  get  well  and  yet  begin  again  when  the 
patient  returns  to  work.  The  lesions  are  often  symmetrical  and  always  multiple 
(Broca).  It  is  a  condensing  osteitis  and  undergoes  spontaneous  cure  if  the 
patient  gives  up  the  occupation  (Deturk,  in  "Archives  Generales  de  Chirurgie," 
Nov.,  1908).  It  is  thought  to  be  due  to  dust  entering  the  lungs  and  reaching 
vessels  in  the  bone.     The  dust  is  composed  of  carbonate  of  lime  and  konchiolin. 

Osteitis  may  terminate  in  resolution  or  it  may  terminate  in  sclerosis,  the 
mass  of  proliferating  cells  being  converted  first  into  fibrous  tissue  and  next 
into  dense  bone  which  contains  a  very  few  small  cancellous  spaces.  If  the 
exudation  is  under  the  periosteum,  the  bone  will  be  thickened  at  this  point, 
bone  stalactites  marking  the  points  of  passage  of  the  vessels.  Osteitis  may 
terminate  in  suppuration,  this  condition  being  often  called  caries.  In  tuber- 
culous osteitis  caseation  of  the  inflammatory  products  is  very  apt  to  arise  {tuber- 
cidous  caries,  the  strumous  caries  of  our  predecessors).  Acute  osteitis  may 
terminate  in  necrosis,  the  inflammatory  exudate  compressing  the  vessels  in 
their  bony  canals,  a  portion  of  the  bone  being,  in  consequence,  deprived  of 
nutritive  material.  The  portion  cut  off  from  nutritive  fluid  dies  e^i  masse 
(necrosis).  Osteitis  is  usually  associated  with  more  or  less  periostitis.  A 
simple  acute  periostitis  without  involvement  of  the  bone  may  arise  from  trau- 
matism or  strain;  but  in  all  severe  cases  of  periostitis,  in  all  chronic  cases, 
in  all  cases  due  to  s^-philis,  rheumatism,  measles,  scarlatina,  or  enteric  fever 
the  bone  is  involved  at  the  same  time  or  subsequently.  In  syphilitic  states 
gummatous  degeneration  frequently  ensues. 

Symptoms  of  Osteitis  and  Osteoperiostitis. — As  a  chronic  process,  osteitis 
is  most  commonly  found  in  the  femur.  The  history  may  exhibit  a  record 
of  an  antecedent  injury  or  chilling  of  the  body.  Pain  is  severe,  boring  or 
aching  in  character,  deep  seated,  worse  at  night,  and  aggravated  by  a  depend- 
ent position  of  the  part.  The  symptoms  closely  resemble  those  of  periostitis, 
with  which  disease  it  is  almost  sure  to  be  linked.  Tenderness  exists  on  per- 
cussion, and  sometimes  on  pressure.  Subperiosteal  swelling,  fusiform  in  shape, 
is  noted;  cutaneous  edema  and  discoloration  are  observed  if  a  superficial  bone 
is  inflamed.  In  s}'philis  atrophic  osteitis  may  attack  the  cranial  bones  and 
produce  softening  or  even  perforation,  or  osteophytic  osteitis  may  arise,  exosto- 
ses being  formed.  Osteoperiostitis  may  be  acute  or  chronic,  circumscribed 
or  diffused,  and  may  terminate  in  resolution,  organization,  or  suppuration. 
It  arises  from  cold,  blows,  wounds,  strains,  the  spread  of  adjacent  inflammation, 
specific  febrile  maladies,  pyogenic  infection,  s}^hilis,  rheumatism,  or  tubercu- 
losis. The  symptoms  are  pain  (which  is  worse  at  night  and  which  is  aggra- 
vated by  motion,  pressure,  or  a  dependent  position),  swelling,  edema,  and 
discoloration  of  the  soft  parts.  Pain  in  the  s}'philitic  form  is  not  so  severe  as 
in  other  varieties.  Acute  diffuse  osteoperiostitis  has  been  called  acute  necrosis. 
It  is  very  improbable  that  a  violent,  diffuse,  pyogenic  inflammation  can  attack 
the  periosteum  without  the  bone  and  medulla  becoming  involved,  in  fact  it  is 
always  described  as  a  pyogenic  inflammation  of  bone  and  periosteum  common- 
est in  boys  about  the  age  of  puberty.  The  condition  is  really  acute  osteomye- 
litis (page  575).  In  simple  acute  periostitis  a  swelling  is  felt  upon  the  osseous 
surface.  The  swelling  is  firmly  fixed  and  is  very  tender,  but  the  bone  itself 
is  not  enlarged.  There  is  some  local  heat,  discoloration,  often  fever,  and  the 
patient  complains  of  an  aching  pain,  which  is  worse  at  night. 


568  Diseases  and  Injuries  of  the  Bones  and  Joints 

Periostitis  due  to  strain  demands  some  special  attention.  Sir  James  Paget, 
years  ago,  pointed  out  that  muscular  exertion  might  cause  periostitis.  C.  T. 
bent  has  written  a  valuable  article  upon  this  subject.^ 

It  is  common  to  hear  football  players  complain  of  some  swelling  of  the 
knee-joint.  Examination  finds  tenderness  over  the  tubercle  of  the  tibia  with 
slight  swelling  of  the  joint.  Dent  points  out  that  pain  is  felt  on  straightening 
the  leg,  not  on  rotating  it.  The  same  observer  states  that  omnibus  drivers 
suffer  from  periostitis  of  the  fibula,  due  to  pressing  forcibly  against  the  foot- 
board; those  who  ride  may  develop  periostitis  of  the  adductor  insertion  (riders' 
bone) ;  the  victims  of  fiat-foot  may  labor  under  periostitis  of  the  inner  tuberosity 
of  the  OS  calcis;  bar-keepers,  from  working  a  beer-pump,  may  get  periostitis 
of  the  scapula,  pain  being  marked  on  contracting  the  biceps;  a  housemaid  may 
develop  periostitis  at  the  points  of  bony  origin  of  the  great  pectoral  from  the 
chest,  the  condition  being  due  to  sweeping  and  scrubbing.^ 

Treatment  of  Osteitis  and  Osteoperiostitis. — In  syphilitic  forms  the  local 
treatment  consists  in  rest,  elevation  of  the  part,  the  application  of  iodin  and 
mercurial  ointment,  and  bandaging.  Specific  treatment  is  given  by  the  stom- 
ach or  hypodermatically.  Operation  is  rarely  justifiable.  In  other  forms,  if 
the  case  be  recent  and  severe,  put  the  patient  to  bed,  place  the  limb  in  a  splint 
and  elevate  it,  employ  cold,  apply  a  bandage,  and  give  salines  and  iodid  of 
potassium  internally.  Later  use  ichthyol  inunctions  locally  and  apply  a 
hot-water  bag.  Morphin  is  administered  for  pain.  If  these  means  fail, 
order  counterirritation  by  iodin  and  blue  ointment  or  blisters,  and  apply  heat 
locally.  In  severe  cases  take  a  tenotome  and  slit  the  periosteum  subcutane- 
ously  to  relieve  tension;  this  procedure  often  quickly  relieves  the  pain.  Some 
cases  demand  longitudinal  osteotomy,  which  is  performed  by  taking  Hey's 
saw  and  dividing  the  bone  longitudinally  into  the  medullary  canal.  If  pus 
forms,  drain  at  once. 

Difuse  osteoperiostitis  requires  early  and  free  incisions  through  the  peri- 
osteum, antiseptic  irrigation,  drainage,  rest  and  elevation  of  the  limb,  and 
strong  supporting  and  stimulating  treatment.  Amputation  is  sometimes 
demanded,  as  when  the  patient  grows  weaker  and  weaker  even  after  incision, 
and  when  a  joint  is  seriously  involved.  If  the  necrosis  affects  the  entire  shaft, 
which  separates  from  its  epiphyses,  and  new  bone  has  not  yet  formed  from  the 
periosteum,  make  a  subperiosteal  resection  of  the  shaft. 

Chronic  periostitis  is  usually  syphilitic.  A  node  is  a  chronic  inflamma- 
tion of  the  deep  periosteal  layers.  Nodes  occurring  early  in  the  secondary 
stage  remain  soft  and  soon  pass  away  under  treatment,  but  those  occurring 
two  years  or  more  after  infection  are  apt  to  cause  a  bony  deposit.  A  node 
may  soften,  leaving  a  sinus,  at  the  bottom  of  which  is  a  piece  of  dead  bone. 
Gumma  of  the  periosteum  is  one  form  of  node  which  is  apt  to  produce  caries 
or  necrosis. 

Osteoplastic  periostitis  accompanies  chronic  osteitis  and  causes  the  de- 
posit of  new  bone,  which  undergoes  sclerosis.  The  chief  symptom  is  aching 
pain,  which  is  worse  when  the  patient  is  warm  in  bed,  and  is  aggravated  by 
damp  and  wet.  A  hard  swelling  is  found  at  the  seat  of  pain  (often  over  the 
tibia,  ulna,  clavicle,  or  sternum).  The  soft  parts  are  uninflamed  and  move 
freely  unless  softening  or  suppuration  has  occurred.     Tenderness  is  manifest. 

treatment  of  Chronic  Periostitis  and  Osteoplastic  Periostitis. — For  the  nodes 
of  early  syphilis  administer  mercury  by  the  plan  usually  followed  in  secondary 
syphilis;  for  the  nodes  of  late  syphilis  give  mercury  and  large  advancing  doses 
of  iodid  of  potassium.  Blisters,  blue  ointment,  and  iodin  are  applied  to  the 
skin  over  the  area  of  periostitis  in  both  forms,  and  subcutaneous  division  of 
the  periosteum  is  of  value.  If  suppuration  occurs,  incise  antiseptically  and 
drain. 

1  "Practitioner,"  Oct.,  1897.  -Ibid. 


Chronic  Abscess  of  Bone,  or  Brodie's  Abscess 


569 


Chronic  Abscess  of  Bone,  or  Brodie's  Abscess. — This  condition  is 
sometimes  due  primarily  to  tuberculous  infection,  symptoms  being  absent 
for  a  longer  or  shorter  time  and  arising  because  of  secondary  infection  with 
staphylococci.  It  is  always  chronic,  never  acute.  A  very  acute  inflammation, 
such  as  is  induced  by  virulent  pyogenic  organisms,  causes  acute  necrosis  rather 
than  an  acute  abscess.  After  typhoid  fever  an  area  of  suppuration  may  slowly 
form  in  the  head  of  a  long  bone,  due  to  action  of  typhoid  bacilli.  Non- virulent 
staphylococci  may  be  responsible,  and  the  condition  may  follow  long  after  a 
staphylococcus  osteomyelitis.  In  84  per  cent,  of  cases  of  Brodie's  abscess  this 
is  the  history  (Alexis  Thomson).  The  same  author  says  the  latent  period 
between  the  osteomyelitis  and  the  abscess  varies  from  one  to  fifty-seven  years. 
Chronic  abscess  of  bone  was  first  described  by  Sir  Benjamin  Brodie,  and  is  often 
called  Brodie's  abscess.  It  occurs  in  the  cancellous  structure  of  the  ends  of 
bones — usually  in  the  head  of  the  tibia,  sometimes  in  the  femur  (Fig.  287)  or 
humerus.  It  seldom  occurs  in  the  shaft  of  a  long  bone.  A  tuberculous  abscess 
of  bone  may  follow  a  slight  injury,  which  constitutes  a  point  of  least  resistance. 
Bacteria  lodge  and  multiply;  bone  rarefaction  leads  to  the  formation  of  a 
ca\dty,  the  inflammatory  products  caseate,  suppuration  arises,  and  the  surround- 
ing bone  thickens  and  hardens  because  of 
growth  from  the  periosteum.  The  abscess  is 
apt  to  break  and  often  breaks  into  a  joint, 
as  the  joint  surface  is  not  covered  by 
periosteum  and  no  barrier  of  bone  is  there 
formed.  Brodie's  abscess  may  induce 
necrosis. 

Alexis  Thomson  thus  describes  Brodie's 
abscess  ("Edinburg  Med.  Jour.,"  April, 
1906): 

In  the  first  or  quiescent  stage  there  is  a 
cavity  filled  with  serum  and  lined  with  a 
membrane  like  the  periosteum  of  young 
bones.  The  outer  layer  of  the  membrane  is 
forming  new  bone  of  a  spongy  nature,  "further 
away  the  old  bone  is  sclerosed  and  the 
medullary  canal  obliterated." 

When  the  mature  stage  or  abscess  stage 
arises  the  lining  membrane  is  converted  into 
granulation  tissue,  and  the  cavity  becomes 
filled  with  staphylococcus  pus.  The  outer 
layer  of  granulations  erodes  the  bone  and  the  abscess  progressively  enlarges. 
As  the  bone  is  eroded  within,  new  bone  is  formed  by  the  periosteum  and  the 
bone  enlarges.  If  pus  formation  is  more  rapid  than  bone  erosion  there  is 
tension  and  pain,  but  if  bone  erosion  is  sufficiently  rapid  to  prevent  tension 
there  is  little  or  no  pain.  Finally,  the  abscess  perforates  the  bony  shell  ''on  the 
periosteal  surface  or  into  an  adjacent  joint." 

Symptoms. — There  are  attacks  of  boring  pain,  worse  at  night  and  aggra- 
vated by  motion  and  pressure  and  a  dependent  position.  The  pain  is  inter- 
mittent, may  be  absent  for  many  days  at  a  time,  and  is  in  many  cases  thought 
to  be  rheumatic.  The  tenderness  is  marked,  even  when  there  is  an  intermission 
in  the  spontaneous  pain.  The  patient  is  apt  to  believe  the  pain  is  in  the  joint  but 
examination  demonstrates  that  the  tenderness  is  in  the  bone.  If  the  head  of 
the  tibia  or  the  great  trochanter  is  the  seat  of  disease,  percussion  over  that  region 
develops  pain  most  certainly.  At  times  pain  in  the  bone  becomes  excruciating 
and  tenderness  acute.  There  is  more  or  less  loss  of  function  in  the  Hmb  and  in 
far  advanced  cases  the  bone  is  enlarged.  There  may  be  thickening  of  the  bone 
and  soft  parts,  edema  and  discoloration  of  the  skin  over  the  seat  of  trouble, 


Fig.  287. — Chronic  abscess  in  the 
great  trochanter  ("American  Text- 
Book  of  Surgery"). 


570  Diseases  and  Injuries  of  the  Bones  and  Joints 

and  attack  after  attack  of  synovitis  in  the  nearest  joint.  Irregular  fever  and 
sweats  are  usually  noted,  but  there  may  be  no  fever.  The  harrassing  pain 
causes  sleeplessness,  exhaustion,  and  emaciation.  When  the  pus  breaks 
through  the  bone,  abscess  develops  in  the  soft  parts.  If  this  abscess  bursts  or 
is  opened  pain  ceases  (Thomson).  The  x-rays  aid  greatly  in  making  the 
diagnosis. 

Treatment. — In  treating  bone-abscess,  trephine  the  bone  at  the  point  of 
greatest  tenderness,  and  if  the  abscess  is  missed,  follow  the  advice  of  Holmes 
and  perforate  the  wall  of  bone  with  the  trephine,  opening  in  several  directions, 
to  discover  the  pus.  It  is  often  easy  to  open  into  the  abscess  with  a  chisel  or 
gouge.  After  opening  the  cavity  scrape  its  walls,  remove  dead  bone,  thoroughly 
dry  with  gauze,  touch  with  pure  carbolic  acid,  and  pack  with  iodoform  gauze. 
If  the  abscess  opens  into  a  joint,  trephine  the  bone,  and  also  open,  irrigate,  and 
drain  the  joint. 

Caries  was  a  term  once  used  universally  to  signify  suppuration  or  molecular 
death  of  bone.  In  some  cases  caries  means  suppurative  osteitis;  in  others, 
tuberculous  osteitis;  in  still  others,  gummatous  osteitis.  Typhoid  fever  is 
occasionally  followed  by  a  carious  condition  of  bone.  Osteitis  is  apt  to  become 
purulent  when  the  bone  is  exposed  to  the  air,  when  rest  is  not  secured,  when  the 
health  of  the  individual  is  below  normal,  when  a  foreign  body  such  as  a  bullet  is 
in  the  bone,  or  when  tubercle  or  syphilis  exists.  The  term  is  seldom  used  to-day 
except  loosely,  and  then  usually  to  signify  tuberculous  disease  of  bone.  When 
caries  arises  the  softened  and  granulating  bone  breaks  down  and  is  eventually 
discharged  through  a  sinus.  After  drainage  is  secured,  organization,  sclerosis, 
and  healing  may  result.     In  these  cases  new  bone  may  form  and  a  cure  follow. 

Tuberculous  or  strumous  caries  {caseous  osteitis),  a  condition  produced  by 
the  caseation  of  the  products  of  a  tuberculous  osteitis,  seldom  shows  any  tend- 
ency to  self-cure,  neither  organization  nor  sclerosis  takes  place,  and  new  bone 
seldom  forms  unless  an  operation  is  performed.  The  interior  of  bones,  espe- 
cially of  the  carpus  and  tarsus,  is  entirely  softened  and  destroyed  and  thin  shells 
only  are  left. 

Caries  necrotica  is  a  condition  in  which  small  but  visible  portions  of  soft 
and  dead  bone  are  cast  off;  caries  sicca  is  molecular  death  of  bone  without 
liquefaction  or  suppuration. 

The  caseating  masses  in  tuberculous  caries  contain  tubercle  bacilli.  If  a 
tuberculous  collection  is  evacuated  and  infection  with  pus  organisms  occurs, 
genuine  suppuration  takes  place,  and  constitutional  infection  causes  septic 
fever  and  may  cause  death.  Pyogenic  osteitis  may  affect  any  part  of  any 
bone;  but  caseous  osteitis  (tuberculous  caries)  tends  to  arise,  especially  in 
cancellous  structure  (heads  of  long  bones,  vertebral  bodies,  ribs  and  sternum, 
and  bones  of  the  carpus  and  tarsus).  Tuberculous  osteitis  of  the  shaft  of  a 
long  bone  occasionally,  but  rarely,  arises.  Tuberculous  osteitis  is  apt  to  cause 
tuberculous  disease  in  an  adjacent  joint.  Tuberculous  osteitis  may  be  followed 
by  the  formation  of  a  cold  abscess. 

Symptoms. — In  the  beginning  the  evidences  of  caries  are  usually  those 
of  osteitis,  but  the  first  sign  noted  may  be  a  fluctuating  swelling  due  to  pus 
or  to  caseated  tubercle.  After  a  time,  at  any  rate,  a  fluctuating  swelling  is 
discovered.  If  not  opened,  the  softened  mass  breaks  externally,  voids  its 
contents,  and  leaves  a  sinus  from  which  flows  caseated  matter  which  after  a 
time  becomes  thin,  reddish,  and  irritating  to  the  skin,  contains  small  portions 
of  gritty  bone,  and  has  a  foul  smell.  The  opening  of  the  sinus  fills  up  with 
edematous  granulations.  A  probe  carried  to  the  bottom  of  the  sinus  finds  bone 
which  is  sieve-like  (worm-eaten),  and  which  on  being  struck  gives  a  muffled 
note  rather  than  the  clear,  sharp  note  of  necrosis;  the  bone  is  rough,  is  bared, 
and  is  so  soft  that  the  probe  can  usually  be  stuck  into  it.  In  old  cases  of  caries 
amyloid  disease  may  arise. 


Necrosis  ^^^i 

Treatment. — If  syphilis  exists,  give  iodid  of  potassium  in  advancing  doses 
and  a  mild  mercurial  course.  If  tuberculosis  exists,  give  iodid  of  iron,  arsenic, 
cod-liver  oil,  and  nourishing  foods,  and  recommend  ocean  air  and  living  in  the 
open  air.  Locally,  in  all  cases,  insist  on  rest  and  at  once  secure  drainage, 
enlarging  the  opening,  if  necessary,  and  inserting  a  tube,  and  even  making 
additional  openings;  s\Tinge  often  with  antiseptic  fluids  and  dress  antiseptic- 
ally.  If  the  case  is  seen  before  spontaneous  evacuation  has  occurred,  open 
under  strict  antiseptic  precautions.  When  a  chronic  sinus  exists  there  arises 
the  question  of  operation.  Incomplete  operations  are  worse  than  useless,  for 
they  may  be  followed  by  dififuse  tuberculosis  or  pyemia.  If  the  gouge  is  used, 
try  to  remove  all  carious  bone.  The  diseased  bone  is  white,  crumbles,  and 
does  not  bleed;  the  non-carious  bone  is  pink  and  vascular.  Scrape  away  all 
granulations,  swab  the  cavity  with  pure  carbolic  acid,  and  pack  it  with  iodo- 
form gauze.  Instead  of  gouging  away  bone,  there  may  be  used  the  actual 
cautery,  sulphuric  acid,  or  hydrochloric  acid.  In  severe  cases  excision  is  re- 
quired, and  in  some  rare  cases  amputation  may  be  necessary.  Caries  of  the 
spine  is  considered  under  Diseases  of  the  Spine. 

Necrosis  is  the  death  of  visible  portions  of  bone  from  circulatory  im- 
pediment or  the  direct  action  of  bacterial  toxins.  It  is  analogous  to  gangrene. 
One  cause  of  necrosis  is  traumatism  (such  as  the  tearing  off  of  periosteum) 
which  deprives  the  bone  of  blood.  Inflammation  of  the  periosteum  further 
lessens  the  nutrition.  Acute  inflammation  in  bone  causes  necrosis,  the  ex- 
cessive exudation  in  the  canals  and  spaces  occluding  the  blood-vessels  by 
pressure.  The  occlusion  of  vessels  by  bacterial  thrombi  or  emboli  may  lead 
to  necrosis,  or  the  direct  action  of  toxins  may  first  inflame  and  finally  destroy 
a  portion  of  the  bone.  A  thin  shell  of  bone  only  may  necrose  from  periosteal 
separation,  or  an  entire  shaft  may  die  from  acute  pyogenic  osteomyelitis  or 
diffuse  infective  periostitis.  Osteomyelitis  is  the  most  usual  cause  of  necrosis. 
Necrosis  is  most  frequently  met  with  in  the  diaphyses  of  the  long  bones,  caries 
in  the  cancellous  tissue  of  bones.  The  ribs  may  become  carious,  but  very  rarely 
become  necrotic.  A  sequestrum  may,  but  does  not  often,  form  in  a  vertebral 
body,  in  the  cancellous  head  of  a  long  bone,  in  the  carpus,  or  in  the  tarsus.  If  a 
sequestrum  arises  from  tuberculous  osteomyelitis  it  is  seldom  found  completely 
detached,  but  still  retains  some  vascular  connection.  In  tuberculous  osteo- 
myelitis of  a  long  bone  the  sequestrum  is  wedge  shaped  with  its  base  toward 
the  joint,  and  is  due  to  infarction  of  terminal  arteries.  A  fragment  of  dead 
bone  is  a  foreign  body;  the  healthy  bone  adjacent  to  it  inflames  and  softens; 
granulations  form,  and  this  line  of  granulation,  like  the  line  of  demarcation  of 
gangrene,  tends  to  separate  the  dead  part  from  the  living,  the  white  dead  bone 
being  surrounded  by  the  red  zone  of  granulation  tissue.  A  bit  of  dead  bone  is 
called  a  sequestrum,  and  Nature  tries  to  cast  it  off.  A  superficial  sequestrum  is 
known  as  an  exfoliation. 

Nature's  method  of  casting  off  a  sequestrum  is  as  follows:  Suppuration 
takes  place  at  the  line  of  demarcation,  osteitis  extends  for  a  considerable  dis- 
tance around  this  line,  the  periosteum  shares  in  the  inflammation,  and  new  bone 
forms.  A  cavity  is  made  within  by  suppuration,  and  a  box  or  case  is  formed 
without  by  ossification,  the  now  entirely  loosened  sequestrum  being  so  encased 
that  it  cannot  escape.  The  pus  finds  its  way  through  the  new  bone,  and  there 
is  presented  the  condition  so  often  seen  by  the  surgeon — namely,  a  case  of  new 
bone  known  as  the  involucrum,  a  cavity  containing  pus  and  the  dead  fragment  or 
sequestrum,  and  a  discharging  sinus  or  cloaca  (Fig.  288).  Nature  may  eventu- 
ally cast  off  the  fragment,  but  the  surgeon  should  not  wait  for  the  completion 
of  this  slow  process. 

When  a  portion  of  the  bone  surrounding  the  medullary  canal  dies,  the 
condition  is  called  central  necrosis.  In  some  rare  cases  necrosis  occurs  with- 
out apparent  suppuration,   a  painless  swelling  of  bone  simulating  sarcoma. 


572 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  288. — Diagram  illustrating  the  formation  of 
a  sequestrum:  A,  A  ,  Sound  bone;  B,  B,  new  bone; 
C,  C,  granulations  lining  involucrum;  D,  cloaca;  E, 
sequestrum. 


This  condition  is  known  as  quiet  necrosis,  and  has  been  described  by  Sir  James 
Paget  and  Mr.  Morrant  Baker.  Mercury  is  an  occasional  cause  of  necrosis. 
The  fumes  of  phosphorus  may  cause  necrosis  of  the  lower  jaw  in  those  with 
decayed  teeth.  Necrosis  may  be  produced  also  by  frost-bites  and  burns. 
Many  fevers  (measles,  typhoid,  scarlet  fever,  etc.)  are  occasionally  followed 
by  necrosis.     Syphilis  and  tuberculosis  are  occasional  causes. 

The  symptoms  of  necrosis  are  at  first  those  of  osteitis  or  osteomyelitis.  The 
abscess,  when  formed,  opens  itself  or  is  opened  by  the  surgeon,  and  a  sinus 
or  sinuses  form  in  the  soft  parts,  as  happens  in  caries.  As  a  matter  of  fact, 
were  cases  of  acute  osteomyelitis  operated  on  early,  extensive  necrosis  would  be 
rare.     If  surgeons  followed  the  rule  of  removing  hopelessly  damaged  bone  at 

... — the  primary  operation  for  osteo- 

myehtis  it  would  seldom  be 
necessary  to  do  extensive  oper- 
ations for  dead  bone  at  a  later 
period.  When  a  sequestrum 
exists  a  probe  introduced  into 
the  sinus  strikes  upon  hard  bone 
with  a  clear,  ringing  note,  and 
often  finds  a  sinus  or  sinuses 
in  the  bone.  In  superficial 
necrosis  the  discharge  is  slight 
and  the  probe  shows  the  limita- 
tions of  the  disease.  In  ex- 
tensive necrosis  the  discharge 
is  prof  use,  much  new  bone  forms, 
several  sinuses  appear  far  apart,  and  the  probe  must  pass  through  a  consider- 
able thickness  of  new  bone  before  it  finds  the  bit  of  dead  bone.  In  a  chronic 
case  in  which  there  is  an  involucrum  the  surgeon  may  not  operate  until  the 
dead  bone  is  separated  from  the  living  by  a  line  of  demarcation  unless  there  is 
general  sepsis.  He  may  wait  until  the  sequestrum  is  loose  unless  the  patient 
is  being  poisoned  during  the  wait.  The  tendency  of  thought  is  against  such 
long  delay  as  was  formerly  the  custom.  In  youth  dead  bone  loosens  quickly, 
but  in  old  age  slowly.  An  exfoliation  becomes  loose  sooner  than  the  sequestrum 
of  central  necrosis.  In  diffuse  periostitis  the  necrosed  shaft  loosens  quickly, 
Necrosed  portions  of  the  upper  extremity  loosen  more  rapidly  than  those  of 
the  lower.  In  a  young  adult  two  or  three  months  will  be  required  to  loosen  a 
necrosed  fragment  in  the  lower  extremity  and  from  six  weeks  to  two  months  in 
the  upper.  A  loose  sequestrum  may  be  moved  by  the  probe,  and  when  struck 
gives  a  hollow  note.  In  protracted  cases  of  necrosis  there  is  always  danger 
that  amyloid  disease  may  arise. 

Quiei  necrosis  is  a  rare  condition  which  has  led  to  some  deplorable  but 
pardonable  mistakes,  because  it  resembles  ossifying  sarcoma.  It  follows 
injury,  particularly  fracture.  The  bone  enlarges  greatly.  There  is  little 
or  no  pain  and  no  fever.  The  diagnosis  can  only  be  made  by  exploratory 
incision,  and  it  may  even  be  necessary  to  remove  portions  for  microscopic 
study  before  a  conclusion  can  be  reached. 

Postfebrile  necrosis  is  most  usually  caused  by  typhoid  fever.  The  bacilli 
of  tjqjhoid  cause  chronic  osteomyelitis,  and  this  may  be  followed  by  necrosis. 
Scarlet  fever,  measles,  and  other  febrile  processes  may  also  induce  necrosis.  It 
is  certain  that  bacilli  accumulate  in  the  bones  during  typhoid  fever.  They 
may  promptly  induce  disease;  they  may  remain  for  long  periods  apparently 
inactive  and  finally  pass  away;  or  after  a  slight  strain  or  injury  these  organisms 
may  induce  bone  disease  months  or  even  years  after  the  primary  infection.  Ty- 
phoid bone  disease  is  often  multiple,  many  bones  being  involved  successively.^ 
^  Keen's  "Surgical  Complications  of  Typhoid  Fever." 


Treatment  of  Necrosis  573 

Not  unusually  after  typhoid  fever  muscle  strain  causes  periostitis  and 
osteitis,  and  at  such  a  point  necrosis  may  occur.  Either  exfoliation  or  central 
necrosis  may  follow  typhoid  fever.  The  tibia  is  involved  more  often  than  other 
bones. 

Treatment. — An  exfoliation  should  be  removed  as  soon  as  it  becomes  loose, 
the  seat  of  trouble  should  be  touched  with  pure  carbolic  acid,  and  packing 
of  iodoform  gauze  should  be  inserted.  The  treatment  of  central  necrosis 
comprises  free  incisions  for  drainage,  removal  of  the  sequestrum  and  disinfection, 
antiseptic  dressing,  frequent  cleansing,  rest,  nourishing^  food,  stimulants,  and 
tonics.  When  a  sequestrum  exists  the  operation  of  sequestrectomy  should  be 
performed.  The  extremity  is  drained  of  blood,  an  Esmarch  band  is  applied, 
the  bone  is  exposed  by  a  longitudinal  incision,  the  periosteum  is  reflected  on 
each  side,  the  involucrum  is  broken  through,  and  the  opening  is  enlarged 
with  the  chisel,  gouge,  and  rongeur.  The  dead  bone  should  be  removed  by 
sequestrum  forceps.  The  medullary  cavity  on  each  side  of  the  sequestrum  is 
usually  blocked  with  bone.  This  bone  must  be  broken  through  in  order  that 
new  blood-vessels  may  form  and  enter  the  old  cavity.  The  cavity  is  to  be  ■ 
scraped  by  a  sharp  spoon,  the  lateral  edges  of  the  involucrum  are  cut  down  until 
the  cavity  which  formerly  contained  the  sequestrum  is  very  shallow,  the  wound 
is  irrigated  with  hot  salt  solution,  dried,  painted  with  pure  carbolic  acid  and  then 
with  alcohol,  again  irrigated  with  salt  solution,  and  firmly  packed  with  iodo- 
form gauze.  Remove  the  Esmarch  band,  tie  the  vessels  in  the  soft  parts,  suture 
the  wound,  and  apply  dressings.  It  was  long  the  rule  of  surgery  to  remove  a 
sequestrum  only  when  loose,  and  wait  if  necessary  for  it  to  become  loose. 
This  rule  has  been  abandoned  in  favor  of  early  operation.  If  possible  a  se- 
questrum should  be  removed  before  the  involucrum  has  become  rigidly  ossified. 
If  we  wait  until  the  involucrum  is  rigid  we  may  be  sure  that  the  osteogenetic 
layer  of  the  periosteum  has  struck  work  and  the  bone  cavity  will  have  to  be 
filled  by  artificial  means.  If  we  operate  from  the  sixth  to  the  ninth  week  the 
osteogenetic  layer  is  hardening  but  is  not  rigid,  is  still  active  and  the  cavity 
will  probably  heal.  The  simple  removal  of  a  sequestrum — i.e.,  the  operation 
of  sequestrectomy — often  fails  to  effect  a  cure,  and  even  in  the  most  satisfactory 
cases  healing  requires  a  very  long  time.  "The  involucrum  always  contains 
pyogenic  germs  that  may  live  in  its  small  foramina  and  crevices  almost  in- 
definitely. For  this  reason,  and  on  account  of  the  denseness  of  bony  structure, 
it  is  well-nigh  impossible  to  disinfect  it"  (Dr.  J.  Shelton  Horsley,  in  the  "  Med- 
ical Record,"  Oct.  20,  1900).  Because  of  the  difficulty  of  curing  a  case  when 
an  involucrum  has  formed.  Dr.  Gushing  has  warmly  advocated  early  opera- 
tion in  osteomyelitis;  that  is,  operation  before  an  involucrum  has  formed,  and 
when  the  osteoblasts  of  the  periostum  are  extremely  active.  He  points  out 
that  if  an  involucrum  has  formed,  the  sequestrum  and  involucrum  should 
be  removed  after  stripping  the  periosteum  from  this  region.  If  the  perios- 
teum is  found  not  to  be  infected,  it  may  be  stitched  together  at  the  gap  where 
the  bone  has  been  removed,  so  that  a  periosteal  cord  exists  between  the  two 
ends  of  the  bone;  and  the  soft  parts  above  this  may  be  closed.  If  the  peri- 
osteum is  found  to  be  infected,  we  agree  with  Gushing  that  the  cavity  should 
be  packed  with  gauze.  The  cavity  that  is  left  by  the  removal  of  a  sequestrum 
and  the  chiseling  of  the  walls  of  the  involucrum,  if  large,  may  be  filled  by  vari- 
ous methods  more  or  less  satisfactory.  In  some  cases  of  widespread  necrosis 
due  to  diffuse  infective  osteoperiostitis  or  to  osteomyelitis,  extensive  resection, 
or  even  amputation,  may  be  necessary.  After  removing  a  sequestrum  from  a 
limb  devoid  of  a  splint  bone  always  apply  splints  to  the  extremity.  If  the 
entire  shaft  of  the  tibia  requires  removal  the  length  of  the  limb  may  be  main- 
tained by  implanting  the  head  of  the  fibula  into  the  head  of  the  tibia.  Other- 
wise extension  must  be  used  during  repair. 


574  Diseases  and  Injuries  of  the  Bones  and  Joints 

Treatment  of  Bone-cavities.^ — Before  filling  a  bone-cavity  try  to  disinfect 
it.  This  can  be  done  only  relatively.  It  may  be  swabbed  with  pure  carbolic 
acid,  followed  in  one  minute  by  alcohol,  or  can  be  mopped  with  pieces  of  gauze 
wet  with  boiling  water.  Schede  does  not  pack  the  bone-cavity,  but  allows  it  to 
fill  up  with  blood-clot  after  the  wound  in  the  soft  parts  has  been  closed  by  sutures. 
The  blood-clot  obliterates  the  dead  space  in  the  bone,  acts  as  a  support 
for  granulations  from  the  margins,  and  is  slowly  eaten  by  phagocytes.  Un- 
fortunately, it  is  an  excellent  culture-medium  and  it  often  fails  of  its  purpose. 
Sherman  arrests  hemorrhage,  fills  the  gap  with  normal  salt  solution,  and  sutures 
the  soft  parts  without  drainage.  Some  advocate  filling  the  gap  with  trans- 
planted fat,  others  with  a  pedicled  flap  of  muscle.  The  surgeon  may  try  to 
fill  the  cavity  by  smoothing  down  the  bone  edges  until  the  cavity  has  become  a 
trough,  taking  flaps  of  skin  from  the  sides  of  the  wound,  separating  them  freely 
from  the  fascia  beneath,  and  holding  them  within  the  bone-cavity  by  inversion 
sutures  or  fastening  them  to  the  bottom  with  tacks  (Neuber's  operation). 
Bayer  turns  in  a  fold  of  skin  and  periosteum  and  holds  it  in  place  by  a  roll  of 
gauze  sutured  firmly  upon  the  wound.  Another  operation  consists  in  breaking 
the  edges  of  the  involucrum  and  turning  them  in.  Some  surgeons  insert  de- 
calcified bone-chips.  The  cavity  in  the  bone  is  made  as  sterile  as  possible  and 
is  well  dusted  with  iodoform,  the  bone-chips  are  dried  and  inserted  into  the 
cavity,  a  capillary  drain  is  employed,  the  periosteum  is  stitched  over  the  open- 
ing, and  the  soft  parts  are  sutured;  but  if  this  cannot  be  done,  iodoform  packing 
is  used  to  keep  the  chips  in  place.  This  method  we  owe  to  the  genius  of  Senn. 
Senn's  method  often  fails  because  of  the  impossibility  of  completely  steriliz- 
ing the  walls  of  the  bone-cavity.  Attem-pts  have  been  made  to  fill  bone- 
cavities  as  a  dentist  fills  teeth — with  gutta-percha,  plaster-of-Paris,  copper 
amalgam,  etc.,  but  each  of  these  materials  acts  as  a  foreign  body  in  the  bone 
(James  E.  Moore,  on  "The  Treatment  of  Bone-cavities,"  "Jour.  Amer.  Med. 
Assoc,"  May  20,  1905).  Schleich  uses  formalin-gelatin  to  fill  bone-cavities. 
The  difficulty  in  every  case  is  the  impossibility  of  completely  sterilizing  the 
walls  of  the  cavity.  Dressman  has  advised  for  this  purpose  the  use  of  boiling 
oil,  but  it  is  apt  to  cause  superficial  necrosis.  In  some  cases  the  cavity  has  been 
healed  by  the  insertion  of  a  Thiersch  skin-graft.  This  method  has  been  ad- 
vocated by  J.  P.  Lord  ("Jour.  Amer.  Med.  Assoc,"  May  31,  1902).  Von 
Mosetig-Moorhof's  method  is  one  of  the  best  ("Zeitschrift  fiir  Chirurgie," 
Ixxi,  No.  5).  He  pours  into  the  cavity  a  melted  material  which  completely  fills 
the  cavity,  which  will  not  act  as  a  culture-medium  or  as  a  foreign  body,  which 
is  gradually  absorbed,  and  which  "possesses  the  inhibitory  and  medicinal 
properties  of  iodoform  without  causing  iodoform  intoxication"  (James  E. 
Moore,  Loc  cit.).  Mosetig-Moorhof's  material  consists  of  60  parts  of  iodoform, 
40  parts  of  spermaceti,  and  40  parts  of  oil  of  sesame.  These  materials  are 
mixed  by  heating  gradually  up  to  100°  C,  On  cooling,  a  solid  mass  is  formed. 
When  the  surgeon  wishes  to  use  it  he  heats  it  up  to  50°  C.  and  stirs  it  while 
heating  (Moore),  and  pours  it  into  the  cavity  in  the  bone.  On  entering  the 
cavity  it  at  once  solidifies.  A  capillary  drain  is  introduced,  the  periosteum 
is  sutured  with  catgut,  and  the  other  soft  parts  are  sutured  with  silkworm-gut. 
Usually  union  by  first  intention  is  secured.  Even  if  the  wound  gaps  the  wax 
is  apt  to  hold.  Mosetig-Moorhof  has  used  this  material  in  4000  cases  without 
ill  effect.  Cases  of  poisoning  and  at  least  i  case  of  death  have  been  reported 
(Durvergey,  in  "Presse  Medicale,"  July  i,  191 1).  Bismuth  paste  is  preferred 
by  me  to  the  Mosetig-Moorhof  wax.  Many  attempts  have  been  made  to  fill 
the  defect  by  bone-grafting.  The  first  case  of  satisfactory  transplantation 
from  one  of  the  lower  animals  with  the  retention  of  a  vascular  attachment  was 
reported  by  A.  W.  Morton,  in  "American  Medicine,"  July  12,  1902.  The 
patient  suffered  from  a  compound  comminuted  fracture  of  both  bones  of  the 
right  leg.  The  fracture  in  the  fibula  united,  but  the  tibia  underwent  necrosis, 
1  The  views  of  Macewen  and  Murphy  on  repair  of  bone  will  be  found  on  pages  136  and  137. 


Acute  Infective  or  Pyogenic  Osteomyelitis  575 

and  it  was  necessary  to  remove  5  inches  of  the  lower  end  of  the  bone.  Some 
days  later  the  periosteum  was  raised  from  the  ends  of  the  bone  and  these  ends 
were  freshened.  The  left  leg  of  a  dog  was  amputated  just  above  the  tarsus, 
the  bones  being  sawed  so  that  the  ulna  was  i  inch  longer  than  the  radius.  The 
lower  end  was  partly  bared  of  periosteum,  and  the  ulna  of  the  dog  was  forced  into 
the  cavity  of  the  tibia  of  the  man,  and  wired  to  that  bone  with  silver  wire.  The 
incision  in  the  man's  leg  was  then  sutured,  and  powerful  tendons  in  each  leg  of 
the  dog  were  divided.  Each  of  the  dog's  other  legs  was  wrapped  separately  in  a 
plaster-of-Paris  bandage,  and  the  entire  animal  and  the  leg  of  the  man  were  than 
put  up  in  a  plaster-of-Paris  dressing.  Five  weeks  later  the  cast  was  removed, 
and  the  bones  were  sawed  and  placed  in  contact  with  the  astragalus.  Union 
took  place,  and  the  man  was  fortunate  enough  to  obtain  a  useful  leg.  In  some 
cases  a  bone  defect  may  be  supplied  by  transference  of  another  bone.  Nichols 
reported  11  cases  and  insisted  on  the  necessity  of  preserving  the  periosteum 
("Jour.  Amer.  Med.  Assoc,"  Feb.  3,  1904).  Huntington  has  reported  a 
case  similar  to  case  No.  2  in  Nichols's  list.  The  patient  was  a  boy  of  seven.  A 
large  piece  of  the  entire  thickness  of  the  tibia  was  lost  as  a  result  of  acute  osteo- 
myelitis. There  was  a  gap  of  5  inches  between  the  ends  of  the  bone,  and  the  leg 
was  a  mere  flail.  Eight  months  after  the  beginning  of  the  osteomyelitis  the 
fibula  was  sawed  opposite  the  lower  end  of  the  upper  fragment  of  the  tibia  and 
the  upper  end  of  the  lower  fragment  of  the  fibula  was  fixed  in  a  cup-shaped 
depression  in  the  lower  end  of  the  upper  fragment  of  the  tibia.  Six  months  later 
union  was  solid,  but  in  order  to  improve  the  weight-bearing  power  of  the  limb, 
nine  months  after  the  first  operation,  the  lower  end  of  the  upper  fragment  of 
fibula  was  fastened  to  the  upper  end  of  the  lower  fragment  of  tibia.  The  result 
was  excellent.     The  shortening  is  only  ^^  inch  ("Annals  of  Surgery,"  Feb., 

1905)- 

Albee's  operation  of  bone-grafting  has  proved  of  great  value  in  filling  bone 
defects.  In  some  cases  a  piece  of  the  tibia  may  be  used  in  others  a  rib 
(see  page  782). 

Osteomyelitis. — By  this  term  we  mean  inflammation  arising  in  and  about 
the  blood-vessels  and  attacking  the  marrow  of  bone.  It  may  attack  the  soft 
tissues  and  cells  in  the  Haversian  canals,  in  the  cancellous  spaces,  or  in  the 
medullary  cavity.  It  may  be  acute  or  chronic,  localized  or  diffused.  Simple 
osteomyelitis  is  not  due  to  bacteria.  If  localized  it  usually  depends  upon  a 
traumatism  (fracture,  contusion,  wrench  of  an  epiphysis).  Simple  diffuse 
osteomyelitis  may  arise  in  a  victim  of  rickets  or  osteitis  deformans.  An  acute 
simple  inflammation  may  cause  softening  and  permit  bending.  A  chronic 
inflammation  causes  sclerosis. 

Acute  infective  or  pyogenic  osteomyelitis  is  an  acute  and  diffuse  in- 
flammation of  the  bone-marrow  due  to  pyogenic  organisms.  Infection  from 
staphylococci  may  be  limited  to  a  portion  of  one  bone.  Streptococcus  infec- 
tion causes  widespread  involvement  of  a  bone  or  of  several  bones.  Acute 
osteomyelitis  may  be  due  to  mixed  infection  with  bacilli  of  typhoid  and  pyogenic 
organisms,  or  bacilli  of  tubercle  and  pyogenic  organisms,  a  t\^hoid  process  or 
a  tuberculous  process  serving  to  establish  a  point  of  least  resistance.  The 
gonococcus  and  the  pneumococcus  occasionally  produce  acute  osteomyelitis. 
In  a  case  of  gonorrheal  arthritis  in  which  I  resected  the  wrist-joint  cultures  of 
gonococci  were  obtained  from  the  interior  of  the  bone  removed. 

It  was  at  one  time  believed  that  osteomyelitis  was  due  to  a  specific  organism, 
but  Pasteur  proved  that  micrococci  are  the  cause,  and  Ogston  demonstrated 
pyogenic  bacteria  in  pus  obtained  from  cases  of  osteomyelitis.  In  some  cases 
there  is  pure  staphylococcus  infection  (aureus  or  albus),  both  aureus  and  albus 
may  be  present,  there  may  be  mixed  infection  with  streptococci  and  staphylo- 
cocci, streptococci  and  several  sorts  of  bacilli,  or  staphylococci  and  bacilli. 
Mixed  infections  with  streptococci  are  more  malignant  than  staphylococcus 


57^  Diseases  and  Injuries  of  the  Bones  and  Joints 

infections.  Most  cases  of  osteomyelitis  are  due  to  staphylococci.  Trauma  is  a 
common  predisposing  cause.  It  creates  an  area  of  tissue  damage  which  cap- 
tures bacteria  from  the  blood.  UUman  was  unable  to  induce  experimentally 
osteomyelitis  without  first  creating  by  bone  injury  a  point  of  least  resistance. 
When  he  applied  a  ligature  to  a  rabbit's  leg  for  fourteen  hours  distinct  changes 
were  found  to  occur  in  the  marrow  of  the  bones.  These  changes  consisted 
chiefly  in  extravasation  and  localized  hemorrhages.  When  the  marrow  was  in 
this  condition,  if  virus  were  injected  into  the  animal,  osteomyelitis  resulted, 
because  the  bones  presented  points  of  least  resistance,  vulnerable  points  in 
which  pus  cocci  lodged  and  multiplied. 

The  pyogenic  organisms  may  gain  entrance  directly  by  way  of  a  wound 
(a  gunshot-wound,  a  compound  fracture,  an  amputation).  The  causative 
organisms  may  reach  the  bone  by  way  of  the  blood,  having  entered  the  blood 
originally  through  the  lymphatic  system  or  from  a  focus  of  suppuration  in 
the  skin,  the  subcutaneous  tissue,  or  a  deeper  part.  Staphylococcus  infection 
commonly  depends  on  cutaneous  suppuration. 

Pus  organisms  may  pass  into  the  blood  from  the  tonsils  or  respiratory  organs 
(Kraske);  the  intestinal  canal  (Kocher);  the  genito-urinary  tract;  or  from  ex- 
coriations, bruises,  small  wounds,  or  suppurations  in  the  skin.  Certain  fevers 
strongly  predispose  to  the  disease  by  preparing  the  soil,  as  it  were,  for  the 
growth  of  pyogenic  bacteria.  Typhus  fever,  small-pox,  malarial  fever,  scarlet 
fever,  measles,  and  diphtheria  lessen  the  vital  resistance  of  bone-marrow. 
Typhoid  fever  is  not  unusually  followed  by  chronic  osteomyelitis,  due  solely  to 
typhoid  bacilli.  If  mixed  infection  wdth  pus  organisms  occurs,  acute  osteomye- 
litis arises.  Vital  resistance  of  marrow  is  lessened  by  exhausting  diseases,  over- 
exertion, unhealthy  and,  especially,  putrid  food.  We  know  that  various  in- 
fections produce  various  reactions  in  marrow,  and  in  this  changed  marrow  vital 
resistance  is  probably  lessened  or  even  seriously  impaired.  Longcope  made  a 
study  of  the  marrow  in  26  fatal  cases  of  enteric  fever,  and  he  invariably  found 
numerous  hmiphoid  cells,  phagocytes  of  large  size,  and  multiple  foci  of  distinct 
necrosis.  The  cells  whose  function  is  to  form  blood  were  noted  to  be  undergoing 
hyperplasia.  In  persons  dead  of  perforation  and  general  peritonitis  there  were 
numerous  foci  of  necrosis,  and  also  widespread  degenerative  changes  in  the 
blood-making  cells  and  pronounced  edema  and  congestion  of  the  marrow  (''A 
Text-Book  of  Pathology,"  by  Alfred  Stengel).  When  organisms  gain  entrance 
directly  by  a  wound  (as  in  a  compound  fracture),  the  endosteum,  the  medulla, 
and  the  cancellous  tissue  inflame  and  suppurate,  and  the  entire  length  and  thick- 
ness of  the  bone  may  be  involved.  The  periosteum  becomes  infiltrated, 
detached  from  the  bone,  and  retracted  from  the  edges  of  the  wound  in  the  bone. 
The  soft  tissues  around  the  bone  may  inflame,  suppurate,  or  slough.  More  or 
less  necrosis  inevitably  occurs. 

Acute  pyogenic  osteomyelitis  without  a  wound  is  often  called  acute  epiphy- 
sitis. Acute  epiphysitis  is  a  bad  term.  The  process  does  not  start  in  the  epiphy- 
sis. Tuberculosis  may  start  in  the  epiphysis  but  not  a  pyogenic  inflammation 
(Moore,  "Annals  of  Surgery,"  August,  1916).  This  condition  is  most  common 
in  infants  or  children  of  one  or  two  years  of  age,  but  is  not  uncommon  in  older 
children  (from  ten  to  seventeen  years),  and  even  occurs  in  adults.  It  is  vastly 
more  common  among  males  than  females.  The  upper  end  of  the  tibia  and  the 
lower  end  of  the  femur  are  the  regions  most  prone  to  attack.  The  hip  is  seldom 
attacked.  It  is  most  common  during  the  period  of  active  growth  of  bone. 
It  is  frequently  preceded  by  one  of  the  predisposing  causes  before  mentioned 
(an  exanthematous  fever,  etc.).  In  some  cases  a  strain  or  bruise  is  followed  by 
pyogenic  infection,  because  the  damaged  tissue  extends  a  hospitable  welcome 
to  micro-organisms  which  are  traveling  in  the  body-fluids  and  pass  through  the 
injured  area.  The  most  usual  antecedent  injury  is  a  twist.  As  Oilier  showed, 
a  twist  damages  the  weakest  structure,  which  is  the  soft,  new  bone.     In  at  least 


Acute  Infective  or  Pyogenic  Osteomyelitis 


577 


half  of  the  cases  a  history  of  trauma  can  be  obtained.  In  some  cases  there 
doubtless  was  trauma,  even  though  we  can  obtain  no  history  of  it.  In  some 
cases  chilling  of  the  surface  of  the  body  is  a  predisposing  cause.  In  others  no 
predisposing  cause  is  discoverable. 

The  compact  bone  suffers  secondarily,  but  is  never  attacked  primarily. 
New  tissue  is  more  susceptible  to  infection  than  old  tissue,  and  the  disease, 
as  a  rule,  begins  near  the  epiphyseal  line,  where  new  bone  is  being  formed. 
This  point  was  spoken  of  by  Oilier  as  "the  zone  of  election  of  pathological 
processes."  Warren  points  out  that  in  a  growing  bone  near  the  epiphyseal 
cartilage  there  exists  a  newly  formed  spongy  tissue,  very  vascular  and  connected 
with  the  cartilage  by  a  spongy  layer  of  tissue,  which  is  not  yet  bone,  but  which 
does  not  possess  a  cartilaginous  structure.  It  is  in  this  portion  of  the  skeleton 
that  the  most  active  changes  take  place  during  the  period  of  growth.  The 
medullary  substance  is  very  vascular  at 
this  point;  it  is  red  and  without  fatty 
tissue.  It  communicates  with  the  me- 
dullary canal  and  with  the  periosteum 


^^^H 

■ 

■ 

1 

^i^' 

^^^H 

K 

'^^  *^ 

■ 

* 

^  ^ 

1 

1^ 

Fig.  289. — Fracture  of  femur  after  acute  os- 
teomyelitis. 


Fig.  290. — Osteomyelitis,  showing  sequestrum 
formation. 


by  a  number  of  vascular  channels.  The  epiphyseal  cartilage  itself  is  inti- 
mately blended  with  the  periosteum.  The  diaphyseal  side  of  the  cartilage 
produces  much  more  bone  than  is  found  in  the  epiphyseal  margin.  There  is 
also  an  active  growth  of  bone  in  the  periosteum,  and  it  is  in  these  regions 
and  in  the  medullary  canal  that  the  inflammatory  process  originates.^  The 
end  of  the  diaphysis  is  very  vascular,  but  the  blood-stream  is  sluggish  because 
of  the  large  size  of  the  capillary  loops  ("Practice  of  Surgery"  by  Spencer 
and  Gask).  The  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  are  the 
regions  most  commonly  attacked;  but  the  upper  end  of  the  femur  and  the 
lower  end  of  the  tibia  may  suffer,  and  other  bones  may  be  attacked,  especially 
the  humerus,  radius,  ulna,  and  inferior  maxilla.  The  adjacent  joint  not  unusu- 
ally becomes  involved.  Though  the  inflammation  begins  in  the  spongy  tissue 
1  Warren's  "Surgical  Pathology." 
37 


578  Diseases  and  Injuries  of  the  Bones  and  Joints 

or  medulla,  it  passes  to  the  canals  and  spaces  of  the  compact  bone.  The 
inflammatory  exudate  in  the  canals  compresses  the  vessels  and  cuts  off  nutri- 
tion from  certain  areas.  Suppuration  begins,  clots  form  in  the  medulla  from 
thrombophlebitis,  and  the  clots  in  the  vessels  of  the  Haversian  canals  become 
septic.  A  small  sequestrum  forms  at  the  seat  of  origin  of  the  disease,  and  the 
pus  about  the  sequestrum  is  apt  to  empty  into  the  medullary  canal,  causing 
diffuse  osteomyelitis,  or  into  the  adjacent  joint,  causing  suppurative  inflam- 
mation of  the  articulation. 

Marked  constitutional  symptoms  arise  from  absorption  of  toxins  (sup- 
purative fever),  and  sometimes  true  septic  infection  or  even  pyemia  arises. 

Very  extensive  necrosis  may  follow  osteomyelitis  if  the  patient  recovers. 
Fracture  of  the  bone  may  occur  (Fig.  289).  An  acute  pyogenic  osteomyehtis 
may  involve  the  medulla,  may  break  into  the  adjacent  joint,  or  may  remain 
localized  in  the  head  of  a  bone  and  cause  an  abscess  containing  fragments  of 
bone  or  a  distinct  sequestrum  (Fig.  290).  The  walls  of  such  an  abscess  are 
composed  of  sclerosed  bone. 

When  the  medullary  canal  is  involved  in  a  pyogenic  inflammation,  a  part 
or  the  whole  of  the  medulla  may  suffer.  The  condition  may  result  in  central 
necrosis  or  in  suppurative  periostitis  and  death  of  the  shaft  of  the  bone.  The 
mortality  of  acute  osteomyelitis  is  high.  In  the  309  cases  collected  by  Kennedy 
the  mortality  was  34  per  cent.  ("Brit.  Med,  Jour.,"  July  20,  1912),  The 
earlier  the  operation,  the  less  the  mortality.  Operation  within  forty-eight 
hours  of  the  initial  chill  has  a  mortality  of  less  than  10  per  cent. 

Symptoms, — Osteomyelitis  secondary  to  a  wound  of  the  bone  may  occur 
in  a  person  of  any  age.  If  a  wound  exists — for  instance,  a  compound  fracture, 
— the  diagnosis  is  evident.  The  constitutional  symptoms  of  septic  absorption 
are  positive:  there  is  a  profuse,  offensive,  purulent  discharge  containing  bone- 
fragments  and  tissue-sloughs;  the  periosteum  is  red,  thick,  and  separated; 
there  are  swelling  over  the  bone,  great  tenderness,  and  violent  boring,  gnawing, 
or  aching  pain.  Osteomyelitis  occurring  without  a  wound,  the  condition  often 
known  as  acute  epiphysitis,  occurs  in  the  young,  and  particularly  in  children 
under  three  years  of  age. 

The  symptoms  of  acute  osteomyelitis  without  a  wound  of  the  bone  usually 
come  on  suddenly  and  especially  at  night,  and  the  attack  may  be  so  acute 
as  to  cause  death  by  systemic  poisoning  before  a  diagnosis  is  arrived  at.  The 
disease  is  generally  ushered  in  by  a  chill,  which  is  followed  by  septic  febrile 
temperature.  The  history  will  sometimes  contain  the  statement  that  a  blow 
had  been  received,  that  a  febrile  process  had  existed,  or  that  the  patient  had  been 
suddenly  chilled  after  having  been  overheated  (sitting  in  a  draft  or  in  a  cellar 
on  a  hot  day,  possibly  swimming  when  very  warm,  etc.).  There  is  violent 
aching  pain  in  the  bone  and  acute  tenderness  near  the  joint.  Within  seventy- 
two  hours  of  the  initial  chill  there  will  usually  be  pus  in  the  medullary  cavity 
and  a  quantity  of  hopelessly  damaged  bone  if  operation  has  not  been  performed. 
The  soft  parts,  which  at  first  are  healthy  in  appearance,  after  a  time  discolor, 
swell,  and  present  distended  veins,  and  may  become  glossy  and  edematous 
because  pus  is  gathered  below.  The  medullary  cavity  becomes  filled  with  pus. 
An  abscess  sometimes  reaches  the  surface  and  may  break  spontaneously.  The 
neighboring  joint  swells,  and  may  become  filled  with  pus;  the  periosteum  and 
the  shaft  are  involved  for  a  considerable  distance;  each  epiphysis  may  become 
affected,  the  shaft  between  being  comparatively  uninvolved,  and  the  epiphyses 
may  separate,  displacement  and  shortening  taking  place.  Extensive  necrosis 
may  occur.  This  disease  is  often  mistaken  for  rheumatism  because  of  the 
joint  swelling,  occasionally  for  typhoid  fever  because  of  the  fever,  and  in  some 
cases  for  erysipelas  because  of  the  redness  of  the  skin.  It  gives  a  very  grave 
prognosis.  Sometimes  an  epiphysitis  shows  milder  symptoms  and  is  slower 
in  progress  (subacute).     These  cases  are  very  often  mistaken  for  rheumatism. 


Acute  Infective  or  Pyoi^enic  Osteomyelitis  ;;7c> 

But  in  rheumatism  the  joint  is  the  part  involved  from  the  beginning,  while  in 
epiphysitis  the  joint  is  involved  secondarily  after  obvious  evidence  of  inflamma- 
tion well  clear  of  the  articulation.  Further,  the  symptoms  of  rheumatism 
will  be  rapidly  improved  by  the  use  of  the  alkalis  or  the  salicylates.  In  the 
hip  osteomyelitis  is  usually  mistaken  for  inflammation  of  the  joint.  Diagnosis 
cannot  be  made  with  certainty  without  opening  the  joint. 

Treatment. — If  osteomyelitis  arises  secondarily  to  a  wound,  apply  a  tourni- 
quet, sterilize  the  parts,  enlarge  the  wound,  expose  and  curet  the  medullary 
cavity,  remove  loose  fragments  of  bone,  irrigate  the  medullary  cavity  with  a  hot 
solution  of  corrosive  sublimate  or  hot  salt  solution,  scrape  it  with  bits  of  gauze 
held  in  the  bite  of  a  forceps,  paint  with  pure  carbolic  acid,  pack  lightly  with 
iodoform  gauze,  dress  with  hot  antiseptic  fomentations,  and  secure  rest  for  the 
parts  by  splints  and  bandages.  The  constitutional  treatment  is  the  same  as 
that  for  septicemia.  In  some  cases 
amputation  is  necessary.  Acute 
osteomyelitis  without  a  wound  is  a 
most  serious  condition,  rapidly  pro- 
gressive, apt  to  be  quickly  fatal,  and 
requiring  prompt  and  radical  treat- 
ment. Operation  should  be  done  as 
soon  as  possible  after  the  initial  chill. 
Murphy  has  insisted  upon  this  for 
years.  Gushing,  Le  Conte,  and  others 
warmly  advocate  it.  I  always  practise 
it  when  possible.  Within  seventy- 
two  hours,  perhaps  within  forty-eight 
hours  of  the  initial  chill,  there  will  be 
pus  in  the  medullary  cavity  and  a 
quantity  of  bone  will  be  hopelessly 
damaged.  Operation  consists  in 
opening  the  medullary  cavity  by 
means  of  a  burr,  trephine,  or  chisel. 
x\t  such  an  early  stage  drainage  is 
all  that  is  necessary,  as  dead  bone 
has  not  as  yet  formed.  Very  early 
operation  anticipates  pus  formation. 
It  is  not  desirable  to  curet  the  cavity 
because  the  medulla  is  needed  in 
regeneration.  A  delay  of  a  very  few 
hours  will  be  responsible  for  pus  and 
dead  bone.  When  dead  bone  forms, 
the  medullary  cavity  must  then  be  freely  opened  and  curetted.  The  former 
custom  was  to  pack  with  iodoform  gauze  and  wait  for  the  formation  and 
loosening  of  a  sequestrum.  It  is  safer  and  wiser  to  remove  dead  bone  freely 
at  the  primary  operation  (Le  Conte,  "Boston  Med.  and  Surg.  Jour.,"  June 
I,  19 1 1).  When  the  active  symptoms  have  passed,  the  pus  has  drained  exter- 
nally and  dead  bone  has  formed  the  best  time  to  remove  the  sequestrum  will 
be  from  the  sLxth  to  the  ninth  week  after  the  attack.  At  this  time  the  osteo- 
genetic  layer  of  the  periosteum  is  still  active.  If  a  needle  be  pushed  through  it, 
it  will  be  found  that  the  involucrum  is  not  yet  rigid.  Operation  done  at  this 
stage  will  probably  be  followed  by  healing  of  the  cavity  without  artificial  aids. 
In  any  case  if  the  joint  is  involved  it  must  be  drained.  In  the  hip  enter  the 
joint  by  an  anterior  incision  and  remove  dead  bone  if  there  be  any,  but  save 
all  of  the  neck  possible.  In  all  cases  employ  rest,  anodynes,  strong  supporting 
treatment,  and  other  remedies  advised  in  septicemia.  In  a  neglected  or  pro- 
longed case  very  extensive  necrosis  occurs  and  a  formidable  operation  may  be 


Fig.  291. — Chronic  osteomyelitis  of  the  tibia. 


58o 


Diseases  and  Injuries  of  the  Bones  and  Joints 


required.  Even  amputation  may  be  necessary.  It  may  be  necessary  to  remove 
the  entire  shaft,  a  bloody  and  dangerous  operation.  When  dead  bone  exists 
and  reparative  power  is  not  present  in  the  periosteum  some  method  must  be 
employed  to  fill  the  bone  cavity  (page  574). 

Chronic  osteomyelitis  is  usually  linked  with  osteitis.  Pus  may  or 
may  not  form.  There  may  be  only  thickening  of  and  pain  in  the  bone.  Such 
a  condition  can  be  caused  by  attenuated  bacteria  or  by  bacteria  of  ordinary 
power  acting  on  tissue  possessed  of  a  very  high  vital  resistance.  It  may  even- 
tuate in  osteosclerosis  with  filling  up  of  the  medullar>^  canal,  in  limited  suppura- 
tion, in  chronic  abscess  of  the  cancellous  tissue  (Brodie's  abscess),  or  in  necrosis. 

A  tuberculous  inflammation  is 
one  form  of  chronic  osteomye- 
litis (see  page  275).  S>TDhilis, 
typhoid  fever,  etc.,  may  cause  it, 
and  it  can  be  caused  by  glanders, 
leprosy,  and  actinomycosis. 

The  typhoid  bacillus  under 
certain  conditions  is  pyogenic. 
Frankel  taught  this  some  years 
ago,  and  Keen  proves  it  in  his 
work  on  "  The  Surgery  of  Typhoid 
Fever."  Osteomyelitis  due  purely 
to  typhoid  bacilli  is  chronic.  When 
the  medulla  contains  typhoid  bacilli 
pus  infection  is  apt  to  take  place, 
and  if  such  a  mixed  infection  arises 
acute  osteomyelitis  develops.  Ty- 
phoid osteomyelitis  is  most  apt  to 
arise  in  the  ribs,  femur,  tibia, 
humerus,  ulna,  radius,  and  meta- 
tarsus. It  may  begin  during  con- 
valescence or  as  late  as  six  or  seven 
years  after  the  fever. 

In  chronic  osteomyelitis  there 
are  pain,  tenderness,  and  swelling, 
but  no  marked  constitutional 
symptoms.  In  some  cases  the 
real  trouble  is  not  identified  until 
an  abscess  forms  (see  Necrosis). 
There  is  a  form  of  chronic  osteomyelitis  which  is  nearly  always  mistaken  for 
rheumatism.  J.  C.  Stewart  describes  it  fully  ("N.  Y.  Med.  Jour.,"  March  25, 
191 1).  It  is  sometimes  preceded  by  a  fever,  sometimes  by  a  trivial  traumatism, 
but  usually  comes  on  insidiously  and  endures  indefinitely  as  a  chronic  condition. 
Stewart  shows  that  the  bone  enlarges  because  of  subperiosteal  production  of 
new  spongy  bone.  The  marrow  cavity  fills  with  tissue  resembling  red  marrow. 
The  thick  bone  is  tender  at  points,  there  is  aching  pain,  and  a  trivial  rise  of 
temperature  toward  night. 

Treatment. — If  an  abscess  exists,  at  once  evacuate  it  by  incising  the  soft 
parts  and  chiseling  the  bone.  Do  not  wait  for  an  involucrum  to  form,  but 
promptly  incise,  disinfect,  and  drain.  If  dead  bone  is  present  it  must  be 
removed.  In  the  insidious  form,  so  often  mistaken  for  rheumatism,  ex-pose  and 
cut  through  the  new  bone  formation  and  open  the  marrow  cavity.  A  case  of 
chronic  osteomyelitis  may  be  operated  on  several  times  and  by  different  surgeons. 
The  final  operation  which  cures  may  happen  to  be  the  most  trivial  of  all  yet 
to  that  operation  goes  all  the  credit.  It  is  well  if  possible  to  make  the  first 
operation  sufficiently  extensive  to  be  thorough. 


Fig.   292. — Chronic  osteomyelitis  of  the  femur. 


Treatment  of  Osteomalacia  581 

Osteomalacia,  or  Mollities  Ossium. — In  this  disease  the  bones  are 
partly  decalcified,  and  consequently  soften  and  bend.  Masses  of  new  uncal- 
cified  bone-tissue  are  formed.  Many  bones  are  usually  involved,  but  the  bones 
of  the  head  are  not  obviously  affected.  It  is  commoner  beyond  than  before 
middle  age,  though  it  may  occur  in  infancy,  and  a  case  has  been  reported  in 
which  the  disease  arose  at  the  age  of  seventy.  It  is  more  frequently  met  with 
in  women  than  in  men,  and  pregnancy  seems  to  bear  more  than  a  casual  rela- 
tion to  its  production.  The  disease  is  particularly  apt  to  arise  when  preg- 
nancies are  rapidly  repeated  (Marquis,  "L'Obstetrique,"  June,  1910).  In 
osteomalacia  the  medulla  increases  in  bulk  and  becomes  more  fatty,  and  the 
osseous  matter  is  absorbed  gradually,  first  from  the  cancellous  tissue  and  then 
from  the  compact  tissue.  Some  observers  believe  that  this  curious  condition 
is  due  to  lactic  acid  in  the  blood,  an  abnormal  amount  of  acid  having  been  pro- 
duced and  absorbed  because  of  disorder  of  the  primary  assimilation.  That 
there  is  from  some  cause,  an  acidosis  in  this  disease  seems  reasonably  sure 
(Novak  and  Poiges,  in  "Wien.  klin.  Wochen.,"  1913,  xxvi).  The  observers 
above  cited  state  that  normal  pregnancy  and  osteomalacia  present  like  condi- 
tions of  acidosis  and  they  reach  the  conclusion  that  the  disease  is  due  to  the 
ovarian  changes  similar  to  but  more  intense  than  those  which  occur  during 
pregnancy.  It  is  known  that  in  osteomalacia  studies  in  metabolism  show  that 
the  body  loses  calcium  and  gains  sulphur.  Volkmann  maintained  that  some 
inflammatory  condition  disturbs  the  blood-supply  of  the  medulla,  and  von  Reck- 
linghausen asserted  that  arterial  hyperemia  is  responsible.  Honnicke  suggests 
that  the  disease  is  due  to  hypersecretion  of  the  thyroid  gland.  The  probability 
that  the  parathyroids  play  a  part  in  calcium  metabolism  leads  us  to  suspect 
them  of  causal  influences.  In  some  cases  of  osteomalacia  tumors  of  the  para- 
thyroids have  been  found. 

Fehling,  influenced  by  finding  that  improvement  may  follow  removal  of  the 
ovaries,  set  forth  the  view  that  the  disease  is  due  to  overaction  of  the  ovaries, 
causing  reflex  dilatation  of  the  blood-vessels  of  bone.  The  answer  to  this 
theory  is  the  fact  that  the  disease  can  occur  in  the  male.  Some  have  thought 
that  the  disease  is  of  bacterial  origin.  It  is  most  common  in  those  who  dwell 
in  damp  or  dark  habitations.  It  may  arise  after  a  soaking  and  "taking  cold." 
It  is  a  rare  disease  in  England  and  America,  but  is  much  more  common  in 
Germany. 

The  symptoms  of  osteomalacia  are  as  follows :  many  points  of  pain  which 
are  often  thought  to  be  due  to  rheumatism;  deformities  from  twisting  and 
bending  of  bone;  sometimes  lactic  acid  and  occasionally  an  excess  of  calcium 
salts  in  the  urine.  There  is  no  fever  early  in  the  case,  but  later  there  may 
be  a  hectic  fever.  When  the  disease  comes  on  after  childbirth  the  iliac  bones 
suffer  first.  Severe  pain  arises  in  the  pelvis  and  back  and  the  pain  radiates 
into  the  thighs,  the  pain  is  worse  at  night,  and  is  greatly  aggravated  by  pres- 
sure or  movements.  Finally,  standing  and  walking  become  unbearably  pain- 
ful. The  earliest  pain  may  be  in  the  sacrum  and  be  felt  only  when  supine. 
Pains  eventually  become  generalized  throughout  the  skeleton.  Pain  in  the 
bony  walls  of  the  thorax  makes  respiration  difficult.  Great  deformity  occurs 
because  the  partly  decalcified  bones  bend.  Many  of  these  patients  become 
fat.  Fractures  occur  from  very  slight  force.  In  the  majority  of  cases  the  disease 
is  not  cured,  but  grows  progressively  worse  until  the  patient  dies,  after  several 
years,  from  exhaustion.  In  some  cases  the  process  is  arrested  and  the  osteoid 
tissue  is  calcified. 

Treatment. — In  treating  osteomalacia  in  women  insist  that  pregnancy  must 
not  occur.  In  all  cases  put  braces  and  supports  upon  distorted  limbs  to  pre- 
vent further  bending  and  fracture.  Advise  hygienic  surroundings  and  nourish- 
ing food,  and  insist  on  the  value  of  fresh  air.  Among  the  medicines  that  can 
be  used  may  be  mentioned  cod-liver  oil,  lime  salts,  extract  of  the  pituitary 


582 


Diseases  and  Injuries  of  the  Bones  and  Joints 


body,  preparations  of  phosphorus,  and  bone-marrow.  In  women  the  removal 
of  the  ovaries  sometimes  produces  great  improvement.  It  has  been  asserted 
that  the  production  of  anesthesia  by  means  of  chloroform  may  be  of  benefit. 
Acromegaly.  In  1886  Marie  reported  two  cases  with  acquired  and  sym- 
metrical enlargement  of  the  face,  hands,  and  feet.  He  named  the  condition 
acromegaly.  This  curious  disease  is,  in  all  probability,  due  to  hypersecretion 
or  perverted  secretion  of  the  anterior  portion  of  the  pituitary  body.  There  is 
a  hypertrophy  or  a  h^qierplasisa  of  this  body.  As  a  result  of  the  perverted  se- 
cretion or  accentuated  secretory  activity  there  is  accelerated  growth  of  the 
skeleton.  It  was  once  thought  that  tumor  was  always  the  cause  of  acromegaly, 
but  it  is  now  knowTi  that  whereas  tumor  may  be  a  cause,  many  cases  occur  with- 
out tumor.  Cases  of  adiposis  dolorosa  may  show  hypophyseal  symptoms. 
Gigantism  is  probably  acromegalic.  (For  a  masterly  discussion  of  this  subject 
see  ''The  Pituitary  Body  and  its  Disorders,''  by  Harvey  Gushing).  Acromeg- 
aly is  a  disease  which  causes  progressive,  s\Tnmetrical  and  often  great  enlarge- 
ment of  both  the  bones  and  soft  parts  of  the  extremities,  and  this  enlargement  is 

symmetrical.  The  cranium  becomes  triangular  in 
shape,  with  the  base  below,  at  the  lower  jaw.  The 
lower  jaw  projects  in  advance  of  the  upper  jaw,  the 
nose  becomes  prominent  and  thick,  the  supra-orbital 
ridges  are  accentuated  (Fig.  293),  and  the  costal 
cartilages  and  inner  ends  of  the  cla\'icles  become 
protuberant.  Later  the  larynx,  ribs,  shoulder- 
blades,  and  vertebrae  become  involved,  and  the 
back  becomes  markedly  humped  (cer\dcodorsal 
hump).  The  hands  and  feet  are  affected  in  ad- 
vanced cases.  As  a  rule,  the  thyroid  gland  is 
enlarged,  and  a  postmortem  examination  rhay  detect 
a  diseased  pituitary  gland.  Severe  and  uncon- 
trollable headache  is  sometimes  a  distressing  feature 
of  the  disease.  In  some  cases  there  is  marked 
somnolence.  A  fireman  who  suffered  from  acro- 
megaly would  go  to  sleep  almost  the  moment  he 
sat  down.  Early  there  is  low  assimilation  of 
carbohydrates,  often  with  glycosuria.  The  disease 
is  not  regularly  progressive,  but  exhibits  episodes 
of  rapid  increase,  and  periods  in  which  the  con- 
dition remains  stationary  or  may  even  retrogress. 
In  a  prolonged  case  signs  of  pituitary  insufficiency 
are  noted,  viz.:  such  high  assimilation  of  carbo- 
hydrates that  it  is  difficult  or  impossible  to  cause  alimentar}'  glycosuria, 
adiposity,  subnormal  temperature,  and  atrophy  of  the  sexual  organs.  Perhaps 
such  a  patient  can  take  400  gm.  of  glucose  during  two  hours  and  yet  it  will  not 
appear  in  the  urine.  Puberty  is  later.  In  the  male  the  axillary  hair  is  scanty, 
the  beard  is  scanty  or  absent,  the  facial  outline  is  feminine,  the  pubic  hair  is 
arranged  in  a  triangle  with  the  base  above,  and  the  mammary  glands  are  en- 
larged. Polyuria  and  polydipsia  may  be  noted.  Sexual  perversion  is  not 
uncommon.  The  skin  is  soft  like  velvet.  In  both  males  and  females  the 
fingers  are  short  and  the  skin  upon  them  is  thick  and  furrowed.  The  nails  are 
very  brittle.  The  .r-ray  shows  enlargement  of  the  sella.  In  all  suspected  cases 
an  .v-ray  picture  should  be  taken.  If  a  tumor  is  present  or  if  the  gland  is  hyper- 
trophied  the  plate  will  show  an  enlarged  sella  tuicica.  A  tumor  causes  rapid 
blindness.  The  disease  slowly  but  surely  causes  death.  Medical  treatment 
is  of  no  avail  in  cases  of  pituitar}^  overactivity  {hyperpituitarism).  If  there 
is  evidence  of  hypophyseal  insufficiency  {hypopituitarism)  administer  hypophy- 
seal extract. 


Fig.  293. — Face  in  acro- 
megaly. Note  enlarged 
superciliary  ridge,  thickened 
lips,  massive  jaw,  and  general 
grossness.  (Church  and 
Peterson.) 


Osteitis  Deformans 


583 


If  there  is  hyperpituitarism  it  is  justifiable  to  extirpate  the  gland  partially, 
on  the  same  principle  as  we  partially  extirpate  the  thyroid  in  a  case  of  exophthal- 
mic goiter.  In  Cushing's  case  the  operation  of  partial  extirpation  of  the  pitui- 
tary body  relieved  subjective  discomforts  and  modified  acromegalic  conditions. 
If  there  are  evidences  of  tumor  of  the  hypophysis  it  is  justifiable  to  under- 
take its  removal  by  operation.  This  has  been  accomplished  successfully  by 
Hochenegg,  Von  Eiselsberg,  Brochardt,  Gushing,  Sir  Victor  Horsley,  and  others. 
In  the  cases  of  Hochenegg  and  Gushing  not  only  were  pressure  symptoms  re- 
lieved, but  acromegalic  conditions  were  greatly  benefited. 

Leontiasis  Ossea  or  Hyperostosis  Cranii    (Virchow's  Disease). — This 
is  a  rare  condition  there  being  not  over  40  cases  on  record.     It  begins  at  pu- 
berty as  a  hypertrophy  usually  symmetHcal  and  knobby,  limited  to  the  facial 
and  cranial  bones,  and  starting,  as  a  rule, 
in    the   superior  maxillae.     The  facial  in- 
volvement is  much  greater  than  the  cranials. 
The  soft  parts  are  not  involved.     I  do  not 
say  always  symmetrical.  '  I  operated  upon 


Fig.  294. — Leontiasis  ossium. 


Fig.  295. — Paget's  disease. 


a  case  involving  the  facial  and  cranial  bones  of  one  side.  The  hypertrophy 
progressively  increases,  causes  difficulty  of  mastication,  and  is  accompanied  by 
headache.  It  produces  distinct  deformity  of  the  jaw  like  a  tumor,  whereas 
acromegaly  enlarges  all  of  the  proportions  of  a  bone  (Fig.  294).  The  cause 
is  unknown.  It  is  slow  in  progress,  now  seeming  to  cease  advancing,  now 
advancing  with  greater  rapidity.  The  bone  changes  resemble  those  of  osteitis 
deformans.  The  subjective  symptoms  are  due  to  pressure.  There  may  be 
nasal  obstruction.  Violent  headache  is  usual.  It  may  produce  bhndness,  new 
bone  pressing  upon  the  optic  nerves.  Its  course  is  inexorable  and  it  causes 
death  usually  in  the  fourth  decade  of  life.  Treatment  is  very  unsatisfactory. 
Horsley  has  obtained  some  degree  of  amelioration  by  operating  and  removing 
masses  of  bone.     (See  E.  D.  Telford,  in  "Med.  Ghron.,''  1914,  lix.) 

Osteitis  Deformans  {Paget's  Disease)  (Fig.  295).— This  disease  was  fiirst 
described  by  Sir  James  Paget  in  1877.     Higbee  and  Ellis  state  that  up  to  Janu- 


584 


Diseases  and  Injuries  of  the  Bones  and  Joints 


ary,  1911,  isScases  have  been  reported  ("Jour.  Med.  Research,"  vol.  xxiv,  No.i). 
Packard  and  Steel  were  of  the  opinion  that  many  reported  cases  were  not  genu- 
ine instances  of  the  disease,  some  being  ordinary  osseous  tumors,  others  being 
cases  of  enlargement  after  fracture,  and  still  others  being  instances  of  moUities 
ossium  ("Amer.  Jour.  Med.  Sciences,"  Nov.,  1901).  Many  of  the  reports  are 
purely  clinical.  The  disease  does  not  appear  to  be  hereditary.  Although  in 
14  instances  two  or  more  cases  occurred  in  the  same  family  (DaCosta,  Funk, 
Bergeim  and  Hawk,  in  Report  of  JelT.  Med.  College  and  Hospital  for  1915). 
It  is  usually  associated  with  widespread  arterial  sclerosis.  Sixty-seven  per  cent, 
of  reported  cases  were  in  males.     There  is  no  evidence  that  gout,  rheumatism, 

or  disease  of  the  nervous  system  plays  any 
part  in  causation.  Lannelongue  and 
Fournier  considered  the  condition  para- 
s^'philitic,  but  there  is  no  real  evidence  of 
such  origin,  in  fact  a  great  majority  of  cases 
reported  during  recent  years  showed  a 
negative  Wassermann  reaction.  Some 
observers  claim  to  have  found  organisms 
in  the  bone.  In  two  of  my  cases  bacteria 
could  not  be  demonstrated.  It  has  been 
asserted  that  heat  or  cold  may  be  causal 
and  that  the  condition  has  begun  after 
injury  of  a  long  bone.  A  possible  cause 
is  disturbance  of  some  internal  secretion. 
The  enlarged  thyroid  in  Askanazy's  case 
led  him  to  suggest  the  theory.  In  one  of 
my  cases  the  thyroid  was  atrophied,  in 
two  it  was  obviously  enlarged.  In  two 
the  .x:-ray  indicated  pituitary  enlargement. 
No  parathyroids  were  found  at  autopsy  in 
the  patient  of  Higbee  and  Ellis.  These 
two  observers  suggest  that  Paget 's  disease 
may  be  due  to  absence  of  parathyroid 
secretion  and  the  consequent  formation  of 
substances  which  abstract  calcium  from 
the  bones.  In  this  disease  great  quantities 
of  new  bone  are  formed,  but  calcification 
does  not  occur.  The  material  undergoes 
absorption,  and  the  medullary  substance  of 
the  bone  becomes  extremely  vascular  and 
filled  with  white  blood-cells,  and  also  with 
giant-cells.  The  bones  lengthen  and 
thicken.  The  long  bones  bend  and  the 
bones  of  the  skull  bulge.  An  .v-ray  picture 
shows  great  thickening  of  the  bones  of  the  skull  and  perhaps  of  the  jaws.  The 
bending  of  the  long  bones  has  been  believed  to  depend  upon  the  weight  of  the  body 
acting  on  uncalcified  new  bone,  but  fracture  is  not  particularly  apt  to  occur.  It  is 
now  maintained  that  the  bending  and  bulging  are  active  processes,  "since  the 
bending  is  always  well  marked  in  those  bones  which  are  fixed  at  both  ends  by 
muscles  and  ligamentous  attachments,  e.g.,  the  clavicle,  radius,  and  tibia, the 
accompanying  bone  (fibula  or  ulna)  acting  as  the  string  to  the  bow"  (Gruner, 
Scrimger,  and  Foster,  in  "Archives  of  Internal  Medicine,"  June,  191 2).  It  is  ex- 
tremely rare  before  the  age  of  forty,  and  usually  begins  between  forty  and  fifty  or 
later,  but  cases  are  reported  which  began  between  eight  and  twenty.  The  enlarge- 
ment of  the  bones  is  usually  accompanied  by  pain  in  the  back  and  legs,  which  may 
be  severe.     Headache  is  unusual.     Enlargement  maybe  first  detected  in  the  cra- 


FiG.   296. —  Tagct's  disease. 


Osteo-arthropathie  Hypertrophiante  Pneumique  585 

nium,  but  is  more  often  first  seen  in  some  other  bone — for  instance,  the  clavicle, 
the  tibia,  the  spine,  or  the  radius.  The  tibia  in  most  cases  suffers  first,  and  other 
bones  become  involved  later.  In  fact,  in  some  cases  the  bones  of  the  head  do 
not  enlarge  at  all;  but,  taking  all  the  reported  cases,  the  skull  is  affected  more 
frequently  than  any  of  the  other  bones.  In  some  cases  the  enlargement  of  the 
bones  seems  to  be  symmetrical;  in  others  it  is  not.  The  man  finds  that  at 
intervals  he  has  to  buy  a  hat  of  larger  size,  the  forehead  is  prominent  and  ex- 
tremely broad.  The  posterior  part  of  the  head  bulges  less  than  the  sides  and 
front.  In  the  disease  known  as  leontiasis  ossea  the  chief  enlargement  is  mani- 
fested in  the  face;  in  Paget 's  disease  there  is  no  enlargement  of  the  bones  of 
the  face,  or  else  these  bones  are  trivially  involved.  In  Paget's  disease  the  thick- 
ened bones  are  smooth,  in  leontiasis  ossea  these  are  knobby.  Packard  and 
Steele  point  out  that  the  diagnosis  is  extremely  difficult  when  but  a  single  bone 
is  involved;  but  that  if  two  or  more  bones  are  involved,  we  should  think  of 
Paget's  disease  as  the  condition,  especially  if  we  are  able  to  exclude  syphilis, 
cancer,  and  sarcoma.  In  moUities  ossium  the  head  is  not  involved  at  all, 
and  there  is  not  nearly  so  much  thickening  of  the  bone.  The  two  authors 
before  quoted  show  that  in  acromegaly  the  cranium  is  a  triangle  with  its  base 
below  at  the  lower  jaw,  the  orbital  arches  being  distinctly  involved,  but  that 
in  Paget's  disease  the  involvement  is  chiefly  of  the  calvarium  The  patient 
actually  diminishes  in  height.  The  chest  becomes  deformed.  There  is  an- 
gular curvature  in  the  dorsocervical  region.  The  lower  extremities  are  usually 
bent,  and  the  pelvis,  as  a  general  thing,  is  broadened.  Paget  says:  "The  most 
characteristic  features  are  the  loss  in  height,  indicated  by  the  low  position  of 
the  hands,  the  stooping  with  round  shoulder,  the  head  held  forward  with  the 
chin  raised  and  the  chest  sunken  toward  the  pelvis,  the  abdomen  pendulous, 
the  curved  lower  limbs  held  apart  and  usually  with  one  advanced  in  front  of 
the  other  and  both  with  knees  slightly  bent,  the  ankles  overhung  by  the  legs, 
and  the  toes  turned  out.  The  enlarged  cranium,  square  looking  and  bossed, 
may  add  distinctness  to  these  characteristics,  and  they  are  completed  in  the 
slow  and  awkward  gait  of  the  patients . "  In  some  of  the  cases  there  is  a  tendency 
to  tumor  formation.  In  the  67  cases  collected  by  Packard  and  Steele,  3  suffered 
from  cancer  and  5  from  sarcoma.  In  the  158  cases  collected  by  Higbee  and 
EUis  ("Jour.  Med.  Research,"  vol.  xxiv.  No.  i)  there  were  14  instances  of 
tumor  growth.  In  some  the  tumors  were  in  diseased  bone,  in  some  they  were 
in  normal  bone.     In  Paget's  disease  there  is  no  particular  tendency  to  fracture. 

In  a  case  reported  by  Gruner,  Scrimger,  and  Foster  ("Archives  of  Internal 
Medicine,"  June,  191 2)  sarcoma  appeared  in  the  radius,  head  of  the  humerus, 
and  other  places.  Some  cases  are  associated  with  goiter.  It  has  been  suggested 
that  there  is  a  bacterial  cause  for  Paget's  disease.  An  Italian  investigator 
claimed  to  have  discovered  a  bacterium  and  made  a  serum  for  use  in  treatment. 
In  2  cases  I  exposed  areas  of  new  bone,  removed  portions,  and  took  cultures.  One 
set  of  cultures  remained  sterile.  A  tube  of  the  other  was  found  contaminated 
by  the  skin  staphylococcus.  In  two  of  my  cases  metabolism  studies  were  made 
(DaCosta,  Funk,  Bergeim  and  Hawk,  Ibid.).  Much  more  calcium  and  less 
sulphur  were  retained  than  is  the  case  in  normal  individuals.  This  is  opposite 
to  what  is  seen  in  osteomalacia,  in  which  condition  the  body  loses  calcium  and 
gains  sulphur. 

Treatment  is  practically  useless  except  to  the  extent  of  removing  surgically 
some  large  bony  mass.  Abbe  did  this  in  a  man  who  suffered  from  a  large  mass 
growing  from  the  hard  palate.  No  known  remedy  diminishes  the  size  of  the 
bones,  although  iodid  of  potassium  is  said  occasionally  to  mitigate  pain.  Abbe 
points  out  that  excellent  repair  takes  place  after  operating  upon  a  bone 
affected  with  Paget's  disease  ("Jour.  Am.  Med.  Assoc,"  Feb.  9,  1918). 

Osteo=arthropathie  Hypertrophiante  Pneumique  {Marie's  Disease). — 
(Seepage  732.) 


586 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Multiple  Myeloma. — By  this  term  we  mean  a  new  growth  in  the  cancellous 
tissue  of  bone  which  occurs  particularly  in  the  ribs,  sternum,  and  vertebrae.  It 
may  occur  also  in  the  diploe  bones  of  the  cranium,  in  the  clavicles,  in  the  bones  of 
the  hands  and  feet,  and  in  the  ends  of  the  long  bones.  The  multiplicity  is 
not  due  to  metastasis,  but  the  growths  start  as  separate  foci.  The  nature 
of  the  cells  in  the  growths  is  uncertain.  They  almost  certainly  spring  from 
marrow  cells.  Some  consider  them  myelocytes,  some  bone-marrow  plasma 
cells.  Some  of  these  tumors  seem  to  be  truly  malignant.  Multiple  myelomata 
are  related  to  leukemia,  chloromata,  etc.  (Vance,  in  "Am.  Jour.  Med.  Sciences," 
1916,  cUi).  The  effect  of  the  growth  is  to  thin  the  bones  and  make  them  very 
brittle.  This  condition  was  first  described  by  Rustitzky  in  1873.  About  60 
cases  have  been  reported. 

The  condition  begins  insidiously,  in  either  sex,  during  middle  age,  sometimes 
in  advanced  life.  It  begins  usually  with  attacks  of  aching  in  the  limbs  and 
weakness.  Such  attacks  may  come  and  go  over  a  considerable  period  of  time. 
Eventually  the  back,  chest,  and  ribs  become  the  seats  of  pain  and  tenderness. 
Finally,  the  pain  becomes  constant  and  the  patient  is  confined  to  bed.  In 
many  cases  a  sternal  tumor  can  be  palpated.  Spontaneous  fractures  are  apt 
to  occur.  Usually  Bence- Jones  protein  is  found  in  the  urine.  The  finding  of 
this  protein  is  not  proof  of  the  diagnosis,  as  it  is  sometimes  found  in  other  bone 
disorders.  Death  is  due  usually  to  exhaustion.  Treatment  is  futile.  (See 
article  by  Meyer  and  Swain,  in  "Am.  Jour,  of  Med.  Sciences,"  Sept.,  1918). 


Fractures 

Definition. — A  fracture  is  a  solution,  by  sudden  force,  of  the  continuity 
of  a  bone  or  of  a  cartilage.  Clinically,  under  this  head  are  placed  epiphyseal 
separations  and  the  tearing  apart  of  ribs  and  their  cartilages.  Blake  insists  on 
the  difference  between  a  fracture  and  a  wound  of  a  bone.  He  says:  "A  bone 
may  be  perforated  or  a  portion  of  it  broken  off  or  removed  by  a  missile,  and  its 


Fig.  297. — Compound  comminuted  fracture  of  the  tibia. 

continuity  still  remain  intact.  Such  a  condition  is  more  often  observed  in  an 
epiphysis  than  in  a  diaphysis.  It  frequently  occurs  that  a  missile  penetrates 
or  even  perforates  an  epiphysis  without  causing  a  true  fracture;  but  usually, 
when  a  diaphysis  is  perforated,  any  slight  indirect  violence  is  sufficient  to  break 
the  remaining  line"  ("Gunshot  Fractures  of  the  Extremities,"  by  Lt.  Col. 
Joseph  A.  Blake,  U.  S.  A.). 

Varieties  of  Fractures. — The  varieties  of  fractures  are  as  follows: 
Simple  fracture  is  a  subcutaneous  fracture,  or  one  in  which  there  is  no  wound 
extending  from  the  surface  to  the  seat  of  bone  injury.     This  corresponds  to 
a  contusion  of  the  soft  parts. 

Compound  fracture  (Figs.  297  and  307)  is  an  open  fracture,  or  one  in  which  an 
open  wound  extends  from  the  surface  to  the  seat  of  bone  injury  or  in  which  a 
wound  opens  up  a  passage  from  the  fracture  to  the  surface.     This  corresponds 


Varieties  of  Fractures 


587 


to  a  contused  or  lacerated  wound  of  the  soft  parts.  The  opening  may  be 
through  the  skin;  through  a  mucous  membrane,  as  in  some  fractures  of  the 
base  of  the  skull  and  pelvis;  through  the  drum  of  the  ear,  as  in  some  fractures 
of  the  middle  fossa  of  the  base  of  the  skull;  through  the  lung,  as  when  a  broken 
rib  penetrates  that  organ;  or  through  the  bowel  or  bladder,  as  in  some  fractures 
of  the  pelvis. 

A  primary  compound  fracture  is  one  in  which  the  breach  in  the  soft  parts 
is  produced  at  the  time  of  the  accident,  either  by  the  direct  violence  of  the 
injury  or  by  the  forcing  of  a  bone  or  bones  through  the  tissues. 

A  seco)idary  compound  fracture  is  one  in  which  the  breach  in  the  soft  parts 
occurs  after  the  accident,  either  from  sloughing  of  damaged  tissues,  from 
ulceration  because  of  the  pressure  of  ill-adjusted  fragments,  or  from  the  forc- 
ing of  a  bone  or  bones  through  the  soft  parts  because  of  rough  handling,  neglect, 
or  the  tossing  of  delirium. 

Complicated  fracture  is  a  fracture  plus  the  complication  of  a  joint  injury, 
arterial  or  venous  damage,  or  injury  to  the  nerves  or  soft  parts.  When  a  frac- 
tured rib  injures  the  lung  or  when  a  broken  vertebra  damages  the  cord  a  com- 
plicated fracture  exists.     The  term  is  unfortunate,  as  it  convevs  no  definite 


a.  b  c  <f 

Fig.  298. — Complete  fractures:  a.  Transverse;  h,  spiral;  c,  dentated;  d,  oblique  or  multiple. 

meaning,  and  its  use  is  no  more  justifiable  than  it  would  be  to  speak  of  ''com- 
plicated pneumonia"  or  "complicated  t^^jhoid,"  for  the  complication  should 
be  named  in  any  case.  It  must  be  remembered  that  damage  to  the  soft  parts 
not  sufficiently  severe  to  produce  a  wound  reaching  from  the  surface  to 
the  seat  of  fracture  does  not  make  the  case  a  compound  fracture,  but  rather 
complicates  a  simple  fracture.  Remember  also  that  even  superficial  areas  of 
tissue  destruction  must  be  treated  antiseptically,  otherwise  absorption  of 
pyogenic  bacteria  and  their  deposition  at  the  seat  of  injury  may  cause  diffuse 
osteomyeUtis. 

Complete  fracture  is  t?hat  which  extends  through  the  whole  thickness  of  a 
bone  or  entirely  across  it  (Fig.  298). 

Incomplete  fracture  is  that  which  extends  only  partially  through  the  thick- 
ness of  a  bone  or  only  partially  across  it  (Fig.  299). 

A  linear,  hair,  capillary,  or  fissured  fracture,  or  a  fissure,  is  a  crack  in  a  bone 
with  very  little  separation  of  the  edges.  This  is  an  incomplete  fracture,  but 
may  be  associated  with  a  complete  break  (Fig.  298,  h). 

A  green-stick,  hickory-stick,  willow,  or  hent  fracture  is  a  true  incomplete  break 
(Fig.  299).  The  bones  most  frequently  so  broken  are  the  radius,  ulna,  clavicle, 
and  ribs.  It  arises  from  indirect  force,  and  it  is  very  rare  after  the  age  of 
sixteen.  In  rickets  green-stick  fractures  are  very  common.  It  is  called  ''green- 
stick"  because  the  bone  breaks  like  a  green  stick  when  forced  across  the  knee, 
first  bending  and  then  breaking  on  its  convex  surface.  The  bone,  being  com- 
pressed between  two  forces,  bends,  and  the  fibers  on  the  outer  side  of  the  curve 


Diseases  and  Injuries  of  the  Bones  and  Joints 


are  pulled  apart,  while  those  on  the  concavity  are  not  broken,  but  are  com- 
pressed. In  correcting  the  deformity  such  fractures  are  often  made  complete. 
The  permanent  bending  of  a  bone  without  a  break  may  possibly  occur  in 
youth.  In  children  a  portion  of  a  bone  of  the  skull  may  be  bent  inward,  caus- 
ing depression.  In  some  cases  such  a  depression  is  permanent;  in  others  it  is 
temporary,  the  bone  returning  to  its  proper  level. 

Depression-fracture  occurs  when  a  portion  of  the  thickness  of  a  bone  is 
driven  in  by  crushing.  Fracture  by  depression  is  a  result  of  the  bending  in  of  a 
bone  (as  the  parietal),  a  fragment  breaking  off  from  the  side  toward  which 
the  bone  is  bending.  A  depressed  fracture  is  complete,  not  incomplete,  and  by 
this  term  is  meant  an  injury  in  which  a  fragment  of  the  entire  thickness 
of  the  bone  is  driven  below  the  level  of  the  surrounding  surface. 

Splinter-  and  Strain-fracture. — The  breaking  off  of  a  splinter  of  bone  (splinter- 
fracture)  or  of  an  apophysis  constitutes  a  form  of  incomplete  fracture.  A 
strain  upon  a  ligament  or  a  tendon  may  tear  off  a  shell  of  bone,  and  this  injury 
is  the  "strain-fracture"  or  "sprain-fracture"  of  Callender. 

Longitudinal  fracture  is  a  fracture  whose  line  is  for  a 
considerable  distance  parallel,  or  nearly  so,  with  the  long 
axis  of  the  bone.  Such  fractures  are  common  in  gunshot 
injuries  (Fig.  300). 


Fig 


299. — Green-stick  frac- 
ture. 


Fig.  300.— Longitudinal  and     Fig.  301. — Appearances  of 
oblique  fracture.  the  ends  of  fragments. 


Oblique  fracture  is  a  fracture  the  direction  of  which  is  positively  oblique  to 
the  long  axis  of  the  bone.  Most  fractures  from  indirect  force  are  obhque  (Fig. 
298,  d). 

Transverse  fracture  is  a  fracture  the  direction  of  which  is  nearly  transverse 
to  the  long  axis  of  the  bone  (no  fracture  is  mathematically  transverse)  (Fig. 
298,  a).  The  cause  is  often,  but  not  invariably,  direct  force.  The  fracture 
en  rave  (radish-fracture,  so  called  because  the  bone  breaks  as  does  a  radish) 
is  transverse  at  the  surface,  but  not  within. 

Toothed  or  dentate  fracture  is  a  form  of  fracture  in  which  the  end  of  each  frag- 
ment is  irregularly  serrated  and  the  fragments  are  commonly  locked  together; 
hence  it  is  difficult  to  correct  the  deformity  (Fig.  298,  c,  and  Fig.  301).  Most 
simple  fractures  from  direct  force  are  serrated. 


Varieties  of  Fractures 


589 


Wedge-shaped,  V-shaped,  cuneated,  or  cuneiform  fracture  ("fracture  oblique 
spiroide,"  "fracture  en  V"  of  Gosselin,  "fracture  en  coin")  is  one  the  lines  of 
which  take  the  shape  of  a  V,  which  may  be  entire  or  may  lack  the  point.  It 
occurs  at  the  articular  extremity  of  a  long  bone,  and  a  fissure  usually  arises  from 
its  point  and  enters  the  joint.  If  complete,  it  is  a  "comminuted  fracture." 
J -shaped  fracture  is  a  fracture  which  presents  a  transverse  or  oblique  line 
and  also  a  longitudinal  or  vertical  line.  It  occurs  at  the  lower  end  of  either  the 
humerus  or  femur,  the  transverse  line  being  above,  and  the  vertical  line  (inter- 
condyloid)  between,  the  condyles.  If  complete,  it  is,  in  reality,  a  form  of  com- 
minuted fracture. 

Multiple  or  composite  fracture  is  a  condition  in  which  a  bone  is  broken  into 
more  than  two  pieces,  the  lines  of  fracture  not  intercommunicating,  or  a  con- 
dition in  which  two  or  more  bones  are  broken.  Multiple  fractures  of  one  bone 
are  divided  into  double,  treble,  quadruple,  etc.     Multiple  fractures  involving 

more  than  one  bone  are  seldom  seen,  and 
represent  less  than  2  per  cent,  of  fracture 
cases.     The  reason  of  their  rarity  in  hospitals 


Tig.  302. — Comminuted    fracture    of    the 
lower  extremity  of  radius. 


Fig.  303. — Comminuted  fracture  of  the  upper 
part  of  femur. 


is  that  they  result  from  severe  force  and  many  of  the  victims  die  before  they 
can  be  brought  to  an  institution.     The  mortality  in  cases   which  reach  the 


Fig.  304. — Impacted  fracture  of  the  neck  of         Fig.  305. — Impacted  fracture  of  the  neck  of 
the  femur.  the  femur. 

hospital  is  large,  over  27  per  cent.  (Astley  P.  C.  Ashhurst,  in  "Annals  of 
Surgery,"  August,  1907).  ' 

Comminuted  fracture  is  a  condition  in  which  a  bone  is  broken  into  more  than 
two  pieces,  the  lines  of  fracture  intercommunicating  (Figs.  302  and  303). 

The  bone  may  be  broken  into  many  small  fragments,  there  may  be  much 
splintering,  or  the  osseous  matter  may  actually  be  ground  up. 

Impacted  fracture  is  one  in  which  one  fragment  is  driven  into  the  other  and 
solidly  wedged  (Figs.  304,  305,  and  306). 


590  Diseases  and  Injuries  of  the  Bones  and  Joints 

Fracture  with  crushing  or  penetration  is  a  fracture  in  which  one  fragment  is 
driven  into  the  other,  the  encasing  bone  being  so  splintered  that  the  impacting 
bone  is  not  firmly  held. 

Pathological,  spontaneous,  or  secondary  fracture  is  one  occurring  from  a  very 
insignificant  force  acting  on  a  bone  rendered  brittle  by  disease. 

Ununited  fracture  is  a  fracture  in  which  bony  union  is  absent  long  after  the 
passage  of  the  period  normally  necessary  for  its  occurrence. 

Direct  fracture  is  one  occurring  at  the  point  at  which  the  force  was  primarily 
applied. 

Indirect  fracture  is  one  occurring  at  a  point  distant  from  the  area  of  primary 
application  of  force. 

Stellate  or  starred  fracture  (fracture  par  irradiation)  is  one  in  which  several 
fissures  radiate  from  a  center.  If  the  fracture  be  complete,  the  condition  is, 
in  reality,  a  form  of  comminuted  fracture. 


Fig.  306. — Impacted  fracture  of  neck  of  femur  (Conner). 

Helicoid,  spiral,  or  torsion  fracture  is  a  fracture  resulting  in  a  long  bone  from 
twisting. 

Fracture  by  contrecoup  is  a  fracture  of  the  skull  which  is  on  the  opposite 
side  of  the  head  to  that  which  was  the  recipient  of  the  force. 

Epiphyseal  Separation  or  Diastasis. — This  injury  occurs  only  before  the  age 
of  twenty-five.  In  order  of  frequency,  the  bones  chiefly  subject  to  epiphyseal 
separation  are:  the  upper  end  of  the  humerus,  the  lower  end  of  the  radius,  the 
lower  end  of  the  femur,  and  the  lower  end  of  the  tibia  (John  Poland,  in  the 
"Practitioner,"  Sept.,  1901).  This  injury  induces  deformity,  which  is  often 
difficult  to  reduce,  and  by  damaging  the  cartilage  may  retard  or  inhibit  a  fur- 
ther lengthening  of  the  limb  by  growth.  Occasionally,  after  damage  to  an 
epiphysis  suppuration  will  occur;  sometimes  thickening  takes  place.  Non- 
union is  very  rare/  After  a  sprain  of  an  epiphysis  tuberculous  disease  some- 
times develops,  but  very  rarely  after  a  separation. 

Intra-uterine  fractures  are  usually  due  to  injuries  of  the  mother's  abdomen 
sustained  toward  the  end  of  pregnancy.  Some  hold  that  they  can  arise  as  a 
consequence  of  the  force  of  violent  uterine  contractions.  Many  so-called 
"intra-uterine"  fractures  are  wrongly  named,  as  they  result  from  injury  during 
delivery.     In  sporadic  cretinism  the  bones  are  fragile  and  ill-ossified,  and  many 


Causes  of  Fractures  591 

fractures  may  occur  in  utero.  In  the  fetal  type  of  fragilitas  ossium  fractures 
may  occur  before,  during,  or  soon  after  birth. 

Designation  According  to  Seat  of  Fracture. — A  fracture  may  be  designated 
according  to  its  anatomical  seat;  for  instance,  fracture  of  the  upper  third  of  the 
shaft  of  the  femur,  fracture  of  the  olecranon  process  of  the  ulna,  fracture  of  the 
middle  third  of  the  clavicle,  and  fracture  of  the  body  of  the  lower  jaw.  Intra- 
articular fracture  is  one  within  or  extending  into  a  joint;  intracapsular  fracture 
is  one  within  the  capsule  of  either  the  shoulder- or  hip-joint;  and  extracapsular 
fracture  is  one  just  without  the  capsule  of  either  the  shoulder-  or  hip-joint. 

Causes  of  Fracture. — The  causes  of  fracture  are:  (i)  exciting,  imme- 
diate or  direct,  and  (2)  predisposing  or  indirect. 

Exciting  causes  are:  (a)  external  violence  and  (b)  muscular  action. 

External  violence  is  the  most  usual  exciting  cause.  Two  forms  are  noted: 
(i)  direct  violence  and  (2)  indirect  force. 

Fractures  from  direct  violence  occur  at  the  point  struck,  as  when  the  nasal 
bones  are  broken  with  the  fist.  In  such  fractures  the  soft  parts  are  injured; 
they  may  be  destroyed  at  once  in  part,  they  may  be  damaged  so  severely  that 
a  portion  sloughs,  or  they  may  be  damaged  so  slightly  that  they  do  not  lose 
vitality;  hence  fractures  by  direct  violence  may  be  compound  from  the  start, 
may  become  so,  or  may  remain  simple.  In  fractures  by  direct  force  discolo- 
ration, due  to  efTused  blood,  usually  appears  at  the  point  struck  soon  after  the 
accident.  In  compound  fractures  by  direct  violence  the  soft-part  injury  is 
so  great  that  primary  tissue  union  cannot  occur. 

Fractures  from  indirect  force  do  not  occur  at  the  point  of  application  of  the 
force,  but  at  a  distance  from  it,  the  force  being  transmitted  through  a  bone 
or  a  chain  of  bones,  as  when  the  clavicle  is  broken  by  a  fall  upon  the  extended 
hand.  Such  fractures  tend  to  occur  in  regions  of  special  predilection.  If 
they  are  not  compound,  there  is  no  injury  of  the  surface  over  the  fracture.  If 
they  become  compound  by  projection  of  fragments,  primary  union  may  still 
occur.  Discoloration  over  the  seat  of  fracture  is  usually  not  present  soon  after 
the  accident,  but  may  occur  later.  Discoloration  rapidly  appears  in  soft  parts 
at  the  point  where  the  force  was  first  applied. 

Muscular  action  is  rather  an  unusual  cause  except  in  the  patella.  Fractures 
thus  produced  result  from  sudden  or  violent  muscular  contraction.  Bones  so 
broken  are  usually  diseased.  Violent  coughing  may  fracture  the  ribs;  attempt- 
ing to  kick  may  fracture  the  femur;  saving  one's  self  from  falling  backward 
may  fracture  the  patella;  throwing  a  stone  may  fracture  the  humerus;  and  sud- 
den extension  of  the  forearm  may  fracture  the  olecranon  process  of  the  ulna. 

Predisposing  Causes. — There  are  two  classes  of  predisposing  causes,  namely: 
(i)  physiological,  natural  or  normal,  and  (2)  pathological  or  abnormal. 

Natural  Predisposing  Causes. — Under  this  head  is  considered  the  liability 
to  fracture  possessed  by  individual  bones  because  of  their  shape,  structure, 
function,  or  position.  Those  predispositions  occasioned  by  special  ages  are 
also  considered.  In  youth  epiphyseal  separation  is  commoner  than  fracture 
and  a  fracture  is  apt  to  be  incomplete.  Fractures  are  commonest  between 
the  ages  of  twenty-five  and  sixty.  From  two  to  four  years  of  age  a  child  is 
more  liable  to  fracture  than  later,  because  he  is  then  learning  to  walk  (Mal- 
gaigne).  The  bones  of  the  old  are  easily  broken,  but  the  normal  lack  of  ac- 
tivity of  the  aged  saves  them  from  more  frequent  injury.  Thus,  the  predisposi- 
tions of  age  are  in  part  due  to  habits  and  in  part  to  bony  structure.  The  bones 
of  the  young,  being  elastic,  bend  considerably  before  they  break;  the  bones 
of  the  old,  being  brittle  and  inelastic,  break  easily,  but  do  not  bend.  In  old 
age  the  bones  become  lighter  and  more  porous,  though  they  do  not  diminish 
in  size.  Absorption  takes  place  from  the  interior  of  a  bone,  particularly  at  its 
articular  head,  the  medullary  canal  increases  in  size,  the  cancellous  spaces 
become  notably  larger,  and  portions  of  the  remaining  bone  of  the  interior  show 


592  Diseases  and  Injuries  of  the  Bones  and  Joints 

a  fatty  change.  There  is  no  increase  in  the  amount  of  mineral  salts  present, 
as  was  long  taught.  These  alterations  occur  earlier  in  women  than  in  men.' 
The  change  of  age  is  a  diminution  in  the  amount  of  bone  present,  and  some- 
times a  fatty  change  in  a  portion  of  what  remains.  If  the  atrophy  of  bone  is 
other  than  that  normal  to  senility,  it  constitutes  a  pathological  predisposing 
cause  of  fracture.  Normal  predisposing  causes  include  the  person's  weight 
(which  determines  the  force  of  a  fall),  muscular  development,  habits,  sex, 
occupation,  and  the  season  of  the  year. 

Pathological  Predisposing  Causes. — Hereditary  fragility,  a  form  of  fragilitas 
ossium,  is  a  condition  commonest  among  women,  often  existing  in  genera- 
tion after  generation,  and  in  this  condition  fractures  occur  from  a  very  slight 
force.  There  exists  in  these  cases  bony  rarefaction — in  fact,  a  premature 
senility.  Fragilitas  ossium  {osteopsathyrosis)  may  be  congenital,  may  be 
infantile  or  may  come  on  later  in  life.  Osteogenesis  imperfecta  was  discussed 
on  page  564.  Brittleness  may  result  from  senility,  wasting  diseases,  scurvy, 
scarlatina,  bone-cyst,  malignant  disease  of  the  bone,  certain  nervous  disorders, 
rickets,  osteomalacia,  and  atrophy  due  to  disuse.  Workers  in  phosphorus  are 
particularly  liable  to  spontaneous  fracture  of  the  long  bones. 

Nervous  Diseases. — Bony  nutrition  is  dependent  on  the  spinal  cord,  and 
the  trophic  influence  is  probably  exerted  through  the  posterior  nerve-roots. 
In  diseases  of  the  anterior  cornua  bony  growth  is  much  interfered  with;  in 
diseases  of  the  posterior  columns,  as  in  locomotor  ataxia,  a  true  bony  atrophy 
bespeaks  trophic  disorder.  Syringomyelia  causes  brittleness  of  the  osseous 
structures,  and  in  paralysis  agitans  bones  are  thought  to  break  easily.  Trophic 
changes  may  occur  in  the  bones  of  the  insane,  most  commonly  when  insanity 
is  linked  to  organic  disease.  About  one-quarter  of  paretic  dements  show  un- 
due brittleness  or  unnatural  softness  of  bones. ^  The  bones  of  maniacs  are 
frequently  fragile.  Fractures  among  the  insane  are  not  necessarily  an  indica- 
tion of  abuse. 

Rickets  predisposes  to  fracture  because  of  altered  bone  structure  and  the 
great  liabihty  to  falls. 

Osteomalacia   predisposes    to   fracture   of    the   long    bones,   sternum,    and 

ribs. 

Atrophv  of  Bone. — This  condition,  as  has  been  stated  (see  above),  is  nor- 
mal in  senility.  It  may  arise  from  want  of  use,  as  is  observed  in  the  bedfast, 
in  the  wasted  femur  of  hip-joint  disease,  and  in  the  bones  of  a  stump.  It 
may  arise  from  pressure,  as  when  an  aneurysm  compresses  the  ribs,  sternum, 
or  vertebrse.  Among  other  of  the  pathological  predisposing  causes  are  to  be 
mentioned  cancer,  sarcoma,  hydatid  and  sohtary  cysts  of  bone,  caries,  necrosis, 
gout,  scrofula,  syphilis,  mollities  ossium,  and  scurvy. 

Symptoms  of  Fractures.  History  of  an  Injury. — In  spontaneous  frac- 
ture there  may  be  no  record  of  violence;  for  instance,  a  bone  may  break  while 
an  individual  is  turning  in  bed.  In  investigating  the  history,  not  only  seek 
for  a  record  or  for  evidences  of  violence,  but  try  to  determine  exactly  how  the 
accident  happened. 

A  sound  of  cracking  is  occasionally  audible  to  a  bystander  at  the  time  of  the 
injury.  The  patient  may  have  heard  it,  but  very  rarely  does.  A  rupture  of  a 
tendon  or  a  ligament  produces  a  similar  sound. 

Pain  is  usually,  but  not  invariably,  present  (absent  often  in  rickets). _  In 
some  fractures  the  pain  is  slight,  in  some  there  is  no  pain,  in  others  pam  is 
torturing,  and  in  most  it  is  severe  for  a  time  after  the  injury,  but  gradually 
abates  unless  reinduced  by  movement.  Pain  developed  at  the  time  of  the 
accident  is  far  less  important  as  a  symptom  than  that  which  can  subsequently 
be  produced  by  movement.     In  indirect  fracture  there  is  an  area  of  pain  at  the 

1  Humphrey  on  "Old  Age." 

2  "Manual  of  Insanity,"  by  Spitzka. 


Varieties  of  Displacement  593 

point  of  application  of  the  force,  and  another  at  the  seat  of  fracture.  Pain  at 
the  seat  of  fracture  can  be  greatly  aggravated  by  pressure  or  movement  and  is 
rather  narrowly  localized. 

Deformity  or  aUeration  in  length  or  outline  is  due  in  part  to  swelling  and 
in  part  to  a  change  in  the  mutual  relation  of  the  fragments  (displacement). 
The  deformity  due  to  swelling  is  no  aid  to  diagnosis,  as  the  same  condition 
occurs  in  contusion,  and  often  hides  some  positive  symptomatic  distortion. 
The  swelling  is  due  first  to  blood  and  next  to  inflammatory  products  and 
pressure-edema,  and  is  very  great  in  joint  fractures.  Swelling  due  to  bleeding 
is  early  and  rapid.  Swelling  due  to  inflammatory  exudation  is  later  and  grad- 
ual. Swelling  due  to  pressure-edema  may  be  rapid.  The  greater  part  of  the 
swelling  is  due  to  hemorrhage  and  exudation  from  the  damaged  soft  parts,  a 
portion  of  it  is  due  to  hemorrhage  and  exudation  from  the  bone.  The  swell- 
ing is  usually  in  direct  ratio  to  the  mobility,  the  greater  the  mobility,  the 
greater  the  swelling.  "The  swelling  in  fractures  of  the  skull  is  inconsiderable, 
notwithstanding  that  the  total  area  of  bone  surface  involved  is  commonly 
more  than  in  fractures  of  the  leg  or  arm,  and  the  vascularity  greater.  The 
reason  for  this  is  the  natural  immobility  of  fractures  of  the  skull"  (James  P. 
Warbasse,  in  "Jour.  Amer.  Med.  Assoc,"  March  13,  1909).  The  deformity  of 
displacement  may  be  produced  by  the  violence  of  the  injury  (as  is  the  depres- 
sion in  a  skull  fracture),  by  the  weight  of  an  extremity  (as  is  the  falling  of 
the  shoulder  in  a  fracture  of  the  clavicle),  or  by  muscular  action  (as  is  the 
pulling  upward  of  the  fragment  of  a  fractured  olecranon  process). 

The  varieties  of  displacement  are:  (i)  transverse  or  lateral,  where  one 
fragment  goes  to  the  side,  front,  or  back,  but  does  not  overlap  the  other; 
(2)  angular,  the  bony  axis  at  the  point  of  fracture  being  altered  and  the  frag- 
ments forming  with  each  other  an  angle;  (3)  rotary,  one  fragment  rotating 
in  the  bony  circumference,  the  other  remaining  stationery.  As  a  rule,  it  is 
the  lower  fragment  which  turns  on  its  long  axis,  the  limb  below  the  level  of 
the  break  rotating  with  it;  (4)  overlapping  or  overriding,  when  the  upper  level 
•of  one  fragment  is  above  the  lower  level  of  the  other  fragment.  It  is  usually 
the  lower  fragment  which  is  drawn  by  the  muscles  above  the  upper,  but  in  a 
fracture  of  the  lower  extremity  the  body-weight  and  sliding  down  in  bed 
may  push  the  upper  below  the  lower  fragment.  In  overriding  the  ends  are 
near  together  and  the  bones  are  usually  in  contact  at  their  periphery.  It 
is  obvious  that  overlapping  is  associated  -with  transverse  displacement,  as 
'one  fragment  must  go  front,  back,  or  to  the  side;  (5)  penetration  or  impaction 
when  one  fragment  is  driven  into  the  other,  thus  producing  shortening;  (6) 
separation  of  the  two  fragments  occurs  in  fracture  of  the  patella,  olecranon, 
OS  calcis,  certain  articulations,  and  in  some  breaks  of  the  humerus  when  the 
arm  is  not  supported. 

It  is  important  to  remember  that  a  dislocation  as  well  as  a  fracture  may 
produce  displacement,  but  these  two  conditions  may  be  differentiated  by 
the  observation  that  the  displacement  of  fracture  tends  to  reappear  even 
after  complete  reduction,  while  the  displacement  of  dislocation  does  not  re- 
appear after  correction.  A  displacement  is  difficult  of  detection  in  a  flat 
bone  and  when  one  of  two  parallel  bones  is  broken. 

Loss  of  function  may  be  shown  by  inability  to  move  the  limb  because  of 
the  break,  but  it  is  not  always  markedly  present,  though  some  degree  in- 
variably exists.  It  is  slight  in  "green-stick"  and  impacted  fractures  (unless 
the  loss  of  power  arises  from  pain  or  nerve  injury).  A  person  can  walk  when 
the  fibula  alone  is  broken,  and  likewise  in  some  cases  of  intracapsular  fracture 
of  the  femur,  and  can  often  put  the  hand  on  the  head  in  fractui^d  clavicle 
(Malgaigne).  The  pain  of  an  injury  or  the  loss  of  power  from  netve  trauma- 
tism may  cause  loss  of  movement  in  the  limb.  This  symptom  is  of  slight  diag- 
nostic value  in  most  fractures.    - 


594  Diseases  and  Injuries  of  the  Bones  and  Joints 

Extravasation  of  Blood. — A  contusion  of  the  surface  accompanied  by  skin 
abrasion  indicates  merely  the  point  of  application  of  direct  external  violence. 
If  contusion  is  extensive  over  a  superficial  bone,  as  the  tibia  or  parietal,  after 
a  few  hours  it  often  simulates  fracture  by  presenting  a  soft,  compressible 
center  surrounded  by  a  ring  of  hard,  condensed  tissues  and  coagulated  blood. 
Direct  external  violence  may  merely  occasion  ecchymosis,  and  in  fracture 
from  indirect  force  ecchymosis  may  occur  throughout  a  considerable  area. 
In  regard  to  this  symptom,  note  that  even  great  external  violence  may  occasion 
no  evident  contusion  or  ecchymosis,  and  in  any  fracture  this  symptom  may  be 
present  or  absent.  In  old  people,  anemic  subjects,  fat  individuals,-  alcoholics, 
and  opium-eaters  extravastion  of  blood  is  frequently  marked  and  persistent. 
By  suggillation  is  meant  an  extravasation  of  blood  which  slowly  invades  wide 
areas  of  tissue  and  which  appears  at  the  surface  after  some  time  only,  and 
then  usually  as  a  yellowish  discoloration,  red  hemoglobin  having  been  changed 
to  yellow  hematoidin.  Linear  ecchymosis  has  been  esteemed  by  some  as  a 
sign  of  fissure,  and  it  is  often  noted  after  fracture  of  the  fibula.  Linear  ecchy- 
mosis over  the  line  of  the  posterior  auricular  artery  was  shown  by  Battle  to  be  a 
valuable  sign  of  fracture  of  the  posterior  fossa  of  the  base  of  the  cranium. 

Preternatural  mobility  is  a  most  important  symptom,  which  is  pathogno- 
monic when  surely  found.  The  unbroken  bone  is  nowhere  mobile  in  con- 
tinuity. By  preternatural  mobility  is  meant  that  a  bone  is  mobile  in  con- 
tinuity or  that  there  is  abnormality  in  the  direction  or  extent  of  joint  mobility. 
In  some  fractures  this  symptom  does  not  exist  (impacted,  green-stick,  and 
locked  serrated  fractures);  in  others  it  cannot  be  found  (fractures  of  tarsus, 
carpus,  vertebral  bodies);  in  others  it  is  difficult  to  obtain,  but  at  times  can 
be  developed  (fractures  near  or  into  many  joints).  To  develop  this  symptom 
try,  when  the  case  admits,  to  grasp  the  fragments  and  to  move  them  in  op- 
posite directions.  In  a  fracture  of  the  shaft  of  the  femur  or  humerus  fix  the 
upper  fragment  and  carry  the  knee  or  elbow  in  various  directions  to  develop 
bending  at  the  point  of  fracture.  In  fracture  of  the  clavicle  push  the  shoulder 
downward  and  inward.  In  fractures  of  either  bone  of  the  forearm  grasp  the 
parallel  bone  with  four  fingers  of  each  hand  and  make  pressure  on  the  sus- 
pected bone  alternately  with  either  thumb,  and  the  same  procedure  can  be 
used  in  fractures  of  the  leg.  In  fracture  of  the  neck  of  the  femur  the  altered 
rotation-arc  of  the  great  trochanter  demonstrates  preternatural  mobility 
(Desault).  In  fracture  of  the  lower  end  of  the  radius  bend  the  hand  back,  and 
in  a  break  of  the  lower  end  of  the  fibula  evert  the  foot  (Maisonneuve).  In 
seeking  preternatural  mobility  remember  that  the  elastic  ribs  when  forced 
in  give  a  sense  of  bending,  and  that  the  fibula  at  its  middle  is  "  normally  flexible" 
(Dupuytren).     Some  rachitic  bones  may  be  bent. 

Crepitus  or  crepitation  is  both  a  sensation  and  a  sound,  which  indicates 
the  grating  together  of  the  two  rough  surfaces  of  a  broken  bone.  This  symp- 
tom is  of  great  value,  but  it  is  not  always  present.  It  is  absent  in  locked 
serrated  fractures,  in  impacted  fractures,  in  cases  where  the  broken  ends 
cannot  be  approximated  (as  in  overlapping),  is  rare  when  a  fractured  surface 
is  against  the  side,  and  not  the  broken  face,  of  the  other  fragment,  and  is 
unusual  in  incomplete  fractures.  Crepitus  is  often  absent  in  epiphyseal 
separation,  in  softened  bones,  and  in  fractures  in  or  near  joints,  and  it  may 
be  prevented  from  occurring  by  blood-clot,  fascia,  synovial  membrane,  perios- 
teum, or  muscle  between  the  broken  surfaces.  The  grating  found  in  teno- 
synovitis must  not  be  mistaken  for  the  crepitus  of  fracture;  the  former  is 
diffuse,  large,  soft,  and  moist;  the  latter  is  limited,  small,  harsh,  and  dry. 
The  clicking  of  an  inflamed  or  eroded  joint  and  the  crackUng  of  emphysema 
must  also  be  separated  from  bony  crepitus.  Crepitus  of  fracture  may  be 
present  at  one  moment,  but  absent  the  next.  It  is  often  not  detected  during 
the  time  swelling  is  marked,   and   cannot  be  discovered   after  organization 


Diagnosis  of  Fractures  5Q[^ 

of  the  callus  begins.  In  but  few  fractures  is  it  needful  to  try  to  hear  crepitus 
with  the  unaided  ear  or  with  a  stethoscope  upon  the  part,  but  in  doubtful 
cases  of  fractures  of  ribs  and  joints  this  evidence  should  be  sought  for. 

The  above-named  symptoms  are  known  as  "direct."  There  are  other 
symptoms  knowoi  as  "circumstantial,"  such  as  the  flow  of  blood  and  cere- 
brospinal fluid  from  the  ear  after  some  fractures  of  the  middle  fossa  of  the  base 
of  the  skull;  emphysema  of  the  face  and  epistaxis  after  fracture  of  the  nasal 
bones;  hemoptysis  and  emphysema  after  crushes  of  the  chest;  discoloration 
following  the  line  of  the  posterior  auricular  artery  after  fracture  of  the  pos- 
terior fossa  of  the  skuU,  and  subconjunctival  ecchymosis  after  fracture  of  the 
anterior  fossa  of  the  base  of  the  skull. 

Diagnosis. — Examine  as  soon  as  practicable  after  the  injury — before 
the  onset  of  swelling,  if  possible.  Ex^jose  the  part  completely,  taking  off 
the  clothing,  if  necessary,  by  clipping  it  along  the  seams.  Attentively  scru- 
tinize the  part  and  compare  it  with  the  corresponding  part  on  the  opposite 
side.  If  any  deformity  be  present,  it  must  be  ascertained  that  it  did  not 
exist  before  the  accident.  If  the  nature  of  the  injury  be  uncertain,  if  the 
patient  be  very  nervous,  or  if  the  part  be  acutely  painful,  it  is  better  to  give 
ether  to  diagnosticate,  set,  and  dress.  In  injuries  of  the  elbow-joint  anes- 
thetize before  examination,  unless  an  a;-ray  apparatus  is  accessible  to  settle 
the  diagnosis,  and  even  then  it  is  usually  well  to  anesthetize  in  order  to  facili- 
tate reduction  and  dressing.  In  every  case  of  suspected  fracture  get  an  a;-ray 
picture  if  possible.  A  correct  diagnosis  is  of  the  first  importance  and  on  a  cor- 
rect diagnosis  proper  treatment  primarily  depends. 

A  fracture  is  distinguished  from  a  dislocation  by  its  preternatural  mobility, 
its  easily  reduced  but  recurring  displacement,  and  its  crepitus,  as  contrasted 
with  a  dislocation's  preternatural  rigidity,  deformity,  absence  of  crepitus,  and 
early  strenuous  resistance  to  reduction,  with  a  final  tendency  to  remain  in  place 
when  once  reduced.  Further,  in  dislocation  the  bone,  when  rotated,  moves  as 
one  piece,  whereas  in  fracture  it  does  not  so  move;  in  dislocation  the  bony 
processes  are  felt  occupying  their  proper  relations  to  the  rest  of  the  same  bone, 
while  in  fracture  some  of  them  present  altered  relations.  In  dislocation  the 
head  of  the  bone  is  found  out  of  its  socket,  but  in  fracture  it  is  felt  in  place. 
It  is  important  to  remember,  moreover,  that  a  fracture  and  a  dislocation  may 
occur  together,  and  that  the  rubbing  of  a  dislocated  bone  against  an  articular 
edge,  when  the  joint  has  been  roughened  by  inflammation,  simulates  crepitus. 

Great  contusion,  by  inducing  extreme  tumefaction,  may  mask  charac- 
teristic deformity  and  obscure  crepitus.  When  only  a  contusion  exists, 
pain  is  apt  to  be  widespread;  but  if  a  fracture  has  occurred,  the  pain  is  accen- 
tuated at  some  narrow  spot.  In  many  cases,  before  he  can  give  a  certain 
opinion,  the  surgeon  must  wait  some  days  until  the  swelling  has  largely  sub- 
sided. In  such  a  case  it  is  best  to  assume  in  our  treatment  that  a  fracture 
exists  until  the  contrary  is  known.  Combat  swelling  by  rest,  the  use  of  evapo- 
rating lotions,  and  moderate  compression. 

In  impaction  the  diagnosis  is  difiicult.  The  moderate  deformity  is  con- 
cealed by  swelling;  crepitus  and  preternatural  mobility  do  not  exist  unless 
the  fragments  are  pulled  apart,  and  there  is  not  necessarily  much  loss  of  func- 
tion. A  conclusion  is  reached  largely  by  considering  the  nature,  direction, 
and  extent  of  the  violence,  the  seat  of  the  pain,  and  by  a  careful  study  of  the 
most  minute  deformity.  It  is  difficult  to  recognize  fissures.  They  rarely 
present  any  evidence  of  their  existence  except  a  localized  pain,  and  possibly 
a  linear  ecchymosis  appearing  after  a  few  days. 

In  green-stick  fractures  the  age,  the  deformity,  and  possibly  crepitus 
during  reduction  help  in  the  diagnosis,  although  in  many  cases  no  crepitus  is 
obtained.  Epiphyseal  separations  are  diagnosticated  by  the  age,  the  pre- 
ternatural mobility,   the  pain,   the  swelling,   the  ecchymosis,  the  deformity, 


596  Diseases  and   Injuries  of  the  Bones  and  Joints 

the  situation  of  the  injury,  and  the  absence  of  crepitus  or  the  presence  only 
of  a  soft  crepitus.  It  is  important,  however,  to  remember  that  an  epiphyseal 
separation  is  sometimes  incomplete,  and  even  when  it  is  complete  there  may 
be  no  displacement.  In  cases  without  displacement  the  :v-rays  will  not  enable 
us  to  make  a  diagnosis.  In  many  cases  of  complete  separation  soft  crepitus  is 
obtainable,  but  in  not  a  few  cases  it  is  not  to  be  found.  In  incomplete  separation 
crepitus  is  absent.  If  absent  in  complete  separation,  probably  some  tissue  is 
caught  in  the  opened  area  between  the  fragments.  Fractures  are  often  difficult 
to  recognize  when  occurring  in  a  group  of  bones  (which  are  firmly  joined  by 
dense  ligaments)  like  those  of  the  carpus  and  tarsus,  or  in  one  of  two  parallel 
bones.  There  is  not  always  a  certainty  that  a  fracture  exists  (see  below),  ^nd 
when,  after  a  careful  examination,  there  is  still  uncertainty,  do  not  prolong  the 
efforts  or  use  great  force,  but  treat  the  case  as  a  fracture  until  a  cure  ensues  or 
the  diagnosis  becomes  apparent. 

In  a  child  the  diagnosis  of  fracture  is  sometimes  difficult.  Pain  may  be 
trivial.  Children  are  liable  to  a  form  of  fracture  in  which  the  periosteum  is 
but  slightly  torn  or  is  not  torn  at  all,  the  disability  and  pain  are  often  slight, 
and  the  fracture  may  be  easily  overlooked  (Cotton  and  Vose).  If  after  a  fall, 
blow,  or  twist,  a  child  refuses  to  use  the  limb  for  a  considerable  time  the  surgeon 
should  always  suspect  the  existence  of  a  fracture. 

In  1895  a  method  of  incalculable  value  in  diagnosticating  fracture  was  given 
to  the  surgeon,  that  is,  the  use  of  the  force  known  as  the  x-ray  or  the  Rontgen 
ray.  We  can  look  through  a  part  with  a  fluoroscope  and  see  the  bones  as 
shadows,  or  we  can  take  a  negative  of  the  shadows  and  print  skiagraphs  from 
it.  This  method  is  applicable  even  when  the  parts  are  swollen,  and  even  when  a 
limb  is  clothed  or  wrapped  in  dressings.  It  is  possible  to  obtain  a  picture  of  a 
fractured  skull;  fractured  ribs  and  vertebrae  can  be  detected;  and  the  process 
is  of  the  greatest  use  in  detecting  fractures  of  the  limbs.  It  is  not  infallible. 
An  epiphyseal  separation  may  not  be  detected,  and  a  slight  angling  of  the  plate 
may  give  a  deceptive  appearance  of  distortion.  An  ;v-ray  picture,  to  be 
useful,  must  be  taken  by  an  expert  and  should  be  interpreted  by  a  surgeon  in 
association  with  the  x-ray  expert.  It  is  imperative  to  employ  this  method  in 
doubtful  cases  if  an  .r-ray  apparatus  is  accessible.  It  is  advisable  to  use  it 
in  all  recognized  cases  and  in  all  suspected  cases. 

Complications  and  Consequences. — Some  of  the  consequences  and 
complications  of  fractures  are — sloughing  of  the  soft  parts,  thus  making  the 
fracture  compound;  extravasation  of  blood,  causing  swelling  or  even  gan- 
grene; rupture  of  the  main  artery  or  vein  of  the  limb;  dislocation;  edema 
from  pressure  of  extravasated  blood,  from  inflammatory  exudation,  from  tight 
bandaging,  from  thrombosis,  or,  later,  from  the  pressure  of  callus;  stiffness  of 
joints  from  synovitis  with  adhesion,  from  displaced  fragments,  or  from  intra- 
articular callus;  stiffness  of  tendons  from  adhesive  thecitis  or  from  the  pressure 
of  callus;  paralysis  from  traumatic  neuritis,  the  pressure  of  callus  upon  nerve- 
trunks,  or  from  division  of  a  nerve;  muscular  spasm;  painful  callus;  exuberant 
callus;  embolism;  fat-embolism;  pulmonary  congestion;  pulmonary  embolism; 
gangrene;  shock;  septicemia;  pyemia;  tetanus;  delirium  tremens;  urinary  re- 
tention; extensive  laceration  of  the  soft  parts;  rupture  of  large  nerves,  and 
involvement  of  joints.  A  fracture  may  fail  to  unite,  fibrous  union  or  carti- 
laginous union  only  being  obtained.  An  epiphyseal  separation  may  arrest  the^ 
future  growth  of  the  limb. 

Repair  of  Fractures.  Simple  Fracture. — In  a  simple  fracture  the 
bone  is  broken,  the  medullary  contents  are  lacerated,  the  periosteum  is  torn, 
and  the  overlying  soft  parts  are  damaged  to  a  considerable  degree.  The 
periosteum  is  stripped  more  or  less  from  each  fragment,  but  it  is  rarely  com- 
pletely torn  through,  an  untorn  portion  known  as  the  periosteal  bridge  re- 
maining.    The  amount  of  blood  effused  is  usually  considerable,  and  it  forms 


Repair  of  Fractures  597 

a  decided  prominence  at  the  seat  of  fracture;  it  gradually  gathers  because 
of  oozing,  and  soon  clots.  This  clot  lies  in  the  medullary  canal,  between  the 
fragments,  under  the  periosteum  at  the  ends  of  the  fragments,  and  in  the 
tissues  outside  of  the  periosteum.  Very  rapidly  after  the  accident  the  dam- 
aged parts  inflame  (bone,  endosteum,  periosteum,  and  the  torn  periosseous 
structures).  The  inflammatory  exudate  enters  into  the  blood-clot  and  the 
leukocytes  eat  up  and  destroy  the  clot.  The  clot  is  simply  dead  material 
and  in  no  way  contributes  to  repair.  The  cells  of  the  damaged  tissue  pro- 
liferate and  the  young  proliferating  cells  (fibroblasts)  enter  into  the  spaces  in 
the  clot  which  were  eaten  out  by  the  leukocytes.  Finally,  the  entire  clot  is 
replaced  by  fibroblasts  and  much  of  this  cellular  mass  quickly  becomes  vas- 
cularized (granulation  tissue). 

The  osteoblasts  which  exist  in  the  deeper  layers  of  the  periosteum  and, 
in  the  tissue  of  the  medulla  itself,  begin  to  proliferate  actively  soon  after  the 
fracture  has  taken  place.  The  fibroblasts  have  been  formed  by  the  prolifera- 
tion of  the  ordinary  connective-tissue  cells,  and  the  proliferating  osteoblasts 
soon  enter  into  and  become  widely  distributed  through  this  mass  of  fibroblasts. 
Some  observers  maintain  that  the  fibroblasts  themselves  are  directly  trans- 
formed into  bone;  others  deny  this,  and  think  that  all  bone  formation  comes  from 


Fig.  307. — Compound  fracture. 

the  osteoblasts.  Osteoblasts  may  form  bone  directly,  or  may  form  cartilage 
first  and  then  bone.  When  a  fracture  takes  place,  a  bridge  of  periosteum  is 
usually  left  untorn,  and  this  bridge  holds  the  fragments  in  contact  at  some  point, 
just  as  a  strap  nailed  to  a  trunk  and  also  to  its  lid  holds  these  two  objects 
in  contact  at  some  point.  The  new  tissue  about  the  periosteal  bridge  always 
becomes  cartilaginous  for  a  time,  but  the  rest  of  the  callus  rarely  shows  the  de- 
velopment of  cartilage,  and  passes  directly  into  bone.  If,  however,  osteoblasts 
fail  to  proliferate  with  sufficient  activity,  the  mass  of  granulation  tissue  becomes 
fibrous  tissue;  bone  is  not  formed  at  all,  or  is  very  scantily  formed,  and  fibrous 
union  occurs.  If  the  osteoblasts  lack  activity,  but  are  more  active  than  in  the 
case  just  cited,  they  form  cartilage  extensively — but  cartilage  only;  conse- 
quently, cartilaginous  union  occurs.  During  the  process  of  the  repair  of  a 
fracture  the  ends  of  the  bony  fragments  are  always  softened,  and  some  of  the 
bone  is  absorbed  by  the  osteoclasts.  The  osteoclasts  are  really  large  osteoblasts 
that  have  lost  the  power  of  producing  bone  and  that  furnish  a  secretion  to 
absorb  bone  (the  elder  Senn).  After  bony  union  has  been  accomplished  the 
osteoclasts  absorb  the  superfluous  callus.  The  mass  of  new  tissue  around 
and  between  the  bone-ends  is  called  callus.  It  will  be  observed  that  the 
name  is  applied  successively  to  fibroblastic  tissue,  granulation  tissue,  fibrous 
tissue,  and  bone.  Warren  tells  us  that  callus  has  no  well-defined  outline, 
and  "involves  not  only  the  bone  and  periosteum,  but  also  the  connective 
tissue  and  some  of  the  surrounding  muscular  tissue."     Within  a  few  days 


598 


Diseases  and  Injuries  of  the  Bones  and  Joints 


after  the  injury  the  inflammatory  mass  is  much  firmer  than  that  which  follows 
inflammation  involving  other  structures,  and  the  bone  ends  have  become 
deeplv  embedded  in  a  dense  mass. 

During  the  second  week  the  callus  is  greatly  strengthened  by  the  forma- 
tion of  dense  fibrous  tissue  in  and  below  the  periosteum,  of  less  dense  fibrous 
tissue  outside  the  periosteum,  and  of  cartilage  from  the  periosteal  bridge. 
The  newly  formed  tissue  contracts  decidedly.  During  the  third  week  ossifi- 
cation begins  at  the  points  farthest  from  the 
fracture,  and  in  the  course  of  a  short  time 
(from  three  to  six  weeks)  is  complete.  The 
mass  of  ossified  callus,  or  new  bone,  is  spindle 
shaped  and  spongy. 

The  terms  intermediate,  definitive,  or  perma- 
nent callus  are  used  to  describe  the  material 
which  forms  between  the  ends  of  the  broken 
bone.  The  names  provisional  or  temporary 
callus  are  given  to  the  material  within  the 
canal  (central  callus)  and  external  to  the  bone 
(ensheathing  callus).  The  amount  of  provis- 
ional callus  depends  directly  on  the  extent 
of  separation  and  the  amount  of  motion  be- 
tween the  fragments.  It  is  Nature's  splint, 
and  when  the  break  is  not  well  immobilized 
a  large  amount  is  formed.  The  greater  the 
amount  of  motion,  short  of  a  degree  sufiicient 
to  cause  non-union,  the  larger  the  amount  of 
provisional  callus. 

The  ensheathing  callus  is  after  a  time 
largely  absorbed,  and  the  central  callus  in  the 
course  of  a  long  time  may  also  be  absorbed, 
with  the  restoration  of  the  medullary  canal, 
although  this  latter  result  is  rare.  An  ex- 
cessive amount  of  pro\asional  callus  may 
ossify  nearby  tendons,  may  unite  parallel 
bones  (radius  to  ulna,  tibia  to  fibula,  a  rib  to 
its  neighbors),  may  block  a  joint  just  as  a 
stone  in  the  crack  of  a  door  will  block  a 
door,  or  may  absolutely  abolish  a  joint. 
Fragments,  even  if  entirely  detached,  often 
unite,  but  they  may  be  surrounded  by  pro- 
visional callus;  sometimes  they  do  not  cause. trouble,  but  sometimes  suppuration 
takes  place.  It  takes  about  one  year  for  Nature  to  remove  the  temporary 
callus.  The  definitive  or  permanent  callus  after  a  time  ceases  to  be  porous 
and  becomes  very  dense  bone. 

Compound  fractures  (Fig.  307)  without  much  destruction  or  bruising  of  soft 
parts,  if  treated  antiseptically,  soon  become  simple  fractures  and  unite  as  such. 
If  the  wound  is  not  drained  and  asepticized  and  septic  inflammation  occurs, 
pus  forms,  and  union  by  granulation  is  the  best  that  can  be  obtained.  Com- 
pound fractures  by  direct  violence  will  not  heal  by  first  intention  because 
of  the  loss  of  vitality  of  a  large  area  of  the  soft  parts. 

Delayed  union  is  usually  due  to  imperfect  approximation  or  unstable 
fixation  of  the  fragments.  Imperfect  approximation  may  result  from  failure 
to  reduce  the  fracture  (muscle,  ligament,  or  s>Tiovial  membrane  being  caught 
between  the  bone-fragments);  the  use  of  unsuitable  splints;  too  tight  applica- 
tion of  bandages;  pregnancy;  and  general  causes  of  ill  health,  for  instance,  ane- 
mia, scurvy,  Bright's  disease,  rickets,  or  s>^hilis;  disobedience  of  the  patient 


Fig.     308. — Ununited     fracture 
humerus;  unsuccessful  wiring. 


Vicious  or  Faulty  Union 


599 


or  delirium  tremens.  In  delayed  union  there  is  pain  on  passive  motion;  in 
non-union  there  seldom  is.  In  delayed  union  there  is  loss  of  voluntary  motion; 
in  non-union  there  is  power  of  voluntary  motion  (A.  H.  Tubby,  in  "Brit.  Med. 
Jour.,"  Dec.  7,  1901).  In  delayed  union  there  is  apt  to  be  tenderness  on 
pressure  and  often  a  cjuantity  of  callus  can  be  palpated.  Delayed  union  is 
not  non-union,  but  may  eventuate  in  non-union.  The  exact  time  requisite 
for  the  solidification  of  a  particular  fracture  cannot  be  predicted.  The  average, 
taken  from  a  large  majority  of  patients,  is  not  true  in  a  minority.  For  no 
apparent  reason  consolidation  may  require  two  or  three  weeks  more  than  the 
average,  but  be  accomplished  at  last.  Mr.  Jones,  of  Liverpool,  well  says  that 
ununited  fracture  is  often  the  result  of  "surgical  impatience,"  the  surgeon 
frequently  examining  a  part  in  which  union  is  slow,  and  that  "non-union  would 


Fig.  309. — Vicious  union  of  fractured 
tones  of  the  leg.  View  from  inner  side  of 
limb. 


Fig.  310. — Ununited  fracture  of  tlie  femur. 


rarely  occur  if  delayed  union  obtained  proper  attention"  ("Brit.  Med.  Jour.," 
Dec.  7,  1912). 

Bending  of  Callus. — Sometimes  apparently  sound  callus  will  bend.  This 
is  particularly  apt  to  occur  in  the  leg  if  the  bones  are  not  in  correct  alignment. 
Failure  of  correct  alignment  means  great  deflection  of  the  weight  of  the  body. 
I  have  seen  shortening  of  the  femur  increase  during  the  third  month  after  a 
iracture.  Mr.  Jones,  of  Liverpool  (Ibid.),  points  out  that  the  surgeon  can  re- 
fracture  bones  by  manipulation  up  to  four  months  after  the  break.  It  is  obvi- 
ous that  fractures  are  not  soundly  united  as  early  as  we  used  to  believe,  and 
that  a  patient  must  not  be  allowed  to  walk  too  early. 

Vicious  or  faulty  union  is  union  with  great  deformity  (Fig.  309).  This 
occurs  when  no  treatment  has  been  employed,  or  when  immobihzation  has  been 
imperfect,  or  when  deformity  has  not  been  reduced.     It  may  arise  because  re- 


6oo  Diseases  and  Injuries  of  the  Bones  and  Joints 

tentive  dressings  have  been  removed  by  the  patient  at  too  early  a  period,  the 
callus  yielding.  In  many  cases  it  is  slight  and  produces  little  or  no  pain  or 
impairment  of  usefulness.  In  other  cases  it  is  pronounced  and  produces  func- 
tional impairment  or  disastrous  pressure  on  nerves  or  vessels.  Vicious  union 
near  a  joint  always  impairs  function.  If  there  is  pronounced  vicious  union 
the  bone  should  be  rebroken  and  set  as  a  fresh  fracture.  In  some  recent  cases 
the  bone  is  broken  by  manual  force,  and  for  a  number  of  weeks  after  a  fracture 
this  can  be  easily  accomplished.     In  older  cases  osteotomy  should  be  performed. 

Non=union  of  Fractures. — An  ununited  fracture  is  a  fracture  in  which 
union  is  not  effected  at  all  or  in  which  it  is  not  brought  about  by  bone  (Figs. 
308  and  310).  Non-union  is  especially  common  in  fractures  of  the  U[)per  third 
of  the  femur  and  of  the  middle  third  of  the  humerus.  The  causes  are  local  and 
constitutional.  The  local  causes  are:  (i)  Want  of  approximation  of  fragments; 
a  frequent  cause  of  want  of  approximation  is  interposition  of  soft  tissues — viz., 
muscle,  fascia,  or  periosteum;  this  is  a  common  cause  of  non-union,  a  cause 
responsible  for  a  decided  majority  of  the  cases;  if  soft  tissues  are  interposed 
between  bone-fragments  non-union  is  almost  inevitable;  (2)  want  of  rest.  As 
pointed  out  above,  delayed  union  may  result  in  non-union  because  of  frequent 
meddlesome  examinations.  As  Sir  Robert  Jones  says,  if  there  is  no  union  at 
the  end  of  the  fifth  week  do  not  examine  daily,  but  leave  the  parts  alone  for  a 
fortnight  at  least;  (3)  want  of  blood-supply  (as  seen  in  the  heads  of  the  humerus 
and  femur,  or  when  a  nutrient  artery  is  torn,  or  when  a  thrombus  forms  in  a 
vein  near  the  fracture);  (4)  defective  innervation;  (5)  bone  disease;  (6)  the 
use  of  unsuitable  splints;  (7)  tight  bandaging.  The  constitutional  causes  are 
debility,  scurvy,  Bright's  disease,  syphilis,  etc.  Sometimes  union  fails  without 
appreciable  reason.  In  an  ununited  fracture  the  broken  ends  of  the  bone  round 
off  and  the  medullary  canal  of  each  fragment  becomes  closed  by  bone.  The 
fragments  may  not  be  held  together  by  any  material,  or  they  may  be  held  by 
very  thin  and  much-stretched  fibrous  tissue  {membranous  union),  or  by  strong, 
thick,  fibrous  tissue  {ligamentous  or  fibrous  union).  WTien  the  ends  of  the  bones 
come  together,  are  held  by  a  fibrous  capsule,  and  move  on  each  other,  there 
exists  a  false  joint  or  pseudo-arthrosis.  Such  a  joint  may  after  a  time  secrete 
serous  fluid  for  lubrication.  In  very  rare  cases  a  fracture  once  apparently 
soundly  united  may  at  a  later  period  be  obviously  ununited,  callus  having  been 
absorbed  or  broken.  Pain  on  active  motion  in  the  region  of  a  fracture  a  num- 
ber of  weeks  old  suggests  non-union.  If  there  is  also  tenderness  non-union  is 
highly  probable.  If,  with  pain  and  tenderness,  there  is  marked  thickening  from 
callus,  non-union  is  certain  ("Brit.  Med.  Jour.,"  Dec.  7,  191 2). 

Treatment  of  Fractures. — If  a  man  is  found  in  the  street  with  a  frac- 
ture, further  injury  must  be  prevented  by  applying,  after  cutting  off  the  cloth- 
ing over  the  fracture,  some  temporary  support.  If  an  ambulance  or  patrol- 
wagon  cannot  be  obtained,  move  the  patient  by  hand.  If  the  l6wer  extremity 
be  involved,  an  improvised  stretcher  (a  board  or  a  shutter)  is  placed  on  the 
ground  beside  the  patient,  who  is  laid  on  the  stretcher,  the  surgeon  lifting 
the  injured  limb,  and  the  patient  is  then  carried  to  the  hospital  and  care- 
fully transferred  to  a  fracture-bed,  or,  if  taken  home,  to  a  small  ordinary 
bed,  several  boards  being  placed  transversely  beneath  a  rather  hard  but  even 
mattress.  The  temporary  appliances  are  now  removed  and  a  diagnosis  is 
made  by  the  methods  before  given.  Whenever  possible  have  x-ray  pictures 
taken  (see  page  596).  After  determining  the  nature  of  the  injury  the  fragments 
must  be  adjusted.  This  should,  if  possible,  be  done  at  once,  because  a  fracture 
remaining  unreduced  may  become  compound,  the  fragments  may  injure  im- 
portant structures,  and  they  are  apt  to  cause  intense  pain.  Reduction  is 
easily  effected  during  shock,  as  the  muscles  are  in  a  state  of  relaxation.  Early 
reduction  and  fixation  largely  prevent  swelling.  If  there  is  very  great  swelling, 
reduction  may  be  impossible,  and  the  part  must  then  be  supported,  moderate 


Treatment  of  Fractures  6or 

cold,  sorbefacients,  and  gentle  pressure  being  used,  ice  and  tight  bandaging, 
which  predispose  to  gangrene,  not  being  employed.  In  most  cases  we  can 
reduce  displacement  in  spite  of  swelling  and  cure  swelling  by  the  reduction. 
Set  the  fracture  at  the  first  possible  moment.  Velpeau's  axiom  was  to  reduce 
fractures  at  once,  regardless  of  pain,  spasm,  or  inflammation,  as  reduction  is 
their  cure.  The  longer  we  wait  to  reduce  a  fracture,  the  greater  the  amount 
of  force  necessary  to  accomplish  it  because  of  progressive  infiltration  of  the  soft 
parts  with  inflammatory  exudate  and  blood,  a  process  which  lessens  and  finally 
destroys  tissue  elasticity.  In  reduction  tr}^  to  get  broken  ends  in  even  appo- 
sition. In  this  we  may  fail,  but  wq  must  at  least  strive  to  obtain  a  correct 
alignment.  In  order  to  obtain  apposition  or  alignment  it  may  be  necessary 
to  make  traction  by  pulleys,  and  if  this  is  done  the  patient  must  be  anesthet- 
ized (Sir  Robert  Jones,  "Brit.  Med.  Jour.,"  Dec.  7,  191 2).  He  says  that 
"end-to-end  apposition  with  an  angle  of  deflection  is  less  satisfactory  than  slight 
overlapping  in  the  presence  of  correct  alignment"  (Ibid.). 

If  the  patient  is  very  nervous,  if  the  pain  is  severe,  or  if  rigid  muscles  antag- 
onize the  efforts  of  the  surgeon,  reduce  the  fracture  under  anesthesia.  In 
some  fractures  (as  those  of  the  clavicle)  adjustment  is  effected  by  altering 
the  position,  and  in  others  (as  those  of  the  femur)  by  extension  and  counter- 
extension,  aided  perhaps  by  pulleys;  in  some  by  tenotomy,  and  in  some  by 
kneading,  bending,  and  coaptation.  When  extension  is  employed,  always  en- 
deavor to  get  a  point  of  counterextension.  The  extension  is  to  be  made  on  the 
broken  bone  (if  possible,  in  the  axis  of  the  bone),  is  to  be  steady,  and  neither 
jerky  nor  violent.  In  some  cases  complete  reduction  is  impossible.  This  may 
be  due  to  spasm,  to  swelling,  to  the  catching  of  soft  parts  between  the  frag- 
ments, to  the  existence  of  a  loose  fragment,  to  locking,  or  to  impaction.  An 
impaction  by  rotation  can  generally  be  released,  but  it  is  sometimes  undesir- 
able to  unlock  it.  If  the  fragments  cannot  be  adjusted  without  violence,  retain 
them  in  the  best  attainable  position,  combat  the  antagonistic  cause,  and  set 
them  properly  as  soon  as  possible  or  else  operate. 

After  adjusting  the  fragments  maintain  them  in  position  by  some  appa- 
ratus. Do  not  use  set  splints  for  each  variety  of  injury.  The  splints  we 
describe  as  commonly  used  are  suited  to  many  cases,  but  in  each  case  a  sur- 
geon uses  the  plan  of  treatment  which  in  his  opinion  is  suitable  to  that  case. 
In  a  given  case  the  routine  plan  may  prove  unsuitable.  The  treatment  is 
to  be  adjusted  to  the  individual  case.  The  case  is  never  to  be  forced  to  an 
unsuitable  routine  treatment.  All  sorts  of  materials  are  used  for  splints; 
among  them  may  be  mentioned  wood,  felt,  pasteboard,  plaster  of  Paris,  silicate 
of  sodium,  tin  (Levis),  and  aluminum  (Elsberg).  Avoid  pressure  over  joints 
or  bony  prominences  and  particularly  guard  against  tight  or  improper  bandag- 
ing. In  fracture  of  a  bone  of  a  limb  the  circulation  in  the  fingers  or  toes  must 
be  observed  as  an  index  of  circulation  in  the  limb;  hence  leave  those  digits 
exposed.  A  retentive  apparatus  should  prevent  the  redevelopment  of  deformity, 
and  not  be  itself  productive  of  pain  or  harm.  For  the  first  few  days  of  treat- 
ment of  a  simple  fracture  the  dressing  (if  not  plaster  or  silicate)  is  to  be  removed 
every  day,  to  make  sure  that  deformit)^  has  not  recurred,  and  if  it  does  recur 
the  fragments  must  at  once  be  reset.  The  splints  should  be  padded  thoroughly, 
especially  when  over  joints  or  bony  prominences,  and  they  should,  if  possible, 
fix  the  joints  immediately  above  and  below  the  break.  A  primary  roller  should 
not  be  used  unless  plaster  is  to  be  employed.  By  a  primary  roller  is  meant  a 
bandage  applied  to  the  extremity  before  splints  are  placed  upon  it. 

Some  years  ago  Steinmann  proposed  to  obtain  extension  in  fractures  by 
what  is  called  nail  extension.  A  steel  wire  nail  should  be  driven  through  the 
end  of  the  lower  fragment.  This  nail  is  used  as  a  fLxed  body  on  which  to  set 
an  apparatus  for  extension.  It  can"  also  be  used  to  antagonize  rotation.  The 
nail  is  removed  in  from  eighteen  to  twenty-one  days.     If  it  is  retained  longer 


6o2  Diseases  and  Injuries  of  the  Bones  and  Joints 

it  will  produce  pressure  necrosis  (Dyas,  in  "Surgery,  Gynecology,  and  Obstet- 
rics," 191 6,  xxiii). 

J.  C.  A.  Gerster  leaves  it  in  from  twenty-eight  to  thirty-five  days  ("Jour. 
Am.  Med.  Assoc,"  1916,  Ixvii).  Ransohoflf  devised  a  tongs,  the  points  of  which 
catch  in  the  femoral  condyles  fFig.  311),  and  Codavilla  uses  a  pin  for  the  same 
purpose. 

There  is  no  doubt  that  by  this  method  powerful  traction  can  be  brought  to 
bear  exactly  where  it  is  needed.  It  is  said  to  be  safer  than  treatment  by  opera- 
tion. I  have  nev^er  used  the  method.  It  seemed  to  me  to  possess  some  of 
the  objections  long  ago  filed  against  Malgaigne's  hooks  used  for  fracture  of  the 
patella.  Blake,  however,  tells  us  that  it  is  the  most  perfect  of  methods  by  which 
traction  can  be  made  upon  the  femur  ''because  it  permits  the  placing  of  the 
limb  in  an  absolutely  correct  position  and  acts  directly  upon  the  fragment  with- 
out fixing  or  injuring  the  knee.  With  it  a  weight  of  six  kilos  produces  as  much 
eflfect  as  fifteen  kilos  attached  by  the  ordinary  adhesive  bands.  The  objection 
to  it  is  the  fear  of  infection  at  the  site  of  the  pin  or  tongs,  but  present  experience 
seems  to  prove  that  the  tongs  at  least  may  be  emploved  with  impunity"  (Lt. 
Col.  Blake,  Ibid.).  '  ' 

Some  surgeons  at  once  apply,  an  immovable  dressing.  This  proceeding  is 
safe  in  simple  fractures  without  much  displacement  or  soft-part  injury.     This 


Fig.  311. — Showing  the  use  of  Steinmann  pins  in  the  treatment  of  multiple  simple  fracture 
of  the  middle  third  of  femur  (Fauntleroy). 

dressing  is  valuable  in  military  practice,  for  the  old  and  feeble  whom  we  fear 
to  put  to  bed,  for  the  young  who  are  very  restless,  and  for  the  insane  or  the 
delirious.  If,  however,  there  is  great  deformity,  much  soft-part  injury,  or 
marked  swelling,  immovable  dressings  may  induce  sloughing,  edema,  gangrene, 
or  faulty  union.  In  the  above-named  cases  use  ordinary  splints  for  the  first  few 
days;  then,  if  it  is  desirable,  the  immovable  dressing  can  be  applied.  Plaster-of- 
Paris  bandages  are  used  with  great  care  in  very  young  children,  as  gangrene  might 
result  from  careless  application.  It  is  dangerous  to  keep  old  or  feeble  persons 
long  in  bed,  as  they  are  prone  to  develop  bed-sores  and  hypostatic  pulmonary 
congestion.  The  period  for  the  artificial  retention  of  the  fracture  varies  with 
the  seat  of  the  fracture  and  the  age  and  condition  of  the  patient.  Passive 
motion  is  to  be  made  in  most  fractures  in  from  two  to  three  weeks,  though  it  is 
sometimes  made  earlier  to  prevent  ankylosis,  and  sometimes  later  because  of 
risk  of  non-union.  Landerer  strongly  advocates  massage,  believing  that  it 
hastens  union  and  prevents  wasting.     He  applies  it  as  soon  as  there  is  no 


Prevention  and  Treatment  of  Complications  603 

danger  of  the  callus  bending  (in  from  eight  to  fourteen  days).  Massage  should 
not  be  used  when  great  edema  points  to  the  possibility  of  venous  thrombosis. 
The  movements  might  break  up  a  clot  and  cause  fatal  embolism.^  Very 
early  massage  may  cause  fat-emboHsm.  In  fracture  of  the  patella,  wiring  is 
frequently  performed,  and  wiring  or  plating  is  frequently  practised  in  fracture 
of  the  clavicle,  fracture  of  the  tibia,  fracture  of  the  upper  third  of  the  femur 
and  other  regions.  If  fragments  cannot  be  approximated  or  retained  by 
ordinary  methods,  an  incision  should  be  made,  approximation  effected,  and 
the  fragments  retained  by  wire,  a  clamp,  a  plate,  or  a  bone  ferrule. 

The  plan  known  as  the  ambulatory  treatment  of  fractures  of  the  lower 
extremities  has  had  warm  advocates.  The  ambulatory  splint  is  an  apparatus 
which  enables  a  man  to  walk  about  a  few  days  after  receiving  a  fracture  of  the 
leg  or  thigh.  It  was  devised  by  Hessing,  a  carpenter  dwelling  in  a  village  near 
Augsburg.  Its  aim  is  not  only  to  get  the  patient  about  on  crutches,  but  also 
to  cause  him  to  use  the  hmb.  It  is  held  that  this  plan  of  treatment  greatly 
lessens  the  patient's  sufferings  and  actually  favors  union  by  the  stimulation  of 
walking.  Bardeleben,  in  his  report  to  the  German  Surgical  Congress,  gave  the 
records  of  in  fractures  of  the  lower  extremity  thus  treated  (77  simple  and 
12  compound  fractures  of  the  leg,  17  simple  and  5  compound  fractures  of 
the  thigh).  The  patients  were  gotten  about  a  few  days  after  the  accident, 
were  able  to  attend  to  business,  had  excellent  appetites,  digested  their  food 
perfectly,  slept  well,  and  were  saved  from  muscular  atrophy.  Pilcher  has 
warmly  advocated  the  method.  It  can  be  used  in  fractures  as  high  up  as  the 
middle  of  the  femur.  The  apparatus  which  we  should  employ  in  the  ambu- 
latory treatment  reaches  below  the  sole  of  the  foot,  and  is  supported  firmly 
above  the  seat  of  fracture,  the  weight  of  the  body  being  transferred  from 
above  the  fracture  to  the  firm  pad  below  the  sole  of  the  foot  on  which  the 
patient  walks  (Figs.  31 2  and  313).  This  appHance  in  a  fractured  thigh  is  put  on 
about  one  week  after  the  infliction  of  the  injury.  While  the  patient  sits  on  the 
ischial  tuberosities  extension  is  made  upon  the  leg.  The  seat  of  fracture  is  en- 
circled by  a  thin  plaster  cast.  The  sole  of  the  other  foot  is  raised  by  a  cork 
sole.  Albers,  when  treating  a  fractured  thigh,  uses  plaster  of  Paris  strength- 
ened by  bits  of  wood,  running  horn. below  the  sole  of  the  foot  to  the  ihac  crest. 
Krause  says  in  fracture  of  the  ankle  carry  the  dressing  to  the  head  of  the  tibia; 
in  fracture  of  the  leg  carry  it  to  the  middle  of  the  thigh;  in  fracture  of  the  lower 
end  of  the  femur  carry  it  to  the  pelvis.^  Bradford  warmly  advocates  the  use  of 
Thomas's  splint  often  combined  with  plaster  of  Paris.  During  the  last  few 
years  surgeons  have  come  to  recognize  that  ambulatory  treatment  must  not  be 
used  for  all  fractures  of  the  lower  extremity  and  is  only  suited  to  selected 
cases.  The  ambulatory  treatment  is  warmly  commended  by  some  military 
surgeons  on  the  ground  that  it  secures  full  return  of  function  and  also  favors 
union  of  the  bone  and  healing  of  the  wound  (Captain  C.  Max  Page,  R.  A.  M.  C). 
In  fracture  of  the  femur  Delbet  uses  the  apparatus  shown  in  Figs.  312,  313. 
He  gets  his  patients  up  and  has  them  walking  about  a  few  days  after  the  injury. 

Prevention  and  Treatment  of  Complications. — In  every  case  of  fracture 
of  an  extremity  feel  for  the  pulse  between  the  periphery  and  the  seat  of  injury 
in  order  to  be  sure  the  artery  is  not  ruptured.  If  the  soft  parts  are  badly 
contused,  try  to  prevent  sloughing  by  employing  rest  and  relaxation  and  by 
applying  heat.  If  superficial  sloughing  occurs,  treat  antiseptically,  remember- 
ing that  even  a  superficial  excoriation  can  admit  bacteria  which,  carried  by  the 
blood  or  lymph,  may  infect  the  bones.  If  a  slough  leads  down  to  the  fracture, 
treat  the  case  as  a  compound  fracture.  If  there  be  great  blood  extravasation 
the  danger  is  gangrene,  and  after  fracture  of  the  lower  extremity  the  foot  of  the 
bed  may  be  elevated,  or,  better,  after  fracture  of  the  upper  or  lower  limb  the 

1  Cerne's  case,  in  "Normandie  med.;"  "Bull,  med.,"  1895,  No.  44. 
^  "Centralbl.  f.  Chir.,"  vol.  xxii,  1895. 


6o4 


Diseases  and  Injuries  of  the  Bones  and  Joints 


extremity,  to  which  spHnts  and  bandages  are  to  be  loosely  applied,  is  to  be 
raised  and  surrounded  with  hot  bottles.  If  a  bleb  forms,  it  is  to  be  opened 
with  a  clean  needle  and  dressed  antiseptically.  If  gangrene,  occurs,  treat  by 
the  usual  rules.  Frequently  after  fracture  of  a  bone  blebs  containing  reddish 
serum  form  on  the  skin.  The  appearance  of  blebs  when  the  circulation  is  good 
does  not  mean  gangrene,  and  is  not  of  any  particular  consequence.  If  blebs 
are  distinct  symptoms  of  circulatory  impairment,  gangrene  impends  or  already 
exists. 

Ede?na  may  be  due  to  tight  bandaging.  If  it  is  due  to  phlebitis,  there  is 
danger  of  pulmonary  or  cerebral  embolism.  In  phlebitis  elevate  the  limb, 
remove  all  constriction,  and  employ  locally  ichthyol  ointment;  do  not  use  mas- 
sage, and  give  stimulants  by  the  mouth.     In  edema  due  to  weak  circulation  or 


Figs.  312,  313. — Delbet's  apparatus  for  ambulatory  treatment  of  fractures  of  the  femur 

(Leriche). 


venous  relaxation  use  daily  frictions  and  firm  bandaging.  If  the  fracture  in- 
volves a  joint,  carefully  adjust  the  fragments,  make  passive  motion  early,  and 
inform  the  patient  that  he  is  in  danger  of  a  permanently  stiff  joint. 

A  dislocation  occurring  with  a  fracture  is  reduced  at  once  if  possible.  To 
do  this,  splint  the  limb  and  give  ether,  and  try  to  reduce  while  the  limb  is  manipu- 
lated, using  the  splint  as  a  handle.  Allis  is  often  able  to  reduce  a  dislocation 
accompanied  by  a  fracture.  He  uses  the  untorn  portion  of  periosteum  as  a 
hinge,  pulls  upon  the  lower  fragment,  and  thus  draws  down  the  upper  frag- 
ment and  pushes  it  in  place  by  manipulation.  If  this  fails,  it  is  best  to  incise  and 
pull  the  separated  end  in  place  by  the  hook  of  McBurney  and  Dowd  (Figs. 
314-316) ;  but  some  surgeons  say,  get  the  bones  in  the  best  possible  position,  set 
them,  await  union,  and  then  treat  the  unreduced  dislocation.  A  rupture  of 
the  main  artery  of  the  limb  presents  the  symptoms  of  absent  pulse  below  the 
rupture,  a  tumor  which  may  pulsate,  and  possibly  a  whirring  sound  or  an  aneurys- 


Treatment  of  Compound   I'Yactures 


605 


mmmsmmmmaii^iMiMi 


Fig.  314. — Fracture-hook  (McBurney  and  Dowd). 


mal  thrill  and  bruit.  This  condition  demands  that  the  surgeon  should  apply 
an  Esmarch  bandage,  cut  down  upon  the  tumor,  turn  out  the  clot,  and  ligate 
each  end  of  the  vessel.  Rupture  of  the  main  vein  of  a  limb  causes  intense  edema 
and  calls  for  sutures,  lateral  ligature,  or  com[)lcte  ligation.  If  these  measures 
fail  after  injury  of  vein  or  artery  it  is  seldom  successful  to  ligate  higher  uj).  Such 
a  course  might  succeed  in  the 
upper  extremity.  It  would  almost 
certainly  fail  in  the  lower.  Ampu- 
tation will  probably  be  necessary. 
If  gangrene  appears,  amputate 
at  once  above  the  seat  of  the 
fracture. 

Injiammation  is  to  be  treated 
by  compression,  rest,  moderate 
cold,  and  later  by  50  per  cent, 
ichthyol  ointment.  Muscular 
spasm  requires  morphin  internally, 

firm  bandaging,  or  even  tenotomy.  Fat-embolism  is  treated  by  stimulants 
and  inhalation  of  oxygen,  and  possibly  artificial  respiration.  Shock,  delirium 
tremens,  urinary  retention,  etc.,  are  treated  according  to  the  ordinary  rules  of 
surgery. 

Functional  Result  of  Non-operative  Treatment. — Union  with  a  good  anatom- 
ical result  means  a  good  functional 
result  in  over  90  per  cent,  of  the 
cases.  We  used  to  suppose  that  a 
good  functional  result  is  usual  even 
with  a  poor  anatomical  result,  but 
Jones  ("Brit.  Med.  Jour.,"  Dec. 
7,  191 2)  shows  that  we  get  it  in 
less  than  30  per  cent,  of  cases  in 
which  the  anatomical  result  is  bad. 
Treatment  of  Compound  Frac- 
tures.— In  a  compound  fracture  of 
a  limb  the  first-aid  treatment 
consists  in  arresting  hemorrhage 
temporarily  by  the  elastic  band, 
painting  the  wound  and  the  skin  about  it  with  iodin,  packing  the  wound 
.and  covering  the  wound  with  sterile  gauze,  applying  a  temporary  splint  for 
transportation,  and  adopting  means  for  combating  shock.  During  transport 
it  may  be  necessary  to  administer  morphia  because  of  pain.  The  .T-rays  are  of 
great  value  in  determining  the  condition  of  the  bones  in  a  crushed  part. 
Thorough  examination  and  satis- 
factory disinfection  require  the 
giving  of  ether,  then  the  surgeon 
can  determine  whether  or  not 
amputation  is  necessary.  The 
question  is  sometimes  deter- 
mined by  the  age  and  general 
health  of  the  patient.  When  in 
•doubt  and  the  patient  is  a 
healthy  young  person,  give  the 

limb  the  benefit  of  the  doubt,  and  wait.  It  is  needless  to  say  that  amputation 
is  demanded  when  the  limb  is  completely  crushed  or  pulpified  through  its  entire 
thickness.  If  the  artery  alone  is  ruptured,  cut  down  upon  it  and  tie  both  ends. 
If  the  vein  alone  is  torn,  suture  it,  apply  a  lateral  ligature,  or,  if  necessary, 
tie  both  ends.     If  the  nerve  is  severed,  suture  it.     If  a  joint  is  opened,  drain 


Fig.  315. — Fracture-hook  applied   at   base  of 
acromion  process  (McBurney  and  Dowd). 


Fig.  316. — Fracture-hook  inserted  in  displaced 
fragment  (McBurnej^  and  Dowd). 


6o6  Diseases  and  Injuries  of  the  Bones  and  Joints 

and  asepticize.  W.  L.  Estes  ("Jour.  Amer.  Med.  Assoc.,"  1914,  Ixii),  from  an 
experience  of  800  cases  reaches  the  following  important  and  specific  conclusions 
as  to  the  indications  for  amputation. 

1.  If  the  skin  has  been  so  crushed  or  torn  that  it  is  obvious  that  at  least  three- 
fourths  of  the  skin  of  the  periphery  and  over  the  fracture  will  slough — amputate. 

2.  If  the  entire  periphery  of  the  limb  at  or  near  the  site  of  fracture  has  been 
subjected  to  a  destructive  circular  or  annular  pressure — amputate. 

3.  If  there  is  much  annular  laceration  of  the  skin  and  the  muscles  are  also 
badly  crushed  or  torn — amputate. 

4.  If  the  limb  has  been  subjected  to  immense  pressure  (as  by  a  car  wheel)  and 
the  skin  though  intact,  so  completely  cut  off  from  nourishment  that  its  doom 
is  sealed,  the  muscles  torn  and  the  bone  comminuted — amputate. 

5.  A  nerve  trunk  can  usually  be  sutured.  If  the  chief  blood-vessels  are  torn 
across  in  the  usual  jagged  way  either  anastomosis  or  transplant  will  be  useless, 
and  the  surgeon  should  amputate. 

6.  If  the  comminution  is  so  extensive, that  the  fragments  be  free  and  stripped 
of  periosteum  and  the  condition  would  demand  the  sacrifice  of  3  inches  or  more 


Fig.  317. — Fenestrated  plaster-of-Paris  dressing.     Drainage-tube  pulled  through  limb 
If  Dakin's  fluid  is  used  this  drainage  is  not  employed. 

of  the  shaft,  and  if  (as  is  almost  sure  to  be  the  case)  there  are  extensive  lacerations 
of  muscles  and  skin — amputate. 

If  an  attempt  is  made  to  save  the  limb,  be  ready  at  any  time  to  amputate 
for  gangrene,  secondary  hemorrhage  (if  religation  at  original  point  and  compres- 
sion high  up  fail),  extensive  cellulitis,  and  profuse  and  prolonged  suppuration.^ 
When  it  is  determined  to  try  to  save  the  limb,  the  part  must  be  cleansed 
thoroughly  by  the  antiseptic  method  (in  no  injuries  is  this  more  important). 
If  a  small  portion  of  bone  protrudes,  cleanse  the  skin  of  the  extremity  and  the 
protruding  bone,  push  the  spicule  out  a  little  more,  and  cut  it  off.  If  a  large 
piece  of  bone  is  protruded  it  must  not  be  cut  away,  but  should  be  thoroughly 
disinfected,  and  after  the  skin  wound  has  been  enlarged  should  be  returned  into 
place.  Hemorrhage  requires  a  free  incision  to  permit  of  ligation  of  bleeding 
points.  In  comminuted  fractures  loose  splinters  should  be  removed.  Attached 
splinters  covered  by  periosteum  should  not  be  removed.  To  remove  them  favors 
non-union.  Personally  I  seldom  use  bone  plates  in  compound  fractures.  All 
hopelessly  lacerated  tissue  is  cut  away,  the  wound  is  left  wide  open  or  is  par- 
tially sutured  and  Dakin's  fluid  is  used  (page  329).  In  some  cases  a  counter- 
opening  must  be  made  and  the  Dakin's  fluid  used  as  shown  in  Fig.  151.     If 

^See  Howard  Marsh,  on  "Fractures,"  in  Heath's  "Dictionary  of  Practical  Surgery." 


Treatment  of  Compound  Fractures 


607 


circumstances    do    not  admit   of  using   the  Carrel-Dakin  treatment  make  a 
counteropening  and  pass  a  drainage-tube  through  the  Umb  (Fig.  317). 

An  antiseptic  dressing  is  applied,  and  the  extremity  is  either  subjected  to 
extension  or  dressed  with  plaster.  The  plaster  can  be  applied  over  a  narrow 
strip  of  wood,  trap-doors  or  fenestra  being  cut  in  the  plaster  before  it  sets  (the 
fenestrated  splint).     The  wound  is  then  covered  with  gauze  and  a  bandage. 

The  bracketed  splint  is  a  better  dressing  than  the  one  just  described.  After 
the  wound  has  been  dressed  with  gauze,  plaster  is  at  once  applied  over  the  ends 
of  brackets  (Fig.  318).  For  fractures  of  the  femur  or  the  bones  of  the  leg  we  may 
use  a  Thomas  traction  splint  or  the  Balkan  frame,  sling  and  weights  (Fig. 
326).  For  the  leg  a  Hodgen  splint  is  satisfactory,  the  knee  being  slightly  bent 
(Fig,  325).  In  some  fractures  of  the  humerus  use  suspension  and  traction.  In 
others  use  a  Thomas  spHnt  (Figs.  346  and  348).  Some  fractures  of  the  forearm  are 
treated  by  the  Thomas  splint,  others  by  suspension,  traction,  and  counter-exten- 
sion. The  above  methods  not  only  immobilize  the  fractured  bones,  but  keep  the 
parts  aseptic  and  afford  easy  access  to  the  wound.  If  drainage-tubes  are  used  they 
are  usually  removed  if  suppuration  does  not  occur  in  from  forty-eight  to  seventy- 
two  hours.  The  wound  is  treated  as  any  other  wound.  In  some  compound  frac- 
tures it  is  found  difficult  or 
impossible  to  retain  the  f  rag- 
men ts  in  apposition  by 
splints  or  extension  (lower 
end  of  femur,  upper  third  of 
femur).  In  such  cases  the 
ends  of  the  bone  should  be 
resected  and  the  bones 
should  be  fastened  together 
as  in  a  case  of  ununited  frac- 
ture, with  silver  wire,  alumi- 
num wire,  chromicized  cat- 
gut, kangaroo-tendon,  or  the  bones  should  be  plated.  In  a  compound  fracture  of 
the  patella,  after  free  incision  and  disinfection,  investigate  to  determine  the  gravity 
of  the  injury.  In  an  ordinary  case  in  which  there  are  two  or  three  fragments, 
open  the  joint,  irrigate  with  saline  fluid,  drill  the  fragments,  and  fasten  them 
mth  silver  wire.  Very  small  fragments  should  be  removed.  The  wound  is 
partially  sutured,  Carrel's  tubes  are  inserted,  dressings  are  applied,  the  limb  is 
immobilized  in  extension,  and  Dakin's  fluid  is  used.  In  a  case  of  severe  com- 
pound comminuted  fracture  of  the  patella,  after  disinfection,  any  completely 
loose  piece  should  be  removed  and  ''the  remaining  portions  made  smooth  with 
bone  forceps  and  the  sharp  spoon. "^  The  wound  is  only  partially  sutured, 
Carrel's  tubes  are  inserted,  dressings  are  applied,  the  limb  is  placed  on  a  straight 
posterior  splint,  and  Dakin's  fluid  is  used.  If  a  fracture  of  a  rib  is  compound 
internally,  resect  the  rib;  if  it  is  compound  externally,  dress  antiseptically. 

Compound  fractures  may  be  followed  by  gangrene,  sloughing,  periostitis, 
septicemia,  pyemia,  osteomyelitis,  necrosis,  etc.  If  cellulitis  arises  after  a 
compound  fracture  open  freely,  remove  sloughs  and  employ  Dakin's  fluid  until 
suppuration  is  controlled.  Many  surgeons  have  been  opposed  to  suturing  after 
infection  of  a  compound  fracture.  Some  do  it.  Morison,  Good  and  others, 
when  suppuration  has  been  controlled,  proceed  as  foUows:  Cleanse  the  skin 
about  the  wound  and  also  the  wound.  Dry  the  wound.  Cover  the  wound  and 
fill  aU  pockets  and  bone  cavities  with  "bipp.''  Wring  out  gauze  in  liquid 
paraffin,  put  a  quantity  of  "  bipp  "  in  its  center  and  bring  the  gauze  in  contact 
with  the  entire  wound  surface.  Dressings  need  changing  only  in  from  5  to  15 
days.  The  infection  soon  becomes  entirely  local.  Then  the  skin  surfaces 
are  brought  toward  each  other  by  heavy  mattress  button  sutures  of  silk, 
coated  with  "bipp."  In  six  or  seven  days  much  will  be  gained  and  then  new 
^Lilienthal's  "Imperative  Surgery." 


Fig.  318. — Bracketed  plaster-of-Paris  dressing. 


6o8  Diseases  and  Injuries  of  the  Bones  and  Joints 

sutures  are  introduced  and  the  skin  edges  curve  nearer  together.  At  each 
seance  "bipp"  is  introduced  into  the  wound.  The  skin  will  require  undercut- 
ting to  prevent  inversion.  From  time  to  time  any  loose  bone  fragments  should  be 
removed.  (The  above  is  taken  from  the  "  International  Abstract  of  Surgery," 
Nov.  1918,  which  took  it  from  F.  B.  Gurd's  article  in  the  "Lancet,"  1918, 
cxciv.)  Gurd  treats  sinuses  by  passive  hyperemia.  If  that  fails,  he  excises 
the  scar,  cuts  awav  dead  bone,  introduces  "  bipp"  and  inserts  mattress  sutures 
(Ibid.). 

Operative  Treatment  of  Recent  Fractures. — Many  cases  are  now  operated 
upon  immediately  (within  ten  days  of  the  injury).  Others  are  operated  upon 
at  a  later  period  than  ten  days  after  the  injury  because  non-operative  methods 
fail  to  obtain  or  to  maintain  good  position  (delayed  operation).  In  some 
fractures  reduction  and  fixation  are  only  possible  by  operation. 

Skiagraphs  have  demonstrated  that  the  ordinary  non-operative  treatment 
is  often  followed  by  permanent  displacement.  In  many  cases  this  does  not 
seriously  impair  function,  in  not  a  few  it  does.  There  is  much  impairment 
of  function  after  fracture  of  the  patella  with  wide  gaping  of  the  fragments, 
and  after  fracture  of  the  femur  with  repair  in  a  position  of  marked  angulation 
or  decided  overlapping. 

The  most  perfect  results  are  obtained  by  operation,  which  exposes  the  frac- 
ture and  enables  the  surgeon  to  correct  the  deformity  and  fix  solidly  the  frag- 
ments. Practically  all  surgeons  agree  that  for  fracture  of  the  patella,  fracture 
of  the  olecranon,  and  fracture  of  a  long  bone  with  incomplete  reduction,  or  in 
which  deformity  recurs  in  spite  of  splinting,  operation  gives  the  best  chance  for 
a  good  functional  result.  In  most  fractures  of  long  bones  treated  conserva- 
tively perfect  apposition  of  the  fragments  is  not  obtained,  although  we  may 
think  it  has  been.  Bloodgood  points  out  that  in  fractures  near  joints  there  is 
great  difficulty  in  reduction  and  little  evidence  of  deformity. 

The  Special  Committee  of  Inquiry  of  the  British  Medical  Association  in  a 
recent  report  warmly  advocates  operation  in  many  cases.  Sir  Robert  Jones, 
of  Liverpool,  although  believing  as  a  general  rule  in  non-operative  treatment, 
says  that  if  in  any  case  there  is  sound  reason  to  doubt  the  successful  outcome  of 
non-  operative  treatment,  operation  should  be  performed.  He  opposes  waiting 
to  see  what  happens  because  the  delay  may  lose  the  chance  of  obtaining  a  good 
functional  result  ("Brit.  Med.  Jour.,"  Dec.  7,  1912). 

Personally,  I  follow  Sir  Robert  Jones's  rule  and  operate  when  I  fear  that  con- 
servative treatment  may  fail.     I  operate  primarily  for: 

Fractures  that  cannot  be  well  reduced  or  which  cannot  be  kept  reduced. 
Many  fractures  about  joints  are  of  this  character. 

Fractures  in  which  crepitus  cannot  be  obtained  because  soft  parts  are  caught 
between  the  fragments. 

Fracture  of  the  patella. 

Fracture  of  both  bones  of  the  leg  in  the  lower  third. 

Most  fractures  of  the  os  calcis. 

Some  cases  of  Pott's  fracture. 

Most  cases  of  fracture  of  the  upper  third  of  the  femur. 

Some  fractures  of  the  neck  of  the  femur  in  the  young  and  middle  aged.^ 

Some  fractures  of  the  surgical  neck  of  the  humerus. 

Fractures  of  the  olecranon,  especially  those  in  which  the  upper  fragment  has 
rotated. 

Some  fractures  of  the  elbow-joint. 

Some  fractures  of  both  bones  of  the  forearm  (in  order  to  preserve  pronation 
and  supination). 

Some  fractures  of  the  metacarpus. 

Fractures  of  the  zygoma. 

Some  fractures  of  the  mandible. 


Treatment  of  Fractures 


609 


Fractures  of  the  clavicle  when  complete  reduction  is  impossible  or  when 
sharp-pointed  fragments  threaten  to  pierce  the  skin  or  damage  important 
structures. 

In  cornpound  fractures  and  in  many  comminuted  fractures  operation  is  neces- 
sary. If  in  any  case  of  fracture  an  important  nerve  or  blood-vessel  has  been 
divided  an  operation  is  necessary  to  arrest  hemorrhage,  to  treat  traumatic 
aneurysm,  or  to  perform  nerve-suture. 

Most  children  are  manageable  by  conservative  methods  and  do  not  do  as 
well  as  adults  after  operation.  Hence  in  children  I  am  more  conservative  than 
in  adults. 

Again,  do  not  forget  that  operation  may  not  give  a  good  functional  result. 
It  often  fails  to  do  so.  If 
this  is  not  well  understood 
both  the  surgeon  and  pa- 
tient may  be  disappointed 
after  operation.  There  is,  of 
course,  some  risk  in  the  treat- 
ment by  incision,  and  it  is 
only  justifiable  in  competent 
hands  and  amid  proper  sur- 
roundings. The  occasional 
operator  should  look  to  it 
with  less  confidence  than 
the  daily  operator.  If  in- 
fection occurs  it  will  be  a 
catastrophe,  and  may  cause 
death,  hence  perfect  asepsis 
is  required  imperatively. 
Operation  for  recent  frac- 
tures can  never  be  routine 
treatment  and  will  never  be 
extensively  employed  outside 
of  a  hospital. 

If  operation  is  determined 
upon  the  best  period  to  select, 
unless  some  grave  complica- 
tion calls  for  haste,  is  from 
seven  to  ten  days  after  the 
accident.  x\n  incision  is 
made,  the  bone  is  inspected, 
tissue  intervening  between 
the  fragments  is  removed, 
and  the  fragments  are  co- 
aptated  and  fixed  by  screws 
and  a  perforated  plate,  by  silver  wire  sutures,  bone-ferrules,  chromic  catgut, 
nails,  some  form  of  clamp  or  an  autogenous  bone-graft. 

Plates  and  screws  are  used  by  many.  Wire  used  for  fracture  of  a  long  bone 
acts  as  a  hinge,  and  in  a  wired  fracture  the  alignment  is  apt  to  be  disturbed. 
Wire  was  first  used  for  this  purpose  in  1775  by  Lapeyode  and  Sicre,  of  Toulouse 
(Geo.  W.  Guthrie,  "Amer.  Med.,"  March  7,  1903).  It  is  now  seldom  used 
except  for  the  patella,  the  olecranon,  the  clavicle,  the  zygoma,  and  the  anatom- 
ical neck  of  the  humerus.  I  prefer  the  steel  plates  of  Arbuthnot  Lane  (Fig.  319) 
or  the  silver  plates  of  Halsted.  These  plates  are  perforated  for  screws.  The 
plate  is  not  removed  unless  it  loosens  or  gives  trouble.  iVf  ter  operation  the  ex- 
tremity must  be  carefully  fixed  by  splints  or  plaster  of  Paris;  the  circulation 
must  be  watched,  guarded,  and  maintained;  massage  should  be  used  and  pas- 
39 


Fig.  319. — Lane's  vanadium  steel  plates. 


6io 


Diseases  and  Injuries  of  the  Bones  and  Joints 


sive  motion  be  employed  as  in  a  case  treated  by  the  non-operative  method.  If 
rigid  fixation  of  the  fragments  is  obtained  and  maintained  repair  will  usually 
occur  with  very  little  callus  formation.  Too  firm  approximation  may  be  followed 
by  so  httle  callus  formation  that  there  is  delayed  union  or  the  fracture  fails 
entirely  to  unite.  In  some  cases  the  screws  cause  bone  absorption  and  the  plate 
loosens.     Occasionally  necrosis  occurs.     I  agree  with  J.  B.  Lowman  ("Penn. 


MMIIlff        (^ 


Fig.  320. — Richter's  bone-drill  (pistol  grip). 


Med.  Jour.,"  191 5,  xix)  that  in  some  cases  plating  prevents  union.  Months 
after  operation  the  plate  may  be  found  to  be  loose  and  bent  and  the  break 
entirely  ununited. 

In  one  of  my  cases  of  fractured  femur  the  plate  broke.  Bone-grafting  is  a 
superior  method  unless  there  is  a  strong  tendency  on  the  part  of  the  fragments 
to  bend,  rotate,  or  override.  Then  a  plate  should  be  used.  Gallie  uses  a  plate 
of  boiled  bone  and  screws  of  bone  ("Canadian  Jour,  of  Med.  and  Surg.,"  1916, 

xxxix).  It  is  seldom  that  a 
plate  requires  removal  from  the 
humerus  or  femur.  It  not  un- 
usually requires  removal  when 
applied  to  more  superficial 
bones. 

Treatment  of  Delayed  Union 
and  Ununited  Fracture  (see  page 
782). — When  delayed  union  ex- 
ists, seek  for  a  cause  and  remo»ve 
it,  treating  constitutionally  if 
required,  and  thoroughly  im- 
mobilizing the  parts  by  plaster. 
Orthopedic  splints  may  be  of 
value.  Use  of  the  limb  while 
splinted,  percussion  over  the 
fracture,  with  a  rubber  hammer, 
and  rubbing  the  fragments  to- 
gether, thus  in  each  case  pro- 
ducing irritation,  have  all  been 
recommended.  Blistering  the 
skin  with  iodin  or  firing  it 
has  been  employed.  Buechner  advocates  the  induction  of  hyperemia  by  a 
constricting  band,  just  as  Bier  induces  congestive  hyperemia  in  treating 
tuberculous  areas.  At  first  the  constriction  is  permitted  to  remain  but  a 
short  time,  but  the  period  is  lengthened  every  day,  until  in  a  few  days  it 
remains  almost  continuously  day  and  night.  It  is  to  cause  a  pinkish-blue 
flush  of  skin,  but  not  pain.  The  limb  must  be  warm  to  the  touch.  During 
the  two  or  three  hours  daily  that  the  band  is  off  raise  the  limb  to  relieve  edema. 
Ten  days  of  this  treatment  will  inaugurate  union  in  some  cases.     Helferich 


Fig.  321. — Compound  fracture  of  the  tibia  and 
fibula.  The  Thomas  splint  is  supported  by  a  bracket 
in  order  to  suspend  the  leg.  Continuous  irrigation 
apparatus  and  bandage  drains  are  in  use  (Hull). 


Treatment  of  Fractures 


6ii 


of  Greifswald  devised  this  method  in  1887.  In  several  cases  I  have  thought  that 
it  did  good.  I  also  administered  thyroid  extract  to  these  patients.  Lanne- 
longue  and  Menard  inject  a  1:10  solution  of  zinc  chlorid  between  the  frag- 
ments. I  have  had  several  successes  with  this  plan.  Leaving  acupuncture 
needles  in  for  days  is  approved  by  some,  and  electropuncture  is  advocated  by 


Fig.  322. — Thomas  traction  leg  splint  (Osgood). 


Others.  Lisowskaja  takes  a  piece  of  periosteum  from  the  tibia,  cuts  it  into 
small  bits,  puts  them  into  normal  salt  solution  and  injects  the  mixture  between 
the  fragments.  Kauffer  makes  a  mixture  of  pulverized  bone  and  sterile  petro- 
latum and  injects  it  between  the  fragments.     If  the  union  be  very  long  delayed, 


Fig.  323. — Blake-Keller  hinged  half  ring  modification  of  Thomas  traction  leg  splint  (Osgood). 


forcibly  separate  the  fragments  and  put  up  the  limb  in  plaster  as  we  would  a 
fresh  break.  If  these  means  fail,  irritate  by  subcutaneous  drilling  or  scraping, 
or,  better,  by  laying  open  the  parts  and  then  drilling  and  scraping  at  many  places. 
Cases  of  ununited  fracture  must  be  treated  by  excision  of  the  bony  ends  and 
fibrous  tissue,  securing  the  fragments  together  by  periosteal  sutures,  by  pins,  by 
screws  and  plates,  by  ivory  pegs,  by  screws,  by  silver  or  aluminum  bronze  wire, 


6l2 


Diseases  and  Injuries  of  the  Bones  and  Joints 


by  kangaroo-tendon,  by  Senn's  bone-rings  or  bone-ferrules,  by  chromicized  catgut 
or  by  a  bone  graft.     I  have  used  extensively  Halsted's  plates  of  silver  and  Lane's 


b 


enHgp 


d 


Fig.  324. — Cabot  posterior  wire  splint  (a)  in  skeleton,  (b)  bandaged,  (c)  applied  with 
side  splints  of  ladder  material;  {d)  ladder  splint  material  (Osgood).  This  is  very  useful  for 
transport. 


Fig. 


325- 


-Modified  Hodgen's  splint. 


plates  of  vanadium  steel.     Delorme  makes  an  incision,  removes  bone-splinters 
and  fibrous  tissue,  smooths  off  one  end,  forces  this  into  the  bored-out  medullary 


Treatment  of  Fractures 


613 


canal  of  the  other  fragment,  and  sutures  the  periosteum.  Gussenbauer's  clamp 
will  often  give  a  good  result,  and  was  used  for  years  by  Billroth.  This  is  a 
metal  Ijar  with  two  nails  set  at  right  angles  to  the  bar.  One  nail  is  driven  into 
each  fragment.  Langenbeck  fixed  a  screw  into  each  fragment  and  connected 
the  screws  by  a  piece  of  iron.     Parkhill's  clamp,  which  is  an  improvement  on 


Fig. 


-Frame  for  suspension  and  extension. 


useful 


Langenbeck's  instrument,  secures  absolute  immobility  and   is  a  very 
instrument. 

Sometimes  union  fails  in  spite  of  a  formidable  operation.  In  such  cases  there 
is  no  tendency  to  bone  production.  A  bone-graft  may  be  partially  separated 
from  one  of  the  fragments  and  interposed  between  the  freshened  ends,  a  bone- 
graft  may  be  taken  from  the  sound  tibia  and  be  interposed  (Albee's  Method), 


Fig.  327. — Lowman-Lambotte  bone-holding  forceps. 


fresh  bone-splinters  may  be  interposed,  or  a  portion  of  a  rib  may  be  used  with 
screws  or  nails  as  a  clamp.  It  is  always  desirable  to  take  the  bone-graft  from 
the  individual.  Such  a  graft  is  more  powerfully  stimulating  to  bone  growth 
than  a  graft  from  another  individual  or  from  one  of  the  lower  animals.  Tran.s- 
plantation  from  the  lower  animals  has,  however,  been  successfully  practised 
(see  page  574).     Albee  believes  that  in  a  recent  fracture  Lane's  plates  fulfil 


6i4 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  328. 


-Lowman's  combination  bone  and  plaLc 
holder. 


the  indications  but  in  an  ununited  fracture  they  do  not,  because  in  the  latter 
there  is  lessened  osteogenetic  activity.  The  bone-graft  fixes  the  fragments, 
stimulates  osteogenetic  activity,  furnishes  a  scaffold  for  bone  growth,  and  also 
grows  bone  itself.     For  further  remarks  on  operation  see  page  782. 

Treatment  of  Vicious  Union. — If  angular  deformity  results  from  faulty  union, 
it  can  be  corrected  by  molding  the  part  into  shape  while  the  callus  is  soft.  If 
the  callus  has  become  hard,  the  bone  can  be  refractured.  If  faulty  union  occurs 
with  overriding,  an  osteotomy  can  be  performed. 

Gunshot  Fractures. — Of  course 
simple  fractures  occur  in  war,  but 
they  present  nothing  peculiar. 
Compound  fractures  are  extremely 
common  and  are  frequently  fatal. 
We  have  already  set  forth  the 
difiference  between  a  bone  wound 
and  a  gunshot  fracture  (page  586). 
Leriche  points  out  that  a  missile 
may  fracture  a  bone  (impact),  may 
fracture  it  and  lodge  (penetration), 
may  fracture  it  and  pass  through 
(perforation).     Gunshot  fractures 

are  regarded  as  certainly  infected  except  some  fractures  due  to  rifle  or 
shrapnel  bullets,  infection  being  brought  about  by  a  contaminated  projectile  or 
by  a  bit  of  clothing  or  other  foreign  ,body  which  was  carried  in.  Bits  of 
clothing  are  particularly  apt  to  be  carried  in  by  shell  fragments.  All  sorts 
of  breaks  may  occur.  Comminution  is  the  rule,  except  in  fractures  by  impact. 
A';  rifle  bullet  striking  a  point  ahead  is  apt  to  split  a  bone,  but  it  may  only 
cause  comminution.  A  rifle  bullet  striking  side  on  causes  comminution  like  a 
shell  fragment.  In  fractures  due  to  shell  fragments  the  bone  is  comminuted 
extensively  and  the  soft  parts  are  badly  damaged  and,  as  Blake  and 
others  point  out,  the  tissues  for  some  distance  wide  of  the  lacerations  are 
in  a  state  of  lowered  vitality  because  of  tissue  shock. 
Military  surgeons  dwell  on  the  frequency  with  which  bone 
fragments  are  driven  widely  before  the  missile,  causing 
pulpification  of  muscle  and  perhaps  a  huge  wound  of 
exit. 

Blake  ("Gunshot  Fractures  of  Extremities")  says  that 
in  many  thigh  fractures  in  which  the  wounds  of  entrance 
and  of  exit  are  small,  incision  makes  evident  a  great  area 
of  pulpy   muscle,  strewn  with  bone  fragments.     In  shell 

wounds  the  bones  and 
soft  parts  are  damaged 
more  gravely  than  is 
commonly  seen  in  the 
compound  fractures  of 
civil  life.  A  great  deal 
of  tissue  is  not  quite 
Such  tissue  serves  as  a  luxurious  breeding 


43!nnn! 


4S!ny|Mniiini|iniiiiiiii 
<■ 34  - 


Fig.  329. — Sherman's  bone  bolts  and  nut-driv^er. 


dead 
place 


but  is  on  the  verge  of  death. 

for  bacteria.  Captain  Basil  Hughes,  R.  A.  M.  C,  calls  attention  to  the 
facts  that  amputation  performed  through  such  tissue  does  not  cause  pain,  and 
that  the  use  of  a  rubber  tourniquet  or  the  application  of  a  powerful  antiseptic 
causes  the  death  of  such  decadent  tissue  ("Brit.  Med.  Jour.,"  March  3,  191 7). 

Bits  of  clothing  and  other  foreign  bodies  are  apt  to  be  carried  into  the 
tissues.  Infection  is  inevitable.  Compound  fractures  are  very  common  from 
shell  wounds.  In  shell  wounds  the  bones  and  soft  parts  are  damaged  more 
gravely  than  is  commonly  seen  in  the  compound  fractures  of  civil  life.  A  great 
deal  of  tissue  is  not  quite  dead  but  is  on  the  verge  of  death.  Such  tissue  serves 
AS  a  luxurious  breeding  place  for  bacteria. 


Fractures  of  the  Nasal  Bones  615 

The  wounded  man  is  gravely  shocked  and  is  predisposed  to  infection  because 
of  this  damaged  tissue  and  his  fatigue  and  exposure.  Transportation  is  a  great 
strain  and  radical  treatment  may  be  long  deferred. 

Usually  at  the  hrst-aid  station  iodin  is  painted  on  the  parts,  an  antiseptic 
dressing  is  apphed,  the  limb  is  fixed  in  an  emergency  splint  and  antitetanic 
serum  is  given.  A  large  T  is  written  on  the  forehead  with  iodin  or  an  anilene 
pencil  to  show  that  antitoxin  has  been  given.  A  tourniquet  is  not  to  be 
applied.  Few  persons  will  bleed  to  death  for  want  of  it.  Many  would  develop 
gangrene  were  it  used.  The  patient  is  then  transported  to  the  rear.  Attempts 
at  immediate  sterihzation  have  not  been  successful.  This  is  a  notable  contrast 
to  the  South  African  war  in  which  such  treatment  proved  very  serviceable. 
Radical  operation  must  be  done  at  the  first  possible  moment.  In  trench  warfare 
it  may  be  possible  to  apply  it  at  the  first  dressing  station.  It  may  be  done  at 
the  field  hospital,  at  the  evacuation  hospital,  or  in  some  unfortunates,  at  the 
base  hospital.  The  rule  should  be  to  do  it  at  the  earhest  possible  minute. 
The  danger  of  gas  gangrene,  tetanus,  sepsis,  is  intensified  by  every  minute 
of  delay.  During  transportation  pulmonary  embolism  may  arise,  there  mav 
be  hemorrhage,  shock  may  be  aggravated,  insecurity  of  fixation  may  lead 
to  tearing  of  the  tissue  by  the  bone-ends  and  to  the  dissemination  of  infection 
(Hughes,  Ibid.).  Some  cases  require  immediate  amputation.  Most  cases  in 
which  tourniquets  were  in  use  for  a  considerable  time  require  amputation 
(Hughes,  Ibid.).  The  treatment  for  the  average  case  which  does  react  from 
shock  is,  give  an  anesthetic,  shave  the  sk-in,  clean  the  parts  with  gasolene 
and  paint  with  iodin.  Make  a  free  incision,  remove  foreign  bodies,  remove 
T^one-fragments  which  are  entirely  loose  or  which  are  stripped  of  periosteum 
and  excise  freely  damaged  tissue.  The  wound  is  left  open.  It  is  not  the 
custom  to  close  compound  fractures  without  drainage.  Tubes  are  inserted 
Dakin's  fluid  is  introduced,  dressings  are  applied  and  the  limb  is  imm.obihzed  in 
the  form  of  splint  obtainable  and  best  suited  to  the  case.  Suspension  with  ex- 
tension is  praised  by  many  surgeons  (Fig.  326).  Some  prefer  plaster.  The 
special  splints  are  legion.  A  treatise  is  necessary  to  discuss  gunshot  fractures 
and  that  treatise  must  be  written  by  a  mihtary  surgeon.  Figs.  321,  322,  323, 
324,  325^  346,  347,  348,  349,  35°,  35^  show  some  of  the  many  apparatuses 
employed.  In  fractures  through  or  near  the  hip-joint  the  abduction  frame  of 
Major  Robert  Jones  is  most  satisfactory  (Fig.  403).  In  other  fractures  of  the 
femur  and  in  fractures  of  the  leg  the  Thomas  sphnt  is  the  appliance  preferred 
by  many.  The  desirable  treatment  is  Carrel's  method.  In  some  cases  the 
exigencies  of  the  situation  restrict  the  treatment  to  free  drainage  and 
immobilization. 

Special  Fractures. — Nasal  bones,  because  of  their  situation,  are  often 
broken.  The  commonest  seat  of  fracture  is  through  the  lower  -third,  where 
the  bones  are  thin  and  lack  support.  The  fracture  is  usually  compound  exter- 
nally or  through  the  mucous  membrane  internally.  There  may  be  a  transverse 
fracture  or  a  comminuted  fracture.  The  cause  is  direct  violence.  Dis- 
placement may  not  occur  at  all,  but  when  present  at  once  after  injury  it  arises 
primarily  from  force,  and  never  from  muscular  action,  no  muscle  being  attached 
to  these  bones.  If  the  force  is  from  the  front,  the  nose  is  flattened;  if  from  the 
side,  it  is  deflected.  Manipulation,  blowing  the  nose,  or  sneezing,  may  cause  or 
add  to  displacement.  In  a  transverse  fracture  the  lower  fragment  is  driven 
backward  so  it  may  drive  back  the  quadrangular  cartilage  and  "the  cartilage 
may  be  fractured,  bent  or  dislocated  from  its  attachment  to  the  upper  border  of 
the  muscle,  or  its  lower  angle  may  be  torn  loose  from  the  membranous  portion 
of  the  septum,  or  from  its  connection  with  the  maxillary  bones  at  the  anterior 
end  of  the  vomer"  (Fractures  by  Roberts  and  Kelly).  Side  blows  may  luxate  , 
■one  or  both  nasal  bones.  A  blow  from  in  front  may  luxate  one  or  both  bones 
from  the  frontal  bone.     Displacement  is  soon  masked  by  swelling.     Crepitus 


6i6 


Diseases  and   Injuries  of  the  Bones  and  Joints 


can  sometimes  be  elicited  by  lightly  grasping  the  upper  part  of  the  nose  with  the 
fingers  of  one  hand  and  moving  it  gently  below  from  side  to  side  with  the 
fingers  of  the  other  hand.  Preternatural  mobility  is  valueless  as  a  sign, 
because  of  the  natural  mobility  of  the  cartilages.  Nose-breathing  is  difficult 
because  of  blocking  of  the  nostrils  by  blood-clot.  When  deformity  is  absent, 
diagnosis,  except  by  the  ;v-rays,  may  be  almost  impossible. 

The  complications  that  may  be  noted  are  cerebral  concussion,  brain  symp- 
toms from  implication  of  the  frontal  bone  or  cribriform  plate  of  the  ethmoid 
bone,  and  extension  of  the  fracture  to  the  superior  maxillary  or  lachrymal  bones. 
The  vomer  or  the  nasal  spine  of  the  frontal  may  be  broken.  Emphysema 
of  the  root  of  the  nose,  the  eyelids,  and  the  cheeks  is  common,  and  means 
either  a  rent  in  the  mucous  membrane  of  Schneider  or  a  crack  in  the  frontal 
sinus.  There  may  be  much  discoloration  because  of  subcutaneous  hemor- 
rhage. Epistaxis  is  usual,  and  is  distinguished  from  the  epistaxis  produced 
by  fracture  of  the  base  of  the  skull  by  the  facts  that  the  bleeding  in  the  first 
condition,  although  profuse,  is,  as  a  rule,  soon  checked,  and  is  not  followed  by 
oozing  or  cerebrospinal  fluid, whereas  in  the  second  condition  it  is  profuse,  con- 
tinued, and  is  perhaps  followed  by  a  flow  of  cerebrospinal  fluid.  Fracture  of 
the  bony  septum  occasionally  complicates  nasal  fractures,  and  deviation  of  the 
cartilaginous  septum  often  takes  place.  Suppuration  may  occur  and  necrosis 
of  bone  or  cartilage  may  follow.  The  prognosis  is  usually  good  if  reduction 
is  accomplished  early.     Fixation  occurs  soon. 

Treatment. — Whenever  possible  nasal  fractures  should  be  treated  by  a  rhinolo- 
gist.  After  cocainizing  the  nares  a  careful  inspection  should  be  made  by  means  of 
a  mirror  and  a  light  to  determine  whether  or  not  there  is  any  injury  of  the  sep- 
tum. This  point  must  be  determined  in  order  that  the  deformity  of  the  sep- 
tum may  be  corrected  at  the  same  time  as  the  deformity  of  the  nasal  bones. 
When  there  is  no  displacement,  or  when  a  displacement  does  not  tend  to  be 
reproduced  after  reduction,  employ  no  retentive  apparatus  of  any  kind.  Order 
the  patient  not  to  blow  his  nose  for  ten  days  and  syringe  it  daily  with  a  solu- 
tion of  bicarbonate  of  sodium.  If  deformity  be  noted,  correct  it  at  once,  as  the 
bones  soon  unite  in  deformity.  If  the  attempts  at  reduction  are  very  painful, 
or  if  the  subject  be  a  child,  a  woman,  or  a  nervous  man,  give  ether  to  obtain 
primary  anesthesia.  Reduction  is  effected  by  a  grooved  director  or  steel  knit- 
ting-needle wrapped  in  iodoform  gauze  and  passed 
into  the  nostril;  the  fragments  are  lifted  with  this 
instrument,  and  the  fingers  externally  mold  them 
into  place.  A  rubber  dilator  can  be  used  in  re- 
duction. This  is  pushed  into  the  nose  and  inflated 
by  air  or  water.  If  the  septum  is  deviated  and 
cannot  be  pushed  in  place  by  a  metal  sound,  it  must 
be  twisted  into  place  by  means  of  septum  forceps. 
If  bleeding  is  moderate,  check  it  with  cold;  if  severe, 
by  plugging.  "For  fractures  high  up  with  dis- 
placement, gauze  packing  carried  well  up  will  be 
required  to  retain  the  elevated  bones.  For  lower 
deviations  the  Asch  tube  will  be  needed"  (Scudder, 
on  "The  Treatment  of  Fracture").  A  hollow  vul- 
canite plug  is  inserted  in  each  nostril  and  the  nose  is 
molded  into  correct  shape  over  the  plug.  The 
patient  breathes  through  the  hollow  plug.  A  thread  runs  from  each  plug  and 
is  fastened  to  the  cheek  by  adhesive  plaster.  Once  or  twice  a  day  the 
plugs  are  removed,  cleaned,  and  greased  with  iodoform  ointment.  The  nose 
is  cleared  and  the  plugs  are  reinserted.  If  flattening  tends  to  recur,  pass  a 
Mason  pin  (Fig.  330)  just  beneath  the  fragments,  through  the  line  of  fracture 
and  out  the  opposite  side.     Steady  the  fragments  by  a  piece  of  rubber  externally" 


Fig.  330. — -Mason's  pin. 


Fractures  of  the  Superior  Maxillary  Bone  617 

caught  on  each  end  of  the  pin,  or  with  figurc-of-8  turns  around  the  ends  with 
silk.  Leave  the  pin  in  place  for  five  days.  The  instrument  of  Mason  is  a  sharp, 
strong,  nickel-plated  pin,  with  a  triangular  point. 

If  lateral  deformity  tends  to  recur,  hold  a  compress  over  the  fracture  or 
fix  a  molded-rubber  splint  over  the  nose  by  a  piece  of  rubber  plaster  i}<^  inches 
broad  and  long  enough  to.  reach  well  across  the  face,  and  use  compression  for 
ten  days.  In  neither  of  the  above  cases  is  the  nose  to  be  blown,  and  in  both 
cases  it  is  to  be  syringed  once  or  twice  a  day.  In  fractures  rendered  compound 
by  tears  in  the  mucous  membrane,  irrigate  with  normal  salt  solution  or  boric 
acid  solution,  holding  the  head  so  that  the  solution  will  not  run  into  the  mouth; 
plug  with  iodoform  gauze  around  a  small  rubber 
catheter,  which  instrument  permits  nose-breath- 
ing; carefully  remove  the  gauze  daily  and  syringe. 
In  fractures  compound  externally  cleanse  ex- 
ternally, antisepticize  with  iodin,  and  dress 
with  a  film  of  cotton  soaked  in  iodoform  col-  Fig.  331. — Jones's  nasal  splint. 
lodion   or    compound    tincture     of     benzoin,    or 

apply  sterile  gauze.  Fractures  of  the  bony  septum,  if  showing  a  tendency 
to  reproduction  of  deformity,  require  packing  as  above  explained,  or  the  use 
of  a  special  splint  within  the  nostrils  (Fig.  331),  or  the  application  of  vulcanite 
plugs,  so  made  that  the  patient  can  breathe  through  them  and  threads  can  be 
attached  to  them.  Fractures  of  the  nasal  cartilages  are  to  be  pinned  in  place. 
Fractures  of  the  nose  are  entirely  united  in  from  ten  to  twelve  days.  If  an 
unreduced  fracture  unites  in  deformity  osteotomy  and  refracture  is  the  only 
resource.  If  bone  and  cartilage  are  involved  in  a  lateral  deformity  the  septum 
is  usually  deviated.  In  such  a  case  a  septal  deviation  should  be  amended 
by  submucous  resection  and  the  cartilage  deviation  be  corrected  by  intranasal 
surgery. 

Fractures  of  the  Lachrymal  Bone. — The  lachrymal  bone  may  be  broken 
when  the  nasal  bones,  a  superior  maxillary  bone,  or  the  lateral  plate  of  the 
ethmoid  is  fractured,  and  union  is  solid  in  from  three  to  four  weeks.  The 
question  of  how  much  deformity  is  to  be  expected  is  always  uncertain,  and  in 
not  a  few  cases  obstruction  of  the  nose  follows  fracture  because  of  damage  to 
the  septum. 

Treatment. — Treat  the  chief  injury,  which  is  the  fracture  of  the  other  bone 
or  bones.  Maintain  the  patency  of  the  lachrymal  duct  by  frequently  pass- 
ing a  clean  probe. 

Fractures  of  the  Superior  Maxillary  Bone. — Although  a  fragile  bone,  the  su- 
perior maxillary  is  rarely  broken  except  through  the  alveolar  border.  It  may  be 
broken  by  transmitted  force  from  blows  on  the  chin,  or  on  the  head  when  the 
chin  is  fixed;  but  direct  violence  is  the  usual  cause.  The  walls  of  the  antrum 
may  be  crushed  in,  the  palatine  process  in  the  nasal  process  may  be  broken, 
transverse  fracture  may  occur,  there  may  be  intermaxillary  separation,  or  sepa- 
ration of  the  alveolar  process.  The  pterygoid  processes  are  seldom  broken. 
Comminution  may  exist.  Fracture  of  the  orbital  surface  is  a  not  uncommon  re- 
sult of  a  gunshot  wound.  If  the  causal  force  has  been  very  violent,  the  line  of  frac- 
ture may  extend  into  the  base  of  the  skull.  Comminution  is  the  rule,  and  the  injury 
is  often  compound.  These  fractures  induce  great  swelling,  pain,  asymmetry, 
and  inability  to  chew.  Mobility  and  crepitus  may  be  detected.  Deformity 
is  due  to  the  breaking  force,  and  not  to  the  action  of  any  muscle.  When  a  por- 
tion of  the  alveolar  arch  is  fractured,  as  may  occur  in  pulling  teeth,  the  small 
fragment  is  depressed  backward,  and  there  exist  irregularity  of  the  teeth  (some 
of  which  may  be  loosened)  and  inability  to  chew  food.  Fracture  of  the  nasal 
process  is  apt  to  injure  or  cause  pressure  upon  the  lachrymal  duct.  When  the 
antrum  is  broken  in  there  are  great  sinking  over  the  fracture,  depression  of  the 
malar  bone,  and  if  the  mucous  membrane  has  been  torn,  emphysema.     Transverse 


6i8 


Diseases  and  Injuries  of  the  Bones  and  Joints 


fracture  of  the  upper  part  of  the  body  of  the  bone  may  cause  no  deformity. 
The  force  required  to  break,  the  superior  maxillary  borne  is  so  great  that  frac- 
tures of  other  bones  almost  certainly  occur,  and  concussion  of  the  brain  not 
infrequently  exists.     Injury  of  the  infra-orbital  nerve  is  not  unusual,  causing 


Fig.  332. — Hard-rubber  splint;  wire  arms  and  chin-piece  held  together  by  metal  rods  and  nuts- 


pain,  numbness,  or  an  area  of  anesthesia  involving  one-half  of  the  upper  lip,  the 
ala  of  the  nose,  and  a  triangle  whose  base  is  one-half  the  upper  lip  and  whose 
apex  is  the  infra-orbital  foramen.  There  is  also  loss  of  sensation  in  the  gums 
and  upper  teeth  of  the  injured  side.  Orbital  fracture  causes  subconjunctival 
ecchymosis.     Fractures  of  the  superior  maxillary  bone  occasionally  induce 

fierce  hemorrhage  from  branches 
of  the  internal  maxillary  artery; 
and  if  this  has  happened,  be  on 
the  watch  for  secondary  hem- 
orrhage (these  vessels  being  in 
firm  canals) . 

Treatment. — If  the  fracture 
does  not  implicate  the  alveolus, 
or  if  no  deformity  exists,  apply 
no  apparatus,  but  feed  the  pa- 
tient on  liquid  for  four  weeks. 
Reduce  deformity,  if  it  exists, 
by  inserting  a  finger  in  the 
mouth.  If  the  antrum  is  broken 
in,  put  the  thumb  in  the  mouth 
and  push  the  malar  bone  up 
and  back.  In  certain  cases  of 
deformity  make  an  incision  at 
the  anterior  border  of  the 
masseter  muscle,  insert  a  ten- 
aculum or  aneurysm  needle,  and 
pull  the  bone  into  place  (Ham- 
ilton). If  the  malar  bone  or 
malar  process  is  driven  into  the 
antrum.  Weir  tells  us  to  incise 
the  mucous  membrane  above 
and  external  to  the  canine  tooth  of  the  upper  jaw,  break  into  the  antrum  with  a 
bone-gouge,  insert  a  steel  sound,  lift  out  the  malar  bone,  and  pack  the  antrum 
with  gauze.  Loose  teeth  are  not  to  be  removed;  they  are  pushed  back  into  place 
and  held  by  wiring  them  to  their  firmer  neighbors.     Hemorrhage  is  arrested 


ric.  2>3>2,- 


-Front  view  of  splint  (Fig.  332),  with  mouth 
closed  (Moriarty). 


Fractures  of  the  Zygomatic  Arch 


619 


by  cold  and  pressure.     If  hemorrhage  is  dangerously  profuse  or  prolonged,  tie 
the  external  carotid  artery. 

If  the  line  of  the  teeth,  notwithstanding  the  wiring,  is  not  regular,  mold  on 
an  interdental  splint.  The  usual  splint  for  the  upper  jaw  is  the  lower  jaw  held 
firmly  against  it  by  the  Gibson,  the  Barton,  or  the  four-tailed  bandage.  There 
is  a  great  amount  of  dribbling  of  saliva  during  the  treatment,  and  a  dressing  must 
be  used  to  catch  this  fluid.  Every  day  remove  the  bandage  and  dressing, 
and  wash  the  face  with  soap  and  water.  The  patient,  who  is  ordered  not  to 
talk,  is  to  live  on  liquid  food  administered  by  a  nasal  tube  or  by  pouring  it  into 
the  mouth  back  of  the  last  molar  tooth  by  means  of  a  tube  or  a  feeding-cup. 
Never  pull  a  tooth  to  obtain  a  feeding  space;  but  if  a  tooth  is  lost,  utilize  the 
vacant  space  for  this  purpose.  After  every  meal  wash  out  the  mouth  with 
peroxid  of  hydrogen,  followed  by  chlorate  of  potassium,  boric  acid,  or  normal 
salt  solution,  and  thus  prevent  foulness  and  the  digestive  disorders  it  may  induce. 
Dispense  with  the  dressings  in  four 
or  five  weeks,  and  let  the  patient 
gradually  return  to  ordinary  diet. 

In  fractures  compound  externally 
do  not  remove  fragments,  antisepticize 
by  dichloramin-T,  arrest  bleeding  as 
far  as  possible  by  Hgature,  by  pressure, 
or  by  plugging,  wire  the  fragments  if 
feasible,  dress  with  gauze,  and  wash 
the  mouth  with  great  frequency. 
Fractures  compound  internally  are 
treated  as  simple  fractures,  except 
that  the  mouth  is  washed  more  fre- 
quently. 

The  malar  bone  is  rarely  broken 
alone.  Hamilton  says  no  uncom- 
plicated case  is  on  record.  The 
malar  is  a  strong  bone  resting  on  a 
fragile  support,  and  hence  it  may 
become  a  wedge  to  break  other  bones 
and  yet  itseh  be  unfractured.  The 
cause  of  fracture  is  violent  direct 
force.  A  fracture  of  the  orbital  sur- 
face   of    this    bone    causes   subcon- 


FiG.    334. — Hard-rubber    splint    in    position, 
upper  teeth  resting  upon  it  (Moriarty). 


junctival  hemorrhage  like  that  encountered  in  fracture  at  the  base  of  the 
skull,  and  may  produce  irritation  of  the  infraorbital  nerve.  Protrusion  of  the 
eye  may  result  either  from  hemorrhage  or  from  crushing  in  of  the  malar  bone. 
There  is  a  hollow  below  and  to  the  outer  side  of  the  orbit.  Occasionally  the 
line  of  fracture  is  detectable,  but  mobility  and  crepitus  are  very  rarely  dis- 
coverable. Chemng  is  apt  to  cause  pain,  and  often  the  motions  of  the  lower 
jaw  are  limited,  the  coronoid  process  being  pressed  upon  by  a  depressed  malar 
bone,  an  associated  fracture  of  the  zygoma,  a  blood-clot,  or  swollen  tissue  (see 
Scudder,  on  "Treatment  of  Fractures"). 

Treatment. — If  no  deformity  exists,  there  is  practically  nothing  to  be  done. 
If  deformity  exists,  try  to  correct  it  as  in  fractures  of  the  superior  maxillary 
bone.  If  correction  is  impossible  by  ordinary  methods  and  the  movements 
of  the  lower  jaw  are  impeded  by  the  displaced  bone,  make  a  small  incision 
and  through  this  insert  an  instrument  and  endeavor  to  lift  the  bone  into  place. 
As  these  cases  are  almost  invariably  compHcated  by  fracture  of  the  upper  jaw, 
they  are  treated  in  the  same  manner  as  the  latter  injury.  The  union  is  com- 
plete in  three  weeks. 

Fractures  of  the  zygomatic  arch  are  very  rare.     The  causes  are:  (i)  direct 


620 


Diseases  and  Injuries  of  the  Bones  and  Joints 


violence;  (2)  indirect  force  (from  depression  of  the  malar),  and  (3)  forcing 
foreign  bodies  through  the  mouth.  Direct  violence  is  the  usual  cause.  Direct 
violence  causes  inward  displacement,  and  indirect  force  may  cause  outward 
displacement.  The  usual  seat  of  fracture  is  at  the  smallest  portion  of  the 
process — that  is,  on  the  temporal  side  of  the  temporomalar  suture  (Matas). 
The  symptoms  are  pain,  ecchymosis,  swelling  displacement,  and  difficulty  in 
moving  the  jaw  (because  of  injury  to  the  masseter  muscle). 

Treatment. — In  simple  fracture  give  ether  and  try  to  push  the  arch  in  place. 
Many  surgeons  do  not  make  an  incision,  as  depression  will  do  no  harm  and  the 
functions  of  the  jaw  will  be  restored.  Simply  dress  with  a  compress,  adhesive 
strips,  and  the  crossed  bandage  of  the  angle  of  the  jaw.  Union  will  take  place 
in  three  weeks.  Matas^  advises  operation.  An  anesthetic  is  administered 
and  the  parts  are  antisepticized.  A  long  semicircular  Hagedorn  needle  is 
threaded  with  silk,  is  entered  i  inch  above  the  middle  of  the  displaced  fragment, 
is  passed  well  into  the  temporal  fossa,  and  is  made  to  emerge  3^  inch  below  the 
arch.  The  silk  is  used  to  pull  a  silver  wire  around  the  fracture,  and  this  wire 
is  employed  to  pull  the  bone  into  position.  A  firm  pad  is  applied  externally  and 
the  wire  is  twisted  over  the  pad.  Antiseptic  dressings  are  applied,  and  on 
the  ninth  or  tenth  day  the  wire,  splint,  and  dressings  are  removed  permanently. 
I  have  employed  this  plan  in  2  cases  with  perfect  satisfaction. 

Fractures  of  the  inferior  maxillary  bone  (the  mandible)  may,  and  usually  do, 
involve  the  body,  although  they  occasionally  occur  in  the  rami.  Any  part  of  the 
body  may  be  fractured,  the  most  usual  seat  being  near  the  canine  tooth  or  a  little 
external  to  the  symphysis  (Pick).  A  portion  of  alveolus  may  be  broken  off.  In 
fractures  of  the  ramus  either  the  angle,  the  condyloid  neck,  or  the  coronoid  pro- 
cess may  be  broken.     In  fractures  of  the  body  the  posterior  fragment  generally 

overrides  the  anterior.  Fractures  of  the  lower 
jaw  are  often  multiple  and  those  of  the  hori- 
zontal portion  are  almost  always  compound, 
because  the  oral  mucous  membrane  and 
alveolar  periosteum  are  torn.  Fractures  of 
the  ramus  are  seldom  compound.  A  portion 
of  the  alveolus  may  be  broken  during  the 
extraction  of  teeth.  The  cause  is  usually 
direct  violence,  as  a  blow,  a  kick,  a  fall  or  a 
gunshot  wound.  Indirect  violence  (lateral 
pressure)  may  fracture  the  body  at  or  near 
the  symphysis.  Fractures  near  the  angle  are 
always  due  to  direct  violence.  Indirect 
violence  may  fracture  the  neck  of  the  con- 
dyle (falls  on  the  chin),  and  so  may  direct 
violence.  Fractures  of  the  coronoid  process 
are  very  rare,  and  they  arise  from  great 
direct  violence  (usually  a  gunshot  wound  or 
some  other  penetrating  force)  or  by  muscular 
action  (violent  contraction  of  the  temporal  muscle).  Comminuted  fractures 
are  rare.     Multiple  fractures  are  by  no  means  unusual. 

Symptoms. — In  fracture  of  the  body  preternatural  mobility  and  crepitus 
generally  exist.  The  gum  over  the  fracture  swells  rapidly  and  decidedly.  There 
is  bleeding  because  of  laceration  of  the  gum;  saliva  dribbles  constantly;  the 
patient  supports  the  jaw  with  the  hand;  great  pain  exists  (possibly  from  injury  of 
the  nerve),  and  deformity  is  present,  shown  by  inequality  of  the  teeth  if  the 
fracture  is  anterior  to  the  masseter,  the  anterior  fragment  going  downward  and 
backward  and  the  posterior  fragment  going  upward  and  forward.  The  down- 
ward displacement  is  due  to  muscular  action  (action  of  the  digastric,  geniohyoid, 
*  "New  Orleans  Med.  and  Surg.  Jour.,"  Sept.,  1896. 


Fig.  335. — Hamilton's  bandage. 


Fractures  of  the  Inferior  Maxillary  Bone 


621 


and  geniohyoglossus).  The  backward  displacement  is  due  to  the  violence. 
The  temporal,  internal  pterygoid,  and  masseter  muscles  draw  the  posterior 
fragment  upward  and  to  the  front.  In  a  fracture  of  the  lower  jaw  at  any 
point  below  the  orifice  of  the  dental  canal  the  nerve  will  be  more  or  less  injured 
and  examination  will  discover  areas  of  anesthesia  on  the  skin  of  the  chin, 
on  the  side  of  the  cheek,  on  the  inner  surface  of  the  lower  lip  and  on  the 
buccal  surface  of  the  gum.  These  areas  represent  the  trajectory  of  the  mental 
branch  of  the  inferior  maxillary  nerve  (Imbert  and  Gauthier,  in  ''Paris  Medi- 
cale,"  Jan.  20,  1917).  Two  or  three  days  after  fracturing  the  jaw  some  of  the 
cervical  lymph-glands  enlarge.  WTien  a  fracture  of  the  lower  jaw  is  com- 
pound internally,  suppuration  usually  takes  place  and  the  odor  of  decom- 
position becomes  marked.  In  fracture  of  the 
neck  of  the  condyle  the  jaw  is  drawn  toward 
the  injured  side,  and  the  condyle  is  pulled 
inward  and  forward  by  the  action  of  the  ex- 
ternal pterygoid  muscle.  In  fracture  of  the 
coronoid  process  the  temporal  muscle  pulls  the 
small  fragment  upward. 

The  complications  are:  digestive  disorders 
and  diarrhea  from  swallowing  foul  discharges ; 
loosening  of  the  teeth;  lodgment  of  loosened 
teeth  between  the  fragments ;  bleeding  (usually 
only  oozing  from  the  gum,  but  there  may  be 
hemorrhage  from  the  inferior  dental  artery), 
and  suppuration.  Necrosis  may  follow  these 
fractures,  an  abscess  of  the  neck  may  develop, 
or  a  sinus  may  form. 

Treatment. — The  advice  and  aid  of  a  dental 
surgeon  are  invaluable.  Correct  deformity  with 
great  care  and  be  sure  to  bring  the  teeth  into 

normal  alignment.  As  a  rule,  push  loose  teeth  into  place  and  put  back  detached 
ones;  but  occasionally  a  tooth  obstinately  prevents  perfect  approximation,  and  if 
it  does  it  must  be  removed.  Remove  a  tooth  if  it  lies  between  the  fragments, 
but  replace  it  in  its  socket  after  reducing  the  fracture.  Wash  the  mouth  with 
hot  water  to  clean  it  and  to  check  bleeding.  If  bleeding  is  very  severe,  com- 
press the  carotid  artery  for  a  time.  The  fracture  can  be  dressed  with  a  pad 
of  lint  over  the  chin  and  Hamilton's  four- tailed  bandage  (Fig.  335).  A  common 
plan  is  to  take  a  splint  of  pasteboard,  felt,  or  gutta-percha;  pad  it  lightly  with 

cotton,  mold  it  to  the  part,  and  hold  it  in  place 
T\ith  a  Barton  or  a  Gibson  bandage.  If  appo- 
sition of  the  fragments  cannot  be  maintained  by 
the  above  methods,  fasten  the  teeth  together 
•\^ith  wire,  wire  the  fragments  together,  or  have  a 
dentist  apply  an  interdental  splint  (Figs.  336, 
337).  Fracture  of  the  lower  jaw  can  often  be 
satisfactorily  treated  by  Angle's  bands.  These 
bands  are  of  great  value  in  complicated  cases,  in 
which  two  or  more  fractures  exist.  Each  band 
consists  of  thin  metal  and  a  screw  and  a  nut  to  fit 
the  screw.  The  band  is  adjusted  around  a  firm 
tooth  and  a  nut  is  applied  so  as  to  hold  the  band 
tightly.  Several  bands  are  placed  upon  teeth  in  both  jaws.  Silver  \\ire  of 
silk  is  thrown  around  the  pins  of  the  bands  so  as  to  catch,  and  the  jaws  are  thus 
held  firmly  together.  In  some  cases  holes  are  drilled  in  the  bones  and  the 
fragments  are  held  together  by  means  of  silver  wire.  In  some  few  cases  plates 
and  screws  are  used.     The  patient  is  to  be  fed  on  liquid  food  (see  Fracture  of 


Fig.  336. — Vulcanite  splint  with 
boxes  vulcanized  on  each  side.  If 
the  jaw  is  fractured  in  the  region  of 
the  molars,  considerable  pressure  is 
required  to  get  the  parts  in  position; 
therefore  it  is  best  to  ^•ulcanize  on 
to  the  sides  of  the  vulcanite  splint 
boxes  into  which  wire  arms  can  be 
inserted  (Pilcher). 


Fig.    337. — Interdental   splint. 


622  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  Upper  Jaw),  the  mouth  is  to  be  washed  frequently  with  peroxid  of  hydrogen, 
followed  by  boric  acid  solution  or  normal  salt  solution,  and  if  bandages  are  used 
they  should  be  changed  every  second  day.  The  union  should  be  complete 
in  five  weeks.  The  best  plan  of  treatment  in  all  cases  not  operated  upon  is 
to  send  the  patient  to  a  skilful  dentist  and  have  him  apply  an  interdental 
splint  and  direct  the  treatment.  A  specialist  may  succeed  in  obtaining  such 
fixation  that  union  in  good  ahgnment  follows  when  a  general  surgeon  might 
only  secure  union  in  poor  alignment.  Though  these  fractures  are  often  com- 
pound, they  very  seldom  endanger  life. 

Fractures  of  the  Hyoid  Bone. — These  fractures  are  uncommon  injuries,  and 
are  caused  by  hanging,  by  throttling,  by  blows,  and  by  falls  in  which  the  neck 
strikes  some  obstacle.  If  the  bone  breaks  by  throttling,  it  is  its  body  which 
fractures  (indirect  force).  Fractures  by  muscular  action  are  most  unusual. 
The  thyroid  cartilage,  the  cricoid  cartilage  or  the  trachea  may  also  be  broken. 

Symptoms. — The  symptoms  are:  A  sensation  of  something  breaking; 
bleeding  from  the  mouth  if  the  mucous  membrane  be  lacerated;  pain,  which 
is  worse  on  opening  the  jaws  or  on  moving  the  head  or  tongue;  difficulty  in 
swallowing;  muffied,  hoarse  voice  or  aphonia;  swelling,  and  frequently  ecchy- 
mosis,  of  the  neck.  There  are  observed  occasionally,  though  rarely,  harsh 
cough  and  dyspnea,  irregularity  of  bony  contour,  and  crepitus.  Always  look 
into  the  mouth  and  see  if  there  can  be  detected  ecch^nnosis  or  laceration  of 
the  mucous  membrane  or  projection  of  a  bony  fragment.  The  displacement 
is  produced  by  contraction  of  the  middle  constrictor  of  the  pharynx.  A  simple 
fracture  of  the  hyoid  bone  is  seldom  dangerous  but  if  there  is  laryngeal  involve- 
ment that  condition  may  destroy  life. 

Treatment. — For  dyspnea,  be  ready  to  perform  intubation  or  tracheotomy 
at  a  moment's  notice.  Edema  of  the  glottis  is  a  great  danger.  Try  to  restore 
the  fragments  with  one  hand  externally  and  with  a  finger  in  the  mouth.  Put 
the  patient  to  bed  and  have  him  lie  back  upon  a  firm  rest  so  that  his  shoulders 
are  elevated.  His  head  is  to  be  placed  between  extension  and  flexion,  a  paste- 
board splint  or  collar  is  molded  on  the  neck,  and  a  bandage  is  applied  around 
the  forehead,  neck,  and  shoulders  to  keep  the  head  immobile.  The  patient 
must  not  utter  a  word  for  a  week;  he  must  be  fed  at  first  by  enemata,  and  then  for 
some  time  on  hquid  diet,  which  is  given  through  a  stomach  tube  early  in  the  case. 
Endeavor  to  control  the  cough  by  opiates.  A  fractured  hyoid  bone  requires 
about  four  weeks  to  unite. 

Fractures  of  the  tracheal  and  laryngeal  cartilages  are  caused  by  direct 
violence,  as  hanging,  throtthng,  blows,  or  kicks.  Very  seldom  is  muscular 
action  responsible.  The  thyroid  or  cricoid  may  be  broken  alone  or  together. 
The  hyoid  bone  may  be  broken  with  them  both  or  with  the  thyroid  alone. 
The  tracheal  cartilages  may  suffer  alone  or  with  the  laryngeal  cartilages.  The 
arytenoid  may  break.  These  injuries  are  greatly  more  common  among  men 
than  women.  They  are  rare  in  young  persons,  and  are  commonest  when 
the  cartilages  have  begun  to  ossify.  They  are  very  grave  injuries.  The  mor- 
tahty  is  between  30  and  40  per  cent.  Death  may  be  caused  by  edema  of  the 
glottis,  hemorrhage  beneath  the  mucous  membrane  or  hemorrhage  into  the  air 
passage  causing  obstruction  to  the  entrance  of  air. 

The  symptoms,  which  are  severe,  are  pain,  aggravated  by  attempts  at  swal- 
lowing or  speaking;  swelling,  ecch>Tnosis  it  may  be,  and  emphysema  of  the  neck; 
cough;  aphonia;  intense  dyspnea;  and  bloody  expectoration  if  the  mucous 
membrane  is  ruptured.  There  can  be  detected  inequality  of  outline  (flattening 
or  projection)  and  perhaps  moist  crepitus.  The  usual  seat  of  injury  is  the 
thyroid  cartilage. 

Treatment. — Cases  without  dyspnea  require  quiet,  avoidance  of  all  talking, 
feedmg  with  a  stomach-tube,  the  apphcation  of  compresses  and  adhesive 
strips  over  the  fracture,  and  the  use  of  remedies  to  quiet  cough.     The  surgeon 


Fractures  of  the  Ribs  625 

must  be  ready  to  operate  at  any  moment.  In  most  cases  dyspnea  exists, 
due  to  projection  of  the  fragments  or  submucous  extravasation.  When  there 
is  dyspnea,  emphysema,  or  spitting  of  blood,  at  once  practise  intubation, 
or,  if  unable  to  do  this,  open  the  larynx  or  trachea  below  the  seat  of  fracture. 
If  laryngotomy  or  tracheotomy  is  performed,  try  to  restore  displaced  frag- 
ments to  proper  position.  If  the  fragments  will  not  remain  reduced,  introduce 
a  Trendelenburg  cannula  or  a  tracheotomy  tube,  and  pack  gauze  around  it. 
Take  out  the  packing  in  four  days,  and  remove  the  tube  as  soon  as  the  patient 
breathes  well,  when  the  opening  may  be  allowed  to  close.  In  these  cases  feed 
with  a  stomach-tube  and  keep  the  patient  absolutely  quiet.  Union  takes  place 
in  four  weeks. 

Fractures  of  the  Ribs.^The  ribs,  owing  to  their  shape,  elasticity,  and 
mode  of  attachment,  readily  bend  and  as  readily  recover  shape,  and  thus 
\\-ithstand  considerable  force  without  breaking.  Notwithstanding  these  facts, 
the  situation  of  the  ribs  so  exposes  them  that  in  16  per  cent,  of  all  cases  of 
fractures  noted  by  Gurlt  these  bones  were  involved.  In  children  fracture 
of  a  rib  seldom  occurs  and  is  usually  incomplete;  it  is  common  in  adults  and 
the  aged,  and  in  them  is  generally  complete.  It.  is  more  frequent  among 
men  than  among  women.  The  ribs  commonly  broken  are  from  the  fifth 
to  the  ninth,  the  seventh  being  the  one  that  most  frequently  suffers.  Fracture 
of  the  first  rib  alone  is  an  excessively  rare  accident.  The  eleventh  and  twelfth 
ribs  are  seldom  broken.  A  rib  may  be  broken  in  several  places,  and  several 
ribs  are  often  broken  at  the  same  time.  Fracture  of  a  single  rib  is  not  nearly 
so  common  as  fracture  of  several  ribs.  These  fractures  may  be  compound, 
either  through  the  skin  or  through  the  pleura.  Damage  of  the  lung  will  result 
in  pneumothorax.  Fractures  compound  by  a  wound  of  the  skin  surface  are 
very  rare,  except  from  gunshot  wounds. 

Causes. — Direct  force,  as  buffer  accidents,  kicks,  blows  with  heavy  instru- 
ments, or  being  jumped  on  while  recumbent,  may  produce  these  injuries.  A 
fracture  from  direct  violence  occurs  at  the  point  struck,  and  the  ends,  projecting 
inward,  may  damage  a  viscus.  Indirect  force,  as  great  pressure  or  blows  which 
exaggerate  the  natural  bony  curves,  tends  to  produce  fractures  near  the  middle 
of  the  ribs  or  in  front  of  their  angles  and  to  force  the  ends  outward.  A  number 
of  ribs  are  apt  to  be  broken.  Muscular  action,  as  in  coughing,  sneezing,  lifting, 
or  parturition,  occasionally,  but  very  rarely,  is  a  cause. 

Symptoms. — In  connection  with  the  history  of  the  accident  the  s>Tnptoms 
are:  acute  localized  pain  (a  stitch)  on  breathing,  increased  by  pressure  over 
the  seat  of  pain,  pressure  backward  over  the  sternum,  cough,  and  forcible 
inspiration  or  expiration.  Respiration  is  largely  diaphragmatic,  the  patient 
endeavoring  to  immobilize  the  injured  side;  cough  is  frequent  and  is  suppressed 
because  of  pain.  Crepitus  is  often,  but  not  invariably,  found.  The  surgeon 
seeks  for  it,  first,  by  resting  the  palm  of  his  hand  over  the  seat  of  pain  while 
the  patient  takes  long  breaths;  second,  by  placing  a  thumb  before  and  one 
behind  the  seat  of  pain  and  making  alternate  pressure;  third,  by  ausculta- 
tion. It  should  be  remembered  that  incomplete  fractures  are  the  rule  in 
children;  hence  in  them  do  not  expect  crepitus.  Deformity  is  usually  trivial 
unless  several  ribs  are  broken,  because  shortening  cannot  occur  and  the  inter- 
costal attachments  prevent  vertical  displacement.  Preternatural  mobility 
may  occasionally  be  elicited,  when  the  region  is  not  deeply  covered  with  mus- 
cles, by  pressing  on  one  side  of  the  supposed  break  and  observing  that  a  part 
of,  and  not  the  entire,  rib  moves.  If  air  gathers  in  the  subcutaneous  tissue 
and  there  is  no  wound  of  the  surface,  it  is  proof  of  rib  fracture  with  lung  dam- 
age. In  such  a  case  the  lung  has  been  penetrated  by  a  fragment,  and  air  has 
been  forced  out  into  the  tissues.  This  condition  is  recognized  by  great  and 
growing  swelling,  which  crackles  when  touched.  Such  a  collection  of  air  is 
kno-^^-n  as   cellular  emphysema.     Bloody   expectoration  suggests  lung  injury; 


624  Diseases  and  Injuries  of  the  Bones  and  Joints 

bloody  expectoration  and  cellular  emphysema,  without  an  external  wound, 
prove  injury  of  the  lung.  A  simple,  uncomplicated  case  of  fracture  of  a  rib 
or  ribs  in  a  young  person  gives  a  good  prognosis. 

The  complications  are:  additional  injury,  making  the  fracture  externally 
or  internally  compound;  laceration  of  the  pleura,  pericardium,  heart,  lung, 
diaphragm,  liver,  spleen,  or  colon;  rupture  of  an  intercostal  artery;  hemo- 
thorax; cellular  emphysema;  pulmonary  emphysema;  pneumothorax;  pyo- 
thorax;  traumatic  pleurisy;  pneumonia;  bronchitis;  congestion  or  edema  of 
the  lungs. 

Treatment. — In  an  uncomplicated  case  the  patient  is  not  kept  in  bed,  as 
breathing  is  easier  when  erect  than  when  recumbent.  Angular  displacement 
outward  is  corrected  by  direct  pressure.  Displacement  inward  is  soon  corrected 
as  a  rule,  by  the  expansion  of  ordinary  respiratory  action;  but  if  it  is  not  thus 
corrected,  etherize,  the  deep  breathing  of  the  anesthetic  state  almost  always 
succeeding.  If  ether  fails,  and  dangerous  symptoms  ensue,  incise  under  strict 
antiseptic  precautions,  elevate,  or  sometimes  resect  a  portion  of  the  rib. 

After  correcting  any  existing  deformity  immobilize  the  injured  side.  If  the 
patient  is  a  man,  shave  the  chest.  Direct  the  patient  to  raise  his  arms  above  his 
head,  to  empty  his  chest  of  air  by  forced  expiration,  and  to  keep  it  empty  until  a 
piece  of  rubber  plaster  (2  inches  wide)  is  forcibly  applied  a  number  of  inches 
below  the  fracture  and  from  the  spine  to  the  sternum.  The  patient  is  now 
allowed  to  take  a  breath  and  is  then  directed  to  empty  the  chest  again,  another 
piece  of  plaster  being  applied,  covering  the  upper  two-thirds  of  the  width  of 
the  first  strip.  This  process  is  continued  until  the  side  is  strapped  well  above 
and  well  below  the  fracture  (PI.  7,  Fig.  13).  Over  the  plaster  light  turns  of  a 
spiral  bandage  of  muslin  are  carried,  or  a  figure-of-8  bandage  of  the  chest  is 
applied,  the  turns  crossing  over  the  seat  of  injury.  About  once  a  week  the 
plaster  is  removed  and  fresh  pieces  applied  after  rubbing  the  chest  with  soap 
liniment,  drying,  and  anointing  excoriations  with  an  ointment  of  oxid  of  zinc. 
The  dressing  is  worn  for  three  or  four  weeks.  The  patient  avoids  cold,  damp, 
and  drafts.  The  diet  must  be  nutritious  but  non-stimulating,  and  any  cough 
should  be  treated  by  opiates  and  expectorants.  A  person  with  this  injury  who 
has  reached  the  age  of  sixty  must  take  stimulant  expectorants  (ammonii  carb., 
10  gr.,  in  infus.  senegae,  3^  oz.,  /.  i.  d.)  or  employ  a  steam-tent  several  times  a 
day.  The  old  method  of  treatment,  in  which  the  chest  was  included  in  a  forci- 
bly applied  broad  rib-roller,  is  not  to  be  used  except  as  a  temporary  expedient; 
it  compresses  the  entire  chest,  causes  pain  and  dyspnea,  and  tends  to  loosen  and 
slip. 

Fracture  of  the  ribs  complicated  by  visceral  injury  is  highly  dangerous, 
and  requires  confinement  to  bed.  The  treatment  is  that  of  the  visceral  injury. 
If  there  be  bloody  expectoration,  apply  adhesive  strips  as  above  indicated, 
put  the  patient  to  bed  reclining  on  a  bed-rest,  keep  him  quiet,  subdue  the  circu- 
lation, and  employ  opium,  diaphoretics,  and  expectorants  (a  good  mixture 
consists  of  squill,  ipecac,  ammonium  acetate,  and  chloroform;  opium  is  given 
separately).  Inflammations  of  the  lung  or  the  pleura,  fortunately,  are  apt 
to  be  localized,  and  are  treated  as  ordinary  inflammations  of  these  parts. 
In  laceration  of  an  intercostal  artery  incise  and  try  to  ligate;  if  unable  to  ligate, 
resect  a  rib  and  apply  a  ligature.  If  the  signs  point  to  internal  bleeding,  resect 
a  rib,  search  for  the  bleeding  point,  ligate  and  drain  the  pleura.  Emphysema 
usually  soon  disappears;  but  if  it  does  not,  make  many  small  incisions  in  the 
cellular  tissue,  dress  antiseptically,  and  employ  pressure.  Pneumothorax,  if 
increasing  dangerously,  demands  tapping  with  a  trocar  and  if  this  fails  the 
introduction  of  a  drainage  tube.  When  there  arises  a  sudden  attack  of  dyspnea, 
which  is  prone  to  happen  in  these  cases,  and  in  which  the  face  becomes  blue, 
the  heart  labors,  and  suffocation  seems  imminent,  bleed  the  patient  almost  to 
syncope.     Empyema  calls  for  operation. 


Fractures  of  the  Sternum  625 

Fractures  of  the  costal  cartilages  are  not  common,  even  in  the  aged.  Such 
fractures  occur  either  through  the  cartilages  or  through  their  points  of  junc- 
tion with  the  ribs.  These  injuries  generally  arise  from  direct  violence,  the 
cartilage  of  the  eighth  rib  being  most  prone  to  suffer.  Bennett,  of  Dublin, 
has  seen  over  25  specimens  of  fracture  of  the  first  costal  cartilage.  Indirect 
force  (such  as  a  blow  upon  the  shoulder)  is  occasionally  the  cause,  but  when  it 
is  the  cause  some  other  injury  besides  the  fracture  of  the  cartilages  is  apt 
to  be  noticed.     IMuscular  action  is  a  possible  cause. 

Sympto7ns. — Displacement  is  often  absent;  but  if  present,  it  is  forward  or 
backward  of  either  fragment,  and  is  due  chiefly  to  the  force  of  the  injury, 
but  partly,  it  may  be,  to  muscular  action.  When  displacement  is  absent, 
crepitus  ^^ill  not  often  be  found;  in  fact,  crepitus  is  usually  absent  in  these 
injuries.  Localized  pain,  swelling,  and  ecchymosis  are  noted.  Preternatural 
mobility  may  or  may  not  be  detected.     Union  by  bone  is  to  be  expected. 

Treatment. — If  displacement  exists,  try  to  reduce  it.  If  the  fragment  is 
displaced  backward,  reduce  by  deep  inspirations;  if  the  fragment  is  displaced 
forward,  reduce  by  pulling  back  the  shoulders.  In  this  attempt  failure  is  the 
rule,  and  the  surgeon  may  then  adopt  Malgaigne's  expedient  of  applying  a 
truss  over  the  projection  for  a  day  or  two.  Dress  and  treat  the  case  as  if  a 
rib  were  broken,  dispensing  with  dressings  in  four  weeks. 

Fractures  of  the  Sternum. — The  sternum  may  be  broken,  along  with 
the  ribs  and  spine,  from  great  violence.  Fractures  of  the  sternum  alone 
are  infrequent,  because  the  bone  rests  on  a  spring-bed  of  ribs.  Fractures 
of  the  sternum  may  be  simple  or  compound,  complete  or  incomplete,  single 
or  multiple.  The  most  usual  injury  is  a  simple  transverse  fracture  at  or 
near  the  gladiomanubrial  junction,  at  which  point  dislocation  may  also  occur. 
Both  fracture  and  separation  of  the  ensiform  cartilage  are  very  rare.  The 
sternum  may  be  broken  along  with  the  ribs  or  clavicle. 

Causes. — These  are:  direct  force,  as  by  a  fall  of  an  embankment  or  of  a 
wall,  by  a  car-crush,  or  by  the  passing  of  a  cart-wheel  over  the  body;  indirect 
force,  as  by  a  fall  upon  the  head,  thus  driving  the  chin  against  the  chest;  by 
a  fall  upon  the  feet,  the  buttocks,  or  the  shoulder;  by  forced  flexion  or  ex- 
tension of  the  body  over  an  edge  or  angle  (as  may  occur  during  labor-pains). 

Symptoms.— In  fracture  of  the  sternum  displacement  is  not  always  present, 
but  when  it  does  occur  the  lower  fragment  is  apt  to  pass  forward;  displace- 
ment may,  however,  be  transverse  or  angular,  or  there  may  be  overriding. 
The  posterior  periosteum,  which  rarely  tears,  limits  displacement,  but  some 
deformity  can,  as  a  rule,  be  detected.  The  history  of  the  nature  of  the  acci- 
dent has  a  valuable  bearing  upon  the  question  of  diagnosis.  The  position 
assumed  by  the  patient  is  with  the  head  and  body  bent  forward,  as  attempts 
to  straighten  up  cause  much  suffering.  There  is  fixed  and  localized  pain, 
increased  by  deep  respiratory  action,  by  body  movements,  or  by  cough. 
Crepitus  is  sought  for  by  auscultation  and  by  placing  the  hand  over  the  in- 
jury and  directing  the  patient  to  make  quick  respirations.  Mobility  may 
become  manifest  on  external  pressure,  during  respiration,  or  while  attempts 
are  being  made  to  bring  the  body  erect.  Respiration  in  these  cases  is  usually 
much  interfered  with.  It  is  not  important  to  separate  diagnostically  diastasis 
from  fracture. 

Complications. — Other  fractures  generally  complicate  fracture  of  the 
sternum,  and  laceration  of  the  pleura  or  pericardium  and  hemorrhage  into 
the  anterior  mediastinum  may  exist.  Abscess  of  the  mediastinum  and  necrosis 
of  the  sternum  may  appear  as  late  consequences.  The  prognosis  is  good  in 
uncomplicated  cases. 

Treatment. — The  deformity  attending  fracture  of  the  sternum  is   to   be 
corrected,   if  possible,   by  external  pressure.     If  overriding  is  found,   effect 
reduction  by  bending  the  body  back  over  a  firm  pillow  and  ordering  the  patient 
40 


626  Diseases  and  Injuries  of  the  Bones  and  Joints 

to  respire  deeply;  if  this  method  fails,  give  ether  and  then  bend  the  body 
backward.  The  deformity,  after  reduction,  tends  to  recur,  but  the  bones 
unite  well  even  in  deformity,  and  no  great  harm  results.  The  fragments 
need  not  be  cut  down  on  or  be  hooked  up  unless  there  be  internal  injury. 
After  reducing  the  deformity,  cover  the  front  of  the  chest  with  adhesive  strips 
extending  laterally  from  one  axillary  line  to  the  other,  and  covering  a  region 
from  above  the  fracture  down  to  the  ensiform  cartilage.  Place  over  this 
covering  an  anterior  figure-of-8  bandage  of  the  chest.  In  some  cases,  where 
deformity  recurs  after  reduction,  a  circular  bandage  of  the  chest  is  applied 
and  the  shoulders  are  pulled  strongly  back  with  a  posterior  figure-of-8  bandage. 
The  plaster  is  to  be  reapplied  once  a  week.  Some  surgeons  treat  these  cases 
by  means  of  a  large  compress  held  by  adhesive  plaster  and  a  broad  tight  roller. 

The  patient  goes  promptly  to  bed,  and  reposes,  erect  or  semi-erect,  on 
a  bed-rest.  This  position  favors  easy  respiration  and  antagonizes  the  tend- 
ency to  displacement.  The  diet  should  be  light,  nutritious,  and  non-stimu- 
lating. Convalescence  is  established  in  four  weeks,  and  the  plaster  should  be 
permanently  removed  in  five  weeks.  When  the  ensiform  cartilage  is  so  bent 
in  as  to  cause  intense  pain  or  to  injure  the  stomach,  it  should  be  exposed  by 
incision  and  resected.  Edema  of  the  skin  and  fever,  if  they  appear,  indicate 
pus,  in  which  case  an  incision  should  be  made  at  the  edge  of  the  sternum  and 
the  pus-cavity  should  be  irrigated  and  drained. 

Fractures  of  the  Pelvis. — In  some  of  the  indicated  fractures  serious  injury 
of  the  pelvic  contents  is  apt  to  be  found. 

Fractures  of  the  False  Pelvis. — Fractures  of  this  region  are  seldom  dan- 
gerous unless  comminuted.  There  may  be  fracture  of  the  iliac  crest  or  of  the 
anterior  superior  spine,  or  the  line  of  fracture  may  traverse  the  entire  length 
of  the  fianged-out  ilium,  or  the  bone  may  be  comminuted  with  the  association 
of  grave  visceral  damage.  The  anterior  superior  and  posterior  superior  spines 
may  be  broken  off. 

Causes. — The  cause  of  fracture  of  the  false  pelvis  is  generally  violent  direct 
force,  as  the  passage  of  a  wagon-wheel,  the  fall  of  a  wall,  the  kick  of  a  horse 
or  mule,  or  the  force  of  car-crushes.  Violent  contraction  of  the  rectus  femoris 
muscle  may  tear  off  the  anterior  inferior  spine  of  the  ilium. 

Symptoms. — In  fracture  of  the  false  pelvis  the  history  of  violent  force  is 
noted.  The  patient  leans  toward  the  injured  side.  Pain  exists,  which  is 
aggravated  by  movements  (particularly  by  bending  forward),  by  coughing, 
or  by  straining  to  empty  the  bowels  or  the  bladder.  Ecchymosis  and  swelling 
are  manifest.  Crepitus  and  preternatural  mobility  are  detected  by  moving 
the  iliac  crest.  Deformity  is  very  rarely  present.  A  person  with  fracture  of 
the  crest  alone  or  of  a  spine  alone  can  stand  and  walk.  Cases  uncomplicated 
by  visceral  injury  make  good  recoveries. 

Complications. — The  fracture  may  be,  but  rarely  is,  compound,  as  the 
parts  are  well  protected  by  muscles.  The  colon  may  be  injured  when  com- 
minution has  taken  place. 

Treatment. — If  there  are  symptoms  of  injury  to  the  colon,  perform  lapar- 
otomy, search  for  the  injured  region,  and  suture  it.  In  treating  an  ordinary 
fracture  of  the  false  pelvis  the  Bradford  frame  is  probably  the  best  apparatus 
but  many  surgeons  simply  put  the  patient  on  a  fracture-bed,  raise  the  shoulders, 
and  apply  a  canvas  binder  about  the  pelvis,  or  encase  the  pelvis  in  broad  pieces 
of  rubber  plaster,  or  employ  the  belt  or  girdle.  The  pressure  of  the  binder, 
girdle,  or  plaster  must  not  be  so  great  as  to  force  the  fragment  of  ihum  inward. 
The  knees  should  be  bent  over  two  pillows  so  as  to  semifiex  the  legs  and  thighs, 
and  the  knees  should  be  tied  together.  To  restrain  thigh  movements  it  may 
be  necessary  to  encase  a  restless  patient  in  splints  or  bind  him  to  sand-bags.  If 
the  pelvic  binder  displaces  the  fragments  or  causes  pain,  abandon  it  and  trust 
to  position.     If  the  fragment  cannot  be  retained  in  place,  wire  it.     The  dressings 


Fractures  of  the  True  Pelvis  627 

can  be  removed  in  six  weeks,  and  the  patient  is  allowed  to  get  up  in  eight  weeks. 
In  simple,  uncomplicated  fracture  of  the  false  pelvis  the  prognosis  is  good. 
In  compound  fractures  of  the  false  pelvis  asepticize,  drain  and  dress,  put  on  a- 
binder,  and  direct  the  same  position  to  be  maintained  as  for  simple  fractures. 

Fractures  of  the  True  Pelvis. — The  most  usual  seat  of  these  fractures 
is  through  the  obturator  foramen,  the  ascending  ischial  and  horizontal  pubic 
rami  being  broken.  A  fracture  may  occur  near  the  symphysis  pubis,  the 
symphysis  may  be  separated,  a  hne  of  fracture  may  run  near  to  or  into  the  sacro- 
iHac  joint;  the  same  may  involve  each  side  of  the  body  of  the  pubis,  and  there 
may  be  multiple  fractures.  Fractures  of  the  acetabulum  and  of  the  tuberosity 
of  the  ischium  may  occur.  Before  the  seventeenth  year  the  innominate  bone 
may  be  broken  into  its  three  anatomical  segments.  Fractures  of  the  true 
pelvis  are  highly  dangerous  because  of  the  damage  which  is  apt  to  be  inflicted 
on  the  pelvic  contents.  There  may  be  laceration  of  the  bladder  or  membranous 
urethra,  injury  of  the  vagina,  the  rectum,  the  uterus,  or  the  small  gut.  The 
cause  of  pelvic  fracture  is  violent  force,  direct  or  indirect.  Front  force  tends 
to  produce  direct,  and  side  force  indirect,  fracture.  The  acetabulum  may  be 
broken  by  falls  upon  the  feet. 

Symptoms. — In  pelvic  fracture  there  is  a  history  of  violent  force.  There 
are  great  shock,  swelUng,  and  intense  pain  increased  by  attempts  at  motion, 
coughing,  and  straining'.  There  is  also  inability  to  sit  or  to  stand.  Mobihty 
becomes  obvious  on  grasping  an  ilium  in  each  hand  and  moving  the  hands. 
Crepitus  may  be  noticed  by  this  maneuver  or  by  moving  an  ilium  witt  one  hand, 
a  finger  of  the  other  hand  being  inserted  in  the  rectum  or  vagina.  In  making 
movements  for  diagnostic  purposes  be  very  gentle,  as  rough  manipulation 
may  cause  injury  by  sharp  fragments.  There  may  be  doubt  as  to  whether 
crepitus  is  to  be  referred  to  pelvic  fracture  or  to  fracture  of  the  neck  of  the  femur; 
in  this  case  follow  the  rule  of  John  Wood:  "The  surgeon  grasps  the  femur 
with  one  hand  and  places  the  other  firmly  upon  the  anterior  superior  iliac  spine 
or  crest  or  upon  the  pubes;  then,  on  mo\dng  the  femur  and  abducting  it  freely, 
if  a  crepitus  be  detected,  it  will  be  felt  the  more  distinctly  by  that  hand  which 
rests  on  or  grasps  the  fractured  bone."  In  from  one  to  three  days  ecchymosis 
usually  appears  in  the  perineum  and  scrotum  of  the  male  and  in  the  perineum 
and  labia  of  the  female.  This  sign  is  similar  in  origin  to  Battle's  sign  of  frac- 
ture of  the  posterior  fossa  of  the  base  of  the  skull  (Coopernail,  in  "Medical 
Record,"  March  4,  1916).  In  a  fracture  of  the  pubes  without  much  tearing  of 
the  soft  parts  there  may  be  simply  a  linear  discoloration. 

Rupture  of  the  bladder  is  made  manifest  by  pain  in  the  h^-pogastric  region, 
intense  desire  to  micturate,  inability  to  pass  urine  in  quantity,  although  a 
few  drops  of  bloody  urine  may  be  voided,  great  shock,  sometimes  dulness  on 
percussion  in  the  loins,  and  evidences  of  extravasation  in  the  prevesical  space. 
The  condition  is  proved  to  exist  by  practising  the  maneuvers  suggested  under 
Rupture  of  Bladder.  The  symptoms  of  ruptured  urethra  are  set  forth  later. 
Bleeding  from  vagina  or  rectum  points  to  laceration  of  the  part  by  a  fragment. 
The  vagina  maybe  badly  lacerated  and  the  bowels  may  emerge  from  the  lacera- 
tion (Maurice  H.  Richardson's  case).  Intestinal  injury  is  apt  to  induce 
septic  peritonitis.'  Fractures  of  the  acetabulum  occur.  Fracture  of  the 
brim  of  the  acetabulum  permits  dorsal  dislocation  of  the  femur  which 
will  not  remain  reduced,  and  causes  shortening,  which  at  once  reours  when 
extension  is  abandoned;  also  inversion  and  adduction,  although  the  power 
of  eversion  and  abduction  is  preserved  (Stokes).  There  is  crepitus,  and  the 
head  of  the  bone  goes  with  the  fragment  upward  and  backward  (Stokes).  If 
the  head  of  the  femur  be  driven  through  the  acetabulum  into  the  pelvis,  the 
injury  is  very  grave;  there  are  then  found  shortening,  adduction,  and  semi- 
flexion of  the  thigh,  absence  of  the  prominence  of  the  great  trochanter,  and 
more  capacity  for  movement  than  is  noted  in  dislocation.     This  injury  is  called 


628  Diseases  and  Injuries  of  the  Bones  and  Joints 

internal  dislocation  of  the  femur  (Fig.  338).     Fracture  of-  the  ischium  rarely 
occurs  alone. 

Treatment. — Examine  carefully  to  determine  if  the  bowel,  the  bladder,  the 
urethra,  or  the  vagina  is  injured.  If  such  an  injury  exists,  radical  operation 
is,  of  course,  demanded.  Always  use  a  catheter  to  see  if  the  urine  is  bloody. 
Bloody  urine  suggests,  but  does  not  prove,  the  existence  of  a  torn  bladder. 
It  may  be  due  to  simple  contusion  of  the  bladder  or  to  contusion  of  the  kidney. 
In  some  cases  the  bladder  is  sutured.  In  others  it  is  drained  suprapubicly 
without  suturing.  In  treating  a  pelvic  fracture  endeavor  to  restore  the  parts 
to  a  normal  position,  employing  external  manipulation  and  inserting  a  finger 
into  the  rectum  or  in  the  vagina.  If  reduction  is  difficult,  administer  ether. 
The  pelvis  should  be  encircled  by  a  canvas  binder  and  the  patient  should  be 
placed  upon  a  Bradford  frame.  If  this  is  done  he  can  be  cleaned  readily  and 
the  bed-pan  can  be  easily  used.  If  movements  of  the  thighs  distort  the  pelvic 
bones,  each  thigh  should  be  bound  to  the  frame.     In  fracture  with  senaration 


Fig.  338. — RuKh\^  case  of  fracture  of  the  acetabulum  with  internal  dislocation  of  I'cmur. 

of  the  pubic  bones  the  bones  should  be  wired  in  place.  If  urinary  extravasation 
from  urethral  rupture  occurs,  perform  perineal  section.  If  there  are  signs  of 
bowel  injury  or  intraperitoneal  rupture  of  the  bladder,  perform  laparotomy; 
and  if  the  bladder  is  found  to  be  torn,  apply  sutures  and  drain  suprapubically. 
All  visceral  injuries  are  treated  by  general  rules.  Remove  the  dressings  in  six 
weeks  and  allow  the  patient  to  get  about  in  twelve  weeks.  *  In  fracture  of  the 
acetabulum,  if  the  limb  is  shortened,  give  ether  and  reduce  by  extension  and 
counterextension.  Treat  these  fractures  in  the  same  way  as  intracapsular 
fractures  of  the  femur.  Fractures  of  the  ischium  are  best  treated  by  the 
application  of  a  pad  and  adhesive  plaster,  and  rest  in  bed. 

E.  P.  Quain  ("Surgery,  Gynecology,  and  Obstetrics,"  July,  1916)  collected 
126  cases  of  rupture  of  the  bladder  associated  with  fracture  of  the  pelvis.  To 
these  he  adds  one  of  his  owti.  In  most  of  the  cases  a  spicule  of  bone  tore  the 
bladder.  Most  of  the  lacerations  were  extraperitoneal  and  in  several  cases 
they  were  multiple.     Only  34  of   the  cases  recovered,  a  mortality  of  74  per 


Fractures  of  the  Coccyx  629 

cent.  Fort)^  four  of  the  cases  were  reported  since  1890,  and  of  these  2^ 
recovered,  a  mortahty  of  48  per  cent.  Out  of  21  cases  reported  since  1905  only 
8  died,  a  mortahty  of  38  per  cent.  Quain  maintains  that  suturing  or  wiring 
of  fragments  is  unsatisfactory  when  there  is  extravasation  of  urine.  He 
practised  indirect  fixation  of  the  pelvic  bone  fragments  by  "percutaneous 
screws  and  external  clamps  at  points  distant  from  the  fracture  and  extrava- 
sated  urine"  (Ibid.). 

Fractures  of  the  Sacrum. — This  bone  may  be  broken  by  direct  force,  such 
as  a  kick,  but  the  injury  is  rare.  The  sacral  plexus  is  usually  injured,  and  if  it 
is,  paralysis  is  observed  in  the  territory  of  its  branches. 

The  symptojns  of  fracture  of  the  sacrum  are  pain,  frequently  incontinence 
of  feces  and  retention  of  urine,  irregularity  of  the  sacral  spines,  ecchymosis, 
and  crepitus.  Crepitus  may  be  sought  for  with  one  hand  externally  and  a 
finger  of  the  other  hand,  in  the  rectum.  The  lower  fragment  passes  forward 
and. may  obstruct  or  may  tear  the  rectum.  Paralysis  may  be  found  in  the 
area  of  distribution  of  the  sacral  plexus. 

Treatment. — In  any  case  of  fracture  of  the  sacrum,  if  there  are  evidences 
of  pressure  upon  nerves  by  displaced  bone,  expose  and  elevate  the  depressed 
bone.  If  the  rectum  is  lacerated,  sutures  must  be  inserted.  In  many  cases 
of  fracture  of  the  sacrum  the  older  conservative  treatment  is  sufficient.  The 
conservative  treatment  is  as  follows:  Press  the  fragments  into  place  with  a 
hand  externally  and  a  finger  in  the  rectum.  Do  not  plug  the  rectum.  Put  a 
pad  over  the  upper  fragment,  hold  it  by  a  plaster  or  a  binder,  place  the  patient 
recumbent  on  a  fracture-bed,  and  insert  a  large  cushion  underneath  the  pad. 
Some  surgeons  give  opium  to  induce  constipation,  and  allow  a  fecal  support 
to  accumulate  in  the  rectum.  Use  a  clean  catheter  regularly,  and  guard 
against  bed-sores.  Union  occurs  in  about  four  weeks,  when  the  dressing  can 
be  removed.  The  patient  can  get  about  again  in  six  weeks.  If  urinary  reten- 
tion persists,  or  if  intractable  bed-sores  form  after  eight  or  ten  weeks,  cut 
down  on  the  seat  of  injury  and  elevate  or  remove  the  portion  of  bone  causing 
pressure. 

Fractures  of  the  Coccyx. — The  coccyx  may  be  broken  or  be  separated  from 
the  sacrum  by  a  fall,  a  blow,  a  kick,  or  the  straining  of  parturition.  Its  mobility 
is  so  great,  however,  that  it  does  not  often  break. 

Symptoms. — The  chief  symptom  of  fracture  of  the  coccyx  is  pain,  which 
is  much  aggravated  by  sitting,  walking,  or  straining  at  stool.  If  the  index- 
finger  is  inserted  into  the  rectum,  the  displaced  bone  is  felt;  if  the  thumb  of 
the  same  hand  is  also  placed  externally,  a  rocking  motion  will  develop  crepitus 
and  preternatural  mobility. 

Treatment. — In  treating  fracture  of  the  coccyx  reduce  by  external  pressure 
and  by  the  manipulations  of  a  finger  in  the  rectum  and  put  the  patient  to  bed. 
In  four  weeks  the  fracture  should  be  united.  If  union  does  not  take  place, 
defecation,  micturition,  rising  from  a  chair,  or  even  sitting,  and  all  movements 
of  the  coccyx  will  cause  excruciating  pain  by  pressure  on  the  last  sacral  nerve. 
A  finger  in  the  rectum  will  locate  a  very  painful  spot.  This  condition  is  known 
as  coccygodynia.  It  was  first  described  and  named  by  Sir  James  Y.  Simpson 
of  Edinburgh  in  1859. 

It  must  not  be  understood  that  coccygodynia  always  results  from  fracture 
of  the  coccyx,  or  that  fracture  of  the  coccyx  is  the  only  cause.  As  a  matter  of 
fact,  coccygodynia  is  a  rare  condition  and  is  seldom  a  result  of  fracture  of  the 
coccyx.  It  may  arise  after  confinement,  or  a  fall  or  blow  upon  the  region  of  the 
coccyx,  may  be  due  to  caries,  may  result  from  exposure  to  cold  and  wet. 

In  most  cases  it  is  a  referred  pain  due  to  some  central  trouble,  and  is  common 
in  various  functional  disorders  of  the  nervous  system.  It  is  especially  common 
in  hysterical,  neurasthenic,  or  anemic  women.  In  the  traumatic  neuroses  it  is 
complained  of  not  unusually,  and  it  is  frequently  associated  with  irritable  spine. 


630  Diseases  and  Injuries  of  the  Bones  and  Joints 

In  very  rare  cases  it  is  a  neuralgia.  The  treatment  is  aimed  at  the  causative 
condition.  In  very  obstinate  cases  it  demands  a  subcutaneous  division  of  the 
nerve  or  of  the  muscles  which  move  the  coccyx.  Resection  of  the  bone,  which 
was  suggested  by  Tillaux  in  1885  ^-nd  has  been  advocated  by  a  numl)er  of  sur- 
geons is  only  justifiable  when  the  bone  is  diseased  or  distorted.  The  operation 
weakens  the  pelvic  floor  (Yeomans,  in  "Tr.  Am.  Proctolog.  Soc,"  1914). 
Yeomans  (Ibid.)  warmly  advocates  injection  of  alcohol  (80  per  cent.)  into  and 
about  the  painful  spot. 

Fractures  of  the  Vertebrae. — (See  page  g6i.) 

Fractures  of  the  Skull. — (See  page  885.) 

Fractures  of  the  Clavicle. — The  clavicle  is  more  often  fractured  than  any 
other  bone.  The  fracture  may  occur  at  any  age,  but  is  commonest  before  the 
sixth  year  (Hulke  says  one-half  of  the  recorded  cases).  It  may  be  simple, 
multiple,  comminuted,  oblique,  transverse,  complete,  incomplete,  or,  very 
rarely,  compound.  Both  clavicles  may  be  broken.  Fractures  are  most  apt 
to  occur  just  external  to  the  middle,  at  the  point  where  the  inner  or  large  curve 
meets  the  outer  or  small  curve,  at  which  junction  the  bone  is  at  its  smallest 
diameter.  Fractures  of  the  acromial  end  are  more  frequent  than  fractures  of 
the  sternal  end,  and  less  frequent  than  fractures  of  the  shaft.  The  causes  of 
fracture  of  the  clavicle  are  direct  violence,  indirect  violence,  and,  very  rarely, 
the  contractions  of  "the  deltoid  and  clavicular  fibers  of  the  great  pectoral" 
(Treves,  in  "Applied  Anatomy,"  from  Polaillon). 

Fractures  of  the  shaft  are  usually  due  to  indirect  violence,  as  falls  upon 
the  shoulder  or  upon  the  outstretched  hand.  In  the  latter  accident,  which 
is  the  usual  mode  of  origin,  the  concussion  of  the  fall  travels  up  and  the  body 
weight  travels  down,  and  these  two  forces  compress  the  bone,  which  snaps  at 
its  weakest  point.  Fractures  from  indirect  force  are  oblique,  and  in  children 
are  of  the  green-stick  form.  Fractures  from  direct  force  are  usually  transverse, 
and  are  occasionally  comminuted.  Fractures  from  muscular  action  have  been 
recorded  (Rubini,  the  tenor,  recorded  by  Melay). 

Symptoms. — In  fracture  of  the  shaft  of  the  clavicle  the  attitude  of  the  patient 
is  peculiar.  He  supports  the  elbow  or  wrist  of  the  injured  side  with  the  hand 
of  the  sound  side,  and  also  pulls  the  extremity  against  the  chest;  the  head  is 
iiurned  down  toward  the  shoulder  of  the  damaged  side,  as  if  trying  to  listen  to 
something  in  the  joint,  thus  relaxing  the  pull  of  the  sternocleidomastoid  muscle 
upon  the  inner  fragment.  The  shoulder  is  nearer  the  sternum,  on  a  lower  level, 
and  farther  front  than  that  of  the  sound  side.  Loss  of  function  is  showTi  by 
inability  to  abduct  the  arm,  and  in  many  cases  by  inability  to  place  the  hand 
on  the  top  of  the  erect  head.  Considerable  pain  exists,  which  is  increased  by 
motion,  by  pressure,  and  by  the  extremity  hanging  down  without  support. 

The  deformity  above  noted  is  described  by  stating  that  the  shoulder  goes 
downward,  inward,  and  forward  (d.  i.  f.).  The  downward  deformity  is  chiefly 
due  to  the  weight  of  the  extremity,  which  pulls  dowm  the  unsupported  outer 
fragment,  and  is  contributed  to  by  the  action  of  the  pectoralis  minor  muscle. 
The  inward  deformity  is  chiefly  due  to  the  contraction  of  the  pectoralis  minor 
and  subclavius  muscles  assisted  by  the  action  of  the  pectoralis  major.  The 
forward  deformity  is  due  to  rotation  of  the  outer  fragment,  which  is  brought 
about  by  the  serratus  magnus  muscle  carrying  the  scapula  forward.  In  this 
deformity  the  inner  end  of  the  outer  fragment  is  below  and  behind  the  outer 
end  of  the  inner  fragment,  which  overrides  it.  The  inner  fragment,  though 
pulled  on  by  the  sternocleidomastoid  muscle  and  relatively  higher  than  the 
outer  fragment,  is  really  but  little,  if  at  all,  elevated,  marked  elevation  being 
prevented  by  the  attachment  of  the  rhomboid  ligament.  Mter  noting  the 
deformity,  detect  with  the  finger  the  irregularity  of  bony  contour.  Examine 
for  preternatural  mobility  and  crepitus  by  raising  and  throwing  back  the 
shoulder.     In  looking  for  these  signs  in  children  it  is  to  be  remembered  that  the 


Fractures  of  the  Shaft 


631 


fracture  is  probably  incomplete.  The  prognosis  is  good,  the  bone  uniting, 
but,  if  unoperated  upon,  with  some  shortening  or  inequality. 

Complications. — Fractures  of  the  shaft  are  rarely  compound,  because  the 
sharp  end  of  the  outer  fragment  passes  backward  and  because  of  the  free  play 
the  skin  makes  over  the  bone  (Pickering  Pick).  Both  cla\dcles  may  be  broken. 
One  or  more  ribs  may  be  fractured  at  the  same  time.  In  fractures  from  direct 
force  deeper  structures  may  be  injured  by  fragments.  Thus,  injury  of  the 
brachial  plexus  will  induce  paralysis.  There  are  11  recorded  cases  of  simple 
fracture  of  the  clavicle  complicated  by  laceration  of  a  large  vessel.  Eight  of 
these  cases  died.  The  vessel  ruptured  may  be  the  subclavian  vein,  the  sub- 
cla\dan  artery,  or  the  jugular  vein.  After  a  rupture  a  huge  blood-clot  forms 
(Gallois  and  Poillet,  in  ''Rev.  de  Chir.,"  July  and  Aug.,  1901). 

Treatment. — -In  treating  a  fracture  of  the  shaft  of  the  clavicle  correct  the 
deformity  as  soon  as  possible  by  tliro-\ving  the  shoulder  upward,  outward,  and 
backward.  If  the  patient  is  a  girl,  it  is  desirable  to  minimize  the  deformity. 
Place  her  upon  her  back  upon  a  hard  bed,  with  a  small  pillow  under  her  head, 
a  firm  and  narrow  cushion  between  the  shoulders,  a  bag  of  shot  resting  over 
the  seat  of  fracture,  and  the  forearm  lying 
on  the  front  of  the  chest,  the  arm  being 
held  to  the  side  by  a  sand-bag.  In  three 
weeks  there  will  be  union,  practically  with- 
out deformity.  In  a  child  with  an  in- 
complete fracture  a  handkerchief  sling  for 
the  forearm,  worn  three  weeks,  is  all  that  is 
needed.  In  a  fracture  of  the  collar-bone  of 
an  adult  the  Velpeau  bandage  is  usually 
efficient.  Before  applying  it,  place  hnt 
around  the  chest  and  cotton  over  the 
elbow.  Change  the  bandage  every  day 
for  the  first  week,  and  after  that  period 
every  third  day.  Each  time  it  is  changed 
rub  the  skin  with  alcohol,  ethereal  soap, 
or  soap  liniment,  dry  carefully,  and  ex- 
amine for  excoriations;  if  any  are  found, 
they  are  anointed  with  zinc  ointment 
before  the  dressing  is  reapplied.  The 
dressing  is  permanently  removed  at  the  end 

of  four  weeks,  the  arm  being  carried  in  a  sling  for  another  week.  The  classical 
apparatus  of  Desault  is  now  rarely  used.  The  posterior  figure-of-8  bandage 
associated  with  the  second  roller  of  Desault,  some  turns  being  made  from  the 
elbow  of  the  injured  side  to  the  shoulder  of  the  sound  side,  can  be  used  in  cases 
in  which  the  forward  deformity  is  apt  to  return.  The  apparatus  of  Fox,  which 
is  very  comfortable  and  useful,  consists  of  a  pad  for  the  axilla,  a  shng  for  the 
forearm,  and  a  ring  for  the  opposite  shoulder,  to  which  ring  are  tied  the  tapes 
from  both  the  pad  and  the  sling  (Fig.  339). 

The  dressing  of  Moore,  of  Rochester,  is  valuable  in  an  emergency.  It 
consists  of  a  piece  of  cotton  cloth,  2  yards  long,  and  folded  like  a  cravat  imtil 
it  is  8  inches  in  width  at  the  middle.  The  center  of  the  bandage  rests  upon 
the  elbow,  the  posterior  tail  is  carried  across  the  front  of  the  shoulder  of  the 
injured  side.  The  forearm  is  at  an  acute  angle  with  the  arm,  and  the  other  end 
of  the  bandage  is  carried  across  the  forearm,  across  the  back  over  the  opposite 
shoulder,  and  around  the  axilla,  where  the  extremities  are  stitched  together. 
The  forearm  is  suspended  in  a  bandage  sling  (S.  D.  Gross,  in  "A  System  of 
Surgery").  The  four-tailed  bandage  is  preferred  by  Pick.  Sa\T:e's  dressing 
has  many  advocates  (Fig.  340).  For  this  there  are  required  two  pieces  of  rubber 
plaster,  each  piece  being  3  inches  wide  and  sufficiently  long  to  go  around  the 


Fig.  339. 


Fox's  apparatus  for  fractured 
clavicle. 


632 


Diseases  and  Injuries  of  the  Bones  and  Joints 


chest  one  and  a  half  times.  The  end  of  one  piece  encircles  the  arm  of  the  injured 
side  just  below  the  arm-pit;  the  plaster  strip  is  pulled  across  the  back,  to  the 
other  side,  to  the  front  of  the  chest,  and  returns  again  to  the  middle  of  the  back. 
This  procedure  pulls  the  elbow  back,  and  throws  the  shoulder  out.  The  hand 
of  the  injured  side  is  placed  on  the  breast  of  the  opposite  side,  cotton  being 
interposed,  and  the  second  strip  of  plaster  runs  from  the  elbow  of  the  injured 
side  to  the  front  of  the  opposite  shoulder,  around,  and  back,  pressing  the  elbow 
forward,  upward,  and  inward.  If  not  changed  frequently  it  may  cause  severe 
edema  about  the  elbow.  In  children,  if  it  is  found  difficult  to  immobilize  the 
parts  in  them,  the  most  satisfactory  result  is  obtained  by  the  application  of  the 
Velpeau  bandage,  which  is  overlaid  by  a  thin  plaster-of-Paris  bandage.  If  the 
fragments  cannot  be  coaptated,  sterihze  the  parts,  administer  ether,  incise, 
clear  away  the  muscle  from  between  the  fragments,  saw  the  ends,  bore  each 
end  and  hold  them  in  contact  by  means  of  kangaroo-tendon  or  silver  wire.  The 
same  procedure  should  be  pursued  when  a  fracture  is  compound  or  threatens 
to  become  so,  or  if  signs  indicate  pressure  upon  vessels  or  nerves.     If  a  large 

vessel  has  been  injured,  the  operation  is 
imperatively  necessary.  If  a  patient  suffer- 
ing under  a  fracture  which  threatens  to 
become  compound  refuses  the  aid  of  oper- 
ation, keep  him  in  bed  and  hold  the  arm  in 
abduction.  In  a  number  of  cases  I  have 
wired  the  fragments  with  excellent  results. 
Year  by  year  I  become  more  inclined  to 
recommend  wiring  in  cases  of  fractured 
collar-bone.  It  secures  union  without  de- 
formity, saves  the  vessels  and  nerves,  and 
obviates  the  necessity  of  prolonged  and 
very  uncomfortable  fixation  of  the  arm  and 
forearm. 

After  a  broken  collar-bone  has  united, 
if   the  shoulder  is  found  to  be  stifif,  make 
passive    movements    daily;    if    these    fail, 
move  the  joint  forcibly,  first  giving  ether  or  nitrous  oxid. 

Fractures  of  the  Acromial  end  of  the  clavicle  are  due  to  direct  force.  If 
the  fracture  is  between  the  two  coracoclavicular  ligaments,  deformity  is  very 
slight,  crepitus  is  elicited  by  manipulating  with  the  fingers,  and  pain  exists,  but 
loss  of  function  is  not  markedly  manifest  unless  it  is  due  to  pain.  These  frac- 
tures are  treated  by  interposing  cotton  between  the  arm  and  the  side,  binding 
the  arm  to  the  side  with  the  second  roller  of  Desault,  and  hanging  the  hand  in  a 
sling.  In  fractures  external  to  the  ligaments  crepitus  is  manifest  on  moving 
the  shoulder,  the  outline  of  the  bone  is  irregular,  severe  pain  is  developed  by 
movement,  and  deformity  is  pronounced.  The  deformity  is  due  to  the  ser- 
ratus  magnus  muscle  rotating  the  scapula  forward,  the  inner  end  of  the  outer 
fragment  of  the  clavicle  often  coming  in  contact  with  the  anterior  surface  of  the 
outer  portion  of  the  inner  fragment.  Fracture  of  the  acromial  end  of  the 
clavicle  is  reduced  by  pulling  both  of  the  shoulders  strongly  backward,  and  it 
is  kept  reduced  by  the  use  of  a  posterior  figure-of-8  bandage.  In  fracture 
external  to  the  ligaments  the  displacement  frequently  cannot  be  corrected  by 
position  and  manipulation.  Such  cases  demand  incision  and  wiring.  In 
either  variety  of  fracture  the  dressings  are  worn  for  four  weeks. 

Fractures  of  the  sternal  end  of  the  clavicle  are  very  rare.  They  are 
caused  by  either  direct  or  indirect  force.  In  such  a  fracture  there  are  found 
crepitus,  projection  at  the  seat  of  fracture,  rigidity  of  the  sternocleido- 
mastoid muscle,  and  shortening  of  the  clavicle.  The  inner  end  of  the  outer 
fragment  always  passes  forward,  and  often  also  downward  and  inward. 
Reduce    these   fractures  by  pulling   the  shoulders  back,   and  treat  them  by 


Fig.  340. — Sayre's  adhesive-plaster 
dressing  for  fracture  of  the  clavicle 
(Stimson):  A,  First  piece;  S,  second 
piece. 


Fractures  of  the  Humerus  633 

means  of  the  posterior  figure-of-8  bandage  worn  for  four  weeks.     Wiring  may 
be  necessary. 

Fractures  of  the  Scapula. — This  bone  is  not  often  broken,  as  it  rests  upon 
thick  muscles  and  elastic  ribs;  it  is  freely  movable,  and  it  has  attached  to  it  a 
bone  which  easily  breaks. 

Fractures  of  the  Body  of  the  Scapula. — These  are  due  to  direct  violence. 
The  symptoms  are  pain  (which  becomes  agonizing  on  attempting  to  rotate  the 
shoulder-blade),  ecchymosis,  and  swelling.  Crepitus  is  sought  for  by  placing 
the  hand  over  the  bone  and  making  movements  of  the  arm;  also  by  holding  the 
point  of  the  shoulder  and  lifting  up  the  lower  angle  of  the  bone.'  The  latter 
plan  may  develop  mobility.  The  spine  of  the  scapula  is  uneven  onlv  when  it 
is  itself  fractured.  Examine  for  unevenness  of  the  vertebral  border  of  the 
shoulder-blade.  In  fractures  of  the  body  of  the  scapula  a  shoulder-cap  is 
applied,  a  gutta-percha  splint  is  molded  over  the  scapula,  the  arm  is  bound  to  the 
side,  and  the  hand  is  carried  in  a  sling.     The  apparatus  is  worn  for  four  weeks. 

Fractures  of  the  spine  of  the  scapula  are  treated  as  fractures  of  the  body 
of  the  bone,  and  for  the  same  time. 

Fractures  of  the  Neck  of  the  Scapula. — Fracture  of  the  anatomical  neck 
has  not  been  proved  to  exist.  Fracture  of  the  surgical  neck  is  evinced  by  flat- 
tening of  the  shoulder,  prominence  of  the  acromion,  and  the  presence  of  a 
lump  in  the  axilla,  crepitus  being  developed  by  pressing  the  axillary  promi- 
nence upward  and  backward.  The  coracoid  process  descends  with  the  humerus. 
The  deformity  is  reduced  with  ease,  but  it  at  once  recurs.  The  condition 
is  treated  b}-  placing  a  pad  in  the  axilla,  a  shoulder-cap  on  the  shoulder,  apply- 
ing the  second  roller  of  Desault,  and  supporting  the  forearm  and  elbow  in' a 
sling.  A  Velpeau  dressing  can  be  used,  associated  with  the  application  of  a 
folded  towel  in  the  axilla.     The  dressing  is  to  be  worn  for  five  weeks. 

Fractures  of  the  glenoid  cavity  are  not  very  unusual,  and  may  occur  with 
or  w^ithout  dislocation.  Fracture  of  this  region  arises  from  direct  force  applied 
to  the  shoulder.  The  existence  of  this  fracture  is  determined  by  excluding 
fractures  of  other  bones  and  by  detecting  crepitus  when  the  arm  is  at  a  right 
angle  to  the  body  and  the  humerus  is  pushed  against  the  glenoid  cavity,  the 
crepitus  not  being  found  when  the  arm  hangs  by  the  side. 

Treatment  is  by  the  second  roller  of  Desault  and  a  forearm  sling  worn  for 
four  weeks;  careful  passive  movements  limit  ankylosis.  If  ankylosis  occurs, 
adhesions  must  be  broken  up  while  the  patient  is  under  ether  or  nitrous  oxid. 

Fractures  of  the  acromion  process  are  often  met  with  as  the  result  of 
direct  violence.  The  existence  of  fracture  of  the  acromion  is  indicated  bv  pain, 
by  inability  to  abduct  the  arm,  by  flattening  of  the  shoulder,  by  sudden  lower- 
ing of  the  point  of  the  shoulder,  by  mobility,  and  by  crepitus.  To  treat  a 
case  of  this  kind,  put  a  large  pad  with  the  base  down  in  the  axilla,  bind  the 
arm  over  the  pad  with  the  second  roller  of  Desault,  lifting  the  elbow  with 
turns  of  the  roller  carried  over  it  and  the  opposite  shoulder,  thus  splinting 
the  bone  in  place  by  the  head  of  the  humerus  pushing  against  the  coraco- 
acromial  ligaments.     The  dressing  is  to  be  w-orn  for  four  weeks. 

Fractures  of  the  coracoid  process  rarely  happen  alone,  and  are  usually  due  to 
direct  force.  Muscular  action  is  very  seldom  the  cause.  Petty  found  in 
literature  but  three  cases  so  caused.  He  adds  one  of  his  own  (Annals  of 
Surgery,  March,  1907).  But  Uttle  displacement  is  found.  •  Crepitus  and 
mobiUty  are  usually  detected.  Inability  to  shrug  the  shoulder  inward  was 
pointed  out  as  a  symptom  by  Byers.  Such  a  case  is  well  treated  by  a  Velpeau 
bandage,  which  is  to  be  worn  for  four  weeks. 

Fractures  of  the  humerus  are  divided  into:  (i)  fractures  of  the  upper  ex- 
tremity; (2)  fractures  of  the  shaft,  and  (3)  fractures  of  the  lower  extremity. 
In  examining  any  fracture  of  the  humerus,  feel  at  once  for  the  pulse,  so  as  to 
ascertain  if  the  artery  has  been  torn;  in  any  fracture  near  the  head  of  the 
humerus  be  certain  that  dislocation  does  not  exist. 


634  Diseases  and  Injuries  of  the  Bones  and  Joints 

Examination  of  the  Shoulder. — In  some  cases  ether  must  be  administered. 
Compare  the  injured  shoulder  with  the  sound  shoulder,  the  patient,  if  not 
anesthetized,  being  seated  on  a  chair  or  stool.  The  direction  of  the  axis  of 
the  arm  is  noted.  The  surgeon  grasps  the  flexed  elbow  with  one  hand  and 
the  shoulder  with  the  other;  he  thus  can  move  the  extremity  and  palpate  the 
joint  and  adjacent  points.  The  shoulder  is  moved  gently  in  every  direction, 
and  the  surgeon  notes  if  the  head  of  the  bone  moves  with  the  shaft.  Exami- 
nation shows  if  the  head  of  the  bone  is  in  place  or  if  the  glenoid  cavity 
is  vacant — if  the  head  of  the  bone  is  in  an  abnormal  situation,  if  it  is  altered 
in  contour,  if  there  is  crepitus  or  preternatural  mobility,  and  if  any  movement 
is  impaired.  The  acromion  process,  outer  end  of  the  clavicle,  coracoid  process 
of  the  scapula,  and  neck  of  the  scapula  are  also  investigated.  The  length  of 
the  arm  is  obtained  by  measuring  from  the  apex  of  the  acromion  process 
of  the  scapula  to  the  apex  of  the  external  condyle  of  the  humerus,  and  it  is 
compared  with  the  length  of  the  sound  extremity. 

Fractures  of  the  upper  extremity  of  the  humerus  include:  (o)  fractures 
of  the  anatomical  neck;  (b)  fractures  of  the  surgical  neck;  (c)  fractures  of  the 
head,  oblique  and  longitudinal,  and  (d)  separation  of  the  upper  epiphysis. 

Fractures  of  the  Anatomical  Neck  of  the  Humerus. — The  anatomical  neck 
is  the  constricted  circumference  of  the  articular  surface,  and  fractures  of  it, 
though  rare,  do  occur,  especially  in  the  aged.  The  line  of  fracture  in  some 
cases  follows  the  insertion  of  the  capsule,  in  others  it  is  entirely  within  the 
capsule,  but  in  most  it  is  without  the  capsule  above  and  within  the  capsule 
below;  hence  the  term  "intracapsular"  is  rarely  correct  as  a  designation. 
Such  a  fracture  may  be  impacted.  The  cause  is  direct  violence  or  a  fall  or 
a  blow  upon  the  elbow  when  the  arm  is  abducted.  PoUoson,  of  Lyons, ^  has 
reported  a  case  due  to  muscular  action.  The  patient  died  in  eclampsia,  and 
at  the  necropsy  it  was  found  that  both  humeral  heads  were  fractured  and 
impacted.  The  fractures  must  have  been  produced  by  the  muscles  throwing 
the  heads  of  the  bones  violently  against  the  glenoid  cavities,  probably  by 
adduction. 

The  symptoms  of  fracture  of  the  anatomical  neck  are  pain,  tenderness,  swell- 
ing, ecchymosis,  slight  irregularity  of  the  shoulder  (which  irregularity  is  soon 
hidden  by  tumefaction),  and  inabihty  to  abduct  the  arm  actively.  Deformity, 
as  a  rule,  is  slight  or  is  absent,  because  the  capsule  is  rarely  entirely  torn  from 
the  lower  fragment.  If  deformity  exists,  it  is  due  to  the  muscles  inserted  on 
the  bicipital  groove  and  to  the  coracobrachialis,  which  pull  the  lower  fragment 
inward  and  forward.  Treves  says  that  a  tear  of  the  reflected  fibers  of  the  cap- 
sule leads  to  subsequent  necrosis  of  bone  because  this  joint  has  no  ligamentum 
teres.  In  unimpacted  cases  there  is  crepitus,  and  mobility  of  the  shaft  can 
be  detected  near  the  head  of  the  bone.  In  some  cases  impaction  occurs,  the 
upper  fragment  impacting  into  the  lower.  In  this  condition  there  are  very 
slight  shortening  and  trivial  shoulder-flattening,  no  crepitus  unless  the  tuber- 
osity is  broken  off,  no  mobility,  and,  as  Erichsen  says,  the  head  of  the  bone, 
while  it  can  be  felt  through  the  axilla,  is  not  in  the  axis  of  the  limb. 

The  prognosis  of  fracture  of  the  anatomical  neck  is  usually  good  for  bony 
union  (Hamilton,  Pick,  and  R.  W.  Smith),  but  a  stiff  joint  is  apt  to  result. 

Treatment. — Feel  the  pulse  to  be  sure  the  artery  is  untorn.  In  most  cases 
an  anesthetic  should  be  given  in  order  to  examine  with  ease  and  dress  with 
satisfaction.  Sometimes  the  fragments  are  readily  coaptated;  occasionally 
they  are  not.  In  a  case  reported  by  Carl  Beck  the  axes  of  the  fragments 
were  at  right  angles  and  they  could  only  be  kept  in  contact  by  holding  the 
arm  at  a  right  angle  to  the  body  ("New  York  Med.  Jour.,"  April  5,  1902). 
Albee,  of  New  York,  reported  a  series  of  these  fractures  treated  by  wiring  and 
maintaining  the  arm  at  a  right  angle  with  the  body.     The  result  was  com- 

i"Rev.  de  Chir.,"  vol.  viii,  1888. 


SPLINTS. 


I'LAIE  7, 


I.  Fracture-box.  2.  Double  Inclined  Plane  Fracture-box.  3.  Jaw-cup  (unfolded).  4.  Jaw-cup 
(folded).  5.  Anterior  Angular  Splint.  6.  Internal  Angular  Splint.  7.  Bond  Splint.  8.  Shoulder-cap. 
9.  Dupuytren  Splint  in  Pott's  Fracture.  10.  Agnew  Splint  for  Fracture  of  the  Metacarpus.  11.  Agnew 
Splint  for  Fracture  of  the  Patella.  12.  Agnew  Splint  applied.  13.  Strapping  the  Chest  in  Fractured 
Ribs.  14.  Extension  Apparatus  in  Fracture  of  the  Femur.  15,  16.  Adhesive  Strips  for  Extension 
Apparatus. 


Fractures  of  the  Anatomical  Neck  of  the  Humerus 


635 


plete  preservation  of  function.  Some  surgeons  treat  this  fracture  by  simply 
hanging  the  wrist  in  a  sling  and  suspending  a  bag  of  shot  from  the  elbow  to 
make  extension.     The  usual  plan  of  treatment  is  as  follows:  abduct  the  arm  to 


Fig.  341. — Fracture  at  upper  end  of  the  Fig.  342. — Fracture  at  upper  end  of  the 

humerus.  Note  hand,  forearm,  and  elbow  humerus.  Arm  and  elbow  bandaged.  Axil- 
bandaged;  axillary  pad  and  strap,  plaster-of-  lary  pad  and  shoulder-cap  in  position.  Ap- 
Paris  shoulder-cap,  sling  (Scudder).  plication  of  circular  bandage  to  trunk  and 

shoulder.     Sling  not  sho^m  (Scudder). 

a  right  angle  with  the  body,  and  carry  up  from  the  base  of  the  fingers  to  above 
the  elbow  the  turns  of  a  spiral  reversed  bandage  made  of  flannel.  Interpose 
lint  between  the  arm  and  the  side,  and  place  a  V-shaped  pad  with  the  apex 
upward  in  the  axilla,  tying  the  tapes  over  the  oppo- 
site shoulder.  A  shoulder- cap  made  of  pasteboard 
(PL  7,  Fig.  8)  or  plaster  of  Paris  (Fig.  341), 
molded  to  fit  and  well  lined  with  cotton,  is  ap- 
pHed.  The  plaster-of-Paris  cap  is  the  most  satis- 
factory. It  is  applied  "so  as  to  cover  the  whole 
shoulder,  the  anterior  and  posterior  aspects  of  the 
chest,  and  the  outer  side  of  the  upper  arm  down 
to  the  external  condyle  of  the  humerus"  (Scudder, 
on  "The  Treatment  of  Fractures")  (Fig.  341). 
The  arm  with  the  shoulder-cap  is  fixed  to  the 
side  by  the  second  roller  of  Desault,  and  the 
wrist  is  hung  in  a  sling  (Fig.  342).  The  edges  of 
the  bandage  should  be  stitched  together.  This 
apparatus  is  changed  daily  for  the  first  few  days, 
the  body  and  arm  being  rubbed  at  each  change 
with  alcohol,  soap  liniment,  or  ethereal  soap. 
After  this  period  a  change  every  third  or  fourth 
day  is  often  enough.  Massage  is  begun  at  the  end  of  one  week,  but  rotation 
and  motion  of  the  joint  are  not  employed  until  after  three  weeks.  The 
dressings  are  removed  at  the  end  of  four  weeks,  the  forearm  being  carried  in 
a  sling  for  two  weeks  more.  In  impacted  fracture  do  not  pull  apart  the  im- 
paction, do  not  use  a  pad,  but  apply  a  cap  to  the  shoulder  and  fix  the  arm  to 
the  side  for  five  weeks.     The  fracture  unites  with  deformitv. 


Fig.  343. — Internal  angular 
splint  and  shoulder-cap  in 
fracture  of  the  surgical  neck 
of  the  humerus. 


636 


Diseases  and    Injuries  of  the  Bones  and  Joints 


Fractures  of  the  Surgical  Neck  of  the  Humerus. — ^The  surgical  neck  is 
the  constricted  portion  of  bone  between  the  tuberosities  and  the  upper  Hne 
of  the  insertion  of  the  muscles  on  the  bicipital  groove.  Fractures  in  this 
region  are  usually  transverse,  but  they  may  be  oblique.  The  causes  are: 
direct  force  almost  always;  indirect  force  occasionally;  and  muscular  action  in 
rare  instances.  The  common  cause  is  a  fall  or  blow  upon  the  shoulder  when 
the  elbow  is  fixed.  When  the  shoulder  is  fixed  forcible  abduction  of  the  elbow 
may  cause  the  fracture.  The  middle  aged  and  the  elderly  are  most  liable  to 
this  fracture  but  youths  are  not  exempt.  Over  13  per  cent,  of  Ross's  cases  were 
under  sixteen  years  of  age  ("Penn.  Med.  Jour.,"  1914,  xvii). 

The  symptoms  in  fracture  of  the  surgical  neck  are:  pain  running  into  the 
fingers  from  pressure  upon  the  brachial  plexus;  crepitus;  mobility  on  extension; 

and  flattening,  which  differs  from  the  flat- 
tening of  dislocation  in  that  it  occurs 
farther  below  the  acromion  and  that  this 
process  is  not  so  prominent.  Shortening 
to  the  extent  of  an  inch  is  noted.  The 
head  of  the  bone  can  be  felt  in  the  glenoid 
cavity,  but  it  does  not  move  on  rotating 
the  arm.  The  upper  end  of  the  lower  frag- 
ment is  felt  and  moves  on  rotating  the  arm. 
The  displacement  is  pronounced.  The 
lower  fragment  is  pulled  upward  by  the 
deltoid,  biceps,  coracobrachialis,  and  tri- 
ceps; inward  by  the  muscles  of  the  bicipital 


P"iG.  344. — Fracture   of   humerus  below 
surgical  neck. 


Fig.  345. — Preliminary  splinting  for  complete 
dressing  as  shown  in  Fig.  354. 


groove,  and  forward  by  the  great  pectoral;  thus,  the  upper  end  of  the  lower  frag- 
ment projects  into  the  axilla,  and  the  elbow  stands  out  from  the  side  and  backward. 
Pean  holds  that  the  violence  drives  the  lower  fragment  forward.  The  upper 
fragment  is  abducted,  rotated  outward,  and  flexed,  which  position  is  due,  it 
is  generally  taught,  to  the  action  of  the  supraspinatus,  infraspinatus,  and 
teres  minor  muscles.  In  some  cases  displacement  is  forward,  and  in  other  cases 
it  is  not  obvious.  The  lower  fragment  may  impact  into  the  upper,  in  which 
case  the  symptoms  are  obscure  and  the  diagnosis  is  made  by  exclusion.  If  the 
impaction  is  solid  and  complete,  there  are  the  history  of  direct  force,  the 
impaired  movements,  the  slight  deformity,  and  the  absence  of  crepitus.  In  all 
fractures  of  the  upper  end  of  the  humerus  the  distinction  can  be  made  from 
dislocation  by  feeling  the  head  of  the  bone  under  the  acromion  and  by  noting 
that  it  does  not  move  on  rotating  the  arm.     Among  complications  are  fracture 


Fractures  of  the  Surgical  Neck  of  the  Humerus 


637 


Fig.  346.— a,  Thomas'  splint  for  arm.     This  is        Fig.  347, — Bowlby's  or  Clarke's 
bent  to  nearly  a  right  angle  at  a  a*  for  transport  arm  splint, 

on  a  stretcher.    B,  Thomas'  arm  splint  with  swivel. 


Fig.  348. — D,  Bowlby's  splint  applied  for  fracture  of  right  humerus.     A  narrow  sling  should 
also  be  used.     E,  Thomas'  arm  splint  (bent  near  ring),  applied  for  low  fracture  of  left  humerus. 


638 


Diseases  and  Injuries  of  the  Bones  and  Joints 


of  the  tuberosities  (nearly  18  per  cent,  of  Ross's  cases)  and  dislocation  of  the 
head  of  the  bone  (nearly  6  per  cent,  of  Ross's  cases). 

The  prognosis  of  fracture  of  the  surgical  neck  of  the  bone  is  good. 

Treatment. — Some  surgeons  treat  a  fracture  of  the  surgical  neck  in  exactly 
the  same  manner  as  a  fracture  of  the  anatomical  neck.  I  prefer  the  following 
plan:  In  many  cases  give  ether  in  order  to  examine  and  dress.     Feel  the  pulse 


Fig.  349. — A,  Depage  modified  humerus  splint.     B,  Applied  for  fracture  of  right  humerus. 


Fig.  350.— a,  Extempore  aluminum  or  strong  wire  splint  for  fracture  of  humerus.     B,  Applied 

for  fracture  of  left  humerus. 

to  see  that  the  artery  has  not  been  damaged.  Reduce  by  traction  and  manipu- 
lation, especially  abduction.  If  there  is  an  impaction  do  not  pull  it  apart 
unless  the  fragments  are  in  a  vicious  position.  Take  an  internal  angular  splint 
(PI.  7,  Fig.  6)  and  pad  it  well,  putting  on  extra  padding  at  the  points  that  are 
to  rest  against  the  palm,  the  inner  condyle,  and  the  axillary  folds.  Lay  the 
arm  and  pronated  forearm  upon  the  splint.  Apply  a  padded  shoulder-cap. 
Fix  the  splint  and  can  in  place  with  a  spiral  reversed  bandage  terminating  as  a 


Longitudinal  and  Oblique  Fractures  of  the  Head  of  the  Humerus     639 

spica  of  the  shoulder,  and  hang  the  hand  or  forearm  in  a  sling  (Fig.  343). 
The  dressing  is  to  be  worn  for  four  weeks,  and  the  rules  to  be  followed  in  chang- 
ing it  are  the  same  as  in  fracture  of  the  anatomical  neck.  Massage  is  used 
after  one  week,  and  passive  motion  to  amend  stilTness  after  four  weeks.  Forcible 
breaking  up  of  adhesions  is  not  admissible  for  at  least  three  months.  In 
rare  cases — those  with  strong  anterior  projection  of  the  lower  end  of  the  upper 
fragment — apply  an  anterior  angular  splint.  If  the  deformity  strongly  tends  to 
recur,  support  by  a  plaster-of-Paris  trough  on  the  back  and  sides  of  the  arm  and 
shoulder,  or  sling  the  extremity  and  obtain  extension  by  weights  and  pulleys 
used  with  a  frame,  the  patient  being  kept  in  bed  (Jones'  extension  splint  is  a 
very  valuable  appliance).  In  a  case  with  great  deformity  abduction  with 
extension  is  a  very  useful  method.     I  have  reached  the  conclusion  that  quite  a 


Fig.  351. — A,  Jones'  extension  humerus  splint.     B,  Applied  for  fracture  of  left  humerus. 
The  padded  portion  should  be  higher  up  in  the  axilla. 

number  of  cases  of  fracture  of  the  surgical  neck  are  best  treated  by  incision 
and  fixation.  Operation  is  often  necessary  if  the  upper  end  of  the  lower  frag- 
ment is  displaced  to  the  outer  side.  If  the  fracture  is  complicated  by  a  com- 
plete dislocation  operation  is  needed  to  replace  the  head  and  fix  the  fragments. 
A  partial  dislocation  may  disappear  under  extension  (Ross,  Ibid.). 

Longitudinal  and  Oblique  Fractures  of  the  Head  of  the  Humerus. — By 
this  term  may  be  designated  separation  of  the  great  tuberosity  or  separation 
of  a  portion  of  the  articular  surface,  together  with  the  great  tuberosity,  from 
the  shaft  and  lesser  tuberosity  (Pickering  Pick,  Guthrie,  and  Ogston).  The 
cause  is  usually  direct  violence  to  the  front  of  the  shoulder,  but  the  greater 
tuberosity  may  be  torn  off  by  muscular  action. 

The  symptoms  in  longitudinal  and  oblique  fracture  of  the  head  are  broad- 
ening and  flattening  of  the  shoulder  with  projection  of  the  acromion.  The 
upper  fragment  passes  upward  and  outward,  and  the  lower  fragment  passes 
upward  and  inward  to  rest  on  the  margin  of  the  glenoid  ca\dty  below  the 


640  Diseases  and  Injuries  of  the  Bones  and  Joints 

coracoid  process.  The  elbow  is  drawn  from  the  side,  there  is  some  shortening, 
and  the  patient  cannot  abduct  his  arm.  If  the  surgeon  grasps  the  patient's 
elbow  and  holds  it  to  the  side  and  rotates  the  arm  while  with  his  other  hand  he 
grasps  the  upper  fragment,  crepitus  is  very  positive.  Examination  develops 
wide  separation  of  the  fragments.  The  deformity  cannot  be  entirely  corrected, 
because  the  biceps  tendon  is  apt  to  get  between  the  fragments  (Ogston),  but 
a  useful  limb  can  usually  be  obtained. 

Treatment. — The  plan  which  gives  the  best  result  in  treating  longitudinal 

and  oblique  fracture  of  the  head  of  the  bone  is  to  place  the  {)atient  on  his  back 

upon  a  hard  bed  with  a  small,  firm  pillow  under  his  head, 

abduct  the  arm  above  the  head,  rotate  it  outward  so 

that  the  back  of  the  hand  rests  on  the  bed,  and  hold 

it   in    place    by   sand-bags.     This    position   should   be 

maintained  for  three  weeks,  at  the  end  of  which  period 

the  fracture  can  be  treated  for  three  weeks  more  as  a 

fracture  of  the  anatomical  neck.     If  the  patient  refuses 

to   go   to   bed,   treat   the  injury  as  a  fracture  of  the 

anatomical    neck,    padding  well  over   the  tuberosities. 

The  dressings   should  be  worn  for  five  weeks,  passive 

motion   being  made  after  four  weeks.     In  the  above 

Pig.    352. — Linear  frac-     injury  feel  at  once  for  the  pulse,  to  see  if  the  artery  has 

ture  of  humerus.  been  torn. 

Separation  of  the  Upper  Epiphysis  of  the  Humerus. — 
The  epiphysis  is  united  during  the  twentieth  year.  Separation  is  a  rare  acci- 
dent and  is  produced  by  direct  force. 

Symptoms. — The  chief  symptom  in  separation  of  the  upper  epiphysis  is 
projection  of  the  upper  end  of  the  lower  fragment  inward,  forward,  and 
upward  beneath  the  coracoid,  and  consequently  a  projection  of  the  elbow 
backward  and  from  the  side.  If  the  lower  fragment  passes  forward  and  not 
inward,  the  elbow  simply  passes  back.  The  upper  end  of  the  lower  fragment 
is  smooth  and  convex.  Rotation  of  the  shaft  develops  soft  crepitus  when  the 
fragments  are  in  contact. 

The  prognosis  is  good  for  bony  union,  though  the  future  growth  of  the 
limb  may  be  impaired. 

The  treatment  for  separation  of  the  upper  epiphysis  is  a  pad  in  the  axilla, 
a  shoulder-cap,  binding  the  arm  to  the  side,  and  hanging  the  hand  in  a  sling. 
Wear  the  dressing  for  four  weeks,  and  begin  passive  motion  as  directed  when 
dealing  with  fracture  of  the  upper  end  of  the  humerus. 

Fracture  of  the  shaft  of  the  humerus  is  a  very  common  accident.  The 
cause  is  usually  direct  violence,  such  as  a  blow.  The  fracture  may  arise  from 
indirect  violence,  such  as  a  fall  upon  the  elbow.  Muscular  action  is  occasion- 
ally a  cause,  as  in  throwing  a  ball,  in  catching  a  tree-limb  while  falling,  or  in 
turning  another's  wTist  outward  as  a  test  of  strength  (Treves).  This  test  of 
strength  is  known  by  the  French  as  "le  tour  de  poignet." 

The  opponents  sit  opposite  to  each  other  and  each  rests  his  elbow  on  a 
table.  They  clasp  hands  and  each  one  strives  to  rotate  the  other's  hand  out- 
ward. Ashhurst  collected  57  cases  due  to  throwing  a  ball  and  23  cases  due  to 
"le  tour  de  poignet."  He  believes  that  in  some  cases  the  humerus  is  broken  as 
a  stick  may  be  broken  by  holding  one  end  and  swinging  the  other  through  the 
air  and  that  in  other  cases  fracture  results  from  twisting  (Astley  P.  C.  Ash- 
hurst, in  "University  of  Pennsylvania  Med.  Bulletin,"  Feb.,  1906).  In  frac- 
ture due  to  muscular  action  the  break  is  nearly  always  below  the  deltoid  inser- 
tion and  the  line  of  fracture  approaches  the  transverse. 

The  symptoms  of  fracture  of  the  shaft  of  the  humerus  are  pain,  tenderness, 
swelling,  ecchymosis,  inability  to  move  the  arm,  mobility,  and  distinct  crepitus. 
Shortening  to  the  extent  of  %  inch  occurs.     The  displacement  varies  with  the 


Fracture  of  the  Shaft  of  the  Humerus 


641 


situation  of  the  fracture  and  the  direction  of  the  force.  If  the  fracture  is  above 
the  insertion  of  the  deltoid,  the  lower  fragment  is  pulled  up  by  the  triceps, 
biceps,  and  deltoid,  and  pulled  out  by  the  deltoid,  and  the  upper  fragment  is 
pulled  inward  by  the  arm-pit  muscles.  In  fracture  below  the  (Klloid  ihis  mus- 
cle is  apt  to  pull  the  lower  end  of  the 
upper  fragment  outward,  while  the  lower 


Fig.  353.— Fracture  of  middle  of  humerus.       Fig.  354. — Apparatus  for  fracture  of  the  hume- 
rus at  any  point  above  the  condyles. 

fragment  passes  inward  and  upward  because  of  the  action  of  the  biceps  and 
triceps.     Injury  of  the  niiiscidospiral  nerve  sometimes  occurs.     The  nerve  may 


Fig.  355. — The  humerus  triangle.     This  splint  is  one  of  the  most  useful  splints  for  the  treat- 
ment of  fractures  of  the  arm  and  forearm  (Hull). 

be  contused,  producing  pain  at  the  seat  of  bruising,  and  tingling  and  numb- 
ness in  the  region  supphed  by  the  nerve.     In  most  cases  the  symptoms  soon 
pass  away,  but  sometimes  neuritis  ensues.     A  severe  contusion  produces  not 
41 


042 


Diseases  and  Injuries  of  the  Bones  and  Joints 


only  pain,  but  paralysis  of  the  muscles  supplied  by  the  nerve,  and  surface 
anesthesia.  In  most  cases  this  condition  is  recovered  from  in  a  few  weeks, 
but  sometimes  it  lasts  a  long  while  or  even  permanently.  In  musculospiral 
paralysis  the  patient  is  unable  to  extend  the  wrist  and  fingers  or  to  supinate 
the  forearm.  There  is  "complete  loss  or  impaired  sensation  in  the  lower 
half  of  the  outer  and  anterior  aspect  of  the  arm  and  in  the  middle  of  the  back 
of  the  forearm  as  far  as  the  wrist"  (Scudder,  in  "The  Treatment  of  Fractures"). 
The  nerve  may  be  divided  by  a  sharp  fragment,  paralysis  of  motion  and  anes- 
thesia resulting  at  once.  In  some  cases  the  nerve  is  caught  in  and  compressed 
by  callus,  scar-tissue,  or  fragments,  motor  and  sensory  disturbances  resulting. 

The  prognosis  is  good,  but  the 
fact  should  always  be  remembered 
that  ununited  fractures  are  com- 
moner in  the  humerus  than  in  any 
other  bone.  Treves  believes  this 
to  be  due  to  entanglement  of 
muscle    between    the    fragments, 


Fig.  356. — Modified  Thomas  splint 
used  by  Major  Robert  Jones  in  cases 
of  fracture  of  the  humerus  (Hull). 


Fig.  357. — Jones  humerus  traction  splint.  The 
American  pattern  of  the  splint  is  here  illustrated.  By 
changing  the  pattern  of  the  axillary  crutch  the  splint 
is  made  adaptable  to  either  side  of  the  body.  By 
slightly  lengthening  the  forearm  piece,  traction  on 
the  forearm  may  be  obtained  (Osgood). 


lack  of  fixation  of  the  shoulder-joint,  and  imperfect  elbow  support.  Hamilton 
believes  that  it  is  due  to  the  facts  that  the  elbow  soon  becomes  fixed  at  a 
right  angle,  and  that  any  movement  of  the  forearm  moves  the  seat  of  fracture 
and  not  the  elbow. 

Treatment. — It  is  rarely  necessary  to  anesthetize  unless  the  patient  be  a 
nervous  woman  or  an  excitable  child.  Feel  the  pulse,  to  be  certain  the  artery 
has  not  been  lacerated.  Reduce  the  fracture  by  extension,  counterextension,  and 
manipulation.     The  injury  may  be  treated  by  Bowlby's  splint  (Fig.  348) ,  Jones's 


Fracture  of  the  Shaft  of  the  Humerus 


643 


extension  spHnt  (Figs.  351, 356  and  357)  or  Thomas's  spUnt  (Figs.  346  and  348)  or 
the  humerus  triangle  (Fig.  355).  Depage's  spUnt  (Figs.  349  and  350)  is  a  useful 
improvised  appliance.  I  usually  employ  humeral  splints  (Fig.  345).  The  internal 
splint  reaches  from  the  axilla  to  just  above  the  internal  condyle  of  the  humerus. 
A  short  straight  spUnt  is  applied  front  and  another  back,  each  being  the  length  of 
the  arm.  A  shoulder-cap  is  applied,  which  cap  ''is  prolonged  below  into  an 
external  angular  splint  reaching  as  far  down  as  the  lower  third  of  the  forearm" 
("Manual  of  Surgical  Treatment,"  by  Cheyne  and  Burghard).  The  elbow 
is  brought  to  a  right  angle  with  the  arm  and  the  forearm  is  placed  midway 
between  pronation  and  supination.  As  Cheyne  and  Burghard  say:  "It  is 
necessary  that  the  arm  should  hang  vertically  at  the  side  with  the  long  a.xis 
of  the  forearm  parallel  with  the  anteroposterior  diameter  of  the  trunk;  if  the 
forearm  be  brought  at  all  forward  across  the  chest,  rotation  of  the  lower  frag- 
ment upon  its  vertical  axis  is  apt  to  take  place."     Splints  are  to  be  worn  for 


Fig.  358. — Fracture  of  the  shaft  of  the 
humerus.  Note  bandage  to  hand,  forearm, 
and  elbow;  a.xillary  pad  and  strap;  coaptation 
splints  and  sling.  Bandage  does  not  cover 
fracture  (Scudder). 


Fig.  359. — Fracture  of  the  shaft  of  the 
humerus.  Note  bandage  to  hand,  forearm, 
and  elbow;  adhesive-plaster  swathe  holding 
arm  upon  axillary  pad  and  covering  coapta- 
tion splints.     Sling  (Scudder). 


five  or  six  weeks,  and  after  the  removal  of  the  splints  the  wrist  is  hung  in  a 
sling.  The  sling  is  dispensed  with  eight  weeks  after  the  infliction  of  the  injury. 
Passive  movements  are  not  to  be  made  until  the  fracture  is  well  united  (after 
five  or  six  weeks),  for,  if  made  too  soon,  they  predispose  to  non-union,  and,  as 
no  joint  is  involved,  genuine  ankylosis  will  not  occur.  Many  surgeons  treat  these 
fractures  by  applying  plaster  of  Paris  to  the  forearm  and  the  arm  (the  elbow  being 
flexed  to  a  right  angle),  binding  the  arm  to  the  side,  and  hanging  the  wrist  in  a 
sling.  Others  apply  a  trough  to  the  arm  and  forearm.  With  Scudder  I  usually 
prefer  to  bandage  the  hand,  forearm,  and  elbow,  and  apply  an  axillary  pad, 
coaptation  splints,  a  swathe  of  adhesive  plaster  holding  arm  to  the  side,  and  a 
sling  (Figs.  358,  359).  In  any  case  in  which  it  is  impossible  to  obtain  and 
maintain  correct  apposition  of  the  fragments,  cut  down  upon  them,  and  apply 
a  plate.  If  the  nerve  is  divided,  an  incision  must  be  made  at  once,  the  nerve 
sutured,  and  the  bone  plated.  If  the  nerve  is  caught  in  the  callus,  after  repair 
has  taken  place  if  must  be  liberated  by  chiseling  the  callus  away.     Neuritis  is 


644  Diseases  and  Injuries  of  the  Bones  and  Joints 

treated  by  blisters  over  the  nerve,  the  use  of  the  descending  galvanic  current, 
and  the  administration  of  salicylate  of  ammonium  and  the  bromids. 

Fractures  of  the  Lower  Extremity  of  the  Humerus. — These  fractures  are 
spoken  of  as  fractures  in,  or  in  the  neighborhood  of,  the  elbow-joint,  and 
they  include:  (a)  fractures  of  the  external  condyle;  (b)  fractures  of  the  in- 
ternal condyle;  (c)  fractures  of  the  internal  epicondyle;  (d)  fractures  at  the 
base  of  the  condyles;  (e)  T-  or  Y-shaped  fractures;  (/)  epiphyseal  separation, 
and  (g)  fractures  of  the  capitellum  and  trochlea.  There  may  be  more  than  one 
fracture,  or  there  may  be  also  a  dislocation  of  the  humerus,  of  the  ulna,  or  of 
both  bones.  Rarely  the  fracture  is  compound.  These  fractures  are  frequent 
injuries  in  childhood,  and  are  not  uncommon  in  adults. 

Method  of  Examination. — A  fracture  of  the  elbow  is  rapidly  followed  by 
great  swelling,  and  the  diagnosis  is  often  very  difficult.  In  most  cases,  when 
possible,  the  x-rays  should  be  used  in  arriving  at  a  diagnosis.  In  every  case 
in  which  the  x-rays  are  not  used,  and  in  most  cases  in  which  they  are,  the  sur- 
geon examines  the  parts  carefully  while  the  patient  is  under  ether.  If  swelling 
is  very  great;  it  is  necessary  to  abate  it  in  order  to  reach  any  conclusion  as  to  the 
condition.  We  can  bandage  the  arm,  rest  it  semiflexed  on  a  pillow,  and  apply 
evaporating  lotions  or  even  an  ice-bag  for  a  few  hours,  or,  what  is  better,  tem- 
porarily diminish  the  swelling  by  Gerster's  plan,  which  is  as  follows:  Apply  an 
Esmarch  bandage  from  the  hand  to  well  above  the  seat  of  fracture;  this  will 
drive  away  extra-articular  swelling  and  permit  of  thorough  examination.  It 
is  a  great  advantage  to  have  the  patient  anesthetized,  for  then  not  only  can 
we  make  an  accurate  diagnosis,  but  we  can  reduce  the  fracture  satisfactorily 
and  apply  a  careful  first  dressing. 

Compare  the  injured  with  the  sound  elbow.  Note  swelling  and  local 
ecchymosis.  Feel  for  the  radial  pulse.  Note  the  "carrying  angle"  (Fig.  361). 
Measure  each  arm  from  the  tip  of  the  acromion  process  of  the  scapula  to  the 
tip  of  the  external  condyle  of  the  humerus.  Feel  each  prominent  bony  point 
and  note  if  it  is  mobile  (condyles,  olecranon,  head  of  ulna).  Feel  the  shaft 
just  above  the  condyles.  Mark  with  ink  on  each  elbow  the  tip  of  the  ex- 
ternal condyle,  the  tip  of  the  internal  condyle,  and  the  tip  of  the  olecranon, 
and  observe  the  relation  between  these  points  of  each  elbow  in  flexion  and  in 
extension.  In  an  uninjured  elbow  a  straight  line  transverse  to  the  long  axis  of 
the  limb  with  the  joint  in  extension  will  pass  through  the  condyles  and  leave 
the  tip  of  the  olecranon  just  a  shade  above  it.  "  When  the  elbow  is  at  a  right 
angle,  these  three  points  will  be  found  in  the  same  plane  with  the  back  of  the 
upper  arm"  (Scudder,  in  "The  Treatment  of  Fractures").  Rotate  the  radius 
while  a  thumb  is  held  against  the  head  of  the  bone.  Make  flexion  and  exten- 
sion of  the  elbow  and  determine  if  there  is  any  lateral  motion.  Test  for  mobility 
just  above  the  condyles.  The  above  maneuvers  will  determine  the  presence  or 
absence  of  crepitus,  preternatural  mobility,  deformity,  etc. 

Fractures  of  the  External  Condyle  of  the  Humerus. — A  fracture  of  the 
external  condyle  runs  into  the  joint  and  the  capitellum  is  usually  broken  oflf. 
Such  an  injury  occurs  oftenest  in  children,  being  due  to  fafling  on  the  hand; 
but  it  may  occur  from  direct  force,  and  may  happen  to  adults. 

The  symptoms  of  fracture  of  the  external  condyle  are  severe  pain,  great 
swelhng,  and  crepitus  (found  on  pressing  or  moving  the  condyle  and  on  ro- 
tating the  radius).  MobUity  may  also  be  discovered.  A  projection  is  felt  on 
the  outer  and  posterior  surface  of  the  elbow.  The  forearm  is  semiflexed  and 
supinated.     The  patient  cannot  use  the  joint. 

Fractures  of  the  Inner  Epicondyle  of  the  Humerus. — The  inner  epicondyle 
is  an  epiphysis  which  unites  during  the  seventeenth  year.  It  not  infrequently 
breaks  from  muscular  action  or  from  direct  violence,  and  the  fracture  does  not 
involve  the  joint.  Crepitus  and  mobility  can  be  detected.  Displacement 
is  slight.     The  outer  epicondyle  is  never  fractured  alone. 


T-fractures  of  the  Humerus 


645 


Fractures  of  the  Internal  Condyle  of  the  Humerus. — The  Hne  of  fracture  after 
a  break  of  the  iniernal  condyle  runs  into  the  joint  through  the  trochlear  surface 
of  the  humerus.  The  cause  is  nearly  always  direct  violence.  Packard,  of  Phila- 
delphia, observed  a  case  in  which  the  condyle  had  been  torn  off  while  lifting  a  tub. 

Symptoms. — In  fracture  of  the  internal  condyle  the  fragment,  accompanied 
by  the  ulna,  goes  upward  and  backward,  and  when  the  forearm  is  extended 
tihe  ulna  projects  posteriorly, 
the  lower  end  of  the  humerus 
being  felt  in  front.  The  frag- 
ment forms  a  projection  back 
of  the  elbow.  Crepitus  and 
preternatural  mobility  can  be 
found  if  swelling  is  not  too 
great.  Crepitus  is  detected 
by  flexing  and  extending  the 
forearm.  The  space  between 
the  condyles  is  broader  than 
normal,  and  the  forearm  takes 
a  bend  toward  the  ulnar  side, 
the  "carrying  function'' of  the 
forearm  being  lost  (Fig.  360). 
\\Tien  a  person  carries  a  heavy 
object,  such  as  a  bucket  of 
coal,  he  instinctively  rests  the 
inner  condyle  upon  the  pelvis, 
and  the  normal  deviation  of 
the  forearm  outward  keeps  the 
bucket  from  strikmg  the  leg. 
This  deviation  outward  when 
the  inner  condyle  rests  against 
the  ilium  gives  us  the  carrying 
function.  In  fracture  of  the 
inner  condyle  the  broken  con- 
dyle ascends  and  the  "carrying  function"  is  lost  (Fig.  361 
is  known  as  gunstock  deformity. 

Fractures  at  the  Base  of  the  Condyles  of  the  Humerus  (Figs.  362  and 
363). — A  fracture  in  this  region  is  just  above  the  level  of  the  tip  of  the  olec- 
ranon and  is  on  a  higher  level  behind  than  in  front.  The  cause  is  direct  force 
acting  upon  the  olecranon. 

The  symptoms  are  loss  of  function,  and  pain  from  injury  to  the  median  or 
ulnar  nerve.  Crepitus  and  mobility  are  readily  found.  The  lower  fragment  is 
drawn  backward  and  upward  by  the  action  of  the  triceps,  biceps,  and  brachialis 
anticus  muscles.  The  lower  end  of  the  upper  fragment  projects  in  front  of 
the  joint.  This  lesion  may  be  mistaken  for  dislocation  of  the  bones  of  the 
forearm  backward.  In  fracture  the  limb  is  mobile;  in  dislocation  it  is  rigid. 
In  fracture  the  deformity  is  easily  reduced  and  strongly  tends  to  recur;  in 
dislocation  the  deformity  is  reduced  with  difficulty  and  does  not  tend  to  recur. 
In  dislocation  there  is  shortening  of  the  forearm,  but  not  of  the  arm;  in  fracture 
there  is  shortening  of  the  arm,  but  not  of  the  forearm.  In  dislocation  there 
is  a  smooth,  large  projection  below  the  crease  in  front  of  the  elbow;  in  fracture 
there  is  a  sharp  projection  above  the  crease.  In  fracture  there  is  crepitus; 
in  dislocation  there  is  no  crepitus. 

The  diagnosis  can  be  settled  by  the  .i;-rays. 

T-fractures  of  the  Humerus. — A  T-f racture  consists  of  a  transverse  fracture 
above  the  condyles  plus  a  vertical  fracture  between  them.  The  cause  is  violent 
direct  force  applied  posteriorly. 


Fig.  360. — Loss  of  "carrjang  function"  after  fracture 
of  inner  condvie  of  the  humerus. 


This  deformity 


646 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  361. — Diagram  to  exhibit  the  "carrying  function"  of  the  forearm,  and  the  loss  of  this 
function  in  fracture  of  the  inner  condyle  of  the  humerus:  a  and  h  show  the  normal  relation  of 
the  parts  when  carrying;  c  shows  the  alteration  of  axis  of  the  forearm  when  the  inner  condyle 
is  fractured,  what  is  known  as  gunstock  deformity  resulting  (after  Allis). 

The  symptoms  are  increase  in  breadth  of  the  joint  (Fig.  364),  preternatural 
mobiUty,  crepitus,  pain  and  swelUng.  The  internal  condyle  mounts  up 
back  of  the  elbow  on  the  inner  side  of  the 
joint.  The  external  condyle  mounts  up  back 
of  the  elbow  on  the  outer  side  of  the  joint. 
The  forearm  is  semiflexed  and  supinated,  and 
the  carrying  function  is  lost. 


Fig.  362. — Supracondylar  Iraclure  of  the  humerus. 


Fig.  363.- — Fracture  of  the  humerus 
above  the  condyles. 


Prognosis  of  Fractures  In  or  Near  the  Elbow-joint. — In  many  fractures 
it  is  difficult  or  impossible  to  obtain  reduction,  and  in  some  it  is  impossible  to 


Treatment  of  Fractures  in  or  Near  the  Elbow-joint 


647 


maintain  reduction.  Stimson  is  undoubtedly  riglit  when  he  says  that  "in 
intercondyloid  fracture  with  marked  separation  there  is  no  practicable  means 
merely  to  maintain  reduction."^  In  fracture  in  or  about  the  elbow-joint  I 
have  regarded  the  prognosis  for  complete  restoration  of  function  as  poor,  and 
believed  that  in  most  of  these  fractures  some  deformity  and  considerable  stiff- 
ness are  inevitable.  Of  late,  however,  influenced  largely  by  Astley  P.  C.  Ash- 
hurst's  study  of  "Fractures  of  the  Lower  End  of  the  Humerus"  ("Samuel  D. 
Gross  Prize  Essay  of  Phila.  Acad,  of  Surgery,"  1910),  I  have  been  studying 
this  question  anew,  and  as  a  result  take  a  less  gloomy  view  of  the  situation, 
and  am  disposed  to  agree  with  Ashhurst  that  "in  the  vast  majority  of  cases 
the  ultimate  results  will  be  perfectly  satisfactory."  Nevertheless  I  am  still 
cautious  as  to  what  I  can  safely  predict  to  the  patient  and  the  patient's  family. 
Ankylosis,  partial  or  complete,  is  always  a  possible  sequence.  Ankylosis  may 
result  from  prolonged  immobilization,  the  muscles  contracting  and  becoming 
fibrous,  the  fascia  and  ligaments  about  the  joint  shortening,  the  capsule  shrink- 
ing and  thickening,  some  of  the  cartilages  becoming  fibrous,  and  the  joint  being 
partly  obliterated.  It  may  result 
from  extravasation  of  blood  into 
the  joint  and  tendon-sheaths  with 
subsequent  formation  of  fibrous 
tissue.  It  may  arise  from  organi- 
zation of  inflammatory  exudate 
within  and  about  the  joint  and  in 
the  sheaths  of  muscles  and  tendons. 
It  may  arise  from  the  formation 
of  an  excess  of  callus.  Bruns 
claims  that  in  fracture  in  the  joint 
excess  of  callus  rarely  forms,  and 
that  masses  of  callus  form  chiefly 
in  the  line  of  fracture  near  but  not 
in  a  joint. 2  Excessive  callus  forma- 
tion is  sure  to  take  place  if  reduc- 
tion is  not  thoroughly  accom- 
plished or  if  the  fragments  are 
not  well  immobilized,  but  move 
upon  each  other.  A  mass  of 
callus  in  or  about  a  joint  limits 
or  prevents  motion.  The  two  greatest  causes  of  impaired  function  are  block- 
ing by  callus  and  stiffness  from  traumatic  arthritis  (Jones,  of  Liverpool). 

Treatment  of  Fractures  in  or  Near  the  Elbow-joint. — Thoroughly  set 
the  fracture  while  the  patient  is  under  ether.  It  is  advisable,  when  it  can  be 
done  conveniently,  to  use  the  rv-rays  to  confirm  the  diagnosis  and  to  use  them 
again  after  dressings  have  been  applied,  to  be  sure  that  the  bones  remain  in 
good  position.  If  swelling  is  very  great,  it  may  be  necessary  to  delay  setting  for 
two  or  even  three  days,  the  arm  being  bandaged  and  laid  upon  a  pillow  or 
lightly  supported  on  an  anterior  angular  splint  during  the  waiting  period. 

In  all  cases  except  transverse  fracture  above  the  condyles  and  fracture  of 
the  olecranon  reduction  is  best  effected  by  drawing  upon  the  forearm,  supi- 
nating  it,  extending  it,  and  then  bending  it  slowly  into  a  position  of  acute 
flexion,  the  degree  of  flexion  being  in  inverse  ratio  to  the  amount  of  swelling. 

In  transverse  fracture  above  the  condyles  reduction  is  effected  by  drawing 
the  forearm  and  the  lower  fragment  downward  and  forward  and  at  the  same 
time  pushing  the  upper  fragment  back. 

Some  surgeons  advocate  dressing  the  fracture  on  an  anterior  angular  splint, 

1  "Transactions  American  Surgical  Association,"  vol.  ix. 

2  Max  Oberst.  in  Volkmann's  "Sammlung  Vortrage." 


Fig. 


364.^ — Deformity  following  fracture  of  the 
humerus  between  the  condyles. 


648  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  forearm  being  fully  supinated  (Fig.  365).  The  advantage  claimed  for  this 
splint  is  that  if  ankylosis  occurs  the  joint  is  in  a  position  to  be  useful,  which  it  is 
not  if  ankylosed  in  extension.  Some  deformity  is  usually  apparent  after  treating 
a  case  with  this  splint;  the  deformity  following  fracture  of  the  inner  condyle 
is  not  corrected  by  it,  but  if  the  splint  is  carefully  applied  the  result  is  usually 
a  useful  extremity  in  all  cases  except  fracture  of  the  inner  condyle.  In  trans- 
verse fracture  of  the  shaft  of  the  humerus  above  the  condyles  the  anterior 
angular  splint  is  the  best  method  of  treatment,  as  it  prevents  displacement. 
The  splint  must  not  be  applied  when  there  is  great  swelling,  and  swelling  must 
be  removed  by  resting  the  extremity  on  a  pillow,  the  elbow  being  semiflexed, 

applying  evaporating  lotions  or  even  an 
ice-bag,  employing  massage,  and  gently 
compressing  by  bandaging.  In  some  cases 
the  joint  should  be  aspirated.  In  order  to 
apply  this  dressing,  take  a  right-angled 
splint  and  pad  its  outer  surface,  being 
careful  to  place  thick,  soft  pads  over  the 
convexity  which  will  press  in  front  of  the 
elbow  and  over  each  end  of  the  splint. 
Fasten  the  upper  end  to  the  arm,  then 
make  extension  of  the  forearm,  and  if  the 
fracture  is  found  to  be  completely  reduced, 
fasten  the  hand  and  forearm  to  the  splint 
(Fig.  365).  If  thehand  and  forearm  are  first 
Fig.  365.— Anterior  angular  splint  for  fi-'^ed  to  the  splint,  there  will  be  no  ex- 
fractures  in  or  near  the  elbow-joint.         tension  from  the  elbow  and  deformity  will 

result.  If  posterior  projection  exists,  a 
pasteboard  cup  is  molded  over  the  elbow.  The  extremity  is  hung  in  a  tri- 
angular sling.  At  night  the  extremity  is  kept  in  the  sling  or  laid  on  a  pillow. 
Every  third  or  fourth  day,  while  the  extremity  is  carefully  steadied,  the  splint 
is  removed,  the  arm  and  forearm  well  rubbed  with  alcohol,  massaged,  and  the 
splint  reapplied.  The  splint  is  worn  between  five  and  six  weeks.  At  the  end 
of  the  third  w^eek,  after  removing  the  dressings,  slightly  Hex,  slightly  extend, 
and  slightly  pronate  the  forearm,  and  reapply  the  splint.  At  the  end  of  the 
fourth  week  repeat  this  maneuver,  making  movements  of  greater  range.  In 
the  middle  of  the  fifth  week  and  at  the  end  of  the  fifth  week  do  it  again,  and 
flex  and  extend  as  much  as  possible.  Very  early  and  very  frequent  passive 
motion  is  objectionable,  as  it  leads  to  overproduction  of  callus  and  ankylosis, 
but  passive  motion  as  above  described  is  imperatively  necessary.  Many 
surgeons  at  the  end  of  the  second  week  apply  a  Stromeyer  splint,  which  permits 
the  patient  and  the  surgeon  to  make  some  motion  by  means  of  the  screw  with- 
out removing  the  dressings.  In  very  stout  persons  an  anterior  angular  splint 
will  not  stay  in  place.  In  such  a  case  the  forearm  may  be  placed  at  a  right 
angle  to  the  arm  and  plaster  of  Paris  be  used.  After  the  dressings  are  removed 
employ  passive  motion,  massage,  hot  and  cold  douches,  baking,  inunctions  of 
ichthyol  or  mercurial  ointment,  iodin  locally,  corrosive  sublimate  and  iodid  of 
potassium  internally,  and  direct  the  patient  to  use  the  arm  systematically. 
If  in  any  case  after  four  weeks  non-union  exists,  put  up  the  arm  in  a  plaster 
splint  for  three  or  four  weeks  more.  Some  surgeons  use  a  posterior  right- 
angled  trough  instead  of  an  anterior  angular  splint. 

Allis  warmly  advocates  treating  fractures  in  and  about  the  joint  in  exten- 
sion. He  holds  that  the  extended  position  secures  the  best  circulation,  and 
if  either  condyle  is  unbroken  secures  the  benefit  derivable  from  a  natural  splint. 
Furthermore,  in  fractures  of  the  inner  condyle  it  restores  the  carrying  func- 
tion, which  the  flexed  position  does  not  do.  For  one  week  after  the  accident 
the  patient  stays  in  bed,  with  his  arm  extended  upon  a  pillow.     After  swell- 


Treatment  of  Fractures  in  or  Near  the  Elbow-joint  649 

ing  subsides  the  Hmb  is  wrapped  firmly  in  a  spiral  flannel  bandage  and  plaster 
of  Paris  is  rubbed  in  or  the  bandage  is  covered  with  plaster. 

Some  surgeons  extend  the  limb  and  apply  an  ordinary  plaster  bandage, 
and  in  about  three  weeks  substitute  an  anterior  angular  splint.  The  trouble 
with  treatment  in  extension  is  that  if  ankylosis  ensues  the  limb  is  nearly  useless. 
Furthermore,  treatment  in  extension  requires  confinement  to  bed. 

Jones,  of  Liverpool,  thinks  that  splints  and  bandages  are  largely  responsible 
for  the  stiffness  which  so  commonly  ensues  upon  an  elbow  injury.  He  advo- 
cates treatment  by  supination  and  acute  flexion  in  all  elbow  injures  except 
fracture  of  the  olecranon.  It  has  been  demonstrated  that  the  position  of  acute 
flexion  forces  the  fragments  into  place  and  holds 
them  firmly  between  the  coronoid  process  of  the 
ulna,  the  trochlear  surface  of  the  ulna,  the  fascia, 
and  the  triceps  tendon.  The  surgeon  must  be 
certain  that  the  radial  pulse  is  perceptible  ajter 
the  elbow  has  been  flexed.  Flexion  is  maintained 
by  fastening  a  bandage  around  the  wrist  and  neck. 
The  bandage  around  the  neck  passes  through  a 
rubber  tube,  which  serves  to  protect  the  neck. 
The  ball  of  the  thumb  should  rest  against  the 
neck.  The  bandage  is  fastened  to  a  leather  band 
around  the  wrist  or  to  a  glove,  the  fingers  of  which 
have  been  cut  off.  The  most  convenient  dressing 
to  maintain  Jones's  position  is  shown  in  Fig.  366. 

After  the  dressing  has  been  applied  certain 
precautions  are  to  be  observed.  For  the  first  week 
or  ten  days  look  at  the  arm  daily.  If  the  swell- 
ing grows  worse,,  diminish  the  degree  of  flexion, 
and  do  the  same  if  there  is  severe  pain.  If  the 
radial  pulse  disappears,  diminish  the  flexion  until 
free    circulation    is     obtained.     This    position    is 

maintained  from  three  to  six  weeks. ^  After  the  first  two  weeks  lower  the 
wrist  an  inch  or  two.  At  the  end  of  three  weeks  make  a  little  passive 
motion  (just  one  movement  in  each  direction).  Passive  motion  and  massage 
are  applied  as  if  an  anterior  splint  were  being  used.  The  author  has  treated 
many  cases  by  Jones's  method,  and  now  prefers  it  to  any  other  plan  in  all 
fractures  of  the  elbow  except  fracture  of  the  olecranon,  transverse  fracture 
above  the  condyles,  fracture  of  the  inner  condyle  near  the  line  of  the  ulnar 
nerve,  and  fracture  between  the  condyles  in  which  the  coronoid  process  gets 
between  the  fragments  in  flexion.  The  first-mentioned  injury  must  be  dressed 
in  extension,  the  transverse  fracture  above  the  condyles  requires  an  anterior 
angular  splint,  and  the  other  two  injuries  should  be  treated  in  extension.  If  a 
fracture  near  the  line  of  the  ulnar  nerve  is  treated  in  acute  flexion,  the  callus 
poured  out  will  be  apt  to  entangle  and  press  upon  the  nerve. 

If  it  is  found  impossible  to  reduce  the  fragments  or  to  maintain  reduction 
we  should  make  an  incision  and  nail  or  screw  the  fragments  in  place.  A  com- 
minuted fracture  requires  operation. 

In  young  children  the  anterior  angular  splint  must  not  be  used.  It  will 
become  loosened,  and  motion  will  inevitably  take  place  at  the  seat  of  fracture. 
Such  cases  can  be  treated  satisfactorily  in  Jones's  position,  the  arm  being  held 
to  the  chest  by  plaster-of-Paris  bandages,  or  they  can  be  treated  in  extension. 
Bertomier's  plan  is  very  useful  in  young  children.-  The  extremity  is  dressed 
without  pressure  in  extension  and  supination.  This  can  be  effected  by  flannel 
bandages.     In  from  four  to  eight  days  a  silicate  of  sodium  bandage  is  applied 

1  "Provincial  Medical  Jour.,"  Dec,  1894,  and  Jan.,  1895. 
^  "Revue  de  Chir.,"  vol.  viii,  1888. 


Fig.  366. — Jones's  dressing  for 
injuries  of  the  elbow-joint. 


6sO 


Diseases  and  Injuries  of  the  Bones  and  Joints 


in  order  to  prevent  pronation.  About  the  sixteenth  day  the  bandage  is  cut 
so  as  to  form  two  troughs.  From  this  period  every  third  day  the  spUnts  are 
removed  and  gentle  passive  motion  is  made.  The  splints  are  removed  perma- 
nently at  the  end  of  four  weeks. 

If  false  ankylosis  follows  fracture  of  the  elbow,  the  adhesions  should  be 
broken  up  under  ether,  and  for  some  time  the  hot-air  apparatus  should  be 
used  daily,  and  massage,  passive  motion,  and  the  hot  and  cold  douche  should 
be  employed.  In  true  ankylosis  an  operation  should  be  performed  and  the 
interlocking  callus  or  the  interposed  tissue  or  fragment  be  removed,  if  a  skia- 
graph shows  that  operation  promises  success.  If  gunstock  deformity  results 
and  produces  marked  disablement,  it  should  be  operated  upon.  An  osteot- 
omy is  performed  on  the  inner  condyle.  The  arm  is  set  in  the  extended  posi- 
tion, plaster  of  Paris  applied,  and  is  not  removed  for  six  weeks. ^ 

Separation  of  the  lower  epiphysis  of  the  humerus  is  not  an  unusual  accident. 
The  inferior  extremity  of  the  humerus  may  be  separated,  or  the  condyles  may 
be  separated  from  each  other  and  from  the  shaft  of  the  bone. 

The  symptoms  are  prominence  in  front 
of  the  joint,  caused  by  the  lower  end  of 
the  shaft  of  the  humerus;  projection  back- 
ward of  the  olecranon;  the  forearm  rests 
midway  between  pronation  and  supination. 
Epiphyseal  separation  may  retard  growth 
and  produce  deformity. 

Treatment. — Jones's  position  or  an  an- 
terior splint  as  above  directed. 

Fractures  of  the  ulna  comprise  the 
following  varieties:  (i)  fracture  of  the 
coronoid  process;  (2)  fracture  of  the  ole- 
cranon process;  (3)  fracture  of  the  shaft, 
and  (4)  fracture  of  the  styloid  process. 

Fractures  of  the  coronoid  process  of  the 
ulna  (Fig.  369)  are  rarely  observed,  and 
practically  occur  only  as  a  complication 
of  backward  dislocation  of  the  ulna  or  in 
association  with  other  fractures. 

Symptoms. — When  fracture  of  the  coro- 
noid process  is  associated  with  a  dislo- 
cation, crepitus  is  appreciated  on  reduction, 
and  it  is  found  that  the  deforjnity  of  the  dislocation  promptly  returns  on 
cessation  of  extension.  The  upper  fragment  may  be  pulled  upward  by  the 
brachialis  anticus  muscle,  and  there  exists  an  inability  to  flex  the  forearm 
completely.  The  position  is  one  of  extension  with  posterior  projection  of 
the  olecranon.     The  broken  piece  is  felt  in  front  of  the  joint. 

The  treatment  is  by  an  anterior  splint  the  angle  of  which  is  less  than  a 
right  angle.  Jones's  position  may  be  used  in  treating  such  a  case.  A  stiff 
joint  may  follow. 

Fractures  of  the  olecranon  process  of  the  ulna  occur  not  uncommonly 
in  adults.  Hulke  states  that  such  a  fracture  never  occurs  before  the  age  of 
fifteen,  but  the  writer  has  seen  in  the  Jefferson  Medical  College  Hospital  a 
girl  aged  fourteen  with  a  fractured  olecranon.  The  cause  is  direct  violence 
or  muscular  action.  Only  a  small  fragment  may  be  torn  away,  or  the  entire 
olecranon  may  be  broken  off,  and  the  break  may  be  comminuted  or  may  even 
be  compound. 

The  symptoms  of  most  fractures  of  the  olecranon  are:  swelling;  partial  flexion 
of  the  forearm;  separation  of  the  fragments,  the  upper  piece  being  puUed  up 
1  G.  G.  Davis,  "Phila.  Med.  Jour.,"  May  13,  1889. 


Fig.  367. — Fracture  between  tin 
condyles  treated  by  Jones's  position 
Degree  of  voluntary  flexion  obtained. 


Fractures  of  the  Olecranon  Process  of  the  Ulna 


651 


from  Y2  inch  to  2  inches  by  the  triceps;  the  space  between  the  fragments  is 
increased  by  flexion  at  the  elbow,  and  lessened  by  extension  at  the  elbow;  and 
there  is  inability  to  extend  the  arm.  Bulging  of  the  triceps  and  crepitus  on 
approximating  the  fragments  are  observed.  In  some  few  cases  there  is  no 
separation,  the  periosteum  being  untorn  or  the  fascial  expansions  from  the 


Fig.  368. — Fracture  between  the  condyles  treated  by  Jones's  position. 

extension  obtained. 


Degree  of  voluntary 


triceps  holding  the  fragments  in  apposition.     In  such  cases  crepitus  can  be 
elicited  by  rocking  the  upper  fragment  from  side  to  side. 

When  treated  by  non-operative  methods  the  prognosis  is  usually  fair, 
fibrous  union  being  the  rule.  Some  joint  stiffness  usually  occurs,  and  much 
ankylosis  may  be  unavoidable.  The  prospect  of  a  freely  movable  joint  is 
better  when  extra-articular  wiring  is  practised. 


Fracture  of  coronoid  process. 


Treatment. — Fracture  of  the  olecranon  is  usually  treated  with  a  well- 
padded  anterior  splint  almost,  but  not  quite,  straight.  A  perfectly  straight 
splint  is  uncomfortable,  and  by  opening  a  retiring  angle  between  the  fragments 
and  into  the  joint  favors  non-union  and  ankylosis.  The  splint  should  reach 
from  a  level  with  the  axillary  margin  to  below  the  fingers.  If  the  upper  frag- 
ment does  not  come  in  contact  with  the  lower,  pull  it  down  by  adhesive  plaster 


6<2 


Diseases  and  Injuries  of  the  Bones  and  Joints 


and  fasten  the  strips  to  the  splint.  The  author  in  i  case  employed  a  glove 
to  which  strings  from  the  adhesive  plaster  were  attached.  After  applying 
the  splint  keep  the  patient  in  bed  for  three  weeks.  The  danger  of  anky- 
losis in  this  fracture  is  very  great,  and,  in  case  it  occurs  in  the  position  of  exten- 
sion, an  almost  useless  arm  results.  Follow  the  rule  of  T.  Pickering  Pick,  and 
at  the  end  of  three  weeks  anesthetize  the  patient,  press  the  thumb  firmly  down 
upon  the  top  of  the  olecranon,  carry  the  forearm  slowly  to  a  right  angle,  and 
apply  an  anterior  angular  splint  and  direct  it  to  be  worn  for  two  weeks.  When 
the  anterior  splint  has  been  applied,  passive  motion  should  be  made  every 
other  day,  or  every  third  day,  and  massage  should  be  used  at  the  same  time. 
UTien  the  splint  is  removed,  try  to  increase  the  range  of  motion  as  previously 
directed.  Surgeons  usually  incise  and  apply  wires  only  when  it  is  found 
impossible  to  secure  apposition  of  the  fragments  after  fracture  of  the  olec- 
ranon.    Such  a  course  is,  I  am  persuaded,  injudicious  conservatism.     I  do  not 


Fig.  370. — Murphy's  method  of  treating  fracture  of  the  olecranon  by  subcutaneous  extra- 
articular wiring.  Lateral  view  and  posterior  view.  Wiring  the  fragments  of  the  olecranon 
together:  a,  Incision;  b,  twist  or  tie  of  wire;  c,  hole  drilled  in  bone  for  passage  of  wire;  d,  frac- 
ture; e,  passage  of  wire  through  tendon  of  triceps  (Murphy). 


advise  that  the  rule  should  be  to  treat  fractures  of  the  olecranon  as  a  routine 
by  opening  and  wiring,  but  I  do  advise  that  we  should  treat  them  by  extra- 
articular operation  and  wiring  as  advocated  by  John  B.  Murphy  ("Jour. 
Am.  Med.  Assoc,"  Jan.  27,  1906).  The  conservative  non-operative  treatment 
often  fails.  Sometimes  the  fragments  cannot  be  approximated,  frequently  they 
cannot  be  maintained  in  approximation,  and  not  unusually  a  stiff  or  actually 
ankylosed  joint  results.  Murphy  thus  describes  the  operation  which  should  be 
done  C' Jour.  Am.  Med.  Assoc,"  Jan.  27,  1906)  (Fig.  370):  "A  longitudinal 
incision  1  ^  inch  long  was  made  on  the  external  aspect  of  the  ulna,  }-2  inch  from  its 
articular  surface,  and  tissues  were  divided  to  the  bone.  A  smaller  incision  was 
made  on  the  corresponding  inner  side.  I  perforated  the  base  of  the  olecranon 
with  an  eyelet  drill,  which  ran  transversely  from  outward  inward.  I  threaded 
the  drill  with  a  fine  aluminum-bronze  wire,  drawing  it  through  this  transverse 
canal.     The  wire  was  carried  upward  under  the  skin  on  the  inner  surface  of  the 


Fractures  of  the  Shaft  of  the  Ulna 


653 


elbow  and  then  drawn  out  through  another  small  incision,  }{q  inch,  made  at  the 
level  of  the  apex  of  the  olecranon.  The  wire  was  then  reinserted  and  directed 
transversely  from  inward  outward,  passing  it  through  the  tendon  of  the  triceps 
above  the  olecranon,  and  then  drawn  out  to  corresponding  outward  point 
through  a  very  small  incision  similar  to  that  made  on  the  inner  side.  The  wire 
was  again  reinserted  and  pushed  downward  under  the  skin  until  it  was  finally 
brought  out  through  the  initial  external  incision.  The  circle  once  completed, 
traction  was  exerted  on  the  wire  until  I  was  sure  that  the  two  fragments  were 
in  perfect  coaptation,  the  latter  being  easily 
and  satisfactorily  accomplished.  The  ends 
of  the  wire  were  twisted  several  times  and 
then  divided  by  scissors  close  to  the  bone. 
By  this  procedure  the  skin  was  incised 
at  four  points,  the  largest  incision  being  }^ 
inch  in  length."  The  extremity  is  placed 
in  flexion  upon  an  anterior  splint,  which  is 
worn  for  four  weeks.  Passive  motion  is 
begun  on  the  third  day.  A  compound 
fracture  and  a  comminuted  fracture  always 
require  operation,  in  which  the  joint  is 
freely  opened.  Non-union  requires  open- 
ing of  the  joint  and  wiring  of  the  fragments. 

Fractures  of  the  shaft  of  the  ulna  alone 
are  most  usual  near  the  middle  of  the 
bone,  are  always  due  to  direct  violence, 
and  are  not  infrequently  compound.  An 
injury  which  breaks  the  ulna  is  very  apt  to 
break  the  radius  also. 

Symptoms. — By  running  the  finger  along 
the  inner  surface  of  the  bone  there  are  de- 
tected inequality  and  depression;  crepitus 
and  mobility  are  easily  developed;  there 
are  pain  and  the  evidence  of  direct  violence. 
The  long  axis  of  the  hand  is  not  on  a  line 
with  the  long  axis  of  the  forearm,  but  is 
internal  to  it.  If  deformity  exists,  it  is  due 
to  the  lower  fragment  passing  into  the  in- 
terosseous space  because  of  the  action  of 
the  pronator  quadratus;  the  upper  frag- 
ment, acted  on  by  the  brachialis  anticus, 
passes  a  little  forward  (Fig.  371).  The 
forearm  at  and  below  the  seat  of  fracture 
is  narrower  and  thicker  than  normal. 

Treatment. — In  treating  fracture  of  the 
shaft  of  the  ulna  place  the  forearm  mid- 
way between  pronation  and  supination, 
so  as  to  bring  the  fragments  together  and  to  obtain  the  widest  possible  in- 
terosseous space,  and  thus  limit  the  danger  of  union  taking  place  between  the 
radius  and  ulna.  The  position  midway  between  pronation  and  supination  is 
obtained  by  flexing  the  forearm  to  a  right  angle  with  the  arm  and  pointing 
the  thumb  to  the  nose.  Take  two  well-padded  straight  splints,  one  long 
enough  to  reach  from  the  inner  condyle  to  below  the  fingers,  the  other  from 
the  outer  condyle  to  below  the  wrist;  place  a  long  pad  of  lint  over  the  in- 
terosseous space  on  the  flexor  side  of  the  limb,  and  another  on  the  extensor 
side;  apply  the  splints  and  hang  the  forearm  in  a  triangular  sling  (Fig.  372). 
Passive  motion  is  to  be  begun  in  the  third  week,  and  the  splints  are  to  be  worn 


L_ 


FiG.  371. — Fracture  of  the  shaft  of 
the  ulna  (case  in  the  Pennsylvania  Hos- 
pital; skiagraphed  by  Dr.  Gaston  Tor- 
rance) . 


654  Diseases  and  Injuries  of  the  Bones  and  Joints 

for  four  weeks.     Fractures  of  the  ulna  can  be  treated  very  efficiently  by  plaster 
of  Paris.     The  best  results  are  secured  by  wirinpj  or  plating. 

Fractures  of  the  styloid  process  of  the  ulna  are  due  to  direct  force.  The 
displacement  is  obvious. 

Treatment. — In  treating  fracture  of  the  styloid  process  push  the  fragment 
back  into  place  and  use  a  Bond  splint  with  a  compress  for  four  weeks,  or  apply 
a  plaster-of-Paris  dressing. 

Fractures  of  the  radius  include  the  following  varieties:  (a)  Fractures  of 
the  head;  (6)  fractures  of  the  neck;  (c)  fractures  of  the  shaft,  and  {d)  fractures 
of  the  lower  extremity. 

Fracture  of  the  head  of  the 
radius  has  been  studied  by  Dr. 
T.  Turner  Thomas  ("University 
of  Penna.  Med.  Bulletin,"  Oct., 
1905;  and  "Annals  of  Surgery,'^ 
August,  1907).  He  has  furnished 
me  with  the  following  resume 
of  his  views,  with  which  I  entirely 

Fig.  372.- — Two  straight  splints  in  fracture  of  both      agree: 

bones  of  the  forearm.  "Fracture  of  the  head  of  the 

radius  is  not  infrequent,  and  is 
usually  the  result  of  a  fall  on  the  hand  with  the  elbow  in  extension  and  the  fore- 
arm in  pronation.  In  extension  of  the  elbow  the  capitellum  of  the  humerus  is 
in  contact  with  only  the  anterior  part  of  the  radial  head.  Since  the  carpus 
articulates  almost  entirely  with  the  radius,  the  force  of  the  usual  fall  on  the 
hand  is  transmitted  almost  entirely  through  this  bone,  and  at  the  elbow  is 
received  by  only  the  anterior  part  of  the  radial  head.  According  to  the  degree 
of  violence  applied,  more  or  less  damage  may  be  done  to  the  head,  or  head  and 
neck.  The  anterior  portion  of  the  rim  may  be  split  off,  the  intact  ulna  pre- 
venting the  humerus  from  pursuing  the  detached  fragment  and  pushing  it  away 
from  its  fellow,  and  the  intact  orbicular  ligament  holding  the  two  in  close  apposi- 
tion. This  uncomplicated  fracture  is  the  most  common,  but  the  least  trouble- 
some. Union  with  ultimately  good  function  is  the  rule,  even  though  the  frac- 
ture go  unrecognized  and  untreated,  because  of  the  close  splinting  of  the 
untorn  orbicular  ligament.  Since  it  is  the  same  accident,  a  fall  on  the  out- 
stretched hand,  which  usually  produces  Colles's  fracture,  fracture  of  the  ex- 
ternal condyle  of  the  humerus,  fracture  of  the  neck  of  the  radius,  fracture  of  the 
coronoid  process,  and  posterior  dislocation  of  both  bones  of  the  forearm, 
any  one  or  several  of  these  injuries  may  complicate  the  fracture  of  the  radial 
head.  When  the  anterior  part  of  the  head  breaks  off  the  bony  resistance  to  the 
descent  of  the  capitellum  by  the  radius  is  lost,  so  that  if  the  force  of  the  accident 
is  severe  enough,  lateral  bending  of  the  elbow  to  the  radial  side  with  further 
descent  of  the  capitellum  may  result  with  greater  separation  of  the  fragments^ 
tearing  of  the  orbicular  ligament,  and  more  damage  to  the  head.  The  descent 
of  the  condyle  in  a  posterior  dislocation  may  carry  before  it  the  detached  frag- 
ment of  the  head,  and  this  fragment  be  left  buried  in  the  tissues  of  the  fore- 
arm several  inches  below  its  normal  position  after  the  dislocation  has  been 
reduced. 

^'Prognosis. — In  the  vertical  or  oblique  fissured  fracture  of  the  head  with 
close  approximation  of  the  fragments,  after  union  takes  place,  limitation  of  all 
movements  of  the  elbow  results  from  adhesions  and  slight  irregularities  in  the 
bone.  The  function  rapidly  returns  in  the  succeeding  weeks,  although  some 
limitation  of  extension  will  continue  for  months.  More  marked  irregularity 
in  the  circumference  of  the  head  may  last  much  longer  and  may  produce 
permanent  limitation  of  rotation.  Bony  union  between  the  head  and  corre- 
sponding surface  of  the  ulna  will  prevent  all  rotation  of  the  forearm.     la 


Fracture  of  the  Shaft  of  the  Radius  655 

either  case  flexion  and  extension  usually  return  almost  if  not  completely. 
Non-union  of  the  fragments  may  induce  pain  and  limitation  of  movement, 
especially  rotation;  but  with  close  approximation  of  the  fragments  and  an 
untorn  orbicular  ligament,  an  apparently  perfect  return  of  function  may  follow, 
the  fragments  moving  smoothly  as  one  piece  within  the  ligament.  The  prog- 
nosis will  depend  chiefly  upon  the  degree  of  damage  done  to  the  head  and  the 
separation  of  the  fragments. 

'^Symptoms. — The  most  characteristic  feature  of  this  fracture  is  its  ob- 
scurity. The  thick  muscular  covering  of  the  radial  head,  except  posteriorly,  the 
splinting  eiJect  of  the  orbicular  ligament,  and  the  close  contact  of  the  head  with 
the  humerus  and  ulna,  make  the  diagnosis  of  the  small  intra-articular  fracture 
particularly  difficult.  In  the  uncomplicated  vertical  fracture  there  will  usually 
be  no  movements  of  the  fragments  on  each  other,  and,  therefore,  no  crepitus, 
and  there  will  be  no  deformity.  A  history  of  a  fall  on  the  hand ;  some  swelling 
of  the  elbow,  particularly  on  the  radial  side;  severe  pain  and  limitation  in  all 
movements  of  the  elbow,  particularly  in  rotation;  pain  and  tenderness  dis- 
tinctly localized  to  the  head  of  the  radius;  and  the  exclusion  of  fracture  of  the 
humerus,  ulna,  and  the  shaft  of  the  radius,  will  point  strongly  to  a  fracture  of 
the  head  of  the  radius.  If  the  injury  is  treated  as  a  fracture,  and  two  or  three 
weeks  later,  when  fixation  is  removed,  there  is  marked  limitation  of  all  move- 
ments of  the  elbow,  the  diagnosis  will  be  more  than  reasonably  assured.  The 
x-r2iy  may  be  misleading  unless  directed  in  the  line  of  the  fracture,  and  this  is 
not  easy  to  accomplish,  since  the  position  of  the  fragments  in  their  relation  to  the 
humerus  vary  with  every  change  in  rotation  of  the  forearm.  In  most  cases  an 
exposure  to  the  .x-ray  in  the  transverse  plane  of  the  humeral  condyles,  with  the 
forearm  in  pronation,  will  give  a  successful  skiagraph.  If  the  a;-ray  is  directed 
at  right  angles  to  the  line  of  fracture  the  skiagraph  will  usually  be  negative.  If 
the  fragments  are  freely  separated  and  if  crepitus  is  elicited,  the  diagnosis  wiU 
be  more  easily  determined. 

"  Treatment. — In  the  uncomplicated  fracture  without  crepitus  or  deformity, 
Jones's  position  or  a  right-angled  splint  for  three  weeks  will  be  sufficient. 
The  resulting  fibrous  ankylosis  will  largely  disappear  from  forced  use  in  the  fol- 
lowing weeks,  but  several  months  will  be  necessary  before  extension  is  com- 
plete. If  crepitus  is  present,  four  or  five  weeks'  fixation  will  be  better,  and  in 
this  case  the  return  of  function  will  probably  take  longer.  As  a  rule,  if  union 
is  obtained  function  will  return.  If  pain  on  movement  persists  for  many 
months,  a  detached  fragment  or  the  whole  head  should  be  excised.  Marked 
limitation  of  movement  from  enlargement  of  the  head  or  bony  union  between 
it  and  the  ulna  calls  for  excision  of  the  head." 

Fracture  of  the  neck  of  the  radius  (Fig.  373)  is  by  no  means  so  rare  an 
accident  as  was  thought  before  the  discovery  of  the  ic-rays.  It  seldom  occurs 
alone  and  is  usually  associated  with  fracture  of  the  radial  head.  These  frac- 
tures are  transverse  and  frequently  impacted.  The  cause  is  a  faU  upon  the 
pronated  hand  when  the  forearm  is  extended. 

Symptoms. — In  this  structure  the  forearm  is  pronated  and  the  patient  is 
found  to  have  the  lost  power  of  voluntary  pronation  and  supination.  Under 
forced  pronation  and  supination  it  wiU  be  noted  that  the  head  of  the  radius  does 
not  move  unless  there  is  impaction.  Crepitus  is  sometimes  absent  because  of 
impaction.  Thomas  points  out  that  there  is  angulation  of  the  neck  due  to 
driving  of  the  radial  head  downward  and  forward  ("Annals  of  Surgery," 
August,    1907).     Reduction  is  always  difficult  and  may  be  impossible. 

The  treatment  for  fracture  of  the  neck  of  the  radius  is  the  same  as  for  other 
fractures  of  the  elbow-joint — namely,  an  anterior  angular  splint  or  Jones's 
position. 

Fracture  of  the  shaft  of  the  radius  (Fig.  374)  is  far  commoner  than  fracture 
of  the  shaft  of  the  ulna.     It  may  occur  above  or  below  the  insertion  of  the 


6s6 


Diseases  and  Injuries  of  the  Bones  and  Joints 


pronator  radii  teres  muscle.  It  may  arise  from  either  direct  or  indirect  force. 
Fracture  of  the  shaft  of  the  uhia  may  coexist  as  a  result  of  the  same  accident. 

Fracture  of  the  Shaft  of  the  Radius  Above  the  Insertion  of  the  Pronator 
Radii  Teres  Muscle.  ^y»iploms. — The  upper  fragment  is  drawn  forward  by 
the  biceps  and  is  fully  supinated  by  the  biceps  and  the  supinator  brevis.  The 
lower  fragment  is  fully  pronatcd  by  the  pronator  quadratus  and  j)ronator  radii 
teres,  and  its  upper  end  is  pulled  into  the  interosseous  space.  There  are  crepi- 
tus, mobility,  pain,  narrowing  and  thickening  of  the  forearm  below  the  seat 
of  fracture,  and  loss  of  the  power  of  pronation  and  supination.  The  head  of 
the  bone  is  motionless  during  passive  pronation  and  supination.  The  hand  is 
prone. 

Treatment. — In  treating  this  fracture  do  not  put  the  forearm  midway  be- 
tween pronation  and  supination,  as  this  position  will  not  bring  the  fragments 
into  contact,  the  upper  fragment  remaining  flexed  and  supinated.  To  bring 
the  lower  fragment  in  contact  with  the  upper,  flex  and  fully  supinate  the  fore- 


FlG.  373. — Fracture-  of  the  neck  ni  the  radius. 


Fig.  374. — Fracture  of  radius  alone. 


arm.  Apply  an  anterior  angular  splint  to  the  extremity  for  four  weeks,  and 
begin  passive  motion  in  the  third  week. 

Fracture  of  the  Shaft  of  the  Radius  Below  the  Insertion  of  the  Pronator 
Radii  Teres  Muscle  (Fig.  374). — In  this  variety  of  fracture  the  upper  fragment 
is  acted  on  by  the  biceps,  the  supinator  brevis,  and  the  pronator  radii  teres, 
and  it  remains  about  midway  between  pronation  and  supination,  passing  for- 
ward and  also  into  the  interosseous  space.  The  lower  fragment  is  acted  on  by 
the  supinator  longus  and  the  pronator  quadratus,  the  latter  being  the  more  pow- 
erful of  the  two,  hence  the  lower  fragment  is  moderately  pronated,  its  upper 
extremity  being  drawn  into  the  interosseous  space.  Other  symptoms  are  iden- 
tical with  those  of  fracture  above  the  insertion  of  the  pronator  radii  teres, 

Treat7nent. — In  treating  fracture  below  the  pronator  radii  teres  the  forearm 
is  flexed  and  is  placed  midway  between  pronation  and  supination;  two  inter- 
osseous pads  and  two  straight  splints  are  applied  as  for  fracture  of  the  ulna  (see 
Fig.  372).  The  splints  are  worn  for  four  weeks,  and  passive  motion  is  begun 
in  the  third  week.  Plaster  of  Paris  is  a  most  satisfactory  dressing.  Loss  of 
function  is  best  obviated  in  this  fracture  bv  incision  and  fixation. 


Fracture  of  the  Shafts  of  Both  Bones  of  the  Forearm 


657 


Fracture  of  the  shafts  of  both  bones  of  the  forearm  (Figs.  375-379)  is  not 
frequently  seen.  It  is  caused  either  by  direct  or  indirect  force.  If  due  to 
indirect  force  the  radius  breaks  lirst. 

Symptoms. — After  fracture  of  both  bones  of  the  forearm  the  hand  is  pro- 
nated,  and  the  two  lower  fragments  come  together  and  are  drawn  upward  and 
backward  or  upward  and  forward  by  the  combined  force  of  flexor  and  extensor 
muscles,  shortening  being  manifest  and  the  projection  of  the  lower  fragments 
being  detected  on  either  the  dorsal  or  the  flexor  surface  of  the  forearm.  The 
upper  fragment  of  the  ulna  is  somewhat  flexed  by  the  brachialis  anticus;  the 
upper  fragment  of  the  radius  is  flexed  by  the  biceps  and  is  pronated  and  drawn 
toward  the  ulna  by  the  pronator  radii  teres.     The  forearm  is  narrower  than  it 

r-— -MM^M— -^amMg,  'j   .  HIM       should  be  (the  ends  of  the  fragments 

^^^^B         ^^:  T       having  passed  into  the  interosseous 

space)    and   is   thicker  than  normal 
from  front  to  back  (the  contents  of 


Fig.  375.  Fig.  376. 

Figs.  375,  376:^ — ^Fracture  of  both  bones  of  the  forearm. 

the  interosseous  space  having  been  forced  out).  Crepitus,  mobility,  pain,  and 
inequahty  exist,  the  power  of  rotation  is  lost,  and  on  passive  rotation  the  head 
of  the  radius  does  not  move.     The  forearm  is  prone  and  semiflexed. 

Treatment  of  this  fracture  usually  consists  in  the  application  of  two  straight 
splints  and  two  interosseous  pads,  the  forearm  being  flexed  to  a  right  angle 
and  placed  midway  between  pronation  and  supination  (see  Fig.  372).  As  a 
matter  of  fact  if  the  ulna  is  held  straight  the  radius  will  take  care  of  itself  (Sir 
Robert  Jones,  in  "  Amer.  Jour,  of  Orthop.  Surg.,"  1913,  xi).  The  splints  are  worn 
for  four  weeks,  and  passive  motion  is  begun  in  the  third  week.  Before  the 
callus  has  become  hard  the  surgeon  must  ascertain  that  supination  is  possible. 
Instead  of  these  splints  a  plaster-of-Paris  dressing  can  be  used.  I  am  persuaded 
that  pronation  and  supination  are  best  preserved  by  incision  and  fixation 
(Figs.  378  and  379). 
42 


658 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fractures  of  the  Lower  Extremity  of  the  Radius. — Until  comparatively 
recent  years  what  we  call  Colles's  fracture  was  called  backward  dislocation  of 
the  wrist.  It  was  long  taught  that  all  wrist  injuries  were  dislocations.  Poutean, 
of  Lyons,  was  the  first  to  describe  fracture  of  the  lower  end  of  the  radius.  He  did 
so  in  1783  ("Dislocations  and  Joint  Fractures,"  by  Cotton).  In  1814  Colles,  of 
Dublin,  fully  described  the  fracture  which  bears  his  name.  In  1820  Dupuytren 
made  a  study  of  it  and  it  is  known  to  the  French  of  today  as  Dupuytren's 
fracture.  It  took  long  years  for  the  views  of  Colles  and  Dupuytren  to  gain 
general   acceptance.     Colles's  fracture   is    a    transverse   or   nearly   transverse 

fracture  of   the   lower  m^^~^  ^-^^t^^'    

end  of  the  radius,  be-  ^1  ..•:/.;.;^H^^l  I 

tween  the  limits  of  }:4 
inch  and  1I4  inches 
above  the  wrist-joint, 
the  lower  fracjment 


Fig.  377.^ — Fracture  of 
both  bones  in  the  lower 
third  of  the  forearm. 


Fr,.  378.  FiG_.  379. 

Figs.   378,  379. — Ununited  compound  comminuted  fracture 

of  both  bones  of  forearm  (.v-ray  by  Dr.  Senders). 


sometimes  mounting  upon  the  dorsum  of  the  upper  fragment  (Fig.  380),  the 
two  fragments  sometimes  impacting  (Fig.  381).  An  oblique  fracture  beginning 
within  }'2  inch  of  the  joint  and  passing  into  the  joint  is  known  as  Barton's 
fracture  (Fig.  382).  It  was  described  in  i838by  John  Rhea  Barton.  Reversed 
Colles's  fracture  was  described  by  R.  W.  Smith  in  1850  and  by  Callender  in  1865. 
In  it  the  lower  fragment  undergoes  displacement  to  the  flexor  side,  pro- 
ducing the  ''gardener's  spade  deformity."  Chaiifeur's  fracture  is  caused  by 
cranking  an  automobile.  It  ''may  be  of  various  t\'pes,  the  most  frequent  of 
which  is  one  spHtting  off  the  outer  surface  of  the  articular  surface  of  the  radius 
through  the  base  of  the  styloid  process"  (Ashhurst's  "Surgery,  Principles  and 
Practice").  Colles's  fracture  is  a  very  common  injury,  is  met  with  most  fre- 
quently in  those  beyond  the  age  of  forty,  and  oftener  in  women  than  in  men. 
It  is  due  to  transmitted  force  (a  fall  upon  the  palm  of  the  pronated  hand). 
Some  think  that  the  force  is  received  by  the  ball  of  the  thumb  and  passes  to  the 
carpal  bones  and  the  edges  of  the  radius;  a  fracture  beginning  posteriorly  rather 
than  anteriorly  and  the  force  driving  the  lower  fragment  upon  the  dorsal  surface 
of  the  radius,  the  carpus  and  lower  fragment  moving  upward  and  outward. 
It  is  much  more  likely  that   this  fracture  is  due  to  cross-strain  on  the  bone. 


Fractures  of  the  Lower  Extremity  of  the  Radius 


659 


There  is  sudden  traction  upon  the  anterior  ligaments,  which  drag  upon  the  bone 
and  break  it  at  a  point  where  the  cancellous  end  of  the  radius  joins  the  compact 


A  B 

Fig.  380. — CoUes's  fracture  before  reduction:  A,  Anteroposterior;  B,  lateral  views. 

shaft  (Fig.  383).     The  fragments  are  not  unusually  impacted  (Fig.  381).     In 
the  author's  experience  dislocation  of  the  lower  end  of  the  ulna  is  not  a  very 

-^  unusual  complication.  It  arises  from 
a  fracture  of  the  ulnar  styloid  or  tear- 
ing off  of  the  internal  lateral  ligament 
of  the  wrist. 


?lt 


Impacted  Colles's  fracture. 


Fig.  382. — Barton's  fracture. 


Symptoms. — In  Colles's  fracture  there  are  pain,  swelling,  tenderness  of  the 
region  and  very  acute  tenderness  along  the  line  of  fracture.  This  line  of  tender- 
ness can  be  tracked  by  the  pressure  of  a  lead-pencil  all  the  way  around  the 
radius  (Dwight,  in  "Surg.  Report  of  Roosevelt  Hosp.  of  N.  Y.,"  1915). 


66o 


Diseases  and  Injuries  of  the  Bones  and  Joints 


The  hand  is  abducted  (drawn  to  the  radial  side  of  the  forearm)  and  pronated, 
the  head  of  the  ulna  is  prominent,  the  styloid  process  of  the  radius  is  raised, 
and  the  lower  fragment  may  mount  on  the  back  of  the  lower  end  of  the  upper 
fragment,  causing  a  dorsal  projection,  termed  by  Liston  the  "silver-fork 
deformity"  (Figs.  384,  385).  Silver-fork  deformity  is  present  in  from  60  to  70 
per  cent,  of  cases.  The  lower  end  of  the  upper  fragment  can  be  felt  beneath 
the  flexor  tendons  above  the  wrist.  The  position  in  deformity  is  produced  by 
the  force.  Some  consider  it  is  maintained  by  the  action  of  the  supinator  longus 
and  the  flexor  and  extensor  muscles,  but  particularly  by  the  extensors  of  the 
thumb.  Pilcher  has  demonstrated  the  fact  that  in  this  fracture  a  portion  of 
the  dorsal  periosteum  is  untom,  and  this  untorn  portion  acts  as  a  binding  band 
to  hold  the  fragments  in  deformity.  Pronation  and  supination  are  lost.  In 
this  fracture  the  hand  can  be  greatly  hyperextended  (Maisonneuve's  symptom). 
Crepitus,  which  is  best  obtained  by  alternate  hyperextension  and  flexion,  can 
be  secured  unless  swelling  is  great  of  impaction  exists.  Crepitus  on  side 
movements  is  rarely  obtainable.  Impaction  may  greatly  modify  the  deformity, 
though  displacement  generally  exists  to  some  extent,  and  the  fragments  do  not 


Fig.  385. 

Fig.  383.— Effect  upon  the  lower  Figs.  384  and  385.— Deformity  at  the  ^vrist  con- 
end  of  the  radius  of  the  cross-break-  sequent  upon  displacement  backward  of  the  lower 
ing  strain  produced  by  extreme  back-  fragment  of  the  radius  after  fracture  at  its  lower 
ward  flexion  of  the  hand  (Pilcher).  extremity  (Levis). 

ride  easily  on  each  other.  The  stvloid  process  of  the  ulna  may  be  broken,  or 
the  inferior'  radio-ulnar  articulation  may  be  separated  (dislocation  of  the  lower 
end  of  the  ulna).  This  latter  complication  allows  the  lower  fragment  to  roU 
freely  upon  the  upper,  and  the  characteristic  silver-fork  deformity  does  not 
appear.  If  the  styloid  process  of  the  ulna  is  broken,  pressure  over  it  causes 
great  pain.  If  a  person  in  fallmg  strikes  the  back  of  the  hand  and  a  fracture 
of  the  radius  occurs,  the  lower  fragment  is  driven  upon  the  front  surface  of 
the  upper  fragment  and  is  felt  under  the  flexor  tendons  at  the  wrist  {reversed 
deformity).  An  elaborate  study  of  fracture  of  the  radius  with  forward  dis- 
placement of  the  lower  fragment  has  been  published  by  John  B.  Roberts.      _ 

Treatment.— In  treating  an  ordinary  Colles's  fracture  reduce  the  deformity 
by  hyperextension  to  unlock  the  fragments  and  relax  the  dorsal  periosteum  fol- 
low by  longitudinal  traction  to  separate  the  fragments,  and  forced  flexion  to  force 
them  into  position.  This  formula  was  introduced  many  years  ago  by  the  late 
R.  J.  Levis.  It  is  of  the  first  importance  to  reduce  this  fracture  thoroughly, 
and  very  often  it  is  not  thoroughly  reduced.  Imperfect  reduction  means  perma- 
nent deformity,  stiffness  of  the  tendons  and  wrist,  and  possibly  an  almost  useless 
1  "Am.  lour.  Med.  Sci.,"  Jan.,  1897. 


Fractures  of  the  Lower  Extremity  of  the  Radius 


66i 


hand.  Reduction  under  ether  is  easier  and  in  difficult  cases  more  complete 
than  reduction  without  the  aid  of  an  anesthetic.  The  extremity  can  be  placed 
upon  a  Levis  splint  (Fig.  386),  the  position  maintaining  reduction  and  the  tense 
extensor  tendons  giving  dorsal  support.  Some  surgeons  use  Gordon's  pistol- 
shaped  splint.  The  favorite  splint  in  Philadelphia  practice  in  the  past  has 
been  Bond's  (PI.  7,  Fig.  7).  It  places  the  hand  in  a  natural  position  of  rest 
(semiflexion  of  the  fingers,  semi-extension  of  the  WTist,  and  deviation  of  the 
hand  toward  the  ulna).     Two  pads  are  used:  a  dorsal  pad  which  overlies  the 


Fig.  386. — Levis's  radius-splints,  right  and  left,  for  fracture  of  the  lower  end  of  the  radius. 

lower  fragment,  and  a  pad  for  the  flexor  surface  which  overHes  the  lower  end 
of  the  upper  fragment.  A  bandage  is  appHed,  the  thumb  and  fingers  being 
left  free  (Fig.  387).  Passive  motion  is  begun  upon  the  fingers  in  three  or  four 
daye,  and  upon  the  wrist  during  the  second  week.  The  splint  is  removed  in 
three  weeks,  and  a  bandage  is  worn  for  a  week  or  two  more  because  of  the 
swelHng.  In  applying  the  Bond  splint,  do  not  pull  the  hand  too  much  up  on 
the  block,  or  the  fracture  will  xmite  with  a  projection  upon  the  flexor  surface 
of  the  extremity  and  the  tendons  of  the  wrist  will  be  apt  to  be  caught  in  the 
callus.  The  most  satisfactory 
dressing  is  the  straight  dorsal 
splint  ad\dsed  by  Roberts  (Fig. 
388).  It  runs  from  just  below 
the  external  condyle  to  the 
beginning  of  the  fingers.  I  use  it 
almost  invariably.  It  prevents 
the  recurrence  of  deformity  and 
is  mechanically  the  proper  mode 
of  treatment.  It  should  be  worn 
for  three  weeks.  Undoubtedly  more  or  less  stiffness  often  follows  Colles's 
fracture,  and  some  very  able  surgeons  have  been  so  impressed  with  the  fre- 
quency of  crippling  stiffness  that  they  have  dispensed  with  the  use  of  a  sphnt. 
Sir  Astley  Cooper  long  ago  spoke  of  simply  placing  the  arm  in  a  sling  as  proper 
treatment  for  fracture  of  the  radius.  Moore,  of  Rochester,  applied  a  cylindrical 
compress  over  the  ulna,  held  in  place  for  six  hours  by  adhesive  plaster,  then 
cut  the  plaster,  placed  the  forearm  in  a  sling,  and  let  the  hand  hang  over  the 
edge  of  the  sling.  Pilcher  applies  a  band  of  adhesive  plaster  around  the  wrist 
and  supports  the  \\Tist  in  a  sHng,  but,  as  Storp  says,  dispensary  patients  are  apt 
to  disarrange  this  dressing.  Storp  wTaps  a  piece  of  rubber  plaster  4  inches 
wide  around  the  \\Tist,  and  places  a  second  piece  around  the  first  so  arranged 


Fig.  3S7. — Bond's  splint  in  Colles's  fracture. 


662 


Diseases  and  Injuries  of  the  Bones  und  Joints 


as  to  form  a  fold  over  the  radius;  an  opening  is  made  through  the  fold  for  the 
passage  of  a  sling.  In  ten  days  the  plaster  is  removed  and  the  forearm  is  carried 
in  a  sling.  Massage  is  begun  in  the  third  week.  Impaired  function  follows  in 
about  40  per  cent,  of  these  fractures.  If  a  stiff  joint  and  limited  tendon  motion 
eventuate  from  the  fracture,  use  massage,  frictions,  sorbefacient  ointments, 
tincture  of  iodin,  electricity,  hot  and  cold  douches,  and  the  hot-air  apparatus, 
or  give  ether  and  forcibly  break  up  adhesions.  If  reduction  was  not  thoroughly 
effected  and  too  great  a  length  of  time  has  not  elapsed,  and  the  hand  is  helpless 
and  painful,  the  bone  should  be  refractured.  In  a  young  or  middle-aged  per- 
son, in  whom  a  useless  hand  has  followed  an  ill-reduced  fracture,  osteotomy  is 
justifiable. 

Fracture  of  Both  the  Radius  and  Ulna  Near  the  Wrist. — Colles's  frac- 
ture may  be  complicated  by  a  fracture  of  the  ulna  other  than  of  its  styloid 
process. 

Symptoms. — In  fracture  of  the  radius  and  ulna  near  the  wrist  the  lower  ends 
of  the  upper  fragments  come  together,  the  upper  fragment  of  the  radius  is  pro- 
nated,  and  the  lower  fragment  of  the  radius  is  drawn  up.  Pain,  crepitus, 
mobility,  shortening,  and  loss  of  function  exist. 

Treatment. — Fracture  of  the  radius  and  ulna  near  the  wrist  should  be 
treated  by  the  straight  dorsal  splint,  as  is  Colles's  fracture. 

3pli  n  t 


Fig.  388.- — Diagram  showing  the  arrangement  of  compresses  and  splint  best  adapted  to  retain 
fragments  in  proper  position  after  reduction  (Pilcher). 

Separation  of  the  Lower  Radial  Epiphysis. — This  accident  occurs  in  children 
from  falling  upon  the  palm  of  the  hand.  It  never  happens  after  the  twentieth 
year. 

Symptoms. — In  separation  of  the  lower  radial  epiphysis  the  lower  fragment 
mounts  upon  the  upper  and  produces  a  dorsal  projection  like  that  found  in 
Colles's  fracture,  but  the  hand  does  not  deviate  to  the  radial  side.  The  de- 
formity resembles  that  of  a  backward  carpal  dislocation,  but  is  differentiated 
from  dislocation  by  the  unaltered  relation  in  the  fracture  between  the  styloid 
processes  and  the  carpal  bones. 

The  treatment  in  separation  of  the  lower  radial  epiphysis  is  the  same  as  for 
Colles's  fracture. 

Fractures  of  the  carpus  were  until  recently  thought  to  be  infrequent,  but 
the  a;-rays  have  taught  us  differently,  and  we  now  know  that  many  supposed 
sprains  of  the  wrist  are,  in  reality,  simple  fractures  of  the  carpus.  Ernest 
Amory  Codman  and  Henry  Melville  Chase  show  that  a  majority  of  carpal 
injuries  "are  either  simple  fractures  of  the  scaphoid  or  anterior  dislocations 
of  the  semilunar  bone,"  the  two  injuries  being  frequently  combined  ("The 
Diagnosis  and  Treatment  of  Fracture  of  the  Carpal  Scaphoid  and  Dislo- 
cation of  the  Semilunar  Bone,"  in  "Annals  of  Surgery,"  March  and  June, 
1905).  The  cause  of  carpal  fracture  may  be  violent  direct  force  or  a  fall  upon 
the  extended  palm. 

Symptoms. — Fractures   of   the   carpus   in   general   are   indicated   by   pain. 


Fracture  of  the  Carpal  Scaphoid 


663 


tenderness,  swelling,  evidences  of  the  infliction  of  direct  force,  sometimes 
crepitus,  loss  of  power  in  the  hand,  and  a  very  little  displacement. 

Treatment. — Many  compound  comminuted  fractures  of  the  carpus  require 
amputation.  In  an  ordinary  compound  fracture  asepticize,  drain,  dress  with 
antiseptic  gauze  and  a  plaster-of-Paris  bandage,  cutting  trap-doors  in  the 
plaster  over  the  ends  of  the  drainage-tube.  In  a  simple  fracture  dress  the 
hand  upon  a  well-padded  straight  palmar  splint  (PL  7,  Fig.  10)  reaching  from 
beyond  the  fingers  to  the  middle  of  the  forearm,  and  place  the  hand  and  fore- 
arm in  a  sling.  The  splint  is  worn  for  four  weeks,  and  passive  motion  of  the 
wrist  is  begun  in  the  second  week. 

Fracture  of  the  carpal  scaphoid  (see  previously  quoted  article  by  Codman 
and  Chase)  usually  results  from  falls  upon  the  palm  of  the  extended  hand 
and  is  most  common  in  males  between  the  ages  of  twenty-five  and  thirty- 
five.  It  is  rarely  recognized  at  the  time  of  the  accident;  the  patient  com- 
plains of  severe  pain,  tenderness,  and  disability  and  is  thought  to  have  a  sprain. 
According   to    Codman   and    Chase,  the  symptoms  improve  up  to  a  certain 


Fig.  389. — ^Jones's  "cock-up"  or  "crab"  wrist  splint  (Osgood). 

point,  but  not  beyond  it,  and  the  joint  remains  in  a  condition  of  irritation  and 
weakness.  After  months  or,  perhaps,  years  the  diagnosis  is  made.  In  one 
case  of  my  own,  a  locomotive  engineer,  the  injury  resulted  from  a  blow  on 
the  palm  with  the  reverse  lever.  He  came  to  me  three  years  after  the  injury, 
when  I  recognized  the  condition  as  the  one  described  by  Codman  and  Chase. 
These  writers  say  that  the  fingers  are  normally  flexible,  active  and  passive 
movements  of  the  wrist  are  restricted  to  one-half  or  more  of  the  normal  excur- 
sion, and  movements  of  flexion  or  extension  beyond  this  are  limited  by  muscular 
spasm,  resembling  the  spasm  occurring  in  a  tuberculous  joint.  Any  attempt 
forcibly  to  overcome  the  spasm  produces  violent  pain.  Crepitus  is  absent. 
The  radial  side  of  the  wrist-joint  exhibits  some  swelling,  which  obscures  some- 
what the  flexor  tendons  of  the  thumb.  There  is  tenderness  on  pressure  over 
the  scaphoid  and  it  is  most  acute  in  the  anatomical  snuft'-box.  The  .r-ray 
shows  a  transverse  fracture  of  the  scaphoid  bone  ("Annals  of  Surgery,"  March 
and  June,  1905).  Professor  Dwight  considers  the  above-described  injury  to 
be  due  to  the  two  portions  of  the  bone  (there  are  two  centers  of  ossification) 
having  never  formed  a  bony  union  and  having  been  wrenched  apart  by  violence. 
Codman  believes  the  injury  is  the  result  of  violence  acting  on  a  normal  bone, 
the  resulting  non-union  being  due  to  lack  of  fixation  and  the  presence  of  synovial 
fluid  between  the  fragments. 


664 


Diseases  and  Injuries  of  the  Bones  and  Joints 


The  fracture  may  be  accompanied  by  forward  dislocation  of  the  semi- 
lunar bone.  If  for  several  weeks  after  an  accident  causing  fracture  of  the 
scaphoid  the  wrist  is  immobilized,  union  may  occur,  otherwise  non-union  will 
surely  result. 

Treatment. — This  injury  should  be  thought  of  when  violence  has  been 
apphed  to  the  carpus.  It  may  be  treated  by  a  straight  palmar  splint  if  the 
case  is  seen  early.  Cases  do  best  when  treated  with  the  wrist  in  dorsitiexion 
(Fig.  389).  If  seen  when  there  is  non-union,  the  proximal  half  of  the  scaphoid 
should  be  excised  (the  incision  being  posterior  and  external  to  the  extensor 
communis  digitorum  tendons)  and  passive  motion  should  be  begun  within  one 
week  (Codman  and  Chase,  Ibid.). 

Fractures  of  the  Metacarpal  Bones. — Fracture  of  the  metacarpus  is  very 
common.  One  or  more  bones  may  be  broken.  The  first  metacarpal  bone  is 
oftenest  broken;  the  third  is  seldom  broken  (Hulke).     The  cause  is  direct  or 

indirect  force.  Fracture  at  the 
base  of  the  first  metacarpal  bone 
was  described  by  E.  H.  Bennett  in 
1 88 1.  It  is  called  Bennett's  frac- 
ture, or,  as  its  discoverer  named 
it,  stave  of  the  thumb.  The  frac- 
ture may  be  transverse  at  the 
neck  or  longitudinal,  "the  anterior 
basal  projection  being  broken  off" 
(Raymond  Russ,  in  "Jour.  Amer. 
Med.  Assoc,"  June  16,  1906). 
This  injury  results  from  violent 
force  applied  to  the  distal  end  of 
the  metacarpal  (as  in  striking 
with  the  fist)  or  to  the  end  of  the 
extended  thumb,  and  Russ  regards 
it  as  the  most  common  metacarpal 
fracture.  It  is  usually  mistaken 
for  a  sprain  of  the  thumb  and  is 
sometimes  regarded  as  subluxation 
backward  of  the  first  metacarpal. 
Symptoms.  —  The  signs  of  a 
metacarpal  fracture  are:  dorsal 
projection  of  the  upper  end  of  the 
lower  fragment  or  the  lower  end 
of  the  upper  fragment;  pain, 
crepitus;  and  often  evidences  of 
direct  violence.     In  fracture  of  the 


Fig.  390. — Coaptation  traction  splint  of  Russ. 


first  metacarpal  (Bennett's  fracture)  there  is  swelling,  particularly  evident  in  the 
flexor  tendon  sheaths  on  the  thenar  eminence  (Russ),  disability,  pain,  tender- 
ness near  the  base  of  the  metacarpal,  and  deformity,  apparent  shortening  of 
the  thumb,  and  crepitus  on  reduction.     The  Arrays  solve  a  doubtful  case. 

Treatment. — To  treat  a  fracture  of  a  metacarpal  bone  reduce  by  extension; 
place  a  large  ball  of  oakum,  cotton,  or  lint  in  the  palm  to  maintain  the  natural 
rotundity,  and  apply  a  straight  palmar  splint  like  that  used  for  fracture  of  the 
carpus.  It  may  be  necessary  to  apply  a  compress  over  the  dorsal  projection. 
The  duration  of  treatment  is  three  weeks,  and  passive  motion  is  begun  after 
two  weeks.  A  plaster-of-Paris  dressing  is  often  used.  Raymond  Russ  ("Jour. 
Amer.  Med.  Assoc,"  June  16,  1906)  describes  the  following  splint  as  success- 
fully used  in  a  case  of  Bennett's  fracture  (Fig.  390).  I  have  used  it  in  a  case 
with  much  satisfaction.  "The  thumb  was  put  in  strong  abduction  and  three 
wooden  butcher's  skewers  neatly  padded  were  placed  about  the  metacarpal, 


Fractures  of  the  Phalanges  665 

one  posteriorly  in  the  interosseous  space,  one  along  the  outer  border,  and  the 
third  over  the  thenar  eminence.  These  extended  from  well  above  the  meta- 
carpal bone  to  the  first  phalangeal  joint.  They  were  fastened  tightly  in  place  by 
two  strips  of  adhesive  plaster.  Traction  was  then  exerted  on  the  thumb  and 
maintained  by  strips  of  adhesive  plaster  passing  about  the  first  phalanx  and 
the  projecting  ends  of  the  three  skewers.  This  dressing  was  reinforced  by  a 
rectangular  cardboard  splint.  Accurate  coaptation  and  sufficient  traction  to 
overcome  the  deformity  and  muscular  action  are  most  necessary  in  the  treat- 
ment of  this  fracture.  Slate  pencils  or  small  lead  pencils  can  be  used  in  place 
of  the  wooden  skewers.  The  soapstone  slate  pencils  are  less  brittle  than  the 
ordinary  kind." 

Fracture  of  the  Sesamoid  Bones  of  the  Thumb. — There  are  two  sesamoid 
bones  on  the  palmar  surface  of  the  metacarpophalangeal  articulation  in  the 


Fig.  391. — Intracapsular  fracture  of  the  hip  (author's  case). 

thumb,  lying  in  the  tendons  of  the  flexor  brevis  pollicis,  and  one  in  the  palmar 
surface  of  the  interphalangeal  joint  of  the  thumb.  Skillern  ("Annals  of 
Surgery,"  1915,  Ixii)  reports  a  case  of  fracture  of  the  ulnar  sesamoid  of  the 
thumb  and  says  three  cases  have  been  reported  previously.  The  condition 
causes  swelling  of  the  thumb,  ecchymosis  of  the  thenar  eminence,  and  acute 
tenderness  at  the  base  of  the  first  metacarpal  bone.  The  treatment  is 
immobilization  for  four  weeks  and  then  passive  motion  and  massage. 

Fractures  of  the  Phalanges. — The  phalanges  are  often  broken.  The  frac- 
ture may  be  compound.     The  cause  usually  is  direct  force. 

Symptoms. — Fracture  of  a  phalangeal  bone  is  indicated  by  pain,  tenderness, 
bruising,  crepitus,  and  mobility,  with  very  little  or  no  displacement. 

Treatment. — If  the  middle  or  distal  phalanx  is  broken,  mold  on  a  trough- 
like splint  of  gutta-percha  or  of  pasteboard,  which  splint  need  not  reach  into 


666  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  palm.  If  the  proximal  phalanx  is  broken,  carry  the  splint  into  the  palm 
of  the  hand.  Make  the  splint  of  gutta-percha,  pasteboard,  wood,  or  leather. 
The  splint  is  worn  three  weeks.  A  sling  must  be  worn,  otherwise  the  fmger 
will  be  knocked  and  hurt.  Some  cases  require  a  dorsal  as  well  as  a  palmar 
splint.  These  cases  may  be  treated  very  satisfactorily  with  a  silicate  of  sodium 
or  plaster-of-Paris  bandage. 

Fracture  of  the  femur  is  a  very  common  injury.  The  divisions  of  the 
femur  are:  (i)  the  upper  extremity;  (2)  the  shaft;  (3)  the  lower  extremity. 

Fractures  of  the  upper  extremity  of  the  femur  are  divided  into:  (a)  intra- 
capsular; (b)  extracapsular;  (c)  of  the  great  trochanter,  and  (d)  epiphyseal  sepa- 
ration (either  of  the  great  trochanter  or  the  head). 

Examination  of  the  Hip. — It  is  sometimes  though  seldom  necessary  to  give 
ether.  Remove  all  the  patient's  clothing  and  place  him  recumbent  upon  a 
table.  Note  the  position  of  the  extremity.  Feel  with  care  the  great  trochanter 
and  femoral  neck.  Very  gradually  and  gently  make  movements  to  determine 
if  there  be  impairment,  undue  mobility,  or  crepitus.  Never  make  sudden 
or  violent  movements  in  looking  for  crepitus.  The  diagnosis  can  be  made 
even  if  crepitus  is  not  obtained,  and  rapid  or  violent  movements  may  tear 
apart  an  impaction.  Measure  the  sound  extremity  and  the  injured  extremity. 
The  measurement  is  made  from  the  anterior  superior  spine  of  the  ilium  to  the 
inner  malleolus.     Other  symptoms  to  be  looked  for  are  set  forth  on  pages 

667  and  668. 

Intracapsular  Fracture  of  the  Femur. — Intracapsular  fracture  of  the  neck 
of  the  femur  is  transverse  or  only  slightly  oblique  (Fig.  391),  and  is  not  un- 
usually impacted  (see  Figs.  304,  305,  306).  Stokes  follows  Gordon,  of  Belfast, 
in  classifying  fractures  of  the  femoral  neck.  He  divides  them  into  intracapsular 
and  extracapsular,  and  subdivides  intracapsular  fractures  into  fracture  with 
penetration  of  the  cervix  into  the  head;  fracture  with  reciprocal  penetration; 
intraperiosteal  fracture  at  the  junction  of  the  cervix  and  head;  intraperiosteal 
fracture  of  the  center  of  the  cervix;  extraperiosteal  fracture,  with  laceration 
of  the  cervical  ligaments.  The  last-named  fracture  is  the  most  common. 
The  first  four  forms  may  unite  by  bone,  the  fifth  form  will  not  because  of 
non-apposition,  lack  of  nutrition,  effusion  of  blood,  synovitis,  or  interstitial 
absorption.^  Stokes  points  out  that  we  may  have  penetration  without  impac- 
tion. The  cause  is  often  slight  indirect  force,  of  the  nature  of  a  twist,  acting 
upon  a  person  of  advanced  years  (more  often  a  woman  than  a  man),  but  not 
unusually  a  fall  upon  the  great  trochanter  is  the  cause.  A  fall  upon  the  knees, 
a  trip,  or  an  attempt  to  prevent  a  fall  may  produce  this  fracture.  It  often 
happens  that  the  fall  is  due  to  the  fracture  rather  than  that  the  fracture  arises 
from  the  fall.  Intracapsular  fracture  is  never  caused  by  direct  force  unless 
it  is  due  to  gunshot  violence.  The  aged  are  more  liable  to  intracapsular 
fracture  than  the  young  or  the  middle-aged,  because,  first,  the  angle  which 
the  neck  forms  with  the  axis  of  the  femur  becomes  less  obtuse  with  advanc- 
ing years,  and  may  even  become  a  right  angle;  this  change  is  more  pronounced 
in  women  than  in  men;  second,  the  compact  tissue  becomes  thinned  by 
absorption,  the  cancelli  diminish,  the  spaces  between  them  enlarge,  the  bony 
portions  of  the  cancellous  structure  are  thinned  and  destroyed,  and  the  can- 
cellous structure  becomes  fatty  and  degenerated.  The  injury  is  not,  how- 
ever, limited  to  the  aged.  It  has  been  positively  shown  that  this  fracture 
may  occur  in  the  young,  even  before  the  union  of  the  epiphyses.  In  fact, 
fracture  of  the  femoral  neck  is  not  very  uncommon  in  children  and  in  young 
and  vigorous  adults  (Royal  Whitman,  "Med.  Record,"  March  19,  1904).  I 
have  seen  one  case  in  a  man  of  twenty-five,  one  in  a  man  of  twenty-eight, 
and  several  cases  in  those  under  forty-five.  In  the  aged  the  fracture  is,  of 
course,  complete,  but  in  children  and  even  in  young  adults  it  is  usually 
1  Stokes,  in  "Brit.  Med.  Jour.,"  Oct.  12,  18Q5. 


Intracapsular  Fracture  of  the  Femur  667 

incomplete,  and  for  this  reason  the  fracture  is  often  not  recognized  in  children 
and  young  adults. 

Symptoms.— In  intracapsular  fracture  there  is  usually  shortening  to  the 
extent  of  from  ^-^  to  i  inch,  but  in  some  cases  no  shortening  can  be  detected. 
Shortening  of  3^  inch  does  not  count  in  making  a  diagnosis,  for  one  limb  is  often 
naturally  a  little  shorter  than  the  other.  If  the  reflected  portion  of  the  capsule 
is  not  torn,  the  shortening  is  trivial  in  amount  or  is  entirely  absent.  In  some 
cases  shortening  gradually  or  suddenly  increases  some  little  time  after  the  acci- 
dent. This  is  due  to  separation  of  a  penetration  or  of  an  impaction,  tearing 
of  the  previously  unlacerated  fibrous  synovial  reflection,  or  restoration  of  mus- 
cular strength  after  traumatic  paresis  has  passed  away.  A  gradually  increasing 
shortening  arises  from  absorption  of  the  head  of  the  bone.  Shortening  is  due 
chiefly  to  pulling  upon  the  lower  fragment  by  the  hamstring,  the  glutei,  and 
the  rectus  muscles. 

Pain  is  usually  present  anteriorly,  posteriorly,  and  to  the  side.  The  area 
of  pain  is  localized,  and  motion  or  pressure  greatly  increases  the  suffering. 
Pain  is  not  commonly  severe  except  upon  motion  or  from  pressure,  when  it 
may  be  localized  in  the  joint.     In  some  cases  the  pain  is  violent. 

Eversion  exists  and  is  spoken  of  as  helpless  eversion,  though  in  a  very  few 
instances  the  patient  can  still  invert  the  leg.  The  eversion  is  due  to  the  force 
of  gravity,  the  limb  rolling  outward  because  the  line  of  gravity  has  moved 
externally.  That  eversion  is  not  due  to  the  action  of  the  external  rotator 
muscles,  as  was  taught  by  Sir  Astley  Cooper,  is  proved  by  the  fact  that  when  a 
fracture  happens  in  the  shaft  below  the  insertion  of  these  muscles  the  lower 
fragment  still  rotates  outward.  This  is  further  demonstrated  by  the  con- 
siderations that  the  internal  rotators  are  more  powerful  than  the  external, 
that  some  patients  can  still  invert  the  Hmb  after  a  fracture,  and  that  eversion 
persists  during  anesthesia.^  In  some  unusual  cases  inversion  attends  the 
fracture.  Inversion,  if  it  exists,  is  due  to  the  fact  that  the  limb  was  adducted 
and  inverted  at  the  time  of  the  accident,  and  after  the  accident  it  remains 
in  this  position  (Stokes).  Besides  shortening  and  eversion,  the  leg  is  some- 
what flexed  on  the  thigh  and  the  thigh  on  the  pelvis,  the  extremity  when  rolled 
out  resting  upon  its  outer  surface.  Abduction  is  commonly  present.  Limited 
abduction  suggests  impaction. 

Loss  of  power  is  a  prominent  symptom:  the  limb  can  seldom  be  raised  or 
inverted;  although  in  rare  cases,  when  the  fibrous  synovial  envelope  is  untorn, 
the  patient  may  stand  or  even  take  steps.  Crepitus  often  cannot  be  found, 
either  because  the  fragments  cannot  be  approximated,  because  there  is  impac- 
tion or  penetration,  or  because  the  bone  is  greatly  softened  by  fatty  change. 
To  obtain  crepitus  the  front  of  the  joint  must  be  examined  while  the  limb  is 
extended  and  rotated  inward.  But  why  try  to 
obtain  crepitus?  The  diagnosis  is  readily  made 
without  it;  in  many  cases  it  cannot  be  detected, 
and  the  endeavor  to  obtain  it  inflicts  pain  and  may 
produce  damage.  These  fractures  in  the  aged  have 
a  not  very  flattering  chance  for  repair,  and  efforts 
to  find  crepitus  may  produce  serious  damage. 

Altered  Arc   of  Rotation  of  the  Great  Trochanter        „  a  -d  at'i        > 

{DesaiMs  Sign).-i:h^   pivot   on   which   the   great     iJrA-C-D  bS'^'ii^! 
trochanter    revolves    is   no   longer  the  acetabulum,     femoral  triangle  (Owen). 
and   the  great   trochanter  no   longer   describes  the 

segment  of  a  circle,  but  rotates  only  as  the  apex  of  the  femur,  which  rotates 
around  its  own  axis.  It  is  needless  to  try  to  obtain  this  sign;  to  do  so  inflicts 
violence  on  the  parts. 

Relaxation  of  the  fascia  lata  (Allis's  sign)  simply  means  shortening.     The 
1  Edmund  Owen,  "A  Manual  of  Anatomy." 


668  Diseases  and  Injuries  of  the  Bones  and  Joints 

fascia  lata  is  attached  to  the  ilium  and  the  tibia  (iliotibial  band),  and  when 
shortening  brings  the  tibia  nearer  to  the  ilium,  this  band  relaxes  and  permits 
the  surgeon  to  push  his  lingers  more  deeply  inward  on  the  injured  side,  between 
the  great  trochanter  and  the  iliac  crest,  and  nearer  the  knee  above  the  outer 
condyle,  than  on  the  sound  side.  In  this  examination  each  limb  should  be 
adducted.  Allis  has  pointed  out  another  sign:  when  the  patient  is  recum- 
bent the  sound  thigh  cannot  be  lifted  to  the  perpendicular  without  flexing 
the  leg;  the  injured  thigh  can  be. 

Lagoria's  sign  is  relaxation  of  the  extensor  muscles. 

Ascent  of  the  Great  Trochanter  Above  Xelaton^s  Line. — This  line  is  taken 
from  the  anterior  superior  iliac  spine  to  the  most  prominent  part  of  the  ischial 


Fig.  393. — Author's  case  of  recent  intracapsular  fracture  in  a  woman  aged  loriy  successfully 
nailed.     Nail  is  still  in  place  after  live  years. 

tuberosity  (Fig.  392).  In  health  the  great  trochanter  is  below,  and  in  intra- 
capsular fracture  it  is  above,  this  line. 

Relation  oj  the  Trochanter  to  Bryant's  Triangle  (Fig,  392). — Place  the  patient 
recumbent,  carry  a  hne  around  the  body  on  a  level  with  the  anterior  superior 
iliac  spines,  draw  a  line  from  the  anterior  ihac  spine  on  each  side  to  the  summit 
of  the  corresponding  great  trochanter,  and  measure  the  base  of  the  triangle  from 
the  great  trochanter  to  the  perpendicular  line  to  determine  the  amount  of 
ascent.  The  difference  in  measurement  between  the  two  sides  shows  the  amount 
of  ascent  of  the  trochanter;  that  is,  shows  the  extent  of  shortening. 

Morris's  measurement  shows  the  extent  of  inward  displacement.  Measure 
from  the  median  line  of  the  body  to  a  perpendicular  line  drawm  through  the 
trochanter  on  each  side  of  the  body. 

Diagnosis. — The  x-rays  are  a  valuable  aid  to  diagnosis  (Fig.  393).     Intra- 


Intracapsular  Fracture  of  the  Femur  66q 

capsular  fracture  without  separation  of  fragments  may  be  mistaken  for  a  mere 
contusion,  and  the  diagnosis  may  continue  obscure  unless  the  fragments  sepa- 
rate. Loss  of  function  in  contusion  is  rarely  complete  or  prolonged,  although 
occasionally  the  head  of  the  bone  undergoes  absorption.  Early  after  a  con- 
tusion, and  usually  throughout  the  case,  there  is  no  alteration  between  the 
relation  of  the  spine  of  the  ilium  and  the  trochanter,  and  no  shortening.  Some 
time  after  a  severe  contusion  the  head  of  the  bone  may  be  absorbed.  Contusion 
of  a  rheumatic  joint  leads  to  much  difficulty  in  diagnosis.  Intracapsular 
fracture  may  be  confused  with  extracapsular  fracture  or  with  dislocation  of  the 
hip-joint.  Extracapsular  fracture,  which  is  common  in  advanced  life,  but  is 
met  with  not  unusually  in  middle  life  and  even  occasionally  in  the  young,  results 
usually  from  great  violence  over  the  great  trochanter;  if  non-impacted,  there 
are  noted  shortening  of  from  il^  to  3  inches,  crepitus  over  the  great  trochanter, 
and  usually,  but  not  invariably,  eversion;  if  impacted,  there  is  less  eversion, 
crepitus  is  absent,  and  the  shortening  is  limited  to  about  an  inch.  The  extensor 
muscles  are  relaxed.  Great  tenderness  exists  over  the  great  trochanter  in  both 
impacted  and  non-impacted  fractures.  In  dislocation  on  the  dorsum  of  the 
ilium  the  patient  is  usually  a  strong  young  adult.  There  is  a  history  of  forcible 
internal  rotation.  There  are  inversion  (the  ball  of  the  great  toe  resting  on  the 
instep  of  the  sound  foot),  rigidity,  ascent  of  the  great  trochanter  above  Nelaton's 
line,  and  shortening  of  from  i  to  3  inches.  The  head  of  the  bone  is  felt  on  the 
dorsum  of  the  ilium,  and  the  trochanter  mounts  up  toward  the  spine  of  the 
ilium,  and  pressure  upon  it  causes  no  pain.  In  dislocation  into  the  thyroid 
notch  there  is  possibly  eversion,  but  it  is  linked  with  lengthening.  Gay  points 
out  that  a  diagnosis  of  dislocation  has  no  standing  in  the  aged,  that  occasionally 
a  person  with  fracture  ''can  rotate  the  limb  slightly,  or  even  raise  it  from  the 
bed"  and  that  the  cardinal  symptoms  of  a  hip  fracture  are  "loss  of  function, 
eversion  of  the  foot  and  severe  pain  on  motion"  (George  W.  Gay,  in  "Boston 
Med.  and  Surg.  Jour.,"  Sept.  5,  1918). 

In  fracture  of  the  brim  of  the  acetabulum  there  is  shortening,  which  occurs 
on  the  removal  of  extension,  inversion,  abduction,  flexion  of  the  knee,  the 
head  of  bone  is  drawn  upward  and  backward  with  the  acetabular  fragment, 
and  there  is  retention  of  the  power  of  eversion  and  of  adduction  (Stokes). 
Crepitus  is  most  distinctly  appreciated  by  a  hand  resting  on  the  ilium. 

In  fracture  of  the  fundus  of  the  acetabulum  (see  Fig.  338)  there  is  shortening, 
and  the  head  of  the  bone  enters  the  pelvis  (Stokes). 

The  prognosis  is  not  favorable  for  perfect  restoration  of  function.  Some 
aged  patients  die  in  a  day  or  two  from  shock.  Not  a  few  perish  later  from 
hj^ostatic  congestion  of  the  lungs,  kidney,  failure  or  exhaustion.  The  majority 
of  cases  recover  with  a  little  shortening,  some  stiffness,  and  a  permanent  limp. 
There  is  a  much  better  chance  for  firm  union  if  the  fracture  is  impacted  than  if 
it  is  not.  Even  if  non-union  results  after  an  intracapsular  fracture,  and  it  is 
not  unusual,  a  patient  may  get  about  fairly  well  with  a  proper  support.  In 
some  cases  after  intracapsular  fracture  rheumatoid  arthritis  develops.  Many 
surgeons  have  maintained  that  bony  union  never  occurs,  but  it  certainly 
does  sometimes  take  place.  Stokes  holds  that  bony  union  is  possible  in 
fractures  with  penetration,  and  even  in  fractures  without  penetration  when  the 
fracture  is  within  the  periosteum.^ 

Treatment. — In  treating  a  very  feeble  old  person  for  intracapsular  fracture 
make  no  attempt  to  obtain  union.  Keep  the  patient  in  bed  for  two  weeks; 
give  lateral  support  by  sand-bags;  tie  around  the  ankle  a  fillet,  attach  a  weight 
of  a  few  pounds  to  the  fillet,  and  hang  the  weight  over  the  foot-board  of  the 
bed.  When  pain  and  tenderness  abate,  order  the  patient  to  get  into  a  reclining- 
chair,  and  permit  him  very  soon  to  get  about  on  crutches.  If  hypostatic  con- 
gestion of  the  lungs  sets  in,  if  bed-sores  appear,  if  the  appetite  and  digestion 
^  See  the  masterly  paper  by  Stokes,  before  quoted. 


670  Diseases  and  Injuries  of  the  Bones  and  Joints 

utterly  fail,  or  if  diarrhea  persists,  abandon  attempts  at  cure  in  any  case,  and 
get  the  patient  up  and  lake  him  into  the  sunshine  and  fresh  air,  simply  immo- 
bilizing the  fracture  as  thoroughly  as  possible  by  means  of  pasteboard  splints 
or  plaster  of  Paris.  In  the  vast  majority  of  cases,  no  matter  how  old  the 
patient  may  be,  undertake  treatment.  We  may  be  forced  to  abandon  it,  but 
should  at  least  attempt  to  obtain  a  cure.  If  it  is  determined  to  treat  the  case, 
place  the  patient  on  a  hair  mattress,  several  boards  being  laid  transversely 
under  the  mattress  in  order  to  prevent  unevenness  and  the  formation  of  hollows. 
A  fracture-bed  is  a  valuable  adjunct  to  treatment. 

Treatment  by  the  Extension  Apparatus  of  Gurdon  Buck. — Extend  the  knee 
and  place  the  leg  in  a  natural  posture,  and  put  a  pillow  beneath  the  knee. 


Fig.  394. — Adhesive  plaster  applied  to  make  extension. 

Combine  extension  with  lateral  support  by  means  of  sand-bags.  The  extension 
should  be  gentle,  never  forcible.  It  is  not  wise  to  pull  apart  an  impaction  in 
an  old  person,  but  it  should  always  be  done  in  a  young  or  middle-aged  person. 
Place  the  subject  on  a  firm  mattress  or  a  fracture-bed.  Shave  the  leg.  Cut  a 
foot-piece  out  of  a  cigar-box,  perforate  it  to  admit  the  passage  of  a  cord,  wrap 
it  with  adhesive  plaster  as  shown  in  Plate  7,  Figs.  15  and  16,  run  the  weight- 
cord  through  the  opening  in  the  wood,  and  fasten  a  piece  of  adhesive  plaster  on 
each  side  of  the  leg,  from  just  below  the  seat  of  fracture  to  above  the  malleolus 
(PI.  7,  Fig.  14).     The  plaster  is  guarded  from  sticking  to  the  malleoli  by  having 


Fig.  395.  Fig.  396. 

Figs.  395  and  396. — Cradle  to  keep  clothing  from  leg,  made  from  two  barrel-hoops  (Scudder).    . 

another  piece  stuck  to  its  under  surface  opposite  each  of  these  points.  Apply 
an  ascending  spiral  reversed  bandage  over  the  plaster  to  the  groin  (Fig.  394)  and 
finish  the  bandage  by  a  spica  of  the  groin.  Slightly  abduct  the  extremity.  Put 
a  brick  under  each  leg  of  the  bed  at  its  foot,  thus  obtaining  counterextension  by 
the  weight  of  the  body.  Run  a  cord  over  a  pulley  at  the  foot  of  the  bed,  and 
obtain  extension  by  the  use  of  weights.  In  an  adult  from  15  to  20  pounds  will 
probably  be  necessary  at  first,  but  after  a  few  days  from  8  to  10  pounds  will  be 
found  sufficient  (remember  that  a  brick  weighs  about  5  pounds).  Dawbarn's 
rule  as  to  the  proper  weight  to  be  attached  is  i  pound  for, every  year  up  to 
twenty.  When  the  foot  of  the  bed  is  raised  and  the  weight  to  make  extension  is 
applied,  very  gently  rotate  the  extremity,  put  the  foot  at  a  right  angle  with  the 


Intracapsular  Fracture  of  the  Femur 


671 


leg,  and  make  a  bird's-nest  pad  of  cotton  or  oakum  to  save  the  heel  from  pressure. 
Take  two  canvas  bags,  one  long  enough  to  reach  from  the  crest  of  the  ilium  to  the 
outer  malleolus,  the  other  long  enough  to  reach  from  the  perineum  to  the  inner 
malleolus.  Fill  the  bags  three-quarters  full  of  dry  sand,  sew  up  their  ends, 
cover  the  bags  with  slips,  and  put  the  bags  in  place  in  order  to  correct  eversion. 
The  slips  may  be  changed  every  third  or  fourth  day  Keep  the  bed-clothing 
from  coming  in  contact  with  the  extremity  by  means  of  a  cradle  (Figs.  395,  396). 
The  bowels  are  to  be  emptied  and  the  urine  is  to  be  voided  in  a  bed-pan,  Imless 
using  a  fracture-bed.  For  two  weeks  the  patient  remains  recumbent,  after 
which  time  he  can  be  propped  up  on  pillows.     Maintain  extension  for  three 


Fig.  397. — Method  of  using  Thomas'  arm  splint  for  fracture  of  leg  bones  (in  C.  C.  S.  or 
base  hospital  only).  The  lower  and  upper  strips  of  plaster  make  extension  and  counter-ex- 
tension respectively,  and  are  prevented  from  slipping  by  encircling  bandage  or  plaster  strap- 
ping. Perforated  zinc  or  calico  bandage  slings  support  the  fragments  and  popliteal  space. 
Rotation  of  the  foot  is  prevented  by  padding  on  each  side  or  by  a  wire  "foot  piece,"  The 
splint  is  slung  from  a,  a*  and  b  (Captain  R.  D.  Laurie). 

weeks,  then  simply  maintain  support  by  sand-bags  or  molded  pasteboard 
splints  upon  the  part,  and  keep  up  this  support  three  to  five  weeks  more. 
After  removing  the  extension  he  can  be  transferred  daily  to  a  couch.  In  from 
six  to  eight  weeks  after  the  infliction  of  the  injury  he  can  be  moved  about  in  a 
wheeling-chair,  the  leg  being  extended  or  the  knee  flexed  in  accordance  with  the 


Wi'll'i'i^Hl'inll:H''l'l'li'''Hi|l|M'!!iil!.|!.''h!M!r|TTril(iiin||i|i|iVi'|MTiM-''U'l'l|ll|l'iininiNi^ 

Fig.  398. — Fracture  of  thigh  put  up  in  Thomas's  splint. 


dictates  of  comfort.  After  a  week  or  so  of  such  movement  a  thick-soled  shoe 
is  placed  on  the  sound  foot  and  the  patient  is  allowed  to  use  crutches;  but  weight 
is  not  put  upon  the  injured  extremity  until  from  ten  to  twelve  weeks  have 
elapsed  from  the  time  of  the  accident.  For  many  months,  at  least,  and  possibly 
permanently,  he  walks  with  the  aid  of  a  cane.  Union,  if  it  takes  place,  is  usually 
cartilaginous,  but  is  sometimes  bony,  and  there  will  surely  be  some  shorten- 
ing and  also  some  stiffness  of  the  joint.  Passive  motion  is  not  made  until  at 
least  eight  weeks  have  elapsed  since  the  accident.  Treatment  by  the 
extension  apparatus  is  far  from  satisfactory,  as  it  does  not  afford  sufficient 
immobilization. 


672 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Treatment  by  Thomases  Splint. — Scudder,  in  his  valuable  treatise  on  "  The 
Treatment  of  Fractures,"  advocates  in  intracapsular  fracture  the  use  of 
Thomas's  hip  splint.  If  the  bones  are  unimpacted,  the  fragments  are  brought 
into  apposition  by  extension,  inversion,  and  pressure  upon  the  great  tro- 
chanter, and  the  Thomas  splint  is  bent  to  fit,  is  padded,  and  is  applied  (Figs. 


Fig.  399. — Jones'  abduction  frame  applied  for  fracture  of  right  femur.     The  extension  strap- 
ping should  reach  high  up  on  each  limb. 

401,  402).  When  the  bed-pan  is  to  be  used  or  the  bed  is  to  be  smoothed,  the 
patient  can  be  lifted  without  disturbing  the  fracture.  He  can  be  turned  on 
the  sound  side.  If  hypostatic  congestion  is  developing,  raise  the  head  of 
the  bed  and  tie  the  splint  to  the  iron  of  the  head  of  the  bed.  In  addition 
to  the  use  of  the  splint  Scudder  advocates  the  making  of  lateral  pressure  over 


FiG^4oo. — Balkan  splint  as  used  at  the  American  Ambulance,  Neuilly-sur-Seine,  Paris, 
France.  (Crile,  in  "Annals  of  Surgery,"  July,  191 5.  Attributed  to  Lt. -Col.  Miles  by  Sir  Geo.  H. 
Makins,  "Brit.  Med.  Jour.,"  June  16,  1917.) 

'the  great  trochanter  by  a  graduated  compress  and  a  bandage.  The  splint  is 
worn  for  six  or  eight  weeks.  It  is  then  removed,  the  patient  remaining  in 
bed  four  weeks  longer  without  any  apparatus  (Scudder,  from  Ridlon). 

Jones,  of  Liverpool,  treats  fractures  of  the  femoral  neck  by  means  of  an 
extension  frame  (see  Fig.  414).     Some  surgeons  use  the  Hodgen  splint. 


Intracapsular  Fracture  of  the  Femur 


673 


Whitman's  Treatment  in  Abduction. — The  plan  advocated  by  Royal  Whit- 
man ("Med.  Record,"  March  19,  1904)  is  a  most  excellent  one.  It  aims  to 
abolish  traumatic  depression  of  the  neck  of  the  femur. 

We  can  apply  this  plan  in  a  young  person  to  any  fracture  even  if  impacted. 
In  an  aged  person  we  apply  it  in  a  complete  non-impacted  fracture  only.  In 
a  young  person  we  usually  give  ether  and  pull  apart  an  impaction  by  abduc- 
tion.    In  an  aged  person  we  should  not  do  so. 

In  regard  to  impaction  Jones  says,  if  the  shortening  is  trivial  and  there  is 
no  rotation  an  impaction  is  not  to  be  pulled  apart;  if  there  is  marked  shorten- 
ing and  eversion,  it  is  to  be. 

Whitman  says  ("Lancet,"  June  14,  19 13)  in  complete  fracture  the  limb  is 
shortened,  somewhat  flexed,  rotated  outward  and  usually  slightly  abducted.  The 
outer  fragment  (that  is  the  lower  fragment)  is  turned  forward  and  upward  and  is 
usually  on  a  lower  plane  than  the  head.  One  cannot  control  the  inner  fragment 
so  the  outer  fragment  must  be  carried  to  the  inner.     The  patient  is  to  be  anesthet- 


FlG. 


401. — Thomas's  single  hip-splint 
in  position  (Ridlon). 


Fig.  402. — Thomas's  double  hip-splint 
in  position  (Ridlon). 


ized,  placed  upon  a  sacral  support,  the  shoulders  are  to  be  rested  on  a  box  of 
equal  height  and  the  lower  limbs  are  to  be  extended  and  supported.  The 
assistant  abducts  the  sound  limb  to  the  anatomical  limit.  The  degree  depends 
upon  age  and  individual  limitation.  It  is  usually  4o°-5o°.  This  gives  us  a 
gauge  on  the  proper  position  in  which  to  place  the  other  hip.  The  surgeon 
flexes  the  thigh  of  the  injured  side  and  thus  separates  the  fragments.  The 
shortening  is  abolished  by  the  manual  extension  of  an  assistant.  He  then 
performs  inw^ard  rotation  and  abduction  to  the  proper  degree.  The  abduction 
relaxes  the  muscles  which  interfere  with  reduction  and  carries  the  outer  frag- 
ment against  the  inner. 

The  extremity  is  set  in  extension  and  extreme  abduction.  The  tension  of 
the  capsule  pushes  the  outer  fragment  against  the  inner  and  holds  it;  fixation 
is  obtained  by  the  neck  of  the  femur  being  in  contact  with  the  acetabulum  and 
the  great  trochanter  with  the  pehis,  deformity  cannot  be  caused  by  muscular 
action,  and  the  psoas  helps  pull  the  fragments  together  (Whitman). 

The  limb  is  kept  fixed  in  abduction  by  plaster-of-Paris  for  six  weeks  and  then 
43 


674 


Diseases  and  Injuries  of  the  Bones  and  Joints 


a  Thomas  sphnt  with  extension  is  used.     Jones  uses  an  abduction  frame  instead 
of  plaster  of  Paris. 

Extracapsular  Fracture  {Fracture  oj  the  Base  oj  the  Neck  of  the  Femur). — 
The  line  of  extracapsular  fracture  is  at  the  junction  of  the  neck  with  the  great 
trochanter,  and  is  partly  within  and  partly  without  the  capsule,  the  fracture 
being  generally  comminuted  and  often  impacted.  The  cause  is  violent  force 
over  the  great  trochanter  (as  by  falling  upon  the  side  of  the  hip).  This  frac- 
ture is  most  usual  in  elderly  people,  but  is  met  with  in  the  middle  aged  and 
is  not  very  uncommon  in  young  adults.  Stokes  has  described  six  forms  of 
extracapsular  fracture:  extracapsular  fracture  with  partial  impaction  posterior; 


Fig.  403. — A,  Jones'  abduction  frame  for  fracture  of  femur,  when  the  accompanying 
wounds  prevent  the  use  of  Thomas's  splint  outfit.  These  frames  ought  to  be  made  with  joints 
opposite  the  hip,  so  that  they  can  be  used  for  either  side  and  can  be  "closed"  for  transport  on 
a  stretcher.  C,  To  show  the  method  of  apphcation.  Temporary  clove-hitch  used  around 
each  aniile. 

fracture  with  complete  impaction;  fracture  with  partial  impaction  above;  frac- 
ture with  partial  impaction  below,  the  shaft  being  spht;  splitting  of  the  neck 
longitudinally  without  impaction;  comminuted  non-impacted  fracture.^ 

Symptoms. — When  impaction  is  absent  there  is  marked  crepitus  on  motion, 
which  is  manifested  most  distinctly  when  the  fingers  are  placed  upon  the 
great  trochanter;  there  is  severe  pain,  pressure  upon  the  great  trochanter  is 
very  painful,  swelling  and  ecchymosis  are  marked;  there  is  absolute  inability 
on  the  part  of  the  patient  to  move  the  limb,  and  passive  movements  cause 
1  "Brit.  Med.  Jour.,"  Oct.  12,  1895. 


Fractures  of  the  Femoral  Neck  in  Children 


67s 


violent  pain;  there  is  shortening  to  the  extent  of  at  least  ij-^  inches,  and  some- 
times to  the  extent  of  3  inches,  and  this  shortening  is  made  manifest  by  noting 
the  ascent  of  the  trochanter  above  Nelaton's  line,  by  a  comparison  of  measure- 
ments of  the  injured  limb  and  the  sound  limb,  and  by  measuring  the  base-line 
of  Bryant's  triangle  on  each  side.  Absolute  eversion  usually  exists  with  slight 
flexion  both  of  the  leg  and  the  thigh.  In  some  rare  cases  there  is  inversion. 
This  happens  if  at  the  time  of  the  accident  the  limb  was  inverted  and  adducted 
(Stokes).  Langoria's  sign,  Desault's  sign,  and  Allis's  sign  are  present.  All 
these  symptoms  follow  violent  direct  lateral  force  to  the  great  trochanter.  In 
the  impacted  form  of  extracapsular  fracture,  in  addition  to  the  aid  given  the  sur- 
geon by  the  history,  there  is  severe  pain,  which  is  intensified  by  movement 
or  pressure;  shortening  probably  to  the  extent  of  i  inch,  which  is  not  corrected 
by  extension;  limited  abduction;  great  loss  of  function;  and  whereas  the  limb 
may  be  straight  or  even  inverted,  it  is  usually  everted.     The  trochanter  is  above 


Fig.  404. — The  long  spica  as  applied  for  fracture  of  the  neck  of  the  femur  in  the  adult; 
illustrating  the  advantage  of  an  appliance  which  permits  movement  without  danger  of  dis- 
placing the  fragments;  an  opening  has  been  made  to  lessen  the  constriction  of  the  abdomen 
(Whitman). 


Nelaton's  line,  the  base-line  of  Bryant's  triangle  is  shortened,  but  not  so  much 
as  in  the  unimpacted  form;  there  is  no  crepitus  unless  the  impaction  is  loose  or 
is  pulled  apart,  and  the  arc  of  rotation  of  the  great  trochanter  is  larger  than  in  a 
non-impacted  fracture. 

Treatment. — In  impacted  extracapsular  fracture  it  is  best  to  pull  apart 
the  impaction  if  the  patient  is  in  good  physical  condition.  Southam,  of  Man- 
chester, in  an  impressive  article  has  insisted  on  the  absolute  necessity  of  pulling 
apart  an  impaction.  He  gives  ether,  and  when  the  patient  is  anesthetized 
unlocks  the  fragments.^  This  unlocking  is  best  accomplished  by  abduction, 
the  rim  of  the  acetabulum  acting  as  the  fulcrum  of  the  lever  (Whitman).  In 
treating  extracapsular  fracture  we  can  use  the  extension  apparatus  with  sand- 
bags (see  page  670)  for  three  weeks  and  then  apply  a  plaster  dressing.  Get  the 
patient  on  crutches  after  the  plaster  has  been  in  place  for  two  weeks.  Remove 
the  plaster  at  the  end  of  four  weeks.  Thomas's  splint  may  be  used  instead  of 
Buck's  extension.     Some  prefer  one  of  the  apparatus  shown  in  Figs.  399, 400, 403. 

Fractures  of  the  Femoral  Neck  in  Children. — Fracture  of  the  femoral 
neck  in  children  and  in  young  adults  can  scarcely  be  regarded  as  very  unusual, 
and  is  certainly  more  often  encountered  than  separation  of  the  upper  epiph- 

^  "Lancet,"  Dec.  21,  1895. 


676 


Diseases  and  Injuries  of  the  Bones  and  Joints 


ysis.  The  accident  results  from  a  fall  rather  than,  as  so  often  in  an  adult,  from 
a  twist,  and  it  is  the  product  of  considerable  violence  rather  than  of  sHght  force. 
In  children  such  fractures  may  be  impacted,  and  most  of  those  which  are  unim- 
pacted  are  of  the  green-stick  variety.  The  disability  is  not  nearly  so  great  as 
in  an  adult;  in  fact,  it  is  not  unusual  for  the  victim  of  such  an  injury  to  be  able 
to  hobble  about  a  few  days  afterward.  The  symptoms  are  shortening,  some 
eversion,  impairment  of  joint  movements,  and  a  limp  when  the  patient  gets 
about.  Fractures  of  the  hip  in  children  are  often  unrecognized  and  lead  fre- 
quently to  permanent  impairment  because  of  the  development  of  coxa  vara. 
The  .T-rays  should  be  used  in  making  the  diagnosis. 

A  green-slick  fracture  may  be  treated  with  Thomas's  splint,  and  after  four 
weeks  in  bed  "the  child  may  be  allowed  up,  wearing  a  traction  hip-splint  for 

several  months  until  union  is  so  firm  that 
the  danger  from  coxa  vara  is  practically 
eliminated.  A  light  plaster-of-Paris  spica 
bandage  from  the  calf  to  the  axilla  will 
maintain  immobility  after  the  splint  is 
omitted"  (Scudder,  on  "The  Treatment  of 
Fractures").  An  impacted  fracture,  after 
the  impaction  has  been  pulled  apart,  is 
treated  exactly  as  a  green-stick  fracture. 
Royal  Whitman's  plan  for  treating  a 
green-stick  fracture  is  very  satisfactory. 
This  surgeon  ("Med.  Record,"  March  19, 
1904)  dresses  these  cases  by  placing  the 
limb  in  extreme  abduction  and  holding  it 
so  by  means  of  a  plaster-of-Paris  spica 
(Figs.  404,  405).  In  a  case  of  acute  dis- 
ability of  the  hip-joint  in  a  child,  follow- 
ing some  time  after  fracture  of  the  femoral 
neck,  make  a  careful  differentiation  from 
tuberculous  disease  of  the  joint  and  apply 
a  traction  splint  to  support  the  body  and 
give  rest  to  the  joint.  If  coxa  vara  be- 
comes marked  and  causes  great  disability,  osteotomy  is  justifiable. 

Operative  Treatment  of  Fracture  of  the  Femoral  Neck. — I  have  practised 
this  but  once.  The  patient  was  a  woman  forty  years  of  age  and  the  result 
was  excellent  (see  Fig.  ,'593).  The  operation  is  not  indicated  in  elderly  sub- 
jects. If  is  not  indicated  at  all  if  the  fragments  can  be  coaptated  and  retained 
by  extension  and  counterextension  or  by  abduction.  In  a  youth  or  a  middle- 
aged  person  in  whom  retention  in  correct  posture  is  impossible  it  is  indicated. 
McGlannan  sets  forth  the  following  contra-indications  to  operation  ("  Surgery, 
Gynecology,  and  Obstetrics,"  March,  1916):  Dilated  heart,  intermittent  pulse, 
irregular  pulse,  very  high  blood-pressure,  pulmonary  congestion,  marked  renal 
insufficiency,  evidences  of  a  nervous  breakdown,  signs  of  uremia,  alcoholism 
or  a  drug  habit. 

Some  advocate  incision,  suture  of  the  torn  capsule,  and  nailing.  In  my 
case  I  nailed  through  a  very  small  skin  incision  and  did  not  suture  the  capsule. 
It  is  held  that  suture  of  the  capsule  improves  the  circulation  in  the  broken 
off  head,  but  possible  attainment  of  the  object  is  not  justification  for  the  risk. 
The  small  cutaneous  incision  and  nailing  answers  the  purpose.  It  is  not  neces- 
sary to  drill  the  trochanter  as  Konig  did. 

Before  operating  an  x-rsiy  picture  is  taken,  while  the  fragments  are  brought 
into  apposition  by  abduction  or  by  extension  and  counterextension.  From 
this  picture  the  angle  of  the  neck  is  ncted  and  the  length  of  nail  required  is 
determined.     A  silver  nail  may  be  used.     When  ready  to  operate,  the  fragments 


Fig.  405. — Reduction  and  fixation 
in  abduction,  showing  security  assured 
by  direct  bony  contact  of  the  neck  and 
trochanter  with  the  pelvis,  also  the 
effect  of  the  attitude  on  muscular 
action:  a,  Abductor  group;  b,  iliopsoas; 
c,  capsule  (Whitman). 


Fractures  of  the  Great  Trochanter 


677 


are  again  brought  into  apposition  by  extension  and  counterextension  or  abduc- 
tion, A  small  incision  is  made  through  the  skin  over  the  external  aspect  of  the 
great  trochanter,  and  the  nail  is  driven  through  the  trochanter  and  neck  into 
the  head.  The  wound  is  closed  and  dressed.  The  pelvis  and  extremity  are 
then  put  up  in  plaster,  a  trap-door  being  cut  over  the  seat  of  incision.  The 
plaster  dressing  is  retained  for  five  or  six  weeks.  Cure  is  obtained  without 
shortening  and  with  retention  of  joint  mobility.  This  operation  is  also  used 
for  ununited  fracture.  Dr.  G.  G.  Davis  was  the  first  to  do  a  nailing  operation 
for  a  recent  intracapsular  fracture  of  the  femur.  Albee  prefers  a  peg  of  bone 
cut  from  the  tibia,  because  he  believes  that  nails  of  metal  act  as  foreign  bodies, 
retard  callus  formation,  produce  necrosis  of  adjacent  bone  and  loosen.  One 
incision  is  made  in  front  over  the  fracture.  Another  is  made  over  the  great 
trochanter.  The  bone-graft  is  shaped  into  a  peg.  The  neck  of  the  femur  is 
drilled  and  the  peg  is  inserted.     The  extremity  is  put  in  abduction  and  is  so 


Fig.  406. — Comminuted  fracture  of  up- 
per third  of  femur. 


Fig.  407. — Epiphyseal  separation  of  head  of  the 
femur. 


held  in  plaster  for  six  weeks  ("Annals  of  Surgery,"  1915,  Ixii).  If  a  fracture 
of  the  femoral  neck  is  found  to  have  united  in  a  deformity  which  is  crippling 
subtrochanteric  osteotomy  is  the  treatment. 

Separation  of  the  upper  epiphysis  of  the  femoral  head  (Fig.  407)  is  a  very 
rare  result  of  accident;  it  occurs  most  often  from  disease.  It  is  met  with  in 
early  youth,  results  in  considerable  permanent  shortening,  and  perhaps  in  coxa 
vara. 

Symptoms  and  Treatment. — The  symptoms  are  like  those  of  fracture  of 
the  neck,  except  that  the  crepitus  is  soft.  The  treatment  is  as  for  fracture  of 
the  neck. 

Fractures  of  the  Great  Trochanter. — This  is  a  very  rare  injury.  There 
seem  to  be  only  8  cases  on  record,  but  probably  the  diagnosis  has  been  missed  in 
some  cases  in  which  the  fragment  was  held  to  the  bone  by  periosteum.  This 
process  may  be  (i)  broken  off  without  any  other  injury.  In  some  cases  it 
is  completely  broken  off;  in  some  it  remains  attached  by  periosteum  and  fibrous 
tissue.  (2)  The  hne  of  fracture  may  run  through  the  trochanter  and  leave 
one  portion  of  the  trochanter  attached  to  the  head  and  neck  and  the  other 
part  attached  to  the  shaft  of  the  femur.     The  cause  is  violent  direct  force  over 


678 


Diseases  and  Injuries  of  the  Bones  and  Joints 


and  behind  the  great  trochanter  or  a  fall  (Armstrong,  in  "Annals  of  Surgery," 
August,.  1907).  Neck  lepovted  a  case  due  to  muscular  action  ("Zentralb. 
fiir  Chir.,"  1903). 

Symptoms  and  Trealment. — The  symptoms  of  the  first  form  resemble  those 
of  epiphyseal  separation  and,  of  course,  there  is  no  shortening.  The  symptoms 
of  the  second  form  are  similar  to  those  of  the  extracapsular  fracture.  On  rotat- 
ing the  femur  the  lower  part  of  the  trochanter  moves  with  it,  but  not  the  upper. 
The  lower  fragment  goes  upward  and  backward  and  projects  by  the  side  of  the 
sciatic  notch.  There  are  shortening,  eversion,  crepitus,  and  altered  position 
of  the  trochanter.  The  Ircaimcnt  of  the  second  form  is  like  that  in  extra- 
capsular fracture,  and  the  first  form 
is  treated  like  separation  of  the 
epiphysis  of  the  trochanter. 

Separation  of  the  epiphysis  of  the 
great  trochanter  is  a  rare  accident. 
The  cause  is  direct  violence  and  the 
injury  occurs  in  those  under  eighteen 
years  of  age.  Poland  in  1 898  collected 
12  cases. 

Symptoms. — The  trochanter,  if 
completely  separated,  is  found  to 
have  ascended  and  passed  posteri- 
orly; there  is  no  shortening  of  the 
thigh;  all  the  motions  of  the  hip-joint 
can  be  obtained;  if  the  thigh  is  flexed, 
abducted,  and  rotated  externally,  and 
the  fragment  is  pushed  downward  and 
forward,  crepitus  may  be  obtained — 
soft  in  epiphyseal  separation,  haid  in 
fracture.  There  is  no  shortening.  If 
the  process  is  not  completely  sepa- 
rated, diagnosis  is  impossible  with- 
out the  .T-rays. 

Treatment. — If  the  epiphysis  is 
not  completely  separated,  immobilize 
the  limb  in  the  position  of  abduc- 
tion. If  it  is  completely  separated, 
incise  the  soft  parts  and  either  suture 
or  nail  the  fragment  in  place. 
Separation  of  the  Epiphysis  of  the  Small  Trochanter. — This  is  a  rare  lesion. 
Metcalf  ("Jour.  Am.  Med.  Assoc,"  1915,  Ixiv)  reported  two  cases  and  discussed 
the  lesion.  It  may  be  due  to  direct  or  indirect  force  but  is  usually  caused  by 
sudden  and  forcible  contraction  of  the  iliopsoas  muscle.  It  causes  severe  local 
pain  and  tenderness.  The  patient  cannot  flex  the  hip.  Ludloff's  sign  may  be 
present.  That  sign  consists  of  swelling  and  ecchymosis  at  the  base  of  Scarpa's 
triangle.     The  case  is  treated  by  flexing  and  immobilizing  the  thigh. 

Fractures  of  the  shaft  of  the  femur  may  affect  any  portion  of  the  shaft, 
but  especially  the  middle  third,  and  may  occur  at  any  age.  Fracture  of  the 
upper  third  is  a  rare  accident.  Allis  estimates  that  each  year  in  Philadelphia 
there  is  i  case  of  fracture  of  the  upper  third  of  the  femur  to  every  100,000 
inhabitants.  Separation  of  the  lower  epiphysis  occasionally  occurs.^  The 
cause  of  fractures  in  the  upper  third  is  usually  indirect  force;  fractures  in  the 
lower  third  are  due  to  direct  force;  and  in  fractures  of  the  middle  third  these 
two  causes  are  about  equally  potential.  Fracture  from  muscular  action  oc- 
casionally occurs.  Oblique  fracture  is  the  usual  variety.  In  many  cases  the 
soft  parts  are  badly  lacerated  and  sometimes  a  great  vessel  is  torn. 


Fig.  408. — Intertrochanteric  fracture. 


Fractures  of  the  Shaft  of  the  Femur 


679 


Symptoms. — The  chief  symptom  in  fracture  of  the  shaft  of  the  femur  is 
great  displacement,  except  when  impaction  occurs,  when  the  break  is  due  to 
direct  force,  or  when  the  injury  is  in  a  child.  In  a  child  the  Hne  of  fracture 
is  often  transverse  and  the  periosteum  may  be  untom.  Green-stick  fractures 
occur  in  children.  As  a  rule,  in  fracture  of  the  shaft  of  the  femur  the  lower 
fragment  is  drawn  upward  and  the  upper  end  of  the  lower  fragment  is  found 
posterior  and  somewhat  to  the  inside  of  the  lower  end  of  the  upper  fragment, 
and  the  lower  fragment  also  undergoes  external  rotation  (the  drawing  up  is 
due  to  rectus  and  hamstrings;  the  passing  inward  is  due  to  the  adductor  muscles; 
the  rotation  outward  arises  from  the  weight  of  the  limb).  If  a  fracture  of  the 
lower  two-thirds  of  the  shaft  is  produced  by  direct  force,  there  is  usually  but 


Fig.  409. — Deformity  following  fracture  of  upper  third  of  femur. 

little  deformity,  because  the  line  of  fracture  is  nearly  transverse.  If  produced 
by  indirect  force,  there  is  often  great  deformity,  the  line  of  fracture  being  oblique. 
In  fracture  of  the  lower  third  of  the  shaft  the  gastrocnemius  pulls  upon  the 
condyles  and  tilts  the  lower  fragment,  so  that  its  upper  end  projects  into  the 
pophteal  space  and  may  damage  the  vessels.  In  fracture  of  the  upper  third  the 
upper  fragment  is  apt  to  be  thrown  strongly  forward  and  outward  (Fig.  409). 
Some  attribute  this  to  the  action  of  the  psoas,  iliacus,  and  external  rotator 
muscles,  but  AlHs  thinks  it  is  due  chiefly  to  the  lower  fragment  pushing  the  upper 
fragment  into  this  position,  a  part  of  the  tendon  of  the  gluteus  maximus  acting 
as  a  hinge  for  the  fragments.^  In  rare  cases  the  angular  deformity  is  backward. 
In  fracture  of  the  shaft  of  the  femur  there  is  complete  loss  of  function,  the  thigh 

^  "Fracture  in  the  Upper  Third  of  the  Femur  Exclusive  of  the  Neck,"  by  Oscar  H.  Allis, 
"Medical  News,"  Nov.  21,  1891. 


68o 


Diseases  and  Injuries  of  the  Bones  and  Joints 


and  leg  are  slightly  flexed  and  usually  everted.  In  some  cases  the  leg  and  lower 
fragment  are  inverted.  There  are  shortening  to  the  extent  of  2  or  3  inches, 
pain  on  movement,  preternatural  mobihty,  crepitus,  and  obvious  deformity, 
and  the  ends  of  the  fragments  can  be  felt  by  the  surgeon.  In  impaction  there  is 
alteration  of  the  axis  of  the  limb  and  some  shortening.  Always  feel  for  the  pulse 
below  the  fracture  to  learn  if  the  artery  is  damaged. 

Treatment. — In  setting  and  dressing  a  fracture  of  the  thigh  ether  should 
be  given  and  the  parts  must  be  handled  with  great  care  to  prevent  a  sharp 
end  of  bone  from  tearing  the  soft  parts  and  puncturing  the  skin.  In  frac- 
ture of  the  shaft  of  the  femur,  if  impaction  exists,  the  fragments  must  be  pulled 
apart,  when  the  case  should  be  treated  exactly  as  is  a  non-impacted  fracture. 


Fig.  410. — Dressing  of  fracture  of  the  femur  in  the  upper  third  with  extension  upon  a  double 

inclined  plane  (Agnew). 

After  a  fracture  of  the  shaft  of  the  femur  some  amount  of  permanent  shortening 
IS  almost  inevitable.  In  fracture  of  the  upper  third  in  an  adult  conservative 
treatment  is  usually  unsatisfactory,  and  there  is  permanent  shortening  from 
angular  union  or  from  overlapping.  In  youths  under  fifteen  a  good  result  is 
obtained  in  over  90  per  cent,  of  cases.  Horizontal  extension  fails  to  correct  the 
displacement  of  the  upper  fragment  in  fracture  of  the  upper  third.  The  double 
inclined  plane  will  not  correct  the  tilting  of  the  upper  fragment  while  shortening 
exists.     Agnew  used  a  double  inclined  plane  and  corrected  shortening  by  the  use 

of  extension  in  the  axis  of  the  partly  flexed 
thigh  (Fig.  410).  This  plan  is  one  of  the 
most  serviceable  of  those  usually  employed, 
but  it  too  fails  completely  to  correct  the 
displacement.  If,  notwithstanding  po- 
sition and  extension,  the  upper  fragment 
projects,  it  should  be  pushed  into  place 
and  be  retained  if  possible  by  short  splints 
bound  upon  the  thigh.  In  many  cases  a 
Thomas  knee-splint  is  the  best  apparatus. 
In  fracture  of  the  upper  third  with  marked 
projection  of  the  upper  fragment  the  ab- 
duction frame  may  prove  satisfactory. 
Extension  should  be  continued  for  four 
weeks,  a  plaster-of-Paris  bandage  being 
used  for  four  weeks  more,  the  patient 
being  then  allowed  to  go  about  on 
crutches.  Some  surgeons,  in  fracture 
of  the  upper  third,  apply  a  plaster-of- 
Paris  bandage  to  the  leg,  thigh,  and  pelvis,  extension  being  made  from  the  foot 
while  the  dressing  is  being  applied.  This  method  does  not  give  good  results 
because  such  extension  wiU  not  correct  the  tilting  of  the  upper  fragment. 
The  anterior  splint  of  Nathan  R.  Smith  is  used  by  some  in  treating  fractures  of 
the  upper  third  of  the  femur  (Fig.  411).     It  is  bent  to  the  desired  shape,  fast- 


FiG.  411. — Smith's  anterior  splint. 


Fractures  of  the  Shaft  of  the  Femur 


68i 


ened  to  the  anterior  surfaces  of  the  leg  and  thigh,  and  hung  to  a  gallows,  the  limb 
being  suspended  at  the  desired  height.  This  splint  is  open  to  the  same  objection 
as  the  double  inclined  plane.  Suspension,  adjustment  by  weights  and  traction 
by  Blake's  splint  or  a  like  apparatus  is  used  by  many  (Figs.  323,  398,  399,  400). 
In  fact,  in  many  fractures  of  the  upper  third  of  the  shaft  of  the  femur  no 
apparatus  will  maintain  reduction.  In  such  cases  it  is  advisable  to  incise, 
separate  the  muscles  from  between  the  fragments,  and  fasten  the  ends  of  the 
bone-fragments  together  with  bone  plates.  This  radical  treatment  has  certain 
dangers  of  its  own,  but  it  is  the  plan  which  promises  best  to  secure  a  thoroughly 


Fig.  412. — Hodgen's  apparatus  as  applied  by  Dr.  George  S.  Brown. 

good  limb.  In  fracture  oj  the  middle  third  or  upper  part  of  the  lower  third  of  the 
shaft  of  the  femur  the  Thomas  knee-splint  is  an  excellent  instrument.  The  ex- 
tension apparatus  and  sand-bags  will  usually  secure  a  satisfactory  result  (PI.  7, 
Fig.  14).  The  strips  of  adhesive  plaster  are  carried  to  just  below  the  seat  of 
fracture,  and  the  turns  of  the  roller  bandage  should  be  taken  to  a  little  above 
this  point.  Extension  should  be  continued  for  four  weeks,  when  the  plaster-of- 
Paris  bandage  ought  to  be  applied.  The  plaster  is  kept  in  place  for  four  weeks. 
Many  surgeons  use  Hodgen's  splint  in  treating  fractures  of  the  thigh.  The  limb 
is  suspended  in  a  cradle  and  extension  is  obtained  by  strapping  the  foot  of  the 
cross-bar  of  the  frame  and  pulling  upon  the  frame  by  cords  (Fig.  41 2) .     Hodgen's 


682 


Diseases  and  Injuries  of  the  Bones  and  Joints 


apparatus  as  applied  by  Brown,  of  Birmingham,  Ala.,  is  one  of  the  most  satis- 
factory methods  of  treatment  in  fracture  below  the  upper  third.  The  extremity 
can  be  raised  or  lowered  at  will  without  disturbing  the  approximation  of  the 
fragments,  extension  to  the  required  degree  can  be  obtained,  and  the  patient 
can  be  moved  in  bed.  I  consider  this  apparatus  one  of  the  most  comfortable 
appliances  which  can  be  worn  and  excellent  results  are  obtained  by  its  use. 
Blake's  splint  is  even  more  comfortable  and  useful  (Fig.  323).  In  fracture  of 
the  middle  third  or  upper  part  of  the  lower  third  of  the  shaft  if  the  line  of 
fracture  is  transverse  and  there  is  little  deformity,  as  is  seen  often  after  a 
fracture  by  direct  force,  and  often  in  children,  immobilization  in  an  immov- 
able dressing  may  be  all  that  is  required;  but  if  shortening  exists,  extension 
must  be  used.  If  extension  is  used,  continue  it  for  four  weeks  and  then  sub- 
stitute a  plaster-of-Paris  dressing  for  four  weeks.  The  amount  of  weight 
required  is  pointed  out  by  Dawbarn — i  pound  for  each  year  up  to  twenty.^ 
In  fracture  near  the  knee-joint  {lower  part  of  the  lower  third  of  the  femur)  it  may 
be  impossible  to  effect  reduction  by  horizontal  traction.  In  such  a  case  make 
traction,  and  while  it  is  being  made  gradually  bring  the  leg  to  a  right  angle. 


Fig.  413. — Mclntyre's  splint. 

Place  the  limb  in  a  double  inclined  plane  (PI.  7,  Fig.  2).  A  McInt>Te  splint 
(Fig.  413)  is  a  useful  form  of  double  inclined  plane.  After  four  weeks  of  the 
use  of  a  double  inclined  plane  apply  a  plaster-of-Paris  dressing,  which  is  to  be 
worn  for  four  weeks.  Useful  appliances  for  fracture  of  the  femur  are  shown 
in  Figs.  398,  399,  400  and  403. 

Fractures  of  the  Shaft  of  the  Femur  in  Children. — In  children  under  three 
years  of  age  the  extension  apparatus  will  not  satisfactorily  immobilize  the 
fragments.  Fractures  of  the  thigh  in  children  are  reduced  by  extension  and 
counterextension;  a  well-padded  splint  reaching  from  the  axilla  to  below  the 
sole  of  the  foot  may  be  applied  to  the  outer  side  of  the  limb  and  body.  This 
splint  is  held  in  place  by  bandages  which  are  overlaid  by  plaster  of  Paris.  It  is 
worn  for  four  weeks,  when  it  is  removed  and  a  plaster  bandage,  applied  so  as  to 
include  the  entire  limb,  is  worn  for  four  weeks. 

The  abduction  frame  (Fig.  414)  is  a  very  useful  plan  of  treatment. 

Bryant^ s  extension  (Fig.  415)  is  very  satisfactory  in  treating  a  young  child. 
Both  the  injured  limb  and  the  sound  limb  should  be  flexed  to  a  right  angle 
with  the  pelvis,  fixed  by  light  splints,  and  fastened  to  a  bar  above  the  bed. 
The  weight  of  the  body  produces  counterextension  and  the  child  can  be  easily 
cleaned.  ^ 

Another  plan  is  that  of  Theodore  Dunham.^  The  child  is  placed  upon  a 
table,  and  the  knee  and  hip  are  partly  flexed.     After  first  applying  flannel 

^  "Annals  of  Surgery,"  Oct.,  1897. 
^Thomas  Bryant's  "Practice  of  Surgery." 
^"Phila.  Med.  Jour.,"  April  23,  1898.    ■ 


Fractures  of  the  Shaft  of  the  Femur  in  Children 


683 


rollers,  plaster-of-Paris  bandages  are  applied  from  the  roots  of  the  toes  to  the 
spine  of  the  tibia,  and  as  a  spica  about  the  upper  part  of  the  thigh  and  pelvis. 
Two  pieces  of  iron,  suitably  bent,  are  used  to  anchor  the  two  plaster  bandages 
together.  One  end  of  one  iron  is  attached  to  the  plaster  over  the  groin  and  one 
end  of  the  other  iron  is  attached  to  the  plaster  over  the  front  of  the  leg.  The 
free  ends  of  the  irons  overlap.  At  the 
points  over  the  joints  and  the  front  of 
the  leg  where  the  irons  are  to  rest 
masses  of  plaster  are  placed.  The 
iron  is  sunk  into  the  plaster  and  sup- 
ported at  each  spot  by  several  turns 
of  a  plaster  bandage.  While  the  irons 
are  being  adjusted  the  thigh  is  so  held 
as  to  prevent  bending  or  rotation,  and 
the  hip  and  knees  are  semiflexed.  When 
the  plaster  has  set  an  assistant  makes 
extension  on  the  leg  and  another  as- 
sistant makes  counterextension  by 
pressing  on  the  pelvis.  Any  shorten- 
ing is  thus  reduced  and  the  two  irons 
are  lashed  together  by  strong  cord 
(Fig.  416). 

Van  Arsdale's  triangular  splint  is 
a  very  useful  appliance.  It  is  made 
of  binders'  board.  A.  Ernest  Gallant^ 
describes  its  preparation  and  applica- 
tion as  follows:  Measure  the  length  of 
the  sound  thigh  from  the  middle  of  the 
groin  to  the  end  of  the  femur.  Draw 
upon  cardboard  an  outline  of  a  double 
spade  (playing-card  spade)  (Fig.  417). 
Each  of  the  four  sections  (A,  B,  C,  D)  must  be  equal  to  the  length  of  the 
child's  thigh,  the  flanged  portions  being  equal  to  the  widest  part  of  the  thigh. 

The  figure  is  then  cut  out.  The  cardboard  is  moistened 
on  one  side  and  folded  on  the  dotted  line,  section  A 
being  lapped  over  D,  so  as  to  form  a  triangle.  It  is 
fastened  together  by  adhesive  plaster.  The  thigh  is 
flexed  and  the  triangle  is  apphed  so  that  one  flanged 
portion  embraces  the  thigh  and  the  other  flanged 
portion  rests  upon  the  abdomen  (Fig.  418).  The 
triangle  is  fixed  in  position  by  bandages,  figure-of-8 
•turns  being  made  around  the  knee  and  around  the 
thigh  and  body.  Plaster  or  starch  bandages  are 
then  applied  to  fix  the  splint  firmly.  The  leg  should 
be  bandaged  from  the  toe  to  the  knee  to  prevent 
swelling  (Fig.  418).  This  splint  is  worn  for  three 
weeks.  A  child  wearing  this  splint  can  sit  on  a  chair, 
nurse,  play  on  the  floor  and  crawl  about,  may  sleep 
on  either  side,  and  the  dressing  is  not  soiled  by  the 
evacuations. 

If    a    thigh    is    fractured   during  parturition,   or 

during  the  first  few  weeks  of  life,  Wyeth's  dressing  may 

be  very  serviceable.     It  is  applied  as  follows:  The 

leg  is  flexed  on  the  thigh  and  the  thigh  on  the  abdomen.     A  flannel  bandage  is 

applied  so  as  to  include  the  leg,  the  thigh,  and  the  body  from  the  axilla  to  the 

1  "Jour.  Amer.  Med.  Assoc,"  Dec.  18,  1897. 


Fig.  414. — Jones's  abduction  frame, 
showing  continued  traction  and  counter- 
extension  (courtesy  of  Sir  Robert  Jones, 
Liverpool,  England). 


Fig.  415. — Bryant's  ex- 
tension for  fracture  of  the 
thigh  in  a  child. 


684 


Diseases  and  Injuries  of  the  Bones  and  Joints 


pelvis.  Plaster  of  Paris  is  applied  over  this;  the  dressing  is  worn  for  four  weeks. 
A  better  dressing  than  the  above  is  Ware's,  a  modification  of  Van  Arsdale's 
splint  ("Annals  of  Surg.,"  August,  1905)  (Fig.  419).  It  is  lighter,  the  patient 
can  be  moved  about  with  ease,  the  child's  toilet  can  be  carried  out  efficiently,  and 
breathing  is  not  embarrassed.  A  right-angled  triangle  is  made  of  bookbinders' 
board.  The  length  of  one  side  is  the  distance  from 
the  trunk  at  the  level  of  the  lower  angle  of  the 
scapula  to  the  inguinal  fold.  The  length  of  the  other 
side  is  the  length  of  the  thigh.  The  hypotenuse  is, 
of  course,  longer  than  the  sides.  The  cardboard  is 
marked,  bent  into  the  triangle,  and  the  overlapping 
edges  are  secured  by  means  of  adhesive  plaster.  The 
thigh  is  flexed  and  abducted,  the  inner  surface  of  the 
splint  is  padded,  the  apparatus  is  applied  and  retained 
by  a  muslin  spica  about  the  trunk  and  thigh.     Several 


Fig.  416.  —  Dunham's 
apparatus  for  treating  frac- 
tures of  the  thigh  in  in- 
fants and  children. 


Fig.  417. — I,  Diagram  showing  outline  of  Van  Arsdale's 
splint;  the  end  band  to  be  folded  on  the  dotted  lines;  each 
section  to  equal  the  length  of  the  child's  thigh.  2,  Diagram, 
splint  folded,  fastened  by  rubber  plaster,  flanges  bent  to  em- 
brace the  thigh  and  abdomen,  ready  for  adjustment  (Gallant). 


turns  of  a  dextrin  bandage  are  applied  over  this  to  give  strength.  The  leg 
hangs  free.  The  dressing  is  worn  for  three  or  four  weeks.  Figure  419  shows 
this  dressing  apphed  for  fracture  of  the  right  femur,  and  Fig.  420  shows  it 
applied  when  both  bones  are  broken. 

Fractures  Just  Above  the  Condyles  of  the  Femur.— The  line  of  fracture  above 
the  condyles  is  well  above  the  epiphyseal  line.     The  popliteal  artery  is  in  danger 


Fig.  418.— Showing  Van  Arsdale's  triangular  splint  in  position.     Note  the  wide  space  between 
the  dressings  and  the  excretory  passages  (Gallant). 

from  the  fragments.  The  cause  of  the  break,  as  a  rule,  is  direct  violence.  Indi- 
rect force  is  sometimes  responsible  (falls  upon  the  feet).  The  knee-joint  may 
be  opened.     The  fracture  is  sometimes  compound. 

Symptoms.— The  upper  end  of  the  lower  fragment  is  drawn  upward  and 
backward,  because  of  the  action  of  the  rectus,  hamstrings,  gastrocnemius,  and 
popliteus.  The  upper  fragment  passes  inward,  and  the  deformity  is  very  mani- 
fest.    There   are   pain,    tenderness,  shortening,  crepitus,  and  mobility.     The 


Fractures  just  above  the  Condyles  of  the  Femur  685 


Fig.  419. — Ware's  combined  pasteboard  triangle  and  plaster-of-Paris  spica  apparatus  for 
fracture  of  the  femur  in  infancy  (Ware,  in  "Annals  of  Surgery,"  August,  1905). 


Fig.  420. — Ware's  apparatus  for  treatment  of  fracture  of  both  femora  (Ware,  in  "Annals  of 

Surgery,"  August,  1905). 


686 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Fig.  421. — Mechan- 
ism of  fracture  of  the 
patella  by  muscular 
action  (after  Treves). 


ends  of  the  fragments  can  be  fell  by  the  surgeon.  If  the  force  has  been  very 
great,  a  T-fracture  results.  In  T-fracture  the  knee  is  broadened  and  crepitus 
is  obtained  by  moving  the  condyles,  one  up  and  the  other  down.  The  popliteal 
vessels  may  be  torn.     Always  feel  for  the  pulse  below  the  fracture. 

Treatment. — In  treating  fracture  above  the  condyles, 
reduce  the  deformity  by  horizontal  extension.  If  this 
fails,  make  traction  at  the  same  time,  gradually  bringing 
the  leg  to  a  right  angle  with  the  thigh.  Place  the  limb  on 
a  doul^le  inclined  plane  for  five  weeks,  then  begin  passive 
motion  once  every  other  day,  reapplying  the  splint  after 
the  movements  are  completed.  At  the  end  of  eight  weeks 
after  the  accident  remove  the  dressings,  and,  if  the  knee- 
joint  be  stiff,  use  for  some  time  massage,  passive  motion, 
hot  air,  hot  and  cold  douches,  ichthyol  inunctions,  etc. 
Bryant  treats  this  fracture  in  extension,  cutting  the  tendo 
Achillis,  if  necessary,  to  amend  deformity.  It  is  occasion- 
ally necessary  to  plate  the  fragments.  Some  cases  demand  amputation  because 
of  injury  to  the  structures  in  the  popliteal  space. 

Fracture  Separating  Either  Condyle. — The  cause  is  direct  force. 
Symptoms   and    Treatment. — The  broken  piece  is  drawn  upward,  the  leg 
bends  toward  the  injury,  crepitus  exists,  the  knee  is  much  broadened,  there  is  no 
shortening,  and  considerable  swelling 
is  sure  to  arise.     In  treating  a  frac-     ^-    " 
ture  separating   either  condyle,  use 
a   double   inclined  plane  as  directed 
above.     If    there   is  great   displace- 
ment, the  condyle  should  be  nailed 
in  place.  , 

Longitudinal    fractures    run    up- 
ward   from    the    knee-joint.       The     ' 
cause  is  a  fall  upon  the  feet  or  the 
knees. 


Fig.  422. — Fracture  of  the  patella. 


Fig.  423. — Senseman's  case  of  frat iurr  of  lower 
epiphysis  of  the  femur  in  a  boy  seven  years  of 
age. 


Symptoms  and  Treatment. — The  symptoms  of  longitudinal  fracture  are  often 
obscure.  The  femur  is  broadened  when  the  knee  is  flexed.  The  split  may  be 
detected  between  the  condyles.  The  treatment  is  the  straight  position  in  plaster 
for  eight  weeks. 


Transverse  Fracture  of  the  Patella  687 

Separation  of  the  lower  epiphysis  occurs  only  before  the  twenty-first  year. 
It  is  not  a  very  rare  accident  in  children. 

The  symptoms  in  separation  of  the  lower  epiphysis  are  like  those  of  transverse 
fracture,  but  crepitus  is  moist.  The  lower  fragment  is  tilted,  so  that  the 
articular  surface  looks  forward.  The  lower  end  of  the  upper  fragment  projects 
into  the  popliteal  space.  There  is  danger  to  the  structures  in  the  popliteal 
space.  The  growth  of  bone  may  be  stunted.  Feel  for  the  pulse  in  the  leg  or 
foot. 

Treatment. — Reduction  may  be  effected  in  some  cases  by  horizontal  ex- 
tension. Occasionally  this  is  impossible.^  In  such  a  case  adopt  the  plan  of 
Hutchinson  and  Barnard,  make  extension,  and  while  it  is  being  made  gradually 
place  tlie  leg  at  a  right  angle  to  the  thigh.     This  is  effected  by  an  assistant 


Fig.  424. — Fracture  of  the  patella,  showing  wide  separation  of  the  fragments  (author's  case). 


making  traction  on  the  leg,  while  the  surgeon  clasps  his  hands  beneath  the 
lower  part  of  the  thigh  and  draws  upward.  The  treatment  for  separation  of 
the  lower  epiphysis  is  the  use  of  a  double  inclined  plane  as  above  directed.  In 
some  cases  replacement  is  impossible  without  incision.  In  a  case  of  my  own, 
amputation  was  performed  because  of  laceration  of  the  popliteal  vessels. 

Fracture  of  the  patella  is  a  very  common  accident.  The  cause  is  direct  force 
(often  producing  vertical,  star-shaped,  or  oblique  lines  cf  fracture,  but  not 
uncommonly  transverse)  or  muscular  action  (producing  a  transverse  line  of 
fracture) . 

Transverse  Fracture  of  the  Patella. — The  knee-cap  is  more  often  broken 
by  muscular  action  than  is  any  other  bone.  When  the  knee  is  partly  flexed 
the  middle  third  of  the  patella  rests  upon  the  condyles  of  the  femur  and  the 
upper  third  of  the  knee-cap  projects  above  them:  when  in  this  position  a 

^  See  the  case  reported  by  Jonathan  Hutchinson,  Jr.,  and  Howard  L.  Barnard,  "Lancet," 
May  13,  1899. 


588  Diseases  and  Injuries  of  the  Bones  and  Joints 

contraction  of  the  quadriceps  may  cause  easily  a  fracture  near  the  center  of 
the  bone  (Fig.  421).  The  accident  may  be  due  to  sudden  flexion  of  the  knee 
when  the  quadriceps  is  contracting.  The  most  usual  cause  is  a  fall  or  an 
attempt  of  the  patient  to  save  himself  from  a  fall  backward.  Both  patellae 
may  be  broken  at  once.  In  fracture  of  the  patella  the  joint,  and  often  the 
prepatellar  bursa,  are  opened.  Fractures  by  muscular  action  and  many  frac- 
tures from  direct  force  are  transverse.  The  injury  is  more  common  in  males 
than  in  females,  and  is  extremely  rare  in  the  very  young  and  the  old.  It  is 
usually  an  injury  of  active  manhood  and  middle  life,  but  I  have  seen  a  woman 
of  eighty-six  with  fracture  of  the  patella. 

Symptoms. — When   the  accident  happens  there  is  often  an  audible  crack. 
As  a  rule,  the  patient  will  not  try  to  use  the  limb,  although  it  is  possible  for 


Fig.  425. — Fracture  of  the  patella  (Pennsylvania  Hospital  case;  skiagraphed  by  Dr.  Gaston 

Torrance). 

him  to  stand,  to  walk  backward,  and  to  move  slowly  forward  when  the  ex- 
tremity is  kept  straight.  After  the  accident  there  is  rapid  and  enormous 
swelling,  due  to  the  effusion  first  of  blood  and  then  of  synovia  and  inflamma- 
tory products  into  and  around  the  joint.  The  patient  is  absolutely  unable  to 
raise  the  limb  from  the  bed.  The  fragments  are  movable  and  usually  widely 
separated  (Fig.  424),  this  separation  being  distinctly  manifest  to  the  touch 
unless  swelling  is  great.  The  separation  is  accentuated  by  flexion  of  the  leg. 
The  separation  may  be  to  the  extent  of  i  inch  or  even  more.  In  cases  in 
which  the  lateral  fibrous  expansions  and  periosteum  are  but  slightly  torn,  there 
may  be  trivial  separation  or  no  separation.  Separation  is  due  in  part  "to  the 
retraction  of  the  quadriceps  and  the  tension  of  the  fascia  lata,  and  in  part  to 
distention  of  the  joint  by  blood  and  exudate.^  If  fragments  are  not  approxi- 
1  Stimson's  "Treatise  on  Fractures  and  Dislocations." 


Treatment  of  Transverse  Fractures  of  the  Patella 


689 


mated  and  union  does  not  occur,  the  separation  becomes  gradually  greater 
because  of  the  progressive  shortening  of  the  muscle  and  the  retraction  of  the 
ligamentum  patellse  (Stimson).  In  some  cases  an  anterior  angular  displace- 
ment occurs  because  of  the  intra-articular  distention  (Fig.  425).  It  may 
be  produced  by  the  pressure  of  bandages  or  strips  of  plaster  when  the  frag- 
ments have  been  brought  togethei.  Crepitus  is  detected  if  the  upper  frag- 
ment can  be  pushed  do^vn  until  it  touches  the  lower  piece;  but  if  swelling  is 
great,  or  if  fibrous  tissue  is  interposed  between  the  bones,  crepitus  cannot  be 
elicited.  It  is  not  necessary  to  obtain  crepitus  in  order  to  make  the  diagnosis: 
the  condition  is  usually  obvious  without  this  sign.  The  anterior  fibroperiosteal 
layer  is  torn,  and  the  tear  does  not  correspond  exactly  with  the  line  of  frac- 
ture. A  portion  of  this  torn  fibroperiosteal  layer  may,  as  Macewan  pointed 
out,  drop  between  the  fragments  and  prevent  union  (Fig.  426).  The  lateral 
expansions  of  the  capsule  are  usually  extensively 
torn.  If  union  occurs  after  a  transverse  fracture, 
it  will  probably  be  ligamentous,  and  if  the  patient 
gets  about  too  soon,  even  apparently  well-united 
fragments  will  by  degrees  stretch  far  asunder. 

Treatment  of  Transverse  Fractures  of  the 
Patella. — The  Conservative  Plan. — If  the  swelling 
is  so  great  as  to  prevent  approximation  of  the 
fragments,  reduce  it  by  bandaging  for  a  day  or 
two,  by  using  ice-bags,  or  by  aspirating  the 
joint.  As  a  rule,  the  blood  does  not  coagulate 
for  several  days.  After  it  coagulates  it  cannot 
be  withdrawal  by  asph-ation,  but  only  by  incision. 
When  the  swelling  diminishes,  bring  the  two  frag- 
ments into  apposition,  pull  them  together  by  ad- 
hesive plaster,  and  put  on  a  well-padded  posterior 
splint.  Carry  a  piece  of  adhesive  plaster  over 
the  upper  end  of  the  upper  fragment,  draw  the 
bone  down,  and  fasten  the  plaster  to  the  splint 
behind  and  below  the  level  of  the  joint.  Carry 
another  piece  of  plaster  over  the  lower  end  of  the 
lower  fragment,  draw  the  bone  up,  and  fasten 
the  plaster  to  the  splint  behind  and  above  the 

joint.  Carry  a  third  piece  over  the  junction  of  the  fragments  to  prevent  tilting. 
Agnew's  splint  enables  us  to  accomplish  satisfactorily  this  approximation 
(PL  7,  Figs.  II,  12).  A  bandage  holds  the  splint  in  place,  and  may  be  carried 
around  the  knee  by  figure-of-8  turns.  The  heel  is  sometimes  raised  upon  a 
pillow  so  as  to  extend  the  leg  and  to  semiflex  the  thigh,  but  this  is  not  essential. 
Remove  and  reapply  the  dressing  every  few  days,  as  it  inevitably  becomes 
loose.  At  each  removal  employ  massage.  At  the  end  of  three  weeks  remove 
the  splint  permanently  and  apply  a  plaster-of-Paris  dressing  from  just  above 
the  ankle  to  the  middle  of  the  thigh,  and  get  the  patient  about  on  crutches. 
Have  the  plaster  cut  so  that  it  may  he  easily  removed  and  every  day  employ 
massage  and  gentle  passive  movements,  the  surgeon  fixing  the  upper  end  of 
the  upper  fragment  by  his  thumb  during  the  movements.  The  dressing  is  to 
be  worn  for  five  weeks.  After  eight  weeks  of  treatment  allow  the  patient  to 
walk  about  on  crutches,  the  joint  being  left  free  at  night,  but  kept  fixed  during 
the  day  by  pasteboard  splints  or  by  a  light  plaster-of-Paris  bandage.  After 
four  weeks  more  he  gets  about  with  canes  or  a  cane.  For  months  after  remov- 
ing the  splints  and  plaster  a  lacing  knee-cap  of  leather  should  be  worn  in  the  day- 
time to  support  the  joint.  The  plan  of  prolonged  immobilization  renders 
more  or  less  muscular  atrophy  and  joint-stiffness  certainties,  but  these  are 
less  serious  impediments  than  the  wide  separation  of  the  fragments  that  inevit- 

44 


Fig.  426. — Transverse  frac- 
ture of  the  patella;  fractured  sur- 
face partially  covered  by  irregular 
flaps  of  torn  aponeurosis  (Hoffa). 


690  Diseases  and  Injuries  of  the  Bones  and  Joints 

ably  attends  an  early  use  of  the  joint,  liryant,  of  New  York,  has  devised 
an  ambulatory  dressing. 

Operative  Treatment. — Malgaigne's  hooks  are  obsolete. 

It  is  said  that  John  Rhea  Barton" wired  an  ununited  fracture  of  the  patella 
in  1843.  In  1877  Hector  Cameron  wired  an  ununited  friction  of  the  patella, 
and  a  few  months  later  Lord  Lister  operated  on  a  fracture  of  the  knee-cap  two 
weeks  after  the  accident.  The  question  of  the  advisability  of  suturing  a  recent 
fracture  has  been  very  much  disputed.  The  ordinary  non-operative  plans  of 
treatment  do  not  endanger  life  and  generally  give  a  fairly  good  functional  result, 
although  the  joint  remains  insecure  on  extension,  the  patient  is  apt  to  fall,  and 
a  fall  may  refracture  the  bone.  The  operative  method  will  usually  succeed, 
and  is  capable  of  obtaining  a  better  functional  result  and  of  obtaining  it  more 
rapidly.  There  is  some  danger  of  infection,  and  if  infection  should  occur,, 
the  results  may  be  most  disastrous.  Some  cases  obviously  cannot  be  treated 
by  the  conservative  method  with  any  chance  of  success;  cases,  for  instance, 
in  which  a  flap  of  fibroperiosteum  intervenes  between  the  fragments,  or  cases 
in  which  from  some  other  cause  the  bones  cannot  be  approximated.  Such 
cases  should,  of  course,  be  operated  upon.  But  in  the  great  majority  of  cases 
a  good  result  will  follow  conservative  treatment,  and  conservative  treatment 
should  be  trusted  unless  the  case  is  in  the  hands  of  a  surgeon  and  in  a  place 
where  every  antiseptic  precaution  can  be  taken.  We  agree  with  Stimson 
when  he  says  that  operative  methods  can  be  used  with  confidence  when  sur- 
rounded by  every  protection;  he  habitually  uses  them,  but  he  never  teaches 


Fig.  427. — Needle  specially  designed  to  carry  a  thick  wire.     The  eye  is  drilled  obliquely,  and 
should  receive  onlj'  a  little  loop  on  the  end  of  the  wire;  this  loop  should  be  made  previously. 

them  as  proper  routine  practice,  and  strongly  advises  against  their  use  except 
by  those  who  have  had  experience  in  operating,  who  have  formed  the  habit 
of  taking  precautions,  and  who  have  the  aid  of  skilled  assistants.^  Operation 
should  only  be  performed  on  healthy  persons  of  suitable  age,  when  the  separa- 
tion is  over  3^^  inch  or  when  there  is  much  laceration  or  interposition  of  the  cap- 
sule.^ If  a  patient  is  still  able  to  extend  the  limb  and  the  lateral  expansions  of 
the  quadriceps  have  not  been  widely  torn,  a  useful  limb  will  be  obtained  by 
conservative  treatment  even  if  the  bone-fragments  separate,  and  operation  is 
not  demanded.  A  working  man  needs  the  operation  more  than  a  gentleman 
of  leisure  because  he  is  in  more  vital  need  of  a  sound  knee-joint.  A  young 
or  middle-aged  person  is  more  active  than  an  elderly  person,  hence,  in  him 
operation  is  more  strongly  indicated  than  in  an  elderly  man.  Barker  believes 
strongly  in  wiring  recent  transverse  fractures.  He  does  it  with  antiseptic  care 
soon  after  the  accident,  and  permits  passive  motion  or  even  slight  active 
motion  immediately  after  the  operation.  Massage  is  begun  the  day  after  the 
operation,  and  is  practised  daily  for  two  weeks. 

Barker^  uses  a  special  needle  (Fig.  427)  and  silver  wire  of  the  thickness  of  a 
No.  I  English  catheter.  This  wire  is  straightened  and  softened  in  a  spirit-flame. 
He  rubs  the  bone-fragments  together  in  order  to  dislodge  blood  or  fibrous 
material,   and   when  marked  grating  occurs,   introduces   the   wire.     A  punc- 

1  "Annals  of  Surgery,"  August,  1898. 
^  Powers,  in  "Annals  of  Surgery,"  July,  1898. 

^  See  the  objections  of  Sir  William  Stokes  to  Barker's  method,  in  "Brit.  Med.  Jour.,'" 
Dec.  3,  1898. 


Treatment  of  Transverse  Fractures  of  the  Patella 


6qi 


ture  with  a  small  knife  is  made  through  the  middle  of  the  upper  attachment  of 
the  patellar  ligament.     The  needle,  not  carrying  any  wire,  is  made  to  enter 


Fig.  428. — Needle  (a)  introduced  behind  the 
fragments,  and  receiving  one  end  (b)  of  the  silver 
wire  (b,  c)  (Barker). 


Fig.  429. — Needle  (a)  passed  in  front 
of  the  fragments  and  receiving  the  other 
end  (c)  of  the  silver  wire  (b,  c)  (Barker). 


through  this  opening  into  the  joint,  is  passed  back  of  the  fragments,  pierces 
the  tendon  of  the  quadriceps,  at  the  upper  edge  of  the  upper  fragment,  and 
its   point  is  cut  upon  with  a  knife.  „ 

The  wire  is  inserted  into  the  eye 
of  the  needle  and  the  needle  is  with- 
drawn and  unthreaded.  The  empty 
needle  is  pushed  through  the  lower 
opening,  is  carried  in  front  of  the 
patella,  is  made  to  emerge  at  the 
upper  opening,  is  threaded  with  the 
protruding  wire  and  withdrawn  (Figs. 
428,  429).  The  wires  are  threaded 
into  bars  and  twisted  (Fig.  430),  the 
ends  are  cut  off.  and  antiseptic  dress- 
ings are  applied.  There  are  objections 
to  Barker's  operation:  It  does  not 
allow  us  to  remove  blood-clots  from 
the  joint;  if  a  bit  of  tissue  intervenes 
between  the  fragments,  it  cannot  be 
removed;  and  a  foreign  body  is  left 
permanently  in  the  joint. ^  If  an 
operation  is  thought  advisable,  we 
deem  it  best  to  do  an  open  operation. 
An  open  operation  may  be  performed 
within  a  very  few  hours  of  the  injury. 
If  it  is  not  done  then  it  should  be  post- 
poned for  five  days  or  longer.  In  the  period  between  the  first  day  and  the  fifth, 
tissue  resistance  is  lowest  and  the  parts  are  most  prone  to  infection.  By  the 
i"Brit.  Med.  Jour.,"  April  11,  1896. 


Fig.  430. — Wire  in  position  around  frag- 
ments and  threaded  through  metal  bars.  The 
lower  and  posterior  wire  runs  upward  to  the 
left  of  the  upper,  ready  for  twisting  (Barker). 


6q2 


Diseases  and  Injuries  of  the  Bones  and  Joints 


tenth  or  eleventh  day  it  will  be  found  more  difficult  to  separate  the  tissue 
and  hemorrhage  may  be  profuse. 

To  perform  the  open  operation  make  a  semilunar  or  a  central  longitudinal 
incision,  free  the  joint  from  blood-clots  by  irrigation  with  hot  salt  solution, 
remove  all  tissue  from  between  the  fragments,  drill  the  fragments,  pass  silver 
wire,  twist  the  wire  and  draw  the  fragments  together,  and  close  the  wound 
(Fig.  431).  Wire  seems  to  have  a  tendency  to  set  up  arthritic  changes.  Instead 
of  wire,  silk  may  be  used.  In  cases  in  which  there  is  no  very  strong  tendency 
to  separation  the  fragments  can  be  held  together  by  several  catgut  sutures 
through  the  capsule,  the  periosteum  at  the  fractured  edges  and  the  peripatellar 


Fig.   431. — Wired   fracture   of  the  patella  (St.  Joseph's  Hospital  case;  operated  upon  and 

skiagraphed  by  Dr.  Nassau). 

ligaments,  or  by  a  strong  catgut  or  silk  suture  passed  through  the  ligamentum 
patellae  and  the  quadriceps  tendon  and  carried  in  front  of  the  fracture  (Stimson). 
The  limb  should  be  placed  on  a  posterior  splint.  In  seven  or  eight  days  the 
superficial  sutures  are  removed  and  a  plaster-of-Paris  splint  is  applied.  In 
a  few  days  the  patient  gets  about  on  crutches.  In  a  month  the  dressing  is  cut 
down  the  front  and  worn  only  in  the  daytime,  and  passive  motion  is  begun. 
The  splint  is  discarded  at  the  end  of  the  third  month. ^  Among  other  operative 
procedures  we  may  mention  the  following:  encircling  the  fragments  by  a  silk 
suture  (the  circumferential  suture),  which,  however,  may  impair  bone  nutrition 
and  retard  union;  drilling  the  bones  subcutaneously  and  passing  wire  through 
1  Stimson,  "Annals  of  Surgery,"  August,  1898. 


Fractures  of  the  Patella  by  Direct  Force  693 

the  drill-holes  in  the  form  of  a  figure  of  8  (Ceci);  passing  subcutaneously  a 
ligature  around  and  over  the  fragments  (Butcher);  and  incising  and  approxi- 
mating of  the  fragments  by  fixation  hooks  or  metal  pins. 

Fractures  of  the  patella  by  direct  force  are  vertical,  stellate,  oblique,  V- 
shaped,  or  transverse;  are  often  incomplete  and  occasionally  compound  or  com- 
minuted (Fig.  432).  Ransohoff  maintains  that  fractures  from  direct  force  are 
more  common  than  from  muscular  action  and  are  usually  transverse  and  asso- 
ciated with  some  comminution  ("Jour.  Amer.  Med.  Assoc,"  Oct.  13,  1906). 

Compound  fraciure  of  the  patella  is  very  rarely  seen  in  Philadelphia  hospitals. 
The  records  of  the  Boston  City  Hospital  (an  institution  in  which  multitudes  of 
fractures  are  treated)  show  only  8  compound  fractures  of  this  bone  in  forty- 
two  years  (Scannell,  in  "Boston  Med.  and  Surg.  Jour.,"  Nov.  15,  1906). 

Symptoms  of  Simple  Fracture. — Fractures  of  the  patella  by  direct  force  are 
followed  by  discoloration,  swelling,  great  difficulty  in  movement,  and  much  pain. 
There  may  or  may  not  be  crepitus.  The  degree  of  separation  of  the  fragments 
depends  upon  the  direction  of  the  line  of  fracture  and  the  extent  of  bone  in- 


FiG.  432. — Comminuted  fracture  of  patella. 

volved.     Bony  union  is  apt  to  occur  after  such  a  fracture  when  there  has  not 
been  wide  separation. 

Treatment. — A  fracture  resulting  from  direct  force  may  often  be  treated 
by  a  posterior  splint  and  the  application  of  a  bandage.  If  there  is  any  separa- 
tion, the  fragments  should  be  approximated  by  adhesive  strips,  bandages,  and 
compresses.  At  the  end  of  three  weeks  remove  the  posterior  splint,  apply  a 
plaster-of -Paris  splint,  and  get  the  patient  about  on  crutches.  The  danger  in 
these  cases  is  ankylosis  rather  than  non-union;  hence,  in  the  fourth  week  cut 
the  plaster  splint  down  the  front  and  begin  passive  motion  of  the  knee-joint. 
At  the  end  of  six  weeks  cease  wearing  the  dressing  in  the  daytime,  and  at  the 
end  of  three  months  discard  it  entirely.  In  those  cases  in  which  an  oblique 
fracture  or  a  transverse  fracture  with  wide  separation  arises  from  direct  force, 
treat  as  advised  for  transverse  fracture  from  muscular  action.  The  question  of 
operation  is  practically  the  same  as  for  transverse  fracture  from  muscular  action. 
In  every  compound  fracture  of  the  patella,  if  amputation  can  be  avoided, 
incise  the  soft  parts  freely  and  irrigate  the  joint  with  hot  saline  fluid.  Remove 
hopelessly  loosened  fragments.  Those  not  completely  separated  may  in  some 
cases  be  sutured  into  place.     Drain  for  twenty-four  or  forty-eight  hours. 


694  Diseases  and  Injuries  of  the  Bones  and  Joints 

Ununited  and  Badly  United  Fracture  of  the  Patella. — There  is  usually  a 
band  of  union,  but  it  may  be  very  thin  and  the  fragments  may  be  far  asun- 
der. It  is  commonly  taught  that  the  degree  of  functional  impairment  depends 
directly  on  the  amount  of  separation.  This  is  not  strictly  true.  There  may 
be  great  separation  and  but  little  impairment  of  function,  the  fragments  being 
firmly  united  by  a  dense  fibrous  band.  There  may  be  little  separation  and 
yet  lameness,  stiffness  of  the  joint,  and  imperfect  power  of  extension.  The 
reason  for  this  has  been  pointed  out  by  Bruns,  of  Tubingen.^  He  says  there 
may  be  complete  failure  of  union,  even  when  the  separation  is  trivial,  and  fail- 
ure of  union  produces  impaired  function.  If  separation  is  considerable,  the 
fragments  are  apt  to  tilt  and  tissue  is  often  interposed  between  them.  Func- 
tional difficulty  is  more  often  met  with  when  the  fragments  are  far  apart  than 
when  they  are  near  together,  because  non-union  is  more  common.  As  a  matter 
of  fact  in  most  cases  of  non-union  John  B.  Murphy  said  a  man  could  get  along 
very  well  "without  his  patella"  ("Surgical  Clinics,"  vol.  i,  No.  3,  page  326  and 
vol.  iv,  No.  4,  page  771).  In  non-union  the  quadriceps  is  still  able  to  act  upon 
the  tibia  by  means  of  the  fascia  lata,  ligaments  at  the  sides  of  the  joint,  or 
bands  from  the  vasti  to  the  lower  fragment.  Besides  non-union,  functional 
impairment  may  be  due  to  anchoring  of  the  upper  fragment  to  the  femur.  The 
upper  fragment  may  be  anchored  to  the  femur  by  the  interposition  of  the  fibrous 
investment  of  the  knee-cap,  which  covers  the  fractured  surface  of  the  upper 
fragment  and  may  grow  fast  to  the  capsule  of  the  joint  (Bruns). 

The  treatment  of  ununited  and  badly  united  fracture  is  discussed  on  page 
61G. 

Fractures  of  the  Leg. — In  leg-fractures  both  bones  or  only  one  bone  may 
be  broken. 

Fractures  of  the  tibia  are  divided  into:  (i)  fractures  of  the  upper  end;  (2) 
separation  of  the  upper  epiphysis;  (3)  fractures  of  the  shaft;  (4)  fractures  of 
the  lower  end,  and  (5)  separation  of  the  lower  epiphysis. 

Fractures  of  the  upper  end  of  the  tibia  are  uncommon.  They  may  be  trans- 
verse, oblique,  or  vertical,  running  into  the  joint.     The  cause  is  direct  violence. 

Symptoms. — In  fracture  of  the  upper  end  of  the  tibia  there  is  contusion  of 
the  soft  parts.  In  a  transverse  fracture  there  are  mobility  and  crepitus,  but 
there  is  little  displacement.  In  oblique  fracture  crepitus  and  mobility  are 
marked,  the  axis  of  the  limb  is  altered,  and  the  fragments  may  be  displaced. 
In  fractures  entering  the  joint  there  is  great  swelling  of  the  knee-joint.  Com- 
minuted fractures  exhibit  marked  signs,  union  is  readily  obtained,  but  if  the 
joint  has  been  damaged,  stiffness  is  sure  to  ensue. 

Treatment. — Reduce  displacement  by  extension  and  manipulation.  The 
special  apparatus  used  for  treatment  depends  on  the  case.  In  some  cases 
extension  is  required,  in  some  a  posterior  splint  is  applied  and  the  limb  is  sus- 
pended from  a  gallows,  in  some  a  double  inclined  plane  is  employed,  and  in 
some  a  plaster-of-Paris  splint  is  used. 

The  double  inclined  plane  in  the  form  of  Mclntyre's  splint  is  frequently 
employed,  or  a  double  inclined  plane  in  the  form  of  a  fracture-box  may  be 
preferred.  The  Balkan  splint  secures  traction  and  is  very  useful  (Fig.  400), 
The  extremity  should  be  immobilized  for  four  weeks,  when  passive  motion  should 
be  begun.  Passive  motion  is  to  be  made  daily,  the  dressing  being  reapplied 
after  each  seance.  In  five  or  six  weeks  the  dressings  are  removed  and  the  patient 
allowed  to  go  about  on  crutches.  The  crutches  are  soon  abandoned  for  a 
cane,  and  later  all  support  is  dispensed  with.  If  a  fracture  extends  into  the 
knee-joint  and  the  ill-adjusted  fragments  block  the  articulation,  the  joint  should 
be  opened  and  the  fragments  placed  and  fixed  in  proper  position. 

Separation  of  the  tubercle  of  the  tibia  is  due  to  violent  contraction  of  the 

'  "Beitrage  zur  klinischen  Chirurgie,"  "Mittheilungen  aus  der  chirurg.  Klinik  zu  Tubin- 
gen," Bd.  iii,  Heft  2,  1888. 


Fractures  of  the  Lower  End  of  the  Tibia  695 

quadriceps,  and  occurs  only  in  those  under  twenty  years  of  age.  The  frag- 
ment is  drawn  up  and  can  be  felt,  and  the  patient  is  unable  to  use  the  hmb. 
In  a  case  in  which  the  tibial  spine  has  been  torn  off,  it  may  be  nailed  in  place, 
or  the  limb  should  be  placed  on  a  posterior  straight  splint  and  the  fragment 
should  be  pulled  down  into  place  by  adhesive  strips  and  bandages.  The  splint 
should  be  worn  for  five  weeks. 

Avulsion  of  the  Spine  of  the  Tibia. — This  is  a  very  rare  accident.  There  are 
but  very  few  cases  on  record,  and  in  only  i  of  them  (Pringle's)  was  the  diagnosis 
made  during  life,  and  it  was  made  in  that  case  by  exploratory  incision.  The 
tibial  spine  is  torn  off  by  the  anterior  crucial  ligament.  The  causative  force 
is  probably  flexion,  abduction,  and  internal  rotation  of  the  leg  (J.  Hogarth 
Pringle,  "Annals  of  Surg.,"  August,  1907).  After  the  accident  the  leg  at  the 
knee  is  in  extreme  abduction.  Exploratory  incision  may  be  necessary  for 
diagnosis.     The  treatment  is  to  suture  or  nail  the  bone-fragment  in  place. 

Separation  of  the  Upper  Epiphysis  of  the  Tibia. — This  is  an  injury  of  ex- 
treme rarity.  It  does  not  seem  to  occur  after  the  sixteenth  year.  It  is  caused 
by  a  twist  or  crush,  or  by  violent  abduction  or  adduction  of  the  leg.  It  may 
lead  to  lessened  growth  of  the  limb.  I  have  seen  two  cases.  One  in  a  boy 
of  twelve  who  was  knocked  down  by  a  trolley  car.  One  in  a  boy  of  fifteen  who 
was  riding  on  the  back  of  a  truck  while  another  truck  ran  into  it.  In  both 
cases  amputation  was  performed ;  in  one  case  because  of  hemorrhage  from  the 
popliteal  vessels,  in  the  other  because  of  gangrene.  The  treatment  is  as  for  a 
fracture  of  the  upper  end  of  the  bone. 

Fractures  of  the  Shaft  of  the  Tibia. — The  causes  of  these  fractures  are  direct 
force,  indirect  force,  or  torsion.  A  fracture  in  the  upper  part  of  the  bone  is 
usually  transverse;  in  the  lower  part  it  is  usually  obUque  (T.  Pickering  Pick). 

Symptoms. — In  transverse  fracture  of  the  shaft  of  the  tibia  there  is  no  deform- 
ity, and  the  support  of  the  fibula  may  even  permit  of  walking;  there  is  fixed 
pain;  there  may  or  may  not  be  inequality  of  the  fragments  felt  by  the  finger; 
and  there  are  pain,  tenderness,  crepitus,  mobility,  and  often  hnear  ecchymosis. 
In  obHque  fractures  there  usually  exist  crepitus,  a  little  mobility,  and  distinct 
deformity.  The  deformity  depends  on  the  direction  of  the  line  of  fracture,  and, 
as  this  line  is  usually  from  above  downward,  inward,  and  a  little  forward,  the 
lower  fragment  usually  passes  behind  the  upper  fragment  and  rotates  inward. 

Treatment. — In  treating  fractures  of  the  shaft  of  the  tibia  effect  reduc- 
tion by  making  extension  from  the  foot  and  coimterextension  from  the  knee, 
the  knee-joint  being  in  partial  flexion.  If  there  is  much  swelling,  put  the 
limb  in  a  fracture-box  (Figs.  433,  434,  and  PL  7,  Fig.  i),  swing  the  box  from  a 
gallows,  and  apply  an  ice-bag  for  twenty-four  hours.  A  siUcate  of  sodium  or  a 
plaster-of-Paris  dressing  is  applied  when  the  swelling  subsides,  or  the  dressing 
may  be  used  at  once  instead  of  a  fracture-box  if  swelling  is  shght.  As  soon  as 
the  Umb  is  immobiHzed  in  a  siHcate  or  plaster  dressing  the  patient  gets  about 
on  crutches.  The  dressing  is  removed  after  five  weeks,  and  the  patient  goes 
about  for  one  week  on  crutches,  lightly  using  the  foot,  and  then  for  a  time  walks 
with  the  aid  of  a  cane.  At  the  end  of  eight  or  nine  weeks  the  cane  may  often 
be  dispensed  with,  the  amoimt  of  use  of  the  leg  being  daily  augmented.  The 
Thomas  arm  spHnt  is  an  efficient  emergency  apparatus  for  fracture  of  the  tibia 
(Fig.  397). 

Fractures  of  the  Lower  End  of  the  Tibia :  Fracture  of  the  Inner  Malleolus. — 
The  cause  of  fracture  of  the  inner  malleolus  is  direct  force  or  traction  upon  the 
internal  lateral  hgament. 

Symptoms  and  Treatment. — ^The  symptoms  of  fracture  of  the  iimer  malleolus 
are  pain,  tenderness,  some  downward  displacement,  depression  above  the  ends  of 
the  fragments,  mobility,  and  crepitus.  The  treatment  is  to  push  the  fragments 
into  place  and  use  side-splints  or  a  fracture-box  for  two  weeks,  when  a  plaster-of- 
Paris  or  a  silicate  dressing  may  be  substituted  and  the*  patient  ordered  to  use 


696 


Diseases  and  Injuries  of  the  Bones  and  Joints 


crutches.  Remove  the  plaster  four  or  five  weeks  after  it  is  applied,  and  direct 
the  patient  gradually  to  bear  his  weight  upon  the  leg,  as  outlined  above. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  a  rare  accident,  but  is  com- 
moner than  separation  of  the  upper  epiphysis.  The  treatment  is  a  fixed  dress- 
ing for  six  weeks. 

Fracture  of  the  fibula  alone  is  commoner  by  far  than  is  fracture  of  the  tibia 
alone.  Fractures  in  the  upper  two-thirds,  which  are  rare,  are  usually  due  to 
direct  force.  Fractures  in  the  lower  third  are  frequent,  and  arise  from  indirect 
force. 

Fractures  of  the  Upper  Two-thirds  of  the  Fibula. — In  these  fractures  the 
cause  is  direct  force. 

Symptoms. — In  fracture  of  the  upper  two-thirds  of  the  fibula  the  patient 
is  frequently  able  to  walk.     The  bone  is  deeply  situated,  and  displacement 


Figs.  433,  434. — Fracture-box  in  fractures  of  the  bones  of  the  leg. 

cannot  often  be  detected.  There  is  a  fixed  pain,  which  is  intensified  by  move- 
ment and  by  pressure.  Pressure  upon  the  lower  fragment  does  not  move 
the  upper  fragment.  Crepitus  is  sometimes  obtained,  and  linear  ecchymosis  is 
apt  to  appear.  The  bone  is  normally  elastic,  hence  slight  mobility  is  of  no  value 
diagnostically. 

Treatment. — In  treating  a  fracture  of  the  upper  two-thirds  of  the  fibula  apply 
a  plaster-of-Paris  or  a  silicate  bandage  and  direct  that  it  be  worn  for  five  weeks. 
Weight  is  not  to  be  put  upon  the  foot  for  six  weeks  after  the  accident. 

Fractures  of  the  Lower  Third  of  the  Fibula. — In  these  fractures  the  cause  is 
usually  indirect  force,  especially  twists  of  the  foot.  Forcible  inversion  of  the  foot 
pulls  upon  the  external  lateral  hgament  and  the  external  malleolus,  forces  the 


Pott's  Fracture 


697 


fibula  outward,  and  tends  to  break  it,  the  lower  fragment  being  displaced  out- 
ward. Forcible  eversion  pulls  the  internal  lateral  hgament  from  the  inner 
malleolus  (often  breaks  the  malleolus)  and  fractures  the  fibula  above  the  ankle, 
the  bone  being  displaced  inward. 

Pott's  Fracture. — By  the  term  "Pott's  fracture"  is  meant  a  fracture  of  the 
lower  fifth  of  the  fibula  produced  by  eversion  and  abduction  of  the  foot.  Stim- 
son  points  out  that  the  production  of  Pott's  fracture  is  often  aided  by  the  weight 
of  the  body.  The  lesions  which  arise  depend  upon  whether  the  chief  force  is 
eversion  or  abduction.  "If  eversion  is  the  sole,  or  main,  movement,  the  force 
is  exerted  through  the  internal  lateral  ligament  and  breaks  the  internal  malleolus 

squarely  off  at  its  base;  then  it  presses  the 
external  malleolus  outward,  rupturing  the 
tibiofibular  ligament,  and  breaks  the  fibula 
close  above  the  malleolus.  Sometimes  in- 
stead of  pure  rupture  of  the  tibiofibular  liga- 
ment there  is  avulsion  of  the  portion  of  the 
tibia  to  which  it  is  attached."^  Stimson 
further  points  out  that  if  abduction  is  the 
preponderating  force  there  is  an  oblique  frac- 
ture of  the  anterior  portion  of  the  internal 
malleolus  or  more  frequently  rupture  of  the 
anterior  portion  of  the  internal  lateral  liga- 
ment.    There    are,    as  in    the  former    case, 


Fig.  435. — Pott's  fracture.  Dupuy- 
tren's  splint.  Note  length  of  splint; 
position  of  straps;  arrangement  of  pad- 
ding; space  between  foot  and  splint 
(Scudder) . 


Fig.   436. — Pott's  fracture. 


rupture  of  the  tibiofibular  ligament  and  an  oblique  fracture  of  the  fibula 
several  inches  above  the  external  malleolus.  It  is  evident  that  the  degree  of 
injury  produced  by  eversion  and  abduction  depends  on  the  point  at  which 
the  force  is  arrested.  It  may  be  arrested  after  the  inner  malleolus  has  been 
separated  or  the  anterior  fibers  of  the  deltoid  Hgament  torn,  and  in  this  case 
the  tibiofibular  articulation  remains  intact  and  the  fibula  is  not  broken. 
It  may  cease  after  separating  the  tibiofibular  articulation,  and  in  this  case  too 
the  fibula  escapes.  It  may  be  continued  until  the  fibula  breaks.  In  this  frac- 
ture the  astragalus  passes  outward,  somewhat  backward  and  also  upward,  the 
later  deviation  being  due  to  separation  of  the  tibiofibular  articulation.  The 
1  "A  Practical  Treatise  on  Fractures  and  Dislocations,"  by  Lewis  A.  Stimson. 


698  Diseases  and  Injuries  of  the  Bones  and  Joints 

chief  trouble  in  reduction  and  treatment  is  this  outward  and  backward  disloca- 
tion of  the  foot. 

Symptoms. — The  foot  is  displaced  outward,  and  a  little  backward  and  up- 
ward, and  the  inner  malleolus  or  the  tibia  from  which  it  was  torn  is  extremely 
prominent.  There  is  great  lateral  mobility  and  often  anteroposterior  mobility 
at  the  ankle-joint.  Stimson  points  out  that  there  are  three  points  where 
pressure  is  certain  to  provoke  pain;  in  front  of  the  tibiofibular  ligament,  at  the 
base  or  anterior  border  of  the  inner  malleolus,  and  over  the  seat  of  fracture 
through  the  fibula. 

Treatment. — Thorough  reduction  is  of  the  greatest  importance.  If  thor- 
ough reduction  is  effected,  a  good  result  will  probably  be  obtained;  but  if 
thorough  reduction  is  not  effected,  the  patient  will  be  permanently  crippled 
to  a  greater  or  less  extent.  In  order  to  effect  reduction  it  may  be  necessary 
to  anesthetize  the  patient.  The  patient's  knee  is  flexed,  the  heel  is  pulled 
strongly  forward  and  inward,  and  the  lower  end  of  the  tibia  is  pushed  backward. 
This  corrects  the  ankle  dislocation,  and  then  the  valgus  must  be  overcorrected 
(Jones).     Inversion  of  the  ankle  is  imperative. 

Some  surgeons  at  once  after  reduction  apply  a  plaster-of-Paris  bandage. 
This  treatment  is  objectionable  because  the  deformity  may  be  partially  repro- 
duced after  the  application  of  the  dressing,  the  surgeon  being  unable  to  see 
it  and  unable  to  correct  it. 

If  there  seems  to  be  no  strong  tendency  to  a  recurrence  of  deformity,  a  frac- 
ture-box can  be  used.  After  reducing  displacement  in  such  a  case,  place  the 
limb  in  a  fracture-box  containing  a  soft  pillow.  A  bird 's-nest  pad  of  cotton  or 
oakum  is  made  for  the  heel  (see  Figs.  433,  434).  A  fillet  around  the  ankle  fas- 
tens the  foot  to  the  foot-piece  of  the  box;  a  pad  of  oakum  rests  between  the  foot- 
piece  and  the  sole.  A  compress  is  placed  below  the  outer  malleolus  and  another 
one  above  the  inner  malleolus.  Close  the  sides  of  the  box  and  tie  them  together 
with  a  bandage,  and  swing  the  box  on  a  gallows.  Every  day  let  down  the  sides 
of  the  box  and  rub  the  leg,  the  ankle,  and  the  foot  with  alcohol.  In  ten  days 
apply  a  plaster-of-Paris  bandage  and  let  the  patient  get  about  on  crutches. 
Remove  plaster  at  the  end  of  the  fifth  week  after  the  accident,  and  let  patient 
go  about  with  crutches  for  one  week  and  with  a  cane  for  a  week  longer. 

I  am  accustomed  to  dress  most  cases  of  Pott's  fracture  with  a  Dupuytren 
splint.  This  is  a  straight  splint  (Fig.  435  and  PI.  7,  Fig.  9  )  which  reaches  from 
above  the  head  of  the  tibia  to  below  the  sole  of  the  foot.  This  splint  is  padded, 
and  a  pyramidal  pad  with  the  base  down  is  laid  upon  the  inner  surface  of 
the  leg,  above  the  inner  malleolus,  the  splint  being  put  upon  the  inner  sur- 
face of  the  leg,  over  the  pad.  The  splint  is  fastened  as  shown  in  Plate  7,  Fig.  9, 
and  Fig.  435.  If  the  short  splint  shown  in  Plate  7  is  used  (it  only  goes  to  the 
head  of  the  tibia),  the  leg  is  semiflexed  upon  the  thigh  and  is  laid  upon  its  outer 
surface  upon  a  pillow.  After  ten  days  of  Dupuytren's  splint,  apply  the 
plaster-of-Paris  bandage,  which  is  to  be  worn  as  above  directed.  Bryant  treats 
Pott's  fracture  with  a  posterior  splint,  two  lateral  splints,  and  a  swing.  Stimson 
uses  a  posterior  and  lateral  splint  of  plaster  of  Paris.  This  splint  does  not  sUp, 
as  may  Dupuytren's  dressing,  and  does  not  hide  the  seat  of  fracture  from  view, 
as  does  complete  encasement  with  plaster  of  Paris.  It  is  a  most  useful  dressing. 
When  the  patient  begins  to  walk  the  callus  may  bend.  If  it  does,  eversion  will 
be  produced.  In  order  to  prevent  this  make  the  patient  walk  for  a  number  of 
weeks  upon  a  shoe  heel  raised  on  the  inside  in  order  to  induce  the  position  of 
varus.  A  very  heavy  man  should  also  wear  for  several  weeks  an  iron  brace 
on  the  outside.  I  have  given  above  the  conservative  treatment  of  Pott's 
fracture.  I  have  come  to  the  conclusion  that  operation  should  be  the  rule  in 
this  injury  and  not  the  exception.  The  fracture  is  so  often  followed  by  pain, 
swelling,  and  disability.  Pain  and  disability  are  so  largely  due  to  malunion 
or  fibrous  union  of  the  broken  malleolus,  and  it  is  so  easy  to  fix  the  fragment  in 


Fracture  of  Both  Bones  of  the  Leg 


699 


place  by  nails  or  sutures,  that  the  conclusion  seems  obvious  that  in  proper  sub- 
jects operation  should  be  performed.  As  Heath  and  Selby  show,  in  an  impor- 
tant article  ("  Annals  of  Surg.,"  Jan,  1908),  operation  also  allows  us  to  return  the 
tibialis  posticus  to  its  normal  position  and  thus  fiat-foot  is  prevented.  The 
plan  suggested  by  Heath  and  Selby  ("Annals  of  Surgery,"  Jan.,  1908)  is  excel- 
lent. The  fragment  may  be  sutured  in  place  by  silver  wire  or  chromic  gut. 
If  the  tendon  of  the  posterior  tibial  is  displaced,  the  torn  annular  ligament  is 
sutured  so  as  to  hold  the  tendon  in  place,  a  drain  of  rubber  tissue  is  carried  down 
to  the  bone,  and  the  soft  parts  are  sutured.  The  parts  are  dressed  and  a 
fixation  apparatus  is  applied.  The  drain  is  removed  in  twenty-four  hours.  In 
eight  weeks  the  patient  should  be  walking 
freely  (see  cases  reported  by  Heath  and 
Selby,  Ibid.).  Pott's  fracture  may  be 
compound,  a  portion  of  the  inner  malleolus 
or  of  the  tibia  above  it  projecting  through 
the  wound.  If  it  is  necessary  to  introduce 
through-and-through  drainage,  the  foot 
must  be  placed  and  kept  at  a  right  angle  to 
the  leg.  If  a  compound  fracture  exists, 
the  malleolus  must  be  nailed  in  place  or 
sutured  by  silver  wire  or  chromic  gut.  In 
a  reported  case  the  wire  was  passed  through 
the  joint  and  around  the  fragment,  and  the 
result  was  good.^  Nailing  seems  a  better 
plan. 

Fracture  of  both  bones  of  the  leg  is  a 
very  common  injury,  is  often  compound, 
and  is  not  unusually  comminuted.  Frac- 
tures by  direct  force,  such  as  blows  or 
kicks,  are  commonest  in  the  upper  half  of 
the  leg.  Fractures  by  indirect  force,  as  by 
falls,  are  commonest  in  the  lower  half  of 
the  leg.  In  fractures  from  indirect  force 
the  tibia  breaks  first,  and  then  the  fibula 
breaks  at  a  higher  level.  The  point  of 
greatest  Hability  to  fracture  from  indirect 
force  is  the  junction  of  the  lower  and 
middle  thirds.  Fractures  of  the  leg  are 
usually  oblique,  but  they  may  be  trans- 
verse if  arising  from  direct  force.  Spiral, 
torsion,  or  V-shaped  fractures  and  longi- 
tudinal breaks,  sometimes  occur.  In  oblique  fractures,  as  a  rule,  the  line  of 
fracture  runs  from  behind,  downward,  inward,  and  a  Httle  forward. 

Symptoms. — Fracture  of  both  bones  of  the  leg  is  easy  of  recognition.  The 
fibular  fracture  is  detected  as  before  described.  By  running  the  finger  along 
the  crest  of  the  tibia  displacement  will  be  found,  except  in  transverse  fractures, 
when  it  may  not  occur.  The  common  displacement  is  for  the  lower  fragment 
to  ascend  and  pass  behind  the  lower  end  of  the  upper  fragment  and  to  rotate 
a  Httle  outward,  and  for  the  upper  fragment  to  project  in  front.  The  ascent  of 
the  lower  fragment  is  due  to  the  action  of  the  gastrocnemius  and  soleus  muscles. 
If  the  line  of  fracture  is  in  a  direction  the  reverse  of  that  which  is  usual,  the 
lower  fragment  ascends  in  front  of  the  lower  end  of  the  upper  fragment.  In 
fracture  of  both  bones  of  the  leg  there  are  marked  mobility  and  crepitus,  severe 
pain,  and  inability  to  walk.  In  fractures  from  direct  force  there  is  more  or  less 
damage  to  the  soft  parts.  A  fracture  of  the  shaft  of  the  tibia  near  the  ankle  is 
V'Rev.  de  Chir.,"  vol.  viii,  1888. 


'^^                -.'ffl 

w 

-*m 

1        '^^ 

H; 

i 

1     w 

1 

^^H^P'f 

■  .- 1 

tu««i*4-«.*S'.:i 

Hk 

[  _  ^ 

Fig. 


437. — Fracture   of   both  bones  of 
leg.     Bad  position. 


700  Diseases  and  Injuries  of  the  Bones  and  Joints 

distinguished  from  a  dislocation  by  the  fact  that  the  deformity  is  easily  reduced, 
but  tends  to  recur  in  the  fracture,  and,  further,  that  in  a  fracture  the  relations 
of  the  malleoli  to  the  tarsus  are  unaltered,  whereas  in  a  dislocation  they  are 
altered. 

Treatment. — If  the  fracture  is  near  the  ankle-joint,  the  action  of  the  tendo 
Achillis  may  maintain  deformity,  and  in  such  cases  the  tendon  should  be 
divided.  All  fractures  of  the  lower  third  are  difficult  to  reduce  and  often  require 
extension  by  the  pulley.  In  very  few  will  perfect  apposition  of  the  fragments 
be  brought  about,  and  the  best  we  can  usually  attain  is  good  alignment  (Jones). 
In  treating  a  simple  fracture  of  the  lower  two-thirds  of  the  bones  reduce  by 
extension  and  counterextension,  and  use  a  fracture-box  (see  Figs.  433,  434). 
The  compresses  used  in  Pott's  fracture  are  not  required.  If  the  soft  parts 
are  bruised,  use  evaporating  lotions  for  a  da}';  if  they  are  abraded,  apply  anti- 
septic dressings.  The  fracture-box  should  be  swung  upon  a  gallows.  After 
three  weeks  apply  a  plaster-of-Paris  or  silicate  of  sodium  dressing  and  let  the 
patient  sit  up  in  a  chair  during  one  week;  at  the  end  of  this  time  the  patient 
may  get  about  on  crutches.  At  the  end  of  six  weeks  after  the  accident  remove 
the  plaster,  and  let  the  sufferer  go  about  on  crutches  for  two  weeks  and  with  a 
cane  for  two  weeks  more.  Brinton  was  accustomed  to  dress  a  fracture  of  both 
bones  of  the  leg  for  two  weeks  in  a  fracture-box,  for  two  weeks  in  side-splints 
made  of  metal,  and  for  two  weeks  in  an  immovable  dressing,  allowing  the 
patient  to  get  about  on  crutches  as  soon  as  the  plaster  was  put  on.  In- 
stead of  the  fracture-box  we  may  use  a  posterior  splint,  two  lateral  splints^ 
and  a  swing.  The  Thomas  bed-splint  is  a  very  useful  dressing.  So  is  the 
Balkan  frame  with  traction  (Fig.  400).  Nathan  R.  Smith's  anterior  splint 
is  used  by  some  in  the  treatment  of  fractures  of  the  leg.  Some  surgeons 
apply  plaster-of-Paris  in  the  form  of  an  ambulatory  dressing.  In  this  dressing 
a  solid  apparatus  reaches  to  the  lower  third  of  the  thigh  and  below  the  sole 
of  the  foot.  When  the  patient  walks  the  weight  is  transmitted  to  the  thigh. 
In  fractures  of  the  upper  third  of  the  leg  the  Mclntyre  splint  or  the  double 
inclined  plane  is  used.  If  the  fracture  is  compound,  asepticize  thoroughly,  make 
a  counteropening,  insert  a  drainage-tube,  dress  with  bichlorid  gauze,  apply 
a  plaster  bandage,  and  cut  trap-doors  over  the  openings  of  the  tube  (see 
Fig.  317),  or  dress  with  the  bracketed  splint  and  plaster  of  Paris  (see  Fig. 
318).  Remove  the  tube,  as  a  rule,  in  about  forty-eight  hours;  but  the  patient's 
temperature  is  the  guide  not  the  time  of  retention. 

In  many  fractures  of  the  lower  third  operation  is  indicated  to  accomplish 
reduction  and  fixation. 

Fractures  of  the  bones  of  the  foot  are  rather  rare  accidents,  although  not 
so  unusual  as  we  once  thought,  for  the  .x-ray  has  taught  us  that  a  considerable 
number  of  supposed  sprains  are,  in  reality,  fractures.  Owing  to  the  number 
of  the  bones  and  to  the  elasticity  of  their  connections  the  force  of  blows  and 
falls  is  spread  and  dissipated.  The  bones  most  often  broken  are  the  astragalus 
and  the  os  calcis.  Fractures  from  direct  force  are  often  compound.  The 
cause  of  fracture  of  either  the  scaphoid,  the  cuboid,  or  one  of  the  cuneiform  bones 
is  direct  force.  Simple  fractures  of  the  os  calcis  and  astragalus  may  arise  from 
crushes  or  twists  of  the  foot,  but  result,  as  a  rule,  from  falls.  The  calcaneum 
may  be  broken  by  a  direct  blow.  A  fractured  os  calcis  is  usually  much  crushed. 
In  rare  instances  the  os  calcis  has  been  broken  by  contraction  of  the  great  calf- 
muscles.  Forcible  dorsal  flexion  of  the  foot  may  fracture  the  neck  of  the 
astragalus  (Eisendrath).  Compound  fractures  may  result  from  gunshot- 
wounds,  crushes,  and  falls. 

Symptoms. — The  history  of  the  nature  of  the  accident  is  of  great  impor- 
tance. In  fracture  of  the  os  calcis  there  are  severe  pain,  tenderness,  swelling, 
crepitus,  mobility,  often  an  apparent  widening  of  the  bone,  and  not  unusually  a 
loss  of  the  longitudinal  arch  of  the  foot  (Pick).  The^wndening  can  be  detected 
under  the  outer  malleolus,  lateral  motion  in  the  calcaneo-astragaloid  joint  is 


Fractures  of  the  Metatarsal  Bones  701 

interfered  with  (Cotton,  in  "Annals  of  Surgery,"  1916,  Ixiv).  In  some  cases 
the  posterior  fragment  is  drawn  up  by  the  calf-muscles,  and  in  other  cases  there 
is  no  deformity.  In  fracture  of  the  astragalus  displacement  may  occur  which 
resembles  that  of  a  dislocation.  Crepitus  may  or  may  not  be  detected.  It 
can  be  elicited,  as  a  rule,  by  rotating  the  foot  while  the  heel  is  firmly  held.  If 
crepitus  cannot  be  detected  we  are  not  certain  that  a  fracture  is  present,  even 
though  the  patient  may  be  unable  to  stand  and  there  are  swelling  and  pain  on 
pressure.  The  malleoli  may  seem  on  a  lower  level  than  normal  if  the  astragalus 
and  OS  calcis  have  been  crushed.  Sometimes  the  foot  is  shortened  and  perhaps 
the  fragments  have  been  dislocated  (Eisendrath,  in  "Annals  of  Surg.,"  March, 
1905).  The  .T-rays  will  make  the  diagnosis  certain.  Fractures  of  the  other 
bones  of  the  tarsus  are  difficult  of  detection  except  by  the  x-rays.  There  may  or 
may  not  be  crepitus,  which,  if  it  exists,  is  difificult  to  localize;  there  is  pain  on 
standing  and  on  pressure,  and  there  is  bruising  of  the  soft  parts. 

Treatment. — In  simple  fracture  of  the  os  calcis  and  astragalus  without 
displacement  the  usual  plan  is  to  place  the  foot  at  a  right  angle  to  the  leg  and 
apply  a  plaster  cast.  This  is  cut  down  the  front  so  that  it  may  be  removed 
easily.  On  the  third  or  fourth  day  follow  Eisendrath's  advice  and  begin  mas- 
sage to  reduce  swelling  and  prevent  muscular  atrophy  (Ibid.).  The  cast  is 
worn  for  eight  weeks,  when  the  patient  may  begin  to  put  weight  upon  the 
extremity.  The  results  are  often  poor.  If  a  flat-foot  has  resulted  from  the  acci- 
dent, a  support  must  be  worn  (see  page  833).  If  there  is  displacement  in  a  simple 
fracture  of  the  os  calcis  or  astragalus  it  is  wisest  to  operate.  Perfect  correction 
is  not  possible  otherwise  and  no  apparatus  is  satisfactory.  The  fragments  are 
restored  after  incision  and  may  be  sutured,  nailed  or  wired  in  place.  A  fragment 
may  require  removal  or  the  badly  splintered  bone  itself  may  have  to  come 
away.     If  the  tendo  Achillis  is  torn  loose,  it  should  be    p—- —  ■  -  i 

sutured  to  the  os  calcis.  In  fracture  of  the  os  calcis  ; 
alone  Cotton  anesthetizes  the  patient,  pulls  down  the 
heel,  and  by  lateral  pressure  and  the  use  of  a  pad 
and  mallet  creates  an  impaction  ("Annals  of  Surgery," 
Ixiv) .  Another  plan  is  to  cut  the  Achilles  tendon,  and 
while  the  heel  and  ball  of  the  foot  are  being  held  with 
a  pull  toward  each  other  to  create  the  arch,  plaster  of 
Paris  is  applied  as  high  as  the  knee  (Lounsbury ,  in ' '  Sur- 
gery, Gynecology,  and  Obstetrics,"  1916,  xxii).  Frac- 
tures of  the  other  bones  of  the  tarsus  are  almost  always 
compound,  and  the  injury  may  require  drainage  and 
immovable  dressing,  excision  of  bones,  or  even  ampu- 
tation. If  they  are  not  compound,  they  may  be 
treated  by  a  plaster-of-Paris  dressing  or  may  require 
incision  and  fixation  or  removal.  jric_  ^^S. Fracture  of 

Fractures  of  the  metatarsal  bones  are  almost  in-  metatarsal  bones, 

variably  due  to  direct  force  and  are  almost  always 

compound.  Robert  Jones  has  published  skiagraphs  of  a  fracture  of  the  fifth 
metatarsal  bone  from  indirect  force.  Crepitus  may  be  absent  because  of 
impaction  or  fixation  by  interosseous  ligaments.  Jones  says  such  a  fracture 
may  be  produced  by  the  pressure  of  the  body  weight  on  an  inverted  foot 
the  heel  of  which  is  raised  ("Annals  of  Surgery,"  June,  1902).  When  only 
one  bone  is  broken,  displacement  is  slight,  there  is  severe  pain  on  motion  and 
pressure,  and  crepitus  can  generally  be  obtained.  Pain  is  produced  by  flexing 
the  toes,  putting  weight  upon  the  toes,  as  in  walking,  and  by  inverting  or  evert- 
ing the  foot.  Fracture  of  the  third  metatarsal  is  apt  to  destroy  the  arch  of  the 
foot.  A  simple  fracture  of  a  metatarsal  bone  is  treated  by  an  immovable 
dressing  for  four  weeks.  Fractures  from  crushes  usually  demand  excision  or 
amputation. 


702  Diseases  and  Injuries  of  the  Bones  dnd  Joints 

Fractures  of  the  phalanges  of  the  toes  are  due  to  direct  force  and  are  often 
compound.     They  may  require  immediate  amputation. 

Treatment. — In  a  compound  fracture  where  amputation  is  unnecessary, 
drain  with  strands  of  catgut  for  forty-eight  hours  and  dress  antiseptically, 
at  the  end  of  this  time  apply  over  the  bichlorid  gauze  a  gutta-percha  or  a 
pasteboard  splint  extending  from  beyond  the  end  of  the  toe  to  well  up  upon 
the  sole  of  the  foot,  and  fix  the  splint  in  place  with  a  spiral  bandage  of  the 
toe  and  instep.  The  splint  is  to  be  worn  for  four  weeks.  In  a  simple  fracture 
fasten  the  injured  toe  to  an  adjacent  toe  or  toes  by  a  plaster  bandage  and 
wear  the  dressing  for  three  weeks. 

Diseases  of  the  Joints 

Synovitis  is  a  primary  inflammation  of  the  synovial  membrane  alone. 
If  other  structures  besides  the  synovial  membrane  are  involved  the  condition 
is  known  as  "arthritis."  Two  forms  of  simple  synovitis  exist — namely,  acute 
and  chronic.     Some  surgeons  speak  also  of  subacute  cases. 

Acute  Simple  Synovitis. — The  causes  of  acute  simple  s}Tiovitis  are  con- 
tusions, sprains,  twists,  and  overuse.  The  causative  influence  of  exposure 
to  cold  or  damp  has  been  much  debated.  It  seems  probable  that  in  some 
cases  cold  produces  vasomotor  paresis  of  the  vessels  of  the  synovial  mem- 
brane, a  condition  which  may  be  followed  by  inflammation.  In  syno\atis 
the  synovial  membrane  is  red  and  swollen,  and  the  joint  contains  an  excess 
of  turbid  fibrinous  fluid.  If  the  inflammation  advances,  arthritis  arises  and 
sometimes  blood  is  effused. 

Symptoms. — A  prominent  symptom  of  acute  synovitis  is  pain,  which  is 
increased  by  motion  of  the  joint,  by  pressure  upon  the  articulation,  and  by  a 
dependent  position  of  the  limb.  The  pain  is  worse  at  night.  Pressure  upon  the 
edge  of  the  cartilage  does  not  cause  pain,  but  friction  of  the  synovial  membrane 
at  once  develops  it.  The  patient  places  the  limb  in  the  position  which  gives 
the  greatest  ease,  and  the  part  becomes  more  or  less  fixed  in  this  position 
because  the  muscles  about  the  joint  are  rigid.  A  fluctuating  swelling  is  noted 
in  a  superficial  joint,  most  marked  between  the  ligaments,  which  swelling  bulges 
out  the  synovial  area  and  hides  or  obscures  the  articular  heads  of  the  bones. 
The  sweUing  is  due  early  to  excessive  secretion  of  synovia,  and  later  to  effusion 
of  hquor  sanguinis.  Bulging  takes  place  at  points  where  the  capsule  is  thin,  and 
at  such  points  fluctuation  may  be  detected.  Fluctuation  in  the  elbow  is  sought 
for  posteriorly.  Fluctuation  in  the  knee  is  sought  for  on  either  side  in  front.  A 
large  effusion  in  the  knee  floats  the  patella  up  from  the  condyles  (floating  patella). 
A  small  effusion  in  the  knee  can  be  detected  by  Fiske's  plan,  which  is  as  follows: 
Tell  the  standing  patient  to  bend  forward  at  the  hips,  resting  each  hand  on  the 
front  of  the  corresponding  thigh.  The  anterior  structures  of  the  joint  are  thus 
relaxed,  and,  by  tapping  the  patella,  even  a  small  effusion  can  be  discovered. 
Bulging  cannot  be  distinctly  recognized  in  the  hip  or  shoulder  unless  effusion  is 
great.  The  skin  over  the  joint  is  rarely  reddened,  but  feels  hot  to  the  hand  of 
the  observer  (over  superficial  joints,  but  not  over  the  shoulder  and  hip);  the 
joint  is  partly  flexed;  fever  exists,  varying  in  degree  with  the  size  of  the  joint, 
the  acuteness  of  the  attack,  and  if  infection  occurs  fever  is  a  striking  feature. 
Suppuration  rarely  follows  simple  synovitis,  but  it  may  do  so,  the  area  of 
synovitis  being  a  point  of  least  resistance  to  organisms  carried  by  the  blood 
or  lymph.  If  suppuration  takes  place,  rigors  occur,  there  is.a  septic  tempera- 
ture, and  the  joint  soon  gives  evidences  of  containing  pus.  These  evidences 
are  violent  pain,  increased  tenderness,  dusky  discoloration  if  the  joint  be  super- 
ficial, greater  muscular  spasm,  periarticular  edema,  and  constitutional  symptoms 
of  sepsis.  Traumatic  synovitis  without  infection  tends  toward  cure  without 
suppuration  if  the  patient  is  healthy,  and  after  it  ankylosis  is  rare. 


Chronic  Synovitis  703 

Treatment. — In  treating  acute  synovitis  immobilize  the  joint.  In  severe 
cases  place  it  in  such  a  position  that  the  limb  will  still  be  useful  even  if  anky- 
losis occurs.  In  mild  cases  immobilize  in  the  position  of  rest,  apply  leeches, 
and  use  the  ice-bag  or  the  Leiter  coil  for  a  few  hours.  After  a  day  or  two  apply 
gentle  pressure,  intermittent  heat,  and  iodin  and  ichthyol.  If  the  effusion  is 
very  great  and  persistent,  and  pressure,  heat,  and  sorbefacients  fail  to  remove 
it,  aspirate  with  aseptic  care.  If  effusion  recurs  after  aspiration,  use  massage 
and  the  hot-air  oven,  or  apply  plaster-of-Paris  dressing  or  use  flying-blisters. 
If  there  is  any  evidence  of  infection,  follow  Murphy's  advice,  that  is,  aspirate 
the  joint  and  inject  a  mixture  of  formalin  in  glycerin  (2  per  cent.).  As  a  rule 
this  treatment  will  rapidly  bring  about  a  cure.  The  mixture  of  formalin  and 
glycerin  should  have  been  made  at  least  twenty-four  hours  before  use.  A  rubber 
bandage  is  often  useful  toward  the  termination  of  a  case  of  acute  synovitis. 

Chronic  synovitis  follows  acute  synovitis  or  it  may  be  chronic  from  the 
start.  Many  cases  called  chronic  synovitis  are,  in  truth,  tuberculous  disease. 
The  synovial  membrane  looks  nearly  natural,  but  is  edematous,  and  the  joint 
contains  an  excess  of  fluid.  If  the  quantity  of  fluid  is  large,  the  disease  is 
called  hydrops  articuli,  or  dropsy.  A  large  amount  of  fluid  in  the  knee-joint 
"floats"  the  patella  upward.  Tuberculous  infection  may  occur  in  very  pro- 
longed cases.  In  prolonged  tuberculous  synovitis  the  synovial  membrane 
may  thicken  in  some  places,  soften  in  others;  it  is  often  adherent,  and  the 
villous  processes  hypertrophy.  If  the  membrane  becomes  extensively  softened 
(ptdpy  degeneration),  the  softened  areas  bulge  and  caseation  eventually  occurs. 
In  the  knee-joint  a  traumatic  synovitis  is  sometimes  linked  with  inflammation 
of  the  semilunar  cartilages.  Roux  tells  us  that  this  inflammation  may  be  pro- 
duced by  a  squeeze,  a  twist,  or  a  direct  force,  but  a  squeeze  is  the  common 
cause.  Hyperextension  of  the  knee  may  squeeze  the  cartilage,  and  so  may 
attempting  to  rise  from  a  stooping  posture.^  If  this  injury  has  taken  place,  the 
disability  will  be  prolonged. 

Symptoms. — In  chronic  synovitis  pain  may  be  absent  or  may  be  present 
only  during  exercise  or  from  pressure,  and  be  slight  even  then.  There  may  be 
seizures  of  pain;  there  is  some  Umitation  of  movement;  passive  motion  may 
develop  creaking  or  joint-crepitus;  fluctuation  is  apparent  and  there  is  atrophy 
in  the  muscle  about  the  joint.  The  atrophy  of  the  muscles  associated  with  an 
inflamed  joint  is  a  reflex  atrophy  and  is  named  after  Charcot.  The  aspirating; 
needle  will  give  exit  to  a  viscid  straw-colored  or  bloody  fluid  unless  the  mate- 
rial is  gelatinous. 

Treatment. — Rest  and  pressure  are  of  great  service.  Pressure  may  be 
obtained  by  the  application  of  Martin's  rubber  bandage.  A  plaster-of-Paris. 
dressing  is  probably  the  best  way  to  combine  rest  and  compression.  Massage^ 
douches,  frictions,  passive  movements,  and  flying  bUsters  should  be  used. 
Painting  the  joint  with  iodin  and  spreading  over  it  blue  ointment,  and  rub- 
bing in  ointment  of  ichthyol  (50  per  cent,  with  lanolin)  may  do  good.  Counter- 
irritation  by  the  actual  cautery  is  a  valuable  expedient.  The  Bier  treat- 
ment (see  page  122)  is  often  of  benefit.  Injections  of  dilute  carbohc  acid  in  the 
parts  about  the  joint  rapidly  relieve  the  pain  (see  page  727).  Some  sur- 
geons advise  aspiration,  washing  out  with  salt  solution,  injecting  a  5  per  cent, 
solution  of  carbolic  acid  or  formalin-glycerin  (2  per  cent.),  and  immobihzing. 
Incision  and  drainage  constitute  a  radical  but  proper  plan  in  cases  in  which 
simpler  methods  have  failed.  If  pulpy  degeneration  exists,  perform  an  excision 
or  an  erasion.  If  pus  forms,  incise  at  once  and  drain.  Internally,  treat  any  exist- 
ing diathesis  and  give  nutritious  food,  tonics,  and  stimulants.  Chronic  synovitis 
is  often  greatly  benefited  by  the  use  of  a  hot-air  apparatus.  The  hmb  is  wrapped 
in  flannel  and  is  placed  in  an  oven.  The  oven  is  heated  by  Bunsen  burners. 
The  temperature  is  raised  to  250°  or  even  300°  F.,  and  the  hmb  is  subjected  to 
1  "Gaz.  des  Hop.,"  No.  125,  1895. 


704 


Diseases  and  Injuries  of  the  Bones  and  Joints 


this  for  one  hour.  The  oven  should  be  used  daily,  and  as  the  patient  becomes 
accustomed  to  it  even  a  higher  degree  of  heat  can  be  tolerated.  This  high 
degree  of  heat  can  be  borne  only  when  it  is  perfectly  dry.  Any  moisture  scalds 
the  patient.  The  Lentz  oven  has  in  it  ventilation  openings  to  get  rid  of  mois- 
ture and  the  sweat  is  taken  up  by  the  flannel.  The  flannel  must  not  be  applied 
so  thickly  as  to  keep  the  heat  notably  from  the  joint,  nor  must  so  little  of  it 
be  used  as  to  permit  of  its  soaking  with  sweat.  Fig.  439  shows  the  Sprague 
hot  dry-air  apparatus.  Dr.  H.  A.  Wilson  inserts  in  the  oven  humidin,  a  product 
obtained   in   the  purification  of    salt,   which   absorbs    the  moisture  entirely. 

Cotton  should  not  be  used  to 
wrap  the  limb,  because,  if  the 
bottom  of  the  oven  becomes 
very  hot,  the  cotton  may 
ignite  and  burn  the  patient. 
A  physician  or  nurse  should 
constantly  watch  the  appa- 
ratus during  its  employ- 
ment.^ Bier's  box  is  of  wood 
lined  with  asbestos.  It  is 
heated  through  a  flue  by  gas 
or  alcohol  lamps.  Aspiration 
and  the  subsequent  use  of  a 
plaster-of-Paris  bandage  may 
be  tried  in  Hngering  cases  of 
chronic  synovitis. 

Arthritis. — By  this  term 
is  meant  not  only  inflamma- 
tion of  a  synovial  membrane, 
but  also  of  other  structures 
composing  and  surrounding 
a  joint.  It  may  follow  trau- 
matic synovitis;  it  may  be 
due  to  pus-organisms,  to 
tubercle  bacilU,  to  infectious 
diseases  (gonorrhea  and  ty- 
phoid fever),  to  rheuma- 
tism, to  gout,  to  syphilis, 
Arthritis   may    be    either    acute   or 


Fig.  439. — Sprague  hot  dry-air  apparatus, 
lesions    of    the    spinal   cord. 


and    to 
chronic. 

Poncet's  Tuberculous  Arthritis  {Tuberculous  Articular  Rheumatism,  see 
page  275J. — It  was  pointed  out  by  Grocco  in  the  early  8o's  that  tuberculous 
patients  may  develop  joint  disease  without  tubercles,  cold  abscesses,  or  de- 
struction of  the  joint;  Poncet,  of  Lyons,  has  written  extensively  on  this  subject. 
He  maintains  that  joint  inflammation  is  often  the  first  evidence  of  extra-articular 
tuberculosis  or  of  a  distant  latent  lesion  of  tuberculosis.  The  joint  inflammation 
is  due  to  toxins,  the  joint  fluid  does  not  contain  bacilli,  and  tubercles  do  not 
develop  in  the  joint  structures. 

Such  a  joint  may  eventually  develop  into  a  true  tuberculous  joint  with 
bacilli  and  tubercles.  In  many  cases  the  joint  recovers,  with  some  stiffness  or 
perhaps  even  ankylosis.  The  process  may  be  acute,  subacute,  or  chronic. 
One  joint  only  may  sufifer.  Several  or  most  of  the  joints  may  be  simultaneously 
involved.  It  is  most  apt  to  arise  after  an  operation  on  tuberculous  glands  or 
bone.  Fever  exists  in  Poncet's  arthritis.  Matas  ("  Southern  Med.  Jour.,"  Oct., 
191 1)  thus  describes  tuberculous  rheumatism: 

"It  may  be  a  flitting  arthralgia,  a  mere  soreness,  a  dropsical  synovitis,  or 
1  H.  \.  Wilson,  in  "Annals  of  Surgery,"  Feb.,  1899. 


Tuberculous  Arthritis 


705 


it  may  persist  as  a  hypertrophic  or  atrophic  arthritis.  It  may  present  itself  as 
a  progressive  polyarthritis  deformans  or  as  a  dry  senile  arthritis  (morbus 
coxarius  senilis).  The  acute,  as  well  as  the  chronic,  form  of  this  type  of  rheu- 
matism may  end  in  ankylosis.  Many  cases  of  spinal  rigidity,  spondylosis, 
scoliosis,  painful  flat-foot,  genu  valgum,  coxa  vara,  and  even  certain  cases  of 
dry  otitis  media  with  ankylosis  of  the  ossicles  of  the  ear,  and,  in  fact,  all  the 
osteo-articular  affections  of  childhood  and  adolescence  associated  with  defect- 
ive osteogenesis,   may  owe  their      ^  

origin  to  the  disturbing  influence      "^  ^v.™  "^^         'wwjr      -^ 

of  a  latent  or  obscure  tuberculous 

toxemia. 

"The  most  benign  of  the 
tuberculous  rheumatic  affections 
is  a  simple  arthralgia — a  sore  or 
painful  joint.  There  is  pain  with- 
out any  objective  signs,  and  yet 
this  is  often  the  precursor  of  a 
manifest  visceral  tuberculosis. 
The  acute  and  subacute  forms  of 
the  disease  are  us,ually  confused 
at  the  bedside  with  the  manifesta- 
tion of  ordinary  acute  rheumatism. 
Nevertheless,  the  clinical  picture 
of  acute  tuberculous  rheumatism 
is  distinctly  graver;  there  are  fever, 
rapid  pulse,  profuse  sweats,  and 
frequent  attacks  of  dyspnea.  This 
is  brought  about  by  associate  gen- 
eral infections  involving  the  serous 
cavities,  the  pleura,  peritoneum, 
pericardium,  and  the  meninges. 
But  in  the  majority  the  evolution 
of  the  disease  is  slow  and  more 
benign.  The  joint  symptoms  ap- 
pear in  successive  stages  separated 
by  intervals  of  rest  more  or  less 
long,  and  are'  distributed  over 
various  joints,  ending  ultimately 
in  ankylosis.  The  disease  is  more 
often  chronic,  and  many  patients 
either  recover  altogether  or  remain 
permanently  crippled  or  deformed; 
others  die  of  marasmus  or  com- 
plications from  associate  visceral  disease.  Therapeutically,  this  form  of  rheu- 
matism is  not  reheved  by  any  of  the  usual  antirheumatic  remedies,  and  is 
improved  or  cured  soW^  by  treatment  which  aims  at  the  cure  of  the  tuberculous 
infection." 

Tuberculous  Arthritis  iyVhite  Swelling,  so  christened  by  Richard  Wiseman; 
Strumous  Joint;  Pulpy  Degeneration).  Pathology  and  Symptoms. — The  predis- 
posing causes  of  tuberculous  arthritis  may  be  strains,  blows,  twists,  or  cold  (see 
page  247).  The  real  cause  is  the  tubercle  bacillus.  A  single  joint  is  attacked. 
Other  joints  may  subsequently  become  involved  so  that  several  suffer  simul- 
taneously, but  it  is  rare  that  the  process  is  active  in  more  than  one  joint  at  the 
same  time.  During  the  course  of  tuberculous  disease  of  a  joint  (except  of  the 
shoulder-joint)  phthisis  is  not  common,  although  it  may  develop  after  the  joint 
gets  well.     The  same  is  true  of  tuberculous  glands.     During  the  existence  of 

45 


Fig.  440. — Tuberculous  arthritis  of  wrist. 


7o6  Diseases  and  Injuries  of  the  Bones  and  Joints 

phthisis  or  tuberculous  glands,  tuberculous  arthritis  does  not  frequently  arise. 

The  primary  infection  with  tubercle  bacilli  is  usually  in  the  bone,  though 
it  may  be  in  the  synovial  membrane,  the  joint-capsule,  or  the  structures  about 
the  joint.  The  frequency  of  the  bony  origin  of  tuberculous  arthritis 
is  shown  by  John  B.  Murphy's  statement  that  in  128  cases  of  tuberculosis  of 
the  knee  it  was  demonstrated  in  all  but  2  that  the  condition  originated  in  the 
bone  ("Jour.  Am.  Med.  Assoc,"  May  20-27,  June  3,  1905).  If  the 
primary  infective  focus  is  in  the  bone,  a  portion  of  the  cartilage  undergoes  de- 
struction and  the  joint  is  opened,  or  a  sinus  forms  and  perforates  the  synovial 
membrane.  When  tuberculous  inflammation  attacks  the  synovial  membrane 
granulation  tissue  is  formed,  and  the  capsule  and  periarticular  structures  soon 
become  involved  in  the  process;  the  parts  thicken  and  soften  from  caseation, 
and  they  may  be  covered  with  tubercles,  though  but  little  fluid  is  usually  effused 
into  the  joint.  Some  few  cases  present  large  joint  effusions,  but  in  most  cases 
fluctuation  is  absent.  Capsular  thickening  may  or  may  not  be  manifest.  Soon 
after  tuberculous  arthritis  begins  the  joint  becomes  rigid,  irritation  having 
induced  muscular  spasm.  This  reflex  rigidity  fixes  the  joint  more  or  less  com- 
pletely, and  atrophy  of  the  rigid  muscles  soon  begins.  There  is  usually  some 
pain  in  tuberculous  arthritis;  it  is  seldom  marked  except  on  motion  or  when 
the  epiphysis  is  involved,  and  it  may  be  referred  to  a  distant  part.  For  in- 
stance, in  hip-joint  disease  the  pain  is  often  referred  to  the  inner  side  of  the 
knee,  and  in  Pott's  disease  of  the  spine  the  pain  may  be  referred  to  the  abdo- 
men. A  cardinal  symptom  of  tuberculous  disease  of  a  joint  is  localized  tender- 
ness. In  other  types  of  infection  the  tenderness  is  widespread.  Attempts  at 
motion  demonstrate  the  limitation  of  movement  due  to  muscular  rigidity  and 
also  produce  pain.  A  child  that  suffers  from  a  tuberculous  joint  is  apt  to  be 
restless  in  sleep,  moaning  and  tossing,  and  to  wake  at  times  crying  out  in  terror 
(night-cries  and  nighf-f errors).  In  the  ordinary  form  of  tuberculous  arthritis 
there  occurs  what  is  known  as  gelatiniforni  degeneration;  the  granulation  tis- 
sue is  formed  in  large  amount  as  fungous  growths;  the  structures  are  markedly 
edematous  and  softened;  the  relaxed  ligaments  yield  under  pressure;  the  natural 
contour  of  the  joint  is  lost  and  it  becomes  spindle  shaped;  all  the  structures, 
articular  and  periarticular,  are  glued  into  one  mass;  the  skin  about  the  joint 
is  white,  thick,  and  adherent,  and  in  it  one  or  more  large  veins  are  seen;  fluc- 
tuation or  pseudofluctuation  is  noted  when  caseation  has  occurred;  pain  is 
not  often  severe,  but  it  can  usually  be  elicited  by  certain  motions  or  by  firm 
pressure,  but  the  pain  will  always  be  severe  when  the  epiphysis  is  involved; 
the  temperature  of  the  part  is  seldom  elevated;  deformity  results  from  destruc- 
tion of  bone,  cartilage,  and  ligament,  from  muscular  spasm,  and  from  the 
habitual  assumption  of  certain  attitudes  to  secure  relief  from  pain.  There 
is  soon  impairment  of  joint  motions.  When  the  products  of  a  tuberculous 
arthritis  caseate  the  thick  Hquid  seeks  exit  by  forming  sinuses,  and  from  them 
caseous  pus  flows.  If  a  sinus  becomes  infected  with  pyogenic  cocci,  and  the 
joint  itself  becomes  their  prey,  acute  suppuration  arises  in  the  joint,  and  con- 
stitutional involvement  is  pronounced  and  perilous  to  life. 

In  pannous  synovitis  a  large  effusion  is  formed,  there  is  but  little 
granulation  tissue,  though  the  tubercles  are  present  in  large  numbers, 
and  the  ligaments  and  structures  about  the  joint  are  slightly  or  not  at  all 
implicated. 

Diagnosis  and  Prognosis. — Tuberculous  chronic  synovitis  produces  great 
swelling  and  distinct  thickening  of  the  capsule  with  obliteration  of  the  outlines 
of  the  joint,  no  severe  pain,  and  no  tendency  to  early  subluxation.  Tuberculous 
arthritis  rarely  causes  distinct  fluctuation,  does  not  thicken  the  capsule,  causes 
reflex  muscular  spasm,  rigidity  of  the  joint,  muscular  atrophy,  severe  pain  on 
movement,  and  eventually  subluxation  (Shaffer).  In  syphilitic  arthritis 
there  is  usually  some  fluctuation,  distinct  enlargement  of  the  joint,  limitation 


Tuberculous  Arthritis  707 

of  motion,  no  reflex  spasm,  trivial  atrophy,  but  distinct  pain  on  motion  (James 
K.  Young,  "Therapeutic  Gazette,"  June  15,  1902).  Acute  rheumatism  at- 
tacks more  than  one  joint,  is  very  rare  in  children  under  five,  and  produces 
high  fever.  The  x-rays  aid  in  the  diagnosis  of  tuberculous  arthritis  and  enable 
us  to  tell  the  extent  of  bone  involvement. 

The  diagnosis  of  a  tuberculous  joint  is  often  difficult,  and  sometimes  im- 
possible, and  the  prognosis  is  always  grave.  In  only  a  very  few  cases,  even 
when  recognized  early,  is  a  cure  obtained  without  some  impairment  of  joint 
function.  The  best  that  can  usually  be  accomplished  is  a  cure  with  more 
or  less  ankylosis,  fibrous  or  bony;  and  often  ankylosis  is  complete.  Long 
after  the  disease  is  apparently  cured,  it  may  break  forth  anew.  Tuberculous 
lesions  may  arise  in  a  distant  organ  or  general  tuberculosis  may  occur.  Casea- 
tion is  apt  to  produce  severe  constitutional  disorder.  Infection  by  pus  organ- 
isms gives  rise  to  grave  danger  of  septicemia.  Death  is  not  unusual  from 
exhaustion,  from  septicemia,  from  disseminated  tuberculosis,  from  tubercu- 
losis of  an  important  organ,  or  from  amyloid  disease. 

Treatment. — No  serum  or  vaccine  is  of  any  proved  value.  Many  surgeons 
believe  in  small  doses  of  tuberculin  but  Ridlon  says:  "Tuberculin  in  harmless 
doses  is  useless;  administered  in  larger  doses  it  is  both  dangerous  and  harmful." 
It  seems  to  do  harm  in  articular  cases  with  fever,  in  very  late  cases  and  in 
very  early  cases.  Conservative  treatment  is  especially  successful  in  children. 
According  to  Hoffa,  in  75  per  cent,  of  cases  in  children  non-operative  treat- 
ment will  produce  cure  ("Die  Bekampfung  der  Knochen-u.  Gelenktuberculose 
in  Kindesalter  Tuberculosis,"  iv,  i,  1905).  The  conservative  treatment 
consists  in  open-air  life,  if  possible  in  a  sanatorium,  the  following  of  the  plans 
outlined  under  Tuberculosis,  heliotherapy,  immobilization  and  extension  of 
the  joint,  and  injections  of  iodoform  emulsion  or  formalin-glycerin  (2  per  cent.). 
Even  when  tuberculous  pus  forms,  the  same  treatment  may  be  followed  unless 
there  is  violent  pain  or  elevated  temperature  which  does  not  quickly  abate, 
in  which  case  operation  must  be  performed.  Cases  treated  early  by  con- 
servative methods  may  get  well  with  a  movable  joint,  but  in  most  cases  there 
is  a  stiff  joint  when  the  disease  is  arrested.  Constitutionally,  the  treatment 
is  directed  against  the  tuberculous  diathesis.  The  patient  should  be  placed 
under  good  hygienic  conditions.  A  change  of  climate  is  often  of  the  greatest 
importance.  Many  cases  do  well  at  the  seaside;  others  require  high  altitudes, 
and  all  should  live  in  the  open  air.  The  value  of  sunlight  is  set  forth  on  page  256. 
It  causes  local  hyperemia  which  is  bactericidal,  stimulates  oxidation  and 
metabolism  and  produces  lymphocytosis  of  the  peripheral  blood  after  one  hour's 
exposure  (Taylor,  in  "Internat.  Abstract  of  Surgery,"  July,  1915).  Personally 
I  have  only  used  local  exposure  beginning  with  a  few  minutes  and  reaching 
three  or  four  hours  a  day  taking  care  that  the  skin  is  not  hurt  and  avoiding 
burning  by  using  talcum  powder  freely  for  the  first  week  (Taylor,  in  "Internat. 
Abstract  of  Surgery,"  July,  191 5).  A  hat  should  be  worn  and  if  necessary 
goggles.  Electric  light  has  been  used  instead  of  sunlight.  The  Finsen  light, 
too,  is  of  service.  The  Rontgen  rays  may  prove  of  great  value  in 
synovial  tuberculosis  and  in  very  chronic  sinuses.  Treatment  by  tuberculin 
is  considered  on  page  258.  Locally,  rest  is  of  the  first  importance,  and 
fixation  is  maintained  for  many  weeks.  Rest  is  best  secured  by  immo- 
bilization and  traction,  and  traction  is  applied  or  maintained  by  splints, 
by  plaster-of-Paris  bandages,  or  by  extension  appHances.  The  hot-air  ap- 
paratus may  be  of  some  benefit.  If  it  is  employed,  it  should  be  used  daily,  the 
limb  being  immobilized  during  the  remainder  of  the  twenty-four  hours.  Fixa- 
tion must  be  maintained  as  long  as  pain  exists  or  muscular  spasm  is  present. 
Fixation  must  be  abandoned  gradually,  and  mobility  is  to  be  slowly  regained. 
During  restoration  to  mobility,  if  pain  arises,  the  part  must  be  immobilized 
temporarily.     Movements  should  never  be  violent,  prolonged,  or  repeated  at  too 


7o8  Diseases  and  Injuries  of  Ihe  Bones  and  Joints 

close  intervals.  Forcible  breaking  up  of  an  ankylosis  is  never  advisable  in  the 
knee,  ankle,  or  hip;  it  is  seldom  advisable  in  the  wrist,  elbow,  or  shoulder.  Such 
an  attempt  may  be  followed  by  a  fresh  outbreak  of  the  disease.  Osteotomy  or 
resection  will  more  safely  correct  a  faulty  and  disabling  deformity.  In  a  tuber- 
culous joint  injection  of  formalin-glycerin,  as  advised  by  Murphy,  is  a  valuable 
procedure.  Several  or  a  number  of  injections  may  be  made.  The  joint  is  aspi- 
rated and  the  mixture  introduced.  About  4  drams  are  used  in  the  knee,  about 
2  drams  in  the  ankle.  After  injection  extension  is  applied.  The  mixture  used 
must  be  at  least  twenty-four  hours  old.  In  tuberculous  joints  intra-articular 
injections  of  iodoform  are  often  of  the  greatest  value.  This  drug  strongly 
stimulates  the  formation  of  fibrous  tissue.  If  sufficient  fibrous  tissue  is  formed 
the  tuberculous  foci  will  be  firmly  encapsuled  and  the  case  will  be  cured.  Iodo- 
form is  particularly  called  for  when  no  bone  disease  is  shown  by  the  .r-ray  or 
discovered  by  incision.  The  joint  is  incised,  adhesions  are  gently  broken  up,  the 
capsule  is  sutured  except  for  a  small  space,  the  nozzle  of  a  syringe  is  inserted  and 
a  mattress  suture  draws  the  capsule  tightly  about  the  nozzle  (Brackett's  plan). 
The  emulsion  is  injected  under  tension  and  then  the  capsule  is  closed  tightly. 
In  a  large  joint  a  4  per  cent,  emulsion  is  used;  in  a  small  joint  a  10  per  cent, 
emulsion.  The  part  must  not  bear  weight  for  six  months.  Bier's  plan  of 
inducing  passive  hyperemia  is  often  of  great  service  (see  pages  122-125).  As- 
piration or  incision  can  be  used  for  fluid  accumulations.  Caseous  masses  are 
often  let  alone,  or  an  aspirator  is  used  and  the  joint  drained,  washed  out  with 
saline  solution,  and  injected  with  an  emulsion  of  iodoform  and  glycerin  (10  per 
cent.).  From  i  to  2  drams  are  injected  into  the  joint  of  a  child,  from  2  to  5 
drams  into  the  joint  of  an  adult.  Even  surface  lesions  are  not  curetted.  Bier's 
treatment  should  be  associated  with  immobilization  and  systemic  treat- 
ment. It  is  more  serviceable  in  tuberculosis  of  the  small  joints  than  in  disease 
of  the  large  articulations.  There  are  certain  contra-indications  to  Bier's 
treatment,  viz.:  serious  pulmonary  involvement,  extensive  amyloid  degenera- 
tion, and  the  existence  of  such  an  unfavorable  position  of  the  parts  that  cure 
by  ankylosis  would  mean  a  less  useful  limb  than  cure  by  resection  (Bier  at 
Internat.  Surg.  Congress  of  1905).  One  advantage  of  this  treatment  is  that  we 
can  employ  active  and  passive  motion  early,  except,  according  to  Bier,  when 
the  foot  or  knee  is  diseased.  Even  in  very  serious  cases  cure  may  be  obtained 
without  any  Hmitation  of  activity,  and  as  the  patient  can  get  about  it  is  not 
necessary  to  restrain  him  long  in  a  hospital.  Bier  advocates  his  suction  ap- 
paratus to  empty  sinuses.  The  enthusiasm  for  Bier's  hyperemia  has  largely 
waned.  It  finds  its  best  field  in  elbow  and  wrist  cases  (Taylor,  in  "  Internat. 
Abstract  of  Surgery,"  July,  1915).  Personally  I  believe  that  fixation  should 
be  the  basis  of  treatment  in  most  cases,  and  that  passive  hyperemia,  com- 
pression, counterirritation,  heliotherapy,  radiotherapy,  and  intra-articular 
injections  may  be  used  as  additions  to  fixation.  Injections  of  balsam  of  Peru 
or  of  iodoform  emulsion  about  the  joint  once  a  week  are  efficient  in  some  pro- 
longed cases,  but  are  not  to  be  used  early.  It  is  not  w^se  to  attempt  to  correct 
faulty  position  until  the  focus  is  well. 

Fistulae  are  frequently  treated  by  the  method  of  Beck,  of  Chicago,  that  is, 
by  the  injection  of  a  paste  containing  bismuth.  In  early  cases  a  bisrnuth-vase- 
lin  paste  is  used,  in  late  cases  a  bismuth-wax-paraffin  paste. 

Beck  described  his  method  in  the  "Illinois  Med.  Jour.,"  April,  1908.  The 
vaselin  paste  is  composed  of  30  parts  of  subnitrate  of  bismuth  and  60  parts 
of  vaselin,  mbced  and  well  stirred  while  boiling.  The  paste  for  later  cases 
is  composed  of  30  parts  of  subnitrate  of  bismuth,  5  parts  of  white  wax,  5  parts  of 
soft  paraffin,  and  60  parts  of  vaselin,  mixed  while  boiling.  One  per  cent,  formalin 
is  often  added  to  these  pastes.  The  paste  is  injected  before  an  .v-ray  picture 
is  taken,  and  the  picture  shows  all  the  ramifications  of  the  fistula.  The  paste 
is  left  in  for  treatment.     If  a  sequestrum  exists  it  should  be  removed  before 


Tuberculous  Arthritis  709 

the  paste  is  injected.  It  is  not  necessary,  but  is  advisable,  to  dry  the  fistula 
before  injecting. 

The  paste  is  sterilized  before  using.  It  is  sucked  up  into  the  syringe  while 
still  liquid  and  is  cooled  to  the  requisite  temperature  and  hardened  to  the 
proper  consistency  by  running  cold  water  over  the  syringe.  It  is  injected  very 
slowly  and  the  injection  is  continued  until  a  sense  of  pressure  annoys  the 
patient.  Then  the  syringe  is  laid  aside,  a  bit  of  gauze  is  held  for  a  time  over  the 
outlet  of  the  fistula  to  keep  the  paste  from  running  out,  and  an  ice-bag  is  put 
over  the  region  to  harden  quickly  the  injected  material.  There  is  no  pain 
from  such  an  injection.  Beck  employs  the  first  paste  until  pus  disappears  and 
then  uses  the  second. 

The  value  of  this  paste  is  that  it  distends  and  fills  the  abscess-cavity  and 
sinus,  and  affords  a  trestle  or  frame  for  granulations  to  grow  upon.  A  consider- 
able amount  of  the  paste  may  run  out  of  the  fistula  during  the  first  twenty-four 
hours.  In  shallow  sinuses  it  all  runs  out.  In  deep  and  tortuous  fistulae  much 
of  it  remains  for  weeks  and  is  slowly  absorbed.  In  frnpyema  and  bone-cavities 
it  is  slowly  absorbed.  Beck  holds  that  the  paste  is  bactericidal,  astringent, 
and  non-toxic.  Cases  of  pigmentation  of  the  Ups,  gums  and  cheeks,  and  cases  of 
ulceration  in  the  mouth  from  absorption  of  bismuth  have  been  recorded,  and  at 
least  8  deaths  are  on  record  (Reich,  in  "  Beitrage  zur  klinischen  Chirurgie,"  Nov., 
1909).  Beck  limits  the  first  dose  to  100  gm.,  but  increases  the  amount  later. 
Because  of  possible  danger  of  poisoning  Blanchard  uses  a  paste  of  white  wax  and 
vasehn  without  bismuth.  Not  over  4  oz.  of  bismuth  paste  should  be  injected. 
As  Bell  points  out,  if  a  large  quantity  is  injected  an  opening  must  be  left.  This 
precaution  may  prevent  poisoning.  Some  think  the  poisoning  is  due  to  bis- 
muth, others  believe  it  is  due  to  arsenic  held  as  an  impurity.  David  and 
Kauffman  ("  Illinois  Med.  Jour.,"  Oct.,  1909)  point  out  that  there  may  be  acute 
cases  of  poisoning  which  are  liable  to  be  fatal,  and  chronic  cases  which  tend 
to  recovery.  In  an  acute  case  of  bismuth-poisoning  there  is  pigmentation  of 
the  gums,  ulcerative  stomatitis,  dyspnea,  delirium,  and  albuminuria.  David 
and  Kauffman  regard  pigmentation  of  the  gums,  lips,  or  cheeks  as  an  indication 
of  toxic  action  and  a  sign  to  discontinue  the  drug.  The  use  of  bismuth  paste 
is  undoubtedly  a  valuable  method.  I  have  seen  sinuses  heal  under  it  after 
they  had  resisted  various  other  plans  of  treatment.  It  may  be  used  in  sinuses, 
cold  abscesses,  empyemata,  tuberculous  joints,  and  other  conditions.  Ridlon 
and  others  have  obtained  with  plain  vasehn  results  as  good  as  have  been  obtained 
by  the  use  of  Beck's  paste. 

If  these  means  fail,  if  the  patient  gets  worse,  if  there  is  persistent  fever  or 
violent  pain,  if  sequestra  exist,  if  there  is  mixed  infection,  or  if  the  condi- 
tion of  the  sufferer  renders  dangerous  the  prolonged  conservative  course, 
operate,  removing  the  entire  diseased  area  by  erasion,  by  excision,  or  possibly 
by  amputation.  If  the  x-ray  picture  shows  extensive  sequestrum  forma- 
tion, operation  is  indicated.  If  amyloid  degeneration  exists,  conservative 
treatment  is  contra-indicated  and  so  is  resection.  Amputation  must  be  done. 
Always  remember  that  an  incomplete  operation  or  a  partial  removal,  unless  it 
consists  of  simple  drainage,  is  worse  than  no  operation,  as  it  opens  the  portals 
to  systemic  infection,  and  may  be  responsible  for  the  development  of  general 
tuberculosis,  septicemia,  or  pyemia.  Simple  drainage,  as  previously  stated,  is 
seldom  advisable.  Garre  is  of  the  opinion  that  the  hip,  wrist,  and  shoulder 
do  best  by  conservative  treatment;  the  knee,  elbow,  and  ankle,  by  operative 
treatment  (John  W.  Churchman,  in  "Am.  Medicine,"  April,  1906).  Many 
mobihzing  operations  have  been  done  for  stiff  joints  and  in  many  cases  the  results 
have  been  imperfect  and  disappointing.  Certain  it  is  that  no  tuberculous 
joint  should  be  subjected  to  this  operation  until  the  disease  is  soundly  cured. 

It  is  small  advantage  to  substitute  a  movable  and  painful  for  a  stiff  and 
painless  joint.     The  results  are  far  better  in  cases  of  traumatic  ankylosis. 


7IO  Diseases  and  Injuries  of  the  Bones  and  Joints 

Tuberculosis  of  Special  Joints;  Tuberculosis  of  the  Vertebrae  (see 
page  951). — Tuberculosis  of  the  Sacro-iliac  Joint  {Sacro-iliac  Disease). — This 
is  an  uncommon  affection,  and  is  especially  rare  before  the  age  of  fifteen. 
The  disease  may  begin  in  the  joint,  may  arise  in  adjacent  bones,  or  may  result 
from  a  cold  abscess  burrowing  into  the  joint.  In  some  cases  it  is  associated  with 
extensive  disease  of  the  pelvic  bones.  The  disease,  if  undetected,  may  lead  to 
dissemination  of  tubercle,  to  abscess,  or  even  to  death. 

Symptoms  are  often  obscure.  The  disease  is  frequently  confounded  with 
vertebral  caries,  hip-joint  disease,  or  sciatica.  The  patient  limps  on  walking, 
the  joint  has  a  feeling  of  insecurity,  especially  on  ascending  stairs  or  carrying  a 
weight,  but  can  stand  on  either  leg.  There  is  pain  in  the  sacro-iliac  joint, 
about  the  hip,  and  do\\Ti  the  back  of  the  thigh  and  occasionally  also  along  the 
front  of  the  thigh.  Pain  may  be  complained  of  about  the  knee.  Pain  may  be 
increased  by  a  jar,  a  misstep,  perhaps  by  coughing  or  sneezing  (Howard  Marsh, 
on  "Diseases  of  the  Joints  and  Spine").  Tenderness  is  manifest  on  pressure 
over  the  joint  and  on  pushing  the  iha  together;  there  may  be  fulness  over 
the  sacro-iliac  joint,  but  the  hip  is  not  flexed  unless  iliac  abscess  exists.^  The 
thigh  is  usually  extended.  There  may  be  apparent  lengthening.  Muscular 
wasting,  especially  of  the  gluteal  region,  is  apparent.  Frequently  a  diagnosis 
of  sciatica  is  made.  I  have  known  appendicitis  mistaken  for  sacro-iliac  disease. 
Sometimes  a  diagnosis  of  hip-joint  disease  is  made,  sometimes  of  lumbar  caries. 

Treatment. — Rest  in  bed  for  months,  using  also  a  felt  case  for  the  pelvis. 
Counterirritation  by  blisters  and  the  actual  cautery.  In  some  cases  injection 
of  formalin-glycerin  or  of  iodoform;  in  others,  incision  and  curetting.  I  have 
operated  on  9  cases,  with  i  death.  In  i  case  in  the  Jefferson  Medical  College 
Hospital  the  abscess  was  pointing  in  both  the  back  and  groin.  Both  areas  were 
incised,  the  diseased  bone  was  removed,  and  the  boy  ultimately  recovered.  In 
another  case  the  abscess  pointed  in  the  groin.  The  treatment  was  as  pre- 
viously set  forth,  and  the  patient,  a  woman,  recovered.  The  best  way  to  reach 
the  joint  is  to  chisel  or  bore  through  the  ilium  above  the  great  sacrosciatic 
foramen. 

Tuberculosis  of  the  Hip-joint  {Hip  Disease;  Morbus  Coxarius;  Morbus 
Coxcb;  Hip-joint  Disease). — The  primary  lesion  may  be  in  the  synovial  mem- 
brane, but  it  is  more  often  in  the  bone.  It  may  begin  in  the  acetabulum; 
it  may  begin  in  the  femur.  In  95  per  cent,  of  cases  it  begins  in  the  head 
of  the  femur.  If  it  begins  in  the  femur,  it  usually  arises  on  "the  distal 
side  of  the  epiphyseal  cartilage"  (Senn).  Sometimes  primary  tuberculosis 
arises  in  the  trochanter  major,  and  never  involves  the  joint.  When  the 
synovial  membrane  becomes  involved  at  any  point,  spread  throughout  the 
joint  is  rapid.  In  many  cases  the  articular  cartilages  are  attacked,  and  in  some 
cases  the  epiphyseal  cartilage  is  destroyed.  It  is  commonest  in  children,  but 
it  may  arise  in  adults  and  even  occasionally  in  those  of  advanced  years;  62 
per  cent,  of  cases  arise  in  children  under  ten  years  of  age  and  80  per  cent,  of 
cases  occur  before  the  twentieth  year  (Bryant).  Traumatism  and  cold  may 
be  predisposing  causes.  The  disease  strongly  tends  to  caseation  and  the  forma- 
tion of  sequestra. 

Symptoms. — It  has  been  usual  to  divide  the  disease  into  three  stages:  (i) 
the  stage  of  microbic  deposition  and  multiplication,  the  products  of  the  bacilli 
causing  irritation  and  new  growth;  (2)  the  stage  of  progression,  with  formation 
of  masses  of  granulation  tissue  and  effusion  into  the  joint,  and  (3)  the  stage 
of  caseation,  with  destruction  of  the  joint  and  often  of  the  structures  about  it. 
Bradford  andLovett^  protest  against  this.  They  say:  "It  has  been  customary 
to  divide  hip-disease  into  stages,  and  to  ascribe  to  these  stages  certain  definite 
symptoms.     Neither  from  a  cUnical  nor  a  pathological  point  of  view  is  it 

1  See  A.  G.  Miller,  "Edinburgh  Med.  Jour.,"  May,  1895. 
"^  "Orthopedic  Surgery." 


Tuberculosis  of  the  Hip-joint  711 

desirable  to  attempt  such  a  division."  As  H.  Augustus  Wilson  says:  "Tuber- 
culous bone  and  joint  disease  should  be  considered  as  the  primary  invasion 
or  incipiency,  and  all  other  symptoms  should  be  regarded  as  results  and  not  as 
an  integral  and  necessary  part  of  the  trouble." 

The  symptoms  of  incipient  coxalgia  are  slight  and  may  be  overlooked 
entirely.  In  a  child  there  are  night-terrors;  on  getting  about  in  the  morning 
the  child  shows  no  lameness,  but  a  limp  develops  during  the  day,  and  the  little 
one  soon  grows  tired  while  playing  and  lies  down  to  rest.  There  is  a  slight 
limp;  some  muscle  spasm  may  be  noted,  and  pain  may  be  complained  of  at 
night  in  the  hip,  in  the  front  of  the  thigh,  or  at  the  inside  of  the  knee.  Tapping 
the  sole  of  the  foot,  the  thigh  and  leg  being  extended,  may  develop  pain,  just 
as  it  will  develop  pain  in  any  inflammatory  involvement  of  the  joint,  but  the 
employment  of  this  method  is  objectionable.  It  may  injure  a  joint  already 
damaged  by  the  tuberculous  process,  and  it  gives  no  information  which  cannot 
be  obtained  by  a  safer  mode  of  investigation.  After  all,  pain  on  tapping  the 
sole  of  the  foot  means  only  what  muscular  rigidity  means,  and  muscular  rigidity 
is  always  present  and  is  easily  demonstrable  by  careful  manipulation.  The 
diagnosis  of  incipient  coxalgia  is  more  or  less  problematical. 

As  the  disease  progresses  more  positive  symptoms  are  observed.  The 
limp  grows  worse;  the  hip  is  broadened  by  an  effusion  into  the  joint,  and  fluctua- 
tion may  possibly  be  detected;  the  thigh  muscles  atrophy;  the  extremity  is 
pushed  forward,  abducted,  and  everted.  The  position  is  described  as  flexion, 
abduction,  and  outward  rotation  (Fig.  441).  This  position  may  not  be  obvi- 
ous; in  fact,  the  limb  may  be  extended  by  the  side  of  the  companion  extremity. 
When  it  is,  there  is  a  forward  curve  of  the  lumbar  spine  (lordosis)  and  a  lateral 
curve  of  the  lumbar  spine,  which  raises  the  pelvis  on  the  sound  side  and  de- 
presses it  on  the  diseased  side.  These  lumbar  curves  serve  to  bring  the  femur 
toward  the  middle  line,  give  the  extremity  the  appearance  of  being  lengthened, 
enable  the  sufferer  to  walk  (Fig.  441),  and  cause  him  to  rest  his  weight  on  the 
sound  limb.  Apparent  lengthening  means  abduction.  In  some  few  cases 
adduction  exists  rather  than  abduction.  The  abduction,  which  is  usual, 
releases  tension  of  the  fascia  lata,  and  thus  abolishes  pressure  upon  the  joint 
through  lessening  of  pressure  upon  the  great  trochanter,  and  also  relaxes  the 
outer  portion  of  the  Y-ligament  and  the  ligament um  teres.  The  flexion  relaxes 
the  anterior  portion  of  the  capsule  and  the  psoas  muscle  and  prevents  pressure 
of  its  tendon  upon  the  front  of  the  joint.  Outward  rotation  relaxes  the  inner 
portion  of  the  Y-ligament  and  the  posterior  portion  of  the  capsule.  Pain  exists, 
often  sudden  or  starting,  and  is  located  in  the  joint,  on  the  front  of  the  thigh, 
and  to  the  inner  side  of  the  knee  in  the  course  of  the  obturator  nerve;  the  pain 
is  aggravated  at  night,  and  full  extension  and  complete  abduction  are  not 
possible.  The  gluteal  muscles  waste,  and  the  gluteal  crease  is  on  a  lower  level 
than  is  that  of  the  sound  side.  The  gluteal  crease  may  be  nearly  or  quite 
effaced  because  of  hypertrophy  of  the  subcutaneous  layer  (Alexandroff) ,  or 
from  slight  flexion  of  the  leg  (McClellan).  As  the  disease  progresses  adductor 
spasm  causes  adduction,  and  the  limb  is  flexed,  adducted,  and  apparently 
shortened.  This  apparent  shortening  is  accomplished  by  a  lateral  curvature 
of  the  spine,  which  keeps  the  limb  from  crossing  its  fellow  and  being  useless. 
It  does  so  by  raising  the  hip  of  the  diseased  side  and  drawing  the  femur  outward 
(Fig.  441).  This  causes  apparent  shortening  (Howard  Marsh,  in  Treves's 
"Manual  of  Surgery").  The  above  symptoms  arise  chiefly  from  unconscious 
efforts  to  obtain  ease,  from  joint-effusion,  reflex  irritation,  and  involuntary 
or  spasmodic  muscular  contractions.  There  is  an  appearance  of  lengthening  or 
shortening,  but  it  is  only  apparent,  not  real.  The  real  position  is  shown  on 
Plate  8,  Fig.  4.  The  fluid  effusion  may  be  absorbed  or  may  find  its  way  exter- 
nally by  means  of  sinuses.  The  latter  condition  is  known  as  abscess  of  the  hip. 
The  absorption  of  the  exudate  or  the  rupture  of  the  capsule  permits  the  con- 


712 


Diseases  and  Injuries  of  the  Bones  and  Joints 


tracting  muscles  to  bring  the  head  of  the  femur  into  firm  contact  with  the 
acetabulum  or  its  brim;  the  bones  are  worn  away  and  destroyed,  real  shortening 
results,  there  is  adduction,  and  flexion  is  increased  as  shortening  becomes 
more  marked. 

In  advanced  cases  of  coxalgia  the  head  of  the  femur  passes  upward  and 
outward  upon  the  rim  of  the  acetabulum,  the  thigh  is  flexed  and  fixed,  and 
attempts  at  extension  when  the  patient  is  recumbent  cause  the  pelvis  to  tilt 
forward  and  occasion  a  marked  lumbar  curve  (lordosis)  (PI.  8,  Fig.  2),  which  is 
due  to  the  pelvis  moving  with  the  femur  as  if  ankylosed,  and  which  disappears 
on  flexion.  In  this  condition  adduction  occurs  because  of  the  ascent  and  move- 
nient  outward  of  the  head  of  the  bone.  Shortening  is  marked.  After  a  hip 
abscess  finds  an  external  outlet  pyogenic  infection  is  very  apt  to  take  place 
and  suppuration  arises,  which  is  followed  by  that  state  which  is  designated 
as  "hectic."  If  a  cure  follows  advanced  coxalgia,  partial  or  complete  anky- 
losis takes  place;  if  death  ensues,  it  may  be  due  to  septicemia,  tuberculosis 
of  the  viscera,  exhaustion,  or  amyloid  degeneration. 

Diagnosis  is  very  easy  in  well-established  cases  of  hip-disease,  but  very 
difficult  when  the  disease  is  incipient.     Always  make  a  systematic  and  thorough 


Fig.  441. — Positions  in  hip-joint  disease,  a:  e-f,  lumbar  spine;  b-d,  limb  fixed  in  flexion 
and  abduction,  useless  for  walking.  B:  e-f,  lumbar  spine.  Patient  corrects  the  condition  in 
Figure  a  by  curving  the  lumbar  spine  forward  and  rotating  the  pelvis  on  its  transverse  axis, 
thus  making  the  femur  point  downward.  The  lumbar  spine  is  curved  laterally,  the  pelvis 
ascending  on  the  sound  side  and  descending  on  the  affected  side  (apparent  lengthening),  c: 
b-d,  limb  fixed  in  flexion  and  adduction,  d:  e-f.  curve  of  lumbar  spine  to  correct  condition 
in  Figure  c  (apparent  shortening).     (After  the  plan  of  Howard  Marsh  and  Treves.) 

examination.  Undress  the  patient  and  place  him  recumbent  with  his  legs 
extended  upon  a  table  or  a  hard  mattress.  Note  if  the  heels  are  level  and  if 
the  iUac  spines  are  on  the  same  level  (a  depressed  spine  on  the  affected  side 
means  abducted  extremity,  the  degree  of  which  is  determined  by  carrying 
the  limb  out  until  the  spines  are  horizontal;  elevation  of  the  iliac  spine  on  the 
affected  side  means  adduction,  the  amount  of  which  is  determined  by  adducting 
the  limb  until  the  spines  are  horizontal.  Fig.  441).  The  amount  of  flexion 
is  ascertained  by  lifting  the  knee  until  the  curved  spine  has  become  straight. 
Try  all  the  movements  belonging  to  the  joint,  to  detect  any  limitations;  ob- 
serve if  bringing  down  the  knee  produces  lordosis;  look  for  swelling  and  for 
muscular  wasting;  feel  if  the  head  of  the  bone  is  enlarged;  determine  if  motion 
produces  pain  or  if  pressure  develops  tenderness;  and  always  carefully  elicit 
the  history  of  the  attack,  of  the  person,  and  of  the  family. 

Hip  disease  may  be  confounded  with  spinal  caries  in  which  a  psoas  or  a 
lumbar  abscess  has  formed,  with  •  sacro-iliac  disease,  with  infantile  paralysis, 
with  congenital  dislocation  of  hip,  with  lordosis  from  rickets,  with  gluteal 
abscess,  and  with  bursitis  of  the  gluteal  bursae.  In  hip  disease  there  is  always 
some  lameness;  pain  may  be  severe,  may  be  trivial,  or  may  be  absent  entirely, 
and  may  be  in  the  hip  or  be  referred  to  the  front  of  the  thigh  or  the  inner 
side  of  the  knee.  Always  remember  that  the  pain  is  not  characteristic,  and  that 
pain  in  the  same  localities  may  arise  from  aneurysm  of  the  femoral  or  iliac 
arteries,  from  abscess  in  Scarpa's  triangle,  from  caries  of  the  lumbar  vertebrae. 


Tuberculosis  of  the  Hip-joint 


1^2> 


from  sacro-iliac  disease,  and  from  cancer  of  the  rectum.  Altered  position  of 
the  limb,  limitation  of  movement  in  the  hip-joint,  muscular  wasting,  and 
swelling  soon  arise  in  hip-joint  disease. 

In  disease  of  the  sacro-ihac  joint  examination  shows  that  the  movements 
of  the  hip-joint  are  unlimited  and  produce  no  pain,  and  that  pain  is  developed 
by  pressure  over  the  sacro-iliac  articulation  and  by  pressing  the  ilia  together. 
In  infantile  paralysis  there  is  no  pain,  but  there  is  paralysis  with  great  muscular 
atrophy,  which  comes  on  with  considerable  rapidity.  In  spinal  caries  with 
psoas  abscess  the  evidences  of  disease  of  the  vertebrae  are  clear  and  a  collection 
of  fluid  is  located  in  the  groin  external  to  the  femoral  vessels.  The  tuberculous 
pus  of  hip  abscess  generally  gathers  under  the  tensor  vaginas  femoris  muscle, 
but  it  may  reach  Scarpa's  triangle  by  passing  through  the  cotyloid  notch  or 
through  the  bursa  under  the  psoas  muscle;  it  may  even 
appear  under  the  glutei.  Matter  from  a  caseating 
acetabulum  may  reach  the  interior  of  the  pelvis  and 
appear  above  Poupart's  ligament. 

In  gluteal  bursitis  the  symptoms  last  for  many 
months,  and  do  not  remit  as  the  symptoms  of  early 
hip  disease  are  apt  to  do.  The  pain  is  but  moderate, 
and  is  aggravated  by  exercise,  but  passes  away  on 
going  to  bed,  and  is  felt  back  of  the  hip  and  back  of 
the  knee.  There  is  a  certain  amount  of  limitation  of 
motion  and  there  is  a  positive  limp,  which  arises  early. 
In  marked  cases  fluctuation  can  be  detected  in  the 
upper  gluteal  region.^ 

Prognosis. — If  the  case  of  hip  disease  is  seen  early 
the  chances  of  cure  are  excellent  in  children,  in  whom 
the  disease  may  be  arrested  at  any  stage.  The  longer 
the  duration  of  the  disease  and  the  older  the  subject, 
the  more  unfavorable  is  the  prognosis.  Many  months 
will  elapse  before  a  cure  can  be  effected,  and  advanced 
cases  only  get  well  by  means  of  ankylosis  with  short- 
ening and  deformity.  Hip  disease  may  recur  years 
after  apparent  cure,  and  a  person  who  has  or  has  had  hip  disease  runs  a  chance 
of  developing  visceral  tuberculosis. 

Complications. — The  complications  that  may  accompany  hip  disease  are 
the  following:  Abscess,  as  above  noted.  Tuberculous  meningitis,  or  the  con- 
dition known  as  "acute  hydrocephalus"  or  "water  on  the  brain,"  may  arise 
during  the  progress  of  the  case  or  after  apparent  cure,  and  is  apt  to  ensue  upon 
incomplete  operations.  It  is  almost  inevitably  fatal.  Phthisis  pulmonalis 
is  a  rare  complication,  but  a  not  uncommon  sequence,  perhaps  arising,  sooner 
or  later,  after  the  hip  disease  has  been  cured  Amyloid,  lardaceous,  or  waxy 
degeneration  of  viscera  (see  page  265)  follows  upon  profuse  and  long-continued 
suppuration  and  is  apt  to  arise  in  the  liver,  spleen,  kidneys,  or  intestinal  mucous 
membrane.  Tuberculosis  is  not  the  only  cause  of  amyloid  degeneration, 
syphilis  being  responsible  for  at  least  30  per  cent,  of  all  cases.  In  amyloid 
disease  of  the  liver  the  organ  is  much  enlarged,  smooth,  painless,  and  of  increased 
consistency;  there  is  no  jaundice,  the  spleen  is  apt  to  be  enlarged,  and  albuminu- 
ria is  the  rule.  In  amyloid  kidney  large  amounts  of  pale  urine  of  low  specific 
gravity  are  voided;  albumin  is  usually  present  in  large  amount,  but  may  be 
absent;  globulin  may  often  be  found,  as  may  also  hyaline,  fatty,  or  granular 
casts;  the  patient  is  anemic  and  dropsy  usually  exists.  Test  the  hyaline  casts 
with  iodin  for  amyloid  material.  Amyloid  changes  are  usually  slow  in  onset, 
but  they  may  be  rapid;  they  are  commoner  in  men  than  in  women,  and  are 

^       ^  See  E.  G.  Brackett's  important  paper  on  "Gluteal  Bursitis"  in  the  "Transactions  of  the 
American  Orthopedic  Association,"  vol.  x. 


Fig.  442. — Thomas's  poste- 
rior splint. 


714  Diseases  and  Injuries  of  the  Bones  and  Joints 

most  frequently  encountered  in  individuals  between  the  ages  of  ten  and  thirty. 
Slight  amyloid  change  may  be  recovered  from,  but  an  extensive  degeneration 
brings  about  a  fatal  result. 

Treatment. — In  most  of  these  cases  conservative  treatment  is  advisable. 
Antituberculous  treatment  is  used  in  all  cases.  In  incipient  hip  disease  the 
treatment  usually  advocated  is  rest.  The  patient  is  placed  upon  a  solid  mattress 
and  extension  is  applied.  In  children  under  ten  years  of  age  a  weight  of  from 
3  to  5  pounds  is  used;  in  individuals  between  ten  and  twenty  a  weight  of  from 
5  to  8  pounds  is  used.  A  long  splint  is  often  applied  to  the  sound  side  to  keep 
the  patient  recumbent  and  horizontal.  A  cradle  is  employed  to  hold  up  the 
bed-clothing.  The  extension  is  applied  in  the  long  axis  of  the  limb,  the 
extremity  being  placed  in  the  line  of  the  deformity  due  to  disease  and  being 
properly  supported.  Lordosis  means  that  there  is  flexion  of  the  thigh,  and 
when  lordosis  exists  the  limb  is  to  be  raised  until  the  lumbar  spine  flattens  out 
on  the  bed  and  extension  is  to  be  applied  (PI.  8,  Fig.  5).  If  the  anterior  superior 
spine  of  the  ilium  is  depressed  on  the  affected  side  and  there  is  apparent  length- 
ening abduction  exists.  The  limb  is  to  be  moved  until  the  anterior  superior 
spines  of  the  iUa  are  on  a  horizontal  level  and  then  extension  is  to  be  applied 
(PI.  8,  Fig.  6). 

If  the  anterior  superior  spine  is  elevated  and  there  is  apparent  shortening, 
adduction  exists.  The  limb  should  be  moved  inward  across  its  fellow  until 
the  spines  of  the  ilia  are  on  the  same  horizontal  level,  and  the  extension  is 
to  be  applied  (PI.  8,  Fig.  7).  The  object  of  extension  is  to  overcome  muscular 
spasm  and  so  put  the  part  in  a  condition  of  physiological  rest.  Muscular 
spasm  is  a  great  factor  in  destroying  structures.  Spasm  presses  the  parts 
together,  and  as  a  result  of  pressure  plus  bacterial  action  destruction  occurs. 
The  extension  and  traction  tire  out  the  muscles  and  cause  spasm  to  cease. 
Extension  will  remove  flexion  in  two  weeks  in  a  recent  case  and  in  the  course  of 
some  months  in  an  older  case.  As  flexion  is  relieved  the  pillows  are  removed 
and  the  leg  lowered,  but  extension  is  maintained  in  the  long  axis  of  the  thigh. 
Abduction  and  adduction  cannot  be  removed  by  simple  extension  in  the  axis 
of  the  limb. 

Abduction  demands  no  special  treatment.  In  a  movable  joint  it  will  dis- 
appear, and  in  an  ankylosed  joint  it  is  an  advantage,  compensating  by  apparent 
lengthening  for  the  shortening  due  to  bone-absorption  or  to  stunted  growth 
of  the  limb.  Adduction  requires  an  addition  of  several  pounds  to  the  extension 
weight,  the  use  of  a  long  splint  on  the  sound  limb,  and  the  drawing  up  of  the 
sound  side  by  a  rope  and  pulley  toward  the  head  of  the  bed.  The  weight 
used  to  pull  the  sound  side  toward  the  head  of  the  bed  is  equal  to  that  used 
to  pull  the  diseased  side  to  the  foot  of  the  bed.  This  expedient  is  used  for  a 
month  or  six  weeks.  In  old  cases,  in  which  the  weight  will  not  bring  about 
extension,  the  patient  is  anesthetized,  the  limb  is  gently  straightened  a  very 
little,  and  the  weight  is  reapplied. 

Extension  in  a  mild  case  must  be  continued  for  three  months  after  the 
symptoms  have  disappeared,  and  in  a  severe  case  the  period  must  be  six  months. 
The  weight  is  gradually  taken  off;  if  symptoms  recur,  the  weight  is  reapplied; 
if  they  do  not  recur,  apply  a  traction  splint  or  a  plaster  dressing,  put  a  high- 
heeled  boot  on  the  sound  limb,  and  send  the  patient  out  on  crutches.  In 
young  children  extension  can  be  made  while  the  child  is  in  a  wheeled  carriage, 
thus  enabling  the  patient  to  go  out  in  the  fresh  air  and  sunlight.  The  general 
treatment  is  tonic  and  restorative.  The  joint  is  so  deeply  placed  that  external 
applications  are  useless.  In  the  treatment  of  hip  disease  Thomas's  splint 
(Fig.  442)  is  used  by  many,  and  it  may  be  combined  with  weight  extension; 
or  Sayre's  splint  (Fig.  443)  may  be  employed.  Wyeth's  apparatus  (Fig.  444) 
is  a  favorite  with  many  American  surgeons. 

If  the  Umb  is  in  good  position,  or  has  been  brought  into  good  position,  either 


HIP-JOINT    DISEASE. 


Plate  6. 


1,  2.  Effects  on  the  Lumbar  Spine  of  Flexing  and  Extending  the  Diseased  Leg  in  Hip  Disease 
(Albert).  3,  4.  Positions  in  Coxalga  (Albert).  5.  Extension  in  Hip  Disease  (Treves).  6.  Ex- 
tension of  the  Limb  in  a  Flexed  and  Adducted  Position  (Treves).  7.  Extension  of  the  Limb  in  a 
Flexed  and  Abducted  Joint  (Treves). 


Tuberculosis  of  the  Hip-joint 


715 


by  weight  extension  or  straightening  under  ether,  plaster  of  Paris  is  a  useful 
dressing.  It  is  applied  from  the  toes  up,  and  includes  the  entire  extremity  and 
also  the  pelvis.  A  patient  wearing  plaster  may  get  about  on  crutches  when 
the  sole  of  the  foot  of  the  sound  extremity  is  raised  by  the  wearing  of  a  thick- 
soled  shoe. 

Treatment  hy  Weight-bearing  and  Fixation  ly  Hip  Spica  of  Plaster  of  Paris 
(Lorenz's  Method). — This  plan  is  based  upon  the  principle  that  ankylosis  is  to 
be  secured  in  every  instance.  To  keep  the  patient  in  bed  is  to  keep  him  from 
the  open  air  and  sunlight,  which  are  so  necessary  in  tuberculosis.  Such  con- 
finement favors  muscular  atrophy,  leads 
to  anemia,  and  lessens  vital  resistance. 
The  hip  is  placed  in  20  degrees  of  flexion. 


Fig.  443. — Sayre's  long  splint. 


Fig.  444. — Wyeth's  combination  method. 


20  degrees  of  abduction,  and  5  degrees  of  external  rotation,  and  is  fixed  by  a 
short  plaster  spica  of  the  hip.  The  patient  walks  and  so  antagonizes  muscular 
spasm.  The  joint  surfaces  bear  weight,  which  leads  to  a  useful  increase  of 
blood  supply  (curative  hyperemia),  but  do  not  grind  upon  each  other,  hence,  the 
spread  of  the  disease  is  not  favored.  That  muscles  increase  in  size  is  shown  by 
the  fact  that  the  cast  gets  tight  and  must  be  changed  from  time  to  time.  The 
open-air  life  and  exercise  are  of  the  greatest  benefit  to  the  patient  and  a  gain 
in  weight  is  the  rule.  Cases  in  a  debihtated  condition  or  those  with  discharg- 
ing sinuses  must  not  be  treated  by  this  plan ''without  the  temporary  use  of 
crutches"  (H.  A.  Wilson,  in  "Southern  Med.  Jour.,"  Dec,  1908).  The  plan  is 
more  suitable  for  incipient  than  for  advanced  cases.  The  average  duration 
of  treatment  is  claimed  to  be  about  ten  months  (H.  A.  Wilson,  Ibid.).  It  is 
true  that  the  method  affords  easier  access  to  the  open  air  than  does  the  bed 
treatment,  but  why  should  every  patient  be  doomed  to  ankylosis  when  we  know 
that  in  many  cases  joint  fimction  may  be  retained  by  treatment  looking  to 
that  end? 

Intra-articidar  Injections  and  Operation. — ^If  in  spite  of  treatment  the  con- 
dition does  not  improve  or  if  it  becomes  worse,  use  intra-articular  injections  of 
formaHn-glycerin  or  iodoform.     Always  try  these  injections  before  doing  a 


7i6  Diseases  and  Injuries  of  the  Bones  and  Joints 

resection  unless  the  .v-rays  show  a  large  sequestrum.  Sometimes  they  succeed 
and  if  they  do,  resection  is  unnecessary.  Asepticize  the  surface,  carry  a  small 
aspirating  needle  into  the  joint,  irrigate  the  joint  with  salt  solution,  and  inject 
a  sterile  emulsion  of  iodoform  and  glycerin  (see  page  708).  In  one  week,  if 
reaction  has  ceased,  repeat  the  injection.  In  another  week  again  use  the  injec- 
tion. It  may  be  necessary  to  give  from  ten  to  twenty  injections.  The  proper 
spot  for  puncture  is  thus  determined:  Draw  a  line  from  a  point  }/2  inch  outside 
of  the  middle  of  Poupart's  hgament  to  the  outer  edge  of  the  great  trochanter. 
Puncture  at  the  middle  of  the  outer  half  of  this  line  (De  Vos).  I  have  not 
attempted  to  remove  the  disease  surgically  early  in  any  case  and  greatly  doubt 
the  wisdom  of  doing  so.  Huntington  and  some  other  surgeons  advocate  early 
operation  in  children  instead  of  simply  fixation,  extension,  and  rest.  Hunting- 
ton ("Amer.  Jour.  Med.  Sciences,"  July,  1905)  recalls  that  when  the  lesion 
is  in  the  head  of  the  femur  it  tends  to  perforate  into  the  joint,  and  he  advises 
trephining  at  the  lower  border  and  outer  aspect  of  the  great  trochanter  and 
tunnelling  the  neck  and  head  of  the  femur  with  a  curet  Bradford  objects  to 
this  method  in  most  cases  on  the  ground  that  unless  the  disease  is  localized 
and  the  cavity  is  well  walled  off  and  unless  injury  to  the  localizing  barrier  is 
avoided,  the  operation  may  be  responsible  for  dissemination  of  the  bacteria. 

If  an  abscess  forms,  incise  it  with  the  most  thorough  antiseptic  care,  let  the 
fluid  drain  away,  irrigate  the  cavity  with  salt  solution,  remove  any  sequestra, 
inject  with  iodoform  emulsion,  sew  up  without  drainage,  and  dress  antiseptic- 
ally.  In  some  cases  the  sequestrum  is  extra-articular.  In  many  cases  no 
sequestrum  is  found.  If  this  method  fails,  drainage  must  be  employed.  The 
old  plan  of  not  operating  until  rupture  was  seen  to  be  inevitable  would  be  wrong 
to-day.  To  open  early  and  antiseptically  often  means  rapid  healing,  the  preven- 
tion of  burrowing,  a  lessened  danger  of  visceral  infection,  and  an  earlier  cure. 
In  contrast  to  what  happens  when  a  very  large  cold  abscess  is  opened,  hectic 
fever  will  rarely  arise  when  a  tuberculous  joint  is  opened  and  drained  with 
aseptic  care. 

Excision  of  the  hip  is  to  be  performed  when  there  is  a  large  sequestrum 
or  severe  fistulae  (Garre,  "Deutsch.  med.  Woch.,"  1905,  Nos.  47  and  48); 
when  the  head  of  the  femur  is  detached  and  lies  loose  in  the  joint;  when  profuse 
suppuration  continues  for  a  long  tirne,  and  other  methods  fail  to  arrest  it; 
when  amyloid  disease  is  threatening;  or  when  very  faulty  position  is  inevitable 
without  operation.  Excision  is  an  operation  of  considerable  danger,  and  the 
older  the  person,  the  greater  the  danger.  Schede  advocates  arthrectomy  in 
some  cases  as  a  substitute  for  resection.  Senn  tells  us  that  opinion  as  to  resec- 
tion has  greatly  changed  of  late,  and  it  is  now  taught  that  the  operation  is 
advisable  in  all  cases  where  fixation,  extension,  intra-articular  and  parenchy- 
matous injections  have  failed  to  arrest  the  disease  (Senn,  on  "Tuberculosis  of 
Bones  and  Joints").  Resection  of  the  hip  does  not  give  a  very  satisfactory 
functional  result.  When  there  is  extensive  disease  of  the  femur,  when  excision 
has  been  tried  and  has  failed,  when  the  patient  has  not  the  recuperative  power 
to  withstand  the  long  siege  of  illness  following  excision,  or  when  there  is  amyloid 
disease,  amputate.^  Amputation  of  the  hip-joint  for  tuberculous  disease  is  a 
very  successful  procedure. 

Kneer-joint  Disease  {White  Swelling). — After  the  hip,  the  knee  is,  of  all 
joints,  the  commonest  site  of  tuberculous  disease.  Knee-joint  disease  can 
begin  as  a  synovitis,  but  oftener  begins  as  tuberculous  inflammation  of  the 
femoral  or  the  tibial  epiphysis.  Tuberculous  disease  rarely  attacks  the  bone 
on  the  diaphyseal  side  of  the  epiphyseal  line;  a  single  focus  only  exists,  as  a 
rule,  and  a  sequestrum  is  seldom  formed.  In  very  rare  instances  the  patella 
or  the  semilunar  cartilage  is  primarily  attacked.  It  may  begin  at  any  age, 
but  is  most  common  in  children  and  young  adults.  If  an  acute  synovitis 
1  See  the  admirable  article  by  Howard  ]Marsh  in  Treves's  "Manual  of  Surgery." 


Ankle-joint  Disease 


717 


^^'^ 


Fig.  445. — Sajrre's 
knee  splint  applied. 


Ushers  in  the  case,  there  may  be  a  large  effusion  into  the  knee-joint  and  partial 
Hexion,  but  swelHng  is  usually  slight  in  knee-joint  disease.  Pulpy  degenera- 
tion of  the  s}Tiovial  membrane  occurs;  the  joint  enlarges;  the  ligaments 
soften;  the  skin  becomes  edematous,  and  muscular  spasm  exists.  The  leg 
becomes  flexed;  the  tibia  displaced  backward  and  outward;  the  foot  is  everted; 
and  lameness  arises,  due  chiefly  to  deformity.  Muscle  atrophy  is  marked 
above  and  below  the  joint.  Pain  may  be  absent,  is  often  slight,  and  is  rarely 
severe.  Local  tenderness  is  very  common.  When  the  disease  begins  in  the  bone 
or  an  epiphysis  there  are  pain,  tender- 
ness, lameness,  swelling,  inability  to  ex- 
tend the  limb  completely,  sudden  spas- 
modic muscular  contractions,  and  final 
involvement  of  the  joint.  When  an 
abscess  forms,  it  may  destroy  the  joint 
v^ery  rapidly  or  it  may  break  externally. 

Treatment. — In  treating  knee-joint 
disease  conservative  treatment  is  usually 
tried,  but  often  fails.  A  plan  of  doubtful 
value  is  to  make  a  mixture  of  guaiacol 
and  olive  oil  (1:4).  Once  a  day  the 
surface  of  the  knee  is  exposed  by  remov- 
ing dressings,  is  painted  with  this  mix- 
ture, and  the  painted  surface  is  covered 
wath  cotton-wool.  Rest  is  of  the  first 
importance,  and  may  be  secured  by  the 
application  of  splints  (Figs.  445, 446),  the 
use  of  extension  (Fig.  447) ,  or  the  employ- 
ment of  a  plaster-of -Paris  bandage.  In 
any  case  the  patient  must  be  kept  in 
bed  for  a  few  weeks;  he  may  then  be  permitted  to  go  out  upon  crutches,  wearing 
a  high-heeled  shoe  upon  the  foot  of  the  sound  Hmb.  In  cases  in  which  treatment 
is  begun  early  the  disease  may  often  be  arrested  in  from  eight  to  twelve  months. 
If  the  symptoms  do  not  abate  after  a  number  of  weeks,  or  if  the  condition  grows 
worse  and  caseation  occurs,  aspirate,  irrigate,  and  inject  iodoform  emulsion  or 
formalin-glycerin.  Intra-articular  injections  are  not  unusually  curative.  Insert 
the  needle  in  the  angle  between  the  outer  edge  of  the  patella  and  the  ligament  of 
the  patella  (De  Vos).  Repeat  the  injection  in  one  week  if  reaction  has  abated, 
and  continue  as  directed  for  the  injection  of  the  hip-joint.  If  this  plan  fails,  in- 
cise the  capsule,  remove  all  fragments  and  tuberculous  foci,  irrigate  with  normal 
salt  solution,  inject  iodoform  emulsion,  and  sew  up  without  drainage  (Neuber's 
plan).  A  more  severe  case  requires  drainage.  If  these  means  fail,  or  if  the  case 
is  too  far  advanced  to  permit  of  their  use,  open  the  joint  and  perform  an  excision 
or  an  erasion  (see  pages  787  and  793).  Excision  gives  a  satisfactory  result  in 
most  cases,  although  it  leaves  a  rigid  knee  and  marked  shortening.  Garre 
considers  any  shortening  over  5  cm.  a  bad  result,  and  he  got  such  a  bad  result 
in  7.5  per  cent,  of  his  117  cases.  In  children  shortening  follows  even  con- 
servative treatment,  and  the  shortening  which  follows  excision  is  due  in  part 
to  removal  of  bone  and  in  part  to  impairment  of  the  nutritive  power  of  the 
epiphyseal  cartilage.  In  most  cases  in  children  conservative  treatment  should 
be  tried.  In  most  adult  cases  resection  is  indicated.  Some  cases  demand 
amputation,  which,  if  the  patient's  health  is  much  impaired  or  if  amyloid  disease 
exists,  is  to  be  preferred  to  excision.  Amputation  is  preferred  to  excision  in  very 
yoimg  children  and  aged  people. 

Ankle-joint   disease  may  begin  in  the  s}mo\dal  membrane,  in  the  tibial 
epiphysis,  or  in  the  tarsus.     The  origin  is  frequently  synovial. 

The    symptoms    are    pain,    swelling,    lameness,   limitation   of  joint-move- 


FiG.  446. — Hutch- 
in  s  o  n '  s  knee-joint 
splint. 


7i8 


Diseases  and  Injuries  of  the  Bones  and  Joints 


ments,  and  atrophy  of  the  calf  muscles.  Caseation  often  occurs  and  sinuses 
form. 

Treatment. — Conservative  treatment  with  injections  of  iodoform  or  of  for- 
malin-glycerin will  cure  many  cases.  Rest  is  obtained  by  means  of  splints  or 
plaster-of-Paris  bandages.  Caution  the  patient  to  avoid  standing  upon  the 
diseased  extremity.  In  making  an  intra-articular  injection  insert  the  needle 
below  the  outer  malleolus.  When  caseation  occurs,  it  is  advisable  to  open  the 
joint,  wash  out  with  normal  salt  solution,  inject  iodoform  emulsion,  sew  up 
the  incision,  and  put  up  the  ankle-joint  in  plaster.  When  there  is  considerable 
bone  disease,  when  fistulas  exist,  when  adjacent  joints  or  tendons  are  diseased, 
or  when  joint-disorganization  occurs,  perform  an  excision  or  an  erasion.  Some 
cases  demand  amputation  (Syme's  amputation  being  preferred  by  some,  amputa- 
tion above  the  ankle  being  approved  by  many).  Osteoplastic  resection  is  some- 
times advised  (Wladimiroff-Mikulicz  operation).  Operative  treatment  is 
more  satisfactory  in  children  than  in  adults  (Garre). 

Shoulder-joint  disease  is  not  common;  it  is  rare  in  children  but  is  less  rare 
in  adults;  it  may  begin  in  the  synovial  membrane,  but  usually  begins  in  the  head 
of  the  humerus.     The  glenoid  cavity  is  rarely  attacked.     Pain  is  slight,  atrophy 


Fig.  447. — Sayre's  double  extension  of  the  knee-joint. 


of  the  deltoid  and  other  muscles  is  noted,  the  joint  is  stiff,  and  the  scapula 
follows  the  motions  of  the  humerus.  Caries  sicca  is  the  usual  cause  of  destruc- 
tion. In  many  cases  swelling  is  not  obvious,  the  joint  shrinking  because  of 
destruction  of  the  head  of  the  bone  and  contraction  of  the  capsule  (Senn). 
Abscess-formation  is  unusual.  If  an  abscess  forms,  it  may  open  in  the  axilla, 
through  the  deltoid  muscle,  or  at  some  far  distant  point.  Shoulder- joint  disease 
is  frequently  complicated  by  pulmonary  tuberculosis. 

Treatment. — A  majority  of  cases  recover  by  the  use  of  conservative  treat- 
ment, a  stiff  joint  resulting.  Put  on  a  shoulder-cap,  apply  the  second  roller  of 
Desault,  and  hang  the  hand  in  a  shng.  Maintain  rest  for  at  least  four  months. 
Arthur  Gillette's  plan  is  very  efficient.  It  consists  in  placing  in  the  axilla  a 
wedge-shaped  pad  with  the  base  up.  The  arm  is  allowed  to  hang.  Aspiration 
and  injection  of  iodoform  emulsion  or  of  formahn-glycerin  are  of  great  service 
in  synovial  tuberculosis.  In  making  an  intra-articular  injection  the  needle  is 
entered  below  the  acromion,  while  the  arm  is  held  against  the  side  and  the  fore- 
arm is  at  right  angles  to  the  arm  and  across  the  front  of  the  chest  (De  Vos). 
If  caseation  occurs,  open  the  joint,  remove  tuberculous  foci,  wash  with  hot 
saline  fluid,  inject  iodoform  emulsion,  and  close  without  drainage.  In  a 
decidedly  severe  case,  drain.  Caries  sicca  may  occur.  In  rare  instances  dead 
bone  will  have  to  be  gouged  away.  Excision  is  sometimes  required,  but  the 
results  are  seldom  satisfactory. 

Elbow-joint  disease  may  begin  in  the  humerus  or  the  ulna.  The  head  of 
the  radius  is  rarely  the  primary  focus.  In  some  cases  the  synovial  membrane 
is  first  attacked.     The  disease  is  most  frequent  in  young  adults.     The  joint  is 


Osteochondritis  Deformans  Juvenalis  719 

swollen,  its  movements  are  somewhat  limited,  muscular  wasting  is  pronounced,, 
and  pain  is  generally  slight.     Tuberculous  pus  may  form. 

Treatment. — In  treating  early  elbow-joint  disease,  especially  in  young  chil- 
dren, conservative  treatment  is  very  successful.  Rest  is  secured  by  means, 
of  an  anterior  angular  splint  (Fig.  448)  and  a  triangular  sling  or  a  plaster-of- 
Paris  dressing.  Splints  are  to  be  worn  for  from  four  months  to  a  year.  Injec- 
tions of  iodoform  emulsion  or  formalin-glycerin  are  usually  employed.  Insert 
the  needle  close  to  the  outer  side  of  the  olecranon.  In  a  cure  by  conserva- 
tive methods  a  stifif  joint  will  usually  result.  It  may  be  necessary  to  perform 
resection  because  of  extensive  bone  disease.  Resection  gives  an  excellent 
functional  result. 

Wrist-joint  disease  may  arise  at  any  age,  and  is  sometimes  met  with  in  late 
middle  life  or  even  in  old  age.  The  joint  presents  a  puflfy  swelhng,  loses  its 
normal  contour,  and  becomes  spindle  shaped.  Hand-movements  are  impaired, 
pronation  and  supination  cannot  be  performed  completely  or  satisfactorily, 
the  joint  is  stiff  and  partly  flexed,  the  grasp  is  enfeebled,  pain  may  be  severe 
or  slight,  the  skin  is  sometimes,  but  seldom,  hot,  and  muscular  atrophy  is 
marked.     This  form  of  tuberculosis  may  begin  in  the  synovial  membrane, 


Fig.  448. — Stromeyer's  anterior  angular  splint. 

in  the  bones,  or  in  the  tendon-sheaths.  The  prognosis  is  better  than  in  tuber- 
culosis of  any  other  joint.  There  is  usually  preservation  of  considerable  function 
on  recovery. 

Treatment  is  usually  conservative  and  very  successful,  giving,  as  a  rule,  a 
functionally  useful  joint  and  movable  fingers.  Garre  recommends  a  trial  of  the 
method  even  when  there  are  fistulas  and  when  there  is  necrosis  of  the  carpus. 
Apply  a  Bond  splint  and  sling  or  put  on  a  plaster-of- Paris  bandage  and  main- 
tain strict  rest  for  from  four  to  six  months.  Aspiration  and  injection  of  iodo- 
form emulsion  of  formalin-glycerin  may  be  practised.  Enter  the  needle  at  the 
dorsal  edge  of  the  radial  styloid  process,  and  again  at  the  upper  edge  of  the 
pisiform  bone  (De  Vos).  In  some  cases  it  is  well  to  incise,  wash  with  salt  solu- 
tion, inject  iodoform  emulsion,  and  close  without  drainage.  Severe  cases 
demand  incision  and  drainage  with  the  maintenance  of  rest.  Resection  is  to 
be  avoided  if  possible.  It  gives  a  bad  functional  result,  the  amount  of  bone 
removed  leaving  the  tendons  too  long  and  contractures  of  muscles  being  com- 
mon (Garre).  It  may  be  demanded  because  of  extensive  caries  or  sequestra 
formation.     Amputation  is  occasionally  necessary. 

Non-tuberculous  Arthritis. — Most  of  these  cases,  acute  and  chronic,  are 
of  infectious  origin.  Some  of  them  are  non-infectious.  Among  the  non-infect- 
ive forms  are  the  joint  lesions  of  locomotor  ataxia  and  syringomyelia — con- 
stitutional conditions,  as  gout,  purpura,  hemophilia,  and  scurvy — afunctional 
derangements  expressed  by  articular  neuralgia  or  intermitting  hydrops  and 
traumatic  states  (Hoffa,  in  "Zentralbl.  f.  Chir.,"  xxxiv,  1907;  and  Bloodgood, 
in  "Progressive  Medicine,"  Dec.  i,  1907). 

Osteochondritis  Deformans  Juvenalis  (Quiet  Hip  Disease.  Legg's  Disease. 
Perthes's  Disease). — Legg,  of  Boston  discovered  this  condition  in  1909  ("  Boston 
Med.  and  Surg.  Jour.,"  1910,  clxii).  Perthes  of  Tubingen  described  it  in  1910. 
(See  Leonard  V.  Ely,  in  "  Annals  of  Surgery,"  Jan.,  1919.)     In  this  disease  there  is 


720  Diseases  and  Injuries  of  the  Bones  and  Joints 

atrophy  and  rarefaction  of  the  head  of  the  femur  and  if  weight-bearing  is  con- 
tinued the  head  of  the  femur  will  be  almost  destroyed.  In  many  cases  a  diagnosis 
of  tuberculous  hip  has  been  made.  The  cause  is  unknown.  Legg  con- 
siders trauma  causal  in  67  per  cent,  of  cases  ("Boston  Med.  and  Surg.  Jour." 
Feb.  7,  1910).  Taylor  and  Freider  consider  trauma  a  possible  but  very  doubtful 
cause  ("Am.  Jour.  Orthop.  Surg."  Vol.  xiii,  1915).  Kidner  suggests  infection 
of  the  tonsils  as  causal  ("Am.  Jour.  Orthop.  Surg.,"  Vol.  xiv,  1916).  Others 
regard  the  lesion  as  nutritional.  The  latter  explanation  gains  much  in  proba- 
bility from  Blanchard's  observation  that  there  is  also  "decreased  bone  density 
and  some  atrophy  of  the  pelvis  of  the  diseased  side  in  the  acute  cases." 
("Jour.  Am.  Med.  Assoc,"  Sept.  29, 1917).  It  is  probably  a  nutritional  disease 
of  growing  bone  and  muscle.  The  first  symptom  is  a  limp.  There  may  be 
some  pain  running  down  the  thigh.  Fever  is  absent.  There  are  no  night 
cries.  There  is  some  limitation  of  rotation,  and  atrophy  of  the  hip  and  buttock. 
If  the  case  is  untreated  shortening  will  occur.  After  about  a  year  the  head  of 
the  femur  may  be  largely  destroyed.  The  neck  will  be  shortened  and  in  a  coxa 
vara  or  coxa  valga  position  (Blauchard,  Ibid.).  There  are  2  or  3  cm.  of  short- 
ening. "Abduction  is  partly  lost  and  movements  of  the  hip  in  other  directions 
are  slightly  limited "(Blanchard,  Ibid.).  In  a  year  or  more  the  disease  ceases 
to  progress  and  the  bone  begins  to  harden  and  to  undergo  repair.  If  weight- 
bearing  is  prevented  during  the  existence  of  the  disease  the  head  of  the  femur 
will  never  lose  its  rotundity  and  by  the  end  of  the  second  year  will  have 
become  hard  again.  Even  if  the  head  of  the  femur  has  been  destroyed  proper 
mechanical  treatment  for  a  year  or  two  will  cause  almost  complete  regeneration. 
A  limp  remains  after  recovery. 

The  plan  of  letting  these  cases  walk  about  without  treatment  is  to  be  con- 
demned. Treatment  is  highly  successful.  A  plaster-of-Paris  spica  running 
from  the  foot  nearly  to  the  axilla  is  an  excellent  plan  of  treatment.  It  is  asso- 
ciated with  a  high  shoe  on  the  sound  side  and  crutches. 

Some  use  the  abduction  splint  as  in  tuberculosis  of  the  hip  and  guard  the 
patient  from  treading  on  the  diseased  limb  (Sever,  in  "Jour.  Am.  Med.  Assoc," 
Sept.  29,  1917). 

Traumatic  Arthritis. — This  may  be  due  to  a  single  injury  (a  sprain  or  a  bruise) 
or  to  some  continuing  cause  (genu  valgum  may  cause  arthritis  of  the  knee; 
flat-foot  may  be  responsible  for  arthritis  of  the  knee  or  hip). 

If  a  contusion  or  sprain  causes  relaxation  of  the  capsule  or  fixing  tendons, 
the  joint  becomes  loose  and  injures  itself  again  and  again  during  movement. 
It  does  the  same  thing  when  there  are  loose  bodies  or  enlarged  synovial  fringes. 
Traumatic  arthritis  usually  involves  but  one  joint.  Recent  traumatic  arthritis 
is  treated  by  protecting  the  joint,  massage,  hot  air,  and  passive  motions. 

If  a  continuing  cause  is  present  it  is  to  be  removed.  Distant  causes  may 
be  removed  by  orthopedic  apparatus  or  by  operation.  Causes  within  the  joint 
may  be  sought  for  by  arthrotomy,  and  when  found  they  should  be  removed. 
For  instance,  in  the  knee,  iuflamed  synovial  fringes  may  be  responsible  for 
chronic  inflammation.  They  get  caught  between  the  joint  surfaces,  are 
squeezed,  and  trip  the  victim.  They  should  be  removed.  Lockwood  ("Brit. 
Med.  Jour.,"  July  3,  1909)  points  out  that  an  overgrowth  of  fat  may  get 
between  the  tibia  and  femur  and  be  squeezed.  This  surgeon  calls  attention  to 
the  fact  that  there  are  "adipose  pads  immediately  above  the  articular  surface  of 
the  femur,  and  on  either  side  of  the  upper  end  of  the  patella"  (Ibid.).  He  calls 
them  the  pads  of  Malgaigne,  after  the  French  surgeon  who  described  them  in 
1859.     If  they  are  subject  to  repeated  traumatism  they  should  be  removed. 

Infective  Arthritis. — In  this  condition  the  inflammation  is  due  to  bacteria. 
Various  forms  of  bacteria  may  be  responsible.  A  streptococcic  arthritis  begins 
in  from  one  to  five  days  after  the  primary  infection,  a  tv^jhoid  joint  many 
days  or  even  weeks  after.     In  some  cases  pus  forms  and  pyogenic  bacteria  are 


Pyogenic  or  Acute  Suppurative  Arthritis  721 

demonstrable  in  fluid  removed  by  aspiration.  In  other  cases,  perhaps  exhibit- 
ing symptoms  as  acute,  no  pus  forms  and  no  bacteria  are  demonstrable  in  the 
fluid  removed  by  aspiration.  The  latter  cases  are  due  to  toxins  or  to  bacteria  of 
attenuated  virulence.  Secondary  infection  may  occur.  In  most  cases  the  disease 
is  polyarticular,  but  if  a  wound  is  causal  the  arthritis  will  be  monarticular.  The 
bacteria  may  reach  a  joint  by  way  of  a  wound  from  an  adjacent  focus  of  osteo- 
myelitis, from  a  near  or  distant  area  of  infection,  from  the  genito-urinary  tract, 
the  teeth,  or  by  way  of  the  tonsils.  Bacteria  not  directly  introduced  into  the 
joint  reach  it  by  way  of  the  blood  or  lymph. 

The  disease  may  arise  during  the  course  of  gonorrhea,  scarlatina  or  any 
infectious  process.  The  source  of  the  bacteria  may  be  oral  sepsis,  chronic 
appendicitis,  prostatic  inflammation  or  some  other  focal  infections.  It  may  arise 
when  no  area  of  infection  can  be  discovered.  It  may  arise  in  the  course  of  an 
acute  infectious  disease  (such  as  erysipelas,  cerebrospinal  fever,  broncho- 
pneumonia, typhoid  fever,  pneumonia,  influenza,  mumps,  dysentery,  diphtheria, 
measles,  scarlatina,  variola),  and  may  be  due  to  pyogenic  cocci,  to  the  specific 
micro-organism  of  the  acute  infectious  disease,  or  to  microbic  products.  Ar- 
thritis may  follow  empyema.  Infective  arthritis  may  be  followed  by  pneumonia . 
Rosenau  claims  that  streptococci  can  be  converted  into  pneumococci.  So  too, 
he  asserts,  pneumococci  may  be  converted  into  streptococci  ("Illinois  Med. 
Jour."  1 9 14,  XX v).  Joint  inflammation  arising  in  the  course  of  or  as  a  sequel 
to  an  acute  infectious  disease  may  or  may  not  suppurate. 

Symptoms. — If  no  suppuration  takes  place,  the  symptoms  of  the  attack 
resemble  those  of  rheumatism;  if  suppuration  occurs,  the  symptoms  are  the 
same  as  those  of  acute  suppurative  arthritis,  with  which  disease  this  form  of 
infective  arthritis  is  identical.  Suppuration  rarely  occurs.  Ashby  has  well 
described  the  arthritis  which  sometimes  follows  scarlatina.  It  involves  the 
wrists,  finger-joints,  tendons  of  the  forearms,  the  knees,  ankles,  or  spine.  The 
joints  are  painful,  but  are  rarely  much  swollen  or  discolored  (Howard  Marsh). 
We  can  distinguish  infective  arthritis  from  rheumatism  by  the  fact  that  it 
does  not  migrate  and  is  uninfluenced  by  antirheumatic  remedies.  Dislocation 
may  follow  the  acute  manifestations  of  infective  arthritis.  In  the  hip  it  may 
simulate  congenital  misplacement. 

Treatment. — In  every  early  case  in  which  we  suspect  the  condition,  diagnostic 
aspiration  is  performed.  If  the  fluid  obtained  contains  bacteria  Murphy's 
formahn  and  glycerin  should  be  injected  (2  per  cent.).  An  injection  is  followed 
by  the  apphcation  of  an  extension  apparatus.  The  mixture  must  be  at  least 
twenty-four  hours  old.  In  many  cases  this  treatment  is  of  the  greatest  value. 
If  aspiration  and  injection  fail,  arthrotomy  and  irrigation  are  indicated.  In 
all  clinically  severe  cases  and  in  all  prolonged  cases,  open  and  irrigate,  first 
with  corrosive  sublimate  solution  (1:1000),  then  with  normal  salt  solution. 
If  the  joint  contains  pus  Dakin's  fluid  may  be  used  every  hour.  Recent  cases 
which  are  not  very  acute  and  are  free  from  pus  may  have  the  capsule  closed 
without  drainage  of  the  joint.  The  soft  parts  above  the  capsule  are  not  sutured 
(Cotton,  in  "Boston  Med.  and  Surg.  Jour."  1915,  clxxiii). 

Pyogenic  or  Acute  Suppurative  Arthritis. — This  condition  is  a  form  of 
infective  arthritis  and  is  usually  due  to  the  Staphylococcus  pyogenes  aureus  or 
to  the  Streptococcus  pyogenes,  which  finds  entrance  by  means  of  a  wound,  by 
the  spontaneous  evacuation  into  a  joint  of  the  products  of  an  osteomyelitis, 
by  extension  of  suppurative  inflammation  through  contiguous  structures,  or 
by  the  blood-stream.  It  is  necessary  to  remember  that  causative  bacteria 
may  have  entered  the  blood  or  lymph  at  a  point  near  to  or  distant  from  the 
joint  (tonsils,  ethmoid  cells,  urethra,  a  focus  of  osteomyelitis,  puerperal  sepsis, 
etc.).  Of  course,  a  wound  into  a  joint  may  be  the  open  gateway  for  infection. 
A  traumatism  may  create  a  point  of  least  resistance  and  bacteria  may  be 
derived  from  the  blood  or  lymph.  It  is  not  very  unusual  for  traumatic  arthritis 
46 


722  Diseases  and  Injuries  of  the  Bones  and  Joints 

to  eventuate  in  pyogenic  arthritis.  Particularly  in  youths  and  young  children 
the  symptoms  of  arthritis  may  overlie  and  hide  a  causative  osteomyelitis. 
Sometimes  gonorrhea  is  the  cause  and  in  rare  cases  septicemia  is  causal.  In 
pyogenic  arthritis  all  the  joint-structures  are  involved  and  suppuration  rapidly 
appears.  Synovial  membrane  is  converted  into  granulation  tissue  and  cartilage 
is  destroyed  by  pus.  The  greater  the  intensity  of  the  inflammation,  the  larger 
the  amount  of  granulation  tissue,  hence,  ultimately,  the  greater  the  amount  of 
scar  tissue  and  the  greater  impairment  of  joint  function. 

The  symptoms  of  acute  suppurative  arthritis  are  usually  a  chill  followed 
by  fever  and  a  rapid  pulse.  There  are  severe  pain,  which  is  aggravated  by 
motion  and  is  worse  at  night;  discoloration,  heat,  and  edema  of  the  skin,  partial 
flexion  of  the  joint;  fluctuation,  and  marked  constitutional  symptoms  of  sepsis. 
The  joint  tends  to  rapid  disorganization,  and  fatal  septicemia  is  very  apt  to 
occur.     In  pyemic  arthritis  several  joints  become  infected. 

Treatment. — In  every  suspicious  case  immediately  aspirate.  If  bacteria 
are  found  in  the  aspirated  fluid,  at  once  open  the  joint  {arthrotomy)  and  irri- 
gate it  with  corrosive  sublimate  solution  (i  :iooo)  and  then  with  salt  solution. 
In  early  cases  which  are  not  very  violent  formalin-glycerin  may  be  injected, 
the  wound  closed,  and  the  joint  immobilized  or  subjected  to  extension  after 
the  operation.  In  a  late  case  or  a  violent  case  treatment  consists  of  in- 
cision, drainage,  immobilization  and  antiseptization.  We  introduce  Carrel's 
tubes  and  instil  Dakin's  fluid  at  proper  intervals.  Always  be  sure  whether 
or  not  arthritis  is  the  result  of  osteomyelitis.  If  osteomyelitis  exists  the  area 
jf  bone  disease  must  also  be  operated  upon.  Arthritis  due  to  staphylococci 
and  streptococci  is  often  secondary  to  bone  suppuration.  If  a  periosteal 
abscess  exists  the  joint  condition  is  almost  certainly  secondary.  If  osteomyelitis 
exists  it  requires  prompt  and  radical  treatment  (see  page  579).  In  advanced 
cases  involving  the  knee  Allen  and  Alden  ("  Surg.,  Gynecol.,  and  Obstet.,"  July, 
1909)  open  the  joint  by  a  transverse  incision  below  the  patella,  disinfect  with 
pure  carbolic  acid  followed  by  alcohol,  and  pack  with  iodoform  gauze.  I 
would  only  regard  this  as  justifiable  in  advanced  and  very  severe  cases,  as  it 
is  sure  to  be  followed  by  ankylosis.  Although  in  late  cases  which  recover  after 
arthrotomy  and  irrigation  there  is  aways  more  or  less  ankylosis,  many  cases 
treated  early  recover  without  serious  impairment  of  joint  function.  Early 
arthrotomy  is  of  the  utmost  importance,  and  if  the  aspirated  fluid  contains 
bacteria  we  should  never  postpone  operation  or  hold  it  in  reserve  while  we 
employ  Bier's  hyperemic  or  any  other  conservative  method.  Radicahsm  is 
here  the  course  which  promises  the  greatest  safety,  and  the  surest  retention 
of  joint  function.  If  we  decide  that  the  best  we  can  get  will  be  ankylosis  and  if 
that  is  what  we  seek  every  care  must  be  taken  to  place  the  joint  at  the  angle 
which  will  be  most  useful.     Sir  Robert  Jones  advocates  the  following  positions:^ 

Shoulder. — Fixed  in  abduction  of  50°. 

Elbow. — Fixed  at  an  angle  of  110°. 

Wrist. — Dorsiflexion. 

Hip. — Fixed  in  extension. 

Knee. — Fixed  in  extension. 

Ankle. — Fixed  at  a  right  angle. 

Free  drainage,  immobilization  and  antiseptization  are  imperative.  It  is 
thought  best  not  to  remove  loose  pieces  (Osgood,').  Resection  or  amputa- 
tion may  be  required.  In  some  cases  ample  or  partial  resection  is  indicated. 
In  some  amputation  is  necessary.  Septic  joints  following  gunshot  fractures 
constitute  a  special  group  (page  734). 

Typhoid  Arthritis. — This  disease  is  a  form  of  infective  arthritis.  That 
the  bacteria  of  typhoid  may  inflame  the  joints  is  proved,  and  it  seems  certain 
that  they  can  cause  suppuration,  although  their  pyogenic  power  has  been 
'  See  Lt.-Col.  Osgood,  in  "  Am?  Jour.  Orthop.  Surgery.,"  Oct.,  1918. 


Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism  723 

disputed.  Some  claim  that  mixed  infection  is  the  real  cause  of  pus  formation 
in  a  t\T)hoid  joint.  The  typhoid  baciUi  enter  the  bones  in  many  typhoid  cases 
and  sometimes  cause  osteomyelitis.  Joint-disease  is  more  common  than  bone- 
disease.  Bone  cases  are  apt  to  occur  in  older,  joint  cases  in  younger  persons. 
One  joint,  two  joints  or  several  joints  may  be  involved.  Typhoid  disease  of  a 
joint  begins  when  the  fever  is  abating,  and  more  than  one  joint  may  be  involved. 
Typhoid  joints  may  recover  permanently,  may  become  ankylosed,  may  dislocate, 
or  the  joint-disease  may  lead  to  fatal  sepsis.  In  most  cases  the  joints  recover. 
In  slight  cases  the  synovial  membrane  only  is  involved;  in  more  severe  cases 
capsule,  cartilages,  ligaments,  and  even  bones  are  involved.  Some  cases  sup- 
purate. Septic  t}^hoid  arthritis  may  result  from  a  mixed  infection  with  typhoid 
bacilli  and  pyogenic  bacteria,  and  is  identical  in  symptoms  and  progress  with 
ordinary  septic  arthritis.  Typhoid  arthritis  proper  may  be  monarticular  or  poly- 
articular, the  monarticular  form  being  the  most  common,  and  the  hip-joint  being 
the  articulation  most  liable  to  be  attacked.  In  most  cases  tj^hoid  arthritis 
causes  little  pain.  The  swelling  is  marked,  although  in  the  hip  it  is  concealed. 
Pus  rarely  forms.  Keen  calls  attention  to  the  fact  that  in  the  84  cases  of  ty- 
phoid arthritis  which  he  collected  spontaneous  dislocation  occurred  in  43,  nearly 
all  in  the  hip.^  Fluid  from  a  typhoid  joint  may  be  sterile  (bacteria  having 
died),  may  show  mixed  infection,  or  may  give  a  pure  culture  of  typhoid  bacilli 
(A.  G.  ElHs,  in  "Jour,  of  Infectious  Diseases,"  April  i,  1909). 

Treatment. — -A  mild  case  is  treated  as  a  simple  synovitis.  If  diagnostic 
puncture  obtains  fluid  free  from  bacteria,  no  more  radical  method  than  aspira- 
tion and  irrigation  is  required.  If  the  fluid  contains  bacteria,  inject  formalin- 
glycerin.  If  this  fails,  incision  and  drainage  are  demanded.  In  some  cases  an 
autogenous  vaccine  appears  to  be  of  service,  in  others  it  fails  utterly. 

Typhoid  arthritis  may  be  responsible  for  spontaneous  dislocation.  If,  for 
instance,  the  hip  becomes  painful  and  the  limb  assumes  an  abnormal  position, 
weight  extension  should  be  used  and  aspiration  should  be  practised  to  relieve 
effusion  (J.  B.  Murphy,  in  "Surgery,  Gynecology  and  Obstetrics,"  August, 
1916).  If  luxation  has  occurred  Murphy  insists  on  aspiration,  but  reduction 
should  not  be  made  until  well  into  convalescence  and  then  should  be  by  the 
method  Lorenz  teaches  for  congenital  dislocation  (Murphy,  Ibid.).  If  a  luxa- 
tion is  found  in  advanced  convalescence  it  should  be  reduced  promptly. 

Gonorrheal  Arthritis  or  Gonorrheal  Rheumatism. — During  the  progress 
of  gonorrhea  the  development  of  a  painful  joint  does  not  of  necessity  prove 
the  existence  of  gonorrheal  rheumatism,  for  ordinary  rheumatism  is  just  as 
likely  to  arise  when  a  man  has  clap  as  when  he  has  not  this  malady.  Further- 
more, the  term  is  inaccurate,  as  gonorrheal  rheumatism  is  not  rheumatism  at 
all,  but  is  an  infective  disorder  of  the  joints  or  of  the  synovial  membranes,  the 
infective  material  being  contained  primarily  in  the  urethral  discharge.  Gonor- 
rheal arthritis  is  one  of  the  forms  of  infective  arthritis.  Occasionally  this  form 
of  arthritis  arises  from  gonorrheal  ophthalmia  (Heiman's  case);  it  sometimes, 
though  rarely,  arises  during  the  height  of  a  gonorrhea,  but  it  is  more  frequently 
met  with  in  chronic  cases  or  when  the  intensity  of  the  inflammation  is  abating 
in  acute  cases.  Men  suffer  from  gonorrheal  arthritis  far  more  frequently  than 
do  women,  and  the  seizure  is  very  apt  to  recur  again  and  again.  In  some  cases 
many  joints  are  involved,  but  in  most  cases  only  a  few  joints  suffer.  Osier  states 
that  the  knees  and  ankles  are  most  apt  to  be  involved  in  gonorrheal  rheuma- 
tism, and  that  this  form  of  arthritis  is  peculiar  in  often  attacking  joints  that  are 
usually  exempt  in  acute  rheumatism  ("  the  sternoclavicular,  the  intervertebral, 
the  temporomaxillary,  and  the  sacro-ihac  ").  There  are  two  forms  of  gonorrheal 
rheumatism — an  acute  and  a  chronic  form.  The  poison  reaches  the  joint 
by  way  of  the  blood.  In  some  cases  gonococci  are  found  in  the  joint  fluid; 
in  other  cases  they  are  not  found.  I  am  inclined  to  believe  that  in  the  milder 
^  Keen  on  "The  Surgical  Complications  and  Sequels  of  Typhoid  Fever." 


724  Diseases  and  Injuries  of  the  Bones  and  Joints 

cases,  which  recover  without  genuine  pus  formation,  only  toxins  are  present 
in  the  joint.  In  the  severe  cases  the  organisms  themselves  exist  in  the  articu- 
lar fluid.  Osier  suggests  that  the  non-suppurative  cases  are  due  to  the  action 
of  toxins  taken  up  from  the  area  of  primary  infection,  and  that  the  suppura- 
tive cases  are  due  to  infection  with  pyogenic  bacteria.  Endocarditis  may 
occur,  and  it  is  due  to  micro-organisms  and  not  to  toxins. 

Changes  In  and  About  the  Joint. — ^The  inflammation  of  gonorrheal  arthritis 
may  be  located  around  rather  than  in  the  joint,  and  especially  in  the  tendon- 
sheaths.  Suppuration  is  unusual,  but  it  may  occur  in  joints  and  in  tendon- 
sheaths.  Cultures  of  the  exudate  may  or  may  not  show  the  gonococci.  Cover- 
glass  preparations  carefully  stained  may  or  may  not  show  gonococci. 

Symptoms. — The  acute  form  attacks,  as  a  rule,  but  a  single  joint,  but  may 
attack  several  joints.  The  joint  trouble  begins  with  great  suddenness,  and 
is  often  ushered  in  by  chilly  sensations  or  by  a  distinct  chill.  Moderate  fever 
arises.  The  pain  in  the  joint,  severe  from  the  first,  becomes  excruciating. 
If  superficial  joints  suffer,  the  skin  over  them  becomes  red  and  hot,  and  peri- 
articular edema  soon  presents  itself.  The  fluid  in  the  joint  is  in  most  cases  serous, 
but  may  become  purulent.  If  pus  forms,  the  fever  becomes  very  high  and 
chills  may  occur. 

A  chronic  condition  may  follow  the  acute,  but  the  condition  may  be  chronic 
from  the  start.  The  symptoms  resemble  those  of  the  acute  form,  but  are 
far  milder,  although  acute  exacerbations  may  occur.  The  joint  fluid  is  usually 
serous.^  In  gonorrheal  arthritis  there  may  be  transitory,  intermittent,  and 
wandering  pain  in  and  about  the  joint,  without  any  other  symptom;  one  or 
more  joints  may  become  swollen  and  painful,  and  moderate  fever  may  develop. 
One  joint,  especially  the  knee,  may  swell  to  an  enormous  extent,  pain,  peri- 
articular edema,  redness,  and  fever  being  absent  (hydrarthrosis,  or  dropsy 
of  the  joint).  Suppuration  in  this  form  of  the  disease  seldom  occurs.  The  ten- 
dons, the  tendon-sheaths,  the  bursae,  and  the  periosteum  may  inflame. 
Whether  the  joints  are  inflamed  or  not  inflamed,  the  tendon-sheaths  about 
the  wrist  and  ankle  and  the  retrocalcaneal  bursae  may  suffer.  In  some  cases 
numerous  bursse  are  involved.  It  is  often  difficult  and  is  perhaps  impossible 
to  check  gonorrheal  arthritis.  It  may  last  for  a  long  period,  and  tends  to 
recur  again  and  again.  Iritis,  periostitis,  pleuritis,  endocarditis,  and  pericarditis 
have  been  observed  as  complications. 

The  diagnosis  between  gonorrheal  arthritis  and  acute  rheumatism  rests 
chiefly  on  the  great  chronicity,  the  lesser  degree  of  fever,  the  excessive  tend- 
ency to  recurrence,  and  the  absence  of  profuse  acid  sweats  in  gonorrheal 
arthritis;  and  on  the  shorter  course,  the  higher  fever,  the  profuse  acid  sweats, 
the  lesser  tendency  to  rapid  recurrence,  the  greater  proneness  to  symmetrical 
involvement,  and  the  great  liabiUty  to  cardiac  and  visceral  complications  in 
rheumatic  fever.  Furthermore,  in  gonorrheal  arthritis  a  gonorrheal  infection 
(urethral  or  ocular)  certainly  exists  or  recently  existed;  in  ordinary  rheumatism 
a  urethral  discharge  may,  of  course,  happen  to  be  present.  Gonorrheal  arthritis 
is  apt  to  affect  certain  joints  which  acute  rheumatism  seldom  attacks.  Gonor- 
rheal rheun;atism  of  the  spine  comes  on  suddenly,  causes  elevation  of  tempera- 
ture, pain  but  no  tenderness. 

Treatment. — Because  of  the  lingering  character  and  dangerous  nature  of 
gonorrheal  arthritis  and  because  if  unchecked  it  is  liable  to  produce  grave 
impairment  of  function,  treatment  should  be  prompt  and  radical,  as  advocated 
by  Halsted  many  years  ago.  The  joint  should  be  aspirated  and  if  the  fluid 
obtained  contains  gonococci  or  any  pyogenic  bacteria,  formalin-glycerin  should 
be  injected.  If  this  fails,  the  joint  should  be  opened  and  irrigated.  If  pus  is 
absent  and  the  case  not  very  violent,  the  joint  may  be  injected  with  formalin- 
^See  Schuller,  in  "Aertztl.  Pract.,"  No.  17,  1896. 


Pneumococcus  Arthritis  725 

glycerin  and  the  wound  can  be  closed  without  drainage.  If  pus  is  found  by 
incision,  irrigate,  drain,  and  immobihze.  In  cases  free  from  pus  Bier's  treat- 
ment is  of  value  (see  page  122).  Drug  treatment  is  of  Uttle  value  in  gono- 
coccal arthritis.  The  salicylates,  the  alkalis,  and  salol  are  useless;  iron,  arsenic, 
and  strychnin  are  possibly  of  some  benefit.  Quinin  is  thought  to  be  helpful  in 
some  cases.  Large  doses  (i  dram)  of  syrup  of  iodid  of  iron  are  given  by  some 
clinicians,  associated  with  tonic  doses  of  corrosive  sublimate.  Iodid  of  potas- 
sium seems  to  be  of  a  certain  amount  of  value.  The  inflamed  joints  are  usually 
wrapped  in  cotton  and  bandaged,  and  every  day  a  little  blue  ointment  is 
rubbed  into  the  skin  about  them.  If  the  inflammation  lingers,  it  is  customary 
to  use  the  hot-air  oven,  massage,  and  gentle  passive  motion,  to  apply  blisters, 
or  to  counterirritate  with  the  hot  iron.  The  object  in  this  stage  is  to  absorb 
infiltrations  and  adhesions  and  thus  lessen  stiffness.  Early  passive  motion 
allays  reflex  muscular  contractures,  combats  atrophy,  and  prevents  adhesion 
(see  Bier  and  Baetzner,  in  "Practitioner,"  June,  1912).  It  is  thought  by  some 
competent  clinicians  that  antigonococcic  serum  possesses  distinct  value,  greatly 
alleviating  pain  and  favoring  the  restoration  of  joint  mobility.  My  experience 
with  it  is  as  yet  too  insignificant  to  justify  me  in  expressing  an  opinion. 

The  value  of  vaccine  treatment  is  estimated  highly  by  some,  but  many  have 
obtained  no  beneficial  results. 

Arthroplasty  for  ankylosis  caused  by  gonorrheal  rheumatism  is  usually 
followed  by  re-ankylosis  but  sometimes  by  a  flail-joint.  Gonorrheal  ankylosis 
gives  a  worse  prognosis  for  this  operation  than  ankylosis  of  another  origin 
because  of  the  amount  of  exudate  in  the  tissue  about  the  joint.  Operation 
may  be  tried  and  even  if  it  fails  ankylosis  in  a  more  useful  position  may  be  ob- 
tained. Cases  of  anchoring  of  the  patella  give  a  very  good  prognosis  after 
arthroplasty.  Cases  of  ankylosis  of  the  knee  are  very  unfavorable.  A  pain- 
ful partial  ankylosis  calls  for  resection  and  the  creation  of  a  firm,  and  hence 
painless  ankylosis  (see  Okinczyc,  in  "Jour,  de  Chir.,"  1914,  xiii) 

Pneumococcus  Arthritis. — This  is  a  rare  condition,  although  Bulkley  has 
collected  172  cases  from  literature  and  added  one  of  his  own  (''Annals  of  Surgery," 
1914,  lix):  Examination  of  the  blood  may  or  may  not  discover  pneumococci, 
and  pneumococci  may  be  found  in  the  blood  during  pneumonia,  when  the  joints 
are  free  from  disease.  The  inflammation  may  attack  any  joint,  but  is  most 
apt  to  arise  in  a  joint  weakened  by  previous  injury  or  damaged  by  rheumatism 
or  gout.  In  three-fourths  of  the  cases  but  one  joint  suffers.  In  one-fourth  of 
the  cases  the  disease  is  polyarticular.  Infants  are  most  liable.  Alcoholics 
are  prone  to  suffer.  In  a  great  majority  of  cases  the  disease  is  associated  with 
lobar  pneumonia,  but  Cole's  case  proves  that  the  lung  may  be  free  ("American 
Medicine,"  May  31,  1902).  Seventy-five  per  cent,  of  cases  are  associated  with 
pneumonia,  about  93  per  cent,  following  and  7  per  cent,  preceding  the  lung 
lesion  (Bulkley,  Ibid.).  Bulkley  points  out  that  the  most  common  date  of  oc- 
currence is  within  two  weeks  after  the  onset  of  pneumonia.  As  a  rule,  a  single 
large  joint  is  attacked,  and  the  knee  is  most  liable  to  suffer.  The  synovial 
membrane  alone  may  be  involved  or  cartilages  may  suffer  and  bone  may  be 
attacked.  The  fluid  may  be  serous,  but  is  usually  purulent.  I  have  seen  2 
cases :  in  i  case  the  knee  only  was  involved;  in  the  other,  both  knees,  one  elbow, 
and  one  shoulder  were  attacked.  In  Cole's  series  of  41  cases,  13  exhibited 
involvement  of  more  than  one  joint.  The  inflamed  joint  is  frequently  com- 
pletely destroyed.  Pneumococcus  arthritis  develops,  as  a  rule,  soon  after  the 
crisis  of  pneumonia,  but  Herrick  says  it  may  arise  as  late  as  three  weeks  after 
the  crisis. 

The  diagnosis  is  made  by  the  history  of  pneumonia,  the  development  of 
septic  symptoms,  and  the  signs  of  joint  inflammation.  It  is  confirmed  by 
aspiration  and  examination  of  the  fluid.  The  disease  is  very  fatal.  In  Her- 
rick's  series  of  cases  over  65  per  cent,  were  fatal  ("Am.  Jour.  Med.  Sciences," 


726  Diseases  and  Injuries  of  the  Bones  and  Joints 

July,  1902).  In  Cole's  series  of  cases  there  were  28  deaths  and  13  recoveries. 
Even  if  the  patient  recovers,  the  convalescence  is  prolonged  and  more  or  less 
ankylosis  is  to  be  expected. 

Treatment. — A  non-purulent  effusion  may  be  treated  by  aspiration  if  bacteria 
are  not  found  in  the  fluid.  If  the  aspirated  fluid  contains  bacteria,  formalin- 
glycerin  is  injected.  If  this  fails,  or  if  pus  is  present,  the  joint  should  be  opened 
and  drained. 

Syphilitic  Arthritis. — (See  pages  376  and  380.) 

Acute  Rheumatic  Arthritis;  Rheumatic  Fever  or  Acute  Rheumatism. — 
Acute  rheumatism  is  a  self-limited  febrile  malady  whose  characteristic  features 
are  polyarthritis,  profuse  acid  sweats,  and  a  tendency  to  heart  involvement. 
There  is  some  evidence  to  indicate  that  acute  rheumatism  is  a  form  of  infective 
arthritis,  the  bacteria  being  deposited  in  the  synovial  tissues  and  later  perhaps 
entering  into  the  joint  cavity.  Arthritis  of  many  joints  has  followed  intraven- 
ous injection  into  animals  of  diplococci  obtained  from  the  throat  of  a  man  suf- 
fering from  rheumatic  angina  (Poynton  and  Paine  at  Manchester  meeting  of  the 
"Brit.  Med.  Assoc,"  1902).  Rosenau  in  14  out  of  16  cases  of  acute  rheumatism 
was  able  to  isolate  organisms  from  joint  fluid,  in  4  out  of  7  cases  from  the  blood 
and  in  2  cases  from  the  stools.  These  organisms  were  similar  to  those  described 
by  Payne  and  Poynton  (Rosenau,  in  "Illinois  Med.  Jour.,"  1914,  xxv).  When 
the  virulence  of  these  bacteria  is  in  different  stages  they  produce  different  effects 
when  injected  into  animals.  In  one  stage  of  virulence  they  produce  endo- 
carditis, arthritis,  and  fever.  In  another  stage  they  cause  myositis.  John 
O'Conor^  believes  that  acute  rheumatism  is  a  condition  "something  similar  to 
gonorrheal  arthritis  and  pyemia,  the  germ  or  toxin  gaining  admission  to  the 
body  through  the  tonsil  or  other  microbic  trap-door,  and  that  the  joint  inva- 
sion is  promptly  followed  by  a  form  of  infective  arthritis  accompanied  with 
general  toxemia;  and,  furthermore,  the  infected  joints  serve  as  incubators, 
where  the  poison  is  elaborated  and  passed  into  the  circulation  and  thus  con- 
veyed to  other  articulations  and  to  the  heart." 

Symptoms  of  Acute  Rheumatism.. — In  acute  rheumatism  the  case  begins  with 
malaise  and  fever,  and  one  or  more  joints  become  affected.  The  inflam- 
mation spreads  from  joint  to  joint,  is  apt  to  be  symmetrical,  and  when 
it  arises  in  fresh  joints,  usually  disappears  quickly  in  those  previously  affected. 
The  temperature  is  high,  the  skin  sweats  copiously,  the  joints  are  red,  swollen, 
hot,  and  excruciatingly  painful,  and  the  structures  about  the  joints  are  edema- 
tous. After  a  short  time  the  inflammation  subsides  in  one  joint  and  passes 
into  another,  the  joint  first  attacked  regaining  its  functions.  Suppuration 
does  not  take  place.  Anemia  is  pronounced,  exhaustion  is  profound,  the 
sweat  is  sour,  the  saliva  is  acid;  the  urine  is  acid,  scanty,  high  colored,  often 
contains  albumin,  and  is  deficient  in  chlorids.  Cardiac  disease  is  apt  to  be 
produced  (endocarditis,  pericarditis,  or  myocarditis).  Nodules  may  form 
upon  fibrous  structures,  hyperpyrexia  is  not  unusual,  and  cerebral  or  pulmonary 
complications  may  occur. 

The  treatment  of  acute  rheumatism  comprises  the  use  of  alkalis,  salic- 
ylates, etc.  (See  a  book  upon  practice  of  medicine.)  O'Conor  is  a  believer 
in  incising  and  draining  the  inflamed  joints;  and  if  the  theory  of  an  infective 
origin  is  correct,  this  treatment  is  rational.  I  have  never  ventured  to  do  it, 
but  would  consider  the  advisability  of  doing  so  if  the  ordinary  treatment 
proved  futile.  O'Conor  operates  early  and  believes  that  this  is  the  real  way  to 
arrest  the  disease  and  prevent  complications,  but  his  views  have  not  met  with 
general  acceptance. - 

Chronic  rheumatism  sometimes  follows  repeated  attacks  of  acute  rheuma- 
tism, but  oftener  arises  insidiously  in  people  who  have  been  exposed  to  cold 
and  damp,  who  have  suffered  from  poverty,  hardship,  and  privation,  or  have 
■^  "Lancet,"  Jan.  24,  1903.  -  Ibid. 


Osteo-arthritis  727 

had  much  worry.  The  capsule  and  tendon-sheaths  thicken,  and  there  is  usu- 
ally but  little  effusion  into  the  joint,  but  the  articulation  becomes  stiff  and  pain^ 
ful.     The  joint-cartilages  are  occasionally  eroded.     Muscular  atrophy  occurs. 

Symptoms  of  Chronic  Rheumatism. — In  chronic  rheumatism  the  affected 
joints  are  stiff  and  painful  and  are  a  little  swollen,  but  not  red.  Dampness 
and  cold  aggravate  the  symptoms.  One  joint  or  many  may  be  affected,  but 
usually  several  are  involved.  Passive  movements  cause  the  joint  to  creak  and 
develop  crepitus  in  the  tendon-sheaths.  The  muscles  are  wasted.  Anemia 
is  usually  pronounced.  The  smaller  blood-vessels  become  surrounded  by 
fibrous  tissue  which  progressively  contracts  and  lessens  the  blood-supply  of 
the  synovial  structures.  The  joints  may  ankylose.  There  is  no  fever  and  no 
tendency  to  suppuration,  and  the  disease  is  incurable. 

Treatment. — In  chronic  rheumatism  maintain  the  general  health  of  the 
patient,  give  courses  of  iron,  arsenic,  and  strychnin,  and  an  occasional  course 
of  iodid  of  potassium  or  a  salt  of  lithium,  and,  if  possible,  send  him  every  winter 
to  a  warm  climate.  Turkish  baths  give  considerable  temporary  relief.  The 
waters  and  regimen  of  Carlsbad  and  Vichy  are  of  positive  though  temporary 
benefit,  and  the  sufferer  may  obtain  relief  at  the  hot  springs  of  Virginia.  The 
patient  must  avoid  damp  and  must  wear  woolens.  Frictions,  the  douche, 
massage,  flying  blisters,  counterirritation  with  the  hot  iron,  ichthyol  ointment, 
and  mercurial  ointment  are  of  benefit.  Subjecting  the  diseased  joint  to  a  very 
high  temperature  by  placing  it  daily  in  a  hot-air  apparatus  often  does  great 
good.  The  pains  of  chronic  rheumatism  may  be  greatly  benefited  by  the  plan 
communicated  to  me  by  Dr.  J.  T.  Rugh.  He  makes  a  mixture  of  14  min. 
of  glycerin,  14  min.  of  sterile  water,  and  i  gr.  of  crystallized  carbolic  acid.  This 
is  injected  at  two  points,  about  the  articulation  and  in  the  extracapsular  struc- 
tures. As  soon  as  an  injection  has  been  made  the  area  must  be  vigorously  rubbed 
to  diffuse  the  fluid  and  prevent  sloughing.  The  joint  must  be  kept  at  rest  for 
three  days.  Injections  can  be  repeated  at  intervals  of  five  days.  In  partial 
ankylosis  it  is  proper  in  some  cases  to  give  ether  and  break  up  the  adhesions. 

Gouty  arthritis,  which  appears  especially  in  the  smaller  joints  (as  the 
fingers  and  the  metatarsophalangeal  joints  of  the  great  toes),  is  due  to  a 
deposition  of  urate  of  sodium  in  the  joint  and  in  the  periarticular  structures. 
The  irritant  urate  of  sodium  causes  inflammation,  inflammation  leads  to  the 
formation  of  granulation  tissue,  granulation  tissue  is  converted  into  fibrous  tis- 
sue, and  the  fibrous  tissue  contracts  and  thus  deforms  the  joint  and  limits  its 
molaility.     A  great  mass  of  urates  clinging  to  a  joint  constitutes  a  chalk-stone. 

Symptoms. — The  premonitory  symptoms  may  be  observed  for  a  day  or 
so,  but  the  acute  seizure  usually  occurs  early  in  the  morning,  the  patient, 
as  a  rule,  being  aroused  by  excruciating  pain  in  the  metatarsophalangeal 
articulation  of  one  of  the  great  toes.  The  joint  swells,  and  the  skin  over  it 
feels  hot  to  the  touch  and  becomes  red  and  shiny.  There  is  often  consider- 
able fever.  After  a  few  hours  the  intensity  of  the  seizure  abates,  only  to  recur 
again  with  renewed  violence  early  the  next  morning,  these  remissions  and 
recurrences  taking  place  during  six  or  eight  days,  until  the  attack  subsides. 
In  patients  wdth  chronic  gout  many  joints  are  stiffened  and  deformed  as  a  result 
of  repeated  attacks.  Chalk-stones  form,  and  the  skin  above  them  may  ulcer- 
ate. Such  patients  are  chronic  dyspeptics,  have  high-tension  pulses,  their 
hearts  are  hypertrophied,  and  their  urine  contains  albumin  and  casts. 

The  treatment  of  gouty  arthritis  belongs  to  the  physician,  and  not  to  the 
surgeon,  although  to  the  latter  the  symptoms  of  the  disease  should  be  known, 
so  that  it  may  be  diagnosticated  from  other  maladies. 

Osteo-arthritis  {Rheumatoid  Arthritis;  Arthritis  Deformans;  Rheumatic 
Gout). — In  this  disease,  which  is  not  a  combination  of  gout  and  rheumatism, 
the  synovial  membrane  and  cartilages  are  affected,  the  periarticular  struc- 
tures are  involved,  and  masses  of  new  bone  are  formed. 


728  Diseases  and  Injuries  of  the  Bones  and  Joints 

Osteo-arthritis  possibly  has  in  certain  cases,  as  John  K.  Mitchell  long  ago 
pointed  out,  a  nervous  origin.  It  arises  especially  in  persons  who  have  been 
worried,  driven,  and  harassed.  There  is  apt  to  be  muscular  atrophy,  trophic 
lesions  of  the  hair  and  nails  are  likely  to  appear,  and  the  symptoms  are  disposed 
to  be  symmetrical.  The  causative  lesion  has  not  been  determined.  The  con- 
dition is  now  generally  regarded  as  of  toxic  origin.  The  suspected  cause  is 
streptococcic  infection  (Payne  and  Poynton,  quoted  by  Rosenau,  in  Illinois  Med. 
Jour.,  1 91 4,  xxv).  The  foci  of  infection  may  lie  in  any  part  of  the  body,  but  are 
most  frequent  in  the  teeth,  tonsil,  accessory  sinuses  of  the  nose  and  nasopharynx, 
the  middle  ear,  the  bronchial  glands,  the  mesenteric  glands,  and  the  intestines, 
especially  the  large  intestine.  The  disease  is  commoner  in  women  than  in  men. 
The  greatest  liability  exists  between  the  ages  of  twenty  and  forty,  but  children 
may  acquire  the  disease,  and  it  may  also  be  developed  in  people  far  beyond 
middle  life.  Apes  in  captivity  may  develop  it.  Arthritis  deformans  may 
attack  the  rich  or  the  poor;  it  does  not  result  from  gout,  nor  does  it  often  follow 
rheumatism;  it  is  not  caused  by  damp  and  cold,  and  only  in  rare  cases  does  it 
arise  after  traumatism  of  a  joint. 

Osteo-arthritis  differs  from  gout  in  the  entire  absence  of  urate  deposit, 
and  it  differs  from  chronic  rheumatism  in  the  extensive  alterations  in  the 
joint  structures.  The  changes  begin  in  the  cartilage;  the  cartilage-cells 
multiply,  the  intercellular  substance  degenerates,  the  pressure  of  the  bone 
causes  thinning,  and  at  length  the  cartilage  is  entirely  destroyed  and  the  bone 
exposed.  The  exposed  bone  is  altered  in  shape,  is  hardened,  and  is  worn  away 
in  the  center,  the  periphery  increasing  in  thickness  by  ossific  deposit,  the  center 
deepening  by  absorption.  The  margins  are  not  only  thickened,  but  are  bulged 
and  lengthened  by  deposit.  The  fringes  of  the  synovial  membrane  hyper- 
trophy and  multiply,  and  some  of  them  are  apt  to  break  off  {loose  cartilages). 
Muscular  atrophy  arises  and  contractures  occur.  It  is  usually  taught  that  these 
are  due  to  nerve  influence.  It  seems  probable  that  they  are  caused  by  myositis 
(Billings,  in  "Illinois  Med.  Jour.,"  1914,  xxv).  The  capsule  and  the  liga- 
ments of  the  joints,  as  a  rule,  become  fibrous  and  contract;  but  they  may 
soften,  relax,  and  permit  of  dislocation.  The  joint  usually  contains  no 
effusion,  but  in  some  cases  there  is  great  effusion  {hydrarthrosis).  The  tendons 
about  the  joint  may  become  fibrous  and  contracted,  they  may  ossify,  they 
may  be  separated  from  the  bone,  or  they  may  be  destroyed  entirely. 
Deformity  is  marked  and  motion  is  limited.  The  fingers,  when  involved,  show 
nodules  on  the  sides  of  the  joints  (Heberden's  nodules).  The  vertebrae  may 
be  involved.     Almost  all  the  joints  may  suffer.     Suppuration  does  not  occur. 

Symptoms. — Charcot  divides  osteo-arthritis  into  three  forms,  and  gives 
their  symptoms,  as  follows: 

1.  Heberden's  nodosities,  which  are  commoner  in  women  than  in  men,  usually 
begin  between  the  ages  of  thirty  and  forty,  and  are  especially  common  in 
neurotic  subjects.  The  interphalangeal  joints  become  the  victims  of  attacks 
of  moderate  swelling  and  of  some  tenderness,  and  these  attacks  are  not 
severe,  but  recur  again  and  again.  After  a  time  small  hard  swellings  (no- 
dosities) appear  upon  the  sides  of  the  dorsal  surface  of  the  second  and  third 
phalanges,  remain  permanently,  and  slowly  increase  in  size.  The  joints 
become  stiff  and  creak  on  movement,  the  cartilages  are  destroyed,  and  con- 
tractions and  rigidity  develop,  but  there  is  no  fever  and  the  larger  joints  are 
not  involved.     The  malady  is  incurable. 

2.  Progressive  rheumatic  gout,  which  may  be  acute  or  chronic.  The  acute 
form  begins  as  does  rheumatic  fever.  There  are  moderate  fever  and  swelling, 
without  redness,  of  a  number  of  joints,  of  bursae,  and  of  tendon-sheaths;  the 
joints  are  stiff  and  crepitate,  and  are  apt  to  be  symmetrically  involved;  niuscular 
atrophy  begins  early  and  rapidly  becomes  decided;  pain  is  slight.  This  acute 
form  is  apt  to  arise  in  young  women  after  pregnancy,  but  is  not  unusual  at 


Osteo-arthritis  or  Partial  Rheumatic   Gout  of  the  Hip-joint     729 

the  cHmacteric  and  in  children.  Anemia  always  exists.  The  case  is  apt  to 
advance  progressively  until  a  number  of  joints  are  firmly  locked,  when  it  may 
become  stationary.  Another  pregnancy  will  develop  anew  the  acute  symptoms. 
In  the  chronic  form  swelling  and  pain  on  movement  are  noted  in  certain  joints. 
The  involvement  is  apt  to  be  symmetrical.  Attacks  of  swelling  and  pain  alter- 
nate with  periods  of  apparent  quiescence,  but  the  disease  does  not  cease  its 
advance.  Articulation  after  articulation  is  attacked  by  the  malady  until 
almost  all  the  joints  are  involved;  deformity  and  stiffness  become  pronounced, 
and  pain  may  or  may  not  be  severe.  There  is  no  fever.  Muscular  atrophy 
is  marked. 

3.  Partial  rheumatic  gout  or  monarticular  rheumatism  attacks  one  articu- 
lation, and  it  is  most  often  met  with  in  old  men.  It  may  fix  itself  on  the  verte- 
bral column,  on  the  knee,  on  the  shoulder,  on  the  elbow,  or  on  the  hip.  The 
joint  grates  and  becomes  stiff,  swollen,  and  deformed;  the  muscles  atrophy; 
there  is  usually  pain,  but  fever  is  absent. 

StilVs  disease  is  a  form  of  arthritis  deformans  in  which  the  spleen  enlarges 
greatly  and  in  which  the  joint  changes  cause  permanent  disability  early  in  the 
case. 

Osteo-arthritis  or  partial  rheumatic  gout  of  the  hip-joint  seldom  occurs 
before  the  age  of  forty-five,  but  is  occasionally,  though  very  rarely,  met  with 
in  persons  under  twenty-five.  If  the  disease  arises  in  an  elderly  person,  it 
is  often  called  morbus  coxce  senilis.  In  some  cases  the  hip-joint  only  is  attacked; 
in  many  cases  other  joints  are  also  diseased.  Osteo-arthritis  of  the  hip  may 
follow  an  injury.  Usually  the  disease  is  unconnected  with  traumatism,  be- 
gins very  gradually,  and  advances  slowly.  There  is  pain,  often  mistaken 
for  sciatica,  in  and  about  the  joint,  and  there  is  increasing  stiffness.  The  pain 
and  stiffness  are  worse  when  the  patient  first  moves  after  resting.  Lameness 
becomes  noticeable,  and  grating  can  be  detected  in  and  about  the  joint.  The 
symptoms  become  gradually  worse,  although  at  times  they  may  seem  to  im- 
prove for  brief  periods.  The  lameness  and  the  stiffness  are  greatly  aggravated, 
and  the  pain  becomes  very  severe,  even  when  at  rest.  Shortening  takes  place, 
the  great  trochanter  ascends  above  Nelaton's  line,  the  limb  is  usually  abducted, 
but  in  very  rare  cases  is  adducted,  and  finally  ankylosis  occurs. 

Partial  rheumatic  gout  of  the  vertebral  articulations  causing  fixation  is 
called  spondylitis  deformans  (see  page  955). 

Treatment. — Osteo-arthritis  cannot  be  cured,  but  in  some  cases  it  remains 
stationary  for  many  years.  I  have  seen  one  case  apparently  arrested  by  re- 
moval of  a  diseased  appendix.  Diseased  tonsils  should  be  removed.  Billings 
(Ibid.)  has  cultures  grown  from  them  and  from  the  cultures  obtains  autogenous 
vaccines.  It  is  claimed  by  some  that  Lane's  operation  of  extirpation  of  the  large 
intestine  may  arrest  it.  Bottomley  (''Jour.  Am.  Med.  Assoc,"  Sept.  9,  1916) 
believes  that  in  all  cases  the  operation  has  some  beneficial  influence,  but  that 
it  is  disappointing.  If  an  intestinal  cause  is  suspected  the  operation  is  justifi- 
able but  if  we  are  to  obtain  benefit  it  must  be  done  early.  In  far  advanced 
cases  it  can  do  material  good.  Bottomley  thinks  the  risks  and  uncertainties 
should  be  set  forth  to  the  patient.  The  same  surgeon  prefers  colectomy  to 
ileosigmoidostomy  in  spite  of  the  greater  risk  of  the  former  procedure.  As  yet 
I  would  not  feel  justified  in  recommending  a  theoretical  operation  with  the 
idea  of  directly  benefiting  osteo-arthritis.  I  would,  however,  remove  if  possi- 
ble, any  obvious  area  of  infection.  The  usual  plan  of  medical  procedure  is 
to  treat  the  anemia  by  iron,  arsenic,  nourishing  food,  and  have  the  patient 
out  in  the  fresh  air  as  much  as  possible.  Debility  is  met  by  the  adminis- 
tration of  strychnin.  Hot  baths  of  mineral  water  do  good.  It  is  claimed 
that  the  hot-air  apparatus  is  of  service.  Douches  improve  these  cases,  but 
electricity  is  useless.  Counterirritants  are  usually  regarded  as  useless.  I  am 
sure  that  bHsters  and  the  actual  cautery  are  sometimes  of  benefit.     Injection 


730 


Diseases  and    Injuries  of  the   Hones  and  Joints 


of  2  per  cent,  formalin  in  olive  oil  followed  by  immol^ilization  for  2  to  8 
weeks  may  prove  of  service  (Porter,  m  "Am.  Jour.  Orthoi)edic  Surg.,"  191 5,  xii). 
Massage  retards  the  progress  of  the  case,  relieves  the  pain,  aids  in  the  absorption 
of  effusion,  and  delays  tixation.  During  an  acute  exacerbation  the  joint  should 
be  put  at  rest  for  a  time  and  evaporating  lotions  ap])hed  for  a  few  hours.  In 
an  exacerbation  in  disease  of  the  hip  the  patient  should  be  put  to  bed  and  have 
extension  applied.  The  patient  is,  unfortunately,  liable  to  develop  the  opium- 
habit.  If  dropsy  of  a  joint  arises,  try  compression  by  Martin's  bandage,  and, 
if  this  fails,  aspirate  and  wash  out  the  joint  with  a  2  per  cent,  solution  of  carbolic 
acid.  Patients  with  rheumatic  gout  do  best  in  a  warm,  dry  climate.  Cod- 
liver  oil  does  good,  as  it  improves  nutrition  and  hence  retards  the  progress  of  the 
disease.  Do  not  be  tempted  to  immobilize  the  joints  in  an  early  case  beyond 
a  dav  or  two:  fixation  only  hastens  ankylosis.     Howard  Marsh'  maintains  that, 

as  a  rule,  but  httle  good  comes 
from  manipulation.  He  makes 
the  following  exceptions;  when 
one  joint  only  is  affected;  when 
the  joint  is  very  stiff  but  not 
very  painful;  when  the  patient 
is  in  good  general  health  and 
is  not  beyond  middle  age.  If 
ankylosis  is  inevitable  the  sur- 
geon should  endeavor  to  have 
it  take  place  in  the  position  of 
greatest  usefulness.  If  only  one 
joint  is  involved  it  may  be  proper 
to  produce  ankylosis  by  oper- 
ation. When  ankylosis  occurs 
all  symptoms  subside.  Albee 
describes  an  operation  for  osteo- 
arthritis of  the  hip-joint.  He 
removes  a  thin  layer  from  the 
top  of  the  head  of  the  femur 
and  a  similar  amount  of  bone 
from  the  roof  of  the  acetabulum.  The  two  surfaces  are  held  in  contact  until 
union  occurs.  In  the  knee-joint  Hibbs  bridges  the  front  part  of  the  joint  with 
the  denuded  patella. 

After  ankylosis  osteotomy  may  be  advisable  to  correct  deformity.  In  chil- 
dren the  deformity  can  usually  be  corrected  by  manipulation.  After  ankylosis 
arthroplasty  may  be  advisable,  fascia,  fat,  muscle,  or  chromicized  pig's  bladder 
being  interposed  between  the  bony  surfaces.  The  best  results  are  in  the  elbow 
and  hip.  Knee  cases  are  not  satisfactory.  Jones  ("Brit.  Med.  Jour.,"  19 14, 
ii)  says  that  arthroplasty  is  contraindicated  in  children,  if  there  is  active 
disease,  in  cases  in  which  the  muscles  have  been  destroyed  or  if  scar  tissue  about 
the  joint  would  put  the  flaps  in  danger. 

Trophic  Joint  Affections  {Arthropathies). — It  is  well  known  that  certain 
diseases  and  injuries  of  brain,  cord,  and  nerves  may  be  responsible  for  arthritic 
changes  (hemiplegia,  injury  of  the  cord,  locomotor  ataxia,  neuritis). 

From  three  to  six  weeks  after  an  apoplexy  the  joints  of  the  palsied  side  are 
apt  to  suffer  from  inflammation.  The  condition  following  apoplexy  is  one  of 
synovitis.  Any  joint  may  suffer,  but  the  hip  seldom  does.  A  well-known 
arthropathy  is  Charcot's  joint  (Figs.  449,  450). 

Osteochondritis  Dissecans.— This  disease  of  the  knee  was  first  described  by 
Koenig  in  1888.     It  is  one  of  the  causes  of  foreign  bodies  in  a  joint.     It  follows 
a  single  severe  traumatism  or  many  acts  of  slight  traumatism,  usually  occupa- 
'  "Diseases  of  the  Joints  and  Spine." 


Fig.  449. — Charcot's  joint. 


Charcot's  Disease 


731 


tional,  brought  about  by  kneeUng  (Brackctt  and  Hall,  in  "Amer.  Jour,  of  Ortho- 
pedic Surg.,"  Feb.,  1917).  If  a  violent  traumatism  causes  it  the  symptoms  of 
the  disease  begin  after  the  acute  symptoms  of  the  injury  clear  up.  The  ordi- 
nary case  which  follows  repeated  and  trivial  traumatisms  comes  on  gradually 
with  weakness  and  sHght  disabihty  but  no  pain.  After  a  time  the  joint  begins 
to  catch  or  perhaps  lock  as  it  does  in  an  ordinary  case  of  joint-mice.  The  catch- 
ing suggests  the  squeezing  of  a  synovial  fringe.  The  locking  is  not  followed  by 
anything  like  the  customary  amount  of  synovitis  and  disability  which  are 
apt  to  follow  locking  in  the 
ordinary  case  of  movable 
cartilage,  and  there  is  a  rapid 
return  to  the  usual  functional 
level.  The  a:-rays  show  an 
area  of  bone  defect  on  the 
outer  part  of  the  internal 
condyle  and  perhaps  mov- 
able bodies  in  the  anterior 
chamber  of  the  joint.  There 
is  no  osteo-arthritis.  Ex- 
ploration through  a  median 
patella  incision  proves  the 
absence  of  general  arthritis 
and  discloses  irregular  eleva- 
tions of  thinned  and  frayed 
cartilage  to  the  outer  side  of 
the  inner  condyle  near  the 
attachment  of  the  posterior 
crucial  ligament,  a  depression 
in  the  condyle,  and  cartilage 
hanging  or  separated  (Brack- 
ett  and  Hall,  Ibid.).  The 
nature  of  the  lesion  has  been 
much  disputed.  Ludloff 
("Archiv  f .  klin  Chir.,"  1908, 
Bd.  Ixxvii)  says  the  exfolia- 
tion of  the  cartilage  is  due 
to  trauma  occluding  a  ter- 
minal artery.  Brackett  is 
convinced  that  traumatism 
is  causal.  A  median  patella 
incision ,  permits  free  exposure 
of  the  anterior  chamber  of  the 
joint  and  removal  of  a  loose 
or  a  partially  separated  cartilage.  This  operation  is  followed  by  cure  with 
little  or  no  impairment  of  function. 

Charcot's  disease  {Tabetic  Arthropathy;  Charcot's  Joint;  Neuropathic  Ar- 
thritis).— This  condition  is  an  osteo-arthritis  due  to  trophic  disturbance,  arising 
in  a  sufferer  from  locomotor  ataxia,  and  is  anatomically  identical  with  osteo- 
arthritis, which  was  described  above.  The  knee  is  most  apt  to  be  attacked,  and 
the  hip  suffers  more  often  than  any  joint  but  the  knee.  The  condition  may  de- 
velop in  the  shoulder  or  elbow.  The  smaller  joints  sometimes,  though  seldom, 
are  involved.  More  than  one  joint  may  suffer.  Vertebral  arthropathy  has 
been  observed.  Ochsner  ("Practical  Medicine  Series,"  vol.  i,  1917)  sets  forth 
the  joints  selected  by  the  disease  in  947  cases:  Knee,  394;  hip,  210;  shoulder, 
128;  foot,  89;  ankle,  50;  elbow,  39;  hand,  16;  jaw,  2;  various,  19.  The  disease 
in  most  cases  begins  acutely,  often  as  a  sudden  effusion,  which  after  a  time  may 


Fig.  450. — Charcot's  joint. 


732  Diseases  and  Injuries  of  the  Bones  and  Joints 

disappear.  In  most  cases,  however,  the  joint  becomes  rapidly  disorganized. 
The  sweUing  is  usually  very  marked  and  is  sometimes  enormous.  In  the  earliest 
stages  it  is  due  to  periarticular  edema  and  to  articular  effusion.  Pain  is  slight 
or  is  absent,  there  is  no  constitutional  involvement,  and  the  condition  is  un- 
connected with  injury.  Some  cases  begin  without  this  preliminary  acute  swell- 
ing, disorganization  being  manifest  from  the  beginning.  When  disorganization 
has  once  begun,  it  continues  inexorably.  Bony  masses  form  around  the  articular 
ca\'ity,  in  the  ligaments,  and  in  the  cartilages.  The  bones  and  cartilages  are 
rapidly  destroyed  and  absorbed;  fracture  is  apt  to  occur;  the  joint  creaks  and 
grates;  the  softening  and  relaxation  of  the  ligaments  permit  an  extensive  range 
of  movement;  great  deformity  ensues;  dislocation  is  apt  to  occur;  muscular  atro- 
phy is  decided,  and  pus  occasionally,  though  very  rarely,  forms.  There  is  some- 
times, but  seldom,  repair.  Charcot's  joint  differs  from  rheumatoid  arthritis  in 
the  usual  acute  onset  and  the  painless  course.  The  complete  or  nearly  complete 
freedom  from  pain  is  one  of  the  most  striking  features  of  the  condition.  In  say- 
ing there  is  freedom  from  pain  we  mean  freedom  from  pain  in  the  joint,  from 
the  pain  and  tenderness  in  the  regions  in  which  we  expect  to  find  them  in  an 
inflamed  joint.  Usually  these  patients,  though  free  from  pain  in  the  joint, 
suffer  much  from  the  lightning  pains  of  locomotor  ataxia.  Gastric  crises  are 
not  uncommon  (Bramwell).  The  Wassermann  reaction  is  usually  positive. 
Charcot's  joint  is  more  common  in  female  than  in  male  tabetics.  In  saying 
that  Charcot's  joint  is  often  of  sudden  origin,  we  mean  that  in  a  single  night, 
as  Charcot  pointed  out,  swelling  of  a  joint  may  arise.  In  a  day  or  two  the 
joint  swelling  becomes  great,  and  if  aspiration  is  performed,  yellow  serum  is 
obtained.     In  a  week  or  two  the  joint  begins  to  creak  on  movement. 

The  treatment  of  Charcot's  disease  consists  in  the  wearing  of  an  appa- 
ratus to  sustain  the  joint.  Resection  is  recommended  by  some,  but  most 
surgeons  do  not  adxdse  its  performance.  Southam  advocates  amputation  for 
certain  cases  of  Charcot's  joint.  He  has  performed  the  operation  on  4  patients. 
He  amputated  twice  for  ankle-joint  disease  and  twice  for  disease  of  the  tarsus. 
In  every  case  the  stumps  healed  quickly  and  without  suppuration.  Southam 
was  led  to  perform  amputation  on  his  first  case  by  the  report  of  Jonathan 
Hutchinson's  case  of  amputation  of  the  leg  for  perforating  ulcer  and  disease  of 
the  bones  of  the  foot  in  a  tabetic. 

Osteo-arthropathie  Hypertrophiante  Pneumique  {Marie's  Disease). — A  con- 
dition associated  with,  and  possible  springing  from,  pulmonary  disease,  and 
characterized  by  widespread  enlargement  of  joints,  thickening  of  the  finger- 
ends,  and  the  formation  of  a  dorsolumbar  kyphosis.  The  joints  are  painful, 
the  skin  undergoes  pigmentation,  and  profuse  perspiration  is  often  present. 
The  head  entirely  escapes  in  this  disease,  and  this  immunity  marks  a  distinction 
from  acromegaly.  The  disease  is  probably  a  toxemia  caused  by  a  focus  of 
tissue  destruction  especially  if  the  focus  be  purulent,  but  it  may  be  due  to  al- 
teration of  bodily  metabolism.  (Oilman  in  "Edin.  Med.  Jour.,"  1914,  xii). 

Hysterical  joint  {Brodie's  joint)  is  a  condition  mostly  encountered  in  young 
women.  The  disease  occurs  most  commonly  in  the  knee  and  the  hip,  and 
often  follows  a  sUght  injury  which  acts  as  an  autosuggestion,  a  latent 
hysteria  being  awakened  into  action  and  localized,  though  severity  of  the 
injury  does  not  determine  the  severity  of  the  symptoms.  The  disease  may 
ensue  upon  syno\dtis  or  arthritis,  or  may  arise  without  apparent  cause.  The 
patient  complains  of  pain  in  and  stiffness  of  the  joint,  resists  passive  motion 
strenuously,  and  claims  that  it  causes  much  pain.  There  is  occasionally  some 
muscular  atrophy  from  want  of  use,  and  the  joint  is  a  little  swollen.  The 
skin  is  hyperesthetic,  and  a  light  touch  causes  more  pain  than  does  deep 
pressure.  The  muscles  may  be  rigid.  The  joint  may  be  maintained  either 
in  flexion  or  in  extension,  but  it  is  rarely  in  the  exact  degree  of  flexion  assumed 
for  ease  in  a  true  joint  inflammation,  and  the  position  is  apt  to  be  changed 


Neuralgia  of  a  Joint  733 

from  day  to  day  or  from  hour  to  hour.  The  skin  is  usually  pale  and  cool, 
but  may  be  red  and  hot,  because  of  hyperemia.  A  periodically  developed 
heat  may  be  observed,  especially  at  night,  accompanied  apparently  by  much 
pain.  The  alleged  pain  in  some  cases  is  neuralgia,  but  in  most  cases  is  a  pain 
hallucination.  There  is  no  effusion  into  the  joint,  and  swelling  does  not  exist, 
although  occasionally  there  is  slight  periarticular  edema.  In  some  rare  cases 
organic  disease  arises  in  a  hysterical  joint. 

Hysterical  phenomena  are  seldom  isolated,  but  are  associated  with  certain 
stigmata  which  may  be  latent.  These  stigmata,  some  of  which  may  be  absent, 
are  concentric  contraction  of  the  visual  fields,  pharyngeal  anesthesia,  con- 
vulsions, hysterogenic  zones,  globus  hystericus,  clavicus  hystericus,  zones  of 
anesthesia,  especially  hemianesthesia,  and  hyperesthetic  areas.  Such  patients 
are  predisposed  by  inheritance,  and  have  had  previously,  as  a  rule,  nervous 
troubles.  Hysterical  phenomena,  be  it  remembered,  lack  regularity  of  evolution, 
and  are  produced,  altered,  or  abolished  by  mental  influences  and  physical 
sensations  which  are  without  effect  in  causing,  modifying,  or  curing  organic 
disease.  The  general  health,  as  a  rule,  is  good,  but  neurasthenia  may  coexist. 
In  examining  these  patients  the  observer  will  note  that  the  symptoms  disappear 
when  the  attention  is  diverted;  that  they  are  out  of  all  proportion  to  the  local 
evidences  of  disease;  that  there  is  no  sign  of  joint  destruction,  and  that  a  light 
touch  may  cause  more  pain  than  does  firm  pressure.  If  the  patient  is  anesthet- 
ized, perfect  joint  mobility  will  be  found  without  any  evidences  during  move- 
ments of  joint  changes. 

The  treatment  for  a  hysterical  joint  comprises  attention  to  the  general  health, 
the  employment  of  nourishing  and  easily  digested  food,  the  prevention  of 
constipation,  and  the  administration  of  tonics  if  they  are  needed.  The  surgeon 
must  dominate  his  patient's  mind  and  make  her  realize  that  he  is  master  of  the 
case.  He  is  to  be  an  inexorable  but  just  ruler — never  a  brutal  or  a  cruel  one. 
If  possible,  send  the  patient  away  from  the  harmful  sympathies  of  her  home 
and  let  her  have  the  rest  treatment  of  S.  Weir  Mitchell.  Local  remedies 
applied  to  the  joint  do  harm,  as  a  rule,  by  concentrating  afresh  the  patient's 
attention  upon  the  articulation,  although  the  hot  iron  sometimes  does  good. 
Suggestion  in  the  hypnotic  state  may  be  tried.  The  use  of  morphin  should  be 
avoided  as  being  the  worst  of  enemies.  Never  immobilize  the  joint,  and  always 
use  massage,  passive  motions,  and  frictions. 

Neuralgia  of  a  joint  as  an  independent,  isolated  affection  is  extremely 
rare,  though  as  a  complication  of  other  diseases  it  is  by  no  means  uncommon. 
Neuralgia  is  more  common  outside  of  the  joints  than  in  them,  and  periar- 
ticular neuralgia  is  especially  frequent  about  the  knee  and  the  ankle.  Joint- 
neuralgia  may  arise  in  any  person,  but  it  is  more  commonly  present  in  young 
neurotic  females.  The  pain  may  be  persistent,  or  it  may  occur  in  periodic 
storms,  and  it  is  often  associated  with  neuralgia  in  other  parts.  The  pain 
may  be  dull  and  aching,  but  it  is  more  often  sharp  and  shooting.  Joint-neu- 
ralgia is  associated  with  tenderness  on  pressure,  soreness  on  motion,  often 
with  transitory  swelling  without  redness,  and  sometimes  with  numbness  of  the 
extremities.  The  diagnosis  depends  on  the  temperament  of  the  patient,  the 
sudden  onset  of  the  pain,  the  absence  of  constitutional  symptoms,  and  the 
free  mobility  of  the  joint,  especially  under  ether.  Articular  neuralgia  may 
depend  upon  disease  or  injury  of  the  central  nervous  system,  upon  malaria, 
syphilis,  neurasthenia,  rheumatism,  gout,  hysteria,  or  neuritis,  and  may  be 
due  to  reflected  irritation,  especially  from  the  ovaries,  the  uterus,  or  the 
rectum. 

The  treatment  to  be  observed  in  joint-neuralgia  is  to  maintain  the  general 
health.  Examine  for  a  possible  exciting  cause,  and,  if  found,  remove  it.  Give 
a  long  course  of  iron,  quinin,  strychnin  or  arsenic.  In  rheumatic  or  gouty 
subjects  administer  suitable  drugs  and  insist  upon  the  use  of  a  proper  diet. 


734  Diseases  and   Injuries  of  the  Bones  and  J(jints 

During  the  attack  use  phenacctin.  Morphin  nuisL  occasionally  be  given  in 
severe  cases,  but  be  sparing  of  it,  and  ne\er  tell  the  patient  she  is  taking 
it,  as  there  is  a  possibility  of  her  forming  the  opium-habit.  Locally,  employ 
frictions,  ointment  of  aconite,  heat,  and  keej)  u])on  the  part  a  piece  of  flannel 
soaked  in  a  mixture  of  soap  liniment,  laudanum,  and  chloroform  (Gross). 
Never  allow  the  joint  to  stiffen;  any  tendency  to  stiffness  should  be  met  by 
daily  massage,  frictions,  passive  motion,  and  hot  and  cold  douches.  In  some 
rare  cases  nerve-stretching  or  neurectomy  becomes  necessary. 

Articular  Wounds  and  Injuries. — A  penetrating  wound  is  very  serious, 
and  it  may  be  due  to  a  compound  fracture,  to  a  compound  dislocation,  to  a 
gunshot- wound,  or  to  a  stab.  If  a  bursa  near  a  joint  be  opened,  secondary 
penetration  may  occur  as  a  result  of  suppuration.  In  a  penetrating  wound, 
besides  pain,  hemorrhage,  and  swelling  there  is  a  flow  of  synovial  fluid.  A 
small  amount  of  synovia  flows  from  an  injured  bursa,  a  large  amount  from  an 
open  joint. 

Treatment. — If  a  joint  is  opened  aseptically  (as  when  incised  by  the  sur- 
geon) the  wound  heals  nicely  under  rest  and  asepsis.  If  a  joint  is  opened 
by  a  septic  body,  suppurative  arthritis  is  apt  to  arise,  and  the  surgeon  en- 
deavors to  prevent  it  by  antisepticizing  the  surface,  irrigating  the  joint,  draining, 
applying  antiseptic  dressing,  and  securing  rest.  Normal  salt  solution  is  the 
best  agent  for  irrigation,  as  it  does  not  injure  joint  endothelium.  Active 
antiseptics  may  lessen  tissue  resistance,  and  thus  may  actually  favor  infection. 
In  gunshot-wounds  inflicted  by  pistol  bullets  or  sporting  rifle  bullets,  if  anti- 
sepsis is  not  employed,  suppuration  is  inevitable;  hence  mihtary  surgeons 
in  the  past,  as  a  rule,  have  advocated  amputation  or  excision  in  gunshot- 
splinterings  of  large  joints.  We  now  know  that  the  wound  of  a  large  joint 
produced  by  a  hard-jacketed  and  small-caliber  bullet  may  heal  with  little 
trouble.  This  statement  is  true  in  open  fighting.  It  is  not  true  in  trench 
fighting.  If  we  are  able  to  regard  the  wound  as  probably  aseptic  the  surface 
is  sterilized,  and  usually  the  wound  is  enlarged,  the  finger  is  introduced  to  dis- 
cover and  remove  foreign  bodies,  through-and-through  drainage  is  secured, 
a  tube  is  inserted,  the  joint  is  irrigated,  antiseptic  dressings  are  applied,  and 
the  extremity  is  placed  upon  a  spHnt.  In  trench  warfare  every  joint  wound 
is  regarded  as  infected,  be  it  bullet  wound  (with  or  without  fracture),  shrapnel 
wound,  or  wound  by  a  shell  fragment.  At  the  front  the  skin  about  the  wound 
or  wounds  is  painted  with  iodin,  a  field  dressing  is  applied,  the  part  is  immobil- 
ized, and  the  patient  is  taken  to  the  rear  as  soon  as  possible.  Radical  opera- 
tion should  be  done  at  the  first  possible  minute.  It  is  done  at  the  field  hospital, 
the  evacuation  hospital,  or  the  base  hospital  in  accordance  with  grim  military 
necessities. 

In  many  cases  the  track  of  the  wound  is  moistened  with  iodin,  the  wound  is 
excised  to  the  joint  capsule,  or  synovial  membrane,  the  projectile  if  lodged,  is 
removed,  bone  fragments  loose  or  hanging  are  taken  away,  the  joint  is  irrigated 
with  salt  solution,  the  wound  is  sutured  (a  drainage-tube  being  inserted  down 
to  the  synovial  membrane),  dressings  are  applied  and  the  part  is  immobilized. 
If  in  spite  of  this  treatment  infection  occurs,  or  if  pus  exists  when  operation  is 
performed,  make  free  incisions  and  use  continuous  irrigation  or  Dakin's  fluid. 
In  severe  wounds  arthrotomy,  the  usual  operation  in  civil  practice,  is  usually  a 
failure,  and  is  employed  only  when  a  missile  is  not  retained  or  when  it  is  well 
within  reach.  When  it  is  done  the  synovial  membrane  should  be  removed 
(Taddei).  The  Carrel  treatment  is  most  disappointing.  When  the  articular 
head  is  damaged  a  partial  resection  is  performed  by  many,  but  a  typical  sub- 
periosteal resection  is  usually  the  preferable  procedure,  and  drainage  should  be 
secured  (Taddei  in  "Chir.  d.  organ  di  mov.,"  Bologna,  1918,  ii). 

After  operation  the  limb  should  be  mobilized.  Place  the  parts  in  the 
position  indicated  by  Jones  (pages  642  and  674). 


Sprains  73^ 

^  If  the  temperature  mounts  and  suppuration  persists,  especially  if  albu- 
minuria develops,  amputate  (Taddei,  Ibid.). 

In  some  cases  it  is  necessary  to  remove  considerable  bone.  Very  severe 
joint  injuries  demand  resection  or  even  amputation.  Ankylosis,  more  or  less 
complete,  often  follows  a  gunshot-wound  of  a  joint.  Because  of  the  likelihood 
of  ankylosis  Robt.  Jones  lays  down  rules  for  the  best  position  in  which  to 
dress  each  joint  ("Brit.  Med.  Jour.,"  1916, 1). 

They  are  as  follows: 

1.  Shoulder-joint:  Arm  abducted  to  50°.  Elbow  shghtly  in  front  of  body's 
coronal  plane.  When  forearm  is  in  supination  and  elbow  at  right  angles  the 
palm  looks  toward  the  face. 

2.  Elbow-joint:  Fixation  at  100°.  If  both  elbows  have  been  wounded  fix 
one  at  80°  and  the  other  at  100°. 

3.  Wrist-joint:  In  dorsiflexion. 

4.  Hip-joint:  Very  slight  abduction,  extension  of  thigh  and  a  little  external 
rotation. 

5.  Knee-joint:  Extension  and  fixation. 

6.  Ankle-joint:  Foot  at  right  angles  to  leg,  sole  in  position  of  shght  varus. 
If  the  joint  suppurates,  the  drainage  must  be  made  more  free,  sinuses  must 

be  slit  up  and  packed,  sloughs  must  be  cut  away,  dead  bone  must  be  gouged 
out,  and  the  patient  must  be  placed  upon  a  stimulant  and  tonic  plan  of  treat- 
ment. A  plan  found  to  be  valuable  is  the  introduction  of  a  drainage-tube 
into  the  subcrural  pouch  and  placing  the  patient  prone  (Kellogg  Speed,  in 
"Jour.  Am.  Med.  Assoc,"  March  30,  1918). 

Sprains. — A  sprain  is  a  joint-wrench  due  to  a  sudden  twist  or  traction,  the 
ligaments  being  pulled  upon  or  lacerated  and  the  surrounding  parts  being  more 
or  less  damaged.  A  sprain  is  often  a  self-reduced  dislocation  (Douglas  Gra- 
ham). The  joints  most  Hable  to  sprains  are  the  knee,  the  elbow,  the  wrist,  and 
the  ankle.  The  smaller  joints  are  also  often  sprained,  but  the  ball-and-socket 
joints  are  infrequently  sprained,  their  normal  range  of  free  movement  saving 
them;  they  do  occasionally  suffer  severely,  however,  as  a  result  of  abduction. 
In  a  severe  sprain  the  ligaments  are  torn;  the  synovial  membrane  is  contused  or 
crushed;  cartilages  are  loosened  or  separated;  hemorrhage  takes  place  into  and 
about  the  joint;  muscles  and  tendons  are  stretched,  displaced,  or  lacerated; 
vessels  and  nerves  are  damaged;  the  skin  is  often  contused;  and  portions  of 
bone  or  cartilage  may  be  detached  from  their  proper  habitat,  though  still 
adhering  to  a  ligament  or  tendon  (sprain  fractures).  Very  often  a  case  is 
diagnosed  as  a  mere  sprain  when  a  fracture  also  exists.  The  wrist  is  a  common 
seat  of  such  a  lesion.  Ross  and  Wilbert  ("Amer.  Med.,"  Jan.  25,  1902)  caution 
us  to  remember  that  when  a  patient  comes  to  us  a  week  or  ten  days  after  an 
accident,  displaying  "a  wrist  which  is  much  swollen  and  rather  painful,"  all 
ordinary  remedies  having  failed,  we  should  suspect  a  fracture  of  "  one  or  more  of 
the  bones  of  that  joint,"  This  article  of  Ross  and  Wilbert  is  very  valuable  and 
considers  so-called  sprains  in  various  regions.  George  Ross  and  L.  F.  Stewart 
("Annals  of  Surgery,"  Oct.,  1912)  believe  that  all  dislocations  are  "permitted  by 
the  primary  occurrence  of  sprain  fracture,"  the  bony  tissues  giving  way  more 
easily  than  tendons  or  ligaments.  This  article  is  a  comprehensive  study  of 
sprain-fracture.  Sprains  are  commonest  in  young  persons  and  in  adults  with 
weak  muscles.  They  happen  from  sudden  twists  and  movements  when  the 
muscles  are  relaxed.  A  large  part  of  the  support  of  joints  comes  from  muscles, 
and  when  muscles  are  suddenly  caught  unawares  they  do  not  properly  support 
the  joint,  and  a  sprain  results.  A  joint  once  sprained  is  very  liable  to  a  repeti- 
tion of  the  damage  from  slight  force.  Sprains  are  common  in  a  limb  with 
weak  muscles,  in  a  deformed  extremity  in  which  the  muscles  act  in  unnatural 
lines,  and  in  a  joint  with  relaxed  ligaments. 

Symptoms. — There   is  severe  pain  in  the  joint,  accompanied  by  general 


736  Diseases  and  Injuries  of  the  Bones  and  Joints 

weakness.  Nausea,  vomiLing,  and  even  s>Ticope  may  occur.  There  is  im- 
pairment or  loss  of  abiUty  to  move  the  joint.  The  above-described  condition 
is  succeeded  by  a  season  of  reUef  from  pain  while  at  rest,  numbness  being  com- 
plained of,  and  pain  on  motion  being  severe.  Swelling  arises  very  early  if 
much  blood  is  effused.  In  any  case  swelling  begins  in  a  few  hours.  Extensive 
effusion,  by  separating  joint  surfaces,  produces  slight  lengthening  of  the  limb. 
Movements  of  the  joint  become  difficult  or  impossible;  the  tear  in  the  ligament 
may  sometimes  be  distinctly  detected  by  the  examining  fingers;  pain  and  ten- 
derness become  intense;  joint-crepitus  will  be  manifested,  and  in  a  day  or  two 
discoloration  becomes  marked.  Moullin  and  others  have  pointed  out  that 
when  a  muscle  is  strained  the  skin  above  it  becomes  sensitive,  especially  at 
tendinous  insertions  over  joints.  As  muscles  are  invariably  strained  when  a 
joint  is  sprained,  there  is  always  some  cutaneous  tenderness.  There  is  also 
tenderness  over  a  sprained  joint  due  to  capsular  injury,  bands  of  adhesions,  etc. 
Tenderness  is  apt  to  arise  at  certain  reasonably  fixed  points:  in  a  hip-joint 
injury  it  is  found  behind  the  great  trochanter,  in  a  knee-joint  injury  by  the 
side  of  the  patella,  in  an  ankle-joint  injury  to  the  inner  side  of  the  external 
malleolus  (Gulp).  When  the  vertebral  articulations  are  sprained  the  muscles 
of  the  back  are  rigid,  the  skin  is  often  sensitive,  pain  may  be  awakened  by  pres- 
sure or  by  certain  movements,  but  there  is  no  sign  of  cord  injury  in  an  uncom- 
plicated case. 

Diagnosis  and  Prognosis. — Sprain-fractures  can  be  diagnosticated  with 
certainty  by  the  .\--rays  only.  In  the  diagnosis  of  a  sprain,  fracture  and  dis- 
location must  be  considered.  In  fracture,  crepitus  and  mobility  exist;  in  dis- 
location, rigidity.  The  diagnosis  of  sprain  should  be  made  by  a  consideration 
of  the  joint  involved,  of  the  age,  of  the  nature  of  the  force,  of  the  length  of  the 
limb,  of  the  fact  that  the  patient  could  use  the  joint  for  at  least  a  short  time  after 
the  accident,  and  of  the  local  feel  and  movements  of  the  part.  In  some  cases 
examine  under  ether,  in  some  apply  the  x-rays.  Many  injuries  about  the  ankle 
which  we  would  have  formerly  regarded  as  sprains,  are  shown  by  the  .r-rays 
to  be  fractures.  The  prognosis  depends  on  the  size  of  the  joint,  on  the  ex- 
tent of  laceration,  on  the  amount  of  intra-articular  hemorrhage,  and  on  the 
age  of  the  patient.  The  danger  is  ankylosis.  A  sprained  joint  is  a  point 
of  least  resistance  to  tubercle  bacilU.  In  rare  cases  after  a  sprain  of  the  hip- 
joint  osteo-arthritis  arises.  In  some  few  cases  after  a  sprain  of  the  hip  the 
head  of  the  bone  undergoes  absorption. 

Treatment. — In  a  mild  sprain  apply  at  once  a  sihcate,  rubber  plaster,  or 
plaster-of-Paris  dressing.  The  first  indication  after  the  infliction  of  a  severe 
sprain  is  to  arrest  hemorrhage  and  limit  inflammation.  For  the  first  few  hours 
apply  pressure  and  an  ice-bag.  Wrap  the  joint  in  absorbent  cotton  wet  with 
iced  water,  apply  a  wet  gauze  bandage,  and  put  on  an  ice-bag.  After  some 
hours  place  the  extremity  upon  a  spHnt  and  to  the  joint  apply  flannel  kept 
wet  with  lead-water  and  laudanum,  iced  water,  alcohol  and  water,  or  a  solution 
of  chlorid  of  ammonium.  These  evaporating  lotions  produce  cold.  Instead 
of  them  an  ice-bag  may  be  used  for  a  day.  Leeches  around  the  joint  do 
good.  Constitutionally,  employ  the  remedies  for  inflammation.  Morphin  or 
Dover's  powder  is  given  for  the  pain.  Judicious  bandaging  Umits  the 
swelling. 

After  twenty-four  hours,  if  the  symptoms  continue  or  if  they  grow  worse, 
use  hot  fomentations,  the  hot-water  bag,  plunge  the  extremity  frequently  in  very 
hot  water,  or  apply  heat  by  Leiter's  tubes.  When  the  acute  symptoms  begin 
to  subside  rub  stimulating  liniments  upon  the  joint  once  or  twice  a  day  and 
employ  firm  compression  by  means  of  a  bandage  of  flannel  or  rubber.  Fric- 
tions should  be  made  from  the  periphery  toward  the  body.  Many  cases  do 
well  at  this  stage  under  the  local  use  of  ichthyol  and  lanolin  (50  per  cent.), 
tincture  of  iodin,  or  blue  ointment.     Later  in  the  case  use  hot  and  cold  douches, 


Schlatter's  Disease  737 

massage,  frictions,  passive  motion,  and  the  bandage.  Passive  motion  and 
massage  are  begun  a  day  or  so  after  swelling  ceases.  If  they  cause  the  swelHng 
to  return,  abandon  them  for  several  days  and  then  try  them  again.  BHsters 
are  used  when  tender  spots  persist  and  stiffness  is  manifest.  If  stiffness  becomes 
marked,  move  the  joint  forcibly.  Give  iodid  of  potassium  and  tonics  inter- 
nally, and  insist  on  open-air  exercise.  If  the  person  is  gouty  or  rheumatic, 
use  appropriate  remedies.  Van  Arsdale  treats  sprains  by  massage  almost  from 
the  start.  Gibney  treats  them  by  strapping  with  adhesive  plaster.  Gibney's 
dressing  is  of  great  service  in  a  sprain  of  the  ankle  (Figs.  451  and  452).  Many 
sprains  may  be  put  up  in  an  immovable  dressing  the  first  day  or  two  after  the 
accident.  If  the  joint  contains  much  blood,  aspiration  should  be  practised 
before  the  dressing  is  applied. 

The  hot-air  oven  is  a  very  valuable  method  for  treating  recent  sprains,  and 
the  swelling,  pain,  and  stiffness  which  follow  sprains  of  the  extremities.  The 
sprained  extremity  is  placed  in  an  oven,  and  the  part  is  subjected  to  heat  for  an 
hour.  The  next  day  the  treatment  is  repeated,  and  on  as  many  subsequent 
days  as  may  be  necessary.     In  an  acute  sprain  the  pain  often  disappears  during 


Fig.  451.  Fig.  452. 

Figs.  451,  452. — Gibney's  method  of  strapping  in  sprains  of  the  ankle. 

the  first  application  of  heat.     In  the  intervals  between  the  use  of  the  oven  the 
extremity  should  be  at  rest,  perhaps  upon  a  spUnt. 

Schlatter's  Sprain  (Schlatter's  Disease.  Osgood-Schlatter  Disease). — 
This  condition  of  partial  functional  incapacity  is  due  to  thickening,  separation 
or  partial  separation  of  the  tibial  tuberosity.  Some  think  the  condition  is  due  to 
inflammation,  others  that  it  is  a  dystrophy.  In  view  of  the  fact  that  many 
cases  are  bilateral,  and  that  other  muscular  and  ligamentous  insertions  may  show 
periosteal  thickening,  the  view  that  the  condition  is  systemic  would  seem  probable, 
the  systemic  trouble  being  manifested  by  weakening  of  connective  tissues  and 
thickening  of  periosteum.  That  attention  is  usually  called  to  this  condition  by 
traumatism  is  certain.  For  instance,  in  a  reported  case  a  boy  threw  a  stone 
and  fell  to  the  ground  because  of  a  disabling  pain  in  the  right  knee.  He  walked 
home  but  the  pain  and  partial  disabihty  continued.  A  month  later  examination 
made  clear  that  there  was  swelling  over  the  tuberosity  of  the  tibia  and  great 
tenderness  of  the  tuberosity,  but  neither  ecchymosis  nor  crepitus.  The  x-rays 
showed  that  a  small  fragment  of  bone  had  been  partially  torn  off.  In  such  a 
case  we  would  infer  that  a  sprain-fracture  had  occurred  in  the  diseased  area 
(Costa's  case.  See  "Abstract  of  Surgery,"  Jan.,  1917). 
47 


73^  Diseases  and  Injuries  of  the  Bones  and  Joints 

Some  suggest  that  the  bone  trouble  is  due  to  staphylococcic  infection. 
Perhaps  Basseta's  view  of  the  condition  is  that  pull  by  the  ligament  of  the 
patella  causes  chronic  irritation  and  excessive  ossification  ("Arch,  di  ortop.," 
1913.     See  "Abstract  of  Surgery,"  June,  1914). 

R.  Connell  ("Practitioner,"  1914,  xciii)  believes  that  Schlatter's  sprain  is  a 
purely  traumatic  condition,  most  common  in  those  under  seventeen  years  of 
age,  and  predisposed  to  by  imperfect  union  of  the  tibial  tubercle. 

In  some  marked  cases  the  tubercle  should  be  nailed  in  place.  In  partiid 
separation  treatment  by  a  posterior  si)lint  is  indicated. 

Sprain  of  the  Sacro=iliac  Articulation. ^ — This  condition  was  first 
described  by  Goldthwait.  A  fall,  lifting  a  heavy  weight,  a  blow,  or  a  twist 
may  injure  the  articulation.  Normally  slight  motion  is  possible  at  the  joint. 
Rupture  or  stretching  of  ligaments  may  lead  to  increased  motion,  and  any  con- 
siderable range  of  motion  at  the  synchondrosis  means  lack  of  solidity  and  want 
of  support.  A  sprain  may  arise  from  long-continued  standing,  bending,  lying, 
or  sitting.  A  sprain  of  this  articulation  may  be  caused  by  parturition,  and  also, 
as  shown  by  Dunlop,  it  may  develop  during  anesthesia  because  of  obliteration 
of  the  normal  lumbar  curve  by  lying  on  a  flat  table  without  a  support  under  the 
lumbar  region  ("  New  York  Med.  Jour.,"  July  10, 1909).  Dunlop  thus  explains, 
and  I  think  truly,  the  severe  backache  which  is  so  common  after  anesthesia. 

A  sprain  causes  severe  pain,  greatly  aggravated  by  standing,  by  rising  up 
from  recumbency,  by  movements  of  the  ilia  which  jar  the  joint,  and  frequently 
by  direct  pressure  upon  the  synchondrosis.  There  is  often  lateral  spinal  curva- 
ture due  to  spasm,  and  the  concavity  is  toward  the  injured  side. 

There  is  pain  in  the  injured  articulation,  but  there  may  be  a  general  back- 
ache, and,  just  as  in  sacro-iliac  tuberculosis  (see  page  710),  there  maybe  pain 
in  the  sciatic  nerve,  in  the  groin,  and  in  the  hip-joint. 

When  some  of  the  sacro-iliac  ligaments  are  ruptured  or  relaxed  we  get  the 
chronic  condition  described  by  John  Dunlop  (Ibid.)  and  which  he  calls  sacro- 
iliac relaxation.  When  this  exists  the  individual  may  injure  the  articulation 
again  and  again  because  of  its  unsteadiness,  he  may  now  and  then  have  trouble,' 
he  may  be  in  a  constant  condition  of  helplessness,  with  backache,  groinache, 
pain  in  the  hip  and  over  the  ischial  tuberosity,  lumbar  rigidity  producing  lateral 
curvature,  etc.     I  believe  in  the  reality  of  the  condition. 

Treatment. — A  recent  sprain  is  treated  by  rest  in  bed  and  adhesive-plas- 
ter strapping,  reinforced  by  a  canvas  roller  around  the  pelvis.  In  a  chronic 
case  (sacro-iliac  relaxation),  after  securing  by  manipulation  normal  relations 
in  the  articulation,  insist  on  rest  and  apply  a  spica  bandage  of  plaster  of  Paris 
or  a  brace.  If  there  is  marked  tendency  to  displacement,  ankylosis  may  be 
secured  by  operation.  Fixation  by  a  bone-graft  from  the  tibia  should  give  the 
most  rapid  and  permanent  result. 

Rupture  of  the  Crucial  Ligaments  of  the  Knee. — This  is  a  rare  injury. 
Rupture  of  both  ligaments  is  unusual  except  in  very  grave  injury,  such  as 
complete  dislocation,  and  then  other  ligaments  are  also  torn  or  destroyed. 

The  anterior  crucial  ligament  instead  of  rupturing  from  force  may  cause 
avulsion  of  the  tibial  spine  (see  page  695).  A  bit  of  bone  may  be  torn  from  a 
femoral  condyle.  In  most  cases  the  x-rays  show  small  bits  of  separated  bone. 
When  a  portion  of  bone  is  not  torn  off,  the  ligament  itself  tears  ofif  from  the 
femur  rather  than  from  the  tibia.  Bits  of  cartilage  may  be  torn  off.  The 
posterior  ligament,  too,  tends  to  tear  off  from  femur  rather  than  tibia.  Pagen- 
stecher  ("Deutsch.  Med.  Wochenschrift,"  Bd.  xxix)  believes  that  the  anterior 
ligament  may  be  ruptured  by  forced  flexion  of  the  knee  and  by  blows  applied 
to  the  posterior  part  of  the  head  of  the  tibia  when  the  knee  is  flexed.  The 
same  surgeon  maintains  that  the  posterior  ligament  may  be  ruptured  by  blows 
applied  to  the  front  of  the  head  of  the  tibia  when  the  knee  is  flexed.  Pringle 
("Annals  of  Surgery,"  August,   1907)   maintains  that  the  anterior  ligament 


Diagnosis  of  Bony  Ankylosis  739 

may  be  ruptured  by  "flexion,  abduction,  and  internal  rotation  of  the  leg  at 
the  knee."  If  the  ligaments  are  ruptured  there  will  probably  be  abnormal 
freedom  of  anteroposterior  movement  between  the  femur  and  tibia. 

Pringle  (Ibid.)  states  that  if,  after  an  injury,  the  knee-joint  becomes  dis- 
tended 'with  blood,  the  inference  should  be  that  one  or  other  crucial  Hgament 
has  been  injured  or  that  the  tibial  spine  has  been  torn  off,  unless  some  other 
lesion  is  obviously  present;  that  if  internal  rotation  of  the  extended  leg  is  possible 
at  the  knee,  or  if  the  head  of  the  tibia  can  be  brought  forward  on  the  femur, 
or  if  there  is  unnatural  abduction,  the  indications  are  that  the  anterior  crucial 
ligament  has  been  injured  or  the  tibial  spine  torn  ofT;  that  injury  of  the  pos- 
terior crucial  is  suggested  by  the  possibiUty  of  pushing  the  head'  of  the  tibia 
backward  during  flexion  of  the  knee-joint. 

The  condition  causes  great  disability,  pain  and  muscular  weakness.  In  many 
cases  exploratory  incision  is  required  to  make  the  diagnosis. 

The  treatment  is  to  open  the  joint,  remove  loose  bone  and  cartilage  and 
suture  the  torn  ligament.  Disability,  pain  and  weakness  to  a  considerable 
degree  may  persist  ofter  operation. 

Ankylosis. — When  a  joint-inflammation  eventuates  in  the  formation  of 
new  tissue  in  and  about  the  joint,  contraction  of  this  tissue  limits  or  destroys 
joint  mobility,  producing  the  condition  known  as  "ankylosis."  Ankylosis  may 
be  complete  (bony)  or  incomplete  (fibrous);  it  may  arise  from  contractures  in 
the  joint  {true  or  ititra-articiilar  ankylosis)  or  from  contractures  in  the  struc- 
tures external  to  the  joint  {false  or  exfra-artictdar  ankylosis). 

There  are  qualifying  terms  to  indicate  the  extent  of  stiffness — viz.,  false, 
spurious,  true,  bony,  ligamentous,  partial,  complete,  or  incomplete  ankylosis. 
The  significance  of  the  above  terms  will  be  better  appreciated  if  ankylosis  is 
considered  as  meaning  a  stiff  joint.  It  may  be  stiff  without  being  rigid. 
Fibrous  adhesions  produce  stiff  joints  and  they  become  rigid  only  when  bony 
union  takes  place  between  the  bones  forming  a  joint. 

Spondylitis  deformans  is  bony  ankylosis  of  vertebrae  due  to  osteo-arthritis. 

Arthritis  ossificans  is  a  progressive  bony  ankylosis  in  which  numerous  joints 
are  involved  and  are  finally  completely  obliterated.     It  is  an  ossifying  arthritis. 

Etiology. — There  are  various  causes — viz.,  traumatism,  eruptive  fevers 
resulting  in  acute  or  suppurative  synovitis  or  arthritis,  gonorrheal  arthritis, 
tuberculous  arthritis,  syphiUtic  affections  of  joints,  bony  fixation  when  a 
fracture  is  near  or  extends  into  a  joint,  and  osteitis  deformans.  Simple  fixa- 
tion of  an  uninflamed  joint  cannot  cause  true  ankylosis. 

Pathology. — In  complete — i.  e.,  bony — ankylosis  the  bones  forming  a  joint 
become  united  by  callus  in  much  the  same  manner  as  bone-fragments  are 
united  after  a  fracture,  or  osseous  bridging  takes  place  at  one  or  more  places 
around  the  joint.  Osseous  ankylosis  is  preceded  by  a  more  or  less  prolonged 
stage  of  fibrous  or  partial  ankylosis.  In  fibrous  ankylosis,  bands  of  fibrous 
connective  tissue  unite  the  bones  forming  a  joint,  thereby  limiting  the  motion. 
In  cases  of  joint  stiffness  produced  by  extra-articular  fibrous,  tendinous,  or 
cicatricial  contracture  the  joint  proper  remains  free  from  adhesions  for  years, 
provided  it  is  not  and  has  not  been  involved  in  inflammatory  action. 

Diagnosis  of  bony  ankylosis  is  usually  made  without  difficulty  except  where 
there  are  several  joints  near  together,  as  the  carpus,  tarsus,  and  the  spine. 
When  there  are  several  joints  near  together  the  limitation  of  motion  in  one 
joint  is  generally  compensated  for  by  the  excess  in  mobility  of  another,  thereby 
rendering  the  associated  parts  capable  of  closely  approaching  normal  function. 
Fibrous  ankylosis  is  more  difficult  to  recognize,  especially  if  pain  accompanies 
manipulative  measures.  It  is  most  apt  to  be  confused  with  fibrous,  liga- 
mentous, or  cicatricial  contractures  of  soft  parts  outside  of  a  joint,  but  having 
more  or  less  direct  functional  relations  therewith. 

Extra-articular  thickening  may  usually  be  detected  by   the  existence   of 


740  Diseases  and  Injuries  of  the  Bones  and  Joints 

resistance  to  free  joint  motion  in  one  direction  only,  i.  e.,  that  produced  by  the 
fibrous  contracture  while  the  joint  moves  freely  in  other  directions.  Muscular 
contracture,  whether  voluntary  or  involuntary,  is  but  temporary,  and  is  easily 
detected  by  the  preternatural  rigidity  of  surrounding  parts.  In  bony  ankylosis 
no  voluntary  muscular  action  can  be  detected,  inasmuch  as  in  the  process  of 
the  formation  of  the  callus  uniting  the  bones  the  muscles  have  become  atro- 
phied from  disuse.  Conversely,  voluntary  muscle  action  about  a  joint  always 
indicates  that  joint  mobility  is  not  entirely  destroyed. 

As  muscular  rigidity  is  one  of  the  most  important  and  reliable  symptoms  of 
joint  inflammation  and  tuberculous  invasion,  it  is  a  serious  error  to  anesthetize 
a  patient  for  examination  of  a  joint  until  the  full  significance  of  the  muscular 
action  has  been  carefully  studied. 

Anesthesia  removes  the  pain  and  abolishes  muscle  fixation  and  thus  leaves 
the  unguarded  joint  free  for  manipulative  movements,  which  are  generally 
prejudicial  and  rarely  beneficial.  Where  no  muscle  fixation  is  present,  much 
may  be  learned  by  the  careful  study  of  a  joint  while  the  patient  is  anesthetized. 
We  thus  determine  the  character  of  the  adhesions,  whether  they  are  extra- 
articular or  intra-articular,  whether  they  are  fibrous,  cicatricial,  or  osseous,  and 
if  bony  union  exists,  whether  it  involves  the  entire  joint  or  only  a  portion  of  it. 

Skiagraphs  are  invaluable  helps  in  making  an  accurate  diagnosis,  espe- 
cially when  stereoscopic  plates  are  made.  Definite  information  can  thus  be 
obtained  as  to  the  character  of  the  uniting  material,  its  extent,  and  definite 
location.  Positive  information  will  be  given  as  to  the  relationship  of  the  bones 
composing  the  joint,  whether  there  is  luxation,  subluxation,  flexion,  or  other 
abnormal  position  that  may  influence  decision  as  to  the  therapeutic  measures 
to  be  adopted.  It  is  important  to  remember  that  a  joint  very  rarely  becomes 
ankylosed  in  the  position  of  extension  (the  elbow  may  if  treated  in  extension  for 
intra-articular  fracture) .  The  almost  invariable  rule  is  that  flexion  is  the  posture 
of  such  joints,  and  the  tendency  is  toward  increase  of  the  flexion  until  bony 
ankvlosis  occurs.  In  the  steady  progress  of  the  flexion  subluxation  is  apt  to  be 
induced. 

Treatment  of  Intra-articular  Ankylosis. — It  is  most  important  to  prevent 
the  occurrence  of  ankylosis,  or  in  the  event  of  its  becoming  inevitable,  to  avoid 
postures  that  will  render  the  parts  unfit  for  future  usefulness  when  ankylosed. 

The  most  useful  position  for  a  stiff  joint  is  a  matter  of  individual  opinion; 
no  definite  rules  have  been  accepted.  In  ankylosis  of  the  elbow  the  flexed  posi- 
tion is  more  useful  in  certain  occupations  than  the  fully  extended  arm.  In 
other  occupations  the  extended  arm  is  most  useful.  In  walking  when  the 
knee  is  ankylosed  and  does  not  tend  toward  flexion  the  extended  leg  is  more 
useful  than  the  flexed  leg,  but  it  is  more  difficult  to  manage  when  sitting. 

The  hip,  when  ankylosed  at  various  angles,  is  made  useful  by  the  increased 
latitude  of  motion  of  the  other  hip  and  by  the  compensatory  motion  of  the  lum- 
bar spine.  To  such  an  extent  is  the  lower  spine  reciprocal  when  one  or  both 
hips  are  abnormal  that  it  has  been  termed  the  third  hip-joint.  For  general 
usefulness  the  best  position  for  an  ankylosed  hip  is  lo  to  15  degrees  of  flexion, 
10  to  15  degrees  of  abduction,  and  5  degrees  of  external  rotation.  In  this  posi- 
tion, when  supplemented  by  reciprocal  action  of  the  other  hip  and  by  the  lower 
spine,  a  gait  very  closely  approaching  normal  carriage  may  be  obtained  in 
walking,  and  the  sitting  posture  may  be  possible. 

Each  individual  joint  has  its  own  peculiar  requirement  and  must  become  a 
subject  for  careful  study  in  determining  the  most  useful  posture  if  ankylosis 
is  to  be  permanent.  The  trend  of  modern  surgery  is  to  reduce  greatly  the  time 
of  fixation  of  a  fractured  bone  in  order  to  avoid  joint  stiffness  and  prevent 
muscular  wasting.  Early  passive  motion  when  judiciously  employed  does  not 
interfere  with  the  efficient  treatment  of  a  fracture,  but  does  lessen  the  joint 
stiffness  that  is  often  a  serious  and  painful  sequel. 


Treatment  of  Intra-artic:ular  Ankylosis  741 

Stereo-arthrolysis  "is  that  branch  of  arthroplasty  whose  object  is  to  loosen 
stifiF  joints  and  produce  new  joints  with  mobility,  following  ankylosis"  (R. 
Tunstall  Taylor,  "Surgery,  Gynecology,  and  Obstetrics,"  April,  191 2). 

Brisenient  force  or  redressement  are  terms  applied  to  the  use  of  such  manipu- 
lative force  as  the  surgeon  can  judiciously  employ  in  freeing  a  joint  from 
fibrous  adhesions.  It  is  important  to  keep  constantly  in  mind  the  danger  of 
breaking  the  shaft  of  a  bone  or  of  separating  the  epiphysis  when  unguarded 
leverage  of  the  entire  shaft  of  the  bone  is  used.  It  is  of  paramount  importance 
to  avoid  brisement  force  in  all  cases  where  the  ankylosis  has  resulted  from  tuber- 
culosis. The  plan  is  said  to  have  been  suggested  by  Louvrier,  of  Paris.  It  was 
advocated  by  Langenbeck.  Brisement  force  is  only  curative  when  the  adhesions 
are  limited  to  the  synovial  membrane.  When  portions  of  that  membrane 
have  been  destroyed  or  when  there  are  dense  fibrous  adhesions  the  ankylosis 
invariably  recurs  after  manipulative  force  and  often  becomes  worse  than 
before.     In  bony  ankylosis  the  method  is  out  of  the  question. 

In  applying  manipulative  force  it  is  not  always  advantageous  to  have  the 
patient  profoundly  anesthetized.  If  he  is  profoundly  anesthetized  we  may 
be  tempted  to  apply  too  violent  force.  Severe  lacerations  of  fibrous  adhesions 
produce  painful  joints  which  necessitate  fixation  or  rest  for  several  days  to 
permit  the  reunion  of  the  torn  structures.  A  little  gain,  care  being  taken  to 
maintain  the  motion  gained,  mobility  being  gradually  increased  by  short  pro- 
gressive steps,  is  always  better  than  attempts  to  do  a  great  deal  at  once.  Of 
course  the  patient's  co-operation  is  necessary. 

When  pain  is  great,  much  can  be  accomplished  during  primary  ether  anes- 
thesia or  while  the  patient  is  under  the  influence  of  nitrous  oxid.  Bromid  of 
ethyl  and  chlorid  of  ethyl  are  used  by  many  because  of  their  rapid  action  and 
brief  effect.  As  stated  elsewhere  (see  page  1350),  I  seldom  use  either  of  these 
drugs. 

Fixation  appliances  of  any  kind  are  contra-indicated  during  corrective 
manipulations,  as  increased  freedom  of  motion  is  essential  rather  than  fixation. 
Voluntary  efforts  are  needed  to  maintain  the  joint  motion  already  secured  as 
well  as  to  increase  the  muscle  function  controlling  the  affected  joint. 

Among  the  operative  procedures  applicable  to  intra-articular  ankylosis  are 
excision  to  obtain  a  false  joint  (pseudo-arthrosis),  excision  to  obtain  a  better 
position  for  the  usefulness  of  the  limb,  breaking  the  bone  after  partially  cutting 
it  with  an  osteotome  (osteotomy),  and  breaking  the  bone  without  any  incision 
(osteoclasis).  These  several  procedures  have  special  advantages  in  different 
joints. 

Lexer  ("Zeit.  f.  Chir.  Med.  Orth.,"  Oct.,  1908,  p.  476),  after  resecting  a 
knee-joint  ankylosed  at  a  right  angle,  transplanted  the  entire  knee-joint  appa- 
ratus from  a  freshly  amputated  limb.  Complete  union  resulted.  Muscle 
training  was  subsequently  practised  to  improve  the  weak  muscular  control. 
Three  and  a  half  years  later  the  result  was  excellent. 

Weglowski  ("Zeit.  f.  Chir.,"  April  27,  1907)  resorted  to  cartilage  transplan- 
tation in  a  case  of  ankylosis  of  the  elbow.  After  freeing  and  re-forming  the 
ends  of  the  three  bones,  two  plates  of  cartilage  (one-half  thickness  of  rib  car- 
tilage) with  perichondrium  were  taken  from  the  sixth  and  seventh  ribs  and 
placed  between  the  newly  formed  joint  surfaces,  the  perichondria!  surface 
being  turned  toward  the  humeral  epiphysis.  No  special  fixation  was  used.  No 
drainage  was  employed.  Active  and  passive  motion  was  begun  on  the  tenth 
day.  In  a  month  the  patient  had  60  degrees  of  free  flexion  and  extension  and 
full  pronation  and  supination.  Death  from  pleuropneumonia  of  three  days' 
duration  occurred  in  five  weeks.  Postmortem  showed  that  the  perichondria! 
surface  of  the  cartilage  was  united  to  the  humerus,  while  the  opposite  side  was 
smooth,  even  shining;  the  cartilage  was  enlarging  and  passed  without  definite 
margin  into  the  surface  of  the  humerus. 


742  Diseases  and  Injuries  of  the  Bones  and  Joints 

Microscopic  examination  showed  newly  formed  blood-vessels  between  the 
cartilage  and  bone;  the  cartilage  was  well  preserved  in  its  entire  extent,  the 
cells  and  nuclei  staining  well. 

Huguier  and  Murphy  revive  a  suggestion  fifty  years  old.  They  interpose 
soft  tissue  between  the  bone  ends  after  freeing  the  ends  from  ankylosing 
material  ("Traitement  des  Ankyloses  par  la  Resection  Orthopedique  et 
L'interposition  Musculaire,"  par  Le  Dr.  Alphonse  Huguier).  The  plan  was 
first  suggested  by  Verneuil  in  i860  ("Archives  de  Medicine,"  i860).  He 
cured  temporomaxillary  ankylosis  by  the  interposition  of  temporal  muscle  and 
fascia.  In  1899  Helferich  suggested  inserting  a  portion  of  the  vastus  internus 
muscle  between  the  patella  and  femur,  and  two  years  later  Cramer  reported 
some  successful  cases.  Hoffa  followed  this  method.  Helferich,  in  1893,  mob- 
ilized the  temporomaxillary  joint  by  the  insertion  of  a  flap  from  the  temporal 
muscle.  This  was  repeated  by  Lentz,  Henle,  and  others.  Mikulicz,  in  1895, 
used  a  flap  from  the  masseter  muscle.  Similar  procedures  were  employed  by 
Bilezguski,  Hoffa,  and  Kusnetzow.  Rochet  and  Schnudt  with  Gliick,  in  1902, 
used  a  skin-flap  and  had  previously  employed  ivory  joints  to  take  the  place 
of  the  excised  structures.     In  1901  Murphy  operated  by  Verneuil's  plan. 

J.  B.  Murphy  ("Jour.  Amer.  Med.  Assoc,"  May  20-27,  June  3,  1905) 
reviews  the  literature  of  the  attempt  to  produce  new  joints  and  says:  "In 
our  work  we  have  been  able,  by  the  interposition  of  fascia  and  muscle,  covered 
with  a  layer  of  adipose  tissue,  to  produce  normal  movable  joints  with  capsules 
and  collagen  intra-articular  fluid."  In  cases  of  synovitis  with  adhesions  he 
resects  the  capsule  and  replaces  it  by  aponeurosis  or  muscle,  and  it  is  desirable, 
when  possible,  that  the  replacing  piece  contains  fat,  which,  under  pressure, 
will  form  a  hygroma  or  artificial  synovial  cavity.  In  bony  ankylosis  he  operates, 
separates  the  bones,  removes  adjacent  bony  prominences  or  processes,  frees 
the  soft  parts,  prevents  the  bones  comfng  again  in  contact,  and  interposes 
between  them  tissue  which  will  remain  fibrous  or  will  form  a  hygroma  or  artificial 
synovial  surface.  After  wound  healing  has  taken  place,  passive  motion, 
active  motion,  and  forcible  extension  are  required. 

W.  S.  Baer  ("Amer.  Jour.  Orthop.  Surg.,"  1907,  p.  234)  advocates  the  use 
of  sterilized  oil  injected  into  joints  to  prevent  the  formation  of  adhesions  and 
thus  increase  the  arc  of  motion.  It  may  also  be  poured  into  a  joint  after  arthrot- 
omy.  After  using  oil  in  the  manner  described,  Baer  summarizes  as  follows: 
"That  injection  of  oil  into  joints  under  proper  precautions  is  a  harmless  pro- 
cedure; that  the  joint  will  apparently  tolerate  as  much  as  it  will  hold. 

"It  is  most  useful  in  cases  where  adhesions  have  followed  some  acute  in- 
fectious process,  or  in  those  stiff  joints  which  are  classified  as  arthritis  defor- 
mans of  the  infectious  type. 

"Passive  motions  are  made  with  less  pain  where  the  joint  contains  oil. 

"It  plays  some  part  in  preventing  adhesions,  so  that  the  mobility  of  the  joint 
is  increased  more  rapidly." 

W.  S.  Baer  (Ibid.,  August,  1909)  reviews  the  Hterature  of  the  operative 
treatment  for  mobilizing  joints,  and  advocates  the  use  of  chromicized  pig's 
bladder  as  the  most  satisfactory  material  to  place  between  the  surfaces  of 
the  recently  separated  bones. 

Chlumsky,  disappointed  with  the  results  of  muscle  flaps,  used  non-absorb- 
able  materials,  zinc,  rubber,  celluloid,  silver,  and  layers  of  colloidin,  but  no 
permanent  mobility  was  obtained.  He  then  employed  absorbable  plates  of 
decalcified  bone,  ivory,  and  magnesium,  with  somewhat  better  results.  Baer's 
method  of  inserting  chromicized  pig's  bladder  followed  the  unsuccessful  em- 
ployment by  him  of  Cargile  membrane.  The  pig's  bladder  is  tightly  stitched 
by  catgut  sutures  around  the  recently  denuded  bone  and  the  wound  is  closed. 
A  hip-joint  two  months  after  this  procedure  showed  a  voluntary  flexion  of  35 
degrees;  abduction  of  15  degrees;  adduction  of  10  degrees;  rotation  of  25  degrees. 


Treatment  of  Extra-articular  Ankylosis  74^ 

Seven  months  after  operation  the  mobiUty  was  better  than  that  recorded  at 
two  months.     Similar  results  are  recorded  of  the  knee  and  elbow. 

Baer  emphasizes  the  necessity  of  having  the  [)ig's  bladder  absorbable  in 
thirty  to  forty  days.  It  should  be  pliable  enough  to  be  adapted  to  the  contour 
of  the  joint.  Every  raw  surface  should  be  absolutely  separated  by  it  from  that 
with  which  it  would  tend  to  come  in  contact. 

Thorn,  after  mobilizing  the  joint,  transplants  a  free  flap  of  fascia  to  between 
the  bone  ends  (''Zeitschr.  f.  Chirurgie."  Bd.  cviii).  Bauer,  of  Baltimore,  has 
also  done  this  successfully.  R.  Tunstall  Taylor  has  experimented  elaborately 
in  the  endeavor  to  find  a  liquid  and  absorbable  animal  substance  which,  when 
injected  by  a  syringe  between  the  denuded  ends  of  the  bones,  would  immediately 
solidify  and  prevent  contact  of  bone  ends  for  six  or  eight  weeks.  He  finally 
selected  yellow  wax  i  part  and  lanolin  from  2  to  6  parts  (this  melts  at  from 
120°  to  135°  F.).  Taylor  has  had  some  excellent  results  from  this  method 
("Penna.  Med.  Jour.,"  Jan.,  1913).  He  cautions  us  not  to  operate  by  any 
method  for  ankylosis  due  to  infective  arthritis  until  joint  inflammation  has 
been  quiescent  for  a  year  or  more. 

Surgical  mobilization  by  interposition  of  flaps  of  fat,  fascia,  or  muscle 
has  not  come  up  to  our  expectations.  The  hip  and  elbow  show  the  best 
results,  the  knee  the  worst.  Good  results  often  follow  mobilization  of 
the  patella  and  lower  jaw.  Gonorrheal  ankylosis  gives  a  poor  prospect  be- 
cause of  the  thickening  about  the  joint.  In  such  a  case  ankylosis  is  apt  to 
recur. 

In  the  lower  extremity  we  must  have  solidity.  The  surgeon  may  regard 
ankylosis  in  a  useful  position  as  preferable  to  a  mobilization  operation  with 
the  danger  of  a  flail-joint.  In  most  cases  of  ankylosis  in  the  lower  extremity 
the  wisest  plan,  if  the  limb  is  in  a  faulty  position,  is  to  do  an  operation  which 
will  let  the  surgeon  set  it  in  a  useful  position  when  it  will  undergo  re-ankylosis. 
Bergman  opposed  doing  mobilization  operations  upon  the  lower  extremity 
("Internat.  Abstract  of  Surgery,"  Jan.,  191 7). 

Personally  I  am  doubtful  about  such  an  operation  on  the  hip  and  ankle. 
I  would  not  do  it  at  all  on  the  knee.  Even  in  the  upper  extremity  when  the 
operation  succeeds  there  is  marked  loss  of  strength.  Tubby  would  minimize 
the  loss  of  stability  apt  to  follow  the  operation  on  a  lower  extremity  by  having 
only  a  small  space  between  the  bones.  In  the  upper  extremity  he  secures  a 
much  larger  space  between  the  bones.  If  autoplastic  flaps  are  employed 
drainage  is  unnecessary,  otherwise  it  should  be  used  ("Internat.  Abstract  of 
Surgery,"  Jan.,  1915).  A  mistake  that  has  been  made  after  arthroplasty  is  too 
early  movement  of  the  joint.  This  is  apt  to  loosen  the  flap,  cause  bleeding 
and  spoil  the  result.  The  joint  should  not  be  moved  for  five  or  six  weeks.  In  a 
few  cases  entire  joints  have  been  successfully  transplanted.  Tufi&er  twice 
transplanted  an  elbow-joint.  In  one  case  the  elbow-joint  of  fresh  cadaver  was 
transplanted  after  having  been  in  cold  storage  five  days.  A  year  and  a  half 
later  there  was  a  good  functional  result. 

Lexer  reported  a  knee-joint  six  years  after  transplantation.  The  :v-rays 
showed  that  there  was  partial  absorption  but  the  functional  condition  was  satis- 
factory (see  "Review  of  Recent  Advances  in  Orthopedic  Surgery,"  by  M.  S. 
Henderson,  in  "Internat.  Abstract  of  Surgery,"  Jan.,  1915). 

Treatment  of  Extra-articular  Ankylosis. — The  treatment  of  false  anky- 
losis depends  upon  the  case.  Recently  contracted  muscles  or  tendons  require 
motion*  massage,  frictions  with  stimulating  liniments,  hot  and  cold  douches, 
and  the  use  of  the  hot-air  apparatus.  Violent  breaking  up  is  not  satisfactory, 
neither  is  tenotomy  nor  myotomy.  Old  contractions  of  tendons  require  tendon 
lengthening  by  tendoplasty  or  myoplasty.  Chronic  inflammation  of  tendon- 
sheaths  with  adhesion  of  tendons  requires  excision  of  the  sheaths.  Whenever 
possible,  excise  a  cicatrix  that  causes  false  ankylosis,  and  fill  the  gap  with 


744  Diseases  and  Injuries  of  the  Bones  and  Joints 

sound  cutaneous  tissue  and  fat.  When  the  fixation  is  due  to  adhesive  synovitis 
of  the  capsule,  excise  the  capsule  and  attached  ligaments;  "the  head  and  neck 
of  the  bone  should  then  be  surrounded  by  an  aponeurosis  or  muscle  to  prevent 
the  re-forming  of  adhesions"  (John  B.  Murphy,  in  "Jour.  Amer.  Med.  Assoc," 
May  20-27  and  June  3,  1905).  Bony  deposits  are  gouged  away  and  tumors 
are  removed.  Contractures  in  cases  of  paralysis  require  electricity,  passive 
motions,  frictions  with  stimulating  hniments,  the  hot-air  bath,  and  general 
treatment.  Constant  and  graduated  pressure  by  means  of  splints  and  braces 
(with  ratchet  or  screws)  will,  in  many  instances,  restore  function.  The  patient 
can  be  taught  to  alter  the  pressure  frequently,  making  it  as  powerful  as  he  is 
able  to  bear  it. 

Loose  Bodies  in  Joints  (Floating  Cartilages). — The  knee  is  the  joint 
affected  in  90  per  cent,  of  cases,  but  the  elbow,  shoulder,  hip,  wrist,  lower  jaw, 
and  ankle  may  suffer.  There  may  be  but  one  loose  body  in  a  joint,  there  may 
be  two  or  more,  there  may  be  many,  or  even  hundreds.  More  than  one  joint 
may  be  involved.  The  condition  is  commonest  in  adult  men.  These  bodies 
may  be  free  or  each  may  have  a  stalk  or  pedicle;  they  may  move  about  and 
occasionally  block  the  joint,  or  may  He  quietly  in  a  joint-recess  or  diverticulum. 
They  may  be  flat  or  ovoid,  smooth  or  irregular,  as  small  as  peas  or  as  large  as 
plums,  and  may  be  composed  of  fibrous  tissue,  of  cartilage,  or  of  bone.  There 
are  numerous  different  modes  of  origin  of  these  bodies,  many  being  "detached 
ecchondroses  or  pieces  of  hyaline  cartilage  hanging  by  narrow  pedicles"  (Sir 
J.  Bland-Sutton),  and  they  result  from  enlargement  and  chondrification  of  the 
villi  of  the  synovial  membrane.  Loose  bodies  are  found  in  the  course  of  osteo- 
arthritis and  osteochondritis  dissecans. 

Symptoms. — Some  bodies  give  rise  to  no  symptoms  for  a  long  time  and 
others  merely  cause  synovitis.  A  loose  body  may  produce  pain  and  inter- 
fere with  joint-function.  The  joint  is  weak  and  a  little  swollen,  and  the  patient 
can  perhaps  feel  the  body  and  can  even  push  it  into  a  superficial  area  of  the 
joint,  where  it  may  be  felt  by  the  surgeon.  From  time  to  time  the  body  may 
get  caught,  thus  suddenly  locking  the  joint  and  producing  intense  and  sick- 
ening pain,  extension  and  flexion  being  impossible  until  the  body  slips  out. 
It  may  slip  out  in  a  moment,  but  may  not  for  hours  or  even  for  many  days.  A 
rather  small  body  seems  more  apt  to  cause  locking  than  a  very  large  one,  but 
if  a  large  one  does  cause  locking,  it  is  more  difficult  to  dislodge  than  is  a  small 
one.  Locking  of  a  joint  by  a  loose  body  is  followed  by  inflammation  and 
effusion.  If  the  loose  body  is  dense  and  large,  the  x-ray  may  disclose  it.  Sesa- 
moid bones  in  the  gastrocnemius  muscle  must  not  be  confused  with  loose 
bodies  in  the  knee-joint.  In  some  cases  of  loose  body  in  the  knee  the  diagnosis 
is  impossible  from  dislocation  of  a  semilunar  cartilage,  inflamed  semilunar 
cartilage,  and  synovitis  with  proliferation  of  villi. 

Treatment. — To  relieve  locking,  employ  forced  flexion  and  sudden  exten- 
sion. Cure  can  be  obtained  by  operation  only.  Let  the  patient  bring  the 
foreign  body  to  a  point  where  it  can  be  felt  by  the  surgeon,  so  that  he  can  deter- 
mine where  it  lodges.  Asepticize  the  knee  with  the  utmost  care.  Operate  if 
possible  under  cocain;  if  not,  give  ether.  If  the  body  is  felt  before  operating, 
fix  it  with  a  pin.  The  joint  is  now  opened,  explored  with  the  finger,  the  foreign 
body  extracted,  and  an  exploration  made  to  see  that  no  other  bodies  are  present. 
If  a  body  has  an  attachment  the  pedicle  is  snipped  through  by  scissors.  The 
wound  is  sutured  in  two  layers  and  the  leg  is  placed  upon  a  splint.  Asepsis 
must  be  most  rigid.  The  operation  does  not  cure  the  causative  process,  and 
these  bodies  are  apt  to  form  again.  When  the  knee  is  involved,  some  surgeons 
saw  the  patella  transversely,  open  the  joint  widely,  remove  all  foreign  bodies, 
and  seek  to  cure  any  causative  process.  Robert  Jones  divides  the  patella 
longitudinally. 


Congenital  Dislocations  745 

Luxations  or  Dislocations 

A  dislocation  is  the  persistent  separation  from  each  other,  partially  or  com- 
pletely, of  two  articular  surfaces.  A  self-reduced  dislocation  is  called  a  sprain 
(Douglas  Graham).  There  are  three  forms  of  dislocations:  (i)  traumatic; 
(2)  spontaneous  or  pathological;  (3)  congenital. 

1.  Traumatic  dislocations  are  due  to  injury.  They  are  divided  into — 
complete  dislocation,  in  which  the  two  articular  surfaces  are  entirely  separated 
and  the  ligaments  are  torn;  incomplete  or  partial  dislocation  or  subluxation, 
in  which  the  two  articular  surfaces  are  not  completely  separated  and  the  liga- 
ments are  rarely  lacerated;  simple  dislocation,  in  which  there  is  no  wound 
leading  from  the  surface  to  the  articulation;  compound  dislocation,  in  which 
a  wound  leads  from  the  surface  to  the  joint;  complicated  dislocation,  in  which, 
besides  the  dislocation,  there  is  a  fracture,  extensive  damage  of  the  soft  parts, 
an  opening  which  makes  the  case  compound,  or  damage  of  a  nerve  or  blood- 
vessel; primitive  or  primary  dislocation,  in  which  the  bones  remain  as  originally 
displaced;  secondary  dislocation,  in  which  the  dislocated  bone  assumes  a  new 
position,  for  instance,  a  subglenoid  luxation  of  the  humerus  is  primary,  and 
it  may  become  secondarily  a  subcoracoid  luxation  because  of  muscular  contraction 
or  attempts  at  reduction;  recent  dislocation,  in  which  the  displaced  bone  is 
not  firmly  fastened  by  tissue  changes  in  its  new  situation,  and  its  old  socket 
is  not  obliterated;  old  dislocation,  in  which  the  displaced  bone  is  firmly  fastened 
by  tissue  changes  in  its  new  habitat,  and  the  old  socket  is  to  a  great  extent 
obliterated  (whether  a  dislocation  is  old  or  new  depends  on  the  state  of  the 
parts  rather  than  on  the  time  which  has  elapsed  since  the  accident);  double 
dislocation,  in  which  corresponding  bones  on  each  side  are  dislocated;  single 
dislocation,  in  which  only  one  joint  is  dislocated;  unilateral  dislocation,  in 
which  one  articulation  of  one  bone  is  out  of  place;  bilateral  dislocation,  in  which 
symmetrical  articulations  are  dislocated;  and  relapsing  or  habitual  dislocation, 
which  recurs  frequently  from  slight  force  because  of  relaxed  ligaments  or  lack 
of  complete  repair  after  the  ligamentous  rupture  of  a  first  dislocation. 

2.  Spontaneous,  Pathological,  or  Consecutive  Dislocations. — Spon- 
taneous dislocation  arises  from  such  very  slight  force  that  the  cause  may  not  be 
identified,  and  it  acts  on  a  joint  rendered  lax  by  disease.-  It  may  arise  in  the  course 
of  chronic  synovitis,  tuberculous  joint-disease,  or  rheumatoid  arthritis.  In 
Charcot's  joint  a  spontaneous  dislocation  will  occur  sooner  or  later.  In  typhoid 
fever  spontaneous  dislocation  is  not  uncommon.  The  hip-joint  is  most  often 
the  one  attacked.  Dislocation  of  the  hip  in  typhoid  fever  follows  a  severe  joint 
inflammation,  is  usually  upon  the  dorsum  of  the  ilium,  and  is  frequently  not 
noticed  until  convalescence  has  set  in.  If  a  typhoid  dislocation  is  seen  early, 
reduction  is  easily  effected,  but  if  seen  late,  is  impossible.  The  treatment  for 
irreducible  typhoid  dislocation  is  the  same  as  for  any  other  irreducible  dis- 
location. Dislocation  may  occur  in  the  acute  infectious  arthritis  of  scarlatina, 
pneumonia,  etc.,  from  distention  of  the  joint  cavity  with  septic  products  or 
exudates.  In  infantile  palsy  muscular  atrophy  may  be  so  great  that  a  shoulder 
or  hip  may  be  easily  dislocated. 

3.  Congenital  Dislocations. — A  congenital  dislocation  is  due  to  a  con- 
genital joint  malformation  which  renders  it  impossible  for  the  bone  to  main- 
tain a  normal  position,  or  is  due  to  external  violence  during  the  period  of 
uterine  gestation.  Congenital  dislocations  should  not  be  confounded  with 
dislocations  produced  during  delivery.  The  hip  is  the  joint  most  often  in- 
volved. The  shoulder  suffers  occasionally.  Lannelongue  maintains  that 
congenital  dislocation  of  the  hip  is  due  to  atrophy  of  the  muscles  and  of  the 
acetabulum  following  spinal-cord  disease.  Verneuil  thinks  the  dislocation  is 
paralytic.  Broca  says  that  in  view  of  the  fact  that  the  head  of  the  bone  is 
larger  than  the  cavity  in  which  it  belongs,  it  is  useless  to  attempt  reduction 


746  Diseases  and  Injuries  of  the  Bones  and  Joints 

by  manipulation  or  extension,  but  many  successful  cases  by  the  Lorenz  blood- 
less method  prove  Broca's  condemnation  to  have  been  too  sweeping.  Lorenz 
and  Hoffa  have  each  devised  an  operation  for  this  condition  (see  pages  800, 
801 ).  Congenital  dislocation  of  the  shoulder  requires  incision,  possibly  excision, 
or  the  paring  down  of  the  head  to  fit  the  glenoid  cavity  (Phelps). 

Traumatic  Dislocations.— In  the  succeeding  pages  the  traumatic  form  of 
dislocation  will  Ije  particularly  considered. 

The  causes  of  traumatic  dislocations  are  divided  into  predisposing  and  exciting. 

Predisposing  causes  are:  (i)  age;  dislocations  are  commonest  in  middle  life, 
the  usual  lesion  of  the  young  being  green-stick  fracture,  and  that  of  the  old 
being  fracture;  dislocations  of  the  radius  are  not  uncommon  in  youth;  (2) 
muscular  development,  dislocations  being  commonest  in  those  with  powerful 
muscle;  (3)  sex,  males  being  more  predisposed  than  females,  because  of  their 
occupations  and  muscular  strength;  (4)  occupation  predisposes  as  a  cause  ac- 
cording as  it  demands  the  emj)loyment  of  muscular  force,  as  in  the  carrying 
of  burdens;  (5)  nature  of  the  joint,  ball-and-socket  joints  being  more  liable  to 
luxation  than  are  ginglymoid  joints,  because  of  the  wider  range  of  motion  of 
the  former;  (6)  joint-disease  predisposes  by  relaxing  the  ligaments;  (7)  situation 
of  the  joint,  some  joints  being  more  exposed  to  injury  than  others. 

Exciting  causes  are  divided  into — (i)  external  violence  and  (2)  muscular 
action.  External  violence  may  be  direct,  as  when  a  blow  upon  one  of  the  bones 
forces  it  directly  away  from  the  other;  or  it  may  be  indirect,  as  when  force 
applied  to  a  distant  part  of  a  bone  is  transmitted  to  its  end  and  drives  the 
bone  out  of  its  socket.  Muscular  action  is  a  cause  when  sudden  and  violent 
muscular  contraction  occurs  during  the  maintenance  of  a  position  of  the  joint 
\yhich  gives  the  muscles  full  sway,  and  throws  the  head  of  the  bone  against 
the  weakest  part  of  its  retaining  ligaments. 

Pathological  Conditions. — In  a  recent  complete  traumatic  dislocation  the 
ligaments  are  damaged,  and  may  perhaps  exhibit  extensive  laceration,  or  may 
show  only  a  buttonhole  laceration  through  which  a  bone  projects.  Exter- 
nal force  produces  much  laceration  and  little  stretching  of  the  ligaments; 
muscular  action  produces  little  laceration  and  much  stretching  of  the  liga- 
ments. In  some  cases  of  dislocation  due  to  external  violence  the  structures 
about  the  joint  are  bruised  or  otherwise  damaged;  the  old  socket  is  filled  with 
blood,  and  the  bone  in  its  new  situation  lies  in  a  bloody  area.  Large  vessels 
and  nerves  are  rarely  torn,  though  they  are  not  unusually  compressed.  Sprain- 
fracture  is  certainly  common,  in  fact  almost  invariable  (Ross  and  Stewart, 
"Annals  of  Surgery,"  Oct.,  191 2). 

If  a  dislocation  is  not  soon  reduced,  inflammation  arises  in  the  old  joint  cavity 
and  about  the  displaced  bone,  and  the  whole  area  becomes  glued  together,  first, 
by  coagulated  exudate,  and  finally  by  fibrous  tissue.  After  a  time,  in  ball-and- 
socket  joints,  the  old  socket  fills  with  fibrous  tissue,  contracts,  becomes  irregu- 
lar, and  may  even  be  obliterated;  the  head  of  the  dislocated  bone  is  altered  in 
shape,  its  cartilage  is  destroyed  or  converted  into  fibrous  tissue,  and  the  pres- 
sure of  the  head  of  the  bone  forms  a  hollow  in  its  new  situation,  which  hollow 
becomes  surrounded  by  fibrous  tissue  or  even  by  bone.  A  new  joint  may 
form,  the  surrounding  tissue  becoming  a  compact  capsule,  and  a  bursa  forming 
between  the  head  of  the  bone  and  its  new  socket.  In  a  dislocated  hinge- 
joint  the  ends  of  the  bone  alter  greatly  in  shape  and  their  cartilage  is  con- 
verted into  fibrous  tissue.  In  an  unreduced  dislocation  the  muscles  shorten 
or  lengthen  or  undergo  atrophy  or  fatty  degeneration,  as  the  case. may  be. 
An  unreduced  dislocation  of  a  ball-and-socket  joint  may  give  a  fairly  movable 
new  joint,  but  an  unreduced  dislocation  of  a  hinge-joint  rarely  allows  of  much 
motion. 

General  Symptoms  of  Traumatic  Dislocation. — In  general,  traumatic  dis- 
locations are  indicated — (i)  by  pain  of  a  sickening,  nauseating  character;  (2) 


Treatment  of  Traumatic  Dislocation  747 

by  rigidity,  voluntary  motion  being  impossible  except  to  a  slight  extent  in  the 
direction  of  the  deformity.  (For  instance,  in  dislocation  of  the  inferior  maxil- 
lary the  jaw  can  be  opened  a  little  more,  but  it  cannot  be  closed.)  This  rigidity 
brings  about  loss  of  function.  When  the  surgeon  attempts  to  move  the  joint 
he  finds  it  very  rigid;  (3)  by  change  in  the  shape  of  the  joint  (as  flattening  of  the 
shoulder  after  dislocation  of  the  humerus);  (4)  by  alteration  in  the  mutual 
relations  of  bony  prominences  about  a  joint  (as  the  alteration  of  the  relation 
between  the  olecranon  and  humeral  condyles  in  dislocation  of  the  elbow  back- 
ward); (5)  by  feeling  the  displaced  bone  in  its  new  situation;  (6)  by  missing 
the  head  of  the  bone  from  its  proper  situation;  (7)  by  alteration  in  the  length  of 
the  limb  (in  dislocation  of  the  femur  into  the  thyroid  foramen  the  limb  is 
lengthened,  but  in  dislocation  on  to  the  dorsum  of  the  iUum  it  is  shortened); 
and  (8)  by  alteration  in  the  axis  of  the  bone  (in  dislocation  upon  the  dorsum 
of  the  ilium  the  axis  of  the  injured  thigh  would,  if  prolonged,  pass  through  the 
lower  third  of  the  sound  thigh) ;  (9)  by  seeing  the  dislocation  with  a  fluoroscope 
or  looking  at  a  skiagraph  of  it. 

Diagnosis  of  Traumatic  Dislocation. — A  dislocation  may  be  mistaken  for 
a  fracture.  In  dislocation  there  is  rigidity,  in  fracture  there  is  preternatural 
mobility;  in  dislocation  there  is  no  true  crepitus  (there  may  be  tendon-  or 
joint-crepitus),  in  fracture  there  usually  is  crepitus;  in  dislocation  the  deformity 
does  not  tend  to  recur  after  reduction,  in  fracture  it  does  recur  after  exten- 
sion is  relaxed.  In  a  sprain  the  movements  of  the  joint  are  only  limited,  not 
abolished,  by  the  aknost  complete  rigidity  encountered  in  dislocation.  The 
change  which  a  sprain  may  cause  in  the  shape  of  a  joint  is  due  to  effusion  or 
to  bleeding;  there  is  no  alteration  in  the  relation  of  the  bony  prominences  to 
one  another;  there  is  no  notable  alteration  in  the  length  of  the  limb  (in  a 
sprain  a  very  slight  increase  in  the  length  of  the  limb  may  arise  from  joint- 
effusion,  or  the  head  of  the  bone  may  subsequently  be  absorbed  and  thus  pro- 
duce shortening  after  some  weeks);  there  is  no  alteration  in  the  axis  of  the 
bone;  the  bony  head  is  not  felt  in  a  new  position,  and  it  is  found  in  its 
normal  place.  Always  remember  that  a  fracture  may  exist  with  a  dislocation. 
In  any  doubtful  case — in  fact,  in  most  cases — give  ether,  for  a  dislocation 
should  be  reduced  while  the  patient  is  anesthetized  (except  in  dislocation  of 
the  jaw,  of  a  finger,  of  the  carpus,  etc.).  In  some  cases  swelling  renders  the 
diagnosis  difficult  or  impossible.  Always  compare  the  injured  joint  with  the 
corresponding  joint  of  the  sound  side.  The  .^•-rays  constitute  an  invaluable 
method  of  diagnosis. 

Treatment  of  Traumatic  Dislocation.  Recent  Simple  Dislocation. — Reduce 
a  simple  dislocation  under  ether,  as  a  rule.  Try  manipulation,  a  procedure 
which  seeks  to  make  the  bone  retrace 
its  owm  pathway.  If  this  procedure 
fails,  employ  extension  and  counter- 
extension.  If  considerable  force  is 
needed,  an  assistant  makes  counter- 
extension,  and  the  surgeon  fastens  to 
the  extremitv  a   clove-hitch,  which  he  Fig.    453.— Clove-hitch   knot    applied 

ties   about  his   waist,  and  thus  secures     ^J°7,  ^^!t,  •''"';'* \  ^"^  dislocation  of   the 
c   ■,         ,        .  '  ^         ,  ,        .  shoulder  this  knot  is  put  above  the  elbow 

powerful   extension.      Counterextension     (after  Erichsen). 
may    be    obtained    by    bands,    or,    in 

some  instances,  by  the  foot  of  the  surgeon.  The  clove-hitch  is  used  because 
it  will  not  tighten  by  traction;  a  tightening  band  would  lacerate  the  soft  parts 
(Fig.  453).  If  great  power  is  needed,  compound  pulleys  may  be  employed, 
such  as  the  Jarvis  adjuster  or  some  similar  appliance,  but  at  the  present  day 
pulleys  are  rarely  used  (see  page  757).  If  these  means  fail,  cut  down  upon  the 
bone  and  restore  it  to  position;  operation  is  much  safer  than  the  application  of 
great  force.  After  reducing  a  dislocation,  immobilize  the  joint  for  a  time,  which 
varies  for  different  joints,  and  for  the  first  few  days  combat  swelling  and  in- 


748  Diseases  and  Injuries  of  the  Bones  and  Joints 

flammation  by  rest  of  the  part  and  the  use  of  evaporating  lotions  or  an  ice-bag. 
If  there  exists  a  fracture  of  the  dislocated  bone,  apply  splints  and  then  try 
to  reduce  by  manipulations,  grasping  the  limb  and  the  splints  with  one  hand 
below  and,  if  possible,  the  head  of  the  bone  with  the  other  hand  above  the  seat 
of  the  fracture.  AUis  believes  that  a  dislocation  can  be  reduced  even  when  a 
fracture  exists.  It  is  possible  to  pull  the  dislocated  head  down  to  the  joint, 
because  a  portion  of  periosteum  and  possibly  tendinous  material  and  muscle 
still  hold  the  two  fragments  as  a  strap  might  unite  two  sticks.  The  head  may 
be  forced  into  place  by  the  fingers  while  traction  is  being  made.  If  the  fracture 
is  near  the  joint  and  the  fragments  cannot  be  fixed,  try  to  reduce  the  dislo- 
cation, first  striving  to  press  the  bone  into  place.  This  attempt  can  be  greatly 
aided  by  traction  upon  the  lower  fragment.  In  some  cases  with  fracture 
reduction  can  be  much  aided  by  making  a  small  incision,  screwing  a  gimlet 
into  the  head  of  the  bone,  and  using  this  tool  as  a  handle.  McBurney  incises, 
drills  a  hole  in  each  bone,  inserts  hooks  into  them,  and  pulls  the  dislocated 
bone  into  position  (see  Figs.  315  and  316).  When  the  dislocation  has  been  re- 
duced, the  bone-fragments  should  be  wired  or  plated  together. 

Compound  Traumatic  Dislocation. — The  opening  in  the  soft  parts  may  be 
due  to  external  violence  or  to  projection  of  a  bone.  Compound  dislocations 
are  very  serious.  Hinge- joints  are  more  liable  to  these  injuries  than  are  ball- 
and-socket  joints.  Many  cases  require  excision;  some,  amputation;  one 
that  does  not  demand  excision  or  amputation  should  be  treated  by  sterilizing 
the  parts,  restoring  the  dislocated  bone,  making  a  counteropening,  draining, 
dressing  antiseptically,  and  immobilizing.  Considerable  ankylosis  generally 
ensues,  except  sometimes  in  the  small  joints.  It  is  scarcely  ever  necessary 
to  cut  away  any  portion  of  the  protruding  bone  to  effect  reduction.  If  a 
joint  is  badly  splintered,  or  if  the  soft  parts  are  extensively  damaged,  it  may 
be  necessary  to  excise  or  amputate;  if  the  main  vessels  of  a  limb  are  seriously 
injured,  amputation  must  be  considered.  If  the  patient  is  so  old  or  so  feeble 
that  it  is  perilous  to  force  him  to  combat  a  long  illness,  amputation  should 
be  performed. 

Old  Traumatic  Dislocation. — The  problem  always  presented  in  an  old 
dislocation  is.  Shall  reduction  be  tried  or  shall  the  bones  be  let  alone?  Sir 
Astley  Cooper  laid  down  this  rule:  "Do  not  attempt  to  reduce  a  shoulder- 
dislocation  after  three  months,  nor  a  hip  dislocation  after  two  months;"  but 
this  rule  was  put  forth  before  the  days  of  ether.  Do  not  select  any  fixed  period 
of  time  to  determine  what  action  is  advisable.  In  dislocation  of  sl  ball-and- 
socket  joint  considerable  motion  may  become  possible  and  a  new  joint  may 
form.  If  movement  does  not  produce  pain,  a  useful  new  joint  may  be  obtained 
by  the  persistent  employment  of  active  and  passive  movements;  if  movement 
of  the  limb  does  produce  pain,  enough  motion  will  not  be  attempted  by  the 
patient  to  produce  a  useful  joint.  In  the  former  case  it  may  be  best  to  try  to 
obtain  a  useful  new  joint,  and  in  the  latter  case  the  surgeon  should  endeavor 
to  reduce  the  old  dislocation.  Always  remember  that  dislocation  of  a  hinge- 
joint,  if  left  unreduced,  will  never  eventuate  in  a  useful  new  joint. 

In  trying  to  reduce  an  old  dislocation  give  ether,  make  movements  to 
break  up  adhesions,  and  persist  in  making  these  motions  until  the  head  of 
"  the  bone  is  felt  to  move;  then  try  at  once  to  reduce  by  manipulation  or  exten- 
sion and  counterextension,  not  waiting  for  two  days,  as  some  suggest.  If 
the  head  of  the  bone  cannot  be  made  to  move,  the  Dieffenbach  plan  has  been 
advised,  which  is  to  cut  the  tense  restraining  bands  with  a  tenotome.  Lord 
Lister,  being  much  impressed  with  the  danger  inevitably  linked  with  forcibly 
dragging  old  dislocations  into  place,  preferred  to  cut  down  and  restore  the  bone, 
employing,  of  course,  the  strictest  asepsis,  and  surgeons  in  general  have  adopted 
this  view.  In  some  old  dislocations  excision  of  the  head  of  the  bone  is  the 
proper  operation. 


Special  Traumatic  Dislocations  749 

Special  Traumatic  Dislocations. — Mandible. — A  dislocation  of  the  lower 

jaw,  when  there  is  no  fracture,  is  almost  invariably  forward.  Backward 
dislocation  without  fracture  is  extremely  rare,  and  some  have  maintained 
that  it  cannot  occur.  Croker  King  reported  a  case  in  1858.  Theim  has 
observed  it  seven  times  in  five  women.  The  condyle  passes  under  the  lower 
surface  of  the  auditory  canal.  "^  The  common  dislocation  is  forward,  and  this 
is  the  form  meant  when  we  simply  speak  of  dislocation  of  the  jaw.  There 
are  two  forms  of  forward  dislocation — the  unilateral,  which  is  rare,  and  the 
bilateral,  which  is  common.  Dislocations  of  the  jaw  are  commonest  in  women 
and  during  middle  life.  When  the  mouth  is  open,  contraction  of  the  external 
pterygoid  muscle  may  pull  the  condyle  over  the  articular  eminence;  this  con- 
traction may  be  brought  about  by  yawning,  vomiting,  scolding,  etc.  When  the 
mouth  is  open,  dislocation  of  the  lower  jaw  may  be  caused  by  a  blow  upon  the 
chin;  it  may  also  be  caused  by  forcing  the  mouth  more  widely  open  by  pushing 
a  bulky  body  between  the  teeth. 

Symptoms  of  Lower-jaw  Dislocation. — In  the  bilateral  form  the  mouth  is 
open  and  fixed,  and  it  cannot  be  closed,  though  it  can  be  opened  a  little  more. 
The  condyles  are  in  front  of  the  articular  eminences,  and  are  fixed  by  the 
action  of  the  masseters  and  internal  pterygoids,  the  coronoid  processes  being 
wedged  against  the  malar  bones.  The  lower  jaw  is  advanced  in  front  of  the 
upper  jaw  and  the  face  looks  longer  than  natural.  The  lips  cannot  close, 
the  saliva  dribbles,  swallowing  and  speech  are  difficult,  there  is  a  depression  in 
front  of  each  ear,  the  condyles  are  recognizable  in  their  new  abodes,  the  coro- 
noid processes  are  detected  by  a  finger  in  the  mouth,  and  the  masseters  and 
temporals  stand  out  in  a  state  of  rigidity.  Pain  may  be  severe,  may  be  moder- 
ate, or  may  be  absent.  In  the  unilateral  form  the  chin  deviates  toward  the  sound 
side,  and  the  mouth  is  not  so  widely  open  as  in  the  bilateral  form,  neither  is 
the  jaw  so  fixed.  The  symptoms  are  similar  to  those  of  a  bilateral  luxation, 
but  are  not  so  pronounced.  The  hollow  in  front  of  the  ear  and  the  abnormal 
situation  of  the  condyle  are  detected  upon  one  side  only.  In  an  unreduced 
dislocation  the  patient  may  after  a  time  establish  some  movements  of  the 
jaw,  but  the  power  of  mastication  will  always  be  seriously  impaired. 

Treatment  of  the  Lower-jaw  Dislocation. — In  reducing  a  dislocation  of  the 
lower  jaw  the  patient  is  usually  placed  with  his  head  against  the  back  of  a  chair 
or  against  the  body  of  an  assistant.  The  surgeon,  after  wrapping  up  his  thumbs 
to  protect  them  from  being  bitten,  stands  in  front  of  the  patient,  puts  his 
thumbs  upon  the  last  molar  teeth,  and  grasps  the  chin  with  his  free  fingers. 
He  now  presses  downward  and  backward  on  the  jaw,  and  as  soon  as  the  con- 
dyle is  loosened,  closes  the  jaw  over  the  thumbs  by  pushing  up  the  chin,  using 
his  thumbs  as  levers.  For  the  last  year  I  have  followed  the  excellent  sugges- 
tion of  W.  J.  Young  ("Brit.  Med.  Jour.,"  March  23,  1913),  which  is  to  stand 
behind,  the  right  thumb  far  back  in  the  right  side  of  the  patient's  mouth  and 
grasp  the  chin  with  the  left  hand.  The  right  hand  easily  depresses  the  jaw  and 
the  left  guides  the  condyle  into  place.  Then  the  procedure  is  reversed  and  the 
left  side  reduced.  If  reduction  by  the  hands  fails,  wedges  should  be  put 
between  the  molar  teeth  and  the  chin  should  be  pushed  up  either  by  the  hands 
or  by  a  tourniquet,  the  band  of  which  surrounds  the  head  and  chin.  In  a 
unilateral  dislocation  the  wedge  should  be  used  only  on  the  injured  side.  In 
difficult  cases  Sir  Astley  Cooper  pushed  a  round  wooden  ruler  between  the  molar 
teeth,  used  the  upper  teeth  as  a  fulcrum,  and  raised  the  end  of  the  ruler  as 
the  handle  of  a  lever.  The  forceps  used  by  an  anesthetist  may  depress  the  con- 
dyle from  its  point  of  fixation,  whereupon  the  chin  may  be  pushed  up  and  back. 
Nelaton  advises  that  the  surgeon  place  his  thumbs  in  the  mouth  of  the  patient 
and  push  the  coronoid  processes  backward.  After  reduction  a  Barton  bandage 
should  be  applied  and  worn  for  over  two  weeks.  The  dressing  should  be 
1  Theim,  in  "Rev.  de  Chir.,"  vol.  viii,  1888. 


75©  Diseases  and  Injuries  of  tlic  Bones  and  Joints 

renewed  once  a  day,  and  passive  motion  be  begun  in  the  second  weelc.  1  he- 
bandage  may  be  discarded  at  the  end  of  the  third  week.  Liquid  diet  is 
advisable  for  three  weeks  after  the  accident.  In  an  old  dislocation  reduction  is 
always  attempted,  at  least  up  to  a  period  of  six  or  seven  months  after  the 
accident.  An  irreducible  dislocation  requires  osteotomy  of  the  neck  of  the 
bone  if  the  part  cannot  be  restored  after  incision. 

Dislocation  of  the  Clavicle.  Sternal  End. — ^There  are  three  forms  of 
dislocation  of  the  sternal  end  of  the  clavicle,  namely:  (i)  forward;  (2)  back- 
ward, and  (3)  upward. 

Forward  Dislocation  of  the  Sternal  End  of  the  Clavicle  (Presternal  Dis- 
location).— The  causes  of  forward  dislocation  of  the  clavicle  are  blows,  falls, 
or  pulls  which  drive  or  draw  the  shoulder  backward. 

Symptoms  and  Treatment  of  Forward  Dislocation  of  the  Sternal  End  of  the 
Clavicle. — The  symptoms  manifest  in  dislocation  of  the  clavicle  are:  promi- 
nence in  front  of  the  sternum;  the  acromion  is  nearer  to  the  sternum  on  the 
injured  than  on  the  sound  side;  the  clavicular  origin  of  the  sternocleido- 
mastoid muscle  is  rigid;  movement  is  difficult  and  painful.  To  reduce  a  dis- 
location of  the  clavicle,  pull  the  shoulders  back  against  the  knee  of  the 
surgeon,  which  is  placed  between  the  scapulae.  Dress  with  a  posterior  figure- 
of-eight  bandage  (Fig.  915)  or  a  Velpeau  bandage  (Fig.  917),  the  dressing 
to  be  worn  for  three  weeks.  After  removal  of  the  dressing  apply  a  truss, 
the  pad  of  which  is  put  over  the  head  of  the  clavicle.  The  instrument 
is  to  be  worn  for  a. month.  Dislocation  of  the  clavicle  is  difficult  to  keep 
reduced,  but  even  if  it  becomes  fixed  in  deformity,  the  motions  of  the  arm  will 
not  be  impaired  permanently.  It  can  be  reduced  and  fixed  by  incision  and 
wiring. 

Backward  dislocation  of  the  sternal  end  of  the  clavicle  is  very  rare.  The 
causes  are  direct  violence  and  indirect  force,  such  as  falls  or  blows  which  drive 
the  shoulder  forward  and  inward. 

Symptoms  and  Treatment  of  Backward  Dislocation  of  the  Sternal  End  of 
the  Clavicle. — The  symptoms  are:  pain,  loss  of  function  in  the  arm;  inclination 
of  the  head  toward  the  injured  side;  stiffness  of  the  neck;  the  shoulder  passes 
forward  and  inward,  and  often  falls  downward;  a  depression  exists  over  the 
sternoclavicular  joint;  the  head  of  the  clavicle  cannot  be  felt,  or  is  found  back 
of  the  sternum.  The  displaced  clavicle  may  press  upon  the  trachea,  the 
esophagus,  or  the  great  vessels,  inducing  dyspnea,  dysphagia,  obliteration  of 
pulse  in  the  arm  of  the  injured  side,  or  great  venous  congestion  of  the  head 
(see  Pick).  The  usual  method  of  treatment  is  to  pull  the  shoulders  backward 
and  apply  a  posterior  figure-of-eight  bandage  (Fig.  915),  which  must  be  worn 
for  three  weeks.  If  pressure-symptoms  are  urgent,  it  is  the  rule  to  incise, 
restore  the  bone  to  place  and  wire  it,  or  resect  the  displaced  head. 

Upward  dislocation  of  the  sternal  end  of  the  clavicle  is  ver\'  rare.  The 
cflM^e  is  indirect  force,  Avhich  carries  the  shoulder  downward,  inward,  and  back- 
ward (Smith). 

Symptoms  and  Treatment  of  Upward  Dislocation  of  the  Sternal  End  of  the 
Clavicle.— The  chief  symptom  is  impaired  function  of  the  arm;  the  shoulder 
passes  downward  and  inward,  the  clavicular  axis  is  altered,  and  the  displaced 
head  is  felt.  Dyspnea  may  or  may  not  exist.  To  treat  this  dislocation,  put  a 
jiad  in  the  axilla  and  press  the  elbow  to  the  side  (in  order  to  throw  the  bone 
outward),  and  try  to  push  the  head  into  place.  Apply  a  Desault  bandage 
(Fig.  918)  and  place  a  firm  pad  over  the  sternoclavicular  joint.  The  deformity 
is  apt  to  recur,  but  a  useful  limb  will  nevertheless  be  obtained.  The  best 
method  of  treatment  is  to  wire  the  bones  in  place. 

Dislocation  of  the  acromial  end  of  the  clavicle  is  almost  always  upward, 
but  it  may  be  below  the  acromion.  The  cause  is  violent  force,  which,  if  so 
applied  to  the  scapula  as  to  drive  the  shoulder  forward,  may  produce  a  dis- 


Dislocation  of  the  Lower  Angle  of  the  Scapuhi  751 

location  upward.     A  dislocation  downward  is  due  to  blows  ui)on  the  upper 
surface  of  the  outer  end  of  the  clavicle. 

Symptoms  and  l^rcatment.— In  dislocation  of  the  acromial  end  of  the  clavi- 
cle upward  there  are  noted:  prominence  of  the  clavicle  upon  the  top  of  the 
acromion;  impaired  function  of  the  arm  (it  cannot  be  lifted  over  the  head); 
the  shoulder  falls  downward  and  passes  inward;  there  is  apparent  lengthening 
of  the  arm;  the  head  is  bent  toward  the  injured  side,  and  the  clavicular  origin 
of  the  trapezius  is  strongly  outlined  (Pick),  In  dislocation -downward  both 
the  acromion  and  the  coracoid  are  very  prominent,  the  clavicular  axis  is  altered, 
and  there  is  depression  over  the  sternoclavicular  joint.  The  surgeon  usually 
endeavors  to  reduce  a  dislocation  upward  by  placing  the  patient  supine  on 
a  hard  table,  pulHng  the  shoulder  back,  and  pushing  the  bone  into  place.  After 
reduction  the  old  method  of  treatment  was  to  apply  a  Desault  bandage,  which 
was  kept  on  for  three  weeks,  and  decided  deformity,  enduring  pain,  and  disa- 
bility were  looked  for  as  inevitable.  Stimson  used  to  apply  dressings  of  ad- 
hesive plaster.  The  author  has  seen  several  cases  treated  by  the  apparatus 
of  Thomas  Leidy  Rhoads.  The  apparatus  completely  corrected  the  deformity, 
and  the  patients  made  a  most  satisfactory  recovery.     The  essential  element 


Fig.  454. — Dislocation  upward  of  acromial  end  of  cla\ic!c. 

•  of  Rhoads's  apparatus  is  a  trunk-strap  applied  after  reduction  of  the  disloca- 
tion, as  shown  in  Figs.  455,  456.  If  the  deformity  can  be  completely  corrected, 
Rhoads's  apparatus  will  serve  a  good  purpose,  but  in  many  cases  it  is  impossible 
really  to  reduce  the  deformity  or  after  apparent  reduction  the  deformity  at  once 
returns.  This  is  due,  as  Moore^  points  out,  to  the  fact  that  the  superior  acro- 
mioclavicular Hgament  is  torn  from  the  clavicle,  but  remains  attached  to  the 
scapula,  and  when  reduction  is  attempted,  is  pushed  under  the  clavicle  and 
nothing  remains  to  hold  the  clavicle  "  in  place  but  the  skin  and  superficial  fascia." 
I  agree  with  Moore  that  the  best  treatment  is  incision,  replacement,  and  sutur- 
ing the  acromion  to  the  outer  end  of  the  clavicle.  The  bones  are  sutured  with 
silver  wire  or  kangaroo  tendon,  the  acromioclavicular  ligament  is  sutured  with 
catgut,  the  wound  is  closed  with  sutures  of  silkworm-gut,  and  the  patient  is 
kept  supine  in  bed  for  three  weeks.  I  have  operated  successfully  on  5  of  these 
cases. 

Dislocation  downward  is  reduced  and  treated  in  the  same  manner  as  dis- 
location upward. 

Simultaneous  dislocation  of  both  ends  of  the  clavicle  is  a  very  rare  injury.  It 
is  treated  as  is  single  dislocation. 

The  so-called  dislocation  of  the  lower  angle  of  the  scapula  is  not,  as  was  long 
1  "Annals  of  Surgery,"  May,  1902. 


752 


Diseases  and  Injuries  of  the  Bones  and  Joints 


taught,  a  dislocation  at  all.  The  lower  angle  and  vertebral  border  deviate 
from  the  chest.  This  condition  was  thought  to  be  due  to  the  bone  sUpping 
from  under  the  latissimus  dorsi  muscle,  but  it  is  now  known  to  be  due  to  par- 
alysis of  the  serratus  magnus  muscle,  iht  bone  being  acted  upon  by  the  trapezius, 


Fig.  455.  Fig.  456. 

Figs.  455,  456. — Rhoads's  apparatus  for  treating  dislocation  upward  of  the  acromial  end 

of  the  clavucle. 

pectoralis  minor,  levator  anguU  scapulae,  and  the  rhomboid  muscles.  Examina- 
tion shows  that  the  scapula  will  not  rotate  normally  forward.  This  is  demon- 
strated by  extending  the  arms  in  front  to  a  right  angle,  the  gliding  forward  of 

the  scapula  upon  the  sound  side 
"^    being  marked,  but  upon  the  dis- 
eased side  being  slight  or  absent 

Treatment  of  paralysis  of  the 
serratus  magnus  muscle  comprises 
massage,  electricity,  passive  mo- 
tion, and  deep  injections  of  strych- 
nin. 

Katzenstein  advocates  opera-' 
tion  for  serratus  palsy.  He  makes 
an  incision  near  to  the  midline  of 
the  back,  exposes  portions  of  origin 
of  the  trapezius  and  rhomboideus 
major,  divides  them,  carries  the 
cut  muscles  downward  and  out- 
ward, and  sutures  them  to  the 
periosteum  of  the  seventh,  eighth, 
and  ninth  ribs  and  to  the  latissimus 
dorsi.  He  then  makes  an ' '  incision 
along  the  inner  surface  of  the  arm 
from  the  middle  up  through  the 
axilla  to  end  on  the  thoracic  wall." 
He  divides  the  humeral  insertion 
of  the  great  pectoral  and  sutures 
its  tendon  to  the  axillary  border  and  the  anterior  scapular  muscles  (Binnie's 
"Operative  Surgery"). 

Dislocation  of  the   Humerus   (Shoulder -joint). — This  injury  is  quite  fre- 
quent because  of  the  free  mobility  of  the  shoulder-joint,  its  anatomical  inse- 


Fig.  457. — Subcoracoid  dislocation  of  shoulder. 


Dislocation  of  the  Humerus  (Shoulder-joint) 


753 


curity,  and  its  exposed  situation;  it  rarely  occurs  in  the  very  young  and  in 
the  aged,  and  is  oftenest  encountered  in  muscular  young  adults.  Shoulder 
dislocation  is  produced  by  throwing  the  arm  into  abduction.  In  this  position 
the  head  of  the  humerus  presses  against  the  lower  and  front  part,  that  is, 
against  the  thinnest  and  most  poorly  supported  portion  of  the  capsule.  In 
almost  all  cases  the  tear  in  the  capsule  occurs  between  the  tendon  of  the  sub- 
scapularis  and  the  triceps.  Hence,  most  dislocations  are  primarily  subglenoid, 
although  the  bone  usually  moves  to  some  other  position,  being  dragged  or 
driven  there  by  the  injuring  force  or  being  pulled  there  by  muscular  action. 
Dislocation  forward  is  much  more  common  than  dislocation  backward  because 
the  long  head  of  the  triceps  keeps  the  head  of  the  bone  from  going  posterior  and 
because  the  anterior  are  stronger  than  the  posterior  muscles.  Four  chief  forms 
of  shoulder-joint  dislocation  exist,  namely:  (i)  forward,  inward,  and  downward, 
under  the  coracoid  process — subcoracoid;  (2)  downward,  forward,  and  inward, 


Fig.  458. — Subcoracoid  dislocation  of  the  left  humerus  (St.  Joseph's  Hospital  case;  photo- 
graphed by  Dr.  Nassau). 

beneath  the  glenoid  cavity — subglenoid;  (3)  backward,  inward,  and  downward, 
imder  the  spine  of  the  scapula — subspinous;  and  (4)  forward,  inward,  and 
upward,  under  the  clavicle — subclavicular. 

A  very  rare  form  of  shoulder-joint  dislocation  is  know-n  as  the  siipracora- 
coid.     Another  rare  form  is  the  luxatio  erecta. 

Subcoracoid  Luxation  (Figs.  457,  458). — The  subcoracoid  variety  of  disloca- 
tion embraces  three-fourths  of  all  shoulder-joint  luxations.  It  may  be  caused  by 
direct  force  driving  the  head  of  the  humerus  forward  and  inward,  or  by  indirect 
force,  such  as  falls  upon  the  hand  or  the  elbow.  In  this  dislocation  the  head 
of  the  bone  lies  against  the  anterior  surface  of  the  scapular  neck  below  the 
coracoid  process.  A  part  of  the  anatomical  neck  of  the  humerus  hes  upon  the 
anterior  margin  of  the  glenoid  cavity,  and  the  head  of  the  bone  is  above 
the  tendon  of  the  subscapularis  muscle. 

Subclavicular  luxation  is  very  rare.     It  is  caused  by  the  same  sort  of  vio- 

48 


754 


Diseases  and  Injuries  cf  the  Bones  and  Joints 


lence  which  produces  subcoracoid  luxation.  The  head  of  the  bone  rests  upon 
the  thorax,  below  the  clavicle,  and  underneath  the  pectorahs  major  muscle. 
Subglenoid  or  Axillary  Luxation  (Fig.  459). — It  may  be  produced  by  con- 
traction of  the  great  pectoral  and  latissimus  dorsi  muscles  when  the  arm  is  at 
aright  angle  to  the  body,  but  it  is  usually  due  to  falls  upon  the  hand  or  the  elbow 
when  the  arm  is  raised  and  the  head  of  the  bone  is  against  the  lower  portion  of 
the  capsule.  In  this  dislocation  the  head  of  the  bone  rests  upon  the  border 
of  the  scapula,  below  the  tendon  of  the  subscapularis,  in  front  of  the  long  head  of 
the  triceps,  and  above  the  teres  muscles.  Most  dislocations  of  the  shoulder  are 
primarily  subglenoid,  the  position  perhaps  being  subsequently  altered  by 
muscular  action. 

Subspinous  luxation  is  a  rare  injury.  Pick  met  with  this  accident  in  a 
man  who,  while  having  his  hands  in  his  pockets,  fell  upon  the  front  of  the  point 
of  the  shoulder.  The  head  of  the  bone  reposes  beneath  the  scapular  spine, 
between  the  infraspinatus  and  teres  minor  muscles. 

Supracoracoid  luxation  is  seldom  encountered.  The  head  of  the  humerus 
rests  upon  the  coraco-acromial  ligament  or  upon  the 
acromion  process,  and  the  acromion  or  the  coracoid 
is  always  fractured. 

Luxatio  Erecta. — In  this  injury  the  arm  is  mark- 
edly abducted  and  in  some  cases  the  elbow  is 
actually  raised  above  the  patient's  head.  As  a 
rule,  the  forearm  rests  behind  the  occiput,  some- 
times on  the  top  of  the  head.  The  patient  holds 
the  forearm  to  the  occiput  or  vertex  to  avoid  pain. 
It  is,  in  reality,  a  form  of  subglenoid  luxation.  In 
such  an  injury  the  head  of  the  bone  has  passed 
under  the  subscapularis  muscle  and  also  under  the 
teres  major  or  the  lower  border  of  the  great  pectoral. 
Judd,  Hulke,  Cleland,  and  others  have  reported 
cases. 

Symptoms  of  Dislocation  of  the  Shoulder-joint. — 
Dislocation  is  diagnosticated  by — (i)  pain  of  a 
sickening  character;  (2)  flattening  of  the  shoulder, 
the  head  of  the  bone  having  ceased  to  bulge  out 
the  deltoid  muscle;  (3)  apparent  projection  of  the 
acromion  through  sinking  in  of  the  deltoid;  (4) 
hollow  beneath  the  acromion,  over  the  empty 
glenoid  cavity,  and  the  bone  missing  from  its  normal 
habitat.  This  hollow  may  be  easily  appreciated  by 
the  finger,  especially  when  the  extremity  is  some- 
what abducted;  (5)  rigidity  (some  movement  is  pos- 
sible in  the  direction  especially  of  an  existing  deform- 
ity, but  mobility  is  strictly  limited  and  attempts  at  motion  produce  great  pain); 
(6)  Dugas's  sign:  the  elbow  cannot  touch  the  side  when  the  hand  is  placed 
upon  the  sound  shoulder,  and  the  hand  cannot  be  placed  upon  the  sound 
shoulder  if  the  elbow  is  to  the  side  (this  is  due  to  the  rotundity  of  the  chest. 
In  a  dislocation  the  head  of  the  bone  is  already  touching  the  chest,  and  the  bone, 
being  approximately  straight,  cannot  touch  the  spherical  surface  of  the  chest 
in  two  places  at  the  same  time.  If  the  elbow  can  be  placed  against  the  chest 
with  the  hand  on  the  sound  shoulder  there  cannot  be  dislocation;  if  it  cannot  be 
so  placed,  there  must  be  dislocation);  (7)  finding  the  head  of  the  bone  in  a  new 
situation;  (8)  examining  by  means  of  the  x-rays.  Symptoms  i  to  5  inclusive  may 
be  grouped  as  Erichsen's  list  of  signs.  The  form  of  dislocation  is  made  out  by 
a  study  of  the  direction  of  the  axis  of  the  limb,  the  existence  and  extent  of 
lengthening  or  of  shortening,  and  the  situation  of  the  head  of  the  bone. 


Fig.    459. — Axillary  disloca- 
tion of  the  right  humerus. 


Dislocation  of  the  Humerus  (Shoulder-joint) 


755 


In  a  shoulder-joint  dislocation  the  head  of  the  bone  may  press  upon  the 
brachial  plexus  and  produce  pain  and  numbness,  and  occasionally  traumatic 
neuritis  or  paralysis;  sometimes  pressure  ui)on  the  axillary  vein  causes  intense 
edema,  and  pressure  upon  the  axillary  artery  diminishes  or  obliterates  the 
pulse.  The  axillary  vessels  may  be  torn  and  the  muscles  may  be  lacerated 
badly.  The  capsule  is  torn  and  considerable  blood  is  usually  effused.  Swell- 
ing is  due  first  to  hemorrhage,  and  secondly  to  inflammation.  Partial  dis- 
location sometimes,  though  rarely,  occurs.  What  is  usually  spoken  of  as 
"partial  dislocation"  or  "subluxation"  is  a  condition  in  which  the  head  of 
the  humerus  passes  forward  under  the  coracoid  because  of  rupture  of  the 
long  head  of  the  biceps  or  because  this  tendon  slips  out  of  its  groove,  the  liga- 
ments of  the  shoulder-joint  being  intact. 

The  following  table  from  T.  Pickering  Pick's  work  on  "Fractures  and 
Dislocations"  makes  the  above  points  clear: 


Direction  of  the  axis           Alteration  in  the  length      Presence  of  the  Head  of  the 

ot  the  limb                                of  the  limb                |        bone  in  new  situation 

Subcoracoid. 

The  elbow  is  carried        Very  slight  length- 

The  head  of  the  bone 

backward  and  slightly    ening. 

cannot  easily  be  felt;  it 

away  from  the  side.      ' 

is  found  at  the  upper  and 
inner  part  of  the  a.xilla. 

Subglenoid. 

The  elbow  is  carried        Very   considerable 

The  head  of  the  bone 

away  from  the  trunk 

lengthening.                      can  easily  be  felt  in  the 

and  slightly  backward. 

1  axilla. 

Subspinous. 

The  elbow  is  raised 

Lengthening  interme-       The  head  of  the  bone 

from  the  side  and  car- 

diate in  degree  between  can  be  felt  and  be  grasped 

ried  forward. 

the  subglenoid  and  the    beneath  the  spine  of  the 

subcoracoid. 

scapula. 

Subclavicular. 

The  elbow  is  carried 

Shortening. 

The  head  of  the  bone 

outward  and  backward. 

can  readily  be  seen  and 
be  felt  beneath  the  clavi- 
cle. 

Diagnosis  of  Shoulder-joint  Dislocation. — In  fracture  of  the  neck  of  the  scapula 
the  acromion  is  prominent,  a  hollow  is  detected  below  it,  and  a  hard  body  is  felt 
in  the  axilla;  but  the  coracoid  process  descends  with  the  head  of  the  humerus, 
which  it  does  not  do  in  dislocation.  Furthermore,  in  fracture  there  is  mobility, 
in  dislocation,  rigidity.  In  fracture  crepitus  is  present;  in  dislocation  it  is 
absent.  In  fracture  the  deformity  is  easily  reduced,  but  it  at  once  recurs;  in 
dislocation  the  deformity  is  with  difficulty  reduced,  but  does  not  recur.  In 
fracture  the  elbow  can  be  made  to  touch  the  side  when  the  hand  is  upon  the 
sound  shoulder;  in  dislocation  it  cannot  be  so  manipulated.  In  fracture  of  the 
anatomical  neck  of  the  humerus  deformity  is  slight;  the  head  of  the  humerus  is 
found  in  place,  does  not  move  when  the  shaft  is  rotated,  and  is  not  in  line  with 
the  axis  of  the  bone.  Crepitus  exists  in  the  fracture  if  impaction  is  absent. 
In  paralysis  of  the  deltoid  muscle  there  is  distinct  flattening,  but  the  bone  is  felt 
in  place  and  there  is  no  rigidity.     The  x-rays  are  invaluable  in  diagnosis. 

Treatment  of  Shotdder-joint  Dislocation. — Reduction  by  manipulation  is  usu- 
ally readily  accomplished  in  a  recent  case  of  shoulder-joint  dislocation.  If  a 
simple  trial  without  ether  fails,  an  anesthetic  should  be  administered.  Ether 
is  given,  but  not  chloroform,  for  chloroform  seems  to  be  particularly  dan- 
gerous to  fife  when  given  to  enable  the  surgeon  to  reduce  a  dislocation  of  the 
shoulder.  Forward  dislocations  (subcoracoid,  subclavicular,  and  axillary) 
are  reduced  by  Kocher's  method  (Fig.  460).  This  method  was  introduced  by 
Kocher  in  1870  ("Sammlung  klin.  Vortrage,"  No.  83).  Reduction  by  this 
method  can  frequently  be  effected  without  the  aid  of  ether.  The  patient  should 
be  recumbent.     Slowly  but  forcibly  adduct  the  abducted  elbow  and  get  it  finally 


756 


Diseases  and  Injuries  of  the  Bones  and  Joints 


against  the  side.  At  the  same  time  draw  it  sHghtly  backward.  The  forearm 
is  flexed.  If  there  is  much  muscular  resistance,  follow  Keetley's  advice,  and 
not  only  bring  the  elbow  to  the  side,  but  push  it  backward  and  inward  toward 
the  spine.  Grasp  the  elbow  with  one  hand,  and  the  wrist  with  the  other,  and 
slowly  make  external  rotation  until  the  forearm  points  outward  from  the  body. 
We  thus  carry  the  head  of  the  humerus  to  the  margin  of  the  glenoid  cavity. 
External  rotation  must  be  done  slowly  and  gently.  When  we  first  try  it  there 
is  much  muscular  resistance.  If  enough  force  is  used  to  overcome  the  resistance 
the  surgical  neck  of  the  bone  may  be  broken.  By  gently  and  gradually  per- 
sisting in  external  rotation  the  muscles  are  finally  tired  out  and  relax.  Next 
lift  the  elbow  anteriorly  as  far  forward  as  it  will  go,  so  as  to  bring  the  head  of 
the  humerus  to  the  glenoid  margin  just  opposite  the  capsular  tear  (Keetley). 
Then  throw  the  bone  into  place  by  gradually  swinging  the  forearm  inward 
across  to  the  other  side  of  the  chest,  that  is,  by  internal  rotation.  The  formula 
is,  flexion  of  the  forearm,  external  rotation,  lifting  the  elbow  forward,  internal 
rotation  of  the  arm,  and  lowering  the  elbow.  The  motions  to  unlock  the  bone 
and  start  it  to  retrace  the  steps  it  took  when  emerging  should  be  gentle,  not 
forcible,  slow,  not  sudden,  and  rigid  muscles  should  be  tired  out  and  made  to 
relax  by  steady  traction  upon  them.  Sudden  and  violent  motions  increase 
rigidity.     Adduction  stretches  the  upper  portion  of   the  capsule  and  presses 


Fig.  460. — Kocher's  method  of  reduction  by  manipulation:  a,  First  movement,  outward 
rotation;  b,  second  movement,  elevation  of  elbow;  c,  third  movement,  inward  rotation  and 
lowering  of  the  elbow  (Ceppi). 

the  head  against  the  glenoid.  External  rotation  opens  the  tear  in  the  capsule. 
Elevation  relaxes  the  untorn  part  of  the  capsule  and  coracohumeral  ligament 
and  stretches  the  torn  portion.  On  this  fulcrum  the  head,  which  is  the  end  of  a 
lever,  is  forced  into  place.  If  in  trying  Kocher's  plan  external  rotation  of  the 
humerus  does  not  take  place,  abandon  the  method,  as  persistence  will  fracture 
the  humerus.  Another  method  of  manipulation  is  as  follows:  if  the  right 
shoulder  is  dislocated,  the  surgeon  stands  behind  the  patient  (who  is  sitting 
erect);  if  the  left  shoulder  is  dislocated,  he  stands  in  front  of  the  patient.  The 
surgeon  holds  the  forearm  flexed  upon  the  arm  with  his  right  hand  and  makes 
external  traction  and  rotation,  and  with  the  fingers  of  his  left  hand  he  tries  to 
force  the  bone  into  place. 

In  Henry  H.  Smith's  method  for  forward  dislocation  the  surgeon  stands 
in  front  of  the  patient.  If  the  left  shoulder  is  dislocated,  the  surgeon  grasps 
it  with  his  left  hand;  if  the  right  shoulder  is  dislocated,  he  grasps  it  with  his 
right  hand,  the  thumb  resting  on  the  head  of  the  bone.  With  his  disengaged 
hand  the  surgeon  grasps  the  elbow,  abducts  it,  makes  traction  and  external 
rotation,  and  suddenly  sweeps  the  elbow  inward,  aiming  it  at  the  sternum, 
and  tries  with  his  thumb  to  push  the  bone  into  place.  In  subspinous  luxa- 
tions reduction  may  be  effected  if  the  surgeon  stands  behind  the  patient,  makes 
abduction,  traction,  and  internal  rotation,  sweeps  the  elbow  inward  toward  the 
spine,  and  with  thumb  aids  the  bone  in  its  return  into  position.  Raising  the 
elbow  far  above  the  head  and  sweeping  it  inward  will  reduce  some  dislocations. 
As  the  head  of  the  bone  shps  back  a  distinct  jar  is  felt  and  a  snap  is  heard,  the 


Unreduced  and  Irreducible  Dislocations  of  the  Shoulder        757 

motions  of  the  joint  are  again  obtainable,  and  with  the  hand  on  the  opposite 
shoulder  the  elbow  may  be  made  to  touch  the  side. 

Reduction  by  Extension. — Before  attempting  the  reduction  of  a  dislocation 
of  the  shoulder-joint  by  extension  the  patient  should  be  anesthetized  and  placed 
upon  a  low  bed  or  upon  the  floor.  The  surgeon  then  places  his  foot,  covered  only 
by  a  stocking,  in  the  axilla.  Place  the  sole  of  the  foot,  not  the  heel,  against  the 
chest  high  up,  the  instep  being  made  to  touch  the  humerus  and  the  heel  the  bor- 
der of  the  shoulder-blade,  a  towel  being  first  put  into  the  axilla  to  rest  the 
foot  against  (Fig.  461).  If  the  left  arm  is  dislocated,  use  the  left  foot,  and  vice 
versa.  The  elder  Gross  approved  of  making  extension  while  sitting  between 
the  patient's  limbs.  Make  steady  extension,  which  will  in  many  cases  bring 
about  the  reduction.  If  it  fails  to  cause 
reduction,  bring  the  patient's  arm  across 
the  chest  and  use  the  foot  as  the  fulcrum 
of  a  lever.  If  the  humerus  is  pretty 
firmly  fixed  in  its  abnormal  position, 
make  counterextension  with  a  foot  in 
the  axilla  and  make  extension  by  fixing 
a  clove-hitch  (see  Fig.  453)  above  the 
elbow  and  fastening  to  it  bands  which 
go  over  one  shoulder  and  under  the 
other    shoulder   of    the    surgeon.      The  p^;  461. -Reduction  of  shoulder-Toint 

back  may  thus  be  used  for  extension,  dislocation  by  the  foot  in  the  axilla  (Cooper). 
the  hands  being  left  free  for  manipula- 
tion (Allis's  and  Pick's  plan).  Lateral  extension  is  used  by  some  surgeons. 
The  patient  lies  down,  a  large  piece  of  canvas  is  spht,  the  arm  is  passed 
through  the  split,  and  the  body  is  thus  fixed.  The  arm  is  pulled  to  a  right 
angle  with  the  body  and  traction  is  applied. 

The  late  Prof.  Joseph  Pancoast  favored  Sir  Astley  Coopers  method  of  placing 
the  unanesthetized  patient  in  a  chair  and  using  the  knee  as  a  fulcrum,  pushing 
the  elbow  to  the  side  (Fig.  462).  Brunus,  in  the  thirteenth  century,  devised  the 
method  of  upward  extension.  In  applying  this  method  the  surgeon  takes 
his  place  behind  the  patient,  steadies  the  scapula  with  his  hand,  and  carries 
the  patient's  arm  upward  and  backward  above  his  head,  making  extension  and 
external  rotation  (Fig.  463).  La  Mothe's  method  is  applied  with  the  patient 
supine  upon  the  floor.  The  surgeon  places  his  foot  upon  the  shoulder  to  make 
counterextension,  and  makes  extension  as  in  Brunus's  method.  It  is  a  useful 
expedient,  when  either  of  these  plans  is  applied,  to  have  an  assistant  make  the 
traction  while  the  surgeon  manipulates  the  head  of  the  bone.  Cock  advises, 
when  reduction  fails,  that  an  air-pad  be  placed  in  the  axilla  and  the  arm  be  bound 
to  the  side — a  method  by  which  reduction  will  sometimes  take  place  after  two  or 
three  days. 

Pulleys  should  not  be  used  to  pull  the  bone  into  place,  as  they  develop  a 
dangerous  force.  In  a  dislocation  irreducible  by  ordinary  force,  antiseptic 
incision  is  safer  and  better  than  the  pulleys.  After  incision  try  to  restore  the 
bone  to  place. 

In  reducing  a  dislocation  the  axillary  artery  or  vein  may  be  ruptured, 
fracture  of  the  neck  of  the  humerus  may  take  place,  injury  to  the  brachial 
plexus  may  occur,  or  the  soft  parts  may  be  badly  damaged.  After  reducing 
a  dislocation  apply  a  Velpeau  bandage,  keep  the  shoulder  immobile  for  one 
week,  then  make  passive  motion  daily,  reapplying  the  dressing  after  each 
seance.  The  patient  may  wear  a  sling  only  during  the  third  week,  after 
this  period  he  may  use  the  arm.  (For  Compound  Dislocations,  see  page 
748.) 

Unreduced  and  Irreducible  Dislocations  of  the  Shoulder. — In  some  cases 
where  we  find  there  is  considerable  movement  without  pain  we  can,  by  manipu- 


758 


Diseases  and  Injuries  of  the  Bones  and  Joints 


lation  and  active  motion,  increase  the  range  of  movement  and  the  usefulness  of 
the  new  joint. 

As  a  rule,  in  a  youth  or  a  middle-aged  person  we  attempt  bloodless  reduction 
if  the  head  of  the  bone  is  movable  and  there  is  no  prospect  of  a  useful  new  joint. 
Give  ether,  break  up  adhesions  by  forced  flexion  and  extension,  and  try  Kocher's 
method,  and,  if  this  fails,  the  other  methods,  but  never  use  violent  force.  In 
reducing  an  old  dislocation  we  may  fracture  the  surgical  neck  of  the  humerus. 
I  have  seen  this  happen  twice.  The  proper  treatment  is  incision  and  pulling 
the  head  into  place  by  McBurney's  hooks.  In  attempting  reduction  of  an  old 
dislocation  by  force  the  brachial  plexus  may  be  lacerated  or  one  or  both  of 
the  axillary  vessels  may  be  torn.  If  an  axillary  vessel  is  torn,  it  must  be  at 
once  exposed  by  incision.     A  larger  tear  in  either  vessel  requires  a  ligature 

about  the  vessel  on  each  side  of  the  tear. 
A  small  tear  may  be  sutured  (Keetley,  in 
"Lancet,"  Jan.  23,  1904).  Rather  than 
use  sufficient  force  to  endanger  the  ves- 
sels in  attempting  to  reduce  an  old  dis- 


FiG.  462. — Reduction  of  shoulder- 
joint  dislocation  by  the  knee  in  the 
axilla  CCooper). 


Fig.  463. — Reduction  of  shoulder-joint  dislocation 
by  upward  e.xtension  CCooper). 


location,  practice  incision.  In  some  cases  after  incision  the  head  of  the  bone 
can  be  pulled  and  pushed  into  place.  In  other  cases  the  head  must  be  resected. 
After  reduction  of  an  old  dislocation  immobilize  for  three  weeks,  and  begin 
passive  motion  after  seven  days. 

If  a  dislocation  is  complicated  by  a  fracture  of  the  humerus,  try  to  pull  the 
head  of  the  bone  opposite  the  joint.  This  may  be  possible  if  the  two  frag- 
ments are  held  partly  together  by  a  fair  amount  of  periosteum  and  muscle. 
Traction  is  exerted  upon  the  arm,  and  an  attempt  is  made  to  manipulate  the 
head  into  the  socket  (Allis's  plan  in  the  hip).  McBurney  incises,  fixes  a  hook 
in  the  scapula  and  a  hook  in  the  head  of  the  humerus,  pulls  the  head  into 
place,  and  wires  the  fragments  (see  Figs.  315,  316).  In  an  emergency  gimlets 
may  be  used  instead  of  the  hooks.  In  some  cases  it  is  necessary  to  excise 
the  head  of  the  bone. 

Habitual  or  Recurrent  Dislocation. — Habitual  or  recurrent  dislocation 
of  the  shoulder,  following  an  original  traumatic  dislocation,  results  usually 
from  a  slight  or  trivial  force.  It  is  apt  to  take  place  when  the  arm  is  in  ab- 
duction, slight  rotation  frequently  being  necessary.  In  some  cases  rotation 
will  produce  a  dislocation  while  the  arm  is  near  the  side  of  the  body.  Little 
is  known  of  the  frequency  with  which  these  cases  occur,  but  they  are  probably 
much  more  frequent  than  is  generally  supposed.  The  frequency  of  the  recur- 
rences in  the  individual  cases  varies  widely.  In  some  they  occur  more  or  less 
regularh'  every  two  or  three  years,  while  in  others  they  have  been  known  to 
take  place  daily  and  even  several  times  a  day.  In  most  cases  in  the  intervals 
between  the  recurrences  the  joint  functionates  normally  without  difficulty, 
although  the  patient  fears  abduction  because  of  its  influence  in  favoring  a 
recurrence.     In  rare  cases  pain  persists  a  long  time  after  each  dislocation,  so 


Dislocation  of  the  Elbow-joint 


759 


Fig.  464. — Dislocation  of  both  bones  of  the  fore- 
arm backward. 


that  if  the  recurrences  are  frequent,  the  patient  may  be  compelled  to  give  up 
work. 

Cause.-^The  essential  cause  is  a  relaxation  of  the  capsule  at  the  site  of  the 
original  tear,  produced  by  the  addition  to  the  old  or  original  portion  of  capsule 
of  a  new  or  cicatricial  portion  bridging  over  the  gap  between  the  margins  of 
the  tear  produced  by  the  first  dis- 
location. The  failure  of  these 
margins  to  unite  closely  is  due  to 
the  repeated  emergence  of  the 
humeral  head  forcing  them  apart 
before  union  is  complete.  The 
defects  in  the  head  of  the  humerus 
which  have  been  found  at  autopsy 
and  operation  have,  probably,  only 
a  slight  and  secondary  causal  im- 
portance, while  the  fractures  of  the 
greater  tuberosity  of  the  humerus 
sometimes  occurring  in  dislocations 
of  the  shoulder  are  probably  not 
followed  by  recurrent  dislocations. 
Treatment.  —  Excision  of  the 
head  of  the  humerus  has  been 
abandoned  in  these  cases.  Cap- 
sulorrhaphy  for  the  shortening  of 
the  relaxed  anterior  portion  of  the 
capsule  has  given  excellent  func- 
tional results.  Dawbarn,  of  New  York,  did  this  operation  in  my  clinic,  upon 
a  city  fireman,  and  the  result  was  a  perfect  success.  I  have  had  two  grati- 
fying results.  The  capsule  may  be  exposed  through  the  usual  resection 
incision  along  the  anterior  margin  of  the  deltoid.  This  may  be  modified  by  an 
additional  incision  outward  at  right  angles  to  the  first,  and  the  insertion  of  the 
pectoralis  major  may  be  partially  divided.  T.  Turner  Thomas  advocated  an 
axillary  incision  along  the  inner  border  of  the  coracobrachialis,  passing  between 

this  muscle  and  the  axillary  vessels  and 
nerves,  and  avoiding  particularly  the  cir- 
cumflex and  musculocutaneous  nerves. 
The  subscapularis  muscle  is  partially  di- 
vided to  give  a  freer  exposure  of  the  cap- 
sule. This  route  exposes,  by  a  small  incision, 
the  site  of  the  original  tear  in  the  capsule. 
It  avoids  division  of  the  deltoid  and  gives 
dependent  drainage  if  drainage  is  necessary. 
At  present  he  prefers  a  posterior  axillary 
incision.  He  has  operated  on  18  shoulders 
and  has  had  16  complete  successes  ("Sur- 
gery, Gynecology  and  Obstetrics,"  1914, 
xviii) . 
The  relaxed  portion  of  the  capsule  may  be  shortened  by  taking  up  a  reef 
with  catgut  or  silk  sutures,  without  opening  and  exploring  the  joint  for  loose 
pieces  of  bone;  the  capsule  may  be  incised  transversely  to  its  longitudinal 
fibers  and  the  margins  of  the  incision  overlapped;  an  oval  piece  may  be  ex- 
cised and  the  edges  united  by  sutures ;  or  the  margins  of  the  original  tear  may 
be  found  and  sutured  together. 

Dislocation  of  the  elbow-joint  is  not  infrequent,  and  is  commonest  in  chil- 
dren. Both  bones  or  only  one  bone  of  the  forearm  may  be  dislocated,  and  the 
dislocation  may  be  partial  or  complete. 


465 


-Reduction  of  elbow-joint 
dislocation. 


760  Diseases  and  Injuries  of  the  Bones  and  Joints 

Dislocation  of  Both  Bones  Backward  (Fig.  464). — The  causes  of  backward 
dislocation  of  both  bones  of  the  forearm  are  falls  upon  the  extended  hand  or 
twists  inward  of  the  ulna  (Malgaigne).  The  coronoid  process  lodges  in  the 
olecranon  fossa  of  the  humerus. 

Symptoms  of  Backward  Dislocation. — In  complete  dislocation  of  both 
bones  of  the  forearm  the  olecranon  is  very  prominent.  The  distance  between 
the  point  of  the  olecranon  and  the  apex  of  the  inner  condyle  is  notably  greater 
than  on  the  sound  side;  the  forearm  is  flexed,  supinated,  and  shortened;  the  lower 
end  of  the  humerus  projects  in  front  of  the  joint,  below  the  skin-crease;  the 
head  of  the  radius  is  found  back  of  the  outer  condyle;  and  there  are  the  general 
symptoms  of  dislocation.  Fracture  of  the  coronoid  rarely  occurs  with  back- 
ward dislocation,  but  if  it  does  occur,  there  will  be  crepitus  and  mobility.  Frac- 
ture at  the  base  of  the  condyles  is  distinguished  from  dislocation  of  both  bones 
of  the  forearm  backward  by  the  following  points:  in  fracture  there  are  found 
the  ordinary  symptoms;  measurement  from  the  condyles  to  the  styloid  processes 
does  not  show  shortening;  there  is  no  alteration  of  the  normal  relation  between 
the  olecranon  process  and  the  condyles;  and  the  projection  in  front  of  the  joint 
is  above  the  crease  of  the  bend  of  the  elbow. 


Fig.  466. — Forward  dislocation  of  the  radius. 

Treatment  of  Backward  Dislocation. — Reduction  must  be  effected  early  in 
dislocation  of  both  bones  of  the  forearm,  because  it  will  soon  become  impos- 
sible, and  an  unreduced  dislocation  means  a  limb  without  the  powers  of 
flexion,  pronation,  and  supination.  The  surgeon  may  place  his  knee  in  front 
of  the  elbow-joint,  grasp  the  patient's  wrist,  press  upon  the  radius  and 
ulna  with  his  knee,  and  bend  the  forearm  with  considerable  force,  the  muscle 
pulling  the  bones  into  place  (Sir  Astley  Cooper's  plan).  Forced  flexion,  traction 
and  extension  may  be  tried  (Fig.  465).  Put  the  arm  in  Jones's  position  for 
two  weeks,  and  make  passive  motion  daily  after  the  first  few  days. 

Dislocation  of  Both  Bones  Forward. — The  cause  of  forward  dislocation 
of  both  bones  of  the  forearm  is  a  blow  on  the  olecranon  when  the  arm  is  flexed. 
It  is  an  unusual  accident. 

Symptoms  and  Treatment. — The  symptoms  of  forward  dislocation  of  both 
bones  of  the  forearm  are:  the  forearm  is  flexed  and  lengthened;  some  sHght 
motion  is  possible;  the  olecranon  is  on  a  level  with  the  condyles  if  unfractured, 
hence  its  prominence  is  gone;  the  humeral  condyles  are  felt  posteriorly,  and 
the  radius  and  ulna  are  felt  anteriorly.  The  treatment  of  this  injury  consists 
in  early  reduction,  which  is  accomplished  by  means  of  forced  flexion,  extension, 
and  pressure,  placing  the  part  in  Jones's  position  for  two  weeks,  and  making 
passive  motion  daily  after  the  first  few  days. 

Lateral  dislocation  of  both   bones  of   the  forearm  is  usually  incomplete. 

Symptoms  and  Treatment  of  Outward  Dislocation. — The  symptoms  of  out- 
ward dislocation  of  both  bones  of  the  forearm  are:  the  forearm  is  flexed, 
fixed,  and  pronated;  the  joint  is  widened;  the  head  of  the  radius  projects  ex- 


Dislocation  of  the  Radius  Backward 


761 


ternally  and  has  a  depression  above  it;  the  inner  condyle  projects  internally 
and  has  a  depression  below  it;  the  olecranon  is  nearer  than  normal  to  the 
external  condyle  and  further  than  normal  from  the  internal  condyle.  Reduction 
is  effected  by  extension  of  the  forearm  and  pressure  inward  upon  the  head  of 
the  radius.  Apply  an  ascending  spiral  reversed  bandage  of  the  forearm,  a 
figure-of-8  bandage  of  the  elbow-joint,  and  a  sHng.  Make  passive  motion 
after  a  few  days.     The  bandages  must  be  worn  for  two  weeks. 

Symptoms  and  Treatment  of  Inward  Dislocation. — In  dislocation  inward 
of  both  bones  of  the  forearm  the  position  of  the  forearm  is  the  same  as  that  in 
dislocation  outward;  the  sigmoid  cavity  of  the  ulna  projects  internallv,  and 
the  external  condyle  projects  ex- 
ternally. Reduction  is  effected 
by  extension  of  the  forearm  and 
pressure  outward  on  the  ulna, 
subsequent  treatment  being  the 
same  as  that  employed  in  the 
preceding  form. 

Dislocation  of  the  ulna  alone 
is  very  rare,  and  can  take  place 
backward  only. 

Symptoms  and  Treatment. — 
Dislocation  of  the  ulna  alone 
is  indicated  by  the  forearm 
being  flexed  and  pronated. 
The  head  of  the  radius  is  found 
in  place,  and  the  olecranon 
projects  posteriorly.  The  treat- 
ment of  this  injury  is  the  same 
as  that  for  dislocation  of  both 
bones. 

Dislocation  of  the  radius  for- 
ward (Fig.  466)  is  the  common- 
est form  of  dislocation  of  the 
elbow.  This  injury  is  caused 
by  a  fall  upon  the  hand  with 
the  forearm  in  pronation  and 
extension,  or  is  produced  by 
blows  on  the  back  of  the  joint; 
forced  pronation  alone  will  not 
cause  it. 

Symptoms  and  Treatment. — 
The  symptoms  in  dislocation  of 
the  radius  forward  are:  the  fore- 
arm is  midway  between  pronation  and  supination,  and  is'  semiflexed;  attempts 
to  increase  flexion  cause  the  radius  to  strike  against  the  humerus  with  a 
distinct  blow;  the  head  of  the  radius  is  felt  in  front  of  the  outer  condyle  and 
is  missed  from  its  proper  abode.  Reduction  is  effected  by  flexion  over  the 
knee,  extension,  and  manipulation.  The  subsequent  treatment  is  Jones's 
position  and  passive  motion.  Deformity  is  apt  to  recur  after  reduction  be- 
cause of  rupture  of  the  orbicular  ligament.  If  permanent  dislocation  exists, 
resection  of  the  head  of  the  radius  is  necessary.  Passive  motion  should  be 
begun  in  two  weeks  after  the  resection.  The  results  as  to  function  and 
strength  are  usually  excellent. 

Dislocation  of  the  radius  backward  (Fig.  467)  is  caused  by  falls  on  the  hand 
or  by  blows  on  the  front  of  the  joint. 

Symptoms  and  Treatment. — Backward  dislocation  of  the  radius  is  indicated 


Fig.  467. — Dislocation  of  the  radius  backward. 


762  Diseases  and  Injuries  of  the  Bones  and  Joints 

by  the  forearm  being  sUghtly  flexed  and  fixed  in  pronation,  by  some  impair- 
ment of  flexion  and  extension,  and  by  the  head  of  the  radius  being  felt  behind 
the  outer  condyle.  Reduction  is  efTccted  by  flexion  over  the  knee,  extension, 
and  manipulation,  and  the  subsequent  treatment  is  the  same  as  that  given  for 
the  preceding  dislocation. 

Dislocation  of  the  radius  outward  is  very  rare.  In  this  injury  the  head  of 
the  radius  is  distinctly  felt.  Reduction  is  effected  by  extension  and  pres- 
sure; the  subsequent  treatment  is  the  same  as  that  for  the  above-mentioned 
dislocations. 

Subluxation  of  the  Head  of  the  Radius. — This  name  is  given  to  an  injury 
which  is  very  frequent  in  children  between  two  and  four  years  of  age.  It 
results  from  traction  upon  the  hand  or  the  forearm,  and  often  arises  when  the 
nurse  or  the  mother  pulls  upon  a  child's  arm  to  save  it  from  a  fall  or  to  lift  it 
over  a  gutter.  Some  writers  hold  that  pronation  as  well  as  extension  is  required 
to  produce  the  injury;  many  surgeons  claim  that  extension  and  adduction  are 
the  causative  forces.  Hutchinson  asserts  that  supination  may  cause  subluxa- 
tion.    Bardenheuer  assigned  falls  as  causes. 

The  symptoms  are  very  characteristic.  The  history  points  to  the  injury. 
Pain  and  perhaps  a  click  may  be  felt  about  the  elbow,  and  pain  and  a  click  may 
also  be  felt  in  the  wrist  at  the  time  of  the  accident.  The  arm  hangs  by  the  side, 
with  the  elbow-joint  slightly  flexed  and  the  forearm  midway  between  pronation 
and  supination.  Flexion  to  an  angle  of  less  than  60  degrees  and  complete 
extension  are  resisted  and  are  very  painful,  but  movements  between  60  and  130 
degrees  are  free  and  painless.^  The  movements  of  the  wrist-joint  are  free  and 
])ainless.  The  elbow-joint  presents  no  deformity.  Pressure  over  the  head  of 
the  radius  causes  pain.  Strong  pronation  is  painful;  strong  supination  is  very 
painful,  and  there  seems  to  be  a  mechanical  obstacle  to  its  performance.  Forced 
supination  develops  a  distinct  click  at  the  head  of  the  radius,  and  causes  prona- 
tion and  supination  to  become  natural  and  free  from  pain.  The  condition 
will  be  reproduced  if  the  parts  are  not  immobilized  for  a  time.  The  nature  of 
the  lesion  is  not  understood,'  and  various  conditions  have  been  thought  to  exist 
by  different  observers.  Among  them  may  be  mentioned  the  following:  a 
slight  anterior  displacement  of  a  head  of  the  radius;  a  slight  posterior  displace- 
ment; locking  of  the  tuberosity  of  the  radius  behind  the  inner  edge  of  the  ulna; 
dislocation  of  the  triangular  cartilage  of  the  wrist;  intracapsular  fracture  of  the 
radial  head;  painful  paralysis  from  nerve-injury;  displacement  by  elongation, 
the  return  of  the  bone  being  prevented  by  collapse  of  the  capsule;  and  the 
slipping  up  of  the  margin  of  the  orbicular  ligament  over  the  rim  of  the  head 
of  the  radius. 

Treatment. — In  order  to  reduce,  place  the  forearm  at  a  right  angle  to  the 
arm  and  make  forcible  supination.  Apply  an  anterior  angular  splint,  and  have 
it  worn  for  four  or  five  days,  or  put  the  part  in  Jones's  position  for  an  equal  period. 

Dislocation  of  the  Inferior  Radio-ulnar  Articulation. — See  page  763. 

Dislocation  of  the  Ulna  Backward. — This  is  caused  by  forcible  pronation, 
for  instance  wringing  clothes.  The  wrist  is  pronated  and  extended,  the  fingers 
are  extended  or  semiflexed  and  almost  powerless,  supination  is  impossible, 
the  hand  is  adducted  and  the  head  of  the  bone  is  prominent  posteriorly  on  the 
radius.  This  is  reduced  by  separating  the  two  bones  with  the  thumbs  and 
pushing  on  the  ulna  while  an  assistant  supinates  the  hand. 

Dislocation  of  the  Ulna  Forward. — This  is  caused  by  forcible  supination. 
Pronation  is  impossible.  The  wrist  is  narrowed  and  the  ulna  projects  anteriorly. 
Reduction  is  secured  by  manipulation,  extension  and  pronation. 

Madelung's  deformity  results  from  the  strain  of  persistent  heavy  work 
upon  the  radius  of  one  who  has  not  yet  reached  puberty.     The  lower  end  of 

'See  the  instructive  article  by  W.  W.  Van  Arsdale,  in  "Annals  of  Surgery,"  vol.  ix,  1889. 


Dislocation  of  Individual  Carpal  Bones  763 

the  radius  becomes  flexed,  the  ulna  projects  posteriorly.  Slight  backward 
projection  of  the  ulna,  the  radius  not  being  flexed,  may  arise  from  overwork  in 
childhood.  In  such  a  case  the  ulna  is  hypertrophied  and  full  extension  is 
impossible. 

Dislocation  of  the  wrist  is  very  uncommon  and  is  caused  by  a  fall  upon 
the  hand. 

Backward  Dislocation  of  the  Wrist.  Symptoms. — The  deformity  in  back- 
ward dislocation  of  the  wrist  (Fig.  468,  a)  resembles  that  of  Colles's  fracture 
(Fig.  468,  b).  The  lingers  are  flexed,  the  wrist  is  bent  backward,  the  radius 
projects  on  the  front  of  the  wrist,  the  carpus  projects  on  the  dorsal  surface  of 
the  forearm,  the  relation  of  the  styloid  process  of  the  radius  to  the  styloid 
process  of  the  ulna  is  unaltered  (it  is  altered  in  Colles's  fracture),  there  is 
rigidity,  and  crepitus  is  absent. 

Forward  dislocation  of  the  wrist  is  very  unusual  and  is  caused  by  a  fall 
upon  the  back  of  the  hand. 

Symptoms  and  Treatment. — In  forward  dislocation  of  the  wrist  the  radius 
and  ulna  project  posteriorly  and  the  carpus  projects  in  front.     The  treatment 


Pig.  468. — Deformity  in  dislocation  of  the  wrist  backward  (a)  and  in  Colles's  fracture  (b) 

(Stimson). 

in  both  of  these  dislocations  is  reduction  by  extension  and  manipulation,  the 
use  of  a  Bond  splint  for  ten  days,  and  the  employment  of  passive  motion  after 
five  or  six  days. 

Dislocation  at  the  inferior  radio-ulnar  articulation  is  rare  and  is  caused 
by  twisting.     A  fracture  occurs  with  it. 

Symptoms  and  Treatment. — In  forward  dislocation  at  the  inferior  radio- 
ulnar articulation  the  forearm  is  pronated,  the  space  between  the  styloid  proc- 
esses is  diminished,  and  the  ulna  forms  a  projection  posteriorly.  In  backward 
dislocation  the  forearm  is  supinated,  the  space  between  the  styloid  processes 
is  diminished,  and  the  ulna  projects  in  front.  Reduction  is  accomplished  by 
extension  and  manipulation.  Two  straight  splints  (as  in  fracture  of  both 
bones)  are  to  be  applied  for  four  weeks,  and  passive  motion  is  to  be  made  in 
the  third  week. 

Dislocation  of  Individual  Carpal  Bones. — Pick  says  there  is  one  weak  spot, 
which  is  "between  the  head  of  the  os  magnum  and  the  scaphoid  and  semilunar 
bones,"  and  the  os  magnum  may  be  forced  up.  The  lesion  is  called  by  some 
dislocation  of  the  os  magnum  backward.  Some  surgeons  believe  the  condition 
is  a  dorsal  dislocation  of  the  carpus  over  the  semilunar  bone.  Codman  and 
Chase  ("Annals  of  Surgery,"  March  and  June,  1905)  regard  the  injury  as 
really  dislocation  of  the  semilunar  forward,  a  dislocation  which  may  be  associated 
with  fracture  of  the  carpal  scaphoid.  The  injury  is  caused  by  forcible  overex- 
tension or  by  twisting  of  the  wrist.  According  to  Codman  and  Chase,  the  in- 
jury is  most  frequently  met  with  in  men  between  the  ages  of  thirty  and  forty, 
results  from  violent  force,  immediately  produces  severe  pain,  soon  followed  by 
tenderness  and  ecchymosis.  On  examination  a  slight  silver-fork  deformity  is  ob- 
served, the  posterior  projection  being  the  os  magnum,  this  projection  being 
separated  from  the  radius  by  a  groove  which  marks  the  former  situation  of  the 
dislocated  semilunar.  The  dislocated  bone  is  felt  under  the  flexor  tendons 
of  the  wrist,  the  palm  seems  shorter  than  its  fellow,  the  fingers  are  partly  flexed, 


764  Diseases  and  Injuries  of  the  Bones  and  Joints 

active  or  passive  motion  causes  pain,  and  the  x-rays  exhibit  the  dislocated 
bone  (Ibid.). 

A  trauma,  even  a  sHght  one,  which  damages  the  Hgament  carrying  the  blood 
supply  to  the  semilunar,  may  be  followed  by  rarefaction  of  that  bone,  and  pos- 
sibly fracture  from  slight  force.  Pain  and  swelling  of  the  wrist  persist,  motion 
is  circumscribed  and  strength  is  lessened. 

Treatment. — According  to  Codman  and  Chase,  recent  dislocations  (even 
after  the  fifth  week)  may  be  reduced  by  hyperextension  followed  by  hyper- 
flexion  over  "the  thumbs  of  an  assistant  held  firmly  in  the  flexure  of  the  wrist 
or  the  semilunar"  (Ibid.). 

If  bloodless  reduction  fails,  the  author  advises  palmar  incision  and  reduction, 
and  if  this  fails,  excision  of  the  bone.  If  in  excising  the  semilunar  the  scaphoid 
is  found  to  be  fractured,  the  proximal  part  or  the  entire  scaphoid  must  also 
be  removed.     The  functional  result  from  operation  is  excellent. 

Dislocation  of  a  metacarpal  bone  is  seldom  encountered.  The  first  meta- 
carpal bone  is  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocation  of  a  metacarpal  bone  is  obvious 
because  of  projection.  It  is  reduced  by  extension  and  manipulation,  a  straight 
splint  and  large  pad  for  the  palm  are  applied  (as  in  fracture  of  the  metacarpus), 
and  the  splint  is  worn  for  three  weeks. 

Dislocation  at  a  metacarpophalangeal  articulation  is  unusual.  Backward 
dislocation  is  the  most  common.     The  cause  is  a  fall  upon  the  hand. 

Symptoms  and  Treatment. — A  dislocation  at  a  metacarpophalangeal  articu- 
lation is  obvious.  Reduction  is  easily  effected  by  extension  and  manipulation, 
except  in  the  case  of  the  thumb.     A  splint  must  be  worn  for  three  weeks. 

Dislocation  of  the  Metacarpophalangeal  Joint  of  the  Thumb. — In  this 
dislocation  the  phalanx  usually  passes  backward.  In  some  cases  the  long  flexor 
of  the  thumb  gets  to  the  ulnar  side  of  the  head  of  the  metacarpal  bone  and 
hinders  reduction  (J.  Hutchinson,  Jr.,  in  "Brit.  Med.  Jour.,"  Jan.  15,  1898). 
The  chief  impediments  to  reduction,  as  demonstrated  by  Farabeuf,  are  the 
sesamoid  bones  and  glenoid  ligament,  which  accompany  the  base  of  the  phalanx 
in  the  dislocation.  It  is  not  probable  that  the  catching  of  the  metacarpal  bone 
between  the  two  heads  of  the  flexor  brevis,  which  often  happens,  is  an  important 
impediment. 

The  symptoms  of  backward  dislocation  are  as  follows:  The  base  of  the 
first  phalanx  rests  upon  the  metacarpal  bone;  the  head  of  the  metacarpal  bone 
projects  forward  and  buttonholes  the  muscles  of  the  thumb;  the  first  phalanx 
of  the  thumb  is  strongly  extended,  and  the  terminal  phalanx  is  semiflexed. 
The  symptoms  of  forward  dislocation  are  as  follows:  The  base  of  the  first 
phalanx  is  felt  in  the  palm,  and  the  head  of  the  metacarpal  bone  is  felt  posteriorly. 

Treatment. — In  treating  backward  dislocation  of  the  metacarpophalangeal 
joint  of  the  thumb  reduction  is  difficult.  Always  give  ether.  Keetley's 
directions  are  to  adduct  the  metacarpal  bone  into  the  palm  (this  relaxes  the 
flexor  muscles)  and  to  have  an  assistant  hold  it;  bend  the  thumb  strongly  back, 
extend,  pull  the  thumb  toward  the  fingers,  and  suddenly  flex.  To  get  a  firm 
enough  grasp  for  these  manipulations  use  the  apparatus  of  Charriere  or  of  Levis 
(Figs.  469,  470).  If  the  above  maneuvers  fail,  incise  freely  on  the  dorsum  and 
reduce.  Tenotomy  is  seldom  of  service.  After  reduction  of  this  dislocation 
a  splint  must  be  worn  for  three  weeks.  In  forward  dislocation  reduction  is 
easily  effected  by  strong  extension  and  forced  flexion.  A  splint  is  to  be  worn 
for  three  weeks. 

A  dislocation  of  a  phalanx  may  be  complete  or  may  be  partial.  It  is  most 
common  between  the  first  and  second  phalanges. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious. 
In  reducing  such  dislocations  employ  extension  and  manipulation.  Use  a 
splint  for  one  week. 


Pelvic  Dislocations 


765 


Dislocations  of  the  Ribs  and  Costal  Cartilages. — The  ribs  may  be  dislocated 
from  the  vertebrae.  This  accident  is  seldom  uncomplicated,  and  cannot  be 
differentiated  from  fracture  without  a  skiagraph.  The  diagnosis  is  rarely 
made,  and  the  injury  is  treated  as  a  fracture.  The  ribs  may  be  dislocated  from 
their  cartilages,  one  or  more  ribs  being  displaced.  The  end  of  the  rib  forms  an 
anterior  projection,  there  is  a  depression  over  the  cartilage,  and  crepitus  is 
absent.  Treatment  is  the  same  as  that  employed  for  fractured  ribs.  The  cos- 
tal cartilages  may  be  displaced  from  the  sternum,  forming  an  anterior  projection 
upon  this  bone.  Reduction  is  brought  about  by  placing  the  patient  upon  a 
table,  with  a  sand-pillow  between  the  scapulae,  pushing  back  the  shoulders  and 
chest,  and  forcing  the  cartilage  into  place.  The  dressings  are  the  same  as  those 
used  for  fractured  sternum.     The  cartilages  of  the  lower  ribs  (sixth,  seventh. 


Fig.  469. — ^Levis's  splint  for  reducing  dislocation  of  phalanges. 

eighth,  ninth,  and  tenth)  may  be  separated.  The  inferior  cartilage  goes  for- 
ward and  can  be  felt.  Pick  states  that  reduction  is  brought  about  by  causing 
the  patient  to  hold  the  chest  full  of  air  while  efforts  are  made  to  push  the  car- 
tilage into  place.  The  injury  is  dressed  as  are  fractured  ribs  (see  page  624). 
Dislocation  of  the  Sternum. — In  dislocation  of  the  body  of  the  sternum 
the  manubrium  is  separated  from  the  gladiolus.  The  injury  is  a  rare  one,  is 
usually  associated  with  fracture,  and  is  most  common  in  the  young.  It  is  due 
in  most  cases  to  violent  direct  force  inflicted  by  a  fall  or  heavy  blow;  it  may  be 
due  to  indirect  force  and  arose  in  a  reported  case  of  acute  tetanus.  The  symp- 
toms and  treatment  are  the  same  as  those  of  fracture  (see  page  625).  Dislocation 
of  the  ensiform  process  is  one  of  the  rarest  of  injuries.  It  is  usually  due  to  direct 
force,  but  Polaillon  reports  a  case  caused  by  tight  lacing. 


Fig.  470. — Levis's  splint  applied. 

Pelvic  dislocations  are  almost  always  complicated  by  fracture.  A  pubic  bone 
can  be  dislocated  by  falls  from  a  height  or  by  the  appHcation  of  violent  force 
to  the  acetabula.  The  condition  may  happen  from  accident  while  riding  a 
horse.  The  dislocation  may  be  up  or  down,  front  or  back,  and  it  may  damage 
the  urethra  or  the  bladder.  The  patient  cannot  stand;  there  are  great  pain  and 
recognizable  deformity.  Treat  by  molding  the  bones  into  place,  by  applying 
a  pehdc  girdle,  and  by  rest  in  bed  for  four  weeks.  Pure  separation  or  relaxation 
of  the  symphysis  is  seldom  the  result  of  injury  and  is  usually  due  to  childbirth. 
In  this  condition  there  is  mobility,  pain  on  pressure  and  movement,  and  pain  on 
abduction  of  the  thighs.  The  treatment  is  rest  in  bed  and  the  appHcation  of  a 
pelvic  girdle.  Occasionally  in  traumatic  and  also  in  post-obstetric  separation 
it  is  necessary  to  wire  the  bones.  Dislocation  of  the  sacro-iHac  joint  is  produced 
by  falls.  Movement  on  the  part  of  the  patient  is  difficult  or  impossible;  there 
is  violent  pain,  and  often  paralysis  (from  pressure  upon  nerves).  In  dislocation 
backward  there  is  apparent  shortening  of  the  leg,  eversion  of  the  foot  exists, 


766 


Diseases  and  Injuries  of  the  Bones  and  Joints 


and  the  ilium  moves  posteriorly  and  upward.  In  dislocation  forward  the  ante- 
rior superior  iliac  spine  projects  and  the  pelvis  is  broadened.  Sacro-iliac  dis- 
location is  reduced  by  holding  the  pelvis  firm  and  making  extension  by  means 
of  a  pulley.  The  patient  stays  in  bed  for  four  weeks  and  wears  a  pelvic  belt 
as  in  fracture. 

Dislocation  of  the  coccyx  is  considered  on  page  629. 

Dislocation  of  the  Femur  (Hip-joint). — Dislocation  of  this  joint  is  not  often 
encountered,  as  the  hip-joint  is  very  strong.  In  23,000  surgical  admissions  to 
the  Episcopal  Hospital  of  Philadelphia,  6000  of  which  were  surgical  injuries 
there  were  10  dislocations  of  the  hip  (Steinke,  in  "Annals  of  Surgery,"  1914,  Ix). 

It  is  far  more  common  in  males  than  in  females  and  is  most  apt  to  occur  in  a 
young  adult.     It  is  very  rare  in  those  beyond  middle  life  but  occasionally  occurs 


Fig.  471. — Thyroid  dislocation  of  the  femur  eight  weeks  after  the  accident.     Reduced  by- 
open  section  (Rugh). 

in  the  early  sixties.  In  forcible  extension  the  head  of  the  femur  presses  against 
the  capsule  of  the  joint,  but  the  capsule  here  is  very  thick,  and  certain  muscles, 
the  rectus,  psoas,  and  iliacus,  are  pulled  tight  and  serve  to  strengthen  it.  The 
head  of  the  bone  cannot  go  directly  upward  because  of  the  acetabulum  (Ed- 
mund Owen).  The  weak  point  of  the  acetabular  rim  is  below;  the  weak  part 
of  the  capsule  is  also  below;  hence  forced  abduction  is  apt  to  push  the  head  of  the 
bone  through  the  lower  part  of  the  capsule,  a  dislocation  occurring  primarily 
into  the  thyroid  foramen.  The  signs  of  the  dislocation  depend  upon  the  untorn 
portion  of  the  capsule.  The  anterior  portion  of  the  capsule,  including  the  Y-hga- 
ment,  usually  escapes  laceration.  Vessels  are  rarely  injured.  Muscles  are 
often  torn.  In  some  cases  the  sciatic  nerve  is  lacerated,  bruised,  or  caught  up 
on  the  neck  of  the  femur  during  the  circumduction  of  attempted  reduction. 


Dislocation  upon  the  Dorsum  of  the  Ilium 


767 


Four  forms  of  hip-joint  dislocation  are  usually  described:  (i)  upward  and  back- 
ward, on  the  dorsum  of  the  ilium;  (2)  backward,  to  the  border  of  the  sciatic 
notch;  (3)  downward,  into  the  obturator  foramen,  and  (4)  inward,  on  the  pubes. 
All  dislocations  are  primarily  inward  or  outward.  From  these  initial 
positions  the  head  may  be  shifted  to  any  region  about  the  socket  within  reach 
of  the  remnant  of  untorn  capsule  (Oscar  H.  Allis).  Allis  rejects  the  old  classi- 
fication and  suggests  the  following; 


All  present  abduction  and  outward  rotation. 


All  present  adduction  and  inward  rotation. 


Low  thyroid, 
Mid-       " 
High       " 
Reversed  thyroid: 
Low  dorsal, 
Mid-     " 
High     "        J 

Dislocation  upon  the  dorsum  of  the  ilium  (Fig.  472)  is  the  commonest  form. 
One-half  of  all  hip  dislocations  are  of  this  variety.  It  is  caused  by  a  fall  or  a 
blow  when  the  limb  is  flexed  and  abducted  (as  in  carrying  a  weight  upon  the 
shoulder),  by  a  fall  upon  the  knee  r 
or  foot,  by  a  weight  striking  the  1 
back  while  bending,  etc.  AUis 
says  rotation  inward  is  the  chief 
element  in  its  production.  In  this 
dislocation  the  head  of  the  femur 
goes  upward  and  backward,  rests 
upon  the  ilium,  and  is  always 
above  the  tendon  of  the  obturator 
internus  muscle.  This  dislocation 
is  secondary  to  thyroid  dislocation, 
muscular  action  shifting  the  bone 
from  its  seat  of  displacement. 

Signs. — Dislocation  upon  the 
dorsum  of  the  ilium  is  indicated 
by  the  following  symptoms:  the 
buttock  appears  fiat  and  broad; 
the  great  trochanter  is  above 
Nelaton's  line  and  is  deeply 
placed;  the  head  of  the  bone  can 
be  detected  in  its  new  situation; 
deep  pressure  in  front  of  the  joint 

finds  a  hollow ;  the  leg  is  shortened  by  about  2  or  3  inches ;  the  fascia  lata  is  relaxed ; 
in  some  thin  people  the  socket  can  be  outhned;  when  the  patient  is  recumbent 
the  injured  extremity  can  be  brought  to  the  perpendicular  without  flexing  the 
leg  (AlHs);  the  knee  is  somewhat  flexed;  the  thigh  is  sUghtly  flexed,  inwardly 
rotated,  and  adducted  (Fig.  473)  (this  is  shown  by  the  fact  that  the  axis  of 
the  thigh  of  the  injured  side,  if  prolonged,  would  pass  through  the  lower  third 
of  the  sound  thigh) ;  when  the  capsule  is  extensively  lacerated  there  may  be 
no  adduction  and  may  be  eversion  (Alhs);  the  heel  is  raised,  and  the  great 
toe  of  the  foot  of  the  injured  side  rests  upon  the  front  of  the  instep  or  the  ankle 
of  the  sound  side  (Fig.  473);  rigidity  exists;  voluntary  movement  is  impossible, 
though  some  passive  motion  is  possible  in  the  direction  of  the  deformity  (the 
deformity  can  be  made  more  marked).  If  a  patient  is  recumbent  and  the  knees 
vertical,  the  foot  of  the  sound  extremity  is  free  of  the  bed,  but  the  foot  of  the 
injured  extremity  touches  the  bed  {Allis' s  sign). 

Diagnosis. — Examine  first  without  anesthesia.     The  a;-rays  are  invaluable 
in  diagnosis.     If  the  x-rays  are  not  obtainable,  examine  again  while  the  patient 


Fig.  472. — Dislocation  of  femur  upon  the  dorsum 
of  the  ilium  (Dr.  Ohnesorg's  case). 


768 


Diseases  and  Injuries  of  the  Bones  and  Joints 


is  anesthetized.  Dislocation  is  distinguished  from  intracapsular  fracture  by- 
noting  the  inversion,  the  great  shortening,  the  absence  of  crepitus,  the  age 
of  the  subject,  and  the  nature  of  the  force.  The  nature  of  the  force,  the 
inversion,  and  the  absence  of  crepitus  mark  the  diagnosis  from  extracapsular 
fracture. 

Treatment. — The  chief  obstacle  to  reduction  in  dislocation  upon  the  dorsum 
of  the  ilium,  Bigelow  states,  is  the  untorn  portion  of  the  capsule,  especially 
the  Y-ligament.  The  iliofemoral,  Y,  or  Bigelow's  ligament  resembles  an 
inverted  Y,  arises  from  the  anterior  inferior  spine  of  the  ilium,  is  inserted  into 
the  anterior  intertrochanteric  line,  and  is  incorporated  into  the  front  of  the 
capsule.  To  reduce  a  dislocation  this  ligament  must  be  relaxed  by  manipula- 
tion or  be  torn  by  extension.  Manipulation  makes  the  head  of  the  bone  retrace 
its  steps  over  the  same  route  it  took  in  emerging.  Give  ether;  place  the 
patient  supine  upon  a  mattress  on  the  floor;  flex  the  leg  on 
the  thigh  (to  relax  the  hamstrings),  flex  the  thigh  on  the 
pelvis;  increase  the  adduction  over  the  middle  line;  strongly 
abduct;  perform  external  rotation  and  extension.  This 
treatment  may  be  summed  up  as  flexion,  adduction,  ex- 
ternal circumduction,  and  extension;  or,  as  Pick  puts  it, 
"bend  up,  roll  out,  turn  out,  and  extend."  AlHs's  advice 
is  to  fix  the  pelvis  to  the  floor,  lift  the  head  of  the  bone  to 
the  level  of  the  socket,  rotate  outward  by  carrying  the  leg 
toward  the  pubis,  and  extend  the  femur.  If  extension  and 
counterextension  are  employed,  make  extension  in  the  axis 
of  the  dislocated  limb  and  obtain  counterextension  by  a 
perineal  band.  The  extension  band  is  fastened  to  the  thigh 
by  a  clove-hitch.  After  reduction  put  the  patient  to  bed 
and  use  sandbags  (as  in  fracture  of  the  hip)  for  four  weeks. 
We  may  tie  the  knees  together  instead  of  using  the  sand- 
bags. Passive  motion  is  made  in  the  third  week.  The 
pulleys  must  not  be  used  in  reduction.  They  may  inflict 
great  or  even  fatal  injury.  If  the  surgeon  fails  to  reduce  the  deformity,  there 
are  two  courses  open  to  him.  He  may  let  it  alone.  He  may  operate.  If  he 
lets  it  alone,  the  limb  will  almost  certainly  become  ankylosed,  though  probably 
useful.  If  he  determines  to  operate,  he  must  recognize  that  tenotomy  is  use- 
less.    It  is  necessary  to  make  a  free  incision  in  order  to  restore  the  bone. 

Dislocation  Onto  the  Border  of  the  Sciatic  Notch. — In  this  dislocation  the 
head  of  the  bone  passes  backward  and  a  little  upward,  and  rests  upon  the 
ischium  at  the  margin  of  the  sciatic  notch  (not  in  the  notch),  below  the  tendon 
of  the  obturator  internus  muscle.  The  causes  are  the  same  as  those  given 
for  the  previous  dislocation. 

The  signs  of  dislocation  into  the  border  of  the  sciatic  notch  are  like  those  of 
dislocation  upon  the  dorsum  of  the  ilium  but  they  are  not  so  marked.  There  are 
flattening  and  broadening  of  the  hip;  ascent  of  the  trochanter  above  Nelaton's 
line;  shortening  to  the  extent  of  an  inch;  relaxation  of  the  fascia  lata.  If  the  knee 
of  the  injured  side  is  vertical,  the  sole  of  the  foot  touches  the  bed.  Flexion, 
inward  rotation,  and  adduction  exist,  but  the  axis  of  the  femur  of  the  injured 
side  passes  through  the  knee  of  the  sound  side,  and  the  ball  of  the  great  toe 
of  the  injured  side  rests  upon  the  great  toe  of  the  sound  side  (Fig.  474).  Other 
symptoms  are  identical  with  those  of  dislocation  upon  the  dorsum  of  the  ilium, 
but  are  less  pronounced.  AUis's  signs  of  this  dislocation  are  of  value:  if,  with 
the  patient  recumbent,  the  thighs  are  brought  to  a  right  angle  with  the  body, 
shortening  on  the  affected  side  is  materially  increased;  if  the  dislocated  thigh 
is  extended,  the  back  arches  as  in  hip  disease. 

Diagnosis  atid  Treatment. — The  signs  of  dislocation  on  the  border  of  the 
sciatic  notch  are  similar  to,  but  are  less  marked  than  those  of  dorsal  dislocation, 


Fig.  473.  —  Hip- 
joint  dislocation 
upon  the  dorsum  of 
the  ilium  (Cooper). 


Dislocation  upon  the  Pubis 


769 


Fig.  474. — Hip-joint 
dislocation  onto  the  sci- 
atic notch  (Cooper). 


and,  being  a  backward  dislocation,  the  reduction  and  treatment  are  the  same 

as  for  dislocation  backward  upon  the  dorsum  of  the  ilium. 

Dislocation  Downward  Into  the  Obturator  Foramen  (Figs.  47iand475). — 

Downward  dislocation  is  the  primary  position  of  most  dislocations  of  the  hip, 

the  bone  rarely  remaining  in  the  thyroid  foramen,  but  usually  mounting  up 

as  a  result  of  muscular  action  or  of  the  initial  \iolence.     The  cause  is  a  violent 

abduction  by  falls  or  by  stepping  from  a  moving  car. 

Signs. — Dislocation   dowmward   into   the   obturator  foramen   is   indicated 

by  flattening  of  the  hip;  the  head  of  the  bone  is  felt  in  its  new  position  and 

is  missed  from  the  acetabulum;  rigidity  exists;  passive 

motion  is  only  possible  in  the  direction  of  deformity,  and 

that  to  a  slight  extent;  a  hollow  is  noted  over  the  great 

trochanter,  which  process  is  well  below  Nelaton's  line  and 

nearer   than  normal  to   the   middle  line.     The  gluteal 

crease  is   lower  than  is   the  crease  of  the  opposite  side; 

there  is  lengthening  to  the  extent  of  i  to  2  inches;  the 

body  is  bent  forward  by  the  traction  upon  the  psoas  and 

iliacus  muscles,  and  is  also  deviated  to  the  side,  thus 

causing  great  apparent  lengthening;  the  Hmb  is  advanced 

partially  flexed  and  abducted,  and  the  foot  is  pointed 

straight  ahead  or  is  a  little  everted  (Fig.  475);  when  the 

patient  is  recumbent  extension  is  impossible,  the  knees 

cannot  be  pushed  together  without  great  pain,  and  the 

abductor  muscles  are  hard  and  rigid.     Allis's  signs  are 

absent.     Unreduced    dislocations    do   well,    the   patient 

obtaining  a  very  useful  hip-joint  (Sedillot). 

Treatment. — In  treating  dislocation  downward  into  the  obturator  foramen 

give  ether  and  effect  reduction,  if  possible,  by  manipulation,  and,  if  this  fails,  by 

extension.     To  reduce  by  manipulation,  flex  the  leg  on  the  thigh  and  the  thigh 

on  the  peKas,  and  then  perform,  in  the  following  order,  abduction,  internal 

circumduction,  and  extension.  Allis's  rule  of  reduction  is  as  follows:  fix  the 
peKds  to  the  floor;  pull  the  head  of  the  femur  outward  and 
above  the  socket;  fijj  the  head;  push  the  knee  toward  sound 
knee  and  extend  the  femur.  If  extension  is  made,  make 
traction  in  the  axis  of  the  limb  by  means  of  muslin  fastened 
around  the  thigh  by  a  clove-hitch.  Do  not  use  pulleys; 
incise  rather  than  use  them. 

Dislocation  upon  the  pubis  is  a  very  uncommon  acci- 
dent. The  head  of  the  bone  usually  rests  just  internal 
to  the  anterior  inferior  spine  of  the  ilium.  The  primary 
position  of  the  bone  is  in  the  thyroid  foramen;  the  pubic 
dislocation,  when  it  occurs,  is  always  secondary,  and  is  due 
to  the  initial  force  and  to  muscular  action. 

Symptoms. — In  pubic  dislocation  the  head  of  the  bone 
can  be  felt  and  seen  in  its  new  position;  the  hip  is  flattened; 
there  is  a  hollow  over  the  great  trochanter,  this  process  being 
found  below  the  anterior  superior  spine  of  the  ihum;  there 
is  shortening  to  the  extent  of  i  inch;  the  limb  is  in  abduction 
with  eversion  (Fig.  476),  and  the  knees  cannot  be  approxi- 
mated without  great  pain. 
In  the  treatment  of  pubic  dislocation  give  ether  and  employ  manipula- 
tion as  for  thyroid  dislocation.     If  this  fails,  employ  extension.     The  limb 

is  well  abducted,  extension  is  made  downward  and  backward,  and  the  head 

of  the  femur  is  pulled  outward  "by  a  towel  around  the  thigh,  just  beneath  the 

groin"  (Keetley).     The  after-treatment  is  the  same  as  that  for  the  previous 

forms. 


FiG._  475.  — Hip- 
joint  dislocation  into 
the  obturator  or 
thyroid  foramen 
(Cooper). 


49 


770 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Central  or  Internal  Dislocation  (Fig.  477). — By  this  term  we  mean  that 
the  head  of  the  femur  has  been  displaced  and  perhaps  forced  through  a  frac- 
tured acetabulum  into  the  pelvis.  It  is  not  a  genuine  dislocation.  There  is 
neither  tearing  nor  stretching  of  the  capsule  and  the  acetabular  floor  may  re- 
main in  contact  with  the  femoral  head.  Skillem  and  Pancoast  ("Annals  of 
Surgery,"  Jan.,  191 2)  point  out  that  "the  injury  varies  from  a  light  depres- 
sion of  the  floor  of  the  acetabulum  ...  to  the  passage  of  the  femoral  head 
into  the  pelvic  cavity."  For  the  first  injury  they  suggest  the  term  Jractura 
acetabuli  perjorans;  for  the  second,  fradura  acetabuli  perforata.  This  injury 
is  due  to  violent  force.  The  usual  cause  is  a  fall  upon  the  great  trochanter. 
The  symptoms  vary  with  the  degree  of  depression  or  fracture  of  the  floor  of 
the  acetabulum.  If  there  is  only  slight  depression  of  the  floor,  there  may  be 
no  appreciable  shortening  and  very  slight  approach  of  the 
trochanter  toward  the  symphysis  pubis.  The  .v-rays  may 
be  needed  to  make  a  diagnosis.  If  the  head  has  per- 
forated, shortening  will  be  evident,  there  will  be  marked 
approach  of  the  trochanter  toward  the  midline,  and  vaginal 
or  rectal  palpation  will  discover  the  displaced  femoral  head. 
In  both  injuries  there  are  pain,  tenderness,  and  impaired 
mobility.  There  may  be  serious  damage  within  the  pelvis. 
Intrapelvic  hemorrhage  is  common.  The  peritoneum  may 
be  lacerated,  the  bowel  may  be  damaged,  the  bladder  injured, 
or  the  obturator  nerve  bruised  (Skiflern  and  Pancoast,  Ibid.). 
Treatment. — If  complications  such  as  are  mentioned 
above  exist,  at  once  open  the  abdomen  and  repair  the  in- 
jury. Reduce  the  deformity  by  extension  and  counter- 
extension.  Treat  by  "extension  in  the  axis  of  the  limb  in 
conjunction  with  lateral  traction  upon  the  femoral  neck" 
(Ibid.).  After  a  week,  if  there  is  no  contra-indication,  ap- 
ply a  plaster-of-Paris  dressing  from  the  toes  to  the  chest. 
Skillern  and  Pancoast  (Ibid.)  state  that  the  injury  was  first  described  by 
Callisen  in  1788,  and  that,  with  their  4  cases,  55  have  been  reported. 

Anomalous  Dislocations  of  the  Hip. — In  supraspinous  dislocation  the  dis- 
location of  the  hip  is  backward,  the  head  of  the  femur  resting  upon  the  ilium 
above  or  even  anterior  to  the  anterior  superior  spine.  In  ischial  dislocation 
the  dislocation  is  downward  and  backward,  the  head  of  the  femur  resting  on 
the  ischial  tuberosity  or  in  the  lesser  sciatic  notch.  Monteggia's  dislocation  is 
a  supraspinous  dislocation  with  eversion  of  the  hmb.  In  perineal  dislocation 
the  head  of  the  femur  is  in  the  perineum.  In  suprapubic  dislocation  the  head 
of  the  femur  passes  above  the  pubes.  In  subspinous  dislocation  the  femoral 
head  rests  on  the  horizontal  ramus  of  the  pubes. 

Dislocation  with  Catching  Up  of  the  Sciatic  Nerve  During  Reduction. — 
This  accident  causes  severe  pain.  The  leg  is  flexed  on  the  thigh  and  the 
thigh  is  flexed  on  the  pelvis.  Allis  tells  us  that  the  task  of  reduction  is  very 
unpromising.  We  must  strive  to  put  the  neck  of  the  femur  in  such  a  position 
that  the  nerve  will  "drop  off,"  and  yet  often  the  nerve  cannot  drop  off  because 
it  is  held  by  adhesion  to  the  injured  muscles.  AlHs  attempts  reduction  by 
the  following  plan : 

1.  Place  the  patient  upon  his  back  and  redislocate  the  femur. 

2.  Extend  the  thigh. 

3.  Flex  the  leg  on  the  thigh. 

4.  Turn  the  ankle  out  until  the  leg  is  horizontal  (this  causes  the  head  of 
the  bone  to  look  downward). 

5.  "Shake,  shock,  jar,  adduct,  and  abduct,"  to  disengage  the  nerve. 

6.  Rotate  into  socket  without  flexing  leg   (without   making  nerve   tense). 

7.  If  this  fails,  make  an  incision  above  the  popliteal  space,  and  draw  the 


Fig.  476. — Dislo- 
cation on  pubis 
(Cooper). 


Dislocation  of  the  Knee 


771 


nerve  out  of  the  wound.  Detach  the  head  of  the  bone  from  its  entanglement 
and  rotate  it  into  the  socket.^ 

Dislocation  of  the  Head  of  the  Femur  with  Fracture  of  the  Shaft  of  the 
Bone. — We  may  incise,  replace,  and  plate  the  fragments.  We  may  use  Mc- 
Burney's  hooks  as  in  the  shoulder.  We  may  be  forced  to  do  a  resection  of  the 
head. 

Allis  maintains  that  it  is  possible  to  reduce  it  by  manipulation.  He  states 
that  the  upper  fragment  is  the  entire  lever,  and  the  lower  fragment  "is  only 
the  agent  through  which  we  apply  our  force."  The  fragments  are  not  com- 
pletely separated,  but  are  connected  at  one  side  by  material  which  is  "partly 
periosteal,  partly  tendinous,  and  partly  muscular."  This  connecting  mate- 
rial enables  us  to  make  traction  upon  the  upper  fragment,  but  does  not  allow 
"rotation,  circumduction,  and  leverage  through  the  agency  of  the  lower  frag- 
ment." Hence  "the  only  agency  at  our  command  is  traction."  If  the  disloca- 
tion is  inward  (forward),  draw  the  head  outward  and  have  an  assistant  make 
direct  pressure  upon  the  head  of  the  bone.  If  this  fails,  the  assistant  holds 
the  head  of  the  bone  to  prevent  its  slipping  into  the  thyroid  depression,  and 


Fig.  477. — Dislocation  of  left  hip.     Fracture  of  acetabulum,  ischium,  and  pubes  (right),  with 
central  dislocation  of  hip.     Separation  of  pubic  arch. 

the  surgeon  makes  traction  inward  or  inward  and  downward.  If  the  disloca- 
tion is  outward  (backward),  make  traction  directly  upward  to  Hft  the  head  of 
the  bone  to  the  level  of  the  socket,  and  try  to  place  the  head  over  the  socket  by 
traction  obliquely  upward  and  inward.  During  all  these  manipulations  an 
assistant  presses  upon  the  trochanter  to  prevent  the  head  of  the  bone  slipping 
back.  Traction  is  now  made  downward  and  inward,  and  the  tightened  liga- 
ment may  drag  the  head  of  the  bone  into  place. 

Dislocation  of  the  Knee. — It  is  a  rare  injury.  There  are  four  forms — 
forward,  backward,  outward,  and  inward.  Any  one  of  the  four  may  be  com- 
plete or  incomplete;  the  commonest  dislocations  are  lateral.  The  cause  is 
violent  force,  such  as  a  fall,  or  in  jumping  from  a  moving  train,  or  in  being 
caught  by  the  foot  and  dragged. 

1  Allis's  views  will  be  found  in  "An  Inquiry  Into  the  Difl&culties  Encountered  in  the  Reduc- 
tion of  Dislocations  of  the  Hip,"  by  Oscar  H.  Allis,  M.  D.  This  highly  original  and  valuable 
treatise  received  the  Samuel  D.  Gross  Prize  of  the  Philadelphia  Academy  of  Surgery  in  1895. 


772 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Dislocation  Forward  of  the  Knee-joint. — In  the  complete  form  of  forward 
dislocation  the  deformity  is  ol^vious.  The  limb  is  usually  extended,  but  it 
may  be  flexed.  Much  shortening  exists;  the  condyles  are  felt  posterior  and 
below;  the  head  of  the  tibia  is  felt  anterior  and  above;  the  patella  is  movable 
and  the  quadriceps  is  lax;  pressure  of  the  condyles  upon  the  contents  of  the 
popliteal  space  arrests  the  tibial  pulse  and  causes  edema  and  intense  pain.  In  in- 
complete dislocation  the  sympt  )ms  are  identical  in  kind,  but  are  less  pronounced. 
Treatment. — Compound  dislocation  of  the  knee-joint  often  demands  ex- 
cision or  amputation.  In  simple  dislocation  give  ether,  have  one  assistant 
extend  the  leg  while  another  makes  counterextension  on  the  thigh,  and  the 
surgeon  pushes  the  bone  into  place.  Reduction  is  easy  because  of  ligamentous 
laceration.  Place  the  limb  on  a  double  inclined  plane,  and  combat  inflamma- 
tion by  the  usual  methods  (see  Syno\dtis,  page  702).     Begin  passive  motion 

in  the  third  week.  The  patient  must 
wear  a  knee-support  for  months. 
Very  extensive  laceration  of  liga- 
ments calls  for  incision  and  sutur- 
ing. If  the  popliteal  vessels  are  much 
damaged,  gangrene  will  supervene 
and  amputation  will  be  demanded. 

Dislocation  Backward  of  the 
Knee-joint. — In  the  complete  form  of 
backward  dislocation  of  the  knee-joint 
displacement  is  not  so  great  as  in  dis- 
location forward.  The  head  of  the 
tibia  projects  posteriorly  and  above, 
the  femoral  condyles  anteriorly  and 
below;  the  leg  is,  as  a  rule,  partly 
flexed,  but  it  may  be  extended,  and 
there  is  moderate  shortening.  In 
incomplete  dislocation  the  symptoms 
are  less  marked. 

The  treatment  of  backward  dis- 
location of  the  knee-joint  is  the  same 
as  for  forward  dislocation. 

Dislocation  outward  of  the  knee- 
joint  is  usually  incomplete.  The 
inner  tuberosity  of  the  tibia  in  out- 
ward dislocation  lies  upon  the  outer 
condyle  of  the  femur  (Pick);  the  inner  condyle  of  the  femur  projects  internally; 
the  outer  tibial  tuberosity  and  fibular  head  project  externally,  the  former 
having  a  depression  below  it,  and  the  latter  above  it;  the  leg  is  semiflexed,  but 
shortening  is  absent. 

Dislocation  inward  of  the  knee-joint  is  usually  incomplete.  The  outer 
tuberosity  of  the  tibia  in  inward  dislocation  Hes  upon  the  inner  condyle  of  the 
femur;  the  outer  condyle  of  the  femur  forms  an  external  prominence,  and  the 
inner  tuberosity  of  the  tibia  forms  an  internal  prominence.  Pick  cautions  us 
not  to  mistake  a  separation  of  the  lower  femoral  epiphysis  for  lateral  disloca- 
tion (the  former  is  reduced  easily,  the  deformity  tends  to  recur,  and  there  is  soft 
crepitus). 

Treatment. — In  treating  lateral  dislocation  of  the  knee-joint,  effect  extension 
and  counterextension  as  in  anteroposterior  dislocations.  The  leg  is  moved 
from  side  to  side  and  attempts  are  made  at  rotation.  The  after-treatment 
is  the  same  as  that  for  anteroposterior  luxations. 

Dislocation  of  the  patella  is  seldom  congenital.  There  are  35  congenital 
cases  on  record  (Bajardi).     There  are  three  forms  of  dislocation  of  the  patella: 


Fig.  478. — Old  dislocation  of  the  patella  out- 
ward. 


Dislocation  of  the  Semilunar  Cartilages  of  the  Knee-joint      773 

outward,  inward,  and  edgewise.     The  so-called  dislocation  upward  is,  in  reality, 
rupture  of  the  ligamentum  patellas  (see  page  809). 

Dislocation  of  the  patella  outward  (Fig.  478)  may  be  due  to  muscular 
action  or  to  direct  force,  and  occurs  during  extension  of  the  leg.  It  occasionally 
happens  on  a  person  with  knock-knee.  If  dislocation  is  complete  the  bone 
lies  upon  the  external  surface  of  the  external  condyle;  if  incomplete,  the  patella 
rests  upon  the  anterior  surface  of  the  external  condyle.  The  leg  is  extended 
flexion  is  impossible,  and  attempts  at  flexion  produce  great  agony.  In  the 
patient  shown  in  Fig.  478  flexion  became  possible  in  an  unreduced  dislocation, 
but  not  until  months  after  the  accident.  The  knee  is  wider  than  normal! 
There  is  a  hollow  in  front  of  the  joint.     The  bone  is  felt  in  its  new  position. 

Dislocation  of  the  patella 
inward  is  very  rare.  The  signs 
are  like  those  of  dislocation 
outward,  except  that  the  pa- 
tella rests  upon  the  inner 
condyle. 

Treatment  of  Lateral  Dis- 
locations of  the  Patella. — Give 
ether.  Raise  the  body  upon 
a  bed-rest  and  flex  the  thigh. 
Grasp  the  patella  and  depress 
the  margin  which  is  farthest 
from  the  center  of  the  joint 
(Pick) .  The  muscles  may  pull 
the  bone  into  place.  Extend 
the  extremity  and  immobilize 
for  three  weeks,  and  then  be- 
gin passive  motion.  Incision 
may  be  necessary  in  order  to 
effect  reduction. 

Dislocation  of  the  Patella 
Edgewise.  —  The  patella  ro- 
tates vertically,  one  edge  rest- 
ing between  the  condyles.  As 
a  rule,  the  outer  border  is  in 
the  intercondyloid  notch. 
This  condition  is  produced  by 
direct  force  when  the  extrem- 
ity is  partly  flexed.  Twisting 
and  muscular  action  have  been 
assigned  as  causes.  The  con- 
dition is  obvious  at  a  glance. 

Treatment. — Give  ether. 
Pick  recommends  "sudden 
and  forcible  bending  of  the 
knee."     In    some    cases    the 

bone  can  be  pushed  into  place,  the  limb  being  extended  and  flexed  as  in  the 
reduction  of  a  lateral  dislocation.     In  some  cases  incision  will  be  necessary. 

Dislocation  of  the  Semilunar  Cartilages  of  the  Knee-joint  {the  Internal 
Derangement  of  Hey;  Subluxation  of  the  Knee-joint). — The  condition  was  de- 
scribed by  Hey,  of  Leeds,  in  1803.  The  interarticular  cartilages  of  the  knee- 
joint  are  attached  in  front  of  and  behind  the  tibial  spine,  and  the  convexity 
of  each  cartilage  is  attached  to  the  edge  of  the  corresponding  tibial  tuberosity 
by  means  of  the  coronary  ligament.  The  internal  cartilage  is  fastened  to  the 
internal  lateral  ligament  and  has  a  moderate  freedom  of  movement.     The 


Fig.  479. — Dr.  Morris  Booth  Miller's  case  of  out- 
ward dislocation  of  the  patella  from  direct  force.  Six 
months  after  the  fall.  Failed  of  reduction  under  ether 
anesthesia. 


774  Diseases  and  Injuries  of  the  Bones  and  Joints 

outer  cartilage  is  not  connected  with  the  external  lateral  Hgament  and  is  not 
freely  movable.  It  has  been  stated  that  the  outer  cartilage  is  more  frequently 
dislocated  than  the  inner,  but  modern  experience  indicates  that  this  is  not  true, 
and  that  the  internal  cartilage  is  the  one  to  suffer  in  at  least  nine  cases  out  of 
ten.  In  17  cases  operated  upon  by  Barker  the  internal  cartilage  was  involved  in 
every  case  ("Lancet,"  Jan.  4,  1902).  Those  persons  whose  occupations  force 
them  to  pass  considerable  time  upon  their  knees  are  predisposed  to  this  accident 
(Annandale).  The  derangement  of  the  cartilage  is  usually  caused  by  a  sudden 
external  rotation  or  abduction  of  the  tibia  while  the  knee-joint  is  in  partial 
flexion;  for  instance,  when  the  patient  stumbles  over  an  obstacle,  the  knee-joint 
being  partially  flexed,  the  tibia  is  twisted  outward  When  the  joint  is  flexed 
a  normal  cartilage  moves  backward,  and  when  it  is  extended  moves  forward 
again.  When  the  cartilage  is  thrown  out  by  the  sudden  eversion  and  flexion 
of  the  tibia  it  is  caught  and  does  not  move  into  place  readily  when  the  leg  is 
extended.  The  tear  takes  place  in  the  direction  of  the  fibers  of  the  cartilage. 
In  a  very  few  cases  the  cartilage  has  been  displaced  by  abduction  during  ex- 
tension.    In  nearly  all  cases  the  cartilage  is  displaced  inward. 

Symptoms. — The  iirst  indication  of  interarticular  cartilage  displacement 
is  a  sudden,  violent,  sickening  pain  in  the  knee,  which  may  be  so  severe  as  to 
cause  the  patient  to  fall  to  the  ground.  The  knee  is  in  a  position  of  fixed  semi- 
flexion. Further  flexion  is  possible,  but  extension  is  impossible.  In  some 
cases  the  patient  can  voluntarily  make  further  flexion;  in  others,  the  pain 
is  so  severe  that  he  either  cannot  or  will  not  do  it;  but  increase  of  flexion  can 
be  obtained  by  passive  motion.  The  joint  is,  however,  blocked  both  to 
passive  and  to  voluntary  extension.  Attempts  at  passive  motion  are  pro- 
ductive of  fierce  pain.  If  either  cartilage  is  displaced  away  from  the  tibial 
spine,  a  prominence  may  be  found  on  one  or  the  other  side  of  the  knee-joint. 
If  the  displacement  takes  place  toward  the  tibial  spine  a  prominence  may  be 
found  on  one  side  of  the  ligament  of  the  patella.  Subluxation  is  rapidly  fol- 
lowed by  inflammation  of  the  synovial  membrane  of  the  joint  and  inflamma- 
tion of  the  cartilage  itself;  and  swelling  quickly  masks  the  projection  of  the  car- 
tilage. This  accident  is  frequently  mistaken  for  the  blocking  of  the  joint  by  a 
floating  cartilage;  but  a  dislocated  cartilage  always  remains  in  the  same  posi- 
tion, and  a  loose  cartilage  changes  its  position  from  time  to  time  (Turner). 
Loose  bodies  in  a  joint  produce  pain  of  a  shifting  character  and  interference 
with  both  flexion  and  extension,  or  with  either  flexion  or  extension  in  an 
irregular  way  (Cotterill).  In  regard  to  the  diagnosis,  Cotterill  points  out  that 
in  a  sprain  of  the  joint  extension  is  not  painful,  but  flexion  is  interfered  with; 
whereas,  in  the  dislocation  of  a  cartilage  of  the  joint,  flexion  is  still  possible, 
but  extension  cannot  be  carried  out  ("Lancet,"  Feb.  22,  1902). 

Treatment. — To  reduce  a  displaced  semilunar  cartilage  I  have  used  with 
satisfaction  a  method  described  by  Henry  W.  Jacob  ("Brit.  Med.  Jour.," 
March  7,  1908).  It  is  not  followed  by  severe  synovitis  unless  the  patient 
has  walked  or  has  made  repeated  efforts  to  reduce  the  displacement,  and  as 
it  is  a  painless  method  ether  is  not  required.     Jacob  describes  it  as  follows: 

"The  patient  lies  on  a  bed  or  couch,  the  surgeon  standing  on  the  outer  side 
of  the  hmb  affected,  with  his  face  toward  the  patient's  foot;  the  patient  then 
raises  his  leg  off  the  couch  in  the  semiflexed  position,  the  surgeon  grasps  the 
patient's  leg  in  both  hands,  and  using  his  own  thigh  as  a  fulcrum,  by  means  of  a 
steady  pulling  movement  draws  the  patient's  leg  outward  while  the  surgeon's 
thigh  keeps  the  patient's  femur  in  a  fixed  position;  directly  this  movement  is 
effected  the  patient  must  steadily  extend  the  limb,  and  the  displaced  cartilage 
will  probably  go  back  with  a  slight  click;  if  the  first  movement  of  extension  is 
not  successful  the  maneuver  must  be  repeated  without  any  hurry  or  unnecessary 
force,  and  after  a  few  attempts  the  cartilage  can  usually  be  felt  to  slip  in  with- 
out pain  or  inconvenience." 


Lateral  Dislocation  of  the  Ankle-joint  775 

In  treating  dislocation  of  a  semilunar  cartilage  of  the  knee  it  is  customary 
to  give  ether  and  reduce  by  forced  flexion,  and  internal  rotation  of  the  tibia. 
Extension  becomes  possible  if  the  cartilage  is  freed.  During  these  maneuvers  an 
assistant  endeavors  to  push  any  projection  of  cartilage  into  place.  Robert 
Jones  reduces  the  cartilage  by  acutely  flexing  the  leg,  rotating  the  tibia  inward, 
telling  the  patient  to  make  forcible  extension  and  aiding  him  in  the  accomplish- 
ment of  it.  After  reduction  apply  a  splint  for  two  weeks  and  combat  inflam- 
mation by  proper  remedies  (see  Synovitis);  then  begin  passive  motion.  At 
the  end  of  two  weeks  apply  a  firm  knee-cap  made  of  leather  and  let  the  patient 
get  about  on  crutches.  After  a  couple  of  weeks  the  crutches  can  be  laid  aside. 
As  recurrence  of  the  displacement  is  usual,  the  patient  should  wear  a  knee-cap 
during  the  day  for  many  months.  A  partial  tear  may  entirely  heal  when  thus 
treated  by  rest  and  support;  an  extensive  tear  will  not,  although  even  in  such 
cases  a  useful  but  somewhat  stiff  joint  may  be  obtained.  If  it  is  found  impos- 
sible to  unlock  the  blocked  joint,  or  if  the  tear  is  extensive  and  redislocation  is 
prone  to  occur,  an  operation  is  advisable.  The  joint  is  opened  and  the  loose 
cartilage  is  pushed  into  place  and  held  by  stitches  to  the  periosteum,  or  the 
loosened  portion  is  excised.  Annandale,  in  1885,  sutured  through  a  transverse 
incision.  Freeman  and  others  used  sutures  to  fix  the  cartilage.  Excision  is 
just  as  satisfactory  as  suturing,  and  after  excision  recurrence  of  the  trouble 
is  impossible.  After  excision  the  extremity  is  placed  upon  a  posterior  sphnt. 
Passive  motion  is  begun  in  two  weeks. 

Dislocation  of  the  Fibula  at  the  Superior  Tibiofibular  Articulation. — This 
injury  is  rare.  The  head  of  the  fibula  may  go  forward  or  backward.  The 
causes  are  direct  force  and  violent  adduction  of  the  foot  with  abduction  of  the 
knee  (Bryant). 

Symptoms. — After  dislocation  of  the  fibula  the  position  is  one  of  semiflexion 
of  the  knee,  voluntary  extension  and  flexion  being  impaired  or  lost.  A  dis- 
tinct movable  projection  is  readily  noticed  in  front  or  behind,  which  is  found 
to  be  continuous  with  the  fibula.  There  is  a  depression  over  the  normal  posi- 
tion of  the  head  of  the  fibula. 

Treatment. — In  treating  dislocation  of  the  fibula  bend  the  knee  to  relax 
the  biceps,  and  proceed  to  push  the  bone  into  place.  Put  a  compress  over 
the  head  of  the  fibula,  apply  a  bandage,  and  put  the  Hmb  on  a  double  inclined 
plane.  The  peroneal  nerve  winds  around  the  neck  of  the  fibula  and  care  must 
be  taken  to  avoid  making  injurious  pressure  upon  the  nerve.  At  the  end  of 
three  weeks  put  a  lacing  knee-support  upon  the  knee  and  let  the  patient  up. 
As  displacement  is  liable  to  recur,  a  knee-cap  must  be  worn  for  a  year. 

Dislocation  of  the  Ankle-joint. — This  injury  is  not  unusual.  Fracture  is 
a  frequent  complication.  There  are  five  forms  of  ankle-joint  dislocation — 
outward,  inward,  forward,  backward,  and  upward. 

Lateral  dislocation  of  the  ankle-joint  is  either  outward  or  inward,  and 
may  be  complete  or  incomplete.  In  these  dislocations  the  astragalus  rotates. 
In  incomplete  dislocation  ''there  is  no  great  separation  of  the  trochlear  sur- 
face of  the  astragalus  from  the  under  surface  of  the  tibia,  but  the  outer  or 
inner  margin  of  this  surface  is  brought  into  contact  with  the  articular  surface 
of  the  tibia,  and  the  whole  foot  presents  a  lateral  twist"  (Pick).  The  causes 
of  these  dislocations  are  twists  of  the  joint. 

Symptoms. — Incomplete  outward  dislocation  of  the  ankle-joint  occurs 
in  Pott's  fracture  (see  page  697).  Dupuytren's  fracture  comprises  complete 
outward  dislocation  of  the  astragalus,  the  articular  surface  of  the  astragalus 
being  displaced  completely  outward  from  the  articular  surface  of  the  tibia,  and 
a  fracture  of  the  fibula  with  separation  of  the  inferior  tibiofibular  articulation. 
In  incomplete  dislocation  the  foot  goes  outward  and  upward,  the  fibula  is 
fractured,  and  the  tibiofibular  hgaments  are  torn  off.     In  Dupuytren's  fracture 


7^6  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  ankle  is  broad,  the  inner  malleolus  projects  and  looks  lower  than  natural, 
the  outer  malleolus  ascends  with  the  foot,  the  foot  rotates  outward,  and 
crepitus  can  be  detected.  In  inward  dislocation  which  is  associated  with 
fracture  of  the  inner  malleolus  there  is  inversion,  the  outer  malleolus  projects, 
and  crepitus  can  be  detected.  In  incomplete  separation  the  symptoms  are 
similar,  but  are  not  so  marked. 

Treatment. — In  treating  a  case  of  dislocation  of  the  ankle-joint  the  de- 
formity is  reduced  by  flexing  the  leg  on  the  thigh  and  the  thigh  on  the  pelvis; 
an  assistant  makes  countercxtension  from  the  knee;  the  surgeon  makes  ex- 
tension from  the  foot,  and- at  the  same  time  rocks  the  astragalus  into  place. 
Dupuytren's  fracture  is  treated  in  the  same  manner  as  Pott's  fracture  (see  page 
698).  Dislocation  inward  is  treated  in  a  fracture-box  for  the  same  period  as 
Pott's  fracture. 

Anteroposterior  dislocation  of  the  ankle-joint  is  rare.  The  caiise  is  the 
catching  of  the  foot  in  jumping  or  falling — direct  violence.  In  dislocation 
forward  the  foot  is  lengthened,  the  heel  is  not  conspicuous,  the  tibia  and  fibula 
project  against  the  tendo  Achilhs,  and  the  relation  of  the  malleoli  to  the  tarsus 
is  altered.  In  incomplete  dislocation  the  symptoms  are  similar,  but  less  pro- 
nounced. In  dislocation  backward  the  foot  is  shortened,  the  tibia  and  fibula 
project  in  front,  the  heel  is  prominent,  and  the  relation  between  the  malleoli 
and  the  tarsus  is  altered.  In  incomplete  dislocation  the  symptoms  are  similar, 
but  less  marked. 

Treatment. — In  anteroposterior  dislocation  of  the  ankle-joint  reduce  as 
in  lateral  dislocations.  Sometimes  the  tendo  Achillis  must  be  cut.  Apply 
a  plaster-of-Paris  dressing  and  let  it  be  worn  for  two  weeks;  then  begin  passive 
motion,  and  let  the  patient  wear  side-splints  for  a  week  longer. 

Dislocation  upward  of  the  ankle-joint,  or  Nelaton''s  dislocation,  is  a  very 
rare  injury.  The  astragalus  is  wedged  between  the  widely  separated  tibia  and 
fibula.  This  dislocation  is  usually  associated  with  fracture.  The  cause  is  a 
fall  upon  the  feet  from  a  great  height. 

Symptoms. — Upward  dislocation  of  the  ankle-joint  is  indicated  by  the  widen- 
ing of  the  ankle  and  by  the  flattening  of  the  foot.  The  malleoli  are  nearly  on 
a  level  with  the  plantar  surface  of  the  foot,  and  there  is  absolute  rigidity. 

Treatment. — In  treating  upward  dislocation  of  the  ankle-joint  give  ether, 
and  try  to  reduce  by  powerful  extension  and  counterextension.  Treat  the 
injury  afterward  in  the  same  manner  as  an  anteroposterior  luxation. 

Dislocation  of  the  Astragalus. — The  astragalus  may  be  displaced  from  the 
bones  of  the  leg  and  at  the  same  time  be  separated  from  the  rest  of  the  tarsus. 
The  displacement  may  be  forward,  backward,  outward,  inward,  or  rotary. 

Dislocation  of  the  astragalus  forward  or  backward  is  caused  by  falls  or  twists. 

Symptoms. — In  forward  dislocation  the  astragalus  projects  strongly;  there 
is  shortening  of  the  foot,  and  the  malleoli  approach  the  plantar  aspect  of  the 
foot;  the  foot  is  deviated  to  one  side  or  to  the  other,  and  there  is  absolute 
rigidity  of  the  ankle-joint.  In  incomplete  luxations  the  symptoms  are  similar, 
but  less  marked.  This  dislocation  may  be  obliquely  forward.  In  backward 
dislocation  of  the  astragalus  the  foot  is  not  deviated  to  either  side;  the  astragalus 
projects  between  the  malleoli  and  above  the  os  calcis,  and  the  tendo  Achilhs 
is  stretched  over  the  projection.  Rigidity  is  absolute.  This  dislocation  may 
be  obliquely  backward. 

Lateral  and  Rotary  Dislocations  of  the  Astragalus. — Lateral  disloca- 
tions of  the  astragalus  are  rare,  are  always  compound,  and  are  always  associ- 
ated with  fracture.  In  rotary  dislocation  the  astragalus  remains  in  its  normal 
habitat  after  rotating  on  its  own  axis,  either  horizontally  or  vertically.  The 
causes  of  rotary  dislocation  are  twists  of  the  foot  when  it  is  at  a  right  angle  to 
the  leg  (Barwell).  The  symptoms  of  rotary  dislocations  are  obscure.  There  is 
rigidity,  but  sometimes  the  position  of  the  astragalus  may  be  made  out. 


Osteotomy  777 

Treatment  of  Dislocation  of  the  Astragalus. — In  treating  astragalus  dislo- 
cation reduce  under  ether  by  flexing  the  knee  to  relax  the  gastrocnemius, 
extending  the  foot,  and  pushing  the  bone  into  place.  It  may  be  necessary 
to  cut  the  tendo  AchiUis.  After  reduction  put  up  the  foot  and  leg  in  a  plaster- 
of-Paris  dressing  for  two  weeks,  and  then  begin  passive  motion  and  apply 
side-splints,  which  are  to  be  worn  for  one  week  more.  If  reduction  fails, 
support  the  limb  on  splints,  combat  inflammation,  and  endeavor  to  bring 
about  union  between  the  dislocated  bone  and  the  tissues.  Often,  in  unre- 
duced dislocation,  the  skin  sloughs  over  the  projecting  bone.  Excision  is 
demanded  the  moment  sloughing  is  seen  to  be  inevitable.  Cases  of  com- 
pound dislocation  of  the  astragalus  require  immediate  excision. 

Subastragaloid  Dislocation. — This  condition  is  a  separation  of  the  astragalus 
from  the  os  calcis  and  scaphoid,  without  separation  from  the  bones  of  the 
leg.  Pick  states  that  the  usual  classification  for  these  dislocations  is  for- 
ward, backward,  inward,  and  outward,  but  that  the  displacement  is,  as  a  rule, 
oblique,  the  foot  passing  backward  and  outward  or  backward  and  inward. 
The  cause  is  twisting. 

Symptoms. — In  subastragaloid  dislocation  the  astragalus  projects  on  the 
dorsum;  the  foot  is  everted  in  outward  dislocation  and  inverted  in  inward 
dislocation;  the  relation  of  the  malleoli  to  the  astragalus  is  unaltered;  the 
ankle-joint  is  not  absolutely  rigid;  the  foot  "is  shortened  in  front  and  is  elon- 
gated behind"  (Pick). 

Treatment. — To  treat  subastragaloid  dislocation  make  extension  in  the 
direction  opposite  to  that  of  the  displacement.  In  dislocation  of  the  tarsus 
backward  fix  a  bandage  around  the  foot,  on  a  level  with  the  heads  of  the  meta- 
tarsal bones,  which  bandage  the  surgeon  ties  around  his  shoulders.  The 
surgeon  puts  one  knee  in  front  of  the  ankle  and  thus  fixes  the  leg,  raises  him- 
self up  to  make  extension  upon  the  tarsus,  and  molds  the  bone  into  position. 
Tenotomy  may  be  necessary.  After  reduction  apply  a  plaster-of-Paris  dress- 
ing and  have  it  worn  for  three  weeks.  The  ankle-joint,  fortunately,  is  not 
involved,  and  stiffness  of  this  articulation  need  not  be  apprehended.  If  re- 
duction is  impossible,  take  the  same  course  as  in  luxations  of  the  astragalus. 

Dislocations  of  the  other  tarsal  bones  are  very  rare.  Single  bones  may 
be  dislocated,  or  the  luxation  may  occur  at  the  mediotarsal  articulation. 

Symptoms  and  Treatment. — Projection  is  an  obvious  symptom  in  disloca- 
tion of  the  other  tarsal  bones.  The  treatment  is  to  reduce  by  extension  and 
molding,  the  part  being  put  up  in  plaster-of-Paris  dressing  for  two  weeks. 

Dislocations  of  the  metatarsal  bones  are  rare. 

Symptoms  and  Treatment. — Shortening  of  the  toes  and  projection  of  the 
dislocated  bone  are  symptoms  of  dislocation  of  the  metatarsal  bones.  To 
treat  these  dislocations  reduce  by  extension  under  ether  and  put  up  in  a  plaster- 
of-Paris  dressing  for  two  weeks.  If  reduction  fails,  the  functions  of  the  foot 
will  not  be  much  impaired. 

Dislocations  of  the  phalanges  are  very  rare.  The  first  phalanx  of  the 
big  toe  is  the  one  most  liable  to  dislocation. 

Symptoms  and  Treatment. — Dislocations  of  the  phalanges  are  obvious.  '  The 
treatment  is  by  reduction  and  fixation,  as  in  dislocation  of  the  thumb.  Im- 
mobilize for  two  weeks. 

Operations  Upon  Bones  and  Joints 

Osteotomy. — By  the  term  osteotomy  the  modern  surgeon  means  literally 
the  sectioning  of  a  bone  for  the  purpose  of  straightening  a  limb  ankylosed 
in  a  bad  position,  correcting  a  bony  deformity,  or  amending  a  vicious  union 
of  a  fracture.  In  a  linear  osteotomy  the  bone  is  transversely  or  obhquely  divided 
at  one  spot;  in  a  cuneiform  osteotomy  a  wedge-shaped  portion  of  bone  is  removed. 


778  Diseases  and  Injuries  of  the  Bones  and  Joints 

The  operation  of  osteotomy  may  be  performed  with  a  saw  (Fig.  480)  or  with 
an  osteotome.  The  saw  creates  dust,  draws  much  air  into  the  wound,  and 
lacerates  the  tissues  to  a  considerable  degree.  Most  surgeons  prefer  the 
chisel  or  the  osteotome.  The  osteotome  slopes  down  to  a  point  from  each  side 
(Fig.  481);  the  chisel  is  straight  on  one  side  and  on  the  other  is  bevelled  to  a 
point. 

Osteotomy  for  Genu  Valgum,  or  Knock-knee  (Macewen's  Operation,  Fig. 
482). — Operation  is  never  done  until  the  subacute  stage  of  rickets  has  passed 
and  the  greatest  care  is  taken  not  to  traumatize  the  epiphysis.  The  patient 
Hes  upon  his  back,  being  rolled  a  little  toward  the  diseased  side.  The  leg  of 
the  diseased  side  is  partly  flexed  upon  the  thigh  and  the  thigh  upon  the  pelvis, 
and  the  extremity  is  laid  upon  its  outer  surface,  a  sand-bag  being  pushed 
between  the  extremity  and  the  bed,  opposite  to  the  site  of  section.  The  flexion 
of  the  knee  relaxes  the  popliteal  vessels  and  saves  them  from  injury.  The 
surgeon,  if  operating  on  the  right  leg,  stands  outside  of  that  extremity;  if 
operating  on  the  left  leg,  he  stands  opposite  the  left  hip  (Barker).  The  knife 
is  inserted  into  the  tissues  and  carried  to  the  bone  at  the  inner  side  of  the  knee, 


Fig.  480. — Adams's  large  saw.     (In  this  day  of  surgery  the  saw  has  a  metal  handle.) 


just  in  front  of  the  adductor  tubercle  of  the  inner  condyle  and  on  a  level  with  the 
upper  border  of  "the  patellar  articular  surface  of  the  femur"  (Barker).  An  in- 
cision is  made  upward  i  inch  in  length,  in  the  direction  of  the  axis  of  the  femur. 

The    knife    is  left   in   as   a  guide  until  the 
osteotome   is  inserted  at  the  lower  angle  of 
this  wound.     After  the  insertion  of  the  os- 
FiG.  481. — Osteotome.  teotome  the  knife  is  withdrawn  and  the  blade 

of  the  osteotome  is  turned  to  a  right  angle  with 
the  shaft  of  the  femur,  3''2  i^ch  above  the  epiphysis  (Fig.  482).  The  osteotome  is 
struck  several  times  with  a  mallet;  the  handle  is  moved  several  times  toward  and 
from  the  body,  so  as  to  widen  the  cut  in  the  bone  (Fig.  483);  the  osteotome  is 
again  struck  with  the  mallet  several  times;  it  is  again  moved  to  and  fro,  and  this 
process  is  continued  until  the  bone  is  cut  two-thirds  through.  If  the  osteotome 
becomes  tightly  fixed,  it  should  be  withdrawn  and  a  smaller  one  introduced. 
In  the  soft  bone  of  a  young  girl  this  to-and-fro  movement  of  the  chisel,  if 
carefully  executed,  is  not  liable  to  break  the  instrument.  In  dense  bone  it 
may  break  the  instrument;  hence,  when  doing  an  osteotomy  in  dense  bone,  the 
osteotome  is  moved  to  and  fro  across  the  limb  and  sUght  downward  pres- 
sure upon  the  handle  will  to  a  great  extent  prevent  binding.  When  the  bone  is 
cut  two-thirds  through  the  osteotome  is  withdrawn,  a  piece  of  wet  antiseptic 
gauze  is  held  over  the  wound,  and  the  surgeon  fractures  the  femur  by  strong 
adduction.  The  wound  is  neither  sutured  nor  drained,  but  is  dressed  asep- 
tically,  the  entire  extremity  is  wrapped  in  cotton,  and  a  plaster-of-Paris  dress- 
ing is  applied  and  carried  up  to  the  groin.  The  dressing  may  be  removed  in  two 
weeks,  and  the  patient  may  subsequently  be  treated  with  sand-bags,  as  for 
an  ordinary  fracture  of  the  thigh,  but  without  extension.  This  operation  is 
scarcely  ever  fatal. 


Osteotomy  through  the  Neck  of  the  Femur 


779 


Ogstori's  Operation  for  Knock-knee  (Fig.  482). — In  this  operation  the  in- 
ternal condyle  is  sawed  off  obliquely  with  an  Adams  saw — a  proceeding  which 
permits  the  straightening  of  the  knee.  The  objection  to  the  procedure  is  that 
it  opens  the  knee-joint,  and  that  this  cavity  fills  up  more  or  less  with  a  mixture 
of  blood  and  bone-dust.     Macewen's  operation  is  decidedly  the  safer. 

Osteotomy  for  a  Bent  Tibia. — The  tibia  is  divided  transversely  or  obliquely 
(linear  osteotomy),  or  a  wedge-shaped  piece  is  removed  (cuneiform  osteotomy). 
The  oblique  incision  is  the  best.  If  the  convexity  of  the  tibial  curve  is  inward, 
cut  the  bone  from  above  downward  and  from  in  front  backward;  if  the  curve  is 
forward,  section  the  bone  from  above  downward  and  from  within  outward. 
The  fibula  need  rarely  be  interfered  with.  After  the  osteotomy  the  limb  is 
treated  just  as  it  would  be  for  a  fracture. 

Osteotomy  for  Faulty  Ankylosis  of  the  Hip-joint. — This  operation  is  per- 
formed in  order  to  allow  straightening  of  a  limb  that  has  undergone  bony 
ankylosis  in  a  faulty  or  an  inconvenient 
position.  In  some  cases  an  attempt  is 
made  to  obtain  a  movable  joint,  but  in 
most  cases  the  surgeon  must  be  satis- 
fied with  ankylosis  in  extension.  Os- 
teotomy may  be  performed  through  the 
neck  of  the  femur  or  through  the  shaft 
of  the  femur  below  the  trochanters. 


Fig.  482. — Osteotomy  of  the  right  femur 
in  a  case  of  knock-knee:  a  b,  Epiphyseal 
line;  c,  section  of  Macewen;  d  e,  section  of 
Ogston. 


Fig.  483. — Macewen's  operation  for  genu 
valgum.  The  chisel  is  held  in  the  line  for 
striking  with  a  mallet;  the  arrow  shows  the 
direction  in  which  the  chisel  is  levered  up 
and  down  so  as  to  make  a  wide  gap  in  the 
bone  (after  Barker). 


Osteotomy  through  the  neck  of  the  femur  is  performed  (i)  with  a  saw 
(Adams's  operation)  or  (2)  with  an  osteotome. 

Adams'' s  Operation  (Fig.  484,  a). — The  patient  lies  upon  his  sound  hip;  the 
surgeon  stands  upon  the  side  to  be  operated  upon,  and  back  of  the  patient.  The 
knife  is  entered  a  finger's  breadth  above  the  great  trochanter,  is  pushed  in  until 
it  strikes  the  neck  of  the  bone,  is  then  carried  across  the  front  of  and  at  a  right 
angle  with  the  neck,  and  is  withdrawn,  enlarging  the  wound,  in  the  soft  parts 
as  it  emerges,  to  the  extent  of  i  inch.  The  saw  is  then  introduced  and  the 
neck  of  the  femur  is  entirely  divided.  After  the  osteotomy  dress  the  wound 
antiseptically  and  place  the  extremity  straight.  To  straighten  the  limb  it  may 
be  found  necessary  to  cut  contracted  tendons  and  fascial  bands.  After  secur- 
ing extension  and  applying  dressings  use  the  weight-extension  apparatus  and 
the  sand-bags.  Begin  passive  movements  from  the  start  if  a  movable  joint  is 
desired;  few  patients  can  tolerate  the  pain  necessary  to  bring  this  about.  If  it 
is  determined  to  aim  for  a  stiff  joint,  treat  the  case  as  an  intracapsular  fracture 
would  be  treated. 

With  an  Osteotome. — The  position  of  the  patient  is  the  same  as  that  for 
Adams's  operation.  An  incision  i  inch  long  is  made,  starting  just  above  the 
great  trochanter,  ascending  in  the  axis  of  the  femoral  neck,  and  reaching  to 


780  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  bone.  An  osteotome  is  introduced,  is  turned  to  a  right  angle  with  the  neck  of 
the  bone,  and  is  struck,  with  a  mallet  until  the  bone  is  completely  divided.  (It  is 
not  to  be  divided  partially  and  then  broken.)  The  after-treatment  is  the  same 
as  that  for  Adams's  operation.  The  operation  by  the  osteotome  is  to  be  pre- 
ferred to  that  by  the  saw. 

Osteotomy  of  the  Shaft  of  the  Femur  Below  the  Trochanters  {Ganfs  Opera- 
tion).— In  this  operation  (Fig.  484,  b)  the  saw  may  be  used,  but  the  osteotome  is 
to  be  preferred.  The  position  in  Gant's  is  like  that  in  Adams's  operation. 
A  longitudinal  incision  i  inch  long  is  made  upon  the  outer  aspect  of  the  femur 
and  on  a  level  with  the  lesser  trochanter.  The  osteotome  is  inserted  and  the 
bone  is  completely  divided  below  the  lesser  trochanter.  The  after-treatment 
is  the  same  as  that  for  Adams's  operation.  Gant's  operation  is  the  best  method 
for  correcting  faulty  position  in  bony  ankylosis,  and  Adams's  operation  can 
only  be  employed  in  those  cases  in  which  the  femur  still  has  a  neck  which  is 
practically  unchanged. 

Osteotomy  for  Faulty  Ankylosis  of  the  Knee-joint. — This  operation  is  per- 
formed for  bony  ankylosis  of  a  knee  in  a  position  of  flexion.     In  these  cases 
it  is  nearly  always  necessary  to  cut  contracted  tendons  and  fascia.     These 
contractures    tend  to  draw  the  tibia  backward  as  in  a 
A  f\)  posterior  dislocation.    The  patient  lies  upon  his  back  with 

y^^ .\J  ^^^  thighs  fiat  upon  the  bed,  the  legs  hanging  over  the  end 

I  /  of  the  bed.     The  surgeon  stands  on  the  patient's  right 

I  \  side.     Just  above  the  patellar  articular  surface  upon  the 

\  /  femur  a  transverse  incision  is  made,  i  inch  in  length  and 

reaching  to  the  bone.     The  osteotome  is  introduced  and 
the  bone  is  cut  nearly  through.     The  leg  is  then  forcibly 
extended.     It  must  not  be  extended  too  violently  or  the 
popliteal  vessels  may  be  injured.     In  cases  in  which  the 
structures  of  the  popliteal  space  are  tense  and  have  not 
been  divided  the  leg  must  not  be  brought  at  once  into 
Fig.  484  —  Osteot-     extension,  but  this  position  should  be  attained  gradually 
oHhe femur:  A, Adams's     by  means  of  weights.     The  wound  is  dressed  aseptically, 
operation;   b,'g ant's     and  the  extremity  is  placed  upon  a  double  inclined  plane 
operation.  and  is  treated  as  for  fracture  near  the  knee-joint. 

Osteotomy  for  vicious  union  of  a  fracture  is  per- 
formed in  case  of  angular  deformity,  and  is  carried  out  in  the  same  manner 
as  are  the  above  procedures.  It  is  best,  when  possible,  to  enter  the  osteot- 
ome upon  the  concavity  of  the  bent  bone,  so  that  the  periosteum  will  not 
rupture  when  extension  is  made,  and  the  patient  will  in  consequence  gain  a 
longer  limb. 

Osteotomy  for  Hallux  Valgus. — In  this  operation  a  linear  osteotomy  is 
made  through  the  neck  of  the  metatarsal  bone  of  the  great  toe,  the  toe  is  forcibly 
adducted,  and  a  splint  is  appUed  to  the  inside  of  the  foot  and  the  toe.  A 
cuneiform  osteotomy  may  be  done  instead  of  a  Unear  osteotomy.  The  osteo- 
tomy is  made  through  the  neck  of  the  metatarsal  bone.  A  wedge-shaped 
piece  of  bone  (the  base  of  which  is  to  the  inner  side  of  the  foot)  is  removed. 
Charles  H.  Mayo  makes  a  flap  of  the  bursal  sac  and  capsular  ligament,  divides 
the  metatarsal  bone  with  a  Gigli  wire  saw,  sutures  the  flap  over  the  bone  end, 
closes  the  skin  incision,  and  fixes  the  toe  in  the  adducted  position. 

Osteotomy  for  Talipes  Equinovarus  {Ajtcr  Barker).— The  patient  lies  upon 
his  back,  the  thigh  is  semiflexed,  the  knee  is  bent,  and  the  sole  of  the  foot  rests 
upon  the  table.  The  surgeon  stands  to  the  right  side  if  it  is  the  right  limb 
which  is  to  be  operated  upon,  and  to  the  left  side  if  it  is  the  left  limb.  He 
feels  for  the  outer  surface  of  the  cuboid  bone,  and  cuts  away  from  over  the  latter 
a  piece  of  skin  corresponding  in  size  with  the  bone- wedge  intended  to  be  removed 
(this  piece  of  skin  must  include  the  bursa  which  forms  in  these  cases).     The 


Bone-grafting  or  Transplantation  781 

foot  is  then  turned  outward,  the  astragaloscaphoid  articulation  is  located,  and 
over  this  an  incision  is  made  "from  the  lower  to  the  upper  dorsal  border  of  the 
scaphoid  bone"  (Barker),  reaching  through  the  skin  only;  the  foot  is  placed 
again  in  the  first  position,  all  the  soft  parts  are  raised  from  off  the  superior 
surface  of  the  tarsus,  and  a  triangular  surface  corresponding  with  the  base  of 
the  wedge  to  be  removed  is  cleared;  a  "kite-shaped"  director  (Fig.  485)  is 
passed  into  the  external  wound  and  projected  from  the  internal  wound;  the 
saw  is  pushed  through  the  groove  of  the  director  nearest  the  toes,  and  is  made  to 
cut  through  the  tarsus,  from  the  dorsum  to  the  sole,  at  right  angles  to  the  meta- 
tarsal bones;  the  saw  is  pushed  through  the  groove  of  the  director  nearest  the 
ankle,  and  is  made  to  cut  from  the  dorsum  to  the  sole,  at  right  angles  to  the  long 
axis  of  the  calcaneum;  the  wedge-shaped  piece  of  bone  is  grasped  by  sequestrum 
forceps  and  cut  out  by  scissors,  by  bone-forceps,  or  by  a  blunt  bistoury.  The 
wound  is  well  irrigated,  the  foot  is  straightened,  the  internal  wound  is  sewed 
up,  the  external  wound  is  sutured  except  at  its  lowest  portion,  where  a  drainage- 
tube  is  to  be  retained  for  twenty-four  hours,  and  dressings  are  applied  to  the 
wound.  The  foot  is  put  up  in  plaster  or  upon  a  Davy  splint.  Some  surgeons 
insert  the  wedge  of  bone  into  the  opening  made  by  a  linear  osteotomy  on  the 
inner  side  of  the  foot. 

Osteotomy  for  Talipes  Equinus. — -This  operation  is  described  by  Mr. 
Davy,  who  devised  it,  as  follows:^  "Taking  the  line  of  the  transverse  tarsal 
joint  as  a  guide,  on  the  outer  and  inner  sides  of 
the  foot,  and  immediately  over  the  joint,  two 
wedge-shaped  pieces  of  skin  are  removed,  equal 
in  extent  to  the  amount  of  bone  demanded. 
The  soft  structures  are  freed  on  the  dorsum  of 
•the  foot  in  the  way  previously  described;  but,  as  Fig.  485. — Davy's  director  (Pye). 
the  base  of  the  osseous  wedge  for  equinus  cases 

is  at  the  dorsum  and  its  apex  at  the  sole,  the  parallel  wire  director,  instead 
of  the  kite-shaped  varus  one,  is  used.  The  saw  is  successively  inserted  in  its 
grooves,  and  by  keeping  in  mind  the  idea  of  a  keystone  a  clean  wedge  of  bone 
is  cut  out  from  the  dorsum  to  the  sole  of  the  foot."  The  wedge  is  extracted,  and 
the  foot  is  straightened  and  is  put  up  in  plaster  of  Paris  or  is  placed  on  a  Davy 
splint. 

The  Question  of  Operation  for  Recent  Fractures. — (See  page  608.) 
Operation  for  Recent  Simple  Fracture. — Very  early  after  the  injury  is 
a  fairly  safe  period  for  operation.  Lane  favors  very  early  operation.  During 
the  first  week,  excluding  the  early  hours  after  the  injury,  is  a  dangerous  period " 
to  operate  because  the  area  of  injury  has  a  low  resistance  to  infection.  About 
the  tenth  day  is  a  safer  period  for  operation.  Very  careful  sterilization  is 
imperatively  necessary.  Make  a  free  incision  and  expose  the  fracture.  Re- 
move all  tissue  from  between  the  bone  ends.  Konig  disagrees  with  Lane  that 
all  blood-clot  should  be  removed.  Arrest  bleeding.  Bring  the  fragments  into 
apposition  by  extension  and  by  using  powerful  forceps  (Fig.  325)  as  a  lever. 
Apply  nails,  screws,  or  what  apparatus  we  desire. 

The  Lane  plate  is  an  excellent  device  (see  Fig.  319).  Select  a  suitable 
place,  remove  the  lever,  fix  the  plate  and  bones  by  Lowman's  clamp  (see  Fig. 
326),  bore  the  bone  by  a  drill  (see  Figs.  320,  486,  487)  at  each  screw  hole,  insert 
and  fix  the  screws,  remove  the  clamp,  and  close  the  wound  without  drainage  or 
with  a  cigarette  drain.     The  part  is  placed  upon  a  splint.  . 

Figure  374  shows  Lane's  plate  applied.  If  it  does  not  loosen  and  does  not 
give  trouble  a  plate  is  not  removed  surgically. 

Recent  Transverse  Fracture  of  the  Patella. — (See  page  689,) 

Recent  Fracture  of  the  Olecranon  Process  of  the  Ulna. — (See  page  650.) 

Bone=grafting,  or  Transplantation. — (See  pages  574  and  610.) 

'  Barker's  "Manual  of  Surgical  Operations." 


782  Diseases  and  Injuries  of  the  Bones  and  Joints 

Operative  Treatment  of  Ununited  Fracture. — A  method  of  operation 
long  in  vogue  and  still  used  is  as  follows:  Incise  longitudinally  down  to  the  seat 
of  fracture,  retract  the  periosteum  from  the  bone,  drill  the  bones  before  cutting 
them,  chisel  away  the  material  imperfectly  uniting  the  fragments,  saw  through 
each  bone  end  far  enough  from  the  seat  of  fracture  to  reach  sound  tissue,  cut  away 
the  hard  plug  in  each  medullary  cavity,  pass  large  silver  wire  through  the  holes 
(this  wire  should  be  3f  0  inch  in  diameter  for  the  femur, }  f  e  inch  for  the  patella, 
etc.)  (Fig.  488),  twist  the  wires  a  fixed  number  of  times  (two  complete  turns)  in 
the  direction  that  the  hands  of  a  watch  move  (this  is  Keen's  direction;  in  case 
removal  of  the  wires  should  be  demanded  later  we  know  how  to  untwist  them; 
of  course  the  surgeon  must  remember  where  he  stood  in  relation  to  the  limb  and 
regard  the  hypothetical  watch  as  being  face  up  upon  the  part),  sev^er  the  ends  of 
the  wires,  and  hammer  their  stems  against  the  bones.  The  wires  may  never 
require  removal.  The  soft  parts  are  sutured,  no  drain  or  a  cigarette  drain  is 
used,  and  the  limb  is  encased  in  plaster  of  Paris.  The  objection  to  wire  in 
fracture  of  a  long  bone  is  that  the  wire  acts  as  a  hinge  and,  as  a  consequence, 
alignment  is  apt  to  be  disturbed.  Various  plans  besides  wiring  have  been  em- 
ployed in  ununited  fracture.  Gussenbauer's  clamp  is  used  by  some.  Clayton 
Parkhill's  bone-clamp  is  a  useful  appliance,  and  holds  the  fragments  firmly  in 


^ 


Fig.  486. — Hamilton's  improved  bone-drills. 


Fig.  487.— Brainard's  drills  with  Wveth's  adjustable  handles. 

contact.  vSome  surgeons  unite  the  fragments  with  kangaroo-tendon  instead  of 
wire  (suturing  of  bone);  others  use  nails  of  bone  or  ivory;  others  use  screws. 
Senn  asserted  that  the  above  methods  will  not  hold  fragments  in  contact  if  these 
fragments  have  a  tendency  to  become  displaced.  Senn  fastened  the  bones 
together  by  hollow  cylinders  of  decalcified  bone  or  ivory,  the  cylinders  being  per- 
forated in  many  places  (bone-ferrules).  I  regard  the  silver  p^ate  of  Halsted 
and  steel  plate  of  Lane  as  the  most  satisfactory  appliances  in  use  for  fixation. 
Albee's  Operation. — Albee  has  emphasized  the  true  principle.  Fixation 
alone  is  seldom  successful.  The  osteogenetic  power  is  impaired  in  these 
injuries.  Plates  will  fix  the  fragments  but  will  not  stimulate  bone  production. 
This  can  be  done  by  a  bone-graft.  The  graft  is  cut  from  sound  bone  ends 
or  from  another  bone  on  the  same  individual.  When  fixed  in  place  a  graft 
holds  the  fragments  like  a  plate,  stimulates  osteogenetic  power,  acts  as  a 
scaffolding  for  new  bone-cells,  and,  at  least  so  Albee  believes,  actively  par- 
ticipates in  repair.  It  is  far  and  away  the  best  method.  The  method  for 
ununited  fracture  is  as  follows:  Expose  the  fracture,  cut  away  fibrous  union 
and  freshen  the  bone  ends,  remove  the  sclerosed  plug  from  the  medullary 
cavity  of  each  fragment;  if  there  is  overriding  make  traction,  divide  the 
periosteum,  take  the  twin  saw  and  cut  the  groove  for  the  insert.  This  groove 
goes  through  the  cortex.  The  loose  bone  is  removed.  Drill  holes  through  the 
cortex  on  each  side  of  the  groove.  Expose  the  tibia  and  cut  a  groove  with 
the  twin  saw.     Remove  the  graft  from  the  sound  tibia  and  insert  it  into  the 


Ununited  Fractures   of  the  Femoral  Neck 


783 


groove  of  the  fractured  bone.  Kangaroo  tendon  having  been  run  through  the 
drill  holes  is  now  tied  over  the  graft.  (See  Albee,  in  "Am.  Jour,  of  Surgery," 
1914,  xxviii  and  "Bone-graft  Surgery,"  by  Albee.) 

Ununited  Fractures  of  the  Femoral  Neck. — Loreta  did  the  first  successful 
operation  for  this  condition  a  number  of  years  ago.     The  operation  is   not 
adapted  to  the  aged,  but  should  certainly  be  employed  in  youths  and  middle- 
aged  individuals  if  the  general  condition 
of   the   patient    or   some  particular  dis- 
eased state  does  not  forbid,  and  if  pain  is 
severe  and  disability  is  pronounced. 

Leonard  Freeman  advises  an  anterior 
incision  beginning  below  and  external  to 
the  anterior  superior  iliac  spine  and  ex- 
tending downward,  external  to  the 
sartorious,  for  3  or  4  inches  ("Annals  of 
Surg.,"  Oct.,  1904).  When  the  frag- 
ments are  exposed,  the  connective  tissue 
between  them  is  cut  away  by  means  of 
scissors,  the  surfaces  of  the  fragments 
are  freshened  by  a  chisel  or  a  curet, 
oozing  is  arrested  by  pressure  and  hot 
water,  and  loose  osseous  splinters  are  re- 
moved (Freeman).  Some  surgeons  have  fixed  the  fragments  together  by 
nails,  screws,  or  pegs  of  bone  or  ivory,  access  to  the  trochanter  being  best 
obtained  for  this  purpose  by  making  a  second  incision  over  the  outer  portion 
of  that  bony  process.  As  Freeman  points  out,  however,  the  head  is  often  so 
very  soft  that  none  of  these  appliances  will  secure  fixation. 


Fig.  488. — Wiring  of  bones  for  un- 
united fracture:  a,  a,  Sawn  surfaces  ap- 
proximated after  removal  of  old  material 
which  was  interposed  between  the  frag- 
ments; b-b,  b-b,  perforations  drilled  com- 
pletely across  the  bone;  c,  c,  wires  ready 
for  twisting. 


Fig.  489. — Method  of  securing  screw  of  Freeman's  apparatus  in  fracture  of  neck  of  femur;  the 
wooden  plates  embracing  screws  (Freeman,  in  "Annals  of  Surgery,"  Oct.,  1904). 

Freeman  has  devised  a  clamp  for  this  purpose  (Figs.  489,  490).  An  addi- 
tional incision  is  made  over  the  trochanter  and  holes  are  bored  for  the  clamp 
screws,  one  hole  being  drilled  "through  the  base  of  the  trochanter,  the  exter- 
nal fragment  of  the  neck,  and  into  the  head  of  the  bone"  ("Annals  of  Sur- 
gery," Oct.,  1904).  The  wound  is  closed,  dressings  are  applied,  and  extension 
is  made  on  a  long  side  splint,  a  pad  being  placed  beneath  the  trochanter  to 
prevent  the  disposition  to  pass  backward,  as  this  movement,  if  it  occurs,  will 
cause  external  rotation  of  the  limb  and  separation  of  the  fragments.     In  about 


784 


Diseases  and  Injuries  of  the  Bones  and  Joints 


eight  weeks  the  extension  is  removed  and  the  patient  is  allowed  about  on 
crutches.  Dr.  H.  Augustus  Wilson  has  succeeded  by  simply  nailing  the  frag- 
ments together  without  attempting  to  freshen  their  faces.  He  got  his  patient 
up  on  crutches  in  two  weeks  ("Amer.  Jour.  Orthopedic  Surgery,"  Jan.,  1908). 
Tn  Freeman's  case  the  screws  were  removed  in  two  weeks  because  of  infection 


Fig.  490. — Completed  screw  and  clamp  of  Freeman's  apparatus  for  fixation  of  fracture  of 
neck  of  femur  (Freeman,  in  "Annals  of  Surgery,"  Oct.,  1904). 

of  the  cancellous  tissue.  A  similar  condition  arose  in  Davis's  case,  in  which 
two  steel  drills  were  used.  Dr.  H.  Augustus  Wilson  has  collected  36  cases  of 
direct  fixation  of  old  intracapsular  fractures  (Ibid.). 

Ununited  Fracture  of  Patella. — Ten  days  before  operating  inject  the  knee- 
joint  with  15  c.c.  of  a  2  per  cent,  solution  of  formalin  in  glycerin.     This  will 

produce  a  chemical  inflammatory  reaction,  which 
coffer-dams  the  lymph  spaces  and  strengthens  im- 
munity to  infection  (John  B.  Murphy,  in  his 
"Surgical  Clinics,"  Vol.  iv).  A  semilunar  incision 
is  made  about  the  fragments,  the  convexity  point- 
ing up  or  down  (this  avoids  the  prepatellar  bursa), 
or  an  incision  is  made  in  the  long  axis  of  the  limb, 
over  the  middle  of  the  space  between  the  frag- 
ments, from  well  above  the  upper  fragments  to  well 
below  the  lower  piece.  The  soft  parts  are  retracted, 
but  the  periosteum  is  undisturbed;  each  fragment 
is  bored  (Fig.  491,  i)  in  one  or  two  places;  the  sur- 
faces of  the  fragments  are  sawed  straight  across, 
through  sound  bone;  all  old  reparative  material  is  cut 
away;  the  wires  are  passed  through  the  perforations, 
twisted,  cut  off,  and  hammered  down  (Fig.  491,  2). 
If  the  bone-fragments  cannot  be  approximated,  it 
may  become  necessary  to  incise  the  muscle  around 
and  above  the  patella  or  partially  to  separate  the 
tuberosity  of  the  tibia  and  bend  this  process  up- 
ward. A  small  drain  is  inserted  above  the  bone, 
the  wound  is  sutured,  aseptic  dressings  are  applied,  and  the  limb  is  put  upon 
a  Macewen  splint. 

Treves's  Operation  for  Caries  of  the  Lumbar  and  Last  Dorsal  Ver= 
tebrae,  with  Abscess  in  the  Psoas  Magnus  or  Quadratus  Lumborum 
Muscle. — The  patient  lies  upon  his  left  side,  with  the  knees  drawn  up  and  a 


Fig.  491. — Wiring  of  the 
patella:  i.  Fragments  cut  and 
cleaned  and  the  wires  passed; 
2,  wires  twisted  and  hammered 
down  upon  the  bone  (after 
Barker). 


Aspiration  of  Joints 


785 


sand-bag  under  the  left  loin.  The  surgeon  stands  behind  the  patient  (Barker). 
An  incision  is  made  at  the  outer  border  of  the  erector  spinae  mass,  reaching  from 
the  last  rib  to  the  iliac  crest  and  going  down  at  once  to  the  lumbar  fascia.  The 
lumbar  aponeurosis  is  opened,  the  erector  s[)ina'  muscle  is  retracted  inward,  and 
the  anterior  portion  of  the  erector  spinae  sheath  is  incised.  The  quadratus  lum- 
borum  muscle  is  next  cut,  and  then  the  anterior  leaflet  of  the  lumbar  aponeu- 
rosis is  slit.  The  abscess  is  thus  reached  and  opened  and  tuberculous  pus 
flows  out.  The  abscess-cavity  is  irrigated  with  ciuantities  of  warm  corrosive 
sublimate  solution  (i  :  5000).  The  cavity  is  tilled,  the  fluid  is  allowed  to  flow 
out,  its  exit  being  aided  by  pressure  in  front  and  changes  of  posture;  the  cavity 
is  filled  again,  and  so  on,  and,  after  all  loose  debris  is  removed,  the  bodies  of 
the  vertebras  are  carefully  examined  with  the  finger  and  diverticula  are  opened. 
Loose  pieces  of  bone  are  removed  by  spoons  or  forceps,  and  cavities  are  thor- 
oughly but  lightly  curetted,  as  in  some  places  the  wall  is  very  thin.  By  means 
of  properly  shaped  spoons  carious  bone  can  be  removed  even  from  the  anterior 
surface  of  the  column  (Treves).  Thus  the  wall  of  the  abscess  is  completely 
removed.     Finally,  all  debris  is  washed  out  by  irrigation  with  mercurial  solu- 


FiG.  492. — Aspirator  and  injector. 

tion;  any  mercurial  solution  which  might  remain  is  washed  out  by  warm  water 
or  salt  solution,  and  the  interior  of  the  cavity  is  wiped  dry.  At  this  stage 
most  operators  introduce  iodoform  emulsion.  Whether  or  not  this  is  done, 
"the  wound  is  closed  by  a  series  of  silkworm-gut  sutures,  passed  sufficiently 
deep  to  include  the  greater  part  of  the  muscular  and  tendinous  structures  with 
the  skin"  (Treves's  "Operative  Surgery").  Treves 's  operation  gives  a  high 
mortality. 

Aspiration  of  Joints. — In  certain  cases  of  joint-effusion  from  inflamma- 
tion, tuberculous  or  otherwise,  and  sometimes  in  hemorrhage  into  a  joint,  it  is 
desirable  to  remove  the  fluid  by  aspiration.  The  pneumatic  aspirator  (Fig. 
492)  is  used.  The  trocar  and  cannula  are  thoroughly  asepticized  and  the  joint 
is  prepared  as  for  a  set  operation.  The  needle  is  entered  at  a  point  free  from 
large  vessels.  The  directions  for  using  an  aspirator  are  as  follows:  insert  the 
stopper  firmly  into  a  strong  bottle  (preferably  a  clear  glass  one),  then  attach  the 
short  elastic  hose  to  the  stopcock  B  of  the  tube  projecting  from  the  stopper, 
and  attach  the  other  end  of  the  same  elastic  hose  to  the  exhausting  or  inward- 
flowing  chamber  of  the  pump.  Next,  attach  one  end  of  the  lower  elastic  hose 
to  the  stopcock  A  projecting  from  the  stopper  and  the  other  end  to  the  needle. 
Care  should  be  taken  that  all  the  fittings  or  attachments  are  placed  firmly  into 
their  respective  places.  Now^  close  the  stopcock  A  and  open  the  stopcock 
B.  By  giving  from  thirty-five  to  fifty  strokes  of  the  pump  a  sufficient  vacuum 
can  be  produced  to  fill  with  the  fluid  from  the  joint  a  bottle  holding  from  a  pint 
to  a  quart.  After  having  formed  the  vacuum,  close  the  stopcock  5,  and  insert 
50 


786  Diseases  and  Injuries  of  the  Bones  and  Joints 

the  needle  in  the  joint.  When  the  stopcock  A  is  opened,  suction  through  the 
needle  draws  the  fluid  from  the  joint.  The  trocar  may  be  used  to  inject 
antiseptic  agents.  After  the  completion  of  aspiration  the  part  is  dressed  anti- 
septically  and  the  extremity  is  put  at  rest  upon  a  splint. 

Excisions  of  Bones  and  Joints. — The  ancients  practised  excision  and 
resection  for  compound  dislocations  and  fractures.  For  centuries  surgeons 
removed  pieces  of  diseased  bone  from  joints.  The  operation  was  set  forth  as 
a  definite  procedure,  and  was  first  formally  advised  as  a  substitute  for  ampu- 
tation in  joint  disease  by  Mr.  Park,  of  Liverpool,  in  1781.  In  1782  the  elder 
Moreau,  of  Bar-sur-Ornain,  independently  devised  a  like  operation.  The 
terms  "excision"  and  ''resection"  are  usually  employed  as  synonymous,  but 
such  a  use  is  not  strictly  accurate.  According  to  Professor  Ashhurst,  the  term 
excision  means  "the  removal  of  an  offending  part  without  that  total  ablation 
of  the  affected  portion  of  the  body  which  is  implied  by  the  term  'amputation.' 
Hence  we  speak  of  excisions  of  tumors,  of  joints,  of  the  eyeball,  etc."  Resec- 
iion  has  a  more  restricted  meaning;  it  signifies  "an  operation  which  takes  away 
a  middle  portion  and  brings  the  ends  together  again,  and  is  thus  in  strict  sur- 
gical language  limited  to  partial  excisions  of  the  long  bones"  ("International 
Encyclop.  of  Surgery,"  edited  by  John  Ashhurst,  Jr.).  Excision  of  a  joint  is  the 
removal  of  the  articular  portions  of  the  bones  of  the  joint,  and  also  the  carti- 
lage and  synovial  membrane.  In  the  hip-joint  and  shoulder-joint  only  the 
head  of  the  long  bone  may  be  removed,  and  not  the  articular  surfaces  of  both 
bones.  In  partial  excision  of  a  long  bone,  excision  (resection)  for  bone  disease, 
enough  bone  is  known  to  have  been  removed  only  when  the  remaining  bone 
bleeds.  Complete  excision  of  a  bone  is  the  removal  of  an  entire  bone.  Partial 
excision  or  resection  is  the  removal  of  a  portion  only  of  a  bone.  Excision  is  a 
conservative  operation  which  often  averts  amputation. 

Excision  may  be  performed  by  the  open  method,  in  which  the  periosteum 
is  not  preserved,  or  it  may  be  performed  by  the  subperiosteal  method,  in  which 
the  periosteum  is  carefully  separated  by  a  rugine  and  the  capsular  ligament  is 
preserved.  This  method  was  devised  by  Oilier,  of  Lyons.  Arthrectomy,  or 
erosion,  is  the  excision  of  the  diseased  synovial  membrane  and  ligament,  and 
also  small  foci  of  disease  of  bone  and  cartilage. 

Excision  may  be  employed  for  compound  dislocation,  and  in  compound  dis- 
locations of  the  elbow  and  "the  shoulder  it  is  usually  performed.  Excisions  for 
compound  dislocations  in  other  large  joints  are  very  dangerous ;  they  are  rarely 
attempted  in  battlefield  practice,  and  are  to  be  avoided  even  in  civil  practice 
unless  the  patient  is  young  and  vigorous  and  every  advantage  can  be  given 
him  during  the  operation  and  convalescence.  Excision  for  deformity  is  rarely 
performed  except  upon  the  hip,  the  knee,  and  the  shoulder,  and  these  excisions 
must  not  be  employed  if  the  patient's  condition  leads  one  to  fear  the  result  of 
a  protracted  convalescence.  Excision  of  the  elbow,  however,  is  usually  a  safe 
operation.  In  excising  for  deformity  always  consider  the  patient's  trade  and 
the  demands  of  habitual  position  which  it  makes  upon  him.^ 

Excision  is  largely  employed  for  joint-disease,  especially  for  tuberculous 
joints.  Bell  states  that  attempts  to  preserve  the  limb  without  excision  are 
more  justifiable  in  the  lower  than  in  the  upper  limbs,  because  operation  in 
the  lower  extremity  is  more  dangerous  than  in  the  upper,  and  because  a  cure 
without  operation  in  the  lower  limbs,  if  this  cure  can  be  brought  about,  gives 
as  good  a  result  as  a  cure  by  excision.  In  the  upper  extremity  the  danger 
from  operation  is  less  than  is  the  danger  from  waiting.  In  a  young  subject 
an  excision  may  remove  the  epiphysis,  and  thus  lead  to  permanent  shorten- 
ing, which  is  productive  of  less  inconvenience  and  deformity  in  the  arm  than 
in  the  leg.  A  danger  of  excision  operations  is  that  the  section  may  be  made 
through  cancellous  bony  tissue;  hence,  if  infection  -takes  place,  disastrous 
1  Joseph  Bell,  in  his  "Manual  of  Surgical  Operations." 


Excision  of  the  Shoulder-joint  787 

suppuration,   phlebitis,   myelitis,  septicemia,  or  pyemia  will  follow;  further, 
in  excision  the  cut  is  often  made  through  diseased  tissue,  and  a  protracted 
convalescence  is   then   inevitable.     Amputation   is   effected   through    healthy 
tissue,  and  the  convalescence  is  short.     Excision,  however,  when  successful 
gives  the  patient  a  very  useful  limb. 

Erasion,  or  Arthrectomy. — This  operation  was  suggested  by  Cross,  of  Bris- 
tol, and  was  perfected  and  established  by  Wright,  of  Manchester, '  between 
1881  and  1888.  Erasion  is  the  complete  removal  of  diseased  synovial  mem- 
brane, ligaments,  and  small  foci  of  disease  in  bone  and  cartilage.  This  opera- 
tion seeks  to  remove  a  depot  of  infection  in  an  early  stage  of  tuberculous 
synovitis,  and  it  possesses  the  conspicuous  merit  of  not  interfering  with  the 
epiphysis.  The  term  ''erasion"  is  also  used  by  some  to  designate  the  opera- 
tion of  removing  healthy  synovial  membrane,  ligaments,  etc.,  for  the  purpose 
of  producing  fixation  of  a  flail-joint  due  to  infantile  paralysis,  but  in  such  cases 
arthrodesis  is  the  proper  term  for  the  operation.  Erasion  is  oftenest  practised 
upon  the  knee-joint. 

Erasion  of  the  Knee-joint. — The  patient  lies  upon  his  back;  the  leg  is  flexed, 
with  the  sole  of  the  foot  planted  upon  the  table,  and  an  Esmarch  bandage  is 
appHed  at  a  point  well  up  on  the  thigh.  The  surgeon  stands  to  the  right 
of  the  patient.  The  incision  is  begun  in  the  midline  of  the  thigh  (on  the 
side  opposite  to  that  occupied  by  the  surgeon),  about  3  inches  above  the 
patella;  it  is  carried  down  across  the  ligament  of  the  patella  and  up  to  a  corre- 
sponding point  on  the  opposite  side  of  the  thigh.  This  incision  goes  down 
to  the  bone;  the  flap  is  turned  up  and  the  joint  exposed;  the  knee-joint  is 
strongly  flexed,  and  the  synovial  membrane  and  diseased  ligaments  are  dis- 
sected away  with  scissors  and  forceps,  great  care  being  taken  that  the  posterior 
ligaments  (which,  fortunately,  are  rarely  implicated  early  in  the  case)  are  not 
divided  and  that  the  contents  of  the  popHteal  space  remain  intact.  After  remov- 
ing the  diseased  ligaments  and  synovial  membrane  the  cartilage  is  examined 
and  any  diseased  portion  is  removed.  The  bone  is  then  examined  and  any 
tuberculous  foci  are  gouged  away.  Exposed  vessels  are  ligated.  The  wound  is 
irrigated  by  salt  solution,  the  extremity  is  straightened,  and  the  ends  of  the 
ligamentum  patellae  are  sutured,  a  drainage-tube  is  inserted  at  each  angle  of 
the  wound,  the  skin  is  sutured,  and  antiseptic  or  sterile  dressings  are  applied.  The 
limb  is  placed  upon  a  posterior  splint  for  a  few  days,  then  the  drainage-tubes 
are  removed,  the  dressings  are  changed,  and  a  plaster-of -Paris  cast  is  applied, 
trap-doors  being  cut  on  each  side,  and  the  joint  is  kept  immobile  for  two  or  three 
weeks.  This  operation  is  only  suited  to  early  cases  in  which  the  lesion  involves 
chiefly  or  purely  the  synovial  membrane  and  ligaments,  and  in  these  cases  it 
frequently  gives  a  good  result,  some  capacity  for  motion  being  not  unusually 
preserved. 

Excision  of  the  Shoulder-joint. — Bent,  of  New  Castle,  performed  the  opera- 
tion in  1771  ("Manual  of  Operative  Surgery,"  by  Sir  Frederick  Treves).  Syme 
really  established  the  operation  in  surgical  confidence.  In  the  shoulder- 
joint  partial  excision  is  often  performed,  the  head  of  the  humerus  being  re- 
moved and  the  glenoid  being  undisturbed;  but  some  patients  require  complete 
excision,  the  entire  glenoid  depression,  as  well  as  the  head  of  the  humerus, 
being  removed  by  the  surgeon.  Excision  of  the  shoulder-joint  is  made,  if  possi- 
ble, an  intracapsular  operation,  the  capsule  being  opened,  but  the  capsular 
attachment  to  the  anatomical  neck  of  the  humerus  not  being  interfered  with. 
In  advanced  cases,  however,  the  capsular  attachment  must  be  destroyed. 
Excision  of  the  shoulder-joint  for  trauma  is  a  far  less  common  operation  in 
civil,  than.in  military,  practice.  It  is  performed  for  gunshot-wounds,  compound 
dislocations,  tuberculous  disease,  and  tumors  of  the  head  and  upper  portion  of 
the  humerus. 

Operation  hy  Anterior  Incision. — The  patient  lies  supine;  a  pillow  is  placed 


788  Diseases  and  Injuries  of  the  Bones  and  Joints 

beneath  the  shoulders,  and  a  sand-pillow  is  put  beneath  the  shoulder  to  be 
operated  upon.  The  arm  is  held  to  the  side  with  the  outer  condyle  forward 
and  the  bicipital  groove  inward  (Barker's  directions).  The  surgeon  stands 
by  the  affected  side.  An  incision  3  or  4  inches  in  length  is  made  from  just 
external  to  the  coracoid  .process  of  the  scapula,  running  straight  down  the 
humerus  (Fig.  493,  a).  This  incision  divides  the  border  of  the  deltoid  muscle 
and  brings  into  sight  the  long  head  of  the  biceps.  The  tendon  of  the  biceps 
is  retracted  inward,  unless  it  is  diseased,  in  which  case  it  is  resected.  The  knife 
is  carried  up  the  groove  and  opens  the  capsule  of  the  joint.  The  periosteum 
is  lifted  from  the  neck  of  the  bone  while  an  assistant  rotates  the  elbow  to  make 
the  muscles  tense.  In  some  places,  if  the  periosteum  tears,  muscular  inser- 
tions must  be  cut  with  a  knife.  The  head  of  the  bone  is  sawn  off  while  the 
bone  is  in  place,  or  the  elbow  is  strongly  pulled  back,  and  the  head  of  the 
bone  is  forced  out  of  the  wound,  and  is  then  sawn  off  at  the  point  required.  In 
ordinary  cases  only  the  articular  head  is  removed;  in  other  cases  the  section  is 
made  just  above  the  surgical  neck;  in  still  others  a  portion  of  the  shaft  must  also 
be  cut  away.  If  the  glenoid  cavity  is  found  slightly  diseased,  the  dead  bone 
must  be  removed  by  the  chisel  and  mallet  or  by  the  cutting  forceps.  If  the 
cavity  is  seriously  diseased,  the  entire  glenoid  should  be  removed.  Scrape 
away  all  damaged  tissue;  ligate  bleeding  points;  irrigate  the  wound  with  cor- 
rosive sublimate  solution;  swab  it  out  with  a  solution  of  chlorid  of  zinc  (20  gr. 
to  I  oz.) ;  dust  with  iodoform ;  close  the  upper  portion  of  the  wound  and  insert 
a  drainage-tube  in  the  lower  angle;  dress  the  wound  antiseptically;  place  a  small 
pad  in  the  axilla;  apply  the  second  roller  of  Desault;  and  put  the  patient  in  bed 
Avith  a  pillow  under  the  affected  shoulder.  In  seven  days  the  hand-sling  is 
substituted  for  the  bandage,  and  with  the  elbow  hanging  free  the  patient  is  per- 
mitted to  get  up  and  is  advised  to  move  his  arm  frequently.  Drainage  is  main- 
tained until  the  wound  is  well  healed  from  the  bottom.  Great  limitation  of 
movement  inevitably  follows  a  shoulder-joint  resection. 

Excision  by  the  deltoid  flap  is  performed  when  the  head  of  the  bone  is  much 
enlarged  (as  by  a  tumor)  or  when  the  tissues  are  thick  and  indurated.  The 
deltoid  flap  is  in  the  shape  of  a  U  or  is  semilunar  (Fig.  494,  a).  Raising  this 
flap  exposes  the  head  of  the  bone  most  satisfactorily.  Bell  states  that  when  the 
glenoid  cavity  is  chiefly  involved  the  incision  should  be  posterior  (Fig.  494,  b). 

Senn's  Method. — Senn^  described  an  incision  which  does  not  damage 
important  vessels,  muscles,  tendons,  or  nerves,  and  which  is  followed  by  good 
functional  results.  A  semilunar  skin-flap  is  formed,  the  incision  running  from 
the  coracoid  process  to  the  posterior  border  of  the  axillary  space.  The  flap  is 
turned  up,  exposing  the  upper  half  of  the  deltoid  muscle.  The  acromion  is 
sawn  off  and  turned  down  with  the  attached  deltoid.  The  capsule  is  now 
freely  exposed;  it  is  opened,  and  either  arthrectomy  or  excision  is  performed, 
according  to  conditions.  In  closing  the  wound  it  is  not  necessary  to  bore  the 
acromion  and  pass  silver  wires  to  join  the  fragments;  it  is  enough  to  suture  the 
periosteum  with  catgut. 

Excision  of  the  Elbow -joint. — This  operation  was  suggested  by  Park  in 
1782,  but  the  first  employment  of  it  was  by  Moreau  in  1794.  It  is  performed 
for  wounds,  faulty  ankylosis,  and  chronic  articular  disease.  Excision  must  be 
complete.  Endeavor  to  make  a  subperiosteal  resection;  this  maintains  the 
shape  of  the  articulation  and  gives  the  best  chance  for  a  movable  joint.  The 
patient  is  "supine,  but  incUning  to  the  sound  side,  the  affected  arm  being  held 
almost  vertical,  with  the  forearm  flexed  and  nearly  horizontal"  (Barker). 
The  incision  is  made  on  the  posterior  surface  of  the  joint.  A  single  poste- 
rior incision  is  usually  employed  (Fig.  494,  d).  An  incision  is  made  a  little 
internal  to  the  long  axis  of  the  olecranon,  beginning  2  inches  above  and  ter- 
minating 2  inches  below  the  tip  of  the  olecranon.  This  incision  goes  down 
1  -'Phila.  ]\Ied.  Jour.,"  Jan.  i,  1898. 


Excision  of  the  Head  of  the  Radius 


789 


to  the  bone,  and  throughout  the  entire  operation  the  surgeon  must  guard 
and  shield  the  ulnar  nerve.  The  periosteum  and  soft  parts  are  well  separated; 
the  olecranon  is  sawn  off;  forced  flexion  exposes  the  joint-cavity  freely,  and 
enables  the  surgeon  to  lift  the  periosteum  and  soft  parts  from  the  humerus;  the 
humerus  is  sawn  through  at  the  beginning  of  its  condyloid  processes;  the  radius 
and  ulna  are  cleared  and  are  sawn  at  a  level  below  that  of  the  base  of  the  coro- 
noid  process  of  the  ulna.  Diseased  tissues  are  cut  and  scraped  away;  the  wound 
is  irrigated,  sutured,  drained,  and  dressed.  In  some  cases  an  H-shaped  incision 
is  employed  (Fig.  494,  c),  but  the  cicatrix  of  a  transverse  cut  will  limit  flexion 
of  the  limb. 

After  excision  of  the  elbow  the  patient  is  put  to  bed  and  the  arrtl  is  laid 
upon   a   pillow,  the  elbow  being  placed  midway  between  a  right  angle  and 


Fig.  493.  Fig.  494. 

Fig.  493. — 1-9,  Amputations  (Joseph  Bell):  i,  i,  of  arm  by  double  flaps;  2,  at  shoulder- 
joint;  3,  at  ankle-joint  by  internal  flap  (Mackenzie's);  4,  5,  of  leg  just  above  the  ankle-joint 
(Syme's);  6,  7,  below  the  knee  (modified  circular);  8,  through  condyles  of  femur  (Syme's); 
9,  at  lower  third  of  thigh  (Syme's).  a,  excision  of  head  of  humerus;  b,  of  knee-joint  (semilunar 
incision) . 

Fig.  494. — 1-8,  Amputations  (Joseph  Bell):  i,  at  elbow-joint  (posterior  flap);  2,  at  shoul- 
der-joint, posterior  incision  (first  method);  3,  at  ankle-joint  (Mackenzie's);  4,  through  condyles 
of  femur  (Syme's);  5,  at  lower  third  of  thigh  (Syme's);  6,  at  knee  (posterior  incision);  7,  of 
thigh  (Spence's);  8,  at  hip-joint,  a-g,  Excisions:  a,  excision  of  shoulder-joint  (deltoid  flap); 
B,  of  shoulder-joint  (posterior  incision);  c,  of  elbow-joint  (H-shaped  incision);  D,  of  elbow- joint 
(linear  incision);  e,  of  hip-joint  (Gross's);  f,  of  os  calcis;  G,  of  scapula. 

complete  extension,  the  forearm  being  placed  midway  between  pronation 
and  supination.  No  spHnt  is  used,  as  a  rule.  Esmarch  used  the  splint  shown 
in  Fig.  495.  The  aim  in  treatment  is  to  obtain  a  freely  movable  joint.  Pass- 
ive motion  is  begun  in  one  week,  at  which  time  the  patient  gets  up.  The 
hand  is  carried  in  a  sling  for  a  time  after  heaHng  of  the  wound  is  complete. 

Excision  of  the  Head  of  the  Radius. — This  operation  is  practised  for  irre- 
ducible dislocation  of  the  radius.  An  incision  is  made  through  the  supinator 
longus  muscle  down  to  the  head  of  the  radius,  and  the  neck  of  the  bone  is 
divided  by  means  of  a  Gigli  saw  or  bone-cutting  forceps.  The  musculospiral 
nerve  lies  to  the  inner  side.  Some  bone  is  always  taken  from  the  external 
condyle  in  order  to  make  a  sufficient  gap  to  prevent  subsequent  ankylosis 
("The  Operations  of  Surgery,"  by  Jacobson  and  Rowlands). 


79©        •  Diseases  and  Injuries  of  the  Bones  and  Joints 

Excision  of  the  Wrist-joint. — This  operation  was  first  performed  by  Moreau 
in  1794.  Bell  states  that,  whatever  method  of  excision  is  chosen,  three 
cardinal  rules  must  be  borne  in  mind:  (i)  remove  all  the  diseased  bone,  includ- 
ing the  y^ortions  of  the  radius,  ulna,  carpus,  and  metacarpus  which  are  cov- 
ered with  cartilage;  (2)  interfere  with  the  tendons  to  the  least  possible  degree, 
and  (3)  begin  passive  motion  of  the  fingers  very  early.  Many  surgeons  pre- 
fer the  simple  gouging  away  of  diseased  foci  and  the  scraping  of  sinuses  instead 
of  a  formal  resection  of  the  wrist,  amputation  being  employed  in  severe  cases 
or  when  scraping  fails  after  several  trials.  Formal  excision  is  not  frequently 
performed,  and  the  results  cannot  be  regarded  as  very  favorable. 

Lister's  Open  Method  of  Excision. — Break  up  adhesions  as  completely  as 
possible  by  forcible  movements.  Apply  a  tourniquet  or  an  Esmarch  appa- 
ratus. The  patient  lies  upon  his  back,  the  arm  and  the  forearm  being  brought, 
from  stage  to  stage,  into  the  most  desirable  positions.  Begin  an  incision 
over  the  middle  of  the  dorsum  of  the  radius,  on  a  level  with  the  styloid  process; 
carry  it  downward  in  the  direction  of  the  inner  edge  of  the  articulation  of  the  first 
phalanx  of  the  thumb  with  the  first  metacarpal  bone,  and  when  the  knife  reaches 
the  radial  side  of  the  second  metacarpal  bone  alter  the  direction  of  the  inci- 
sion and  carry  ,it  downward  in  the  long  axis  of  the  metacarpal  bone  to  about 
its  middle  (Fig.  496,  a).  This  is  known  as  the  radial  incision,  and  the  only 
tendon   divided   is    that  of  the  extensor  carpi  radialis  brevior  muscle.     The 


Fig.  495. — Esmarch's  splint  for  the  treatment  of  a  limb  after  excision  of  the  elbow-joint. 

tissues  upon  the  radial  aspect  of  the  incision  are  dissected  up,  the  tendon  of  the 
extensor  carpi  radialis  longior  muscle  is  divided  at  its  point  of  insertion  (Bell), 
and  all  the  soft  structures  are  retracted  outward,  exposing  the  trapezium,  which 
is  cut  off  from  the  rest  of  the  carpus,  but  which  is  left  in  place,  as  its  removal 
at  this  stage  endangers  the  radial  artery  (Barker).  By  extending  the  hand 
the  tendons  are  loosened  and  the  carpus  is  cleared  in  the  direction  of  the  ulnar 
border  of  the  hand. 

Another  incision  is  made,  starting  upon  the  inner  surface  of  the  wrist,  2 
inches  above  the  articular  surface  of  the  ulna,  and  midway  between  the  ulna 
and  the  flexor  carpi  ulnaris  tendon.  This  incision,  which  is  known  as  the 
ulnar  incision,  is  carried  down  until  it  is  opposite  the  middle  of  the  fifth  meta- 
carpal bone  in  the  palm  (Fig.  496,  b).  "The  dorsal  li':>  of  this  incision  is  raised" 
(Bell),  and  the  extensor  carpi  ulnaris  tendon  is  divided  and  dissected  from  its 
depression,  but  is  not  separated  from  the  integument.  The  extensor  tendons 
are  lifted;  the  ligaments  upon  the  dorsum  and  sides  of  the  wrist-joint  are  cut; 
the  flexor  tendons  are  raised  from  the  carpal  bones;  the  pisiform  bone  is  cut 
from  the  carpus,  but  is  not  yet  removed;  and  the  unciform  process  of  the  unci- 
form bone  is  cut  wdth  forceps.  The  anterior  radiocarpal  ligament  is  divided, 
the  carpometacarpal  articulations  are  cut  through,  and  the  carpus  is  pulled 
out  with  bone-forceps.  The  ends  of  the  radius  and  ulna  are  forced  out  of  the 
ulnar  incision.  All  that  portion  of  the  ulna  which  is  crusted  with  cartilage  is 
to  be  removed,  the  saw-cut  is  to  be  oblique,  and  the  base  of  the  styloid  process 


Excision  of  Metacarpal  Bones  and  of  Phalanges  791 

is  to  be  left  behind.  A  thin  section  is  to  be  sawn  from  the  radius,  and  the  ten- 
don-grooves are  not  to  be  impinged  upon.  The  articular  surface  of  the  ulna 
is  cut  away  by  pliers  (Bell).  If  foci  of  disease  are  discovered  beyond  these 
points,  they  are  to  be  gouged  out.  The  ends  of  the  metacarpal  bones  are  sawn 
off,  and  their  articular  facets  are  cut  away  by  means  of  pliers.  The  trape- 
zium is  dissected  out,  the  end  of  the  first  metacarpal  bone  is  sawn  off  and  its 
facet  is  cut  away  with  phers,  and  a  portion  of  the  pisiform  bone  is  removed 
(the  entire  bone  being  removed  if  it  be  diseased).  The  wound  is  irrigated, 
vessels  are  tied,  the  radial  incision  is  closed,  the  ulnar  incision  is  partly  closed, 
a  drainage-tube  is  inserted  by  way  of  the  ulnar  incision,  the  wounds  are  dressed 
antiseptically,  and  the  Esmarch  apparatus  is  taken  off.  The  forearm  and  hand 
are  placed  upon  a  splint  which  immobilizes  the  wrist  and  leaves  the  fingers 
semiflexed.  Passive  motion  of  the  fingers  is  be- 
gun after  thirty-six  hours.  The  splint  is  worn 
for  many  months  until  the  wrist-joint  is  immobile 
and  solid.  Esmarch  uses  the  splint  shown  in 
Fig.  498. 


Fig.  496.  Fig.  497. 

Fig.  496. — 1-18,  Amputations  (Joseph  Bell):  i,  amputation  at  wrist-joint  (dorsal  inci- 
sion); 2,  at  wrist-joint  (palmar  incision);  3,  at  forearm  (dorsal  incision);  4,  at  forearm  (palmar 
incision);  5,  at  elbow-joint  (anterior  flap);  6,  at  arm  (Teale's);  7,  at  shoulder-joint  (first 
method);  8,  9,  of  metatarsus  (Hey's);  10,  11,  at  ankle  (Syme's);  12,  13,  of  leg,  posterior  flap 
(Lee's);  14,  at  knee-joint  (Garden's);  15,  of  thigh  (B.  Bell's);  16,  of  thigh  (Spence's);  17,  of 
thigh  in  middle  third;  18,  18,  at  hip-joint.  A,  excision  of  wrist  (radial  incision);  B,  of  wrist 
(ulnar  incision). 

Fig.  497. — I- 10,  Amputations  (Joseph  Bell):  i,  of  lower  third  of  forearm  (Teale's);  2,  at 
shoulder- joint  by  large  postero-external  flap  (second  method);  3,  at  shoulder- joint  by  triangu- 
lar flap  from  deltoid  (third  method);  4,  5,  through  tarsus  (Chopart's);  6,  7,  at  knee-joint; 
8,  by  single  flap  (Garden's);  9,  10,  of  thigh  (Teale's).  A,  excision  of  hip,  b,  b,  of  ankle-joint 
(Hancock's  incision). 

Excision  of  Metacarpal  Bones  and  of  Phalanges. — Excision  of  a  meta- 
carpal bone,  except  in  cases  of  necrosis  with  the  formation  of  large  quantities 
of  new  bone,  usually  leaves  a  useless  finger;  hence  amputation  of  the  bone  with 
the  finger  is  usually  preferred  to  excision.  This  rule  does  not  apply  to  the  meta- 
carpal bone  of  the  thumb,  which  is  occasionally  excised.  The  incision  for  this 
operation  is  made  upon  the  dorsum,  and  is  straight.  Excision  of  the  proximal 
phalanx  of  the  thumb  is  sometimes  performed.  Excision  for  disease  is  rarely 
performed  upon  the  finger-joints,  amputation  being  preferred,  though  the  opera- 
tion is  sometimes  undertaken  for  compound  dislocation.  In  the  metacarpo- 
phalangeal joint  of  the  thumb  excision,  if  it  can  be  performed,  is  preferred  to 
amputation.  The  incision  for  resection  of  this  joint  is  placed  upon  the  radial 
aspect. 


792 


Diseases  and  Injuries  of  the  Bones  and  Joints 


Excision  of  the  Hip-joint. — Treves  and  Jonathan  Hutchinson,  Jr.  ("Manual 
of  Operative  Surgery"),  tell  us  that  the  operation  was  first  performed  by 
Anthony  White,  of  the  Westminster  Hospital,  in  1818.  Sir  William  Fergusson 
established  the  operation  in  surgical  confidence.  Some  surgeons  advocate 
this  operation;  others,  notably  Marsh,  are  emphatically  opposed  to  it.  Exci- 
sion should  be  performed  in  the  early  stage  of  tuberculous  disease  if  less  radical 


Fig.  498. — Esmarch's  interrupted  splint  applied. 

treatment  has  failed.  In  this  stage  the  usual  position  of  the  limb  is  one  of 
flexion,  abduction,  and  eversion.  In  cases  of  long  duration,  especially  where 
dislocation  exists,  excision  is  an  easy  and  a  comparatively  safe  operation; 
in  recent  cases  it  is  difficult  and  carries  with  it  decided  dangers,  but  the  peril 
of  delay  may  be  greater  than  the  peril  of  an  early  excision.  In  cases  of  hip 
disease  with  involvement  of  the  acetabulum  the  mortality  is  50  per   cent., 

whether  operation  is  or  is  not  attempted.  Excision 
is  performed  especially  for  tuberculous  disease  and 
for  gunshot-injuries. 

Operation  hy  Anterior  Incision  (Fig.  499) 
{Barker's  Operation). — In  this  operation  the  pa- 
tient is  supine,  with  the  thighs  extended  as 
thoroughly  as  circumstances  permit.  The  surgeon 
stands  to  the  right  of  the  patient.  An  incision  is 
begun  }2  inch  below  and  }^2.  inch  external  to  the 
anterior  superior  iliac  spine,  and  it  is  carried  down- 
ward and  a  little  inward  for  about  3  inches  (Fig. 
499,  d).  If  dislocation  exists,  the  incision  need  not 
be  so  long.  This  incision  is  carried  at  once  deeply 
between  the  muscles,  and  the  capsule  of  the  joint 
is  opened.  The  neck  of  the  bone  is  divided  from 
its  upper  surface  downward  by  a  saw  or  an  osteot- 
ome, and  without  dislocating  the  bone  through  the 
wound  by  forcible  extension  and  eversion.  The 
head  of  the  bone  is  removed.  All  tuberculous  foci 
must  be  scraped  away,  and  the  flushing  gouge  is 
used  upon  tuberculous  areas  of  the  acetabulum. 
All  sinuses  should  be  thoroughly  scraped.  Bleed- 
ing is  arrested,  the  wound  is  irrigated  with  normal 
salt  solution,  mopped  with  chlorid  of  zinc  solu- 
tion, and  dusted  with  iodoform.  A  drainage-tube 
is  inserted  at  the  lower  angle  of  the  incision,  and  the  upper  portion  of  the  cut 
is  closed.  The  wound  is  dressed  antiseptically.  Extension  is  made  by  the 
extension  apparatus  until  healing  has  obtained  good  headway,  when  a  double 
Thomas  splint  is  applied,  so  that  the  patient  may  be  taken  out  daily  in  the  air 
and  sunlight.  As  a  rule,  rigid  ankylosis  results  from  resection  of  the  hip,  but 
occasionally  a  joint  results  with  a  small  range  of  movement. 

Operation  by  Lateral  Incision  (Langenbeck' s  Operation). — In  this  operation 
a  straight  incision  2  inches  in  length  is  made  in  the  direction  of  the  axis  of  the 


Fig.  499. — Excision  of  the 
hip-joint:  a,  Gluteus  muscle; 
B,  tensor  vaginae  femoris  mus- 
cle; c,  sartorius  muscle;  d,  an- 
terior incision. 


Excision  of  the  Knee-joint  793 

femur,  and  passing  downward  from  the  apex  of  the  great  trochanter.  From  the 
beginning  of  this  incision  a  curved  incision  is  carried  toward  the  head  of  the 
bone,  the  convexity  of  the  curve  being  backward  (see  Fig.  497,  a).  Bell  advises 
the  use  of  the  saw  after  bringing  the  head  of  the  bone  into  the  wound  by  ab- 
duction and  eversion  of  the  thigh.  Barker  applies  the  saw  with  the  bone  in 
situ,  and  strongly  opposes  wrenching  the  bone  out  of  the  incision  because 
of  the  danger  of  peeling  off  the  periosteum,  which,  if  it  takes  place,  favors 
necrosis. 

Incision  of  Gross. — In  Gross's  operation  a  semilunar  flap  is  made  with  the 
convexity  backward  (see  Fig.  494,  e). 

Excision  of  the  Knee-joint. — The  complete  operation  was  first  performed 
by  Park,  of  Liverpool,  in  1781.  In  this  operation  a  complete  excision  should 
be  performed,  and  the  patella  ought  to  be  removed.  The  operation  is  per- 
formed for  tuberculous  disease,  some  compound  fractures  and  compound 
dislocations,  and  some  cases  of  angular  ankylosis.  It  is  rarely  employed  for 
gunshot-injuries. 

Operation  by  Anterior  Semilunar  Flap. — The  patient  lies  upon  his  back, 
and  the  joint,  if  not  ankylosed  in  extension,  should  be  semiflexed.  The  surgeon 
stands  to  the  right  side.  An  incision  is  made  which  at  once  opens  the  joint. 
The  incision  begins  at  one  condyle  and  reaches  the  other  condyle  by  a  curve 
which  passes  through  the  ligamentum  patellae  midway  between  the  tuberosity  of 
the  tibia  and  the  inferior  margin  of  the  patella  (see  Fig.  493,  b).  The  flap  is  dis- 
sected up,  the  knee  is  thrown  into  forced  flexion,  the  lateral  ligaments  and 
crucial  ligaments  are  cut,  and  the  end  of  the  femur  is  well  cleared.  The  blade  of 
Butcher's  saw  is  passed  beneath  the  bone,  which  is  sawn  from  below  upward 
(Ashhurst).  The  end  of  the  tibia  is  cleared  and  a  portion  is  sawn  off.  If,  after 
sawing,  diseased  foci  are  discovered,  another  section  can  be  sawn  off  or  the  foci 
can  be  gouged  away.  Ashhurst,  who  had  a  vast  experience  with  this  operation, 
insisted  that  in  sawing  through  the  femur  the  natural  obliquity  of  the  bone 
must  be  borne  in  mind  and  the  section  must  be  made  in  "a  hne  parallel  to  that 
of  the  free  surface  of  the  condyles."  If  the  section  is  made  transverse  to  the 
axis  of  the  femur,  "the  limb,  after  adjustment,  will  be  found  to  be  markedly 
bowed  outward."  The  same  surgeon  said  that  the  epiphyseal  line  is  somewhat 
higher  on  the  front  than  it  is  on  the  back  of  the  femur,  and  in  consequence  the 
following  rule  is  formulated  for  section  of  the  condyles:  the  section  of  the  con- 
dyles should  be  "in  a  plane  which,  as  regards  the  axis  of  the  femur,  is  oblique 
from  behind  forward,  from  below  upward,  and  from  within  outward."  Ash- 
hurst advocated  section  of  the  tibia  "in  a  plane  transverse  to  the  long  axis  of 
the  bone,  with  a  slight  anteroposterior  obliquity,  so  as  to  correspond  with 
that  of  the  section  of  the  condyles,"  and  he  further  says  that  the  patella  must 
be  removed  whether  it  is  diseased  or  not,  and  quotes  Peniere's  observations 
to  the  effect  that  excision  of  the  patella  diminishes  the  risk  of  death  one-third, 
and  its  retention  doubles  the  probability  of  an  amputation  becoming  necessary 
in  the  future. 

After  removing  the  patella  the  diseased  synovial  membrane  is  clipped  away 
with  scissors  and  all  sinuses  and  diseased  territories  are  well  curetted.  The 
posterior  ligament  of  the  joint  is  not  removed  unless  it  is  diseased;  its  retention 
prevents  displacement  and  guards  the  popliteal  space.  In  some  cases  tenotomy 
is  required  to  permit  extension.  In  children  the  fragments  should  be  wired 
together;  in  adults  this  need  not  be  done.  After  hemostasis,  irrigate  by  salt 
solution,  insert  a  drainage-tube,  suture,  dress  antiseptically,  and  adjust  the 
limb  upon  Price's  splint  or  Ashhurst's  bracketed  wire  splint.  Instead  of  the 
bracketed  splint,  a  long  fracture-box  may  be  used.  If  the  femur  tends  to 
project  anteriorly,  use  an  anterior  splint.  If  there  be  a  tendency  to  outward 
bowing,  adopt  Ashhurst's  expedient  of  carrying  a  strip  of  adhesive  plaster 
around  the  outside  of  the  limb  and  fastening  it  to  the  inner  side  of  the  splint. 


794 


Diseases  and  Injuries  of  the  Bones  and  Joints 


The  splint  is  kept  on  until  bony  union  is  complete,  as  in  this  operation  a  movable 
joint  is  never  sought.  Many  surgeons  use  a  fenestrated  or  interrupted  plaster- 
of-Paris  splint,  which  is  employed  until  the  parts  have  become  apparently  lirm 
and  solid  (Fig.  500).  Even  for  many  months  after  the  parts  have  apparently 
become  solidly  united,  bending  may  occur.  How  long  fixation  should  be  used 
has  been  much  debated.  In  order  to  avoid  the  danger  of  flexion  or  other  de- 
formity, fixation  by  some  form  of  apparatus  should  be  maintained  for  "at 
least  a  year  and  probably  nearly  two  years  after  excision"  (J,  Torrance  Rugh, 
'"Am.  Jour.  Orthopedic  Surgery,"  Feb.,  1909). 

Excision  of  the  Ankle-joint. — Excision  of  the  ankle  was  first  performed 
by  Moreau  in  1792.  This  operation  is  performed  chiefly  for  gunshot-wounds, 
compound  dislocations,  and  in  some  cases  of  tuberculous  joint  disease.  Ex- 
cision of  the  ankle  is  an  operation  which  is  seldom  performed. 

Operation  by  Hancock's  Method. — In  this  operation  the  patient  lies  upon 
his  back,  the  foot  rests  upon  its  inner  side,  and  the  surgeon  stands  to  the  outer 
side  of  the  damaged  limb.  Begin  an  incision  just  behind  and  2  inches  above 
the  external  malleolus,  and  carry  it  across  the  front  of  the  joint  to  a  correspond- 
ing point  above  and  behind  the  internal  malleolus  (see  Fig.  497,  b);  this  in- 
cision goes  through  the  skin  only,  and  the  flap  thus  marked  out  is  reflected. 
"Cut  down  upon  the  external  malleolus,  carrying  the  knife  close  to  the  edge 


Fig.  500. — Watson's  plaster-of- Paris  swing-splint. 

of  the  bone  both  behind  and  below  the  process,  dislodge  the  peronei  tendons, 
and  divide  the  external  lateral  ligaments"  (Joseph  Bell).  Cut  the  fibula  i 
inch  above  the  malleolus  by  means  of  pliers;  divide  the  tibiofibular  ligament; 
turn  the  foot  upon  its  outer  side;  dissect  from  their  habitat  back  of  the  inner 
malleolus  the  tendon  of  the  posterior  tibial  muscle  and  the  tendons  of  the  flexors 
of  the  toes ;  carry  the  knife  around  the  inner  malleolus  close  to  the  bony  edge ;  sepa- 
rate the  internal  lateral  ligament,  and  dislocate  the  lower  end  of  the  tibia  through 
the  wound  by  turning  the  sole  of  the  foot  downward;  saw  off  the  lower  end  of 
the  tibia  and  the  articular  process  of  the  astragalus,  sawing  away  from  the  tendo 
Achillis,  and  removing  the  fragments  by  bone-forceps.  Cut  away  diseased 
synovial  membrane,  and  curet  all  sinuses  and  tuberculous  areas.  Arrest 
bleeding,  irrigate,  and  drain.  Sew  up  the  wound,  insert  a  tube  at  the  outer 
angle,  and  cause  it  to  emerge  at  the  inner  angle.  Apply  antiseptic  dressings, 
and  put  up  the  foot  in  fixed  dressing  or  in  splints  at  a  right  angle  to  the  leg  (Fig. 
501).  In  Langenbeck's  operation  the  excision  is  subperiosteal.  If,  in  an  ex- 
cision of  the  ankle-joint,  the  astragalus  is  found  extensively  diseased,  remove 
the  entire  bone. 

Excision  of  the  Os  Calcis. — In  caries  limited  to  the  os  calcis  most  surgeons 
prefer  to  gouge  away  the  dead  bone,  leaving  the  periosteum  and,  if  possible, 
a  shell  of  healthy  bone,  and  draining  thoroughly.  Others  advocate  excision 
in  some  cases.     Extensive  disease  limited  purely  to  the  os  calcis  is  rare,  and 


Excision  of  the  Metatarsophalangeal  Articulation  of  the  Great  Toe     795 

most  surgeons  advise  gouging  for  limited  caries,  and  Syme's  amputation  in 
the  event  of  the  disease  extending  beyond  the  periosteum  or  reaching  adjacent 
bones. 

Operation  by  Subperiosteal  Method. — In  this  operation  the  position  assumed 
by  the  patient  is  supine,  with  the  leg  extended  and  the  foot  resting  on  its  inner 
side.  The  incision,  which  cuts  the  tendo  Achillis  and  reaches  the  bone  at  once, 
is  begun  at  the  upper  border  of  the  os  calcis  and  the  inner  margin  of  the  tendo 
Achillis,  and  is  taken  outward  and  horizontally  forward  to  a  point  in  front  of 
the  calcaneocuboid  articulation  (see  Fig.  494,  f).  A  vertical  incision  is  begun 
near  the  forward  termination  of  the  initial  incision,  is  carried  across  the  outer 
edge  and  plantar  surface  of  the  foot,  and  terminates  at  the  external  margin 
of  the  inner  surface  of  the  os  calcis.  Some  surgeons  carry  the  vertical  incision 
a  little  upward,  toward  the  dorsum.  The  periosteum  is  entirely  stripped  by 
an  elevator,  the  os  calcis  is  removed,  the  cavity  is  packed  with  iodoform  gauze, 
the  wound  is  stitched,  a  drain  is  inserted  posteriorly,  the  foot  is  dressed  anti- 
septically,  is  placed  at  a  right  angle  to  the  leg,  and  plaster  of  Paris  is  applied, 
trap-doors  being  cut  for  drainage.  Later  the  drain  is  removed  and  the  packing 
of  gauze  changed  daily. 


Fig.  501. — Volkmann's  dorsal  splint  for  excision  of  the  ankle. 


Astragalectomy,  or  excision  of  the  astragalus,  is  seldom  performed.  As- 
tragalectomy  is  employed  occasionally  for  relapsed  and  inveterate  cases  of  club- 
foot. The  indications  are  pointed  out  by  Willard  ("International  Clinics," 
vol.  iii,  12th  series):  "(i)  Adults  with  great  bony  deformity;  (2)  neglected 
children  of  five  to  fifteen  years,  who  have  markedly  distorted  their  tarsi  by 
locomotion;  (3)  relapsed  cases  which  have  resisted  the  milder  forms  of  opera- 
tion, or  which  have  been  neglected  by  parents  after  previous  operation;  (4) 
only  occasionally,  young  children  in  whom  from  infancy  the  bones  of  the  foot 
have  been  exceedingly  rigid  and  unyielding,  and  where  there  is  practically  but 
little  motion  either  at  the  ankle-joint  or  in  the  tarsus." 

Operation  by  the  Subperiosteal  Plan. — Barker  advises  an  incision  going  at 
once  to  the  bone,  from  the  "tip  of  the  external  malleolus  forward  and  a  Uttle 
inward,  curving  toward  the  dorsum  of  the  foot."  The  foot  is  extended  and 
turned  inward,  the  periosteum  is  lifted,  the  astragalus  is  removed,  and  the 
wound  is  treated  and  the  foot  is  dressed  as  is  done  after  excision  of  the  os 
calcis 

In  cases  of  paralytic  calcaneus  Whitman  ("Orthopedic  Surgery")  recom- 
mends removal  of  the  astragalus  through  a  curved  external  incision;  freeing 
the  malleoli  and  making  new  sockets  for  them  beside  the  cuboid  and  scaphoid 
bones.     He  puts  the  foot  in  marked  plantar  flexion  and  holds  it  by  plaster. 

Excision  of  the  Metatarsophalangeal  Articulation  of  the  Great  Toe. — 
In  this  operation  make  a  lateral  incision  and  cut  off  or  saw  off  the  proximal  end 
of  the  first  phalanx  and  the  distal  third  of  the  first  metatarsal  bone.  (See 
Mayo's  Operation  for  Bunion,  page  780.) 


796  Diseases  and  Injuries  of  the  Bont-s  and  Joints 

•  Excision  of  the  Metatarsal  Bone  of  the  Great  Toe  (Biitchcr\s  Method). 
— In  this  operation  a  lateral  straight  incision  is  made,  thei)eriosteum  is  elevated, 
and  the  shaft  is  sawn  from  each  extremity  and  removed. 

Excision  of  the  clavicle  may  be  required  for  dislocation,  caries,  necrosis, 
gunshot-wound,  tumor  of  this  bone,  as  a  preliminary  to  ligation  of  the  artery 
and  vein  in  certain  cases  of  amputation  at  the  shoulder-joint,  or  in  cases  of 
removal  of  the  entire  upper  extremity.  In  excision  of  the  clavicle  the  position 
of  the  patient  is  the  same  as  that  for  ligation  of  the  third  part  of  the  subclavian 
artery  (see  page  545).  An  incision  is  made  down  to  the  bone,  from  the  sterno- 
clavicular joint  to  the  acromioclavicular  articulation.  If  the  case  is  suitable, 
the  periosteum  is  stripped  and  the  bone  is  sawn  and  removed;  if  not,  the  bone 
is  sawn  and  each  half  is  separately  disarticulated.  The  wound  is  sutured  and 
dressed,  and  the  limb  is  put  up  in  a  Velpeau  bandage.  McCreary,  of  Ken- 
tucky, in  181 1  performed  the  first  complete  excision  of  the  clavicle. 

Excision  of  the  Scapula. — Complete  excision  of  the  scapula  is  usually 
performed  for  tumors.  Partial  excision  requires  no  detailed  description. 
In  excision  of  the  scapula  the  patient  lies  upon  his  sound  side.  Treves  suggests 
the  following  incisions:  one  outside  the  vertebral  border  of  the  scapula,  from 
its  superior  to  its  inferior  angle;  another  from  over  the  acromioclavicular 
joint,  along  the  acromion  process  and  spine  of  the  scapula,  to  meet  the  first 
incision.  Syme  used  an  incision  carried  transversely  inward  from  the  acromion 
process  to  the  vertebral  border  of  the  scapula,  and  another  cut  directly  down- 
ward from  the  center  of  the  first  incision  (see  Fig.  494,  g).  In  the  method  of 
Treves^  the  upper  flap  is  reflected  and  the  trapezius  muscle  is  divided;  the  lower 
flap  is  reflected  and  the  deltoid  muscle  is  divided.  The  patient's  hand  is  placed 
on  the  sound  shoulder;  the  muscles  of  the  vertebral  border  are  divided,  the  pos- 
terior scapular  artery  is  tied,  and  while  the  vertebral  border  of  the  scapula  is 
pulled  toward  the  surgeon,  the  serratus  magnus  muscle  is  cut,  the  upper  border 
of  the  shoulder-blade  is  cleared,  and  the  suprascapular  artery  is  tied.  The 
hand  is  now  brought  down  to  the  side;  the  acromioclavicular  joint  is  disarticu- 
lated; the  conoid  and  trapezoid  ligaments  are  divided;  the  muscles  of  the 
coracoid  process  are  cut;  the  capsule  is  incised,  with  the  supraspinatus  and  in- 
fraspinatus, the  subscapularis,  and  the  scapular  origins  of  the  biceps  and  triceps 
muscles;  and  finally  the  teres  major  and  minor  muscles  are  divided,  the  sub- 
scapular artery  is  tied,  and  the  bone  is  removed.  The  wound  is  stitched,  a 
drain  is  introduced,  and  antiseptic  dressings  are  applied.  The  patient  lies 
upon  his  back  until  healing  is  well  under  way,  when  the  arm  is  placed  in  a  sling. 
The  drainage-tube  may  be  removed  in  twenty-four  hours.  Langenbeck,  of 
Berlin,  in  1855  performed  the  first  complete  excision  of  the  scapula. 

Excision  or  Resection  of  a  Rib  (Fig.  658). — In  caries  the  gouge  and  ron- 
geur may  remove  the  disease.  In  other  cases  excision  is  performed.  In  this 
operation  the  patient  lies  upon  his  sound  side  unless  the  operation  is  performed 
for  empyema,  in  which  case  he  lies  on  his  back  or  only  partly  on  the  sound  side. 
(See  Empyema,  Operation  for.)  The  surgeon  faces  the  patient.  Make  an 
incision  down  to  the  bone,  in  the  long  axis  of  the  rib.  The  periosteum,  if  not 
diseased,  is  lifted  from  the  bone,  and  the  intercostal  artery  is  lifted  out  of  the 
way  with  the  periosteum  and  is  thus  saved  from  being  cut.  After  dividing  the 
bone  beyond  the  limits  of  disease,  remove  it.  During  the  sawing  a  metal  re- 
tractor is  held  beneath  the  rib,  between  the  rib  and  the  periosteum.  It  is  better  to 
saw  it  than  to  cut  it  with  ordinary  biting  forceps,  because  the  latter  splinters  the 
bone.  The  author  usually  uses  a  forceps  known  as  a  costotome,  which  cuts  the 
rib  without  splintering.  If  the  periosteum  is  diseased,  remove  it  after  tying 
the  intercostal  arter}^  It  should  be  removed  in  a  case  of  empyema,  otherwise 
bone-formation  may  interfere  with  drainage.  In  empyema,  after  removing  the 
periosteum,  open  into  the  pleural  cavity,  allow  pus  to  flow  out  slowly,  remove 
'  "Manual  of  Operative  Surgery." 


Complete  Excision  of  One-half  of  the  Upper  Jaw  797 

fibrinous  masses,  employ  a  finger  to  feel  if  there  are  adhesions  and  if  the  lung 
will  probal)ly  expand,  and  insert  a  drainage-tube.  In  resection  for  rib  disease 
curct  sinuses  and  pack  with  iodoform  gauze  ior  some  days.  Sew  up  the  wound 
except  at  one  end.  Dress  antiseptically  and  apply  a  binder.  (See  Operations 
Upon  the  Chest  and  Estlander's  Operation.) 

In  removing  a  cervical  rib  make  an  incision  along  the  posterior  edge  of  the 
sternocleidomastoid,  avoid  the  pleura,  subclavian  vessels,  and  brachial  plexus, 
and  remove  the  periosteum  with  the  rib  in  order  that  the  bone  will  not  be 
reproduced. 

Complete  Excision  of  One-half  of  the  Upper  Jaw. — The  whole  upper  jaw 
has  been  removed,  but  in  what  follows  only  resection  of  one-half  the  jaw  will 
be  described.  This  operation  is  performed  for  malignant  tumors  of  the  supe- 
rior maxillary  bone  or  its  antrum.  Up  to  1826,  at  which  time  Lizars,  of  Edin- 
burgh, suggested  the  operation,  tumors  of  the  antrum  were  treated  by  scraping 
them  away  with  a  sharp  spoon.  Gensoul,  of  Lyons,  in  1827  performed  the 
first  operation  for  resection  of  the  upper  jaw.  Heyf elder,  in  1844,  removed  both 
superior  maxillary  bones.  Excision  of  a  superior  maxillary  bone  is  not  justi- 
fiable except  as  a  palliative  measure,  if  the  orbit  is  invaded,  if  the  skin  and 
subcutaneous  tissues  are  infiltrated,  or  if  the  disease  extends  widely  beyond  the 
superior  maxillary  and  palate  bones.  The  mortality  is  about  15  per  cent. 
Half  the  sarcoma  cases  which  recover  from  operation  will  show  no  return  in  a 
year.  One-third  of  the  recoveries  show  no  return  in  3  years.  Carcinoma  almost 
invariably  returns  and  quickly. 

Some  surgeons  ligate  the  external  carotid  artery  or  compress  it  temporarily. 
In  a  number  of  excisions  of  the  upper  jaw  I  have  always  found  the  hemorrhage 
readily  controllable  as  soon  as  the  bone  is  removed,  and  have  never  felt  it 
necessary  to  resort  to  preliminary  ligation  or  compression. 

Operation  by  Median  Incision. — ^The  patient,  whose  face  has  been  shaved, 
is  placed  in  the  Trendelenburg  position,  thus  avoiding  the  possible  need  of 
instant  tracheotomy;  or,  what  is  even  better,  he  lies  horizontal  or  with  the 
head  a  little  raised  and  takes  ether  by  intratracheal  insufflation  (seepage  1340). 
The  surgeon  stands  to  the  right  side  of,  and  faces,  the  patient.  The  in- 
cisor tooth  on  the  diseased  side  is  pulled  out.  The  incision,  which  is 
really  Weber's  incision  (called  by  some  Nelaton's,  by  some  Fergusson's, 
by  some  Liston's),  is  begun  3^-2  inch  below  the  inner  canthus  of  the  eye,  and  is 
carried  along  the  side  of  the  nose,  around  the  ala  of  the  nose,  by  the 
margin  of  the  nostril,  and  through  the  middle  of  the  lip.  While  the  Up  is 
being  incised  the  assistant  arrests  hemorrhage  by  grasping  the  corners  of  the 
mouth,  and  after  the  lip  has  been  divided  the  coronary  arteries  are  at  once 
ligated.  Some  operators  approach  the  mucous  membrane  cautiously  and 
Hgate  the  vessels  before  opening  the  cavity  of  the  mouth.  The  upper  portion 
of  the  wound  having  been  compressed  by  another  assistant  during  these 
manipulations,  pressure  is  now  removed  and  bleeding  points  are  ligated. 
Another  incision  is  now  carried  outward  from  the  beginning  of  the  first  incision, 
along  the  orbital  margin  to  well  over  the  malar  bone  (Fig.  502).  The  flap 
is  lifted  from  the  periosteum,  and  the  bleeding  from  the  infra-orbital  artery 
and  the  small  vessels  is  restrained  by  pressure.  The  nasal  cartilage  is  separated 
from  the  bone,  and  the  nasal  process  of  the  superior  maxillary  is  sawn  (hne 
A-B,  Fig.  503).  The  orbital  periosteum  is  lifted  up,  and  the  orbital  plate  is  cut 
by  forceps  from  the  saw-cut  in  the  superior  maxillary  bone  to  the  sphenomaxil- 
lary fissure  (line  b-c,  Fig.  503).  The  malar  bone  is  sawn  or  is  bitten  through 
about  its  center,  the  cut  running  into  the  sphenomaxillary  fissure  and  taking  a 
downward  and  outward  direction  (Hne  c-d,  Fig.  503).  The  soft  parts  covering 
the  hard  palate  are  incised  in  the  median  line,  a  corresponding  incision  is  made 
along  the  floor  of  the  nose  near  the  septum,  and  the  soft  palate  is  separated  from 


798 


Diseases  and  Injuries  of  the  Bones  and  Joints 


the  hard  palate  by  a  transverse  cut.  The  saw  is  introduced  through  the  nose, 
and  the  palate  is  sawn  (line  e,  Fig.  503).  The  upper  jaw-bone  is  grasped  by 
Fergusson's  lion-jaw  forceps  and  removed,  the  removal  being  aided  by  the  use 
of  the  scissors  and  bone-cutters;  the  latter  are  used  to  se]iarate  the  up])er  jaw 
from  the  ptervgoid  process  (Treves).  Every  vessel  that  can  be  seen  is  tied,  and 
severe  bleeding  from  bone  is  arrested  by  antiseptic  wax.  Oozing  is  controlled 
by  hot  water  and  pressure  or  by  Paquelin's  cautery.  Examine  carefully  to 
see  if  all  the  diseased  area  is  removed;  if  it  is  not,  use  the  gouge,  scissors,  chisel, 
and  saw  until  healthy  tissue  is  reached.  The  wound  is  packed  with  iodoform 
gauze,  and  the  end  of  the  strip  is  so  placed  as  to  be  accessible  through  the  mouth. 
The  wound  is  sutured  (the  mucous  membrane  of  the  lip  must  be  stitched,  as  well 
as  the  skin)  and  is  dressed  antiseptically  (the  eye  being  protected  by  aseptic 
gauze),  and  a  crossed  bandage  of  the  angle  of  the  jaw  is  applied.  After  this 
operation  it  is  common  to  have  the  eye  sink  to  a  lower  level  (causing  double 
vision),  to  have  persistent  swelling  of  the  lower  lid,  and  to  have  tears  flow  over 
the  lid  instead  of  down  the  duct.  This  may  be  prevented  in  some  cases  by 
making  a  hammock  for  the  orbital  contents  from  a  flap  of  the  temporal  muscle. 
Excision  of  One-half  of  the  Lower  Jaw. — In  some  rare  instances  the  entire 
inferior  maxillary  bone  is  removed.     The  lesions  necessitating  removal  of  the 


Fig.  502. — A-B,  Incision  of  the  soft  parts 
preliminary  to  excision  of  the  upper  jaw; 
C-D-E,  incision  of  soft  parts  preliminary  to 
excision  of  the  lower  jaw. 


Fig.  503. — I,  Excision  of  the  upper  jaw: 
A-B,  Section  of  the  nasal  process;  b-c,  section 
of  the  orbital  plate;  d,  section  of  the  malar 
bone  and  orbital  plate;  E,  section  of  the 
alveolus  and  hard  palate.  2,  Excision  of  the 
lower  jaw:  g,  Section  of  the  inferior  maxillary; 
H,  section  of  the  ramus  in  partial  resection. 


lower  jaw  are  of  the  same  nature  as  cause  us  to  remove  the  upper  jaw.  The 
names  of  many  surgeons  are  connected  with  this  operation,  viz.,  Deadrick, 
White,  Dupuytren,  Sir  Astley  Cooper,  and  Valentine  Mott. 

In  this  operation  the  patient  is  placed  in  the  same  position  as  for  excision 
of  the  upper  jaw,  the  chin  having  been  previously  shaved.  A  vertical  cut 
is  made  through  the  chin-tissue,  starting  below  the  margin  of  the  Hp  and  reach- 
ing to  below  the  border  of  the  jaw  (c-d.  Fig.  502).  From  the  point  d  an  incision 
is  carried  outward  below  the  border  of  the  jaw  and  then  back  of  the  ramus,  as 
shown  in  the  line  d-e  (Fig.  502).  Treves's  advice  is  to  carry  this  incision  down 
to  the  bone,  except  at  the  line  of  the  facial  artery,  at  which  point  it  must  go 
through  the  skin  only.  The  facial  artery  is  now  to  be  sought  for,  tied  in  two 
places,  and  divided.  Except  in  malignant  cases  the  periosteum  is  lifted  from 
the  external  surface  of  the  bone,  from  the  symphysis  outward.  Hemorrhage  is 
arrested.  The  buccal  mucous  membrane  is  cut  from  the  alveolus.  A  lateral 
incisor  tooth  is  pulled,  and  the  bone  is  sawn  in  the  line  g  (Fig.  503).  The  bone 
is  grasped  in  a  lion-jaw  forceps  and  is  drawn  outward.  The  mylohyoid  inser- 
tion is  cut;  the  internal  pterygoid  muscle  is  cut  and  the  periosteum  at  this  spot  is 


Operation  for  Congenital  Dislocation  of  Hip  799 

lifted;  the  inferior  dental  artery  is  cut  and  tied;  the  jaw  is  pulled  down;  the 
insertion  of  the  temporal  muscle  upon  the  coronoid  process  is  cut  away,  and 
the  external  pterygoid  muscle  is  divided.  The  capsule  of  the  joint  is  opened, 
and  the  bone  is  separated  from  the  ligaments  which  still  hold  it  in  place.  Bleed- 
ing is  arrested,  the  wound  is  sutured,  a  tube  is  introduced  in  the  posterior  por- 
tion of  the  wound  and  retained  for  twenty-four  hours,  and  antiseptic  dressings 
and  a  Gibson  or  a  Barton  bandage  are  apphed.  Partial  excisions  of  the  alveolus 
may  be  performed  through  the  mouth  by  means  of  chisels  and  rongeur  forceps, 
and  Wyeth  has  thus  removed  half  of  the  jaw;  but  if  any  considerable  part  of 
the  body  of  the  jaw  is  to  be  removed,  it  is  usually  best  to  make  an  incision  below 
the  inferior  maxillary. 

Partial  Excision. — This  operation  is  frequently  made  necessary  by  epithe- 
lioma involving  the  periosteum  or  bone.  After  this  operation,  unless  means 
are  taken  to  prevent  deformity,  there  will  be  asymmetry  of  the  two  portions  of 
jaw  bone  remaining  and  malrelation  of  the  teeth.  Various  attempts  have  been 
made  to  fill  up  this  gap  at  the  time  of  operation  by  some  material,  or  to  hold  the 
two  portions  of  the  mandible  in  symmetrical  relation  by  the  insertion  of  trusses 
of  silver  wire,  or  by  fastening  each  piece  of  bone  to  a  metal  plate. 

John  B.  Murphy  suggested  the  use  of  a  bridge  of  silver  wire.  All  of  my 
trials  with  such  a  bridge  failed.  It  always  ulcerated  out  and  usually  through  the 
skin,  but  did  some  good  by  keeping  the  bone  ends  further  apart  than  they  other- 
wise would  have  been. 

Stanley  Stillman  ("Annals  of  Surgery,"  July,  1912)  advocates  bone-grafting 
as  the  only  proper  method,  in  order  to  prevent  contraction  during  healing 
after  the  removal  of  the  jaw  bone.  "When  the  teeth  on  the  sound  side  are 
numerous  and  firm  enough  to  stand  the  strain,  they  may  be  prepared  before- 
hand with  the  aid  of  a  dentist,  so  that  a  few  days  after  the  operation  they  may 
be  clamped  firmly  to  those  of  the  upper  jaw"  (Ibid.).  When  the  wound  heals, 
Stillman  separates  the  flap,  freshens  the  bone-ends,  and  wedges  a  section  of 
rib  between  them.  The  clamps  are  left  in  place  until  the  bones  unite,  which 
requires  six  to  eight  weeks.  In  cases  in  which  the  teeth  cannot  be  used  to 
clamp,  a  silver  bridge  is  inserted,  which  is  left  in  place  until  the  parts  are  ready 
for  the  insertion  of  the  bone. 

Barker's  Operation  for  Dislocation  of  the  Semilunar  Cartilages  of  the 
Knee-joint.^— Begin  the  incision  over  the  ligament  of  the  patella,  3-^  inch  above 
the  articular  surface  of  the  tibia,  and  carry  it  in  a  curve  downward  and  outward 
to  the  anterior  edge  of  the  internal  ligament.  The  periosteum  should  be  divided 
by  the  cut.  This  incision  forms  a  flap  the  lower  edge  of  which  is  3^^  inch  below 
the  border  of  the  articular  surface  of  the  tibia.  The  flap  is  lifted  until  the  car- 
tilage is  seen  "under  the  attachment  of  the  meniscus,  which  if  partially  attached 
will  rise  with  the  flap  until  its  under  surface  is  seen."  If  partially  torn  ante- 
riorly it  is  stitched  to  periosteum  by  a  few  silk  sutures.  The  periosteum  is  then 
stitched  in  place,  no  drain  is  used,  the  joint  is  immobilized,  and  for  one  week  ice 
is  kept  upon  the  part.  If  the  meniscus  is  found  completely  separated  and  curled 
up,  it  may,  if  the  injury  was  recent,  be  reduced.  If  the  injury  was  old  and  if 
the  cartilage  is  shrunken,  it  should  be  completely  cut  away  (Barker).  Person- 
ally I  would  omit  the  apphcation  of  ice. 

Operation  for  Congenital  Dislocation  of  Hip. — Lorenz's  Bloodless  Method 
of  Reduction. — The  method  of  reducing  by  manipulation  a  congenital  dislo- 
cation of  the  hip  was  advised  by  Paci  and  modified  and  improved  by  Lorenz. 
It  has  long  been  known  that  reduction  is  easy  at  birth  because  an  acetabulum, 
though  probably  a  shallow  one,  exists,  and  the  head  of  the  bone  is  not  firmly 
held  in  its  new  situation.  In  an  older  child  the  problem  is  far  more  difiicult, 
because,  even  if  reduction  is  effected,  the  acetabulum  may  be  extremely  shallow 
or  absent,  and  redislocation  may  readily  occur.     Lorenz  aims  to  effect  thorough 

1  "Lancet,"  Jan.  4,  1902. 


8oo 


Diseases  and  Injuries  of  the  Bones  and  Joints 


reduction  and  then  fixes  the  limb  in  abduction  for  months,  so  that  the  acetabu- 
lum will  deepen  and  the  bone  will  become  firm  in  its  proper  socket.  This  opera- 
tion is  rarely  successful  in  children  over  six  years  of  age.  The  child  is  anesthe- 
tized and  an  attempt  is  made  to  draw  the  femoral  head  on  to  a  line  with  the 
acetabulum.  If  the  child  has  never  walked,  this  is  readily  accomphshed.  If  it 
has  walked,  the  procedure  may  be  very  difficult,  and  it  may  be  necessary  to 
make  extension  by  a  fillet  fastened  above  the  knee,  and  counterextension  by  a 
screw  and  a  perineal  band.  The  drawing  down  of  the  head  is  made  easier 
by  stretching  and  massaging  the  adductor  muscles.  The  next  step  is  to  flex  the 
thigh,  strongly  rotate  it  a  trifle  internally,  and  then  abduct  it  while  flexion  is 
maintained.  This  causes  the  head  of  the  femur  to  pass  around  the  posterior 
margin  of  the  acetabulum  and  frequently  produces  reduction.  "Full  abduc- 
tion being  kept  up,  the  thigh  is  rotated  out,  thus  forcing  the  head  of  the  femur 
more  firmly  into  the  socket."  (See  the  description  of  the  Lorenz  method  in 
J.  Jackson  Clark's  "Orthopedic  Surgery.'')  The  strongly  abducted  limb  is 
put  up  in  plaster  of  Paris.  In  about  three  months  the  plaster  is  removed,  the 
abduction  is  diminished,  the  plaster  is  reapplied,  and  is  retained  for  another 
three  months.     During  the  continuance  of  immobilization  of  the  hip  the  child 

walks  about,  with  the  knees  bent. 
When  the  plaster  is  finally  removed, 
manipulation,  massage,  and  exer- 
cise strengthen  the  muscles  and  give 
freedom  to  the  joint.  In  a  double 
dislocation  one  joint  may  be  cured 
before  the  other  is  operated  upon, 
or  both  may  be  operated  upon  at 
the  same  seance.  In  double  dis- 
location plaster  must  be  worn  more 
than  six  months.  The  Lorenz  op- 
eration is  safe  when  applied  to  very 
young  children,  but  has  elements 
of  danger  which  increase  with  the 
years  of  the  subject.  A  patient 
may  suffer  grave  lacerations  of 
muscles  and  ligaments,  and  even 
vessels  and  nerves.  Death  may  re- 
sult from  shock,  and  extensive  deep- 
seated  hemorrhage  may  occur.  In 
fact,  it  is  a  mistake  to  call  it  a  bloodless  method.  The  blood  flows,  though 
we  do  not  see  it.  An  untrained  man  may  do  fearful  mischief  by  this  opera- 
tion, and  it  should  only  be  attempted  by  an  experienced,  skilful  manipulator  and 
upon  properly  selected  cases,  when  it  is  a  very  successful  procedure.  I  am 
satisfied  that,  except  in  the  case  of  a  very  young  child,  in  whom  reduction  is 
easy,  one  who  performs  the  Lorenz  operation  should  be  something  more  than 
skilful  and  experienced.  He  should  be  physically  strong,  so  that  traction  and 
abduction  will  be  powerful  and  steady.  A  weak  man  will  jerk,  vAW  throw  his 
weight  upon  the  part,  and  will  be  apt  to  tear  structures  instead  of  stretching 
them.     Sudden  forcible  movements  are  apt  to  break  the  bone. 

Hoffd's  Cutting  Operation. — Make  the  external  incision  of  Langenbeck  to 
open  the  joint  (see  page  792).  The  capsule  is  incised  at  its  insertion  into  the 
neck,  and  the  periosteum  and  muscles  are  lifted  from  the  great  trochanter. 
Hoffa  claims  that  in  children  less  than  five  years  of  age  the  head  of  the  bone 
can  be  readilv  replaced  into  the  acetabulum  by  flexing  the  thigh  and  making 
direct  pressure  upon  the  head  of  the  bone.  After  replacing  the  femoral  head 
it  is  held  in  place  while  an  assistant  extends  the  leg  in  order  to  stretch  the 
muscles.     In  children  over  five  years  of  age  cut  wath  a  tenotome  the  muscles 


Fig.  504. — Lorenz  mt-lhod.  Unilateral  con- 
genital dislocation  of  hip  (reduced).  Cast  applied 
with  leg  in  "frog  position." 


Myalgia,  or  Muscular  Rheumatism  80 1 

which  spring  from  the  ischial  tuberosity  and  also  the  adductors;  cut  the  fascia 
lata  and  muscles  which  arise  from  the  anterior  superior  iliac  spine  by  incision; 
open  the  joint  and  liberate  the  head  of  the  bone;  remove  the  ligamentum  teres; 
scrape  out  the  acetabulum,  removing  "cartilage,  fat,  and  considerable  spongy 
tissue"  (Tubby);  and  replace  the  head  of  the  bone  in  the  acetabulum.  The 
limb  is  maintained  in  inversion,  abduction,  and  extension  for  several  weeks, 
when  it  is  straightened.  Massage  and  passive  motion  are  begun  in  the  fifth 
week.  The  patient  now  gets  about,  wearing  for  many  weeks  an  apparatus 
which  permits  the  head  of  the  bone  to  move  in  the  socket,  but  prevents 
redislocation. 

Lorenz^s  Cutting  Operation. — This  is  a  modification  of  Hoffa's.  The  muscles 
inserted  into  the  greater  and  the  lesser  trochanter  are  not  cut;  the  sartorius, 
the  hamstrings,  and  the  external  portion  of  the  fascia  lata  are  cut  (Tubby). 

The  incision  of  Lorenz  is  longitudinally  from  the  anterior  superior  spine. 
Another  incision  is  carried  inward  from  this  at  the  level  of  the  lesser  trochanter. 
The  capsule  is  opened  by  a  crucial  cut;  the  acetabulum  is  enlarged;  the  head 
of  the  bone,  if  it  remains,  is  inserted  into  the  acetabulum;  if  there  is  no  true 
head,  a  new  one  is  formed  and  inserted  into  the  cavity.  The  limb  is  immo- 
bilized in  a  position  of  moderate  abduction.  Massage  and  passive  motion 
are  begun  in  the  fifth  week,  and  are  continued  for  months.^ 

Reduction  by  Means  of  Mechanical  Appliances. — As  the  chief  factor  in 
the  reduction  of  a  congenital  dislocation  is  thorough  stretching  of  the  muscles 
and  ligaments  before  attempting  replacement,  numerous  forms  of  levers  have 
been  devised  to  accomplish  this.  The  best-known  one  is  that  of  Bartlett,  of 
Boston.  It  consists  of  a  pelvic  rest  with  perineal  support,  rods  to  fix  the  pelvis 
and  traction  rods  to  make  extension.  Great  care  is  necessary  in  the  use  of  all 
such  appliances  because  of  the  danger  of  injury  to  vessels  and  nerves  or  of 
fracturing  bony  parts.  After  the  parts  have  been  thoroughly  stretched 
replacement  is  accomplished  by  manipulation,  as  in  the  usual  methods  of 
manual  reposition. 


XXI.  DISEASES  AND  INJURIES  OF  MUSCLES,  TENDONS,  AND 

BURS/E 

Myalgia,  or  muscular  rheumatism,  is  a  painful  disorder  of  the  volun- 
■  tary  fnuscles  and  of  the  fibrous  and  periosteal  areas  where  they  are  attached. 
The  term  "muscular  rheumatism"  is  not  strictly  correct.  It  is  possible  that 
in  some  cases  the  muscular  structure  is  inflamed,  but  it  is  certain  that  in  many 
cases  the  pain  is  distinctly  neuralgic.  Muscular  rheumatism  may  be  due  to 
cold  and  wet,  to  overexertion  and  strain,  to  acute  infectious  disorders,  to  syph- 
iHs,  to  chronic  intoxications  (lead,  mercury,  and  alcohol),  and  to  disturbances  of 
the  circulation.  Gouty  and  rheumatic  persons  are  especially  predisposed,  men 
being  more  liable  to  the  disease  than  women.  The  disease  is  usually  acute,  but 
it  may  be  chronic. 

Symptoms. — Muscular  rheumatism  is  apt  to  come  on  suddenly.  The 
pain,  which  may  be  very  acute  and  lancinating  or  dull  and  aching,  is  in  some 
cases  constantly  present;  in  other  cases  it  is  awakened  by  muscular  contraction 
only,  and  it  is  frequently  relieved  by  pressure,  though  there  is  often  some  sore- 
ness. The  skin  above  the  muscle  is  sometimes  tender  to  light  pressure.  The 
disease  usually  lasts  for  a  few  days,  but  it  tends  to  recur.  There  is  little,  if  any, 
fever. 

Lumbago  is  myalgia  of  the  muscles  of  the  loins.  Rheumatic  torticollis  is 
myalgia  of  the  muscles  of  the  neck.     Usually  one  side  of  the  neck  is  attacked. 

^  I  have  drawn  upon  the  very  lucid  description  of  these  operations  in  A.  H.  Tubby's  treatise 
upon  "Deformities." 

51 


8o2  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursic 

The  chin  is  turned  from  the  affected  side  and  the  neck  is  stiff.  Pleurodynia 
is  myalgia  of  the  intercostal  muscles.  The  ]min  is  very  severe,  is  aggravated 
by  deep  respiration,  by  coughing,  and  by  yawning,  there  may  be  tenderness, 
and  the  patient  tries  to  limit  chest-movement.  In  intercostal  neurali^ia  the 
pain  is  limited,  is  not  constant,  but  occurs  in  distinct  paroxysms,  and  is  linked 
with  the  presence  of  the  tender  spots  of  Valleix.  Pleurodynia  lacks  the  physical 
signs  of  pleurisy.  Cephalodynia  is  myalgia  of  the  muscles  of  the  scalp.  The 
muscles  of  the  shoulder,  upper  dorsal  region,  abdomen,  and  extremities  may 
also  be  attacked  by  myalgia.  Myalgia  must  not  be  confused  with  the  pains 
of  locomotor  ataxia. 

Treatment. — Remove  any  obvious  cause.  Treat  any  existing  diathesis, 
such  as  gout  or  rheumatism.  Rest  is  of  the  first  importance.  For  lumbago, 
put  the  person  to  bed.  For  pleurodynia,  strap  the  side  of  the  chest.  A  hypo- 
dermatic injection  of  morphin  and  atropin  into  the  affected  muscles  at  once 
allays  the  pain,  and  a  deep  injection  of  distilled  water  is  sometimes  curative. 
Relief  may  be  afforded  by  painting  the  surface  with  30  drops  of  a  mixture  of 
equal  parts  of  guaiacol  and  glycerin  and  covering  the  painted  area  with  cotton. 
The  introduction  of  four  or  five  aseptic  needles  into  the  muscles,  and  their  reten- 
tion for  a  few  minutes,  sometimes  acts  most  favorably.  Ironing  the  skin  above 
the  painful  muscles  with  a  very  warm  iron,  a  piece  of  flannel  being  interposed, 
is  a  useful  domestic  remedy.  Vigorous  rubbing  of  the  area  with  a  piece  of  ice 
allays  the  pain.  Hot  poultices  do  good.  If  the  pain  is  widely  diffused,  alters 
its  seat,  or  is  very  obstinate,  order  hot  baths  or  Turkish  baths  and  administer 
diuretics.  In  chronic  cases  employ  blisters  or  counterirritation  by  the  cautery, 
give  iodid  of  potassium  and  nux  vomica,  and  have  the  patient  take  a  Turkish 
bath  every  week.  The  constant  electric  current  finds  advocates.  In  an 
ordinary  severe  case  order  a  hot  bath,  put  the  patient  to  bed  with  a  hot-water 
bag  over  the  part,  and  administer  10  gr.  of  Dover's  powder;  the  next  morning 
order  to  be  taken  four  times  daily  a  capsule  containing  5  gr.  of  salol  and  3  gr. 
of  phenacetin,  until  the  pain  disappears.  Citrate  of  potassium,  citrate  of  lith- 
ium, chlorid  of  ammonium,  or  the  salicylate  of  colchicin  may  be  ordered  instead 
of  salol  and  phenacetin. 

Infective  myositis  is  a  widespread  inflammation  of  the  voluntary  mus- 
cles, due  to  an  unknown  infective  cause.  It  is  a  disorder  accompanied  by 
pain  and  stiffness,  by  cutaneous  edema,  and  by  various  paresthesias.  Myo- 
sitis resembles  trichinosis,  and  can  be  distinguished  from  it  only  by  spearing 
out  a  bit  of  muscle  and  examining  it  microscopically.  Occasionally  diffuse 
suppuration  occurs. 

Ordinary  myositis  arises  from  injuries,  from  syphilis,  or  from  rheu- 
matism, and  it  presents  the  usual  inflammatory  symptoms.  Contraction  and 
adhesions  may  follow.  I  operated  upon  a  case  of  myositis  of  the  rectus 
abdominis  in  a  boy  of  eight.  There  was  a  large  mass  like  a  full  bladder.  There 
had  not  been  an  attack  of  t^^phoid  and  there  was  not  hereditary  syphilis.  Casea- 
tion existed.  The  condition  was  possibly  tuberculous,  although  no  bacilli 
were  found. 

Treatment  of  Myositis. — Infective  myositis  is  treated  by  anodynes,  stimu- 
lants, nutritious  food,  hot  applications,  and  rest.  If  pus  forms,  it  should  be 
evacuated.  Rheumatic  myositis  calls  for  the  administration  of  the  salicylates, 
the  alkalis,  or  salol.  Syphilitic  myositis  is  treated  with  mercury  and  iodid  of 
potassium.     The  remedies  employed  for  myalgia  are  used  in  traumatic  myositis. 

Hypertrophy  of  the  muscles  may  arise  from  their  increased  use.  In 
pseudohypertrophic  paralysis '  the  muscle  is  greatly  augmented  in  bulk,  but  it 
contains  less  muscle-structure  and  more  fat  or  connective  tissue. 

Atrophy  of  the  muscles  arises  from  want  of  use,  from  injury,  from  con- 
tinuous pressure,  from  interference  with  the  blood-supply,  from  disease  of  the 
nerves  or  their  centers,  or  from  lead-poisoning. 


Myositis  Ossificans  Progressiva 


803 


Degeneration  of  Muscles.— The  muscles  may  undergo  granular  de- 
generation, waxy  degeneration,  fatty  degeneration  and  calcareous  degeneration, 
and  may  become  pigmented. 

Local  Ossification  and  Myositis  Ossificans. — It  is  not  unusual  for 
a  small  portion  of  bone  to  form  in  the  periosteal  insertion  of  a  muscle  which  is 
subjected  to  frequent  strain.  In  persons  who  ride  many  hours  a  day  there  not 
infrequently  develops  the  riders'  bone,  which  is  an  area  of  ossification  in  the  ad- 
ductor muscles  of  the  thigh. 

Myositis  ossificans  traumatica  is  a  circumscribed  ossification  of  muscle 
due  to  a  single  severe  closed  injury.  It  does  not  follow  open  injuries  (O.  M. 
Shere,  in  "Jour.  km.  Med.  Assoc,"  1915,  Ixv).  The  usual  cause  is  a  contusion 
and  laceration  of  muscle  by  a  dislocated  bone  or  a  rupture  of  muscle  may  be  fol- 
lowed by  the  ossifying  process.     The  bone  formed  is  cancellous.     The  nature  of 


Fig.  505. — Myositis  ossificans 
progressiva. 


Fig.  506. — iMyositis  ossificans 
progressiva. 


the  process  is  uncertain.  Some  observers  believe  the  process  is  inflammatory,  a 
real  myositis.  Many  believe  that  the  osteoblasts  come  from  the  periosteum 
or  that  a  bit  of  periosteum  was  pulled  off  by  the  muscle.  OHver  ("Jour.  Am 
Med,  Assoc,"  1914,  Ixiii)  says  the  process  is  not  a  myositis  but  is  a  meta- 
plasia of  connective  tissue  or  a  periosteal  growth.  The  treatment  is  early 
excision.  This  treatment  is  particularly  important  when  we  remember  that  the 
condition  may  be  mistaken  for,  and  perhaps  may  sometimes  be,  sarcoma. 

I  operated  upon  a  traumatic  case  by  removing  an  ossified  area  in  the  thigh 
muscles.  The  laboratory  report  was  myositis  ossificans.  Growth  quickly 
recurred  after  operation,  but  the  new  growth  showed  very  little  ossification. 
The  laboratory  report  was  spindle-celled  sarcoma.  This  case  and  also  another 
one  reacted  to  Coley's  fluid.  It  seems  possible  that  local  myositis  ossificans 
may,  in  some  cases  at  least,  be  a  sarcoma  in  which  rapid  ossification  occurs. 

Myositis  ossificans  progressiva  is  a  widespreadv ossification  of  the  muscles 
arisihg  during  the  fi.rst  ten  years  of  fife  and  much  more  common  in  males  than 
in  females.  The  cause  of  this  rare  condition  is  unknoum.  It  is  probably  due  to 
congenitally  defective  organization.  The  thumbs  and  great  toes  are  commonly 
short  (microdactylia).  This  is  due  to  imperfect  development  of  the  proximal 
phalanges  or  of  the  metacarpal  and  metatarsal  bones.     There  may  be  osteomata 


8o4 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursrc 


of  the  skull,  scapula  and  other  bones.  The  disease  usually  begins  about  the 
back,  shoulders  and  neck.  There  are  stiffness,  local  cyanosis  and  a  feeling  of 
doughiness.  The  areas  later  become  hard.  Most  of  the  muscles  may  suffer 
(the  tongue,  heart,  diaphragm,  muscles  of  deglutition,  and  the  sphincters  are 
never  attacked).  Involvement  of  the  masseters  locks  the  jaws.  The  x-rays 
show  the  bone.  Death  takes  place  usually  before  the  twentieth  year,  in  most 
cases  from  bronchopneumonia.     No  treatment  is  of  even  the  slightest  avail. 

Tumors  of  the  Muscles.^Primary  tumors  of  the  muscles  are  rare. 
Among  those  which  may  occur  are  sarcoma,  fibroma,  lipoma,  osteoma,  angioma, 
myxoma,  and  enchondroma.  Most  cases  of  supposed  primary  sarcoma  of 
muscle  are,  in  reality,  cases  of  syphiloma  (Esmarch). 

Syphilis  may  cause  inflammation.  Gummata  may  form,  or  gumma- 
tous infiltration  may  take  place. 

Trichinosis  or  trichiniasis  is  a 
disease  due  to  the  embryos  of  the 
Trichina  or  Trichinella  spiralis.  Sir 
James  Paget  recognized  the  nature  of 
the  previously  known  encysted  or 
larval  form.  It  was  long  believed 
that  the  Trichina  spiralis  was  a  harm- 
less parasite,  but  in  i860  Zenker,  of 
Dresden,  proved  that  it  might  be 
responsible  for  dangerous  epidemics. 
The  trichina  is  normally  a  parasite 
of  the  rat.  Man  is  infected  by  eat- 
ing flesh  which  contains  trichinae  and 
has  been  insufficiently  cocked.  The 
flesh  of  the  pig  is  the  medium  of 
infecting  man.  The  pig  becomes  in- 
fected by  eating  rats  suffering  from 
the  disease  or  offal  and  slaughter- 
house refuse  containing  trichinallized 
flesh.  Dr.  Joseph  Leidy  discovered 
the  trichina  in  pork.  People  are  most 
commonly  affected  by  eating  raw 
sausage,  smoked  sausage,  or  under- 
done pork.  Imperfectly  boiled  ham 
may  be  responsible.  Albert  reported 
14  cases  from  eating  boiled  ham. 
W.  Oilman  Thompson  found  records  of  52  sporadic  cases  occurring  in  New 
York  City  during  six  years  ("Amer.  Jour.  Med.  Sciences,"  August,  1910). 
These  nematodes  are  carried  into  the  intestine,  there  to  develop  and  multiply. 
In  from  seven  to  nine  days  a  horde  of  embryos  develop  in  the  bowel,  and  leave 
the  alimentary  canal  by  passing  through  the  peritoneum  or  by  means  of  the 
blood,  and  finally  reach  the  connective  tissue  of  the  muscles.  From  the  con- 
nective tissue  the  embryos  migrate  into  the  primitive  muscle-fibers,  where  they 
dwell  and  enlarge.  Myositis  develops,  and  in  the  course  of  five  or  six  weeks 
the  parasites  become  encapsulated  and  develop  no  further.  The  cyst-walls 
may  calcify  and  the  worms  may  become  calcified,  or  may  live  for  years.  The 
eating  of  infected  meat  is  not  inevitably  followed  by  the  disease,  and  a  few 
embryos  lodged  in  muscle  may  cause  no  symptoms. 

The  symptoms  of  trichinosis  often  appear  in  a  day  or  two  after  eating  infected 
meat.  The  symptoms  of  acute  gastro-intestinal  catarrh  or  of  cholera  morbus 
are  common,  but  in  some  cases  no  gastro-intestinal  manifestations  usher  in 
the  disease.  In  from  seven  to  fourteen,  days  after  the  infected  meat  is  eaten 
the  migration  of  the  parasites  develops  obvious  symptoms.     A  chill  may  be 


Fig.  507. — Trichinosis  of  right  leg. 


Ischemic  Myositis,  or  Volkmann's  Contracture  8o,s 

noted;  there  is  usually  fever;  muscular  pain,  tenderness,  sweUing,  and  stiff- 
ness are  complained  of.  This  condition  may  be  widespread.  Involvement  of 
the  muscles  of  mastication  interferes  with  chewing;  of  the  larynx,  with  talking 
and  respiration;  of  the  intercostals  and  diaphragm,  with  respiration.  Skin- 
edema  and  itching  are  marked.  In  some  cases  delirium  exists.  The  writer 
saw  in  the  Philadelphia  Hospital  one  fatal  case  which  was  mistaken  for  ery- 
sipelas because  of  the  high  fever,  the  dehrium,  and  the  edematous  redness  of 
the  face  and  neck.  Dyspnea  is  frequent.  Mild  cases  get  well  in  a  week  or 
two;  severe  cases  may  last  many  weeks.  The  mortality  varies  in  different  epi- 
demics from  I  to  30  per  cent.  (Osier).  The  diagnosis  is  made  by  spearing  out 
a  piece  of  muscle,  which  is  then  examined  for  trichinae  under  a  microscope;  or 
the  worms  may  perhaps  be  detected  in  the  feces  by  means  of  a  pocket-lens. 
In  a  case  under  the  care  of  the  author,  in  St.  Joseph's  Hospital,  there  was  no 
record  of  any  attack  of  gastro-intestinal  disturbance  and  the  first  manifesta- 
tion was  enlargement  of  the  calf  of  the  left  leg.  In  most  cases  of  trichinosis 
there  is  eosinophilia,  but  in  the  author's  case,  previously  referred  to,  eosino- 
philia  was  not  present. 

Treatment. — To  treat  trichinosis  employ  purgatives  (senna  and  calomel) 
early  in  the  case,  and  give  glycerin,  and  also  santonin  or  iilix  mas.  When 
muscular  invasion  has  taken  place,  sedatives,  hypnotics,  nourishing  diet,  and 
stimulants  are  indicated. 

Ischemic  Myositis,  or  Volkmann's  Contracture  (Volkmann's Paralysis; 
Ischefnic  Paralysis;  Ischemic  Muscular  Atrophy,  with  Contractures  and  Paraly- 
sis, Fergusson  calls  it). — It  is  occasionally  noticed,  particularly  in  children, 
after  prolonged  fixation  of  the  forearm,  especially  after  prolonged  fixation  of 
the  elbow-joint  by  some  appliance  that  impedes  the  freedom  of  circulation 
in  the  part.  Contractures  of  the  fingers  occur  and  perhaps  rigidity  and  flexion 
of  the  wrist.  In  1875  Volkmann  described  severe  contractures  of  the  hand 
observed  in  some  cases  as  a  result  of  the  use  of  tight  bandages  to  hold  splints  in 
place  in  treating  fractures  of  the  arm.  He  believed  that  the  condition  was  due 
to  deprivation  of  arterial  blood,  that  the  muscles  perished  for  want  of  oxygen, 
and  that  rigor  mortis  occurred.  He  pointed  out  that  paralysis  and  contracture 
occur  simultaneously,  whereas  in  primary  nerve  lesion  paralysis  precedes  con- 
tracture. The  condition  may  come  on  after  the  application  of  an  Esmarch 
band,  after  a  severe  injury  in  the  neighborhood  of  the  elbow-joint,  may  follow 
ligation  of  the  main  artery  of  a  limb,  venous  embolism,  venous  thrombosis  from 
injury  or  infectious  disease,  Raynaud's  disease,  or  exposure  to  cold.  One  of 
Sir  Robert  Jones's  cases  followed  a  rapidly  developing  traumatic  myositis 
ossificans;  two  followed  crushes;  in  one  an  elastic  tourniquet  had  been  kept  on  a 
child's  arm  to  prevent  bleeding  after  an  operation  for  webbed  fingers ;  in  one 
pad  pressure  had  been  maintained  for  twenty-four  hours  to  check  bleeding 
("Amer.  Jour.  Orthop.  Surg.,"  April,  1908).  A  case  of  mine  resulted  from 
embolism  of  the  brachial  artery.  There  are  two  forms,  one  due  to  almost  complete 
arterial  ischemia,  lasting  for  several  hours  at  least;  another  due  to  interference 
with  venous  return.  Volkmann's  contracture  is  due  to  muscular  degeneration, 
infiltration,  induration,  and  contraction,  the  result  of  marked  and  prolonged 
arterial  ischemia,  or  interrupted  venous  return,  and  it  is  frequently  spoken  of 
as  ischemic  myositis  (Dudgeon,  ''Lancet,"  Jan.  11,  1902).  In  some  cases  dis- 
tinct neuritis  with  paralysis  also  exists.  One  characteristic  of  ischemic  con- 
tracture is  the  rapidity  with  which  it  comes  on.  Dudgeon  points  out  that  in 
half  a  day,  or  even  in  less  time  in  some  cases,  the  symptoms  appear,  these  symptoms 
being  paralysis  of  the  part  with  contracture.  Pain  is  unusual,  unless  the  nerves 
are  seriously  involved  and  then  it  is  violent.  In  some  cases  the  fingers  and 
hand  swell  and  become  discolored.  The  absence  of  pain  frequently  prevents  the 
recognition  of  the  condition;  therefore,  the  causative  splint  or  bandage  pressure 
may  be  maintained  for  days  after  the  trouble  has  become  serious.     When  the 


8o6 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursas 


splints  and  bandages  are  removed  and  the  forearm  is  examined,  there  is  almost 
always  tenderness  over  the  muscles  and  the  nerve-trunks;  and  in  the  majority  of 
cases  in  which  a  splint  has  been  the  cause  a  portion  of  the  skin  will  have  sloughed. 
Dudgeon  points  out  the  characteristic  position  of  the  deformity  as  follows: 
When  the  wrist  is  extended,  the  metacarpophalangeal  joints  are  also  extended; 
but  the  interphalangeal  joints  of  the  fingers  and  the  terminal  joint  of  the  thumb 
are  so  strongly  bent  that  the  tips  of  the  lingers  touch  the  palm,  and  this  position 
cannot  be  corrected  by  any  justifiable  amount  of  force.  As  soon  as  the  wrist- 
joint   is    bent   to   a   right   angle,    the   interphalangeal    joints  can  readily  be 

extended.  In  a  very  severe  case  the 
wrist  itself  will  become  markedly  fiexed, 
and  it  will  be  impossible  to  extend  it. 
The  forearm  is  usually  semiflexed  and 
the  hand  pronated.  The  ulceration  or 
sloughing  so  frequently  present  causes 
a  splint-sore.  There  is  always  marked 
induration  about  a  splint-sore.  The 
flexor  muscles  themselves  are  indurated 
and  usually  wasted.  The  condition  of 
sensation  depends  upon  the  state  of  the 
nerves  of  the  part.  When  neuritis  is 
absent,  sensation  will  be  normal;  but 
in  accordance  with  the  amount  of 
neuritis  and  degeneration  there  will  be 
h\'peresthesia,  partial  anesthesia,  or 
complete  anesthesia.  A  curious  feature 
of  these  cases  that  is  dwelt  upon  by 
Dudgeon  and  commented  upon  by 
Turner  is  the  fact  that  in  young 
children  there  is  a  cessation  of  growth 
of  the  bone.  Sir  Robert  Jones  (loc.  cit.) 
reports  that  19  cases  out  of  40  were  as- 
sociated with  fracture.  In  13  of  the  19 
cases  there  was  pronounced  malunion. 

Treatment. — The  old  view  of  this  con- 
dition was  that  it  was  practically  hope- 
less. Anderson  and  Dudgeon,  however, 
maintain  that  restoration  may  usually 
be  obtained,  the  treatment  consisting  in 
regular,  active  motion,  passive  move- 
ment, massage,  and  electricity.  Forcible 
extension  under  ether  is  of  no  benefit 
whatever. 
Jones's  plan  of  treatment  is  very  beneficial  ("Amer.  Jour.  Orthop.  Surg.," 
April,  1908). 

Operative  procedures  on  arms  that  necessarily  have  deficient  circulation  are 
hazardous,  and  Jones  has  discontinued  all  operative  correction  and  relies  upon 
purely  mechanical  and  manipulative  routine,  as  follows: 

Five  splints  are  cut  out  of  zinc,  tin,  or  sheet  wire,  to  fit  each  finger  and  the 
thumb.  The  wrist  is  forcibly  flexed  and  held  while  each  finger  is  separately 
spHnted.  It  wall  be  observed  that  in  the  fully  fle.xed  position  of  the  wrist  the 
fingers  are  all  relaxed. 

When  the  finger  splints  have  been  applied  the  wrist  is  released,  and  the  patient 
is  directed  to  systematically  extend  the  metacarpophalangeal  joints.  In  a 
few  days  the  second  splinting  may  usually  be  employed  by  embedding  the  entire 
hand  to  the  wrist  and  the  already  splinted  fingers  in  plaster  of  Paris,  while  the 


Fig.  508. — Rugh's  splint  for  Volkmann's 
contracture.  Splint  applied.  Looking  at 
the  palmar  surface. 


Wounds  and  Contusions  of  the  Muscles 


807 


wrist  is  again  flexed.  Several  days  are  devoted  to  systematic  voluntary  efforts 
at  extension  of  the  hand  in  a  similar  manner  employed  for  the  metacarpopha- 
langeal joints. 

The  third  splinting  embraces  that  already  employed  and  in  addition  embraces 
the  wrist  in  the  fuUesi  extension  possible,  which  in  a  few  days  mav  be  increased 
until  full  extension  is  obtained.  The  latter  position  of  full'  extension  of  wrist, 
hand,  and  fingers  is  maintained  for  some  weeks  until  all  contractible  elasticity 
has  disappeared. 

It  is  usually  observed  that  when  the  hand  can  be  held  in  hyperextension 
without  tendency  to  relapse,  the  circulation  will  almost  invariably  improve 
and  the  fingers  resume  their  normal  function  and  appearance  except  in  cases 
of  nerve  destruction.  Jones  has  found  that  in  many  cases  in  which  the  nerves 
had  lost  their  function  during  contracture,  the  extension  of  the  hand  was  the 
starting-point  of  recovery. 

In  making  any  splint  pressure  to  straighten  the  fingers  the  greatest  care 
must  be  exercised.  The  skin  of  the  dorsum  of  the  fingers  will  not  endure  pro- 
longed pressure.     I  have  used  Rugh's  splint  with  much  satisfaction   (Figs. 


Fig.  509. — Lateral  \-iew  of  splint  shown  iii  Fig.  508. 


508,  509).  It  is  best  in  the  beginning  to  apply  the  splint  for  five  or  ten  min- 
utes twice  a  day.  The  time  of  each  seance  is  gradually  increased  as  the  tis- 
sues develop  resistance.  Frequent  bathing  %\ith  alcohol  aids  the  skin  to  bear 
pressure. 

R.  H.  Sayre  ("Volkmann's  Ischemic  Paralysis  and  Contracture/'  "Amer. 
Jour.  Orthop.  Surg.,"  Nov.,  1908,  p.  221)  advocates  the  Jones  method  in  all 
cases,  inasmuch  as  cutting  operations  may  be  employed  later  if  the  results 
of  Jones's  treatment  are  not  entirely  satisfactory.  The  improvement  in  the 
circulation  and  function  obtained  by  Jones  method  will  make  the  operative 
field  more  capable  of  rapid  recovery. 

In  a  persistent  and  long-continued  case  an  operation  may  be  necessary. 
The  operation  may  consist  in  dividing  in  the  forearm  the  flexor  muscles  of  the 
fingers,  as  advised  by  Davies  Colley,  and  then,  at  a  later  period,  dividing  the 
flexor  tendons.  The  objection  to  his  procedure  is  that  it  destroys  permanently 
the  capacity  to  flex  the  fingers.  Another  suggestion  has  been  to  excise  a  piece 
from  both  the  radius  and  the  ulna,  and  wire  the  fragments  together.  The 
best  surgical  treatment  is  probably  exposing  the  nerves,  separating  them  from 
adhesions,  stretching  them,  and  then  doing  tendon-lengthening,  but  this  should 
not  be  done  until  all  the  improvement  it  is  possible  to  secure  by  conservative 
treatment  has  been  obtained.  Conservative  treatment  should  be  tried  for  at 
least  three  months. 

Wounds  and  Contusions  of  the  Muscles. — Wounds  of  muscles  may  be 
either  open  or  subcutaneous.  In  a  longitudinal  wound  the  edges  He  close  together, 
and  hence  drainage  must  be  provided  for  by  the  surgeon.     In  a  transverse 


8o8  Diseases  antl  Injurits  of  Muscles,  Tendons,  and  Bursas 

wound  the  edges  separate  widely,  and  catgut  stitches  must  be  inserted.  Con- 
tusions of  muscles,  like  contusions  of  other  tissues,  vary  in  extent  and  in  severity. 
There  are  pain  (which  is  increased  by  attempts  to  use  the  muscle),  loss  of  func- 
tion, swelling  beneath  the  deep  fascia,  and  discoloration,  which  may  appear  at 
once  because  of  superficial  damage  from  the  initial  injury,  or  which  may  appear 
in  dependent  parts  after  many  days  because  of  gravitation  of  blood  and  blood- 
stained scrum.  As  a  result  of  contusion,  suppuration,  inflammation,  or  atrophy 
may  arise. 

Treatment. — In  a  longitudinal  wound,  drain;  in  a  transverse  wound,  suture 
the  muscle.  The  further  indications  in  wounds  and  contusions  of  muscles 
are  to  obtain  rest  by  means  of  splints  and  to  secure  relaxation.  Limitation 
of  swelling  is  secured  by  bandaging.  Inflammation  is  combated  first  by  cold  and 
lead- water  and  laudanum;  later  by  iodin,  blue  ointment,  ichthyol,  and  inter- 
mittent heat.  To  prevent  loss  of  function  employ,  as  soon  as  the  acute  symp- 
toms subside,  massage,  passive  motion,  and  stimulating  liniments,  and,  later  in 
the  case,  electricity  (galvanism  if  the  reactions  of  degeneration  exist;  faradism, 
if  they  are  absent). 

Strains. — A  muscular  strain  is  a  stretching  of  a  muscle  with  rupture  of  a 
few  fibers.  It  is  caused  by  traction  in  the  long  axis  of  the  muscle.  The 
muscle  becomes  swollen,  tender,  stiff,  weak,  and  sore,  and  attempts  at  motion 
produce  sharp  pain.  A  strain  of  a  tendon  is  a  trivial  or  partial  rupture.  It 
leads  to  the  development  of  acute  thecitis,  with  fluid  swelling  and  pseudocrepi- 
tation.  Strains  are  common  in  the  deltoid,  the  ham-string  muscles,  the  back, 
the  calf,  the  biceps,  and  the  great  pectoral.  Strain  of  the  psoas  muscle  causes 
pain  on  voluntary  flexion  of  the  thigh,  and  is  associated  with  tenderness  in  the 
iliac  fossa.  Strain  of  the  right  psoas  may  be  mistaken  for  appendicitis,  but  it 
lacks  the  intense  local  tenderness,  the  abdominal  rigidity,  and  the  constitutional 
symptoms.  Lawn-tennis  arm  is  a  strain  of  the  pronator  radii  teres  muscle. 
Riders'  leg  is  a  strain  of  the  adductor  muscles  of  the  thigh.  A  strain  of  the  long 
head  of  the  biceps  flexor  cubiti  produces  the  condition  called  by  ball  players  a 
glass  arm.  A  strain  may  be  the  only  injury,  or  may  be  associated  with  some 
other  condition  (fracture  of  bone,  dislocation,  sprain,  contusion,  etc.).  A  strain 
may  be  followed  by  periostitis  at  the  point  of  insertion  of  the  muscle.  Atrophy 
of  the  muscle  occasionally  follows  a  strain. 

A  strained  muscle  is  usually  rigid,  is  tender,  and  pains  greatly  when  an 
attempt  is  made  to  use  it.  The  skin  over  it,  especially  over  its  point  of  insertion, 
is  usually  tender. 

A  strain  of  the  back  is  a  very  common  accident,  which  is  often  associated 
with  sprains  of  the  vertebral  articulations.  There  is  great  pain  when  the  patient 
voluntarily  straightens  up.  If  the  vertebral  ligaments  are  not  damaged, 
the  patient  can  be  straightened  by  passive  motion  without  pain.  The  skin  is 
tender  in  certain  areas.  The  muscles  are  often  rigid.  There  may  be  uni- 
lateral rigidity.  In  a  back  injury  make  a  careful  examination  to  be  sure  no 
damage  has  been  inflicted  upon  the  vertebrae  or  cord. 

Treatment. — Relaxation  by  suitable  position;  rest  by  the  use  of  splints 
or  by  putting  the  patient  to  bed;  bandages  for  compression;  hot  fomentations 
or  a  hot-water  bag,  and  ichthyol.  As  soon  as  acute  symptoms  subside,  employ 
friction  and  massage.  Strapping  with  adhesive  plaster  is  of  service  in  strain 
of  the  back  and  of  the  calf.  If  there  is  severe  pain  after  a  strain,  administer 
Dover's  powder,  or  even  morphin. 

Rupture  of  Muscles  and  Tendons. — Rupture  of  a  muscle  is  announced 
by  a  sudden  and  violent  pain  and  by  loss  of  function,  arising  during  powerful 
muscular  contraction  or  strong  traction  in  the  long  axis  of  a  muscle.  The 
rupture  may  be  announced  by  a  clearly  audible  snap  (A.  Pearce  Gould).  A 
distinct  gap  is  felt  between  the  retracted  ends  of  the  torn  muscle;  great  pain 
develops   on  movement;  there  are  tenderness,  loss  of   power,  and  swelling. 


Rupture  of  the   Biceps  Flexor  Cubiti  or  its  Tendon 


809 


Rupture  may  be  followed  by  atrophy,  so  may  a  contusion.  Among  the  muscles 
which  occasionally  rupture  we  may  mention  the  quadriceps,  biceps,  triceps, 
deltoid,  plantaris,  etc. 

Rupture  of  the  biceps  flexor  cubiti  or  its  tendon  is  not  very  common;  72 
cases  have  been  collected  by  W.  W.  Keen,  ("Annals  of  Surgery,"  May,  1905). 
Alexander  collected  74.  cases  and  added  8  ("Annals  of  Surgery,''  1915,  Ixi). 
It  is  much  more  common  in  men  than  in  women.  Loos's  table  of  66  cases 
contains  records  of  only  2  women  (Doane,  in  "Jour.  Amer.  Med.  Assoc,"  May 


.iif«f»^'i^< 


Fig.  510. — Author's  case  of  rupture  of  the  long  head  of  the  biceps. 

16,  1908),  The  rupture  may  be  where  the  muscular  belly  passes  into  the  lower 
tendon,  through  the  muscular  belly,  in  the  muscular  part  passing  either  to  the 
long  or  short  head,  or  at  the  part  where  the  muscular  belly  joins  the  long  or 
short  head.  The  tendon  of  the  long  head  may  be  torn  through  or  the  long 
head  may  be  torn  from  the  glenoid  cavity.  The  muscular  portion  is  far  more 
often  injured  than  the  tendinous.  In  rupture  of  the  muscle  belly  a  part  of  the 
muscle,  in  rupture  of  the  long  head  the  entire  muscle,  becomes  soft  and  relaxed. 


Fig.  511. — ^ Author's  case  of  rupture  of  the  long  head  of  the  biceps. 

In  rupture  of  the  belly  there  is  a  gap  between  the  two  portions  and  each  por- 
tion causes  a  lump.  In  rupture  of  the  tendon  there  are  not  two  lumps  with 
a  gap  between,  but  there 'will  be  a  single  muscular  lump.  In  rupture  of  the 
long  head  the  muscular  belly  is  much  nearer  the  elbow  than  in  health  (Figs. 
510  and  511).  If  rupture  takes  place  at  the  lower  part  of  the  belly,  the  muscle 
passes  toward  the  shoulder.  Rupture  of  the  long  head  of  the  biceps  allows  the 
humerus  to  pass  somewhat  forward  and  upward. 

Flexion  with  the  forearm  supinated  is  much  less  powerful  than  flexion 
with  the  forearm  pronated  {Hiiter's  sign). 


8io  Diseases  and  Injuries  of  Muscles.  Tendons,  and  Bursa? 

In  a  case  of  my  own  in  the  Blockley  Hospital  the  accident  had  occurred 
while  carrying  a  heavy  bucket.  Forearm  flexion  was  possible,  but  slow,  feeble, 
partial,  and  incomplete.  On  flexion  the  short  head  contracted,  but  the  mus- 
cular "bunch"  of  the  belly  was  nearer  the  elbow  than  normally.  Rupture 
of  the  plantaris  muscle  {coup  de  fouet;  lawn-tennis  leg)  is  an  injury  which  is 
frequently  not  diagnosticated.  It  occurs  during  exercise  (walking,  bicycling, 
jumping, "playing  tennis)  or  is  first  complained  of  after  exercise.  It  produces 
sudden  pain  in  the  middle  of  the  calf,  swelling,  and  often  ecchymosis  and 
inability  to  walk  except  with  a  rigid  ankle  and  everted  toes.  Rupture  of  the 
quadriceps  extensor  femoris  toidon  results  occasionally  from  force  which  in  other 
cases  fractures  the  patella.  The  rupture  is  just  above  the  patella.  The  patient 
cannot  extend  the  thigh  and  cannot  walk  or  stand  and  there  is  severe  pain. 
A  gap  can  be  felt  just  above  the  patella,  unless  it  is  hidden  by  synovial  effusion, 
and  the  muscle  is  bunched  above.  Rupture  of  the  extensor  longus  pollicis  ten- 
don {drummer  s  paralysis)  ma>-  take  place  when  the  tendon  has  become  necrotic 
from  injurv  or  weakened  by  repeated  traumatism.  Sometimes  it  occurs, 
apparently  spontaneously,  a  number  of  weeks  after  the  occurrence  of  Colles's 
fracture. 

Treatment. — In  limited  rupture  treat  as  a  severe  strain.  In  treating 
extensive  rupture  of  an  important  muscle,  when  the  ends  are  widely  separated, 
expose  by  incision,  unite  the  divided  ends  by  sutures  of  chromicized  catgut 
(Fig.  112),  and  sew  up  the  skin  with  silkworm-gut.  Treat  the  part  in  any 
case  by  rest  and  relaxation  and  combat  inflammation  by  appropriate  means. 
Passive  motion  and  massage  are  employed  as  soon  as  union  is  firm.  In  rupture 
of  the  quadriceps  extensor  femoris,  operation  should  be  undertaken,  because 
mechanical  treatment  frequently  gives  a  bad  result  and  confines  the  patient 
to  bed  for  weeks.  Rupture  of  the  biceps  requires  incision  and  suture.  In  a  case 
in  the  Blockley  Hospital  (Figs.  510,  511)  I  operated  and  found  that  the  long 
head  with  a  portion  of  periosteum  had  been  torn  from  the  glenoid  cavity. 
A  portion  of  the  upper  end  of  the  tendon  was  cut  away  and  the  tendon  was 
fastened  to  the  short  head  by  splitting  and  suture.  Nine  months  later  the 
result  was  perfect  (Keen,  in  "Annals  of  Surgery,"  May,  1905).  In  Alexander's 
table  of  82  cases  only  10  were  operated  upon  (Ibid.).  Rupture  of  the  plantaris 
is  treated  at  first  by  rest  on  a  posterior  splint  and  compression  and  later  by  mas- 
sage and  the  use  of  an  elastic  bandage.  The  patient  is  allowed  to  walk  with  the 
aid  of  a  cane  in  one  week,  but  he  should  not  raise  the  heel  for  several  weeks. 
Rupture  of  the  quadriceps  is  treated  by  suturing.  In  rupture  of  the  extensor 
longus  pollicis  tendon  the  torn  ends  may  be  freshened  and  sutured,  or.  as  Heineke 
recommends,  the  peripheral  end  can  be  fastened  to  the  extensor  tendon  of  the 
index  finger  or  to  the  tendon  of  the  long  extensor  of  the  carpus. 

Hernia  of  Muscles. — When  a  tear  takes  place  in  a  muscular  sheath, 
a  portion  of  the  muscle  protrudes. 

The  treatment  is  incision,  restoration  or  extirpation  of  the  protruding  mass 
of  muscle,  and  suturing  of  any  muscle  wound  and  of  the  sheath. 

Contractions  of  muscles  may  result  from  injury,  from  joint  disease,  from 
malposition  of  parts  (as  in  old  dislocation  or  torticollis),  or  from  diseases  of 
the  nervous  system. 

The  treatment  in  some  cases  is  sudden  extension,  in  other  cases  gradual 
extension,  tenotomy,  or  myotomy.  Macewen  recommends  the  making  of  a 
number  of  V-shaped  incisions  in  the  muscle.  In  some  cases  of  spasmodic  con- 
traction nerve-stretching  is  of  value. 

Dislocations  of  Muscles  and  Tendons.— The  long  head  of  the  biceps  is 
oftenest  displaced.  The  flexor  carpi  ulnaris,  the  peroneus  brevis,  the  per- 
oneus  longus,  the  tibialis  posticus,  the  sartorius,  the  plantaris,  the  quadriceps 
extensor  femoris,  and  the  extensors  back  of  the  wrist  may  be  dislocated.  What 
is  known  as  dislocation  of  the  latissimus  dorsi,  a  condition  in  which  that  muscle 


Acute  Thecitis 


pii 


no  longer  lies  upon  the  angle  of  the  scapula,  is,  in  reality,  paralysis  of  the  ser- 
ratus  magnus  (see  page  843).  Most  of  these  accidents  are  associated  with 
chronic  disease  or  with  fracture,  but  disi^lacement  may  exist  as  a  solitary 
injury.  Dislocation  of  the  long  head  of  the  biceps  may  occur  tolerably  early  in  the 
progress  of  rheumatoid  arthritis  of  the  shoulder-joint,  and  the  displaced  tendon 
may  be  absorbed. 

Symptoms. — After  dislocation  of  a  tendon  the  muscle  of  the  tendon  can 
still  contract,  but  it  acts  at  a  disadvantage;  thus  the  corresponding  joint 
exhibits  partial  loss  of  function.  The  displaced  tendon  can  be  felt,  and  a 
hollow  exists  where  it  normally  resides. 

When  the  muscle  contracts,  the  tendon  is  felt  to  slip  from  its  groove.  When 
the  tendon  of  the  biceps  is  dislocated,  the  head  of  the  bone  passes  forward 
(so-called  subluxation  of  the  humerus) . 

Treatment. — In  tendon  dislocation  reduction  is  easy,  but  the  displace- 
ment is  apt  to  recur  because  of  laceration  of  the  sheath.  The  treatment  usually 
advised  is  to  effect  reduction  by  relaxation  of  the  limb  and  manipulation  of 
the  tendon,  to  place  the  part  upon  a  splint  so  that  the  muscle  belonging  to  the 
tendon  will  be  relaxed,  and  to  apply  pressure  over  the  point  of  injury.  This 
treatment  generally  fails,  and  if  the  tendon  does  not  become  firmly  anchored  in 
its  proper  situation  in  four  weeks  we  should  operate.  In  some  tendons  it  is 
enough  to  incise,  freshen  the  edges  of  the  torn 
sheath,  and  sew  up  with  kangaroo-tendon  or 
chromicized  catgut.  In  a  tendon  lying  in  a  long 
groove  make  a  halter  for  the  tendon  by  incising 
the  periosteum  and  suturing  it  over  the  tendon.^ 
Passive  movements  are  begun  at  the  end  of  the 
first  week.  Even  if  the  tendon  will  not  remain 
reduced,  a  useful  joint  will  probably  be  obtained. 

Wounds  of  Tendons.  —  Subcutaneous 
wounds  of  tendons  are  usually  inflicted  by  the 
surgeon,  and  they  heal  well.  Open  wounds 
require  rigid  antisepsis  and  suturing  of  the 
tendon.  In  wounds  of  the  wrist  especially 
always  suture  the  divided  tendons  (see  Fig. 
.  113),  and  be  sure  to  bring  the  proper  ends  into 
apposition. 

Rupture  of  Tendons. — A  violent  muscular 
effort  may  rupture  a  tendon  and  as  the  acci- 
dent occurs  a  snap  may  often  be  heard. 

The  symptoms  are  sudden  pain  and  loss  of 
power,  fulness  of  the  associated  muscle  from 
retraction,  and  absolute  inability  to  bring  the 
tendon  into  action.  A  gap  may  often  be  felt  in 
the  tendon  (see  page  809). 

Treatment. — The  best  procedure  in  treating  rupture  of  a  tendon  is  exposure 
by  incision  and  the  introduction  of  sutures.  Some  surgeons  relax  the  parts 
and  apply  splints  (see  page  808). 

Thecitis,  or  tenosynovitis,  is  inflammation  of  the  sheath  of  a  tendon. 

Acute  thecitis  may  arise  from  a  contusion,  from  a  wound,  from  repeated 
overaction  in  working  or  while  engaged  in  some  sport,  from  rheumatism, 
from  gonorrhea,  from  pyogenic  infection,  from  influenza,  from  a  continued 
fever,  or  from  syphihs.  In  early  syphilis  certain  tendon-sheaths  may  rapidly 
develop  effusion  because  of  hyperemia  of  the  sheaths  (Taylor). 

Symptoms. — In  nonsuppurative  cases  of  thecitis  the  symptoms  are  pain, 
swelling,  tenderness,   and   moist    crepitus    along   the   tendon-sheath,    due    to 
iWalsham's  case  of  dislocation  of  the  peroneus  longus,  "Brit.  Med.  Jour.,"  Nov.  2,  1895. 


Fig.  512. — Palmar  synovial 
sheaths  (vaginte  tendinurti),  normal 
adult  type  (Poirier  and  Charpy). 


8i2  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursa; 

inflammatory  roughening.  The  crepitus  disappears  as  the  swelling  increases, 
but  it  reappears  as  the  swelling  diminishes.  In  suppurative  cases  (phlegmon  of 
the  tendon-sheaths)  the  symptoms  are  great  swelling,  pulsatile  pain,  dusky 
discoloration,  inflammation  spreading  up  the  tendon-sheaths,  and  often  the 
constitutional  symptoms  of  sepsis. 

Treatment. — In  treating  non-suppurative  thecitis  employ  splints,  use  the 
hot-air  oven,  and  apply  locally  iodin,  blue  ointment,  or  ichthyol,  and  administer 
suitable  remedies  to  combat  any  causative  constitutional  disease.  In  the 
suppurative  form  inject  i  c.c.  of  formalin-glycerin  (2  per  cent.)  after  withdrawal 
of  part  or  all  of  the  exudate.  If  this  fails,  make  free  incisions,  irrigate,  drain, 
dress  with  hot  antiseptic  fomentations,  and  employ  Bier's  method  (see  page  122). 
(See  Felon,  page  814.) 

Palmar  Abscess. — We  mean  by  this  term  an  abscess  beneath  the  palmar 
fascia  and  not  a  superficial  collection  of  pus.  Palmar  abscess  may  arise  after 
wounds,  abrasions,  burns,  or  inflammations  of  the  skin  of  the  palm.  A  thecal 
abscess  in  a  flexor  tendon  of  a  finger  travels  rapidly  upward  and  may  produce  a 
palmar  abscess.  A  thecal  abscess  of  either  the  index,  ring,  or  middle  finger 
is  usually  arrested  at  the  lower  end  of  the  palm,  but  suppurative  thecitis  of 
the  thumb  or  the  little  finger  conducts  pus  along  the  tendon-sheath  and  up  the 
arm  fFig.  512).     If  the  theca  ruptures,  pus  is  diffused  over  the  palm.     Abscess 


Fig.   513. — Tuberculous  thecitis  (compound  ganglion). 

produces  great  swelling  of  the  hand  and  fingers,  the  dorsum  being  swollen  as 
well  as  the  palm.  The  fingers  become  flexed  and  rigid.  Violent  pulsatile  pain 
and  decided  constitutional  disturbance  exist.  Discoloration  is  late  in  appear- 
ing. Related  lymph-glands  enlarge.  Palmar  abscess  is  a  most  serious  affec- 
tion. The  pus  may  dissect  up  all  the  structures  of  the  palm,  may  pass  between 
the  bones  and  reach  the  dorsum,  or  may  pass  beneath  the  anterior  annular 
ligament  into  the  connective-tissue  planes  of  the  forearm.  In  some  cases  it 
leaves  a  clawed,  stiff,  and  useless  hand. 

Treatment. — A  palmar  abscess  demands  radical  treatment  at  the  earliest 
possible  moment;  delay  will  be  responsible  for  stiff  and  contracted  fingers  and 
hyperesthetic  skin,  a  damaged  and  perhaps  a  useless  hand.  The  patient 
should  be  placed  under  the  influence  of  ether.  The  incision  is  made  in  the 
line  of  the  metacarpal  bone  and,  if  possible,  below  the  palmar  arches.  A 
line  in  the  transverse  axis  of  the  palm  and  in  line  with  the  palmar  surface  of 
the  fully  extended  thumb  is  distal  to  both  the  palmar  arches.  In  an  incision 
above  this  line  try  not  to  cut  either  arch;  but  if  one  should  be  cut,  at  once 
take  means  to  arrest  the  hemorrhage  (see  page  512).  In  a  severe  case  it  may 
be  necessary  to  make  several  palmar  incisions,  to  open  the  tendon-sheaths 
on  the  flexor  surface  of  the  forearm  above  the  wrist,  and  to  make  counter- 
openings  in  the  back  of  the  hand,  and  it  is  sometimes  necessary  to  introduce 
tubes,  and  drain  through  and  through  the  hand.  After  operation,  if  the 
patient  will  consent  to  enter  the  hospital  use  Dakin's  fluid.  If  the  patient 
refuses  to  enter  the  hospital  apply  hot  antiseptic  fomentations  and  put  the  part 
upon  a  splint.     Bier's  passive  hyperemia  is  very  useful.     When  granulations 


Treatment  of  Chronic  Thecitis  813 

begin  to  form,  dry  dressings  are  substituted  for  hot  moist  dressing.  It  may  be 
necessary  to  give  morphin  for  j)ain,  and  stimulants  may  be  needed.  There  is 
great  danger  of  stiffness  of  the  fingers  occurring,  the  tendons  becoming  adherent 
to  their  sheaths.  Hence  passive  movements  are  inaugurated  as  soon  as  granula- 
tions begin  to  form. 

Chronic  thecitis  may  follow  acute  thecitis,  but  may  be  due  to  injury, 
to  rheumatism,  to  gummatous  infiltration,  to  rheumatoid  arthritis,  or  to  tubercu- 
lous inflammation  of  a  tendon-sheath.    Chronic  thecitis 
is  commonest  in  the  tendons  at  the  wrists,  the  ankles,  r\ 

and   the   knees;   it   may  spread   to  a  joint  or  it  may      — ' 

arise  from  a  tuberculous  joint.     This  condition  causes 


very  little  pain.     In  ordinary  non-tuberculous  thecitis       yy^    \ 

the  part  is  weak,  tender,  painful  and  stiff,  crepitates  '^^— V ^ 

on    motion,    and    is    swollen.     In   tuberculoses  thecitis  \ 

there  is  at  first  distention  of  the  tendon-sheath  with  J 

serum.     The  serum  contains  rice,  riziform,  or  melon-  pj,.  Method  of 

seed  bodies,  and  the  wall  of  the  tendon-sheath  is  here     suturing  the  annular  liga- 
and  there  thickened  and  caseating.     Later  in  the  case     rnent  of  the  wrist. 
the  interior  of  the  tendon-sheath  becomes  lined  with 

tuberculous  granulations  and  a  tuberculous  abscess  may  form.  Rice  bodies  are 
sometimes  fibrinous  masses,  are  sometimes  pieces  of  separated  and  dead 
recently  formed  fibrous  tissue,  and  are  sometimes  masses  of  proliferating  cells. 
In  tuberculous  cases  the  swelling  is  firm  or  doughy  when  due  to  granula- 
tion tissue,  but  is  fluctuating  when  due  to  fluid.  Grating  is  marked.  Tubercle 
bacilli  are  present  in  the  fluid  or  in  the  granulation  tissue.  Tuberculous  thecitis 
is  most  common  about  the  wrist,  constituting  the  so-called  compound  ganglion 
(Fig.  513)- 

Treatment. — Tuberculous  cases  are  treated  as  follows:  If  there  is  a  fluid 
effusion  and  no  rice  bodies,  make  a  small  incision,  wash  out  with  salt  solu- 


FiG.   515. — Ganglion  of  extensor  tendon-sheaths  of  the  wrist. 

tion,  introduce  iodoform  emulsion  or  formalin-glycerin,  and  close  the  wound. 
In  cases  in  which  there  are  rice  bodies,  open  the  sheath,  evacuate  the  con- 
tents, scrape  the  walls  thoroughly,  inject  iodoform  emulsion  or  formalin- 
glycerin,  and  close  the  wound.  (If  the  annular  ligament  requires  division, 
stitch  it  before  closing  the  wound — Fig.  514.)  In  cases  with  extensive  thick- 
ening apply  an  Esmarch  bandage,  make  a  large  incision,  and  remove  all 
infected  tissue  from  the  sheath,  around  the  sheath,  and  from  the  tendon.  In 
tuberculous  thecitis  Bier's  method  (see  page  122)  may  be  of  service  and  so  may 
the  x-rays.  In  ordinary  traumatic  thecitis  use  for  the  first  few  days  rest  asso- 
ciated with  applications  of  ichthyol.     Later  employ  hot  and  cold  douches,  mas- 


8i4 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursa? 


sage  and  passive  movements,  strapping  of  the  part,  inunctions  of  ichthyol,  and 
the  hot-air  bath.  If  eflusion  is  persistent  or  rice  bodies  exist,  make  an  incision 
and  scrape  the  interior  of  the  tendon-sheaths.  In  rheumatic  cases  give  anti- 
rheumatic remedies  and  employ  the  hot-air  bath.  In  syphilitic  cases  administer 
mercury  and  iodid  of  potassium. 

Simple  Ganglia. — In  connection  with  tendon-sheaths  and  joints  simple 
ganglia  may  develop.  They  are  small,  tense,  round  swellings,  which  are  firm, 
grow  progressively  though  slowly,  are  painless  when  uninflamed,  and  contain  a 
fluid  of  the  appearance  and  consistence  of  glycerin- jelly  (Bowlby).  Ganglia  are 
commonest  upon  the  dorsum  of  the  wTist  and  they  occur  especially  in  those 
who  constantly  use  the  wrist  muscles.  Ganglia  are  occasionally  seen  on  the 
dorsum  of  the  foot.  Paget  states  that  a  simple  ganglion  is  due  to  cystic 
degeneration  of  a  synovial  fringe  inside  a  tendon-sheath,  and  that  the  fluid  of 
the  ganglion  does  not  communicate  with  the  fluid  of  the  tendon-sheath.  Other 
pathologists  have  maintained  that  a  simple  ganglion  is  a  hernia  of  synovial 
membrane  through  a  rent  in  a  tendon-sheath,  all  communication  between  the 

herniated  part  and  the  tendon- 
sheath  being  soon  obliterated. 
The  belief  is  now  general  that 
a  ganglion  is  due  to  cystic 
degeneration  of  an  area  of  con- 
nective tissue  adjacent  to  a 
joint  or  a  tendon,  this  area  of 
tissue  having  been  rendered 
extremely  cellular  by  trau- 
matism. A  number  of  minute 
cysts  form  and  they  coalesce 
into  one  cyst.  The  cyst  may 
form  a  secondary  communica- 
tion with  the  interior  of  a 
tendon-sheath  or  joint.  Ganglia 
occasionally  diminish  in  size  or 
even  disappear  spontaneously. 
Treatment. — A  ganglion  is 
treated  by  aseptic  puncture  by 
a  tenotome,  evacuation,  scari- 
fication of  the  walls,  antiseptic 
dressing,  and  pressure.  An 
old-time  method  of  treatment  was  subcutaneous  rupture  brought  about  by 
striking  with  a  heavy  book.  Duplay  treats  a  ganglion  by  injecting  a  few 
drops  of  iodin  through  a  hypodermatic  needle.  The  cyst  is  not  evacuated 
before  injection.  The  parts  are  dressed  antiseptically,  and  cure  is  obtained 
in  one  week.  Recurrent  ganglia,  very  large  ganglia,  and  ganglia  with  very 
thick  contents  should  be  dissected  out. 

Felon,  or  whitlow,  is  a  violent,  rapidly  spreading  pyogenic  inflamma- 
tion of  a  finger  or  a  toe  which  resembles  cellulitis,  and  which  is  sometimes 
followed  by  gangrene  of  the  soft  parts  or  by  necrosis  of  bone  (Fig.  516).  An 
injury  precedes  the  whitlow— an  abrasion  of  the  surface  which  admits  pus- 
organisms  or  a  contusion  which  creates  a  point  of  least  resistance.  The  com- 
monest seat  of  a  felon  is  the  last  digit  of  a  finger  or  the  thumb.  An  abrasion 
of  the  surface  at  this  point  absorbs  pus-organisms  and  the  superficial  lymphatics 
carry  the  bacteria  directly  inward,  the  micro-organisms  lodging,  it  may  be,  in 
the  skin,  in  the  subcutaneous  tissues,  in  the  tendon-sheath,  or  beneath  the 
periosteum.  The  perpendicular  direction  of  the  fibers  of  the  subcutaneous 
tissue  favors  this  passage  inward. 

Felons  are  very  rare  in  infants,  but  may  occur  in  children.     Women  are  more 


Fig.  5i6.^Deep  felon,  with  sloughing  of  soft  parts 
and  necrosis  of  bone. 


Deep  Felons  815 

liable  to  them  than  men.  The  fingers  are  much  more  prone  to  infection  than 
the  toes,  because  they  are  more  exposed  to  injury.  Several  fingers  may  be 
attacked  at  once  or  successively  in  persons  of  dilapidated  constitution.  Whitlow 
is  most  apt  to  occur  and  is  most  severe  in  persons  broken  down  by  disease, 
alcoholism,  overwork,  or  worry.  In  certain  cases  of  neuritis  painless  suppura- 
tion may  arise.  In  syringomyelia  painless  felons  are  common,  and  they  are  apt 
to  be  associated  with  necrosis  of  bone.  Painless  and  destructive'  whitlows 
constitute  a  characteristic  part  of  Morvan's  disease. 

There  are  two  forms  of  felons,  the  superficial  and  the  deep. 

Superficial  Felons. — One  form  of  superficial  felon  is  between  the  cuticle 
and  the  true  skin  and  is  rarely  followed  by  involvement  of  deeper  parts.  The 
infection  is  in  the  skin.  The  point  of  infection  becomes  dark  red,  swollen, 
painful,  and  tender.  The  epidermis  is  lifted  up  into  a  pustule  by  the  seropus 
which  forms,  and  a  considerable  area  may  be  attacked  before  the  spread  of  the 
process  is  arrested.  The  commonest  form  of  superficial  felon  is  subcutaneous 
suppuration,  the  pus  collecting  in  the  fibrofatty  pad  at  the  palmar  surface 
of  the  last  digit  (G.  B.  Mower  White,  in  "Brit.  Med.  Jour.,"  Feb.  24,  1906). 
This  form  often  spreads  deeply.  If  the  subcutaneous  tissues  only  are  involved 
the  symptoms  are  those  of  an  ordinary  cellulitis.  There  is  severe  pain,  increased 
by  motion,  pressure,  and  a  dependent  position.  Swelling  and  discoloration 
are  early  and  marked.  Pus  forms  within  forty-eight  hours.  Paronychia,  or 
ring  around,  is  cellulitis  starting  at  the  end  or  side  of  the  digit,  and  involving 
the  parts  around  and  below  the  nail.  The  pus-organisms  obtain  entrance 
by  means  of  an  abrasion,  a  puncture,  or  an  ulcerated  ''step-mother."  In 
paronychia  pain  is  throbbing  and  violent;  is  increased  by  motion,  pressure,  or  a 
dependent  position;  the  skin  is  dusky  jred,  but  the  swelling  is  slight.  In  about 
forty-eight  hours  pus  forms  in  the  superficial  parts,  the  epidermis  being  lifted 
into  pustules  or  blebs,  and  pus  may  also  form  under  the  nail.  A  portion  of  the 
nail  or  the  entire  nail  may  be  lost. 

If  the  tendon-sheath  becomes  involved  as  well  as  the  subcutaneous  tissue, 
the  symptoms  are  those  of  suppurative  thecitis,  with  more  marked  discoloration 
of  the  skin. 

Deep  Felons  (Fig.  516). — There  are  two  forms  of  deep  felon.  One  is  a 
thecal  suppuration  involving  the  flexor  tendon-sheath,  arising  secondarily  to 
subcutaneous  suppuration  and  spreading  widely.  In  suppurative  thecitis  of 
the  three  middle  fingers  the  process  seldom  reaches  the  palm;  in  suppurative 
thecitis  of  the  theca  of  the  thumb  or  little  finger  the  pus  may  pass  above  the  wrist 
and  a  true  palmar  abscess  may  form  (see  Fig.  512).  Another  form  is  suppura- 
tion beneath  the  periosteum.  This  form  is  the  so-called  hone  felon.  It  is 
occasionally  primary,  but  more  often  arises  secondarily  to  suppurative  thecitis 
or  to  subcutaneous  suppuration.  In  some  cases  a  deep  felon  involves  most  of 
the  structures  of  the  finger  (periosteum,  bone,  tendon,  tendon-sheath,  and 
cellular  tissue),  and  may  destroy  the  digit  or  the  finger.  The  bacteria  causative 
of  a  deep  felon  are  lodged  in  the  deeper  parts.  The  pain  is  agonizing,  entirely 
preventing  sleep,  pulsatile  in  character,  associated  with  excruciating  tenderness, 
greatly  aggravated  by  motion  or  a  dependent  position,  and  often  extend- 
ing up  the  hand  and  forearm.  The  skin  is  dusky  red  and  edematous,  and 
the  part  is  enormously  swollen.  Pus  forms  quickly;  diffuse  cellulitis  may  arise; 
sloughing  of  the  tendon  and  subcutaneous  tissue  may  take  place;  necrosis  of 
one  or  more  bones  may  ensue,  and  in  some  cases  gangrene  of  the  finger  follows. 

In  deep  whitlow  lymphangitis  of  the  forearm  and  arm  is  not  unusual,  adeni- 
tis of  the  axillary  glands  is  common,  and  almost  always  there  is  fever.  In 
superficial  felon  constitutional  symptoms  are  slight  or  absent,  and  lymphangitis 
and  adenitis  arise  in  a  minority  of  cases. 

Treatment. — In  a  subcuticular  felon,  after  cleansing,  soften  the  parts  well  in  an 
antiseptic  fluid  and  then  pare  off  the  cuticle  with  a  very  sharp  knife.     This  plan 


8i6 


Diseases  and  Injuries  of  Muscles,  Tendons,  dud  lUirsae 


of  White's  is  an  excellent  one;  it  gives  vent  to  pus  and  prevents  the  inoculation 
of  the  deeper  tissues  which  may  follow  incision.  In  subcutaneous  suppuration 
incise  the  abscess,  but  be  careful  not  to  open  the  tendon-sheath  or  periosteum, 
as  this  would  diffuse  infection  (White,  in  "Brit.  Med.  Jour.,"  Feb.  24,  1906). 
In  neither  of  the  above  instances  is  it  necessary  to  give  an  anesthetic.  After 
operating,  the  parts  must  be  irrigated,  dressed  with  hot  antiseptic  fomentations, 
the  hand  must  be  placed  upon  a  splint,  and  Bier's  passive  hyperemia  is  to  be 
induced  daily.  In  a  deep  felon  I  am  convinced  that  we  should  operate  imme- 
diately. Allay  tension  and  prevent  pus  formation  by  early  incision.  Do  not 
waste  time  with  poultices;  to  wait  means  agonizing  pain,  sleepless  nights, 
constitutional  involvement,  and,  perhaps,  sloughing  of  tendons  or  death  of  bone. 
Incision  and  drainage  constitute  the  treatment,  but  incision  conducted  in  a  par- 
ticular manner.  I  have  only  lately  learned  how 
to  treat  a  deep  felon.  I  formerly  treated  all 
cases  by  incisions  down  to  the  bone  alongside  of 
the  tendon  (Fig.  517),  and  was  frequently  disap- 
pointed by  a  spread  of  the  suppuration  in  spite  of 
incisions,  by  necrosis  of  bone,  or  by  extensive 
sloughing  of  tendons.  I  obtained  new  light  upon 
this  subject  from  an  article  on  "Whitlow,"  by 
G.  B.  Mower  White  ("Brit.  Med.  Jour.,"  Feb.  24, 
1 906) .  I  immediately  put  in  practice  the  common- 
sense  suggestions  in  this  valuable  article  and  have 
seen  a  surprising  improvement  in  results.  The 
chief  points  in  White's  plan  of  treatment  are  as 
follows:  To  plunge  a  knife  through  an  area  of  in- 
fection into  a  tendon-sheath,  if  that  sheath  is  not 
infected,  will  lead  to  infection,  and  the  way  to  be 
sure  whether  it  is  or  is  not  infected  is  to  look  through 
a  carefully  made  incision  and  see.  After  careful 
sterilization,  anesthetize,  drain  the  extremity  of 
blood  by  elevation,  and  apply  an  Esmarch  band  to 
the  arm.  This  enables  us  to  see  what  we  are  doing. 
Slowly  and  carefully  make  an  incision  by  the  side  of 
the  tendon-sheath  (Fig.  517),  and  on  reaching  it  see  if  it  is  distended.  If  in  doubt, 
insert  a  hypodermatic  needle  and  withdraw  fluid.  If  we  get  turbid  serum,  the 
theca  is  infected.  If  the  theca  is  not  infected,  do  not  open  it,  but  incise  the 
subperiosteal  area  of  suppuration  if  it  exists.  If  the  theca  is  infected,  remember 
that  this  infection  has  surely  ascended  more  or  less,  and  we  must  not  only  open 
at  the  lower  point,  but  must  also  incise  at  the  upper  point.  Do  not  incise  the 
theca  over  the  length  of  the  tendon,  as  sloughing  will  follow.  If  one  of  the  three 
middle  fingers  is  involved,  incise  the  distal  end  of  the  theca  and  also  the  proximal 
end  over  the  head  of  a  metacarpal  bone  in  the  midline,  wash  from  opening  to 
opening,  and  drain.  If  the  theca  of  the  thumb  or  little  finger  is  involved,  open 
distally  and  then  proximally  above  the  wrist.  To  reach  the  proximal  end  of 
the  theca  of  the  thumb  cut  at  the  radial  side  of  the  tendon  of  the  flexor  carpi 
radialis.  Also  open  the  palmar  sac  of  the  flexor  longus  pollicis,  making  the  cut 
along  the  inner  border  of  the  outer  head  of  the  flexor  brevis  pollicis. 

To  reach  the  proximal  end  of  the  theca  of  the  little  finger  begin  an  incision 
at  the  upper  margin  of  the  annular  ligament  and  carry  it  up  along  the  inner 
border  of  the  flexor  sublimis.  Retract  the  tendons  and  pus  will  usually  be 
found  between  the  tendons  of  the  superficial  and  deep  flexor.  Look  beneath 
the  profundus  tendons  for  the  bursa  and  open  it.  Then  open  the  palm  by  an 
incision  in  the  line  of  the  axis  of  the  ring-finger.  Thus  three  openings  are  made 
in  either  case,  and  the  theca  can  be  thoroughly  washed  and  drained.  If  either 
the  thumb  or  little  finger  bursa  is  found  infected,  the  other  must  be  exposed 


Fig.  517. — I,  2,  and  3,  In- 
cisions for  felon  of  finger  and 
for  ordinary  suppuration;  4. 
palmar  incision. 


Bursitis 


817 


and  examined,  as  they  usually  communicate  at  their  proximal  ends  or  a  com- 
munication may  form  as  a  result  of  suppuration.  Rupture  of  either  bursa  may 
diffuse  pus  widely.  White,  in  order  to  prevent  secondary  hemorrhage,  ligates 
the  radial  artery  in  two  places  and  removes  i '  2  inches  of  it  (if  operating  on  the 
thumb  bursa);  and  ligates  the  superficial  arch  and  removes  i  inch  of  it  (if 
operating  on  the  palmar  expansion  of  the  little  finger  theca).  These  arterial 
ligations  seem  a  serious  and  perhaps  unnecessary  addition  to  the  operation  and 
I  have  not  practised  them.  After  thorough  irrigation  apply  antiseptic  fomen- 
tations, splint  the  extremity,  and  induce  Bier's  passive  hyperemia  daily.  If 
the  patient  cannot  sleep,  give  morphin.  See  that  the  bowels  are  moved  once  a 
day.  Give  quinin,  iron,  and  milk-punch.  As  soon  as  granulations  begin  to 
form,  use  dry  dressings  and  make  passive  motion  daily.  If  bone  undergoes 
necrosis,  let  it  loosen  and  then  remove  it.     Amputation  is  sometimes  necessary. 

Bursitis  is  inflammation  of  a  bursa. 
Acute  bursitis  arises  from  strain,  from 
traumatism,  or  from  infection.  The 
symptoms  of  acute  bursitis  are  pain, 
limited  swelling,  moist  crepitus,  fluctua- 
tion, and  discoloration  in  the  anatom- 
ical position  of  a  bursa.  In  chronic 
bursitis  there  is  intermittent  pain,  tender- 
ness, and  progressive,  fluctuating  swell- 
ing. Bursitis  of  the  retrocalcaneal  bursa 
(Albert's  disease)  is  a  painful  afifection 
which  is  often  overlooked.  It  is  rather 
common  in  storekeepers  who  rise  often 
on  the  toes  to  reach  shelves,  in  motor- 
men  who  use  a  foot  gong,  in  street-car 
conductors,  and  in  clerks  who  stand  at 
desks.  It  may  follow^  gonorrhea  and 
may    be    tuberculous.     Walking   causes 

great  pain  in  the  heel.  Raising  up  on  the  toes  is  exceedingly  painful.  It  is 
usually  associated  with  flat-foot.  In  these  cases  osteophytes  often  form  within 
the  bursa.  There  are  numerous  bursae  about  the  hip.  Some  anatomists  count 
twenty-one.^  The  two  most  important  bursae  and  the  ones  usually  affected  are 
the  iliac  and  the  deep  bursa  over  the  great  trochanter.^  Inflammation  of  the 
iliac  or  iliopsoas  bursa  produces  below^  Poupart's  ligament  a  swelling  which 
is  tense,  but  exhibits  fluctuation  on  careful  examination.  Often  the  swell- 
ing attains  large  size.  In  some  cases  the  sac  can  be  emptied  by  pressure,  the 
fluid  passing  into  an  adjacent  bursa  or  into  the  joint.  The  swelling  is  beneath 
the  femoral  artery  and  consequently  lifts  that  vessel  (F.  B.  Lund,  in  "Boston 
Med.  and  Surg.  Jour.,"  Sept.  25,  1902).  The  enlargement  often  presses  on 
the  anterior  crural  nerve  and  causes  spasmodic  pain  throughout  the  nerve's 
trajectory.  The  limb,  according  to  Zuelzer,  is  usually  slightly  flexed,  abducted 
and  rotated  outward,  and  movement  in  an  opposite  direction  causes  pain. 
Inflammation  of  the  bursae  about  the  hip  may  produce  symptoms  resembling 
those  of  incipient  coxalgia,  but  in  bursitis  the  symptoms  do  not  remit,  as  in  hip- 
disease.  Iliopsoas  bursitis  occasionally  results  from  gonorrhea.  The  bursa  is 
sometimes  involved  in  joint-disease.  In  inflammation  of  the  iliac  bursa  flexion 
is  not  so  marked  as  in  coxalgia,  and  the  trochanter  is  never  above  Nekton's 
line.  In  inflammation  of  the  deep  trochanteric  bursa  the  position  is  the  same 
as  in  iliac  bursitis,  and  resembles  that  of  coxalgia.  In  coxalgia,  however,  there 
is  pain  on  pressure  upon  the  front  of  the  joint  or  directly  on  the  trochanter  or  on 
tapping  the  sole  of  the  foot.  These  manipulations  do  not  cause  pain  in  bursitis 
(Zuelzer).  In  inflammation  of  the  gluteal  burscB  there  is  moderate  pain  back 
1  Synnestvedt.  of  Sweden.  -  Zuelzer,  in  "Zeit.  f.  Chir.,"  vol.  1. 

52 


Fig    ti8 — Olecranon  bursitis. 


8i8 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursae 


of  the  thigh  and  knee,  which  disappears  when  the  patient  is  at  rest;  there 
are  a  marked  Ump,  Umitation  of  motion,  and  an  area  of  deep  fluctuation  in  the 
buttock  (Brackett). 

It  is  difficult  to  differentiate 
between  inflammation  of  a  deep 
bursa  and  synovitis;  indeed,  in 
bursitis  the  joint  is  apt  to  be 
secondarily  affected.  This  diffi- 
culty is  especially  vexatious  in 
distinguishing  between  joint- 
injury  and  injury  of  the  bursa 
beneath  the  deltoid.  In  sub- 
deltoid bursitis  there  is  a  tender 
spot  over  the  bursa  when  the  arm 
is  by  the  side.  When  the  surgeon 
abducts  the  patient's  arm  the  bursa 
slips  up  under  the  acromion  and 
no  tender  spot  can  be  found. 
Suppuration  may  take  place  in  a 
bursa.  Direct  force  may  rupture 
a  bursa.  The  bursa  beneath  the 
deltoid  is  frequently  ruptured. 
When  this  accident  happens,  there 
are  pain,  marked  swelling,  a  large 
area  of  moist  crepitus,  and  later 
extensive  discoloration  from  blood.  Chronic  bursitis  may  follow  acute  bur- 
sitis, or  the  disease  may  be  chronic  from  the  start.  It  may  be  due  to  tuber- 
culosis. Bursas  particularly  apt  to  become  tuberculous  are  those  about  the  hip, 
the  subdeltoid,  the  olecranon,  the 
prepatellar,  and  the  retrocalcaneal. 
In  tuberculous  bursitis  during  the 
first  stage  the  bursa  is  distended 
by  fluid,  due  to  oversecretion,  the 
walls  are  thickened  here  and  there, 
and  perhaps  contain  caseous  foci 
and  rice  bodies  are  found  in  the 
bursal  fluid.  In  a  more  advanced 
stage  the  bursal  wall  is  lined  with 
caseating  granulation  tissue  and 
the  bursa  may  become  a  tubercu- 
lous abscess ,  the  walls  may  give  way 
with  diffusion  of  the  process,  or 
mixed  infection  with  pyogenic  or- 
ganisms may  occur.  In  some  cases 
of  tuberculous  bursitis  tending  to 
cure  the  bursal  walls  become  enor- 
mously thickened  by  fibrous  tissue. 
The  symptom  of  chronic  bursitis 
is  swelling  but  little  or  no  pain  un- 
less acute  inflammation  arises. 
Chronic  bursitis  of  the  prepatellar 
bursa  is  known  as  housemaids''  knee 
(Fig.  519).  Chronic  bursitis  of  the 
subhyoid  bursa  is  known  as  Boyer's 

cyst.  There  are  six  bursae  about  the  ham,  the  largest  of  which  is  the  bursa  of 
the  semimembranosus  muscle. 


Fig.  520. — Diagram  from  a  frozen  section. 
Notice  the  deltoid  and  its  origin,  from  the  edge 
of  the  acromion.  Notice  the  subdeltoid  or  sub- 
acromial bursa  with  its  roof  made  by  the  under 
surface  of  the  acromion  and  by  the  fascia  beneath 
the  upper  portion  of  the  deltoid.  Its  base  is  on  the 
greater  tuberosity  and  the  tendon  of  the  supra- 
spinatus,  which  separates  it  like  an  interarticular 
fibrocartilage  from  the  true  joint  (Codman). 


Bursitis  of  the  Subacromial  Bursa 


819 


Treatment. — Acute  bursitis  is  treated  by  rest,  pressure,  and  the  appli- 
cation of  iodin,  blue  ointment,  or  ichthyol.  If  the  swelling  persists,  aspirate 
and  apply  pressure,  or  incise  the  sac  and  remove  it  partly  or  completely. 
If  pus  forms,  incise,  paint  the  interior  of  the  sac  with  pure  carbolic  acid,  and 
pack  with  iodoform  gauze.  Chronic  bursitis  may  be  cured  by  the  use  of  pres- 
sure and  the  application  of  blue  ointment,  and  with  treatment  of  any  causative 
diathesis,  but  most  cases  require  incision  and  packing.  A  ruptured  bursa  is 
treated  as  an  acute  bursitis.  In  bursal  tuberculosis  the  best  treatment  is  exci- 
sion. If  we  are  dealing  with  a  very  deep  bursa  the  proper  treatment  is  incision, 
scraping  with  a  sharp  spoon,  mopping  with  carbolic  acid,  and  packing  with  iodo- 
form gauze. 

Bursitis  of  the  subacromial  bursa  has  been  considered  by  A.  E.  Codman 
("Boston  Med.  and  Surg.  Jour.,"  Oct.  22  and  29,  Nov.  5,  12,  19,  and  26,  and 
Dec.  3,  1908),  who  points  out  that  the  deltoid  and  the  subacromial  bursa  are 
one  and  the  same  thing.  When  the  arm  is  abducted,  the  entire  bursa  is  subacro- 
mial; when  it  is  adducted,  a  large  portion  of  the  bursa  is  subdeltoid.  Codman 
describes  three  types  of  conditions  associated  with  inflammation  of  this  bursa, 
first:  The  acute,  or  spasmodic  type, 
in  which  there  is  local  tenderness 
on  the  point  of  the  shoulder,  just 
below  the  acromion  process  and 
outside  the  bicipital  groove.  In 
some  cases  Dawbarn  has  shown 
that  the  tender  point,  which  is  the 
base  of  the  bursa,  disappears  under 
the  acromion  when  the  arm  is  ab- 
ducted. Codman  goes  on  to  show 
that  in  attempting  abduction 
about  ten  degrees  of  motion  can 
be  obtained  without  moving  the 
scapula.  Then  the  scapula  is 
locked  by  spasm  and  moves  with 
the  humerus.  This  spasm  may  be 
temporary  in  mild  cases.  Some- 
times pain  prevents  the  patient 
from  voluntarily  raising  the  arm, 
though  it  may  be  raised  by  passive 
motion.  The  pain  may  run  down 
the  outer  side  of  the  arm,  even  into 
the  hand;  the  patient  frequently 
locates  the  pain  about  the  insertion 
of  the  deltoid,  and  may  be  able  to 
note  sweUing  of  the  bursa. 

Codman  describes  type  two,  the  subacute  or  adherent  t5^e,  in  which  there 
are  adhesions  between  the  roof  and  floor  of  the  bursa  and  a  definite  mechanical 
hindrance  to  abduction  and  external  rotation.  There  may  or  may  not  be 
local  tenderness,  but  Dawbarn's  sign  is  absent,  owing  to  the  presence  of  the 
adhesions.  Abduction  is  limited  to  such  a  great  degree  that,  as  a  rule,  the 
tuberosity  will  not  pass  beneath  the  acromion.  Any  movement  in  abduction 
beyond  ten  degrees  causes  the  scapula  to  move.  The  pain  is  located  as  in  type 
one,  and  frequently  also  passes  into  the  neck.     In  some  cases  it  is  very  severe. 

Codman 's  third  form  is  the  chronic  and  non-adherent.  In  this  the  full 
arc  of  motion  is  retained,  but  motion  is  painful.  The  bursa  is  thickened  and 
irregular.  There  may  or  may  not  be  local  tenderness;  and  if  this  is  present, 
one  will  find  Dawbarn's  sign.  Abduction  and  external  rotation  are  limited 
little,  if  at  all,  but  at  some  point  during  abduction  there  is  severe  tenderness, 


Fig. 


521. — Showing  incision  used  for  demon- 
stration of  the  bursa  (Codman). 


820 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursa; 


which  disappears  as  soon  as  the  tuberosity  passes  beneath  the  acromion.  The 
scapula  does  not  accompany  the  motions  of  the  humerus.  There  is  often 
considerable  pain  after  motion. 

Codman  points  out  that  the  prognosis  in  type  one  is  very  favorable  if 
treatment  is  correct.  In  type  two  the  disability,  even  without  treatment, 
seldom  lasts  more  than  two  years.     He  says  that  even  se^^ere  or  adherent 


Fig.  522. — Showing  the  abdiulion  splint  in  iH)>itiun,  ihc  patient  standing.  It  is  held  by  a 
figure-of-8  bandage,  which  crosses  behind  the  shoulders  and  by  a  belt  about  the  hips.  The 
arm  is  at  rest  (Codmanj. 

Description  of  Splint. — The  frame  of  the  splint  which  I  use  is  made  of  iron  wire  (diameter, 
J<t  inch),  stiff  enough  to  maintain  its  form  and  to  carry  the  weight  of  the  arm  securely. 
Sufficient  wadding  to  pad  it  thoroughly  is  bandaged  over  it  and  the  whole  covered  with  cot- 
ton or  hnen  cloth.  The  general  shape  is  shown  in  the  photograph.  It  should  be  just  long 
enough  to  extend  from  the  axilla  to  the  seat  of  the  chair  on  which  the  patient  sits.  It  is  best 
held  in  position  by  a  belt  around  the  pelvis  and  a  figure-of-8  flannel  bandage  about  the 
shoulders  crossing  back  of  the  neck.  A  pad  should  be  placed  in  the  opposite  axilla  to  prevent 
excoriation  of  the  skin  by  the  bandage. 

During  the  first  twenty-four  hours  and  afterward,  if  worn  at  night,  the  arm  should  also  be 
lightly  bandaged  to  the  projecting  part  of  the  splint.  Additional  security  is  given  by  the 
application  of  a  swathe,  which  may  be  pinned  to  the  bandage  of  the  axilla. 

When  properly  adjusted  it  is  perfectly  comfortable.  Unless  it  is  comfortable  it  is  useless. 
The  use  of  the  splint  is  not  essential  and  is  even  harmful  if  not  skilfully  cared  for. 

cases,  if  there  are  no  secondary  contractures  in  the  forearm  muscles,  will  recover 
in  from  one  to  two  years.  In  infective  cases  the  prognosis  is  far  worse  than  in 
traumatic  cases.  In  chronic  cases,  in  which  the  arc  of  mobility  is  not  affected, 
the  prognosis  is  fairly  good. 

Treatment. — Acute  cases  of  subacromial  bursitis  should  be  treated  by 
keeping  the  arm  abducted  in  a  .splint  (Fig.  522).     Monks  suggests  that  the 


Miners'  Elbow 


821 


patient  may  sit  by  a  table,  the  arm  being  abducted  and  placed  upon  a  pillow 
that  is  on  the  table.     This  relaxes  the  short  rotators  and  the  deltoid,  and  keeps 


Fig.  523. — Bursitis  of  left  olecranon  bursa  of  three  years'  duration. 


the  base  of  the  bursa  from  being  in  contact  with  the  acromion.  At  night 
Codman  places  the  arm  on  a  pillow,  with  its  long  axis  at  right  angles  to  the 
patient's  body  as  he  lies  recumbent.  If  the  patient  has  to  get  about,  he  may 
use  a  sling  most  cautiously.  He  should 
take  the  arm  out  from  time  to  time  and 
rest  it  on  a  table.  Massage  should  be 
used  about  the  bursa,  but  not  directly 
over  it.  In  the  more  severe  cases  with 
adhesions  one  may  employ  massage,  passive 
and  active  movements,  baking,  forcible 
movement  and  manipulation  under  an 
anesthetic,  followed  by  fixation  in  the 
position  of  abduction  (Fig.  522),  or  per- 
haps incision  of  the  bursa  with  division 
of  the  adhesions  or  excision  of  the  sub- 
deltoid portion  of  the  bursa  (Codman). 
In  the  cases  in  which  there  is  irregularity 
of  the  surface  of  the  bursa,  one  should 
excise  and  remove  the  thickened  folds  or 
other  irregularities. 

Housemaids'  knee  (see  Fig.  519)  is 
thickening  and  enlargement  of  the  prepa- 
tellar bursa,  the  result  of  intermittent  press- 
ure. In  effusion  into  the  knee-joint  the 
fluid  is  behind  the  patella  and  the  bone 
floats  up;  in  housemaids'  knee  the  fluid  is 
above  the  bone  and  the  osseous  surface 
can  be  felt  beneath  it. 

In  bursitis  of  the  deep  infrapatellar 
bursa  the  swelling  is  under  the  ligament 
of  the  patella. 

Miners'  elbow  (Figs.  518  and  523),  which  is  a  condition  similar  to  house- 
maids' knee,  affects  the  olecranon  bursa. 


Fig.  524. — Enlargement  of  the  deep 
infrapatellar  bursa;  chronic  and  the  re- 
sult of  traumatism. 


822  Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursa." 

Weavers'  bottom  is  enlargement  of  the  bursa  over  the  tul^erosity  of  the 
ischium.  A  bursa  which  is  simply  thickened  and  enlarged  rarely  gives  rise 
to  annoyance;  but  when  it  inflames,  as  it  is  apt  to  do,  it  causes  the  ordinary 
symptoms  of  bursitis. 

The  bursa  of  the  semimembranosus  muscle  is  the  largest  one  about  the 
ham.  It  lies  between  the  inner  femoral  condyle  and  inner  head  of  the  gastroc- 
nemius and  the  semimembranosus  muscle.  It  communicates  with  the  knee- 
joint.  When  the  joint  is  flexed,  it  partly  empties  into  the  joint  and  becomes 
small  and  lax.     When  the  joint  is  extended,  it  becomes  large  and  tense. 

Treatment  of  Special  Forms. — Some  few  cases  of  housemaids'  knee  may 
be  cured  by  rest  and  blistering,  but  in  most  cases  it  is  necessary  to  incise  and 
pack  with  iodoform  gauze.  In  enlargement  of  the  bursa  beneath  the  liga- 
mentum  patella,  if  rest  and  bhstering  fail  to  cure,  aspirate  or  incise.  In 
enlargement  of  the  bursa  beneath  the  tendon  of  the  semimembranosus  and 
also  in  "weavers'  bottom"  and  in  "miners'  elbow,"  incise  and  pack.  In 
operating  for  iliopsoas  bursitis  I  follow  Lund's  advice  and  make  a  vertical 
incision  below  Poupart's  ligament,  and  between  the  an- 
terior crural  nerve  and  the  femoral  artery.  The  fibers  of 
the  iliopsoas  muscle  are  separated  and  the  bursa  is  opened 
and  drained.  Some  few  cases  of  retrocalcaneal  bursitis 
recover  after  rest,  but  most  of  them  require  incision  and 
drainage.  If  osteophytic  formations  exist,  the  bony 
stalactites  must  be  removed  by  means  of  the  rongeur. 
Flat-foot,  if  it  exists,  is  treated  by  a  support  (see  page 
833).  The  treatment  of  subacromial  bursitis  is  considered 
on  page  820. 

Fig.    525. — Bigg's   ap-  A  bunlon  is  a  bursa  due  to  pressure,  and  it  is  most 

paratus  for  bunions.  commonly  situated  above  the  metatarsophalangeal  ar- 
ticulation of  the  great  toe,  but  is  occasionally  seen  over 
the  joint  of  another  toe.  When  the  big  toe  is  pushed  toward  the  other  toes 
by  ill-fitting  boots  a  bunion  forms.  When  a  bunion  is  not  inflamed  it  may 
cause  but  little  trouble,  but  when  it  inflames  the  bursa  enlarges  and  the  parts 
become  hot,  tender,  and  exceedingly  painful.  Suppuration  may  occur  and  pus 
mav  invade  the  joint,  and  the  bone  not  unusually  becomes  diseased  and  very 
greatly  enlarged. 

Treatment. — In  treating  a  bunion  the  patient  must  wear  shoes  that  are 
not  pointed,  that  have  the  inner  border  straight,  and  that  have  rounded  toes 
(Jacobson).  For  a  mild  case  a  bunion-plaster  gives  comfort.  Sayre  advises  the 
use  of  a  linen  glove  over  the  toe,  the  toe  being  drawn  toward  the  inner  side  by  a 
piece  of  elastic  webbing,  one  end  of  which  is  fastened  to  the  glove  and  the  other 
end  to  a  piece  of  strapping  from  the  heel.  A  special  apparatus  may  be  worn  (Fig. 
525).  In  many  cases  osteotomy  of  the  first  phalanx  or  of  the  first  metatarsal 
bone  is  required;  in  some  cases  excision  of  the  joint  is  necessary;  in  others 
amputation  must  be  performed.  Charles  H.  Mayo  has  operated  on  65  cases 
successfully.  He  removes  the  head  of  the  metatarsal  bone  and  with  it  two- 
thirds  of  the  hypertrophy  on  the  inner  side,  and  turns  the  bursa  into  the  joint 
area  in  front  of  the  bone.  He  sutures  this  bursa  in  place  and  now  has  a  synovial 
membrane  for  a  joint  which  becomes  satisfactorily  movable  ("Annals  of 
Surgery,"  August,  1908).  When  the  bursa  is  not  inflamed,  but  only  thickened, 
blisters  should  be  employed  over  it,  or  there  should  be  applied  tincture  of  iodin, 
ichthyol,  or  mercurial  ointment.  When  the  bursa  inflames,  ichthyol  oint- 
ment is  applied,  and  intermittent  heat  by  foot-baths  gives  relief.  Suppuration 
demands  immediate  incision  and  antiseptic  dressing.  If  an  ulcerated  bunion 
does  not  heal  by  antiseptic  dressing,  stimulate  it  with  nitrate  of  silver  and  dress 
it  with  unguent,  hydrarg.  nitrat.  (i  part  to  7  of  cosmolin).  Jacobson  recom- 
mends skin-grafting  for  some  cases. 


Subcutaneous  Tenotomy  of  the  Peroneus  Longus  and  Brevis  Muscles     823 

Operations  Upon  Muscles  and  Tendons 

Tenotomy  is  the  cutting  of  a  tendon.     It  may  be  open  or  sttb cutaneous, 

the  open  operation  being  preferred  in  dangerous  regions. 

Open  Division  of  the  Sternocleidomastoid  Muscle  for  Wry=neck. — 

Subcutaneous  tenotomy  for  wry-neck  has  been  largely  abandoned.  It  is  not 
only  more  unsafe  than  the  open  operation,  but  it  never  completely  divides 
all  the  contracted  band. 

The  patient  is  placed  recumbent,  the  chin  being  drawn  more  than  is  habitual 
toward  the  opposite  side.  A  transverse  incision  is  made  over  the  muscle 
about  3^^  inch  above  the  clavicle.  The  superficial  parts  are  divided,  the  muscle 
is  exposed  and  sectioned,  bleeding  is  arrested,  and  the  skin  is  sutured.  Avoid 
the  anterior  jugular  vein,  which  is  underneath  the  muscle,  and  also  the  external 
jugular,  which  is  close  to  the  outer  edge  of  the  muscle.  Mikulicz  advocates 
the  removal  of  almost  the  entire  muscle,  leaving,  however,  the  upper  and 
posterior  portion  where  the  spinal  accessory  nerve  passes.  After  operation  for 
wry-neck  plaster  of  Paris  is  used  to  secure  fixation  for  from  four  to  eight  weeks. 
Then  inaugurate  motions,  active  and  passive. 

Subcutaneous  Tenotomy  of  the  Tendo  Achillis. — This  operation  is  per- 
formed for  club-foot,  in  which  the  heel  is  raised.  The  tendon  is  cut  about  i  inch 
above  its  point  of  insertion.  The  instrument  used  for  the  first  puncture  is  a 
sharp  tenotome.  The  patient  lies  upon  his  back,  "with  his  body  rolled  a 
little  toward  the  affected  side"  (Treves),  the  foot  being  placed  so  that  its  outer 
side  rests  on  a  sand-pillow.  The  surgeon  stands  to  the  outer  side.  The  tendon  is 
rendered  moderately  rigid,  and  a  sharp  tenotome,  with  its  blade  turned  upward, 
is  inserted  along  the  anterior  border  of  the  tendon  until  the  surgeon's  finger 
feels  the  knife  approaching  the  outer  side.  The  sharp-pointed  instrument 
is  withdrawn  and  a  blunt-pointed  tenotome  is  inserted  in  its  place.  The  tendon 
is  drawn  into  rigidity,  and  the  surgeon  turns  the  blade  of  his  knife  toward  the 
tendon,  places  his  finger  over  the  skin,  and  saws  toward  his  finger.  The  tendon 
gives  way  with  a  snap.  Treves  states  that  a  beginner  is  apt  not  to  push  the 
knife  far  enough  toward  the  outside,  or  he  may  in  the  first  puncture  push  the 
knife  through  the  tendon;  in  either  case  the  tendon  is  not  completely  cut. 
Another  method  is  to  insert  the  tenotome  between  the  skin  and  the  tendon 
and  cut  the  tendon  by  a  sawing  motion.  In  this  method  the  danger  of  cutting 
through  the  skin  is  obviated.  The  little  wound,  which  is  covered  by  a  bit  of 
gauze,  will  be  entirely  closed  in  forty-eight  hours.  In  club-foot  cases  after 
tenotomy  some  surgeons  at  once  correct  the  deformity  and  immobilize  the  limb 
in  plaster;  some  partially  correct  the  deformity  and  apply  plaster  for  one  week, 
at  which  time  they  remove  the  plaster,  correct  the  deformity  further,  reapply 
the  plaster,  and  so  on;  other  surgeons  do  not  attempt  correction  of  the  deformity 
until  the  cut  tendon  has  begun  to  unite,  when  they  gradually  stretch  the  new 
material. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Anticus 
Muscle. — The  tendon  is  divided  about  i}-^  inches  above  its  point  of  insertion. 
It  can  be  made  tense  by  extending  and  abducting  the  foot.  The  sharp-pointed 
tenotome  is  entered  upon  the  outside  of  the  tendon,  and  is  passed  well  around 
it.     The  blunt-pointed  tenotome  is  used  to  cut  the  tense  tendon. 

Subcutaneous  Tenotomy  of  the  Tendons  of  the  Peroneus  Longus 
and  Brevis  Muscles. — These  two  tendons  are  cut  together  back  of  the  exter- 
nal malleolus,  and  i}4,  inches  above  the  tip  of  the  malleolus,  so  as  to  avoid  the 
synovial  sheath  (Treves).  The  patient  lies  upon  the  sound  side,  the  outer 
aspect  of  the  deformed  foot  being  upward  and  the  inner  aspect  of  the  ankle 
resting  upon  a  sand-pillow.  A  sharp  tenotome  is  introduced  close  to  the  fibula, 
and  is  carried  around  the  loose  tendons.     A  blunt-pointed  tenotome  is  now 


824 


Diseases  and  Injuries  of  Muscles,  Tendons,  and  Bursa? 


introduced,  its  edge  is  turned  toward  the  tendons,  and  these  structures  are 
cut  as  they  are  made  tense. 

Subcutaneous  Tenotomy  of  the  Tendon  of  the  Tibialis  Posticus 
Muscle. — This  tendon  is  sectioned  above  the  point  where  its  synovial  sheath 
begins;  that  is,  above  the  internal  annular  ligament  (Treves).  The  tendon 
is  made  tense  and  the  pointed  knife  is  entered  above  the  base  of  the  inner 
malleolus.  The  knife  is  entered  just  back  of  the  inner  edge  of  the  tibia,  and 
is  carried  around  the  muscle  and  is  kept  close  to  the  bone.  The  tendon  is 
sectioned  with  a  blunt  knife. 

Subcutaneous  Fasciotomy  of  the  Plantar  Fascia. — The  contracted 
bands  are  discovered  by  motions  which  render  them  tense,  and  they  are 
divided  just  in  front  of  the  attachments  to  the  os  calcis.     The  sharp  knife 

L 


1 


Fic. 


;2b.^Tendon-sutures:   i,  Of  Le  Fort; 
2,  of  Le  Dentu;  3,  of  Lejars. 


Fig.    527. — Anderson's    method    of    tendon- 
lengthening. 


passes  between  the  skin  and  fascia  at  the  inner  side  of  the  sole  of  the  foot. 
Tlte  fascia  is  cut  from  without  inward  by  the  blunt-pointed  tenotome.  It  is 
usually  necessary  to  section  the  fascia  at  more  than  one  point. 

Tendon=sutureand  Tendon=lengthening. — Chromicized  gut,  kangaroo- 
tendon,  or  silk  is  used  for  an  ordinary  case,  silver  wire  for  a  suppurating  wound. 
In  performing  tendon-suture  make  the  part  aseptic  and  bloodless.  It  is  wise 
to  apply  a  rubber  bandage  on  the  proximal  side,  the  bandage  being  applied 
centrifugally,  forcing  the  proximal  end  of  the  tendon  into  view  (Haegler). 
If  searching  for  the  proximal  end  of  a  flexor  of  the  finger,  flex  the  injured  finger 
and  hyperextend  the  adjoining  fingers  (Filiget).     If  this  expedient  fails,  enlarge 

the  incision  or,  what .  is  better,  make  a 
large  flap  in  the  skin.  After  finding  the 
ends,  approximate  them,  being  sure  the 
proper  ends  are  brought  into  contact;  stitch 
them  together  by  a  continuous  suture  or 
by  one  of  the  sutures  shown  in  Fig.  526, 
I,  2,  and  3.  In  a  suppurating  wound  suture  by  silver  wire  should  be  tried, 
though  it  usually  fails.  After  suturing,  remove  the  Esmarch  apparatus,  arrest 
bleeding,  close  the  wound  and  dress  it  antiseptically,  relax  the  parts,  and 
place  the  limb  on  a  splint.  If,  after  suturing,  there  is  much  tension,  stitch  the 
cut  tendon  above  the  sutures  to  an  adjacent  tendon,  and  apply  a  splint,  the  finger 
which  was  injured  being  flexed,  the  others  being  extended.  If  only  the  distal 
end  of  the  tendon  can  be  found,  graft  it  upon  the  nearest  tendon  with  a  like  ana- 
tomical course  and  function.  After  a  tendon  has  been  sutured,  begin  gentle 
massage  in  two  weeks.  Positive  passive  motion  is  begun  in  three  or  four  weeks. 
In  old  injuries,  when  the  ends  cannot  be  brought  into  apposition,  lengthen 
one  end  or  both  ends.  Dr.  J.  Neely  Rhoads  (''Med.  News,"  Nov.  28,  1891) 
suggested  that  slight  lengthening  could  be  accomplished  by  "cutting  half 
through  the  tendon  at  different  levels  and  from  opposite  sides,  lea\ang  some 
longitudinal  fibers  to  slip  on  each  other,  thus  gaining  sHght  elongation"  (H. 


Fig.  528. — Czerny's  method  of  tendon- 
lengthening. 


Tendon-transplantation  and  Silk  Inserts 


Augustus  Wilson,  in  ''International  Clinics,"  vol.  i,  4th  series).  Poncet 
makes  several  zigzag  incisions  on  each  side  of  the  tendon,  and  when  the  tendon 
is  pulled  upon  it  elongates  decidedly.  Bayer's  method  is  shown  in  Fig.  529. 
.\nderson's  open  method  is  the  most  satisfactory  (Fig.  529a).  One  of  these 
methods  of  lengthening  maybe  used  if  there  is  deformity  from  tendon  contraction. 
If  the  tendon  cannot  be  lengthened  sufficiently,  make  a  bridge  of  catgut  from  one 
cut  end  of  it  to  the  other,  or  graft  in  another  tendon  from  one  of  the  lower 
animals,  or  graft  the  distal  end  to  a  tendon  of  like  function  (tendon-grafting). 

The  annular  hgament  is  sutured  as  shown  in  Fig.  514. 

Tendon=transplantation  and  Silk  Inserts. — Tendon-transplantation  is 
the  transplantation  of  the  tendon  of  a  healthy  muscle  to  take  the  place  of  the  tendon 
of  a  paralyzed  muscle.  Silk  inserts  have  been  used  to  take  the  place  of  paralyzed 
muscles,  "to  lengthen  normal  ten- 
dons for  the  purpose  of  using  them 
in  transplanting,  and  to  reinforce 
joints  as  artificial  ligaments,  in 
place  of  arthrodesis"  (James  W. 
Sever,  "Jour.  Am.  Med.  Assoc," 
May  II,  1 91 2).  Tendon-trans- 
plantation is  usually  said  to  have 
been  de^^sed  bv  Nicoladoni  in 
1882 ;  as  a  matter  of  fact,  Duplay     Fig.  529.— Bayer's  method  of  tendon-lengthemng. 

did  the  operation  in  1876,  endeav- 
oring to   secure  function  in  an  arm  rendered  nearly  powerless  by  an  injury 
(Elting,  in  "Albany  Med.  Annals,"  April,  1902). 

The  first  American  surgeon  to  do  the  operation  was  Parrish,  of  New  York, 
who  in  1892  transplanted  tendons  in  a  case  of  club-foot.  In  some  cases  in 
which  a  muscle  has  been  paralyzed  surgeons  have  di\dded  the  tendon  of  the 
paralyzed  muscle  and  have  united  its  distal  end  with  the  tendon  of  a  normal 
muscle,  the  normal  tendon  being  split  to  receive  it.  It  has  also  been  stated 
that  when  a  muscle  or  the  tendon  of  a  muscle  is  sutured  so  as  to  replace  a  para- 
lyzed antagonistic  muscle,  the  transplanted  structure  will  actually  execute  the 
functions  of  the  paralyzed  muscle.  For  instance,  a  flexor,  when  so  transplanted, 
may  become  an  extensor  and  act  under  the  mental  impulse  of  extension;  a 
pronator  may  become  a  supinator  (H.  A.  Wilson,  in  "American  Med.,"  April  8, 

1905).  As  a  matter  of 
fact  the  surgeon  selects  a 
tendon  to  receive  the 
graft,  the  muscle  of  which 
is  nearest  in  action  to  the 
palsied  muscle.  These 
principles  have  been  util- 
ized when  some  or  many 
of  the  muscles  of  a  limb 
have  been  paralyzed,  the 
tendon  of  an  unparalyzed 
muscle  or  the  tendons  of 
an  unparalyzed  group  of  muscles  being  fastened  to  the  tendons  of  the  paralyzed 
muscle.  It  has  been  shown  that  the  success  of  the  procedure  depends  upon  the 
accurac}^  of  diagnosis,  the  division  of  secondary  contractures,  the  correction  of 
existing  deformities,  and  careful  after-treatment.  (See  the  article  by  Dr.  J.  Hilton 
Waterman,  in  "Med.  News,"  July  12,  1902.)  The  muscle  of  the  transplanted 
tendon  must  not  be  put  under  tension.  In  a  paralysis  of  the  lower  extremit}",  as 
Goldth wait  points  out,  the  sartorius  usually  retains  power,  and  it  may  be  ad\-isable 
in  such  a  case  to  di\dde  the  sartorius  and  suture  its  upper  end  to  the  quadriceps 
above  the  patella.     A  strip  of  the  tendo  Achillis  may  be  grafted  upon  the  peronei 


I 


Fig.  529a. — Anderson's  method  of  tendon-lengthening. 


826  Orthopedic   Surgery 

in  certain  cases.  Unfortunately  the  suturing  of  tendon  to  tendon  seldom  holds. 
Experience  has  shown  that  it  is  better,  whenever  possible,  to  make  a  subperiosteal 
insertion  of  a  tendon.  An  artificial  tendon  may  be  made  of  silk,  being  passed 
from  the  sound  to  the  paralyzed  tendon.  This  method  was  devised  by  Auger  in 
1875.  The  silk  must  have  been  boiled  in  paraffin,  otherwise  it  will  slough  out. 
The  silk  eventually  becomes  surrounded  by  fibrous  tissue.  Some  maintain  that 
silk  is  eventually  absorbed.  Lange  showed  that  tendon  regeneration  may  take 
place  along  the  strands  of  silk.  Strands  of  silkworm-gut  may  be  used  for  the 
same  purpose  (Kummell).  It  is  useless  to  make  a  silk  insert  on  a  tendon  in  a 
patient  under  nine  or  ten  years  of  age.  Cooperation  between  surgeon  and 
patient  is  essential  if  we  would  develop  function,  and  cooperation  is  sure  to  be  lack- 
ing before  that  period  of  life.  The  consensus  of  opinion  among  orthopedic 
surgeons  is  that  silk  tendons  should  not  be  used  if  there  is  much  strain  or  trauma. 
Under  active  use  silk  will  be  cast  ofiF  by  a  process  of  noninfective  sloughing 
and,  unless  sufificient  scar  tissue  has  been  formed  by  that  time,  the  result  is 
bound  to  be  a  failure.  The  operation  of  tendon-transplantation  is  occasionally 
of  distinct  benefit,  but  I  agree  with  Ridlon,  and  am  not  usually  sanguine  of 
results.  Ridlon  wisely  reminds  us  that  in  such  cases  much  good  may  perhaps 
result  from  the  proper  use  of  braces,  tenotomy,  and  hand  stretching,  followed 
by  prolonged  retention  in  plaster,  the  patient  using  his  limb  actively, 

Ridlon  points  out  that  most  brace  treatment  is  not  curative  because  it 
only  aims  to  prevent  deformity  developing,  and  tenotomy  and  stretching  fail 
because  they  only  seek  to  remove  existing  deformity.  The  object  should 
be  some  restoration  of  function.  This  is  often  obtained  by  following  Thomas's 
direction  and  "posturing"  the  limb  so  as  to  permit  structural  shortening  of 
the  paralyzed  muscles  and  then  fixing  them  for  months. 

XXII.  ORTHOPEDIC  SURGERY 

This  branch  of  surgery  formerly  dealt  only  with  the  treatment  of  deformi- 
ties by  means  of  mechanical  appliances,  but  of  recent  years  its  domain  has 
been  enlarged  to  include  the  treatment,  surgical  and  mechanical,  of  deformities, 
contractures,  and  many  joint  diseases. 

Torticollis  (wry=neck)  is  a  condition  in  which  contraction  of  certain  of 
the  neck  muscles  causes  an  alteration  in  the  position  of  the  head.  The  deformity 
is  one  sided;  the  sternocleidomastoid  is  the  muscle  chiefly  involved,  though 
the  trapezius,  the  splenius,  and  other  muscles  sometimes  suffer.  Acute  torti- 
collis, which  is  rare,  is  a  temporary  condition,  and  results  from  cold  or  from 
injury  (see  Myalgia).  Chronic  torticollis  may  be  congenital  (due  to  injury 
before  birth  or  during  birth),  may  be  due  to  nerve  irritation,  to  an  assumed 
attitude  because  of  eye  defect,  to  polio-encephalitis  (Golding  Bird),  to  infiam.- 
mation  of  the  glands  or  to  disease  of  the  vertebras,  and  it  ma\-  be  inter- 
mittent, but  is  usually  persistent.  The  muscle  stands  out  in  bold  outline, 
the  head  is  turned  to  the  opposite  side,  the  ear  of  the  affected  side  is  turned 
toward  the  shoulder,  the  chin  is  thrown  forward,  and  spinal  curvature  may 
arise.  The  corresponding  side  of  the  face  becomes  distorted.  Secondary 
facial  changes  result  from  Nature's  effort  to  balance  the  face  and  keep  the  eyes 
on  a  level,  in  accordance  with  Wolff's  law.  When  the  muscular  deformity  is 
over-corrected  the  face  again  becomes  symmetrical.  There  is  no  pain.  In 
many  cases  the  head  may  be  restored  to  its  normal  position  by  passive  move- 
ment or  by  voluntary  effort,  but  it  at  once  returns  to  its  habitual  position. 
Mikulicz  asserts  that  torticollis  is  a  chronic  fibrous  myositis,  due  often  to  com- 
pression during  labor.  He  further  says  that'  the  lesion  known  as  hematoma 
of  the  sternomastoid,  which  occasionally  follows  labor,  is  not  hematoma, 
but  thickening  due  to  myositis.     D'Arcy  Power  reported  the  autopsy  on  a 


Treatment  of   Torticollis  827 

child  one  month  of  age.  The  sternomastoid  muscle  contained  a  fibrous  mass, 
the  result,  Power  believes,  of  a  hemorrhage  into  the  muscle  prior  to  birth 
("Med.  Chir.  Trans.,"  vol.  Ixxvi).  Power,  Glutton,  and  Owens  have  all  traced 
cases  of  hematoma  of  the  sternomastoid  from  early  infancy  to  the  time  when 
tenotomy  was  required  for  torticollis.  W.  W.  Richardson  ("Surg.,  Gynec, 
and  Obstet.,"  1906)  believes  that  interstitial  myositis  is  always  present,  but 
doubts  the  causal  influence  of  the  lateral  position  of  the  head  in  titero.  In 
some  cases  hereditary  influence  is  evident.  One  woman  gave  birth  succes- 
sively to  7  wry-necked  children  (Nove-Jusserand  and  Vianny,  in  "Revue  D'- 
Orthop.,"  1906).  Many  writers  advocate  the  ischemic  theory  as  explanatory 
of  the  causation  of  torticollis.  This  theory  is,  that  during  labor  lateral  flex- 
ion of  the  head  with  elongation  of  the  neck  or  lateral  flexion  with  torsion  pro- 
duces occlusion  of  the  sternomastoid  branch  of  the  superior  thyroid  artery, 
which  vessel  supplies  the  sternocleidomastoid  muscle  (see  Tubby's  "Orthop. 
Surgery").  In  congenital  torticollis  the  muscle  and  the  cervical  fascia  are 
shortened,  and  the  muscle  does  not  relax  under  the  influence  of  an  anesthetic. 
In  torticollis  due  to  rheumatism  and  reflex  causes  the  tonically  contracted 
muscle  relaxes  when  the  patient  is  anesthetized.  In  spasmodic  wry-neck  the 
muscle  is  thrown  repeatedly  into  clonic  contractions. 

Symptoms. — Congenital  wry-neck  is  due  to  central  nervous  disease,  to 
spinal  deformity,  or  to  injury  during  birth,  and  in  this  form  the  sternomastoid 
is  shortened,  hardened,  and  atrophied.  It  may  not  be  noticed  for  some  years 
because  of  the  short  neck  of  infancy.  It  is  associated  with  asymmetrical 
development  of  the  face,  and  is  almost  invariably  upon  the  right  side.  Spas- 
viodic  wry-neck  may  present  tonic  spasm  only,  intermittent  spasm  alone, 
or  both  may  appear  alternately.  It  sometimes  arises  in  those  whose  occupa- 
tion demands  frequent  rotation  of  the  head,  but  more  often  no  such  cause 
can  be  discovered.  It  is  probably  a  disease  of  the  cortical  area  which  presides 
over  rotation  of  the  head.  (See  article  by  C.  .A.  Hamann,  in  "Buffalo  Med. 
Jour.,"  Dec,  1901.)  It  is  a  disease  especially  of  adults;  in  women  it  is  often 
linked  with  hysteria.  Pahl  ("California  State  Med.  Soc,"  1906)  analyzed 
68  reported  cases.  Men  and  women  appeared  equally  liable,  it  was  most 
frequent  between  the  ages  of  twenty  and  thirty,  and  the  right  side  was  affected 
in  twice  as  many  cases  as  the  left  side.  The  exciting  cause  may  be  a  cold, 
a  blow,  or  a  mental  storm;  the  predisposing  cause  is  the  neurotic  tempera- 
ment. It  may  be  due  to  enlarged  glands,  to  carious  teeth,  or  to  eye-strain. 
In  some  rare  cases  bilateral  spasm  occurs,  the  head-  being  pulled  backward 
and  the  face  being  turned  upward.  Clonic  spasms  may  come  on  unannounced, 
or  they  may  be  preceded  by  pain  and  stiffness;  the  head  can  be  held  still  for  a 
moment  only;  there  is  sometimes  pain,  always  fatigue,  but  during  sleep  the 
contractions  cease.  The  attack  will  probably  pass  away,  but  will  recur  almost 
certainly. 

Treatment. — Congenital  wry-neck  is  treated  by  myotenotomy  through  a 
superficial  incision  which  is  vertical  or  transverse  (see  page  823).  The  muscle 
and  fascia  are  divided  in  a  line  parallel  to  and  just  above  the  clavicle  or  just  below 
the  mastoid  attachment.  The  flaps  are  raised,  access  is  free  to  the  origin  of  the 
muscle,  the  muscle  is  readily  divided.  Any  bands  should  be  thoroughly  kneaded 
and  stretched  and  the  head  should  be  twisted  into  a  position  which  over-corrects 
the  deformity.  The  wounds  in  the  skin  and  fascia  are  closed.  This  incision 
leaves  a  trivial  scar.  After  operation  plaster  of  Paris  is  used  to  secure  fixation 
and  fixation  is  maintained  from  four  to  eight  weeks.  Early  operation  favors 
the  establishment  of  muscular  co-ordination  before  the  development  of  perma- 
nent bony  deformity  of  the  vertebrae.  Some  surgeons  cut  the  scalene  muscles 
as  well  as  the  sternocleidomastoid.  Gerdes  Rowland  lengthens  the  sternomas- 
toid and  carefully  sutures  it  ("Practitioner,"  Sept.,  1908).  The  old  subcu- 
taneous myotenotomy  should  be  abandoned,  as  aseptic  incision  enables  the 


828 


Orthopedic  Surgery 


surgeon  to  see  and  to  feel  all  the  contracted  bands  of  fascia,  muscle,  and  tendon, 
and  to  avoid  vital  structures  (see  page  823).  In  spasmodic  wry-neck  there 
is  a  fair  chance  of  recovery.  Pahl's  table  {Loc.  cil.)  shows  that  out  of  68 
cases,  28  recovered,  17  were  improved,  and  11  were  not  improved  by  treat- 
ment. Results  in  12  were  not  stated.  Treat  the  neurotic  temperament  and 
remove  any  obvious  irritation  (eye-strain,  carious  teeth,  enlarged  glands). 
Drugs  usually  are  practically  useless,  although  Chas.  S.  Potts  reported  a  cure 
after  the  hypodermatic  use  of  atropin.  The  rest  cure  is  sometimes  beneficial. 
Tenotomy  is  not  to  be  employed.  In  1890  Mayo  Collier  suggested  ligation  of 
the  spinal  accessory  nerve  with  silver  wire.  In  persistent  cases  stretch  or 
divide  and  exsect  a  part  of  the  spinal  accessory  nerve  (Keen).  To  reach  this 
nerve    make  an  incision   along  the  posterior  edge  of  the  sternocleidomastoid 

muscle,  find  the  nerve  as  it  emerges  from 
under  the  middle  of  the  muscle,  about 
1^4,  inches  below  the  tip  of  the  mastoid 
process,  retract  the  muscle  at  this  point, 
and  remove  at  least  i  inch  of  nerve. 
Neurectomy  of  the  spinal  accessory  nerve 
paralyzes  the  sternocleidomastoid  muscle, 
in  spite  of  the  fact  that  that  muscle  has 
also  a  nerve-supply  from  the  cervical 
nerves.  The  paralysis  is  followed  by 
atrophy,  and  if  the  spasm  affected  the 
sternomastoid  muscle  only  the  operation 
will  cure  the  case.  Unfortunately,  other 
muscles  are  usually  involved,  and  cure  will 
only  be  obtained  by  performing  neurectomy 
on  the  nerves  which  innervate  the  affected 
muscles.  (For  the  treatment  of  rheumatic 
wry-neck,  see  Myalgia,  page  801.) 

Dupuytren's  contraction  was  first 
described  by  Sir  Astley  Cooper.  In  1831 
Dupuytren  made  the  first  dissection  of  a 
case  (Black,  in  "Brit.  JNIed.  Jour.,"  1915,  i). 
It  is  a  fibrosis  and  contraction  of  the 
palmar  fascia,  of  its  digital  prolongations,  and  of  the  fibers  joining  the  fascia  and 
skin  without  any  inflammation  of  the  skin.  The  process  starts  in  the  digital  pro- 
longations. Fixed  contraction  of  one  or  more  fingers  occurs  (Fig.  530).  The 
ring-finger  and  the  little  finger  most  often  suffer,  but  any  finger  or  the  thumb 
may  be  involved.  The  condition  may  be  symmetrical.  It  is  far  more  common 
in  men  than  in  women.  The  disease  arises  oftenest  in  men  beyond  middle  age, 
but  is  sometimes  met  with  in  youths.  The  cause  of  this  disease  is  unknown ;  some 
refer  it  to  gout,  rheumatism,  or  osteo-arthritis;  others,  to  traumatism,  syphilis, 
organic  nervous  diseases,  arteriosclerosis,  reflex  irritation,  or  neuritis.  In  one- 
fourth  of  the  cases  heredity  seems  to  be  influential.  If  due  to  traumatism,  the 
right  hand  should  suffer  most  frequently;  but  it  occurs  in  the  left  hand  nearly 
as  often  as  in  the  right  (P.  Jansen,  in  "Arch.  f.  klin.  Chir.,"  Bd.  Ixvii,  H.  4). 
Working  men  are  not  more  liable  to  it  than  others.  Jansen  examined  speci- 
mens from  7  cases  and  found  connective-tissue  hypertrophy  and  circulatory 
disturbance,  the  contraction  being  a  result  of  the  above-named  processes. 

Symptoms. — Dupuytren's  contraction  is  indicated  by  a  small  hard  lump 
or  crease  which  appears  over  the  palmar  surface  of  the  metacarpophalangeal 
joint.  This  nodule  grows  and  the  corresponding  finger  is  gradually  pulled 
down.  In  some  cases  the  tip  of  the  finger  is  forced  against  the  palm.  The 
skin  becomes  dimpled  or  puckered.  In  some  cases  the  interphalangeal  joints  of 
the  contracted  finger  dislocate. 


530' 


—Dupuytren's  contraction  ot 
the  middle  finger. 


Trigger-tinger  or  Jerk-linger 


Treatment. — Fibrolysin,  which  is  a  soluble  combination  of  thiosinamin  and 
salicylate  of  sodium,  has  been  used  hypodermatically  in  Dupuytren's  con- 
traction and,  it  is  claimed,  with  success  (Schwalbach).  In  very  slight  and 
early  cases  the  wearing  of  a  splint  at  night,  associated  with  daily  manipulation 
and  massage  retards  the  development  of  the  deformity.  In  treating  Dupuy- 
tren's contraction  subcutaneous  multiple  incisions  may  be  made,  the  tense 
fascia  and  the  fasciocutaneous  fibers  being  cut.  The  finger  is  straightened 
and  is  placed  upon  a  straight  splint,  which  is  worn  continuously  for  a  week 
or  ten  days  and  is  worn  at  night  for  at  least  a  month.  A  more  satisfactory 
operation  is  that  of  Keen.  He  divides  the  skin  by  a  V-shaped  cut,  the  base 
of  the  V  being  downward,  lifts  up  the  flap,  and  dissects  out  the  contracted 
tissue.  A  valuable  method  is  that  of  McCurdy.  He  makes  a  long  incision 
which  crosses  the  contracture  obliquely,  stretches  thoroughly,  closes  the  wound, 
and  keeps  up  mechanical  fixation  for  a  time.  A  cure  is  most  certain  to  be 
obtained  by  Lexer's  radical  operation.  This  surgeon  excises  the  entire  aponeu- 
rosis and  considerable  portions  of  the  palmar  skin  adherent  to  the  aponeurosis. 
In  order  to  cover  this  wound  it  may  be  necessary  to  slide  a  pedunculated  flap 
into  the  raw  surface. 

Syndactylism  (webbed  fingers)  is  always  congenital,  and  may  persist 
through  several  generations.  Simple  incision  of  the  web  is  useless;  the  opera- 
tion to  be  performed  is  that  of  Agnew  or  of  Diday  (Figs.  531,  532). 


Fig.  531. — Agnew's  operation  for  webbed 
fingers  (Pye). 


Fig. 


532. 


-Diday's    operation    for    webbed 
fingers  (Pye). 


In  Agnew's  operation  a  flap  of  skin  from  the  dorsum  is  inserted  between 
the  fingers  and  sutured  in  place. 

In  Diday's  operation  a  flap  is  taken  from  the  dorsal  surface  and  another 
flap  is  raised  from  the  palmar  surface,  and  each  flap  is  sutured  to  the  finger 
to  which  it  is  attached. 

Polydactylism  (supernumerary  digits)  is  always  congenital,  is  often 
hereditary,  and  is  usually  symmetrical.  There  may  be  an  incomplete  digit,  or 
there  may  be  an  entire  and  well-developed  finger  or  toe  with  a  metacarpal 
or  metatarsal  bone.  The  connection  to  the  metacarpus  or  metatarsus  may 
be  by  a  fibrous  pedicle  only.  If  the  digit  is  complete,  with  a  metacarpal  bone, 
no  operation  is  required;  if  it  is  incomplete  or  is  ill-developed,  it  should  be 
removed. 

Trigger=finger  or  Jerk=finger  (Lock=finger,  Snapping=finger). — ^The 
patie  nt  can  usually  close  the  fingers ,  but  on  trying  to  open  them  one  finger  remains 
closed.  It  can  be  opened  by  grasping  it  with  the  other  hand,  but  flies  open  with  a 
snap,  like  an  opening  blade  of  a  pen  knife  (Abbe).  In  some  cases  two  fingers  are 
involved.  In  a  reported  case  (Frederick  Grifiith,  "Annals  of  Surgery,"  1904)  the 
ring  and  middle  fingers  of  the  left  hand  locked  at  the  knuckle-joints  on  attempt- 
ing flexion.  The  locking  occurred  when  about  one-third  the  amount  of  flexion 
necessary  to  grasp  an  object  was  achieved.  By  bending  the  fingers  with  the 
other  hand  unlocking  was  accomplished  and  flexion  was  finished  voluntarily. 
In  attempting  extension  blocking  occurred  at  the  same  point  and  unlocking 
was  accomplished  in  the  same  manner.  In  most  cases,  but  not  in  all,  there  is 
pain  when  locking  occurs.     The  condition  is  gradual  in  onset.     Trigger-finger 


830  Orthopedic  Surgery 

is  often  associated  with  rheumatism  (in  52  cases  out  of  121,  according  to 
Necker),  It  is  said  by  Tubby  to  be  due  to  enlargement  of  the  flexor  tendon, 
or  to  contraction  of  the  groove  in  the  transverse  Hgament  in  the  palm.  It  may 
be  due  to  a  ganglion,  enchondroma,  or  tenosynovitis.  Traumatism  or  irritation 
may  produce  it.  The  tendon-sheath  may  be  thickened  or,  according  to 
Marcano,  there  may  be  a  nodule  on  the  tendon  which  rubs  against  the 
sesamoid  bone.  It  may  result  from  occupation.  Abbe  seems  to  prove  that 
the  trouble  is  in  the  flexor  tendon  which  "crumples  up  as  a  tape  might 
crinkle  when  slack  above  a  slot. "  It  catches  under  the  transverse  fibers  ("Med. 
Record,"  March  27,  1914). 

freatment. — If  a  gangUon,  a  loose  cartilage,  or  a  tendon  nodule  exists, 
treat  by  excision.  A  sesamoid  bone  may  be  excised.  If  there  is  inflammation, 
use  massage  and  counterirritation.  Abbe  recommends  a  very  simple  and  effect- 
ive operation.  Subcutaneous  division  of  the  constricting  fibers  is  the  plan  of 
Abbe.  The  cut  is  in  the  direction  of  the  tendon  (''Med.  Record,"  March  7, 
1914).  If  there  is  no  obvious  cause,  put  a  compress  over  the  tunnel  in  the 
ligament  and  apply  a  splint.  A  short  splint  supporting  the  proximal  phalanx 
and  running  into  the  palm  may  be  worn  like  a  finger  ring.  Prolonged  rest  so 
obtained  may  stop  the  tendon's  tendency  to  crinkle. 

Mallet-finger. — This  is  called  also  drop- finger,  dropped  phalangette,  and 
rupture  of  the  extensor  tendon.  It  is  due  to  a  blow  in  the  direction  of  flexion 
when  the  finger  is  extended.  It  is  supposed  to  be  due  partly  to  stretching  and 
partly  to  rupture  of  the  extensor  tendon  at  the  point  at  which  it  is  the  posterior 
ligament  of  the  distal  interphalangeal  joint.  Abbe  has  shown  that  baseball 
players  are  liable  to  a  condition  which  is  the  reverse  of  this,  in  which  the  last 
phalanx  is  dislocated  backward  (baseball-finger).  Drop-finger  is  treated  by 
incision  and  suture  of  the  tendon  to  the  periosteum. 

Genu  valgum  (knock=knee)  results  from  an  unnatural  growth  of  the 
internal  femoral  condyle  or  of  the  internal  part  of  the  head  of  the  tibia,  or  from 
absorption  or  atrophy  of  the  external  femoral  condyle  or  of  the  external  part 
of  the  head  of  the  tibia.  Any  of  these  conditions  causes  the  shaft  of  the  femur 
to  curve  inward  and  the  internal  lateral  ligament  of  the  knee-joint  to  stretch,  the 
knees  coming  close  together  and  the  feet  being  widely  separated.  The  condition 
may  also  be  caused  by  cur\-ing  of  the  tibial  shaft  just  below  the  epiphysis.  This 
deformity  is  usually  noted  when  the  child  begins  to  walk,  but  it  may  not  appear 
until  puberty  or  even  long  after.  Knock-knee  may  arise  from  rickets,  from  an 
occupation  demanding  prolonged  standing,  or  from  flat-foot.  It  may  occur  in 
one  knee  or  in  both  knees. 

Treatment. — Mild  rachitic  cases  of  knock-knee  may  remain  in  slight  de- 
formity, or  may  get  well  from  improvement  of  the  general  health,  though  they 
seldom  do.  In  an  early  case  properly  applied  braces  will  correct  deformity. 
In  a  later  case  operation  will  be  necessary.  In  ordinary  cases  simply  treat  the 
rickety  condition.  The  patient  is  forbidden  to  stand  or  to  walk,  and  the  limb, 
after  being  put  as  straight  as  can  be,  is  fixed  on  an  external  splint  and  a  pad  is 
put  over  the  inner  condyle.  Later  in  the  case  plaster  of  Paris  is  used.  Some 
surgeons  prefer  to  immobilize  while  the  leg  is  flexed  to  a  right  angle  with  the 
thigh.  In  a  severe  case  the  surgeon  can  immobilize  after  forcibly  straightening 
(causing  an  epiphyseal  separation)  or  after  the  performance  of  osteotomy  (see 
page  778).  Osteotomy  is  preferable  to  fracture  by  a  mechanical  appliance 
(osteoclasis). 

Genu  varum  (bow=legs)  is  the  opposite  of  knock- knee.  It  tends  much 
more  to  self-correction  than  knock-knee  because  of  the  arrangement  of  the 
thigh  muscles,  the  powerful  adductors  acting  strongly  on  the  knee  and  mid- 
dle of  the  leg  (J.  Torrance  Rugh,  in  "Am.  Jour.  Orthop.  Surg.,"  April,  1908). 
Usually  both  legs  are  bowed  out,  the  knees  being  widely  separated,  the  tibiae 
and  femora,  as  a  rule,  being  curved,  and  the  feet  being  turned  in.     This  disease 


Talipes 


831 


Fig.  533. — Club-hand. 


in  early  life  is  due  to  rickets,  the  weight  of  the  body  producing  the  deformity. 
In  older  people  incurable  bow-legs  may  arise  from  osteitis  deformans. 

Treatment. — Some  mild  cases  of 
genu  varum  recover  as  a  result  of 
improvement  in  the  health.  Or- 
dinary cases  are  treated  by  braces, 
by  plaster-of-Paris  bandages,  and 
by  attention  to  the  general  health. 
Braces  usually  suffice  prior  to  three 
andahalf  years  of  age.  Later,  when 
the  bones  have  hardened  in  severe 
deformity,  osteotomy  is  necessary 
and  should  be  done  at  the  apex 
fo  the  curve. 

Club=hand  (Fig.  533)— A 
congenital  deformity  in  which  the 
hand  deviates  from  the  normal  re- 
lation to  the  forearm.  It  is  usually 
associated  with  other  deformities. 
In  some  cases  the  radius  and  pos- 
sibly some  of  the  carpal  bones  are 
absent. 

Treatment. — By  massage  and 
passive  motion,  by  immobilization, 
by  tenotomy  or  osteotomy,  or  by 
bone-grafting. 

Talipies  (club=foot)  is  a  per- 
manent deviation  of  the  foot  into  deformity.  There  are  several  forms:  talipes 
egwi/m5J(Fig.  535)  is  a  confirmed  plantar  flexion;  talipes  calcaneus  (Fig.  536)  is  a 
confirmed  dorsi-flexion;  talipes  varus  is  a  confirmed  adduction  and  to/i_pe5  i!a/gM.y 

is  a  confirmed  abduction.  Two  of 
these  forms  may  be  combined,  as  in 
talipes  equinovarus  (Fig.  537),  talipes 
equinovalgus,  tahpes  calcaneo varus, 
and  talipes  calcaneo  valgus.  The 
causes  of  talipes  are  congenital  or 
acquired.  The  congenital  form  may 
be  due  to  persistence  of  the  fetal  form 
of  the  foot.  There  are  three  theories 
of  the  cause  of  the  deformity:  viz., 
the  nervous  theory,  the  mechanical 
theory  (intra-uterine  pressure),  and 
arrest  of  development.  Acquired 
cases  may  arise  from  infantile  paraly- 
sis, from  spastic  contractions,  from 
cicatrices,  from  traumatisms,  from 
arrest  of  bony  growth  following  upon 
the  inflammation  of  bone,  or  from 
hysterical  contractures. 

Talipes  equimis  is  rarely  con- 
genital. In  this  condition  the  patient 
walks  upon  the  toes  and  cannot  bring 
the  heel  to  the  groimd. 

Talipes  Calcaneus. — The  patient 
walks  upon  the  heel  and  cannot  bring  the  toes  to  the  ground.  In  congenital 
cases,  the  flexors  of  the  foot  are  shortened  and  the  tendo  Achillis  is  lengthened. 


Fig.  534. — Deformities  of  hands  and  feet. 


832 


Orthopedic  Surgery 


In  paralytic  cases  the  dorsal  flexors  are  normal  and  the  muscles  which  act 
upon  the  tendo  Achillis  are  paralyzed. 

Talipes  varus  is  seldom  seen  without  equinus.  In  this  condition  the 
patient  walks  on  the  outer  edge  of  the  foot. 

Talipes  valgus  is  met  with  in  flat-foot.  The  patient  walks  on  the  inner 
edge  of  the  foot. 

Talipes  Equinovarus. — The  heel  is  raised  and  the  patient  walks  upon  the 
outer  edge  of  the  foot.     This  is  the  usual  congenital  form. 

Talipes  equinovalgus  is  very  rarely  congenital.  The  heel  is  raised  and  the 
patient  walks  upon  the  inner  side  of  the  foot. 

Talipes  calcaneovarus  is  a  combination  of  calcaneus  and  \-arus. 

Talipes  calcaneovalgns  is  a  combination  of  calcaneus  and  valgus  and  commonly 
follows  infantile  paralysis. 

Treatment. — In  congenital  cases  the  condition  is  usually  manifest  on 
both  sides,  and  is  nearly  always  talipes  equinovarus.  It  is  better  that  both 
sides  should  be  affected,  as  the  feet  wall  then  be  symmetrical  through  life.  Con- 
genital club-foot  should  be  treated  in  infancy,  and  when  a  restoration  to  position 
can  be  effected  by  the  hands  of   the  surgeon,  is  treated  by  plaster-of-Paris 


Fig.     535. — Talipes     Fig.  536. — Talipes  cal-       Fig.  537. — Double  equinovarus  ("American 
equinus  (Albert).  caneus  (.Albert).  Text-Book  of  Surgery"). 

bandages.  If  a  child  has  begun  to  walk,  it  may  still  be  possible  to  correct  the 
deformity  eventually  by  manipulations,  by  plaster-of-Paris  bandages,  or  bv 
club-foot  shoes,  but  most  cases  require  tenotomy  of  the  tendo  Achillis  and  other 
contracted  structures  before  the  application  of  the  shoe  or  the  plaster.  The 
club-foot  shoe  may  do  good  service,  but  in  many  instances  it  is  painful  and  is  not 
so  efficient  as  plaster  of  Paris.  In  severe  cases,  before  applying  the  plaster,  the 
patient  is  given  ether;  the  surgeon  cuts  the  tendons  of  the  anterior  and  posterior 
tibial  muscles,  the  plantar  fascia,  the  tendo  Achillis,  and  the  long  flexor  of  the 
toes,  in  the  order  named,  and  forcibly  corrects  the  deformity.  In  all  cases  of 
congenital  club-foot  the  secret  of  successful  treatment  is  the  daily  stretching  of 
the  foot  after  operative  correction.  In  old  cases,  with  alteration  in  the  shape 
of  the  bones,  cuneiform  osteotomy,  or  the  removal  of  the  cuboid  or  other 
tarsal  bones,  may  be  indicated.  Buchanan  employs  subcutaneous  division 
of  all  resistant  structures.  Occasionally,  in  relapsed  and  inveterate  cases, 
astragalectomy  is  performed.  It  is  seldom  practised  upon  young  children 
(see  page  795).  In  some  cases  of  talipes  calcaneus  shortening  of  the  tendo 
Achillis  is  advised;  but  such  an  operation  is  only  of  temporary  value,  as  stretch- 
ing occurs  after  two  years  or  more.  In  talipes  due  to  infantile  paralysis  the 
operative  treatment  is  the  same,  but  we  should  not  immobilize  in  plaster, 
but  rather  in  some  apparatus  which  can  easily  be  removed  to  permit  the  use 
of  massage  and  electricity.  In  paralytic  cases  tendon-transplantation  is 
occasionally  employed.  This  consists  in  transferring  the  tendon  of  an  active 
muscle  so  that  it  will  take  the  place  of  the  tendon  of  a  paralyzed  muscle.  The 
transferred  tendon  should  alw3,ys  be  attached  to  the  periosteum  (Tubby  and 
Jones  on  the  "Surgery  of  Paralysis"). 


Treatment  of  Pes  Planus 


^35 


Pes  planus  (flat=foot)  is  a  condition  in  which  there  is  loss  of  the  arch  of 
the  foot  due  to  muscuhir  paralysis  or  ligamentous  weakness,  to  prolonged 
standing,  or  to  trauma.  Flat-foot  is  especially  apt  to  occur  in  rickets.  Spu- 
rious flat-foot,  or  i nji a inmatory  flat-foot,  occurs  in  Pott's  fracture  and  in  inflam- 
mation of  the  ankle-joint  or  of  the  tendon  of  the  peroneus  longus  muscle. 
Paralytic  flat-foot  is  seen  after  infantile  paralysis.  Static  flat-foot  is  due  to  dis- 
proportion between  the  body  weight  and  the  support  of  that  weight.  All 
children  are  born  with  pronated  feet;  the  arch  usually  begins  to  form  soon 
after  birth,  but  in  some  individuals  it  never  forms.  Flat-foot,  according  to 
de  Vlaccos,  is  thus  produced:  If  we  suppose  a  straight  line  prolonged  downward 
from  the  center  of  the  leg,  most  of  the  astragalus  and  os  calcis  will  be 
external  to  it;  hence  the  body  weight  presses  on  the  inner  side  of  the  foot, 
and  tends  to  flatten  the  arch  and  cause  outward  rotation,  tendencies  which 
are  antagonized  by  the  flexors  of  the  toes  and  by  the  tibialis  posticus  muscle. 
The  OS  calcis  is  pronated  and  is  pushed  to  the  side,  the  astragalus  moves  after 
the  OS  calcis,  and  the  ligaments  are  stretched  ("Rev.  de  Chir.,"  Aug.,  1901). 
A  very  common  cause  is  contraction  of  the  tendo  Achillis.  In  childhood  the 
condition  is  seldom  recognized,  but  in  an  adult  with  con- 
tracted Achilles  tendon  long  hours  of  standing  will  quickh- 
precipitate  the  acute  symptoms  of  flat-foot.  Pes  planus  is 
productive  of  much  pain  upon  standing  or  walking;  in  fact, 
the  indi\'idual  may  be  completely  crippled.  Pain  is  quickly 
relieved  upon  sitting  down.  Walking  upon  the  toes  is  not 
painful.  A  marked  flat-foot  can  at  once  be  recognized  by 
wetting  the  sole  of  the  patient's  foot  with  a  colored  fluid  and 
causing  him  to  step  firmly  upon  a  piece  of  paper  (Fig.  538,  b). 
Beginning  flat-foot  cannot  be  thus  recognized  and  is  frequently 
overlooked,  the  patient  being  treated  for  gout  or  rheuma- 
tism. Even  a  slight  case  can  be  detected  by  carefully  ob- 
serving the  inner  surface  of  the  foot.  When  weight  is  placed 
upon  it,  it  is  seen  to  descend  as  the  arch  falls.  A  more 
accurate  method  is  measurement,  to  find  the  middle  of  the 
foot.  In  flat-foot  the  extremity  is  lengthened.  Golding-Bird  points  out  that 
the  middle  of  the  normal  foot  is  the  point  of  articulation  of  the  inner  cuneiform 
and  the  metatarsal  bone  of  the  great  toe.  In  flat-foot  the  greatest  change  is 
in  the  posterior  half  of  this  line.  The  extent  to  which  the  posterior  measurement 
exceeds  the  anterior  is  the  degree  of  flat-foot.     The  excess  may  reach  ^^  inch. 

Treatment. — In  paralytic  flat-foot,  which  arises  from  infantile  paralysis, 
employ  exercise,  electricity,  and  massage.  To  maintain  a  correct  position  of 
the  ankle  and  to  facilitate  normal  muscular  action,  apply  suitable  braces.  In 
some  cases  of  paratytic  flat-foot  it  is  advisable  to  stiffen  permanently  the 
ankle-joint  by  operation.  Operation  is  not  indicated  before  the  tw^elfth  year, 
because  during  the  earlier  years  of  life  union  will  probably  fail  to  occur.  Gold- 
thwait  removes  the  cartilagej^from  the  articular  surfaces  of  the  astragalus, 
calcaneus,  tibia,  and  malleoli,  and  seeks  to  obtain  permanent  bony  ankylosis. 
In  static  flat-foot  it  has  long  been  customary  to  advise  rest  in  bed  for  two  weeks, 
and  then  exercise  for  several  hours  a  day  to  increase  the  arch.  The  usually 
recommended  exercise  has  been  to  rise  upon  the  toes  and  low^er  again  and  again, 
with  the  ankles  turned  outward.  The  patients  rests  for  a  time  after  each 
seance  of  exercise  by  sitting  tailor-fashion  with  the  legs  crossed  under  him  or  by 
standing  on  the  outer  edges  of  the  feet.  Massage  is  ordered  and  a  special  shoe 
is  made  to  raise  the  arch  of  the  foot.  The  shoe  must  fit  the  heel  snugly  and 
have  a  firm,  broad  heel.  In  some  cases  it  is  necessary  to  use  a  Thomas  heel; 
in  others,  a  steel  shank.     The  patient's  general  health  is,  of  course,  attended  to. 

Many  orthopedic  surgeons  have  come  to  regard  this  usual  treatment  as 
unphilosophical  and  improper  for  many  cases. 

S3 


Fig.  538. — Print 
of  a  normal  foot 
sole  (a)  and  of  a 
flat-foot  sole  (b) 
(Albert). 


834 


Orthopedic  Surgery 


It  is  essential  to  understand  that  a  static  flat-foot  may  be  a  fully 
functionating  foot,  free  from  pain  and  disability,  and,  therefore,  not  a  sub- 
ject for  treatment.  For  convenience,  flat-foot  is  divided  into  rigid  and  flex- 
ible. Either  form  may  be  free  from  pain.  The  pain  of  flat-foot  is  usually 
the  result  of  excessive  use.  It  must  be  differentiated  from  Albert's  disease 
(achillodynia),  metatarsalgia,  osteophytes  on  the  under  surface  of  the  os  calcis, 
and   Raynaud's   disease.     Rigid   flat-foot  can   be  made  flexible  by   manipu- 


FiG.  539. — H.  Augustus  Wilson's  flat-foot  correction  screw. 


lative  measures  (according  to  Whitman's  method)  or  by  the  employment 
of  H.  Augustus  Wilson's  flat-foot  correction  screw  (Fig.  539).  This  appa- 
ratus pulls  down  on  the  posterior  part  of  the  os  calcis  and  the  distal  extremi- 
ties of  the  metatarsal  bones  and  pushes  up  beneath  the  tarsus.  The  force 
employed  is  very  great  and  much  care  should  be  exercised  when  it  is  used  upon 
a  patient  under  anesthesia.  It  is  preferable  to  use  it  without  ether,  relying 
upon  the  patient  to  state  when  the  pressure  becomes  unendurable.  A  flexible 
flat-foot  is  capable  of  correction  by  exercises. 


Fig.  540.- 


^Ui4^ui  I    Lii'-    ai 


ji  the  foot  in  flat-fouL  (Towler's  "Surgery"). 


It  was  formerly  customary  to  prescribe  always  various  forms  of  steel  plates 
to  correct  the  broken-down  arch,  but  some  orthopedic  surgeons  are  discouraging 
their  use,  beUeving  that  they  destroy  the  muscular  control  of  the  foot,  and  by 
weakening  the  foot  render  it  susceptible  to  sprains  and  other  injuries.  It  is  my 
beUef  that  steel  plates  should  often  be  used,  but  never  abused  (Fig.  540). 
When  plates  are  necessary  because  the  patient  is  heavy  or  because  he  must  con- 
tinue a  trying  occupation,  they  must  be  fitted  to  the  individual  case  and  must  be 


Treatment  of  Hallus  Valgus  835 

worn  until  such  time  as  the  use  of  exercise  has  enabled  the  patient  to  maintain 
properly  the  body  weight  with  the  strengthened  arches.  If  the  tendo  Achillis  is 
shortened  it  must  be  lengthened  by  operation  or  else  the  heel  of  the  shoe  must 
be  raised  to  permit  the  fullest  range  of  dorsal  llexion  the  tendon  allows.  When 
muscle  tone  is  low  and  there  is  small  chance  of  restoring  it,  H.  A.  Wilson  ("  Amer. 
Medicine,"  May  6,  1905,  page  725)  advocates  the  employment  of  the  method 
devised  by  Professor  Miiller  ("Central,  f.  Chir.,"  January  10,  1903,  page  40) 
for  paralytic  valgus.  It  consists  of  an  arthrodesis  of  the  astragaloscaphoid 
joint,  and  transplantation  of  the  tendon  of  the  extensor  proprius  hallucis  into  a 
hole  drilled  free  from  above  downward  through  the  scaphoid.  Fixation  in 
plaster  of  Paris  in  an  ov'ercorrected  position  is  maintained  for  four  weeks  and 
then  corrective  exercises  are  employed.  The  anterior  tibial  tendon  is  supple- 
mented in  its  action  by  the  transplanted  tendon. 

Gleich  shortens  the  foot  and  raises  the  arch  by  sawing  through  the  os  calcis 
and  fastening  the  posterior  part  of  this  bone  at  a  lower  level.  Trendelenburg 
advises  supramalleolar  osteotomy.  This  operation  permits  of  adduction,  and 
the  adducted  foot  should  be  put  up  in  an  immovable  dressing  of  plaster  of 
Paris.  Ogston  resects  the  astragaloscaphoid  joint.  Golding-Bird  and  Davy 
remove  the  scaphoid  bone.  Stokes  removes  a  wedge-shaped  piece  from  the 
head  and  neck  of  the  astragalus.  Rugh  has  taken  a  wedge-shaped  piece  of 
bone  from  the  inner  side  and  inserted  it  in  the  outer  side. 

Pes  cavus  (hollow  foot)  is  an  increase  in  the  arch  of  the  foot,  due,  pos- 
sibly, according  to  Golding-Bird,  to.  paralysis  of  the  peronei  muscles.  When 
the  peronei  muscles  are  paralyzed  the  adductors  act  unopposed,  and  secondary 
contraction  of  the  plantar  fascia  occurs.  Certain  it  is  that  a  contracted  plantar 
fascia  is  the  chief  obstacle  to  correction.  In  many  cases  the  cause  is  the 
wearing  of  shoes  which  are  too  short  for  the  feet.  The  pressure  made  upon  the 
toes  causes  spasm  of  the  plantar  flexors  and  this  spasm  permits  the  fascia  to  con- 
tract. 

Treatm.ent. — In  a  paralytic  case  a  shoe  is  worn  containing  a  plate  of  steel 
in  the  sole,  and  pressure  is  applied  over  the  instep.  If  equinus  exists  tenotomy 
of  the  Achilles  tendon  is  indicated.  If  there  is  calcaneus  divide  the  plantar 
fascia  or  perhaps  transplant  the  tendons  of  peronei  and  posterior  tibial  to 
the  OS  calcis  (G.  G.  Davis,  "Am.  Jour.  Orthop.  Surg.,"  1913,  xi).  The  operation 
of  Forbes  transplants  the  tendon  of  extensor  longus  hallucis  to  the  head  of  the 
first  metatarsal  bone.  In  all,  if  the  calf  muscles  are  entirely  paralyzed  and 
there  is  marked  calcaneus  perform  astragalectomy.  In  paralytic  cases  apply 
electricity  and  massage  to  the  paralyzed  muscles.  If  there  is  no  palsy  cut  with 
a  tenotome  the  plantar  fascia  and  the  tendon  of  the  flexor  longus  hallucis. 

Hallus  valgus  or  varus,  a  displacement  of  the  great  toe  outward  or  in- 
ward may  occur  in  the  young,  but  it  is  most  frequent  in  old  persons,  especially 
old  women.  It  arises  often  from  wearing  pointed  shoes,  shoes  that  are  too  short, 
or  high  heels,  but  may  be  due  to  gout  or  to  rheumatic  gout.  In  many  cases 
an  exostosis  forms  in  the  inner  portion  of  the  distal  end  of  the  metatarsal  bone. 
In  hallux  valgus  a  bunion  (bursa)  is  apt  to  form  over  the  metatarsophalangeal 
joint  and  it  may  inflame  or  ulcerate. 

Treatment. — An  arrangement  may  be  worn  to  straighten  the  toe  and 
to  protect  the  bunion  (see  Fig.  525).  The  prominent  and  hypertrophied  inner 
portion  of  the  head  of  the  metatarsal  bone  may  be  removed  by  means  of  a 
chisel,  osteotomy  may  be  performed  upon  the  metatarsal  bone,  the  joint 
may  be  excised.  Amputation  should  not  be  done  as  it  removes  the  weight- 
bearing  head  of  the  metatarsal  bone.  H.  A.  Wilson  advocates  lateral  excision. 
By  means  of  bone-forceps  he  cuts  away  that  part  of  the  distal  extremity  beyond 
the  phalanx,  and  by  a  chisel  removes  the  remaining  sharp  line  edge.  He 
places  the  phalanx  in  normal  position  and  holds  it  so  for  two  weeks  ("Am. 
Jour.  Orthopedic  Surgery,"  Jan.,  1906). 


836 


Orthopedic   Surgery 


Fig 


541. — Ham- 
mer-toe. 


J 


Fig.  542. — X-ray  of  ham- 
mer-toe. 


Hammer=toe  (Figs.  541  and  542)  is  a  condition  in  wliich  there  is  flexion 
of  one  or  more  toes  at  the  first  interphalangeal  joint.  Shattuck  shows  that 
this  condition  is  due  to  contraction  of  "  the  plantar  fibers  of  the  lateral  ligaments 
of  the  joint. "^  This  disease  usually  begins  in  youth  and  may  be  congenital. 
A  bunion  is  apt  to  form,  and  the  joint  may  become  dislocated. 

Treatment. — Subcutaneous  division  of  the  lateral  ligaments  and  flexor 
tendon  usually  allows  straightening  of  the  toe.  After  the  operation  the 
toe  must  be  held  in  extension  for  several  months  by  means  of  a  short  splint 
and  adhesive  plaster.  Terrier's  plan  of  treatment  con- 
sists in  making  a  dorsal  flap,  removing  a  bursa  if  one 
is  found,  dividing  the  extensor  tendon,  opening  the 
articulation,  removing  each  articular  surface  by  cut- 
ting forceps,  suturing  the  soft  parts,  and  applying  a 
plantar  spHnt  for  two  weeks. ^  The  base  of  the 
proximal  phalanx  may  be  removed.  Some  surgeons 
simply  excise  the  joint.  Amputation  should  not  be 
performed  except  perhaps  in  the  case  of  the  little 
toe.     Amputation  of  a  toe  weakens  the  foot. 

Metatarsalgia   (Morton's  Disease). — This  dis 
ease  was  first  described  by  Dr.  Thomas  G.  Morton, 

of   Philadelphia,  in  1876.     It  is  a 

painful     condition     of     the    fool, 

caused  by  ligamentous  relaxation, 

which  permits  the  sagging  down  of 

the    heads    of    the    second,  third, 

or  fourth  metatarsal  bones,  two  of 

them  or  all  of  them.  Morton  be- 
lieved the  pain  to  be  due  to  jam- 
ming of  a  nerve  between  the  heads  of  the  fourth  and  fifth  metatarsal  bones. 
The  head  of  the  fifth  metatarsal  bone  is,  by  lateral  pressure,  forced  against 
and  below  the  neck  of  the  fourth  metatarsal,  and  as  a  result  the  superficial 
branch  of  the  external  plantar  nerve  and  its  two  digital  branches  are  squeezed. 
It  is  usually  associated  with  flat-foot.  Loss  of  the  metatarsal  arch  will  jam 
other  nerves  than  that  between  the  fourth  and  fifth  metatarsals,  and  will  pro- 
duce a  condition  similar  to  Morton's  disease,  the  pain  being  differently  situated. 
Pain,  in  Morton's  disease,  is  produced  by  walking,  and  the  suffering  may  be 
so  severe  that  the  patient  is  obliged  to  sit  down  at  once.  When  the  shoe  is 
removed  and  the  foot  is  rested  the  pain  soon  abates.  The  pain  is  felt  usually 
between  the  fourth  and  fifth  toes  and  about  the  head  of  the  fifth  and  the 
neck  of  the  fourth  metatarsal  bones.  Pain  can  be  developed  by  grasping 
the  foot  in  the  hand  and  squeezing  it.  If  flat-foot  exists,  there  is  also  pain  due 
to  this  trouble.  The  condition  is  common  in  golfers  and  is  then  called  golfer's 
foot. 

Treatment. — Mild  cases  may  be  cured  by  wearing  well-fitting  shoes  and 
an  arch  support,  the  use  of  hot  air,  proper  exercise  and  massage.  The  shoe 
should  have  a  small  elevation  in  the  sole  to  restore  the  metatarsal  arch  and  so 
relieve  lateral  pressure  on  the  nerve.  Some  cases  require  a  brace.  Jones 
puts  a  bur  on  the  sole  of  the  shoe  so  that  the  weight  will  be  thrown 
behind  the  heads  of  the  metatarsal  bones.  He  also  raises  the  heel  \i  inch 
on  its  inner  side,  binds  a  band  of  adhesive  plaster  around  the  base 
of  the  metatarsals,  directs  exercise  of  the  small  muscles  of  the  foot  and  orders 
massage.  If  an  early  case  is  treated  in  this  manner  a  cure  will  be  obtained 
in  a  few  weeks.  Sev^ere  cases  demand  resection  of  the  fourth  metatarsopha- 
langeal joint,  or  amputation  of  the  fourth  toe,  and  with  it  the  head  of  the  fourth 

1 "  American  Text-book  of  Surgery." 
^"Rev.  de  Chir.,"  July,  1895. 


Coxa  Vara  and  Coxa  Valga  837 

metatarsal   bone.     Graham,  of  Washington,  has  cured  cases   by  excising  a 
portion  of  the  superficial  branch  of  the  external  plantar  nerve. 

Coxa  Vara  and  Coxa  Valga.— Coxa  vara  ibicurvalion  or  infraction  of  the 
neck  of  the  femur)  (Fig.  543)  is  a  disease  characterized  by  bending  of  the  neck  of 
the  femur,  the  femoral  neck  being  depressed  below  its  normal  obtuse  angle  with 
the  shaft,  the  hip- joint  being  perfectly  healthy,  and  the  condition,  as  a  rule,  being 
unilateral,  but  sometimes  bilateral.  This  condition  was  described  by  Miiller 
in  1889.  Coxa  vara  is  first  noticed,  as  a  rule,  between  the  thirteenth  and 
twentieth  years,  and  the  commonly  accepted  view  has  been  that  the  deformity 
is  rachitic,  but  Kredel  has  reported  2  congenital  cases. ^  Traumatic  coxa 
vara  may  follow  impacted  fracture  of  the  neck  of  the  femur  in  a  child.  An 
individual  with  coxa  vara  develops  a  limp,  and  grows  tired  after  slight  ex- 
ertion, but  there  is  no  swelling,  no  tenderness,  and  little  or  no  pain.  Shorten- 
ing after  a  time  becomes  apparent,  the  great  trochanter  can  be  detected  above 
Nelaton's  line,  and  the  head  of  the  bone  is  in  the  acetabulum.     If  the  head 


Fig.  543. — Congenital  dislocation  of  the  hip  on  one  side  and  coxa  vara  on  the  other. 

is  in  the  acetabulum  it  can  be  recognized  as  being  there  by  locating  the  femoral 
artery  Xi  inch  below  Poupart's  ligament  and  making  pressure  directly  back- 
ward at  that  point.  The  head,  if  in  place,  will  be  felt.  The  extremity  is 
adducted  and  usually  rotated  outward.  Abduction  is  limited.  In  some  cases 
in  which  there  is  joint  irritation  all  joint  motions  may  be  distinctly  limited. 

In  a  bilateral  case  there  is  lordosis,  but  shortening  may  not  be  detected 
because  both  legs  are  the  same  length.  Each  great  trochanter,  however,  is 
above  Nelaton's  line  and  the  head  of  each  bone  is  in  the  acetabulum. 

Coxa  valga  is  a  condition  in  which  the  angle  of  the  neck  to  the  shaft  of 
the  femur  is  more  obtuse  than  normal.  The  neck  may  assun:i^  a  position  in 
line  with  the  long  axis  of  the  shaft.  It  occurs  particularly  in  children  who 
have  had  infantile  palsy,  but  it  may  be  congenital,  may  occur  in  rickets  and 
osteomalacia,  and  after  a  prolonged  period  of  disuse  of  a  limb.  The  patient 
has  pain  and  a  limp,  the  extremity  is  lengthened,  abducted,  and  in  external 
rotation  there  is  limitation  of  adduction  and  the  trochanter  is  flattened.  Coxa 
valga  is  usually  unilateral,  but  may  be  bilateral. 

'  ••Centralbl.  f.  Chir.,"  Oct.  17,  1S96. 


838 


Diseases  and  Injuries  of  Nerves 


Without  the  .v-rays  the  differential  diagnosis  in  coxa  vara  and  coxa  valga  is 
often  very  difficult,  and  the  accompanying  table  will  materially  aid  in  contrast- 
ing the  conspicuous  features  of  the  various  conditions  with  which  these  two 
deformities  of  the  neck  of  the  femur  may  be  confounded: 

TABLE   MODIFIED  FROM  THAT  OF  DR.  H.  AUGUSTUS  WILSON 


Hip 

Infantile 

Congenital 

Psoas 

Coxa  vara 

Knee 

disease 

paralysis 

dislocation 

abscess 

or  valga 

disease 

Age. 

Three   to  fif- 

Three  to    fif- 

Any age. 

Three,  to  fif- 

Any age. 

Three  to  fif- 

teen. 

teen. 

teen. 

teen. 

Onset. 

Insidious. 

Sudden. 

From  birth. 

Insidious. 

Childhood. 

Insidious. 

Pain. 

Referred      to 

None. 

None. 

Referred    to 

None  in  hip. 1  In  knee. 

knee. 

abdomen. 

History. 

Tuberculous. 

Inflammatory 
disease. 

Limp  from 
birth. 

Tuberculous. 

Limp. 

Tuberculous 

Posture. 

Flexion, 

Uncontrolled. 

Shot  tening 

Flexion. 

Great 

Knee  flexed. 

abduction. 

and    exter- 

adduction. 

trochanter 

external    ro- 

nal rotation. 

external  ro- 

higher   in 

tation. 

tation. 

vara    and 
lower      in 
valga. 

Muscular  rigidity. 

Present  in  all 
directions. 

Absent. 

Absent. 

In  one  direc- 
tion. 

None. 

About  knee. 

Temperature. 

I  degree  high. 

Normal. 

Normal. 

I  degree. 

Normal. 

I  degree. 

Local  tenderness. 

In  hip. 

None. 

None. 

None. 

None. 

In  knee. 

Night  cries. 

Present. 

Absent. 

Absent. 

Present. 

Absent. 

Present. 

Tendency    to    ab- 

Yes. 

No. 

No. 

Yes. 

No. 

Yes. 

scess. 

X-ray. 

Diseased 

Atrophy. 

Alteration  in 

Normal  hip. 

Alteration 

Normal    hip. 

focus  in  hip. 

joint. 

in  neck 
angle. 

focus   in 
knee. 

Muscular  atrophy. 

Profound. 

Profound. 

Absent. 

Absent. 

Absent. 

Profound. 

The  x-rays  clearly  show  the  deformed  bone  in  either  coxa  vara  or  coxa  valga. 

Treatment. — In  co.xa  vara,  as  long  as  bending  is  progressing,  employ  rest. 
When  the  bone  hardens,  it  may  be  necessary  to  perform  osteotomy  below  the 
trochanters.  In  coxa  valga  Galeazzi  performs  osteotomy  through  the  neck 
of  the  femur  and  allows  the  trochanter  to  ascend. 

Flail=joints  from  Infantile  Palsy. — In  the  subacute  stage  of  infantile 
palsy,  there  is  paralysis  but  no  fever.  Neither  massage  nor  electricity  are 
admissible  until  tenderness  has  disappeared.  Splints  are  used  to  antagonize 
deformity.  When  the  patient  is  convalescent  massage  and  electricity  are  of 
great  use  and  braces  are  used.  After  an  attack  of  infantile  paralysis  invoh-ing 
the  entire  lower  extremity  of  each  side  the  limbs  become  limp  and  swing  flail- 
like when  the  extremity  is  made  to  move,  and  the  joints  are  much  relaxed. 
In  such  cases  the  psoas  and  iliacus  muscles  are  never  completely  paralyzed,  and 
the  aim  of  the  surgeon  is  to  utilize  these  muscles  in  enabling  the  patient  to 
walk.  In  many  cases  the  application  of  apparatus  is  sufficient.  In  others 
ankylosis  may  be  established  in  the  ankles  and  knees  by  operation.  If  ankylosis 
is  established  in  these  joints,  the  psoas  and  iliacus  muscles  become  able  to 
move  the  legs.  Tendon  transplantations  may  be  performed,  tenotomy  or 
osteotomy  may  be  indicated.  A  joint  is  stabilized  most  securely  by  utilizing 
as  ligaments  the  tendons  of  totally  paralyzed  muscles,  attaching  them  subperi- 
osteally  or  to  the  bone  (Putti). 


XXIII.  DISEASES  AND  INJURIES  OF  NERVES 

Diseases  of  Nerves 

Neuritis,  or  inflammation  of  a  nerve,  may  be  limited  or  be  widely 
distributed  {multiple  neuritis).  The  first-mentioned  form  will  here  be  con- 
sidered. The  causes  of  neuritis  are  traumatism,  wounds,  overaction  of  muscles, 
gout,  rheumatism,  s\^hilis,  fevers,  and  alcoholism. 

The  symptoms  of  neuritis  are  as  follows:  excessive  pain,  usually  inter- 
mittent, in  the  area  of  nerve-distribution.     The  pain  is  worse  at  night,,  is 


Neuralgia 


839 


aggravated  by  motion  and  pressure,  and  occasionally  diffuses  to  adjacent 
nerve-areas  or  awakens  sympathetic  pains  in  the  opposite  side  of  the  body. 
The  nerve  is  very  tender.  The  area  of  nerve-distribution  feels  numb  and  is 
often  swollen.  Early  in  the  case  the  skin  is  hyperesthetic;  later  it  may  become 
anesthetic.  The  muscles  atrophy  and  present  the  reactions  of  degenera- 
tion; that  is,  the  muscles  first  cease  to  respond  to  a  rapidly  interrupted  faradic 
current,  and  next  to  one  with  slower  interruptions;  faradic  excitability 
diminishes,  but  galvanic  excitability  increases.  When,  in  neuritis,  faradism 
produces  no  contraction,  a  slowly  interrupted  galvanic  current  which  is  so 
weak  that  it  would  produce  no  movement  in  the 'healthy  muscle  causes  marked 
response  in  the  degenerated  muscle.  In  health  the  most  vigorous  contraction 
is  obtained  by  closing  with  the— pole;  in  degenerated  muscles  the  most  \'igorous 
contraction  is  obtained  by  closing  with  the  -{-  pole.  When  voluntary  power 
returns,  galvanic  excitability  declines; 
but  power  is  often  nearly  restored  before 
faradic  excitability  becomes  manifest 
(Buzzard). 

The  treatment  of  neuritis  consists 
of  rest  upon  splints  and  the  use  of  an 
ice-bag  early  in  the  case  and  a  hot- 
water  bag  later.  Blisters  over  the 
course  of  the  nerve  are  of  value, 
especially  in  traumatic  neuritis.  JSIas- 
sage  and  electricity  must  be  used  to 
antagonize  degeneration.  A  descending 
galvanic  current  allays  pain  to  some 
extent.  Deep  injections  of  chloroform 
or  cocain  may  allay  pain.  Treat  the 
patient's  general  health,  especially  any 
constitutional  disease  or  causative 
diathesis.  The  salicylate  of  ammonium 
or  phenacetin  may  be  given  internally. 
In  some  cases  nerve-stretching  is 
ad\'isable. 

Neuralgia  is  manifested  by  violent 
paroxysmal  pain  in  the  trajectory  of 
a  nerve.  This  disease,  unless  it  is  ex- 
ceedingly severe  and  persistent,  is 
treated,  as  a  rule,  by  the  physician. 
Injections  of  alcohol  or  osmic  acid  into 
the  nerve  may  secure  relief  or  cure. 
If  neuralgia  is  due  to  adhesions  about 
the  nerve  or  to  the  pressure  of  scar  or 
callus,     these     conditions     should     be 


Fig.  544.^Distribution  of  the  cu- 
taneous sensitive  nerves  upon  the  head: 
oma,  omi,  The  occipit.  maj.  and  minor 
(from  the  X.  cer\-ical.  II  and  III);  am,  N. 
auricular  magn.  (from  X.  cervic.  Ill);  cs, 
X.  cervical,  superfic.  (from  X.  cer\-ic.  Ill) ; 
Fi,  first  branch  of  the  fifth  {so,  X.  supra- 
orbit.;  st.  X.  supratrochl.;  X.  infratrochl.; 
e,  X.  ethmoid.;  I,  X.  lachrymal.);  V2, 
second  branch  of  the  fifth  {sm,  X.  sub- 
cutan.  malfe  seu  zj^gomaticus) ;  Vz,  third 
branch  of  the  fifth  {at,  X.  auriculotempor. ; 
h,  X.  buccinator;  vi,  X.  mental.);  B, 
posterior  branches  of  the  cer\-ical  nerves 
(Seeligmiiller). 

amended    surgically.      There    is    some 

e\'idence  that  neuralgia  arises,  at  least  occasionally,  from  dilatation  of 
the  vessels  of  the  sheath  and  subsequent  edema  and  exudation.  If 
this  be  the  case  cure  may  follow  opening  the  sheath  and  separating 
adhesions  between  the  sheath  and  nerve  (Robert  M.  Simon,  in  "Brit.-  Med. 
Jour.,"  April  10,  1909).  Neuralgia  of  stumps  and  scars  is  a  surgical  condition, 
and  is  due  to  neuromata,  or  entanglement  of  nerve-filaments  in  a  cicatrix. 
Tic  douloureux  and  other  intractable  neuralgias  require  careful  removal  of 
any  cause  of  reflex  irritation.  Causal  reflex  irritation  may  arise  from  disease  of 
the  stomach,  eyes,  teeth,  uterus,  nose,  throat,  etc.  Tic  douloureux  has  been 
treated  by  removal  of  the  Gasserian  ganglion;  intracranial  neurectomy  of  the 
second  and  third  di\dsions;  section  of  the  sensory  root;  removal  of  Meckel's 


840  Diseases  and  injuries  of  Nerves 

ganglion;  ligation  of  the  common  carotid  artery;  neurectomy  of  terminal 
branches  of  the  fifth  nerve;  division  of  motor  nerves;  injections  of  osmic  acid 
(see  page  856);  injections  of  alcohol  (see  page  856) ;  advancing  doses  of  strychnin 
(Dana)  and  purgatives  (Esmarch).  The  distribution  of  the  fifth  nerve,  the 
seat  of  j)ain  in  tic  douloureux,  is  shown  in  Fig.  544. 

Sciatica. — This  may  be  acute  or  chronic,  a  neuralgia  or  a  neuritis.  True 
sciatica  is  perineuritis  of  the  sciatic  nerve,  a  very  rare  lesion.  In  most  cases 
sciatica  is  a  symptom.  Violent  and  perhaps  long-continued  pain  in  the  nerve 
may  be  a  reflex  phenomenon.  In  three  cases  most  obstinate  and  crippling 
sciatic  pain  was  cured  by  removing  a  diseased  appendix.  In  each  case  the 
appendix  was  posterior.  It  may  be  due  to  pelvic  disease,  to  disease  or  injury  of 
the  sacro-ihac  joint,  the  lumbosacral  joint  or  the  lumbar  articulations,  to  disease 
of  the  rectum,  to  traumatism,  to  exposure  to  cold  or  damp,  to  syphilis,  or  to 
alcohol. 

Exposure  to  cold  causes  the  rheumatic  form.  Indiscretions  in  diet  may 
instigate  a  gouty  form.  In  some  cases  of  diabetes  violent  nerve  pain  is 
experienced;  the  same  is  true  of  malaria.  Sitting  long  hours  on  a  hard  and  ill- 
shaped  bench  or  chair  may  be  responsible  ("Jour.  Am.  Med.  Assoc,"  March  18, 
1916).     Of  course  focal  infection  has  been  blamed  (teeth,  tonsils,  etc.). 

Flat-foot  causes  some  cases.  Tumor  of  the  nerve  or  the  nerve-sheath 
causes  violent  pain. 

Treatment. — Seek  for  any  possible  cause  of  reflex  irritation  and  remove  it. 
Remove  any  cause  of  nerve  pressure.  Treat  any  existing  disease  or  diathesis. 
Rigid  diet,  rest  in  bed,  splinting  of  the  extremity,  warmth,  application  of 
blisters  or  the  actual  cautery  over  the  nerve  and  the  high-frequency  current 
do  good.  If  the  case  does  not  improve  inject  salt  solution  or  cocain  about 
the  nerve.     A  very  severe  and  prolonged  case  may  call  for  nerve -stretching. 

Treatment  of  Neuralgia- of  Stumps. — Excise  the  scar;  find  the  bulbous  end 
of  the  nerve  and  cut  it  off.  Senn  tells  us  to  section  the  nerve  by  V-shaped 
cuts,  the  apex  of  the  V  being  toward  the  body,  and  to  suture  the  flaps  together. 
Senn's  method  will  prevent  recurrence.  In  some  cases  reamputation  is  per- 
formed. In  entanglement  of  a  nerve  in  a  scar  remove  a  portion  of  the  nerve 
above  the  scar  and  also  the  neuroma  in  the  scar. 

Wound's  and  Injuries  of  Nerves 

Section  of  Nerves  (as  from  an  incised  wound). — After  nerve-section 
sensation  and  motor  power  are  lost  at  once.  The  entire  peripheral  portion  of 
the  nerve  degenerates  and  ceases  structurally  to  be  a  nerve  in  a  few  weeks, 
but  after  many  months,  or  even  years,  the  nerve  may  regenerate.  The  proxi- 
mal end  degenerates  only  in  the  portion  immediately  adjacent  to  the  section; 
it  rapidly  regenerates,  and  if  it  does  not  adhere  to  the  peripheral  segment 
a  bulb  or  enlargement  composed  of  fibrous  tissue  and  small  nerve-fibers  forms 
just  above  the  line  of  section;  this  bulb  adheres  to  the  perineural  tissues.  The 
entire  distal  end  degenerates,  but  new  axis-cylinders  form  in  this  segment 
by  proliferation  of  the  nuclei  on  the  sheath  of  Schwann.  Union  of  a  divided 
nerve  is  brought  about  by  the  projection  of  axis-cylinders  from  the  proximal 
end  or  from  each  end  and  the  fusion  of  these  cylinders.  The  nearer  the  two 
ends  are  to  each  other,  the  better  the  chance  of  union.  When  a  ner\-e  has  been 
di\dded  and  has  not  been  sutured,  abolition  of  function  may  be  permanent 
or  restoration  may  occur.  Sensation  may  return  in  from  six  weeks  to  several 
months.  Motor  power  may  never  return.  If  it  does  return  it  will  do  so  long 
after  sensory  restoration.  Restoration  of  motor  power  requires  from  twelve 
weeks  to  three  and  one-half  years.  It  is  seldom  noted  before  six  months. 
The  return  is  always  slow  (John  B.  Murphy,  in  "Surg.,  Gjoiec,  and  Obstet.," 
April,  1907).  Failure  of  return  means  that  the  ends  are  separated  by  a  wide 
interval  or  that  fascia  is  interfused  between  them.     In  some  recorded  cases 


The  Symptoms  of  Division  of  Nerves  841 

motion  and  sensation  have  returned  with  great  rapidity,  due,  some  have  said, 
to  anastomoses  with  adjacent  nerves.  Murphy  shows  that  when  restoration 
begins,  trophic  energy  returns  even  before  sensation,  and  when  trophic  energy 
returns  the  blueness  and  coldness  of  the  hmb  lessen. 

The  nerve-fibers  which  convey  impressions  of  cutaneous  pain  and  of  ex- 
treme heat  and  cold  regenerate  far  more  rapidly  than  those  which  subserve 
sensations  of  light  touch  and  slight  degrees  of  heat  and  cold. 

The  investigation's  of  Head  and  others  show  that  restoration  of  sensation 
does  not  begin  at  the  normal  area  and  spread  from  there  over  the  anesthetic 
area,  but  that  the  reverse  is  the  case.  It  begins  from  the  confines  of  the 
anesthetic  area  and  spreads  toward  the  normal  part. 

General  Symptoms. — Immediately  after  nerve-section  vasomotor  paralysis 
comes  on,  and  for  a  few  days  the  paralyzed  part  presents  a  temperature 
higher  than  normal.  It  then  becomes  blue  and  cold.  Pronounced  changes 
occur  in  the  trajectory  of  a  divided  nerve.  The  muscles  degenerate,  atrophy 
and  shorten,  and  develop  the  reactions  of  degeneration.  When  union  of  the 
nerve  occurs  the  muscles  are  restored  to  a  normal  condition.  If  the  nerve 
contains  sensory  fibers,  complete  anesthesia  (to  touch,  pain,  and  temperature) 
usually  follows  its  division;  but  if  a  part  is  supplied  by  another  nerve  as  well  as 
by  the  divided  one,  anesthesia  will  not  be  complete.  Trophic  changes  arise 
in  the  paralyzed  parts.  Among  these  changes  are  muscular  atrophy;  glossy 
skin;  cutaneous  eruptions;  ulcers;  dry  gangrene;  painless  felons;  falhng  of  the 
hair;  brittleness,  furrowing,  or  casting  off  of  the  nails;  joint  inflammations, 
and  ankylosis.  The  diagnosis  as  to  which  nerve  is  cut  depends  upon  a  study 
of  the  distribution  of  motor  and  sensory  paralysis. 

A  curious  fact  that  was  pointed  out  by  Letievant  is  that  after  division  of  a 
nerve  blunt  pressure  may  be  appreciated  over  the  entire  analgesic  area.  This 
phenomenon  was  long  thought  to  be  due  to  nerve  anastomoses,  the  sensory  areas 
from  different  nerves  overlapping.  The  explanation  now  given  is  founded  on 
Sherrington's  demonstration  that  the  motor  branches  of  a  mixed  nerve  carry 
sensory  fibers  through  muscles  and  tendons,  and  Head's  proof  that  certain 
afferent  fibers  convey  impressions  of  deep  sensibility  as  produced  by  pressure. 

The  Symptoms  of  Division  of  'Nerves.— Brachial  Plexus. — If  one  or  more 
cords  of  the  brachial  plexus  are  divided,  motor  paralysis  and  anesthesia  appear 
in  the  limb,  the  extent  of  the  paralysis  and  the  area  of  the  anesthesia  depending 
upon  the  cord  or  cords  involved.  It  should  be  remembered  that  the  inner 
cord  of  the  brachial  plexus  gives  origin  to  the  ulnar  nerve;  the  inner  and  outer 
cords  give  branches  which  fuse  to  form  the  median  nerve.  The  posterior  cord 
gives  origin  to  the  subscapular,  the  circumflex,  and  the  musculospiral  nerves. 
The  outer  cord  gives  origin  to  the  external  anterior  thoracic  and  the  musculo- 
cutaneous, as  well  as  to  the  outer  trunk  of  origin  of  the  median. 

Avulsion  or  rupture  of  the  brachial  plexus  is  sometimes  effected  by  an  injury, 
when  the  arm  is  not  lost.  Most  cases  are  due  to  indirect  violence  and  are 
associated  with  skeletal  injury,  for  instance,  dislocation  of  the  shoulder,  frac- 
ture of  the  humerus,  or  fracture  of  the  clavicle  (Frazier  and  Skillern,  paper 
before  Section  on  Surgery,  "Amer.  Med.  Assoc,"  191 1).  Bristow  ("Annals 
of  Surgery,"  Sept.,  1902)  reported  3  cases  of  avulsion  of  the  plexus  and  col- 
lected 24  more.  Frazier  and  Skillern  (Loc.  cit.)  collected  23  cases  of  avulsion 
without  skeletal  injuries  and  confirmed  by  operation.  In  each  of  these  cases 
the  rupture  was  between  the  clavicle  and  the  transverse  process  of  the  ver- 
tebra. In  the  case  of  Frazier  and  Skillern  the  rupture  was  within  the  dura. 
The  patient  was  seen  by  them  three  months  after  the  accident.  He 
suffered  from  horrible  pain  in  the  arm  and  hand.  Sensations  to  touch  and 
pain  were  entirely  lost  in  the  hand  and  forearm  and  in  the  arm  to  2  or  3  inches 
above  the  elbow.  From  this  point  to  about  4  inches  below  the  shoulder 
they  were  much  impaired.     Sensation  was  impaired  in  the  entire  distribu- 


842  Diseases  and  Injuries  of  Nerves 

tion  of  the  intercostohumeral  nerve,  and  of  the  fifth  and  sixth  cervical  roots, 
as  well  as  in  the  distribution  of  the  brachial  plexus.  There  was  flaccid  palsy  of 
the  entire  extremity,  including  the  deltoid.  On  the  injured  side  the  pupil  was 
contracted  and  the  jialpcbral  fissure  narrowed.  One  of  Bristow's  cases  was 
operated  upon  the  third  day  after  the  accident  (Log.  cit.).  In  this  case  there 
was  complete  paralysis  of  the  upper  extremity,  with  the  exception  of  the 
sensory  area  of  the  intercostohumeral  and  the  circumflex  nerves.  The  acci- 
dent had  been  inflicted  by  the  patient's  forearm  becoming  entangled  in  a  rope, 
which  was  pulled  upon  by  a  steam  winch.  On  reaching  the  hospital  he  felt 
severe  pain,  referred  to  the  arm.  There  was  much  swelling  in  the  inner 
portion  of  the  subclavian  triangle,  the  left  pupil  was  contracted,  and  it  seemed 
likely  that  the  nerves  had  been  avulsed  close  to  the  intervertebral  foramina. 
From  the  fact  that  sensation  was  preserved  in  the  skin  of  the  convexity  of 
the  shoulder  down  to  the  insertion  of  the  deltoid,  Bristow  concluded  that 
some  fibers  of  the  posterior  cord  of  the  plexus  had  escaped  division;  but  when 
the  operation  was  performed  this  conclusion  was  found  to  be  erroneous. 
An  incision  was  made,  and  it  was  found  that  the  plexus  had  given  way  at  the 
point  where  the  four  cervical  nerves  arid  the  last  dorsal  unite  to  form  the 
three  trunks.  In  order  to  reach  the  lower  ends  it  was  necessary  to  saw 
the  clavicle  and  divide  the  two  pectoral  muscles;  and  the  torn  ends  of  the 
nerve-trunks  were  found  underneath  the  clavicle.  Suturing  was  performed. 
The  ends  of  the  sawn  clavicle  were  sutured  together,  the  wound  was  closed  and 
dressed,  and  the  arm  was  put  up  in  Sayre's  dressing. 

After  the  performance  of  this  operation  sensation  over  the  entire  upper 
arm  returned.  The  author  once  operated  upon  a  patient  that  had  developed 
paralysis,  motor  and  sensory,  after  violent  stretching  of  the  arm.  In  the  light 
of  Bristow's  case  I  assumed  that  avulsion  of  the  plexus  had  probably  taken 
place.  Incision  disclosed  the  fact  that  the  plexus  was  intact,  but  was  sur- 
rounded with  dense  scar-tissue.  The  tissue  was  removed,  so  as  to  loosen  the 
nerves,  which  felt  like  hard  cords;  but  I  have  lost  track  of  the  patient,  and  do  not 
know  the  result.  My  patient  was  operated  upon  many  months  after  the  injury. 
I  operated  upon  another  case  and  found  intravertebral  rupture.  I  anasto- 
mosed two  divided  nerves  to  a  sound  one.  The  operation  was  done  months  after 
the  injury  and  the  patient  is  apparently  slightly  improved  three  months  after 
operation.  The  location  of  the  seat  of  injury  is  of  great  importance.  Lesion 
within  the  vertebrte  is  positively  indicated  by  contraction  of  the  pupil,  nar- 
rowing of  the  palpebral  fissure,  and  enophthalmos  on  the  affected  side  (Frazier 
and  Skillern,  "Amer.  Med.  Assoc,"  191 1),  but  there  can  be  intravertebral 
injury  without  these  phenomena.  The  ciliospinal  fibers  on  which  these  phe- 
nomena depend  usually  accompany  the  eighth  cervical  and  first  thoracic  nerves. 

Injury  above  the  clavicle  will  involve  the  circumflex  and  musculospiral. 
As  the  great  pectoral  is  supplied  from  both  the  external  and  internal  cords  of 
the  plexus,  complete  paralysis  of  the  great  pectoral  proves  that  both  cords 
are  involved,  and  unimpaired  movements  of  the  diaphragm  on  the  side  of  the 
lesion  (observed  with  the  fluoroscope)  show  that  the  cords  of  the  plexus  are  not 
divided  wathin  the  foramina,  but  well  outside  of  them  (John  B.  Murphy,  in 
"Surg.,  Gynec,  and  Obstet.,"  April,  1907).  In  all  cases  of  rupture  prompt 
operation  is  indicated.     Long  delay  means  a  hopeless  prognosis. 

In  injury  without  complete  rupture  the  nerves  become  fibrous  and  embedded 
in  scar-tissue.  If  operation  is  done  before  scar-tissue  forms  follow  the  advice  of 
Frazier  and  incise  the  sheaths  of  the  trunks  or  cords  to  liberate  inflammatory 
exudate.  If  scar-tissue  has  formed,  excise  it.  It  may  be  necessary  to  excise 
portions  of  nerves  or  trunks  with  it.  If  this  is  done,  suture  the  divided  ends 
together.  It  may  be  necessary  to  do  nerve-lengthening,  suture  a  distance, 
or  grafting  in  of  a  nerve  from  a  recently  amputated  limb  (if  one  can  be  ob- 
tained), or  of  the  sciatic  of  a  rabbit.     In  accessible  rupture  suture  the  dixaded 


The  Symptoms  of  Division  of  Nerves  843 

nerves.  In  some  cases  a  divided  cord  or  trunk  may  be  anastomosed  into  a 
sound  one.  Ruptures  near  to,  in,  or  within  the  intervertebral  foramina  do  not 
admit  of  suturing.  If  a  sound  nerve  is  left  the  divided  nerve  or  nerves  should  be 
anastomosed  to  it.  If  the  entire  plexus  is  ruptured  we  should  consider  the  plan 
of  Alexinsky  (quoted  by  Frazier  and  Skillern,  Loc.  cit.) :  effect  anastomosis  be- 
tween nerves  of  the  injured  side  and  nerves  of  the  sound  side.  When  intract- 
able neuralgia  follows  rupture  the  posterior  roots  may  be  divided. 

Brachial  Plexus  Palsy. — ^This  can  occur  in  the  adult  or  at  birth.  In  the 
adult  it  is  due  to  a  fall  upon  the  side  of  the  head  or  blows  over  the  side  and  base 
of  the  neck  (Wm.  Sharpe  in  "Jour.  Am.  Med.  Assoc,"  March  18,  1916).  It  is 
rare  in  the  adult.  It  is  far  more  common  a.s  a.  birth  palsy.  Brachial  palsy  may 
arise  after  a  difficult  dehvery.  In  most  cases  forceps  have  been  used.  Seventy 
per  cent,  of  Sharpe's  56  cases  involved  the  right  arm  and  28  per  cent,  the  left  • 
arm,  78  per  cent,  followed  head  presentation  and  22  percent,  breech  presentation. 
It  has  been  pointed  out  by  Clark,  Taylor,  and  Prout  ("Am.  Jour.  Med. 
Sciences,"  Oct.,  1905)  that  brachial  birth  palsy  results  from  tension  on  the  nerve- 
trunks  by  overstretching  during  delivery,  the  nerve-sheath  first  rupturing  and 
then  the  nerve-fibers.  When  the  sheath  ruptures  hemorrhage  occurs,  fibrous 
tissue  forms,  and  the  scar  presses  on  the  intact,  slightly  stretched,  or  actually 
lacerated  nerve,  and  prevents  repair.  The  authors  tell  us  that  the  fifth  cervical 
root  first  gives  way,  then  the  sixth,  and  so  on  down  the  plexus  if  there  be 
sufiicient  force.  In  the  milder  cases  the  fifth  root  alone  suffers.  They  call 
it  brachial  birth  palsy,  or  laceration  palsy,  and  sum  up  the  symptoms  in  a 
severe  case  as  follows:  The  arm  hangs  powerless;  abduction  at  the  shoulder 
is  impossible  because  of  deltoid  and  supraspinatus  palsy;  the  forearm  is 
extended  and  flexion  is  impossible  because  of  biceps,  brachiahs  anticus,  and 
supinator  longus  palsy;  palsy  of  supinator  brevis  and  biceps  causes  pronation 
of  hand;  there  is  inward  rotation  of  the  humerus  because  of  palsy  of  the 
supraspinatus,  infraspinatus,  and  teres  minor. 

In  a  less  severe  case  in  which  only  the  fifth  and  sixth  cervical  roots  and  the 
suprascapular  nerve  are  involved,  the  upper  arm  is  paralyzed  but  only  the 
supinators  of  the  forearm. 

Klumpke's  paralysis  is  a  birth  palsy  in  which  the  forearm  alone  is  involved. 

Brachial  birth  palsy  is  manifest  soon  after  its  infliction  by  evidences  of 
pain  on  handling  the  extremity,  the  pain  being,  due  to  neuritis  (authors  above 
quoted).  The  pupils  may  be  unequal.  This  means  injury  to  the  sympathetic 
and  to  the  eighth  cervical  or  first  dorsal  which  receive  communications  from  the 
sympathetic  (Sever,  in  "Am.  Jour.  Orthop.  Surg.,"  1916,  xiv).  The  same  force 
which  caused  the  nerve  injury  may  also  have  dislocated  the  humerus. 

The  usual  plan  of  treatment  is  to  reduce  a  dislocation  if  it  exists  and  fix  the 
arm  in  a  bandage  which  elevates  the  shoulder.  This  relaxes  the  injured  nerve- 
roots  and  so  favors  union.  Sharpe  (Ibid.)  points  out  that  this  plan  may  be  effi- 
cient in  mild  cases  in  which  the  roots  have  been  merely  overstretched  or  in  which 
the  impairment  is  due  to  dislocation.  This  treatment  should  be  restricted  to  the 
mild  cases.  It  is  not  the  proper  treatment  for  a  case  of  "total  paralysis  of  the 
arm,  hand  and  fingers."  It  is  true  that  improvement  may  occur  even  in  severe 
cases,  but  "improvement  rarely  continues  beyond  one  year  of  age,  and  the  • 
end-result  is  an  impaired  arm  of  greater  or  less  severity;  a  useful  arm  is  seldom 
obtained"  (Sharpe,  Ibid.).  In  a  case  of  total  paralysis  I  am  convinced  we 
should  follow  Sharpe's  plan  and  expose  the  plexus  when  the  child  is  one  month 
of  age.  At  this  early  age  very  little  ether  need  be  given,  very  little  fibrous  tissue 
will  be  met  with,  the  nerve-ends  will  not  have  retracted  and  the  results  are 
always  better  from  early  than  from  late  neurorrhaphy. 

Posterior  {Long)  Thoracic  Nerve. — Division  of  this  nerve  causes  paralysis  of 
the  serratus  magnus  muscle,  which  is  made  evident  by  eversion  from  the  thorax 
and  rotation  of  the  scapula  when  the  arm  is  taken  forward  (wing-like  scapula). 
In  paralysis  of  this  muscle  the  arm  cannot  be  raised  above  the  horizontal. 


844 


Diseases  and  Injuries  of  Nerves 


Suprascapular  Xervc. — Division  of  this  nerve  produces  some  anesthesia 
over  the  scapula  and  paralysis  of  the  supraspinatus  and  the  infraspinatus 
muscles.  The  supraspinatus  is  but  an  adjuvant  to  the  deltoid  and  palsy  of 
it  is  not  manifestly  disabling.  Palsy  of  the  infraspinatus  renders  external 
rotation  of  the  humerus  impossible,  and  writing  becomes  most  difficult  because 

the  pen  cannot  be  moved  along 
the  paper.  Sewing,  too,  is 
greatly  interfered  with. 

Circumflex  Xerve. — Division 
of  the  circumflex  nerve  pro- 
duces paralysis  of  the  deltoid 
muscle,  so  that  it  becomes  im- 
possible to  lift  the  arm  to  a 
right  angle  with  the  body. 
There  is  some  slight  retention 
of  power  in  the  anterior  fibers, 
which  are  supplied  by  the 
anterior  thoracic  nerve.  The 
skin  over  the  lower  part  of 
the  muscle  is  usually  anesthetic. 
Musculocutaneous  Nerve. — 
Division  of  this  nerve  produces 
paralysis  of  the  biceps  and  of 
the  brachialis  anticus  muscles 
(paralysis  of  the  forearm  flex- 
ors). This  palsy  becomes 
especially  evident  when  the 
forearm  is  supinated,  because 
in  this  position  the  supinator 
longus  can  no  longer  act  as  a 
flexor  of  the  elbow.  There  is 
anesthesia  of  the  radial  side  of 
the  forearm  anteriorly  and 
posteriorly. 

The  M us ctdo spiral  or  Radial 
Nerve. — Division  of  this  nerve 
high  up  near  the  plexus  causes 
paralysis  of  the  extensor  mus-^ 
cles  of  the  elbow  and  the  wrist, 
of  the  supinators,  and  of  the 
long  extensors  of  the  thumb 
and  fingers.  When  divided 
near  the  middle  of  the  humerus, 
the  triceps  usually,  but  not 
invariably,  escapes.  If  the 
injury  is  below  the  branch 
going  to  the  supinator  longus, 
that  muscle  will  escape;  other- 
wise it  will  become  paralyzed. 
The  extensor  palsy  causes  wrist- 
drop and  loss  of  the  power  of 


Anterior  surface.  Posterior  surface. 

Fig.  545. — Distribution  of  the  cutaneous  nerves 
to  the  shoulder,  arm,  and  hand.  The  region  of  the 
N.  radialis  is  represented  by  the  unbroken  hatched 
line,  that  of  the  N.  ulnaris  bj'  the  broken  hatched  lines. 
a,  Anterior,  h,  posterior  surface;  >?f,  Nn.  suprascapular 
(plexus  cervicalis);  ax,  chief  branch  of  N.  a.\illar.;c/»vf, 
cpi,  Nn.  cutanei  post.  sup.  and  inf.  (from X. radialis); 
ra,  terrftinal  branches  of  X.  radialis;  cm,  cl,  -Xn. 
cutanei  medius  (also  to  the  plexus)  and  lateralis 
(chiefly  to  the  X^.  medianus);  cp,  X.  cutan.  palmar., 
X.  rad.;  cmd,  X.  cutan.  medialis;  mc,  X^.  medianus; 
u,  X.  ulnaris;  cpit,  X*.  cutan.  palm,  ulnaris  (Henle). 


extending  the  first  phalanges 
of  the  fingers  and  thumb;  and,  as  Gowers  has  pointed  out,  flexion  i^  reduced 
to  one-third  of  the  normal,  the  flexors  having  lost  power  ''from  the  loss  of 
antergic  support."  As  a  rule,  in  musculospiral  palsy  there  is  loss  of  supination. 
Sensibility  is  sometimes  greatly  affected,  and  sometimes  very  slightly.     If  the 


The  Symptoms  of  Division  of  Nerves 


84; 


injury  is  above  the  level  of  the  musculospiral  groove  there  will  be  anesthesia  in 
the  area  suppHed  by  the  sensory  fibers  of  the  nerve  (Fig.  545).  If  the  nerve  is 
injured  in  the  musculospiral  groove  there  are  seldom  sensory  disturbances. 
Anesthesia  rarely  occurs  in  the  upper  arm  in  any  case,  and  even  after  an  injury 
in  the  groove  sensation  in  the  hand  may  be  normal  or  nearly  so.  Fig.  546 
shows  the  position  of  the  parts  in  musculospiral  palsy  and  Figs.  545  and  547 
the  sensory  distribution  of  the  nerve.  Fracture  of  the  humerus  may  cause 
division  of  the  musculospiral  nerve. 

The  Median  Nerve. — After  division  of  this  nerve  there  is  paralysis  of  the 
pronators;  the  flexor  carpi  radialis;  the  finger  flexors,  except  the  ulnar  por- 
tion of  the  deep  flexor;  the  abductors,  and  the  flexors  of  the  thumb;  and  the 
two  radial  lumbricales.  The  forearm  can  be  placed  in  a  position  midway 
between  pronation  and  supination;  but  further  pronation  cannot  be  volun- 
tarily effected.  In  executing  flexion  of  the  wrist  a  strong  deviation  toward  the 
ulnar  side  takes  place.  The  thumb  is  in  a  position  of  extension  and  abduction, 
and  cannot  be  brought  into  apposition  with  the  finger-tips.  The  second  pha- 
langes of  the  fingers  cannot  be  flexed  on  the  first,  and  the  distal  phalanges 


Fig.    546. — Paralysis    of    musculospiral    nerve  Fig.    547. — Distribution   of  sensory 

after  fracture  of  the  humerus  ("wrist-drop");  but  nerves  on  the  backs   of   the   fingers:  r, 

when  fingers  have  been  flexed  into  palm,  a,  they  can  Musculospiral  or  radial  nerve;  «,  ulnar 

be  extended,  b,  at   first  interphalangeal  Joints  by  nerve;  m,  median  nerve  (Krause). 
lumbricals  and  interossei,  which  are   supplied   by 
the  ulnar  and  median  nerves  (Erichsen). 

of  the  first  and  second  fingers  cannot  be  voluntarily  flexed.  The  corresponding 
phalanges  of  the  third  and  fourth  fingers  can  be  flexed,  this  being  accompHshed 
by  the  unparalyzed  ulnar  half  of  the  deep  flexor.  Flexion  of  the  first  pha- 
langes is  still  possible,  as  it  is  accomplished  by  means  of  the  interossei.  The 
extensor  action  of  the  interossei  muscles  upon  the  middle  and  distal  phalanges, 
being  unopposed,  may  eventually  cause  subluxation.  The  sensory  distri- 
bution of  the  median  nerve  is  shown  in  Figs.  545  and  547-549.  It  is  the  sen- 
sory nerve  of  the  radial  side  of  the  palm,  the  front  of  the  thumb,  the  first  and 
second  fingers  and  half  of  the  third  finger,  and  the  back  of  the  last  phalanx 
of  the  index  and  the  middle  finger  (Gowers).  The  sensory  changes  after 
median  paralysis  are  quite  variable — sometimes  widespread  and  complete, 
at  other  times  trivial,  and  occasionally  absent.  Gowers  says  that  if  there  is 
anesthesia  it  is  usually  of  the  palmar  surface,  but  it  may  also  occur  on  the  dorsal 
aspect  of  the  ends  of  the  first  two  fingers. 

The  Ulnar  Nerve. — When  this  nerve  is  divided  there  is  paralysis  of  the 
flexor  carpi  ulnaris,  of  the  ulnar  portion  of  the  deep  flexor,  of  the  muscles  of 
the  little  finger,  of  the  abductor  polHcis,  and  of  the  inner  end  of  the  flexor 
brevis  pollicis  (Gowers).  It  becomes  impossible  to  adduct  the  thumb,  and 
the  majority  of  the  movements  of  the  little  finger  are  abohshed.  Flexion  of 
the  fingers  is  impossible  at  the  first  joints,  and  extension  is  impossible  at  the 


846 


Diseases  and  Injuries  of  Nerves 


other  joints;  but,  as  Gowers  points  out,  the  loss  is  slighter  in  the  first  two 
fingers  than  in  the  others  because  the  lumbricales  of  the  first  two  fingers  are 


Fig.  548. — Section  of  median  nerve;  areas 
of  anesthesia  (heavy  shading)  and  of  dyses- 
thesia (light  shading)  on  palmar  surface  of 
hand  (Bowlby). 


Fig.  549. — Section  of  median  nerve;  re- 
gions of  anesthesia  and  dysesthesia  on 
dorsal  surface  of  hand  (Bowlby). 


supplied  by  the  median  nerve.     Interosseal  flexion  is  impossible,  and  the  op- 
ponents of  the  internssei,  acting  without  normal  antagonism,  contract  and  pro- 


FiG.  550. — Division  of  ulnar  nerve. 

duce  what  is  known  as  claw-hand  (Figs.  550  and  551),  a  condition  in  which  the 
first  phalanges  are  overextended  and  the  others  are  flexed.     The  sensory  loss 


FiG.  551. — Paralysis  of  ulnar  nerve  from  wound  at  A;  contracture  of  common  extensor  with 
posterior  luxation  of  first  phalanges;  B,  head  of  metacarpal  bone  (Duchenne). 

in  ulnar  paralysis  is  extremely  variable.  The  sensory  distribution  is  to  the 
ulnar  side  of  the  hand,  both  back  and  front,  involving  the  little  finger,  the  ring- 
finger,  and  the  ulnar  half  of  the  middle  finger  (Figs.  545,  547,  552,  and  553). 


The  Symptoms  of  Division  of  Nerves 


847 


The  lumbar  plexus  supphes  the  cutaneous  surface  of  the  lower  portion  of 
the  abdomen,  of  the  front  and  the  sides  of  the  thigh,  and  of  the  inner  por- 
tion of  the  leg  and  foot  (Fig.  554).  It  innervates  the  flexors  and  adductors 
of  the  hip-joint,  the  extensors  of  the  knee,  and  the  cremaster  muscle.  The 
branches  sent  to  the  leg  are  the  obturator  and  the  anterior  crural  nerves. 

The  sacral  plexus  supplies  the  extensors  and  rotators  of  the  hip,  the  knee- 
fiexors,  and  all  the  muscles  of  the  foot;  also  the  skin  of  the  gluteal  region,  the 
back  of  the  thigh,  the  outer  portion  and  the  posterior  part  of  the  lower  leg, 
and  most  of  the  foot  (Gov/ers)  (Fig.  554).  Its  chief  branches  are  those  to  the 
external  rotators  of  the  hip — the  gluteal  nerve,  the  small  sciatic,  and  the  great 
sciatic. 

The  Anterior  Crural  Nerve. — -When  this  nerve  is  divided  the  extensor  mus- 
cles of  the  knees  are  paralyzed.     The  psoas  muscle  is  not  affected,  even  if 


Fig.  552.  Fig.  553. 

Figs.  552  and  553. — Showing  sensory  loss  and  ordinary  position  in  injuries  of  the  ulnar  nerve 

(Bowlby). 

the  nerve  is  divided  within  the  abdomen;  but  high  division  may  produce  paraly- 
sis of  the  iliacus  muscle.  In  anterior  crural  palsy  the  skin  is  anesthetic  over 
almost  the  entire  thigh,  the  inner  surface  of  the  leg  and  foot,  and  the  inner 
sides  of  the  first  and  second  toes  (Fig.  554). 

The  Obturator  Nerve. — In  obturator  palsy  the  adductor  muscles  of  the 
thigh  are  paralyzed,  and,  in  consequence,  the  patient  is  unable  to  cross  one 
leg  over  the  other.  Gowers  points  oat  that  external  rotation  of  the  thigh  is 
also  interfered  with. 

The  Superior  Gluteal  Nerve. — The  division  of  this  nerve  paralyzes  the  gluteus 
medius  and  the  gluteus  minimus  muscles,  and  there  is  "loss  of  abduction  and 
circumduction  of  the  thigh"  (Gowers). 

The  Small  Sciatic  Nerve. — Division  of  this  nerve  paralyzes  the  gluteus  maxi- 
mus  muscle  and  produces  anesthesia  of  the  upper  half  of  the  calf  of  the  leg  and 
of  the  middle  third  of  the  back  of  the  thigh  (Gowers)  (Fig.  554). 

The  Great  Sciatic  Nerve. — If  this  nerve  is  divided  near  the  sciatic  notch 
there  is  a  paralysis  of  the  flexor  muscles  of  the  leg.  These  muscles,  as  Gowers 
points  out,-  are  also  extensors  of  the  hip.  There  is  likewise  paralysis  of  all  the 
muscles  below  the  knee.  If,  however,  the  injury  is  below  the  upper  third  of  the 
thigh,  there  is  no  paralysis  of  the  flexors  of  the  leg.  If  the  nerve  is  damaged 
on  a  level  below  the  small  sciatic,  there  is  anesthesia  of  the  outer  portion  of  the 
leg,  of  the  sole  of  the  foot,  and  of  most  of  the  dorsum  of  the  foot  (Fig.  554). 


848 


Diseases  and  Injuries  of  Nerves 


VVllCl 

..^—"^^  I    the  f( 

I  ('  "'■••.       /     tualb 

^- -^i       I         psiho 


The  External  Popliteal  Nerve. — When  this  neve  is  aivided,  there  is  paralysis 
of  the  tibiahs  anticus  muscle,  the  extensor  longus  digitorum,  the  extensor  brevis 
(ligitorum,  and  the  peronei;  and  the  patient  is  unable  to  Hex  the  ankle  and  ex- 
tend the  first  phalanges  of  the  toes. 
When  he  tries  to  walk  he  cannot  lift 
the  foot  from  the  ground;  and  even- 
tually there  is  the  development  of 
pes  equinus  (Gowers).  The  an- 
esthesia is  manifest  on  the  outer 
portion  of  the  anterior  surface  of  the 
leg,  and  also  on  the  dorsum  of  the  foot 
(Fig.  554)- 

The  Internal  Popliteal  Nerve. — 
Damage  to  this  nerve  paralyzes  the 
posterior  tibial  muscle,  the  flexor 
longus  digitorum,  the  muscles  of  the 
calf,  the  popliteus  muscle,  and  the 
muscles  of  the  plantar  surface  of 
the  foot.  The  toes  become  flexed 
at  the  two  distal  joints,  and  extend 
at  the  proximal  joints.  Walking 
is  greatly  interfered  with.  There 
is  loss  of  the  power  of  rotating  the 
flexed  leg  inward,  if  the  damage  is 
above  the  branch  to  the  popliteus 
muscle;  and  extension  of  the  ankle- 
joint  is  lost.  As  the  consequence, 
talipes  calcaneus  develops  (Gowers). 
The  anesthesia  is  variable,  but 
usually  involves  the  sole  of  the  foot 
and  the  outer  surface  and  lower  por- 
tion of  the  back  of  the  leg  (Fig.  554). 
The  Plantar  Nerves. — Division  of 
the  internal  plantar  nerve  paralyzes 
the  short-toe  flexor,  the  two  inner 
lumbricales,  and  the  plantar  muscles 
of  the  great  toe,  except  the  adductor 
(Gowers).  There  is  anesthesia  of 
the  inner  portion  of  the  sole  of  the 
foot  and  of  the  plantar  surface  of 
the  three  inner  toes  and  of  half  of 
the  fourth  toe  (Fig.  554). 

Division  of  the  external  plantar 
nerve  causes  paralysis  of  the  muscles 
of  the  little  toe,  of  the  adductor  of 
the  great  toe,  of  all  the  interossei,  of 
the  two  outer  lumbricales,  and  of 
the  flexor  accessorius  (Gowers). 
There  is  anesthesia  of  the  skin  of  the 
outer  half  of  the  sole  of  the  foot, 
of  the  little  toe,  and  of  half  of  the 


Anterior  surface. 


Posterior  surface. 


Fig.  554. — Distribution  of  the  cutaneous 
nerves  of  the  lower  extremity:  ii,  N.  ilio-inguinal. 
(plex.  lumb.);  li,  N.  lumbo-inguinal.  (to  the 
genitocrural,  plex.  lumbal.);  sc,  N.  spermat.  ext. 
(to  the  genitocrural);  cp,  N.  cutan.  post.  (plex. 
ischiad.);  c/,  N.  cutan.  lateral,  (plex.  lumb.);  cr, 
N.  cruralis  (plex.  lumbal.);  oht,  N.  obturator, 
(plex.  lumb.);  sa,  N.  saphen.  (plex. lumbal.) ; c/^f", 
N.  commun.  peron.  (N.  pcron.  tibial.);  cti,  N. 
commun.  tibial;  per',  per",  N.  peronaei  ram. 
superfic.  et  prof.;  cpm,  N.  cutan.  post.  med.  (plex. 
ischiad.);  cpp,  N.  cut.  plant,  propr.  (N.  tib.); 
phn,  pll,  N.  plantar,  medial,  et  lateral.  (N.  tib.) 
(Henle). 


fourth  toe  (Fig.  554). 
The  Facial  Nerve. — This  nerve  may  be  divided  during  the  mastoid  opera- 
tion or  may  be  lacerated  by  a  fracture  of  the  petrous  portion  of  the  temporal 
bone,  and  a  peripheral  palsy  results.     The  face  is  asymmetrical  and  is  drawn 
to  the  sound  side.     Asymmetry  becomes  more  marked  on  attempting  to  smile 


The  Treatment  of  Division  of  Nerves  849 

or  to  show  the  teeth.  Whisthng  and  frowning  are  impossible.  The  sense  of 
taste  may  be  less  acute  or  lost  on  the  anterior  two  thirds  of  the  tongue.  There 
is  relaxation  of  the  palate  and  deviation  of  the  u\Tila.  Reactions  of  degenera- 
tion can  be  demonstrated  in  the  palsied  muscles.  In  some  cases  there  are 
sensory  disturbances  (hx-peresthesia  or  anesthesia)  and  in  some  there  are  vaso- 
motor perturbations  on  the  palsied  side.  On  the  paralyzed  side  the  muscles 
are  relaxed,  the  nasolabial  fold  is  to  a  great  extent  gone,  the  nostril  cannot 
be  dilated.  The  brow  wrinkles  have  been  smoothed  out,  the  eyelids  cannot 
be  closed;  on  attempting  to  close  the  eye  the  globe  tilts  upward  and  outward. 
The  cornea  and  conjuntiva  inflame,  the  lower  lid  droops,  and  tears  run  down 
the  cheek. 

Treatment. — In  every  wound  in  which  a  nerve  or  nerves  might  be  damaged 
make  careful  search  and  examination  to  determine  whether  such  damage  is  present . 
Always  suspect  nerve  injury  in  wounds  of  the  wrist.  In  all  recent  cases  of  nerve- 
section  try,  if  possible,  to  suture  the  ends  of  the  divided  nerve.  The  earlier  suture 
is  done  the  better  the  chance  for  restoration  of  function.  For  instance,  in  fracture 
of  the  humerus,  with  division  of  the  musculospiral,  operate  at  once.  Primary 
suture  is  suture  within  twenty-four  hours  of  the  accident.  Within  two  weeks 
of  the  injury  it  is  possible  to  recognize  and  save  undestroyed  fibers  and  at  this 
period  suture  is  easy.  After-care  is  of  the  greatest  importance  in  all  cases  of 
nerve  suture.  Suture  may  fail.  There  may  be  partial  or  complete  restoration 
of  function.  In  123  reported  cases  of  primary  siUure,  119  were  cured  in  from 
one  day  to  one  year  (Willard).  The  return  of  sensation  may  be  rapid  or  may  be 
slow;  muscular  power  returns  more  slowly  than  sensation.  If  the  patient  is  not 
seen  until  long  after  the  accident,  incise  and  apply  sutures  (secondary  suttires) ;  if 
the  nerve  cannot  be  found,  extend  the  incision,  find  the  trunk  above  and  trace  it 
down,  and  find  the  trunk  below  and  follow  it  up.  The  results  are  not  nearly  so 
good  as  are  those  of  primary  suture.  Long  after  the  accident  a  considerable 
amount  of  scar  tissue  is  found  between  the  nerve  ends,  this  must  be  removed  and 
the  removal  creates  a  gap  which  when  bridged  by  nerve-suture  is  responsible 
for  tension  on  the  nerve.  The  earlier  the  operation  the  less  the  scar  tissue,  the 
narrower  the  gap  and  the  less  the  tension.  After-care  for  months  is  highly  im- 
Dortant.  In  130  reported  cases  of  secondary  suture  80  per  cent,  were  more  or 
less  improved  (Willard).  Even  after  primary  suture  loss  of  function  is  bound 
to  occur  for  a  time.  After  secondary  suture  sensation  may  return  in  a  few 
days,  but  it  may  not  return  until  after  a  much  longer  period;  in  any  case  mus- 
cular function  is  not  restored  for  months.  It  is  usually  stated  that  if  return 
of  function  is  not  manifested  in  six  months  it  will  not  occur,  but  Miiller  had  a 
radial  nerve  case  in  which  signs  of  return  of  function  were  not  noted  for  eleven 
months.  After  partial  section  of  a  nerve  the  ends  should  be  sutured.  In  per- 
forming secondary  suture  it  may  be  necessary  to  effect  lengthening  in  order  to 
approximate  the  ends  (see  page  851).  Transplantation  of  a  portion  of  nerve 
is  sometimes  practised  {implantation  or  anastomosis).  Nerve-grafting  is  bridg- 
ing the  gap  by^means  of  a  portion  of  nerve  from  one  of  the  lower  animals  or 
from  a  recently  amputated  human  limb.  Nerve-transplantation  may  fail 
utterly;  it  may  be  followed  by  great  improvement,  but  absolute  and  perfect 
restoration  of  function  cannot  be  obtained.  R.  Peterson^  has  made  a  study  of 
the  20  recorded  cases  of  nerve-grafting;  8  of  the  operations  were  primary  and  12 
were  secondary.  The  periods  after  the  injur}^  at  which  operation  was  performed 
varied  from  forty-eight  hours  to  a  year  and  a  quarter;  4  of  the  8  primary  cases 
improved;  8  of  the  12  cases  of  secondary  operation  showed  improvement  in 
motion  or  sensation.  The  distance  between  the  nerves  did  not  seem  to  affect 
the  results.  No  cases  recovered  completely,  but  in  i  case  sensation  returned 
completely  and  only  the  abductors  of  the  thumb  remained  weak.  In  most  of 
the  cases  that  were  benefited  sensation  returned  by  the  tenth  day  and  motion 

^  "Amer.  Jour.  Med.  Sciences,"  April,  1899. 

54 


850  Diseases  and  Injuries  of  Nerves 

within  two  and  a  half  months.  In  one  of  the  successful  cases,  that  of  A.  W. 
Mayo  Robson,^  the  spinal  cord  of  a  rabbit  was  used.  A  facial  nerve  divided  in 
the  aqueduct  of  Fallopius  may  perhaps  be  sutured  at  the  site  of  the  injury. 
This  should  be  attempted  as  soon  as  the  palsy  is  observed,  as  was  suggested,  I 
believe,  by  Frederick  Sydenham  ("Brit.  Med.  Jour.,"  May  8,  1909).  If  the 
ends  of  the  di\aded  nerve  cannot  be  approximated,  suture  a  distance  may  be 
practised,  as  was  done  successfully  by  Sydenham  (Ibid.).  If  suture  at  the 
site  of  injury  is  impossible  the  end  of  the  peripheral  segment  of  the  divided 
nerve  may  be  anastomosed  to  the  hypoglossal,  glossopharyngeal,  or  spinal 
accessory  nerve  (see  page  853). 

Pressure  upon  nerves  may  arise  from  callus,  scars,  a  dislocated  bone, 
a  tumor,  or  an  external  body. 

The  symptoms  may  be  anesthetic,  paralytic,  or  trophic. 

The  treatment  is  as  follows:  Remove  the  cause  (reduce  a  dislocated  bone^ 
chisel  away  callus,  excise  a  scar,  etc.);  then  employ  massage,  douches,  exercise^ 
and  electricity. 

Dislocation  of  the  Ulnar  Nerve  at  the  Elbow. — This  condition  is 
very  rare.  It  may  occur  as  a  complication  of  a  fracture  or  a  dislocation,  or 
as  an  uncomplicated  condition.  It  may  be  produced  by  violence  or  by  muscu- 
lar effort,  which  ruptures  the  fascia,  the  function  of  which  is  to  retain  the 
nerve  back  of  the  inner  condyle  of  the  humerus.  In  some  cases  the  symptoms 
are  slight  and  transitory,  the  nerve  functionating  well  in  its  new  situation. 
As  a  rule,  there  are  pain,  numbness,  or  anesthesia  of  the  ulnar  trajectory,  some 
stiffness  of  the  elbow,  and  stiffness  of  the  little  finger  and  ring-finger.  The 
nerve  can  be  felt  in  front  of  the  inner  cond3de  of  the  humerus.  In  some  cases 
neuritis  follows,  with  trophic  changes. 

Treatment. — Expose  the  nerve  by  an  incision,  incise  the  fibrous  tissue  back 
of  the  inner  condyle,  and  press  the  nerve  into  the  bed  prepared  for  it  and  hold 
it  in  place  by  sutures  of  chromic  catgut  passing  through  the  triceps  tendon. 
WTiarton  ad\ases  suturing  also  ''the  margin  of  the  fascial  expansion  of  the 
triceps  tendon  superficial  to  the  nerve. "^ 

Contusion  of  Nerves. — The  sjonptoms  of  contusion  of  nerves  may  be 
identical  with  those  of  section.  Sensation  or  motion,  or  both,  may  be  lost.  The 
case  may  recover  in  a  short  time,  or  the  nerve  may  degenerate  as  after  section. 

The  treatment  at  first  is  rest,  and  later  electricity,  massage,  friction,  and 
douches. 

Punctured  Wounds  of  Nerves. — The  symptoms  of  punctured  wounds 
of  nerves  may  be  partly  irritative  (hyperesthesia,  acute  pain,  and  muscular 
spasm)    and   partly   paralytic    (anesthesia,    muscular  wasting  and  paralysis). 

The  treatment  after  the  puncture  has  healed  is  the  same  as  that  for  con- 
tusion. 

Gunshot  Wounds  of  Peripheral  Nerves. — There  have  been  many 
nerve  injuries  in  this  war.  On  the  whole  the  results  of  treatment  have  been 
disappointing. 

The  nerves  most  commonly  injured  are  the  musculospiral  and  ulnar, 
next  to  them  comes  the  median  and  next  the  sciatic  and  the  external  popliteal 
(Moynihan,  Ibid.). 

A  bullet  may  split  a  nerve  longitudinally,  dividing  few  or  no  fibers — may 
partially  divide  or  completely  sever  a  nerve.  It  may  simply  open  a  sheath. 
The  resultant  scar  is  a  lateral  neuroma.  A  bruise  by  a  bullet,  or  the  passage  of 
a  bullet  near  a  nerve  may  cause  a  complete  physiological  interruption 
which  for  weeks  cannot  be  distinguished  from  anatomical  interruption. 
If  the  interruption  has  been  physiological  and  not  anatomical,  function  will 

i"Amer.  Jour.  Aled.  Sciences,"  April,  1899. 

-  A  report  of  14  cases  of  dislocation  of  the  ulnar  nerve  at  the  elbow,  by  H.  R.  Wharton, 
".\mer.  Jour.  Med.  Sciences,"  Oct.,  1895. 


Neurorrhaphy,  or  Nerve-suture  851 

show  positive  evidences  of  restoration  in  a  few  weeks.  Moynihan  says  we 
cannot  tell  before  operation  if  the  nerve  was  or  was  not  divided  ("American 
Addresses").  When  a  bullet  actually  strikes  a  nerve  it  produces  wide  damage 
to  the  nerve  tnnik  and  much  fil)rous  tissue  forms.  The  fibrous  tissue  which 
forms  between  the  ends  is  a  terminal  neuroma. 

If  a  nerve  is  injured  and  pus  forms  the  scar  is  sure  to  be  enormous  and  densely 
hard.  A  dense  scar  may  cause  frightful  pain.  It  is  sure  to  do  so  in  the  median 
nerve. 

If  a  bone  has  been  broken  by  a  bullet,  splinters  of  bone  may  be  driven  about 
and  into  the  nerve.  The  nerve  may  grow  first  to  the  broken  bone  or  callus  may 
press  upon  the  nerve.  Either  condition  produces  \dolent  pain.  An  intraneural 
scar  may  be  responsible  for  pain  or  palsy.     It  is  called  a  central  neuroma. 

If  early  suturing  were  always  possible  the  results  would  doubtless  be  much 
better.  But  it  is  seldom  that  a  surgeon  knows  a  nerve  has  been  completely 
divided.  There  is  often  a  very  grave  associated  injury  of  bone,  soft  parts  or 
both.  The  wound  must  be  regarded  as  infected  and  suture  in  a  purulent  area 
would  be  bound  to  fail.  Most  of  the  operations  have  been  done  after  cicatriza- 
tion of  the  wound. 

The  operation  may  show  no  lesion,  may  show  an  uncut  nerve  in  a  scar, 
may  show  a  partly  divided  or  a  completely  divided  nerve  in  a  scar. 

In  some  cases  even  on  exposing  the  nerve  we  cannot  be  sure  it  is  divided 
(Quenut) .  The  hard  mass  of  scar  between  the  ends  may  be  the  shape  and  size 
of  the  nerve  trunk.  Tuffier  has  been  so  disappointed  with  resection  of  the  scar 
and  suturing  that  he  now  simply  liberates  the  nerve  from  the  surrounding  scar 
and  surrounds  it  with  a  sheath.  He  leaves  a  bridge  of  scar  the  shape  and  diam- 
eter of  the  nerve  and  hopes  it  may  be  canalized  by  nerve-fibers.  Stoffel  not 
only  removes  the  perineural  scar  but  also  the  endoneural  scar  by  gently  sepa- 
rating the  nerve  tracts  longitudinally.  English  surgeons  believe  in  suturing 
(see  Neurorrhaphy). 

Moynihan's  rules  are  as  follows  ("American  Addresses"):  Operation  is 
decided  upon: 

1.  In  cases  of  complete  division. 

2.  In  cases  of  incomplete  division  where  progress  ceases. 

3.  Where  there  is  severe  neuralgic  pain  {causalgia). 
Operation  is  deferred: 

1.  For  one  month  after  closure  of  the  wound  if  the  soft  parts  only  were 
injured. 

2.  For  two  or  three  months  after  complete  closure  if  bone  was  involved. 

3.  Definitely   so   long  as   evidences   of  progressive   restoration  are  found. 

Operations  Upon  Nerves 

Neurorrhaphy,  or  Nerve=suture. — When  a  nerve  has  been  completely  or 

partially  divided  by  accident  it  should  be  sutured  at  the  first  possible  moment. 
Round  needles  are  used.  If  there  is  no  tension  the  best  suture  material  is 
fine  plain  catgut;  if  there  is  any  tension,  lightly  chromicized  catgut  (Sherren, 
in  "Brit.  Med.  Jour.,"  Jan.  15,  1910).  Sherren  points  out  that  if  silk  or  linen 
is  used  it  interferes  with  complete  recovery  and  may  cause  symptoms  months 
after  the  operation.  In  primary  suture  render  the  part  aseptic.  Formerly  I 
used  the  elastic  band  to  secure  a  bloodless  field.  Lately  I  have  given  it  up. 
It  may  damage  the  di\dded  nerve  or  other  nerves  and  may  be  followed  by 
oozing  of  the  blood  between  and  about  the  nerve-ends.  Enlarge  the  incision 
if  necessary.  Handle  the  nerve  as  little  as  possible  and  do  not  raise  it  from  its 
bed  for  any  considerable  distance.  If  the  ends  can  readily  be  approximated, 
pass  two  or  three  sutures  through  the  sheath  and  connective  tissue  outside,  and  tie 
them  (Figs.  555,  556).    If  the  ends  cannot  be  approximated,  stretch  each  end  and 


8^2 


Diseases  and  Injuries  of  Nerves 


Fig.  555. — Nerve-suture. 


then  suture.  The  sutures  do  not  traverse  the  nerve,  but  go  through  the  perineu- 
rium and  adjacent  connective  tissue.  If  the  nerve  is  found  partially  divided  the 
cut  fibers  are  sutured  in  the  same  way  and  the  undivided  portion  is  folded  upon 
itself  so  as  to  permit  approximation.  Suture  the  deep  fascia.  Arrest  bleeding, 
suture  the  skin,  dress  antiseptically,  and  put  the  muscles  supplied  by  the  injured 
nerve  in  a  relaxed  position  and  fix  the  limb  on  a  splint.  After  union  of  the  wound 
continue  the  use  of  thesplint  to  maintain  muscular  relaxation  as  long  as  the  muscles 
are  paralyzed  (Ibid.),  and  use  massage,  friction,  electricity, 
and  the  douche.  When  voluntary  power  returns  remove 
the  splint  and  insist  on  active  exercise.  The  operation 
in  some  instances  fails,  but  in  many  cases  succeeds.  In 
some  few  cases  sensation  returns  in  a  few  days,  but  in 
most  cases  does  not  return  for  many  weeks  or  months. 
Sensation  is  restored  before  motor  power.  After  successful 
suturing  of  a  divided  median  nerve  sensations  of  skin  pain  and  of  extreme  heat 
and  cold  appeared  in  fifty-six  days  and  were  restored  in  two  hundred  and  seven 
days.  Sensations  of  light  touch  and  slight  degrees  of  heat  and  cold  appeared  in 
two  hundred  and  sixty  days  and  were  not  completely  restored  for  one  year 
(Kenneth  A.  J.  Mackenzie,  in  "Annals  of  Surg.,"  July,  1909).  Secondary  suture 
is  performed  upon  cases  long  after  division  of  a  nerve.  If  operation  is  not  done 
for  three  years  or  more  after  division  it  is  very  improbable  that  complete  regenera- 
tion will  ever  occur,  and  yet  it  is  always  worth  trying,  for  muscular  control  has 
been  regained  after  suturing  in  i  case  twenty-nine  years  subsequent  to  nerve 
division  (Alfred  S.  Taylor,  in  "Jour,  of  Orthopedic  Surg.,"  Nov.,  1908).  The 
part  is  rendered  aseptic.  An  elastic  band  is  not  used.  An  incision  is  made.  The 
nerve  trunk  is  looked  for  and  identified  above  and  below  the  point  of  division. 
The  bulbous  upper  end  is  easily  found,  the  lower  end  is  much  more  difficult  to 


't  IS 


n  'It'      i'    'I 

Fig.  556. — Nerve-suture:  a.  Direct;  b,  perineurotic;  c,  paraneurotic;  d,  e,  ncuroplasty  (Senn). 

locate.  The  perineural  scar  is  dissected  from  the  nerve  with  a  very  sharp 
knife,  scrupulous  care  being  taken  to  save  the  nerve  from  injury,  and  to  avoid 
squeezing,  pulling,  twisting  and  lifting  the  nerve  extensively  from  its  bed. 

The  bridge  of  fibrous  tissue  between  the  ends  in  examined.  If  the  distance 
between  the  ends  is  considerable  gently  stretch  each  end  by  making  traction 
up  and  down  on  the  fibrous  bridge.  Moynihan  ("American  Addresses")  says: 
"The  fibrous  band  is  now  split  longitudinally,  and  then  its  ends  are  divided  above 
in  one  direction,  below  in  the  other,  so  that  to  each  cut  end  of  nerve  a  fibrous 
tag  is  attached  by  means  of  which  the  nerve-ends  can  be  drawn  together." 
"Progressive  transverse  cuts  are  now  made  into  the  nerve-cells  until  on  the 
cross-section  nothing  but  nerve  fibers  are  seen.  Even  the  tiniest  particle  of 
fibrous  tissue  must  be  removed  or  the  operation  wall  fail." 


Nerve-grafting  853 

If  in  spite  of  the  preliminary  stretching  approximation  is  not  possible 
some  surgeons  adopt  the  expedient  shown  in  Fig.  556,  </,  or  that  portrayed  in 
Fig.  557.  This  operation  is  neuroplasfy  by  the  flap  method.  Another  method 
is  to  make  a  bridge  of  strands  of  catgut  running  from  one  divided  end  to 
the  other.  We  speak  of  this  plan  as  suture  a  distance  (Fig.  556,  e).  The  catgut 
bridge  is  thought  to  support  the  growing  reparative  material.  It  does  not 
seem  possible  to  me  that  either  neuroplasty  or  suture  a  distance  can  be  of  any 
service.  In  fact  Sir  Berkley  Moynihan  says  of  them  that  they  "are  methods 
with  nothing  whatever  to  recommend  and  with  everything  to  discredit  them." 
("American  Addresses"). 

Allis  suggested  shortening  the  limb  by  resecting  a  piece  of  bone.  This  has 
been  done  successfully  by  Keen,  Rose,  and  others. 

Guelliot  suggested  tuhulization  after  all  operations  of  nerve-suture,  that  is, 
erecting  barriers  along  the  path  of  reparative  material  to  save  the  ends  of  the 
nerve  from  cellular  invasion  from  the  perineural  struc- 
tures,  which  would  deviate  the  new  nerve  fibers  and  ^^~^\       \ 
would  block  repair.     Even  a  blood-clot  might  prevent 
repair.     Tubulization    is    supposed     to    guide    and 
protect    the    new   fibers.     Vanlair    uses   a  piece  of 
artery  which  has  just   been   removed  or  surrounds 

the  ends  with  decalcified  bone.     Payr  uses  a  tube  of  

absorbable    magnesium.     Hashimoto    and    Toknoka    nerve  Vsph^in^g  "the  ends 

use  a  vem  or  artery  from  a  recently  slaughtered  calf,    (Beach). 

hardened  in  formalin.     Many   surgeons    have    used 

Cargile  membrane.     Edinger  uses  a  bit  of  artery  filled  with  agar  jelly. 

Gelatin  tubes  have  been  used,  silver-foil  has  been  tried,  and  Cargile  mem- 
brane has  been  employed.  None  of  these  plans  is  entirely  satisfactory.  Murphy 
covers  the  line  of  nerve-suture  with  fascia,  muscle,  or  fat.  In  regions  where 
he  cannot  obtain  suitable  covering  tissue  he  wraps  about  the  suture  line  a  material 
composed  of  equal  parts  of  paraffin  and  oil  of  sesame.  This  mixture  can  be 
flattened  out  very  thin  ("Surg.,  Gynec,  and  Obstet.,"  April,  1907). 

I  used  to  surround  the  nerve  with  Cargile  membrane  but  abandoned  the 
practice. 

-Sir  Berkley  Moynihan  ("American  Addresses")  questions  the  value  of  sur- 
rounding the  nerve  with  any  protective  material,  says  that  such  procedures  are 
sometimes  harmful,  that  they  prevent  free  access  of  blood  and  cause  adhesions 
and  compression  of  the  nerve.  He  advises  us  to  avoid  all  such  membranes 
and  simply  to  be  certain  that  "the  nerve  is  laid  along  the  path  of  uninjured 
tissues." 

Implantation  or  anastomosis  is  employed  in  some  cases.  In  this  operation 
the  distal  end  of  a  palsied  nerve  is  inserted  into  an  adjacent  nerve  of  like  or  simi- 
lar function.  Letievant  attaches  the  peripheral  portion  of  a  divided  nerve  into 
a  longitudinal  slit  in  a  sound  nerve  {end-to-side  anastomosis).  Some  surgeons 
have  implanted  the  divided  ends  into  a  sound  nerve,  either  splitting  the  sound 
nerve  or  leaving  it  unsplit. 

Moynihan  (Ibid.)  in  speaking  of  nerve  anastomosis  says:  "All  such  proce- 
dures are  worthless  and  cannot  be  too  strongly  condemned.  I  have  never 
seen  any  good  come  of  them ;  indeed,  nothing  but  harm  could  conceivably  result 
from  section  of  a  healthy  nerve."  The  operation  of  anastomosis  is  employed 
after  an  exsection  which  leaves  a  very  large  gap,  for  facial  palsy,  for  infantile 
palsy,  for  avulsion  of  the  brachial  plexus,  and  for  brachial  birth  palsy. 

Nerve=grafting  is  practised  by  some.  A.  W.  Mayo  Robson  used  the 
spinal  cord  of  a  rabbit  to  fill  a  gap  between  the  ends  of  the  divided  median 
nerve  of  a  man.  The  restoration  of  function  was  almost  complete.  Some 
surgeons  have  grafted  in  bits  of  nerve  obtained  from  a  recently  amputated 
Hmb.     It  makes  no  difference  whether  the  grafted  nerve  is  motor,  sensory. 


854  Diseases  and  Injuries  of  Nerves 

or  mLxed.  The  results  of  grafting  are  seldom  good.  Some  use  as  a  graft  a  bii 
of  cutaneous  nerve,  for  instance  the  radial,  the  internal  cutaneous  of  the  thigh 
or  an  intercostal  nerve.  Chas.  A.  Powers  ("Transactions  of  the  American 
Surgical  Assoc."  1904)  collected  22  cases  from  literature,  20  from  Peterson's 
paper,  i  case  of  Durante's,  and  i  of  his  own.  In  this  series  there  were  3  good 
results  and  3  "fair"  results.  Robson  ("Brit.  Med.  Jour."  Jan.  27,  1917)  reports 
another  striking  case  of  nerve-grafting.  All  the  nerves  supplying  the  forearm, 
except  the  musculospiral  had  been  cut  seven  months  before.  The  gap  between 
the  ends  of  the  ulnar  was  bridged  by  a  part  of  the  sciatic  nerve  of  a  rabbit. 
The  gap  between  the  ends  of  the  median  was  bridged  by  a  part  of  the  rabbit's 
spinal  cord.  In  eleven  days  sensation  began  to  return.  Complete  restoration, 
motor  and  sensory,  was  obtained  in  six  months.  The  bit  of  nerve  grafted  does 
not  participate  in  repair — it  is  a  mere  bridge,  and  acts  as  would  the  suture  a 
distance  if  it  worked. 

If  a  divided  nerve  cannot  unite  tendon  transplantation  may  be  practised. 
"Tendon  transplantation,  especially  in  the  case  of  the  musculospiral  nerve  and 
the  posterior  interosseous,  gives  results  which,  in  point  of  function,  are  almost  as 
good  as  those  which  come  from  nerve  suture  and  in  point  of  time  are  much 
quicker." 

Neurectasy,  Neurotomy,  and  Neurectomy. — Neurectasy,  or  nerve- 
stretching  may  be  applied  to  motor,  sensory,  or  mixed  nerves.  A  nerve  can 
be  stretched  about  one-twentieth  of  its  length.  Neurectasy  has  been  employed 
for  neuralgia,  neuritis,  muscular  spasm,  hyperesthesia,  anesthesia,  painful 
ulcer,  perforating  ulcer,  the  pains  of  locomotor  ataxia,  and  many  other  condi- 
tions. The  operation,  which  was  once  the  fashion,  seems  to  benefit  some  cases, 
but  it  is  not  now  thought  so  highly  of  as  formerly.  The  incision  for  neu- 
rectasy is  identical  with  the  incision  for  neurectomy  or  neurotomy  of  the  same 
nerve.  Neurotomy,  or  section  of  nerve,  is  performed  only  upon  small  and  purely 
sensory  nerves  (in  spasmodic  wry-neck  a  motor  nerve  is  cut).  It  is  performed 
chiefly  for  peripheral  neuralgia  or  for  some  other  painful  malady.  It  is  almost 
useless  in  painful  conditions,  because  sensation,  as  a  rule,  soon  returns.  Paget 
saw  complete  return  of  sensation  in  four  weeks  after  division  of  the  median 
nerve.  Corning  endeavors  to  prevent  this  regeneration  by  inserting  oil  between 
the  ends.  He  uses  oil  of  theobroma  containing  enough  paraffin  to  make  the 
melting-point  105°  F.  The  oil  is  melted,  is  injected  around  the  nerve,  and 
cold  is  applied.  The  nerve  is  now  sectioned  with  a  canaliculated  knife,  the 
ends  are  separated  widely,  more  oil  is  injected,  and  cold  is  again  applied.  The 
theory  is  that  this  oil,  which  is  solid  at  the  temperature  of  the  body,  devitalizes 
the  nerve  at  the  point  of  section  and  acts  as  a  barrier  to  the  passage  of  regenerat- 
ing fibers.  This  method  has  been  applied  especially  in  cervicobrachial  neu- 
ralgia-^  Neurectomy,  or  excision  of  a  portion  of  a  nerve-trunk,  is  applicable  to 
sensory  nerves  and  to  painful  aff'ections. 

Sympathectomy. — Jonnesco's  Operation. — It  has  long  been  known  that 
division  of  the  sympathetic  nerve  in  the  neck  may  produce  important  changes 
in  the  eye  and  in  the  cerebral  circulation.  In  1893  Jaboulay  divided  the 
sympathetic  on  each  side  for  the  purpose  of  treating  epilepsy.  The  removal 
of  the  ganglia  of  the  sympathetic  was  proposed  by  Baracz;  and  the  operation 
was  first  performed  by  Jonnesco,  in  1896,  for  epilepsy.  The  operation  is 
performed  by  some  surgeons  for  epilepsy,  for  exophthalmic  goiter,  for  glau- 
coma, and  for  trifacial  neuralgia.  In  operating  for  glaucoma  the  superior 
cervical  gangHon  on  each  side  is  removed,  as  it  is  from  this  that  the  sympa- 
thetic fibers  that  pass  to  the  eye  are  derived.  If  the  operation  is  done  at  all, 
it  should  be  a  bilateral  one. 

This  operation  is  used  in  epilepsy  on  the  theory  that  there  is  an  anemic  con- 
dition of  the  brain  in  this  disease  which  is  corrected  by  producing  a  h\T)ere- 
1  "Medical  Record,"  Dec.  5,  1896. 
-"^Medical  Record,"  Dec.  5,  1896. 


Neurectomy  of  the  Supra-orbital  Nerve  855 

mia,  and  that  the  hyperemia  improves  cerebral  nutrition.  The  opera- 
tion in  epilepsy  is  largely  theoretical,  although  Jonnesco  claims  12  per  cent, 
of  cures  in  a  large  number  of  operations.  In  exophthalmic  goiter  there  seems 
to  be  some  distinct  evidence  that  the  operation  may  be  beneficial,  but  Curtis 
shows  that  the  mortality  is  high.  Personally,  I  have  not  employed  it  in  epi- 
lepsy, and  at  the  present  time  I  should  not  be  inclined  to  do  so.  In  exoph- 
thalmic goiter,  if  any  operation  is  necessary,  I  perform  partial  thyroidectomy 
or  ligation  of  the  thyroid  arteries;  but  in  progressive  glaucoma,  which  is  always 
so  absolutely  hopeless,  the  operation  is  a  justiiiable  procedure  and  occasionally 
seems  to  have  a  distinct  influence  in  retarding  the  development  of  the  disease. 

The  incision  should  be  made  along  the  posterior  margin  of  the  sterno- 
cleidomastoid muscle.  I  have  become  convinced,  in  performing  two  opera- 
tions of  this  kind  and  through  studies  made  upon  the  dead  body,  that  the 
ganghon  may  be  more  easily  reached  from  behind  the  sternocleidomastoid 
than  from  in  front  of  it.  The  internal  jugular  vein  and  the  carotid  artery 
are  lifted  upward  and  forward;  and  the  superior  ganglion  will  usually  adhere 
to  the  under  portion  of  the  carotid  sheath  and  be  lifted  up  with  it.  Theo- 
retically, it  is  not  necessary  to  open  the  carotid  sheath  in  this  operation,  but, 
practically,  this  had  better  be  done,  so  that  one  may,  without  any  possibihty 
of  doubt,  distinguish  between  the  pneumogastric  and  the  sympathetic  nerve. 
The  moment  the  nerve  is  cut  the  pupil  on  that  side  will  contract. 

Stretching  of  the  Sciatic  Nerve.— Some  surgeons  stretch  the  sciatic 
nerve  by  anesthetizing  the  patient  and  holding  the  leg  and  thigh  in  hne,  strong 
flexion  being  made  upon  the  hip,  the  entire  lower  extremity  being  used  as  a 
lever.  This  method,  which  has  caused  death,  inflicts  needless  damage,  and 
stretching  after  an  incision  has  been  made  is  safer  and  better.  The  patient  lies 
prone,  the  thigh  and  legs  being  extended.  An  incision  4  inches  in  length  is  made 
a  little  external  to  the  middle  of  the  thigh,  and  going  at  once  through  the  deep 
fascia;  the  biceps  muscle  is  found  and  is  drawn  outward;  the  nerve  is  discovered 
between  the  retracted  biceps  on  the  outside  and  the  semitendinosus  on  the 
inside,  resting  upon  the  adductor  magnus  muscle.  The  nerve,  which  is  caught 
up  by  the  finger,  is  first  pulled  down  from  the  spine  and  then  up  from  the  per- 
iphery, and  finally  the  hook  of  a  scale  is  inserted  beneath  the  trunk  and  the 
nerve  is  stretched  to  the  extent  of  40  pounds.  Very  rarely  is  even  a  single 
ligature  needed.  The  wound  is  sutured  and  dressed.  If  the  incision  is  made 
at  a  higher  level,  just  below  the  gluteofemoral  crease,  the  sciatic  nerve  will  be 
found  just  at  the  outer  border  of  the  biceps. 

Neurectomy  of  the  Infra=orbital  Nerve. — This  operation  was  first 
performed  by  Abernethy  in  1793.  The  patient  lies  upon  his  back,  the  head 
being  raised  a  little  by  pillows.  The  surgeon  stands  to  the  outside  of  and 
faces  the  patient.  A  curved  incision  i3^^  inches  long  is  made  below  the  lower 
border  of  the  orbit.  The  nerve  lies  in  a  line  dropped  from  the  supra-orbital 
notch  to  between  the  two  lower  bicuspid  teeth  and  is  found  upon  the  levator 
labii  superioris  muscle.  A  piece  of  silk  is  passed  under  the  nerve  by  an  aneu- 
rysm needle  and  firmly  fastened.  The  upper  border  of  the  incision  is  drawn 
upward;  the  periosteum  of  the  floor  of  the  orbit  is  elevated  and  held  by  a 
retractor;  the  roof  of  the  infra-orbital  canal  is  broken  through;  the  nerve 
is  picked  up  far  back  by  the  blunt  hook  and  is  divided  by  scissors,  and  the 
entire  nerve  in  front  of  the  section  is  drawn  out  by  making  traction  upon  the 
silk.  The  bleeding  in  the  orbit  is  checked  by  pressure.  The  wound  is  stitched 
without  drainage. 

Neurectomy  of  the  Supra=orbital  Nerve. — Before  sterilizing  the  parts 
shave  off  the  eyebrow.  A  curved  incision  i  inch  long  discloses  the  nerve  as 
it  emerges  from  the  supra-orbital  notch  or  foramen  at  the  junction  of  the 
inner  and  middle  thirds  of  the  eyebrow.  The  nerve  is  pulled  forward  and  cut 
off  above  and  below. 


856  Diseases  and  Injuries  of  Nerves 

Neurectomy  of  the  Inferior  Dental  Nerve. — Make  a  curved  incision 
around  the  angle  of  the  jaw.  Lift  the  supramaxillary  branch  of  the  facial 
nerve  downward  (Kocher).  Separate  the  masseter  muscle  by  a  periosteum 
elevator  and  slight  touches  of  the  knife.  Chisel  an  oj)ening  in  the  center 
of  the  ascending  ramus  (Velpeau's  rule).  This  opening  exposes  the  beginning 
of  the  dental  canal.  If  necessary,  the  opening  may  be  enlarged  by  a  rongeur. 
Pull  the  nerve  out  by  a  hook  and  remove  a  piece  from  it. 

Extracranial  Operation  for  Neuralgia  of  the  Fifth  Nerve  (Tic  Dou- 
loureux.— Removal  of  portions  of  the  pain-haunted  nerve-trunks  some- 
times cures  the  condition  and  often  ameliorates  it  for  a  considerable  time. 
Avulsion  of  a  nerve  by  the  method  of  Thiersch  removes  a  large  piece  and  gives 
better  results  especially  if  the  nerve-canal  is  plugged  to  prevent  regeneration. 
The  nerve  is  twisted  slowly  around  a  blunt  forceps  and  Mayo  plugs  a  canal  with 
a  silver  screw.  Albee  and  others  use  a  bone-graft.  The  injection  of  osmic  acid 
into  the  peripheral  nerves,  or  of  alcohol  into  the  nerves  as  they  emerge  from  the 
cranium,  may  actually  cure  or  secure  prolonged  relief.  The  serious  operation 
of  remo\'ing  the  ganglion  may  be  performed  if  peripheral  operations  and  injec- 
tions fail,  or  in  violent  and  intractable  cases  of  long  standing  in  which  pain  is  felt 
in  more  than  one  branch.  Removal  of  nerves  by  ordinary  neurectomy  often 
gives  comfort  for  a  few  months,  but  rarely  gives  prolonged  relief.  In  the 
worst  forms  of  tic  douloureux,  particularly  in  those  cases  in  which  there  are 
facial  spasm  and  vasomotor  phenomena,  relief  following  peripheral  operations  is 
usually  transitory.  If  we  seek  striking  benefit  by  an  extracranial  operation,  it 
must  be  thoroughly  done. 

Injection  of  Osmic  Acid. — As  long  ago  as  1874,  Bartholow  injected  chloro- 
form about  and  into  nerves.  Osmic  acid  was  suggested  by  Billroth  and  Neuber 
in  1884.  It  was  strongly  advocated  by  Bennett,  of  London,  in  1897.  Osmic 
acid  had  been  used  for  many  years  in  a  sort  of  haphazard  way,  having  been 
injected  into  tissues  about  the  nerves  by  means  of  a  hi-podermic  syringe. 
Bennett  suggested  exposure  of  the  nerve  and  the  injection  of  5  to  10  min.  of  a 
I  per  cent,  solution.  Acid  when  so  used  actually  destroys  nerve-fibers,  and  a 
considerable  amount  of  fibrous  tissue  forms  which  intercepts  regenerating  fibers. 
It  is  probable  that  secondary  degenerative  changes  occur  in  the  nerve-trunks, 
but  they  do  not  ascend  and  reach  the  ganglion.  Murphy  warmly  advocates 
the  method.  It  certainly  produces  immediate  relief  by  causing  anesthesia,  but 
such  relief  is  very  seldom,  if  ever,  permanent.  I  have  used  it  in  several  cases 
with  satisfaction.  In  i  case  in  which  I  exposed  the  ganglion  I  injected  that 
structure,  and  the  result  seemed  to  be  the  same  as  if  I  had  removed  the  ganglion. 
In  neuralgia  of  the  fifth  nerve  the  painful  nerve  or  nerves  should  be  exposed,  and 
from  5  to  10  min.  of  a  2  per  cent,  solution  of  osmic  acid  injected  into  several 
different  parts  of  the  nerv^e  and  also  between  the  nerve-sheath  and  the  bony 
canal  (Murphy).     The  osmic  acid  method  does  not  seem  to  grow  in  favor. 

Injections  of  Alcohol  into  the  Second  and  Third  Division  of  the  Fifth  Nerve. 
— Dr.  Matas  as  long  ago  as  1889  planned  routes  to  reach  the  branches  of  the 
fifth  nerv^e  in  order  to  produce  regional  anesthesia  (Urban  Maes  Review  of  Sur- 
gical Treatment  of  Tic  Douloureux  in  Internat.  Abst.  of  Surgery,  Oct.,  1915). 
Alcohol  injections  were  introduced  by  Schlosser  in  1903.  The  injections  are 
made  into  peripheral  branches  or  di\asions  of  the  ganglion,  and  have  even  been 
made  into  the  ganglion.  Hartel  enters  the  needle  through  the  foramen  ovale 
and  injects  the  ganglion,  a  difficult  and  uncertain  procedure.  Pollock  and 
Potter  suggest  injecting  the  ganglion  under  fluoroscopy  ("Jour.  Am.  Med. 
Assoc,"  Nov.  14,  1916).  Siccard  and  others  have  warmly  praised  the  alcohol 
injection  method.  It  acts  similarly  to  osmic  acid.  It  produces  local  necrosis 
of  the  nerve  and  fibrosis  about  it.  The  necrosis  does  not  tend  to  ascend 
(May,  "Brit.  Med.  Jour.,"  Aug.  31,  1912).  It  gives  relief  sometimes  after  one 
injection,  sometimes  after  two  or  more.     The  permanence  of  the  relief  is  uncer- 


Rose's  Method  of  Neurectomy  857 

tain.  Usually  it  is  complete  for  six  months  and  then  recurrent  pain  may 
require  renewed  injection.  Recurrences  are  milder  than  the  previous  condition. 
Apparent  cure  may  last  for  three  or  four  years. 

I  have  used  the  method  many  times  and  am  satisfied  as  to  its  value  in  proper 
cases.  It  is  superior  to  peripheral  operations.  It  is  used  in  very  old  subjects, 
feeble  subjects,  the  victims  of  grave  organic  disease,  and  in  those  who  refuse 
radical  operation.  In  strong  young  persons  removal  of  the  ganglion  may  still 
be  preferred.  In  some  cases  alcohol  is  used  before  a  ganglion  extirpation  in  order 
to  remove  pain  and  permit  of  such  improvement  in  health  and  strength  as  to 
make  the  radical  operation  safer.  Never  attempt  to  make  a  deep  injection 
about  the  ophthalmic  branch.  To  do  so  may  damage  a  great  vessel,  the  optic 
nerve,  the  third,  fourth,  or  sixth  nerve,  or  the  alcohol  may  enter  the  orbit 
and  destroy  the  eye.  If  there  is  pain  in  the  supra-orbital  and  supratrochlear 
branches,  inject  them  where  they  are  superficial. 

Injection  of  the  Supra-orbital  Branch. — Use  an  ordinary  hypodermic  needle 
and  inject  10  to  20  min.  of  the  fluid  recommended  below.  Throw  the 
fluid  about  the  nerve  at  the  foramen.  After  withdrawing  the  needle  make 
pressure  at  the  puncture.  Such  pressure  is  advised  by  Patrick  to  stop  bleed- 
ing, prevent  a  black  eye,  keep  the  tissues  exsanguine,  and  add  to  the  effect 
C'Jour.  Am.  Med.  Assoc,"  Jan.  20,  191 2).     The  lids  always  swell. 

I  used  for  a  time  80  per  cent,  alcohol,  each  dram  of  which  contained  ^-q  gr. 
of  stovain,  but  this  hardens  the  tissues  so  much  that  they  become  resistant  to 
reinjection.  I  now  use  Patrick's  formula,  viz.:  2  gr.  of  muriate  of  cocain,  2}^'^ 
drams  of  alcohol,  and  distilled  water  sufficient  to  make  }'2  oz.  The  usual  dose  is 
2  c.c.  A  special  needle  is  used.  It  is  straight,  is  graduated  in  centimeters, 
and  carries  a  stylet  which  is  flush  with  the  point.  The  stylet  is  pulled  back 
slightly  while  the  needle  is  being  driven  through  the  skin  and  fascia;  it  is  then 
pushed  all  the  way  in.  Various  plans  have  been  suggested  for  reaching  the 
nerves  (see  Dorran  plan  in  "Penna.  Med.  Jour.,"  August,  1916).  I  follow  the 
method  of  Levy  and  Baudoin  (''Presse  Med.,"  April  17,  1906),  which  is  as 
follows : 

Superior  Maxillary  Division. — Drop  a  perpendicular  from  the  posterior 
border  of  the  orbital  process  of  the  malar  bone  (the  beginning  of  the  zygoma) 
to  the  inferior  edge  of  the  zygoma;  %o  c.c.  back  of  this  point  is  where  the 
needle  should  be  introduced.  It  is  carried  in  and  very  slightly  upward.  At 
a  depth  of  2  cm.  the  coronoid  process  may  obstruct;  at  a  greater  depth,  the 
external  pterygoid  plate.  Either  obstruction  may  be  avoided  by  inclining  the 
needle  very  slightly  forward  (never  much  or  alcohol  may  enter  the  orbit). 
At  a  depth  of  5  cm.  the  needle  encounters  the  nerve  as  it  emerges  from  the 
foramen  rotundum.  The  injection  usually  causes  decided  but  brief  pain.  If 
the  injection  reaches  the  nerve  there  will  be  immediate  analgesia  throughout 
its  trajectory.     This  should  last  two  or  three  days. 

Inferior  Maxillary  Division. — The  point  for  entrance  of  the  needle  is  at  the 
lower  border  of  the  zygoma,  2.5  cm.  in  front  of  the  anterior  root  of  the  zygoma. 
The  needle  is  carried  inward,  somewhat  backward,  and  slightly  upward.  At  a 
depth  of  4  cm.  the  nerve  is  reached.  Be  sure  the  nerve  has  been  reached  by 
finding  analgesia  throughout  its  trajectory  after  injection. 

Rose's  Method  of  Neurectomy.^ — This  operation  is  a  modification  of 
the  Braun-Lossen  method,  and  is  employed  when  the  second  division  of  the 
fifth  nerve  is  the  seat  of  pain.  The  infra-orbital  nerve  is  exposed  by  an 
incision,  a  Hgature  is  tied  around  it,  the  roof  of  the  infra-orbital  canal  is  opened 
by  a  chisel,  and  the  nerve  is  traced  back  as  far  as  possible.  The  wound  is  then 
packed  temporarily  with  gauze.  The  next  step  in  this  operation  is  to  open 
a  way  into  the  sphenomaxillary  fossa  (Fig.  558).  The  knife  is  inserted  slightly 
below  the  external  angular  process  of  the  frontal  bone,  is  carried  back  along  the 
^See  article  by  Wm.  Rose,  "Practitioner,"  March,  1900. 


«58 


Diseases  and  Injuries  of  Nerves 


zygoma,  down  in  front  of  the  ear  to  just  above  tlie  angle  of  the  jaw,  and  then 
forward  for  2  inches.  This  flap,  which  is  composed  of  skin  and  subcutaneous 
fat  only,  is  dissected  forward,  and  Steno's  duct  and  branches  of  the  facial  nerve 
are  not  damaged.  The  flap  is  wrapped  in  gauze  and  temporarily  stitched  to  the 
side  of  the  nose.  The  zygoma  is  exposed  by  a  transverse  incision.  At  the 
root  of  the  zygoma  two  holes  are  drilled  I4  inch  apart,  and  two  more  holes  3^^ 
inch  apart  are  drilled  through  the  zygomatic  process  of  the  malar  bone.  The 
zygoma  is  then  divided  by  a  saw  (Fig.  559).  The  posterior  saw  line  runs 
between  the  two  drill-holes  at  the  root  of  the  zygoma.  The  anterior  cut  passes 
between  the  two  anterior  drill-holes.  The  direction  of  the  first  cutis  directly 
downward.  The  direction  of  the  second  cut  is  downward  and  forward  from 
above.     The  arch  is  freed  and  detached  downward  and  backward.     The  exposed 

tendon  of  the  temporal  muscle  is  retracted 
-     ~  ^  backward.     The  removal    of    a  little   fat 


Fig.  558. — a,  The  Braun-Lossen  in- 
cision; c,  Rose's  incision  for  reacliing  the 
sphenomaxillary  fossa  (Rose). 


Fig.  559. — Lower  jaw  and  zygoma. 
Drill-holes  and  saw-cuts  are  shown 
(Rose). 


exposes  the  pterygomaxillary  fossa.  The  internal  maxillary  artery  is  ex- 
posed, two  ligatures  are  applied,  and  the  vessel  is  divided  between  them. 
The  finger  feels  for  the  sphenomaxillary  and  pterygomaxillary  fissures.  The 
external  pterygoid  muscle  is  separated  from  the  greater  wing  of  the  sphenoid 
and  from  the  root  of  the  external  pterygoid  process.  On  the  edge  of  the  greater 
wing  of  the  sphenoid  a  long  prominence  is  usually  detectable.  It  overhangs  the 
sphenomaxillary  fossa  and  should  be  cut  away  by  the  use  of  a  chisel.  The 
superior  maxillary  nerve  is  lifted  on  a  blunt  hook,  is  grasped  by  forceps,  and  is 
twisted  off  as  near  the  ganglion  as  possible  (Fig.  560).  The  distal  end  is  drawn 
upon,  and  the  nerve,  having  been  previously  loosened,  is  drawn  back  through 
the  infra-orbital  canal.  The  zygomatic  arch  is  wired  in  place,  the  temporal 
fascia  is  sutured  with  buried  sutures,  and  the  skin-wound  is  closed.  If  the  pain 
involved  not  only  the  second  division,  but  also  the  third  division,  the  operation 
previously  described  should  be  performed  first,  and  the  third  division  should  be 
attacked  a  few  weeks  later.  The  third  division  is  reached  by  removing  the 
coronoid  process.  The  inferior  dental  and  lingual  nerves  are  found,  and  are 
traced  up  to  the  foramen  ovale,  and  are  twisted  off  close  to  the  ganglion,  and 
the  distal  portions  are  removed. 

Removal  of  the  Qasserian  Ganglion. — This  formidable  procedure 
was  first  suggested  by  J.  Ewing  Mears  in  1884.  Wm.  Rose  in  1890,  was  the 
first  surgeon  to  perform  it  successfully.     It  is  only  undertaken  in  very  severe 


The  Hartley  Operation  for  Removal  of  the  Gasserian  Ganglion     859 


cases  of  tic  douloureux,  in  which  the  first  division  is  involved,  or  in  cases  upon 
which  less  grave  procedures  have  failed.  Jaboulay  and  Cavaillin  ("Lyon. 
Med.,"  May  17,  1908)  speak  of  it  as  a  grave  operation  of  difficult  technic  which 
shouUl  be  left  as  a  linal  resort.  Many  operators  deny  that  there  is  a  large 
mortality  after  gassercctomy  and  claim  that  it  is  only  about  5  per  cent.  Some 
operators  report  a  mortality  of  from  10  to  17  per  cent.  The  greater  the 
experience  of  the  surgeon  in  this  operation,  the  smaller  will  be  the  mortality. 
Knowledge  of  the  region  and  parts,  dexterity  from  frequent  repetition,  and 
special  training  count  for  much.  The  operation  usually  cures  the  pain  if  the 
patient  recovers  from  the  actual  procedure.  It  is  claimed  that  the  pain  may 
recur  even  after  complete  removal  of  the  ganglion.  I  am  disposed  to  think  that 
recurring  pain  is  apt  to  mean  that  there  was  a  partial  removal.  In  one  case  of 
undoubted  complete  removal  the  patient  still  claims  to  suffer.  The  victims  of 
tic  are  usually  elderly,  weakened  by  pro- 
longed suffering  and  shattered  by  opiates. 
They  would  be  poor  risks  for  any  operation. 

Frazier  ("Keen's  Surgery,"  Vol.  v) 
collected  230  cases  and  finds  a  mortality 
of  only  3.7  per  cent.  These  figures  come 
from  the  clinics  of  men  particularly  skilled 
in  this  operation  (clinics  of  Gushing, 
Horsley,  Frazier,  Lexer  and  so  on).  The 
figures  of  some  other  writers  are  far  less 
favorable.  In  a  series  of  121  intracranial 
operations  Frazier  had  but  4  deaths.  One 
hundred  and  thirteen  of  the  operations 
were  upon  the  sensory  root  (Personal 
Communication).  Carson  collected  100 
cases;  Murphy  and  Neff,  42  cases.  The 
mortality  in  this  group  of  142  cases  was  15 
per  cent.  Most  of  the  cases  reported  by 
Murphy  and  Neff  were  operated  upon 
during  or  after  1899,  and  in  this  group 
the  mortality  was  10  per  cent.  ("Pro- 
gressive Medicine,"  March,  1903).  In 
Lexer's  series  of  201  cases,  referred  to  below, 
the  mortality  was  17  per  cent.  In  many 
cases  a  perfect  cure  is  obtained.  In 
some  few  the  pain  returns  upon  the  side 
operated  upon.  Occasionally  it  arises  on  the  side  not  operated  upon.  In 
some  cases  ulceration  of  the  cornea  follows  operation.  Such  ulceration  may  be 
trivial,  may  result  in  opacity,  or  may  destroy  the  eye.  Paralysis  of  the  abdu- 
cens  occurs  in  some  cases.  The  hemorrhage  may  be  so  profuse  as  to  require 
packing  of  the  wound  and  suspension  of  the  operation  for  a  few  days.  The 
bleeding  may  come  from  the  meningeal  artery,  from  the  sinus,  or  from  the 
veins  of  Santorini.  Lexer  ("Arch.  f.  klin.  Chir.,"  Bd.  Ixv,  H.  4)  gives  a  table 
of  201  cases.  Of  the  survivors,  93.4  per  cent,  were  apparently  cured.  In  two- 
thirds  of  the  cases  the  trouble  was  right  sided.  In  10  the  operation  was  tempo- 
rarily abandoned  because  of  hemorrhage.  The  experience  of  surgecms  in 
general  is  that  after  the  removal  of  the  ganghon  there  is  apt  to  be  some  atrophy 
of  the  tongue  and  the  eye  usually  becomes  insensitive  and  watery.  The  masse- 
ter  muscle  will  be  paralyzed. 

The  Hartley  Operation  for  Removal  of  the  Gasserian  Ganglion. — This 
operation  was  first  performed  by  Hartley  in  1891,  five  months  before  Krause 
performed  it.  An  electric  forehead-light  is  required.  Long  strips  of  gauze 
must  be  ready  for  packing  in  case  of  hemorrhage.     Some  operators  place  the 


Fig.  560. — a,  The  zygomatic  arch, 
turned  down  after  sawing;  h,  tendon  of 
the  temporal  muscle  retracted;  c,  su- 
perior maxillary  nerve  and  Meckel's 
ganglion;  d,  infra-orbital  nerve  emerg- 
ing from  canal;  e,  internal  maxillary 
artery. 


86o 


Diseases  and  Injuries  of  Nerves 


patient  recumbent,  with  head  turned  to  the  opposite  side.  If  the  patient  is 
placed  semierect  venous  bleeding  will  be  much  lessened,  as  was  pointed  out  by 
Lexer.  The  application  of  a  provisional  ligature  or  clamp  to  the  external  carotid 
arterv  is  advocated  by  Crile,  but  this  step  will  not  control  the  venous  bleeding, 
which  is  the  most  harassing  hemorrhage  encountered.  Many  operators  form 
a  large  osteoplastic  iiap  in  front  of  the  ear  (Figs.  561  and  562).  I  do  not 
believe  that  an  osteoplastic  flap  is  necessary.  The  temporal  fascia  is  so  thick 
and  tense  that  when  the  wound  in  it  is  carefully  sutured  protection  is  perfect 
and  safety  is  secured.  Hemorrhage  is  to  be  carefully  arrested.  Most  of  the 
bleeding  is  venous  and  from  the  diploe.  It  can  be  arrested  by  pressure  with 
compresses  soaked  in  hot  water,  Horsley's  wax  or  plugging  the  bone  spaces  with 
bits  of  frayed  out  temporal  muscle.  It  may  be  found  that  the  meningeal  artery 
has  been  ruptured.  If  this  accident  has  happened  and  the  vessel  lies  in  a  bony 
canal,  plug  with  Horsley's  wax. 
If  the  vessel  is  bleeding  upon 
the  dura,  ligate  by  passing 
suture-ligatures  around  it.  If 
it  is  torn  off  at  the  foramen 
spinosum,  pack  the  foramen 
with  iodoform  gauze,  and  post- 
pone    the     conclusion     of     the 


Fig.  561. — Hartley's  os- 
teoplastic flap  in  removal  of 
Gasserian  ganglion  (Tiffany). 


Fig.  562. — Removal  of  Gasserian  ganglion:  a, 
Middle  meningeal  artery;  //,  ophthalmic  division; 
///,  submaxillary  division;  C,  ganglion  (Krause). 


operation  for  forty-eight  hours.  It  may  be  necessary  at  any  stage  of  this  opera- 
tion to  pack  the  wound  and  postpone  completion  for  two  days.  Some  surgeons 
(Krause,  Bergmann)  ligate  the  meningeal  artery  as  a  routine  procedure,  but 
this  operation  may  be  difficult  and  require  much  time.  If  the  unligated  vessel 
is  divided,  the  hemorrhage  can  be  arrested  by  gauze  packing  or  by  plugging  the 
foramen  spinosum  with  a  bit  of  sterile  wood,  but  it  is  best  to  ligate  the  vessel. 
If  the  head  and  body  of  the  patient  were  not  elevated  before  they  should  be  now. 
This  position  allows  the  brain  to  drop  posteriorly  and  renders  forcible  retraction 
unnecessary,  and,  further,  it  lessens  venous  bleeding  (Lexer).  The  next  step 
is  to  lift  up  the  dura  and  with  it  the  brain  (Fig.  562).  Find  the  inferior  maxil- 
lary nerve  and  clamp  it  with  hemostatic  forceps.  Find  the  superior  max-illary 
nerve  and  clamp  it.  Uncover  the  ganglion.  Loosen  the  nerves  from  their  beds 
by  a  dry  dissector  and  divide  each  one  at  its  foramen  of  exit.  Twist  the  clamp 
forceps  so  as  to  reel  up  the  nerves.  This  pulls  out  the  ganglion  intact  with  the 
motor  root  and  the  root  of  origin,  as  far  back  as  the  pons  (Krause's  method). 
Arrest  bleeding;'  close  the  flap;  sew  together  by  a  couple  of  stitches  the  lids  of 
the  affected  side  in  order  to  keep  them  temporarily  closed,  and  cover  the  eye 


Abb6's  Operation  of  Intracranial  Neurectomy  86i 

with  a  watch-crystal.     The  eye  is  to  be  washed  out  frequently.     Thus  irritants 
are  excluded. 

Gushing  has  modified  the  Hartley  operation  so  as  to  permit  of  extradural 
manipulation  below  the  arch  made  by  the  middle  meningeal  artery  and  thus 
lessen  the  danger  of  laceration  of  the  artery  ("Jour.  Amer.  Med.  Assoc," 
April  28,  1900).  The  anterior  arm  of  the  incision  of  the  soft  parts  is  so  placed 
that  it  does  not  cut  the  nerve  to  the  occipitofrontalis  muscle.  Thus  drooping  of 
the  lid  and  oblation  of  brow  wrinkles  on  that  side  are  avoided.  He  trephines 
the  wall  of  the  temporal  fossa  very  low  down,  opens  into  the  skull  below  the  arch 
of  the  meningeal  vessels,  and  thus  avoids  the  meningeal  at  the  foramen  spinosum 
of  the  sphenoid  bone  and  the  sulcus  arteriosus  of  the  parietal  bone. 

Horsley's  Intradural  Method. — An  opening  is  made  into  the  middle  fossa 
of  the  skull,  the  dura  is  opened,  and  the  ganglion  is  found  and  removed.  This 
operation  is  easier  than  the  extradural  method,  but  is  beheved  to  be  more 
dangerous. 

The  Frazier=SpiHer  Operation  of  Intracranial  Neurotomy  of  the 
Sensory  Root  of  the  Trigeminus. — This  operation  was  first  performed  by 
Frazier  in  190 1.  If  experience  shows  that  after  division  of  the  sensory  root 
the  nerve  does  not  regenerate,  and  it  seems  probable  that  it  does  not,  the  opera- 
tion must  be  regarded  as  a  valuable  addition  to  our  resources.  This  operation  is 
by  many  surgeons  preferred  to  removal  of  the  ganglion.  The  patient  is  placed 
semierect.  A  horseshoe-shaped  flap  is  made,  starting  at  the  middle  of  the 
zygoma  and  ending  behind  and  below  the  helix.  The  flap  is  turned  down.  The 
temporal  fossa  is  exposed,  the  bony  wall  is  trephined,  at  a  point  slightly  poste- 
rior to  that  used  by  most  surgeons  to  reach  the  ganglion.  The  center  of  this 
opening  is  on  a  line  with  the  point  at  which  the  sensory  root  joins  the  ganglion. 
The  trephine  opening  is  enlarged  to  the  infratemporal  crest  by  the  use  of  a 
rongeur.  The  dura  is  separated  from  the  base  of  the  skull  to  the  foramen 
spinosum.  The  meningeal  artery  is  tied  and  divided.  The  dura  is  divided  over 
the  third  division  and  is  separated  from  the  upper  surface  of  the  ganglion 
posteriorly.  The  dural  envelope  of  the  ganglion  is  opened,  separated,  and  the 
sensory  root  exposed.  The  sensory  root  is  then  picked  up  on  a  blunt  hook  and 
divided  or  avulsed.  It  is  frequently  possible,  Frazier  tells  us,  to  separate  the 
sensory  root  from  the  motor  root.  When  the  sensory  root  has  been  divided 
the  anesthetic  is  put  aside  as  the  parts  are  now  anesthetic.  As  soon  as  the 
reflexes  return  test  the  conjunctional  reflex  to  be  certain  that  no  sensory  fibers 
retain  their  continuity.  Suture  the  flap  and  use  a  drain  of  rubber  tissue. 
In  this  operation  we  avoid  the  venous  hemorrhage  from  the  foramen  ovale  and 
foramen  rotundum  which  is  apt  to  be  encountered  when  removing  the  ganglion, 
and  escape  the  bleeding  which  always  occurs  when  the  ganglion  is  lifted  from  its 
seat,  and  escape  the  danger  of  injuring  the  cavernous  sinus,  the  third,  fourth, 
and  sixth  nerves,  and  the  motor  root,  Frazier  has  had  great  success  with 
this  operation,  is  convinced  that  the  sensory  root  does  not  regenerate  and  that 
ulceration  of  the  cornea  is  less  common  than  after  removal  of  the  ganglion. 
Abbe's  Operation  of  Intracranial  Neurectomy  of  the  Second  and 
Third  Divisions. — This  operation  is  preferred  by  Charles  A.  Ballance,  who 
opposes  exposure  of  the  ganglion  or  division  of  the  sensory  root  unless  the 
first  division  of  the  nerve  is  the  seat  of  pain.  He  advocates  this  in  spite  of 
knowing  full  well  that  the  pain  may  return  in  a  few  years.  He  advocates  it 
because  of  its  safety,  its  simplicity,  its  freedom  from  serious  hemorrhage,  its 
avoidance  of  opening  the  intradural  space  and  of  all  danger  of  corneal  anesthe- 
sia, and  also  because  if  pain  returns  the  operation  can  be  repeated.  The 
operation  is  performed  as  follows:  Ligate  the  external  carotid  artery  of  the 
diseased  side,  make  a  vertical  incision  over  the  middle  of  the  zygoma  down  to 
the  bone.  An  opening  into  the  skull  is  made  by  a  mallet  and  gouge,  and  this 
opening  is  enlarged  by  a  rongeur  until  it  is  i3^^  inches  in  diameter.     The  dura  is 


362  Diseases  and  Injuries  of   Nerves 

lifted  from  the  middle  fossa  and  the  nerves  are  exposed.  Each  nerve-trunk  is 
clamped,  is  divided  near  its  foramen  of  exit,  and  is  separated  from  the  ganglion 
by  cutting  or  twisting  by  the  forceps.  A  strip  of  sterile  rubber  tissue,  il-i  inches 
in  length  and  'j/^  inch  in  width,  is  laid  over  the  round  foramen  and  the  oval  fora- 
men and  is  pressed  into  place  by  gauze.  In  a  few  moments  the  gauze  is  with- 
drawn and  the  ganglion  is  allowed  to  descend  upon  the  rubber  tissue.  The 
wound  is  then  closed.  (See  Robert  Abbe,  in  "Annals  of  Surgery,"  Jan.,  1903.) 
The  rubber  tissue  is  used  to  block  the  foramina  of  exit  and  prevent  future  emer- 
gence of  regenerating  nerves.  Mayo  Robson  blocks  the  foramina  by  a  thin 
plate  of  lead  or  silver,  a  knob  of  the  plate  entering  the  oval  foramen  to  prevent 
displacement.     Kanavel  uses  bone-grafts.     Mixter  used  amalgam. 

Division  of  the  Auditory  Nerve  for  Tinnitus  Aurium  and  for  Aural 
Vertigo. — This  operation  was  proposed  for  tinnitus  by  Krause  in  1902.  Ball- 
ance  did  it  on  the  right  side  with  success  in  a  most  distressing  case  of  painful 
tinnitus.  When  the  cerebellar  hemispheres  were  displaced  by  sponges  the 
nerves  of  the  posterior  fossa  were  brought  into  view.  He  divided  the  eighth 
nerve,  but  made  no  attempt  to  preserve  the  nerve  of  Wrisberg.  Five  months 
after  operation  the  patient  was  well  except  for  deafness  and  de\aation  of  the 
tongue  to  the  left.  (See  Ballance,  in  "Lancet,"  1908,  vol.  ii.)  Frazier  has 
divided  the  auditory  nerve  for  aural  vertigo,  with  partial  relief. 

Operation  for  Facial  Paralysis  of  Extracerebral  Origin  (Facio= 
accessory  Anastomosis  and  Faciohypoglossal  Anastomosis). — ^^(See 
"Remarks  on  the  Operative  Treatment  of  Facial  Palsy  of  Peripheral  Origin," 
by  Chas.  A.  Ballance,  Hamilton  A.  Ballance,  and  Purves  Stewart,  "Brit.  Med. 
Jour.,"  May  2,  1903;  and  also  the  "Surgical  Treatment  of  Facial  Paralysis  by 
Nerve  Anastomosis,"  by  Harvey  Gushing,  "Annals  of  Surgery,"  May,  1903.) 
In  1898  Furet  suggested  to  Faure  that  he  should  anastomose  the  peripheral 
end  of  a  divided  facial  nerve  to  that  portion  of  the  spinal  accessory  nerve  which 
goes  to  the  trapezius  muscle.  Faure  did  this,  but  the  operation  failed.  Robert 
Kennedy,  of  Glasgow,  did  the  first  successful  operation.  He  divided  the  facial 
for  the  rehef  of  spasm  and  at  once  anastomosed  to  a  partly  di\aded  spinal  acces- 
sory. The  procedure  first  employed  by  Ballance  was,  after  noting  by  galvanism 
that  muscular  fiber  still  remained,  to  expose  the  facial  nerve  at  its  point  of 
exit  from  the  stylomastoid  foramen,  to  cut  the  nerve-trunk  across  as  high  up  as 
possible,  to  expose  the  spinal  accessory,  and  to  suture  the  distal  end  of  the  facial 
into  the  trunk  of  the  spinal  accessory.  The  spinal  accessory  was  cut  half 
through  to  make  a  bed  for  the  end -of  the  facial.  The  paper  of  the  Ballances 
and  Stewart  above  referred  to  recommends  end-to-side  anastomosis  between 
the  divided  facial  and  the  hypoglossal.  The  authors  have  operated  five  times 
for  facial  palsy.  Gushing,  Keen,  Hackenbruch,  Korte,  Gurrie,  Beck,  Vidal, 
Girard,  Lund,  Alt,  Frazier,  and  others  have  done  similar  operations.  Marked 
improvement  may  follow  operation  even  if  palsy  has  lasted  for  a  considerable 
time.  Improvement  followed  operation  in  Gurrie's  case,  although  the  palsy 
was  nearly  a  year  old.  The  period  when  improvement  should  be  expected  is 
uncertain.  Signs  of  improvement  may  not  be  evident  for  six  months  or  longer. 
In  Gushing's  case  they  began  in  thirteen  days;  in  Kennedy's  case,  in  seven  days. 
In  most  cases  operation  restores  facial  symmetry  when  at  rest  and  in  many  cases 
during  volitional  movements.  The  patient  will  often  become  able  to  close  the 
eye  and  raise  the  angle  of  the  mouth.  Gurious  associated  movements  may 
occur.  In  Gurrie's  case  when  the  patient  lifted  his  shoulder  there  was  contrac- 
tion of  the  occipitofrontalis  muscle  ("South  African  Med.  Record,"  1907). 
Grant  operated  upon  a  case  of  traumatic  facial  paralysis  over  four  months  after 
the  injury.  He  anastomosed  the  facial  to  the  spinal  accessory  and  the  per- 
ipheral end  of  the  accessory  to  the  descendens  hypoglossi.  At  the  end  of  fifteen 
weeks  there  were  feeble  association  movements  of  the  face  and  shoulder,  which 
later  disappeared.  At  the  end  of  a  year  the  result  was  most  gratifying  ("Jour.. 
Am.  Med.  Assoc,"  Oct.  22,  1910). 


Diseases  and  Injuries  of  the  Head  863 

Facio-accessory  anastomosis  does  not  restore  emotional  movements,  but 
faciohypoglossal  anastomosis  may  restore  tliem.  Kiister  reports  a  case  which 
confirms  this. 

Operation  is  indicated  when  a  complete  facial  palsy  is  of  such  duration  that 
recovery  is  not  to  be  hoped  for  by  longer  delay.  The  Ballances  and  Stewart 
believe  that  when  palsy  has  lasted  six  months  without  sign  of  recovery,  opera- 
tion is  indicated.  A  paralysis  due  to  traumatism  gives  a  much  better  prognosis 
after  operation  than  does  a  paralysis  due  to  a  septic  process  (Chas.  A.  Ballance, 
Hamilton  Ballance,  and  Purves  Stewart,  in  "Brit.  Med.  Jour.,"  May  2,  1Q03). 
Murphy  has  collected  33  cases  of  anastomosis  of  the  facial  nerve  with  the  spinal 
accessory,  hypoglossal,  or  glossopharyngeal,  and  Joseph  Beck  has  added  5  cases 
of  his  owai  in  which  he  performed  faciohypoglossal  anastomosis. 

The  hypoglossal  is  preferred  to  the  accessory.  Its  trunk  is  larger  and  its 
cortical  center  is  adjacent  to  the  facial  cortical  area.  After  such  an  operation 
associated  movements  are  not  observed  when  the  mouth  is  kept  closed,  and, 
if  Gowers  is  correct,  the  fibers  of  the  facial,  which  supply  the  muscles  closing  the 
mouth,  may  take  origin  from  the  hypoglossal  nucleus  (John  B.  Murphy,  in 
"Surg.,  Gynec,  and  Obstet.,"  April,  1907).  Murphy  points  out  that  an 
anastomosis  may  be  end  to  end,  implantation  of  the  facial  into  a  slit  in  the  other 
nerve,  implantation  of  the  facial  into  a  partial  transverse  division  of  the  other 
nerve,  or  end  to  side  (Ibid.). 

Operation  for  Brachial  Birth  Palsy. — (See  article  by  L.  P.  Clark, 
A.  S.  Taylor,  and  T.  P.  Prout,  in  "Am.  Jour.  Med.  Sciences,"  Oct.,  1905.) 
These  authors  report  8  cases  of  operation  with  some  notable  improvements  and 
with  2  deaths.  In  these  cases  they  found  great  thickening  of  the  fascia  and  in 
some  cases  fibrous  tissue  almost  completely  obscured  the  remains  of  lacerated 
trunks  or  roots.  They  advise  that  the  patient  be  placed  recumbent,  with  a 
sand-pillow  beneath  the  shoulders  and  with  the  head  extended  and  bent  toward 
the  opposite  shoulder.  An  incision  is  made  at  the  posterior  border  of  the  sterno- 
cleidomastoid and  the  plexus  is  exposed  and  explored.  Sharpe  reports  56 
cases  upon  which  he  operated  ("Jour.  Am.  Med.  Assoc,"  March  18,  1916). 
He  makes  a  transverse  skin  incision  above  and  parallel  to  the  clavicle  and  over 
the  supraclavicular  space  of  the  posterior  triangle.  If  the  lesion  is  above 
the  clavicle,  it  is  at  once  attacked;  if  below  that  bone,  the  incision  is  carried 
down  and  the  bone  is  sawed  in  two.  The  scar  tissue  with  the  lacerated  nerves 
is  removed  and  the  nerves  or  nerve-roots  are  sutured.  The  wound  is  closed,  the 
clavicle  being  wired  if  it  has  been  divided.  After  dressings  are  applied  the  head 
is  bent  toward  the  shoulder  of  the  damaged  side  and  fixed  with  plaster  of  Paris. 

I  operated  on  a  case  of  Dr.  Charles  S.  Potts's  in  the  Philadelphia  Hospital. 
The  roots  were  not  torn,  but  were  found  embedded  in  a  thin  layer  of  scar 
which  it  was  possible  to  remove.  The  result  was  good.  Nerve  anastomosis 
may  be  necessary  if  exsection  of  scar  leaves  an  unbridgable  gap  or  if  nerve- 
roots  have  been  divided  within  the  foramina. 

Operation  for  Avulsion  of  the  Brachial  Plexus. — (See  page  842.) 


XXIV.  DISEASES  AND  INJURIES  OF  THE  HEAD 

Diseases  of  the  Head 

In  approaching  a  case  of  brain  disorder,  first  endeavor  to  locate  the  seat 
of  the  trouble;  next,  ascertain  the  nature  of  the  lesion;  and,  finally,  deter- 
mine the  best  plan  of  treatment,  operative  or  otherwise.  In  all  operations 
upon  the  brain  the  surgeon  must  be  able  to  determine  accurately  the  situations 
of  certain  fissures  and  convolutions,  the  finding  of  the  situations  of  these  convo- 
lutions and  fissures  comprising  the  science  of  craniocerebral  topography. 


864 


Diseases  and  Injuries  of  the  Head 


The  regional  terms  used  in  craniocerebral  topography  are  derived  from 
Broca  (Fig.  563).  The  middle  meningeal  artery  is  found  at  the  pterion,  i}i 
inches  posterior  to  the  external  angular  process,  on  a  level  with  the  roof  of  the 


Fig.  563. — Skull,  showing  the  points  named  by  Broca:  As,  Asterion  (Junction  of  the  occipi- 
tal, parietal,  and  temporal  bonjs);  basion,  middle  of  anterior  wall  of  foramen  magnum;  B, 
bregma  (junction  of  the  sagittal  and  coronal  sutures);  G,  ophryon  (on  a  level  with  the  superior 
border  of  the  eyebrows,  and  corresponding  nearly  to  the  glabella,  the  smooth  swelling  between 
the  eyebrows) ;  g,  gonion  (angle  of  the  lower  jaw) ;  /,  inion  (external  occipital  protuberance) ; 
L,  lambda  (junction  of  sagittal  and  lambdoidal  sutures);  N,  nasion  (junction  of  the  nasal  and 
frontal);  Ob,  obelion  (the  sagittal  between  the  parietal  foramina);  P,  p'terion  (point  of  junction 
of  great  wing  of  sphenoid  and  the  frontal,  parietal,  and  squamous  bones — this  may  be  H- 
shaped  or  K-shaped  or  "retourne,"  in  which  the  frontal  and  temporal  just  touch);  S,  stephanion; 
(or,  better,  the  superior  stephanion,  intersection  of  ridge  for  temporal  fascia  and  coronal  suture) ; 
S',  inferior  stephanion  (intersection  of  ridge  for  temporal  muscle  and  coronal  suture). 

orbit  (Fig.  564).     The  fissures  and  convolutions  of  the  brain  are  shown  in  Figs. 

565,  566  and  567.     The  fissure  of  Bichat  is  marked  by  a  line  on  each  side  drawn 

from  the  inio7i  to  the  external  auditory  process.     A  line  from  the  glabella  to  the 

inion  overlies  the  median    fissure  and 

the  superior   longitudinal   sinus.     The 

fissure  of  Rolando  IS  very  important,  as 

marking  the  posterior  limit  of  the  motor 

region  of  the  brain.     It  begins  near  the 

median  line,  3^   inch  posterior  to  the 

middle    of    the   distance    between   the 

inion  and  glabella  (Thane).    This  fissure 


Fig.  564. — The  meningeal  artery  ex- 
posed by  trephining  (after  Esmarch) . 


Fig.  565.- 


-View  of  the  brain  from   above 
(Ecker). 


runs  downward  and  forward  at  an  angle  of  67.5°  for  a  distance  of  3^^  inches. 
Chiene  finds  the  fissure  of  Rolando  by  the  following  method:  He  takes  a  square 
piece  of  paper  and  folds  it  into  a  triangle  (Fig.  568,  i);  the  angle  b-a-c  of  this 
triangle  is  45°;  the  edge  d-a  is  folded  back  on  the  dotted  line  a-e;  the  angle 


Craniocerebral  Topography 


865 


i>-A-E  equals  half  of  45°,  or  22.5°,  and  the  angle  c-a-e  equals  the  same  (Fig. 
568,  2) ;  the  paper  is  unfolded  in  the  line  c-a;  in  the  figure  thus  formed  b-a-c  = 
45°  and  E-A-c  =  22.5°;  E-A-B  = 
67.5°,  which  is  the  angle  desired. 
Place  the  point  A  in  the  midline 
of  the  head,  over  the  point  of 
origin  of  the  Rolandic  fissure; 
the  side  a-b  is  laid  along  the 
middle  line  of  the  head,  and  the 
line  A-E  corresponds  to  the  fissure 
of  Rolando.^  Horsley  determines 
the  situation  of  the  Rolandic 
fissure  by  the  use  of  his  metal 
cyrtometer  (Fig.  569).  He  places 
the  point  marked  zero  over  the 
inioglabellar  line  and  midway  be- 
tween the  inion  and  the  glabella. 
To  find  the  fissure  of  Sylvius 
(Fig.  566,  S,  S',  S"),  draw  a 
line  from  the  external  angular 
process  to  the  occipital  protuber- 
ance. The  '  fissure  of  Sylvius 
begins  on  this  line  i\'^  inches  behind  the  external  angular  process;  the 
main  branch  of  the  fissure  runs  toward  the  parietal  eminence;  the  ascending 


Fig.  566. 


-Outer  surface  of  the  left  hemisphere  of 
the  brain  (Ecker). 


Fig.  567. — Inner  surface  of  the  right  hemisphere  of  the  brain  (Ecker). 


Fig.  568. — Chiene's  method  of  fixing  position  of  Rolandic  fissure  ("American  Text-Book  of 

Surgery"). 

branch   of   the  fissure  corresponds  to  the  squamosphenoidal  suture,  and  con- 
tinues upward  in  the  same  line  3^^  inch  above  the  suture.     The  precentral 
sulcus  (Fig'  566,  f)  limits  anteriorly  the  ascending  frontal  convolution;  it  runs 
^  "American  Text-Book  of  Surgery." 
SS 


866 


Diseases  and  Injuries  oi   the  Head 


parallel  with  and  just  behind  the  coronal  suture,  and  a  finger's  breadth  in 
front  of  the  fissure  of  Rolando.  The  intraparietal  fissure  (Figs.  565  and  566,  ip) 
Umits  the  ascending  parietal  convolution  posteriorly.  It  begins  opposite 
the  junction  of  the  lower  and  middle  thirds  of  the  fissure  of  Rolando,  passes- 


».  ,71.,  .61  .  ,    SI  .  ,  .^1  .   ,  .»!  .  ,  ..|   .  ,  ..I      .  °|      .      IV  ,   .   I»  .  .  13.  ,  .  I«  ■  .  It.  ,  .  |..   ,  .  |T.  ,  ..j 


Fig.  570. — Head,  skull,  and 


Fig.  569. — Horsley's  cyrtometer. 

upward  in  a  line  parallel  with  the  longitudinal  fissure  and  midway  between 
the  Rolandic  fissure  and  the  parietal  eminence,  passes  by  the  parieto-occipital 
fissure,  and  downward  and  backward  into  the  occipital  lobe.     The  motor  areas, 

which  on  the  outer  surface  are  adjacent  to  the 
fissure  of  Rolando,  are  shown  in  Figs.  565  and 
566.^  The  superior  longitudinal  sinus  is  overlaid 
by  a  line  from  the  inion  to  the  glabella.  The 
lateral  sinus  is  indicated  by  a  line  running  from 
the  occipital  protuberance  horizontally  outward 
to  a  point  i  inch  posteriorly  to  the  external 
auditory  meatus,  and  from  this  point  by  a  second 
line  dropped  to  the  mastoid  process.  The 
suprameatal  triangle  of  Macewen  is  bounded  by 
the  posterior  root  of  the  zygoma,  the  posterior 
bony  wall  of  the  auditory  meatus,  and  a  line 
joining  the  two.  The  mastoid  antrum  is  opened 
through  Maceweii's  triangle  to  avoid  injury  to  the 
cerebral  fissures:  B  corresponds  lateral  sinus.  Barker's  point,  the  proper  spot  to 
to  Broca's  convolution;  EAP,  apply  the  trephine  for  abscess  of  the  temporo- 
external  angular  process;  FR,  sphenoidal  lobe,  is  ii'4  inches  above  and  ji^  inches 
f^n^rJutas  °IpV  in.'"apaH-  behind  the  middle  of  the  external  auditory  meatus, 
etal  sulcus;  MM  A,  middle  Fig.  570  shows  clearly  the  mam  pomts  of  cranio- 
meningeal  artery;  OPr,  occipital  cerebral  topography,  obtained  by  methods 
protuberance;     PE,      parietal     approved  by  manv  scientists. 

enunence;  POF   parieto-occip-  Rrdnlein's  method  for  localizing  certain  areas  is 

ital  fissure;  SP,  Sylvian  fissure;       ,  ^  ,,  .        1,      /t^-  ,  \ 

A,  its  ascending  limb;  TS,  tip  the  most  generally  serviceable  (Figs.  571  and  572). 
of  temporosphenoidal  lobe.  A  line,  known  as  the  base  hne,  z-m,  is  carried 
The  pterion  (to  the  left  of  B)  horizontally  backward  from  the  lower  border  of 
is  the  region  where  three  ^^^  ^^^^^  through  the  upper  border  of  the  external 
sutures  meet,  VIZ.,  those  bound-  ,.,  *         1         1       •  it  / 

ing  the  great  wing  of  the  auditory  meatus.  Another  horizontal  Jme,  k-k  , 
sphenoid  where  it  joins  the  is  drawn  parallel  with  this,  on  a  level  with  the 
frontal,  parietal,  and  temporal  supra-orbital  ridge.  A  line  z-K  is  erected  from 
Ws ^adapted  from  ^larshall    ^^g   j^j^dle  of  the  zygoma   to   the   supra-orbital 

line.  A  vertical  line  is  drawn  from  the  articula- 
tion of  the  lower  jaw,  a,  and  is  prolonged  to  r.  A  vertical  line  is 
drawn  from  the  posterior  border  of  the  mastoid  base  (m-k')  and  is  taken 
to  p,  the  middle  hne  of  the  skull.  A  line  is  drawn  from  k  to  p,  and  between 
the  points  r  and  p'  it  overlies  the  fissure  of  Rolando.  The  angle  p-k-k'  is 
1  Recent  studies  indicate  that  the  motor  region  is  entirely  in  front  of  the  Rolandic  fissure. 


Head  Injuries  During  Labor 


867 


bisected  by  the  line  k-s,  which  corresponds  to  the  fissure  of  Sylvius  from  its 
point  of  bifurcation  to  its  posterior  termination;  k  marks  the  bifurcation  of 
the  fissure  of  Sylvius.  To  reach  the  anterior  branch  of  the  middle  meningeal 
artery  trephine  at  k;  to  reach  the  posterior  branch,  trephine  at  k'. 

Head  Injuries  During  Labor. — Caput  Succedaneum. — This  condi- 
tion is  edema  of  the  scalp  due  to  prolonged  pressure.  The  edema  is  circular 
and  circumscribed  and  occupies  the  part  not  subjected  to  continued  pres- 


Fig.  571. 

P/ 

f 

E 

/^ 

:y 

Supra-orbital  line  {upper  horizontal)  _g 

Ax 

K' 

Auriculo-orbital  line  (lower  horizontal)   Z 


M 


A 

Fig.  572. 
Figs.  571  and  572. — Kronlein's  method  of  locating  the  fissure  of  Rolando  (R-P')  and 
Sylvius  (K-S);  Kronlein's  point  of  trephining  for  hemorrhage  from  the  middle  rneningeal 
{K-K') ;  and  von  Bergmann's  region  for  trephining  for  abscess  of  the  temporosphenoidal  lobes 
{A-a-K'-M)  ("American  Text-Book  of  Surgery")- 

sure  during  the  uterine  contractions  of  labor.  The  ring  of  tissues  around 
which  circumferential  pressure  is  exerted  by  the  os  uteri  project  Kke  a  cup  into 
the  birth  canal.  The  veins  become  congested  and  edema  results.  The  parts 
subjected  to  pressure  may  appear  normal  or  may  exhibit  ecchymoses  or  even 
excoriations.  The  pressure  is  usually  made  by  the  os,  and  its  situation  varies 
with  the  presentation,  but  because  the  most  frequent  presentation  _  is  left 
occipito-anterior,  the  common  position  of  the  caput  is  over  the  superior  and 


868  Diseases  and  Injuries  of  the  Head 

posterior  portion  of  the  right  parietal  bone.  In  a  face  presentation  great  dis- 
figurement may  occur.  It  is  seldom  that  a  double  caput  is  encountered.  It 
always  means  that  the  presentation  has  shifted.  The  worst  cases  of  caput 
follow  prolonged  labor.  The  edematous  swelling  contains  bloody  serum,  pits 
on  pressure,  does  not  fluctuate,  is  not  limited  to  the  outline  of  one  bone,  and 
the  skin  above  it  is  usually  discolored  by  ecchymoses.  No  treatment  is 
necessary,  as  the  condition  will  disappear  in  from  a  few  hours  to  three  days. 

Cephalhematomata. — By  this  term  we  mean  extravasations  of  blood  be- 
neath the  untorn  pericranium.  It  is  supposed  by  many  to  be  due  always 
to  pressure  and  venous  congestion,  as  is  a  caput  succcdaneum.  As  Gushing 
points  out,  the  condition  cannot  result  from  the  venous  stasis  of  prolonged  pres- 
sure alone.  If  it  did  it  would  always  exhibit  above  it  a  caput  succedaneum, 
"and  this  is  far  from  our  actual  experience"  (Harvey  Gushing,  in  "Keen's 
Surgery,"  vol.  iii).  It  is  certainly  due  in  some  cases  to  bending  or  breaking  of 
a  cranial  bone.  The  condition  is  said  to  occur  in  i  labor  out  of  200.  In  most 
cases  there  is  but  one  cephalhematoma,  but  there  may  be  two,  three,  or  even 
four.  The  commonest  situation  is  over  the  right  parietal  bone  (the  common 
seat  of  caput  succedaneum),  and  caput  succedaneum  may  be  associated  with  a 
cephalhematoma.  The  condition  may  be  bilateral.  The  blood  begins  to 
flow  beneath  the  pericranium  during  labor  and  the  swelhng  increases  during 
the  first  few  days  after  birth;  in  fact,  it  is  frequently  not  noticed  for  two  or 
three  days.  The  swelling  is  tense  and  smooth,  with  a  convex  outline  and  when 
recent  feels  like  a  cyst.  It  may  cover  but  a  small  portion  of  a  bone  or  an  entire 
bone,  but  never  extends  beyond  the  bounding  sutures.  This  limitation  is 
due  to  the  fact  that  the  pericranium  is  attached  to  the  sutures.  In  the  course 
of  a  couple  of  weeks  the  raised  and  irritated  periosteum  begins  to  produce 
bone  and  the  ring  of  hardness  usually  detected  at  the  margin  of  the  lump  at 
this  time  is  due  to  the  formation  of  new  bone.  Bone-plates  usually  develop 
over  the  surface  of  the  swelling.  If  plates  form  crepitus  can  be  detected.  A 
shell  of  bone  may  eventually  surround  and  cover  over  the  clot,  an  area  of  per- 
manent bony  thickening  remaining.  In  other  cases  no  bone  forms,  but  the  clot 
gradually  disappears.  Extradural  and  even  subdural  hemorrhage  may  be 
associated  with  a  subpericranial  bleeding. 

Gephalhematomata  unassociated  with  cerebral  symptoms  usually  disappear 
without  operation.  If  there  is  no  sign  of  subsidence  after  two  weeks,  follow 
Gushing's  rule,  evacuate  by  a  puncture-like  incision  and  apply  pressure.  If 
suppuration  occurs,  incision  is  necessary.  Suppuration  may  occur  if  the  scalp 
has  been  excoriated.  In  cephalhematoma  with  cerebral  symptoms  operation  is 
indicated  (incision  of  the  scalp  and  removal  of  a  piece  of  bone). 

Diseases  of  the  Scalp. — The  scalp  is  composed  of  skin,  subcutaneous 
fat,  the  occipitofrontalis  muscle  and  aponeurosis,  the  subaponeurotic  cellular 
tissue,  and  the  pericranium.  The  scalp  is  liable  to  inflammation  from  vari- 
ous causes,  and  also  to  certain  diseases — namely,  tumors,  cysts,  wart^,  moles 
(local  cutaneous  hypertrophies),  cirsoid  aneurysm  (see  page  496),  nevi,  and 
lupus.  Abscesses  of  the  scalp  are  common.  If  an  abscess  forms  beneath  the 
pericranium,  the  pus  diffuses  over  the  area  of  one  bone,  being  limited  by  the 
attachment  of  the  pericranium  in  the  sutures.  In  cranial  osteomyelitis  pus 
may  gather  between  the  dura  and  bone  and  between  the  bone  and  pericra- 
nium. The  condition  is  known  as  Pott's  puffy  tumor.  If  an  abscess  forms  in 
the  tissue  between  the  occipitofrontalis  and  the  pericranium,  it  is  widely  dif- 
fused. Treves  calls  this  subaponeurotic  connective  tissue  "the  dangerous  area.'' 
Abscess  of  the  subcutaneous  tissue  is  apt  to  be  limited  because  of  the  great 
amount  of  fibrous  tissue.  Abscess  beneath  the  pericranium  does  not  spread 
beyond  the  suture  lines.  It  is  limited  by  the  sutural  membrane  which  runs 
from  pericranium  to  dura.  Abscess  is  treated  by  instant  incision  at  the  most 
dependent  part  and  drainage.     In  abscess  beneath  the  occipitofrontalis  ap- 


Treatment  of  Microcephalus  869 

Oneurosis  it  is  necessary  to  open  and  drain  above  the  eyebrows,  above  the 
superior  curved  line  of  the  occipital  bone,  and  at  each  side  above  the  line  of 
origin  of  the  temporal  fascia. 

Diseases  and  Malformations  of  the  Bones  of  the  Skull. — The  bones 
of  the  skull  are  liable  to  caries,  necrosis,  osteitis,  periostitis,  osteomyelitis, 
atrophy,  hypertrophy,  tumors,  etc.     (See  Diseases  of  Bones.) 

Cranial  Pneumatocele. — This  rare  condition  is  a  result  of  perforation 
of  a  bone  which  permits  air  to  collect  beneath  the  periosteum.  It  may  occur 
in  the  mastoid  or  occipital  region  or  over  the  frontal  region.  These  pro- 
trusions vary  greatly  in  size;  and  as  their  shape  depends  upon  the  periosteal 
attachment  to  sutures  in  the  neighborhood,  they  vary  in  shape.  The  over- 
lying tissues  are  natural  in  appearance.  The  protrusion  is  tense,  but  may 
lessen  or  disappear  on  pressure.  McArthur  ("Jour.  Am.  Med.  Assoc,"  May 
6,  1905)  points  out  that  if  diminished  by  pressure,  the  patient  may  hear  a 
sound  like  rushing  air  or  water  in  the  ear  if  the  protrusion  is  occipital  or  mastoid; 
and  in  the  nose,  if  it  is  frontal.  An  elevated  ridge  of  bone  surrounds  a  pneu- 
matocele. The  protrusion  is  tympanitic  on  percussion.  The  condition  is 
due  to  perforation  of  the  bony  wall  of  an  air  sinus  by  disease,  injury  or  rupture. 
McArthur  points  out  that  in  half  of  the  reported  cases  the  rupture  was  not 
preceded  by  any  history  of  inflammation  or  injury.  The  condition  is  not 
dangerous. 

Treatment. — Incision,  finding  the  opening  in  the  bone,  enlarging  it,  remov- 
ing osteophytes;  bringing  the  walls  of  the  cavity  together  and  applying  pressure. 

Microcephalus. — ^By  "microcephalus"  is  meant  unnatural  smallness  of 
the  head  due  to  imperfect  development.  Marked  microcephalus  is  not  a 
common  condition,  but  it  is  an  occasional  cause  or  associate  of  idiocy.  A  child 
may  be  born  with  a  skull  completely  ossified  even  at  the  fontanels,  or  the 
ossification  may  become  complete  soon  after  birth,  but  in  many  cases  of  micro- 
cephalus ossification  takes  place  late  or  not  at  all.  In  microcephalus  the  face 
is  usually  fairly  well  developed;  the  jaws  are  prominent;  the  forehead  is  flat; 
the  cranium  and  brain  are  small ;  the  convolutions  of  the  brain  are  simpler  than 
is  natural;  there  is  apt  to  be  marked  asymmetry  of  the  two  sides  of  the  brain; 
internal  hydrocephalus  may  exist;  areas  of  sclerosis  and  atrophy  are  common; 
porencephaly  is  not  unusual.  Some  patients  have  perfect  motor  power; 
others  are  slow  and  incoordinate.  Epilepsy,  chorea,  and  athetosis  frequently 
complicate  the  case.  Idiots  of  this  type  often  present  deformities  such  as 
cleft  palate,  strabismus,  distorted  ears,  hypertrophied  tongue,  deformed  genitals 
or  extremities,  ill-shaped  and  irregularly  developed  teeth.  They  exhibit  irregu- 
lar muscular  movements,  are  frequently  paralyzed  in  childhood  (infantile 
paraplegia  or  hemiplegia),  and  suffer  from  subsequent  contractures.  They  are 
active,  destructive,  excitable,  and  are  liable  to  be  violent  and  almost  demoniacal. 
As  Clouston  says,  they  look  impish  and  unearthly. 

Treatment. — Skilled  training  in  a  school  for  the  feeble  minded  or  in  an  in- 
stitution for  idiots  is  necessary  in  treating  microcephalic  idiocy.  Idiots  have 
but  little  power  of  attention,  and  sensory  impressions  give  rise  to  but  few 
concepts,  and  these  are  feeble  and  fleeting.  In  order  to  educate  the  idiot 
it  is  highly  desirable  that  speech  be  acquired,  and  "the  more  strongly  the 
attention  can  be  aroused,  the  more  perfect  does  speech  become "  (Kirchhoff). 
The  principle  of  the  education  of  idiots  is  to  stimulate,  coordinate,  and  guide 
sight,  hearing,  feeling,  taste,  and  smell. 

Lannelongue,  of  Paris,  suggested  an  operation  for  idiocy  with  premature 
ossification  (see  Linear  Craniotomy,  page  936).  In  this  procedure  the  author 
has  no  confidence.  Idiocy  is  a  general  disorder  and  not  a  local  brain  disease. 
Soft  parts  mold  bone,  and  bone  does  not  control  soft  parts.  There,  is  no  evi- 
dence that  the  brain  is  being  compressed;  in  fact,  the  simplicity  of  the  convolu- 
tions  suggests   the  contrary.     In  many  typical  cases  of  microcephalic  idiocy 


870  Diseases  and  Injuries  of  the  Head 

there  is  no  synostosis  even  years  after  birth.  The  operation  has  been  much* 
abused.  It  is  sometimes  fatal,  and,  although  a  fatality  may  gratify  the  family, 
a  surgeon  should  not  be  a  legal  executioner.  The  remarkable  improvement  which 
has  been  reported  in  some  cases  is  wrongly  supposed  to  be  due  to  the  operation. 
As  a  matter  of  fact,  the  new  surroundings,  the  strange  faces,  the  firm  discipline, 
the  effect  of  the  anesthetic,  and  the  shock  of  the  operation  attract  the  feeble 
attention  and  rouse  the  sluggish  senses.  Many  cases  are  brought  for  operation 
because  they  are  for  the  time  being  unusually  intractable  and  excitable,  and  the 
return  to  the  usual  level  of  conduct  after  operation  is  regarded  as  a  permanent 
gain,  when  it  is  often  but  a  temporary  alleviation.  We  believe  that  scientific 
training  is  the  proper  treatment,  and  that  the  efficiency  of  training  is  not 
increased  by  the  previous  performance  of  craniotomy,  and  we  follow  the  precept 
of  Agnew,  that  a  surgeon  might  as  well  cut  a  piece  out  of  a  turtle's  back  to  make 
a  turtle  grow  as  to  cut  a  piece  out  of  the  skull  to  make  the  brain  grow.  It 
would  be  as  wise  to  take  a  piece  out  of  the  dome  of  a  cathedral  to  increase  the 
stature  of  the  dean  and  chapter. 

Diseases  and  Malformations  Involving  the  Brain. — Cephaloceles. 
— A  cephalocele  is  a  congenital  protrusion  of  intracerebral  contents  through 
a  defect  in  the  skull.  These  protrusions  are  covered  by  skin.  The  defect 
through  which  the  protrusion  occurs  is  always  in  the  median  line,  although 
in  some  cases  (as  at  the  inner  angle  of  the  orbit)  the  visible  protrusion  may  be 
at  the  side.  Nearly  all  such  protrusions  are  either  frontal  or  occipital,  although 
now  and  then  one  presents  in  the  pharynx,  having  emerged  from  the  skull 
between  the  body  of  the  sphenoid  and  the  ethmoid. 

Frontal  cephaloceles  are  divided  into: 

1.  Nasofrontal — those  which  are  in  the  region  of  the  glabella. 

2.  Naso-orbital — those  at  the  inner  angle  of  the  orbit. 

3.  Naso-ethmoidal— those  below  the  nasal  bone. 

Each  one  of  the  above  forms  passes  through  the  horizontal  plate  of  the 
ethmoid. 

Occipital  cephaloceles  are  divided  into : 

1.  Superior — those  above  the  external  occipital  protuberance.  In  these 
the  bony  gap  may  join  the  posterior  fontanel. 

2,  Inferior — those  below  the  external  occipital  protuberance.  In  these 
the  bony  gap  may  join  the  foramen  magnum. 

The  above  regional  classification  is  that  advocated  in  von  Bergmann's 
*' System  of  Practical  Surgery"  (translated  and  edited  by  Wm.  T.  Bull  and 
Walton  Martin). 

The  commonest  form  is  hydrencephalocele,  and  all  other  forms  result 
from  retrograde  change  in  this. 

Hydrencephalocele. — This  is  by  far  the  commonest  and  is  also  the  most  dan- 
gerous form  encountered.  The  protrusion  consists  of  arachnoid,  a  layer  of 
brain  tissue,  and  a  cavity  containing  ventricular  cerebrospinal  fluid  and  con- 
nected with  the  lateral  ventricle.  It  is,  in  reality,  a  protrusion  of  the  lateral 
ventricle.  It  is  covered  by  skin — natural  skin — unless  the  protrusion  is  very 
large,  in  which  case  the  skin  is  more  or  less  atrophied.  Beneath  the  skin  is 
fascia,  and  beneath  this,  arachnoid.  The  pericranium  and  dura  do  not  cover 
it,  but  each  has  a  gap  in  it  and  these  two  tissues  join  each  other  around  the  bone 
margins. 

Encephalocele  results  from  retrograde  changes  in  a  hydrencephalocele. 
The  protrusion  of  the  ventricle  has  become  reduced  and  the  hernia  consists 
of  a  portion  of  brain  covered  by  arachnoid.  Encephalocele  is  only  seen  in  the 
nasofrontal  region.  If  there  is  any  fluid  in  this  protrusion  it  is  not  in  its  interior, 
but  on  its  surface,  and  results  from  a  cyst  of  the  arachnoid. 

Meningocele. — We  formerly  understood  by  a  meningocele  a  protrusion  of 
the  membranes  alone;  we  now  regard  it  as  a  condition  resulting  from  retro- 


Spurious  Meningocele  871 

grade  changes  in  a  hydrencephalocele.  The  brain  tissue  of  the  latter  disap- 
pears; beneath  the  arachnoid  is  a  layer  of  cells  identical  with  those  which  line 
the  ventricles ;  the  connection  with  the  ventricle  is  entirely  or  almost  completely 
cut  off;  a  cyst  forms  in  the  subarachnoid  tissue,  and  thickened  pia  surrounds 
the  cyst.  (See  "System  of  Practical  Surgery,"  by  Iv  von  Bergmann,  vol.  i, 
translated  and  edited  by  Wm.  T.  Bull  and  Walton  Martin.)  The  above  con- 
dition is  called  by  von  Bergmann  encephalocystomeningocele. 

Diagnosis. — The  congenital  origin  and  situation  make  certain  that  the 
condition  is  cephalocele.  The  bony  gap  can  usually  be  felt;  whether  it  can  or 
cannot,  an  rv-ray  picture  should  be  taken.  Such  a  picture  may  indicate 
that  the  mass  contains  brain  matter.  The  protrusions  vary  greatly  in  size 
and  shape.  Some  are  rounded,  some  are  flattened,  some  are  stalked.  The  skin 
covering  them  may  be  natural,  atrophied,  filled  with  vessels,  scarred,  or  ulcer- 
ated. Sometimes  the  cephalocele  is  very  tense;  sometimes  it  is  loose.  In  natu- 
rally hairy  regions  the  skin  over  the  summit  of  the  protrusion  is  bald,  but  that 
around  the  base  is  hairy.  If  there  is  connection  between  the  interior  of  the  pro- 
trusion and  the  ventricle,  the  mass  can  be  diminished  in  size  by  compression.  If 
it  shrinks  rapidly  from  compression,  the  opening  into  the  ventricle  is  large.  In 
such  cases  compression  of  the  mass  quickly  causes  signs  of  cerebral  pressure. 
Lumbar  puncture  may  cause  the  protrusion  to  diminish  in  size;  crying  may 
cause  it  to  increase  in  size.  Large  cephaloceles  fluctuate  and  perhaps  pulsate. 
Meningocele  feels  and  looks  like  a  cyst  (is  translucent  and  fluctuates) ;  it  does 
not  usually  pulsate,  it  has  a  small  base,  it  becomes  tense  on  forcible  expiration, 
and  some  cases  can  be  very  slowly  diminished  by  compression. 

Encephalocele  is  small,  opaque,  does  not  fluctuate,  has  a  broad  base,  does 
pulsate,  becomes  tense  on  forced  expiration,  and  attempts  at  reduction  fail 
.and  cause  pressure  symptoms. 

Hydrencephalocele  is  larger  than  a  meningocele,  is  translucent,  fluctuates, 
rarely  pulsates,  is  pedunculated,  is  rendered  a  little  tense  on  forced  expiration, 
"and  can  be  lessened  in  size  by  compression,  but  cannot  be  reduced. 

Treatment. — In  von  Bergmann 's  "System  of  Practical  Surgery"  we  find 
the  wise  caution  to  attempt  no  operation  for  an  occipital  protrusion  beneath 
the  protuberance  when  the  cleft  enters  the  foramen  magnum  and  is  associated 
with  cleft  of  the  cervical  vertebrae — for  a  condition  in  which  the  soft  parts 
are  defective  and  the  brain  is  exposed  {cranio schists) — on  a  case  complicated 
by  hydrocephalus  or  on  a  case  complicated  by  some  other  condition  which 
is  of  necessity  fatal.  We  no  longer  refuse  to  operate  because  the  mass  con- 
tains some  brain  matter  or  because  it  communicates  with  the  ventricle,  although 
if  it  does  so,  the  prognosis  is  much  worse.  For  a  large  hydrencephalocele 
nothing  can  be  done  and  early  death  is  inevitable.  In  rare  instances  an  en- 
cephalocele is  converted  into  a  meningocele,  and  the  bony  aperture  closes, 
thus  bringing  about  a  cure.  Among  the  expedients  for  treating  meningocele 
are  electrolysis,  injection  of  Morton's  fluid  (10  gr.  of  iodin,  30  gr.  of  iodid  of 
potassium,  i  oz.  of  glycerin),  pressure,  and  excision.  In  cases  of  cephalocele, 
when  portions  of  the  nerve-centers  are  not  contained  in  the  sac,  A.  W.  Mayo 
Robson  advises  the  performance  of  a  plastic  operation.  He  ligates  the  neck  of 
the  sac,  excises  the  sac,  sutures  the  skin-flaps  separately,  and  leaves  the  stump 
outside  the  line  of  superficial  sutures.  It  is  usually  possible  to  tell  by  palpa- 
tion if  nerve-centers  are  in  the  sac,  but  if  in  doubt,  make  an  exploratory  in- 
cision, and  sweep  the  finger  around  inside  of  the  sac.^  Meningoceles  should  be 
operated  upon  by  Robson's  plan. 

Spurious  Meningocele. — It  occasionally  happens,  after  a  fracture  of  a 
child's  skull,  that  cerebrospinal  fluid  gathers  beneath  the  pericranium  and 
bulges  the  pericranium  and  scalp.  This  condition  is  called  spurious  men- 
ingocele.    When  a  spurious   meningocele  forms,   the  bone  must  have   been 

^  "Amer.  Jour.  Med.  Sciences,"  Sept.,  1895. 


872  Diseases  and  Injuries  of  the  Head 

broken  and  the  dura  and  arachnoid  ruptured.  This  protrusion  fluctuates, 
pulsates,  and  is  influenced  by  respiration.  In  some  cases  there  is  commu- 
nication with  the  ventricles  of  the  brain.  The  parietal  and  frontal  regions 
are  the  most  usual  seats  of  the  trouble.  The  opening  in  the  skull  may  close; 
it  may  remain  stationary;  it  may  actually  enlarge  by  bone-absorption.  In 
some  cases  the  spurious  meningocele  undergoes  spontaneous  cure;  in  some  cases 
rupture  occurs;  in  other  cases  death  takes  place  as  a  result  of  the  cerebral 
injury.  (See  Joseph  Sailer  on  "Spurious  Meningocele,"  "University  Med. 
Magazine,"  Sept.,  1900). 

Treatment. — Close  the  opening  by  a  plastic  operation. 

Hydrocephalus. — In  external  hydrocephalus  the  fluid  is  on  the  surface  of 
the  brain;  in  internal  hydrocephalus  the  fluid  is  in  the  ventricles.  Hydro- 
cephalus may  be  acute  or  chronic,  congenital  or  acquired. 

Acute  hydrocephalus  is  usually  internal,  but  may  be  external.  It  results 
from  meningitis — usually  tuberculous  meningitis  of  the  base.  The  symp- 
toms are  headache,  elevated  temperature,  delirium,  stupor,  convulsions, 
paralysis,  and  choked  disk. 

Treatment  of  acute  hydrocephalus  by  medical  means  is  of  no  avail.  Tap- 
ping of  the  ventricles  may  be  tried.  Drainage  of  the  cisterna  magna  has  been 
suggested. 

Chronic  internal  hydrocephalus  is  usually  congenital,  but  may  arise  after 
birth  in  children  under  seven.  In  congenital  hydrocephalus  the  condition 
may  be  due  to  circulatory  disturbances  in  the  brain  of  the  embryo  resulting 
from  uterine  disease  or  injury  during  pregnancy.  Syphilis  and  alcoholism 
in  parents  seem  sometimes  to  be  responsible.  Chronic  acquired  hydrocephalus 
results  from  inflammation,  especially  tuberculous  inflammation.  A  tumor 
pressing  on  the  veins  of  Galen  may  cause  it.  In  chronic  acquired  internal 
hydrocephalus  there  is  overproduction  or  underabsorption  of  cerebrospinal 
fluid  and  perhaps  both  conditions  may  exist.  The  usually  causative  condition 
is  an  inflammation  of  the  interior  of  the  ventricles,  particularly  of  the  choroid 
plexuses,  and  as  a  consequence  venous  return  is  obstructed  and  oversecretion 
occurs.  In  very  rare  cases  one  or  both  foramina  of  Monro  may  be  closed,  and 
if  only  one  is  closed,  unilateral  hydrocephalus  may  arise  (Alfred  S.  Taylor, 
in  "Am.  Jour.  Med.  Sciences,"  August,  1904).  The  aqueduct  of  Sylvius, 
the  foramen  of  Magendie,  and  the  central  canal  of  the  cord  may  be,  but  sel- 
dom are,  occluded.  Guthrie  ("Practitioner,"  July,  1910)  studied  182  cases 
of  meningitis  at  autopsy.  In  about  40  per  cent,  of  the  tuberculous  cases 
and  in  56  per  cent,  of  the  non-tuberculous  cases  hydrocephalus  existed.  A 
tumor  may  cause  hydrocephalus  by  directly  obstructing  the  flow  of  fluid 
from  the  ventricles,  but  a  tumor  far  away  from  such  a  position  may  cause 
it  by  so  increasing  the  intracerebral  tension  that  the  brain  stem  is  forced  down 
into  the  foramen  magnum.  Such  a  position  of  the  pons  and  cerebellum  cuts 
off  the  flow  of  cerebrospinal  fluid  between  the  subarachnoid  spaces  of  the  brain 
and  cord.  Thomas  produced  internal  hydrocephalus  in  animals  by  injecting 
into  the  ventricles  an  insoluble  material  known  as  aleuronat.  Chronic  inflam- 
mation ensued,  obstruction  and  hydrocephalus  followed  ("Jour,  of  Exper. 
Med.,"  1914,  xix).  Thomas  says  the  obstruction  may  occur  in  the  foramen 
of  Monro  or  the  aqueduct  of  Sylvius  but  occurs  most  frequently  in  the  foramen 
of  Magendie.  Drandy  and  Blackfan  ("Beitrag.  z.  klin.  Chir.,"  1914,  xciii) 
after  elaborate  experiments  concluded  that  an  obstruction  placed  in  the  Sylvian 
aqueduct  causes  internal  hydrocephalus  even  after  extirpation  of  both  choroid 
plexuses.  This  proves  that  fluid  is  produced  within  the  ventricles  more  rapidly 
than  it  can  be  alDsorbed  from  them.  Internal  hydrocephalus  also  results  from 
ligation  of  the  great  vein  of  Galen  near  its  point  of  origin  but  does  not  from 
distal  ligation  of  the  vein  or  from  ligation  of  the  straight  sinus  (collaterals  save 
the  situation).     The  chief  but  not  the  only  source  of  cerebrospinal  fluid  is  the 


Treatment  of  Chronic  Internal  Hydrocephalus  873 

choroid  plexus  of  each  ventricle.  It  is  formed  by  processes  of  secretion  and 
filtration.  The  amount  of  the  fluid  is  increased  by  venous  congestion  and  by  the 
administration  of  pilocarpin. 

Production  and  absorption  should  go  on  hand  in  hand,  the  entire  amount  of 
the  fluid  should  be  changed  within  twenty-one  hours,  the  lymphatics  play  only  a 
small  part  in  absorption,  the  bulk  of  the  fluid  is  taken  up  by  the  blood  from  the 
subarachnoid  space.  There  is  almost  no  absorption  from  the  ventricles.  If 
there  is  not  free  communication  between  the  ventricles  and  the  subarachnoid 
space  the  just  balance  between  absorption  and  formation  is  destroyed  and  fluid 
accumulates  in  and  distends  the  ventricles.  The  communication  is  made  by 
the  valveless  foramina  in  the  fourth  ventricle,  the  foramen  of  Magendie  and  the 
two  foramina  of  Key  and  Retzius  (called  also  the  foramina  of  Luschka).  In 
hydrocephalus  the  cranium  enlarges  enormously  and  the  bones  of  the  skull  are 
widely  separated.  The  brain  is  distended  and  thinned  and  the  sulci  are  oblit- 
erated. The  broad  forehead  overhangs  the  eyes;  the  fontanels  are  elevated. 
The  fontanels  and  sutures  are  open.  The  child  is  mentally  weak  or  is  an  idiot, 
and  very  often  does  not  learn  to  walk  or  to  talk.  Convulsions,  palsies,  and  con- 
tractures are  common,  and  blindness  is  frequently  present.  Such  children  usually 
die  young.  Any  case  of  chronic  hydrocephalus  may  develop  evidences  of  h^-po- 
pituitarism.  In  such  a  case  it  is  probable  that  the  distended  third  ventricle 
presses  upon  the  h}'pophysis.  There  may  be  adiposity,  undeveloped  genitalia, 
scantiness  of  hair  or,  some  hairy  overgrowth,  and  optic  atrophy.  Hemianopsia 
does  not  occur  a  fact  which  at  once  marks  off  these  cases  from  tumors  of  the 
hj-pophysis.     (SeeLewds  J.  Pollock,  in  "Jour.  Am.  Med.  x\ssoc.,"'  Jan.  30,  1915). 

The  treatment  of  chronic  hydrocephalus  is  rarely  of  much  avail.  Pressure 
by  strapping  with  adhesive  plaster  has  been  tried.  Tappings  through  a  fon- 
tanel may  be  performed  by  means  of  a  trocar  (only  2  or  3  oz.  of  fluid  being 
withdrawn  at  a  time).  If  much  fluid  is  allowed  to  flow  out,  the  head  must  be 
strapped  with  adhesive  plaster  afterward.  If  the  skull  ossifies,  the  lateral  ven- 
tricles may  be  tapped  after  trephining.  It  has  been  proposed  to  drain  by  tap- 
ping the  theca  of  the  spinal  cord  (Quincke).  This  last  operation  is  called 
lumbar  puncture  (see  pages  969,  970).  It  will,  of  course,  fail  if  the  foramina  in 
the  floor  of  the  fourth  ventricle  or  the  aqueduct  of  Syhius  are  blocked.  Even  if 
they  are  open,  it  is  of  little  service.  The  operation  which  promises  most  was 
devised  by  Sutherland  and  Cheyne,  and  is  known  as  intracranial  drainage 
C'Brit.  Med.  Jour.,"  Oct.  15,  1898).  Their  theory  is  that  in  hydrocephalus 
fluid  distends  the  ventricles  because  the  channels  of  communication  between 
the  ventricles  and  the  subarachnoid  spaces  are  closed.  The  subarachnoid 
spaces  communicate  directly  with  veins,  hence  fluid  cannot  collect  under  pres- 
sure in  these  spaces.  Intracerebral  drainage  estabhshes  a  communication 
between  the  subarachnoid  space  and  one  ventricle.  It  is  not  necessary  to 
operate  on  both  sides  in  bilateral  hydrocephalus,  because  the  lateral  ven- 
tricles communicate.  A  smaU  opening  is  made  in  the  skull.  The  dura  is 
incised.  A  number  of  strands  of  catgut,  which  are  tied  together,  are  pushed 
through  the  brain  so  that  one  end  of  the  catgut  mass  lies  in  a  ventricle  and  the 
other  end  beneath  the  dura.  The  dura  and  scalp  are  then  sutured.  Brewer 
makes  an  osteoplastic  occipital  flap,  also  a  dural  flap,  lifts  the  cerebral  lobe, 
and  pushes  a  drain  of  rubber  tissue  into  a  lateral  ventricle. 

The  elder  Senn  passed  a  rubber  tube  into  the  ventricle  and  put  the  cuter 
end  of  the  tube  beneath  the  skin  of  the  scalp. 

Alfred  S.  Taylor  ("Am.  Jour.  Med.  Sciences,"  August,  1904)  makes  an 
osteoplastic  flap  ■\;\-ith  its  base  over  the  right  mastoid,  cuts  a  dural  flap,  passes 
a  slender  aspirating  needle  through  the  second  temporosphenoidal  convolution 
into  the  lateral  ventricle,  draws  off  a  little  fluid,  and  measures  the  thickness 
of  the  brain.  He  then  takes  6  strands  of  No.  2  forty-day  catgut,  each  strand 
}/2  inch  longer  than  the  thickness  of  the  brain.     The  strands  are  tied  together 


874  Diseases  and  Injuries  of  the  Head 

with  a  spiral  of  catgut,  iji  inches  of  the  loop  being  left  free.  Three  layers  of 
Cargile  membrane  are  wrapped  about  the  shaft,  but  the  tip  remains  free.  It  is 
carried  into  the  ventricle  along  the  needle  track  by  thumb  forceps,  and  the 
loops  are  slipped  here  and  there,  but  chiefly  downward,  under  the  dura.  Cargile 
membrane  is  placed  between  the  loops  and  dura  and  the  dura  and  skin  are 
sutured.  Taylor  operated  on  6  cases  and  2  recovered,  with  relief  of  all  signs 
of  pressure. 

The  cisterna  magna  may  be  drained.  Cotterill  actually  opened  the  foramen 
of  Magendie,  and  the  patient  distinctly  improved  ("Lancet,"  Nov.  12,  1910). 

Gushing,  after  determining  by  lumbar  puncture  that  the  ventricles  can  be 
emptied,  obtains  retroperitoneal  drainage  by  a  combined  laparotomy  and 
laminectomy.  Marmion  establishes  drainage  from  the  ventricles  into  the  highly 
lymphatic  tissues  about  the  parotid  gland  ("Zentralb.  fur  Chirurgie,"  August 
12,  191 1 ),  and  Payr,  with  the  internal  jugular  vein  by  means  of  a  transplanted 
artery  or  vein  ("  Archiv.  fiir  Klin.  Chirurgie,"  August  26,  191 1). 

Puncture  of  the  corpus  callosum  has  been  recommended  by  Anton,  Ringel, 
Tillmann,  Stieda,  Bramann  and  others.     The  opera.tion  is  caWed  vent  r  tail  ostomy. 

The  mortality  is  said  to  be  less  than  2  per  cent.  Any  relief  must  be  tempo- 
rary as  the  puncture  cannot  be  kept  open.  The  operation  is  performed  as 
follows,  according  to  Bramann:  Expose  the  skull  i  inch  posterior  to  the  coronal 
suture  and  in  the  middle  line.  Make  a  small  opening  in  the  skull  and  make 
a  small  dural  opening  near  to  the  margin  of  the  sinus.  Pass  a  cannula  or  sinus 
forceps  into  the  longitudinal  fissure.  Carry  it  vertically  downward  guided  by  the 
falx  and  push  it  through  the  corpus  collosum.  Open  the  blades  of  the  forceps 
or  remove  the  mandrin  of  the  cannula,  enlarge  the  opening  by  moving  the  instru- 
ment gently  to  and  fro,  remove  the  instrument  and  close  the  scalp  wound 
(Binnie's  "Operative  Surgery"). 

Injuries  of  the  Head 

One  of  the  most  important  subjects  in  surgery  is  that  of  head  injuries.  The 
frequency  of  their  occurrence,  their  great  fatality,  the  extraordinary  recoveries 
that  are  sometimes  encountered,  the  common  difficulty  in  diagnosis,  the  drama 
which  often  leads  to  or  accompanies  them,  combine  to  surround  these  cases 
with  a  peculiar  interest. 

Gross  says:  "  It  was  long  ago  remarked  by  Mr.  Pott,  and  the  observation  has 
been  verified  a  thousand  times  since,  that  there  is  no  lesion  of  the  head  so 
trifling,  on  the  one  hand,  as  not  to  endanger  life,  or  so  severe,  on  the  other, 
that  it  may  not  be  followed  by  recovery"  ("A  System  of  Surgery"). 

Liston,  in  his  Lectures  on  the  "Operations  of  Surgery,"  sets  forth  the  same 
idea  more  concisely.  He  says:  "It  has  been  said,  and  truly,  that  no  injury  of 
the  head  is  too  slight  to  be  despised,  or  too  great  to  be  despaired  of." 

After  every  injury  of  the  head  an  .t-ray  examination  should  be  made.  In 
many  cases  a  fracture  cannot  be  detected  by  any  other  method. 

After  any  head  injury  symptoms  and  signs  of  compression  should  be  watched 
for  most  carefully.  If  they  arise  they  are  to  be  regarded  as  commands  for 
surgical  interference.     Choked  disk  is  an  early  and  important  sign  of  pressure. 

Lumbar  puncture  should  be  performed  after  head  injuries.  Bloody  cerebro- 
spinal fluid  is  very  significant  though  we  can  obtain  clear  fluid  in  some  cases  of 
subdural  hemorrhage. 

Caput  Succedaneum. — (See  page  867.) 

Cephalhematoma. — (See  page  868.) 

Scalp=wounds  bleed  profusely  because  the  scalp  is  very  vascular,  because 
many  of  the  blood-vessels  are  in  fibrous  tissue  and  cannot  contract  and  retract, 
and  because  even  blunt  force  splits  the  scalp  almost  like  an  incision.  Scalp- 
wounds  are  treated  as  are  other  wounds.  Even  a  large  piece  of  scalp  with  only 
a  narrow  pedicle  may  not  slough;  hence  try  to  save  any  piece  that  has  an  attach- 


Concussion,  Contusion,  and  Laceration  of  the  Brain  875 

ment.  Always  shave  a  wide  area  and  disinfect  the  shaved  area  and  the  wound. 
Arrest  hemorrhage,  and  exercise  great  care  in  cleansing  the  wound  and  the 
parts  about  it.  Stitch  the  wound  with  silkworm-gut.  Very  few  sutures  are 
needed  if  the  wound  is  longitudinal,  but  many  are  required  if  it  is  transverse. 
Deep  vessels  are  ligated.  The  permanent  arrest  of  hemorrhage  from  the  skin 
and  subcutaneous  tissue  is  rarely  effected  by  ligatures,  but  rather  by  sutures 
judiciously  placed.  If  drainage  is  required,  use  a  few  strands  of  silkworm-gut; 
but  drainage  is  rarely  used  unless  we  know  the  wound  to  be  grossly  infected.  Wet 
antiseptic  dressings  are  used  for  the  first  few  days  and  moderate  pressure  is 
applied  by  wet  gauze  bandages.     Avulsion  of  the  Scalp  is  discussed  on  page  301. 

Contusions  of  the  Head. — Scalp  swelling  from  hemorrhage  is  usually 
considerable.  The  patient  may  be  stunned  or  dazed.  The  swelling  of  hema- 
toma of  the  scalp  must  not  be  mistaken  for  fracture  with  depression.  In  hema- 
toma there  is  a  central  depression;  hard  pressure  on  the  center  finds  bone  on 
a  level  with  the  general  contour  of  the  bone,  and  the  margin  of  a  hematoma 
is  circular,  is  not  quite  hard,  and  is  elevated  above  the  general  contour.  In 
depressed  fracture  the  edge  is  on  a  level  with  the  central  depression,  is  below 
the  level  of  the  general  bony  contour,  and  the  margin  is  sharp  and  irregular. 
The  treatment  is  by  bandage-pressure.     Should  suppuration  arise,  at  once  incise. 

Concussion,  Contusion,  and  Laceration  of  the  Brain  J — For  many 
years  it  was  customary  to  regard  concussion  as  a  condition  produced  by  molec- 
ular vibrations  in  the  nervous  substance  of  the  brain.  Buret's  classical  obser- 
vations profoundly  modified  surgical  thought,  and  led  to  the  opinion  that  in 
concussion  of  the  brain  there  is  injury  to  the  brain  itseh,  a  rupture  of  cere- 
bral vessels  brought  about  by  the  advance  and  recession  of  waves  of  cere- 
brospinal fluid.  This  wave,  it  is  thought,  first  flows  in  the  direction  of  the 
force.  Keen  says  that  there  may  be  slight  brain  injuries  which  can  properly  be 
called  "concussions,"  but  it  is  better  to  consider  concussion  as  synonymous 
with  laceration  of  the  brain.  Kocher  considers  concussion  as  identical  with 
contusion  of  the  brain.  It  seems,  however,  highly  improbable  that  slight 
•cases  of  concussion  are  accompanied  by  vascular  rupture  or  organic  mischief; 
the  symptoms  are  too  transitory  and  reaction  too  rapid  and  complete  to  permit 
of  any  such  view.  Experiments  on  animals  show  we  can  develop  concussion 
without  laceration  or  contusion.  Autopsies  have  been  carefully  made  in  some 
cases  of  death  from  concussion,  and  no  organic  lesion  has  been  discovered.  It 
is  quite  true  that  the  same  force  which  causes  the  concussion  may  cause  con- 
tusion or  multiple  lacerations,  and  a  severe  force  is  apt  to  do  so.  But  we  are  not 
then  justified  in  assuming  that  concussion  is  contusion  or  laceration:  we  should 
rather  conclude  that  the  individual  had  both  concussion  and  a  demonstrable 
injury.  Both  conditions  arise  from  violence,  but  the  two  conditions  are  not 
identical.  I  believe,  with  von  Bergmann,  that  there  is  such  a  condition  as 
•concussion,  which  may  be  pure  concussion  or,  may  be  associated  with  organic 
damage,  and  even  if  a  man  dies  and  is  found  to  have  an  organic  injury,  the 
concussion  may  have  caused  or,  at  least,  have  hastened  the  fatal  result.  I 
believe,  with  von  Bergmann,  that  it  is  not  repeated  waves  of  force  from  the  blow, 
b)ut  the  concussion  of  the  blow  itself  that  does  the  harm.  The  brain  is  momen- 
tarily displaced  by  the  blow.  The  blow  acts  on  the  entire  brain;  the  centers  are 
first  stimulated  and  then  depressed,  and  in  fatal  cases  are  not  only  depressed,  but 
are  paralyzed.  The  cause  of  concussion  is  violent  force,  either  direct  (as  a 
IdIow  upon  the  head)  or  indirect  (as  a  fall  upon  the  buttocks).  This  force 
momentarily  displaces  the  brain,  giving  rise  to  stimulation  and  then  to  exhaustion 
of  the  nerve-centers,  and  perhaps  to  rupture  of  vascular  twigs,  large  vessels,  or 
even  the  membranes.  In  the  less  severe  cases  concussion  only  exists;  in  the 
more  severe  cases  there  is  also  contusion  or  laceration  or  compression  soon  arises. 

As  von  Bergmann  points  out,  the  entire  cortex  in  concussion  is  momentarily 
1  See  the  author  in  "U.  S.  Naval  Bulletin,"  Vol.  x,  No.  3. 


gy6  Diseases  and  Injuries  of  the  Head 

stimulated  and  then  depressed.  The  momentary  stimulation  exists  when  a 
man  "sees  stars"  as  a  result  of  a  blow.  The  depression  or  exhaustion  is  mani- 
fested by  heaviness,  dulness,  stupor,  perhaps  by  unconsciousness.  The  stimu- 
lation of  the  medullary  centers,  von  Bergmann  points  out,  lasts  longer,  as 
a  rule,  than  the  stimulation  of  the  cortex,  and  is  manifested  particularly  by  a 
slow  pulse.  If  the  pulse  grows  rapid  and  weaker,  the  pneumogastric  center 
is  becoming  exhausted  and  the  patient  is  in  danger  of  death.  In  slight  cases 
of  concussion  the  cortex  only  may  be  involved,  the  medullary  center  escap- 
ing. In  rapidly  fatal  cases  of  concussion  the  medullary  centers  are  quickly 
paralvzed. 

Symptoms. — In  a  very  trivial  case  the  patient  "sees  stars,"  is  slightly  and 
momentarily   dazed  and    confused,    is   for    a   time    pale,    weak,    giddy    and 
nauseated,  and  the  pulse  is  temporarily  slow  and  weak,  but  he  is  otherwise 
unafTected.     In  a  rather  slight  case  of  brain  concussion  the  patient  may  or  may 
not  fall;  his  face  is  pale;  he  feels  weak,  giddy,  nauseated,  and  confused,  but 
he  soon  reacts,  and  often  vomits.     The  pulse  is  slow  for  a  tim.e  and  then  becomes 
normal.     In  a  severe  case  he  falls  down  and  hes  in  a  state  of  complete  muscular 
relaxation.     He  cannot  stand  up.     The  extremities  are  cold;  the  skin  is  pale 
and  cold;  the  pulse  is  small  and  slow.     The  face  is  ghastly,  the  skin  is  cold  to 
the  touch  and  lacks  the  flush  and  heat  noted  in  compression.     The  slow  pulse 
is  due  to  stimulation  of  the  pneumogastric  center;  the  respiration  varies,  being 
sometimes  deep,  sometimes  superficial,  sometimes  rapid,  sometimes  irregular,  but 
not  stertorous.     He  seems  unconscious,  but  can  usually  be  roused  to  monosyl- 
labic response  by  shouting,  pinching,  or  holding  a  bright  light  near  his  face. 
He  does  not  originate  an  idea,  does  not  volunteer  a  word,  scarcely  moves  a 
muscle.     Occasionally,  however,  there  is  complete  unconsciousness.     The  urine 
and  feces  are  often  passed  involuntarily.     The  pupils  may  be  unaltered,  may  be 
dilated  or  contracted,  may  be  equal  or  unequal,  but  in  any  case  they  will  react 
to  light.     Paralysis  rarely  exists,  but  if  there  be  paralysis,  it  is  temporary. 
The  temperature  at  first  is  subnormal.     In  a  very  severe  concussion  in  which 
there  is  great  danger  of  death  the  pulse  is  very  rapid,  small,  weak,  and  probably 
irregular  because  of  exhaustion  of  the  medullary  center,  and  the  patient  is 
absolutely  unconscious  because  of  depression  of  the  cortex.     If  there  is  a  severe 
cortical  laceration  there  will  be  twitchings  or  even  general  convulsions,  or  the 
patient  will  lie  curled  up  with  hmbs  flexed  and  eyelids  shut,  and  will  resist 
all  attempts  to  open  his  eyes  or  mouth  or  to  move  his  limbs  (A.  Pearce  Gould). 
Erichsen  called  this  condition  "cerebral  irritabihty."     If  a  patient  with  very 
severe  concussion  and  very  rapid  pulse  is  recovering,  the  pulse  will  become  slower. 
If  a  patient  with  severe  concussion  and  a  slow  pulse  is  improving,  the  pulse  will 
become  normally  rapid;  if  he  is  getting  worse,  it  will  become  abnormally  rapid 
and  weaker.     Always  perform  lumbar  puncture  and  make   ophthalmoscopic 
examinations  at  intervals  of  from  6  to  12  hours.     Bloody  cerebrospinal  fluid  and 
choked  disk  are  significant — the  first  of  subdural  bleeding  the  second  of  com- 
pression.    How  long    may  concussion    last?     As  von    Bergmann  well    says: 
Concussion  is  transient  in  its  manifestations.     It  is  a  matter  of  a  few  minutes  or, 
at  most,  a  few  hours,  and  any  prolongation  of  severe  symptoms  beyond  this 
time,  especially  if  they  are  intensifying  as  time  goes  on,  indicates  an  associated 
injury.     When  the  patient  reacts  from  concussion  he  will  probably  vomit. 
Within  twenty-four  hours  he  usually  improves,  but  is  feverish  and  complains  of 
headache  and  lassitude,  sometimes  becomes  delirious,  and  in  rare  cases  develops 
mania.     If  the  patient  in  concussion  recedes  from,  instead  of  advances  toward, 
recovery,  coma  will  set  in  or  inflammation  will   develop.     The   prognosis  is 
always    uncertain.     Any   concussion    producing    more  than  very  temporary 
unconsciousness  is  almost  surely  a  serious  injury,  because  considerable  laceration 
has  probably  occurred.     Recovery   from   concussion   may   be   complete   and 
permanent,  but,  on  the  contrary,  the  entire  nature  may  undergo  a  change. 


Treatment  of  Concussion,  Contusion  and  Laceration  of  the  Brain      877 

Such  a  change,  which  may  not  be  evident  for  weeks  or  months,  is  apt  to  be 
manifested  by  egotism,  selfishness,  censoriousness,  mendacity,  great  irritabil- 
ity, outbreaks  of  violent  rage  about  trivial  things,  and  forgetfulness.  The 
forgetfulness  is  particularly  as  to  recent  events.  There  are  headaches, 
insomnia,  attacks  of  depression,  lassitude,  and  vertigo.  Such  a  patient  is  very 
susceptible  to  alcohol,  the  heat  of  the  sun,  and  physical  or  mental  strain. 
He  can  do  nothing  requiring  mental  effort. 

After  concussion  a  patient  may  develop  hysteria,  epilepsy,  amnesia,  or 
actual  insanity.  A  condition  resembling  Korsakow's  psychosis  may  develop 
(a  condition  of  confusion  with  gaps  in  memory  which  are  filled  up  spontane- 
ously by  fabrications,  the  patient  also  having  multiple  neuritis),  confusional 
insanity,  or  mania  may  arise,  or  a  condition  like  hallucinatory  paranoia  or  mental 
weakness,  which  may  resemble  paresis.  Concussion  may  pervert  or  wipe  out  all 
memory  of  the  causative  accident  and  also,  strange  to  say,  of  a  var}dng  period 
preceding  the  accident.  The  loss  of  memory  of  the  accident  is  permanent; 
the  amnesia  for  a  period  preceding  the  accident  may  be  permanent  or  may  only 
be  temporary.  Statements  made  regarding  an  accident  by  one  who  has  had 
concussion  must  be  received  with  many  grains  of  salt.  A  man  may  tell  a  story 
he  believes  himself,  and  yet  it  may  be  a  mass  of  dream  fancies  without  a  word 
or  with  scarcely  a  word  of  truth.  Victims  of  arteriosclerosis  are  particularly 
apt  to  develop  mental  trouble  and  neurasthenia.     Regis    insists  upon  this. 

After  concussion  we  may  find  sugar  in  the  urine.  We  may  find  it  also  from 
fracture  of  the  skull,  compression  of  the  brain,  tumor  of  the  brain,  etc.  It  used 
to  be  thought  that  traumatic  diabetes  was  the  result  of  vasomotor  disturbances 
which  flooded  the  liver  with  blood  and  took  quantities  of  glycogen  into  the 
circulation.  From  the  islands  of  Langerhans  in  the  pancreas  comes  a  secretion 
which  exerts  control  over  carbohydrate  metabolism.  If  that  secretion  is 
absent  or  is  present  in  small  amount  the  tissues  cannot  assimilate  carbohy- 
drates, those  materials  appear  in  the  blood,  the  tissues  break  down,  the  glycogen 
stored  up  in  the  liver  is  swept  into  the  circulation  and  diabetes  exists.^  The 
administration  of  adrenalin,  puts  sugar  in  the  urine,  so  does  pituitary  disease,  so 
may  thyroid  disease. 

H\'persecretion  from  these  glands  antagonizes  the  internal  secretion  of 
the  pancreas  and  so  causes  diabetes.  Traumatic  diabetes  is  probably  due  to 
incoordination  between  the  ductless  glands.  In  all  probabihty  sugar  in  the 
urine  after  a  head  injury  means  that  there  is  irritation  of  the  floor  of  the  fourth 
ventricle  and  also  to  the  nerves  that  go  to  the  suprarenals,  and  that  as  a  result 
there  is  an  increased  formation  of  suprarenal  secretion. 

Hypertraumatic  diabetes  is  usually  temporary.  If  it  should  last  for  a  long 
time  organic  disease  of  the  pancreas  may  arise  and  genuine  diabetes  begin. 

Traumatic  polyuria  is  common  after  head  injury.  Polyuria  results  from 
jarring  compression  or  irritation  of  the  posterior  portion  of  the  hypophysis, 
cerebri.  The  excess  of  secretion  causes  polyuria.  Traumatic  polyuria  is  more 
common  after  fracture  of  the  base  than  after  pure  concussion.  When  it  occurs 
after  fracture  of  the  base  there  may  have  been  actual  laceration  of  or  compres- 
sion upon  the  pituitary  body. 

Treatment. — In  treating  brain  concussion  bring  about  reaction  by  the  ad- 
ministration of  aromatic  spirits  of  ammonia  (no  alcohol,  as  this  agent  excites 
the  brain) ,  by  pouring  a  few  drops  of  ammonia  on  a  handkerchief  and  holding 
it  near  the  nose,  by  surrounding  the  patient  (who  lies  in  bed  with  his  head  on 
a  pillow)  with  hot  bottles,  by  hot  irrigation  of  the  head,  by  the  application  of 
mustard  over  the  heart,  and  by  the  administration  of  enemata  of  hot  coffee  or  of 
hot  sahne  fluid.  Do  not  pour  fluid  into  the  patient's  mouth  until  he  becomes 
able  to  swallow  easily.  If  he  cannot  easily  swallow,  rely  on  hot  enemata  and 
hypodermatic  injections  of  strychnin.     Place  the  patient  in  bed  in  a  quiet  room 

^  The  author  in  U.  S.  Naval  Bulletin,  Vol.  10,  No.  3,  1916. 


878  Diseases  and  Injuries  of  the  Head 

and  watch  him.  If  reaction  is  inordinate,  apply  cold  to  the  head,  give  arterial 
sedatives  and  diuretics,  and  purge.  For  some  days  or  for  some  weeks,  accord- 
ing to  the  case,  insist  on  a  very  quiet  life.  For  many  weeks  after  a  grave  con- 
cussion a  patient  must  be  kept  away  from  business  and  be  watched,  because  of 
the  possibility  of  an  abscess  of  the  brain  arising,  and  because  of  the  liability 
of  such  patients  to  develop  hysteria,  neurasthenia,  or  insanity.  Give  a  plain 
diet  containing  a  minimum  of  meat,  administer  an  occasional  purgative,  and 
secure  sleep.  Sleep  can  often  be  obtained  by  some  simple  expedient,  such  as  the 
administration  of  warm  milk,  placing  a  hot-water  bag  to  the  abdomen  or  feet, 
or  applying  a  mustard  plaster  for  a  short  time  to  the  back  of  the  neck.  In 
cases  in  which  obstinate  wakefulness  exists,  it  becomes  necessary  to  give  bromid, 
chloral,  sulphonal,  trional,  or  some  other  hypnotic.  Morphin  is  avoided 
because  it  is  thought  to  increase  venous  congestion  of  the  brain,  but  the  elder 
Gross  often  used  it,  especially  in  cerebral  irritation.  If  signs  of  compression 
arise,  it  is  best  to  trephine,  as  the  compressing  agent  may  be  a  clot  (see  page 
881).  If  inflammation  arises,  some  surgeons  will  not  trephine;  but  most  regard 
it  as  wise  and  proper,  especially  if  the  damage  seems  to  be  localized,  to  incise 
the  scalp  and  inspect  the  bone.  If  a  fracture  is  discovered  and  the  symptoms 
are  serious,  perform  an  exploratory  trephining,  open  the  dura,  and  secure 
drainage  for  inflammatory  products.  Personally,  I  believe  that  trephining 
for  drainage  is  indicated  in  such  cases  even  when  there  is  no  fracture. 

In  any  severe  concussion  of  the  brain  with  contusion  of  the  scalp  the  sur- 
geon should  at  once  incise  the  scalp  and  inspect  the  bone. 

Compression  of  the  Brain. — The  combination  of  symptoms  indica- 
tive of  cerebral  compression  may  be  present  in  a  number  of  different  condi- 
tions. We  find  these  symptoms  in  abscess  of  the  brain,  tumor  of  the  brain, 
intracranial  hemorrhage,  foreign  bodies,  inflammatory  exudate,  and  fracture 
of  the  skull  with  marked  depression.  The  symptoms  of  compression  are 
expressive  of  impairment  of  the  functions  of  the  entire  brain  by  insufficient 
and  imperfect  circulation  of  blood,  this  impairment  of  circulation  being  the 
result  of  a  lessening  in  capacity  of  the  cavity  containing  the  brain,  its  mem- 
branes, the  blood-vessels,  and  the  cerebrospinal  fluid  (von  Bergmann).  Duret 
injected  wax  within  the  cranium  of  an  animal  and  showed  that  a  diminution  of  5 
per  cent,  in  the  intracranial  capacity  produced  somnolence,  and  a  diminution  of 
8  per  cent,  caused  death.  If  a  brain  tumor,  abscess,  blood-clot,  or  portion  of 
depressed  bone  occupies  space  previously  given  to  brain  matter,  vessels,  etc., 
there  is  less  room  within  the  skull  to  contain  the  special  structures.  The  bones 
cannot  yield,  the  brain  is  incompressible,  so  the  cerebrospinal  fluid  is  displaced, 
the  vessels  are  squeezed,  and  the  circulation  is  greatly  impeded.  Pressure  upon 
either  arteries  or  veins  causes  the  condition  called  compression  (Fig.  573). 
This  condition  of  cerebral  pressure  or  compression  is  one  of  anemia.  In 
reality  it  is  compression  of  the  vessels  which  feed  the  brain  with  blood,  and 
such  compression  grievously  disturbs  the  normal  relationship  between  the  blood- 
supply  of  the  brain  and  the  circulation  of  cerebrospinal  fluid.  Compression 
begins  in  obstruction  to  the  onflow  of  venous  blood.  It  extends  gradually  to 
the  arteries.  The  circulation  is  slowed,  and  because  of  slow  circulation  the 
activity  of  the  centers  is  finally  inhibited.  It  is  stated  by  Gushing  that  the  rise 
which  occurs  in  the  blood-pressure  is  conservative  and  is  expressive  of  Nature's 
effort  to  maintain  the  circulation  in  the  compressed  medullary  centers.  In- 
creased vascular  tension  is  made  manifest  by  estimating  the  blood-pressure  and 
observing  venous  stasis  in  the  optic  disk.  Increased  tension  of  cerebrospinal 
fluid  is  shown  by  lumbar  puncture.  The  fluid  flows  out  rapidly  or  jets  out. 
The  cortex  is  temporarily  stimulated  and  then  depressed,  because  of  impair- 
ment of  nutrition.  The  medullary  centers  are  first  stimulated.  The  respira- 
tory center  is  stimulated  by  retention  of  CO2  in  the  blood,  then  the  vasomotor 
center  is  stimulated,  then  the  vagus,  and  finally,  perhaps,  the  convulsive  center 


Symptoms  of  Compression  of  the  Brain  879 

(von  Bergmann's  "  System  of  Practical  Surgery").  The  stimulation  of  the  cere- 
bral centers  is  followed  after  a  time  by  weakening  or  actual  paralysis.  The  cen- 
ters are  said  to  suffer  in  regular  order,  viz.,  the  cortex,  the  corona  radiata,  the  gray 
matter  of  the  cord,  and,  finally,  the  medulla  (Huguenin).  As  von  Bergmann 
points  out,  by  the  time  the  convulsive  center  becomes  stimulated  the  cortex 
is  usually  exhausted  and  the  patient  is  unconscious.  In  compression  the 
sensitive  cortex  first  feels  the  effect  and  feels  it  most  gravely,  and  the  cortical 
impairment  may  last  long  after  other  trouble  has  passed.  In  some  cases  the 
cortex  alone  seems  to  be  distinctly  involved.  When  the  vagus  center  is  stimu- 
lated the  pulse  becomes  slow;  later,  as  the  center  becomes  exhausted,  it  becomes 
rapid  and  weak,  and  this  change  has  the  same  unfavorable  significance  as  in 
concussion.  If  death  occurs  it  results  from  paralysis  of  respiration  and  not  of 
circulation.  The  displaceable  cerebrospinal  fluid  is  a  great  safeguard  against 
compression,  but  Gushing  has  shown  us  that  in  intracranial  obstruction  of  the 
venous  circulation  the  flow  of  cerebrospinal  fluid  into  the  space  about  the  cord 
is  prevented  because  the  medulla  and  cerebellum  are  jammed  down  in  the 
foramen  magnum. 

Symptoms. — Pressure  symptoms  are  divided  into  those  occurring  during 
the  period  of  stimulation  and  those  occurring  during  the  period  of  increas- 
ing exhaustion.  The  symptoms  of  the  first  stage  are  headache,  vomiting, 
flushing  of  the  face,  contraction  of  the  pupils,  choked  disk,  mental  excite- 
ment, elevation  of  blood-pressure,  restlessness,  and  slowing  of  the  pulse.  The 
pulse  becomes  slow,  regular,  and  strong.  The  symptoms  of  the  second  stage 
are  heaviness,  dulness,  drowsiness,  passing  into  stupor,  and  finally  into 
coma.  The  respirations  are  stertorous  and  after  a  time  become  Cheyne- 
Stokes.  The  pulse  is  weak,  intermittent,  compressible,  and  increasingly 
rapid.  There  are  involuntary  evacuations  of  feces  and  urine,  and  finally 
paralysis  of  respiration  which  causes  death,  the  heart  beating  for  a  time  after 
respiration  has  ceased  (von  Bergmann's  "System  of  Practical  Surgery"). 

The  headache  usually  present  in  the  first  stage  of  compression  is  intense, 
persistent,  sometimes  general  and  sometimes  more  or  less  localized,  and  often 
aggravated  by  percussion  of  the  cranium.  It  persists  even  in  delirium,  and 
the  patient  ceases  to  appreciate  it  only  when  unconsciousness  begins.  The 
vomiting  is  usually  without  nausea  and  is  due  to  stimulation  of  the  medullary 
center.  At  first  vomiting  may  arise  from  taking  food,  but  it  soon  continues 
independent  of  food.  The  tongue  is  probably  clean.  Cerebral  vomiting 
is  usually  associated  with  severe  headache.  Restlessness  is  a  pressure  symptom 
in  the  stage  of  stimulation,  and  the  patient  rolls  his  head,  tosses  his  body,  and 
groans  with  pain.  The  Iieart  does  not  begin  to  slow  until  the  patient  begins 
to  be  dull  and  drowsy,  or  until  stupor  arises,  when  the  pulse  slows  and  the 
tension  rises.  Finally  it  becomes  very  slow — perhaps  less  than  50  or  even  40 
in  a  minute.  A  very  slow  pulse  is  ominous  as  edema  of  the  medulla  is  apt  to 
arise.  If  the  condition  grows  worse,  the  slow  pulse  after  a  time  suddenly 
becomes  rapid  and  of  low  tension,  instead  of  slow  and  of  high  tension,  a  most 
unfavorable  sign,  indicating  exliaustion  and  approaching  paralysis  of  the  vagus. 
In  the  stage  of  stimulation  the  patient  is  excited,  unstable,  delirious,  and  the 
condition  of  delirium  gradually  gives  way  to  drowsiness,  stupor,  and  coma.  In 
some  cases  of  compression  there  is  distinct  protrusion  of  the  eyeballs.  Before 
the  patient  becomes  unconscious  the  pupils  are  contracted.  When  the  patient 
is  comatose,  they  are  usually  dilated,  but  may  be  contracted.  In  coma  the 
pupils  respond  slowly  to  light  or  not  at  all.  If  the  conjunctival  reflex  is  gone, 
they  will  not  respond  at  all  (Gowers).  In  a  lesion  making  unilateral  compres- 
sion toward  the  base  the  pupil  on  the  side  of  the  compressing  cause  is  apt  to  be 
much  dilated  and  even  immobile.  Choked  disk  begins  in  the  stage  of  stimula- 
tion and  continues  to  the  end.  That  choked  disk  is  due  to  intracranial  pressure 
seems  demonstrated  by  numerous  operation  reports,  especially  by  Gushing,  of 


88o  Diseases  and  Injuries  of  the  Head 

Harvard,  in  which  rehef  of  pressure  abated  choked  disk  (see  page  912).     The 
existence  of  choked  disk  is  determined  by  the  use  of  the   ophthalmoscope. 
In  every  case  of  traumatism  repeated  ophthalmoscopic  examinations  should  be 
made.     The  respirations  become  stertorous  or  snoring  as  coma  develops  because 
of  the  vibrations  of  the  relaxed  palate  in  the  air-current,  and  the  cheeks  flap  dur- 
ing expiration.     As  the  activity  of  the  respiratory  center  fails  from  increasing 
anemia,  the  respirations  become  shallow  and  infrequent,  or,  perhaps,  of  the 
Cheyne-Stokes  type.     Gowers  defines  Cheyne-Stokes  breathing  as  "alternating 
periods  of  decreasing  and  increasing  depth  of  breathing,  separated  by  a  pause" 
("Lectures  on  Diseases  of  the  Brain").     The  unconsciousness  of  compression 
may  be  sudden  or  gradual,  may  be  partial  or  complete.     Apoplexy  and  many 
traumatisms  cause  immediate  unconsciousness:  the  irritation  of  such  a  sudden 
lesion  at  once  inhibits  the  cortex.     A  meningeal  hemorrhage  causes  a  gradually 
increasing   unconsciousness.     A  brain   tumor  may  cause  heaviness,  dulness, 
stupor,  or,  perhaps,  after  a  long  time,  even  coma.     If  compression  comes  on 
gradually,  the  brain  more  or  less  accommodates  itself,  and  unconsciousness,  if  it 
occurs  at  all,  is  considerably  deferred.     A  sudden  increase  of  pressure  may  pro- 
duce immediate  unconsciousness.     Stupor  is  partial  unconsciousness,  a  con- 
dition in  which  a  person  lies  as  though  asleep,  though  he  arouses  partially 
and   temporarily   when  positively  spoken   to.     In  profound   coma  the    limb 
reflexes  are  usually  but  not  always  diminished  or  lost.     The  superficial  reflexes 
are  impaired  or  lost.     The  muscles  are  flaccid  and  swallowing  is  impossible. 
In  coma  there  is  incontinence  of  feces  and  either  incontinence  or  retention  of 
urine.     There  may  be  the  incontinence  of  retention.     The  temperature  of  a 
patient  suffering  from  compression  varies.     In  traumatic  cases  it  may  be  at 
first  subnormal  and  later  normal  or  elevated.     In  inflammatory  conditions  it 
is  elevated,  except  in  abscess  of  the  brain,  in  which  it  is  subnormal,  for  a  time 
at  least,  in  half  the  cases.     After  an  apoplex\'  it  is  for  a  time  subnormal,  but  as 
shock  passes  away  it  becomes  somewhat  elevated.     Any  sudden  compression 
causes  shock  and  temporarily  subnormal  temperature.    Lesions  of  the  pons 
and  medulla  cause  elevation — perhaps  remarkable  elevation — of  temperature. 
In  great  or  sudden  brain  compression  complete  coma  always  exists  and  there  is 
no  voluntary  movement.     In  cerebral  compression  paralysis  may  exist,  which 
may  be  very  Umited  (monoplegia),  may  be  of  one  side  (hemiplegia),  or  may  be 
general.     In  hemorrhage  into  the  interior  of  the  brain  the  unconsciousness  is  im- 
mediate or  nearly  so.     In  bleeding  from  the  middle  meningeal  artery  a  period  of 
consciousness  intervenes  between  the  injury  and  the  coma,  during  which  period 
blood    collects    and    the   coma   comes   on   gradually.     In   compression    from 
depressed  fracture  or  from  a  foreign  body  the  s>Tnptoms  usually  come  on  at  once, 
but  they  may  be  deferred  for  some  hours.     Compression  from  inflammation 
or  pus  begins  gradually  after  a  considerable  time  has  elapsed.     The  symptoms 
described  as  pressure  symptoms  are  those  of  pure  compression.     When  trau- 
matism causes  the  condition,  the  compression  s\Tnptoms  are  mingled  with 
those  of  concussion,  or  perhaps  of  contusion  or  hemorrhage.     The  brain  adjacent 
to  any  lesion  causing  compression  suffers  more  than  the  brain  distant  from  it. 
The  blood-supply  of  the  entire  brain  is  affected,  but  the  adjacent  brain  has 
its  capillaries  particularly  and  directly  compressed.     Hence  Umited  paralysis 
is  sometimes  produced  by  compressing  lesions.     The  course  of  compression 
depends  on  the  nature  and  persistence  of  the  cause.     Great  temporary  pres- 
sure may  produce  no  permanent  harm.     Moderately  severe  pressure  may  be 
recovered  from  even  after  weeks  of  stupor.     Great  pressure,  suflScient  to  induce 
coma,  if  not  reheved  quickly,  will  cause  death.     Persistent  cerebral  symptoms 
after  a  head  injury,  when  no  obvious  lesion  can  be  made  out,  are  probably  due 
to  edema  of  the  brain. 

Determination    of   the    Cause  of  Coma  in  a  Patient, —  A  diagnosis  must 
be  made  between  coma  due  to  brain  injury   and  the  comatose   condition   of 


Treatment  of  Brain  Compression  88 1 

apoplex}',  uremia,  epilepsy,  hysteria,  diabetes,  opium-poisoning,  gas-poisoning, 
meningitis,  lobar  pneumonia,  and  alcoholic  intoxication.  In  hospital  practice 
cases  of  unconsciousness  without  a  known  history  are  frequent.  In  attempting 
to  diagnosticate,  examine  carefully  for  any  evidence  of  traumatism,  and  inquire 
as  to  how  and  where  the  patient  was  found,  if  any  lit  occurred,  and  if  a  bottle 
or  a  pill-box  was  found  near  by  or  in  the  pockets.  The  surgeon  should  himself 
examine  the  pockets.  Smell  the  breath  to  notice  alcohol  or  opium,  but  always 
remember  that  an  alcoholic  is  often  a  victim  of  Bright's  disease,  that  a  man 
with  Bright's  disease  is  liable  to  apoplexy,  that  a  man  may  be  stricken  with 
apoplexy  while  he  is  drunk,  and  may  fracture  his  skull  by  falling  when  under 
the  influence  of  opium  or  of  alcohol.  The  odor  of  acetone  (violets)  on  the  breath 
or  in  the  urine  indicates  the  existence  of  diabetes.  Draw  the  urine  with  the 
catheter  if  any  water  is  in  the  bladder.  Examine  the  urine  for  albumin,  acetone, 
and  sugar,  and  take  the  specific  gravity.  In  doubtful  cases  of  coma  have 
an  ophthalmologist  use  the  ophthalmoscope.  He  might  find  optic  atro- 
phy, indicative  of  Bright's  disease,  or  choked  disk,  indicating  compression. 
The  cerebrospinal  fluid  obtained  by  lumbar  puncture  should  contain  blood  if 
hemorrhage  has  taken  place  beneath  the  cerebral  dura  or  in  a  ventricle  of  the 
brain.  This  test  is  valuable  in  fracture  of  the  base  of  the  skull,  for  in  this  con- 
dition cerebrospinal  fluid  is  usually  bloody.  In  postepileptic  coma  the  tem- 
perature is  never  below  normal,  there  are  no  unilateral  symptoms,  the  condition 
resembles  sleep,  and  after  a  time  the  patient  can  be  aroused  or  comes  to 
of  himself.  Hysterical  coma  occurs  in  boys  and  women;  there  are  no  objective 
symptoms,  and  the  patient,  though  swallowing  what  is  put  into  his  mouth, 
cannot  be  aroused.  In  uremia,  besides  the  condition  of  the  urine  (and  always 
remember  that  a  person  with  albuminuria  is  apt  to  develop  apoplexy),  there  is  a 
persistent  subnormal  temperature,  and  convulsions  are  prone  to  occur.  There 
is  perhaps  edema  of  the  legs,  but  paralysis  and  stertor  are  absent.  In  apoplexy 
hemiplegia  exists,  and  the  initial  temperature  is  for  a  short  time  subnormal.  A 
single  convulsion  may  have  ushered  in  the  case.  Alcoholic  unconsciousness 
is  often  diagnosticated  when  apoplexy  really  exists.  A  man  will  smell  of  alcohol 
who  has  had  one  drink,  but  one  drink  will  not  produce  coma;  hence  the  smell 
of  alcohol  is  not  conclusive.  In  any  case  of  doubt  some  hours  of  watching 
will  clear  up  the  diagnosis.  Regard  a  doubtful  case  as  serious  until  the  truth 
is  clear.  In  opium-poisoning  the  pupils  are  contracted  to  a  pin-point,  the 
respirations  are  usually  slow,  shallow  and  quiet,  and  may  be  stertorous,  but 
there  is  no  paralysis.  Always  remember  that  hemorrhage  into  the  pons  will 
produce  pin-point  pupils,  but  it  also  causes  paralysis  (crossed  paralysis  if  in 
the  lower  half  of  the  pons)  and  high  temperature  with  sweating.  In  opium- 
poisoning  the  temperature  is  subnormal.  In  diabetic  coma  the  pupils  will  react 
to  a  very  bright  Hght,  the  temperature  is  subnormal,  and  the  breath  and  the 
urine  smell  of  acetone.  (See  Acidosis,  page  1348,  and  Diabetic  Coma,  page 
191.)  An  ophthalmoscopic  examination  and  lumbar  puncture  may  furnish 
explanations  of  a  doubtful  case. 

Treatment  of  Brain  Compression. — ^The  treatment  of  brain  compres- 
sion depends  on  the  cause.  Hemorrhage  (extradural  or  subdural)  requires 
trephining  and  arrest  of  bleeding;  coma  from  depressed  fracture  demands 
trephining  and  elevation;  foreign  bodies  must  be  removed;  abscesses  must 
be  evacuated;  some  tumors  are  to  be  removed.  In  many  tumor  cases  the 
grow^th  is  not  removed,  but  a  decompression  operation  is  performed  (see  page 
937).  In  cerebral  compression,  if  death  is  threatened  by  respiratory  failure, 
institute  artificial  respiration  and  at  once  trephine  over  the  supposed  region 
of  compression.  Horsley  has  shown  that  irrigation  of  the  head  with  hot 
water  is  of  great  value  in  bringing  about  reaction  from  shock  in  cases  of  brain 
injury. 


882 


Diseases  and  Injuries  of  the  Head 


Intracranial  hemorrhage  may  be  either  spontaneous  or  traumatic.  In 
the  vast  majority  of  instances  spontaneous  hemorrhage  comes  from  the  len- 
ticulostriate  artery  (Charcot's  artery  of  cerebral  hemorrhage),  and  produces 
apoplexy,  a  disease  in  the  province  of  the  physician,  except  in  some  ingravescent 
cases,  for  which  ligation  of  the  common  carotid  on  the  same  side  as  the  rupture 
has  been  advised.  In  adults  traumatism  is  almost  always  the  cause  of  a  men- 
ingeal hemorrhage.  The  blood  may  How  from  a  sinus,  from  the  middle  men- 
ingeal artery  or  one  of  its  branches,  or  from  vessels  of  the  pia.  Trauma- 
tism during  delivery  is  an  occasional  cause  of  hemorrhage  from  the  middle 
meningeal  artery  (Richardiere)  and  a  not  unusual  cause  of  hemorrhage  from 
cortical  veins.  Violent  paroxysms  of  coughing  in  whooping-cough  occasionally 
produce  extradural  hemorrhage  or  subdural  hemorrhage.  Geo.  S.  Brown 
reported  such  a  case.  He  diagnosticated  the  condition  and 
operated  successfully  ("New  York  Med.  Jour.,"  April  25, 

1903)- 

Traumatic  Intracranial  Hemorrhage.— Hemorrhage 

may  take  place-(i)  between  the  bone  and  the  dura  {ex- 
tradural); (2)  between  the  dura  and  the  brain  {subdural), 
and  (3)  in  the  brain  substance  {cerebral). 

Extradural  meningeal  hemorrhage  arises  usually  from 
the  middle  meningeal  artery  or  from  one  of  its  branches. 
A  spicule  of  bone  may  penetrate  a  venous  sinus  and  pro- 
duce extradural  hemorrhage,  or  a  sinus  may  rupture. 
Rupture  of  the  meningeal  artery  or  one  of  its  branches  is 
usually,  but  not  always,  accompanied  by  fracture  (Fig. 
573);  in  fact,  in  some  cases  not  even  a  bruise  can  be  found 
(Fig.  574).  The  ruptured  vessel  may  be  upon  the  opposite 
side  to  that  on  which  the  force  was  applied,  hence  the 
evidence  of  scalp  injury  is  not  a  certain  sign  of  the  side 
of  the  skull  involved.  The  accident  may  or  may  not 
cause  temporary  unconsciousness;  but  even  if  it  does,  from 
this  unconsciousness  the  patient  almost  always  reacts  unless 
there  are  other  grave  injuries,  and  there  is  usually  a  distinct 
period  of  consciousness  between  the  accident  and  the  lasting 
coma,  the  coma  being  due  to  pressure  from  a  continually 
increasing  mass  of  extra vasated  blood  (Fig.  575).  If  the 
main  trunk  or  a  large  branch  has  been  ruptured  the  period  of 
consciousness  will  be  short;  if  a  small  branch  has  been  ruptured  the  period  of 
consciousness  will  be  prolonged  for  hours  or  perhaps  for  days.  As  the  clot  forms 
and  enlarges  the  patient  becomes  heavy,  dull,  stupid,  and  sleepy;  he  sleeps 
so  soundly  he  can  scarcely  be  aroused,  and  snores  loudly,  and  finally  passes 
into  stupor  and  then  into  coma.  The  other  signs  of  this  condition  are  paralysis 
of  the  side  opposite  the  blood-clot  (not  necessarily  of  the  side  opposite  the  point 
of  application  of  the  force,  for  the  artery  may  rupture  from  contre-coup  on 
the  uninjured  side);  this  paralysis  is  apt  at  first  to  be  localized,  but  it  gradually 
and  progressively  widens  its  domain.  If  the  clot  extends  toward  the  base,  the 
pupil  on  the  same  side  as  the  clot  ceases  to  react  to  light,  and  the  immobile 
pupil  dilates  widely.  If  the  clot  be  on  the  left  side,  aphasia  may  be  noted.  As 
the  clot  enlarges  adjacent  centers  become  involved.  The  face  becomes  para- 
lyzed, then  the  arm,  and  finally  the  leg.  Not  unusually  epileptiform  attacks 
occur,  starting  in  discharges  from  the  centers  which  are  irritated  by  the  advanc- 
ing clot  before  their  function  is  abolished  by  pressure.  The  pulse  becomes  full, 
strong,  usually  slow,  but  occasionally  frequent ;  the  breathing  becomes  stertorous ; 
the  temperature  rises,  that  of  the  paralyzed  side  exceeding  that  of  the  sound 
side.  In  a  compound  fracture  the  pressure  of  escaping  blood  may  force  brain 
matter  out  of  the  wound.     In  extradural  hemorrhage  from  a  sinus  the  symptoms 


Fig.  573. — Frac- 
ture of  skull  with 
middle  meningeal 
hemorrhage.  Com- 
pression of  brain  by 
blood  (Scudder). 


Cerebral  Hemorrhage 


883 


cannot  be  differentiated  from  those  produced  by  arterial  rupture.  If  there 
is  no  free  bleeding  beneath  the  dura  the  fluid  obtained  by  lumbar  puncture 
will  be  clear.  The  ophthalmoscope  discloses  an  early  and  reliable  sign  of  pres- 
sure.    The  .v-rays  make  a  fracture  evident. 

Treatment: — In  treating  extradural  hemorrhage  localize  the  clot,  not  by 
the  seat  of  the  wound  or  contusion,  but  entirely  by  the  symptoms.  In  a  doubtful 
case  endeavor  to  bring  about  reaction;  but  if  the  state  of  shock  deepens  or 
does  not  improve  and  if  pressure  symptoms  increase,  operate  at  once.  To 
reach  the  middle  meningeal  artery  or  its  arterior  branch  trephine  i)-^  inches 
back  of  the  external  angular  process,  at  the  level  of  the  upper  border  of  the 
orbit  (see  Fig.  564,  571,  572).  If  the  incision  does  not  expose  the  clot,  trephine 
again  at  the  level  of  the  upper  border  of  the  orbit  and  just  below  the  parietal 
eminence  (see  Figs.  571,  572).  The  first  incision  gives  access  to  the  main  trunk 
and  to  the  anterior  branch;  the  second  incision  exposes  the  posterior  branch. 
If  signs  indicate  that  the  clot  is  traveling 
to  the  base,  the  trephine  should  be  used 
1  2  inch  lower  than  the  point  first  directed. 
Arrest  bleeding  by  a  suture  ligature  or  by 
packing  (see  page  515),  and  always  open 
the  dura  and  inspect  the  brain.     By  this 


Jiu£tuTe  on  tcuysrteaUi 
plaek  brisilf  m  lumen, 
^       of  arter^' 


'.  ^ 


fiddle  mfTtfiy! 
aaaht 


post  bran 


/€^ 


Fig.  574. — A  case  of  rupture  of  middle 
meningeal  artery.  Preparation  of  dura.  In 
the  Warren  Museum.  The  specimen  is  viewed 
from  the  outer  side  (Scudder). 


Fig.  575. — Frontal  section  of  skull. 
Middle  meningeal  hemorrhage.  The  dura 
bulges  inward  toward  the  skull  cavity 
(diagram)  (Scudder). 


procedure  we  may  discover  a  subdural  hemorrhage  which  otherwise  might  be 
missed.     Drainage  must  be  employed. 

Subdural  meningeal  hemorrhage  is  usually  due  to  depressed  fracture  and 
rupture  of  the  middle  cerebral  artery  or  of  a  number  of  small  vessels. 

The  symptoms  are  identical  with  those  of  extradural  bleeding,  but  are 
usually  very  rapid  in  onset  and  are  accompanied  by  a  more  distinct  drop  in 
temperature  and  graver  depression.  The  cerebrospinal  fluid  obtained  by 
lumbar  puncture  is  usually  bloody,  but,  strange  to  say,  is  sometimes  clear. 

I  have  fancied  that  headache  is  more  violent  before  the  onset  of  uncon- 
sciousness than  it  is  in  extradural  hemorrhage.  Pressure  is  detected  early  by 
ophthalmoscopic  examination. 

The  treatment  is  trephining  for  exploration  at  a  point  il^  inches  back  of  the 
external  angular  process,  enlarging  the  opening  upward  and  backward  by  a 
rongeur,  opening  the  dura  and  turning  out  the  clot.  Hemorrhage  is  arrested 
by  Ught  pressure  with  a  piece  of  freshly  cut  muscle  or  by  ligating  the  bleeding 
point.  Elevate  any  depression  of  bone,  and  stitch  the  dura  by  catgut. 
Hemorrhage  from  internal  pachymeningitis  requires  the  same  treatment. 

Cerebral  Hemorrhage. — The  symptoms  of  cerebral  hemorrhage  are  identical 
with  those  of  apoplexy.  The  treatment  is  the  same  as  that  for  apoplexy,  ex- 
cept in  ingravescent  cases,  when  the  common  carotid  on  the  same  side  as  the 
clot  may  be  ligated. 


884  Diseases  and  Injuries  of  the  Head 

Rupture  of  a  sinus  may  arise  without  a  bone  injury,  but  is  usually  due 
to  a  compound  fracture.  A  sinus  may  be  wounded  during  a  brain  operation. 
The  treatment,  if  the  rupture  happens  from  fracture,  is  trephining.  P^nlarge 
the  bone  opening  by  the  rongeur,  cut  a  piece  of  muscle  from  the  temporal 
or  some  other  muscle  and  hold  it  for  a  time  against  the  bleeding  point.  If  this 
fails  apply  a  lateral  ligature  or  a  suture  ligature  or  catch  the  rent  with  hemostatic 
forceps,  leaving  them  in  place  for  three  or  four  days.  A  gauze  plug  is  a  last 
resort.  Its  use  may  cause  palsy  and  be  followed  by  infection.  Elevate 
depressed  bone.  If  during  an  operation  a  sinus  should  be  wounded,  use  a  lateral 
ligature,  a  suture-ligament,  or  control  hemorrhage  by  packing. 

Intracranial  Hemorrhage  in  the  Newborn. — Certainly  most  of  the  cases 
of  birth  palsy  seen  in  children  are  the  result  of  subdural  and  subarachnoid 
hemorrhage  at  birth  and  damage  of  the  cortical  motor  area.  In  such  condi- 
tions there  is  spastic  paralysis  of  the  hemiplegic  type,  or  if  both  hemispheres 
suffered  there  is  plastic  diplegia  and  usually  amentia  (Gushing,  in  "Amer. 
Jour.  Med.  Sciences,"  Oct.,  1905).  In  some  cases  there  is  hemorrhage  be- 
neath the  tentorium  due  to  rupture  of  that  shelf.  It  has  not  been  the  custom 
to  operate  for  hemorrhage  in  the  newborn;  most  of  the  cases  do  not  die,  but 
remain  for  life  weakened  and  paralyzed,  choreic,  epileptic,  or  idiotic. 

The  hemorrhage  in  cases  of  birth  palsy  is,  as  Gushing  points  out,  usually 
venous  and  due  to  "rupture  of  some  of  the  delicate  and  poorly  supported 
venous  radicles  of  the  cerebral  cortex"  (Ibid.).  It  may  result  from  trauma- 
tism due  to  bone  overlapping  or  forceps  pressure  during  parturition,  or  may 
arise  during  asphyxia  after  birth.  Gushing  discovered  in  examining  stillborn 
infants  and  infants  that  died  soon  after  birth  that  many  of  them  died  from 
cortical  hemorrhage.  In  some  the  extravasations  were  very  large,  in  fact,  com- 
pletely overlying  a  cerebral  hemisphere.  In  some  they  were  much  smaller.  In 
one  the  clot  was  in  the  cerebellar  fossa. 

The  vessels  usually  torn  are  on  one  side  and  are  the  unsupported  venous 
radicles  which  enter  the  longitudinal  sinus,  hence  the  leg  center  of  one  side 
is  the  cortical  area  most  apt  to  be  gravely  damaged.  If  the  vessels  of  both 
sides  are  torn,  a  bilateral  cortical  lesion  results.  The  sinus  itself  may  be 
ruptured. 

Symptoms  of  Hemorrhage  in  the  Newborn. — In  Gushing's  masterly  paper 
(Ibid.)  the  symptoms  of  recent  hemorrhage  are  set  forth.  There  is  the  history 
of  a  long  and  difficult  labor,  forceps  perhaps  having  been  used,  or  a  history  of 
postpartum  asphyxiation.  The  head  of  the  child  may  be  unusually  large. 
The  birth-canal  may  be  unusually  small,  as  is  found  in  contracted  pelvis. 
The  non-distensible  soft  parts  of  a  primipara  in  middle  life  may  be  responsible. 
Syphilis  and  eclampsia  predispose.  In  some  cases  none  of  the  above-named 
causes  are  evident.  In  them  the  condition  may  result  from  the  alteration  in 
pressure  when  the  head  emerges  from  the  os  uteri.  In  hemorrhage  of  the 
convexity  the  fontanel  bulges  and  perhaps  does  not  pulsate.  The  fluid 
obtained  by  lumbar  puncture  contains  blood-corpuscles.  There  is  usually 
twitching  and,  as  a  rule,  convulsions  occur.  They  may  occur  soon  after 
birth  or  several  days  later.  When  they  occur  soon,  they  may  be  general; 
when  they  occur  later,  they  may  be  unilateral.  Paralysis  is  rare  in  the  early 
days  after  birth.  There  may  be  alterations  in  the  circulation  and  respiration. 
Pupillary  alteration  and  ocular  palsy  seldom  occur.  If  the  hemorrhage  is 
below  the  tentorium  the  fontanel  still  pulsates,  the  neck  muscles  are  rigid, 
stupor  exists,  and  the  respirations  are  very  irregular.  If  the  child  is  not  operated 
upon  it  may  die  or  it  may  apparently  recover.  If  it  apparently  recovers  after 
a  consideralDle  hemorrhage,  several  months  may  pass  before  ominous  symptoms 
are  recognized.  The  late  manifestations  of  the  disease  may  be  "spastic  palsies, 
or  blindness,  or  deafness,  or  feeble-mindedness,  or,  in  severe  cases,  even  com- 
plete amentia"  (Gushing).     Epilepsy  may  be  a  result. 


Fractures  of  the  Skull 


885 


Treatment.— li  the  motor  area  is  involved  osteoplastic  craniotomy  should 
be  performed  in  the  parietal  region,  on  one  side  or  both,  according  to 
the  unilateral  or  bilateral  nature  of  the  hemorrhage;  opening  of  the  dura; 
washing  out  and  turning  out  the  clot;  suturing  the  dura  and  closing  the  scalp 
without  drainage.  Both  sides  may  require  operation.  Gushing  reports  16 
cases  of  operation  with  7  recoveries.  He  says  chloroform  should  be  given 
and  that  the  parietal  bone  can  be  cut  with  blunt,  curved  scissors.  If  the  hemor- 
rhage is  beneath  the  tentorium  no  operation  is  recommended  although  some 
surgeons  advise  lumbar  puncture. 

For  slight  cases  of  spastic  paralysis  following  hemorrhage  tendon  lengthening 
may  be  all  that  is  required.  Those  cases,  "particularly  of  the  hemiplegic 
and  paraplegic  types,  which  show  signs  of  increased  intracranial  pressure 
by  an  ophthalmoscopic  examination,  are  the  cases  that  can  be  very  much  im- 
proved" by  cranial  decompression  (Sharpe  and  Farrell,  in  "Jour.  Am.  Med. 
Assoc,"  Feb.  6,  1915). 

Fractures  of  the  skull  may  be  simple,  compound,  depressed,  non-depressed , 
or  punctured.  Fracture  by  diastasis  means  separation  of  a  suture  or  of  sutures 
by  violence.  A  fracture  of  the 
skull  may  be  produced  by  a 
bending  force,  by  a  hirsting 
force,  or  by  an  explosive  force 
(see  Gunshot-wounds). 

A  bending  force  is  usually 
applied  by  the  forcible  impact 
of  a  body  of  small  area.  It 
produces  a  fracture  and  seldom 
causes  distant  injuries.  The 
fracture  may  be  of  the  inner 
table  only,  or  of  both  tables. 
If  both  tables  are  fractured  the 
broken  bone  is  displaced  and 
remains  so. 

In  fracture  by  bursting,  lines 
of  fracture  run  to  distant  points 
from  the  seat  of  application  of 

the    force.       Such    an    injury    is  Fig.  576.— Fracture  of  the  vault  with  extensive 

inflicted  by  the  impact  of  a   flat     depression    of   the    inner    table    ("American   Text- 
surface  of  considerable  area.     In    ^°°^  °^  Surgery"). 
some  cases  we  have  a  force  which 

first  is  bending  in  character,  but  causes  bursting  also  to  occur,  because  there 
is  no  rebound. 

Falls  of  large  heavy  objects  or  falls  on  the  head,  blows  on  the  head  from 
large  flat  objects,  crushes  in  railroad  accidents,  etc.,  may  burst  the  skull. 
In  bursting  fracture  there  is  often  widespread  injury.  The  skull  may  be 
fractured  during  labor. 

Fractures  are  divided  into  fractures  of  the  vault,  usually  due  to  direct  force, 
and  fractures  of  the  base,  due  to  extension  of  fractures  of  the  vault,  to  indirect 
violence  (a  fall  upon  the  feet,  the  buttocks,  or  the  vault),  to  forcing  of  the 
condyles  of  the  lower  jaw  against  or  through  the  base,  or  to  foreign  bodies 
breaking  through  the  orbit,  vault  of  the  pharynx,  the  ear,  or  the  roof  of  the 
nostrfls.  Fracture  by  contre-coup  was  the  name  long  given  to  a  fracture  which 
was  supposed  to  occur  on  the  side  opposite  the  point  of  application  of  the 
violence.  It  is  very  doubtful  if  such  a  fracture  ever  occurs.  I  have  seen 
meningeal  hemorrhage  by  contre-coup,  but  not  fracture.  Fractures  of  the  skull 
are  uncommon  in  early  youth,  but  they  are  much  more  frequent  in  the  aged. 
Usually  the  entire  thickness  of  the  bone  is  fractured,  but  either  the  outer 


'886 


Diseases  and  Injuries  of  the  Head 


or  the  inner  table  (Fig.  576)  may  be  broken  alone.  In  complete  fractures 
the  inner  table  is  broken  more  extensively  than  is  the  outer  table,  because  the 
inner  table  is  the  more  brittle,  because  the  force  diffuses,  and  also,  as  Agnew 
taught,  because  the  inner  table  is  part  of  a  smaller  curve  than  is  the  outer 
table,  and  violence  forces  bone-elements  together  at  the  outer  table,  but  tears 
them  asunder  at  the  inner  table  (Figs.  577,  578). 


Fig.  577.- 
tables,  with 
Agnew). 


-Section  of  outer   and    inner 
two     parallel     lines     (after 


Fig.  578. — Greater  yielding  of  the  inner 
table  than  of  the  outer  after  the  application 
of  violence  (after  Agnew). 


Fractures  of  the  Vault. — In  every  suspected  fracture  examine  with  the 
.v-rays  and  suspect  fracture  in  every  head  injury.  A  fracture  may  involve 
the  vault  alone,  but  in  over  60  per  cent,  of  such  fractures  the  base  is  involved. 
A  fracture  of  the  vault  of  the  skull  may  be  simple  and  undepressed,  or  it  may  be 
depressed  (Fig.  576),  compound,  or  comminuted  (Fig.  579).  A  mere  crack 
may  exist  in  a  bone,  and  if  a  rent  exists  in  the  soft  parts,  a  bit  of  dirt  or  a  hair 
may  be  caught  in  the  crack.  Fractures  of  the  vault 
arise  from  direct  force.  A  fissure  may  escape  recogni- 
tion, although  in  some  cases  percussion  gives  a 
"cracked-pot"  sound.  This  is  known  as  Macewetis 
sign.  The  stethoscope  is  placed  upon  the  glabella. 
Percussion  with  fingers  or  percussion  hammer  is  begun 
over  the  parietal  eminence  and  approaches  the  stetho- 
scope. The  same  procedure  is  carried  out  on  the 
opposite  side  of  the  head.  Those  who  would  employ 
this  method  must  make  a  study  on  percussion  of  nor- 
mal skulls  at  different  ages,  etc.  (see  H.  B.  Wilcox, 
in  "Arch.  Pediatrics,"  1915,  xxxii.  He  has  thoroughly 
discussed  this  sign).  Any  considerable  depression  can 
be  detected.  In  a  simple  fracture  occasionally  the 
cerebrospinal  fluid  collects  under  the  scalp  and  forms 
a  tumor  which  pulsates  and  becomes  tense  on  forcible 
expiration  (see  Spurious  Meningocele,  page  871). 
Compound  fracture  can  be  readily  recognized,  but  do 
not  mistake  a  suture,  a  Wormian  bone,  or  a  tear  in  the 
pericranium  for  a  fracture.  A  fracture  bleeds,  a  suture 
does  not.  Even  a  narrow  fracture  is  marked  by  a  dark 
line  of  blood  which  sponging  will  not  remove.  Fracture 
of  brain  by  bone  of  the  inner  table  alone  can  only  be  suspected  unless  the 
(Scudder).  arrays  make  it  evident.     The  prognosis  of  fracture  of 

the  vault  depends  upon  the  extent  of  intracranial  injury 
rather  than  upon  the  extent  of  bone  injury.  Simple  fractures  may  unite  by 
bone;  compound  fractures  with  loss  of  bone  unite  by  fibrous  tissue  only. 
The  dangers  may  be  immediate  (hemorrhage,  brain  injury,  and  septic  inflam- 
mation) or  be  distant  (epilepsy,  insanity,  and  persistent  headache).  In  an 
open  fracture  the  danger  of  infection  is  added  to  the  danger  of  brain  injury. 
A  spinal  tap  may  give  valuable  information.  Bloody  fluid  means  bleeding 
beneath  the  dura.  In  simple  fracture  if  we  decide  against  immediate  opera- 
tion have  an  ophthalmologist  watch  the  eye  grounds  for  signs  of  beginning 
pressure. 


Fig.  579. — Fracture 
of  skull  with  depressed 
fragments.  Compression 


Fractures  of  the  Base  887 

Treatment. — The  mortaHty  of  fracture  of  the  skull  was  formerly  much 
greater  than  at  present.  Before  the  days  of  antisepsis  it  was  51  per  cent. 
(Harle).  Trephining  is  performed  much  oftener  than  was  once  the  custom, 
and  is  vastly  safer.  Out  of  26  trephined  cases,  3  died  (Harte).  In  any  case 
of  fracture  of  the  skull  endeavor  to  bring  about  reaction  before  operating, 
unless  the  signs  of  pressure  continually  increase  or  the  evidences  of  shock 
remain  unimproved  or  become  graver.  A  simple  fracture  without  depression 
and  without  brain  sy?nptoms  is  treated  expectantly  (by  rest,  quiet,  low  diet, 
purgation,  moderate  elevation  of  and  cold  to  the  head,  and  arterial  sedatives). 
-I  simple  fracture  with  moderate  depression  and  without  cerebral  symptoms  is  treated 
expectantly,  and  so  also  is  a  simple  fracture  in  which  symptoms  existed  but  are 
abating.  Simple  fracture  with  marked  depression  requires  immediate  trephin- 
ing, even  when  brain  symptoms  are  absent.  We  make  an  exception  in 
young  children,  and  wait  a  while  before  trephining,  in  the  expectation  that 
the  expansile  brain  will  lift  the  depressed  but  elastic  bone  up  to  the 
level.  Trephining  in  cases  in  which  no  symptoms  exist,  although  there  is 
marked  depression,  often  prevents  disastrous  consequences  arising  in  the 
future,  and  is  known  as  preventive  trephining  (Agnew,  Keen,  Horsley,  Macewen, 
von  Bergmann,  and  others).  In  all  compound  fractures  shave  and  asepticize 
the  entire  scalp,  enlarge  the  incision,  and  explore  the  bone.  If  a  fissure  exists, 
it  must  be  asepticized,  and  if  a  hair  or  other  foreign  body  is  found  in  it,  in  order 
to  effect  removal  and  secure  asepsis  the  outer  table  of  the  skull  at  this  spot 
must  be  cut  away  by  a  chisel,  the  fissure  being  thus  converted  into  a  broad 
grooye.  In  a  compound  fracture  with  much  depression  trephine,  elevate,  and 
irrigate.  In  any  fracture  trephine  if  distinct  symptoms  exist.  In  punctured 
wounds  of  the  brain  {punctured  fractures)  always  trephine,  open  the  dura, 
and  disinfect.  In  a  comminuted  fracture  the  usual  custom  is  to  remove  loose 
fragments.  Schaak  has  recently  advocated  their  reimplantation  ("Archiv 
ftir  klin.  Chir.,"  April  6,  1912).  My  usual  custom  has  been  to  remove  them. 
In  any  case  of  fracture  of  the  vault  in  which  trephining  has  been  performed  it 
is  wise  to  open  the  dura  and  examine  the  brain.  In  an  open  fracture  and  after 
every  operation  of  trephining  in  which  the  dura  has  been  opened  administer  uro- 
tropin  in  order  to  make  the  cerebrospinal  fluid  bactericidal. 

Fractures  of  the  Base. — A  fracture  of  the  base  of  the  skull  may  exist  in 
only  one  of  the  three  fossee,  in  two  of  them,  or  it  may  involve  all.  Figure  580 
shows  an  extensive  fracture  of  the  base  of  the  skull.  The  middle  fossa  is 
oftenest  involved.  Fracture  of  the  posterior  fossa  is  the  most  fatal.  These 
fractures  may  be  due  to  direct  violence,  to  indirect  force,  and  to  extension  of 
a  fracture  of  the  vault.  Extension  from  the  vault  is  always  by  the  shortest 
route.  Fractures  of  the  base  may  extend  up  into  the  vault,  and  do  so  in  over 
80  per  cent,  of  cases.  Fracture  by  direct  violence  may  arise  from  the  pene- 
tration of  the  nasal  roof,  the  orbital  roof,  or  the  pharyngeal  roof  by  a  foreign 
body.  The  posterior  fossa  may  suffer  from  a  fracture  by  direct  violence  applied 
to  the  neck.  Fractures  by  indirect  force  may  arise  from  blows  upon  the  frontal 
bone  (the  orbital  portion  of  the  frontal  or  the  cribriform  process  of  the  ethmoid 
breaking),  from  falls  upon  the  chin  (the  condyle  of  the  jaw  breaking  the  middle 
fossa),  or  from  falls  upon  the  buttocks,  the  knees,  or  the  feet  (fracture  occurring 
in  the  posterior  fossa).     The  base  is  not  broken  by  contre-coup. 

Symptoms. — Fractures  of  the  base  of  the  skull  are  apt  to  be  compound.  A 
solution  of  continuity  in  the  pharynx,  roof  of  the  nares,  orbit,  or  ear  permits 
access  of  air  to  the  seat  of  fracture  and  allows  blood  and  cerebrospinal  fluid  to 
flow  externally.  In  fracture  of  the  anterior  fossa  the  fracture  may  be  com- 
pound because  of  laceration  of  the  mucous  membrane  of  the  nares  or  of  the 
conjunctiva.  Blood  may  run  from  the  nose,  its  source  being  the  vessels  of 
the  mucous  membrane  or  the  dura,  the  fracture  being  compound.  Epistaxis 
does  not  prove  the  fracture  to  be  compound,  but  only  suggests  it;  but  if  the 


888 


Diseases  and  Injuries  of  the  Head 


epistaxis  is  prolonged,  the  probabiHty  is  greatly  increased;  and  if  the  flow  of 
blood  is  succeeded  by  a  flow  of  cerebrospinal  fluid  the  diagnosis  of  compound 
fracture  is  positive.  A  flow  of  cerebrospinal  fluid  from  the  nose  is  seldom 
observed  or  at  least  the  fluid  is  seldom  recognized.  Cerebrospinal  fluid  appears 
onlv  when  the  mucous  membrane,  the  dura,  and  the  arachnoid  are  each  lacerated. 
In  fractures  of  the  anterior  fossa  blood  is  apt  to  flow  into  the  orbit,  producing 
subconjunctival  eccliymosis,  and  perhaps  pushing  the  globe  of  the  eye  forward. 
Some  blood  is  often  swallowed  and  vomited.  In  the  middle  fossa  the  bones 
are  very  thin  and  fractures  are  far  more  common  in  this  region  than  in  other 
parts  of  the  base.  In  fractures  of  the  middle  fossa  blood  may  flow  from  one 
ear  or  both  ears.  Blood  obtains  exit  through  a  tear  in  the  tympanum,  its 
source  being  the  vessels  of  the  tympanum,  the  meningeal  vessels,  or  a  sinus. 

Blood  may  flow  through  the 
Eustachian  tube  and  come 
from  the  nose,  may  be  spat 
up,  or  may  be  swallowed 
and  vomited.  In  some  cases 
a  quantity  of  cerebrospinal 
fluid  flows  from  the  ear,  the 
discharge  being  increased  by 
expiratory  effort  and  a  posi- 
tion which  favors  gravity. 
Cerebrospinal  fluid  is  at 
first  blood-stained,  but  later 
becomes  clear.  The  flow 
of  clear  cerebrospinal  fluid 
occurs  in  only  a  small  mi- 
nority of  the  cases.  The 
cerebrospinal  fluid  must  not 
be  confused  with  either 
blood-serum  or  liquor  Co- 
tunnii.  The  cerebrospinal 
fluid,  if  it  flows  at  all,  is 
always  present  in  large 
amount;  the  liquor  Cotunnii 
can  be  present  only  in  minute 
amount.  Blood-serum  is 
highly  albuminous;  cerebro- 
spinal fluid  is  a  serous  fluid 
of  very  low  specific  gravity,  it  is  devoid  of  formed  elements,  never  shows 
more  than  a  trace  of  albumin,  and  contains  considerable  chlorid  of  so- 
dium and  a  carbohydrate  now  known  to  be  a  dextrose  which  reduces  the 
copper  of  FehHng's  solution  and  reacts  to  Trommer's  and  to  Moore's  tests, 
but  does  not  refract  polarized  light  nor  easfly  ferment  wdth  yeast.  Treves^ 
states  that  cerebrospinal  fluid  cannot  flow  from  the  ear  in  fractures  of  the  middle 
fossa — (i)  unless  the  line  of  fracture  crosses  the  internal  meatus;  (2)  unless  the 
prolongation  of  the  membranes  into  the  meatus  is  torn;  (3)  unless  a  com- 
munication exists  between  the  internal  ear  and  tympanum,  and  (4)  unless 
the  drum-membrane  is  torn.  Miles,  of  Edinburgh,-  claims  that  bleeding  from 
the  ear  foUowed  by  a  flow  of  cerebrospinal  fluid  is  not  pathognomonic  of 
fracture  of  the  middle  fossa  of  the  base.  He  maintains  that  when  the  drum  is 
ruptured  we  may  have  these  signs;  when  bone  is  not  broken  the  chief  source 
of  the  blood  being  the  vessels  of  the  pia  and  temporosphenoidal  lobe,  the  blood 
and  cerebrospinal  fluid  flowing  inside  the  sheath  of  the  auditory  nerve,  passing 
into  the  vestibule,  through  the  lamina  cribrosa,  and  from  the  vestibule  into  the 
1  "Applied  Anatomy."'  -  "Edinburgh  Med.  Jour.,'"  Nov.,  1895. 


Fig.    580. — Extensive  fracture  of  the  base  of  the  skull 
("American  Text-Book  of  Surgery"). 


Fractures  of  the  Base  889 

middle  ear,  finding  exits  from  this  space  by  way  of  the  Eustachian  tube  and  also 
through  the  rent  in  the  drum-membrane.  Profuse  mucous  discharge  may  flow 
from  the  ear  after  an  injury  without  fracture  when  the  drum  is  ruptured,  the 
fluid  coming  from  the  cells  of  the  mastoid.  It  must  be  understood  that  frac- 
ture of  the  base  may  exist  when  there  is  no  flow  of  blood  or  of  serous  fluid.  A 
fracture  of  the  middle  fossa  is  usually  compound,  made. so,  even  when  the 
drum  is  not  ruptured,  by  the  Eustachian  tube,  and  there  is  often  paralysis 
of  the  seventh  or  eighth  nerve  or  of  both  of  them.  In  fracture  of  the  posterior 
fossa  there  is  usually  respiratory  derangement  and  blood  accumulates  beneath 
the  deep  fascia  and  produces  discoloration  in  the  line  of  the  posterior  auricular 
artery  {Battle's  sign),  the  discoloration  first  appearing  near  the  tip  of  the 
mastoid.  The  discoloratio  appears  in  the  line  of  nerves  and  vessels  which 
emerge  from  the  deep  fascia,  the  vessels  passing  through  openings  and  the 
extravasated  blood  emerging  from  the  same  openings.  Fractures  of  the 
posterior  fossa  are  apt  to  be  compound  through  the  pharynx,  and  in  such 
cases  the  patient  spits  or  vomits  blood.  Fractures  of  the  posterior  fossa  are 
more  fatal  than  fractures  in  either  of  the  other  fossae  because  of  the  adjacency 
of  vital  centers.  Fractures  of  the  base  are  apt  to  be  associated  with  paralysis 
of  cranial  nerves.  The  palsy  indicates  the  situation  of  the  fracture.  In  frac- 
ture of  the  anterior  fossa  the  olfactory  nerve  may  suffer.  In  fracture  of  the 
middle  fossa  the  facial  nerve  most  often  suffers.  The  eighth  is  sometimes 
injured.  .  Other  nerves  which  may  sufl'er  alone  or  in  combination  in  fracture  of 
the  base  are  the  abducens,  the  motor  oculi  communis,  the  trigeminus,  the  pneu- 
mogastric,  the  optic,  the  spinal  accessory,  the  hypoglossal,  and  the  glossopha- 
ryngeal. Optic  neuritis  often  arises  after  the  first  week.  In  fractures  of  the 
base  the  temperature  is  subnormal  during  the  shock,  rises  to  100°  to  101°  F., 
falls  again  to  about  normal,  and  remains  normal  or  subnormal  unless  there  is 
inflammation  or  sepsis.  Lumbar  puncture  may  obtain  bloody  fluid.  Such  a 
finding  means  subarachnoid  bleeding  and  indicates  fracture.  In  any  fracture 
injur}^  of  the  brain  may  exist.  Such  an  injury  wiU  be  made  manifest  by  symp- 
toms, and  we  may  or  may  not  be  able  to  diagnosticate  and  localize  it.  The 
prognosis  is  greatly  influenced  by  the  nature  and  extent  of  the  intracranial 
damage.  Harte  ("Annals  of  Surgery,"  Oct.,  1901)  has  collected  46  positive 
cases  of  fracture  of  the  base  of  the  skull  from  the  records  of  the  Penns}dvania 
Hospital;  35.5  per  cent,  recovered.  Ransohoff  collected  190  cases  of  fracture 
of  the  base  of  the  skull.  The  mortality  was  65  per  cent.  Over  one-half  of  the 
fatahties  were  within  twelve  hours.  Only  15  per  cent,  died  after  the  second 
day.  Of  98  cases  with  profound  coma  and  respiratory  disturbance  70  per  cent, 
died  ("Annals  of  Surgery,"  July,  1910).  According  to  Hartley,  in  cases  treated 
expectantly  the  mortality  is  90  per  cent.,  in  cases  treated  by  operation  it  is 
less  than  35  per  cent.  ("Am.  Jour,  of  Surgery,"  Dec,  1910). 

Treatment. — In  fracture  of  the  base  I  now  perform  a  subtemporal  de- 
compression, usually  on  both  sides,  as  Gushing  advocates.  This  is,  first  of  afl, 
exploratory^,  and  may  disclose  a  bleeding  meningeal  artery.  After  the  dura  is 
opened  it  enables  us  to  evacuate  fluid  causing  pressure  and  in  which  bacteria 
could  multiply,  and  to  prevent  recurrence  of  pressure  after  the  wound  has  been 
closed.  If  there  is  bleeding  under  the  dura  the  brain  should  be  lifted  to  let 
the  blood  out,  and  a  drain  of  rubber  tissue  should  be  inserted.  If  there  is  only 
brain  edema  no  drain  is  required.  In  some  cases  drainage  has  been  obtained 
from  the  anterior  fossa  by  breaking  through  the  cribriform  plate  and  intro- 
ducing a  tube  by  way  of  the  nostril  (x\llis) ,  and  from  the  middle  fossa  b}-  tre- 
phining above  and  behind  the  external  auditory  meatus.  In  a  compound 
fracture  of  the  orbit  disinfect  and  drain.  It  may  be  necessar}^  to  trephine  the 
roof  of  the  orbit  to  secure  drainage. 

In  addition  to  performing  decompression  I  always  give  urotropin,  as  ad- 
vised by  surgeons  in  Johns  Hopkins  Hospital  (S.  J.  Crowe,  in  "The  Johns 


890  Diseases  and  Injuries  of  the  Head 

Hopkins  Hospital  Bulletin,"  April,  1909).  This  drug  renders  the  cerebrospinal 
fluid  bactericidal.  Other  methods  of  treatment  are  secondary  to  the  above. 
My  experience  is  that  this  plan  saves  many  cases  which  would  otherwise 
perish.  In  treating  a  compound  fracture  of  the  base  of  the  skull  disinfect 
any  cavity  involved.  In  fractures  of  the  middle  fossa  with  ruptured  drum 
clean  the  ear  mechanically,  wash  it  out  by  a  stream  of  warm  salt  solution 
(turn  the  head  toward  the  affected  side  while  washing,  so  that  the  solution 
will  not  run  down  the  Eustachian  tube),  insufflate  iodoform,  insert  a  piece 
of  iodoform  gauze,  and  apply  an  antiseptic  dressing.  Several  times  daily 
the  ear  is  to  be  irrigated  and  insufflated  with  iodoform.  The  nasopharynx 
must  be  frequently  irrigated  by  normal  salt  solution  or  boric  acid  solution 
and  insufflated  with  iodoform.  The  conjunctival  sac  is  frequently  irrigated 
by  boric  acid  solution.  If  after  a  head  injury  blood  accumulates  back  of  the 
drum,  this  membrane  should  be  incised  to  permit  of  drainage  and  disinfection.  In 
fractures  of  both  the  middle  and  anterior  fossae  and  in  fractures  of  the  posterior 
fossa  communicating  with  the  pharynx,  the  nasopharynx  must  always  be 
cleaned.  The  exact  method  depends  on  the  choice  of  the  surgeon.  We  may 
wash  out  these  cavities  frequently  by  hot  water,  next  by  peroxid  of  hydrogen, 
and  finally  by  boric  acid  solution,  or  can  simply  use  normal  salt  solution. 
After  washing,  insufflate  the  nasopharynx  with  iodoform.  Repeat  the  cleansing 
at  regular  intervals  and  also  cleanse  the  conjunctival  sac  frequently.  In 
fracture  of  the  posterior  fossa  examine  to  see  if  the  fracture  is  compound, 
into  the  pharynx,  and  if  it  is,  cleanse  with  great  care  the  nasopharynx  and 
mouth,  as  previously  directed.  In  a  very  extensive  fracture  of  the  base, 
besides  use  of  the  methods  set  forth  above,  the  entire  head  should  be  shaved 
and  a  plaster-of-Paris  cap  applied.  A  patient  with  fracture  of  the  base  must 
be  put  into  a  quiet  and  darkened  room  and  kept  upon  a  low  diet,  sleep  being 
secured,  and  the  bowels  and  bladder  being  attended  to.  If  we  are  uncertain 
as  to  whether  a  fracture  exists  or  not,  keep  the  patient  quiet,  in  a  darkened 
room  and  on  a  low  diet.  Attend  to  the  bladder,  keep  the  bowels  loose,  examine 
the  nasopharynx  with  a  mirror  and  the  ear-drum  through  a  speculum,  and  make 
a  lumbar  puncture. 

Obstetric  Depressions  of  the  Skull. — These  lesions  seem  to  have  been 
first  studied  by  Danyau  in  1849.  The  depression  may  be  cf  the  parietal  or 
frontal  bone  and  may  or  may  not  be  accompanied  by  fracture.  It  may  have 
been  caused  by  the  promontory  of  the  mother's  sacrum  or  by  obstetric  forceps. 
A  sHght  depression  does  no  harm,  because  it  is  gradually  and  spontaneously  cor- 
rected. A  marked  depression,  especially  if  accompanied  by  fracture,  places  the 
child  in  danger  of  epilepsy,  idiocy,  and  non-development  of  body,  and  requires 
treatment.  The  usual  treatment  is  trephining  and  elevation.  Some  claim  to 
elevate  by  an  apparatus  making  pneumatic  suction.  Some  make  a  small 
incision,  insert  a  screw  (Heine's  screw),  and  elevate  by  making  traction  on  the 
screw.  Hanch  elevated  by  means  of  a  corkscrew.  (See  Frazier,  in  '*  Progressive 
Medicine,"  March,  1913.) 

Wounds  of  the  brain  are  produced  by  violence  and  especially  by  foreign 
bodies  (knives,  bullets,  etc.).  Except  when  due  to  penetration  of  a  fontanel 
in  a  child  or  of  a  parietal  foramen  in  adults,  wounds  of  the  brain  are  accompanied 
by  fracture  of  the  skull.  These  wounds  are  very  dangerous;  foreign  bodies 
(bone,  hair,  clothing,  etc.)  are  often  lodged  in  the  brain,  hemorrhage  is  usually 
severe,  and  without  proper  treatment  sepsis  is  almost  inevitable.  Such  cases 
are  very  fatal,  though  some  astonishing  recoveries  are  on  record.  Figs.  581 
and  582  show  gunshot-fractures  of  the  skull. 

The  symptoms  of  a  brain  wound  may  be  slight  and  .long  deferred  or  ma}- 
be  immediate  and  overwhelming;  they  depend  upon  the  site  and  extent  of  the 
injury.  Localizing  symptoms  may  exist,  and  encephalitis  with  coma  is  apt 
to  arise.     Abscess  mav  follow. 


Wounds  in  War 


891 


In  treating  wounds  of  the  brain  always  shave  the  entire  scalp  and  examine 
the  weapon,  if  possible,  to  see  if  a  piece  has  been  broken  off.  Antisepticize,  en- 
large the  wound,  trephine,  arrest  bleeding,  elevate  any  depression,  remove 
foreign  bodies,  irrigate  the  wound  %\ath  salt  solution,  drain  by  gauze,  suture 
the  dura,  dress,  and  administer  urotropin. 

Wounds  in  War. — When  the  bullet  of  a  military  rifle,  fired  at  very  close 
range,  crosses  the  brain  it  may  blow  the  skull  into  fragments,  but  often  it  does 
not,  but  produces  fracture  of  the  skull  and  wound  of  the  brain.  The  "ex- 
plosive effect"  is  far  less  marked  in  the  head  of  a  living  man  than  in  the  head 
of  a  corpse  and  may  even  be  absent  when  the  range  has  been  only  100  yards.  At 
moderate  range,  at  the  point  of  initial  contact  of  the  bullet  \vith  the  skull, 
a  fracture  is  produced,  the  opening  is  sHghtly  larger  than  the  bullet,  and  short 


Fig.    581. — Extensively     comminuted     gunshot- 
fracture  of  the  skull  (after  von  Bergmann). 


Fig.  582. — Gunshot-fracture  of  in- 
ternal table  of  the  skull  (after  von 
Bergmann). 


fissures  commonly  radiate  from  it.  Fragments  from  the  internal  table  are 
usually  displaced  and  driven  into  the  brain.  The  wound  of  exit  is  more  ir- 
regular and  is  apt  to  exhibit  more  and  longer  fissures  than  the  wound  of  entrance. 
When  a  bullet  strikes  a  glancing  blow  (tangential  wound)  it  may  fracture  the 
outer  table  alone;  it  may  produce  a  "gutter-fracture"  (two  scalp  openings,  and 
""a  gutter  ploughed"  through  one  or  both  tables  of  a  portion  of  the  skull, 
as  O'Reilly  expressed  it),  very  seldom  a  fracture  of  the  inner  table  only,  penetra- 
tion of  the  skull,  and  lodgment  of  the  bullet,  or  perforation  of  the  skull,  the  bul- 
let passing,  through  the  head  and  emerging.  Nearly  haK  the  cases  are  instances 
of  perforating  wound.  A  piece  of  shrapnel  case,  a  bit  of  explosive  shell,  or  a 
shrapnel  bullet,  may  fracture  the  skull,  may  lodge  or  may  tear  all  the  way 
through  the  head.  The  base  may  be  fractured  by  a  penetrating  or  a  perforating 
wound  or  fracture  of  the  vault  may  track  into  the  base.  There  is  usually 
much  spHntering,  in  whicTi  the  inner  table  suffers  most.  There  may  be  or  may 
not  be  depression. 

.  In  all  of  these  injuries  there  are  usually  great  shock  and  concussion,  but  con- 
cussion symptoms  may  be  absent.  Some  of  the  patients  walk  to  the  first 
dressing  station.     The  patient  ma 3'  die  at  once  or  almost  at  once,  but  if  he  be 


892  Diseases  and   Injuries  of  the  Head 

alive  a  few  hours  after  the  injury  he  has  slill  to  face  the  chances  of  hemorrhage 
and  the  danger  of  infection  and  resuhing  inflammation.  The  danger  depends 
on  the  brain  injur)-  and  the  amount  of  infection  and  not  on  the  extent  of  the 
bone  damage.  The  symptoms  vary  according  to  the  part  of  the  brain  injured 
and  the  extent  of  the  damage.     In  some  cases  there  are  no  brain  svm])toms. 

In  practically  all  cases  bone-fragments  are  driven  into  the  brain,  and  as 
the  scalp  is  a  dirty  region,  the  wound  is  more  or  less  infected.  AH  wounds  re- 
ceived in  trench  warfare  are  regarded  as  infected.  All  wounds  from  shell 
fragments,  even  those  inflicted  in  open  fighting,  are  infected. 

Injuries  of  sinuses,  especially  of  the  superior  longitudinal  sinus,  are  common. 
Serious  injury  may  be  caused  directly  by  the  projectile  or  may  be  due  to  bone- 
fragments.  Injury  of  the  superior  longitudinal  sinus  is  due  in  most  cases  to 
tangential  wounds  in  which  there  is  usually  a  gutter-fracture,  the  inner  table 
being  splintered  more  extensively  than  the  outer  table.  A  bullet  or  shell 
fragment  which  merely  grazes  the  bone  may  produce  a  gutter-fracture. 

A  tangential  injury  of  the  vertex,  may  give  rise  to  a  symptom  which  Holmes 
and  Sargent  ("Brit.  Med.  Jour."  Oct.  2, 1915)  call  the  longihidinal  sinus  syndrome. 
There  may  or  may  not  be  fracture  or  depression  and  the  sinus  or  some  of  its 
large  tributaries  may  or  may  not  be  torn.  In  some  cases  there  is  contusion  of 
the  brain  and  in  consequence  anemia  of  a  considerable  area  or  of  considerable 
areas.  In  some  cases  there  is  no  hemorrhage  but  the  blood  in  some  of  the  para- 
sinoidal sinuses  and  large  cerebral  veins  is  in  a  condition  of  stasis.  The  char- 
acteristic symptom  is  bilateral  spastic  paraplegia  coming  on  at  once  after  the 
injury,  the  lower  extremities  being  more  seriously  involved  than  the  upper 
extremities. 

In  a  tangential  injury  by  a  rifle  bullet  there  is  practically  always  a  fracture. 
In  a  tangential  injury  by  a  shell  fragment  there  may  or  may  not  be  a  fracture. 

A  bullet  lodged  in  the  brain  may  remain  fixed,  or  may  shift  its  position  with 
the  movements  of  the  patient.  In  a  case  of  my  o\vn  a  bullet  which  lay  in  the 
longitudinal  fissure  against  the  falx  cerebri  made  a  half  revolution  on  its  short 
axis  when  the  patient  became  recumbent  and  resumed  its  former  position  when 
the  patient  sat  up.  Dr.  Manges  demonstrated  these  movements  by  ;i--ray 
studies.  A  bullet  in  the  brain  may  gradually  shift  its  position  and  come  to  in- 
habit a  location  a  considerable  distance  away  from  its  original  habitat.  Prob- 
ably it  could  not  do  this  in  an  undamaged  brain  but  it  may  do  it  in  a  damaged 
brain.  As  a  patient  usually  lies  supine  the  bullet  usually  tends  to  move  toward 
the  occiput.  Villvandre  and  Morgan  ("Archiv.  of  Radiology  and  Electrothera- 
peutics," June,  1916)  report  a  number  of  cases  in  which  .v-ray  pictures,  taken 
from  time  to  time,  showed  that  bullets  did  move.  The  above  facts  show  that 
.T-ray  localization  must  be  practised  just  before  operation  and  with  the  patient 
in  the  exact  position  he  is  to  occupy  during  the  operation. 

The  mortality  from  these  injuries  is  very  large.  In  the  war  between  the 
States  4350  cases  were  recorded  in  the  Northern  hospitals  and  the  mor- 
tality (including  mortahty  from  late  comphcations),  was  59.2  per  cent.  In 
the  Franco-Prussian  War  it  was  51.3  per  cent.  In  the  Boer  War,  among  the 
British  it  was  only  33.1  per  cent.,  a  very  notable  improvement.  (See  "Mili- 
tary Surgery,"  by  Surgeon  General  Robert  M.  O'Reilly,  U.  S.  A.,  in  "Keen's 
Surgery,"  yol.  iv.)  In  the  Russo-Japanese  War  the  mortality  seems  to  have 
been  something  over  37  per  cent.  The  mortahty  from  cranial  injuries  in  this 
war  does  not  seem  to  be  better  than  that  of  40  odd  years  ago,  and  has  been  far 
greater  than  that  of  the  Boer  and  of  the  Russo-Japanese  War.  Rehn  calls  the 
brain  surgery  of  this  war  "a  sad  chapter." 

In  estimating  mortality  those  killed  outright  and  those  dying  before  reach- 
mg  the  hospital  are  not  counted  by  makers  of  statistics.  Much  brain  matter 
may  ooze  out  from  such  a  wound.  There  may  be  severe  or  fatal  hemor- 
rhage.    Meningitis   or   abscess  may  follow.     Cerebral  hernia  (Fig.   586)    and 


Treatment  of  Wounds  in  War  893 

fungus  cerebri  (Fig.  587)  are  common  after  these  injuries,  especially  if  much 
bone  has  been  destroyed  by  the  injury  or  removed  by  the  surgeon.  Various 
late  complications  may  develop  (abscess,  softening,  paralysis,  epilepsy,  insanity, 
aphasia,  etc.). 

Treatment  of  Wounds  in  War. — During  this  war  enormous  numbers  of 
men  have  received  head  injuries  in  spite  of  steel  helmets  (about  one-fourth 
of  those  wounded  in  the  trenches).  About  25  per  cent,  of  head  injuries  were 
injuries  of  the  cranium.  A  great  majority  of  those  who  receive  cranial  wounds 
by  bullets  or  shell  fragments,  perish  at  once  or  very  soon.  Comparatively 
few  of  those  with  such  wounds  reach  the  first-aid  station.  Fewer  still  reach  the 
field  hospital  and  fewer  still  the  evacuation  hospital,  because  some  die  in 
transit.  Gushing  believes  that  not  more  than  25  per  cent,  of  those  with  cranial 
injuries  are  operated  upon. 

Tuffier  claims  that  50  per  cent,  of  those  operated  upon  recover  but  admits 
that  an  unknown  number  die  later  from  secondary  troubles  ("Surgery,  Gyne- 
cology and  Obstetrics,"  1915,  xxi). 

InLapointe's  127  cases  themortality  was  58.75  per  cent,  (cited  by  Gushing,  in 
''Military  Surgery,"  June,  1916).  It  is  true  that  some  reports  show  a  re- 
markable improvement  on  the  ghastly  figures  cited  above  but  the  general 
conclusion  must  be  that  the  mortality  has  been  enormous.  In  cases  operated 
upon  early  and  completely  the  results  have  been  better.  Gayet  ("Lyon.  Ghir.," 
1915,  xii)  reports  198  cases  operated  upon  within  six  hours  of  injury  and  claims 
100  recoveries.  Gushing  speaks  of  them  as  "presumptive  recoveries" 
(Ibid.). 

Early  in  the  war  many  fractures  were  overlooked.  Roberts  tells  us  that 
over  40  per  cent,  of  cases  with  supposed  scalp  wounds  had  fractured  skulls 
("Brit.  Med.  Jour."  Oct.  2,  1915).  In  many  cases  of  fracture  the  symptoms  at 
first  may  be  so  trivial  that  the  patients  walk  to  the  first  dressing  station.  If 
the  fracture  escapes  recognition  it  is  probable  that  a  grave,  perhaps  a  fatal, 
condition  will  arise.  As  a  general  proposition  the  earlier  operation  is  done  the 
better,  pro\ided  the  operation  can  be  done  completely.  In  the  first  dressing 
station  and  in  a  field  hospital  thorough  operation  is  impossible.  It  is  seldom 
possible  in  an  evacuation  hospital,  and  even  if  possible  the  patient  must  be  moved 
in  a  day  or  two,  which  is  too  soon  for  safety.  It  has  been  found  safer  to 
move  victims  of  skull  injury  upon  whom  no  operation  has  been  done  than  to 
move  them  soon  after  a  trephining.  The  rapid  pulse  and  the  lowered  tension 
of  those  upon  whom  operation  has  been  perform.ed  recently,  militate  strongly 
against  recovery. 

The  custom  among  most  surgeons  was  to  operate  very  early,  even  in  the 
absence  of  an  rc-ray  apparatus.  The  method  was  to  enlarge  the  wound,  tre- 
phine if  necessary,  elevate  depressed  fragments,  remove  as  well  as  possible  all 
bone-fragments  lodged  in  the  brain,  drain  with  iodoform  gauze,  and  as  soon  as 
possible  send  the  patient  to  a  rear  hospital.  When  such  a  case  reaches  a  base 
hospital  there  may  still  be  a  lodged  projectile,  there  may  be  bone-fragments  yet  in 
the  brain,  infection  may  have  developed  or  be  developing  and  infection  will  proba- 
bly prove  fatal.  Such  an  operation  was  incomplete,  delayed  the  transfer  of  the 
patient  to  a  place  where  a  complete  operation  could  have  been  done.  Preliminary 
operations  have  had  a  mortaHty  of  over  45  per  cent.  Gushing  (Ibid.)  says  "pre- 
liminary and  necessarily  incomplete  measures,"  taken  when  "the  field  hospital 
equipment  is'primitive,"  gravely  lessen  the  chance  of  permanent  recovery.  When 
such  a  preliminary  operation  has  been  done  the  surgeon  in  the  base  hospital  finds 
it  a  most  difficult  problem  to  determine  what  should  be  done,  a  difficulty  enhanced 
by  the  usual  absence  of  records  showing  what  has  been  done,  information  essential 
to  determine  the  proper  method  of  treating  the  case.  The  operation  should  be 
done  as  soon  as  the  patient  reaches  a  hospital  where  there  is  a  surgeon  experi- 
enced in  brain  work,  where  there  is  ample  equipment  (rc-ray  apparatus,  electro- 


894 


Diseases  and  Injuries  of  the  Head 


magnet,  etc.),  where  there  are  experienced  assistants,  where  there  are  trained 
nurses,  where  a  neurologist  can  be  had  for  consultation,  where  the  patient  can 
be  kept  in  bed  the  proper  time  (about  three  weeks).     If  these  things  can  be  had 


I  I 


LOOP  or 

6iLV£KW/KC 


Ba/vDAO£ 


RuBecnTuac 
'/6  li^CM 


Fig.  583. — Materials  for  making  capillary  drains  for  drainage  of  the  brain  (Hull,  "Surgery  in 

War"). 

near  the  front  operate  near  the  front.  If  they  cannot  be  obtained  until  a  base 
hospital  is  reached  send  the  man  to  the  base  hospital.  By  following  this  plan 
cases  will  seldom  be  operated  upon  until  between  two  to  four  days  after  the  injury, 

yet  in  spite  of  the  delay  the  results 
are  better  than  those  of  imperfect 
operations  done  promptly.  Before 
operation,  an  rc-ray  should  be 
taken  and  if  a  projectile  is  lodged 
it  should  be  located.  The  scalp 
should  be  shaved  and  asepticized. 
Many  operations  are  done  under 
local  anesthesia.  The  wound  in 
the  scalp  (including  the  pericran- 
ium) should  be  excised  by  elliptical 
incisions.  A  large  flap  (with  the 
gunshot  wound  within  its  margins) 
should  be  laid  down  to  permit  of 
exploration.  The  old  custom  of 
enlarging  the  original  woundshould 
be  abandoned.  The  exploration 
through  a  large  opening  is  neces- 
sary. It  enables  the  surgeon  to 
see  a  fracture.  In  40  per  cent,  of 
supposed  scalp  wounds  fracture 
exists.  The  excision  of  both  the 
wound  in  the  bone  and  the  wound 
in  the  scalp  is  imperative.  Extirpate  completely  both  the  scalp  wound  and  the 
bone  wound.  Gushing  removes  the  entire  wound  in  the  bone  cutting  completely 
around  it.  It  prevents  infection  from  pus  organisms,  gas  bacilli,  etc.  When 
the  wound  is  not  excised  late  infection  is  common.  If  extirpation  of  the 
wounds  is  delayed  for  three  or  four  days  it  is  of  little  use.     Excision  enables  us  to 


Fig.  584. — The  drain  has  been  bent  to  the  re- 
quired depth  and  fixed  to  the  scalp  by  plaster.  Two 
sutures  placed  about  3  inches  from  the  wound  forms 
a  better  method  of  fixing  the  drain.  By  placing  the 
sutures  at  a  distance  from  the  wound  the  drain  is 
made  very  flexible  and  moves  freely  with  the  pulsat- 
ing brain  without  exerting  injurious  pressure  (Hull, 
"Surgery  in  War"). 


Treatment  of  Wounds  in  War  895 

dispense  with  drainage  in  many  cases.  Without  excision  prolonged  drainage 
is  always  necessary.  Brief  drainage  combats  infection.  Prolonged  drainage 
opens  the  doors  to  infection.  If  drainage  is  prolonged  until  the  hair  grows  above 
the  skin,  infection  is  inevitable.  If  a  wound  injures  the  dura  and  involves  the 
brain  drainage  is  always  necessary.  A  metal  tube  blocks  up.  A  rubber  tube 
blocks  up  and,  sooner  or  later,  is  forced  out  upon  the  dressings.  Gauze  dams 
up  pus  and  thus  aids  in  the  development  of  meningitis  or  abscess.  Drainage 
may  be  made  by  rubber  tissue.  It  should  emerge  from  the  angles  of  the  flap 
and  not  from  the  region  of  the  gunshot-wound.  The  most  serviceable  drain 
is  made  as  follows  (see  "Surgery  in  War,"  by  Major  Hull,  R.  A.  M.  C). 

Take  a  piece  of  stout  silver  wire  much  larger  than  the  depth  of  the  wound. 
Bend  it  into  the  shape  of  a  hair-pin.  Wrap  it  with  rubber  tissue.  Surround  it 
with  a  gauze  bandage,  and  let  the  free  end  of  the  bandage  be  long.  Fix  to  the 
bandage  by  hgatures  a  Carrel  tube.  Carry  the  appliance  to  the  depth  of  the 
wound,  bend  the  free  end  so  as  to  keep  the  other  end  from  stabbing  the  brain 
imder  the  instigation  of  movements,  fix  the  bent  part  to  the  scalp  by  adhesive 
plaster  to  keep  the  appliance  from  being  forced  out  and  from  shpping  out. 
At  intervals  run  hypertonic  salt  solution  (5  per  cent.)  through  the  tube.  The 
saline  fluid  is  delivered  in  the  very  depths  of  the  wound,  attracts  to  that  region 
currents  of  water  and  fluid  proteins  from  the  tissue,  establishes  a  flow  of  infec- 
tion from  the  brain  into  the  wound  rather  than  from  the  wound  into  the  brain, 
and  takes  the  infected  material  to  the  surface  by  capillary  attraction. 

In  a  case  in  which  there  are  no  cerebral  symptoms  and  in  which  after  exci- 
sion of  the  wound  inspection  of  the  bone  shows  no  sign  of  fracture  it  is  not 
necessary  to  open  the  skull  unless  cerebral  symptoms  develop. 

In  a  tangential  wound  with  a  gutter-fracture  of  the  outer  table  it  is  practi- 
cally certain  that  the  inner  table  is  splintered  and  trephining  should  be  done. 
Tangential  wounds  of  the  vertex  are  often  responsible  for  the  condition  mani- 
fested by  the  sinus  syndrome.  Clots  form  in  parasinoidal  and  perhaps  in  the 
longitudinal  sinus.  There  may  be  hemorrhage  caused  by  bone -fragments 
tearing  the  vessel.  In  some  cases  there  is  paralysis  of  both  legs.  In  other  cases 
there  is  spastic  paraplegia.  If  the  damage  is  in  front  of  the  fissure  of  Rolando 
sensation  will  be  normal.  If  it  is  back  of  the  fissure  wide  areas  of  anesthesia 
may  exist. 

If  sure  no  fracture  exists  operation  is  not  required.  If  fracture  exists  tre- 
phine. If  there  is  a  depressed  fracture  without  dural  injury,  trephine,  remove 
depressed  bone,  and  close  without  drainage  the  wound  left  by  excision. 
Hull  ("Surgery  in  War")  points  oat  the  indications  for  opening  an  unlacerated 
dura.  He  tells  us  to  open  it  if  there  are  definite  signs  of  "interference  with 
brain  function,  or  of  increased  intracranial  pressure,  if  the  dura,  on  exposure, 
is  found  to  be  muddy  looking,  if  there  is  loss  of  pulsation,  or  if  there  is  circum- 
scribed loss  of  elasticity,"  In  such  a  case  brain  matter  is  probably  pulpified 
and  may  cause  pressure  by  acting  as  a  foreign  body,  may  lead  to  abscess  and 
may  lead  to  the  formation  of  a  large  and  irritating  scar.  A  small  crucial 
incision  is  made  in  the  dura  and  the  disorganized  brain  matter  runs  out.  If 
sound  brain  matter  does  not  bulge,  close  the  dura  and  scalp  wound  without  drain- 
age.    If  there  is  marked  intracranial  pressure  do  a  decompression. 

When  the  skull  is  fractured  and  the  dura  lacerated  but  there  is  no  foreign 
body  in  the  brain  we  may  regard  the  brain  wound  as  aseptic.  In  such  a  case 
Hull  (Ibid.)  advises  us  to  excise  the  scalp  wound,  trephine,  enlarge  the  opening, 
remove  bone-fragments,  cut  away  ragged  parts  of  the  dura,  close  the  dural 
gap  by  suturing  in  it  a  piece  of  aponeurosis,  and  close  the  scalp  wound  without 
drainage.  If  operation  is  not  performed  early  on  such  cases  fatal  infection  will 
arise.  Hull  says  (Ibid.):  "A  larger  proportion  of  cranial  operations  for  the 
relief  of  gunshot- wounds  come  under  this  heading  than  under  any  other." 
When  a  foreign  body  has  entered  into  the  brain  sepsis  exists.  Localization 
of  the  body  is  made  by  the  a;-rays.     The  scalp  wound  is  excised,  the  skull  is 


896  Diseases  and  Injuries  of  the  Head 

opened  freely,  bone-fragments  are  removed  from  under  the  dura  and  from  in 
the  brain.  If  the  wound  in  the  brain  is  large  eno"orh  to  admit  the  finger,  the 
custom  has  been  for  the  surgeon  to  insert  the  finger,  gently  seek  for  the  bullet 
striving  to  avoid  injuring  sound  brain  tissue.  The  bullet  is  removed  with 
scoop  or  forceps.  If  the  wound  is  small  a  soft  catheter  is  carried  down  to  the 
bullet  and  the  forceps  are  carried  along  the  catheter  as  a  guide.  By  sticking 
close  to  the  catheter  damage  to  the  brain  is  avoided.  The  wound  is  disinfected 
by  dichloramin-T.  Such  a  case  must  be  drained  (see  page  894).  If  the  bullet 
was  shown  by  the  x-rays  to  have  crossed  the  brain  and  lie  near  the  skull  it  is 
usually  wise  to  trephine  the  opposite  side,  and  remove  the  foreign  body.  If  a 
bullet  or  shell  fragment  passes  right  through  the  head,  trephine  each  side  and 
drain  from  each  side. 

Trephining  may  be  necessary  after  any  head  injury  because  of  hemorrhage. 
In  most  cases  hemorrhage  can  be  arrested  by  cutting  out  a  piece  of  musgle, 
laxnng  it  on  the  bleeding  point  and  holding  it  there  for  a  time  with  light  pres- 
sure. In  other  cases  a  suture-ligature,  a  ligature  or  a  lateral  ligature  is  used. 
Gauze  pressure  is  to  be  used  under  the  dura  only  if  we  are  driven  to  it.  If 
after  any  cranial  operation  high  intracranial  pressure  becomes  e\ident,  and  if 
lumbar  puncture  fails  to  control  it,  perform  decompression.  Abadie  is  an  ad- 
vocate of  the  extraction  of  projectiles  in  two  stages  ("Ball.  Soc.  de  chir.  de  Par.," 
1916,  xlii).  If  the  bullet  is  far  from  the  point  of  entrance,  or  if  for  any  reason 
the  point  of  entrance  is  not  the  correct  route  for  approach  he  trephines  over 
the  projectile,  opens  the  dura,  temporarily  closes  the  wound,  and  in  a  day 
or  two  searches  for  the  bullet  with  aid  of  a  fluoroscope.  For  the  second  opera- 
tion ether  is  not  given. 

Wounds  from  Revolver  Bullets. — The  bullet  may  strike  the  skull  and 
glance  (if  fired  at  an  angle)  with  or  without  the  production  of  a  fracture.  A 
small  bullet  (No.  .22)  may  even  strike  perpendicularly  and  fail  to  enter,  some- 
times causing  a  fracture  and  sometimes  not  doing  so.  Even  a  No.  .22  may 
enter  the  skull.  I  removed  a  bullet  of  this  size  which  had  entered  and  crossed 
the  skull  and  lodged  beneath  the  cortex  on  the  opposite  side  of  the  brain. 
A  bullet  may  cause  a  ''gutter-fracture" — may  enter  the  cranium  and  lodge 
— or  may  cause  a  complete  perforation.  A  revolver  bullet  is  much  more  apt 
to  lodge  than  a  military  bullet. 

The  wound  of  entrance  is  small;  the  wound  of  exit  is  larger.  At  the  wound 
of  entrance  the  inner  table  is  more  extensively  fractured  than  the  outer  table; 
at  the  wound  of  exit  the  outer  table  is  more  widely  broken  than  the  inner  table. 
In  these  cases  there  is  always  great  shock  and  usually  concussion,  and  con- 
cussion symptoms  may  exist  even  when  the  bullet  has  not  entered  the  brain. 
In  moderate  concussion  the  action  of  the  heart  is  retarded;  in  severe  con- 
cussion it  is  accelerated  (see  page  876).  A  bullet  may  be  lodged  within  the 
cranium  when  merely  a  fracture  without  a  bullet-hole  can  be  detected.  In 
these  cases  the  bullet  produced  a  fracture  and  entered  the  cranium,  and  then 
the  depressed  bone  flew  back  into  place  (von  Bergmann).  In  such  cases,  if  com- 
plete perforation  occurs,  the  one  existing  opening  in  the  bone  is  the  opening  of 
exit.  A  bullet  may  lodge  in  the  bone,  between  the  dura  and  the  bone,  be- 
tween the  dura  and'  brain,  in  the  brain,  between  the  dura  and  the  brain  or  the 
dura  and  the  bone  of  the  opposite  side,  or  in  the  bone  of  the  opposite  side,  in 
the  nasal  fossa,  maxillary  antrum,  or  orbit.  Always  examine  the  side  of  the 
head  opposite  to  the  wound  of  entrance  to  determine  if  there  is  a  wound  of  exit 
or  any  bulging  or  fracture.  A  bullet  may  pass  across  the  brain  and  be  de- 
flected from  the  inner  surface  of  the  skull.  Ruth  does  not  believe  the  bullet 
can  rebound  from  the  opposite  wall.^  If  certain  regions  are  injured,  localizing 
symptoms  may  arise.  Much  brain  matter  may  ooze  out  from  the  wound. 
Loss  of  brain  matter  sometimes  causes  great  impairment  of  function,  some- 
'  See  the  instructive  article  by  Fowler,  in  •'x\nnals  of  Surgery,"  Nov.,  1895. 


Treatment  of  Wounds  from  Revolver  Bullets  897 

times  little  or  none.  The  secondary  symptoms  of  gunshot-wounds  of  the  head 
are  varied  and  uncertain,  and  mav  not  be  oljserxed  at  all  before  death.  Fow- 
ler wisely  points  out  that  a  patient  with  a  gunshot-wound  of  the  head  may 
have  also  received  other  injuries,  and  the  other  injuries  may  be  in  part,  at 
least,  responsible  for  cerebral  symptoms. 

Treatment  of  Wounds  from  Revolver  Bullets. — Endeavor  to  bring  about 
reaction  (see  Concussion).  In  severe  cases  apply  heat  to  the  head  and  make 
artiticial  respiration.  It  will  sometimes  be  necessary  to  operate  while  artificial 
respiration  is  being  made.  In  treating  gunshot-wounds  of  the  head  shave  and  anti- 
septicize  the  \\hole  scalp,  excise  the  wound,  turn  down  a  large  flap  and  proceed 
as  indicated  on  pages  894  and  895,  disinfect  the  entire  track  of  the  ball,  and  arrest 
hemorrhage  at  the  wounds  of  entrance  and  exit,  using  the  rongeur  to  expose 
the  bleeding  points  if  the  bullet  be  large,  emplopng  the  trephine  if  it  be  small. 
If  the  bullet  has  emerged  and  has  been  picked  up,  examine  it  to  see  if  it  is  entire. 
The  bullet,  if  retained,  is  to  be  sought  for.  The  .v-rays  are  invaluable  in  locat- 
ing the  missile.  Place  the  head  in  such  a  position  that  the  track  of  the  ball 
will  be  vertical,  then  introduce  Fluhrer's  aluminum  probe  or  Senn's  probe, 
and  let  it  find  its  way  by  gra\ity.  The  probe  may  find  the  ball  near  the  wound 
of  entrance,  in  which  case  extract  the  ball  with  forceps;  or  the  probe  may  find 
the  ball  near  the  opposite  side  of  the  head,  in  which  case  make  a  counteropening 
through  the  bone  at  a  point  the  probe  would  touch  if  it  were  pushed  entirely 


^^j^BiM^MMi  iiiiii(iimiBMI< 


Fig.  585. — Senn's  modification  of  Nelaton's  bullet-probe. 

across.  Take  a  new  and  dean  rubber  catheter  (No.  9,  French),  insert  a  stylet, 
and  carry  the  catheter  through  the  wound  (Keen).  Knowing  the  depth  of 
the  baU,  search  for  it  around  the  catheter-tube  as  an  axis,  and  when  found, 
extract  it.  In  some  cases  it  is  advdsable  to  search  for  and  remove  the  ball 
with  the  aid  of  the  fluoroscope  (page  310).  After  extraction  drain  the  wound 
as  shown  on  page  894.  When  a  counteropening  exists,  drain  from  each  side. 
If  the  ball  cannot  be  detected,  drain  from  the  depths  of  the  wound.  After 
dressing  always  place  the  head  in  a  position  favorable  to  drainage.  Fluhrer 
tells  us  that  when  a  counteropening  fails  to  disclose  the  bullet,  use  the  new 
opening  as  a  doorway  through  which  to  search  for  the  ball.  He  believes  the 
bullet  is  not  unusually  deflected.  The  angle  of  deflection  is  somewhat  greater 
than  the  angle  of  incidence,  and  the  bullet  is  apt  to  fall  a  little  toward  the  base. 
Splinters  of  bone  are  often  driven  into  the  brain  by  a  bullet,  and  these  should  be 
removed  whether  the  ball  is  found  or  not.  Several  varieties  of  probes  have  been 
recommended.  Fluhrer  uses  a  large-sized  aluminum  probe.  Senn  used  an 
instrument  shaped  like  the  Nelaton  probe,  but  of  the  same  diameter  as  the 
buUet  (Fig.  585).  (Of  course,  the  porcelain  probe  ^\dll  not  show  a  black  mark 
from  contact  wdth  a  hard-jacketed  bullet.)  Fowler  uses  a  graduated  pressure 
nrobe;  so  long  as  the  pressure  is  within  the  limits  of  the  spring,  as  shown  by 
the  scale,  the  probe  is  in  the  bullet-track.  Girdner's  telephonic  probe  has 
been  used  as  an  aid  to  localization.  Bullets  are  now  certainly  located  by  the 
Rontgen  rays.  There  can  be  no  doubt  that  many  ganshot-wounds  have  been 
recovered  from  without  operation,  and  it  is  beyond  question  that  many  deaths 
follow  operation  (about  33^:3  per  cent.,  according  to  Hahn).  Von  Bergmann 
was  so  impressed  with  these  facts  that  he  did  not  operate  when  cerebral 
symptoms  were  absent.     I  usually  operate. 


898 


Diseases  and  Injuries  of  the  Head 


Prolapse  of  the  Brain  and  Hernia  of  the  Brain. — In  a  compound  fracture, 
especially  a  gunshol-fracture,  with  torn  dura  and  jjia,  brain  matter  may  emerge 
from  the  wound.  In  fracture  of  the  base,  brain  matter  may  enter  the  orbit,  the 
nose,  or  the  ear.  A  flow  of  brain  matter  may  continue  from  a  wound  for  many 
hours.  A  week  or  more  after  an  injury  a  portion  of  the  brain  may  protrude  or 
prolapse.  To  this  condition  the  term  prolapse  of  the  brain  should  be  applied. 
In  many  instances  the  protrusion  is  covered  v\ath  pia,  but  if  the  pia  has  been  torn 
or  cut,  it  will  not  be  a  covering.  This  protrusion  emerges  from  the  opening  in 
the  skull,  mounts  up,  growing  larger  and  larger,  until  it  may  become  the  size  of  a 
list.  It  usually  pulsates.  When  bare  it  is  soft,  lobulated,  of  a  dirty-white  color, 
pulsating,  painless  to  the  touch,  often  bleeding,  and  sometimes  discharging 
cerebrospinal  liuid.  Death  may  soon  follow  such  protrusion,  but  the  pro- 
truding mass  may  become  necrotic  and  slough  off,  a  granulating  surface  remain- 
ing, which  heals.  Hernia  cerebri  (Fig. 
586)  sometimes  follows  operations  upon 
the  brain  or  injuries  of  the  skull  and 
dUra,  when  large  pieces  of  bone  have 
been  removed  or  when  the  dura  has 
been  widely  cut  or  torn  and  has  not 
been  carefully  sutured.  It  is  due  to 
brain  edema.  The  protrusion  may  be- 
come strangulated  in  the  dural  opening 
or  adherent  to  the  margins  of  the  open- 
ing. The  hernia  begins  a  few  hours 
after  the  injury.  Many  cases  of  gun- 
shot-wounds develop  herniae.  It  is 
most  common  in  the  parietal  region  and 
is  uncommon  in  the  frontal  and  occipital ' 
regions.  The  condition  is  not  due  en- 
tirely to  increased  pressure  else  lumbar 
puncture  would  be  distinctly  instead 
of  slightly  beneficial.  The  chief  lesion 
is  congestion  and  edema  of  the  dam- 
aged and  protruding  brain.  In  some 
cases  abscess  exists.  Hernia  of  the 
brain  is  protrusion  through  the  dura, 
but  not  through  the  scalp,  the  scalp 
wound  being  healed  above  the  protrusion.  In  a  decompression  operation  we 
deliberately  create  a  hernia  of  the  brain.  Prolapse  of  the  brain  is  treated  by 
antiseptic  dressings  and  perhaps  by  a  decompression  operation.  Skin-grafting 
benefits  some  cases.  Pressure  is  dangerous.  Excision  by  the  knife  or  cautery 
seldom  does  any  good.  Hernia  in  some  cases  can  be  treated  by  repeated  lum- 
bar punctures,  in  some  others  by  craniotomy  of  the  opposite  side  of  the  skull. 
Probably  the  best  treatment  is  removal  of  bone-fragments  and  incision  of  the 
dural  margin  of  the  opening,  followed  by  the  use  of  Dakin's  oil  and  by  com- 
pression. If  epileptiform  convulsions  arise  make  repeated  lumbar  punctures 
(Marchack,  in  "Presse  Med.,"  1916).  If  abscess  exists  it  must  be  drained. 
Fungus  Cerebri  (Fig.  587).— When  the  brain  is  exposed,  a  granuloma 
may  grow  from  the  neuroglia  and  fungate  through  the  opening  in  the  skull. 
This  condition  is  fungus  cerebri  and  is  not  composed  of  brain  matter.  It  is  due 
to  infection  of  the  brain,  and  is  most  frequent  when  a  bit  of  bone  or  some  other 
foreign  body  is  retained.  A  fungus  is  soft  to  the  touch,  is  livid  in  hue,  bleeds 
easily,  frequently  contains  multiple  foci  of  suppuration,  and  pulsates.  It  often 
attains  the  size  of  a  small  orange.  It  is  treated  by  removing  the  granulations 
and  any  foreign  body,  and  applying,  with  moderate  pressure,  aseptic  dressing 
soaked  in  alcohol.     After  healing,  a  depression  marks  the  site  of  the  fungus. 


Fig.  586. — Hernia  cerebri  under  scalp  after 
operation  for  brain  tumor  (W.  W.  Keen). 


Pach\mcniniii;ilis  Externa 


899 


Traumatic  inflammation  of  the  brain  and  its  membranes  is  di\  ided 
into  encephalitis  or  cercbrilis,  inllammalion  of  the  cerebrum;  cercbellitis,  inflam- 
mation of  the  cerebellum;  meningitis,  intlammation  of  the  meninges;  arachnitis, 
inllammalion  of  the  arachnoid;  pachymeningitis,  inflammation  of  the  dura;  and 
leptomeningitis,  inflammation  of  the  arachnoid  and  pia. 

Meningitis. — Of  recent  years  our  views  regarding  meningitides  have 
changed.  We  no  longer  regard  each  form  as  a  separate  and  distinct  disease, 
but  we  regard  all  the  forms  as  different  phases  of  one  disease,  that  disease 
being  a  reaction  to  infection  on  the  part  of  the  membranes  of  the  brain  and 
cord.  We  must  still,  for  clinical  convenience,  classify  meningitides  into  many 
types.  We  speak  of  men- 
ingitis as  serous  or  purulent, 
local  or  diffuse.  We  speak 
of  it  as  basilar,  leptomenin- 
gitis, etc.,  or  as  tuberculous, 
meningococcic,  etc.  But, 
after  all,  meningitis  is  an 
infection  for  which  many 
varieties  of  bacteria  may  be 
responsible,  and  in  which 
there  are  many  dift'erent 
routes  for  the  entrance  of  the 
causal  micro-organisms,  but 
the  effects  of  these  organisms 
upon  the  tissues  are  similar 
and  the  variety  of  the  symp- 
toms produced  depends  upon 
the  region  diseased  and  the 
power  and  nature  of  the 
toxins. 

This  \-iew  has  been  most  ably  set  forth  by  Kopetzky  ("The Laryngoscope," 
June,  1 91 2).  The  same  careful  observer  points  out  that  in  every  form  of 
meningitis  there  is  increased  tension  of  the  cerebrospinal  fluid  and  poisoning  of 
the  central  nervous  system  b}'  toxins  and  products  of  tissue  metabolism. 

The  chief  factors  in  causing  increased  tension  of  cerebrospinal  fluid  are 
edema  of  brain  tissue  and  edema  of  the  membranes. 

Kopetzky  ("The  Laryngoscope,"  June,  1912)  further  points  out  that  very 
early  in  the  progress  of  every  case  of  meningitis  there  is  a  disappearance  from 
the  "cerebrospinal  fluid  of  the  copper-reducing  substance  dextrose.  Bacteria 
are  greedy  for  carbohydrates  and  eat  up  dextrose.  The  disappearance  of  dex- 
trose is  highly  signiticant  of  the  existence  of  meningitis.  Its  reappearance 
indicates  abatement  of  the  inflammation. 

Treatment. — Kopetzky  (Ibid.)  in  acute  cases  advocates  the  administration 
of  serum  or  antitoxin  and  the  early  performance  of  an  operation  to  reduce 
intracranial  tension.  If  operations  were  done  early,  before  pus  had  time  to  be 
imprisoned  between  the  convolutions,  results  of  operation  would  be  much  better. 
Lumbar  puncture  is  of  high  diagnostic,  but  of  small  therapeutical  value.  The 
fluid  obtained  by  puncture  contains  polymorphonuclear  leukocytes.  Drainage 
of  the  spinal  theca  by  lumbar  laminectomy  is  practised  by  some.  The  most 
promising  operation  is  one  which  drains  the  cisterna  magna  (see  Haynes's 
Operation,  page  938).     Radical  drainage  has  saved  many  lives. 

Pachymeningitis  Externa. — Inflammation  of  the  external  layer  of  the 
dura  is  called  pachymeningitis  externa.  It  may  arise  from  tumor,  caries, 
necrosis,  middle-ear  disease,  sunstroke,  or  traumatism.  SyphiUs  is  a  not 
unusual  cause.  The  other  membranes  may  become  involved.  Suppuration 
may  arise,  having  extended  by  contiguity  from  neighboring  parts. 


Fig.  587. — Fungus  cerebri  (W.  W.  Keen). 


Qoo  Diseases  and  Injuries  of  the  Head 

The  symptoms  of  pachymeningitis  externa  are  uncertain.  They  resemble 
often  those  of  leptomeningitis  (see  below).  Pressure  symptoms  may  arise. 
Headache  is  always  present.  Paralysis  may  or  may  not  exist.  If  pus  forms, 
the  ordinary  constitutional  symptoms  of  suppuration  are  evident  (high  tem- 
perature and  sweats),  not  the  usual  symptoms  of  abscess  in  the  brain.  In  a 
severe  case  the  other  membranes  become  involved. 

The  treatment  consists  in  removing  the  cause  (carious  bone,  pus,  middle- 
ear  disease).  In  pachymeningitis  from  traumatism  it  is  sometimes  advisable 
to  trephine  in  order  to  drain  inflammatory  products;  in  a  case  with  localizing 
symptoms  always  trephine;  in  an  ordinary  case,  without  pus  and  with  no 
evidences  of  traumatism,  use  wet  cups  liack  of  the  mastoid  processes,  apply  an 
ice-bag  to  the  head,  and  purge  by  means  of  calomel.  Administer  iodid  of 
potassium  in  most  cases.  If  sunstroke  is  the  cause,  treat  according  to  ordi- 
nary medical  rules. 

Pachymeningitis  Interna. — This  term  means  inflammation  of  the 
inner  layer  of  the  dura.  Inflammation  may  extend  from  the  pia  or  from  the 
outer  layer  of  the  dura.  The  disease  is  most  often  met  with  in  infants  and 
in  the  chronic  insane,  but  may  occur  in  those  not  insane  in  late  middle  age  or 
beginning  old  age.  The  form  known  as  hematoma  of  the  dura  mater,  or  paehy- 
meningitis  interna  hcemorrhagica,  may  arise  during  infectious  disease  (typhoid 
fever  or  rheumatism),  in  persons  of  the  hemorrhagic  diathesis,  in  diseases 
causing  atrophy  of  the  brain,  in  chronic  diseases  of  the  heart  and  kidneys, 
and  in  syphilitics.  Among  the  exciting  causes  are  traumatism,  inflamma- 
tion in  adjacent  parts,  and,  especially,  the  abuse  of  alcohol.  In  this  disease 
blood  is  extravasated  on  the  inner  surface  of  the  dura.  Many  observers  do  not 
class  hemorrhagic  pachymeningitis  as  inflammation,  but  regard  the  hemor- 
rhage as  primary. 

The  symptoms  of  internal  pachymeningitis  are  very  chronic,  come  on 
graduallv,  are  not  characteristic,  and  may  be  absent.  They  consist  usually  of 
mental  irritability  or  excitement,  followed  perhaps  by  hebetude  and  persistent 
headache;  and  apoplectiform  attacks,  with  contraction  of  the  pupils,  slow 
pulse,  and  vomiting;  there  may  also  be  muscular  rigidity  and  spasm  of  the  ex- 
tremities. Choked  disk  is  not  infrequent;  locahzing  symptoms  may  be  made 
out,  and  coma  is  apt  to  arise.     Cranial  nerves  are  seldom  affected. 

The  treatment  is  operation,  which  removes  the  clot.  This  is  unpromis- 
ing, but  Munro  saved  i  case  out  of  5  ("Chicago  Med.  Recorder,"  Dec,  1902). 

Acute  leptomeningitis  is  a  purulent  inflammation  of  the  soft  mem- 
branes of  the  brain.  The  pathological  changes  can  be  noted  in  the  pia  and  in 
the  brain  substance.  The  brain  is  edematous,  the  pia  purulent,  the  convolu- 
tions are  flattened,  the  ventricles  are  distended  with  fluid,  and  hemorrhages 
occur  into  the  brain  substance.  Pus  may  be  localized  upon  the  pia,  but  it  is 
usually  diffused  over  one  hemisphere  or  over  both.  Various  organisms  may 
be  found,  especially  streptococci,  staphylococci,  and  diplococci.  In  some 
cases  we  find  the  BaciUus  pyocyaneus  or  the  Bacillus  pyocyaneus  f(etidus, 
which  is  identical  with  the  colon  bacillus  and  with  the  Bacillus  meningitidis 
purulentae  (Park).  Saprophytic  organisms  are  occasionally  present.  This 
disease  may  be  acute  or  chronic,  and  a  severe  case  is  spoken  of  as  encephalitis. 
Secondary  leptomeningitis  is  apt  to  affect  the  convexity;  primary  leptomeningitis 
is  apt  to  affect  the  base. 

The  causes  of  leptomeningitis  are  epidemic  cerebrospinal  fever,  tubercu- 
culosis,  acute  general  diseases  (pneumonia,  typhoid,  erysipelas,  and  rheuma- 
tism), bone  diseases,  traumatism,  middle-ear  disease,  syphihs,  and  sun- 
stroke. In  diplococcic  meningitis  the  tissues  of  the  pia  and  the  cerebrospinal 
fluid  contain  diplococci  identical  with  pneumococci.  Infection  may  take  place 
by  various  avenues.  It  may  pass  from  the  pharynx  by  w^ay  of  the  Eustachian 
tube  to  the  ear,  or  from  the  nose  to  the  frontal  sinus  or  ethmoid  sinuses  (Hirt), 


Tuberculous  Meningitis  901 

and  from  these  situations  to  the  brain.  It  may  pass  from  the  middle  ear  or 
mastoid  to  the  membranes  of  the  brain.  In  fractures  at  the  base  the  organisms 
enter  by  way  of  the  pharynx  and  the  Eustachian  tube,  or  the  ear.  The  symp- 
toms of  acute  leptomeningitis  early  in  the  case  are:  rising  blood-pressure  (deter- 
mined by  the  sphygmomanometer),  edema  of  the  optic  papillae,  absence  of 
carbohydrates  from  the  cerebrospinal  fluid  (obtained  by  lumbar  puncture),  "an 
irritable  or  clouding  sensorium"  (Irving  S.  Haynes,  in  "The  Laryngoscope," 
June,  1Q12).  The  same  author  adds  that  vagus  pulse  and  respirations  irregular 
in  depth  and  rate  may  also  be  present.  As  the  case  progresses  there  are  \aolent 
headache  persisting  during  delirium,  flushing  of  the  face,  rigidity  of  the  neck, 
cerebral  vomiting,  a  pulse  small  and  irregular  in  force  and  frequency,  but  often 
slow,  elevated  temperature,  leukocytosis,  photophobia,  contraction  and  perhaps 
inequality  of  the  pupils,  intolerance  of  sound,  h^-peresthesia  of  the  skin  and 
muscles,  and  delirium  passing  into  stupor  and  coma.  There  are  rigidity  of  the 
muscles  of  the  neck,  retraction  of  the  head,  retraction  of  the  abdominal  muscles 
(boat-shaped  abdomen),  inability  to  extend  the  legs  when  sitting  up,  though  it 
can  be  done  when  recumbent.  If,  while  lying  down,  the  thigh  is  flexed  on  the 
belly  the  leg  cannot  be  extended  on  the  thigh  {Kernig's  sig)i).  If  a  dull  point 
is  drawn  along  the  skin  a  red  line  follows  it  {tache  cerehrale).  A  chill  or  a  suc- 
cession of  chills  may  occur.  Choked  disk,  strabismus,  and  nystagmus  are  not 
unusual.  Twdtching  convulsions  or  paralyses  may  occur.  Death  is  the  rule 
within  one  week.  In  a  case  of  meningitis  the  fluid  obtained  by  lumbar  punc- 
ture may  contain  bacteria  and  may  be  actually  purulent.  The  presence  of 
numerous  leukocytes  is  usual,  there  being  an  excess  of  pohonorphonuclear 
forms  in  pyogenic  infections. 

Treatment. — Flexner's  serum  is  valuable  in  cerebrospinal  meningitis,  a 
condition  caused  by  the  Diplococcus  intracellularis,  but  is  useless  in  all  other 
conditions.  Lumbar  puncture  is  of  immense  diagnostic  importance,  but  is 
useless  therapeutically.  It  is  not  entirely  safe.  The  rapid  wdthdrawal  of  fluid 
may  cause  death  by  allowing  the  foramen  magnum  to  be  plugged  by  the  brain 
stem.  Ordinary  trephining  mth  tapping  of  the  ventricle  is  practically  useless. 
An  operation  which  promises  is  the  exposure  and  drainage  of  the  cisterna  magna 
(see  page  938).  If  employed  it  should  be  done  early,  that  is,  when  what  we 
regard  as  early  symptoms  are  present.  Late  operations  are  of  no  avail.  Any 
causal  condition,  for  instance,  suppurative  otitis  media,  must  also  be  treated  by 
operation.  After  operating  administer  urotropin.  Should  the  patient  recover, 
he  must  be  guarded  for  a  long  time  from  physical  exertion,  mental  excite- 
ment, worry,  irritation,  constipation,  and  insomnia. 

Chronic  Leptomeningitis  {or  Chro7iic  Encephalitis). — The  causes  of 
chronic  leptomeningitis  are  the  same  as  those  of  the  acute  form.  If  trauma- 
tism is  the  cause,  the  inflammation  arises  at  a  later  period  than  it  would  in 
acute  encephalitis.  The  symptoms  of  concussion  follow  a  head  injury.  Days, 
or  even  weeks,  after  the  accident  a  series  of  s^onptoms  may  occur,  namely, 
localized  pain  at  the  seat  of  injury,  often  accentuated  by  tapping;  listlessness; 
irritabihty;  apathy  regarding  business  affairs  and  home  obligations,  or 
profound  depression  and  hypochondria  ^^dth  inabihty  to  attend  to  business. 
Choked  disk  may  exist.  In  any  case  acute  encephahtis  may  arise,  with  or  with- 
out a  chiU.  The  treatment  of  this  disease  is  symptomatic  unless  local  s\Tnp- 
toms  exist.  Always  trephine  if  localizing  symptoms  are  found.  Intense  local 
pain  justifies  trephining. 

Tuberculous  Meningitis  (Acute  Hydrocephalus;  Water  on  the 
Brain). — This  inflammatory  condition  is  due  to  the  bacilli  of  tuberculosis. 
In  a  child  affected  with  tuberculous  meningitis  there  is  often  a  record  of  a 
fall,  the  injury  acting  as  an  exciting  cause  by  establishing  an  area  of  least 
resistance.  Prodromal  symptoms  lasting  several  weeks  are  common  (restless- 
ness, irritability,  anorexia,  loss  of  flesh,  change  of  character).     The  attention 


go2  Diseases  and  Injuries  of  the  Head 

of  the  physician  is  attracted  to  the  meninges  by  a  convulsion  or,  what  is  more 
common,  by  headache,  fever,  and  vomiting.  The  fever  is  persistent,  but 
irregular.  The  child  cries  out  from  pain  {the  hydrencephalic  cry)  and  the  bowels 
are  constipated.  The  pulse  is  rapid  in  the  beginning,  but  later  becomes  slow, 
irregular,  and  of  high  tension.  The  pupils  are  contracted,  there  is  muscular 
twitching,  and  the  sleep  is  impaired.  The  temperature  is  about  103°  F.  There 
is  usually  edema  of  the  optic  papilla?  and  carbohydrate  disappears  from  the 
cerebrospinal  fluid  (see  page  899).  In  the  second  period  of  the  disease  the 
vomiting  ceases,  constipation  ])ccomes  more  marked,  the  belly  retracts,  head- 
ache is  not  so  violent,  and  the  patient  Hes  in  a  soporose  condition  interspersed 
with  episodes  of  delirium.  In  this  stage  the  pupils  dilate  and  are  often  un- 
equal, the  head  is  retracted,  convulsions  occur  or  limited  rigidity  is  noted,  the 
respirations  are  sighing,  and  if  a  finger-nail  is  drawn  along  the  skin,  a  red  line 
develops  (the  tache  cerebrale,  due  to  vasomotor  paresis).  Kernig's  sign  is 
present  (see  page  901).  Squint  and  consequent  double  vision  are  usual.  In 
the  last  stage  coma  becomes  absolute  and  general  convulsions  or  limited  spasms 
are  apt  to  occur.  Optic  neuritis  exists,  and  the  child  passes  to  death  along 
a  road  identical  with  that  of  typhoid  collapse.  In  many  cases  the  examination 
of  cerebrospinal  fluid  withdrawn  by  lumbar  puncture  throws  light  upon  the 
diagnosis.  The  fluid  is  turbid,  is  devoid  of  carbohydrate  and  usually  contains 
an  excess  of  lymphocytes.  In  most  cases  it  contains  the  baciUi.  It  may  be  sterile. 
Sterile  fluid  from  a  patient  with  symptoms  of  meningitis  suggests  that  the  con- 
dition is  tuberculous.  In  children  the  base  of  the  brain  is  usually  involved,  and 
the  disease  is  apt  to  last  from  two  to  four  M^eeks;  in  adults  the  convexity  is  usu- 
ally involved,  and  death  is  apt  to  occur  in  a  few  days.  When  the  meningitis  is 
basilar,  occipital  headache,  rigidity  of  the  neck,  and  vomiting  are  severe,  paraly- 
sis of  various  cranial  nerves  may  occur,  and  there  may  be  hemiparesis  from 
pressure  on  the  crus.  Absence  of  leukocytosis  points  to  a  tuberculous  cause  for  a 
meningitis.  The  existence  of  leukocytosis  does  not  disprove  the  tuberculous 
cause  of  the  disease. 

.  The  treatment  is  like  that  for  traumatic  meningitis.  The  operation  of 
trephining,  perhaps  with  tapping  a  ventricle,  seldom  offers  any  chance  of  im- 
provement, and  never  does  unless  the  process  is  limited  in  area  and  confined 
to  the  convexity.  Lumbar  puncture  is  performed  for  diagnostic  rather  than 
for  therapeutic  reasons.  Draining  the  cisterna  magna  should  be  tried  (see 
page  938). 

Abscess  of  the  brain  is  a  localized  collection  of  pus.  The  bacteria  which 
may  be  found  are  noted  upon  page  900  (Acute  Leptomeningitis).  The  causes 
are  suppurative  otitis  media  (in  half  of  all  the  cases),  fracture  of  the  skull, 
osteomyelitis  of  the  cranial  bones,  erysipelas  of  the  scalp,  subaponeurotic 
abscess  of  the  scalp,  abscess  of  the  lung,  gangrene  of  the  lung,  empyema,  con- 
cussion or  wound  of  the  brain,  and  general  infections.  As  Ballance  points 
out,  abscess  of  the  brain  complicating  head  injury  is  not  reaUy  an  abscess 
of  the  brain  unless  the  wounding  material  entered  into  the  brain  substance. 
In  most  cases  the  abscess  is  "a  local  meningeal  suppuration  with  participa- 
tion of  the  adjacent  brain  cortex,  a  meningocortical  abscess  rather  than  a  brain 
abscess  proper"  ("Some  Points  in  the  Surgery  of  the  Brain,"  by  Chas.  A. 
Ballance).  General  infections  may  cause  abscess  (pyemia,  tuberculosis,  and 
specific  fevers).  A  tuberculous  mass  may  caseate  (tuberculous  abscess). 
The  abscess  may  be  between  the  dura  and  the  skull  (extradural),  between  the 
dura  and  brain,  adhesions  forming  and  preventing  general  leptomeningitis 
(subdural),  or  in  the  brain  substance  (cerebral  or  cerebellar).  Leptomenin- 
gitis may  arise  because  no  adhesions  are  created,  because  septic  clots  form  in 
veins  or  sinuses,  or  because  infected  blood  regurgitates  into  the  sinuses  (Park). 
A  traumatic  abscess  is  generally  beneath  the  area  to  which  the  traumatism  was 
applied,  but  it  may  be  on  the  opposite  side.     The  source  of  infection  may  be  the 


Abscess  of  the  Brain  903 

nose,  the  orbit,  or  tlie  middle  ear  (see  page  900).  Rosvvell  Park  says  infection 
may  pass  along  blood-vessels,  lymph-vessels,  nerve-sheaths,  or  the  prolongations 
of  the  membranes  which  extend  outside  of  the  skull.  An  acute  inflammation 
of  the  middle  ear  rarely  causes  abscess,  because  an  acute  inflammation 
in  sound  tissue  causes  the  formation  of  granulation  tissue,  which  acts  as 
a  barrier  to  infection.  Chronic  inflammation  of  the  middle  ear  is  the  most  fre- 
quent cause  of  abscess.  Park  tells  us  that  if  the  roof  of  the  tympanum  is 
involved,  it  may  perforate  and  abscess  of  the  middle  fossa  may  form;  if  the 
tympanum  is  perforated  toward  the  mastoid  antrum,  the  abscess  arises  in  the 
temporosphenoidal  lobe;  if  the  perforation  is  toward  the  sigmoid  groove  the 
abscess  forms  in  the  cerebellum.^ 

Chronic  bone  disease  is  seldom  followed  by  spreading  meningitis,  often  by 
abscess.  When  infection  reaches  the  brain  by  direct  extension  from  a  sup- 
purating bone  it  must  pass  through  the  membranes,  but  it  is  usually  limited 
by  adhesions.  The  cortex  is  very  vascular,  strongly  resists  infection,  and 
is  seldom  extensively  destroyed,  but  the  white  matter  is  far  less  resistant  and 
abscess  tends  to  form  in  it  (Ballance,  Ibid.).  In  some  cases  of  abscess  of  the 
temporosphenoidal  lobe  following  ear  disease  the  cortex  seems  normal,  in  others 
the  membranes  and  cortex  are  fused  over  a  narrow  area  which  constitutes  the 
stalk  of  an  abscess  in  the  white  substance  of  the  lobe.  This  is  the  mushroom 
abscess  of  Ballance.  An  abscess  may  increase  rapidly  in  size  and  finally  break 
into  a  ventricle  or  through  the  cortex.  It  may  become  encapsulated  and 
latent.  A  slowly-growing  abscess  may  push  aside  nerve-fibers  as  does  an  en- 
capsulated tumor,  but  a  rapidly  growing  abscess  destroys  them. 

In  the  cerebrum,  multiple  abscesses,  except  in  cases  of  general  infection,  are 
seldom  seen.  In  the  cerebellum  they  are  not  uncommon.  One  or  several  ab- 
scesses may  arise  from  a  primary  one.  If  they  are  adjacent  to  the  primary  one 
they  are  called  satellite  abscesses  and  tend  to  break  into  the  older  purulent  area. 

Ballance,  in  considering  the  onset  of  abscess,  adopts  the  views  as  to  the  five 
types  set  forth  by  Brissaud  and  Souques.  These  types  are  as  follows  (Bal- 
lance, Ibid.): 

(i)  A  subacute  evolution.  In  this  there  is  a  febrile  onset,  like  the  onset  of  a 
specific  fever,  with  headache,  vomiting,  and  elevated  temperature.  After  a  few 
days  there  comes  a  remission,  the  period  of  delusive  calm.  In  this  period 
symptoms  are  absent  or  trivial.  Though  there  may  be  progressive  emaciation, 
there  is  no  elevation  of  temperature  in  this  period. 

Suddenly  convulsions  occur  which  are  followed  by  coma,  or  coma  arises 
without  antecedent  convulsions.  The  patient  may  die  in  coma  or  the  coma 
may  pass  away,  "the  symptoms  indicating  a  local  brain  lesion"  (Ballance, 
"Some  Points  in  the  Surgery  of  the  Brain").  In  this  stage  elevated  tempera- 
ture may  appear  again. 

(2)  Evolution  with  violent  general  infection,  the  symptoms  of  abscess 
being  merged  and  usually  lost  in  the  symptoms  of  general  infection. 

(3)  Evolution  with  complete  latency.  The  patient  presents  no  symptoms 
until  a  few  hours  before  death,  or  he  may  die  suddenly  without  a  symptom 
having  been  observed.  In  this  connection  Ballance  speaks  of  the  difference 
between  "symptoms  not  noticed  and  symptoms  not  present"  (Ibid.). 

(4)  Only  when  symptoms  were  not  present  does  he  use  the  term  "com- 
plete latency"  to  indicate  the  condition.  Ransohoff  has  reported  the  case  of 
a  boy  in  whom  an  abscess  in  the  frontal  lobe  was  latent  for  three  years,  and  an- 
other case  in  a  man,  due  to  gunshot-injury,  in  whom  the  abscess  was  latent  for 
four  and  a  half  years  and  in  which  nearly  ten  years  elapsed  between  the  injury 
and  death  ("Annals  of  Surgery,"  July,  1909). 

(s)  Onset  not  to  be  distinguished  from  a  brain  tumor. 

(6)  Onset   with  headache  and  fever,   or  with  mental  excitement.     Then 
1  Park,  in  "Chicago  Med.  Record,"  Feb.,  1895. 


904  Diseases  and  Injuries  of  the  Head 

the  jjalient  appears  to  get  completely  well  and  remains  so  for  weeks,  for  months, 
or  for  a  year  or  more.  This  condition  may  occur  in  abscess  secondary  to 
influenza  (Ibid.). 

Symptoms  of  Abscess  of  the  Cerebral  Substance  or  of  the  Cerebellum. — 
The  symptoms  due  to  pus  formation  are  as  follows:  There  is  an  initial  rise 
of  temperature,  but  (except  in  extradural  abscess)  the  temperature  may 
quickly  become  normal  or  even  subnormal.  Years  ago  Sir  Samuel  Wilks 
called  attention  to  the  depression  of  temperature  frequently  noted  in  cerebral 
abscess.  Subnormal  temperature  is  not  nearly  so  common  as  is  supposed. 
It  has  been  present  in  about  one-half  of  the  cases  I  have  seen.  Toward  the 
end  of  the  case  the  temperature  may  rise  and  the  fever  become  linked  with 
delirium.  Surface  elevation  of  temperature  over  the  seat  of  the  abscess  is 
occasionally  observed.  A  chill  may  occur,  but  seldom  does.  Anorexia  and 
vomiting  are  present.  Urinary  chlorids  are  diminished  and  the  phosphates  are 
increased  (Somerville).  Certain  symptoms  are  due  to  pressure:  Headache 
is  the  earliest  symptom.  Headache  is  at  first  general,  then  local,  and  grows 
worse  later  in  the  case,  and  exists  even  in  delirium;  this  fact  distinguishes 
it  from  the  headache  of  fever,  which  ceases  in  delirium;  pulse  is  full,  re  ular, 
and,  in  the  absence  of  complications,  becomes  very  slow;  respiration  tends  to 
alterations  of  rhythm  and  the  Cheyne-Stokes  t>T3e;  drowsiness  lapses  into 
stupor  and  stupor  passes  into  coma;  paralysis  of  the  sphincters  takes  place; 
superficial  reflexes  gradually  disappear  on  the  side  opposite  to  the  lesion; 
convulsions  are  common;  sensation  is  rarely  impaired,  and  paralysis  of  the 
basal  nerves  may  occur  (third  and  sixth  especially).  The  pupil  on  the  same 
side  as  the  abscess  is  sometimes  dilated  and  fixed.  Choked  disk  is  not  invari- 
ably found.  It  may  be  more  marked  on  the  same  side  as  the  abscess.  It  is 
more  moderate  in  degree  than  in  meningitis.  Localizing  symptoms,  spasmodic 
and  paralytic,  depend  upon  the  center  which  is  irritated  or  destroyed.  In 
abscess  of  the  temporosphenoidal  lobe  hemiplegia  of  the  opposite  side  is  apt 
to  develop.  The  face  is  most  and  first  involved,  next  the  arm,  next  the  trunk, 
and  finally  the  leg  (Sir  Victor  Horsley,  ''Lancet,"  Jan.  27,  1912).  In  an  abscess 
far  posterior  the  motor  palsy  may  be  so  slight  as  to  almost  escape  recognition, 
but  there  is  loss  of  the  sense  of  position  of  a  limb  and  loss  of  power  to  localize 
touch.  In  cerebellar  abscess  there  are  vertigo,  vomiting,  occipital  headache, 
rigidity  of  the  postcervical  muscles,  and  incoordination.  Choked  disk  may 
be  present  or  absent.  A  cerebral  or  a  cerebellar  abscess  causes  a  decidedly 
high  leukocytosis. 

Meningitis  arises  soon  after  an  accident;  a  traumatic  abscess  cannot  arise 
until  more  than  a  week  has  elapsed  after  an  accident,  and  many  weeks  may 
elapse.  Meningitis  presents  high  temperature  and  the  general  symptoms  before 
outlined.  Mastoid  disease  may  occasion  cerebral  symptoms  without  abscess,  or 
it  may  cause  abscess.  It  is  curious  that  in  some  cases  of  mastoid  disease  with- 
out brain  abscess  choked  disk  arises.  In  sinus-thrombosis  there  is  septic  tem- 
perature, the  veins  of  the  face  and  neck  are  enlarged,  and  a  clot  can  usually  be 
felt  in  the  jugular.  A  tumor  grows  slowly,  may  present  localizing  symptoms, 
and  double  choked  disk  is  frequently  present.  In  tumor  the  temperature  is  apt 
to  be  normal.  There  is  no  symptom  and  no  group  of  symptoms  positively 
significant  of  abscess  in  contrast  to  tumor.  If  abscess  and  tumor  occur  together 
the  diagnosis  is  impossible.  There  are  34  such  cases  on  record  (Hirschman, 
in  "Zeitschr.  fiir  Ohrenh.,"  1914,  Ixxi). 

Treatment. — If  abscess  is  due  to  ear  disease  with  implication  of  the  mastoid 
cells,  at  once  open  and  clear  out  the  mastoid  (see  Fig.  599),  and  after  doing  this 
proceed  to  trephine  the  skull  in  order  to  reach  the  abscess.  In  any  case,  if 
symptoms  of  abscess  exist,  trephine  the  skull  at  once.  If  localizing  symptoms 
are  present,  open  over  the  suspected  region.  If  localizing  symptoms  are  not 
present,  and  the  cause  is  ear  disease,  trephine  at  Barker's  point  (see  Fig.  599). 


Brain  Disease  from  Suppurative  Ear  Disease  905 

If  no  pus  is  found  between  the  bone  and  dura,  open  the  membrane.  When 
the  dura  is  opened,  if  the  abscess  is  subdural,  pus  will  be  evacuated;  if  the 
abscess  is  in  the  brain  substance,  the  brain  will  bulge  very  much  and  will 
not  pulsate.'  A  grooved  director  is  plunged  into  the  brain,  in  the  direction 
of  the  abscess,  for  2  or  2}/'2  inches.  It  is  pointed  to  the  external  angular  process 
of  the  opposite  side.  If  pus  is  not  found,  withdraw  the  director  and  introduce  it 
near  the  first  point,  and  point  it  to  the  nostril  of  the  opposite  side.  If  pus  is 
not  found,  withdraw  the  director  and  introduce  it  again,  pointing  it  to  the  angle 
of  the  jaw  of  the  opposite  side.  When  pus  is  discovered,  incise  the  brain  with  a 
knife,  enlarge  the  opening  by  inserting  a  closed  pair  of  forceps  and  with- 
drawing the  instrument  with  the  blades  open.  Scrape  away  the  granulation 
tissue  lining  the  abscess-cavity,  irrigate  with  hot  salt  solution,  and  introduce 
a  rubber  drainage-tube  and  suture  it  to  the  scalp;  stitch  the  dura,  but  leave  an 
ample  opening  for  the  tube;  bring  the  tube  out  through  a  button-hole  in  the 
scalp,  and  after  the  first  two  days  pull  the  tube  out  a  little  every  day  and  cut 
off  a  piece.  If  the  first  trephining  does  not  find  pus,  trephine  at  another 
point.  If  we  are  seeking  for  an  abscess  due  to  middle-ear  disease  and  fail  to 
find  it  in  the  temporosphenoidal  lobe,  seek  for  it  in  the  cerebellum.  In  cere- 
bellar abscess  make  a  flap  with  the  base  up,  and  trephine  or  gouge  away  the 
bone  just  below  the  line  of  the  lateral  sinus.  Puncture  the  brain  for  explora- 
tion as  for  cerebral  abscess. 

Brain  Disease  from  Suppurative  Ear  Disease. — Acute  otitis  media 
sometimes,  and  chronic  otitis  media  much  more  often,  cause  meningitis  {otitic 
meningitis).  This  may  be  a  circumscribed  inflammation  of  the  dura  eventu- 
ating perhaps  in  an  extradural  abscess,  a  serous  leptomeningitis,  or  a  purulent 
leptomeningitis.  There  may  or  may  not  be  involvement  of  the  mastoid 
{mastoiditis) .  There  are  always  fever  and  pain  and  tenderness  over  the  region 
of  meningitis.  The  pain  and  tenderness  are  above  the  zygoma  or  back  of 
the  mastoid . (Dench,  in  "New  York  Med.  Jour.,"  August  27,  1910).  With 
these  symptoms  there  may  or  may  not  be  signs  of  mastoid  involvement.  Dench 
points  out  that  the  occurrence  of  sudden  and  profound  deafness  during  middle- 
ear  suppuration  usually  means  beginning  meningitis  (Ibid.).  Chronic  disease 
of  the  middle  ear  is  apt  to  destroy  the  bone  between  the  tympanum  and  the 
middle  fossa  of  the  skull,  and  thus  produce  meningitis,  thrombosis  of  the  petrosal 
or  lateral  sinuses,  abscess  of  the  temporosphenoidal  lobe  or  of  the  cerebel- 
lum, or  extradural  abscess.  In  chronic  otitis  media  the  reflexes  of  the  oppo- 
site side  of  the  body  are  frequently  altered  (Russell  Reynolds,  Sir  Victor 
Horsley).  In  some  cases,  even  without  any  other  evidence  of  cerebral  in- 
volvement, there  is  choking  of  the  disk.  Choked  disk  is  apt  to  be  the  earliest 
symptom  of  abscess,  the  other  symptoms  not  having  developed.  Absence 
of  eye  symptoms  is  not  proof  that  abscess  is  absent,  and  their  presence  is  not 
absolute  proof  of  abscess.  In  many  cases  the  infection  is  direct,  by  bone  in- 
volvement or  by  the  lateral  sinus.  In  many  other  cases  the  infection  is 
through  the  labyrinth.  If  labyrinthine  infection  arises,  it  produces  symptoms 
(disturbances  of  equilibrium  and  nystagmus).  Chronic  otitis  media  is  apt  to 
induce  inflammation  or  suppuration  of  the  mastoid  cells  {empyema  of  the 
mastoid).  Pus  in  the  mastoid  may  discharge  itself  into  the  middle  ear,  and 
from  this  point  into  the  external  auditory  canal,  through  a  perforation  in  the 
drum-membrane  (especially  in  acute  cases).  In  some  cases  the  pus  becomes 
blocked  up  within  the  mastoid  process.  Pus  in  the  mastoid  may  after  a  time 
break  into  the  cavity  of  the  cranium  or  into  the  groove  for  the  lateral  sinus,  or 
may  find  its  way  externally  {post auricular  abscess)  and  open  into  the  sheaths  of 
muscles  arising  from  the  mastoid.  It  not  unusually  opens  into  the  sheath  of  the 
digastric  muscle  {Bezold's  abscess).  These  facts  teach  the  surgeon  that  inflam- 
mation of  the  middle  ear  should  never  be  neglected,  but  should  if  possible,  receive 
the  closest  attention  of  the  specialist.     If  no  perforation  exists  in  the  drum,  the 


go6  Diseases  and  Injuries  of  the  Head 

surgeon  must  make  one.  In  ordinary  cases  cleanliness  and  antisepsis  are  suffi- 
cient, the  ear  being  syringed  every  day  with  a  warm  2  per  cent,  solution  of  com- 
mon salt.  If  only  a  small  drum-perforation  exists,  10  drops  of  pure  alcohol  or  of 
corrosive  sublimate  solution  (i  :  5000)  are  dropped  into  the  ear  daily;  but  if  a 
large  drum-perforation  exists,  boric  acid  and  ioodform  (7  to  i)  are  insufflated. 
Never  inject  alum.  A  strong  silver  solution  is  not  safe;  if  it  is  used,  wash  the 
ear  out  afterward  with  warm  salt  water.  If  granulations  or  polypi  exist,  they 
must  be  removed.  Some  cases  require  the  removal  of  the  drum-membrane  and 
the  ossicles  of  the  ear.  Some  cases  of  mastoid  necrosis  are  due  to  tuberculosis. 
If  headache,  vomiting,  and  mastoid  tenderness  exist,  open  the  mastoid  (see  page 
936)  in  order  to  prevent  abscess  of  the  brain.  In  acute  otitis  media  it  is  very 
rarely  necessary  to  open  the  mastoid.  The  middle  ear  is  on  a  lower  level  than  the 
antrum  of  the  mastoid,  and  in  most  acute  cases  both  the  middle  ear  and  mastoid 
cells  drain  safely  through  a  drum-perforation.  Because  a  man  has  chronic  otitis 
media  it  is  by  no  means  always  necessary  to  trephine  the  mastoid.  In  many 
cases  removal  of  the  ossicles  and  drum-membrane  effects  a  cure.  In  chronic 
otitis  media,  even  if  the  mastoid  is  trephined,  the  ossicles  and  membrane  ought 
to  be  removed  in  most  cases. 

Cerebral  abscess  from  ear  disease  (see  page  905)  is  almost  always  in 
the  temporosphenoidal  lobe,  but  may  arise  in  the  cerebellum.  The  symptoms 
are  a  regular,  full,  slow  pulse  (except  in  complicated  cases),  a  transient  rise  of 
temperature,  followed  in  many  cases  by  a  normal  or  subnormal  temperature; 
vomiting;  mastoid,  frontal,  and  temporal  pain.  The  mind  is  dull,  and  stupor 
arises  which  passes  into  coma;  the  bowels  are  constipated;  choked  disk  may  be 
present;  and  convulsions  or  spasms  or  paralyses  may  exist.  Trephine  and 
clean  out  the  mastoid,  and  asepticize  (see  Operations  Upon  the  Skull  and 
Brain).  Also  trephine  at  Barker's  point,  iM  inches  behind  and  the  same  dis- 
tance above  the  middle  of  the  external  auditory  meatus,  open  the  dura,  and 
seek  for  pus  in  the  brain.     If  pus  is  not  found,  open  the  cerebellum. 

Extradural  Abscess. — The  eye-symptoms  and  pain  are  the  same  in 
this  as  in  cerebral  or  subdural  abscess,  but  the  temperature  is  different,  rising 
to  103°  or  104°  F.,  and  never  being  subnormal.  There  is  often  considerable 
tenderness  above  and  behind  the  mastoid.  In  extradural  abscess  following 
disease  of  the  middle  ear  trephine  and  clear  out  the  mastoid;  follow  up  a  bone- 
sinus  to  the  abscess,  rongeur  away  the  bone,  being  careful  to  avoid  injuring 
the  lateral  sinus;  curet,  irrigate,  and  drain. 

Infective  Sinus=thrombosis. — ^Any  sinus  may  be  attacked.  The  dis- 
ease may  result  from  scarlet  fever,  small-pox,  diphtheria,  influenza,  t>T)hoid,  or 
any  acute  suppuration.  In  erysipelas  of  the  scalp,  subaponeurotic  abscess 
of  the  scalp,  and  cranial  osteomyehtis  septic  clots  may  form  in  the  veins  which 
pass  through  the  bone  and  reach  the  longitudinal  sinus.  Infective  thrombosis 
of  the  superior  longitudinal  sinus  is  thus  produced. 

In  carbuncle  of  the  lip  and  orbital  suppuration  the  cavernous  sinus  may 
become  involved. 

In  caries  of  the  basilar  portion  of  the  occipital  bone  the  circular  sinus  or 
the  cavernous  sinus  may  suffer.  The  veins  of  the  tympanum  join  the  inferior 
cerebral  veins,  and  one  of  the  inferior  cerebral  veins  empties  into  the  cavernous 
sinus.  The  vein  of  Trolard,  which  arises  on  the  parietal  convolution  and  empties 
into  the  cavernous  sinus,  receives  blood  from  the  diploic  veins  which  com- 
municate with  the  veins  of  the  tympanum  (C.  G.  Crane,  in  ''Laryngoscope," 
1916,  xxvi).  The  anatomy  of  the  region  shows  that  cavernous  sinus  thrombosis 
may  be  secondary  to  middle-ear  disease,  with  or  without  mastoid  involvement. 
In  caries  of  the  petrous  portion  of  the  temporal  bone,  and  in  suppuration 
of  the  middle  ear  and  mastoid  process,  infective  thrombosis  of  the  lateral 
sinus  may  occur. 

In  any  case  the  symptoms  are  those  of  pyemia.     The  lateral  sinus  is  the 


Prognosis  of  Infective  Sinus-thrombosis  goy 

one  most  frequently  attacked.  In  infective  thrombosis  of  the  lateral  sinus 
there  is  usually  a  history  of  an  old  discharge  from  the  ear. 

Infective  thrombosis  of  the  lateral  sinus  may  result  from  a  specific  fever,  but 
is  usually  due  to  chronic  suppuration  of  the  middle  ear  associated  in  most 
cases  with  carious  bone  and  pus  in  the  mastoid  process.  Thrombosis  of  the 
lateral  sinus  occasionally  follows  an  operation  upon  a  suppurating  mastoid, 
or  develops  in  an  individual  who  suffers  from  middle-ear  disease,  who  has  been 
struck  upon  the  head,  who  has  had  the  ear  syringed  with  force,  or  who  has  had 
injected  a  corrosive  or  very  irritant  fluid.  Tuberculous  bone  disease  is  an 
occasional  cause. 

Symptoms. — In  most  cases  there  is  a  history  of  chronic  ear  disease.  In 
children  the  symptoms  are  more  acute  than  in  adults.  In  any  case  the  symp- 
toms may  rapidly  become  violent.  In  some  cases  there  are  preliminary  symp- 
toms of  extradural  abscess,  pus  being  lodged  in  the  groove  of  the  sinus.  It 
has  been  pointed  out  that  pus  in  the  jugular  foramen  may  make  pressure  upon 
the  pneumogastric,  spinal  accessory,  and  glossopharyngeal  nerves,  producing 
aphonia,  hoarseness,  dyspnea,  dysphagia,  and  slow  pulse  (George  F.  Cott^). 
Marked  headache  and  often  an  initial  chill  usher  in  sinus-thrombosis.  The  pain 
is  apt  to  be  localized  about  the  ear  and  mastoid  process,  but  may  become  gen- 
eral. There  is  usually  acute  tenderness  of  the  mastoid.  There  is  high  fever 
from  the  start,  but  when  the  clot  begins  to  soften  and  break  down,  hard  rigors 
develop  and  the  temperature  fluctuates  violently.  The  temperature  varies 
greatly  each  day,  fluctuating  it  may  be  between  subnormal  and  io6°  to  107°  F. 
A  chni  may  occur  once  or  even  twice  a  day,  and  it  lasts  from  ten  to  twenty 
minutes.  The  pulse  is  soft  and  usually  rapid.  The  patient  is  nauseated,  labors 
under  vertigo,  is  very  restless,  is  sometimes  delirious,  may  become  dull  and 
stupid,  and  the  muscles  of  the  neck  are  stiff.  Tenderness  and  marked  edema  are 
detected  over  the  mastoid,  and  the  veins  of  the  neck  and  mastoid  region  may 
be  enlarged.  When  the  clot  extends  into  the  jugular  vein  there  is  pain  on 
moving  the  head  and  on  swallowing,  the  cervical  glands  are  swollen,  and  a 
cord-like  clot  may  be  felt  in  the  neck.  Choked  disk  exists  in  about  half  or 
perhaps  two-thirds  of  all  cases.  There  is  often  a  profuse  discharge  of  pus 
from  the  ear,  but  in  some  cases  a  discharge  is  found  to  have  abated  or  ceased. 
Exophthalmos  and  swelling  of  the  eyelids  point  to  involvement  of  the  cavernous 
sinus  in  the  process.  In  early  cases  there  is  thrombosis  of  the  lateral  sinus  alone, 
or  of  the  lateral  sinus  and  jugular  vein.  In  advanced  cases  other  sinuses  become 
involved  (superior  petrosal,  inferior  petrosal,  both  cavernous,  the  lateral  sinus 
of  the  opposite  side,  the  ophthalmic  veins,  and  the  torcular  Herophili).  In 
sinus-thrombosis  there  is  leukocytosis  unless  the  patient  is  profoundly  septic. 
A  patient  with  sinus-thrombosis  is  in  great  danger  of  developing  pulmonary 
metastasis  and  septic  meningitis  (Jansen).  Septic  meningitis  is  accompanied 
by  abscess  about  the  sinus.  Infective  sinus-thrombosis  is  a  very  fatal  disease 
and  usually  runs  its  course  in  from  seven  to  ten  days,  but  occasionally  lasts 
for  several  weeks.  It  is  a  form  of  pyemia,  and  death  arises  from  the  causes 
which  have  been  referred  to  in  discussing  that  disease. 

Infective  thrombosis  of  the  cavernous  sinus  occurs  when  an  infected  clot 
comes  from  another  sinus,  from  disease  of  the  nasal  sinuses,  from  orbital  in- 
fection, or  from  a  pyogenic  process  of  the  face  or  lids.  It  causes  pain  and 
the  general  symptoms  of  pyemia,  and  also  edema  of  the  lids,  chemosis,  and  an 
extreme  degree  of  exophthalmos.  Choked  disk  exists.  Vision  may  be  nor- 
mal or  impaired.  The  condition  almost  invariably  spreads  to  the  other  eye 
along  the  circular  sinus. 

Infective  thrombosis  of  the  petrosal  sinus  produces  pyemic  symptoms,  but 
no  characteristic  signs. 

The    prognosis    largely    depends    upon    early   recognition.     The    surgeon 

1  "Am.  Med.,"  April  19,  1902. 


go8  Diseases  and  Injuries  of  the  Head 

should,  whenever  it  is  possible,  open  a  mastoid  before  sinus-thrombosis  arises, 
and  should  evacuate  an  abscess  about  the  sinus  before  a  clot  forms  in  the  venous 
channel,  or  at  least  before  that  clot  becomes  septic  (Jansen). 

Treatment. — In  1880  Zaufal  proposed  the  operation  now  practised,  and 
Horsely  did  it  in  1886.  (See  article  by  Geo.  F.  Cott,  in  "American  Medi- 
cine," April  19,  1902.)  Infective  thrombosis  of  the  lateral  sinus  is  treated  as 
follows:  Open  and  clear  out  the  mastoid,  and  expose  the  sinus  by  the  use  of  the 
chisel  or  rongeur  (see  Fig.  599).  Follow  Mr.  Ballance's  advice  and  expose  the 
sinus  from  the  bulb  to  the  torcular.  The  jugular  vein  should  now  be  exposed 
at  the  level  of  the  cricoid  cartilage  and  ligated  below  any  clot  which  may  exist. 
This  is  done  to  prevent  propagation  of  an  infected  clot  and  diffusion  of  sepsis. 
Even  if  a  clot  does  not  exist  in  the  jugular,  the  vein  should  be  tied  in  two  places 
and  divided,  because  the  sinus  contains  infected  clot  or  putrid  material  even 
when  the  vein  as  yet  does  not.  According  to  Ballance,  the  portion  of  the 
vein  above  the  point  divided  should  be  extirpated.  Some  surgeons  after  ligating 
the  jugular  do  not  excise  it,  but  if  it  contains  a  septic  clot,  incise  the  vein  up 
to  the  base  of  the  skull  and  pack  the  wound.  After  attacking  the  vein  open 
the  sinus,  and  if  a  clot  is  found  to  exist,  cut  away  the  wall  of  the  sinus.  Intro- 
duce a  small  spoon  into  the  lumen  and  carry  it  toward  the  torcular  Herophili, 
and  scrape  away  the  clot  until  blood  flows.  Arrest  hemorrhage  by  forcing  a 
piece  of  iodoform  gauze  into  the  wound  and  toward  the  torcular.  Jansen 
opposes  removing  the  entire  clot  toward  the  jugular,  and  does  not  tie  the  jugular, 
believing  that  to  do  so  increases  the  danger  of  thrombosis  of  the  inferior 
petrosal  and  cavernous  sinuses.  He  simply  removes  the  soft  clot,  but  does  not 
disturb  the  solid  clot  toward  the  heart.  Most  surgeons  differ  from  him. 
Surgeons  are  of  the  opinion  that  it  is  futile  to  do  any  operation  if  pulmonary 
metastasis  has  taken  place.  In  a  case  of  the  author's  in  the  Jefferson  Medical 
College  Hospital  the  patient  recovered  after  operation  in  spite  of  the  fact  that 
endocarditis  had  developed. 

Until  recently  it  was  thought  that  the  lateral  sinus  was  the  only  sinus 
which  should  be  attacked  surgically,  but  in  one  case  Knapp,  of  New  York, 
requested  Hartley  to  remove  from  the  cavernous  sinus  a  clot  which  was  causing 
blindness  and  was  due  to  sarcoma.  The  operation  was  successfully  executed 
bv  Hartley,  the  incision  being  the  same  as  is  employed  to  reach  a  Gasserian 
ganglion  in  the  Hartley  operation.  This  patient  lived  several  months.  Dwight 
operated  upon  another  case  by  incision  of  the  sinus  (E.  W.  Dwight  and  H.  H. 
Germain,  "  Boston  Med.  and  Surg.  Jour.,  "May  i,  1902).  Some  surgeons  advise 
removal  of  the  eyeball  and  curettement  of  the  sinus. 

Postoperative  Insanity. — Various  mental  disturbances  may  follow  sur- 
gical operation  (delirium,  obsessions,  hysterical  excitement,  morbid  fears, 
illusions,  hallucinations,  amnesia,  confusion,  hypochondria,  psychasthenia, 
melancholy,  and  genuine  insanity).  Insanity  is  no  more  frequent  after  ab- 
dominal operations  than  after  other  operations  if  we  exclude  operations  involving 
the  ovaries.     Removal  of  the  testicles  and  ovaries  are  peculiarly  provocative. 

Postoperative  insanity  is  most  common  in  females  and  in  adults.  The  pre- 
disposing elements  connected  with  a  surgical  operation  are:  Apprehension, 
fear,  pain,  insomnia,  and  exhaustion  before  operation.  The  effects  of  the 
anesthetic,  shock,  and  hemorrhage.  Postoperative  pain,  insomnia,  worry,  and 
perhaps  homesickness.  There  is  always  predisposition,  hereditary  or  acquired. 
The  patient  may  have  been  on  the  brink  of  an  outbreak  when  the  operation 
was  performed.  The  insanity  may  be  apparent  as  the  patient  awakes  from  the 
anesthetic  sleep  (Savage),  and  in  these  very  rare  cases  the  anesthetic  is  blamed. 
Most  acute  insanities  come  on  in  from  three  to  five  days  after  operation. 

If  a  man  has  ever  had  an  attack  of  insanity  operation  exposes  him  to  dis- 
tinct danger  of  another  attack.  No  special  mental  condition  characterizes 
postoperative  insanity.     There  may  be  mania,  melancholia,  stupor,  delusional 


Intracranial  Tumors  909 

insanity,  or  acute  confusion.  Acute  confusional  insanity  is  the  most  usual  form. 
In  some  cases  sepsis  is  present,  in  others  it  is  not.  We  must  not  mistake 
insanity  for  febrile  delirium,  delirium  tremens,  delirium  from  opium  deprivation, 
delirium  from  taking  morphin  or  cocain,  delirium  of  iodoform-poisoning, 
dehrium  of  the  senile,  traumatic  delirium,  hysterical  delirium,  uremic  coma,  or 
bromism. 

]\Iany  cases  of  postoperative  insanity  must  be  sent  to  a  hospital  for  the 
insane.  Only  cases  of  brief  duration  can  be  properly  cared  for  in  a  general 
hospital. 

Intracranial  Tumors. — An  encephalic  tumor  may  originate  within 
the  skull.  It  may  have  arisen  from  an  external  growth  invading  the  cranial 
cavity,  or  may  be  metastatic.  A  tumor  that  arises  within  the  cranium  mav 
take  origin  from  the  periosteum,  from  one  of  the  membranes  of  the  brain, 
from  the  vessels,  from  the  neurogha,  or  from  the  brain  substance. 

No  region  of  the  body  is  so  liable  to  tumors  as  the  brain.  During  the 
course  of  a  number  of  years  the  autopsies  of  the  Munich  Pathological  Insti- 
tute are  stated  by  BolKnger  to  have  shown  i  tumor  of  the  brain  in  every  85 
autopsies.  Hale  White's  experience  is  that  such  tumors  are  even  more  common 
than  this,  and  he  estimates  them  at  i  in  every  59  autopsies. 

In  endeavoring  to  determine  the  causes  of  intracranial  tumors  we  must 
accredit  heredity  with  considerable  influence  in  tuberculoma,  and  possibly 
with  some  force  in  sarcoma  and  carcinoma.  Tumors  of  the  brain  are  decidedly 
more  common  in  males  than  in  females,  probably  because  of  the  greater  male 
liability  to  injury,  syphilis,  and  alcoholism. 

The  majority  of  cases  of  tumor  of  the  brain  occur  between  the  ages  of 
twenty-five  and  fifty.  Children  are  particularly  prone  to  suffer  from  glioma 
and  from  tuberculous  growths.  In  aged  persons  a  tumor  of  the  brain  very 
rarely  develops.  In  100  cases  of  brain-tumor  collected  by  Hale  White  only 
2  were  aged  seventy  or  over.  In  100  cases  collected  by  Mills  and  Lloyd  onlv 
I  was  over  seventy. 

Injury  may  be  responsible  for  the  development  of  sarcoma,  of  fibroma, 
and  possibly  of  other  forms;  in  fact,  a  syphiloma  may  arise  in  a  s\'philitic 
person  at  the  seat  of  an  injury. 

We  use  the  terms  ''intracranial"  or  ''encephalic  tumor"  not  only  to  include 
true  neoplasms,  but  also  to  designate  growths  of  parasitic,  syphilitic,  or  tuber- 
culous origin.  It  is  of  importance  to  attempt  to  make  a  diagnosis  as  to  the 
form  of  tumor  that  is  present,  and  this  may  be  possible  on  account  of  the 
fact  that  in  many  cases  the  form  affects  the  symptoms.  A  useful  classifica- 
tion of  these  growths  has  been  made  by  Knapp,  and  is  as  follows:  (i)  The 
infective  granulomata,  including  tuberculous  growths,  gummata,  and  actino- 
mycotic areas;  (2)  connective-tissue  growths;  (3)  epithelial  growths;  (4) 
aneurysms.  The  most  common  of  all  these  tumors  is  undoubtedly  that  due 
to  tubercle.  In  fact,  Gowers  estimates  that,  if  we  exclude  syphiloma,  tubercle 
is  responsible  for  one-half  of  the  cases,  and  glioma  and  sarcoma  together  for 
one-third. 

Tuberculous  Tumors  {Tuberculous  Gummata;  Tuber  culomata). — Tuber- 
culous growths  may  be  primary,  but  are  usually  secondary  to  tuberculosis 
in  some  other  region  of  the  body.  Tuberculous  tumors  are  the  most  common 
form  met  with.  They  are  at  least  four  times  as  common  in  children  as  in  adults. 
They  may  be  single,  especially  in  adults,  but  are  often  multiple,  especiallv  in 
children;  and  multiple  growths  may  be  very  widespread.  According  to  Allan 
Starr,  these  growths  are  most  common  in  the  cerebral  axis  (especially  in  the 
basal  ganglia),  next  in  the  cerebellum,  next  in  the  cerebral  cortex,  and  are  least 
common  in  the  centrum  ovale.  A  tuberculous  tumor  usually  arises  in  the  pia 
mater,  particularly  in  an  arterial  distribution,  but  may  begin  in  a  ventricle,  or 
even  in  the  brain  substance.     Some  of  these  growths  are  distinctly  subcortical. 


{^lo  Diseases  and  Injuries  of  the  Head 

The  tubercle  bacilli  responsible  for  the  condition  are  carried  by  the  blood.  Some 
of  these  growths  are  small  aggregations  of  miliary  tubercles  in  thickened  pia. 
Others  are  large  masses.  A  large  tuberculous  tumor  is  due  to  the  coalescence  of 
many  foci.  It  undergoes  caseation  in  the  center,  and  is  surrounded  by  a  zone 
of  softened  or  sclerotic  brain  substance.  Tuberculous  meningitis  is  present  in 
two-thirds  or  three-fourths  of  the  cases  of  tuberculoma. 

Gummatous  Tumors  {Syphilomata). — As  gumma  seldom  arises  from  inher- 
ited s\TDhilis,  the  condition  is  very  rare  in  children.  There  may  be  a  single 
gumma,  but,  far  more  often,  syphilitic  growths  are  multiple.  A  gumma  may 
be  round  or  may  be  irregular  in  outline;  in  fact,  the  outline  is  frequently  blurred 
and  indistinct.  Some  of  these  growths  are  soft,  and  some,  which  contain  a 
quantity  of  connective  tissue,  are  hard,  A  syphiloma  usually  arises  from  the 
membranes,  and,  hence,  is  generally  on  the  surface  of  the  brain;  and  the  mem- 
branes in  the  region  of  the  growth  usually  show  distinct  inflammation.  Soft 
gummata  are  most  common  at  the  base;  hard  gummata,  in  the  cortex  of  the 
cerebrum  or  cerebellum. 

Actinomycosis. — This  is  a  very  rare  condition,  in  which  the  mass  may 
remain  solid  like  a  tumor,  but  is  far  more  apt  to  break  down  into  an  actino- 
mycotic abscess. 

Sarcomata. — Injury  seems  to  play  a  considerable  part  in  the  production 
of  intracranial  sarcoma.  Any  variety  of  sarcoma  may  arise.  Giant-cell  sar- 
coma is  very  rare  but  has  been  observed.  Sarcomata  may  arise  from  blood- 
vessels, meninges  or  bone.  It  may  be  primary  or  secondary.  As  a  rule,  at 
least  in  the  beginning,  the  growth  is  single;  but  it  may  be  multiple  or  may  become 
so.  The  majority  of  sarcomata  arise  from  the  membranes  or  from  the  perios- 
teum, but  some  cases  take  origin  from  beneath  the  cortex.  Early  in  their 
progress  these  growths  may  be  encapsulated,  but  some  of  them,  from  the  very 
start,  are  infiltrating;  and  even  those  that  were  at  first  encapsulated  later  infil- 
trate. The  cortex  and  the  cerebellum  are  the  most  common  seats  for  sarcoma. 
Endothelioma  is  sometimes  met  with.  What  is  called  angioma  of  the  brain  is, 
in  reality,  angiosarcoma.     A  psammoma  is  usually  sarcomatous. 

Gliomata. — A  glioma  is  a  growth  of  epiblastic  origin  but  it  resembles  in  many 
particulars  connective  tissue  growths.  It  grows  by  infiltration  and  does  not 
push  tissue  aside  as  do  tumors  which  grow  by  expansion  (W.  T.  Councilman, 
in  "Long  Island  Med.  Jour.,"  1914,  viii).  The  growth  is  often  so  ill  defined  and 
so  slightly  differentiated  in  appearance  from  the  brain  substance  that  it  may 
easily  be  overlooked  in  an  e.xploratory  operation.  It  arises  much  more  fre- 
quently from  the  white  than  from  the  gray  matter,  and  develops  from  the  neu- 
roglia of  the  cerebrum,  of  the  cerebellum,  of  the  pons,  or  of  the  medulla  oblon- 
gata. The  growth  remains  strictly  limited  to  nervous  tissue  and  may  extend 
on  the  surface  to  a  great  distance  from  its  point  of  origin  (Councilman,  Ibid.). 
A  glioma  may  be  soft  or  may  be  hard.  A  soft  glioma  is  sometimes  spoken  of  as 
gliosarcoma.  Hemorrhage  is  very  apt  to  occur  in  these  growths.  They  have 
a  tendency  to  become  cystic.  They  destroy  tissue  as  they  grow  hence  pressure 
signs  are  late  or  absent.     Gliomata  are  the  most  common  of  brain  tumors. 

Fibromata. — Intracranial  fibroma  is  a  rare  growth.  Tumors  of  the  cere- 
bellopontile  angle  are  apt  to  be  of  this  character.  It  is  of  firm  consistence, 
is  encapsulated,  and  may  grow  to  a  large  size.  Such  growths  can  be  readily 
enucleated.     Injury  seems  occasionally  to  be  responsible  for  their  formation. 

Osteomata. — Osteophytic  growths  not  uncommonly  take  origin  from  the 
inner  surface  of  the  skull,  but  the  osteomata  arising  in  the  dura  or  in  the  brain 
substance  are  rare.     Such  growths,  however,  occasionally  occur. 

Cholesteatomata. — These  tumors  are  fibrous  growths  covered  with  endo- 
thelium and  containing  layers  of  cholesterin.  They  are  particularly  apt  to 
arise  in  the  pia  mater,  but  may  begin  in  either  of  the  other  membranes  or 
in  the  brain  substance.     A  cholesteatoma  is  commonly  called  a  pearl  tumor. 


SNn-ii)t()ms  of  Intracranial  Tumors  911 

Enchondromata  and  Inic  ncuromala  are  rare,  and  lipomata  are  exceedingly 
uncommon. 

Adenomata. — An  adenoma  occasionally  springs  from  the  conarium  or  the 
pituitary  body. 

Carciiwmata. — Primary  intracerebral  carcinoma  is  rare,  but  does  occur. 
Secondary  carcinoma  is  more  common,  and  may  follow  cancer  of  any  part 
of  the  body,  although  it  is  most  apt  to  follow  cancerous  growths  about  the 
face  or  neck.  A  primary  growth  may  begin  in  the  meninges,  in  the  hypophysis 
cerebri  or  in  the  lining  of  the  ventricle.  Intracerebral  carcinomata  may  be 
single  or  multiple.  They  are  soft  and  non-encapsulated  growths,  infiltrating 
and  very  vascular. 

Cysts. — Mills  says  that  cysts  arise  about  an  old  hemorrhage,  are  small 
retention-cysts  of  a  vascular  plexus,  or  are  porencephalic.  Dermoid  cysts 
are  extremely  rare.  Hydatid  cysts  are  very  rare  in  the  United  States.  A  cyst 
may  result  from  the  degeneration  of  a  glioma  or  of  a  sarcoma. 

Symptoms. — They  are  divided  into  two  sets:  (i)  General,  due  to  increase 
of  pressure,  and  (2)  local,  localizing,  or  special,  arising  because  of  the  part  of 
the  brain  involved. 

In  some  cases  general  symptoms  are  absent,  in  some  special  symptoms 
are  absent,  in  others  even  tumors  of  large  size  produce  no  recognizable  symp- 
toms, either  general  or  special.  A  large  infiltrating  growth,  a  glioma,  for 
instance,  may  produce  no  symptoms  at  all  if  situated  in  a  silent  region,  and 
if  it  destroys  brain  substance  as  it  grows,  so  that  intracerebral  pressure  is  not 
increased. 

General  Symptoms. — The  chief  general  symptoms  are  headache,  vomiting, 
and  choked  disc.  All  of  these  may  be  present,  any  one  of  them  may  be  absent, 
any  two  of  them  may  be  absent,  and  in  some  cases  all  of  them  are  absent. 
Other  general  symptoms  that  may  or  may  not  be  present  are  vertigo,  general 
convulsions,  insomnia,  mental  failure,  and  somnolence  or  partial  stupor. 

Headache. — This  is  the  symptom  most  commonly  present.  It  occurs 
sooner  or  later  in  a  very  great  majority  of  cases. 

At  first  it  may  be  noted  only  at  certain  times  of  the  day  and  it  is  usually 
complained  of  most  on  rising  in  the  morning.  The  headache  of  brain  tumor 
when  once  established  is  intense  in  most  cases,  and  as  a  general  thing  it  is 
practically  continuous,  with  episodes  of  increased  violence.  In  rare  cases  it  is 
paroxysmal.  In  some  cases  it  is  trivial,  in  some  few  cases  it  never  arises  at 
all.  The  headache  of  brain  tumor  usually  interferes  with  sleep.  It  may  be 
general,  one  sided,  frontal,  or  occipital.  The  situation  of  the  pain  is  without 
localizing  value  unless  there  is  tenderness  on  percussion  or  pressure  over  the 
seat  of  pain,  which  is  sometimes  noted  in  growths  of  the  meninges  or  cortex. 

Headache  is  less  common  in  children.  In  very  young  children  the  ex- 
planation of  this  is  found  in  the  open  fontanels  and  the  expansile  cranium; 
in  older  children,  in  the  fact  that  gliomata  are  common  in  children  and  gliomata 
may  not  cause  intracerebral  pressure. 

The  dura  is  sensitive,  as  Gushing  says,  to  "pull  or  pressure,  not  to  an  inci- 
sion."    The  headache  of  brain  tumor  is  due  to  stretching  of  the  dura. 

Vomiting  is  present  at  times  in  many  of  the  cases.  It  may  happen  oc- 
casionally or  it  may  never  occur. 

It  is  usually  cerebral,  that  is,  vomiting  with  a  clean  tongue  without  nausea, 
and  without  any  relation  to  the  taking  of  food.  In  some  cases  it  is  projectile, 
quantities  of  vomitus  being  suddenly  projected  from  the  mouth.  It  may, 
however,  be  associated  with  nausea,  and  in  some  cases  there  is  nausea  v/ithout 
vomiting.  It  is  apt  to  be  most  severe  on  getting  up,  especially  on  rising  in 
the  morning.     It  is  usually  most  severe  when  headache  is  most  intense. 

The  worst  attacks  of  vomiting  occur  in  cases  of  cerebellar  tumor. 

The  cause  of  vomiting  is  uncertain.     Some  believe  it  to  be  due  to  stimula- 


^12  Diseases  and    Injuries  of  the  Head 

tion  of  the  vagus  center;  others,  to  reflex  stimulation  of  a  vomiting  center  in  the 
medulla.  If  associated  with  vertigo  it  may  arise  from  the  auditory  centers. 
Choked  Disk  {Optic  Xeuritis,  Papillitis,  Descending  Xcuritis,  Papillo-edema). — 
This  is  a  most  important  symptom.  It  is  disclosed  by  the  ophthalmoscope. 
When  present  it  is,  as  Gushing  says,  one  of  the  "most  reliable"  signs  of  tumor. 
It  is  present  in  80  per  cent,  of  all  cases.  It  may  be  noted  in  a  few  weeks  after 
a  tumor  begins  to  grow,  in  a  few  months,  or  longer.  It  may  come  on  rapidly 
or  gradually. 

It  is  particularly  common  and  severe  in  growths  beneath  the  tentorium.  It 
is  decidedly  less  common  in  tumors  of  the  motor  cortex.  It  is  nearly  always 
bilateral,  but  it  is  common  to  find  it  more  marked  in  one  eye  than  in  the  other. 
That  it  is  worse  on  one  side  suggests,  but  only  suggests,  that  the  tumor  may  be 
on  the  side  on  which  the  choked  disk  is  worst.  Monocular  choked  disk  is 
very  rare.  When  it  exists  it  indicates  that  the  growth,  in  all  likelihood,  is 
situated  near  the  back  of  the  orbit  on  the  same  side  as  the  choking  of  the  disk. 
Gowers  recorded  a  case  of  unilateral  choked  disk  due  to  a  tumor  compressing 
the  left  optic  nerve  ('"Lancet,"  July  10  ,19051). 

Ghoked  disk  may  exist  for  some  time  and  attain  a  high  grade  without 
noticeably  impairing  vision,  but  ultimately  it  leads  to  retinal  hemorrhage, 
white  atrophy,  and  blindness.  When  atrophy  begins,  vision  wanes.  The 
presence  of  choked  disk  does  not  prove  the  existence  of  tumor.  The  cerebral 
edema  of  Bright's  disease  may  cause  a  condition  known  as  albuminuric  retinitis, 
which  practically  is  not  to  be  distinguished  from  the  choked  disk  caused  by 
tumor.  Gushing  believes  that  the  processes  are  identical  in  tumor  and  Bright's 
disease.  Ghoked  disk  may  occur  in  meningitis,  brain  abscess,  cerebral  syphilis, 
sinus-thrombosis,  myelitis,  infectious  diseases  (t^-phoid,  influenza,  diphtheria, 
and  other  conditions),  toxemias  from  lead,  arsenic,  and  alcohol,  anemia,  dia- 
betes, or  as  an  hereditary  or  family  disease  in  the  victims  of  the  cranial  deformity 
known  as  oxycephaly.  In  this  condition  there  is  a  high  and  usually  narrow 
head  with  a  prominence  over  the  site  of  the  anterior  fontanel  (see  Wm.  Sharpe 
in  "Am.  Jour.  Medical  Sciences,"  June,  1916).  Diabetes  or  diabetes  insipidus 
associated  with  primary  optic  atrophy  especially  bitemporal  hemianopsia  is 
probably  due  to  hypophyseal  disease. 

The  cause  of  choked  disk  has  been  much  disputed.  Some  believe  that  the 
condition  is  a  neuritis  due  to  a  toxic  condition  of  the  cerebrospinal  fluid.  Others 
believe  that  it  is  not  inflammatory,  but  is  a  papillo-edema  due  purely  to  mechan- 
ical pressure,  and  is  an  edema  or  dropsy.  The  latter  theory  is  largely 
held  by  surgeons  because  they  have  become  convinced  by  experience  that  relief 
of  intracranial  pressure  relieves  or  cures  choked  disk.  De  Schweinitz  and 
Holloway  ("Therapeutic  Gazette,"  July  15,  1909)  make  the  following  state- 
ment in  regard  to  mechanical  pressure  causing  choked  disk:  "That  this  is 
the  only  etiologic  factor  may  with  propriety  be  disputed;  indeed,  it  seems  cer- 
tain that  a  combination  of  factors  must  be  active  in  the  production  of  this 
condition,  but  increased  intracranial  pressure  is  the  one  of  which  we  have 
most  certain  knowledge." 

Gushing,  of  Harvard,  who  has  done  such  notable  work  on  this  subject, 
beheves  that  "almost  all,  if  not  all,  cases  of  choked  disk  are  primarily  of  mechan- 
ical origin  and  do  not  justify  the  term  'neuritis"  "  ("Keen's  Surgery,"  vol.  iii). 
Gompression  forces  the  cerebrospinal  fluid  out  of  its  reservoirs.  Some  of  it 
is  forced  into  the  vaginal  sheath  of  the  optic  nerve.  It  reaches  the  head  of  the 
nerve  and  the  swollen  disk  and  large,  tortuous  veins  are  seen  by  aid  of  the 
ophthalmoscope.  If  a  tumor  was,  from  its  start,  in  contact  with  the  nerves, 
primary  atrophy  occurs  instead  of  choked  disk.  In  such  a  case  choked  disk 
cannot  arise  because  the  fluid  cannot  be  forced  down  the  blocked  nerve  sheaths. 
Primary  atrophy  occurs  in  hypophyseal  tumors. 

Conv^ulsions. — Generalized  convulsions   may  occur,   and  children  are  espe- 


Diagnosis  of  Intracranial   Tumors  913 

cially  liable  to  them.  Many  cases  of  supposed  general  convulsions  have  an 
unobserved  local  beginning  which  is  a  focal  symptom. 

Vertigo. — Mills  says  it  is  noted  in  one-third  of  all  cases  and  is  due  to  dural, 
ocular,  or  labyrinthine  irritation. 

Itisomnia  is  often  due  to  headache  and  is  apt  to  be  associated  with  rest- 
lessness, lack  of  emotional  control,  and  irritability.  It  is  most  pronounced  in 
cases  of  syphiloma  and  some  forms  of  malignant  disease,  and  is  worse  in  adults 
than  in  children. 

In  rare  cases  there  is  somnolence  or  partial  stupor  rather  than  insomnia. 
In  such  cases  slow  speech  is  often  noted. 

Mental  Failure. — There  is  often  great  lack  of  emotional  control,  charac- 
terized by  irritabihty  and  outbreaks  of  anger.  Failure  of  memory  is  common 
and  change  of  character  is  the  rule.  There  may  be  great  slowness  of  thought 
and  of  mental  response  to  stimuli,  with  defective  power  of  orientation.  Pro- 
gressive mental  deterioration  may  occur.  There  may  be  mental  depression, 
apathy,  or  mental  excitement.  Tumors  in  certain  regions  may  cause  delusions, 
illusions,  or  hallucinations. 

Hysteria  and  neurasthenia  sometimes  arise. 

Pidse  and  Respiration. — Whereas  the  pulse  is  often  slow,  it  is  very  variable, 
and  I  agree  with  Gushing  that  "pressure-symptoms  which  characterize  acute 
lesions  (namely,  rise  in  blood-pressure;  slow,  vagus  pulse,  and  Cheyne-Stokes 
respiration)  are  conspicuous  by  their  absence"  ("Keen's  Surgery,"  vol.  iii). 

Anemia  is  a  not  uncommon  symptom  of  brain  tumor.  It  is  usually  a  result 
of  secondary  hydrocephalus. 

Special  Focal  or  Localizing  Symptoms. — These  symptoms,  when  present, 
indicate  the  situation  of  the  growth.  If  the  tumor  is  in  a  silent  region  there  will 
be  no  focal  symptoms.  General  symptoms  may  exist  without  focal  symptoms 
and  focal  symptoms  may  exist  without  general  symptoms. 

Among  localizing  symptoms  we;  should  mention  various  forms  of  aphasia, 
hemianopsia,  paralysis,  Jacksonian  epilepsy,  sensory  disturbances  (to  touch, 
pain,  or  temperature),  a  sensory  aura,  disturbances  of  taste,  hearing,  and  smell, 
impairment  of  muscular  sense,  alteration  or  impairment  of  reflexes,  nystag- 
mus, and  incoordination.  Nystagmus  is  often  noted  when  there  is  general 
compression. 

Exophthalmos  unless  due  to  complicating  hyperthyroidism  or  ventricular 
tumor,  means  direct  pressure  upon  the  cavernous  sinus.  A  unilateral  exoph- 
thalmos is  nearly  always  upon  the  side  of  the  tumor.  In  bilateral  exophthalmos 
the  protrusion  is  usually  worst  on  the  side  of  the  lesion  (Weisenberg,  in  "Jour. 
Amer.  Med.  Assoc,"  vol.  Iv). 

Diagnosis. — In  many  cases  a  diagnosis  is  made  at  a  period  so  late  that 
irreparable  damage  has  already  been  inflicted.  Early  diagnosis  is  of  the  first 
importance.  A  careful  and  painstaking  study  of  the  patient  and  of  his  history 
will  usually  enable  us  to  make  a  diagnosis  before,  and  often  long  before,  the 
attainment  of  a  degree  of  pressure  which  causes  papillo-edema,  headache, 
and  vomiting.  In  doubtful  cases  an  exploratory  operation  should  be  performed. 
Exploration  is  always  called  for  in  advancing  cerebral  palsy  and  in  focal 
epilepsy. 

In  abscess  the  symptoms  usually  develop  much  more  acutely  than  in  tumor. 
It  is  true  that  some  cases  of  abscess  last  for  months,  but  in  them  intervals  of  com- 
plete remission  of  symptoms  occur,  which  is  not  the  case  in  tumor.  An  abscess 
follows  middle- ear  disease  or  some  other  pyogenic  process  or  perhaps  a  head 
injury.  There  may  be  fever  and  leukocytosis.  Ghoked  disk  is  far  less  common 
than  in  tumor. 

Chronic  meningitis  from  syphilis  exhibits  periods  of  increase  and  periods 
of  subsidence  of  the  symptoms,  and  usually  palsy  of  one  or  more  cranial  nerves. 
The  symptoms  may  pass  away  under  the  use  of  mercury  and  iodid  of  potassium. 
58 


914  Diseases  and  Injuries  of  the  Head 

There  may  be  clinical  evidences  of  syphilis.     There  should  be  a  positive  Was- 
sermann  reaction. 

Chronic  tuberculous  meningitis  causes  a  headache  which  is  apt  to  be  general 
and  more  violent  than  that  of  tumor,  and  there  is  more  commonly  cutaneous 
hyperesthesia  and  hyperesthesia  of  the  organs  of  sight  and  hearing.  Optic 
neuritis  may  be  absent.  When  present  it  is  of  less  intensity  than  that  observed 
in  tumor.  In  some  cases  the  ophthalmoscope  discloses  tubercles  on  the  choroid. 
In  meningitis  there  is  a  continued,  irregular  fever.  The  cerebrospinal  fluid 
obtained  by  lumbar  puncture  usually  exhibits  an  excess  of  lymphocytes.  It 
may  contain  the  bacilli.  Carbohydrate  is  absent.  It  may  be  sterile.  Of 
course,  a  tumor  might  exist  with  meningitis. 


Fig.  588. — Professor  Gibbon's  case  of  brain  tumor. 

In  Bright' s  disease  symptoms  strongly  suggestive  of  tumor  may  arise  (head- 
ache, vomiting,  and  choked  disk)  with,  perhaps,  but  little  change  in  the  urine. 
The  difficulty  in  diagnosis  becomes  evident  when  we  recall  that  in  cases  of 
brain  tumor  the  urine  may  contain  casts  and  albumin.  A  sudden  onset  and 
brief  duration  of  the  symptoms  suggest  uremia. 

Ependymitis  with  ventricular  dropsy  may  cause  symptoms  resembling 
tumor  with  hydrocephalus.  Optic  neuritis  is  not  so  common  as  in  tumor. 
Bilateral  spastic  paralysis  may  arise. 

Severe  anemia  is  capable  of  producing  symptoms  which  suggest  tumor. 
It  can  even  produce  choked  disk.  A  blood  examination  and  the  rapid  improve- 
ment under  proper  treatment  makes  the  diagnosis  evident. 

In  some  cases  of  brain  tumor  (especially  frontal  lobe  tumors)  there  are 
striking  evidences  of  hysteria  and  neurasthenia.  Always  think  of  this  when 
inclined  to  make  a  diagnosis  of  hysteria  or  neurasthenia. 

The  .r-rays  m.ay  aid  us  in  diagnosis  and  many  brain  tumors  can  be  skia- 
graphed  (Fig.  588).     Lumbar  puncture  may  aid  in  the  diagnosis,  but  it  must  be 


Localization  of  a  Tumor  915 

used  with  the  greatest  care,  because  in  tumor  the  withdrawal  of  any  con- 
siderable quantity  of  fluid  may  be  followed  by  sudden  death  due  to  the  brain 
stem  sinking  into  the  foramen  magnum. 

Cause,  Duration,  and  Termination. — A  brain  tumor,  unless  caused  b\' 
syphilis,  is  a  certainly  fatal  lesion  if  not  removed  by  operation. 

Some  brain  tumors  grow  for  years  before  they  produce  symptoms.  Some 
grow  with  great  rapidity.  When  pressure  symptoms  appear  the  patient's  life 
will  terminate  within  a  few  months  unless  an  operation  is  performed.  It  is 
usually  stated  that  the  average  duration  of  life  is  three  years. 

Sudden  death  may  occur  at  any  time. 

Horsley  states  that  in  a  very  few  cases  brain  tumors  have  disappeared 
after  mere  operative  exposure,  the  tumor  not  having  been  removed.  Gushing 
has  had  the  same  experience,  and  regards  such  an  amazing  disappearance  as 
due  to  the  cystic  degeneration  of  a  glioma. 

Localization  of  a  Tumor. — The  situation  of  a  tumor  is  determined  not  only 
by  localizing  symptoms,  but  also  from  their  mode  of  onset  and  manner  of 
combination.  In  some  cases  the  symptoms  are  not  characteristic,  in  others 
they  are  definite.  The  more  marked  the  signs  of  compression,  the  less  the  value 
of  localizing  symptoms.  The  nature  of  the  tumor,  its  depth,  and  whether  it 
is  single,  and  if  other  tumors  exist  is,  if  possible,  determined.  Localizing  symp- 
toms may  be  due  to  irritation  or  destruction  of  functionating  power.  Irrita- 
tion causes  spasm,  and  destruction  induces  paralysis.  Convulsions  which  are 
local  or  which  begin  locally  are  known  as  Jacksonian  epilepsy.  A  local  convul- 
sion points  to  an  irritative  lesion  of,  or  immediately  adjacent  to,  the  center 
which  presides  over  the  muscular  movements  of  the  part  convulsed.  Local 
paralysis  points  to  a  destructive  lesion  of  the  center  which  presides  over  the 
movements  of  the  paralyzed  part.  In  some  cases  a  center  is  damaged  and  the 
muscular  movements  it  controls  are  paralyzed,  but  the  adjacent  brain-areas 
are  irritated  and  the  muscles  they  represent  are  attacked  with  spasms.  In 
some  cases  an  apparently  paralyzed  part  becomes  convulsed,  the  center  not 
being  completely  destroyed  and  sudden  hyperemia  serving  to  awaken  spasm. 
Always  note  the  order  of  invasion  of  different  regions  and  observe  if  spasm  is 
followed  by  muscular  weakness  or  anesthesia. 

The  Bdrdny  Tests. — These  are  tests  of  the  vestibular  apparatus.  We  know- 
that  failure  in  certain  normal  responses  indicates  impairment  of  a  certain 
part  of  the  vestibular  apparatus.  These  failures  may  enable  us  to  locate 
a  tumor  or  an  abscess.  Tumors  of  the  cerebeUopontile  angle  and  tumors 
of  the  third  ventricle  can  thus  be  located.  The  tests  must  be  made  and  inter- 
preted by  an  expert.  My  colleague  Prof.  S.  MacCuen  Smith  described  for  me 
the  accepted  methods  of  making  the  Barany  tests.     The  description  follows. 

I.  Rotation  Test. — {a)  The  patient,  seated  erect  in  a  smoothly  revolving  chair, 
with  the  head  at  an  angle  of  30°  forward  and  the  eyes  closed,  is  given  10  com- 
plete revolutions  to  the  right,  occupying  about  10  seconds.  On  the  completion 
of  the  tenth  turn  the  chair  is  locked.  The  patient  is  directed  to  gaze  into  the 
distance.  There  will  be  a  left  stimulatory — being  to  the  right,  and  the  quick 
component — <:erebral,  inhibitory — being  to  the  left.  The  average  duration 
of  the  nystagmus  is  24  seconds. 

{b)  When  rotation  is  to  the  right,  the  left  labyrinth  is  the  one  receiving  the 
greater  stimulus,  because  on  the  left  side  the  endolymph  in  the  external  semi- 
circular canal  is  made  to  flow  toward  the  ampulla,  while  in  the  right  external 
semicircular  canal  the  endolymph  movement  is  away  from  the  ampulla. 

The  Pastpointing  Reaction  {after  Stimulation). — (c)  The  patient  is  rotated  to 
the  right,  as  in  the  manner  just  described,  with  the  exception  that  the  eyes 
remain  closed  throughout  the  test.  At  the  completion  of  the  tenth  revolution 
the  patient's  extended  right  index-finger  is  placed  directly  on  the  examiner's 
index-finger,  held  stationary.     This  is  done  to  give  him  the  location  of  the 


9i6  Diseases  and  Injuries  of  the  Head 

examiner's  finger.  The  patient  is  then  directed  to  raise  his  horizontally  ex- 
tended arm  to  a  vertically  extended  position  and  then  to  return  to  the  examiner's 
linger.  The  same  is  repeated  with  the  left  arm.  A  normal  individual  will 
bring  his  finger  down  several  inches  to  the  right  of  the  examiner's  finger,  for  the 
reason  that  when  the  revolutions  cease  he  experiences  vertigo,  the  subjective 
sensation  being  that  of  rotation  in  the  opposite  direction,  namely,  to  the  left. 
This  reaction  depends  upon  the  pathway  of  the  stimulus  over  the  fibers  of  the 
eighth  nerve  being  unobstructed  from  the  external  canals  to  the  cerebral  cortex. 
If  there  is  a  lesion  along  the  pathways,  or  if  the  labyrinth  is  dead,  there  will  be  no 
pastpointing. 

(d)  All  the  rotation  tests  are  the  same,  with  the  exception  that  the  head 
is  placed  at  an  angle  backward  of  60^  in  order  to  bring  the  vertical  canals  in 
the  plane  of  rotation.  Reactions  are  normally  as  follows:  After  rotation  to  the 
right,  there  will  occur  left  rotatory  nystagmus,  the  slow  movement  being  to 
the  right  and  the  quick  component  being  to  the  left.  Pastpointing  will  be 
to  the  right.  If  there  is  a  lesion  along  this  pathway,  or  if  the  labyrinth  is 
dead,  there  will  be  no  nystagmus  or  pastpointing. 

2.  Caloric  Tests. — (a)  The  caloric  test  is  mxade  by  irrigating  the  right  external 
auditor\'  canal  with  water  at  67°  F.  under  the  following  conditions:  The  patient 
is  seated  erect,  with  the  head  at  an  angle  of  30°  forward.  The  w^ater  is  per- 
mitted to  flow  through  a  tube  in  a  continuous  stream,  without  undue  pressure, 
from  a  glass  reservoir  into  the  canal  until  nystagmus  is  noted,  usually  within 
40  seconds,  or  until  the  examiner  is  satisfied  that  it  will  not  occur.  In  a  normal 
individual,  with  this  chilling  of  the  labyrinth  wall  there  is  a  flow  downward  of 
the  endolymph  in  the  vertical  canals  toward  the  ampulla,  producing  left  rota- 
tory nystagmus;  the  slow  movement  to  the  right,  the  quick  component  to  the 
left  and  causing  pastpointing  to  the  right. 

(b)  One  of  the  advantages  of  the  caloric  test  is  that  only  one  set  of  canals  and 
their  pathways  is  stimulated  at  one  time.  The  reactions  depend  upon  the  path- 
ways from  the  vertical  canals  on  the  right  side  to  the  cerebral  cortex  being 
unobstructed.  Should  there  be  a  lesion  along  the  pathway,  nystagmus  and 
pastpointing,  one  or  both,  may  not  occur.  If  the  labyrinth  is  entirely  dead, 
neither  will  occur. 

(c)  To  stimulate  the  external  canal,  it  is  only  necessary  to  place  the  patient's 
head  at  an  angle  backward  of  60°,  because  the  endolymph  is  already  chilled  from 
the  irrigation  just  performed.  The  flow  of  the  endolymph  is  now  away  from  the 
ampulla,  and  in  a  normal  individual  a  left  horizontal  nystagmus  will  occur; 
the  slow  movement  will  be  to  the  right,  the  quick  component  to  the  left.  Past- 
pointing  will  be  to  the  right.  The  pathway  of  the  stimulus  is  now  that  from 
the  external  canal  to  the  cerebral  cortex  and  the  reactions  depend  upon  its 
being  intact. 

(d)  When  the  irrigations  are  performed  with  hot  water  at  112°  F.,  the  flow 
of  the  endolymph  is  reversed  and  the  reactions  are  reversed. 

Summary. — (a)  Rotation  to  the  right,  horizontal  nystagmus  to  the  left  for  an 
average  of  24  seconds,  pastpointing  to  the  right  with  both  arms,  and  continu- 
ing so  long  as  the  vertigo  is  experienced;  when  the  rotation  is  to  the  left,  the 
same  reactions  will  occur,  only  in  the  opposite  direction,  as  when  rotated  to  the 
right.  When  the  head  is  extended  back  during  rotation,  there  will  result  a 
rotatory  nystagmus;  the  duration  of  the  nystagmus  and  pastpointing  will  be 
the  same  in  the  first  stimulation. 

(b)  In  rotation  to  the  right,  two-thirds  stimulation  is  obtained  from  the  left 
and  one-third  from  the  right  labyrinth.  The  stimulation  passes  over  the  vesti- 
bular fibers  of  the  eighth  nerve,  from  the  semicircular  canals  to  the  cerebral 
cortex. 

(c)  The  caloric  test  with  water  at  67°  F.  will  stimulate  one  set  of  semicircular 
canals  at  a  time;  head  erect,  the  vertical  canals  are  stimulated  and  will  produce 


Inferior  Frontal  Areas  917 

rotatory  nystagmus  to  the  opposite  side,  with  pastpointing  to  the  same  side; 
with  the  head  thrown  back  60°  there  will  be  horizontal  nystagmus  to  the  oppo- 
site side,  with  pastpointing  to  the  same  side.  The  stimulation  passes  over  the 
vestibular  fibers  of  the  eighth  nerve  from  the  semicircular  canals  to  the  cerebral 
cortex.  Pathological  lesions  will  interrupt  the  stimulus  and  in  this  way  its 
location  may  be  studied. 

Aphasia. — The  localizing  value  of  aphasia  is  a  subject  of  dispute. 

It  is  generally  held  that,  in  right-handed  persons,  word  blindness  results 
from  cortical  destruction  in  the  neighborhood  of  the  angular  gyrus  of  the  left 
side,  that  word  deafness  results  from  injury  or  disease  of  the  left  first  temporal 
convolution,  and  that  motor  aphasia  is  due  to  damage  to  the  convolutions  around 
the  fissure  of  Sylvius,  except  the  foot  of  the  third  frontal  and  the  base  of  the 
ascending  parietal  (Broca's  center).  All  agree  that  complete  aphasia  means 
destruction  or  inhibition  of  all  the  language  centers. 

Marie  does  not  believe  that  motor  aphasia  is  due  to  lesion  of  the  left  third 
frontal  convolution.  He  maintains  that  motor  aphasia  is  due  to  lesion  of  the 
lenticular  nucleus  and  island  of  Reil  (Frauent,  in  "Lyon,  med.,"  1914,  cxxii). 

Lesions  in  the  Cortical  Motor  Area. — A  slow-growing  tumor  which  irri- 
tates the  cortex  will  cause  tonic  or  clonic  convulsions  on  the  opposite  side  of 
the  body.  These  convulsions  have  a  local  beginning  (Jacksonian  epilepsy). 
After  a  time  paralysis  may  develop  (monoplegias  and  perhaps,  ultimately, 
hemiplegia).  An  irritative  lesion  of  the  lower  third  of  this  area  causes  spasm  of 
the  opposite  side  of  the  face,  angle  of  mouth,  or  tongue;  and  this  condition  is 
often  associated  with  tingling.  The  spasm  may  remain  limited  or  may  extend 
widely,  and  may  even  become  general.  An  irritative  lesion  of  the  middle  third 
of  the  cortical  area  causes  spasm,  which  is  limited  to  or  begins  in  the  fingers, 
thumb,  wrist,  or  shoulder.  An  irritative  lesion  of  the  upper  third  of  the  cortical 
motor  area  causes  spasm,  which  is  limited  to  or  begins  in  the  toes,  ankle,  leg, 
or  thigh.  If  such  lesions  exist,  an  aura  is  occasionally  felt  in  the  affected  region 
before  the  spasm  begins,  and  there  is  often  numbness  after  the  spasm.  De- 
structive lesions  of  the  motor  area  cause  local  paralysis,  which  may  be  preceded 
by  local  spasm  of  the  same  parts,  and  is  often  associated  with  local  spasm  of 
other  parts.  If  paralysis  comes  on  unpreceded  by  convulsions  the  lesion  is 
subcortical  rather  than  cortical,  that  is,  it  is  in  the  white  matter  between  the 
motor  area  and  the  internal  capsule. 

Tumors  of  the  anterosuperior  portion  of  the  prefrontal  region  give  no 
definite  localizing  symptoms,  but  produce  general  symptoms.  Mental  disor- 
ders may  arise  in  tumors  of  any  area  of  the  brain,  but  in  tumors  of  the  pre- 
frontal region  they  are  most  apt  to  occur.  The  intelligence  is  nearly  always 
impaired,  and  there  is  apt  to  be  mental  apathy,  loss  of  memory,  hysteria, 
irascibility,  and  pronounced  change  of  character.  As  the  tumor  grows  it  may 
subsequently  involve  the  motor  region,  which  in  all  probability  lies  entirely  in 
front  of  the  fissure  of  Rolando. 

In  tumors  of  the  prefrontal  region  there  may  be  focal  convulsions  or  local 
palsy  on  the  opposite  side,  due  either  to  a  spread  of  irritation  froni  a  super- 
ficial tumor  to  the  motor  cortex  or  to  involvement  by  a  deep  tumor  of  the 
commissural  fibers  which  join  the  frontal  lobe  and  the  motor  cortex. 

Tumors  of  the  Antero -inferior  Portion  of  the  Prefrontal  Region. — In  a 
right-handed  man  tumor  of  the  second  left  frontal  convolution  causes  agraphia, 
and  of  the  third  left  frontal  convolution,  motor  aphasia.  In  a  left-handed 
person  these  localizations  are  on  the  right  side  of  the  brain. 

Inferior  Frontal  Areas. — Foster  Kennedy  C'Jour.  Am.  Med.  Assoc,"  Nov. 
14,  1916)  describes  the  following  syndrome:  On  the  side  of  the  lesion  there  is 
true  retrobulbar  neuritis  with  central  scotoma  and  primary  atrophy.  If  pres- 
sure is  considerable  there  will  be  choked  disk  of  the  other  eye  and  "ipsolateral 
anosmia." 


giS  Diseases  and  Injuries  of  the  Head 

Malcolm  Gunn  pointed  oul  years  ago  the  pupillary  reaction  characteristic 
of  retrobulbar  neuritis.  When  light  is  poured  upon  the  pupil  quick  contraction 
occurs  but  the  contraction  is  slight  and  very  temporary.  The  pupil  quickly 
dilates  to  its  former  diameter  in  spite  of  light  continuing  to  pour  upon  it. 

Tumors  of  the  parietal  lobe  may  occupy  a  silent  region  of  this  lobe.  The 
centers  of  general  sensibility  and  for  the  muscular  sense  are  back  of  the  fissure 
of  Rolando  in  the  parietal  lobes.  Hence  a  tumor  in  this  region  may  cause 
disturbance  of  muscular  sense  and  general  sensibility  in  the  limbs  without 
spasm  or  palsy  (Durante).  There  may  be  word-blindness  when  the  left 
angular  gyrus  is  affected. 

The  extension  forward  of  a  parietal  tumor  will  involve  the  motor  zone  and 
produce  spasm  or  palsy.  Extension  backward  will  involve  the  occipital  lobe 
and  produce  hemianopsia. 

Tumors  of  the  occipital  lobe  are  apt  to  produce  lateral  homonymous  hemia- 
nopsia (blindness  of  the  nasal  half  of  one  retina  and  the  temporal  half  of 
the  other  retina.  If  the  right  side  of  the  brain  contains  the  lesion  the  right 
side  of  each  retina  is  blind,  and  vice  versa).  Wernicke's  pupillary  sign  is  absent. 
By  this  sign  we  mean  loss  of  pupillary  light  reflex  when  Hght  is  cast  upon  the 
blind  part  of  the  retina.  This  sign  only  occurs  in  a  lesion  in  or  in  front  of  the 
centers  for  pupillary  reflex.  Lesions  of  the  cuneus  and  of  the  calcarine  fissure 
are  especially  apt  to  produce  hemianopsia.  A  lesion  of  the  occipital  cortex 
may  produce  it.  Tumors  of  both  occipital  lobes  cause  blindness.  In  tumor  of 
an  occipital  lobe  color  vision  only  may  be  affected  (Gushing).  Tumor  of  the 
optic  radiation  may  produce  hemianopsia  (that  is,  growths  of  the  chiasm, 
opcic  nerve,  or  pulvinar  may,  but  it  is  not  certain  that  a  growth  of  the  quadri- 
geminal  bodies  or  of  the  external  geniculate  body  can). 

In  a  tumor  of  the  occipital  lobe  (the  left  lobe  in  right-handed  persons  and 
vice  versa)  there  may  be  mind-blindness,  that  is,  an  inability  to  know  what  is 
seen.  The  patient  may  fail  to  understand  written  or  printed  words  {word- 
blindness),  the  nature  of  things  {apraxia),  or  signs  (asemia). 

Tumors  of  the  temporosphenoidal  lobe  frequently  produce  no  symptoms. 
In  the  temporal  lobes  the  cortical  centers  for  hearing  are  placed,  and  each  center 
is  connected  with  both  auditory  nerves,  but  the  crossed  auditory  bundle  is 
larger  and  more  active  than  the  direct  (Francesco  Durante,  "Brit.  Med.  Jour.," 
Dec.  13,  1902).  Tumors  in  the  left  lobe  are  particularly  apt  to  cause  deafness 
and  may  cause  word-deafness.  Tumors  at  the  apex  of  the  lobe  may  cause 
perversion  or  impairment  of  taste  and  smell.  Tumors  of  the  temporosphenoidal 
lobe  may  make  pressure  on  the  motor  tract  and  cause  paralysis  of  the  opposite  side. 

Tumors  of  the  Corpus  Callosum.— These  growths  affect  mentality  as  do 
tumors  of  the  frontal  lobes  and  frequently  cause  hemiplegia  of  each  side. 

Tumors  of  the  Cms. — These  tumors  cause  hemiplegia  of  the  opposite 
side  and  paralysis  of  the  third  nerve  on  the  side  of  the  lesion.  If  the  optic  tract 
is  pressed  upon  there  will  be  hemianopsia.  If  the  tegmentum  is  involved  there 
will  be  hemianesthesia. 

Tumors  In  or  About  the  Optic  Thalamus. — On  the  side  of  the  lesion  there 
are  nystagmus  and  impairment  in  the  movements  of  the  eyeball.  There 
are  muscular  weakness  and  impairment  of  sensation  in  the  limbs  of  the  opposite 
side.  There  may  be  sudden  and  uncontrollable  movements,  astereognosis, 
mental  dulness,  emotional  outbreaks,  and  impairment  of  emotional  control 
of  the  facial  muscles.  A  lesion  of  the  posterior  part  of  the  thalamus  causes 
hemianopsia  and  the  pupillary  reaction  of  Wernicke. 

Tumors  of  any  size  in  or  about  the  corpus  striatum  cause  hemiplegia  of  the 
opposite  side  by  pressure  upon  the  internal  capsule.  Pressure  upon  the  optic 
thalamus  produces  homonymous  hemianopsia  and  hemianesthesia.  Growths 
near  the  basal  ganglia  produce  intense  choking  of  the  disk  and  early  pressure 
because  of  distention  of  the  ventricles. 


Tumors  of  the  Cerebellum  gig 

Tumors  of  the-  Corpora  Quadrigemina, — These  tumors  produce  cerebellar 
ataxia,  palsy  of  the  eye  muscles,  and  sometimes,  perhaps,  hemianopsia.  Hear- 
ing may  be  impaired  in  the  ear  opposite  to  the  lesion.  Tumors  of  the  corpora 
quadrigemina  are  apt  to  involve  the  crura,  and  later  the  third  nerve.  Ocular 
symptoms  are  always  present  (loss  of  pupillary  reflex  and  nystagmus).  If 
the  third  nerve  is  involved  there  are  paralysis  of  the  motor  oculi  area  on  the 
side  of  the  lesion  (external  strabismus,  dilated  pupil,  and  drop-lid)  and  hemi- 
plegia of  the  opposite  side  of  the  body  from  pressure  upon  the  crus.  This  con- 
dition is  a  form  of  crossed  paralysis. 

Tumors  of  the  Third  Ventricle. — Symptoms  are  due  in  part  to  pressure  on 
nearby  structures  and  in  part  to  secondary  hydrocephalus.  Weisenburg  on  the 
strength  of  30  reported  cases,  each  case  with  an  autopsy,  pointed  out  a  syn- 
drome, viz.,  exophthalmos,  dilated  pupils,  impaired  pupillary  reactions,  cerebel- 
lar ataxia  and  paralysis  of  upward  associated  eye  movements  ("Brain,"  1910, 
xxxiii).  Bassol  ("Jour.  Am.  Med.  Assoc,"  Nov.  11,  1916)  reports  a  case  of 
soft  glioma  filling  the  third  ventricle.  There  was  secondary  hydrocephalus. 
The  symptoms  were  headache,  mental  dulness,  drowsiness,  papillitis  and 
blindness,  ataxia,  and  limitation  of  ocular  movements.  The  patient  was  four- 
teen years  of  age  and  there  was  precocious  development  of  hair  and  also  of  the 
genitals. 

Tumors  of  the  Fourth  Ventricle. — The  symptoms  result  from  internal  hydro- 
cephalus and  pressure  upon  the  cerebellum,  pons  and  medulla.  So  far  diagnosis 
^om  cerebellar  tumors  has  not  been  possible. 

Tumors  of  the  Pons. — Pontine  lesions  produce  symptoms  by  pressure 
upon  the  particular  nerves  which  come  from  this  region,  with  or  without  the 
evidences  of  pressure  upon  the  motor  path.  Forms  of  crossed  paralysis  may 
exist.  Lesions  in  the  lower  half  of  the  pons  may  affect  the  fifth,  sixth,  and 
seventh  nerves  on  the  side  of  the  lesion  and  the  limbs  on  the  opposite  side. 
The  auditory  nerve  may  be  involved  in  the  lesion.  In  crossed  paralysis  the 
face  on  the  side  of  the  limb  paralyzed  is  usually  not  affected,  but  in  extensive 
tumors  it  may  be  paralyzed.  Conjugate  deviation  of  the  eyes  may  occur  away 
from  the  facial  paralysis.  In  tumors  of  the  upper  part  of  the  pons  the  pupils 
may  be  first  contracted  because  of  irritation  of  the  third  nerve  nuclei,  and  later 
dilated  by  destruction  of  these  nuclei.  Anesthesia  as  a  result  of  pontine  tumors 
is  not  nearly  so  common  as  motor  paralysis,  and  convulsions  are  rare.  There 
may  be  hemiplegia  with  crossed  hemianesthesia.  A  tumor  on  the  side  of  the 
pons  which  involves  the  peduncles  causes  ataxia  and  sudden,  uncontrollable 
movements.     Knee-jerk  may  be  absent  in  a  case  of  pontine  tumor. 

Tumors  of  the  Medulla. — An  extensive  lesion  inevitably  causes  death. 
Cranial  nerves  only  may  be  involved,  but  crossed  paralysis  may  take  place. 
There  may  be  hemiplegia  with  crossed  paralysis  of  the  hypoglossal  nerve. 
Vomiting  is  common,  retraction  of  the  head  is  not  unusual;  respiratory  and 
circulatory  disturbances  and  dysphagia  are  usually  noted;  sometimes  there 
is  numbness  and  occasionally  there  are  convulsions;  usually  there  is  inco- 
ordination because  of  pressure  upon  the  cerebellum. 

Tumors  of  the  Cerebellum. — The  main  function  of  the  cerebellum  is  to 
synergize  body  movements  and  the  symptoms  of  cerebellar  disease  are  due  to 
impairment  of  this  power. 

As  a  rule  tumors  are  gliomatous,  they  grow  slowly  and  affect  particularly  the 
middle  regions  of  the  cerebellum.  Tumors  often  cause  internal  hydrocephalus. 
In  general  it  may  be  said  that  tumors  of  the  cerebellum  cause  headache,  vomit- 
ing, vertigo,  choked  disk,  and  early  blindness.  Tumors  of  the  middle  peduncle 
cause  sudden  uncontrollable  movements  of  the  trunk,  either  toward  the  side 
of  the  tumor  or  away  from  it.  Vertigo  and  nystagmus  are  common.  Symp- 
toms are  frequently  complicated  by  evidences  of  pontine  disease  proper. 

Tumors  of  the  middle  lobe  of  the  cerebellum  cause  a  sense  of  lost  equilibrium 


920 


Diseases  and  Injuries  of  the  Head 


and  obvious  unsteadiness  in  attempting  to  walk  or  even  to  stand.  The  knee- 
jerks  vary.  The  Babinski  reflex  is  absent  in  an  uncomplicated  case.  The 
patient  has  a  tendency  to  fall  backward;  there  are  giddiness  and  vomiting, 
early  and  violent  choked  disk  and  occipital  headache,  nystagmus,  inability  to 
stand  steady  when  the  feet  are  together  and  the  eyes  shut,  and  perhaps  tem- 
porary palsies  of  the  eye  muscles.  Nystagmus  which  is  brought  into  being 
by  voluntary  movement  is  probably  due  to  a  lesion  outside  of  the  cerebellum 
which  lesion  affects  vestibular  fibers.  Cranial  nerve  symptoms  usually  mean 
extracerebellar  lesions.  The  same  may  be  said  of  dizziness  with  ear  symptoms. 
Motor  involvement  points  to  a  pontine  lesion  (Weisenburg,  "Jour.  Am.  Med. 
"Assoc,"  191 5,  Ixv). 

Cerebellar  symptoms  are  common  in  cases  of  internal  hydrocephalus. 
Tumors  of  the  cerebellar  hemisphere  produce  no  localizing  symptoms.     The 
usual  unsteadiness  of  gait  is  due  to  pressure  upon  the  middle  lobe  (Nothnagel). 

Tumors  of  the  Cerebellopontile 
Angle. — Tumors  of  this  region  are 
usually  attached  to  the  acoustic  nerve, 
sometimes  to  the  seventh,  sixth  or 
fifth  nerve.  They  are  usually  fibro- 
matous  and  are  occasionally  cystic. 
They  produce  general  pressure-symp- 
toms and  may  cause  cerebellar  or 
pontine  symptoms  by  making  direct 
pressure  on  those  parts.  In  these 
cases  localizing  symptoms  may  be  late 
in  appearing.  The  Barany  tests  are 
valuable.  If  the  tumor  arises  from 
the  cerebellum  the  first  symptoms  will 
be  cerebellar.  If  the  tumor  springs 
from  a  cranial  nerve  the  first  symptoms 
will  point  to  that  nerve.  If  the  tumor 
involves  the  acoustic  nerve  there  will  be 
tinnitus,  objective  vertigo  (sometimes 
with,  sometimes  without  forced  move- 
ments), a  liability  to  sudden  attacks 
of  falling  to  the  ground,  failure  of 
hearing  or  actual  deafness,  perhaps 
sudden  blindness  or  sudden  uncon- 
sciousness, and  sometimes  tonic  ex- 
tensor spasms.  If  the  tumor  involves 
the  trigeminal  nerve  there  will  be  violent  neuralgia  in  the  course  of  the  nerve 
and  anesthesia  of  the  face  on  the  same  side  as  the  tumor,  the  anesthesia  in- 
volving the  cornea.  If  the  seventh  nerve  is  involved  there  will  be  peripheral 
facial  palsy  of  the  same  side.  If  the  sixth  nerve  is  involved  internal  strabismus 
will  arise  because  of  palsy  of  the  external  rectus  muscle. 

Tumors  of  the  Hypophysis  Cerebri. — The  hypophysis  cerebri  is  a  ductless 
gland  of  immense  importance  to  the  economy.  It  is  present  in  all  vertebrates. 
If  the  anterior  lobe  is  removed  death  follows.  If  the  anterior  lobe  is  damaged 
or  partially  removed  developmental  disturbances  occur.  The  pars  intermedia 
of  the  posterior  lobe  furnishes  a  very  active  substance  which  is  called  pituitrin 
which  acts  upon  the  kidney,  uterus,  urinary  bladder,  intestine,  the  secretory 
cells  of  the  mammary  gland,  the  heart  and  the  blood-vessels.  Overaction  of 
the  anterior  lobe,  however  induced,  is  the  cause  of  acromegaly.  Underaction 
produces  Frohlich\s  syndrome.  This  syndrome  is  composed  of  adiposity,  re- 
tarded development  of  the  genital  organs  and  generally  delayed  development. 
The   posterior    lobe    can    be  removed   without  dangerous  results.     Diabetes 


Fig.  589. — Case  of  cerebellar  tumor. 
Bulging  of  flap  after  osteoplastic  exploratory 
operation. 


Tumors  of  the  Hypophysis  Cerebri  921 

insipidus  is  probably  due  to  underaction  of  the  posterior  lobe.  In  this 
disease  subcutaneous  injection  of  extract  of  the  posterior  lobe  will  diminish 
the  amount  of  urine  one-half  or  more  (J.  L.  Miller,  "Jour.  Am.  Med.  Assoc," 
1916,  clii). 

Pituitrin  arrests  hemorrhage  by  its  power  in  causing  coagulation.  It  is 
used  in  intestinal  stasis  and  peritonitis  following  operation  to  cause  peristalsis. 
It  stimulates  uterine  and  vesical  contractions,  raises  blood-pressure,  and  lessens 
the  rapidity  of  the  heart. 

In  pituitary  tumor  the  a;-rays  show  enlargement  of  the  pituitary  fossa. 

A.  D.  Dunn  ("Am.  Jour.  Med.  Sciences,"  1914,  cxlvii)  has  drawn  up  the 
following  useful  schedule  of  classification  of  disorders  of  the  function  of  the 
pituitary  body.  I  quote  it  in  the  words  of  the  abstract  in  "  Surgery,  Gynecology 
and  Obstetrics,"  Dec,  1914. 

"i.  Affections  of  the  pars  anterior: 

a.  Hyperfunction — acromegaly,  gigantism. 

b.  Hypofunction — true  or  pituitary  dwarfism — not  chondrodystrophic, 
rachitic,  or  cretinic  dwarfs. 

2.  Affections  of  the  pars  posterior: 

a.  Hyperfunction — diabetes  insipidus. 

b.  Hypofunction — hypophysial    obesity^ — dystrophia    adiposogenitalis. 

3.  Mixed  affections: 

a.  Hyperfunction  of  the  pars  anterior  with  hypofunction  of  the  pars  pos- 
terior— acromegaly  wath  hypophysial  obesity. 

b.  Hypofunction  of  both  lobes — dwarfism  with  hypophysial  obesity. 

4.  Hypophysial  disturbance,  in  conjunction  with  perverted  activity  of 
other  glands. 

a.  Ovarian  or  testicular  hypofunction  with: 

1.  Hyperfunction  of  the  pars  anterior — acromegaly  with  sexual  impotence — 
eunuchoid  giants. 

2.  Hypofunction  of  the  pars  anterior — pituitary  dwarfism  with  sexual 
impotence. 

3.  Hypofunction  of  the  pars  posterior — dystrophia  adiposogenitalis. 

b.  Associated  with  disturbances  of  the  functions  of  other  ductless  glands; 
i.  e.,  adrenals,  pancreas,  thyroid,  pineal  gland,  th3anus  (status  thymolymphat- 
icus),  etc 

The  size  of  the  pituitary  fossa  is  determined  by  the  x-rays. 

When  the  gland  is  imperfectly  developed  and  hypopituitarism  exists  the 
fossa  is  small. 

The  fossa  may  be  deformed  by  tumors  enlarging  from  within  or  by  tumors 
pressing  down  from  above.  Enlarged  sella  may  be  due  to  adenoma  of  the 
anterior  lobe,  to  malignant  growth  of  the  fossa,  perhaps  to  repeated  physio- 
logical enlargement,  sometimes  to  general  or  local  hydrocephalus,  to  local  men- 
ingitis or  to  distant  brain  tumors  (V.  Z.  Cope,  in  "Lancet,"  1916,  cxc). 

Cope  says  that  if  the  dorsum  sellse,  or  anterior  or  posterior  clinoid  processes 
are  obliterated  or  definitely  absorbed  there  is  decided  intracranial  extension  of 
the  tumor  (Ibid.).  The  pituitary  body  may  be  subjected  to  pressure  from, 
or  become  involved  in,  tumors  of  the  region  about  it  or  tumors  or  cysts  may 
spring  from  it  directly.  Tumors  of  or  tumors  making  pressure  upon  the  hypo- 
physis may  in  some  cases  cause  acromegaly,  and  in  others  impotence,  genital  in- 
fantilism, a  tendency  to  fat  deposit  and  stunted  stature,  and  airenorrhea 
in  women.  There  is  intense  headache,  amblyopia  due  to  primary  atrophy  (no 
preceding  choked  disk) ,  appearing  often  as  a  bitemporal  hemianopsia  (Cushing, 
"Jour.  Amer.  Med.  Assoc,"  July  24,  1909).  In  some  cases  extreme  drowsiness 
has  been  noted,  and  in  some  cases  there  has  been  binasal  hemianopsia.  When 
there  is  stimulation  of  the  pituitary  (h3qDerpituitarism)  acromegaly  develops; 
when  there  is  lessened  secretion  (hypopituitarism)  there  are  obesity  and  genital 


92  2  Diseases  and  Injuries  of  the  Head 

atrophy.  In  hyperpituitarism,  dextrose  may  be  found  in  the  urine.  In  hypo- 
pituitarism there  may  be  polyuria  and  polydipsia  and  immense  increase  in 
carbohydrate  tolerance. 

Any  brain  tumor  which  causes  internal  hydrocephalus  may  thus  cause 
pressure  on  the  hypophysis  and  lead  to  the  development  of  hypophyseal  symp- 
toms. (For  full  information  regarding  the  hypophysis  see  the  classic  mono- 
graph by  Harvey  Gushing,  called  "The  Pituitary  Body  and  Its  Disorders")-' 

Treatment. — If  any  doubt  exists  as  to  the  existence  of  brain  syphilis,  and 
if  the  Wassermann  reaction  is  positive,  give  the  patient  a  dose  of  salvarsan 
(intravenously)  and  a  course  of  iodid  of  potassium.  Give  the  iodid  at  first  in 
small  amounts,  but  rapidly  increase  it  until  heroic  doses  are  taken  (loo  or 
more  grains  a  day).  Mercury  should  also  be  given  hypodermatically  or  by  in- 
unction. If  salvarsan,  iodid  of  potassium,  and  mercury  really  relieve  the  symp- 
toms, and  if  the  improvement  is  not  merely  temporary,  operation  is  unneces- 
sary, although  it  may  be  demanded  later  in  order  to  remove  an  irritant  scar. 
If  antisyphihtic  treatment  fails,  the  question  of  operation  must  be  considered. 
The  test  of  success  is  improvement  in  the  choked  disk.  If  this  improves,  the 
treatment  is  succeeding;  if  it  does  not,  the  treatment  is  a  failure.  It  should 
not  be  persisted  in  over  six  weeks  if  there  is  no  improvement  in  the  eye-grounds. 
To  delay  operation  further  may  mean  blindness.  We  must  always  bear  in 
mind  that  in  certain  cases  of  glioma  the  symptoms  temporarily  improve  under 
antisyphihtic  treatment.  The  term  operable  case  does  not  of  necessity  mean  a 
tumor  which  can  be  entirely  removed  by  operation.  Some  tumors  which  can 
be  only  partially  removed  should  be  operated  upon.  An  operable  case  is  one 
in  which  an  attempt  may  be  made  to  remove  the  tumor  and  in  which  the  tumor 
can  be  entirely  removed  or  in  which  a  part  can  be  removed,  the  removal  of 
this  part  promising  relief.  We  are  justified  in  being  radical,  because  without 
operation  a  brain  tumor  is  a  certainly  fatal  malady.  In  many  cases  of  un- 
doubted tumor  excision  for  cure  is  not  attempted  because  of  the  absence  of 
localizing  symptoms  or  because  of  the  inaccessible  situation  of  the  growth. 
In  all  cases  operation  is,  first  of  all,  exploratory.  Tumors  of  the  dura  which 
have  not  infiltrated  the  brain,  many  cortical  and  some  subcortical  growths, 
are  operable.  Gerebral  and  cerebellar  cysts  may  be  opened  and  drained  in 
hope  that  benefit  will  result.'  Tumors  of  the  lateral  lobe  of  the  cerebellum 
and  tumors  of  the  cerebellopontile  angle  have  been  removed.  Byron  Bram- 
well  maintains  that  tumors  at  the  base,  tumors  of  the  pons  and  medulla,  of 
the  corpus  callosum,  of  the  basal  ganglia,  and  of  the  deeper  parts  of  the  cen- 
trum ovale  are  irremovable.  Surgeons  now  regard  some  tumors  of  the  cerebello- 
pontile angle  as  operable,  but  agree  with  B  ram  well's  views  as  to  growths  in 
the  other  situations  he  mentions.  Frazier  has  concluded  that  "if  the  tumor 
is  found  to  be  very  vascular  and  of  the  infiltrating  type,  it  is  very  questionable 
.  .  .  as  to  whether  any  attempt  whatsoever  should  be  made  to  extirpate" 
("University  of  Penna.  Med.  Bull.,"  April-May,  1906),  and  with  this  opinion 
I  certainly  agree.  In  tumors  which  are  very  extensive  complete  removal  is 
usually  out  of  the  question.  There  is  no  use  in  removing  secondary  malignant 
tumors.  It  often  happens  that  the  brain  itself  (as  in  syphilis)  is  so  extensively 
diseased,  or  that  other  organs  (as  in  tuberculosis)  are  so  involved,  as  to  render 
attempts  at  removal  of  the  tumor  futile  or  actual  removal  useless.  Mills 
thinks  that  50  per  cent,  of  cerebellar  tumors  can  be  attacked  surgically  ("New 
York  and  Phila.  Med.  Jour.,"  Feb.  11-18,  1905).  He  classifies  operable  tumors 
of  the  cerebellum  as  follows:  i.  Tumors  situated  entirely  or  chiefly  in  the 
lateral  lobe.  2.  Tumors  upon  or  even  invading  a  part  of  the  vermis  or  middle 
lobe,     3.  Tumors  of  the  cerebello-oblongatopontile  angle.     The  most  favorable 

^  For  full  consideration  of  localizing  symptoms  see  particularly  the  writings  of  Gowers, 
Mills,  Allan  Starr,  Potts,  Lloyd,  Burr,  Dana,  Dercum,  Osier,  and  Gushing,  which  have  been 
freelv  used  in  the  above  section. 


Treatment  of  Intracranial   Tumors  923 

tumors  for  removal  are  fibromata  and  encapsuled  sarcomata.  Gliomata  and 
gliosarcomata  have  been  removed,  but  are  very  apt  to  return.  A  syphiloma 
requires  removal  as  truly  as  a  real  tumor.  The  cases  are  commonly  unfavorable, 
as  there  is  often  widespread  brain  disease.  The  same  is  true  of  tuberculoma. 
Among  inoperable  tumors  arc  most  gliomata  and  all  infiltrating  sarcomata, 
metastatic  tumors,  and  multiple  tumors.  BramwelP  tells  us  that  he  has  studied 
82  cases  of  intracranial  tumor,  and  he  considers  that  in  only  5  of  them  could 
the  tumor  have  been  entirely  removed.  In  157  reported  cases  the  tumor  was 
either  not  found  or  not  removed;  in  104  reported  cases  the  tumor  was  found, 
and  in  some  of  them  it  was  removed  (Ransohoflf,  in  "Jour.  Amer.  Med.  Assoc," 
Oct.  II,  1902).  The  conclusion  is  that  though  some  tumors  of  the  brain  may 
be  successfully  removed,  extirpation  is  feasible  in  only  a  small  minority  of 
cases  and  is  to  be  decided  on  only  after  careful  study  of  all  the  indications  and 
contra-indications  olfered  by  the  case.  When  about  to  operate,  apply  an  appa- 
ratus to  the  arm  and  take  the  blood-pressure  just  before  the  operation  and 
at  frequent  intervals  during  it.  Thus  by  noting  a  great  fall  in  blood-pressure 
the  surgeon  gets  early  warning  of  dangerous  shock,  learns  when  to  hasten,  and 
whether  or  not  the  operation  should  be  temporarily  abandoned  and  be  completed 
at  another  time  (two-stage  operation).  We  may  be  driven  to  abandon  operation 
after  cutting  the  bone  and  dural  flaps,  and  if  we  are  forced  to  stop,  we  restore 
the  bone  and  dura  to  position,  and  complete  the  operation  after  a  day  or  two. 
I  agree  with  Frazier  that  the  lessening  of  hemorrhage  by  temporarily  clamping 
the  common  carotids  in  the  neck  is  not  free  from  danger,  and  it  is  not  proper 
to  do  more  than  apply  Crile's  clamp  to  the  vessel  on  the  side  operated  upon. 
In  a  brain  tumor  when  the  dura  is  first  opened  there  is  usually  at  once  marked 
bulging  of  the  brain,  which  is  called  initial  bulging;  after  working  for  a  time  on 
a  brain,  even  when  there  is  no  tumor,  bulging  occurs  from  traumatic  edema,which 
is  called  consecutive  bulging.  That  consecutive  bulging  may  occur  is  a  sound 
reason  for  operating  rapidly  (Frazier).  The  mortality  from  tumor  operations  is 
large,  death  being  due  to  shock  and  hemorrhage.  Haas  collected  122  cases  in 
which  the  tumor  was  removed;  the  mortality  was  60  per  cent.  Operations 
completed  at  one  seance  give  a  larger  mortality  than  two-stage  operations. 
During  the  operation  an  erect  posture  causes  the  brain  to  recede  and  permits  of 
extensive  exploration  under  the  dura  (Ransohoff-Cushing).  The  same  thing  is 
accomplished  by  lumbar  puncture  (Gushing).  The  fibromata  constitute  the 
best  cases  for  operation.  In  operating  on  a  cerebral  tumor  make  a  large  osteo- 
plastic flap.  If  on  opening  the  dura  the  tumor  is  not  visible,  and  if  the  localiz- 
ing symptoms  have  been  reasonably  positive,  the  surgeon  is  justified  in  making  an 
exploratory  incision  through  the  cortex  to  see  if  there  is  a  subcortical  growth. 
Operations  for  cerebellar  tumors  are  peculiarly  diflicult  because  of  the  large 
blood  sinuses,  because  of  the  limited  space  through  which  one  must  work, 
because  of  the  great  bulging  after  the  dura  has  been  opened,  because  of  the  impos- 
sibility of  reaching  the  anterior,  mesial,  or  upper  surfaces  through  the  incision, 
because  of  the  liability  to  injure  the  pons  and  medulla,  and  because  of  the  difl&- 
culty  of  retracting  the  parts  (Frazier,  "New  York  and  Philadelphia  Med.  Jour.," 
Feb.  11-18,  1905).  In  approaching  tumors  which  are  not  ^^^thin  a  cerebellar 
hemisphere  by  a  one-sided  exposure  of  the  cerebellum,  it  may  be  best  to  remove 
a  considerable  portion  of  the  hemisphere  in  order  to  obtain  free  access  to  the 
growth.  I  prefer  Cushing's  "cross-bow"  incision  and  bilateral  exposure  (see 
Fig.  601).  This  enables  the  surgeon  to  dislocate  the  sound  lobe  outward  and  so 
obtain  room  to  work  upon  the. lobe  containing  the  tumor.  The  diagnosis  of 
cerebellar  tumor  is  usually  doubtful,  hence  practically  aU  operations  are  at  first 
exploratory  and  are  then  made  palliative  or  radical  as  the  case  demands. 
Operation  must  be  early  because  cerebellar  growths  quickly  cause  blindness. 
If  we  operate  for  cerebellar  tumor  and  find  nothing,  puncture  the  callosum  and 
1  ''Edinburgh  Med.  Jour.,"  June,  1S94. 


924  Diseases  and  Injuries  of  the  Head 

then  explore  the  fourth  ventricle  (Bassol,  "Arch.  f.  Psychiat.,"  1911,  xlviii). 
Cerebellar  operations  are  very  dangerous  particularly  because  of  the  sudden 
relief  of  pressure. 

In  tumor  of  the  cerebellopontile  angle,  the  usual  method  is  to  retract  a  lobe 
of  the  cerebellum  to  gain  access  to  the  growth.  Some  hold  that  the  mortality 
of  the  operation  is  70  per  cent,  or  over.  This  high  mortality  is  due  to  the  sudden 
relief  of  pressure,  to  hemorrhage,  to  contusion  of  the  brain  and  disturbances  of 
circulation  caused  by  retraction  of  the  lobe.  In  tumors  involving  the  acoustic 
nerve,  not  involving  the  cerebellopontile  angle  Zange  reaches  the  growth  by  a  trans- 
labyrinthine operation  ("Berlin,  klin.  Wochen.,"  1915,  lii).  It  would  seem  possi- 
ble to  remove  a  tumor  of  the  fourth  ventricle  if  it  arises  from  the  roof  and  many  do 
arise  from  the  roof.  Sir  Victor  Horsley,  McArthur,  Hochenegg,  vonEiselsberg, 
Gushing,  Frazier ,  and  others  have  operated  for  tumor  of  the  hypophysis.  Removal 
of  a  healthy  pituitary  body  from  dogs  is  sure  to  be  fatal,  as  the  gland  is  necessary 
to  the  life  of  the  dog.  Removal  of  a  healthy  pituitary  in  man  would  in  all  proba- 
bility prove  fatal.  The  entire  anterior  lobe  should  not  be  removed.  If  the 
tumor  is  associated  with  acromegaly,  removal  of  the  tumor  may  arrest  the 
acromegaly.  One  route  of  approach  to  the  hypophysis  is  from  the  side,  just 
as  we  reach  the  Gasserian  ganglion  (Garton,  Paul,  Horsley).  Another  route  is  by 
way  of  osteoplastic  frontal  resection,  the  longitudinal  sinus  being  ligated  and  the 
frontal  lobes  lifted  (Krause,  Hartley,  Borchardt).  Another  method  involves 
osteoplasic  resection  of  the  anterior  wall  of  the  frontal  sinus  and  nose.  This  is 
called  the  transphenoidal  route.  The  transphenoidal  route  has  been  variously 
modified.  Gushing's  plan  of  approach  through  a  sublabial  incision  is  described 
on  page  940.  Though  thorough  extirpation  of  a  brain  tumor  is  feasible  in  only  a 
minority  of  cases,  operation  should  often  be  performed  for  palliative  purposes 
when  the  tumor  cannot  be  located,  when  it  is  in  a  region  from  which  it  cannot 
be  removed,  or  when  its  nature  forbids  removal.  Grainger  Stewart,  Annandale, 
Horsley,  Macewen,  Gushing,  and  Keen  have  advocated  palliative  trephining 
in  certain  cases.  Simple  trephining  is  of  Httle  value.  In  order  to  really  relieve 
pressure  the  dura  must  be  opened  and  left  unsutured,  so  that  hernia  cerebri 
may  follow.  Gushing  has  had  some  cases  of  extraordinary  improvement  in 
cases  of  cerebral  tumor  after  trephining  in  the  right  temporal  region  and  remov- 
ing a  piece  of  the  dura.  The  operation  is  called  by  Gushing  a  decompression 
operation.  The  brain  bulges  through  the  dural  opening,  but  the  dense  temporal 
fascia  stitched  together  over  it  prevents  fungation.  It  is  the  temporosphenoidal 
lobe  that  bulges,  and  the  right  side  is  selected  because  word-deafness  might 
ensue  if  the  operation  were  done  on  the  left  side.  I  have  seen  several  of  Gush- 
ing's cases.  One  of  them,  a  colored  man,  had  been  almost  blind  for  some  time, 
and  was  unconscious  and  had  rapidly  failing  respiration  when  the  operation 
was  performed.  He  was  so  much  benefited  that  he  returned  to  work  and  has 
useful  vision  and  no  pain.  I  have  had  several  very  gratifying  results  in  my  own 
practice.  A  decompression  may,  in  rare  cases,  cause  a  glioma  to  degenerate 
and  pass  away.  Horsley  saw  such  a  case.  In  cases  of  cerebral  tumor  subtem- 
poral decompression,  and  in  cases  of  cerebellar  tumor  suboccipital  decom- 
pression, may  be  performed.  Sir  Victor  Horsley  believes  that  the  opening  for 
decompression  should  be  near  the  tumor  and  not  always  in  the  subtemporal 
region.  He  beUeves  an  opening  near  the  tumor  possesses  the  advantage  of 
aiding  us  later  if  the  tumor  should  become  operable.  He  maintains  that 
subtemporal  decompression  may  later  confuse  the  localizing  symptoms  should 
such  symptoms  develop. 

Decompression  may  relieve  choked  disk  and  thus  retard  or  prevent  optic 
atrophy  and  blindness.  Gushing  demonstrates  that  intracerebral  pressure  is 
the  chief  element  in  choked  disk. 

This  procedure  is  of  value  in  diminishing  excessive  intracranial  pressure, 


Operative  Treatment  of  Epilepsy  925 

and  thus  relieving  headache  and  choked  disk,  and  decreasing  the  tendency 
to  sudden  death  from  inhibition  of  the  heart  or  from  respiratory  failure.  The 
usual  method  of  decompression  will  not  relieve  the  headache  caused  by  tumor 
of  the  hypophysis.  This  headache  is  due  to  distention  of  the  dural  box  in  which 
the  gland  is  placed,  and  can  be  reheved  only  by  incision  into  the  dural  box  (Harvey 
Gushing,  ''Jour.  Amer.  Med.  Assoc,"  July  24,  1909). 

We  conclude  that  in  most  cases  of  brain  tumor  operation  should  be  per- 
formed for  exploration;  in  some  cases  extirpation  may  be  performed;  in  most 
cases  extirpation  is  impossible,  and  the  surgeon  must  be  content  with  the  pallia- 
tive influence  of  Cushing's  decompression  operation.  A  tumor  of  the  brain  if 
not  cured  by  antisyphilitic  treatment  is  of  necessity  fatal  if  unoperated  upon, 
and  exploratory  operation  is  not  very  dangerous. 

Thorburn  ("Med.  Chronicle,"  1914,  lix)  tabulated  490  cases  of  operation  for 
brain  tumor.  In  nearly  40  per  cent,  of  the  cases  the  operation  was  useless 
and  in  some  of  them  it  hastened  death.  In  nearly  24  per  cent,  of  cases  it  cured 
the  patient  or  at  least  prolonged  life  greatly.  In  over  38  per  cent,  the  value  of 
the  operation  was  uncertain.  Thorburn  takes  the  ground  that  most  brain  tumors 
are  malignant  and  that  the  surgeon  seldom  aims  at  cure  but  in  most  cases  simply 
seeks  to  prolong  hfe,  prevent  blindness  and  abolish  headache.  Operations 
which  expose  the  surface  have  little  danger.  Operations  involving  brain  sub- 
stance are  very  dangerous.  Heuer  and  Dandy  ("Bull.  Johns  Hopkins  Hospi- 
tal," 1916,  xxvii)  report  upon  62  cases  of  brain  tumor  operated  upon  in  Prof . 
Halsted's  clinic.  On  these  62  cases  71  operations  were  performed.  Six  deaths 
occurred  within  twenty-four  hours  to  five  days  of  the  operation,  an  operative 
mortality  of  8.6  per  cent.  Two  cases  died  later.  Including  these  the  total 
operative  mortality  was  11  per  cent.     No  patient  died  upon  the  table. 

In  a  case  of  brain  tumor  if  operation  is  refused,  if  extirpation  is  impossible, 
or  if  decompression  fails,  it  may  be  necessary  to  use  the  bromids  for  convul- 
sions and  morphin  for  headache.  The  headache  is  often  benefited  by  pur- 
gatives, courses  of  potassium  iodid,  and  the  ice-bag  to  the  head. 

Operative  Treatment  of  Epilepsy. — The  shock  of  an  accident  or  a 
cerebral  concussion  may  establish  epilepsy,  especially  in  those  predisposed 
by  heredity  or  other  causes.  Traumatic  epilepsy,  Le  Dentu^  tells  us,  may 
be  due  to:  (i)  Bone-fragments  from  skull  fracture;  (2)  outgrowths  of  bone 
due  to  tumor;  (3)  cicatrices  of  meninges  resulting  from  laceration  of  mem- 
branes by  bone-fragments;  (4)  chronic  meningitis  which  ends  in  sclerosis 
of  membranes;  (5)  cysts  resulting  from  intracranial  hemorrhage  at  the  point 
of  fracture;  (6)  arteriovenous  aneurysm.  We  would  add:  (7)  tumors  of  the 
brain;  (8)  sclerosis  of  the  cortex.  We  refer  here,  in  speaking  of  traumatic 
epilepsy,  purely  to  the  condition  when  it  follows  a  head  injury,  and  this  is 
the  common  meaning  of  the  term.  Remember  that  epilepsy,  as  shown  by 
Sachs,  may  follow  a  long-forgotten  injury.  Before  undertaking  a  brain  opera- 
tion for  epilepsy  it  is  a  sound  rule  to  remove  all  sources  of  definite  peripheral 
irritation.  I  have  seen  apparent  cure  follow  the  removal  of  a  tender  cicatrix 
and  follow  circumcision  of  a  patient  with  phimosis.  Briggs  reported  a 
case  of  epilepsy  in  which  there  was  a  distinct  depression  of  a  portion  of  the 
skull.  There  was  also  necrosis  of  the  tibia,  and  after  the  cure  of  the  necrosis 
the  convulsions  ceased.  The  removal  of  supposed  peripheral  irritation,  how- 
ever, is  only  occasionally  beneficial.  Are  operations  upon  the  skull  and  brain 
curative?  Surgeons  are  much  less  enthusiastic  than  they  were  a  few  years 
ago.  I  believe  operation  can  cure  less  than  5  per  cent,  of  cases,  but  it  is  im- 
portant to  remember  that  in  some  cases  in  which  operation  seems  to  have 
failed  medical  treatment  becomes  much  more  efficient  than  it  was  before  the 
operation.  The  high  rate  of  cure  (70  per  cent.)  once  claimed  for  operations 
was  due  to  failing  to  follow  the  patient  sufficiently  long.  A  patient  should 
^  "La  Presse  medicale,"  June  9,  1894. 


926  Diseases  untl  Injuries  of  the  Head 

not  be  reported  as  cured  until  at  least  three  years  or,  better,  five  years  have 
passed  without  any  evidence  of  the  disease.  Another  source  of  error  was  a 
failure  to  understand  that  any  traumatism  may  improve  epilepsy  for  a  time. 
"The  administering  of  an  anesthetic,  the  shock  of  an  injury,  the  traumatism 
of  an  operation,  just  like  a  febrile  seizure,  may  interrupt  an  epileptic  habit 
and  cause  a  patient  to  go  for  weeks  or  months  without  an  attack"  (the  author, 
in  "Medicine,"  Feb.,  1904). 

Operation  must  never  be  indiscriminately  applied.  In  some  cases  it  gives 
hope  of  relief,  in  others  it  is  obvious  that  it  would  be  utterly  futile.  In  order 
to  determine  if  a  case  is  or  is  not  suitable  for  operation  it  must  be  studied 
with  great  care.  The  history  must  be  carefully  obtained,  particularly  as  to 
hereditary  predisposition,  the  first  convulsion,  and  its  supposed  cause.  The 
question  of  injury,  recent  or  old,  should  be  thoroughly  investigated,  and  it 
is  a  sound  rule  to  have  the  head  shaved  and  then  examine  for  a  scar  and  for  a 
depression.  Convulsive  seizures  must  be  studied  by  an  expert,  hence  the  patient 
should  be  in  a  hospital,  constantly  watched  by  a  trained  nurse,  until  one  or  two 
fits  have  occurred.  The  nurse  watches  the  convulsion  and  describes  it  in 
writing,  noting  particularly  if  it  had  a  local  beginning.  The  general  health 
must  be  investigated.     An  .r-ray  should  be  taken. 

I  am  accustomed,  for  surgical  purposes,  to  make  the  following  classification 
of  epilepsy.  It  is  a  modification  of  Sir  Victor  Horsley's  classification  (the 
author,  in  "Medicine,"  Feb.,  1904): 

1.  Reflex  epilepsy,  the  surgical  treatment  of  which  I  shall  not  discuss  in 
detail. 

2.  The  common  non-traumatic,  idiopathic,  or  essential  epilepsy,  in  which 
the  attacks  are  general  and  are  without  a  local  onset. 

3.  Idiopathic  epilepsy  with  a  local  onset  of  attacks  (focal  or  Jacksonian 
epilepsy). 

4.  Traumatic  epilepsy.  This  may  be  subdivided  into  two  forms:  {a) 
attacks  without  a  local  onset,  and  {b)  attacks  with  a  local  onset  (focal  or  Jack- 
sonian epilepsy). 

5.  Jacksonian  epilepsy  due  to  gross  brain  disease  (tumor,  aneurysm,  etc.). 

6.  Epilepsy  following  infantile  cerebral  palsy. 

7.  The  posthemiplegic  epilepsy  of  adults. 

1.  Reflex  Epilepsy. — Remove  the  supposed  cause  of  irritation.  When 
epilepsy  follows  traumatism  and  a  scar  is  found  on  the  scalp,  excise  the  scar. 
This  is  an  imperative  duty  if  the  scar  is  tender  or  the  seat  of  an  aura. 

2.  Essential  or  Idiopathic  Epilepsy. — Operation  upon  the  brain  is  useless. 
If  persistent  headache  exists,  it  may  be  proper  to  trephine  and  open  the  dura 
for  exploration.  Such  an  operation  is  done  to  relieve  headache.  Some 
claim  remarkable  results  from  bilateral  excision  of  the  cervical  ganglia  of  the 
sympathetic  (see  page  854).  The  operation  is  a  theoretical  one  and  of  doubtful 
utility.  It  was  founded  upon  a  misconception  as  to  the  cause  of  epilepsy, 
and  favorable  reports  are  no  more  favorable  than  have  been  set  forth  regarding 
various  other  now  abandoned  procedures. 

3.  Idiopathic  Epilepsy  with  Local  Onset  of  Attacks  {Focal  or  Jacksonian 
Epilepsy). — Many  of  these  cases  begin  in  young  children  who  have  had  infan- 
tile palsy,  the  traces  of  the  palsy  having  disappeared.  In  such  cases  the  con- 
vulsions may  begin  on  one  side,  and,  in  fact,  may  be  nearly  limited  to  one  side. 
If,  from  the  very  beginning,  the  attacks  began  in  one  group  of  muscles  or  in 
one  extremity,  whether  or  not  they  spread  to  the  rest  of  the  body,  and  if  the 
case  is  seen  within  two  years  of  the  first  attack,  the  surgeon  is  justified  in  ex- 
posing the  brain  and  excising  the  irritated  portion  of  cortex.  This  operation, 
it  is  true,  cures  very  few  cases,  but  it  benefits  many  for  a  considerable  time 
and  seems  to  make  them  more  amenable  to  medical  treatment.  In  the  vast 
majority  of  cases  fits  recur,  but  rarely  as  severely  as  before.     After  fits  have 


Traumatic  Epileps}-  927 

been  going  on  for  two  years  operation  offers  no  prospect  of  cure,  as  the  associa- 
tion fibers  have  surely  degenerated.  But,  even  in  very  old  cases,  if  the  attacks 
are  frequently  repeated  and  thus  threaten  life,  the  excited  center  should  be 
removed  to  save  life. 

In  cortical  excision  more  of  the  cortex  than  the  excited  center  is  of  neces- 
sity removed,  because,  in  order  to  get  the  entire  center,  we  must  go  wide  of 
it.  Paralysis  of  the  parts  controlled  by  the  extirpated  cortical  area  follows. 
The  paralysis  is  seldom  permanent  except  to  the  finer  movements.  The 
operation  gives  the  best  prognosis  in  young  persons,  and  when  done  early 
in  the  case.  The  return  of  fits  after  apparent  cure  is  thought  to  be  due,  at 
least  in  some  cases,  to  the  formation  of  adhesions  between  the  brain  and  its 
membranes.  Various  unsatisfactory  attempts  have  been  made  to  prevent 
adhesion  by  the  insertion  of  silver-foil,  gold-foil,  rubber  tissue,  egg-shell  mem- 
brane, and  Cargile  membrane.  In  operating  for  cortical  epilepsy  a  large 
osteoplastic  flap  is  required.  In  the  previous  remarks  we  dealt  with  partial 
epilepsy  and  with  generalized  epilepsy  in  which,  from  the  first,  the  attacks 
had  a  local  beginning.  If  cases  of  apparent  idiopathic  epilepsy  develop  Jack- 
sonian  attacks  (attacks  with  a  local  beginning),  it  is  useless  to  excise  the  cortex. 
The  entire  cortex  is  diseased,  though  one  region  is  particularly  unstable. 

4.  Traumatic  Epilepsy. — Always  remember  the  origin  of  epilepsy  subsequent 
to  a  traumatism  may  be  a  coincidence;  the  condition  may  be  essential  epilepsy 
and  the  traumatism  may  have  had  nothing  to  do  with  it.  Epilepsy  ensuing 
upon  traumatism  may  not  begin  until  months  or  even  several  years  after  the 
injury.  In  the  earliest  attacks  consciousness  may  or  may  not  be  lost.  The 
causative  injury  may  have  been  slight  or  severe.  "An  injury  may  cause  a 
hemorrhage  or  a  depressed  fracture;  may  be  followed  by  a  scar  upon  the  mem- 
branes; may  occasionally  lead  to  the  development  of  an  innocent  or  malignant 
tumor  or  a  cyst,  or  may  merely  induce  some  trivial  change  in  the  subtle  chemis- 
try of  the  nerve-cells"  (the  author,  in  "Medicine,"  Feb.,  1904).  Injury  may 
produce  general  epilepsy  or  Jacksonian  epilepsy.  If  an  identified  traumatism 
exists,  the  surgeon  should  operate  even  after  years.  When  the  traumatism 
has  not  left  definite  evidence,  the  surgeon  is  justified  in  making  an  exploration 
any  time  up  to  the  termination  of  the  third  year  after  the  accident.  The  earlier 
the  operation,  the  better  the  prognosis.  The  best  prognosis  of  any  form  of 
epilepsy  is  given' by  Jacksonian  epilepsy  of  traumatic  origin. 

"In  focal  epilepsy  with  evidences  of  skull  injury  or  depression,  trephining 
is  imperative  and  somewhat  promising.  The  dura  should  invariably  be  opened, 
even  if  it  seems  in  good  condition.  A  dural  scar  should  be  extirpated.  The 
brain  should  be  examined  by  sight  and  by  touch,  and  should  be  explored  with 
the  little  finger  and  with  the  dural  separator  to  well  beyond  the  limits  of  the 
opening  in  the  dura.  If  a  tumor  is  found,  it  should  be  removed;  if  a  scar  upon 
the  brain  exists,  it  shouid  be  extirpated;  if  a  cyst  is  discovered,  it  should  be 
drained;  and  if  there  is  any  obviously  damaged  area  in  the  brain  tissue,  it 
should  be  unhesitatingly  cleared  away.  If  nothing  obvious  is  found  on  ex- 
ploration, and  if  the  attacks  have  been  distinctly  local  in  origin,  it  is  justifiable 
to  extirpate  the  motor  center  from  which  the  discharge  seems  to  originate. 

"When  Jacksonian  epilepsy  has  followed  an  injury  in  the  motor  region, 
the  chances  of  effecting  a  cure  are  much  better  than  they  are  when  the  epilepsy 
has  followed  an  injury  in  the  sensory  region.  When  it  has  followed  an  injury 
in  the  frontal  region,  operation  affords  very  little  hope  of  cure. 

"When  the  condition  is  not  focal  but  essential  epilepsy,  the  surgeon  will 
remove  a  scalp  scar;  and  if  there  is  any  evidence  of  bone  injury,  he  will  tre- 
phine the  bone,  open  the  dura,  and  explore  the  brain.  It  is  needless  to  say, 
however,  that  in  such  a  case  he  will  not  extirpate  any  of  the  cortex. 

"In  cases  of  focal  epilepsy  I  use  the  osteoplastic  method  of  operating. 
In  cases  of  generalized  epilepsy  I  use  the  simple  trephine  and  leave  the  button 


928  Diseases  and  Injuries  of  the  Head 

of  bone  out,  as  a  means  of  effecting  a  prolonged  modification  in  the  intra- 
cerebral pressure"  (the  author,  in  "Medicine,"  Feb.,  1904). 

Bramwell  maintains  that  when  traumatism  is  followed  by  epilepsy  and 
the  epileptic  discharge  starts  from  a  cortical  center  which  is  not  beneath  the 
scar,  the  surgeon  should  trephine  first  at  the  seat  of  injury,  and  if  this  fails, 
he  should  trephine  over  the  excited  center. 

5.  Jacksonian  Epilepsy  Due  to  Gross  Brain  Disease. — The  treatment 
of  this  condition  is  the  treatment  of  the  brain  disease. 

6.  Epilepsy  Following  Infantile  Cerebral  Palsy. — In  this  group  of  cases 
the  palsy  is  manifest.  It  is  justifiable  to  operate  upon  a  child,  but  not  later  in 
life.     The  prospect  of  benefit  is  poor  even  in  a  child. 

7.  The  Posthemiplegic  Epilepsy  of  Adults. — Operation  is  useless. 

Our  conclusions  are  that  these  operations  sometimes  seem  to  cure  epilepsy, 
but  so,  occasionally,  does  any  operation.  White^  records  90  trephinings  in 
which,  though  no  cause  was  found  for  the  epilepsy,  great  relief  followed,  and 
2  cases  were  apparently  cured;  he  mentions  benefit  or  apparent  cure  fol- 
lowing tracheotomy,  ligation  of  the  carotid  artery,  incision  of  the  scalp,  etc. 
The  same  effect  may  be  obtained  by  a  great  shock,  high  fever,  the  adminis- 
tration of  an  anesthetic,  or  an  accident.  The  fact  seems  to  be  that  any  opera- 
tion, by  means  of  nervous  shock,  may  interrupt  the  epileptic  habit;  but  in 
ordinary  operations  the  fits  tend  after  a  time  to  recur  and  soon  reach  their 
old  standard  of  frequency.  In  the  special  brain  operations  with  removal  of 
obvious  lesions  or  extirpation  of  discharging  centers  the  fits  usually  recur, 
but  they  will  rarely  reach  the  old  standard  of  frequency,  and  will  be  more 
amenable  to  medical  treatment. 

In  non-traumatic  chronic  epilepsy  without  locaHzing  symptoms  trephining 
is  not  justifiable  unless  persistent  headache  calls  for  it  as  a  means  of  relief 
from  intracranial  pressure.  Annandale  advised  us  to  consider  experimental 
operation  in  such  cases  when  the  drug-treatment  has  failed  and  when  the 
patient's  condition  seems  hopeless.  He  says  there  is  no  chance  of  improvement 
without  operation,  and  operation  may  possibly  disclose  a  removable  lesion.^ 
After  trephining  for  epilepsy  five  years  should  elapse  without  a  convulsion 
before  cure  is  reasonably  assured;  and  if  convulsions  arise,  they  must  at  once 
be  met  by  medical  treatment.  A  man  having  once  had  a  convulsion  may 
at  any  time  have  others;  hence  he  should  always  be  watched.  It  is  not 
unusual  for  a  few  convulsions  to  occur  soon  after  an  operation  for  epilepsy, 
and  then  to  cease  for  a  considerable  time.  These  early  fits  result  from  habit 
{habit  fits).  Among  the  operative  procedures  suggested  for  the  treatment  of 
epilepsy  may  be  mentioned  circumcision,  clitoridectomy,  ocular  tenotomy,  liga- 
tion of  the  vertebral  arteries,  removal  of  the  cervical  ganglia  of  the  sym- 
pathetic (see  page  854)  (Alexander,  Jonnesco,  Jaboulay),  the  actual  cautery 
to  the  head  (Fere),  puncture  of  the  corpus  callosum,  drainage  of  a  lateral 
ventricle,  and  appendicostomy.  Dr.  Charles  L.  Reed  is  convinced  that  epilepsy 
is  a  chronic  convulsive  toxemia  and  bears  a  constant  relation  to  constipation 
due  to  mechanical  causes  and  associated  with  acidosis.  In  severe  cases  or 
cases  of  long  standing  he  finds  conservative  treatment  of  little  avail  and  operates. 
"The  local  conditions  may  require  parietal  implantation  of  the  colon  with 
or  without  either  appendicostomy  or  cecostomy;  an  ileosigmoidostomy  sup- 
plemented by  either  an  anatomical  or  a  physiological  colectomy;  or  a  resection 
may  be  required"  ("Medical  Herald,"  Feb.,  191 7). 

Operative  Treatment  of  Insanity. — (See  the  author,  in  "Journal  of 
Nervous  and  Mental  Diseases,"  June,  1904.) 

I.  Epileptic  Insanity. — The  conditions  which  call  for  operation  on  a  non- 
insane  epileptic  (see  page  926)  call  for  it  on  an  insane  epileptic.     It  is  sometimes 

^  "The  Supposed  Curative  Effects  of  Operations  per  se."  "Annals  of  Surgery,"  Aug.  and 
Sept.,  1891. 

^  "Edinburgh  Med.  Jour.,"  April,  1894. 


Operations  for  Traumatic  Insanity  929 

justifiable  to  operate  if  there  has  been  a  head  injury,  and  operation  may  lessen 
the  number  and  diminish  the  violence  of  the  attacks.  If  focal  seizures  exist, 
we  may  proceed  as  for  focal  seizures  in  the  sane.  In  status  epilepticus  we 
mav  operate  to  relieve  pressure.  It  will  be  observed  that  operation  is  for  the 
convulsions  and  not  for  the  insanity. 

2.  Paresis. — I  do  not  advocate  operation  in  paresis.  If  we  believe  in 
traumatic  paresis,  we  may  be  inclined  to  advise  operation.  Personally  I  do 
not  believe  that  genuine  paresis  is  ever  cured;  the  lesions  of  the  disease  are 
widelv  disseminated;  the  pons,  medulla,  and  even  the  cord  may  be  diseased 
and  the  lesions  cannot  be  removed. 

3.  Non-traumatic  Insanity  and  Paranoia. — Operation  cannot  cure  the 
insanity  and  is  not  to  be  advised. 

4.  Hypochondriacal  Delusions. — Operation  is  useless.  Some  practice  it 
with  the  idea  of  getting  rid  of  a  delusion  by  remo\dng  a  part  to  which  the 
attention  is  directed.  Such  attempts  always  fail,  because  it  is  the  insanity 
which  causes  the  delusion,  not  the  delusion  which  causes  the  insanity. 

5.  Operations  for  Traumatic  Insanity. — A  psychosis  constructed  on  the 
basis  of  a  traumatic  neurosis  never  calls  for  operation.  The  only  cases  in 
which  operation  is  ever  justifiable  are  those  in  which  traumatism  is  the  direct 
cause.  Insanity  may  begin  at  once  or  soon  after  an  injury,  but  is  often  unrecog- 
nized for  weeks  or  even  months.  Nearly  all  of  these  cases  are  predisposed 
to  insanity  and  the  injury  has  been  only  an  exciting  cause.  Traumatism 
is  the  direct  cause  in  about  2  per  cent,  of  cases  of  insanity. 

'"An  antecedent  injury  may  have  directly  induced  the  alienation;  it  may 
have  had  no  bearing  at  all  upon  the  latter;  or  it  may  have  produced  an  insanity 
by  fear  and  shock,  and  not  b}-  creating  a  direct  brain  lesion.  Again,  the 
head  injury,  by  increasing  the  individual's  susceptibihty  to  alcohol  and  to 
the  effects  of  the  sun,  may,  if  this  person  drinks  alcohol  or  exposes  himself  to 
the  rays  of  the  sun,  be  indirectly  resonsible  for  lunacy. 

"In  insanity  following  an  injury  to  the  head  there  may  be  various  sup- 
posed causative  lesions:  A  fracture  of  the  skull,  with  or  without  depression; 
the  development  of  an  exostosis;  sclerosis  or  softening  of  the  cortex;  edema 
of  the  membranes  or  of  the  brain  itself;  cerebral  hj^Deremia  or  congestion; 
thickening  of  the  membranes;  adhesion  of  the  membranes  to  the  skuU,  to 
each  other,  or  to  the  brain;  new  growth;  inflammation  of  the  membranes; 
or  minute,  slowly  developing,  widespread  nutritive  changes.  The  injury 
may  be  assumed  to  be  the  cause  of  the  insanity  if  the  insane  condition  becomes 
manifest  almost  at  once  or  soon  after  the  accident;  but  if  the  symptoms  do 
not  appear  until  long  after  the  accident  the  traumatism  may  be  considered 
to  be  the  directly  exciting  cause  in  some  cases,  and  not  in  others.  It  may  be 
blamed  if,  between  the  time  of  the  accident  and  the  appearance  of  the  insanity, 
there  has  been  a  marked  change  in  the  patient's  disposition,  temperament, 
or  character;  if  he  has  developed  headache,  insomnia,  irritability,  passionate 
outbreaks  of  temper,  moodiness,  or  lapses  of  memory;  if  he  has  plunged  into 
immorality  or  excesses  in  alcohol;  if  he  has  displayed  a  tendency  to  neglect 
business  or  family  obligations,  and  if  he  has  showm  increased  susceptibility 
to  alcohol  and  to  the  sun.  Sometimes  epilepsy  may  develop  during  this 
period  (Richardson,  'American  Journal  of  Insanity,'  July,  1903.  The 
author's  'Address  on  Surgery,'  delivered  before  the  meeting  of  the  Medical 
Society  of  the  State  of  Pennsylvania,  May  iS,  1897).  If  there  was  none  of 
these  intermediate  changes  in  the  normal  mode  of  thinking  and  way  of  acting, 
one  cannot  count  the  traumatism  as  causative.  Many  persons  that  have 
received  severe  head  injuries  have  shown  these  changes,  but  have  never  gone 
insane.  I  have  been  studj-ing  this  point  for  a  number  of  years,  and  have 
decided  that  quite  a  few  patients  that  have  been  trephined  for  fracture  or 
for  meningeal  hemorrhage  have  subsequently  shown  pronounced  and  per- 

59 


930  Diseases  and  Injuries  of  the  Head 

manent  changes  in  character  and  disposition.  Of  the  number  that  show 
such  changes,  many  never  go  insane,  but  some  do.  Such  an  insanity  is  distinctly 
traumatic  in  origin  "  (the  author,  in  "  Journal  of  Nervous  and  Mental  Diseases," 
June,  1904).  The  prognosis  is  very  unfavorable;  some  recover  sanity  after 
operation,  many  do  not.  Some  recover  sanity  without  operation.  Sometimes 
operation  cures  by  removing  a  lesion;  sometimes  by  shock,  etc.  Some  cures 
following  operation  did  not  result  from  the  operation. 

On  what  cases  should  we  operate? 

We  should  operate  on  cases  "in  which  insanity  has  soon  followed  a  head 
injury.  If  the  site  of  the  trauma  is  indicated  by  a  scar,  a  depression  of  bone, 
local  tenderness,  fixed  headache,  or  some  localizing  symptom — motor  or  sensory 
— operation  should  positively  be  undertaken.  In  a  case  in  which  the  insanity 
has  developed  later,  in  which  the  intermediate  period  between  the  injury  and 
the  development  of  the  insanity  has  shown  the  change  from  the  normal  mode 
of  thinking  and  way  of  acting  previously  alluded  to,  and  in  which  the  site  of 
trauma  is  indicated  by  any  of  the  evidences  mentioned  above — operation 
should  positively  be  performed.  One  should  not  operate  upon  a  case  simply 
because  there  is  a  dubious  record  of  an  antecedent  fall  or  blow,  which  merely 
suggests  the  possibility  of  a  traumatic  origin  for  the  insanity.  In  any  case 
in  which  there  are  positive  signs  of  increased  pressure  it  may  be  considered 
proper  to  trephine  as  a  palliative  measure"  (the  author,  Ibid.). 

Abdominal,  Gynecological,  and  Genito-urinary  Operations.-^If  an  insane 
person  has  a  disease  which  is  dangerous  to  life  or  which  is  productive  of  pain, 
discomfort,  or  ill  health,  he  or  she  is  entitled  to  be  cured,  if  possible,  by  a  surgical 
operation.  The  removal  of  pain  and  other  depressing  influences  may  result 
in  great  improvement  in  the  general  health  and  in  notable  mental  improve- 
ment. The  operation  may  thus  indirectly  exercise  a  beneficial  influence  on  the 
insanity,  but  the  influence  is  not  direct  and  it  is  never  justifiable  to  do  such 
an  operation  as  oophorectomy  upon  an  insane  woman  unless  the  condition  of 
the  ovaries  would  call  for  it  in  one  not  insane. 

Operations  on  the  Skull  and  Brain. — As  a  preliminary  it  is  well  to 
note  that  urotropin  (hexamethylenamin)  given  by  the  mouth  quickly  appears 
in  the  cerebrospinal  fluid,  and  that  the  fluid  contains  the  maximum  amount 
in  from  one-half  hour  to  an  hour  after  ingestion.  The  presence  of  this  drug  de- 
cidely  inhibits  the  growth  of  bacteria  in  the  fluid.  This  is  Crowe's  discovery. 
We  believe  it  wise  to  give  this  drug  in  all  cases  in  which  meningitis  is  threat- 
ened or  exists  (S.  J.  Crowe,  in  "Johns  Hopkins  Hospital  Bulletin,"  April, 
1909).  It  should  be  given  for  twenty-four  hours  preceding  and  for  several 
days  after  an  operation  upon  the  brain  or  spinal  cord.  From  40  to  60  gr.  a 
day  are  given  by  mouth.  Cushing  has  subjected  this  drug  to  the  severest 
test  in  his  operations  to  reach  the  pituitary  body.  He  gave  60  gr.  a  day  of  this 
drug  "on  the  day  preceding  and  for  some  days  after  the  operation"  ("The 
Pituitary  Body  and  Its  Disorders,"  by  Harvey  Cushing).  After  33  trans- 
sphenoidal operations  there  were  2  cases  of  meningitis.  One  of  these  cases 
(which  was  inaugurated  by  violent  sneezing)  was  fatal.  Cushing  now  does 
much  work  upon  the  skull  and  brain  \\ath  the  aid  of  local  anesthesia.  He 
beUeves  that  any  watery  solution  damages  brain  tissue  and  in  cases  requiring 
the  direct  appUcation  of  an  antiseptic  employs  dichloramin-T. 

Trephining  for  a  Fracture  of  the  Skull. — The  patient  should  be  anes- 
thetized unless  he  is  unconscious,  and  should  be  placed  upon  the  back  with 
the  shoulders  a  little  raised.  A  sand-pillow  is  placed  under  the  neck,  and 
his  head  is  turned  away  from  the  side  to  be  operated  upon.  The  position 
of  the  surgeon  is  such  that  the  patient's  head  is  a  httle  to  his  left.  A  large 
semilunar  incision  is  made  with  the  base  down,  which  incision  goes  through 
the  periosteum,  and  the  flap  is  lifted.  The  bleeding  vessels  of  the  flap  are 
caught  by  forceps.     The  fracture  is  sought  for  and  found.     The  pin  of  the  tre- 


Trephining  for  a  Fracture  of  the  Skull 


931 


Fig.  590. — Gait's  conical  trephine. 


phine  is  projecled  beyond  the  crown  and  is  set  upon  sound  bone,  the  crown 
overhanging  the  line  or  edge  of  the  fracture.  The  surgeon  tries  to  avoid  the 
region  of  a  sinus  or  large  artery.  A  gutter  is  cut  in  the  bone,  the  pin  of  the  in- 
strument is  withdrawn,  and  the  trephining  is  completed.  In  going  through  the 
diploe  bleeding  is  copious.  In  a  young  child  the  diploe  may  be  absent. 
The  inner  table  feels  very  dense.  Stop  from  time  to  time,  clean  out  the  gutter 
in  the  bone  with  gauze,  and  try  the  bone  with  an  elevator  to  see  if  it  is  loose. 
In  an  old  person  the  skull  may  be  much  thinned  by  absorption.  Bear  in  mind 
Holden's  valuable  admonition: 
"Think  that  you  are  operating  on 
the  thinnest  skull  ever  seen,  and 
thinner  in  one  portion  of  the  circle 
than  the  other."  When  the  frag- 
ment is  loose  enough,  pry  it  out.  If 
the   surgeon    desires   to  replace  the 

button,  hand  it  to  an  assistant,  who  places  it  at  once  in  a  bowl  of  warm  normal 
salt  solution,  kept  warm  by  standing  in  a  basin  of  water  at  105°  F.,  or  in  warm 
carbolized  towels.  The  edges  of  the  opening  should  be  rounded  by  a  rongeur, 
and  the  bone,  If  depressed,  must  be  elevated.  Sometimes  it  may  be  necessary 
to  remove  splinters  and  fragments  of  bone.  After  removing  the  fragments 
the  edges  of  the  opening  should  be  smoothed  by  the  use  of  the  rongeur  forceps. 
The  dura  should  be  examined  to  see  if  injury  exists,  and  hemorrhage  must  be 
stopped.     Bleeding  from  the  dura  is  arrested  by  passing  a  ligature  of  silk  or 

catgut  threaded  in  a  small  curved 
— -F«  needle  under  the  vessel  on  each 

^  1  nsHBffi^HBBH  side  01  the  wound,  and  tying  the 

ligatures  {suture-ligatures) .  Bleed- 
ing from  the  pla  is  arrested  by 
direct  ligation,  by  suture  Hgature, 
or  by  gauze  packing.  Bleeding 
from    the    diploe    is    arrested  by 


Fig.  591. 


Fig.  592. 
Figs.  591-593. — Hudson's  burrs. 


Fig.  593. 


the  use  of  Horsley's  wax.  The  wound  is  cleansed,  the  edges  of  the  dura 
are  sutured  by  catgut  or  fine  silk;  in  some  cases  the  button  of  bone 
is  reintroduced;  in  other  cases  some  chips  are  cut  from  the  bone  and 
scattered  upon  the  dura,  but  in  most  cases  no  attempt  is  made  to  fill 
up  the  gap  in  the  bone.  The  scalp  is  sutured  by  silkworm-gut,  and 
horse-hair  or  gauze  drainage  is  employed  for  a  day  or  two.  Sterilized  gauze 
dressings  are  put  on,  and  a  gauze  bandage  is  applied.  In  a  young  person 
the  opening  may  close  partly  or  entirely  by  thin  bone.  In  most  youths  and  in 
practically  all  older  persons  the  closure  will  be  by  fibrous  tissue  or  fibro- 
cartilage  and  a  soft  area  remains  on  the  cranial  vault.  In  many  cases  a  raised 
ring  of  bone  forms  around  the  opening.     In  some  cases  the  bone  thins  and  the 


932 


Diseases  and  Injuries  of  the  Head 


opening  is  slightly  lessened  in  size  by  a  ring  of  new  bone.  A  soft  spot  is  of 
course  vulnerable  to  traumatism  and  to  that  extent  a  danger.  The  older 
surgeons  were  accustomed  to  protect  the  region  by  wearing  a  plate  of  silver 
upon  the  scalp.  This  custom  gave  rise  to  the  popular  belief  that  the  opening 
in  the  bone  was  closed  by  the  insertion  of  a  silver  plate.  If  the  bone  defect  is 
very  large  it  may  be  closed  by  bone  trans- 
plantation. In  some  cases  the  transplant 
becomes  absorded.  In  others  the  operation 
is    successful.     Some    surgeons    have     used 


Fig.  594. — Hudson's  modified  DeVilbiss  forceps. 


I'lG.  595. — Combined  osteoplastic 
operation.  First  step.  Incision  through 
superficial  tissues  and  bone.  Flap  held 
in  place  on  the  bone  by  tacks. 


plates  of  horn,  cut  to  the  required  shape  and  sterilized  by  keeping  for 
three  days  in  alcohol.  Estor  has  closed  defects  in  a  number  of  cases  by 
gold  plates,  inserted  about  two  months  after  trephining.  He  slips  the  edges 
of  the  plate  between  the  two  tables  of  the  skull.  The  operation  is  indicated 
when  coughing  or  straining  causes  the  brain  to  bulge  at  the  opening.  Gold 
undergoes  no  change  ("Bull,  et  mem.  Soc.  de  Chir.  de  Paris,"  1915,  xH). 


Fig.  596.-  Ciimhirud  osteoplastic 
operation.  Second  step.  Bone  flap  turned 
down. 


Fig.  597.  —  Combined  osteoplastic 
operation.  Third  step.  Showing  exposure 
of  brain  by  removal  of  dural  flap. 


Instead  of  the  trephine  some  surgeons  use  the  chisel  or  gouge  and  hammer  to 
remove  a  portion  of  the  bone.  Other  operators,  believing  that  this  procedure 
may  cause  concussion,  employ  the  surgical  engine. 

I  now  seldom  use  the  old  trephine,  preferring  instead  the  instruments  of 
Hudson  (Figs.  591-594). 


Trephining  the  Frontal  Sinus  933 

Osteoplastic  Resection  of  the  Skull. — Wolff  suggested  this  operation,  and 
in  1889  Wagner  performed  it.  It  is  employed  for  the  removal  of  tumors 
and  the  Gasserian  ganglion,  for  focal  epilepsy,  and  for  exploration.  It  is  the 
operation  of  choice  when  a  large  opening  is  needed,  as  when  the  operation  is, 
first  of  all,  for  diagnosis.  The  incision  shown  in  Fig.  595  is  made  through 
the  scalp  and  periosteum,  and  the  tiap  is  tacked  to  the  bone,  ordinary  long 
tacks  being  used.  Otherwise  our  manipulations  may  separate  the  flap  from 
the  bone  (Fig.  595).^  A  groove  corresponding  to  this  incision  may  be  cut 
in  the  bone  by  special  gouges  or  chisels.  I  do  not  use  chisels.  lam  con- 
\'inced  that  the  blows  of  the  mallet  add  to  shock,  may  cause  hemorrhage 
or  add  to  existing  hemorrhage,  may  extend  a  line  of  fracture  or  cause  a  fracture, 
may  diffuse  a  purulent  collection,  or  produce  concussion  of  the  brain. 
Some  surgeons  use  the  surgical  engine.  It  is  difficult  to  keep  it  sterile,  it 
runs  at  too  high  a  speed  to  be  readily  controlled,  and  it  is  troublesome  to  cut 
a  bevel  with  it.  The  instrument  is  dangerous  except  when  in  verv  skilful 
and  highly  trained  hands.  Some  surgeons  make  trephine  openings  and  then 
cut  from  within  outward  by  the  GigH  wire  saw  (Obalinski).  Gushing,  of 
Harvard,  does  what  is  called  the  combined  method.  I  prefer  this  to  anv  other 
plan.  It  is  rapid  and  free  from  all  danger  of  wounding  the  dura.  I  make  two 
or  several  openings  with  Hudson's  burr.  This  excellent  instrument  divides 
bone  vdth.  great  rapidity,  but  does  not  divide  the  dura.  In  fact,  one  cannot 
divide  the  dura  with  it,  for  the  burr  binds  as  soon  as  it  is  through  the  bone. 
Figs.  591  to  593  show  Hudson's  burrs.  The  sides  of  this  bone-flap  are  rapidly 
cut  by  Hudson's  improvement  of  the  DeVilbiss  forceps  (Fig.  594).  The 
upper  margin  is  cut  on  a  bevel  with  the  Gigli  saw.  Because  of  this  bevel 
when  the  flap  is  restored  to  place  the  upper  edge  of  the  flap  rests  on  a  shelf 
of  bone  and  does  not  press  on  the  brain.  By  whatever  method  performed, 
three  sides  of  the  bone-flap  are  cut  through,  but  the  bone  is  left  attached  to  the 
scalp.  It  is  a  good  plan  to  save  the  scalp  from  detachment  by  temporarily 
nailing  it  in  place  (Fig.  595).  The  bone  is  then  broken  outward,  the  fracture 
taking  place  at  the  base  of  the  bone-flap,  the  dura  is  opened  a  httle  distance 
from  the  edge  (sufficient  space  being  retained  for  sutures),  and  the  exploration 
is  made  and  the  operation  is  performed  (Figs.  596  and  597).  WTien  we  are 
ready  to  suture  the  dura  we  note  if  the  brain  bulges  greatly.  If  it  does,  manipu- 
lation will  surely  injure  it,  and  we  should  cause  the  brain  to  recede  before 
suturing  by  placing  the  patient  nearly  erect  or  by  performing  lumbar  puncture. 
After  suturing  the  dura  the  bone  which  is  still  adherent  to  the  pericranium  and 
scalp  is  restored  to  its  proper  place,  and  the  scalp  is  sutured.  In  cases  of 
injury  or  tumor  in  which  a  considerable  portion  of  dura  requires  removal  the 
defect  is  filled  by  a  flap  of  aponeurosis  or  a  piece  of  transplanted  fascia  which  is 
sutured  in  place. 

Besides  restoring  a  flap  of  bone  into  position,  or  replacing  a  button  of 
bone,  or  strewing  the  dura  with  bone-fragments,  other  methods  of  closing  the 
opening  have  been  practised — ^for  instance,  heteroplasty  with  a  decalcified 
bone-plate,  with  a  celluloid  plate,  or  other  foreign  material.^ 

Trephining  the  Frontal  Sinus. — This  operation  may  be  employed  for 
inflammation  of  the  lining  membrane  of  the  sinus  or  for  empyema.  Make 
a  vertical  incision  in  the  middle  of  the  forehead,  starting  1I2  inches  above 
the  nasion  and  terminating  at  the  root  of  the  nose.  The  button  of  bone  is 
removed  and  the  opening  is  enlarged  if  necessary.  The  mucous  membrane  is 
incised,  the  opening  into  the  nose  is  found  and  is  dilated,  and  a  drainage-tube 
is  passed  into  the  nose  from  the  sinus,  the  upper  end  being  left  in  the  sinus. 
In  some  severe  cases  Jacobson  ad\ises  us  to  curet  the  sinus,  to  disinfect  it  by 
the  use  of  silver  nitrate  or  chlorid  of  zinc,  and  to  insufflate  an  "aseptic  powder." 
In  some  cases  resect  the  mucous  membrane.  I  prefer  an  osteoplastic  resection 
to  trephining  the  frontal  sinus. 

1  See  Bretano,  in  "Deutsche  med.  Woch.,"  May  17,  1S94. 


gj4  Diseases  and  Injuries  of  the  Head 

Trephining  the  Mastoid. — (See  Operation  for  Mastoid  Suppuration,  page 
936.; 

Technic  of  Brain  Operations. — In  focal  epilepsy  a  faradic  battery  is  required. 
Always  shave  the  scalp  and  always  antisepticize  it.  In  localizations,  mark  out 
the  fissure  upon  the  scalp  with  an  anilin  pencil,  with  iodin,  or  with  silver  nitrate. 
Have  the  patient  semirecumbent.  Mark  three  points  upon  the  bone  with  the 
center-pin  of  the  trephine  before  incising  the  scalp  (both  ends  of  the  Ro- 
landic  fissure  and  the  point  at  which  the  trephine  is  to  be  applied).  Make 
a  semilunar  flap  3  inches  in  diameter,  with  the  base  below.  Control  bleeding 
in  the  flap  by  forceps  pressure.  If  the  operation  is  by  trephining  the  i3-2-ir>ch 
trephine  should  be  employed,  but  if  a  smaller  trephine  or  the  Hudson  burr 
is  used  the  opening  must  be  enlarged  with  a  rongeur.  Before  enlarging  the 
opening  separate  the  dura  from  the  bone  by  a  dural  separator.  In  most  cases 
an  osteoplastic  flap  is  preferable  to  trephining.  It  is  always  employed  in 
explorations  for  tumor.  As  a  rule,  open  the  dura  and  examine  the  brain. 
The  dura  is  lifted  by  a  mouse-toothed  forceps  and  is  opened  by  scissors  along 
a  line  3-4  ii^ch  from  the  bone  edge,  a  broad  pedicle  of  dura  being  left  uncut. 
Hemorrhage  is  arrested  by  pressure  and  hot  water  or  by  passing  suture- ligatures 
of  silk  or  catgut  around  any  bleeding  vessel  by  means  of  a  curved  needle.  In 
some  cases  packing  must  be  retained  or  forceps  must  be  kept  on.     In  packing, 


r 


L. 

Fic.  598. — Showing  terminal  and  connection  of  Cushing's  electrode  (H  natural  size).     Instru- 
ment should  be  16  inches  or  more  in  length. 

endeavor  to  use  but  one  piece  of  gauze,  so  as  to  avoid  leaving  in  a  forgotten  piece. 
Upon  opening  the  dura  cerebrospinal  fluid  flows  out,  the  stream  being  increased 
at  each  expiration.  Absence  of  pulsation  of  the  brain  points  to  abscess  or  tumor, 
and  a  livid  color  indicates  subcortical  growth.  An  old  laceration  is  brownish. 
If  the  brain  bulges  through  the  opening,  it  means  increased  pressure  (tumor, 
abscess,  effusion  into  the  ventricles,  etc.).  After  opening  the  dura  employ 
no  antiseptics,  especially  when  the  surgeon  intends  using  electricity  to  locate 
a  center.  Irrigate  by  warm  salt  solution  only.  In  operating  for  tumor  the 
dura  is  opened  and  in  some  cases  the  brain  is  incised.  The  tumor  is  turned 
out  by  the  finger  or,  if  this  is  impossible,  by  the  dry  dissector,  the  scissors, 
the  dull  knife,  or  the  sharp  spoon.  If  the  entire  tumor  cannot  be  removed,  it 
is  sometimes  proper  to  take  away  as  much  as  possible.  The  removal  of  a 
portion  may  retard  the  growth  of  the  remainder,  and  the  trephining,  by  lessening 
cerebral  pressure,  may  relieve  the  svTnptoms  and  prolong  life.  After  removing 
a  tumor  arrest  distinct  points  of  bleeding  by  ligatures  or  by  suture-ligatures. 
Pack  the  tumor  cavity  with  gauze  and  bring  the  end  of  the  strand  out  of  the 
wound.  Stitch  the  dura  with  silk  and  suture  the  scalp  with  silkworm-gut. 
In  electrifying  the  brain  faradism  is  employed  of  a  strength  about  sufliicient 
to  move  the  fibers  of  the  exposed  temporal  muscle.  The  best  electrode  is 
that  of  Gushing  (Fig.  598).  It  is  a  "glass  unipolar  electrode  carrying  a  fine 
platinum  wire  core,  coiled  into  a  spkal  at  the  end"  (Gushing,  in  "Keen's 
Surgery,"  vol.  iii).  The  other  pole  is  attached  to  an  extremity,  "preferably 
on  the  homolateral  side."  During  the  electrical  test  the  patient  must  not 
be  deeply  anesthetized.  A  careful  observer  watches  the  muscular  movements. 
If,  for  instance,  the  surgeon  wishes  to  remove  the  thumb  center,  he  moves 
the  electrode  from  point  to  point  until  he  obtains  thumb  movements.  The 
region  is  sliced  away  bit  by  bit  until  the  center  which  is  responsible  fcr  the 


Colli lol   (.)!'  Hemorrhage  in   Brain   Operations 


935 


convulsive  movements  is  removed.  It  will  be  found  impossible  to  remove 
only  the  thumb  center.  Adjacent  centers  are  sure  to  be  more  or  less  damaged, 
and  a  certain  amount  of  paralysis  follows  the  operation.  If  we  wish  to  tap  the 
ventricles,  Keen  directs  the  trephine  opening  to  be  i)^  inches  behind  the  external 
auditory  meatus  and  the  same  distance  above  the  base-line  of  Reid  (Fig.  599,  a). 
A  grooved  director  or  metal  tube  is  passed  into  the  brain  in  the  direction  of  a 
point  "  2}.^  to  3  inches  above  the  opposite  meatus."  The  normal  ventricle  will 
be  entered  at  a  depth  of  2  to  23^^  inches,  but  the  dilated  ventricle  will  be  en- 
tered so-jner.  The  moment  of  entry  is  marked  by  lessened  resistance  and  a 
flow  of  cerebrospinal  fluid.  Drainage  can  be  maintained  by  introducing  a 
rubber  tube.  This  operation  has  been  employed  in  hydrocephalus.  Kocher 
punctures  the  ventricle  2}^  cm.  from  the  midline  and  3  cm.  in  front  of  the 


Fig.  599. — Opening  the  mastoid  antrum  and  the  lateral  sinus;  exposure  of  the  temporo- 
sphenoidal  lobe  and  puncture  of  the  descending  horn  of  the  lateral  ventricle:  a,  Temporo- 
sphenoidal  lobe  (descending  cornu  of  lateral  ventricle  is  i  cm.  deeper);  b,  inner  surface  of 
periosteum;  c,  mastoid  antrum;  d,  lateral  sinus  (Kocher). 

fissure  of  Rolando.  After  an  aseptic  cerebral  operation,  as  a  rule,  do  not  drain 
unless  hemorrhage  has  been  considerable.  In  many  cases  after  trephining 
replace  the  bone,  but  not  when  the  bone  is  diseased,  is  infected,  is  very  com- 
pact, or  if  we  desire  to  alter  pressure. 

Control  of  Hemorrhage  in  Brain  Operations. — Elevation  of  the  patient's 
head  decidedly  lessens  hemorrhage.  A  table  should  be  used  which  permits 
elevation.  If  the  blood-pressure  falls  rapidly  the  head  must  be  lowered. 
A  rubber  band  around  the  head  usually  controls  scalp  bleeding ;  but  will  actually 
increase  it  if  there  is  a  large  cortical  growth  with  greatly  enlarged  vessels 
joining  intracranial  and  extracranial  veins  (Landon,  in  "Surgery,  Gynecology, 
and  Obstetrics,"  1914,  xviii).  I  seldom  use  the  band  and  depend  upon  clamp 
forceps  for  the  temporary  arrest  of  scalp  hemorrhage  and  upon  the  sutures 
which  close  the  wound  for  permanent  arrest.     Bleeding  from  diploe  is  controlled 


936  Diseases  and  Injuries  of  the  Head 

by  Horsley's  wax  or  by  bits  of  muscle.  Bleeding  on  the  dura  can  usually  be 
arrested  by  hot-water  and  pressure  or  by  the  application  of  a  bit  of  muscle. 
If  this  fails  a  suture  ligature  is  used.  Bleeding  from  a  pial  vessel  is 
arrested  by  suture-ligatures  if  a  bit  of  muscle  fails.  When  the  patient  comes 
out  of  ether  he  should  be  placed  erect  in  bed. 

Operation  for  Mastoid  Suppuration. — Place  a  sand-bag  under  the  neck. 
An  Incision  is  made  }i  inch  posterior  to  the  auricle  and  down  to  the  bone, 
and  in  the  direction  of  the  long  axis  of  the  mastoid.  The  bone  is  bared  and 
examined,  especially  at  a  point  in  the  line  of  the  incision,  which  is  on  a  level 
with  the  roof  of  the  meatus  (Fig.  599,  c).  The  bone  will  usually  be  found 
softened.  Gouge  it  away  and  thus  open  the  mastoid  antrum.  The  bone- 
opening  is  within  the  limits  of  Macewen's  suprameatai  triangle,  a  space  bounded 
by  the  posterior  root  of  the  zygoma,  the  posterior  bony  wall  of  the  meatus, 
and  an  imaginary  line  joining  the  two.  If  the  mastoid  is  opened  in  this  triangle 
the  antrum  is  entered  directly  and  there  is  no  chance  of  wounding  the  lateral 
sinus.  If,  in  the  adult,  pus  is  not  found  on  opening  the  mastoid  antrum,  gouge 
downward  and  backward,  but  with  great  care,  so  as  to  avoid  the  lateral  sinus. 
If  there  be  any  possibility  of  the  existence  of  pus  in  the  groove  of  the  sinus, 
the  sinus  should  be  unhesitatingly  exposed.  After  evacuating  the  pus  from 
the  mastoid,  gouge  away  bony  septa,  enlarge  the  opening  between  the 
mastoid  and  the  middle  ear  with  the  gouge  and  remove  the  superior  half  of 
the  posterior  bony  wall  of  the  meatus  (avoid  the  facial  nerve  on  the  floor  of  the 
meatus),  turn  the  head  toward  the  side  operated  upon,  and  irrigate  the  mastoid 
with  salt  solution,  dust  with  iodoform,  pack  with  iodoform  gauze  for  a  few  days, 
and  then  introduce  a  silver  drainage-tube.  Treat  the  causative  ear  disease. 
Sheild  and  ^lacewen  operate  on  inveterate  cases  of  mastoid  disease  as  follows: 
A  thick  flap  is  raised  behind  the  auricle,  the  flap  including  the  orifice  of  any 
sinus  and  being  "left  attached  by  its  stalk."  The  auricle  is  "detached  forward 
and  the  soft  parts  over  the  mastoid  are  turned  backward  by  horizontal  incision." 
The  "lining  membrane  of  the  canal  is  separated  from  the  bone."  The  mastoid 
is  opened  and  dead  bone  and  caseous  matter  are  removed,  overhanging  edges 
are  chiseled  down,  and  the  posterior  bony  wall  of  the  external  auditory  meatus 
is  gouged  away.  The  skin-flap  is  pushed  into  the  cavity  and  is  held  in  place  by 
pads  of  gauze.  The  margins  of  the  flap  may  be  sutured,  but  this  is  not  neces- 
sary.    Macewen  calls  this  procedure  "papering"  the  cavity  with  skin.^ 

If  mastoid  suppuration  has  established  abscess  in  the  tevtporosphenoidal 
lobe,  trephine,  i]i  inches  behind  and  1^ i  inches  above  the  middle  of  the  ex- 
ternal meatus  (Barker's  point),  and  search  for  pus  as  directed  on  page  904.  If 
abscess  of  the  cerebellum  exists,  trephine  below  the  line  of  the  lateral  sinus.  "  The 
position  of  the  lateral  sinus  is  indicated  by  a  line  running  horizontally  outward 
from  the  occipital  protuberance  to  within  about  i  inch  of  the  external  auditory 
meatus,  and  thence  downward  to  the  mastoid  process"  (Owen's  "Manual  of 
Anatomy").  If  infective  sinus-thrombosis  exists,  break  into  the  lateral  sinus 
(Fig.  599,  d)  from  the  mastoid  opening  and  proceed  as  directed  on  page  908. 

Linear  Craniotomy. — Make  a  large  flap.  Trephine  the  skull  a  finger's 
breadth  from  the  sagittal  suture,  and  the  same  distance  back  of  the  coronal 
suture.  Rongeur  the  bone  away  in  a  line  parallel  with  the  sagittal  suture 
and  a  safe  distance  from  the  longitudinal  sinus,  up  to  a  point  in  front  of  the 
lambdoidal  suture.  Remove  the  pericranium  which  covered  the  bone  excised. 
Insert  the  dural  separator  or  pass  it  along  the  margins.  In  some  cases  an 
additional  portion  of  the  bone  is  removed  over  the  fissure  of  Rolando.  Various 
suggestions  have  been  made  as  to  the  direction  and  situation  of  bone-sections. 
Bleeding  is  arrested  and  the  flap  is  closed  without  drainage. 

Removal  of  Gasserian  Ganglion. — (See  page  859.) 

Operation  for  Infective  Sinus-thrombosis. — (See  page  908.) 

1  "Lancet,"  Feb.  8,  1896. 


The  Decompression  Operation 


937 


The  Decompression  Operation  {Decompressive  Trephining). — This  opera- 
tion is  employed  particularly  in  cases  of  inoperable  brain  tumor.  It  differs 
from  palliative  trephining  in  the  fact  that  the  dura  is  incised  and  an  opening 
left  to  permit  of  bulging  of  the  brain.  The  bulging  reheves  pressure.  By 
Cushing's  method  we  get  a  hernia  of  the  brain,  but  not  a  fungus  cerebri.  I 
have  followed  Cushing's  recommendation  in  tumors,  and  have  used  it  on  both 
sides  in  fractures  of  the  base  of  the  skull,  and  I  believe  it  often  saves  vision 
and  life. 

Gushing  and  Bordley  have  performed  it  in  cases  or  uremia  and  improve- 
ment has  followed  ("Amer.  Jour.  Med.  Sciences,"  Oct.,  1908).  They  sug- 
gest that  the  operation  be  used  in  certain  cases  of  renal  disease  when  medical 
treatment  and  lumbar  puncture  have  failed  to  abate  uremic  symptoms,  or 
when  blindness  is  impending.  It  has  been  used  in  apoplexy  and  in  pneumonia 
with  cerebral  symptoms. 


Fig.  600. — Sketch  of  the  intermusculotemporal  field  of  operation,  showing  exposure  with  sub- 
temporal bone  defect  partly  made  (Gushing,  in  "Keen's  Surgery"). 

The  effect  of  the  operation  in  cases  of  brain  tumor  is  sometimes  extra- 
ordinarily beneficial.  In  other  cases  it  does  no  good  at  all.  I  beheve  at  least 
haH  the  cases  are  improved.  1  have  seen  paralysis  practically  disappear 
after  a  few  months.  It  does  little  good  when  a  tumor  has  caused  coma  unless 
the  operation  is  associated  with  tapping  the  ventricles.  Its  most  prominent 
benefit  is  in  abolishing  choked  disk.  It  must  not  be  done  over  a  tumor,  because 
the  bulging  tumor  might  become  the  seat  of  hemorrhage.  It  may,  however, 
be  done  near  the  tumor  (see  page  924). 

It  is,  of  course,  useless  in  relieving  blindness,  for  blindness  means  atrophy, 
but  it  is  often  very  valuable  in  preventing  blindness.  Blindness  of  even  a  day's 
duration  is  not  recovered  from  by  relieving  pressure.  Choked  disk  should 
be  regarded  as  a  late  symptom  of  brain  tumor.     When  choked  disk  exists 


938  Diseases  iind    Injuries  of  the  Head 

operation  should  be  done  early  even  if  there  be  good  vision.  If  in  advanced 
cases  any  sight  remains,  it  should  be  performed.  Now  and  then  there  is  an  un- 
favorable result,  for  instance,  the  development  of  retinal  hemorrhages  or  even  the 
loss  of  vision,  which  may  have  been  good  previous  to  operation.  (SeedeSchweinitz 
and  Holloway  on  ''Operative  Treatment  of  Papillo-edema  Dependent  Upon  In- 
creased Intracranial  Tension,"  "Therapeutic  Gazette,"  July  15,  1909.)  De- 
compression will  probably  be  fatal  if  there  is  a  tumor  of  the  third  or  of  the 
fourth  ventricle.  The  patient  may  die  upon  the  table  or  a  few  hours  later. 
Elsberg  ("Surgery,  Gynecology  and  Obstetrics,"  August,  1916)  points  out 
that  if  a  subtemporal  decompression  is  made  for  subtentorial  tumor  and  the 
ventricle  is  dilated,  the  ventricle  may  be  dragged  upon  and  nerve  tracts  damaged. 
He  further  says  that  in  a  (i)  left  or  right  midbrain  tumor  a  subtemporal 
decompression  on  the  right  side  usually  aggravates  motor  symptoms.  So  it 
does  in  a  tumor  to  the  (2)  inner  side  of  the  internal  capsule.  In  these  two 
classes  of  cases,  (i)  and  (2),  bilateral  decompression  is  advisable,  the  right 
side  being  done  first  and  the  ventricle  punctured,  so  as  to  avoid  too  great  a 
prolapse  of  the  left  temporal  lobe  and  a  resulting  aphasia.  The  duration  of 
the  relief  to  the  choked  disk  is  variable.  It  is  not  always  permanent.  The 
operation  may  be  done  for  an  unlocated  tumor  and  later  the  tumor  may  perhaps 
be  located  and  removed.  It  may  be  done  for  an  inoperable  tumor  and  later, 
the  decompression  having  made  the  danger  less,  operation  may  perhaps  be  per- 
formed. 

Cushing's  subtemporal  decompression  is  done  upon  the  right  side,  as  a  rule, 
but  in  some  cases  on  the  left  side.  An  objection  to  doing  it  on  the  left  side  is 
that  the  bulging  of  the  left  temporosphenoidal  lobe  may  cause  word-deafness. 
A  curved  incision  is  made  through  the  skin  and  subcutaneous  tissue,  the  flap 
is  turned  down,  the  temporal  fascia  is  incised  in  the  direction  of  the  muscle- 
fibers  beneath  it,  the  temporal  muscle  is  split  and  not  cut,  the  periosteum  is 
separated  from  the  bone,  the  soft  parts  are  retracted,  the  bone  is  opened  as  the 
surgeon  prefers,  and  the  opening  is  enlarged  by  a  rongeur  (Fig.  600).  The 
dura  is  opened  and  radiating  incisions  are  made  through  it  toward  the  edges 
of  the  bone  gap.     The  wound  is  closed  by  four  layers  of  fine  silk  sutures. 

Figure  601  exhibits  the  exposure  for  suboccipital  depression  as  done  for 
subtentorial  tumors.  The  same  exposure  is  obtained  in  order  to  remove  a 
cerebellar  tumor.  "In  subtentorial  decompressions  a  puncture  of  the  corpus 
callosum  or  at  least  a  ventricular  puncture  should  always  precede  the  opening 
of  the  dura"  (Elsberg,  Ibid.). 

Drainage  of  the  Cisterna  Magna  (Haynes^s  Operation). — This  operation 
was  suggested  by  Cunningham  and  the  technic  was  developed  by  Haynes 
(see  Deuch,  in  "Laryngoscope,"  1913,  xxiii).  An  incision  is  made  in  the 
middle  Une  from  the  occipital  protuberance  to  the  posterior  arch  of  the  atlas. 
The  periosteum  is  stripped  from  a  portion  of  the  occipital  bone  at  and  above 
the  foramen  magnum.  The  bone  is  trephined  and  is  cut  away  into  the  foramen 
magnum.  The  occipital  sinus  may  not  be  present.  If  present  as  a  double 
sinus,  incise  the  dura  between  the  two  sinuses.  If  there  is  one  sinus,  divide 
the  dura  between  two  ligatures.  Open  the  dura  and  arachnoid  by  a  very 
small  incision.  As  soon  as  excess  of  fluid  has  escaped  enlarge  the  incision.  By 
lifting  and  separating  the  cerebellar  lobes  the  surgeon  can  determine  if  the 
foramen  of  Magendie  is  patent.  Gutta-percha  tissue  is  used  as  a  drain.  The 
muscles  are  sutured  together  by  catgut.  The  skin  is  closed  below  the  drain 
by  silkworm-gut  (abbreviated  from  Haynes's  description  in  "The  Laryn- 
goscope," June,  191 2).  So  far  the  results  of  this  operation  in  meningitis  have 
not  been  encouraging.  It  is  said  to  have  succeeded  in  hydrocephalus.  1  had 
one  gratifying  case. 

Methods  of  Reaching  the  Pituitary  Body. — The  subtemporal  route  was  sug- 


Methods  of   Reaching  the  Pituitary   Body 


939 


gesled  by  Car  Ion  and  Paul.  Horsley  has  operated  in  this  way.  The  bone  is 
removed  from  the  subtemporal  region,  the  dura  is  opened,  the  brain  is  Uf ted  and 
the  dural  box  of  the  hypophysis  is  incised.  It  may  be  necessary  to  remove  bone 
from  each  subtemporal  region  and  raise  the  brain  from  both  sides.  Borchardt 
performed  osteoplastic  frontal  resection,  hgated  the  superior  longitudinal 
sinus,  and  lifted  the  brain. 


Fig.  6oi. — The  suboccipital  exposure,  showing  opening  partly  made  and  Cushing's  "cross- 
bow" incision  (Gushing,  in  "Keen's  Surgery")- 

Giordano  suggested  a  transsphenoidal  operation,  and  Schloffer  improved 
his  method.  Schloffer  freed  the  nose  so  as  to  turn  it  toward  the  right  side  and 
then  excised  the  turbinates,  orbital  wall,  maxillary  sinus,  the  middle  septum, 
the  left  nasal  process  of  the  superior  maxillary,  and  the  ethmoid  cells  (Gushing, 
"The  Pituitary  Body  and  Its  Disorders")-  In  the  inferior  route  of  Kanavel 
most  of  these  structures  are  preserved  and  the  incision  is  within  the  mouth. 

McArthur  ("Jour.  Amer.  Med.  Assoc,"  June  29,  1912)  trephines  the  frontal 
eminence  of  one  side  4  cm.  above  the  supra-orbital  notch  and  preserves  the 
button  in  warm  salt  solution.  By  means  of  the  DeVilbiss  forceps  and  the 
chisel  he  cuts  away  a  bone-fragment,  which  brings  with  it  a  considerable  part 
of  the  roof  of  the  orbit.  This  fragment,  too,  is  placed  in  warm  salt  solution. 
The  rest  of  the  orbital  roof  is  cut  away  by  a  rongeur.     The  dura  covering  the 


g^o  Diseases  and  Injuries  of  the  Head 

inferior  surface  of  the  frontal  lobe  is  separated  from  the  bone,  while  the  lobe  is 
raised  and  the  orbital  contents  are  held  out  of  the  way.  Between  the  clinoid 
processes  the  dura  is  divided  by  Krauses  hook-shaped  knife.  An  enlarged 
hypophysis  will  now  be  accessible.  At  the  conclusion  of  the  operation  on  the 
hypophysis  the  bone-fragments  are  replaced,  Frazier  has  modified  McArthur's 
operation  ("Annals  of  Surgery,"  Feb.,  1913).  I  have  performed  the  operation 
once  for  a  cvst  of  the  hypophysis.  Gushing  has  had  wonderful  success  with 
his  nasal  method  which  involves  resection  of  the  septum  (i  death  in  32  cases). 
To  perform  this  one  must  be  highly  skilful  in  working  in  a  very  small  area. 
To  most  surgeons  the  fronto-orbital  method  will  be  easier.  The  operation 
can  be  done  aseptically  and  by  aid  of  sight  and  the  brain  must  be  retracted 


Fig.  602. — Horner  B.  Smitli'b  head- 


re-t    lur  iipi.;rcltinn>  LU^un   the 

liam  J.  Taylor). 


rebellura  (modified  by  Wil- 


far  less  than  in  the  temporal  approach.  A  soHd  tumor  can  be  removed  more 
satisfactorily  than  by  the  nasal  route.  After  the  operation  there  may  be  edema 
of  the  eye  and  the  eyeball  may  not  be  quite  on  a  level  with  the  other  eyeball. 

The  Combined  Method  of  Harvey  Gushing  (From  Gushing  s  "The  Pitui- 
tary' Body  and  Its  Disorders"). — This  surgeon,  whose  experience  is  very  large, 
operates  as  follows:  Intratracheal  anesthesia.  Place  the  patient  with  the 
shoulders  sUghtly  raised  so  that  the  head  drops  back.  Pack  the  posterior  nares 
with  a  sea-sponge.  Insert  cotton  wet  with  adrenalin  in  each  nostril.  Lift 
the  upper  Up.  Make  a  transverse  incision  across  the  Irenum,  and  carry  it  down 
to  the  anterior  nasal  spine.  By  blunt  dissection  raise  the  soft  parts  on  each 
side  from  the  inferior  margin  of  the  osseous  nasal  opening  until  the  cartilaginous 
septum  Is  exposed.  From  now  on  the  operation  is  submucous.  Separate  the 
membrane  on  each  side  from  the  bony  and  cartilaginous  septum.  Introduce 
a  retractor  on  each  side  between  the  separated  mucous  membrane  and  the 
septum.  Separate  the  blades  of  the  instrument.  Remove  "most  of  the  vomer, 
the  lower  edge  of  the  median  plate  of  the  ethmoid,  and  a  small  strip  of  cartilage." 
It  may  be  necessary  to  remove  by  means  of  a  rongeur  the  anterior  maxillary 
spine.     With  the  retractors  retained,  a  series  of  dilating  plugs  are  introduced. 


Congenital  Deformities  941 

These  "flatten  the  turbinates."  The  largest  dilator  has  a  diameter  of  1.8  cm. 
The  retractors  are  removed  and  a  bivalve  speculum  is  inserted.  An  electric 
head-light  must  now  be  used.  It  may  now  be  found  necessary  to  remove 
"the  prow  of  the  vomer." 

The  body  of  the  sphenoid  is  identified  and  the  "anterior  and  lower  walls 
of  the  sinuses  are  chipped  away  with  long-handled  nasal  rongeurs."  The 
lining  of  mucous  membrane  is  removed,  when  the  protrusion  of  the  sella  can  be 
identified.  The  floor  of  the  pituitary  fossa  is  then  clipped  away.  The  dural 
case  of  the  gland  (or  tumor)  is  divided  by  a  hook-shaped  knife. 

Removal  of  the  entire  anterior  lobe  mUst  never  be  done,  as  this  lobe  is  neces- 
sary to  life. 


XXV.  SURGERY  OF  THE  SPINE 

Congenital  Deformities.  Myelocele  or  Rachischisis. — This  condition 
is  due  to  deficiency  in  the  formation  of  the  vertebral  arches,  the  cord  being 
rudimentary,  the  medullary  plates  having  failed  to  coalesce,  the  central 
canal  not  having  formed,  and  the  endothelium  which  should  line  it  being 
exposed.  If  the  entire  cord  is  involved,  the  condition  is  called  amyelia  or 
total  rachischisis.  If  a  part  of  the  cord  is  involved,  the  condition  is  called  partial 
rachischisis.  In  partial  rachischisis  a  portion  of  skin  is  absent  in  the 
midline.  At  this  area  is  a  circular,  dark  red  focus  surrounded  by  a  very  thin 
and  glistening  membrane  which  becomes  continuous  with  the  skin.  A  dimple 
at  the  upper  part  and  a  dimple  at  the  lower  part  of  the  dark  area  indicates  the 
situation  of  the  central  canal  above  and  below.  Victims  of  rachischisis  are 
usually  stillborn  or,  at  most,  live  but  a  few  days. 

Spina  Bifida. — This  is  a  deformity  s^'m^lar  to  the  one  just  discussed,  but 
in  it  the  cord  is  much  more  developed.  The  first  accurate  description  of  it 
was  given  by  Tulpius  in  1685.  It  is  a  congenital  sac  of  fluid  due  to  vertebral 
deficiency,  permitting  protrusion  of  the  contents  of  the  spinal  canal  in  the 
median  line.  In  this  condition  the  cutaneous  epiblast  is  adherent  to  the  spinal 
exiblast,  because  structures  from  the  mesoblast  have  failed  to  grow  between. 
The  lammse  or  spines  of  one  vertebra  or  of  several  vertebrae  or  of  many  vertebrae 
may  be  deficient,  most  frequent'y  in  the  lumbosacral  region.  In  very  rare 
cases  there  is  division  of  the  vertebral  bodies  and  the  projection  is  forward  and 
to  the  side.  A  case  in  which  there  are  ununited  laminae  but  no  protrusion  is 
called  spina  bifida  occulta.  Sometimes  there  are  two  protrusions  in  one  person. 
In  spina  bifida  the  dura  does  not  cover  the  sac  because  it  is  cleft  as  well  as  the 
laminae.  There  are  three  distinct  varieties  of  spina  bifida:  i.  Meningocele. 
In  this  condition  the  dura  is  cleft  (Hildebrand),  there  is  a  protrusion  of  the 
arachnoid,  fluid  gathers  in  the  arachnoid  meshes  and  "distends  this  so  as  to 
form  one  continuous  cavity  which  is  traversed  by  nerve-roots"  (Henle,  in  "A 
System  of  Practical  Surgery,"  by  von  Bergmann,  Bruns,  and  von  Mikulicz. 
Translated  and  edited  by  Wm.  T.  Bull  and  Carlton  P.  Flint).  The  cord  is  not 
in  the  sac.  2.  Meningomyelocele  (the  commonest  form)  is  a  protrusion  of 
arachnoid  and  cord  substance,  the  sac  containing  cerebrospinal  fluid,  nerves, 
and  cord-substance.  The  cord  may  spread  upon  the  sac  wall  or  it  may  pass 
through  the  sac  and  re-enter  the  canal.  A  cutaneous  dimple  or  furrow  indicates 
that  the  cord  is  attached  and  hence  is  within  the  sac.  3.  Syringomyelocele 
a  protrusion  of  cord.  There  is  great  distention  of  the  central  canal,  the  sac 
wall  being  formed  of  the  thinned  cord  and  the  spinal  membranes.  A  spina 
bifida  varies  in  size  from  that  of  a  walnut  to  that  of  an  infant's  head;  it  grows 
rapidly  during  the  early  weeks  of  life;  it  is  usually  sessile,  but  may  present,  where 
it  joins  the  body,  a  definite  constriction  or  even  a  pedicle,  the  base  of  the  sac 
is  covered  by  healthy  skin,  and  the  fundus  is  covered  by  thin  epidermis  only 


94^  Surgery  of  ihc  Spine 

or  by  the  spinal  membranes  themselves.  Pressure  upon  the  tumor  may  dimin- 
ish its  size  and  increase  the  tension  of  the  anterior  fontanel,  and  possibly  cause 
convulsions  or  stupor.  The  cyst  in  meningocele  is  translucent  and  the  margins 
of  the  bony  aperture  are  distinct.  Meningomyelocele  and  syringomyelocele 
are  not  translucent  but  usually  pulsate.  Crying,  coughing,  or  pressure  upon 
the  anterior  fontanel  makes  a  spina  bifida  more  tense.  Spina  bifida  is  apt  to 
be  associated  with  club-foot,  with  hydrocephalus,  and  with  rectal  or  vesical 
paralysis.  Spina  bifida  usually  causes  death  (90  per  cent,  of  cases  die  during 
the  first  year  of  life).  A  few  meningoceles  and  a  very  few  meningomyeloceles 
undergo  spontaneous  cure  by  growth  of  the  vertebral  arches  constricting 
the  neck  of  the  sac.  The  sac  may  remain  distended  with  fluid  or  may  shrink. 
Syringomyelocele  is  invariably  fatal.  The  cause  of  death  may  be  rupture  of  the 
sac  or  marasmus.  The  x-rays  show  the  bony  gap.  Spina  bifida  occulta  is  a 
cleft  in  the  vertebral  column  without  any  protrusion  of  the  cord  or  of  the  mem- 
branes. In  this  condition  there  is  usually  a  profuse  growth  of  hair  in  the  skin 
over  the  bony  gap.  and  the  hairy  condition  maybe  much  more  widespread. 
In  some  cases  the  hair  is  present  at  birth;  in  others  it  appears  at  puberty. 
Trophic  changes  and  deformities  may  exist  in  the  lower  extremities. 

Treatment. — ^Very  small  protrusions  which  grow  slowly  and  are  covered 
with  sound  skin  may  be  treated  by  the  use  of  a  compress  and  bandage,  Ijy  an 
elastic  bandage,  or  by  applications  of  contractile  collodion.  It  was  formerly 
regarded  as  proper  to  tap  and  drain  the  sac.  Injection  was  used  by  many.  The 
skin  having  been  cleansed,  the  child  was  placed  on  its  side  and  a  little  chloroform 
was  given.  A  fine  trocar  was  plunged  obliquely  in  at  the  side  of  the  sac  through 
sound  skin,  little  or  no  fluid  being  drawn  off,  and  i  dram  of  Morton's  fluid  in- 
jected (iodin,  10  gr.;  iodid  of  potassium,  30  gr.;  glycerin,  i  oz.).  The  trocar 
was  withdrawn  and  the  puncture  was  sealed  with  a  bit  of  gauze  and  iodoform 
collodion.  The  child  was  put  to  bed.  If  injection  proved  successful,  the  sac 
was  found  to  shrink;  if  the  injection  failed,  it  was  the  custom  to  repeat  it  at 
intervals  of  from  seven  to  ten  days  (Jacobson,  White).  Surgeons  now  prefer 
excision  of  the  sac  (see  page  968).  Whenever  possible  the  incision  should  be 
through  healthy  skin.  If  the  sac  contains  nerves  they  should  be  placed  within 
the  canal.  Bayer  treats  it  as  he  would  a  hernia.  Robson  in  some  cases  excises 
the  entire  sac.  Operations  upon  children  much  under  the  age  of  five  have  an 
enormous  mortality.  Operations  are  comparatively  safe  when  the  child  reaches 
the  age  of  five.  Operations  for  spina  bifida  have  been  done  successfully  imme- 
diately after  birth  (Lovett,  in  ''Amer.  Jour.  Orthop.  Surg.,"  Oct.,  1907),  We 
should  not  operate  if  there  is  hydrocephalus  or  extensive  paralysis,  if  the  mass  is 
very  large  and  growing  rapidly,  or  if  there  are  other  marked  deformities.  A 
ruptured  sac  or  a  sac  about  to  rupture  should  be  operated  on  at  once;  otherwise 
death  is  practically  certain. 

Tumors  of  the  Vertebrae. — Secondary  tumors  (sarcoma,  carcinoma)  of 
the  vertebral  bodies  are  not  very  uncommon. 

Primary  tumors,  except  osteomata,  are  very  seldom  found.  Only  9  or  10 
cases  are  on  record  as  having  been  operated  upon.  Enchondroma  is  the 
most  common  growth.  Sarcoma  (spindle-cell  or  giant-cell)  may  arise.  Chon- 
drosarcoma and  myxosarcoma  have  been  met  with. 

Sacrococcygeal  Tumors. — Dermoids  dorsal  to  the  sacrum  are  occasionally 
seen  in  this  region.  In  the  lower  sacral  or  coccygeal  region  the  cutaneous 
structures  sometimes  fail  of  complete  coalescence  and  a  postanal  dimple  or 
simis  is  the  result.  Such  a  sinus  is  lined  with  skin  and  its  wall  contains  numer- 
ous glands  and  often  hairs.  It  may  inflame  or  suppurate.  If  it  blocks  up  at 
the  outlet,  a  form  of  dermoid  develops.  Lipomata  and  hydatid  cysts  may  be 
found  in  front  of  the  sacrum.  The  term  sacrococcygeal  tumor  should  mean 
a  tumor  ventral  to  the  sacrum  and  arising  from  misplaced  anlages.  Early  in 
embryonic  development  the  neurenteric  canal  joins  the  central  canal  of  the  spinal 


Extramedullary  Tumors  943 

cord  with  the  primitive  aUmentary  canal.  The  neurenteric  canal  later  under- 
goes obliteration.  At  a  certain  point  the  ectoderm  and  entoderm  grow  together, 
pushing  aside  the  mesoderm  and  forming  the  canal  plate.  The  plate  becomes 
depressed  forming  the  canal  pit  or  proctoderm.  The  proctoderm  invaginates 
more  and  more  in  front  of  a  portion  of  the  gut  and  reaches  the  gut  above  the 
neurenteric  canal.  There  is  a  section  of  gut  behind  the  anus  known  as  the 
postanal  gut  which  is  obliterated  during  development.  This  is  a  region  of 
tissue  vestiges,  remains  and  misplacement;  in  it  developmental  defects  are 
not  unusual  and  new  growths  may  arise.  Tissue  misplacement  may  give  rise 
to  dermoid  formation.  Teratomata  and  curious  mixed  tumors  may  arise 
which  are  apt  to  show  growth  from  ail  three  embryonic  layers  (Law,  in  ''Surgery, 
Gynecology,  and  Obstetrics,  19 13,  xvii).  Mammary  tissue,  testicular  tissue, 
an  eye,  a  limb  may  be  found.  In  fact,  some  observers  regard  such  a  tumor  as 
in  reality  a  suppressed  fetus. 

Law  (Ibid.)  says  sacrococcygeal  tumors  vary  so  much  and  show  such  diverse 
tissue  elements  that  they  have  been  called  "histological  potpourri." 

As  a  rule  they  originate  in  the  connective  tissue  of  the  pelvis  and  are 
encapsuled.     They  are  on  the  verge  of  maUgnancy. 

Treatment. — Dermoids  require  extirpation.  If  a  postanal  dimple  causes 
no  trouble,  it  is  let  alone;  otherwise  it  should  be  dissected  out.  It  may  or 
may  not  be  possible  to  remove  teratomata.  Lipomata  and  hydatid  cysts 
are  extirpated. 

Tumors  of  the  Spine  and  of  the  Spinal  Cord. — Tumors  ma}^  arise  from 
the  cellular  tissue,  fatty  tissue,  the  nerve-roots,  the  membranes  of  the  cord,  or 
from  the  vertebra  {extramedullary  tumors).  They  may  arise  within  the  cord 
(cord  tumors  proper  or  intramedullary  tumors). 

Extramedullary  Tumors. — Syphilomata,  hydatid  cysts,  tuberculomata,  and 
inflammatory  masses  or  adhesions  may  compress  the  cord  and  produce  s}-mp- 
toms  indistinguishable  from  genuine  tumor.  Among  extramedullary  tumors 
are  secondary  carcinoma,  sarcoma  (primary  or  secondary),  fibroma,  myxoma, 
lipoma,  chondroma,  and  neuroma.  Dermoid  sacral  cysts  may  exist.  Lipoma, 
fibroma,  and  certain  cysts  may  be  congenital.  Injury  of  the  back  sometimes 
seems  to  bear  a  causal  relation  to  extramedullary  tumors. 

The  symptoms  are  due  to  pressure  upon  nerve-roots  and  the  cord.  The  most 
prominent  symptoms  are  pain  in  the  back  and  evidences  of  nerve-root  irritation. 

The  early  or  irritative  symptoms  are  pain  and  stiffness  of  the  back,  usually 
very  severe  and  interfering  with  sleep,  shooting  pains  in  the  area  of  the  impli- 
cated nerve-roots,  and  sensory  abnormalities  in  the  same  area.  There  may  be 
hyperesthesia  of  a  limited  area.  The  area  of  distribution  from  one  or  tw^o  roots 
is  involved  in  pain,  sensory  disturbance,  and  slight  motor  impairment.  In 
some  cases  the  nerve-roots  of  one  side  only  exhibit  irritation  and  the  symptoms 
are  strictly  unilateral.  In  other  cases  the  symptoms  are  bilateral,  but  are  most 
marked  on  one  side.  In  some  cases  the  symptoms  are  symmetrically  bilateral 
and  indicate  pressure  upon  the  cord  rather  than  upon  nerve-roots.  Muscular 
spasms  may  occur.  There  may  be  lateral  curvature  of  the  back,  the  concavity 
of  the  curve  being  on  the  side  of  the  tumor.  Sooner  or  later  paralytic  symptoms 
come  on  (motor  and  sensory  paralysis).  They  may  be  due  to  pressure  upon  and 
destruction  of  nerve-roots  or  to  compression  of  the  cord.  When  anesthesia 
exists  there  may  be  a  zone  of  hyperesthesia  above  its  upper  limit.  As  motor 
palsy  develops  from  root  compression  the  pain  usually  abates.  The  muscles 
undergo  atroph5\ 

A  tumor  may,  by  cord  pressure,  produce  the  symptoms  of  compression- 
myelitis,  locomotor  ataxia,  or  myelitis.  Contractures  or  paraplegia  may  arise 
from  tumor.  The  location  of  the  growth  can  be  inferred  by  a  study  of  the  terri- 
tory of  paralysis  and  the  zone  of  sensory  disturbance.  The  tumor  is  always 
situated  somewhat  above  the  upper  limit  of  anesthesia.     In  many  cases  the 


944  Surgery  of  the  Spine 

diagnosis  is  impossible.  Gradually  increasing  painful  paraplegia,  with  pain  in 
the  back  and  with  hyperesthesia  or  anesthesia  appearing  after  a  time  and  ascend- 
ing from  the  feet  toward  the  trunk,  points  to  ttimor  as  a  cause.  The  paralysis 
is  usually  spastic,  but  may  be  flaccid,  or  it  may  be  spastic  at  first  and  become 
flaccid.  In  spastic  paraplegia  the  retlexes  are  increased.  In  flaccid  paraplegia 
they  are  decreased.  In  spastic  paraplegia  there  are  ankle  clonus,  the 
Babinski  sign  (extension  of  the  great  toe  or  all  the  toes  when  the  sole  of  the  foot 
is  irritated),  Gordon's  paradoxical  reflex  (extension  of  the  great  toe  or  ah  the  toes 
when  pressure  is  made  upon  the  deep  calf  muscles),  and  Oppenheim's  reflex 
(extension  of  the  great  toe  or  all  the  toes  when  the  handle  of  the  percussion 
hammer  is  drawn  along  the  inner  edge  of  the  tibia  so  as  to  make  pressure  from 
above  downward).  Trophic  lesions  are  apt  to  arise  in  the  trajectory  of  nerve 
involvement.  The  sphincters  are  usually  involved.  Growths  outside  the 
membranes  produce  particularly  pain  and  spasm;  growths  within  the  membranes 
produce  especially  motor  paralysis  and  anesthesia.  Symptoms  that  are  unilateral , 
were  at  first  unilateral,  or  which  are  [most  marked  on  one  side,  are  very 
significant. 

Intramedullary  Tumors. — These  tumors  develop  in  the  substance  of  the 
cord.  They  are  far  less  common  than  extramedullary  growths  and  are  more 
often  benign.  These  growths  are,  as  a  rule,  primary  and  solitary  and  do  not 
produce  symptoms  of  pressure  until  they  attain  the  size  of  a  hazelnut.  The 
most  common  tumors  are  glioma,  sarcoma,  and  tuberculoma.  Syphiloma  occa- 
sionally arises.  Most  tumors  in  cord-substance  are  small,  but  the  glioma  may 
inv^olve  practically  the  entire  cord.  A  tumor  is  often  for  a  time  limited  to  one 
side  of  the  cord,  but  later  it  presses  upon  and  finally  involves  the  opposite 
side.  When  the  cord  is  pressed  upon,  degeneration  occurs.  In  some  cases  a 
wrench  or  bruise  of  the  back  is  supposed  to  be  causal.  Glioma  may  be 
congenital. 

Symptoms. — They  are  at  first,  in  most  cases,  very  uncertain.  In  some 
cases,  however,  paralysis  develops  early. 

There  is  often  pain  in  the  back,  but  it  is  not  nearly  so  severe  as  in  extra- 
medullary  tumor.  The  most  prominent  symptom  is  a  slow-developing  motor 
palsy.  In  some  cases  the  palsy  is  at  first  unilateral,  but  later  becomes  bilateral. 
Irritative  root  symptoms  are  absent  (spasm  and  darting  pain).  Anesthesia  or 
hyperesthesia  develop.  The  sphincters  are  involved  and  trophic  disturbances 
arise.  There  may  be  spastic  paraplegia  or  flaccid  paraplegia.  If  the  tumor 
is  in  or  presses  upon  the  anterior  cornu  there  will  be  limited  muscular  atrophy. 
Tuberculoma  produces  the  symptoms  of  transverse  myelitis. 

In  glioma  there  are  paresis  and  muscular  atrophy.  Although  sensibility 
to  pain,  heat,  and  cold  are  lost,  sensibility  to  touch  is  preserved  (sensory  dis- 
sociation). 

Treatment  of  Tumors  of  the  Cord. — If  syphilis  is  suspected,  give  the  patient 
a  course  of  heroic  doses  of  iodid  of  potassium,  and  administer  mercury  hypo- 
dermatically  or  by  inunction.  Intravenous  injection  of  salvarsan  is  advisable. 
In  a  focal  lesion  not  due  to  dissemination  of  a  known  malignant  growth,  perform 
the  operation  of  laminectomy  to  permit  of  exploration  and  possibly  of  removal. 
The  laminag  of  at  least  three  vertebrae  should  be  removed  and  the  tumor  looked 
for  distinctly  above  the  upper  level  of  the  zone  of  anesthesia.  It  is  not  necessary 
for  the  patient  to  wear  a  spinal  support  after  the  performance  of  laminectomy. 
Extramedullary  tumors  are  usually  removable.  Localized  intramedullary 
tumors  should  be  removed  if  they  can  be  located  and  if  removal  can  be  accom- 
plished without  serious  injury  to  the  cord.  After  exposing  the  cord  and  dis- 
covering an  intramedullary  tumor,  follow  the  advice  of  Elsberg  and  Beer 
("Amer.  Jour.  Med.  Sciences,"  Nov.,  igii)  and  make  a  short  incision  in  the 
posterior  median  column  a  little  external  to  the  posterior  median  fissure.  The 
cut  reaches  the  tumor,  which  bulges  through  it.     Do  not  attempt  removal  now. 


Symptoms  of  Acute  Osteomyelitis  of  the  Vertebrae  945 

Suture  the  skin  and  muscles  and  wait  one  week.  On  opening  the  wound  the 
tumor  will  be  found  almost  completely  extruded  from  the  cord.  In  order  to 
remove  it  it  is  only  necessary  to  divide  a  few  strands  of  tissue.  Extrusion  by 
this  method  probably  inflicts  little  injury  upon  nerve-fibers.  This  method  is 
called  delivery  by  extrusion.  I  had  one  very  promising  case  after  this  plan. 
The  patient  improved  greatly  and  was  apparently  on  the  high  road  to  recovery 
when  he  developed  empyema  from  pneumonia  and  died.  McCosh  truly  said 
that  operation  for  spinal-cord  tumor  was  decidedly  more  hopeful  than  for  brain 
tumor,  because  localization  was  much  more  accurate  and  removal  could  be 
effected  with  less  permanent  damage.  The  mortality  from  laminectomy  is 
certainly  not  over  10  per  cent,  and  is  probably  less.  Lloyd  collected  51  opera- 
tions: 10  per  cent,  died  and  31  per  cent,  were  actually  cured  or  improved. 
Joseph  Collins  ("  Med.  Record,"  Dec.  6,  1902)  collected  70  cases  of  spinal  tumor, 
30  of  which  were  operated  upon.  In  12  the  operation  was  a  success,  that  is,  the 
pain  disappeared  and  motor  power  returned;  in  8  the  operation  was  partly 
successful,  that  is,  the  pain  disappeared  and  the  motor  power  improved;  in 
10  the  operation  failed  and  death  occurred  within  a  few  weeks.  Complete 
recoveries  have  been  obtained.  Elsberg  cites  a  number  of  cases  "Internat. 
Abstract  of  Surgery,"  June,  1914).  If  the  tumor  is  found  to  be  irremovable, 
McCosh  suggests  division  of  several  nerve-roots  to  relieve  the  pain. 

Acute  osteomyelitis  of  the  vertebrse  is  a  rare  disease;  it  may  be  associated 
with  osteomyelitis  of  other  bones,  may  be  secondary  to  some  distant  suppurative 
focus,  or  may  occur  alone.  It  may  begin  in  the  periosteum  or  in  the  marrow. 
Infection  of  the  viscera  not  unusually  accompany  it.  In  many  cases  there  is  a 
history  of  trauma.  Any  part  of  the  spine  and  any  part  of  a  vertebra  may 
suffer  from  it.  The  vertebral  arch  is  most  apt  to  be  attacked  whereas  in  tuber- 
culosis the  body  is  usually  diseased.  This  condition  maj^  follow  cold,  over- 
exertion, distant  suppuration,  any  focal  infection  or  traumatism,  and  is  more 
common  in  the  first  two  decades  of  life  than  in  elderly  people.  The  process 
may  be  superficial  or  it  may  involve  the  bone  deeply  and  widely.  Suppuration 
always  occurs;  sequestra  generally  form,  and  phlebitis  is  a  dangerous  complica- 
tion. Any  region  of  the  spine  may  be  attacked,  but  the  lumbar  region  is  par- 
ticularly liable  to  invasion,  next  the  dorsal,  next  the  cervical.  The  sacral 
region  is  least  often  affected.  The  situation  of  the  abscess  varies  with  the  sit- 
Tiation  of  the  disease.  If  the  vertebral  bodies  are  diseased  the  pus  passes  for- 
ward (retropharyngeal,  mediastinal,  psoas,  or  pelvic  abscess).  If  the  vertebral 
arches  suffer  the  pus  passes  backward  (cervical  lumbar  or  dorsal  abscess). 
Rupture  in.to  the  spinal  canal  may  occur.  The  membranes  of  the  cord,  the 
cord  itself,  the  nerves,  and  the  vertebral  articulations  are  frequently  involved 
in  the  process.  Motor  palsy  and  anesthesia  may  arise.  Paraplegia  is  not 
uncommon  from  pressure  or  myelitis.  Staphylococci,  streptococci,  or  other 
pyogenic  bacteria  may  be  cultivated  from  the  pus. 

Symptoms. — The  general  symptoms  are  those  of  osteomyelitis.  The  local 
symptoms  depend  on  the  seat  of  disease.  If  the  posterior  portion  of  the  col- 
umn is  diseased  there  is  a  hard  swelling  which,  in  the  neck,  is  in  the  middle  line; 
in  the  dorsal  and  lumbar  regions,  in  the  middle  or  to  the  side;  and  in  the  sacral 
region,  invariably  to  one  side. 

Rigidity  o  the  spine  always  exists.  If  the  vertebral  bodies  are  affected, 
rigidity  is  noted,  the  spine  is  tender,  and  special  symptoms  appear,  their  nature 
dependent  on  the  region  affected  (retropharyngeal  abscess,  etc.).  Occasionally 
symptoms  of  meningomyelitis  are  noted.  The  constitutional  sjonptoms  of 
sepsis  are  marked.  The  condition  is  sudden  in  onset,  the  general  symptoms 
are  \dolent,  and  purulent  collections  diffuse  widely  and  rapidly.  Mentality 
is  frequently  markedly  dulled.  These  points  enable  the  surgeon  to  make  a 
diagnosis  between  osteomyelitis  and  Pott's  disease.  In  osteomyelitis  angular 
deformitv  rarely  arises,  because  the  patient  is  obliged  to  be  recumbent  and 
60 


946 


Surgery  of  the  Spine 


because  hyperostosis  is  taking  place.  The  mortality  is  from  40  to  60  per  cent. 
Metastatic  abscesses  are  apt  to  arise.  Death  may  be  due  to  pachymeningitis, 
pneumonia,  empyema,  retropharyngeal  abscess,  invasion  of  the  cord,  or  amyloid 
disease  (H.  S.  Warren,  "Boston  Med.  and  Surg.  Jour.,"  May  7,  1903). 

Treatment. — The  patient  is  kept  recumbent.  His  constitutional  treat- 
ment is  such  as  will  combat  sepsis  (food,  stimulants,  etc.).  The  treatment 
is  early  operation.  A  purulent  area  must  be  incised  and  disinfected.  If  bone 
denuded  of  periosteum  is  found,  it  is  touched  with  a  solution  of  chlorid  of  zinc 
or  with  the  actual  cautery.  If  a  sequestrum  exists,  it  is  removed.  A  drainage- 
tube  is  inserted  and  dressings  are  applied  (Miiller,  Makins,  Abbot,  Tscherniak, 
Hahn,  Volkmann,  and  Chipault). 

Typhoid  Spine. — It  was  pointed  out  by  Gibney  in  1889  that  typhoid 
fever  may  leave  as  a  legacy  a  painful,  stiff,  and  weak  back;  74  cases  of  the  con- 
dition have  been  reported  (F.  W.  White,  in  "Jour.  Amer.  Med.  Assoc,"  Feb. 
13,  1908).  The  muscles  of  the  back  are  found  to  be  rigid  and  there  is  tenderness 
of  one  or  more  vertebrae.  The  pain  may  only  be  appreciated  on  motion,  but 
in  some  cases  there  is  aching  even  when  the  patient  is  at  rest.  The  pain  may  be 
localized,  may  run  into  one  or  both  thighs,  or  may  be  felt  in  the  abdomen. 
The  symptoms  arise  at  an  uncertain  period  after  the  fever,  develop  rapidly, 
and  are  occasionally  associated  with  transient  episodes  of  elevated  temperature. 
Kyphosis  or  lateral  curvature  may  develop.  (See  L.  W.  Ely,  "  Medical  Record," 
Dec.  20,  1902.)  Many  of  the  patients  are  hysterical.  The  condition  is  due  to 
osteitis  and  periosteitis,  or  chronic  osteomyelitis.     The  prognosis  is  excellent. 

Treatment. — The  use  of  a  plaster  or  leather  jacket;  counterirritation  by 
the  hot  iron;  later,  massage  and  electricity. 


Fig.  603. — Cervical  ribs. 

Cervical  Rib. — -This  condition  was  first  described  by  Hunauld  in  1743. 
A  cervical  rib  is  most  commonly  seen  arising  from  the  fifth  cervical  vertebra 
but  on  every  rib  there  is  a  nodule  upon  the  transverse  process  from  which 
development  may  occur.  It  may  arise  from  the  sixth  cervical,  from  the  fifth, 
etc.     The  anterior  limb  of  the  transverse  process  of  the  seventh  cervical  vertebra, 


Spinal  Curvature  947 

which  has  an  independent  center  of  ossification,  may  develop  into  a  separate 
bone  of  large  size,  known  as  a  cervical  rib.  Such  a  rib  may  form  on  one  side 
but  is  apt  to  form  on  both.  It  may  scarcely  reach  beyond  the  transverse 
process,  it  may  project  well  beyond  the  transverse  process  and  have  a  free  end, 
or  it  may  constitute  a  complete  rib  which  fuses  anteriorly  with  the  sternum^, 
the  cartilage  of  the  first  rib,  or  with  a  cervical  rib  of  the  opposite  side. 

Most  instances  described  were  found  in  the  dead  body,  although  Tillmanns 
collected  26  cases  among  the  living  (Carl  Beck,  in  "Jour.  Amer.  Med.  Assoc," 
June  17,  1905).  It  is  three  times  as  common  in  women  as  in  men.  Of  late 
.T-ray  findings  indicate  that  the  condition  is  much  more  common  than  was 
formerly  supposed.  I  have  seen  6  cases  and  have  operated  successfully  on 
one  case.  It  may  never  produce  any  uneasiness,  and  hence  may  escape  detec- 
tion and  seldom  does  produce  trouble  in  youth.  It  raises  up  the  brachial 
plexus  and  subclavian  vessels,  if  the  rib  is  large.  It  may  lead  to  damage  of  the 
subclavian  artery  (Keen's  case  developed  aneurysm),  or  gangrene  of  the  hand 
may  result  from  bending  or  blocking  of  the  vessel,  or  neuritis  of  the  brachial 
plexus  may  arise  from  pressure.  Pain  is  common.  Anesthesia,  palsy  or  both 
may  develop.  When  sufficiently  large  to  produce  venous  or  vascular  trouble, 
a  cervical  rib  can  be  felt  and  the  pulsating  artery  over  it  is  very  distinct  ar.d 
higher  than  natural  in  the  neck.  Sooner  or  later  the  artery  dilates  distal  to 
the  rib.  The  x-rays  confirm  the  diagnosis.  The  treatment,  when  the  rib  is  caus- 
ing trouble,  is  excision  of  the  rib  with  its  periosteum.  In  a  case  of  cervical  rib 
the  operation  is  by  no  means  easy.  (See  Kammerer,  in  "Annals  of  Surgery," 
Nov.,  1901,  on  "The  Diagnostic  Difficulties.")  The  operation  should  be  done 
by  the  plan  of  A.  A.  Law  (Abstract  in  "Surgery,  Gynecology,  and  Obstetrics," 
1914).  He  makes  a  vertical  incision  parallel  to  the  border  of  the  scalenus 
medius  muscle,  divides  the  scalenus  anticus  across  (being  careful  to  avoid  the 
phrenic  nerve),  frees  the  subclavian  artery  and  plexus  by  dissection,  separates 
the  pleura  from  the  inner  surface  of  the  rib  and  divides  the  rib  by  means  of  cut- 
ting forceps. 

Variations  in  the  Lateral  Process  of  the  Fifth  Lumbar  Vertebra. — 
If  this  process  is  sufficiently  long  it  impinges  on  the  anterior  portion  of  the  iliac 
brim  when  the  patient  is  in  an  upright  position.  The  pain  may  develop  suddenly 
after  a  twist  or  contusion.  It  may  develop  gradually.  It  may  only  be  felt  when 
the  patient  is  in  certain  positions,  or  it  may  be  more  or  less  constant,  being  aggra- 
vated by  certain  postures.  Over-extension  is  particularly  prone  to  develop  it. 
Pain  may  radiate  on  the  fifth  lumbar  nerve  which  emerges  between  the  sacrum  and 
fifth  lumbar  vertebra.  The  sciatic  nerve  may  be  affected.  Radiating  pain  and 
paralysis  may  develop  in  one  or  both  lower  extremities.  In  making  the  .T-ray 
diagnosis  a  picture  must  be  taken  from  several  directions.  The  treatment 
usually  suggested  is  operative  removal  of  the  process.  The  operation  fails  more 
often  than  it  succeeds  because  it  is  almost  impossible  to  avoid  doing  damage 
to  the  fifth  lumbar  nerve.  Paralysis  may  follow  operation.  H.  A.  Wilson 
maintains  that  in  less  than  30  per  cent,  of  reported  operations  was  the  result 
perfectly  satisfactory  (Paper,  delivered  before  the  "West  Virginia  Medical 
Association,"  Oct.,  1917).  It  has  been  suggested  that  instead  of  excising  the 
lateral  process  the  portion  of  the  ilium  against  which  it  impinges  should  be  re- 
moved.    In  the  latter  operation  the  nerve  escapes. 

Spinal  Curvature. — There  are  four  chief  forms  of  spinal  curvature: 
(i)  Lateral  curvature  (the  scoliosis  of  the  older  surgeons);  (2)  posterior  cur- 
vature (the  excurvation,  gibbosity,  or  kyphosis  of  the  older  surgeons);  (3) 
anterior  curvature  (the  lordosis  of  the  older  surgeons),  and  (4)  angular  cur- 
vature (from  spinal  caries).  The  normal  spine  has  four  curves:  the  cervical 
curve,  the  convexity  of  which  is  forward;  the  dorsal  curve,  the  convexity  of 
which  is  backward;  the  lumbar  curve,  which  is  convex  anteriorly,  and  the 
pelvic  curve,  which  is  concave  anteriorly.     The  dorsal  and  the  pelvic  curves, 


948 


Surgery  of  the  Spine 


which  are  primary,  are  due  to  the  formation  of  the  cavities  of  the  chest  and  pelvds, 
and  depend  upon  the  shape  of  the  bones  (Treves).  The  cervical  and  lumbar 
curves,  which  are  compensatory,  depend  upon  the  shape  of  the  intervertebral 
disks,  and  only  appear  after  birth  when  the  erect  position  is  assumed. 

COXDEXSED  DIFFEREXTIAL  DIAGXOSIS  TABLE  OF  SPIXAL  DISEASES  AXD  CONDITIOXS 

WITH  WHICH  THEY  MAY  BE  COXFOUXDED 

(After  Profes<.or  H.  Augustus  Wilson) 


Scoliosis 

Rachitic 
spine        ' 

Pott's 
disease 

Hyper-    ! 
esthetic    ; 
spine 

Arthritis 
deformans 

! 

Torticollis, 
congenital 

Hip  disease 

Age. 
Onset. 

8  to  i6. 

4  to  6. 

4  to  6. 

l6  to  20. 

After  30. 

Any  age. 

4  to  6. 
Insidious. 

Insidious. 

Insidious. 

Insidious. 

Sudden. 

Insidious. 

From  birth. 

Pain. 

In  back. 

None. 

Referred    to 
anterior  ab- 
domen. 

Severe  in 
spine. 

In  spine. 

None. 

In  knee. 

History. 

Xone. 

Rachitic. 

Tuberculous. 

Trauma. 

None. 

From  birth. 

Tuberculous. 

Posture. 

Free. 

Excessively 
free. 

Guarded 
spine. 

Guarded. 

Guarded 

spine. 

Typical. 

Guarded  hip. 

Muscular 

None.            , 

Free. 

In  spine. 

In  spine. 

In  spine. 

In    one    di- 

In hip  in  all 

rigidity. 

rection 
only. 

directions. 

Temperature. 

Xormal. 

Xormal. 

I  degree  rise. 

Varies. 

Normal. 

Xormal. 

I  degree  rise. 

Local  tender- 

Xone. 

None. 

In  spine. 

Painful 

All   over 

None. 

In  hip. 

ness. 

all  over. 

spine. 

Night  cries. 

Absent. 

Absent. 

Present. 

Absent. 

Absent. 

Xone. 

Present. 

Tendency   to 

None. 

None. 

Probable 

Xone. 

Xone. 

Xone. 

Probable. 

abscess. 

X-ray. 

Character- 

Xormal. 

Focus  in 

Xormal. 

Late 

Distortion 

Spine     nor- 

istic defor- 

spine. 

bridges  of 

of  cervical 

mal. 

mity. 

bone.     No 
necrosis. 

•    spine. 

Hot-water 

No  tender- 

None. 

Localized  in 

Sensitive 

Sensitive- 

No tender- 

No    tender- 

test. 

ness. 

spine. 

all  over 
spine. 

ness. 

ness. 

ness  in 
spine. 

General 

Constant. 

Constant. 

Intermit- 

Constant. 

Constant. 

Constant. 

Intermit- 

symptoms. 

tent. 

tent. 

Scoliosis  is  a  non-pathological  distortion  of  the  spine  characterized  by  rota- 
tion and  lateral  bending,  hence  the  name,  rotary  lateral  curvature  (Plate  9). 
It  is  either  functional  or  organic. 

Functional  scoliosis  is  caused  by  any  prolonged  alteration  in  the  relation- 
ship normally  existing  between  the  axis  of  the  shoulders  and  the  axis  of  the  hips. 
The  etiological  factors  depend  upon  the  maintenance  of  faulty  postures  in  occu- 
pations, especially  during  the  period  of  growth.  School-life  is  especially  in- 
fluential in  producing  the  condition  because  school  furniture  is  adapted  to  the 
average  requirements  of  a  given  class,  and  therefore  a  very  small  proportion  of 
pupils  are  able  to  find  desks  and  benches  that  are  suitable.  Properly  furnished 
modern  schools  are  supplied  \\-ith  desks  and  seats  that  are  adjustable  to  each 
occupant.  Gould  ("The  Ocular  Factors  in  the  Etiology  of  Spinal  Curvature," 
H.  Augustus  Wilson,  "New  York  Medical  Journal,"  July  12,  1906)  has  directed 
attention  to  the  errors  of  refraction  that  produce  head  tilting  and  thereby 
induce  scoliosis.  In  adults,  scoliosis  is  observable  in  blacksmiths,  fencing 
masters,  and  waiters,  in  whom  excessive  use  of  the  right  arm  produces  an  asym- 
metrical posture  of  the  body.  If  a  child  has  chronic  appendicitis  it  holds  the 
trunk  bent  toward  the  right  side.  A  spinal  conve.xity  to  the  left  forms  in  the 
lumbar  region  and  to  the  right  in  the  dorsal  region. 

When  functional  scoliosis  is  not  corrected  or  occurs  in  rachitic  or  indolent 
children,  it  results  in  organic  or  permanent  changes  in  the  contour  of  the  bones 
composing  the  spinal  column.  Organic  scoliosis  may  be  congenital,  caused  by 
prenatal  deficiencies  or  augmentations  of  the  spinal  column. 

Postmortem  e.xaminations  reveal  a  confirmation  of  Wolfe's  law  that  pro- 
longed alteration  of  the  normal  functions  always  results  in  changes  of  anatomical 
structures.  In  extreme  cases  the  bones  of  the  spinal  column  become  extensively 
altered  in  shape,  the  ribs  are  altered  in  contour,  and  the  thoracic  and  abdominal 
viscera  are  forced  into  unnatural  positions  and  assume  abnormal  shapes,  their 
functions  often  being  materially  altered. 


SPINAL    CURVATURE. 


Plate  9. 


Rotary  lateral  ciirvature  of  the  SDinc 


Scoliosis 


949 


Diagnosis. — The  patient  is  usually  taken  to  the  physician  because  of  appar- 
ent elevation  of  one  shoulder,  or  because  one  hip  is  thought  to  be  larger  than 
its  mate,  or  one  mamma  higher  than  the  other.  Dressmakers  and  corset 
makers  are  generally  the  first  ones  to  direct  attention  to  the  faulty  posture 
(as  scoliosis  occurs  in  8  girls  to  i  boy).  A  patient  suspected  of  having  scoliosis 
should  be  nude  at  the  time  of  inspection,  as  clothing  hampers  the  normal  action 
and  tends  to  conceal  the  movements  of  the  body.  The  accompanying  diagnostic 
table  (see  page  948)  is  a  condensed  comparative  statement  of  the  important 
features  in  diseases  and  conditions  that  may  resemble  scoliosis  in  some  respects. 
It  is  only  by  carefully  studying  the  symptom-complex  that  a  definite  decision 
can  be  reached.  It  is  frequently  observed  that  patients  with  mild  types  of 
functional  scoHosis  can  sit  or  stand  erect  for  a  few  minutes  and  thereby  deceive 
even  a  critical  observer.  The  habitual  posture,  and  also  the  rapidity  with 
which  the  patient  returns  to  the  distorted  position  after  temporary  voluntary 
correction,  demand  careful  attention.  Young  children,  when  chided  by  parents 
or  teachers,  often  temporarily  assume  an  approach  to  a  normal  posture  without 
actual  correction.  The  ease  with  which  their  surrounding 
joints  yield  in  compensatory  action  is  often  overlooked.  A 
patient  with  contracture  of  the  pectoral  muscles  will  elevate 
the  shoulders  into  an  apparent  correction  of  stoop  or  round 
shoulders  instead  of  throwing  the  shoulders  well  back,  a 
posture  that  is  to  them  impossible. 

Goldthwait  has  directed  attention  to  forward  curves  of 
the  scapula  that  are  often  present  in  patients  who  are 
stoop-shouldered  and  has  devised  an  operation  for  correction. 

In  the  same  way,  a  patient  who  has  preternatural  con- 
tracture of  the  ham-string  tendons,  either  unilateral  or 
bilateral,  will  often  conceal  that  condition  by  bending  the 
knee  or  knees  enough  to  permit  the  pelvis  and  trunk  to 
bend  forward. 

Treatment  consists  especially  in  removing  the  cause. 
If  the  eyes  produce  head-tilting,  proper  refraction  will  be 
necessary.  Adenoids  should  be  removed.  The  clothing 
should  be  regulated  to  avoid  constriction  and  the  shoulder 
straps  should  fit  close  to  the  neck  and  not  be  allowed  to  slip  on  to  the 
shoulder-joint. 

Contractures  of  the  pectoral  muscles  should  be  stretched  by  corrective 
manipulations.  Hamstring  contracture  should  be  removed  by  corrective 
manipulation.  Hoke  ("A  Study  of  a  Case  of  Lateral  Curvature  of  the  Spine:  A 
Report  On  an  Operation  for  the  Deformity,"  "Amer.  Jour.  Orthop.  Surg.," 
vol.  i,  November,  1903,  p.  169)  has  devised  an  operation  of  rib  resection  for 
cosmetic  purposes.  Every  effort  should  be  made  to  prevent  the  occurrence  of 
scoliosis.  The  successful  treatment  of  scoliosis  depends  on  preventing  its 
progress.  Each  individual  patient  requires  careful  study  to  determine  the 
special  characteristics  that  may  be  present. 

Remedial  measures  should  be  employed  that  meet  the  peculiar  individual 
requirements  of  each  case. 

School  gymnastics  are  generally  more  harmful  than  beneficial  in  cases  of 
scoliosis.  No  one  but  a  physician  should  prescribe  the  gymnastic  work.  The 
soft  bones  may  be  still  further  distorted  by  injudicious  exercises. 

The  first  requirement  in  the  application  of  applied  physical  culture  is  to 
secure  the  hearty  cooperation  of  the  patient.  Without  such  cooperation  pro- 
gress cannot  be  expected. 

No  gymnastic  apparatus  of  any  kind  is  required  when  the  patient  can  be 
instructed  in  the  proper  methods  of  autoresistance.  There  are  over  four 
thousand  movements  of  the  body  that  may  be  employed  in  remedial  physical 


Fig.  604. 
Lateral  dorsal 
curvature  to  the 
right,  and  com- 
pensatory lumbar 
curve  to  the  left. 


950  Surgery  of  the  Spine 

culture.  From  this  vast  assorlment  those  may  be  selected  that  are  suitable  to 
the  peculiar  conditions  of  the  patient.  At  first  the  least  tiresome  forms  are  to 
be  employed,  and  gradually  and  progressively  others  are  resorted  to  until  the 
patient  presents  a  strong  robust  development.  Usually  about  a  year  is  required 
for  the  purpose,  as  the  progress  must  be  essentially  educational.  Training 
in  developing  muscle  action  goes  hand  in  hand  with  instruction  in  walking,  in 
sitting,  and  in  all  the  postures  assumed  by  the  human  body  in  the  various  occu- 
pations of  the  patient. 

In  organic  scoliosis,  in  which  the  distortion  is  more  or  less  of  a  permanent 
character,  much  can  be  accomplished  in  preventing  the  progess  of  the  condi- 
tion as  well  as  in  aiding  correction  by  removing  any  rigidity  that  may  be  pres- 
ent. By  increasing  the  flexibility  we  facilitate  muscular  development  in  much 
the  same  manner  as  in  functional  scoliosis. 

When  rigidity  is  present  it  must  be  considered  in  the  same  light  as  rigidity 
of  any  other  joints.  Its  presence  prevents  muscular  development.  Manipu- 
lative measures  are  similar  in  effect  to  those  employed  in  fibrous  ankylosis  of 
any  joint,  and  are  peculiar  to  the  parts  involved.  In  the  majority  of  cases  the 
force  for  manipulative  correction  must  be  applied  through  the  interposition  of 
the  ribs,  and  the  great  danger  of  producing  fractures  of  these  structures  should 
be  realized. 

If,  however,  there  is  any  tendency  to  increase  of  the  deformity,  a  suitable 
brace  or  removable  jacket  of  plaster  or  celluloid  should  be  applied  to  maintain 
correction  until  the  musculature  has  been  strengthened  and  trsined  to  perform 
its  full  functions. 

Organic  or  structural  scoliosis  has  been  shown  by  Abbott,  of  Portland, 
to  be  capable  of  correction  by  several  types  of  fixed  jackets  (E.  G.  Abbott, 
"New  York  Med.  Jour.,"  1912,  and  A.  M.  Forbes,  Ibid.,  July  6,  1912).  The 
keynote  of  the  treatment  in  each  method  is  flexion  of  the  spine,  as  in  that 
position  the  vertebrae  are  unlocked.  Partial  correction  is  secured  by  means 
of  bandages  pulling  in  various  directions  and,  after  proper  padding,  a  plaster 
jacket  is  applied.  Further  progress  to  overcorrection  is  continued  by  means  of 
pads  of  felt  slipped  under  the  jacket  to  increase  the  pressure  in  certain  direc- 
tions. After  overcorrection  has  been  obtained,  a  celluloid  jacket  is  worn  to 
maintain  this  and  exercises  are  assiduously  employed  to  restore  muscle  function. 
These  methods  of  treatment  constitute  the  greatest  advances  in  this  work  in 
many  years,  but  to  secure  the  best  results  they  must  be  followed  out  most  care- 
fully by  a  skilled  physician.  Special  forms  of  apparatus  are  essential  in  the 
appUcation  of  these  jackets.  The  combination  of  the  gymnastic  and  mechan- 
ical treatment  in  severe  functional  and  in  organic  scoliosis  proves  the  most 
satisfactory  in  that  it  not  only  restores  muscle  balance,  but  also  corrects  de- 
formity, and  secures  as  great  correction  of  the  deformity  as  possible  before 
ankylosis  occurs.  Any  appliance  used  in  these  cases  should  be  made  to  order 
to  fit  the  peculiarities  of  the  patient  and  should  never  be  one  of  the  shop-kinds 
that  are  so  extensively  advertised.  Much  valuable  time  is  often  lost  while  unme- 
chanical  and  unsuitable  apparatus  is  being  used,  during  which  time  the  bony 
changes  may  become  permanent  and  beyond  repair. 

Anteroposterior  curvature  (not  from  spinal  caries  or  from  hip-joint  dis- 
ease) is  an  increase  of  the  normal  anteroposterior  curves.  Increase  of  the 
dorsal  curve  is  posterior  curvature,  kyphosis,  or  excurvation  (Fig.  605,  a)  ;  in- 
crease of  the  lumbar  curve  is  anterior  ncrvature,  lordosis,  or  saddle-back  (Fig. 
605,  b).  Both  lordosis  and  kyphosis  are  apt  to  be  present.  Scoliosis  has  nearly 
always  some  anteroposterior  curvature  associated  with  it.  Lordosis  is  apt  to 
be  compensatory,  to  prevent  the  center  of  gravity  going  too  far  forward.  Lor- 
dosis is  found  in  pregnant  women  and  in  very  fat  men.  In  an  old  man  kyphosis 
arises  because  of  flattening  out  of  the  vertebral  disks  from  pressure.  Rheu- 
matic gout  may  cause  anteroposterior  curvature.     Anteroposterior  curvature 


Angular  Curvature  951 

is  often  due  to  paralysis  of  the  erector  spinie  mass  (from  infantile  paralysis). 
Pseudohypertrophic  paralysis  causes  lordosis. 

Symptoms  aiul  Treatment. — The  symptoms  of  anteroposterior  curvature  are 
as  follows:  the  thora.x  is  flattened  or  pigeon  breasted;  the  shoulder-blades  are 
widely  separated  and  the  scapular  angles  project;  the  abdomen  is  protuberant; 
the  patient  complains  of  backache  and  soon  tires.  A  recent  kyphosis  disappears 
when  the  patient  lies  upon  his  stomach.  The  facts  that  the  erector  spinas 
muscles  are  soft  and  that  pain  is  absent  on  concussion  transmitted  to  the  back 
separate  kyphosis  from  caries.  Lordosis  is  unmistakable.  When  the  spine  is 
movable,  employ  the  same  plan  of  treatment  as  in  lateral 
curvature,  suiting  the  gymnastics  to  the  deformity.  In 
painful  kyphosis  with  partial  ankylosis  endeavor  to  make 
the  ankylosis  complete  in  order  to  prevent  pain,  obtaining 
this  result  by  applying  a  plaster  jacket  which  laces  up 
and  letting  the  patient  wear  it  for  several  years. 

Angular  curvature  {spinal  caries;  spondylitis;  Pottos 
disease)  is  usually  due  to  tuberculous  caries  of  the 
vertebral  bodies,  and  occurs  particularly  in  children 
who  are  the  victims  of  tuberculosis,  but  it  may  arise  at 
any   age.     Any   portion   of   the    spinal    column    may    be 

attacked.     The  dorsolumbar  region  is  most  prone  to  suffer.    -^^^    ,         t-     u    • 
rr,i        1  •   r  •         1  1-1  1  -I-  1  1  t"iG.  605. — Kyphosis 

ihe  chief  cause  is  tuberculosis,  but  syphilis  and  secondary      (a)  and  lordosis  (b). 
cancer  of  the  vertebrae  are  occasional  causes,   and  acute 
osteomyelitis  is  a  very  rare  cause  (see  page  945).     Blows  or  sprains  appear  to 
have  a  causal  influence  in   some   cases   (see  Trauma  in  Tuberculosis,   page 
247).     Angular  curvature  may  develop  after  an  exanthematous  fever. 

The  cancellous  tissue  of  the  anterior  portion  of  the  vertebral  body  becomes 
primarily  carious,  or  the  inflammation  begins  in  an  intervertebral  disk.  The 
changes  of  tuberculous  osteitis  have  previously  been  set  forth  (see  pages  275, 
565,  and  566).  The  body  of  the  vertebra  and  the  vertebral  disk  are  destroyed, 
and  the  process  extends  to  adjacent  vertebrae.  The  weight  which  rests  upon 
the  spinal  column  causes  softened  bone  to  crumble,  compresses  the  diseased 
vertebrae  and  disks,  and  produces  angular  deformity  (the  anterior  part  of  the 
column  formed  by  the  vertebral  bodies  is  shortened,  the  posterior  part  is  not, 
and  hence  the  spines  project).  In  some  cases  the  disease  is  spontaneously 
arrested  by  organization  of  inflammatory  products,  and  ankylosis  (fibrous  or 
bony)  in  deformity  is  Nature's  cure.  In  most  cases,  however,  the  disease 
spreads  and  caseous  pus  is  formed,  which,  according  to  the  point  of  formation 
and  the  route  it  takes,  causes  lumbar  abscess,  dorsal  abscess,  psoas  abscess, 
or  postpharyngeal  abscess  (see  pages  266  and  267).  In  some  cases  the  spinal 
cord  is  compressed,  but  in  most  cases  it  is  not,  and  even  when  it  is  compressed 
paraplegia  is  rare  and  is  usually  temporary.  Compression  of  the  cord  may 
be  caused  by  the  displaced  vertebrae,  by  inflammatory  material  or  caseous  mat- 
ter between  the  bone  and  dura  mater,  but  is  most  often  due  to  pachymen- 
ingitis. Caries  of  the  cervical  region  constitutes  a  more  dangerous  disease 
than  caries  of  either  the  dorsal  or  the  lumbar  region  {dangerotis  pressure 
may  occur  here).  Death  may  be  caused  by  exhaustion,  sepsis,  hemorrhage, 
amyloid  disease,  pneumonia,  peritonitis,  pleuritis,  tuberculous  dissemination, 
pressure  upon  the  cord,  or  inflammation  of  the  cord  or  its  membranes. 

Symptoms. — The  sufferer  from  Pott's  disease,  if  a  child,  grows  tired  easily. 
The  disposition  alters.  The  victim  becomes  weak,  sickly,  moody  and  irritable, 
and  complains  of  vague  pains  in  many  places,  and  is  disposed  to  lean,  rest,  or 
lie  down,  suffers  on  movement  but  is  easy  when  at  rest.  The  child  w^alks 
with  the  back  rigid,  which  produces  a  peculiar  gait.  Examination  may  dis- 
close evidences  of  pulmonary  or  glandular  tuberculosis.  A  painful  spot  may 
be  found  by  pressing  upon  the  spines.     Faradism  to  the  back  causes  pain. 


952  Surgery  of  the  Spine 

Spasm  of  the  erector  spinae  mass  is  detected  (Hilton,  Golding-Bird).  It 
is  not  proper  to  seek  to  develop  pain  by  jarring  the  back  or  by  pressing  the 
head  downward.  The  posture  of  the  child  and  the  muscular  rigidity  prove 
the  existence  of  inflammation,  and  to  seek  to  develop  pain  by  the  methods 
referred  to  may  do  harm,  and  at  best  can  only  call  attention  to  what  is  already 
known.  Pain  in  the  back,  which  is  increased  by  motion,  by  pressure,  and 
by  vertebral  jars,  may  be  absent  until  late  in  the  case.  Distinct  pain  and 
tenderness  in  the  back  often  mean  abscess  formation.  Neuralgic  pains 
pass  into  distant  parts  (sciatica,  intercostal  neuralgia)  and  are  often  linked 
with  muscular  spasm.  A  chronic  bilateral  pain  in  the  trunk  or  extremities  is 
suggestive  of  Pott's  disease.  "Chronic  bilateral  bellyaches  in  children  are 
almost  diagnostic"  (Jordan  Lloyd).  The  pain  of  dorsal  caries  can  be  re- 
lieved by  lifting  the  shoulders;  the  pain  of  cervical  caries,  by  traction  on  the 
head.  Cramp  in  the  legs  occurs  in  dorsal  and  in  lumbar  caries.  The  pres- 
ence of  the  knuckle  due  to  bending  the  spine  at  an  acute  angle  is  a  very  im- 
portant sign  of  the  disease.  In  many  cases  angular  deformity  appears  late; 
in  some  cases  it  does  not  appear  at  all.  An  angular  deformity  is  detected 
sooner  in  those  regions  where  the  normal  curves  are  posterior  than  where 
the  normal  curves  are  anterior.  The  deformity  appears  early  in  the  dorsal 
region,  but  late  in  the  cervical  and  lumbar  regions.  In  many  cases  lateral 
deformity  occurs.  Rigidity  is  an  early  sign  of  great  importance.  It  is  always 
present.  Rigidity  is  manifest  very  early  in  cervical  caries,  tolerably  early 
in  lumbar  caries,  late  in  dorsal  caries.  Lloyd  gives  the  following  practical 
rules  to  enable  us  to  detect  rigidity. ^  In  the  cervical  region:  seat  the  patient 
in  a  chair  and  tell  him  to  nod  the  head  affirmatively.  Stiffness  in  nodding 
points  to  occipito-atloid  disease.  Tell  him  to  look  far  to  the  right  and  then 
far  to  the  left.  Stiffness  of  these  motions  suggests  atlo-axoid  disease.  Tell 
him  to  place  his  shoulders  against  the  back  of  the  chair  and  carry  his  eyes 
back  along  the  ceiling.  Stiffness  in  this  movement  indicates  disease  below 
the  second  cervical  vertebra.  It  is  practically  useless  to  examine  the  dorsal 
region  of  an  adult  for  rigidity,  but  such  an  examination  can  be  made  in  a  child. 
Place  the  patient  prone  on  an  adult's  lap,  mark  the  tip  of  each  spinous  process 
with  an  anilin  pencil,  then  make  the  child  stand  up  straight  on  the  floor,  and 
observe  if  any  of  the  pencil  marks  fail  to  come  nearer  together.  If  it  is  seen 
that  two  or  more  marks  do  not  approach  each  other,  there  is  rigidity  which 
prevents  approximation.  To  test  for  rigidity  in  the  lumbar  region  lay  the 
naked  patient  prone  upon  a  couch.  Grasp  the  patient's  ankles  and  raise 
the  pelvis  from  the  couch.  If  the  lumbar  spine  is  flexible,  the  pelvis  can 
be  lifted  without  raising  the  chest  from  the  bed,  and  the  maneuver  deepens 
the  hollow  of  the  loin.  If  the  lumbar  spine  is  stiff,  the  maneuver  lifts  the 
trunk  and  produces  no  alteration  in  the  vertical  outline  of  the  lumbar  spines. 
If  a  child  with  Pott's  disease  is  asked  to  pick  up  something  from  the  ground, 
because  of  rigidity  or  pain  on  movement  he  will  not  bend  the  back,  but  will 
bend  the  knees  or  get  upon  the  knees.  Paralysis  may  exist,  and  it  is  due  to 
pachymeningitis  more  often  than  to  pressure  from  bone.  Cervical  caries 
causes  dyspnea  and  torticollis,  the  head  requiring  support  with  the  hands. 
Dysphagia  indicates  abscess.  In  adults  the  first  signs  of  Pott's  disease  to  at- 
tract attention  are  headache,  backache,  neuralgia,  girdle  pain,  cramp,  or  even 
paralysis.  In  abscess  due  to  caries  of  the  dorsolumbar  vertebrae  the  pus  usually 
enters  the-  psoas  muscle  and  passes  out  of  the  pelvis  below  the  junction  of 
the  middle  and  outer  thirds  of  Poupart's  ligament.  It  may  point  here  or  may 
pass  to  the  inner  aspect  of  the  thigh  and  point  a  little  below  the  spot  where 
a  femoral  hernia  is  met  with  if  it  exists.  In  a  psoas  abscess  a  mass  is  always 
felt  in  the  iliac  fossa  above  Poupart's  ligament;  in  a  hernia  no  such  mass  exists 
(J.  T.  Rugh).  In  sacral  caries  there  is  no  deformity  and  frequently  no  pain. 
*  "Birmingham  Med.  Review,"  April,  1897. 


Angular  Curvature 


953 


The  diagnosis  becomes  apparent  when  bilateral  abscess  is  detected  in  the  but- 
tocks or  groins  (Jordan  Lloyd).  If  an  abscess  due  to  spinal  caries  opens  spon- 
taneously, sinuses  form  and  persist,  there  will  be  free  discharge  of  tuberculous 
pus  containing  tubercle  bacilli  and  healing  will  not  occur.  The  .T-rays  will 
usually  show  some  large  sequestra.  If  mixed  infection  takes  place  death  may 
follow. 

Treatment  of  Caries  of  the  Spine. — Wlien  recent  caries  of  the  spine  is  active 
and  affects  a  child;  when  it  is  accompanied  by  pain  and  fever;  and  when  pa- 
ralysis threatens,  insist  upon  perfect  rest.  Place  the  child  supine  on  a  hard 
mattress,  and,  if  possible,  take  it,  while  in  a  portable  bed,  out  of  doors  daily. 
Leeches,  blisters,  or  the  hot  iron  over  the  area  of  pain  may  do  good.  When 
the  activity  of  the  process  abates,  apply  a  fixation  apparatus.  In  diseases 
at  or  near  the  vertebro-occipital  articulation,  as  long  as  dyspnea  persists, 
keep  the  patient  supine  with  a  small  hard  pillow  under  the  nape  of  the  neck 
(Hilton)  and  a  sand-bag  on  each  side  of  the  head  and  neck.  After  several 
months  mechanical  support  can  be  given  by  Furneaux  Jordan's  method. 
Jordan  applies  his  support  as  follows:  The  patient  lies  on  a  flat,  hard  table,, 


Fig.  606. — Plaster-of-Paris  jacket  (Sayre). 


Fig.  607. — Plaster-of-Paris  jacket  and  jury- 
mast  applied  (Sayre). 


his  arms  are  raised  above  his  head,  and  traction  is  made  upon  the  head  by 
means  of  a  pulley  and  a  weight.  Cotton  pads  are  placed  over  the  ears,  the 
back  of  the  neck  and  the  clavicles,  and  are  held  in  place  by  a  broad  flannel 
bandage  applied  as  a  figure-of-8  on  the  head,  neck,  and  chest.  The  flannel  band- 
age is  overlaid  with  plaster-of -Paris  bandages. ^  In  disease  of  the  cervical  region 
below  the  axis,  or  of  the  dorsal  region  above  the  seventh  vertebra,  use  Sayre 's 
jury-mast  (Fig.  607),  or  some  other  form  of  head  support.  Instead  of  the 
jury-mast  a  steel  upright  may  be  used  to  hold  the  head  rigid.  Sayre's  ap- 
pliance relieves  the  spine  from  the  weight  of  the  head  and  acts  admirably. 
In  most  cases  of  dorsal  and  lumbar  caries  a  steel,  leather,  or  plaster  jacket 
as  a  fixation  apparatus  must  be  employed.  The  best  of  all  fixation  apparatus 
is  Sayre's  plaster-of -Paris  jacket  applied  while  the  patient  is  suspended  (Fig. 
606)  or,  better,  while  the  column  is  in  hyperextension.  The  Sayre  apparatus 
applied  in  this  manner  is  used  for  the  treatment  of  caries  of  the  lumbar  re- 
gion and  the  lower  half  of  the  dorsal  region,  or  a  plaster  jacket  may  be  applied 
while  the  patient  is  lying  prone  in  a  hammock  or  stretched  between  two  tables. 
Greater  corrective  pressure  over  the  deformity  is  secured  by  this  method  than 
by  suspension.     When  all  subjective  signs  cease,  substitute  for  the  plaster-of- 

1  See  "Children's  Deformities,"  by  Walter  Pye. 


954  Surgery  of  the  Spine 

Paris  jacket  a  felt  or  sole-leather  jacket  which  laces  down  the  front.  Caries 
of  the  upper  half  of  the  dorsal  region  is  often  treated  by  a  Sayre's  jury-mast 
(F"i".  607);  but  if  the  jury-mast  fails,  it  may  be  necessary  to  place  the  patient 
horizontally  in  "an  open  cuirass,  fitted  to  the  back  from  occiput  to  sacrum, 
and  combined  with  pulley  extension  to  the  head  and  pelvis."^ 

During  the  course  of  caries  of  the  spine  have  the  patient  eat  fat-forming 
and  nutritious  food,  insist  on  a  plentiful  supply  of  fresh  air  day  and  night, 
and  administer  tonics.  Full  antituberculous  treatment  is  imperative  (see 
page  255).  Sea-air  is  very  beneficial.  When  all  active  disease  ceases  and 
only  angular  curvature  remains,  use  an  apparatus  to  combine  extension  with 
mechanical  support,  the  plaster  jacket  being  generally  employed. 

Albee's  Bone  Transplantation  Method  of  Treatment.— The  ordinary 
ambulatory  treatment  of  Pott's  disease  is  seldom  satisfactory.  It  is  particu- 
larly unsatisfactory  in  the  upper  dorsal  region.  Ridlon  and  Jones  emphasize 
this  fact  and  declare  that  when  the  disease  is  situated  in  that  region  only  pro- 
longed recumbency  prevents  increase  of  the  deformity.  Albee  reached  the 
conclusion  that  the  treatment  should  be  one  which  secures  bony  union  and 
hence  perfect  immobihty.     Perfect  bony  fixation  means  cure. 

Albee  was  accustomed  to  see  perfect  cure  in  hip  tuberculosis  after  anky- 
losing the  joint,  and  in  knee  tuberculosis  after  erasion.  He  has  secured  a 
Hke  result  in  vertebral  caries  by  grafting  into  the  spinous  processes  a  large  piece 
of  bone  cut  from  the  patient's  tibia.  This  graft  usually  becomes  fixed  to  the 
spinous  processes.  It  at  least  unites  with  the  surrounding  ligamentous  struc- 
tures and  gives  unyielding  support  which  produces  cure  (see  page  968).  It 
is  a  highly  useful  method  (Albee,  in  ''New  York  Med.  Jour.,"  March  9,  191 2; 
in  "Post-Graduate,"  Nov.,  191 2). 

Beyond  question  this  is  a  very  valuable  method.  The  mortality  is  extremely 
low.  The  fixation  is  secured  within  a  year  (other  methods  require  several  or  a 
number  of  years).  The  diseased  area  undergoes  cure.  An  abscess  usually 
disappears  without  being  opened  and  in  most  cases  all  manipulations  are  carried 
out  on  healthy  tissue  (J.  T.  Rugh,  in  "Am.  Jour.  Orth.  Surg.,"  1916,  xiv). 

Spinal  abscesses  are  treated  as  indicated  on  pages  270  and  271. 

Paralysis  in  Pott's  Disease. — Partial  or  complete  motor  and  sensory  pa- 
ralysis may  develop  in  the  course  of  vertebral  caries.  It  may  be  due  to  the 
pressure  of  tuberculous  material  or  to  pachymeningitis  with  thickening  of 
the  membrane.  In  only  2  per  cent,  of  cases  of  paralysis  is  the  paralysis  due  to 
the  pressure  of  angled  bone  (Willard).  The  paralysis  may  come  on  gradually. 
There  are  weakness  in  walking  or  actual  inabihty  to  walk,  exaggerated  reflexes, 
muscular  rigidity,  and  impaired  sensation  in  the  legs,  and  loss  of  control  of 
the  bladder  and  rectum.  Caries  in  the  high  dorsal  region  is  more  apt  to  result 
in  paralysis  than  in  any  other  region  because  of  the  small  size  of  the  canal. 
Pressure  in  the  cervical  region  is  highly  dangerous. 

Treatment.— V^e.  must  remember  that  angulation  is  the  rare  cause,  tubercu- 
lous masses  the  common  cause.  Treatment  for  paralysis  due  to  tuberculous 
masses  is  the  full  open-air  treatment  of  tuberculosis,  with  rest,  fixation, 
and  progressive  straightening  of  the  spine.  The  patient  is  kept  in  bed  (see 
Treatment  of  Tuberculosis,  page  255)  on  a  Bradford  frame  and  with  his  head 
over-extended.  If  after  one  year  the  condition  is  not  notably  improved, 
do  laminectomy  and  clear  away  tuberculous  masses.  If  angulation  is  the 
cause  of  the  paralysis,  consider  gradual  correction,  laminectomy,  and  Albee's 
bone  transplantation.  In  several  of  the  cases  reported  by  Albee  recovery 
from  paralysis  occurred  soon  after  bone-grafting. 

Gradual    Correction    of   Angular   Deformity.— Pressure   is  made  upon  the 
hump  with  the  hand,  and  while  the  hand  is  thus  held  the  weight  of  the  body  is 
allowed    to  bear  upon  it  above  and  below.     Something  is  perhaps  gained  and. 
1  Jordan  Lloyd,  in  "Birmingham  IMcd.  Review,"  April,  iSq;. 


Symptoms  of  Spondylitis  Deformans  955 

then  plaster  of  Paris  is  applied,  somewhat  later  a  little  more  gain  is  obtained,  and 
so  on.     This  method  is  safer  and  more  satisfactory  than  forcible  correction. 

Forcible  correction  of  angular  deformity  was  advocated  by  Chipault  and 
Calot  in  cases  of  Pott's  disease  without  abscess.  It  was  only  used  in  angu- 
lar deformity  of  the  middle  and  lower  part  of  the  dorsal  region  and  was  not 
advised  in  the  cervical,  upper  dorsal,  or  lumbar  regions.  The  operation  is  not 
safe,  and  a  number  of  deaths  have  been  reported.  Gabaert^  pointed  out  certain 
disasters  which  might  follow  forcible  correction;  they  are:  death  during  an- 
esthesia; rupture  of  an  abscess;  subsequent  paralysis  of  the  legs  and  bladder; 
disseminated  tuberculosis,  and  shock,  with  convulsions  and  death.  1  do  not 
believe  in  forcible  correction  and  I  do  believe  that  the  alleged  dangers  are 
real  dangers,  that  the  operation  is  unsafe,  and  that  it  should  never  be  done. 

Laminectomy  is  warmly  advocated  by  some  surgeons  for  paraplegia  from 
spinal  caries.  This  operation  is  rarely  necessary,  but  in  some  few  cases  it 
is  imperatively  demanded.  Many  cases  recover  from  paraplegia  without 
operation.  Operation  for  paraplegia  has  a  very  heavy  mortality  (25  per  cent.), 
and  many  are  not  benefited  at  all  by  it.  If  degeneration  of  tracts  in  the  cord 
has  occurred,  operation  cannot  help  the  paralysis.  Nevertheless,  in  some 
cases  laminectomy  has  certainly  cured  palsy  and  saved  life.  Menne  has  col- 
lected 132  cases  of  laminectomy.  Of  these  56  per  cent,  were  cured  or  perma- 
nently improved  and  18  per  cent,  were  temporarily  improved. 

Laminectomy  should  not  be  undertaken  until  treatment  by  rest,  fixation, 
and  extension  has  been  applied  for  at  least  one  year.  Laminectomy  may 
become  necessary  in  cervical  caries  to  prevent  asphyxia.  The  operation  en- 
ables the  surgeon  to  remove  masses  of  inflammatory  material  which  make 
pressure  on  the  cord,  and  also  to  free  the  cord  from  pressure  due  to  angulation. 
The  dura  should  not  be  opened  unless  there  is  evidently  trouble  beneath  it,  in 
which  case  it  is  incised  and  any  tuberculous  area  removed,  the  dura  being  sub- 
sequently sutured.  Menard  removes  the  transverse  process  of  the  diseased 
vertebvEe  and  the  heads  and  necks  of  the  associated  ribs  in  order  to  give  the 
surgeon  access  to  diseased  vertebral  bodies. 

Spondylitis  Deformans  {Bechterew's  Disease). — This  is  the  name  usually 
apphed  to  osteo-arthritis  of  the  spine  (see  page  729).  In  this  disease  osteo- 
phytic  formation  takes  place  at  the  vertebral  borders,  and  the  vertebrce  be- 
come ankylosed.  The  vertebral  bodies,  as  a  rule,  are  most  affected  by  the 
disease,  but  any  portion  of  a  vertebra  may  be  attacked,  and  often  the  heads 
of  the  ribs  are  anchored  to  the  spine  by  bone. 

The  disease  may  begin  in  infancy,  childhood,  youth,  adult  life,  or  old  age. 

Symptoms. — There  are  decided  and  persistent  pain  and  tenderness  of  the 
spine,  and  occasionally  evidence  of  pressure  on  the  nerve-roots.  Early  in 
the  case  deformity  is  apt  to  occur,  because  at  this  peroid  there  is  inflammatory 
softening.^  The  deformity  is  not  angular,  but  is  usually  a  total  kyphosis, 
the  column  being  bent  forward  from  above  and  made  into  a  single  curve.  Lat- 
eral curvature  may  occur.  In  many  advanced  cases  and  in  some  compara, 
tively  recent  cases  the  spine  becomes  rigid  and  ankylosed,  and  when  it  does- 
there  may  be  evidences  of  irritation  of  the  posterior  nerve-roots.  In  this 
condition  there  is  rigidity  of  part  or  of  the  entire  spine,  other  joints  escaping. 
If  the  entire  spine  is  involved,  there  is  rigid  cervicodorsal  kyphosis,  a  condition 
which  causes  the  neck  to  stick  forward  and  the  head  to  appear  as  if  forcibly 
driven  down  between  the  shoulders.  If  the  entire  spine  is  involved,  the  lum- 
bar spine  is  rigid  and  the  normal  lumbar  curve  disappears.  As  a  consequence 
the  patient  stands  in  an  unnatural  attitude,  the  hips  and  knees  being  partly 
flexed,  and  the  legs  and  feet  being  in  a  condition  of  external  rotation.  In 
Bechterew's  disease  there  are  compression  of  the  posterior  nerve-roots,  severe 

^  "Ann.  de  la  Soc.  Beige,"  July  15,  1898. 

-  J.  Jackson  Clarke's  book  on  ''Orthopedic  Surgery.'" 


956  Surgery  of  the  Spine 

pain,  muscular  atrophy,  and  ascending  degeneration  of  the  cord.  WTiat  Marie 
calls  spondylitis  rhizomelique  is  said  by  Osier  to  be  a  form  of  arthritis  deformans. 
There  is  rigidity  of  the  spine,  shoulders,  and  hips,  but  no  nervous  lesions,  as  in 
Bechterew's  disease. 

Treatment. — Cure  is  impossible,  but  amelioration  can  be  obtained. 

The  local  and  constitutional  treatment  is  as  for  osteo-arthritis  in  any 
region  (see  page  729).  If  spinal  curvature  begins,  a  mechanical  support  must 
be  appHed  or  Albee's  bone-grafting  operation  performed.  Rugh  operated  on 
such  a  case  with  gratifying  results  ("Internat.  Clinics,"  Vol.  I,  Twenty-third 
Series).     So  did  Finkelstein  ("Annals  of  Surgery,"  1916,  Ixiv). 

Injuries  of  spinal  ligaments  and  muscles,  which  may  complicate 
more  serious  injuries  or  may  exist  alone,  are  caused  by  wrenches,  twists,  and 
violent  muscular  efforts  (as  in  lifting).  Railway  accidents  may  be  respon- 
sible for  these  sprains  and  strains.  The  injury  is  called  railway  spine  when  it 
is  caused  by  a  railway  accident. 

Symptoms. — Injuries  of  the  back,  even  without  cord  injury,  are  frequently 
linked  with  very  deceptive  nervous  symptoms.  Symptoms  are  often  severe, 
but  are  usually  temporary.  In  some  few  cases  the  symptoms  are  persistent. 
Secondary  disease  of  the  cord  is  extremely  rare.  Any  region  may  be  affected, 
but  the  lumbar  is  most  usually  injured,  and  the  entire  spine  may  suffer.  The 
three  marked  symptoms  are  pain,  tenderness,  and  stiffness  of  the  back.  At 
the  time  of  injury  and  for  a  while  after  there  is  often  marked  shock,  and 
hysterical  excitement  is  occasionally  observed.  The  cardinal  symptoms 
may  arise  very  soon,  but  may  not  become  severe  for  a  day  or  two.  The  pain 
is  not  acute  when  at  rest,  but  becomes  acute  on  movement.^  The  pain  is 
felt  in  the  back  and  sometimes  darts  into  the  extremities.  The  muscles  of  the 
back  are  rigid,  the  spasm  being  due  to  pain.  The  patient  is  very  careful  not 
to  twist  or  bend  the  spme,  because  to  do  so  increases  pain.  In  a  one-sided 
injury  the  rigidity  is  unilateral,  and  this  symptom  cannot  be  simulated.  Often, 
but  by  no  means  always,  the  region  of  the  back  is  swollen  and  the  skin  is  dis- 
colored. The  tenderness  is  not  of  the  skin,  but  of  the  muscles.  Firm  pressure 
on  a  spot  of  real  tenderness  causes  rapid  pulse  (Mannkopfs  sign).  The 
vertebral  spines  are  regular  and  are  not  mobile.  There  is  no  distant  paralysis 
or  hyperesthesia  unless  the  cord  is  damaged  (though  in  some  rare  cases  the 
bladder  and  the  rectum  are  paralyzed  when  no  cord  lesion  can  be  detected, 
and  hyperesthesia  may  exist  over  the  spines).  Moullin  tells  us  that  the  ex- 
tremities feel  weak  because  they  are  deprived  of  proper  support  on  account 
of  the  immobility  of  the  muscles  of  the  back.  For  the  same  reason  the  action 
of  the  abdominal  muscles  is  interfered  with,  and  the  power  of  micturition 
and  of  defecation  is  impaired  (there  are  constipation  and  difficulty  in  emptying 
the  bladder). 

The  treatment  of  recent  injuries  comprises  rest,  the  application  of  an 
ice-bag,  and  leeching  over  the  painful  area.  After  a  day  or  two  hot  fomenta- 
tions, tincture  of  iodin,  compression  by  adhesive  strips,  and  inunctions  of 
ichthyol  and  lanolin  are  used;  and,  later  still,  massage,  douches,  and  frictions 
with  a  stimulating  liniment  are  employed.  Phenacetin  helps  to  relieve  pain, 
though  in  some  cases  opium  is  temporarily  necessary. 

Traumatic  neurasthenia  is  apt  to  arise  after  the  immediate  effects  of  the 
accident  subside.  In  this  condition  the  patient  grows  tired  easily  and  com- 
plains of  pains  and  aches  in  the  back  and  loins,  interfering  with  or  preventing 
work;  paresthesia  and  numbness  exist  in  the  extremities;  in  many  cases  sexual 
intercourse  is  impossible  because  of  premature  ejaculation  or  of  incapacity 
for  erection.  There  are  dyspepsia,  eye-strain,  tremor,  insomnia,  loss  of  memory, 
headache,  rapid  and  irregular  pulse,  elevated  blood-pressure,  cardiac  palpita- 
tion, and  mental  depression  or  confusion.     The  reflexes  are  usually  exaggerated^ 

'  Moullin  on  "Sprains." 


Traumatic  Hysteria  957 

but  they  can  be  exhausted  more  easily  than  can  the  exaggerated  reflexes  of 
organic  cord  disease  (because  of  irritable  weakness).  Some  rigidity  and  tender- 
ness exist  in  the  back,  and  the  skin  over  this  region  is  often  hyperesthetic. 
Attacks  of  retention  of  urine  may  occur.  Hypochondriasis  is  not  unusual. 
Neurasthenia  is  not  unusual  as  a  result  of  war  wounds.  Arteriosclerosis  pre- 
disposes to  neurasthenia  and  neurasthenia  aggravates  sclerosis.  It  is  probable 
that  the  ductless  glands  play  a  part  in  neurasthenic  states.  The  prognosis 
is  much  better  in  the  young  than  in  the  elderly,  as  the  former  are  free  from 
arteriosclerosis  (Dore,  in  "N.  Y,  Med.  Jour.,"  Sept.  9,  1916). 

Treatment  of  Traumatic  Neurasthenia. — Employ  rest,  tonics,  massage, 
douches,  and  frictions  to  the  back.  Secure  sleep,  and  endeavor  to  bring 
about  a  gain  in  weight.  If  sexual  incapacity  or  seminal  emissions  worry 
the  patient,  dilate  the  urethra  with  steel  sounds. 

Traumatic  hysteria  develops  only  in  those  predisposed  by  a  neuropathic 
hereditary  tendency;  traumatic  neurasthenia  may  arise  in  any  one.  In  the  first 
named  disease  the  accident  is  only  the  exciting  cause;  in  the  second  disorder 
it  is  the  cause.  Many  cases  of  so-called  "railway  spine"  are  really  examples 
■of  traumatic  hysteria.  Traumatic  hysteria  and  neurasthenia  may  be  asso- 
-ciated.  Neurasthenia  is  a  condition  of  exhaustion  associated  with  a  number 
•of  chronic  disorders;  it  forms  a  foundation  on  which  hysteria  is  apt  to  build 
its  structure.  The  structure  of  hysteria  is  made  up  of  morbid  impression- 
ability, hyperesthesia  of  centers,  lowered  self-control,  and  sensitiveness  of 
the  peripheral  nervous  system.  The  accident  plays  a  double  part  in  pro- 
ducing traumatic  hysteria — first,  by  its  effect  on  the  mind  (psychical  trau- 
matism); second,  by  its  effect  on  the  body,  which  anchors  the  attention  to 
one  point.  An  area  of  pain  or  stiffness  often  serves  as  an  autosuggestion 
which  undergoes  morbid  magnification  when  viewed  through  the  distorting 
medium  of  hysteria.  Erichsen  taught  that  the  symptoms  of  what  he  named 
"railway  spine"  arose  from  inflammation  of  the  cord  and  its  membranes, 
a  view  now  abandoned.  A  blow  given  to  a  hysterical  person  causes  a  feeling 
•of  numbness,  and  thus  negative  sensation  from  local  shock  may  establish 
the  idea  of  paralysis,  or  traumatism,  acting  as  a  suggestion,  may  inhibit  motor 
representations  and  destroy  the  normal  ideas  of  motion  and  feeling  (Charcot" 
and  Pitre).  Terror  always  causes  a  feeling  of  loss  of  power  in  the  legs,  and 
the  terror  of  the  accident  may  thus  develop  the  idea  of  paraplegia.  The  site 
of  a  traumatism  may  localize  symptoms;  for  instance,  a  blow  upon  the  eye 
may  cause  amaurosis  or  blepharospasm.  It  is  important  to  remember  Charcot's 
saying  that  a  hysteria  long  latent  and  unrecognized  may  be  awakened  into 
obvious  activity  by  a  blow  or  an  accident.  Pitre  shows  the  same  to  be  true 
of  epilepsy.  A  not  unusual  lesion  is  hysterical  traumatic  monoplegia,  not 
coming  on  at  once  after  the  accident,  but  usually  some  days  afterward,  and 
presenting  flaccid  muscles,  the  electrical  reactions  and  reflexes  remaining  normal, 
but  the  muscular  sense  being  lost  (Pitre).  The  muscles  usually  waste.  The 
skin  of  the  paralyzed  limb  is  anesthetic  or  analgesic.  There  may  be  anesthesia 
limited  to  a  limb,  hemianesthesia,  or  general  anesthesia.^  Hysterical  paralysis 
is  usually  associated  with  the  permanent  stigmata  of  hysteria — concentric 
contraction  of  the  visual  field,  pharyngeal  anesthesia,  convulsive  seizures, 
and  hysterogenic  zones  (Clarke  and  Pitre).  The  permanent  stigmata  may  be 
latent.  Hysterical  phenomena  lack  regularity  of  evolution,  and  they  may  be 
produced,  altered,  or  abohshed  by  mental  influences  or  by  physical  forces 
which  produce  no  effect  on  organic  disease.  In  most  hysterical  conditions 
the  general  health  is  not  profoundly  impaired. ^  In  making  a  diagnosis  of 
hysteria  we  must  be  most  careful  to  exclude  both  mahgnant  disease  and  im- 
posture, because  hysteria  is  a  sort  of  diagnostic  waste-basket  into  which  we 

ij.  Mitchell  Clark,  in  "Brain." 

2  Read  the  works  of  Thorburn  and  Pitre. 


958  Surgery  of  the  Spine 

cast  most  things  which  we  fail  to  understand.  Babinski  proposes  that  we 
should  call  phenomena  hysterical  only  when  they  can  be  produced  or  can  be 
cured  by  suggestion  ("Brit.  Med.  Jour.,"  Jan.  23,  1909,  p.  234).  Brain  tumor 
may  cause  hysterical  symptoms. 

The  constant  strain,  the  exhaustion,  the  expectancy,  the  homesickness, 
the  privations,  the  exposures  of  war  are  responsible  for  many  cases  of  hysteria. 
Many  arise  in  those  who  have  been  wounded.  In  others  who  have  not  been 
wounded  and  may  have  served  long  and  gallantly,  the  overtense  strings  of 
the  nervous  system  may  seem  to  relax  suddenly  or  snap  asunder.  Many  cases 
have  been  reported  in  men  who  were  near  a  shell  explosion  but  yet  received  no 
ob\nous  physical  injury,  although  it  is  always  necessary  to  bear  in  mind  that 
even  if  no  organic  injury  presents  symptoms  which  permit  detection  there  may 
be  multiple  hemorrhages  of  the  brain  or  of  the  brain  and  cord.  Hysteria 
arising  in  men  on  the  fighting  front  is  called  war  hysteria  or  war  shock.  Many 
writers  have  called  it  shell  shock,  a  very  incorrect  term  because  it  implies  that 
all  cases  are  due  to  shell  explosions.  We  know  that  many  cases  result  from 
the  numerous  strains  and  depressions  of  war.  If  phenomena  so  induced  are 
purely  hysterical  they  are  recovered  from  entirely.  If  they  have  an  organic 
basis,  as  they  may  have  when  induced  by  the  detonation  of  a  high  explosive 
shell  the  patient  does  not  recover  completely.  We  are  not  justified  in  regarding 
bleeding  from  the  ears  after  a  shell  explosion  as  in  any  sense  proof  of  basal 
fracture.  An  explosion  may  rupture  the  ear  drums  and  thus  cause  bleeding. 
In  war  shock  strange,  temporary  conditions  arise;  among  them  are:  deafness,, 
dumbness,  blindness,  convulsions,  monoplegia,  hemiplegia,  paraplegia,  states 
resembling  cerebral  concussion,  symptoms  of  neuritis,  zones  of  anesthesia, 
muscular  contractures,  delirium,  mania,  tremor,  and  anterior  spinal  curvature 
(Rosanoff-Saloff,  in  "Nouvelle  Iconographie  de  la  Salpetriere,"  No.  I,  1916-17), 

Treatment  is  by  moral  means  chiefly.  Gain  the  confidence  of  the  patient. 
Suggestion  is  of  great  value.  So  is  discipline.  In  many  cases  separation  from 
family  and  friends  is  necessary  and  isolation  is  desirable.  The  Weir  Mitchell 
rest-cure  is  often  the  best  plan  of  treatment,  and  all  its  details  should  be  carried 
out  faithfully.  It  is  said  by  some  that  cases  of  war  shock  are  best  treated  near 
the  front,  in  an  environment  of  discipline.  When  so  treated  they  get  well. 
If  discharged  from  the  service  they  may  spend  their  days  on  endless  pilgrimages 
from  clinic  to  clinic. 

Malingering. — Persons  often  pretend  to  sufTer  from  maladies  of  the  spinal 
cord  or  column  as  a  result  of  accident  when  no  diseases  of  those  parts  exist. 
Some  get  well  upon  the  rendering  of  a  favorable  verdict  by  a  jury  (litigatioa 
backs).  In  any  case  always  examine  carefully,  so  as  to  be  able  to  exclude 
malingering.  Note  the  patient's  behavior  and  motions  when  his  attention 
is  diverted  from  his  disease.  Meningomyelitis  can  be  excluded  if  there  be  no 
spasm,  paralysis,  hyperesthesia,  paresthesia,  or  anesthesia  at  a  distance  (A. 
Pearce  Gould).  If  pain  has  lasted  for  months;  if  pressure  downward  upon 
the  head  or  shoulders  does  not  increase  pain;  if  the  vertebras  are  movable  and 
there  is  no  angular  displacement,  exclude  caries.  Gould  states  that  when 
there  are  wasted  muscles,  when  moderate  spine  movement  is  painless,  but  effort 
in  bringing  the  body  erect  causes  pain  in  the  erector  spinae  region,  the  trouble 
is  a  strain  of  the  erector  spincB  muscle.  If  the  muscle  is  not  wasted  and  the  pain 
is  in  bending  forward  rather  than  in  straightening  up,  the  vertebral  ligaments 
are  the  seat  of  trouble.  Unilateral  spasm  cannot  be  simulated.  The  ad- 
ministration of  ether  may  dispose  of  a  pretended  paralysis,  the  patient  moving 
the  suspected  extremity  while  drunk  from  the  anesthetic.  Naturally  cases 
of  simulation  are  encountered  by  army  and  naval  surgeons.  Marie  ("Brit. 
Med.  Jour.,"  Aug.  14,  1915)  divides  supposed  hysterical  patients  into  two 
classes:  i.  Unconscious  simulators.  This  class  includes  neuropaths  and  vic- 
tims of  hysteria  and   traumatic  hysteria.     2.  Exaggerators  who  have  really 


Injuries  of  the  Spinal  Cord  in  War  959 

been  wounded  but  who  multiply  and  magnify  their  troubles  and  in  so  doing 
commit    "physiological   solecisms.'' 

Anosacral  Cysts. — These  cysts  develop  between  the  sacrum  and  rec- 
tum and  originate  from  remnants  of  the  postanal  gut  and  neurenteric  canal. 
Such  cysts  may  be  multilocular  or  unilocular.  They  can  be  detected  by  a 
finger  in  the  rectum. 

Treatment. — Some  of  these  growths  are  removed  after  osteoplastic  resec- 
tion of  a  portion  of  the  sacrum;  others  are  removed  by  incising  the  rectal  wall. 

Concussion  of  the  Spinal  Cord. — This  term  has  no  definite  patho- 
logical meaning.  It  is  probable  that  there  is  such  a  condition,  but  it  is  usu- 
ally associated  with  laceration  of  capillaries  and  of  cord  substance. 

The  symptoms  are  shock,  intense  pallor,  nausea,  often  vomiting,  and  some- 
times syncope.  With  this  condition  special  symptoms  may  be  linked — as 
temporary  paralysis,  a  girdle  sensation,  numbness  and  loss  of  power  in  the 
limbs,  hiccup,  torticollis,  coarse  tremors,  pains  in  the  back  and  limbs,  areas  of 
anesthesia  and  analgesia — depending  on  the  portion  of  cord  lacerated. 

The  treatment  in  concussion  of  the  spinal  cord  is  the  same  as  that  for 
sprains.  Traumatic  neurasthenia  and  hysteria  or  organic  cord  disease  may 
follow  this  injury. 

Contusion  of  the  spinal  cord  may  arise  from  a  blow  or  a  sprain,  but 
it  is  usually  due  to  extreme  flexion  of  the  spine.  It  causes  hemorrhage  into 
the  gray  matter  of  the  cord  {hematomyelia).  The  symptoms  are  motor  and 
sensory  palsy  and  diminished  reflexes.  Some  cases  recover,  but  others  end 
in  myelitis. 

Wounds  of  the  spinal  cord  are  rare  and  are  very  dangerous.  A  knife 
is  sometimes  thrust  in  between  the  occiput  and  atlas.  Wounds  above  the 
origin  of  the  phrenic  nerves  cause  almost  instant  death.  Gunshot-wounds  are 
the  most  usual  form,  the  cord  being  damaged  by  the  bullet  and  by  bone- 
fragments. 

In  the  American  Civil  War  gunshot  injuries  of  the  cord  were  very  rare  (3^:4  of 
I  per  cent,  of  all  wounds),  but  at  the  present  day  in  war  they  represent  a  con- 
siderably greater  per  cent,  of  all  w^ounds,  the  increase  in  frequency  being  due  to 
the  increased  penetrating  power  of  the  modern  military  bullet.  The  mortality 
is  about  60  per  cent. 

A  revolver  bullet  or  a  small-caliber  bullet  fired  at  long  range  may  produce 
vertebral  fracture  without  cord  injury,  and  any  bullet  may  fracture  a  process 
of  a  vertebra  without  cord  injury.  If  the  lamins  are  fractured  the  cord  is 
almost  sure  to  be  injured.  The  cord  may  be  concussed,  lacerated,  or  cut 
across  by  bone  or  bullet,  or  compressed  by  bone  or  blood.  The  bullet  may 
lodge  or  may  perforate. 

Treatment. — In  a  suspected  gunshot-wound  of  the  cord  excise  the  wound  in 
the  soft  part,  perform  exploratory  laminectomy,  arrest  hemorrhage,  and  reHeve 
pressure  if  bone  is  depressed.  If  a  bullet  or  a  bone  fragment  lodged,  remove  it. 
I  operated  upon  a  young  man  who  was  shot  accidentally  twenty  years  before  and 
who  had  had  complete  flaccid  paraplegia  and  paralysis  of  the  bladder  and 
rectum  aU  that  time.  He  sought  help  because  of  \dolent  pain  in  the  abdomen 
and  back.  The  .v-rays  showed  a  buUet  within  the  canal  and  in  front  of  the  cord. 
He  was  operated  upon  in  the  Jeft'erson  Hospital.  The  bullet  was  found  outside 
of  the  theca  and  was  removed.  It  had  passed  forv\-ard  between  the  bone  and  the 
theca.  In  a  few  weeks  spastic  paraplegia  replaced  flaccid  paralysis.  He  lived 
several  years,  gaining  power  slowly  all  the  time  and  regaining  control  of  the 
bowels  and  bladder.     He  died  of  an  intercurrent  malady. 

Injuries  of  the  Spinal  Cord  in  War. — Injuries  of  the  cord  as  seen  in 
civil  practice  are  usually  due  to  a  "vvide  application  of  violent  force  (crushes, 
caving  of  embankments  or  roofs  of  coal  mines,  falls  of  masonry,  railroad  acci- 
dents, etc.).     The  resulting  lesion  of  the  cord  is  extensive,  and  in  most  cases 


960  Surgery  of  the  Spine 

operation  is  of  no  avail.  ''In  gunshot- wounds,  on  the  other  hand,  a  larger 
proportion  of  incomplete  injuries  is  seen,  and  these  are  due  to  small  missiles 
which  though  they  hit  the  spine,  do  not  often  make  a  direct  hit  upon  the  theca" 
(D.  M.  Hughes,,  in  "Brit.  Med.  Jour.,"  March  9,  iyi8). 

If  the  theca  should  be  struck  directly  by  the  missile  or  by  a  fragment  of  bone 
a  complete  lesion  will  almost  certainly  be  produced  or  ensue. 

There  will  be  flaccid  palsy,  absent  reflexes  and  loss  of  sphincter  control. 
When  the  cord  is  exposed  by  the  surgeon  the  laceration  is  usually  evident, 
though  damage  which  is  not  visible  exists  far  wide  of  the  lesion.  Occasionally 
a  cord  appears  uninjured  when  it  has  been  damaged  beyond  hope  of  recovery. 
Hughes  (Ibid.)  points  out  that  in  incomplete  injuries  the  theca  has  not  been  pene- 
trated by  bone  or  buflet  and  that  the  resulting  paraplegia  may  be  "  transitory 
and  flaccid,  but  apparently  complete  "^ — may  be  for  a  time  flaccid  and  become 
spastic— may  not  appear  until  after  an  interval. 

The  condition  may  be  due  to  concussion  or  contusion  of  the  cord,  to  hemor- 
rhage, to  pressure  of  bone  or  bullet  and  later  to  pus.  If  a  bullet  is  lodged  within 
the  spinal  canal  it  is  apt  to  cause  dreadful  girdle  pains.  In  cases  in  which  there 
is  persistent  palsy,  or  violent  girdle  pains,  or  spastic  palsy,  operation  is  necessary. 
Lodged  missiles  must  be  removed.  Sepsis  requires  appropriate  treatment. 
When  an  operation  is  performed  excise  the  wound. 

In  but  few  cases  is  there  recovery  of  function.  Urinary  and  pulmonary 
complications  are  prone  to  develop.  Gray  (N.  Y.  Med.  Jour.,  1918,  cvii)  points 
out  that  local  concussion  may  cause  extensive  palsy  but  it  will  begin  to  clear 
up  in  a  few  days. 

Compression  of  the  spinal  cord  may  be  due  to  blood  or  to  inflammatory 
exudate,  as  well  as  to  displaced  bone  (see  page  951).  Compression  from  blood 
may  be  due  to  extramedullary  hemorrhage  or  to  intramediiilary  hemorrhage. 
Extramedullary  hemorrhage  causes  sudden  pain  in  the  back,  the  pain  radiating 
from  compressed  nerve-roots;  hyperesthesia  and  paresthesia  in  the  area  of  the 
radiated  pain;  spasm  of  muscles  supphed  by  the  compressed  nerves,  some- 
times of  muscles  whose  nervous  supply  is  below  the  lesion;  tremors;  convul- 
sions; retention  of  urine;  paralytic  symptoms  following  the  signs  of  irritation, 
but  no  absolute  paralysis  (Mills).  A  girdle  sensation  is  usual.  Intramedul- 
lary hemorrhage  causes  pain,  a  girdle  sensation,  abolition  of  reflexes, 
and  paralysis.  Spasms,  rigidity,  and  paralysis  come  on  early.  Bedsores 
may  form,  and  retention  of  urine  and  incontinence  of  feces  may  be  observed. 
Paralysis  from  hemorrhage  is  rapidly  progressive  from  below  upward  {crawl- 
ing paralysis).  Compression  from  extramedullary  hemorrhage  may  be 
recovered  from  without  operation,  and  in  some  cases  recovery  is  rapid. 

Treatment. — If  paralysis  from  spinal  bleeding  extends  rapidly  and  life 
is  endangered  through  the  probable  involvement  of  a  vital  center,  perform 
a  laminectomy,  remove  the  clot,  and  arrest  hemorrhage.  It  is  wise  always 
to  open  the  dura  and  inspect  the  cord.  Extramedullary  hemorrhage  may 
be  arrested  by  sutures  or  by  packing.  Intramedullary  hemorrhage  may 
be  arrested  by  suture-ligatures  or  by  packing.  If  an  extramedullary  clot 
is  extensive  it  is  proper  to  make  a  second  laminectomy  near  the  lower  end 
of  the  spinal  column  in  order  to  permit  the  surgeon  to  wash  it  out  thoroughly. 
The  dura  must  be  sutured  and  drainage  is  to  be  employed.  If  there  is  para- 
plegia, complete  anesthesia  of  the  paralyzed  parts,  and  entire  abolition  of 
the  deep  reflexes,  operation  is  probably  useless,  but  it  is  justifiable  to  try  it 
because  of  a  possibility  that  the  cord  has  not  been  completely  divided.  In  some 
cases  with  persistent  paraplegia  the  operation  should  be  undertaken.  If  opera- 
tion is  not  undertaken,  have  the  patient  lie  upon  his  side,  apply  an  ice-bag  to 
the  spine,  and  give  morphin  hypodermatically.  If  hemorrhage  continues  in 
the  cord  and  if  the  patient  be  plethoric,  perform  venesection.  To  promote 
absorption  of  the  clot  and  exudate  give  a  combination  of  carbonate  and  acetate 


Fractures  and  Dislocations  of  the  Spine 


961 


of  ammonium,  order  pilocarpin,  and  employ  spinal  galvanism  and  hot  douches, 
lodid  of  potassium  may  be  given. 

Fractures  and  dislocations  of  the  spine  are  very  rare.  The  spinal 
regions  most  liable  to  injury  are  the  atlo-axial,  the  cervicodorsal,  and  the 
dorsolumbar  (Treves).  A  vertebra  may  be  fractured  alone,  but  dislocation 
without  fracture,  except  in  the  upper  cervical  region,  very  rarely  occurs.  These 
two  lesions,  dislocation  and  fracture,  are  so  often  associated  that  the  term 
fracture-dislocation  is  used  by  many  surgeons  to  include  them  both.  The 
causes  of  fracture  and  dislocation  are  direct  force  (seldom)  and  indirect  vio- 
lence (commonly).  In  fracture  by  direct  force  the  laminae  and  spinous  proc- 
esses are  most  apt  to  suffer.  In  most  cases  the  fragments  are  not  greatly 
displaced.  A  fracture  by  indirect  force  may  result  from  a  fall  on  the  shoulders, 
from  a  weight  falling  on  the  shoulders,  or  from  a  fall  on  the  buttocks.     Forced 


Fig.  608. — Fracture  of  third  lumbar  vertebra. 

flexion  or  overextension  is  the  commonest  cause.  In  fractures  from  indirect 
force  the  cord  generally  suffers.  In  some  cases  the  displacement  of  the  ver- 
tebrae lacerates  the  cord,  the  vertebrae  return  into  place,  and  no  deformity  is 
detectable.  Fracture-dislocation  from  direct  force  may  occur  at  any  part  of 
the  column,  and  in  this  accident  the  posterior  vertebral  segments  are  driven 
together,  and  the  cord,  as  a  rule,  escapes  injury.  Fracture-dislocations  from 
indirect  force  most  commonly  happen  in  the  dorsolumbar  region,  but  are  met 
with  in  the  cervical  and  dorsal  regions.  In  the  cervical  region  reduction  can 
usually  be  secured,  but  in  the  lumbar  region  reduction  is  impossible. 

Fractures  of  the  cervical  spine  often  cause  immediate  death  and  are  par- 
ticularly apt  to  crush  the  cord  completely  across.     Fractures  in  the  lower  dorsal 
and  lumbar  region  are  apt  to  contuse  partially  the  cord  and  nerves  of  the' 
Cauda  equina.     Edema  of  the  cord  follows  injury. 
61 


96: 


Surgery  of  the  Spine 


Symptoms. — In  fracture-dislocation  great  displacement  is  unusual,  but 
some  is  almost  always  recognizable  (irregularity  of  the  spines  or  angular 
deformity).  There  are  pain  (which  is  increased  by  motion),  tenderness, 
ecchymosis,  and  motor  and  sensory  paralysis.  Priapism,  cystitis,  and  reten- 
tion of  urine  often  occur.  Horsley 
has  pointed  out  that  in  many  cases 
paralysis  passes  away  only  to  recur 
subsequently,  the  recurrence  being 
due  to  edema  of  the  cord.  In  some 
cases  of  spinal  injury  there  is  temporary 
paralysis  due  to  shock.  Persistent 
paralysis  may.  be  due  to  laceration 
of  the  cord,  division  of  the  cord,  or 
compression  of  the  cord  by  bone, 
blood-clot  (Fig.  609),  or  products  of 
inflammation.  The  extent  of  paralysis 
depends  on  the  seat  of  the  cord  injury. 
We  must  always  try  and  decide  if  the 


^r^^ 


Fig.  609. — Fracture  of  the  cervical 
spine,  cord  compressed  by  bone  and  blood. 
Hemorrhage  into  the  cord  at  the  seat  of 
the  lesion  and  below  the  lesion  CWarren 
Museum).  (From  Scudder's  "Treatment 
of  Fractures."     Drawn  by  Byrnes.) 


Fig.  610. — Spine  sawed.  Iraciure  of  the 
spinous  processes  of  the  seventh  cervical  and 
first  and  second  dorsal  vertebras.  Fracture 
of  the  bodies  of  the  fifth,  sixth,  and  seventh 
cervical  vertebrae  with  displacement  backward 
of  the  upper  fragment.  Total  crush  of  the 
cord.  The  section  passes  a  little  to  one  side  of 
the  cord,  which  is  seen  in  place,  and  the  stain- 
ing of  the  cord  by  hemorrhage  into  its  sub- 
stance shows  plainly  through  the  membranes 
even  in  photograph.  The  spinous  processes  of 
the  second  and  third  dorsal  vertebrae  were 
found  fractured  at  the  operation,  and  were 
removed  (Thomas). 


spinal  cord  is  completely  divided  or  hopelessly  crushed  (Fig.  610).  WTien  the 
symptomsare  not  immediate  in  onset;  whenall  themuscles  below  the  seat  of  injury 
are  not  completely  paralyzed ;  when  there  is  some  retention  of  sensation ;  when  re- 
flexes are  present  and  muscular  rigidity  exists,  we  may  be  sure  that  the  cord 


Prognosis  of  Fractures  and  Dislocations  of  the  Spine 


963 


is  not  completely  divided.  When  the  cord  is  compFetely  divided  the  symptoms 
are  immediate,  there  are  absolute  flaccid  motor  paralysis  and  complete  sen- 
sory paralysis  (loss  of  appreciation  of  pain,  touch,  and  temperature).  The 
line  of  anesthesia  is  definite  and  suddenly  terminates  (Walton).  The  bladder 
and  rectum  are  paralyzed  and  there  may  be  priapism.  All  the  reflexes,  su- 
perficial and  deep,  except,  perhaps,  the  plantar  have  disappeared.  There  is 
pain,  there  are  no  muscular  spasms,  there  is  vasomotor  paralysis  with  sweating 
of  the  paralyzed  parts,  and  the  symptoms  persist  and  do  not  vary  (J.  J.  Thomas, 
in  "Boston  City  Hospital  Med.  and  Surg.  Reports").  There  is  usually 
tympanites  (Walton).  If  this  latter  symptom-group  is  due  to  shock,  it  will 
usually  be  temporary,  but  occasionally,  even  when  so  caused,  it  persists  some 
considerable  time.     It  is  also  probable  that  concussion  of  the  cord  may  in  some 


Fig.  611. — Fracture  of  the  odontoid  process  of  the  second  vertebra  and  dislocation  between 
the  first  and  second  vertebra  a  number  of  years  after  injury.  (From  X-ray  Dept.  of  Jefferson 
Hospital.) 

cases  simulate  complete  division.  As  Walton  says,  no  symptoms  prove  a  hope- 
less crush  of  the  cord:  it  is  the  persistence  of  the  symptoms  which  does  prove 
it  ("Jour.  Nervous  and  Mental  Diseases,"  Jan.,  1902);  I  would  add,  the  per- 
sistence of  and  lack  of  change  in  the  symptoms  prove  it. 

A.  J.  McCosh  ("Jour.  Amer.  Med.  Assoc,"  Aug.  31  and  Sept.  7,  1901) 
points  out  that  definite  pressure  is  indicated  by  marked  symptoms  and  ab- 
sence of  reflexes.  When  there  is  not  definite  pressure  the  symptoms  are 
irregular;  there  is  incomplete  palsy,  or  muscles  of  the  same  group  show  differ- 
ent degrees  of  paralysis;  anesthesia  is  partial;  signs  of  irritation  are  not  dis- 
tinct, and  there  are  patches  of  hypereslJiesia  and  zones  of  paresthesia.  If  in 
doubt  at  the  end  of  twelve  hours,  perform  an  exploratory  operation. 

The  prognosis  depends  on  the  amount  of  damage  done  to  the  cord.  Frac- 
ture-dislocations in  the  cervical  region  produce  ob\dous  deformity,  stiffness 
of  the  neck  and  irregularity  of  the  spines,  and  a  displaced  vertebra  may  occa- 
sionally be  detected  by  a  finger  in  the  pharynx.  Crepitus  can  rarely  be 
detected  unless  a  spinous  process  is  fractured.  The  Rontgen  rays  aid  diagno- 
sis immensely.  The  seat  of  cord  injury  may  be  determined  by  a  study  of  the 
palsy  and  other  symptoms. 

Fracture-dislocation  of  the  atlas  or  axis  usually  causes  instant  death. 
When  the  displacement  is  only  trivial,  the  patient  may  recover,  or  may  die 
of  secondary  cord  disease.  A  dislocation  of  the  atlas  without  fracture 
of  the   odontoid   is   extremely  rare.     If   it  occurs  it  will  be   unilateral,  that 


964  Surgery  of  the  Spine 

is,  only  one  articular  process  will  be  displaced.  A  unilateral  dislocation  seldom 
compresses  the  cord,  and  gives  a  fair  prognosis.  A  bilateral  dislocation  with 
fracture  of  the  odontoid  gives  an  extremely  bad  prognosis.  Dr.  N.  J. 
Blackwood  of  the  U .  S.  Navy  records  a  case  of  fracture  of  the  atlas  and  axis 
and  forward  dislocation  of  the  occiput  on  the  spinal  column,  life  having  been 
maintained  for  thirty-four  hours  and  forty  minutes  by  artificial  respiration, 
during  which  time  laminectomy  was  performed  on  the  third  cervical  vertebra 
("Annals  of  Surgery,"  May,  1908).  Lofton  has  recorded  a  case  of  recovery 
after  dislocation  of  the  anterior  arch  of  the  atlas  on  to  the  odontoid  process 
"New  York  Med.  Jour.,"  April  18,  1908).  Fig.  6ri  exhibits  a  case  which 
recovered  after  fracture  of  the  odontoid  and  dislocation  between  the  first 
and  second  vertebrae.  We  had  a  man  in  Jefferson  Hospital  who  could  at  will 
produce  and  then  reduce  a  unilateral  dislocation  of  the  fifth  cervical  vertebra. 
Years  before  the  dislocation  was  originated  by  striking  the  head  when  diving. 
The  man  made  a  living  by  getting  himself  apparently  hurt  in  street  cars  and 
then    collecting   damages.     LeBreton    (''Am.    Jour.    Orth.    Surg.,"    1916,    ix) 

records  a  case  of  fracture  of  the  base  of  the 
odontoid,  without  paralysis.  It  was  reduced 
bv  the  patient  himself  and  the  man  was  cured. 
Grifhth  ("Am.  Jour.  Orth.  Surg.,"  1914, 
xii)  reports  three  cases  of  partial  luxation  of 
the  atlas  on  the  axis.  In  none  of  the  cases 
was  the  odontoid  fractured.  All  recovered 
after  reduction.  In  injury  of  the  third  cer- 
vical vertebra  the  phrenic  nerve  is  involved, 
Fig.  612.— Lesion  of  spine  between  the  diaphragm  is  paralyzed,  and  death  soon 
fifth  and  sixth  cervical  vertebrae,  occurs.  In  fracture-dislocation  of  the  fifth 
Note  position  of  arms,  due  to  paralysis  cervical  vertebra  the  subscapularis  muscles 
of  subscapularis.    Brachialis  anticus,  paralvzed,  but  the  biceps,  brachialis  anti- 

supinator  longus,  and  deltoid  muscles  ^         t  '  j    j   u    •  j  1 

intact.  Elbow  flexed,  shoulders  ab-  cus,  supmator  longus,  and  deltoid  muscles 
ducted  and  rotated  outward  (after  escape,  and  the  patient  assumes  a  character- 
Thorburn).  istic  attitude  (Fig.  612).     In  Jones's  case  of 

fracture  of  the  fifth  cervical  vertebra  no  opera- 
tion was  performed,  but  the  patient  partly  recovered  and  became  able  to  walk, 
but  with  a  spastic  gait  ("Lancet,"  Nov.  28,  1903).  If  the  sixth  cervical  verte- 
bra is  dislocated  there  is  palsy  of  the  muscles  of  the  hand.  In  injuries  below  the 
sixth  cervical  vertebra  no  muscle  of  the  arm,  forearm,  or  hand  is  paralyzed  at 
first,  although  after  some  days  paralysis  may  develop.  Damage  to  the  cord 
above  the  sixth  cervical  vertebra  produces  anesthesia  of  the  body  below  the 
injury  and  of  the  entire  upper  extremity  except  the  shoulder.  In  injury  just 
above  the  upper  level  of  the  seventh  cervical  there  are  body  anesthesia  and 
anesthesia  of  the  outer  surfaces  of  the  arms  and  ulnar  margins  of  the  fore- 
arms and  hands.  In  any  cervical  injury  there  are  body  anesthesia  and  dia- 
phragmatic respiration,  and  in  cases  without  paralysis  of  the  arms  there  is 
sure  to  be  pain.  Injuries  of  the  dorsal  spine  can  be  accurately  located.  There 
is  paralysis  of  motion  and  sensation  up  to,  or  almost  up  to,  the  seat  of  injury. 
The  arms  are  not  paralyzed.  Very  great  pain  in  the  legs  occurs  if  the  lumbar 
enlargement  is  involved.  In  injury  of  the  twelfth  dorsal  or  upper  lumbar 
vertebras  there  are  paralysis  of  the  bladder  and  rectum,  incomplete  anesthesia, 
and  partial  motor  paralysis  of  the  limbs. 

Treatment  of  Fracture -dislocations. — Unilateral  dislocation  of  the  atlas 
or  the  axis  mav  be  reduced  by  manipulation.  Walton's  plan  for  a  unilateral 
cervical  dislocation  is  as  follows:  Give  the  patient  ether  and  hold  him  erect 
and  sitting  on  a  chair.  The  surgeon  stands  behind  the  patient  and  holds  the 
head  with  both  hands.  The  first  motion  is  a  slight  degree  of  rotation  to  carry 
the  dislocated  process  forward  and  "unlock"  it.  The  head  is  then  rocked 
toward  the  sound  side  and  somewhat  backward  and  finally  the  process  is  re- 


Treatment  of  Fracture-dislocations  965 

placed  by  rotation.  No  force  is  used  (Clopton,  in  "Interstate  Med.  Jour.," 
Jan.,  1908.  Quoted  in  "General  Surgery,"  by  John  B.  Murphy,  1909).  After 
reducing  a  fracture-dislocation  of  the  cervical  region,  place  the  patient  in  bed, 
elevate  the  head  of  the  bed  a  few  inches,  and  immobilize  the  neck  and  head. 
If  complete  dislocation  of  the  body  of  a  vertebra  obviously  exists  the  surgeon 
may  attempt  reduction  by  extension  and  rotation.  The  maneuver  is  very 
dangerous  in  the  cervical  region,  and,  as  deaths  have  happened,  some  eminent 
surgeons  advise  against  reduction  when  the  injury  affects  that  region.  In 
fracture-dislocation  of  the  dojsal  or  lumbar  region  the  traditional  plan  is  to 
straighten  the  spine,  gently  if  possible,  and  to  put  the  patient  upon  his  back 
upon  a  water-bed  or  upon  air-cushions.  Empty  the  bladder  every  six  hours 
with  a  soft  catheter,  wnich  is  kept  strictly  aseptic.  Take  every  precaution 
to  prevent  bed-sores.  Some  surgeons  advocate  reduction  of  the  deformity 
by  extension  and  counterextension,  and  the  application  of  a  firmly  fitting 
but  removable  jacket  with  the  suspension  collar  (as  used  in  Pott's  disease). 
If  this  plan  is  employed,  the  head  of  the  bed  is  raised  and  the  collar  is  fastened 
to  it.  Every  day  extension  is  made  gently — from  the  shoulders  in  dorsolumbar 
fracture  and  from  the  chin  and  occiput  in  cervical  fractures.  Extension 
may  be  maintained  permanently  until  cure.  Surgeons  have  come  rather  slowly 
to  a  belief  in  laminectomy.  One  deterrent  factor  has  been  the  high  mortality: 
Lloyd  collected  the  records  of  159  operations  and  found  that  59  patients  died 
almost  at  once  and  39  died  later.  In  Lloyd's  collection  of  185  cases  there  were 
but  24  recoveries  and  40  improvements.  In  82  immediate  operations  only 
5  recovered.  In  103  late  operations  there  were  19  recoveries  (John  B.  Murphy, 
in  "Surg.,  Gynecol.,  and  Obstet.,"  April,  1907).  Some  employ  purely  expect- 
ant treatment  in  vertebral  fractures.  My  own  feeling  is  that  when  simply 
a  spinous  process  or  some  other  part  is  fractured,  and  there  are  no  cord  symp- 
toms, we  may  treat  the  patient  expectantly,  following  Burrell's  advice,  and 
fixing  the  patient  in  bed  on  a  Bradford  frame  and  having  him  carefully  nursed 
and  watched.  Reduction  by  extension  and  counterextension  is  dangerous 
and  unjustifiable  if  there  is  marked  kyphosis  and  if  cord  symptoms  exist.  I 
agree  with  Burrell  that  it  should  only  be  done  if  operation  is  refused,  or  if 
there  are  no  cord  symptoms  and  no  marked  kyphosis  ("Annals  of  Surgery," 
Oct.,  1905).  If  it  is  attempted  it  must  be  done  slowly  and  as  gently  as  possible 
because  it  may  cause  grave  or  even  irreparable  damage  to  the  cord.  I  fear 
to  delay,  and,  with  Burrell,  Lloyd,  Walton,  and  others,  operate  when  the 
patient  recovers  from  shock,  if  there  seems  to  be  even  a  gleam  of  hope  that 
operation  may  help  him.  To  wait  when  pressure  exists  means  that  during 
every  hour  of  delay  the  pressure  is  damaging  the  cord.  Another  reason  for 
operating  is  that  we  cannot  know  the  condition  of  the  cord  without  direct 
inspection.  The  operation  to  be  performed  is  laminectomy.  As  before  stated, 
this  is  to  be  done  even  if  we  suspect  division  or  hopeless  crush  of  the  cord. 
In  some  cases,  it  is  true,  we  may  commit  the  error  of  operating  when  there  is 
only  concussion,  but  such  a  mistake  is  less  grave  than  to  fail  to  operate  when 
there  is  bone-pressure  or  hemorrhage.  An  objection  filed  by  the  neurologist 
against  laminectomy  is  that  portions  of  cord  above  and  below  the  level  of  the 
fracture  may  be  damaged  (see  Fig.  609),  but,  as  Lloyd  says,  this  fact  does 
not  forbid  operation,  but  renders  it  necessary  to  make  a  wider  exploration 
than  has  been  the  custom.  In  many  cases  after  prompt  laminectomy  we 
get  some  considerable  improvement,  and  this  improvement  may  be  sufiicient 
to  enable  a  man  to  earn  a  living.  It  is  true  that  statistics  would  indicate 
that  late  operations  have  been  more  successful  than  early  ones,  but  these 
figures  must  be  analyzed  in  the  light  of  the  knowledge  that  many  of  the  fatah- 
ties  after  early  operation  would  have  occurred  if  no  operation  had  been  done, 
and  some  improvements  after  late  operation  would  have  occurred  to  as  great 
or  a  greater  degree  after  early  operation.     The  prognosis  of  any  operation, 


966  Surgery  of  the  Spine 

earlv  or  late,  is  never  gratifying,  and  Thorburn  feels  no  confidence  in  obtain- 
ing improvement  except  in  injuries- of  the  lamina;,  hemorrhage,  or  injuries  of 
the  Cauda  equina,  as  he  says  laminectomy  in  the  cervical  region  is  followed 
by  death,  and  laminectomy  in  the  dorsal  region,  though  not  commonly  fatal, 
is  seldom  followed  by  recovery  of  function.  Our  statistics  of  early  laminec- 
tomy will  show  fewer  deaths  and  fewer  useless  operations  if  we  do  not  operate 
till  shock  abates.  As  Lloyd  ("  Phila.  Med.  Jour.,"  Feb.  5,  1902)  says:  "It 
is  therefore  evident  that  if  we  operate  immediately  after  the  injury  we  will 
have  failures  that  should  not  be  charged  against  the  operation  itself,  and,  if 
possible,  we  should  wait  before  operating  until  the  question  can  be  settled 
whether  the  patient  will  overcome  the  shock  or  will  succumb  directly  to  the 
effects  of  the  injury."  All  surgeons  operate  for  compound  fracture,  for  hem- 
orrhage, and  for  cases  with  marked  bone  pressure.  If  early  operation  were 
not  performed  and  if  pachymeningitis  arises,  operation  is  called  for. 

My  own  convictions  are  that  if  symptoms  are  sigYiificant  we  should  ex- 
plore as  soon  as  shock  has  passed  away,  even  if  we  think  it  probable  that  the 
cord  has  been  divided;  and  if  it  is  found  divided,  it  should  be  sutured.  If 
in  any  case  we  are  in  doubt  twelve  hours  after  the  injury  as  to  whether  or  not 
pressure  exists,  we  should  explore.  If  soon  after  the  accident  we  think  pressure 
by  bone  exists,  we  should  operate.  If  the  case  is  improving,  we  should  not 
operate  even  if  there  are  pressure  signs,  unless  there  is  a  chance  that  pressure 
is  due  to  bone,  in  which  case  we  should  operate.  As  McCosh  says,  pressure 
by  blood  or  inflammatory  exudate  may  pass  away;  pressure  by  bone  cannot. 
Even  long  after  an  injury  laminectomy  may  be  productive  of  some  benefit. 

The  rather  radical  views  set  forth  above  regarding  the  advisability  of 
operating  even  if  the  symptoms  point  to  complete  division  of  the  cord  arose 
largely  from  a  knowledge  of  the  well-known  case  operated  upon  by  Stewart 
for  total  division  of  the  cord.  In  a  case  of  gunshot-wound  of  the  dorsal  spine 
treated  at  the  Pennsylvania  Hospital  by  Francis  T.  Stewart,  and  reported  by 
Francis  T.  Stewart  and  Richard  H.  Harte  ("Phila.  Med.  Jour.,"  June 
7,  1902),  an  exploratory  incision  made  three  hours  after  injury  showed  that 
the  spinal  cord  was  completely  divided.  There  was  a  fracture  of  the  laminae 
of  the  seventh  dorsal  vertebra.  The  spines  and  laminae  of  the  seventh  and 
eighth  dorsal  vertebrae  were  removed.  The  bullet-hole  was  recognizable  in 
the  membranes,  and  the  bullet  and  some  bone-fragments  were  removed.  When 
the  dura  was  opened,  the  ends  of  the  completely  divided  dorsal  cord  were 
found  to  be  ^.^  inch  apart.  Stewart  freshened  these  ends  and  brought  them 
together  with  two  sutures  of  chromicized  catgut.  In  this  case  a  considerable 
degree  of  restoration  of  function  took  place.  At  the  time  of  the  operation, 
three  hours  after  the  injury,  there  were  complete  paralysis  and  absence  of 
reflexes  below  the  seat  of  injury;  but  sixteen  months  later  the  patient  was 
able  voluntarily  to  flex  the  toes,  flex  and  extend  the  legs,  flex  and  extend  the 
thighs,  and,  while  sitting,  lift  an  extended  leg  from  the  floor.  The  movements 
of  the  lower  extremity  became  more  forcible  when  reinforced  by  contracting 
the  muscles  of  the  upper  extremity  while  making  them.  The  patient  could 
stand  with  one  hand  resting  on  the  back  of  a  chair,  and  could  get  herself  from 
her  bed  to  her  chair  by  sliding.  The  bowels  were  under  perfect  control,  and 
there  was  no  incontinence  of  urine  when  she  was  awake,  although  there  was 
occasionally  some  when  she  was  asleep.  There  were  occasional  cramp-like 
pains  in  the  lower  limbs.  The  senses  of  touch,  temperature,  pain,  and  position 
were  perfect  all  over  the  previously  paralyzed  parts.  Below  the  knee  the 
localization  of  sensation  was  not  so  accurate.  There  was  a  slight  amount  of 
muscular  rigidity;  and  on  each  side,  an  ankle  and  patella  clonus,  which  was 
easily  exhausted.  When  the  sole  of  the  foot  was  tickled,  the  big  toe  flexed,  the 
thigh  abducted,  and  there  was  slight  contraction  of  the  anterior  tibial,  the 
hamstring,  and  the  tensor  vaginae  femoris  muscles.     There  were  no  reactions 


Treatment  of  Fracture-dislocations  967 

of  degeneration  and  no  trophic  changes.  There  had  never  been  any  bed-sores. 
George  Ryerson  Fowler  ("Annals  of  Surgery,"  Oct.,  1905)  operated  on  a  gun- 
shot-wound of  the  dorsal  spine  eleven  days  after  the  injury.  He  removed  the 
laminas  of  the  tenth,  eleventh,  and  twelfth  dorsal  vertebrae  and  found  the  cord 
divided,  the  bullet  lying  between  the  severed  ends.  A  piece  of  dura  J-^  inch 
wide  was  intact.  The  bullet  and  blood-clot  were  removed.  The  cord  was 
sutured  by  three  sutures  of  chromicized  gut,  which  included  the  dura,  and 
more  sutures  were  taken  through  the  dura  only.  The  ends  of  the  cord  were 
easily  approximated.  The  patient  recovered  from  the  operation.  Twenty-six 
months  later  voluntary  motion  was  found  to  be  practically  lost  in  the  area 
below  the  injury,  although  when  supported  by  the  hands  he  could  stand  and 
when  in  a  frame  could  move  a  little  by  a  swinging  movement.  He  is  able  to  tell 
when  his  bowels  or  bladder  are  about  to  move,  and,  if  furnished  promptly 
with  a  utensil,  does  not  soil  himself.  When  asleep,  he  passes  urine  involun- 
tarily. Both  legs  exhibit  spastic  rigidity,  but  there  are  no  reactions  of  de- 
generation. Patella  reflex  on  each  side  exaggerated.  Ankle  clonus  is  found 
on  one  side,  but  not  on  other.  There  is  complete  anesthesia  of  the  affected  area, 
except  in  a  region  5  inches  in  length  on  the  outer  side  of  the  right  thigh.  Touch 
is  appreciated,  but  not  correctly  localized.  In  connection  with  the  fore- 
going important  cases  we  would  note  that  Dr.  Estes,  of  Bethlehem,  has  also 
operated  upon  a  case  of  complete  division  of  the  spinal  cord,  in  which  suturing 
was  apparently  followed  by  some  restoration  of  function. 

In  the  light  of  these  positive  reports  we  must  ask  ourselves  if  we  have  not 
been  wrong  in  the  view  that  the  spinal  cord  cannot  regenerate.  If  there  is 
even  a  chance  that  we  have  been  wrong,  we  must  reverse  our  former  con- 
servative treatment  and  follow  a  radical  plan.  The  3  cases  strongly  sug- 
gest the  possibility  of  some  regeneration,  but  do  not  prove  it.  The  cord  may 
have  appeared  to  be  completely  divided  and  yet  minute  undivided  bundles 
may  have  escaped  recognition.  Again,  as  Fowler  suggests,  there  may  be  a 
nerve  anastomosis  through  an  uninjured  portion  of  the  dura  or  between  adja- 
cent nerve-trunks  which  arise  above  and  below  the  lesion.  At  my  request 
Dr.  Samuel  Lloyd,  of  New  York,  kindly  wrote  me  a  personal  communication 
setting  forth  his  views  on  this  important  subject.  They  are  as  follows:  "The 
question  of  the  regeneration  of  the  spinal  cord  after  traumatism  of  the  spine 
deserves  careful  consideration  in  all  cases  that  are  operated  upon.  Up  to 
the  present  time,  however,  although  a  number  of  operators  have  reported 
improvement  following  suture  of  the  spinal  cord  in  these  cases,  a  careful  analysis 
does  not  substantiate  the  fact  that  that  improvement  is  due  to  an  actual 
regeneration.  It  is  a  recognized  fact  on  the  part  of  all  who  have  had  experience 
with  the  surgery  of  the  spinal  cord  that  in  almost  every  instance  a  certain 
amount  of  improvement  is  noted  during  the  first  few  months.  This  is  probably 
due  to  the  fact  that  at  the  time  of  the  injury  minute  hemorrhages  occur  into 
the  adjoining  segments,  and  that  pressure  is  also  increased  in  those  portions  of 
the  cord  by  the  inflammatory  exudate  and  edema.  Within  a  short  time  after 
the  injury  these  conditions  improve,  and  there  seems  to  be  an  improvement  in 
function;  but  in  every  case  of  spinal  suture  yet  reported  the  amount  of  im- 
provement may  be  explained  by  these  facts.  In  no  instance  has  there  been  a 
complete  recovery  of  function,  but  in  every  one  there  has  remained  more  or  less 
permanent  disability.  This,  however,  should  not  discourage  attempts  at 
spinal  suture,  and  in  every  .case  operated  upon  the  dura  should  be  opened  and 
the  condition  of  the  cord  examined.  In  those  cases  where  a  complete  destruc- 
tion has  occurred  and  where  the  extent  of  it  is  not  over  ^14  inch,  it  may  be 
possible  to  cut  out  the  lacerated  portions  and  coaptate  the  surfaces  by  a  series 
of  sutures  placed  in  the  dura.  In  all  these  cases  the  patient  should  be  put  up 
in  a  plaster  retaining  bandage  in  extreme  extension,  even  the  head  being  thrown 
back  so  as  to  relax  as  much  as  possible  the  tension  on  the  line  of  suture.     The 


968  Surgery  of  the  Spine 

operator  should  be  very  sure,  however,  that  there  are  no  undestroyed  fibers 
traversing  the  lacerated  area,  for  the  destruction  of  these  in  case  regeneration 
did  not  occur  would  increase  the  amount,  of  paralysis."  With  the  views  of 
Lloyd  I  am  in  entire  agreement,  and  now  I  always  follow  this  plan,  bearing  in 
mind  that  it  is  often  impossible  to  tell  whether  the  spinal  cord  is  completely 
divided  or  seriously  damaged  without  examining  it,  and  it  can  be  examined  by 
exploratory  operation  only;  therefore,  if  the  serious  symptoms  already  indicated 
exist  after  shock  has  passed  away,  exploratory  operation  should  be  performed ; 
if  pressure  exists,  it  should  be  removed;  and  if  the  spinal  cord  is  found  to  be 
completely  divided,  it  should  be  sutured.  It  is  well  to  remember  that  Abbe's 
experiments  have  shown  that  there  may  be  great  difficulty  in  bringing  the  divided 
ends  of  the  cord  into  apposition.  In  order  to  effect  this  it  may  be  necessary  to 
resect  a  vertebra. 

Opjerations  on  the  Spine.  Operation  for  Spina  Bifida. — A.  W.  Mayo 
Robson^  maintains  that  operation  is  not  demanded  when  the  sac  is  of  small 
size  and  is  well  protected  by  sound  integument;  that  operation  is  improper  when 
a  large  portion  of  the  column  is  fissured,  or  when  paraplegia  or  hydrocephalus 
exists;  that  operation  is  advisable  only  in  meningocele,  in  cases  in  which  the 
integument  is  thin  and  translucent,  in  cases  in  which  the  cord  is  flattened  out 
or  the  nerves  are  fused.  Robson  has  closed  the  osseous  defect  by  trans- 
planting periosteum. 

Surround  the  sac  by  elliptical  incisions.  Find  the  neck  of  the  sac,  and 
if  it  contains  no  visible  nerves,  ligate  it  and  cut  off  the  protrusion.  Push 
the  stump  into  the  canal.  Freshen  the  bone-margins  and  spring  a  piece  of 
celluloid  beneath  them  to  close  the  gap  (Park).  Suture  over  the  stump  with 
small  sutures  of  catgut.^ 

Treves's  Operation  for  Vertebral  Caries. — (See  page  784.) 

Laminectomy. — The  patient  lies  prone  and  a  sand-pillow  is  placed  under 
the  lower  ribs.  Make  a  vertical  incision  over  and  down  to  the  vertebral  spines, 
the  middle  of  the  incision  corresponding  to  the  seat  of  injury  or  disease.  The 
sides  of  the  spinous  processes  and  the  laminse  are  cleared.  The  periosteum 
is  incised  in  the  angle  between  the  laminae  and  spines,  and  is  lifted  away  from 
the  arches.  It  is  my  custom  to  bore  through  a  lamina  on  each  side  of  a  spinous 
process  by  means  of  Hudson's  burrs.  When  this  has  been  done  the  spinous 
process  and  lamina  are  easily  bitten  through  and  removed.  The  usual  method 
of  operating  is  as  follows:  The  spinous  processes  are  cut  off  close  to  their  bases 
by  means  of  bone-cutting  forceps,  the  laminae  are  removed  on  each  side  with 
the  same  instrument  or  the  rongeur,  and  the  dura  is  exposed.  In  some  cases 
of  fracture  fragments  will  be  found  on  exposing  the  vertebra,  or  a  blood-clot 
will  be  seen  between  the  dura  and  the  bone;  in  other  cases  the  dura  must  be 
opened  by  scissors  vertically  in  the  middle  line  while  it  is  grasped  by  mouse- 
toothed  forceps.  After  reaching  and  removing  the  compressing  cause,  or  after 
failing  to  find  or  remove  it,  it  is  best  not  to  close  the  dura  completely,  because, 
if  we  do  so,  cord  pressure  may  result  from  hemorrhage.  The  dural  wound  is 
left  open  or  is  partly  closed.  I  used  to  insert  a  drain  of  rubber  tissue,  but  have 
given  it  up.  Horsley  shows  that  it  is  not  necessary,  and  if  we  refrain  from  drain- 
ing we  lessen  the  tendency  to  headache,  temporary  pyrexia,  and  rapid  pulse, 
which  frequently  follow  laminectomy.  The  superficial  parts  are  stitched  with 
silkworm-gut  and  dressings  are  applied. 

Albee's  Method  of  Bone -grafting  for  Pott's  Disease  of  the  Spine. — In 
1891  Hadra,  of  Galveston,  advocated  the  treatment  of  Pott's  disease  of  the  spine 
by  wiring  the  spinous  processes  of  the  diseased  vertebras  to  adjacent  vertebrae 
for  the  purpose  of  securing  fixation.     Chipault,  in  1895,  and  Calot,  in  1896,  did 

1  "Annals  of  Surgery,"  vol.  xxii,  No.  i. 

^  A  full  consideration  of  the  various  plans  of  operating  will  be  found  in  an  article  by  Marcy^ 
in  "Annals  of  Surgery,"  March,  1895. 


Puncture  of  the  Spinal  Theca  or  Lumbar  Puncture  969 

this  after  forcible  correction  of  angular  deformity.  Lange  buried  steel  wires 
on  each  side  of  the  spine  and  anchored  each  one  at  each  end  by  silver  wire 
(J.  T.  Rugh,  in  "Internat.  Clinics,"  Vol.  I,  Twenty-third  Series).  The  object 
of  these  operations  was  to  do  away  with  the  necessity  for  an  external  supporting 
.jacket  or  brace.  The  objection  to  them  was  the  introduction  of  a  foreign 
material,  and  the  fact  that  strain  caused  that  material  to  cut  through  the 
tissues  and  permit  relaxation. 

In  191 1  both  Hibbs  and  Albee,  working  independently,  reported  methods 
for  producing  fusion  of  the  arches  of  the  vertebrae. 

Hibbs  (''New  York  Med.  Jour.,"  May  27,  191 1,  and  "Annals  of  Surgery," 
May,  19 1 2)  takes  strips  of  the  periosteum  from  the  spines  and  laminae,  trans- 
poses the  spinous  processes,  and  sutures  the  periosteum  and  the  supraspinous 
ligament  over  these  processes.  The  periosteum  is  depended  upon  to  produce 
new  bone,  which  fuses  the  parts  together.  Phis  operation,  if  successful,  lessens 
kyphosis  and  produces  fusion  of  spines  and  laminae.  Albee,  doubting  the  relia- 
bility of  the  periosteum  as  a  bone  producer,  practises  bone-grafting.  An 
.T-ray  picture  must  be  taken  in  order  to  determine  that  vertebral  bodies  are 
being  broken  down  and  the  region  of  such  destruction.  We  thus  learn  the 
vertebra  or  vertebrae  which  are  diseased  and  where  the  graft  is  to  be  applied. 
The  patient  is  placed  prone.  An  incision  is  made  to  expose  the  spines  of  the 
diseased  vertebrae  and  also  one  or  two  vertebrae  above  and  one  or  two  below. 
Some  make  a  straight  incision.  Rugh  makes  a  curved  incision  at  one  side  of  the 
spine  and  turns  back  a  flap.  Each  spine  is  split  vertically  by  a  chisel  and  each 
split  portion  is  broken  and  pushed  over  toward  the  corresponding  side.  The 
interspinous  ligaments  are  cut  so  as  to  correspond  to  the  split  in  the  spines. 
We  thus  obtain  a  wedge-shaped  incision  through  bone  and  ligament. 

The  length  of  the  cut  is  measured  on  a  probe.  The  wound  is  packed  tem- 
porarily. The  leg  is  flexed  upon  the  thigh.  An  incision  is  made  over  the  an- 
terior surface  of  the  tibia.  A  wedge-shaped  graft  of  bone  is  cut  by  means  of 
a  surgical  engine,  a  Gigli  saw,  or  a  chisel  and  mallet.  The  graft  is  covered  with 
periosteum  on  one  side  and  contains  some  medullary  tissue  on  the  other.  It 
is  }-^  inch  thick  at  its  base.  This  graft  is  fitted  to  the  unbroken  sides  of  the 
spinous  processes.  If  the  kyphosis  is  marked,  numerous  cross-cuts  are  made 
with  a  saw  into  the  thin  edge.  Thus  the  graft  will  be  made  flexible.  No 
attempt  is  made  to  correct  forcibly  the  deformity.  Here  and  there  the  perios- 
teum is  incised  to  favor  the  emergence  of  osteoblasts.  The  interspinous  liga- 
ments are  sutured  over  the  graft  by  sutures  of  kangaroo  tendon.  The  incision 
is  closed.  The  patient  is  put  on  a  Bradford  frame  or  plaster-of-Paris  is  applied. 
The  patient  remains  recumbent  for  from  six  to  twelve  weeks,  then  he  is  allowed 
to  sit  up  and  soon  after  to  walk,  of  course  wearing  a  brace  or  plaster. 

The  brace  or  jacket  is  removed  in  five  or  six  months.  The  results  of  this 
operation  are  excellent.  The  fate  of  the  bone-graft  is  a  matter  of  dispute. 
Some  hold  that  it  really  lives.  Others  hold  that  it  is  simply  a  scaffold  for  new 
bone.  One  thing  is  certain — it  strongly  stimulates  the  production  of  new  bone 
from  the  raw  surfaces  of  the  split  spinous  processes.  New  bone  comes,  and  new 
.bone,  however  formed,  constitutes  the  permanent  splint  (iVlbee,  in  the  "Post- 
Graduate,"  Nov.,  1912,  and  in  "N.  Y.  Med.  Jour.,"  March  9,  1912;  J.  Torrance 
Rugh,  in  "Monthly  Cyclopedia  and  Medical  Bulletin,"  Feb.,  1913,  and  in 
"International  Clinics,"  Vol.  I,  Twenty-third  Series). 

Albee  ("Am.  Jour.  Orthop.  Surg.,"  1916,  xiv)  reports  198  personal  cases  of 
Pott's  disease  that  were  operated  on  a  year  or  more  ago  by  bone-graft.  In 
184  cases  the  disease  was  arrested.  In  2  improvement  occurred,  up  to  the  date 
of  the  paper  12  had  died.  Six  of  the  12  were  relieved  of  symptoms  of  Pott's 
disease  and  died  of  conditions  unconnected  with  the  operation. 

Puncture  of  the  spinal  theca,  or  lumbar  puncture,  was  devised  by  Quincke^ 
for  hydrocephalus  in  1891,  and  has  been  carefully  tested  by  many  surgeons. 


g-jo  Surgery  of  the  Spine 

It  is  the  operation  for  withdrawing  cerebrospinal  fluid  from  the  subarachnoid 
space  of  the  cord.  It  is  employed  as  a  means  of  diminishing  cerebral  pressure 
in  hydrocephalus,  cerebral  tumor,  uremia,  infantile  palsy,  and  tuberculous 
meningitis,  but  in  these  cases  it  has  proved  of  little  or  only  of  temporary  thera- 
peutic value.  It  may  be  of  some  service  in  cerebrospinal  meningitis,  in  acute 
anterior  poliomyelitis  and  in  delirium  tremens.  The  condition  of  a  patient  with 
a  fracture  of  the  base  of  the  skull  is  sometimes  temporarily  improved  by  the 
operation.  Pain  is  often  temporarily  relieved.  In  the  performance  of  a  brain 
operation  the  brain  may  bulge  so  that  the  dura  cannot  be  sutured.  Lumbar 
puncture  makes  suturing  possible.  Puncture  is  the  preliminary  step  of  spinal 
anesthesia.  In  some  cases  the  examination  of  the  fluid  has  been  of  great  diag- 
nostic value.  The  fluid  is  not  only  subjected  to  a  naked-eye  study,  it  is  also 
studied  microscopically  and  bacteriologically.  If  the  fluid  from  the  puncture 
gives  no  positive  finding,  the  operation  should- be  repeated  (Xorgo).  When  a 
diagnostic  tap  is  made  we  must  know  the  appearance,  nature,  and  pressure  of 
the  fluid  normally. 

Normally  the  fluid  is  clear,  transparent,  alkaline,  and  under  a  pressure  of 
from  40  to  60  mm.  of  mercury  (Dana),  its  specific  gravity  is  from  1.006  to 
1.008,  and  from  5  to  10  c.c.  will  flow  out  at  a  tap.  It  contains  a  faint  trace  of 
coagulable  protein,  inorganic  salts  as  does  the  blood-plasma,  a  carbohydrate 
resembling  glucose  but  no  formed  elements.  The  carbohydrate  is  probably 
dextrose.  In  cases  of  increased  tension  the  fluid  flows  out  more  forcibly, 
rapidly,  and  profusely  (brain  tumor,  hydrocephalus,  meningitis,  pneumonia, 
influenza  and  some  other  infectious  conditions).  When  there  is  meningeal 
inflammation  the  specific  gravity  is  increased.  In  apoplexy  and  other  hemor- 
rhages beneath  the  cerebral  arachnoid,  in  fracture  of  the  base  of  the  skull,  and  in 
hemorrhage  beneath  the  arachnoid  of  the  cord,  the  fluid  contains  blood. 
Laceration  of  the  brain  tissue  without  subarachnoid  or  ventricular  hemorrhage 
does  not  make  the  fluid  bloody.  The  fluid  is  turbid  in  purulent  meningitis 
of  the  cord  or  brain,  may  contain  many  polymorphonuclear  leukocytes,  and  also 
bacteria.  Lumbar  puncture  is  of  great  diagnostic  use  in  the  cerebral  hemor- 
rhage of  the  newborn  and  in  some  fractures  of  the  base  of  the  skull. 

The  chemical  study  of  the  fluid  is  sometimes  of  value. 

In  intracranial  tumor,  purulent  meningitis,  subarachnoid  hemorrhage  of 
the  brain  or  cord,  and  apoplexy  coagulable  protein  is  increased.  The  carbo- 
hydrate substance  resembling  glucose  is  absent  in  purulent  meningitis  and  is 
increased  in  saccharine  diabetes.  In  most  cases  of  tuberculous  meningitis  at 
some  period  of  the  disease  there  is  a  decrease  in  carbohydrate.  In  some  cases 
there  is  no  decrease. 

In  uremia  the  chlorids  are  diminished. 

Cytodiagnosis  (a  microscopical  study  of  the  cells  of  the  fluid)  may  furnish 
useful  information;  numerous  polymorphonuclear  leukocytes  are  found  in 
meningitis.  Lymphocytosis  suggests  a  tuberculous  lesion  rather  than  an 
acute  meningeal  inflammation.  Lymphocytosis  occurs  also  in  syphihs  of 
the  brain  and  cord,  locomotor  ataxia,  paresis,  and  uremia. 

Bacteriologic  study  by  cover-glass  preparations  or  cultures  may  give  im- 
portant information.  In  over  74  per  cent,  of  cases  of  tuberculous  meningitis 
of  the  brain  membranes  the  fluid  contains  bacilli.  Stadelmann  has  reported 
37  cases  in  which  tubercle  bacilli  were  found  in  the  fluid. ^  In  tuberculous 
meningitis  the  fluid  may  or  may  not  contain  tubercle  bacilli.  In  cerebrospinal 
meningitis  the  cerebrospinal  fluid  contains  the  meningococcus.  In  this  disease 
diagnostic  puncture  is  unnecessary  if  the  nasal  mucus  contains  the  Diplococcus 
intracellularis.  The  operation  of  lumbar  puncture  is  simple,  and  if  done  with 
proper  precautions  is  harmless.  The  back  should  be  carefully  sterilized  and 
thorough  asepsis  must  be  preserved  in  every  detail.  The  patient  may  lie  on  the 
*  "Berliner  klinische  Wochenschrift,"  July  8,  1895. 


The  Mingazzini-Foerster  Operation  in  Tabes  971 

right  side  with  the  left  knee  well  drawn  up,  may  lie  prone,  with  a  pillow  under 
the  belly,  or  may  sit  in  a  chair,  with  the  body  bent  forward.  He  must  not 
straighten  up  during  the  operation.  If  he  does  the  needle  may  be  broken.  The 
site  of  the  intended  puncture  may  be  frozen  with  ethyl  chlorid,  but  no  general 
anesthetic  is  required.  A  suction  apparatus  is  not  to  be  used  as  it  might  cause 
hemorrhage.     A  Pravaz  syringe  is  employed.     The  needle,  which  should  be 

3  inches  in  length,  is  guarded  by  the  surgeon's  index-finger  and  the  point  is 
inserted  }4  inch  to  the  right  of  the  median  line  and  between  the  third  and 
fourth  lumbar  vertebrae.  It  is  pointed  upward  and  a  little  inward  under  a 
spinous  process.  It  enters  the  canal  in  the  middle  line.  In  a  child  the  needle 
enters  the  canal  at  a  depth  of  from  2  to  3  cm. ;  in  an  adult,  at  a  depth  of  from 

4  to  5  cm.  The  fluid  is  permitted  to  fall  drop  after  drop  into  a  sterile  test- 
tube.  In  some  cases  only  a  few  drops  of  fluid  can  be  obtained;  in  other  cases 
many  cubic  centimeters  may  be  removed.  It  is  not  wise  to  draw  for  diagnostic 
purposes  over  5  c.c.  from  a  child  and  10  c.c.  from  an  adult.  If  we  evacuate 
too  much  cerebrospinal  fluid,  the  ventricles  are  emptied  and  compression 
of  the  cerebellum  may  arise.  The  flow  should  be  spontaneous  and  suction 
ought  not  to  be  used.  After  operation  the  patient  must  remain  in  bed  for  at 
least  twenty-four  hours,  with  the  head  low  for  the  first  twelve  hours.  The 
erect  posture  is  to  be  assumed  gradually.  To  let  a  patient  sit  up  or  walk 
about  soon  after  puncture  is  dangerous.  Sometimes  nausea,  vertigo,  and 
severe  headache  follow  the  operation,  and  sudden  deaths  have  been  reported. 
For  a  number  of  hours  after  tapping  the  patient  should  remain  recumbent. 
Ft  is  probable  that  lumbar  puncture  is  free  from  danger  in  a  healthy  person. 
It  has  certain  dangers  in  uremia,  intracranial  hemorrhage  and  intraspinal 
hemorrhage.  It  brings  definite  peril  in  meningitis,  brain  abscess,  and  brain 
tumor  because  it  may  cause  the  brain-stem  to  sink  in  the  foramen  magnum 
and  so  be  responsible  for  respiratory  failure.  If  we  decide  upon  puncture  in 
a  case  in  which  brain  tumor  is  suspected  keep  the  patient  recumbent  for 
at  least  twenty-four  hours  before  the  operation,  perform  the  puncture  while 
the  patient  is  upon  his  side  and  the  head  is  lower  than  the  body,  keep  him  in 
bed  for  forty-eight  hours  after  operation,  the  head  being  kept  low  for  the  first 
twelve  hours  of  this  period.  The  erect  position  is  assumed  gradually  (Schoen- 
beck,  in  "Arch.  f.  klin.  Chir.,"  1915,  cvii). 

The  Mingazzini-Foerster  Operation  in  Tabes. — Painful  crises  of  tabes  are 
not  connected  with  the  vagus  but  originate  in  the  posterior  roots.  Mingazzini 
suggested  intradural  division  of  the  posterior  sacrolumbar  nerve-roots  for 
unbearable  pain  in  the  lower  extremities  due  to  tabes. 

Foerster  follows  a  like  method  in  treating  gastric  crises.  He  divides  the 
posterior  dorsal  roots  on  both  sides  from  the  sixth  to  the  ninth.  Sauve  divides 
the  posterior  roots  from  the  fifth  to  the  eleventh.  Some  of  these  operations 
have  been  notably  successful.  Many  have  failed  (Leriche,  Delbet,  Nocquot). 
In  at  least  one  case  the  condition  was  aggravated  (Doerr,  in  the  "  Wien.  med. 
Woch.,"  No.  45,  191 1).  Intradural  operations  have  a  decided  mortality. 
For  the  pains  and  crises  of  tabes  some  surgeons  advise  extradural  division 
within  the  canal  of  the  posterior  roots  (Guleke).  Frankl  advocates  an  opera- 
tion without  laminectomy.  He  exposes  the  intercostals  from  the  fifth  to  the 
seventh  and  avulses  them  with  the  corresponding  posterior  roots.  Jaboulay 
employed  stretching  of  the  solar  plexus.  Delbet  and  others  find  it  useless. 
It  is  necessary  to  remember  that  tabetic  crises  occur  only  early  in  tabes  and 
cease  later  when  the  root  fibers  are  destroyed.  Operation  is  justifiable  only 
when  nutrition  is  dangerously  interfered  with,  or  when  the  pains  occur 
so  violently  and  often  as  to  be  unbearable.  The  posterior  roots  may  be 
divided  for  spastic  paralysis,  for  intractable  neuralgia  and  for  athetosis. 
The  roots  selected  depend  upon  the  area  of  palsy,  the  seat  of  pain  or  the  region 
of  athetosis. 


972  Surgery  of  the  Spine 

Intradural  Root  Anastomosis  in  Cases  of  Vesical  Paralysis. — Kilvington 
("Brit.  Med.  Jour.,"  1907,  vol,  i)  suggested  intraspinal  anastomosis  of  nerve- 
roots.  He  found  by  experiments  on  dogs  that  the  last  lumbar  root,  when  joined 
to  the  roots  of  the  second  and  third  sacral  nerves,  gives  contraction  to  a  palsied 
bladder.  Bird,  at  the  suggestion  of  Kilvington,  did  the  operation  on  a  human 
being,  but  it  was  a  failure.  Frazier,  in  a  case  of  Mills's,  anastomosed  the  root 
of  the  last  lumbar  to  the  roots  of  the  third  and  fourth  sacral  nerves.  There  was 
decided  improvement  (Frazier  and  Mills,  ''Jour.  Am.  Med.  Assoc,"  Dec.  21, 
1912).  N.  Sharpe  ("N.  Y.  Med.  Jour.,"  1916,  civ)  advocates  the  operation 
for  paralysis  of  the  lower  limbs  when  little  or  no  improvement  could  be  expected 
from  braces  or  tendon  transplantation.  He  advocates  using  the  twelfth  dorsal, 
the  second  lumbar  or  the  third  lumbar  as  the  energizing  root.  He  advocates 
a  two-stage  operation.  The  first  stage  is  laminectomy,  in  the  second,  the 
theca  is  opened  and  the  anastomosis  made. 

Horsley's  Operation  for  Chronic  Spinal  Meningitis  and  the  Decompression 
of  Bailey  and  Elsberg. — Sir  Victor  Horsley  ("Brit.  Med.  Jour.,"  Feb.  27, 
1909)  states  that  during  the  past  ten  years  he  has  operated  on  a  number  of 
cases  for  what  he  calls  chronic  spinal  meningitis.  Such  cases  are  commonly 
confused  with  tumor,  are  much  more  frequent  than  tumors,  and  are  often 
cured  or  greatly  improved  by  operation.  The  first  published  case  of  this 
sort  was  reported  by  Spiller,  Musser,  and  Martin  ("Univ.  of  Penna.  Med. 
Bulletin,"  March,  1903),  Martin  performed  laminectomy,  found  a  "circum- 
scribed meningitis,"  and  cured  the  patient.  In  these  cases  a  fluid  accumula- 
tion is  found  and  this  fluid  is  stagnating  and  under  pressure.  The  cord  passes 
into  a  condition  of  sclerogliosis.  The  symptoms  are  pain,  advancing  loss  of 
power  in  the  legs,  perhaps  slight  kyphosis,  and  eventually  progressive  and 
fatal  paraplegia  (compression  paraplegia). 

The  pain  in  these  cases  involves  an  extensive  area,  not  as  in  extramedullary 
tumor  a  small  area  supplied  by  one  or  two  nerve-roots,  and  there  may  be 
hyperesthesia  over  an  entire  extremity,  which  does  not  occur  in  extramedullary 
tumor  (Horsley,  Loc.  cit.).  Horsley  has  never  seen  absolute  abolition  of  tactile 
sense.  The  operation  consists  in  laminectomy,  opening  the  theca,  washing 
it  out  with  mercurial  solution  (1:500  followed  by  1:2000),  and  closing  with- 
out drainage.  Bailey  and  Elsberg  ("Jour.  Am.  Med.  Assoc,"  March  9,  191 2) 
suggest  the  term  spinal  decompression  for  laminectomy  and  opening  of  the  dura 
when  no  lesion  is  located  or  found.  They  believe  that  in  such  cases  the  lamin- 
ectomy and  opening  of  the  dura  do  the  good.  A  number  of  other  intradural 
conditions  may  perhaps  be  benefited  by  the  operation.  Some  remarkable 
cases  have  been  reported.  I  operated  on  a  case  of  supposed  transverse  mye- 
litis. On  inspecting  the  cord  no  lesion  was  discovered  yet  the  patient  made 
an  apparently  complete  recovery  from  his  trouble.  I  am  satisfied  that  in  some 
cases  the  operation  is  of  great  value.  Why  it  ever  improves  a  case  I  do  not 
know.  That  it  may  I  do  know.  In  none  of  the  cases  reported  by  Bailey  and 
Elsberg  were  there  any  signs  of  pressure.  Elsberg  ("Jour.  Nervous  and  Mental 
Dis.,"  1911)  pointed  out  that  laminectomy  and  incision  of  the  dura  often  produce 
an  immediate  effect  on  spinal  reflexes.  In  many  cases  within  half  an  hour 
knee  and  ankle  jerks  become  depressed  and  remain  so  from  several  hours  to 
24  hours.  This  condition  probably  results  from  change  of  pressure  modifying 
circulation.  Elsberg  and  Bailey  ("Jour.  Am.  Med.  Assoc,"  June  10,  1916)  ad- 
vocate exploration  in  the  cervical  and  dorsal  regions  but  caution  us  not  to 
expose  the  cauda  equina  without  very  strong  indications.  The  cauda  is  ex- 
tremely sensitive  to  pressure  changes,  and  bladder  and  rectal  symptoms  may 
arise  after  mere  exposure  of  the  conus. 


XXVI.  SURGERY  OF  THE  RESPIRATORY  ORGANS 

Asphyxia. — In  drowning,  strangulation,  suffocation,  and  hanging  the  mode 
of  death  is  by  the  same  process,  that  is,  by  asphyxia  or  apnea.  "  iVsphyxia," 
though  the  commonly  used  designation,  is  an  unfortunate  term,  and  apnea  is  the 
more  correct  one.  By  asphyxia  we  mean  the  non-oxygenation  or  the  incomplete 
oxygenation  of  the  blood,  and  yet  even  in  this  condition  death  is  not  immediate, 
for  the  heart  may  continue  to  beat  for  some  little  time  after  all  breathing  has 
ceased.  A  man  may  be  apparently  dead  from  asphyxia  and  yet  be  capable  of 
resuscitation.  In  general,  it  may  be  said  that  asphyxia  produces  lividity,  a 
struggle  like  a  convulsion  to  obtain  breath,  and  finally,  in  many  cases,  genuine 
convulsions.  In  the  very  beginning  of  non-oxygenation  the  senses  may  be 
remarkably  acute,  but  consciousness  is  soon  lost.  The  veins  stand  out  and 
the  pulse  becomes  weaker  and  weaker.  The  individual  may  bleed  from  the 
nose,  from  the  rectum  and  other  mucous  membranes,  and  there  may  be  in- 
voluntary passage  of  urine.  For  a  short  time  the  chest  heaves,  making  res- 
piratory attempts,  and  after  a  short  time  the  heart  stops  beating. 

Asphyxia  is  a  common  mode  of  death.  It  is  the  mode  of  death  occasioned 
by  a  foreign  substance  in  the  air-passages,  by  paralysis  or  by  tetanic  fixation  of 
the  respiratory  muscles,  by  great  pressure  upon  the  chest  or  abdomen,  by  acute 
traumatic  pneumothorax,  by  a  clot  in  the  pulmonary  artery  which  cuts  off  the 
blood-supply  of  the  lungs,  by  hanging,  throttling,  drowning,  absence  of  sufi&- 
cient  oxygen  from  the  gases  breathed,  presence  of  quantities  of  irrespirable 
gases  (CO,  CO2),  or  the  presence  of  irritant  gases  (CI,  SO2)  which  cause  spasm 
of  the  glottis. 

The  terms  smothering,  stifling,  and  suffocation  mean  prevention  of  entry  of 
air  into  the  lungs  in  sufficient  quantity  to  properly  aerate  the  blood. 

Treatment  in  General. — Of  course,  each  form  requires  some  particular 
method  of  care.  In  general,  it  may  be  said  that  the  surgeon  should  at  once 
endeavor  to  determine  the  cause  of  the  asphyxia  and  should  particularly  ascer- 
tain if  it  came  on  gradually  or  suddenly.  As  a  rule,  a  gradual  asphyxia  is  due 
to  some  intrathoracic  lesion.  If  the  asphyxia  were  sudden  the  surgeon  must 
examine  the  neck  and  chest  externally  to  see  if  there  is  any  sign  of  injury. 
Then  the  mouth  is  opened,  the  tongue  pulled  forward,  and  the  glottis  felt  by 
the  finger  to  see  that  no  foreign  material  is  blocking  the  air-passages.  The 
patient  will  do  best  in  a  free  draft  of  fresh  air,  and  it  may  be  possible  to  excite 
respiratory  activity  by  dashing  hot  water  and  then  cold  water  on  the  face  and 
chest  and  making  a  number  of  these  alternate  applications.  The  application 
of  electricity  to  the  phrenic  nerve  may  do  good  (the  anode  at  the  root  of  the  neck 
and  the  cathode  over  the  epigastric  region).  If  there  is  cardiac  dilatation, 
bleeding  is  urgently  indicated.  When  the  patient  is  breathing,  inhalations  of 
oxygen  do  good.  If  there  is  laryngeal  obstruction,  tracheotomy  or  intubation 
should  be  done.  In  most  cases  of  threatened  asphyxiation  artificial  respiration 
is  necessary.     There  are  several  different  methods. 

973 


974 


Surgery  of  the  Respiratory  Organs 


Artificial  respiration  is  resorted  to  in  case  of  suspension  of  breathing 
from  anv  cause;  among  the  more  frecjuent  causes  are  the  inhalation  of  smoke 
or  poisonous  gases,  drowning,  profound  anesthesia,  oi)ium-poisoning,  and  electric 
shock.  It  should  be  inaugurated  at  the  earliest  possible  second  and  expecta- 
tion of  the  arrival  of  special  apparatus  should  never  cause  a  moment's  delay 
in  making  it.  If  the  heart  is  still  beating  life  can  be  prolonged  more  certainly 
bv  the  use  of  an  apparatus  than  by  manual  procedures,  but  one  must  not  stand 
by  with  folded  hands  until  an  apparatus  is  obtainable. 

After  breathing  has  ceased  for  ten  minutes  from  drowning,  poisoning  by 
illuminating  gas,  electric  shock,  effects  of  an  anesthetic  or  any  other  form  of 
asphyxia,  its  restoration  is  usually  impossible  (Y.  Henderson,  in  "  Jour.  Am. 
Med.  Assoc,"  1916,  Ixvii). 

There  are  several  methods  of  giving  artificial  respiration.  One  method  may 
have  an  advantage  over  another  in  a  certain  type  of  case,  as  will  hereafter  be 
described. 


I  I'.   M.^      Syl\i -icr'-  nirt  li'iil.     Inspiration. 

Before  resorting  to  any  method  the  clothing  about  the  neck,  chest,  and 
abdomen  must  be  free  and  loose;  the  mouth  unobstructed  by  foreign  bodies, 
as  false  teeth,  etc.,  the  throat  clear  of  mucus,  etc. 

If  edema  of  the  glottis,  malignancy  of  the  tongue,  or  an  immovable  foreign 
body  should  obstruct  the  air-passages,  tracheotomy  should  be  performed  be- 
fore attempting  artificial  respiration. 

When  giving  artificial  respiration  the  operator  should  not  desist  because 
respirations  are  not  established  in  a  few  minutes,  but,  on  the  contrary,  should 
persist  (even  using  relays  of  men  if  necessary)  for  an  hour  or  more.  Many 
cases  of  drowning,  opium-poisoning,  asphyxia  from  smoke,  etc.,  have  been 
resuscitated  after  artificial  respiration  had  been  carried  on  for  an  almost  incredi- 
ble period  of  time. 

During  the  manipulations  of  artificial  respiration  it  should  be  remembered 
that  the  patient  must  be  cared  for  as  in  shock:  the  body  kept  warm,  friction 
applied  by  the  hands  or  rough  towels,  and  massage  over  the  heart  practised. 
Enemas  of  cofTee  by  rectum  and  stimulating  hypodermatic  injections  are  im- 
portant. The  author  prefers  an  enema  of  5  oz.  of  hot  coffee  with  i  oz.  of  brandy 
and  a  hypodermatic  injection  of  atropin  sulph.,  gr.  ^oo,  or  strychnin,  gr.  Ho- 
One  of  the  oldest  methods  of  artificial  respiration  and  the  one  most  applicable  in 


Artificial   Respiration 


975 


children  is  mouih-io-mouth  insujjlaiion.  In  this  method  the  operator  holds  the 
victim's  tongue  forward  with  a  suture  or  with  a  piece  of  string  tied  around  the 
tongue;  with  the  other  hand  he  closes  the  nostrils,  and  then,  after  taking  a  deep 
inspiration,  blow&  directly  into  the  patient's  mouth.  The  air  is  then  expelled 
from  the  patient's  lungs  by  direct  pressure  on  the  walls  of  the  thorax.  This 
procedure  is  repeated  i6  times  a  minute.  Instead  of  the  direct  mouth-to- 
mouth  inflation  a  soft-rubber  catheter  may  be  passed  through  the  mouth  into 
the  trachea  and  the  patient's  lungs  be  expanded  by  the  operator  blowing 
through  the  catheter. 

Artificial  respiration  must  be  stopped  when  the  patient  has  taken  one  or  two 
breaths,  but  should  be  continued  until  the  respiratory  movements  are  regular 
and  normal.  The  patient  must  be  carefully  watched  for  fear  of  secondary 
apnea. 

Sylvester's  method  is  a  popular  one,  and  is  probably  the  best  in  many  cases 
of  severe  electric  shock,  but  if  there  is  any  fluid  in  the  lungs  or  air-passages 
(as  in  cases  of  drowning)  or  if  an  arm  or  forearm  is  broken,  another  method  may 
be  preferred. 


Fig.  614. — Sylvester's  method.     Expiration. 

To  make  artificial  respiration  by  this  method  the  patient  is  placed  on  his 
back  with  a  folded  coat  or  blanket  under  his  shoulders.  The  tongue  is  pulled 
forward  and  held  by  forceps,  a  suture,  or,  in  an  emergency,  may  be  tied  with  a 
string,  or  even  a  necktie  can  be  used.  The  operator,  kneeling  at  the  head  of  the 
patient,  grasps  the  forearms  just  below  the  elbows  and  circumducts  the  arms 
outward  and  upward,  meanwhile  making  traction  until  the  arms  are  perpendicu- 
lar to  the  body  (Fig.  613).  By  this  movement  the  chest  is  expanded  and  in- 
spiration is  caused.  The  arms  are  now  brought  slowly  to  the  sides  of  the  chest 
and  firm  pressure  is  made  for  two  or  three  seconds,  thus  forcing  the  air  from 
the  lungs  and  causing  expiration  (Fig.  614).  This  procedure  should  be  re- 
peated about  15  or  16  times  a  minute. 

This  method  is  best  suited  to  those  overcome  by  gas,  smoke,  or  apnea  other 
than  that  due  to  drowning. 

Howard's  Method. — If  the  patient  has  sustained  fracture  of  the  ribs  some 
other  method  should  be  selected.  Howard's  method  is  now  used  by  the  United 
States  Life  Saving  service  in  cases  of  drowning.  The  procedure  as  laid  down  by 
Dr.  Howard  is  as  follows: 

"Rule  i:  To  expel  water  from  the  stomach  and  lungs,  strip  the  patient  to 
the  waist,  and,  if  the  jaws  are  clinched,  separate  them  and  keep  them  apart  by 
placing  between  the  teeth  a  cork  or  a  small  piece  of  wood.     Place  the  patient 


g'j6  Surgery  of  the  Respiratory  Organs 

face  downward,  the  pit  of  the  stomach  being  raised  above  the  level  of  the 
mouth  by  a  roll  of  clothing  placed  beneath  it.  Throw  your  weight  forcibly  two 
or  three  times  upon  the  patient's  back  over  the  roll  of  clothing  so  as  to  press  all 
fluids  in  the  stomach  out  of  the  mouth." 

"Rule  2:  To  perform  artificial  respiration  quickly  turn  the  patient  upon  his 
back,  placing  the  roll  of  clothing  beneath  it  so  as  to  make  the  breast  bone  the 
highest  point  of  the  body.  Kneel  beside  or  astride  of  the  patient's  hips.  Grasp 
the  front  part  of  the  chest  on  either  side  of  the  pit  of  the  stomach,  resting  the 
fingers  along  the  spaces  between  the  short  ribs  (Fig.  615).  Brace  your  elbows 
against  your  sides,  and  steadily  grasping  and  pressing  forward  and  upward, 
throw  your  whole  weight  upon  the  chest,  gradually  increasing  the  pressure  while 
you  count  'one,  two,  three.'  Then  suddenly  let  go  with  a  final  push,  which 
springs  you  back  to  your  first  position.     Rest  erect  upon  your  knees  while  you 


J 


Fig.  615. — Howard's  method  of  artificial  respiration. 


count  'one,  two;'  then  make  pressure  as  before,  repeating  the  entire  motions 
at  first  about  4  or  5  times  a  minute,  gradually  increasing  them  to  about  10  or 
1 2  times.  Use  the  same  regularity  as  in  blowing  bellows  and  as  seen  in  natural 
breathing,  which  you  are  imitating.  If  another  person  is  present  let  him, 
with  one  hand,  by  means  of  a  dry  piece  of  gauze,  hold  the  tip  of  the  tongue  out 
of  one  corner  of  the  mouth,  and  with  the  other  hand  grasp  both  wrists  and  pin 
them  to  the  ground  above  the  patient's  head." 

Schdftr's  Method  or  the  Prone  Method. — Schafer's  method  is  not  suitable 
if  the  patient  has  sustained  fracture  of  the  ribs.  In  this  method,  instead  of 
lying  on  his  back  as  in  the  Howard  method,  the  patient  lies  on  his  stomach,  his 
face  being  turned  to  one  side.  The  arms  are  placed  above  the  head.  A  roll  of 
blankets  or  clothing  is  placed  under  the  chest.  The  operator  now  kneels  astride 
of  the  patient  and  grasps  the  thorax  with  both  hands,  the  fingers  running  par- 
allel with  the  ribs.  Brace  your  elbows  against  your  sides  and  press  firmly 
inward  and  upward,  throwing  your  whole  weight  against  the  chest.  Release 
your  pressure  after  two  or  three  seconds,  count  "one,  two,"  and  again  make 
pressure  as  before.     This  sequence  should  be  repeated  about  15  times  a  minute. 

The  advantages  of  this  method  are  that  fluid  in  the  air-passages  will  gravi- 
tate out  through  the  mouth  and  the  tongue  falls  forward  without  being  held. 

Marshall  Hall's  method  is  more  easily  applied  on  the  operating  table  than 
any  other  method  of  artificial  respiration.  On  the  other  hand,  it  is  not  as 
eflicient  and  is  only  justifiable  when  the  patient's  normal  respirations  are  re- 
sumed after  three  or  four  applications  of  pressure.     The  patient  lies  on  his 


ArtiRcial  Respiration  by  the  Pulmotor 


977 


back,  and  the  operator,  with  a  hand  on  either  side  of  the  tliorax  near  the  costal 
region,  makes  pressure  upward  and  inward.  This  pressure  is  continued  for 
two  or  three  seconds,  then  suspended  for  the  same  length  of  time,  and  then 
pressure  again  made.     This  procedure  is  repeated  about  15  times  a  minute. 

Labordes  method  is  not  as  efficacious  as  the  foregoing,  but  has  its  uses  in 
cases  in  which,  because  of  injury  to  the  chest,  shoulders,  or  arms,  Sylvester's 
or  Schafer's  method  or  their  modifications  cannot  be  employed. 

Laborde's  method  rests  on  the  assumption  that  "systematic  and  rhythmic 
traction"  upon  the  tongue  produces  respiratory  reflexes  and  causes  contrac- 
tions of  the  diaphragm,  hence  establishing  respirations. 

The  toHgue  is  grasped  by  tongue-forceps  or  a  piece  of  gauze  held  between 
the  forefinger  and  thumb,  and  is  pulled  well  out  of  the  mouth  with  considerable 
traction.  It  is  held  for  two  or  three  seconds  and  then  relaxed.  This  pro- 
cedure is  repeated  about  15  times  a  minute. 

When  a  certain  amount  of  resistance  is 
felt,  it  is  a  sign  that  respiratory  function  is 
being  restored.  Noisy  respiration  first  occurs, 
termed  inspiratory  hiccup. 

When  the  condition  of  the  chest  will 
allow,  that  is,  if  there  are  no  fractured  ribs, 
empyema,  etc.,  Laborde's  method  and 
Marshall  Hall's  method  may  be  combined. 

It  can  be  readily  realized  that  Laborde's 
method  cannot  be  used  when  there  is  disease 
or  injury  of  the  tongue. 

Intratracheal  Insufflation. — This  consists 
in  forcing  air  by  external  pressure  through  a 
tube  which  passes  through  the  mouth  and 
larynx  into  the  trachea.  The  air,  under  the 
influence  of  the  same  force  which  drove  it  in, 
emerges  between  the  tube  and  tracheal  wall. 
"The  air-stream  has  to  be  interrupted  several 
times  a  minute  for  only  about  two  seconds 
at  a  time  "  (S.  J.  Meltzer,  in  "  Keen's  Surgery," 
vol.  vi).  (See  Insufflation  Anesthesia, 
p.  1340.) 

Artificial  Respiration  by  the  Pulmotor. — 
The  pulmotor  is  a  most  ingenious  apparatus. 
It  is  for  two  purposes:  (i)  To  give  artificial 
respiration;   (2)  to  administer  oxygen. 

Both  the  administration  of  oxygen  and 
the    production  of  artificial    respiration  are 

.accomplished  by  means  of  oxygen  which  is  under  pressure.  This  fact  makes 
the  instrument  especially  valuable  in  cases  of  asphyxiation  from  illuminat- 
ing gas  or  other  poisonous  vapors.  The  apparatus  should  be  a  part  of 
the  equipment  of  every  modern  hospital  (for  work  on  the  ambulance,  in  the 
accident  ward,  and  in  the  operating  room),  of  every  gas  and  electric  company, 
of  every  mine,  should  be  accessible  at  resorts  where  bathers  congregate  in  any 
large  number,  and  should  be  on  the  ground  at  every  city  fire. 

The  apparatus  is  contained  in  a  narrow  wooden  case  which  can  be  carried 
by  one  person.  The  weight  of  the  case  with  the  apparatus  is  less  than  50 
pounds.  A  diagram  of  the  apparatus  (Fig.  616)  is  here  given  which  shows 
its  mechanism:  C  is  a  cylinder  containing  11,1^  cubic  feet  of  oxygen,  which  will 
keep  the  apparatus  in  operation  and  create  artificial  respiration  for  forty  min- 
utes ;  V  is  a  valve  which  opens  and  closes  the  oxygen  tank  and  which  is  the  sole 
governor  of  the  apparatus. 

62 


Fig.  616. — Diagrammatic  illus- 
tration showing  the  action  of  the 
pulmotor.  (See  text  for  explanation 
of  letters.) 


978 


Surgery  of  the  Respiratory  Organs 


The  mask  is  fitted  on  the  patient's  head  as  in  Fig.  617.  The  oxygen  is  then 
turned  on  by  the  valve  V.  The  oxygen  passes  through  the  reducing  valve  D 
to  the  injector  S,  which  has  the  property  of  drawing  in  a  large  volume  of  air 
witli  a  certain  force  of  suction,  and  propelling  that  air  forward  with  equal  force 
through  the  flexible  tube  in  front  of  the  injector.  This  suction  and  delivery 
injector  therefore  serves  as  a  motor,  automatically  filling  the  lungs  by  pressure 
and  emptying  them  by  suction.  The  suction  is  accomplished  by  the  leather 
accordion  bellows  B,  which  effects  without  cessation  the  automatic  reversal 
of  the  apparatus  from  suction  to  delivery  and  vice  versa.  During  inflation 
the  same  pressure  obtains  in  the  bellows  as  in  the  lungs,  but  as  soon  as  the  latter 
are  filled  the  bellows  becomes  inflated,  and  in  moving  forward  throws  over  the 
valve  in  the  reversing  chamber  L,  which  becomes  reversed  into  position  for 
suction.  This  operation  is  now  reversed,  and  as  soon  as  the  lungs  have  been 
emptied  the  bellows  contracts  and  automatically  reverses  the  valve  into  posi- 
tion for  inflation. 


Fig.  617 


—Application  of  mask  of  pulmotor,  the  tongue  being  held  forward  by  forceps,  and 
oxygen  prevented  from  entering  esophagus  by  pressure  with  right  hand. 


The  apparatus  adapts  itself  to  any  pulmonary  capacity.  The  rhythm  will 
be  slow  when  the  lungs  are  capacious  and  faster  when  they  are  of  less  capacity. 
It  causes  all  the  movements  of  respiration  without  any  assistance  being  re- 
quired from,  the  hands  other  than  to  keep  the  windpipe  of  the  patient  open  and 
the  gullet  closed  in  order  that  air  will  not  be  forced  into  the  stomach.  This 
latter  maneuver  is  accomplished  by  placing  the  hand  on  the  windpipe,  as  in 
Fig.  617,  and  making  pressure  sufficient  to  close  the  esophagus.  The  tongue 
must,  of  course,  be  held  forward,  as  in  Fig.  617. 

The  apparatus  is  devised  so  that  no  residual  air  from  the  system  can  find 
its  way  into  the  lungs  again.  In  this  way  no  air  contaminated  with  poison- 
ous or  asphyxiating  gas  is  breathed. 

After  respiration  has  been  established,  the  lever,  which  is  seen  in  Fig.  616, 
is  thrown  from  pulmotor  to  inhalation,  and  oxygen  is  then  given  as  shown  in 
Fig.  618. 

In  addition  to  this  regular  sized  pulmotor,  there  is  an  iniant  pulmotor  which 
is  especially  adapted  for  use  in  maternity  hospitals  and  by  obstetricians.  Both 
the  adult  and  the  infant  apparatus  have  a  lever  with  which  the  operator  can 
regulate  expiration  and  inspiration  at  will  instead  of  using  the  automatic 
bellows. 

If  the  mask  fits,  the  pulmotor  works  as  it  should.     If  it  does  not  fit,  it  fails. 


Drowning 


979 


The  mask  fits  some  faces  and  not  others.     A  great  need  of  the  instrument 
is  a  certainly  and  universally  adjustable  mask. 

The  pulmotor  has  failed  to  reach  our  expectations.  Experiments  show  that 
the  air  deHvered  by  the  pulmotor  does  not  contain  more  than  30  per  cent,  of 
oxygen.  The  positive  and  negative  pressures  succeed  each  other  so  rapidly 
that  the  lungs  are  never  properly  inflated  and  the  reducing  valve  is  very  apt  to 
get  out  of  order  (Y.  Henderson,  in  "Jour.  Am.  Med.  Assoc,"  1916,  Ixvii). 


Fig.  618. — Administration  of  oxygen  after  respirations  have  been  established. 

Artificial  Respiration  by  the  Lungmotor. — This  apparatus  not  only  furnishes 
air  to  the  lungs  but  also  causes  the  thorax  to  exert  the  proper  suction  upon  the 
great  vessels  and  heart.  This  instrument  is  worked  by  hand  and  it  can  be 
adjusted  to  any  subject  with  great  rapidity.  Before  using  the  instrument  a 
tube  is  inserted  into  the  esophagus.  By  squeezing  a  hand  bulb  a  bulb  within 
the  esophagus  is  distended  so  as  to  block  that  canal.  In  this  way  it  is  made 
certain  that  air  will  not  enter  the  stomach  instead  of  the  lungs.  The  mask  is 
then  fastened  in  place  and  the  air  pumps  are  worked.  One  makes  pressure, 
the  other  suction.  When  the  handle  is  lifted  cylinder  E  (Fig.  619)  fills  with  air 
drawn  from  the  lungs  and  cylinder  A  with  air,  with  O  or  with  air  and  O,  as  may 
be  desired.  When  the  handle  is  pushed  downward  the  air  or  the  O  mixture  is 
forced  into  the  lungs  and  the  expired  air  is  forced  out  of  the  suction  cylinder. 
The  marks  on  the  handle. of  the  piston  indicate  the  degree  of  movement  necessary 
for  age  periods. 

Drowning  is  asphyxia  brought  about  by  having  the  mouth  and  nose  sub- 
merged in  fluid,  air  being  thus  excluded  from  the  lungs.  It  is  not  only  water 
that  may  be  responsible  for  drowning.  An  individual  may  be  drowned  in 
mud  or  in  a  cesspool.  Drowning  is  a  common  accident.  Every  year  in  the 
United  States  there  are  at  least  15,000  deaths  from  drowning. 

Phenomena  of  Drowning. — As  asphyxia  begins  the  victim  struggles  fright- 
fully and  clutches  at  anything  that  seems  to  be  within  reach.  He  usually 
sinks  and  rises  an  uncertain  number  of  times.  The  old  rule  of  three  times 
has  no  particular  force.  It  ma}^  be  that  the  victim  sinks  and  rises  oftener,  it 
may  be  that  he  does  so  less  frequently.     He  may  not  rise  at  all.     During  the 


980 


Surgery  of  the  Respiratory  Organs 


awful  struggle  air  and  water  are  inhaled,  and,  as  a  rule,  some  of  the  water  is  cast 
out  by  vomiting  and  violent  cough.  During  drowning  water  is  certain  to  be 
drawn  into  the  bronchial  tubes.  It  is  doubtful  if  any  water  enters  the  air- 
vesicles.  They  become  distended  with  CO2  and  other  gases  (J.  M.  Booher). 
While  this  struggle  is  going  on  the  blood  becomes  less  and  less  oxygenated,  ex- 
haustion deepens;  finally  the  patient  sinks  to  rise  no  more,  some  air  is  forced 
from  the  lungs  causing  bubbles  on  the  surface  of  the  stream,  the  ears  ring,  the 
muscles  are  convulsed,  the  mind  wanders,  merciful  insensibility  arrives,  and 
death  follows.  During  the  mental  wandering  the  memory  may  take  clear 
and  extensive  or  irregular  and  incoherent  journeys  through  the  events  of  years 
or  a  lifetime,  but  this  does  not  always  happen. 


NEWBOt«.N 

5  YEARS 

10  Yeft*^5 

15  YEA««i  o.s"».u.  poutT 

ADULT     /Wcf^AOe. 

AOOLT   l-A«\6E. 


ttwato   oi« 


Fig.  619. — This  illustration  shows  the  lungmotor  givinc;  air  only.  A  small  self-contained 
oxygen  generator  is  regularly  supplied  with  the  outfit.  The  instrument  can  be  used  with  an 
ordinary  oxygen  tank. 

The  .duration  of  the  death  struggle  is  uncertain:  it  may  be  very  brief,  it 
may  last  a  considerable  time.  The  weaker  a  person  is,  the  sooner  it  is  over.  It 
is  probable  that  death  occurs  in  two  minutes  after  the  final  sinking.  In  spite 
of  some  specially  trained  divers  being  able  to  remain  in  water  as  long  or  even 
longer  than  this,  "we  may  conclude,  from  all  data,  that  fatal  asphyxia  is  prob- 
able at  the  end  of  two  full  minutes'  submersion  of  the  head"'  (Draper's  ''Legal 
Medicine"). 

A  man  may  die  when  under  water  from  some  cause  other  than  drowning,  for 
instance  from  syncope,  apoplexy,  or  cardiac  disease.  If  a  man  should  be  taken 
from  the  water  apparently  drowned  his  face  will  be  swollen  and  cyanotic,  the 
conjunctivae  reddened,  the  tongue  swollen  and  not  unusually  caught  between 
the  teeth,  the  hands  may  clutch  weeds  or  mud  from  the  bottom,  the  body  will 
be  cold  to  the  touch,  the  mouth  contains  fluid  which  may  be  bloody,  fluid  of 
an  identical  nature  can  be  poured  from  the  air  passages,  the  stomach  also  con- 
tains water  which  has  been  swallowed.  In  most  cases  the  victim  is  pulseless 
and  there  are  no  respirations.  In  less  grave  cases  there  is  a  pulse  or  perhaps 
only  an  occasional  heart-beat  and  possibly  an  occasional  gasp. 

Treatment. — Because  it  is  probable  that  a  person  is  dead  after  two  minutes' 
continuous  immersion  is  not  a  sufficient  reason  for  refusing  to  attempt  resusci- 


Throttling  981 

tation  when  it  is  alleged  that  the  body  has  been  immersed  for  longer  than  that 
period. 

As  Draper  says,  "the  evidence  as  to  time  may  be  incorrect,  clnd  there  are 
probably  exceptional  people  who  would  not  drown  in  two  minutes.  Recusci- 
tation  has  been  successful  after  five  minutes  and  i  case  is  recorded  of  re- 
covery after  twenty-five  minutes"  (Draper's  "Legal  Medicine").  The  common 
practice  of  blowing  into  the  victirn's  mouth  is  of  no  avail  as  most  or  all  of  the 
breath  goes  to  the  stomach.  The  immensely  popular  practice  of  rolUng  on  a 
barrel  is  usually  insisted  upon  by  Life  Savers.  It  is  a  poor  excuse  for  artificial 
respiration  and  exhausts  a  Hx^ing  subject.  The  ordinary  emergency  treatment 
should  be  conducted  out  of  doors.  The  mouth  is  emptied  by  turning  the  body 
on  the  face,  wdth  the  head  on  a  lower  level  than  the  body,  and  holding  it  so  for 
a  few  seconds.  While  this  is  being  done  the  mouth  is  opened,  the  tongue  is 
drawn  out,  and  any  foreign  matter  is  removed.  The  body  is  turned  upon  the 
back,  the  head  and  shoulders  being  slightly  elevated.  The  clothing  is  rapidly 
removed,  and,  ^vhile  artificial  respiration  is  being  made  (see  page  976),  hot  bot- 
tles and  hot  blankets  are  being  placed  around  the  body  and  legs,  and  the  mouth 
and  nostrils  are  kept  free  of  froth.  If  the  individual  makes  an  effort  to  breathe, 
help  each  respiration  along.  Give  hypodermatic  injections  of  brandy  and 
strychnin. 

Artificial  respiration  is  continued  until  the  patient  breathes  naturally  and 
aU  cyanosis  has  passed  away.  As  soon  as  he  can  swallow  he  should  be  given 
hot  coffee  and  brandy.  If  minute  follows  minute  and  the  patient  does  not 
attempt  to  breathe,  we  must  still  continue  our  efforts.  Artificial  respiration 
should  not  be  abandoned  for  a  full  hour.  Even  after  he  begins  to  breathe  he 
must  be  carefully  watched  for  some  time,  as  secondary  respiratory  failure  is  not 
uncommon. 

On  a  battleship  and  upon  the  beach  of  a  large  seaside  resort,  where  every 
preparation  has  been  made  to  treat  such  accidents,  more  can  be  done  than  is 
described  above.  Artificial  respiration  can  be  made  by  the  pulmotor  by  the 
lungmotor  or  by  the  insufflation  apparatus  of  Meltzer  and  Auer  (seepage  977). 
Adrenalin  may  be  injected  centripetally,  as  advised  by  Crile  (see  page  538). 
Hot  enemata  may  be  given  and  galvanism  may  be  applied  to  the  phrenic  nerve. 

After  resuscitation  there  is  danger  of  exhaustion  and  of  bronchopneumonia. 

Hanging. — A  physician  is  occasionally  called  to  a  case  of  attempted  suicide 
by  hanging.  In  these  cases  there  is  no  fracture  and  no  dislocation  of  cer- 
vical vertebrae,  as  may  occur  in  legal  execution  by  the  drop.  The  victim  is 
dead  or  almost  dead  because  of  obstruction  to  the  pulmonary  air-way,  the 
pressure  upon  the  great  vessels  of  the  neck,  and  perhaps  also  upon  the  pneu- 
mogastric  nerves. 

Treatment. — The  subject,  after  being  cut  down,  is  treated  much  like  a  case 
of  drowning.  Resuscitation  is  always  difficult,  no  matter  how  soon  the  victim 
is  cut  down.     It  is  impossible  if  asph}rxiation  is  far  advanced. 

The  neck  and  chest  are  bared,  cold  water  may  be  applied  to  the  head  or  face, 
as  it  sometimes  will  incite  respiration.  Artificial  respiration  is  begun  at  once, 
external  heat  is  applied,  a  hot  enema  containing  brandy  and  hypodermatic 
injections  of  brandy  are  given.  When  there  is  distinct  lividity,  bleed  from  a 
vein  of  the  leg  (to  do  so  from  a  vein  of  the  arm  might  interfere  with  artificial 
respiration).  Galvanism  of  the  phrenic  nerve  is  advisable.  Even  when  breath- 
ing begins  there  is  for  some  time  the  gravest  danger  of  relapse  and  death. 

Throttling. — When  the  assailant  grasps  the  opponent's  throat  wdth  the 
hands  and  squeezes  the  wind-pipe  or  larynx  and  forces  it  against  the  vertebrae 
the  victim  is  said  to  be  throttled.  The  ordinary  fighter  makes  the  attack  from 
in  front.  The  garroter  seizes  the  throat  from  behind.  Death  from  throttling 
is  death  from  asphyxia  plus  an  influence  from  the  pressure  upon  the  great 
vessels. 


982  Surgery  of  the  Respiratory  Organs 

Treatment. — As  for  hanging. 

Smoke  Asphyxia.' — One  of  the  first  duties  required  of  an  intern  in  a  hospital 
of  a  large  city  is  ambulance  service,  and  in  performing  such  duty  he  is  not 
infrequently  called  upon  to  attend  fires.  In  fact,  any  physician  may  be  called 
upon  in  such  an  emergency,  and  while  on  the  fire  ground  may  meet  cases  of 
asphyxiation  by  smoke.  The  clinical  aspect  and  the  treatment  of  such  cases  are 
not  taught  in  the  classroom.  Literature  on  the  subject  is  scanty.  It  is  for 
these  reasons  that  the  author  has  deemed  it  expedient  to  insert  a  few  words 
regarding  it. 

There  are  several  factors  which  govern  the  character  of  smoke  cases.  In 
the  first  place,  there  are  many  different  kinds  of  smoke.  All  smoke  is  hard  to 
bear,  but  some  kinds  are  worse  than  others.  Some  smoke  is  merely  irrespirable, 
while  other  smoke  is  not  only  irrespirable,  but  is  highly  poisonous.  Smoke 
from  lumber,  varnish,  furniture,  paper,  rags,  and  wet  hay  is  difficult  to  tolerate, 
whereas  smoke  from  pitch,  tar,  and  oils  is  not  so  pungent.  Smoke  impregnated 
with  the  fumes  of  ammonia,  sulphur  dioxid,  chlorin,  or  pepper  and  other  spices 
is  frightfully  irritant.  Smoke  containing  nitric  acid  is  highly  irritant,  and  is 
apt  to  produce  edema  of  the  glottis  and  lungs.  The  hotter  the  smoke,  the 
more  irrespirable  it  is. 

Again,  the  individual  idiosyncrasy  or  susceptibility  of  the  person  plays  an 
important  part.  It  is  remarkable  how  firemen  can  accustom  themselves  to 
remaining  in  a  smoke-laden  atmosphere.  The  older  members  of  a  fire  depart- 
ment can  tolerate  smoke  much  longer  than  those  recently  appointed.  Fire- 
men learn  that  the  best  air  is  near  the  floor  or  near  the  nozzle  of  the  hose.  There 
is  a  current  of  air  along  the  floor,  as  the  smoke  naturally  tends  to  rise,  and  the 
water  carries  through  the  hose  a  certain  amount  of  air. 

For  clinical  purposes,  smoke  asphyxia  may  be  divided  into  three  stages: 
the  first  stage  is  that  in  which  the  victim  is  conscious;  the  second  is  when  con- 
sciousness is  lost,  but  respirations  are  still  present;  the  third  stage,  when  respira- 
tions have  ceased. 

The  first  symptoms  which  occur  are  a  choking  sensation,  severe  throbbing 
in  the  head,  dizziness,  nausea,  and  muscular  weakness.  If  at  this  time  one  is 
able  to  reach  a  window  or  able  to  leave  the  building  and  get  fresh  air  he  will 
probably  recover  quickly.  His  eyes  are  red  and  watery.  He  coughs  and  tries 
to  vomit,  and  although  his  face  may  be  hot  and  sweaty,  yet  his  hands  will  be 
cold  and  clammy.  His  pulse  is  slow  but  bounding.  Headache  is  intense  and 
the  eyes  burn  violently. 

A  patient  in  this  condition  should  be  rapidly  removed  to  a  spot  where  the 
air  is  free  from  smoke.  He  should  be  laid  on  a  blanket.  All  constricting 
clothing  should  be  loosened  and  he  ought  to  be  fanned.  If  he  gags  or  attempts 
to  vomit,  but  cannot  do  so,  he  may  be  given  a  drink  of  an  effervescing  salt,  such 
as  a  Seidlitz  powder  or  a  dessertspoonful  of  effervescent  sodium  phosphate  in 
a  tumbler  of  water.  Firemen  have  great  faith  in  weiss  beer.  It  usually  makes 
them  belch  and  vomit  and  thus  relieves  them  of  much  of  the  mucus  and  the 
gases  in  their  lungs  and  in  their  stomach.  In  this  manner  it  acts  as  does  an 
emetic  dose  of  ipecac  in  the  first  stage  of  bronchitis.  A  drink  which  is  often 
given,  but  which  is  most  injurious,  is  whisky.  The  fireman  who  is  a  whisky 
drinker  stands  smoke  poorly,  and  to  take  whisky  after  having  been  overcome 
with  smoke  only  adds  to  the  headache  and  nausea.  Usually  after  vomiting 
has  been  induced  and  after  he  has  had  fresh  air  the  fireman  is  able  to  return 
to  his  work.  If  he  does  not  rapidly  recuperate  or  should  he  be  overcome  a 
second  time,  he  should  not  be  allowed  to  return  to  the  smoky  atmosphere. 
If  a  man  who  has  been  overcome  by  smoke  has  a  chill  he  must  be  sent  to  a  hos- 
pital. His  usefulness  is  at  an  end  for  that  fire.  When  a  man  becomes  uncon- 
scious his  comrades  carry  him  to  the  street.  Pictures  of  a  very  quick  and 
1  The  author,  in  "Therapeutic  Gazette,"  March,  1903. 


Smoke  Asphyxia 


983 


Fig.  620. — Fire  carry.     Step  one. 


Fig.  621. — Fire  carry.     Step  two. 


Fig.  622.— Fire  carry.     Step  three. 


satisfactory  fire  carry  are  shown  in  Figs.  620-622.  It  is  unusual  for  a  man  to 
leave  a  smoky  building  conscious  and  to  lose  consciousness  after  reaching 
the  fresh  air  unless  the  smoke  has  been  impregnated  with  Illuminating  Gas 
(page  985). 


9S4  Surgery  of  the  Respiratory  Organs 

When  an  unconscious  man  is  carried  from  a  smoky  building  he  must  be 
taken  to  a  spot  where  the  air  is  free  from  smoke,  his  clothing  musfbe  loosened, 
and  his  body  kept  warm  with  blankets.  His  hands  and  face  should  be  rubbed 
with  a  coarse  towel,  and  oxygen  (which  should  be  carried  on  all  ambulances 
and  on  all  patrol  wagons)  should  be  administered.  If  the  circulation  or  respira- 
tion is  weak,  he  should  be  given  a  hypodermatic  injection  of  strychnin  or  atropin, 
and  when  he  is  able  to  swallow  he  can  be  given  a  stimulant  by  mouth  (as  Hoff- 
mann's anodyne  or  aromatic  spirits  of  ammonia),  or  if  he  is  trying  to  vomit  he 
niay  be  given  weiss  beer,  effervescent  sodium  phosphate,  or  Seidlitz  powder. 
He  should  not  be  given  anything  by  mouth  until  he  is  entirely  conscious  and 
able  to  swallow.  I  mention  this  emphatically  because  I  have  often  seen 
attempts  made  to  pour  whisky  or  some  other  stimulant  down  the  throat  of  an 
unconscious  fireman.  The  danger  of  such  a  procedure  is  obvious.  As  soon 
as  practical  he  should  be  removed  to  the  nearest  hospital.  The  man  should 
be  taken  to  the  nearest  hospital  unless  the  receiving  ward  of  that  hospital  is 
overcrowded.     He  should  then  be  taken  to  the  next  nearest  hospital. 

The  third  stage  of  asphyxiation  by  smoke  is  that  in  which  respirations  have 
been  suspended.  The  lips  are  cyanotic,  the  skin  is  cold  and  clammy,  the  pupils 
are  fixed,  and  usually  dilated.  The  conjunctival  reflex  may  be  gone.  The 
mouth  may  be  open  or,  on  the  other  hand,  the  teeth  may  be  tightly  clenched. 
The  pulse  is  weak  and  fluttering,  even  imperceptible.  There  is  frequently 
bleeding  from  the  nose  and  mouth  and  involuntary  evacuations  of  urine  and 
feces  may  occur.  A  man  in  this  state  should  never  be  placed  in  an  ambulance 
to  be  taken  to  the  hospital  until  respirations  have  been  re-established.  I 
have  seen  stupid  and  assertive  policemen  on  many  occasions  insist  on  putting 
such  cases  in  ambulances.  He  should  be  quickly  laid  on  his  back,  all  mucus 
cleared  from  his  throat  and  mouth,  all  constricting  clothing  loosened,  torn,  or 
cut  away.  Artificial  respiration  is  started  at  once.  The  pulmotor  or  lungmotor 
described  on  page  977  is  most  useful  under  such  circumstances.  If  Sylvester's 
method  is  used,  oxygen  may  be  administered  with  a  tube  through  the  nostrils. 
The  body,  must  be  covered  with  blankets  and  the  man  must  be  stimulated 
with  strychnin,  atropin,  camphor,  etc.  When  respirations  have  been  estab- 
lished he  may  then  be  removed  to  the  nearest  hospital.  As  a  rule,  the  man 
should  be  kept  in  a  hospital  at  least  twelve  to  twenty-four  hours  and  may  then 
be  allowed  to  go  home  if  there  is  no  complication  or  sequel.  In  severe  smoke 
cases  there  is  a  tympanitic  percussion  note  extending  well  above  each  collar- 
bone and  due,  I  believe,  to  blocking  of  bronchial  tubes  by  spasm.  It  lasts 
often  for  several  hours  and  then  fades  away. 

In  cases  of  edema  of  the  glottis  from  the  inhalationof  irritant  vapor,  trache- 
otomy should  be  performed  and  artificial  respiration  given,  oxygen  passing 
in  through  the  tracheotomy  tube.  It  is  imperative  that  the  first-aid  kits  of 
all  ambulances  should  contain  a  tracheotomy  set.  I  have  been  compelled  to 
do  a  tracheotomy  with  a  penknife  upon  a  fireman  lying  on  the  pavement. 

A  chill  or  a  series  of  chills  not  infrequently  follows  smoke  asphyxiation,  and 
a  man  who  has  or  has  had  a  chill  must  always  be  sent  to  a  hospital.  If  the 
smoke  has  been  impregnated  with  ammonia,  a  piece  of  gauze  or  a  handkerchief 
should  be  saturated  with  vinegar  and  held  over  the  face  so  that  the  vapor  may 
be  inhaled.  On  the  other  hand,  a  few  whiffs  of  diluted  ammonia  should  be 
given  after  the  inhalation  of  fumes  from  acids.  The  eyes  should  be  carefully 
treated.  Ice-compresses  are  most  grateful.  Pieces  of  lint  or  gauze  are  placed 
on  ice  and  are  transferred,  when  cold,  to  the  eyes.  They  are  changed  at  fre- 
quent intervals.  The  eyes  must  be  washed  with  a  saturated  solution  of  boric 
acid  at  frequent  intervals.  Even  after  the  acute  symptoms  have  subsided 
it  may  be  necessary  to  wear  blue  glasses  for  several  days  and  to  use  an  astrin- 
gent eye-wash  twice  a  day. 

To  relieve  headache  an  ice-bag  can  be  applied  to   the  head  and   bromid 


Illuminating  Gas-poisoning  985 

should  be  administered  by  mouth,  liromid  also  relieves  the  severe  nervousness 
which  often  ensues.  Occasionally  bronchitis  or  even  bronchopneumonia  may 
occur.  Even  after  mild  smoke  cases  there  is  usually  a  cough  for  several  days, 
the  sputum  being  streaked  with  black,  carbonaceous  material. 

Inhalation  of  the  vapor  of  nitric  acid  is  apt  to  cause  edema  of  the  lungs  and 
glottis  and  death.  The  acute  edema  may  not  come  on  for  some  hours  after 
the  inhalation.  The  treatment  of  edema  of  the  lungs  consists  in  venesection, 
hypodermatic  injection  of  camphorated  oil,  the  administration  of  alcohol  and 
digitalis,  and  counterirritation  of  the  chest.  The  treatment  of  edema  of  the 
glottis  is  set  forth  on  page  984. 

Illuminating  Gas-poisoning. — Poisoning  by  illuminating  gas  is  becoming 
more  common.  The  statistics  for  the  city  of  Philadelphia  during  191 2  showed 
that  152  cases  died  from  illuminating  gas-poisoning.  Of  these  77  were  suicides 
and  75  were  accidental.  The  number  of  cases  has  increased  since  the  sub- 
stitution of  the  so-called  water-gas  for  coal-gas.  The  coal-gas  formerly  used 
was  not  nearly  so  dangerous.  Coal-gas  contains  a  small  amount  (about  7 
per  cent.)  of  carbon  monoxid.  In  comparatively  recent  years,  however,  in 
order  to  reduce  the  cost  and  simplify  the  manufacture  the  new  water-gas  has 
been  used.  This  is  developed  by  forcing  steam  through  hot  coals  or  coke. 
To  this  water-gas  hydrocarbons  are  added  (methane,  ethane,  etc.).  The 
amount  of  carbon  monoxid  in  water-gas  is  about  38  per  cent. 

Jones  ("Amer.  Jour,  Med.  Sci.,"  1909,  vol.  cxxxvii)  gives  as  further  rea- 
sons for  the  marked  increase  in  poisoning  by  illuminating  gas:  first,  concen- 
tration of  population  in  cities;  second,  increased  susceptibility  to  emotional 
states  and  insanity. 

Suicide  from  illuminating  gas  is  growing  in  frequency,  due  to  the  means 
being  at  hand,  the  known  painless  nature  of  the  death,  and  also  to  the  fact  that 
the  sale  of  certain  toxic  drugs  to  laymen  is  now  forbidden. 

Carbon  monoxid  has  a  marked  affinity  for  hemoglobin.  It  completely 
destroys  the  oxygen-carrying  power  of  the  red  blood-cells  and  this  deprives 
the  tissues  of  oxygen.  It  enters  the  system  solely  through  the  lungs.  An  atmos- 
phere becomes  dangerous  when  it  contains  0.05  per  cent,  of  carbon  monoxid 
(Gruber,  cited  by  Edsall,  in  Osier's  "System  of  Medicine;"  Haldane,  "An 
Investigation  of  Mine  Air,"  1895).  It  is  not  proved  whether  carbon  mon- 
oxid has  any  direct  action  of  its  own,  or  whether  it  acts  solely  by  robbing  the 
blood  of  its  oxygen.  Edsall  ("Amer.  Jour.  Med.  Sci.,"  1907,  and  Osier's 
"  System  of  Medicine")  says  it  is  highly  probable  that  both  conditions  occur. 
McCombs  ("Amer.  Jour,  Med,  Sci.,"  1912,  vol.  cxliv)  says  that  carbon  monoxid 
has  a  direct  toxic  action  on  a  human  being. 

Suicide  cases  make  up  approximately  one-half  of  all  the  fatalities  from 
illuminating  gas  in  Philadelphia  and  in  Massachusetts  (McCombs,  "Amer. 
Jour.  Med.  Sci.,"  1912,  vol.  cxliv).  Cases  of  accidental  poisoning  are  due 
either  to  a  leak  from  a  gas-pipe  or  failure  to  close  a  gas-jet.  Pettenkofer 
(cited  by  Edsall,  in  Osier's  "System  of  Medicine")  has  shown  that  the  leak 
may  not  be  in  the  building  itseK,  but  the  gas,  having  escaped  from  a  broken 
main,  may  travel  through  the  ground  for  some  distance  and  finally  enter  a 
house.  This  is  especially  liable  to  occur  in  the  winter  when  the  heating 
of  the  building  causes  active  motion  of  the  atmosphere,  thus  drawing  gas 
into  the  house  by  aspiration.  Numbers  of  the  employees  of  the  large  gas 
companies  are  overcome  while  working  in  the  ditches  in  the  city,  yet  among 
aU  such  cases  that  have  occurred  in  the  city  of  Philadelphia  there  has  been  but 
one  fatality.  This  is  due  to  the  careful  instruction  given  to  the  men  by  the 
physicians  connected  with  the  gas  company.  The  men  are  not  only  instructed, 
but  they  also  carry  a  first-aid  kit  and  are  competent  to  give  immediate  treatment. 

Illuminating  gas-poisoning  has  been  divided  into  the  acute  and  chronic 
forms.     There  is  little  evidence,  however,  to  support  the  theory  of  chronic  gas- 


gS6  Surgery  of  the  Respiratory  Organs 

poisoning.  McCombs  (Loc.  cit.)  has  examined  the  blood  of  men  who  are  con- 
stantly in  contact  with  carbon  monoxid,  some  of  whom  have  been  frequently 
overcome  by  it.  He  has  found  the  average  blood-count  shows  polycythemia. 
He  has  not  noted  any  cases  of  muscular  weakness,  irregularity  of  the  heart, 
bradycardia,  lack  of  concentration,  poor  memory,  cardiac  dilatation,  splenic 
enlargement,  or  pleural  effusion.     The  acute  cases  are,  of  course,  well  known. 

The  symptoms  of  an  acute  case  are  ushered  in  by  a  sensation  of  vertigo 
or  dizziness,  headache,  and  muscular  weakness.  They  are  oiten  accompanied 
or  even  preceded  by  a  throbbing  sensation  in  the  head  and  throbbing  of  the 
vessels  of  the  neck.  McCombs  (Ibid.)  states  that  at  first  the  pulse  is  slow, 
from  stimulation  of  the  pneumogastric.  I  have  probably  never  seen  a  case  in 
so  early  a  stage,  as  every  case  T  have  examined  has  had  a  rapid  and  weak  pulse. 

During  the  early  stage  there  is  occasionally  cerebral  excitement.  The 
pupils  are  dilated  and  the  respirations  are  increased,  both  in  depth  and  in 
frequency.  There  is  no  irritation  of  the  mucous  membranes.  The  victim 
has  an  odor  of  gas  emanating  from  him.  Unconsciousness  now  ensues.  In 
some  cases,  however  (as  in  the  case  of  firemen  working  in  smoke  impregnated 
with  illuminating  gas),  the  irritant  and  suffocative  qualities  of  smoke  may 
overshadow  all  early  symptoms  of  illuminating  gas,  and  the  victim  may  drop 
as  suddenly  as  though  he  had  been  shot. 

The  foregoing  symptoms  have  been  called  by  McCombs  the  first  stage 
of  gas-poisoning.  He  then  states  that  the  second  stage  begins  with  syncope 
and  ends  with  aj)nea.  In  the  second  stage,  therefore,  the  patient  is  uncon- 
scious, but  respirations  are  still  in  progress. 

The  respirations  may  be  rapid  and  stertorous  or  may  be  of  the  Cheyne- 
Stokes  type.  The  face  is  cyanosed.  There  is  often  frothing  at  the  mouth. 
The  froth  may  contain  blood.  The  blood -pressure  falls,  but  the  temperature 
is  usually  elevated.  There  may  be  general  tetaniform  convulsions.  The 
pulse  is  rapid  and  weak.  The  temperature  varies  from  99°  to  103°  F.  Occa- 
sionally the  temperature  may  rise  rapidly,  reaching  105°  to  110°  F.,  these 
cases  usually  terminating  fatally.  A  great  rise  of  temperature  is  usually  co- 
incident with  the  development  of  edema  of  the  lungs.  The  high  temperature 
is  not  due  to  the  edema,  but  is  probably  due  to  the  overwhelming  toxemia. 
The  toxemia  is  purely  hemolytic  in  origin.  The  tongue  is  swollen  and  is  cherry 
red,  and  the  same  peculiar  cherry-red  color  makes  its  appearance  on  the  skin 
of  the  neck,  trunk,  and  buttocks.  The  blood,  if  drawn,  is  bright  cherry-red 
in  color  and  will  show  by  the  spectroscope  the  presence  of  carbon  monoxid. 

Edsall  ("Amer.  Jour.  Med.  Sci.,"  1907)  believes  that,  with  the  exception 
of  the  spectroscope,  the  best  test  for  carbon  monoxid  in  the  blood  is  the  Hoppe- 
Seyler  test.  The  blood  containing  carbon  monoxid,  if  treated  with  twice  its 
volume  of  a  solution  of  sodium  hydrate,  yields  a  beautiful  red  color  when  spread 
on  a  porcelain  plate,  while  blood  not  containing  carbon  monoxid  is  changed 
into  a  dirty,  brownish  mass. 

Katagama's  test  consists  in  adding  to  10  c.c.  of  blood,  diluted  with  water, 
2  c.c.  of  ammonium  sulphate  solution  and  0.2  c.c.  of  30  per  cent,  acetic  acid. 
Carbon  monoxid  blood  gives  a  bright  red  precipitate,  while  normal  blood  gives 
a  greenish  precipitate.  These  tests  should  be  used  in  cases  of  coma  of  un- 
certain origin. 

Pettenkofer  insists  upon  the  importance  of  searching  for  gas-poisoning  as 
the  cause  of  the  trouble,  when  various  persons  in  the  same  house  have  a  tend- 
ency to  wake  with  headache  or  nausea. 

In  the  third  stage  there  is  coma  with  apnea.  The  pulse  is  more  rapid 
and  is  weaker.  It  is  often  impossible  to  count  the  rate.  The  skin  is  usually 
cyanosed,  is  cold  and  dry,  and  occasionally  blebs  appear  on  the  extremities 
and  the  back.  Blebs  usually  occur  in  chains  and  are  most  apt  to  appear 
in  cases  in  which  the  coma  persists  for   twelve  hours  or  longer.     The   blebs 


Illuminating  Gas-poisoning  987 

contain  clear  serum  and  have  frequently  been  mistaken  for  burns  from  the 
application  of  hot-water  bags.  The  reflexes  are  abolished.  There  is  paralysis 
of  the  sphincters.     Coma  may  last  for  days  and  yet  be  followed  by  a  recoven>\ 

Oilman  Thompson  ("N.  Y.  Med.  Record,"  July  9,  1904)  considers  it  a  bad 
sign  if  leukocytosis,  which  is  usually  present,  is  of  high  degree.  Reported 
cases,  however,  do  not  seem  to  substantiate  this  belief.  The  leukocvtosis 
varies  from  10,000  to  22,000.  Thompson,  moreover,  reports  an  increase  in 
the  number  of  red  blood-cells.  The  same  observation  is  made  by  McCombs, 
but  is  denied  by  Glenn  Jones. 

Glenn  Jones  ("Amer.  Jour.  jNIed.  Sci.,"  1909,  vol.  cxxxvii)  found  the  red 
cells  reduced  in  number.  The  specific  gravity  and  the  coagulabilit}'  of  the  blood 
are  increased. 

The  pathology  of  gas-poisoning  consists  principally  of  the  characteristic 
cherry-red  spots  on  the  surface  of  the  body,  the  cherry-red  color  of  the  blood, 
and  the  same  color  of  many  or  all  of  the  organs.  There  is  usually  intense 
h}-peremia  of,  and  occasionally  small  free  hemorrhages  into,  all  the  organs. 
Nephritis  is  usually  present  and  is  apt  to  be  of  the  acute  hemorrhagic  type. 
There  may  be  small  scattered  hemorrhages  throughout  the  brain  and  cysts 
may  form  as  the  result  of  softening.  Cardiac  dilatation,  fatty  degeneration 
of  the  heart,  and  splenic  enlargement  have  been  described  by  Koren  in  cases  of 
supposed  chronic  gas-poisoning. 

The  sequels  of  gas-poisoning  are  principally  nervous  manifestations.  In 
the  milder  class  of  cases  nervousness,  insomnia,  and  headache  are  usually 
present  for  several  days;  in  the  more  severe  cases,  intention  tremors,  loss  of 
sexual  power,  delirium,  neuritis,  transient  hemiplegia,  confusional  insanity, 
leptomeningitis,  and  encephalomyelitis  have  been  reported.  Prolonged  fever 
and  glycosuria  have  also  been  found. 

There  may  be  acute  congestion  of  the  lungs,  edema,  emphysema,  or  bron- 
chopneumonia. McCombs  states  that  all  of  the  sequelae  usually  clear  up  within 
six  months  or  less,  and  that  cases  with  sequelse  constitute  less  than  2  per  cent. 
of  all  cases,  and  are  usually  confined  to  those  persons  who  have  absorbed  large 
amounts  of  the  carbon  monoxid.  Sequelae  are,  of  course,  more  apt  to  occur  in 
those  of  advanced  years  and  feeble  condition  than  in  those  who  are  young  and 
vigorous. 

The  prognosis  should  be  based  upon  the  duration  of  the  exposure,  the  age  of 
the  victim,  the  degree  of  coma,  the  condition  of  the  blood,  and  the  character 
of  the  pulse  and  respiration.  Usually  a  short  exposure  to  illuminating  gas 
means  a  case  amenable  to  treatment  and  which  will  promptly  recover.  Longer 
exposure,  or  exposure  of  the  aged  and  feeble,  means  a  far  worse  prognosis. 

Edsall  cites  39  cases  treated  in  the  Episcopal  Hospital  of  Philadelphia,  of 
which  34  recovered.  Of  the  5  fatalities,  several  were  due  to  sequels.  If  the 
onset  of  the  symptoms  is  rapid,  if  edema  develops,  or  if  pronounced  hemolytic 
changes  are  present,  the  prognosis  is  unfavorable.  The  persistence  of  coma  is 
highly  unfavorable,  and  Jones  states  that  all  cases  that  develop  cutaneous 
blebs  end  fatally. 

The  treatment  of  poisoning  by  illuminating  gas  must  be  prompt  and  heroic. 
In  the  milder  cases,  in  which  there  is  neither  coma  nor  apnea,  the  patient  must 
be  removed  to  an  atmosphere  free  from  the  poison  and  must  be  given  oxygen 
freely.  The  object  of  all  treatment  is  to  give  oxygen  in  suflicient  quantities  to 
displace  the  carbon  monoxid  from  the  blood.  Nausea  and  the  feeling  of  fulness 
in  the  stomach  can  be  relieved  by  the  administration  of  efi"ervescent  sodium 
phosphate,  Seidlitz  powder,  or  a  bottle  of  weiss  beer.  These  procedures  will 
usually  cause  vomiting  and  give  relief.  The  patient  should  be  kept  quiet,  an 
ice-bag  being  applied  to  the  head  to  relieve  the  headache.  Doses  of  bromid  of 
potash  will  give  comfort.  Hofltmann's  anodyne  and  aromatic  spirits  of  ammo- 
nia act  as  useful  stimulants  and  carminatives.     Caffein,  digitalis,  strychnin, 


q88  Surgery  of  the  Respiratory  Organs 

and  camphor  should  be  given  if  necessary.  They  will  hardly  be  necessary, 
however,  unless  the  victim  is  in  the  second  stage  or  the  stage  of  unconsciousness. 
When  the  patient  is  unconscious,  venesection  should  be  performed,  followed  by 
transfusion,  or  by  the  intravenous  injection  of  salt  solution. 

The  patient  must  be  kept  quiet,  as  many  victims  have  died  from  sudden 
exertion.  Venesection  without  the  injection  of  salt  solution  or  without  trans- 
fusion is  usually  condemned,  but  Halsted  reported  2  cases  in  which  he  thought 
it  did  good.  Transfusion  of  defibrinated  blood  was  practised  in  the  70's  and 
8o's  and  successful  cases  were  reported.  Reinfusion  of  blood  was  attempted  by 
Halsted  in  1884,  at  which  time  he  reported  a  successful  case:  512  c.c.  of  blood 
were  withdrawn  from  the  radial  artery,  defibrinated  and  strained,  and  280  c.c. 
were  reinfused  into  the  artery.  In  1907  Crile  and  Lenhart  reported  studies 
of  transfusion,  and  their  procedure  supplanted  all  former  methods  of  treatment. 

Of  course,  in  the  third  stage,  that  of  coma  with  apnea,  artificial  respiration 
must  be  made,  and  for  this  purpose  the  pulmotor  is  most  valuable,  as  it  not 
only  gives  artificial  respiration,  but  at  the  same  time  administers  large  quantities 
of  oxygen  under  pressure. 

Massage  is  an  important  feature  of  treatment.  It  increases  circulation  in 
the  extremities.  Transfusion,  of  course,  requires  the  presence  of  a  skilled  sur- 
geon, whereas  intravenous  injection  of  saline  solution  is  not  nearly  so  difficult  a 
procedure.  It  is  most  important  that  artificial  respiration  should  not  be  aban- 
doned for  a  number  of  hours,  as  cases  have  been  reported  in  which  artificial  res- 
piration was  finally  successful  after  a  period  of  six  hours.  In  conditions  which 
lead  one  to  suspect  that  chronic  poisoning  may  be  present,  the  cause  should  be 
sought  and,  if  found,  removed,  and  the  case  be  treated  symptomatically.  The 
general  public  should  be  instructed  as  to  the  danger  of  acute  gas-poisoning. 

Diseases  and  Injuries  of  the  Nose  and  Antrum 

Foreign  bodies  in  the  nose  (see  Poulet  on  "Foreign  Bodies  in  Surgery") 
are  usually  introduced  through  the  anterior  nares,  but  in  rare  instances  dur- 
ing swallowing  they  enter  by  way  of  the  posterior  nares,  a  sudden  expiration 
being  the  cause  of  the  entry.  During  vomiting  foreign  bodies  may  enter  the 
posterior  nares.  Small  particles  are  often  expelled  spontaneously;  larger 
pieces  collect  mucus  and  epithelium  and  become  fixed.  Some  materials  swell 
after  lodgment.  Others  become  encrusted  with  lime  salts.  Seeds  may  sprout. 
In  very  rare  cases  insects  enter  and  lodge.  Cases  are  on  record  of  leeches, 
taken  in  with  drinking-water,  passing  into  the  nasal  fossae  from  the  pharynx. 
In  the  tropics  flies  may  deposit  within  the  anterior  nares  larvje  which  develop 
with  great  rapidity.  A  foreign  body  is  usually  near  the  floor  and  may  be 
between  the  vomer  and  turbinate  bones.     It  may  shift  after  lodgment. 

Treatment. — In  many  cases  general  anesthesia  is  required.  Illuminate  the 
nostril,  and,  if  the  foreign  body  can  be  seen,  insert  a  hook  back  of  it  and  effect 
its  removal  by  means  of  forceps.  Some  foreign  bodies  must  be  pushed  back 
into  the  nasopharynx.  Occasionally  expulsion  may  be  eff"ected  by  insert- 
ing a  rubber  tube  into  the  unblocked  nostril  and  telling  the  patient  to  blow 
forcibly  through  the  tube.  In  serious  cases  a  specialist  should  be  summoned  to 
remove  a  portion  of  the  turbinated  bone  or  to  perform  whatever  operation  he 
may  think  best. 

Inflammation  and  Abscess  of  the  Antrum  of  Highmore  (the  Maxil= 
lary  Antrum). — The  source  of  this  disease  may  be  inflammation  within 
the  nose  or  periostitis  around  the  roots  of  the  teeth  which  are  in  relation  with 
the  antral  floor.  Apical  disease  of  the  roots  may  be  demonstrable  by  the 
-T-rays  only.  In  some  cases  the  natural  opening  into  the  meatus  is  patent;  in 
other  cases  it  is  partly  or  completely  blocked.  Caries  and  necrosis  may  arise. 
The  symptoms  are  pain,  edematous  swelling  of  the  face,  and  thinning  of  the 


Distention  and  Abscess  of  the  Frontal  Sinus  989 

bone  so  that  it  may  crepitate  under  pressure.  When  pus  has  formed,  if  the 
antral  opening  is  patent,  certain  positions  of  the  head  will  cause  a  purulent 
flow  from  the  nose,  and  if  a  speculum  is  inserted  pus  may  be  seen  as  it  flows 
into  the  nose.  The  opening  of  the  maxillary  antrum  into  the  nasal  channel 
is  at  the  summit  of  the  antrum;  hence  the  antrum  drains  when  the  head  is 
inverted.  The  ethmoidal  cells  and  frontal  sinus  drain  best  when  the  patient 
is  upright.  Wipe  the  interior  of  the  nose  and  place  the  patient  with  his  head 
between  his  knees.  If  the  nostril  fills  with  pus,  it  comes  from  the  antrum 
(Cobb).  In  severe  cases  the  jaw  expands,  the  eye  protrudes,  and  great  tender- 
ness of  the  alveolus  exists..  Percussion  exhibits  a  dull  note.  In  making  a 
diagnosis  it  is  weh  to  take  the  patient  into  a  dark  room,  insert  an  electric  light 
into  the  mouth  and  note  the  diminution  of  light  transmission  on  the  diseased 
side  as  contrasted  with  the  sound  side.  Transillumination  may  be  easily 
practised  by  the  use  of  a  cautery  electrode,  protected  by  a  small  glass  vial. 
Any  cautery  battery  may  be  employed  (plan  suggested  by  Ohls).  Exploratory 
puncture  will  settle  a  doubtful  diagnosis.  This  may  be  by  way  of  the  lower 
meatus,  the  canine  fossa,  or  the  alveolar  process.^ 

Treatment. — Before  pus  forms  order  the  use  of  hot  fomentations  and  remove 
any  diseased  teeth.  When  pus  has  formed,  evacuate  it  at  once.  Before  per- 
forming a  severe  operation  try  the  effect  of  opening  into  the  antrum  from 
the  nose,  by  means  of  Krause's  trocar,  followed  by  insufflation  of  iodo- 
form. If  this  procedure  fails,  other  means  may  be  employed.  If  the  disease 
arises  from  a  carious  tooth,  pull  the  tooth  and  push  a  trocar  through  its  socket 
into  the  antrum.  If  the  teeth  are  sound,  bore  a  hole  with  a  large  gimlet  or 
with  a  bone-drill  above  the  root  of  the  second  bicuspid  tooth  and  i  inch  above 
the  edge  of  the  gum.  A  counteropening  should  be  made  into  the  inferior  nasal 
meatus.  A  drainage-tube  is  pulled  from  the  first  opening  into  the  nose  and  is 
allowed  to  protrude  from  the  nostril.  Irrigate  daily  with  normal  salt  solution. 
In  three  or  four  days  discontinue  through-and-through  drainage,  but  prevent 
the  first  opening  closing  until  the  discharge  ceases  to  be  purulent.  In  severe 
cases  make  a  free  incision  through  the  canine  fossa  by  means  of  a  chisel. 

Distention  and  Abscess  of  the  Frontal  Sinus. — The  anatomy  of  the 
frontal  sinus  is  extremely  variable.  It  is  not  constant  in  size  or  in  shape.  The 
right  and  left  sinuses  are  nearly  always  asymmetrical  and  "either  or  both 
may  be  present  in  duplicate  or  triplicate"  (J.  Parsons  Schaeffer,  in  "Annals 
of  Surgery,"  Dec,  1916).  The  usual  cause  of  abscess  is  an  injury  which  may 
long  antedate  the  symptoms.  This  injury  causes  or  leads  to  blocking  of  the 
infundibulum;  secretion  accumulates  and  distends  the  sinus,  and  in  some  cases 
pus  forms.  In  many  cases  the  fluid  slowly  accumulates,  and  it  may  require 
years  to  produce  marked  symptoms.  In  other  cases  infection  takes  place 
early  or  existed  from  the  start,  and  the  symptoms  are  positive  and  violent.  If 
the  outlet  into  the  nose  is  not  permanently  blocked,  the  fluid  may  discharge 
itself  from  time  to  time.  In  the  chronic  cases  there  is  seldom  much  pain. 
The  chief  sign  is  a  swelling  of  the  inner  or  upper  part  of  the  orbit,  which  swelling 
progressively  increases  and  finally  displaces  the  eye.  If  at  any  time  acute 
symptoms  supervene,  there  will  be  pulsatile  pain,  discoloration,  and  tenderness. 

Treatment. — In  some  cases  it  is  possible  to  pass  a  trocar  upward  from  the 
nose  into  the  sinus,  and  so  drain  and  irrigate.  In  most  cases  an  incision  should 
be  made  through  the  soft  parts,  and  the  sinus  be  opened  by  a  trephine  or  chisel. 
After  the  sinus  has  been  opened  it  must  be  curetted.  The  opening  into  the 
meatus  should  be  restored  ana  enlarged,  ana  a  drainage-tube  must  be  passed 
from  the  forehead  incision  into  the  nostril.  I  usually  prefer  to  open  the  sinus 
by  making  an  osteoplastic  flap  in  the  anterior  wall. 

^  Cobb,  in  "Boston  Med.  and  Surg.  Jour.,"  May  7,  1896. 


990  Surgery  of  the  Respiratory  Organs 

Diseases  and  Injuries  of  the  Larynx  and  Trachea 

Edema  of  the  Larynx  {Edema  of  the  Glottis). — The  causes  of  edema 
of  the  larynx  are:  acute  laryngitis;  chronic  diseases,  such  as  tuberculosis, 
malignant  disease,  or  syphilis;  inflammatory  disorders,  such  as  diphtheria  and 
erysipelas;  acute  infectious  diseases;  Bright's  disease;  aneurysm;  whooping- 
cough,  pneumonia;  quinsy;  wounds  of  the  larynx;  wounds  of  the  neck;  scalds 
and  burns  of  the  larynx,  and  the  inhalation  of  irritating  vapors,  such  as  those 
of  ammonia,  nitric  acid,  or  sulphur. 

The  symptoms  are  sudden  and  rapidly  increasing  dyspnea,  respiratory 
stridor,  huskiness  of  the  voice,  and  finally  aphonia.  The  swollen  epiglottis 
may  be  felt  with  the  finger  and  may  be  seen  with  the  help  of  a  mirror. 

Treatment. — In  cases  in  which  edema  of  the  larynx  is  not  excessively  acute, 
introduce  a  gag  between  the  teeth,  hold  the  mouth  open,  take  a  knife  wrapped 
to  within  }i  inch  of  its  point,  make  multiple  punctures  into  the  epiglottis,  and 
favor  bleeding  by  the  inhalation  of  steam.  In  severe  cases  perform  intubation 
or  tracheotomy. 

Wounds  and  Injuries  of  the  Larynx. — The  larynx  may  be  injured 
internally  by  foreign  bodies,  and  externally  by  blows  and  cuts.  A  condition 
often  met  with  is  cut  throat,  the  result  usually  of  a  suicidal  attempt  on  the  part 
of  the  patient  or  a  homicidal  effort  on  the  part  of  an  assailant.  The  cut  of  the 
suicide  is  usually  in  front;  as  a  rule,  it  misses  the  great  vessels,  but  divides  the 
.cricothyroid  or  thyrohyoid  membrane.  The  epiglottis  may  be  incised,  or 
even  be  cut  off.  If  a  large  vessel  is  cut,  death  rapidly  occurs.  The  immediate 
dangers  of  cut  throat  are  hemorrhage,  suft'ocation  by  blood  in  the  wind-pipe 
and  bronchi,  or  by  displacement  of  parts,  and  entrance  of  air  into  veins.  The 
secondary  dangers  are  bronchopneumonia,  infection  and  sepsis,  exhaustion, 
and  secondary  hemorrhage.  The  remote  dangers  are  stricture  and  fistula 
(Keetley). 

Treatment. — In  wounds  of  the  throat  arrest  hemorrhage,  remove  clots 
from  the  larynx  and  trachea,  bring  about  reaction,  asepticize  the  parts  as  well 
as  possible,  suture  the  deeper  structures  with  silver  wire,  catgut,  or  kangaroo- 
tendon,  and  the  superficial  parts  with  silkworm-gut,  dress  antiseptically,  and 
place  a  bandage  around  the  head  and  chest  so  as  to  pull  the  chin  toward  the 
sternum.  If  laryngeal  breathing  is  much  interfered  with,  perform  tracheot- 
omy. Feed  the  patient  through  a  tube  until  union  is  well  advanced.  The  old 
method  of  leaving  the  wound  open  is  to  be  condemned.  When  sutures  are 
used,  primary  union  may  be  obtained.     This  fact  was  proved  by  Henry  Morris. 

War  Wounds  of  the  Larynx  and  Trachea. — Because  of  its  mobility, 
the  larynx  is  seldom  injured.  Sudden  death  may  occur  when  the  larynx  is 
struck.  If  a  bullet  penetrates  the  larynx  or  trachea  stenosis  is  apt  to  follow. 
These  cases  may  be  treated  by  division  or  by  gradual  dilatation.  Gradual 
dilatation  is  carried  out  above  the  tracheotomy  tube  (Canuyt,  in  "Jour,  dc 
med.  de  Bordeaux,"  1916,  Ixxxvii). 

Scalds  of  the  Glottis. — (See  section  on  Burns  and  Scalds.) 

Foreign  Bodies  in  the  Air=passages. — The  lodgment  of  foreign  bodies 
in  the  air-passages  is  a  frequent  accident.  A  multitude  of  different  things 
have  been  reported  as  having  lodged  in  the  air-passages.  Small  solid  bodies 
are  usually  expelled  by  coughing.  Liquids  and  soHds  rarely  pass  beyond 
the  larynx  (except  in  laryngeal  disease  or  palsy,  wounds  of  the  floor  of  the  mouth, 
cut  throat,  and  in  people  unconscious  or  very  drunk).  In  vomiting  during 
or  after  the  administration  of  an  anesthetic  or  in  the  vomiting  of  drunkards  the 
vomited  matter  may  find  its  way  into  the  larynx  or  lungs.  There  is  great 
danger  of  this  accident  in  an  operation  upon  a  patient  with  intestinal 
obstruction  who  has  stercoraceous  vomiting.  In  most  instances  of  foreign 
bodies  lodged  in  the  air-passages  it  will  be  found  that  the  object  was  being  held 


Foreign  Bodies  in  the  Air-passages  991 

in  the  mouth  when  a  sudden  deep  inspiration  was  taken  (often  during  laughter). 

The  symptoms  are  immediate,  due  to  obstruction  by  the  body  and  by  spasm; 
and  secondary,  due  to  the  situation  of  the  body  and  the  changes  it  undergoes 
or  induces. 

Lodgment  in  the  pharynx  causes  violent  dyspnea.  The  body  can  be  seen 
or  felt. 

Lodgment  in  the  Larynx. — A  foreign  body  may  lodge  in  the  superior  open- 
ing of  the  larynx,  in  the  rima,  or  in  the  ventricle.  In  a  severe  case  the  patient 
fights  madly  for  air;  his  face  becomes  livid  and  cyanotic;  his  veins  stand  out 
prominently;  speech  is  impossible,  though  he  may  make  noises  and  utter  harsh 
cries;  violent  coughing  begins,  and  then  vomiting;  he  tries  to  force  a  finger 
down  his  throat  and  clutches  at  his  neck;  sweat  pours  from  him;  he  feels  a  sense 
of  impending  dissolution,  and  he  falls  unconscious,  with  incontinence  of  feces 
and  urine.  ^  In  a  less  severe  case  violent  dyspnea  gradually  departs  and  the 
patient  hes  exhausted;  but  dyspnea  and  cough  are  liable  to  recur  suddenly  at 
any  time  because  of  spasm,  and  they  may  be  induced  by  a  change  of  position. 
These  attacks  of  fierce  spasmodic  cough  are  not  at  first  linked  with  expecto- 
ration, but  after  inflammation  begins  there  is  a  profuse  and  often  bloody 
expectoration.  Inflammation  foUows  more  rapidly  the  lodgment  of  a  sharp 
or  irregular  body  than  it  does  that  of-  a  round  or  smooth  one.  Inflamma- 
tion is  apt  to  produce  edema  of  the  glottis,  bronchopneumonia,  or  ulceration 
and  necrosis  of  the  larynx.  Any  sort  of  foregin  body  in  the  larynx  may  at 
any  moment  produce  spasmodic  dyspnea,  and  is  always  very  liable  to  cause 
edema  of  the  glottis.  The  body  if  bony  or  metallic  can  be  detected  by  the 
-T-rays.  A  body  may  remain  lodged  in  the  ventricle  for  a  long  time  without 
producing  symptoms. 

Lodgment  in  the  Trachea. — The  immediate  symptonis  of  a  foreign  body 
in  the  trachea  depend  on  the  shape  and  weight  of  the  body,  and  whether  it  be- 
comes fixed  in  the  mucous  membrane  or  moves  to  and  fro  with  the  air-current. 
A  smooth,  heavy  body  falls  to  the  tracheal  bifurcation,  and,  if  it  does  not  enter 
a  bronchus,  moves  with  every  breath,  and  by  its  movement  causes  violent  laryn- 
geal spasm,  cough,  and  whooping  inspiration  without  aphonia.  The  patient  is 
often  conscious  of  the  movements  of  the  foreign  body,  and  the  surgeon  may 
detect  them  by  the  stethoscope.  The  foreign  body  may  be  found  by  the 
Rontgen  rays.  A  foreign  body  in  the  trachea  is  liable  to  cause  death  by  suf- 
focation, or  it  may  ascend  so  as  to  be  caught  in  the  larynx,  or  may  even  be 
expelled.  Irregular  or  sharp  bodies  lodge  in  the  mucous  membrane,  produce 
inflammation,  frequent  cough  and  expectoration,  and  finally  lead  to  ulcera- 
tion. Bodies  which  swell  from  heat  and  moisture  tend  to  lodge  and  to  become 
fixed  (seeds  may  sprout). 

Lodgment  in  a  Bronchus. — Foreign  bodies  in  the  bronchi  seriously  endanger 
life.  They  usually  lodge  in  the  right  bronchus.  The  right  bronchus  is  more 
nearly  the  direct  continuation  of  the  trachea  than  the  left  bronchus.  When  a 
small  area  of  lung  is  obstructed  the  obstructed  side  shows  diminished  respira- 
tory movement  and  murmur  with  occasional  whistling  sounds  and  large  moist 
rales;  the  percussion-note  is  at  first  normal  and  later  dull.  When  an  entire 
lobe  is  obstructed  all  respiratory  sounds  are  absent  over  it,  and  over  the 
unobstructed  lung  respiration  is  exaggerated;  the  percussion-note  over  the 
obstructed  area  is  at  first  resonant,  but  becomes  dull.  The  .i:-rays  will  often 
enable  the  surgeon  to  detect  foreign  bodies  in  a  bronchus.  Lodgment  in  a  bron- 
chus may  cause  bronchopneumonia,  abscess,  hemorrhage,  and  even  gangrene. 
In  some  cases  the  body  has  been  expelled  spontaneously.  In  rare  instances 
people  have  lived  for  years  with  lodged  foreign  bodies.  If  death  does  not  soon 
follow  the  lodgment  of  a  foreign  body,  an  abscess  is  very  apt  to  form. 

Professor  Chevalier  Jackson  ("Am.  Jour.  Med.  Sciences,"  Nov.,  1918)  points 
^  See  Moullin's  graphic  description  in  his  "Treatise  on  Surgery." 


99^ 


Surgery  of  the  Respiratory  Organs 


out  an  important  symptom  of  the  presence  of  a  foreign  body  in  the  trachea  or 
bronchi.  He  calls  it  the  asthmatoid  wheeze.  The  surgeon  listens  for  it  with 
his  ear  near  the  patient's  open  mouth.  In  some  cases  it  is  audible  at  a  consider- 
able distance.  In  asthma  the  wheezing  is  more  apt  to  be  associated  with 
rales  than  in  a  foreign  body  case. 


Fig.  623. — Author's  case  of  pin  in  bronchus  removed  by  low  tracheotomy. 

Treatment. — If  a  foreign  body  lodges  in  the  pharynx,  try  to  pull  it  for- 
ward; if  this  fails,  it  may  be  wise  to  push  it  back  into  the  esophagus.  In 
lodgment  in  the  laryjix  or  below,  if  the  symptoms  are  very  urgent,  at  once 
perform  quick  laryngotomy  or  tracheotomy.  If  the  symptoms  are  not  so 
urgent,  get  a  complete  history  of  the  accident  and  find  out  the  nature  of  the 
foreign  body.     Be  sure  that  a  foreign  body  is  really  retained  in  the  respiratory 


Fig.  624.- — Gibbon's  case  of  tack  in  the  right  bronchus  removed  by  low   traclieotomy,  child 

six  years  old. 

tract,  and  then  try  to  determine  what  its  situation  may  be.  A  person  some- 
times imagines  a  body  is  lodged  when  it  has  been  expelled  or  even  vy-hen  it  has 
never  been  in  the  larynx,  trachea,  or  bronchus,  but  has  been  swallowed.  Often 
a  lacyngologist  can  remove  a  foreign  body  from  the  larynx  by  means  of  forceps, 
a  mirror  and  lamp  being  used  for  illumination.  The  fatices  and  upper  portion 
of  the  larynx  should  have  cocain  applied  to  them  to  lessen  pain  and  spasm. 
If  the  surgeon  fails  in  extraction  by  forceps,  and  laryngotomy  has  been  per- 


Tracheotomy  993 

formed,  continue  the  search  through  the  opening  in  the  cricothyroid  membrane; 
if  laryngotomy  has  not  been  performed,  let  the  larynx  be  opened  by  thyrotomy 
(a  vertical  incision  between  the  ala?  of  the  thyroid  cartilage,  and  the  separation 
of  these  alse  to  permit  of  exploration).  After  a  thyrotomy  suture  the  peri- 
chondrium with  catgut.  If  the  foreign  body  is  in  the  trachea,  perform  ordinary 
tracheotomy;  if  it  is  in  a  bronchus,  perform  low  tracheotomy.  Tracheotomy 
prevents  suffocation  from  laryngeal  spasm  or  edema  of  the  glottis.  It  may  be 
possible  to  remove  the  body  in  the  bronchus  through  the  incision  of  a  low- 
tracheotomy,  and  this  ought  to  be  tried.  By  this  method  I  succeeded  in  5 
cases,  removing  a  pin,  a  bone,  a  bean,  a  tack,  and  a  broken  tracheotomy  tube 
from  the  right  bronchus.  The  foreign  body  may  be  expelled  through  the 
tracheotomy  wound;  if  it  is  not  expelled,  search  the  trachea  and  bronchi  with 
Gross's  forceps,  with  probes,  with  hooks,  or  with  the  finger.  If  the  foreign 
body  cannot  be  found,  put  the  patient  to  bed  and  maintain  a  moist  atmosphere 
in  the  room.  As  a  rule,  when  the  foreign  body  is  not  found,  insert  a  tube. 
If  the  foreign  body  be  extracted,  do  not  insert  a  tube  (unless  edema  of  the  glottis 
exists  or  is  likely  to  come  on),  do  not  suture  the  wound,  but  cover  it  with  moist 
gauze  and  let  it  heal  by  granulation.  Morphin  and  sedative  cough-mixtiu-es 
are  given.  Gross  says  that  even  when  a  foreign  body  has  long  been  retained 
an  operation  should  be  performed  if  the  air-passages  are  not  seriously  diseased. 
What  shall  be  done  when  a  foreign  body  is  lodged  in  a  bronchus  and  we  are 
unable  to  extract  it  through  a  tracheotomy  wound  or  by  tracheobronchoscopy? 
True  said  if  "the  patient  is  in  danger  of  death"  cut  through  the  chest-wall 
and  attempt  to  remove  the  body.  He  said  this  with  a  full  knowledge  of  the 
difficulty  of  locating  the  body.  This  difficulty  has  been  partly  overcome 
by  the  .-v-rays,  and  it  seems  now  more  certainly  our  duty  to  operate  than  it  was 
a  short  time  ago.  Nasiloff  proposed  to  reach  the  obstruction  by  the  posterior 
route  after  rib  resection.  Curtis  attempted  this,  and  though  the  patient  died, 
his  operation  proves  that  the  method  is  feasible.  An  operation  by  the  posterior 
route  should  be  performed  at  once  if  low  tracheotomy  fails.  The  danger  of 
pulmonary  collapse  will  be  aboHshed  by  the  use  of  a  suitable  apparatus  to 
prevent  it  (see  pages  1020  and  1032). 

Tracheobronchoscopy. — Killian,  of  Freiburg,  devised  a  bronchoscope  for 
introduction  through  a  tracheotomy  wound.  I  have  used  the  endoscope  in 
this  manner.  Later  Killian  devised  a  straight  instrument  which  could  be  used 
through  the  mouth  and  larynx,  tracheotomy  being  unnecessary.  During  its 
introduction  the  head  was  held  far  back. 

Briining,  of  Freiburg,  improved  the  instrimient.  His  tube  is  long  enough  to 
reach  between  the  vocal  cords  to  the  divisions  of  the  bronchi.  In  1907  Killian 
was  able  to  coUect  164  cases  of  foreign  bodies  removed  by  this  direct  method. 

My  coheague.  Professor  Chevalier  Jackson,  has  devised  a  tracheobronchoscope 
through  which  he  has  succeeded  in  removing  foreign  bodies  from  the  trachea 
and  from  a  bronchus.  In  10  cases  of  foreign  body  in  the  bronchus  he  removed 
the  offender  in  7.  In  7  cases  of  foreign  body  in  the  trachea  he  was  successful 
in  each  case,  but  2  of  the  cases  required  tracheotomy.  Whenever  there  is 
dyspnea  he  always  prepares  to  do  tracheotomy  ("Annals  of  Surgery,"  March, 
1908).  In  Jackson's  highly  trained  hands  the  instrument  is  incomparably  use- 
ful, but  an  untrained  man  with  it  would  be  Hke,  or  rather  would  be  worse 
than  an  untrained  man  with  a  cystoscope.  When  used  by  a  fully  trained  man. 
the  instrument  prevents  many  cutting  operations  and  saves  many  lives  (see 
page  996J. 

Operations  on  the  Larynx  and  Trachea 

Tracheotomy. — In  a  formal  operation  give  ether  or  chloroform,  but  in 
an  emergency  this  cannot  be  done.     The  patient  may  be  placed  supine  with 
a  sand-piUow  under  the  neck  and  with  the  head  thrown  over  the  end  of  the 
63 


994  Surgery  of  the  Respiratory  Organs 

table.  If  a  child,  Listen  used  to  wrap  it  up  to  tlie  neck  in  a  sheet  to  prevent 
movements  of  the  limbs,  would  seat  himself  on  a  chair,  place  the  child  upon 
the  nurse's  lap,  and  take  its  head  between  his  knees.  The  head  must  be  exactly 
in  the  middle  line  and  extended  (in  an  adult  this  gives  2^^  inches  of  trachea 
above  the  manubrium;  in  a  child  of  ten,  2]i  inches;  in  a  child  of  six,  about 
2  inches).  The  operator  stands  to  the  right  side  when  the  patient  is  supine. 
If  bleeding  is  profuse  when  the  surgeon  is  ready  to  open  the  trachea,  place  the 
patient  in  the  Trendelenburg  position  with  the  neck  extended.  The  trachea 
may  be  opened  above  or  below  the  isthmus  of  the  thyroid  gland.  The  isthmus 
in  an  adult  usually  lies  over  the  second  and  third  rings  (Figs.  625  and  626). 
The  isthmus  in  a  child  usually  lies  over  the  first  ring  or  even  over  the  space  be- 
tween the  cricoid  cartilage  and  the  first  ring.  The  high  operation  is  always 
chosen  except  in  cases  in  which  it  is  desired  to  search  for  a  foreign  body  in  a 
bronchus. 


.^:}Jt 


Fig.  625. — Blood-supply  of  the  larynx  and 
trachea  (Esmarch  and  Kowalzig). 


Fig.    626. — Parts  exposed  in  tracheotomy 
(Esmarch  and  Kowalzig). 


High  tracheotomy  is  preferred  because  in  this  region  the  muscles  are 
distinctly  separated  (Fig.  625),  the  main  vessels  of  the  neck  and  the  inferior 
thyroid  vessels  are  not  encountered,  the  anterior  jugular  veins  are  small  and 
have  very  few  transverse  branches,  and  the  trachea  is  near  the  surface  (Treves). 
The  surgeon  accurately  locates  the  cricoid  and  thyroid  cartilages.  An  incision 
is  begun  at  the  upper  border  of  the  cricoid  cartilage,  and  is  carried  down  pre- 
cisely in  the  middle  line  for  about  1^^  inches.  Treves  advises  the  operator  to 
steady  the  skin  of  the  neck  with  the  fingers  of  the  left  hand  and  to  cut  with  the 
unsupported  right  hand  (if  the  hand  be  supported,  the  respirations  will  inter- 
fere with  the  operation).  The  skin,  the  superficial  fascia,  and  the  anterior  layer 
of  the  cervical  fascia  are  incised,  the  sternohyoid  and  sternothyroid  muscles  are 
separated,  and  the  fascia  over  the  trachea  is  divided.  This  fascia  is  attached 
above  to  the  cricoid  cartilage,  and  it  divides  below  into  two  layers  to  invest  the 
thyroid  body  and  its  isthmus.  If  veins  are  in  the  line  of  the  incision,  they  are 
pushed  aside,  but  it  is  not  necessary  to  take  the  time  to  apply  double  ligatures. 
Even  if  bleeding  is  profuse,  as  soon  as  the  trachea  is  opened  and  air  enters 
freely  into  the  lungs,  venous  congestion  is  relieved  and  bleeding  is  apt  to  cease. 
If  hemorrhage  be  violent  and  the  veins  are  not  at  once  caught  by  forceps,  it 
may  be  well  to  place  the  patient  in  the  Trendelenburg  position  before  incis- 
ing the  windpipe,  in  order  to  prevent  the  entrance  of  blood  into  the  lungs. 
Before  opening  the  trachea  the  isthmus  of  the  thyroid  gland  is  pushed  down- 
ward; if  it  cannot  be  pushed  down  sufficiently,  a  transverse  incision  is  made 
through  the  fascia  at  the  upper  border  of  the  cricoid  cartilage,  and  the  fascia 
and  the  isthmus  with  it  are  lifted  off  the  trachea  (Bose's  method).     A  tenacu- 


Intubation  of  the  Larynx  995 

lum  is  inserted  into  the  cricoid  cartilage  in  order  to  steady  the  tube.  The 
back  of  the  knife  is  turned  toward  the  sternum,  a  finger  being  held  upon  the 
blade  to  prevent  too  deep  a  cut  being  made.  The  knife  is  plunged,  as  if  it 
were  a  trocar,  into  the  midline  of  the  trachea  above  the  isthmus,  and  two  or 
three  rings  are  divided  from  below  upward.  The  hook  is  not  removed  until 
the  operation  is  completed.  If  a  foreign  body  is  present,  an  attempt  is  made 
to  remove  it;  if  success  attends  the  effort,  no  tube  need  be  worn;  but  if  the 
body  is  not  found,  a  tube  must  be  used.  In  croup  or  diphtheria  remove  mem- 
brane (by  means  of  a  feather  and  a  solution  composed  of  bicarbonate  of  sodium 
2  oz.,  glycerin  i  oz.,  water  10  oz. — Parker)  and  insert  a  tube.  The  edge  of 
the  cut  is  grasped  with  the  dissecting  forceps,  the  mucous  membrane  being 
included  in  the  bite;  the  head  is  placed  erect,  the  tube  is  introduced,  and  the 
tenaculum  is  removed.  Secure  the  tube  by  tapes,  and  suture  the  wound 
below  the  tube.  Remove  the  tube  at  the  first  moment  consistent  with  safety. 
After  tracheotomy  put  a  screen  around  the  bed;  have  the  air  kept  moist  by 
steam;  remove  the  inner  tube  and  clean  it  every  few  hours  at  first;  clean  the 
outer  tube  whenever  required.  In  croup  or  diphtheria  put  the  patient  in  a 
croup  tent  and  keep  the  air  moist  by  a  steam  atomizer  or  a  croup  kettle.  Re- 
move and  clean  the  inner  tube  every  two  hours.  Clean  the  larynx  and  trachea 
from  time  to  time  by  means  of  a  feather  and  Parker's  solution. 

Quick  laryngotomy  must  never  be  attempted  upon  a  child  under  thir- 
teen years  of  age,  because  of  the  small  size  of  the  cricothyroid  space  before  this 
age  (Treves).  In  view  of  the  difliculty  of  introducing  a  tube  and  of  wearing  it 
so  near  the  vocal  cords,  laryngotomy  should  not  be  performed  for  croup,  diph- 
theria, or  for  any  condition  in  which  a  tube  must  be  long  worn.  The  operation 
is  performed  as  follows:  Make  an  incision  i3^^  inches  in  length  in  the  middle 
line,  from  above  the  level  of  the  lower  edge  of  the  thyroid  cartilage  to  below 
the  level  of  the  lower  border  of  the  cricoid  cartilage.  Divide  the  skin,  super- 
ficial fascia,  and  deep  fascia,  separate  the  cricothyroid  and  sternothyroid  muscles, 
divide  the  deep  layer  of  fascia,  and  cut  the  cricothyroid  membrane  transversely 
just  above  the  cricoid  cartilage.  The  tube  must  be  shorter  than  the  ordinary 
tracheotomy  tube.  An  operation  which  opens  vertically  the  cricothyroid 
membrane,  the  cricoid  cartilage,  and  the  upper  rings  of  the  trachea  is  called 
laryngotracheotomy. 

Intubation  of  the  Larynx  {O^Dwyer's  Operation). — Bouchot  conceived 
the  idea  of  intubation;  O'Dwyer  perfected  it  and  made  it  a  genuine  scientific 
proceeding.  The  instruments  required  for  the  performance  of  this  operation 
are  a  mouth-gag,  an  instrument  to  hold  the  tube  and  introduce  it,  and  an 
instrument  for  extracting  the  tube.  The  collar  of  the  tube  has  a  perforation 
through  which  is  fastened  a  piece  of  silk  with  which  the  tube  can  be  withdrawn. 
The  child  is  wrapped  in  a  sheet  to  secure  the  limbs,  is  seated  in  a  nurse's  lap, 
and  its  head  is  held  by  an  assistant.  The  jaws  are  opened  and  held  apart  by 
the  self-retaining  mouth-gag.  The  surgeon  sits  in  front  of  the  patient,  wraps 
a  piece  of  rubber  plaster  about  the  index-finger  of  his  left  hand,  and  passes  the 
finger  into  the  child's  mouth  until  its  tip  touches  the  epiglottis.  He  introduces 
the  holder  and  tube  (observing  if  the  silk  is  free)  along  the  surface  of  the  tongue 
until  the  obturator  touches  the  epiglottis;  raises  the  epiglottis  with  the  left 
index-finger,  and  passes  the  tube  into  the  larynx;  places  the  left  index-finger 
against  the  tube,  and  withdraws  the  holder  with  the  right  hand.  The  silken 
thread  is  tied  to  the  ear,  and  the  nurse  is  directed  to  employ  the  thread  to 
remove  the  obturator  if  it  becomes  obstructed  or  is  coughed  up.  The  tube  is 
removed  in  two  or  three  days;  if  breathing  is  easy,  it  is  not  reintroduced;  but 
if  dyspnea  recurs,  it  is  replaced  for  two  or  three  days  more.  If,  in  introducing 
the  tube,  a  mass  of  false  membrane  is  pushed  before  it  into  the  trachea,  breath- 
ing ceases,  and,  if  the  mass  is  not  at  once  coughed  up,  tracheotomy  must  be 
performed.  Feed  these  patients  on  semisolids  rather  than  upon  liquids  (mush, 
soft  eggs,  and  cornstarch);  and  if  trouble  occurs  in  swallowing  these  articles. 


996 


Surgery  of  the  Respiratory  Organs 


feed  by  the  rectum  or  by  means  of  a  nasal  or  an  oral  tube.  In  opium-poisoning, 
in  asphyxia,  in  acute  traumatic  pneumothorax,  and  in  cerebral  injuries,  in- 
tubation may  be  associated  with  the  use  of  Fell's  apparatus  (see  page  102 1). 

Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  Esophago= 
scopy  and  Qastroscopy  (My  distinguished  colleague,  Prof.  Chevalier  Jack- 
son did  me  the  honor  to  write  the  following  section  for  this  book). — These 
are  procedures  using  self-illuminated  tubes  that  serve  as  specula  for  the  endo- 
scopic examination  and  treatment  of  the  interior  of  the  larynx,  trachea,  bronchi, 
csooliasrus  and  stomach. 


Fig.  627. — Jackson's  instruments  fwr  ilircct  hir\::-  -  'py,  bronchoscopy,  and  csophagos- 
copy:  A,  Bronchoscope;  B,  olive  bougie  for  esophagoscopic  bouginage;  C,  sponge-holder  for 
sponging  the  field  and  obtaining  specimens  of  secretion;  D,  forceps  for  removing  foreign  bodies; 
E,  forceps  for  removing  tissue;  F,  laryngeal  speculum,  called  also  slide  speculum  and  direct 
laryngoscope;  G,  bite-block;  //,  esophagoscope  with  tubing  (/)  leading  to  aspirator  (/,  A') 
for  removal  of  secretions.  The  tubing  (L)  is  connected  with  the  positive  pressure  side  of  the 
syringe  (K)  for  use  when  needed  to  blow  out  obstructions,  such  as  clots  of  pus,  food,  etc., 
that  have  been  aspirated  into  the  drainage  canal  of  the  esophagoscope.  At  M  is  shown  a 
gastroscope.     The  filiform  bougie  (Fig.  646)  has  superseded  the  olive  bougie  shown  above  at  B. 

The  endoscopic  tubes  (Fig.  627)  are  without  lenses  and  are  straight  and 
rigid  instruments,  serving,  as  do  other  specula,  to  draw  out  of  the  way  tissues 
that  obstruct  direct  vision,  or  to  draw  the  tissues  to  be  inspected  into  a  new 
position  in  the  line  of  sight.  Through  these  tubes  many  ingenious  instruments, 
such  as  forceps,  sponge-holders,  loops,  hooks,  bougies,  etc.,  are  used  for 
various  procedures,  such  as  removal  of  foreign  bodies,  dilatation  of  strictures, 
diagnosis  of  disease  by  inspection  and  by  removal  of  specimens  of  tissues  and 
secretions. 

Anesthesia. — For  direct  laryngoscopy,  bronchoscopy  and  esophagoscopy 
in  children  no  anesthetic,  general  or  local,  is  needed  after  skill  in  peroral  endo- 
scopy is  acquired.  The  procedures  are  not  painful,  though  disagreeable  and  sonie- 
what  terrifying.     Cocain  is  dangerous  in  children  and  other  local  anesthetics 


Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  etc.    997 

are  unsatisfactory  Ether  anesthesia  is  only  slightly  more  dangerous  than  in 
ordinary  surgical  work.  General  anesthesia  is  absolutely  contraindicated  in 
dyspneic  patients,  either  adults  or  children.  In  adults  no  anesthetic  is  needed 
for  esophagoscopy  or  gastroscopy.  For  direct  laryngoscopy  and  bronchoscopy 
in  adults  the  cough  reflex  may  be  lessened  by  the  hypodermatic  injection  of 
morphin  in  full  dosage.     This,  with  the  local  painting  with  a  small  quantity 


Fig.  628. — Schema  illustrating  manner  of  exposure  of  the  larynx  with  the  direct  laryngo- 
scope. At  A  the  laryngoscope  has  been  inserted  posterior  to  the  dorsum  of  the  tongue  until 
the  epiglottis  has  come  into  view.  The  laryngoscope  is  then  inserted  about  i  centimeter 
deeper,  the  spatula  tip  going  posterior  to  the  epiglottis.  A  strong  lifting  motion  is  now 
exerted  in  the  direction  of  the  dart,  even  lifting  the  patient's  head  from  the  table  as  shown  at 
B.     The  glottis  and  the  tracheal  axis  thus  are  brought  in  line  with  the  observer's  visual  axis. 

of  a  ID  per  cent,  solution  of  cocain,  using  small  gauze  sponges  (Fig.  629)  held  in 
the  sponge  carrier  (C,  Fig.  627),  will  suffice  in  skilful  hands.  The  inexperi- 
enced operator  will  require  the  patient  to  be  fully  relaxed  by  general  anesthesia, 
preferably  ether. 

Direct  laryngoscopy  is  so  called  in  contradistinction  to  ordinary  indirect 
laryngoscopy  in  which  the  operator  looks,  not  directly  at  the  larynx  but  at  a 
reversed  image  of  it  in  a  mirror.     Instead  of  looking  down  back  of  the  tongue 


Fig.  629. — Manner  of  keeping  endoscopic  sponges.  About  a  dozen  of  one  size  are  trans- 
fixed on  a  safety  pin,  wrapped,  the  size  marked  on  the  wrapper,  and  then  sterilized,  to  be  opened 
only  as  needed.  About  5  dozen  sponges  of  each  of  the  4  sizes  should  be  kept  on  hand.  Only 
one  sponge  is  placed  in  the  sponge-carrier  at  a  time.  These  sponges  are  made  for  the  author 
by  Messrs.  Johnston  and  Johnston,  of  New  Brunswick,  N.  J.,  and  are  known  as  "  bronchoscopic 
sponges." 


with  the  aid  of  a  throat-mirror  the  tongue  is  dragged  forward  out  of  the  way 
with  the  direct  laryngoscope.  Though  easier  of  accomplishment  in  some 
patients  than  in  others,  the  larynx  of  any  human  being  can  be  exposed  to  view 
by  direct  laryngoscopy  unless  the  jaws  are  so  ankylosed  that  the  mouth  cannot 
be  opened.  The  technic  of  the  method  is  shown  in  Fig.  628.  The  error  which 
everyone  makes  on  first  attempt  is  the  use  of  the  upper  teeth  as  a  fulcrum  in 
an  effort  to  pry  the  tongue  anteriorly  out  of  the  way.  Instead,  the  tongue, 
the  hyoid  bone  and  attached  tissues  should  be  lifted  out  of  the  way  with  the 
spatular  tip  of  the  laryngoscope.  Great  care  should  be  taken  to  avoid  pinching 
the  patient's  upper  lip  between  the  laryngoscope  and  the  teeth.  This  will  cause 
real  pain,  vastly  harder  to  endure  than  any  annoyance  from  the  presence  of 
the  laryngoscope  in  the  laryngopharynx.     For  the  insertion  of  a  silk- woven 


998 


Surgery  of  the  Respiratory  Organs 


catheter  for  insufflation  anesthesia  (Fig.  630)  and  for  endolaryngeal  operations 
the  patient's  head  should  be  on  the  table,  not  hanging  over  the  end.  An  as- 
sistant holds  the  head,  keeping  the  patient's  nose  toward  the  ceiling  and  ex- 
tending the  head  only  at  the  occipitoatloid  joint.  Rotation  of  the  head  would 
distort  the  interior  landmarks,  and  extension  distributed  throughout  the  cervical 
spine  would  obtrude  a  rigid  convexity  of  the  posterior  pharyngeal  wall.  The 
essential  part  of  the  procedure  in  exposure  of  the  larynx  with  the  direct  laryngo- 
scope is,  however,  the  lifting  motion  (Fig.  628)  made  as  if  to  suspend  the  patient 
by  his  hyoid  bone  with  the  tip  of  the  spatular  end  of  the  laryngoscope.  Every- 
thing else  is  secondary  to  this.  Much  less  anteriorly  displacing  effort  is  required 
if  the  laryngoscope  is  passed  at  the  side  of  the  tongue  (preferably  the  right  side), 
but  experience  is  required  to  recognize  the  thus  distorted  landmarks. 


P^G.  630. — Direct  laryngoscopy  for  the  introduction  of  a  silk-woven  catheter  for  intra- 
tracheal insufflation  anesthesia.  The  patient's  head  is  on  the  table,  but  extended.  The 
anesthetist  has  exposed  the  larynx  by  lifting  strongly  with  the  spatular  tip  of  the  laryngoscope 
inserted  posterior  to  the  epiglottis. 


Papilloma  and  other  benign  growths  of  the  larynx  are  removed  with  the  crush- 
ing alligator  forceps.  Specimens  are  removed  with  cutting  forceps  (E,  Fig. 
627).  In  case  of  large  growths,  the  forceps  or  snare  may  be  passed  along  the 
outside  of  the  laryngoscope,  the  latter  being  used  only  for  ocular  guidance  of 
the  forceps  when  it  comes  into  view  at  the  distal  end  of  the  tube. 

Bronchoscopy. — The  first  step  in  the  introduction  of  the  bronchoscope  and 
the  chief  technical  difficulty  to  be  mastered  is  the  exposure  of  the  glottis  by 
direct  laryngoscopy  (q.  v.).  Once  the  art  of  doing  this  is  mastered,  both  pro- 
cedures, exposure  of  the  larynx  and  the  introduction  of  the  bronchoscope,  should 
not  require  more  than  a  minute,  usually  less.  The  bronchoscope  can  be  inserted 
in  any  patient  whose  mouth  can  be  opened.  As  in  all  manual  procedures  prac- 
tice is  necessary.  When  direct  laryngoscopy  is  done  for  the  introduction  of 
the  bronchoscope,  the  patient's  head  is  brought  beyond  the  head  of  the  table 
sufficiently  far  to  bring  the  middle  of  the  patient's  scapulae  to  the  edge  of  the 
table.  This  permits  of  the  patient's  head  and  neck  being  moved  about  so  as  to 
facilitate  following  with  the  bronchoscope  various  bronchial  axes;  but  during 


Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  etc.    999 

the  introduction  of  the  bronchoscope  the 
patient's  head  must  be  maintained  as 
high  as  though  the  occiput  were  on  the 
table.  If  the  head  is  allowed  to  drop 
into  the  Rose  position  great  difficulty 
in  introduction  will  be  encountered. 
The  head  is  held  by  an  assistant,  as 
shown  in  Fig.  642. 

In  Fig.  631,  a  repetition  of  Fig. 
628  is  shown  at  A,  a  strong  Hfting  mo- 
tion being  exerted  in  the  direction  of 
the  dart.  When  the  glottic  chink  is 
seen  the  bronchoscope,  lighted  by  its 
own  separate  cord,  is  inserted,  its 
handle  pointing  outward  horizontally 
to  the  right.  The  eye  of  the  broncho- 
scopist  is  then  transferred  from  the 
laryngoscope  to  the  bronchoscope.  The 
lip  of  the  latter  is  then  insinuated 
through  the  glottis  into  the  trachea. 
The  laryngoscope  is  then  removed  by 
withdrawal  of  first  its  slide,  afterward 
itself.  If  the  laryngoscope  is  allowed 
to  come  outward  during  the  removal 
of  the  slide  there  will  not  be  room 
enough  for  the  withdrawal  of  the  slide 
without  pulling  out  the  bronchoscope 
so  far  as  to  risk  withdrawal  of  the  distal 
end  of  the  bronchoscope  from  the 
trachea.  This  accident  would  require 
repetition  of  the  whole  procedure.  The 
fact  that  the  bronchoscope  is  in  the 
trachea  and  not  in  the  esophagus,  is 
recognized  by  the  strong  expiratory 
blast,  the  absence  of  voice  and  the 
visible  tracheal  rings.  It  must  be  re- 
membered, however,  that  there  is  a 
slight  pseudorespiratory  current  through 
a  tube  in  the  esophagus,  that  a  very 
small  bronchoscope  in  the  trachea  may 
permit  phonation,  and  that  endotracheal 
inflammation  may  obliterate  the  visi- 
bility of  the  rings.  The  trachea  stands 
open,  whereas  the  cervical  esophagus 
does  not;  but  the  posterior  wall  of  the 
trachea  collapses  forward,  especially  in 
children,  and  the  thoracic  esophagus 
remains  somewhat  open  when  an  en- 
doscopic tube  is  in  place  Some  practice 
is  therefore  required  to  be  prompt  in 
making  sure  that  the  bronchoscope 
does  not  enter  the  esophagus  instead  of 
the  trachea.  To  prevent  this  accident 
it  is  well  to  give  a  little  additional  lift 
to  the  laryngoscope  at  the  moment 
when  the  bronchoscopic  tube-mouth  is 


Fig.  63 1 . — Schema  illustrating  the  technic 
of  oral  bronchoscopy.  The  portion  of  the 
table  here  shown  under  the  head  is,  in  actual 
work,  dropped  all  the  way  down  perpendicu- 
larly. It  appears  in  these  drawings  as  a 
dotted  line  to  emphasize  the  fact  that  the 
head  must  be  above  the  level  of  the  table 
during  introduction  of  the  bronchoscope  into 
the  trachea.  A,  Exposure  of  larynx;  B, 
bronchoscope  introduced;  C,  slide  removed; 
D,  laryngoscope  removed,  leaving  broncho- 
scope alone  in  position.  The  handle  of  the 
laryngoscope  in  C  and  D  should  be  shown  as 
rotated  down  to  the  left. 


lOOO 


Surgery  of  the  Respiratory  Organs 


inserted  into  the  glottis.  Once  assured  the  bronchoscope  is  in  the  trachea, 
the  laryngoscope  is  detached  and  the  bronchoscope  is  inserted  deeper  into 
the  tracheobronchial  tree.  The  bifurcation  is  the  first  important  landmark 
to  be  identified.  To  avoid  missing  it.  and  passing  unknowingly  into  the  right 
bronchus,  the  patient's  head  is  moved  slightly  to  the  right,  and' the  left  wall  of 


Fig.  632. — Large  fence  staple  in  lung  of  man  aged  43  years.  Removed  bloodlessly  by 
bronchoscopy  through  the  mouth  after  2  year's  sojourn.  Complete  cure  of  septic  pulmonary 
focus  resulted. 


Fig.  633. — Radiograph  showing  tack  in  the  right  main  bronchus  of  a  boy,  'aged  eight 
years.  _  Tack  removed  by  oral  bronchoscopy  without  anesthesia,  general  or  local,  in 
four  minutes. 


the  trachea  is  watched  in  order  to  be  certain  of  exposing  the  left  bronchial 
orifice.  The  lip  of  the  bronchoscope,  which  corresponds  to  the  handle  of  the 
instrument,  is  always  turned  toward  any  orifice  it  is  desired  to  enter,  the  patient's 
head  being  moved  to  the  opposite  side.  The  middle-lobe  bronchus  is  given 
off  anteriorly,  being  the  largest  of  all  anterior  branches.     To  enter  it,  the  Hp 


Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  etc.      looi 

of  the  bronchoscope  is  turned  upward  and  the  patient's  head  is  lowered  far 
below  the  position  proper  for  introduction  of  the  bronchoscope  through  the  glot- 
tis. All  the  time  the  bronchoscope  is  in  place,  great  care  must  be  taken  not  to 
pinch  the  patient's  lip  between  the  bronchoscope  and  the  upper  teeth,  which 
would  cause  pain  and  distress  infinitely  greater  than  the  presence  of  the  bron- 
choscope in  the  lung.  The  lip  is  held  out  of  the  way  by  the  bronchoscopist's 
left  thumb,  after  the  laryngoscope  is  removed,  the  thumb  and  index  finger 
together  fixing  the  tube  against  the  upper  teeth.  As  with  any  other  surgical  pro- 
cedure, a  "dry"  field  is  necessary  for  clear  vision.  In  bronchoscopy,  the  sponge 
is  inserted  with  a  carrier  (C,  Fig.  627)  until  the  sponge  emerges  at  the  distal 


Fig.  634. — Roentgenogram  showing  atomizer-tip  in  rigiit  lung  of  a  man,  aged  fifty-eight 
years,  where  it  had  been  for  a  year  and  a  half.  Removed  in  two  minutes,  fifty-five  seconds 
under  local  anesthesia  by  peroral  bronchoscopy.     Complete  cure  of  lung  condition  resulted. 


end  of  the  bronchoscope.  If  the  patient  does  not  cough,  he  is  asked  to  do  so. 
In  either  case  the  secretions  are  coughed  into  the  bronchoscope,  from  which  they 
are  withdrawn  by  pulling  out  the  sponge-carrier,  just  as  a  pump  lifts  the  water 
that  is  above  the  plunger.  This  "sponge-pumping"  is  much  more  rapid  and 
efficient  than  any  form  of  aspirator  with  the  thick  secretions  usually  encoun- 
tered in  bronchoscopy. 

Duration  of  Bronchoscopy. — This  is  of  such  vital  importance,  especially  in 
case  of  children,  as  to  merit  a  separate  paragraph.  The  author's  work  has  dem- 
onstrated that  the  reaction  after  bronchoscopy,  other  things  being  equal, 
is  directly  as  the  duration,  and,  after  a  certain  limit,  directly  as  the  square  of 
the  duration.  A  15-minute  bronchoscopy  may  be  repeated  every  ten  days  for 
months  without  injury  to  the  health  of  an  infant,  whereas  a  single  bronchoscopy 
may  be  fatal  if  continued  for  an  hour.  This  refers  only  to  the  procedure  of 
bronchoscopy  per  se.     Of  course  it  may  be  modified  by  various  factors,  such  as , 


I002 


Surgery  of  the  Respiratory  Organs 


the  disturbance  of  the  epithelium  in  the  presence  of  pus,  the  use  of  unsterile 
instruments,  etc.  A  safe  working  rule,  to  be  modified  as  deemed  best  in  the  in- 
dividual case,  is:  One  hour  in  adults,  half  an  hour  in  children,  15  minutes  in 
infants.  As  a  matter  of  fact,  however,  in  most  cases  in  our  clinic  the  foreign 
body  is  removed  by  the  bronchoscope  in  less  than  five  minutes. 

Bronchoscopic  removal  of  foreign  bodies  from  the  trachea  and  bronchi  has 
been  successful  in  our  clinic  in  over  98  per  cent,  of  our  cases.  In  386  cases  there 
were  6  failures  to  remove.  The  mortality,  taking  the  cases  as  they  came,  the 
condition  being  good  or  bad  on  admission,  was  1.7  per  cent.  In  no  case  was 
mortality  directly  attributable  to  bronchoscopy.  Of  41  cases  of  lung  abscess 
due  to  foreign  body  of  prolonged  sojourn  (i  to  26  years)  complete  cure  followed 
oral  bronchoscopic  removal  in  39  cases. 


r 


Fig.  635. — Radiographs  showing  a  dental  root-canal  broach  in  a  small  posterior  branch 
■of  a  larger  posterior  branch  of  the  inferior-lobe  bronchus  of  a  man  of  thirty-nine  j-ears. 
The  foreign  body  is  seen  just  above  the  dome  of  the  diaphragm  in  the  anteroposterior 
radiograph,  though  really  in  the  part  of  the  lung  down  back  of  the  dome,  as  shown  in  the 
lateral  radiograph.  Removed  through  the  mouth  by  bronchoscopy  under  local  anesthesia. 
This  is  the  lowest  position  from  which  a  foreign  body  has  ever  been  removed  by  broncho- 
scopy. The  full  length  of  a  40-centimeter  bronchoscope  was  barely  sufficient  to  reach  it. 
(Author's  case.) 

Extreme  care  is  necessary  to  avoid  tearing  the  bronchi  in  the  use  of  forceps, 
and  especially  in  the  extrication  of  entangled  pointed  foreign  bodies  such  as 
tacks,  nails,  pins,  safety-pins,  etc.  In  all  cases  of  pointed  objects  (which  are 
almost  invariably  point  upward)  great  care  is  necessary  to  extricate  the  point 
first  and  to  get  it  into  the  tube-mouth  before  any  traction  is  made;  otherwise 
the  slightest  traction  will  cause  the  point  to  rip  in,  and  crosswise  fixation 
will  not  only  defeat  removal  but  will  rupture  the  bronchial  wall  and  result 
almost  certainly  in  death  from  mediastinal  emphysema  or  septic  mediastinitis. 
The  cardinal  rule  is  that  no  harm  should  be  done  and  if  gentle  methods  are 


Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  etc.      1003 

not  successful,  in  say  25  minules  in  case  of  children,  further  effort  should  be 
postponed  for  a  week,  when  another  radiograph  should  be  made  and  anew 
bronchoscopic  effort  may  be  made.     While  it  is  true  that  if  not  removed  a 


Fig.  636. — Radiograph  of  a  boy,  aged  eleven  years,  showing  nail  that  had  been  in  lung  for 
about  four  years,  producing  all  the  symptoms  of  bronchiectasis.  Bronchoscopic  removal  of 
the  foreign  body  without  anesthesia  resulted  in  complete  cure. 


Fig.  637. — Radiograph  showing  a  staple  in  a  posterior  branch  of  the  inferior-lobe  bronchus, 
ID  centimeters  (4  inches)  below  the  bifurcation  of  the  trachea,  in  a  man  aged  forty-four  years. 
Staple  was  turned  (version)  and  removed  bloodlessly  by  bronchoscopy  through  the  mouth. 
(See  Fig.  639.)      (Plates  made  by  Dr.  George  W.  Grier.     Author's  case.) 


foreign  body  in  the  lung  will  prove  fatal,  there  is  no  immediate  danger  that  would 
justify  ruthlessly  tearing  the  foreign  body  out  at  all  hazards.  If  no  harm  is  done 
further  study  of  the  mechanical  problem  involved  will  almost  certainly  succeed 
in  solving  the  problem  of  safe  removal.     A  few  of  the  many  problems  and  their 


I004 


Surgery  of  the  Respiratory  Organs 


solutions  are  illustrated  in  Figs.  639,  640,  and  647.     If  the  greatest  care  be 
not  taken  a  very  simple  and  easy  problem  of  removal  may,  by  an  improper  touch 


Fig.  638. — Radiographs  showing  an  iron  casting  in  the  right  bronchus  of  a  child  of 
eight  years.  Foreign  body  removed  by  peroral  bronchoscopy  without  anesthesia  in  six 
minutes,  fifty-two  seconds. 

or  traction,  be  converted  into  an  exceedingly  difficult  problem.     In  fully  half 
of  our  cases  this  has  happened  before  coming  to  our  clinic.     Soft,  friable  objects,. 


Fig.  639. — Schema  illustrating  the  method  of  removal  of  bronchially  lodged  staples  or 
double-pointed  tacks.  H,  Bronchoscope;  ^,  swollen  mucosa  covering  points  of  staple.  At 
E  the  staple  has  been  manipulated  upward  with  bronchoscopic  lip  and  hooks  until  the  points 
are  opposite  the  branch  bronchial  orifices,  B,  C.  Traction  being  made  in  the  direction  of  the 
dart  (/),  by  means  of  the  rotation  forceps,  and  counterpressure  being  made  with  the  broncho- 
scopic lip  on  the  points  of  the  staple,  the  points  enter  the  branch  bronchi  and  permit  the  staple 
to  be  turned  over  and  removed,  with  points  trailing  harmlessly  behind  (A.').  This  method 
slightly  modified  has  now  been  successfully  used  in  9  cases,  without  mortality.    (See  Fig.  637.) 

such  as  nut-kernels,  maize,  beans,  egg-shells,  glass,  and  the  like,  must  be  grasped 
with  a  delicately  calculated  forceps-pressure  sufficient  to  hold  the  foreign  body 


Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  etc.      1005 

and  prevent  its  being  stripped  off  at  the  glottis,  yet  not  sufficient  to  crush  it. 
The  latter  disaster  is  usually  fatal  from  scattering  the  fragments  which  are 
promptly  aspirated  into  many  minute  bronchi.  In  the  removal  of  any  kind  of 
a  foreign  body  that  is  too  large  to  come  through  the  bronchoscope,  the  latter 
is  removed  along  with  the  forceps  and  the  foreign  body.  To  get  through  the 
glottis  the  intruder  must  be  turned  with  its  greatest  plane  sagittally.     Other- 


FlG.  640. — Schema  showing  various  manipulations  in  tlie  disengaging  and  safe  removal 
of  tacks  from  the  bronchi  by  peroral  bronchoscopy  without  general  anesthesia.  In  18  cases 
of  this  kind  of  tack  all  have  been  successfully  removed  without  anesthesia  and  without  mor- 
tality in  our  clinic. 

wise  it  may  jam,  the  forceps  slip  off,  and  then  only  prompt  work  with  pre- 
cision will  be  required  to  remove  the  foreign  body  before  the  patient  is 
asphyxiated. 

Introduction  of  the  esophagoscope  is  easy  of  accomplishment  in  any  patient 
whose  mouth  can  be  opened;  but  Hke  all  technical , manual  procedures  practice 
is  necessary.  Fatal  trauma  is  readily  inflicted  by  the  inexperienced,  and  readily 
avoided  by  the  facile.  The  esophagus  has  very  thin,  dehcate  walls,  and  is  very 
intolerant  of  trauma,  in  addition  to  its  being  surrounded  by  many  vital   struc- 


ioo6 


Surgery  of  the  Respiratory  Organs 


T 


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TT 


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w 


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t 


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O 


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9  *i  9 


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Fig.  641 . — Foreign  bodies  removed  from  the  bronchi  by  peroral  bronchoscopy  without  general 
anesthesia  and  without  mortality. 


Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  etc.      1007 


Fig.  642. — Position  of  patient  and  second  assistant  in  bronchoscopy  and  esophagoscopy 
(Boyce  position).  The  left  hand  is  supported  on  the  left  knee,  the  left  foot  being  elevated  on 
a  stool.  The  right  forearm  is  under  the  patient's  neck,  the  right  index  carrying  the  bite-block. 
The  right  forearm  carries  little  weight,  most  of  the  extension  being  done  with  the  left  hand. 


Fig.  643. — Esophagoscopy  by  the  author's  "high-low"  method.  First  stage.  Finding 
the  right  pyriform  sinus.  In  this  and  the  second  stage  the  patient's  vertex  is  about_  15 
centimeters  above  the  level  of  the  table  and  in  full  extension  limited  to  the  occipito-atloid  joint. 


ioo8 


Surgery  of  the  Respiratory  Organs 


tures.  There  is  no  mortahty  associated  with  a  carefully  done  esophagoscopy. 
The  position  of  patient  and  assistant  for  esophagoscopy  is  the  same  as  that 
described  for  bronchoscopy   (Fig.   642),     The  easiest  and  most  satisfactory 


Fig.  644. — Schema  showing  how  the  tube-mouth  (.4)  is  lifted  forward  to  raise  it  over  the 
cricopharnygeal  fold  (B)  as  the  latter  relaxes,  and  the  lumen  opens  up  at  the  top  of  the 
field  (C). 


Fig.  645. — Esophagoscopy  by  the  author's  "high-low"  method.     Stage  4.     Passing  the  hiatus. 
The  patient's  vertex  is  about  5  centimeters  below  the  top  of  the  table. 

way  of  introducing  the  esophagoscope  is  that  known  as  "Chevalier  Jackson's 
high-low  method  of  esophagoscopy"  (Fig.  643).  The  handle  is  upward;  the 
thumb  and  finger  of  the  right  hand  lightly  grasp  the  proximal  end  of  the  tube, 


Chevalier  Jackson's  Direct  Laryngoscopy,  Bronchoscopy,  etc.     1009 

while  the  left  hand  supports  the  distal  end  and  at  the  same  time  pushes  back 
the  patient's  upper  lip  with  the  thumb,  on  which  the  tube-mouth  rests.  The 
fingers  of  the  left  hand  are  on  the  inside  of  the  upper  alveolus  back  of  the  teeth, 
steadying  the  tube.  The  long  axis  of  the  esophagoscope  at  this,  the  first  stage, 
is  nearly  vertical  (Fig.  643).  The  tube-mouth  then  is  passed  down  along  the 
right  side  of  the  patient's  tongue,  under  guidance  of  the  eye  watching  the  land- 
marks through  the  tube,  until  the  bottom  of  the  right  pyriform  sinus  is  reached, 
the  proximal  end  of  the  esophagoscope  being  gradually  lowered  to  about  20 
degrees  above  the  horizontal.     Here  firm  resistance  is  encountered,  due  to 

^_. 60-cm- ■> 


< -4-cm > 

Fig.  646. — Filiform  Dougie  for  minute  cicatricial  strictures  of  the  esophagus.  The  filiform 
silk-woven  end,  .4 ,  is  joined  securely  to  a  spring  steel  shaft,  B,  thus  giving  all  the  advantages 
in  safety  of  a  silk-woven  bougie  at  the  tip,  with  a  stiff  shank  that  enables  the  bougie  to  be 
carried  down  rigidly  through  the  length  of  the  esophagoscope.  Twelve  sizes  are  made.  The 
great  safety  of  these  instruments  lies  in  the  accuracy  with  which  they  are  used  through  the 
esophagoscope,  under  guidance  of  the  eye. 

contraction  of  the  cricopharyngeus  muscle.  Though  not  apparent  through 
the  tube,  this  muscle  raises  a  rigid  fold  from  the  posterior  pharyngeal  wall, 
as  shown  in  the  schema.  Fig.  644.  The  best  way  to  overcome  this  obstacle 
is  to  raise  the  tube-mouth  forward  with  the  thumb,  without  depressing  the 
proximal  end  of  the  tube.  At  the  same  time  the  eye  watches  through  the  tube 
for  the  opening  up  of  the  lumen  at  the  anterior  portion  of  the  endoscopic  field. 
Moderate  but  continuous  pressure  downward  (i.e.,  toward  the  deeper  esophagus) 


Fig.  647. — Schema  illustrating  the  endoscopic  closure  of  open  safety  pins  lodged  point 
upward.  The  closer  is  passed  down  under  ocular  control  until  the  ring,  R,  is  below  the  pin. 
The  ring  is  then  erected  to  the  position  shown  dotted  at  M,  by  moving  the  handle,  H,  down- 
ward to  L  and  locking  it  there  with  the  latch,  Z.  The  fork,  A,  is  then  inserted  and,  engaging 
the  pin  at  the  spring  loop,  K,  the  pin  is  pushed  into  the  ring,  thus  closing  the  pin.  Slight 
rotation  of  the  pin  with  the  forceps  may  be  necessary  to  get  the  point  into  the  keeper. 
Altogether  44  safety  pins  have  been  removed  by  this  and  other  endoscopic  methods  without 
anesthesia  and  without  mortality  in  the  author's  clinic. 

the  long  axis  of  the  esophagoscope  coinciding  with  the  long  axis  of  the  esophagus, 
should  be  made  on  the  esophagoscope  until  the  cricopharyngeal  contraction 
yields  and  the  lumen  opens.  Intermittent  contraction  fails  here  as  it  does  in 
using  a  tongue  depressor.  The  pressure,  though  continuous,  must  be  very 
moderate.  If  anything  approaching  force  be  used,  the  esophagoscope  will  be 
forced  through  the  posterior  esophageal  wall  in  the  weak  place  in  the  support 
between  the  circular  and  the  oblique  fibres  of  the  cricopharyngeus;  that  is, 
in  precisely  the  place  where  the  esophageal  hernia,  known  as  pulsion  diver- 
ticulum, occurs.  Fatal  perforation  with  the  esophagoscope,  and  even  with  the 
silk- woven  bougie,  has  occurred  here  many  times  in  inexperienced  hands.  Once 
the  cricopharyngeus  yields,  usually  no  further  difficulty  is  encountered  until 
the  hiatal  region  is  encountered.  The  thoracic  esophagus,  unlike  the  cervical, 
opens  its  lumen  before  the  tube-mouth  on  inspiration  and  does  not  completely 
close  on  expiration.  The  ridge  formed  by  the  crossing  of  the  left  bronchus 
64 


lOIO 


Surger}^  of  the  Respiratory  Organs 


may  be  noted  on  the  anterior  wall  of  the  esophagus  if  searched  for  with  the  tube- 
mouth.  When  the  tube-mouth  passes  back  of  the  heart  it  is  noted  that  the 
lumen  deviates  anteriorly  so  that  to  follow  the  lumen  axially  it  is  necessary  to 
drop  the  patient's  head  lower  and  lower.  This  should  be  done  and  constitutes 
the  last  stage  of  the  "high-low"  method  (Fig.  645).  Just  before  the  hiatal 
level  is  reached  careful  observation  of  the  direction  of  the  lumen  will  note  the 
deviation  to  the  left.     Then  the  tube-mouth  encounters  an  apparently  insur- 


FiG.  648. — The  problem  of  the  hurizontaUy  transfixed  foreign  body  in  the  esophagus. 
The  point,  D,  had  caught  as  the  bone,  A,  was  being  swallowed.  The  end,  E,  was  forced  down 
to  C,  by  food  or  by  blind  attempts  at  pushing  the  bone  downward.  The  wall,  F,  should  be  pushed 
laterally  out  to  J ,  permitting  the  forceps  to  grasp  the  end,  M ,  of  the  bone.  Traction  in  the 
direction  of  the  dart  will  disimpact  the  bone  and  permit  it  to  rotate.  The  author's  rotation 
forceps  are  used  as  at  K. 


Fig.  649.— Solution  of  the  mechanical  problem  of  the  button  or  other  disk-like  object  with 
a  sharp  point.  If  withdrawn  with  a  plain  forceps  applied  as  at  A,  the  point,  B,  will  rip  open 
the  esophageal  wall.  If  grasped  at  C ,  the  point,  D,  will  rotate  in  the  direction  of  F  and  will 
trail  harmlessly  behind.     To  permit  rotation,  the  author's  rotation  forceps  are  used  as  at  U. 

mountable  obstruction.  This  is  the  constriction  made  in  the  esophagus  by  the 
contraction  of  the  diaphragmatic  musculature.  To  overcome  this,  moderate 
but  continuous  pressure  in  the  right  place  is  necessary.  The  proper  place  is  a 
rosette-like  sUt  to  be  found  by  aiming  the  tube  in  the  direction  of  the  left  an- 
terior superior  spine  of  the  ileum.  As  soon  as  the  hiatus  yields  the  tube-mouth 
traverses  the  abdominal  esophagus  (about  3  cm.  in  length  in  the  adult)  so 
quickly  that  the  tube  seems  at  once  to  enter  the  stomach.  So  deceptive  is 
this   that   until   demonstrated   by   the  author,   esophagoscopists  mistook  the 


Chevalier  Jackson's  Direct  J.aryngoscopy,  Bronchoscopy,  etc.      loii 


Fig.  650. — Foreign  bodies  removed  from  the  esophagus  by  peroral  esophagoscopj'  without 

anesthesia  and  without  mortalit)^ 


lOI  2 


Surgery  of  the-  Rcsi)iratory  Organs 


hiatal  constriction  for  the  cardia.  The  so-called  "  cardiospasm "  is  really  an 
exaggeration  of  the  normal  spasmodic  contraction,  not  at  or  of  the  cardia 
but  of  the  diaphragmatic  musculature  at  the  hiatus  esophageus.  Throughout 
an  esophagoscopy  the  aspirator,  I,  F,  K,  Fig.  627,  is  kept  going  by  a  nurse 
This  is  efficient  with  the  usually  thin  secretions  encountered.  Sponges  on 
carriers  as  described  under  bronchoscopy  arc  used  as  adjuncts. 

Esophagoscopy  and  Gastroscopy  for  Surgical  Diagnosis. — The  ease  and 
certainty  with  which  diagnoses  can  be  made  in  a  few  minutes  without  anes- 
thesia and  without  pain  in  cases  of  esophageal  disease,  have  resulted  from 
development  of  a  perfected  technic.     Endo-esophageal  lues,  tuberculosis  and 


Fig.  651. — Safety  pin,  open  and  point  upward,  in  the  esophagus  of  a  child,  aged   eleven 
months.     Removed  by  peroral  esophagoscopy. 

malignancy  are  readily  diagnosticated  by  clinical  appearances  and  by  the 
taking  of  specimens  for  biopsy.  With  the  forceps,  E,  Fig.  627,  a  specimen  of 
tissue  is  ver}^  readily  taken,  and  it  is  safe  to  do  so  in  case  of  fungating,  ulcerating 
or  projecting  growths,  or  any  process  involving  the  esophageal  wall  itself.  In 
the  case  of  peri-esophageal  growths  compressing  the  esophagus,  and  covered 
with  normal  mucosa,  it  doubtless  involves  risks  and  may  prove  disappointing 
because  the  disease  lies  beyond  reach  and  the  specimen  will  include  only  the 
interveni.ig  normal  covering.  Growths  in  the  left  half  of  the  stomach  can  be 
found  w'th  the  esophagoscope,  and  specimens  taken,  constituting  gastroscopy; 
but  doubtless  this  procedure  will  be  most  frequently  of  use  in  cases  that  refuse 
exploratory  operation.  In  cases  of  pulsion  diverticulum  the  diagnosis  is  made 
by  the  discovery  of  a  blind  pouch  which  seems  like  a  continuation  of  the 
pharynx,  and  m  the  upper  anterior  part  of  which  the  opening  into  the  sub- 
diverticular  esof  hagus  is  found. 


Chevalier  Jackson's  Direct  Larynj^oscopy,  Bronchoscop}',  etc.       roi3 

Cicatricial  slenosis  of  the  esophagus  is  treated  with  all  the  safety  afforded  by 
ocular  inspection.  The  filiform  bougies  (Fig.  646)  in  increasing  sizes  are  in- 
serted into  the  lumen  of  the  stricture  under  guidance  of  the  eye. 

Esophagoscopy  for  foreign  bodies  has  reached  such  a  high  state  of  develop- 
ment that  the  exceedingly  dangerous  blind  methods  with  bougie,  probang, 
Graefe's  basket,  Bond's  forceps  and  the  like  are  relegated  to  districts  remote 
from  medical  centers.  It  usually  requires  but  a  few  minutes  without  anesthesia 
and  without  pain  or  serious  risk  to  remove  a  foreign  body  by  esophagoscopy 
in  practiced  hands.  Any  foreign  body  that  has  gone  down  the  natural  passages 
can  be  brought  back  the  same  way,  provided  it  be  turned  so  as  to  present  the 


Fig.  652. — Pin  button  in  the  esophagus  of  a  child,  aged  two  and  one-half  months.     Turned 
and  removed  by  peroral  esophagoscopy  in  two  minutes  without  anesthesia,  general  or  local. 


same  way  relatively  to  the  upward  direction  that  it  previously  presented  rela- 
tively to  its  downward  course.  This  can  be  done  by  an  experienced  esophagos- 
copist  in  probably  every  case.  Foreign  bodies  without  points  or  projections 
may  be  seized  and  withdrawn  with  the  forceps,  D,  Fig.  627.  If  the  foreign 
body  is  too  large  to  come  through  the  tube,  as  is  usually  the  case,  the  forceps 
holds  the  foreign  body  close  up  against  the  distal  tube-mouth  while  forceps, 
foreign  body  and  esophagoscope  are  all  withdrawn  together. 

In  cases  of  pointed  objects,  such  as  safety-pins  lodged  point  upward,  if 
the  intruder  be  grasped  and  pulled  upon  by  the  presenting  part,  the  point  or 
points  will  catch,  the  intruder  will  become  transfixed  and  cannot  be  removed 
at  all,  or  fatal  trauma  will  be  inflicted.  A  radiograph  should  be  taken  and  the 
position  of  the  intruder  should  be  studied  esophagoscopically  and  a  safe  method 
of  seizure,  and  version  if  necessary,  be  devised  before  any  traction  is  made. 
Too  much  emphasis  cannot  be  placed  upon  the  necessity  of  care  in  esophagoscopy 
for  foreign  bodies.  Various  methods  of  working  out  mechanical  problems 
are  shown  in  Figs.  647,  648,  and  649.     In  cases  of  bones,  which  are  ver>'  fre- 


1014  Surgery  of  the  Respiratory  Organs 

quent  intruders,  the  foreign  body  should  be  manipulated  so  as  to  bring  its 
greatest  diameter  into  the  long  axis  of  the  esophagus.  The  next-to-the  greatest 
diameter  must  be  transverse  to  get  the  intruder  past  the  cricoid  cartilage. 

Diseases  and  Injuries  of  the  Chest,  Pleura,  and  Lungs 

Traumatic  Asphyxia  {Pressure  Stasis;  The  Ecchymotic  Mask). — This 
is  a  condition  that  occasionally  arises  when  the  trunk  is  subject  to  sudden 
and  violent  compression  (caught  under  an  elevator,  caught  under  a  heavy 
box,  cave  in  of  earth,  crushed  in  the  rush  of  a  panic,  etc.).  The  compression 
may  be  upon  the  chest,  the  abdomen,  or  both;  and  in  the  majority  of  cases  it  has 
been  very  temporary.  The  discoloration  arises  immediately,  and  is  mani- 
fested over  the  head  and  neck  down  to  and  sometimes  below  the  clavicle.  The 
hue  is  a  violet  lividity.  There  are  a  great  many  spots  in  the  skin  in  which  the 
color  is  much  deeper,  which  have  been  supposed  to  be  hemorrhages,  and  similar 
spots  exist  on  the  labial,  buccal,  glossal,  palatine,  and  pharyngeal  mucous  mem- 
branes. Subconjunctival  hemorrhage  is  the  rule.  There  may  be  bleeding  from 
the  nose,  mouth,  and  ears.  There  is  brief  or  prolonged  unconsciousness,  circula- 
tory and  respiratory  depression,  sometimes  cough  and  bleeding  from  the  lungs. 
There  has  never  been  a  reported  instance  of  intracerebral  hemorrhage.  There 
are  (rarely)  convulsions,  there  is  no  paralysis  and  no  delirium.  The  lividity 
may  clear  up  in  a  few  hours.  The  spots  seldom  fade  for  days.  The  spots  do 
not  fade  at,  all  from  pressure,  the  livid  area  fades  but  shghtly. 

If  death  occurs,  it  results  from  associated  injuries.  The  condition  in  the 
cases  without  severe  associated  injuries  has  soon  disappeared,  and  entire  re- 
covery has  followed.  The  view  generally  taught  is  that  traumatic  asphyxia 
is  the  result  of  compression  of  the  abdominal  veins,  causing  distention  of  the 
superior  cava  and  its  tributary  veins,  this  region  of  the  body  showing  the  effect 
more  than  the  limbs,  because  of  the  comparative  feebleness  of  the  valves 
(Villemin).  The  blood  is  forced  back  along  the  veins  and  into  the  capillaries, 
and  capillary  paresis  ensues.  One  thing  is  sure,  and  that  is,  that  the  condition 
is  particularly  apt  to  arise  if  the  patient  struggles  violently  to  free  himself 
from  the  compression;  and  many  observers  have  held  the  opinion  that  actual 
vascular  ruptures  take  place.  There  are  certainly  some  cases,  however,  in 
which  there  is  simply  great  venous  and  capillary  distention  in  the  skin  without 
rupture,  because  pieces  of  skin  have  been  excised  and  microscopical  examination 
has  indicated  that  there  had  been  no  blood  effused.  The  selection  of  the  face 
and  neck  as  the  regions  of  discoloration  is  due,  perhaps,  to  absence  or  incom- 
petence of  valves  in  the  jugular  and  facial  veins.  The  fluid  state  of  the  blood 
which  has  been  noted  occurs  in  all  forms  of  asphyxia.  (See  Winslow,  ''Medical 
News,"  Feb.  4,  1906;  Birge,  "Cleveland  Medical  Journal,"  Sept.,  1905;  Beach 
and  Cobb,  in  "Annals  of  Surgery,"  April,  1904;  Villemin,  "Bull,  et  mem.  de 
la  Soc.  Chir.  de  Paris,"  No.  9,  1906.)  Despard  ("Annals  of  Surgery,"  June, 
1909)  has  reported  i  case  and  collected  17  from  recent  literature.  Ettinger  in 
1907  collected  36  cases  and  added  i  of  his  own  ("  Wein.  klin.  Wochen.,"  1907, 
vol.  xx).     I  have  seen  2  cases. 

Pleuritic  effusion  may  arise  from  the  lodgment  of  foreign  bodies,  from 
injury  by  fragments  of  a  broken  rib,  from  tumors,  and  from  inflammation  of  the 
lung,  but  most  usually  is  due  to  pleuritis.  The  commonest  cause  of  primary 
pleuritis  is  tuberculosis.  Inflammatory  effusion  is  nearly  always  unilateral 
(except  in  tuberculous  pleuritis;  but  even  in  this  form  it  is  often  one-sided 
in  origin). 

The  signs  of  pleuritic  effusion  are:  dulness  on  percussion  over  the  area  of 
effusion,  this  dulness,  when  the  patient  is  erect,  being  at  the  lower  part  of  the 
chest  and  ascending  higher  posteriorly  than  anteriorly  (alternation  of  position 
alters  che  situation  of  the  dulness);  the  intercostal  spaces  are  widened,  the 
intercostal  depressions  are  obliterated,  the  intercostal  muscles  are  rigid,  and 


Empyema  1015 

their  rigidity  lessens  the  mobility  of  the  ribs  (Prze walski) ,  No  breath-sounds 
can  be  detected  in  the  area  of  percussion  llatness  when  the  collection  of  fluid 
is  large,  but  in  small  effusions  deeply  situated  the  breath-sounds  are  often 
audible;  the  percussion-note  above  the  liquid  is  hyperresonant  or  tympanitic, 
and  is  often  associated,  at  the  edge  of  the  liquid,  with  a  friction-sound;  pos- 
teriorly, high  up  and  near  the  spine,  there  are  bronchial  respiration  and  bron- 
chophony. In  cases  of  pleurisy  with  effusion  pain  almost  or  quite  disappears 
with  the  advent  of  effusion,  dyspnea  comes  on,  and  the  patient  lies  upon  the 
diseased  side.  Cough  always  exists  if  there  is  pleuritic  effusion,  and  fever  is 
usually  present.  In  serous  effusions  the  diagnosis  may  be  confirmed  by  the 
aseptic  introduction  of  a  clean  aspirating-needle.  Ramond  has  pointed  out 
that  in  serofibrinous  pleurisy  the  iliocostal  and  longissimus  dorsi  muscles  are 
always  noticeably  enlarged  on  the  side  of  the  effusion  (''Bull,  de  la  Soc.  Med. 
des  hop.,"  1910,  vol.  xxvii). 

The  treatment  in  this  stage  is  to  discontinue  arterial  sedatives  and  to 
stimulate  if  the  circulation  calls  for  it.  The  exudation  may  be  removed  by 
the  administration  of  salines,  compound  jalap  powder,  or  elaterium.  If  these 
means  fail,  if  the  effusion  is  excessive,  or  if  it  is  producing  severe  dyspnea,  at 
once  aspirate.  Aspiration  should  be  performed  for  an  effusion  which  fills  the 
whole  chest,  which  produces  great  dyspnea,  or  which  has  lasted  for  three  weeks. 
In  tuberculous  pleuritis  early  aspiration  is  not  advisable,  but  aspiration  should 
be  performed  if  the  fluid  becomes  purulent,  if  the  effusion  displaces  the  heart 
considerably,  and  if  it  adds  notably  to  the  dyspnea.  If  a  non-tuberculous 
effusion  becomes  purulent,  the  proper  procedure  is  incision,  resection  of  a 
portion  of  a  rib,  and  drainage. 

Empyema  is  a  coUection  of  pus  in  the  pleural  cavity  displacing  and  com- 
pressing the  lung.  It  may  begin  suddenly,  but  rarely  does  so.  Among  the 
causes  of  empyema  are  those  of  serious  effusion.  Empyema  is  due  to  infection 
of  the  pleura,  and  in  every  case  a  bacteriological  study  should  be  made  of  the 
exudate  to  discover  the  causative  bacterium.  The  pneumococcus,  the  strep- 
tococcus, the  staphylococcus,  the  bacillus  of  influenza,  or  the  colon  bacillus 
or  the  typhoid  bacillus  may  be  found.  The  pneumococcus  is  the  causative 
micro-organism  in  many  of  the  cases  which  follow  pneumonia.  There  may  be 
mixed  infection  of  pneumococci  and  streptococci,  or  other  mixed  infection. 
Pneumococci  live  but  a  short  time,  and  in  empyema  due  to  pneumococci  these 
micro-organisms  may  not  be  discoverable  when  the  pus  is  evacuated,  only 
streptococci  or  staphylococci  being  found.  These  micro-organisms  may  appear 
in  an  empyema  induced  originally  by  pneumococci  (Stephen  Paget).  In 
empyema  developing  during  or  after  typhoid  fever  typhoid  bacilli  may  be  dis- 
covered. In  putrid  empyema  various  bacteria  are  found.  Bouchard  thinks 
acute  empyema  has  a  special  organism.  Bacilli  of  tuberculosis  are  present 
for  a  time  a  least  in  tuberculous  empyema,  but  may  disappear,  and  are  par- 
ticularly apt  to  after  mixed  infection  with  pyogenic  bacteria.  In  adults  many 
cases,  in  children  few  cases,  are  secondary  to  tuberculosis.  In  empyema 
blood  cultures  are  usually  sterile  unless  taken  from  the  moribund.  If  an  organ- 
ism is  found  it  is  usually  a  hemolytic  streptococcus  though  occasionally  pneu- 
mococci are  demonstrated.  Empyema  may  be  due  to  a  wound  or  contusion, 
an  attack  of  pneumonia,  bronchopneumonia,  bronchitis,  tonsillitis,  pharyngitis, 
tuberculous  pleuritis,  phthisis,  influenza,  pyogenic  infection  of  a  serous  efi'usion, 
caries  of  a  rib,  specific  fevers,  especially  measles,  typhoid,  peritonitis,  abscess 
of  the  liver,  suppurating  hydatid  cyst  of  the  liver,  subphrenic  abscess,  malig- 
nant disease  of  the  pleura,  gangrene  of  the  lung,  and  pneumothorax.  Pneu- 
monia is  the  common  cause  in  children.  In  them  we  find  streptococci  in 
only  15  per  cent,  of  the  cases  and  sterile  fluid  in  20  per  cent.  In  65  per  cent, 
of  the  cases  we  find  pneumococci.  In  adults  the  pus  is  often  thin  and  very 
putrid.     In   children  the  pus  is  nearly  always  thick.     Pneumococcic  pus  is. 


ioi6  Surgery  of  the  Respiratory  Organs 

fairly  thick,  contains  some  clots,  and  is  white  or  greenish  white.  In  our  mili- 
tary camps  during  the  winter  of  191 7-18,  almost  20  per  cent,  of  pneumonia 
victims  developed  empyema.  (See  the  study  of  various  reports  by  Evarts 
A.  Graham,  M,  R.  C,  from  the  office  of  the  Surgeon  General,  U.  S.  A.) 

Acute  Empyema. — The  physical  signs  are,  in  reality,  those  of  pleuritis  with 
effusion — viz.,  dulness  on  percussion,  absent  breath-sounds  over  the  purulent 
matter,  bulging  of  the  intercostal  spaces,  and  sometimes  edema  of  the  skin  of 
the  chest.  The  intercostal  muscles  are  rigid.  The  effusion  may  be  large 
and  in  some  case  it  forms  very  quickly.  It  may  be  thick  or  thin.  In  some 
cases  there  is  very  little  effusion  and  adhesions  form.  In  such  cases  thick  pus 
is  liable  to  pocket.  The  symptoms  of  acute  empyema  are  pain,  dyspnea,  pallor, 
cough,  sweats,  chills,  and  usually  irregular  fever,  but  fever  may  be  absent. 
There  is  marked  leukocytosis.  The  fingers  may  become  clubbed.  Pericarditis, 
endocarditis,  peritonitis,  synovitis,  or  empyema  of  the  other  side  may  arise. 
Streptococcic  empyema  is  an  acute,  violent  and  very  fatal  malady  in  which  there 
are  evidences  of  grave  systemic  infection  and  in  which  there  is  a  strong  tendency 
to  involvement  of  other  serous  membranes  (the  other  pleura,  the  pericardium, 
the  synovial  membranes,  the  peritoneum,  the  endocardium).  Many  cases 
begin  with  a  chill  and  in  twenty-four  to  forty-eight  hours  the  pleural  sac  con- 
tains a  very  large  effusion.  The  eft'usion  swarms  with  streptococci  which  can 
usually  be  demonstrated  by  smears.  Sometimes  blood  cultures  are  positive. 
The  effusion  is  usually  serofibrinous  and  devoid  of  odor.  There  is  a  decided 
tendency  to  the  development  of  peritonitis  and  other  dangerous  complications. 

Streptococcic  empyema  may  arise  after  pneumonia,  bronchopneumonia, 
tonsillitis,  or  pharyngitis.  A  peculiarly  fatal  form  is  seen  after  measles.  Strep- 
tococci may  attack  the  pleura  even  when  the  lung  is  free,  the  empyema  being 
primary.  If  thick  pus  forms  it  is  apt  to  be  pocketed  between  the  lobes  or  between 
the  upper  lobe  and  pericardium  back  of  the  sternum.  If  peritonitis  arises 
adhesions  form  and  pus  gathers  in  pockets.  An  empyema  may  pulsate, 
particularly  an  empyema  of  the  left  side.  The  cause  of  pulsating  empyema 
has  been  much  debated.  The  most  probable  explanation  is  that  of  W.  J. 
Calvert  ("Am.  Jour.  Med.  Sciences,"  Nov.,  1905).  He  says  the  requirements 
for  such  a  condition  are:  "A  firmly  fixed,  pulsating  organ;  distention  of  the 
pleural  sac  with  fluid  or  air  or  solid  material;  and  a  collapsed  condition  of  the 
lung."  In  all  probabiHty  the  thoracic  aorta  is  the  "fixed  pulsating  organ." 
The  left  parietal  pleura  is  in  close  relation  with  the  aorta,  and  most  pulsating 
empyemas  are  left  sided.  The  right  parietal  pleural  may  be  "pushed  against 
the  aorta."  If  a  lung  contains  air,  it  is  elastic  and  compressible  to  a  degree 
that  enables  it  to  absorb  the  aortic  impulse;  if  it  is  collapsed  and  solid  it  cannot, 
and  aortic  pulsations  are  transmitted  to  fluid  in  the  pleural  cavity  and  the  thoracic 
wall  pulsates.  A  neglected  empyema  may  break  into  the  lung,  esophagus,  or 
pericardium,  through  an  intercostal  space,  or  may  point  in  the  lumbar  region. 
When  an  empyema  is  pointing  externally,  the  condition  is  called  empyema 
necessitatus.  A  total  empyema  is  a  condition  involving  the  entire  pleural  sac. 
In  a  partial  or  localized  empyema  the  purulent  matter  is  encapsulated.  A 
closed  empyema  is  one  in  which  no  opening  has  been  made  by  the  surgeon 
and  no  opening  has  formed  spontaneously.  In  a  closed  empyema  the  pus 
is  rarely  putrid;  in  an  open  empyema  the  pus  is  often  putrid.  After  an  empy- 
ema ruptures  spontaneously  it  rarely  heals  without  surgical  interference,  a 
pleural  fistula,  as  a  rule,  persisting.  A  subphrenic  abscess  may  follow  an  em- 
pyema. When  an  empyema  ruptures  into  a  bronchus,  pneumothorax  arises, 
as  a  rule.  Empyema  may  cause  death  by  compression  of  the  heart  and  lung, 
pulmonary  embolism,  pericarditis,  peritonitis,  cerebral  embolism,  cerebral 
abscess,  septicemia,  exhaustion,  or  rupture  into  a  bronchus.  Empyema  is  par- 
ticularly fatal  in  childhood.  In  empyema  of  the  early  months  of  life  nearly  all 
the  victims  die.     In  those  under  one  year  of  age  50  per  cent,  of  the  affected  will 


Treatment  of  Empyema  1017 

die  (Holt).  In  older  children  30  per  cent.  die.  In  civil  practice  the  mor- 
tality of  pneumonic  emp}ema  is  from  12  to  20  per  cent.  The  mortality  of  strepto- 
coccic empyema  is  much  higher.  In  our  military  camps  the  average  mortality 
has  been  over  30  per  cent.  In  one  camp  it  was  over  53  per  cent.  In  another 
it  was  over  84  per  cent.  Streptococcic  empyema  is  far  more  fatal  than  pneu- 
mococcic  empyema.  Empyema  following  measles  or  the  pneumonia  or  bron- 
chopneumonia of  measles  has  a  dreadful  mortality  (Graham,  Ibid.). 

A  small  empyema  due  to  pneumococci  occasionally,  though  very  rarely, 
undergoes  spontaneous  cure,  the  pus  being  absorbed  (Stephen  Paget). 

A  small  empyema  is  occasionally  cured  by  encapsulation  by  fibrous  tissue. 

Under  exceptional  circumstances  even  a  large  empyema  may  be  cured  by 
breaking  externally  or  into  a  bronchus. 

Empyema  is  so  rarely  cured  spontaneously  that  it  does  not  do  to  trust  to 
Nature  at  all,  and  practically  almost  all  cases  die  without  surgical  treatment. 

Double  empyema  is  an  extremely  fatal  condition.  In  civil  practice  I  have 
seldom  seen  it.  In  our  military  camps  8.7  per  cent,  of  the  cases  of  empyema 
have  been  bilateral  (Graham,  Ibid.).  Exploratory  puncture  is  of  great  value 
in  diagnosis.  If  there  is  massive  fibrinous  deposit  it  may  lead  to  a  dry  tap 
below  and  a  tap  higher  up  may  obtain  fluid.  If  a  needle  is  caught  in  an  ad- 
hesion there  will  be  a  dry  tap.  So  there  may  be  in  a  case  with  pocketed  pus. 
Any  matter  obtained  should  be  studied  bacteriologically.  The  .T-rays  are  of 
decided  value  in  diagnosis. 

Chronic  empyema  may  follow  acute  empyema,  or  the  condition  may  be 
chronic  from  the  beginning.  It  is  more  common  in  adults  than  in  children. 
In  chronic  empyema  the  lung  is  compressed,  shrunken,  does  not  expand  and  is 
strongly  adherent,  and  the  pleura  is  very  thick.  In  some  cases  the  pleura  is 
over  an  inch  thick.  This  thickening  is  brought  about  by  the  deposition  of 
layer  after  layer  of  fibrin.  In  not  a  few  cases  a  chronic  empyema  succeeds  an 
acute  one.  Sometimes  chronic  empyema  is  maintained  because  a  drainage- 
tube  has  slipped  into  the  pleural  cavity  and  remains  lodged. 

Treatment  of  Empyema. — The  treatment  is  purely  surgical,  and  the  ear- 
lier it  is  applied  the  better.  To  delay  allows  the  pleura  to  thicken  and  per- 
mits adhesions  to  form,  conditions  which  prevent  lung  expansion  and  retard  or 
even  prevent  cure.  The  results  of  operation  for  chronic  empyema  are  better  in 
children  that  are  not  very  young  than  in  adults.  In  acute  empyema  the  prog- 
nosis is  better  in  small  collections  than  in  large;  in  recent  than  in  advanced  cases; 
in  pneumococcus  empyema  than  in  empyema  due  to  other  organisms.  The  sur- 
gical methods  for  various  stages  of  empyema  comprise  aspiration,  incision,  rib- 
resection,  the  operation  of  Schede,  the  operation  of  Estlander,  and  the  operation 
of  Fowler  (see  pages  1036  to  1040  inclusive). 

I  do  not  believe  in  any  of  the  appliances  to  drain  with  a  small  tube  and  main- 
tain negative  pressure  in  the  chest  to  favor  lung  expansion.  The  Thiersch 
method  consists  in  introducing  a  trocar  into  the  cavity,  passing  a  Nelaton 
catheter  through  the  trocar,  and  removing  the  trocar.  The  external  end  of  the 
catheter  is  attached  to  an  easily  collapsible  rubber  tube,  the  other  end  of  which 
is  in  a  bottle  of  water.  The  catheter  is  fixed  to  the  side  by  rubber  tissue  and 
rubber  plaster.  "The  theory  is,  that  when  the  patient  expires,  the  pus  runs 
out  through  the  tube,  and  on  inspiration  the  collapsible  walls  of  the  tube  are 
sucked  together  and  prevent  the  entrance  of  air,  and  cause  negative  pressure 
in  the  chest,  favoring  expansion  of  the  lung"  (Lund,  "Jour.  Am.  Med.  Assoc," 
August  26,  191 1).  In  any  method  of  suction  so  far  devised  the  tube  is  so  small 
that  it  blocks  up,  and  though  the  drainage-tube  may  at  first  make  an  air-tight 
joint  with  the  chest,  it  always  loosens  sooner  or  later  and  leaks  air. 

In  acute  empyema  general  practitioners  are  very  apt  to  aspirate,  and  yet 
aspiration  is  almost  never  curative.  It  may  cure  a  pneumococcus  empyem.a 
in  a  child  and  an  encysted  empyema,  but  even  in  these  it  will  usually  fail. 


ioi8  Surgery  of  the  Respiratory  Organs 

Aspiration  is  not  to  be  considered  a  method  of  curative  treatment.  It  is  to  be 
regarded  as  the  surgical  treatment  only  in  a  tuberculous  empyema  in  a  young 
person  with  rapidly  progressing  phthisis,  because  in  such  a  case  incision  will 
probably  prove  fatal  (Lockwood).  It  is  a  very  useful  diagnostic  expedient, 
and  enables  the  surgeon  to  prove  the  existence  of  pus,  and  the  pus  which  is 
obtained  can  be  examined  bacteriologically.  In  a  verylarge  effusion  it  is  wise 
to  aspirate  and  withdraw  part  of  the  effusion  a  short  time  before  operating. 
This  enables  the  patient  to  take  an  anesthetic  with  greater  safety  and  obvi- 
ates the  danger  attending  the  rapid  evacuation  of  a  large  amount  of  pus. 

In  a  recent  empyema,  incision  and  drainage  or  rib  resection  and  drainage 
will  often  cure  the  case,  and  yet  many  of  the  results  are  unsatisfactory.  In 
some  cases  the  discharge  ceases  and  yet  pulmonary  function  is  not  completely 
restored.  In  other  cases  a  pleural  fistula  persists.  If  a  profuse  discharge  is 
maintained,  amyloid  disease  may  arise.  An  acute  empyema  is  to  be  drained  by 
intercostal  incision  or  by  resection  of  a  rib  (see  page  1036).  Of  late  I  have  tried 
washing  out  empyemata  with  Dakin's  fluid.  The  irrigation  is  practised  every 
two  hours.  It  lessens  putridity  but  does  not  seem  to  me  to  shorten  the  dura- 
tion of  the  case  notably.  The  same  may  be  said  of  Dakin's  oil.  Occasionally  a 
convulsive  seizure  known  as  pleuritic  epilepsy  occurs  (page  1037).  Dr.  Toland, 
U.  S.  N.  R.  F.,  had  four  cases  of  pleuritic  epilepsy  following  irrigation  with  Dakin's 
fluid,  but  no  fatality.  A  chronic  closed  empyema  is  drained  in  the  same  manner 
as  an  acute  empyema,  and  if  the  lung  will  not  fully  expand  and  remains  sta- 
tionary for  one  year,  Schede's  or  Estlander's  operation  is  required.  An  open 
chronic  empyema,  in  which  the  lung  will  not  expand,  requires  the  operation  of 
Schede,  Estlander  or  Fowler  (see  pages  1038  and  1039).  The  results  of  operation 
for  acute  or  chronic  are  best  in  children  almost  in  the  teens.  Extensive  decorti- 
cation is  sometimes  impossible,  and  then  Ransohoff's  operation  may  be  done. 
He  calls  it  discission  of  the  pulmonary  pleura  (see  page  1040).  When  there  is 
an  external  opening  which  persists  and  which  joins  a  long,  narrow  cavity,  the 
condition  is  spoken  of  as  pleural  fistula,  and  pleural  fistula  is  often  produced  by 
the  prolonged  use  of  a  drainage-tube  and  sometimes  by  caries  of  a  rib.  Even  if 
there  is  no  opening  on  the  cutaneous  surface,  there  may  be  one  into  a  bronchus. 
A  pleural  fistula  may  sometimes  be  cured  by  dilatation  of  the  sinus.  If  this 
fails,  and  it  usually  does,  it  is  the  custom  to  resect  one  or  more  ribs. 

Before  resorting  to  operative  treatment  in  chronic  empyema  we  may  try,  in 
some  open  cases  at  least,  the  injection  of  bismuth  paste.  We  owe  this  method 
to  Dr.  Emil  Beck.  This  plan  will  sometimes  succeed.  Ochsner  has  strongly 
commended  it  ("Annals  of  Surgery,"  July,  1909).  The  injection  is  made  by 
a  glass  syringe  and  the  material  should  fill  but  not  stretch  the  cavity.  After 
injecting  the  paste  the  external  opening  of  the  fistula  is  plugged  with  gauze. 
The  treatment  is  begun  with  solution  No.  1(1  part  of  subnitrate  of  bismuth 
devoid  of  arsenic  and  2  parts  of  yellow  vaselin). 

This  is  used  every  second  day  until  pus  has  practically  disappeared.  Then 
solution  No.  2  (30  parts  of  bismuth,  60  parts  of  yellow  vaselin,  and  10  parts 
of  parafl&n)  is  substituted  for  it.  The  injections  are  made  often  enough  to 
keep  the  sinus  and  pocket  full.  They  are  made  at  first  every  day,  then  every 
other  day,  and  so  on  until,  finally,  every  eighth  or  tenth  day  is  often  enough. 
If  poisoning  should  arise  from  these  injections  Beck  advises  the  injection  of  olive 
oil  at  a  temperature  of  110°  F.  to  dissolve  the  paste  and  favor  its  evacuation. 
McKelvey  Bell  recommends  a  paste  which  is  more  stimulating  than  Beck's. 
He  takes  i  oz.  of  subnitrate  of  bismuth  and  2  oz.  of  white  petrolatum,  dissolves 
over  a  hot-water  bath,  and  stirs  until  cool.  Then,  while  stirring,  he  adds  72  gr. 
of  iodoform  (5  per  cent.).  This  must  be  kept  in  a  dark  place  to  prevent  decom- 
position of  the  iodoform  ("New  York  Med.  Jour.,"  May  4,  191 2).  (See  page 
708.) 

Treatment  of  Empyema  in  Army  Camps  (From  report  by  Graham,  Ibid.). — 
Empyema  has  been  very  common  in  our  training  camps..    The  Surgeon  General 


Non- traumatic  Pneumothorax  1019 

of  the  Army  directed  a  thorough  study  of  it.  Various  plans  of  treatment  have 
been  tried  and  the  greatest  differences  of  opinion  are  manifest.  The  high  mortality 
shows  that  treatment,  on  the  whole,  has  not  been  satisfactory.  The  reason  is 
that  no  treatment  has  been  devised  to  combat  the  multiple  lesions  of  strepto- 
coccic empyema,  such  an  empyema  being  often  but  part  of  a  generalized  trouble 
(Graham,  Ibid.).  Some  surgeons  maintain  that  early  repeated  aspirations  are 
better  than  immediate  operation.  Some  operate  at  once  unless  the  pneumo- 
nia is  still  active-.  Some  surgeons  will  not  operate  while  the  fluid  is  thin  and 
serofibrinous  preferring  to  wait  until  it  is  distinctly  purulent.  Some  drain 
as  soon  as  the  diagnosis  is  made.  Most  surgeons  operate  by  rib  resection. 
Some  make  intercostal  drainage.  Most  operations  have  been  done  with  the 
aid  of  a  local  anesthetic. 

Some  have  used  antistreptococcic  serum.  If  given  in  considerable  doses 
intravenously  it  may  be  of  service. 

In  only  one  camp  was  postoperative  negative  pressure  used  at  all  exten- 
sively. The  surgeons  of  that  camp  praise  it.  Other  surgeons  abandoned  it 
because  it  caused  pain  and  bleeding. 

In  several  camps  blowing  bottles  meet  with  approval.  In  a  number  of 
camps  irrigation  has  not  been  employed.  Some  have  used  Dakin's  fluid, 
some  dichloramin-T,  others  2  per  cent,  formalin  and  glycerin,  others  tincture 
of  iodin,  others  normal  salt  solution,  others  peroxid  of  hydrogen,  others  boric 
acid.  A  number  of  surgeons  fail  to  approve  of  Dakin's  fluid  and  claim  that  it 
brings  no  benefit  except  the  diminution  of  the  odor  of  the  pus.  Some  surgeons 
recommend  it  strongly. 

Non=traumatic  Pneumothorax. — By  the  term  "pneumothorax"  is  meant 
the  presence  of  air  in  the  pleural  cavity.  As  a  rule,  besides  air  there  is  serous 
fluid  or  pus.  It  may  be  due  to  the  rupture  of  an  empyema  into  a  bronchus; 
to  the  rupture  into  the  pleural  sac  of  a  tuberculous  area,  an  area  of  gangrene, 
an  abscess  of  the  lung,  an  air-cell  in  a  state  of  emphysema,  or  of  pulmonary 
tissue  softened  because  of  hemorrhagic  infarction.  The  condition  is  by  no 
means  uncommon  in  phthisis.  In  473  autopsies  held  in  the  Henry  Phipps 
Institute  of  Philadelphia  upon  persons  dying  of  pulmonary  tuberculosis  there 
were  41  cases  of  pneumothorax,  or  in  8.6  per  cent,  of  the  autopsies  this  lesion 
was  found  (J.  M.  Cruice,  "Med.  Record,"  Sept.  23,  191 1).  In  60  per  cent,  of 
the  cases  the  lesion  is  on  the  left  side.  It  is  inaugurated  by  cough,  straining 
at  stool,  vomiting,  or  lifting.  It  is  more  frequent  in  men  than  in  women  and 
is  most  common  between  the  ages  of  thirty  and  forty.  The  immediate  effect  of 
the  entrance  of  air  into  the  pleural  sac  is  to  compress  the  lung,  the  degree  of 
compression  being  in  proportion  to  the  amount  of  air  present.  In  severe  cases 
the  lung  is  squeezed  against  the  vertebral  column,  and  the  heart  and  diaphragm 
are  displaced.  In  a  right-sided  case  the  liver  may  be  displaced.  In  some  cases, 
when  the  admission  of  air  does  not  continue,  the  amount  set  free  in  the  pleural 
sac  is  absorbed.     In  most  cases  pyopneumothorax  (empyema)  follows. 

The  symptoms  usually  arise  suddenly  (in  three-fourths  of  the  cases),  and 
consist  of  distressing  dyspnea,  pain  in  the  chest,  lividity,  and  rapidity  and 
weakness  of  the  pulse.  In  some  cases  of  phthisis  the  symptoms  are  gradual 
and  not  very  severe.  There  may  be  pain  and  dyspnea  or  only  dyspnea.  In 
the  latter  case,  if  dyspnea  existed  before,  the  accident  may  be  unrecognized. 
It  has  been  pointed  out  that  occasionally  in  phthisis  pneumothorax  seems 
actually  to  benefit  the  tuberculous  area  in  the  lung.  There  is  nothing  charac- 
teristic in  the  attitude.  The  patient  usually  lies  on  the  opposite  side,  but  may 
he  on  the  side  of  the  trouble  or  on  the  back.  He  may  sit  erect  or  semi-erect. 
He  may  place  himself  in  a  knee-chest  position.  The  physical  signs  of  pneu- 
mothorax are  as  follows:  The  affected  side  of  the  chest  is  often  bulged,  move- 
ments are  lessened  or  absent,  and  the  heart  is  displaced,  especially  if  the  con- 
dition affects  the  left  side.  Palpation  discoA^ers  that  vocal  fremitus  is  lessened 
or  absent.     On  auscultation  it  is  found  that  the  breath-sounds  are  very  feeble 


I020  Surgery  of  the  Respiratory  Organs 

or  absent  in  70  per  cent,  of  cases.  Occasionally  they  are  amphoric,  bron- 
chovesicular,  or  cavernous.  The  voice  may  be  transmitted  as  a  metallic 
sound  (this  is  present  in  about  half  the  cases),  rales  may  sound  metallic,  and 
on  coughing  there  may  be  metallic  tinkling.  The  percussion-note  is  hyper- 
resonant  or  tympanitic  in  95  per  cent,  of  cases.  Very  seldom  it  is  normal.  In 
some  rare  cases  the  percussion-note  is  dull.  When  fluid  gathers,  there  is  a 
positively  dull  note  on  percussion  over  the  fluid. 

Treatment. — Osier  says  the  treatment  should  be  the  same  as  that  for  pleurisy 
with  efTusion.  In  many  cases  it  is  wise  to  perform  paracentesis  without 
suction  to  remove  air  and  serous  effusion.  If  pus  forms,  a  rib  should  be 
resected  and  a  tube  inserted  (see  Empyema).  In  pneumothorax  occurring 
during  chronic  phthisis  operation  is  of  service.  In  cases  with  rapidly  pro- 
gressive phthisis  it  is  practically  useless. 

If  the  opening  into  a  bronchus  or  air-cell  remains  patent,  aspiration  will 
not  get  rid  of  air;  the  air  will  enter  into  the  pleura  as  rapidly  as  the  aspirator 
removes  it.  Incision  has  dangers  of  its  own:  the  diaphragm  is  flapping  dur- 
ing respiration  and  may  be  injured  (Fowler),  and  when  the  pleura  is  opened 
there  is  a  great  alteration  produced  in  the  air-pressure  in  the  chest,  and  the 
patient  may  "drown  in  his  own  secretions."  After  incision  irrigation  is  not 
justifiable,  because  the  fluid  may  enter  a  bronchus  and  produce  suffocation 
(Fowler). 

West's  rules^  are  those  which  I  follow.  West  says  early  incision  is  dangerous. 
In  an  early  stage  use  paracentesis  without  suction.  This  will  often  relieve  the 
patient.  If  paracentesis  does  reKeve  him,  wait  a  while  and  perhaps  repeat  the 
operation  if  the  symptoms  again  become  severe.  If  paracentesis  does  not 
relieve,  incise,  resect  a  portion  of  a  rib,  and  drain.  If  pus  forms,  an  incision 
must  be  made  and  a  portion  of  a  rib  be  resected  to  afford  exit  to  the  fluid. 

Fowler  pointed  out  that  if  the  lung  is  bound  down  by  adhesions,  incision  is 
dangerous  but  justifiable.  Operation  at  the  proper  time  often  prevents  the 
lung  being  bound  down  by  adhesions. 

Acute  Traumatic  Pneumothorax. — This  is  produced  by  the  sudden 
admission  of  a  quantity  of  air  into  the  pleural  cavity  as  a  result  of  a  wound  of 
the  chest  wall.  A  small  quantity  of  air,  or  the  gradual  introduction  of  con- 
siderable air,  does  not,  as  a  rule,  produce  very  serious  symptoms.  The  sudden 
admission  of  a  quantity  of  air  causes  very  dangerous  symptoms  and  even 
death.  A  quantity  of  air  may  be  admitted  rather  suddenly  as  a  result  of  an 
accident  or  during  the  performance  of  a  surgical  operation  which  opens  the 
pleura.  It  sometimes  arises  during  the  removal  of  tumors  from  the  chest  wall, 
during  operations  upon  the  lung,  and  during  empyema  operations.  As  a  rule, 
when  pulmonary  adhesions  exist,  dangerous  symptoms  do  not  arise,  even  when 
the  pleura  is  widely  opened,  and  adhesions  exist  in  25  per  cent,  of  empyema 
cases  seen  by  the  surgeon. - 

It  was  formerly  taught  whenever  the  pleura  is  opened  there  is  a  stron? 
tendency  to  the  development  of  pneumothorax,  but  West  has  shown  that  the 
surfaces  of  the  pleura  often  cohere  with  a  force  superior  to  pulmonary  elas- 
ticity, and  in  such  cases  pneumothorax  does  not  arise. 

In  surgical  operations  in  which  it  is  necessary  to  open  the  pleura  widely 
(as  in  operation  for  sarcoma  of  the  chest  wall)  the  surgeon  endeavors  to  pre- 
vent acute  pneumothorax,  which  may  prove  fatal.  This  may  be  done  by 
operating  in  the  Sauerbruch  negative  pressure  chamber  (see  page  1032)  or 
by  applying  positive  pressure  (see  page  1033). 

Symptoms. — When  the  pleura  is  opened  during  an  operation  or  by  an 
injury,  the  symptoms  may  be  trivial  an'd  transitory,  may  be  tolerably  severe, 

"^  "British  Medical  Journal,"  Nov.  27,  1897. 

^  Rudolph  Matas,  "Annals  of  Surgery,"  April,  1899. 


Contusions  and  Wounds  of  the  Chest 


I02I 


may  be  extremely  grave,  and  the  patient  may  quickly  die  (Quenu  andLonguet). 
Rudolph  Matas^  sets  forth  the  symptoms  as  presented  l>y  the  French  observers. 

The  mild  symptoms  are  weak,  slow  pulse  and  irregular,  noisy  respiration. 

The  severe  symptoms  are  slow  pulse,  slow  and  irregular  respiration,  and 
dyspnea,  continuing  after  the  anesthetic  has  been  withdrawn. 

The  grave  symptoms  are  cyanosis;  collapse;  small,  weak  pulse;  shallow 
and  noisy  respiration;  and  spells  of  syncope.  Death  may  occur  suddenly 
from  inhibition,  or  later  from  mechanical  asphyxia  (Matas). 

Treatment. — Various  plans  have  been  adopted;  suturing  the  opening  in 
the  pleura;  plugging  the  opening;  pulling  the  diaphragm  into  the  wound  in  the 
chest  wall  and  suturing  it;  and  grasping  the 
lung  and  suturing  it  to  the  wound.  When- 
ever the  pleura  is  to  be  widely  opened, 
operate  in  a  Sauerbruch  chamber  or  use  a 
positive  pressure  apparatus,  and  when  the 
operation  is  complete,  suture  the  lung  to  the 
margin  of  the  opening  in  the  pleura  with  a 
continuous  catgut  suture.  The  apparatus 
for  insufflation  anesthesia  accomplishes  the 
object.  Parham,  Keen,  and  the  author  fol- 
lowed this  plan,  using  the  Fell-O'Dwyer 
emergency  apparatus,  and  the  lung  was  kept 
from  collapsing.^  This  apparatus  is  shown 
in  Fig.  653. 

O'Dwyer's  tube  is  introduced  into  the 
glottis  as  is  the  tube  in  intubation,  and  is 
attached  to  a  bellows,  the  lung  is  inflated, 
respiration  is  maintained  by  the  use  of  the 
bellows,  and  collaspe,  with  all  its  dangers,  is 
avoided.  The  modern  positive  pressure  ap- 
paratus or  the  apparatus  for  insufflation 
anesthesia  is  better  (see  page  1033).  So  is  the 
pulmotor  and  lungmotor  (see  pages  977, 979). 

Contusions  and  Wounds  of  the  Chest. 
— ^Contusions. — A  contusion  may  be  trivial 
and  limited  to  the  superficial  parts  of  the  chest 
wall;  it  may  involve  the  muscles;  it  may  be 
associated  with  fracture  of  the  ribs  or 
sternum  or  with  visceral  injury. 

Symptoms. — In  an  ordinary  contusion 
without  visceral  injury  there  are  considerable 
pain,  discoloration,  and  often  much  swelling. 


Fig.  653.— The  Fell-O'Dwyer  ap- 
paratus. This  illustration  shows  an 
early  model;  since  then  the  bellows 
has  been  improved  by  the  addition 
of  a  strong  wooden  frame,  which 
holds  it  steadily,  and  is  provided 
with  a  long  arm  that  acts  as  a  pow- 

The  patient  prefers  to  lie  upon  the  back  and    Silr'wlir.h'r leS" TmS  *o1 

the  respiration  is  abdominal.     After  a  severe    muscular  effort. 
blow  upon  the  chest  there  is  great  shock  and 

may  even  be  instant  death.  The  condition  of  shock  so  produced  is  called 
concussion  of  the  chest.  After  a  severe  blow  upon  the  chest  a  limited 
area  of  inflammation  may  arise  in  the  pleura  {traumatic  pleuritis). 
Severe  visceral  injury  is  announced  by  positive  symptoms.  A  contusion 
of  the  lung  causes  extravasation  of  blood  and  leads  to  pain,  cough,  expectora- 
tion of  bloody  mucus,  dyspnea,  and  possibly  distinct  hemophthisis.  Over 
the  contused   region  the  percussion-note  is  dull  and  on   auscultation  crepi- 

1  Rudolph  Matas,  "Annals  of  Surgery,"  April,  1899. 

^F.  W.  Parham's  paper  on  "Thoracic  Resection  for  Tumors  Growing  from  the  Bony  Walls 
of  the  Chest."     Read  before  the  Southern  Surgical  and  Gynecological  Association,  November, 


I022  Surgery  of  the  Respiratory  Organs 

tus  is  audible.  It  may  be  mistaken  for  phthisis,  but  complete  and  early  re- 
covery soon  dispels  this  fear.  Traumatic  pneumonia  always  follows.  This 
usually  involves  a  limited  area  of  lung  tissue,  but  genuine  croupous  pneumonia 
may  arise  after  injury  of  the  chest  even  when  no  rib  has  been  broken. 
The  physical  signs  and  symptoms  are  not  evident  until  two  or  three  days  after 
the  accident  (Sir  Thomas  Oliver,  in  "Erit.  Med.  Jour.,"  April  30,  igio).  Trau- 
matic pneumonia  may  be  caused  by  other  things  than  external  violence,  viz., 
inhalation  of  illuminating  gas,  of  dust,  or  of  a  foreign  body. 

In  rupture  of  the  lung  the  physical  signs  are  dependent  on  the  extent  and 
situation  of  damage.  A  minute  rupture  would  not  produce  definite  physical 
signs.  If  the  lung  is  ruptured  and  the  pulmonary  pleura  is  not,  there  will 
not  be  pneumothorax,  but  there  may  be  cellular  emphysema  first  becoming 
evident  at  the  root  of  the  neck.  If  the  pleura  is  torn  as  well  as  the  lung, 
there  will  be  pneumothorax  and  hemothorax,  the  amount  of  hemorrhage 
depending  upon  the  situation  and  extent  of  the  injury. 

Robt.  G.  Le  Conte  ("Annals  of  Surgery,"  March,  1908)  points  out  five  ways 
in  which  rupture  may  be  caused:  (i)  Bruising  (simply  causes  subpleural  ec- 
chymosis);  (2)  bursting  (violent  force — a  lung  unable  to  empty  itself  of  air 
is  broken  as  an  inflated  paper  bag  is  broken  by  a  sharp  blow);  the  question 
as  to  whether  the  glottis  must  be  closed  for  such  an  injury  to  occur  is  not  set- 
tled; (3)  penetration  by  a  green-stick  fracture  of  a  rib;  (4)  compression  of  the 
lung  against  some  resistant  structure;  (5)  tearing  (when  the  lung  has  previously 
been  adherent  to  the  wall  of  the  chest). 

These  five  causes  might  be  sententiously  designated  as  bruising,  bursting, 
puncturing,  squeezing,  and  tearing. 

The  symptoms  are  shock,  dyspnea,  cough  with  or  without  bloody  expectora- 
tion, rapid  and  irregular  pulse,  cyanosis,  emphysema  (appearing  first  over  the 
region  of  injury  if  a  broken  rib  penetrated  the  lung;  at  the  root  of  the  neck 
if  there  is  ruptured  lung  but  intact  pleiira),  and  in  some  cases  pneumothorax 
and  hemothorax  (Le  Conte,  Ibid.). 

Rupture  of  the  diaphragm  causes  pain,  dyspnea,  and  often  vomiting.  The 
stomach  or  intestine  may  pass  into  the  pleural  sac.  If  this  happens,  there 
will  be  a  tympanitic  percussion-note  over  the  displaced  viscus  and  symptoms 
will  vary  with  the  viscus  involved.  Such  a  diaphragmatic  hernia  may  be- 
come strangulated  (see  page  1291  and  1303).  In  a  case  in  the  Jefferson  Medical 
College  Hospital,  in  which  the  stomach  passed  into  the  left  pleural  sac,  there 
were  persistent  vomiting,  violent  pain  in  the  chest  and  upper  abdomen,  great 
thirst,  and  displacement  of  the  apex-beat.  The  condition  may  be  confused 
with  pulmonary  rupture  causing  pneumothorax,  but  in  rupture  of  the  dia- 
phragm persistent  nausea  and  vomiting  are  prominent  features;  whereas,  in 
pulmonary  rupture,  if  they  exist  at  all,  they  are  early  and  temporary;  further, 
in  rupture  of  the  diaphragm  the  tympanitic  percussion-note  is  not  found  over 
the  pleural  apex,  but  in  pulmonary  rupture  with  pneumothorax  a  tympanitic 
note  is  found  all  over  the  entire  pleural  cavity  (Le  Conte,  Ibid.). 

Treatment  of  Contusions  of  the  Chest. — A  contusion  of  the  chest  wall 
is  treated  as  directed  in  the  section  on  Contusions  (see  page  285),  and  the  chest 
is  strapped  with  adhesive  plaster,  as  in  the  treatment  of  fractured  ribs.  In  con- 
cussion of  the  chest  the  treatment  for  shock  is  applied.  It  may  be  necessary 
to  employ  artificial  respiration  for  a  time.  If  a  diaphragmatic  hernia  is  diag- 
nosticated, the  abdomen  should  be  opened,  the  displaced  viscera  restored  to 
their  proper  abode,  and  the  diaphragm  sutured.  The  diaphragm  may  also  be 
reached  by  resecting  several  ribs  and  opening  the  pleural  sac.  In  contusion 
of  the  lung  cold  is  applied  to  the  chest  early  in  the  case,  and  any  inflammation 
which  arises  is  treated  according  to  general  rules.  In  rupture  of  the  lung  the 
case  may  be  treated  expectantly,  but  dangerous  and  continued  bleeding  or 
pneumothorax  may  render  surgical  interference  necessary.     For  pneumothorax 


Wounds  of  the  Chest  1023 

paracentesis  without  suction  is  employed.  If  this  fails,  it  may  be  repeated.  If 
it  fails  again,  resect  a  portion  of  a  rib  and  put  in  a  tube.  If  bleeding  is  danger- 
ously profuse  resect  a  portion  of  a  rib  and  insert  a  drainage-tube  into  the  pleural 
cavity. 

Wounds  of  the  Chest. — Non-penetrating  wounds  are  not  particularly 
grave,  and  are  treated  according  to  general  principles,  the  chest  being  immo- 
bihzed.  Penetrating  wounds  are  extremely  grave,  as  viscera  are  apt  to  be 
injured.  In  such  a  wound  an  intercostal  artery  may  be  severed  or  the  internal 
mammary  artery  may  be  divided.  An  intercostal  artery  is  rarely  divided 
unless  a  rib  is  broken.  The  surgeon  should  always  examine  carefully  in  order  to 
determine  whether  an  intercostal  artery  or  the  internal  mammary  artery  has 
been  divided,  and,  in  doing  so,  should  bear  in  mind  the  admonition  of  Matas — 
that  is,  the  bleeding  from  these  vessels  may  be  internal,  the  blood  collect- 
ing in  the  pleural  sac.  The  pericardium  or  heart  may  be  injured  (see  page  460). 
A  wound  of  the  pleura  is  usually,  but  not  always,  associated  with  a  wound  of 
the  lung.  If  the  lung  is  injured,  there  are  usually  great  shock,  pain  in  the 
chest,  dyspnea,  and  cough.  In  a  large  wound,  damage  to  the  lung  will  be 
indicated  if  air  is  sucked  into  the  wound  during  inspiration  and  expelled  during 
expiration,  and  if  blood  is  forced  out  of  the  wound  by  coughing.  The  lung  may 
be  visible  or  may  protrude  {protrusion  of  the  lung) .  In  a  small  wound  it  is  often 
difficult  and  sometimes  impossible  to  determine  whether  the  lung  has  been  in- 
jured. Pneumothorax  with  pulmonary  collapse  proves  it  has.  Severe  hemo- 
thorax strongly  suggests  it.  Spitting  blood  does  not  prove  it.  In  some  severe 
cases  there  is  no  hemoptysis;  in  some  slight  bruises  the  amount  of  blood  coughed 
up  is  large.  Emphysema  about  the  wound  does  not  prove  lung  injury.  An 
incised  wound  of  the  lung  is  apt  to  produce  rapid  death  from  hemorrhage, 
especially  if  the  wound  is  at  the  root  of  the  lung.  A  pistol-bullet  or  a  sporting- 
rifle  bullet  may  not  be  productive  of  great  primary  hemorrhage;  but  infection 
will  probably  follow,  and  secondary  hemorrhage  will  be  apt  to  occur.  The  modern 
military-rifle  ball,  if  it  strikes  exactly  point  on,  passes  through,  rarely  lodges, 
and  is  practically  aseptic  if  it  has  not  struck  the  ground  in  its  course  and  if 
the  victim's  skin  and  clothing  have  not  been  seriously  soiled.  It  often  produces 
astonishingly  little  trouble.  If  the  bullet  enters  side  on  it  produces  grave 
laceration.  A  pist!ol-bullet  and  an  old-time  rifle-bullet  may  lodge  or  may  per- 
forate. A  bullet  lodged  in  the  lung  seldom  causes  much  pain.  If  it  is  in  con- 
tact with  the  pleura  or  pericardium  it  causes  severe  pain.  Pain  from  pericar- 
dial irritation  is  felt  in  the  side  of  the  chest  or  in  the  shoulder  (either  side  or 
both  sides). 

Treatment. — Bring  about  reaction  as  previously  directed  (see  page   290). 

An  incised  wound  of  the  chest,  if  large,  should  be  carefully  inspected. 
If  the  wound  is  small,  cut  down  layer  by  layer  until  the  depths  of  the  wound 
are  reached.  Disinfect  the  wound  and  arrest  hemorrhage.  If  the  pleura  is 
not  open,  proceed  according  to  general  rules.  If  the  pleura  is  found  to  have 
been  opened,  suture  it  with  catgut,  close  the  superficial  wound,  dress  with 
gauze,  and  immobilize  the  chest  wall. 

The  above  proceeding  should  be  carried  out  whether  it  is  or  is  not  believed 
that  the  lung  has  been  damaged,  provided  there  is  no  pneumothorax  and  no 
violent  hemorrhage.  What  course  should  be  pursued  if  the  lung  has  been 
injured  by  a  stab?  If  hemorrhage  does  not  threaten  life  and  there  is  no  pneu- 
mothorax, the  patient  is  kept  at  rest  and  observed.  If  pneumothorax  occurs, 
the  pleural  sac  must  be  drained  by  means  of  a  tube,  because  clots  must  be 
evacuated  and  infection  should  be  anticipated.  If  hemorrhage  into  the  pleural 
sac  persists,  active  measures  become  necessary.  The  use  of  ice-bags  and  drugs 
is  but  waste  of  time.  Some  surgeons  believe  that  the  mere  closure  of  the  ex-  "> 
ternal  wound  leads  to  arrest  of  hemorrhage,  blood  accumulating  and  making 
pressure.     It  is  true  that  hemorrhage  often  ceases  after  suturing  or  plugging  a 


I024  Surgery  of  the  Respiratory  Organs 

wound  and  strapping  the  chest,  but  it  is  not  probable  that  it  ceases  because  of 
these  measures.  It  has  long  been  taught  that  blood  in  the  pleura  usually  remains 
unclotted  for  several  or  many  days.  Elliot  and  Henry  ("Lancet,"  191 7,  ii)  as 
a  result  of  experience  in  this  war  assert  that  clotting  occurs  quickly  because  of 
ferment  Uberated  from  the  wounded  tissues,  though  complete  clotting  may  be 
hindered  by  the  respiratory  movements.  Further,  as  Le  Conte'  shows,  as  the 
blood  is  forced  against  the  root  of  the  lung  the  right  heart  is  engorged,  the 
blood-pressure  is  raised,  and  the  bleeding  continues. 

Bleeding  from  the  lung  can  sometimes  be  arrested  by  aspiration  of  blood  and 
injection  of  the  pleural  sac  with  nitrogen  gas.  It  may  often  be  arrested  by 
inserting  the  end  of  a  drainage  tube  into  the  pleural  sac.  In  cases  in  which  a 
drainage-tube  is  inserted  into  the  pleural  cavity  and  free  drainage  established 
the  pleura  is  immediately  filled  with  air,  and  the  muscles  of  respiration  are  kept 
from  acting  on  the  lung.  The  lung  contracts  by  its  own  elastic  tissue,  as  well  as 
by  the  pressure  exerted  by  the  pneumothorax,  and  at  the  same  time  the  presence 
of  the  air  favors  clotting  in  the  severed  vessels.-  Baudet  maintains  that  all 
grave  wounds  of  the  lung  should  be  operated  upon.  If  the  insertion  of  a  tube 
fails,  or  if  the  bleeding  is  rapid  and  obviously  threatens  life  seriously,  several 
ribs  must  be  rapidly  resected  and  the  bleeding  part  explored.  In  some  cases 
the  bleeding  may  be  arrested  by  ligation,  in  some  cases  by  packing  a  small  wound 
with  gauze,  in  some  cases  by  the  suture-ligature.  Two  cases  of  lung  suture 
have  been  recorded  by  Philadelphia  colleagues  (Jopson,  in  "Annals  of  Surgery," 
1906,  vol.  xliii;  Kelly,  in  "Annals  of  Surgery,"  1910,  vol.  li).  In  a  violent  sec- 
ondary hemorrhage  following  a  gunshot-wound  of  the  lung  I  packed  the  enthe 
pleural  cavity  with  sterile  gauze  to  obtain  a  base  of  support,  and  arrested  the 
bleeding  by  carrying  iodoform  gauze  directly  against  the  oozing  surface.^  The 
man  recovered.  I  did  the  same  thing  on  a  Chinaman  suffering  from  a  gunshot- 
wound  of  the  lung.  The  hemorrhage  was  arrested  and  he  lived  three  weeks, 
dying  finally  from  pericarditis.  After  directly  arresting  hemorrhage  from  the 
lung,  turn  clots  out  of  the  pleural  sac  and  insert  a  drainage-tube.  In  a  per- 
forating wound  inflicted  by  a  bullet,  reaction  must  be  brought  about,  the  wound 
dressed  antiseptically,  the  chest  strapped,  and  the  patient  kept  quiet.  If 
pneumothorax  occurs,  the  pleura  should  be  drained  with  a  tube.  If  hemorrhage 
occurs,  it  should  be  met  as  directed  above.  In  a  wound  in  which  the  bullet  has 
lodged,  an  examination  should  be  made  to  see  if  the  bullet  is  under  the  skin, 
and  if  it  is,  it  is  removed  after  the  patient  has  reacted.  It  should  always  be 
borne  in  mind  that  a  pistol-bullet  may  be  deflected  by  a  rib  or  may  pass  from  the 
front  to  the  back  part  of  the  chest  by  making  a  burrow  under  the  skin  (o  contour 
wound).  If  a  bullet  is  lodged,  no  attempt  should  be  made  to  remove  it  unless 
an  operation  must  be  done  for  bleeding,  unless  the  bullet  causes  trouble,  or 
unless  it  is  felt  under  the  skin.  Under  no  circumstances  conduct  a  long  search 
for  a  bullet.  If  emphysema  of  the  chest  walls  is  moderate,  strapping  or  a 
bandage  will  control  it;  if  it  is  great,  make  multiple  punctures  and  then  apply 
pressure.  In  protrusion  of  a  portion  of  the  lung  try  to  restore  the  protru- 
sion; but  if  restoration  is  impossible  or  if  gangrene  seems  likely  to  occur,  ligate 
the  base  of  the  protrusion  with  silk  and  cut  away  the  mass. 

Moller  ("Archiv.  f.  klin,  Chhurgie,"  1909-10,  vol.  Ivi)  collected  26  cases  of 
gunshot-wounds  in  civil  life,  which  were  operated  upon,  and  11  died  (42  per 
cent.).  In  20  suturing  was  done,  with  7  deaths.  In  2  the  wound  was  sutured 
to  the  pleural  opening,  with  i  death.  In  2  lung  resection  was  followed  by  death. 
One,  in  which  pleural  packing  was  used,  recovered.  He  collected  10  stab- 
wounds:  7  were  sutiued,  with  i  death.  In  3  the  pleiura  was  packed  and  all 
recovered. 

^"Annals  of  Surgery,"  April,  1899. 

^Le  Conte,  in  "Annals  of  Surgery,"  April,  1899. 

^The  Author,  in  "Annals  of  Surgery,"  Jan.,  1898. 


Chest  Wounds  in  War  1025 

Wounds  of  the  Chest  Involving  the  Diaphragm. — In  such  a  case  abdominal 
viscera  may  pass  through  the  wound  in  the  diaphragm  and  appear  in  the  wound 
of  the  cliest.  If  there  is  no  indication  of  a  wound  of  the  abdominal  viscera 
some  surgeons  would  suture  the  wound  of  the  diaphragm  by  way  of  the  thorax. 
If  there  are  indications  of  injury  of  abdominal  viscera  the  abdomen  must  be 
opened.  Personally,  I  prefer  to  open  the  abdomen  in  every  chest  wound  im- 
plicating the  diaphragm,  even  when  symptoms  of  injury  to  abdominal  viscera 
are  not  as  yet  manifest. 

Chest  Wounds  in  War. — In  many  recent  engagements  chest  wounds  represent 
I  in  40  of  the  wounded.  Our  knowledge  of  these  wounds  is  gathered  from  the 
immense  experience  of  many  military  surgeons  (Moynihan,  Hull,  Gray, 
Anderson,  Duval,  Depage,  Rouvihois,  Henry,  Elliot  and  many  others). 
A  missile  may  perforate  the  chest,  making  a  wound  of  entrance  and  a  wound  of 
exit  (perforating  wound).  It  may  penetrate  the  chest  and  lodge,  in  which  case 
there  is  a  wound  of  entrance  but  no  wound  of  exit  (penetrating  wound).  A 
tangential  wound  may  do  as  much  damage  as  though  the  missile  entered  the  chest, 
the  damage  being  caused  by  bone-fragments.  H.  M.  W.  Gray  ("N.  Y.  Med. 
Jour.,"  June  8,  1918}  divides  chest  wounds  clinically  in  the  following  useful 
manner : 

1.  No  operation  required. 

2.  Operation  required  at  the  earliest  possible  moment. 

3.  Question  as  to  immediate  operation  doubtful. 

4.  Moribund  and  useless  to  operate. 

We  consider  here  wounds  of  the  lungs  and  pleura.  For  heart  wounds  see 
page  464. 

Sir  Berkeley  Moynihan  ("American  Addresses")  discusses  the  mortality  of 
chest  wounds  and  shows  that  it  differs  greatly  "at  various  parts  of  the  line  of 
communication."  At  the  first-aid  stations  it  is  from  25  to  30  per  cent.  At 
the  casualty  clearing  stations  it  is  18  to  20  per  cent.  In  the  base  hospitals  it  is 
10  per  cent.  "At  the  aid  post,  where  the  mortality  is  25  per  cent.,  there  will 
remain  alive,  of  100  patients,  75.  At  the  ambulance,  of  these  75,  20  per  cent, 
will  die  and  there  will  remain  60  patients.  At  the  base  of  these  60,  10  per  cent, 
will  die,  so  that  finally  54  cases  will  survive." 

Moynihan  (Ibid.)  points  out  that  the  mortality  is  influenced  by  the  nature  of 
the  projectile.  A  rifle  bullet  makes  a  very  dangerous  wound  if  it  divides  a 
large  vessel.  It  makes  a  comparatively  benign  wound  if  the  lung  is  wounded 
but  no  large  vessel  is  damaged.  Wounds  from  shell  fragments  are  torn  and  ir- 
regular and  bits  of  skin  and  portions  of  clothing  are  apt  to  be  carried  in.  Such 
wounds  are  very  grave  because  of  the  great  probability  of  infection.  It  is  well 
known  that  many  cases  of  perforating  bullet  wounds  recover  easily.  A  rifle- 
bullet  lodged  in  the  lung  may  cause  no  symptoms  and  become  encapsuled. 
Large  shell  fragments  are  always  dangerous  and  should  be  removed. 

Little  or  nothing  can  be  done  for  chest  wounds  at  the  first-aid  station. 
When  such  cases  reach  the  evacuation  hospital  station  they  are  usually  gravely 
shocked.  They  require  stimulants  and  if  there  is  an  open  wound  which  sucks 
air  it  should  be  sutured  or  plugged  to  make  it  air-tight.  Usually  in  a  couple 
of  hours  alarming  symptoms  have  largely  subsided  (Gray,  Ibid.).  It  is  desirable, 
if  circumstances  admit,  to  perform  any  urgently  necessary  operation  in  the  evac- 
uation hospital.  Some  cases  are  kept  for  several  days  and  then  sent  to  the 
base.  There  may  be  a  lodged  bullet.  A  rifle  ball  may  have  perforated.  A 
rib  or  ribs  may  be  broken.  So  may  the  scapula.  A  shell  fragment  may  have 
broken  ribs  and  driven  them  in,  may  have  crushed  the  chest  in  or  may  have  torn 
away  a  part  of  the  wall  of  the  thorax.  A  hail  of  bone-fragments  may  have  been 
driven  into  the  lung  or  pleura. 

The  bronchi  usually  escape  injury.  It  is  seldom  that  fissures  or  tears 
radiate  in  the  lung  from  the  track  of  the  missile  (Moynihan,  Ibid.).  Distant 
65 


I026  Surgery  of  the  Respiratory  Organs 

parts  of  the  lung  or  pleura  may  be  damaged  due  to  the  force  of  the  impact  or 
by  the  alteration  in  air  pressure  j)roduced  by  the  explosion  of  the  shell.  "There 
may  be  hemorrhages  by  "contrecoup"  in  the  upper  lobe  if  the  lower  is  wounded, 
or  in  the  lower  if  the  upper  is  injured,  or  in  both  if  the  projectile  has  passed  near 
the  base  of  the  lung."  There  may  be  hemorrhages  in  the  other  lung  or  beneath 
its  pleura,  bronchopneumonia  may  arise  in  it  or  septic  matter  may  be  inhaled 
from  the  trachea  ("American  Addresses,"  by  Sir  Berkeley  Moynihan).  In 
some  cases  hemothorax  is  sHght  in  some  a  quart  or  more  of  blood  gathers. 
Inflammation  soon  arises  and  exudate  is  added  to  the  blood.  As  hemothorax 
increases  the  lung  collapses  and  collapse  lessens  and  perhaps  arrests  bleeding. 
It  was  formerly  taught  that  blood  in  the  pleural  sac  did  not  tend  to  clot.  We 
now  know  that  it  does  clot.  Hemothorax,  if  infection  does  not  occur,  will  sel- 
dom be  fatal  but  infection  will  occur  in  two-fifths  of  the  cases  (Moynihan,  Ibid.). 
Moynihan  points  out  the  important  fact  that  the  upper  portion  of  the  fluid  may 
be  uninfected  when  the  lower  is  infected,  hence  a  tap  may  give  deluding  results. 

Duval  points  out  that  in  nearly  half  of  all  infections  the  infecting  agents 
are  anaerobic  bacteria.  Such  infection  arises  from  the  wound  (bacillus  of  gas 
gangrene.  Bacillus  sporogencs).  Aerobic  infection  rnay  come  from  the 
respiratory  tract  (pneumococci,  staphylococci,  etc.)  or  from  the  wound 
(streptococci  or  colon  bacilli). 

Treatment. — We  have  spoken  previously  of  the  reactive  treatment  necessary 
when  the  patient  is  brought  into  the  evacuation  hospital.  Immediate  operation 
is  necessary  when  there  is  great  dyspnea  due  to  hemothorax  or  hemopericardium; 
to  a  foreign  body  in  the  diaphragm  or  to  rapidly  increasing  infection  especially 
by  bacteria  which  form  gas;  severe  and  lasting  pain  (due  probably  to  irritation 
of  pleura  or  pericardium  by  a  sharp-edged  foreign  body  or  a  rib  fragment) 
(H.  M.  W.  Gray,  Ibid.).  Many  cases  with  a  wound  of  entrance  and  a  wound 
of  exit  have  very  little  hemothorax  and  soon  recover  from  shock.  "If  the  hemo- 
thorax does  not  reach  higher  than  the  nipple  line,  shows  no  sign  of  increasing,  and 
if  there  is  no  evidence  of  infection,  such  cases  may  be  sent  to  the  base  without 
danger  in  the  course  of  three  to  six  days''  _(H.  M.  W.  Gray,  Ibid.).  In  non- 
infected,  closed  hemothorax  the  pulse,  respiration  and  temperature  should  be- 
come practically  normal  in  twenty-four  hours,  if  they  do  not  do  so  an  exploratory 
puncture  should  be  made  and  the  fluid  obtained  should  be  subjected  to  a  bacterio- 
logical study.  If  the  fluid  has  a  foul  odor,  if  the  froth  in  the  syringe  has  a  "  crim- 
son purple  color  "  no  further  proof  of  anaerobic  infection  is  necessary  (H.  M.  W. 
Gray,  Ibid.).  This  test  should  be  made  every  day  until  the  situation  has  be- 
come clear,  "The  test  is  by  no  means  infallible.  Sepsis  may  develop  in  is- 
lands or  areas  of  the  clot  or  fluid  which  are  not  tapped  by  the  needle.  Increase 
of  pneumothorax  or  development  of  resonant  patches  in  previously  dull  areas 
should  make  one  suspicious  of  gas  infection.  If,  then,  other  symptoms  point- 
ing to  infection  are  sufficiently  prominent  operation  should  be  undertaken 
without  waiting  for  bacteriological  confirmation"   (H.  M.  W.   Gray,  Ibid.). 

A  small,  non-infected  hemothorax  does  not  require  aspiration;  usually  the 
fluid  will  be  absorbed  rapidly,  but  if  it  lingers,  diagnostic  puncture  and  a  bac- 
teriologic  examination  of  the  fluid  are  called  for.  Gray  (Ibid.)  says  that  a  mild 
infection  may  be  cured  by  repeated  aspiration. 

If  a  hemothorax  is  large  it  will  not  do  to  send  the  patient  to  a  base  sooner 
than  from  three  to  six  days.  If  during  the  wait  respiration  becomes  difhcult  a 
slow  aspiration  is  indicated,  and  the  withdrawal  of  fluid  is  to  cease  as  soon  as 
respiration  is  relieved.  Rapid  aspiration  may  cause  the  hemorrhage  to  start 
again  (Gray,  Ibid.).  If  after  rehef  by  aspiration  urgent  symptoms  arise  again, 
operate.  The  operation  consists  in  evacuating  blood,  clots  and  exudate,  arrest- 
ing the  bleeding  and  closing  the  wound  in  the  chest- wall.  In  many  chest  wounds 
we  are  in  doubt  what  to  do.  If  we  do  not  operate  sepsis  may  arise.  The  opera- 
tion is  dangerous.     On  one  side  is  a  danger  which  is  problematical.     On  the  other 


Occluding  Pulmonary  Embolism  1027 

is  an  operation  which  might  give  relief  and  save  from  sepsis  but  which  is  danger- 
ous. Gray  (Ibid.)  says  that  in  many  of  these  cases  operations  followed  by  com- 
plete closure  of  the  chest  wound  have  been  highly  successful,  and  that  the  use 
of  the  blood  transfusion  in  early  stages  would  secure  better  results  and  give 
strength  for  a  radical  operation.  If  there  is  a  severe  open  wound  and  the  patient 
is  not  moribund,  operate  at  once.  If  the  wound  is  large  and  lacerated  and  a  shell 
fragment  is  lodged,  clothing  and  other  infected  matter  has  in  all  probability 
l)een  carried  in.  There  may  be  a  sucking  wound,  a  tangential  wound.  Take 
an  x"-ray  picture.  Give  nitrous  oxide  and  oxygen  in  preference  to  ether.  Excise 
the  damaged  tissue.  In  some  cases  use  this  wound  as  the  door  of  entrance  for 
our  work.  In  others  close  it  at  once  and  remove  the  fifth  rib  to  permit  of  neces- 
sary procedures.  Liquid  blood  is  to  be  drawn  off  or  poured  out,  clot  is  to  be 
spooned  and  mopped  out,  the  lung  is  grasped  and  drawn  out  of  the  wound.  The 
missile  is  located,  cut  down  upon  and  removed.  The  lung  wound  is  excised,  is 
sutured  with  catgut,  the  lung  is  wiped  off  with  ether,  sutured  with  catgut  and 
restored  to  place.  The  wound  in  the  chest-wall  is  sutured  and  sealed  hermeti- 
cally.    The  pleural  sac  is  aspirated.     As  air  is  withdrawn  the  lung  expands. 

Occluding  Pulmonary  Embolism. — By  this  term  we  mean  an  embolism 
which  completely  blocks  the  pulmonary  artery  or  some  of  its  chief  branches. 
Such  cases  occasionally  follow  a  surgical  operation,  especially  an  abdominal 
operation.  They  are  more  frequent  than  used  to  be  thought.  The  clot  is 
derived  from  a  vein.  The  calamity  is  most  apt  to  occur  between  the  second  and 
fourth  weeks  after  an  operation  (Bartlett  and  Thompson,  in  "Annals  of  Sur- 
gery," May,  1908).  Pulmonary  embolism  may  arise  from  fractures,  inflamed 
veins  anywhere,  and  during  or  after  pneumonia,  erysipelas,  typhoid  fever, 
and  any  acute  infection.  In  malignant  endocarditis  and  mitral  stenosis  small 
emboli  are  common.  If  the  pulmonary  artery  is  completely  blocked  death 
occurs  at  once.  If  one  branch  only  is  blocked  the  patient  may  recover  if  the 
heart  is  sound  and  strong.  If  the  artery  proper  is  partly  blocked  the  patient 
has  a  period  of  suffering  and  dyspnea  before  death,  but  death  is  sure  to  occur 
from  subsequent  complete  blocking. 

Bartlett  and  Thompson  (Ibid.)  report  22  cases  of  occlusive  pulmonary 
embolism,  20  of  which  were  fatal.  The  greatest  cause  in  a  surgical  operation 
seems  to  be  varicose  veins,  especially  about  an  abdominal  or  pelvic  tumor. 
I  am  convinced  that  most  sudden  deaths  in  infected  cases  are  due  to  pulmonary 
embolism.  I  have  seen  pulmonary  embolism  after  an  operation  for  varicocele, 
for  hydrocele,  for  duodenal  ulcer,  and  for  appendicits. 

I  found  myself  wondering  if  more  care  in  hemostasis  might  not  lessen  the 
liability  to  the  accident.  If  vessels  ooze  and  a  clot  gathers,  the  clot  projects 
into  the  lumen  of  open  vessels  and  muscular  effort  or  even  slight  infection 
inay  loosen  it  (see  page  207). 

The  symptoms  of  a  mild  case  of  embolism  are  rapid  pulse,  dyspnea,  after 
some  hours  dulness  of  the  base  and  impaired  breath  sounds,  and,  perhaps  later, 
spitting  of  blood.  In  a  real  occluding  embolism  there  are  sudden  collapse, 
cyanosis  or  pallor  with  livid  lips,  the  pulse  at  the  wrist  is  absent  or  very  rapid, 
and  irregular.  There  are  pain  in  the  chest,  intense  dyspnea,  dilated  pupils, 
and  early  unconsciousness.  The  right  side  of  the  heart  distends  greatly  and 
the  second  sound  is  accentuated  in  the  pulmonary  area. 

Schumacher  in  discussing  these  cases  says  there  are  three  classes  of  them: 
Those  in  which  almost  immediate  death  occurs;  those  in  which  death  occurs  in  a 
few  minutes,  and  those  which  last  much  longer.  In  the  last  mentioned  cases 
a  main  branch  becomes  blocked  and  total  obstruction  is  gradual  (Willy  Meyer, 
in  "  Annals  of  Surgery,"  August,  1913).  These  cases  only  are  suitable  for  opera- 
tion. The  surgeon  must  bear  in  mind  the  danger  of  embolism  and  endeavor  to 
prevent  it  in  operations  by  handling  and  exposing  viscera  as  little  as  possible, 
by  applying  ligatures  above  all  clots  in  veins  and  all  varicosities,  and  removing 


I028  Surgery  of  the   Respiratory  Organs 

the  affected  structures.  Quenu  proposed  to  lessen  the  danger  of  postoperative 
thrombosis  by  administering  citric  acid  before  operation.  This  agent  lessens 
the  coagulability  of  the  blood,  Tuffier  fears  this  remedy,  believing  that  it  makes 
an  existing  thrombus  more  apt  to  break  up  and  form  emboli  ("Presse  Medi- 
cale,"  April  20,  1910). 

Treatment. — In  small,  non-occluding  emboli,  in  which  condition  the  only 
symptoms  are  dyspnea,  pain,  rapidity  of  pulse,  and,  after  some  hours,  dulness 
at  the  base  and  impaired  breath  sounds,  give  stimulants,  dry  cup  the  chest,  and 
administer  morphin  if  there  is  no  cyanosis.  In  a  very  severe  case  death  is 
rapid  and  there  is  nothing  to  do  medically. 

Trendelenburg,  of  Leipzig,  suggests  surgical  treatment  (German  Congress 
of  Surgery,  1908).  He  points  out  that  death  is  not  always  sudden  (in  7  cases 
out  of  9  the  victim  lived  from  ten  minutes  to  one  hour),  and  advises  opening  of 
the  pulmonary  artery  and  removal  of  the  embolus.  The  first  patient  operated 
on  died  before  the  completion  of  the  operation.  "Since  then  it  was  done, 
twelve  times  in  all,  at  the  Leipzig  clinic,  without  one  permanent  recovery 
(Willy  Meyer  in  "Annals  of  Surgery,"  August,  1913).  One  patient  lived  four 
days;  I  died  on  the  table;  i  died  in  fifteen  hours  from  cardiac  failure;  i  lived 
for  thirty-seven  hours  and  died  of  reactionary  bleeding  from  the  internal 
mammary  artery.  Kruger  did  one  operation  for  embolism.  The  early  result 
was  apparently  successful,  but  the  patient  died  of  infection  on  the  eighteenth  day 
("Zentral.fiir  Chir.,"May  22, 1909).  In  Sauerbruch's  clinic  at  Zurich  the  opera- 
tion has  been  performed  four  times  without  a  recovery  (Willy  Meyer,  Loc.  cit.). 
Of  15  recorded  cases  not  one  recovered,  though  one  lived  until  the  fourth  day. 

Trendelenburg  thinks  that  the  surgeon  has  about  fifteen  minutes  in  which  to 
work.  The  operation  is  done  under  differential  pressure.  The  pleura  is 
opened,  then  the  pericardium.  A  rubber  tube  is  passed  through  the  transverse 
sinus  of  the  pericardium  and  the  aorta  and  pulmonary  artery  are  constricted. 
This  constriction  must  be  released  within  forty-five  seconds.  The  artery  is 
opened,  the  clot  removed,  the  arterial  wound  clamped,  and  the  elastic  constric- 
tion released.     The  arterial  wound  is  then  sutured. 

Abscess  of  the  lung  may  follow  ordinary  pneumonia.  It  is  more  apt  to 
follow  aspiration-pneumonia.  Wessler  states  that  28  per  cent,  of  all  cases  of 
lung  suppuration  examined  in  the  a:-ray  department  of  Mt.  Sinai  Hospital, 
N.  Y.,  arose  after  operation  upon  the  mouth,  tonsils  or  pharynx  (Lilienthal 
in  "Annals  of  Surgery,"  1916,  Ixiv).  It  is  usually  caused  by  streptococci  or, 
staphylococci,  but  it  may  result  from  pneumococci  or  colon  bacilli.  These 
germs  may  reach  the  pulmonary  tissue  by  direct  entrance  from  adjacent  organs, 
by  way  of  the  blood,  or  by  way  of  the  bronchi  and  alveoli.  Osier'  tells  us 
that  pulmonary  abscess  may  result  from  the  aspiration  of  septic  particles 
after  "wounds  of  the  neck,  operations  upon  the  throat,"  and  suppurative 
lesions  of  the  nose,  larynx,. or  ear.  Aspiration-pneumonia  may  develop  when 
there  is  difficulty  in  swallowing  from  any  cause,  when  there  is  profound  ex- 
haustion, and  when  there  is  palsy  or  incoordination  of  any  of  the  muscles  of 
deglutition.  Cancer  of  the  esophagus  may  be  a  cause;  so  may  perforation 
of  the  lung  by  an  abscess,  wound  of  the  lung,  impaction  of  a  foreign  body  in 
the  lung,  suppuration  about  a  focus  of  tuberculosis  or  a  metastatic  abscess.  A 
pulmonary  abscess  may  be  of  trivial  size  or  it  may  be  very  large,  involving  an 
entire  lobe.  There  may  be  one  abscess,  several,  or  many.  When  suppura- 
tion results  from  aspiration-pneumonia  or  blood-infection,  there  are  usually 
multiple  abscesses. 

Symptoms. — The  expectoration  is  not  frequent,  but  is  profuse,  and  dur- 
ing a  paroxysm  mouthfuls  are  coughed  up  in  rapid  succession.  The  expecto- 
rated matter  is  sour  or  very  offensive  in  odor  and  contains  fragments  or  shreds 
of  pulmonary  tissue,  which  can  be  identified  as  such  by  the  microscope.     The 

^  "Practice  of  Medicine." 


Bronchiectasis  1029 

patient  lies  upon  the  diseased  side  in  order  to  keep  the  pus  from  running  into 
the  bronchi  and  causing  cough.  When  the  cavity  fills  and  pus  reaches  the 
bronchi,  violent  cough  and  expectoration  begin,  continue  until  the  cavity 
is  partly  or  entirely  emptied,  and  then  subside,  perhaps  for  several  hours. 
If  the  abscess-cavity  is  large  and  full  of  pus,  an  area  of  dulness  on  percussion 
can  be  mapped  out.  When  the  pus  is  coughed  out  and  the  air  enters,  physical 
signs  of  a  cavity  are  clear.     The  .r-rays  often  show  the  situation  of  such  a  cavity. 

The  course  of  abscess  of  the  lung  is  usually  acute.  There  are  fever  of  the 
hectic  type,  rapid  loss  of  weight,  weakness  and  rapidity  of  circulation,  dyspnea, 
pallor,  sleeplessness,  and  great  weakness.  Gangrene  may  arise;  empyema 
or  pyopneumothorax  may  develop;  very  rarely  the  abscess  breaks  through 
the  chest  wall;  recovery  may  follow  spontaneous  evacuation  or  drainage  by 
coughing  up  pus;  death  may  result  from  exhaustion  or  secondary  septic  lesions. 
If  operation  is  performed,  from  70  to  80  per  cent,  of  the  patients  will  recover. 
In  an  abscess  which  opens  into  a  tube,  it  may  be  possible  to  collapse  the  lung 
and  hence  the  abscess  by  filling  the  pleura  with  nitrogen  gas.  This  can  only 
be  done  in  cases  free  from  pleural  adhesions.  (Greer,  in  "Jour.  Am.  Med. 
Assoc,"  April  i,  1916  and  Tewksbury,  in  "Jour.  Am.  Med.  Assoc,"  March  10, 
1917). 

The  treatment  in  most  cases  is  purely  surgical  {pneumotomy) .  Make  an  in- 
cision over  the  cavity.  Resect  a  portion  of  one  or  more  ribs.  Expose  the  pleura. 
If  the  two  layers  of  the  pleura  are  not  adherent,  suture  them  together  and  either 
wait  two  days,  or  surround  the  area  to  be  incised  by  a  coffer-dam  of  gauze 
and  then  operate.  If  they  are  adherent,  always  proceed  at  once.  Search  for 
the  abscess  with  an  aspirating  needle  When  the  cavity  is  found,  open  into 
it  with  the  actual  cautery  and  insert  a  drainage-tube  (see  page  1040).  The 
direct  mortality  is  about  20  per  cent. 

Gangrene  of  the  Lung. — This  term  means  the  putrefaction  of  a  devital- 
ized portion  of  pulmonary  tissue.  The  tissue  is  devitalized  by  the  action  of 
pyogenic  micro-organisms.  Gangrene  may  follow  abscess,  bronchitis,  or  pneu- 
monia, or  may  be  due  to  diabetes,  to  embolism  of  a  branch  of  the  pulmonary 
artery,  bronchiectasis,  tuberculosis,  malignant  disease,  wounds,  or  the  lodge- 
ment of  foreign  bodies.  Gangrene  may  be  circumscribed  or  diffused.  There 
may  be  one  cavity,  small  or  large,  or  multiple  cavities  may  form.  The  gan- 
grenous area  putrefies,  softens,  and  the  softened  matter  maybe  expectorated,  a 
gangrenous  cavity  being  formed.  In  the  rare  cases  which  undergo  spontaneous 
cure  the  cavity  is,  after  a  time,  surrounded  by  fibrous  tissue  and  obliterated  by 
granulations.     The  mortality  from  operation  is  about  30  per  cent. 

Symptoms. — Expectoration  occurs  only  now  and  then,  but  at  each  seizure 
a  great  quantity  of  matter  is  brought  up  and  this  matter  is  horribly  offensive. 
Occasionally  there  is  no  expectoration.  The  patient,  as  in  lung  abscess,  lies 
upon  the  diseased  side.  The  expectorated  matter  is  mucopurulent,  contains 
particles  or  shreds  of  pulmonary  tissue,  bacteria,  and  altered  blood.  The 
fetor  of  the  pus  is  much  greater  than  is  the  fetor  of  the  pus  of  an  abscess.  The 
breath  is  very  foul.  Physical  signs  may  indicate  either  consolidation  or  a 
cavity.  There  are  hectic  fever,  great  exhaustion,  deathly  pallor,  and  diarrhea. 
Pulmonary  hemorrhage  is  not  unusual,  and  complications  spoken  of  in  the 
article  upon  Abscess  may  occur  (see  page  1028).  Recovery  sometimes  ensues, 
the  cavity  closing  by  granulation.  Death  may  take  place  in  a  few  days.  Often 
the  patient  lives  for  weeks,  being  sometimes  better  and  sometimes  worse,  dying 
finally  from  exhaustion  or  from  the  effects  of  a  compHcation. 

The  treatment  is  to  operate  as  for  pulmonary  abscess. 

Bronchiectasis.— This   term   means   dilatation   of   the  bronchial   tubes. 
The  dilatation  may  be  fusiform,  saccular  or  trabecular.     The  first  form,  or  true ' 
bronchiectasis,  is  great  dilatation  of  a  tube  caused  by  strain.     It  is  most  common 
in  children  and  in  them  is  a  result  of  coughing.     The  other  two  forms  occur  in 


I030  Surgery  of  the  Respiratory  Organs 

adulls  and  result  from  chronic  inflammation.  There  may  be  one  or  more  cavi- 
ties. Not  only  are  the  bronchi  dilated  but  fibrous  tissue  has  formed  about  them. 
The  condition  may  result  from  bronchial  inflammation,  from  j^ulmonary 
sclerosis,  or  from  the  presence  of  a  foreign  body.  Surgeons  sometimes  see  bron- 
chiectasis following  tonsillectomy  or  operation  for  adenoids  (Lilienthal,  in  "An- 
nals of  Surgery,"  1916,  Ixiv).  In  bronchiectasis  there  are  parosysms  of  vio- 
lent cough  with  intervals  of  hours  between  them.  The  expectoration  is  pro- 
fuse, mucopurulent  and  fetid.  If  very  purulent  it  is  like  the  matter  coughed  up 
by  a  victirn  of  pulmonary  abscess.  Hemoptysis  may  occur.  The  physical  signs 
are  uncertain.  Fever  is  seldom  present  unless  purulent  matter  is  long  retained. 
The  .T-rays  and  the  bronchoscope  are  very  useful  in  diagnosis.  The  fingers 
may  become  clubbed.  Most  cases  are  treated  medically.  Drugs  may  be 
directly  introduced  through  the  bronchoscope.  If  medical  and  local  treat- 
ment fails  surgery  must  be  considered.  Pneumotomy  does  not  cure  the  case. 
Radical  operation  is  only  to  be  considered  in  a  unilateral  lesion  which  is  not 
very  extensive  and  in  which  in  spite  of  medical  and  local  treatment  the 
patient  grows  progressively  worse.  Radical  operation  consists  in  extirpation 
of  the  diseased  lobe.     Lilienthal  (Ibid.)  cured  4  cases  out  of  7. 

The  operation  of  lobar  resection  has  a  large  but  not  a  prohibitory  mortality. 
Samuel  Robinson  reports  five  complete  resections  of  the  lower  lobe  of  a  lung 
with  one  death  (Surgery,  Gynecology  and  Obstetrics,  Feb.,  1917). 

Torek's  interpleural  pneumolysia  may  be  considered  for  the  treatment  of 
bronchiectasis  (page  1032). 

Surgical  Treatment  of  Pulmonary  Tuberculosis.— For  a  number 
of  years  past  surgical  thought  has  been  actively  directed  toward  placing 
on  a  scientific  footing  operations  for  pulmonary  phthisis.  The  matter  is  still 
in  a  transition  stage,  and  operations  at  present  have  a  very  limited  field  of 
application,  although  Sonnenberg  and  others  have  reported  cures.  Baglivi, 
in  1643,  endeavored  to  tap  and  inject  tuberculous  cavities.  Hastings  and 
Stucke  did  the  same  thing  in  the  eighteenth  century.  Mosler,  a  number 
of  years  ago,  attempted  to  treat  cavities  by  introducing  a  trocar  into  the  cav- 
ity and  injecting  permanganate  of  potassium  solution  through  the  cannula. 
Patients  were  not  benefited  by  this  procedure.  The  plan  was  revived  by  Pepper 
in  1874.  The  results  are  bad  and  the  operation  is  dangerous.  Hillier  tried 
injection  of  corrosive  sublimate  into  the  lung  parenchyma,  but  the  effect  of  the 
injections  was  disastrous.  Vidal  advocates  counterirritation  by  the  actual 
cautery  and  maintains  that  congestion  improves  nutrition.  When  the  strength 
of  the  patient  is  well  preserved  and  the  pulmonary  lesion  is  circumscribed  and 
slowly  progressive,  it  may,  in  some  few  cases,  be  justifiable  to  perform  an  opera- 
tion, open  the  cavity,  and  treat  it  directly  {pnetimotomy) .  That  pneumotomy 
might  be  performed  successfully  was  suggested  to  surgeons  by  observing  that 
some  patients  recovered  after  sword-thrusts  into  the  lung.  Fowler  said  it  is 
not  justifiable  to  operate  if  the  disease  has  come  "to  a  standstill."  The  same 
surgeon  stated  that  the  only  accessible  region  is  bounded  above  by  the  clavicle, 
to  the  inner  side  by  the  manubrium,  to  the  outer  side  by  the  lesser  pectoral 
muscle,  and  below  by  the  second  rib.^  This  operation  does  not  cure  any  one, 
but  it  may  cause  distinct  improvement  when  there  is  hectic  fever  from  an  ill- 
drained  cavity  containing  the  products  of  a  mixed  infection.  In  an  advanced 
case  there  is  usually  more  than  one  cavity,  and  if  there  is,  the  operation  is  contra- 
indicated.  Before  attempting  it,  be  sure  the  case  is  advanced  and  not  incipient 
and  that  the  cavity  is  single.  Locate  the  cavity  by  auscultation,  percussion, 
and  the  x'-rays.     TuflRer  collected  45  cases  and  only  i  was  a  success. 

Mauclaise^   says   that   pneumotomy   is   justifiable   only   in   circumscribed 

'  See  the  very  full  and  thoughtful  article  by  George  Ryerson  Fowler  on  "The  Surgery  of 
Intrathoracic  Tuberculosis,"  "Annals  of  Surgery,"  Nov.,  1896. 
^  "La  Tribune  nedicale,"  Sept.  21,  1893. 


Plastic  Operations  on  the  Chest  Wall  1031 

tuberculous  cavities  without  peripheral  infiltration  and  in  pulmonary  ab- 
scesses. Bronchiectatic  cavities  are  usually  multiple;  they  are  exceedingly 
difiicult  to  locate,  and  treatment  by  pneumotomy  should  not  be  attempted. 
In  the  treatment  of  pulmonary  tuberculosis  resection  of  the  diseased  area  was 
proposed  by  Ruggi  (piieumeclomy).  Tufher  successfully  performed  this  opera- 
tion. Surgeons,  as  a  rule,  do  not  believe  in  pneumectomy.  Reclus^  voices 
the  general  opinion  when  he  says  the  operation  is  not  required  if  the  area  of 
disease  is  very  limited,  as  such  a  condition  is  frequently  curable  by  medicinal 
means,  and  it  does  no  good  if  the  area  of  disease  is  extensive. 

Only  two  methods  of  surgical  treatment  seem  to  have  won  a  distinct  place: 
one  is  the  artificial  production  of  pneumothorax;  the  other,  some  form  of  plastic 
operation  upon  the  thorax  to  collapse  and  immobilize  the  lung. 

Artificial  Pneumothorax. — It  has  long  been  known  that  pneumothorax 
might  benefit  a  tuberculous  lung.  Carson,  of  Edinburgh,  in  1843,  tried  to  create 
artificial  pneumothorax  by  making  a  puncture  in  the  visceral  pleura  to  allow 
the  passage  of  air  into  the  pleural  sac.  Farlanini  suggested  the  introduction 
of  a  gas  into  the  pleural  sac  and  reported  a  successful  case  in  1894.  In  1898 
Murphy  began  the  use  of  nitrogen.  In  191 2  there  were  on  record  about  400 
cases  (Mary  E.  Lapham,  in  "Am.  Jour.  Med.  Sciences,"  April,  191 2).  Since 
then  many  cases  have  been  recorded.  The  method  should  only  be  used  in 
unilateral  cases  which  are  not  far  advanced.  It  is  used  when  the  patient  con- 
tinues to  grow  worse  in  spite  of  medical  treatment.  The  method  is  useless  if 
there  are  adhesions,  and  is  contraindicated  if  diabetes  exists  or  if  there  is  uncom- 
pensated valvular  disease  of  the  heart  (Lapham,  Ibid.).  Adhesions  forbid 
because  they  prevent  pulmonary  collapse.  If  adhesions  exist  the  surgeon 
may  consider  Torek's  operation  to  permit  pulmonary  collapse  (page  1032).  It 
is  maintained  that  the  operation  occludes  the  lymph-channels,  lessens  the 
absorption  of  toxins  (shown  by  the  abatement  of  fever),  prevents  bleeding, 
compresses  the  lung,  arrests  its  mobility,  approximates  the  walls  of  cavities, 
squeezes  masses  of  bacteria  out  of  the  tubes,  favors  the  development  of  fibrous 
tissue,  and  leads  to  healing  of  cavities. 

Certainly  it  seems  that  the  once  widely  condemned  therapeutic  pneumothorax 
is  of  real  value  in  proper  cases  and  causes  not  only  improvement  but  sometimes 
cure  (Burnand,  in  "Rev.  med.  de  la  Suisse  Rom.,"  1915,  xxxv).  Nitrogen 
is  the  best  gas  to  use.  It  is  non-irritant  and  remains  long  in  the  pleural  ca\dty. 
Our  aim  is  to  keep  the  lung  compressed  for  one  year.  The  nitrogen  is  introduced 
by  means  of  a  special  apparatus.  At  first  injections  are  made  daily,  then  every 
other  day,  then  tvnce  a  week,  then  twice  a  month.  The  injection  is  made  "  over 
an  area  where  the  breath  sounds  and  resonance  are  best"  (Lapham,  Ibid.). 
There  is  httle  danger  in  the  method,  but  trouble  may  follow.  There  may  be 
shock,  dyspnea,  or  spasm  of  the  glottis  from  pleural  reflex.  Other  dangers 
are:  gas  embolism,  convulsions,  edema  of  the  lung,  empyema,  pulmonary 
abscess  (if  the  lung  is  stuck),  cerebral  embolism,  and  emphysema  of  the  chest 
wall.  A  danger  is  an  unfavorable  influence  on  the  other  lung.  In  18  cases 
out  of  46  subjected  by  Mayer  to  the  formation  of  an  artificial  pneumothorax 
exudate  formed.  In  eight  of  the  cases  the  exudate  contained  tubercle  bacilli, 
in  two  staphylococci,  and  in  one  pneumococci  (Boit,  in  Beitrag.  z.  klin.  Chir., 
1 9 14,  xciii). 

Plastic  Operations  on  the  Chest  Wall  (Mobilization  of  the  Thorax). — 
Freund  and  others  asserted  that  a  rigid  thorax  is  a  cause  of  phthisis.  Allis^. 
suggested  that  in  extensive  unilateral  tuberculosis  of  the  lung  resection  of  a 
number  of  ribs  would  favor  cure  by  permitting  retraction  of  the  chest  wall. 
This  operation  is  founded  on  the  belief  that  the  chief  element  in  effecting  a  cure 
is  the  formation  and  contraction  of  fibrous  tissue.     Pulmonary  collapse  and 

^  ''Revue  de  Chirurgie,"  Nov.  ii,  1895. 
-  To  State  Med.  Soc.  of  Penna.,  in  1891. 


1032  Surgery  of  the  Respiratory  Organs 

abolition  of  movements  favor  the  formation  of  fibrous  tissue.  In  this  operation 
the  pleura  is  not  opened.  Quincke,  Landerer,  and  others  remove  portions 
of  ribs  with  periosteum  along  the  axillary  line.  Some  surgeons  remove 
portions  of  ribs  and  periosteum  from  directly  over  the  lesion.  In  tuberculosis 
of  the  apex  in  a  person  with  a  narrow  and  rigid  chest  the  followers  of  Freund 
remove  the  first  rib.  Freeman  removes  portions  of  ribs  without  periosteum 
and  applies  a  truss  to  push  in  the  chest  wall  ("Annals  of  Surgery,"  July,  1909). 
Friedrich,  of  Marburg,  removes  all  the  ribs  from  the  second  to  the  tenth  in- 
clusive and  mobilizes  the  first  rib  {thoracico plastic  plenropneiimolysis  with  sub- 
costal apicolysis).  The  pleura  is  not  opened.  He  used  to  remove  the  perios- 
teum, but  does  so  no  longer.  He  now  leaves  the  periosteum  so  that  after  a 
time  enough  bone  will  re-form  to  prevent  lung  bulging  on  coughing.  Sauer- 
bruch,  Wilms,  and  others  have  individual  operations.  When  pneumothorax 
induction  would  be  indicated  were  it  not  for  adhesions  Torek  performs  what  he 
calls  interpleural  pneumolysis. 

A  long  incision  is  made  in  the  sixth  or  seventh  intercostal  space,  the  pleura 
is  opened,  the  head  is  lowered,  the  ribs  are  held  apart,  the  adhesions  are  sepa- 
rated by  the  fingers  and  later  the  hand  is  carried  into  the  pleural  cavity.  When 
adhesions  have  been  well  separated  the  lung  collapses.  The  wound  is  then 
closed  (Surgery,  Gynecology  and  Obstetrics,  1914,  xix).  The  results  of  none  of 
the  above  operations  seem  very  encouraging. 

Operations  on  Pleura  and  Lungs 

Intrathoracic  Operations  Under  Positive  or  Negative  Air=pres= 
sure. — (This  subject  has  been  fully  and  judicially  discussed  by  Jopson  in 
"Annals  of  Surgery,"  May,  191 1.)  When  under  ordinary  conditions  the  chest 
wall  is  widely  opened  the  lung  often  rapidly  collapses  and  the  patient  is  placed 
in  deadly  peril  (see  Acute  Traumatic  Pneumothorax  on  page  1020).  The 
reality  of  the  danger  has  to  a  great  extent  retarded  progress  in  the  surgery  of 
the  heart,  lungs,  and  lower  portion  of  the  esophagus.  Of  late,  however,  methods 
have  been  devised  for  maintaining  normal  respiratory  movements  and  prevent- 
ing pulmonary  collapse  during  operations  which  open  the  pleura.  There  are 
two  forms  of  pressure  apparatus  and  each  form  finds  warm  advocates.  Nega- 
tive pressure  is  the  form  that  is  advocated  by  Sauerbruch.  In  Sauerbruch's 
negative  pressure  chamber  the  lung  is  kept  from  collapse  by  suction  exerted 
upon  its  exposed  surface.  Positive  pressure  is  advocated  by  Brauer.  Positive 
pressure  keeps  the  lung  from  collapsing  by  distending  it  from  within.  The 
two  methods  act  similarly  in  many  respects.  Clinical  observations  and  numer- 
ous experiments  seem  to  prove  that  "emphysema,  persistent  pneumothorax, 
difficulty  of  narcosis,  and  infection  of  the  pleura  are  not  dangers  associated 
with  the  use  of  positive  pressure  as  such"  (Samuel  Robinson  and  George  Adams 
Leland,  in  "Surg.,  Gynecol.,  and  Obstet.,"  March,  1909). 

The  Sauerbruch  Chamber  (Fig.  654). — This  is  an  air-tight  cabinet.  The 
sides  are  of  boards  covered  with  tin,  the  corners  being  soldered.  The  roof  is 
of  glass.     The  sides  contain  air-tight  windows.     There  is  one  air-tight  door. 

The  room  is  lighted  by  electricity  and  contains  a  telephone.  The  larger 
chambers  have  a  communicating  room.  Instruments  which  are  Minted  cai? 
be  placed  in  this  room  so  that  the  surgeon  may  reach  them.  The  patient's 
head  projects  outside  of  the  cabinet  and  a  tightly  fitting  rubber  collar  is  placed 
around  the  neck.  The  body  and  legs  are  surrounded  by  a  canvas-covered  rub- 
ber sac  the  interior  of  which  is  in  communication  with  the  external  air. 

The  chamber  is  sufficiently  large  to  hold  the  patient,  the  surgeon,  and  the 
assistant.  By  means  of  an  electric  suction  air  pump,  the  valve  of  which  is  in  the 
wall,  negative  pressure  is  obtained  and  is  continuously  maintained  in  the 
cabinet.     The  patient's  thorax  is  exposed  to  the  suction  of  negative  pressure. 


Intratracheal  Insufflation 


1033 


but  the  bronchioles  are  subjected  to  ordinary  atmospheric  pressure,  hence, 
even  when  a  wide  opening  is  made  in  the  chest  wall,  the  lung  does  not  collapse. 
The  operator  does  not  suffer  from  the  negative  pressure. 

The  Positive  Pressure  Apparatus. — Numerous  apparatuses  have  been  de- 
vised. Positive  pressure  used  to  be  obtained  by  the  Fell-0'Dwyer  apparatus 
(see  Fig.  653).  The  larynx  was  intubated  and  bellows  were  used.  It  can  be 
obtained  with  this,  but  the  apparatus  is  uncertain  and  difficult  to  use.  Positive 
pressure  can  be  obtained  by  the  pulmotor  and  by  the  lungmotor. 


I'lG.  654. — Sauerbruch's  cabinet:  Position  of  patient  in  chamber  ready  for  operation  under 

negative  pressure. 

Brauer  advocated  the  following  plan:  When  the  patient  has  been  anes- 
thetized and  the  surgeon  is  ready  to  open  the  pleura,  a  glass  case  is  placed  over 
the  patient's  face  and  the  air  in  the  case  is  condensed  by  means  of  an  apparatus. 

Bauer  subsequently  modified  the  head  chamber  so  that  the  hands  and 
wrists  of  the  anesthetist  are  admitted  within  it.  Some  surgeons  have  given 
compressed  air  by  the  nose,  the  mouth  being  sealed.  Some  give  it  by  intuba- 
tion from  the  mouth.     The  trouble  with  this  method  in  man  is  that  no  com- 


FiG.  655. — Scheme  of  apparatus  for  the  maintenance  of  distention  of  the  lung  by  positive 

pressure  (Robinson  andLelandj. 

pletely  satisfactory  tube  has  yet  been  made.  As  a  general  thing  the  best 
way  to  give  it  is  by  a  well-fitting  face  mask.  A  small  motor  runs  a  rotary 
air  pump  and  thus  we  dispense  with  the  trouble  and  uncertainty  of  clumsy 
reservoirs.  Robinson  and  Leland  (Ibid.)  state  that  any  positive  pressure 
apparatus  consists  of  four  elements:  (i)  A  supply  of  compressed  air;  (2)  an 
anesthetizing  segment;  (3)  a  device  for  introducing  air  and  ether  into  the  res- 
piratory tract;  (4)  a  means  of  varying  the  resistance  of  exhaled  air  (Fig.  655). 
Intratracheal  Insufflation  (Method  of  Meltzer  and  Auer). — This  method  is 
highly  valuable.     It  can   be   used   to  maintain  respiration  and,  at  the  same 


I034 


Surgery  of  the  Respiratory  Organs 


time,  to  give  ether.  The  patient  is  first  anesthetized  by  the  ordinary  method. 
A  flexible  and.  elastic  tube  is  then  carried  through  the  larynx  well  into  the 
trachea.  In  order  to  get  it  into  the  larynx  use  a  tube  director  (Cotton  and 
Boothby),  or  use  Chevalier  Jackson's  direct  laryngoscope,  as  do  Elsberg  and 
Peck.  The  tube  usually  enters  the  right  bronchus  before  it  blocks.  When  it 
blocks  it  should  be  drawn  back  5  or  6  cm.  (Meltzer,  in  "Keen's  Surgery,"  vol. 
vi).  The  tube  is  an  English  catheter  or,  as  Elsberg  prefers,  a  woven  silk 
catheter.  The  eye  should  be  at  the  end.  It  is  always  decidedly  less  in 
diameter  than  the  trachea.  Meltzer  says  the  largest  size  used  should  not  ex- 
ceed 8  mm.  in  diameter.     The  tube  is  attached  to  the  insufllation  apparatus. 

This  forces  the  air,  the  air  and  ether,  or  the 
oxygen  and  ether  into  the  lungs,  and  the 
vapor  returns  between  the  tube  and  the 
tracheal  wall. 

Elsberg's  apparatus  is  shown  in  Fig.  656. 
An  electric  current  is  turned  on  at  the  switch 
A.  It  is  carried  by  wire  to  the  motor  C. 
This  motor  drives  blower  D.  The  air  passes 
through  a  tube  E,  an  oil  filter  F,  and  a 
tube  G,  into  a  bottle  H,  containing  hot 
water.  The  air  is  then  forced  through  the 
tube  I  to  a  rubber  tube  connected  to  the 
tracheal  catheter.  The  tube  I  is  also  con- 
nected to  the  ether  jar  J.  The  tube  P  is 
joined  to  a  foot  bellows.  This  is  a  "  safety 
device,"  for  use  if  the  motor  or  blower 
fails  or  if  electricity  is  not  available. 

Exploratory  Puncture  of  the  Pleural 
Sac. — Puncture  often  gives  valuable  in- 
formation as  to  the  existence  of  fluid  in  the 
pleural  sac  and  as  to  the  nature  of  the  fluid. 
The  operation  must  be  performed  with 
aseptic  care,  otherwise  a  serous  effusion 
might  be  converted  into  a  purulent  effusion, 
and  either  a  serous  or  a  purulent  effusion 
might  be  rendered  putrid.  A  large  hypo- 
dermatic syringe  with  a  long  and  strong 
needle  is  used  for  exploratory  puncture.  A 
slender  needle  breaks  easily  and  is  unsafe. 
In  order  to  prevent  breaking  the  needle,  im- 
press upon  the  patient  the  absolute  necessity 
of  keeping  quiet  and  avoiding  any  violent  respiratory  or  general  movement  during 
the  operation.  It  is  not  desirable  to  stick  the  lung,  although  harm  rarely  results 
from  such  an  accident.  If  no  fluid  is  found  in  the  pleura  on  one  trial,  several 
other  punctures  should  be  made.  WTiat  is  known  as  a  dry  tap  may  be  due 
to  the  entire  absence  of  fluid,  to  encapsulation  of  fluid  in  a  region  not  invaded 
by  the  needle,  to  the  lodgment  of  the  point  of  the  needle  in  thickened  pleura 
or  in  an  adhesion,  or  to  blocking  of  the  lumen  of  the  needle  with  coagula. 
Fowler'  points  out  that  if  a  person  has  been  recumbent  for  a  long  time  the 
upper  layer  of  fluid  may  be  clear,  while  the  lower  layer  is  purulent.  The  fluid 
should  be  collected  in  a  sterile  glass  tube  and  subjected  to  a  careful  bacterio- 
logical study. 

Paracentesis  Thoracis. — The  operation  of  tapping  with  a  trocar  and 
allowing  the  fluid  to  flow  out  through  the  cannula  is  no  longer  practised 
except  in  an  emergency,   when   an   aspirator   cannot   be   obtained,  or   in  an 

^  ".\nnals  of  Surgery,"  November.  1896. 


Fk;.  656. — Diagram  of  Elsberg's  ap- 
paratus showing  essential  parts. 


The  Operation  for  Creating  Artificial  Pneumothorax         1035 

early  stage  of  iion-lraumatic   pneumothorax.     An  aspirator  is  a  much  better 
instrument. 

Aspiration  consists  in  the  introduction  into  the  jileural  sac  of  the  tip  of  a 
hollow  needle,  the  other  end  of  which  is  attached  by  means  of  a  rubber  tube  to  a 
bottle  from  which  the  air  has  been  exhausted.  The  fluid  does  not  run  out,  but 
is  sucked  out,  air  is  excluded,  and  bacteria  do  not  enter  the  pleural  sac.  Fig.  492 
shows  a  pneumatic  aspirator.  No  anesthetic  is  required.  The  patient's  skin, 
the  instruments,  and  the  surgeon's  hands  must  be  thoroughly  asepticized. 
The  patient  is  given  a  little  whisky,  and,  unless  he  is  very  weak,  he  assumes 
a  semi-erect  attitude,  with  the  arm  hanging  by  the  side.  The  trocar  is  intro- 
duced in  the  tifth  interspace,  just  in  front  of  the  angle  of  the  scapula.  The 
surgeon  marks  the  upper  border  of  the  sixth  rib  with  the  index-finger,  and 
plunges  in  the  trocar  just  above  the  finger,  thus  avoiding  the  intercostal  artery, 
which  lies  along  the  lower  border  of  the  rib  above.  He  guards  the  needle 
with  the  index-finger  to  prevent  its  going  in  too  far.  The  fluid  is  withdrawn 
rather  slowly  in  order  that  the  patient  may  escape  syncope  and  violent  cough. 
If  the  patient  becomes  very  faint  the  operation  should  be  abandoned.  All 
the  fluid  present  should  not  be  removed  at  one  sitting — complete  removal 
of  a  large  effusion  is  not  safe.  The  operation  can  be  repeated  if  necessary. 
After  withdrawing  the  cannula  place  iodoform  collodion  over  the  opening 
in  the  chest.  In  an  early  stage  of  non-traumatic  pneumothorax  perform 
paracentesis  without  suction.  In  non-purulent  pleuritic  effusion,  if  the  lungs 
will  not  expand  after  tappings,  perform  thoracotomy.  In  some  cases  aspiration 
is  followed  by  pulmonary  embolism  or  embolism  at  a  distance.  Syncope  is  a 
not  unusual  result.  Convulsions  occasionally  occur.  In  rare  cases  the  sudden 
withdrawal  of  a  large  effusion  is  followed  by  albuminous  expectoration,  as  was 
pointed  out  by  Pinault  in  1853.  It  usually  begins  from  a  few  minutes  to  half 
an  hour  after  aspiration.  When  this  complication  arises  the  pulse  is  very 
weak,  there  are  severe  dyspnea,  cyanosis,  cough,  and  the  expectoration  of 
quantities  of  a  yellow,  frothy  fluid.  Riesman  ("Amer.  Jour.  Med.  Sciences," 
April,  1902)  demonstrates  that  the  condition  is  due  to  pulmonary  edema 
and  not  to  puncture  of  the  lung.  The  sudden  withdrawal  of  fluid  by  aspiration 
relieves  the  pressure  which  was  compressing  the  lung,  the  lung  becomes  con- 
gested with  blood  (congestion  by  recoil,  Riesman  calls  it),  the  blood  distends 
weakened ,  vessels,  and  profuse  transudation  takes  place  into  the  air-cells. 
Most  cases  recover  in  a  few  hours  or  a  day  or  two.  Severe  cases  die 
from  asphyxia.  Terrilon  collected  23  cases,  with  2  deaths.  If  albuminous 
expectoration  arises,  dry  cup  the  chest  and  counterirritate  with  mustard  plasters. 
Perform  venesection.  Give  ox}^gen  by  inhalation.  Administer  atropin  hypo- 
derma  tically.     Employ  artificial  respiration  if  necessary. 

The  Operation  for  Creating  Artificial  Pneumothorax. — Murphy's 
apparatus  as  modified  by  Brauer  is  shown  in  Fig.  657.  The  manometer  is  on 
the  left-hand  side  of  the  figure.  The  jar  for  nitrogen  (.4)  contains  a  solution  of 
corrosive  sublimate  through  which  the  gas  flows.  The  water  jar  (B)  is  lowered 
and  the  nitrogen  tube  is  opened,  and  as  the  stream  of  nitrogen  passes  along  the 
glass  tube  it  goes  through  a  filter  of  sterile  cotton.  The  tube  from  the  jar  of. 
nitrogen  joins  a  three-way  stopcock  (C).  The  nitrogen  may  be  made  to  flow- 
through  the  needle  (H),  or  deUver  the  intrapleural  pressure  to  a  water  man- 
ometer and  a  'mercury  manometer.  After  determining  that  the  functional 
capacity  of  the  other  lung  is  sufficient  to  sustain  the  demands  about  to  be  put 
upon  it,  proceed  with  the  operation.  Follow  Brauer 's  plan  because  it  is  the 
safest.  Select  a  spot  where  the  healthy  sounds  and  resonance  are  best  heard 
(Mary  E.  Lapham,  ''Amer.  Jour.  Med.  Sciences,"  April,  1912).  Expose  the 
pleura  by  an  incision.  If  adhesions  are  absent,  puncture  by  a  blunt  instrument 
and  explore  by  a  catheter  to  be  sure  there  is  a  pleural  cavity.  If  a  cavity 
exists  attach  the  needle  to  the  apparatus  and  inject  the  nitrogen.     After  in- 


1036 


Surgery  of  the  Respiratory  Organs 


jection  suture  the  wound.  Subsequent  injections  are  made  b\-  the  needle  alone, 
no  incision  being  required. 

Thoracotomy  is  an  incision  into  the  cavity  of  the  pleura.  It  may  be 
merely  an  intercostal  incision,  or  may  be  an  opening  into  the  chest  after  re- 
secting a  portion  of  a  rib.  Often  in  a  child  with  empyema  good  drainage 
can  be  obtained  by  an  intercostal  incision,  but  in  most  children  and  in  all  adults 
a  rib  should  be  resected. 

If  there  is  very  little  dyspnea,  ether  may  be  given.  If  there  is  considerable 
dyspnea,  chloroform  should  be  given.  If  there  is  severe  dyspnea,  no  general 
anesthetic  is  admissible.  In  severe  dyspnea  the  patient  is  using  certain  vol- 
untary muscles  to  aid  him  in  obtaining  air.  A  general  anesthetic  abolishes 
the  activity  of  the  voluntary  muscles  of  respiration,  and  so  may  cause  sufTo- 
cation.     In  such  cases  the  operation  can  be  done  with  fair  satisfaction  after 


Fig.  657. — Brauer  and  Spengler's  modification  of  Murphy's  apparatus  for  nitrogen  injections. 


the  injection  of  eucain  or  after  infiltrating  the  superficial  tissues  of  the  chest 
wall  with  Schleich's  fluid,  or,  what  is  better,  preliminary  aspiration  can  be 
performed.  Aspiration  wall  permit  of  the  subsequent  administration  of  a 
general  anesthetic.  The  patient  on  whom  thoracotomy  is  to  be  performed 
is  placed  supine,  the  diseased  side  being  at  or  over  the  edge  of  the  table.  He 
must  never  be  placed  on  the  sound  side,  because  he  breathes  with  that  side 
only,  and  pressure  on  it  may  be  dangerous. 

The  arm  of  the  diseased  side  should  be  elevated  to  a  right  angle  with  the 
body.  If  the  surgeon  desires  to  obtain  intercostal  drainage  only,  he  should 
make  a  longitudinal  incision  about  3  inches  in  length  at  the  upper  border  of 
the  sixth  or  seventh  rib,  and  the  middile  of  this  incision  should  correspond  to  the 
midaxillary  Line.  This  incision  is  carried,  layer  by  layer,  to  the  pleura.  If, 
as  will  usually  be  the  case,  he  wishes  to  remove  a  portion  of  a  rib,  he  will  make 
an  incision  about  3  inches  in  length  directly  upon  the  outer  surface  of  the  rib 
he  wishes  to  remove,  and  the  middle  of  this  incision  should  correspond  to  the 
midaxillary  line.  Some  surgeons  resect  a  portion  of  the  fifth  rib,  some  remove 
a  bit  of  the  eighth  rib,  and  Munro^  shows  that  at  the  level  of  the  eighth  rib  there 
is  no  danger  of  injuring  the  diaphragm.  By  many  operators  a  portion  of  the 
seventh  or  eighth  rib  is  removed  in  front  of  the  line  of  the  posterior  axillary  fold. 

*  "Medical  News,"  Sept.  2,  1899. 


Thorac()t()m\-  1 0,^5  7 

I  agree  with  HuUon  that  a  portion  of  the  sixth  rib  in  the  midaxillary  Hne 
should  be  removed.^  The  reasons  given  by  Hutton  for  the  selection  of  this 
rib  are:  (i)  It  is  over  the  portion  of  the  lung  which  expands  last.  An  empyema 
is  drained  only  partly  by  gravity,  and  most  of  the  fluid  is  really  forced  out 
and  the  cavity  is  obliterated  by  lung  expansion.  If  an  incision  is  made  anterior 
or  posterior  to  this  point  the  expanding  lung  will  block  the  drainage  opening, 
and  a  pus-cavity  without  drainage  will  remain  in  the  midaxillary  line.  (2) 
Such  an  incision  permits  a  patient  to  lie  on  his  back  without  making  pressure 
on  the  drainage-tube. 

The  periosteum  of  the  outer  surface  of  the  rib  must  be  divided  in  the  same 
direction  as  the  superficial  incision.  The  exposed  rib  is  stripped  of  periosteum 
front  and  back  by  means  of  a  periosteal  separator,  and  with  the  periosteum 
at  the  lower  border  of  the  rib  the  intercostal  artery  is  lifted  out  of  harm's  way. 
The  rib  can  be  divided  by  means  of  cutting  forceps  or  a  Gigli  saw.  The  usual 
method  is  to  push  a  periosteal  separator  under  the  rib  and  saw  the  bone  in  two 
places  by  means  of  a  metacarpal  saw  (Fig.  658).     I  prefer  * 

a  costotome,  as  it  accomphshes  the  section  most  rapidly. 
An  inch  or  more  of  the  rib  should  be  removed.  The  in- 
tercostal artery  is  ligated  at  each  end  of  the  incision, 
the  periosteum  is  removed,  and  the  pleura  is  opened. 
The  object  of  removing  the  periosteum  is  to  prevent  the 
rapid  formation  of  bone  which  might  narrow  the  opening 
and  interfere  with  drainage.  The  actual  opening  of  the 
pleura  is  carried  out  in  the  same  way  in  intercostal  in- 
cision and  after  rib  resection.  A  grooved  director  is 
pushed  into  the  pleural  sac,  and  the  opening  is  enlarged 
by  means  of  the  forceps  and  the  finger.  yig.  658. Resec- 

The  finger  removes  all  masses  of  tuberculous  material  tionof  arib(Esmarch 
or  aplastic  lymph  within  reach.  If  the  finger  finds  the  and  Kowalzig). 
lung  firmly  bound  down  by  dense  adhesions  so  that  it 
cannot  expand,  simple  rib-resection  will  not  cure  the  patient.  If  the  ad- 
hesions between  the  parietal  and  visceral  pleura  can  be  separated  by  the 
finger  the  lung  may  expand.  In  order  to  accomplish  this  separation  a 
piece  of  more  than  one  rib  must  be  removed,  because  it  is  necessary  to  insert 
more  than  two  fingers  (Samuel  Lloyd,  quoted  by  Lund,  in  "Jour.  Am.  Med. 
Assoc,"  August  26,  191 1).  If  adhesions  cannot  be  separated  so  that  the  lung 
can  expand,  Estlander's,  Schede's,  or  Fowler's  operation  should  be  done.  Some 
surgeons  advocate  immediate  irrigation  after  opening  an  acute  empyema, 
but  this  procedure  has  long  been  thought  unsafe.  It  is  true  that  in  most  cases 
flushing  does  no  harm,  but  in  no  case  will  a  single  flushing  sterilize  the  cavity, 
and  in  some  cases  it  is  very  dangerous.  The  pleura  is  very  susceptible  to  the 
action  of  irritants.  This  is  especially  true  of  young  children.  It  happens 
occasionally  that  the  injection  of  the  blandest  fluid  is  followed  by  intense 
dyspnea,  great  shock,  disturbances  of  respiration  and  circulation,  convulsions, 
and  even  death  (Quenu).  The  convulsions  which  occasionally  follow  pleural 
irrigation  were  called  by  de  Cerenville  pleural  epilepsy.  In  putrid  empyema 
I  have  always  irrigated.  Irrigation  will  remove  part  of  the  actively  poisonous 
putrid  matter,  and  the  retention  of  putrid  matter  is  a  greater  danger  than 
irrigation.  I  now  irrigate  all  empyemata  gently  every  two  hours  with  Dakin's 
fluid.  This  combats  foulness,  fever,  and  suppuration,  and  favors  healing. 
It  is  much  safer  than  flushing  by  means  of  a  large  and  forcible  stream  but 
even  this  process  sometimes  produces  pleural  epilepsy  (seepage  1018).  Some 
beheve  that  pleural  epilepsy  is  a  reflex  phenomenon.  Others,  especially  Breuer, 
maintain  that  it  is  due  to  embolism.  In  favor  of  the  reflex  theory  is  the  fact 
that  a  preliminary  injection  of  morphia  prevents  it.     I  regard  the  method  as 

^  See  W.  Menzies  Hutton  on  "Empyema,"  in  "Brit.  Med.  Jour.,"  Oct.  29,  1898. 


1038  Surgery  of  the  Respiratory  Organs 

an  immense  improvement  in  practice.  It  saves  many  lives  in  spite  of  its  occa- 
sional danger.  The  balance  is  strongly  in  its  favor.  It  was  formerK-  a  common 
custom  to  make  a  counteropening  by  cutting  down  upon  the  long  probe  pushed 
against  the  chest  wall  after  being  introduced  through  the  incision,  but  a  counter- 
opening  is  of  no  particular  use.  A  drainage-tube  about  2  inches  in  length, 
carrying  a  Carrel  tube  fastened  upon  it,  is  introduced  and  stitched  in  place. 
The  tube  must  not  be  long  enough  to  touch  the  lung.  A  safety-pin  is  clamped 
upon  the  tube  to  keep  it  from  slipping  into  the  chest.  A  tape  should  be  fastened 
to  each  side  of  the  tube  and  tied  about  the  chest  to  prevent  it  from  slipping  out. 
Arrest  bleeding,  suture  the  skin,  dress  with  gauze  and  a  binder,  and  have  the 
dressings  changed  as  soon  as  they  become  soaked  at  one  point.  The  Carrel 
tube  is  kept  blocked  except  when  we  irrigate.  Then  the  drainage  tube  is 
blocked  and  the  fluid  is  permitted  to  flow  in.  When  sufl5cient  has  entered 
the  Carrel  tube  is  blocked  and  the  drainage  tube  is  opened.  This  process 
is  repeated  until  the  fluid  runs  out  clear.  Several  times  a  day  change  the 
patient's  position.  At  each  change  of  dressings  direct  him  to  lie  on  the  diseased 
side  with  the  foot  of  the  bed  raised  for  half  an  hour.  Healing  takes  place  by 
ascent  of  the  diaphragm,  expansion  of  the  lung,  and  retraction  of  the  chest  wall. 
Expansion  of  the  lung  is  favored  by  expiratory  acts;  hence  cause  the  patient 
several  times  a  day  to  blow  through  a  rubber  tube  into  a  i-gallon  Wolff  bottle 
filled  with  water.  The  water  is  blown  into  another  bottle  attached  to  the  first 
by  a  tube.  Remove  the  drainage-tube  when  the  discharge  becomes  thin  and 
scanty  (about  the  eighth  or  tenth  day,  as  a  rule).  If  an  empyema  ceases  to  im- 
prove and  remains  stationary  for  months  after  it  has  been  drained,  firm  adhe- 
sions exist.  If  after  one  year  has  passed  a  cavity  still  exists  and  there  is  a 
flow  of  pus,  the  surgeon  must  perform  the  operation  of  Schede,  Estlander, 
Fowler,  or  Ransohoff. 

Thoracoplasty  (Estlander's  operation)  was  first  proposed  by  Warren 
Stone,  an  American  surgeon,  but  was  set  forth  in  detail  by  Estlander,  of 
Helsingfors,  in  1879.  It  is  employed  in  old  cases  of  empyema  in  which  drainage 
has  failed  and  in  cases  with  retracted  chest  wall,  collapsed  lung,  thickened 
pleura,  and  cavities  whose  rigid  walls  will  not  collapse.  The  procedure  recog- 
nizes the  fact  that  after  pus  is  evacuated,  if  the  lung  is  adherent,  it  cannot 
expand  to  fill  the  space  once  occupied  by  fluid,  and  that  the  rigid  chest  wall 
cannot  fall  in  as  a  substitute  for  the  lung.  It  seeks  to  destroy  the  rigidity 
of  the  chest  wall  and  to  permit  it  to  collapse  and  thus  obliterate  the  cavity 
of  the  empyema.  In  this  operation  a  piece  is  removed  from  every  rib  which 
overlies  the  cavity.  When  the  surgeon  resects  a  rib  and  finds  a  cavity  with 
uncollapsible  walls,  or  a  lung  bound  down  with  firm  adhesions,  he  should 
perform  thoracoplasty.  This  operation  causes  the  obliteration  of  the  cavity  by 
collapsing  that  portion  of  the  chest  wall  overlying  it.  The  cavity  is  usually 
in  the  upper  or  central  part  of  the  pleural  space.  The  instruments  required 
are  the  same  as  those  for  resection  of  a  rib.  The  position  is  the  same-as  that 
for  rib  resection.  The  length  of  the  incision  depends  on  the  size  of  the  cavity. 
The  surgeon  usually  removes  portions  of  the  second,  third,  fourth,  fifth,  sixth, 
and  seventh  ribs.  Make  a  transverse  incision  along  the  center  of  an  intercostal 
space,  and  through  this  incision  remove  the  ribs  above  and  below  by  the 
method  set  forth  on  page  1036  (the  removal  of  six  ribs  will  require  three  incisions) . 
Instead  of  this  incision,  we  can  make  a  vertical  incision  or  a  U-shaped  flap. 
Always  take  away  the  periosteum  in  order  to  prevent  reproduction  of  the 
ribs.  In  cavities  which  are  surrounded  by  firm  adhesions,  and  in  old  cases  in 
which  the  pleura  is  greatly  thickened,  irrigation  is  safe.  If  the  cavity  is  small, 
it  should  be  packed  with  iodoform  gauze  and  allowed  to  granulate;  if  large, 
it  should  be  drained  by  a  large  tube,  the  skin  being  sutured  by  silkworm-gut. 

Schede's  Operation. — Schede,  of  Hamburg,  showed  that  when  the  pleura  is 
much  thickened,  even  Estlander's  operation  will  not  permit  the  chest  wall  to 


Total  Pleurectomy  or  Pulmonary  Decortication 


1039 


collapse  and  fill  the  cavity  once  occupied  by  the  fluid.  The  instruments  used 
are  the  same  as  for  Estlander's  operation.  A  U-shaped  flap  is  made  from 
the  level  of  the  axilla  in  front  to  the  level  of  the  second  rib  and  between  the 
scapula  and  spine  behind.  The  lowest  level  of  this  incision  corresponds  to 
the  lowest  limit  of  the  pleura  (Fig.  659).  The  flap  is  loosened  and  raised  and 
the  scapula  is  lifted  with  it.  The  ribs  from  the  second  rib  down  and  from 
the  costal  cartilages  to  the  tubercles  are  removed,  along  with  the  intercostal 
muscles  and  the  pleura.  This  is  accomplished  by  cutting  with  bone-shears 
and  scissors.  Hemorrhage  is  arrested.  The  pleura  is  curetted.  A  drainage- 
tube  or  a  piece  of  iodoform  gauze  is  introduced,  and  the  raw  flap  is  laid 
against  the  visceral  layer  of  the  pleura.  The  superficial  incision  is  sutured, 
except  at  the  point  where  the  tube  or  the  gauze 
emerges.  The  average  mortality  from  Schede's 
operation  is  from  15  to  20  per  cent.  The 
operation  is  far  more  often  necessary  in  adults, 
but  the  results  are  much  better  in  children. 

Total  Pleurectomy  or  Pulmonary  De= 
cortication  (Fowler's  Operation). — In  the 
spring  of  1893  de  Lorme,  of  the  Val  de  Grace, 
performed  some  experiments  on  dogs  looking  to 
the  development  of  the  operation.  In  October, 
1893,  the  late  George  Ryerson  Fowler,  of 
Brooklyn,  having  no  knowledge  of  de  Lorme 's 
investigation,  operated  on  a  man  and  cured  a 
chronic  empyema.  The  French  surgeon's  first 
operation  was  months  later.  De  Lorme  sought 
to  do  without  the  great  mutflation  of  the 
Schede  operation.  His  idea  was  to  make  an 
opening  in  the  chest  \yr\1  large  enough  to 
work  through  (but  not  nearly  so  large  as  that 
caused  by  Schede's  operation),  incise  the  dense 
fibrous  membrane  which  binds  down  the  lung, 
and  allow  the  lung    to    expand   and    fill    the 

cavity.  De  Lorme  makes  a  trap-door  incision.  Fowler  resected  ribs  ex- 
tensively to  obtain  room.  The  thickened  fibrous  membrane  is  removed  from 
the  chest  wall,  lung,  pericardium,  and  diaphragm,  any  sinus  is  extirpated, 
and  all  granulation  tissue  is  taken  away.  The  shrunken  lung  expands  to  fill 
the  cavity. 

Lund  describes  the  operation  as  follows  ("Jour.  Am.  Med.  Assoc,"  August 
26,  1911):  "In  regard  to  the  technic  of  the  operation,  the  method  of  the  re- 
section of  i}4,  inches  of  five  or  six  ribs,  through  an  incision  running  upward  an 
forward  from  the  anterior  end  of  the  old  drainage  incision,  has  proved,  to  my 
mind,  very  satisfactory.  In  slitting  up  the  thickened  pleura  beneath  the  ribs 
I  have  had,  in  one  or  two  cases,  to  grab  the  intercostal  artery,  but  have  been 
very  much  surprised  to  find  how  little  trouble  there  has  been  from  bleeding. 
The  visceral  pleura,  which  is  about  ^i  inch  thick  and  which  is  more  like  the 
sole  of  an  old  rubber  shoe  than  anything  else,  is  carefully  incised  with  a  knife 
over  the  lower  part  of  the  lung.  The  finger  is  inserted  through  the  incision  and, 
as  soon  as  the  soft  surface  of  the  lung  is  felt,  is  swept  to  an  fro  with  the  pulp  of 
the  finger  tow^ard  the  pleura  and  pressing  outward  so  as  to  cause  the  least 
possible  damage  to  the  lung.  Then  a  pair  of  blunt-pointed  scissors  is  inserted 
and  the  membrane  slit  clear  up  to  the  top  of  the  chest,  and  cleared  off  from  the 
lung  with  the  finger.  A  wound  of  one  or  two  of  the  air-cells  resulted  in  2  or  3 
of  my  cases,  allowing  the  escape  of  bubbles  of  air  on  exploration,  but  so  small  an 
area  of  the  lung  was  afl'ected  that,  apparently,  no  harm  resulted.  In  regard  to 
the  after-treatment,  it  is  probable  that  after  the  patient  is  put  to  bed  the  lung 


Fig.  659.  —  Incision  for 
Schede's  operation  of  thoracoplasty 
(Esmarch  and  Kowalzig). 


1 040  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

does  retract  to  a  certain  extent,  but  the  occasional  coughing  keeps  up  the  expan- 
sion. The  thick,  pus-soaked  dressing,  if  tightly  applied,  to  my  mind,  acts  as 
a  more  efficient  valve  than  any  mechanical  valve  which  one  could  employ." 

Fowler  made  a  report  of  30  cases.  Eleven  cases  were  completely  cured. 
In  17  cases  the  empyema  was  cured,  but  6  of  them  had  tuberculosis.  There 
were  3  deaths.  The  combined  statistics  of  Fowler,  de  Lorme,  and  Cestan 
show  35.7  per  cent,  cured,  19.7  per  cent,  improved,  33.9  per  cent,  not  cured,, 
and  10  per  cent,  died  (Kurpjweit,  in  ''Beitrage  fur  klinischen  Chirurgie,"  Bd. 
xxxiii,  H.  3). 

Discission  of  the  Pulmonary  Pleura  (Ransohofif's  Operation). — This 
operation  was  devised  by  Ransohoff,  of  Cincinnati.  It  can  be  employed 
when  decortication  is  impossible,  and  it  may  be  used  as  a  substitute  for  decor- 
tication in  certain  cases.  It  permits  the  shrunken  lung  to  expand.  It  is 
founded  on  the  observation  that  if  the  thickened  pleura  over  a  shrunken  lung 
is  incised  the  cut  widens  with  each  respiration  and  quickly  becomes  a  groove 
(Ransohoff,  in  "Annals  of  Surgery,"  April,  1906).  The  pulmonary  pleura  is 
divided  by  numerous  parallel  incisions  3<4  inch  apart,  and  then  similar  incisions 
are  made  to  cross  these.  An  incision  is  also  carried  through  the  costal  side 
of  the  angle  of  reflection  of  the  pulmonary  and  costal  pleura. 

Pneumotomy  for  Abscess  and  Gangrene  of  the  Lung. — Pneumotomy 
is  employed  for  abscess,  gangrene,  and  bronchiectasis.  Give  chloroform 
or  use  a  local  anesthetic.  Place  the  patient  recumbent  with  the  shoulders  a 
little  raised.  Make  a  U-shaped  flap  over  the  seat  of  disease.  Resect  a  portion 
of  a  rib.  If  it  is  found  that  adhesions  do  not  exist  between  the  pulmonary  and 
costal  layers  of  the  pleura,  stitch  these  layers  together  with  catgut,  and  either 
postpone  further  operation  for  forty-eight  hours  or  surround  the  area  by  gauze 
and  operate  at  once.  If  adhesions  exist,  proceed  at  once.  Chloroform  can  be 
put  aside  when  the  pleura  is  exposed.  Fowler  called  attention  to  the  fact  that 
lung  tissue  is  so  insensitive  that  the  administration  of  an  anesthetic  can  be 
suspended  as  soon  as  the  pleura  has  been  opened.  Incise  the  agglutinated 
layers  of  the  pleura,  and  pass  an  aspirating  needle  into  the  lung  in  various 
directions.  When  the  abscess  is  located,  open  it  by  the  cautery.  Carry  the 
Paquelin  cautery  slowly  into  the  lung  in  the  direction  of  the  abscess-cavity. 
The  cautery  knife  should  be  at  a  dull-red  heat. 

When  the  cautery  opens  the  cavity  of  the  abscess,  withdraw  the  instrument 
and  insert  a  drainage-tube,  and  suture  the  flap  of  superficial  tissue.  If  the 
abscess  is  not  found  after  one  or  two  punctures  by  the  aspirating  needle,  aban- 
don the  attempt. 

Tuffier  explores  for  an  abscess  by  what  he  calls  decollcment  of  the  parietal 
pleura.  He  exposes  the  parietal  layer  of  the  pleura,  passes  his  hand  between 
this  layer  and  the  chest  wall,  strips  the  pleura  ofif  over  a  considerable  area, 
and  is  able  to  feel  the  lung  beneath  and  thus  determine  its  condition. 

Hartmann  ("Presse  Medicale,"  April  27,  191 2)  states  that  Garre  collected 
96  cases  of  abscess,  with  19  deaths,  and  122  cases  of  gangrene,  with  42  deaths. 
In  bronchiectasis  pneumotomy  may  be  employed.  Hartmann  (Ibid.)  com- 
bines the  cases  of  Korte  and  Sauerbruch,  and  states  that  in  149  cases  there 
were  46  cures.  In  Sauerbruch's  133  cases  there  were  40  cures,  43  deaths,  and 
7  were  improved. 

XXVII.  DISEASES  AND  INJURIES  OF  THE  UPPER 
DIGESTIVE  TRACT 

Injuries  and  Diseases  of  the  Face,  Nose,  Mouth,  Salivary  Glands, 
Tongue,  Jaws,  and  Esophagus.  Closure  of  the  Jaws. — This  condition  may 
be  caused  by  tetanus,  by  the  irritation  of  a  non-erupted  wisdom  tooth,  carious 
teeth,  by  cancer  of  the  mouth,  sarcoma  of  the  jaws,  alveolar  abscess,  cicatricial 
contractions  due  to  burns  or  noma,  and  temporomaxillary  ankylosis.     In  many 


Necrosis  of  the  Jaw  1041 

cases  of  old  wounds  and  scars  constriction  is  due  to  rapidly  developing  muscular 
contracture.  It  seldom  arises  if  the  jaw  is  fractured.  It  is  a  condition  of 
hysterical  hypermyotonia,  and  is  analogous  to  contractures  of  the  limb.  The 
jaws  c5n  always  be  opened  widely  by  the  gradual  use  of  a  dilator.  Treatment 
of  contracture  is  by  repeated  gradual  dilatation  and  by  suggestion.  The  con- 
dition is  curable. 

Temporomaxillary  Ankylosis. — Ankylosis  of  the  temporomaxillary  joint 
may  result  from  gonorrheal  arthritis,  rheumatoid  arthritis,  or  fracture  of  the 
condyle.  Even  when  one  joint  is  completely  ankylosed,  the  jaws  upon  the 
sound  side  can  be  somewhat  separated  because  of  the  elasticity  of  the  mandible. 
The  constriction  may  be  fibrous,  the  result  of  peri-arthritis  of  the  articulation. 
It  may  be  bony. 

Treatment. — Gradual  dilatation  by  means  of  box-wood  screws  is  useless 
even  for  fibrous  constriction.  Violent  separation  is  without  value.  After 
either  method  the  condition  always  recurs  rapidly.  Esmarch  removed  a 
wedge-shaped  piece  of  bone  from  the  angle  of  the  jaw  in  order  to  form  a  false 
joint.  Other  operators  do  a  like  operation  on  the  ramus.  A  simple  osteotomy 
is  certain  to  fail  because  bony  union  will  occur. '  That  is  the  trouble  with  Swain's 
operation  (sawing  the  body  at  the  angle).  Bony  union  may  be  prevented  by 
resecting  the  zygoma  and  putting  a  flap  of  temporal  muscle  between  the  frag- 
ments (Helferich).  The  masseter  may  be  used.  Removal  of  the  condyle  and 
a  portion  of  the  neck  is  usually  efficient.  In  double  ankylosis  both  condyles 
should  be  resected.  Verneuil,  in  i860,  suggested  mobilizing  the  joint  and  inter- 
posing an  attached  flap  of  temporal  muscle  between  the  condyle  and  the  socket. 
Such  an  operation  may  give  a  gratifying  result.  Murphy  divided  the  neck 
of  the  mandible  and  removed  sufficient  tissue  to  permit  of  the  interposition  of 
a  flap  of  fat  and  fascia.  He  fixed  the  lower  border  of  the  flap  to  the  upper  border 
of  the  zygoma  and  sutured  the  flap  in  place  between  the  bones. 

Alveolar  Abscess, — This  condition  is  caused  by  a  decayed  tooth.  A  super- 
ficial abscess  is  known  as  a  gum-boil.  The  process  may  spread  to  the  jaw- 
bone, causing  necrosis.  From  the  maxilla  the  suppuration  may  enter  the 
antrum.     From  the  lower  jaw  pus  may  track  into  the  neck. 

Treatment. — Early  and  free  incision;  usually,  but  not  always,  the  extraction 
of  the  offending  tooth,  and  drainage. 

Necrosis  of  the  Jaw. — Extensive  necrosis  is  much  more  common  in  the  lower 
than  in  the  upper  jaw.  Necrosis  of  the  alveolar  process  of  either  jaw  may  be 
due  to  suppurative  periostitis,  the  result  of  carious  teeth.  In  suppurative 
periostitis  of  this  form  an  alveolar  abscess  arises  which  is  followed  perhaps 
by  circumscribed  necrosis.  In  rare  cases  widespread  suppurative  periostitis 
occurs  which  may  result  in  extensive  necrosis. 

Syphilis  produces  periostitis  and  osteomyelitis,  but  more  commonly  causes 
caries  than  necrosis.  Tuberculous  periostitis  may  result  in  limited  necrosis. 
Its  most  common  site  is  the  orbital  margin  of  the  maxilla. 

Actinomycosis  is  a  rare  cause  of  necrosis.  In  mercurial  salivation  extensive 
necrosis  is  prone  to  occur.  A  child  suffering  during  dentition  from  an  exan- 
thematous  fever  or  other  virulent  infection  is  liable  to  a  violently  acute  sup- 
purative periostitis  and  osteomyelitis  with  evidence  of  severe  general  infection. 
In  the  lower  jaw  particularly  extensive  and  usually  symmetrical  necrosis  follows. 

Treatment. — In  an  acute  suppurative  periostitis,  if  there  is  a  carious  tooth, 
extract  it,  and  incise  the  gum  to  the  bone;  if  osteomyelitis  exists  open  the  outer 
plate  of  the  bone,  and  order  frequent  cleansing  of  the  mouth  by  antiseptic 
washes.  In  syphilitic  caries  place  the  patient  on  anti syphilitic  treatment  and 
use  a  curet  to  remove  carious  bone.  In  tuberculous  caries  use  a  curet  and  em- 
ploy antituberculous  treatment. 

When  necrosis  occurs  it  is  usual  to  wait  until  the  sequestrum  loosens  before 
removing  it,  but  early  sequestrectomy  is  a  better  plan.     The  sequestrum  is 

66 


I042  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

usually  removed  through  the  mouth  or  nose.     If  there  is  profuse  suppuration, 
remove  the  dead  bone  by  subperiosteal  resection  (Tillmanns's  "Text-Book  of 

Surgery")- 

Phosphorus  Necrosis, — This  condition  was  first  observed  by  Lorinser,  of 
Vienna,  in  1838  and  was  fully  described  by  Bibra  and  Geist  in  1847.  It  is  seen 
among  those  who  mix,  box  and  dip  in  factories  in  which  matches  are  made  from 
yellow  phosphorus.  Recent  legislation  against  the  use  of  yellow  phosphorus 
is  wiping  out  the  affliction.  The  condition  is  most  common  in  the  lower  jaw, 
but  it  may  occur  in  either  jaw,  or  in  both  jaws.  Most  sufferers  have  decayed 
teeth  but  Lewin  of  Berlin  claims  that  decayed  teeth  do  not  exist  in  all  cases. 

It  is  supposed  that  the  fumes  dissolve  in  saliva  and  the  fluid  enters  the  cavities 
in  the  diseased  teeth.  We  know  that  fumes  are  not  the  sole  cause.  If  a  worker 
eats  food  without  washing  his  hands  he  may  come  to  trouble.  In  some  cases 
the  condition  does  not  manifest  itself  for  a  year  or  even  two  years  after  a  man 
has  ceased  working  in  a  match  factory.  There  may  be  serious  impairment  of 
the  general  health  when  the  necrosis  begins  (albuminuria,  pallor  and  dyspnea). 

Oliver  points  out  that  in  phosphorus  workers  there  is  a  decided  tendency 
to  fracture  of  the  long  bones. 

The  first  lesion  is  periostitis.  The  gums  and  jaw  swell  and  become  painful, 
salivation  occurs,  pus  forms  eventually  even  if  there  is  ossifying  periostitis. 
In  that  case  the  pus  gathers  between  the  periosteum  and  new  bone  or  between  the 
new  bone  and  old  bone.  The  jaw  enlarges  enormously  and  the  bone  is  slowly 
destroyed.  Eventually  extensive  necrosis  takes  place,  sinuses  form  and  the 
patient  may  become  toxic  from  swallowing  quantities  of  foul  pus.  Dead  bone 
may  be  cast  off.  The  entire  lower  jaw  may  be  lost.  The  bones  of  the  base  of 
the  skull  may  be  destroyed  and  meningitis  may  arise. 

Most  of  the  victims  of  phosphorus  necrosis  get  many  teeth  pulled  but  even 
wholesale  extraction  does  not  cure  the  pain. 

Tillmanns  (quoting  Maas,  Binz  and  others)  states  that  arsenic  and  pyrogalHc 
acid  act  like  phosphorus,  and  tend  to  produce  ossifying  periostitis. 

If  yellow  phosphorus  is  used  the  paste  should  be  mixed  in  closed  vessels  by 
a  machine.  Dipping  and  boxing  are  sources  of  danger  from  fumes  and  should 
be  done  only  in  ver\'  well-ventilated  places. 

Phosphorous  workers  should  always  wash  their  hands  before  eating,  should 
never  eat  in  the  factory  and  should  take  the  best  of  care  of  the  teeth.  The 
treatment  of  necrosis  consists  in  the  removal  of  the  victim  from  the  fumes, 
making  him  live  in  the  open  air  and  frequently  use  antiseptic  mouth-washes. 
If  pus  forms  incisions  are  required.  Early  subperiosteal  sequestrectomy  by 
means  of  a  chisel  and  mallet  is  indicated. 

Wounds  of  the  Salivary  Glands. — An  aseptic  wound  usually  heals  and 
rarely  results  in  a  salivary  fistula,  although  after  healing  it  is  not  unusual  for 
an  encysted  collection  of  saliva  to  gather  under  the  skin.  Such  a  collection  of 
saliva,  if  it  does  not  disappear  spontaneously,  can  usually  be  caused  to  disappear 
by  continued  pressure.  When  a  wound  of  a  salivary  gland  is  infected  a.  single 
fistula  or  multiple  fistula  may  be  left  as  a  legacy.  A  salivary  fistula  is  very 
annoying,  because  the  saHva  flows  constantly.  A  fistula  of  a  gland  usually 
heals  spontaneously  after  a  long  time,  but  healing  may  be  quickly  brought 
about  by  touching  the  orifice  with  the  Paquelin  cautery. 

Wound  of  Stem's  duct  is  apt  to  cause  a  fistula,  and  the  condition  is  often 
difficult  to  cure.  In  this  condition,  if  the  duct  has  been  cut  across,  the  central 
end  grows  fast  to  the  cutaneous  surface.  Fistula  of  Steno's  duct  inay  also  be 
caused  by  obstruction  and  rupture  of  the  duct  and  by  suppurative  or  gan- 
grenous processes. 

In  wounds  of  the  duct  the  ends  should  be  brought  as  near  together  as 
possible  by  catgut  sutures  which  do  not  enter  the  lumen  of  the  duct.  If  the 
mucous  membrane  is  not  already  opened  an  incision  should  be  made  through 


Parotitis 


1043 


Fig.  660. — De   Guise's  operation   for  salivary 
fistula  (Esmarch  and  Kowalzig). 


it  to  permit  drainage  of  saliva  into  the  mouth,  and  the  skin  should  be  sutured. 
In  some  cases  the  central  end  of  the  duct  may  be  carried  into  the  mouth  and 
sutured  to  the  mucous  membrane.  If,  after  any  injury  of  Steno's  duct,  saliva 
gathers  under  the  skin,  make  an  incision  through  the  mucous  membrane  to 
give  a  route  for  the  saliva  to  enter  the  mouth,  and  apply  pressure  externally. 
When  an  external  fistula  forms,  it  may  perhaps  be  cured  by  the  cautery  and 
pressure,  but,  if  the  peripheral  portion  of  the  duct  is  obliterated  (which  can  be 
determined  by  a  sound)  a  cutting  operation  must  be  performed.  Tillmanns 
advocates  cutting  out  the  external  portion  of  the  fistula  by  two  elliptical  inci- 
sions. A  trocar  is  passed  through  the  bottom  of  the  wound  in  two  places,  about 
3^^  cm.  apart;  a  piece  of  stout  silk  is  drawn  through  the  holes  and  tied  tightly 
and  the  superficial  incision  is  closed.  The  silk  cuts  through  and  makes  an 
internal  fistula.  Another  method  is  to  make  an  incision,  find  and  isolate 
the  central  end  of  the  duct,  open 
the  mucous  membrane,  sutm-e  the 
duct  to  it,  and  close  the  superficial 
wound. 

De  Guise's  operation  is  shown 
in  Fig.  660.  He  threads  a  piece 
of  silk  through  two  needles  and 
carries  the  needles  into  the  mouth 
so  that  the  silk  will  embrace  a  bit 
of  tissue  y-2  cm.  in  length.  The  silk 
is  tied  tightly  within  the  mouth,  the 
ends  are  cut  off,  and  the  margins 
of  the  fistula  at  the  surface  are 
freshened  and  sutured.  I  prefer 
silver  wire  to  silk. 

Parotitis. — Mumps,  or  epidemic  parotitis,  is  treated  by  the  physician. 
In  this  condition  the  submaxillary  and  sublingual  glands  are  usually  involved 
as  well  as  the  parotid.  In  pyemia,  metastatic  abscesses  may  form  in  the  pa- 
rotid gland.  If  such  abscesses  form  great  swelling  arises,  respiration  is  often 
embarrassed,  and  early  incision  is  necessary.  Parotid  inflammation  other  than 
mumps  is  usually  due  to  the  passage  of  bacteria  up  Steno's  duct,  the  source  of 
the  microbes  being  a  foul  condition  of  the  mouth,  particularly  noma  or  stomatitis. 
Hence  such  inflammation  is  most  common  during  the  existence  of  acute  infec- 
tious diseases  and  sepsis.  Suppuration  or  even  gangrene  may  occur.  As  a 
rule,  only  one  gland  is  attacked,  but  both  may  be.  It  is  a  well-known  fact  that 
occasionally,  though  very  rarely,  after  an  abdominal  operation  inflammation  of 
the  parotid  gland  occurs  {sympathetic  parotitis).  The  condition  is  more  common 
in  adults  than  in  children.  This  form  of  parotitis  may,  of  course,  be  due  to 
septic  metastasis  and  may  be  produced  by  trauma,  but  I  am  satisfied  that  most 
cases  result  from  foul  mouths,  the  infection  ascending  from  the  mouth  along  the 
duct.  Oral  cleanliness  tends  strongly  to  prevent  the  so-called  sympathetic 
parotitis.  In  about  one-third  of  the  cases  the  condition  is  not  to  be  distin- 
guished from  mumps  and  is  recoveied  from  in  seven  to  eight  days.  Mild  cases 
seldom  suppurate,  and  if  they  do,  the  pus  may  flow  down  the  duct  into  the 
mouth.  In  nearly  one  half  of  the  cases,  according  to  Marchetti  ("Epitome  of 
Surgery,"  in  "Brit.  Med.  Jour.,"  March  6,  1909),  there  is  phlegmonous  inflam- 
mation with  necrosis  and  suppuration  of  the  tissues  and  formation  of  a  salivary 
fistula.  In  non-suppurative  parotitis  there  are  pain,  tenderness,  obvious  swell- 
ing, and  hyperemia  of  the  skin,  and  it  is  difficult  to  open  the  mouth  or  swallow. 
When  suppuration  occurs,  all  of  the  above  symptoms  are  intensified,  the  dis- 
coloration becomes  dusky,  the  skin  becomes  shiny  and  edematous,  the  constitu- 
tional symptoms  of  pus  formation  exist,  and  there  is  usually  delirium. 

Treatment. — In  the  non-suppurative  form  apply  heat.     Wash  the  mouth 


I044  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


out  frequently  with  an  antiseptic  wash  and  apply  ichthyol  and  laholin  to 
the  swollen  region.  In  the  suppurative  form  make  several  openings  by  Hilton's 
method,  seeking  for  points  of  softening;  apply  hot  antiseptic  fomentations, 
wash  the  mouth  frequently  with  an  antiseptic  fluid,  and  combat  sepsis  by 
appropriate  constitutional  treatment. 

Salivary  Concretions  (Sialolithiasis). — The  saliva  contains  in  solution 
certain  salts  which  may  be  deposited.  Deposited  on  the  teeth  they  constitute 
tartar.  Deposited  in  a  salivary  duct  or  the  acini  of  a  gland  they  constitute  a 
calculus.  The  salts  deposited  are  carbonate  and  phosphate  of  lime.  A  calculus 
may  consist  purely  of  these  two  salts  or  there  may  be  a  foreign-body  nucleus.  A 
calculus  is  a  possible  result  of  an  inflammation  which  blocks,  constricts,  or 
roughens  a  duct  or  acinus  and  decomposes  saliva.  Inflammation  of  a  duct  is 
known  as  sialodochitis.  Small  concretions  are  often  passed.  Concretions  the 
size  of  a  bean  are  retained.  A  concretion  may  attain  the  size  of  an  English 
walnut.  A  concretion  does  not  block  a  duct  continuously,  but  does  so  now  and 
then,  causing  swelling  and  tenderness  of  the  gland.  A  retained  calculus  can  be 
palpated  by  a  finger  in  the  mouth  and  a  finger  externally.  Whenever  a  salivary 
gland  enlarges  an  attempt  should  be  made  to  probe  the  duct.  In  some  cases 
the  stone  can  be  touched.  In  others  the  duct  is  found  to  be  blocked.  The 
.T-rays  demonstrate  the  stone.  Salivary  calculus  is  more  common  in  adults  than 
in  children  but  is  not  very  rare  in  children.  The  duct  of  the  parotid,  of  the 
^^^^—p^w^  -^ji^H^^^-^^E^^^^  sublingual,  or  of  the  submaxillary,  may 
^^^^^^  ^^^^^^^^^S^^^^^l  contain  a  calculus,  but  it  is  unusual  to 
^^^v  ^wKt^^W^^^^^    ^^'^  ^  stone  in  Wharton's  duct. 

^B^  ^^r  "^^^^H  Treatment. — A  calculus  in  a  duct 'is 

^m--  ^^^H    extracted  by  making  an  incision  through 

^m  ;  ^1^^,  ^l^li     ^^^  mucous  membrane.     If  a  very  large 

^^'         ^^Hf||^  J^^^^l    calculus  forms  in  the  submaxillary  gland, 

^B         W^^^  jfl^^^H    ^^®  gland  should  be  removed  through 

^V  *  -^^j^^^^^tk    ^^  external  incision. 

^B  fl^^^^^^^H  Ranula  is   a   retention-cyst    of    the 

^ft  ^^^^^^^^^1    ^^^^  ^^  ^^^  submaxillary  or  the  duct  of 

^m  ^i^^^^^^^H    ^^^  sublingual  gland.     A  ranula  when 

V  i^^H^^^^^^^^^H    ^''^^  formed  contains  saliva,  but  after 

■  ji^S^^^tl^^^^^^k    ^  ^™^  ^he  saliva  undergoes  a  change, 

I  ^sHKJ^^^IHJilH    and  then  resembles  mucus.    Mucotis  cysts 

occur  in  the  floor  of  the  mouth,  resulting 
from  obstruction  of  the  ducts  of  the 
mucous  glands  of  Nuhn  and  Blandin.  These  glands  lie  on  each  side  of  the 
frenum  of  the  tongue.  Such  a  cyst  is  often  spoken  of  as  a  ranula.  A  cyst  of  the 
incisive  gland  forms  just  back  of  the  lower  jaw  and  lifts  up  the  frenum.  A  true 
ranula  appears  upon  the  floor  of  the  mouth  on  one  side  and  pushes  the  tongue 
toward  the  opposite  side  (Fig.  66i).  The  treatment  of  a  mucous  cyst  is  by  exci- 
sion of  a  portion  of  the  cyst  wall  and  cauterization  of  the  interior  with  pure  car- 
bohc  acid;  or  by  cutting  a  flap  from  the  cyst  wall  and  stitching  it  aside  so  as  to 
keep  a  permanent  opening.  Such  an  operation  may  cure  a  genuine  ranula, 
but  will  often  fail.  In  true  ranula  it  is  usually  advisable  to  make  an  external 
incision,  and  through  this  remove  both  the  cyst  and  the  gland.  This  plan  is 
recommended  by  Mintz.^ 

Lymphomata  of  the  Salivary  and  Lachrymal  Glands  (Mikulicz's  Disease), — 
Mikuhcz,  of  Breslau,  described  this  condition  in  1888  (see  BiUroth's  Fest- 
schrift for  1892).  It  is  a  chronic  brawny,  and  non-inflammatory  swelUng, 
painless  though  sometimes  tender,  perhaps  fluctuating  in  size  and  unconnected 
with  any  known  systemic  condition.  In  ^Mikulicz's  early  cases  the  lachrymal, 
parotid,  and  submaxillary  salivary  glands  of  both  sides  were  enlarged,  hence 
i"Zeitschrift  fiir  Chirurgie,"  March,  1899. 


Fig.  0. 


-Ranula. 


Harelip  and  Cleft-palate  1045 

he  r2garded  it  as  symmetrical.  We  now  know  that  non-symmetrical  cases 
occiir,  in  fact,  only  one  gland  may  be  enlarged,  although,  of  course,  such  cases 
may  eventually  develop  growths  on  the  other  side.  In  some  cases  the  sublin- 
guals have  been  involved,  in  some  the  accessory  lachrymals,  in  some  the  glands 
of  Nuhn  and  Blandin.  In  a  case  of  Osier's  there  was  enlargement  of  the  spleen, 
tonsils,  and  cervical  lymph-glands.  In  a  typical  case  the  cheeks  are  much 
broader  than  natural,  and  the  eyelids  droop  on  the  temporal  side  like  "those  of  a 
bloodhound"  (Zeigler,  in  ''New  York  Med.  Jour.,"  Dec.  11,  1909).  The  mouth 
is  very  dry  because  of  deficiency  of  salivary  secretion.  The  conjunctiva  is  dry 
for  want  of  enough  tears.  Chronic  inflammation  in  the  nasopharynx  is  not 
unusual.  In  some  cases  the  blood  findings  resemble  those  of  lymphatic  leuke- 
mia (Paton,  in  "Proc.  Roy.  Soc.  Med.,"  1915,  viii). 

The  condition  may  occur  at  practically  any  age  after  three  or  four.  A  case 
four  years  of  age  has  been  reported.  The  glands  may  undergo  regression 
during  pneumonia,  appendicitis,  or  some  other  infection.  The  cause  is  doubt- 
ful. Some  think  it  is  due  to  bacteria,  but  the  tissue  is  not  inflammatory,  being 
merely  hyperplastic  lymph  tissue.  Others  regard  it  as  due  to  a  toxic  material 
in  the  blood.  Ziegler  believes  that  the  causal  toxic  material  comes  from  the 
nasal  sinuses. 

Treatment. — Arsenic  internally  will  perhaps  produce  cure.  The  iodids  are 
used  by  some  and  pilocarpin  has  been  recommended.  The  ;r-rays  should  be 
applied.  Operative  removal  has  not  been  successful.  All  diseased  conditions 
of  the  nasopharynx  should  be  corrected,  if  possible.  (See  Ziegler's  thorough 
study,  in  "New  York  Med.  Jour.,"  Dec.  11,  1909.) 

Harelip  and  Cleft-palate. — Harelip  is  a  congenital  cleft  in  the  upper  lip 
due  to  defective  development.  Cleft-palate  is  a  congenital  fissure  in  the  soft 
palate  or  in  both  the  hard  and  soft  palates.  In  harelip  the  cleft  is  usually 
complete,  through  the  entire  lip  into  the  nostril,  but  in  rare  cases  it  may  show 
only  as  a  furrow  in  the  mucous  edge  or  as  a  split  from  the  nostril  partly  into  the 
lip.  It  is  most  common  on  the  left  side.  In  double  harelip  the  central  por- 
tion of  the  lip  is  often  adherent  to  the  tip  of  the  nose.  Double  harelip  may  be 
free  from  complication,  but  is  often  associated  with  a  malformation  of  the  alveo- 
lus and  palate.  The  term  "harelip"  is  a  poor  one,  as  the  cleft  in  a  hare's  lip 
is  the  shape  of  the  letter  Y,  the  stem  of  the  Y  being  median  and  an  arm  enter- 
ing each  nostril.  Median  harelip  is  exceedingly  rare.  Dupuytren  said  it 
never  occurred,  but  at  least  9  cases  have  been  reported  (Ransohoff,  in  "Lancet 
Clinic,"  Nov.  2,  191 2).  Ordinary  or  lateral  harelip  is  due  to  failure  of  fusion  of 
the  lateral  maxillary  and  frontal  processes.  Median  harelip  is  due  to  "failure 
of  union  between  the  lateral  tubercles  of  the  frontonasal  process  which  is  placed 
on  each  side  of  the  middle  line"  (Ransohoff,  Ibid.).  We  recall  His's  teaching, 
that  the  central  portion  of  the  upper  lip  is  formed  from  the  lower  portion 
of  the  frontonasal  process  by  the  fusion  of  its  two  buds  (Ransohoff,  Ibid.). 
In  cleft-palate  the  septum  of  the  nose  is  usually  adherent  to  the  palatine  process 
opposite  the  side  upon  which  the  fissure  exists.  In  those  rare  cases  of  cleft- 
palate  double  in  front,  the  nasal  septum  is  attached  to  the  premaxillary  bone 
only,  and  the  premaxillary  bone  is  not  attached  at  all  to  the  superior  maxillary 
bone.  In  harelip  there  is  frequently  a  cleft  in  the  alveolus,  and  almost  always 
flattening  of  the  corresponding  side  of  the  nose.  Harelip  is  often  associated 
with  cleft-palate,  talipes,  and  other  deformities.  It  is  a  great  deformity,  and 
interferes  with  sucking,  swallowing,  and  articulation. 

It  was  long  taught  that  operation  must  not  be  done  until  the  child  is  several 
years  old.  In  1868  Thomas  Smith  insisted  that  operation  should  be  done  before 
the  child  has  learned  to  talk. 

Operation  for  harelip  uncomplicated  by  cleft-palate  should  be  performed 
between  the  third  and  sixth  months  of  life  in  a  child  in  good  health,  free  from 
stomach  trouble,  cough,  or  coryza,  but  operation  is  not  advisable  in  the  early 


1046  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

weeks  of  life.  Always,  if  possible,  operate  before  dentition  begins  (seventh 
month).  If  the  child  is  in  poor  health,  postpone  the  operation  until  restora- 
tion has  so  far  advanced  as  to  render  operation  safe.  While  waiting  for  opera- 
tion be  sure  the  child  is  getting  enough  food.  If  it  cannot  suck,  feed  it  with 
a  spoon.  If  a  cleft  exists  in  the  palate,  we  sometimes  operate  first  upon  the 
lip,  because  the  pressure  of  the  parts  after  the  edges  of  the  gap  are  approxi- 
mated aids  in  the  closure  of  the  bony  cleft.  In  other  cases  we  operate  first  on 
the  palate.  Cleft-palate  interferes  with  sucking,  deglutition,  mastication,  and 
articulation.  In  severe  cases  the  food  passes  into  the  nose  and  excites  inflam- 
mation. Loss  of  control  of  the  palate  muscles  always  exists,  and  liquids  and 
solids  are  liable  to  pass  into  the  wind-pipe.  Clefts  in  the  hard  palate  should 
not  be  operated  on  until  the  second  year,  but  should  be  operated  upon  then, 
otherwise  speech  will  be  permanently  affected.     Some  surgeons  refuse  to  oper- 


FlG.  662. 


-Dr.  Teller's   case  of  harelip  and 
cleft-palate. 


Fig.  663. — Dr.  Teller's  case  of   harelip  and 
cleft-palate. 


ate  until  the  tenth  or  twelfth  year,  but  operation  done  this  late  will  not  correct 
speech-defect.  The  patient  at  the  period  of  operation  should  be  well  and  free 
from  cough.  In  many  cases  the  passage  of  food  and  drink  into  the  nose  can 
largely  be  prevented  by  the  use  of  a  diaphragm. 

Operation  for  Harelip. — Wrap  the  child  in  a  sheet;  place  it  in  the  Tren- 
delenburg position,  and  rest  the  head  upon  a  sand-pillow.  The  surgeon  stands 
to  the  right  side  of  the  patient.  Ether  or  chlorofprm  is  given.  For  single 
harelip,  separate  with  the  scissors  the  upper  lip  from  the  bone  on  each  side 
of  the  cleft  until  approximation  of  the  edges  can  be  effected  without  tension. 
If  the  premaxillary  bone  of  one  side  projects  more  than  its  fellow,  grasp  it  with 
sequestrum  forceps  and  bend  it  back  (Jacobson  and  Treves).  Clamp  the 
upper  lip  at  each  angle  of  the  mouth  to  prevent  hemorrhage.  If  the  edges 
are  of  equal  or  nearly  equal  length,  and  if  the  gap  is  not  very  wide,  perform 
Malgaigne's  operation.  This  is  performed  as  follows:  A  flap  is  detached  on 
each  side,  the  detachment  beginning  at  the  upper  angle  of  the  gap;  each  flap 
is  detached  above,  but  remains  attached  below.  The  flaps  are  separated 
from  the  bone,  and  are  drawn  downward  so  as  to  form  a  prominence  at  the 
vermilion  border  (Fig.  664).  If  the  edges  qre  pared  so  that  in  closure  the 
vermilion  border  is  even,  when  the  parts  are  healed  a  gutter  wfll  be  visible  at 


Harelip  and  Cleft-palate 


1047 


the  line  of  union.  The  edges  are  approximated  by  an  assistant,  and  silkworm- 
gut  sutures  or  silver  wires  are  jmssed  by  means  of  a  straight  needle.  Each 
suture  goes  down  to  the  mucous  membrane.  The  first  suture  is  passed  through 
the  middle  of  the  lip,  }>-^  inch  from  the  cleft.  Three  or  four  main  sutures 
are  passed  through  the  thickness  of  the  lip,  and  are  tied  and  cut  off.  Two 
or  three  fine  silk  or  catgut  sutures  are  passed  by  a  curved  needle  through  the 
vermilion  border  of  the  lip  and  the  mucous  membrane  of  the  mouth,  and 
are  tied  and  cut  off.  A  small  piece  of  gauze  is  placed  over  the  lip  and  is  held 
in  place   by   straps   of   rubber   plaster.     After   operation   prevent    the   child 


Fig.     664.  —  Malgaigne's 
operation  for  harelip. 


Fig.  665. — Mirault's  opera- 
tion for  single  harelip 
(Esmarch). 


Fig.  666. — Incisions  for 
double  harelip  (Esmarch  and 
Kowalzig). 


crying  by  feeding  it  often  and  giving  it  small  doses  of  laudanum.  Heath 
orders  2  drops  of  laudanum  in  i  oz.  of  distilled  water,  a  teaspoonful  to  be 
given  every  two  or  three  hours.  About  the  sixth  day  one-half  the  sutures  are 
taken  out,  and  on  the  eighth  or  ninth  day  the  remaining  ones  are  removed. 
.  In  many  cases  no  further  procedure  is  necessary,  but  if  after  some  weeks  the 
prominence  at  the  lip  border  does  not  shrink,  it  can  be  readily  clipped  away. 
Harelip-pins  are  not  used  at  the  present  time,  and  are  not  needed  if  the  lip 
is  well  separated  from  the  bone.  If  the  edges  of  the  cleft  are  of  unequal  length, 
Edmund  Owen's  operation  can  be  performed  (see 
below,  under  Double  Harelip),  or  we  can  perform 
Mirault's  operation,  as  shown  in  Fig.  665. 


Fig.  667.- — Double  harelip,  the  pro- 
labium  and  incisive  bone  having  been 
removed    (Owen) . 


Fig.  668.— The  two  sides  of 
the  lip  drawn  together  and  se- 
cured by  sutures  (Owen). 


In  double  harelip  the  operation  is  similar  to  that  for  single  harelip.  If  the 
intervening  piece  is  vertical  and  is  covered  with  healthy  skin,  complete  each 
operation  as  for  single  harelip,  closing  both  fissures  at  once  with  silver  wire  in  a 
strong,  healthy  child;  closing  them  at  intervals  of  three  weeks  in  one  not  so 
lusty  (Fig.  666).  Excise  the  septum  if  it  is  deformed.  The  premaxillary  bone 
should  in  most  instances  be  removed,  the  skin  over  it  being  preserved.  Sir  Wil- 
liam Fergusson  was  accustomed  to  incise  the  mucous  membrane  and  shell  out 
this  bone.  The  premaxillary  bone  can  be  forced  back  into  line,  being  held,  if 
necessary,  by  catgut  suture  of  the  periosteum;  but  if  saved,  it  is  liable  to  necrose 
and  its  teeth  soon  decay.  Heath  removes  this  bone  two  weeks  before  operat- 
ing on  the  lip.  If  there  is  much  hemorrhage  after  removal  of  the  bone,  arrest 
it  with  a  hot  wire,  the  electric  cautery,  or  with  Horsley's  wax.  Figure  666  shows 
incisions  for  double  harelip.  Edmund  Owen's  operation  is  very  useful  (Figs. 
667,  668).     In  this   operation  very  thick  flaps  are  cut.     The  prolabium  and 


1048  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

incisive  bone  are  removed.  The  flaps  are  cut  as  shown  in  Fig.  667,  on  one 
side  by  a  Hne  a-b,  and  on  the  other  side  the  piece  c-d-e  is  removed;  a  is  brought 
to  e,  b  is  brought  to  d,  f  is  brought  to  c,  and  sutures  are  appUed  (Fig.  668). 

Operation  for  Cleft-palate. — HareHp  was  operated  upon  in  the  days  of  long 
ago.  Operation  for  cleft-palate  is  much  more  modem.  Chelius  published  his 
surger}'  in  1 7 1 8.  He  states  that  openings  in  the  palate  cannot  be  healed  Vjy  opera- 
tion. It  is  usually  said  that  Roux  in  1819  did  the  first  staphylorrhaphy  but 
it  seems  to  be  proved  that  Le  Monnier  operated  in  1764  and  that  von  Graefe. 
sewed  and  cured  a  soft  palate  cleft  in  1816  (Blakeway,  in  "Practitioner,"  1914, 
xcii).  No  man  except  Langenbeck  did  as  much  to  perfect  the  operation  as 
Sir  William  Fergusson.  It  is  true  that  during  the  early  years  of  its  growth  a 
cleft  diminishes  in  size,  and  particularly  if  a  harelip  is  closed,  but  to  wait 
too  long  before  we  operate  means  permanent  speech  impairment.  Bony  clefts 
should  be  operated  upon  early  in  the  second  year.  Clefts  of  the  soft  palate 
only  may  be  operated  upon  during  the  first  six  months  of  life.  If  both  the 
hard  and  soft  palates  are  cleft,  close  both  at  one  operation.  In  an  ill-nourished 
child  in  which  the  covering  of  the  bone  is  obviously  thin  it  is  best  to  postpone 
any  operation  upon  a  bony  cleft  until  the  end  of  the  third  year.  I  agree  with  Berry 
that  operation  is  justifiable  up  to  the  age  of  twenty,  but  early  operation  is  highly 
desirable.  Edmund  Owen  put  forth  a  convincing  plea  for  early  operation.^  He 
said  he  was  operating  earlier  and  earlier,  and  quoted  Chilton  as  the  gentleman 
who  led  him  to  do  so.  Owen  maintained  that  if  speech  were  to  be  improved, 
operation  must  be  done  early,  and  he  formulated  some  very  valuable  rules  for 
preparation  and  care.  I  have  never  been  convinced  that  operation  in  early 
infancy  is  sufficiently  safe  or  has  any  notable  advantages.  Wlien  one  comes  to 
treat  congenital  clefts  of  the  lip,  the  alveolar  process,  and  the  hard  and  soft 
palate,  the  necessities  one  should  seek  to  obtain  are  the  surgical  closure  of  the 
clefts,  the  establishment  of  the  function  of  the  involved  tissues,  the  correction 
of  the  congenital  deformity,  and  the  prevention  of  postoperative  or  acquired 
deformity.  There  are  few  if  any  cases  of  cleft-palate  that  cannot  be  success- 
fully treated  by  surgical  means;  and  it  is  a  very  unusual  thing  for  a  case  really 
to  need  any  mechanical  appliance,  such  as  the  obturator  and  velum. 

In  deciding  upon  the  time  for  operating  and  the  nature  of  the  operation, 
the  safety  of  the  patient  should  be  the  first  consideration.  One  must  care- 
fully consider  the  physical  condition,  especially  in  respect  to  nutrition.  An 
operative  method  that  has  a  greater  mortality  than  is  incident  to  minor  sur- 
gery ought  not  to  be  selected,  and  no  operation  should  be  performed  until  the 
condition  of  the  patient  justifies  it.  Having  considered  the  physical  condi- 
tion of  the  patient  and  the  relative  safety  of  different  operative  plans,  a  care- 
ful study  of  the  individual  case  should  be  made,  and  in  this  study  each  of 
the  four  requirements  above  set  forth  must  be  attentively  regarded.  If  we 
succeed  in  closing  the  cleft  without  establishing  the  function  of  the  tissues, 
without  correcting  congenital  deformity  and  without  preventing  postoperative 
or  acquired  deformity,  we  leave  the  patient  worse  ofiF  than  he  was  before,  and 
perhaps  render  subsequent  satisfactory  treatment  impossible. 

We  should  attempt  to  secure  closure  of  the  cleft  with  the  least  possible  for- 
mation of  cicatricial  tissue.  The  simplest  technic  is  the  best,  and  we  should 
endeavor  to  avoid  all  unnecessary  additional  traumatism.  One  should  refrain 
from  passing  additional  approximation  sutures,  from  bruising  the  tissues  by 
overtension  or  by  traction-forceps,  and  from  using  large  needles  and  coarse 
suture  materials,  which  make  large  suture-cicatrices.  The  amount  of  scar 
tissue  bears  directly  upon  the  functional  result.  In  addition,  when  dealing 
with  the  Up,  and  especially  with  the  soft  palate,  one  must  seek  to  avoid  in- 
cisions that  involve  muscles,  and  particularly  the  nerve-supply  of  muscles. 

The  periosteal-flap  operation  separates  portions  of  the  soft  palate  from  the 
^"Lancet,"  Jan.  4,  1896. 


Harelip  and  Cleft-palate  1049 

palatine  bones.  A  large  amount  of  cicatricial  tissue  is  necessary  to  effect  re- 
pair, and  this  mass  of  new  tissue  lessens  the  good  functional  results.  In  the 
periosteal-ilap  operation  the  repaired  soft  palate  is  anterior  and  inferior  to  the 
position  secured  by  the  osteoplastic  method  and,  to  that  extent,  interferes  with 
the  closure  of  the  nasopharynx.  Nevertheless,  in  my  opinion,  the  operation 
which  uses  the  soft  tissues  only  is  by  far  the  safest  and  is  the  one  I  usually 
employ.  In  cases  of  complete  cleft,  associated  congenital  deformities  are 
especially  manifest  in  the  nose,  lips,  premaxilla,  and  maxillae. 

To  correct  congenital  deformities  and  to  prevent  postoperative  or  acquired 
deformities  are  the  most  neglected  and  the  least  understood  phases  of  the  sub- 
ject, and  it  is  a  very  complicated  question  to  hope  to  make  clear  in  a  brief 
statement.  The  key  to  the  difficulty  is  the  normal  contour  of  the  face  as 
established  by  the  proper  occulsion  of  the  permanent  teeth.  In  finding  this 
out  there  is  no  better  guide  than  the  rules  laid  down  by  Dr.  Angle  in  the  latest 
edition  of  his  "Orthodontia."  He  maintains  that  every  tooth  must  be  held 
in  its  proper  relation  and  occlusion;  and  that  if  any  teeth  are  lost  they  must 
be  replaced  in  order  to  establish  or  restore  the  proper  expression  and  contour 
of  the  face.  To  comply  with  the  foregoing  requirements  one  should  avoid  any 
operation  that  would  not  maintain  or  would  fail  to  replace  the  normal  posi- 
tion of  the  premaxilla  and  the  maxillse  and  their  future  complement  of  teeth. 
If  the  premaxilla  is  only  slightly  in  advance  of  its  normal  position,  the  early 
closure  of  the  cleft  of  the  lip  will  help  to  replace  it.  If,  however,  the  premax- 
illa is  far  in  advance  of  its  normal  position,  it  is  hopeless  to  expect  the  pressure 
of  a  reunited  lip  to  restore  it  to  position.  In  such  a  case  sufficient  of  the  nasal 
septum  posterior  to  the  premaxilla  must  be  resected,  and  the  premaxilla  must 
be  carried  back  and  sutured  in  position;  but  this  operation  should  be  done 
after  the  closure  of  the  cleft  soft  and  hard  palates,  and  seldom  at  the  same 
operation.  If  the  cleft  is  unilateral  in  relation  to  the  premaxilla  and  that  bone 
is  swung  to  the  opposite  side,  and  anterior  to  its  normal  position,  the  pressure 
exerted  by  an  early  repaired  lip  will  often  correct  the  condition.  Until  the 
deciduous  incisors  have  erupted  it  is  difficult  to  determine  how  far  the  in- 
termaxillary bone  really  protrudes;  and  it  is  often  surprising  to  observe  how 
little  correction  is  needed  in  what  had  appeared  to  be  marked  protrusion  of 
the  premaxilla  in  a  unilateral  or  bilateral  cleft.  ]f  in  doubt  about  this  point 
it  is  better  to  wait  until  the  eruption  of  the  deciduous  incisors,  when  one  may 
decide  with  certainty  whether  there  is  enough  anterior  protrusion  to  warrant 
the  closure  of  the  lip  before  operation  on  the  palate.  Early  closure  of  the  cleft 
of  the  lip  brings  very  considerable  pressure  to  bear,  especially  in  double  cleft 
or  the  typical  harelip,  as  the  lateral  portions  are  comparatively  short  and 
the  lip  is  usually  quite  tense.  Sometimes  this  pressure  is  quite  efficient,  when 
exerted  upon  these  cases  of  protrusion  of  the  premaxilla,  which  are  frequent, 
and  of  lateral  separation  of  the  maxilla,  which  are  infrequent;  but  when  such 
pressure  is  exerted  upon  cases  without  protrusion  or  separation,  it  produces 
an  unfortunate  postoperative  deformity,  and  one  that  is  too  frequently  en- 
countered. It  causes  the  alveolar  arch  to  lose  its  parabolic  curve,  and  what 
should  be  an  arch  is  frequently  V  shaped  or  triangular,  and  not  infrequently 
the  cuspid  teeth  are  closely  approximated.  One  thus  gets  marked  flattening 
of  the  anterior  lateral  region  of  the  face  or  cheek,  with  loss  of  contour  and  posi- 
tion of  the  upper  lip  and  apparent  protrusion  of  the  lower  lip  and  chin.  It 
is  true  that  such  a  postoperative  deformity  can  be  corrected  by  modern  ortho- 
dontic methods,  but  it  is  better  to  prevent  it  than  to  be  obliged  subsequently 
to  correct  it. 

From  the  preceding  remarks  it  is  evident  that  it  is  to  be  regarded  as  advis- 
able in  many  cases  to  close  the  cleft  in  the  soft  and  hard  palates  before 
operating  upon  the  lip.  The  best  time  for  operating  is  just  before  the  patient 
begins  to  employ  articulate  speech.     In  most  cases  the  cleft  in  the  alveolar 


1050  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

process,  including  the  floor  of  one  or  both  nares,  should  be  repaired  sepa- 
rately, and  after  the  repair  of  the  hard  and  soft  palates.  A  comparatively 
short  time  after  operating  upon  the  palate  the  lip  may  be  repaired,  and  the 
lip  also  should  be  repaired  before  the  establisment  of  articulate  speech.  An 
advantage  in  operating  with  the  harelip  still  unclosed  is  that  one  can  see  better 
and  work  better  during  the  operation  on  the  palate,  and  can  give  the  palate 
better  local  care  after  the  operation.  Unfortunately,  however,  many  child- 
ren with  cleft  palates  are  never  brought  for  advice  until  they  have  cultivated 
articulate  speech.  It  is  always  very  difficult  and  often  impossible  to  correct 
the  manner  of  speaking  that  they  have  taught  themselves.  Only  long  train- 
ing and  much  perseverance  is  of  any  avail.  The  earlier  the  operation 
is  performed,  the  better  will  be  the  result — not  only  from  the  functional 
standpoint,  but  also  as  regards  the  correction  of  existing  deformity  and  the 
prevention  of  future  deformity.  So  far  as  obtaining  good  surgical  results  go 
there  is  practically  no  set  age  limit. 

I  am  not  convinced  that  modern  operators  obtain  results  greatly  superior 
to  those  obtained  by  some  of  their  predecessors.  Sir  William  Fergusson,  "be- 
tween 1828  and  1864"  operated  upon  400  cases  of  harelip  with  only  3 
failures  and  134  cases  of  cleft  palate  with  only  5  failures  (Garrison's  "History 
of  Medicine  "). 

If  operation  is  refused  for  cleft  of  the  hard  palate,  if  it  offers  no  real  hope, 
or  if  it  is  very  dangerous,  an  obturator  must  be  worn.  An  obturator  is  made 
by  a  dentist.  In  preparing  a  child  for  operation  I  follow  Edmund  Owen's 
rules,  viz.:  Have  the  child  in  the  best  condition,  free  from  cough  and  stomach 
disorder.  Operate  in  summer.  Place  the  child  under  the  charge  of  a  nurse 
several  days  before  the  operation. 

Operation  for  Suture  of  the  Soft  Palate  {Staphylorrhaphy) . — The  operation 
of  staphylorrhaphy,  which  is  applied  to  clefts  of  the  soft  palate  alone,  is  a 
comparatively  easy  procedure.  In  performing  this  operation  the  patient 
should  be  anesthetized  and  be  placed  in  the  Trendelenburg  position,  or  else 
with  the  head  hanging  over  the  end  of  the  operating  table.  The  mouth  is 
held  open  by  Whitehead's  gag,  and  an  assistant  holds  an  electric  light  and 
a  reflector  to  illuminate  the  oral  cavity.  If  the  patient  is  not  a  young  child, 
the  operation  may  be  done  under  cocain,  with  the  subject  sitting  erect  in  a 
chair  and  the  surgeon  sitting  directly  in  front  of  him. 

The  surgeon  should  have  at  hand  several  knives  of  different  shapes.  The 
double-edged,  pointed  knife  is  an  excellent  one  for  freshening  the  margins 
of  the  palate.  Special  forms  of  needle-holders  have  been  devised  for  the  pur- 
pose of  carrying  the  needle.  The  heavy,  curved,  sharp-pointed  bistoury  is 
the  best  instrument  for  dividing  the  muscles  of  the  palate;  and  a  sharp  hook 
should  be  at  hand,  in  order  to  catch  the  edge  of  the  cleft,  if  necessary. 

The  surgeon  first  of  all  separates  the  soft  palate  from  the  posterior  edge 
of  the  palate  bones  and  from  the  nasal  mucous  membrane.  This  step  is  nec- 
essary in  order  that  the  edges  may  meet  in  the  middle  line  (Berry).  One 
edge  of  the  cleft  uvula  is  now  grasped  with  a  pair  of  forceps  or  a  sharp  hook, 
and  is  pulled  upon  to  make  it  tense.  This  edge  is  then  pared  from  below 
upward,  the  piece  being  continuous  from  the  base  to  the  apex  of  the  cleft.  This 
piece  is  severed,  and  then  the  other  margin  of  the  cleft  is  pared  in  the  same  way. 
It  is  now  advisable  to  free  the  margins  of  the  wound  from  tension.  These 
lateral  incisions  not  only  relieve  tension,  but  temporarily  paralyze  the  soft 
palate.  Figures  669  and  670  show  the  incisions  as  recommended  by  Berry. 
These  incisions  divide  the  tendons  of  the  levator  palati  and  the  palatophar- 
yngeus  muscles  and  temporarily  paralyze  the  palate.  The  impairment  of 
palate  function  is  not  permanent,  as  the  nerves  to  the  muscles  are  not  cut. 

The  sutures  are  inserted  by  means  of  a  special  needle-holder,  so  arranged 
that  the  needle  may  be  directed  in  many  different  positions  when  grasped. 


Harelip  and  Cleft-palate 


1051 


The  sutures  are  introduced  from  below  upward,  silkworm-gut  being  used 
for  the  uvula  and  the  lower  part  of  the  velum,  and  silver  wire  for  the  balance 
of  the  cleft.  Each  suture,  as  it  is  passed,  is  tied  or  twisted,  and  it  is  not  cut 
off  until  the  next  suture  is  inserted,  and  thus  serves  as  a  handle.  If  there  is 
too  much  tension  to  allow  of  the  sutures  being  tied  as  they  are  inserted,  all 
the  sutures  are  passed  and  lightly  twisted  before  one  is  tied. 

Closure  of  Clefts  in  the  Hard  Palate  (Uranoplasty). — As  previously  stated, 
the  best  time  to  perform  these  operations  is  during  the  second  year  of  life. 
In  some  few  cases  we  postpone  the  operation  until  the  end  of  the  third  year. 
If  the  child  learns  to  talk  with  the  palate  cleft,  articulation  will  never  be  very 
greatly  improved,  even  by  operation.  One  should,  therefore,  try  to  operate 
before  the  child  learns  to  talk.  Even  after  the  closure  of  the  cleft  the  speech 
does  not  become  entirely  normal;  in  fact,  as  Berry  says,  it  never  becomes  even 
very  good.     One  should  exercise  the  greatest  care  in  forming  the  soft  palate, 


Fig.  670. 

Fig.  669. — Cleft  of  soft  and  part  of  hard  palate.  Shows  exact  situation  in  which  the 
lateral  incisions  should  be  made  (Berry). 

Fig.  670. — Semidiagrammatic  view  of  complete  left  cleft  palate.  The  septum  nasi  is  at- 
tached to  the  palate  on  the  (patient's)  right  side.  The  mucous  membrane  on  the  left  side  of 
the  septum  may  be  detached  and  brought  down  if  necessary  to  help  in  the  closure  of  the  ante- 
rior half  of  the  cleft.  Shows  exact  situation  in  which  the  lateral  incisions  should  be  made 
(Berry). 


because  good  articulation  is  largely  dependent  upon  a  well-formed  soft  palate 
(Berry,  in  "Brit.  Med.  Jour.,"  Oct.  7,  1905).  The  surgeon  may  be  able  to 
close  the  entire  gap  at  one  operation;  or,  owing  to  undue  tension,  he  may  be 
forced  to  close  it  but  partly,  completing  the  closure  at  some  subsequent  period. 
The  operation  that  to  my  mind  is  the  best  is  one  that  uses  the  soft  tissues 
alone — such  a  one  as  is  advised  by  Berry.  I  have  entirely  abandoned  the 
operation  of  wedging  the  bone  over  with  a  chisel.  I  am  satisfied  that  it  is 
far  more  dangerous  than  is  the  other  method;  it  is  more  liable  to  fail;  and, 
if  it  fails  because  of  necrosis,  it  is  difficult  or  impossible  to  cure  the  defect  by 
a  second  operation.  The  essence  of  a  successful  operation,  using  the  soft 
tissues  alone,  is,  as  Berry  insists,  the  complete  detachment  of  the  soft  palate 
from  the  posterior  edge  of  the  palate-bone  (Fig.  671),  because,  if  one  fails 
to  secure  this,  the  edges  of  the  gap  mil  not  approximate  in  the  median  line. 
One  should  also  separate  the  soft  palate  from  the  mucous  membrane  of  the 
nose  (Fig.  671). 


1052  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


A  second  very  important  point  is  the  imperative  necessity  of  making  inci- 
sions to  the  sides  to  reheve  tension  and  to  paralyze  for  a  time  the  soft  palate. 
The  incisions,  as  recommended  by  Berry,  are  shown  in  Figs.  66g,  670.  The 
cut  is  close  to  the  teeth,  and  is  taken  as  far  posterior  as  the  middle  of  the  soft 
palate,  at  the  junction  of  that  structure  with  the  lateral  pharyngeal  wall.  In 
this  cut  there  is  some  risk  of  dividing  the  anterior  palatine  artery,  but  hemor- 
rhage from  this  vessel  can  be  arrested  by  pressure.  Berry  insists  that  the  in- 
cision need  not  go  forward  more  than  the  level  of  one  or  two  premolar  teeth; 
or,  in  older  children,  to  the  first  or  second  molars.  The  edges  of  the  fissure 
are  pared  on  each  side,  from  the  tip  of  the  uvula  to  the  top  of  the  gap.  Strips 
of  the  mucoperiosteum  are  lifted  up  on  each  side  of  the  gap  and  shifted  toward 

the  cleft,  and  at  this  stage  the  pos- 
terior border  of  the  soft  palate  is 
separated  from  the  posterior  border 
of  the  hard  palate  (Fig.  671). 

The  parts  are  sutured  with  silver 
wire,  following  the  advice  of  Edmund 
Owen  to  twist  and  cut  each  wire, 
leaving  an  end  ^^  inch  in  length. 
This  procedure  causes  the  child  to 
keep  his  tongue  from  the  suture  line. 
For  the  first  twenty-four  hours 
water  only  is  given.  After  this 
period  the  patient  is  fed  with  jelly 
and  liquids.  Only  fluid  or  soft  food 
is  used  for  two  or  three  weeks. 
Talking  is  forbidden.  A  day  or 
two  after  the  operation  the  child 
should  be  taken  into  the  open  air 
and  kept  in  it  all  day.  As  Owen 
shows,  this  greatly  stimulates  vital 
resistance  and  lessens,  to  a  consid- 
erable extent,  the  danger  of  slough- 
ing of  the  suture  line.  The  mouth 
is  washed  frequently,  and  always 
The  sutures  are  allowed  to  remain 


Fig.  671. — Longitudinal  vertical  section 
through  the  hard  and  soft  palates:  a,  Before 
operation;  b,  palatine  mucoperiosteum  de- 
tached and  brought  do\\Ti,  blades  of  scissors 
introduced  to  cut  attachment  of  soft  palate 
to  the  bony  palate  and  to  the  nasal  mucous 
membrane;  c,  the  same  after  the  cut  has  been 
made  and  the  soft  palate  thus  brought  down 
(Berry). 


after  taking  food,  with    Condy's   fluid 
between  two  and  three  weeks. 

Sir  William  Fergnsson's  Operation. — In  this  operation  the  mucous  edges  are 
pared,  the  bones  are  drilled  for  wires,  and  the  sutures  are  inserted,  but  not  tied. 
An  incision  is  made  on  each  side  of  the  cleft  down  to  the  bone,  each  incision 
being  midway  between  the  cleft  and  the  corresponding  alveolus.  The  bone  is 
divided  on  each  side,  by  means  of  a  chisel,  to  the  full  length  of  the  incision; 
and  the  chisel  is  used  as  a  lever  to  force  each  half  of  the  bone  toward  the  gap. 
The  sutures  are  tied,  and  each  lateral  incision  is  plugged  with  iodoform  gauze. 

Brophy's  Operation. — This  operation  is  employed  particularly  for  children 
under  three  months  of  age,  and  cannot  be  used  when  the  child  is  over  six  months. 
In  this  operation  the  palate  is  closed  before  the  harelip  is  touched.  Operat- 
ing at  this  time  the  bones  are  soft,  and  by  leaving  the  harelip  untouched  the 
surgeon  has  more  room  to  work.  The  author  of  the  operation  believes  that 
when  it  is  performed  at  this  early  age  the  palate  muscles  do  not  atrophy,  but 
develop,  and  that  the  patient  does  not  form  the  evil  habit  of  talking  through 
the  nose. 

In  performing  this  operation  the  very  strong-handled  needles  of  Brophy 
are  necessary.  The  patient  is  anesthetized  and  put  into  the  Trendelenburg 
position  and  a  strong  piece  of  silk  is  put  through  the  tip  of  the  tongue  as  a 
traction-suture.     The  edges  of  the  cleft  in  the  hard  palate  are  pared,  a  little 


Carcinoma  of  the  Lower  Lip  1053 

of  the  bone  being  taken  away  with  the  paring.  Then  the  edges  of  the  cleft  in 
the  soft  palate  are  pared.  The  needle  is  threaded  with  strong  silk;  the  cheek 
is  Hfted,  and  the  threaded  needle  is  forced  through  the  superior  maxillary 
bone  from  without  inward,  starting  just  back  of  the  malar  process  and  just 
above  the  palate.  As  the  needle  shows  in  the  cleft  the  thread  is  picked  up 
with  a  pair  of  forceps,  and  the  needle  is  pulled  out,  the  loop  of  thread  remain- 
ing in  the  cleft.  Through  a  part  of  the  opposite  superior  maxillary  cor- 
responding with  this  first  point  of  entrance  the  needle  is  entered  again  and 
another  loop  is  got  into  the  cleft.  The  second  loop  is  caught  into  the  first 
loop,  and  when  the  former  is  pulled  out  it  carries  the  latter  with  it.  This  thread 
now  passes  through  both  the  superior  maxillary  bones  and  usually  through 
the  nasal  septum  as  well.  This  thread  is  used  to  pull  a  piece  of  strong  silver 
wire  through.  One  other  silver  wire  is  introduced  in  the  same  manner  more 
to  the  front.  The  silver  wire  ends  are  threaded  through  perforated  lead  plates, 
which  fit  the  external  outhne  of  the  bones  on  each  side.  The  wires  are  tightened 
and  twisted.  For  instance,  on  one  side  the  end  of  the  anterior  wire  is  twisted 
to  the  end  of  the  posterior  wire,  and  so  on.  The  thumbs  are  used  to  jam  the 
two  ends  of  the  maxillary  bones  forcibly  together,  thus  closing  the  cleft,  and 
then  the  wires  are  twisted  more  firmly  to  hold  the  edges  in  contact.  The 
cleft  in  the  soft  palate  is  then  sutured,  although  the  surgeon  may  deem  it  advis- 
able to  wait  one  day  before  doing  so.  After  the  palate  heals  the  harehp  is 
closed. 

Carcinoma  of  the  Lower  Lip. — Cancer  frequently  arises  in  the  lower  lip, 
very  rarely  in  the  upper  lip.  Males  suffer  frequently,  but  females  are  not 
very  often  attacked.  In  some  cases  it  seems  to  arise  in  smokers  at  the  point 
on  the  lip  where  the  pipe  habitually  rests.  A  short-stemmed  clay  pipe,  which 
grows  hot  when  it  is  smoked,  is  particularly  apt  to  lead  to  the  causal  irrita- 
tion. The  region  of  the  lip  which  is  most  liable  to  cancer  is  the  junction 
of  the  skin  and  mucous  membrane.  The  growth  may  begin  in  a  fissure  or 
abrasion,  may  start  in  an  eczematous  area  or  a  wart,  but  most  frequently  arises 
as  an  indurated  area  which  quickly  ulcerates.  After  a  cancer  has  existed  for 
a  variable  time  the  submental,  submaxillary,  and  cervical  lymphatic  glands 
become  diseased.  These  glands  are  usually  involved  within  three  months  after 
the  beginning  of  the  cancer  but  may  remain  free  for  seven  or  eight  months. 
In  a  case  of  my  own  they  were  found  to  contain  carcinoma  cells  in  less  than  three 
months  after  the  origin  of  the  carcinoma  of  the  lip.  This  involvement  cannot 
be  detected  by  external  manipulation  in  the  earliest  stages,  hence  it  is  not  proper 
to  conclude  that  the  glandular  involvement  is  absent  simply  because  it  cannot 
be  palpated.  In  many  cases  when  glands  cannot  be  detected  by  palpating 
beneath  the  jaw  they  will  be  discovered  by  placing  one  finger  in  the  mouth 
back  of  the  lower  jaw  and  one  finger  beneath  the  chin.  It  occasionally  happens 
that  glands  enlarge  because  of  septic  absorption,  and  this  enlargement  may 
even  precede  carcinomatous  involvement.  From  an  operative  point  of  ^dew 
the  glands  should  always  be  regarded  as  carcinomatous.  If  cancer  is  not  oper- 
ated upon  it  destroys  the  lip,  extensively  involves  the  glands  of  the  neck,  the 
floor  of  the  mouth,  the  periosteum  and  the  lower  jaw,  and  produces  death  in 
from  three  to  five  years.  If  the  jaw  is  involved  the  prognosis  is  bad,  and  it  is 
almost  hopeless  if  the  floor  of  the  mouth  is  involved. 

The  treatment  consists  in  the  early  and  thorough  removal  of  the  growth 
by  the  knife,  and  also  in  the  removal  of  the  fatty  tissue  and  glands  from  the 
submaxillry  triangles,  from  the  submental  region,  and  down  to  the  carotid  bi- 
furcation. The  growth  must  be  thoroughly  removed,  that  is,  the  incision  must 
be  at  least  3^  inch  wide  of  the  disease.  For  many  years  a  favorite  operation  was 
the  V-shaped  incision,  the  skin  edges  being  sutured  by  silkworm-gut,  the  sutures 
being  passed  almost  to  the  mucous  membrane  and  being  inserted  so  as  to  com- 
press the  vessels  when  tied,  and  the  mucous  membrane  being  sutured  with  fine 


I054  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


silk  or  catgut.  The  V-shaped  incision  should  only  be  used  for  a  very  small  and 
very  recent  growth.  After  the  removal  of  the  growth  from  the  lip  a  vertical  in- 
cision is  made  from  the  point  of  the  V  over  the  cricoid  cartilage,  and,  from  the 
origin  of  this  incision  incisions  are  made  in  each  direction  along  the  under  surface 
of  the  body  of  the  jaw.  The  glandular  area  is  thus  exposed,  and  after  the  re- 
moval of  the  fat  and  glands  the  wound  is  sutured  with  silkworm-gut.  Far  better 
than  the  V-shaped  incision  is  the  operation  devised  by  W.  W.  Grant,  of  Den- 
ver.^    In  this  operation  the  growth  is  removed  and  cheiloplasty  is  performed. 

Grant's  Operation  for  Cancer  of  the  Lip. — This  operation  gives  a  useful 
mouth  and  a  more  natural-looking  lip  than  does  the  ordinary  operation,  and 
there  is  decidedly  less  tension  on  the  suture  line.  Furthermore,  the  suture 
line  in  a  man  is  apt  to  be  soon  covered  with  a  beard.  The  procedure  has 
great  advantages  over  the  ordinary  V-shaped  operation,  which  greatly  lessens 
the  size  of  the  mouth,  making  it  what  is  known  as  a  sucker-mouth,  and  the 
new  lip  is  rigid  and  ugly. 

In  Grant's  operation  two  vertical  incisions  are  made,  one  on  each  side 
of  the  growth,  and  these  are  connected  by  a  horizontal  incision  at  the  base 
(Figs.  672,  673).     Thus,  a  quadrangular  gap  is  formed,  which  must  be  filled 


Fig.  672. — Grant's   method    for  removal  Fig.  673. — Grant's   method  for  removaJ 

of  carcinoma  of  the  lower  lip.  The  of  carcinoma  of  the  lower  lip.  Second  step, 
incision.  The  mass  removed. 

by  flaps.  An  incision  is  made  on  each  side  from  each  inferior  angle  of  the 
wound,  obliquely  downward  and  backward  beneath  the  maxilla,  on  a  line 
about  midway  between  the  angle  of  that  bone  and  the  apex  of  the  chin  (Fig. 
672).  Its  further  extension  is  determined  by  the  amount  of  lip  removed  and 
by  the  degree  of  glandular  involvement. 

The  submaxillary  lymph-glands  are  removed  through  these  incisions. 
The  glands  in  the  midline,  however,  beneath  the  chin  may  require  a  separate 
incision.  If  the  lip  is  extensively  involved,  the  cheek  ought  to  be  completely 
separated  from  the  inferior  maxillary  bone  to  the  middle  of  the  masseter  mus- 
cle (Fig.  674).  When  the  glands  have  been  removed,  the  triangular  flaps  are 
brought  together  and  united,  first  of  all,  in  the  middle  line  (Fig.  675).  If  the 
tension  is  marked,  owing  to  the  amount  of  tissue  excised,  it  is  wise,  to  insert 
a  traction  suture,  ^|  inch  from  the  center  line,  and  tie  it  over  pads  of  gauze 
covered  with  muslin.  One  thus  prevents  undue  tension  upon  the  sutures  in 
the  center  of  the  flap.  The  stitches  that  unite  the  cheek  posteriorly  are  in- 
serted and  tied,  and  the  entire  thickness  of  the  cheek  must  be  included.  Silk- 
worm-gut sutures  are  used.  A  drainage-tube  is  inserted  in  the  posterior  angle 
of  the  wound  on  each  side.  It  is  very  useful  to  use  also  a  T-drainage-tube 
as  advised  by  Grant.     This  tube  is  about  the  diameter  of  a  lead  pencil  and 

1"  Medical  Record,"  May  27,  1899. 


Tongue-tie 


'50 


the  cross-piece  rests  behind  the  incisor  teeth  or  symphysis  and  beneath  the 
tip  of  the  tongue.  It  drains  away  all  of  the  mouth  secretions,  saves  the  lines 
of  incision  from  being  constantly  bathed  in  them,  and  renders  very  frequent 
changes  of  dressing  unnecessary. 

I  have  employed  this  operation  repeatedly,  and  regard  it  as  the  most  use- 
ful method  we  have  for  the  purpose.  Thorough  removal  of  the  carcinoma 
of  the  lip  and  of  the  related  glands  will  cure  from  60  to  80  per  cent,  of  cases. 

The  glands  should  be  removed  in  all  cases.  If  the  lesions  on  the  hp  and  the 
glands  are  removed  and  the  glands  show  no  metastasis  Bloodgood  obtains 
95  per  cent,  of  cures,  setting  the  five-year  limit  as  a  cure  ("  Surgery,  Gyne- 
cology, and  Obstetrics,"  1914,  x:\-iii).  Bloodgood  shows  that  when  the  lip  lesion 
is  removed  but  the  glands  are  not  there  are  37  per  cent,  of  recurrences  in  the 
glands.     In  this  stage  not  over  20  per  cent,  of  operations  will  secure  a  cure. 

Operations  for  recurrence  give  but  10  per  cent,  of  cures.  If  the.  bone  is 
involved  in  cancer,  cure  is  practically  never  obtained. 


Fig.  674. — Grant's  method  for  removal  of 
carcinoma  of  the  lower  lip.  Dissection  pre- 
liminary to  suturing. 


Fig.  675. — Grant's  method  for  removal 
of  carcinoma  of  the  lower  lip.  The  wound 
sutured. 


Carbuncle  of  the  Upper  Lip. — In  contrast  to  carbuncle  in  other  regions 
of  the  body,  facial  and  labial  carbuncles  are  most  common  in  young  persons. 
Carbuncle  of  the  lip  is  due  to  staphylococcus  infection  and  begins  as  a  papule. 
Numerous  pustules  appear,  and  sloughing  usually  takes  place.  There  may  or 
or  may  not  be  serious  constitutional  involvement.  The  condition  is  very 
dangerous,  as  thrombophlebitis  may  arise  and  track  up  into  the  cranium 
by  way  of  the  ophthalmic  vein  and  cavernous  sinus.  I  have  known  two  persons 
to  die  from  carbuncle  of  the  lip. 

Treatment. — Excise  if  possible.  If  excision,  is  impossible,  make  a  crucial 
incision,  cutting  away  the  skin  corners  and  edges  with  scissors  and  di\dding 
the  venous  connection  with  the  cranium.  Scrape  out  the  carbuncle  with  a 
sharp  and  strong  curet,  swab  with  pure  carbolic  acid,  pack  with  iodoform 
gauze,  and  dress  T^dth  antiseptic  poultices. 

Tongue-tie  {congenital  ankyl aglossia  or  adherent  tongue)  is  congenital  short- 
ness of  the  frenum,  the  tip  of  the  tongue  adhering  to  the  floor  of  the  mouth. 
It  is  due  to  the  projecting  portion  of  the  tongue  being  incompletely  developed 
from  the  tuberculum  impar.  ''In  many  of  the  slighter  cases  the  development 
has  merely  lagged  behind  and  \nll  be  completed  as  the  child  grows  after  birth  " 
("Diseases  of  the  Tongue,"  by  Henry  T.  Butlin,  Second  Edition).  The  tongue 
cannot  be  protruded  beyond  the  incisor  teeth.     Swallowing  is  interfered  with, 


1056  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

and  later  in  life  articulation  is  impeded.  It  is  not  very  unusual  in  infants, 
but  in  the  great  majority  of  cases  disappears  as  the  child  grows  older.  Per- 
sisting tongue-tie,  Butlin  says,  is  one  of  the  rarest  of  conditions,  and  my  ex- 
perience is  in  absolute  accord  with  his — in  fact,  I  have  never  seen  a  single  case. 
Many  unnecessary  or  even  harmful  operations  are  done  for  a  condition  which, 
if  let  alone,  will  usually  correct  itself.  Improper  operation  may  result  in  fatal 
hemorrhage  or  in  "swallowing  of  the  tongue."  The  operation  usually  done  is 
to  tear  up  the  frenum  with  a  thumbnail.  This  is  unsurgical  and  makes  a  lace- 
rated wound.  A  better  way  is  to  raise  the  tip  of  the  tongue  to  make  the 
bands  tense,  and  then  snip  with  the  scissors  close  to  the  mucous  membrane 
of  the  lower  jaw.  The  slit  in  the  handle  of  the  grooved  director  was  placed 
there  to  catch  the  frenum  in,  but  a  short  frenum  will  not  enter  it  (Butlin). 

Tuberculosis  of  the  Tongue. — This  is  rather  a  rare  trouble  although  Durante 
was  able  to  collect  250  cases  from  literature  and  to  report  5  cases  ("Annals  of 
Surgery,"  1916,  Ixiii).  The  tongue,  being  a  muscle,  resists  tuberculous  infection 
as  does  all  muscle  and  it  is  not  easy  for  the  bacilli  to  pass  through  the  epithelial 
covering.  The  lesion  is  never  found  in  infancy  and  is  most  common  between 
the  twentieth  and  fiftieth  years,  and  met  with  far  oftener  in  men  than  in  women 
(Durante,  Ibid.).  It  is  predisposed  to  by  irritation  or  injury  of  the  mucous 
membrane.  In  the  great  majority  of  cases  the  lesion  is  secondary  to  distant 
tuberculosis,  especially  the  pulmonary  form,  but  primary  tuberculosis  is  occa- 
sionally found.  Durante  (Ibid.)  asserts  that  in  a  primary-  case  the  infection 
is  hematogenous. 

In  one  type  of  the  disease,  an  elevated,  gray,  uninflamed  induration  forms  in 
the  mucous  membrane.  There  may  be  multiple  lesions  (miliary  tuberculosis 
of  the  tongue).     Nodular  tuberculosis  arises  in  the  tongue  parenchyma. 

Ulceration  may  be  early  or  late.  Its  edges  are  irregular,  reddish  in  color,  and 
non-indurated  and  the  floor  is  yellowish  (Durante,  Ibid.).  I  recently  saw  an 
indurated  tuberculous  ulcer  which  was  thought  to  be  cancer.  Any  part  of  the 
tongue  may  be  attacked  but  the  tip  is  most  apt  to  suffer.  The  glands  under  the 
jaws  on  each  side  enlarge  and  become  tender.  Diagnosis  is  difficult.  To  mistake 
it  for  cancer  is  a  grave  misfortune  as  cancer  calls  usually  for  amputation  of  the 
organ.  In  very  few  cases  can  the  bacilli  be  found.  Always  take  a  section  and 
have  it  studied  by  the  pathologist.  In  every  doubtful  case  make  the  therapeutic 
test,  which  is  the  administration  of  salvarsan.  Primary  cases  give  a  favorable, 
secondary  cases  an  unfavorable,  prognosis.  The  treatment  is  destruction  by 
the  high  frequency  current. 

Thyrolingual  or  Thyroglossal  Cysts  and  Sinuses. — In  early  embryonal 
life  the  thyroid  gland  has  a  duct  which  passes  from  the  thyroid  isthmus  to 
the  foramen  caecum  of  the  dorsum  of  the  tongue.  The  duct  may  be  lined  with 
one  layer,  two  layers,  or  several  layers  of  epithelium,  and  there  are  mucous 
glands  and  lymph-follicles  in  its  walls,  these  structures  being  derived  from 
the  mucous  membrane  of  the  tongue.  The  wall  of  the  duct  presents  numerous 
irregularly  placed  and  irregularly  shaped  diverticula.  It  is  known  as  the  thyro- 
glossal or  thyrolingual  duct.  The  duct  runs  from  the  base  of  the  tongue  down 
the  midline  of  the  neck.  It  is  connected  with  the  body  of  the  hyoid  bone,  with 
the  periosteum  in  front  of  the  bone,  and  with  the  thyrohyoid  bursa  behind  the 
bone.  It  passes  to  the  upper  portion  of  the  front  surface  of  the  trachea,  where  it 
bifurcates,  each  branch  passing  to  a  lateral  lobe  of  the  thyroid  gland.  This 
fetal  structure  under  normal  conditions  begins  to  atrophy  in  the  fifth  week  and 
closes  by  the  eighth  week,  the  foramen  caecum  marking  its  old  orifice  on  the  dor- 
sum of  the  tongue.  When  the  duct  is  obliterated,  it  becomes  a  cord  of  epithe- 
lium. In  more  than  30  per  cent,  of  bodies  the  remains  of  this  primitive  passage 
can  be  found  (Weglowski,  in  "Zentralb.  f.  Chir.,"  1908,  xxxv,  289).  The  duct 
may  persist  between  the  foramen  caecum  and  the  hyoid  bone,  developing, 
it  may  be,  into  a  sublingual  dermoid.     The  portion  behind  and  below  the 


Carcinoma  of  the  Tongue  1057 

hyoid  may  remain  and  develop  into  a  subhyoid  cyst.  The  part  inferior  to  the 
hyoid  may  persist,  give  origin  to  a  cyst  which  ruptures,  and  constitute  an  in- 
complete median  cervical  fistula.  The  duct  may  remain  open  from  the  mouth 
and  make,  by  bursting  an  opening  into  the  neck,  a  complete  median  cervical  fistula. 
A  patent  duct  may  exist  for  years  and  announce  its  existence  by  some  acute 
inflammatory  process.  The  small  diameter  of  a  cervical  fistula  renders  prob- 
ing to  any  depth  impossible.  Some  have  told  us  to  determine  if  a  fistula  is 
complete  by  injecting  quassia  solution  into  the  lower  end.  The  patient  will 
perhaps  experience  a  bitter  taste.  If  we  inject  a  colored  fluid  we  may  see  it  if 
it  runs  from  the  mouth.  I  have  never  succeeded  in  doing  either.  Tumors 
may  spring  from  the  duct. 

Treatment. — If  a  thyroglossal  cyst  or  tumor  arises  on  the  dorsum  of  the 
tongue,  and  if  it  is  increasing  in  size  and  interferes  with  swallowing  and  speech, 
it  must  be  removed  through  the  mouth.  A  general  anesthetic  should  be  given. 
In  some  cases  preliminary  tracheotomy  is  necessary. 

A  cyst,  tumor,  or  fistula  about  the  hyoid  bone  requires  excision,  the  patient 
being  under  the  influence  of  a  general  anesthetic.  A  portion  of  the  cyst  wall 
adheres  strongly  to  the  posterior  surface  of  the  hyoid  bone  and  must  be  care- 
fully removed  even  if  it  be  necessary  to  split  the  bone  to  accomplish  it.  In 
treating  fistula  the  surgeon  injects  the  tract  with  methylene-blue  and  makes 
an  elliptical  incision  of  the  skin  about  its  orifice  so  as  to  free  the  fistula  from  the 
subcutaneous  tissue.  When  traction  is  made  upon  the  cutaneous  end  of  the 
duct  it  will  stand  out  clearly  and  can  be  dissected  out  (M.  S.  Seelig,  in  "Surg., 
Gynec,  and  Obstet.,"  May,  1907).  It  is  useless  to  try  to  cure  a  fistula  by 
cauterization.  A  fistula  requires  the  complete  removal  of  its  epithelial-lined 
walls.  No  lesser  operation  will  cure.  In  i  case  I  operated  four  times  before 
securing  success.  In  another  case  I  divided  the  hyoid  bone,  removed  the  fistula, 
sutured  the  bone  by  chromic  gut,  and  obtained  a  cure. 

Carcinoma  of  the  Tongue. — This  is  one  of  the  most  dreadful  forms  of  cancer. 
It  is  quite  a  common  disease.  For  a  time  it  may  grow  slowly  but  sooner  or 
later  it  takes  on  very  rapid  growth.  In  most  of  the  cases  I  see  it  is  far  advanced 
when  first  brought  to  the  hospital.  Almost  without  exception  cancer  of  the 
tongue  is  composed  of  squamous-cells  but  columnar-cell  growths  have  been 
reported.  It  is  much  more  common  in  men  than  in  women.  It  is  a  disease  of 
adult  life  and  is  very  rare  before  the  age  of  thirty-five.  The  period  of  greatest 
liability  is  between  the  age  of  forty  and  sixty.  Only  30  cases  are  recorded  in 
those  of  less  than  thirty  years  of  age  ("Collective  Review  in  Internat.  Abstract 
of  Surgery,"  Feb.,  1916,  by  Vilray  Papin  Blair.)  It  begins,  as  a  rule,  near  the 
tip,  on  the  side  or  at  the  base  of  the  anterior  two-thirds  of  the  tongue,  as  a  warty 
growth,  as  an  ulcer  having  at  first  a  papillary  structure,  as  a  fissure  which  indu- 
rates, or  as  an  indurated  area  which  ulcerates.  The  cause  of  the  growth  may 
sometimes  be  traced  to  the  irritation  of  a  jagged  tooth  or  an  ill-fitting  plate, 
or  to  the  smoking  of  a  pipe,  or  to  holding  nails  in  the  mouth,  as  is  done  by  those 
who  nail  laths.  Abbe  states  the  case  against  tobacco  very  strongly  and  claims 
that  90  per  cent,  of  cases  of  cancer  of  the  tongue  result  from  the  use  of  tobacco 
and  only  10  per  cent,  from  a  jagged  tooth  ("N.  Y.  Med.  Jour.,"  July  3,  1915). 
Cancer  may  follow  a  chronic  inflammation — leukoplakia,  for  instance.  Chronic 
ulcers  are  liable  to  become  cancerous  and  any  indurated  ulcer  has  potentialities 
of  deadly  peril  and  should  be  promptly  removed.  Syphilis  predisposes  to 
cancer  especially  if  leukoplakia  arises.  It  is  highly  probable  that  leukoplakia 
is  due  to  syphilis.  Fournier  regards  syphilis  as  an  influential  cause,  and  states 
that  in  184  cases  of  cancer  of  the  mouth  or  tongue  155  had  had  syphilis.  There 
has  been  no  such  proportion  of  syphilitics  in  my  personal  cases.  In  White- 
head's 104  cases  only  7  had  had  syphilis.  In  most  cases  the  disease  spreads 
rapidly;  produces  early  and  extensive  glandular  involvement;  disease  of  the  floor 
of  the  mouth;  dribbling  of  saliva;  difficulty  in  masticating,  swallowing,  and 
67 


1058  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

talking;  foulness  of  the  breath;  severe  pain  which  is  apt  to  radiate  toward  the 
ear  and  is  certain  to  if  the  base  of  the  tongue  is  involved.  Fatal  septic  trouble 
may  arise  at  any  time.  Cases  not  operated  upon  usually  die  in  much  less  than 
two  years.  Wolfcr  described  a  very  rare  form  of  carcinoma,  which  grows  very 
slowly  or  even  remains  latent  for  years. 

One  reason  why  cancer  of  the  tongue  grows  so  rapidly  has  been  pointed  out 
by  Heidenhain,  of  Greifswald.  The  lingual  muscles  are  contracting  almost 
constantly  and  as  a  result  cancer-cells  are  forced  along  the  lymph-spaces  to 
healthy  areas.  In  advanced  cases  the  diagnosis  is  easy.  In  early  cases  it  may 
be  very  difficult.  Early  cases  are  the  only  curable  cases  and  in  them  correct 
diagnosis  is  imperative.  The  diagnosis  from  tuberculosis  is  set  forth  on  page 
1056.  A  positive  Wassermann  test  does  not  prove  that  the  ulcer  is  syphilitic. 
It  is  well  known  that  cancer  may  arise  from  syphilitic  lesions.  It  is  necessary 
in  every  doubtful  case  to  take  a  section  for  examination  and  to  apply  the  thera- 
peutic test  (salvarsan  or  mercury  and  the  iodids). 

The  superficial  ulcer  of  a  broken-down  gumma  affects  the  mucous  membrane. 
It  is  small,  indurated,  has  perpendicular  edges  and  is  covered  by  a  white  and 
adherent  slough.  It  is  most  common  on  the  edge  or  tip  of  the  tongue.  Such 
sores  may  be  multiple  and  are  usually  at  least  bilateral.  A  parenchymatous 
gumma  begins  beneath  the  mucous  membrane.  When  it  ruptures  it  exposes 
a  cavity,  lined  by  slough  and  surrounded  by  induration. 

The  results  of  operation  have  improved  much  of  late,  probably  because  cases 
are  brought  earlier  and  operations  are  more  thorough.  Up  to  very  recent  years 
surgeons  were  able  to  obtain  only  10  to  15  per  cent,  of  recoveries  (cases  which 
passed  three  years  without  recurrence).  Johns  Hopkins  Hospital  now  reports 
50  per  cent,  cured. 

Treatment. — A  cancer  of  the  tongue  should  be  removed  radically  at  the 
earliest  possible  moment.  Specific  treatment  for  diagnostic  purposes  should 
not  be  continued  beyond  a  very  few  weeks.  In  doubtful  cases  a  Wassermann 
test  is  made,  and  if  it  is  positive,  salvarsan  is  given  intravenously.  If  still  in 
doubt  as  to  the  nature  of  the  growth,  remove  it  and  have  a  pathologist  at  hand 
to  study  it  immediately  by  frozen  sections  (Warren,  in  "Annals  of  Surgery," 
Oct.,  1908).  Have  permission  beforehand  to  proceed  at  once  to  radical  opera- 
tion if  conditions  demand  it.  The  study  of  a  small  section  is  always  of  somewhat 
uncertain  value,  hence,  if  the  growth  is  small  or  of  moderate  size  remove  it 
for  study.  If  the  growth  is  larger  take  a  considerable  piece  for  study.  This 
piece  must  include  a  part  of  the  floor  and  the  edge  of  ulcer  and  of  apparently 
sound  tissue  bevond  the  ulcer.  An  ulcerating,  warty  or  indurating  lesion  of 
the  tongue  requires  removal.  If  it  is  not  cancer  it  will  be  apt  to  become 
cancerous.  Befoie  any  operation  is  undertaken  all  stumps  of  teeth 
should  be  extracted  and  a  dentist  should  clean  tartar  from  the  teeth. 
During  several  days  preceding  an  operation  the  teeth  should  be  scrubbed 
twice  a  day  with  a  brush  and  soap  and  the  mouth  rinsed  with  hydrogen 
peroxid.  The  nares  and  nasopharynx  should  be  sprayed  with  peroxid  of 
hydrogen  and  then  with  boric  acid  solution  every  second  or  third  hour  when 
the  patient  is  awake. 

In  some  cases  the  entire  tongue  is  removed;  in  some,  half  of  it;  in  some,  only 
a  piece  of  it.  Not  only  the  diseased  tongue,  but  also  the  adjacent  lymphatic 
glands  must  be  removed.  Cancer  of  the  tip  of  the  tongue,  as  a  rule,  involves  the 
submental  and  sublingual  groups  of  glands  early.  Cancer  of  the  anterior  two- 
thirds  of  the  dorsum  of  the  tongue  first  involves  the  lingual  and  submaxillary 
lymph-nodes.  Cancer  of  the  under  surface  of  the  tip  of  the  tongue,  first  in- 
volves the  submaxillary  glands.  Sooner  or  later  the  superior  deep  cervical 
glands  about  the  carotid  bifurcation  become  involved  as  a  result  of  cancer  of 
the  tip  or  edges  of  the  anterior  portion  of  the  tongue.  In  cancer  of  the  dorsum 
the  deep  cervical  glands  become  involved  as  well  as  the  superficial  nodes.     The 


Carcinoma  of  the  Tongue 


1059 


lymphatic  system  of  the  base  of  the  tongue  is  distinct  from  that  of  the  balance 
of  the  organ.     It  drains  into  the  deep  cervical  groups. 

It  was  forme/ly  my  belief  that  in  a  very  recent  and  limited  case  only  the 
glands  on  the  diseased  side  required  removal,  but  that  in  an  advanced  case 
the  glands  must  be  removed  from  both  sides  of  the  neck.  Experience  has 
convinced  me  that  in  any  case  the  glands  on  both  sides  should  be  removed. 
Kuttner,  of  Tiibingen,  has  demonstrated  that  lymph  from  one  side  of  the 
tongue  may  flow  to  glands  on  the  same  side  of  the  neck,  but  some  also  may  flow 
to  the  opposite  side  of  the  tongue.  Remove  the  obviously  involved  glands  by 
the  block  dissection  of  Crile.  In  a  bad  case  everything  is  removed  but  the  carotid 
arteries.  The  sternocleidomastoid  muscle,  the  omohyoid,  the  jugular  vein, 
even  the  pneumogastric  and  phrenic  nerves  of  one  side  may  be  taken  away. 
After  a  week  or  two  the  other  side  of  the  neck  should  be  operated  upon.  It 
seldom  requires  a  wide  removal  of  structures.  If  the  pneumogastric  or  phrenic 
were  cut  on  one  side  it  must  be  preserved  on  the  other.  The  jugular  vein  can 
be  removed  after  a  collateral  circulation  has  been  established  subsequent  to 
removing  the  jugular  of  one  side.  Two  operations  are  to  be  considered:  partial 
removal  and  complete  removal. 

Partial  Removal  of  the  Tongue. — This  operation  is  restricted  to  recent  cases 
in  which  one  side  only  of  the  anterior  portion  of  the  tongue  is  involved.  The 
operation  does  not  offer  as  good  a  chance  of  cure  as  complete  excision,  because 
lymph  containing  cancer-cells  may  have  reached  the  opposite  side  of  the  tongue. 
Even  in  partial  removal  the  glands  should  be  removed  from  both  sides.  Intra- 
tracheal anesthesia  is  employed. 

In  performing  the  operation  of  partial  excision  introduce  a  mouth-gag, 
pass  a  silk  ligature  through  each  half  of  the  tip  of  the  tongue,  and  draw  the 
organ  out  of  the  mouth.  Place  the  patient  recumbent  with  the  head  a  little 
raised.  Split  the  tongue  back  in  the  middle  line  by  the  scissors,  and  loosen 
the  cancerous  side  from  the  floor  and  side  of  the 
mouth.  Pass  a  stout  silk  ligature  through  the 
base  of  the  tongue  posterior  to  the  cancer.  Draw 
the  organ  out  and  cut  off  the  diseased  side  in 
front  of  the  ligature,  but  well  back  of  the  disease. 
Tie  the  vessels,  remove  the  traction  threads,  and 
treat  subsequently  as  in  cases  of  complete  removal. 

Complete  Removal  of  the  Tongue  {Kocher's 
Method). — Kocher  recommends  a  preliminary 
tracheotomy  in  tongue  excision,  but  the  Tren- 
delenburg position  renders  this  procedure  unneces- 
sary so  far  as  fear  of  the  passage  of  blood  into  the 
larynx  and  trachea  is  concerned.  I  operated 
many  times  with  the  patient  in  that  position.  At 
present  I  operate  with  the  head  a  little  raised 
and  the  patient  taking  ether  by  intratracheal 
insufflation.  Because  of  the  insufflation  there  is  no  respiratory  difi&culty 
and  the  stream  of  escaping  air  and  ether  keeps  blood  out  of  the  bronchial 
tubes.  The  method  is  most  satisfactory.  The  surgeon  stands  to  the 
side.  Ether  is  given  by  intratracheal  insufflation  (see  page  13.40).  Ligate 
the  lingual  artery  on  the  side  opposite  to  the  one  where  the  main 
incision  is  to  be  made.  Remove  the  glands  on  that  side  and  suture  the 
wound.  An  incision  is  then  made  on  the  side  opposite  to  that  on  which 
the  artery  was  ligated.  This  incision  passes  from  behind  the  lobe  of  the 
ear,  along  the  anterior  edge  of  the  sternocleidomastoid  to  about  the  middle 
of  the  margin  of  this  muscle.  From  this  point  the  incision  is  carried  to  the 
level  of  the  hyoid  bone  and  then  to  the  symphysis  menti,  along  the  anterior 
belly  of  the  digastric  muscle  (Fig.  676).     The  flap  is  dissected  and  turned  up; 


Fig.  676. — Kocher's  excis- 
ion of  tongue  CEsmarch  and 
KowalzigJ. 


io6o  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

the  facial  and  Ungual  arteries  are  ligated;  "the  submaxillary  fossa  is  evacuated" 
(Treves);  the  sublingual  and  submaxillary  glands  are  removed;  the  mylohyoid 
muscle  is  divided;  the  mucous  membrane  is  incised  close  to  the  jaw,  and  the 
tongue,  caught  by  tenaculum  forceps,  is  drawn  through  the  opening.  The 
tongue  is  split  in  the  middle  by  scissors,  and  the  near  half  is  removed,  bleeding 
is  arrested,  the  remaining  half  of  the  tongue  is  cut  through,  and  the  vessels 
are  tied.  Stitch  the  mucous  membrane  of  the  stump  to  the  mucous  membrane 
of  the  floor  of  the  mouth  with  catgut  sutures.  Kocher  does  not  suture  the  skin 
wound.  I  prefer  to  suture  it  and  employ  drainage-tubes.  I  follow  the  sug- 
gestions of  Treves  as  to  after-treatment.  Some  hours  after  the  operation, 
when  oozing  has  ceased,  dust  the  mouth  wound  with  iodoform.  The  patient, 
as  soon  as  possible,  is  propped  up  in  bed,  and  he  must  not  swallow  the  discharges 
if  it  can  be  avoided.  The  mouth,  every  half-hour,  is  sprayed  with  peroxid  of 
hydrogen  and  washed  with  a  carboHc  solution  (i  :  60).  Every  three  hours,  after 
washing  the  floor  of  the  mouth  and  the  stump,  the  parts  should  be  dried  with 
absorbent  cotton  and  dusted  with  iodoform.  For  twenty-four  hours  after 
the  operation  nothing  is  given  by  the  mouth  except  a  little  cracked  ice,  the 
patient  being  fed  by  rectum.  At  the  end  of  twenty-four  or  forty-eight  hours 
some  liquid  food  is  given  from  a  feeding-cup.  The  patient  wUl  soon  learn  to 
swallow;  but  if  he  cannot  swallow  easily,  he  is  fed  by  a  tube.  Treves,  in  his 
clear  and  positive  directions  for  after-treatment,  states  that  nutrient  enemata 
are  to  be  continued  until  sufhcient  nourishment  is  taken  by  the  mouth;  that 
the  mouth  should  be  flushed  by  irrigation,  and  must  be  washed  immediately 
after  taking  food;  that  morphin  is  to  be  avoided,  and  that  the  patient  can  usu- 
ally leave  the  hospital  in  from  seven  to  ten  days. 

Whitehead's  Operation. — Whitehead  removes  one-half  of  or  the  entire  tongue 
from  within  the  mouth  by  the  use  of  scissors.  He  passes  a  ligature  through  the 
tip,  cuts  the  frenum,  draws  the  tongue  strongly  forward,  and  separates  by  a 
series  of  clips  with  the  scissors.  The  lingual  arteries  are  tied  as  cut.  "The 
stump  should  be  kept  under  control,  as  regards  hemorrhage,  by  a  stout  silk 
ligature  passed  through  the  remains  of  the  glosso-epiglottidean  fold  and  re- 
tained for  twenty-four  hours." ^ 

Heath  has  shown  that  if  the  forefinger  be  passed  to  the  epiglottis  and  used 
to  "hook  forward"  the  hyoid  bone,  the  lingual  arteries  are  stretched  and 
portions  of  the  tongue  can  be  removed  almost  without  bleeding.  It  is  rarely 
desirable  in  Whitehead's  operation  to  remove  the  glands  and  the  tongue  at 
one  seance.  To  do  so  increases  shock  and  the  danger  of  death.  The  rule  of 
procedure  set  forth  by  W.  Watson  Cheyne^  is  eminently  wise.  This  rule  is  as 
follows:  If  glandular  involvement  is  trivial  or  not  detectable,  it  is  perfectly 
proper  to  remove  the  tongue  first,  and  after  a  week  or  so  remove  the  glands. 
If  the  glandular  involvement  is  marked,  growth  in  the  glands  will  be  much  more 
rapid  than  growth  in  the  tongue.  In  such  a  case  the  glands  should  be  removed 
before  the  tongue,  because,  if  the  tongue  is  removed  before  the  triangles  are 
cleared,  in  the  week  or  two  of- waiting  the  case  may  become  inoperable.  ^  In  the 
majority  of  cases  clear  out  the  triangle  before  removing  the  tongue,  doing  the 
other  operation  in  one  or  two  weeks  when  the  wound  in  the  neck  is  healed.  If 
the  disease  in  the  mouth  is  far  advanced,  do  both  operations  at  one  seance. 

Examination  of  the  Esophagus. — The  v-rays  are  ot  great  value  not  only 
in  detecting  foreign  bodies,  but  in  finding  carcinoma,  pouches,  and  constric- 
tions. As  Waggett  ("Brit.  ]\Ied.  Jour.,"  Oct.  19,  191 2)  says,  by  means  of  the 
:i;-rays  we  may  learn  that  there  is  a  stricture  (or  are  strictures),  where  it  is  (or 
they  are),  how  narrow  it  is  for  they  are),  and  whether  or  not  there  is  extrinsic 
pressure.  In  this  examination  the  patient  first  swallows  material  through 
which  the  rays  pass  with  difficulty.     A  salt  of  bismuth  is  generally  used.     The 

1  "American  Text-Book  of  Surgery." 

2  "The  Practitioner,"  April,  1S99. 


Examination  of  the  Esophagus  1061 

carbonate  of  bismuth  is  a  safe  and  satisfactory  salt.  It  is  given  in  glutoid 
capsules  (Kohler,  in  "Brit.  Med.  Jour.,"  Oct.  19,  1912).  Barium  sulphate  may- 
be used  instead  of  a  bismuth  salt. 

Esophageal  Sounds  and  Bougies. — These  instruments  were  long  our  only 
mechanical  means  of  diagnosis.  They  are  used  far  less  than  formerly.  They 
possess  certain  dangers.  For  instance,  it  an  aneurysm  exists  and  we  are  misled 
in  believing  that  the  condition  is  stricture,  the  rigid  sound  and  even  the  flexible 
bougie  may  penetrate  the  sac  of  the  aneurysm  and  cause  death.  I  have  personal 
knowledge  of  such  a  case.  If  a  person  has  ever  brought  up  blood,  neither  a 
sound  nor  bougie  should  be  used.  Again,  neither  the  bougie  nor  sound  can 
prove  the  existence  of  a  slight  stricture.  They  give  no  information  at  all  as 
to  the  nature  of  a  stricture.  I  find  their  greatest  diagnostic  use  is  to  locate 
the  situation  of  a  constriction  before  passing  the  esophagoscope.  In  view 
of  the  fact  that  such  an  examination  may  cause  bleeding,  and  that  blood  in- 
terferes with  an  examination  by  the  esophagoscope,  the  bougie  or  sound,  if  used 
at  all,  should  be  employed  the  day  before  the  introduction  of  the  esophagoscope. 

The  olive  tip  flexible  bougie  is  made  from  elastic  web.  It  is  a  safer  in- 
strument than  the  sound  with  a  hard  bulbous  tip  (see  Fig.  683,  e).  The  latter 
has  a  series  of  removable  ivory  or  metal  tips  which  vary  in  size.  Used  diagnos- 
tically,  the  olive  tip  bougie  is  to  impart  information  as  it  enters;  the  bulbous 
sound,  as  it  enters  and  as  it  is  withdrawn.  On  withdrawing  the  bulbous  sound 
it  may  catch  upon  the  lower  border  of  a  constriction  which  it  passed  on  entering. 

Before  being  passed  the  bougie  or  sound  should  be  warmed  and  greased  with 
glycerin.  The  patient  sits  in  a  chair  and  throws  the  head  well  back  against 
the  breast  of  an  assistant.  The  mouth  is  opened  widely  and  is  held  open  by  a 
large  cork  or  by  a  gag.  The  patient  is  directed  to  breathe  deeply  and  regularly 
while  the  instrument  is  being  passed.  Depress  the  tongue  with  the  finger  and 
carry  the  instrument  beyond  the  glottis.  As  it  reaches  the  back  of  the  pharynx 
the  patient  will  gag  a,nd  choke.  Tell  him  to  swallow  and  breathe  regularly. 
The  fact  that  he  can  breathe  regularly  shows  that  the  instrument  is  not  within 
the  larynx.  It  may  then  be  gently  urged  along  the  gullet.  All  maneuvers 
are  to  be  conducted  with  the  utmost  gentleness.     Force  means  danger. 

Remember  that  in  an  adult  the  esophageal  orifice  is  5  or  6  inches  from  the 
incisor  teeth,  that  the  esophagus  has  a  length  of  from  9  to  10  inches,  hence,  that 
the  cardiac  orifice  of  the  stomach  is  from  14  to  16  inches  from  the  incisor  teeth 
(Maylard's  "Surgery  of  the  Alimentary  Canal").  It  is  further  important  to 
remember  that  the  normal  esophagus  is  of  smaller  caliber  in  some  regions  than 
in  others.  There  are  four  points  of  physiological  narrowing,  viz. :  On  a  level 
with  the  cricoid  cartilage,  where  it  is  crossed  by  the  aorta,  where  it  is  crossed 
by  the  left  bronchus,  and  where  the  tube  passes  through  the  diaphragm. 

Auscultation  may  enable  the  surgeon  to  hear  the  food  bolus  rub  against  a 
stenosis  and  to  note  delay  in  the  passage  of  liquid.  Fluid  normally  passes  in 
four  seconds. 

The  Esophagoscope. — This  instrument  is  of  the  highest  value,  a  value  just 
beginning  to  be  properly  appreciated.  It  is  not  altogether  free  from  danger. 
Deaths  have  occurred  from  it.  The  mandrel  does  the  harm,  and  should  not  be 
used  at  all  or  should  be  withdrawn  as  soon  as  the  tube  has  passed  the  cricoid 
constriction.  The  rest  of  the  way  the  instrument  is  carried  along  while  the  sur- 
geon is  looking  through  it  and  seeing  what  is  ahead.  It  is  not  carried  into  a 
constriction;  it  is  not  carried  by  an  ulcer  or  a  pulsating  lump.  It  enables  us  to 
make  diagnoses  otherwise  impossible,  to  diagnosticate  cancer  in  an  early  stage, 
to  treat  local  conditions,  and  to  remove  a  fragment  of  tissue  for  exam'nation. 
I  prefer  to  pass  the  instrument  without  general  anesthesia  even  in  children,  and 
highly  nervous  people,  unless  there  is  very  severe  spasm.  Until  I  watched 
Jackson  work  it  was  my  custom  to  apply  cocain  to  the  back  of  the  tongue,  pil- 
lars of  the  fauces,  epiglottis,  and  pharynx  and  to  place  the  patient  on  the  right 
side  with  the  head  thrown  back.     This  is  known  as  Starch's  position,  and, 


io62  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

as  Gottslein  shows,  it  relaxes  the  diaphragmatic  crura.  An  assistant  supports 
the  head  and  follows  every  movement  of  the  surgeon.  The  patient  is  cautioned 
to  breathe  tranquilly,  and  is  told  if  the  pain  or  annoyance  becomes  intolerable 
to  raise  his  left  arm,  when  the  surgeon  will  cease  for  a  time.  The  surgeon  must, 
of  course,  keep  his  word  on  this  point.  Artificial  teeth  are  removed.  The 
instrument  is  kept  in  the  midline  and  is  inserted  as  is  a  sound  or  bougie.  As 
soon  as  it  passes  the  cricoid  narrowing  the  mandrel  is  withdrawn,  and  the 
instrument  is  passed  slowly  and  gently  along  while  the  surgeon  is  looking  through 
and  ahead  of  it.  For  Chevalier  Jackson's  method  of  esophagoscopy  see  page 
1005.  His  work  is  a  masterpiece  which  combines  knowledge,  dexterity,  gentle- 
ness and  psychical  control  of  the  patient. 

The  cervical  esophagus  is  closed  and  seems  to  unroll  before  the  instru- 
ment. The  thoracic  esophagus  is  open,  and  while  the  esophagoscope  enters 
into  the  upper  part  of  this  region,  if  the  gullet  is  normal,  the  surgeon  can  see 
all  the  way  down  to  the  diaphragm.  At  the  diaphragm  the  esophagus  bends 
forward  and  to  the  left  and  this  point  must  not  be  mistaken  for  the  cardia 
(Kohler,  in  "Brit.  Med.  Jour.,"  Oct.  19,  1912). 

The  cardia  may  be  found  closed  or  may  be  seen  to  open  and  close  with 
respiration.  This  instrument  is  of  great  value  in  the  extraction  of  foreign 
bodies,  in  the  diagnosis  and  treatment  of  many  esophageal  diseases,  and  in  the 
diagnosis  of  certain  peri-esophageal  conditions.  Every  surgeon  should  be 
able  to  use  the  esophagoscope.  (See  Gottstein,  in  "Keen's  Surgery,"  vols,  iii 
and  vi;  Waggett,  in  "Brit.  Med.  Jour.,"  Oct.  19,  1912;  Kohler,  in  "Brit. 
Med.  Jour.,"  Oct.  19,  1912;  "Reports  of  Eightieth  Meeting  of  the  British 
Medical  Assoc,"  July,  191 2;  Lewdsohn,  in  "Annals  of  Surgery,"  Jan., 
■  1913.)  For  Chevalier  Jackson's  directions  as  to  the  use  of  the  esophagoscope 
see  page  1005. 

Stricture  of  the  Esophagus. — Fibrous  or  cicatricial  stricture  or  scar  of  the 
esophagus  is  due  to  the  healing  of  an  ulcer,  and  results  from  traumatism,  chronic 
inflammation,  scarlet  fever,  syphilis,  tuberculosis,  chronic  ulcer,  prolonged 
vomiting,  variola,  gout,  or  to  swallowing  a  corrosive  substance  or  a  boiling 
liquid.  In  about  15  per  cent,  of  cases  of  scarlet  fever  there  is  inflammation  of 
the  esophagus  and  larynx  and  stricture  may  result.  Fibrous  stricture  is  com- 
monest in  the  young,  and  is  apt  to  be  situated  opposite  the  cricoid  cartilage, 
at  the  tracheal  bifurcation  or  near  the  cardiac  end.  Cicatricial  strictures, 
except  when  due  to  boiling  or  corrosive  liquid,  are  usually  single,  but  may  be 
multiple.  A  cicatrix  may  be  of  irregular  shape,  may  be  cylindrical,  may  be 
annular,  may  be  narrow,  or  may  be  broad.  Stricture  following  impaction  of 
a  foreign  body  is  located  at  the  seat  of  impaction  unless  the  tube  has  been  in- 
jured by  efforts  at  extraction,  in  which  case  multiple  strictures  may  exist  (May- 
lard).  Strictures  which  result  from  swallowing  boiling  fluid  or  corrosive  hquid 
are  usually  very  extensive,  may  be  multiple,  and  give  early  symptoms.  In 
some  cases  they  are  shght  and  may  not  give  symptoms  for  years  after  the  injury. 
Syphilitic  stenosis  is  due  to  the  healing  of  a  gummatous  ulceration,  but  there 
is  nothing  characteristic  in  this  kind  of  stenosis.  Tuberculous  stenosis  is 
extremely  rare.     The  esophagus  above  an  extensive  scar  is  usually  dilated. 

Symptoms  of  Cicatricial  Stenosis. — The  condition  is  most  common  in  youth, 
but  may  begin  at  any  age.  The  chief  symptom  is  difficulty  in  swallowing,  at 
first  slight,  but  becoming  more  and  more  pronounced  until  swallowing  is  almost 
or  quite  impossible.  The  dysphagia  is  first  manifested  to  dry  solids,  then  to 
all  sohds,  and  finally  to  Uquids.  In  some  cases  vomiting  occurs  after  swallow- 
ing. If  the  stricture  is  high  up,  the  vomiting  is  almost  immediate;  if  it  is  low 
down,  the  vomiting  is  delayed,  especially  if  the  canal  is  dilated  above  the  stric- 
ture. From  time  to  time  the  patient  vomits  independently  of  taking  food,  the 
ejected  matter  containing  no  gastric  juice,  only  saliva  and  mucus  which  gathered 
in  the  dilated  gullet  about  the  scar.     The  vomited  matter  is  not  bloody.     The 


Stricture  of  the  Esophagus 


1063 


patient  feels  weak,  hungry,  and  thirsty,  becomes  exhausted  and  emaciated,  and 
suffers  from  flatulence,  gastralgia,  and  constipation. 

There  is  occasionally  slight  uneasiness  or  even  pain  in  the  region  of  the 
stricture,  possibly  ''about  the  epigastrium  or  between  the  shoulder-blades" 
("The  Surgery  of  the  Alimentary  Canal,"  by  Maylard),  If  there  is  cer- 
tainly no  aneurysm  and  if  blood  has  never  been  brought  up,  the  flexible  bougie 
may  be  used  first  and  then  the  solid  tipped  sound,  in  order  to  find  a  stricture. 
The  stricture  may  be  located  by  auscultation  over  the  spine  on  a  line  with  the 
supposed  obstruction.  While  a  patient  is  swallowing  water,  the  arrest  of 
the  fluid  at  the  seat  of  stricture  may  be  audible.  Even  if  the  fluid  passes, 
it  will  be  delayed  for  a  time  and  the  duration  of  deglutition  is  thus  prolonged. 
In  order  to  determine  the  time  of  deglutition  put  the  ear  just  below  the  angle 


Fig.  677. — Cicatricial  stricture  of  esophagus. 

of  the  left  scapula,  or  else  between  the  left  sternocostal  margin  and  the  xiphoid 
cartilage,  place  a  finger  on  the  patient's  Adam's  apple,  and  hold  a  watch  in 
the  other  hand.  Have  the  patient  take  a  drink  of  water.  Count  the  time 
from  the  moment  the  Adam's  apple  begins  to  rise  until  the  fluid  is  heard  to 
gurgle  into  the  stomach  (Ogston's  method).  It  ordinarily  requires  four  seconds 
for  fluid  to  pass  from  the  mouth  into  the  stomach  (Maylard,  Ibid.).  The 
a;-rays  are  used  to  diagnosticate  stricture  and  to  locate  it.  They  are  valuable 
in  diagnosis.  An  emulsion  of  bismuth  or  barium  sulphate  is  swallowed  and  a 
skiagraph  is  taken.  The  metallic  salt  is  seen  on  the  plate  as  a  black  mass 
extending  above  the  seat  of  constriction  (Fig.  677).  A  fluoroscopic  examina- 
tion shows  the  bismuth  or  barium  through  a  constriction.  A  bougie  can  be 
passed  until  it  reaches  the  block  and  a  skiagraph  may  be  taken  with  bougie  in 
position. 

In  a  case  reported  by  Seelig  ("Surgery,  Gynecology,  and  Obstetrics,"  Sept., 
1908)  the  patient  was  directed  to  swallow  a  fine  gold  chain  as  thick  as  ordinary 
wrapping  twine.     The  chain  was  about  2  feet  long.     If  a  diverticulum  exists 


1064  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

the  chain  will  fill  the  sac  and  a  skiagraph  will  show  the  position  of  the  diver- 
ticulum. If  no  diverticulum  exists  the  plate  will  show  the  chain  nearly  in  the 
middle  line  of  the  body.     The  esophagoscope  should  be  used  (see  page  106 1). 

The  history  of  the  case  is  of  much  importance  in  diagnosis.  The  surgeon 
must  inquire  about  impaction  of  a  foreign  body,  or  swallowing  of  acids,  alka- 
lis, or  boiling  fluids;  and  must  examine  for  evidence  of  syphilis.  If  there  is 
no  history  of  injury,  syphilis,  tuberculosis,  scarlatina,  variola,  or  prolonged 
vomiting,  and  the  patient  is  over  forty  years  of  age,  the  indications  point  to 
cancer  rather  than  to  cicatricial  stenosis.  The  easy  passage  of  a  bougie  when 
the  patient  is  anesthetized  shows  that  spasm  is  the  cause,  and  not  organic 
disease.  Narrowing  due  to  external  pressure  {compression  stenosis)  is  marked 
by  positive  symptoms  of  the  causative  disease.^  Compression  stenosis  may 
arise  in  goiter,  vetebral  growths,  enlargement  of  the  heart,  glandular  enlarge- 
ment, peri-esophageal  abscess,  aneurysm,  lordosis,  and  mediastinal  tumor 
(Kohler,  in  ''Brit.  Med.  Jour.,"  Oct.  19,  191 2). 

Treatment. — Thiosinamin  is  given  by  some  physicians,  but  I  have  never 
seen  it  accomplish  the  slightest  good.  Telleky-  recommends  it  in  old  scars 
without  inflammation.  He  makes  a  15  per  cent,  alcoholic  solution  and  in- 
jects from  3  2  to  I  syringef ul  at  a  dose,  throwing  the  fluid  beneath  the  skin  be- 


FiG.  678. — Symonds's  short  tube  for  intubation  of  the  esophagus  (Morrow). 

tween  the  scapulae.  He  uses  twenty  doses  in  the  course  of  two  weeks.  Gradual 
dilatation  through  the  mouth  is  a  method  employed  for  at  least  a  time  in  almost 
every  case.  It  is  the  method  of  choice  when  it  can  be  carried  out,  and  usually 
it  can  be  carried  out.  Begin  with  the  largest  flexible  bougie  which  will  easily 
pass.  Warm  the  bougie,  oil  it,  pass  it  gently,  and  hold  it  in  position  for 
several  minutes,  prolonging  the  time  of  retention  of  the  bougie  as  treatment  pro- 
gresses. Pass  an  instrument  every  second  or  third  day,  gradually  increasing  the 
size.  Chevalier  Jackson  is  impressed  with  the  danger  of  blind  dilatation.  He 
inaugurates  dilatation  by  using  instruments  through  the  tube  of  the  esophago- 
scope. Plummer  ("Northwestern  Lancet,"  Jan.  15,  191 2)  dwells  on  the  danger 
of  using  bougies,  especially  in  cancerous  constriction,  and  advocates  the  use 
of  the  string  guide  of  Mixter  in  tight  or  tortuous  stenoses.  Mixter's  plan  is 
to  have  a  patient  put  a  piece  of  silk  on  the  back  of  the  tongue  and  swallow 
it  while  drinking  water.  The  string  may  thus  be  floated  through  the  stric- 
ture. Plummer  proceeds  as  follows:  He  takes  a  spool  of  buttonhole  twist  and 
inserts  a  safety-pin  so  as  to  make  a  reel.  He  unwinds  the  thread,  marks  it  with 
black  ink  at  intervals  of  i  yard,  rewinds  it,  takes  a  few  inches  of  the  free  end  of  the 
thread,  moistens  it,  places  it  on  the  back  of  the  patient's  tongue,  and  gives  the 
patient  a  swallow  of  water.  The  patient  is  directed  to  swallow  2  or  3  yards  be- 
fore bedtime,  "and  an  equal  amount  at  the  rate  of  a  foot  an  hour  the  following 
forenoon."  The  first  portion,  in  a  state  of  snarl,  enters  the  intestine  during 
the  night.     By  afternoon  the  thread  may  be  rendered  taut  by  pulling  upon  it; 

^  See  the  valuable  article  in  Maylard's  "Surgery  of  the  Alimentary  Canal." 
^"Wien.  klin.  Woch.,"  Feb.  20,  1902. 


Stricture  of  the  Esophagus 


1065 


yet  it  will  not  be  pulled  out.  The  thread  may  remain  in  place  for  some  time, 
dilating  the  stricture.  It  may  be  used  as  a  guide  to  direct  a  bougie  through  a 
tight  or  tortuous  constriction,  the  eyed  bougie  being  threaded  upon  the  strand 
(Plummer,  in  ''  Collected  Papers  of  the  Mayo  Staff  in  Rochester,"  191 1).  If  the 
stenosis  involves  a  considerable  portion  of  the  esophagus,  gradual  dilatation 
will  almost  certainly  fail  to  cure. 

Symonds  advocates  the  insertion  of  a  tube  through  the  stricture  and  leav- 
ing it  in  place  until  there  is  decided  dilatation,  and  then  replacing  the  tube  with 
a  larger  instrument.  The  patient  is  fed  through  the  tube  (Fig.  678).  In 
some  cases  in  which  it  is  impossible  to  pass  a  bougie  through  the  stricture 
by  the  ordinary  plan  it  is  possible  to  pass  one  when  viewing  the  opening  through 
the  stricture  by  means  of  the  esophagoscope.  Whalebone  or  olive-tipped  in- 
struments may  be  passed  in  increasing  sizes.     Strands  of  silkworm-gut  may 


Fig.  679. — Abbe's  method  of  cutting  esophageal  strictures. 

be  passed.  If  they  are,  they  can  be  left  in  place  a  few  hours,  when  a  larger 
bundle  of  gut  or  perhaps  an  instrument  can  be  passed.  Surgeons  have  divulsed 
strictures  and  performed  internal  esophagotomy  through  an  esophagoscope. 
Either  of  these  plans  is  preferable  to  forcible  dilatation  or  internal  esophagotomy 
by  a  special  instrument,  but  without  the  esophagoscope. 

Electrolysis  has  been  advocated  by  Fort  and  others.  Gradual  dilatation 
from  below  has  been  practised  in  cases  in  which  a  bougie  could  not  be  passed 
from  the  mouth.  A  gastrostomy  is  performed,  and  after  the  fistula  has  become 
sound  the  patient  is  made  to  swallow  "a  shot  to  which  is  attached  a  silk  thread" 
(Maylard).  The  silk  thread  is  brought  out  through  the  fistulous  orifice  and 
is  attached  to  a  bougie,  and  the  dilating  instrument  is  pulled  up  through 
the  esophagus.  Forcible  dilatation  can  be  employed  through  a  gastrotomy 
opening,  by  means  of-  bougies,  tents,  or  divulsing  instruments.  A  fibrous  steno- 
sis in  the  region  of  the  cricoid  cartilage  which  is  not  cured  by  gradual  dilata- 
tion should  be  treated  by  the  operation  of  external  esophagotomy.  In  this 
operation  the  stricture  is  divided  by  a  longitudinal  incision;  "funnel-shaped 
retraction  of  the  cut  portion  is  caused  by  adhesion  to  the  external  tissues  divided, 
and  it  lessens  future  contraction."^  If  dilatation  fails  in  the  case  of  a  stenosis 
anywhere  above  the  line  of  the  aortic  arch,  the  esophagus  may  be  opened  above 
the  stricture  (external  esophagotomy).  If  the  stricture  is  below  the  wound 
a  tenotome  may  be  introduced  through  the  wound,  and  the  stricture  cut  and 
well  dilated  by  the  passage  of  instruments.  This  operation  is  known  as  Gus- 
senbauer's  combined  esophagotomy. 

^W.  J.  Mayo,  "Jour.  Amer.  Med.  Assoc,"  July  29,  1899. 


io66  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


If  a  stricture  is  impassable  from  above,  the  stomach  should  be  opened 
and  retrograde  dilatation  be  carried  out.  Billroth  showed  years  ago  that  a  stric- 
ture impassable  from  above  may  be  passable  from  below.  This  is  because  the 
esophagus  above  the  stricture  is  basin  shaped  and  immediately  below  the 
stricture  is  funnel  shaped  (Abbe).  If  a  fine  bougie  is  carried  from  the  stomach 
to  the  mouth  it  is  used  to  carry  a  piece  of  string  through  the  same  route,  and 
this  string  is  used  to  pull  bougie  after  bougie  through  the  stricture.  A  firm, 
non-dilatable  stricture  in  the  thoracic  portion  of  the  esophagus  can  be  treated 
by  Abbe's  method  (Figs.  679,  680).  He  performs  a  gastrotomy,  sutures  the 
stomach  to  the  abdominal  wound  to  prevent  contamination  of  the  peritoneum, 
and  seeks  for  the  esophageal  opening  by  two  fingers  passed  within  the  stomach. 
Abbe  points  out  that  finding  the  orifice  would  seem  much  more  easy  than  it  is. 
In  a  recent  case  I  found  it  only  after  a  prolonged  search,  the  entire  esophageal 
region  feeling  smooth  to  the  touch.     Abbe  says  that  "  this  surface  is  maintained 

by  the  circular  sphincter  muscle 
layers,  and  it  is  not  until  a 
moment's  pressure  of  the  finger 
at  the  right  place  causes  them 
to  yield  that  it  slips  upward 
into  the  esophagus"  ("Med. 
Record,"  Nov.  30, 1907).  Abbe 
then  passes  a  long  filiform 
whalebone  bougie  from  the 
stomach  into  the  mouth,  ties  a 
piece  of  braided  silk  to  the 
bougie,  withdraws  the  instru- 
end  of  the  silk  emerges  from 
gastrotomy  wound.  In  some 
the    stric- 


FlG. 


680. — The  bougie  engaged  in  the  stricture  while 
the  string-saw  is  being  used. 


ment,   and  leaves   the   silk  in   place.     One 
the    mouth   and    the    other    end    from    the 

cases  he  opens  the  stomach  and  also  opens  the  esophagus  above 
ture;  one  end  of  the  string  comes  out  of  the  esophagotomy  wound  and  the 
other  end  out  of  the  gastrotomy  wound.  A  large  dilating  bougie  is  then 
passed  from  the  stomach  into  the  esophagus  and  pushed  as  forcibly  as  is  safe 
into  the  lumen  of  the  stricture.  The  string  is  used  as  a  string-  or  bow-saw,  and 
the  stricture  is  divided,  the  dilating  bougie  being  pushed  firmly  upward  while 
the  saw  is  being  used.  If  this  is  not  done  the  saw  will  not  cut.  Only  stretched 
tissue  will  be  divided.  When  the  stricture  has  been  divided  the  silk  is  with- 
drawn and  full-sized  bougies  are  passed.  The  surgeon  usually  makes  a  tempo- 
rary gastrostomy  and  then  sutures  the  wound  in  the  neck. 

An  operation  devised  by  A.  J.  Ochsner  is  thus  described  by  Mayo :^  "The 
anterior  wall  of  the  stomach  is  d^awn  out  of  a  left  oblique  incision  through  the 
abdominal  coverings;  a  small  opening  is  made  into  the  stomach  sufficient  in  size 
to  introduce  the  finger.  A  whalebone  probe,  to  the  tip  of  which  a  silk  string 
guide  has  been  tied,  is  now  passed  through  the  esophagus  either  from  above 
or  retrograde,  as  in  the  Abbe  method.  With  this  guide  a  loop  of  silk  is  drawn 
out  of  the  gastric  incision  in  such  manner  as  to  leave  the  guide  as  a  third 
string.  Into  this  loop  a  small  soft-rubber  drainage-tube  3  feet  or  more  in 
length  is  caught  in  the  middle  by  traction  on  the  ends  of  the  doubled  thread 
through  the  mouth;  this  loop  of  rubber  tube  is  drawn  through  the  stomach  and 
made  to  engage  in  the  stricture. 

"The  greater  the  amount  of  traction,  the  smaller  the  stretched  rubber 
tube,  until  it  is  sufficiently  reduced  in  size  to  enter  the  stenosed  portion;  by 
alternating  the  direction  of  the  pull  the  tube  is  drawn  out  by  its  free  ends  and 
in  by  the  silk  loop.  Increasing  sizes  of  tubes  can  be  employed,  and  if  necessary 
the  third  string  can  be  used  as  a  string-saw,  after  the  Abbe  plan  of  procedure." 
In  a  very  severe  case  of  stenosis  gastrostomy  is  performed  to  keep  the  patient 

^"Jour.  Amer.  Med.  Assoc, "July  29,  1899. 


Carcinoma  of  the  Esophagus  1067 

from  starving.  In  a  case  of  fibrous  stenosis  in  charge  of  the  author  it  was  found 
impossible  to  insert  any  instrument  from  above  or  from  below.  Gastro- 
stomy was  performed  by  Kader's  method.  The  patient  was  fed  through  the 
artificial  opening  and  the  esophagus  was  thus  put  at  rest.  Two  weeks  after 
the  operation  it  became  possible  to  pass  a  bougie  from  the  mouth.  The  gullet 
was  gradually  dilated  to  its  normal  caliber  and  the  gastrostomy  wound  was 
closed.  This  case  demonstrates  that  a  stricture  of  the  esophagus,  like  a  stric- 
ture of  the  urethra,  may  become  temporarily  impassable  from  inflammation, 
edema,  and  spasm;  but,  after  the  part  is  put  at  rest,  may  again  permit  the 
passage  of  an  instrument. 

In  some  cases  of  incurable  stricture  cervical  esophagostomy  is  performed 
below  the  stenosis,  and  the  patient  is  fed  permanently  through  the  opening. 
The  operation  is  performed  like  esophagotomy,  except  that  the  mucous  mem- 
brane is  sutured  to  the  skin. 

Carcinoma  of  the  Esophagus, — Cancer  causes  obstruction  of  the  esoph- 
agus. It  arises  in  those  beyond  middle  life,  and  is  far  more  common  in  men 
than  in  women.  The  disease  may  begin  at  any  portion  of  the  gullet,  but  is 
least  often  met  with  in  the  central  portion  (Maylard,  Butlin).  Epithelioma 
is  the  usual  form,  but  scirrhus  or  encephaloid  may  occur.  Cancer  soon  ulcer- 
ates, involves  adjacent  parts,  and  affects  the  deep  cervical  and  posterior  medi- 
astinal glands.  In  at  least  75  per  cent,  of  cases  of  chronic  obstruction  of  the 
esophagus  cancer  is  the  cause. 

Symptoms  of  Cancerous  Stenosis. — The  patient  is  over  forty  years  of  age, 
is  usually  a  male,  and  presents  the  same  difi&culty  of  swallowing  met  with 
in  cicatricial  stenosis.  Regurgitation  is  common.  The  regurgitated  matter  is 
alkaline  and  is  apt  to  contain  blood.  There  is  generally  decided  pain  and  very 
rapid  and  great  emaciation  occurs.  The  seat  of  obstruction  may  be  located  by 
the  very  gentle  use  of  a  soft  or  semisolid  bougie,  but  it  is  wiser  to  use  no  bougie 
and  to  rely  on  the  a;-rays  and  the  esophagoscope.  In  a  very  recent  case  diag- 
nosis is  possible  only  by  esophagoscopy.  The  stomach  is  the  seat  of  pain;  the 
mouth  is  dry,  and  there  is  often  great  thirst.  As  the  disease  infiltrates,  the 
involvement  of  adjacent  regions  produces  other  symptoms.  Dyspnea  may  re- 
sult from  tracheal  pressure.  Pleuritis,  pericarditis,  or  pneumonia  may  arise. 
There  may  be  paralysis  of  the  sympathetic  or  recurrent  laryngeal  nerves. 

In  suspected  cases  of  cancer  never  try  to  pass  unguided  bougies  or  sounds 
through  the  constriction.  In  a  cancer  case  dilating  instruments  are  weapons 
rather  than  tools.  If  a  bougie  is  used  to  locate  the  constriction  it  will  prob- 
ably start  bleeding  and  be  bloody  when  withdrawn.  A  solid  instrument  might 
perforate  the  esophagus.  If  it  does,  death  will  follow.  The  x-rays  should  first 
be  used  and  then  the  esophagoscope. 

Treatment. — The  disease  is,  of  necessity,  fatal,  and  treatment  is  only  pallia- 
tive. Complete  excision  of  the  cancer  is  scarcely  feasible  even  in  the  cervical 
region.  I  know  of  but  one  successful  resection  of  the  thoracic  esophagus, 
which  was  the  case  reported  by  Torek  ("Surgery,  Gynecology,  and  Obstetrics," 
June,  1 9 13).  The  operation  was  intrathoracic  and  through  the  pleura.  At 
present  the  justifiability  of  such  an  operation  has  not  yet  been  conclusively 
demonstrated.  Zaaijer  of  Leyden  successfully  resected  a  carcinoma  of  the 
cardia,  going  through  the  pleura  to  accomplish  it  (Hirschmann  and  Frohse, 
in  " Beitr ag.  z.  klin.  Chir .  ,"1915,  xcv) .  Arch,  Voelcker,  Kiimmel  and  Sauerbruch 
also  obtained  recovery  after  such  an  operation  (Meyer,  in  "Trans,  of  Am.  Surg. 
Assoc,"  1915).  The  patient  should  be  put  upon  a  soft,  bland  diet,  small  quan- 
tities being  given  frequently.  When  trouble  is  experienced  in  swallowing  even 
the  bland  and  soft  food,  pass  a  soft  bougie  every  third  or  fourth  day.  When  the 
patient  becomes  entirely  unable  to  swallow  soft  food,  we  may  insert  a  Symonds 
tube  (see  Fig.  678)  or  do  an  esophagostomy  (if  this  can  be  performed  below  the 
stricture),   or  perform  gastrostomy.     In   every   doubtful   case   of   esophageal 


io68  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

stricture  give  salvarsan.  This  might  clear  up  a  gumma.  In  these  days  of 
esophagoscopy  the  chance  of  diagnostic  error  is  far  less  than  formerly. 

Spasmodic  Stricture  of  the  Esophagus  {Esophagismus;  Hysterical  Stric- 
ture).— By  this  term  is  meant  a  spasm  of  the  circular  muscular  fibers  of  the 
gullet,  which  is  most  common  near  the  larynx  or  the  cardia.  This  condi- 
tion not  unusually  arises  in  a  hysterical  individual,  in  whom  it  will  be  associ- 
ated with  the  stigmata  of  hysteria,  especially  globus  hystericus.  In  some 
cases  evidence  of  hysteria  are  wanting,  although  the  patient  is  neurotic  and 
ill-nourished,  the  condition  being  due  to  a  reflex  irritation.  A  spasm  of  the 
muscular  fibers  of  the  esophagus  may  be  clonic  or  may  be  tonic.  A  clonic 
spasm  may  arise  during  vomiting  or  from  some  reflex  cause;  it  may  affect 
one  part  of  the  tube  for  a  f  ime  and  then  shift  to  another,  or  may  develop  in 
one  particular  region  only.  Globus  is  a  spasm  which  moves  upward.  Tonic 
spasm  is  in  one  fixed  place.  Most  reflex  spasms  are  tonic  and  result  from 
cancer  of  the  liver,  cancer  of  the  stomach,  tonsillitis,  glossitis,  pharyngitis, 
gall-stones,  cholecystitis,  or  inflammation  of  the  epiglottis  (A.  L.  Benedict, 
in  "Am.  Jour.  Med.  Sci.,"  Aug.,  1904).  It  occasionally  occurs  in  tetanus; 
sometimes  in  epilepsy.  Spasmodic  stricture  may  also  arise  during  pregnancy 
and  as  a  result  of  laryngeal  ulceration.  I  have  seen  several  instances  due  to  cancer 
of  the  stomach.  In  i  of  these  cases  the  esophageal  spasm  entirely  disappeared 
after  the  performance  of  pylorectomy. 

Symptoms  of  Spasmodic  Stenosis. — It  arises  suddenly  in  a  hysterical  or  neu- 
rotic individual.  It  may  last  for  a  time  and  suddenly  pass  away,  or  may  per- 
sist for  a  considerable  time.  The  difficulty  in  swallowing  is  irregular,  rarely 
interfering  seriously  with  nourishment.  Usually  fluids  are  taken  more  easily 
than  solids,  but  sometimes  solids  are  taken  more  readily  than  fluids. 

There  may  be  regurgitation;  but  in  recent  cases,  if  it  occurs,  it  does  so  at  once 
on  swallowing  food.  Examination  with  a  bougie  detects  the  obstruction.  If 
the  bougie  is  held  firmly  against  it,  in  most  cases  the  spasm  will,  after  a  time, 
relax  suddenly  or  gradually  and  let  the  instrument  pass.  A  medium-sized  in- 
strument or  a  large  one  may  not  pass  until  the  patient  has  been  anesthetized, 
but  in  every  case  a  bougie  can  be  passed  after  an  anesthetic  has  been  given. 

Treatment  of  Spasmodic  Stenosis  Above  the  Cardia. — The  systematic  passage 
of  bougies.  Occasionally  the  passage  of  an  instrument  but  once  will  cure  a 
case.  The  general  health  must  be  improved,  and  in  persistent  cases  it  may 
be  necessary  to  use  electricity  within  the  esophagus,  employ  cold  locally,  and 
administer  the  bromids. 

Cardiospasm  (Abdominal  Esophagismus). — When  the  cardiac  sphincter  con- 
tracts the  condition  is  known  as  cardiospasm.  It  may  or  may  not  be  associ- 
ated with  cancer,  ulcer,  or  some  other  disease  of  the  stomach,  with  gall-bladder 
disease  or  cancer  of  the  liver.  The  attacks  are  periodic,  with  a  variable  time 
between  them,  but  sooner  or  later  diffuse  dilatation  occurs.  Before  dilatation 
takes  place  the  patient  has  periodic  attacks  of  difficulty  in  swallowing,  being 
perfectly  well  between  the  attacks.  One  of  Plummer's  cases  had  periodical 
attacks  of  dysphagia  lasting  from  three  to  fourteen  days,  and  during  these 
attacks  it  was  impossible  to  swallow  either  solids  or  liquids.  In  many  cases 
the  attacks  are  neither  so  severe  nor  prolonged.  They  usually  begin  suddenly 
while  swallowing,  but  may  begin  at  a  time  when  no  food  is  being  taken.  The 
attack  is  a  feeling  of  choking  or  obstruction  felt  in  the  cardiac  region  and  the 
back.  Soon  after  these  attacks  originate  the  patient  begins  to  suffer  very  soon 
after  eating  from  regurgitation  into  the  mouth.  As  the  esophagus  dilates  the 
regurgitation  is  postponed  longer  and  longer  after  eating,  until  finally  the  gullet 
is  never  completely  empty  (Plummer,  "Northwestern  Lancet,"  Oct.  i,  1906). 
The  matter  which  is  regurgitated  is  not  sour,  because  it  contains  no  gastric 
elements.  Plummer  points  out  that  a  stomach-tube  cannot  be  passed,  but  a 
large-sized  sound  can  be  passed  easily.     The  fact  that  a  large  sound   can  be 


Diverticula  of  the  Esophagus  1069 

passed  proves  that  there  is  no  organic  stricture.  When  external  causes  of 
pressure  are  excluded  the  diagnosis  rests  between  diverticulum  and  dilatation 
of  the  esophagus  (Plummer,  Ibid.).  The  a;-rays  aid  in  diagnosis.  Plummer 
gives  methods  in  detail  (Ibid.). 

Treatment. — Russell's  plan  is  to  dilate  the  cardia  with  a  silk-covered  balloon 
of  rubber.  Plummer  describes  how  to  construct  it  ("  Collected  Papers  of  the 
Staff  of  St.  Mary's  Hospital,  Mayo  Chnic,  1 905-1 909").  The  distention  is  to 
be  gradual,  and  at  once  suspended  if  there  is  violent  pain  indicating  laceration. 
Mikulicz  and  others  have  performed  gastrotomy  and  dilated  the  cardia.  Willy 
Meyer  ("Am.  Jour.  Surg.,"  June,  191 2)  has  opened  the  thorax  under  positive 
pressure,  plicated  the  dilated  portion  of  the  esophagus  into  two  longitudinal 
double  folds,  and  separated  the  pneumogastric  nerves,  tearing  off  the  minute 
esophageal  branches  {eso  pha  go  plication  and  vagolysis).  This  patient  was  cured. 
This  operation  was  attempted  on  2  other  patients.  One  was  improved.  The 
other  turned  out  to  have  organic  stricture.  In  another  case  Wendel  performed 
cardioplasty  in  the  same  manner  as  pyloroplasty  is  done.  He  did  it  by  the 
abdominal  route.     Meyer  suggests  that  it  may  be  done  transthoracically. 

Diverticula  of  the  Esophagus. — Rokitansky  in  1849  described  traction  di- 
verticula and  pressure  diverticula.  Maylard  tells  us  that  these  pouches  may 
he  due  to  one  of  four  causes:  they  may  be  congenital;  may  be  due  to  stricture; 
may  be  caused  by  pressure  from  within  upon  a  weak  spot  of  the  wall;  may  be 
due  to  traction  from  without  by  the  healing  and  contraction  of  an  area  of 
inflammation.  To  these  another  cause  should  be  added,  muscular  weakness 
resulting  in  dilatation.  The  usual  situation  for  such  a  pouch  is  on  the  posterior 
wall  of  the  gullet  on  a  level  with  the  cricoid  cartilage.  At  this  point  there  is 
a  space  devoid  or  nearly  devoid  of  muscle,  called  the  Lannier-Hackerman  area 
(Charles  H.  Mayo,  "Jour.  Am.  Med.  Assoc,"  July  22,  1912).  As  the  pouch 
enlarges  the  fundus  comes  toward  the  side,  usually  the  left  side.  Pouches  are 
rare  in  the  thoracic  esophagus. 

Symptoms. — In  spite  of  the  statement  that  a  diverticulum  may  be  con- 
genital, we  encounter  the  condition  clinically  in  adults  only.  The  first  symptom 
is  difficulty  in  swallowing,  like  that  in  cancer.  There  may  be  cough  from  nerve 
irritation  and  dyspnea  from  pressure  on  the  trachea  (Chas.  H.  Mayo,  "Annals  of 
Surgery,"  June,  1910).  Regurgitation  may  occur,  the  regurgitated  matter 
heing  free  from  gastric  juice.  As  the  opening  of  the  sac  is  usually  a  prolonga- 
tion of  the  esophageal  canal  a  sound  or  bougie  tends  to  enter  the  sac.  When 
the  diverticulum  is  in  the  neck  a  lump  forms  during  deglutition,  and  this  lump 
may  be  obliterated  by  pressure.  Food  will  pass  into  the  stomach  only  when 
the  diverticulum  is  full.  A  bougie  can  seldom  be  passed  unless  the  pouch  is  full 
of  food,  at  which  time  it  may  pass  or  may  not.  Sometimes  it  enters  the  pouch. 
This  striking  symptom,  the  variability  in  the  passage  of  the  bougie,  is  evidence 
suggesting  the  diagnosis  of  intrathoracic  diverticulum.  By  listening  through  a 
stethoscope  fluid  may  be  heard  to  pass  into  the  pouch.  The  diverticulum 
causes  obstruction.  "The  depth  of  the  obstruction  can  be  measured  with  a 
stomach-tube,  bougie,  or  acorn  probe,  but,  as  a  matter  of  fact,  these  pro- 
cedures do  not  differentiate  between  diverticula  and  strictures  which  are  per- 
vious to  liquids  and  yet  impassable  to  sounds"  (Charles  H.  Mayo,  "Annals 
of  Surgery,"  June,  1910).  After  a  patient  swallows  an  emulsion  of  bismuth  or 
barium  or  food  mixed  with  one  of  these  salts  a  diverticulum  may  be  skiagraphed. 
When  a  bougie  is  passed  as  far  as  it  will  go  a  skiagraph  should  be  taken  with 
the  bougie  in  position.  The  plate  may  show  that  the  instrument  is  so  much 
deviated  to  the  side  that  it  must  be  in  a  pouch.  If  a  fine  gold  chain  is  swal- 
lowed it  may  fill  up  the  pouch,  and  if  it  does,  a  skiagraph  will  indicate  the  di- 
verticulum. The  opening  of  the  pouch  may  be  seen  by  means  of  an  esopha- 
goscope.  Plummer's  test  is  valuable.  He  has  the  patient  swallow  a  string 
guide,  as  described  on  page  1064.     The  protruding  end  of  the  thread  is  passed 


lo-jo  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 

through  the  eye  of  an  oUve  tip  set  on  a  whalebone  stem.  The  instrument  is 
passed  onward  until  it  meets  an  obstruction.  "Should  the  trouble  be  due  to 
stricture  the  tip  will  not  change  its  level  when  the  thread  is  tightened,  but  if 
there  is  a  diverticulum  the  probe  will  be  elevated  to  the  level  of  the  opening 
in  the  lower  esophagus,  proving  at  once  the  existence  of  a  pocket  and  also  its 
depth  by  the  amount  of  elevation  of  the  probe  upon  tightening  the  thread" 
(Charles  H.  ]Mayo,  Ibid.). 

Treatment. — In  very  early  cases  dilatation  may  cure.  In  advanced  cases 
in  the  cervical  esophagus  we  must  perform  extirpation  and  suture,  as  done  by 
von  Bergmann,  Hearn,  the  author,  and  others.  For  five  days  after  operation 
no  food  is  given  by  the  mouth.  No  attempt  should  be  made  to  extirpate  a 
pouch  in  the  thoracic  esophagus.     In  such  a  case  gastrostomy  may  be  necessary. 

Injuries  of  the  Esophagus  from  Within.^ — Injuries  of  the  internal  surface 
are  more  common  than  injuries  from  without.  Burns  and  scalds  are  among 
these  injuries.  Wounds  may  be  inflicted  by  foreign  bodies.  Injuries  of  the 
gullet  cause  pain  on  swallowing,  and  a  wound  induces  bleeding,  the  blood 
being  both  coughed  up  and  vomited.  A  severe  wound  may  involve  a  large 
vessel  and  cause  violent  or  even  fatal  hemorrhage.  If  the  bronchus  or  trachea 
is  involved,  there  will  be  "cough  and  expectoration  of  blood,  mucus,  and  food" 
(Maylard).     The  pleural  or  pericardiac  sacs  may  be  perforated. 

treatment.— Freed  by  the  rectum  only.  Give  morphin  hypodermatically. 
Do  not  feed  by  the  mouth  for  ten  days,  and  even  then  give  only  fluid  food,  ohve 
oil  and  jelly.  Symptoms  are  met  as  they  arise.  After  burns  by  caustic,  admin- 
ister the  antidote;  give  large  drafts  of  water  and  wash  out  the  stomach.  From 
two  to  four  weeks  after  a  caustic  has  been  swallowed  and  after  a  burn  or  scald 
the  use  of  sounds  should  be  begun  (provided  there  is  no  raw  surface),  and 
sounding  should  be  persisted  in  for  a  considerable  time  to  prevent  contraction. 

Injuries  of  the  Esophagus  from  Without,  Other  Structures  Not  Being 
Involved  Seriously. — Such  injuries  are  rare.  Esophageal  injuries,  as  a  rule, 
are  associated  with  serious  damage  to  adjacent  structures.  Injuries  may 
be  due  to  stabs  or  to  bullets.  Besides  the  obvious  external  signs  of  the  injury 
there  will  be  difficulty  in  swallowing,  cough,  bloody  expectoration,  or  vomiting; 
and  mucus  or  the  contents  of  the  stomach  may  run  out  of  the  wound. 

Treatment. — Suture  the  wound,  and  feed  by  the  rectum  for  ten  days. 

Spontaneous  Rupture  of  the  Esophagus. — By  this  we  mean  rupture  of 
an  apparently  healthy  gullet.  It  is  a  very  rare  accident.  Most  recorded 
cases  of  rupture  have  been  in  those  in  whom  the  esophagus  was  ulcerated  or 
cicatricial.  Vomiting  is  the  cause  of  rupture.  Alcoholism  predisposes. 
Rupture  may  occur  when  the  wall  undergoes  auto  digestion,  as  it  may  do  in 
protracted  vomiting.  The  symptoms  are  the  sudden  onset  of  violent  pain, 
vomiting,  collapse  and  not  unusually  emphysema  above  the  clavicle.  If  a 
diagnosis  is  made  operation  is  indicated  provided  the  case  is  seen  early  enough. 
Without  operation  death  is  certain. 

Foreign  Bodies  Lodged  in  the  Esophagus. — These  accidents  occur  especially 
in  children  and  lunatics,  and  women  are  more  apt  to  suff'er  from  them  than  men. 
A  list  of  various  bodies  which  have  been  swallowed  will  be  found  in  Poulet's 
elaborate  treatise.  There  are  three  regions  where  a  foreign  body  is  especially 
apt  to  lodge — \dz.,  opposite  the  cricoid  cartilage,  at  the  level  of  the  diaphragm, 
and  at  the  point  where  the  left  bronchus  crosses  the  gullet.  Small  and  sharp 
bodies  may  lodge  anywhere. 

The  symptoms  are  variable;  if  the  body  is  large,  there  will  be  pain  and 
difficulty  in  swallowing,  and,  in  many  cases,  dyspnea  from  pressure  upon 
the  trachea  or  bronchus.  Occasionally  the  dyspnea  is  such  a  prominent 
feature  that  it  misleads  the  physician  into  the  belief  that  the  foreign  body 
is  lodged  in  the  air-passages.  Death  may  actually  result  from  asphyxia.  In 
some  other  cases  the  symptoms  are  very  slight.     If  the  body  is  sharp,  there 


Foreign  Bodies  Lodged  in  the  Esophagus 


1071 


will  be  hemorrhage  and  severe  pain.  The  blood  may  be  hawked  up,  or  may 
be  swallowed  and  vomited.  In  rare  cases  a  patient^  grows  accustomed  to  a 
foreign  body  and  ceases  to  notice  it;  but,  more  often,  the  foreign  body  pro- 
duces inflammation.  It  may  even  ulcerate  into  the  wind-pipe,  the  pleura, 
the  pericardium,  or  the  aorta.  In  many  cases  of  impaction  a  patient  makes 
violent  efforts  to  hawk  up  the  foreign  body  and  so  produces  aphonia.  There 
may  be  violent  retching.     Even  after  a  foreign  body  has  been  removed  by  swal- 


FiG.  681. — Author's  case  of  whistle  in  esophagus,  removed  by  external  esophagotomy. 

lowing,  by  vomiting,  or  by  surgical  extraction  a  sensation  is  apt  to  remain  as 
if  the  body  were  still  lodged.  The  diagnosis  is  made  by  the  history,  the  detec- 
tion of  the  body  by  external  manipulation,  by  feeling  it  with  an  esophageal 
bougie,  by  esophagoscopy,  and,  if  bone  or  metal,  by  seeing  it  with  the  fluoro- 
scope  or  obtaining  a  skiagraph. 

Treatment. — The  surgeon  should  learn,  if  possible,  the  size,  shape,  weight, 
and  nature  of  the  foreign  body,  and  should  locate  its  point  of  impaction.     The 


Fig.  682. — Author's  case  of  jackstone  in  esophagus,  removed  by  external  esophagotomy. 


exact  point  of  lodgment  of  bone  or  a  metallic  body  is  determined  by  the  :r-rays. 
An  anesthetic  is  given  before  manipulating  a  child,  a  nervous  woman,  or  a 
lunatic,  and  is  sometimes  necessary  for  a  man.  If  the  foreign  body  is  soft, 
external  manipulation  may  succeed  in  altering  its  shape,  so  that  it  may  be 
swallowed  or  ejected.  If  the  foreign  body  is  hard,  external  manipulation  may 
shift  its  position.  It  is  usually  impossible  to  reach  the  foreign  body  through 
the  mouth  by  means  of  the  fingers  (when  the  body  is  in  the  rear  of  the  pharynx 
it  may  be  pulled  forward  or  pushed  down).     Sharp  foreign  bodies  may  be  en- 


1072  Diseases  and  Injuries  of  the  Upper  Digestive  Tract 


tangled  and  carried  down  when  the  patient  eats  mush,  bread,  or  boiled  potatoes. 
The  administration  of  emetics  is  an  old  plan  which  occasionally  succeeds, 
but  which  is  too  unsafe  to  be  employed.  The  esophagoscope  is  of  immense 
value.  By  means  of  it  a  surgeon,  skilled  in  its  use,  may  remove  many  foreign 
bodies  which,  otherwise,  would  demand  the  performance  of  grave  operations 
(see  page  1073).  Nevertheless  I  believe,  with  E.  Fletcher  Ingalls,  that  the 
esophagoscope  "cannot  entirely  supplant  the  older  methods"  ("Amer.  Jour, 
of  Surg.,"  Jan.,  1912).  The  instrument  is  not  always  at  hand,  and  to  use  it 
successfully  and  safely  one  must  be  well  trained  in  its  management.  Maylard 
says  that  when  a  mass  of  food  is  impacted  it  is  occasionally  possible  to  soften 
and  disintegrate  the  mass  by  administering  a  mixture  containing  pepsin.  The 
bristle  probang  (Fig.  683,  c)  is  a  very  useful  instrument  for  the  removal  of 
fish-bones,  pins,  and  other  small  objects.  It  may  be  used  to  push  a  body 
downward  into  the  stomach,  or  to  catch  the  body  and  pull  it  up.     When  this 

instrument  is  withdrawn  it  opens 
like  an  umbrella.  It  has  been  shown 
that  in  an  adult  the  cardiac  open- 
ing is  from  14  to  16  inches  from 
the  incisor  teeth,  a  point  to  be  re- 
membered in  deciding  whether  to 
push  down  or  pull  up  the  impacted 
article.  Esophageal  forceps  (Fig. 
683  A,  b)  are  valuable  in  some  cases. 
The  coin-catcher  (Fig.  683  d)  is  a 
useful  instrument.  Crequy's  plan 
of  removal  is  to  take  a  tangled  mass 
of  threads,  tie  a  stout  piece  of  string 
about  the  middle  of  it,  coat  it  with 
sugar,  and  have  the  patient  swallow 
it.  It  may  pass  the  foreign  body;  if 
it  does  so,  on  withdrawal  it  may  en- 
tangle the  object  and  extract  it.  To 
remove  a  fish-hook  with  line  at- 
tached the  following  plan  may  prove 
successful;  stick  the  line  which  pro- 
jects from  the  mouth  into  a  metal 
catheter,  carry  the  catheter  dowoi 
to  the  hook,  and  push  the  hook 
out.  It  is  not  proper  to  allow  a 
foreign  body  to  remain  in  the  esopha- 
gus until  it  causes  ulceration.  Neither  is  it  proper  to  make  prolonged  efforts  to  ex- 
tract it  through  the  mouth.  Such  efforts  may  do  great  harm,  and  if  one  careful 
and  consistent  effort  fails,  and  the  esophagoscope  is  not  suited  to  the  case,  fails,  or 
is  unobtainable,  or  if  there  is  no  skilled  man  to  use  it,  an  operation  should  be  per- 
formed. If  the  body  is  lodged  anywhere  above  the  lower  third  of  the  esophagus, 
external  esophagotomy  is  performed,  and  usually  on  the  left  side.  Through 
this  wound  the  foreign  body  is  extracted.  The  cut  is  made  on  the  left  side, 
between  the  trachea  and  larynx  in  front  and  the  carotid  sheath  behind,  the 
center  of  the  incision  being  opposite  the  cricoid  cartilage.  After  the  foreign 
body  has  been  extracted  the  mucous  membrane  is  sutured  with  chromicized 
catgut,  and  the  superficial  structures  are  closed  with  silkworm-gut  after  a 
drainage-tube  has  been  inserted.  The  patient  is  fed  by  the  rectum  for  eight 
or  ten  days.  When  a  foreign  body  is  lodged  in  the  lower  portion  of  the 
tube  the  stomach  is  opened  and  the  body  extracted,  by  this  route.  In 
White's  case  of  jackstone  in  the  gullet  gastrotomy  was  performed.  A  string 
was  tied  about  some  rolls  of  gauze,   the  string   was  passed  by  means  of  a 


Fig.  683. — Esophageal  instruments:  A,  B, 
Forceps;  c,  Gross's  bristle  probang;  d,  coin- 
catcher;  E,  bulbous  esophageal  sound. 


Diagnosis  of  Intra-abdominal  Emergencies  io73 

whalebone  from  the  stomach  into  the  mouth,  and  the  body  was  entangled  and 
drawn  out. 

Surgical  Invasion  of  the  Mediastinum. — The  posterior  mediastinum  has 
been  entered  in  order  to  remove  a  foreign  body  from  the  bronchus  and  to 
extract  a  set  of  false  teeth  wedged  in  the  esophagus.  The  same  method  can 
be  followed  to  reach  suppurative  processes  in  the  mediastinum,  abscesses 
of  the  lung  otherwise  inaccessible,  and  diverticula  and  carcinomata  of  the  lower 
end  of  the  gullet.  Nassilov  resects  ribs  close  to  the  spine.  The  portion  of  the 
esophagus  above  the  aortic  arch  can  be  reached  after  partial  resection  of 
the  third,  fourth,  fifth,  and  sixth  ribs  of  the  left  side.  Willy  Meyer  has  made 
four  heroic  attempts  to  resect  cancers  of  the  esophagus.  All  the  patients 
perished.  He  does  it  under  positive  pressure  ("Surg.,  Gynec,  and  Obstet.," 
Dec,  191 2).  Out  of  35  known  operations  i  recovered  and  i  lived  two  weeks 
after  operation.  Torek's  case  was  successful  (page  1067).  The  anterior  medi- 
astinum may  be  entered  to  remove  a  bullet,  to  drain  an  abscess,  to  reach  a 
wound  of  the  heart  or  lung,  and  to  explore  for  the  cause  of  obscure  and 
dangerous  symptoms.  I  explored  the  anterior  mediastinum  after  rib  resec- 
tion, found  a  bullet  embedded  in  the  aorta,  and  allowed  it  to  remain.  The 
patient  recovered.  M.  H.  Milton^  splits  the  sternum  and  separates  the  two 
pieces. 

Invasion  of  the  mediastinum  is  much  safer  if  the  operation  is  performed  in 
the  Sauerbruch  chamber  or  with  the  aid  of  positive  pressure  within  the  bronchi. 
Either  of  these  plans  will  prevent  pulmonary  collapse  if  the  pleura  is  opened. 

XXVIII.  DISEASES  AND  INJURIES  OF  THE  ABDOMEN 

Diagnosis  of  tntra=abdominaI  Emergencies. — The  exact  diagnosis 
is  always  difi&cult  and  in  many  cases  is  impossible.  What  a  surgeon  must 
try  to  determine,  and  what  he  usually  can  determine,  is  whether  he  is  dealing 
with  a  trivial  and  temporary  derangement  for  the  relief  of  which  an  operation 
is  entirely  unnecessary,  or  whether  he  is  confronted  by  a  grave  calamity  which 
imperatively  demands  immediate  surgical  aid.  We  can  decide  that  a  calamity 
exists,  but  the  exact  nature  of  the  lesion  is  often  doubtful  until  operation  is 
performed.  Every  operation  in  such  a  case  is  exploratory.  Before  the  diag- 
nosis of  a  calamity  is  made  morphin  should  not  be  given,  because  it  allays  the 
pain,  relieves  the  anxiety,  causes  the  disappearance  of  rigidity,  lowers  the  pulse, 
abates  mental  shock,  and  hence  veils  the  real  situation,  so  that  the  most  dis- 
cerning surgeon  will  probably  be  misled.  If  shock  is  profound,  diagnosis  is 
usually  impossible,  unless  shock  is  due  to  hemorrhage,  and  immediate  operation 
during  shock  is  not  to  be  thought  of  except  for  a  perforation  or  to  arrest  bleeding. 
If  excessive  and  continued  hemorrhage  is  suspected,  immediate  operation  is 
indicated.  If  it  is  not  suspected,  the  patient  should  be  covered  with  blankets 
and  surrounded  with  hot-water  bags,  atropin  should  be  given  hypodermatically, 
and  hot  salt  solution  should  be  administered  by  rectum,  subcutaneously  or 
intravenously.  When  the  patient  reacts,  and  he  usually  will  react,  an  attempt 
"is  made  to  make  a  diagnosis.  An  ice-bag  should  not  be  used.  Truly  it  allays 
pain,  but  it  abates  rigidity  and  masks  other  symptoms  as  would  a  dose  of 
morphia.  Morphia  is  not  given  until  the  diagnosis  has  been  made;  unless 
removal  is  necessary  when  morphia  may  be  required.  If  a  patient  must 
be  moved  to  a  hospital  it  is  perfectly  proper  to  give  a  single  hypodermatic 
injection  of  morphin  (1:3  gr.)  after  the  effort  has  been  made  to  diagnosticate 
the  condition.  The  danger  of  deluding  the  surgeon  is  past,  and  the  drug  abates 
pain,  lessens  peristalsis,  relieves  mental  anxiety,  and  is  distinctly  beneficial. 
Before  the  morphin  was  given  the  surgeon  had  come  to  a  conclusion  as  to  the 

1  "Lancet,"  INIarch  27,  1S97. 
68 


I074  Diseases  and  Injuries  of  the  Abdomen 

necessity  for  operation.  After  the  morphin  has  been  given,  if  an  operation  is 
indicated,  it  is  performed  as  promptly  as  circumstances  admit.  Whenever 
it  is  consistent  with  safety,  the  patient  ought  to  be  removed  to  a  hospital 
for  operation. 

Foreign  Bodies  in  the  Abdomen. — Now  and  then  a  sponge,  a  pad,  or  an 
instrument  is  left  in  the  abdominal  cavity  during  an  operation — left,  not  because 
of  the  surgeon's  carelessness,  but  in  spite  of  the  most  painstaking  precautions. 
Instruments  and  sponges  are  counted  before  and  after  the  operation.  A  mis- 
count means  calamity.  The  surgeon  does  not  and  cannot  make  the  count 
himself.  He  has  not  time.  He  is  doing  a  more  difficult  thing  which  he  is 
trained  to  do  and  which  the  patient  expects  him  to  do,  that  is,  operating, 
closing  the  wound,  and  dressing  it.  The  surgeon  must  delegate  the  duty 
of  counting  pads,  sponges  and  instruments,  and  he  delegates  it  to  assistants  or 
nurses,  who  do  it  with  as  much  accuracy  as  he.  At  least  two  people  count 
sponges,  pads,  and  instruments  and  at  least  twice  before  and  twice  after  the 
operation.  If  the  count  is  short,  and  the  missing  instrument  or  material  is 
not  discovered  on  the  floor,  in  a  bucket,  on  or  under  the  table,  the  abdomen 
must  be  opened  and  the  lost  object  sought  for  and  found. 

A  great  safeguard  is  to  use  no  small  sponge  or  pad  unless  it  has  a  bit  of 
tape  sewed  to  it.  The  tapes  stick  out  of  the  wound  and  on  each  one  a  forceps 
is  clamped.  Another  precaution  is  to  refrain  from  cutting  a  pad  in  two  after 
the  operation  has  been  begun.  The  safest  way  of  all  is  to  use  rolls  of  gauze 
(Halsted's  packs  or  rolls).  To  do  so  means  a  long  broad  end  sticking  out  of 
the  wound  so  that  the  pack  cannot  be  lost  in  the  belly. 

If  a  septic  body  of  any  sort  is  left  in  the  abdomen  it  at  once  produces  acute 
disturbances. 

If  an  aseptic  gauze  pad  or  sponge  is  left  it  may  become  encapsuled  and  cause 
no  trouble  for  months  or  years.  Sooner  or  later  it  will  cause  trouble  or  even 
death.  The  sufferer  may  become  a  chronic  invalid.  The  object  may  make 
its  way  into  the  intestine  or  into  the  bladder.  It  may  even  passs  out  through 
the  rectum.  Usually  a  piece  of  retained  aseptic  gauze  or  an  aseptic  instru- 
ment produces  abdominal  pain  and  a  tendency  to  intestinal  obstruction. 
Sooner  or  later  an  abscess  forms  and  the  symptoms  of  an  acute  septic  condition 
arise. 

Schachner  says  the  mortality  in  reported  cases  is  about  50  per  cent.  Many 
fatal  cases  have  not  been  reported.  If  we  suspect  the  presence  of  a  metal 
instrument  the  x-rays  will  show  it. 

Treatment. — Laparotomy  (which  is  often  exploratory)  and  removal  of  the 
offending  material. 

Simple  Contusion  of  the  Abdominal  Wall  Without  Injury  of  Vis= 
cera. — In  some  cases  of  contusion  of  the  abdominal  wall,  only  the  parietes  are 
damaged;  in  other  cases  the  viscera  or  the  abdominal  tissues  are  injured.  Con- 
tusion may  involve  the  skin  alone,  or  may  involve  the  skin,  muscles,  and 
peritoneum.  In  simple  contusion  there  is  considerable  shock  if  the  injury 
be  severe.  There  is  pain,  increased  by  respiration,  motion,  pressure,  and 
attempts  at  urination  or  defecation.  When  tenderness  is  not  found  soon  after 
the  accident  but  appears  some  days  later  there  is  usually  deep-seated  injury. 
Extensive  ecchymosis  may  appear.  Even  after  a  severe  contusing  force  has 
been  applied  there  may  be  no  discoloration,  and  it  may  happen  that  after  a 
slight  force  there  is  much  discoloration.  There  is  great  ecchymosis  in  anemic 
persons,  victims  of  hemiplegia,  obese  individuals,  opium-eaters,  and  drunkards. 
In  severe  cases  the  tissues  are  pulpified  and  sloughing  inevitably  ensues.  Abscess 
occasionally  follows  contusion.  The  prognosis  after  abdominal  contusion  is 
always  uncertain. 

Treatment  of  Simple  Contusion. — In  treating  simple  contusion  place  the 
patient  at  rest  in  a  supine  position,  with  the  thighs  flexed  over  a  pillow.     Obtain 


Rupture  of  the  Stomach  Without  External  Wound  1075 

reaction  from  the  shock.  If  pain  be  severe,  and  we  are  certain  there  is  no 
visceral  injury  and  no  internal  hemorrhage,  give  morphin.  After  shock  has 
passed  off  it  is  advisable  to  place  an  ice-bag  over  the  seat  of  injury.  If  much 
blood  is  extravasated  into  the  abdominal  wall,  aspirate  and  apply  a  binder. 
After  twenty-four  hours  apply  local  heat  by  means  of  the  hot-water  bag,  employ 
an  ointment  of  ichthyol,  and  move  the  bowels,  if  necessary,  by  salines.  Regard 
every  contusion  as  serious,  and  watch  carefully  for  the  development  of  signs 
of  internal  hemorrhage  or  visceral  injury. 

Muscular  Rupture  from  Contusion. — In  this  injurv  there  are  severe  shock, 
and  pain  (increased  by  respiration  and  movement).  Separation  between  the 
fibers  of  the  muscle  is  distinct  at  first,  but  it  is  soon  masked  by  effusion  of 
blood.  Such  injuries  may  cause  death  or  may  lead  to  hernia.  The  rectus 
is  the  muscle  most  apt  to  rupture.  The  rupture  is  due  to  sudden  contraction 
rather  than  to  the  direct  effect  of  a  blow. 

The  treatment  is  the  same  as  for  simple  contusion.  Always  apply  a  binder. 
If  a  hernia  exists  it  is  returned  and  a  compress  is  applied  over  the  opening 
through  which  it  emerged.  Later  operation  is  performed.  If  strangulation 
occurs,  operate  at  once. 

Injuries  with  Damage  to  the  Peritoneum  or  the  Viscera.  Rup- 
ture of  the  Peritoneum. — The  peritoneum  may  be  involved  in  an  abdominal 
contusion.  It  may  rupture  even  when  there  is  no  visceral  injury  or  muscular 
contusion.  The  uterine  peritoneum,  the  parietal  peritoneum,  the  visceral 
peritoneum,  or  the  mesentery  may  rupture.  Rupture  of  the  peritoneum 
causes  intra-abdominal  hemorrhage. 

The  treatment  consists  in  opening  the  abdomen,  arresting  the  hemorrhage, 
and  bringing  about  reaction. 

An  injury  to  the  peritoneum  creates  a  point  of  least  resistance,  and  at 
such  a  point  peritonitis  may  develop.  The  peritonitis  is  usually  local,  but 
may  become  general.  After  any  severe  intra-abdominal  injury  the  symp- 
toms of  peritoneal  shock  appear  {peritonism),  and  the  patient  may  rapidly- 
die.  In  the  condition  of  peritoneal  shock  the  temperature  is  subnormal;  the 
extremities  are  cold;  the  face  is  pallid  and  sunken;  the  pulse  is  small,  weak, 
and  very  frequent;  the  respiration  is  shallow  and  sighing;  there  is  great  thirst; 
the  patient  is  restless  and  turns  uneasity,  and  there  is  rigidity  and  disten- 
tion. Vomiting  almost  always  occurs.  In  some  cases  there  is  regurgitation 
rather  than  vomiting.  The  abdomen  is  the  seat  of  a  violent,  persistent  pain. 
The  patient  is  fearful  of  impending  death.  As  the  symptoms  develop  in  a 
grave  case  they  will  point  to  one  of  two  conditions — hemorrhage  or  peritonitis. 

In  intra-abdominal  hemorrhage  the  subnormal  temperature  and  other 
evidences  of  shock  persist.  Vomiting  ceases,  but  nausea  exists.  The  patient 
is  uncontrollably  restless  and  tosses  about  in  bed.  The  thirst  is  great.  The 
abdomen  is  rarely  rigid,  Fainting-spells  occur.  Blood  examination  shows  a 
marked  fall  in  the  percentage  of  hemoglobin.  Percussion  demonstrates  the 
existence  of  an  effusion  which  alters  its  position  as  the  patient's  position  is 
altered,  and  which  gradually  increases  in  amount.  Dulness  is  first  met  with 
in  the  loins.  Digital  examination  of  the  rectum  or  vagina  may  aid  in  diagnosis, 
because  in  hemorrhage  blood  gathers  in  the  rectovesical  or  in  Douglas's  pouch. 
If  peritonitis  develops,  the  vomiting  is  aggravated,  the  pain  is  intensified,  and  the 
abdomen  grows  rigid  and  distended. 

Rupture  of  the  Stomach  Without  External  Wound. — The  usual  course 
of  rupture  is  a  violent  blow,  although  the  accident  may  happen  while  washing 
out  the  stomach.  Rupture  is  more  apt  to  occur  when  the  stomach  is  distended 
with  food  than  when  it  is  empty.  The  rupture  may  be  partial,  the  peritoneal 
coat  not  being  torn.  The  rupture  may  be  complete.  Either  the  anterior  or 
the  posterior  wall  may  suffer.  The  region  of  the  pylorus  is  most  apt  to  be 
lacerated.     The  symptoms  of  rupture  are  collapse,  severe  pain  over  the  entire 


1076  Diseases  and  Injuries  of  the  Abdomen 

abdomen,  great  thirst,  excessive  tenderness,  especially  over  the  epigastric  region, 
occasionally  vomiting,  the  vomited  matter  being  usually,  but  not  invariably, 
bloody;  tympanitic  distention  and  muscular  rigidity  coming  on  after  a  few 
hours.  Austin  Flint  pointed  out  years  ago  that  after  complete  rupture  or 
perforation  gas  may  enter  the  abdominal  cavity  and  cause  the  diminution  or 
disappearance  of  liver-dulness,  but  the  area  of  liver-dulness  can  be  lessened  by 
great  intestinal  distention,  and  I  have  seen  cases  of  perforation  of  the  stomach 
and  intestine  in  which  liver-dulness  was  not  lessened  at  all.  (See  article  on 
Perforating  Ulcer  of  the  Stomach.)  The  flatter  the  abdomen  the  greater  the 
significance  of  the  sign.  After  incomplete  rupture  local  peritonitis  is  frequent; 
in  complete  rupture  the  escape  of  stomach  contents  into  the  peritoneal  cavity 
causes  general  peritonitis.  The  contents  of  the  stomach  are  not  so  liable  to 
escape  after  rupture  of  that  viscus  as  are  the  contents  of  the  intestine  after 
rupture  of  the  gut,  because  of  the  thickness  of  the  stomach  wall  and  the  tend- 
ency of  the  mucous  membrane  to  evert  and  block  the  opening.  Perforations 
of  the  anterior  wall  are  most  apt  to  lead  to  extravasation  and  general  peri- 
tonitis. Posterior  laceration  may  cause  subphrenic  abscess.  To  diagnosticate 
between  complete  and  incomplete  rupture,  Senn  favored  distending  the  viscus 
with  hydrogen  gas.  In  incomplete  rupture  the  contour  of  the  dilated  stomach 
can  be  made  out  upon  the  surface;  in  complete  rupture  the  viscus  cannot  be 
distended,  and  the  gas  passes  into  the  peritoneal  ca\'ity,  producing  the  physical 
signs  of  tympanites.  This  maneuver  is  open  to  the  objection  that  it  may 
increase  extravasation  in  a  complete  rupture. 

The  treatment  for  complete  rupture  is  immediate  operation.  Treatment  for 
shock  is  at  once  instituted  and  an  intravenous  infusion  of  salt  solution  is  given 
before  or  during  operation.  In  doubtful  cases  endeavor  to  bring  about  reac- 
tion and  explore.  Open  the  abdomen.  Note  if  gas  emerges  from  the  wound 
or  if  stomach,  fluid  appears.  Search  for  the  rupture  in  the  same  manner  as 
we  would  search  for  the  opening  of  a  perforated  ulcer.  When  the  rupture  is 
discovered,  flush  out  the  stomach  and  the  peritoneal  cavity  with  hot  salt 
solution;  sew  up  the  stomach  wound  with  a  double  row  of  silk  sutures,  the 
first  row  being  buried  and  including  the  muscular  coat  and  mucous  coat, 
the  second  row  being  Halsted  sutures;  drain  the  abdomen;  close  the  wound 
in  the  parietes;  place  the  patient  in  Fowler's  position;  let  salt  water  at  low 
pressure  flow  continuously  into  the  rectum;  feed  by  the  rectum  for  four  days, 
and  then  begin  the  administration  of  a  very  little  food  by  the  mouth.  In 
incomplete  rupture  the  danger  is  perforation.  The  patient  is  put  to  bed,  and 
after  reaction  has  taken  place  is  fed  by  the  rectum  for  several  days.  Cases 
of  complete  rupture  not  operated  upon  occasionally  recover,  adhesions  arising 
and  perigastric  suppuration  taking  place.  The  mortality  is  extremely  large. 
In  1896  Petry  collected  23  cases  in  which  operation  was  not  performed.  The 
mortaUty  was  59  per  cent.  This  mortality  is  not  so  large  as  one  would  anti- 
cipate. It  is  quite  possible  that  some  of  the  cases  were  not  genuine  instances 
of  rupture.  Many  fatal  cases  have  not  been  reported.  Nevertheless,  the  lesion, 
for  reasons  previously  stated,  is  not  nearly  so  dangerous  as  rupture  of  the  in- 
testine. Another  reason  for  the  greater  danger  of  intestinal  rupture  is  that 
fecal  matter  is  much  more  poisonous  than  the  gastric  contents.  Laparotomy 
has  lessened  the  mortality  of  rupture  of  the  stomach.  Petry  and  also  Eisendrath 
mass  together  operations  for  rupture  of  the  stomach  and  rupture  of  the  intestine. 
Petry  finds  the  group  mortality  to  be  52.3  per  cent.,  and  Eisendrath  finds  it  to 
be  52.5  per  cent.  Statistics  referring  to  the  stomach  alone  should  show  a 
much  lower  death-rate. 

Rupture  of  the  Intestine  Without  External  Wound. — In  the  great 
majority  of  cases  the  damage  is  produced  by  direct  violence.  In  some  few 
cases  the  force  is  indirect  (falls  on  the  feet  or  buttocks,  blows  on  the  back 
or  loin).     The  injury  mav  result  from  oscillation  or  from  compression  (the 


Rupture  of  the  Intestine  Without  External  Wound  1077 

younger  Senn).  The  common  cause  is  undoubLedly  compression  of  the  gut 
against  the  pelvis  or  vertebral  column,  but  it  is  certain  that  a  gut  containing 
fluid  may  be  ruptured  purely  by  violent  shaking  or  oscillation.  If  oscillation 
produces  the  damage,  the  rupture  is  of  the  portion  of  gut  furthest  from  the 
mesentery;  if  compression  be  the  cause,  any  part  of  the  bowel  may  suffer.  Rup- 
ture is  most  apt  to  occur  if  the  belly  is  relaxed.  It  is  predisposed  to  by  adhesions, 
disease  of  the  wall  of  the  bowel,  and  irreducible  hernia.  Most  ruptures  are 
complete.  In  a  very  few  cases  the  tear  extends  through  one  or  two  of  the  coats 
only  and  the  rupture  is  incomplete.  A  contusion  of  the  gut  may  be  followed 
by  rupture  several  days  after  the  injury.  A  complete  rupture  usually  permits 
leaking  of  feces,  but  in  very  rare  cases  a  small  opening  is  closely  plugged  by 
pouting  mucous  membrane.  Leaking  from  a  rupture  may  be  delayed  because 
intra-abdominal  pressure  may  for  a  time  keep  the  opening  pressed  against  a 
section  of  sound  gut  (the  younger  Senn).  The  amount  of  damage  to  the  belly 
wall  does  not  convey  any  notion  of  the  extent  of  visceral  injury.  The  belly  wall 
may  be  severely  injured  and  the  viscera  escape.  With  only  slight  contusion 
of  the  wall  there  may  be  extensive  visceral  injury.  Homer  Gage^  collected  85 
cases;  in  75  the  injury  was  due  to  direct  force,  and  in  32  of  these  the  force  was  in- 
flicted by  the  kick  of  a  horse  or  of  a  man.  In  i  of  my  cases  it  was  due  to  the 
kick  of  a  horse,  in  i  to  the  kick  of  a  man,  and  in  i  to  a  crush  inflicted  by  a 
cart-wheel.  The  victims  in  the  majority  of  reported  cases  were  young  men, 
probably  because  young  men  are  most  apt  to  be  exposed  to  violence.  In 
78  collected  cases  (Gage)  the  situation  of  the  injury  was  specified:  The  duo- 
denum, 10;  jejunum,  20;  ileum,  42;  large  intestine,  6.  Curtis  found  the  large 
intestine  injured  in  4  cases  out  of  113,  and  Poland,  in  5  cases  out  of  64.  In 
many  cases  there  is  more  than  one  tear,  and  sometimes  many  tears  exist. 
Both  the  large  and  small  intestines  may  suffer.  Chavasse  collected  106  cases 
in  which  the  ileum  or  jejunum  suffered,  19  in  which  the  large  intestine  did, 
7  in  which  the  duodenum  did,  7  in  which  both  the  large  and  small  intestine 
were  involved,  and  i  case  in  which  the  rectum  was  ruptured  (quoted  by  the 
younger  Senn,  in  "Am.  Jour.  Med.  Sciences,"  June,  1904).  As  Makins  points 
out,  the  portion  of  gut  most  apt  to  be  injured  is  a  portion  hanging  low  in  the 
pelvis,  because  a  loop  in  this  situation  is  most  easily  squeezed  against  bone 
by  a  blow  on  the  belly.  The  mesentery  may  be  lacerated  (it  is  in  7  per  cent. 
of  cases,  according  to  Gage;  in  16  per  cent.,  according  to  Curtis).  Now  and 
then  we  read  of  a  death  resulting  from  someone  introducing  into  the  anus  of 
an  unfortunate  person  the  nozzle  of  a  hose  carrying  compressed  air.  The 
victim  of  this  perversion,  cruelty,  or  morbid  sense  of  humor  whichever  it  may 
be,  usually  dies  from  multiple  ruptures  of  the  intestine.  Bendixen  and  Blything 
report  a  case  in  which  operation  was  followed  by  recovery  ("Surgery,  Gyne- 
cology, and  Obstetrics,"  1914,  xviii).  They  call  the  condition  pneumatic  rup- 
ture. In  their  case  there  were  9  lacerations  in  the  large  gut  and  i  in  the  small 
gut.  The  lacerations  were  from  2  to  7  inches  in  length.  There  was  also  a  tear  in 
the  mesentery.  The  symptoms  of  rupture  of  the  intestine  are  profound  shock, 
tympanites,  abdominal  pain,  and  rigidity,  rapidly  followed  by  peritonitis  if  the 
patient  survives.  In  some  cases  pain  is  referred  to  the  back.  Vomiting  comes 
on  soon  after  the  accident,  the  vomited  matter  being  possibly  at  first  bloody  and 
later  stercoraceous.  The  respiration  is  costal,  dyspnea  exists,  the  tongue 
is  dry,  and  great  thirst  exists.  The  pulse,  which  may  be  slow  at  first  but 
seldom  is,  soon  becomes  small ,  rapid ,  and  of  high  tension.  Blood  in  the 
stools  rarely  appears  early  enough  to  be  of  diagnostic  value,  and  there  may  be 
diarrhea  or  constipation.  There  may  be  no  marked  symptoms  for  an  hour  or 
two  or  for  many  hours.  Cases  are  on  record  of  people  with  ruptured  intestine 
returning  to  work  perhaps  for  hours.  One  of  my  cases  walked  over  two  miles 
to  reach  the  hospital.     Holland's  patient  had  no  symptoms  for  twenty-four 

^  "Annals  of  Surgery,"  March,  1902. 


loyS  Diseases  and  Injuries  of  the  Abdomen 

hours,  although  the  jejunum  had  been  ruptured.  Poland's  patient  ruptured 
the  duodenum,  but  walked  one  mile  in  spite  of  it.  The  escape  of  gas  into  the 
peritoneal  cav^ity  may  cause  the  diminution  or  disappearance  of  liver  dulness. 
After  anesthetizing  the  patient,  hydrogen  gas  insutllated  into  the  rectum  will 
come  from  the  mouth  if  there  is  no  perforation  in  the  stomach  or  the  intestine; 
if  a  perforation  exists,  tympanites  is  much  increased  and  the  area  of  liver  dulness 
may  disappear.  To  apply  rectal  insufflation  of  hydrogen,  generate  the  gas 
in  a  bottle  by  means  of  zinc  and  sulphuric  acid,  catch  the  gas  in  a  large  rubber 
bag,  and  attach  the  tube  from  the  gas  reservoir  to  a  tip  which  is  inserted  in  the 
rectum.  Give  the  patient  ether  to  relax  the  abdominal  muscles,  direct  an 
assistant  to  press  the  anal  margins  against  the  rectal  tip,  and  when  the  patient 
is  unconscious  turn  on  the  stopcock  and  press  upon  the  reservoir  (the  elder  Senn). 

It  has  been  suggested  that  ether  vapor,  mixed  with  air,  can  be  used  instead 
of  hydrogen  gas.^  In  this  method  a  little  ether  is  poured  into  the  bottle  cf 
an  aspirator,  the  valves  are  opened,  one  tube  is  carried  into  the  rectum,  the 
other  tube  is  attached  to  a  bicycle  pump,  and  by  working  the  pump  the  ether 
vapor  is  driven  into  the  bowel.  If  there  be  perforation,  tympanites  is  notably 
increased.  Most  surgeons  regard  the  rectal  insufflation  test  as  unsatisfactory 
and  often  dangerous.  Personally,  I  am  not  inclined  to  use  it.  Its  application 
requires  considerable  time;  it  must,  of  necessity,  increase  fecal  extravasation. 
If  we  operate  after  insufflation  the  gaseous  distention  is  an  embarrassment  to 
the  surgeon;  as  Le  Conte-  says,  it  "so  distends  the  intestines  that  it  may  be 
impossible  to  return  them  to  the  abdominal  cavity  until  they  have  been  emptied 
of  gas." 

Treatment  for  Rupture  of  Intestine. — After  an  abdominal  injury,  if  symp- 
toms point  to  dangerous  hemorrhage,  and  in  any  case  in  which  the  patient 
does  not  seem  to  be  reacting,  but  is  rather  getting  worse,  operate  at  once. 
If  in  doubt  as  to  whether  or  not  rupture  exists,  make  every  endeavor  to  bring 
about  reaction  and  explore.  Reaction  is  brought  about  as  previously  directed. 
Asepticize  and  anesthetize.  Perform  a  laparotomy,  making  the  incision  in  the 
middle  line  and  below  the  umbilicus;  observe  if  gas  escapes  when  the  perito- 
neum is  opened  or  if  fecal  material  or  an  inflammatory  exudate  flows  out; 
check  hemorrhage;  start  at  a  fixed  point  and  conduct  a  careful  search  to  find 
the  rent.  When  the  rent  is  found,  it  should  be  closed  by  Halsted  sutures  if 
possible,  but  only  a  small  rupture  can  be  so  treated.  A  large  tear  makes 
resection  necessary  Because  of  the  frequency  of  multiple  lesions  the  surgeon 
must  not  be  sure  he  has  finished  his  work  when  he  finds  and  closes  one  tear, 
but  he  must  determine  by  careful  search  that  no  other  tears  exist.  The 
surgeon  notes  if  there  is  injury  of  the  mesentery  and  if  the  circula- 
tion of  any  portion  of  the  bowel  is  interferred  with.  If  there  is  serious 
impairment  of  circulation  in  any  part  of  the  bowel  wall,  perform  intestinal 
resection,  followed  by  end-to-end  approximation  or  lateral  anastomosis.  In 
some  cases  of  rupture  the  patient  is  so  severely  shocked  that  it  is  impossible 
to  do  a  resection  with  any  hope  of  his  living.  In  such  a  case  stitch  the  ruptured 
portion  of  gut  to  the  belly  wall.  The  opening  in  the  gut  becomes  a  fecal  fistula, 
and  if  the  patient  survives,  can  be  subsequently  closed.  The  same  procedure 
is  proper  if  the  bowel  is  distended  and  paralyzed.  After  closing  the  opening 
in  the  bowel  or  resecting,  flush  the  abdominal  cavity  with  hot  saline  solution, 
and  wipe  the  peritoneal  fossae  and  the  space  between  the  liver  and  diaphragm 
with  gauze.  Finney  eviscerates,  wipes  out  the  abdominal  cavity,  and  wipes 
the  intestines  as  he  restores  them.  This  is  justifiable  if  the  operation  is  done 
soon  after  the  rupture,  but  not  in  later  cases,  in  which  the  lymph  has  gathered 
on  the  bowel.  Whatever  method  is  used  to  cleanse  the  abdomen,  remember  that 
infectious  material  is  apt  to  accumulate  between  the  liver  and  diaphragm 

^  Emerson  INI.  Sutton,  of  Geneva,  in  "Jour.  Am.  Med.  Assoc,"  July  23,  1S98. 
^"Jour.  Am.  Med.  Sciences,"  Dec,  1901. 


Location  of  a  Loop  of  Small  Intestine  io79 

and  in  Douglas's  pouch.  Drainage  is  to  be  used.  Suprapubic  drainage  is 
most  advantageous.  Place  the  patient  semi-erect  and  employ  continuous 
proctoclysis  of  normal  salt  solution  as  directed  for  peritonitis.  The  value 
of  operation  for  intestinal  rupture  is  conclusively  demonstrated.  Curtis 
collected  ii6  cases  which  occurred  before  1887.  Not  a  case  was  operated  upon, 
and  every  patient  died.  Homer  Gage  collected  85  cases  since  1887:  45  were 
not  operated  upon  and  every  one  died;  40  were  operated  upon  and  17  recovered. 
Eisendrath  collected  40  cases  operated  upon:  19  recovered  and  21  died 
(52.5  per  cent.).  The  mortality  of  cases  not  operated  upon  is,  according  to 
Eisendrath,  at  least  93  per  cent.  The  sooner  after  the  injury  operation  is 
performed,  the  greater  the  chance  for  success.  The  younger  Senn  points  out 
that  in  operations  done  within  four  hours  the  mortality  is  15.2  per  cent.;  in 
those  done  between  five  and  eight  hours  it  is  44.4  per  cent. ;  in  those  done  between 
nine  and  twelve  hours  it  is  63.6  per  cent.,  and  in  those  done  later  it  is  70  per  cent. 

Identification  of  the  Small  Intestine  and  of  the  Large  Intestine. — ''In 
abdominal  operations  it  is  frequently  imperatively  necessary  that  the  large 
intestine  be  recognized  with  certainty  or  the  small  bowel  be  positively  identi- 
fied. The  size  of  the  tube  will  not  always  aid  in  this  recognition,  as  a  smaU 
intestine  may  be  distended  enormously,  and  a  large  intestine  may  be  con- 
tracted to  the  size  of  a  finger  because  of  obstruction  above.  The  longitudinal 
muscular  fibers  of  the  large  bowel  are  accentuated  in  three  portions;  these 
accentuations  constitute  the  three  longitudinal  bands  which  begin  at  the 
cecum  and  terminate  at  the  end  of  the  sigmoid  flexure  of  the  colon.  Each 
band  is  composed  of  a  number  of  shorter  bands,  the  shortness  of  these  con- 
stituent bands  permitting  the  sacculation  of  the  large  intestine.  Longitudinal 
bands  and  sacculation  are  not  met  with  in  the  small  gut,  their  presence  or 
absence  being  a  means  of  identification  in  many  cases;  but  when  the  colon 
is  much  distended  the  bands  cannot  be  seen  distinctly  and  the  sacculation 
disappears.  From  the  large  intestine  only  spring  the  appendices  epiploicae 
(small  overgrowths  of  fat  in  pouches  of  peritoneum),  but  they  are  sometimes 
not  well  marked  except  upon  the  transverse  colon,  and  when  emaciation  exists 
they  may  almost  entirely  disappear.  The  relatively  fijced  position  of  the 
large  intestine  and  the  free  mobility  of  the  smaU  bowel  are  important  points 
of  distinction.  The  foregoing  indicates  that  it  is  not  always  easy  to  distinguish 
between  colon  and  small  gut,  and  that,  according  to  old  rules,  it  may  be  often 
necessary  to  make  large  incisions,  to  see  as  well  as  feel,  and  to  handle  a  large 
extent  of  the  bowel.  Any  scrap  of  knowledge  that  will  shorten  an  abdominal 
operation,  that  will  permit  of  as  certain  work  through  a  smaller  incision,  and 
that  A\dll  diminish  handhng  of  intraperitoneal  structures  tends  to  increase  the 
chances  of  recovery.  For  these  reasons  the  writer  suggests  a  method  of  bowel 
identification  which  rests  upon  the  facts  that  each  bowel  has  a  posterior  attach- 
ment, that  the  origin  of  the  attachment  differs  according  to  the  bowel  it  sup- 
ports, that  a  single  finger  can  detect  the  origin  of  the  peritoneal  support  of  any 
section  of  the  bowel,  and,  this  origin  being  kno"s\Ti,  the  portion  of  the  bowel  it 
supports  is  vdth  certainty  deducible.  In  an  exploratory  operation,  for  instance, 
the  finger  comes  in  contact  with  the  bowel:  to  determine  whether  it  is  a  large 
or  a  small  bowel,  note  first  if  the  structure  is  movable  or  is  firmly  fixed;  next, 
pass  the  finger  over  the  bowel  and  let  it  find  its  way  posteriorly.  If  dealing 
with  a  small  bowel,  the  finger  will  reach  the  origin  of  the  mesentery  between  the 
left  side  of  the  second  lumbar  vertebra  and  the  right  sacro-iliac  joint;  if  dealing 
with  the  large  bowel,  the  finger  will  reach  the  origin  of  the  mesocolon,  or  the 
point  where  the  colon  is  fixed  posteriorly  and  to  the  side."^ 

Location  of  a  Loop  of  Small  Intestine  (Figs.  684-687). — Monks  points 
out  a  plan  by  which,  in  most  instances,  we  can  learn  with  approximate  accu- 
racy what  portion  of  the  small  intestine  we  may  have  hold  of  ("Annals  of 
1  "The  author,  in  "IMedical  News,"  June  9,  1S94 . 


io8o 


Diseases  and  Injuries  of  the  Abdomen 


Surg.,"'  Oct.,  1903).  He  learns  first  by  observation  of  the  mesenteric  ves- 
sels. Opposite  the  upper  portion  of  the  bowel  there  are  primary  vascular 
loops  only  with  perhaps  an  occasional  small  secondary  loop.     As  we  descend 


Fig.  684. — A  loop  of  intestine,  the  middle  of  which  is  exactly  3  feet  from  the  end  of  the  duo- 
denum. The  gut  is  of  large  size.  The  mesenteric  loops  are  primary,  and  the  vasa  recta  large, 
long,  and  regular  in  distribution.  The  translucent  spaces  (lunettes)  between  the  vessels  are 
extensive.  Below,  the  mesentery  is  streaked  with  fat.  The  veins,  which  had  a  distribution 
similar  to  the  arteries,  are  for  simplicity  omitted  from  this  and  from  the  subsequent  drawings. 
The  subject  from  which  the  specimen  was  taken  was  a  male  of  forty  years,  with  rather  less  than 
the  usual  amount  of  fat.     The  entire  length  of  the  intestine  was  23  feet  (Monks). 


Fig.  685. — A  loop  of  intestine  at  6  feet.  As  compared  with  Fig.  684  the  gut  is  somewhat 
smaller.  The  vascularity  of  the  intestine  and  mesentery  is  less.  Secondary  loops  are  a  promi- 
nent feature.  The  vasa  recta  are  smaller.  The  lunettes  are  also  present,  but  are  not  so  large 
as  in  Fig.  684.  The  subject  was  a  male  of  about  thirty-five  years,  with  an  average  amount  of 
fat.     The  entire  length  of  the  intestine  was  20  feet  (Monks). 

"secondary  loops  become  more  numerous,  larger,  and  approach  nearer  to  the 
bowxl  than  the  primary  loops  in  the  upper  part,''  and  about  the  fourth  foot 
these  secondary  loops  first  become   a  "prominent   feature."     As  we  descend 


Location  of  a  Loop  of  Small  Intestine 


io8r 


primary  loops  become  smaller,  secondary  loops  become  more  numerous  and 
nearer  the  bowel,  and  possibly  tertiary  loops  appear.  Opposite  the  lower  por- 
tion of  the  ileum  the  loops  are  not  definite  in  arrangement,  but  are  simply  a 


Fig.  6S6. — A  loop  of  intestine  at  12  feet.  The  vessels  are  smaller.  The  primar}-  loops  are 
lost  in  the  fat,  but  secondary  and  even  tertiary  loops  are  visible.  The  vasa  recta  are  shorter, 
more  irregular,  and  branching.  The  specimen  came  from  the  same  subject  which  furnished 
Figs.  6S4  and  685  (Monks). 


Fig.  6S7. — A  loop  of  intestine  at  20  feet.  The  gut  appears  to  be  thick  and  large.  The 
mesenterj'  is  quite  fat  and  opaque,  and  large  and  numerous  f at.tabs  are  present.  The  vessels, 
which  are  complicated,  are  seen  \\-ith  difficulty,  and  are  represented  by  mere  grooves  in  the  fat. 
The  subject  was  a  stout  woman,  and  the  entire  length  of  the  gut  was  21  feet  (Monks). 

network.  Monks  points  out  that  opposite  the  upper  bowel  the  vasa  recta, 
when  put  gently  on  the  stretch,  "are  straight,  large,  and  regular,  and  rarely 
give  off  branches  to  the  mesentery,"  and  are  about  5  cm.  long.     In  the  lower 


io82  Diseases  and   Injuries  of  the  Abdomen 

third  they  are  usually  less  than  i  cm.  long,  are  smaller,  are  not  quite  so  straight, 
are  not  so  regular,  and  give  off  numerous  mesenteric  branches.  Monks  further 
shows  that  fat  impairs  the  translucency  of  the  mesentery.  The  thinnest 
mesentery  is  that  connected  with  the  upper  gut.  As  we  descend  the  mesentery 
becomes  thicker  and  thicker  because  of  fibrous  tissue,  unstriated  muscle,  and 
fat.  Translucency  varies  greatly.  If  a  loop  of  upper  intestine  is  raised  against 
the  light,  one  notices  close  to  the  gut  and  between  the  vase  recta  transparent 
lunettes.  The  lunettes  become  smaller  and  fatty  as  we  descend,  and  disappear 
at  the  eighth  foot.  In  an  incision  in  the  median  line,  if  the  loop  of  intestine 
is  pulled  downward,  we  can  determine  if  "the  line  of  resistance  from  above  is 
from  the  median  line  of  the  body  or  from  the  left  or  right  of  it."  This  resistance 
of  the  mesentery  indicates  to  which  point  the  loop  is  attached,  and  hence  what 
portion  of  bowel  the  loop  comprises.  I  have  used  these  observations  of  Monks 
repeatedly  to  great  advantage. 

Rupture  of  the  Liver. — (See  page  1170.) 

Rupture  of  the  gall=bladder  and  the  bile=ducts  (see  page  11 70)  is 
most  apt  to  happen  from  injury  when  gall-stones  e.xist.  Peritonitis,  general  or 
local,  is  almost  certain  to  follow  such  a  rupture.  Besides  those  symptoms 
common  to  all  severe  abdominal  injuries  there  may  be  intense  jaundice. 

Treatment. — Suture  the  laceration  or  make  a  biliary  fistula. 

Rupture  of  the  Pancreas. — (See  page  1192.) 

Rupture  of  the  Spleen. — (See  page  1201.) 

Rupture  of  Mesenteric  Arteries. — The  symptoms  are  those  of  hemor- 
rhage. The  superior  mesenteric  artery,  the  inferior  mesenteric  artery,  or 
branches  of  either  or  both  may  be  damaged.  If  branches  of  the  superior  mes- 
enteric artery  are  divided  near  the  bowel,  gangrene  of  the  bowel  will  result,  but 
wound  of  a  branch  far  from  the  intestine  does  not  cause  gangrene.  The  branches 
near  the  gut  are  terminal  arteries,  hence  the  gangrene.  The  branches  of  the 
artery  divide  and  form  arcades  arranged  concentrically  and  the  terminal  arteries 
come  from  the  peripheral  arcades.  In  wounds  of  the  vessels  far  removed  from 
the  gut  anastomosis  prevents  gangrene  (Labastie,  in  "Archives  Generales  de 
Chirurgie,"  Jan.  25,  1908).  In  most  cases  in  which  there  has  been  rupture  of 
mesenteric  arteries  death  from  hemorrhage  rapidly  occurs  If  the  victim 
should  not  die  of  hemorrhage  he  is  in  danger  of  gangrene  and  peritonitis.  Al- 
drich^  reported  a  case  in  which  death  was  deferred  until  the  seventh  day. 
The  treatment  is  immediate  laparotomy.  If  the  wound  is  found  close  to  the 
gut,  the  portion  of  gut  supplied  by  the  cut  vessel  should  be  resected.  If  well 
removd  from  the  gut,  simply  ligate  the  vessel  (Labastie,  Ibid.).  In  a  wound 
near  the  root  of  the  mesentery  perform  extensive  resection  of  the  gut  and  re- 
move also  a  portion  of  the  mesentery. 

Rupture  of  the  Kidney .^ — (See  page  1424.) 

Rupture  of  the  Ureter. — (See  page  1426.) 

Wounds  of  the  Abdominal  Wall. — Non-penetrating  wounds  are  to  be 
treated  on  general  principles.  They  are  sutured  with  great  care  and  are  firmly 
supported  externally.     Ventral  hernia  may  follow  a  large  wound. 

Penetrating  Wounds. — The  symptoms  of  penetrating  wounds  of  the  ab- 
dominal wall  are  usually  those  of  shock  and  hemorrhage,  and  later  of  septic 
peritonitis.  Emphysema  is  apt  to  occur  and  viscera  may  protrude,  and  often 
do  in  the  case  of  a  large  incised  or  lacerated  wound.  Extravasation  of  con- 
tents of  intra-abdominal  viscera  is  very  apt  to  occur,  and  is  sure  to  occur  if  the 
viscus  was  distended  when  injured.  Normal  urine  and  normal  bile  may  do 
little  harm,  but  if  either  excretion  is  septic,  disastrous  consequences  are  certain 
to  ensue.  If  intestinal  contents  escape,  septic  peritonitis  is  sure  to  arise. 
Bleeding  is  usually  profuse  and  prolonged,  because  spontaneous  arrest  of  hemor- 

1  "Annals  of  Surgerj-,"  March,  1902. 


Penetrating  Wounds  1083 

rhage  from  any  vessel  of  considerable  size  will  seldom  take  place  unless  the 
abdomen  be  opened. 

Treatment. — The  surgeon  endeavors  to  discover  promptly  if  a  wound  of  the 
abdominal  wall  is  or  is  not  penetrating  in  character.  This  fact  may  be  proved 
by  protrusion  of  viscera,  by  the  appearance  of  stomach  contents  in  the 
wound,  or  by  a  flow  of  bile,  urine,  or  feces  from  the  wound.  If  none  of 
the  above  indications  exists,  and  if  there  are  no  signs  of  serious  hemorrhage, 
the  wound  should  be  irrigated  with  hot  salt  solution,  and  should  be  dressed 
with  gauze,  and  every  effort  should  be  made  to  bring  about  reaction;  otherwise 
opertion  should  be  immediate. 

When  reaction  is  obtained,  the  wound  should  be  enlarged  layer  by  layer 
until  it  becomes  obvious  whether  or  not  the  peritoneum  is  open.  Madelung,'^  of 
Strassburg,  points  out  that  incision  layer  by  layer  will  be  of  no  use  in  settling  the 
question  of  penetration  if  the  wound  is  in  the  chest,  the  buttock,  the  perineum, 
or  the  back  of  a  fat  individual.  If  after  incision  layer  by  layer  it  becomes 
evident  that  penetration  has  not  occurred,  the  wound  should  be  closed  and 
treated  on  general  principles.  If  it  becomes  evident  that  it  has  occurred, 
the  abdomen  should  be  opened  at  the  point  of  penetration,  and  a  thorough 
exploration  of  intra-abdominal  structures  should  be  made  in  order  to  locate 
injury  and  be  able  to  treat  it  properly. 

In  a  case  still  doubtful  after  incision  by  layers,  do  an  exploratory  lapa- 
rotomy in  the  middle  line.  It  is  impossible  from  the  appearance  of  the  wound 
and  it  may  be  impossible  from  the  symptoms  to  affirm  that  visceral  injur\" 
has  not  occurred;  hence  in  every  case  in  civil  practice  in  which  it  is  evident 
that  penetration  has  occurred,  laparotomy  is  necessary  in  order  to  detect  and 
correct  intra-abdominal  injury,  and  to  clean  the  peritoneum  by  flushing  with 
hot  salt  solution.  If  viscera  protrude,  they  must  be  washed  off  with  hot  salt 
solution  and  covered  with,  hot  sterile  pads,  and  after  the  patient  has  reacted 
the  wound  should  be  enlarged,  the  condition  of  the  contents  of  the  abdomen 
investigated,  hemorrhage  arrested,  wounds  properly  treated,  and  the  \-iscera 
returned. 

It  is  customary  to  flush  the  belly  with  hot  salt  solution,  some  of  the  fluid 
being  allowed  to  remain.  This  procedure  mechanically  cleanses  the  perito- 
neum, removes  blood-clots,  strongly  combats  shock,  and  antagonizes  infection. 
It  is  not  absolutely  necessary  to  flush  out  the  belly  unless  a  considerable  hem- 
orrhage has  occurred  or  feces  or  stomach  contents  have  been  extravasated.  If 
extravasation  of  stomach  contents  or  feces  has  occurred,  not  only  should  flush- 
ing be  practised,  but  evisceration  should  be  '"'',: ried  out;  the  fouled  intestine 
should  be  ^\dped  off  w^th  gauze  pads  wet  witn  hot  salt  solution,  and  while  ex- 
truded should  be  kept  wTapped  in  hot  moist  towels;  the  peritoneal  fossae  should 
be  rubbed  \\ath  gauze  pads  and  the  space  between  the  liver  and  the  diaphragm 
should  be  carefuUy  wiped. 

A  wound  of  the  stomach  should  be  sutured;  a  wound  of  the  bowel  may  be 
sutured,  or  resection  and  anastomosis  or  resection  and  end-to-end  suturing 
may  be  required.  Visceral  injuries  are  treated  by  appropriate  means.  In  a 
punctured  wound  or  a  gunshot-wound  of  the  intestine  rectal  insufflation  of 
hydrogen  gas  when  the  abdomen  is  open  may  disclose  the  situation  of  the  injury, 
but  evisceration  is  usually  practised  instead  and  is  preferable. 

After  the  completion  of  intra-abdominal  manipulations  the  surgeon  restores 
any  protruding  bowel. 

Drainage  is  required  if  the  contents  of  the  stomach  or  the  intestines  escaped, 
if  hemorrhage  was  severe,  or  if  the  hver,  pancreas,  kidney,  or  spleen  were 
found  to  have  been  damaged.  The  peritoneum  may  be  sutured  with  a  con- 
tinuous suture  of  catgut;  the  muscles  and  fascia,  with  continuous  or  inter- 

i".\nnal5  of  Surgery,"  Sept.,  1897. 


10S4  Diseases  and   Injuries  of  the  Abdomen 

rupted  sutures  of  catgut,  and  the  skin,  with  interrupted  sutures  of  fine  silk  or 
of  silkworm-gut.  If  there  is  need  of  haste,  through-and-through  sutures  of  silk- 
worm-gut may  be  used.  Active  stimulation  and  artificial  heat  are  needed 
immediately  after  the  operation  to  combat  shock.  In  many  cases  intravenous 
infusion  of  hot  normal  salt  solution  is  given.  It  is  of  great  value.  It  may  be 
given  both  during  and  after  operation.  Enteroclysis,  or  high  rectal  injection 
of  hot  saline  fluid,  is  useful.  So  is  hypodermoclysis,  or  the  subcutaneous 
injection  of  hot  salt  solution.  The  usual  after-treatment  consists  of  the  semi- 
erect  position,  continuous  proctoclysis  of  salt  solution,  avoidance  of  food 
by  the  stomach  for  forty-eight  hours,  and  the  administration  of  brandy  and 
water  from  time  to  time.  For  two  days  the  patient  should  be  fed  bv  the  rec- 
tum. On  the  appearance  of  flatulent  distention,  forty-eight  hours  or  more  after 
the  operation,  give  a  saline  cathartic.  It  is  not  wise  to  purge  during  the  first  forty- 
eight  hours  after  the  operation  unless  a  Murphy  button  has  been  used.  When 
there  is  no  sign  of  peritonitis  a  purge  should  not  be  given  until  the  fourth  day. 
After  forty-eight  hours  liquid  food  can  usually  be  given  by  the  stomach.  Solid 
food  may  be  given  after  seven  or  eight  days,  but  the  patient  must  not  leave  his 
bed  until  the  abdominal  wound  is  firmly  united  because  of  the  danger  of  ventral 
hernia.  A  support  should  be  worn  for  a  long  time.  E.  D.  Fenner^  reports  39 
stab-wounds  of  the  abdomen  operated  upon  in  the  Charity  Hospital  of  New 
Orleans.     There  were  9  deaths  (23.07  per  cent.). 

Gunshot  Wounds  of  the  Abdomen. — The  bullet  may  penetrate  from 
the  front,  the  side,  the  back,  the  chest,  or  the  perineum.  If  a  bullet  has  pene- 
trated, it  may  or  it  may  not  have  produced  visceral  damage;  a  pistol-bullet  or 
the  bullet  of  a  sporting-rifle  almost  invariably  does.  A  projectile  of  a  modern 
military  rifle  may  not  or  may  produce  wounds  which  can  be  recovered  from 
without  operation.  A  urinary  examination  should  be  made  promptly  to  see 
if  blood  is  present. 

In  gunshot  wounds  of  the  belly  shock  is  usually  greatly  added  to  by  hemor- 
rhage, and  in  civil  practice  prompt  operation  is  certainly  indicated.  The 
incision  is  made  through  the  belly  even  when  the  shot  entered  the  back.  In 
some  cases  the  opening  is  made  through  the  wound;  in  others  it  is  not;  but 
in  every  case  the  wound  made  by  the  bullet  is  explored  and  disinfected.  The 
incision  should  be  long  enough  to  permit  of  thorough  work.  After  open- 
ing the  abdomen  our  first  duty  is  to  arrest  hemorrhage,  our  next  is  to  look 
for  perforations  of  the  viscera  and  mesentery  and  close  them.  If  the  anterior 
wall  of  the  stomach  is  perforated,  close  the  opening  and  examine  the  posterior 
wall  through  an  opening  made  in  the  gastrocolic  omentum.  If  a  posterior  per- 
foration is  found,  close  it,  and  insert  posterior  drainage  into  the  lesser  peritoneal 
cavity.  As  a  rule,  an  intestinal  perforation  can  be  closed,  but  occasionally  a 
portion  of  the  intestine  requires  resection.  If  the  bullet  is  encountered  it  is  re- 
moved, but  a  prolonged  search  for  it  should  never  be  made.  Finally,  the  ab- 
dominal cavity  is  cleansed,  drainage  is  provided  for,  and  the  abdominal  wound 
is  closed.  In  one  of  my  fatal  cases  the  bullet  entered  the  rectum  low  down 
and  was  not  found.  In  a  case  of  mine  with  6  perforations  of  the  small  intestine 
recovery  followed  operation. 

E.  D.  Fenner^  reports  113  gunshot  wounds  of  the  abdomen  operated  upon 
in  the  Charity  Hospital  of  New  Orleans;  there  were  78  deaths  (69  per  cent.). 
In  a  series  of  14  cases  operated  upon  by  Vaughan  the  mortality  was  64  per  cent. 
C'Am.  Jour.  Med.  Sciences,"  Feb.,  1906). 

Military  surgeons  have  taught  that  wounds  inflicted  by  the  modern  hard- 
jacketed  projectile  are  not  so  apt  to  involve  fatal  hemorrhage  and  disastrous 
complications;  in  fact,  such  wounds  are  often  recovered  from  without  opera- 
tion, and  sometimes  with  an  entire  absence  of  serious  symptoms.     Again,  it  is 

'  "Annals  of  Surgery,"   January,  1902. 
^  Ibid.,  January,  1902. 


Abdominal  Wounds  in  War  10S5 

difficult  or  impossible  to  treat  such  cases  as  in  civil  practice,  even  were  it  de- 
sirable. The  belief  has  been  until  recently  that  in  military  practice  the  results 
are  slightly  better  from  expectant  treatment,  whereas  in  civil  practice  expectant 
treatment  is  a  dismal  failure.  Still,  even  in  war,  if  conditions  permit,  operation 
should  be  performed  if  there  is  hemorrhage  or  obvious  visceral  injury,  or  if 
septic  peritonitis  develops.  Treves  says  that  in  the  Boer  War  only  40  per  cent, 
of  cases  of  gunshot  wounds  of  the  abdomen  not  operated  upon  died,  but,  as 
pointed  out  by  Hildebrandt,  many  cases  die  on  the  battlefield  and  while  being 
taken  to  the  hospital,  hence  the  real  mortality  of  these  injuries  is  much  more 
than  40  per  cent.  In  the  war  between  China  and  Japan  the  mortality  from 
gunshot  wounds  of  the  abdomen  is  said  to  have  been  about  77  per  cent. 

Abdominal  Wounds  in  War. — In  the  beginning  of  this  war  surgeons 
were  imbued  with  the  conviction  of  Sir  Frederick  Treves  that  in  gunshot  wounds 
of  the  abdomen  abstention  from  operation  is  the  safer  course.  They  were 
dominated  by  the  axiom  Sir  William  MaCormac  put  forth  after  the  Boer  War, 
viz.,  "those  shot  through  the  abdomen  will  live  if  let  alone  and  will  die  if  oper- 
ated upon."  After  four  years  of  violent  war  most  surgeons  have  concluded 
that  the  policy  of  abstention  is  a  ghastly  failure.  It  is  true  that  the  mortality 
has  been  fearful  even  after  operation,  but,  weighing  up  everything  I  believe  that 
the  balance  tips  strongly  in  favor  of  early  operation. 

Early  operation  is  often  impossible.  Any  operation  may  be  out  of  the  ques- 
tion because  of  lack  of  time,  assistants,  and  materials — because  of  close  adja- 
cency to  the  line  of  battle — or  because  of  military  necessity  demanding  evacua- 
tion. As  yet  figures  are  not  conclusive.  Claims  are  made  for  both  sides  of 
the  controversy.  The  advocate  of  one  view  is  certain  to  dispute  conclusions 
and  perhaps  statements  of  the  advocate  of  the  other  view.  Distinguished  sur- 
geons are  found  in  opposition.  The  published  facts  lead  us  to  side  with  Tuffier 
when  he  says  that  if  the  surgeon  has  the  necessary  time,  assistants  and  equip- 
ment operation  gives  a  better  prognosis  than  abstention.  Reports  demonstrate 
the  following  truths:  Shell  fragments  cause  the  worst,  rifle  bullets  the  least 
serious  injuries.  The  least  serious  wounds  are  those  above  the  level  of  the 
pylorus. 

A  wound  from  side  to  side  is  extremely  grave.  So  is  a  vertical  wound. 
Anteroposterior  wounds  in  the  midline  are  usually  rapidly  fatal  because  the 
spine,  aorta  or  the  vena  cava  is  very  apt  to  be  struck  (Wallace,  in  "Lancet," 
1915,  clxxxix).  Rifle-bullet  wounds  of  the  liver,  if  anteroposterior,  and  through- 
and-through  may  be  recovered  from  without  operation.  Oblique  wounds, 
tangential  injuries,  and  shell  wounds  give  a  far  worse  prognosis.  The  kidney 
is  apt  to  be  injured.  Midline  anteroposterior  wounds  are  more  fatal  in  the 
hypogastric  than  in  the  epigastric  region.  A  wound  of  the  buttock,  thigh  or 
perineum  may  enter  the  peritoneal  cavity. 

Exploratory  operations  have  proved  that  a  bullet  can  cross  the  peritoneal 
cavity  without  opening  a  hollow  viscus.  In  such  cases  the  peritoneal  coat  of 
the  stomach  or  intestine  may  be  bruised  or  torn.  Hence  it  is  possible  for  a 
rifle  bullet  to  push  a  hollow  viscus  out  of  the  way  and  not  perforate  it  (Wallace, 
Ibid).  This  can  only  occur  when  the  bullet  is  traveling  with  great  velocity 
and  the  viscus  contains  very  little  fluid.  Only  in  such  cases  is  spontaneous 
recovery  possible.  Wounds  of  the  large  intestine  are  usually  associated  with 
pelvic  fracture,  wound  of  the  bladder,  or  damage  to  nerve  trunks.  They  are 
more  fatal  than  wounds  of  the  small  gut.  Wounds  of  the  small  gut  are  often 
multiple. 

In  wounds  of  the  liver,  spleen  and  pelvis,  hemorrhage  is  the  imminent 
danger.     In  w'ounds  of  the  hollow  viscera  infection  is  the  great  peril. 

There  may  be  no  rigidity  of  the  abdomen.  It  is  especially  prone  to  be  absent 
when  there  is  hemorrhage.  Early  operation  is  the  indicated  treatment  if 
circumstances  admit  of  it,  even  if  the  surgeon  must  operate  without  an  assist- 


io86  Diseases  and  Injuries  of  the  Abdomen 

ant.  As  Keen  says:  "Every  hour  diminishes  such  a  patient's  chance  of  recov- 
ery" ("Treatment  of  War  Wounds"). 

Wallace,  Hughes,  and  Rees  show  that  operations  done  within  six  hours  are 
followed  by  62.8  per  cent,  of  recovery;  those  done  between  six  and  twelve  hours, 
only  36.3  per  cent. — those  done  between  twelve  and  sixteen  hours,  16.6  per  cent. 
The  earlier  operations  were  of  course  upon  the  most  dangerous  cases  (see  Wallace, 
in  "Brit.  Jour,  of  Surgery,"  iv;  Hughes  and  Rees,  in  "Lancet,"  April  28,  1917; 
Walters,Robinson,JordanandBlacksmith,  in  "Lancet,"  Feb.  10,1917).  Certain 
it  is  that  intestinal  operations  are  peculiarly  fatal  if  seen  late.  Bowlby  will  not 
operateon  such  a  caseif  itis  seen  later  than  thirty-six  hours  after  theinjury  because 
operation  offers  scarcely  the  shadow  of  a  chance  ("Lancet,"  Feb.  10,  1917). 

Bowlby  does  not  operate  on  a  through-and-through  wound  of  the  liver 
believing  that  if  the  hemorrhage  is  not  rapidly  fatal  recovery  may  follow. 
Liek  saw  17  gunshot  wounds  of  the  liver  recover  without  operation  ("Arch.  f. 
klin  Chir.,"  1916,  cvii).  If  there  is  no  evidence  of  severe  bleeding  he  secures 
rest  and  gives  morphia.  If  there  are  signs  of  continued  hemorrhage  he  operates 
and  finds  the  mortality  to  be  29  per  cent.  If  a  patient  wounded  in  the  abdomen 
is  suffering  from  hemorrhage  immediate  operation  is  imperative.  If  there  is 
severe  shock  but  no  progressive  hemorrhage  many  surgeons  endeavor  to  estab- 
lish reaction  before  operating.  Lockwood  and  his  associates  consider  the  pulse 
a  valuable  guide.  If  the  pulse  is  above  120  operation  they  postpone  until  le- 
action  occurs  ("Brit.  Med.  Jour.,"  March  10,  1917).  Walters  and  his  associates 
also  regard  the  pulse  as  a  valuable  guide  ("Brit.  Jour,  of  Surgery,"  iv).  Webb 
and  Milligan  ("Brit.  Jour,  of  Surgery,"  iv)  says  that  a  pulse  above  no  gives 
a  bad  prognosis  for  operation,  a  pulse  of  under  85  gives  a  good  prognosis.  As 
a  rule  the  incision  should  be  median  and  should  not  include  or  cross  the  wound 
(see  Fraser,  in  "Brit  Med.  Jour.,"  1916,  i).  The  situation  of  the  wound  or 
wounds  determines  where  the  incision  is  to  be  placed.  An  escape  of  feces,  bile, 
or  urine  from  the  wound  gives  us  valuable  information.  Foreign  bodies, 
especially  bits  of  clothing,  must  be  removed.  If  they  are  allowed  to  remain 
fatal  sepsis  is  almost  inevitable. 

In  intestinal  wounds  suture  is  preferred  to  resection  unless  there  "is  exten- 
sive damage  to  the  mesentery  or  extravasation  between  the  two  layers  of  the  mes- 
entery at  its  attachment  to  the  bowel"  (Views  of  Fraser  and  Drummon  as  set 
forth  by  Keen,  in  "Treatment  of  War  Wounds).  A  kidney  damaged  by  a  gun- 
shot wound  may  recover.  If  nephrectomy  is  demanded  it  should  not  be  done 
immediately,  except  for  hemorrhage  (Fullerton,  in  "Brit.  Jour,  of  Surgery,"  v). 

Many  cases  are  closed  without  drainage.  Many  others  are  drained.  All 
are  placed  in  the  Fowler  position  and  are  given  salt  by  the  plan  of  Murphy. 
In  some  cases  suprapubic  drainage  is  used.  The  wound  inflicted  by  the  missile 
should  be  excised;  sometimes  it  is  sutured;  sometimes  it  is  drained. 

Bowlby  ("Brit.  Med.  Jour.,"  June  2,  1917)  published  the  following  statis- 
tical table: 

Cases 

Considered  with  view  to  operation 1038 

No  operation  advised 73 

Number  of  operations 965 

Per  Cent. 

Total  operative  mortality 53.9 

Total  hollow  viscera  mortality 64.7 

Mortality  from  uncomplicated  stomach  wounds 52.7 

Mortality  from  uncomplicated  wounds  of  the  small  gut 65.8 

Mortality  from  uncomplicated  wounds  of  the  colon 58.7 

Gunshot  Wounds  of  the  Pregnant  Uterus. — It  is  rarely  that  both 
walls  are  perforated  by  a  pistol  bullet,  as  the  force  of  the  bullet  is  greatly  les- 
sened by  the  uterine  contents.     A  rifle  bullet  usually  passes  through  the  organ. 


Mesenteric  Cysts  1087 

Wounds  by  shell  fragments  are  extremely  grave.  There  are  severe  shock  and 
hemorrhage,  and  occasionally  amniotic  fluid  flows  from  the  wound  of  entrance. 
Blood  may  flow  from  the  vagina.  The  intestine  may  also  be  injured.  As  a 
rule,  labor-pains  come  on  soon  after  the  injury.  In  Albarran's  case  the  fetus 
was  expelled  forty-eight  hours  after  operation.  Open  the  abdomen  in  all  cases 
and  empty  the  uterus.  If  the  patient  is  late  in  pregnancy  empty  by  Cesarean 
section.  Hysterectomy  is  indicated  if  the  uterus  is  seriously  torn.  All  cases 
should  be  drained  (Smead)  in  "Trans,  of  Assoc,  Obstetrics  and  Gynecology," 
1916.  Gellhorn'^  has  collected  18  cases.  In  this  series  there  were  12  recoveries. 
Smead  cites  30  cases.  Russel  Fowler  reports  a  case  of  a  patient  eight 
months  pregnant  who  was  shot  twice  in  the  abdomen.  There  were  two  wounds 
in  the  uterus.  Fowler  did  a  Cesarean  operation.  The  incision  in  the  uterus  was 
made  by  enlarging  one  of  the  bullet  wounds.  The  other  bullet  wound  was  sutured. 
The  baby  was  wounded  on  the  fingers  of  the  right  hand.  Both  mother  and 
baby  recovered  ("New  York  State  Jour,  of  Med.,"  Nov.,  191 1).  In  Judge's 
case  ("Jour.  Am.  Med.  Assoc,"  vol.  i,  191 2),  a  girl  of  sixteen,  nearly  at  full 
term,  was  shot  with  a  Winchester  rifle.  The  child  was  in  the  abdominal  cavity 
and  dead.  The  mother  recovered.  Tucker,  of  Shanghai,  did  a  Cesarean 
operation  for  gunshot  wound  of  the  uterus.  The  mother  died  and  the  child 
survived. 

Omental  Cysts. — Cysts  may  spring  from  the  outer  surface  of  the  omen- 
tum (escaped  ovarian  cysts,  lymphatic  cysts,  dermoids). 

True  omental  cysts  arise  within  the  cavity  of  the  great  omentum.  In  50 
per  cent,  of  cases  the  patient  is  an  adult,  but  in  half  of  the  reported  cases  the 
patients  have  been  under  ten  years  of  age.  Some  of  the  cysts  are  probably  of 
embryonic  origin.  Dowd  is  inclined  to  think  that  the  cyst  he  removed  resulted 
from  omental  hematoma  ("Annals  of  Surgery,"  Nov.,  191 1).  In  this  case  there 
was  torsion  of  the  pedicle  of  the  cyst.  Dowd  (Ibid.)  reports  i  case  of  omental 
cyst  and  collected  37  from  literature.  Hasbrouck  ("Annals  of  Surgery," 
x\ugust,  1908)  points  out  that  the  condition  is  much  more  common  in  females 
than  in  males,  that  there  are  no  characteristic  symptoms,  that  the  condition 
begins  as  omental  endothelioma  between  the  two  surfaces  of  omentum  which 
fuse  because  of  inflammation  and  form  a  closed  sac,  that  hemorrhages  are  apt  to 
occur  into  the  cyst,  and  that  operation  shows  a  mortality  of  6  per  cent.  The 
operation  performed  is  extirpation. 

Mesenteric  Cysts. — These  rare  cysts  are  divided  into  (i)  embryonic,  (2) 
hydatid,  (3)  cystic  malignant  disease  (Dowd,  "Annals  of  Surgery,"  1910). 
A  great  majority  of  mesenteric  cysts  are  embryonic.  Moynihan  believes  that 
embryonic  cysts  arise  in  "rests"  from  "the  Miillerian  or  Wolfiian  organs  or 
ducts,  or  from  the  ovary,"  which  are  included  between  the  folds  of  mesentery. 
These  rests  undergo  cystic  degeneration.  Miller  {"  Bull.  Johns  Hopkins  Hosp.," 
1913,  xxiv)  classifies  mesenteric  cysts  as  follows: 

1.  Cysts  of  intestinal  origin: 

{a)  By  sequestration  occurring  during  development  of  the  bowel. 
(b)  From  Meckel's  diverticulum  when  it  arises  from  the  concave  side  of 
the  intestine  (intramesenteric  diverticulum). 

2.  Dermoids. 

3.  Cysts  springing  from  retroperitoneal  organs  (duct  of  Miiller,  body  of 
Wolff,  ovary  or  germinal  epithelium).  Mesenteric  cysts  grow  and  pass  along 
between  the  lavers  of  mesentery  until  they  reach  the  gut  and  then  compress 
the  gut  and  push  its  wall  ahead  of  them.  A  cyst  may  cause  intestinal  obstruc- 
tion.    Volvulus  is  one  of  its  results. 

Such  a  cyst  may  contain  embryonal  material,  bloody  fluid,  serous  fluid, 
chylous  fluid,  or  lymph.     In  Harry  C.  Deaver's  report  of  a  case  ("Annals  of 
Surgery,"  May,  1909)  it  is  shown  that  in  40  cases  there  were  25  females  and 
'  "St.  Louis  Med.  Review,"  Dec.  2  and  9,  1901. 


io88  Diseases  and  Injuries  of  the  Abdomen 

15  males;  that  the  size  varies  from  that  of  a  split  pea  to  enormous  dimensions; 
that  there  may  be  a  pedicle  form  in  front  of  the  vertebral  column  or  from  the 
intestinal  wall;  that  the  sac  wall  may  be  exceedingly  thin  or  as  much  as  i  cm.  in 
thickness;  that  in  some  cases  large  veins  are  present  on  the  surface  of  the  cyst; 
that  adhesions  to  the  abdominal  viscera  are  common;  that  intestinal  obstruc- 
tion may  occur  (kinks,  volvulus,  intussusception) ;  that  cysts  are  most  commonly 
found  in  relation  with  the  lower  end  of  the  ileum;  and  that  there  are  no  charac- 
teristic symptoms  except  perhaps  the  rapid  body  wasting  mentioned  by  Moyni- 
han.  Moynihan  also  points  out  that  the  cyst  fluctuates  and  is  most  promi- 
nent toward  the  navel,  that  it  is  very  mobile,  especially  transversely  (we  should 
add  if  not  anchored  by  adhesions),  and  that  the  cyst  is  surrounded  by  a  reso- 
nant zone  and  crossed  by  a  resonant  band. 

Treatment. — Incision  and  drainage  if  there  are  numerous  and  firm  ad- 
hesions. Enucleation  whenever  possible.  Resection  of  the  involved  portion 
of  gut  with  the  cyst  in  some  cases  of  multiple  cyst  (Harry  C.  Deaver,  Ibid.). 

Torsion  of  the  great  omentum  is  usually  caused  by  a  fall  or  strain  or 
attempts  to  reduce  a  hernia.  In  nearly  all  cases  a  hernia  is  present.  Hedley 
("Brit.  Aled.  Jour.,"  Nov.  11,  1911)  studied  records  of  73  cases.  In  60  there 
was  or  had  been  a  hernia.  In  5  cases  without  a  hernia  there  were  adhesions. 
In  48  of  the  hernia  cases  the  omentum  was  attached  in  the  sac,  in  4  it  was  an- 
chored near  the  sac,  in  3  to  the  bowel,  and  in  i  to  the  Fallopian  tube. 

Symptoms  are  like  those  of  a  strangulated  omental  hernia  or  of  appendicitis. 

The  treatment  is  by  laparotomy. 

Stomach  and  Intestines 

Foreign  Bodies  in  the  Stomach  and  Intestines. — Foreign  bodies 
of  considerable  size  are  rarely  taken  into  the  alimentary  canal  except  by  chil- 
dren, insane  people,  or  drunkards.  Small  bodies  (bits  of  straw,  fragments 
of  bone,  etc.)  are  frequently  swallowed.  Most  foreign  bodies  swallowed  are 
passed  with  the  feces,  but  some  lodge  in  the  stomach  or  intestine.  Any  body 
which  can  pass  the  esophagus  is  not  too  large  to  pass  through  the  intestines. 
Lodgment  is  an  accident,  not  an  inevitable  consequence — an  accident  which  is 
due  to  the  shape  and  size  of  the  body.  A  foreign  body  may  lodge  in  the  stomach. 
In  some  cases  there  are  no  symptoms  or  slight  symptoms.  In  other  cases  symp- 
toms are  violent.  The  severity  of  the  symptoms  depends  upon  the  shape  and 
character  of  the  body.  Some  nervous  women  have  a  tendency  to  chew  and 
swallow  bits  of  their  own  hair.  If  a  person  continues  doing  so  for  years  a  hair- 
hall  (trichobezoar)  may  form.  It  consists  of  a  tangled  mass  of  hairs  aggluti- 
nated together  by  mucus  and  food  remains.  It  grows  slowly.  When  small  it 
acts  like  a  ball-valve  at  the  pylorus  ("Dyspepsia,"  by  W.  S.  Fenwick),  when 
large  it  fills  the  stomach  and  is  moulded  to  the  shape  of  the  organ.  Matas 
reported  an  interesting  case  of  hair-ball  ("  Tr.  Southern  Surgical  and  Gyneco- 
logical Assoc,"  1914).  A  hair-ball  gives  rise  to  dyspeptic  symptoms.  If  the 
ball  is  large  it  causes  pain  and  can  be  palpated.     The  .v-rays  make  the  diagnosis. 

In  some  cases  it  is  possible  to  feel  the  body  from  without.  A  metal  body 
in  the  stomach  will  deflect  a  magnetic  needle  held  over  the  viscus  (Polaillon). 
Many  foreign  materials  can  be  skiagraphed.  A  body  of  small  size  may  pass 
through  the  entire  canal  and  emerge  without  having  done  any  harm,  but  it  may 
lodge  and  may  cause  perforation.  If  perforation  occurs,  the  foreign  matter  may 
become  encysted,  for  instance,  in  the  mesentery;  may  cause  an  abscess  or  may 
cause  general  peritonitis.  A  fish-bone  may  cause  an  anal  abscess.  An  epiploic 
appendix  may  cause  sacculation  of  the  bowel,  perforation  by  a  foreign  body 
may  take  place  in  this  sac,  an  epiploic  abscess  resulting,  which  may  attain 
considerable  size  and  may  be  mistaken  for  carcinoma  (Sir  J.  Bland-Sutton, 
in  "Lancet,"  Oct.  24,  1903).     It  is  not  wise  to  attempt  to  recover  a  foreign 


Treatment  of  Fibromatosis  of  the  Stomach  1089 

body  from  the  stomach  by  inducing  vomiting.  In  some  cases  gastrotomy 
is  necessary.  When  a  small  or  sharp  foreign  body  has  been  swallowed  and 
has  not  caused  perforation,  abscess,  or  obstruction,  the  usual  treatment  is  as 
follows:  a  purgative  should  jiever  be  given  to  expedite  the  passage  of  a  foreign 
body,  because  increased  peristalsis  increases  the  danger  of  impaction  or  of  per- 
foration. Endeavor  to  encrust  the  foreign  body,  and  thus  lessen  the  danger  of 
perforation,  by  feeding  with  bread. and  milk  only  for  several  days,  and  at  the 
end  of  this  period  give  a  mild  laxative.  An  exclusive  diet  of  mush  or  of 
mashed  potatoes  has  been  suggested.  Suet  dumplings  may  be  given.  Pain 
is  relieved  by  opium.  A  foreign  body  rarely  lodges  in  the  duodenum,  but  may 
lodge  lower  down,  and  may  cause  ulceration,  perforation,  abscess,  or  intestinal 
obstruction.     Operation  is  necessary  in  such  cases. 

Volvulus  of  the  Stomach. — ^This  condition  is  very  unusual.  According 
to  T.  Kocher  28  cases  were  on  record  five  years  ago  and  of  these  18  were  oper- 
ated upon  ("  Internat.  Abstract  of  Surgery,"  Dec,  1914).  The  condition  may 
be  maugurated  by  vomiting,  peristalsis  after  vomiting,  by  body  movements 
or  abdominal  trauma  when  the  stomach  is  prolapsed  and  dilated  or  by  a  tumor. 
One-third  of  the  cases  are  associated  with  diaphragmatic  hernia  and  one-fourth 
with  hour-glass  stomach.  The  symptoms  come  on  suddenly.  There  is  violent 
abdominal  pain.  Distention  and  collapse  are  early.  There  is  nausea,  but  the 
patient  can  neither  vomit  nor  belch.  In  the  upper  left  abdomen  there  is  a  tender, 
tense,  and  tympanitic  area.  The  rotation  of  the  stomach  may  be  on  its  verti- 
cal or  on  its  longitudinal  axis.  An  hour-glass  stomach  may  undergo  twisting 
on  its  vertical  or  longitudinal  axis.  Berg  operated  successfully  for  volvulus  of 
the  stomach.  He  opened  the  abdomen,  relieved  distention  by  tapping  the  stom- 
ach with  a  trocar,  and  then  easily  corrected  the  twist.  The  gastrohepatic 
omentum  should  be  shortened  by  Beyea's  operation  (see  page  1243).  Kocher 
had  a  case  in  which  an  hour-glass  stomach  twisted.  At  the  first  operation  he 
untwisted  the  organ.  At  a  second  operation  gastro-enterostomy  was  performed 
upon  the  larger  sac.  The  patient  was  cured  ("  Internat.  Abstract  of  Surgery," 
Dec,  1914). 

Fibromatosis  of  the  Stomach. — This  condition  was  long  ago  described  by 
Brinton  as  cirrhosis  of  the  stomach.  Alexis  Thomson  has  recently  published 
an  admirable  description  containing  many  new  things  ("Annals  of  Surgery," 
July,  1 913).  He  shows  that  ulceration  of  some  form  is  the  cause  (simple 
ulceration  or  cancerous  ulceration).  The  condition  may  be  and  commonly  is 
localized,  but  it  may  involve  the  entire  stomach  ("leather-bottle  stomach"). 
There  may  be  glandular  enlargement.  The  local  form  starts  at  the  pylorus 
and  resembles  cancer,  but  is  not  nodular.  There  may  or  may  not  be  adhesions. 
There  is  no  "cicatricial  stenosis  of  the  pylorus,"  but  the  canal  of  the  pylorus 
is  narrowed  by  submucous  thickening.  The  thickening  is  not  scar-tissue, 
but  is  more  like  a  fibroma  (Ibid.).  It  is  probably  a  reaction  against  infection. 
Thomson  proves  that  there  is  an  innocent  form  of  fibromatosis,  and  thinks 
it  probable  that  there  may  even  be  an  innocent  form  of  leather-bottle  stomach 
(Ibid.). 

The  symptoms  suggest  ulcer,  cancer,  or  some  sequel  of  ulcer.  It  is  often 
possible  to  be  mistaken  as  to  the  nature  of  the  mass  even  when  it  is  exposed 
by  exploratory  incision.  The  cases  of  "pyloric  cancer"  which  have  recovered 
after  gastro-enterostomy  and  some  of  the  cures  of  gastric  cancer  by  gastrec- 
tomy are  explained  when  we  know  how  easy  it  is  to  mistake  innocent  fibro- 
matosis for  cancer. 

Treatment. — Thomson  always  insists  on  an  immediate  microscopical 
examination  of  a  portion  of  the  tumor  or,  better,  of  an  enlarged  lymph- 
gland.  He  advocates  resection  for  local  fibromatosis  because  he  believes 
cancer  is  liable  to  arise.  In  some  cases  gastro-enterostomy  is  performed;  in 
some,  jejunostomy. 
69 


1090  Diseases  and  Injuries  of  the  Abdomen 

Carcinoma  of  the  Stomach. — Innocent  tumors  and  sarcomata  occa- 
sionally attack  the  stomach,  but  they  are  infinitely  rare  in  comparison  with 
primary  cancer.  In  only  i  per  cent,  of  cases  is  cancer  secondary  (Friedenwald, 
"Am.  Jour.  Med.  Sciences,"  1914,  cxlviii).  Cancer  is  a  common  disease,  in 
fact  "30  per  cent,  of  all  cancers  in  civiHzed  man  are  in  the  stomach"  (Wm. 
J,  Mayo,  in  "Surgery,  Gynecology,  and  Obstetrics,"  1918,  xxvi).  The  reason 
for  this  great  gastric  liability  to  cancer  is  unknown.  Mayo  (Ibid.)  thinks  it  may 
be  caused  by  hot  drinks.  This  disease  is  unusual  before  the  age  of  fortv,  and  is 
very  seldom  seen  before  the  age  of  thirty.  The  period  of  greatest  liability  is 
between  the  ages  of  forty  and  sixty.  I  operated  upon  a  man  of  twenty-three 
for  gastric  cancer.  It  is  more  common  in  men  than  in  women,  the  proportion 
being  as  5  to  4.  Beyond  question,  in  some  cases  cancer  arises  from  the 
margins  of  an  ulcer.  We  used  to  regard  such  an  origin  as  rare.  We  now  look 
upon  it  as  common.  In  the  Mayo  clinic  it  is  thought  that  70  per  cent,  of 
cases  thus  originate.  Friedenwald  from  a  study  of  1000  cases  decided  that  7 
per  cent,  exhibit  a  definite  history  of  ulcer  but  in  only  23  per  cent,  of  the  cases 
could  the  cancer  have  arisen  from  an  ulcer  ("Am.  Jour.  Med.  Sciences,"  1914, 
cxlviii).  In  over  half  the  cases  there  is  a  history  of  overeating  or  overdrinking. 
The  forms  of  cancer  which  may  arise  in  the  stomach  are  the  spheroidal  cell 
growth  (either  the  hard  form  known  as  scirrhus  or  the  soft  form  known  as 
medullary  or  encephaloid),  the  cylindrical  cell  growth  or  adenocarcinoma,  and 
colloid  (due  to  the  myxomatous  degeneration  of  either  a  spheroidal  cell  or  a 
cylindrical  cell  carcinoma).  Scirrhus  more  than  any  other  form  produces 
constriction  of  the  pylorus  and  less  often  than  any  other  produces  hemorrhage. 
It  may  spread  for  a  considerable  distance  along  the  submucous  coat,  muscular 
coat,  and  subserous  coat  without  apparent  involvement  of  the  mucous  membrane 
wide  of  the  primary  focus  of  disease.  Fibromatosis  may  develop  about  it. 
In  some  cases  scirrhus  is  limited  to  the  pyloric  region,  in  others  it  is  a  limited 
tumor  of  some  other  part  of  the  wall  of  the  stomach.  In  the  condition  known 
as  malignant  "leather-bottle  stomach"  a  scirrhus  has  invaded  the  entire 
stomach  wall,  or  fibromatosis  has  developed  with  the  cancer  and  the  wall  of  the 
viscus  is  thick  and  rigid. 

Medullary  cancer  and  adenocarcinoma  produce  hemorrhage.  Both  of  these 
forms  most  often  arise  in  the  pyloric  region.  Medullary  cancer  may  remain 
limited,  but,  as  a  rule,  a  cauliflower  growth  arises  and  eventually  fills  the  stomach 
and  portions  of  the  mass  may  slough  away. 

Adenocarcinoma  is  apt  to  spread  along  the  mucous  membrane  instead  of 
"infiltrating  the  deeper  layers,"  as  other  forms  are  prone  to  do  ("Cancer  and 
Tumors  of  the  Stomach,"  by  Samuel  Fenwick  and  W.  Soltau  Fen  wick).  Sphe- 
roidal celled  carcinomata  are  twice  as  common  as  cylindrical  celled,  and  med- 
ullary cancer  is  about  as  common  as  scirrhus.  Any  cancer  may  be  accompanied 
by  fibromatosis. 

Cancer  may  be  limited  to  the  body  of  the  stomach  (either  curvature  or  either 
wall),  the  pyloric  end  or  the  cardiac  end,  but  it  may  involve  two  of  these  regions 
or  almost  the  entire  stomach,  or,  being  multiple,  may  be  found  in  many  parts. 
Sometimes  there  is  a  primary  cancer  on  one  wall,  and  another  growth,  due  to 
contact,  on  a  corresponding  point  of  the  opposite  wall  {contact  cancer).  All 
forms  of  carcinoma  most  frequently  begin  in  the  region  of  the  pylorus.  In 
many  cases  of  gastric  carcinoma  adhesions  form  between  the  stomach  and  the 
liver,  colon,  or  diaphragm.  Even  in  cancer  of  the  pylorus  the  duodenum  is 
seldom  invaded.  Medullary  cancer  not  unusually  passes  into  the  esophagus. 
Gastric  cancer  is  usually  fatal  in  from  four  months  to  two  years,  and  most 
patients  die  within  one  year.  In  60  per  cent,  of  cases  the  pylorus  is  involved. 
In  80  per  cent,  of  cases  the  lesser  curvature  is  diseased.  In  over  half  of  the  cases 
of  cancer  of  the  pylorus  there  is  no  important  lymphatic  involvement  (]\IcArdle). 
In  investigating  any  gastric  disorder  follow  the  advice  of  the  Mayo  brothers 


Symptoms  of  Carcinoma  of  the  Stomach  1091 

and  study  the  history  of  the  case,  the  size  and  situation  of  the  stomach,  the  exist- 
ence and  situation  of  pain  and  tenderness,  the  presence  of  a  tumor,  and  whether 
or  not  the  passage  of  food  is  unhampered. 

Symptoms. — Examine  with  care  a  patient  in  whom  cancer  is  suspected.  In 
unusual  cases  (i  per  cent,  of  all  cases)  it  produces  no  symptoms  until  it  has  lasted 
for  some  time  and  has  attained  a  large  size  (latent  cancer).  In  nearly  all  cases 
it  does  produce  symptoms.  The  disease  comes  on  gradually,  usually  with  indi- 
gestion and  ph3^sical  weakness.  In  over  nine-tenths  of  the  cases  the  patient 
has  persistent  dragging  pain,  which  usually  is  increased  by  eating  and  pressure, 
and  attacks  of  vomiting  are  frequent.  In  seven-tenths  of  the  cases  there  isdefinite 
tenderness.  After  a  short  time  the  victim  of  cancer  becomes  very  weak  and  ex- 
ceedingly anemic,  and  it  is  often  possible  to  feel  a  tumor  in  his  stomach.  Blood 
examination  shows  diminution  of  red  corpuscles  and  hemoglobin  and  perhaps 
absence  of  any  increase  of  leukocytes  after  a  full  meal.  There  is  rapid  loss  of 
weight  and  strength.  The  general  tendency  is  downward  but  now  and  then  there 
may  be  temporary  gain  in  weight  and  strength.  Cachexia  is  not  deferred  long. 
The  vomiting  of  a  patient  with  gastric  cancer  is  at  first  occasional  only,  but 
as  the  case  progresses  it  becomes  more  and  more  frequent.  Vomiting  soon  after 
eating  occurs  when  the  cardiac  region  is  involved;  vomiting  an  hour  or  so 
after  eating  occurs  when  the  pyloric  end  is  involved.  When  the  body  of  the 
organ  is  the  seat  of  disease,  vomiting  may  be  absent.  The  vomited  matter 
in  nine-tenths  of  cases  is  mixed  with  a  small  amount  of  altered  blood  {cofee- 
ground  vomit).  In  one-fourth  of  the  cases  there  is  definite  melena  and  in  most 
cases  occult  blood  is  found  in  the  feces,  especially  if  hydrochloric  acid  be  absent 
from  the  stomach  contents.  These  symptoms  above  cited  associated  with 
"coffee-ground  vomit"  and  lactic  acid  in  the  stomach  contents  are  strongly  in- 
dicative of  cancer  (Wm.  J.  Mayo,  in  ''Surg.,  Gynec,  and  Obstet.,"  May,  1908). 
A  test-meal  is  given,  and  important  conclusions  are  sometimes  derived  from  the 
presence  or  absence  of  hydrochloric  acid  and  lactic  acid.  It  is  my  custom  to 
have  the  stomach  washed  out  and  then  have  Ewald's  test-breakfast  given. 
This  consists  of  one  roll  of  white  bread  (35  gm.),  400  gm.  of  H2O,  and  400  gm. 
of  tea  without  milk  or  sugar.  In  one  hour  the  stomach  is  emptied  by  means 
of  a  tube  and  a  pump  or  a  tube  and  abdominal  compression,  and  the  material 
is  examined.  If  the  result  of  the  test  seems  out  of  accord  with  the  other  symp- 
toms, repeat  the  process  (L.  Boas,  in  "Berlin,  klin.  Woch.,"  No.  440,  1905). 
In  most  cases  free  hydrochloric  acid  is  not  found  in  the  stomach  contents,  but 
lactic  acid  is  found  and  Oppler's  bacillus  can  often  be  detected.  There  may 
be  red  blood-corpuscles  in  the  fluid.  If  the  cancer  is  not  ulcerated,  free  hydro- 
chloric acid  will  probably  be  found;  if  it  is  ulcerated,  it  will  usually  be  absent.^ 
Free  hydrochloric  acid  may  be  absent  from  the  stomach  because  of  atrophy 
of  glands,  cessation  of  secretion,  or  neutralization  by  the  products  of  the 
cancerous  area.  Friedenwald  (Ibid.)  says  that  89  per  cent,  of  cases  exhibit 
anacidity,  3  per  cent,  normal  acidity,  4  per  cent,  hyperacidity,  3  per  cent,  sub- 
acidity.  Lactic  acid  is  present  in  81  per  cent,  of  the  cases,  Oppler's  bacillus 
in  79  per  cent.,  sarcinae  in  32  per  cent.,  coffee-ground  matter  in  71  percent.  I 
believe  that  a  cancer  arising  from  an  ulcer  is  apt  for  a  time  to  be  accompanied 
by  hyperacidity,  and  that  the  advent  of  anacidity  is  delayed.  Free  hydrochloric 
acid  may  be  absent  in  individuals  in  whom  cancer  does  not  exist.  I  have  noted 
its  absence  in  several  cases  of  cicatricial  stenosis  of  the  pylorus. 

It  may  be  absent  in  cancer  of  the  esophagus,  advanced  Bright's  disease, 
cancer  of  the  duodenum,  distant  cancer,  febrile  conditions,  and  amyloid  disease. 
The  constant  presence  of  considerable  quantities  of  hydrochloric  acid  is  strong 
evidence  against  the  existence  of  cancer  of  the  stomach.  If  cancer  arises  from 
ulcer,  free  hydrochloric  acid  is  apt  to  be  present  for  a  considerable  time  after 
the  cancer  has  begun. 

^  Reissner,  in  "Miinchen.  med.  Woch.,"  Dec.  3,  1901. 


1092  Diseases  and  Injuries  of  the  Abdomen 

Distend  the  stomach  with  gas  or  fluid  and  map  out  its  outlines.  Feel  for 
a  tumor.  A  tumor  can  usually  be  felt  if  it  involves  the  greater  curvature  or 
anterior  wall,  and  a  large  tumor  of  the  pylorus  can  be  palpated,  but  in  other 
regions  the  tumor  can  rarely  be  felt.  In  Friedenwald's  1000  cases  a  tumor  was 
palpable  in  72  per  cent,  but  in  only  30  per  cent,  within  the  first  six  months 
after  the  appearance  of  symptoms  (Ibid.). 

Cancer  of  the  cardiac  end  interferes  with  the  entrance  of  food  into  the 
stomach,  and  in  such  a  case  the  stomach  is  shrunken  and  the  esophagus  is  di- 
lated immediately  above  the  growth.  In  cancer  of  "the  pylorus  the  food  is 
partially  or  completely  arrested  as  it  is  being  urged  on  to  pass  the  pylorus,  and 
the  stomach  becomes  much  dilated.  Dilatation  occurs  in  nearly  half  the  cases. 
The  vomited  matter  in  a  case  of  cancer  rarely  contains  recognizable  fragments 
of  the  growth,  but  fluid  with  which  the  stomach  has  been  irrigated  may  contain 
pieces  which  can  be  identified  as  cancer  (Rosenbach). 

In  cancer  of  the  stomach  the  general  course  of  the  temperature  is  normal, 
but  there  are  occasional  deviations  to  below  or  above  normal.  Febrile  seizures 
occur  in  nearly  half  the  cases.  In  many  cases  the  urine  contains  albumin, 
indican,  acetone,  and  casts.  Occasionally  cancer  of  the  stomach  produces 
spasm  of  the  esophagus.  I  have  seen  this  in  several  cases.  Cancer  of  the 
stomach  is  apt  to  involve  secondarily  adjacent  lymph-glands,  or  other 
structures,  especially  the  liver;  in  fact,  the  liver  is  involved  in  30  per  cent, 
of  the  cases  (Welch).  Occasionally  there  is  enlargement  of  the  supraclavicular 
glands  of  the  left  side.  Metastases  are  usual  and  early,  but  in  cancer  of  the  pylo- 
rus over  half  of  the  cases  show  no  distinct  lymphatic  involvement.  In  many 
doubtful  cases  exploratory  incision  is  required  imperatively.  Friedenwald 
(Ibid.)  shows  that  the  average  expectation  of  life  is  less  than  one  year  in  66 
per  cent,  of  cases,  between  one  and  two  years  in  22  per  cent.,  and  over  two  years 
in  II  per  cent. 

Treatment. — The  medical  treatment  consists  in  milk-diet,  the  use  of  mor- 
phin,  and  of  lavage  if  the  pylorus  or  body  of  the  stomach  be  diseased.  Per- 
form lavage  as  follows:  The  tube  for  lavage  should  be  long  enough  to  extend 
about  3  feet  out  of  the  mouth  when  the  other  end  is  in  the  stomach,  it  should 
be  flexible,  should  have  an  opening  in  the  stomach  end  and  another  opening 
on  the  side  about  i  inch  above  the  stomach  end.  The  tube  should  be 
greased  with  glycerin  or  the  end  of  it  chilled  in  a  bowl  of  cracked  ice.  The 
patient  sits  down,  throws  the  head  back,  opens  the  mouth  widely,  and 
is  directed  to  take  deep  breaths,  at  regular  intervals.  The  tube  is  carried 
into  the  pharynx,  the  patient  is  ordered  to  make  efforts  to  swallow  it,  and 
the  tube  is  thus  taken  into  the  stomach.  About  i  quart  of  fluid  is  poured 
into  the  funnel-like  end  of  the  tube,  and  just  before  the  tube  empties  itself  of 
the  last  of  the  water  the  funnel  is  lowered  and  the  fluid  runs  out.  This  pro- 
ceeding is  repeated  until  the  fluid  becomes  clear.  The  best  fluid  to  use  is  a  solu- 
tion of  bicarbonate  of  sodium,  a  teaspoonful  of  the  salt  to  a  quart  of  warm  water. 
Lavage  should  be  practised  before  breakfast,  and  sometimes  also  at  bed-time. 

The  indications  for  operation  are  well  set  forth  by  jMacdonald^:  They  are 
progressive  aggravation  of  symptoms  in  spite  of  a  rigid  diet  and  medical  treat- 
ment, loss  of  gastric  mobility,  progressive  diminution  of  gastric  peristalsis, 
progressive  diminution  of  free  hydrochloric  acid,  emaciation  even  under 
forced  feeding,  progressive  reduction  of  hemoglobin  to  65  per  cent,  or  under, 
and  moderate  leukocytosis.  ■ 

Surgical  treatment  aims  to  remove  the  growth  or  to  obviate  the  effect 
of  obstruction  at  one  of  the  orifices  of  the  stomach. 

In  cancer  of  the  body  of  the  stomach,  if  the  growth  is  not  extensive,  ex- 
cision of  the  growth  may  be  performed;  if  it  is  extensive,  it  is  useless  to  attempt 
it  unless  the  growth  is  absolutely  non-adherent.  Conner,  of  Cincinnati, 
attempted  total  excision  of  the  stomach  in  1883,  l)ut  the  patient  died  on  the 
1  John  B.  Murphy,  in  "Chicago  Med.  Recorder,"  June  15,  1902. 


Symptoms  of  Sarcoma  of  the  Stomach  io93 

table.  In  iSgy  Schlatter,  of  Zurich,  successfully  removed  the  entire  stomach. 
Brigham,  Richardson,  Macdonald,  Boeckel,  De  Carvalho,  Bardeleben,  Haine, 
Gallet,  Dollinger,  Ferry,  Ribera,  and  others  have  successfully  removed  the  entire 
stomach  and  attached  the  esophagus  to  the  small  intestine  {complete  or  total  gas- 
trectomy). In  the  successful  cases  digestion  was  satisfactorily  performed  after 
removal  of  the  stomach.  Very  rarely  will  cases  be  found  suitable  for  such  a 
radical  proceeding.  The  case  suitable  for  this  treatment  is  one  in  which  the 
entire  stomach  is  involved  in  the  growth,  in  which  there  is  no  obvious  glandular 
involvement,  and  in  which  the  stomach  is  not  adherent,  but  is  feely  movable. 
Herbert  J.  Paterson  ("The  Hunterian  Lectures  for  1906")  collected  27  cases  of 
total  gastrectomy  for  cancer:  10  died  and  17  recovered.  If  a  small  portion  of 
the  fundus  is  left  the  operation  is  called  subtotal  gastrectomy.  H.  J.  Paterson 
(Ibid.)  collected  20  cases  of  subtotal  gastrectomy  for  cancer  with  6  deaths.  In 
limited  cancer  of  the  body  of  the  stomach  perform  partial  gastrectomy.  In 
cancer  of  the  cardiac  orifice  of  the  stomach  the  surgeon  usually  keeps  the  pas- 
sage open  as  long  as  possible  by  the  frequent  passage  of  a  tube,  and  through 
this  tube  introduces  liquid  food.  Sometimes  a  small  tube  is  introduced  and  per- 
manently retained.  When  it  becomes  difficult  to  introduce  a  tube,  gastrostomy, 
diiodenostomy,  or  jejunostomy  may  be  performed.  As  a  matter  of  fact,  in  most 
cases  gastrostomy  is  done  as  a  last  resort,  and  it  is  scarcely  worth  doing  in 
cancer  of  the  cardiac  end  of  the  stomach.  It  is  far  more  useful  in  cancer  of  the 
esophagus.  Arch,  Kiimmel,  Sauerbruch,  Voelcker,  and  Zaaijer  succeeded  in  re- 
moving cancer  of  the  cardia.  In  cancer  of  the  pylorus,  limited  in  extent 
and  without  lymphatic  involvement,  pylorectomy  may  be  performed;  but  in 
cancer  which  has  widely  infiltrated  the  coats  of  the  stomach  and  has  involved 
the  lymphatic  glands,  gastro-enterostomy  is  performed  as  a  palliative  measure,  the 
patient  during  the  rest  of  his  fife  subsisting  upon  hquid  or  semiliquid  foods  and 
submitting  to  frequent  irrigation  of  the  stomach  to  remove  food  residue.  In 
cases  of  irremovable  and  far-advanced  cancer  it  is  often  best  to  refuse  to  operate 
and  to  create  deliberately  the  opium-habit  in  the  patient,  although,  in  some  cases, 
duodenostomy  or  jejunostomy  may  be  performed. 

The  most  successful  of  all  the  above  operations  are  pylorectomy  and  partial 
gastrectomv.  The  mortality  used  to  be  large  but  has  been  greatly  reduced 
during  recent  years.  In  the  Mayo  clinic  over  38  per  cent,  pass  the  three-year 
limit  and  may  be  called  cures  (page  1222).  There  are  in  literature  many  cases 
which  have  survived  three  years  or  over.  In  the  Mayo  clinic  gastro-enteros- 
tomy for  cancer  has  a  mortality  of  8  per  cent.  It  seldom  prolongs  life  more  than 
a  few  months  although  in  some  cases  it  does  prolong  it  a  year  or  more. 

Sarcoma  of  the  Stomach. — Of  recent  years  it  has  been  proved  that  sarcoma 
of  this  region  is  more  common  than  was  once  supposed.  There  are  over  60  cases 
on  record.  I  have  had  one  case,  for  which  I  performed  jejunostomy.  It  can 
occur  at  any  age,  but  is  more  usual  in  early  life  than  carcinoma.  It  has  been 
estimated  by  Wm.  T.  Howard^  that  37.7  per  cent,  of  cases  are  under  the  age  of 
forty,  and  11.44  P^r  cent,  are  under  the  age  of  twenty.  The  pylorus  is  involved 
in  about  one-fourth  of  the  cases.  .  In  most  cases  the  posterior  wall  and  greater 
curvature  are  involved.  Howard  says  there  is  a  diffuse  growth  in  21.31  per 
cent,  of  cases  and  that  the  cardiac  end  is  involved  in  only  4.9  per  cent,  of  cases. 
Sarcoma  arises  in  the  submucous  coat.  Any  form  of  sarcoma  may  arise.  It 
causes  stenosis  in  less  than  one-tenth  of  the  cases.  There  is  no  sex  predispo- 
sition in  sarcoma.     The  growth  may  attain  a  great  size. 

Symptoms. — A  tumor  forms,  grows  rapidly  and  often  attains  a,  large  size, 
and  not  unusually  actually  causes  a  projection  of  the  abdominal  wall.  If  it 
ulcerate  there  will  be  hem.atemesis,  but  it  often  does  not  ulcerate,  and  bleed- 
ing is  much  rarer  than  in  carcinoma.  Not  unusually  this  growth  arises  in  a 
person  under  forty,  and  sometimes  in  one  of  less  than  twenty  years  of  age. 
1  "Jour.  Am.  Med.  Assoc,"  Feb.  8,  1902. 


I094  Diseases  and  Injuries  of  the  Abdomen 

Stenosis  is  uncommon.  The  Hver  is  involved  secondarily  in  only  11.47  per 
cent,  of  cases  (Howard),  metastases  are  more  rare  than  in  carcinoma,  free  hy- 
drochloric acid  is  usually  absent  from  the  gastric  contents,  and  microscopical 
examination  of  washings  from  the  stomach  may  detect  fragments  of  sarcoma. 
Certain  diagnosis  is  impossible  without  exploratory  incision.  Howard  esti- 
mates the  average  duration  of  life  to  be  from  nine  to  ten  months. 

Treatment. — If  the  liver  is  free  and  if  there  are  no  metastases,  partial 
gastrectomy  or  complete  gastrectomy  may  be  advisable.  If  pyloric  stenosis 
should  arise,  gastro-enterostomy  may  be  performed.  Scudder  ("Annals  of 
Surgery,"  August,  1913)  reports  a  case.  He  performed  jejunostomy.  Sbc 
weeks  later  he  removed  the  tumor  by  partial  gastrectomy,  closed  the  jejunal 
opening,  and  did  anterior  gastro-enterostomy.  A  year  later  the  man  remained 
well. 

Ulcer  of  the  Stomach  (Peptic  Ulcer  of  the  Stomach). ^ — Ulcer  of 
the  stomach  is  a  condition  due  to  digestion  of  a  portion  of  the  stomach  wall 
by  very  acid  gastric  juice,  the  destroyed  portion  having  been  the  seat  of  low- 
ered vitality.  The  reason  for  the  lowered  vitality  of  the  gastric  mucous  mem- 
brane is  uncertain.  Thrombosis  has  been  suggested  as  a  cause,  but  it  is  rare 
in  gastric  ulcer.  Embolism  is  assigned  by  some  as  a  cause,  but  emboli  are 
seldom  found  on  pathological  examination.  It  has  been  asserted  that  men- 
strual disorders  may  be  responsible  for  ulcer,  that  tight  lacing  may  be,  and 
that  habitually  bending  over  (as  in  making  shoes)  may  be  a  cause.  The  Alayos 
are  of  the  opinion  that  the  grinding  action  of  the  pyloric  portion  of  the  stomach 
may  be  a  traumatic  exciting  cause  of  ulcer  of  that  region.  Some  assert  that 
mental  anxiety,  alcoholism,  and  syphilis  may  be  causal  (Alderson).  Thirty- 
two  per  cent,  of  the  cases  in  the  Mayo  Clinic  used  alcohol.  Ulcers  due  to 
syphilis  and  tuberculosis  are  not  peptic  ulcers. 

Robson  believes  that  gastric  ulcer  is  septic  in  origin,  and  that  oral  sepsis 
is  responsible  for  its  origin  in  most  cases.  "Mild  sepsis  leads  to  gastritis  and 
hyperchlorhydria,  which  in  its  turn  provokes  and  keeps  up  ulceration"  (A.  W. 
Mayo  Robson,  in  "Keen's  Surgery,"  vol.  iii).  In  140  cases  studied  by  Smithies 
in  the  Mayo  clinic  ("Collected  Papers  by  the  Staflf  of  St.  Mary's  Hospital," 
Mayo  Clinic,  191 2)  26  had  had  enteric  fever,  6  pneumonia,  5  syphilis,  8  malaria, 
and  27  some  other  general  infection.  Twelve  had  previously  been  operated  upon 
for  appendicitis  and  2  for  gall-stones.  Some  observers  blame  direct  damage 
to  the  mucous  membrane  by  traumatism  or  the  swallowing  of  corrosive  liquid. 
The  question  of  cause  is  involved  in  uncertainty.  What  does  seem  to  be  cer- 
tain is  that  anemia  predisposes  to  the  formation  of  very  acid  gastric  juice 
{hyperchlorhydria)  and  to  ulceration.  In  some  cases  chlorosis  is  associated  with 
ulcer.  According  to  Wm.  J.  Mayo  there  are  three  known  causal  factors  of  the 
first  importance,  viz.,  anemia,  hyperchlorhydria,  and  traumatism  (April  16, 
1904). 

It  used  to  be  stated  that  ulcers  are  far  more  common  in  females  than  in 
males.  This  statement  is  not  correct.  It  applies  to  acute  ulcers,  but  not  to 
chronic  ulcers.  Up  to  July  i,  191 2,  the  Mayos  had  operated  on  404  proved 
ulcers  of  the  stomach,  and  over  70  per  cent,  of  these  patients  were  males 
(Smithies,  in  "Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,"  IMayo 
Clinic,  1 91 2).  The  acute  round  ulcer  is  vastly  more  common  in  women,  and  in 
young  women  rather  than  in  those  of  middle  or  advanced  age.  The  chronic 
indurated  ulcer  is  most  frequent  in  men.  ]Men  about  forty,  and  women  between 
twenty  and  thirty  are  particularly  liable.  Between  thirty  and  forty  is  the 
period  of  greatest  liability.  I  have  only  once  found  ulcer  in  a  person  under 
twenty,  but  ulcers  do  occur  in  children  and  even  in  infants.  There  is  usually  a 
single  ulcer,  but  in  one-fifth  of  all  cases  there  are  two  or  more,  and  when  there  is 

^  There  is  an  admirable  collective  Review  of  Gastric  and  Duodenal  Ulcer,  by  R.  C.  Coffey, 
in  the  "Internat.  Abstract  of  Surgery,"  March,  1917. 


Symptoms  of  Ulcer  of  the  Stomach  1095 

an  ulcer  on  the  anterior  wall,  it  is  not  uncommon  to  find  one  exactly  opposite 
on  the  posterior  wall  (a  kissing  nicer  JMoynihan  calls  it).  The  Mayos  divide 
ulcers  into  two  clinical  forms — the  indurated  and  the  non-indurated.  In  the 
indurated  ulcer  all  the  coats  of  the  stomach  are  involved,  and  the  mass  of  scar- 
tissue  indicates  an  effort  at  repair.  The  most  common  situation  for  this  form  of 
ulcer  is  the  region  of  the  pylorus  (Wm.  J.  ]\Iayo,  in  ''Jour.  Am.  ]Med.  Assoc," 
Oct.  21,  1905).  The  non-indurated  ulcer  involves  the  mucous  coat  only  and 
may  be  of  microscopical  size,  and  even  a  microscopical  ulcer  may  cause  death 
from  hemorrhage.  These  non-indurated  ulcers  exhibit  no  sign,  or  almost  no 
sign,  on  the  outer  surface  of  the  stomach,  and  may  not  be  detected  even  when  the 
stomach  is  opened  by  the  surgeon.  The  non-indurated  ulcers  are  divided  into 
the  mucous  erosions  of  Dieulafoy  {exulceratio  simplex),  in  which  the  superficial 
epithelium  only  is  involved,  and  the  true  round  fissured  peptic  ulcers  (Wm.  J. 
Mayo,  in  '"Jour.  Am.  ]\Ied.  Assoc,"  Oct.  21,  1905).  Both  conditions  are  rare. 
Ulcers  are  also  divided  into  acute  ulcers,  which  progress  rapidly  and  produce 
definite  symptoms,  and  chronic  ulcers,  which  are  usually  chronic  from  the 
beginning,  but  which  may  exhibit  acute  exacerbations,  and  may  have  periods  of 
great  relief  or  apparent  cure  (Wm.  J.  Mayo,  in  ''Med.  Record,"  August  6,  1904). 
The  most  common  seats  of  ulcers  are  the  posterior  w^all  and  lesser  curvature, 
especially  in  the  pyloric  region;  in  fact,  80  per  cent,  occur  in  the  pyloric  region. 
An  ulcer  may  heal  or  may  perforate.  Only  i  or  2  per  cent,  of  ulcers  on  the  pos- 
terior wall  perforate,  as  they  tend  to  form  adhesions  to  adjacent  structures. 
Ulcers  on  the  anterior  wall  are  unusual,  do  not  tend  to  form  adhesions,  and  are 
apt  to  perforate.  It  is  not  uncommon  to  have  ulcer  of  the  first  portion  of  the 
duodenum  associated  ^^ith  gastric  ulcer.  An  ulcer  may  be  accompanied  or 
followed  by  fibromatosis  which  gives  a  deceptive  likeness  of  cancer  (see  page 
1089).  Gastric  ulcer  is  at  least  four  times  as  frequent  in  England  as  in  the 
United  States.  In  2830  autopsies  made  in  the  Philadelphia  Hospital  there  were 
40  gastric  ulcers,  and  in  3763  autopsies  made  in  four  Philadelphia  institutions 
there  were  51  gastric  ulcers — a  percentage  of  1.35.  (See  A.  P.  Francine,  in 
"Proceedings  Phila.  County  ]\Ied.  Soc,"  ^larch  31,  1905.) 

Ulcer  is  a  frequent  cause  of  cancer  (page  1090). 

Symptoms. — In  an  acute  ulcer  the  symptoms  are  often  t\'pical;  there  are 
pain,  tenderness  on  pressure,  slight  or  distinct  unilateral  muscular  rigidity, 
vomiting,  hemorrhage,  and  h\-perchlorhydria.  In  a  chronic  ulcer  the  symp- 
toms may  be  clear,  may  be  misleading,  may  be  variable,  and  in  some  cases  even 
absent  {latent  ulcer).  In  ulcer  dyspepsia  usually  exists.  It  is  usually  but  not 
always  acid  dyspepsia,  and  is  associated  mth  much  flatulence.  In  most  cases, 
though  not  in  all,  food  promptly  causes  pain.  There  is  a  gna^^dng  sensation 
{hunger-pain)  when  the  stomach  is  empty,  and  there  may  be  actual  pain.  The 
taking  of  food  may  temporarily  relieve  pain,  but  as  gastric  peristalsis  arises 
and  perhaps  as  quantities  of  gastric  juice  are  poured  out  to  digest  the  food 
the  pain  increases.  A  small  quantity  of  bland  food  may  relieve  pain  and  a 
larger  quantity  or  coarser  food  may  cause  pain.  If  h^-perchlorhydria  disappear 
(as  it  may  do  from  chronic  gastritis  and  does  from  gastric  dilatation  following 
pyloric  obstruction),  pain  may  not  be  increased  during  digestion.  In  ulcers  of 
the  cardiac  end  and  lesser  curvature  gnawing  uneasiness  is  but  briefly  or  not  at 
all  relieved  by  taking  food  and  pain  develops  immediately  or  almost  at  once 
after  eating.  In  ulcer  of  the  pyloric  region  the  gnawing  uneasiness  may  be 
distinctly  relieved  by  taking  food,  but  within  an  hour  or  two  pain  is  apt  to  be- 
come severe.  The  time  after  eating  when  pain  occurs  may  not  be  constant 
in  a  case.  In  ulcer  the  pain  is  paroxysmal.  It  is  at  times  very  \'iolent  in  the 
epigastric  region,  and  may  pass  to  the  back,  being  located  between  the  eighth 
and  ninth  dorsal  vertebr£e  to  one  side  of  the  back  (the  right  most  often),  into  the 
esophagus,  into  the  chest,  to  the  left  side  of  the  abdomen,  or  to  the  top  of  the 
ensiform  process. 


1096  Diseases  and  Injuries  of  the  Abdomen 

In  gastric  ulcer  it  is  usual  to  find  distinct  or  severe  tenderness  developed  by 
epigastric  pressure,  and  tenderness  is  associated  with  more  or  less  rigidity.  In 
ulcer  of  the  lesser  curvature  pain  and  tenderness  are  in  the  neighborhood  of  the 
left  costal  margin.  In  ulcer  of  the  pylorus  they  are  above  the  umbilicus  in  or 
to  the  right  of  the  midline.  Vomiting  usually  relieves  the  pain,  so  does  lavage, 
so  does  the  administration  of  an  alkali.  In  ulcers  of  the  anterior  wall  tender- 
ness is  most  acute.  In  many  of  these  patients  vomiting  occurs  about  two 
hours  after  eating.  The  vomited  matter,  as  a  rule,  contains  much  hydrochloric 
acid  and  the  vomiting  usually  relieves  the  pain.  Examination  of  the  gastric 
contents  after  the  administration  of  a  test-meal  shows  in  about  80  per  cent,  of 
the  cases  hyperacidity.  Obvious  hemorrhage  from  the  stomach  occurs  in  less 
than  one-half  of  the  cases,  and  from  3  to  8  per  cent,  of  cases  actually  die  of  hem- 
orrhage. Wm.  J.  Mayo  states  that  "more  than  90  per  cent,  of  hemorrhages 
from  the  stomach  are  from  chronic  ulcers  with  a  well-marked  ulcer  history" 
("Surg.,  Gynec,  and  Obstet.,"  May,  1908).  The  blood  may  be  brought  up 
wjth  food,  and  is  then  black  and  clotted,  or  may  be  vomited  clear  and  in  large 
amount.  Blood  may  be  present  in  vomited  matter  or  stools  in  such  small 
amount  that  its  presence  is  observed  by  the  microscope  only.  The  demonstra- 
tion in  the  feces  of  minute  quantities  of  blood  (occult  blood)  is  important  diag- 
nostically.  It  may  be  demonstrated  by  the  guaiacum  test  or  the  aloin  test. 
For  two  days  before  this  test  the  patient  must  not  eat  rare  meat,  sausages,  or 
fish.  Blood  in  the  stools  does  not  prove  the  existence  of  gastric  ulcer.  The 
blood  may  have  come  from  any  spot  from  the  mouth  to  the  anus.  As  Wm.  J, 
Mayo  ("Surg.  Gynec,  and  Obstet.,"  May,  1908)  says:  "Visible  or  occult 
blood  in  the  stool  affords  proof  as  to  the  fact  that  there  is  blood,  but  it  should 
never  be  lost  sight  of  that  it  bears  with  it  no  evidence  as  to  its  exact  gastro- 
intestinal origin.  The  patient  may  have  bleeding  gums  or  hemorrhage  from 
some  slight  abrasion  in  any  part  of  the  many  feet  of  mucous  membrane  which 
exist  between  the  lips  and  the  anus.  If  occult  blood  is  found  by  one  chemical 
test,  it  must  be  corroborated  by  others,  as  some  unsuspected  food  or  drug  may 
give  rise  to  the  reaction. 

"As  a  matter  of  fact,  hemorrhage  from  ulcer  is  by  no  means  of  frequent 
occurrence.  The  base  of  the  ulcer  is  clean  and  free  from  granulation  tissue,  so 
that  bleeding  may  be  infrequent.  Careful  examination  of  the  stools  for  manv 
days  may  be  necessary  to  detect  its  presence." 

In  hemorrhage  from  an  acute  ulcer  a  pint  or  two  may  be  ejected  in  a  few  min- 
utes, and  such  a  patient  presents  all  the  general  symptoms  of  dangerous  hemor- 
rhage. When  an  ulcer  bleeds  the  blood  is  far  more  apt  to  be  vomited  than 
passed  by  the  bowels,  but  in  some  cases  blood  from  the  stomach  is  passed 
by  the  bowels  in  part  or  wholly.  A  very  large  hemorrhage  may  occur,  and  yet 
the  bleeding  never  be  repeated,  or  a  large  hemorrhage  may  be  followed  by 
another  or  be  the  first  of  three  or  of  a  series.  In  a  great  many  cases  after  a  large 
hemorrhage  there  is  no  further  bleeding  or  there  are  subsequently  a  few  small 
hemorrhages.  Small  hemorrhages  may  occur  indefinitely,  and  may  after  a  time 
eventuate  in  a  large  hemorrhage.  In  chronic  ulcer  in  which  small  hemorrhages 
recur  over  a  long  period  the  condition  is  due  to  bleeding  from  congested  mucosa, 
dilated  veins,  or  to  the  erosion  of  small  vessels  which  cannot  contract  or  retract 
because  they  are  embedded  in  fibrous  tissue.  A  large  hemorrhage  may  be  due 
to  the  erosion  of  a  large  vessel,  but  is  often  produced  by  the  existence  of  a  great 
number  of  erosions  of  the  mucous  membrane,  erosions  perhaps  so  numerous 
that  blood  seems  to  pour  from  every  portion  of  the  mucous  surface.  We  speak 
of  such  erosions  as  the  erosions  of  Dieulafdy  or  exidceratio  simplex.  It  is  usu- 
ally stated  that  in  a  sudden  acute  violent  hemorrhage  there  will  probably 
be  no  history  of  antecedent  stomach  trouble,  but  Wm.  J.  Mayo  is  of  the  opin- 
ion that  "a  single  hemorrhage  from  a  patient  who  has  not  had  previous 
gastric  symptoms  is  probably  not  due  to  ulcer"   (Ibid.).     It  may  arise  from 


Symptoms  of  Ulcer  of  the  Stomach  1097 

rupture  of  veins  about  the  cardia  or  from  blood  from  hemoptysis  having  been 
swallowed. 

In  a  chronic  ulcer  it  is  sometimes,  though  seldom,  possible  to  palpate  the 
indurated  area. 

Constipation  exists  in  at  least  90  per  cent,  of  cases.  There  is  often  very 
marked  anemia,  aggravated  and,  some  think,  occasionally  cause  by  continued 
loss  of  blood.  Indigestion  aggravates  anemia  and  also  may  cause  it.  Most 
cases  complain  of  prolonged  indigestion.  There  is  often  a  tender  area  in  the  back 
a  little  to  the  side  of  the  eighth  and  ninth  dorsal  spines  (usually  the  right  side). 
A  triangular  area  of  hvperesthesia  may  be  found  in  the  left  epigastric  region 
(Head). 

If  the  ulcer  does  not  cicatrize,  but  progresses,  causing  pain  and  hemorrhage, 
the  patient  usually  becomes  thinner,  more  anemic,  weaker,  and  even  exhausted. 
In  140  cases  in  the  Mayo  clinic  studied  by  Smithies  ("Collected  Papers  by  the 
Staff  of  St.  Mary's  Hospital,"  Mayo  Clinic,  191 2)  107  showed  loss  of  weight. 
The  average  loss  of  weight  was  20  pounds.  The  maximum  loss  observed  was 
65  pounds  in  six  months.     The  average  hemoglobin  finding  was  72  per  cent. 

It  is  certain  that  many  cases  of  gastric  ulcer  are  unrecognized;  in  fact,  as 
Habershon  says,  diagnosis  is  rarely  made  unless  hemorrhage  exists,  and  in 
certain  latent  cases  both  vomiting  and  bleeding  are  absent.  It  is  believed  by 
some  that  latent  ulcers  are  even  more  common  than  are  ulcers  causing  symp- 
toms. Hall  ("Am.  Jour,  of  Med.  Sciences,"  May,  1909)  says:  "Rather  than 
look  too  narrowly  for  exactly  this  or  that  evidence,  we  should  take  the  broader 
ground  that  ulcer  probably  exists  in  most  patients  complaining  of  persistent 
indigestion,  even  though  not  of  an  acid  character,  if  pain,  tenderness,  vomiting 
and  rigidity,  or  two  or  three  of  these  phenomena  be  present,  and  even  though 
hyperacidity  be  not  proved."  A  bleeding  ulcer  with  palpable  thickening  of  the 
pylorus,  especially  if  there  be  anemia  and  loss  of  weight,  is  frequently  mistaken 
for  cancer.  Fibromatosis  of  the  stomach  with  or  without  ulcer  is  usually  diagnos- 
ticated as  cancer.  This  condition  was  fully  described  by  Alexis  Thomson  at 
the  1913  meeting  of  the  American  Surgical  Association.  The  entire  stomach 
may  be  indurated.  It  is  cases  like  the  above  that  may  get  well  after  gastro- 
enterostomy and  thus  furnish  the  first  proof  that  the  condition  was  not  cancerous 
(see  page  1089).  The  diagnosis  of  ulcer  is  far  less  dif3[icult  when  there  is  food 
retention  than  when  there  is  not. 

The  fiuoroscope  may  aid  in  the  diagnosis.  Skiagraphs  after  a  bismuth  or 
barium  meal  give  highly  important  information  as  to  the  existence  of  scars,  con- 
traction of  the  pylorus,  dilated  stomach,  and  hour-glass  stomach.  In  many 
cases  it  is  impossible  to  make  a  differential  diagnosis  between  pyloric  ulcer  and 
duodenal  ulcer.  In  duodenal  ulcer  the  pain  and  tenderness  are  above  the 
umbilicus  and  in  the  midline  or  to  the  right,  and  if  the  duodenal  ulcer  bleeds 
the  blood  is  most  apt  to  pass  by  the  bowel,  but  vomiting  of  blood  is  not  unusual. 
A  small  percentage  of  duodenal  ulcers  also  involve  the  pylorus. 

A  gastric  ulcer  may  cicatrize  and  thus  be  cured,  but  the  cure  of  the  ulcer 
may  prove  the  ruin  of  the  stomach  by  producing  stenosis  of  one  of  the  stomach 
orifices  or  hour-glass  contraction  of  the  body  of  the  stomach.  Ap  ulcer  may 
perforate.  Perforation  occurs  in  about  15  per  cent,  of  cases  (Robson).  A 
perforation  may  be  acute;  that  is,  the  ulcer  suddenly  breaks  open  when  the 
stomach  contains  food  or  liquid,  and  the  contents  of  the  stomach  are  poured 
into  the  free  peritoneal  cavity.  A  subacute  perforation  occurs  when  the  stomach 
is  empty  or  nearly  empty.  The  opening  is  small  in  size,  there  is  no  escape 
of  stomach  contents  or  the  escape  of  only  a  small  amount,  and  the  opening 
may  be  quickly  closed  by  adhesion  to  an  adjacent  surface  of  peritoneum  or  to  a 
piece  of  omentum.  If  a  certain  amount  of  stomach  contents  is  extravasated, 
it  is  usually  surrounded  by  adhesions  or  tracks  slowly  toward  the  pelvis.  In 
what  is  known  as  a  chronic  perforation  the  break  takes  place  usually  in  the 


1098  Diseases  and  Injuries  of  the  Abdomen 

posterior  wall  into  a  box  of  preformed  adhesions,  the  extruded  gastric  contents 
are  circumscribed  by  these  adhesions,  the  general  peritoneal  cavity  is  not 
invaded,  but  circumscribed  suppuration  is  inaugurated.'  This  condition  is 
known  as  perigastric  abscess,  and  the  subphrenic  form  is  the  commonest.  In 
such  a  case  the  abscess  may  break  into  the  pleural  cavity  or  even  into  the 
lung.  I  operated  on  a  girl  of  sixteen  and  found  a  perigastric  abscess  and  a  per- 
foration of  the  anterior  wall  near  the  pylorus,  and  this  condition  was  tubercu- 
lous.    A  fistula  persisted  for  months,  but  finally  healed. 

Perforation  is  generally  preceded  by  a  history  of  indigestion,  but  it  may  come 
on  without  a  suggestion  of  antecedent  stomach  trouble,  is  usually  brought  about 
by  muscular  effort,  and  is  most  common  after  a  full  meal,  but  it  may  occur  when 
the  patient  is  perfectly  quiet  and  has  not  eaten  for  some  tine.  The  real  cause 
is  spasm  of  the  pylorus  which  causes  tension  of  the  stomach  walls  and  keeps 
the  viscus  from  emptying.  Pyloric  spasm  is  very  common  in  sufferers  from 
ulcers.  In  acute  perforation  food  is  the  most  active  cause;  in  chronic  perfora- 
tion, muscular  effort.  "The  severity  of  the  symptoms  depends  upon  several 
conditions:  the  previous  state  of  health,  the  size  and  number  of  the  perfora- 
tions, the  condition  of  the  stomach,  whether  full  or  almost  empty,  the  bacterial 
virulence  of  its  contents,  and  the  occurrence  of  vomiting."-  The  situation  of 
the  ulcer  has  some  influence  on  the  symptoms.  "  If  in  the  fundus,  at  the  cardiac 
end,  or  in  the  body  of  the  stomach,  an  acute  infection  of  the  whole  peritoneal 
cavitv  rapidly  follows;  if  the  ulcer  be  at  the  pylorus  or  in  the  first  portion  of  the 
duodenum,  the  fluid  is  directed  down  the  right  side  of  the  abdomen,  owing 
to  the  hillock  formed  by  the  transverse  mesocolon  at  the  pyloric  end  of  the 
stomach."^  In  such  a  case  the  fluid  may  gravitate  toward  the  right  iliac 
region  and  the  condition  may  be  mistaken  "for  appendicitis.  In  a  case  of  sub- 
acute perforation  I  operated,  believing  that  appendicitis  existed.  Alderson 
calls  attention  to  the  fact  that  the  sudden  perforation  of  an  ulcer  may  be  mis- 
taken for  poisoning,  and  he  cites  the  death  of  Henrietta,  Duchess  of  Orleans, 
in  1670. 

Acute  perforation  can  be  certainly  diagnosticated  if  the  case  is  seen  early. 
Such  an  emergency  has  usually,  but  not  invariably,  been  preceded  by  positive 
and  prolonged  symptoms  of  gastric  disorder.  It  causes  sudden  and  intensely 
violent  epigastric  pain,  greatly  increased  by  swallowing  fluids,  by  vomiting, 
by  turning  the  body,  by  cough,  by  inspiration,  and  by  pressure.  This  pain 
may  radiate  throughout  the  abdomen,  but  the  chief  tenderness  is  in  the  region 
of  the  stomach.  The  seat  of  the  pain  after  perforation  does  not,  of  necessity, 
correspond  to  the  seat  of  perforation.  Vomiting  occurs  in  about  half  the  cases 
after  rupture.  When  it  does  occur  it  comes  on  soon  after  the  pain,  may  recur 
again  and  again,  and  does  much  harm  by  increasing  shock  and  by  ejecting 
gastric  contents  into  the  peritoneal  cavity.  Vomiting  of  blood  is  very  un- 
usual. In  many  cases  there  is,  singularly,  little  shock.  Even  when  severe 
shock  exists  its  duration  is  usually  temporary.  This  important  fact  is  insisted 
on  by  Eliot  ("Annals  of  Surgery"  May,  191 2).  Board-like  rigidity  exists,  and 
it  is  most  marked  in  the  upper  portion  of  the  abdomen.  The  area  of  liver 
dulness  is  in,  some  cases  diminished  and  in  exceptional  cases  obliterated.  This 
symptom  is  due  to  gas  passing  into  the  peritoneal  cavity  and  getting  between 
tire  liver  and  the  parietal  peritoneum.  It  is  seldom  present  after  pyloric 
perforation  or  when  the  stomach  at  the  time  of  the  perforation  contained  very 
little  food.  It  is  when  perforation  is  far  from  the  pylorus  and  when  the  stomach 
contains  fermenting  food  that  enough  gas  escapes  to  diminish  liver  dulness 
(Eliot,  Ibid.).  The  sign  is  most  significant  when  the  abdomen  is  flat.  There 
may  be  dulness  in  one  flank  or  both  flanks  due  to  fluid.     Eliot  (Ibid.)  lauds 

'  See  paper  by  B.  G.  A.  Moynihan,  "Brit.  Med.  Jour.,"  Jan.  31,  1903. 

2  Moynihan,  in  "Brit.  Med.  Jour.,"  Jan.  31,  1903. 

3  See  paper  by.  B.  G.  A.  Moynihan,  in  "Brit.  Med.  Jour.,"  Jan.  31,  1903. 


Treatment  of  Ulcer  of  the  Stomach  io99 

auscultation  as  an  aid  to  detecting  small  amounts  of  fluid,  and  calls  attention 
to  Shoemaker's  symptom,  that  is,  a  dull  note  on  light  percussion  giving  way  to 
a  tympanitic  note  when  the  percussed  finger  is  pressed  firmly  against  the  abdomi- 
nal wall,  thus  coming  nearer  to  the  intestine  by  pushing  fluid  away.  The  pulse 
may  be  ver}^  rapid,  but  often  shows  curiously  little  disturbance.  Some  few 
cases  die  rapidly  in  shock,  but,  as  a  rule,  reaction  occurs  and,  if  operation  be 
delayed,  peritonitis  arises.  Acute  perforation  of  the  stomach  may  be  in  cer- 
tain cases  mistaken  for  appendicitis,  cholecystitis,  or  hemorrhagic  pancreatitis. 
If  a  patient  with  acute  perforation  be  not  promptly  operated  upon,  he  will  soon 
exhibit  the  symptoms  of  general  peritonitis.  Subacute  perforation  causes  less 
violent  symptoms  and  they  come  on  more  gradually.  There  is  in  the  beginning 
severe  but  not  agonizing  pain,  which  gradually  abates.  Moynihan  points 
out  that  there  is  gastric  uneasiness  for  several  days  before  the  perforation. 
Peritonitis  develops  slowly  and  the  chief  symptoms  are  often  pelvic.  Chronic 
perforation  gives  the  signs  and  symptoms  of  perigastric  abscess. 

Treatment. — Medical  Treatment  of  Non-perforated  Ulcer. — Rest  in  bed. 
It  is  necessary  to  abandon  stomach  feeding  for  a  time.  For  seven  to  ten  days 
give  nothing  whatever  by  the  mouth  and  give  an  enema  of  lo  oz.  of  normal 
salt  solution  every  sixth  hour.  This  is  preferable  to  a  nutritive  enema  because 
every  time  a  nutritive  enema  is  given  a  flow  of  gastric  juice  takes  place  into  the 
stomach.  (See  W.  Pasteur,  in  "Lancet,"  May  21,  1904;  Seymour  J.  Sharkey, 
in  "Lancet,"  Nov.  10,  1906.)  During  this  treatment  the  patient  is  usually 
comfortable  and  is  not  unbearably  disturbed  by  hunger  and  thirst.  At^  the 
end  of  a  week  or  ten  days  pancreatinized  or  peptonized  mflk  is  cautiously  given 
by  the  mouth.  According  to  some,  nutritive  enemata  should  now  be  substituted 
for  sahne  enemata  and  be  given  for  a  few  days  before  stomach  feeding  is  insti- 
tuted. After  rectal  enemata  (saline  and  nutritive)  have  been  abandoned  the 
patient  is  placed  on  a  very  bland  diet,  preferably  pancreatinized  mflk,  and 
lavage  is  given  twice  a  day.  The  value  of  introducing  food  into  the  rectum  is, 
to  say  the  least,  doubtful.  Saline  fluid  and  certain  drugs  are  absorbed  from 
the  rectum,  but  little  if  any  protein  matter  is  absorbed.  Investigators  are 
now  seeking  for  some  form  of  digested  protein  matter  that  will  be  absorbed. 
Protein  material  when  in  the  rectum  is  not  acted  upon  by  the  enzymes  necessary 
for  its  absorption,  it  undergoes  putrefaction,  causes  irritation,  and  sets  free 
toxic  alkaloids  which  are  absorbed.  It  is  suggested  that  digested  albumin  and 
fat  and  grape-sugar  may  be  absorbed.  In  some  cases  of  ulcer  Carlsbad  salts 
are  given  by  the  mouth  (Ziemssen);  in  others,  silver  nitrate  with  extract  of 
I)elladonna,  bismuth  subnitrate,  or  oxalate  of  cerium.  If  pain  is  severe,  opium 
may  be  required.  Many  cases  are  apparently  cured  by  medical  treatment. 
Russel's  statistics  show  that  40  per  cent,  of  cases  were  reported  cured  under 
medical  treatment,  but  no  one  knows  how  many  of  those  reported  cured  again 
gave  evidence  of  the  disease  or  later  perished  because  of  hemorrhage  or  per- 
foration. Further,  18  per  cent,  of  the  500  London  Hospital  cases  under  med- 
ical treatment  died  and  42  per  cent,  were  not  cured  when  discharged.  Out  of 
the  supposed  40  per  cent,  of  cures  many  later  undoubtedly  developed  or  will 
develop  renewed  symptoms  and  perhaps  fatal  conditions. 

Medical  Treatment  for  Gastrorrhagia  {Hemorrhage  from  the  Stomach). — Some 
claim  that  surgical  treatment  is  not  to  be  employed  in  gastric  hemorrhage  and 
that  statistics  are  decidedly  against  it.  I  beheve  this  statement  to  be  correct. 
Kraft's  table,  which  was  pubhshed  in  1910,  gives  83  cases  operated  upon  with 
30  deaths,  a  mortality  of  37  per  cent.  (Lindenberg,  see  "Lancet,"  Dec.  5,  1914)- 
Tindenberg  (Ibid.)  looked  up  the  records  of  68  cases  of  acute  hemorrhage  treated 
medicafly  in  the  chnic  of  Faber  of  Copenhagen.  There  were  five  deaths  (a 
mortality  of  7.3  per  cent.)  and  he  does  not  believe  operation  could  have  saved 
one  of  the  five.  Some  treat  stomach  bleeding  by  morphia,  and  adrenalin  by  the 
jnouth.     Serum  may  be  useful.     Transfusion  of  blood  may  save  life. 


iioo  Diseases  and  Injuries  of  the  Abdomen 

I  believe  Lindenberg's  plan  to  be  valuable  ("Lancet,"  Ibid.)-  I  have  em- 
ployed it  with  apparent  success.  It  is  as  follows:  Raise  the  foot  of  the  bed. 
Give  no  salt  solution  intravenously  and  give  no  stimulants,  because  each  would 
raise  blood  pressure  and  retard  clotting.  Give  no  morphia.  It  arrests  the 
spasm  of  the  gastric  muscle  which  helps  to  stop  the  bleeding.  No  food  is  to 
be  given  by  stomach  for  several  days.  Put  into  the  stomach  daily  -with  a  small 
tube  IOC  c.c.  of  a  I  per  cent,  solution  of  ferric  chlorid;  let  the  patient  lie  first 
supine  and  then  prone  and  remove  the  fluid  by  aspiration  (Bourget's  plan). 

Once  a  day  give  subcutaneously  40  c.c.  of  a  10  per  cent,  solution  of  gelatin 
the  fluid  being  at  a  temperature  of  40°  C. 

Surgical. — The  exact  curative  value  of  operation  is  not  settled.  Kron- 
lein's  clinic  claims  85  per  cent,  cures,  Von  Eiselsberg's  clinic  but  52  per  cent,  of 
cures  and  15  per  cent,  of  improvements.  The  nearer  the  ulcer  is  to  the  pylorus, 
the  better  the  chance  of  cure.  Following  the  Mayos,  we  would  not  advdse  sur- 
gical treatment  in  acute  ulcer  unless  complicated  by  hemorrhage,  perforation, 
or  obstruction;  or  in  chronic  ulcer,  until  careful  medical  treatment  has  failed. 
Operation  is  indicated  for  chronic  ulcer  when  a  mechanical  cause  is  responsible 
for  retention  and  stagnation  of  stomach  contents,  and  in  certain  cases  of  hemor- 
rhage. Operation  is  also  indicated  in  chronic  ulcer  with  frequent'  exacer- 
bations, but  the  surgeon  should  be  very  chary  of  operating  upon  neurotic 
women  with  gastroptosis  unless,  of  course,  there  be  a  positive  indication  (Wm. 
J.  Mayo,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  21,  1905). 

In  a  chronic  ulcer  if  the  patient  grows  worse  in  spite  of  careful  dietetic 
and  medical  treatment,  if  hemorrhage  has  been  profuse  or  if  there  have  been 
frequent  distinct  hemorrhages,  if  the  pain  is  violent,  or  if  tenderness  is  marked, 
open  the  abdomen  and  inspect  the  stomach.  An  ulcer  with  indurated  edges  is 
easily  found.  The  form,  called  by  the  Mayos  the  non-indurated  ulcer,  gives  no 
evidence  or  little  evidence  of  its  existence  when  the  outer  coat  of  the  stomach 
is  felt  and  inspected  (Wm.  J.  Mayo,  Ibid.).  Even  when  the  stomach  is  opened, 
no  ulcer  may  be  found.  According  to  Mikulicz,  in  some  mucous  ulcers  there 
is  a  verv  little  thickening,  and,  according  to  Moynihan,  the  mucous  coat  may 
be  a  little  adherent  to  the  muscular  coat,  so  that  it  does  not  slide  easily.  An 
enlarged  gland  in  a  portion  of  the  omentum  may  be  a  sign  of  ulcer  (Lund).  An 
indurated  ulcer  may  be  removed  by  an  elliptical  incision  in  the  long  axis  of  the 
stomach,  the  coats  being  sutured  by  the  usual  method,  and  gastro-enteros- 
tomy  being  also  performed.  Balfour  uses  the  cautery  to  effect  excision.  It 
leaves  a  smaller  opening  than  the  knife  and  the  wound  heals  well.  In  ulcer  of 
the  pylorus  with  great  thickening  we  may  excise  the  pylorus,  close  both  the  duo- 
denal and  stomach  openings,  and  perform  posterior  gastro-enterostomy.  In 
some  cases  gastro-enterostomy  alone  leads  to  the  cure  of  chronic  ulcer.  The 
Heineke-Mikulicz  operation  is  not  satisfactory  in  ulcer.  Finney's  gastroduo- 
denostomy  is  not  advisable  if  there  be  an  unhealed  ulcer,  because  food  will  con- 
tinue to  pass  over  the  ulcer  after  the  performance  of  this  operation. 

Wm.  J.  Mayo  ("Annals  of  Surgery,"  1910)  has  described  a  transgastric 
method  for  excising  ulcers  of  the  posterior  wall  which  are  adherent  to  the 
pancreas.  The  excision  passes  through  pancreatic  tissue.  Bleeding  is  arrested 
by  suture-ligatures.  The  wound  in  the  pancreas  is  not  sutured,  but  is  closed 
by  a  mobilized  portion  of  gastrohepatic  or  of  gastrocolic  omentum. 

A  strong  argument  in  favor  of  excision  of  ulcers  instead  of  gastro-enteros- 
tomy alone  is  the  frequency  with  which  ulcer  gives  origin  to  cancer.  Instead 
of  excising  an  ulcer  it  may  be  destroyed,  as  Balfour  suggested,  by  the  actual 
cautery  ("Surgery,  Gynecology,  and  Obstetrics,"  1914,  xix).  This  plan  is  espe- 
cially valuable  on  the  lesser  curvature  and  the  posterior  wall. 

Operation  for  Gastrorrhagia. — Rydygier  proposed  in  1882  to  operate  for 
hemorrhage.  The  first  operation  was  done  by  Mikuhcz  in  1887,  and  the  first 
successful  operation  was  reported  by  Roux  in  1893.  It  may  be  wise  to  trans- 
fuse blood  before  operating. 


Treatment  of  Ulcer  of  the  Stomach  iioi 

In  acute  and  violent  hemorrhage  threatening  life  the  proper  course  to 
pursue  is  somewhat  uncertain.  It  is  not  proper  to  operate  if  there  has  been 
but  one  hemorrhage,  because  the  chances  are  that  the  bleeding  will  not  be 
repeated.  Again,  the  chance  of  arresting  such  a  hemorrhage  bv  operation  is, 
on  the  whole,  poor.  The  danger  of  waiting  after  one  hemorrhage  is  not  so 
great  as  the  danger  of  immediately  operating,  because  collapse  antagonizes 
renewed  hemorrhage,  but  adds  enormously  to  the  risk  of  an  operation.  In 
over  90  per  cent,  of  cases  the  hemorrhage  ceases  spontaneouslv.  In  over  18 
per  cent,  of  those  dying  of  hemorrhage  death  is  so  rapid  that  operation  is  im- 
possible (Savariaud).  If  the  bleeding  is  from  a  distinct  ulcer,  we  mav  succeed 
in  excising  the  ulcer  or  in  Hgating  the  bleeding-point.  Roux,  of  Lausanne, 
saved  a  patient  by  excising  an  ulcer  and  ligating  the  bleeding  coronarv  artery 
on  each  side  of  it.  As  a  rule,  however,  the  bleeding  is  not  from  a  distinct  point, 
but  from  a  multitude  of  excoriations.  In  the  light  of  our  present  knowledge 
we  may  lay  down  the  following  rule:  Do  not  operate  for  one  acute  hemorrhage. 
Simply  bring  about  reaction  by  gentle  means,  let  the  patient  take  bits  of  ice,  and 
give  suprarenal  extract  by  the  stomach.  If  the  bleeding  recurs  once  or  twice 
in  comparatively  trivial  amounts,  do  not  operate;  but  if  it  recurs  violentlv,  we 
should  advise  operation.  I  have  been  shaken  in  my  faith  that  we  must  operate 
after  a  second  severe  hemorrhage  by  two  of  my  cases.  In  one  case  a  man  had 
two  tremendous  hemorrhages.  He  was  transfused,  was  treated  bv  Lindenberg's 
plan  (page  11 00)  and  recovered. 

I  was  associated  ^^•ith  my  colleague.  Professor  Hare,  in  the  case  of  a  young 
woman.  She  had  two  immense  hemorrhages,  refused  operation  and  recovered. 
In  cases  of  ulcer  in  which  bleeding  in  small  amounts  persists,  operation  is  indi- 
cated. In  operating  for  a  severe  hemorrhage  the  surgeon  opens  the  abdomen 
while  hot  salt  solution  is  being  thrown  into  a  vein.  The  stomach  is  opened,  the 
clots  washed  out,  and  a  search  made  for  the  source  of  the  blood.  If  it  be  found 
that  the  blood  comes  from  an  area  of  ulceration,  this  area  may  be  extirpated, 
ligated,  or  cauterized  with  the  thermocautery.  Some  advise  surrounding  it 
with  a  purse-string  suture.  Others,  notably  Moynihan,  simply  perform  gastro- 
enterostomy, which  is  of  ser\'ice  by  draining  and  giving  rest  to  the  dilated  stom- 
ach, the  hemorrhage  being  perhaps  arrested  by  contraction  of  the  gastric  walls 
and  the  rest  secured  preventing  the  detachment  of  hemostatic  clot.  Gastro- 
enterostomy is  of  most  service  in  ulcer  near  the  pylorus  and  in  duodenal  ulcer. 
If  the  ulcer  is  well  above  the  pylorus  it  should  be  excised  if  possible.  As  a  rule, 
it  will  be  found  that  the  vessels  entering  the  ulcer  are  varicose.  Excision  is  indi- 
cated because  of  this  varicosity.  If  excision  is  impossible  "the  main  blood-ves- 
sels leading  into  the  ulcer  should  be  ligated  and  the  peritoneum  and  muscular 
coats  drawn  over  it"  (Wm.  J.  Mayo,  in  "Surg.  Gynec,  and  Obstet.,"  May, 
1908),  If  it  be  found  that  the  bleeding  comes  from  a  multitude  of  excoria- 
tions and  that  the  stomach  is,  as  Moynihan  expresses  it,  "weeping  blood,"' 
we  can  do  nothing  but  gastro-enterostomy,  which  in  such  a  condition  is  of  un- 
certain value. 

Operation  for  Perforation. — In  acute  and  subacute  perforation  operate  at 
once,  ha\-ing  all  proper  means  taken  to  bring  about  reaction  from  shock,  while 
the  abdomen  is  being  sterihzed  and  while  ether  is  being  administered  (hot 
sahne  enemata,  external  heat,  atropin  h}-podermatically,  etc.).  As  a  matter  of 
fact,  shock  is  seldom  so  profound  as  to  cause  us  to  hesitate  about  operating. 
I  formerly  adx-ised  to  wait  tmtil  reaction  was  established  before  operating.  I 
now  beheve  such  advice  erroneous.  To  delay  after  an  acute  perforation  is  to 
wait  for  what  may  never  come.  Open  the  abdomen  at  the  point  of  greatest 
tenderness,  or,  if  there  be  no  such  point,  open  it  in  the  epigastric  region,  a  little 
to  the  right  of  the  midline.  When  the  abdomen  is  opened  there  mav  be  an 
escape  of  odorless  gas,  and  food  or  fluid  may  be  discovered  in  the  peri- 
toneal  cavity.     The  perforation    is   sought  for   and  is  usually  found  in  the 


II02  Diseases  and  Injuries  of  the  Abdomen 

anterior  wall.  When  found,  it  should  be  buried  and  overlaid  by  stomach  wall,  a 
portion  of  which  must  be  inverted  by  two  layers  of  Halsted  sutures.  I  do  not 
believe  that  excision  or  paring  the  edges  is  necessary  or  desirable  in  a  case 
of  perforated  ulcer.  If  it  be  too  large  to  close,  stitch  a  plug  of  omentum  into 
the  opening  or  insert  a  tube  and  create  a  temporary  gastrostomy.  If  no  per- 
foration is  found  on  the  anterior  wall,  make  an  opening  into  the  lesser  peritoneal 
cavity  through  the  gastrohepatic  omentum,  the  transverse  mesocolon  or  the  gas- 
trocolic omentum,  explore  the  posterior  wall,  and  close  and  cover  any  perforation 
found.  In  order  to  reach  the  posterior  wall  of  the  stomach  Lardennois  and  Okin- 
czyc  suggested  the  epiplo-enterocolic  method  (see  B.  Sherwood  Dunn,  in  "Am. 
Jour,  of  Surgery,"  Oct.,  igi6).  The  great  omentum  and  its  mesentery  are 
separated  from  the  colon.  When  this  is  done  the  duodenum,  pancreas  and  pos- 
terior wall  of  the  stomach  can  be  quickly  exposed.  In  addition  to  closing  the 
perforation,  gastroenterostomy  is  indicated  theoretically  in  order  to  drain  the 
viscus,  give  it  rest,  and  lessen  the  tendency  to  recurrence  of  ulceration.  But, 
as  a  matter  of  fact,  such  ulcers  seldom  return.  By  the  time  the  perforation  has 
been  closed  the  patient  is  perhaps  too  severely  shocked  to  render  such  an  addi- 
tional operation  justifiable,  and  I  agree  with  Gibbon  that  such  an  operation 
should  be  performed  only  when  there  are  multiple  ulcers  or  when  there  is  pyloric 
constriction  (John  H.  Gibbon,  in  paper  before  the  Tri-State  Med.  Assoc,  of 
Virginia  and  the  Carolinas,  Feb.  23,  24,  1904).  If  Balfour  excises  an  ulcer  he 
prefers  to  do  so  with  the  cautery.  After  closing  the  perforation  the  abdominal 
cavitv  is  irrigated  with  hot  salt  solution,  and  the  space  between  the  liver  and 
diaphragm  is  sponged  out  with  a  gauze  pad  wet  with  hot  salt  solution.  If  the 
case  is  operated  on  many  hours  after  the  perforation,  or  if  the  peritoneum  has  been 
badly  soiled,  drainage  must  be  used,  but  even  in  other  cases  it  is  safest  to  use  it. 
Drainage  is  obtained  by  means  of  a  cigarette  drain  or  a  piece  of  gauze  passed 
to  the  suture  line  in  the  stomach.  In  cases  with  much  extravasation,  especially 
if  the  extravasation  has  reached  the  pelvis,  a  suprapubic  opening  is  made  and 
a  tube  inserted.  •  After  the  patient  has  reacted  from  the  shock  of  the  operation 
he  should  be  placed  in  a  semi-erect  position  to  direct  the  flow  of  infective  mate- 
rial to  the  pelvis,  and  continuous  proctoclysis  should  be  employed  as  in  peritonitis 
(see  page  1162).  The  treatment  of  chronic  perforation  is  the  treatment  of  peri- 
gastric abscess,  and  consists  of  incision  and  drainage.  Of  late,  a  number  of  cases 
of  acute  and  subacute  perforation  have  been  successfully  operated  upon.  IMoy- 
nihan  estimates  that  35-40  per  cent,  of  acute  perforations  recover  after  operation. 
T.  Crisp  English  ("Lancet,"  Nov.  28,  1903)  reported  42  consecutive  gastric 
perforations  operated  on  in  St.  George's  Hospital;  22  recovered. 

Cicatricial  stenosis  of  the  orifices  of  the  stomach  results  from  the 
healing  of  an  ulcer,  the  swallowing  of  a  corrosive  substance,  or  traumatism 
from  a  foreign  body.  Constriction  of  the  cardiac  orifice  is  indicated  by  gradu- 
ally increasing  difficulty  in  swallowing.  After  a  time  the  esophagus  above  the 
stricture  dilates  or  pouches;  the  fluid  food  passes  into  the  stomach,  but  the 
solid  food  lodges  in  the  esophageal  pouch  and  is  soon  regurgitated.  The  site 
of  the  stricture  is  located  by  a  bougie,  and  by  having  the  patient  swallow  while 
auscultating  over  the  esophagus  and  cardiac  end  of  the  stomach.  If  the  con- 
striction be  malignant,  the  patient  will  be  found  to  be  beyond  middle  life,  the 
vomit  is  occasionally  bloody,  emaciation  is  rapid  and  decided,  and  occasionally 
the  supraclavicular  glands  are  enlarged.  A  tumor  of  the  cardiac  end  of  the 
stomach  can  seldom  be  palpated.  If  the  constriction  be  cicatricial,  the  history 
will  indicate  the  cause.  Constriction  of  the  pyloric  orifice  causes  retention 
of  food  and  dilatation  of  the  stomach.  Dyspeptic  symptoms  will  be  found 
to  have  been  long  present.  A  tube  passed  into  the  stomach  permits  of  the 
injection  of  fluid  so  as  to  fill  the  stomach.  When  the  fluid  runs  out  it  contains 
portions  of  undigested  food,  which  was  perhaps  eaten  days  before,  and  measure- 
ment of  the  liquid  shows  that  the  capacity  of  the  stomach  is  enormously  in- 


Congenital  or  Infantile  Hypertrophic  Stenosis  of  the  Pylorus    1103 

creased.  If  hydrogen  be  forced  through  the  tube,  the  outline  of  the  distended 
stomach  is  at  once  made  clear.  The  usual  method  of  distending  the  stomach  is 
by  a  Seidlitz  powder:  two  solutions  are  made;  the  bicarbonate  solution  is  swal- 
lowed at  once,  and  the  tartaric  solution  is  taken  afterward  in  small  amounts 
at  a  time.  Percussion  over  the  distended  stomach  indicates  the  size  of  the 
viscus.  It  is  well  to  remember  that  when  gastric  ulcer  exists  dilatation  of  the 
stomach  can  occur  without  cicatricial  stenosis.  The  cause  in  such  a  case  is 
pyloric  spasm,  or  perhaps  the  atonic  condition  which  may  result  from  anemia 
and  neurasthenia. 

In  malignant  disease  of  the  pylorus  a  tumor  may  often  be  palpated;  there 
are  tenderness  and  considerable  persistent  pain,  great  cachexia  and  emacia- 
tion, absence  of  free  hydrochloric  acid  from  the  gastric  juice,  diminution  of  red 
corpuscles  and  hemoglobin,  and  perhaps  no  increase  of  white  corpuscles  after  a 
full  meal.  There  is  sometimes  enlargement  of  the  supraclavicular  glands.  Vom- 
iting of  bloody  fluid  occurs  in  40  per  cent,  of  the  malignant  cases.  The  use  of  the 
a;-rays  after  a  bismuth  or  barium  meal  is  a  valuable  aid  in  diagnosticating  pyloric 
constriction.  The  diagnosis  of  cardiac  constriction  is  discussed  in  the  section 
on  Stricture  of  the  Esophagus.  In  cicatricial  stenosis  of  the  pylorus  there  may 
be  paroxysms  of  pain,  there  is  no  tenderness,  emaciation  is  not  so  early  in 
onset  or  so  rapid  in  progress,  and  the  supraclavicular  glands  are  never  enlarged. 
Vomiting  occurs,  but  the  ejected  matter  is  not  bloody. 

Treatment. — Cicatricial  cardiac  stenosis  requires  dilatation  with  bougies 
and  the  maintenance  of  the  restored  caliber.  If  dilatation  from,  above  is 
unsatisfactory,  perform  gastrotomy,  push  a  small  bougie  from  the  mouth  into 
the  stomach,  tie  a  string  to  the  bougie,  draw  the  string  through  the  stric- 
ture, use  the  string  as  a  saw  to  cut  the  fibrous  bands,  pass  a  full-sized  bougie, 
close  the  wound  in  the  stomach,  and  maintain  the  caliber  of  the  cardiac  orifice 
by  the  repeated  passage  of  dilating  instruments.  If  no  instrument  can  be  passed 
through  the  stricture  from  above,  perform  a  gastrotomy,  introduce  an  instru- 
ment from  below  and  pass  it  into  the  mouth,  tie  a  string  to  it,  draw  the  string 
into  the  stomach,  and  use  Abbe's  string-saw  (see  page  1066).  If  no  instrument 
can  be  passed  from  below,  convert  the  gastrotomy  into  a  gastrostomy.  In 
malignant  stenosis  of  the  cardia,  gastrostomy,  if  performed  at  all,  should  be 
performed  early.  Jejunostomy  is  a  better  operation.  Cicatricial  pyloric 
stenosis  was  formerly  treated  by  gastrotomy  and  digital  divulsion  of  the  stric- 
ture (Loreta's  opertion) ;  but  this  operation  is  obsolete,  experience  having  shown 
that  recontraction  is  inevitable.  Pyloroplasty  was  until  recently  advocated 
by  many  surgeons.  This  is  known  as  the  Heineke-Mikulicz  operation.  In 
30  per  cent,  of  the  cases  the  symptoms  are  not  relieved  by  pyloroplasty,  a  con- 
dition which  renders  gastro-enterostomy  necessary.  Mayo  points  out  that  in 
such  cases  pyloroplasty  fails  because  the  pylorus  is  on  a  higher  level  than  the 
gastric  pouch,  the  degenerated  muscle  of  the  stomach  is  unable  to  lift  the  food 
from  the  pouch  to  the  pylorus,  and  the  symptoms  of  gastric  dilatation  and  re- 
tardation of  the  passage  of  food  into  the  duodenum  are  not  relieved.  The  opera- 
tion has  been  generally  abandoned.  Finney's  method  of  gastroduodenostomy 
(Figs.  731-734)  is  a  great  improvement  on  pyloroplasty.  The  opening  is  large 
and  in  a  proper  position  to  afford  satisfactory  drainage.  Gastro-enterostomy 
is  the  most  satisfactory  operation  in  most  cases  and  usually  effects  a  cure. 
Malignant  stenosis  is  treated  by  pylorectomy  or  gastro-enterostomy,  (See 
under  these  heads  respectively.) 

Congenital  or  Infantile  Hypertrophic  Stenosis  of  the  Pylorus  or 
Pyloric  Stenosis  of  Infancy  (Warbasse,  "Surgical  Treatment"). — Osier 
tells  us  that  the  first  case  was  published  by  an  American,  Hezekiah  Beards- 
ley,  in  1778.  Hirschsprung,  of  Denmark,  in  1887  published  the  first  modern 
case  (Bunts,  "Am.  Jour.  Med.  Sciences,"  Jan.,  1912).  Stenosis  in  adults  is 
almost  invariably  due  to  cancer  or  to  ulcer,  but  in  very  young  children  one 
occasionally  meets  with  a  form  that  is  congenital.  The  victims  of  hyper- 
trophic stenosis  not  unusually  have  club-foot  or  imperforate  anus. 


II04  Diseases  and  Injuries  of  the  Abdomen 

The  condition  exists  at  birth  and  about  ten  days  later  the  region  becomes 
edematous  because  of  increased  activity  of  the  stomach  (W.  A.  Downes,  in 
"Surgery,  Gynecology,  and  Obstetrics,"  1916,  xxii).  The  history  of  such  a 
case  is  that  during  the  first  two  or  three  days  after  birth  the  child  seems  in  every 
way  normal,  but  that  after  several  or  a  number  of  days  or  perhaps  weeks  pro- 
jectile vomiting  suddenly  begins — ^vomiting  for  which  no  dietary  cause  seems 
responsible,  and  which  persists  irrespective  of  medication.  After  the  stomach 
has  been  emptied  by  vomiting  the  child  seems  much  relieved,  but  when,  after 
a  time,  food  is  administered,  vomiting  will  begin  again,  either  in  a  very  short 
time  or  after  an  hour  or  so.  It  has  been  noted  that  the  vomited  matter  in  con- 
genital stenosis  of  the  pylorus  never  contains  any  bile  whatever,  for  obvious 
reasons — the  pylorus  is  shut  and  the  bile  cannot  enter  the  stomach.  A  child 
in  this  condition  receives  little  or  no  nourishment,  becomes  quickly  emaciated, 
and  soon  dies.  Some  of  these  children  die  in  a  month;  others,  in  several  months, 
and  a  few  may  live  for  five  or  six  months.  It  may  be  possible,  in  these  cases, 
to  palpate  a  thickened  pylorus,  and  the  outlines  of  the  dilated  stomach  may  be 
made  out.  Regurgitant  vomiting  by  keeping  the  stomach  empty  may  prevent 
dilatation.  The  most  common  symptom  is  gastric  peristalsis.  In  Bunts's 
table  gastric  peristalsis  was  present  in  84  per  cent.,  and  a  palpable  tumor  in 
69  per  cent,  of  cases.  In  true  congenital  stenosis  there  is  hypertrophy.  The 
circular  muscular  fiber  undergoes  great  increase  from  hypertrophy,  perhaps 
with  some  fibrosis.  The  mucous  membrane  is  hypertrophied  and  thrown  into 
folds.  The  opening  into  the  duodenum  may  be  no  larger  in  diameter  than  a 
pin  and  may  be  totally  blocked  by  folds  of  mucous  membrane.  Even  when 
there  is  comparatively  little  or  no  hypertrophy  the  lumen  of  the  pylorus  may  be 
closed  by  spasm.  It  is  these  latter  cases  which  are  benefited  by  medical  treat- 
ment. Such  cases  are  not  to  be  regarded  as  instances  of  congenital  hypertrophy 
and  should  be  classified  as  pyloric  spasm.  In  congenital  hypertrophic  stenosis 
the  intestines  are  very  much  collapsed,  and  the  child  is,  of  course,  much  consti- 
pated. Cases  of  pyloric  closure  have  recovered  after  lavage  carried  out  daily 
for  some  weeks  and  careful  breast  feeding.  Such  cases  are  probably  instances 
of  spasm.  This  plan  is  only  permissible  if  there  be  no  palpable  thickening  at 
the  pylorus.  A  trial  should  be  given  this  method  unless  the  condition  of  the 
patient  demands  immediate  relief.  If  therebe  palpable  thickening  of  the  pylorus, 
operation  is  called  for  imperatively.  The  delay  in  employing  surgery  in  hopes 
of  lavage  succeeding  must  never  be  so  long  as  to  cause  emaciation  in  the  patient. 
If  the  condition  does  not  soon  show  signs  of  improvement  operation  is  indicated. 
Cases  reported  cured  by  medical  means  may  have  been  instances  of  pyloric 
spasm.  The  operation  for  this  condition  is  usually  posterior  gastro-enterostomy . 
The  mortality  after  the  operation  has  been  set  at  over  50  per  cent,  though  in 
Downes's  31  cases  of  gastro-enterostomy  it  was  35  per  cent.  (Ibid.)  and  in 
Scudder's  recent  cases  it  was  13.8  per  cent.  ("Annals  of  Surgery,"  1914,  lix). 
It  is  superior  to  pyloroplasty  because  it  enables  us  to  feed  the  exhausted  child 
at  once.  In  19  posterior  gastro-enterostomies  Richter  had  two  deaths,  a  mor- 
tahtyof  10.5  per  cent.  ("Jour.  Am.  Med.  Assoc,"  1914,  Ixii).  Downes  (Ibid.) 
prefers  partial  pyloroplasty  in  cases  where  great  haste  is  necessary.  He  cuts 
to  but  not  through  the  mucous  membrane.  He  operated  on  35  cases  with  8 
deaths,  a  mortality  of  23  per  cent.  Gastro-enterostomy  saves  the  child  from 
starvation  and  restores  the  function  of  the  intestinal  canal,  but  the  pyloric  tumor 
remains  permanently  (Scudder,  in  "Surg.,  Gynec,  and  Obstet.,"  Sept.,  1910). 

Perigastric  Adhesions. — That  perigastric  adhesions  are  frequently 
responsible  for  stomach  pain  and  digestive  difficulty  is  undoubted.  Such 
adhesions  often  arise  in  cases  of  protracted  ulceration  of  the  stomach  or  duo- 
denum. A  common  cause  of  perigastric  adhesions  is  gall-stone  disease.  Tuber- 
culous peritonitis  causes  dense  adhesions.  In  some  cases  adhesions  are  trau- 
matic, in  some  are  due  to  syphilis,  in  many  the  cause  is  uncertain  (Fred.  D. 


Symptoms  of  Bilocular  Stomach  1105 

Bird,  "Intercolonial  Med.  Jour,  of  Australia,"  Dec.  20,  1900).  Adhesions 
may  cause  blocking  or  kinking  of  the  pylorus,  or  may  glue  the  stomach  to  the 
parietal  peritoneum  or  to  some  adjacent  viscus.  In  Fenwick's  table  of  123  cases 
he  finds  that  the  adhesions  usually  cause  the  stomach  to  adhere  to  the  pancreas 
or  to  the  liver.  The  formation  of  adhesions  in  cases  of  gastric  ulcer  is,  in  many 
instances,  conservative,  serving  to  prevent  perforation  or  to  limit  extravasa- 
tion if  perforation  of  the  stomach  wall  occurs. 

The  symptoms  are  variable.  In  some  cases  the  adhesions  produce  little 
or  no  trouble;  but  in  the  majority  of  cases  they  cause  definite  symptoms,  and 
sometimes  the  condition  becomes  one  of  absolute  disablement.  The  symptoms 
may  be  due  to  blocking  of  the  pylorus,  a  condition  that  is  followed  by  gastric 
dilatation.  They  may  be  due  to  dragging  upon  the  adhesions  when  the  stomach 
contracts  during  digestion,  or  when  peristalsis  occurs  in  an  adherent  piece  of 
intestine. 

The  usual  symptom  is  pain,  frequently  of  a  violent  character.  .  The  pain 
comes  on  in  paroxysms,  and  recurs  over  and  over  again,  it  may  be  during  years. 
H.  Hale  White  ^  points  out  that  in  these  cases  there  is  usually  some  pain  persist- 
ing, which  is  now  and  then  increased  into  violent  paroxysms;  and  that  the  only 
other  condition  that  produces  persistent  pain  with  violent  exacerbations  is 
cancer.  In  adhesion-dyspepsia,  however,  there  is  no  distinct  loss  of  weight; 
the  condition  may  exist  in  youth,  as  well  as  in  middle  age  or  old  age;  it  is  not 
always  increased  by  taking  food,  and  it  very  rarely  causes  death.  If  there 
be  a  history  of  antecedent  gall-stone  disease  or  of  ulcer  of  the  stomach,  it  is 
possible  to  make  the  diagnosis  without  exploratory  operation.  Even  in  other 
cases  the  condition  may  sometimes  be  diagnosticated,  because,  although  there 
are  these  attacks  of  violent  pain,  there  is  no  tenderness.  In  rare  cases  the 
matting  together  of  inflammatory  exudate  produces  a  palpable  mass. 
In  doubtful  cases  of  chronic  and  disabling  stomach  disease  an  explora- 
tory operation  should  be  performed;  if  adhesions  exist,  they  will  then  become 
manifest. 

Treatment. — In  some  cases  simply  dividing  an  adhesion  effects  a  cure; 
in  other  cases  it  is  necessary  to  make  extensive  separation  of  adherent  struc- 
tures, covering  the  raw  surfaces  with  omental  grafts.  In  serious  adhesions 
about  the  pylorus  gastro-enterostomy  is  usually  the  proper  operation. 

Bilocular  Stomach  (Hour=glass  Stomach). ^ — It  is  usually  stated  that 
some  cases  are  congenital,  but  the  writings  of  Mayo  Robson,  Moynihan,  and 
H.  L.  Paterson  cause  us  to  doubt  if  the  condition  is  ever  congenital.  Even  in  the 
so-called  congenital  cases  ulcers  are  found,  or  ulcer  scars  exist,  or  ulcer  adhesions 
are  demonstrable.  The  advocates  of  a  congenital  origin  say  that  the  ulcers 
are  secondary  to  the  narrowing,  and  that  ulceration  tends  to  occur,  particularly 
at  the  seat  of  constriction.  Beyond  doubt,  a  very  great  majority,  at  least,  of 
cases  of  bilocular  stomach  result  from  adhesions  produced  by  the  healing  of 
ulcers.  In  hour-glass  stomach  with  a  large  opening  between  the  two  sacs  there 
may  be  no  symptoms.  When  the  opening  is  small  the  symptoms  resemble 
those  of  pyloric  stenosis.     The  sac  toward  the  cardia  is  frequently  much  dilated. 

Symptoms. — The  diagnosis  of  cancer  is  often  made.  The  protracted  gas- 
tritis may  have  caused  free  hydrochloric  acid  to  disappear  and  acids  of  fermen- 
tation are  usually  found.  The  patient  vomits  from  time  to  time,  bringing  up 
food  which  was  eaten  a  day  or  two  before,  proof  that  food  has  been  retained  in 
the  stomach  and  not  digested.  Occasionally,  perhaps,  blood  is  vomited.  There 
is  pain  and  the  patient  is  harassed  by  foul-smelling  eructations.  Emaciation 
becomes  pronounced.  Cumstom^  points  out  that  in  a  thin  belly  distention 
of  the  stomach  may  make  the  condition  evident ;  f ui-ther,  that  if  water  is  thrown 
into  the  stomach,  only  a  part  returns,  and  when  the  stomach  is  emptied  as 

'  "Lancet,"  Nov.  30,  1901. 
2  "Med.  News,"  Dec,  1901. 
70 


iio6  Diseases  and  Injuries  of  the  Abdomen 

much  as  possible  by  a  tube,  a  splashing  sound  can  still  be  elicited  in  the  stomach 
because  the  pyloric  pouch  is  not  empty.  One  cause  of  death  is  torsion  on  the 
axis.  A  skiagraph  taken  after  a  bismuth  or  barium  meal  gives  diagnostic 
information  of  the  lirst  importance. 

Treatment. — The  diagnosis  becomes  certain  after  exploratory  operation, 
and  exploration  also  enables  the  surgeon  to  decide  with  certainty  what  opera- 
tion should  be  performed.     Cumstom^  gives  us  the  following  suggestions: 

1.  In  rare  cases  resect  the  stricture  and  suture  the  pouches. 

2.  If  there  is  trivial  ulceration  or  a  slight  scar,  do  gastroplasty,  an  operation 
upon  the  constriction  exactly  similar  to  pyloroplasty. 

3.  The  best  operation  in  most  cases  is  gastrogastrostomy — that  is,  anas- 
tomosis of  the  cardiac  pouch  to  the  pyloric  pouch;  but  this  cannot  be  done 
if  the  pvloric  pouch  is  small.     Then  do  gastro-enterostomy. 

Other  operations  are: 

4.  Gastroduodenostomy. 

5.  Gastrojejunostomy. 

6.  Gastrolysis. 

In  malignant  disease  resection  (partial  gastrectomy)  is  indicated.  After 
gastroplasty  recontraction  is  common,  and  I  do  not  believe  in  the  operation. 
Gastro-enterostomy  is  unsatisfactory.  The  ordinary  operation  drains  but  one 
pouch.  Weir  and  Foote  advised  a  double  gastro-enterostomy,  tapping  each 
sac.  In  most  cases  gastrogastrostomy  followed  by  gastro-enterostomy  is  the 
best  procedure. 

Chronic  Dilatation  of  the  Stomach. — A  dilated  stomach,  roughly 
speaking,  is  one  which  can  contain  more  than  1.5  quarts  (Ewald).  Some  few 
cases  of  dilatation  result  directly  from  atrophy  of  the  muscular  coat  brought 
about  by  drinking  quantities  of  Hquid,  especially  beer;  chronic  catarrh  of  the 
stomach;  and  conditions  such  as  cancer,  tuberculosis,  diabetes,  etc.  The 
common  cause  of  dilatation  is  constriction  of  the  pylorus.  In  order  to  force 
food  through  the  pyloric  narrowing  more  force  is  necessary  than  is  required 
normally,  hence  the  stomach  muscle  hypertrophies.  This  muscular  hypertrophy 
is  compensatory,  and  dilatation  does  not  occur  so  long  as  the  muscle  is  efficient. 
But  finally  the  pyloric  opening  becomes  so  narrow  that  compensation  fails,  the 
stomach  contents  accumulate,  and  the  stomach  dilates. 

Symptoms  of  Dilated  Stomach. — There  is  annoying  hunger  unless  cancer 
exists.  Thirst  is  complained  of.  At  intervals  of  a  day  or  two  the  patient 
vomits  enormous  quantities,  and  portions  of  food  may  be  identified  which  were 
eaten  one  or  more  days  before.  The  vomited  matter  is  sour  and  foul  smelling, 
contains  numbers  of  yeasts,  and  much  fermentative  acid.  Free  hydrochloric 
acid  is  often  absent.  In  some  cases  vomiting  occurs  two  or  three  hours  after 
each  meal.  The  patient  suffers  from  foul  gaseous  eructations.  There  are  pro- 
gressive emaciation,  constipation,  scantiness  of  urine;  sometimes  cramp  in  the 
legs,  belly,  and  arms;  tetany  may  occur  (see  Parathyroid  Tetany,  page  1386); 
insomnia  is  the  rule;  cardiac  palpitation  occurs,  and  there  is  dyspnea,  particu- 
larly at  night. 

Physical  Signs  of  Dilated  Stomach. — The  epigastric  region  is  hollow  and 
the  left  side  of  the  abdomen  is  more  prominent  than  the  right.  The  outline  of 
the  greater  curvature  of  the  stomach  can  be  distinguished.  If  the  stomach 
contains  air,  percussion  gives  a  tympanitic  note;  if  it  contains  fluid,  a  dull  note. 
When  it  is  partly  full  of  fluid,  by  altering  the  position  of  the  patient  we  can 
show  by  percussion  that  the  fluid  changes  its  position.  In  a  doubtful  case  give 
a  light  meal  in  the  evening,  and  in  the  morning,  before  the  patient  has  eaten, 
introduce  a  tube  and  remove  any  material  contained  in  the  stomach.  The  pres- 
ence of  undigested  food  points  to  dilatation. 

1  "Med.  News,"  Dec.  7,  1902. 


Acute  Dilatation  of  the  Stomach  1107 

To  Test  the  Motor  Power  of  the  Stomach.  Klemperer's  Test. — Wash  out 
the  stomach.  Introduce  100  c.c.  of  ohve  oil  by  means  of  the  tube.  After 
two  hours  withdraw  the  oil.  The  stomach  cannot  absorb  oil,  and  if  the 
amount  withdrawn  is  subtracted  from  the  amount  introduced  the  difference 
is  the  amount  which  passed  the  pylorus.  If  the  condition  is  normal,  not  more 
than  from  20  to  40  c.c.  should  be  found  in  the  stomach  after  two  hours. 

The  Salol  Test  of  Ewald. — Salol  is  not  decomposed  in  the  stomach,  but 
in  the  intestine  is  broken  up  into  phenol  and  salicylic  acid.  Salicylic  acid  is 
absorbed  and  salicyluric  acid  soon  appears  in  the  urine.  If  salol  cannot  reach 
the  intestine,  salicyluric  acid  will  not  appear  in  the  urine.  If  salol  reaches 
the  intestine  more  slowly  than  normal,  salicyluric  acid  will  appear  after  a 
longer  interval  than  when  there  is  no  pyloric  block  to  retard  the  emptying 
of  the  stomach.  In  a  normal  person  salicyluric  acid  is  found  in  the  urine  in 
from  three-fourths  of  an  hour  to  an  hour  after  swallowing  a  dose  of  salol.  In 
stenosis  of  the  pylorus  it  appears  much  later.  The  test  is  made  as  follows: 
The  bladder  is  emptied  and  the  patient  is  given  three  capsules,  each  containing 
5  gr.  of  salol.  The  patient  is  directed  to  pass  water  every  half-hour  until  he 
has  done  so  four  times.  Each  sample  voided  is  examined  for  salicyluric  acid 
by  adding  neutral  chlorid  of  iron.  If  sahcyluric  acid  is  present,  a  violet  color 
is  noted. 

To  Test  the  Absorptive  Power  of  the  Stomach. — The  absorptive  power  of 
the  stomach  can  be  tested  by  giving  the  patient  a  capsule  containing  i}-^  gr. 
of  iodid  of  potassium.  Normally  the  drug  should  be  found  in  the  saliva  in  from 
ten  to  fifteen  minutes.  When  absorption  is  deficient,  it  may  not  appear  for 
an  hour  or  longer.  In  order  to  test  for  it,  moisten  starch  paper  with  the  saliva 
and  touch  the  moist  paper  with  a  drop  of  fuming  nitric  acid.  If  iodin  is  pres- 
ent, a  blue  color  develops. 

While  the  diagnosis  of  dilatation  of  the  stomach  can  be  certainly  made, 
the  determination  of  the  cause  may  require  an  exploratory  operation. 

Treatment.- — Cases  not  due  to  pyloric  obstruction  are  much  improved  by 
lavage,  regulated  diet,  use  of  an  abdominal  belt,  electricity,  aperients,  and  other 
agents  called  for  by  symptoms. 

In  all  cases  in  which  there  is  pyloric  obstruction,  in  many  doubtful  cases, 
and  in  cases  in  which  medical  treatment  fails,  exploratory  operation  is  indi- 
cated. In  dilatation  without  pyloric  obstruction  some  surgeons  advocate  gas- 
troplication.  If  pyloric  obstruction  exists,  the  surgeon  may  elect  to  do  pylo- 
rectomy,  pyloroplasty  or  gastro-enterostomy,  the  method  selected  depending 
on  the  condition  discovered.  If  gastroptosis  exists,  gastropexy  or  Beyea's 
operation  may  be  performed. 

Acute  Dilatation  of  the  Stomach.' — This  condition  may  arise  suddenly 
in  the  course  of  chronic  dilatation  or  when  no  previous  dilatation  existed. 
Its  clinical  features  were  described  by  Brinton  in  1859.  Hilton  Fagge  in  1873 
furnished  us  with  the  first  comprehensive  description  of  the  signs  and  symptoms. 
It  can  occur  in  association  with  intestinal  paralysis  and  if  it  does  do  so  it  con- 
stitutes but  part  of  the  picture  of  postoperative  paralytic  intestinal  obstruc- 
tion. We  are  considering  only  acute  dilatation  of  the  stomach.  The  cause 
is  uncertain,  and  is  a  subject  of  active  investigation  at  the  present  time.  It  is 
said  to  be  due  to  degeneration  of  the  gastric  muscle  in  the  course  of  specific 
fevers,  to  paresis  arising  in  the  course  of  chronic  gastritis,  or  to  the  drinking  of 
a  quantity  of  effervescing  liquid.  It  is  occasionally  a  fatal  sequence  of  abdomi- 
nal operations,  particularly  operations  upon  the  gall-bladder  and  bile-ducts. 
The  surgeon  sees  it  in  the  course  of  sepsis  and  during  shock  from  operations  in 
which  a  general  anesthetic  was  used,  and  occasionally  in  cases  of  spinal  curvature. 

One  set  of  observers  maintains  that  the  condition  is  brought  about  by  actual 

^  See  Kelling,  in  "Archiv.  f.  klin.  Chir,,"  1901,  Ixiv;  Albrecht,  in  "Virchow's  Archiv.," 
1899,  clvi;  Conner,  in  "Am.  Jour.  Med.  Sciences,"  March,  1907. 


iio8  Diseases  and  Injuries  of  the  Abdomen 

constriction  of  the  duodenum,  the  duodenum  dropping  because  of  relaxation 
of  its  supporting  structures,  the  constricting  cause  being  the  root  of  the  mesen- 
tery and  the  superior  mesenteric  artery  and  the  duodenum  being  squeezed 
against  the  vertebral  column  (Rokitansky,  Albrecht,  Robinson,  and  Kundrat). 
Codman  believes  that  normally  in  man  there  is  more  or  less  tendency  to 
such  constriction  on  standing  erect  or  lying  supine,  and  that  a  trivial  increase  of 
the  constriction,  which  may  be  brought  about  by  various  causes,  may  completely 
obstruct  the  duodenum  ("Boston  Med.  and  Surg.  Jour.,"  1908).  Lewis  A. 
Conner  collected  18  fatal  cases  shown  apparently  by  necropsy  to  be  due  to  mes- 
enteric obstruction  ("Am.  Jour.  Med.  Sciences,"  March,  1907). 

Another  set  of  observers  asserts  that  acute  dilatation  is  due  to  lesion  of  the 
nerve-trunks  or  nerve-centers,  resulting  in  paresis  of  the  muscle  of  the  stomach 
wall  and  perhaps  in  spasm  of  the  pylorus,  putting  the  stomach  in  such  a  con- 
dition that  it  cannot  empty  itself.  The  cause  of  the  nerve  lesion  is  variously 
held  to  be  hyperacidity  of  gastric  secretion,  the  absorption  of  the  toxins  of  fer- 
mentation, the  secretion  of  chloroform  into  the  stomach,  the  overdistention  of 
the  viscus  with  ether  vapor,  or  an  enormously  great  secretion  of  fluid  into  the 
stomach.  Those  who  hold  this  view  claim  that  the  abdominal  organs  are  not 
supported  by  ligaments  (if  they  were,  the  supposed  supporting  structures  would 
contain  ligamentous  fibers),  but  are  supported  by  the  organs  beneath  them  and 
these  by  the  floor  of  the  pelvis,  and  that  all  are  sustained  by  intra-abdominal 
pressure.  Furthermore,  they  are  of  the  opinion,  that  traction  on  the  mesentery' 
sufficient  to  cause  duodenal  occlusion  would  lead  inevitably  to  thrombosis  and 
gangrene,  and  that  the  dilatation  of  the  stomach  and  upper  portion  of  the 
duodenum  when  contrasted  with  the  collapse  of  the  lower  part  of  the  duodenum 
leads  to  the  mistaken  view  that  a  constriction  exists  between  the  two  portions. 

Conner  (Ibid.)  says  that  the  theory  of  pyloric  spasm  being  causative  is  unten- 
able because  in  most  cases  vomited  matter  contains  bile,  and  in  two-thirds 
of  the  cases  the  duodenum  is  involved  in  dilatation.  The  constriction  is  re- 
garded as  secondary  to  the  dilatation.  Some  think  that  acute  dilatation  occurs 
only  in  those  with  atonic  stomachs.  Others  regard  it  as  due  to  lack  of  adrenalin 
or  to  toxic  influence  upon  muscular  fiber.  We  do  know  that  neurotics  and  the 
victims  of  gastric  disease  are  predisposed,  that  the  anesthetic  is  a  danger  (chlo- 
roform being  more  dangerous  than  ether),  that  early  feeding  or  giving  of  much 
liquid  during  the  first  few  hours  after  operation  may  be  an  exciting  cause,  that 
a  person  who  is  predisposed  is  insatiably  thirsty  and  hence  that  great  thirst  is 
a  sign  of  danger,  that  the  condition  never  occurs  unless  the  stomach  is  full  of 
fluid  or  gas  and  that  slight  conditions  of  dilatation  are  very  common  but  pass 
away  in  from  twelve  to  twenty-four  hours. 

It  seems  probable  that  some  cases  of  gastric  dilatation  are  associated  with 
mesenteric  constriction  of  the  duodenum,  brought  about  by  the  intestines 
descending  into  the  pelvis.  The  constriction  inaugurates  the  dilatation  and 
is  aggravated  by  the  dilatation.  Conner  points  out  that  the  intestines  enter 
the  pelvis  as  a  result  of  dorsal  decubitus,  a  long  mesentery,  and  a  gut  nearly 
empty  of  gas  and  feces,  and  that  this  condition  is  favored  by  relaxation  of  the 
belly  wall  ("Jour.  Am.  Med.  Assoc,"  March,  1907). 

Symptoms. — Violent,  profuse,  gushing  vomiting  is  most  frequent  and  the 
most  prominent  symptom;  it  inaugurates  the  attack  and  continues  throughout 
the  illness,  although  occasionally  it  ceases  for  some  time  before  death.^  The 
amounts  vomited  are  always  large  and  often  enormous.  The  vomitus  is  thin 
and  of  a  green  or  black  hue,  usually  contains  bile  and  sometimes  a  little  blood, 
but  very  seldom  feces. 

In  most  cases,  but  not  in  all,  there  is  epigastric  or  umbilical  pain  and  tender- 
ness. Distention  is  the  rule.  Rigidity  is  rare.  In  many  cases  there  is  no 
passage  of  gas  or  feces,  but  in  some  diarrhea  exists.  There  is  great  thirst, 
there  may  be  hiccup,  and  dehrium  may  arise  before  death.     The  temperature 


Symptoms  of  Gastroptosis  1109 

is  nearly  always  normal  or  below  normal.  There  is  seldom  visible  gastric 
peristalsis  (Conner,  Ibid.),  and  splashing  sounds  are  obtainable  over  the  stomach. 

Collapse  arises  early  and  quickly  becomes  profound.  Tetany  occasionally 
occurs.  A  case  of  my  own  died  of  acute  gastric  dilatation  after  an  operation 
for  stone  in  the  kidney.  He  suddenly  developed  attacks  of  violent  and  pro- 
fuse vomiting,  rapidly  went  into  collapse,  lividity  developed  and  hiccup  arose, 
and  he  died  in  forty-eight  hours. 

A  case  may  die  in  less  than  twenty-four  hours  or  may  die  after  ten  days 
or  more.  Conner's  group  of  cases  shows  a  mortality  of  72.5  per  cent.  Fluid 
cannot  reach  the  small  intestine,  and  as  none  is  absorbed  from  the  stomach 
and  little  from  the  duodenum,  the  tissues  starve  for  the  want  of  it  (Laffer,  in 
"Annals  of  Surgery,"  April,  1908).  The  condition  is  frequently  diagnosticated 
acute  intestinal  obstruction  or  peritonitis  from  perforation. 

Treatment. — When  the  stomach  has  dilated  greatly  and  when  collapse  is 
profound,  treatment  is  usually  of  no  avail.  When  an  early  diagnosis  is  made 
treatment  is  often  of  the  greatest  value.  The  stomach  must  be  at  once  emptied 
by  the  use  of  a  tube  and  the  treatment  be  repeated  at  intervals  of  a  few  hours. 
Neither  food  nor  drink  should  be  given  by  the  mouth.  Saline  enemata  and  per- 
haps nutritive  and  stimulating  enemata  should  be  given.  The  patient  should 
at  once  be  placed  upon  the  belly  and  kept  there  with  occasional  changes  to 
the  knee-chest  or  left  lateral  prone  position  until  the  condition  abates,  in 
the  hope  that  this  posture  will  relieve  duodenal  constriction. 

Gastro-enterostomy  has  been  employed,  and  is  advocated  by  Mayo  Robson. 
Byron  Robinson  had  a  recovery  after  operation.  In  a  number  of  cases  the 
stomach  has  been  opened  and  washed  out  without  benefit.  Petit  opened 
the  abdomen  and  discovered  a  kink  at  the  junction  of  the  duodenum  and 
jejunum;  he  raised  the  jejunum  and  sutured  it  to  the  transverse  colon  and 
the  patient  recovered  (Conner,  ''Jour.  Amer.  Med.  Assoc,"  March,  1907). 
I  cannot  see  how  gastro-enterostomy  can  drain  an  acutely  dilated  stomach. 
The  atonic  muscles  must  be  helpless  in  forcing  stomach  contents  through  the 
new  exit. 

Not  until  we  know  definitely  the  cause  or  causes  of  acute  dilatation  of  the 
stomach  will  we  be  able  to  lay  down  with  precision  and  accuracy  the  treatment 
which  is  indicated.  There  is  much  difference  of  opinion  as  to  the  causation  of 
the  condition,  and  widely  different  methods  of  treatment  are  advocated  by 
various  surgeons. 

Gastroptosis  (Fig.  688). — In  this  condition  the  stomach  has  undergone 
displacement  downward,  the  greater  curvature  in  many  cases  being  but  little 
above  the  pubic  symphysis  and  the  lesser  curvature  being  between  the  ensi- 
form  cartilage  and  the  umbilicus.  This  condition  is  far  more  common  in  women 
than  in  men,  and  is  especially  common  in  women  who  have  had  many  children. 
It  may  be  produced  by  tight  lacing  and  may  follow  movability  of  the  right  kid- 
ney, of  the  liver,  or  of  the  spleen.  It  is  often  associated  with  enteroptosis, 
mobile  cecum,  and  prolapse  of  the  colon,  and  is  particularly  prone  to  arise  in  the 
anemic  and  tuberculous. 

Symptoms. — There  may  be  no  symptoms  for  a  long  time,  but  sooner  or 
later  dyspepsia  arises  because  the  stomach  cannot  empty  itself.  The  stomach 
becomes  atonic,  its  secretions  are  scanty  and  altered,  and  while  the  viscus 
may  be  normal  in  size  or  even  shrunken,  it  is  usually  dilated.  The  malposition 
can  be  made  out  by  percussion  when  the  stomach  is  distended  with  air  or  with 
fluid,  and  by  the  a;-rays  after  the  patient  has  drunk  a  pint  of  a  solution  of  muci- 
lage of  acacia  containing  subnitrate  of  bismuth.  The  bismuth  lines  the  stom- 
ach and  intercepts  the  :v:-rays  and  a  radiograph  shows  the  outlines  of  the  stomach 
and  hence  its  size  and  position.  The  pylorus  descends  to  the  umbilical  region, 
which  it  does  not  do  in  plain  dilatation.  In  dilatation  the  pylorus  is  but  slightly 
lower  than  normal,  but  the  lower  border  of  the  stomach  is  notably  depressed. 


IIIO 


Diseases  and  Injuries  of  the  Abdomen 


In  gastroptosis  there  is  often  a  constriction  a  short  distance  from  the  pylorus 
due  to  a  kink  produced  by  the  sagging. 

When  a  patient  with  gastroptosis  stands  erect  the  bulging  is  most  prominent 
in  the  region  of  the  umbilicus  and  the  epigastrium  is  deepened. 

Gastroptosis  is  not  infrequently  associated  with  chlorosis  and  commonly 
with  neurasthenia. 

Treatment. — Lavage,  regulation  of  diet,  improvement  of  the  general  health, 
the  wearing  of  an  abdominal  binder,  and  placing  the  patient  supine  for  a  time 
after  each  meal  comprise  the  medical  treatment.  If  medical  treatment  fails  and 
the  condition  is  producing  grave  impairment  of  the  general  health,  it  may  be 

necessary  to  perform  a 
surgical  operation.  Gas- 
tro-enterostomy  is  ad- 
vocated by  some  on  the 
ground  that  the  un- 
pleasant symptoms  result 
from  stagnation  of  gastric 
contents.  Good  results 
have  been  reported  by 
this  plan.  The  operation 
of  Depage  is  unphilo- 
sophical.  Buret's  opera- 
tion is  objectionable  (see 
page  1243).  Beyea's 
operation  or  Ransohofif's 
method  is  preferred  (see 
page  1243). 

Chronic  Intestinal 
Stasis. — This  is  a  term 
employed  by  Sir  Ar- 
buthnot  Lane  to  designate 
such  a  delay  in  the  pas- 
sage of  material  along 
the  gastro-intestinal  tract 
as  to  permit  of  the  ab- 
sorption of  so  much  toxin 
that  the  body  cannot  suc- 
cessfully deal  with  it 
(Lane's  paper  before  the 
Derby  Med.  Soc,  Oct. 
17,  1911).  Defective 
drainage  permits  absorp- 
tion of  poison,  and  absorp- 
tion of  poison  is  respon- 
sible for  ill  health  and  the  lowering  of  vital  resistance  to  various  bacteria. 
Lane  and  his  followers  are  of  the  opinion  that  toxemia  so  induced  may 
cause  chronic  mastitis,  rheumatoid  arthritis,  gastric  ulcer,  duodenal  ulcer, 
appendicitis,  and,  by  lowering  resistance,  may  be  responsible  for  progressive 
tuberculous  disease.  They  believe  that  the  block  to  drainage  is  brought 
about  by  kinks,  and  that  the  kinks,  which  tend  to  form  in  certain  situations, 
are  due  to  bands;  in  other  words,  the  condition  is  due  to  a  mechanical  cause 
(Lane,  Ibid.).  Mayo  regards  such  bands  as  congenital.  Lane  holds  that 
faulty  feeding  in  early  life  causes  abnormal  distention  and  pull  on  the  gut,  that 
when  the  erect  posture  is  assumed  the  condition  is  exaggerated  by  the  formation 
of  new  peritoneal  bands  which  are  formed  to  resist  the  dropping  of  the  intestine. 
In  1909  Jabez  Jackson  described  a  pseudomembrane  sometimes  seen  over  the 


Gastroptosis  (shown  by  a  skiagraph). 


Acute  Obstruction  mi 

peritoneum  of  the  lower  ileum  and  colon  and  loosely  attached  to  it.  Sometimes 
it  is  also  attached  to  parietal  peritoneum  and  thus  limits  movements  of  the  gut. 
This  thin  membrane  is  known  as  Jackson's  veil,  and  it  is  probably  identical  with 
Lane's  bands.  Some  observers  regard  Jackson's  veil  as  the  result  of  pericolitis, 
some  as  due  to  infantile  colitis,  some  to  chronic  colitis,  some  to  appendicitis. 
Isaacs  ("New  York  jMed.  Jour.,"  Oct.  26,  1912)  points  out  that  this  pseudo- 
membrane  may  be  found  in  other  regions  than  over  the  colon,  and  suggests 
calling  the  condition  membranous  perienteritis.  He  believes  the  membrane  is 
formed  because  of  ulceration  or  inflammation  of  the  gastro-intestinal  tract. 

The  large  intestine  is  thought  by  many  to  play  such  a  prominent  part  in 
toxin  absorption  that  Barclay  Smith  (quoted  in  "Brit.  Med.  Jour.,'"  Dec.  7, 
1912),  Metchnikoff.  Lane,  and  others  put  under  ban  that  portion  of  the  gut, 
regard  it  as  a  useless  and  dangerous  encumbrance,  and  would  take  it  out  and 
cast  it  away.  Biological  teaching  opposes  the  view  that  the  large  gut  is  useless. 
It  has  been  showm  that  animals  like  the  wombat,  which  have  come  do^m  from  an 
antediluvian  species  have  long  large  intestines.  Were  the  theor\'-  that  the  large 
gut  is  useless  true,  these  animals  should  have  been  the  first  to  disappear. 

If  kinks  cause  stasis  it  is  strange  that  the  .v-ray  pictures  fail  to  demonstrate  it 
at  the  hepatic  flexure  or  in  the  ascending  colon  (Knight,  "Lancet  Clinic,"  cxiv). 

Treatment. — If  a  band  or  membrane  exists,  remove  it,  and  if  a  raw  siirface 
is  left,  cover  it  over  with  peritoneum. 

In  partial  blocking  of  the  beginning  of  the  large  intestine  or  of  the  lower 
ileum  some  perform  fleocolostomy.  Lane  found  that  in  20  per  cent,  of  his  opera- 
tions impaction  of  the  cecum  necessitated  a  subsequent  colectomy,  so  now  he 
extirpates  the  colon  and  fastens  the  upper  end  of  the  divided  ileum  to  the  rec- 
tum. He  does  the  same  operation  for  rheumatoid  arthritis,  tuberculous  joints, 
and  other  conditions — long  steps  on  a  radical  road  where,  so  far,  few  have  gone 
more  than  a  short  distance. 

Intestinal  obstruction  (ileus  or  enterostenosis)  is  a  condition  in 
which  fecal  movement  is  mechanically  impeded  or  prevented.  It  may  be 
either  partial  or  complete,  acute  or  gradual.  Acute  obstruction  is  due  to  a  sudden 
narroTsdng  or  occlusion  of  the  lumen  of  a  portion  of  the  intestine.  Chronic 
obstruction  is  due  to  a  gradual  narrowing  of  the  lumen  of  a  portion  of  the  in- 
testine, and  it  may  at  any  time  become  acute.  If  there  is  not  only  interference 
with  the  passage  of  the  fecal  current,  but  also  obstruction  to  the  blood-current 
in  the  wall  of  the  bowel,  the  condition  becomes  strangulation.  The  primal  cause 
is  mechanical  in  nature,  in  most  cases  a  mechanical  block.  In  paralysis  of  the 
bowel  from  peritonitis  there  is  inability  of  the  bowel  wall  to  contract  and  force 
the  feces  onward.  In  all  cases  of  unrelieved  obstruction  the  nerves  are  sooner  or 
later  damaged  and  paralysis  occurs.  In  acute  obstruction  the  stagnated  in- 
testinal contents  become  charged  with  powerful  poisons  which  act  most  harm- 
fully on  the  musculature  of  the  intestinal  wall,  and,  after  absorption,  attack 
the  heart  and  nervous  system.  The  inaugural  shock  is  due  to  the  production  of 
the  block;  later  the  increasing  depression  is  due  to  absorption  of  poisons. 
Gas  forms  in  great  amount  in  the  intestine  and  produces  distention.  Disten- 
tion impairs  the  circulation  in  the  wall  of  the  intestine  and  embarrasses  respira- 
tion by  pushing  up  the  diaphragm. 

Acute  Obstruction. — The  worst  forms  of  this  grave  condition  are  due  to 
sudden  and  absolute  blocking  of  the  bowel  with  strangulation,  as  when  a 
portion  of  bowel  is  caught  under  a  band  or  in  a  hernial  aperture. 

As  soon  as  strangulation  occurs  there  is  violent  peristalsis.  The  bowel  above 
the  strangulation  for  a  short  time  vainly  lashes  itself  into  effort  to  force  intes- 
tinal material  past  the  obstruction.  The  peristalsis  below  empties  the  bowel 
below  the  obstruction,  leaving  it  empty  and  contracted,  but  not  paralyzed. 

Peristalsis  above  the  obstruction  soon  ceases,  and  the  bowel  in  this  region 
becomes  greatly  distended  with  bloody  fecal  fluid  and  gas.     The  putrefaction 


II 12  Diseases  and  Injuries  of  the  Abdomen 

of  the  intestinal  contents  forms  great  quantities  of  gas:  none  of  it  can  pass  the 
obstruction  and  none  of  it  can  be  absorbed  because  of  circulatory  disturbance 
in  the  bowel  wall.  It  is  only  early  in  an  acute  obstruction  that  the 
distended  bowel  above  the  block  is  thin.  It  soon  becomes  congested  and 
edematous,  bleeding  may  occur  from  the  mucous  membrane  which  desqua- 
mates and  may  be  eroded.  When  the  mucous  membrane  is  desquamated, 
bacteria  pass  through  the  bowel  wall  and  cause  peritonitis,  or  erosions  may 
perforate.  Miles  ("A  System  of  Surgery,"  edited  by  C.  C.  Choyce)  points  out 
that  swelling  of  the  gut  is  greatest  when  obstruction  is  in  the  small  intestine 
because  "secretion  of  a  considerable  amount  of  fluid  is  refiexly  stimulated." 
The  distention  may  ascend  all  the  way  to  the  stomach. 

In  most  cases  strangulation  at  first  blocks  veins;  later,  in  severe  cases,  it 
also  blocks  arteries.  In  a  very  sudden  and  complete  strangulation  both  arte- 
ries and  veins  are  shut  off  simultaneously.  Early  in  the  case,  when  the  veins 
only  are  obstructed,  the  coil  of  gut  is  purple,  edematous  and  distended,  and 
bloody  serum  may  pass  into  the  lumen  of  the  bowel  and  also  into  the  cavity 
of  the  peritoneum.  Later  the  arteries  are  blocked  and  then  gangrene  soon 
occurs.  In  very  acute  cases  when  the  arteries  and  veins  are  blocked  simulta- 
neously, gangrene  arises  promptly.  In  such  a  case  the  strangulated  coil  is  not 
distended  and  is  gray  or  greenish  in  color.  When  strangulation  occurs  bacteria 
soon  begin  to  pass  through  the  walls  of  the  strangulated  coil  and  cause  peri- 
tonitis. Perforations  may  take  place  in  the  coil,  at  the  seat  of  constriction,  or 
even  in  the  gut  above  the  block. 

Chronic  Obstruction. — This  comes  on  gradually.  A  tumor  may  slowly 
fill  up  the  lumen  of  the  bowel  or  a  cicatrix  or  tumor  in  the  bowel  wall  may  con- 
strict more  and  more.  Pressure  outside  the  bowel  may  be  responsible.  In 
regions  where  the  feces  are  fluid  great  narrowing  can  occur  without  symptoms. 
When  fecal  passage  is  seriously  hindered  the  bowel  above  the  obstruction  be- 
comes distended  and  its  muscular  wall  undergoes  hypertrophy.  The  hyper- 
trophy depends  on  the  exercise  of  greater  and  greater  effort  to  overcome  the 
obstruction.  Miles  ("A  System  of  Surgery,"  edited  by  C.  C.  Choyce)  states 
that  above  the  obstruction  the  bowel  becomes  thick,  "elongated,  and  tortuous;" 
that  in  the  small  intestine  hypertrophy  exceeds  dilatation,  and  in  the  large  in- 
testine dilatation  exceeds  hypertrophy. 

The  mucous  membrane  is  inflamed  because  of  irritation  of  retained  decom- 
posed material  and  ulceration  may  occur.  Peri-intestinal  suppuration  may 
arise.  Gas  does  not  gather  above  the  obstruction  because  the  circulation  is  still 
active  in  the  bowel  wall  and  because  some  gas  can  still  pass  naturally.  When 
the  narrowed  channel  in  a  partially  obstructed  bowel  suddenly  and  completely 
closes,  acute  obstruction  arises.  When  it  does  the  bowel  above  becomes 
congested  and  distended.  An  active  .purgative  or  indigestible  food  may  be 
responsible  for  acute  obstruction. 

Various  Causes  of  Intestinal  Obstruction.  Obstruction  by  Adhe- 
sions (Fig.  689). — Adhesions  result  from  previous  peritonitis.  There  may  be 
a  few  adhesions  or  a  multitude  of  them.  A  portion  of  bowel  may  be  bent  or 
twisted  by  the  traction  of  adhesions  or  gaseous  movement  may  twist  a  coil  or 
bend  it  above  an  adhesion.  The  obstruction  may  be  acute  or  chronic.  Even 
when  acute,  strangulation  is  unusual. 

Volvulus  (Fig  690). — By  this  term  we  mean  twisting  of  a  loop  of  bowel  upon 
its  mesenteric  axis.  It  is  true  that  under  peculiar  circumstances  the  bowel  may 
twist  on  its  own  long  axis  because  of  adhesions,  but  such  a  twist  is  not  a  true 
volvulus.  Fifteen  per  cent,  of  acute  obstructions  are  due  to  volvulus  (Briggs, 
"Ohio  State  Med.  Jour."  Nov.,  191 2).  Volvulus  may  occur  in  a  hernial  sac. 
In  rare  cases  two  coils  of  intestine  twist  together.  It  is  not  limited  to  the  pel- 
vic colon,  but,  in  a  very  large  majority  of  cases,  it  is  this  portion  of  bowel  which 
suffers.     The  t^vist  may  be  partial,  a  complete  turn,  or  even  two  or  three  complete 


Volvulus 


III3 


Fig.  689. 


Fig.  690. 


Fig.  691. 


Fig.  692. 


Fig.  694. 


Fig.  695.  Fig-  696. 

Figs.  689-696. — Forms  of  intestinal  obstruction. 

Fig.  689.— Stenosed  ulcerated  tumor  of  the  pylorus;  coils  of  intestine  agglutinated  by 
numerous  adhesions.     Resected  intestinal  coils  (Pa>T). 

Fig.  690. — Volvulus  of  the  sigmoid  flexure  (Richardson's  case). 

Fig*.  691. — a,  Invaginatio  iliaca;  h,  invaginatio  ilia-ileocolica  (H.  Lorenz). 

Fig'.  692. — a.  Prolapsus  ilei;  h,  invaginatio  ileocolica  (H.  Lorenz). 

pjg  693  —Obstruction  of  the  jejunum  due  to  gall-stone,  showing  the  contraction  of  the 
muscular  fibers  of  the  intestine  upon  the  stone,  which  is  smaller  in  diameter  than  the  lumen  of 
the  gut  (Mixter's  case). 

Fig.  694. — Meckel's  diverticulum  (Bunts) .  ^ 

Fig.  695. — Hernia  into  the  fossa  duodenojejunalis  (after  Cooper/. 

Fig.  696. — Strangulation  by  a  band  (Warren  IMuseum). 


i'ii4  Diseases  and  Injuries  of  the  Abdomen 

turns.  This  very  dangerous  condition  occurs  particularly  in  adults.  A  colon 
loaded  with  feces  predisposes;  so  does  a  long  mesocolon  and  a  mesocolon  with  a 
narrow  base,  and  so  may  adhesions.  Rotation  may  be  caused  by  straining  at 
stool,  by  a  sudden  shift  in  position,  by  lifting,  by  a  blow  upon  the  abdomen,  or 
by  peristalsis  induced  by  an  active  purgative.  In  most  cases  the  twist  is  tight 
enough  to  occlude  the  blood-supply  of  the  loop.  The  loop  becomes  plum  col- 
ored and  edematous,  bloody  serum  flows  into  the  bowel  and  into  the  peritoneal 
cavity,  and  immense  distention  of  the  loop  occurs.  The  colon  above  the  obstruc- 
tion also  distends.  Peritonitis  occurs  early.  Perforation  may  occur  and  is 
most  apt  to  take  place  above  the  loop. 

Intussusception  (Figs.  691,  692). — By  this  term  we  mean  the  invagination  of 
a  portion  of  bowel  wall  into  the  lumen  of  an  adjacent  part  of  the  gut.  In  nearly 
all  cases  an  upper  segment  invaginates  into  the  lower.  One-third  of  all  cases  of 
obstruction  are  due  to  this  cause  (Treves).  In  young  children  it  usually  causes 
acute  obstruction;  in  an  adult,  chronic  obstruction,  ending  perhaps  in  an  acute 
attack.  Most  cases  of  obstruction  in  children  are  due  to  intussusception.  Pitt 
reports  that  in  St.  Thomas's  Hospital,  from  1875  to  1900  inclusive,  there  were 
115  cases  of  intussusception,  and  every  patient  was  under  fifty  years  of  age. 
Gibbon's  patient  was  fifty-eight.  Rutherford  Morrison  had  a  case  due  to 
polypus,  and  the  patient  was  sixty-two  years  of  age.  Males  are  twice  as  liable 
as  females.  During  the  performance  of  peristalsis  a  localized  circular  con- 
striction forms  and  the  invagination  takes  place  through  the  constricted  area. 
The  great  relative  frequency  of  intussusception  in  childhood  is  due  to  the  greater 
mobility  and  irritability  of  the  child's  bowel  (Treves).  The  irregular  and  local- 
ized spasm  is  due  to  bulky  or  irritant  material  within  the  gut,  and,  according  to 
Rushmore  ("Annals  of  Surgery,"  August,  1907),  the  starting-point  of  invagina- 
tion is  obstruction.  Were  peristalsis  alone  the  cause  the  condition  would  be 
far  more  common  than  it  is  in  the  diarrhea  of  children.  There  are  four  chief 
varieties:  the  ileocecal,  in  which  the  ileum  and  the  ileocecal  valve  pass  into  the 
cecum  and  colon;  the  colic,  in  which  the  large  intestine  is  prolapsed  into  itself; 
the  ileal,  in  which  the  small  intestine  alone  is  involved;  and  the  ileocolic,  in 
which  the  ileum  prolapses  through  the  ileocecal  valve.  Other  forms  are  diver- 
ticular (with  a  diverticulum),  retrograde  (due  to  reversed  peristalsis),  of  MeckeVs 
divert Ictdiim,  ileo-appendiceal,  and  cecal.  The  first  variety  is  vastly  the  most 
common.  In  Rushmore 's  table  ("Annals  of  Surgery,"  August,  1907)  the 
location  was  definitely  stated  in  237  cases:  140  of  these  were  ileocecal  and  31 
were  ileocolic. 

The  intiissiisceptum  consists  of  the  entering  tube  and  the  returning  layer. 

The  intussiiscipiens  is  the  sheath  or  receiving  tube.  As  the  intussusceptum 
grows  longer  and  longer  the  mesentery  is  drawn  between  the  entering  tube  and 
the  sheath.  The  mesentery  becomes  curved  and  draws  the  involved  intestine 
toward  the  back  and  left  side.  The  dragging,  twisting,  and  squeezing  of  the 
mesentery  impairs  the  blood-supply  of  the  intussusception.  The  invaginated 
portion,  especially  the  returning  tube  and  apex,  becomes  congested  and  swollen, 
the  mucous  membrane  secretes  profusely,  and  blood  passes  into  the  bowel. 
From  this  source  come  the  blood  and  mucus  passed  by  the  bowel.  An  intus- 
susception tends  to  become  irreducible  by  adhesion  of  its  walls  and  by  en- 
gorgement, particularly  of  the  apex.  An  intussusception  may  cause  complete 
obstruction  eventually,  strangulation  may  take  place,  gangrene  may  occur, 
peritonitis  may  arise. 

Foreign  Bodies,  Gall-stones,  and  Enteroliths  ((Fig.  693). — Foreign  bodies 
include,  besides  certain  substances  that  have  been  swallowed,  gall-stones  and 
enteroliths  or  intestinal  calculi.  Foreign  bodies  are  apt  to  lodge  in  the  lower 
portion  of  the  ileum  or  in  the  cecum,  and  they  may  cause  ulceration  at  the  seat 
of  lodgment.  If  a  gall-stone  is  sufficiently  large  to  cause  obstruction,  it  can- 
not have  passed  the  duct,  but  must  have  ulcerated  into  the  bowel  from  the  gall- 


Obstruction  by  Bands  and  Abnormal  Openings  mS 

bladder.  About  three-fourths  of  the  cases  of  gall-stone  intestinal  obstruction 
occur  in  women.  The  stone  is  arrested  at  some  point  because  either  local  spasm 
or  paralysis  of  the  bowel  has  developed.  It  may  be  arrested  high  up,  but  is 
most  apt  to  be  in  the  lower  ileum.  A  stone  under  i  inch  in  diameter  ought 
to  pass.  A.  W.  Mayo  Robson  ("Brit.  Med.  Jour.,"  May  i,  1909)  points  out 
that  all  cases  of  obstruction  due  to  gall-stones  are  not  the  result  of  mechanical 
obstruction  by  a  large  stone  which  entered  the  intestinal  canal  by  ulceration, 
but  that  there  are  three  other  possible  conditions,  viz.:  Local  peritonitis  in 
the  gall-bladder  region  causing  paralysis  of  the  bowel;  volvulus  of  the  small 
intestine  due  to  biliary  colic  or  to  ulceration  of  a  gall-stone  into  the  gut;  ob- 
struction coming  on  "after  the  original  cause  has  disappeared"  and  due  to 
adhesions  without  or  obstruction  within  the  gut. 

Enteroliths  (fecal  concretions)  are  usually  deposits  of  salts  from  the  feces, 
especially  apt  to  be  formed  when  the  patient  has  long  suffered  from  catarrhal 
inflammation  of  the  bowel.  The  nucleus  may  be  a  hair-ball  in  a  woman  who 
swallows  hair,  or  the  stone  of  a  fruit.  A  gall-stone  may  have  a  concretion  form 
about  it.  Food  residues  mixed  with  salts  may  constitute  concretions.  So 
may  insoluble  materials  taken  frequently  as  medicine  or  from  habit  (chalk, 
bismuth,  magnesia).  An  enterolith  increases  in  size  up  to  a  certain  point,  but 
seldom  becomes  enormous. 

Internal  Herniae  (Fig.  695). — These  include:  (i)  retroperitoneal  hernia, 
(2)  diaphragmatic  hernia,  and  (3)  other  intraperitoneal  hernia. 

A  hernia  may  pass  into  one  of  the  fossae  about  the  duodenum,  one  of  the 
fossae  about  the  cecum,  the  intersigmoid  fossae,  or  through  the  foramen  of 
Winslow  into  the  lesser  peritoneal  cavity.  Pringle  reported  a  case  of  hernia 
into  the  paraduodenal  fossa  ("  Glasgow  Med.  Jour.,"  1916,  Ixxxvi).  Inter- 
sigmoid retroperitoneal  hernia  is  one  of  the  rarest  of  lesions  and  only  three  cases 
have  been  reported  (John  B.  Murphy's  Clinics,  August,  19 14).  The  appendix 
may  be  strangulated  in  a  pericecal  fossa  and  cause  obstruction.  Diaphragmatic 
hernia  is  described  on  page  1302.  An  internal  hernia  may  become  strangulated 
just  as  an  external  hernia. 

Obstruction  by  Bands  and  Abnormal  Openings  (Fig.  696). — Briggs  con- 
siders adhesions,  bands  and  abnormal  openings  responsible  for  40  per  cent, 
of  cases.  The  band  may  be  a  portion  of  the  great  omentum  which  has  taken 
on  an  unnatural  attachment,  a  Meckel's  diverticulum,  omphalomesenteric 
remnants,  an  appendix  attached  at  its  tip,  a  broad  band  or  cord-like  peritoneal 
adhesion,  a  retroperitoneal  pouch  or  an  abnormal  opening  in  the  diaphragm. 
The  obstruction  in  these  cases  is  apt  to  be  acute  and  is  commonly  accompanied 
by  strangulation.  It  usually  involves  the  ileum,  sometimes  the  colon.  There 
may  be  an  abnormal  opening,  congenital  or  acquired,  in  the  omentum,  the 
mesentery,  or  the  mesocolon.  The  bowel  may  slip  through  such  an  opening 
and  be  caught  and  strangulated. 

Obstruction  may  take  place  by  Meckel's  diverticulum  (Fig.  694)  (see  page 
1 122),  a  structure  due  to  persistence  of  the  vitelline  or  omphalomesenteric  duct, 
coming  off  from  the  ileum  from  12  to  36  inches  above  the  ileocecal  valve,  and 
present  in  about  2  per  cent,  of  persons.  The  vitelline  duct  should  be  ob- 
literated in  the  eighth  week  of  fetal  life.  If  it  persists  the  individual  possess- 
ing it  is  in  constant  and  serious  danger.  The  mortahty  of  a  series  of  cases 
of  obstruction  due  to  Meckel's  diverticulum  is  enormous.  A  Meckel's  di- 
verticulum usually  has  no  mesentery,  is  from  3  to  10  inches  long,  and  arises 
from  the  convex  side  of  the  gut.  It  may  hang  free  or  may  be  attached  to  the 
umbilicus  by  its  tip  or  by  a  fibrous  cord  formed  by  the  obliterated  tip. 
In  some  cases  it  remains  open  at  the  umbilicus  (see  page  457).  In  other  cases 
a  cord  runs  from  the  umbilicus  to  the  gut  or  the  tip  of  the  diverticulum  or 
is  adherent  to  another  portion  of  the  intestine.  The  diverticulum  may  become 
gangrenous  with  or  without  strangulation,  may  enter  a  hernial  sac,  may  ulcer- 


iii6  Diseases  and  Injuries  of  the  Abdomen 

ate  or  perforate  like  an  appendix.  (W.  Sheen,  in  "  Bristol  Medico-Chir.  Jour.," 
Dec,  1901,  gives  an  admirable  account  of  "Some  Surgical  Aspects  of  Meckel's 
Diverticulum;"  see  also  article  on  "Obstruction  of  the  Bowels  by  Meckel's 
Diverticulum,"  by  James  E.  Moore,  in  "Jour.  Am.  Med.  Assoc,"  Oct.  4,  1902 
and  on  "Abdominal  Crises  Caused  by  Meckel's  Diverticulum  by  Miles  F. 
Porter,  in  "Jour.  Am.  Med.  Assoc,"  Sept.  23,  1905.)  Strangulation  of  the 
diverticulum  may  take  place  beneath  an  adherent  appendix,  a  Fallopian  tube, 
a  portion  of  mesentery,  or  the  pedicle  of  an  ovarian  tumor,  or  it  may  take  place 
in  an  omental  or  a  mesenteric  aperture.  Gangrene,  inflammation,  or  twist- 
ing may  occur.  Obstruction  may  be  due  to  invagination  of  the  diverticulum 
into  the  bowel.  H.  Tyrrell  Gray  collected  39  cases  of  invagination  and  added 
I  of  his  own,  40  in  all  ("Annals  of  Surgery,"  Dec,  1908). 

Cicatricial  Stricture. — This  is  not  a  common  cause.  I  have  operated  on  i 
case  due  to  the  scar  of  a  typhoid  ulcer.  The  obstruction  occurred  gradually 
and  became  acute  years  after  the  fever.  Any  healed  ulcer  may  be  responsible. 
Tuberculosis  is  the  most  common  cause.  Syphilis  or  dysentery  may  be  re- 
sponsible.    A  contusion  or  wound  of  the  bowel  may  be  causal. 

Tumors  of  the  Bowel. — They  are  uncommon  in  the  small  intestine.  Ade- 
noma, lipoma,  fibroma,  and  myoma  may  occur.  They  may  cause  obstruction 
from  blocking  or  may  be  responsible  for  intussusception.  Sarcoma  is  seldom 
met  with,  but  more  often  in  the  small  bowel  than  in  the  large  gut.  The  pa- 
tient's general  health  is  much  impaired,  and  a  tumor  can  be  palpated  before 
obstruction  occurs,  and  obstruction  may  never  occur.  Carcinoma  of  the  upper 
bowel  is  rarely  met  with.  Cancer  of  the  small  bowel  is  more  common  than 
benign  tumors  and  sarcoma,  but  less  common  than  cancer  of  the  large  bowel. 
Cancer  of  the  small  intestine  is  most  common  in  the  lower  ileum,  and  arises 
from  columnar  cells.  It  causes  constriction  and  stenosis  and  usually  ulcerates. 
In  the  large  intestine  fibroma,  lipoma,  adenoma,  myoma,  or  sarcoma  may  arise. 
I  removed  an  adenoma  from  the  sigmoid  which  had  produced  obstruction. 
Apparently  it  has  not  recurred  after  four  years.  A  great  number  of  adenomata 
may  be  present  {multiple  adenoma  of  Virchow).  Obstruction  is  rare  from  inno- 
cent tumors.  In  sarcoma  symptoms  are  absent  until  the  growth  attains  a  large 
size  and  obstruction  may  be  the  first  symptom.  Sarcoma  of  the  intestine 
causes  glandular  involvement  as  does  cancer.  The  colon  is  a  common  site  for 
cancer.  It  is  usually  primary,  but  may  be  secondary.  It  produces  chronic 
obstruction.  The  growth  is  columnar  celled,  and  may  be  scirrhous,  encephaloid, 
or  colloid.  A  tumor  causes  obstruction  by  a  block,  a  kink,  a  volvulus  or  an 
intussusception. 

Obstruction  by  Tumors,  etc.,  Outside  the  Bowel. — Among  the  causes  of 
such  obstruction  are  retroflexion  or  retroversion  of  the  womb,  especially  in 
pregnancy,  cysts  or  tumors  of  the  kidneys,  mesentery,  ovaries,  uterus,  etc,  mov- 
able kidney,  enlarged  spleen  or  diverticulum  of  the  bowel  (sigmoid  or  small 
bowel).  Obstruction  from  any  of  the  above  causes  takes  place  in  the  rectum, 
the  sigmoid  flexure,  or  the  colon  above  the  sigmoid. 

Obstruction  from  Fecal  Accumulation. — Fecal  impaction  resulting  from 
prolonged  constipation  is  quite  common.  Obstruction  sometimes,  but  seldom, 
occurs.  When  obstruction  follows  upon  impaction  it  is  usually  brought  about 
by  rotation  of  a  loop  of  bowel  (volvulus)  or  angulation  of  a  segment,  but  may 
be  due  to  abolition  of  peristalsis  because  of  paralysis.  In  impaction  the  fecal 
mass  is  usually  soft,  but  may  be  hard.  There  may  be  one  large  mass  or  numer- 
ous smaller  ones.  The  mass  may  reach  from  the  rectum  even  into  the  trans- 
verse colon  and  may  even  be  mistaken  for  a  neoplasm.  It  usually  begins  to 
form  in  the  pelvic  colon  (Miles,  "A  System  of  Surgery,"  edited  by  C.  C. 
Choyce).  The  weight  of  such  a  quantity  of  feces  may  cause  a  packed  loop  of 
gut  to  sink  into  the  pelvis  and  may  stretch  and  narrow  the  mesocolon. 
Ulcerations  of  the  mucous  membrane  may  form  [stercoral  ulcers). 


Symptoms  of  Intestinal  Obstruction  1117 

Postoperative  Obstruction. — Obstruction  may  come  on  a  day  or  two  after, 
several  or  many  days  after,  or  weeks  or  even  months  after  an  abdominal  opera- 
tion.    We  deal  here  with  early  obstruction. 

Obstruction  may  be  due  to  a  mechanical  cause  at  the  seat  of  operation 
(adhesion  of  the  bowel  to  a  raw  surface,  volvulus,  catching  of  the  gut  under  a 
band,  etc.).  It  may  be  due  to  a  mechanical  cause  distant  from  the  seat  of 
operation  (bands,  adhesions,  displacement  of  the  intestine,  etc.)  It  may  be 
due  to  thrombosis  of  the  mesenteric  vessels.  Although  any  one  of  the  above  con- 
ditions may  arise  after  an  operation,  there  is  nothing  special  and  peculiar  in  it 
when  it  does.  Such  conditions  are  considered  under  special  headings  (bands, 
adhesions,  etc.).  Again,  postoperative  obstruction  may  be  due  to  the  pressure 
upon  the  gut  of  gauze-packing  or  of  a  drainage-tube.  It  may  be  due  to  paralysis 
of  a  loop  of  gut  because  of  local  sepsis  (as  after  an  operation  for  appendicitis), 
or  it  may  be  a  paralytic  ileus  from  widespread  sepsis  (general  peritonitis). 

What  we  really  mean  by  postoperative  obstruction  is  a  condition  arising 
from  gaseous  distention.  Gas  begins  to  accumulate  soon  after  the  operation. 
The  patient  cannot  expel  it.  He  tries,  but  the  straining  efforts  fail  and  may 
burst  the  belly  wound.  More  and  more  gas  gathers  and  annoyance  becomes 
torture.  The  overdistended  bowel  finally  becomes  paralyzed  and  paralytic 
obstruction  occurs.  This  true  postoperative  obstruction  is  particularly  apt 
to  arise  if  evisceration  has  been  practised,  if  the  intestines  have  been  squeezed 
and  handled  and  not  protected  from  chill,  and  if  the  operation  has  been 
prolonged. 

Embolism  or  Thrombosis  of  the  Mesenteric  Vessels. — The  arteries  may 
be  the  seat  of  embolism  or  thrombosis;  the  veins,  of  thrombosis.  A  large 
artery  may  be  blocked  by  an  embolus  or  occluded  by  a  thrombus  or  a  large 
vein  may  be  blocked  by  a  thrombus  or  filled  by  the  extension  of  a  thrombus 
from  a  radical  of  the  portal  system  (especially  from  the  region  of  the  appendix). 
The  section  of  bowel,  large  or  small,  from  which  the  blood  is  kept  undergoes 
paralysis.  Gangrene  and  peritonitis  soon  follow.  This  ver\^  fatal  condition 
manifests  itself  in  most  cases  as  a  paralytic  obstruction  arising  suddenly  in  an 
individual  who  has  cirrhosis  of  the  liver  or  valvular  disease  of  the  heart,  or  who 
has  had  ulcerative  endocarditis. 

Reflex  Obstruction  of  Renal  Origin. — This  condition  may  occur  as  a  result 
of  Bright's  disease,  renal  calculi  and  infections  and  the  stomach  may  dilate  as 
w^ell  as  the  intestine  (see  Daniel  N.  Eisendrath,  in  "Surgery,  GynecologA^  and 
Obstetrics, '^  June,  1916).  This  reflex  paralysis  is  made  manifest  by  distention, 
sudden  obstruction,  vomiting  (which  does  not  become  feculent  early),  pain  and 
abdominal  rigidity.  The  condition  appears  to  be  due  to  splanchnic  inhibition 
(Eisendrath,  Ibid.). 

Pseudo -obstruction  or  Spasm  of  the  Intestine.- — In  this  condition  a  limited 
portion  of  the  bowel  undergoes  spasmodic  contraction,  which  lasts  for  several 
hours  or  even  for  a  day  and  then  passes  quickly  away.  This  contraction  is 
usually  in  the  pelvic  colon.  In  many  cases  a  swelling  can  be  made  out.  It  is 
due  to  a  loop  of  distended  gut  and  disappears  w^hen  the  patient  is  under  ether. 
Such  a  swelling  is  known  as  a  phantom  tumor.  These  attacks  occur  in  neurotic 
women,  especially  those  with  catarrh  of  the  colon.  Besides  the  causes  of  ob- 
struction above  mentioned  we  should  refer  to  shrinking  of  the    mesentery. 

Symptoms  of  Acute  Obstruction. — The  onset  is  marked  by  pain,  shock,  and 
A^omiting.  The  tighter  the  constriction,  the  more  sudden  is  the  attack;  the 
more  bowel  there  is  involved,  the  greater  the  shock.  This  element  of  shock 
often  makes  the  diagnosis  uncertain,  and  we  may  suspect  abdominal  hemorrhage 
or  perforation  when  the  real  lesion  is  strangulation.  The  pain  is  violent  and 
continuous,  with  fierce  exacerbations.  The  continuous  pain  is  due  to  the  con- 
striction; the  exacerbations,  to  the  colic  of  peristalsis.  If  the  small  intes- 
tine is  involved  the  continuous  pain  is  about  the  umbilicus.     If  the  large 


iii8  Diseases  and  Injuries  of  the  Abdomen 

intestine  or  duodenum  is  the  seat  of  trouble  the  continuous  pain  is  located 
about  the  lesion.  The  pains  of  peristalsis  are  generalized  throughout  the 
abdomen.  The  higher  up  the  constriction,  the  tighter  it  is,  and  the  more  bowel 
there  is  caught,  the  greater  the  pain.  Later,  when  paralysis  of  the  gut  occurs 
or  perforation  takes  place,  the  pain  for  a  time  abates,  to  recur  again  with 
peritonitis.  Early  in  the  case  there  is  neither  rigidity  nor  tenderness;  as 
paralysis  begins  tenderness  develops.  Early  in  the  case  pressure  may  actually 
afford  some  relief.  When  tenderness  exists  tapping  is  more  apt  to  cause 
pain  than  is  pressure;  in  peritonitis  pressure  causes  more  pain  than  tapping 
(Battle).  When  peritonitis  arises,  of  course  tenderness  becomes  acute  and 
rigidity  develops. 

Vomiting  comes  on  soon  after  the  development  of  pain,  but  does  not  give 
any  relief.  It  is  accompained  by  nausea  and  violent  retching,  continues  prac- 
ticallv  without  cessation,  and  whether  food  and  drink  are  taken  or  not. 

The  vomited  matter  consists  first  of  the  contents  of  the  stomach,  next  of 
quantities  of  bilious  matter,  and  finally  of  brown  or  yellow  stinking  fluid,  which 
was  long  believed  to  be  feces.  Vomiting  of  this  character  is  called  stercora- 
ceous  vomiting.  Vomiting  of  genuine  feces  may  occur,  but  is  rare.  In  stercora- 
ceous  vomiting  the  fluid  gushes  up  in  quantity  and  by  regurgitation  rather 
than  efforts  of  vomiting.  This  sort  of  vomiting  can  occur  even  when  the  ob- 
struction is  in  the  upper  jejunum  or  duodenum. 

A  notable  characteristic  of  obstruction  is  total  inability  to  pass  gas  or  feces. 
It  is  necessary  to  remember  that  in  the  very  beginning  of  the  case  there  may 
have  been  a  bowel  movement,  due  to  peristalsis  emptying  the  intestine  below 
the  seat  of  lesion.  A  single  movement  early  is  no  proof  that  the  condition  is 
not  obstruction.  It  is  only  in  cases  of  strangulation  in  the  pelvic  colon  that  the 
patient  has  a  strong  desire  and  makes  frequent  attempts  to  move  his  bowel. 
If  an  enema  is  given  it  is  usually  retained,  or  else  leaks  away  without  bringing 
fecal  matter  with  it.  Distention  from  gas  {tympaniies)  is  always  soon  present. 
The  lower  the  obstruction,  the  more  widespread  is  the  distention.  Early  in 
the  case  the  abdomen  is  flat  and  relaxed,  but  this  condition  is  very  temporary. 
We  may  be  able  to  gain  information  by  studying  the  distention.  If  both 
flanks  bulge,  the  block  is  in  the  pelvic  colon.  If  the  left  flank  is  flat  and  the 
right  distended,  the  block  is  in  the  colon  well  above  the  pelvic  colon.  If  only 
the  small  intestine  is  distended,  the  block  is  on  the  proximal  side  of  the  ileo- 
cecal valve.  As  the  case  progresses  distention  increases  and  causes  great 
embarrassment  to  respiration  by  pushing  up  the  diaphragm.  In  thin  patients, 
early  in  the  case,  we  may  occasionally  see  waves  of  peristalsis  above  the  ob- 
struction. We  can  sometimes  feel  them  even  when  they  are  unrecognizable 
by  the  eye.  In  many  cases  of  intussusception  and  in  a  number  of  cases  of 
chronic  obstruction  which  have  become  acute  they  can  be  felt. 

Cases  of  intestinal  obstruction  tend  to  pass  into  collapse.  This  condition 
is  due  to  the  absorption  of  poisons  from  the  decomposing  matter  above  the 
obstruction,  and  is  aggravated  by  vomiting  and  sweating  which  abstract  quan- 
tities of  fluid  from  the  blood.  When  collapse  has  come  on  the  temperature  is 
subnormal;  the  extremities  cold;  the  pulse  very  rapid  and  weak,  often  a  mere 
thread  or  trickle;  the  respirations  are  rapid  and  shallow,  and  the  face  Hippocralic 
(eyes,  cheeks  and  temples  sunken,  eyes  dull  and  often  turned  upward,  lids  droop- 
ing, nostrils  thin  and  drawn,  features  pinched,  the  nose  pointed,  the  malar 
bones  prominent,  ears  retracted  and  cold,  jaw  often  drooped  and  mouth  perhaps 
open,  lips  blue  or  blanched,  skin  livid  or  deadly  pale).  The  amount  of  urine 
passed  is  very  small.  The  higher  the  obstruction,  the  less  the  amount  passed. 
During  or  after  the  second  day  indican  is  usually  present  in  the  urine.  It 
results  from  putrefaction  of  proteids  brought  about  by  anerobic  bacteria  and  the 
formation  of  indol  in  the  intestine.     In  obstruction  there  is  leukocytosis,  the 


Diagnosis  of  Intestinal  Obstruction  1119 

white  count  being  from    15,000   to   30,000    (Bloodgood,   in   "Johns  Hopkins 
Hospital  Reports,"  vol.  vii). 

The  mortality  from  acute  obstruction  is  very  high.  According  to  Elsberg, 
gangrene  occurs  in  13  per  cent,  of  cases.  Seldom  can  a  mass  be  felt.  It  can 
often  be  felt  in  intussusception;  it  can  sometimes  be  palpated  when  there  is  a 
fecal  concretion  or  other  foreign  body.  Obstruction  during  pregnancy  is  very 
dangerous.  If  the  uterus  is  not  emptied  by  operation  most  cases  will  abort  or 
miscarry.  The  diagnosis  is- usually  made  disastrously  late  because  the  pain  of 
obstruction  is  thought  to  be  the  pain  of  parturition. 

Symptoms  of  Chronic  Obstruction. — The  symptoms  come  on  gradually. 
There  are  periods  when  great  constipation  exists,  alternating  with  periods  of 
comfort  or  perhaps  with  seizures  of  fluid  diarrhea.  After  a  time  the  attacks  of 
constipation  become  painful  and  accompanied,  it  may  be,  by  vomiting  after 
eating.  The  patient  feels  abdominal  discomfort  most  of  the  time  and  is  much 
annoyed  by  gas  in  the  intestine.  It  is  very  difficult  to  expel  the  gas  from  be- 
low. All  the  time  the  constipation  is  growing  more  obstinate  and  the  patient 
is  resorting  to  stronger  and  stronger  purgatives  and  obtaining  less  and  less 
response.  Finally,  a  strong  purgative  may  fail  utterly,  only  serving  to  cause 
severe  colic  and  perhaps  vomiting.  It  may  also  cause  pain  at  the  seat  of  the 
lesion.  Patients  in  this  condition  may  develop  attacks  of  diarrhea,  small 
amounts  of  feces  mixed  with  mucus  being  passed.  This  condition  is  due  to 
colonic  catarrh,  is  called  the  "diarrhea  of  constipation,"  and  affords  no  mitiga- 
tion to  the  discomfort  and  pain. 

During  the  progress  of  the  case  the  bowel  above  the  block  distends.  Be- 
cause of  the  hypertrophy  of  the  muscular  wall  of  the  gut  and  of  the  loss  of  flesh 
painful  peristalsis  (which  can  be  felt  and  seen)  is  often  noted  above  the  obstruc- 
tion. This  sign  is  detected  far  oftener  in  chronic  than  in  acute  obstruction. 
The  distended  intestine  showing  peristaltic  contraction  is  a  strong  suggestion 
of  chronic  obstruction.  The  painful  peristalsis  is  often  productive  of  rumbhng 
and  gurgling  noises  (borborygmi).  By  noticing  the  portion  of  gut  distended 
we  may  be  able  to  locate  the  seat  of  stenosis  (see  page  1118).  This  method 
is  more  valuable  in  chronic  than  in  acute  obstruction.  On  digital  examina- 
tion of  the  rectum  the  rugae  may  no  longer  be  felt  and  the  rectum  is  greatly 
distended  because  of  paralysis.     This  is  kno-v\Ti  as  rectal  haUooning. 

The  above-described  condition  may  cease  to  intermit  or  even  remit,  all  the 
symptoms  may  grow  progressively  worse,  constant  nausea  being  present, 
vomiting  ensuing  on  taking  food,  and  the  breath  being  horribly  foul.  Such  a 
patient  is  being  poisoned  to  death  by  putrefactive  toxins.  He  may  perish 
from  exhaustion,  from  perforation,  or  from  peritonitis.  At  any  time  during  the 
progress  of  chronic  obstruction  acute  obstruction  may  develop.  The  sudden 
complete  block  may  be  due  to  a  plug  of  hardened  feces  or  some  foreign  body.  It 
not  unusually  follows  the  taking  of  a  strong  purgative.  It  may  be  due  to 
volvulus  or  to  bending. 

In  some  cases  of  chronic  obstruction  a  tumor  may  be  palpated,  in  some 
intussusception  can  be  made  out,  in  some  there  is  a  history  of  antecedent  peri- 
tonitis, in  many  there  are  evidences  of  malignant  disease. 

Diagnosis. — The  determination  of  the  seat  of  lesion  requires  abdominal 
and  rectal  examination.  An  intussusception  may  sometimes  be  felt  by  a  fin- 
ger in  the  rectum  and  can  often  be  felt  by  palpation  of  the  abdomen.  Vaginal 
examination  may  be  demanded.  Pain  is  apt  to  arise  at  the  seat  of  obstruction 
or  to  radiate  from  there.  Abdominal  palpation  m.ay  detect  a  tumor.  Rec- 
tal insufflation  of  hydrogen  may  locate  the  obstruction  by  causing  great  dis- 
tention below  it.  Entire  suppression  of  urine,  early  vomiting,  absence  of 
abdominal  distention,  and  rapid  collapse  mean  obstruction  in  the  duodenum 
or  in  the  jejunum.  Early  vomiting,  a  rapidly  progressive  case,  with  great  dis- 
tention of  the  umbilical  region,  means  obstruction  of  the  ileum  or  the  cecum. 


II20  Diseases  and  Injuries  of  the  Abdomen 

Distention  of  the  entire  abdomen  and  of  the  flanks,  Unked  with  tenesmus, 
with  less  violent  symptoms,  less  rapidity  of  progress,  and  less  diminution  of 
urine  than  in  the  above-cited  forms,  means  obstruction  low  down  in  the  colon 
or  in  the  rectum.  An  old  test  for  obstruction  in  the  adult  large  intestine  is 
an  injection  by  a  fountain-syringe:  if  6  quarts  can  be  introduced,  there  is  no 
obstruction  in  the  large  intestine;  if  less  than  4  quarts  can  be  introduced,  there 
is  probably  obstruction  in  the  large  intestine.  This  test  is  unreliable.  The 
passage  of  a  sound  in  the  rectum  is  generally  useless  and  is  often  unsafe.  In 
many  cases  the  seat  of  the  lesion  and  the  cause  of  the  obstruction  can  be 
determined  by  exploratory  laparotomy  only. 

The  determindtion  of  ihe  causative  condUion  is  always  difficult  and  is  often 
impossible.  Intusstisception  may  arise  in  child  or  adult.  It  is  the  common 
cause  in  children.  Intussusception  may  induce  acute  or  chronic  obstruction. 
In  the  child  acute  obstruction  is  far  more  common  than  chronic  obstruction. 
In  most  cases  the  child  has  been  previously  healthy  except  for  constipation 
or  diarrhea.  The  attack  begins  with  a  violent  seizure  of  colicky  pain  and  vomit- 
ing, but  although  the  patient  be  pale,  there  is  seldom  shock  at  this  stage.  The 
vomiting  may  be  occasionally  repeated,  but  it  is  not  forcible  retching  and  very 
rarely  becomes  stercoraceous.  The  bowel  below  the  obstruction  is  often  emp- 
tied in  this  stage.  After  a  time  pain  abates  or  disappears,  to  recur  again  and 
again.  Between  the  seizures  of  pain  the  patient  often  appears  to  be  in  good 
condition,  with  a  normal  temperature  and  an  almost  normal  pulse.  Tenesmus 
soon  arises  in  most  cases,  bloody  mucus  in  small  quantities  being  passed  fre- 
quently. The  source  of  the  bloody  mucus  is  the  squeezed  and  congested  intus- 
susceptum.  A  sausage-shaped  mass  can  usually  soon  be  felt  somewhere 
over  the  large  intestine.  It  may  be  in  the  right  iliac  fossa  or  in  the  left  iliac 
fossa,  but  usually  over  the  region  of  the  transverse  colon.  Osier  reports  that 
a  mass  was  palpable  in  66  of  93  cases,  and  in  over  one-third  of  these  cases  it  was 
noted  the  first  day.  It  has  been  felt  as  early  as  three  hours  after  the  onset  of 
pain.  It  becomes  rigid  during  a  pain.  It  may  shift  its  position  hour  by 
hour,  and  it  may  disappear  after  having  been  obvious.  It  may  be  detected 
only  when  an  anesthetic  is  given.  Rectal  examination  gives  no  information  in 
early  cases  or  in  cases  involving  the  small  bowel  only.  In  late  cases  a  mass  may 
perhaps  be  felt  in  the  rectum.  The  abdomen  is  rarely  rigid,  distended,  or  tender 
until  late  in  the  case,  and  at  this  period  there  may  be  shock  r  sepsis.  In 
chronic  intussusception  in  a  child  the  condition  may  progress  very  slowly. 
The  stools  contain  bloody  mucus,  there  are  attacks  of  abdominal  pain,  a  lunip 
may  be  felt  along  the  colon  or  through  the  rectum,  and  peristalsis  may  be  visible. 
If  an  abdominal  lump  is  detectable  it  will  harden  during  colic  and  will  change 
its  position  from  day  to  day. 

Acute  intussusception  in  the  adult  seldom  presents  characteristic  features 
•unless  the  sausage-shaped  lump  can  be  detected. 

Chronic  intussusception  in  an  adult  causes  sudden  attacks  of  vomiting  and 
of  abdominal  colic  which  last  a  short  time  and  pass  away  as  suddenly  as  they 
arose.  Later  they  may  linger  longer.  A  lump  can  usually  be  made  out. 
There  may  be  constipation  or  mucous  diarrhea,  and  blood  may  be  passed  with 
the  mucus.     Acute  obstruction  usually  arises. 

Obstruction  from  adhesions  is  chronic  obstruction  which  may  become  acute. 
There  is  a  history  of  antecedent  peritonitis.  A  local  distention  of  the  intestine 
IS  often  noted.  In  obstruction  from  bands  there  is  a  record  of  antecedent 
peritonitis,  of  a  traumatism,  of  a  violent  effort,  or  of  pelvic  pain.  The  attack 
IS  sudden  in  onset,  is  fierce  in  character,  and  is  usually  excited  by  violent  ex- 
ercise or  the  taking  of  food.  Vomiting  is  early  and  intractable,  and  it  soon 
becomes  stercoraceous;  pain  is  violent;  peristalsis'  above  the  obstruction  is  forci- 
ble for  a  time;  tympanites  and  abdominal  tenderness  appear  after  the  attack  has 
lasted  for  some  little  time;  obstruction  is  complete,  not  even  gas  being  passed; 


Diagnosis  of  Intestinal  Obstruction  1121 

collapse  soon  arises;  no  tumor  can  be  detected,  and  rectal  examination  is  nega- 
tive. Volvulus,  which  is  usually  located  in  the  pelvic  colon,  is  far  commoner 
in  men  than  in  women,  in  the  middle  aged  than  in  those  at  the  extremes  of 
life.  It  is  usually  preceded  by  constipation.  The  symptoms  come  on  with 
explosive  suddenness  and  rapidly  attain  great  severity.  Obstruction  is  abso- 
lute; vomiting  is  late  and  is  rarely  stercoraceous;  no  tumor  can  be  detected; 
rectal  examination  is  negative;  abdominal  distention  is  early  and  pronounced, 
and  may  become  enormous;  peristalsis  above  the  volvulus  is  seldom  discovered; 
collapse  is  not  so  rapid  nor  so  grave  as  in  obstruction  from  bands  and  internal 
hernia.  There  is  severe  continuous  pain  with  frequent  exacerbations.  The 
pain  is  about  the  umbihcus  and  in  the  left  iliac  region  and  left  loin.  Tenderness 
is  soon  manifest  and  is  ominous,  as  it  means  peritonitis.  If  unrelieved,  death 
will  occur  in  from  forty-eight  to  seventy-two  hours.  Cases  of  incomplete  ob- 
struction by  volvulus  are  rarities.  Obstruction  hy  a  foreign  body  may  sometimes 
be  inferred  from  the  history  of  some  such  body  having  been  swallowed.  The 
obstructing  body  may  occasionally  be  felt  during  palpation  or  may  be  dis- 
covered by  the  .v-rays.  Abdominal  distress  may  exist  for  days  or  weeks  before 
obstruction  occurs.  Vomiting  is  late  and  is  rarely  severe,  but  pain,  tenderness, 
and  distention  are  marked.  In  obstruction  from  gall-stones  the  victim  is  elderly 
and  usually  stout.  There  may  be  a  history  of  one  or  more  attacks  of  hepatic 
colic,  but  often  the  only  history  is  of  what  was  supposed  to  be  painful  chronic 
indigestion.  When  the  stone  is  ulcerating  into  the  bowel  it  causes  localized 
pain  and  tenderness.  As  it  slowly  descends  along  the  intestine  it  may  be  ar- 
rested again  and  again,  causing  attack  after  attack  of  blocking.  When  the  gut 
becomes  really  blocked  pain  is  early  and  acute,  and  vomiting  is  invariable  and 
usually  becomes  stercoraceous.  There  is  seldom  much  tenderness.  Rigidity 
is  not  common.  Shock  is  seldom  present  at  the  onset.  Distention  is  not 
marked.     In  rare  cases  the  stone  can  be  palpated. 

In  obstruction  by  an  enterolith  the  patient  may  give  a  history  of  many  attacks 
of  supposed  enteritis  or  colitis,  followed  after  some  time  by  temporary  attacks 
of  obstruction.  The  calculus  in  rare  cases  can  be  palpated.  The  :r-rays  will 
show  it. 

In  obstruction  from  fecal  impaction  the  subject  is  usually  of  advanced  years, 
and  more  often  a  woman  than  a  man.  There  is  a  long  history  of  constipation, 
flatulent  indigestion,  abdominal  annoyance,  painful  straining  at  stool,  and  of 
repeated  attacks  of  the  diarrhea  of  constipation  (small  fluid  movements,  which 
bring  no  relief  because  the  solid  masses  remain  agglutinated  to  the  wall  of  the 
bowel).  The  colon  is  distended  by  a  mass  of  feces,  usually  dough-like,  but 
sometimes  hard,  which  is  appreciable  by  palpation.  Sometimes  hardened  or 
putty-like  masses  can  be  touched  by  a  finger  in  the  rectum.  In  such  a  subject 
acute  obstruction  may  at  any  time  arise.  It  is  characterized  by  severe  colic, 
great  distention,  and  often  by  vomiting,  but  the  vomiting  is  not  violent  and  is 
seldom  stercoraceous.  Collapse  soon  begins.  Obstruction  from  stricture  ox  from, 
pressure  comes  on  acutely  after  a  prolonged  period  of  disturbance,  during 
which  period  attack  after  attack  of  temporary  obstruction,  complete  or  partial,  has 
taken  place.  A  history  of  blood  or  pus  in  the  stools  suggests  tumor  of  the  bowel; 
a  history  of  blood  or  pus  having  been  absent  would  suggest  pressure  from  with- 
out. In  pseudo-obstruction  or  spasm  of  the  bowel  there  is  sudden  apparent  ob- 
struction occurring  in  a  neurotic  subject,  especially  a  female.  It  is  most  apt 
to  arise  in  a  victim  of  old  colitis,  or  in  one  who  has  very  recently  been  subjected 
to  an  abdominal  operation.  There  is  severe  pain,  vomiting,  distention,  and 
inability  to  pass  gas  or  fecal  matter.  The  attack  is  transitory,  lasting  a  few 
hours  or,  at  most,  a  day  or  two,  and  ceasing  as  suddenly  as  it  began.  Some- 
times a  limited  swelling  can  be  detected.  It  is  due  to  a  loop  of  distended  bowel 
and  results  from  a  contracted  segment  of  gut.  It  disappears  under  ether,  and 
is  called  a  phantom  tumor. 
71 


1 1 22  Diseases  and  Injuries  of  the  Abdomen 

The  presence  of  an  internal  hernia  is  not  thought  of  until  strangulation  takes 
place  and  seldom  then.  In  duodenal  hernia  the  patient  has  long  suffered  from 
pain  of  a  colicky  character.  There  is  "a  circumscribed  globular  swelling,  re- 
sembling a  movable  cyst,  except  that  it  is  resonant  on  percussion  and  yields 
intestinal  sounds  on  auscultation.  Owing  to  the  compression  of  the  inferior 
mesenteric  vein  at  the  neck  of  the  fossa,  the  patient  usually  suffers  from  piles 
which  bleed  freely"  (Alexander  Miles,  in  "A  System  of  Surgery,"  edited  by  C. 
C.  Choyce).  When  strangulation  occurs  shock  is  early  and  overwhelming,  and 
vomiting  is  early,  violent,  and  persistent.  Obstruction  from  pericecal  or  in- 
tersigmoid  hernia  is  not  diagnosticated  as  to  cause. 

In  hernia  into  the  foramen  of  Winslow  the  pain  is  violent  and  epigastric,  and 
in  this  region  there  is  a  swelling  which  gives  a  dull  note  on  light  and  a  tympanitic 
note  on  deep  percussion.     Diaphragmatic  hernia  is  considered  on  page  1302. 

Obstruction  due  to  embolism  or  thrombosis  of  the  mesenteric  vessels  is  announced 
by  colicky  abdominal  pain,  but  early  in  the  case  there  is  no  tenderness,  no 
rigidity,  and  no  distention.  Rigidity  comes  on  and  is  usually  general.  There  is 
usually  paroxysmal  abdominal  pain  but  the  pain  may  be  constant.  It  is  most 
acute  at  the  seat  of  lesion  and  there  is  tenderness  at  that  point.  As  the  dam- 
aged loop  is  not  unusually  in  the  pelvis  tenderness  may  be  found  by  rectal 
examination  (Elliot  and  Jameson,  in  "  Annals  of  Surgery,"  Nov.,  1915).  Pain 
in  the  loin  and  back  is  often  complained  of  (McArthur,  "Annals  of  Surg.," 
vol.  xxxiii).  Moderate  vomiting  may  occur  and  there  may  be  blood  in  the 
vomitus.  There  is  great  restlessness  and  usually  collapse.  There  may  be 
free  fluid  in  the  peritoneal  cavity.  Leukocytosis  is  noted,  the  polymorpho- 
nuclear leukocytes  being  increased.  In  one  group  of  cases  there  is  absolute 
obstruction.  About  60  per  cent,  of  the  cases  are  of  this  type.  In  another 
group  of  cases  there  is  watery  diarrhea  which  may  be  bloody.  Even  when 
bloody  diarrhea  does  not  occur  blood  may  perhaps  be  found  in  bowel  washings. 
Cardiac  disease  can  usually  be  demonstrated  and  albuminuria  is  common. 

In  true  postoperative  obstruction  (seepSLge  111  j) as  the  pulse  mounts  the  abdo- 
men distends,  usually  vomiting  comes  on,  and  there  is  an  almost  continuous 
regurgitation  of  brownish  putrid  fluid.  It  may  cease  for  an  hour  or  two,  when 
there  will  be  a  great  gush  of  the  fluid.  The  regurgitated  matter  may  contain 
blood.  There  is  seldom  pain  or  rigidity,  the  temperature  is  subnormal,  the 
extremities  are  cold,  and  the  face  is  Hippocratic  (see  page  11 18).  The  condition 
resembles  acute  gastric  dilatation.  The  cause  is  intestinal  paralysis.  The 
symptoms  of  postoperative  thrombosis  of  the  mesenteric  vessels,  according  to  A.  E.. 
Mavlard,^  are  as  follows:  Abdominal  pain,  perhaps  colicky  in  character, 
gradual  or  acute  in  onset,  and,  as  a  rule,  constant.  Early  in  the  case  there  is  no 
abdominal  tenderness,  no  distention,  and  no  rigidity.  The  pulse  is  rapid, 
the  patient  is  extremely  restless,  there  may  be  vomiting,  but  it  is  never  violent, 
as  in  acute  obstruction;  often  there  is  diarrhea,  and  sometimes  bloody  diarrhea. 
These  symptoms  become  particularly  significant  if  there  be  cardiac  or  vascular 
disease. 

Obstruction  from  McckeVs  diverticulum  is  usually  acute,  but  is  sometimes 
chronic,  and  occurs  particularly  in  young  adults  and  children.  It  has  been 
stated  that  other  and  visible  deformities  are  usually  present,  but  in  a  study 
of  6q  c^ses  by  A.  E.  Halstead^  this  was  true  of  but  i  case,  in  which  harelip 
existed.  In  obstruction  from  Meckel's  diverticulum  there  is  often  a  history 
of  former  mild  attacks  (Ibid.).  Halstead  sums  up  the  symptoms  as  follows: 
As  the  obstruction  is  high  up,  the  abdomen  has  the  shape  of  an  inverted  cone; 
early  in  the  attack  there  is  often  local  meteorism,  especially  under  the  costal 
arch  of  the  right  side,  but  there  is  no  distention  in  the  flanks.  Early,  active 
peristalsis  may  be  \dsible.     The  tenderness  is  just  to  the  right  of  the  umbilicus, 

•  "Brit.  Med.  Jour.,"  Nov.  16,  1901. 
2  ".Annals  of  Surgery,"  April,  1902. 


Treatment  of  Intestinal  Obstruction  1123 

on  a  level  with  it  or  below  it.  In  most  cases  there  is  early  fecal  vomiting. 
Gray  ("Annals  of  Surgery,"  Dec,  1908)  describes  invagination  of  the  diver- 
ticulum into  the  bowel.  The  average  age  for  those  attacked  is  fifteen  years. 
Such  cases  give  a  history  of  previous  abdominal  crises  due  to  twisting,  inflamma- 
tion, or  slight  invagination.  The  acute  attack  is  apt  to  begin  while  the  patient 
is  active.  Gray  says  that  about  30  per  cent,  of  the  patients  pass  blood;  that 
the  pain  is  umbilical  and  usually  very  violent;  that  tenderness  is  seldom  acute 
unless  there  be  peritonitis;  that  there  may  be  an  abnormal  umbilical  cicatrix; 
that  in  a  minority  of  cases  there  is  a  palpable  abdominal  mass,  and  that  the 
mortality  after  operation  in  acute  cases  is  nearly  60  per  cent. 

Differentiation  of  Intestinal  Obstruction  from  Other  Diseases. — Always  ex- 
amine for  a  strangulated  hernia  at  every  hernial  outlet.  If  obstruction  is 
complicated  by  an  irreducible  hernia  above  the  seat  of  lesion,  the  hernia, 
if  it  contains  gut,  will  always  enlarge  and  become  tender  because  of  accumu- 
lation of  feces.  Functional  obstruction  may  attend  peritonitis  or  may  follow 
the  reduction  of  a  hernia.  In  this  condition,  if  peritonitis  be  absent,  there  is 
no  pain,  no  tenderness,  no  tumor,  no  tendency  to  collapse,  but  simply  absolute 
constipation,  distention,  and  perhaps  non-stercoraceous  vomiting.  Appen- 
dicitis with  peritonitis  may  cause  symptoms  similar  to  those  of  obstruction; 
but  there  is  fever,  a  history  of  pain  in  the  right  iliac  fossa,  and  the  vomiting 
is  not  stercoraceous.  Acute  pancreatitis  produces  symptoms  so  similar  to 
those  of  intestinal  obstruction  that  a  diagnosis  cannot  always  be  made  (see 
page  1 19 7).  We  must  consider  in  the  diagnosis  perforation  of  a  gastric  or  duo- 
denal ulcer,  rupture  of  an  extra-uterine  pregnancy  or  a  pus  tube,  strangulation 
of  the  pedicle  of  an  ovarian  tumor,  renal  colic,  and  hepatic  colic.  Poisoning  by 
ptomain,  arsenic  or  by  corrosive  sublimate  should  not  be  confounded  with 
intestinal  obstruction. 

Prognosis. — -Without  surgical  interference  most  cases  of  acute  intestinal 
obstruction  die  within  ten  days — usually  within  seven  days.  In  volvulus 
death  may  occur  in  forty-eight  or  seventy-two  hours.  It  may  occur  as  early  in 
obstruction  by  a  band,  in  internal  hernia,  or  mesenteric  blocking.  Death  may 
be  due  to  shock,  to  exhaustion,  to  perforation,  to  peritonitis,  or  to  obstruc- 
tion of  respiration  and  circulation  by  tympanites.  Recovery  occasionally, 
but  very  rarely,  happens  by  the  formation  of  a  fistula  externally  or  into  another 
portion  of  the  bowel.  In  acute  obstruction  frorn  foreign  bodies  the  obstructing 
body  occasionally  passes.  Volvulus  and  strangulation  by  bands  are  almost 
invariably  fatal  unless  an  operation  is  performed.  In  intussusception  recovery 
occasionally  follows  the  sloughing  away  of  the  prolapsed  gut,  but  stricture 
almost  inevitably  results  from  this  rare  event.  Functional  obstruction  gives 
a  good  prognosis.  The  mortality  is  from  40  to  50  per  cent.  Deaver  and  Ross 
("  Annals  of  Surgery,"  191 5,  Ixi)  give  the  statistics  of  276  cases  of  acute  intestinal 
obstruction.  The  mortality  was  42  per  cent.  The  earlier  the  diagnosis  and  the 
more  prompt  the  operation  the  less  the  mortality.  In  the  table  of  Deaver  and 
Ross  (Ibid.)  the  mortality  of  strangulated  hernia  was  33.5  per  cent.  Obstruc- 
tion from  postoperative  adhesions  had  a  mortality  of  49.3  per  cent.  The 
mortality  from  intussusception  was  40  per  cent.  The  prognosis  of  chronic 
obstruction  depends  upon  the  causative  lesion.  It  does  not  threaten  life 
immediately  to  anything  like  the  degree  that  acute  obstruction  does. 

Treatment, — In  any  abdominal  case  in  which  the  diagnosis  is  uncertain 
and  the  patient  is  shocked  give  an  enema  of  brandy  and  hot  water,  wrap  the 
patient  in  blankets,  surround  him  with  hot- water  bottles,  and. study  the  develop- 
ment of  symptoms  and  signs.  In  half  an  hour,  as  a  rule,  reaction  will  be  brought 
about  and  a  probable  diagnosis  may  be  made  (Greig  Smith).  In  acute  obstruc- 
tion it  is  usually  customary  to  empty  the  stomach  by  lavage  and  to  evacuate 
the  rectum  by  means  of  copious  injections  given  while  the  patient  is  in  the 
knee-chest  position.     The  emptying  of  the  stomach  is  imperative  if  stercora- 


1 1 24  Diseases  and  Injuries  of  the  Abdomen 

ceous  vomiting  has  been  going  on,  for  vomiting  of  a  quantity  of  such  material 
while  a  patient  is  taking  ether  may  cause  death  by  drowning,  the  fluid  flowing  in 
enormous  quantity  into  the  bronchi.  In  very  severe  cases  a  general  anesthetic 
cannot  be  given  and  the  belly  must  be  opened  under  cocain.  Hutchinson's 
method  of  taxis  and  massage  is  uncertain,  and  is  as  liable  to  inflict  harm  as  to 
confer  benefit.  Some  surgeons  apply  constant  compression  to  the  abdomen  by 
means  of  straps  of  adhesive  plaster.  Puncture  of  the  intestine  by  an  aseptic 
hypodermatic  needle  (introduced  obliquely)  to  relieve  gaseous  distention  is  a 
decidedly  dangerous  proceeding.  The  passage  of  a  small  tube  from  the  anus 
as  high  as  possible  will  empty  the  colon  of  gas  if  no  obstruction  intervenes.  In 
intussusception  it  is  the  custom  of  some  surgeons  to  give  no  food  by  the  stomach; 
administer  opium  and  belladonna  to  arrest  peristalsis,  wash  out  the  rectum  with 
copious  injections,  give  an  anesthetic,  and  insufflate  hydrogen  gas  or  carbonic- 
acid  gas  in  order  to  distend  the  bowel.  Other  surgeons  treat  intussusception 
by  forcing  air  into  the  rectum  by  means  of  an  ordinary  bellows,  and  others 
inject  water  by  a  fountain-syringe,  the  reservoir  being  at  a  height  of  3  feet. 
D'Arcy  Power  believes  in  the  value  of  hydrostatic  pressure  in  intussusception 
in  children.  He  states  that  the  child  should  be  anesthetized  and  the  large 
intestine  filled  gradually  with  hot  saline  fluid,  the  reservoir  not  being  raised 
more  than  3  feet  above  the  patient.  The  fluid  should  be  retained  for  ten  minutes. 
My  own  feeling  is  that  whereas  it  may  be  justifiable  to  try  to  reduce  intussuscep- 
tion by  gaseous  or  hydrostatic  pressure  during  the  first  twenty-four  hours  of  the 
attack,  early  operation,  except  in  newborn  infants,  gives  a  better  prognosis  and 
is  safer  and  more  certain.  Without  opening  the  abdomen  it  is  impossible  to 
know  the  condition  of  the  intestine.  Gangrene  may  occur  early  (it  has  been 
found  in  less  than  four  hours  after  the  onset  of  symptoms),  and  if  gangrene 
exists  gaseous  distention  or  hydrostatic  pressure  will  cause  death.  Rushmore's 
reported  case  shows  that  there  may  be  "no  systemic  symptoms  to  indicate  the 
presence  of  gangrene"  ("Annals  of  Surgery,"  August,  1907).  Another  point 
against  conservative  treatment  is  the  common  uncertainty  as  to  whether  com- 
plete reduction  has  been  accomplished.  Vomiting  may  continue  for  hours  after 
genuine  reduction  and  the  bowels  may  not  move  for  some  time.  Waiting  to  be 
sure  that  reduction  has  been  accomplished  will  probably  be  responsible  for  death 
if  reduction  has  not  been  obtained.  After  the  first  twenty-four  hours  it  is  never 
justifiable  to  use  gaseous  or  hydrostatic  pressure  because  of  the  great  risk  that 
ulcer  or  gangrene  may  exist.  Pressure  cannot  be  accurately  regulated,  and  if 
the  bowel  is  much  damaged,  may  lead  to  rupture.  If  the  case  is  not  seen  until 
after  the  first  day,  or  if  injections  have  been  used  and  have  failed,  all  surgeons 
believe  that  laparotomy  should  be  performed. 

Frederick  Holme  Wiggin  has  made  a  study  of  the  reported  cases  of  lap- 
arotomy for  infantile  intussusception,  and  considers  that  operation  done  within 
the  first  forty-eight  hours  will  give  a  mortality  of  22.2  per  cent.^  (see  Operation 
for  Intussusception).  In  very  young  infants  the  mortality  of  laparotomy  is 
very  high,  and  it  is  a  fair  question  if  on  them  immediate  laparotomy  should  be 
advised  without  a  trial  of  conservative  methods,  if  the  case  is  seen  during  the 
first  twelve  or  twenty-four  hours.  The  mortality  of  operation  is  very  large  on 
those  under  eighteen  months  of  age.  But  even  in  those  under  six  months  of  age 
Wiggin  thinks  the  mortality  after  operation  is  not  above  22.2  per  cent.,  if 
operation  is  done  within  forty-eight  hours,  and  my  personal  feeling  is  that  opera- 
tion should  be  the  method  of  treatment  even  in  the  case  of  a  young  baby. 

I  agree  with  Rushmore  that  operation  done  during  the  first  twelve  hours 
would  greatly  reduce  the  mortality,  perhaps  to  the  figures  he  expects  would 
follow  such  a  practice,  vi?..,  12.5  per  cent. 

In  obstruction  of  the  main  mesenteric  vessels  operation  is  of  no  avail. 
In  obstruction  of  branches  it  may  be  possible  to  resect  the  involved  region  of 

i"Med.  Record,"  Jan.  18,  1896. 


Treatment  of  Intestinal  Obstruction  1125 

bowel,  a  region  which  is  found  to  be  gangrenous  or  becoming  so.  Reich  in 
reporting  upon  91  cases  operated  upon  by  resection  and  anastomosis,  records 
18  recoveries  (quoted  by  ElHot  and  Jameson,  in  "Annals  of  Surgery,"  Nov., 

1915)- 

Some  surgeons  advocate  resection,  sewing  of  the  divided  ends  in  the  wound 
and  the  subsequent  performance  of  end-to-end  suture.  This  shortens  the 
primary  operation  and  saves  the  patient  from  the  great  danger  of  leakage  at 
the  point  of  anastomosis  because  of  spread  of  the  thrombosis  (Jackson,  Porter 
and  Quimby,  in  "Jour.  Am.  Med.  Assoc,"  1904). 

Obstruction   in   pregnancy  is  very  fatal.     The  uterus  should  be  emptied' 
before  the  obstruction  is  attacked.     Some  advise  vaginal  others  abdominal  sec- 
tion.    Then  the  obstruction  should  be  relieved  surgically.     In  most  cases  it  is 
due  to  bands. 

In  obstruction  from  fecal  impaction  use  large  rectal  injections  and  give  small 
repeated  doses  of  salines  or  of  castor  oil.  If  there  are  signs  of  inflammation,  do 
not  give  cathartics,  even  in  small  doses,  but  give  opium  and  belladonna  to  arrest 
vomiting  and  to  relax  spasm.  Impactions  in  the  rectum  can  be  removed  by  the 
use  of  a  spoon.  In  acute  intestinal  obstruction  do  not  delay,  but  open  the  abdo- 
men, if  possible,  before  collapse  comes  on,  and  find  the  cause  of  the  obstruction. 
If  it  is  a  gall-stone  or  enterolith,  try  to  crush  it  without  opening  the  intestine; 
if  this  fails,  push  it  up  a  little  distance,  incise  the  bowel,  remove  the  stone,  and 
close  the  incision  with  Halsted  sutures.  Pilcher^  collected  40  cases  operated 
upon  for  gall-stone  obstruction,  with  21  deaths.  If  there  is  fecal  obstruction, 
break  up  the  masses  by  pressure  and  push  the  fecal  plug  down  without  opening 
the  bowel.  If  there  is  intussusception,  reduce  the  prolapse  and  shorten  the 
mesentery;  but  if  reduction  be  impossible,  perform  a  resection  and  enterorrhaphy, 
or  make  an  artificial  anus.  In  volvulus  untwist  and  shorten  the  mesentery; 
but  if  this  be  impossible,  treat  as  an  irreducible  invagination.  In  obstruction 
from  adhesions  try  to  separate  them  and  straighten  out  the  bowel,  stitching 
healthy  peritoneum  over  each  raw  spot  to  prevent  recurrence.  In  obstruction 
by  a  band,  free  the  loop  and,  if  it  be  gangrenous,  resect  or  follow  the  plan  of 
Mikulicz  (seepage  11 26).  Anastomosis  may  be  necessary.  In  flexion  separate 
the  intestines,  remove  the  flexion  by  a  V-shaped  incision,  and  suture  the  wound 
in  the  bowel.  In  chronic  obstruction  it  is  often  advisable  to  perform  an  explora- 
tory laparotomy,  discover  the  condition,  and  determine  what  is  to  be  done  to 
correct  it.  Some  tumors  external  to  the  bowel  may  be  removed.  Growths  in 
the  bowel  wall  may  be  removed  by  resection  of  the  involved  portion  of  intestine, 
or  an  anastomosis  may  be  performed,  or  it  may  be  necessary  to  make  an  artificial 
anus.  In  obstruction  from  Meckel's  diverticulum  that  structure  may  be  found 
twisted,  the  gut  near  it  may  be  kinked  or  twisted,  or  the  diverticulum  may  act 
as  a  band,  the  bowel  being  caught  under  it  or  kinked  over  it.  Intussusception 
of  the  gut  below  it  sometimes  occurs ;  so  does  invagination  of  the  mucous  mem- 
brane of  the  diverticulum;  so  does  chronic  inflammation  and  cicatricial  narrow- 
ing of  the  diverticulum  or  gut  (Halstead).  The  diverticulum  may  be  gangre- 
nous, perforated,  or  cystic.  In  internal  hernia  the  constriction  must  be  divided 
and  the  bowel  removed  from  the  fossa.  Any  gangrenous  gut  should  be  resected 
if  the  patient's  condition  justifies  it,  or  Mikulicz's  plan  should  be  followed 
(see  page  11 26). 

After  opening  the  abdomen  the  surgeon  must  be  guided  by  conditions. 
The  diverticulum  should  be  removed,  just  as  the  appendix  is  removed  in  appen- 
dicitis, and  complications  relating  to  the  gut  must  be  dealt  with. 

The  mortality  after  operations  for  acute  intestinal  obstruction  is  very  high 
(from  40  to  50  per  cent.).  If  the  diagnosis  were  made  earlier,  operations  would 
be  done  earlier  and  the  mortality  would  be  much  less.  Nine  out  of  10  of  these 
cases  that  I  see  in  hospital  work  are  gravely  shocked  and  practically  dying  on 

1  "Med.  News,"  Feb.  8,  1902. 


II26 


Diseases  and  Injuries  of  the  Abdomen 


admission.  If  a  patient  with  obstruction  be  very  gravely  shocked,  I  usually 
follow  Moynihan's  plan,  of  simply  opening  the  bowel  and  draining  it  in  its 
most  distended  coil  without  any  search  being  made  for  the  lesion.  The  object 
is  to  drain  the  poisons  from  the  intestine,  poisons  which  are  the  active  agents 
in  killing  the  patient.  The  abdomen  is  opened  under  cocain,  the  incision  being 
small.  A  distended  coil  of  intestine  is  sutured  to  the  peritoneum  about  the 
abdominal  incision,  every  care  being  taken  that  the  stitches  do  not  penetrate 
the  mucous  membrane  of  the  gut  (Moynihan).  A  purse-string  suture  is  now 
inserted  so  as  to  enclose  an  area  of  the  exposed  gut;  an  incision  is  made  into  the 
gut  in  this  enclosed  area,  and  gas  and  feces  flow  out.  Paul's  glass  tube  (see 
Fig.  804)  is  passed  into  the  gut  and  the  purse-string  suture  is  tied.     Instead  of 

Paul's  tube  we  may  use 
a  rubber  tube  sutured  as 
is  the  tube  in  Kader's 
gastrostomy  (Elsberg,  in 
"Annals  of  Surgery," 
May,  1908).  The  ob- 
struction is  thus  tempo- 
rarily relieved,  and  if  the 
patient  recovers,  the 
causative  lesion  may  be 
subsequently  sought  for 
and  attacked.  If  a  fecal 
fistula  follows  the  enter- 
ostomy and  refuses  to 
close,  it  may  be  closed  by 
operation.  If  Elsberg's 
plan  is  followed  a  persist- 
ing fecal  fistula  will  be 
rare.  My  colleague,  Pro- 
fessor Francis  T.  Stewart, 
has  devised  a  method  by 
which  the  bowel  can  be 
drained  without  any  risk 
of  infection  of  the  peri- 
toneal cavity,  a  risk  which 
always  exists  in  using 
Paul's  tube.  Stewart 
places  a  clamp  at  either 
extremity  of  the  loop  of 
bowel  and  surrounds  it 
with  gauze.  One-half  of 
a  Murphy  button  is  in- 
serted into  the  empty  loop  through  a  small  incision.  The  other  half  of  the  button 
is  squeezed  into  a  rubber  tube  the  diameter  of  which  is  somewhat  smaller  than  the 
flange  of  the  button.  The  two  parts  of  the  button  are  then  clamped,  and  the 
clamps  are  removed  from  the  loop  of  bowel.  The  intestine  is  sutured  to  the  wound 
margins  and  the  feces  drain  into  a  receptacle  on  the  floor.  Fig.  697  shows 
Stewart's  operation.  In  any  case  of  intestinal  obstruction  if  gangrene  exist 
the  temptation  to  do  immediate  resection  is  strong.  I  have  done  it  a  number  of 
times  with  a  very  large  mortality.  Of  late  I  have  been  following  the  plan  of 
Mikuhcz  and  results  have  been  far  better.  The  gangrenous  loop  is  brought 
outside  of  the  abdomen,  it  is  fixed  parallel  to  the  wound,  and  enterostomy  is  per- 
formed above  it.  The  loop  is  dealt  with  later.  If  a  fecal  fistula  forms  it  is 
subsequently  closed  by  appropriate  methods.  Postoperative  obstruction  com- 
ing on  soon  after  a  surgical  operation  is  often  not  recognized  for  a  time,  and 


Fig.  697. — Stewart's  method  of  enterostomy. 


Fecal  Fistula  and  Artificial  Anus 


1127 


the  surgeon  will  be  in  doubt  as  to  whether  he  is  dealing  with  peritonitis  or  in- 
testinal paresis  or  both.  When  distention  becomes  evident  after  an  operation  we 
should  wash  out  the  stomach  with  warm  salt  solution,  administer  salines  in  small 
doses  frequently  repeated,  and  employ  enemata.  Many  surgeons  give  two  or 
three  doses  of  atropin  hypodermatically  at  intervals  of  two  hours.  Each  dose 
should  be  \'2  0  0  gr •  Atropin  is  given  with  the  idea  that  it  increases  peristalsis  and 
contracts  blood-vessels.  It  is  probably  merely  sedative,  relaxes  spasm,  and  is 
useless  if  strangulation  exists.  Eserin  stimulates  the  muscular  coat  of  the  intes- 
tines. There  seems  to  be  no  doubt  that  eserin  given  soon  after  an  operation  tends 
to  prevent  distention.  A  better  plan  than  the  administration  of  atropin  is  to  give 
hypodermatically  ^  39  gr.  of  eserin  (physostigmin  salicylate)  and  j^^o  gr-  of  strych- 
nin every  hour  until  four  doses  have  been  taken.  During  fifteen  minutes  of  this 
period  carry  the  heated  Paquelin  cautery  to  and  fro  over  the  abdomen,  not  touch- 
ing the  skin,  but  near  enough  to  it  to  cause  distinct  reddening.  The  intestinal 
tract  should  be  gone  over  systematically  with  the  cautery,  first,  the  stomach  and 
small  intestine,  then  the  large  intestine.  Pituitrin  is  an  extract  of  the  posterior 
lobe  of  the  pituitary  gland.  When  given  intravenously  or  subcutaneously 
it  raises  blood-pressure,  is  a  diuretic,  and  stimulates  involuntary  muscle 
fiber.  It  is  useful  in  cases  of  flatulent  distention.  It  comes  in  ampoules  each 
of  which  contains  i  c.c.  The  dose  is  one  to  two  ampoules,  repeated  in  two 
hours.  I  have  seen  electricity  succeed.  A  continuous  current  battery  is  used 
and  it  must  be  able  to  furnish  50  milliamperes.  The  patient  lies  upon  the 
back  and  a  flat  electrode  covered  with  chamois  damp  with  salt  solution  is  fast- 
ened to  the  negative  pole  and  is  placed  upon  the  belly.  The  rectal  electrode  is 
fixed  to  the  positive  pole  and  inserted  in  the  rectum.  This  electrode  is  tunneled 
and  through  the  tunnel  salt  solution  is  introduced  into  the  rectum.  This  so- 
lution protects  the  mucous  membrane  and  diffuses  the  current.  The  cur- 
rent is  now  turned  on.     At  first  the  galvanometer  should  register  10  milliamperes. 


Fig.  698. — Fecal  fistula:  a.  Direction 
of  fecal  flow;  h,  b,  belly  wall. 


Fig.  699. — Artificial  anus,  showing  spur: 
a,  Spur;  b,  b,  belly  wall;  c,  direction  of 
fecal  flow. 


The  current  is  slowly  increased  to  30  or  40  milliamperes.  Every  five  minutes 
the  place  of  the  abdominal  electrode  is  changed  and  the  current  is  reversed,  the 
galvanometer  being  brought  to  zero  while  effecting  reversal.  It  is  common  for 
gas  to  escape  and  then  feces.  If  the  salt  solution  should  be  expelled  more  must 
be  introduced.  Fecal  matter  may  appear.  The  current  may  be  used  for 
fifteen  minutes  and  the  procedure  may  be  repeated  in  three  or  four  hours  (the 
above  directions  are  from  a  valuable  book,  rich  in  practical  surgery,  viz.,  Stewart 
McKay,  on  the  "Preparation  and  After-treatment  of  Section  Cases.") 

If  these  measures  are  not  soon  followed  by  the  passage  of  flatus  or  feces, 
open  the  abdomen;  never  wait  for  the  advent  of  stercoraceous  vomiting. 

Fecal  Fistula  and  Artificial  Anus. — A  fecal  fistula  is  an  abnormal  open- 
ing in  the  intestine  through  which  gas  or  a  portion  of  the  feces  escapes  (Fig. 
698).  If  all  the  intestinal  contents  escape  through  the  opening,  it  is  called 
an  artificial  anus  (Fig.  699,  Senn).  A  surgeon  may  make  a  fistula  deliberately 
{intentional  fistula).  A  fistula  may  be  the  product  of  disease  or  injury  (acci- 
dental fistula).  Senn  enumerates  the  following  causes  of  accidental  fistula: 
wounds,  injury  of  the  intestines,  intestinal  ulceration,  intestinal  strangulation, 
foreign  bodies  in  the  intestinal  canal,  malignant  tumors,  actinomycosis,  pelvic 


1 1 28  Diseases  and  Injuries  of  the  Abdomen 

and  abdominal  abscess,  appendicitis,  injury  of  the  bowel  during  an  abdominal 
operation,  the  application  of  ligatures,  catching  by  sutures,  and  the  employ- 
ment of  drainage-tubes. 

Treatment. — Many  fistulae  close  spontaneously.  This  can  be  hoped  for 
only  if  the  opening  is  quite  small,  if  the  general  health  of  the  patient  is  good, 
if  the  cause  has  passed  away,  if  the  fistula  is  not  lined  with  mucous  mem- 
brane, and  if  there  is  no  spur  (spur  is  showTi  at  a,  Fig.  699).  In  most  cases 
of  fistula  not  high  up  it  is  well  to  give  Nature  a  chance  to  effect  a  cure,  and 
not  to  be  in  a  hurry  to  operate.  Most  fistulae  in  the  large  bowel  heal  sponta- 
neously. The  part  is  cleansed  frequently  with  peroxid  of  hydrogen,  the  patient 
is  kept  recumbent,  food  is  given  which  does  not  leave  much  residue,  pads  of 
gauze  are  applied  with  pressure,  and  the  bowels  are  kept  regular. 

If  the  track  be  lined  with  granulations,  it  may  be  touched  with  lunar  caustic; 
if  it  be  lined  with  mucous  membrane,  the  actual  cautery  should  be  applied. 
Any  collection  of  pus  which  exists  should  be  drained.  If  these  methods  fail, 
an  operation  must  be  performed.  The  fistula  may  be  sutured  by  extraperi- 
toneal manipulation  (Greig  Smith);  it  may  be  covered  with  skin  (DieflFenbach); 
the  spur  may  be  removed  by  means  of  a  clamp,  or  resection  may  be  performed. 
In  most  cases  it  is  best  to  incise  a  button  of  skin  around  the  opening,  tempo- 
rarily suture  the  fistula,  open  the  peritoneal  cavity,  deliver  the  bowel,  and 
suture  carefully  (Senn's  method).  In  some  cases  partial  exclusion  of  the 
fistulous  part  is  necessary,  the  bowel  being  divided  above  the  fistula,  the  end 
near  the  fistula  sutured,  and  the  other  end  anastomosed  to  the  bowel  below  the 
fistula.     In  other  cases  complete  exclusion  may  be  performed  (see  page  1257). 

Ulcer  of  the  Bowel. — In  typhoid  fever  and  in  dysentery  ulceration  occurs. 
In  erysipelas,  septicemia,  pemphigus,  melena  neonatorum,  and  uremia  ulcera- 
tion may  occur.  An  ulcer  may  be  due  to  tuberculosis  or  cancer.  Most  ulcers 
of  the  duodenum  (see  below)  are  due  to  the  same  causes  as  ulcer  of  the 
stomach.  In  rare  cases  ulcer  of  the  duodenum  results  from  a  surface  burn 
(Curhng's  ulcer,  page  173).  An  ulcer  of  the  jejunum  sometimes  develops  after 
the  performance  of  gastrojejunostomy  for  gastric  ulcer  (see  page  1229).  An 
ulcer  may  heal  and,  by  causing  thickening  and  constriction,  produce  chronic 
intestinal  obstruction.  It  may  perforate,  causing  collapse  and  subsequent 
peritonitis. 

Ulcer  of  the  duodenum  may  be  due  to  tuberculosis.  It  may  exist  in 
septicemia,  erysipelas,  melena  neonatorum,  and  uremia.  It  may  be  caused  by 
burns.  The  last  named  and  very  rare  condition  is  called  Curling's  ulcer,  he 
having  described  it  in  1841.  Moynihan  shows  in  his  book  on  " Duodenal  Ulcer" 
that  James  Long,  of  Liverpool,  was  really  the  first  one  to  describe  duodenal 
ulceration  following  burns.  He  did  so  in  the  "London  Medical  Gazette,"  1840. 
A  duodenal  ulcer  following  a  burn  or  scald  is  "a  toxic  ulcer,  and,  therefore, 
analogous  to  the  ulcer  which  occurs  in  septicemia,  uremia,  typhoid  fever, 
erysipelas,  and  pemphigus"  (Moynihan,  Ibid.).  It  occurs  only  when  the 
burnt  or  scalded  area  has  become  septic,  and  septic  emboli  may  be  responsible 
for  ulceration.  Some  believe  that  the  irritant  cause  is  in  the  bile.  Ulcer  from  a 
burn  is  extremely  rare  to-day,  rarer  than  formerly,  if  older  reports  are  correct. 
This  is  probably  due  to  the  modern  cleanly  treatment  of  burns  and  scalds. 
When  we  use  without  qualification  the  term  "ulcer  of  the  duodenum"  we  mean 
an  ulcer  like  the  ordinary  stomach  ulcer  and  which  may  be  regarded  as  a  peptic 
ulcer  of  the  duodenum. 

Septic  ulcers  are  acute.     The  peptic  ulcer    is  nearly  always  chronic. 

Peptic  Ulcer  of  the  Duodenum. — The  condition  was  first  described  by 
Traversin  181 7  ("Duodenal  Ulcer,"  by  Sir  Berkley  G.  A.  Moynihan).  It  occurs 
usually  in  that  portion  of  the  duodenum  which  is  above  the  opening  of  the  bile- 
duct;  in  other  words,  in  the  region  acted  on  by  the  acid  fluid  from  the  stomach. 
In  Perry  and  Shaw's  list  of  149  cases  the  first  portion  was  involved  in  123,  the 


Peptic  Ulcer  of  the  Duodenum  1129 

second  portion  in  16,  and  the  third  and  fourth  portions  in  2;  in  8  the  ulcers 
were  scattered.  Moynihan  (Ibid.)  says  the  first  portion  is  involved  in  95  per 
cent,  of  the  cases.  The  most  common  seat  of  ulcer  is  on  the  anterior  wall  of 
the  duodenum,  l^  inch  below  the  pylorus.  The  pylorus  is  definitely  marked  for 
the  surgeon  by  the  pyloric  vein  which  runs  upward  from  the  greater  curvature 
(Moynihan,  Ibid.).  The  ulcer  is  often  puckered  like  a  scar.  Any  old  ulcer  is 
much  indurated.  In  rare  cases  there  is  no  induration.  Sometimes  an  exten- 
sive area  of  the  duodenum  is  indurated,  sometimes  a  duodenal  pouch  or  diver- 
ticulum is  formed.  In  rare  cases  an  ulcer  completely  encircles  the  bowel. 
Duodenal  ulceration  is  much  more  common  in  males  than  in  females  in  the 
proportion  of  3  or  4  to  i.  Out  of  53  cases  reported  by  John  Deaver  47  were 
males  (The  Archives  for  Diagnosis,"  Jan.,  191 7).  It  may  occur  at  any  period  of 
life,  from  early  youth  to  extreme  old  age,  but  is  most  common  between  the 
twenty-fifth  and  forty-fifth  years.  The  average  age  of  Deaver's  male  cases  was 
41.5  years.  The  oldest  was  sixty-three,  the  youngest  twenty-one.  The  average 
age  of  his  6  female  patients  was  36.8  years  (Deaver,  Ibid.).  The  condition 
can  occur  in  infancy,  producing  hemorrhage  and  vomiting.  Veeder  reports  5 
infantile  cases  ("Am.  Jour.  Med.  Sciences,"  1914,  cxlviii).  Duodenal  ulcers  are 
usually  single,  but  may  be  multiple.  It  was  long  taught  that  gastric  ulceration 
is  vastly  more  common  than  duodenal  ulceration.  Some  recent  observers  regard 
duodenal  ulcer  as  likely  to  be  met  with  one-seventh  as  often  as  gastric  ulcer. 
In  this  connection  Codman's  statistics  should  cause  us  to  revise  our  estimates. 
In  3000  autopsies  held  in  the  Massachusetts  General  Hospital  an  open  duodenal 
ulcer  was  found  in  i  per  cent,  of  the  cases.  The  duodenal  ulcers  were  found 
twice  as  often  as  gastric  ulcers  (quoted  by  E.  R.  McGuire,  "Buffalo  Med. 
Jour.,"  June,  1912).  A  gastric  ulcer  may  exist  with  a  duodenal  ulcer.  Murphy 
sums  up  the  supposed  causes  into  hyper chlorhydria,  local  infection,  embolism 
and  thrombosis,  and  disturbances  of  the  organs  of  elimination.  An  indurated 
chronic  ulcer  may  exist,  and  this  may  heal  and  produce  cicatricial  stenosis. 
The  scars  of  two  ulcers  may  cause  double  constriction  or  hour-glass  duodenum. 
An  ulcer  may  heal  and  break  down  many  times.  A  duodenal  carcinoma 
seldom  arises  from  ulcer.  What  Moynihan  calls  the  "tucked  back"  ulcer  be- 
comes adherent  to  the  liver  or  posterior  wall  of  the  abdomen.  An  ulcer  adhe- 
rent to  the  pancreas  may  eat  into  that  organ.  An  ulcer  scar  may  clutch  the 
common  bile-duct  in  the  duodenal  wall  or  block  the  outlet  of  the  ducts  in  the 
ampulla  of  Vater.  Perforation  is  more  common,  but  walling  off  is  more  fre- 
quent than  in  gastric  ulceration  (Wm.  J.  Mayo,  "Med.  News,"  April  16,  1904). 
In  the  vast  majority  of  cases  the  patient  gives  a  history  of  having  suffered 
at  intervals  for  many  years  from  attacks  of  flatulent  or  acid  and  painful  indi- 
gestion. The  pain  is  near  the  umbilicus  and  radiates  to  the  right.  The  attacks 
are  far  more  common  in  fall  and  winter  than  in  spring  and  summer.  Usually 
tenderness  and  rigidity  are  demonstrable  in  the  right  epigastric  region.  A  man 
suffers  thus  for  days  or  weeks,  and  then  gets  apparently  perfectly  well,  but  after 
a  variable  time  the  attack  returns.  The  attack  comes  on  from  two  to  six  hours 
after  a  heavy  meal.  It  seldom  occurs  after  breakfast  but  comes  after  lunch 
and  particularly  after  an  evening  dinner.  If  he  eats  his  heavy  meal  at  7  p.  m. 
his  attack  may  usually  be  expected  about  10  o'clock  or  later.  These  seizures 
of  "indigestion"  may  be  brought  on  by  worry,  overwork,  wet  feet  or  chilling 
of  the  body,  or  by  eating  some  indigestible  article  of  diet.  They  may  be  caused 
to  disappear  by  rest,  ease  of  mind,  or  change  of  climate.  An  alkali  relieves  pain. 
They  have  been  called  "hunger-pains"  because  food  for  a  time  distinctly 
relieves  them.  A  patient  learns  this  and  is  apt  as  soon  as  the  annoyance  begins 
to  eat  some  crackers  or  drink  a  glass  of  milk.  It  was  long  believed  that  hunger 
pain  was  due  to  an  open  pylorus  allowing  acid  material  to  run  into  the  duo- 
denum, and  that  food  or  an  alkali  caused  the  pylorus  to  close.  Moynihan, 
Hertz,  and  others  now  reject  this  explanation  because  a;-ray  studies  show  that 


1 130  Diseases  and  Injuries  of  the  Abdomen 

food  begins  to  leave  the  stomach  at  once  and  that  pain  begins  when  about  half 
the  food  has  left  the  stomach  (Moynihan,  "Duodenal  Ulcer").  It  must  be 
that  the  last  portion  of  food  in  the  stomach  is  much  more  acid  than  the  portions 
which  pass  out  earlier.  When  the  stomach  is  entirely  empty  there  is  no  pain; 
when  half  empty  there  is  pain. 

Arbuthnot  Lane  would  explain  the  relief  of  pain  by  food  by  invoking  a 
reflex  contraction  of  the  duodenum  caused  by  food  and  serving  to  empty  that 
portion  of  the  gut.  The  condition  above  described  may  go  on  for  many  years, 
periods  of  relief  alternating  with  periods  of  pain,  water  brash,  flatulence,  etc. 
Usually,  but  by  no  means  always,  there  is  hyperacidity.  In  some  cases  acid- 
ity is  normal;  in  some,  actually  subnormal.  It  is  probable  that  during  painful 
attacks  there  is  hyperacidity.  We  have  stated  that  the  pain  occurs  from  two  to 
six  hours  after  a  meal.  If  it  occur  very  late  the  ulcer  is  posterior;  if  it  occur 
earlier  than  two  hours  stenosis  has  begun  or  the  ulcer  is  adherent  to  the  liver 
or  belly  wall  (Moynihan,  Ibid.) 

Hemorrhage  occurs  in  about  40  per  cent,  of  the  cases.  The  blood  may  be 
passed  by  bowel  only  or  it  may  be  passed  by  bowel  and  also  vomited.  In 
most  cases  it  is  passed  by  bowel  and  not  vomited.  When  there  is  a  severe 
hemorrhage  the  patient  first  has  a  peculiarly  severe  attack  of  indigestion, 
he  then  grows  deathly  pale,  presents  the  symptoms  of  internal  hemorrhage,  and 
passes  a  quantity  of  blood  which  is  first  tarry  black  and  later  red,  and  perhaps 
he  also  vomits  blood.  Just  as  chronic  gastric  ulcer  may  be  latent,  no  symptoms 
ever  being  observed,  so  may  chronic  duodenal  ulcer  be  latent.  The  pain  is 
located  in  the  epigastric  or  right  hypochondriac  region  and  may  last  until  the 
next  meal.  If  the  digestion  of  the  evening  meal  is  delayed  the  pain  rouses  the 
patient  from  sleep,  but  a  glass  of  milk  will  quiet  it.  The  pain  is  less  severe 
than  is  usual  in  gastric  ulcer  and  in  many  cases  does  not  radiate  to  the  back, 
although  in  others  it  does  radiate  to  the  right  scapular  region.  There  may  be 
tenderness  on  deep  pressure  in  the  right  hypochondriac  region.  Symptoms  of 
indigestion  are  not  nearly  so  marked  as  in  ulcer  of  the  stomach.  Vomiting  is 
far  less  common  than  in  gastric  ulcer  and  it  does  not  relieve  pain.  Vomiting 
occurred  in  one-fourth  of  Deaver's  cases  (Ibid.).  The  hemorrhage  from  the 
bowels  may  be  so  profuse  as  to  kill  or  almost  kill  the  patient.  It  may  be  so 
frequently  repeated  as  to  make  him  profoundly  anemic.  Unlike  the  bleeding 
from  gastric  ulcer,  bleeding  from  duodenal  ulcer  is  often  fatal.  In  some  cases 
the  man  bleeds  insidiously,  perhaps  even  without  knowing  it,  losing  some  blood 
daily,  and  finally  becoming  extremely  anemic.  Probably  in  every  case  of  duo- 
denal ulcer  occult  blood  is  at  times  present  in  the  stools.  In  many  cases  there 
is  no  visible  blood  in  the  feces,  but  the  guaiac  and  aloin  tests  show  occult  blood. 
Vomiting  of  quantities  of  blood  is  much  rarer  than  in  gastric  ulcer.  In  very 
rare  cases  of  duodenal  ulcer  the  first  symptom  is  perforation.  I  have  operated 
on  one  such  case.  In  other  cases  the  first  symptom  is  hemorrhage,  or  is  due  to 
stenosis  or  some  other  complication.  Examination  by  .T-rays  after  the  taking  of 
a  meal  containing  bismuth  or  barium  shows,  if  there  be  ulcer,  greatly  increased 
activity  of  the  stomach.  The  viscus  empties  too  rapidly.  In  some  cases  stenosis 
is  demonstrated,  insomeapseudodiverticulum.  Moynihan^  mentions  the  follow- 
ing complications:  severe  hemorrhage;  perforation;  periduodenitis;  cancer,  and 
cicatricial  contraction  involving  the  bile-duct.  Cancer  is  a  rare  result  of  ulcer. 
Jefferson  reported  one  case  but  could  find  but  30  cases  in  literature  ("  Brit.  Jour, 
of  Surgery,"  1916,  iv). 

Acute  perforation  is  more  common  than  we  once  thought.  Perforation  is 
usually  on  the  anterior  wall.  It  is  much  less  common  on  the  posterior  wall. 
It  is  extremely  rare  on  the  superior  wall  and  practically  never  occurs  on  the 
inferior  wall.  Moynihan  gathered  49  cases  from  literature  and  added  2  of 
his  own.     In  the  great  majority  of  cases  perforation  of  the  duodenum  can- 

^  "Lancet,"  Dec.  14,  1901. 


Treatment  of  Peptic  Ulcer  of  the  Duodenum  1131 

not  be  differentiated  from  perforation  of  the  stomach  by  a  study  of  the  symp- 
toms. In  some  cases  the  symptoms  resemble  appendicitis.  In  most  cases 
there  is  a  sudden  onset  of  violent  abdominal  pain,  followed  by  vomiting,  shock, 
rapid  pulse,  tenderness  of  the  epigastric  or  right  hypochondriac  region,  and 
board-like  rigidity  of  the  upper  abdomen.  Profound  shock  is  rare.  Often  shock 
is  trivial.  Even  if  shock  is  severe  the  patient  usually  reacts  after  a  few  hours. 
Sheild's  case  got  better  in  four  hours  and  walked  some  distance  to  the  hospital.^ 
Lucy's  case  got  better  a  short  time  after  the  onset,  walked  home,  and  attended 
to  a  horse,  but  then  became  rapidly  worse.  The  improvement  is  apparent,  not 
real,  and  is  only  temporary.  The  symptoms  quickly  become  worse,  and  when 
they  become  worse,  besides  the  pain,  tenderness  and  rapid  pulse,  there  will  be 
occasional  vomiting,  rigidity  of  the  abdomen,  usually  an  elevated  or  normal 
temperature,  and  possibly  diminution  of  the  area  of  liver-dulness.  Just  as  in 
stomach  ulcer,  there  may  be  acute,  subacute,  or  chronic  perforation. 

Treatment. — In  duodenal  ulcer  the  risks  of  serious  hemorrhage  and  of 
perforation  are  much  greater  than  in  gastric  ulcer,  and  operation  should  always 
be  recommended  if  the  diagnosis  is  made.  We  used  to  say  operate  only  if 
the  symptoms  are  not  amended  by  rigid  diet  and  medication;  if  severe  hemor- 
rhage occurs  or  if  cicatricial  contraction  interferes  with  the  passage  of  food 
through  the  bowel  or  bile  into  the  duodenum.  Moynihan  refers  to  4  cases 
of  chronic  ulcer  operated  upon,  and  all  recovered.  In  some  cases  excision  is 
practised;  in  others,  excision  with  gastrojejunostomy;  in  still  others,  gastro- 
jejunostomy alone. 

If  grave  hemorrhage  occurs  and  is  repeated  the  surgeon  should  open  the 
abdomen,  ligate  the  bleeding  vessels,  bring  the  outer  coats  of  the  bowel  together 
over  the  indurated  area,  and  perform  posterior  gastrojejunostomy  (Wm.  J. 
Mayo,  in  "Surg.,  Gynec,  and  Obstet.,"  May,  1908).  In  such  a  bleeding  ulcer 
the  vessels  entering  it  are  usually  varicose. 

In  perforation  operation  is  performed,  as  in  gastric  ulcer,  as  soon  as  pos- 
sible. In  these  cases,  as  in  perforated  gastric  ulcer,  I  believe  operation  should 
be  immediate  and  that  we  should  not  wait  for  a  possible  reaction  from  shock. 
Personally,  I  do  not  practise  excision  of  the  ulcer,  as  I  believe  that  closure  is 
just  as  permanently  useful  and  is  safer.  The  ulcer  is  inverted  by  two  rows 
of  silk  sutures  applied  in  a  vertical  line  or  as  purse-string  sutures.  If  the 
gap  of  the  perforation  be  huge  it  may  be  impossible  to  close  it  by  inversion. 
It  may  then  be  closed  by  the  gall-bladder  (as  was  done  by  Downes)  or  by  an 
omental  plug.  Failing  in  this,  a  gauze  tampon  may  be  used  or  a  duodenal 
fistula  can  be  formed,  a  rubber  catheter  being  inserted  in  the  duodenum  and 
wrapped  about  with  a  plug  of  omentum  (Eliot,  Corscaden,  and  Jamieson,  in 
"Annals  of  Surgery,"  May,  1912).  Then  gastrojejunostomy  should  be  done. 
Gastrojejunostomy  is  imperative  if  the  suturing  has  narrowed  the  duodenum. 
It  is  valuable  in  any  case  because  it  removes  irritants  from  the  scar,  aUows  of 
early  administration  of  food,  favors  heahng,  and  antagonizes  recurrence.  Some 
surgeons  do  not  drain,  but  I  feel  it  safer  to  drain.  Sir  Berkeley  G.  A.  Moy- 
nihan^ gathered  49  operations  for  perforated  ulcer,  with  8  recoveries.  Mr.  T. 
Crisp  English  reports  8  operations  for  perforation  of  duodenal  ulcers,  with  2 
recoveries  ("Lancet,"  Nov.  28,  1903).  During  1912  in  the  Mayo  clinic  6  cases 
of  acute  perforating  ulcer  were  treated  by  suture  and  gastro-enterostomy. 
There  was  i  death.  In  perforated  duodenal  ulcer  the  extravasated  fluid  is  apt 
to  flow  into  the  right  iliac  region.  If  an  erroneous  diagnosis  of  appendicitis 
has  been  made,  an  opening  in  the  right  iliac  region,  by  giving  vent  to  this  fluid, 
might  for  a  time  confirm  the  surgeon  in  error,  but  the  character  of  the  fluid 
should  make  evident  the  condition  of  affairs. 

In  subacute  perforation  we  may  separate  adhesions,  find  and  close  the  per- 


^  "Lancet,"  March  29,  1902. 
^  "Lancet,"  Dec.  14,  1901. 


1 132  Diseases  and  Injuries  of  the  Abdomen 

foration,  and  perform  gastrojejunostomy,  or  follow  Lund's  advice  ("Boston 
Med.  and  Surg.  Jour.,"  1905)  and  do  gastrojejunostomy  alone.  Lund  main- 
tains that  as  the  perforation  is  walled  off  it  is  not  necessary  to  open  it  up  in 
order  that  we  may  close  it.  The  treatment  for  chronic  perforation  is  that  for 
an  abscess  about  the  duodenum.  In  every  operation  for  duodenal  ulcer 
Moynihan  examines  the  appendix  and  often  finds  it  diseased  ("Lancet,"  Jan. 
6,  1912). 

LJIcer  of  the  Jejunum  After  Qastro=enterostomy. — (See  page  1229.) 
Perforated  Typhoid  Ulcer. — Perforation  occurs  in  2  or  possibly  3  cases 
out  of  100.  My  colleague  Prof.  John  H.  Gibbon  reported  the  experience 
of  the  Penn.  Hospital  from  1901-1915  inclusive  ("  Annals  of  Surgery,"  Oct.  and 
Nov.,  1915).  There  were  5891  cases  of  typhoid  fever  and  139  perforations. 
Twenty-seven  were  not  and  112  were  operated  upon.  About  70  per  cent,  of 
perforations  occur  in  the  second,  third,  or  fourth  week.  Whenever  a  typhoid 
patient  develops  pain  a  surgeon  should  be  called  in  consultation.  Perforation 
in  a  typhoid  ulcer  is  usually  effected  rapidly,  a  large  opening  is  formed,  and  a 
considerable  quantity  of  fecal  matter  is  passed  into  the  peritoneal  cavity.  In  a 
few  perforations  very  little  fluid  escapes.  Severe  pain  and  a  nervous  chill 
indicate  that  perforation  is  occurring  or  has  occurred.  Some  maintain  that  the 
two  above-named  symptoms  associated  with  marked  leukocytosis  indicate 
that  perforation  is  about  to  occur,  and  they  call  this  stage  the  preperforative 
stage.  That  distinct  symptoms  may  in  some  cases  point  to  impending  per- 
foration is,  I  believe,  true  and  in  i  case  I  operated  on  this  conviction  and  found 
two  areas  almost  perforated.  In  most  cases,  however,  I  do  not  believe  that  there 
is  a  distinct  preperforative  stage,  but  the  perforation  exists  when  the  symptoms 
are  first  noted.  The  conviction  that  perforation  was  occurring  would  be  strength- 
ened by  a  progressive  increase  in  the  leukocyte  count.  "  But  as  leukocytosis 
cannot  occur  for  eight  or  ten  hours,  never  wait  for  it.  It  is  to  be  remembered 
however,  that  the  leukocyte  count  is  increased  by  sweating,  cold  bathing, 
vomiting,  hemorrhage,  severe  diarrhea,  or  some  positive  complication.  When 
perforation  occurs,  violent  pain  develops.  As  a  rule,  there  are  tenderness,  rapid 
pulse,  costal  respiration,  abdominal  ridigity,  vomiting,  and  shock.  A  sudden 
fall  of  temperature  and  increase  of  pulse  rate  may  mean  hemorrhage.  Usually 
in  perforation  there  is  temporary  reaction  from  shock,  the  subnormal  tempera- 
ture giving  way  to  a  normal  or  to  an  elevated  temperature.  The  vomiting  in 
some  cases  becomes  stercoraceous.  There  is  constipation  and  sometimes  dulness 
on  percussing  the  flanks.  It  should  be  the  rule  to  make  a  digital  examination 
of  the  rectum.  The  face  is  Hippocratic.  The  patient  may  die  of  the  prelimi- 
nary shock  or  may  react  and  die  subsequently  of  toxemia  or  lung  complication. 
In  a  few  hours  after  perforation  distinct  leukocytosis  may  be  observed,  but  it 
may  never  take  place  at  all.  Even  when  leukocytosis  arises,  it  may  disappear 
as  peritoneal  infection  spreads  and  systemic  poisoning  deepens.  If  the  abdomen 
is  distended  diminution  of  liver  dulness  is  not  a  reliable  sign.  Diminution 
of  liver  dulness  with  a  fiat  abdomen  is  very  significant.  Micturition  is  usually 
painful  and  difi&cult.  Le  Conte  points  out  that  rupture  of  a  mesenteric  gland 
simulates  intestinal  perforation.  A  case  of  typhoid  with  lung  complication 
or  cholecystitis  may  be  thought  to  have  perforation.  Whereas  violent  pain 
is  the  rule  in  perforation  if  the  patient  be  stuporous,  acute  pain  may  not  be 
manifested. 

Treatment. — In  1884  Leyden  suggested  operation,  and  in  the  same  year 
Milkulicz  obtained  the  first  operative  success.  In  1886  my  colleague  Dr. 
James  C.  Wilson,  published  a  paper  in  which  he  advocated  operation.  Death 
is  practically  certain  without  operation.  Operation  should  save  at  least  one- 
fourth  of  the  cases.  It  should  be  done  at  once,  proper  means  being  adopted 
to  combat  shock.  In  many  cases  a  general  anesthetic  should  not  be  given 
as  it  increases  the  danger  of  pulmonary  complications.     Gas  and  oxygen  or  a 


Treatment  of  Perforated  Typhoid  Ulcer  ^^35 

local  anesthetic  should  be  employed.  The  incision  should  be  made  in  the  right 
iliac  region  and  the  colon  should  be  first  located  and  then  the  end  of  the  ileum. 
By  locating  the  colon  we  obtain  a  fixed  point  from  which  to  begin  our  search  for 
perforations,  and  by  opening  the  abdomen  in  the  right  iliac  region  we  come 
down  at  once  on  to  the  perforated  gut  in  the  vast  majority  of  cases.  When  a 
perforation  is  found,  it  should,  if  possible,  be  inverted  by  two  layers  of  Halsted 
sutures.  It  is  not  wise  to  excise  the  ulcer.  If  the  bowel  be  very  badly 
damaged,  resection  can  be  considered,  but  it  is  usually  wiser  to  make  a  tempor- 
ary artificial  anus.  In  some  cases  the  perforation  can  be  used  as  the  anus,  a 
tube  being  inserted,  or  the  bowel  being  stitched  to  the  skin.  Hayes  ("  Penn. 
Med.  Jour.,"  1908)  advocates  enterostomy  in  typhoid  perforation  and  reports 
38  cases  of  which  36  per  cent,  recovered.  After  finding  a  perforation  and 
closing  it,  examine  to  see  if  there  are  others.  It  is  not  very  unusual  to  have 
from  2  to  5  perforations.  In  26  autopsies  reported  by  Gibbon  there  were 
secondary  perforations  in  14  (Gibbon,  Ibid.).  Close  every  perforation,  and 
if  a  point  is  found  where  the  thinning  of  the  bowel  wall  indicates  that  per- 
foration is  liable  to  occur,  protect  this  point  by  inverting  the  area  of  ulcera- 
tion by  sutures.  Many  surgeons  cleanse  the  peritoneum  by  flushing  with  hot 
salt  solution,  others  do  not  irrigate.  Leave  the  wound  open,  insert  strands  of 
iodoform  gauze,  and  establish  tubular  suprapubic  drainage.  Elevate  the  patient 
in  bed  if  not  too  weak,  and  employ  continuous  proctoclysis  of  salt  solution.  Early 
death  is  due  to  shock  or  exhaustion.  Death  occurring  later  results  from  peri- 
tonitis or  lung  complication.  I  have  operated  10  times  for  typhoid  perforation, 
with  3  recoveries;  3  cases  died  of  shock.  In  i  case  the  perforation  was  not 
found,  but  was  discovered  postmortem  in  the  hepatic  flexure  of  the  colon,  the 
gall-bladder  being  responsible  for  the  ulcer  of  the  bowel.  One  case  improved 
greatly,  lived  for  eight  days,  developed  another  perforation,  and  died  of  shock. 
The  necropsy  showed  that  the  sutured  perforation  was  soundly  closed.  One 
case,  a  young  man,  brought  to  me  by  Dr.  Godfrey,  was  operated  upon  twenty- 
four  hours  after  perforation.  There  was  one  perforation  in  the  ileum  and  con- 
siderable fecal  extravasation.  The  opening  was  large  and  the  stitches  would  not 
hold.  The  6  inches  of  bowel  between  the  ulcer  and  the  ileocecal  valve  presented 
several  ulcers  almost  perforated.  The  patient  was  too  weak  for  a  resection. 
After  cleansing  the  abdomen  an  artificial  anus  was  made  proximal  to  the  per- 
foration. The  patient  recovered  and  subsequently  the  anus  was  successfully 
abolished  by  resection.  In  another  case,  that  of  a  young  woman,  on  opening 
the  abdomen  violent  appendicitis  was  found,  the  appendix  being  swathed 
in  lymph  and  in  a  state  of  gangrene.  The  appendix  was  removed.  Search 
showed  a  perforation  in  a  loop  of  gut  2  feet  from  the  ileocecal  valve.  There 
was  considerable  extravasation.  The  perforation  was  closed.  The  perito- 
neum was  cleansed,  drainage  was  inserted,  and  the  patient  recovered.  Cul- 
tures from  the  appendix  and  from  the  peritoneal  cavity  showed  the  colon 
bacillus  only.  In  a  third  case,  that  of  a  young  woman,  impending  perforation 
was  diagnosticated  by  Dr.  Kalteyer  because  of  pain,  tenderness,  some  rigidity, 
and  definite  and  increasing  leukocytosis.  Two  ulcers  almost  but  not  quite 
perforated  were  found.  They  were  covered  over  by  the  use  of  inversion  sutures, 
the  wound  was  closed  without  drainage,  and  recovery  followed.  Culture  from 
the  peritoneal  cavity  was  negative.  These  3  successful  cases  were  operated 
upon  in  the  Jefferson  College  Hospital.  Harte  and  Ashhurst  collected  the  cases 
operated  upon  up  to  January,  1903.  There  were  362  cases,  with  a  mortality 
of  74.03  per  cent.  Dr.  F.  D.  Patterson  ("Am.  Jour.  Med.  Sciences,"  May, 
1909)  collected  369  cases  occurring  since  the  paper  of  Harte  and  Ashhurst.  Of 
these  cases  242  died,  a  mortality  of  65.58  per  cent.  The  perforations  were  located 
as  follows:  stomach,  i;  jejunum,  i;  Meckel's  diverticulum,  2;  ileum,  279;  cecum, 
5;  appendix,  15;  colon,  12;  not  stated,  54.  In  Gibbon's  112  patients  operated 
upon  there  were  27  recoveries,  a  mortality  of  75.9  per  cent.  (Gibbon,  Ibid.). 


1 134  Diseases  and  Injuries  of  the  Abdomen 

Primary  Intestinal  Tuberculosis. — Although  intestinal  tuberculosis  is 
common  in  patients  with  chronic  pulmonary  tuberculosis,  primary  intestinal 
tuberculosis  is  a  rare  condition.  The  exact  propriety  of  rigidly  regarding  such 
cases  as  primary  is  doubtful.  Kocher's  cases  (reported  before  the  Swiss  Medi- 
cal Congress  in  1892)  came  from  tuberculous  stock,  and  suffered  in  infancy 
from  enlarged  glands,  pleurisy,  or  bronchitis,  and  this  surgeon  says  that,  in  all 
probability,  there  had  for  some  time  been  somewhere  in  the  body  a  latent  tuber- 
culous focus,  and  from  this  focus  came  the  bacteria  which  attacked  the  intestine. 
Intestinal  tuberculosis,  in  the  victims  of  phthisis,  begins  with  the  formation 
of  multiple  ulcers,  due  to  swallowing  tuberculous  sputum.  Primary  intestinal 
tuberculosis  usually  begins  as  one  ulcer  or  several,  or  even  many  ulcers  in  the 
ileum  or  perhaps  in  the  cecum.  These  ulcers  when  they  heal  tend  to  form 
strictures  of  the  small  bowel,  seldom  of  the  large.  Primary  tuberculosis  is 
most  common  in  the  ileocecal  region.  It  may  exist  as  an  ulcerative  process 
with  inflammation  and  abscess  about  the  cecum  or  as  enormous  tumor-like 
thickening  of  the  cecum.  The  first  form  is  called  by  Hartmann  enter 0 peritoneal 
tuberculosis.  The  second  form  is  called  hyperplastic  tuberculosis.  The  cecum 
may  be  involved  alone,  but  usually  a  portion  of  the  ileum  also  suffers.  The 
ulcers  cause  extensive  sloughing.  The  appendix  may  be  involved.  All  about 
the  cecum  a  multitude  of  adhesions  form  containing  masses  of  tuberculous  mat- 
ter, which  may  break  into  the  intestine,  through  the  skin  of  the  abdomen,  or 
in  both  directions.  (See  Hartmann,  in  "Revue  de  Chirurgie,"  Feb.,  1907.) 
Tuberculous  areas  suppurate.  In  tuberculosis  of  the  small  intestine  there  are 
bloody  diarrhea,  colicky  pain,  emaciation,  and  weakness.  There  are  very 
active  peristalsis  and  gurgling.  The  abdomen  may  be  tender.  The  bacilli 
may  be  found  in  the  stools.  As  ulcers  heal  strictures  develop  and  produce 
the  usual  symptoms.  Peritonitis  may  arise  or  death  may  be  due  to  pulmonary 
tuberculosis.  In  primary  intestinal  tuberculosis  the  urine  is  apt  to  show  the 
diazo-reaction  (Kocher). 

In  hyperplastic  (conglomerate)  tuberculosis  the  cecum  and  lower  end  of  the 
ileum  suffer  as  a  rule.  In  some  cases  the  colon  participates  in  the  process. 
Great  fibromatosis  with  adiposis  occurs  simulating  tumor  and  due  to  reaction 
of  tissue  against  infection.  Tuberculosis  of  the  ileocecal  region  is  most  common 
between  the  ages  of  twenty  and  forty.     There  is  seldom  demonstrable  phthisis. 

The  enteroperitoneal  form  of  ileocecal  tuberculosis  simulates  appendicitis. 
At  first  there  may  be  diarrhea,  the  liquid  stools  containing  blood.  Pain  in  the 
right  iliac  fossa  may  be  the  first  symptom.  In  any  case  pain  becomes  tha 
permanent  symptom.  A  lump  can  be  palpated.  After  acute  pain  subsides 
the  lump  persists  and  increases.  There  may  be  attack  after  attack  of  pain. 
The  symptoms  of  abscess  arise.  Spontaneous  opening  finally  occurs,  usually 
about  Poupart's  ligament.  Several  fistulas  may  form.  Each  fistula  discharges 
pus  with  fecal  matter.  An  abscess  may  open  into  the  intestine.  When  it  does, 
pus  appears  in  the  stools.  Bacilli  may  be  found  in  the  stools.  In  enteroperi- 
toneal tuberculosis  death  occurs  because  of  the  development  of  pulmonary 
tuberculosis  or,  in  a  small  number  of  cases,  by  peritonitis  due  to  rupture  of  an 
abscess  into  the  peritoneal  cavity  (Hartmann,  Ibid.).  The  hyperplastic  form 
develops  slowly,  the  individual  complaining  of  indigestion  and  annoying  sensa- 
tions in  the  right  iliac  fossa.  During  many  months  the  patient  feels  at  times 
better  and  at  times  worse.  Then  food  begins  to  disagree  radically.  Several  hours 
after  a  meal  the  patient  suffers  from  colicky  pain  in  the  right  iliac  region  and 
distention  of  the  abdomen.  Severe  pain  simulating  appendicitis  may  occur 
intermittently.  Constipation  may  be  severe  or  may  alternate  with  diarrhea. 
Gradually  a  tumor  mass  forms,  evidences  of  obstruction  become  obvious,  the 
patient  becomes  weak  and  emaciated.  The  lungs  are  involved  very  late,  if  at 
all.  In  some  cases  ulceration  occurs.  Conrath's  study  of  77  cases  led  him  to 
believe  that  death  occurs  in  from  two  and  one-half  to  three  years. 


Malignant  Tumors  1135 

Treatment  of  Primary  Intestinal  Tuberculosis. — In  the  first  stage  the  proper 
treatment  is  excision  of  ulcerated  areas,  possibly  excision  of  the  cecum.  Later, 
if  stricture  is  causing  chronic  obstruction,  an  operation  may  be  performed  to 
give  relief.  Laparotomy,  careful  separation  of  adhesions  which  are  not  fused 
with  the  gut,  and  the  introduction  of  iodoform  into  the  peritoneal  cavity  may 
prove  of  value.  Hartmann  ("Revue  de  Chirurgie,"  Feb.,  1907)  has  collected 
229  operations  for  ileocecal  tuberculosis,  viz.,  partial  excisions  of  the  cecum, 
resections  (with  end-to-end  anastomosis,  side-to-side  anastomosis,  or  end-to- 
side  implantation),  resections  in  two  seances,  ileocolostomies,  unilateral  exclu- 
sions, bilateral  exclusions,  and  other  operations.  There  were  46  deaths  in  these 
229  operations.  He  comments  on  the  fact  that  there  were  58  operations  with 
7  deaths  since  1900,  a  mortality  of  12  per  cent. 

Perforation  in  Intestinal  Tuberculosis. — By  this  term  we  mean  per- 
foration into  the  peritoneal  cavity,  not  into  another  segment  of  gut  and  not 
into  a  mass  of  adhesions.  It  is  supposed  to  be  a  rare  accident.  Cruice  esti- 
mates that  it  occurs  in  from  i  to  5  per  cent,  of  phthisis  cases  ("Am.  Jour.  Med. 
Sciences,"  Nov.,  1911).  It  may  occur  in  either  the  primary  or  secondary 
tuberculosis  of  the  gut.  It  is  very  rare  in  ileocecal  tuberculosis,  commoner  in 
tuberculosis  of  the  small  bowel.  It  causes  sudden  and  severe  pain,  shock,  and 
usually  nausea  and  vomiting.  The  abdomen  becomes  rigid.  Distention  soon 
occurs.  Death  may  be  due  to  shock  or  peritonitis.  Now  and  then  a  perfora- 
tion causes  no  characteristic  symptoms  at  all  (Cruice,  Ibid.). 

Tuberculosis  of  the  Mesenteric  Glands  in  Children. — This  condi- 
tion is  very  common.  Corner  ("Lancet,"  Feb.  17,  191 2)  makes  a  statement 
exactly  in  accord  with  my  own  experience  when  he  says  that  "tuberculous 
mesenteric  glands  will  be  found  in  practically  every  child  patient  submitted 
to  an  abdominal  operation."  They  are  often  recovered  from  unrecognized. 
They  may  produce  the  well-known  symptoms  of  tabes  mesenterica,  viz.,  greatly 
enlarged  abdomen,  constipation  or  constipation  alternating  with  diarrhea, 
loss  of  flesh,  anorexia,  anemia,  and  perhaps  a  palpable  mass.  There  are  abdom- 
inal pains  about  the  umbilicus,  coming  on  after  taking  food  and  particularly 
common  at  night. 

In  some  cases  vomiting  occurs  and  pain  is  in  the  right  iliac  region  and  the 
case  is  mistaken  for  appendicitis.  In  such  a  case  the  pulse  and  temperature 
are  normal  or  only  slightly  elevated  and  there  is  no  leukocytosis.  In  mesenteric 
tuberculosis  the  appendix  is  apt  to  be  dilated,  constricted,  or  kinked.  Mesenteric 
tuberculosis  may  undergo  cure,  the  glands  becoming  fibrosed  and  calcified.  It 
may  lead  to  tuberculosis  of  the  intestine,  tuberculous  peritonitis,  or  tuberculosis 
in  some  distant  part. 

I  agree  with  Corner  that  the  abdomen  should  be  opened,  the  appendix  re- 
moved, and  the  patient  placed  a  long  time  on  full  antituberculous  treatment. 

Tumors  of  the  Intestine. — Innocent  Timiors. — Adenoma,  lipoma,  fibro- 
ma, myoma,  fibromyoma,  papilloma,  angioma,  and  chylangioma  may  occur. 
Such  tumors  are  rare.  If  attached  by  a  pedicle  or  stem  the  growth  is  called  a 
polypus.  Adenoma  is  the  commonest  tumor.  It  may  or  may  not  be  a  polyp. 
It  arises  from  an  intestinal  gland.  There  maybe  one,  several,  or  many.  Adeno- 
mata may  produce  no  symptoms,  may  cause  hemorrhage,  may  produce  blocking, 
or  may  lead  to  intussusception. 

Malignant  Tumors. — Sarcoma  is  very  rare,  but  does  sometimes  arise,  par- 
ticularly in  young  persons,  and  it  enlarges  very  rapidly.  It  is  most  prone  to 
attack  the  large  intestine.  Jopson  and  White^  reported  i  case  and  collected 
22  others.  The  mesenteric  glands  frequently  enlarge.  Cancer  is  not  uncom- 
mon, attacking  especially  the  middle  aged.  According  to  RoUeston,  the  aver- 
age age  in  duodenal  cancer  is  fifty-two  years;  in  jejunal  and  iliac  cancer,  forty- 
seven;  in  cancer  of  the  cecum,  nearly  forty-eight,  and  in  cancer  of  the  rest 
^  "Am.  Jour.  Med.  Sciences,"  Dec,  1901. 


1 136  Diseases  and  Injuries  of  the  Abdomen 

of  the  large  intestine,  about  forty-nine  years.  It  is  most  common  in  the 
neighborhood  of  the  ileocecal  valve  and  in  the  sigmoid  flexure.  Ewald  collected 
1 148  cases  of  cancer  of  the  intestine.  In  64  cases  the  cecum  was  involved; 
in  24  cases  the  ileum  was  involved.  There  is  pain  at  the  seat  of  growth.  ^  After 
a  time  constipation  is  noted,  or  constipation  alternating  with  diarrhea.  Finally, 
intestinal  obstruction  occurs.  In  some  cases  the  symptoms  appear  suddenly, 
acute  obstruction  taking  place  or  intussusception  occurring.  It  is  usually 
possible  to  palpate  the  tumor,  which  is  hard  and  immovable.  The  patient 
wastes  rapidly  and  is  apt  occasionally  to  pass  blood  at  stool.  The  growth 
does  not  enlarge  very  rapidly  and  glands  are  not  involved  early.  In  some 
cases  the  supraclavicular  glands  enlarge.  In  more  than  one-half  of  the  cases 
which  die  of  intestinal  cancer  there  is  no  lymphatic  involvement.^ 

Treatment. — Early  in  the  case  exploratory  laparotomy  should  be  performed, 
followed,  if  possible,  by  excision  with  end-to-end  or  side-to-side  approximation. 
This  is  done  for  either  cancer  or  sarcoma.  It  may  be  possible  to  remove 
enlarged  glands.  In  cancer  of  the  cecum  extirpate  the  cecum  and  imiplant 
the  end  of  the  ileum  into  the  side  of  the  colon  (Wm.  J.  Mayo).  If  excision  is 
impossible,  the  growth  should  be  side-tracked  by  performing  later  anastomosis. 
In  advanced  cancer  of  the  large  bowel,  if  resection  be  impossible,  make  an  artifi- 
cial anus  above  the  tumor.     (See  Cancer  of  Rectum,  page  1326.) 

Appendicitis. — The  vermiform  appendix  is  found  in  man,  the  higher 
anthropomorphous  apes,  the  wombat  and  rodents.  Chimpanzees  in  captivity 
are  apt  to  die  of  appendicitis.  Some  mammals  "closely  allied  to  the  anthro- 
pomorphous apes  possess  very  large  ceca;  and  in  some  of  these  the  terminal 
segment  of  the  cecum  resembles  the  vermiform  appendix  in  that  it  possesses 
a  very  large  proportion  of  the  peculiar  kind  of  tissue  known  as  adenoid  or 
lymphatic"  ("Evolution  and  Disease,"  by  Sir  J.  Bland-Sutton).  Some 
observers  believe  that  it  furnishes  abundantly  digestive  ferments  and  an  internal 
secretion  which  causes  peristalsis.  The  appendix  is  usually  regarded  as  a 
vestigial  structure.  Prof.  Berry,  Dr.  Arthur  Keith,  and  some  others  regard 
the  appendix  as  a  specialized  region  of  the  cecum.  The  fact  that  the  appendix 
of  a  newborn  child  is  as  long  absolutely  as  the  appendix  of  a  full-grown  man  is 
regarded  by  Bland-Sutton  as  proof  "  that  the  part  was  of  great  importance  to  the 
ancestors  of  the  human  species"  (Ibid.).  Appendicitis,  which  is  an  inflam- 
mation of  the  vermiform  appendix  of  the  cecum,  is  almost  invariably  the 
primary  lesion  of  all  of  those  various  conditions  known  as  typhlitis,  perityphlitis, 
paratyphlitis,  etc. — terms  which  seldom  imply  pathological  entities,  and  are  in 
most  instances  well  relegated  to  obscurity.  I  say  in  most  instances,  not  in  all, 
because  1  believe  there  is  such  a  condition  as  primary  inflammation  of  the  cecum, 
although  it  is  extremely  rare.  This  rare  condition  may  cause  perforation, 
perityphlitic  abscess,  or  peritonitis  when  the  appendix  is  sound.  It  is  not  to  be 
distinguished  clinically  from  appendicitis  (McWilliams,  in  "Annals  of  Surgery," 
June,  1907).  Involvement  of  the  cecum  as  a  result  of  appendicitis  is  common. 
Such  a  condition  should  be  expected  because  the  mucous  membrane  is  con- 
tinuous. It  was  recognized  by  some  observers  many  years  ago  that  such  a 
disease  as  inflammation  of  the  appendix  existed,  but  the  majority  of  the  pro- 
fession did  not  grasp  the  fact.  In  1759  Mestevier,  of  France,  reported  a  case 
of  perforation  of  the  appendix  by  a  pin.^  In  181 2  a  perforated  appendix  was 
shown  to  the  Medico-Chirurgical  Society  of  London^  and  in  1835  Southam 
reported  an  appendiceal  abscess  (Manley).  In  1848  Hancock  reported  an 
appendiceal  abscess  ("Lancet,"  1838,  p.  380).  It  is  interesting  to  note  that 
this  was  a  case  of  appendicitis  in  pregnancy.  Ten  days  after  a  premature 
delivery  an  abscess  was  opened.     About  two  weeks  after  operation  two  fecal 

'  Wm.  J.  Mayo,  "Jour.  Am.  Med.  Assoc,"  Oct.  19,  1901. 
^  "Jour.  Med.  Chir.  and  Pharm.,"  vol.  x,  1759. 
'  "Med.  and  Chir.  Trans.,"  London,  181 2,  vol.  iii. 


Appendicitis  1137 

concretions  came  out  of  the  wound.  In  1827  Dr.  L.  Melier  described  appen- 
dicitis, and  named  among  its  symptoms  fixed  pain  in  the  right  iliac  fossa  and 
colic.  This  brilliant  and  original  young  Frenchman  was  years  ahead  of  his 
contemporaries.  He  reported  cases  of  undoubted  appendicitis  verified  by  au- 
topsy, described  gangrene,  perforation,  associated  peritonitis,  and  appendiceal 
concretions.  His  original  article,  jSIanley^  tells  us,  is  in  the  "Journal  of  ISIedi- 
cine.  Surgery,  and  Pharmacy"  for  1827,  second  series,  no.  Howard  Kelly 
quotes  it  from  "Jour.  gen.  de  med.,"  1827,  vol.  c,  p.  317.  Melier  said:  "If 
it  were  possible  to  establish  with  certainty  the  diagnosis  of  this  aft'ection,  we 
could  see  the  possibility  of  curing  the  patient  by  operation.  We  shall  perhaps 
some  day  arrive  at  this  result."^  In  spite  of  Melier's  writings,  the  profession 
adhered  for  half  a  century  to  the  view  of  Dupuytren,  put  forth  in  1833,  that 
abscesses  in  the  iliac  region  take  origin  from  the  cecum  and  not  from  the  appen- 
dix. Dr.  Reginald  Fitz,  of  Boston,  in  1886  persuaded  the  world  that  the  appen- 
dix was  the  real  seat  of  most  inflammations  in  the  right  iliac  fossa,  and  intro- 
duced the  term  "appendicitis"  ("Am.  Jour.  Med.  Sciences,"  1886,  vol.  xcii). 
This  structure  is  particularly  liable  to  infection  because  of  the  large  amount  of 
lymphoid  tissue  in  its  make-up,  because  it  is  in  a  dependent  position,  is  always 
full  of  bacteria,  has  a  poor  blood-supply,  and  is  readily  blocked  by  kinking  or 
by  swelling  of  its  mucous  membrane  Further,  as  a  vestigial  structure,  it 
has  a  low  resisting  power.  A  functionless  part,  like  a  loafer  in  a  city,  is  a  dan- 
gerous element.  Each  is  a  menace.  The  loafer  is  apt  to  become  a  criminal; 
the  appendix  is  apt  to  inflame  and  kill.  The  appendix  is  a  long  and  narrow 
diverticulum  (musculomembranous  in  structure),  which  comes  from  the  pos- 
terior and  internal  part  of  the  cecum,  and  which  probably  has  no  physiological 
function.  The  structure  of  the  appendix  is  similar  to  the  structure  of  the  colon, 
except  that  the  muscular  structure  is  ill  developed  and  trivial  in  amount.  Lock- 
wood^  points  out  that  there  is  an  extensive  lymph  system  in  the  appendix,  and 
that  the  submucous  and  subperitoneal  tissues  communicate  by  numerous 
gaps  in  the  muscles.  This  structure  has  a  poor  blood-supply,  and  in  conse- 
quence gangrene  occurs  from  rather  trivial  causes.  It  is  supplied  by  a  branch 
from  the  superior  mesenteric  artery.  In  women  there  is  sometimes  an  addi- 
tional supply  by  a  vessel  running  in  the  appendiculo-ovarian  ligament.  The 
nerves  are  derived  from  the  superior  mesenteric  plexus.  The  appendbc  averages 
about  4I 2  inches  in  length,  but  varies  in  size  between  the  limits  of  1^  inch  and  a 
little  over  g  inches.  In  641  autopsies  the  longest  appendix  was  9^:3  inches  and 
the  shortest  was  }^  inch  (Monks  and  Blake).  Its  diameter  is,  as  a  rule,  about 
equal  to  that  of  a  No.  9  English  bougie;  its  canal  is  narrow  and  is  partly  closed 
by  the  valve  of  Gerlach  (Talamon).  The  appendix  enters  the  cecum  at  its 
posterior  internal  part,  which  is  usually  the  seat  of  the  most  intense  pain  in 
inflammation,  and  corresponds  to  a  point  on  the  surface  2  inches  from  the 
anterior  superior  spine  of  the  ilium,  on  a  line  drawn  from  the  umbilicus  to  the 
iliac  spine,  which  is  known  as  McBurney^s  point.  The  free  part  of  the  appendix 
in  one-third  of  all  persons  is  in  relation  with  the  posterior  surface  of  the  cecum; 
in  almost  one-third  of  all  persons  it  is  fixed  in  the  iliac  fossa,  so  that  if  perfora- 
tion occurs  the  contents  will  be  voided  into  the  retroperitoneal  tissue  (iliac 
abscess).  In  less  than  2  per  cent,  of  cases  the  appendix  is  extraperitoneal.  In 
some  cases  it  is  external  to  the  cecum;  in  some  it  passes  downward,  and  in  some 
inward.  It  is  important  to  remember  that  the  appendix  may  be  met  with  in 
the  most  unexpected  situations.  Wlien  the  ascending  colon  is  displaced,  the 
diverticulum  may  be  upon  the  left  side.  It  is  not  unusual  to  find  its  tip  in 
the  middle  line,  up  toward  or  adherent  to  the  gall-bladder,  or  in  the  pelvis. 
In  about  two-thirds  of  all  cases  the  appendix  is  completely  covered  by  peri- 

1  "Med.  Record,"  July  19,  1902. 

2  See  R.  J.  Lee  Morrill's  article  in  the  "Amer.  Med.  Surg.  Bull.,"  Dec.  19,  1896. 
^  "Brit.  Med.  Jour.,"  Jan.  27,  1900. 

72 


1 138  Diseases  and  Injuries  of  the  Abdomen 

toneum;  in  one- third  of  all  cases  it  is  in  contact,  in  some  part  of  its  length,  with 
cellular  tissue  (Talamon).  Byron  Robinson  has  called  attention  to  the  fact 
that  the  appendix  in  man  is  frequently  in  contact  with  the  psoas  muscle,  and 
may  be  bruised  by  this  muscle.  The  mesentery  of  the  appendix  (meso-appendix) 
is  attached  to  one-half  or  two-thirds  of  the  diverticulum  but  the  tip  is  nearly 
always  free.  In  10,000  autopsies  the  appendix  is  said  to  have  been  absent 
five  times.  In  most  cases  in  which  surgeons  have  been  unable  to  find  the  appen- 
dix it  was  not  absent,  but  was  covered  and  hidden  by  peritoneum.  Occasionally 
the  appendix  is  found  in  a  hernial  sac. 

Etiology  and  Pathology. — Appendicitis  is  very  rare  in  infants.  I  operated 
unsuccessfully  on  a  male  two  years  of  age  for  gangrenous  appendicitis.  Savage 
operated  unsuccessfully  on  a  baby  sixty-one  days  old,  and  Weiss  operated  un- 
successfully on  a  child  twenty  months  old.^  J.  P.  Crozer  Griffith^  has  collected 
15  cases  in  children  under  two  years  of  age.  One  of  these  patients  was  three 
months  old.  Nine  of  the  15  were  operated  upon,  with  7  recoveries.  In  4  of  the 
cases  the  appendix  was  in  the  scrotum.  In  2  cases  a  diagnosis  of  intussuscep- 
tion was  made.  In  children  nine  or  ten  years  old  the  disease  is  by  no  means  in- 
frequent (see  page  1150).  Appendicitis  is  common  at  any  period  beyond  child- 
hood, being  more  frequent  in  young  and  middle-aged  people  than  in  the  aged. 
It  is  very  rare  in  those  over  sixty  years  of  age.  A  reason  for  this  is  that  over 
half  of  all  the  appendix  is  obliterated  or  is  being  obliterated  in  oeople  over  sixty 
years  of  age. 

Morris  ("Annals  of  Surgery,"  Nov.,  191 7)  believes  that  an  appendix  in  a 
condition  of  fibroid  degeneration  is  saved  from  infection  by  the  destruction  of 
structures  very  liable  to  infection  and  by  the  irritation  productive  of  local 
hyperleukocytosis.  It  is  for  this  reason  that  Morris  refers  to  appendicitis 
obliterans  or  irritants  as  protective  appendicitis.  Appendicitis  is  about  four 
times  commoner  in  males  than  in  females.  It  is  more  common  in  summer  than 
in  other  seasons,  and  in  warm  countries  than  in  cold  or  temperate  climes. 
Appendicitis  is  a  bacterial  disease.  It  is  produced  in  many  cases  by  pus  cocci, 
but  most  commonly  by  the  action  of  the  Bacterium  coli  commune  of  Escherich. 
The  colon  bacilli,  which  normally  inhabit  the  appendix,  are  harmless  when  the 
appendix  is  healthy,  but  become  active  for  harm  when  the  diverticulum  is 
bruised,  obstructed,  irritated  by  the  presence  of  uric  acid,  congested  because 
of  chilling  of  the  cutaneous  surface  of  the  body,  or  distended  by  the  ingress  of 
colonic  fluid  (C.  Van  Zwulenburg,  in  "Annals  of  Surgery,"  March,  1905). 
It  seems  probable  that  flatulent  distention  of  the  colon  may  be  responsible  for 
forcing  fecal  matter  in  quantity  into  the  appendix  and  may  lead  to  plugging  of 
the  opening  (Rubin,  in  "Jour.  Am.  Med.  Assoc,"  vol,  xliii.  No.  i).  It  has  been 
shown  by  Rosenau  that  certain  toxins  which  enter  the  circulation  have  a  selective 
action  for  the  appendix.  Such  toxins  may  come  from  a  distant  focus  of  infec- 
tion. When  inflammation  occurs,  swelling  of  the  mucous  membrane  may 
occlude  the  opening  into  the  colon.  If  this  occurs,  the  lumen  of  the  appen- 
dix is  dilated,  filled  up,  and  becomes  distended  by  a  thick  mucopurulent  fluid. 
Ulcers  sometimes  form  which  may  only  involve  the  mucous  membrane,  may 
pass  deeply  into  the  coats,  or  may  even  perforate.  Dieulafoy^  maintains  force- 
fully that  appendicitis  is  due  always  to  the  conversion  of  the  appendix  into  a 
closed  cavity,  but  cases  are  met  with  which  disprove  this  assertion.  Various 
conditions  may  bring  about  this  transformation.  Partial  obstruction  may  be 
caused  by  calculi,  which  are  composed  of  stercoral  material  and  hordes  of  bac- 
teria mixed  with  salts  of  lime  and  magnesia.  These  calculi  are  not  formed  in 
the  colon,  but  are  formed  in  the  appendix.  The  theory  that  concretions  form 
in  the  colon  and  are  forced  into  the  appendix  by  peristalsis  has  been  very 

*  Manley,  in  "Med.  Record,"  July  9,  1902. 

^  "University  of  Penna.  Med.  Bull.,"  Oct.,    1902. 

'  "Progres  m6dicale,"  No.  11,  1896. 


Etiology  and  Pathology  of  Appendicitis  1139 

largely  abandoned.  Dieulafoy  speaks  of  the  condition  as  appendicular  lithiasis, 
and  says  it  has  a  tendency  to  run  in  family  lines,  and  has  a  kinship  to  gout 
and  rheumatism.  Obstruction  may  be  caused  by  local  infection  of  a  catarrhal 
area,  by  the  formation  of  a  fibrous  stricture,  or  by  several  causes  acting  in 
unison.  The  presence  of  a  concretion  is  always  dangerous.  It  is  frequently 
associated  with  ulceration,  either  as  cause  or  effect.  It  is  a  mass  of  virulent 
bacteria.  It  may  lead  to  perforation  or  gangrene.  Talamon  taught  that  the 
appendix  resents  the  presence  of  the  concretion,  reflex  contraction  of  the 
muscular  coat  taking  place,  with  violent  pain  {appendicular  colic).  The  mus- 
cular structure  is  so  rudimentary  that  it  does  not  seem  probable  that 
attempts  at  contraction,  even  should  they  arise,  would  produce  violent 
pain  and  distant  symptoms.  Pozzi^  believes  that  appendicular  colic  may  be 
caused  by  torsion  or  bending  of  the  appendix  or  malposition  of  the  diver- 
ticulum, and  holds  that  pain  may  arise  when  there  is  no  lesion  in  the  appendix 
and  no  inflammation  of  the  peritoneum  or  pericecal  structures.  What  is 
called  appendicular  colic  is  really  inflammation  of  the  appendix  without  in- 
volvement of  the  peritoneum.  The  term  "appendicular  colic"  has  led  to 
much  injudicious  conservatism,  and,  as  Lockwood  shows,  if  an  appendix  is 
removed  from  an  individual  who  suffers  from  attacks  of  appendicular  colic,  it 
will  usually  be  found  that  the  diverticulum  is  inflamed  or  the  lumen  contains  a 
concretion.  Foreign  bodies  such  as  pins,  fish-bones,  nails,  buttons,  date-stones, 
cherry-stones,  and  grape-seeds,  may  enter  the  appendix,  but  they  do  so  far 
less  often  than  is  generally  supposed,  most  alleged  grape-seeds  from  the  appendix 
being  fecal  concretions.  Fitz  found  concretions  in  15  cases  out  of  300.  Ranvier 
collected  the  records  of  459  postmortems,  and  found  reported  179  fecal  concre- 
tions and  16  foreign  bodies.  In  Burgess's  500  cases  fecal  concretions  were 
found  in  21  per  cent.  ("Brit.  Med.  Jour.,"  Feb.  24,  1912).  Appendicitis  due 
to  a  foreign  body,  such  as  a  grape-seed  or  a  pin,  is  known  as  foreign-body  appen- 
dictis;  appendicitis  in  which  a  concretion  is  the  assumed  cause  is  known  as 
stercoral.  A  foreign  body  may  produce  instant  perforation.  If  impaction  of  a 
foreign  body  or  concretion  occurs,  the  orifice  of  the  appendix  is  closed,  the  cir- 
culation is  soon  cut  off,  the  secretions  are  retained,  the  coats  become  congested, 
the  diverticulum  enlarges  enormously,  microbes  multiply  with  great  rapidity, 
and  the  wall  of  the  congested  appendix  inflames  and  may  become  gangrenous 
or  ulcerated,  and  is  finally  perforated.  Interference  with  the  blood-supply 
of  the  appendix  will  predispose  to  appendicitis.  This  may  be  brought  about 
by  twists,  bruises,  adhesions,  concretions,  pressure,  or  bands;  and  the  psoas 
muscle  may  play  a  part  in  the  production  of  these  conditions.  In  women 
appendicitis  is  occasionally  secondary  to  tubo-ovarian  disease.  Appendicitis 
is  rarer  in  women  than  in  men,  probably  because  in  many  females  the  appendix 
has  a  better  blood-supply  than  in  males,  the  additional  supply  coming  through 
the  folds  of  the  appendiculo-ovarian  ligament.  In  women  disease  of  the  uterus 
or  adnexa  frequently  precedes  or  actually  causes  appendicitis.  Catarrhal  con- 
ditions of  the  intestine,  habitual  constipation,  and  indigestion  with  flatulence 
predispose  to  appendicitis.  In  fact,  in  a  great  many  cases  there  has  been  a 
more  or  less  prolonged  history  of  diarrhea  or  constipation  and  flatulent  indiges- 
tion before  the  development  of  acute  appendicitis.  An  acute  attack  of  appen- 
dicitis may  arise  after  the  eating  of  a  large  and  indigestible  meal,  especially  if 
such  a  meal  was  taken  late  at  night.  Bolting  the  food  and  eating  large  meals 
at  irregular  hours  predispose  to  an  attack.  It  seems  probable  that  catarrhal 
appendicitis  may  result  from  extension  of  catarrh  of  the  colon,  and  possible 
that,  in  rare  cases,  appendicitis  may  arise  from  external  traumatism  (traumatic 
appendicitis).  In  most  cases,  however,  in  which  appendicitis  seems  to  be  pro- 
duced by  a  blow,  the  injury  at  most  simply  "awakened  a  sleeping  dog"  and 
stirred  into  acute  inflammation  an  appendix  already  diseased.  It  is  well  to 
^  "Progres  medicale,"  No.  19,  1896. 


II40  Diseases  and  Injuries  of  the  Abdomen 

be  skeptical  as  to  external  force  causing  appendicitis.  Sprengel  (''  Dcut.  med. 
Woch.,"  Dec.  14,  191 1)  says  that  no  case  in  literature,  ascribed  to  abdominal 
trauma  as  causal,  can  be  confirmed  by  scientific  evidence.  If  before  per- 
foration the  appendix  adheres  to  the  cellular  tissue  behind  the  cecum,  cellulitis 
or  abscess  without  peritonitis  may  result.  When  appendicitis  goes  on  to  per- 
foration, there  is  always  some  peritonitis;  but  if  the  steps  to  perforation  are 
gradual,  and  if  the  causative  organism  is  the  colon  bacillus,  the  peritonitis 
may  be  local.  Sometimes,  by  formation  of  adhesions,  a  barrier  is  made  between 
the  appendix  and  the  peritoneal  cavity  before  perforation  occurs.  When 
perforation  takes  place  suddenly  peritonitis  is  inevitable.  When  the  causative 
organism  is  the  streptococcus,  general  peritonitis  is  very  apt  to  arise.  Peri- 
tonitis may  arise  without  perforation  by  contiguity  of  structure  or  by  migration 
of  bacteria  through  the  congested  walls  of  an  obstructed  appendix.  In  some 
cases  perforation  takes  place  into  the  peritoneal  cavity,  but  pus  is  circumscribed 
by  matting  together  of  the  intestines  with  plastic  exudate.  The  appendix  may 
become  gangrenous  very  rapidly  or  after  some  time.  A  case  of  appendicitis  in 
which  gangrene  and  perforation  come  on  very  quickly  is  spoken  of  as  fulminat- 
ing appendicitis.  In  some  cases,  if  the  perforation  is  very  small  and  the  appendix 
is  swathed  in  lymph,  or  if  perforation  does  not  occur,  the  inflammation  may 
subside.  Perforation  rarely  occurs  from  liquid  pressure  or  from  the  pressure 
of  a  concretion;  it  is  generally  due  to  ulceration  produced  by  the  action  of  micro- 
organisms. Appendicitis  which  subsides  may  at  any  time  recur,  and  the  life  of 
such  a  patient  is  under  constant  menace.  An  enormous  number  of  people  have 
had  appendicitis.  Toft  recorded  500  autopsies,  and  in  36  per  cent,  of  them 
there  were  positive  signs  of  past  attacks.  The  disease  is  occasionally  unsus- 
pected during  life.  These  facts  prove  that  the  disease  may  subside  without 
the  aid  of  surgery. 

Forms  of  Appendicitis. — In  what  is  known  as  appendicular  colic  the  ap- 
pendix is  temporarily  obstructed  because  of  transitory  inflammatory  swelling 
of  the  mucous  membrane  of  the  outlet,  and  the  stercoral  contents  are  retained 
in  the  diverticulum.  The  peritoneal  covering  is  not  involved  in  the  inflam- 
mation. This  condition  is  called  by  Fergusson  constipation  of  the  appendix.  If 
not  relieved,  it  will  eventuate  in  appendicitis  with  involvement  of  the  perito- 
neal coat.  It  is  an  unfortunate  term,  sometimes  used  as  an  excuse  for  avoid- 
ing operation.     In  such  cases  a  concretion  is  frequently  or  usually  present. 

Simple  parietal  or  catarrhal  appendicitis  does  not  remain  limited  to  the 
mucous  membrane;  hence  the  term  catarrhal  is  not  strictly  correct.  The 
vessels  of  the  appendix  are  distended  with  blood,  the  lumen  at  the  intestinal 
end  becomes  partially  or  completely  obstructed,  the  epithelium  desquamates 
from  numerous  glands,  the  mucosa  ulcerates,  and  the  lumen  of  the  appendbc 
becomes  filled  with  a  mixture  of  mucus,  bacteria,  and  portions  of  organic 
matter.  Bacteria  enter  the  lymph-spaces  of  the  wall  of  the  appendix,  and 
pass  rapidly  from  the  submucous  to  the  subperitoneal  tissues.  In  from  twelve 
to  thirty-six  hours  after  the  mucous  coat  begins  to  inflame  the  peritoneal  coat 
will  probably  be  involved.  The  inflammation  may  undergo  resolution  and 
the  patient  get  well,  or  a  wait  for  cure  may  result  disastrously.  The  appendbc 
may  thicken,  ulceration  may  take  place,  and  peritonitis  may  arise.  Sup- 
puration or  gangrene  may  occur,  perforation  may  take  place,  or  pyemia,  with 
abscess  of  the  liver,  may  arise.  The  acute  condition  may  pass  into  chronic 
appendicitis  or  ulcerations  of  the  mucosa  may  remain;  the  mucous  crypts 
may  be  filled  with  bacteria;  a  concretion  may  exist;  cicatricial  contractions 
may  occur.  In  any  of  these  conditions  the  patient  is  in  danger  of  a  fresh  attack 
at  any  time.  In  a  catarrhal  inflammation  secondary  to  catarrh  of  the  colon 
the  case  may  be  chronic  from  the  beginning  but  most  cases  of  chronic  appendi- 
citis follow  acute  attacks.  If  the  lumen  of  the  appendix  is  gradually  and 
completely  obliterated  the  condition  is  denominated  obliterative  appendicitis 


APPENDICITIS. 


Plate  io. 


■■^..¥i 


Various  forms  of  appendicitis  (from  drawings  by  Dr.  M.  H.  Richardson):  i.  Obstruction  from 
stenosis  of  appendix.  2.  Dilatation  of  distal  end  of  appendix  ;  perforation  by  a  fecal  concretion. 
3.  Gangrene  of  nearly  the  whole  of  the  appendix  ;  fecal  concretion  in  lumen. 


Symptoms  and  Signs  of  Appendicitis  1141 

(Senn,  in  "Jour.  Am.  Med.  Assoc.,"  1894).  It  is  present  in  more  than  half  of  all 
appendices  in  people  over  sixty  years  of  age.  Senn  was  of  the  opinion  that  the 
condition  results  from  mild  but  prolonged  relapsing  infection.  Eight  years 
before  Senn's  paper  Fitz  claimed  that  obliteration  of  the  appendix  was  the  result 
of  inflammation.  One  year  before  Senn's  paper  Ribbert  asserted  that  oblitera- 
tion was  the  result  of  non-pathological  involution.  Robt.  T.  Morris  ("Annals  of 
Surg.,"  Nov.,  1917)  believes  appendicitis  obliterans  is  "a  normal  involutional 
process  belonging  to  a  vestigial  structure,"  nerve  structures  persisting  in  the 
midst  of  contracting  hyperplastic  connective  tissue.  It  is  an  area  of  irritation 
occurring  in  those  undergoing  physical  decline  and  is  most  common  in  neu- 
rasthenics. Recurrent  appendicitis,  it  was  once  said,  may  be  due  to  the  inordinate 
size  of  the  mouth  of  the  appendix,  making  of  this  diverticulum  a  drag-net  for 
foreign  bodies;  but  we  now  know  that  it  is  more  probably  due  to  the  smallness  of 
the  opening,  so  that  it  quickly  closes  from  slight  swelhng  and  converts  the  ap- 
pendix into  a  closed  vase  filled  with  septic  material.  Suppurative  appendicitis 
is  due  to  purulent  infiltration  of  the  walls.  Pus  in  the  lumen  is  not  purulent 
appendicitis.  Pus  may  form  about  the  appendix,  a  condition  known  as  appen- 
diceal or  appendicular  abscess.  Gangrenous  appendicitis  is  a  moist  or  septic 
gangrene,  due  to  interference  with  the  circulation  and  to  tissue  destruction  by 
the  action  of  micro-organisms.  Perforation  occurs  and  multiple  perforations 
are  common.  The  entire  appendix  may  slough  off.  Interference  with  circu- 
lation may  be  caused  by  an  obstruction,  by  a  bend  or  twist  or  bruise  of  the  ap- 
pendix, or  by  the  action  of  virulent  organisms  on  an  appendix  whose  tissue 
.resistance  is  lowered  by  injury  or  disease.  In  gangrenous  cases  the  vessels  of 
the  meso-appendix  are  usually  obstructed  by  thrombi  of  the  veins  or  arteries. 
In  rare  instances  appendicitis  is  due  to  tuberculous  ulceration,  in  other  cases  to 
typhoid  ulceration,  and  genuine  appendicitis  may  arise  during  typhoid  fever. 

By  the  term  syncongestive  appendicitis  Morris  means  a  congested  appendix 
the  congestion  being  synchronous  with  "obstruction  to  the  blood  and  lymph 
circulation  of  the  cecum  and  ascending  colon.  For  example,  it  is  a  common 
complication  of  general  enteroptosis  "  ("Annals  of  Surgery,"  Nov.,  1917). 

Fowler  suggests  the  following  classification  of  cases  of  appendicitis:  Endo- 
appendicitis ;    parietal    appendicitis;    peri-appendicitis;   para-appendicitis. 

As  a  matter  of  fact  genuine  appendicitis,  that  is,  actual  inflammation  of  the 
appendix,  is  always  one  disease  which  varies  in  intensity  and  complication.  It 
is  useless  to  divide  it  into  a  great  number  of  symptomatic  groups. 

Symptoms  and  Signs. — In  what  is  known  as  appendicular  colic  the  pa- 
tient suffers  from  disorder  of  digestion  and  occasionally  has  a  brief  attack  of 
abdominal  pain  associated  with  trivial  and  temporary  tenderness  in  the  right 
iliac  fossa.  The  colicky  pain  is  about  the  umbilicus  and  right  iliac  fossa;  there 
is  often  nausea  and  usually  constipation.  This  condition,  if  not  soon  relieved, 
is  followed  by  the  evidences  of  peritoneal  inflammation.  The  symptoms  of 
genuine  acute  appendicitis  are  as  follows:  In  some  cases  the  disease  seems  to 
begin  suddenly,  but  in  most  of  the  cases  there  are  noted  for  a  few  hours  or  even 
for  a  day  or  two  distinct  premonitory  symptoms,  among  which  are  constipation 
or  diarrhea,  flatulence,  nausea,  anorexia,  dyspepsia,  coated  tongue,  weak- 
ness, general  gastro-intestinal  uneasiness,  colicky  pain  about  the  umbilicus, 
and,  perhaps  soon,  tenderness,  a  sense  of  weight,  soreness,  or  uneasiness  in 
the  right  iliac  fossa.  The  acute  symptoms  suddenly  appear  after  the  pre- 
monitory symptoms  have  lasted  a  variable  time,  and  the  acute  symptoms  very 
frequently  appear  in  the  early  hours  of  the  morning.  The  first  definite  symp- 
tom is  severe  colicky  pain.  The  tongue  is  coated  and  usually  dry.  Great 
thirst  is  often  complained  of.  The  face  is  expressive  of  pain  or,  later,  in  a 
fatal  case,  becomes  Hippocratic.  The  posture  assumed  for  greater  ease  is 
one  of  recumbency,  with  the  right  thigh  and  knee  or  both  thighs  and  knees 
partly  flexed.     Respirations  in  acute  appendicitis  are  shallow  and  thoracic. 


1 142  Diseases  and  Injuries  of  the  Abdomen 

The  development  of  acute  pain  is  usually  the  most  prominent  symptom.  The 
pain  is  at  first  colicky  and  located  about  the  umbilicus  or  through  the  abdo- 
men in  general,  this  distant,  primary,  or  generalized  pain,  according  to  Treves, 
corresponding  to  the  (Hstribution  of  the  superior  mesenteric  plexus.  Mr.  Burgess 
("Brit.  Med.  Jour.,"  Feb.  24,  1912)  states  the  present  view  when  he  says  that 
the  primary  pain  is  referred  to  "  the  peripheral  distribution  of  the  spinal  nerves 
arising  from  those  segments  of  the  spinal  cord  with  which  the  appendix  and 
small  intestine  are  connected  through  their  sympathetic  nerve  supply — eighth 
to  eleventh  dorsal."  This  primary  pain  may  subside  if  the  appendix  succeeds 
in  emptying  its  contents  into  the  colon,  but  it  may  also  subside  if  the  appendix 
becomes  gangrenous  or  ruptures  (Murphy).  Usually  in  from  twelve  to  thirty- 
six  hours  the  pain  becomes  localized  in  the  right  iliac  fossa,  and  associated 
with  tenderness  and  hyperesthesia  of  the  skin — in  other  words,  true  inflamma- 
tory pain  develops.  It  is  due  to  peritoneal  inflammation.  "Thus,  the  closer 
the  situation  of  the  appendix  to  the  parietal  peritoneum,  the  earlier  will  the 
latter  be  irritated  and  the  sooner  will  the  pain  be  localized"  (Burgess,  Ibid.). 
The  usual  location  of  the  pain  in  the  right  iliac  fossa  depends  on  the  fact  that 
the  appendix  is  usually  placed  in  that  region.  Occasionally,  when  the  appendix 
crosses  the  belly,  the  pain  is  located  on  the  left  side,  and  occasionally,  for  like 
reasons,  in  the  gall-bladder  region,  the  right  loin,  or  the  pelvis.  "If  the  appen- 
dix lies  among  coils  of  small  intestine  or  in  the  pelvis  there  may  at  no  time  be 
local  pain,  the  initial  umbilical  pain  becoming  steadily  generalized"  (Burgess, 
"Brit.  Med.  Jour.,"  Feb.  24,  1912).  If  the  pain  of  appendicitis  is  violent  the 
patient  presents  some  evidences  of  shock.  Nausea  is  the  rule  in  appendicitis; 
vomiting  usually  occurs  early — about  three  or  four  hours  after  the  beginning 
of  pain.  In  children  vomiting  is  often  early,  violent,  and  persistent,  but  in 
adults,  after  the  early  hours  of  the  attack,  vomiting  occurs,  as  a  rule,  occa- 
sionally or  not  at  all,  although  nausea  is  complained  of.  Early  vomiting  is  a 
reflex  symptom  due  to  distention  of  the  appendix  (Murphy).  If  vomiting  per- 
sists, it  points  to  peritonitis,  to  pus  formation,  or  to  intestinal  obstruction  unless 
it  results  from  the  administration  of  morphin.  There  is  usually  constipation  in 
acute  appendicitis,  although  diarrhea  occasionally  occurs.  In  appendicitis 
there  is  always  some  elevation  of  temperature,  although  it  may  be  very  slight 
and  of  brief  duration.  The  fever  is  not  ushered  in  by  a  chill,  but  the  tempera- 
ture mounts  in  the  course  of  a  few  hours  to  102°  or  103°  F.  or  even  higher. 
The  fever  does  not  begin  until  several  hours  or  a  number  of  hours  after  the 
onset  of  pain.  In  a  very  mild  case  the  temperature  remains  elevated  for  a 
day  or  two  and  then  falls  to  normal.  In  severe  cases  it  is  apt  to  remain  ele- 
vated for  a  longer  period,  but  it  is  always  to  be  borne  in  mind  that  in  very 
grave  appendicitis  the  surgeon  may  find  very  little  elevation  of  temperature, 
no  elevation,  or  actually  a  subnormal  temperature.  In  gangrenous  cases,  and  in 
cases  in  which  a  large  perforation  suddenly  takes  place,  and  when  general  perito- 
nitis develops,  there  is  usually,  for  a  time  at  least,  a  subnormal  temperature. 
A  sudlen  drop  of  temperature  indicates,  as  a  rule,  a  calamity,  particularly 
gangrene  of  the  mucosa  of  the  appendix,  which  prevents  absorption  (Murphy), 
or  perforation  of  the  appendix.  Leukocytosis  is  usually  present  (see  Diagno- 
sis). The  pulse  in  appendicitis  is  in  most  cases  rapid.  A  very  rapid  pulse 
(well  over  100)  is  significant  usually  of  a  severe  case,  and  the  auguries  are 
especially  ominous  if  the  pulse  is  rapid  but  the  temperature  is  normal  or  sub- 
normal.   Occasionally,  however,  a  slow  pulse  exists,  even  in  the  worst  cases. 

Examination  of  the  abdomen  may  discover,  early  in  the  case,  general 
abdominal  rigidity;  but  usually  in  the  course  of  twenty-four  hours  or  more  the 
general  rigidity  passes  away,  the  abdomen  distends  more  or  less,  and  rigidity  of 
the  lower  half  of  the  right  rectus  muscle  becomes  evident  and  persists.  If  gen- 
eral peritonitis  begins  early,  general  abdominal  rigidity  does  not  abate  or  pass 
away.     If  general  peritonitis  begins  later,  general  abdominal  rigidity,  which  was 


Symptoms  and  Signs  of  Appendicitis  1143 

present  at  first  but  which  passed  away,  returns.  Rigidity  may  not  exist  in  the 
very  beginning  of  appendicitis,  in  a  case  in  which  the  appendix  is  retrocecal 
or  pelvic,  in  some  abscess  cases,  or  in  a  case  with  relaxed  belly  walls. 

A  symptom  almost  invariably  present  in  appendicitis  is  tenderness.  In 
some  cases  the  tenderness  is  diffuse;  in  most  it  is  localized,  or  at  least  most 
acute,  in  the  right  iliac  fossa.  The  point  where  tenderness  is  usually  most 
acute  is  a  spot  about  2  inches  internal  to  the  anterior  superior  spine  of  the  ilium, 
on  a  line  drawn  from  that  bony  point  to  the  umbilicus  {pmphalospinous  line). 
This  is  known  as  McBurney's  point,  and  overlies  the  usual  point  of  origin 
of  the  appendix.  In  some  cases,  however,  the  greatest  point  of  tenderness  is 
nearer  the  gall-bladder;  in  others,  in  the  loin;  in  others,  toward  the  umbilicus, 
in  the  midline,  or  on  the  opposite  side;  in  others,  in  the  rectum.  The  seat  of 
greatest  tenderness  depends  on  the  situation  of  the  appendix,  and  it  is  usually 
at  McBurney's  point,  because  this  usually  overlies  the  origin  of  the  appendix. 
The  lesson  is  that  in  appendicitis  there  is  a  point  of  tenderness  or  of  greatest 
tenderness  in  a  region  which  the  appendix  could  occupy.  If  tenderness  exists 
on  the  right  side  and  then  develops  in  'the  left  side,  severe  spreading  perito- 
nitis usually  exists  (W.  Meyer).  When  the  appendix  becomes  gangrenous, 
local  tenderness  may  for  a  time  disappear,  because  the  peritoneum  of  the 
involved  region  has  become  anesthetic;  later,  however,  it  returns,  spreads, 
and  may  become  general.  In  view  of  the  fact  that  tenderness  in  the  right 
iliac  fossa  is  often  demonstrable  in  tubal  and  ovarian  disease,  the  sign  in  males 
^'is  of  greater  significance  than  in  females"  (A.  H.  Tubby,  on  "Appendici- 
tis," in  "Medical  Monograph  Series").  Pressure  upon  the  left  side  will,  in 
some  cases,  cause  pain  in  the  right  iliac  region.  When  rigidity  abates  or  disap- 
pears the  case  may  go  on  to  cure,  but  sometimes  a  mass  becomes  evident  in 
the  right  iliac  fossa.  The  mass,  of  variable  shape,  is  at  first  hard,  and  if  of 
any  considerable  size,  is  dull  on  percussion.  In  some  cases  when  no  mass  is 
palpable  through  the  abdominal  wall,  rectal  examination  detects  one.  This 
mass  may  be  agglutinated  bowel  and  omentum  or  a  collection  of  coagulated 
inflammatory  exudate.  It  may  gradually  disappear  or  an  abscess  may  form. 
The  evidences  of  general  peritonitis  are:  great  distention  because  of  intestinal 
paresis,  general  abdominal  tenderness,  rectal  tenderness,  very  rapid  pulse, 
hiccup,  persistent  vomiting  which  may  become  regurgitation,  and,  as  Meyer 
points  out,  percussion  dulness  over  the  right  iliac  region  or  entire  lower  abdomen. 

In  some  cases  the  symptoms,  at  first  trivial,  become  grave.  In  some  all 
the  symptoms  are  violent  from  the  beginning,  the  attack  tends  to  linger,  and 
is  followed  by  persistent  soreness  of  the  appendix  and  harrassing  digestive  dis- 
turbances. Any  case  of  appendicitis  may  become  suddenly  desperately  grave 
because  of  perforation  or  gangrene,  and  in  any  case  general  peritonitis  may 
develop.  After  sudden  perforation  or  rapid  gangrene  the  temperature  falls, 
hiccup  begins,  abdominal  distention,  pain,  and  tenderness  become  marked 
and  general,  and  the  pulse  becomes  very  rapid.  In  some  cases  these  grave 
symptoms  are  present  almost  from  the  start  (fulminating  cases).  A  sudden 
perforation  produces  collapse  and,  if  reaction  takes  place,  general  peritonitis 
arises.  Peritonitis,  be  it  remembered,  may  arise  without  either  perforation 
or  gangrene.  If  pus  forms,  it  may  be  unlimited  by  adhesions.  In  such  cases 
there  is  the  rapid  onset  of  fatal  peritonitis  and  septicemia.  Pus  may  be  limited 
by  adhesions  and  be  practically  extraperitoneal.  In  such  a  case  a  lump  is 
felt  in  the  right  iliac  region,  but  dusky  discoloration  and  edema  of  skin  very 
seldom  exist.  The  surgeon  does  not  wait  for  fluctuation  before  he  makes  a 
diagnosis.  In  an  abscess  case  there  are  usually  irregular  fever  and  sweating, 
but  rigors  do  not  occur.  Hawkins  says  we  should  always  suspect  pus  if  the 
symptoms  continue  after  the  sixth  day,  and  particularly  when  the  symptoms 
abate  and  suddenly  increase  between  the  seventh  and  tenth  days.  A  limited 
collection  of  pus  may  be  liberated  into  the  peritoneal  cavity  by  rupture  of  the 


1 144  Diseases  and  Injuries  of  the  Abdomen 

abscess  wall.  Such  a  rupture  may  be  caused  by  pressure  or  muscular  effort; 
rupture  is  followed  at  once  by  shock  and  later  by  diffused  peritonitis.  An 
abscess  may  rupture  externally  or  into  the  vagina,  intestinal  tract,  or  bladder. 
It  is  desirable,  if  possible,  to  locate  the  situation  of  the  appendix,  and  this  is 
usually  determined  by  locating  the  seat  of  swelling  and  of  greatest  tenderness. 
The  surgeon  should  not  lose  sight  of  the  fact  that  the  appendix  may  be  found 
in  the  most  unexpected  situations.  In  every  case  a  rectal  or  vaginal  examina- 
tion should  be  made  in  order  to  detect  swelling  and  tenderness,  and  thus 
determine  if  the  inflammation  took  origin  in  or  now  involves  the  pelvic 
region.  Pain  at  the  end  of  micturition  points  to  involvement  of  the  vesical 
peritoneum.^  In  cases  in  which  there  is  no  localized  swelling  and  no  local  ten- 
derness— for  instance,  in  gangrenous  or  perforative  appendicitis  with  general 
peritonitis — "diagnostic  localization"  is  impossible  (Van  Hook). 

Terminations  and  Prognosis. — Acute  appendicitis  may  terminate  in  death, 
in  complete  recovery,  or  in  a  condition  of  lowered  vitality  during  the  existence 
of  which  acute  attacks  are  almost  certain  to  recur.  Sometimes  after  and 
sometimes  without  an  antecedent  acute  attack  the  patient  develops  persistent 
soreness  and  tenderness  in  the  right  iliac  region.  Between  the  attacks  of 
recurrent  appendicitis  there  may  be  soreness,  tenderness,  and  gastro-intestinal 
disturbance,  or  there  may  be  no  evident  trouble  whatever;  yet,  even  in  the 
latter  'case,  there  may  be  an  ulcer  or  ulcers  of  the  mucous  lining.  If  a  patient 
has  once  had  appendicitis  he  will  always  be  liable  to  suffer  from  another  attack 
if  the  appendix  has  not  been  removed.  The  liability  becomes  almost  a  cer- 
tainty if  the  intestinal  end  of  the  appendix  is  narrowed  or  if  the  lumen  is  ob- 
structed at  any  point,  if  a  concretion  exists,  or  if  there  is  an  area  of  ulceration 
or  of  desquamating  epithelium.  After  an  attack  the  appendix  may  remain 
enlarged  and  tender;  exercise  or  indiscretion  in  diet  may  cause  it  to  become 
tender,  or  the  patient  may  have  occasional  attacks  of  colicky  pain.  If  any 
of  the  above  conditions  exist,  another  attack  may  be  confidently  anticipated  if 
operation  is  not  performed.  In  such  cases  the  appendix  can  usually  be  pal- 
pated. The  method  of  palpation  in  an  interval  proposed  by  Robert  T.  jSIorris'^ 
is  very  useful.     It  is  applied  as  follows: 

The  surgeon  stands  to  the  right  of  the  patient  and  uses  three  fingers  of 
the  right  hand  to  feel  with  and  three  fingers  of  the  left  hand  to  press  with. 
Morris  insists  that  no  muscular  effort  should  be  used  by  the  hand  which 
feels.  The  feeling  fingers  are  pressed  by  the  other  fingers  beneath  the  margin 
of  the  right  rectus  muscle  on  a  level  with  the  umbilicus,  and  are  drawn  toward 
the  patient's  right  side,  and  the  colon  will  be  felt  to  roll  under  the  fingers. 
The  process  is  repeated  several  times  until  the  end  of  the  cecum  is  reached. 
The  appendix  is  sought  for  by  rolling  the  cecum  from  side  to  side  with  the 
finger-tips,  and  working  toward  the  proximal  end  of  the  appendix. 

Adhesions  may  form  as  a  result  of  appendicitis,  general  peritonitis  may 
arise,  the  appendLx  may  slough  or  become  perforated,  or  abscess  may  ensue 
upon  local  peritonitis.  Lymphangitis  of  the  appendix  may  accompany, 
and  septic  lymphangitis  or  phlebitis  and  secondary  hepatic  and  lymphatic 
infections  may  follow,  appendicitis.  They  are  thought  to  be  most  common 
after  mild  attacks  of  appendicitis.  The  secondary  lymphatic  and  hepatic 
infections  are  of  the  greatest  importance.  There  may  be  abscess  of  the  liver, 
subphrenic  abscess,  or  retroperitoneal  lymphangitis. 

A  subphrenic  abscess  may  result  from  infection  carried  from  the  appendix 
by  the  lymphatics,  from  pus  ascending  along  the  posterior  cellular  spaces, 
or  from  direct  invasion  via  the  peritoneal  cavity  (John  C.  Munro,  in  "Annals 
of  Surgery,"  Nov.,  1905);  such  an  abscess  is  usually  on  the  right  side,  but  may 
be  upon  the  left. 

^  Van  Hook,  in  "Jour.  Am.  Med.  Assoc,"  Feb.  20,  1S97. 
2  "Medical  Record,"  Sept.  17,  1898. 


Diagnosis  of  Appendicitis  1145 

Lymphangitis  is  the  rule  in  appendicitis,  and  when  we  open  the  abdomen 
there  is  usually  evidence  of  it  in  the  lymph-glands  of  the  mesentery,  and  in 
children  particularly  these  glands  are  apt  to  be  enlarged.  One  lymph  path 
from  the  appendix  is  through  the  ileocecal  glands,  another  is  posterior  to 
the  cecum  and  retroperitoneal,  and  the  latter  reaches  the  liver  and  diaphragm 
(Munro).  In  lymphatic  infection  an  abscess  may  form  anywhere  in  the  course 
of  the  lymphatics.  Abscess  of  the  liver  usually  results  from  portal  invasion, 
but  may  result  from  lymphatic  infection. 

Sometimes  jaundice  arises.  Jaundice  is  due  to  toxins  which  enter  the 
portal  vein  and  reach  the  liver.  It  is  ushered  in  by  a  chill  and  the  chill  is  apt 
to  be  repeated  daily,  every  other  day  or  every  third  day.  Such  a  patient 
may  die  in  two  or  three  days  or  may  live  a  week  or  two.  In  these  cases  the 
liver  is  small,  the  liver-cells  are  degenerating  and  there  is  acute  nephritis.  The 
red  blood-cells  are  destroyed  in  immense  numbers  and  these  dead  cells  add  to 
the  jaundice.  A  similar  jaundice  may  happen  after  anesthesia  by  chloroform 
or  ether  (Lenzmann,  in  Zentralb.  flir  Chir.,  Feb.  14,  1914)  and  in  fatty  de- 
generation of  the  liver  cells  as  a  complication  of  pregnancy. 

Among  other  possible  consequences  of  appendicitis  may  be  mentioned 
pyemia,  empyema,  inflammation  of  the  parotid  gland,  and  thrombosis  of 
the  right  iliac  vein.  A  positive  prognosis  of  any  case  of  appendicitis  is  an 
absolute  impossibility.  The  future  of  every  case  is  clouded  with  uncertainty, 
and  the  most  that  can  be  attained  in  the  field  of  prediction  is  a  scientific  guess 
of  more  or  less  probability.  All  surgeons  have  seen  apparently  hopeless  cases 
recover,  and  have  observed  cases  with  the  most  trivial  symptoms  grow  pro- 
gressively worse  or  suddenly  develop  a  fatal  complication.  Further,  after  one 
attack  other  attacks  are  very  apt  to  arise.  The  medical  man  who  estimates 
that  80  or  90  per  cent,  of  cases  get  well  without  operation  has  probably  dealt 
with  many  catarrhal  cases,  and  he  certainly  is  optimistic  as  to  freedom  from 
future  attacks,  because,  as  stated  before,  recovery  from  an  attack  does  not 
of  necessity  mean  freedom  from  the  disease.  In  appendicitis  there  may  be 
delusive  evidences  of  improvement;  for  instance,  the  abatement  of  pain  and 
the  lessening  of  fever,  being  regarded  by  the  patient  himself  as  indubitable 
signs  of  improvement,  may,  in  reality,  be  indicative  of  gangrene.  In  spite  of 
the  previously  mentioned  difficulties  and  obscurities  we  can  in  the  majority  of 
cases  decide  with  a  reasonable  probability  of  accuracy  whether  or  not  the  patient 
is  becoming  worse.  In  a  delusive  improvement  some  signs  and  symptoms  im- 
prove, but  all  do  not;  and  in  endeavoring  to  form  a  prognosis,  all  the  signs  and 
symptoms  must  be  noted  and  weighed:  pain,  tenderness,  rigidity,  distention, 
nausea  and  vomiting,  delirium,  intestinal  obstruction,  shock,  the  temperature, 
the  rapidity  of  the  pulse,  the  blood  examination,  etc.  If  all  these  elements, 
not  only  some  of  them,  point  to  improvement,  we  may  be  reasonably  confident 
that  improvement  is  really  taking  place.  If  only  some  of  them  point  to  im- 
provement we  will  in  many  cases  be  altogether  uncertain  as  to  the  significance 
of  the  change. 

The  diagnosis  is  not  invariably  so  easy,  as  many  light-hearted  operators 
seem  to  believe.  It  is  frequently  far  from  easy  and  is  sometimes  altogether 
impossible  without  exploratory  operation,  Sonnenburg  maintains  that  we  can 
diagnosticate  the  pathological  condition  of  the  inflamed  appendix.  Personally, 
I  am  unable  to  do  this  with  any  certainty,  although  I  always  try,  and  am 
often  right  and  just  as  often  wrong. 

In  attempting  to  make  a  diagnosis,  besides  the  ordinary  examination 
of  the  abdomen  a  rectal  or  vaginal  examination  should  be  made,  associated 
in  many  cases  with  bimanual  palpation.  If  an  appendbc  is  enlarged  and 
an  individual  has  a  thin  abdomen  which  is  not  rigid,  it  may  be  possible  to 
palpate  the  appendix.  Sometimes  it  can  be  felt  after  the  administration  of 
ether  when  it  could  not  be  detected  before.  In  an  acute  case  forcible  or  pro- 
longed palpation  is  always  unjustifiable,  as  it  may  force  an  ulcer  to  perforate, 


1146  Diseases  and  Injuries  of  the  Abdomen 

or  may  rupture  an  abscess,  and  the  information  gained  is  not  of  sufficient  im- 
portance to  justify  the  risk.  In  a  chronic  case  information  of  great  value- 
may  be  obtained  and  there  is  no  real  risk  in  the  maneuver.  I  am  persuaded 
Johrt  B.  Murphy  is  correct  in  attaching  the  greatest  possible  importance  to 
the  order  in  which  symptoms  appear  in  acute  appendicitis.  Pain  precedes 
nausea  and  vomiting,  elevated  temperature,  and  abdominal  tenderness.  If 
fever  precedes  pain  the  condition  is  not  appendicitis.  If  vomiting  precedes 
pain  the  condition  is  probably  not  appendicitis. 

The  disease  may  be  confused  with  a  number  of  different  conditions.  It 
sometimes  is  confused  with  typhoid  fever;  in  fact,  early  typhoid  fever  asso- 
ciated with  marked  abdominal  pain  gives  a  picture  very  similar  to  that  fur- 
nished by  appendicitis. 

In  typhoid  fever  the  temperature  is  usually  distinctly  higher  than  that 
commonly  encountered  in  appendicitis.  Maurice  H.  Richardson^  tells  us 
that  in  every  case  in  which  typhoid  is  suspected,  operation  is  not  justifiable 
on  the  hypothesis  of  existing  appendicitis,  unless  there  are  local  pain  and 
localized  tenderness  in  the  appendix  region,  associated  with  definite  mus- 
cular resistance  or  distinct  rigidity;  and  that  operation  should  be  postponed 
in  a  case  in  which  the  constitutional  signs  are  severe  and  the  local  signs  are 
difficult  to  detect;  but  when  there  are  pain,  tenderness,  and  rigidity  with 
or  without  distention,  operation  must  be  performed,  even  when  one  recog- 
nizes the  possibility  of  the  existence  of  typhoid  fever.  Richardson  lays  down 
the  following  rule:  Soft  abdomen  plus  high  temperature  suggests  typhoid, 
even  if  there  are  pain  and  tenderness.  In  appendicitis  there  is  usually  leuko- 
cytosis; in  typhoid,  leukocytosis  is  absent,  except  when  perforation  is  imminent 
or  has  occurred,  or  when  some  other  complication  exists.  I  have  seen  the 
operation  performed  twice  for  supposed  appendicitis  when  the  condition  in 
each  case  was  found  to  be  early  typhoid  fever. 

Acute  intestinal  obstruction  is  sometimes  confused  with  acute  appendi- 
citis, and  the  mistake  is  particularly  likely  to  occur  if  the  obstruction  is  due 
to  intussusception.  In  acute  obstruction,  as  in  appendicitis,  the  pain  is  first 
appreciated  about  the  umbilicus;  but  in  acute  obstruction  it  remains  in  that 
region,  does  not  pass  to  and  localize  itself  in  the  right  iliac  fossa,  and  is  not 
associated  with  tenderness  of  the  right  iliac  fossa.  In  obstruction  the  vomit- 
ing is  persistent;  in  appendicitis,  except  in  the  beginning,  it  is  usually  trivial 
and  often  absent,  although  in  children  it  may  be  violent  .and  persistent.  In 
acute  obstruction  shock  is  much  more  pronounced  than  in  appendicitis,  and 
early  and  great  distention  of  the  abdomen  is  noted.  The  temperature  in 
obstruction  is  seldom  elevated  and  is  usually  subnormal;  while  in  appendi- 
citis, at  least  in  the  majority  of  cases,  the  temperature  is  distinctly  elevated. 
Further,  in  acute  intestinal  obstruction  the  constipation  is  absolute,  not  even 
gas  passing.  In  children,  intussusception  is  capable  of  particularly  confusing 
the  diagnosis,  because,  after  the  first  day,  it  is  by  no  means  unusual  to  have 
distinct  fever  in  this  condition,  and  occasionally  a  tumor-like  mass  is  found 
in  the  right  iliac  fossa;  but  in  intussusception  the  tumor  does  not  remain  fixed, 
but  alters  its  position;  it  is  movable;  and  the  patient  usually  suffers  from 
tenesmus  and  the  passage  of  bloody  mucus.  One  should  bear  in  mind  that  in 
acute  appendicitis  associated  with  septic  peritonitis  acute  obstruction  may 
exist;  and  that  the  diagnosis  of  obstruction  may  be  made  without  recognizing 
the  appendicitis. 

In  those  rare  cases  of  typhlitis  occasionally  encountered  the  symptoms  are 
much  milder  than  in  appendicitis:  the  temperature  is  not  much  elevated,  the 
pulse-rate  is  only  slightly  accelerated,  the  leukocytosis  is  not  marked,  there 
is  seldom  rigidity,  there  may  be  tenderness,  but  seldom  pain.  Pain  when  pres- 
ent is  colicky  rather  than  continuous.  There  may  be  a  doughy  mass  or  a 
^  "Boston  Med.  and  Surg.  Jour.,"  Jan.  9,  1902. 


Diagnosis  of  Appendicitis  1147 

mass  feeling  "like  an  air-cushion"  in  the  right  iliac  fossa  (Raymond  Russ,  in 
"Surg.,  Gyn.,  and  Obstet.,"  Oct.,  191 2).  Chronic  typhlitis  causes  muscular 
atony  and  intestinal  stasis  (Russ,  Ibid.). 

Lesions  of  the  kidney  are  sometimes  mistaken  for  appendicitis,  but  in  renal 
colic  the  pain  runs  into  the  groin  and  testicle  of  that  side,  and  occasionally 
passes  down  the  front  of  the  thigh  or  into  the  rectum;  and  if  any  tenderness 
exists,  it  is  found  in  the  loin  or  in  the  groin,  rather  than  in  the  right  iliac  fossa. 
Besides,  there  are  other  symptoms  of  kidney  trouble.  The  urine  may  con- 
tain blood  or  pus,  and  there  may  be  a  history  of  difficult  or  of  frequent  urina- 
tion, though  one  should  bear  in  mind  that  in  appendicitis  with  inflammation 
of  the  vesical  peritoneum  there  may  also  be  a  record  of  urinary  difficulties.  An 
.v-ray  picture  may  exhibit  a  calculus  in  the  ureter  or  kidney,  and  a  movable 
kidney  is  distinctly  palpable.  In  ordinary  renal  colic  there  is  vomiting  in 
the  beginning,  just  as  in  the  beginning  of  appendicitis.  In  movable  kidney 
and  renal  colic  the  vomiting  is  often  more  violent  and  prolonged  than  is  common 
in  appendicitis.  Movable  kidney  and  appendicitis  may  exist  coincidentally. 
Very  confusing  cases  are  those  in  which  hematuria  accompanies  appendicitis. 
I  have  seen  it  twice  and  in  neither  case  was  there  any  apparent  connection 
between  the  appendix  and  the  kidney,  ureter,  or  bladder.  The  hematuria 
must  have  been  due  to  acute  nephritis  which  is  known  to  occur  in  some  cases 
of  appendicitis,  the  nephritis  resulting  from  the  toxins  of  a  bacterial  disease. 
This  form  of  nephritis  Dieulafoy  calls  "nephrite  toxique  appendiculaire." 
As  pointed  out  by  M.  G.  Seelig  ("Annals  of  Surgery,"  Sept.,  1908),  hematuria 
may  also  be  due  to  direct  involvement  of  the  kidney,  ureter,  or  bladder.  When 
the  tip  of  an  inflamed  appendix  is  adherent  in  the  region  of  the  right  ureter 
there  may  be  symptoms  inseparable  from  those  of  renal  colic. 

Gall-bladder  difficulties,  too,  may  be  confounded  with  appendicitis.  I  have 
operated  upon  2  cases  of  cholecystitis  under  the  supposition  that  they  were 
cases  of  appendicitis;  and  upon  several  cases  of  appendicitis  in  the  belief  that 
the  condition  in  each  case  was  cholecystitis.  In  an  inflammation  of  the  gall- 
bladder, with  a  distended  gall-bladder  hanging  low  down,  and  with  muscular 
rigidity,  the  distinction  between  appendicitis  and  cholecystitis  is  always  diffi- 
cult and  sometimes  impossible.  So  it  is  when  the  cecum  has  not  descended 
and  the  appendLx  is  in  the  gall-bladder  region.  So  it  is  when  the  tip  of  the 
appendix  is  adherent  to  the  gall-bladder.  In  ordinary  gall-stone  colic  the  con- 
dition is  generally  sudden  in  onset;  it  is  characterized  by  pain  in  the  epigastric 
region,  passing  toward  the  shoulder-blade  and  the  shoulder,  the  pain  being  most 
acute  and  becoming  more  or  less  localized  in  the  region  of  the  gall-bladder; 
and  there  is  always  tenderness  over  the  gall-bladder  region.  In  gall-bladder 
colic  the  vomiting  is  usually  violent  and  often  almost  continuous. 

The  perforation  of  a  gastric  or  of  a  duodenal  ulcer  may  be  diagnosticated 
as  appendicitis.  In  perforation  of  a  gastric  ulcer  there  is  usually  a  history 
of  previous  difficulty  with  the  stomach,  though  this  is  not  always  the  case. 
The  onset  of  acute  perforation  is  sudden,  with  greater  shock  than  is  character- 
istic of  the  onset  of  appendicitis.  The  pain  is  violent,  the  rigidity  intense, 
and  the  pain,  rigidity,  and  tenderness  are  in  the  epigastric  region. 

Among  other  conditions  that  may  be  confused  with  appendicitis  may  be 
mentioned  maHgnant  disease  of  the  cecum,  tuberculosis  of  the  cecum,  acute 
tuberculous  peritonitis,  twisting  of  the  pedicle  of  an  ovarian  tumor,  tubal  dis- 
ease, extra-uterine  pregnancy,  membranous  colitis,  perinephric  abscess,  tuber- 
culous abscess  of  the  loin  or  of  the  groin,  and  abscess  from  hip-joint  disease. 
I  have  operated  on  three  cases  in  which  sciatica  was  caused  by  appendicitis. 
In  each  case  the  appendix  was  adherent  posteriorly.  All  were  promptly  cured. 
One  had  been  bedridden  for  many  months  before  the  operation. 

Pneumonia  of  the  right  base  and  pleurisy  may  cause  abdominal  pain 
and  be  mistaken  for  appendicitis.  The  pain  may  be  due  to  inflammation  of  the 
diaphragmatic  pleura  or  may  be  reflected  along  the  lower  six  intercostal  nerves 


1 148  Diseases  and  Injuries  of  the  Abdomen 

which  supply  the  lower  part  of  the  pleura  and  the  abdominal  wall.  Irritation 
of  the  eleventh  thoracic  nerve  causes  pain  in  the  iliac  region.  There  may  even 
be  superficial  tenderness  in  the  abdomen,  but  deep  pressure  is  well  tolerated 
(Donald  VV.  Hood,  "Brit.  Med.  Jour.,"  Dec.  30,  1905).  There  may  be  abdom- 
inal rigidity.  The  abdominal  pain  seldom  persists  more  than  a  few  hours. 
It  is  intensified  by  deep  respiration  and  is  accompanied  by  high  fever.  A's 
Hood  says,  whenever  a  patient  suffers  from  vomiting,  abdominal  pain,  and 
high  fever,  examine  the  chest.  Sir  Thomas  Oliver  has  described  what  he  calls 
"the  abdominal  type  of  pneumonia."  It  is  characterized  by  the  sudden  onset 
of  severe  abdominal  pain.  Vomiting  often  occurs.  There  is  then  a  chill, 
usually  a  rise  of  temperature,  and  in  some  cases  collapse.  The  pain  is  accom- 
panied by  tenderness,  and  both  these  phenomena  may  be  in  the  right  iliac 
region.  Early  there  are  no  physical  signs  of  pneumonia.  In  a  few  hours  the 
patient  reacts  from  collapse,  the  abdominal  pain  and  tenderness  subside,  the 
temperature  rises,  and  signs  of  pneumonia  become  evident.  In  young  children 
pneumonia  is  particularly  apt  to  cause  abdominal  pain  and  rigidity.  Beyond  a 
doubt,  more  than  one  abdomen  has  been  opened  for  supposed  appendicitis  when 
the  real  condition  was  pneumonia. 

In  chronic  appendicitis  there  is  no  rigidity.  The  diagnosis  of  chronic  ap- 
pendicitis is  usually  lightly  and  sometimes  wrongly  made.  The  conditions 
which  lead  to  confusion  are  many;  among  them  may  be  mentioned  Lane's  kink, 
enteroptosis,  movable  kidney,  adhesions,  Jackson's  membrane,  twisted  cecum, 
gall-bladder  disease,  pelvic  disease,  etc.  F.  Gregory  Connell  speaks  of  cases 
which  he  calls  pseudo-ap pendicitis  ("Jour.  Am.  Med.  Assoc,"  July  29,  1916). 
They  occur  particularly  in  young,  thin  adults  and  in  females.  Attack  after 
attack  of  pain  may  occur.  The  pain  is  aggravated  by  exercise  and  relieved 
by  recumbency.  During  the  attack  there  is  muscle  spasm,  there  may  or  may 
not  be  tenderness,  the  intestine  is  inflated  with  gas,  the  temperature  is  normal 
or  subnormal,  there  is  no  leukocytosis,  seldom  vomiting,  and  the  patient  is  seldom 
driven  to  bed.  Connell  (Ibid.)  believes  the  condition  to  be  due  to  "a  lack  of 
balance  between  the  vagus  and  sympathetic  divisions  of  the  autonomic  nervous 
system."  Removal  of  the  appendix  does  not  cure  such  a  case.  Robt.  T.  JNIorris 
("Annals  of  Surgery,"  Nov.,  191 7)  points  out  a  fact  of  great  importance  in  regard 
to  chronic  appendicitis.  In  all  forms  of  chronic  appendicitis  there  is  tender- 
ness about  an  inch  and  a  half  to  the  right  of  the  navel.  This  tenderness  is 
due  to  hypersensitiveness  of  the  right  lumbar  sympathetic  ganglion.  It  is  a 
striking  fact,  the  difference  in  the  location  of  the  tenderness  in  acute  and  in 
chronic  appendicitis.  In  the  latter  condition  the  tenderness  is  not  over  the 
appendix.  In  chronic  appendicitis,  in  addition  to  tenderness  of  the  ganglion 
we  note  gaseous  distention  of  the  ascending  colon.  These  two  symptoms  pointed 
out  by  Morris  are  undoubtedly  realities  and  I  have  been  able  to  confirm  their 
genuineness  many  times.  The  explanation  of  them  will  be  found  in  the  study  of 
appendicitis  obHterans.  Robt.  T.  Morris  (''Annals  of  Surgery,"  Nov.,  191 7) 
discusses  the  diagnosis  of  appendicitis  obliterans,  which  he  designates  appendicitis 
irritans.  He  points  out  that  it  occurs  most  frequently  in  neurasthenics  with 
relaxation  of  peritoneal  supports  and  who  show  other  stigmata  of  physical 
decline  ("narrow  costal  angles,  crowded  teeth,  gunstock  scapulae,  or  a  defective 
helix  of  the  ear").  An  advanced  degree  of  atrophy  of  the  appendix  does  not 
occur  in  the  very  young  but  more  or  less  of  the  atrophy  exists  in  one-third  of  all 
appendices  in  people  over  twenty  years  of  age.  The  chief  symptoms  are  those 
of  chronic  appendicitis.     Morris  (Ibid.)  sums  them  up  as  follows: 

I .  Hyperesthesia  of  the  right  lumbar  sympathetic  ganglion.  This  ganglion  is 
an  inch  and  a  half  to  the  right  of  the  navel  and  "a  trifle  caudad"  and  is  near 
the  spinal  column.  There  is  no  direct  nerve  route  from  the  appendix  to  the 
ganglion  and  the  hyperesthesia  is  probably  due  to  an  efferent  impulse  from  the 
spinal  cord  to  the  ganglion.    The  impulse  having  originated  in  the  appendix, 


Appendiceal  Dyspepsia  1149 

passes  first  to  the  cord  center  and  then  to  both  the  ganglion  and  the  skin,  the 
skin  becoming  hyperesthetic,   and  pressure  over  the  ganglion  causing  pain. 

2.  Distention  of  the  flaccid  colon  with  gas.  This  is  due  to  overstimulation  of 
the  innervation  of  the  ascending  colon  by  irritation  from  the  appendix.  As 
Morris  puts  it  "the  muscularis  of  this  part  of  the  colon  becomes  more  or  less 
exhausted  from  persistent  nagging."  Morris  says  in  his  graphic  style:  "the 
percussion  note  of  the  right  side  of  the  abdomen  in  these  cases  is  suggestive  of 
the  percussion  note  of  a  cider  barrel  in  January.  The  percussion  note  of  the 
left  side  of  the  abdomen  in  these  cases  is  suggestive  of  the  percussion  note  of  a 
cider  barrel  in  October." 

3.  Transitory  pains  in  the  appendix  region  which  are  not  sufficiently  severe 
to  send  the  patient  to  bed. 

The  Bastedo  sign  in  chronic  appendicitis  was  suggested  by  Bastedo  in  191 1 
("Am.  Jour.  Med.  Sciences,"  191 1,  cxliii)  and  is  of  service.  A  tube  is  passed  as 
high  as  possible  into  the  rectum  and  air  is  forced  in  by  the  bulb  of  an  atomizer. 
Distention  causes  pain  and  tenderness  over  the  appendix  (see  Rosenbloom, 
in  "Surgery,  Gynecology  and  Obstetrics,"  Oct.,  1916).  Contraction  of  the  psoas 
parvus  muscle  may  be  mistaken  for  chronic  appendicitis  and  may  result  from 
appendicitis.  It  causes  pain  in  the  inguinal  region  and  leg  and  flexion  of  the 
thigh  which  may  persist  under  ether  (Cremer,  in  "Lancet,"  1914,  xxxiv; 
Macdonald,  in  "Surgery,  Gynecology  and  Obstetrics,"  1914,  xix;  White, 
"Annals  of  Surgery,"  1913,  Iviii). 

In  reaching  a  diagnosis  in  doubtful  cases  of  appendicitis  I  believe  that 
the  blood-count  is  often  of  service.  It  is,  of  course,  not  to  be  maintained 
that  the  diagnosis  of  appendicitis  may  be  made  by  counting  the  blood;  but 
the  blood-count  may  furnish  evidence  that,  when  added  to  the  other  signs 
and  symptoms,  may  be  of  great  importance.  In  nearly  every  case  of  acute 
appendicitis  the  hemoglobin  is  diminished  by  at  least  30  per  cent.  In  a  catar- 
rhal appendicitis  or  in  an  interstitial  appendicitis  the  leukocytosis  is  trivial;  but 
in  cases  of  abscess  or  of  gangrene  of  the  appendix  the  leukocytes,  as  a  rule, 
rise  from  15,000  to  20,000.  It  is  to  be  remembered,  however,  that  when 
the  patient  is  profoundly  septic  the  systemic  condition  is  so  depressed  that 
leukocytosis  is  impossible;  hence  leukocytosis  may  be  absent  in  trivial  catarrhal 
cases  or  in  grave  cases  with  overwhelming  general  sepsis.  This  latter  con- 
dition, however,  is  extremely  rare.  The  blood-count  will  not  help  one  in 
making  the  differentiation  between  appendicitis  and  an  inflammatory  disorder 
of  the  pelvis  or  abdomen,  but  will  aid  one  in  making  a  diagnosis  from  typhoid 
fever,  intra-abdominal  or  pelvic  neuralgia,  and  movable  kidney  (see  J.  C. 
DaCosta,  Jr.,  study  of  118  cases,  "Am.  Jour.  Med.  Sciences,"  Nov.,  1901). 

Appendiceal  Dyspepsia. — Indigestion  may,  for  a  longer  or  shorter  time, 
precede  an  attack  of  acute  appendicitis.  A  like  condition  may  follow  an 
attack. 

In  chronic  recurrent  appendicitis  dyspepsia  may  so  dominate  the  clinical 
picture  as  to  lead  the  physician  to  regard  the  case  as  one  of  gastric  disease. 
Such  a  patient  has  prolonged  attacks  of  epigastric  pain  aggravated  by  food. 
The  pain  radiates  downward  toward  the  appendix  and  is  not  so  severe  as  the 
pain  of  duodenal  ulcer.  There  may  or  may  not  be  tenderness  in  the  appendix 
region  but  in  most  cases  there  is  tenderness  to  the  right  of  the  navel  and  the 
ascending  colon  is  distended  with  gas  (page  1148).  The  condition  may  be  due  to 
hypersecretion  of  the  gastric  juice  resulting  reflexly  from  appendix  inflammation. 
Fenwick  regards  chronic  hypersecretion  as  a  direct  cause  of  this  form  of  dys- 
pepsia. The  epigastric  pain  may  be  due  to  pyloric  spasm  or  gastritis  (Euster- 
man,  "Jour.  Missouri  State  Med.  Assoc,"  May,  1913).  At  times,  however, 
during  some  of  the  attacks  appendiceal  tenderness  is  demonstrable  and  perhaps 
there  is  pain  in  the  right  iliac  fossa.  The  epigastric  or  abdominal  uneasiness 
may   be  constant.    Food  may  immediately  cause  pain.    Nausea  and  flatu- 


J 1 50  Diseases  and  Injuries  of  the  Abdomen 

Icnce  are  common.  "As  a  rule  there  is  not  the  regularity  of  onset  of  pain  after 
food — the  periodicity  of  attack — which  characterizes  gastric  ulcer"  (Eusterman, 
Ibid.).  Food  does  not  relieve  pain  except  in  the  less  common  cases  in  which 
there  is  hyperacidity. 

Appendicitis  in  Children. — The  disease  is  much  more  common  than  was 
once  thought  (see  i)age  1138).  Russel  S.  Fowler  ("Am.  Jour.  Diseases  of  Chil- 
dren," August,  191 2)  collected  183  cases  occurring  in  children  under  twelve 
years  of  age  and  brought  to  the  German  Hospital  of  Brooklyn.  During  the 
same  period  (1900-1912)  the  total  number  of  cases  was  11 15,  the  proportion  of 
children  being  16.41  per  cent.  The  youngest  patient  in  this  series  was  two 
years  and  nine  months  old.  Morf  of  the  Cook  County  Hospital  in  Chicago 
reports  822  cases  of  appendicitis  and  150  of  them  were  under  fifteen  years  of  age 
("Jour.  Am.  Med.  Assoc,"  March  24,  1917).  There  is  usually  a  history  of  ante- 
cedent attacks  of  gastro-intestinal  disorder.  The  onset  is  apt  to  be  sudden^ 
but  may  be  insidious,  the  symptoms  as  a  general  thing  are  violent,  and  the  prog- 
ress of  the  disease  is  rapid.  Vomiting  is  usually  more  violent  and  prolonged 
than  in  adults.  There  is  a  great  likelihood  of  pus  formation  and  general  peri- 
tonitis and  gangrene  are  more  common  than  in  adults.  Marked  leukocytosis 
usually  exists.  Occasionally  in  young  children  pneumonia  begins  with  so  much 
pain  and  rigidity  in  the  lower  abdomen  that  the  signs  seem  to  point  to  appendi- 
citis, and  an  attack  of  appendicitis  may  begin  coincidently  with  or  soon  after  a 
pulmonary  inflammation.  I  have  seen  4  cases  in  children  in  which  pneumonia, 
was  ushered  in  by  abdominal  pain  and  rigidity.  The  surgeon  should  be  awake 
to  the  possibility  of  typhoid  fever,  indigestion,  fecal  impaction,  intussuscep- 
tion, and  tuberculous  peritonitis.  In  children  the  appendix  occupies  a  lower 
position  than  in  adults,  the  point  of  abdominal  tenderness  is  usually  lower  than 
in  adults,  the  inflammation  usually  reaches  the  right  side  of  the  pelvis,  a  pain- 
ful point  can  generally  be  discovered  by  a  finger  in  the  rectum,  hence  a  digital 
rectal  examination  must  always  be  made.  This  usual  involvement  of  the  pelvis 
is  responsible  for  the  frequent  and  painful  micturition  which  is  very  common 
(Karewski).  Sometimes  when  the  bladder  symptoms  are  very  prominent  they 
dominate  the  clinical  picture  and  the  bladder  is  thought  to  be  the  real  seat  of 
disease.  An  attack  of  peritonitis  in  a  child  is  more  apt  to  result  in  general  peri- 
tonitis than  is  the  same  disease  in  an  adult  (Selter).  I  agree  with  Springer 
("Prag.  med.  Woch.,"  1909,  xxxiv,  Nos.  7  and  8)  that  operation  in  children 
should  invariably  be  prompt  and  that  purgatives  should  not  be  given.  In 
Fowler's  series  of  cases  ("Am.  Jour.  Dis.  of  Children,"  Aug.,  191 2)  the  opera- 
tive mortality  was  3  per  cent.  Clopton's  mortality  was  4  per  cent.  ("Pedia- 
trics," 191 5,  xxvii). 

Appendicitis  in  Pregnant  Women. — Appendicitis  is  a  very  dangerous,  but^ 
fortunately,  a  very  rare  complication  of  pregnancy.  In  731  women  operated  on 
for  appendicitis  in  the  Mount  Sinai  Hospital,  of  New  York,  from  1898  to  1907, 
only  7  were  pregnant  (Cooke,  in  "New  York  Med.  Jour.,"  May  i,  1909). 
Lobenstine  states  that  in  30,000  cases  under  the  care  of  the  New  York  Lying-in 
Hospital  there  were  but  5  cases  of  acute  appendicitis  (Cooke,  Ibid.).  Most  of 
the  patients  who  develop  appendicitis  during  pregnancy  have  had  previous 
attacks. 

The  condition  may  arise  at  any  stage  of  pregnancy.  It  is  usually  violent^ 
rapid  in  progress,  and  accompanied  by  vomiting.  Early  in  pregnancy  the 
pain  and  tenderness  are  significant  and  are  located  regionally,  as  when  preg- 
nancy is  absent.  Cooke  points  out  that  later  in  pregnancy  the  pains  may 
be  so  spasmodic  as  to  cause  them  to  be  attributed  to  beginning  labor,  and  they 
are  often  located  in  the  region  of  the  liver  or  even  on  the  left  side  of  the  belly 
(Ibid.).  Two  hundred  and  fifty  cases  have  been  reported  and  over  100  have 
been  operated  on  (Ren vail). 

Appendicitis  in  the  pregnant  is  far  more  dangerous  than  in  the  non-pregnant. 


Appendicitis  in  the  Victims  of  Pulmonary  Tuberculosis        1151 

In  from  20  to  40  per  cent,  of  cases  abortion  occurs,  and  usually  the  child  dies 
from  infection.  In  some  cases  of  successful  operation  pregnancy  continues  to 
term.  In  only  10  per  cent,  of  Morf's  22  operations  did  abortion  occur  ("Jour. 
Am.  Med.  Assoc,"  March  24,  191 7).  The  diagnosis  is  often  very  difficult  be- 
cause of  the  enlarged  uterus. 

Appendicitis  Following  Childbirth. — Hilton  collected  reports  of  29  cases 
and  added  i  of  his  own  ("Surg.,  Gynec,  and  Obstet.,"  Oct.,  1907).  Hilton 
demonstrates  that  childbirth  and  the  puerperium  may  be  causal  of  appendicitis. 
The  signs  and  symptoms  are  apt  to  be  masked  or  are  thought  to  be  due  to  the 
puerperal  state.  The  prognosis  is  grave.  In  cases  developing  within  ten  days 
of  labor  45.5  per  cent,  died  (Hilton,  Ibid.). 

Acute  Appendicitis  in  Typhoid  Fever. — An  ordinary  acute  appendicitis  may 
arise  during  or  soon  after  typhoid  fever.  In  some  of  these  cases  a  chronic 
appendicitis  has  been  driven  into 
violence  by  the  fever.  I  have  oper- 
ated on  two  ordinary  cases  of 
gangrenous  appendicitis  and  one 
of  acute  suppurative  appendicitis 
occurring  during  typhoid  fever. 
During  the  fever  a  typhoid  ulcer 
may  form  in  the  appendix  and 
this  ulcer  may  perforate  or  the 
appendicitis  may  be  secondary  to 
typhoid  infection  of  the  lymph- 
follicles.  Undoubted  cases  due  to 
the  typhoid  bacillus  have  been 
reported  (Homer  Gage,  in  "Annals 
of  Surgery,"  August,  1915).  In 
such  cases  the  typhoid  bacilli  are 
lodged  in  the  lining  of  the  appendix. 
Pus  cocci  may  cause  appendicitis 
in  a  victim  of  typhoid.  The  ap- 
pearance of  leukocytosis  during 
t)T)hoid  fever  should  lead  us  to 
investigate  for  some  inflammatory 
complication  especially  appendicitis 
and  perforation.  Pain  and  diarrhea 
usually  exist.  Rigidity  may  be 
absent. 

Tuberculous  Appendicitis  (Fig.  700). — Acute  symptoms  may  develop  re- 
sembling acute  appendicitis.  There  is  usually  a  history  pointing  to  intestinal 
stenosis,  the  stenosis  existing  at  the  ileocecal  valve. ^  There  is  always  great 
thickening,  and  an  abscess  of  large  size  is  apt  to  form.  The  cecum  usually, 
but  not  always,  is  involved  in  the  tuberculous  process.  Chronic  cases,  with 
palpable  enlargement,  are  sometimes  mistaken  for  cancer  of  the  cecum. 

Appendicitis  in  the  Victims  of  Pulmonary  Tuberculosis. — ^Many  cases  pre- 
sent the  well-known  symptoms  of  appendicitis  but  they  may  be  very  mild. 
Appendiceal  dyspepsia  (page  1149)  may  exist.  Dieulafoy  described  a  form  of 
appendicitis  in  the  tuberculous  which  is  characterized  by  pain  and  diarrhea. 
Most  cases  show  no  tuberculous  lesions  of  the  appendix.  One-fourth  of  the 
cases  show  such  lesions.  Lesions  are  found  when  the  pulmonary  tuberculosis 
is  advanced  rather  than  when  it  is  incipient  (Kinghorn,  in  "Jour.  Am.  Med. 
Assoc,"  1916,  Ixvii).  Kinghorn  (Ibid.)  operated  upon  28  patients  and  3  of 
them  died. 


Fig.  700. 


-Tuberculous  appendix  with  perforation 
and  abscess. 


^Andrews,  "x\nnals  of  Surgery,"  Dec,  1901. 


1 152 


Diseases  and  Injuries  of  the  Abdomen 


volved.      In    three-fourths 
cases   the  growth   is   distal 


Malignant  Disease  of  the  Appendix  (Fig.  701). — This  is  a  very  rare  condition 
(less  than  '•_>  of  i  P^'^"  cent,  of  appendices  removed  for  supposed  inflammation). 
It  is  impossible  of  recognition  clinically,  but  is  sometimes  discovered  postmor- 
tem or  during  operation  for  supposed  acute  or  chronic  appendicitis  or  pelvic  dis- 
ease. Inflammation  does  not  cause  the  malignant  disease,  but  the  malignant 
disease  is  apt  to  block  the  appendix  and  so  cause  inflammation.  The  condition 
may  be  carcinoma,  sarcoma,  or  endothelioma,  and  usually  there  are  distinct 
inflammatory  changes.  It  is  more  common  in  women  than  in  men.  Rolles- 
ton  and  Jones  collected  42  cases.  McWiUiams  reported  3  cases  and  collected 
45  not  in  RoUeston's  table.  This  makes  90  reported  cases  ("Am.  Jour.  Med. 
Sciences,"  June,  1908).  Since  writing  his  article  McWilHams  has  found  15 
more  cases  reported. '  No  case  is  counted  in  which  the  colon  is  diseased.  The 
combined  statistics  show  the  average  age  of  the  patients  to  be  only  twenty- 
nine  years.  Two  patients  were  only 
eight.  In  most  cases  the  appendix 
alone  is  diseased;  in  some  the  colon 
or  glands  of   the   mesentery  are  in- 

of  the 
to  the 
middle  of  the  appendix.  Glands 
are  involved  late.  Out  of  90  cases 
in  McWilliams'  table  only  8  had 
enlarged  glands,  and  in  4  of  these 
it  was  proved  that  the  glands  were 
not  cancerous.  In  about  5  per  cent, 
of  cases  concretions  were  found. 
The  chance  for  permanent  cure  after 
removal  of  an  appendix  the  seat  of 
malignant  disease  is  very  good  if 
the  disease  is  limited  to  the  appendix, 
and  is  particularly  good  if  the  growth 
is  spheroidal-celled  carcinoma 
(Rolleston  and  Jones).  Metastasis 
is  rarely  noted.  The  growth  is  seldom 
larger  than  an  almond. 

Treatment.— If  the  diagnosis  were 
always  certain  from  the  beginning, 
and  if  the  case  were  seen  at  the  very 
start  by  a  surgeon,  immediate  opera- 
tion in  every  case  would  be  eminently 
proper.  If  this  plan  could  bef  oil  owed, 
the  mortality  from  appendicitis  would  be  extremely  small.  At  this  early  stage  the 
peritoneum  is  free  from  infection,  and  the  appendix  can  be  rapidly  and  easily  re- 
moved without  risk  of  infecting  the  peritoneum.  Whenever  I  see  a  case  early, 
that  is,  during  the  first  thirty-six  hours  of  the  attack,  I  practically  always  advise 
operation.  Unfortunately,  this  plan  cannot  be  habitually  followed.  As  a  rule, 
when  the  physician  first  sees  the  case  the  appendicular  peritoneum  is  inflamed, 
and  the  surgeon  usually  sees  the  case  at  even  a  later  period  than  the  physician. 
At  this  time  the  barriers  of  leukocytes  are  being  heaped  up  to  limit  the  spread 
of  infection,  and  delicate  encompassing  adhesions  are  usually  being  formed. 
Even  in  these  later  cases  I  often,  in  fact,  usually,  advise  operation.  Operation 
at  this  stage  may  be  imperatively  necessary  because  of  the  rapid  spread  and 
dangerous  nature  of  the  process;  but  when  operation  is  not  done,  in  some  cases 
at  least,  a  temporary  limitation  will  be  secured  and  the  case  will  go  on  to  an 
interval.  Operation  in  the  acute  period  is  always  dangerous;  operation  in  an 
interval  is  safe.     In  some  instances,  when  the  case  is  not  seen  early,  it  is  wiser 


Fig.  701. — Carcinoma  of  bowel  and  belly 
wall  after  appendix  operation.  Appendix  re- 
moved by  English  Army  Surgeon  in  Burmah. 
Portion  of  bowel  removed  at  Heidelberg. 


Treatment  of  Appendicitis  1153 

to  avoid  operating  at  the  time,  and  it  is  proper  to  wait  for  an  interval.  The 
period  in  which  the  surgeon  usually  sees  the  case  for  the  first  time  ^Yas  said  by 
Maurice  Richardson  to  be  "too  late  for  an  early  operation  and  too  early  for  a 
late  operation."  Those  who  say  "operate  as  soon  as  the  diagnosis  is  made," 
operate,  as  a  rule,  in  this  dangerous  period,  and  in  this  period  I  do  not  believe 
that  every  case  should  be  promptly  cut.  Many  cases,  it  is  true,  must  be 
operated  on  as  soon  as  seen,  irrespective  of  the  duration  of  the  disease.  We 
must  operate  promptly  if  the  pulse  is  small,  tense,  and  well  above  100;  if  there 
is  persistent  vomiting;  if  there  is  delirium;  if  intestinal  obstruction  exists;  if  a 
chill  has  occurred;  if  the  pain  and  rigidity  are  very  marked;  if  a  mass  can  be 
felt  in  the  right  iliac  fossa  or  by  rectal  examination;  if  there  is  marked 
abdominal  distention;  if  there  are  evidences  of  pus  formation;  if  the  patient 
is  growing  worse;  if  there  is  or  has  been  shock;  or  if  the  pain  suddenly  passes 
away  without  the  use  of  opiates. 

In  an  ordinary  mild  case,  not  seen  early,  in  which  none  of  the  above- 
named  conditions  or  symptoms  exist,  it  is  best  to  defer  operation.  Those  who 
advocate  operating  upon  every  case  consider  such  delay  reprehensible  and 
dangerous,  point  out  that  even  in  apparently  mild  cases  gangrene  or  perfora- 
tion may  quickly  occur,  and  cite  striking  cases  to  emphasize  their  belief. 
There  is  much  force  in  this  view,  and  it  must  not  be  hastily  rejected.  The 
choice,  however,  is  not  between  a  dangerous  delay  and  a  safe  operation,  but 
rather  between  a  dangerous  delay  and  a  dangerous  operation.  It  is  a  ques- 
tion of  two  dangers,  and  each  side  chooses  the  danger  which  seems  to  it  the 
least.  Richardson's  elaborate  study  of  750  cases,  showing  a  mortality  of  18 
per  cent,  in  operations  for  acute  appendicitis,  determined  us  in  the  practice 
of  the  more  conservative  plan.  General  peritonitis  is  the  most  common  compli- 
cation and  more  than  half  the  deaths  are  due  to  it.  It  may  arise  in  abscess 
cases  from  spontaneous  rupture,  from  rupture  due  to  rough  handling,  from 
digging  out  an  appendix  from  an  abscess-wall  or  from  removing  drainage  too 
early. 

The  mortality  of  abscess  cases  is  not  half  that  of  gangrenous  cases,  Coffey 
collected  13,445  reports  of  operations  for  acute  appendicitis.  The  mortality 
was  7.4  per  cent.  ("New  York  Med.  Jour.,"  August,  1906). 

In  an  ordinary  mild  case  of  appendicitis  in  which  operation  is  refused, 
it  is  a  common  custom  to  purge  by  means  of  Epsom  or  Rochelle  salt.  This 
practice  was  begun  because  of  the  belief  that  inflammation  of  the  appendix 
is  associated  with  fecal  impaction  in  the  head  of  the  colon.  This  belief  has 
been  exploded,  but  the  treatment  is  still  used  by  some  who  regard  it  as  bene- 
ficial. If  the  condition  of  the  stomach  prevents  the  administration  of  salines, 
high  enemata  are  often  given.  My  own  belief  is  that  if  operation  is  refused^ 
or  if  the  surgeon  determines  to  wait  for  an  interval,  he  should  not  give  a  pur- 
gative, but  follow  the  plan  of  treatment  suggested  by  Ochsner  to  control  peris- 
talsis and  favor  limitation  of  infection.  The  patient  is  kept  perfectly  quiet,  is 
placed  in  the  Fowler  position,  no  cathartics  are  given,  no  food  or  drink  is 
administered  by  the  mouthy  and  thirst  is  allayed  by  enemata  of  salt  solution. 
Nutritive  enemata  may  be  given.  It  is  also  my  custom  to  place  a  hot-water 
bag  instead  of  an  ice-bag  over  the  appendix  region. 

To  permit  peristalsis  favors  diffusion  of  the  infection;  to  prevent  peris- 
talsis is  to  favor  the  formation  of  encompassing  and  defensive  adhesions.  A 
purgative  is  very  dangerous.  It  may  cause  rupture  of  the  appendix.  By 
causing  peristalsis  it  diffuses  the  infection. 

Many  surgeons  use  the  ice-bag,  but  I  do  not  believe  in  it  in  these  cases. 
We  have  already  shown  (see  page  107)  that  cold  as  a  remedy  for  inflammation 
is  useful  only  in  the  brief' stage  of  hyperemia,  and  when  a  surgeon  sees  a  case 
of  appendicitis  there  is  certainly  more  or  less  stasis.  Cold  adds  to  stasis  and 
does  harm,  and  I  am  persuaded  that  the  routine  use  of  the  ice-bag  is  responsible 

73 


1154  Diseases  and  Injuries  of  the  Abdomen 

for  some  cases  of  gangrene.  Again,  cold  actually  antagonizes  the  migration 
of  leukocytes  and  the  formation  of  adhesions.  For  a  number  of  years  I  have 
believed  and  taught  that  the  ice-bag  weakened  resistance  in  appendicitis. 
These  views  seem  to  find  confirmation  in  the  article  of  Dr.  A.  M.  Fauntleroy, 
U.  S.  N.  ("The  Ice-bag  and  Appendicitis,"  "Med.  Record,"  August  3,  191 2). 
The  study  of  a  number  of  cases  led  him  to  the  conclusion  that  the  ice-bag  is 
often  responsible  for  "a  noticeable  lack  of  effort  on  the  part  of  Nature  to  wall 
off  from  the  rest  of  the  abdominal  cavity  the  appendix."  Further:  " It  was  also 
noted  in  the  ice-bag  cases  that  there  was  a  surprisingly  low  white  count 
when  one  took  into  consideration  the  condition."  These  reports  are  most 
significant.  They  are  in  strict  accord  with  my  own  results.  It  is  my  belief 
that  the  use  of  the  ice-bag  antagonizes  the  limitation  of  the  infection  and 
favors  dissemination  of  toxins  and  bacteria.  I  believe  that  its  employment  is  a 
grave  mistake. 

Heat  is  a  remedy  which  favors  limitation  of  the  process.  It  relieves  stasis, 
draws  leukocytes  to  the  part  and  stimulates  their  activity,  favors  the  formation 
of  an  encompassing  barrier  of  phagocytic  cells,  and  aids  the  cellular  proliferation 
which  leads  to  the  formation  of  adhesions.     Hence  I  prefer  the  hot-water  bag. 

The  ice-bag,  when  applied  before  the  diagnosis  has  been  made,  that  is, 
in  the  earliest  hours  of  the  attack,  when  it  might  be  thought  to  be  most  ser- 
viceable, allays  pain  and  lessens  rigidity  in  some  cases  almost  like  a  full  dose 
of  opium,  and  hence  masks  the  symptoms  as  does  that  drug. 

Opium  should  never  be  given  until  the  diagnosis  has  been  made.  In  the  first 
place,  it  is  not  needed,  for  if  the  pain  is  so  violent  as  absolutely  to  demand  opium, 
operation  should  be  performed.  In  the  second  place,  opium  masks  the  symp- 
toms, makes  the  patient  feel  comfortable,  and  gives  the  physician  an  unfortunate 
and  ill-founded  sense  of  security.  The  pain  about  the  umbilicus,  if  severe, 
can  be  distinctly  and  safely  relieved  by  the  administration  of  30  min.  of  spirits 
of  chloroform  every  half-hour  until  three  doses  have  been  taken.  Opium 
should  not  be  given  if  the  surgeon,  having  decided  not  to  operate  at  once,  is 
awaiting  an  interval,  because  it  may  prevent  or  delay  the  recognition  of  some 
disastrous  change.     If  a  patient  refuses  operation,  it  can  be  given. 

When  we  are  inclined  to  wait  for  an  interval,  the  case  should  be  seen  again 
within  six  hours.  We  are  accustomed  to  follow  McBurney's  rule,  which  is  as 
follows:  If  on  seeing  the  patient  again,  six  hours  after  the  first  visit,  the  patient 
is  worse,  operate  at  once.     If  he  is  no  worse  there  is  no  pressing  danger. 

If  in  twelve  hours  after  the  beginning  of  the  attack  the  symptoms  are 
not  intensified,  they  will  soon  begin  to  abate;  if  the  symptoms  have  become 
worse  during  this  time,  operate.  If  in  twenty-four  hours  after  the  beginning 
of  the  attack  the  severity  of  the  symptoms  lessens,  it  is  usually  possible  to 
wait  for  an  interval;  but  if  during  the  second  twenty-four  hours  there  has  been 
no  abatement  in  the  severity  of  the  symptoms  and  there  is  doubt  as  to  the 
condition,  operate  at  once.^  When  the  attack  has  subsided,  and  about 
three  weeks  or  more  have  passed,  the  appendix  can  be  removed  with  remark- 
able safety.  After  a  patient  has.  had  two  or  more  attacks  of  appendicitis 
all  surgeons  agree  that  the  appendix  should  be  removed. 

If  pus  is  present  some  surgeons  delay  operation  in  the  hope  that  firm  ad- 
hesions will  form  around  the  pus,  and  that  the  necessary  operation  will  simply 
be  the  opening  of  an  abscess.  I  do  not  believe  it  is  safe  to  delay  operation  in 
a  pus  case.  The  pus  may  become  limited,  but  it  may  instead  pass  up  toward 
the  Uver  or  down  into  the  pelvis.     Delay  is  fraught  with  peril. 

If  only  one  attack  has  occurred,  there  may  never  be  another,  and  the  question 

arises,  "  Should  the  appendix  be  removed  after  one  attack?"     We  do  not  know 

that  a  man  has  really  recovered  after  purely  medical  treatment.     Many  cases 

reported  as  cured  by  medical  means  have  subsequently  required  operation. 

^  For  McBurney's  views,  see  "New  York  Polyclinic,"  Jan.  15,  1897. 


Acute  Diverticulitis  1155 

As  Lockwood^  puts  it,  "To  say  that  a  man  with  appendicitis  has  been  cured  by 
medical  means  is  in  many  cases  equivalent  to  saying  that  a  man  with  a  stone 
in  his  bladder  has  recovered  from  calculus  after  the  cure  of  a  cystitis  by  rest  in 
bed." 

Even  after  a  first  attack,  if  the  appendix  remain  tender  or  become  tender 
after  exercise,  or  if  attacks  of  colicky  pain  occur,  or  if  there  be  tenderness  to  the 
right  of  the  navel  and  gaseous  distention  of  the  ascending  colon,  operate. 

In  some  cases  even  a  single  attack  of  appendicitis  is  followed  by  persistent 
dyspepsia  and  ill  health,  and  in  such  cases  operation  should  be  performed. 
In  the  majority  of  cases,  even  after  one  well-marked  attack,  operation  is  neces- 
sary. It  is  always  necessary  after  two  attacks.  (See  Operation  for  Appendi- 
citis.) 

Appendicitis  cases  which  are  far  advanced  in  general  peritonitis  when  seen 
by  the  surgeon  some  operators  decline  to  touch.  If  we  make  a  custom  of 
operating  on  such  cases  we  will  lose  very  many,  but  will  save  some  few,  and 
these  few  would  have  died  if  we  had  not  operated.  To  operate  spoils  statis- 
tics, but  occasionally  saves  lives.  The  operation  should  consist  of  a  simple 
incision  to  relieve  tension  and  afford  exit  to  infected  fluids — rapid  removal 
of  the  appendix  if  it  is  easily  accessible,  otherwise  leaving  it  alone — and  drainage 
of  the  pelvis.  After  such  an  operation  the  patient  is  placed  in  Fowler's  position 
and  a  continuous  stream  of  salt  solution  at  low  pressure  is  caused  to  trickle  into 
the  rectum.     (See  Murphy's  Treatment  for  Peritonitis,  page  1162.) 

Appendicitis  in  a  child  is  treated  exactly  as  in  an  adult.  Appendicitis 
in  the  pregnant  woman  is  treated  as  in  the  non-pregnant.  Early  operation  is 
particularly  indicated,  and  it  is  not  proper  to  induce  premature  labor  in  a 
patient  far  advanced  in  pregnancy  unless  there  is  general  peritonitis.  Then  it 
is  proper  to  empty  the  uterus — primarily,  to  obtain  drainage  and  to  give  the 
patient  a  chance  for  life,  and  secondarily,  to  obt9,in  a  living  child. 

When  operating  upon  a  woman  for  appendicitis,  bear  in  mind  that  ovarian, 
tubal,  or  uterine  disease  may  have  preceded,  actually  caused,  or  resulted  from 
the  appendicitis;  examine  the  adnexa  and  remove  them  if  necessary. 

An  operation  for  tuberculous  appendicitis  is  rather  apt  to  be  followed 
by  a  fecal  fistula.  An  ordinary  laparotomy  is  sometimes  followed  by  cure, 
but  the  rule  of  an  operator  should  be,  when  possible,  to  remove  the  appendix 
and  resect  the  diseased  bowel.  Andrews^  mentions  as  expedients  suited  to 
special  cases  of  tuberculous  disease:  total  exclusion;  partial  exclusion;  lateral 
anastomosis,  and  the  formation  of  an  artificial  anus.  If,  in  any  operation  for 
appendicitis,  the  psoas  parvus  muscle  is  found  to  be  contracted,  the  peritoneum 
should  be  stripped  up  and  the  tendon  should  be  bared  and  divided. 

Intestinal  Diverticula. — Congenital  diverticula  sometimes  exist  in  the 
duodenum.  Pressure  diverticula  may  arise  in  the  small  intestine;  they  are,  as 
a  rule,  small  and  multiple.  The  descending  colon  and  the  pelvic  colon  are  the 
most  common  seats  of  diverticula.  They  occur  at  any  portion  of  the  circum- 
ference of  the  tube,  are  usually  multiple,  and  vary  much  in  size.  Occasionally 
a  diverticulum  becomes  enormous.  A  diverticulum  contains  fecal  matter  and, 
perhaps,  fecal  concretions.  When  free  from  acute  inflammation  and  when 
unobstructed  a  diverticulum  may  cause  fecal  stasis  or  may  cause  nosymptoms 
whatever.  A  diverticulum  may  inflame,  suppurate,  cause  pericolonic  suppura- 
tion, perforate,  or  become  the  focus  of  a  great  fibrous  area  (fibromatosis), 
which  is  usually  mistaken  for  cancer.    The  .v-rays  are  invaluable  in  diagnosis. 

Acute  diverticulitis  occurs  in  "adults,  mostly  in  males  in  midlife  and  given 
to  obesity"  (Joseph  Ransohoff,  in  "x\nnals  of  Surgery,"  August,  1913).  There 
may  be  catarrhal  inflammation.  An  abscess  may  form  about  the  diverticulum. 
Perforation  may  occur,  followed  by  abscess  or  general  peritonitis,  or  the  diver- 

^  "Brit.  Med.  Jour.,"  Jan.  27,  1900. 
^  "'Annals  of  Surgery."  Dec,  1901. 


1 1 56  Diseases  and  Injuries  of  the  Abdomen 

ticulum  may  become  gangrenous.  When  perforation  occurs  it  is  apt  to  take 
place  into  the  mesocolon  or  through  an  epiploic  appendix.  Diverticulitis  may 
cause  in  the  intestinal  wall  the  formation  of  scar  tissue  which  can  be  mistaken 
easily  for  a  malignant  growth.  As  most  diverticula  are  in  the  lower 
colon  the  symptoms  are  usually  left  sided  and  strongly  resemble  appendicitis. 
Occasionally  the  condition  is  found  in  the  cecum  or  ascending  colon.  Suppura- 
tion about  the  sigmoid  does  not  of  necessity  arise  from  acute  diverticulitis. 
Acquired  diverticula  do  not  arise  in  children,  and  yet  Ransohoff  (Ibid.) 
reported  cases  of  acute  perforating  sigmoiditis  in  children. 

Chronic  Diverticulitis. — This  occurs  particularly  in  the  sigmoid,  produces 
pain,  hemorrhoids,  constipation  and  great  thickening  and  is  commonly  mistaken 
for  carcinoma. 

Meckel's  Diverticulum. — (See  page  11 22.) 

Treatment  of  Acute  Diverticulitis  and  of  Perforating  Sigmoiditis. — As  for 
appendicitis. 

Fibromatosis  of  the  Colon. — This  condition  produces  symptoms  strongly 
resembling  those  caused  by  carcinoma,  and  many  cases  have  been  operated 
upon  under  this  conviction,  the  truth  having  been  discovered  by  microscopical 
examination  of  the  specimen.  It  is  an  inflammatory  condition  most  often 
met  with  in  the  pelvic  colon.  A  large,  hard  mass  forms  and  constriction  occurs. 
The  mucous  membrane  is  thrown  into  deep  folds  and  ulceration  occurs  between 
these  folds. 

The  fibromatosis  is  a  reaction  to  infection.  The  infecting  agent  gains 
entrance  through  a  desquamating  area,  a  wound  of  the  mucous  membrane,  an 
ulcer,  or  an  inflamed  diverticulum.  Even  when  cancer  exists  there  may  be  ex- 
tensive fibromatosis  about  it,  the  area  of  real  malignancy  being  much  less  than 
the  induration  suggests. 

Fibromatosis  may  arise  at  any  age,  but  is  most  common  during  and  beyond 
middle  age.  There  is  continuous  abdominal  uneasiness  now  and  then  rising  to 
pain.  The  general  health  deteriorates.  The  victim  suffers  from  habitual 
constipation,  but  occasional  attacks  of  diarrhea  occur.  Blood  and  mucus  are 
at  times  found  in  the  stools.  If  the  constricting  mass  is  within  reach  of  the 
finger,  it  will  be  found  that  the  induration  is  beneath  thick  and  soft  mucous 
membrane.  If  it  can  be  seen  by  the  sigmoidoscope,  the  folds  of  mucous  mem- 
brane will  be  obvious.  Abdominal  palpation  often  detects  the  mass,  which 
is  sausage  shaped.  (See  Miles,  in  "A  System  of  Surgery,"  edited  by  C.  C. 
Choyce.) 

Treatment. — Resection  and  anastomosis  if  possible.  If  real  obstruction 
exists,  or  if  the  mass  seems  irremovable,  do  colostomy.  After  colostomy  the 
mass  usually  shrinks  greatly  and  may  actually  disappear. 

Congenital  Idiopathic  Dilatation  of  the  Colon  (Hirschsprung's 
Disease;  True  Megacolon). — This  condition  is  of  prenatal  origin.  The 
large  intestine  is  chiefly  invoh^ed.  The  rectum  and  small  bowel  seldom  suffer, 
"and  in  more  than  one-third  of  all  the  cases  the  sigmoid  flexure  is  alone  in- 
volved" (Finney,  in  "Surg.,  Gynec,  and  Obstet.,"  June,  1908).  There  is  no  defi- 
nite mechanical  obstruction  demonstrable  at  autopsy  or  operation.  It  is  in  this 
that  Hirschsprung's  disease  (true  megacolon)  differs  from  pseudomegacolon 
(Finney,  Ibid.).  The  diameter  may  reach  6  or  8  inches,  and  the  colon  may 
seem  elongated  and  be  in  loops.  Dilatation  and  hypertrophy  produce  marked 
changes  in  the  wall  of  the  gut.  The  condition  may  be  obvious  in  early  life 
or  it  may  not  become  so  until  adult  years,  being  aggravated  and  developed, 
but  not  caused  by  habitual  atony  of  the  bowel.  The  supposed  cause  is  an 
anatomical  anomaly  (perhaps  elongation)  leading  to  looping  of  the  colon,  a 
muscular  aplasia  leading  to  dilatation  and  valve  formation.  Various  causes 
have  been  suggested. 

The  victim  of  this  condition  is  obstinately  constipated  and  has  a  distended 
abdomen,  usually  from  early  infancy,  although,  as  previously  stated,  the  con- 


Enteroptosis,  or  Glenard's  Disease  ii57 

dition  may  not  manifest  itself  until  childhood,  youth,  or  even  adult  life. 
It  is  most  difficult  to  get  the  bowels  to  move  at  all.  Gay  reported  a  case  in 
which  there  was  no  bowel  movement  for  three  months.  Periods  of  several 
weeks  without  a  movement  are  by  no  means  uncommon.  Now  and  then  an 
attack  of  diarrhea  may  cause  the  emptying  out  of  great  quantities  of  feces. 
The  abdomen  is  enormously  distended- and  the  patient  is  emaciated. 

The  abdominal  veins  are  distended  and  the  rectus  muscles  may  be  separated. 
In  Finney's  cases  (as  in  some  other  reported  cases)  the  cords  of  distended  gut 
could  be  seen  or  felt  to  be  more  prominent  on  one  side  than  on  the  other.  There 
is  no  abdominal  tenderness  and  pain  is  absent  unless  there  is  diarrhea.  Borbo- 
rygmus  is  often  very  loud.  Vomiting  is  rare.  The  urine  shows  a  marked  in- 
crease of  indican. 

The  disease  does  not  directly  cause  death,  but  the  ill-nourished  condition 
lessens  the  chance  for  recovery  from  any  attack  of  illness. 

In  358  cases  collected  by  Schneiderhohn  (Internat.  Abstract,  Oct.,  191 5,  from 
"Zeits.  f.  Kinderh.,"  1915,  xii)  the  mortality  was  43  per  cent.  Surgical  treat- 
ment shows  a  less  mortality  than  medical  treatment.  Schneiderhohn  (Ibid.) 
collected  143  cases  treated  surgically  mth  a  mortality  of  36  per  cent,  and  with 
46  per  cent,  of  cures. 

Treatment. — Very  early  cases  ought  to  be  treated  medically.  Medical 
treatment  consists  of  the  ordinary  plans  for  combating  constipation.  Surgery 
is  more  dangerous  in  young  children  than  in  older  subjects.  Some  surgeons 
have  removed  almost  the  entire  large  intestine;  others  have  performed  entero- 
anastomosis;  others,  colopexy;  others  have  established  a  permanent  artificial 
anus;  others  have  made  an  artificial  anus  preliminary  to  entero-anastomosis. 
Finney  believes  that  the  operation  of  choice  is  resection  of  the  affected  gut 
followed  by  entero-anastomosis. 

Splanchnoptosis  (Visceroptosis). — Coffey  ("Surg.,  Gynec,  and  Obstet.," 
Oct.,  191 2)  points  out  that  in  man  special  provisions  have  been  made  to  keep 
the  viscera  from  riding  down  because  of  the  upright  posture.  He  names  four 
forms  of  support:  (i)  Peritoneal  fusions  before  birth  to  the  parietal  peritoneum; 
(2)  a  shelf  above  each  psoas  muscle;  (3)  tone  of  the  abdominal  wall;  (4)  packing 
of  subperitoneal  fat  which  regulates  intra-abdominal  pressure.  Visceroptosis 
is  generally  said  to  be  due  to  relaxation  of  the  abdominal  walls  and  decrease  of 
intra-abdominal  tension,  which  lead  to  gradual  stretching  of  suspensory  liga- 
ments and  finally  to  movement  of  the  viscera  downward.  The  prolapse  may 
involve  all  the  abdominal  viscera,  one  viscus,  or  several  \dscera.  The  heart, 
too,  may  droop.  Fossier  collected  a  number  of  cases  of  movable  heart  ("  New 
Orleans  Med.  and  Surg.  Jour.,"  Nov.,  1910).  According  to  Coffey  (Ibid.),  when 
the  intestine  descends,  kinks  occur  at  the  junctions  of  fLxed  and  movable  parts, 
and  general  ptosis  is  an  attempt  on  the  part  of  Nature  to  prevent  intestinal 
kinks.  Prolapse  of  the  stomach  is  known  as  gastroptosis  (see  page  1109); 
prolapse  of  the  liver,  as  hepatoptosis  (seepage  1177);  prolapse  of  the  spleen,  as 
splenoptosis  (see  page  1204);  prolapse  of  the  kidney,  as  nephroptosis  (seepage 
1419) ;  and  prolapse  of  the  intestines,  as  enteroptosis  or  Glenard's  disease  (see 
below). 

The  causative  relaxation  of  the  abdominal  walls  is  most  common  in  women, 
but  is  by  no  means  confined  to  that  sex.  It  may  be  produced  by  ascites, 
pregnancy,  muscular  effort,  febrile  maladies,  or  w^asting  disease.  In  some 
cases  no  cause  can  be  assigned.  Such  a  relaxed  abdomen  may  or  may  not  be 
thin.  The  fascial  strands  and  muscular  fibers  are  stretched,  and  usually  at- 
tenuated and  separated,  the  belly  bulges  downward  and  forward,  and  a  \dscus 
or  the  viscera  follow  because  of  lack  of  support. 

Enteroptosis,  or  Glenard's  Disease. — This  disease  is  a  prolapse  of 
the  intestine.  It  may  be  but  a  part  of  ptosis  or  prolapse  of  all  the  abdom- 
inal viscera;  it  may  exist  alone;  it  may  be  associated  with  movable  kidney, 


1 1 58  Diseases  and  Injuries  of  the  Abdomen 

prolapse  of  the  stomach,  of  the  Hver,  or  of  the  spleen.  The  recti  are  apt  to 
be  separated.  Symptoms  usually  begin  at  puberty  but  may  arise  in  childhood. 
It  is  much  more  common  in  females  than  in  males. 

In  Glenard's  disease  the  intestines  occupy  the  lower  portion  of  the  abdo- 
men, and  the  belly  below  the  costal  margins  is  flat,  is  dull  on  percussion,  and 
the  pulsations  of  the  aorta  are  very  evident.  The  right  portion  of  the  trans- 
verse colon  begins  to  descend  first,  and  other  portions  of  the  intestine  follow. 
The  splenic  and  hepatic  flexures  are  elongated,  and  sometimes  there  is  venous 
engorgement  of  dependent  parts  of  the  mesentery  (Lambotte,  in  "Presse  Med. 
Beige,"  Nov.  24,  1901).  The  victims  of  this  disease  are  irritable,  dyspeptic, 
anemic,  constipated,  hysterical,  and  neurasthenic.  Mucous  colitis  is  common. 
They  suffer  from  severe  migraine,  loss  of  flesh,  weakness,  pain  in  the  back,  the 
coccyx  and  in  various  parts  of  the  body,  attacks  of  pseudo-angina,  vasomotor 
disturbances,  variable  temperature  which  tends  to  become  subnormal  and, 
whereas  there  is  seldom  tenderness,  pressure  may  induce  cramps  (Lerch,in  "  New 
York  Med.  Jour.,"  Dec.  19,  1914).  Most  of  the  victims  of  enteroptosis  are 
emaciated  but  there  is  a  type  of  case  in  which  the  stature  is  short,  the  patient  is 
fat  with  a  pendulous  belly  and  has  an  enlarged  thymus  (Lerch,  Ibid.).  Normally 
the  tenth  rib  is  firmly  attached  by  fibrous  tissue  to  the  ninth  costal  cartilage. 
In  enteroptosis  the  tip  of  the  tenth  rib  is  freely  movable  and  obviously  separated 
from  the  ninth  costal  cartilage  {Stiller' s  sign).  The  .x-rays  used  after  a  bismuth 
or  barium  meal  are  of  the  greatest  help  in  diagnosis.  The  ptosis  may  arise 
without  apparent  cause,  but  may  follow  the  wearing  of  ill-fitting  corsets,  falls, 
blows,  lifting  heavy  weights,  or  prolonged  vomiting.  Lerch  thinks  an  abnormal 
form  of  the  spine  is  responsible  ("New  York  Med.  Jour.,"  Dec.  19,  1914).  In 
one  type  there  is  no  lumbar  curve,  in  another  type  there  is  an  extreme  lumbar 
curve.  The  dyspepsia  is  due  to  dragging  on  the  duodenum,  the  tube  becoming 
flattened  out  (A.  K.  Stone).  The  flattening  of  the  duodenum  may  be  followed 
by  kinking  of  the  pylorus,  and  in  such  a  case  the  stomach  dilates,  otherwise  it 
does  not  dilate.  Where  a  movable  portion  of  the  gut  has  a  junction  with  a 
fixed  portion  a  kink  may  form  and  chronic  intestinal  stasis  may  ensue. 

Treatment  of  Visceroptosis. — In  many  cases  medical  treatment  is  of  benefit. 
The  following  is  the  usual  plan:  Employ  lavage,  abdominal  massage,  and  elec- 
tricity. Fresh  air  and  tonics  are  of  benefit.  Laxatives  and  sedatives  are  re- 
quired. Mineral  oil  is  the  most  useful  laxative.  Insist  on  regular  exercise,  and 
treat  the  anemia  and  dyspepsia.  Abdominal  support  is  of  great  importance. 
It  sustains  the  viscera  in  place  and  saves  them  from  congestion.  Support  is 
obtained  as  in  movable  kidney  by  a  well-fitting,  straight-front  corset.  Thiscorset 
takes  a  bearing  as  low  as  the  great  trochanters.  It  laces  in  front  and  is  applied 
while  the  patient  is  recumbent,  pillows  beneath  the  buttocks  making  the  pelvis 
higher  than  the  head.  It  is  to  be  laced  tighter  below  than  above.  Pads  are 
harmful.  We  strive  to  support  the  organs  by  intra-abdominal  pressure.  Lerch 
(Ibid.)  says  the  patient  should  go  to  bed  for  an  hour  or  two  after  the  midday 
meal  and  should  sleep  on  the  face  without  a  pillow.  Surgery  is  resorted  to  if 
intestinal  stasis  exists  and  cannot  be  relieved  by  medical  and  dietary  treatment. 
The  surgical  methods  applicable  to  special  organs  are  discussed  under  those  head- 
ings. When  the  intestines  are  ptosed  and  there  is  stasis  there  are  two  commonly 
employed  surgical  plans,  and  each  has  its  advocates:  (i)  The  suture  of  the 
prolapsed  intestine  to  some  adjacent  structure  or  shortening  its  supporting 
ligaments.  (2)  Plastic  operation  to  lessen  the  area  of  the  abdominal  wall  and 
thus  increase  intra-abdominal  tension.  Depage  makes  the  abdominal  wall  less 
in  both  directions.  Webster,  in  cases  of  separation  of  the  recti,  resects  and 
sutures  the  fascia  of  the  muscles.  I  believe  that  Depage's  method  of  shortening 
the  diameters  of  the  abdominal  wall  cannot  permanently  succeed,  because  the 
viscera,  hanging  to  relaxed  ligaments,  will  eventually  stretch  the  wall;  it  will  be 


Acute  Peritonitis 


1159 


stretched  easily  because  of  damage  done  to  its  nerve-supply  by  operation,  and 
hernia  will  be  apt  to  occur;  and  if  it  should,  the  patient  will  be  worse  off  than 
before  operation.  Of  course,  whatever  operation  is  done,  diastasis  of  the  rectus 
muscles  must  be  corrected  by  approximation  and  suture.  For  ptosis  of  the  small 
intestine  the  mesentery  may  be  shortened,  as  suggested  and  performed  by  Davis, 
of  Omaha,  in  1897. 

In  prolapse  of  the  transverse  colon  good  results  are  said  to  have  been  ob- 
tained by  attaching  the  splenic  and  hepatic  flexures  to  the  abdominal  wall 
{Lambottes  operation).  The  surgical  treatment  of  ptosis  of  the  stomach  is 
considered  on  page  mo;  of  the  hver,  on  page  1178;  of  the  spleen,  on  page  1204; 
of  the  kidney,  on  page  1422. 

The  Peritoneum 

Acute  Peritonitis. — Peritonitis,  or  inflammation  of  the  peritoneum, 
is  a  common  and  usually  a  very  dangerous  disease. 

Aseptic  irritation  by  a  traumatism  or  a  chemical  irritant  produces  aseptic 
peritonitis,  a  condition  which  is  strictly  limited;  which  may  produce  local 
pain  and  tenderness;  which  may  cause  aseptic  fever  from  the  absorption  of 
fibrin-ferment  and  the  products  of  tissue  change;  which  leads  to  the  formation 
of  temporary  or  permanent  adhesions,  and  which  is,  in  reality,  a  process  of 
repair. 

"  Peritonitis,"  as  the  term  is  used  by  the  surgeon,  is  always  due  to  bacteria. 
Bacteria  may  reach  the  peritoneal  cavity  by  means  of  an  abdominal  wound 
or  the  entrance  of  foreign  bodies ;  by  extravasations  from  the  stomach,  bowel,  ver- 
miform appendix,  gall-bladder,  urinary  bladder,  kidney,  Fallopian  tube  or  uterus, 
or  by  the  passage  of  micro-organisms  through  the  damaged  walls  of  any  of  these 
viscera  or  structures;  by  way  of  an  open  Fallopian  tube;  from  the  breaking  of 
an  abscess  into  the  peritoneal  cavity;  from  rupture  of  an  infected  mesenteric 
gland;  from  perforation  of  a  diverticulitis  of  the  bowel;  from  areas  of  necrosis 
due  to  volviflus,  strangulation,  or  intussusception  of  the  intestine;  twisting  of 
the  pedicle  of  an  ovarian  tumor,  a  floating  kidney,  or  a  floating  spleen;  blocking 
of  a  mesenteric  vessel  by  a  thrombus  or  an  embolism;  gangrene  of  the  pancreas 
or  spleen,  and  fat-necrosis.^  In  some  cases  the  peritoneum  may  contain  a 
point  of  least  resistance,  and  bacteria  contained  in  the  blood  reach  this  point 
and  produce  infection.  Infection  may  be  brought  to  the  peritoneum  by  the  lym- 
phatics during  child-birth.  It  was  once  taught  that  cold  could  produce  peritonitis, 
but  it  seems  probable  that  it  can  only  act  by  producing  an  area  of  least  resist- 
ance.    The  capacity  of  the  rheumatic  poison  to  produce  peritonitis  is  doubtful. 

The  peritoneum,  as  Byron  Robinson  pointed  out  and  Fowler  confirmed, 
is,  in  reality,  a  great  lymph-sac,  and  peritonitis  is  lymphangitis.  "When 
the  peritoneum  is  infected  the  lymphatics  furnish  an  exudate  which  clots 
in  the  lymph-channels,  blocks  them,  and  limits  or  prevents  absorption.  This 
blocking  of  the  lymph-channels  serves  to  preserve  the  life  of  the  subject,  on 
the  one  hand,  while  a  failure  in  this  respect,  either  because  of  the  enormous 
and  overwhelmingly  rapid  increase  of  septic  material  and  the  large  size  and 
number  of  channels  necessary  to  destroy  and  obstruct,  on  the  other  hand, 
permits  the  destruction  of  the  organism."^  Absorption  takes  place  most 
actively  from  the  region  of  the  diaphragm,  hence  peritonitis  in  thiis  region  is 
peculiarly  fatal.  Absorption  takes  place  very  rapidly  from  the  intestinal 
region,  although  not  quite  so  quickly  as  from  the  diaphragmatic  area.  Ab- 
sorption takes  place  slowly  from  the  pelvic  region,  hence  peritonitis  of  this 
region  is  much  less  dangerous  than  is  the  disease  in  the  intestinal  region,  and 
vastly  less  dangerous  than  is  the  disease  in  the  diaphragmatic  region  (Fowler). 

When  severe  bacterial  infection  of  the  peritoneum  occurs,  exudation  of 
blood-liquor    takes    place,    leukocytes    migrate    from    the   blood-vessels  be- 
^  See  Park's  "Surgery  by  American  Authors." 
-  George  R.    Fowler,  "  Diffuse  Septic  Peritonitis,"  in  "  Medical  Record,"  April  14,  1900. 


ii6o  Diseases  and  Injuries  of  the  Abdomen 

neath  the  endotheUal  layer,  particularly  into  the  peritoneal  cavity,  and  the 
causative  bacteria  rapidly  spread  about  the  cavity.  The  fibrinous  exudate, 
in  many  infections,  coagulates  in  masses  on  the  free  surface  of  the  peritoneum, 
and  thus  serves  a  useful  purpose  by  blocking  the  lymph-channels  and  hinder- 
ing the  absorption  of  toxins  and  bacteria.  The  fibrinous  exudate  may  break 
down  in  a  widespread  suppuration  or  may  be  organized  into  an  adhesion. 
In  very  virulent  streptococcic  infections  a  patient  may  die  and  there  may 
be  scarcely  any  coagulated  exudation  or  may  be  none  at  all.  Exudation  and 
migration  take  place  also  in  the  subserous  tissues  and  into  the  muscular  coat 
of  the  bowel,  and  the  segment  of  bowel  which  is  attacked  becomes  paralyzed 
and  distended  with  gas,  the  gas  within  causes  it  to  rise  up,  and,  as  peristalsis 
is  absent,  obstruction  occurs  (James  P.  Warbasse,  in  "  Am.  Jour.  Med.  Sciences," 
July,  1905).  Absorption  of  poison  in  peritonitis  takes  place  in  part  from  the 
peritoneal  cavity  and  in  part  from  the  subserous  tissues.  Warbasse  believes 
that  the  inflamed  peritoneum  is  scarcely  an  absorbing  surface,  but  in  cases  in 
which  coagulated  exudate  has  not  formed  or  has  been  destroyed,  it  seems  prob- 
able that  it  is  an  active  absorbing  surface,  and  absorption  may  occur  from  some 
regions,  but  not  from  others. 

Various  bacteria  may  be  responsible  for  peritonitis,  especially  staphy- 
lococci, streptococci,  pneumococci,  and  colon  bacilli.  The  infections  which 
spread  most  rapidly  and  widely  are  due  to  streptococci.  In  streptococcus 
infection  the  protective  exudate  does  not  coagulate,  barriers  of  leukocytes 
are  not  heaped  up,  encompassing  adhesions  do  not  form,  there  is  rapid  ab- 
sorption of  toxins,  and  overwhelming  systemic  poisoning.  Colon  bacilli 
cause  a  very  grave  form  of  peritonitis,  but  less  rapid  and  diffuse  than  that 
caused  by  streptococci — in  fact,  the  process  is  often  encompassed  for  a  time 
by  coagulated  lymph,  leukocytes,  and  adhesions.  The  omentum  particularly 
is  thickened,  and  is  apt  to  apply  itself  about  the  area  of  infection.  Staphylo- 
cocci and  pneumococci  produce  peritonitis  which  is  more  apt  to  be  limited 
than  that  produced  by  colon  bacilli.  In  most  cases  of  peritonitis  a  mixed 
infection  exists;  for  instance,  colon  bacilli  and  staphylococci  or  colon  bacilli 
and  streptococci.  Gas-forming  bacilli  cause  a  form  of  peritonitis  in  which  gas 
gathers  in  the  abdominal  cavity  (pnciimo peritonitis).  It  may  arise  after  a 
stab  wound  or  a  gunshot  wound.  In  some  apparently  severe  cases  of  acute 
peritonitis  cultures  have  remained  sterile. 

Forms  of  Peritonitis. — An  accurate  bacteriological  classification  is  not 
as  yet  possible. 

Peritonitis  can  be  named,  according  to  regions,  pelvic,  subdiaphragmatic, 
etc.;  it  can  be  divided  pathologically  into  diffuse  septic,  putrid,  hemorrhagic, 
suppurative,  serous,  and  fibrino plastic  (Senn) ;  it  can  be  classified,  etiologic- 
ally,  into  traumatic,  puerperal,  perforative,  metastatic,  scarlatinal,  etc.;  and  it 
can  be  divided,  clinically,  into  circumscribed  suppurative,  diffuse  suppurative, 
and  diffuse  septic. 

Circumscribed  Suppurative  Peritonitis. — In  this  condition,  which  is  fre- 
quently met  with  in  appendicitis,  the  area  of  infection  is  circumscribed  by  coagu- 
lated exudate,  leukocytes,  and  adhesions,  and  an  abscess  forms.  After  a  time 
distinct  localization  becomes  evident. 

The  symptoms  of  circumscribed  peritonitis  are  pain,  at  first  general  and 
then  local,  tenderness  in  a  particular  region,  muscular  rigidity,  distention, 
vomiting,  rapid  and  often  wiry  pulse,  constipation,  fever,  great  weakness, 
and  dorsal  decubitus  with  the  thighs  flexed.  After  a  time  a  distinct  mass  can 
usually  be  detected  by  palpation,  and  there  may  be  dulness  on  percussion, 
local  rigidity,  irregular  temperature,  sweats,  and  possibly  edema  of  the  belly 
wall.  An  abscess,  though  limited  for  a  time,  is  always  liable  to  break  through 
its  walls  and  produce  general  peritonitis.  Such  an  accident  may  be  produced 
by  muscular  effort  on  the  part  of  the  patient  or  by  injudicious  palpation  on 


Treatment  of  Peritonitis  1161 

the  part  of  the  surgeon;  or  by  rough  handling  of  the  patient  while  transporting 
him  from  place  to  place;  its  occurrence  is  announced  by  shock,  and  the  symp- 
toms of  general  peritonitis  quickly  arise. 

Diffuse  or  general  septic  peritonitis  is  apt  to  destroy  life  even  before  the 
peritoneum  presents  any  marked  change.  Death  ensues  from  the  absorption 
of  toxic  alkaloids.  Septic  peritonitis  may  arise  during  the  puerperium,  through 
lymphatic  infection;  it  may  be  due  to  infection  from  without  by  an  operation 
or  an  accident;  to  perforation  of  an  ulcer;  to  gangrene  of  a  portion  of  the  in- 
testine; to  rupture  of  an  abscess  into  the  peritoneal  cavity;  to  rupture  of  a 
mesenteric  gland;  to  perforation  of  a  diverticulitis  of  the  bowel;  or  to  migration 
of  micro-organisms  through  a  damaged  wall  of  the  bowel.  Peritonitis  due  to 
perforation  is  called  perforative  peritonitis.  Perforation  is  made  manifest  by 
pain,  a  chill,  shock,  or  perhaps  collapse.  Gas  may  pass  into  the  peritoneal 
cavity,  and  if  it  does  so,  the  area  of  liver  dulness  may  be  lessened  or  abolished. 
Symptoms  and  signs  of  hemorrhage  may  arise.  Diffuse  septic  peritonitis  is 
announced  by  a  very  rapid  pulse,  which  is  at  first  wiry  and  later  gaseous;  a 
temperature  which  may  at  times  be  febrile,  but  which  is  apt  to  be  subnor- 
mal or  which  soon  becomes  so;  general  abdominal  pain  and  tenderness,  dry 
tongue,  delirium,  persistent  vomiting,  constipation,  and  collapse.  Rigidity 
exists,  and  also  intestinal  obstruction  due  to  paralysis  of  the  gut.  Usually, 
but  not  invariably,  there  is  distention.  In  puerperal  peritonitis  or  septic  peri- 
tonitis from  operation  there  is  often  no  severe  pain.  In  perforative  peritonitis 
there  is  acute  pain.  Victims  of  general  septic  peritonitis  if  unoperated  upon 
usually  die  within  five  or  six  days. 

Diffuse  or  general  suppurative  peritonitis  differs  clinically  from  diffuse 
septic  peritonitis  in  the  fact  that  it  is  less  apt  to  be  fatal  and  widespread.  In 
fact,  adhesions  may  form  about  an  area  representing  a  considerable  portion  of 
the  peritoneal  cavity.  The  causes  of  both  are  identical.  In  septic  peritonitis 
death  occurs  from'  absorption  of  toxins  before  obvious  pathological  changes 
occur  in  the  peritoneum;  in  suppurative  peritonitis  the  microbes  are  fewer, 
are  less  virulent,  or  vital  resistance  is  more  decided,  and  suppuration  follows 
marked  changes  in  the  peritoneum.  In  suppurative  peritonitis  the  pyogenic 
bacteria  are  always  present,  and  there  exists  in  the  peritoneum  a  wound  or 
damaged  area  to  constitute  a  point  of  least  resistance. 

Symptoms. — Chilliness  or  a  rigor  is  common,  followed  by  fever,  the  tem- 
perature rising  to  102°  or  104°  F.;  pain  is  intense,  and  is  accentuated  by  mo- 
tion and  pressure;  the  attitude  of  the  patient  is  assumed  to  relieve  pain  (he 
lies  upon  his  back,  with  the  shoulders  raised  and  the  thighs  drawn  up) ;  there 
are  vomiting,  obstinate  constipation,  and  rigidity  of  the  abdominal  walls, 
followed  by  distention  when  the  intestine  becomes  paretic  from  septic  poisoning. 
The  pulse  is  rapid ;  is  at  first  wiry,  but  may  become  gaseous.  The  constipation 
may  be  due  either  to  tympanitic  distention  or  to  the  shock  and  toxemia  inhibit- 
ing intestinal  peristalsis.  Obstruction  arises.  Vomiting  is  frequent.  In  per- 
foration gas  often  passes  into  the  peritoneal  cavity,  and  it  may  obscure  the  liver 
dulness;  in  tympanites  without  perforation  the  liver  is  apt  to  be  pushed  up  and 
its  dulness  remains,  but  on  a  higher  level.  Pus  unconfined  by  adhesions  will 
gravitate  to  the  most  dependent  part  of  the  peritoneal  cavity.  In  some  cases 
of  suppurative  peritonitis  there  is  no  tympanitic  distention  or  rigidity;  in  some 
cases  there  is  no  elevation  of  temperature,  in  fact,  the  temperature  may  be 
actually  subnormal. 

Treatment  of  Peritonitis. — After  an  abdominal  operation  the  patient  may 
have  pain,  slight  rigidity,  constipation,  nausea,  flatulence,  etc.,  and  the  sur- 
geon is  in  doubt  if  peritonitis  is  beginning  or  about  to  begin.  Our  custom  is 
in  such  cases  to  give  a  saline  cathartic,  which  will  empty  the  peritoneal  cavity 
of  fluid,  will  favor  the  elimination  of  microbes,  and  will  combat  inflammation. 
The  old-time  remedy  was  opium,  but  Tait  denounced  it  as  inefficient,  and 
showed  that  it  masked  the  symptoms  and  often  created  a  false  sense  of  security 


Il62 


Diseases  and  Injuries  of  the  Abdomen 


in  the  very  midst  of  imminent  dangers.  The  usual  method  of  administering 
sahnes  is  to  give  i  dram  of  Rochclle  salt  and  i  dram  of  Epsom  salt  every  hour 
until  a  free  movement  occurs.  Administer  an  enema  of  turpentine  at  the  time 
the  first  dose  of  the  saline  is  given.  Atropin,  eserin,  and  pituitrin  may  be 
useful  (see  page  1127).  This  treatment  will  often  abolish  pain  and  distention 
and  will  perhaps  prevent  peritonitis  after  an, abdominal  operation.  If,  how- 
ever, genuine  peritonitis  is  known  to  exist  no  purgative  should  be  given. 
It  is  a  deadly  dangerous  thing  to  give  one,  as  it  diffuses  infection.  Op- 
eration is  required.  Prompt  operation  is  the  only  hope  in  genuine  postopera- 
tive peritonitis  and  any  delay  means  certain  death.  When  diffuse  septic  or 
suppurative  peritonitis  exists  from  any  cause  and  the  surgeon  sees  the  case 
early  (within  thirty-six  hours)  the  abdomen  should  be  opened.  In  a  perforative 
case  operate  even  if  the  case  is  first  seen  later  than  thirty-six  hours.  If  a  non- 
perforative  case  is  seen  later  it  may  be  wise  to  use  Ochsner's  treatment  and 
wait  for  localization  (Stanton,  in  "New  York  Med.  Jour.,"  Aug.  27,  1910). 
If  a  perforation  exists,  it  should  be  closed.     A  perforated  or  inflamed  appen- 


FiG.  702. — Murphy  treatment  for  suppurative  peritonitis. 

dix  should  be  removed.  Until  recently  it  was  surgical  custom  to  break  up 
adhesions,  eviscerate,  wash  the  belly  with  gallons  of  very  warm  salt  solution, 
wipe  out  the  space  between  the  liver  and  diaphragm,  wipe  out  the  pelvis,  wipe 
oflf  the  intestines,  and  remove  masses  of  adherent  coagulated  exudate.  We  thus 
produced  dreadful  shock,  tried  to  cleanse  the  peritoneal  cavity  when  it  is  im- 
possible thoroughly  to  cleanse  it,  carefully  removed  the  exudate  which  was 
doing  good  by  plugging  the  lymph-spaces,  and  yet  we  did  not  reach  the  infec- 
tion inside  of  the  lymphatics,  which  is,  after  all,  the  greatest  source  of  danger. 
Then  we  drained  through  two  or  more  incisions  and  put  the  patient  recumbent 
in  bed,  and  thus  permitted  infected  material  to  flow  up  to  the  diaphragm,  where 
it  was  quickly  absorbed.  The  mortality  from  this  procedure  was  dreadful. 
John  B.  Murphy  has  taught  us  wisdom  and  has  combined  some  of  the  conser- 
vative views  of  Ochsner  with  the  use  of  the  semi-erect  position  of  Fowler,  and 
with  the  continuous  rectal  irrigations  that  several  advocated.  Murphy's  plan 
is  founded  upon  the  following  principles: 

First,  that  the  initial  lesion  of  the  peritonitis  should  be  removed  as  quickly 
as  possible  and  with  the  slightest  possible  amount  of  handling.  For  instance, 
we  should  remove  a  gangrenous  appendix;  we  should  close  a  perforation  in 
the  bowel,  etc.  Flushing  of  the  peritoneal  cavity  with  gallons  of  salt  solu- 
tion is  inadvisable.  It  cannot  thoroughly  cleanse  the  peritoneum;  it  may 
diffuse  the  infection  to  regions  that  it  had  not  previously  reached,  and  it  may 
tear  up  adhesions.  Inflammatory  exudate  should  not  be  removed  from  the 
intraperitoneal  structures.     It  is  Nature's  method  of  sealing  the  lymph-spaces, 


Treatment  of  Peritonitis 


1 163 


and  if  we  remove  it  we  open  thousands  of  channels,  previously  sealed,  for  the 
dissemination  of  the  infection.  A  drainage-tube  should  be  introduced  through 
the  operation  wound,  and  suprapubic  incision  should  also  be  made  and  a  drain- 
age-tube be  carried  through  this  to  the  depths  of  the  pelvis.  When  the  opera- 
tion is  completed  the  patient  should  be  placed  in  the  semi-erect  position,  which 
is  commonly  called  Fowler's  position.  This  is  done  in  order  that  the  intraperi- 
toneal fluids  may  gravitate  away  from  the  diaphragm,  where  absorption  is 
extremely  rapid,  and  into  the  pelvis,  where  absorption  is  much  slower. 

WTien  the  patient  has  been  placed  in  the  bed  quantities  of  warm  salt  solution 
are  passed  slowly  into  the  rectum.  The  mucous  membrane  of  the  large  intestine 
absorbs  fluid  with  great  rapidity  when  that  portion  of  the  gut  is  in  its  normal 
condition  of  moderate  distention.  Overdistention  leads  to  spasm,  which  expels 
the  fluid.  Hence  the  fluid  must  be  given  at  low  pressure  and  administration 
should  be  continuous.  The  simplest  sort  of  ap- 
paratus is  shown  in  Fig.  703.  It  consists  of  a  foun- 
tain syringe,  a  large  rubber  tube,  and  a  rectal  tip 
of  hard  rubber.  The  nozzle  that  is  used  is  angled, 
has  one  opening  on  the  end  and  several  on  the  side, 
and  this  nozzle  is  passed  so  that  the  angle  fits 
the  sphincter  (see  Fig.  705).  The  tube  is  strapped 
to  the  thighs  by  adhesive  plaster.  The  hose  that 
comes  from  the  nozzle  is  attached  to  a  reservoir, 
the  base  of  which  is  hung  from  4  to  6  inches  above 
the  level  of  the  patient's  buttocks;  and  the  fluid, 
therefore,  enters  the  rectum  only  about  as  fast  as 
the  rectum  will  absorb  it.  The  reservoir  is  kept 
warm  by  bags  of  hot  water  hung  about  it.  The 
fluid  is  allowed  to  enter  '  continuously,  unless  it 
should  run  out  from  the  side  of  the  tube;  if  this 
happens,  the  flow  may  be  cut  off  for  a  short 
time  and  then  allowed  to  begin  again.  Gas  from 
the  bowel  passes  into  the  openings  of  the  tube, 
and  every  now  and  then  bubbles  up  through  the 
reservoir.  By  this  continuous,  low  pressure  in- 
stillation {proctoclysis)  an  enormous  quantity  of 
fluid  is  absorbed  by  the  rectum.  In  some  cases  a 
number  of  quarts  are  taken  up  in  twenty-four 
hours.  The  absorption  of  this  fluid  greatly  in- 
creases the  amount  of  urine  eliminated,  removes 
toxins,  and  stimulates  the  heart.  The  reservoir 
must  not  be  high.     Increase  of  pressure  will  cause 

expulsion  of  fluid  and  defeat  the  possibility  of  continuous  administration.  The 
plan  so  often  followed  of  keeping  the  reservoir  high  and  limiting  the  flow  by  a 
clip  on  the  tube  is  a  mistake.  Murphy  says:  "It  should  never  have  a  head- 
way of  more  than  15  inches  hydrostatic  pressure,  and  it  gives  the  best  and 
most  uniform  results  at  4  to  7  inches"  ("Jour.  Am.  Med.  Assoc,"  April  17, 
1909).  A  straight  tube  is  sometimes  responsible  for  expulsion  of  the  fluid, 
"because  it  touches  the  posterior  rectal  wall  of  a  patient  in  Fowler's  position. 
Fig.  704  shows  a  more  elaborate  apparatus  than  that  just  described. 

After  the  water  has  been  entering  the  rectum  for  some  time  a  profuse 
discharge  of  sour-smelling  material  comes  from  the  drainage-tube.  This 
discharge  may  be  profuse  for  one  day,  two  days,  or  longer,  when  its  sour  smell 
disappears  and  it  greatly  lessens  in  quantity.  The  outflow  of  this  fluid  from 
the  wound  means  that  saUne  fluid  from  the  rectum  has  entered  the  lymph- 
spaces  and  run  into  the  peritoneal  cavity.  Murphy  thinks  the  lymph-cur- 
rent has  been  reversed.    Whether  this  be  true  or  not  the  peritoneum  certainly 


Fig,  703.  —  Proctoclysis 
apparatus  consisting  of  foun- 
tain syringe,  large  rubber 
tube,  and  hard-rubber  or  glass 
tip  (Murphy). 


II64 


Diseases  and  Injuries  of  the  Abdomen 


seems  to  become  a  secreting  instead  of  an  absorbing  surface,  and  the  lymphatics 
are  washed  out.  During  the  time  that  this  treatment  is  pursued  the  patient 
has  no  food  or  water  given  him  by  the  mouth.  Stomach  feeding  is  rigidly  for- 
bidden in  order  to  prevent  peristaltic  movements.  Small  amounts  of  morphin 
may  be  given  to  prevent  peristalsis.  If  the  patient  is  in  a  weak  condition, 
stimulants  or  food  can  be  given  by  the  rectum,  the  solution  in  the  reservoir 
being  allowed  to  reach  a  low  level,  and  then  the  material  that  it  is  desired  to 
give  being  poured  into  the  receptacle.  Besides  the  above  method  of  treat- 
ment antistreptococcic  serum  is  usually  given. 

I  am  convinced  that  this  method  of  treatment  is  of  the  greatest  value,  and 
that  the  principles  upon  which  it  rests  are  entirely  sound,  and  I  have  had  a 
number  of  striking  successes  from  its  employment. 

If  a  case  of  diffuse  peritonitis  has  lasted  for  three  or  four  days  and  any  sign 
points  to  localization,  do  not  operate  at  once.  Wash  out  the  stomach,  place 
the  patient  in  Fowler's  position,  give  salt  solution  by  the  rectum,  and  v^hh- 


FiG.  704. — Alcohol  or  gas  heater  in  operation,  showing  it  properly  connected.     A  short  glass 
tube  connects  catheter  to  rubber  tubing  (Murphy). 

hold  purgatives  and  food.  The  inflammation  may  subside  or  may  localize  into 
a  circumscribed  suppuration.  When  in  a  patient  with  peritonitis  the  skin  is 
blue,  cold,  and  moist,  the  pulse  very  rapid  and  weak,  the  abdomen  immensely 
distended,  and  the  temperature  subnormal  death  is  almost  certain,  and  the 
only  chance  is  the  conservative  plan  set  forth  above.  We  wait  in  hope  that 
the  infection  may  localize  in  an  abscess.  (See  Buchanan,  in  "Med.  Record," 
Jan.  28,  191 1,  and  Stanton,  in  ''New  York  Med.  Jour.,"  Aug.  27,  1910.) 

A  circumscribed  suppuration  is  treated  as  follows:  Open  the  abscess.  It 
will  be  possible,  if  the  abscess  is  adherent  to  the  abdominal  wall,  to  open  the 
abscess  directly  without  opening  the  peritoneal  cavity.  If  this  be  not  possible, 
after  opening  the  abdominal  cavity  pack  gauze  pads  in  a  manner  about  the 
abscess  so  as  to  prevent  the  diffusion  of  pus  when  the  abscess  is  evacuated. 
After  opening  the  abscess  the  primary  lesion  is  sought  for  and,  if  possible, 
removed.  The  surgeon  should  not,  in  most  cases,  tear  away  the  abscess  walls 
in  an  attempt  to  find  the  primary  lesion,  but  should  rather  let  it  go  undis- 
covered.    Pack  iodoform  gauze  against  the  intestines  to  reinforce  the  barrier 


Tuberculous  Peritonitis  1165 

of  lymph  and  insert  a  tube.  It  is  frequently  advisable  to  leave  the  wound 
wide  open  and  drain  by  means  of  gauze. 

Every  patient  with  peritonitis  requires  stimulants. 

Tuberculous  Peritonitis. — Tuberculosis  of  the  peritoneum  is  not  very 
common.  In  11 70  autopsies  in  the  Boston  City  Hospital  tubercle  existed 
in  some  region  in  197,  and  in  14  of  these  the  peritoneum  was  involved.^  Pri- 
mary local  peritoneal  tuberculosis  is  occasionally,  though  rarely,  seen  by  the 
surgeon.  In  a  great  majority  of  cases  of  peritoneal  tuberculosis  other  distant 
structures  are  involved.  In  about  half  of  the  cases  the  lungs  are  involved.  In 
28  cases  reported  by  Bottomly^  not  one  was  primary.  In  every  one  of  these 
cases  the  diagnosis  was  confirmed  by  the  microscope,  by  the  tuberculin  test, 
or  by  autopsy.  In  most  supposed  cases  of  primary  peritoneal  tuberculosis 
another  focus  of  disease  exists,  but  is  not  demonstrable  by  clinical  methods 
or  has  been  overlooked.     The  disease  sometimes  exists  as  a  part  of  general 

tuberculosis.       Tuberculous  

peritonitis  may   be    only    a    p"'~~'  ■  "^ 

part   of  acute    miliary    tu-    j 

berculosis.      Bacteria     may    !     fl|HE39HBBB|i^ik^ 
be    swallowed    with    tuber-         ^^^^^P^^^^H|JN|^^^^ 
culous   food   or  a    tubercu-                                           ^^iSkS*. 
lous    patient    may   swallow                                                  ^^ll^V 
tuberculous  sputum  and  in-    |                                                    ^^IKS^. 
testinal    tuberculosis     may    '                                                         ^"llfcli*"^!..^ 
result,  the  peritoneum  being                                                                  ^^Ifilii^ 
involved   later.      Peritoneal                                                                        ^HIf 
infection  may  follow  a  tu- 
berculous lesion   of   the   in-    L        _     ^  -  i 

testine,  the  bacteria  may  pic.  705.— Tube  with  orifices  filled  with  chalk  in  order 
enter  by  way   of   the  Fal-  to  show  openings  better, 

lopian      tube,      the     initial 

lesion  may  be  tuberculous  appendicitis  or  tuberculosis  of  the  mesenteric 
glands.  The  germ  may  lodge  from  the  blood  or  lymph.  The  lymphatic 
form  most  commonly  attacks  the  cecum.  Tuberculous  peritonitis  is  four 
times  as  common  among  women  as  among  men,  and  most  frequently 
attacks  those  between  twenty  and  forty  years  of  age,  but  I  have  seen 
it  in  a  child  of  two  and  in  a  colored  man  of  sixty.  In  all  probability  it  is  more 
common  in  childhood  and  infancy  than  we  suspected  formerly.  Probably  the 
diagnosis  is  not  unusually  missed  in  such  subjects  and  the  patient  dies,  or  the 
disease  makes  great  advances  before  it  is  recognized.  In  very  early  life  tubercu- 
lous peritonitis  may  be  confounded  with  rickets,  pseudoleukemia  and  other  condi- 
tions (H.  R.  Shefi&eld,  in  "Amer.  Med.,"  1916,  xi).  There  are  two  groups  of  cases 
— the  common  chronic  form  and  the  rarer  acute  condition.  The  acute  form 
begins  suddenly,  and  such  cases,  as  pointed  out  by  Lejars,  resemble  acute 
appendicitis.  In  either  the  acute  or  chronic  condition  it  is  frequently  the  case 
that  pulmonary  phthisis  exists.  Cirrhosis  of  the  liver  is  sometimes  found 
with  tuberculous  peritonitis.  There  are  three  forms  of  chronic  tuberculous 
peritonitis:  the  ascitic,  the  fibrinoplastic,  and  the  caseous,^  although,  as  a  matter 
of  fact,  these  so-called  forms  are  only  stages  of  the  same  disease.  Tuberculous 
infection  may  exist  for  some  time  without  causing  symptoms,  acute  symptoms 
may  suddenly  arise,  or  intestinal  obstruction  may  take  place.  Symptoms  some- 
times develop  quickly  after  pregnancy.  In  other  cases  the  symptoms  appear 
gradually  and  progressively  grow  more  positive. 

Symptoms  of  the  Chronic  Form. — Usually  the  disease  begins   insidiously. 

^  Bottomly,  fn  "Amer.  Med.,"  Feb.  15,  1902. 

2  Ibid. 

'  Parker  Syms,  in  "Medical  Record,"  April  2,  1898. 


1 1 66  Diseases  and  Injuries  of  the  Abdomen 

The  digestion  is  found  to  be  disturbed,  there  is  nausea,  the  bowels  are  out  of 
order,  the  abdomen  is  distended  and  tender,  there  is  occasional  colicky  pain, 
and  the  patient  is  weak,  loses  flesh  rapidly,  and  becomes  very  anemic.  Fre- 
quently pain  is  the  symptom  which  leads  the  patient  to  seek  advice.  The 
pain  may  be  present  from  the  very  beginning,  it  may  arise  after  malaise  and 
gastro-intestinal  disorder  have  existed  for  some  time,  but  sooner  or  later  it 
will  develop. 

In  many  cases  there  is  ascites,  but  the  amount  of  fluid  is  rarely  very  great. 
In  some  cases  the  fluid  is  serous,  in  some  seropurulent,  in  some  purulent,  and 
in  some  bloody.  Chylous  fluid  occasionally  exists  because  of  fatty  degenera- 
tion of  tuberculous  masses.  Ascites  may  be  either  unconfined  or  sacculated  by 
adhesions.  In  some  cases,  and  especially  in  early  youth,  there  is  little  or  no 
ascites,  and  the  condition  is  characterized  by  the  production  of  a  quantity  of 
adhesions  which  bind  coils  of  intestine  to  each  other,  to  the  omentum,  to  the 
stomach,  liver,  and  other  viscera.  In  this  condition,  which  develops  very 
slowly,  small  cavities  are  formed  between  adhesions  and  the  spaces  contain 
fluid  and  bacteria.  This  is  the  most  chronic  form  of  the  disease.  In  any  case 
of  tuberculous  peritonitis  the  mesenteric  glands  may  enlarge.  There  is  usually 
moderate  fever,  but  there  may  be  episodes  of  high  fever  and  protracted  periods 
of  subnormal  temperature,  or  the  temperature  may  be  slightly  elevated  in  the 
evening  and  subnormal  in  the  morning.  When  the  temperature  becomes 
markedly  elevated,  pain,  tenderness,  and  distention  notably  increase.  In 
some  cases  there  is  a  continued  fever  resembling  typhoid.  Tumor-like  forma- 
tions may  be  detected.  These  formations  may  consist  of  indurated  omentum, 
encysted  exudate,  or  enlarged  mesenteric  glands.  If  diarrhea  exists  for  a  long 
period  there  is  probably  tuberculous  ulceration  of  the  gut. 

In  every  suspected  case  a  bimanual  examination  should  be  made  under 
ether,  in  order  to  discover  if  there  are  any  matted  masses  of  intestine  (Thom- 
son). In  young  children  the  tuberculin  reaction  is  of  high  diagnostic  value 
but  it  is  of  far  less  use  in  older  persons. 

In  many  cases  a  careful  examination  will  detect  tuberculous  disease  of  other 
regions  of  the  body,  particularly  of  the  lungs.  If  tuberculous  disease  of  the 
lungs  or  pleura  is  detected,  if  tuberculous  glands  exist  or  have  been  present, 
if  a  nodule  not  due  to  gonorrheal  inflammation  is  palpable  in  an  epididymis, 
or  if  there  are  indurations  in  the  prostate,  the  probability  of  the  presence  of 
tuberculous  peritonitis  is  much  enhanced.  In  many  cases  there  is  dilatation 
of  the  superficial  abdominal  veins.  In  some  cases  tuberculous  peritonitis 
undergoes  spontaneous  cure.  In  the  majority  of  instances  death  ensues  from 
the  tuberculous  peritonitis  directly  or  from  associated  or  secondary  disease  in 
other  organs. 

If  an  intraperitoneal  tuberculous  area  caseates,  a  large  cold  abscess  may 
form,  and  such  an  abscess  may  break  into  the  intestine  or  may  be  opened  ex- 
ternally, and  may  be  responsible  for  the  formation  of  a  fecal  fistula. 

In  a  case  of  tuberculous  peritonitis  intestinal  obstruction  may  occur,  the 
gut  getting  caught  by  bands  or  adhesions,  or  becoming  a  rigid  tube  because  of 
the  formation  of  tubercles. 

Symptoms  of  the  Acute  Form. — This  is  sometimes  mistaken  for  appendicitis. 
It  comes  on  rather  suddenly,  but  a  carefully  elicited  history  will  usually  show 
the  previous  existence  of  malaise,  gastro-intestinal  disturbance,  loss  of  flesh, 
and  anemia.  The  symptoms  are  not  so  strictly  localized  to  the  right  iliac  fossa 
as  in  appendicitis.  There  are  abdominal  distention,  a  certain  amount  of 
rigidity,  nausea  and  vomiting,  colicky  pain  which  may  be  very  severe,  general 
abdominal  tenderness,  fever,  and  exhaustion.  It  may  be  possible  to  palpate 
masses  like  tumors,  or  to  feel  nodules  in  the  prostate  or  epididymis,  or  to  detect 
tuberculosis  in  some  other  part.  In  young  children  the  tuberculin  reaction  is 
of  decided  value. 


Tuberculous  Peritonitis  1167 

Treatment. — In  some  cases  there  is  a  tendency  to  spontaneous  cure,  and  in 
them  medical  treatment  is  of  great  service.  The  patient  should  be  placed 
under  antituberculous  conditions,  nutritious  food  and  tonics  should  be  admin- 
istered (see  page  255),  the  abdomen  should  be  counterirritated  and  massaged, 
and  purgatives  should  be  given  frequently.  Guaiacol  applied  daily  to  the 
abdomen  is  thought  by  some  to  be  of  service,  but  I  doubt  it.  A  mixture  is  made 
of  I  part  of  guaiacol  and  5  parts  of  olive  oil;  i  dram  of  this  mixture  is  rubbed  into 
the  abdomen,  and  the  part  is  covered  with  a  piece  of  flannel  held  in  place  by 
means  of  a  binder.  If  medical  treatment  is  not  soon  productive  of  benefit,  the 
advisability  of  operating  must  be  considered.  It  is  a  curious  fact,  but  one  con- 
firmed by  ample  evidence,  that  after  simple  abdominal  section,  without  the  in- 
troduction of  germicides  and  without  drainage,  at  least  30  per  cent,  of  the  cases 
recover  from  the  disease  in  from  sLx  months  to  one  year.  Some  surgeons 
doubt  the  curative  effect  of  operation.  For  instance,  the  late  Professor  Fenger 
was  strongly  of  the  opinion  that  many  patients  recover  after  operation,  but 
not  as  a  result  of  operation.  In  his  opinion  they  recover  because  they  are 
strong,  free  from  fever,  and  well  nourished,  and  because  the  disease  tends  to 
spontaneous  cure.  He  further  believed  that  some  die  from  operation  because 
the  traumatism  lessens  the  already  lowered  tissue  resistance.  The  majority 
of  surgeons,  however,  believe  that  operation  in  many  cases  tends  to  cure.  Och- 
sner,  in  a  paper  before  the  American  Surgical  Association  in  1902,  apparently 
proved  that  simple  incision  and  evacuation  of  fluid  tends  to  cure.  It  is  uncer- 
tain how  an  operation  tends  to  cure.  It  has  been  thought  that  the  ascitic 
fluid  is  a  culture-medium  for  bacilli,  and  when  it  is  withdrawn  the  bacilli  die, 
but  opposed  to  this  view  is  the  fact  that  aspiration  is  rarely  curative.  It  has 
been  suggested  that  the  operation  brings  numerous  phagocytes  to  the  peri- 
toneum; that  it  stimulates  vital  resistance;  that  it  leads  to  the  exudation  of  anti- 
toxic serum.  The  entrance  of  air  seems  to  play  a  definite  and  important  part 
in  effecting  a  cure. 

The  ascitic  cases  are  most  frequently  benefited  by  operation.  If  there  be 
encysted  fluid  operation  often  cures. 

In  cases  in  which  there  are  numerous  adhesions  operation  is  not  so  likely  to 
produce  a  cure.  Great  care  should  be  exercised  in  separating  adhesions, 
because  the  bowel  is  apt  to  be  torn  and  a  fecal  fistula  may  result.  It  may  be 
necessary  to  separate  adhesions  or  short-circuit  a  portion  of  gut  to  relieve 
obstruction.  Drainage  should  not  be  used  unless  a  cold  abscess  exists.  Not 
only  is  drainage  of  no  service,  but  it  is  dangerous;  death  is  more  apt  to  ensue 
in  a  drained  case  and  a  fecal  fistula  will  arise  in  nearly  one-fourth  of  the  drained 
cases.  If  operation  is  performed  for  cold  abscess,  tube-drainage  must  be  used 
for  some  days.  In  a  woman  with  tuberculous  peritonitis  the  abdomen  should 
be  opened  in  the  midline,  and  if  the  Fallopian  tubes  are  tuberculous  they  should 
be  removed.  In  a  man  the  incision  should  be  made  over  the  appendix,  and  if 
this  is  tuberculous  it  should  be  removed.  In  either  sex  it  may  be  necessar}'  to 
resect  tuberculous  intestine  or  perform  anastomosis  because  of  stricture.  (In 
confirmation  of  these  views  see  W.  J.  ISIayo,  in  "Jour.  Am.  Med.  Assoc,"  April 
15,  1905.)  The  Mayos  have  performed  26  radical  tubal  operations  on  cases  of 
tuberculous  peritonitis  and  25  recovered.  Of  these,  7  had  previously  been 
operated  on  from  one  to  four  times  by  sinple  laparotomy  ("Jour.  Am.  ]Med. 
Assoc,"  April  15,  1905).  In  a  very  advanced  case,  in  a  case  with  notably  high 
temperature,  or  in  a  case  with  marked  and  advancing  tuberculosis  in  another 
region,  an  operation  should  not  be  performed  except  to  relieve  obstruction  or 
drain  an  abscess.  If  a  patient  does  not  die  within  a  few  months  after  an  opera- 
tion, he  will  probably  recover,  and  in  most  cases  operation  secures  at  least 
temporary  improvement  (Bottomly,  "Amer.  Med.,"  Feb.  15,  1902).  The 
mortality  from  operation  is  i  or  2  per  cent.  (Fenger). 


1 1 68  Diseases  and  Injuries  of  the  Abdomen 

Pneumococcus  Peritonitis. — This  condition  is  an  unusual  one.  It  is  most 
apt  to  arise  during  the  progress  or  after  the  termination  of  pneumonia  or  some 
other  pneumococcic  lesion,  but  is  sometimes  primary — is  far  commoner  in  fe- 
males than  in  males  and  in  children  than  in  adults.  Out  of  74  reported  cases, 
57  were  children  under  five  years  of  age  (Dr.  ]\lax  von  Brunn,  in  "  Beitrage  zur 
iclinischen  Chirurgie,"  Bd.  xxxix,  Heft  i).  In  primary  cases  the  bacteria  may 
enter  by  wav  of  the  blood-stream  or,  perhaps,  in  some  cases  through  the  bowel 
wall  or  Fallopian  tube.  In  secondary  cases  infection  may  arise  from  an  ad- 
jacent pneumococcic  area  (pleura)  or  be  carried  by  the  blood  from  a  distant 
point  (pneumococcic  septicemia) .  The  condition  may  appear  in  a  sufferer  from 
otitis  media.  The  symptoms  in  children  are  sudden  in  onset.  The  first 
svmptoms  are  general  abdominal  pain,  usually  a  continuous  pain  with  colicky 
exacerbations,  tenderness,  rigidity,  vomiting,^  elevated  temperature,  disten- 
tion, and  diarrhea.  In  a  few  days  the  symptoms  abate  and  some  of  them 
disappear,  although  pain,  tenderness,  and  rigidity  are  apt  to  localize  at  some 
point,  particularly  about  the  umbilicus,  and  may  remain  for  a  number  of 
weeks.  In  such  a  chronic  case  physical  signs  of  a  fluid  collection  are  usually 
demonstrable.  In  the  chronic  stage,  as  Brunn  points  out,  there  is  seldom  severe 
tenderness  and  there  may  be  no  fever  at  all,  and  a  septic  temperature  is  very 
rarely  observed.  Pus  may  form,  and  if  it  does,  it  contains  pneumococci. 
Adhesions  practically  always  form.  These  adhesions  glue  the  intestines  to- 
gether and  often  encompass  pus.  Rapid  emaciation  and  progressive  weak- 
ness are  always  noted.  In  adults  the  symptoms  are  irregular  and  less  char- 
acteristic than  in  children  (Brunn).     The  prognosis  is  excellent. 

Treatment. — Incision  and  drainage. 

A  subphrenic  abscess  is  a  collection  of  pus  beneath  the  diaphragm. 
It  is  a  rare  condition.  The  pus  may  occupy  a  part  of  the  lesser  peritoneal 
cavity;  it  may  be  extraperitoneal  (when  it  is  of  renal  origin);  in  some  cases  it 
is  contained  in  the  area  between  the  diaphragm,  cardiac  end  of  the  stomach, 
and  liver  or  spleen.  It  is  impossible  to  classify  accurately  these  abscesses  by 
anatomical  position.  George  A.  Ross  (''Jour.  Am.  Med.  Assoc,"  August  12, 
191 1)  classifies  them  as  right,  left,  anterior,  and  posterior.  Most  are  on  the 
right  side,  but  even  an  abscess  due  to  appendicitis  may  be  on  the  left  side. 
It  is  an  unusual  thing  for  such  an  abscess  to  break  into  the  general  cavity 
of  the  peritoneum,  but  it  may  break  into  the  pleural  sac  (Alaydl). 

Causes. — Perforation  of  a  gastric  ulcer,  perforation  of  the  gall-bladder  or 
gall-ducts,  ulceration  of  the  duodenum,  disease  of  the  liver,  spleen,  pancreas, 
intestine,  appendix,  or  kidney,  hydatid  disease,  internal  injury,  metastasis, 
external  injury,  caries  of  rib,  disease  of  the  pleura,  general  peritonitis,  or  portal 
infection  may  be  responsible  for  a  subphrenic  abscess.  We  have  abandoned 
the  notion  that  the  infecting  source  must  be  in  the  upper  abdomen.  Appendi- 
citis is  the  most  common  cause.  Charles  A.  Elsberg^  has  collected  73  cases  of 
subphrenic  abscess  after  appendicitis.  He  points  out  that  the  condition  may 
arise  from  direct  extension  or  by  way  of  the  lymph-channels,  and  may  be 
either  intraperitoneal  or  extraperitoneal,  although  in  the  majority  of  cases  it  is 
intraperitoneal.  In  rare  cases  extension  is  by  way  of  the  portal  vein.  Ross 
claims  that  in  most  cases  due  to  appendicitis  the  infection  extends  by  cellular 
tissue  directly  upward  from  the  lower  peritoneal  fossae.  In  some  cases  infection 
ascends  between  the  colon  and  the  parietal  peritoneum  (the  parietocolic  sinus 
of  our  French  colleagues).  In  all  but  7  of  Elsberg's  cases  there  was  suppura- 
tion about  the  appendix.  The  pus  was  thick  and  foul  in  all  the  cases.  In 
15  per  cent,  of  them  gas  was  also  present,  and  in  25  per  cent,  of  these  cases  the 
diaphragm  was  perforated.  In  3391  consecutive  cases  of  appendicitis  operated 
on  in  the  German  Hospital  of  Philadelphia  there  were  30  cases  of  subphrenic 
abscess  (Ross,  ''Jour.  Am.  Med.  x^ssoc,"  Aug.  12,  1911).     Subphrenic  abscess 

^  ".\nnals  of  Sugery,"  Dec,  1901. 


Treatment  of  Subphrenic  Abscess  1169 

may  develop  soon  after  an  appendicitis,  it  may  develop  extraordinarily  late. 
Ashhurst's  case  arose  four  years  after  appendicitis  ("Trans.  Phila.  Acad,  of 
Surg.,"  1910),  I  of  Ross's  cases,  one  year  after  (Loc.  cit.).  If  ascending  retro- 
peritoneal infection  e.xists  during  appendicitis,  removal  of  the  appendix  does 
not  arrest  it  (Lance,  in  "Gaz.  d.  Hop.,"  1909,  Ixxxvii).  In  2  cases  on  which 
I  operated  the  abscess  developed  after  cholecystitis;  in  2  others,  after  suppura- 
tive appendicitis. 

The  symptoms  usually  come  on  suddenly,  but  may  do  so  gradually.  There 
may  or  may  not  be  abdominal  symptoms.  A  patient  with  subphrenic  abscess 
usually  complains  of  pain  in  the  lower  part  of  the  chest  on  the  right  side.  Usu- 
ally there  is  high  temperature  and  often  delirium,  but,  as  Jopson  ("Annals  of 
Surgery,"  July,  19 10)  says,  the  temperature  may  be  only  moderately  elevated 
and  the  pulse  may  be  nearly  normal.  The  area  of  liver  dulness  is,  in  many  cases, 
distinctly  enlarged,  and  there  is  tenderness  in  the  lower  part  of  the  right  chest 
when  pressure  is  made  through  one  or  through  several  intercostal  spaces.  Fre- 
quently friction  sounds  may  be  heard  about  the  region  of  the  dome  of  the  liver. 
Breath  sounds  and  vocal  fremitus  are  lessened.  The  signs  are  usually  best 
heard  posterior,  but  may  be  lateral  or  anterior.  There  is  cough  and  also  bulg- 
ing of  the  chest  wall.  Jaundice  is  absent  in  uncomplicated  cases.  There  may 
be  hiccough.  Sometimes  the  symptoms  are  obscure  or  indefinite,  and  not  ac- 
companied by  particular  pain.  If  the  abscess  happens  to  contain  not  only  fluid 
but  also  a  considerable  amount  of  gas — and  about  one-half  of  such  abscesses 
do  contain  gas — not  only  will  there  be  no  increase  in  the  area  of  liver  dulness, 
but  the  normal  area  of  dulness  may  be  diminished  or  obliterated.  The  presence 
of  gas  may  be  due  to  some  connection  with  an  organ  which  contains  gas  or  to 
gas-forming  bacteria.  It  is  very  common  for  a  pleural  effusion  to  be  associated 
with  a  subphrenic  abscess.  A  pleural  effusion  will  be  preceded  by  or  accom- 
panied by  symptoms  pointing  to  the  lung  or  pleura;  and  it  is  to  be  remembered 
that  the  area  of  percussion-dulness  found  in  the  pleural  effusion  shifts  its  posi- 
tion whenever  the  position  of  the  patient  is  changed,  which  is  not  true  of  the 
area  of  dulness  found  in  subphrenic  abscess.  When  the  abscess  breaks  through 
the  diaphragm  the  patient  collapses,  cough  and  other  thoracic  symptoms  de- 
velop; and  if  the  abscess  breaks  into  a  bronchus  the  patient  will  expectorate 
pus.  In  subphrenic  abscess  the  diaphragm  of  the  diseased  side  is  paralyzed— 
a  condition  rarely  met  with  in  liver  abscess.  There  are  general  symptoms  of 
suppuration  and  a  swelling  in  the  subdiaphragmatic  region  following  some  rec- 
ognized causative  condition.  The  history  of  chills  with  recurrent  fever  and 
sweats  is  rather  indicative  of  abscess  of  the  liver;  but  in  abscess  of  the  liver  there 
is  usually  pain  in  the  shoulder-blade  of  the  right  side,  and  this  is  rarely  encoun- 
tered in  subphrenic  abscess.  The  x-xsiys  show  that  the  diaphragm  is  elevated 
on  the  side  of  the  lesion.  The  proof  of  the  diagnosis  is  not,  however,  obtained 
until  an  exploratory  incision  has  been  made  and  the  purulent  matter  has  been 
found.  Empyema  and  subphrenic  abscess  resemble  each  other.  In  empyema 
the  upper  limit  of  the  fluid  is  concave;  in  subphrenic  abscess  it  is  convex.  In 
empyema  the  flow  of  pus  through  an  aspirating-needle  will  be  most  marked 
during  expiration;  in  abscess,  during  inspiration.  The  same  is  true  of  the 
rush  of  gas.  In  empyema  the  needle  does  not  oscillate;  in  abscess  it  does.^ 
If  an  abscess  contains  gas,  percussion  elicits  a  tympanitic  note  over  a  part  of 
the  cavity,  and  there  is  an  alteration  in  the  area  of  tympany  with  an  alteration 
in  the  position  of  the  patient.  An  abscess  of  the  liver  almost  never  contains  gas 
and  decidedly  changes  the  outlines  of  the  organ.-  Empyema  may  follow  sub- 
phrenic abscess. 

Treatment. — Incision  and  drainage.     The  incision  is  made  in  the  lumbar 

^  Wharton  and  Curtis,  "Practice  of  Surgery." 

2  In  a  case  of  abscess  of  the  liver  secondary  to  appendicitis  operated  upon  in  the  JefiFerson 
Hospital  the  abscess  did  contain  gas  produced  by  gas-forming  bacteria. 

74 


ii'jo  Diseases  and  Injuries  of  the  Abdomen 

region  if  the  abscess  points  there.  In  some  cases  it  is  made  through  the  ab- 
dominal wall  (epigastric  region,  iliac  region,  hypochondrium).  In  other  cases 
the  chest  wall  is  incised,  the  ninth  or  tenth  rib  is  resected,  and  the  abscess  is 
opened  below  the  pleura  or  the  pleura  is  opened,  the  parietal  and  diaphragmatic 
layers  are  sutured  together,  if  possible,  and  the  diaphragm  is  incised.  If  ap- 
pendicitis has  been  the  cause,  be  sure  the  appendicitis  is  well;  and  if  it  has  not 
been,  open  the  appendix  region  and  drain  freely  (Elsberg).  If  it  be  necessary 
to  open  the  pleural  sac,  first  try  to  stitch  the  parietal  to  the  diaphragmatic 
layer  of  the  pleura,  or,  if  this  be  impossible,  protect  the  cavity  with  iodoform 
gauze  to  prevent  infection. 

The  Liver,  Gall-bladder,  and  Bile-ducts 

Rupture  and  Wounds  of  the  Liver. — Rupture  of  the  liver  is  due  to 
very  great  force,  and  is  usually  accompanied  by  injury  of  other  viscera.  It 
may  be  produced  by  a  blow,  by  a  fall,  or  by  the  end  of  a  broken  rib.  The 
superior  surface  or  margin  most  often  suffers.  It  is  a  very  fatal  accident.  Out 
of  543  reported  cases  over  •  one-half  died  of  hemorrhage  within  twenty-four 
hours  of  the  accident.^  At  least  80  per  cent,  will  die  if  not  operated  upon. 
Wilms^  collected  19  cases,  and  only  3  recovered  after  operation.  Eisendrath^ 
has  collected  37  cases  of  suture  of  the  liver  for  rupture  and  22  of  them  recovered 
(59.5  per  cent.).  The  first  operation  was  performed  by  Willette  in  1888.  Out 
of  Kraussine's  13  stab-wounds  of  the  liver  7  died  (Murphy,  in  "  Practical  Medi- 
cine Series,"  1910,  vol.  ii).  An  attempt  should  certainly  be  made  to  save  the 
patient  by  opening  the  abdomen  and  arresting  hemorrhage,  and  in  a  suspected 
case  an  exploratory  operation  should  be  performed.  A  wound  of  the  liver 
causes  violent  hemorrhage,  which  is  usually  rapidly  fatal.  Such  a  wound  is 
apt  to  divide  bile-ducts  and  allow  bile  to  escape  into  the  peritoneal  cavity,  and 
perhaps  externally.  Bile,  if  sterile,  will  do  little  harm  to  the  peritoneum,  but 
if  it  contains  bacteria  it  will  produce  diffuse  peritonitis.  Even  sterile  bile  is 
corrosive  and  may  cause  fibroplastic  peritonitis.  The  symptoms  of  a  rupture 
or  wound  of  the  liver  are  those  of  severe  intra-abdominal  hemorrhage,  with 
collapse,  accompanied  by  hepatic  tenderness  and  respiratory  embarrassment. 
Soon  after  the  injury  the  abdomen  is  soft  and  flat,  but  it  quickly  becomes 
rigid  and  ultimately  distended.  The  diagnosis  becomes  more  probable  when 
it  is  known  that  violence  was  applied  to  the  hepatic  region.  Usually  there 
is  abdominal  pain  and  often  pain  in  the  back.  Sugar  may  appear  in  the  urine. 
In  a  few  cases  after  several  days  jaundice  and  skin  itching  have  been  noted. 
The  area  of  liver  dulness  is  usully  increased.  Patients  do  not  always  die 
from  a  serious  traumatism  of  the  liver.  Some  recover  because  operation  has 
saved  them.  Some  few  recover  without  operation.  This  last  fact  is  proved 
by  reports  of  autopsies  in  which  scars  were  found  in  the  liver  parenchyma 
(Nussbaum).  The  fatality  which  usually  ensues  after  a  liver  injury  may  be  due 
to  hemorrhage  or  peritonitis.  If  a  surgeon  is  called  to  a  patient  suffering  from 
wound  of  the  liver,  he  must  open  the  abdomen  to  arrest  hemorrhage.  If  a 
penetrating  wound  is  suspected,  it  may  be  desirable  to  enlarge  the  wound  in 
the  abdominal  wall  layer  by  layer,  in  order  to  determine  if  the  liver  be 
wounded.  If  the  left  lobe  of  the  liver  be  wounded,  or  if  it  be  uncertain  which 
lobe  is  wounded,  the  incision  should  be  median.  If  the  right  lobe  be  wounded, 
a  curved  incision  is  made  along  the  line  of  the  costal  cartilages.  In  some  cases 
these  two  incisions  are  joined.'*  The  convex  surface  of  the  liver  can  be  reached 
by  Lannelongue's  plan.  Lannelongue  resects  the  eighth,  ninth,  tenth,  and 
eleventh  costal  cartilages  and  draws  the  ends  of  the  ribs  well  out.    It  can  also 

^  Mercade,  in  "Rev.  de  Chir.,"  Jan.  10,  1902. 

2  "  Deut.  med.  Woch.,"  Nos.  34  and  35,  1901. 

3  "Jour.  Am.  Med.  Assoc,"  Nov.  i,  1902. 

^  See  Schlatter,  "Beitrage  zur  klinischen  Chirurgie,"  Bd.  xv,  Heft  ii,  1896. 


Tumors  and  Cysts  of  the  Liver  1171 

be  reached  by  Langenbuch's  plan,  that  is,  by  cutting  the  coronary  ligament 
and  the  right  lateral  ligament.  This  allows  the  liver  to  be  pulled  well  up  into 
the  wound  in  the  belly  wall.  The  site  of  the  wound  can  be  discovered  if  the 
hepatic  vessels  are  grasped  between  the  thumb  and  a  finger  (the  finger  in  the 
foramen  of  Winslow  and  the  thumb  in  front,  on  the  gastrohepatic  omentum). 
This  completely  arrests  hemorrhage,  and  the  blood  that  has  gathered  may  be 
sponged  out  and  the  wound  sought  for  in  a  clear  field.  (See  Pringle,  of  Glas- 
gow, in  "Annals  of  Surgery,"  Oct.,  1908.)  When  the  wound  in  the  liver  is  dis- 
covered and  well  exposed,  deep  sutures  of  catgut  should  be  inserted  in  the 
liver  and  the  capsule  should  be  stitched  with  fine  silk  (Schlatter).  If  sutures 
fail  to  arrest  hemorrhage,  the  organ  should  be  sutured  to  the  belly  wall  and  the 
wound  in  the  liver  packed  with  iodoform  gauze.  It  is  useless  to  try  packing 
without  first  attaching  the  liver  to  the  abdominal  wall,  because  pressure  will 
simply  push  the  liver  away  and  will  not  arrest  the  bleeding.  The  cautery  is  a 
very  useful  means  of  arresting  bleeding.  It  should  be  avoided  if  jpossible  in  a 
large  wound,  because,  even  if  it  arrests  primary  hemorrhage,  secondary  hemor- 
rhage may  occur.  After  arresting  hemorrhage,  wash  out  the  abdomen  with 
hot  saline  fluid,  insert  drainage,  and  close  the  abdominal  wound.  In  a  case  of 
the  author's  in  the  Philadelphia  Hospital  the  liver  was  wounded  by  the  sharp 
ends  of  fractured  ribs.  The  abdomen  was  opened,  a  wound  was  found,  and 
bleeding  was  arrested  by  suturing  the  liver  to  the  belly  wall  and  packing  the 
wound.  The  patient  died,  and  necropsy  showed  another  wound  on  the  pos- 
terior portion  of  the  organ.  The  possibility  of  such  an  occurrence  should  not  be 
lost  sight  of. 

Tumors  and  Cysts  of  the  Liver. — The  liver  may  be  the  seat  of 
primary  carcinoma,  sarcoma,  endothelioma,  angioma,  lymphangioma,  ade- 
noma, fibroma,  myxoma,  or  lipoma.  Many  tumors  called  adenomata  are 
really  adenocarcinomata.  Secondary  malignant  growths  are  far  more  com- 
mon than  primary  neoplasms — in  fact,  96  per  cent,  of  liver  tumors  are  sec- 
ondary. Primary  cancer  of  the  liver  is  found  once  in  every  2000  autopsies 
(Eggel).  The  commonest  variety  is  nodular,  but  the  diffuse  form,  known 
as  cancerous  cirrhosis,  may  occur.  The  nodular  form  is  most  often  encountered 
in  the  right  lobe,  and  it  has  been  found  in  persons  under  the  age  of  twenty. 
Metastases  occur  early.  "  There  is  always  more  or  less  co-existing  cirrhosis  of 
the  liver"  (Leonard  Freeman,  in  "Trans.  Am.  Surg.  Assoc,"  1904).  It  takes 
origin  from  the  hepatic  cells.  The  frequency  of  cancer  of  the  liver  secondary 
to  cancer  of  the  stomach  has  already  been  alluded  to.  The  commonest 
primary  tumor  of  the  liver  is  cavernous  hemangioma.  It  is  especially  apt 
to  take  origin  in  the  atrophying  liver  of  an  elderly  individual.  Primary 
sarcoma  may  arise  at  any  age  and  may  even  be  congenital.  The  growth  is 
rapid  and  emaciation  is  soon  noted.  The  liver  enlarges,  often  greatly.  Jaun- 
dice and  ascites  are  rather  rare.  The  patient  soon  becomes  very  weak.  There 
is  always  pain.  As  Knott  ("Surg.,  Gynec,  and  Obstet,"  Sept.,  1908)  points 
out,  the  condition  may  simulate  abscess,  and  if  it  arises  in  a  middle-aged  or 
elderly  person  can  scarcely  be  differentiated  from  carcinoma. 

Knott  ("Surg.,  Gynec,  and  Obstet.,"  Sept.,  1908)  has  collected  59  cases 
of  primary  sarcoma  from  literature,  and  adds  14  reported  by  personal  com- 
munications and  I  of  his  own,  74  in  all. 

He  shows  that  28  cases  have  been  operated  upon.  In  9  the  operation  was 
exploratory  and  no  attempt  was  made  to  remove  the  growth.  In  19  the 
growth  was  extirpated,  with  10  recoveries  and  9  deaths.  One  of  these  patients 
was  well  after  nineteen  months,  i  after  two  years,  i  after  seven  months.  Op- 
eration is  indicated  for  a  circumscribed  growth. 

Among  the  cysts  occurring  in  the  liver  are  blood  cysts,  congenital  cysts, 
bile  cysts,  and  hydatid  cysts.  Terrier  and  Auvray  in  1901  collected  52  opera- 
tions for  hepatic  tumors. 


1 1 72  Diseases  and  Injuries  of  the  Abdomen 

Angiomata  have  been  removed  successfully  by  hepatotomy,  a  cautery- 
knife  at  a  red  heat  being  used  to  cut  through  the  normal  liver  tissue  around  the 
base  of  the  tumor,  the  large  vessels  having  been  tied  with  catgut.  Enucleation 
is  not  feasible  because  of  excessive  hemorrhage.  If  a  tumor  be  pedunculated, 
the  base  may  be  encircled  by  an  elastic  ligature  held  in  place  by  a  steel  needle, 
and  five  or  six  days  later  the  tumor  may  be  cut  across  by  the  cautery.^  I 
assisted  Prof.  W.  W.  Keen  in  such  an  operation. 

Carcinoma  of  the  liver  has  been  extirpated,  but  it  is  seldom  that  a  growth 
is  recognized  early  enough  and  is  found  to  be  sufficiently  limited  to  justify 
such  a  procedure.  Operation  is  proper  only  when  there  is  a  limited  nodule  of 
primary  cancer.  In  1901  Terrier  and  Auvray  collected  9  operations  for  pri- 
mary cancer.  In  most  cases  there  has  been  rapid  recurrence  or  secondary 
growth,  but  Schrader's  case  was  well  at  the  end  of  seven  years  and  Leonard 
Freeman's  at  the  end  of  sixteen  months.  (For  operative  methods,  see  Leonard 
Freeman,  iii  "Trans.  Am.  Surg.  Assoc,"  1904.)  Hunbald  has  collected  96 
cases  of  resection  of  the  liver,  with  a  mortality  rate  of  26  per  cent.  Probably 
the  best  method  of  arresting  hemorrhage  is  the  use  of  suture  ligatures  of  doubled 
catgut  passed  by  round,  blunt  needles,  as  advised  by  Mikulicz. 

Hydatid  cysts  of  the  liver  may  be  of  small  size  and  productive  of  no 
signs  or  symptoms;  or  may  be  of  large  size  and  productive  of  the  signs  of  tumor. 
In  the  epigastrium  the  mass  may  be  prominent  and  fluctuate.  In  cyst  of  the 
right  lobe  the  dulness  is  found  in  the  axillary  line  and  the  growth  encroaches  on 
the  pleura.  In  a  large  cyst  fluctuation  and  hydatid  fremitus  may  exist.  Hy- 
datid fremitus  is  a  vibration  imparted  to  the  palpating  fingers  of  one  hand  when 
the  fingers  of  the  other  hand  knock  upon  the  cyst.  There  may  be  no  discomfort 
produced  by  even  a  large  cyst,  but,  as  a  rule,  the  patient  suffers  from  a  dragging 
sensation  in  the  epigastrium  and  pressure  symptoms.  Suppuration  in  the  cyst 
produces  the  symptoms  of  abscess  of  the  liver  and  septicemia.  Rupture  of  the 
cyst  produces  shock  and  even  death.  Rupture  may  take  place  into  the  pleural 
sac,  the  lung,  or  the  peritoneal  cavity.  If  the  shock  is  recovered  from,  inflam- 
mation arises,  the  area  of  which  depends  upon  the  structures  damaged.  The 
escape  of  even  a  small  quantity  of  hydatid  fluid  into  the  peritoneal  cavity 
produces  urticaria  {hydatid  toxemia).  Aspiration  for  diagnostic  purposes  is 
not  advisable. 

Treatment. — ^Exploratory  incision  may  be  necessary  to  confirm  the  diag- 
nosis, and  the  operation  is  completed  at  this  time.  After  exposing  the  cyst 
it  is  packed  around  with  gauze  and  a  trocar  is  introduced.  If  there  be  a  con- 
siderable thickness  of  liver  tissue  over  the  cyst,  incise  the  liver  by  the  cautery 
knife.  When  the  fluid  is  evacuated  the  sac  is  incised  and  is  drawn  partly 
through  the  wound  in  the  abdominal  wall,  and  is  attached  to  the  wound  mar- 
gins {marsupialization) .  The  endocyst  can  then  be  removed  by  the  hand  or 
by  irrigation.     A  large  drainage-tube  is  introduced. 

Syphilis  of  the  liver  is  a  very  able  actor  and  often  impersonates  with 
surprising  accuracy  various  other  diseases.  It  may  be  congenital  or  acquired. 
The  congenital  condition  may  cause  cirrhosis,  miliary  gummata,  spots  of  fibrosis, 
and  occasionally  large  gummata.  Sometimes  the  liver  manifestations  of  con- 
genital or  hereditary  syphilis  may  be  postponed  for  years  (ten,  fifteen,  or  more) 
and  then  appear  as  ordinary  tertiary  lesions.  Acquired  syphilis  ma}''  cause 
hepatic  disease  in  the  secondary  and  in  the  tertiary  stage. 

In  secondary  syphilis  there  may  be  temporary  jaundice  due,  Rolleston 
thinks,  to  catarrh  of  the  smaller  bile-ducts  within  the  liver.  It  is  possible, 
according  to  Rolleston,  for  temporary  pericellular  cirrhosis  to  exist  in  the 
secondary  stage. 

The  tertiary  lesions  are  the  most  common  and  important.  Among  these 
lesions  are  gummata  and  scars.     They  are  most  common  ten  years  or  more 

^Russell  S.  Fowler,  on  "Tumors  of  the  Liver,"  "  Brooklyn  Med.  Jour.,"  Dec,  1900. 


Traumatic  Abscess  ii73 

after  the  primary  sore.  Tertiary  syphilis  may  appear  as  irregular  patches  of 
inflammation  in  Glisson's  capsule  (a  condition  apt  to  eventuate  in  hepatic 
sclerosis) — as  a  large  solitary  gumma  (only  one-eighth  of  cases  of  gumma 
present  a  solitary  lesion) — or  as  multiple  and  usually  small  gummata.  Gum- 
ma ta  are  most  usual  upon  the  anterior  surface  of  the  right  lobe.  A  gumma 
adjacent  to  the  common  duct  or  the  hepatic  duct  causes  jaundice.  A  large 
gumma  is  often  mistaken  for  cancer  of  the  liver,  and  it  is  a  curious  fact  that  in 
many  cases  of  hepatic  gummata  we  are  unable  to  obtain  any  history  of  syphilis. 
Syphilis  may  be  mistaken  for  ordinary  cirrhosis,  but  in  the  latter  disease  the 
general  nutrition  is  more  impaired  than  in  the  former,  and  vomiting  of  blood, 
dilated  cutaneous  veins,  ascites,  and  indigestion  are  far  more  apt  to  be  present 
(Archibald  MacLaren,  in  "Annals  of  Surgery,"  August,  1908).  The  victims  of 
gumma  are  apt  sooner  or  later  to  develop  jaundice,  colicky  pain,  moderate  fever, 
and  palpable  enlargement  of  the  liver.  The  spleen  may  enlarge.  The  fever  may 
be  continuous  or  may  occur  episodically.  In  some  cases  it  continues  for  weeks. 
It  may  be  intermittent,  preceded  by  a  chill  and  followed  by  a  sweat.  Such  a 
fever  may  be  due  to  Spirochasta  cholangitis.  ]  t  may  be  due  to  absorption  of 
toxic  material  from  a  breaking-down  gumma.  The  Wassermann  reaction  is  a 
valuable  aid  to  diagnosis.  A  gumma  sometimes  undergoes  secondary  infection 
and  an  abscess  forms.  A  gumma  may  rupture  into  the  pleural  or  peritoneal 
cavity  or  some  viscus.  . 

Treatment.— Mercury  and  iodid  will  cure  most  cases.  If  these  drugs  fail, 
it  is  proper  to  remove  the  tumor,  if  solitary,  by  resecting  the  involved  area  of  the 
liver.  MacLaren  (Ibid.)  collected  9  cases  of  resection  for  solitary  gumma 
and  added  i  of  his  own.  There  were  2  deaths  in  this  series.  MacLaren's  10 
cases  added  to  Keen's  12  ("Annals  of  Surgery,"  Sept.,  1899)  and  Cumston's  15 
(quoted  by  RoUeston  in  his  work  on  "Diseases  of  the  Liver")  make  37  cases. 

If  an  area  is  opened  for  exploration  and  a  solitary  gumma  is  discovered, 
the  abdomen  should  be  closed  and  specific  treatment  be  tried  before  resorting 
to  resection,  that  is,  if  specific  treatment  has  not  been  tried  before. 

Abscess  of  the  Liver. — An  abscess  of  the  liver  may  be  produced  by  bacteria, 
especially  staphylococci  and  streptococci.  These  organisms  reach  the  liver 
by  the  general  circulation  or,  what  is  more  frequent,  are  taken  up  from  the 
intestinal  tract  and  reach  the  liver  by  the  portal  circulation,  or  pass  to  the 
liver  by  the  lymphatics.  Appendicitis  with  lymphatic  infection  may  result  in 
hepatic  abscess.  A  subphrenic  abscess  may  break  into  the  liver  and  thus  induce 
a  liver  abscess.  Liver  abscess  may  directly  result  from  peritoneal  infection. 
The  fact  that  abscess  of  the  liver  is,  in  hot  countries,  frequently  preceded  by 
amebic  dysentery  led  to  the  presumption  that  the  Amoeba  coli  produces  the 
abscess,  and  in  a  large  majority  of  cases  of  tropical  abscess  amebae  exist  in  the 
pus  or  at  least  on  the  abscess  walls.  Habitual  intemperance  and  constant  over- 
eating predispose  to  abscess  of  the  liver.  The  disease  may  follow  traumatism, 
dysentery,  diarrhea,  cholangitis,  suppuration  of  a  hydatid  cyst,  gall-stones, 
t\Tphoid  fever,  appendicitis,  and  a  chill  to  the  surface  of  the  body.^  Abscess  of 
the  liver  may  be  metastatic,  and  such  abscesses  are  multiple.  It  may  be  caused 
by  foreign  bodies  and  parasites.  A  tropical  abscess  is  an  abscess  of  the  liver 
in  an  inhabitant  of  a  hot  country. 

There  are  three  forms  of  abscess  of  the  liver:  traumatic,  pyemic,  and 
tropical. 

Traumatic  abscess  may  result  from  a  wound  of  the  liver  or  may  follow 
a  contusion  without  a  break  of  the  skin.  In  the  latter  case  bacteria  from 
the  blood  are  arrested  in  the  injured  liver  tissue.  Such  an  abscess  is 
usually  solitary.  Streptococci,  staphylococci,  or  colon  bacilli  may  be  foimd. 
Traumatic  abscesses  are  more  common  in  children  than  in  adults,  are 
situated  superficially,  and  the  symptoms  are  usually  acute.  Recovery  is 
1  G.  B.  Johnston,  "Annals  of  Surgery,"  October,  1897. 


1 1 74  Diseases  and  Injuries  of  the  Abdomen 

usually  rapid  and  permanent  after  incision  unless  the  causal  injury  brings 
danger  or  fatality. 

Pyemic  Abscess. — Multiple  abscesses  exist,  but  they  may  fuse  into  one. 
It  is  frequently  due  to  suppurative  inflammation  of  radicles  of  the  portal  vein, 
infected  emboli  forming  and  reaching  the  liver;  it  may  follow  ulceration  of  the 
intestine,  hemorrhoids,  or  appendicitis. 

Occasionally  abscess  may  arise  from  the  extension  of  an  infective  proc- 
ess, such  as  pylephlebitis.  It  may  arise  from  cholecystitis  or  cholelithiasis 
with  obstruction.  In  these  latter  cases  both  the  Bacillus  typhosus  and  the 
pneumobacillus  of  Friedlander  have  been  found  as  the  direct  bacterial  agent. 
Colon  bacilli  are  a  common  cause.  Abscess  of  the  liver  following  appendicitis 
may  be  due  to  portal  infection  {portal  pyemia)  or  to  lymphatic  infection.  It 
is  usually  multiple,  but  in  a  case  of  mine  in  the  Jefferson  Hospital  it  was  soli- 
tary, several  cavities  having  probably  joined  to  form  one.  Echinococcus  cyst 
of  the  liver  may  suppurate  and  form  abscess.  I  operated  unsuccessfully  on 
I  such  case  which  was  brought  to  me  by  Dr.  Hultsizer.  The  round-worm, 
the  liver  fluke,  and  the  Balantidium  coU  sometimes  cause  abscess,  and,  finally, 
it  has  been  observed  in  measles,  epidemic  influenza,  and  perforating  ulcer  of 
the  stomach.^ 

Tropical  abscess  of  the  liver  is  rare  in  temperate  climates,  but  is  extremely 
common  in  the  tropics.  Its  usual  antecedent  in  either  climate  is  dysentery. 
The  reason  for  the  great  frequency  of  the  disease  in  tropical  regions  is  that  the 
chief  causative  agent,  the  Amoeba  coli,  is  found  widely  distributed  in  hot  coun- 
tries; and  that  passive  congestion  of  the  liver  is  a  common  condition  among  the 
white  inhabitants  of  tropical  regions.  It  has  been  pointed  out  that  tropical 
abscess  is  particularly  common  among  white  persons  who  abuse  alcohol,  the 
condition  of  passive  congestion  of  the  liver  making  that  organ  a  nutritious  soil 
for  a  fruitful  infection.  Predisposing  factors  are  protracted  malaria  and  chilling 
of  the  surface  of  the  body. 

Major  Charles  F.  Kieffer,  U.  S.  A.,^  in  a  lecture  on  tropical  abscess  of  the 
liver,  stated  that  in  his  own  experience  he  found,  in  a  series  of  t^t,  abscess 
cases  in  soldiers,  that  dysentery  was  present  in  every  case;  and  that  in  a  second 
series  of  25  cases  in  natives  and  civilians  he  elicited  a  history  of  dysentery  in 
22  cases.  Some  observers — notably  McLeod — -state  that  dysentery  is  the 
antecedent  factor  in  97.5  per  cent,  of  cases.  Kiefifer  points  out  that  in  all  the 
figures  allowance  must  be  made  for  a  number  of  latent  dysenteries,  as  well  as  for 
cases  in  which  no  effort  has  been  made  to  elicit  a  history  of  dysentery  one  or  two 
years  previously.  It  is  also  to  be  remembered  that  a  case  of  amebic  infection 
of  the  colon  may  have  been  so  mild  in  the  beginning  as  to  have  caused  but  a 
transient  diarrhea,  which  the  patient  may  have  forgotten.  Amebae  occasionally 
exist  in  the  colon  without  producing  any  dysenteric  evidences.  From  20  to 
25  per  cent,  of  severe  amebic  dysenteries  lead  to  the  formation  of  abscess  of  the 
liver,  and  at  least  85  per  cent,  of  all  tropical  abscesses  are  due  to  infection  with 
the  Amoeba  coli.  Occasionally,  an  abscess  begins  very  soon  after  the  dysentery; 
but,  as  a  rule,  it  does  not  form  for  some  time  afterward — weeks,  months,  a 
year,  or  even  two  years. 

When  an  abscess  of  this  sort  forms  in  the  liver  that  organ  becomes  en- 
larged and  congested,  and  an  area  or  areas  of  necrosis  exist  in  it.  But  one 
abscess  may  be  present;  there  may  be  an  abscess  with  satellite  abscesses  about 
it;  several  abscesses  may  coalesce,  making  a  very  large  cavity;  or  genuine 
multiple  abscesses  may  exist.  In  about  70  per  cent,  of  cases,  however,  the 
tropical  abscess  is  solitary. 

The  right  lobe  of  the  liver  is  the  region  most  frequently   involved.    The 

1  Major  Charles  F.  Kieffer,  U.  S.  A.,  in  "Phila.  Med.  Jour.,"  Feb.  21,  1903. 

2  Ibid. 


Tropical  Abscess  of  the  Liver  .  1175 

abscess  is  found  in  the  right  lobe  in  at  least  90  per  cent,  of  cases,  and  it  is  more 
often  toward  the  convexity  of  the  Hver  than  toward  the  base. 

An  abscessof  the  liver  of  this  type  contains  characteristicand  peculiar  material ; 
it  is  different  from  the  pus  found  in  other  abscesses,  and,  in  fact,  is  not  pus, 
but  is  necrotic  liver  substance.  Liver  abscesses  due  to  pyogenic ,  organisms 
contain  true  pus;  a  tropical  abscess,  free  from  pyogenic  infection,  does  not. 
Ordinary  pus  contains  hordes  of  leukocytes,  but  the  fluid  of  a  tropical  abscess 
contains  very  few.  Riesman  is  of  the  opinion  that  the  reason  there  are  so 
few  leukocytes  is  that  the  abscess  contains  a  substance  that,  by  chemotaxis, 
repels  leukocytes.  The  matter  is  of  a  reddish-brown  color,  is  thick,  and  fre- 
quently contains  some  blood.  Occasionally  it  is  offensive  in  odor.  Micro- 
scopic examination  shows  it  to  contain  portions  of  necrotic  liver  tissue,  some 
liver-cells  that  are  not  destroyed,  elastic  tissue,  blood,  some  few  leukocytes,  and 
amebce.  On  bacterial  examination  it  may  be  found  that  the  fluid  is  infected, 
containing  staphylococci,  streptococci,  or  pyogenic  bacteria.  In  about  20 
per  cent,  of  the  cases  the  matter  contains  neither  bacteria  nor  the  Amoeba  coli. 
In  over  60  per  cent,  of  the  cases  the  matter  of  a  recently  opened  abscess  is  free 
from  bacteria.  In  cases  in  which  the  fluid  is  sterile  it  is  possible  that  bacteria 
were  originally  present,  but  have  died.  The  reason  for  the  death  of  micro- 
organisms in  this  matter  is  in  great  doubt,  because,  as  Riesman  points  out, 
bile  cannot  kill  them  as  organisms  may  be  grown  in  this  fluid.  In  the  large 
majority  of  cases  amebas  are  readily  demonstrable  in  the  matter;  but  in  some 
few  cases  it  is  necessary  to  rub  a  piece  of  gauze  on  an  abscess  wall  in  order  to 
obtain  amebce,  and  in  others  they  can  be  demonstrated  only  after  the  abscess 
has  been  discharging  for  some  days.  The  causative  role  of  the  amebse  has 
been  doubted  by  some  observers,  but  most  surgeons  who  have  had  experience 
in  the  tropics  believe  it  to  be  a  fact. 

The  symptoms  may  be  very  definite  and  positive;  they  are  frequently  mis- 
leading and  obscure;  and  in  some  cases  nothing  whatever  directs  the  surgeon's 
attention  to  the  liver  until  the  patient  passes  a  huge  quantity  of  puriform 
fluid  at  stool  or  coughs  up  an  enormous  amount  of  the  characteristic  material. 
If  rupture  takes  place,  death  usually  ensues.  As  a  rule,  the  symptoms  of  a 
tropical  abscess  are  positive  and  marked. 

Kieffer  sums  up  the  chief  symptoms  under  four  heads:  fever,  sepsis,  en- 
largement of  the  liver,  and  pain.  In  about  three-fourths  of  the  patients  fever 
and  sweats  are  definitely  present;  in  about  one-fourth  they  are  absent  or  are 
very  trivial.  The  type  of  fever  met  with  is  what  has  been  previously  spoken 
of  as  hectic.  Usually  there  is  an  evening  rise,  preceded  by  a  chilly  sensa- 
tion or  by  a  chill ;  and  as  the  temperature  begins  to  fall,  toward  morning,  there 
is  a  profuse  sweat.  It  is  seldom  that  there  is  any  violent  chill,  though  there 
are  frequently  slight  ones.  The  sweats  are  extremely  exhausting.  They 
may  occur  either  during  the  night  or  in  the  daytime,  according  to  the  time 
in  which  the  patient  sleeps.  Kieffer  says  that  they  should  not  be  called 
night-sweats,  but  rather  sleeping  sweats.  In  very  chronic  cases  there  may 
be  no  pyrexia.  As  a  rule,  the  temperature  resembles  that  of  malaria,  but 
it  is  not  controlled  by  quinin  and  the  blood  is  free  from  malarial  parasites. 
Sometimes  the  temperature  suggests  typhoid,  with  the  exception  that  from 
time  to  time  there  are  episodes  of  subnormal  temperature.  The  patient  loses 
flesh  and  strength,  the  appetite  fails  completely,  and  the  skin  becomes  pasty  or 
dirty  yellow. 

The  entire  liver  is  usually  enlarged,  and  the  enlargement  may  be  detected 
by  percussion,  and  in  some  cases  a  hard,  smooth  area  can  be  palpated.  Some- 
times the  liver  reaches  as  high  as  the  third  rib  anteriorly,  or  to  the  spine  of 
the  scapula  behind,  and  it  may  extend  downward  to  the  anterior  superior 
spine  of  the  ilium.  It  is  rarely,  however,  that  the  enlargement  takes  place 
in  a  downward  direction;  it  is  usually  upward.     In  many  cases  the  right  side 


1 1 76  .  Diseases  and  Injuries  of  the  Abdomen 

of  the  chest  appears  to  be  rather  full,  and  sometimes  there  is  actual  obliteration 
of  several  intercostal  spaces.  If  an  abscess  becomes  adherent  to  the  surface, 
there  may  be  skin  edema  and  dusky  discoloration.  In  rare  instances,  if  a 
very  large  abscess  comes  near  the  surface,  fluctuation  may  be  obtained.  By 
auscultation  it  is  frequently  possible  to  obtain  friction  sounds  in  the  region  of 
the  diaphragm  and  the  superior  surface  of  the  liver. 

The  liver  becomes  tender.  This  tenderness  may  be  developed  particu- 
larly by  pressure  upon  the  lower  edge  of  the  organ,  and  sometimes  by  pressure 
through  the  intercostal  spaces.  There  is  not  always,  but,  as  a  rule,  there 
is  pain.  The  pain  may  be  dull  and  heavy,  but  as  the  abscess  nears  the  surface 
of  the  organ  the  pain  becomes  sharp  and  lancinating.  The  pain  is  persistent 
and  is  not  strictly  localized,  but  radiates  to  the  back,  the  right  shoulder-blade, 
and  the  point  of  the  shoulder.  Pain  is  increased  by  pressure,  coughing,  sudden 
or  violent  movement,  and  is  sometimes  felt  in  the  esophagus  when  food  is 
swallowed.  When  the  upper  surface  of  the  liver  is  involved  the  patient  breathes 
as  if  he  had  pleurisy;  and  pleurisy  frequently  does  develop,  with  marked  effusion. 

Paralysis  of  the  diaphragm  rarely  occurs  in  abscess  of  the  liver,  and  the 
respiration  is  not  much  affected  unless  the  diaphragm  of  that  side  and  the 
pleura  become  involved,  though  the  patient  frequently  has  a  dry  cough.  A 
severe  cough  suggests  that  the  abscess  is  on  the  convex  surface  of  the  organ. 
Such  a  cough  is  aggravated  by  recumbency.  Kieffer  points  out  that  the  patient 
lies  on  his  right  side,  and  almost  on  the  right  front  aspect,  the  shoulder  being 
drawn  down  and  the  right  knee  drawn  up  to  relieve  the  tension  of  the  abdominal 
muscles.  In  about  one-fourth  of  the  cases  of  tropical  abscess  of  the  Hver  jaun- 
dice occurs.  It  is  most  apt  to  occur  when  the  abscess  is  on  the  inferior  surface. 
Jaundice  does  not  occur  unless  the  common  or  hepatic  ducts  are  compressed  or 
cholangitis  exists.  The  leukocyte  count  is  of  no  particular  help  in  the  diagnosis, 
as  there  may  or  may  not  be  leukocytosis.  The  urine  is  usually  scanty.  Diar- 
rhea is  a  common  accompaniment,  but  constipation  may  exist,  and  nausea  and 
vomiting  are  by  no  means  unusual. 

Diagnosis. — With  an  antecedent  history  of  dysentery  the  diagnosis  is 
easy.  Without  such  a  history,  it  is  always  difficult  and  may  be  impossible. 
In  the  tropics  exploratory  aspiration  is  freely  used,  but  exploratory  incision, 
if  necessary,  with  subsequent  exploratory  aspiration  of  the  liver  after  the  organ 
is  exposed,  would  seem  to  be  safer  and  more  certain. 

Symptoms  of  Traumatic  Abscess. — Similar  to  those  of  tropical  abscess. 

Symptoms  of  Pyemic  Abscess. — The  liver  is  enlarged  and  tender,  there 
is  slight  jaundice,  and  the  general  symptoms  of  pyemia  are  present. 

Treatment  of  Tropical  Abscess. — If  in  doubt  as  to  the  diagnosis,  make  an 
exploratory  incision,  exposing  enough  liver  surface  to  permit  of  exploration  by 
finger  and  needle.  If  pus  is  not  found,  pack  the  wound  with  gauze  to  keep 
it  open,  and  when  adhesions  form  explore  again.  The  operation  for  abscess  is 
incision  and  drainage.  The  abdominal  route  is  used  when  the  liver  bulges  front 
or  when  it  extends  well  below  the  costal  margin  (McGill,  in  ''Surg.,  Gynec, 
and  Obstet.,  Nov.  191 1).  If  the  abscess  is  adherent  to  the  parietal  peritoneum 
and  is  not  covered  by  liver  substance  open  it  at  once.  If  it  is  not  adherent,  or  is 
covered  by  a  considerable  layer  of  Hver  substance,  make  a  ring  of  gauze  about 
the  periphery  of  the  abscess  cavity.  The  abscess  may  be  opened  at  once  within 
the  ring,  the  gauze  being  a  coffer-dam  to  protect  the  peritoneal  cavity.  It  is 
safer  to  catch  the  gauze  to  the  parietal  peritoneum  with  two  or  three  fine  catgut 
sutures  and  wait  for  forty-eight  hours  before  opening.  This  is  an  easier  plan 
and  just  as  safe  as  attempting  to  stitch  the  liver  to  the  visceral  peritoneum  or 
to  the  parietal  peritoneum.  The  operation  consists  in  evacuating  the  pus  by 
a  trocar  and  cannula,  incising  the  abscess,  stitching  its  edges  to  the  edges  of 
the  abdominal  wound,  irrigating,  and  inserting  a  drainage-tube.  If  the  abscess 
be  covered  by  a  layer  of  liver  tissue,  after  locating  it  by  an  aspirating  cannula, 


Signs  and  Symptoms  of  Hepatoptosis     ■  ii77 

open  into  it  by  means  of  a  cautery  knife  and  arrest  hemorrhage  by  packing.  When 
the  parietal  and  visceral  layers  of  peritoneum  are  adherent,  packing  will  arrest 
bleeding;  if  they  are  not  adherent,  packing  will  only  push  away  the  movable 
liver  (John  O'Connor).  The  transpleural  route  gives  the  best  access  to  the  right 
lobe,  which  is  far  and  away  the  commonest  region  for  liver  abscess.  The 
operation  devised  by  McGill  (Ibid.)  may  be  at  first  exploratory;  it  avoids 
pneumothorax  and  empyema.     It  is  performed  as  follows: 

The  ninth  and  tenth  ribs  are  exposed  by  a  curvilinear  incision;  the  flap 
(which  does  not  include  the  fascia  of  the  muscles)  is  raised;  4  inches  of  the 
tenth  rib  are  resected;  the  gutter  left  by  the  removal  of  the  bone  is  closed  by 
catgut  suture.  This  gutter  can  be  pushed  against  the  diaphragm  by  two  fingers 
of  an  assistant,  and  while  the  pressure  is  being  made  an  incision  is  carried  along 
near  to  the  upper  border  of  the  eleventh  rib.  The  incision  goes  directly  into  the 
peritoneal  cavity  through  the  layers  of  chest  wall  and  through  the  diaphragm, 
but,  as  the  parietal  pleura  is  being  pressed  directly  against  the  diaphragmatic 
pleura,  pneumothorax  does  not  occur.  The  edges  of  the  chest  wall  and  dia- 
phragm are  clamped  together  and  sutured,  the  pleural  cavity  being  thus  closed. 
The  liver  is  exposed  and  may  be  needled  for  exploration,  or  an  abscess  can  be 
drained  at  once  or  after  causing  adhesions  by  gauze,  as  previously  described. 

Rogers  and  Wilson  (''Brit.  Med.  Jour.,"  June  16,  1906)  advocate  aspiration 
and  examination  of  the  pus.  If  amebae  only  are  present,  they  inject  a  solution 
of  quinin,  a  material  quickly  fatal  to  amebse.  The  dose  is  30  gr.  of  bihydro- 
chlorate  of  quinin  in  a  sterile  solution.  If  the  abscess  holds  less  than  10  oz. 
of  matter  the  quinin  is  given  in  2  oz.  of  fluid;  if  it  holds  more,  in  4  oz.  of  fluid. 
The  authors  report  2  cases  cured  by  this  method. 

Treatment  of  Traumatic  Abscess. — Same  as  for  tropical  abscess. 

Treatment  of  Pyemic  Abscess. — Surgery  is  usually  futile,  because  multiple 
abscesses  exist,  but  an  operation  should  be  performed  in  the  hope  that  it  may 
do  good.  In  a  case  in  the  Jefferson  Hospital  in  which  abscess  of  the  liver 
followed  appendicitis  the  patient  recovered  after  operation. 

Hepatoptosis  (Floating  or  Movable  Liver). — Hepatoptosis  may  be 
congenital,  but  is  usually  acquired.  In  a  congenital  case  certain  ligamen- 
tous supports  of  the  liver  are  absent.  In  the  following  discussion  the  acquired 
form  is  the  variety  referred  to.  This  condition  is  rare.  Ninety-eight  cases 
have  been  reported.^  It  is  a  form  of  splanchnoptosis  and  is  due  to  relaxation 
of  the  abdominal  wall  and  stretching  of  the  supports  of  the  liver.  It  may 
occur  alone,  but  it  is  more  often  a  part  of  a  general  abdominal  relaxation  or 
of  Glenard's  disease,  and  often  a  kidney  is  movable,  or  uterine  displacement 
or  hernia  may  exist.  The  liver  may  descend  into  the  lower  abdomen,  may 
be  upside  down  (Demarquay),  may  rotate  on  its  transverse  axis  (Griffiths), 
the  anterior  surface  may  become  posterior,  or  the  organ  may  lie  with  the 
superior  surface  in  the  right  flank  and  the  inferior  surface  looking  to  the  left,^ 
may  be  movable,  or  may  be  anchored  by  adhesions.  It  is  most  common  in 
women.  The  liver  is  supported  by  ligaments  and  also  by  the  inferior  vena 
cava  (which  vessel  is  firmly  adherent  to  the  central  tendon  of  the  diaphragm — 
Faure),  by  the  abdominal  waU,  and  by  the  intestines  (Glenard).  The  cause 
of  the  condition  is  in  dispute.  It  can  result  from  relaxation  of  the  belly  wall, 
relaxation  of  the  ligaments,  enteroptosis,  great  enlargement  of  the  gall-bladder, 
increase  in  weight  of  the  liver,  atrophy  of  the  connective  tissue  between  the 
liver  and  diaphragm,  pregnancy,  the  growth  of  a  liver  tumor  and  tight  lacing. 
Either  a  strain,  cough,  or  the  dragging  of  an  adherent  tumor  may  be  the  exciting 
cause. 

Signs  and  Symptoms. — An  abdominal  mass  may  appear  suddenly  after  a 
blow  or  a  strain,  and  if  it  does  appear  suddenly  there  are  always  pain  in  the 

^  J.  H.  Carstens,  "Jour.  Am.  Med.  Assoc,"  May  17,  1902. 
-Terrier  and  Auvray,  "Rev.  de  Chir.,"  Aug.  and  Sept.,  1S97. 


iiyS  Diseases  and  Injuries  of  the  Abdomen 

hepatic  region,  nausea,  and  weakness.  When  the  condition  comes  on  gradu- 
ally there  may  be  no  symptoms  for  a  long  time,  but,  as  a  rule,  there  is  some 
pain  in  the  loin  which  becomes  worse  after  exercise  or  effort.  In  rare  cases 
jaundice  appears,  and  occasionally  there  is  ascites.  The  abdominal  walls 
are  relaxed  and  the  signs  of  splanchnoptosis  are  manifest.  When  the  patient 
stands,  a  transverse  furrow  of  skin  covers  the  lower  part  of  the  umbilicus 
(Gleiiard's  sign).  In  most  cases  the  shape,  the  movability,  and  the  absence 
of  the  liver  from  its  proper  position  are  diagnostic.  Even  when  the  organ  is 
dislocated  and  attached  in  its  new  situation,  it  is  missed  from  its  proper  abode, 
and  palpation  outlines  the  characteristic  shape.  When  the  patient  lies  down  the 
liver  usually  returns  to  place,  and  in  most  cases  it  can  be  restored  by  manipula- 
tion. In  some  cases,  however,  it  will  not  return  to  place  and  cannot  be  restored 
by  manipulation.  A  floating  liver  causes  a  recognizable  enlargement  in  the 
right  loin,  and  t*he  mass  usually  moves  on  respiration. 

Treatment.  —In  many  cases  the  patient  can  be  kept  comfortable  by  wearing 
an  abdominal  support,  and  can  be  distinctly  improved  by  the  application 
of  massage  and  electricity  to  the  abdominal  wall,  the  administration  of  tonics, 
and  a  course  of  forced  feeding.  If  these  means  fail  and  the  patient  suffers, 
an  operation  should  be  performed.  The  operation  of  hepatopexy  was  de- 
vised by  Marchant.  He  opens  the  abdomen  and  tries  to  restore  the  liver 
to  its  proper  position.  This  can  usually  be  accomphshed.  In  some  cases 
it  can  be  done  after  adhesions  have  been  separated.  In  other  cases  it  can 
be  only  partially  accomphshed.  After  the  liver  has  been  restored,  he  sutures 
it  by  means  of  catgut  or  silk  to  the  abdominal  wall  or  costal  cartilages,  the 
stitches  passing  through  the  hepatic  parenchyma  and  being  carried  through 
the  liver  by  means  of  a  round  and  blunt  needle.  The  sutures  attaching  the 
liver  to  the  belly  wall  are  tied  beneath  the  skin.  Marchant  scarified  the  dome 
of  the  liver  in  order  to  favor  adhesions.  Ramsay  rubs  the  upper  surface  of  the 
liver  with  gauze  to  promote  adhesion  and  transfixes  the  round  ligament  with  a 
suture  which  is  carried  around  the  cartilage  of  the  seventh  rib.  In  a 
severe  case  Depage  advises  us  to  associate  hepatopexy  with  an  excisionof  a 
portion  of  the  abdominal  wall  to  amend  relaxation  {laparectomy).  If,  in  operat- 
ing on  a  floating  liver,  it  is  found  impossible  to  get  the  liver  back  into  its 
norml  position,  fix  it  with  sutures  as  near  its  proper  abode  as  is  possible. 
Terrier  and  Auvray  report  ii  cases  of  hepatopexy.  One  case  died  and  8 
completely  recovered. 

Floating  Hepatic  Lobe  (Partial  Hepatoptosis). — This  condition 
is  not  uncommon  in  cases  of  chronic  disease  of  the  gall-bladder  and  is  not 
often  met  in  cholelithiasis.  It  is  beheved  that  it  can  be  caused  by  tight  lacing. 
A  tongue-Hke  projection  forms  upon  the  right  lobe  of  the  Hver  {Unguiforni  lobe, 
lacing  lobe).  It  can  be  palpated  below  the  costal  margin  and  the  dulness  of  the 
mass  on  percussion  is  continuous  with  liver  dulness.  A  linguiform  lobe  can 
usually  be  moved  laterally  and  forward  and  backward;  it  is  always  tender  and 
is  sometimes  the  seat  of  pain. 

Treatment. — When  this  condition  is  associated  with  gall-bladder  trouble, 
it  may  disappear,  or  at  least  cease  to  cause  pain,  when  the  gall-bladder^  is 
drained  by  cholecystostomy.  Langenbuch  has  successfully  removed  a  lin- 
guiform lobe. 

Cholecystitis  (Inflammation  of  the  Qall=bladder). — Inflammation 
of  the  gall-bladder  is  produced  by  infection.  Healthy  bile  is  sterile;  and 
when  bacteria  are  found  in  the  bile,  the  condition  is  one  of  disease.  Micro- 
organisms may  find  entrance  into  the  gall-bladder  by  way  of  the  blood,  the 
bile  becoming  infected  secondarily  to  the  infection  of  the  gall-bladder;  or 
they  may  enter  by  way  of  the  ducts,  from  the  intestine.  The  conditions  that 
follow  infection  depend  upon  the  characteristic  tendency  and  the  virulence 
of  the  infecting  germs.     A  trivial  infection  produces  mucous  catarrh;  a  more 


Bacteriology  of  Cholecystitis  1179 

active  infection  causes  suppuration,  and  possibly  ulceration;  a  very  violent  in- 
fection leads  to  gangrene. 

In  most  cases  of  cholecystitis  an  inflammatory  swelling  blocks  the  cystic 
duct,  and  obstructs  it  so  that  the  bile  stagnates  in  the  gall-bladder.  In  many 
cases  this  condition  lasts  but  a  short  time;  and  when  the  obstruction  is  relieved, 
bile  flows  down  the  duct.  Occasionally,  as  a  secondary  consequence,  cho- 
langitis, or  infection  of  the  hepatic  duct,  follows.^  Occasionally,  also,  the 
obstruction  of  the  duct  is  not  relieved,  and  a  quantity  of  clear,  thin  mucus  gathers 
in  the  gall-bladder  and  overdistends  it — the  condition  known  as  hydrops.  The 
gall-bladder  may  likewise  become  distended  with  pus,  constituting  an  em- 
pyema of  the  gall-bladder;  and  any  overdistended  gall-bladder  may  rupture. 
A  gall-bladder  may  distend  to  a  most  enormous  size.  Terrier  reported  a  case 
of  distended  gall-bladder  in  which  the  viscus  contained  42  pints  of  fluid.  F.  W. 
Collinson  ("Brit.  Med.  Jour.,"  May  29,  1909)  reports  the  case  of  a  woman 
thirty-one  years  of  age  who  was  tapped  twice  before  operation  and  at  each  tap- 
ping 25  pints  of  fluid  were  withdrawn.  At  the  operation  22  pints  were  obtained. 
Collinson's  case  arose  from  blocking  of  the  common  duct  as  a  result  of  trauma- 
tism, followed  by  kinking  of  the  cystic  duct  and  subsequent  opening  of  the  com- 
mon duct.  In  cases  of  very  chronic  inflammation  of  the  gall-bladder  this  struc- 
ture becomes  fibrous  and  contracts,  until  it  may  become  no  larger  than  the 
thumb,  in  which  condition  it  may  contain  a  very  small  amount  of  thickened 
bile.  In  some  inflammatory  conditions  due  to  infection  the  bile  mixes  with 
thickened  mucus,  and  micro-organisms  form  the  nucleus  upon  which  bile  salts 
are  deposited  to  form  gall-stones.  As  the  same  author  points  out,  cholelith- 
iasis may  result  from  cholecystitis,  and  may  cause  chronic  cholecystitis,  because 
the  stones  existing  in  a  gall-bladder  are  sources  of  irritation. 

Bacteriology  of  Cholecystitis. — It  has  been  proved  by  abundant  observa- 
tion that  the  fact  that  bile  contains  micro-organisms  is  no  evidence  that  the 
gall-bladder  is  inflamed;  but  that  when  the  gall-bladder  is  inflamed  micro- 
organisms are  demonstrable  in  the  bile.  We  know  that  the  bile  is  infected  dur- 
ing the  course  of  typhoid  fever,  and  that  it  is  frequently  so  in  pneumonia.  The 
colon  bacillus  is  not  unusually  demonstrable  in  cholecystitis;  and  pus  cocci, 
either  in  pure  culture  or  mixed  with  other  germs,  constitute  the  most  common 
cause  of  the  inflammation.  It  is  probable  that  bacteria  entering  the  gall- 
bladder and  not  being  particularly  virulent  produce  no  immediate  harm  when 
the  flow  of  bile  is  unobstructed,  though  even  then  they  may  become  the  nuclei 
of  gall-stones;  but  if  the  bacteria  are  very  virulent  they  may  actually  lead  to 
obstruction.  Stagnation  of  the  bile  favors  infection,  and  infection  may  be  the 
cause  of  stagnation.  Each  influence  reacts  upon  the  other  and  aggravates 
the  other,  and  it  seems  more  than  possible  that  infection  of  the  gall-bladder  is 
to  be  regarded  as  serious  only  when  there  is  obstruction  to  the  outflow  of  bile. 
The  same  variety  of  germ  may,  under  some  circumstances,  cause  catarrhal, 
and  under  others  suppurative,  inflammation;  that  is,  when  bacteria  are  virulent 
and  tissue  resistance  is  slight,  suppurative  cholecystitis  results;  but  when  the 
bacteria  are  not  virulent  and  the  tissue  resistance  is  powerful,  the  gall-bladder 
is  not  infected  at  all,  or  only  catarrhal  inflammiation  is  produced.  I  operated 
upon  a  case  of  acute  suppurative  inflammation  of  the  gall-bladder  three  weeks 
after  the  termination  of  an  attack  of  typhoid  fever.  The  culture  taken  from 
the  gall-bladder  showed  an  unidentified  bacillus,  which  was  not  the  colon 
bacillus  or  the  paracolon  bacillus,  and  which  was  not  identifiable  as  the  typhoid 
baciflus  or  the  paratyphoid  bacillus.  It  strongly  resembled  the  typhoid  bacillus, 
but  possessed  no  agglutinative  power  (the  author,  in  "New  York  Med.  Jour.," 
April  8,  1905 )._ 

A  patient  in  the  medical  ward  of  the  Jefferson  Hospital  was  supposed 
to  be  developing  a  typhoid  relapse,  but  no  fresh  spots  appeared,  and  there 
were  pain,  tenderness,  and  rigidity  in  the  region  of  the  gall-bladder.  I  oper- 
^Joseph  McFarland,  "Proceedings  of  the  Phila.  County  Med.  Soc,"  Sept.,  1902. 


ii8o  Diseases  and   Injuries  of  the  Abdomen 

ated  and  found  the  gall-bladder  full,  dark  colored,  and  surrounded  by  numer- 
ous recent  adhesions.  It  could  be  emptied  slowly  by  pressure.  There  was 
no  pus.  It  was  drained  and  the  symptoms  promptly  passed  away  and  the 
man  recovered.  The  culture  was  reported  sterile.  I  cannot  understand 
this  finding,  as  inflammation  undoubtedly  existed.  It  may  have  been  peri- 
tonitis rather  than  cholecystitis,  but  from  what  cause  is  unknown.  No  culture 
was  taken  from  the  peritoneal  cavity.  The  finding  of  sterile  bile  at  the  end 
of  an  attack  of  undoubted  typhoid  is  of  interest. 

Catarrhal  Inflammation  of  the  Gall=bladder  and  Bne=ducts. — 
This  condition  is  known  as  catarrhal  jaundice,  acute  or  chronic,  and  is  usually 
treated  by  the  physician;  but,  as  A.  W.  Mayo  Robson  points  out,  chronic 
catarrhal  jaundice  sometimes  resembles  the  jaundice  of  organic  disease,  and 
is  occasionally  associated  with  gall-stones,  malignant  disease,  or  hydatid 
cyst.  The  same  authority  asserts  his  belief  that  chronic  catarrhal  jaundice 
usually  results  from  interstitial  pancreatitis  and  duct  obstruction.  This 
condition  usually  comes  on  without  pain.  If  there  be  pain  it  means  some  com- 
plication. Robson  (''Surg.,  Gynec,  and  Obstet.,"  Jan.,  1908)  names  among 
such  complications  catarrhal  cholecystitis,  cholangitis,  gall-stone,  and  duodenal 
ulcer.  The  jaundice  is  striking.  It  is  often  accompanied  by  itch.  There  is 
loss  of  flesh  and  anemia,  and  the  liver  is  enlarged  and  smooth.  Robson  tells 
us  that  if  the  gall-bladder  is  not  shrunken  from  stone,  and  if  there  is  great 
duct  obstruction,  the  bladder  will  be  distended.  Chills  and  fever  mean  infective 
cholangitis.  In  a  case  of  chronic  catarrhal  jaundice  in  which  medical  treatment 
fails,  surgical  treatment  must  be  considered  (cholecystostomy  or  cholecysten- 
terostomy). 

Catarrhal  Cholecystitis. — This  is  a  catarrhal  inflammation  of  the  gall- 
bladder usually  without  jaundice.  The  gall-bladder  becomes  thick  and 
its  mucous  membrane  is  frequently  plicated.  Very  thick  mucus  is  secreted, 
which  gathers  in  masses,  and  the  descent  of  these  plugs  causes  pain  that  is 
sometimes  indistinguishable  from  that  produced  by  the  passage  of  a  gall-stone. 
Such  a  plug  may  temporarily  block  the  cystic  duct.  In  catarrhal  cholecystitis 
the  gall-bladder  is  frequently  distended,  but  rarely  admits  of  palpation;  and 
there  are  no  adhesions  to  surrounding  structures,  unless  gall-stones  have  been 
present  (Robson).  Catarrhal  cholecystitis  may  lead  to  the  formation  of  gall- 
stones; may  result  from  the  presence  of  gall-stones;  or  may  be  found  in  cases  in 
which  gall-stones  have  been  present,  but  have  passed.  In  i  case  upon  which 
I  operated  the  gall-bladder  was  enlarged,  thick,  and  without  adhesions;  the 
mucous  membrane  was  convoluted;  and  the  viscus  was  filled  with  thick,  tena- 
cious mucus,  and  the  mucous  membrane  of  the  gall-bladder  contained  many 
minute  concretions.  In  this  case  stone  formation  was  probably  beginning  to 
follow  upon  catarrhal  cholecystitis.  In  another  case  a  woman  had  presented 
violent  symptoms  of  gall-stone  colic,  and  stones  had  been  recovered  from  the 
feces;  but  on  opening  the  gall-bladder  no  stones  were  found — only  a  condition 
of  catarrhal  cholecystitis.  Jaundice  is  rare  in  catarrhal  cholecystitis  unless 
gall-stones  are  present;  it  is,  however,  occasionally  noted.  Even  if  jaundice 
does  occur,  it  is  slight  and  lasts  but  a  short  time.  The  painful  attacks  that 
occur  during  catarrhal  cholecystitis  are  similar  to  gall-stone  attacks;  but  the 
pain  is  less  violent  and  of  briefer  duration,  and  jaundice  is  not  apt  to  follow  the 
passage  of  a  plug  of  mucus  and  is  apt  to  follow  the  passage  of  a  gall-stone. 
Further,  as  Robson  has  shown,  in  catarrhal  cholecystitis  with  gall-stones  there 
may  be  tenderness,  but  there  is  rarely  tenderness  in  uncomplicated  catarrhal 
cholecystitis. 

Treatment. — The  majority  of  the  cases  recover  under  medical  treatment. 
If  a  case  fails  to  recover  under  medical  treatment,  one  cannot  be  sure  whether 
there  are  gall-stones  or  not;  but  an  operation  is  indicated  in  either  case.  Chole- 
cystostomy should  be  performed  and  the  gall-bladder  should  be  drained  for  a 
week  or  two.     This  treatment  will  almost  always  produce  cure. 


Simple  Suppurative  Cholecystitis  1181 

Croupous  Inflammation  of  the  Qan=bladder  and  the  Bile=ducts. 

—This  is  an  extremely  rare  condition,  due  to  the  formation  in  the  bile- 
passages  of  a  thick  membrane  which  causes  obstruction  to  the  flow  of  bile  and 
spasmodic  contraction  of  the  gall-bladder.  The  symptoms  are  identical  with 
those  of  gall-stones.  Robson  points  out  that  a  study  jof  the  evacuations  may 
discover  membranous  intestinal  casts;  and  that,  as  membranous  enteritis 
is  usually  associated  with  croupous  inflammation  of  the  gall-bladder  and  bile- 
ducts,  a  diagnosis  may  thus  be  reached.  The  same  author  says  that  one  may, 
in  some  cases,  even  find  a  cast  of  the  gall-bladder  in  the  evacuations. 

Treatment. — If  medical  treatment  fails,  cholecystostomy  should  be  per- 
formed and  drainage  should  be  employed  for  a  considerable  time. 

Suppurative  Inflammation  of  the  QalUbladder  and  Bile=ducts. — 
Adopting  the  classification  of  Mr.  Robson,  we  divide  these  suppurative  in- 
flammations into  simple  suppurative  cholecystitis,  suppurative  and  infective 
cholangitis,  phlegmonous  cholecystitis  and  gangrene  of  the  gall-bladder,  ulcera- 
tion of  the  gall-bladder  and  bile-ducts,  pericystic  abscess  with  adhesions,  and 
certain  consequences  of  these  conditions,  such  as  stricture  of  the  gall-bladder 
and  bile-ducts,  perforation  of  the  gall-bladder  and  bile-ducts,  and  fistula  of 
the  gall-bladder  and  bile-ducts.  Suppurative  inflammations  of  the  gall-bladder 
and  the  bile-passages  are  due  to  infection  by  virulent  organisms  or  to  infection 
when  the  tissue  resistance  is  at  a  low  ebb. 

One  fact  must  strike  the  physician  in  regard  to  these  cases;  that  is,  that 
there  is  a  strong  similarity  between  the  possible  changes  of  acute  cholecystitis 
and  the  possible  changes  of  acute  appendicitis.  In  the  gall-bladder,  as  in 
the  appendix,  there  may  be  a  catarrhal  inflammation,  which  may  not  advance 
beyond  this  stage,  or  which  may  advance  into  a  more  dangerous  form;  in 
each  structure  blocking  and  stagnation  favor  infection  and  aggravate  ex- 
isting infection;  in  each  there  may  be  suppuration,  ulceration,  gangrene,  and 
perforation;  in  each  there  may  be  grave  complications  and  disastrous  and 
fatal  consequences;  and  in  each  prompt  surgical  operation  is  usually  life- 
saving.^ 

Simple  Suppurative  Cholecystitis. — This  condition  is  also  spoken 
of  as  suppurative  catarrh  of  the  gall-bladder  or  simple  empyema  of  the  gall- 
bladder. It  is  a  rare  condition  unless  gall-stones  exist  or  unless  some  infec- 
tious disease — especially  typhoid  fever — has  antedated  the  condition.  I 
operated  for  this  condition  upon  a  boy  eleven  years  of  age  three  weeks  after 
the  termination  of  an  attack  of  typhoid  fever.  It  is  not  only  typhoid  fever 
that  may  be  causative,  but  also  other  continued  fevers.  No  matter,  however, 
what  organism  is  primarily  responsible — be  it  colon  bacillus,  typhoid  bacillus, 
or  what  not — a  mixed  infection  with  pyogenic  cocci  usually  takes  place.  Pyo- 
genic cocci  alone  may  be  causative.  In  simple  suppurative  catarrh  of  the  gall- 
bladder, when  the  duct  becomes  blocked,  the  condition  known  as  simple  em- 
pyema exists;  and  when  hydrops  of  the  gall-bladder  undergoes  suppuration 
simple  empyema  is  produced. 

In  an  ordinary  case  of  suppurative  catarrh  following  gall-stones  one  usually 
obtains  the  history  of  a  number  of  attacks  of  biliary  colic,  the  pain  finally 
having  become  localized  and  persistent  instead  of  radiating  and  intermittent, 
and  a  definite  swelling  being  palpable  in  the  gall-bladder  region.  This  swelling 
is  tender  on  pressure.  There  are  usually  constitutional  symptoms,  sometimes 
trivial,  often  severe.  The  trivial  symptoms  are  a  somewhat  rapid  pulse,  sweating 
at  night,  and  some  elevation  of  temperature.  The  more  severe  symptoms 
are  chills,  a  remittent  fever,  and  profuse  sweats.  The  development  of  severe 
symptoms  indicates  that  a  dangerous  change  is  taking  place — usually  ulcera- 
tion of  the  gall-bladder,  occasionally  phlegmonous  cholecystitis.  Distinct 
jaundice  is  rare  in  simple  empyema,  though  the  patient  usually  shows  loss  of 
flesh,  has  a  very  poor  appetite,  and  suffers  considerably  from  thirst. 
^The  author,  "Proceedings  of  Phila.  County  Med.  Soc,"  Sept.,  1902. 


ii8- 


Diseases  and  Injuries  of  the  Abdomen 


To  distinguish  an  enlarged  gall-bladder  from  any  other  intra-abdominal 
mass  is  sometimes  difficult.  Very  large  gall-bladders,  such  as  have  been  placed 
on  record  by  Collinson,  Terrier,  Lavvson  Tait,  Gersuny,  and  others,  may  be 
mistaken  for  ovarian  cysts.  Alban  Doran  discusses  such  cases  in  the  "Brit. 
Med.  Jour.,"  June  17,  .1905.  An  enlarged  gall-bladder  moves  on  respiration 
unless  the  mass  becomes  adherent  to  the  abdominal  wall,  when  it  will  cease 
to  do  so.  An  enlarged  gall-bladder  is  sometimes  mistaken  for  a  movable 
kidnev,  and  the  diagnosis  between  these  conditions  is  discussed  in  the  section 
on  Movable  Kidney  (see  page  1422). 

Treatment. — The  gall-bladder  should  be  opened  and  drained  by  the 
operation  of  cholecystostomy.  After  it  has  been  exposed,  it  is  packed  about 
with  gauze  pads,  a  considerable  portion  of  the  contents  is  removed  through 
an  aspirator,  the  gall-bladder  is  opened  and  irrigated  with  salt  solution,  and 
a  search  is  made  for  any  cause  of  obstruction  in  the  cystic  duct.  This  cause 
should  be  removed,  and  any  gall-stones  that  are  present  should,  of  course,  be 


Fig.  706. — Gall-bladder  filled  with  calculi.     Removed  by  cholecystectomy. 

taken  away.  The  walls  of  the  gall-bladder  will  frequently  be  found  diseased 
and  softened,  so  that  it  is  impossible  to  apply  stitches.  In  some  cases,  if  the 
gall-bladder  is  badly  diseased,  it  should  be  removed,  but  in  others  incision  with 
drainage  is  sufficient. 

Recurrent  Simple  Empyema  of  the  Gall=bladder. — In  this  con- 
dition a  person  develops,  at  intervals,  pain,  fever,  tenderness,  and  enlarge- 
ment of  the  gall-bladder.  Then  the  symptoms  clear  up  and  he  is  well  for  a 
time,  but  they  again  become  manifest;  and  at  last  they  may  become  persist- 
ent or  violent  because  of  the  development  of  some  complication.  In  these 
cases  it  is  impossible,  after  a  number  of  attacks,  to  palpate  any  enlargement 
of  the  gall-bladder;  and  when  an  operation  is  performed  the  gall-bladder  is 
found  shrunken,  thickened,  and  deeply  placed,  containing  some  purulent  matter, 
and  strongly  fixed  to  the  surrounding  structures  by  adhesions. 

Treatment. — Cholecystectomy  is  usually  the  proper  operation. 

Acute  Phlegmonous  Cholecystitis. — Some  call  this  condition  acute 
empyema.  It  is  extremely  dangerous,  and  is  apt  to  cause  gangrene  of  the 
gall-bladder.  It  is  due  to  infection  by  extremely  virulent  organisms.  It 
may,  even  without  perforation,  produce  rapid  peritonitis  and  death.  As  a 
rule,  in  advanced  cases  perforation  takes  place.  It  is  generally  associated  with 
the  presence  of  calculi,  but  sometimes  none  are  found;  and  the  condition  some- 
times develops  during  typhoid  fever  or  septicemia. 

This  disease  begins  with  sudden  and  violent  pain  in  the  gall-bladder  region. 
This  pain  usually  radiates  toward  the  right  shoulder-blade,  and  soon  becomes 


Infective  Cholangitis  1183 

general  throughout  the  abdomen.  There  are  tenderness  in  and  great  rigidity- 
over  the  gall-bladder  region,  thoracic  respiration,  exhausting  vomiting,  septic 
fever,  and  in  some  cases  jaundice.  If  an  operation  is  not  performed  promptly 
general  peritonitis  quickly  takes  the  patient's  life.  In  one  case  upon  which  I 
operated  there  were  intense  jaundice,  tenderness,  violent  pain,  abdominal 
rigidity  and  distention,  chills,  and  septic  fever;  and  when  the  abdomen  was 
opened  it  was  found  that  a  portion  of  the  gall-bladder  was  gangrenous  and 
that  a  calculus  projected  through  the  gangrenous  opening. 

It  is  this  form  of  cholecystitis  that  is  especially  likely  to  be  mistaken  for 
appendicitis.  In  making  a  diagnosis  the  situation  of  the  primary  pain  is  of 
importance,  and  likewise  the  situation  of  the  tenderness;  but  a  displaced  gall- 
bladder or  an  abnormally  situated  appendix  may  lead  to  error.  Acute  phleg- 
monous cholecystitis  is  usually  accompanied  by  absolute  constipation,  and 
the  sudden  onset  and  the  abdominal  distention  may  lead  to  the  disease  being 
mistaken  for  intestinal  obstruction.  It  may  also  be  confused  with  perforating 
ulcer  of  the  stomach  or  of  the  duodenum. 

Treatment. — In  any  case  of  doubt  an  exploratory  incision  should  be  made. 
If  phlegmonous  cholecystitis  is  found  to  exist,  the  gall-bladder  should,  when- 
ever possible,  be  extirpated;  but  if  the  desperate  condition  of  the  patient  for- 
bids this  operation,  the  bladder  should  be  incised,  surrounded  with  iodoform 
gauze,  and  a  drainage-tube  should  be  carried  well  up  toward  the  cystic  duct. 

Pericystic  abscess  may  follow  infection  of  the  gall-bladder.  It  is  espe- 
cially common  in  the  condition  known  as  recurrent  simple  empyema.  When 
a  pericystic  abscess  exists  there  are  great  localized  abdominal  tenderness  and 
rigidity  and  the  temperature  is  usually  indicative  of  suppuration.  The  causa- 
tive micro-organisms  may  have  passed  through  a  diseased  gall-bladder  wall, 
rupture  not  existing;  or  the  abscess  may  follow  ulceration  or  perforation  of 
the  gall-bladder  wall. 

Treatment. — Operation  should  invariably  be  performed,  though  it  is  fre- 
quently difhcult.  After  a  pericystic  abscess  has  been  drained  it  will  be  found 
necessary  in  some  cases  to  extirpate  the  gall-bladder,  whereas  in  others  incision 
of  the  gall-bladder  and  drainage  will  prove  sufficient. 

Infective  Cholangitis. — Cholangitis  is  usually  inaugurated  by  infected 
bile,  but  when  it  arises  during  a  general  infection  the  bacteria  may  be  brought 
by  the  blood.  It  may  arise  in  a  case  of  hepatic  cirrhosis.  Naunyn  ("  Deutsche 
medizinische  Wochenschrift,"  Berlin,  Nov.  2,  191 1)  says  that  most  germs  can 
cause  cholangitis;  that  mixed  infection  may  occur,  and  that  during  an  acute 
general  infection  cholangitis  is  seldom  recognized.  The  usual  cause  of  infec- 
tive cholangitis  is  gall-stones  lodged  in  the  common  duct.  Some  maintain 
;  that  duct-stones  are  causal,  particularly  in  those  cases  in  which  a  gall-stone 
acts  as  a  ball- valve.  A.  W.  Mayo  Robson,  though  he  believes  that  infective 
cholangitis  does  occur  when  the  gall-stones  are  freely  movable  in  the  common 
duct,  sets  it  forth  as  his  experience  that  it  is  much  more  common  in  such  cases 
to  find  gall-stones  impacted  in  the  common  duct. 

In  such  cases  the  patient  gives  a  history  of  attacks  of  gall-stone  colic  with- 
out jaundice  for  several  years,  and  then  of  attacks  followed  by  temporary 
jaundice  (see  page  11 88).  Finally  comes  an  attack  that  is  followed  by  a  chill 
and  fever;  and  jaundice,  varying  in  intensity,  ensues  upon  this,  and  now, 
though  it  may  fade,  it  seldom  completely  disappears  between  the  attacks  of 
pain.  Robson  points  out  that  the  interval  between  the  attacks  may  be  short 
or  long,  and  that  the  rigors  may  be  repeated  daily  or  at  uncertain  intervals; 
that  the  gall-bladder  is  usually,  but  not  always,  contracted;  and  that  after  the 
condition  has  persisted  for  some  time  the  liver  becomes  distinctly  enlarged. 
There  are  tenderness  over  the  gall-bladder  or  in  the  epigastric  region,  loss  of 
flesh,  and  persistent  jaundice  which  may  vary  in  hue. 

Infective  cholangitis,  even  after  it  has  lasted  for  a  considerable  length  of 


1 184  Diseases  and  Injuries  of  the  Abdomen 

time,  may  be  recovered  from;  but  it  may  pass  on  into  an  acute  condition  in 
which  poisoning  takes  place  from  the  bihary  elements,  suppurative  cholangitis 
may  arise,  an  empyema  of  the  gall-ljladder  may  develop,  and  there  may  be 
an  abscess  of  the  liver  or  some  other  dangerous  or  fatal  complication.  The 
ague-like  attacks  of  infective  cholangitis  have  been  called  by  Charcot  inter- 
mittcnt  hepatic  fever  (see  page  ii8g). 

Treatment.— After  an  incision  has  been  made  the  common  duct  is  opened, 
the  oiuse  removed,  and  the  duct  drained;  but,  as  Mr.  Robson  points  out,  the 
complication  should  be  anticipated.  When  one  finds  that  carefully  applied 
medical  treatment  has  failed  to  free  the  patient  from  gall-stones,  they  should 
be  removed  surgically. 

Suppurative  cholangitis  is  usually  a  development  of  the  ordinary  in- 
fective cholangitis,  which  has  just  been  discussed.  Among  the  other  causes 
that  Robson  sums  up  are  acute  infectious  diseases,  particularly  typhoid  fever 
and  influenza,  cancer  of  the  bile-ducts,  and  hydatid  disease. 

In  this  condition  the  liver  enlarges  notably  and  becomes  tender.  In  some 
cases  there  is  an  empyema  of  the  gall-bladder,  but  this  is  rare;  in  fact,  the  gall- 
bladder is  usually  very  much  shrunken.  When,  in  a  chronic  case,  there  are 
enlargement  of  the  liver,  blocking  of  the  common  duct,  and  enlargement  of 
the  gall-bladder  the  inference  is  in  favor  of  cancerous  obstruction  of  the  com- 
mon duct.  If  the  obstruction  is  due  to  cancer  there  will  usually  be  little  pain; 
but  when  it  is  due  to  gall-stones  there  will  be  violent  attacks  of  pain,  accom- 
panied by  rigors  and  fever,  with  deepening  of  the  jaundice.  In  this  disease 
there  is  always  jaundice,  usually  unfading;  but  in  cases  of  ball- valve  gall- 
stone in  the  duct  it  will  be  mitigated  from  time  to  time  (see  page  1 189).  The 
patient  suffers  from  septic  fever  and  there  is  very  rapid  loss  of  flesh. 

The  condition  is  generally  fatal  unless  operation  is  performed  early.  There 
is  a  strong  tendency  for  abscess  of  the  liver  to  form,  and  in  i  case  upon  which 
I  operated  a  subphrenic  abscess  had  developed. 

Treatment. — Cholecystostomy  with  free  and  prolonged  drainage.  If  an 
abscess  of  the  liver  exists  it  should  also  be  drained.  If  gall-stones  are  gath- 
ered in  the  common  duct  they  should  be  removed. 

Typhoid  Cholecystitis. — Typhoid  bacilli  were  first  found  in  the  bile 
by  Futterer  in  1888,  and  typhoid  cholecystitis  was  first  described  by  Girode 
in  1890.  As  previously  stated,  typhoid  bacilli  are  usually  present  in  the  bile 
during,  and  perhaps  are  present  months  or  years  after,  an  attack  of  typhoid 
fever.  They  are  not  always  present,  however,  for  in  a  case  of  cholecystitis 
following  typhoid  on  which  I  operated  an  unidentified  bacillus  was  found  ("  New 
York  Med.  Jour.,"  April  8,  1905);  in  a  case  on  which  I  had  made  an  artificial 
anus  for  typhoid  perforation  and  subsequently  performed  intestinal  resection 
I  drained  a  greatly  distended  gall-bladder  at  the  second  operation  and  cultures 
of  the  bile  remained  sterile;  and  in  a  case  of  typhoid  with  distended  and  appar- 
ently inflamed  gall-bladder  on  which  I  operated  the  bile  was  reported  to  be 
sterUe.  Because  typhoid  bacilli  are  usually  present  in  the  bile  during  typhoid 
does  not  mean  that  most  cases  of  typhoid  have  cholecystitis.  Cholecystitis  is 
not  very  common,  and  arises  when  bacilli  are  very  numerous  or  very  virulent, 
when  vital  resistance  is  lowered,  when  there  is  antecedent  inflammation  of  the 
gall-bladder,  when  there  are  gall-stones,  and  particularly  if  there  is  a  block  of 
the  duct  causing  stagnation  of  bile.  Bacilli  in  bile  may  do  no  harm  at  all,  but 
they  may  cause  catarrh,  purulent  catarrh,  suppuration  of  the  gaU-bladder 
walls,  suppuration  outside  of  the  gall-bladder,  or  perforation.  When  bile  or 
inflammatory  exudate  contains  typhoid  bacilli,  agglutinins  are  present  and 
may  precipitate  masses  which  become  nuclei  for  gall-stones. 

The  usual  period  for  cholecystitis  to  arise  is  during  the  third  week  of  the 
fever,  but  it  is  not  uncommonly  met  with  during  convalescence  and  is  perhaps 
mistaken  for  a  relapse. 


Causes  of  Gall-stones  11S5 

The  condition  may  arise  months  or  a  year  after  the  attack  of  typhoid,  and 
yet  a  pure  culture  of  typhoid  bacilli  may  be  obtained  from  the  gall-bladder. 
Strange  to  say,  cases  of  cholecystitis  have  been  operated  on  in  persons  giving 
no  history  of  having  had  typhoid,  and  typhoid  bacilli  have  been  obtained 
from  the  gall-l)ladder.  I  operated  upon  such  a  case.  Such  a  person  may  have 
had  a  very  mild  attack  of  typhoid,  or  he  may  be  immune  to  typhoid  fever  and 
yet  the  bacillus  may  be  capable  of  causing  inflammation.  Many  cases  of 
typhoid  cholecystitis  are  probably  unrecognized  because  of  the  trivial  s>Tnptoms, 
or  because  a  high  position  of  the  liver  renders  the  real  seat  of  pain  obscure, 
because  the  general  symptoms  are  uncertain,  because  toxemia  blurs  perception 
of  pain,  or  because  the  condition  is  confused  with  appendicitis.  It  is  rare  in 
children,  more  common  in  adults.  Most  infections  result  from  the  bacilli 
ascending  the  common  duct,  some  are  by  way  of  the  lymphatics  (Charles  H. 
Mayo),  some  by  an  adhesion  of  the  gall-bladder  to  the  bowel,  some  by  way  of 
the  portal  circulation  and  the  bile-ducts.  Mixed  infection  may  occur,  and  a 
secondary  staphylococcus  infection  may  be  followed  by  disappearance  of  the 
typhoid  bacilli.  The  symptoms  of  typhoid  cholecystitis  are  pain  and  tenderness 
in  the  gall-bladder  region,  rigidity  of  the  upper  half  of  the  right  rectus  muscle, 
perhaps  a  palpable  mass,  an  elevated  and  remittent  temperature,  sweats, 
perhaps  jaundice,  and  sometimes  leukocytosis.  In  some  cases  perforation 
occurs.  Erdmann  reported  i  case  and  collected  from  literature  34  cases  of 
perforation  ("Annals  of  Surgery,"  June,  1903). 

Treatment, — In  an  ordinary  case  without  perforation  incise  and  drain  the 
gall-bladder.  If  perforation  exists,  do  cholecystectomy  if  possible;  if  not, 
drain.  No  attempt  should  be  made  to  suture  the  perforation.  If  perforation 
exists  and  operation  is  not  done,  death  is  practically  certain.  Of  27  cases  not 
operated  upon,  all  died;  of  7  cases  operated  upon,  4  recovered  (Erdmann). 

Qall=stones  are  formed  during  life  in  the  gall-bladder  or  bile-ducts  by  the 
agglutination  of  materials  which  have  been  precipitated  from  bile.  The  nucleus 
of  a  gall-stone  may  be  a  mass  of  bacteria,  a  blood-clot,  epithelium,  crystals  of 
cholesterin  or  carbonate  of  lime,  or  a  cast  of  a  small  duct.^  A  condition  of 
the  body  thought  to  lead  to  the  formation  of  gall-stones  is  designated  by  the 
term  cholelithiasis  (Brockbank).  But  one  stone  may  be  present  or  great 
numbers  may  exist.  Solitary  stones  may  be  nearly  round  or  cylindrical. 
AVhen  several  stones  or  many  stones  exist  the  mutual  pressure  often  leads  to 
the  formation  of  facets  (Naunyn).  In  color,  calculi  may  be  pale  yellow,  green, 
black,  or  brown.  Some  are  heavier  than  bile  and  some  are  lighter.  Brockbank 
gives  the  following  varieties  of  gall-stones:  pure  cholesterin  stones,  stratified 
cholesterin  stones,  common  or  gall-bladder  calculi,  mixed  bilirubin-calcium 
calculi,  pure  bilirubin-calcium  calculi,  and  certain  rare  forms.-  Gall-stones 
usually  take  origin  in  the  gall-bladder,  but  may  arise  in  the  common  duct,  the 
cystic  duct,  the  hepatic  duct,  or  the  smaller  ducts  of  the  liver.  As  a  rule, 
however,  calculi  in  the  common  or  cystic  duct  were  not  formed  there,  but  were 
transported  from  the  gall-bladder  or  hepatic  ducts. 

Causes. — Gall-stones  are  very  commonly  found  postmortem.  In  Germany 
it  is  estimated  that  they  are  found  in  12  per  cent,  of  all  cases.  In  1655  autopsies 
in  the  Johns  Hopkins  Hospital  gall-stones  were  present  in  6.94  per  cent,  of  all 
cases. ^  The  usual  estimate  is  5  per  cent,  of  autopsies.  The  cause  is  a  catarrhal 
condition  of  the  bile-ducts,  due  particularly  to  the  entrance  of  bacteria  from  the 
intestine  (colon  bacilli,  typhoid  bacilli,  pus  organisms,  pneumococci).  This 
catarrhal  condition  causes  stagnation  of  bile.  Healthy  bile  is  sterile,  but  not 
germicidal,  and  bacteria  will  grow  in  it.  Bacteria  have  been  found  in  bile  years 
after  the  termination  of  an  attack  of  tj^hoid  fever.     Experimental  infection 

^  Bevan,  in  "Chicago  Med.  Recorder,"  April,  1898. 

2  Brockbank's  treatise  on  "Gall-stones." 

*  C.  D.  Mosher,  in  "Johns  Hopkins  Hosp.  Bull.,"  Aug.,  1901. 


ii86  Diseases  and  Injuries  of  the  Abdomen 

of  the  gall-bladder  producing  mild  cholecystitis  is  almost  "always  followed  by 
gall-stone  formation.^  Welch  pointed  out  that  recent  gall-stones  have  bacteria 
in  their  center.  Gushing  tells  us  that  30  per  cent,  of  gall-stone  cases  operated 
upon  in  the  Johns  Hopkins  Hospital  had  previously  suffered  from  typhoid 
fever,  but  the  experience  of  the  Alayos  is  not  in  accord  with  this  opinion.  In 
view  of  the  fact  that  bile  containing  typhoid  bacilli  may  contain  agglutinins 
we  can  understand  how  masses  could  be  precipitated  to  form  nuclei — 30  per 
cent,  of  Ochsnen's  cases  had  had  appendicitis. 

The  chief  predisposing  causes  are  advancing  years,  insufficient  exercise, 
the  daily  consumption  of  unnecessarily  large  quantities  of  food,  gouty  tendencies, 
and  conditions  which  interfere  with  the  emptying  of  the  gall-bladder.  Cardiac 
disease  and  cancer  of  the  liver  predispose.  Gall-stones  rarely  form  before  the 
age  of  thirty-five.  The  youngest  patient  from  whom  I  have  removed  stones 
was  a  girl  of  twenty.  The  disease  is  more  common  in  the  insane  than  in  the 
mentally 'sound,  in  the  white  race  than  in  the  black,  and  in  women  than  in  men. 
In  25  per  cent,  of  all  females  beyond  sixty  years  of  age  gall-stones  are  present 
(Naunyn).  The  special  liability  of  women  may  be  brought  about  by  tight 
lacing,  pregnancy,  inactivity,  or  movable  right  kidney.  Stout  and  lazy  women 
are  particularly  liable  to  gall-stone  formation,  and  women  who  have  borne 
children  are  far  more  liable  than  those  who  have  not.  Total  abstainers  seem 
to  possess  a  greater  predisposition  than  users  of  alcohol,  probably  because  they 
are  more  apt  to  be  large  eaters  (Herbert  F.  Waterhouse,  in  "Lancet,"  ]May  8, 
1909).  There  are  two  forms  of  the  condition  to  be  considered:  the  acute  tA^je, 
due  to  efforts  made  by  the  gall-bladder  or  duct  to  expel  the  concretion;  and  the 
chronic  condition,  in  which  a  calculus  is  lodged  for  a  long  time,  or  in  which, 
as  soon  as  one  calculus  is  passed  into  the  intestine,  "another  begins  its  journey" 
(Brockbank's  treatise  on  "Gall-stones").  The  fact  that  bacteria  may  cause 
the  condition  must  not  lead  us  to  infer  that  pus  is  of  necessity  formed.  If  the 
bacteria  are  present  in  small  numbers,  or  if  their  virulence  is  greatly  mitigated, 
they  produce  catarrhal  inflammation  only,  the  bile  stagnates,  and  a  stone  forms. 
There  may  be  one  stone,  two,  several,  or  many  stones.  I  have  removed  200 
from  a  patient.  Multiple  stones  are  usually  faceted.  Solitary  stones  are 
not  faceted. 

Many  observers  believe  that  inflammation  of  the  mucous  membrane  causes 
the  secretion  of  quantities  of  cholesterin,  which  material  forms  a  large  part  of 
most  gall-stones.  Others  maintain  that  cholesterin  is  a  normal  constituent 
of  bile  and  is  not  obtained  from  the  mucous  membrane. 

Bachmeister  ("Miinch.  Med.  Woch.,"  Feb.  18,  1908)  demonstrates  that 
if  pure  sterile  bUe  is  permitted  to  stand  for  a  considerable  time  cholesterin 
will  be  precipitated,  and  that  if  epithelial  cells  are  added  to  this  the  cholesterin 
is  precipitated  much  more  rapidly.  The  catarrhal  inflammation  furnishes 
quantities  of  epithelial  cells  and  the  cells  precipitate  cholesterin,  and  in  this  way 
inflammation  causes  gall-stones.  Aschoff  ("Progressive  Med.,"  June,  1914) 
maintains  that  gall-stone  predisposition  depends  on  the  amount  of  cholesterin 
in  the  blood  and  bile. 

The  blood  certainly  contains  cholesterin  (o.  1 6  to  o.  1 8  per  cent. ) .  The  choles- 
terin content  is  increased  by  a  diet  of  meat,  eggs,  fat,  fish,  etc.  It  is  increased 
by  nephritis,  diabetes,  arteriosclerosis,  pregnancy  and  lactation.  When  the 
blood  holds  an  excess  of  cholesterin  a  first  attack  of  colic  may  be  due  to  sudden 
precipitation  of  cholesterin  in  a  normal  gaU-bladder.  Such  an  attack  is  afebrile 
and  the  solitary  stone  is  round  ( Aschoff 's  theory.  Ibid.).  Pigmented  stones 
and  layered  stones  prove  that  inflammation  has  existed.  This  theory  asserts 
that  stones  may  form  originally  without  inflammation  but  that  the  presence 
of  a  stone  favors  inflammation.  It  is  probable  that  when  gall-stones  exist 
they  are  all  due  to  a  common  cause  and  all  have  begun  to  form  at  the  same  time. 
'  Gilbert,  in  "Archives  generales  de  med.,"  Aug.  and  Sept.,  1898. 


,  Symptoms  of  Gall-stones  1187 

It  is  not  likely  that  one  begins  and  then  another,  and  so  on.  After  a  stone  once 
begins  it  may  progressively  increase  in  size.  In  many  cases  the  stone  or  stones 
never  cause  trouble.  A  gall-stone  may  begin  to  descend  because  of  violent 
muscular  exertion,  external  pressure,  or  at  the  onset  of  a  fresh  inflammation 
which  leads  to  loosening  of  the  stone.  A  very  small  stone  usually  passes  freely. 
A  larger  stone  in  passing  causes  colic.  A  still  larger  stone  remains  m  the  gall- 
bladder, or  becomes  fLxed  in  the  cystic  duct  or  in  the  common  duct.  In  most 
cases  gall-stones  form  in  the  gall-bladder.  In  some  they  form  in  the  common 
duct  if  stones  have  pre\'iously  existed  in  the  gall-bladder.  WTien  the  common 
duct  retains  a  st©ne  and  is  suffering  from  some  degree  of  obstruction  and  from 
infection,  stones  not  very  unusually  form  in  the  hepatic  ducts  (\Vm.  J.  and  Chas. 
H.  Mayo,  in  '"Am.  Jour.  Med.  Sciences,"  March,  1905).  Stones  are  occa- 
sionally found  at  necropsy  in  the  radicles  of  the  hepatic  duct. 

Symptoms.— The  formation  of  a  stone  requires  several  months,  a«id  during 
the  antecedent  period  of  gastro-intestinal  catarrh,  the  prodromal  state  of  Kraus, 
certain  symptoms  may  exist,  \az.:  constipation,  flatulence,  loss  of  appetite, 
migraine,  uneasy  sensations  in  the  epigastrium  or  right  hypochondrium,  sallow- 
ness  of  the  skin,  slight  yellowness  of  the  conjunctiva,  scantiness  of  urine, 
which  is  saturated  with  uric  acid,  and  may  after  a  time  contain  a  little 
bile.  If  this  condition  is  not  arrested  by  treatment,  it  grows  worse.  The 
abdomen  becomes  decidedly  distended;  pressure  over  the  stomach  or  liver  may 
cause  distinct  uneasiness  or  even  pain;  acid  indigestion  is  very  troublesome; 
\-iolent  attacks  of  migraine  occur;  constipation  becomes  more  decided,  the 
feces  become  clay  colored,  gastralgia  may  occur,  the  skin  is  apt  to  be  slightly 
jaundiced,  itching  is  complained  of,  the  patient  is  irritable  and  sleeps  poorly. 
The  liver  is  found  to  be  enlarged  and  the  urine  contains  distinct  amounts  of 
bUe.  \Mien  the  patient  reaches  this  stage,  gall-stones  have  formed  or  are  very 
liable  to  form.  These  symptoms  may  pass  away  even  if  a  concretion  forms. 
It  is  quite  true  that  in  some  cases  a  stone  exists  for  years  without  causing 
trouble.  This  is  particularly  true  in  elderly  people.  A  stone  seldom  fails  to 
cause  svmptoms,  but  often  the  s}Tnptoms  are  unrecognized.  In  many  cases 
the  symptoms  which  stones  cause  are  thought  to  be  due  to  disease  of  the 
stomach  (indigestion,  flatulence,  pain  after  eating,  pyloric  spasm,  etc.).  Most 
of  the  cases  I  have  seen  long  thought  they  had  stomach  trouble,  and  the  real 
condition  was  recognized  only  when  there  w^as  a  seizure  of  colic  or  an  attack 
of  inflammation. 

As  Waterhouse  ("Lancet,"  May  8,  1909)  says,  the  symptoms  do  not  bear 
anv  relation  to  the  size  or  the  number  of  the  stones.  In  fact,  gall-stones  give 
rise  to  active  svmptoms  only  when  infection  occurs  or  when  the  ducts  become 
occluded  and  cease  to  drain,  or  when  a  stone  starts  to  pass.  If  infection  occurs, 
it  mav  pass  away  spontaneously,  but  seldom  does  so.  WTien  a  stone  forms, 
pain  is  apt  to  become  a  marked  feature  of  the  case.  John  B.  Murphy  ('"  Med. 
News,"  Xov.  2,  1905)  points  out  that  in  a  person  with  stones  in  the  gall-bladder 
there  may  be: 

1.  The  pain  of  acute  inflammation,  the  result  of  a  severe  infection.  In 
this  condition  there  are  abdominal  rigidity  and  contracted  gaU-bladder. 

2.  The  pain  of  tension.  In  this  there  is  not  persistent  abdominal  rigidity, 
but  pressure  always  causes  sudden  and  transient  tension  of  the  belly  muscles, 
^lurphy's  method  of  demonstrating  tenderness  of  the  gall-bladder  is  most 
valuable,  and  I  always  use  it.  It  is  as  follows:  hook  the  fingers  well  up  under 
the  Kver  and  tell  the  patient  to  take  a  deep  inspiration.  On  inspiration  pain 
becomes  acute  and  respiration  suddenly  ceases. 

3.  Referred  pain  may  exist  with  either  of  the  above  conditions.  Colic  is 
spasmodic  pain,  and  means  that  a  stone  has  left  or  is  trying  to  leave  the  gall- 
bladder, and  is  in  or  is  trying  to  enter  a  duct.  ^Many  persons  with  a  stone  or 
with  stones  in  the  sail-bladder  never  have  coHc.     A  sense  of  pressure  or  of 


ii88  Diseases  and  Injuries  of  the  Abdomen 

soreness  in  the  hepatic  region,  the  result  of  cholecystitis,  has  added  to  it  sudden 
and  transient  paroxysms  of  pain,  due  to  the  passage  of  thick  bile  from  the  gall- 
bladder and  small  ducts,  or  of  gravel  from  the  small  ducts,  urged  on  by  bile 
pressure.  When  any  stone  but  the  very  smallest  begins  to  pass  from  the  gall- 
bladder, violent  colic  is  experienced.  Such  a  colic  usually  comes  on  very 
suddenly,  and  often  about  three  hours  after  a  meal.  It  may,  however,  come 
on  gradually,  the  patient  complaining  greatly  of  flatulence.  In  some  cases 
it  is  so  sudden  and  violent  as  to  simulate  perforation  of  the  stomach  or  duo- 
denum. The  reason  colic  is  particularly  apt  to  come  several  hours  after  a  heavy 
meal  is  that  at  that  time  bile  is  passing  down  into  the  intestine.  A  bladder 
containing  calculi  often  tolerates  the  presence  of  the  foreign  bodies  for  an  in- 
definite length  of  time,  and  then  suddenly  resents  their  presence  and  ejects 
them  forcibly,  or  tries  to  eject  them.  The  pains  are  violent,  spasmodic,  and 
paroxysmal,  and  over  the  hepatic  and  epigastric  regions,  "radiating  upward 
over  the  right  half  of  the  thorax"  (Kraus),  and  passing  particularly  from  the 
epigastrium  to  the  right  shoulder-blade.  The  patient  is  profoundly  nauseated 
and  usually  vomits.  In  many  cases  the  vomiting  is  violent.  The  abdomen 
is  distended  and  a  condition  almost  of  collapse  is  soon  reached.  The  tempera- 
ture is  usually  normal  or  subnormal,  but  is  occasionally  somewhat  elevated. 
The  patient  may  shiver  and  sweating  may  follow,  but  rigors  are  rare.  The 
respirations  are  shallow,  the  patient  groans,  cries  out,  flings  himself  about  in  the 
bed,  and  often,  in  seeking  relief,  assumes  some  strange  or  contorted  position. 
He  frequently  holds  one  hand  over  the  liver  region.  His  expression  is  indicative 
of  intense  suffering  and  apprehension  and  sometimes  of  abject  terror.  The 
pain  is  one  of  the  most  awful  a  human  being  can  feel,  and  women  who  have  felt 
it  assert  that  the  pains  of  parturition  are  trivial  in  comparison.  The  attack 
lasts  a  variable  time,  and  terminates  when  the  stone  passes  into  the  intestine 
or  drops  back  into  the  bladder.  The  usual  duration  of  an  attack  is  from  four 
to  twenty  hours.  I  have  seen  attacks  that  lasted  three  days,  four  days,  or 
even  five  days,  almost  without  intermission.  It  terminates  suddenly  if  the 
stone  passes  or  falls  back  in  the  gall-bladder.  It  abates  very  gradually  if  the 
stone  becomes  wedged  in  a  duct.  In  many  cases  at  the  termination  of  the 
attack  an  enormous  amount  of  clear  pale  urine  is  passed.  During  and  for  a 
time  after  the  attack  the  gall-bladder  may  be  very  tender.  After  the  cessation 
of  colic,  if  the  feces  are  examined  carefully  during  several  days,  the  stone  may  be 
discovered.  The  fact  that  no  stone  is  discovered  does  not  prove  that  one  was 
not  passed,  because  a  cholesterin  stone  may  be  broken  up  in  the  intestinal  canal. 
If  the  stone  is  passed,  jaundice  almost  invariably  follows  the  colic  in  from  twenty 
to  thirty-six  hours  and  lasts  several  days.  The  jaundice  results  from  the  stone 
being  in  or  having  passed  through  the  common  duct.  If  stones  do  not  pass 
from  the  cystic  duct  so  as  to  enter  or  protrude  into  the  common  duct,  jaundice 
does  not  occur.  In  80  per  cent,  of  my  cases  of  gall-stones  (excluding  common 
duct  cases)  there  was  no  history  of  jaundice.  Even  when  a  stone  is  lodged  in 
the  common  duct  jaundice  may  be  slight  or  absent.  When  jaundice  arises 
after  a  colic,  it  comes  on  gradually,  bile  appears  in  the  urine,  and  often,  but 
not  always,  the  stools  become  clay  colored  from  absence  of  bile.  Jaundice 
may  be  first  noticeable  in  the  urine  or  in  the  conjunctiva.  The  skin  is  apt  to 
itch  annoyingly,  even  atrociously.  The  patient  is  constipated  and  very  thirsty. 
The  liver  is  enlarged  and  tender  and  the  spleen  is  enlarged.  Some  writers 
state  that  the  pulse  is  slow  in  jaundice.  My  experience  is  in  agreement  with 
the  much  larger  experience  of  Moynihan,  who  says:  "I  have  not  found  any  re- 
duction in  the  pulse-rate  in  jaundice  unless  a  degree  of  chronic  pancreatitis  is 
present"  {"  Gall-stones  and  Their  Surgical  Treatment").  If  the  stone  becomes 
impacted,  after  a  time  the  pains  become  gradually  less  violent,  and  may  entirely 
cease.  If  it  ceases  and  the  stone  does  not  move,  pains  do  not  recur ;  if  the  stone 
moves  pains  recur,  and,  usually,  again  and  again  the  patient  suffers  from  severe 


Symptoms  of  Gall-stones  1189 

pain.  An  individual  may  get  about  when  a  stone  is  impacted,  but  again  and 
again  fierce  attacks  of  colic  occur,  and  if  the  stone  is  wedged  immovably  in  the 
common  duct,  producing  absolute  obstruction,  the  patient  becomes  and  remains 
deeply  jaundiced.  Continued  deep  jaundice  is  seldom  seen  when  stones  are 
lodged  in  the  common  duct,  because  they  are  not  often  absolutely  fixed  and 
hence  rarely  produce  complete  obstruction.  Usually  the  stone  moves  from  time 
to  time  or  is  at  least  lifted,  so  that  bile  gets  by  it  at  intervals.  This  condition 
constitutes  the  hall-valve  stone,  and  in  it  jaundice,  though  present  more  or  less, 
is  at  times  much  more  intense  than  at  other  times.  It  is  a  jaundice  in  which 
the  hue  is  yellow,  not  deep  brown,  and  it  is  a  jaundice  that  wanes  and  deepens. 
It  deepens  after  each  colic  and  later  wanes,  but  seldom  entirely  disappears 
while  the  stone  remains  in  the  duct. 

In  persistent  jaundice  due  to  gall-stones  the  gall-bladder  is  seldom  enlarged. 
Courvoisier  showed  that  when  persistent  jaundice  is  associated  with  enlarge- 
ment of  the  gall-bladder  the  cause  is  usually  pressure  on  the  duct  from  without 
(malignant  disease  of  the  pancreas). 

Slight  jaundice  is  not  always  easy  of  recognition.  Recognition  is  particu- 
larly difficult  in  sallow  individuals  and  by  artificial  light.  Moynihan  praises 
Hamel's  test  for  slight  jaundice.  It  is  made  by  drawing  a  little  blood  from  a 
puncture  of  the  lobe  of  the  ear  into  a  capillary  tube  and  permitting  the  tube 
to  stand  for  a  few  hours.  If  any  jaundice  is  present  the  serum,  which  collects 
in  the  upper  part  of  the  tube,  will  be  yellow  (Moynihan). 

In  certain  cases  when  a  stone  is  in  the  common  duct  an  attack  of  colic  is 
followed  by  or  accompanied  by  a  chill  or  chills,  which  may  be  very  violent, 
moderate,  or  slight,  and  by  a  febrile  seizure  resembling  malaria  and  called 
hepatic  fever  or  Charcofs  fever.  The  temperature  rises  rapidly,  and  in  an  hour 
becomes  104°  F.  or  more,  remains  high  for  several  hours  and  then,  with  a  pro- 
fuse sweat,  drops  suddenly  to  normal.  It  may  remain  normal  for  a  few  hours, 
a  day,  two  days,  several  days,  or  weeks.  In  this  condition  there  are  jaundice 
and  tenderness  of  the  liver.  Charcot's  fever  is  brief  in  duration.  It  usually 
means  stone  in  the  common  duct.  If  stones  are  in  the  bladder,  we  are  more 
apt  to  get  a  persistent  slightly  elevated  temperature.  These  intermissions 
distinguish  Charcot's  fever  from  the  remittent  fever  of  sepsis,  and  the  absence 
of  the  Plasmodium  in  the  blood  and  the  history  of  colic  distinguish  it  from 
malaria.  The  fever  is  due  to  intoxication  with  toxins  from  infected  bile  retained 
in  the  ducts  by  obstruction.  The  condition  is  ominous  because  it  is  due  to 
infection,   and   may  lead  to  inflammation  of  the  large  ducts  {cholangitis). 

The  chart  of  Charcot's  fever  shows  sudden  elevations,  precipitate  descents, 
and  complete  intermissions.  Moynihan  calls  it  the  "steeple  chart"  ("Gall- 
stones and  Their  Surgical  Treatment").  When  infection  spreads  widely  in  the 
smaller  intrahepatic  ducts  the  temperature  is  high  and  does  not  intermit. 
Continuous  fever  of  this  type  has  usually  been  preceded  by  Charcot's  fever. 

If  a  stone  lodges  in  the  cystic  duct,  it  does  not  cause  jaundice  unless  an  end 
of  the  stone  projects  into  the  common  duct.  It  grows  in  size  from  incrustation, 
prevents  the  entrance  of  bile  into  the  gall-bladder,  and  the  bladder  may  shrivel 
and  thicken  or  become  distended  and  filled  with  mucus,  the  bile  being  absorbed 
{hydrops  of  the  gall-bladder).  If  a  bladder  so  blocked  becomes  infected,  pus 
forms,  and  the  condition  known  as  empyema  of  the  gall-bladder  arises.  An 
empyema  of  the  gall-bladder  may  rupture  into  the  bowel,  the  peritoneal  cavity, 
or  even  through  the  skin. 

The  common  duct  is  involved  in  i  out  of  5  or  6  cases  of  gall-stone  disease.^ 
Brewer  points  out  that  in  67  per  cent,  of  common  duct  cases  the  stone  is  in  the 
duodenal  extremity,  in  15  per  cent,  in  the  hepatic  extremity,  and  in  18  per  cent, 
in  the  middle.  If  a  stone  blocks  the  common  duct,  jaundice  always  exists  and 
persists.  Blocking  may  be  complete  and  the  stone  may  ulcerate  into  the  bowel 
^  Robson,  in  "Lancet,"  April  12,  1902. 


iigo  Diseases  and  Injuries  of  the  Abdomen 

or  the  peritoneal  cavity.  Blocking  may  be  incomplete,  the  stone  acting  as  a 
ball- valve  and  producing  intermittent  colic  and  jaundice,  which  wanes  and 
deepens  (see  page  1 1 89).  Fenger  pointed  out  that  if  a  stone  remains  fixed  in  the 
common  duct  the  liver  becomes  tender  and  enlarged,  but  if  a  stone  floats  about 
in  the  common  duct  the  gall-bladder  undergoes  atrophy.  In  complete  obstruc- 
tion the  stools  become  clay  colored  and  bilirubin  is  found  in  the  urine.  Fluc- 
tuating jaundice,  with  attacks  of  pain  and  fever,  and  a  shrunken  gall-bladder 
are  strongly  suggestive  of  a  ''  ball- valve"  stone  in  the  common  duct.  Persistent 
deepening,  painless  jaundice,  the  color  of  the  skin  becoming  brown  or  even  of  a 
mahogany  hue,  associated  with  a  distended  gall-bladder,  is  strongly  suggestive 
of  malignant  disease  compressing  the  common  duct.  The  above  statements 
constitute  Courvoisier's  law.  It  is  found  true  in  90  per  cent.  of.  cases.  We 
may  add  that  a  persistent  jaundice,  varying  somewhat,  and  associated  with 
pain  or  with  actual  coUc,  suggests  blocking  of  the  duct  by  an  immovable 
stone. 

Gall-stones  may  lead  to  suppurative  inflammation  of  the  gall-bladder  or 
bile-passages,  ulceration,  occlusion  of  the  neck  of  the  gall-bladder,  dilatation 
of  the  stomach  from  the  formation  of  adhesions  which  kink  the  pylorus,  peri- 
cystic abscess,  peritonitis,  empyema  of  the  gall-bladder,  and  cancer  of  the 
gall-bladder.  In  cancer  of  the  ducts  gall-stones  are  seldom  found,  at  least  are 
seldom  found  in  the  ducts.  Eddes  collected  22  cases  of  cancer  of  the  papilla. 
In  3  of  these  cases  there  were  stones  in  the  gall-bladder,  in  i  there  was  a  stone 
in  the  common  duct  (''Boston  ]Med.  and  Surg.  Jour.,"  March  7,  1901),  If  the 
patient  develops  distinct  infection  of  the  gall-bladder  or  bile-ducts,  he  will  suffer 
from  chills,  fever  and  sweats. 

Gall-stones  may  lead  to  cirrhosis  of  the  liver.  A  stone  may  ulcerate  into 
the  bowel  and  cause  intestinal  obstruction.  It  may  be  difficult  to  make  a 
diagnosis  between  gall-stones  with  icterus  and  cirrhosis  of  the  liver  with  icterus. 
In  the  former  case  the  urine  contains  bilirubin  and  in  the  latter  case  urobilin. 
In  less  then  half  the  cases  gall-stones  can  be  detected  bv  the  .v-ravs. 

Treatment. — In  the  prodromal  stage  and  after  recovery  from  an  attack 
insist  on  the  patient  taking  considerable  outdoor  exercise.  Direct  him  to  take 
a  cold  sponge-bath  every  morning,  to  move  the  bowels  freely  every  day,  and  to 
employ  a  simple  diet.  He  should  avoid  all  highly  seasoned  foods,  pastry,  rich 
soups,  fatty  food,  cheese,  alcohol,  and  sweets.  Alkalis  internally  are  of  value. 
Those  who  believe  that  excess  of  cholesterin  in  the  blood  is  responsible  for  gall- 
stone formation  treat  the  condition  as  follows: 

Rothschild's  Diet  (John  C.  A.  Gerster,  "Virginia  Med.  Semi-Monthly," 
August,  II,  1916). — Fast  for  three  or  four  days.  During  the  fast  give  all 
vegetables  except  peas,  beans,  and  lentils.  Give  cereals,  sugar,  buttermilk  free 
of  fat,  and  skimmed  milk.  This  diet  is  too  rigid  to  be  maintained,  so  feast 
for  three  or  four  days,  adding  lean  meat,  fish  (except  salmon,  shad  and  blue 
fish),  and  oleomargarine  but  not  butter.  So  periods  of  feast  and  periods  of 
fast  alternate. 

During  colic  give  a  purgative  enema,  apply  hot  turpentine  stupes  over  the 
hepatic  region,  and  administer  hypodermatic  injections  of  morphin  and  atro- 
pin.  If  vomiting  does  not  occur,  let  the  patient  drink  a  large  amount  of  warm 
water  to  favor  it.     After  the  attack  administer  a  saline  purgative. 

When  the  attack  has  terminated,  examine  carefully  for  any  evidence  of 
inflammatory  trouble  in  the  hepatic  region. 

In  certain  cases  operation  becomes  necessary.  Mr.  A.  W.  Mayo  Robson^ 
advises  operation  in  the  following  cases:  in  frequently  recurring  biliary  colic 
without  jaundice,  whether  the  gall-bladder  is  enlarged  or  not;  in  cases  of 
enlargement  of  the  gall-bladder  without  jaundice,  even  if  there  is  no  pain; 
in  persistent  jaundice  which  was  ushered  in  by  pain,  painful  seizures  occurring, 
1  On  the  "Gall-bladder  and  Bile-ducts." 


Treatment  of  Gall-stones  iigr 

whether  or  not  febrile  attacks  occur;  in  empyema  of  the  gall-bladder;  in  peri- 
tonitis beginning  in  the  gall-bladder  region;  in  intrahepatic  abscess  and"  in 
abscess  about  the  liver,  gall-bladder,  or  bile-ducts;  in  some  patients  in  whom 
the  stones  have  been  passed,  but  adhesions  remain  and  produce  pain;  in  fistula 
cases;  in  some  cases  of  persistent  jaundice  due  to  obstruction  of  the  common 
duct,  although  there  may  be  a  possibility  of  cancer  existing;  in  phlegmonous 
cholecystitis  and  gangrene  of  the  gall-bladder.  Besides  these  conditions,  which 
may  be  produced  by  gall-stones,  Robson  operates  for  wounds  of  the  gall-bladder, 
infective  and  , suppurative  cholangitis,  and  for  some  conditions  of  chronic 
catarrh  of  the  bile-ducts  and  gall-bladder.^  The  tendency  to  operate  early 
for  gall-stones  is  growing.  It  is  true  that  stones  may  cause  no  trouble,  but 
sooner  or  later  they  are  apt  to  cause  it,  there  is  no  tendency  whatever  to 
spontaneous  cure,  and  medicine  cannot  dissolve  them  in  the  bladder.  Early 
operations  are  easy  and  comparatively  safe;  late  operations  are  difficult  and 
dangerous,  and  bv  early  operation  dangerous  complications  (infection,  adhe- 
sions, obstructive  jaundice)  are  avoided.  As  Maurice  H.  Richardson-  says:  An 
earlv  operation  is  less  dangerous  than  the  passage  of  a  stone;  complications  are 
avoided  or  lessened;  even  if  the  diagnosis  is  WTong,  the  real  condition  may  be 
found  and  removed.  If  obstructive  jaundice  exists  operation  is  dangerous  be- 
cause of  the  possibility  of  fatal  oozing  of  blood. 

The  common  operation  is  cholecystostomy,  which  consists  in  opening  the 
gall-bladder,  removing  the  stones,  and  making  a  temporary  fistula  in  the  gall- 
bladder. The  drainage  cures  the  diseased  mucous  membrane.  The  fistula  is 
permitted  to  heal  after  a  time,  hence  many  call  the  operation  cholecystotomy 
rather  than  cholecystostomy.  Operation  should  be  done  promptly  and  shoiild 
not  be  delaved.  Delay  permits  the  gall-bladder  to  thicken  and  shrink,  and 
allows  the  stone  to  enter  the  duct.  After  removing  stones  and  draining  the 
gall-bladder,  symptoms  may  recur.  Recurrence  of  symptoms  may  be  due  to  a 
stone  or  stones  having  been  overlooked,  to  renewed  formation  of  stone,  or  to 
cholecystitis  and  bile-sand.  After  drainage  gall-stones  rarely  re-form.  Wm. 
J.  ]Mavo  collected  looo  operations  done  by  six  surgeons,  and  in  not  i  case 
did  stones  re-form.  Kocher  has  seen  stones  recur  in  3  out  of  31  cases  of  chole- 
lithiasis after  ideal  cholecystotomy  (suturing  the  gall-bladder  after  remov- 
ing stones).  The  operation  of  incision,  removal  of  the  stone,  and  suture  of  the 
gall-bladder  is  known  as  ideal  cholecystotomy  or  cJioIecystendysis.  It  is  not  a 
proper  procedure,  as  it  does  not  cure  the  diseased  mucous  membrane  and  stones 
are  apt  to  re-form.  Cysticotomy  is  incision  of  the  cystic  duct.  If  calculi  exist 
in  the  common  duct,  it  may  be  possible,  after  celiotomy,  to  manipulate  them 
back  into  the  bladder  and  extract  them  from  that  viscus  by  a  scoop,  but  this 
maneuver  is  impossible  unless  the  cystic  duct  is  dilated.  In  some  cases  the 
trail-bladder  is  incised,  a  fistula  is  made,  and  the  duct  and  bladder  are  frequently 
irrigated.  In  other  cases  the  stone  may  be  crushed  by  the  fingers  manipulating 
the"  duct  and  the  concretion  within  it  {choledocholUhotrity).  Robson  points 
out  that  crushing  of  the  stone  is  apt  to  leave  fragments  which  may  cause  trouble, 
and  it  should  be  done  only  when  the  stones  are  soft.  It  is  wTong  to  endeavor 
to  force  a  stone  from  the  common  duct  into  the  duodenum.  The  attempt  will 
fail,  and  in  some  cases  the  patient  wdU  be  placed  in  a  worse  condition  by  the 
stone  lodging  in  Vater's  diverticulum. ^  The  duct  may  be  opened,  and  after 
the  removal  of  the  stone  closed  by  sutures  {choledochotomy)  or  drained  for  a 
time  {choledochostomy) ,  strands  of  gauze  being  carried  down  to  the  opening 
and  in  some  cases  a  tube  being  carried  up  a  dilated  duct  toward  the  liver,  li 
the  stone  be  impacted  near  the  outlet  of  the  duct,  it  may  be  necessary  to  incise 

1  Robson's  treatise,  from  which  the  above  is  taken,  is  a  valuable  exposition  of  the  surgery 
of  the  gall-bladder  and  bile-ducts. 

-  ''Boston  Med.  and  Surg.  Jour.,"  Sept.  5,  1901. 

3  See  A.  W.  :Mayo  Robson,  in  "Lancet,"  April  12,  1902. 


iig2  Diseases  and  Injuries  of  the  Abdomen 

the  duodenum  in  order  to  remove  the  stone  {diiodcnocholedochotomy).  A  dilated 
common  bile-duct  may  be  anastomosed  to  the  bowel  {choledocho-enterostomy) 
or  to  the  surface  {choledochostomy).  The  obstruction  may  be  side-tracked  by 
anastomosing  the  gall-bladder  to  the  bowel  {cholecystenterostomy)  (see  page  1266). 
Cholecystenterostomy  affords  drainage,  but  does  not  remove  the  cause  of 
trouble,  and  infection  is  apt  to  be  received  from  the  bowel.  In  some  rare  cases 
of  common  duct  obstruction,  in  which  the  gall-bladder  is  distended  and  the 
condition  of  the  patient  is  desperate,  anastomose  the  gall-bladder  to  the  colon 
(Robson).  In  some  cases  of  diseased  gall-bladder  the  viscus  is  removed  (cholecys- 
tectomy). Wm.  J.  Mayo  and  others  have  pointed  out  that  a  danger  in  opera- 
tions on  the  common  duct  is  a  sudden  fall  in  blood-pressure  when  the  duct  is 
being  manipulated.  All  operators  have  observed  it.  Ransohoff  maintains 
that  it  arises  only  when  the  portal  vein  is  compressed. 

Carcinoma  of  the  Qall=bladder  and  Ducts. — In  405  operations  on  the 
gall-bladder  and  biliary  passages  the  Mayo  brothers  found  malignant  disease 
20  times  (5  per  cent,  of  cases).  (See  Wm.  J.  Mayo,  in  "Med.  News,"  Dec. 
13,  1902.)  Malignant  disease  may  be  primary  or  secondary.  It  may  arise 
from  carcinomatous  changes  in  papillomata.  We  know  that  papillomata  may 
spring  up  in  any  diseased  gall-bladder.  In  107  of  the  2538  cases  of  cholecys- 
tectomy in  the  Mayo  clinic  (from  Jan.  i,  1907  to  June  i,  191 5),  papillomata 
were  found  (Wm.  J.  Mayo,  in  "Trans.  Amer.  Surg.  Assoc,"  1915).  Papillomata 
are  not  cured  by  a  drainage  operation.  Cholecystectomy  is  necessary.  In 
primary  carcinoma  calculi  are  practically  always  present,  and  are  apparently 
the  cause  of  cancer  by  maintaining  chronic  irritation.  Stones  are  seldom  present 
in  secondary  malignant  disease.  Not  very  infrequently  cancer  of  the  common 
duct  is  encountered.  Now  and  then  a  surgeon  discovers  cancer  of  the  ampulla 
of  Vater. 

Carcinoma  of  the  gall-bladder  can  usually  be  palpated.  It  is  hard  and 
nodular,  and  seldom  accompanied  by  much  abdominal  rigidity.  There  will 
be  a  long  history  of  attacks  of  biliary  colic  and  of  recent  or  comparatively  re- 
cent grave  loss  of  flesh.  Sooner  or  later  jaundice  arises,  deepens,  and  persists. 
In  cancer  of  the  ampulla  or  ducts  jaundice  develops  but  ulceration  opens  a  way 
for  the  bile  and  jaundice  fades,  perhaps  to  recur  again.  So  it  may  disappear 
and  reappear.  In  cancer  of  the  duct  above  the  ampulla  jaundice  arises.  There 
is  no  bile  but  there  is  pancreatic  juice  in  the  intestine.  In  cancer  of  the  ampulla 
during  jaundice  there  is  neither  bile  nor  pancreatic  juice  in  the  intestine. 

Cholecystectomy  has  been  employed  for  this  condition,  but  offers  but  little 
hope.  A  wedge-shaped  piece  of  liver-tissue  should  be  removed  with  the  gall- 
bladder and  hemorrhage  should  be  arrested  by  sutures  or  gauze  packing.  In 
2  cases  in  which  I  opened  the  abdomen  without  suspecting  malignant  disease 
of  the  gall-bladder  the  liver  was  hopelessly  involved.  In  i  case  in  which  I 
operated  for  a  supposed  impacted  stone  in  the  common  duct  an  inoperable 
cancer  of  the  common  duct  was  found.  In  cancer  of  the  common  duct  it  may 
be  possible  to  excise  the  growth  and  suture  the  ends  of  the  duct  as  has  been 
practised  by  Moynihan,  the  Mayos  and  others.  If  this  is  impossible,  follow 
the  advice  of  the  Mayo  brothers:  Ligate  the  distal  end  of  the  duct  and  im- 
plant the  proximal  end  in  a  portion  of  the  duodenum  which  is  covered  by  peri- 
toneum ("Keen's  Surgery,"  vol.  iii).  Cancer  of  the  ampulla  has  been  excised 
successfully. 

Injuries  and  Diseases  of  the  Pancreas 

Injuries  of  the  Pancreas. — The  pancreas  is  very  rarely  ruptured  alone, 
although  this  sometimes  occurs  as  the  result  of  blows  or  crushes.  In  the 
majority  of  cases  in  which  the  pancreas  is  damaged  other  organs  are  involved; 
for  instance,  the  stomach,  the  spleen,  and  the  liver.     A  gunshot  wound  of  the 


Treatment  of  Injuries  of  the  Pancreas  ii93 

pancreas  is  almost  certain  to  injure  the  left  kidney,  the  stomach,  or  the  vertebral 
column.  It  will  be  remembered  that  in  the  case  of  President  McKinley  the 
bullet  passed  through  the  stomach,  damaged  the  left  kidney,  and  injured  the 
pancreas.  Becker  reported  an  isolated  gunshot  wound  of  the  pancreas,  the 
only  case  on  record  (Stephen  H.  Watts).  Garre  ("Beitrage  ztir  Klinische 
Chirurgie,"  xlvi,  No.  i)  collected  30  cases  of  subcutaneous  rupture  of  the  pan- 
creas, and  in  only  8  of  these  cases  was  the  pancreas  alone  damaged. 

Symptoms. — When  the  pancreas  is  injured  alone,  hemorrhage  is  not  usually 
severe;  but  if  adjacent  organs  are  also  damaged,  it  is  sure  to  be  profuse.  Hence 
when  adjacent  organs  are  damaged  immediate  symptoms  of  severe  intra- 
abdominal hemorrhage  appear;  but  profound  collapse  is  not  often  present  when 
the  pancreas  alone  is  injured.  In  fact,  symptoms  may  not  arise  for  a  consider- 
able length  of  time  after  injury  of  the  pancreas.  A  diagnosis  at  this  stage  is 
impossible  without  exploratory  operation.  Wohlgemuth  and  Toguchi  claim 
that  within  a  few  hours  of  a  pancreatic  injury  there  is  an  increase  of  diastase  in 
the  blood  and  urine  ("Berlin,  klin.  Wochen.,"  xlix,  1912).  If  this  observation 
be  correct  we  have  a  very  valuable  diagnostic  test.  Severe  injury  of  the  pan- 
creas is  usually,  but  not  invariably,  fatal.  After  slight  damage  of  the  gland 
the  patient  may  completely  recover;  but,  as  a  rule,  he  partly  recovers,  and, 
after  a  number  of  weeks,  a  smooth  enlargement,  palpable  in  the  epigastric 
region,  is  formed.  When  operation  is  performed  this  mass  is  found  to  be  back 
of  the  stomach.  It  contains  a  quantity  of  fluid  blood,  clot,  and  pancreatic 
fluid.  Such  a  fluid  collection  is  in  the  lesser  peritoneal  cavity  and  is  called  a 
cyst,  though  it  is  not  a  true  cyst  of  the  pancreas.  It  is  a  pseudocyst.  Robson 
and  MoMiihan,  in  their  valuable  treatise  on  "Diseases  of  the  Pancreas," 
explain  the  formation  of  this  collection  of  fluid  as  follows: 

The  injury  lacerates  the  posterior  layer  of  the  lesser  sac  of  the  peritoneum 
and  the  pancreas,  to  which  it  is  adherent.  Blood  and  pancreatic  fluid  enter 
the  lesser  peritoneal  sac.  Peritonitis  follows.  The  foramen  of  Winslow  be- 
comes blocked  bv  adhesions;  and  the  lesser  peritoneal  cavity,  being  now  a  closed 
sac.  is  distended  bv  a  serous  exudate  mixed  with  blood  and  pancreatic  fluid. 
Collections  of  this  character  form  very  rapidly,  and  several  pints  may  gather 
in  a  few  days.  Other  results  of  injury  to  the  pancreas  are  abscess,  pancreatitis, 
and  true  cyst  formation.  A  fistula  may  follow  operation  for  rupture  of  the 
pancreas.  Such  a  fistula  is  very  troublesome,  often  refuses  obstinately  to  heal, 
and  the  pancreatic  fluid  macerates  the  skin  severely. 

Treatment. — Operation  is  imperatively  demanded,  although  the  prospects 
are  bad.  Garre  collected  8  cases,  3  were  operated  upon,  and  all  died.  He 
reported  a  successful  case  of  his  own  (loc.  cit.).  The  pancreas  was  torn  in 
two  and  the  pieces  w^ere  separated.  The  splenic  vessels  were  uninjured.  The 
two  portions  of  gland  were  sutured  together.  This  stopped  the  bleeding. 
Gauze-packing  was  introduced.  MikuHcz  ("Proceedings  of  Amer.  Surg. 
Soc.'')  in  1903  collected  21  wounds  and  24  crushes  of ■  the  pancreas.  Twelve 
of  the  wounds  were  due  to  buflets  and  9  wxre  stabs.  Five  of  the  12  gunshot 
w^ounds  were  operated  upon,  with  2  deaths.  All  unoperated  upon  died.  The 
9  patients  who  had  been  stabbed  w^ere  all  operated  upon  and  only  i  died.  In  a 
gunshot  wound  of  the  abdomen,  when  exploration  leads  the  surgeon  to  surmise 
that  the  pancreas  has  been  injured,  this  organ  is  usuaUy  approached  by  dividing 
either  the  gastrocolic  omentum,  the  transverse  mesocolon,  or  the  gastrohepatic 
omentum.  It  can  be  easily  exposed  by  separating  the  great  omentum  and 
its  mesentery  from  the  colon  (the  epiplo-enterocolic  method).  Accessory 
injuries  must  be  carefuUy  noted,  and  if  a  bullet  has  penetrated  the  posterior 
waU  of  the  stomach,  the  pancreas  is  almost  certain  to  be  damaged.  One 
should  remember  that,  as  Park  says,  even  after  opening  the  abdomen  it  is 
difficult  to  explore  the  pancreas,  especiaUy  in  a  stout  person.  If  there  is  no  evi- 
dence of  posterior  perforation  of  the  stomach  by  a  foreign  body,  one  may 


1 194  Diseases  and  Injuries  of  the  Abdomen 

assume  that  the  pancreas  has  escaped.  When  the  pancreas  is  exposed,  if  it  is 
found  to  be  bleeding,  the  bleeding  vessels  should  be  ligated  and  the  tear  in  the 
gland  should  be  sutured  with  catgut,  care  being  taken  not  to  puncture  the  main 
duct  of  the  gland.  If  this  duct  has  been  cut,  it  should  be  carefully  sutured. 
In  some  cases  of  gunshot  wound  it  is  necessary  to  resect  a  portion  of  the  gland. 
At  the  termination  of  an  operation  upon  the  pancreas  posterior  drainage,  prefer- 
ably at  the  costovertebral  angle,  should  always  be  obtained.  It  is  necessary 
to  drain  away  all  escaping  pancreatic  fluid,  as  it  tends  to  cause  necrosis  of  tissue 
with  which  it  comes  in  contact. 

In  cases  of  crush  with  pancreatic  injury  the  associated  injury  to  other 
structure  usually  proves  rapidly  fatal,  but  in  a  less  severe  case  the  abdomen 
may  be  opened  for  exploration,  and  if  this  is  done,  the  surgeon  should  proceed 
as  previously  directed. 

The  question  of  excising  a  lacerated  portion  of  the  pancreas  is  one  of  great 
interest.  It  is  known  that  dogs  have  lived  for  some  time  after  complete  excision 
of  the  pancreas.  Four-fifths  of  the  pancreas  can  be  removed  from  a  dog  with- 
out producing  permanent  glycosuria,  but  if  more  than  this  is  removed  the  dog 
develops  saccharine  diabetes  and  eventually  dies  of  it.  In  man,  quite  large- 
sized  pieces  of  the  gland  have  been  removed  and  recovery  has  followed.  Hence 
it  is  justifiable  to  excise  a  hopelessly  damaged  portion,  bearing  in  mind  Park's 
caution  that  the  chief  danger  in  excising  a  portion  of  the  pancreas  is  injury  to 
the  splenic  artery. 

Wounds  of  the  Pancreas  During  Operations  on  the  Stomach  and 
Spleen. — In  the  performance  of  gastrectomy,  partial  or  complete,  the  pancreas 
will  be  injured  if  the  growth  or  ulcer  be  adherent  to  it.  Such  an  accident  is  held 
by  most  operators  to  increase  mortality  greatly.  The  Mayos  report  448 
resections  of  the  stomach  for  benign  and  malignant  disease.  The  average  mor- 
tality was  10  per  cent.  In  8  per  cent,  of  these  cases  the  pancreas  was  injured, 
and  the  average  mortality  of  such  cases  was  only  11  per  cent.  (Wm.  J.  Mayo,  in 
"Annals  of  Surgery,"  August,  1913).  The  injuries  reported  by  the  Mayos 
were  superficial  at  the  point  to  which  the  stomach  adhered.  In  no  case  was  the 
main  duct  opened.  It  was  noticed  in  these  cases  that  local  peritonitis  had 
caused  the  formation  of  a  fibrous  capsule.  Bleeding  was  controlled  by  suture- 
ligatures  of  catgut.  The  pancreatic  wound  was  not  sutured.  As  stated  on 
page  1224,  if  the  pancreas  is  wounded  during  pylorectomy,  the  closed  end  of  the 
duodenum  is  placed  in  the  pancreatic  wound  and  the  anterior  peritoneum  and 
adventitious  sheath  is  sutured  to  the  anterior  portion  of  the  duodenum.  If  an 
ulcer  of  the  posterior  wall  of  the  stomach  is  adherent  to  the  pancreas,  trans- 
gastric  excision  removes  considerable  pancreatic  tissue.  Such  a  wound  is  not 
sutured,  but  the  gap  is  filled  by  a  mobilized  bit  of  gastrohepatic  or  gastrocolic 
omentum  (Wm.  J.  Mayo,  Ibid.).  In  2  of  my  cases  of  splenectomy  I  damaged 
the  pancreas,  tying  off  a  bit  of  the  tail  with  the  splenic  vessels.  In  i  case 
leakage  occurred  and  death  followed,  anterior  drainage  having  been  employed. 
In  the  other  case  there  was  profuse  drainage  for  several  days,  which  was  carried 
off  by  a  posterior  drain.  This  patient  recovered.  Both  were  cases  of  Banti's 
disease. 

Pancreatic  Fistula. — A  fistula  may  follow  a  wound  of  the  pancreas. 
It  is  a  very  troublesome  condition,  often  refuses  most  obstinately  to  heal,  and 
the  pancreatic  secretion  causes  maceration  and  violent  irritation  of  the  adjacent 
skin.  The  usual  treatment  is  to  keep  the  way  open  for  easy  drainage.  Wohl- 
gemuth's  plan  is  promising  ("Berliner  klin.  Wochen.,"  1908,  No.  8).  He  re- 
ported 5  successful  cases.  I  have  had  2  cases.  Each  followed  operation 
upon  a  pancreatic  cyst.  The  treatment  consists  in  feeding  upon  strict  anti- 
diabetic diet  and  in  giving  large  doses  of  bicarbonate  of  soda  before  and  after 
meals.  By  cutting  off  carbohydrates  a  powerful  stimulus  to  the  flow  of  pan- 
creatic juice  is  removed.     The  bicarbonate  of  sodium  lessens  the  acidity  of  the 


Pancreatitis  1195 

stomach  contents.  The  more  acid  the  contents  which  enter  the  duodenum, 
the  greater  the  flow  of  pancreatic  juice;  the  less  acid,  the  less  the  flow. 

Displacement  of  the  Pancreas. — In  cases  of  splanchnoptosis  the  pancreas 
may  become  considerably  displaced,  though  this  condition  cannot  be  recognized 
without  opening  the  abdomen.  It  may  be  a  portion  of  the  pedicle  of  a  movable 
spleen.  So  far,  I  know  of  no  case  in  which  fixation  has  been  attempted,  though, 
of  course,  theoretically  it  could  be  done.  The  pancreas  has  been  found  in 
umbilical  herniae.  In  10  per  cent,  of  diaphragmatic  hernise  the  pancreas  con- 
stitutes part  of  the  contents.  Korte  collected  8  cases  in  which  the  pancreas 
prolapsed  through  an  abdominal  wound.  In  several  cases  in  which  the  pan- 
creas prolapsed  into  an  abdominal  wound  the  protruding  part  has  been  excised. 
In  other  cases  it  has  been  restored. 

Pancreatitis  often  leads  to  the  production  of  jaundice;  always  to  very 
rapid  loss  of  weight;  occasionally  to  the  presence  of  fat  and  sugar  in  the  urine; 
sometimes  to  the  presence  of  fat  in  the  stools,  and  frequently  to  the  condition 
known  as  fat  necrosis.  Robson  and  Moynihan'-  point  out  that  when  there  is 
no  diarrhea  and  the  stools  contain  undigested  muscle-fiber,  one, may  assume 
that  there  is  a  deficiency  in  pancreatic  juice.  When  there  is  a  blockage  to  the 
secretion  from  the  pancreas,  if  salol  be  given  by  mouth,  salicyluric  acid  does  not 
appear  in  the  urine.  The  test  is  made  by  putting  15  gr.  of  salol  into  gelatin 
capsules  hardened  with  formalin  (Sahli)  and  giving  them  with  a  roll  and  a  cup  of 
water.  If  pancreatic  ferment  is  in  the  intestine,  salicyluric  acid  appears  in  the 
urine  in  from  three-quarters  of  an  hour  to  one  hour;  if  the  ferment  is  absent  from 
the  intestine,  salicyluric  acid  is  not  found  in  the  urine  because  the  salol  is  not 
split  up  and  absorbed.  The  test  for  the  acid  is  ferric  chlorid,  which,  in  the 
presence  of  the  acid,  turns  the  urine  violet.  The  general  cause  of  pancreatitis 
is  infection.  Often  obstruction  of  the  common  duodenal  outlet  of  the  pancreatic 
duct  and  common  bile-duct  is  followed  by  infection  and  suppuration  of  the  pan- 
creatic ducts  and  pancreatitis.  Besides  the  general  cause,  which  is  infection, 
various  exciting  causes  may  be  named,  among  which  are  gall-stones  in  the 
common  duct  and  calculi  in  the  pancreatic  ducts,  traumatism,  cancer  of  the 
stomach  or  duodenum,  catarrh  of  the  stomach  or  duodenum,  and  many  infec- 
tious diseases.  It  thus  becomes  evident  that  the  infection  may  be  by  way  of 
the  blood;  but,  undoubtedly,  in  the  vast  majority  of  cases,  the  infection  comes 
from  the  duct,  or  gaU-bladder  by  way  of  the  lymphatics.  One  manner  in  which 
the  disease  may  be  produced  was  suggested  by  Halsted  and  Opie,  of  Baltimore: 
A  stone  becomes  impacted  in  the  duodenal  outlet  of  the  common  duct  and  pan- 
creatic duct,  the  pancreatic  duct,  where  it  emerges  above  the  common  duct, 
not  being  blocked.  The  bile  and  pancreatic  juice  are  thus  prevented  from  enter- 
ing the  duodenum,  and  the  bile  flows  back  into  the  pancreatic  ducts.  Swelling 
of  the  papillae  could  act  in  the  same  way.  So  could  a  plug  of  mucus.  It  is 
thought  that  overacid  duodenal  contents  may  enter  the  duct  and  produce  pan- 
creatitis. Deaver  and  Pfeiffer  ("Annals  of  Surgery,"  1913,  58)  believe  that 
pancreatitis  is  lymphangitis.  J.  E.  Sweet  ("Internat.  Clinics,"  vol.  iv,  Series 
25)  makes  the  subject  clear.  According  to  that  investigator  not  all  acute  cases 
are  due  to  stones  in  the  ampulla  but  whether  caused  by  stones  or  not  infection 
is  the  real  cause.  Infection  kiUs  ceUs,  sets  free  in  the  tissues  an  agent  which 
activates  tr}-psinogen  into  trypsin,  trypsin  digests  living  tissue,  erodes  blood- 
vessels, causes  hemorrhage  and  perhaps  gangrene.  If  infection  takes  place 
\%-ithout  activating  the  proteid  ferment,  an  abscess  forms.  Infection  of  the 
interlobar  connective  tissue  is  chronic  pancreatitis.  It  is  lymphangitis.  Pan- 
creatitis is  predisposed  to  by  obesity  and  arteriosclerosis  (Balch  and  Smith, 
"Publications  of  the  Mass.  Gen.  Hosp.,"  Oct.,  191 1). 

That  strange  condition  kno-^m  a.%  fat-necrosis  is  often  present  in  pancreatitis. 
In^  fat-necrosis  the  fat  is  decomposed  into  fatty  acids  and  glycerin.  The 
1  Robson  and  Moynihan,  on  "Diseases  of  the  Pancreas." 


1 196  Diseases  and  Injuries  of  the  Abdomen 

glycerin  is  absorbed,  but  the  fatty  acids  unite  with  calcium  salts  and  remain  in 
the  tissues,  forming  patches  of  yellowish-white  color  and  varying  size.  These 
patches  are  found  in  the  fat  beneath  the  peritoneum,  in  the  omentum,  and  in  the 
mesentery,  and  even  in  distant  parts  (for  instance,  the  pericardium).^  It  is 
an  undoubted  fact  that  fat-necrosis  is  not  uncommonly  found  after  diseases 
and  injuries  of  the  pancreas;  and  many  assume  that  it  is  produced  by  the  en- 
trance of  the  ferment  of  the  pancreas  into  the  fatty  tissue.  How  the  ferment- 
gets  there  is  a  matter  of  some  doubt.  In  the  case  of  a  wound  of  the  pancreas 
one  can  understand  the  flow  of  the  secretion  and  its  imbibition  by  adjacent  parts; 
but  in  other  cases  one  must  assume  that  it  has  been  absorbed  by  the  lymphatics 
and  distributed  to  more  distant  parts.  When  one  reflects  that  in  some  condi- 
tions of  the  pancreas  there  is  no  fat-necrosis,  whfle  in  others  this  condition  arises, 
it  is  presumable  that  the  pancreatic  conditions  associated  with  it  are  such  as  to 
permit  the  fat-splitting  ferment  to  diffuse  into  neighboring  tissues. 

In  pancreatic  disease  hemorrhage  into  that  organ  is  common.  The  hemor- 
rhage is  not,  of  necessity,  fatal,  but  frequently  is  so.  Occasionally  death  takes 
place  as  the  result  of  sudden  pancreatic  hemorrhage  in  a  person  apparently  in 
excellent  health.  It  is  thought  by  Robson  and  Moynihan  that  during  the 
existence  of  cancer  of  the  pancreas  there  is  a  strong  tendency  to  excessive 
hemorrhage  after  any  operation.  In  i  case  of  my  own  the  patient  bled  to  death 
after  the  performance  of  cholecystostomy  for  obstructive  jaundice.  The 
oozing  of  blood  in  this  case  was  from  the  margins  of  the  gall-bladder  and  the 
adjacent  peritoneal  surfaces.  We,  therefore,  conclude  that  in  certain  conditions 
of  the  pancreas  there  is  a  tendency  to  local  hemorrhage  in  that  organ;  and  that 
there  may  also  be  a  tendency  to  the  development  of  a  general  hemorrhagic 
diathesis,  the  general  hemorrhagic  tendency  being  much  increased  if  jaundice 
exists.  During  acute  inflammation  of  the  pancreas  hemorrhage  is  almost 
certain  to  occur  into  that  gland;  in  other  varieties  of  inflammation  hemorrhage 
may  occur  or  may  be  absent.  In  degenerative  lesions  of  the  pancreas  a  material 
like  unfermented  pentose  is  frequently  present  in  the  urine.  When  the  reaction 
for  this  material  is  obtained  we  speak  of  it  as  the  Cammidge  reaction,  after  its 
discoverer.  (For  Cammidge's  improved  method,  see  "Brit.  Med.  Jour.," 
May  19,  1906.)  The  Cammidge  reaction  is  not  by  any  means  conclusive  proof 
of  organic  pancreatic  disease.  It  may  be  found  in  a  great  variety  of  other  con- 
ditions (gall-stones,  cholecystitis,  gastric  carcinoma,  burns,  etc.).  In  most 
patients  who  exhibit  it  there  is  arteriosclerosis  and,  of  course,  this  condition 
might  affect  pancreatic  secretion  (Watson,  "Brit.  Med.  Jour.,"  April  11,  1908). 
My  own  views  coincide  with  those  of  Swan  and  Gilbride  ("New  York  Med. 
Jour.,"  April  23,  1910).  They  believe  a  positive  reaction  indicates  disturbed 
pancreatic  function,  but  not,  of  necessity,  organic  disease. 

Forms  of  Pancreatitis. — This  disease  is  divided  by  Robson  and  Moynihan 
into  the  acute,  the  subacute,  and  the  chronic  forms;  and  they  say  that  recorded 
cases  demonstrate  the  fact  that  three  distinct  classes  of  inflammation  may 
arise:  (i)  Cases  that  die  within  forty-eight  hours  from  the  beginning  of  the 
trouble.  In  this  group  hemorrhage  is  usually  found,  and  if  fat-necrosis  is 
present,  it  is  limited  in  area.  (2)  Those  that  live  for  some  weeks  after  the 
beginning  of  the  trouble.  In  these  cases  the  pancreas  may  become  necrotic 
or  suppuration  may  occur.  Fat-necrosis  is  usually  widespread.  (3)  In  the 
third  class  of  cases  long-continued  inflammation  or  repeated  attacks  produce 
sclerosis  of  the  pancreas. 

Acute  Pancreatitis. — Normal  pancreatic  juice  does  not  digest  living  pan- 
creatic tissue.  In  acute  pancreatitis  the  tissue  is  digested.  Bacterial  infection 
reaches  the  pancreas  and  kills  cells.  The  dead  cells  furnish  a  substance  which 
activates  trypsinogen  into  trypsin  and  trypsin  digests  living  tissues.  If  material 
from  the  duodenum  reaches  the  pancreas  trypsinogen  will  be  activated.     If 

'  Robson  and  Moynihan,  on  "Diseases  of  the  Pancreas." 


Acute  Pancreatitis  1197 

pancreatic  drainage  is  blocked  (as  by  a  stone  in  the  diverticulum)  infection  may 
be  inaugurated  and  existing  infection  intensified.  It  digests  or  ruptures  the 
walls  of  the  small  ducts  and  diffuses  through  the  gland,  producing  necrosis  of 
gland  tissue,  exudation  into  gland  tissue,  necrosis  of  the  blood-vessels,  and,  in 
consequence,  hemorrhage  (Balch  and  Smith,  in  "Publication  of  IMass.  Gen. 
Hosp.,"  Oct.,  iQii).  Hemorrhage  usually  but  not  invariably  occurs.  It  is 
apt  to  be  profuse.  A  part  of  the  gland  or  the  entire  gland  may  be  involved. 
Fat-necrosis  occurs  from  the  action  of  the  fat-splitting  ferment  which  does  not 
require  activation.  A  part  of  the  pancreas  or  the  entire  gland  may  become 
gangrenous. 

The  symptoms  of  this  condition  come  on  suddenly  and  consist  of  violent 
pain  in  the  epigastric  region,  but  seldom  marked  tenderness,  usually  vomiting, 
constipation,  weakness  of  the  circulation,  slow  or  moderately  rapid  pulse,  cold 
extremities,  and  collapse,  with  a  great  fall  in  blood-pressure.  The  tempera- 
ture is  normal  or  moderately  elevated.  Some  maintain  that  collapse  is  due 
to  trypsin;  others,  that  it  results  from  the  absorption  of  toxic  products  from 
the  gland.  The  pain  is  extremely  violent  and  is  intensified  in  paroxysms, 
and  there  is  rigidity  of  the  epigastrium.  In  some  cases  there  is  appreciable 
tenderness.  The  patient  vomits  the  contents  of  the  stomach  and  then  bilious 
matter.  Distention  soon  becomes  distinct  in  the  upper  portion  of  the  abdomen. 
The  patient  presents  the  appearance  of  one  suffering  from  peritonitis.  This 
condition  is  not  unusually  mistaken  for  intestinal  obstruction,  but  in  acute 
pancreatitis  the  constipation  is  not  absolute;  the  patient  passes  gas,  and  may 
even  have  a  bowel  movement  as  the  result  of  the  administration  of  an  enema. 
The  condition  is  usually  fatal  within  a  few  days  but  may  last  for  many  days, 
but  in  very  rare  instances  recovery  takes  place.  In  acute  pancreatitis  from 
stone  in  the  common  duct  there  is  no  leukocytosis  (Murph}-).  In  some  cases 
of  pancreatitis  from  other  causes  there  is  high  leukocytosis. 

The  diagnosis  cannot  be  made  with  certainty  and  is  n;ierely  an  inference. 
Reginald  Fitz  told  us  that  the  existence  of  this  disease  should  be  suspected 
when  a  person  previously  in  good  health,  or  who  has  complained  only  of  occa- 
sional attacks  of  digestive  disorder,  is  suddenly  seized  with  severe  pain  in  the 
epigastric  region,  followed  by  vomiting  and  collapse;  and  when,  within  twenty- 
four  hours  or  more,  there  appears  a  circumscribed  swelling  in  the  epigastrium 
which  is  resistant  or  tympanitic.  Visible  oil  in  the  stools,  a  Cammidge  reaction, 
or  sugar  in  the  urine  add  probability  to  a  diagnosis  of  pancreatitis.  When  an 
exploratory  incision  is  made  in  the  abdomen,  if  fat-necrosis  is  detected,  the 
diagnosis  becomes  certain.  The  peritoneal  cavitv  mav  contain  thin,  bloodv 
fluid. 

Treatment. — Operation  was  suggested  by  Naunyn  in  1903.  Just  as  soon 
as  the  patient  has  been  roused  from  shock,  exploration  is  made  by  way 
of  the  abdomen.  Robson  operates  at  once,  even  in  shock.  It  is  quite 
true  that  the  patient  might,  if  let  alone,  pass  through  the  acute  stage,  and 
that  a  local  abscess  might  then  form,  the  treatment  of  which  would  be  ob- 
vious. But  the  danger  of  waiting  is  too  great  to]  justify  delay,  and  if  sup- 
puration should  occur  it  might  not  remain  local,  but  might  spread  widely  in 
the  retroperitoneal  tissues.  When  observation  after  exploratory  incision  into 
the  greater  cavity  of  the  peritoneum  suggests  the  existence  of  acute  pancreatitis, 
the  infected  area  should  be  exposed,  preferably  above  the  stomach,  through  the 
gastrohepatic  ligament.  The  pancreas  should  be  incised,  necrotic  tissue  should 
be  removed,  hemorrhage  should  be  arrested  by  ligation  or  packing,  the  gauze 
pack  emerging  above  the  lesser  curvature,  a  stab  incision  should  be  made  at  the 
costovertebral  angle,  and  posterior  drainage  should  be  made  from  the  lesser 
peritoneal  cavity.  One  should  follow  the  rule  laid  down  by  Roswell  Park, 
and  explore  in  every  case  in  which  the  disease  is  suspected  to  exist.  Of  Korte's 
16  cases  operated  on  during  the  first  week  11  recovered  (''Annals  of  Surgery," 


iigS  Diseases  and  Injuries  of  the  Abdomen 

1911,  vol.  Iv).  Of  Balch  and  Smith's  cases  (''Publication  of  Mass.  Gen.  Hosp.," 
Oct.,  191 1),  II  were  operated  upon  within  three  days,  and  3  recovered.  The 
two  authors  just  quoted  state  that  the  Massachusetts  General  Hospital  records 
for  twenty-one  years  show  only  i  victim  who  recovered  without  operation. 
Mikulicz  (''Annals  of  Surgery,''  1903,)  recorded  75  operations  for  acute  pan- 
creatitis. In  36  the  pancreas  was  attacked  surgically  with  25  recoveries.  In 
41  the  pancreas  was  not  directly  attacked  and  only  4  recovered. 

Subacute  pancreatitis  comes  on  suddenly,  with  violent  pain,  vomiting,  and 
constipation,  but  there  is  far  less  exhaustion  and  weakness  than  in  the  acute 
form.  The  vomiting  is  less  marked  and  the  swelling  in  the  epigastric  region 
is  not  so  rapid.  The  symptoms  are  similar  to  those  of  the  acute  form,  but  not 
so  violent  nor  so  rapidly  progressive.  The  temperature  frequently  rises  higher 
than  in  the  acute  form,  and  it  may  become  irregular  or  chills  may  occur.  In 
many  cases  the  patient  seems  to  grcrw  better  after  a  time,  the  violent  pain 
abating,  though  distinct  pain  may  remain,  but  he  does  not  gather  strength 
and  continues  to  lose  flesh,  and  there  is  usually  albumin  and  there  may  be 
sugar  in  the  urine.  In  rare  instances  fat  is  found  in  the  urine.  In  subacute 
pancreatitis  abscess  is  prone  to  form.  The  abscess  may  make  a  distinct  swell- 
ing in  front,  and  may  lead  to  the  development  of  a  subphrenic  or  of  a  perirenal 
abscess.  In  rare  cases  an  abscess  of  the  pancreas  tracks  its  way  for  a  long  dis- 
tance in  the  subperitoneal  tissue;  occasionally  it  opens  into  the  stomach  or 
bowel.  Cases  of  subacute  pancreatitis  usually  die,  but  occasionally  recover 
after  a  long  illness. 

Treatment. — Exploratory  incision.  Expose  the  pancreas,  preferably  by 
dividing  the  gastrohepatic  ligament;  determine  its  condition;  remove  purulent 
matter  and  necrotic  areas;  arrest  hemorrhage  with  packing,  and  insert  posterior 
drainage  at  the  costovertebral  angle.  Leave  the  anterior  wound  open  for  the 
emergence  of  the  gauze  packing.^  Drainage  of  the  gall-bladder  has  been  rec- 
ommended, but,  as,  a  matter  of  fact,  it  gives,  as  a  rule,  but  temporary  relief. 

Chronic  Pancreatitis. — There  are  many  causes  which  favor  the  development 
of  chronic  pancreatitis,  viz.,  syphilis,  alcohol,  bacteremia,  block  of  the  common 
duct  (stenosis,  stone,  etc.),  extension  of  inflammation  from  the  bile-ducts, 
and  ascending  infection  from  the  duodenum.  It  is  a  lymphangitis  of  the  inter- 
lobular tissue  and  is  due  to  infection.  It  usually  results  from  disease  of  the  bile- 
passages  and  is  often  associated  with  gall-stones.  In  2200  operations  performed 
by  the  Mayo  brothers  on  the  gall-bladder  and  bile-ducts,  the  pancreas  was  found 
diseased  141  times  (6.4  per  cent.). 

In  168  cases  of  pancreatic  disease  on  which  they  operated  81  per  cent,  were 
caused  by  or,  at  least,  associated  with  gall-stones.  In  operations  upon  the  com- 
mon or  hepatic  ducts  the  pancreas  was  diseased  in  18.6  per  cent,  of  cases.  It 
was  diseased  in  4.45  per  cent,  of  cases  of  operation  upon  the  gall-bladder. 
Chronic  pancreatitis  produces  enlargement  of  the  organ,  and  the  enlarged  area 
is  hard  and  feels  like  a  malignant  growth.  This  condition  is  more  common 
than  the  acute  or  subacute  form.  Robson  and  Moynihan  have  operated  upon 
30  cases.  This  disease  is  frequently  associated  with  gall-stones  or  with  stones 
in  the  pancreatic  duct,  and  occasionally  with  ulcer  of  the  stomach  or  of  the 
duodenum.  In  some  cases  symptoms  of  the  condition  come  on  acutely.  Pain, 
nausea,  and  vomiting  occur,  and  jaundice  develops  rapidly,  as  it  does  after  the 
passage  of  a  gall-stone.  It  is  noted,  however,  that  the  pain  is  not  in  the  region 
of  the  gall-bladder,  but  is  in  the  middle  of  the  epigastrium,  and  it  passes  to 
the  left  rather  than  to  the  right.  The  tenderness,  too,  is  in  the  middle  of  the 
epigastrium  and  not  in  the  gall-bladder  region.  There  is  either  constipation 
or  diarrhea.  A  series  of  these  attacks  may  occur,  the  jaundice  growing  worse 
after  each  attack.  In  some  cases,  however,  the  condition  comes  on  gradually 
and  insidiously,  the  pain  slowly  developing,  but  no  violent  seizures  taking 
1  Roswell  Park,  "Annals  of  Surgery,"  December,  15,  1901 


Pancreatic  Cysts  1199 

place.  There  are  rigidity  of  the  rectus  muscles,  rapid  loss  of  flesh,  anemia, 
sometimes  bronzed  skin,  usually  vomiting,  and  considerable  flatulence.  The 
gall-bladder  is  enlarged  and  commonly  palpable. 

In  some  cases  it  is  possible  to  palpate  the  inflammatory  mass.  There  may 
be  irregular  fever  and  chills  with  episodes  of  subnormal  temperature.  None 
of  the  above  indications  are  conclusive  signs  of  disturbed  pancreatic  function. 
Signs  of  disturbed  function  of  the  gland  are  of  great  importance  in  making  the 
diagnosis,  and  these  signs  are  glycosuria  and  impaired  power  of  digesting  fats 
and  proteins  (Walko,  in  '' Archiv.  f.  Veranungskrankheiten,"  1907,  xiii).  Fatty 
stools  containing  unsaponified  neutral  fat  are  very  significant. 

The  jaundice  in  chronic  pancreatitis  results  from  compression  of  the  duct  by 
the  hyperplastic  mass,  or  blocking  of  the  duct  by  a  stone.  Stenosis  of  the 
duodenum  may  occur.  In  jaundice  from  chronic  pancreatitis  capillary  hem- 
orrhage is  particularly  common  (Robson).  Mayo  Robson  attaches  much  im- 
portance to  the  Cammidge  reaction.  In  the  Jefferson  Hospital  we  regard  it  as 
often  of  decided  use,  but  we  do  not  as  yet  attach  as  much  importance  to  it  as 
do  some  other  clinicians.  This  reaction,  when  present,  indicates  degenerative 
disease  of  the  pancreas.  It  is  obtained  when  the  urine  contains  a  substance 
ha\dng  the  characteristics  of  unfermented  pentose. 

Treatment. — Drainage  of  the  gall-bladder  has  been  the  usual  treatment  either 
by  cholecystostomy  or  cholecystenterostomy.  It  may  cure  a  case  but  in  many 
cases  the  benefit  is  temporar}^  and  after  a  time  the  symptoms  are  apt  to  return. 

Wm.  J.  Mayo  ("Am.  Jour.  Med.  Sciences,"  1914)  says:  "  In  at  least  half  of  the 
cases  operated  on  in  our  clinic  the  following  sequence  has  occurred:  Cholecystos- 
tomy had  been  done  for  chronic  cholecystitis  without  stones,  and  with  a  com- 
pUcating  chronic  pancreatitis.  The  patient  was  relieved  for  some  weeks  or 
months  and  then  the  symptoms  returned."  Drainage  was  again  instituted 
and  there  was  perfect  rehef  so  long  as  drainage  was  continued  but  when  the 
fistula  closed  the  symptoms  returned.  Mayo  now  removes  the  gall-bladder  and 
finds  that  a  permanent  cure  is  obtained. 

Pancreatic  Calculi. — WTien  the  pancreatic  secretion  is  blocked,  stones 
tend  to  form;  and  the  blocking  may  be  due  to  inflammation  of  the  duct  of 
Wirsung,  or  may  result  from  chronic  pancreatitis.  The  stones  may  be  single 
or  multiple. 

Symptoms. — There  is  pain  in  the  epigastric  region,  which  usually  comes 
on  in  parox}^sms  that  resemble  those  due  to  gall-stones,  though  they  are  not 
so  \dolent.  Pain  is  accompanied  by  vomiting,  exhaustion,  and  sometimes 
actual  collapse,  and  may  be  followed  by  rigors.  Portions  of  ^one  are  some- 
times recovered  from  the  feces,  and  sugar  is  occasionally  found  in  the  urine. 
Fat  has  also  been  noted  in  the  stools  in  some  cases.  Sometimes  jaundice 
develops  because  the  calculus  presses  upon  the  common  duct.  Pancreatic 
calcuH  are  composed  of  Hme  salts  and  can  be  skiagraphed. 

Treatment. — Pancreatic  calculi  have,  in  rare  instances,  been  removed  by 
operation;  and  this  is  the  proper  procedure  when  the  diagnosis  can  be  made. 
The  diagnosis  is,  however,  possible  only  after  exploratory  incision.  As  a  rule, 
no  operation  is  performed  until  a  cyst  results  or  an  abscess  forms;  and  when  the 
cyst  or  abscess  is  opened  fragments  of  stone  may  be  found  in  the  fluid,  and 
stones  may  subsequently  come  away  in  the  resulting  fistula.  My  colleague, 
Prof.  Nassau,  removed  successfully  a  pancreatic  calculus. 

Pancreatic  Cysts. — Pancreatic  cysts  are  rare.  In  5000  consecutive  ab- 
dominal operations  performed  at  the  Mayo  clinic  there  were  2  for  pancreatic  cyst, 
^lany  forms  of  cyst  may  develop  in  the  pancreas;  the  following  are  set  forth 
by  Robson  and  Moynihan :  (i)  Retention  cysts;  (2)  proliferation  cysts,  includ- 
ing cystic  adenoma  and  cystic  epithelioma;  (3)  hydatid  cysts;  (4)  congenital 
cysts;  (5)  hemorrhagic  cysts;  (6)  pseudocysts.  What  we  speak  of  as  pseudo- 
cysts have  already  been  considered  in  discussing  effusions  into  the  lesser  peri- 


I200  Diseases  and  Injuries  of  the  Abdomen 

toneal  cax-ity.  They  result  from  lacerations  of  the  pancreas  (see  page  1193). 
Retention  cvsts  are  due  to  blocking  of  the  duct  of  Wirsung  or  of  smaller  ducts. 
The  block,  may  be  due  to  stricture,  calculus,  or  primary  chronic  inflammation. 
Undoubtedly  chronic  pancreatitis  plays  a  great  part  in  the  production  of  re- 
tention cysts.  Blocking  causes  dilation,  acini  fuse,  and  a  cyst  forms.  Such  a 
cyst  is  accompanied  by  diffuse  pancreatitis  involving  a  considerable  portion  of 
the  pancreas  and  seriously  affecting  metabolism  and  secretion.  One-third  of 
such  cysts  follow  traumatism.  Prohferation  cysts  are  neoplastic  and  are  very 
rare.  In  1907  Kleinschmidt  could  collect  from  literature  21  cases  only.  Fifteen 
of  these  cases  involved  the  tail  alone.  Any  chronic  pancreatitis  is  limited  and 
disturbances  in  secretion  and  metabolism  are  slight  or  absent  until  late  in  the 
case.  Proliferation  cysts  are  not  caused  by  traumatism.  Congenital  cystic 
disease  is  extremely  rare.  Hemorrhagic  cysts  result  from  hemorrhage  into  the 
substance  of  the  pancreas  itself. 

Symptoms. — Cysts  are  somewhat  more  common  in  men  than  in  women. 
A  cyst  of  the  pancreas  proper  is  more  often  met  with  in  the  head  of  the  organ 
than  in  its  body  or  tail.  The  cyst  may  be  single  or  multiple.  In  its  growth 
it  either  destroys  the  substance  of  the  pancreas  or  it  grows  away  from  the 
pancreas  and  damages  it  but  little.  In  some  cases  the  cysts  grow  to  a  very 
large  size;  and  Robson  and  Moynihan  refer  to  a  case  in  which  the  cyst  at- 
tained the  size  of  a  man's  head,  and  to  another  in  which  it  was  the  size  of  a 
full-term  pregnancy.  A  pancreatic  cyst  is  smooth,  round,  elastic,  and  rather 
tense  (Robson  and  Moynihan).  The  contained  fluid  varies  .greatly.  As  a 
rule,  it  is  brownish-red  in  color;  in  i  case  upon  which  I  operated  it  was  clear 
yellow;  in  some  cases  it  is  milky,  and  in  others  it  is  nearly  black.  The  fluid 
is  always  albuminous.  Urea  may  be  present,  and  in  many  cases  pancreatic 
ferments  are  found.  In  most  cases  the  cyst  adheres  so  closely  to  the  surrounding 
structures  as  to  render  extirpation  practically  impossible.  A  pancreatic  cyst 
of  considerable  size  causes  epigastric  discomfort,  pain  during  digestion,  and 
frequently  vomiting.  In  some  cases  the  pain  is  trivial,  in  others  it  is  very 
violent.  As  a  general  rule,  the  patient  is  constipated,  but  sometimes  diarrhea 
occurs,  and  the  movements  may  even  contain  blood.  If  the  tumor  presses 
upon  the  common  bile-duct,  jaundice  will  develop.  In  some  cases  the  patient 
loses  flesh  markedly  and  with  considerable  rapidity,  and  he  becomes  very  weak. 
A  large  cyst  causes  marked  pressure  symptoms.  Joseph  Ransohoff  ("  Surgery, 
Gynecology,  and  Obstetrics,"  March,  1916)  had  charge  of  a  case  in  which 
the  pressure  of  a  cyst  upon  the  left  renal  vein  caused  unilateral  hematuria. 
In  rare  instances  fat  is  present  in  the  stools,  and  in  other  unusual  cases  sugar  is 
found  in  the  urine.  A  test  should  always  be  made  with  salol,  to  see  whether 
pancreatic  ferment  is  present  in  the  intestine  (see  page  1195).  In  the  beginning 
the  pancreatic  cyst  is  behind  the  stomach;  but  it  enlarges  and,  as  a  rule,  pushes 
the  stomach  upward  and  to  the  right  side,  and  the  transverse  colon  downward. 
The  cyst  approaches  the  surface  of  the  abdomen  below  the  greater  curvature  of 
the  stomach  (Robson  and  Moynihan).  The  same  authors  tell  us  that  in  rare 
cases  the  cyst  appears  at  the  upper  border  of  the  stomach,  and  that  in  others 
it  inserts  itself  between  the  layers  of  the  transverse  mesocolon.  In  a  case  upon 
which  I  operated  it  had  worked  its  way  through  the  subperitoneal  tissue  into  the 
right  loin,  and  was  looked  upon  by  Professor  Montgomery  and  myself  as  a  hydro- 
nephrosis. As  a  rule,  the  pancreatic  cyst  is  immovable,  but  in  rare  instances 
it  is  movable.  When  a  hand  is  placed  in  the  loin  and  another  on  the  abdomen, 
ballottement  may  be  appreciated.  If  the  distended  stomach  or  colon  overlies 
the  tumor  there  will  be  a  tympanitic  percussion-note,  but  when  the  tumor 
reaches  the  abdominal  wall  there  will  be  a  dull  percussion-note.  On  inquiring 
into  the  history  of  these  cases  it  will  be  found  frequently  that  there  has  been  a 
severe  injury  to  the  upper  abdomen. 


Rupture  of  the  Spleen  1201 

Treatment. — Exploratory  incision  makes  the  condition  clear.  In  the 
majority  of  cases  the  cyst  is  incised,  emptied,  and  stitched  to  the  wall  of  the 
abdomen.  This  operation  may  be  done  in  two  stages — first,  exposing  the  cyst 
and  fixing  it  to  the  abdominal  wall;  second,  when  adhesions  have  formed, 
opening  it.  As  a  rule,  however,  it  is  performed  in  one  stage,  the  abdominal 
cavity  being  carefully  protected  by  gauze.  Some  authors  advocate  exposing 
the  cyst,  opening  and  evacuating  it  through  the  abdominal  wound,  and  draining 
through  the  loin.  Complete  extirpation  is  usually  impossible  because  of  the 
adherence  of  the  cyst.  If  the  cyst  is  movable,  extirpation  may  be  carried  out, 
but  the  safest  operation  consists  of  incision  and  drainage. 

Tumors  and  Other  Growths  of  the  Pancreas. — The  pancreas  may 
be  affected  by  sarcoma,  carcinoma,  adenoma,  tuberculous  disease,  or  syphilis. 
Primary  tumors  are  ver}-  rare.  In  two-thirds  of  the  cases  of  pancreatic  cancer 
the  growth  involves  the  head.  The  body  and  tail  seldom  suffer.  Most  pan- 
creatic cancers  have  an  abundance  of  fibrous  tissue.  Billroth  in  1884  re- 
moved an  adenocarcinoma.  Finney  reported  i  case  and  collected  16  from  litera- 
ture which  came  to  operation  ("Annals  of  Surgery,"  June,  1910).  He  says  the 
diagnosis  can  only  be  made  by  exclusion  and  that  in  25  per  cent,  of  cases  the  mass 
is  not  fijced,  but  is  movable.  In  Finney's  series  of  cases  there  were  9  recoveries 
and  8  deaths.  Wm.  J.  Mayo  reports  the  successful  removal  of  a  cyst  with 
sclerosed  pancreatic  tissue  (Ibid.,  August,  1913). 

Treatment. — Attempts  have  been  made  to  remove  tumors  of  the  pancreas. 
After  an  exploratory  incision  has  determined  the  condition,  the  pancreas  is 
exposed  at  the  point  at  which  the  tumor  projects.  This  is  usually  done  by 
opening  through  the  gastrocolic  omentum.  If  the  tumor  is  in  the  tail  of 
the  pancreas,  however,  the  exposure  may  be  effected  in  the  flank.  When 
the  tumor  has  been  exposed  an  attempt  may  be  made  to  enucleate  or  resect  it. 
Coffey  ("Annals  of  Surgery,"  Jan.,  191 1)  shows  that  ligation  of  the  duct  does 
not  occlude  it  permanently.  Tumors  of  the  splenic  portion  of  the  pancreas 
have  been  removed.  Total  pancreatectomy  or  complete  resection  of  the  head 
of  the  gland  should  not  be  attempted. 

In  a  large  tumor  of  the  head  of  the  pancreas  palliate  the  condition  by  chole- 
cystenterostomy.  Villar  reports  13  cases  of  partial  resection  of  the  pan- 
creas for  tumors,  with  5  recoveries  from  operation  (French  Surgical  Congress 
of  1905).     Finney's  paper  deals  with  17  cases  (see  above). 

Injuries  axd  Diseases  of  the  Spleen 

Wounds  of  the  Spleen. — Stab  wounds  of  the  spleen  alone  are  rare.  Those 
by  way  of  the  pleura  are  more  common  than  those  by  way  of  the  abdomen, 
hence  in  most  stab  wounds  of  the  spleen  the  pleura  and  diaphragm  are  injured. 
A  considerable  wound  of  the  spleen  causes  great  hemorrhage  and,  if  surgical 
aid  is  not  soon  at  hand,  will  almost  inevitably  produce  death.  It  is  caused  by 
a  bullet  or  a  stab  and,  as  a  rule,  other  viscera  are  also  damaged.  Immediate 
operation  is  indicated.  Laparotomy  alone  is  suited  to  few  cases.  In  most  cases 
the  damaged  structures  can  be  reached  by  opening  the  abdomen  through  the 
diaphragm  (that  is,  by  enlarging  the  original  wound).  If  the  injury  is  from  the 
front,  and  there  are  evidences  of  intra-abdominal  hemorrhage,  open  the  abdo- 
men, di\dde  the  eighth,  ninth  and  tenth  costal  cartilages  to  enter  the  pleural 
ca\-ity  and  enlarge  the  wound  in  the  diaphragm.  In  some  cases  remove  the 
spleen.  In  some  arrest  bleeding  by  packing,  by  suture  or  by  transplantation. 
If  operation  be  performed  promptly  the  mortalitj'  is  under  20  per  cent. 

Rupture  of  the  Spleen  (Fig.  707). — Rupture  may  be  spontaneous  from 

distention  if  the  organ  is  much  congested  and  enlarged.     Sometimes  bleeding 

takes  place  beneath  the  capsule  and  at  autopsy  nothing  can  be  found  to  account 

for  it.     If  the  capsule  ruptures  a  subphrenic  hematoma  forms.     In  some  cases  a 

76 


I202 


Diseases  and  Injuries  of  the  Abdomen 


cyst  forms  and  bleeding  takes  place  into  the  cyst.  Rupture  may  occur  in  dia- 
betes. Malarial  spleens  are  prone  to  rupture.  Traumatic  rupture  is  far  more 
common  than  spontaneous  rupture.  It  is  unusual  if  the  organ  be  healthy,  but 
does  occasionally  occur  from  crushes.  It  is  rarely  found  unassociated  with  other 
injuries.  The  spleen  may  be  dislocated  as  well  as  ruptured.  An  enlarged  spleen 
is  particularly  liable  to  rupture  not  only  from  a  crush,  but  from  a  kick,  a  blow, 
or  a  fall.  Rupture  of  the  spleen  produces  pain  in  the  lower  part  of  the  left  side  of 
the  thorax  and  in  the  left  hypochondriac  region,  and  rigidity  in  the  left  hypo- 
chondriac region  and  the  signs  and  symptoms  of  intra-abdominal  hemorrhage. 
There  is  tenderness  over  the  spleen,  pain  over  the  heart,  and  great  shortness 
of  breath.  The  bleeding  is  profuse,  but  sometimes  slow.  The  splenic  blood 
contains  numerous  leukocytes  and  clots  rapidly,  hence  the  bleeding  may  be 

arrested  for  a  time,  and  if  it  should  be  the 
^  patient  will  not  bleed  to  death  rapidly  and 

reaction  will  generally  occur  (Ballance). 
The  blood  in  some  cases  clots  so  rapidly 
that  it  gathers  in  the  left  loin,  and  is  not 
commonly  diffused  throughout  the  ab- 
domen. A  subphrenic  hematoma  forms. 
It  gives  rise  to  an  increasing  area  of  dul- 
ness  on  percussion  in  the  left  flank,  which, 
Ballance  points  out,  seldom  shifts  when 
the  position  of  the  patient  is  shifted,  as  it 
does  in  bleeding  from  other  intra-abdominal 
structures.  In  some  cases,  however,  the 
blood  remains  fluid  and  spreads  through- 
out the  belly,  and  then  there  is  rising  dul- 
ness  in  each  flank.  The  cases  reported  by 
Le  Dentu  and  Mouchet  show  that  the 
blood  may  remain  fluid  ("  Bull,  de  I'Acad- 
emie  de  Med.,"  June  i6,  1903).  In 
some  cases  the  signs  of  hemorrhage  are 
late  and  they  may  even  be  deferred  until 
the  fourth  day  (Eisendrath,  "Annals  of 
Surgery,"  Dec,  1902).  In  some  cases 
there  is  violent  pain  in  the  left  shoulder 
{Kehr's  sign). 
be  required  to 
positively.  In 
52  uncomplicated  cases,  not  a  case  was 
operated  upon  (operation  was  not  the  rule  until  1890),  and  84.6  per  cent, 
died.  Eisendrath^  has  collected  50  cases  operated  upon:  56  per  cent, 
recovered  and  44  per  cent.  died.  Fevrier-  has  collected  56  ruptures  of 
the  spleen.  In  46  cases  operation  was  performed  and  the  mortality  was  50 
percent.  E.  Berger  ("Archiv.  fiir  klinische  Chirurgie,"  Bd.  28,  Heft  3)  col- 
lected 168  fatal  cases  of  rupture  of  the  spleen:  145  died  during  the  first  day 
and  every  one  of  them  died  from  hemorrhage.  After  the  first  day  23  died. 
In  90  per  cent,  of  the  entire  series  hemorrhage  caused  death;  in  10  per  cent, 
infection  was  responsible  for  death.  Vedova  collected  194  cases  of  splenectomy 
for  traumatic  rupture,  with  65  deaths,  a  mortality  of  33.5  per  cent.  ("Practical 
Medicine  Series,"  vol.  ii,  1913).  Hemorrhage  is  the  great  danger  in  ruptured 
spleen — hemorrhage  from  the  parenchyma  rather  than  from  the  great  vessels. 
The  parenchyma  is  friable  and  contains  multitudes  of  capillaries  and 
veins,  there  is  no  muscular  tissue,  divided  vessels  do  not  tend  to  contract, 

^  "Jour.  Am.  Med.  Assoc.,"  Oct.  25,  1902. 
^"Rev.  de  Chir.,"  Nov.,  1901. 


Fig.  707. — Fauntleroy's  case  of  ruptured 
spleen.     External  surface. 


Exploratory  incision  will 
recognize  the  condition 
Elder's    table    there   are 


Enlargements  and  Tumors  of  the  Spleen  1203 

and  the  capsule  is  thm  (the  elder  Senn,  in  "Jour.  Am.  Med.  Assoc.,"  Nov. 
21,  1903). 

Treatment  of  Wounds  and  Rupture. — The  treatment  is  evident  from  the 
previous  remarks.  It  is  as  follows:  Open  the  abdomen  immediately,  the  patient 
being  surrounded  with  hot  bottles  and  hot  salt  solution  flowing  into  a  vein. 
Explore  the  spleen  and  other  viscera.  If  the  spleen  is  damaged,  we  may  do 
splenectomy  (total  or  partial),  may  use  the  suture,  the  cautery,  or  the  tampon, 
and  any  other  visceral  injuries  are,  of  course,  attended  to. 

The  usual  operation  has  been  total  splenectomy.  In  partial  splenectomy 
only  the  injured  part  is  excised  and  the  wound  margins  are  sutured. 

The  arrest  of  hemorrhage  by  suture  is  known  as  splenorrhaphy.  Lamarchia, 
in  1896,  was  the  first  to  perform  this  operation.  The  tear  or  wound  is  sutured 
with  catgut  and  the  suture  line  is  covered  with  omentum.  Berger  collected  14 
cases  of  suturing,  with  2  deaths,  but  these  were  injuries  of  less  severity  than  those 
requiring  splenectomy.  In  some  cases  the  tampon  can  be  used.  Berger  col- 
lected 10  cases,  with  i  death.  Another  method  is  to  crush  the  splenic  structure 
slowly  with  broad  forcipressure  forceps  and  suture  the  crushed  margins  with 
catgut.  Senn  followed  this  plan.  George  Ben  Johnston  (paper  read  before 
Johns  Hopkins  Med.  Soc,  March  2,  1908)  has  collected  150  cases  of  splenec- 
tomy for  wounds  or  ruptures,  with  99  recoveries  and  51  deaths,  a  mortality  of 
34  per  cent. 

Abscess  of  the  spleen  is  a  rare  condition  which  is  usually  metastatic 
in  origin.  It  may  follow  pneumonia  or  typhoid,  may  develop  during  pyemia,  or 
may  result  from  injury.  Chronic  suppuration  may  be  due  to  tuberculosis  or 
actinomycosis.  Some  chronic  cases  are  almost  free  of  symptoms.  There  are 
pain  and  tenderness  if  the  serous  membrane  be  involved,  otherwise  they  may  be 
absent.  There  may  be  simply  a  feeling  of  heaviness.  In  many  cases  enlarge- 
ment is  noted  in  the  splenic  region,  and  the  symptoms  of  pyemia  exist.  In 
acute  cases  there  will  be  chills,  fevers  and  sweats.  Leukocytosis  exists  but  may 
not  be  excessive.  The  abscess  may  become  adherent  to  the  belly  wall,  may 
become  encapsulated,  or  may  rupture  into  a  viscus  or  the  peritoneal  cavity. 
Fluctuation  can  seldom  be  obtained.  What  is  known  as  a  tropical  abscess 
(Fontoynant  and  Jourdrau,  in  "Archiv.  Prov.  de  Chir.,"  No.  11,  1902)  may 
develop  during  a  malarial  attack  as  a  result  of  severe  exertion.  There  are  severe 
pain  in  the  left  hypochondrium,  dyspnea,  and  dry  tongue.  There  may  or  may 
not  be  fever.     The  pus  may  be  sterile. 

The  treatment  of  abscess  of  the  spleen  consists  in  incising  the  abdomen 
at  the  outer  edge  of  the  left  rectus  muscle,  suturing  the  spleen  to  the  abdominal 
wall,  opening  the  abscess,  and  providing  for  drainage  (Tedenat^).  If  the 
abscess  is  adherent  to  the  abdominal  wall,  incise  it  directly.  Splenectomy  has 
been  performed  for  abscess.  In  9  recorded  cases  of  splenectomy  for  abscess 
there  was  i  death  (George  Ben  Johnston,  paper  read  before  Johns  Hopkins 
Med.  Soc,  Mar.  2,  1908). 

Enlargements  and  Tumors  of  the  Spleen. — (See  Royale  H.  Fowler,  in 
"Long  Island  Med.  Jour.,"  July,  191 1.)  The  spleen  undergoes  hjrpertrophy 
in  the  course  of  infectious  disease,  from  amyloid  disease,  from  malaria,  from 
splenic  anemia,  from  tuberculosis,  from  leukemia,  and  from  Hodgkin's  disease. 
Secondary  cancer  is  seen  after  cancer  of  the  stomach.  Genuine  primary 
tumors  are  extremely  rare.  Fibroma,  enchondroma,  hemangioma,  lymphan- 
gioma, angioma,  and  sarcoma  occasionally  develop.  Jepson  and  Albert  re- 
ported a  case  of  primary  sarcoma  of  the  spleen  and  collected  31  others  from 
literature  ("Annals  of  Surgery,"  July,  1904).  Primary  carcinoma  can  only 
arise  from  fetal  inclusion.  It  is  usually  medullary  and  is  sometimes  melanotic. 
Secondary  carcinoma  and  secondary  sarcoma  are  more  common.  Echinococcus 
cysts,  dermoid  cysts,  lymph  cysts,  serous  cysts,  and  blood  cysts  occasionally 
1 "  Rev.  de  Gynec.  et  de  Chir.  Abd.,"  July,  August,  1901. 


I204  Diseases  and  Injuries  of  the  Abdomen 

develop.  The  spleen  alone  may  suffer  from  hydatid  disease.  The  liver  is  apt 
to  be  also  involved.  "There  is  but  a  single  recorded  case  of  dermoid  cyst. 
It  was  reported  by  Andral  in  1830"  (Royale  Hamilton  Fowler,  in  "Surg., 
Gynec,  and  Obstet.,"  August,  1910). 

Non-parasitic  cysts  may  be  unilocular  or  multilocular. 

A  blood  cyst  is  usually  preceded  by  injury  or  an  infectious  disease.  A 
serous  cyst  may  result  from  a  hemorrhagic  cyst,  and  a  blood  cyst  may  be  due 
to  hemorrhage  into  a  serous  cyst  (Fowler,  Ibid.).  There  are  on  record  12  cases 
of  splenectomy  for  sarcoma:  9  recovered  and  3  died  (George  Ben  Johnston, 
Log.  cit.). 

Treatment. — The  condition  may  become  clear  after  exploratory  laparotomy 
only.  For  some  tumors  splenectomy  is  indicated.  A  hydatid  cyst  is  treated 
as  is  a  hydatid  cyst  of  the  liver  (see  page  11 72).  A  blood  cyst  is  sutured  to  the 
incision  in  the  abdominal  wall  and  is  drained. 

Splenoptosis,  or  Wandering  Spleen. — The  spleen  may  wander  into 
any  part  of  the  general  peritoneal  cavity.  This  condition  is  seldom  met  with 
except  in  women.  It  is  most  common  in  women  who  have  borne  children. 
A  wandering  spleen  may  undergo  atrophy,  engorgement,  or  axial  rotation 
(Sir  J.  Bland-Sutton).  The  spleen  may  be  healthy  or  enlarged  from  malaria 
or  leukemia.  As  a  matter  of  fact,  it  is  usually  diseased.  The  organ  when 
displaced  drags  upon  the  stomach,  producing  dilated  stomach;  it  may  interfere 
with  the  bile-duct,  causing  jaundice;  it  may  cause  intestinal  obstruction  by 
forming  adhesions,  or  may  cause  uterine  retroflexion  or  prolapse  by  passing 
into  the  pelvis. 

Sir  J.  Bland-Sutton^  says  this  condition  may  endanger  life,  as  it  may  lead 
to  rupture  of  the  stomach,  intestinal  obstruction,  splenic  abscess,  or  splenic 
rupture.  A  wandering  spleen  can  be  identified  by  the  fact  that  it  has  a  notch 
upon  its  edge,  and  can  be  pushed  about  the  abdomen.  When  the  spleen 
wanders  it  may  be  missed  from  its  normal  situation.  Always  examine  the 
blood  in  oraer  to  determine  if  leukemia  or  malaria  exists. 

Treatment. — Greiffenhagen  advocates  suturing  the  organ  in  place  {spleno- 
pexy). Most  surgeons  prefer  to  perform  splenectomy.  In  a  case  without 
leukemia  the  operation  is  very  successful.  Splenectomy  for  wandering  spleen 
is  rarely  followed  by  serious  blood  changes  or  other  trouble.  The  reason  is 
that  a  wandering  spleen  is  usually  a  diseased  organ,  having  undergone  hyper- 
trophy or  fibroid  change,  and  other  structures  have  taken  on  splenic  function. 
Splenectomy  should  not  be  undertaken  if  leukemia  exists.  In  such  a  case  sur- 
geons usually  apply  a  support  and  employ  medical  treatment  for  the  existing 
disease,  but  some  endeavor  to  suture  the  organ  in  place.  If  the  wandering  spleen 
were  enlarged  by  malaria,  I  would  perform  splenectomy.  If  the  spleen  were 
healthy  I  would  surround  it  with  gauze  exactly  as  is  done  with  the  kidney  in 
a  case  of  movable  kidney.  If  the  spleen  were  enlarged  by  leukemia  I  would 
not  operate  at  all. 

Operations  upon  the  ABDOMEi>f 

Abdominal  Section  {Celiotomy;  Laparotomy). — There  are  many  differ- 
ent methods  of  opening  the  abdomen.  The  plan  selected  depends  upon  the 
nature  and  the  situation  of  the  disease,  and  upon  the  inclinations  and  tlie  custom 
of  the  operator.  The  abdomen  may  be  opened  to  attack  a  recognized  seat  of 
disease  or  injury  or  to  determine  what  the  disease  or  injury  is  and  where  it  is 
situated.  Abdominal  section  performed  for  the  latter  purpose  is  spoken  of  as 
exploratory  section  or  exploratory  incision. 

An  incision  should  not  be  unnecessarily  lengthy,  but  it  should  be  long 
enough  to  permit  of  thorough  exploration  and  rapid  and  safe  work.     A  very 

1  "Brit.  Med.  Jour.,"  Jan.  16,  1897. 


Operation  for  Abdominal  Section  1205 

lengthy  incision  favors  v'sceral  prolapse  and  renders  the  patient  liable  to  hernia. 
Again,  a  lengthy  incision  requires  longer  to  suture  than  a  short  one,  and  so  opera- 
tion is  prolonged.  James  E.  Moore  protests  against  too  small  incisions,  which 
are  often  made  as  a  matter  of  pride  (,"  Jour.  Am.  Med.  Assoc,"  Sept.  16,  191 1). 

Of  recent  years  exploratory  operations  have  become  extremely  common, 
and  many  abdominal  conditions  would  be  unrecognized  without  such  explora- 
tion, or  would  be  recognized  at  so  late  a  period  as  to  be  beyond  the  reach  of 
surgery  after  diagnosis.  This  is  notably  true  of  the  surgical  diseases  of  the 
stomach.  The  wise  surgeon  will  not  be  too  radical  in  employing  exploratory 
operations.  The  fact  that  he  can  explore  with  such  comparative  impunity 
does  not  release  him  from  the  obligation  to  endeavor  by  every  proper  method 
to  make  a  diagnosis  before  resorting  to  operation.  1  fancy  that  of  recent 
years  the  belief  that  it  is  almost  waste  of  time  [to  make  prolonged  efforts  to 
diagnosticate  many  intra-abdominal  troubles  because  the  solution  is  so  much 
easier  by  section,  has  become  so  common  as  to  have  led  young  and  unskilled 
operators  to  perform  section  in  cases  in  which  the  diagnosis  might  have  been 
made  without  this  procedure. 

Before  opening  the  abdominal  cavity  for  exploratory  purposes  or  to  gain 
access  to  some  area  of  abdominal  or  pelvic  disease  the  patient  is  carefully 
prepared  as  for  any  other  operation.  In  an  appendicitis  case  the  patient 
is  moved  with  the  utmost  care  and  is  prepared  for  operation  most  gently, 
because  of  the  possible  danger  of  rupturing  an  abscess.  In  an  emergency 
case  no  prolonged  or  complicated  method  of  cleansing  can  be  employed.  The 
abdomen  and  loins  are  scrubbed  carefully  with  soap  and  water,  special  attention 
being  given  to  the  umbilicus;  the  pubic  region  is  shaved,  the  soap-suds  are 
washed  away  with  sterile  water,  the  surface  is  gently  scrubbed  with  alcohol 
and  then  with  a  hot  solution  of  corrosive  sublimate  (i  :  1000),  and  is  covered 
with  gauze  wet  with  the  sublimate  solution.  In  emergencies  the  iodin  method 
can  be  used  after  dry  shaving  (see  page  77).  As  previously  stated  (see  page 
76),  we  no  longer  regard  it  as  necessary  to  "prepare"  the  abdomen  the  day  before. 
The  patient  can  be  prepared  antiseptically  the  morning  of  the  operation,  or 
can  be  shaved  just  before  etherization,  and  be  cleaned  when  under  ether.  The 
instruments  required  depend  upon  the  nature  of  the  case.  Have  at  hand  an 
electric  light  and  appliances  for  throwing  salt  solution  into  a  vein.  Always  have 
the  instruments,  sponges,  and  pads  counted  twice  by  two  people,  write  down  the 
number,  and  have  two  people  count  them  twice  after  operation.  This  rule  is 
adopted  so  that  no  instrument,  sponge,  or  pad  will  be  left  in  the  abdomen. 
Some  surgeons  do  not  use  abdominal  pads  and  sponges  when  dry,  believing 
that  dry  gauze  injures  the  peritoneum  and  favors  the  subsequent  development 
of  adhesions  (Sanger).  Believers  in  this  hold  that  pads  and  sponges  should  be 
wrung  out  in  hot  normal  salt  solution  before  being  used.  I  find  moist  pads  and 
sponges  satisfactory,  but  moist  packs  cannot  be  satisfactorily  adjusted.  If 
(hry  packs  are  used,  dry  pads  and  sponges  may  as  well  be. 

Operation. — An  anesthetic  is  given.  In  some  cases  the  patient  is  placed 
recumbent.  A  blanket,  made  into  a  roU,  is  placed  in  the  hollow  of  the  back  to 
prevent  sprain  of  the  sacro-ihac  joints,  a  common  cause  of  postoperative  back- 
ache. In  some  cases  the  position  of  Trendelenburg  is  employed  (Fig.  708). 
In  the  Trendelenburg  position  the  pelvis  is  elevated,  the  intestines  fall  toward 
the  epigastrium,  are  removed  from  the  necessity  of  being  handled  and  from  the 
danger  of  being  bruised,  the  pelvis  is  thoroughly  exposed,  and  pelvic  work  be- 
comes easier  and  safer.  This  position  should  not  be  used  if  there  is  myocardial 
disease,  as  the  increased  pressure  in  and  flow  of  blood  from  the  inferior  cava  may 
cause  fatal  acute  dilatation  of  the  heart  (Kraske,  of  Freiburg,  in  "Proceedings 
of  German  Surg.  Congress,"  1903).  The  position  is  of  little  use  in  very  fat 
people  (^Trendelenburg),  and  in  such  subjects  may  cause  intestinal  obstruction 
(Kraske) .     When  this  position  is  employed,  the  table  should  be  lowered  as  soon 


i2o6  Diseases  and  Injuries  of  the  Abdomen 

as  possible,  to  avoid  gastric  hemorrhage  (von  Eiselsberg).  The  normal 
position  should  not  be  suddenly  assumed,  as  this  may  cause  intestinal  ob- 
struction, the  omentum  being  mixed  with  coils  of  intestine,  pulHng  the  colon 
down  (Pasteau,  in  "  Bulletins  and  Mem.  de  la  Soc.  Anat.  de  Paris,"  July,  1905). 
The  position  should  not  be  used  in  a  pelvic  abscess  (Konig),  as  it  may  lead 
to  a  flow  of  pus  from  the  pelvis  into  the  far  more  dangerous  regions  above. 

Volvulus  or  kinking  of  the  ileum  and  of  the  large  intestine  have  followed  the 
use  of  the  position.  Organic  disease  of  the  blood-vessels,  heart,  lungs  or  kidneys 
adds  to  the  risk  of  ill  effects  from  the  position.  The  flexion  of  the  legs  often 
causes  much  pain  and  stiffness  and  may  predispose  to  pulmonary  embolism.  If 
the  Trendelenburg  position  has  been  employed,  before  closing  the  belly  return 
the  omentum  to  its  proper  position  and  spread  it  out  (Lauenstein).  In  every 
abdominal  operation  the  patient  is  to  be  carefully  protected  from  cold,  the 
extremities  and  the  chest  are  covered  with  blankets,  and  sterilized  sheets  are 

placed  well  around  the  field  of  operation.  The 
skin  is  sterilized  anew  Immediately  before  operating. 
The  surgeon  steadies  the  skin  of  the  belly  with  the 
fingers  of  his  left  hand,  and,  holding  the  knife  free 
in  the  right  hand,  makes  an  incision.     Incision  may 

_ be  in  any  region,  and  is  made  as  long  as  is  necessary. 

jj"      "^^         ~ '  If"""""""'""  ""      Incisions  may  be  straight,  curved,  angled,  vertical, 

Pjg  ^qS -phg  Trendelenburg      transverse,   or  oblique.      The  vertical  incision  is 

position.  most  commonly  used.     For  purposes  of  explora- 

tion the  incision  is  made  about  2  inches  in 
length,  and  it  is  lengthened  if  it  is  found  necessary.  The  abdomen  may  be 
opened  in  the  median  line  above  or  below  the  umbilicus.  This  incision  is 
advantageous  for  operations  on  the  pelvis,  for  general  exploration,  and  for 
certain  procedures  upon  the  stomach,  the  intestines,  and  the  left  lobe  of 
the  liver.  The  closure  of  such  an  incision,  however,  lacks  strength,  as  com- 
pared with  the  closure  of  an  incision  where  strong  muscles  will  overlie  the 
scar  through  the  peritoneum  and  the  transversalis  fascia.  Incision  through 
the  semilunar  line  is  practised  by  a  number  of  operators.  A  favorite  incision  is 
through  the  rectus  muscle.  The  fibers  of  this  muscle  are  separated,  the  struc- 
tures beneath  it  are  divided,  and,  after  the  completion  of  the  operation,  the 
deeper  structures  are  sutured  and  the  parts  of  the  separated  muscle  are  allowed 
to  fall  together.  The  scar  resulting  from  such  an  incision  is  well  supported  and 
solid,  hence  the  likelihood  of  hernia  developing  is  diminished.  A  favorite 
method  with  some  is  to  open  the  sheath  of  the  rectus  muscle,  retract  the  entire 
muscle  aside,  incise  the  posterior  portion  of  the  sheath  and  the  structures  back 
of  it,  and,  when  the  operation  has  been  completed,  allow  the  entire  muscle  to 
come  back  into  place,  thus  strengthening  the  deep-seated  scar.  When  the 
abdominal  trouble  is  in  a  region  that  admits  of  it,  I  almost  invariably  go  through 
the  rectus  muscle  or  retract  the  entire  muscle.  Besides  these  methods,  there  are 
special  incisions,  suitable  for  particular  cases:  An  oblique  incision  along  the 
costal  margin,  for  reaching  the  gall-bladder;  an  incision  shaped  like  the  italic 
letter/,  for  the  same  purpose;  special  incisions  for  certain  operations  upon  the 
stomach,  for  abdominal  nephrectomy,  etc.  Some  operators  have  even  used  a 
transverse  incision  in  certain  pelvic  operations  especially.  Years  ago  Billroth 
at  times  divided  the  rectus  muscles  transversely.  Many  surgeons  object  to  a 
transverse  incision  which  divides  the  rectus  muscles  (the  Mayos  and  Moynihan). 
Murphy  did  not  object  to  the  procedure.  Moschowitz  and  Lilienthal  warmly 
advocate  it  for  certain  cases.  I  never  hesitate  to  divide  one  rectus  for  a  gall- 
bladder operation.  Retraction  ceases  at  the  nearest  transverse  lines.  G.  G. 
Davis  makes  a  transverse  incision  outside  of  the  rectus  for  appendectomy 
(page  1211).  Farr  (Ibid.)  points  out  one  advantage  in  the  closing  of  a  transverse 
incision.     If  there  is  any  tension  it  can  be  greatly  lessened  by  raising  the 


Operation  for  Abdominal  Section  1207 

shoulders  in  order  to  curve  the  dorsal  and  lumbar  spine.  (A  full  discussion  of 
abdominal  incisions  will  be  found  in  an  article  by  R.  E.  Farr,  "The  Journal 
Lancet,"  Nov.  i,  191 2.) 

In  an  operation  through  the  median  line  the  first  cut  goes  to  the  aponeu- 
rosis of  the  external  oblique  muscle.  Clamp  the  vessels.  Do  not  hunt  for 
the  linea  alba  below  the  umbilicus,  but  go  right  through  or  between  the  recti 
muscles.  Above  the  umbilicus  the  linea  alba  is  very  distinct  and  the  sur- 
geon often  cuts  through  it.  Divide  the  transversalis  fascia,  beneath  which 
is  a  little  fat,  and  expose  the  peritoneum.  The  latter  structure  is  recognized 
by  its  glistening  appearance,  by  the  ease  with  which  it  can  be  pinched  up  be- 
tween the  finger  and  thumb,  and  by  the  readiness  with  which  its  opposed 
surfaces  may  be  made  to  glide  over  each  other.  On  identifying  the  perito- 
neum, catch  it  at  each  side  of  the  incision  with  forceps,  raise  a  fold,  nick  it 
with  a  knife,  and  open  the  layer  by  scissors  to  the  length  of  the  external  wound. 
To  prevent  stripping  of  the  peritoneum  a  good  plan  is  to  anchor  it  to  the  belly 
wall  with  a  stitch  on  each  side  of  the  incision.  Through  the  wound  thus  made 
the  abdomen  and  its  contents  are  explored,  the  trouble  located,  and  determina- 
tion made  as  to  whether  or  not  further  operation  be  advisable,  and,  if  it  be  ad- 
visable, what  form  it  shall  take.  It  may  be  necessary  to  enlarge  the  wound. 
This  is  done  by  placing  the  index  and  middle  fingers  of  the  left  hand  in  the  belly, 
with  their  pulps  against  the  peritoneum,  in  the  line  where  the  surgeon  will  cut, 
to  serve  as  supports  to  the  scissors  and  as  guards  to  intraperitoneal  structures. 
The  scissors  are  introduced  and  the  wound  is  enlarged  upward  or  downward, 
going  around  the  umbilicus  if  necessary.  As  soon  as  the  incision  is  complete 
for  work  in  the  lower  abdomen  or  pelvis  it  is  a  good  plan  to  push  a  large  pad 
into  Douglas's  pouch  and  leave  it  there  until  the  operation  is  finished,  when  it 
must  be  removed.  Slender  adhesions  are  stripped  off  with  the  finger  or  are 
pushed  off  with  gauze ;  firm  adhesions  are  tied  in  two  places  and  cut  between  the 
ligatures. 

The  toilet  of  the  peritoneum  is  important  after  the  operation  is  completed. 
Following  a  clean  laparotomy,  when  but  little  blood  has  flowed  into  the  cavity, 
flushing  is  not  required;  if  much  blood  has  flowed  or  if  septic  matter  has  passed 
into  the  peritoneal  cavity,  after  removing  the  pad  from  Douglas's  pouch  flush 
the  belly  thoroughly  with  hot  normal  salt  solution.  In  a  clean  case  empty  out 
most  of  the  fluid,  but  let  a  pint  or  more  remain  in  the  abdomen.  In  flushing  the 
abdomen  bear  in  mind  INIonks's  observations  as  to  the  mesentery.  It  is  a  sort 
of  shelf.  If  we  follow  down  the  left  side  of  it  with  the  finger  the  finger  must 
enter  the  left  iliac  fossa;  if  we  follow  down  the  right  side  of  it  the  finger  must 
enter  the  right  iliac  fossa.  Hence  in  order  to  flush  the  right  cavity  carry  the 
nozzle  down  the  right  side  of  the  mesentery  to  its  root,  and  in  order  to  flush 
the  left  fossa  carry  it  down  the  left  side  of  the  mesentery  to  the  root  (^Nlonks, 
"Annals  of  Surgery,"  Oct.,  1903).  The  retention  of  the  saline  fluid  in  the 
belly  minimizes  shock.  It  is  absorbed  with  great  rapidity  after  the  operation 
if  the  patient  is  placed  with  his  head  lower  than  his  feet,  because  in  this  posi- 
tion the  saline  fluid  gravitates  to  the  diaphragmatic  region,  where  absorption 
is  very  active;  in  fact,  in  one  hour  the  peritoneal  cavity  can  absorb  from  3  to  8 
per  cent,  of  the  body  weight.  If  there  be  widespread  infection  with  stomach 
contents  or  feces,  eviscerate,  wipe  out  the  peritoneum  with  pads  soaked  in  hot 
normal  salt  solution,  and  wipe  the  intestines  carefully,  slowly  returning  them 
as  they  are  wiped.  Extra vasated  septic  matter  is  apt  to  collect  in  the  peritoneal 
fossas  and  between  the  liver  and  diaphragm,  and  these  regions  must  be  care- 
fully wiped  and  irrigated.  In  cases  of  septic  and  purulent  peritonitis,  flushing, 
evisceration,  and  wiping  'vNdth  gauze  are  not  advisable  (see  page  1 162).  In  some 
cases  it  is  desirable  to  drain  through  a  lumbar  incision.  Rutherford  Morison 
has  pointed  out  that  a  lumbar  opening  into  the  right  kidney  pouch  wfll  drain  a 
fossag  which  holds  over  a  pint  of  fluid,  and  which,  when  the  patient  is  recumbent. 


i2o8  Diseases  and  Injuries  of  the  Abdomen 

is  the  most  dependent  portion  of  the  peritoneal  cavity.  In  some  cases  a  drain- 
age-opening is  made  through  the  Hnea  alba,  through  one  side  or  on  each  side 
of  the  belly,  or  above  the  pubis  or  through  the  vagina.  In  septic  cases  it  may 
be  advisable  to  drain  with  several  pieces  of  iodoform  gauze  instead  of  inserting 
tubes.  After  most  laparotomies  drainage  is  not  needed,  but  it  should  be  used 
when  stomach  contents  were  extra vasated,  and  it  must  be  used  if  feces  or  urine 
have  been  extravasated,  in  certain  recent  septic  cases,  and  when  hemorrhage 
has  been  severe.  We  may  drain  by  a  rubber  tube,  strands  of  gauze,  a  cigarette 
drain,  or  a  glass  tube.  If'a  glass  tube  is  used,  it  is  introduced  at  the  lower  angle 
of  the  wound  and  reaches  the  bottom  of  the  pouch  of  Douglas.  The  tube  is  re- 
peatedly emptied  during  the  progress  of  the  case  by  means  of  a  syringe.  Before 
closing  the  wound  arrest  hemorrhage  and  ask  for  the  count  of  the  instruments 
and  pads  in  order  to  know  that  nothing  foreign  has  been  left  in  the  belly. 

It  is  highly  important  that  an  abdominal  incision  shall  be  accurately  closed, 
for  any  failure  of  neat  approximation  will,  in  all  probabiUty,  result  in  the  forma- 
tion of  a  hernia  through  the  cicatrix.  Various  methods  have  been  employed. 
Probably  the  majority  of  operators  use  layer  sutures,  sewing  up  the  peritoneum 
with  a  continuous  suture  of  catgut,  and  the  aponeurotic  layers  with  the  same 
material  or  with  chromicized  catgut,  and  closing  the  skin  with  either  interrupted 
sutures  of  silkworm-gut  or  a  subcuticular  stitch  of  catgut,  silkworm-gut,  or 
silver  wire.  Other  operators  close  the  peritoneum  with  a  continuous  suture 
of  catgut,  then  pass  silkworm-gut  sutures  through  all  the  other  structures, 
leaving  them  for  the  time  untied;  put  in  and  tie  layer  sutures  of  catgut  or  of 
chromicized  catgut,  and  then  tie  the  silkworm-gut  sutures.  A  layer  suture 
makes  a  beautifully  neat  approximation,  and  is  frequently  quite  satisfactory; 
but  I  have  become  persuaded  that  the  dead  space,  so  often  left  unobliterated 
when  this  method  of  suturing  is  employed — a  space  in  which  blood  and  inflam- 
matory exudate  may  gather— is  a  danger  to  the  future  integrity  of  the  wound. 
The  combination  of' a  dead  space  with  catgut,  a  material  that  is  always  some- 
what uncertain,  is  an  unfortunate  one  from  the  surgical  point  of  view.  I  have 
returned  in  many  cases  to  the  use  of  the  through-and-through  suture,  applied 
according  to  the  method  of  the  late  Dr.  Joseph  Price.  This  suture  is  inserted 
with  the  straight  needle,  is  composed  of  silk  or  of  silkworm-gut,  is  put  in  close 
to  the  margin  of  the  skin,  gathers  up  a  great  deal  more  muscle  than  skin,  and 
then  passes  close  to  the  margin  of  the  cut  peritoneum  and  transversahs  fascia. 
When  these  sutures  are  adjusted  the  peritoneal  edges  are  brought  into  accurate 
and  firm  apposition,  the  peritoneal  surface  is  overlaid  with  abundant  muscle, 
the  skin  edges  are  brought  into  neat  approximation,  and  the  formation  of  a  dead 
space  is  rendered  impossible.  When  passing  the  sutures  have  a  gauze  pad 
under  the  wound  and  be  very  careful  not  to  include  bowel  or  omentum  in  the 
stitches.  It  is  necessary  to  tighten  and  tie  most  carefully  to  prevent  omentum 
being  caught  in  the  loop  of  the  stitch.  After  closing  a  laparotomy  wound, 
dress  with  aseptic  gauze  and  apply  a  flannel  binder.  In  badly  infected  cases 
the  wound  is  often  kept  open. 

If  a  2-inch  incision  has  been  closed  without  drainage  and  primary  union 
has  taken  place,  the  patient  can  usually  get  out  of  bed  in  seven  or  eight  days. 
A  large  incision  offers  greater  danger  of  subsequent  hernia,  and  the  patient  should 
be  kept  in  bed  for  two  or  three  weeks.  If  the  wound  has  been  kept  open  for 
drainage,  a  prolonged  retention  in  bed  may  be  necessary.  I  allow  patients  up 
at  an  earlier  period  than  used  to  be  my  custom,  but  I  do  not  permit  them  to  get 
up  in  one  to  three  days  as  do  Kiimmel  and  others  (Kiimmel,  in  "Zentralblatt 
f.  Chirurgie/'  1908).  To  get  them  up  reasonably  early  lessens  constipation, 
favors  an  early  return  of  appetite  and  strength,  and  diminishes  the  risk  of 
postoperative  thrombosis  and  embolism  and  of  bronchitis.  We  must  bear 
in  mind  that,  if  there  be  myocardial  degeneration,  the  assumption  of  the  upright 
posture  very  soon  after  abdominal  section  may  prove  disastrous  or  even  fatal. 


After-treatment  of  Abdominal  Section  1209 

and  that  in  septic  diseases  there  is  often  myocardial  degeneration  (E.  W. 
Foote,  in  "Progressive  Medicine,"  June,  1909).  In  a  case  in  which  an  incision 
of  considerable  length  has  been  made,  an  abdominal  support  should  be  worn 
for  a  variaoJe  time.  It:  limits  the  movements  of  cough,  laughter,  etc.,  and 
reminds  the  patient  of  the  necessity  of  caution  in  lifting,  hurrying,  etc. 

The  after- Q-Ratiiient  depends  somewhat  on  the  case,  but  certain  general 
rules  can  be  laid  down.  The  kte  J.  Greig  Smith  said  many  wise  things,  and 
among  them  this:  "A  golden  rule  in  the  treatment  of  cases  of  celiotomy  is  to 
let  the  patient  alone.  Everything  approaching  to  meddlesomeness  is  to  be 
condemnedc  The  patient  must  not  be  upset  by  fussy  appHcations  of  tentative 
therapeutics;  when  an  emergency  arises,  it  is  to  be  met,  promptly  and  decisively, 
by  a  method  which  has  been  approved  trustworthy"  ("  Abdotiiinal  So-rgery"). 
In  many  cases  immediately  after  the  operation  the  patient  must  be  treated 
for  shock  by  methods  previously  set  forth.  The  treatment  of  vomiting  result- 
ing from  the  administration  of  an  anesthetic  is  discussed  on  page  1343.  If 
vomiting  persists  during  the  third  or  fourth  day  it  may  be  due  to  acidosis, 
but  is  probably  due  to  the  development  of  inflammation  which  has  caused 
intestinal  paresis;  and  if  it  is  so  produced,  medicine  is  practically  useless.  In 
this  condition  there  is  usually  marked  tympanitic  distention,  and  vomiting  is, 
in  a  sense,  a  rehef.  5*[othing  should  be  given  by  the  mouth  and  the  patient 
should  be  fed  entirely  by  enemata.  The  insertion  o^  a  rectal  tube  and  its 
retention  for  a  considerable  time  may  afford  relief.  Lying  on  the  side  is  more 
comfortable  than  recumbency.  Washing  out  the  stomach  from  time  to  time 
gives  great  comfort  and  is  often  of  real  service. 

In  the  average  case  of  cehotomy,  in  which  persistent  vomiting  does  not 
occur,  the  question  of  feeding  is  of  much  importance.  Usually,  for  the  first 
twelve  or  twenty-four  hours,  nothing  is  given  by  the  mouth  but  small  quantities 
of  hot  water.  The  day  after  the  operation,  if  everything  is  satistactory,  food 
is  given  to  the  patient.  In  many  cases,  however,  food  is  not  given  by  the 
stomach  for  forty-eight  hours  and  the  patient  is  fed  by  the  rectum  during  the 
wait.  He  should  not  be  given  mUk  because  it  will  not  be  easily  digested,  may 
lead  to  nausea,  and  cause  flatulence.  Peptonized  milk,  if  the  patient  will  take 
it,  does  not  possess  these  hurtful  qualities.  At  first  albumin-water  or  liquid 
beef  peptonoids  should  be  given,  and  later  meat-juice,  beef-jelly,  broth,  etc. 
Food  is  given  every  third  or  fourth  hour,  and  stimulants  are  administered 
if  required.  After  the  first  twenty-four  or  forty-eight  hours  considerable 
quantities  of  plain  water  or  Poland  water  should,  if  possible,  be  taken,  to  favor 
elimination  by  the  kidneys.  Hot  coffee  is  not  only  a  stimulant,  but  is  an  ex- 
cellent diuretic.  The  urine  is  always  scanty  after  an  abdominal  opera- 
tion, and  a  normal  daily  amount  is  not  voided  for  ten  days  or  more.  Solid 
food  is  not  given  for  seven  or  eight  days.  The  patient  is  apt  to  suffer  greatly 
from  thirst,  in  spite  of  the  hot  water  given  during  the  first  twelve  to  twenty- 
four  hours.  He  seldom  takes  and  should  never  have  any  great  amount  of  hot 
water,  and  iced  water  and  ice  are  inadmissible  and  tend  to  induce  nausea  and 
vomiting.  Sucking  ice  or  sipping  water  draws  air  into  the  stomach  and  causes 
distention.  Thirst  can  be  much  mitigated  by  enemata  of  salt  solution.  J. 
Greig  Smith  recommended  an  enema  composed  of  from  4  to  20  oz.  of  tepid 
water  and  some  brandy.  Usually,  after  the  first  twenty-four  hours,  a  suflSicient 
amount  of  liquid  can  be  given  to  keep  the  patient  free  from  actual  distress. 

The  bladder  must  be  watched  to  see  that  retention  does  not  occur.  If 
retention  occurs,  a  clean  catheter  must  be  used  at  regular  intervals.  If 
tympanitic  distention  occurs  after  forty-eight  hours,  a  saline  purgative  should 
be  given  and  it  should  be  followed  by  an  enema  of  turpentine.  The  rectal  tube 
is  frequently  of  signal  service  in  such  cases.  If  obstruction  develops,  it  is 
treated  as  directed  on  page  11 23. 

In   any  ordinary  case  after  operation  the  bowels  should  be  moved  after 


12IO 


Diseases  and  Injuries  of  the  Abdomen 


forty-eight  hours  as  a  prophylactic  measure  against  distention,  peritonitis, 
and  obstruction.  From  four  to  eight  i-dram  doses  of  Epsom  salts  are  given, 
in  hot  water,  the  solution  having  been  filtered  through  gauze.  The  saline  is 
followed  by  the  administration  of  an  enema  consisting  of  soap,  water,  and  }4. 
oz.  of  castor  oil.  Should  opium  be  given?  Never  as  a  routine,  and  not  to 
secure  sleep;  but  if  the  patient  be  in  pain  which  not  onlyharasses  him,  but  causes 
him  to  turn  and  shift  in  torturing  restlessness,  one  or  possibly  two  hypoder- 
matic injections  each  containing 
H  gr.  of  morphin  may  be  given 
with  confidence  that  the  good  will 
overbalance  the  harm. 

Operation  for  Appendicitis. 
— -Before  operating  try  to  locate 
the  situation  of  the  appendix, 
and  the  relation  the  area  of  in- 
fection bears  to  the  ascending 
colon.  The  incision  should  be 
over  the  seat  of  disease.  In  the 
rare  left-sided  cases  and  in 
median  cases  the  incision  is 
median.  In  some  cases  in  which 
the  appendix  is  posterior  the  cut 
may  be  in  the  loin.  In  i  case  I 
opened  a  purulent  collection 
through  the  rectum.  In  the  vast 
majority  of  cases  the  incision  is 
made  in  the  right  iliac  region. 

In  acute  appendicitis,  when 
there  is  not  thought  to  be  a  dis- 
tinct abscess,  the  incision  usually 
made  is  2  inches  internal  to  the 
anterior  superior  iliac  spine  and 
perpendicular  to  a  line  drawn 
from  the  spine  to  the  umbihcus 
(Fig.  709).  The  skin  incision  is 
usually  3  inches  in  length,  the 
upper  third  of  the  incision  being 
above  the  omphalospinous  line; 
the  incision  in  the  peritoneum  is 
about  2  inches  in  length,  but  if 
there  are  many  adhesions,  it  may 
be  necessary  to  make  it  much 
longer.  The  oblique  incision 
may  be  carried  out  as  advised 
by  McBurney,  the  muscles  being  separated  by  blunt  dissection.  Bv  this 
method  very  few  nerve-fibers  are  divided,  and  hence  the  operation  is  not  followed 
by  marked  muscular  wasting,  a  condition  which  strongly  predisposes  to  hernia. 
Further,  as  Van  Hook^  points  out,  the  oblique  incision^ enables  the  surgeon  to 
reach  freely  all  the  ordinary  areas  of  appendix  trouble,  the  wound  is  parallel 
with  the  lines  of  traction  of  the  abdominal  muscles,  and  does  not  tend  to  gape 
widely.  In  an  acute  case  I  make  an  oblique  incision,  but  cut  the  muscles 
(Fig.  709).  In  an  interval  case  I  separate  the  muscular  fibers.  Battle's  inci- 
sion at  the  outer  edge  of  the  rectus  muscle  is  preferred  bv  manv  surgeons.  The 
anterior  layer  of  the  rectus  sheath  is  opened  longitudinallv,  the  rectus  is  drawn 


Fig.  709. — Resection  of  the  vermiform  appendix, 
incision  through  the  abdominal  wall:  a.  External 
oblique  muscle;  b,  internal  oblique  muscle;  c, 
aponeurosis  of  external  oblique;  d,  aponeurosis 
of  internal  oblique;  e,  transversalis  fascia  and 
peritoneum;  /,  outer  border  of  rectus  abdominis 
muscle  (under  it  the  deep  epigastric  vessels) 
(Kocher). 


*  "Jour.  Amer.  Med.  .\ssoc.,"  Feb.  20,  1897. 


Operation  for  Appendicitis 


I2II 


inward,  and  any  existing  portion  of  the  posterior  rectus  sheath  with  the  trans- 
versalis,  fascia  and  peritoneum  is  incised. 

I  have  used  Davis's  transverse  incision  (Figs.  710  and  711)  in  many  interval 
cases  with  entire  satisfaction  (Gwilym  G.  Davis,  in  "Annals  of  Surgery,"  Jan., 
1906).     This  incision  does  not  divide  arteries,  but  it  divides  the  deep  muscles 


Umbilicus. 


Fig.  710. — Davis's  small  transverse  incision  for  simple  cases. 

in  the  direction  of  the  nerves,  hence  the  nerves  are  not  injured.  The  center  of 
this  incision  is  almost  over  the  base  of  the  appendix.  Davis  describes  his  in- 
cision as  follows: 

"For  easy  cases  the  incision  is  made  directly  transverse,  ij^^  inches  long.     Its 
center  is  to  be  on  the  semilunar  line  on  a  level  with  the  anterior  superior  spine. 


Fig.  711. — Davis's  large  transverse  incision  for  difficult  cases. 

The  aponeurosis  of  the  external  oblique  is  divided  in  the  line  of  the  skin  incision, 
but  obliquely  to  the  direction  of  its  fibers.  The  fibers  of  the  internal  oblique 
and  transversalis  muscles  are  parted — not  cut — in  the  same  line  as  the  struc- 
tures above.     The  peritoneum  is  then  opened  and  the  incision  is  carried  inward, 


I2I2 


Diseases  and  Injuries  of  the  Abdomen 


first  through  the  anterior  layer  of  the  sheath  of  the  rectus.  A  blurt  retractor 
^4  inch  wide  is  then  inserted  and  the  muscle  drawn  toward  the  rredian  line. 
This  exposes  the  transversalis  fascia  and  peritoneum  posteriorly,  which  ate 
then  also  divided.  Thus  is  obtained  a  triangular  opening  with  its  base  of  ^ 
inch  and  two  sides  of  about  i  inch  long,  which  is  ample  for  simple  cases. 

^^For  Dificidt  Cases. — If  the  case  is  a  difficult  one,  the  outer  end  of  the  in- 
cision is  prolonged  to  the  anterior  spine  or  even  above  and  inwardly  through 
the  sheath  of  the  rectus  to  within  i  inch  of  the  median  line.  This  will  give  an 
opening  4  to  5  inches  long,  according  to  the  size  of  the  patient,  sufficiently 
large  to  insert  the  hand  if  necessary  and  through  which  the  appendix  can  be 
extracted  under  almost  all  circumstances." 

After  opening  the  peritoneum  examine  very  gently  to  detect  the  situation 
of  the  appendix,  and  if  there  are  or  are  not  adhesions.     In  a  very  recent  case 

and  in  a  very  acute  case  there  will 
probably  be  no  adhesions  unless  chere 
have  been  previous  attacks.  If  there 
be  infection,  surround  the  region  in- 
volved with  packs  of  plain  gauze,  each 
strip  being  2^  inches  wide,  15  inches 
long,  and  four  layers  in  thickness. 
The  edges  of  the  wound  should  be 
lifted  up  by  retractors  and  the  strips 
inserted  around  the  cut,  between 
the  parietal  peritoneum  and  intes- 
tines and  to  a  distance  of  3  inches 
from  the  wound.  Strips  of  gauze  are 
passed,  when  possible,  below  the 
appendix  to  prevent  entrance  of  in- 
fected material  into  the  pelvis,  and 
a  piece  is  pushed  upward  toward 
the  liver  (Van  Hook).  Over  the 
packing  gauze,  which  it  may  be 
necessary  to  leave  in  place  after  the 
operation,  other  pads  are  packed. 
The  appendix  is  sought  for  by  finding 
the  colon.  The  colon  is  found  by 
following  the  parietal  peritoneum 
with  the  finger.  The  course  of  the 
finger  is  first  outward,  next  backward, 
and  finally  inward;  the  first  obstruction  it  encounters  is  the  colon.  The 
fact  that  it  is  the  colon  can  be  confirmed  by  finding  the  longitudinal  bands. 
The  anterior  longitudinal  band  leads  directly  to  the  appendix.  Pass  the 
finger  down  to  the  head  of  the  colon,  find  the  appendix,  usually  posterior 
and  internal,  and  lift  it  and  the  head  of  the  colon  into  the  wound.  In 
many  cases  it  will  be  advisable  to  deliver  the  head  of  the  colon  from  the 
belly  (Fig.  712);  in  other  cases  this  will  not  be  necessary,  in  some  it  will 
not  be  possible.  Do  not  permit  the  appendix  to  touch  the  skin  of  the 
abdomen  as  in  Fig.  712.  If  adhesions  exist,  they  must  be  gently  and  carefully 
separated.  Barker's  method  (Fig.  713)  is  a  very  satisfactory  mode  of  removing 
the  appendix.  It  is  done  as  follows:  Turn  up  a  cuff  of  peritoneum,  pull  down  the 
other  coats,  ligate  at  the  base,  cut  through  the  tube,  let  the  musculomucous 
stump  retract,  and  tie  or  suture  the  peritoneal  cuff  over  the  stump.  Another 
method,  which  is  the  one  I  usually  employ,  is  as  follows:  Pass  a  ligature  through 
the  meso-appendix,  as  shown  in  Fig.  714,  yl,  tie  the  ligature,  and  cut  off  the  meso- 
appendix  on  the  appendiceal  side  of  the  threads.  Crush  the  stump  of  the 
appendix  with  strong  straight  hemostatic  forceps.  This  divides  the  mucous 
membrane^  submucous  tissue  and  muscular  coat,  and  leaves  the  peritoneal  coat 


Fig.  712. — Radical  operation  for  appendicitis 
(Kocher). 


Operation  for  Appendicitis 


1213 


undivided.  Remove  the  forceps.  Surround  the  appendix  with  a  catgut  liga- 
ture and  tie  the  ligature  in  the  groove  produced  by  the  crushing.  When  the 
ligature  is  tied,  peritoneum  is  brought  against  peritoneum.  Cut  off  the  appen- 
dix between  the  ligature  and  a  clamp  by  the  cautery,  a  knife,  or  scissors.  Dis- 
infect the  stump  of  the  appendix  by  pure  carbolic  acid,  being  careful  to  allow 
no  excess  of  the  acid  to  run  over  the  adjacent  peritoneum.  Such  excess 
should  be  touched  quickly  with  an  alcohol  sponge.  The  stump  beyond  the 
ligature  contains  mucous  membrane  and  muscle,  which  are  lifted  out  with 
forceps  and  scissors.  Suture  the  fringe  of  the  meso-appendix,  invert  the  stump 
into  the  wall  of  the  colon,  and  suture  a  portion  of  the  wall  over  it  by  inversion 
stitches.  Figure  714  shows  an  older  method  still  used  by  many.  The  meso- 
appendix  is  tied  off  by  one  ligature,  the  appendix  is  not  crushed,  but  is  tied  off 
by  another  ligature,  and  both  structures  are  cut  off  below  their  respective  liga- 
tures. The  stump  :s  disinfected  with  pure  carbolic  acid  or  the  cautery,  in- 
verted, and  the  fringe  0.'  the  meso-apr>endix  is  sutured.  This  method  does  not 
entirely  remove  the  appendix,  but  inverts  glandular  tissue  into  the  wall  of  the 
bowel.  The  stump  may  not  be  completely  asepticized  by  the  carbolic  acid  and 
hence  may  lead  to  postoperative  abscess,  dense  adhesions  or  fecal  fistula,  or  the 


Fig.  713. — Barker's  technic  of  opera-       Fig.  714. — ^Ligation  of  appendix  and  meso-appendix. 
tion  for  removal  of  the  appendix. 

undestroyed  lymphoid  structure  may  cause  further  trouble,  even  persistent  ill 
health  (Joseph  Price).  Some  remove  the  appendix  by  an  elliptical  incision 
around  its  base,  and  close  the  colon  wound  by  Lembert  sutures.  This  method, 
of  course,  removes  the  appendix  completely.  Dawbarn  surrounds  the  appen- 
dix with  a  continuous  Lembert  purse-string  suture  of  silk.  This  is  inserted  in 
the  superficial  layers  of  the  cecum,  3^^  inch  from  the  appendix.  The  appendix 
is  divided  so  as  to  leave  a  stump  never  shorter  than  }i,  inch.  The  lumen  of  the 
stump  is  gently  stretched  by  inserting  a  pair  of  mouse- toothed  forceps  and 
opening  the  blades.  The  stump  is  then  invaginated  into  the  cecum,  that  is,  it 
is  turned  ''outside  in."  The  sutures  are  tightened,  and  while  this  is  being 
done,  the  mouse-tooth  forceps  used  in  effecting  inversion  are  withdrawn. 
Finally,  the  sutures  are  tied  (Robt.  H.  M.  Dawbarn,  in  "Internat.  Jour,  of 
Surg.,"  May;  1895).  In  tliis  method  the  stump  is  not  ligated  and  hemorrhage 
is  liable  to  take  place  into  the  gut.  Deaths  from  such  hemorrhage  are  on  rec- 
ord. The  retained  bit  of  appendix  drains  into  the  colon.  I  believe  it  is  a 
mistake  to  trust  to  simple  ligation  and  to  fail  to  bury  the  stump  left  after  ap- 
pendectomy. If  a  surgeon  foUows  this  plan  in  any  large  number  of  cases  he 
will  now  and  then  have  a  case  in  which  the  ligature  slips  and  feces  pass  into 
the  peritoneal  cavity,  or  cases  of  temporary  fecal  fistula,  or  cases  of  intestinal 
obstruction  from  adhesion  of  some  portion  of  the  bowel  to  the  exposed  stump 
(Murat  Willis,  in  "Annals  of  Surgery,"  July,  1908).  I  do  not  believe  that  a 
buried  stump  increases  postoperative  pain. 


1 2 14  Diseases  and  Injuries  of  the  Abdomen 

If  there  is  no  pus  and  no  extra vasated  feces,  if  the  peritoneum  is  not  seriously 
affected,  if  the  appendix  is  not  gangrenous  or  perforated,  and  if  there  is  no  pus 
within  the  appendix,  remove  the  pads  which  were  inserted  last,  irrigate  with 
hot  salt  solution,  remove  the  strips  of  gauze  which  were  inserted  first,  and  close 
the  wound.  If  any  of  the  above  conditions  have  been  found,  remove  the  infected 
pads,  but  leave  in  place  the  strips  which  were  first  inserted  in  order  to  limit 
infection  and  secure  drainage.  Pass  sutures  through  wound  edges,  tie  some  of 
them  and  leave  some  untied  until  gauze  is  removed  at  a  later  period  (Van  Hook). 

If  an  operation  is  performed  in  a  distinct  interval,  pus  is  absent  and  the 
surgeon  can  proceed  without  apprehension.  If  there  is  any  question  of  the 
presence  of  pus,  surround  the  region  with  gauze,  as  suggested  above,  before 
breaking  down  adhesions  and  liberating  the  appendix.  An  interval  opera- 
tion should  not  be  performed  until  three  weeks  after  an  attack.  In  an  interval 
case  McBurney  proceeds  as  follows:  He  makes  the  skin  incision  in  the  direc- 
tion of  the  fibers  of  the  external  oblique  muscle,  separates  the  fibers  of  this 
muscle  by  blunt  dissection,  retracts  them,  separates  the  fibers  of  the  internal 
oblique  and  the  transversalis  muscles  in  the  same  way  and  retracts  them,  and 
opens  the  transversalis  fascia  and  peritoneum.  No  muscle-fibers  are  cut  and 
hernia  is  not  apt  to  follow.  Such  a  wound  is  closed  as  follows:  a  continuous 
catgut  suture  for  the  peritoneum,  sutures  of  chromic  gut  for  the  transversaHs 
fascia,  the  muscles  are  restored  to  place,  the  aponeurosis  of  the  external  oblique 
is  sutured  with  chromic  gut,  and  the  skin  is  closed  by  interrupted  sutures  of 
fine  sUk  or  silk-worm  gut  or  by  a  subcuticular  stitch. 

If  an  abscess  is  believed  to  exist,  make  an  incision  parallel  with  Poupart's 
ligament  and  over  the  area  of  dulness  on  percussion  (Willard  Parker's  oblique 
incision).  If  the  abscess  is  adherent  to  the  anterior  abdominal  wall  such  an 
incision  will  not  enter  the  free  peritoneal  cavity.  If,  after  opening  the  abdo- 
men, an  abscess  is  thought  to  exist,  although  it  is  not  adherent  to  the  anterior 
abdominal  wall,  surround  the  abscess  with  gauze  before  opening  it,  as  directed 
under  acute  appendicitis.  The  gauze  is  placed  under  the  margins  of  the  in- 
cision in  the  peritoneum  all  around  the  appendix  area;  a  piece  is  carried  to- 
ward the  pelvis  and  another  piece  toward  the  liver.  Overlay  this  gauze  wth 
gauze  pads  (Van  Hook).  Adhesions  are  broken  through  with  the  finger,  and 
when  pus  appears  it  is  at  once  wiped  away.  Remove  the  appendix  in  most 
cases,  but  not  in  all.  If  the  appendix  lies  loose  in  the  abscess  cavity,  if  it 
is  sloughed  off  or  but  loosely  attached  to  the  abscess  wall,  remove  it.  If  the 
appendix  is  firmly  fixed  in  the  abscess  wall  and  must  be  dug  out  of  a  mass  of 
inflammatory  material  do  not  remove  it.  To  remove  it  under  these  circum- 
stances may  rupture  the  wall  and  disseminate  the  pus  into  regions  not  pro- 
tected by  pads  and  gauze.  Deaver  and  others  tell  us  always  to  remove  the 
appendix.  I  do  not  believe  this  to  be  a  safe  rule  to  follow.  To  insist  on 
removing  the  appendix  may  cause  death.  When  the  appendix  is  left,  it  usually 
sloughs  away.  It  is  true,  a  fecal  fistula  may  result,  but  this  is  in  the  large 
bowel  and  usually  heals  spontaneously.  Even  if  a  fecal  fistula  forms  and  does 
not  heal,  the  surgeon  has  acted  properly  in  not  removing  the  appendix,  because 
a  fecal  fistula  may  be  remedied  by  another  operation.  It  is  rarely  that  sec- 
ondary abscess  forms,  and  there  are  not  a  great  many  cases  recorded  in  which 
an  appendix  has  subsequently  given  serious  trouble  when  left  after  operation. 
In  fact,  in  many  cases  the  appendix  is  destroyed  or  obliterated  by  inflamma- 
tion. In  some  cases,  however,  a  secondary  operation  will  be  required  be- 
cause of  a  fecal  fistula,  a  persistent  sinus,  or  an  acute  inflammatory  attack. 
When  Deaver  decides  to  remove  such  an  appendix,  he  makes  an  incision  in 
the  median  line  of  the  abdomen,  packs  around  the  periphery  of  the  abscess 
with  gauze,  opens  the  abdomen  by  another  incision,  removes  the  appendix, 
disinfects,  inserts  drainage,  and  then  removes  the  surrounding  gauze  and 
closes  the  median  incision.     In  every  abscess  case  search  for  fecal  concre- 


Operation  for  Appendicitis  1215 

tions  and  remove  them  if  found.  Irrigation  should  not  be  employed  in  appen- 
dicular abscess.  The  force  of  the  stream  may  break.  do\\'n  barriers  of  lymph 
and  spread  infection.  After  the  evacuation  of  the  pus,  whether  the  appen- 
dix has  been  removed  or  not,  take  out  the  pads,  but  leave  the  long  strands  of 
gauze  first  placed  to  keep  the  wound  open.  Introduce  iodoform  gauze  into  the 
abscess  cavity  and  insert  a  rubber  tube,  partially  suture  the  wound,  and  dress 
with  dry  gauze.  In  forty-eight  hours  all  the  strands  of  gauze  are  removed  and 
fresh  pieces  are  inserted  for  drainage.  After  this  period  the  gauze  drain  is 
changed  daily,  Morris  maintains  and  proves  that  large  pieces  of  gauze  some- 
times cause  intestinal  obstruction  and  iodoform  gauze  sometimes  causes  iodo- 
form-poisoning,  but  the  risk,  it  seems  to  me,  should  be  taken.  An  interval 
case  should  be  up  and  about  in  from  ten  days  to  two  weeks  after  operation. 
An  abscess  case  may  require  a  much  longer  time  for  complete  recovery.  A 
fecal  fistula  sometimes  results  in  cases  in  which  the  appendix  was  not  removed, 
and  occasionally  forms  when  it  was  removed. 

If  on  opening  the  abdomen  pus  is  found,  unlimited  by  adhesions  but  \\-ide- 
spread  in  the  peritoneal  cavity,  remove  the  appendix,  and  then  bear  in  mind 
Murphy's  ^\dse  counsel  as  to  how  to  treat  general  peritonitis  (see  page  1162). 
Put  a  drainage-tube  into  the  peMs  and  one  in  the  appendix  region,  place  the 
patient  in  Fowler's  position,  and  administer  salt  solution  by  continuous  proc- 
toclysis at  a  low  pressure.  The  after-treatment  of  an  ordinary  appendix 
operation  is  that  ad\'ised  after  celiotomy  (see  page  1209). 

Mortality  after  Operations  for  Appejidicitis. — The  interv^al  operation  is  prac- 
tically without  mortality.  In  over  1000  cases  Treves  had  2  deaths.  In  446 
cases  of  chronic  appendicitis  the  Mayos  had  i  death  (''Report  of  St.  Mary's 
Hospital  for  191 2").  In  grave  acute  cases  the  mortality  is  large.  In  100 
consecutive  cases  of  this  character  collected  by  Hearn  and  operated  upon  in  the 
Jefferson  Hospital  by  Keen,  Hearn,  and  DaCosta,  there  were  8  deaths.  As 
previously  stated,  Maurice  H,  Richardson  reported  a  death-rate  in  such  cases 
of  18  per  cent,  in  750  cases.  Deaver  reports  from  the  German  Hospital  144 
cases,  with  a  mortality  of  17.8  per  cent.  He  eliminates  i  death  from  diabetes, 
I  from  pneumonia,  and  i  from  phtiiisis,  and  estimates  his  personal  mortality 
at  15.9  per  cent.  (Deaver  and  Ross,  in  '"Jour.  Am.  Med.  Assoc,"  Oct.  5,  1901). 
In  124  cases  (including  all  chronic  cases  and  those  acute  cases  in  which  .the 
inflammation  had  not  extended  beyond  the  peritoneal  coat)  there  was  i  death. 
In  347  cases  of  acute  and  suppurative  appendicitis  operated  upon  in  the  ]Mayo 
clinic  in  1912  there  were  but  2  deaths  ("Report  of  St.  Mary's  Hospital  for 
1912").  In  the  Mayo  clinic  from  Jan.  i,  1907  to  Jan.  i,  1918  there  were 
12,329  operations  for  appendicitis  -^ith  a  mortality  of  0.6  per  cent.  (Personal 
Communication  to  the  author).  I  fancy  most  of  these  cases  came  from  a  dis- 
tance and  hence  the  proportion  of  \aolent  and  rapid  cases  must  have  been  less 
than  is  usually  the  rule  in  a  great  city.  In  Burgess's  500  consecutive  operations 
there  were  40  deaths  ("  Brit.  Med.  Jour.,"  Feb.  24,  1912).  WTien  infection  was 
limited  to  the  appendix  the  mortality  was  0.74  per  cent.  (135  cases) ;  when  there 
was  circumscribed  abscess  it  was  4.64  per  cent.  (213  cases);  when  there  was 
diffuse  spreading  peritonitis  it  was  19.07  per  cent.  (152  cases).  The  usual  causes 
of  death  are  intestinal  obstruction,  septic  peritonitis,  septic  endocarditis,  pylo- 
phlebitis,  hepatic  suppuration,  metastatic  abscesses,  endocarditis,  and  gangrene 
of  the  bowel.  In  a  further  report  from  September  i,  1902,  to  September  i, 
1903,  Deaver  reports  -566  cases  in  the  Lankenau  Hospital,  with  an  aggregate 
mortahty  of  5  per  cent.  In  cases  -w-ith  diffuse  peritonitis  the  mortality  was  31 
per  cent.  In  abscess  about  a  necrotic  and  perforated  appendix  it  was  12  per 
cent.  In  early  appendicitis  or  when  disease  was  confined  to  the  appendix  it 
was  0.8  per  cent.  In  107  cases  of  circumscribed  abscess  in  which  Burgess 
removed  the  appendix  the  mortality  was  1.86  per  cent.  In  106  cases  in  which 
he  did  not  remove  the  appendix  it  was  7.54  per  cent.  ("  Brit.  Med.  Jour.,"  Feb, 
24,  1912). 


I2l6 


Diseases  and  Injuries  of  the  Abdomen 


Append icostomy  (Weir's  Operation). — This  operation  was  devised  by 
Weir,  of  New  York,  in  1902.  It  consists  in  opening  the  abdomen,  finding 
the  appendix,  fastening  this  structure  to  the  skin,  closing  the  rest  of  the  wound, 
opening  the  appendix  to  see  that  it  is  patent,  and  applying  a  temporary  ligature 
to  prevent  leaking.  The  temporary  ligature  is  removed  in  a  day  or  two, 
and  a  few  days  later  the  adherent  and  open  appendix  is  used  as  a  route  for 
the  introduction  of  irrigating  fluids.  The  operation  is  of  the  greatest  value 
in  chronic  ulcerative  colitis,  as  it  enables  us  to  irrigate  thoroughly  the  large 
bowel.  Daily  a  large  tube  is  passed  into  the  rectum  and  a  small  tube  into 
the  appendix.  The  fecal  matter  is  washed  out  of  the  bowel  through  the  rectal 
tube  by  salt  solution,  and  then  a  i  :  5000  solution  of  silver  nitrate  or  bismuth 
and  starch  water  (i  dram  to  i  oz.)  is  used  to  irrigate  the  colon.  It  is  injected 
by  way  of  the  appendix  and  it  runs  out  of  the  rectal  tube.  It  is  used  for  the 
same  purpose  in  some  cases  of  tuberculous  rectal  or  anal  fistulas.  A  most  ex- 
traordinary  suggestion   is    that  appendicostomy  be  performed  in  epileptics, 


Fig.  715. — Eye  of 
the  calyx-eyed  needle. 


Fig.  716. 


-Enterrorhaphy:  A,  Lembert  suture;  B  Dupuytren's 
suture. 


so  that  the  opening  may  be  used  to  flush  the  bowel,  a  suggestion  which  I  will 
not  act  upon.  When  the  fistula  exists,  it  does  not  leak  to  any  appreciable 
degree.  When  we  wish  to  close  it  we  insert  within  the  lumen  of  the  tube  the 
Paquelin  cautery  at  a  red  heat.  This  destroys  the  mucous  membrane  and  the 
fistula  closes  (Robt.  Weir,  in  "Med.  Record,"  August  9,  1902). 

Enterorrhaphy,  or  Suture  of  the  Intestine.^ — Surgical  opinion  has 
greatly  altered  in  regard  to  this  operation  since  the  day  when  John  Bell  wrote 
his  famous  attack  on  Benjamin  Bell.  John  Bell  said:  "If  in  all  surgery  there 
is  a  work  of  supererogation,  it  is  this  operation  of  sewing  up  a  wounded  gut." 
To-day  we  know  that  if  in  all  surgery  there  is  a  proceeding  of  imperative  ne- 
cessity, it  is  the  sewing  up  of  a  wound  in  the  intestine.  To  perform  this  opera- 
tion take  fine  sterile  silk  and  thread  a  thin,  round,  straight,  calyx-eyed  needle 
with  it  (Fig.  715).  The  needle  is  very  useful,  as  it  can  be  threaded  rapidly 
by  pushing  the  calyx  eye  down  upon  the  silk  thread  while  the  latter  is  kept 
taut.  Lembert'' s  suture  (Figs.  716,  A,  717,  and  718)  was  devised  in  1823.  Lem- 
bert used  it  on  animals,  but  never  on  man.  It  is  inserted  at  right  angles  to 
the  wound.  It  goes  down  to,  but  not  through,  the  mucous  membrane.  It  is 
formed  by  picking  up  a  fold  of  the  intestine  (3 {2  to  }'g  inch  wide)  }g  inch  from 
the  edge  on  one  side  of  the  wound,  passing  the  needle  through,  picking  up  a  fold 
on  the  opposite  side  of  the  wound,  and  passing  the  needle  through.  On  tying 
the  threads  the  serous  membrane  is  inverted  and  peritoneum  is  brought  into 
contact  with  peritoneum.  For  many  years  it  was  taught  that  this  suture 
should  include  only  the  serous  coat,  but  Halsted,  in  1887,  showed  that  it  must 
include  the  tough  submucous  coat.  The  submucous  coat  is  strong  and  will 
hold  a  suture.  The  other  coats  are  thin,  tear  easily,  and  will  not  hold  a  suture. 
So  thin  are  the  coats  that  a  surgeon  could  not  suture  the  serous  coat  alone  were 
he  to  try.  Sutures  which  include  only  the  muscular  and  serous  coats  tear  out 
easily.     Dupuytren's   suture    (Fig.    716,   b)    is   simply   a   continuous  Lembert 


Enterorrhaphy,  or  Suture  of  the  Intestine  1217 

suture  running  obliquely  across  the  wound.  Cushing's  right-angled  suture  (Fig. 
719)  is  a  conthiuous  suture  catching  up  the  submucous  coat  and  serving  to 
invert  the  serous  layer.  Ford,  of  San  Francisco,  employs  a  continuous  inversion 
suture,  which  is  tied  in  a  single  knot  each  time  it  is  drawn  through  (Fig.  720). 


Serous 

Muse. 

Mucosa. 


Fig. 


-Lembert's  suture. 


Fig.  718. — ^Lembert's  suture  closed. 


Fig.  719. — Cushing's  right-angled  suture 
(Senn). 


Fig.  720. — Ford's  stitch,  showing  a  Lembert  in- 
sertion and  the  needle  passed  so  as  to  tie  a  single 
knot  by  drawing  it  on  through. 


Fig  721. — A,  Halsted  sutures  untied; 
B,  Halsted  sutures  tied  and  serous 
surface   inverted. 


Halsted' s  mattress  or  quilt  suture  is  shown  in  Fig.  721.  Each  stitch  picks  up 
the  submucous  coat.  Mattress  sutures  do  not  tear  out  easily,  they  appose 
evenly  considerable  surfaces,  and  do  not  constrict  the  tissue  as  much  as  Lem- 
bert stitches.  The  Czerny-Lemhert  suture  is  a  suture  passed  through  the  serous 
membrane  on  one  side  of  the  wound,  made  to  perforate  the  mucous  membrane, 
and  to  emerge  at  a  corresponding  point  of  the  serous  membrane.  A  Lembert 
77 


I2l8 


Diseases  and  Injuries  of  the  Abdomen 


suture  is  added  (Fig.  722).  As  at  present  used,  the  Czerny  suture  is  carried  to, 
but  not  through,  the  mucous  membrane  (Fig.  723).  Gussenbaucr  s  suture  is 
similar  to  the  Czerny-Lembert  suture,  except  that  it  apphes  the  Czerny  and 
the  Lembert  with  one  suture,  and  this  suture  does  not  pass  through  the  mucous 
membrane  (Fig.  724).  In  Connell's  suture  (F.  Gregory  Connell,  in  "Phila. 
Med.  Jour.,"  Jan.,  1899)  the  knots  are  placed  within  the  lumen  of  the  bowel 
(Plate  11).  Connell's  very  useful  and  ingenious  stitch  seems  to  be  a  modifica- 
tion of  a  stitch  described  by  Frederick  Holme  Wiggin  ("Med.  Record,"  Nov. 
19,  1898).     Wolfler's  suture  unites  broad  layers  of  the  serous  coat,  the  knots 


Fig.  722. — Czerny-Lembert  suture.  Fig.  723. — Czerny-Lembert    suture    as    at 

present  used. 

being  tied  internally  (Fig.  725).  Senn  says  that  after  suturing  a  large  wound 
of  the  stomach  or  of  the  intestine  a  strip  of  omentum  ought  to  be  laid  over  the 
wound  and  fastened  by  catgut  sutures  {omental  graft).  These  grafts  adhere 
and  are  a  safeguard  against  leakage.  (For  other  methods  of  enterorrhaphy  see 
Intestinal  Resection  and  Anastomosis.) 


Fig.  724. — Gussenbauer's  suture. 


Fig.  725. — Wolfler's  suture. 


Operations  upon  the  Stomach. — In  some  serious  operations,  for  in- 
stance pylorectomy,  it  may  be  found  desirable  to  do  a  two-stage  operation — first 
gastro-enterostomy  and  two  or  three  weeks  later  the  major  operation.  The 
patient  is  thus  nourished  and  strengthened  before  the  great  trial.  After  gastro- 
enterostomy the  disappearance  of  fibromatosis  makes  the  outline  of  the  cancer 
evident.  A  patient  must  be  carefully  prepared  for  an  operation  uj>on  the  stom- 
ach. The  Johns  Hopkins  method,  founded  on  the  researches  of  Harvey 
Gushing  regarding  sterilization  of  the  stomach,  is  to  be  used.  During  the 
two  or  three  days  immediately  preceding  operation  clean  the  mouth  and  teeth 
several  times  during  the  day  with  a  carbolic  solution.  Give  only  sterile  water 
and  sterile  liquid  food  by  the  mouth,  and  for  twelve  hours  before  operation  give 
no  food  whatever.  During  the  two  or  three  days  before  operation  wash  out  the 
stomach  with  boiled  water  night  and  morning.  I  do  not  wash  immediately 
before  operation,  as  it  sometimes  leads  to  annoying  vomiting  and  thus  may 
interfere  with  anesthetization.  If  the  tissues  of  the  patient  are  seriously  de- 
hydrated give  salt  solution  by  hypodermoclysis  for  the  two  or  three  days  pre- 
ceding operation.     After  operation  give  no  food  whatever  for  thirty-six  hours. 


EXPLANATION  OF  PLATE  11. 
Intestinal  suture,  all  knots  inside  (Connell). 

fl.  Suspending  loops  2,  3,  and  4  are  made  with  one  thread  inserted  at  a  point  two  thirds 
of  the  distance  from  mesenteric  to  convex  border.  The  needle  with  suture  is  passed 
ihrough  the  four  walls  of  the  cut  ends,  and  that  portion  of  suture  within  each  lumen  is 
drawn  up  to  a  sufficient  length,  then  cut,  and  the  contiguous  threads  tied  at  the  points 
indicated  by  the  arrows;  thus  having  as  a  result  four  suspending  loops  dividing  the  cir- 
cumference of  each  cut  end  into  thirds.  Instead  of  employing  four  suspending  loops 
which  divide  the  circumference  of  the  bowel  into  thirds,  we  may  use  but  two  loops,  and 
thus  divide  the  circumference  into  halves;  or,  if  available,  the  "holder"  devised  by  Dr. 
E.  H.  Lee  can  be  recommended  highly,  and  will  be  found  a  most  efficient  aid  in  main- 
taining the  cut  edges  in  apposition.  (The  description  of  the  instrument  will  be  found  in 
the  "Annals  of  Surgery,"  January,  1901.) 

b,  Loop  2  has  been  cut  away,  and  loop  i  takes  its  place  in  one  hand  of  the  assistant, 
with  loops  3  and  4  held  in  the  other  hand,  thereby  bringing  into  apposition  that  portion 
of  the  walls  to  be  included  in  the  second  third  of  the  suture.  The  operator  continues 
the  suture  to  the  points  of  insertion  of  loops  3  and  4,  where  again  a  back  stitch  is  taken, 
to  fix  the  suture  and  prevent  a  purse-string  contraction  of  the  same.  The  white  eleva- 
tion in  the  center  of  illustration,  representing  mesentery,  shows  that  that  portion  of  the 
intestinal  wall  not  covered  by  peritoneum,  at  the  mesenteric  border,  has  been  secured 
in  the  suture. 

c,  The  needle,  after  having  entered  the  lumen,  is  passed  out  again  on  the  same  side 
I  inch  distant;  then  over  to  the  opposite  cut  end,  where  it  is  inserted  from  without  in, 
and  again  emerges  from  within  out,  on  the  same  side.  This  step — the  taking  of  a  bite 
— is  repeated  alternately  on  opposing  margins  until  the  necessary  number  of  stitches 
have  been  inserted.  It  will  be  observed  that  when  the  needle  enters  the  lumen  the  last 
time,  it  makes  what  might  be  termed  a  half-stitch,  as  it  does  not  return  again  through 
the  wall;  but  having  reached  the  point  where  the  suture  was  jommenced,  the  free  end 
and  the  needle  end  will  complete  the  last  stitch,  when  tied,  on  the  mucosa.  The  needle 
at  this  point  is  then  brought  out  of  the  lumen  at  the  angle  of  wound  alongside  of  the  free 
end  of  the  suture.  The  cross-over  stitches  are  next  carefully  drawn  up,  thus  bringing 
into  contact  the  opposing  serous  surfaces  at  every  point  except  where  the  suture  ends 
still  protrude. 

d,  The  eye-end  of  threaded  needle  is  made  to  emerge  alongside  of  the  suture  ends, 
and  is  then  withdrawn  a  little,  which  causes  its  thread  to  form  a  loop,  through  which  the 
assistant  passes  the  ends  of  the  suture.  The  operator  ne.xt  withdraws' the  threaded 
needle,  at  the  same  time  bringing  with  it  the  suture  ends,  and  they  present  externally  at 
the  point  of  withdrawal  of  the  needle.  The  serous  coats  throughout  the  entire  circum- 
ference are  now  in  apposition,  and  the  suture  ends  can  be  tied. 

e,  By  slight  traction  on  the  suture  ends  the  opposing  mucous  surfaces  are  brought 
in  close  contact;  the  suture  ends  are  then  tied  firmly,  and  deep  between  the  serous  coats, 
thus  tying  the  knot  upon  the  mucous  coat,  and  the  ends  then  cut  off  short. 


INTESTINAL  SUTURE. 


Plate  ii. 


Pyloroplasty 


1219 


Small  quantities  of  hot  water  are  allowed  as  soon  as  the  patient  recovers  from 
ether.  During  the  first  twenty-four  hours  give  an  enema  of  hot  salt  solution 
and  coffee  every  five  hours  and  then  alternate  nutritive  enemata  with  salt 
encmata.  After  thirty-six  or  forty-eight  hours  usually  begin  to  give  food  by 
the  mouth — at  first  small  doses  of  albumin-water,  and,  if  this  be  tolerated, 
broth  and  milk.     Solid  food  should  not  be  given  for  two  weeks. 

If  the  patient  is  advanced  in  emaciation  and  much  exhausted  we  should  not 
wait  for  thirty-six  hours  to  feed  him,  but  should  give  milk  and  broth  as  soon  as 
the  patient  recovers  from  ether.  The  bowels  should  be  moved  by  enema  the 
day  after  operation.     If  the  enema  fails,  calomel  is  given  (3  or  4  gr.). 

Digital  Dilatation  of  Pylorus  for  Cicatricial  Stenosis  (Loreta's  Opera= 
tion  of  Pylorodiosis). — Place  the  patient  recumbent  and  administer  ether. 
Make  a  vertical  incision  in  the  hnea  alba  or  through  the  right  rectus  muscle. 
The  median  incision  begins  i  inch  below  the  ensiform  cartilage.  The  cut  in 
either  case  should  be  5  inches  in  length.  When  the  peritoneum  has  been  opened 
the  stomach  is  drawn  out  of  the  wound,  any  adherent  omentum  is  separated, 
and  the  pylorus  is  carefully  examined.  The  stomach,  after  being  surrounded 
with  gauze  pads,  is  opened  near  the  center  of  its  anterior  surface,  "but  rather 
nearer  to  its  pyloric  end"  (Jacobson). 


Fig. 


2  6  . — Heineke-Mikulicz's 
plasty:  The  incision. 


P3'loro- 


FiG.  727.— Heineke-Mikulicz's  pyloroplasty: 
The  axis  of  the  incision  is  changed  by  traction 
from  horizontal  to  vertical;  sutures  in  position; 
only  one  of  the  two  rows  of  sutures  is  shown. 


Insert  the  index-finger  through  the  stomach  wound  and  into  the  pylorus, 
and  follow  that  with  the  middle  finger.  The  pylorus  can  be  well  dilated  by 
separating  the  fingers.  If  the  stenosis  is  so  tight  as  to  prevent  the  entry  of  a 
finger,  introduce  a  pair  of  closed  hemostatic  forceps  and  open  the  blades  a  little 
when  they  are  within  the  lumen  of  the  constricted  area.  The  wound  in  the 
stomach  is  closed  by  a  continuous  silk  suture  of  the  mucous  membrane  and 
two  layers  of  Halsted  sutures,  to  invert  and  approximate  the  peritoneal  sur- 
faces.    After  closure  of  the  stomach  wound  the  abdominal  wound  is  sutured. 

Divulsion  by  the  fingers  or  by  an  instrument  is  no  longer  practised,  because 
experience  has  shown  that  the  constriction  is  sure  to  return. 

Pyloroplasty  (Heineke=Mikulicz  Operation). — The  first  operation 
was  performed  by  Heineke  in  1886.  Early  in  1887  Mikulicz,  not  knowing 
of  Heineke's  antecedent  operation,  did  the  same  thing.  Open  the  abdomen  in 
the  middle  line  or,  better,  through  the  right  rectus  muscle.  Draw  up  as  much  of 
the  pylorus  as  possible,  and  pack  warm  moist  gauze  pads  around  it;  make 
an  incision  through  the  stricture  and  in  a  direction  corresponding  to  the  long 
axis  of  the  stomach  and  bowel  (Fig.  726).  Catch  an  aneurysm-needle  under 
the  upper  margin  of  the  incision  and  draw  it  up,  and  an  aneurysm-needle  under 
the  lower  margin  and  draw  it  down.  The  effect  of  traction  is  to  convert  the 
longitudinal  wound  into  a  transverse  wound.  The  sutures  are  applied  so  as  to 
maintain  the  wound  in  a  vertical  line  (Fig.  727).  The  mucous  membrane  is 
sutured  with  a  continuous  suture  of  silk,  and  interrupted  Lembert  or  Halsted 


I220 


Diseases  and  Injuries  of  the  Abdomen 


Fig.  728  . — Heineke-Mikulicz's    pylorO' 
plasty:  After  tying  the  sutures. 


layer 
step    is 


of    peritoneum    i    inch    to 
known    as    mobilization. 


sutures  of  slik  close  the  peritoneal  and  muscular  coats  (Figs.  727  and  728). 
Do  not  drain.  A.  W.  Mayo  Robson  inserts  a  bone  bobbin  and  then  applies 
the  sutures.  The  operation  of  pyloroplasty  shows  a  mortality  about  the  same 
as  or  slightly  less  than  gastro-enterostomy.  In  some  cases  it  is  a  very  satisfac- 
tory procedure,  but  there  are  objections  to  it,  and  in  30  per  cent,  of  cases  it 
fails  to  give  relief  (Wm.  J.  Mayo).  The  outlet  is  not  at  the  most  dependent 
part  of  the  stomach,  hence  the  stomach  may  not  empty  itself.  Further,  as 
Finney  points  out,  it  cannot  be  performed  if  there  are  firm  adhesions  or  active 
ulceration,  and  the  scar  may  contract  and  give  rise  to  stenosis.  Again,  it  is 
difficult  to  suture  the  wound  so  as  certainly  to  provide  against  leakage.  The 
Mayos  reported  21  pyloroplasties  without  a  death,  but  7  cases  required  sec- 
ondary operations  ("Annals  of  Surgery,"  Nov.,  1905).     Pyloroplasty  has  been 

abandoned  by  many  surgeons;  J.  Ruther- 
ford Morison  still  advocates  it.  Finney 
has  devised  an  operation  to  correct  the 
objections  to  pyloroplasty. 

Gastroduodenostomy  by  Finney's 
Method. — This  operation  is  usually 
called  a  method  of  pyloroplasty,  but  it  is 
rather  a  gastroduodenostomy.  The  opera- 
tion was  described  in  the  "Johns  Hopkins 
Hospital  Bulletin,"  July,  1902,  and  was 
then  called  pyloroplasty.  It  is  performed 
as  follows:  Thoroughly  free  the  first  por- 
tion of  the  duodenum  and  the  pyloric  end 
of  the  stomach  by  dividing  the  posterior 
the  right  side  of  the  duodenum.  This 
Insert  three  retractor  sutures  (Fig.  729) 
and  draw  upon  them.  Suture  together,  as  far  posterior  as  possible,  the 
peritoneal  surface  of  the  duodenum  and  the  peritoneal  surface  of  the  stomach 
along  its  greater  curvature  (Fig.  730).  Then  insert  an  anterior  row  of  mattress 
sutiu"es,  but  do  not  tie  them  as  yet  (Fig.  731).  Make  a  horseshoe-shaped  in- 
cision (Fig.  732);  arrest  bleeding;  excise  as  much  scar-tissue  as  possible  on 
either  side  of  the  incision,  and  trim  ofif  the  redundant  mucous  membrane. 
Insert  a  continuous  catgut  suture  on  the  posterior  side  of  the  incision  and  carry 
it  through  all  the  coats  (Fig.  733).  Straighten  out  the  anterior  sutures  and  tie 
them  (Fig.  734).  The  Mayos  reported  58  Finney  operations,  with  4  deaths 
and  2  secondary  operations  (Wm.  J.  Mayo,  in  "Annals  of  Surgery,"  Nov., 

1905)- 

The  mortality  is  greater  than  after  gastro-enterostomy,  due  probably  to  the 
necessity  of  separating  adhesions  and  setting  the  duodenum  free.  The  opera- 
tion should  be  restricted  to  cases  in  which  adhesions  are  not  widespread  and 
firm  and  in  which  the  gastrohepatic  omentum  is  of  fair  length.  In  properly 
selected  cases  it  is  a  very  valuable  operation. 

Pylorectomy  (Excision  of  the  Pylorus). — The  removal  of  a  portion  of 
the  stomach  is  a  partial  gastrectomy,  and  pylorectomy  is  a  partial  gastrectomy 
in  which  the  pylorus  and  also  a  portion  of  duodenum  are  removed. 

The  experiments  of  Gussenbauer  and  von  Winiwarter  on  dogs  in  1876  led 
them  to  suggest  the  operation.  It  was  first  performed  by  Pean  in  1879.  It 
was  next  performed  by  Rydygier  in  1880.  Billroth  did  the  first  successful  pylo- 
rectomy in  1 881.  The  operation  is  seldom  performed  for  anything  but  cancer, 
but  sometimes  is  done  for  plyoric  ulcer  and  its  results.  In  many  cases  of  pyloric 
cancer  the  abdomen  is  opened  only  after  a  palpable  tumor  is  detected,  and  when 
a  palpable  tumor  is  detectable  it  is  usually  too  late  to  perform  pylorectomy.^ 
The  lesson  is  to  explore  suspected  cases  earlier  than  has  been  our  custom. 
^  Keen's  "Cartwright  Lectures  for  1898." 


Pylorectomy 


I22I 


Fig.      729. — Finney's      pyloroplasty:      The       Fig.   730.^ — Finney's  pyloroplasty;  Suture  of 
retractor  sutures.  greater  curvature  of  stomach  to  duodenum. 


Fig.     731.  —  Finney's     pyloroplasty :  Fig.  73 2 . — Finney's  pyloroplasty :  The  anterior. 
Shows    the    three    retractor    sutures,    the  sutures  gathered  and  lifted, 

posterior    line    of    sutures    tied    and    the 
anterior  line  of  sutures  untied. 


Fig.    733. — Finney's  pyloroplasty:   The   con-      Fig.  734. — Finney's  pyloroplasty  completed 
tinuous  posterior  catgut  suture.  by  tying  the  anterior  sutures. 


1222 


Diseases  and  Injuries  of  the  Abdomen 


I  agree  with  Hemmeter  that  stenotic  symptoms,  even  when  no  tumor  is 
palpable,  call  for  exploratory  laparotomy.  If  the  stomach  is  dilated,  if  there 
is  cachexia,  if  there  is  no  free  hydrochloric  acid  in  the  gastric  juice,  if  there  is 
an  excess  of  lactic  acid  in  the  gastric  juice,  if  the  patient  is  forty  or  beyond, 
when  there  is  vomiting  of  blood,  when  the  Oppler  bacillus  is  present,  when 
blood  examination  shows  a  diminution  in  red  corpuscles  and  hemoglobin,  and 
also  shows  that  there  is  no  increase  in  white  corpuscles  after  a  full  meal — 
explore.  After  the  abdomen  has  been  opened  the  stomach  is  examined,  and 
if  a  tumor  exists,  the  surgeon  must  decide  between  the  performance  of  pylo- 
rectomy  and  gastro-enterostomy.  If  the  tumor  is  not  very  extensive,  if  there 
is  no  glandular  involvement  or  only  involvement  which  can  be  removed,  and  if 
adhesions  arc  not  extensive,  pylorectomy  is  chosen;  otherwise  gastro-enteros- 
tomy is  selected. 

Until  lately  the  mortality  from  pylorectomy  was  usually  estimated  to  be 
at  least  25  per  cent.,  even  in  favorable  cases.  During  recent  years  the  mortality 
has  been  much  reduced.  The  operative  mortality  in  the  IMayo  clinic  has  been 
from  13.2  to  14.4  per  cent.  In  38  recent  cases  operated  upon  by  Balfour's 
method  of  partial  gastrectomy  followed  by  anticolic  gastrojejunostomy  the 
mortality  was  5.2  per  cent.  (D.  C.  Balfour,  in  ''Surgery,  Gynecology,  and  Obstet- 
rics," 1917,  xxv).  During  twenty 
years  there  were  in  the  Mayo  clinic 


Fig.  73; 


-Billroth's  method  of  pylorectomy. 


Fig.  736. — Pylorectomy. 


65 1  resections  of  the  stomach  for  cancer.  Of  42  7  patients  operated  upon  more  than 
three  years  ago  who  recovered  from  the  operation  311  have  been  traced  and  of 
these  120  (38.6  per  cent.)  were  alive  three  years  or  more  after  operation.  Of  313 
patients  who  were  operated  upon  more  than  five  years  ago,  239  who  recovered 
were  traced  and  62  (26  per  cent.)  were  alive  five  years  or  more  after  operation. 
Such  results  compare  favorably  with  operations  for  cancer  in  other  regions 
(Collected  Papers  of  the  Mayo  Clinic,  1917)  (seepage  1223).  Prepare  the  patient 
for  pylorectomy  as  for  any  stomach  operation.  The  best  incision  through  the 
abdominal  wall  is  a  vertical  one  in  or  near  the  median  line.  A  small  incision 
is  first  made  to  permit  of  exploration,  and  if  the  growth  is  found  to  be  remov- 
able, the  incision  is  enlarged.  In  some  cases  it  will  be  found  necessary  to  divide 
the  rectus  muscle  by  a  transverse  cut. 

Method  of  the  Mayos. — This  is  the  best  operation.  The  Billroth  method, 
which  was  long  employed,  does  not  remove  enough  of  the  stomach  if  there  is 
malignant  disease,  the  opening  left  in  the  stomach  is  much  larger  than  the 
duodenal  opening,  and  in  suturing  so  as  to  make  the  two  openings  of  equal 
size  an  angle  is  left  which  is  apt  to  leak.  Billroth's  operation  is  shown  in 
I^igs.  735  and  736.  In  the  Mayo  method,  after  the  stomach  has  been  exposed 
the  gastric  artery  is  ligated  close  to  the  stomach,  the  lesser  omentum  is  tied 
in  several  segments  close  to  the  liver  and  then  divided,  and  the  pyloric  artery 
is  tied.  Two  clamps  are  applied  to  the  duodenum  i  inch  apart,  and  the  duo- 
denum is  divided  by  means  of  the  cautery  (Fig.  737). 

The  right  end  of  the  duodenum  is  closed  by  means  of  a  continuous  catgut 


Method  of  the  Mayos  for  Pylorectomy 


1223 


Fig.  737. — Pylorectomy  by  the  Mayo 
method:  Clamps  applied,  duodenum  divided, 
and  continuous  catgut  stitch  introduced 
(Mayo). 


suture,  the  clamp  is  removed,  and  the  closed  end  of  the  duodenum  is  inverted 

by  a  purse-string  suture  (Fig.  738).     A  hand  is  i)assed  from  above  Ijaclc  of  the 

stomach  and  lifts  the  great  omentum 

forward.     The  right  gastro-epiploic 

artery  is  tied  close  to  the  stomach. 

The  left  gastro-epiploic  artery  is  tied 

distinctly  to  the  left  of  any  enlarged 

glands  in  the  great  omentum.     The 

great    omentum  is    tied    in    several 

segments.     The    great    omentum   is 

divided,  leaving  any  enlarged  glands 

attached  to  the  portion  of  the  stomach 

it  is  the  intention  to  remove.     The 

stomach  is  to  be  divided  to  the  left 

of  all  lymphatic  glands  into  which 

the   cancerous    region   drains.     The 

clamps  are  applied  as  shown  in  Fig. 

737.     The  stomach   is    divided    be- 
tween the  clamps  by  a  cautery,  and 

as  the  division  is  being  carried  out 

the  stump  is  caught  here  and  there  by 

hemostatic    forceps    to    prevent    it 

slipping  through  the  clamps.     Slip- 
ping  is    disastrous    and    will    cause 

leaking   and   entrance    of    air    into 

the  stomach,  and  entrance  of  air  is 

apt   to    be   followed  by  pulmonary 

difficulty.     A  row  of  locking  stitches   is  passed  through  all  the  coats  of  the 

stump.     The  stitches  are  tied  and  a  second  row  is  passed  and  tied  (Fig.  738). 

The  clamp  is  removed  and  the  stump 
is  buried  by  Cushing's  right-angled 
suture  or  Dupuytren's  suture.  A 
gastrojejunostomy  is  then  performed 
to  the  posterior  wall  of  the  portion  of 
stomach  which  remains. 

Such  a  patient  is  usually  much 
dehydrated,  and  if  he  is,  salt  solution 
should  be  given  intravenously  during 
the  operation,  and  an  enema  of  warm 
salt  solution  should  be  administered 
every  six  hours  for  several  days 
after  the  operation.  Active  stimu- 
lation is  usually  necessary  and  8  oz. 
of  coffee  should  be  given  by  rectum 
at  the  completion  of  the  operation. 
The  patient  must  be  placed  erect  or 
semi-erect  in  bed  as  soon  as  the 
effects  of  the^  ether  pass  away. 
Twelve  hours  after  operation  begin 
to  give  small  amounts  of  hot  water 
by  the  mouth.  Nourish  by  the 
rectum  from  four  to  six  days,  when 
fluid    food  may   be   given    by    the 

mouth,  starting  with  small  doses  of  albumin-water,  and,  if  this  is  tolerated, 

giving  dessertspoonful  doses  of  peptonized  milk  every  hour.     From  Jan.  i, 
1906,  until  Jan.  i,  191 8,  there  were  589  resections  in  the  Mayo  clinic  with  a 


Fig.  73S. — Pylorectomy  by  the  Mayo  method: 
End  of  divided  duodenum  buried  by  a  purse- 
string  suture.  Row  of  lock  stitches  inserted  in 
stomach  stump  (Mayo). 


1224  Diseases  and  Injuries  of  the  Abdomen 

mortality  of  12.9  per  cent.  Their  mortality  after  resection  for  ulcers  and  benign 
tumors  is  very  small.  If  during  the  operation  the  pancreas  be  wounded  the 
closed  end  of  the  duodenum  is  appUed  directly  to  the  pancreatic  wound,  as 
Willy  Meyer  suggested  ("Trans,  of  Am.  Surg.  Assoc,"  1910).  "The  anterior 
peritoneum  and  adventitious  sheath  of  the  pancreas  are  then  sutured  to  the 
anterior  surface  of  the  duodenum."  This  plan  prevents  leakage  from  the  duo- 
denum and  pancreas  (Wm.  J.  Mayo,  in  "Annals  of  Surgery,"  August,  1913). 

Total  Gastrectomy. — The  entire  stomach  was  first  removed  by  Conner, 
of  Cincinnati,  in  1883.  The  first  successful  operation  was  performed  by 
Schlatter,  of  Zurich,  in  1897.  Total  gastrectomy  will  rarely  be  required,  but  in 
certain  unusual  cases  it  will  be  proper  to  perform  it.  In  some  cases  the  duo- 
denal end  can  be  sutured  to  the  divided  esophagus;  in  others  it  will  be  necessary 
to  close  the  end  of  the  divided  first  portion  of  the  duodenum,  and  anastomose 
the  esophagus  to  the  jejunum. 

The  cases  suitable  for  total  gastrectomy  are  those  in  which  the  entire 
viscus,  or  almost  the  entire  viscus,  is  cancerous,  the  stomach  being  still  freely 
movable,  and  the  glands  not  so  much  implicated  as  to  forbid  attempts  at 
removal.  It  is  a  remarkable  fact,  first  demonstrated  in  Schlatter's  case, 
that  an  individual  can  digest  food  very  well  \\'ithout  a  stomach.  This  state- 
ment is  true  only  if  the  stomach  function  has  been  gradually  abolished  by  dis- 
ease. During  this  period  the  functions  of  the  stomach  have  been  assumed  to  a 
greater  or  less  degree  by  other  parts.  In  a  recent  injury  of  the  stomach  com- 
plete removal  would  almost  certainly  be  followed  by  death,  as  in  such  a  case 
other  parts  would  have  had  no  chance  to  learn  how  to  assume  gastric  duties. 
The  reported  cases  of  total  gastrectomy  show  10  deaths  out  of  27  cases,  but, 
as  Robson  truly  says,  if  all  cases  were  reported,  the  mortality  would  probably 
be  found  to  be  50  per  cent.  Trinkler  ("Archiv.  fiir  klin.  Chir.,"  Berlin, 
xcvi,  No.  2)  reports  i  case  (which  died  on  the  eighth  day)  and  gathers  25  from 
literature;  13  recovered.  When  the  duodenum  was  stitched  to  the  esophagus 
the  mortality  was  57.1  per  cent.  When  the  jejunum  was  stitched  to  the 
esophagus  the  mortality  was  28.5  per  cent. 

I  have  done  the  operation  once.     The  patient  died  on  the  third  day. 

Qastrotomy. — This  term  is  used  to  designate  the  operation  of  opening 
the  stomach  for  the  accomplishment  of  some  purpose,  and  immediately  closing 
the  incision  in  the  gastric  wall  when  that  purpose  has  been  accomphshed.  Gas- 
trotomy  may  be  performed  to  permit  of  the  removal  of  foreign  bodies,  of  explo- 
ration of  the  stomach  and  its  extremities,  of  divulsion  of  the  pyloric  orifice, 
of  the  treatment  of  bleeding  of  an  esophageal  stricture  or  a  stricture  of  the 
cardiac  orifice  of  the  stomach,  or  of  the  removal  of  a  foreign  body  lodged  in 
the  esophagus.  The  first  case  on  record  was  in  1602,  when  Florian  Mathias, 
of  Brandenburg,  removed  from  the  stomach  of  a  juggler  a  knife  which  had  been 
accidentally  swallowed.  When  Evelyn  was  in  Leyden  in  1641  he  saw  a  knife 
which  had'been  removed  by  gastrotomy.  He  says  (Evelyn's  Diary):  _"I_was 
showed  the  knife  newly  taken  out  of  a  drunken  Dutchman's  guts  by  an  incision 
in  his  side,  after  it  had  slipped  from  his  fingers  into  his  stomach.  The  picture 
of  the  surgeon  and  his  patient,  both  living,  were  there." 

The  patient  is  prepared  as  for  pylorectomy.  The  incision  may  be  vertical 
in  the  middle  line  or  identical  with  the  incision  for  pylorectomy.  If  a  large 
foreign  body  can  be  felt,  the  incision  is  made  directly  over  it.  When  the 
peritoneal  cavity  is  opened,  the  surgeon  decides  as  to  the  point  where  the 
stomach  is  to  be  incised,  and  draws  this  portion  out  through  the  wound, 
packing  gauze  pads  under  and  around  it.  The  stomach  is  opened  by  means 
of  scissors,  the  cut  being  at  a  right  angle  to  the  long  axis  of  the  viscus  (Jacob- 
son).  Bleeding  vessels  are  ligated  with  catgut.  The  purpose  for  which  the 
stomach  has  been  opened  is  now^  carried  out,  the  interior  of  the  stomach  and 
the  surface  of  the  extruded  portion  are  irrigated  with  hot  salt  solution,  the 


Gastrostomy 


122: 


mucous  membrane  is  sutured  with  a  continuous  suture  of  silk,  and  two  rows  of 
Halsted  sutures  are  inserted.  The  abdominal  wound  is  closed,  drainage  being 
employed  for  twenty-four  hours. 

Gastrostom\'  is  the  making  of  a  permanent  gastric  fistula,  through  which 
the  patient  can  be  fed.  Gastrostomy  was  first  proposed  by  Egebert  in 
1837  and  was  first  performed  by  Sedillot  in  1849.  In  1875  Sydney  Jones 
operated  upon  the  twenty-ninth  case  and  obtained  the  first  recovery  (Keen). 
Up  to  1SS4  the  estimated  mortality  was  So  per  cent.  At  present  the  mortality 
in  malignant  cases  is  from  20  to  25  per  cent.,  and  in  non-malignant  cases  from 
8  to  10  per  cent.  Gastrostomy  is  employed  in  cases  of  esophageal  obstruction 
or  obstruction  of  the  cardiac  end  of  the  stomach.     In  many  cases  of  malignant 


Hfe3*(~;:M^^^^'^ 


p: 


Fig.  739. — \\'itzer3  method  of  gastros- 
tomy, slio\^-ing  application  of  sutures  in  wall 
of  stomach,  embedding  tube  obliquely 
therein. 


Fig.    740. — Sutures   tied,    completely   em- 
bedding tube  obliquely  therein. 


disease  the  operation  is  performed  too  late,  and  if  performed  when  the  patient 
is  greatly  emaciated  and  exhausted  the  operation  has,  of  course,  a  high  m.ortality. 
AxL  early  operation  is  far  safer  and  confers  the  maximum  of  relief.  The  opera- 
tion should  be  performed,  as  Mikulicz  ad\-ises,  when  the  patient  is  steadUy 
losing  weight  and  there  is  beginning  to  be  difficulty  in  swallowing  semisolids  or 
liquids.  The  surgeon  must  endeavor  to  perform  an  operation  which  will  not 
permit  of  leakage.  Prepare  the  patient  as  for  any  stomach  operation.  It 
•^-ill  usually  be  impossible  to  wash  out  the  stomach. 

Wiizers  Method. — This  operation  was  first  practised  in  1891.  Make  an 
incision  4  inches  in  length,  to  the  left  of  the  middle  line,  just  below  the 
border  of  the  ribs.  After  opening  the  peritoneal  caAdty  seize  the  stomach, 
bring  it  out  of  the  wound,  and  pack  gauze  around  it.  Introduce  a  rubber 
tube  into  the  stomach  and  enfold  it  by  a  double  row  of  Lembert  sutures  (Figs. 
739,  740).  This  tube  should  be  5  inches  long  and  of  the  same  diameter  as  a 
No.  25  French  bougie.  The  opening  is  made  in  the  stomach  toward  the 
cardiac  extremity,  the  tube  is  placed  parallel  with  the  belly  wound,  and  the 


1226 


Diseases  and  Injuries  of  the  Abdomen 


outer  end  of  the  tube  emerges  in  the  median  Hne.  The  tube  is  retained  in  place 
by  a  catgut  stitch  carried  through  the  tube  and  the  stomach  wall.  The  stomach 
is  returned  and  is  stitched  by  three  sutures  to  the  abdominal  wall.  The  ab- 
dominal incision  is  sutured  and  a  clamp  is  placed  on  the  tube.  When  the 
patient  is  fed,  a  funnel  is  slipped  into  the  tube,  the  clamp  is  removed,  and  liquid 


Fig.    741. — Kader's    method    of  gastrostomy: 
Tube  in  place  and  first  row  of  sutures  inserted. 


Fig.  742. — ^Kader's  method  of  gastros- 
tomy: First  row  of  sutures  tied  and  second 
row  inserted. 


food  is  poured  into  the  funnel.     After  the  wound  heals  it  is  not  necessary  to 
retain  the  tube  permanently.     It  is  passed  when  the  patient  desires  food. 

Kader's  Method. — This  operation  was  devised  in  1896.     It  is  a  modification 
of  Witzel's  method.     A  small  incision  is  made  in  the  stomach  and  a  tube  is 

introduced  and  fastened  to  the  stomach  by  one 
catgut  stitch.  Four  Lembert  sutures  are  passed 
so  as  to  form  a  fold  on  each  side  of  the  tube  and 
turn  the  stomach  wall  inward  around  the  tube 
(Fig.  741).  Lembert  sutiu^es  are  inserted  in  the 
furrow  on  each  side  of  the  tube.  Two  more  folds 
are  formed  over  the  first  two  (Figs.  742  and  743). 
The  stomach  wall  is  stitched  to  the  parietal  peri- 
toneum and  sheath  of  the  rectus  muscle  (Willy 
Meyer).  I  prefer  Kader's  method.  It  can  be 
performed  easily  and  rapidly,  even  upon  a  shrunken 
stomach  and  the  wound  does  not  leak.  The  fistula 
can  be  kept  open  by  regular  passing  of  a  tube  and 
closes  rapidly  if  the  passage  of  a  tube  be  abandoned. 
The  Ssabanaj ew-Frank  Method. — This  operation 
is  preferred  by  many  surgeons.  I  used  to  employ 
it  but  only  if  the  stomach  was  not  so  shrunken  as  to 
render  the  pulling  out  of  a  sufhcient  cone  diffi- 
cult. It  was  first  performed  by  Ssabanajew  in 
1890  and  was  performed  independently  by  Frank 
in  1893.  Fenger's  incision  is  made  (a  curved  in- 
cision at  the  margin  of  the  costal  cartilages  of  the  left  side).  A  cone  of  the 
stomach  is  pulled  out  of  the  wound  and  is  passed  under  a  bridge  of  skin 
which  has  been  prepared  for  it.  The  stomach  is  fixed  above  the  margin  of 
the  ribs  and  opened  (Figs.  744,  745).  Von  Hacker  makes  the  gastric  fistula 
through  the  left  rectus  muscles,  and  Hahn  between  two  of  the  rib  cartilages 
(Willy  Meyer). 


Fig.  743. — Kader's  method 
of  gastrostomy:  Second  row  of 
sutures  tied. 


Gastro-entcrostomy  or  Ciastrojcjunostomy 


1227 


The  Younger  Seiin's  Method. — Emanuel  Senn  devised  the  following  method: 
A  cone  of  the  stomach  is  pulled  out  of  the  abdominal  wound,  and  this  cone  is 
puckered  by  the  insertion  of  two  drawing-string  sutures  of  chromicized  catgut. 
A  cuff  of  gastrocolic  omentum  is  sutured  by  silk  around  the  neck  of  the  puckered 
cone.  The  stomach  is  sutured  to  the  belly  wall  with  silk,  the  sutures  including 
the  omental  cuff,  the  serous  and  muscular  coats  of  the  stomach,  and  the  struc- 
tures of  the  belly  wall,  except  the  skin.  The  skin  is  partly  sutured.  The 
stomach  may  be  opened  at  any  time. 

Gastro=enterostomy  or  gastrojejunostomy  is  the  establishment  of 
a  permanent  opening  between  the  stomach  and  the  small  intestine,  in  order 
to  side-track  the  pylorus.  The  operation  is  performed  for  cancer  of  the  pylorus, 
for  non-cancerous  stenosis  of  the  pylorus,  in  some  cases  of  ulcer  of  the  stomach, 
and  for  tetany.  Anterior  gastro-enterostomy  was  proposed  in  1881  by  Wolfler's 
assistant,   Nicoladoni  and  was  first  performed  by    Wolfler    the    same   year. 

In  Wolfler's  early  operations  the 
jejunum  was  so  placed  that  the  prox- 
imal end  was  to  the  right  of  the 
anastomosis    opening.     Hence   peris- 


FiG.  744.  Fig.  745. 

Figs.    744,    745. — The    Ssabanajew-Frank    method   of   gastrostomy  in   carcinoma   of   the 

esophagus. 


talsis  in  the  stomach  was  from  left  to  right  and  in  the  jejunum  from 
right  to  left,  and  this  was  supposed  to  be  responsible  for  the  common 
occurrence  of  regurgitant  vomiting.  It  was  sought  to  prevent  this  by 
altering  the  direction  of  the  loop  (Liicke),  then  by  entero-anastomosis 
(Braun),  and  finally  by  posterior  anastomosis.  Posterior  gastro-enterostomy 
was  first  proposed  by  Courvoisier  in  1883.  His  suggestion  was  that 
the  posterior  surface  of  the  stomach  be  reached  through  the  transverse 
mesocolon.  His  plan  necessitated  a  transverse  division  of  the  mesocolon, 
but  it  was  found  that  this  impaired  the  blood-supply  of  a  part  of  the 
colon  and  might  lead  to  gangrene.  Von  Hacker,  in  1885,  devised  an 
improved  posterior  operation.  As  a  matter  of  fact,  the  transverse  meso- 
colon has  a  marginal  artery,  unlike  other  parts  of  the  colon,  and  the  danger  of 
gangrene  from  a  transverse  incision  is  probably  not  very  great.  In  the  earlier 
operations  by  the  posterior  method  a  long  loop  was  used  and  results  were  not 
notably  better  than  after  the  anterior  operation.  In  1890  Czerny  and  his 
assistant  Peterson  advised  the  making  of  the  jejunal  opening  close  to  the  duo- 
denojejunal flexure.  The  results  from  this  operation  are  vastly  better  than  from 
the  anterior  operation.     Posterior  gastro-enterostomy  has  been  signally  im- 


1228  Diseases  and  Injuries  of  the  Abdomen 

proved  in  technic  by  the  Mayos,  Moynihan,  and  others.  In  the  earlier  opera- 
tions of  anterior  gastro-enterostomy  the  mortality  was  40  per  cent.  In  non- 
malignant  conditions  the  mortality  after  gastro-enterostomy  is  now  very  low 
(under  3  per  cent.),  the  hyperacidity  of  the  gastric  juice  disappears,  and  the 
functions  of  the  stomach  are  restored.  In  malignant  cases  the  mortality  is 
about  20  per  cent.,  but  even  in  such  cases,  if  epe'-ation  be  done  early,  life  may 
be  prolonged  and  made  comfortable  ior  mofths.  Wm.  J.  Mayo  makes  the 
following  report  upon  421  cases  of  gastrojejunostomy:  "Benign,  307  cases, 
19  deaths  (6.18  per  cent.).  In  the  last  140  there  were  4  deaths,  a  mortality 
of  2.85  per  cent.;  the  last  80  gave  but  i  death.  Malignant,  114  cases,  with 
21  deaths  (18.5  per  cent.).  Of  these  114  cases,  63  were  in  connection  with 
pylorectomy  and  partial  gastrectomy,  with  8  deaths  (12.6  per  cent.).  The 
very  unfavorable  cases  of  cancer  obstruction  were  subjected  to  gastro-enter- 
ostomy, so  that  this  operation  gives  a  higher  mortality  than  radical  excision. 
In  the  last  40  gastrojejunostomies  for  malignant  disease  the  mortality  was  8 
per  cent.  In  the  421  gastrojejunostomies  there  were  21  reoperated  cases  (5 
per  cent.)"  ("Annals  of  Surgery,"  Nov.,  1905).  In  the  Mayo  clinic  from 
Jan.  I,  1907  to  Jan.  i,  1918  there  were  302  gastro-enterostomies  for  ulcer 
of  the  stomach  with  a  mortality  of  1.6  per  cent. — 2593  for  duodenal  ulcer  with  a 
mortality  of  1.3  per  cent. — 351  for  pyloric  cancer  with  a  mortality  of  8  per  cent. 
(Personal  communication  to  the  author).  In  about  5  per  cent,  of  cases  of 
gastro-enterostomy  for  benign  disease  secondary  operation  has  been  required. 
In  Kronlein's  clinic,  51  cases  of  malignant  disease  subjected  to  gastro-enteros- 
tomy showed  an  average  duration  of  life  of  192  days;  470  days  after  operation  17 
cases  were  living.  The  causes  of  death,  according  to  Wm.  J.  Mayo,  are: 
exhaustion,  exhaustion  with  vomiting,  pneumonia,  and  detachment  of  the  anas- 
tomosed intestine. 

Treatment  after  Gastro-enterostomy. — On  returning  the  patient  to  bed 
at  once  establish  continuous  proctoclysis  with  deci-normal  salt  solution, 
the  reservoir  being  only  6  inches  above  the  level  of  the  bed.  As  soon  as  the 
patient  is  out  of  ether  place  him  semi-erect.  Mayo  begins  in  from  sixteen 
to  twenty  hours  to  administer  by  the  mouth  i  oz.  of  hot  water  every  hour,  and 
if  it  be  well  tolerated  the  amount  is  quickly  increased,  and  in  thirty-six  hours 
liquid  food  is  given,  and  if  tolerated,  is  continued. 

Complications  Following  Gastro-enterostomy. — Among  them  are  lung  com- 
plications. These  are  not  due  to  the  anesthetic,  for  they  tend  to  occur  even 
when  local  anesthesia  has  been  employed.  They  are  not  due  to  the  epigastric 
incision  interfering  with  cough  and  expectoration,  for  they  are  not  nearly  so 
common  after  operations  upon  the  gall-bladder  (Wm.  J.  Mayo).  Mayo  says 
that  the  latest  theory  is  that  some  of  the  venous  blood  returning  from  the 
stomach  does  not  pass  through  the  liver,  and  infected  emboli  are  deposited  in. 
the  lungs.  The  suture  line  may  leak  after  gastro-enterostomy  because  of 
imperfect  suturing,  or  the  anastomosed  intestine  may  become  detached;  20 
per  cent,  of  the  deaths  among  Mayo's  cases  resulted  from  this  cause.  Con- 
traction of  the  anastomosis  opening  may  gradually  take  place.  This  has  been 
held  by  some  to  be  particularly  common  in  cases  of  dilated  stomach,  shrinking 
of  the  stomach  being  the  efficient  cause,  but  evidence  upon  this  point  is  not 
conclusive.  In  cases  in  which  the  pylorus  is  not  obstructed  shrinking  often 
occurs,  but  it  rarely  takes  place  when  the  pylorus  is  obstructed.  In  some  cases 
after  operation  a  spur  forms  in  the  jejunum  because  of  angulation;  in  other  cases 
adhesions  produce  obstruction;  and  in  rare  instances  ulceration  takes  place  in 
the  jejunum.  The  most  common  complication  after  gastro-enterostomy  is 
persistent  vomiting,  which  may  or  may  not  be  expressive  of  the  formation  of  a 
vicious  circle. 

Peptic  Ulcer  of  the  Jejunum. — The  first  case  was  reported  by  Braun  in  1899. 
The  first  English  case  was  reported  by  Mayo  Robson  in  1903.     Herbert  J.  Pat- 


Complications  Following  Gastro-enterostomy  1229 

erson  reported  a  case  and  collected  reports  of  61  other  cases  (A.  W.  Mayo 
Robson,  ''Brit.  Med.  Tour.,"  Jan.  6,  1912).  F.  Gregory  Connell  has  collected 
38  cases  and  reported  i  of  his  own,  39  in  all  ("Surg.,  Gynec,  and  Obstet.," 
Jan.,  1908).  He  points  out  that  in  many  of  the  reported  cases  acute  per- 
foration occurred.  Most  of  the  reported  cases  suffered  from  non-malignant 
trouble  and  had  hyperacid  gastric  juice.  It  very  seldom  occurs  after  opera- 
tions for  cancer.  Most  of  the  reported  cases  happened  after  the  anterior 
operation  and  when  the  anastomosis  was  very  near  to  the  pylorus.  It  has 
happened,  however,  in  cases  after  the  posterior  operation,  and  cases  have  been 
reported  following  both  the  anterior  and  posterior  methods  associated  with 
entero-anastomosis.  It  is  probable  that  more  cases  seem  to  follow  the  anterior 
method  because  until  late  years  it  has  been  the  operation  commonly  performed. 
In  most  of  the  reported  cases  the  ulcer  was  single;  in  3  out  of  24  cases  it  was 
multiple.  It  is  usually  in  the  distal  loop,  but  may  be  in  the  proximal  loop. 
It  may  be  situated  at  the  anastomosis  level,  a  little  way  below  it,  or  even  5  or 
6  inches  below  it.  The  u?cer  _nay  appear  a  few  days  after  the  operation, 
weeks  after,  months  ?aef,  or  even  years  after.  The  condition  results  from  hy- 
peracid gastric  juice  passing  directly  into  the  jejunum  before  it  has  been  neutral- 
ized by  admixture  with  bile  and  pancreatic  juice.  It  is  possible  that  the  condi- 
tion is  predisposed  to  by  a  twist  in  the  jejunum  and  by  an  anastomosis  opening 
too  small  to  correct  hyperacidity.  Wm  .J.  Mayo  blames  for  the  development  of 
an  ulcer  at  the  suture  line,  silk  or  linen  sutures  which  cut  and  hang  in  the 
lumen.  He  says  they  may  hang  for  months.  In  one  of  his  cases  they  hung 
for  twenty-two  months  ("Brit.  Med.  and  Surg.  Jour./'Jan,  29, 1914), 

There  may  be  no  symptoms  at  all  until  there  is  a  severe  hemorrhage  or 
perforation,  or  symptoms  similar  to  those  which  called  for  the  gastro-enter- 
ostomy may  return.  Connell's  table  shows  that  acute  perforation  took  place 
in  14  of  the  39  reported  cases.  Pain  is  to  the  left  of  the  umbilicus,  comes  on 
two  or  three  hours  after  eating,  and  is  relieved  by  food.  There  may  be  tender- 
ness and  there  may  be  rigidity  of  the  left  rectus  muscle  (Robson,Loc,  cit.).  In 
some  cases  an  ulcer  at  the  suture  line  penetrates  the  transverse  colon.  In  such  a 
condition  colonic  matter  enters  the  stomach  and  may  be  recognized  in  washings 
from  the  stomach.  In  chronic  cases  treatment  is  first  medical ;  if  this  fails,  opera- 
tion is  indicated.  If  on  opening  the  abdomen  it  is  found  that  the  original  pyloric 
or  duodenal  ulcer  has  healed,  but  there  is  an  ulcer  in  the  jejunum,  separate  the 
bowel  from  the  stomach,  close  the  stomach  opening,  excise  the  jejunal  ulcer,  and 
close  the  wound  in  the  bowel.  If  there  is  stenosis  of  the  pylorus  or  duodenum 
we  must  have  a  gastro-enterostomy,  so  we  make  another  after  closing  the  original 
opening  (Robson) .  Very  extensive  ulceration  may  call  for  resection.  If  the  pa- 
tient is  greatly  weakened  or  if  the  ulceration  is  extensive,  jejunostomy  (see  page 
1244)  may  be  done  (Robson),     In  perforation,  operation  must  be  immediate. 

The  Vicious  Circle  and  Regurgitation. — Vomiting  may  occur  after  the  per- 
formance of  gastro-enterostomy.  It  may  soon  cease,  may  be  productive  of  dis- 
astrous consequences,  and  may  be  expressive  of  an  existing  complication  of  great 
gravity.  In  some  cases  of  gastro-enterostomy  vomiting  arises  because  the  anas- 
tomosis has  been  made  high  up  on  the  anterior  gastric  wall  and  the  stomach 
is  not  drained.  In  other  cases  ether  induces  vomiting,  and  the  mechanical 
efforts  force  the  contents  of  the  duodenum  and  even  of  the  jejunum  into  the 
stomach.  The  true  "vicious  circle"  is  a  condition  in  which  the  contents 
of  the  stomach  pass  through  the  anastomosis  opening  into  the  duodenal 
side  of  the  loop  of  intestine,  mix  with  the  duodenal  secretions,  and  return 
to  the  stomach  (Fowler,  in  "Annals  of  Surgery,"  Nov.,  1902).  The  following 
conditions  are  often  classified  under  the  same  head,  but  each  is  called  by  Fowler 
a  regurgitation  or  reflux:  (i)  When  the  duodenal  secretions  pass  back  into 
the  stomach  through  a  permeable  pylorus  (as  in  cases  of  gastroptosis,  non- 
cancerous pyloric  stenosis,   and  gastric   dilatation);    (2)   when  the   duodenal 


I230 


Diseases  and  Injuries  of  the  Abdomen 


secretions  enter  the  stomach  through  the  anastomosis  opening;  (3)  when  the 
contents  of  the  jejunum  pass  into  the  stomach,  because  of  efforts  at  vomiting 
or  as  a  result  of  reversed  peristalsis.  In  some  cases  the  contents  of  the  jeju- 
num may  pass  into  the  afferent  loop  of  intestine  and  distend  it.  It  was  long 
thought  that  the  vicious  circle  was  due  purely  to  bile  passing  into  the  stomach 
from  the  proximal  (afferent)  loop  of  the  jejunum.  Dastre's  experiments  on 
dogs  show  that  bile  in  the  stomach  does  not  impair  either  digestive  power  or 
the  general  health,  and  Moynihan  has  confirmed  these  experiments  by  clinical 
observation.     It  has  been  held  that  the  cause  of  this  condition  is  the  making 

of  an  anastomosis  with  a  long  loop  between  the 
duodenojejunal  flexure  and  the  anastomotic  opening 
into  the  jejunum,  the  loop  being  unable  to  propel 
its  contents  downward  and  tending  by  its  weight  to 
produce  a  bend  or  kink  at  the  seat  of  anastomosis. 
This  is  a  very  douVjtful  theorv. 

Persistent  vomiting  may  be  due  to  spur  formation, 
which  deviates  stomach  contents  into  the  duodenal 
side  of  the  loop.  It  is  in  some  cases  due  to  kinking 
or  twisting  of  the  distal  loop;  in  others,  to  failure  of 
peristalsis  in  the  proximal  loop;  in  still  others,  to  con- 
traction of  the  opening  in  the  stomach  wall  (Chlumsky 
on  ''Gastro-enterostomy  "  in  the  Breslau  Clinic;  article  by  Charles  L.  Gibson, 
in  "Annals  of  Surgery,"  Aug.,  1908).  I  cordially  agree  with  the  statement  of 
Herbert  J.  Paterson,  viz.:  "Most,  if  not  all,  fatal  cases  of  regurgitant  vomiting 
are  due  to  mechanical  obstruction  at  the  afferent  opening"  ("The  Hunterian 
Lectures,"  delivered  before  the  Royal  College  of  Surgeons  of  England,  Feb. 
19,  21,  and  23,  1906).  In  order  to  lessen  the  danger  of  vomiting  after  gastro- 
enterostomy, do  the  operation  under  a  local  anesthetic  whenever  possible;  and 
in  order  to  prevent  regurgitant  vomiting  take  every  care  in  the  operation  to 
prevent  the  formation  of  a  spur  on  the  mesenteric  border  of  the  jejunum  (Her- 
bert J.  Paterson,  Ibid). 


Fig.  746. — Billroth's 
method  of  gastro- 
enterostomy. 


Fig.    74: 


,  —  Gastro-enterostomy    (after 
Lucke). 


Fig 


748.  —  Wolfler-Liicke    method 
gastro-enterostomy. 


After  Billroth's  operation  (Fig.  746)  and  in  all  the  earlier  methods  the  con- 
tents of  the  duodenum  certainly  pass  into  the  stomach,  mix  with  the  stomach 
contents,  and  usually,  but  not  always,  pass  into  the  efferent  loop.  In  all  these 
operations  there  is  great  danger  of  the  development  of  a  vicious  circle. 

Liicke  devised  an  operation  with  the  idea  of  preventing  such  a  complica- 
tion. In  the  Liicke  operation  the  direction  of  peristalsis  in  the  efferent  loop  is 
the  same  as  in  the  stomach  (Fig.  748).  McGraw  points  out  that  the  crossing 
of  the  loop  which  is  effected  is  dangerous.     The  Wolfler-Lucke  operation  is 


Complications  Following  Gastro-cnterostomy 


1231 


shown  in  Fig.  748.  Wolfler  also  devised  the  operation  pictured  in  Fig.  749. 
Von  Hacker's  posterior  operation  is  thought  by  some  to  l)e  less  apt  than  the 
anterior  method  to  be  followed  by  the  vicious  circle  (Fig.  750).  Kocher  devised 
an  operation  in  which  a  valve  is  formed,  but,  as  Fowler  points  out,  this  valve 
does  not  prevent  filling  of  the  duodenum  and  imbibition  of  the  material  by  the 
stomach;  and,  further,  that  the  valve  does  not  work  when  the  parts  become  cica- 
tricial (see  Fig.  754). 

•  The  combination  of  gastro-enterostomy  with  entero-anastomosis  does  tend 
to  prevent  the  vicious  circle.     This  operation  is  shown  in  Figs.  751  and  752. 


Fig.  750.- 


-Von  Hacker's  posterior  gastro- 
enterostomy. 


Fig.  749. — Implantation  of  duodenum 
into  jejunum  and  jejunum  into  stomach 
(after  Wolfler). 

I  do  not  believe  it  should  ever  be  a  primary  operation.  It  permits  acid  gastric 
juice  to  flow  directly  into  the  jejunum  and  keeps  away  the  bile  which  would 
normally  protect  mucous  membrane.  Hence  such  an  operation  exposes  the 
patient  to  the  danger  of  jejunal  ulceration.  Another  defect  in  such  an  opera- 
tion is  that  there  is  still  a  communication  between  the  stomach  and  the  efferent 
loop.     Fowler's  operation  (see  Fig.  758)  closes  the  jejunum  and  corrects  the  de- 


FlG. 


751. — Jaboulay's   method  of   gastro- 
enterostomy. 


Fig. 


752. — Braun's    method     of     gastro- 
enterostomy. 


feet  inherent  in  Braun's  and  in  Jaboulay's  operation.  Other  operators  close 
the  pylorus.  McGraw's  operation  (see  Figs.  755  and  756,  which  show  entero- 
anastomosis)  tends  to  prevent  the  formation  of  a  vicious  circle.  It  seems  certain 
that  the  danger  of  the  formation  of  a  vicious  circle  is  greatest  after  a  long-loop 
anterior  operation  and  least  after  a  short-loop  posterior  operation.  The  shorter 
the  loop,  the  less  the  danger,  hence  the  latter  is  the  operation  of  choice.  _  The 
safest  operations  and  the  [operations  of  choice  are  the  short-loop  operation  of 
Moynihan  or  Scudder  (see  page  1237)  and  the  "no-loop"  operation  of  the  Mayos 
(see  page  1240). 


1232  Diseases  and  Injuries  of  the  Abdomen 

The  Question  of  Closing  the  Pylorus. — This  was  suggested  by  Doyen  in  1893 
and  in  1895  by  von  Eiselsberg.  The  indications  are  absence  of  narrowing  of 
the  pylorus  in  chronic  ulcers  and  active  ulceration  of  the  pylorus  or  duodenum 
(Gibson  and  Beekman,  in  "Annals  of  Surgery,"  April,  1915).  If  the  pylorus  is 
closed  all  gastric  material  passes  through  the  artificial  opening.  Wilms  takes 
a  band  of  fascia  from  the  fascia  lata  or  the  anterior  sheath  of  the  rectus  ab- 
dominis, the  band  being  ^  2  ^^^  i^^ch  in  width  and  4  inches  in  length.  A  clamp  is 
carried  back  of  the  pylorus  through  the  gastrocolic  omentum  and  out  through 
the  gastrohepatic  omentum,  this  clamp  grasps  the  fascia  and  draws  it  around 
back  of  the  pylorus,  the  muscle  surface  of  the  fascia  being  in  contact  with  the 
serous  coat  of  the  stomach.  The  fascia  is  pulled  sufficiently  tight  to  occlude 
the  pylorus  and  the  fascial  ends  are  sutured  with  chromic  catgut.  The  fascia 
is  also  sutured  to  the  stomach.  The  closure  by  this  method  is  not  apt  to  be 
permanent.  Instead  of  a  band  of  fascia  it  has  been  suggested  that  the  round 
ligament  of  the  liver  could  be  used. 

Many  surgeons  have  used  silk  or  linen  to  constrict  but  not  to  strangulate 
the  pylorus.  An  occlusion  effected  thus  is  only  temporary  and  the  ligatures 
finally  cut  into  the  pylorus  and  are  passed  through  the  bowel.  Hoffman  divides 
the  serous  and  muscular  coats,  sutures  the  fascial  strip  around  the  mucous 
membrane  and  closes  the  muscular  and  serous  coats.  This  is  very  difficult 
of  accomplishment  without  opening  through  the  mucous  membrane. 

Von  Eiselsberg  divides  the  stomach  proximal  to  the  pylorus  and  inverts 
each  end.  Other  surgeons  have  divided  the  pylorus,  closed  the  duodenal  end 
and  anastomosed  the  stomach  end  to  the  side  of  a  loop  of  jejunum,  or  to  the 
duodenum  distal  to  the  area  of  ulceration. 

Biondi  incises  the  pyloric  portion  of  the  stomach  the  incision  going  to  but 
not  through  the  mucous  coat.  The  mucous  tube  is  dissected  free,  doubly  ligated, 
divided  between  the  ligatures,  and  the  cuts  in  the  muscular  and  serous  coats  are 
sutured.  Bartlett  makes  a  partial  exclusion  by  dividing  the  prepyloric  portion 
of  the  stomach  from  the  greater  curvature  to  within  an  inch  of  the  lesser  curva- 
ture and  suturing  the  cut  edges. 

Brewer  suggests  obtaining  occlusion  by  the  use  of  an  aluminum  band 
(see  Charles  L.  Gibson  and  Fenwicke  Beekman,  in  "Annals  of  Surgery,"  April, 

1915)- 

Treatment   of    Persistent    Vomiting   after  Gastro-enterostomy. — If    vomiting 

persists  in  spite  of  gastric  lavage  and  rectal  feeding  following  the  operation 
of  gastro-enterostomy  with  a  long  loop  without  entero-anastomosis,  open  the 
abdomen  again  and  perform  anastomosis  between  the  afferent  and  efferent 
loops  of  intestine.  This  was  suggested  by  Braun  in  1892,  and  both  he  and 
Jaboulay  performed  it  in  the  same  year.  The  operation  has  saved  lives.  In  a 
short-loop  operation  we  should  assume  that  the  jejunum  has  been  twisted, 
should  open  the  abdomen,  and  endeavor  to  correct  the  condition.  Herbert 
L.  Paterson  ("Hunterian  Lectures,"  before  the  Royal  College  cf  Surgeons  of 
England,  Feb.  19,  21,  22,  1906)  points  out  that  slight  cases  of  regurgitant  vomit- 
ing not  immediately  following  an  operation  may  be  due  purely  to  constipation, 
and  may  be  recovered  from  if  care  be  taken  to  secure  daily  a  free  bowel  move- 
ment. In  Paterson's  opinion  constipation  causes  reversed  peristalsis,  and  as 
both  the  duodenal  "siphon-trap  and  the  pyloric  sphincter  are  put  out  of  service," 
regurgitation  takes  place  from  the  efferent  loop  into  the  stomach. 

Anterior  Gastro-enterostomy.  Semi's  Method. — A  median  incision  is  made 
through  the  abdominal  wall,  from  below  the  xiphoid  cartilage  to  the  umbilicus. 
An  opening  is  made  in  the  low^er  part  of  the  anterior  wall  of  the  stomach  in  the 
direction  of  the  long  axis  of  the  viscus,  and  its  edges  are  stitched  by  a  con- 
tinuous catgut  suture.  The  contents  of  the  jejunum  are  forced  along  to 
below  the  point  where  an  incision  is  to  be  made.  The  loop  of  jejunum  should 
be  from  12  to  14  inches  in  length.     A  rubber  tube  is  fastened  around  the  bowel 


Anterior  Gastro-enterostomy 


1233 


above  this  point,  and  another  below  it;  an  incision  is  made  in  the  long  axis 
of  the  bowel,  and  the  margins  of  the  wound  are  sutured  in  the  same  manner 
as  the  stomach  wound.  Bone  plates  are  introduced  into  the  stomach  and 
intestine,  and  the  ligatures  are  tied  as  in  intestinal  anastomosis.  Catgut 
rings  or  rubber  rings  may  be  used. 

Mayo's  Anterior  Method  (Fig,  753). — Open  the  abdomen,  and  pick  up  the 
small  intestine  and  find  a  point  of  jejunum  about  14  inches  from  the  point  at 
which  it  emerges  from  under  the  mesocolon.  Effect  the  union  to  the  inferior 
border  of  the  stomach  close  to  the  greater  curvature  and  at  the  lowest  portion 
of  the  stomach  pouch.  When  the  anastomosis  is  completed  the  stomach 
pouch  is  funnel  shaped.     The  usual  custom  has  been  to  place  the  opening  higher 

on  the  anterior  wall.  It  some- 
times led  to  the  formation  of  a 
pouch  on  the  anterior  wall,  did 
not  drain  the  stomach,  and  caused 
vomiting.  After  the  perform- 
ance of  gastro-enterostomy  the 
edges  of  the  omentum  are  caught 


Fig.  753. — INIayo's  method  of  anterior  gastro- 
enterostomy showing  proper  and  improper  loca- 
tions of  openings:  a,  Proper  position,  leaving  no 
pouch;  b,  usual  position  forming  intragastric 
pouch  ("Annals  of  Surgery")- 


Fig.  754. — Kocher's  method  of 
gastro-enterostomy:  a,  Places  of  pos- 
terior annular  suture  through  entire 
wall  of  stomach  and  intestine;  b, 
places  of  anterior  annular  suture 
through  the  entire  wall;  c,  valve  at 
the  jejunum  by  arch-formed  incision; 
d,  posterior  annular  suture  of  the 
serosa;  e,  thread  ends  for  continuing 
anterior  suture  of  the  serosa. 


upon  each  side  of  the  anastomosis  and  are  sutured  to  each  other  and  to  the 
stomach  wall  i  inch  above  the  opening.  The  edges  are  then  united  to  each 
other  in  a  downward  direction  for  about  3  inches  so  as  to  form  an  apron  over 
the  anastomosis,  yet  not  connected  with  it.  Catgut  is  used  for  suturing.  If 
leakage  occurs,  the  omentum  is  adjacent  and  "available."  If  it  does  not  occur, 
the  omentum  soon  returns  to  its  normal  position  (Wm.  J.  Mayo,  "Annals  of 
Surg.,"  Aug.,  1902). 

Kocher's  Method  (Fig.  754). — After  opening  the  abdomen  lift  up  the  omen- 
tum, pull  up  a  loop  of  intestine,  and  find  the  point  where  the  jejimum  appears 
from  under  the  mesocolon.  Select  a  loop  16  inches  from  the  origin  of  the 
jejunum  and  prepare  to  attach  it  to  the  stomach.  Wolfler  believed  that  the 
intestine  should  be  applied  to  the  stomach  in  such  a  manner  that  the  direc- 
tion of  peristalsis  in  the  bowel  would  correspond  to  the  direction  of  the  stomach- 


1234 


Diseases  and  Injuries  of  the  Abdomen 


tide.  This  can  be  accomplished  by  having  the  proximal  portion  of  gut  to  the 
left,  and  the  distal  portion  to  the  right.  The  operation  is  to  be  so  performed 
that  after  its  completion  the  stomach  contents  pass  into  the  distal  portion  of 
the  gut,  and  intestinal  contents  do  not  tend  to  enter  the  stomach  (see  Fig.  748). 
In  order  to  accomplish  this  Kocher  hangs  the  intestine  to  the  stomach  wall  in 
such  a  manner  that  the  proximal  portion  of  the  loop  is  posterior  and  ascending, 
and  the  distal  portion  is  anterior  and  descending.  The  bowel  is  hung  to  the 
stomach  by  a  continuous  serous  suture  of  silk,  the  ends  of  which  are  left  long. 
The  intestine  is  opened  by  a  curved  incision,  the  convexity  of  which  is  down- 
ward. The  stomach  is  opened  so  that  the  convexity  of  the  cut  is  upward.  -  The 
valve-like  portion  of  the  bowel  wall  is  sutured  to  the  stomach  below  the  inci- 
sion in  that  viscus.     The  two  openings  are  well  approximated  by  sutures. 


Fig.  755. — McGraw's   method   of   lateral   anastomosis:  The   elastic   ligature   is   introduced 
(Walker).     Gastro-enterostomy  is  done  by  the  same  plan. 

Operation  by  McGraw's  Elastic  Ligature  (Figs.  755-757). — The  elastic 
ligature  was  introduced  by  Silvestri  in  1862,  and  was  first  used  in  intestinal 
anastomosis  by  the  same  surgeon.  McGraw  perfected  the  operation  in  1891. 
(See  Dudley  Tait,  in  "  Annals  of  Surgery,"  Feb.,  1906.)  The  operation  may  be 
anterior  or  posterior.  The  intestine  and  stomach  are  sutured  together  by 
Lembert  stitches.  The  elastic  cord,  which  is  3  to  5  mm.  in  diameter,  is  passed 
through  the  stomach  and  then  the  bowel,  in  the  long  axis  of  each,  and  is  tightly 
tied,  and  the  knot  is  fastened  with  a  silk  thread.  Another  row  of  Lembert 
sutures  buries  the  elastic  cord  from  sight.  The  cord  cuts  through  in  from  forty- 
eight  to  seventy-two  hours  and  makes  the  anastomosis.  Thus  the  danger 
of  infection  is  greatly  lessened,  for  when  the  anastomosis  opening  is  formed  it  is 
completely  encompassed  by  firm  adhesions.  Further,  the  danger  of  the  forma- 
tion of  a  vicious  circle  is  greatly  lessened,  because  there  is  no  communication 
between  the  stomach  and  bowel  for  between  forty-eight  and  seventy-two  hours, 
the  period  in  which  vomiting  of  the  type  previously  described  is  most  apt  to 
occvir.  The  method  is  not  suitable  for  absolute  pyloric  occlusion.  In  this 
condition  it  is  imperative  to  give  nourishment  early,  and,  again,  an  ordinary 
gastro-enterostomy  allays  auto-intoxication  and  this  operation  cannot  until  the 
ligature  cuts  through.     It  is  particularly  valuable  in  the  performance  of  lateral 


Posterior  Gastro-enterostomy 


1235 


intestinal  anastomosis.     The  cuts  show  the  operation  of  lateral  anastomosis 
of  intestine,  but  gastro-enterostomy  is  performed  in  the  same  manner. 

Jaboulay's  Gastroduodenostomy. — This  operation  was  devised  by  Jabou- 
lay  in  1892.     It  aims  to  obviate  some  of  the  objections  to  pyloroplasty  and  at 


Fig.  756. — McGraw's  method  of  lateral  anastomosis:  One  tie  of  the  elastic  ligature  with 
a  strong  silk  ligature  underneath  ready  to  fasten  the  elastic  ligature  where  it  is  drawn 
taut  (Walker). 

the  same  time  to  retain  the  advantages  this  operation  possesses  over  gastro- 
jejunostomy. Jaboulay's  gastroduodenostomy  has  never  become  popular 
with  surgeons,  and  Finney's  method  is  much  more  satisfactory  (see  page  1220). 


Fig.  757. — ^McGraw's  method  of  lateral  anastomosis:  The  operation  completed  (Walker). 


Posterior  Gastro-enterostomy  (see  pages  123 7-1242). — In  a  thin  subject 
with  a  long  mesocolon  posterior  gastro-enterostomy  is  to  be  chosen,  but  if  the 
mesentery  be  short  or  contain  much  fat,  or  if  the  vascular  loop,  coming  from 


1236  Diseases  and  Injuries  of  the  Abdomen 

the  superior  mesenteric  artery  to  supply  the  transverse  colon,  be  small — so 
that  an  opening  in  the  posterior  layer  of  the  gastrocolic  omentum  would  be 
close  to  the  artery — the  anterior  operation  is  employed  (Wm.  J.  Mayo,  in 
"Annals  of  Surgery,"  Aug.,  1902).  If  a  Murphy  button  is  used,  the  pos- 
terior operation  is  selected.  Posterior  gastro-enterostomy  is  commonly 
performed  as  follows:  After  the  abdomen  has  been  opened  the  stomach  and 
omentum  are  raised;  a  portion  of  the  upper  jejunum  is  seized,  emptied,  and 
a  site  selected  for  the  clamp.  This  site  must  be  within  5  inches  of  the  flexure. 
If  there  be  a  broad  mesocolic  band  preventing  a  near  approach  to  the  flexure 
the  band  must  be  divided.  A  clamp  is  applied  on  the  side  opposite  the  mesen- 
teric attachment.  A  spot  is  selected  on  the  transverse  mesocolon  where  there 
are  no  vessels,  and  an  opening  is  made  through  the  mesocolon  with  a  blunt 
instrument.  The  posterior  wall  of  the  stomach  is  pulled  into  the  opening  and 
sutured  to  its  edges.  This  prevents  downward  displacement  of  the  stomach 
and  obstruction  of  the  loop  of  gut.  A  portion  of  the  posterior  wall  of  the 
stomach  is  pulled  out  into  a  cone  and  clamped.  Openings  are  made  and  the 
sutures  applied  as  directed  on  pages  123 7-1 242.  Regurgitation  is  less  common 
after  posterior  than  after  anterior  gastro-enterostomy.  In  250  posterior  opera- 
tions in  Czerny's  clinic  there  was  not  one  case  of  regurgitant  vomiting;  170  cases 
were  button  operations  and  45  were  by  sutures  alone  (Peterson).  Von  Hacker 
had  one  instance  of  regurgitation  in  60  posterior  operations. 

Operation  by  the  Murphy  Button. — Gastro-enterostomy  may  be  quickly 
performed  by  the  use  of  a  large-sized  Murphy  button.  Murphy  said  that  in 
some  reported  cases  the  button  has  slipped  back  into  the  stomach,  but  this  acci- 
dent can  be  prevented  by  the  use  of  an  oblong  button  and  by  making  the  anas- 
tomosis on  the  posterior  stomach  wall.  The  same  surgeon  advised  us  to  scarify 
the  peritoneum  in  order  to  hasten  union,  and  said  supporting  sutures  about  the 
button  are  not  required,  except  when  considerable  tension  exists.  There  is  no 
question  that  an  anastomosis  on  the  anterior  wall,  accomplished  by  a  Murphy 
button,  can  be  speedily  performed.  Anastomosis  on  the  posterior  wall  cannot 
be  performed  so  speedily,  and  it  sacrifices  to  some  extent  the  great  advantage 
of  the  button  operation — that  is,  speed.  In  spite  of  the  reported  cases  we  can 
positively  assert  that  the  danger  cf  the  button  producing  grave  trouble  is  slight. 
In  some  cases  it  drops  into  the  stomach  and  remains  there,  but  seems  to  do  no 
harm.  In  other  cases  it  takes  a  long  time  to  pass.  In  i  of  the  author's  cases 
it  did  not  pass  until  the  eighty-sixth  day.  In  one  of  Keen's  cases  it  has  been 
retained  for  years.  If  it  does  not  pass  in  four  weeks,  the  rectum  should  be 
explored  by  the  finger  from  time  to  time  to  see  if  it  is  lodged  in  that  region. 
The  x-rays  will  determine  whether  the  button  is  in  transit.  If  the  wall  of  the 
stomach  is  thick,  the  incision  should  be  made  in  the  stomach  wall  before  the 
suture  is  passed,  and  this  suture  should  pick  up  only  a  small  portion  of  the 
stomach  wall,  otherwise  the  button  may  be  retained  in  place  for  a  very  long 
time  (Wm.  J.  Mayo).  "In  many  cases  in  which  the  button  passes,  vomiting 
with  symptoms  of  obstruction  may  appear  during  the  second  or  third  week 
while  it  is  in  transit.  Gastric  lavage  and  rectal  feeding  for  a  day  or  two  cause 
these  symptoms  to  subside"  (Wm.  J.  Mayo,  in  "Annals  of  Surgery,"  Aug., 
1902).  Mayo  long  ago  maintained  that  the  suture  operation  is  as  good  as  the 
button  operation,  and  that  the  results  are  about  the  same.  Mikulicz  says  that 
in  the  suture  operation  entero-anastomosis  is  necessary,  but  not  in  the  button 
operation,  because  the  button,  while  in  place,  prevents  angulation.  The  last- 
named  surgeon  uses  the  button  in  malignant  cases  and  the  suture  in  benign 
cases.  Czerny  is  an  advocate  of  the  button.  Every  button  should  be  tested 
before  it  is  used.  Mayo  finds  nearly  20  per  cent,  of  buttons  imperfect  and 
dangerous. 

Fowler's  Method  (Fig.  758). — Anastomose  the  posterior  wall  of  the  stomach 
to  the  jejunum  and  do  an  entero-anastomosis  between  the  afferent  and  efferent 


Moynihan's  Method  of  Gastro-enterostomy 


1237 


loops  of  jejunum.  Pass  a  No.  20  silver  wire  two  or  three  times  around  the 
afferent  loop  of  jejunum  and  draw  it  sufficiently  tight  to  occlude  the  lumen 
without  strangulating  the  wall  of  the  gut.  The  ends  are  twisted,  cut  short, 
rolled  into  a  flat  coil,  the  cut  ends  being  in  the  coil.  (See  Geo.  Rycrson  Fowler, 
on  the  "Circulus  Vitiosus"  following  gastro-enterostomy,  "Annals  of  Surgery," 
Nov.,  1902).  This  operation  positively  prevents  the  entrance  of  material 
from  the  duodenal  loop  into  the  stomach  and  also  drains  that  loop. 

Moynihan's  Method. — This  plan  I  have 
employed  repeatedly.  It  is  easy,  rapid, 
and  clean:  Make  a  4-inch  incision  i  inch 
to  the  right  of  the  middle  line  and  above 
the  umbilicus.  Open  the  anterior  sheath 
of  the  rectus  and  separate  it  from  the 
front  of  the  muscle  as  far  as  the  middle 
line.  Draw  the  entire  muscle  outward, 
open  the  posterior  portion  of  the  sheath, 
and  then  open  the  belly.  Inspect  and 
feel  the  entire  stomach.  Lift  the  omentum 
and  transverse  colon  out  of  the  abdomen 
and  make  the  mesocolon  taut  by  raising 
the  stomach  and  colon  with  the  left  hand. 
Find  "a  bloodless  spot  in  the  arch  of  the 


Fig.  758. — Fowler's  method  of  gastro-enterostomy. 


Fig.  759.- — Moynihan's  damp  for 
gastric  and  intestinal  operations 
(made  by  Down  Brothers,  London). 


middle  colic  artery,"  pick  up  a  bit  of  the  under  surface  of  the  mesocolon 
by  a  pair  of  hemostatic  forceps,  lift  it  from  the  posterior  stomach 
wall,  and  open  the  lesser  sac  of  peritoneum  by  the  scissors.  Enlarge  the 
opening  by  dilatation  or  tearing  until  it  admits  three  fingers.  Inspect  and 
feel  the  posterior  stomach  wall.  Place  the  stomach  in  its  natural  position, 
mark  with  the  thumb  the  lowest  part  of  the  posterior  stomach  wall,  and  again 
turn  the  viscus  over.  From  the  spot  marked  by  the  thumb  a  fold  is  raised. 
The  fold  is  oblique  and  its  upper  end  is  to  approach  the  cardia  and  lesser  curva- 
ture. A  stomach  clamp  (Fig.  759)  having  a  rubber  tube  stretched  over  each  blade 
is  appHed  obhquely  so  as  to  grasp  the  base  of  this  fold.     In  applying  the  clamp 


1238 


Diseases  and  Injuries  of  the  Abdomen 


Fig.  760. — Moynihan's  method  of  gastro-enterostomy:  The  oblique  application  of  the  clamp 
to  the  stomach  (Moynihan). 


":^A^ 


Fig.  761. — Moynihan's  method  of  gastro- 
enterostomy: The  strip  of  gauze  between 
the  clamps  (Moynihan). 


Fig.  762. — Moynihan's  method  of  gastro- 
enterostomy: The  first  layer  of  serous 
suture  (Moynihan). 


Moynihan's  Method  of  Gastro-enterostomy 


1239 


the  tip  should  point  to  the  right  shoulder  and  the  handle  to  the  outer  side  of 
the  left  hip,  and  the  lowest  portion  of  the  stomach  is  grasped  in  the  tip  of  the 
blade  of  the  clamp  (Fig.  760).  The  clamp  is  now  put  in  a  horizontal  position. 
The  duodenojejunal  flexure  is  found  by  the  finger,  the  jejunum  is  identified 
and  its  natural  position  is  noted.  The  jejunum  is  picked  up  and  "drawn  tight " 
and  a  spot  is  noted  which  reaches  the  greater  curvature  of  the  stomach  when  the 
jejunum  is  in  its  natural  position.  The  point  noted  is  5  inches  from  the  flexure 
and  the  anastomosis  is  made  to  the  jejunum  above  the  spot.  The  clamp  is 
applied  in  the  side  of  the  gut  opposite  the  mesentery.  The  surgeon  must  be 
sure  that  the  jejunum  is  not  twisted  around  its  longitudinal  axis.  If  it  is,  the 
clamps  are  not  rightly  applied,  and  they  must  be  placed  so  that  after  the  anas- 
tomosis the  jejunum  lies  in  its  natural  position  without  a  twist.     The  clamped 


Fig.  763. — Moynihan's  method  of  gastro- 
enterostomy: Removal  of  the  eUipse  of 
mucous  membrane  (Moynihan). 


Fig.  764. — Moynihan's  method  of  gastro- 
enterostomy: The  inner  suture  continued 
(Moynihan). 


gut  is  placed  by  the  side  of  the  clamped  stomach,  a  bit  of  gauze  being  put 
between  them  (Fig.  761).  The  stomach  (except  the  clamped  portion),  the 
omentum,  and  transverse  colon  are  returned  to  the  abdomen  and  the  clamps 
are  surrounded  by  gauze.  Each  clamp  holds  a  fold  33^-2  to  4  inches  in  length. 
Pagenstecher's  celluloid  thread  is  used  for  suturing.  The  first  hne  of  sutures 
is  passed  as  shown  in  Fig.  762.  In  front  of  these  sutures  an  incision  is  made 
into  the  stomach  and  another  into  the  jejunum,  the  serous  and  muscular  coats 
being  first  divided,  and  an  eUipse  of  mucous  membrane  being  removed  (Fig.  763). 
The  next  row  of  sutures  is  inserted  as  shown  in  Fig.  764.  When  this  row  is 
completed  the  clamps  are  removed  and  the  long  suture  of  the  first  row  is  picked 
up  again  and  the  operation  is  completed  (Fig.  765).  Finally  the  edges  of  the 
mesocolic  opening  are  sutured  to  the  jejunum.  The  parts  are  cleansed  with  salt 
solution,  the  sulture  line  is  inspected,  the  parts  are  returned  to  the  belly,  and 
the  abdomen  is  closed.     (See  Moynihan's  "Abdominal  Operations.") 


1 240 


Diseases  and  Injuries  of  the  Abdomen 


The  No-loop  Operation  of  the  Mayos  (Figs.  766-768). — It  is  this  opera- 
tion, I  usually  perform.  By  it  the  gastric  opening, 
which  is  placed  in  the  line  advised  by  Moynihan, 
extends  }i  or  3^  inch  into  the  anterior  wall  of  the 
stomach,  and  thus  the  lowest  part  of  the  opening 
will  be  the  lowest  part  of  the  stomach  (Fig.  766). 
The  incision  in  the  intestine  begins  from  i  to  3  inches 
from  the  origin  of  the  jejunum,  the  measure  being 
made  on  the  anterior  surface  (Fig.  766). 

The  object  is  to  get  as  short  a  piece  of  jejunum 
as  can  be  attached  without  tension.  The  operation 
is  described  as  follows  (Wm.  J.  Mayo,  in  "Annals 
of  Surgery,"  Nov.,  IQ05): 

"  (c)  The  abdominal  incision  is  made  4  inches 
in  length,  ^4  inch  to  the  right  of  the  middle  line, 
the  fibers  of  the  rectus  muscle  being  separated. 
The  lower  end  of  the  external  wound  lies  opposite 
the  umbilicus.  This  opening  also  enables  inspec- 
tion of  the  duodenum  and  gall-bladder  and  is  reliable 
against  hernia  when  closed. 

"  (b)  The  transverse  colon  is  pulled  out  and  the 
mesocolon  made  taut  by  traction  upward  and  to  the 
right,  in  this  manner  bringing  the  jejunum  into  view 
at  its  origin. 

"  (c)  About  3  to  4  inches  of  the  jejunum  opposite 
the  mesentery  are  drawn  into  a  slightly  curved 
clamp.  The  handles  of  the  clamps  should  be  to  the 
right,  to  enable  a  short  grasp  on  the  intestine. 
Three-fourths  of  the  circumference  of  the  bowel  is  pulled  through;  the  pos- 
terior border  is  not  included,  to  prevent  entanglement  of  the  suture  with 


Fig.  765.  —  Moynihan's 
method  of  gastro-enteros- 
tomy:  The  serous  suture  re- 
sumed (Moynihan). 


Fig.  766. — Ma3'o's  method  of  gastro-enterostomy :  Showing  posterior  wall  of  the  stomach 
drawn  through  a  rent  in  the  transverse  mesocolon.  Note  slight  separation  of  gastrocolic  omen- 
tum from  its  attachment  to  the  stomach,  permitting  anterior  wall  of  stomach  to  appear,  and 
insuring  drainage  at  lowermost  level.  Black  lines  mark  site  of  proposed  anastomosis;  the 
jejunum  shows  at  its  origin. 

the  redundant  posterior  mucous  membrane.  The  holding  clamps  are  applied 
sufficiently  tight  to  check  hemorrhage  and  prevent  extravasation  of  intestinal 
contents. 


The  Xo-Ioop  Operation  of  the  jMayos  for  Gastro-enterostomy     1241 

"  {d)  The  hgament  of  Treitz  is  a  short  muscular  mesentery  covered  by  a 
variable  peritoneal  fold  (,too  variable  for  a  reUable  landmark)  extending  upward 
from  the  origin  of  the  jejunum  on  to  the  mesocolon.  This  peritoneal  fold  Hes 
at  the  base  of  the  arterial  loop  of  the  middle  colic  artery  which  supplies  the 


Fig.   767. — Mayo's  method  of  gastro-enterostomy:  Forceps  in  place  and  anastomosis   ha.U 

completed  by  suture. 

transverse  colon.  The  mesocolon  is  opened  within  the  vascular  loop  and  the 
posterior  inferior  border  of  the  stomach  pushed  through.  A  small  separation 
of  the  greater  omental  attachment  to  the  stomach  enables  the  anterior  gastric 


Fig.  768. — Mayo's  method  of  gastro-enterostomy:  Completed  operation  from  behind,     ilar- 
gin  of  torn  mesocolon  attached  by  several  interrupted  sutures  to  line  of  union. 

wall  to  be  dra-^m  out  posteriorly.  The  posterior  gastric  wall  is  dravi-n  into  a 
clamp,  with  the  handles  to  the  right,  in  such  a  manner  as  just  to  expose  the 
anterior  wall  at  the  base.  • 

"  (e)  The  two  clamps  are  laid  side  by  side  and  the  field  carefully  protected 
by  moist  gauze  pads.     With  fine  celluloidal  linen  thread  on  a  straight  needle 


124: 


Diseases  and  Injuries  of  the  Abdomen 


the  intestine  is  sutured  to  the  stomach  from  left  to  right  by  a  Gushing  suture 
at  least  2^^  inches. 

"  (/)  The  stomach  and  intestine  are  incised  }q  inch  in  front  of  the  suture 
line  and  the  redundant  mucous  membrane  excised  flush  with  the  retracted 
peritoneal  and  muscular  coats.  With  a  No.  i  chromic  catgut  on  a  straight 
needle  the  posterior  cut  margins  of  the  entire  thickness  of  the  gastric  and 
jejunal  walls  are  united  by  a  buttonhole  suture  from  right  to  left;  at  the  extreme 
left  the  suture  changes  to  one  which  passes  through  all  the  coats,  of  each  side 
alternately,  from  the  peritoneal  to  the  mucous,  then  directly  back  on  the  same 
side  from  the  mucous  to  the  peritoneal.  This  acts  as  a  hemostatic  suture, 
and  also  turns  the  peritoneal  coats  into  apposition.  It  passes  around  the 
anterior  surface  and  is  tied  to  the  original  end,  which  has  been  left  long  for  the 
purpose.  If  silk  or  linen  is  used  for  this  suture  it  may  hang  in  situ,  suppurating 
for  months. 

"(g)  The  clamps  are  now  removed  and  the  linen  thread  continued  around 
until  it  is  tied  to  the  original  end,  firmly  catching  the  blood-vessels  in  sight 

along  the  suture  line.  The 
parts  are  carefully  cleansed 
and  inspected.  If  necessary, 
a  suture  or  two  are  applied  to 
coapt  accurately  or  to  check 
the  oozing. 

"  {h)  The  margins  of  the 
incised  mesocolon  are  now 
united  to  the  suture  line  by 
3  or  4  interrupted  sutures, 
and  the  parts  returned  into 
the  abdomen."  In  this 
operation  the  greatest  care 
must  be  taken  to  avoid 
twisting  the  gut  around  its 
longitudinal  axis. 

Qastro=anastomosis 
or  gastrogastrostomy  is 
an  operation  performed  for 
hour-glass  contraction  of  the  stomach,  a  condition  which  occasionally  ensues 
on  the  healing  of  an  ulcer.  In  this  operation  an  anastomosis  is  effected  be- 
tween the  pyloric  and  cardiac  pouches.  It  was  devised  and  practised  by 
Wolfier  in  1894,  I  have  performed  it  twice  with  success.  Watson  folds  the 
two  stomachs  over  each  other,  using  the  narrow  isthmus  as  a  hinge;  sutures 
the  pouches  together  and  leaves  the  ends  of  the  sutures  long.  He  incises  the 
anterior  wall  of  the  anterior  stomach  in  order  to  obtain  access  to  the  double 
septum  between  the  two  pouches.  He  makes  an  anastomosis  opening  through 
the  double  septum,  sutures  the  edges,  and  closes  the  wound  in  the  anterior  wall 
of  the  anterior  stomach.  Wolfler  made  a  vertical  cut  in  each  pouch  and  united 
these  openings  to  make  an  anastomosis.  The  best  plan  is  to  apply  clamps  on  each 
side  of  the  isthmus  and  operate  as  we  would  for  gastro-enterostomy  (Fig.  770). 
Qastroplication  (Brandt's  Operation  of  Stomach-reefing  for  Dilated 
Stomach). — Apply  sutures  in  the  anterior  wall  so  as  to  form  reefs,  then  tear 
through  the  great  omentum  and  apply  sutures  in  the  posterior  wall.  The 
sutures  pass  through  the  serous  and  muscular  coats.  A  continuous  suture  may 
be  used  on  the  anterior  wall  and  another  on  the  posterior  wall,  or  numerous 
interrupted  sutures  may  be  inserted.  This  operation  is  of  questionable  value, 
and  must  never  be  used  if  stenosis  of  the  pylorus  exists,  and  stenosis  of  the 
pylorus  is  the  most  common  cause  of  gastric  dilatation. 
Bircher's  method  of  gastroplication  is  shown  in  Fig.  769. 


Fig.  769. — Bircher's  method  of  gastroplication. 


Ransohoff's  Omentopexy  for  Gastroptosis 


1243 


Qastropexy  (Buret's  Operation  for  Gastroptosis). — It  has  been  shown 
by  Duret  that  dyspepsia  of  a  pecuharly  severe  type  may  be  produced  by  pro- 
lapse or  downward  displacement  of  the  stomach.  In  this  condition  he  advised 
the  following  operation:  Perform  a  median  laparotomy,  but  do  not  incise  the 
peritoneum  in  the  upper  portion  of  the  wound.  Expose  the  stomach  and  fix 
it  by  means  of  a  silk  suture  to  the  undivided  but  exposed  peritoneum.  The 
suture  should  be  parallel  to  the  lesser  curvature  and  near  the  pylorus  should  be 
horizontal.^  Rovsing,  too,  fixes  the  stomach  to  the  abdominal  wall.  So  do 
Ha.rtmann  and  Eve.  The  operations  of  Duret,  Rovsing,  Hartmann,  and  Eve, 
of  London,  fix  and  distort  the  stomach.  This  seems  to  me  an  objectional 
procedure  and  liable  to  be  followed  by  pain.     To  fix  an  organ  which  undergoes 


Fig.  770. — Hour-glass  stomach.  The  application  of  clamps  and  the  method  of  suture  in 
gastrogastrostomy.  The  details  are  the  same  as  in  the  operation  of  gastro-enterostomy 
(Moynihan). 

active  peristalsis  must  surely  be  productive  of  difficulty.  Byron  Davis  advises 
the  suturing  of  the  gastrohepatic  omentum  near  its  attachment  to  the  lesser 
curvature  to  the  stomach  wall  as  high  as  possible.  Beyea  has  devised  an  opera- 
tion which  is  free  from  the  objections  which  may  be  urged  against  Duret's 
operation.     Sometimes  gastro-enterostomy  is  also  performed. 

Beyea's  Operation  for  Gastroptosis. — Insert  three  rows  of  interrupted  silk 
sutures  through  the  gastrohepatic  omentum  and  the  gastrophrenic  ligament. 
Each  suture  is  passed  from  above  downward  and  the  row  begins  at  the  right 
and  passes  to  the  left  (Fig.  771).  When  the  sutures  are  tied,  a  fold  or  plication 
is  formed  in  the  ligaments,  the  supports  of  the  stomach  are  shortened,  and  the 
viscus  is  elevated  to  a  normal  position  without  any  disturbance  of  its  physio- 
logical mobihty  ("Univ.  of  Penna.  Med.  Bull.,"  Feb.,  1903). 

Ransohoff's   Omentopexy  for   Gastroptosis. — Ransohoff   ("Medical    Com- 
munications of  the  Mass.  Med.  Soc,"  191 2,  vol.  xxiii)  points  out  that  Beyea's 

1  "Rev.  de  Chir.,"  June,  1896. 


1244 


Diseases  and  Injuries  of  the  Abdomen 


operation  is  insufficient  because  only  the  right  and  left  borders  of  the  gastro- 
hepatic  omentum  act  as  supports.  He  uses  the  omentum  to  raise  and  fix  the 
stomach,  and  at  the  same  time  raises  and  fixes  the  transverse  colon.  He  makes 
spaces  between  the  fascia  and  peritoneum  as  advised  by  Coffey  and  sutures  the 
omentum  into  these  spaces.  If  necessary  he  also  does  gastroplication,  or  colo- 
plication,  or  reefs  the  mesocolon  or  separates  bands  and  adhesions,  or  shortens 
the  round  ligament  of  the  liver. 

Duodenostomy  and  Jejunostomy. — It  has  been  suggested  that  one  of 
the  above  operations  should  be  performed  in  a  case  of  pyloric  obstruction-  in 
which  neither  pylorectomy  nor  gastro-enterostomy  is  feasible.     Duodenostomy 


■e\  z\  1 


Fig.  771. — Beyea's  operation  for  gastroptosis :  i 
one  suture  of  second  row;  3,  one  suture  of  third  row. 
vals  to  and  including  the  gastrophrenic  ligament. 


Position  of  one  suture  of  first  row;    2, 
Others  of  each  row  introduced  at  inter- 


is  said  by  some  to  be  an  easy  operation  because  of  the  mobility  of  the  pylorus 
and  first  part  of  the  duodenum,  and  to  be  not  only  easier,  but  safer,  than 
jejunostomy,  because  it  makes  the  fistula  above  the  opening  of  the  common 
bile-duct  ("Bull,  et  ]Mem.  de  la  Soc.  de  Chir.  de  Paris,"  No.  39,  1901).  Cackove 
advocates  the  operation  in  some  cases  of  gastric  ulcer  with  repeated  hemor- 
rhages and  in  some  cases  of  gastric  cancer.  In  the  latter  cases  he  asserts  that 
the  mortality  is  about  the  same  as  from  gastro-enterostomy  and  the  prolonga- 
tion of  life  is  greater  ("Arch.  f.  klin.  Chir.,"  Bd.  Ixv,  Heft  2).  Hartmann's  case 
of  duodenostomy  lived  two  months.  The  operation  was  performed  for  extreme 
cicatricial  stenosis  of  the  pylorus  due  to  swallowing  hydrochloric  acid. 

Jacobson  disapproves  of  both  procedures,  and  objects  particularly  to 
duodenostomy,  because  it  involves  a  portion  of  the  intestine  which  is  difficult 
to  deal  with,  and  because  important  fluids  escape  constantly  from  the  fistula.^ 

If  duodenostomy  be  performed,  it  should  be  done  in  the  same  manner  as 
gastrostomy  by  Witzel's  method.  I  regard  jejunostomy  a=  an  operation 
which  is  occasionally  justifiable  and  as  preferable  to  duodenostomy.  As  per- 
formed to-day  there  is  little  danger  of  leakage,  even  if  the  tube  slips  out.  This 
operation  puts  the  stomach  at  absolute  rest.     It  is  employed  in  very  extensive 

'  Jacobson's  "Operations  of  Surgery." 


Enterectomy  1245 

ulceration,  in  multiple  ulcers,  and  in  some  cases  of  cancer  in  which  gastro-en- 
terostomy  is  impossible  or  is  contra-indicated,  because  the  opening  would  be  in 
or  too  near  the  malignant  growth.  Wm.  J.  Mayo  ("Am.  Jour.  Med.  Sciences," 
April,  191 2)  regards  the  operation  "as  an  active  competitor  of  gastrostomy  in 
eases  of  esophageal  and  cardiac  obstruction."  Mayo  Robson  ("Brit.  Med. 
Jour.,"  Jan.  6,  191 2)  advocates  the  operation.  Mayo  makes  an  epigastric 
incision,  picks  up  the  jejunum,  makes  a  little  opening  at  a  point  from  12  to 
16  inches  from  the  jejunal  origin,  introduces  a  rubber  catheter  (No.  9  English) 
"down  stream"  for  about  3  inches,  catches  it  to  the  wall  of  the  bowel  by  one 
suture  of  chromic  gut,  infolds  it  for  i  inch  or  more  as  in  Witzel's  gastrostomy, 
using  mattress  sutures  of  linen,  anchors  the  gut  to  the  peritoneum  by  two  or 
three  lines  of  linen  sutures  at  the  lower  angle  of  the  incision,  and  closes  the 
abdominal  wound  (Wm.  J.  Mayo,  Loc.  cit.).     Food  can  be  given  at  any  time. 

If  the  tube  slip  out  it  must  be  put  back  at  once,  as  the  tract  may  close  in  a 
few  hours.  When  the  operation  has  been  done  for  cancer  the  fistula  is  per- 
manently maintained.  If  for  ulcer,  it  can  be  allowed  to  close  or  can  be  closed 
surgically  if  it  persist  after  the  ulceration  heals.  Billon  ("Archiv.  prov. 
de  Chir.")  has  collected  127  cases.  The  direct  mortality  was  29  per  cent. 
Sixty-four  of  the  patients  lived  but  three  months  or  less.  A  single  case  lived 
beyond  a  year.     This  is  not  a  very  gratifying  showing. 

Maydl  does  a  much  more  formidable  operation  (divides  the  jejunum,  at- 
taches the  upper  end  to  a  far-away  portion  of  gut,  and  attaches  the  lower  end 
in  the  abdominal  wound).     He  has  operated  on  25  cases,  with  4  deaths. 

Enterectomy,  or  Resection  of  the  Intestine  with  Approximation 
by  Circular  Enterorrhaphy. — How  much  of  the  intestine  can  be  removed 
without  the  patient  dying  from  lack  of  nutrition?  The  length  of  the  small 
intestine  varies  from  15  to  25  feet.  The  report  of  a  case  with  the  number  of 
feet  removed  tells  us  nothing  as  to  how  many  feet  remain.  The  question  is 
not  settled.  It  has  been  stated  that  the  removal  from  an  adult  of  more  than 
6%  feet  produces  nutritional  disturbance,  and  that  a  child  tolerates  the  re- 
moval of  a  piece  relatively  large  better  than  does  an  adult.  Senn  was  of  the 
opinion  that  excision  of  more  than  one-third  of  the  intestine  makes  inanition  in- 
e\dtable.  Certain  it  is  that  great  lengths  have  been  successfully  removed,  and 
the  patients  have  not  only  lived,  but  have  been  well  nourished.  Ruggi  removed 
II  feet,  Whitall  removed'  10  feet  8  inches.  Von  Eiselsberg,  11  feet  8  inches,  and 
Obulinski,  12  feet  2  inches.  Brougham  removed  11  feet  2  inches  for  mesenteric 
thrornbosis  and  the  patient  recovered.  Childe  successfully  removed  9  feet  6 
inches  of  small  intestine  for  embolism  of  the  mesenteric  artery.  Hayes  removed 
8  feet  4^^  inches  from  a  boy  ten  years  of  age,  and  the  patient  was  well  eight 
months  later.  Dressman  reported  26  cases  in  each  of  which  more  than  3 
feet  3  inches  had  been  removed  (Alexander  Blaney,  in  "Brit.  Med.  Jour.," 
Nov.  16,  1901).  Turck  removed  successfully  10  feet  3,^  inches  of  ileum  to- 
gether with  the  cecum,  ascending  colon  and  part  of  the  transverse  colon  because 
of  adhesions,  sinuses  and  fistulae.  Blaney  adds  7  cases  from  literature,  and  tells 
us  that  in  9  of  the  ^^  cases  death  occurred  soon  after  operation. 

Alexander  Blaney,  in  the  previously  quoted  article,  reviews  the  subject 
of  the  resection  of  great  lengths  of  intestine.  He  tells  us  that  how  much  re- 
mains after  a  resection  is  important,  but  uncertain.  It  is  uncertain  because,  as 
Treves  has  shown,  the  length  of  the  intestine  varies  from  15  feet  6  inches  to 
31  feet  10  inches. 

Could  end-to-end  anastomosis  be  done  as  safely  as  lateral  anastomosis  it 
would  usually  be  the  preferred  method.  The  great  danger  is  infection  from 
soiling.  "Occasionally,  the  circular  suture  is  the  only  feasible  one"  (Haisted, 
"Jour,  of  Exper.  Med.,"  No.  3,  1912). 

Resection  of  the  jejunum  is  much  more  dangerous  than  resection  of  an 
equal  length  of  ileum.     Resection  of  the  ileum  is  more  dangerous  than  resection 


1246 


Diseases  and  Injuries  of  the  Abdomen 


of  the  colon.  If  resection  be  employed,  all  diseased  or  injured  bowel  must  be 
removed  irrespective  of  ultimate  bad  consequences  (Blaney).  The  operation  is 
performed  as  follows:  After  opening  the  al)domen  isolate  the  loop  of  intestine 
we  intend  to  resect.  Push  a  rubl^er  tube  through  the  mesentery  close  to  the 
bowel,  above  the  seat  of  operation,  and  pass  a  rul)bcr  tube  through  the  mesen- 
tery below  the  seat  of  operation.  Instead  of  tubes,  strips  of  iodoform  gauze  may 
be  used  to  encircle  the  bowel.     Empty  this  segment  of  bowel  by  squeezing 


Fig.  772. — Fxcision  of  bowel*  first  step  Fig.     773. — Excision    of   bowel     with 

(Lsmarch  and  Kowalzi^O-  enterorrhaphy    and   stitching   of    the   re- 

dundant mesentery:  second  step  (Esmarch 
and  Kowalzig). 

and  stroking,  tighten  the  rubber  tubes,  and  clamp  them  to  keep  the  bowel 
empty  (Fig.  772).  The  diseased  intestine  is  resected,  each  incision  being  car- 
ried through  a  healthy  segment,  and  care  being  taken  that  the  cuts  are  so 
arranged  that  at  each  end  a  blood-vessel  from  the  mesentery  reaches  the  edge 
of  the  cut  bowel.  Otherwise  repair  can  scarcely  occur.  The  lumen  of  each 
end  of  the  divided  gut  is  irrigated  with  salt  solution.  The  divided  surfaces  are 
approximated  by  a  double  row  of  sutures — a  continuous  suture  for  the  mucous 


Fig.  774. — Suture  of  the  mesentery  after 
circular  enterorrhaphy  (Halsted). 


Fig.  775. — Senn's  modification  of  Jobert's 
invagination  method:  A,  Upper  end  lined 
with  ring;  B,  invagination  sutures  in  place;  C, 
lower  end. 


membrane,  and  Lembert's,  Dupuytren's,  Cushing's  suture,  or  Halsted's  sutures 
— to  effect  inversion.  Thoroughly  satisfactory  approximation  can  be  effected 
by  one  row  of  Halsted  mattress  sutures  (Fig.  774).  If  a  redundant  fold  of  mes- 
entery is  left,  it  can  be  stitched  at  its  raw  edge  (Fig.  773).  Many  surgeons 
remove  a  V-shaped  piece  of  mesentery,  tie  the  divided  mesenteric  vessels  (^Fig. 
772),  and  introduce  sutures  so  that  no  mesenteric  vessel  will  be  constricted 
(Fig.  774).  The  tubes  are  removed,  and  the  wound  is  cleansed,  closed,  and 
dressed. 

Senn  effects  invagination  by  means  of  a  bone  ring  (Fig.  775). 


Enterectomy 


1247 


If  the  two  segments  of  bowel  are  unequal  in  size,  it  was  formerly  the  custom 
to  cut  the  smaller  bowel  obliquely  and  the  larger  part  transversely.  To 
meet  this  complication  Billroth  devised  lateral  implantation  '(see  Fig.  803). 
Suppose  the  cecum  has  been  resected:  its  lower  end  is  closed  by  Lembert  sutures, 
an  opening  is  made  in  the  long  axis  of  the  periphery  of  the  colon  opposite  the 
attachmerit  of  the  mesocolon,  and  the  end  of  the  ileum  is  sutured  into  this  incision. 
This  is  called  cnd-to-sidc  approximation,  or  implantation.  It  is  used  in  the 
sigmoid,  in  the  cecum,  and  in  any  intestinal  segment  in  which  the  circulation 
is  deficient.     Eugene  A.  Smith  ("Amer.  Med.,"  May  10,  1902)  sums  up  the 


Fig.  776. — Resection  of  intestine:  a,  b,  The  two  halves  of  the  button;  c,  the  two  portions 
clamped  together;  d,  introduction  of  the  sutures  for  holding  each  half  of  the  button  in  place. 
The  lower  figure  shows  the  completed  union  of  the  intestine  by  the  Murphy  button;  the  slit  in 
the  mesentery  has  been  closed  by  linear  union  (after  Zuckerkandl). 

advantages  of  end- to-side  approximation  as  follows:  The  strain  of  peristalsis 
is  less  than  in  end-to-end  union;  the  circulation  of  each  end  of  the  bowel  and 
the  parts  of  bowel  adjacent  is  better;  each  cut  edge  of  mesentery  is  free  to  re- 
cover its  circulation,  and  there  is  no  dead  space  at  the  mesenteric  border  to 
lead  to  leakage. 

Senn  advised  the  insertion  of  an  anastomosis  ring  in  the  ileum,  the  in- 
vagination of  the  colon  as  the  ring  is  pulled  into  place,  and  firm  suturing  of  the 
line  of  junction.  By  Senn's  method  the  ileum  may  be  implanted  into  the  end 
of  the  colon  or  into  a  slit  in  the  waU  of  the  large  bowel  after  the  end  of  the 
colon  has  been  closed.  In  some  cases,  in  which  one  portion  of  bowel  is  larger 
than  the  other,  lateral  anastomosis  is  the  preferable  method.     For  a  full  week 


1248 


Diseases  and  Injuries  of  the  Abdomen 


after  an  intestinal  resection  the  patient  is  fed  chiefly  by  nutrient  enemata. 
During  the  first  twenty-four  hours  nothing  is  given  by  the  stomach  but  small 
amounts  of  hot  water,  and  for  the  next  six  days  only  water  and  a  little  liquid 
food  is  allowed  to  be  swallowed. 

The  use  of  Murphy's  button  (Fig.  777)  permits  of  rapid  approximation  after 
resection  (Fig.   776).     This  button  closely  approximates  the  portions  of  the 

intestine  within  its  bite,  rapid 
adhesion  taking  place.  The 
diaphragm  of  tissue  undergoes 
pressure-atrophy  and  liberates 
the  button,  which  is  passed  per 
anum.  It  is  claimed  that  the 
button-opening  contracts  but 
slightly.  For  end-to-end  or  side- 
to-side  approximation  of  the 
small  intestine  a  No.  3  button 
is  used.  For  similar  operations 
on  the  large  intestine  a  No.  4 
button  is  employed  (Murphy). 
After  the  resection  one-half  of 
a  button  is  inserted  into  each  segment,  and  is  held  in  place  by  a 
purse-string  suture  of  silk  which  passes  through  all  the  coats  (Fig.  776). 
The  redundant  mucous  membrane  is  tucked  in  or  clipped  off,  so  that  it 
wUl  not  be  interposed  between  the  serous  surfaces.  The  serous  surfaces 
are  scratched  with  a  needle  and  the  halves  of  the  button  are  locked  (Fig. 
776).     It  is  not  necessary  to  surround  the  margin  of   junction  with  sutures 


Fig.    777.- 


-Comparison   of   old    {a)    and  new 
Murphy  buttons. 


(/') 


Fig.  778. — -The  segmented  ring  of  Harrington  and  Gould. 

Murphy  says  that  liquid  nourishment  should  be  given  as  soon  as  the  patient 
has  recovered  from  the  effect  of  the  ether,  and  that  the  bowels  should  be  moved 
at  an  early  period,  and  frequent  evacuations  should  be  maintained.  If  the 
button  does  not  pass  in  four  weeks,  examine  the  rectum  for  it.^  The  situa- 
tion of  the  button  can  be  ascertained  by  the  x-rays.  An  objection  to  the  but- 
ton is  that  it  is  a  foreign  body  which  must  pass  per  rectum  to  complete 
the  operation  successfully.  It  may  not  pass,  but  trouble  does  not  of  necessity 
follow.  In  some  cases  its  retention  does  lead  to  trouble,  and  intestinal  obstruc- 
tion ensues.  If  the  caliber  of  the  button  blocks  before  dislodgment,  obstruction 
follows,  hence  the  rule  to  give  saline  purgatives  the  day  after  the  operation. 
1  John  B.  Murphy,  in  "Med.  News,"  Feb.  9,  1895. 


Enterectomy 


1249 


Some  surgeons  have  sought  to  make  a  button  which  would  come  apart 
and  be  absorbed  after  it  had  accomplished  its  purpose.     One  of  these  appli- 


-T^^'^^^ 


^^x^^ 


y 


tt 


/ 


Fig.  779. — End-to-end  union  with  aid 
of  segmented  ring.  Contiauous  stitch  be- 
ginning at  one  side  of  the  handle  (Harring- 
ton and  Gould). 


Fig.  7S0. — End-to-end  union  with  aid  of 
segmented  ring.  Handle  unscrewed,  suture 
completed  (Harrington  and  Gould). 


ances  is  Frank's  coupler,  which  is  made  of  bone,  the  compression  being  furnished 
by  rubber.  In  this  apparatus,  however,  the  amount  of  pressure  obtained  is 
always  uncertain  and  the  rub- 
ber is  apt  to  wear  out.  The 
button  gives  a  lower  mortality 
than  the  suture  operation,  and 
some  surgeons  now  use  it  who 
once  condemned  it.  Czemy  is 
a  strong  advocate  of  the 
button. 

Harrington  and  Gould  use 
a  segmented  aluminum  ring. 
This  ring  collapses  into  small 
segments  after  the  anastomosis 
has  been  effected.  By  its  use 
the  authors  believe  that  the 
operation  is  made  more  rapidly 
and  safely  ("'Annals  of  Sur- 
gery," Nov.,  1904).  During 
the  suturing  the  ring  is  held  by 
means  of  a  handle,  which,  after 
the  anastomosis  has  been 
effected,  is  removed.  The 
ring  in  the  handle  is  shown  in 
Fig.  778  and  the  operation  in 
Figs.  779  and  780. 

^Maunsell  has  devised  a 
most  ingenious  method  of  cir- 
cular enterorrhaphy.  The  two 
portions  of  bowel  are  attached 
by  two  fixation  sutures  which 
penetrate   all  the    coats    (Fig. 

781).     An  incision  iH  inches  in  length  is   made  through    the  wall    of    the 
proximal  segment  of  gut,  about  i  inch  from  its  edge.     The  fixation  sutures 


Fig.  781.- 


-Maunsell's  method  of  anastomosis 
Wiggin). 


(after 


I2^0 


Diseases  and  Injuries  of  the  Abdomen 


are  brought  through  this  opening,  traction  is  made  upon  them,  the  distal 
portion  of  the  bowel  is  invaginated  into  the  proximal  portion,  and  the  ends 
emerge  from  the  opening,  their  peritoneal  surface  being  in  contact  (Fig.  781). 
Sutures  of  silk  are  passed  through  both  sides  of  the  area  of  invagination,  the 
threads  are  caught  up  in  the  center,  cut,  and  tied  on  each  side.  The  fixation 
sutures  are  cut  off.  The  invagination  is  reduced  by  traction.  The  longitudinal 
cut  is  closed  bv  Lembert  sutures. 


Fig.  782. — Robson's  decalcified  bone  bobbin. 


Fig.  783. 


-AUingham's  decalcified 
bone  bobbin. 


A.  W.  Mayo  Robson  performs  circular  enterorrhaphy  and  brings  the  ends 
of  the  gut  together  over  a  bobbin  of  decalcified  bone  (Fig.  782).  Allingham 
uses  a  bone  bobbin  the  shape  of  two  cones  joined  at  their  apices.  The  bobbin 
is  decalcified,  except  an  area  at   the  center  (Fig.  783,  a).     Kocher  performs 

circular  enteroiThaphy  as  follows:  A  fixation  suture 
is  introduced  through  the  bowel  at  the  mesenteric 
attachment  and  another  isinserted  at  an  opposite  point. 


Fig.    784.  —  Moynihan's  FiG.    785.  —  Moynihan's  Fig.    786. — Moynihan's 

method  of  end-to-end  anas-  method  of  end-to-end  anas-  method  of  end-to-end  anas- 
tomosis (Moynihan).  tomosis  continued.  tomosis  continued. 

The  intestinal  ends  are  approximated  by  a  continuous  silk  suture,  which  passes 
through  all  of  the  coats,  but  which  includes  more  of  the  serous  than  of  the 
mucous  coat.  The  suture-line  is  overlaid  by  a  continuous  Lembert  suture 
which  includes  the  serous  and  a  portion  of  the  muscular  coat. 

In  doing  an  end-to-end  approximation  I  prefer  to  use  the  clamp  of  Moyni- 
han (see  Fig.  759),  as  shown  in  Figs.  784-786.  We  thus  are  able  to  hold  the 
parts  and  keep  them  clean,  rapidly  make  an  even  and  secure  stitch  line,  and 
have  no  free-edged  septum. 


Entercctomy 


12^1 


Some  surgeons  have  used  inflatable  rubber  cylinders  in  making  an  end-to- 
end  anastomosis  (Halsted,  Downes,  and  others).  The  method  was  devised  by 
Treves,  but  was  subsequently  abandoned  by  him.  Halsted  no  longer  uses  the 
inflatable  cylinders. 

Connell  has  devised  a  method  which  places  the  knots  in  the  lumen  of  the 
bowel  (F.  Gregory  Connell,  ''Medicine,"  April,  1901).  He  maintains  that 
the  placing  of  the  knots  within  the  lumen  of  the  gut  has  the  following  advan- 
tages: there  is  no  foreign  body;  the  suture  passes  away  early;  adhesions  to 
neighboring  organs  are  few;  the  serous  approximation  is  perfect;  the  suture  line 


Fig.   787. — ^Laplace's  forceps  for  intestinal  anastomosis. 


The 


is  more  secure;  the  septum  is  smaller  and  the  danger  of  necrosis  is  less, 
suture  is  shown  in  Plate  11. 

Laplace  has  devised  forceps  which  greatly  facilitate  suturing,  which  make 
it  easy  to  obtain  an  even  suture  line,  and  which  can  be  withdrawn  after  the 
suturing  is  finished,  the  small  opening  through  which  the  instrument  has  emerged 
being  closed  by  a  stitch  (Figs.  787,  788).  By  aid  of  Laplace's  forceps  the 
operation  can  be  neatly  and  rapidly  performed,  but  a  large  diaphragm  is  formed, 


Fig.  788. — End-to-end  anastomosis  with  the  aid  of  Laplace's  forceps. 

a  considerable  area  is  exposed  to  infection,  the  tissues  of  the  diaphragm  are 
bruised  and  may  slough,  the  raw  ends  may  grow  together  and  cause  obstruction, 
and  it  seems  probable  that  considerable  contraction  will  follow.  Another 
objection  is  that  an  infected  instrument  is  withdrawn  from  the  bowel  and  may 
contaminate  the  peritoneum.  O'Hara's  forceps  (Fig.  789)  permit  of  rapid  and 
accurate  suturing,  but  possess  the  same  disadvantages  as  the  Laplace  forceps. 
In   I  case  within  my  knowledge  absolute  obstruction  from  adhesion  of  the 


I2s2 


Diseases  and  Injuries  of  the  Abdomen 


raw  edges  of  the  septum  followed  its  employment.  Figures  790  and  791  show 
the  use  of  O'Hara's  forceps^  Of  the  operations  previously  set  forth,  I  prefer  the 
clamp  and  suture  as  employed  by  Moynihan,  the  oj^eration  of  Halsted  by  mat- 
tress sutures  and  without  mechanical  aids,  and  in  some  cases  the  operation  with 
the  Murphy  button. 

Lateral  Intestinal  Anastomosis. — Approximation  may  be  effected 
by  other  methods  than  by  end-to-end  junction  or  by  implantation.  In  fact,  I 
prefer  in  most  cases  of  resection  to  close  each  end  of 
the  divided  gut  and  perform  lateral  anastomosis. 
It  is  a  safer  operation  than  end-to-end  anastomosis 
and  by  it  we  can  obtain  as  large  an  opening  as  we 
desire.     Again,  after  lateral   anastomosis    the   parts 


Fig.  789. — O'Hara's  anas- 
tomosis forceps  (about  one- 
third  original  size). 


Fig.  790. — Showing  the  manner  of  placing  forceps  in 
resection  of  bowel;  dotted  lines  show  the  incision  to  be  made 
(O'Hara). 


obtain  a  better  blood-supply  than  after  end-to-end  suturing,  because  in  the 
former  operation  the  mesenteric  vessels  are  not  interfered  with.  Further,  in 
lateral  anastomosis  there  is  little  tendency  to  cicatricial  contraction.     Lateral 


/,a:'if/.,^ 


Fig.  791. — End-to-end  anastomosis.     Forceps  brought  together  and  held  hy  serre-fine  (not 
shown);  sutures  introduced,  some  of  which  are  tied  (O'Hara). 

anastomosis  may  be  performed  in  some  cases  without  a  preliminary  resection 
for  the  purpose  of  short-circuiting  the  fecal  current,  throwing  a  diseased  portion 
of  the  bowel  out  of  action,  and  thus  avoiding  obstruction  (Fig.  792).  This 
operation  has  the  disadvantage  that  the  diseased  structure  is  not  removed. 


Operation  with  Rings  for  Lateral  Intestinal  Anastomosis       1253 


Operation  with  Rings, — In  this  operation  a  portion  of  bowel  above  the 
obstruction  and  a  loop  below  the  obstruction  are  brought  into  the  wound. 
These  segments  are  emptied,  and  are  kept  empty  by  fastening  around  them 
rubber  tubes  or  iodoform  strips.  Two  tubes  are  needed  for  each  loop  of  bowel. 
Pack  in  gauze  pads.  Make  an  incision  in  one  loop,  in  the  long  axis  of  the  bowel, 
on  the  surface  away  from  the  mesen- 
tery; permit  the  contents  to  escape  ex- 
ternally; irrigate  this  segment  with 
saline  solution,  and  introduce  the  bone 
plate  of  Senn  (Fig.  792,  a)  or  Abbe's 
catgut  ring  (Fig.  793).  Calyx-eyed 
needles  are  used  to  pass  the  silk,  and 
the   threads   of   the  ring  are   carried 


Fig.  792. — Senn's  entero-anastomosis :  A, 
Senn's  bone  plate;  B,  intestinal  anastomosis; 
C,  operation  complete. 


Fig.  793. — Method  of  passing  the  silk  su- 
tures in  inserting  the  rings  of  Abbe. 


through  the  coats  of  the  bowel  and  are  gathered  together  in  the  bite  of  a  pair  of 
forceps.  The  other  loop  of  intestine  is  treated  in  a  similar  manner.  The  two  seg- 
ments of  intestine  are  so  brought  together  that  the  two  wounds  are  opposite  each 
other,  the  posterior  sutures  being  tied  first,  the  upper  next,  then  the  lower,  and 
finally  the  anterior  threads.  The  ends  of  the  threads  are  cut  off,  and  the  entire  anas- 
tomosis   is    surrounded    by    a 


layer  of  Lembert  or  Halsted 
sutures  or  is  encircled  by  Cush- 
ing's  suture.  Figure  792,  b, 
shows  an  intestinal  anastomosis 
partly  finished,  and  Fig.  792, 
c,  shows  an  anastomosis  com- 
plete. Figure  793  shows  the 
passing  of  the  sutures  when  the 
catgut  rings  of  Abbe  are  em- 
ployed. After  an  intestinal 
resection  each  end  can  be 
closed  and  anastomosis  effected 
described    above.     Lateral 


as 

anastomosis  can  be  accom- 
pHshed  with  a  Murphy  button, 
the  intestine  being  prepared 
for  the  button  as  is  shown  in 
Fig.  794. 

Abbe's  method  of  anastomosis  without  mechanical  aid  is  as  follows:  After 
resecting  the  bowel  and  mesentery  and  closing  the  ends  of  the  bowel  he  places 
the  extremities  side  by  side  and  applies  two  rows  of  a  Dupuytren  suture,  3^^  inch 
apart.  These  rows  of  sutures  are  i  inch  longer  than  the  slit  in  the  bowel  will 
be  (Fig.  795),  the  thread  at  the  end  of  each  low  being  left  long.  An  incision  is 
made  in  the  bowel,  3^^  inch  from  the  sutures,  both  rows  of  threads  being  on  the 


Fig.  794. — Showing  relative  size  of  incision  and 
method  of  introducing  sutures  in  lateral  approximation 
with  Murphy's  button. 


1254 


Diseases  and  Injuries  of  the  Abdomen 


same  side  of  the  cut.  This  incision  is  4  inches  long.  The  other  portion  of  the 
bowel  is  then  incised  in  the  same  way.  The  adjacent  cut  edges  are  united  by 
a  whip-stitch  which  goes  through  all  the  coats,  and  the  free  cut  edges  are 
stitched  in  the  same  manner  (Fig.  796).  The  surgeon  now  utilizes  the  long 
threads  of  the  first  sutures,  and  brings  the  serous  surfaces  of  the  opposite  sides 
together  by  means  of  Dupuytren's  suture.  Halsted  performs  anastomosis 
as  follows:  He  places  the  two  portions  of  bowel  with  their  mesenteric  borders 


Fig.  795. — Suturing  intestines  in  apposition 
before  incision  (Abbe). 


Fig.  796. — Showing  the  4-inch  incision  and 
sewing  of  the  edges  (Abbe). 


in  contact.  Six  quilted  sutures  of  silk  are  introduced,  tied,  and  cut  off  (Fig. 
797,  a).  At  each  end  of  this  row  of  sutures  two  quilted  sutures  are  introduced, 
tied,  and  cut  (Fig.  797,  b).  A  number  of  quilted  sutures  are  introduced,  as  is 
shown  in  Fig.  797,  c.  The  intestinal  openings  are  made  with  scissors,  and  the 
sutures  last  introduced  are  tied  and  cut  off  (Fig.  797,  d). 

J.  Shelton  Horsley  has  suggested  an  ingenious  method  of  intestinal  anasto- 
mosis which  secures  for  the  sutured  portion  a  greater  diameter  than  that  nor- 


Fig.  797. — Halsted's  operation  for  lateral  anastomosis,  showing  four  steps  of  same  (Jessett, 

from  Halsted). 


mal  to  the  intestine.  ^  After  resection  of  the  intestine  and  a  V-shaped  piece  of 
mesentery,  the  ends  of  the  bowel  are  placed  side  by  side,  the  openings  being 
in  the  same  direction,  and  are  clamped  in  place  (Fig.  798).  The  first  stitch 
approximates  the  two  limbs  of  the  bowel  near  the  mesenteric  .attachment,  is 
carried  obliquely  for  about  2  inches  to  the  border  opposite  the  mesenteric 
attachment,  and  continued  over  the  other  side  (Fig.  798).  The  septum  is  cut 
away,  a  margin  being  left  ^i  inch  wide.  The  edge  of  the  shelf  made  by  cutting 
the  septum  is  sutured.  When  the  suture  reaches  the  end  of  the  shelf,  it  is  con- 
tinued by  invaginating  about  the  rest  of  the  resected  ends  (Fig.  799). 


1  "New  York  Polvclinic." 


Operation  with  Rings  for  Lateral  Intestinal  Anastomosis       1255 

Bodine's  method  of  intestinal  anastomosis  is  referred  to  on  page  1262. 
Laplace,  of  Philadelphia,  has  devised  an  operation  in  which  temporary  approxi- 
mation is  effected  by  means  of  forceps,  the  instrument  being  withdrawn  before 


Fig.  798. — Represents  the  ends  of  the  in- 
testine in  position  and  grasped  by  the  artery 
forceps.  The  first  row  of  sutures  has  been 
partially  applied,  the  septum  partly  cut  away, 
and  the  second  row  of  overhand  sutures  begun: 
a,  b,  are  the  two  ends  of  the  intestine;  c,  c' ,  the 
first  row  of  sutures  (Gushing) ;  d,  the  second 
row  of  sutures  (overhand);  e,  the  septum;/, 
and  g,  the  mesentery  (J.  Shelton  Horsley). 


Fig.  799. — Operation  nearly  com- 
pleted. The  septum  has  been  cut  away, 
and  the  row  of  overhand  sutures  has  been 
brought  almost  to  its  point  of  commence- 
ment. The  cut  also  shows  the  first  row 
of  sutures  (Gushing)  as  it  should  be  con- 
tinued after  the  overhand  sutures  are 
finished  (J.  Shelton  Horsley). 


the  abdomen  is  closed.  Junction  of  two  segments  of  intestine  can  be  quickly 
and  neatly  effected  by  this  method  and  the  suture  line  is  even  and  secure.  The 
objections  are  that  an  infected  instrument  is  withdrawn  from  the  bowel  and  may 
contaminate  the  surface;  that  the  septum  is  tightly  squeezed  and  this  septum 


Fig.  800. — Lateral  anastomosis  with  the  aid  of  Laplace's  forceps. 


may  slough  or  may  become  infected,  conditions  which  will  be  followed  by  infec- 
tion of  the  suture  line;  and  that  contraction  of  the  collar  may  ensue.  The 
operation  is  more  liable  to  be  followed  by  leakage  or  by  partial  or  complete 
obstruction  than  is  the  operation  without  forceps.     Figures  800  and  801  illus- 


1256 


Diseases  and  Injuries  of  the  Abdomen 


trate  the  use  of  Laplace's  forceps  in  lateral  anastomosis.  I  usually  perform 
lateral  anastomosis  with  the  assistance  of  Moynihan's  clamps,  the  method  being 
identical  with  the  operation  of  gastro-enterostomy.  Moynihan's  operation  is 
showTi  in  Fig.  802. 

Consideration  of  Methods  of  Intestmal  Approximation. — At  least  250 
methods  of  uniting  a  divided  intestine  have  been  devised  and  the  best  method  is 
a  matter  of  dispute.  The  essentials  of  a  good  method  are:  rapidity  of  execu- 
tion, the  formation  of  an  even  and  reliable  line  of  junction,  and  the  absence  of 
any  considerable  permanent  septum.  The  Murphy  button  can  be  applied 
with  great  rapidity,  and  rapid  operation  is  of  immense  importance  in  intestinal 
work.  The  opening  left  by  the  ^Murphy  button  is  small  (too  small,  some  sur- 
geons think),  but  it  does  not  strongly  tend  in  most  instances  to  contract  because 
the  tissue-diaphragm  is  separated  by  tissue-atrophy  and  not  by  inflammatory 
gangrene.  The  separation  of  the  diaphragm  is  a  most  valuable  feature.  No 
other  instrument  thus  cuts  away  the  objectionable  septum.     Occasionally  the 


Fig.  801. — Withdrawal  of  Laplace's  forceps. 


opening  made  by  the  button  contracts  and  gives  trouble;  occasionally  the 
lumen  of  the  button  blocks  with  feces;  occasionally  the  button  is  retained,  this 
latter  complication  being  especially  frequent  after  anterior  gastro-enterostomy. 
If  the  button  be  used,  liquid  food  should  be  given  soon  after  the  effect  of  the 
anesthetic  has  passed  off,  and  movement  of  the  bowels  should  be  obtained  at  an 
early  period  after  operation  and  frequent  evacuations  should  be  maintained. 
The  button  gives  better  results  in  end-to-end  approximation  than  in  lateral  an- 
astomosis. MovTiihan's  forceps,  Laplace's  forceps,  O'Haia's  forceps,  the  de- 
calcified bone  plates  of  Senn,  the  catgut  rings  of  Abbe,  the  segmented  ring  of 
Harrington,  the  catgut  strands  inside  of  rubber  tubing  of  Biokaw,  Chaput's 
button,  Allingham's  bone  bobbin,  Robson's  bone  bobbin,  Frank's  coupler, 
Clark's  bobbin,  tubes  or  plates  of  potato  or  carrot,  and  rings  or  plates  of  leather, 
all  have  their  adherents.  Of  mechanical  appliances,  the  best  are  Murphy's 
button,  the  bone  ring,  and  Moynihan's  forceps.  Of  recent  years  many  surgeons 
have  abandoned  all  mechanical  aids,  and  have  returned  to  closure  by  simple 
sutures.  The  ideal  operation  is  without  mechanical  contrivances.  But  such 
devices  are  time-savers,  and  to  lessen  the  time  of  operation  will  often  save  life. 
Further,  Moynihan's  forceps  prevent  fecal  extravasation  and  consequent  in- 
fection.    What  method  to  follow  must  be  determined  in  each  particular  case 


Local  Intestinal  Exclusion 


1257 


by  a  study  of  the  necessities  of  the  situation.  Nevertheless,  it  may  be  possible 
to  formulate  a  few  general  rules:  If  the  condition  of  the  patient  is  excellent 
and  the  bowel  is  in  a  fairly  healthy  condition,  well  above  and  well  below  the 
seat  of  trouble,  end-to-end  approximation  should  be  performed  by  circular 
enterorrhaphy  with  the  aid  of  Moynihan's  clamp,  or  each  end  can  be  closed 
after  resection  and  a  lateral  anastomosis  be  effected  with  the  aid  of  the  clamp. 
If  the  condition  of  the  patient  is  such  as  to  make  haste  necessary,  use  a  Murphy 
button.  If  the  bowel  below  the  seat  of  trouble  is  much  contracted  and  haste 
is  necessary-,  do  not  use  a  JMm-phy  button,  but  use  Senn's  bone  plate  or  Robson's 
bobbin.  If  haste  is  not  imperatively 
necessary,  do  simple  enterorrhaphy. 
If  the  surgeon  is  obMged  to  join  a 
very  much  distended  bowel  to  a 
very  much  contracted  bowel,  per- 
form end-to-side  approximation 
(implantation)  with  the  bone  plate 
of  Senn  or  by  simple  suturing,  or 
else  effect  side-to-side  junction  by 
the  method  of  Abbe  or  of  ^Nloynihan.^ 
Local  Intestinal  Exclusion. 
— This  operation  was  introduced 
by  Salzer  in  1891.  ,  It  excludes  the 
fecal  current  from  a  portion  of 
the  intestine.  In  complete  exclu- 
sion the  intestine  is  cut  through 
above  and  below  the  diseased  por- 
tion, and  the  ends  of  the  healthy 
gut  are  united  to  each  other  or 
the  end  of  one  portion  of  gut  is 
implanted  into  the  side  of  the 
other.  Both  ends  of  the  excluded 
portion  may  be  fastened  to  the 
skin,  making  a  double  fistula  (von 
Eiselsberg);  the  distal  end  or  the 
proximal  end  alone  may  be  fastened 
to  the  skin,  the  other  end  being 
closed  by  sutures  and  replaced 
within  the  abdomen.  Sometimes 
•each  end  is  closed  and  dropped 
back,  and  a  fistula  is  made  in  the 
middle  of  the  excluded  portion  to 

permit  of  drainage.  Some  operators  close  each  end  by  suture  and  drop 
them  back,  and  do  not  drain  the  excluded  portion;  and  others  with  the 
same  purpose  in  view  suture  together  the  two  ends  of  the  excluded  part.  It 
seems  wisest  to  suture  both  ends,  or  at  least  one  end  to  the  skin 
(LeDentu,  in  "Rev.  de  Gyn.  et  de  Chir.,"  Jan.  and  Feb.,  1899).  It  is 
true  this  makes  a  permanent  fistula,  but  if  it  be  not  done,  the  loop  may 
become  distended  wdth  secretion  containing  \drulent  bacteria,  a  condition 
which  may  lead  to  perforation  and  death.  Exclusion  is  rarely  performed  upon 
the  small  intestine.  It  is  best  suited  to  the  large  intestine.  If  it  be  done  at 
all,  complete  exclusion  is  the  best  operation  (Fig.  803).  Partial  exclusion  is 
rarely  satisfactory.  Exclusion  has  been  performed  instead  of  colostomy  in 
cases  of  intestinal  obstruction,  but  it  is  best  suited  to  inflammatory  areas  or 
tumors,  irremovable  because  of  adhesions  or  some  other  cause.  After  the 
operation  the  diseased  area  may  improve  because  of  drainage  and  freedom  from 

1  See  the  discussion  of  this  subject  by  the  late  J.  Greig  Smith,  in  his  "Abdominal  Surgery." 


Fig.  802. — Moynihan's  inner  suture  in 
lateral  anastomosis  to  show  the  infolding  of 
the  mucosa  which  results.  A  loop  of  the  suture 
lies  on  the  mucous  surface  (Moynihan). 


1258 


Diseases  and  Injuries  of  the  Abdomen 


irritant  fecal  matter.  In  many  cases  it  can  be  irrigated  through  the  fistula. 
Sometimes  the  diseased  part  improves  sufficiently  after  a  time  to  permit  of 
extirpation. 

Surgical  Treatment  of  Ascites  Resulting  from  Hepatic  Cirrhosis 

(Epiplopexy;  Talma's  Operation;  Drummond's  Operation  ;  Morison's  Opera- 
tionj. — The  portal  system  communicates  with  the  vena  cava  by  means  of  a 
number  of  small  vessels.  Normally,  only  an  insignificant  amount  of  portal 
blood  passes  by  this  route  to  the  general  circulation.  When  cirrhosis  obstructs 
the  flow  of  blood  through  the  liver,  the  radicles  of  communication  between 
the  portal  system  and  the  vena  cava  enlarge  and  an  increased  amount  of 
blood  is  thus  sent  directly  to  the  systemic  circulation.  Adhesions  develop 
between  the  parietal  peritoneum  and  some  of  the  viscera  and  the  collateral 
circulation  is  further  increased.     Thus,  Nature  seeks  to  prevent  ascites.     If, 


Fig.  803. — Operation  of  complete  exclusion  of  the  cecum:  a  and  b,  Lines  of  incision;/  is  im- 
planted into  c;  e  and  d  are  sutured  to  the  abdominal  wall. 

however,  the  obstruction  to  the  passage  of  portal  blood  becomes  so  great  that 
"the  collateral  circulation  is  no  longer  able  to  maintain  an  equilibrium  in  the 
blood-pressure  in  the  portal  radicles,  the  pressure  thus  rises  to  a  point  at  which 
transudation  takes  place  and  ascites  develops'"  (M.  L.  Harris,  paper  read  before 
Chicago  Medical  Society,  Feb.,  1902).  The  theory  above  set  forth  is  the 
^'mechanical  theory;"  but,  as  Harris  points  out,  increased  portal  tension  is 
not?  the  only  factor  concerned  in  the  production  of  ascites,  chronic  inflam- 
matory changes  in  the  peritoneum  being  "materially  instrumental"  in  main- 
taining ascites  by  lessening  the  absorbing  power  of  the  peritoneum.  Influenced 
by  the  mechanical  theory'  of  causation,  Talma,  of  Utrecht,  devised  an  opera- 
tion to  cure  ascites  by  establishing  more  free  communication  between  the  portal 
system  and  the  systemic  circulation.  Drummond  and  Morison  about  the  same 
time  independently  devised  a  like  procedure.^  This  operation  is  called 
epiplopexy.  In  some  cases  the  abdomen  has  been  opened  and  the  omentum 
sutured  into  the  abdominal  wound;  in  others,  between  the  layers  of  the 
anterior  abdominal  wall.  The  results  are  slightly  better  when  the  omentum  is 
sutured  between  the  layers  of  the  abdominal  wall.  The  gall-bladder  may  be 
sutured  to  the  abdominal  wall  as  well  as  the  omentum.  The  liver  and  spleen, 
under  surface  of  the  diaphragm,  and  parietal  peritoneum  about  the  liver  and 
spleen  are  usually  rubbed  harshly  with  a  piece  of  gauze.  Drainage  is  not  used 
by  most  operators.  It  does  not  appear  to  contribute  any  favorable  chances 
and  it  exposes   the  patient  to  the  danger  of  infection.     Morison,  however, 

1  "Brit.  Med.  Jour.,"  Sept.  19,  1896. 


Operation  for  Intussusception  1259 

advocates  it,  and  makes  suprapubic  drainage,  a  glass  tube  being  carried  into 
the  rectovesical  or  recto-uterine  pouch  ("Brit.  Med.  Jour.,"  Jan.  20,  191 2). 

The  operation  ought  to  be  performed  early,  before  the  onset  of  chronic 
inflammation  of  the  peritoneum.  In  a  great  majority  of  cases  the  operation 
proves  futile,  and  not  uncommonly  death  soon  follows  from  complications  or 
because  the  disease  is  very  far  advanced.  In  exceptional  cases  the  operation 
proves  of  distinct  benefit.  The  operation  shows  the  least  mortality  and  the 
greatest  number  of  apparent  cures  when  the  liver  is  large;  the  greatest  mor- 
tality and  the  fewest  cures  when  the  liver  is  contracted.  The  greatly  lowered 
vital  resistance  of  these  patients  is  the  imminent  danger.  Renal  disease,  car- 
diac disease,  other  grave  complications,  and  the  absence  of  sufficient  function- 
ating liver  substance  to  maintain  life  contra-indicate  operation  (Greenough,  in 
"Am.  Jour.  Med.  Sciences,"  Dec,  1902). 

Harris,  in  the  paper  previously  quoted,  collected  46  cases;  23  of  these  were 
instances  of  alcoholic  cirrhosis;  30  per  cent,  were  dead  within  fourteen  days; 
52  per  cent,  were  dead  within  two  months;  56  per  cent,  were  dead  within  six 
months.  Ascites  had  returned  in  all  of  those  who  died  late.  At  the  end  of 
one  year  or  longer  13  per  cent,  had  recovered  from  ascites.  The  remaining 
30  per  cent,  were  either  unimproved  or  were  said  to  be  improved  with  some 
ascites.  < 

Of  the  giToup  of  mLxed  cases  constituting  the  remainder  of  those  Harris 
collected,  10  per  cent,  were  dead  in  four  days,  25  per  cent,  were  dead  in  four 
months.  In  40  per  cent,  no  improvement  took  place.  In  10  per  cent,  the 
report  was  too  early  to  give  any  information.  About  15  per  cent,  were  free 
of  ascites  after  one  year  or  longer,  and  5  per  cent,  were  cured  of  intestinal 
hemorrhage,  ascites  never  having  been  present.  Greenough  collected  105 
operations:  42  per  cent,  were  improved;  58  per  cent,  were  not  improved;  29.5 
per  cent,  died  within  thirty  days.  Two  years  after  operation  9  cases  were 
apparently  in  good  health  ("Am.  Jour.  Med.  Sciences,"  Dec,  1902).  One  of 
Morison's  cases  was  alive  and  well  eleven  years  after  operation;  another  was 
well  for  six  years,  when  an  attack  of  penumonia  lead  to  death;  another  patient 
remained  well  for  two  years,  but  died  after  an  operation  for  ventral  hernia 
(Morison,  in  "Brit.  Med.  Jour.,"  Jan.  20,  1912).  The  results  of  the  TaLma 
operation  are  disappointing.  Wm.  J.  Mayo  ("N.  Y.  Med.  Jour.,"  June  22, 1918) 
performed  the  operation  28  times  with  4  deaths,  8  died  at  various  times  following 
operation,  the  rest  were  benefited.  Mayo  suggests  that  we  divert  the  portal 
circulation  by  removing  the  spleen.  Blood  will  then  be  diverted  from  the  portal 
to  the  pulmonary  circulation  through  the  channels  described  by  Sappey. 

Operation  for  Intussusception. — Air  distention  and  hydrostatic  pres- 
sure are  uncertain;  in  an  advanced  case  may  rupture  the  gut;  even  in  a  recent 
case  may  fail  or  may  reduce  the  bulk  of  the  intussusception,  but  not  its  apex. 
Russel  ("Intercolonial  Med.  Jour,  of  Australasia,"  March  20,  1902)  alludes  to 
the  uncertainty  of  the  method.  He  used  hydrostatic  pressure  in  5  cases.  Two 
died  and  2  recovered.  In  i  case  the  method  failed  and  operation  was  then 
performed.  It  is  safer  and  better  to  operate  early,  but  if  the  conservative  plan 
is  tried  and  fails,  operation  should  certainly  be  done  at  once,  because  an  early 
operation  enables  the  surgeon  easily  to  effect  reduction,  and  also  because  early 
complications  are  unusual.  The  incision  is  made  in  the  midline  above  the 
umbilicus.  The  surgeon  endeavors  by  manipulation  to  reduce  the  intussus- 
ception by  pushing  it  back,  not  by  pulling  it  out.  If  the  intussusception  is 
gangrenous,  perform  intestinal  resection  and  circular  enterorrhaphy.  The 
same  rule  maintains  when  malignant  disease  of  the  gut  exists  (D'Arcy  Power). 
It  is  inadvisable  to  make  an  artificial  anus.  MaunselVs  operation  is  suited  to 
cases  of  irreducible  intussusception.  It  is  performed  as  follows:  A  longi- 
tudinal incision  is  made  in  the  intususscipiens.  The  intussusceptum  is  gently 
pulled  upon  and  is  caused  to  protrude  from  this  opening.     Two  straight  needles 


i26o  Diseases  and  Injuries  of  the  Abdomen 

threaded  with  horse-hair  are  passed  so  as  to  transfix  the  base,  and  \^  inch  above 
the  needles  the  intussusceptum  is  cut  off.  The  needles  are  carried  completely- 
through,  the  sutures  are  hooked  up  in  the  middle  and  cut,  and  the  two  ends  are 
tied  on  each  side.  These  sutures  unite  the  intussusceptum  to  the  intussuscipiens. 
The  two  surfaces  are  now  carefully  approximated  by  sutures.  The  sutures  are 
cut.  The  stump  is  replaced.  The  longitudinal  incision  is  closed  with  Lem- 
bert  sutures.' 

Russell  (Ibid.)  reports  i6  cases  operated  upon:  12  recovered  and  4  died. 
In  every  one  of  the  4  fatal  cases  the  diagnosis  was  not  made  until  the  disease 
had  lasted  several  days.  In  only  2  of  the  successful  cases  the  diagnosis  was 
made  late.  If  operation  is  done  in  the  first  twelve  hours  the  mortality,  even 
in  infants,  will  probably  be  comparatively  small.  If  gangrene  exists  the  mor- 
tality is  enormous  (at  least  90  per  cent.). 

Senn's  Operation  for  Fecal  Fistula.- — Suture  the  opening  transversely 
with  Czerny  sutures  of  silk  in  order  to  prevent  infection.  Cleanse  the  surface 
thoroughly.  Open  the  abdomen  and  separate  the  edges  of  the  bowel  from  the 
parietes.  Deliver  the  portion  of  bowel  which  contains  the  fistula  and  apply 
Lembert  sutures  over  the  Czerny  sutures.  Another  method  is  to  open  the 
abdomen  above  the  fistula,  insert  the  fingers,  cut  out  the  skin  and  tissues  around 
the  fistula  in  an  elliptical  course,  leaving  them  attached  to  the  bowel,  draw  the 
bowel  from  the  abdomen,  pack  gauze  around,  remove  the  tissues  adherent 
to  it,  and  suture  the  fistula  transversely. 

Enterostomy  is  the  making  of  an  artificial  anus.  If  performed  in  the 
large  bowel,  it  is  called  colostomy.  In  some  cases  of  intestinal  obstruction  it  is 
necessary  to  open  the  small  intestine,  and  if  this  is  required,  the  artificial  anus 
should  be  made  as  near  as  possible  to  the  cecum.  The  higher  above  the  cecum 
it  is  made,  the  more  apt  is  the  patient  to  die  of  lack  of  nourishment.  A  small 
intestinal  anus  may  be  made  in  the  middle  line  or  in  the  right  iliac  region.  The 
bowel  is  fixed  and  opened  as  directed  under  Colostomy.  In  acute  intestinal 
obstruction  it  may  be  necessary  to  open  the  bowel  at  once.  In  such  a  case 
Paul's  tube  (Fig.  804)  is  very  useful.  It  is  made  of  glass,  is  bent  to  a  right  angle, 
and  has  a  rim  near  each  end.  The  large  tube  is  used  in  the  colon,  the  small  tube 
in  the  small  intestine.  A  small  opening  is  made  in  the  intestine,  the  tube  is 
introduced,  and  is  tied  in  place  by  a  silk  suture  which  surrounds  all  the  coats  of 
the  bowel,  a  gush  of  feces  is  caught  in  a  basin,  a  rubber  tube  is  fastened  to  the 
glass  tube,  and  fluid  feces  are  collected  in  a  bottle  and  beneath  an  antiseptic 
fluid. ^  In  from  three  or  four  days  to  a  week  the  tube  becomes  loose  and  can 
be  removed.     Stewart's  method  of  enterostomy  was  outlined  on  page  11 26. 

Valvular  Cecostomy  (Gibson's  Operation). — This  operation  was  devised 
in  1900  by  Charles  L.  Gibson,  of  New  York.  It  is  used  in  chronic  dysentery. 
It  allows  us  to  flush  the  large  intestine  and  to  apply  remedies  to  it.  The  incision 
is  made  over  the  caput  coli,  a  small  puncture  is  made  in  the  latter,  a  soft  catheter 
(No.  30  Fr.)  is  introduced  well  ino  the  bowel,  and  is  fixed  there  as  is  the  tube 
in  Kader's  gastrostomy  (seepage  1226).  After  ten  or  twelve  days  the  tube  is 
not  kept  in  place,  but  is  introduced  when  needed.  The  fistula  closes  sponta- 
neously on  the  discontinuance  of  introducing  the  catheter  daily.  Appendi- 
costomy  has,  to  a  great  extent,  replaced  cecostomy,  because,  as  a  rule,  it  is  easier 
and  safer.  "The  appendix  may,  however,  not  be  of  a  suitable  size  or  position 
(retrocecal)  to  lend  itself  properly  to  the  procedure"  (Gibson,  paper  read  before 
the  Internat.  Surg.  Assoc,  at  Brussels,  Sept.,  191 1). 

Inguinal  Colostomy  (Maydl's  Operation)  (Fig.  805).— In  this  opera- 
tion a  vertical  or  oblique  incision  4  inches  in  length  is  made  over  the  portion  of 
colon  to  be  incised.  In  all  cases  when  possible  do  a  left  inguinal  colostomy. 
In  right  inguinal  colostomy  it  is  more  difficult  to  deliver  the  bowel  than  in  a  left 

1  T.  Pickering  Pick,  "Quarterly  Med.  Jour.,"  Jan.,  1897. 
-  Paul,  in  "Liverpool  Med.-Chir.  Jour.,"  July,  1892. 


Inguinal  Colostomy 


1261 


inguinal  colostomy,  because  of  shortness  or  absence  of  mesocolon  at  this  point  of 
the  colon.  Right  inguinal  colostomy  has  been  jjcrformed  for  chronic  amebic 
dysenter>\  It  puts  the  colon  at  rest  and  permits  of  free  irrigation.  It  is  kept 
open  until  the  dysentery  is  well.  Appendicostomy  and  valvular  cecostomy 
have  replaced  it  for  dysentery.  It  has  also  been  employed  for  the  treatment 
of  ulceration  of  the  colon.  After  the  incision  on  the  left  side  the  colon  usually 
bulges  into  the  wound,  but  if  it  does  not,  it  may  easily  be  found  by  following 
with  the  finger  the  parietal  peritoneum  outward,  backward,  and  inward,  the 
first  obstruction  it  encounters  being  the  mesocolon.  Draw  the  colon  out  of  the 
wound  until  its  mesenteric  attachment  is  level  with  the  abdominal  incision. 
Push  a  glass  bar  through  a  slit  in  the  mesocolon  near  the  bowel,  and  wrap  the 


Fig.  804. — Paul's  tube. 


Fig.  805. — Inguinal  colostomy  (after 
Zuckerkandl) . 


ends  of  the  bar  with  iodoform  gauze  to  prevent  slipping.  Instead  of  the  bar, 
a  piece  of  gauze  can  be  employed  (Fig.  805),  or  a  bridge  of  skin  can  be  made 
under  the  bowel  by  suturing  the  two  skin  edges.  In  order  to  make  a  spur  the 
two  parts  of  the  flexure  are  stitched  together  by  sutures  which  penetrate  to 
and  catch  the  submucous  coat.  Stitch  the  serous  coat  of  the  bowel  to  the  parie- 
tal peritoneum  (Fig.  805).  Whenever  possible,  wait  from  twenty-four  to 
forty-eight  hours  before  opening  the  gut.  The  colon  is  opened  by  the  cautery 
or  by  scissors.  If  the  artificial  anus  is  to  be  permanent,  make  a  transverse 
incision  through  the  bowel.     Cut  one-fourth  way  across  the  colon  when  it  is 


Fig.  806. — Stevenson's  bag  for  inguinal  colostomy. 

first  opened,  and  entirely  across  at  a  later  period.  If  the  artificial  anus  is  to 
be  temporary',  the  incision  should  be  longitudinal.  jNIaydl's  operation  has  great 
advantages :  it  is  quick,  certain,  reasonably  safe,  satisfactorily  prevents  fecal  ac- 
cumulation below  the  opening^  and  is  rarely  followed  by  absolute  fecai  incon- 
tinence. In  many  cases  the  bowels  move  but  two  or  three  times  a  day.  The 
movements,  however,  come  quickly  with  but  little  warning.  Sometimes  there 
is  no  warning.  If  diarrhea  develops,  there  will  be  fecal  incontinence  as  long 
as  it  lasts.  An  air-pad  covered  with  gauze  may  be  held  in  place  by  a  firm  belt, 
or  the  appliance  shown  in  Figs.  806  and  807  may  be  worn. 


1262 


Diseases  and  Injuries  of  the  Abdomen 


Bodine's  Operation  (Figs.  808,  809).— Bodine's  method  of  colostomy  per- 
mits of  a  future  restoration  of  the  fecal  current  by  an  easily  performed  anasto- 
mosis. This  surgeon  maintains  that  the  spur  after  colostomy  should  reach  to 
and  remain  at  the  level  of  the  skin,  a  condition  impossible  of  attainment  by 
hanging  the  bowel  over  a  rod  or  piece  of  gauze,  because  a  spur  thus  formed  is  not 
thick  and  rigid  and  is  inevitably  dragged  below  the  skin  level,  and  when  this 
dragging  has  taken  place,  some  fecal  matter  will  pass  into  the  bowel  below 
the  artificial  anus.  Bodine  opens  the  abdomen,  sutures  the  parietal  peritoneum 
to  the  skin,  seeks  for  the  lesion,  and  draws  it  with  6  inches  of  healthy  bowel  out 
of  the  incision.     He  lays  the  limbs  of  the  loop  side  by  side.     He  inserts  a  silk 

stitch,  beginning  at  the  point  where 
exsection  is  to  be  made,  and  for  6 
1  inches  unites  the  two  segments  close  to 
their  mesenteric  borders.  The  loop  is 
dropped  into  the  abdomen  until  the 
beginning  of  the  suture  is  on  a  level 
v\'ith  the  skin,  and  at  this  point  it  is 
fastened  to  the  abdominal  wound  with 
a  continuous  catgut  suture.  The  pro- 
truding lesion  is  cut  off"  along  the  dotted 
line  (Fig.  808).  The  artificial  anus  is 
thus  established.  When  it  is  desired 
to  close  the  artificial  anus,  divide  the 
septum  with  scissors  or  a  Gant  clamp 
(Fig.  809)  and  close  the  abdominal 
wound. ' 

Lumbar  colostomy  is  a  most  un- 
satisfactory operation.  It  does  not 
completely  intercept  the  fecal  current, 
and  it  leaves  the  patient  in  a  con- 
dition of  wretched  discomfort  because 
fecal  incontinence  is  inevitable.  A 
patient  who  has  had  lumbar  colostomy 
performed  upon  him  either  obtains 
little  benefit,  because  the  feces  pass 
into  the  bowel  below  the  opening 
which  was  made  to  intercept  them  or 
else  they  pour  out  of  the  opening  un- 
controlled, making  the  poor  unfortunate 
a  hving  horror  to  himself  and  others.  It 
is  rarely  performed  at  the  present  day. 
The  healthy  gall=bladder  has  a  capacity  of  about  i  oz.,  and  its  hue  is 
bluish.  If  a  gall-bladder  contains  calculi  or  has  contained  them,  its  hue  is 
grayish- white  or  yellowish  (Moynihan). 

Congenital  Absence  of  the  Gall=bladder. — When  the  gall-bladder  is 
shrunken  and  buried  in  adhesions,  it  is  very  difficult  to  find  it  at  operation. 
Sometimes  it  is  not  found  and  one  may  jump  to  the  conclusion  that  it  is  con- 
genitally  absent.  This  is  occasionally,  but  very  seldom,  the  case.  Gray  col- 
lected 19  instances  of  congenital  absence  of  the  gall-bladder  f"  Trans,  of  Chicago 
Path.  Soc,"  1902).  When  it  has  been  absent  the  subject  seems  to  have  done 
perfectly  well  without  it. 

The  Incisions  for  Operations  upon  the  Qan=bladder  and  Bile= 

ducts. — I  have  employed  several  methods,  and  have  frequently  used  Bevan's 

incision  (Fig.  810,  b).     The  primary  portion  of  the  incision  is  shaped  Uke  the 

itahc  letter  /.     It  is  by  the  side  of  or  through  the  right  rectus  muscle,  and 

'  "New  York  Polyclinic,  Feb.  15,  1897. 


Fig.  807. — Stevenson's  bag  applied. 


The  Incisions  for  Operations  Upon  the  Gall-bhidder  and  Bile-ducts         1263 

is  shown  by  the  double  hne  in  Fig.  810,  n.     The  primary  incision  is  used  for 
exploration  and  cholecystotomy.     The  primary  mcision  is  from  3  to  4  inches 


Fig.  808. — Bodine's  method  of  colos- 
tomy, showing  one  side  of  the  loop  after  it 
has  been  sutured,  passed  back  into  the 
cavity  and  stitched  into  the  abdominal 
wound.  The  lesion  is  left  protruding,  and 
the  dotted  line  indicates  where  the  pro- 
trusion is  to  be  clipped  off. 


Fig.  809. — Bodine's  method  of 
colostomy,  showing  the  septum  to  be 
divided  in  restoring  the  fecal  current; 
Gant's  clamp  in  position  for  the 
division.  (In  permanent  colostomy 
this  septum  remains  as  a  rigid  and 
effective  spur.) 


r 

' 

J        <^ 

S 

' 

1- 

^M 

|K: 

r       m 

i 

■ 

H/ 

i 

c ^H 

W" 

! 

p-''''Bjjl 

K 

W^mm 

'  j 

L    .. 

MM 

K\..  _ 

J 

Fig.  810. — Incisions  for  the  surgery  of  the  bile-tracts:  A,  Kocher's  incision;  B,  Sevan's  inci- 
sion; C,  Collins's  incision;  D,  Mayo  Robson's  incision  (Collins). 

long,  and  the  extended  portions,  shown  by  heavy  lines  in  Fig.  810,  B,  are  added 
if  required   (Arthur  Dean  Bevan,   "Annals  of  Surgery,"  July,   1899).     This 


1264 


Diseases  and  Injuries  of  the  Abdomen 


incision  gives  most  satisfactory  exposure,  its  edges  can  be  separated  without 
tension,  and  it  injures  but  few  of  the  nerves  of  the  abdominal  walls. 

Kocher's  incision  (Fig.  810,  a)  gives  a  very  satisfactory  exposure.  It  cuts 
the  two  obliques  and  the  transversalis  muscle  and  divides  intercostal  nerves, 
but  can  be  sewed  up  evenly  and  is  seldom  followed  by  hernia.  Mayo-Robson's 
incision  (Fig.  810,  d)  gives  an  admirable  exposure  of  the  common  duct,  although 
it  damages  the  right  rectus  muscle  and  the  nerve-supply  of  the  inner  part  of  the 
muscle.  None  of  these  incisions  is  entirely  satisfactory.  Collins's  incision 
(Figs.  810,  c,  811)  ("Surg.,  Gynec,  and  Obstet.,"  March,  1909)  seems  to 
correct  to  a  great  extent  the  defects  of  the  previous  operations.  Collins  thus 
describes  his  incision : 


Fig.  811. — A,  Anterior  wall  of  sheath  of  rcciu'^  muscle;  H,  posterior  wall  of  sheath;  C, 
rectus  muscle;  D,  intercostal  nerves.  The  direction  of  the  incision  through  the  skin,  fat,  and 
anterior  wall  of  the  sheath  of  the  rectus  muscle  (Collins). 

"The  incision  for  the  bile-tracts  begins  at  the  inner  edge  of  the  right  mus- 
cle, I  or  2  inches  from  the  ensiform  cartilage,  and  extends  diagonally  down- 
ward and  outward  to  the  outer  edge  of  the  right  rectus,  close  to  the  level  of 
the  umbilicus.  It  cuts  through  the  skin,  fat,  and  anterior  wall  of  the  sheath 
of  the  rectus  (Fig.  811).  A  short  transverse  incision  about  i  inch  in  length 
may  be  made  inward  from  the  upper  end  of  the  diagonal  incision  through  the 
skin,  fat,  and  linea  alba;  and  a  similar  one  through  the  linea  semilunaris  at  the 
lower  end.  In  case  more  room  is  required  the  upper  transverse  incision  may  be 
extended  further  into  the  anterior  and  posterior  walls  of  the  sheath  of  the  left 
rectus. 

"The  rectus  muscle  is  then  separated  from  its  sheath.  It  is  easily  separated 
from  the  posterior  portion  of  its  sheath  by  blunt  dissection,  but  the  anterior 
portion  presents  some  difficulty  at  the  insertion  of  the  lineae  transversae,  one 
of  which  is  found  about  midway  between  the  ensiform  cartilage  and  umbilicus 


Cholecystostomy  1265 

and  is  crossed  by  tliis  incision.  The  attachment  of  the  muscle  to  the  anterior 
wall  of  its  sheath  is  very  close  at  this  linea  transversa,  and  requires  sharp  dis- 
section with  knife  or  scissors. 

"When  the  muscle  is  thoroughly  freed  from  its  sheath  except  at  its  outer 
border,  it  is  easily  retracted  outward  and  allows  the  posterior  wall  of  its  sheath 
and  the  peritoneum  to  be  incised  in  the  same  direction  as  the  skin  and  ante- 
rior wall.  The  upper  end  of  this  diagonal  incision  through  the  posterior 
wall  extends  into  the  short,  transverse  incision  across  the  linea  alba.  When 
this  last  cut  is  made  the  incision  pulls  open  and  gives  ready  access  to  the 
right  upper  abdomen."  This  incision  does  not  damage  the  intercostal  nerves, 
hence  muscular  atrophy  is  avoided.  The  openings  through  the  different  planes 
of  the  abdominal  wall  are  not  continuous,  hence  closure  will  be  more  solid. 
The  opening  in  the  posterior  portion  of  the  rectus  sheath  is  protected  by  un- 
injured muscle. 

Cholecystostomy  or,  as  many  call  it,  cholecystotomy,^  is  the  opera- 
tion of  opening  and  draining  the  gall-bladder  in  order  to  extract  gall-stones 
or  secure  the  removal  of  infectious  material.  In  the  hands  of  the  Mayos 
operations  for  stone  exhibit  a  mortality  of  less  than  i  per  cent. ;  Kocher's  mor- 
tality is  2  per  cent.  When  death  follows  an  operation  on  the  gall-bladder  or 
ducts,  in  about  one-half  the  cases  it  is  due  to  duct  infection  and  is  preceded 
by  grave  nervous  symptoms  (Mayo).  Cholecystostomy  is  performed  in  cases 
of  acute  cholecystitis,  in  hydrops,  and  in  empyema  of  the  gall-bladder;  in  gall- 
stone cases  in  which  jaundice  has  lasted  for  four  weeks  or  more,  and  in  colic  of 
the  gall-bladder  with  fever,  the  colic  having  recurred  a  second  or  third  time 
(Carl  Beck).  The  operation  completed  in  one  stage  is  performed  as  follows: 
The  patient  is  placed  recumbent  with  a  sand-pillow  beneath  the  liver  and 
the  incision  is  made.  The  peritoneum  is  opened.  If  the  gall-bladder  is  dis- 
tended, it  is  surrounded  with  pads  and  aspirated,  and  is  then  opened.  Gall- 
stones are  removed  by  forceps  the  scoop,  or  irrigation.  The  gall-ducts  are 
examined  by  the  fingers  external  to  them  before  opening  the  gall-bladder,  and 
are  sounded,  if  possible.  If  a  stone  is  wedged  in  the  duct,  try  to  manipulate  it 
back  into  the  gall-bladder.  If  this  fails,  introduce  an  instrument  from  the  gall- 
bladder and  break  up  the  stone;  if  this  fails,  open  the  duct,  remove  the  stone, 
and  close  the  incision  in  the  duct  (A.  W.  Mayo  Robson).  The  only  way  to  be 
certain  that  stones  have  been  removed  entirely  from  the  cystic  ducts  is  to  insert  a 
finger  and  dilate.  Sounds  are  unreliable.  After  the  removal  of  all  stones  and 
fragments  pass  a  rubber  tube  which  has  no  side  perforations  into  the  gall- 
bladder, purse  up  the  cut  in  the  gall-bladder  around  the  tube  by  means  of  a 
catgut  suture,  and  suture  the  gall-bladder  to  the  abdominal  aponeurosis.  If 
sutured  to  the  skin,  a  permanent  biliary  fistula  is  apt  to  follow'.  It  will  seldom 
follow  if  the  gall-bladder  is  sutured  to  the  aponeurosis.  A  small  piece  of  gauze 
is  retained  under  the  gall-bladder  in  case  there  should  be  a  leak  into  the  peri- 
toneum and  in  case  the  peritoneum  may  have  been  soiled.  If  gauze  causes  no 
trouble  it  is  retained  in  place  from  five  to  eight  days.  It  can  then  be  removed 
easily  and  without  breaking  encompassing  adhesions.  The  drainage-tube, 
which  drains  into  a  bottle  outside  of  the  dressings  and  below  the  level  of  the 
bed,  can  usually  be  dispensed  with  in  from  one  week  to  ten  days.  It  should 
not  be  dispensed  with  until  the  bile  becomes  sterile. 

Some  surgeons  have  advocated  immediate  suture  of  the  gall-bladder  after 
removing  a  stone  (ideal  cholecystotomy).  I  believe  this  is  never  advisable 
when  the  stones  are  active  for  harm,  because  small  calculi  may  be  in  the  ducts 
and  minute  fragments  of  stone  are  often  left  in  the  bladder,  and  the  drainage 
wiU  remove  them.  Drainage  also  reUeves  the  diseased  condition  of  the  gall- 
ducts  and  bladder.  In  Kocher's  31  operations  by  this  method,  gall-stones 
re-formed  in  3  cases.  Further,  the  operation  with  immediate  suture  is  decid- 
^  First  performed  by  Bobbs,  of  Indianapolis,  in  1867. 
80 


1266  Diseases  and  Injuries  of  the  Abdomen 

edly  more  dangerous  when  infection  exists.  The  Mayos  only  employ  it  in 
latent  cases  of  gall-stone  disease  when  the  existence  of  stones  is  discovered 
during  the  performance  of  an  abdominal  operation. 

It  is  advised  by  some  that  the  operation  of  cholecystostomy  be  performed 
in  two  stages.  First,  the  bladder  is  exposed  and  sutured  to  the  parietal  peri- 
toneum. When  adhesion  takes  place,  the  gall-bladder  can  be  opened  without 
risk,  of  infecting  the  general  peritoneal  surface.  Riedel  advocates  operation 
in  two  stages,  and  so  did  Christian  Fenger  in  certain  cases.  The  two-stage 
operation  is  objectionable  because  it  does  not  permit  of  satisfactory  explora- 
tion of  the  ducts.  The  biliary  fistula  which  is  left  by  cholecystostomy  usually 
closes  spontaneously,  but  may  not.  If  it  does  not  close  and  the  secretion  is 
pure  mucus,  it  is  evident  that  the  cystic  duct  is  absolutely  blocked  and  chole- 
cystectomy should  be  performed. 

If  the  secretion  from  a  persistent  fistula  is  bile  and  if  the  common  duct  is  not 
obstructed,  separate  the  edges  of  the  gall-bladder  opening  from  the  parietal 
peritoneum,  endeavoring  to  avoid  entering  the  abdominal  cavity,  and  close 
the  fistula  with  Lembert  or  Halsted  sutures.  If  the  secretion  is  bile  and  the 
common  duct  is  obstructed  permanently,  perform  cholecystenterostomy.  If  the 
secretion  does  not  contain  bile  and  the  cystic  duct  is  blocked,  remove  the  gall- 
bladder. At  the  end  of  1907  Hans  Kehr  placed  his  mortality  at  2  per  cent. 
("Jour,  de  Chir.,"  Oct.,  igo8).  In  the  Mayo  Clinic  from  Jan.  i,  1907  to 
Jan.  I,  1918,  there  were  5655  operations  for  gall-stones  with  a  mortality  of 
2.4  per  cent.  (Personal  communication  to  the  author). 

The  McArthur  Drip. — In  1909  Lewis  L.  McArthur  suggested  using  a 
biliary  fistula  as  a  means  of  introducing  fluid  or  food  into  the  duodenum.  He 
proved  that  if  a  tube  draining  bile  from  the  gall-bladder  is  connected  to  an 
irrigator  containing  salt  solution  (elevated  not  more  than  20  inches  and  giving 
a  rate  of  flow  not  over  5  or  6  drops  a  second),  there  will  be  a  continuous  flow  of 
fluid  into  the  duodenum  without  any  discomfort  to  the  patient  (McArthur,  in 
"New  York  Med.  Jour.,"  Jan.  27,  191 2).  Matas  has  improved  the  method  by 
introducing  into  the  duodenum  at  the  time  of  operation  and  by  way  of  the 
common  duct  a  ureteral  catheter,  through  which  food,  fluid,  or  medicine  can 
be-  at  any  time  carried  into  the  duodenum  (Rudolph  Matas,  in  "  New  Orleans 
Med.  and  Surg.  Jour.,"  Oct.,  191 1).  The  method  is  used  in  many  cases  of 
obstructive  jaundice  (after  removal  of  the  obstruction).  The  salt  solution 
relieves  thirst,  removes  toxins,  and  stimulates  the  kidneys.  It  relieves  post- 
operative vomiting,  favors  intestinal  peristalsis,  combats  flatulent  distention, 
and  causes  movements  of  the  bowels.  Matas  points  out  that  liquid  food  and 
medicines  (strychnin,  castor  oil,  Hunyadi  water,  etc.)  can  be  given  by  the 
biliary  route.  McArthur  believes  that  the  method  can  be  used  instead  of 
jejunostomy  in  certain  cases  of  pyloric  obstruction  and  stomach  ulceration. 

Cholecystenterostomy^  consists  in  making  an  anastomosis  between  the 
gall-bladder  and  intestine,  preferably  the  duodenum,  or,  if  this  cannot  be 
done,  the  jejunum.  It  is  employed  in  cases  of  irremovable  obstruction  of 
the  common  duct.  It  is  done  chiefly  in  cases  of  mahgnant  obstruction.  It 
is  not  a  suitable  operation  for  gall-stones  impacted  in  the  common  duct,  be- 
cause it  does  not  remove  the  cause  of  trouble,  infection  of  the  bile-passages  may 
foUow,  and  the  fistula  is  liable  to  contract.  In  those  rare  cases  of  common 
duct  obstruction  from  gall-stones,  in  which  the  gall-bladder  is  distended  and  the 
patient  is  desperately  iU,  it  may  be  done  (Robson).  In  such  a  case  Robson 
attaches  the  gall-bladder  to  the  colon  because  the  operation  is  easier  and  because 
he  considers  it  as  useful  as  the  attachment  to  the  duodenum.  Cholecystenter- 
ostomy can  be  done  most  rapidly  and  successfully  by  means  of  a  small  Murphy 
button.     Before  the  gall-bladder  is  incised  it  is  aspirated.     Murphy's  operation 

^  The  operation  was  suggested  by  Nussbaum,  but  was  first  performed  by  Winiwarter  in 
1882  ("A  Manual  of  Operative  Surgery,"  by  Sir  Frederick  Treves). 


Cholecystectomy 


1267 


is  shown  in  Fig.  812,  and  is  similar  in  performance  to  intestinal  anastomosis. 
I  believe  that  Brentano  is  right  and  that  it  is  best  to  do  posterior  cholecyst- 
enterostomy,  bringing  the  jejunum  through  an  opening  made  in  the  transverse 
mesocolon. 

Cholecystectomy  is  the  extirpation  of  the  gall-bladder.  It  was  first 
performed  by  Langenbuch  in  1882.  The  operation  is  done  much  more  com- 
monly than  formerly  because  we  know  that  in  many  cases  symptoms  per- 
sist after  simple  drainage  and  that  an  infected  gall-bladder  is  a  danger  to  the 
pancreas  and  to  the  organism.  Sometimes  primary  extirpation  is  perfomed;  at 
other  times  cholecystectomy  is  performed  as  a  secondary  operation,  chole- 
cystostomy  for  drainage  having  been  first  performed.  Its  performance  may  be 
demanded  by  the  existence  of  phlegmonous  inflammation  or  gangrene;  ulcera- 
tion; "in  chronic  cholecystitis  from  gall-stones  where  the  gall-bladder  is  shrunken 


Fig.  812. — Showing  method  of  holding  parts  while  approximating  a  Murphy  button  in  chole- 

cystenterostomy. 

and  too  small  to  drain  safely,  and  where  the  common  duct  is  free  from  ob- 
struction" (A.  W.  Mayo  Robson);  in  empyema  with  greatly  damaged  walls; 
in  fistula  associated  with  irremediable  obstruction  of  the  cystic  duct,  the  com- 
mon duct  being  free;  in  cancer;  and  in  some  wounds  of  the  gall-bladder. 
Objections  to  the  operation  are  that  drainage  can  only  be  obtained  by  putting 
a  tube  into  the  hepatic  or  the  common  duct,  and  that,  should  renewed  drainage 
be  subsequently  required,  the  necessary  operation  will  prove  difficult  and  dan- 
gerous (Maurice  H.  Richardson,  "Medical  News,"  Ma}^  2,  1903). 

After  opening  the  abdomen  the  gall-bladder  is  found  and  is  drawn  into 
the  wound.  If  it  is  distended  and  tense  or  if  it  is  thought  "to  contain  infec- 
tious fluid"  (Lihenthal),  it  is  packed  about  with  iodoform  gauze  and  emptied 
by  an  aspirating  trocar.  "When  the  walls  are  very  friable,  it  is  even  wise 
to  incise  and  empty  the  viscus,  closing  the  opening  by  ligature  or  clamp  be- 
fore proceeding  with  the  extirpation.  The  gall-bladder  is  usually  quite  a 
tough  organ,  and  in  the  majority  of  cases  it  may  be  grasped  with  an  ovarian 
ring-clamp  applied  near  its  fundus,  which  at  the  same  time  closes  the  aspi- 
ration puncture"    (Lilienthal,   "Annals  of  Surgery,"  July,  1904).     The  peri- 


1268  Diseases  and  Injuries  of  the  Abdomen 

toneum  which  covers  the  gall-bladder  must  be  divided  just  below  the  liver, 
the  gall-bladder  is  dissected  from  the  liver  until  the  cystic  duct  is  reached, 
the  cystic  artery  is  tied  and  divided,  and  if  the  liver  ducts  are  healthy,  the 
cystic  duct  is  ligated  with  silk  and  divided,  the  stump  is  touched  with  pure  car- 
bolic acid  and  is  covered  with  a  layer  of  peritoneum  fastened  by  sutures  of 
fine  silk.  In  cases  free  from  infection  it  is  not  necessary  to  drain  the  bile- 
ducts.  In  cases  with  cholangitis  external  drainage  is  necessary,  and  it  is  ob- 
tained by  incising  the  hepatic  duct  and  inserting  a  drainage-tube,  or,  better, 
by  leavang  the  stump  of  the  cystic  duct  open.  Occasionally  after  cholecystec- 
tomy the  stump  of  the  cystic  duct  gradually  dilates  and  forms  a  new  gall- 
bladder which  may  be  the  seat  of  pain  because  of  adhesions,  blocking  or 
stone  formation.  It  would  seem  that  the  cystic  duct  should  be  divided  at  its 
origin.  Howard  Lilienthal  (Ibid.)  reported  42  cases  with  i  death.  Hans 
Kehr's  mortaUty  at  the  end  of  1907  was  3.6  per  cent.  ("Jour,  de  Chir.," 
Oct.,  1908).  In  the  Mayo  Clinic  from  Jan.  i,  1907  to  Jan.  i,  19 18  there  were 
4064  cholecystectomies  with  a  mortality  of  only  1.2  per  cent.  (Personal  commu- 
nication to  the  author). 

Removal  of  the  Mucous  Membrane  of  the  Qan=bladder. — Mayo 
has  suggested  the  removal  of  the  fundus  and  of  all  the  mucous  membrane 
of  the  gall-bladder  as  an  occasional  substitute  for  cholecystectomy.  By  this 
operation  we  are  enabled  to  drain  the  cystic  duct  and  through  it  the  hepatic 
ducts.  A  serious  objection  to  the  operation  is  that,  as  glands  pass  from  the 
mucous  coat  to  and  through  the  muscular  coat,  it  is  impossible  absolutely  to 
move  the  mucous  membrane  of  the  gall-bladder  alone  (Emil  Reis). 

Drainage  of  the  Hepatic  Duct. — This  operation  is  employed  for  certain 
hepatic  infections.  It  was  first  performed  by  Cabot  in  1892.  If  the  cystic 
duct  is  dilated  throughout,  it  may  be  carried  out  through  that.  After  opening 
the  gall-bladder  a  tube  is  passed  through  the  cystic  and  into  the  hepatic  duct. 
It  is  often  done  after  opening  the  common  duct,  a  tube  being  carried  up  into  the 
hepatic  duct.  The  hepatic  duct  may  be  exposed  and  opened  directly,  a  tube 
being  carried  into  it  for  a  short  distance  and  stitched  to  the  edges  of  the  in- 
cision in  the  duct  by  catgut.     The  tube  should  be  surrounded  by  iodoform  gauze. 

Supraduodenal  choledochotomy  is  the  operation  of  incising  the  com- 
mon bile-duct  above  the  duodenum  for  the  removal  of  a  stone.  It  is  also  called 
choledocholithotomy.  If  drainage  is  used  it  is  choledochostomy.  It  was  first 
performed  by  Kiimmel  in  1889.     Courvoisier  did  his  first  operation  in  1890. 

Cases  upon  which  this  operation  is  done  are  often  deeply  jaundiced  and 
there  is  grave  danger  of  infection  and  perhaps  of  fatal  oozing  of  blood.  In  i  of 
my  cases  this  happened.  The  patient  was  suffering  from  stones  in  the  com- 
mon duct,  associated  with  cancer  of  the  head  of  the  pancreas.  In  every  case 
in  which  operation  is  contemplated  for  obstruction  of  the  bile-ducts  take  the 
coagulation  time  of  the  blood.  Normal  coagulation  time  (taken  by  Wright's 
coagulometer)  is  from  three  to  six  minutes.  Prolongation  to  seven  or  eight 
minutes  calls  for  pre-operative  treatment  to  hasten  coagulability.  If  jaundice 
exists,  it  is  customary  to  endeavor  to  prevent  hemorrhage  by  employing  Rob- 
son's  plan:  Give  by  the  mouth  from  30  to  60  gr.  of  chlorid  of  calcium  three 
times  a  day  during  the  twenty-four  or  forty-eight  hours  preceding  operation, 
and  60  gr.  by  enema  three  times  a  day  for  the  forty-eight  hours  following 
operation.  I  have  followed  this  course  in  a  number  of  cases,  but  am  not  con- 
vinced of  its  value.  Instead  of  this  method  we  may  follow  the  plan  of  giving 
thyroid  extract  (5  gr.  three  times  a  day)  for  several  days  preceding  operation. 

The  plan  I  now  pursue  I  am  certain  does  reduce  the  coagulation  time  dis- 
tinctly. I  give  an  injection  of  horse  serum  the  day  before  operation  and 
another  the  morning  of  the  operation. 

When  ready  to  operate,  a  sand-bag  should  be  placed  under  the  lower  ribs. 
This  will  bring  the  liver  at  least  2  inches  nearer  to  the  abdominal   wound. 


Supraduodenal  Choledochotomy 


1269 


The  abdominal  incision  must  be  longer  than  that  employed  for  cholecystostomy. 
The  pylorus  and  stomach  are  drawn  to  the  left,  the  colon  and  omentum  are 
drawn  downward,  and  the  liver  and  ribs  are  lifted  strongly  upward.  Gauze 
packs  are  inserted. 

"The  operator  should  now,  after  having  separated  adhesions,  have  a  good 
view  of  the  common  duct  within  the  free  border  of  the  lesser  omentum,  and  on 
inserting  his  left  index-finger  into  the  foramen  of  Winslow,  or  on  grasping  the 
duct  between  the  index-finger  and  thumb,  he  can,  without  difficulty,  bring 
the  duct  well  within  reach,  the  concretion  making  a  distinct  projection.  "'•  A 
longitudinal  incision  is  made,  the  stone  is  removed,  and  a  probe  is  introduced 
into  the  duct  to  determine  whether  other  stones  are  present. 

Stones  in  the  second  and  third  portions  of  the  duct  are  often  missed  and  the 
second  portion  of  the  duodenum  should  always  be  palpated  with  the  utmost 
care.  If  the  lowermost  stone  removed  from  the  common  duct  is  faceted,  we 
should  always  search  most  carefully  to  find  a  concretion  which  is  lower  still 
(F.  Gregory  Connell,  "Annals  of  Surgery,"  April,  1908). 

If  a  calculus  is  found  in, 
the  lower  part  of  the  common 
duct,  the  surgeon  tries  to  push 
it  up  so  that  he  may  reach  it. 
This  can  usually  be  accom- 
plished. Failing  to  push  the 
stone  up  into  reach,  some  try 
and  force  it  into  the  duode- 
num. This  attempt  will  some- 
times, but  seldom,  succeed.  If 
it  does  not  succeed,  the  surgeon 
must  perform  a  transduodenal, 
or  a  retroduodenal  operation. 
Only  in  cases  so  shocked  that 
prolonged  operation  is  im- 
possible is  it  proper  to  do 
cholecystostomy  or  cholecys- 
tenterostomy.  If  either  of 
these  palliative  operations  is 
performed  a  radical  operation 
must  be  done  later. 

Many  surgeons  suture  the 
incision  in  the  duct.     This  pro- 
cedure is  rendered  easier  by  the  use  of  Halsted's  hammer  which  draws  the  duct 
toward  the  surface  and  keeps  it  under  control  (Fig.  813). 

Interrupted  sutures  of  fine  catgut  are  used.  The  muscular  and  serous 
coats  may  be  included  in  each  suture,  and  over  this  layer  Lembert  or  Halsted 
sutures  are  applied.  A  drainage-tube  is  inserted  and  a  piece  of  iodoform 
gauze  is  placed  upon  the  suture  line,  the  other  end  being  brought  out  of  the 
abdominal  wound.  This  precaution  is  taken  because  leakage  may  occur. 
If  it  is  found  impossible  to  suture  the  wound  in  the  duct,  the  operation  then 
becomes  a  choledochostomy  (although  this  term  is  usually  used  only  when 
the  incised  duct  is  stitched  to  the  abdominal  wall).  The  surgeon  carries 
a  glass  tube  down  to  the  opening  and  surrounds  it  with  iodoform  gauze,  or 
inserts  a  rubber  drainage-tube  into  the  opening  and  carries  it  up  toward  the 
hepatic  duct,  or  makes  an  incision  into  the  right  loin  after  the  plan  of  Ruther- 
ford Morison,  and  carries  a  tube  into  the  right  kidney  pouch,  which  is  the 
most  dependent  part  of  the  peritoneal  cavity  when  the  patient  is  recumbent. 
Personally  I  always  drain  the  duct,  when  I  have  opened  it  for  stone,  carrying 
^  A.  W.  Ma3-o  Robson's  "Treatise  on  Diseases  of  the  Gall-bladder  and  Bile-ducts." 


Fig.  S13. — Suture  of   duct  over  Halsted's  hammer. 


1270  Diseases  and  Injuries  of  the  Abdomen 

the  tube  up  toward  the  hepatic  duct.     The  same  reasons  which  cause  us  to 
drain   the  gall-bladder  after  removing  stones  should  influence  us  in  this  case. 

Robson  ("Lancet,"  April  22,  1902)  has  performed  the  operation  of  chole- 
dochotomy  60  times.  In  10  cases  of  stone  in  the  common  duct  he  manipulated 
the  stone'  back  into  the  gall-bladder  and  removed  it  through  an  incision  in  that 
viscus  by  means  of  a  scoop.  The  above  maneuver  is  impossible  unless  the  cystic 
duct  be  dilated.  In  30  cases  he  crushed  the  stones  between  his  finger  and  thumb, 
but  this  is  only  possible  when  the  stones  are  soft,  and  it  has  the  objection  that 
it  may  leave  fragments.  If  a  stone  is  lodged  in  the  common  duct  and  cannot 
be  manipulated  back  into  the  gall-bladder,  choledochotomy  should  be  performed. 
Robson's  mortality  in  60  cases  of  choledochotomy  was  16.6  per  cent.  Since 
1900  his  mortahty  has  been  7.1  per  cent.  Before  that  it  was  23.8  per  cent. 
Kehr's  mortality  is  4.1  per  cent.  During  191 2  the  Mayos  performed  (Chole- 
dochotomy 96  times,  with  5  deaths  ("Report  of  St.  Mary's  Hospital  for  1912  "). 

Hepaticotomy. — By  this  term  we  mean  the  opening  of  the  hepatic  duct. 
If  the  opening  be  drained  the  procedure  is,  in  reality,  hepaticostomy,  although 
this  term  is  seldom  used  to  designate  it.  ^lepaticotomy  is  performed  for 
stone  in  the  hepatic  duct.  The  operation  was  first  performed  by  Kocher  in 
1889.  There  were  7  cases  on  record  in  1903  (Delageniere,  in  "Bull,  et  Mem. 
de  Chir.  de  Paris,"  No.  10,  1903). 

Duodenocholedochotomy  (McBurney's  Operation;  the  Transduodenal 
Route). — This  operation  is  seldom  necessary.  In  the  more  than  2000  opera- 
tions performed  by  the  Mayos  on  the  gall-bladder  and  ducts,  it  was  only  re- 
quired in  4  cases.  I  have  never  performed  it.  In  1891  McBurney  proposed 
the  method  for  the  removal  of  gall-stones  impacted  near  the  papilla  ("Annals 
of  Surgery,"  Oct.,  1898).  McBurney's  original  suggestion  was  to  open  the 
duodenum,  dilate  or  incise  the  papilla,  remove  the  stone,  and  suture  the  duo- 
denum. The  duodenum  must  be  mobilized  so  that  it  may  be  lifted  into  the 
wound.  If  the  stone  be  located  in  the  diverticulum  of  Vater,  it  may,  in  some 
few  cases,  be  removed  by  simply  stretching  the  opening  of  the  duct  with  for- 
ceps (Collins's  method).  If  this  be  not  possible,  the  opening  in  the  papilla 
may  be  enlarged  by  cutting  or  the  duodenal  mucous  membrane  over  the  stone 
may  be  incised  (McBurney's  plan).  When  the  stone  is  not  impacted  at  the 
outlet,  but  is  lodged  a  little  higher  up,  and  when  dense  adhesions  render 
access  by  the  ordinary  supraduodenal  route  difficult  or  impossible,  the  anterior 
wall  of  the  duodenum  may  be  opened  longitudinally,  the  posterior  wall  of  the 
duodenum  and  the  common  duct  incised  over  the  stone,  the  stone  removed, 
the  duodenum  and  common  duct  sutured  together  (Kocher's  method,  or  in- 
ternal choledochoduodenostomy) ,  and  the  anterior  wall  of  the  duodenum  closed. 
(See  Charles  Otto  Thienhaus,  in  "Annals  of  Surgery,"  Dec,  1902.)  After 
finding  and  removing  a  stone  by  the  transduodenal  route  we  must  make  a 
careful  search  to  see  that  no  stones  are  left  before  closing  the  duodenal  incision. 
Robson  opposes  the  transduodenal  route  and  says  he  has  abandoned  it  because 
of  the  danger  of  sepsis.  Thienhaus  (Ibid.)  opposes  this  view  of  Robson  and 
shows  that  in  29  operations  by  the  transduodenal  route  there  were  but  2 
deaths. 

Connell  ("Annals  of  Surgery,"  Jan.,  1908)  has  collected  77  cases  in  which 
stones  were  removed  by  the  transduodenal  route.  There  were  10  deaths.  In 
2  of  these  cases  duodenal  fistula  preceded  death. 

Retroduodenal  Choledochotomy. — In  this  operation  the  second  por- 
tion of  the  common  duct  is  incised  back  of  the  duodenum  without  opening  the 
gut.  That  this  may  be  done  the  duodenum  must  first  be  drawn  toward  the 
midline  of  the  body,  and  this  can  be  done  only  by  "mobilizing"  the  duodenum, 
incising  the  posterior  layer  of  the  parietal  peritoneum  i  inch  to  the  right  of  the 
descending  portion  of  the  duodenum.  After  freeing  the  gut  and  retroperitoneal 
structures  the  duodenum  becomes  sufficiently  free  to  lift  toward  the  left  with 


Total  Splenectomy  1271 

a  rotation.  We  thus  expose  the  posterior  aspect  of  the  duodenum,  the  head  of 
the  pancreas,  and  the  common  duct. 

The  duct  is  opened,  the  stone  removed,  the  duct  sutured,  and  a  drain 
inserted. 

This  operation  has  been  successfully  performed  by  a  number  of  surgeons, 
but  there  is  a  great  objection  to  it.  In  nearly  all  cases  the  common  bile-duct 
passes  through  the  pancreas  rather  than  back  of  it.  Biingner  found  this  to  be 
the  case  in  55  out  of  58  dissections  ("Gray's  Anatomy,"  Seventeenth  American 
edition,  p.  1352).  Hence,  incision  of  the  common  duct  in  this  situation  means 
in  nearly  all  cases  incision  of  the  pancreas  and  all  the  grave  dangers  of  leaking 
of  pancreatic  fluid.     The  transduodenal  operation  is  a  much  better  procedure. 

Total  Splenectomy. — This  operation  is  performed  for  wounds  and  rupture 
of  the  spleen,  tumors,  cysts,  floating  spleen,  and  non-leukemic  splenic  hyper- 
trophy. Twisting  of  the  pedicle  of  an  ectopic  or  wandering  spleen  calls  impera- 
tively for  operation.  It  should  not  be  performed  for  hypertrophy  in  leukemia. 
Splenectomy  does  not  interfere  with  the  development  of  a  young  child.  An 
extraordinary  thing  after  splejiectomy  is  how  rapidly  the  normal  proportion  of 
red  blood  corpuscles  is  restored  (Sir  J.  Bland-Sutton,  in  "Proc.  Royal  Soc.  of 
Med.,"  1914). 

Vedova  (quoted  in  "Practical  Medicine  Series,"  1913,  vol.  ii)  collected  134 
cases  of  splenectomy  for  traumatic  rupture  of  the  spleen.  There  were  40  deaths. 
He  adds  these  to  Berger's  60  cases,  with  25  deaths.  This  makes  a  total  of  194 
cases,  with  65  deaths  (33.5  per  cent). 

In  view  of  the  bone-marrow  changes  in  splenomyelogenous  leukemia,  we 
cannot  hope  to  cure  a  patient  by  removing  the  spleen.  In  a  leukemic  patient 
the  operation  has  a  very  high  mortality  from  shock  and  hemorrhage.  Geo. 
Ben  Johnston  ("Annals  of  Surgery,"  Jan.,  1908)  has  collected  49  splenectomies 
in  leukemia  with  only  6  operative  recoveries  (a  mortality  of  87.7  per  cent.). 
One  of  the  6  cases  lived  eight  months,  i  lived  four  years,  and  it  is  claimed  that 
I  was  cured.  Sir.  J.  Bland-Sutton  states  that  the  removal  of  a  leukemic  spleen 
can  do  nothing  but  harm  ("Proc.  Royal  Soc.  of  Med.,"  1914). 

Splenectomy  has  been  performed  for  malarial  hypertrophy  (ague-cake). 
The  operation  has  been  advocated  on  the  theory  that  by  removing  the  spleen 
we  get  rid  of  the  lurking  place  of  the  malarial  parasites,  but  they  also  lurk  in 
the  bone-marrow  and  in  the  capillaries  of  the  liver.  The  operation  should 
not  be  performed  for  malarial  spleen  unless  the  organ  is  movable,  unless  it 
greatly  interferes  with  the  patient's  comfort  or  occupation,  or  unless  we  fear 
rupture,  and  then,  if  it  is  done,  it  is  for  the  movability,  the  discomfort,  or  the 
danger  of  rupture,  and  not  for  the  malaria.  It  is  to  be  noted  that  the  opera- 
tion does  not  cure  the  malaria.  Johnston  ("Annals  of  Surgery,"  Jan.,  1908) 
collected  58  splenectomies  performed  for  malarial  hypertrophy  since  1900. 
There  were  50  recoveries  and  8  deaths.  To  these  he  adds  3  successful  ones  of 
his  own,  making  61  cases,  with  8  deaths  (a  mortality  of  13. i  per  cent.). 

A  number  of  operations  have  been  done  for  splenic  anemia  or  its  terminal 
stage,  which  is  known  as  Banti's  disease.  Those  who  believe  that  the  splenic 
enlargement  and  anemia  result  from  some  underlying  condition  common  to 
both  do  not  operate.  The  theory  of  the  operation  is  that  removal  of  the  spleen 
stops  the  production  of  some  toxic  material  which  causes  anemia  and  cirrhosis 
of  the  liver,  in  other  words,  that]the  splenic  disease  causes  the  anemia.  There 
seems  ample  evidence  that  splenectomy,  if  -done  early,  may  save  the  patient. 
It  is  useless  and  highly  dangerous  to  do  it  after  the  development  of  the  second 
stage  of  Banti's  disease.  Cushing's  case  was  alive  and  well  eight  years  after  the 
operation.  I  had  a  case  alive  and  well  three  years  ofter  operation  at  which 
time  he  died  of  cerebrospinal  meningitis.  Splenectomy  may  cure  hemolytic 
jaundice  (Peck,  in  "Jour.  Am.  Med.  Assoc."  Sept.  9,  1916).  Banti  reported 
the  first  cure  in  191 1.     The  operation  should  be  done  in  Hanot's  cirrhosis  and 


1272  Diseases  and  Injuries  of  the  Abdomen 

in  hypertrophic  cirrhosis  of  the  liver.  Primary  pernicious  anemia  is  probably 
due  to  a  toxin  which  is  intensified  by  splenic  action.  Hence  splenectomy  may 
be  done.     It  produces,  at  the  least,  great  temporary  improvement. 

Johnston  (Ibid.)  has  collected  61  splenectomies  for  splenic  anemia  or  Ban- 
ti's  disease.  There  were  49  recoveries  and  12  deaths,  a  mortality  of  19.5  per 
cent.  I  have  performed  splenectomy  twice  for  Banti's  disease,  with  one  re- 
covery and  one  death. 

Johnston  (Ibid.)  notes  12  splenectomies  for  sarcoma  of  the  spleen,  with  9 
recoveries.  One  lived  eight  and  one-half  years  and  died  of  heart  disease; 
3  are  known  to  have  died  from  recurrent  sarcoma. 

It  is  stated  that  there  are  on  record  4  splenectomies  for  cancer.  Moynihan 
doubts  the  diagnostic  accuracy  of  the  three  earlier  reports.  Mar}^  A.  Smith 
records  a  case  of  colloid  cancer  occurring  in  a  woman  who  had  been  operated 
on  ten  years  before  for  ovarian  cyst  associated  with  pseudomyxoma  of  the 
peritoneum.  The  pathologist  reported  that  the  growth  in  the  spleen  was  a 
metastasis  of  colloid  carcinoma.  This  patient  died  seven  months  after  the 
splenectomy  from  peritoneal  and  omental  cancer  ("  Annals  of  Surg.,"  Jan.,  1908). 

In  Johnston's  table  of  708  splenectomies  for  various  causes  (Loc.  cit.)  the 
mortality  is  27.4  per  cent.  In  the  cases  operated  upon  from  1900  to  1907  in- 
clusive the  mortality  is  18.5  per  cent.  In  anemias  transfusion  before  sple- 
nectomy may  prove  of  great  service. 

In  order  to  remove  the  spleen  most  operators  make  an  incision  from  the 
anterosuperior  spine  of  the  ilium  to  the  ribs.  I  prefer  to  make  an  incision  below 
the  left  costal  margin  like  Kocher's  incision  on  the  right  side  to  reach  the  gall- 
bladder. This  incision  can  be  extended  to  any  necessary  degree,  and  posterior 
drainage  of  the  pancreas  region  can  emerge  from  its  outer  end.  Open  the 
peritoneum  and  divide  adhesions  between  ligatures.  If  the  spleen  be  adherent 
to  the  pancreas,  it  may  be  necessary  to  remove  a  fragment  of  the  last-named 
organ.  It  is  a  very  undesirable  thing  to  have  to  do,  and  I  lost  a  case  from 
pancreatic  leakage  after  having  done  it.  Ligate  the  suspensory  ligament  and 
divide  it.  Bring  the  spleen  well  out  of  the  wound.  Surround  it  with  gauze 
pads.  Transfix  the  pedicle  with  stout  silk.  Tie  it  firmly,  leaving  the  ends  of 
the  ligature  long  for  a  time,  and  cut  through  the  pedicle  beyond  the  ligature. 
Ligate  the  vessels  separately  with  catugt.  Cut  off  the  long  ends  of  the  silk 
ligature  and  drop  the  pedicle  back,  unless  apprehensive  of  bleeding,  when  it  may 
be  fastened  to  the  surface.  The  wound  is  closed  without  drainage,  unless 
the  pancreas  has  been  injured,  in  which  case  posterior  drainage  is  employed. 
Traction  upon  and  ligation  of  the  vessels  in  the  pedicle  may  cause  profound 
shock  by  injuring  the  splenic  plexus,  which  is  in  close  relation  to  the  solar 
plexus  (Jordan,  in  "Lancet,"  Jan.  22,  1899). 

If  splenectomy  is  found  to  present  great  difficulties  the  splenic  artery  may 
be  tied  and  the  spleen  left  in  place  (Lanz).  John  C.  Gerster  ("Jour.  Ani. 
Med.  Assoc,"  Aug.  7,  191 5)  suggests  tying  the  splenic  artery  and  the  gastro-epi- 
ploica  sinistra  where  it  reaches  the  stomach-wall,  before  removing  the  spleen. 
Then  after  splenectomy  the  hemorrhage  will  be  venous  only.  For  the  "Technic  of 
Splenectomy"  as  practised  in  the  Mayo  Clinic,  see  Donald  C.  Balfour,  in  "Sur- 
gery, Gynecology,  and  Obstetrics,"  July,  1916. 

Changes  After  Splenectomy. — About  two  weeks  after  the  removal  of  a 
normal  spleen  certain  definite  changes  happen  in  adults,  but  not  in  children. 
These  changes  last  for  several  weeks,  and  are  manifested  by  enlargement  of  the 
lymph-glands,  pain  in  and  tenderness  of  bones,  blood  changes,  loss  of  weight, 
weakness,  thirst,  polyuria,  abdominal  pain,  elevation  of  temperature,  and  rapid 
pulse.  1  Tizzoni  says  that  these  changes  are  not  obvious  in  children,  because 
in  them  compensatory  organs  act  at  once,  whereas  in  adults  compensator}' 
organs  act  slowly  and  with  painful  effort.  Such  symptoms  are  noticed  when 
>  Ballance  in  "Practitioner,"  April,  1898;  W.  Martyn  Jordan,  in  "Lancet,"  Jan.  22,  1898. 


Abdominal  Hernia  or  Rupture 


1273 


the  spleen  is  removed  because  of  a  wound  or  a  rupture,  but  rarely  after  removal 
of  a  diseased  spleen.  It  is  likely  that  compensating  organs  become  active  when 
the  spleen  is  diseased,  and  consequently  are  in  full  operation  when  such  a  spleen 
is  removed.  After  partial  splenectomy  these  changes  are  not  noted  (Jordan). 
Changes  can  be  prevented  after  splenectomy  by  the  administration  of  tablets 
of  extract  of  spleen,  and  red  bone-marrow  (Ballance),  and  iron  (especially  in 
foods)  is  of  value. 

The  blood  changes  after  splenectomy  consist  of  diminution  in  hemoglobin 
and  red  blood-cells.  The  coloring-matter  and  cells  do  not  become  normal  for 
two  or  three  months. 

Splenopexy. — This  is  the  operation  of  anchoring  a  movable  spleen.  It 
should  only  be  used  when  the  spleen  is  not  enlarged  and  is  not  diseased.  Ry- 
dygier  in  1895  published  the  first  case,  although  both  Tuffier  and  Kouwer 
operated  before  this  date.  Sutures  should  not  be  passed  through  the  spleen:  the 
structure  is  so  soft  that  stitches  are  bound  to  loosen  and  the  insertion  will  cause 
bleeding.  A  promising  method  is  to  create 
adhesions  by  the  use  of  iodoform  gauze,  as  is 
done  for  movable  kidney,  and  as  was  done  by 
Kouwer.  Some  advocate  making  a  pocket 
outside  of  the  peritoneum  and  bringing  the 
spleen  into  this  pocket,  making  it  extra- 
peritoneal. 

Abdominal  Hernia  or  Rupture. — ^A 
hernia  is  a  protrusion  of  peritonemn  liable 
to  contain,  containing  at  times,  or  per- 
manently containing  any  viscus  or  part  of  a 
viscus  from  the  abdominal  cavity.  Mac- 
Cormac  says  the  term  implies  that  the 
protruded  viscus  is  covered  with  integument; 
hence  a  protrusion  of  viscera  through  a  wound 
does  not  constitute  a  hernia.  A  hernia  has 
three  parts — the  sac,  the  sac-contents,  and 
the  sac-coverings  (Fig.  814).  The  sac  is 
formed  of  peritoneum.  A  congenital  sac  is 
due  to  developmental  defect,  and  may  be 
in  the  inguinal  region,  the  femoral  region, 
the  umbiHcal  region,  the  lumbar  region,  or 
in  the  epigastric  region.  In  the  epigastric 
region  it  is  a  result  of  a  congenital  slit  in  the 
transversalis  fascia.  It  used  to  be  stated 
that  femoral  hernia  was  never  congenital, 
but  Russell  and  Coley  both  say  that  a 
femoral  hernia  may  have  a  congenital  sac. 

20  potential  femoral  sacs  (sacs  into  which  a  hernia  had  not  entered).  An 
acquired  sac  is  due  to  intra-abdominal  pressure  bulging  the  peritoneal  covering 
of  an  abdominal  ring  and  converting  it  into  a  pouch.  The  sac  comprises  a 
body,  a  neck,  and  a  motith.  A  sac  once  formed  is  almost  certain  to  persist,  be- 
cause it  adheres  by  its  outer  surface  to  siurounding  parts,  and  hence  the  sac 
of  a  hernia  is  usually  irreducible  even  when  the  contents  are  reducible.  The 
neck  of  the  sac  is  due  to  the  constriction  through  which  the  sac  passes;  it  becomes 
furrowed  and  folded,  and  the  adhesion  of  these  folds  causes  thickening  and  ri- 
gidity. Hernia  of  the  bladder  or  of  the  cecum  may  have  no  sac  or  but  a  partial 
sac.  A  ventral  hernia  following  an  abdominal  operation  may  be  without  a 
sac.  The  contents  of  the  sac  depend  chiefly  on  the  situation,  a  portion  of  the 
ileum  being  the  usual  contents.  The  colon,  the  stomach,  the  great  omentum, 
the  bladder,  and  other  structures  may  enter  the  hernial  sac.     An  enterocele 


Fig.  814. — A  diagrammatic  repre- 
sentation of  the  coverings  of  a  hernia: 
a,  The  skin,;  b,  the  superficial  fascia; 

c,  the  muscular  layer — e.  g.,  the  cre- 
master  muscle  in  an  inguinal  hernia; 

d,  the  transversalis  fascia;  c,  d,  have 
also  been  called  the  fascia  propria 
herniae;  e,  the  peritoneum — i.  e.,  the 
sac  of  the  hernia  (Sultan). 

In  .100  necropsies  Murray  found 


12  74  Diseases  and  Injuries  of  the  Abdomen 

contains  intestine  only;  an  epiplocele  contains  omentum  only;  an  cntero-epiplocele 
contains  both  omentum  and  intestine;  a  cystocelc  contains  a  portion  of  the  blad- 
der. The  coverings  of  the  sac,  which  vary  with  its  situation,  will  be  set  forth 
during  the  consideration  of  special  forms  of  hernia.  In  old  hernia  the  layers 
are  never  distinct,  fat  and  muscle  waste,  tissues  adhere,  and  the  skin  stretches 
and  atrophies.  The  sac  of  an  old  hernia  occasionally  becomes  tuberculous,  and 
the  disease  may  remain  local  in  the  hernial  sac  or  spread  to  the  general  peri- 
toneum. Renault  tells  us  that  tuberculosis  of  a  hernia  is  made  manifest  by  in- 
crease in  size,  pain  on  pressure,  and  loss  of  body  weight. 

Causes  of  Hernia. — Hernia  is  a  common  trouble.  According  to  Berger, 
in  looo  people  4.4  per  cent,  suffer  from  hernia.  It  occurs  at  all  periods  of  life, 
and  hereditary  predisposition  sometimes  seems  to  exist.  The  male  sex  is 
three  times  as  liable  to  hernia  as  the  female  sex.  That  increase  of  intra-ab- 
dominal tension  is  a  common  cause  in  children  has  been  amply  demonstrated. 
(See  Hernia  in  Childhood,  page  1297.)  Excessive  length  of  the  mesentery  has 
been  assigned  as  a  cause.  In  some  instances  a  mass  of  fat  forms  {fat  hernia) 
and  advances  before  the  hernia,  and  seems  to  bear  a  causative  relation  to  it.. 
Lucas-Championniere  explains  this  as  follows:  When  a  person  begins  to  take  on 
fat,  it  is  deposited  not  only  under  the  skin,  but  also  in  the  omentum,  mesentery, 
and  subperitoneal  tissues.  The  semifluid  fat  is  easily  influenced  by  pressure. 
The  deposit  of  fat  within  the  abdomen  lessens  the  size  of  that  cavity,  intra- 
abdominal pressure  is  increased,  and  subperitoneal  fat  protrudes  at  any  weak 
spot  in  the  wall.  The  protruding  mass  of  fat  adheres  to  and  makes  trac- 
tion upon  the  peritoneum,  and  this  membrane  is  drawn  upon  to  form  a  sac, 
and  the  sac  is  surrounded  by  fat.  This  method  of  formation  is  frequently 
noticed  in  umbilical  hernice,  and  occasionally  in  inguinal  hemiae.  Any  labori- 
ous occupation  predisposes  to  rupture.  Any  condition  which  weakens  the 
abdominal  wall  predisposes  to  rupture  (muscular  relaxation  from  fll-health, 
relaxation  of  abdominal  walls  following  the  termination  of  pregnancy,  the  re- 
moval of  a  large  tumor  or  tapping  for  ascites,  and  wounds  or  abscesses  of  the 
abdominal  wall).  The  commonly  assigned  cause  is  repeated  muscular  effort 
which  increases  intra-abdominal  tension  (straining  at  stool,  coughing,  lifting 
weights,  jumping,  the  sexual  act,  and  straining  during  micturition).  In 
25  per  cent,  of  cases  the  cause  is  supposed  to  have  been  lifting  or  carrying  a 
weight  (Coley).  I  am  satisfied  that  in  some  cases  at  least  the  external  abdomi- 
nal ring  enlarges  before  it  has  been  stretched  by  a  descending  hernia.  Such 
a  condition  predisposes  to  hernia  by  weakening  muscular  support  of  the  ab- 
domen. A  hernia  may  appear  gradually  or  suddenly.  Berger  and  Coley  state 
that  nearly  70  per  cent,  of  herniae  in  adult  males  appear  gradually.  The  sac 
of  an  acquired  hernia  exists  for  a  longer  or  shorter  time  before  the  hernia  enters 
it.  The  sac  of  a  congenital  hernia  is  present  at  birth.  The  sac  of  an  acquired 
hernia  forms  gradually.  A  sac  may  exist  for  years  and  yet  remain  empty. 
When  bowel  or  omentum  enters  it  from  some  strain  or  effort,  the  parts  have  been 
long  prepared  to  receive  the  extruded  mass.  This  extrusion  may  occur  gradu- 
ally or  it  may  occur  suddenly.  If  it  occurs  suddenly,  the  sufferer  believes  that 
his  hernia  was  formed  then  and  there,  but,  as  a  matter  of  fact,  the  extrusion 
of  bowel  or  omentum  and  its  entrance  into  the  sac  were  but  the  last  of  a  long 
series  of  antecedent  and  preparatory  changes.  Finally,  a  hernia  appears 
and  often  does  so  during  effort.  In  rare  cases  traumatism  may  cause  a  hernia 
immediately,  no  sac  existing  before  the  accident.  It  does  so  in  the  inguinal 
region  by  stretching  or  tearing  the  internal  ring,  the  inguinal  canal  at  once 
enlarging.  Such  a  condition  is  a  true  traumatic  hernia,  traumatism  being 
the  sole  cause  and  not  simply  the  exciting  cause. 

The  old  and  erroneous  idea  was  that  a  hernia  was  always  formed  by  tearing 
of  the  peritoneum;  hence  the  term  rupture.  This  mode  of  formation  is  ex- 
tremely unusual,  but  occasionally  does  occur.     Coley  saw  such  a  case.     An 


Treatment  of  Reducible  Hernia  1275 

ordinary  non-traumatic  hernia,  when  the  bowel  suddenly  and  for  the  first  time 
enters  the  sac,  is  the  seat  of  some  pain,  but  the  pain  is  not  disabling  and  the 
lump  disappears  on  recumbency.  In  many  cases  the  bowel  or  omentum  gradu- 
aUy  finds  a  way  into  the  sac,  and  in  such  cases  pain  is  usually  trivial  and  may 
even  be  absent.  In  true  traumatic  hernia  there  are  violent  pain,  collapse,  vomit- 
ing, inability  to  walk  and  stand,  and  the  mass  does  not  return  to  the  belly  on 
recumbency,  but  must  be  reduced  by  taxis  or  operation.  True  traumatic 
hernia?  may  occur  anywhere  in  the  abdomen,  but  are  most  common  in  the  in- 
guinal region,  where  they  are  direct  hernias.  (The  relation  born  by  accidents 
to  the  development  of  hernia  is  discussed  by  Paul  Berger,  in  "Rev.  de  Chir.," 
April  and  May,  1906,  and  by  Wm.  B.  Coley,  in  ''Internat.  Jour,  of  Surg.,"  Feb., 
igoS).  All  congenital  herniae  are  due  to  structural  defects.  Herniae  are  divided 
clinically  into  reducible,   irreducible,    incarcerated,    inflamed,   and  strangidated. 

Reducible  Hernia. — In  this  form  of  hernia  the  contents  of  the  sac  can 
be  reduced  into  the  abdominal  cavity.  At  a  known  hernial  opening  the  patient 
has  a  smooth  enlargement  (narrower  above  than  below),  which  began  to  grow 
above  and  extended  downward.  A  distinct  neck  can  often  be  felt.  In  entero- 
cele,  straining,  lifting,  or  standing  enlarges  the  mass;  the  protrusion  becomes 
smaller  and  may  disappear  on  lying  down;  cough  causes  impulse  or  succussion, 
the  protrusion  is  elastic,  and  may  be  tympanitic  on  percussion,  and  on  reduction 
the  mass  suddenly  disappears  and  there  is  a  gurgling  sound.  In  epiplocele 
the  mass  is  often  irregular  and  compressible,  and  feels  bogg}"  rather  than  elastic; 
.muscular  effort  does  not  have  much  influence  in  enlarging  it;  impulse  on  cough- 
ing is  sHght;  percussion  gives  a  duU  note,  and  reduction  is  accomplished  gradu- 
ally and  produces  no  gurgling  sound.  In  entero-epiplocele  some  parts  of  the 
mass  are  smooth,  elastic,  and  perhaps  tympanitic;  others  are  dull  on  percussion, 
irregular,  and  flabby,  but  the  diagnosis  of  this  especial  form  from  the  other 
forms  is  often  uncertain.  The  victims  of  reducible  hernia  complain  of  some 
pain  on  exertion,  of  dyspepsia,  and  often  of  constipation. 

When  a  hernia  is  beginning  to  form  there  is  often  premonitory  uneasiness; 
the  patient  complains  of  muscular  pain  in  the  lower  abdomen,  and  this  condition 
may  exist  for  weeks  or  months  before  it  is  recognized  that  a  hernia  is  present. 
An  inguinal  hernia  can  be  recognized  before  it  protrudes  from  the  external 
ring.  The  tip  of  the  finger  is  inserted  in  the  ring  and  the  patient  is  asked  to 
cough.  If  a  hernia  has  entered  the  canal,  succussion  wfll  be  detected  on  cough- 
ing. In  a  healthy  man  the  external  ring  should  admit  the  tip  of  the  little 
finger,  but  not  the  end  of  the  index-finger.  If  the  end  of  the  index-finger  can 
be  made  to  enter  the  ring  that  aperture  is  dilated,  and  even  if  there  is  no  hernia 
in  the  canal,  in  future  a  hernia  will  probably  descend.  In  a  man,  if  the  surgeon 
desires  to  examine  the  ring,  he  inverts  the  skin  of  the  scrotum  over  the  finger 
and  carries  the  finger  to  or  in  the  ring.  When  the  hernia  first  appears  there 
may  be  pain,  faintness,  and  some  sick  stomach,  but  often  there  is  no  pain 
or  any  discomfort. 

Treatment  of  Reducible  Hernia. — Palliative  Treatment. — Prevent  consti- 
pation and  forbid  sudden  strains  and  violent  exercise.  If  operation  is  re- 
fused or  inadvisable,  order  a  truss.  The  continued  employment  of  a  truss  in 
young  persons  may  bring  about  a  cure.  The  day  truss  should  be  applied 
before  rising  in  the  morning  and  be  removed  after  lying  down  at  night,  when  a 
light  truss  should  be  substituted.  A  special  truss  is  applied  before  bathing. 
In  very  fat  people  there  is  always  trouble  in  adjusting  a  truss.  A  femoral 
hernia  is  more  difficult  to  keep  reduced  than  an  inguinal  hernia.  In  a  hernia 
in  which  the  gut  is  replaceable,  but  a  portion  of  omentum  is  irreducible,  it  is 
difficult  to  maintain  reduction  of  the  gut  with  a  truss,  and  an  operation  should 
be  performed.  In  an  oblique  inguinal  hernia  the  pad  of  the  truss  fits  over  the 
internal  abdominal  ring;  in  a  direct  inguinal  hernia,  over  the  external  abdominal 
ring;  in  a  femoral  hernia,  over  the  femoral  ring  at  the  level  of  Gimbernat's 


1276 


Diseases  and  Injuries  of  the  Abdomen 


ligament.  MacCormac's  method  of  measuring  for  a  truss  is  as  follows:  In 
either  inguinal  or  femoral  hernia  start  the  tape  from  the  lower  part  of  the  hernial 
opening,  carry  it  up  to  the  anterior  superior  iliac  spine  of  the  same  side,  then 
take  it  around  the  body,  i  inch  below  the  crest  of  the  ilium,  to  the  other  anterior 
superior  iliac  spine,  and  then  to  the  upper  part  of  the  hernial  opening.^  A 
well-fitting  truss  will  keep  the  hernia  up  even  when  the  patient  sits  in  a  posi- 
tion to  relax  the  abdominal  walls  and  coughs  and  strains.  A  truss  is  always 
uncomfortable  at  first,  but  a  person  usually  becomes  accustomed  to  it.  It 
should  be  kept  scrupulously  clean,  and  bora  ted  talc  powder  should  be  dusted 
upon  the  skin  under  the  pad  at  least  once  a  day.     A  truss  which  does  not  keep 

the  hernia  up  or  which  causes  pain 
does  harm.  Too  strong  a  spring 
tends  to  enlarge  the  hernial  orifice, 
and  thus  aggravates  the  case.  Even 
after  an  apparent  cure  with  a  truss 
this  device  must  be  worn  for  a  long 
time. 

Radical  treatment  of  reducible  and 
of  non-strangulated  hernia  seeks  to 
obtain  cure  by  plugging  the  mouth 
of  the  sac  or  by  obliterating  the 
canal  of  descent.  Radical  opera- 
tions should  be  performed  upon 
strangulated  hernia  in  ordinary 
cases  of  reducible  hernia,  particu- 
larly if  a  truss  is  very  painful  or 
does  not  keep  the  bowel  up,  in 
most  cases  of  irreducible  hernia,  and 
in  any  case  of  hernia  in  which  there 
are  occasional  attacks  of  obstruc- 
tion. It  was  formerly  believed  that 
a  cure  would  fail  if  the  subject  was 
under  three  years  of  age,  but  Coley 
and  others  have  proved  that  it  is  a 
very  successful  operation  in  child- 
hood. It  is  rarely  recommended 
under  the  age  of  four,  because  in 
two-thirds  of  the  cases  a  truss  will 
cure  very  young  subjects.  It  is 
strongly  advised  in  children  after  the 
age  of  four  when  a  truss  has  failed, 
when  there  is  irreducible  omentum, 
or  when  there  is  a  reducible  hydro- 
cele which  prevents  the  truss  from 
holding  (Wm.  B.  Coley,  in  "Annals  of  Surgery,"  June,  1903).  The  radical 
operation  is  almost  without  danger  in  properly  selected  cases,  and  is  one  of  the 
most  successful  of  surgical  procedures.  We  are  justified  in  doing  the  operation 
upon  an  individual  under  fifty  years  of  age  and  free  from  complications,  purely 
to  relieve  him  or  her  from  the  annoyance  of  wearing  a  truss.  If,  however,  a 
patient  is  sixty  years  of  age  or  over  and  a  truss  keeps  the  hernia  up  satisfactorily, 
the  operation  should  not  be  performed  unless  it  is  demanded  by  some  complica- 
tion. Organic  diseases  of  the  heart,  lungs,  and  kidneys  are  contra-indications. 
Enormous  herniae  (Figs.  815  and  816)  are  unfavorable  for  operation.  Restora- 
tion is  difl&cult  or  impossible,  the  forcible  handling  produces  much  shock,  and 
recurrence  is  to  be  expected.  Restoration  is  difiicult  or  impossible  because  the 
^  Treves's  "Manual  of  Surgery,"  "Hernia." 


Fig.  815. — Hernia  which  has  "forfeited  the  right 
of  domicile." 


Treatment  of  Reducible  Hernia 


1277 


abdominal  cavity  has  contracted  and  holds  with  difficulty  or  cannot  hold  the 
huge  hernia.  As  J.  L.  Petit  said,  the  hernia  has  forfeited  the  right  of  domicile 
(Fig.  815).  In  an  operation  for  an  enormous  hernia  a  great  quantity  of  omen- 
tum will  require  removal,  and  it  may  be  necessary  to  resect  a  considerable  piece 
of  intestine.  If  we  decide  to  operate  upon  an  enormous  hernia,  treat  the  patient 
some  time  before  with  the  object  of  making  him  lose  flesh.  The  absorption  of 
mesenteric  fat  lessens  intra-abdominal  pressure.  That  operation  may  succeed 
in  such  cases  is  shown  by  Figs.  816  and  817.  In  any  operation  for  the  radical 
cure  of  inguinal  hernia  always  remember  that  the  bladder  may  be  part  of  the 
hernia,  and  be  on  the  lookout  for  it.  Eggenberger's  table  of  6778  hernial  opera- 
tions shows  75  bladder  hernise  (  i  per  cent.).  As  a  rule,  the  bladder  is  covered 
with  cellular  fat,  which  differs  in  color  and  consistence  from  omental  fat  and  from 
other  fat  which  may  be  found  about  a  hernia.  The  presence  of  a  quantity  of  ex- 
traperitoneal fat  outside  of  the  sac  suggests  the  adjacency  of  the  bladder  and 
warns  us  not  to  tie  off  the  sac  verv  high  up.     It  was  the  author's  misfortune  on 


Fig.  816. — Oblique  inguinal  hernia  of  large  size  (duration,  sixteen  years). 

two  occasions  to  open  a  bladder  in  operating  for  inguinal  hernia.  In  each  case 
the  bladder  was  sutured  and  both  patients  recovered.  It  has  been  estimated 
that  the  mortality  after  this  accident,  even  when  the  bladder  is  sutured,  is 
from  6  to  16  per  cent.  Among  other  possible  accidents  which  may  occur 
during  hernia  operations  are:  injury  of  an  iliac  vessel,  of  a  femoral  vessel,  of 
an  epigastric  vessel,  or  of  the  obturator  artery. 

The  success  of  an  operation  for  the  radical  cure  of  a  hernia  depends  upon  the 
attainment  of  primary  union.  Primary  union  is  favored  by  thorough  clean- 
liness; by  wearing  gloves  while  operating;  by  cutting  the  parts  with  a  sharp 
knife  instead  of  tearing  them  with  a  dissector;  by  removing  some  fat  and  any 
superfluous  tissue  fragments;  by  tying  the  stitches  firmly,  but  not  tightly  (a 
tight  stitch  causes  necrosis  and  creates  a  point  of  least  resistance);  by  careful 
closure;  by  dressing  with  pressure;  and  by  keeping  the  patient  recumbent  for 
from  fifteen  days  to  three  weeks. 

A  truss  is  not  to  be  used  after  operation.  Ten  years  ago  Wm.  B.  Coley 
("Annals  of  Surgery,"  June,  1903)  had  operated  upon  1075  cases  of  inguinal 
and  femoral  hernia.     In  his  report  he  did  not  consider  operations  performed 


1278 


Diseases  and  Injuries  of  the  Abdomen 


within  the  preceding  six  months,  and  so  presented  a  study  of  1003  cases.  Of 
these,  937  cases  were  inguinal,  66  cases  were  femoral.  In  the  1003  cases,  647 
were  traced  and  were  found  well  from  one  to  eleven  years  after  operation;  705 
were  well  from  six  months  to  eleven  years;  460  were  well  from  two  to  eleven  years. 
If  the  patient  is  well  one  year  after  operation,  he  will  probably  remain  well. 
This  is  proved  by  Coley's  study  of  relapses,  an  investigation  which  shows  that 
65  per  cent,  of  relapses  occur  within  six  months  of  operation  and  80  per  cent, 
within  the  first  year.  Only  13^^  per  cent,  occur  from  one  to  two  years,  and 
only  6%  per  cent,  after  two  years.  Coley  had  2  deaths  in  1075  cases  (less  than 
1'5  of  I  per  cent.).  After  Bassini's  operation  there  are  about  i  per  cent,  of 
relapses.  Coley  reports  that  from  Dec,  1891,  to  Jan.,  1909,  there  were  per- 
formed by  Drs.  Bull,  Walker,  and  himself,  in  the  Hospital  for  Ruptured  and 
Crippled,  2384  operations  for  the  radical  cure  of  hernia.  Of  these,  2218  were 
inguinal  (only  445  in  females).  In  the  1773  male  cases  the  tj-pical  or  modified 
Bassini  operation  was  done  with  12  relapses,  or  0.68  per  cent.  ("Progressive 
Medicine,"  June,  1909). 


Fig.  817. — The  case  shown  in  Fig.  S16  six  months  after  operation. 

Lannelongue' s  Method. — Lannelongue  has  for  certain  cases  returned  to  the 
old  injection  plan,  using  a  10  per  cent,  solution  of  chlorid  of  zinc  instead  of 
white  oak  bark.  The  hernia  is  first  reduced  and  is  held  up  by  an  assistant, 
who  closes  the  internal  ring  with  a  finger  and  also  holds  the  cord  aside.  Several 
injections  of  10  min.  each  are  thrown  in  the  region  of  the  internal  pillar,  the  region 
of  the  external  pillar,  and  into  the  canal  behind  and  outside  of  the  cord.  The 
surgeon  must  be  careful  that  no  zinc  solution  escapes  into  the  subcutaneous 
tissue.  The  effect  of  the  chlorid  of  zinc  is  to  cause  the  formation  of  quantities 
of  fibrous  tissue.  It  is  scarcely  to  be  expected  that  a  cure  so  produced  will  be 
permanent  in  an  adult,  though  it  may  be  in  a  child. 

Macewen's  Operation  for  Inguinal  Hernia.— A  hernia  director  (Fig.  818,  a) 
and  special  hernia  needles  (Fig.  818,  b)  are  required  for  this  operation.  The 
patient  lies  recumbent,  the  thigh  being  abducted  and  partly  flexed  and  rest- 
ing on  a  pillow  beneath  the  knee.  The  bowel  is  reduced,  and  an  incision  3 
inches  long  is  made  in  the  direction  of  the  inguinal  canal,  the  center  of  the 
incision  corresponding  to  the  external  ring.     The  sac  is  freed  from  its  attach- 


Treatment  of  Reducible  Hernia 


1279 


ments  below  and  is  lifted  up.  The  surgeon  introduces  a  finger  into  the  inguinal 
:  canal  and  separates  the  sac  from  the  cord  and  from  the  walls  of  the  canal,  and 
■  then  carries  the  finger  through  the  internal  ring  and  separates  the  peritoneum 
for  I  inch  about  the  periphery  of  this  aperture  (Fig.  819,  a).  A  chromicized 
catgut  stitch  is  fastened  to  the  lowest  portion  of 
'  the  sac,  and  is  passed  through  the  sac  several 
times,  so  that  pulling  on  the  stitch  will  purse 
the  sac  (Fig.  819,  b).  The  free  end  of  this  stitch 
is  carried  through  the  internal  ring  into  the  belly, 
and  is  pushed  out  through  the  abdominal  muscles 
I  inch  above  the  internal  ring,  the  skin  being 
pushed  aside  so  as  to  escape  perforation  by  the 
needle.  The  thread  is  tightened  so  as  to  fold 
up  the  sac  and  pull  it  into  the  belly.  This  plugs 
the  ring.  The  thread  is  handed  to  an  assistant 
to   keep   tight  until  the  sutures  are  introduced 

into  the  ring,  when  the  sac  is  permanently  anchored  by  taking  several 
stitches  in  the  external  oblique  muscle.  A  strong  catgut  suture  is  passed  with 
a  Macewen  needle  through  the  conjoined  tendon  from  below  upward,  the  ends 
of  this  suture  being  carried  through  Poupart's  ligament  and  the  outer  border 
of  the  internal  ring  from  within  outward.     This  suture  is  tightened  and  closes 


Fig.  818. — A,  Hinged  hernia  di- 
rector; B,  hernia  needles. 


Fig.  819. — Macewen's  operation  for  radical  cure  of  inguinal  hernia:  a,  Stripping  of  the  sac; 
B,  purse-string  suture;  c,  fastening  the  purse-string  suture;  d,  passing,  and  E,  tying,  the 
sutures  for  the  internal  ring. 


the  internal  ring.     The  external  ring  is  sutured  and  the  skin  is  stitched  (Fig. 
819,  c,  D,  and  e). 

In  congenital  hernia  the  sac  is  divided  in  its  middle,  and  the  lower  part  is 
closed  by  stitches  of  chromicized  catgut,  forming  a  tunica  vaginalis.  The  upper 
part  of  the  sac  is  slit  posteriorly  to  permit  the  escape  of  the  cord,  and  is  closed  by 
stitches  of  chromicized  catgut  (Fig.  820).     The  operation  is  finished  as  in  the 


,i28o  Diseases  and  Injuries  of  the  Abdomen 

acquired  form.  After  Macewen's  operation  the  patient  should  stay  in  bed  for 
at  least  three  weeks,  and  must  not  work  for  eight  or  nine  weeks.  Workmen  after 
this  operation  should  always  wear  for  a  time  a  pad  and  a  spica  bandage.  Chil- 
dren require  no  pad.  Never  apply  a  truss,  as  strong  pressure  will  produce 
atrophy  of  the  curative  scar. 

Bassini's  Operation  for  Oblique  Inguinal  Hernia. — (See  E.  Wyllys  An- 
drews, in  "Med.  Record,"  Oct.  28,  1899,  who  describes  from  personal  ob- 
servation how  Bassini  does  his  operation.  I  have  drawn  upon  his  descrip- 
tion in  the  following  section.)  Bassini's  operation  displaces  the  spermatic 
cord  from  the  old  canal  and  places  it  in  a  new  canal,  and  this  new  canal  is 
oblique.  Curved  and  rounded  needles  are  employed  to  insert  the  stitches.  The 
suture  material  is  kangaroo-tendon  or  chromicized  catgut.  Silk  or  silver  wire 
is  apt  to  make  trouble — perhaps  long  after  the  operation.  The  patient  is 
placed  supine  with  the  thighs  extended.  An  incision  is  made  parallel  to  Pou- 
part's  ligament  and  extending  from  the  external  ring  to  a  point  external  to 
the  internal  ring.  The  incision  is  about  i^o  inches  above  the  ligament  and  is 
from  5  to  7  inches  in  length.  By  this  incision  the 
aponeurosis  of  the  external  oblique  and  the  pillars  of 
the  external  ring  are  exposed.  All  bleeding  is  arrested, 
the  aponeurosis  is  incised  in  the  direction  of  its  fibers  and 
from  above  downward,  and  the  inguinal  canal  is  opened. 
The  aponeurosis  of  the  external  oblique  is  dissected  up 
with  a  blunt  instrument  until  Poupart's  ligament  is  ex- 
posed. We  speak  of  this  ligament  as  the  shelf.  A 
mass  containing  the  sac  of  the  hernia,  the  cord,  the 
cremaster  muscle,  and  considerable  fat  is  lifted  up. 
_  Bassini  employs  blunt  dissection.     Coley  advocates  the 

Fig  820  —Macewen's  ^^^  °^  ^^^  knife.  Masses  of  fat  and  usually  the  cre- 
operation  for  the  radical  master  muscle  are  removed.  The  sac  is  isolated  first 
cure  of  congenital  hernia,  at  its  neck  and  the  neck  is  stripped  from  the  inner  aspect 
of  the  internal  ring  for  the  distance  of  ^  inch.  The 
object  of  this  stripping  is  to  permit  the  removal  of  the  sac  at  a  high  level. 
High  removal  obviates  the  leaving  of  a  funnel-shaped  depression  of 
peritoneum.  Such  a  depression  would  predispose  to  relapse.  The  sac  is 
opened  at  the  fundus,  the  interior  is  investigated,  and  if  the  contents  are  re- 
ducible, they  are  restored  to  the  abdominal  cavity  and  the  neck  of  the  sac 
is  clamped  high  up.  If  adherent  masses  of  omentum  are  found,  the  adhesions 
are  separated,  bleeding  is  arrested,  and  the  omentum  is  restored  to  the 
abdomen  unless  it  is  in  a  hard  and  thick  mass,  when  it  is  tied  off  and  removed. 
Bassini  ties  off  the  neck  of  the  sac  above  the  clamp  with  a  strong  ligature  of 
silkworm-gut.  If  the  sac  is  large  and  thick,  he  also  threads  both  ends  of  a 
ligature  upon  a  needle,  passes  the  strand  through  the  stump,  and  ties  around 
over  the  first  loop.  (See  E.  Wyllys  Andrews,  "Med.  Record,"  Oct.  28,  1899.) 
Coley  and  many  other  operators  prefer  to  tie  off  the  sac  with  a  catgut  suture 
rather  than  with  silkworm-gut  or  silk.  It  is  my  usual  custom  to  employ  fine 
black  silk,  catching  it  to  prevent  slipping  by  running  a  stitch  through  the  wall  of 
the  neck  of  the  sac.  After  ligating  the  neck  of  the  sac  the  sac  is  cut  across  and  re- 
moved. The  cord  is  now  lifted  out  of  the  way  (Fig.  821,  a),  the  inner  surface 
of  Poupart's  ligament  is  exposed  by  retraction,  and  the  deep  sutures  are  passed 
(Fig.  821,  a).  Bassini  uses  silk  which  has  been  boiled  in  glycerin.  Most 
American  operators  use  kangaroo-tendon  or  chromicized  catgut.  Bassini 
inserts  first  the  sutures  nearest  to  the  pubes.  The  first  suture — and  sometimes 
also  the  second — includes  part  of  the  rectus  sheath  and  rectus  muscle.  Each 
stitch  includes  the  internal  oblique  and  transversahs  muscle  in  the  upper  edge 
and  the  shelf  of  Poupart's  ligament  below  the  lower  margin,  and  from  four 
to  six  stitches  are  passed  behind  the  cord  (Fig.  821,  b).     The  last  stitch  narrows 


Treatment  of   Iveducihle   Hernia 


12S1 


the  internal  ring  so  that  it  fits  tightly  around  the  cord  (E.  Wyllys  Andrews, 
Ibid.).  Coley's  rule  for  passing  this  suture  is  to  insert  it  so  "that  it  just 
touches  the  lower  border  of  the  cord  when  the  latter  is  brought  vertically 
to  the  plane  of  the  abdomen"  (''Annals  of  Surgery,"  June,  1903).  He  always 
places  a  suture  above  the  cord,  and  believes  it  tends  to  prevent  relapse  (Fig. 


Bit  obi 


Fig.    821. — A-c,   Bassini's   operation   for  Fig.     822. — Bassini's      operation      (deep 

the  cure   of  inguinal    hernia    (Esmarch  and     sutures),  showing  extra  suture  above  the  cord, 
Kowalzig).  as  advised  by  Coley. 

822).  The  sutures  are  tied  from  above  downward.  The  cord  is  laid  upon 
this  new  floor  and  the  aponeurosis  of  the  external  oblique  is  sutured  over  it  (Fig. 
82 1 ,  c) .  I  close  the  aponeurosis  by  a  continuous  suture  of  chromic  catgut  and  the 
skin  with  interrupted  sutures  of  silk- 
w^orm-gut  or  fine  silk.  Drainage  is  not 
used  except  when  there  is  excess  of  sub- 
cutaneous fat.  The  wound  is  covered 
with  a  roll  of  iodoform  gauze  and 
some  pieces  of  sterile  gauze,  and  com- 
pression is  made  by  strips  of  adhesive 
plaster,  and  a  piece  of  adhesive  plaster 
run  from  one  thigh  to  the  other  acts  as 
a  shelf  for  the  testicles  to  rest  upon. 
The  adhesive  plaster  is  overlaid  with 
dry  gauze,  and  this  is  covered  with 
absorbent  cotton  and  the  dressing  is 
retained  in  place  by  a  firm  spica  of 
the  groin  {Coley's  dressing).  The 
wound  is  dressed  on  the  seventh  or 
eighth  day,  the  stitches  are  removed, 
the  patient  is  kept  in  bed  for  about 
two  weeks  longer  and  is  allowed  to 
get  about  in  two  and  one-half  to 
three  weeks,  wearing  a  bandage  until 
four  weeks  after  operation. 

In  Bassini's  operation  some  surgeons  treat  the  sac  as  in  JMacewen's  opera- 
tion, carrying  out  the  rest  of  the  procedure  as  directed  above.  In  a  pure  Bas- 
sini  operation  the  funnel-shaped  depression  in  the  peritoneum  at  the  point  of 
emergence  of  the  cord  may  remain  and  predispose  to  hernia,  but  the  use  of 
Macewen's  plan  for  treating  the  sac  obviates  this. 


Fig. 


823. — Exposure  of  the  sac,  the  vas,  and 
the  spermatic  veins  (Halsted). 


1282 


Diseases  and   Injuries  of  the  Abdomen 


The  Ilalsted  Operation. — A  description  of  the  original  Halsted  operation 
is  found  in  "Johns  Hopkins  Hosp.  Reports,"  vol.  vii.  The  operation  at 
present  performed  by  Professor  Halsted  and  his  assistants  has  been  evolved  from 
the  former  operation  so  long  associated  with  his  name,  and  has  been  greatly- 
modified  by  him  and  by  Dr.  Bloodgood.  In  this  operation  the  skin  and  the 
aponeurosis  of  the  external  oblique  are  incised  exactly  as  in  performing  Bassini's 
operation,  and  flaps  of  aponeurosis  are  raised.  Next,  the  cremaster  muscle  and 
the  cremaster  fascia  are  incised  in  a  line  slightly  above  the  center  of  the  sper- 
matic cord.  The  internal  oblique  muscle  is  then  brought  into  distinct  view  at 
the  side  of  the  inguinal  canal  and  the  hernia  is  carefully  inspected  (Fig.  823). 
If  the  veins  are  found  to  be  large  they  should  be  excised;  but  the  surgeon  does 
not  lift  the  vas  from  its  bed,  and  even  avoids  touching  it,  if  he  possibly  can,  for 
fear  that  thrombosis  may  occur  in  its  veins.  The  veins  are  tied  above,  well  up 
in  the  abdomen;  and  below,  well  above  the  testicle,  and  excised  between  the 
ligatures.  The  sac  is  then  ligated  or  sutured  with  a  purse-string  suture.  One 
end  of  the  thread  that  ties  or  sutures  the  sac  is  carried,  by  means  of  a  long, 
curved  needle,  in  an  outward  direction  under  the  internal  oblique  muscle, 


Fig.  824. — Suture  of  the  cremaster  to  the  in-     Fig.  ?,2e,. — Suture  of  the  lower  edge  of  the  in- 
ternal oblique  (Halsted).  ternal  oblique  to  Poupart's  ligament  (Halsted). 

through  which  it  is  then  pulled.  The  other  end  of  the  thread  is  also  pulled 
through  the  muscle  3^^  inch  from  the  first  end,  and  these  two  ends  are  tied  to- 
gether. It  will  be  observed  that  this  treatment  of  the  neck  of  the  sac  is  some- 
what similar  to  the  method  practised  by  Kocher. 

The  next  step  is  to  carry  the  inferior  flap,  composed  of  cremaster  muscle  and 
fascia,  under  the  internal  oblique  muscle,  and  suture  it  there  (Fig.  824).  We 
next  suture  the  internal  oblique  muscle  and  the  conjoined  tendon  to  Pou- 
part's ligament,  the  lower  edge  of  the  internal  oblique  being  tucked  under 
the  edge  of  the  ligament  (Fig.  825).  •  In  order  to  accomplish  this,  it  may  be 
necessary  to  release  the  muscle  by  incising  the  anterior  rectal  sheath.  The 
incision  in  the  external  oblique  is  now  closed  with  sutures  that  overlap  the 
margins  (Figs.  826  and  827),  and  the  skin  wound  is  also  closed. 

Halsted' s  Operation  Plus  Bloodgood' s  Method  oj  Transplanting  the  Rectus 
Muscle. — (See  Jos.  C.  Bloodgood,  in  "Johns  Hopkins  Hosp.  Reports," vol. 
vii.)  When  the  conjoined  tendon  is  very  thin  or  obliterated,  the  ordinary 
operation  is  not  enough.  Insufficiency  of  the  conjoined  tendon  is  known  to 
exist  when  a  finger  does  not  meet  any  obstruction  after  passing  through  the 
external  abdominal  ring,  but  can  be  introduced  for  some  distance  into  the 


']'rcatmcnt  of  Reducible  Hernia 


1283 


abdominal  cavity  (Bloodgood).  To  meet  this  condition  of  affairs,  Bloodgood 
devised  ''a  plastic  operation  on  the  rectus  muscle,  bringing  this  muscle  down 
and  suturing  it  with  the  other  available  tissue  to  Poupart's  ligament  and  to 


Fig.  826. — Suture  of  the  aponeurosis  of  the 
external  oblique  (Halsted). 


Fig.  827. — Suture  of  the  margin  of  aponeu- 
rosis to  Poupart's  ligament  (Halsted). 


the  aponeurosis  of  the  external  oblique  from  the  arch  of  the  pubis  up  to  the 
position  of  the  transplanted  cord"  (Bloodgood,  in  previously  mentioned  re- 
port).    The  first  steps  of  the  operation  are  identical  with  those  previously 


//"/ 


Fig.  828. — The   method  of  transplanting  Fig.  829. — The    transplanted    rectus^  in- 

the  rectus  muscle.     The  sac  has  been  excised      eluded   by  the   deep  sutures.     In  this  illus- 
and  the  peritoneal  cavity  closed;  internal  ob-       tration   the   cord   has  been  excised  in  order 
lique  muscle  has  been  divided,  the  rectus  ex-       to   demonstrate   the   operation  more  clearly 
posed  and  transplanted;  at  this  stage  the       (Bloodgood). 
wound  is  ready  for  the  deep  sutures.     This 
illustration  shows  how  perfectly  the  trans- 
planted rectus  muscle  lines  the  lower  half  of 
the  wound  (Bloodgood). 

described,  but  before  the  insertion  of  the  deep  stitches  the  rectus  sheath  is 
exposed  and  divided  in  the  direction  of  the  muscle-fibers,  from  the  pubic  inser- 
tion upward  for  5  cm.     The  muscle  bulges  from  the  cut  and  is  caught  with 


1284  Diseases  and  Injuries  of  the  Abdomen 

silk  sutures  (Fig.  828).  Deep  sutures  are  now  introduced  as  in  Halsted's 
operation,  except  that  they  include  the  rectus  and  its  sheath  (Fig.  829).  The 
operation  is  completed  as  is  Halsted's.  I  have  performed  this  operation  a 
number  of  times  with  entire  satisfaction. 

Kochers  Operation. — Kocher  exposes  the  aponeurosis  of  the  external  ob- 
lique, makes  a  small  incision  through  the  aponeurosis  above  and  external  to 
the  internal  ring,  and  draws  the  sac  through  this  incision  and  sutures  it  in 
place. 

Foivler's  operation  is  as  follows:  An  incision  is  made  parallel  with  Pouparts 
ligament  from  the  spine  of  the  pubis  to  the  level  of  the  internal  ring,  and  a  flap 
is  turned  up.  The  inguinal  canal  is  opened  and  the  sac  and  cord  are  isolated. 
The  sac  is  opened,  its  contents  reduced,  it  is  cut  off,  and  its  edges  grasped  with 
forceps.  The  deep  epigastric  artery  and  vein  are  sought  for,  each  is  tied  in  two 
places  and  divided  between  the  ligatures.  The  index-finger  is  introduced 
into  the  belly,  and  on  this  as  a  guide  the  floor  of  the  canal  is  divided  (transver- 
salis  fascia,  subserous  tissue,  and  peritoneum).  The  cord  is  placed  in  the 
peritoneal  cavity.  The  edges  of  the  opening  are  sutured  so  that  broad  serous 
surfaces  are  approximated,  through-and-through  sutures  being  passed  from 
side  to  side.  The  cord  is  brought  out  at  the  inner  end  of  the  incision,  the  lower 
angle  of  the  cut  being  at  such  a  level  that  the  cord  curves  upward  and  forward 
as  it  leaves  the  abdomen.  The  inguinal  canal,  the  gap  in  the  aponeurosis,  and 
the  skin  wound  are  closed.^ 

Ferguson's  Operation. — In  studying  a  number  of  recurrences  after  opera- 
tion A.  H.  Ferguson  observed  that  a  hernial  protrusion  is  apt  to  return  at  the 
upper  and  outer  portion  of  the  scar,  above  the  cord  and  near  Poupart's  ligament. 
When  he  operated  upon  relapsed  cases,  he  discovered  a  slit  of  the  aponeurosis 
of  the  external  abdominal  wall,  through  which  the  sac  and  some  fat  protruded. 
In  order  to  determine  the  cause  of  the  failure  of  these  operations,  he  thought  it 
proper  to  make  a  semilunar  incision  and  raise  a  flap  of  skin,  fascia,  and  aponeu- 
rosis of  the  external  oblique.  On  doing  this,  he  was  surprised  to  find  an  angle 
between  the  lower  border  of  the  internal  oblique  muscle  and  the  inner  aspect 
of  Poupart's  ligament  absolutely  unprotected  by  the  internal  oblique  or  the 
transversalis  muscle.  In  some  cases  this  angle  extended  upward  and  outward 
to  the  anterior  superior  iliac  spine.  He,  therefore,  concluded  positively  that 
the  cause  of  a  rupture  returning  in  this  angle  after  an  operation  for  radical 
cure  is  deficient  origin  of  the  internal  oblique  muscle  and  of  the  transversalis 
muscle  at  Poupart's  ligament.  He  is  now  persuaded  that  in  all  cases  of  hernia 
there  is  a  deficient  origin  of  these  muscles,  and  he  has  demonstrated  the  same 
thing  in  a  series  of  dissections  in  the  inguinal  region.  Ferguson  describes  his 
operation  as  follows  ("Jour.  Am.  Med.  Assoc,"  July  i,  1899):  He  begins  his 
incision  over  Poupart's  ligament,  i^  inches  below  the  anterior  superior  iliac 
spine,  carries  it  inward  and  downward  in  a  semilunar  curve,  and  terminates  it 
over  the  conjoined  tendon,  near  the  pubic  bone.  The  incision  goes  down  to  the 
aponeurosis  of  the  external  oblique,  and  the  flap,  with  its  fat  and  fascia,  is 
turned  downward  and  outward  (Figs.  830  and  831).  The  next  step  is  to  incise 
the  external  abdominal  ring  to  the  intercolumnar  fascia  and  separate  the 
longitudinal  fibers  of  the  external  oblique  over  the  inguinal  canal  to  beyond  the 
internal  ring,  at  a  point  nearly  opposite  the  anterior  superior  spine  of  the  ilium. 
Any  transverse  fibers  that  may  be  encountered  are  severed.  The  separated 
aponeurosis  of  the  external  oblique  muscle  is  then  retracted.  One  has  then 
brought  into  view  the  contents  of  the  inguinal  canal,  the  hernial  sac  and  its 
adhesions,  the  spermatic  cord,  the  ilio-inguinal  nerve,  the  internal  abdominal 
ring,  the  subserous  fat,  the  cremaster  muscle,  the  conjoined  tendon,  the  internal 
obhque  and  its  deficient  origin  at  Poupart's  ligament,  the  transversalis  fascia, 
and  the  internal  surface  of  Poupart's  ligament.  The  sac  is  now  dissected  from 
I  "Annals  of  Surgery,''  Nov.,  1897. 


Treatment  of   Rediuiljlc  Hernia 


128: 


the  cord  and  the  internal  ring.  It  is  opened  and  its  contents  are  inspected  and 
properly  dealt  with.  It  is  tied  high  up  and  cut  otT,  and  the  stump  is  dropped 
into  the  abdomen  (Fig.  832).  If  the  sac  be  congenital  it  is  divided  into  two 
parts:  the  distal  portion  is  used  to  make  a  tunic  for  the  testicle  and  the  proximal 
portion  is  treated  as  above  directed.     The  cord  is  not  disturbed,  and  it  is  be- 


SunSpini 
Protf: 


Fig.  830. — Ferguson's  operation:  The  semi- 
lunar skin  incision  ("Jour.  Am.  Med. 
Assoc"). 


Fig.  S31. — Ferguson's  operation:  Flap 
turned  back  exposing  the  aponeurosis  and 
the  sac  of  the  hernia  (''Jour.  Am.  Med. 
Assoc"). 


yond  doubt  that  Ferguson  is  right  in  saying  that  the  testicle  frequently  comes 
to  harm  after  operations  that  disturb  the  cord.  The  veins  in  the  cord  should 
not  be  touched  unless  a  varicocele  also  exists.  Any  excessive  quantity  of 
subserous  adipose  tissue  should  be  removed.  The  next  step  in  the  operation  is 
to  restore  the  structures  to  their  normal  position;  and  one  should  remember  that 


Fig.  S32. — Ferguson's  operation:  Dealing 
with  the  sac  and  its  contents  ("Jour.  Am. 
TMed.  Assoc"). 


Fig.  833. — Ferguson's  operation:  Suture  of 
the  slack  in  the  transversalis  fascia  (^"Jour. 
Am.  Med.  Assoc." 


in  the  transversalis  fascia  is  the  internal  ring.  In  hernia  the  internal  ring  is 
large  and  the  transversalis  fascia  bulges  outward;  one  must,  therefore,  take  up 
the  slack  in  this  fascia  and  make  a  well-litting  ring  for  the  cord  by  means  of  a 
catgut  suture,  either  interrupted  or  continuous  (Fig.  833).  After  this  has  been 
accomplished  the  internal  oblique  and  transversalis  muscles  are  sutured  to  the 


1286 


Diseases  and  Injuries  of  the  Abdomen 


internal  aspect  of  Poupart's  ligament,  after  the  lower  borders  of  the  muscles 
have  been  freshened  and  Pou])art's  ligament  has  been  scarified.  The  sutures 
must  be  carried  two-thirds  of  the  way  down  Poupart's  ligament,  which  is  about 
the  normal  origin  of  this  muscle  in  the  female  (Fig.  834).  The  next  step  is  to 
suture  the  edges  of  the  divided  aponeurosis  of  the  external  oblique;  this  restores 
the  external  abdominal  ring.     The  skin-flap  is  then  carefully  sutured. 

Radical  Cure  of  Direct  Inguinal  Hernia. — If  the  hernia  goes  through  the  con- 
joined tendon  or  pushes  that  structure  before  it,  the  operation  should  consist 
in  transplanting  the  rectus  muscle  as  practised  by  Bloodgood  (see  page  1283) 
and  suturing  the  arched  fibers  of  the  internal  oblique  and  conjoined  tendon  to 
Poupart's  ligament  and  beneath  the  cord. 

If  the  hernia  passes  around  the  outer  edge  of  the  conjoined  tendon  an  over- 
lapping operation,  like  the  Mayo  oper- 
ation for  umbilical  hernia,  should  be 
performed  (G.  G.  Davis,  in  "Annals  of 
Surgery,"  Jan.,  1906). 

Radical  Cure  of  Umbilical  Hernia. — 
The  results  of  operations  for  umbilical 
herniae  have  not  been  satisfactory.  Re- 
currences are  frequent.  This  is  prob- 
ably due  to  the  fact  that  most  of  the 
subjects  are  fat,  and  that  the  muscles 
are  thin  and  flabby.  The  usual  oper- 
ation may  be  thus  described:  Make  a 
longitudinally  elliptical  incision  through 
the  skin  around  the  mass.  Endeavor 
to  separate  the  sac  from  the  superficial 
tissue.  If  this  cannot  be  done,  open 
the  sac  and  separate  it  from  the  contents. 
Even  if  the  sac  can  be  stripped  from  the 
skin,  always  open  it  and  separate  the 
contents.  Return  any  bowel  which 
may  be  present,  and  do  not  forget  that 
there  may  be  a  small  portion  of  bowel  completely  encased  in  omentum.  Tie 
into  segments  and  cut  off  the  superfluous  omentum  and  return  the  stump 
into  the  belly.  Excise  the  umbilicus  (omphalectomy).  Suture  the  peritoneum 
with  a  continuous  catgut  suture.  Close  the  musculofascial  wall  with  two 
layers  of  interrupted  sutures  of  kangaroo-tendon  or  chromic  catgut,  or  one  layer 
of  silver  wire  mattress  sutures.  Close  the  skin  by  interrupted  sutures  of  silk- 
worm-gut or  by  a  subcuticular  stitch. 

Maya's  Operation. — This  is  a  vast  improvement  on  the  older  operation. 
It  gives  a  firm  cicatrix  free  from  disastrous  traction.  Mayo  believes  that  the 
defect  in  the  old  operation  is  that  the  recti  muscles  are  naturally  separated  at 
the  level  of  the  umbilicus,  and  in  bringing  the  recti  together  we  have  virtually 
performed  muscle  transplantation,  and  these  thin  muscles  are  of  no  great  value 
in  preventing  relapse,  and  in  a  large  hernia  it  is  not  even  possible  to  cover  the 
gap  by  muscle.  Mayo  now  operates  as  follows:  Transverse  elliptical  incisions 
are  made  around  the  umbilicus  and  hernia  and  the  base  of  the  protrusion  is 
exposed  (Fig.  835).  The  surface  of  the  aponeurosis  is  cleared  for  1^2  inches 
around  the  neck  of  the  sac.  The  fibrous  and  peritoneal  coverings  of  the 
hernia  are  divided  by  a  circular  incision  around  the  neck  of  the  sac.  Intestine 
is  freed  from  adhesions  and  placed  within  the  abdomen.  Omentum  is 
ligated  and  removed  with  the  sac.  The  margins  of  the  ring  are  grasped  and 
overlapped  in  order  to  indicate  in  which  direction  closure  can  be  most 
easily  effected.  An  incision  is  made  through  the  fibrous  and  perito- 
neal coverings  of  the  ring  i  inch  or  more  transversely  on  each  side,  and  the 


Fig.  834. — Ferguson's  operation :  Suture 
of  the  internal  oblique  and  of  the  trans- 
versalis  muscles  to  the  internal  aspect  of 
Poupart's  ligament  ("Jour.  Am.  Med. 
Assoc"). 


Treatment  of  Reducible  Hernia 


1287 


peritoneum  is  stripped  from  the  under  surface  of  the  upper  flap.  Several 
mattress  sutures  of  silver  wire  are  introduced  i  inch  above  the  edge  of  the 
upper  flap  and  are  carried  through  the  margin  of  the  lower  flap;  sufficient  trac- 
tion is  made  to  permit  of  the  closing  of  the  peritoneum  with  a  continuous  catgut 

suture  (Fig.  836).  When  this  has 
been  accomplished,  the  silver  wire 
sutures  are  drawn  so  as  to  slide  the 
lower  flap  into  the  pocket  between 
the  peritoneum  and  the  under  sur-_ 
face  of  the  upper  flap  (Fig.  837). 
The  free  margin  of  the  upper  flap  is 


Fig.  835. — Mayo's  operation  for  the  radical 
cure  of  umbilical  hernia:  Exposure  of  hernia 
and  lateral  incision. 


Fig.  836. — Mayo's  operation  for  the 
radical  cixre  of  umbilical  hernia:  Perito- 
neum sutured. 


fixed  by  catgut  sutures  to  the  aponeurosis  (Fig.  838),  and  the  superficial  in- 
cision is  closed  as  usual.  Wm.  J.  Mayo  ("Jour.  Am.  Med.  Assoc,"  June  i,  1907) 
reported  upon  88  operations  for  umbilical  hernia  by  this  method  between  1894 


Fig.  837. — Mayo's  operation  for  the 
radical  cure  of  umbilical  hernia:  Aponeurosis 
sutured. 


Fig.  838. — Mayo's  operation  for  the  rad- 
ical cure  of  umbilical  hernia:  Aponeurosis 
sutured  second  time  with  gut  sutures. 


and  1905;  75  were  traced;  i  had  a  partial  relapse;  i  was  supposed  to  have  a 
relapse,  but  operation  disclosed  a  second  opening  above  and  outside  of  the  closed 
umbilical  opening. 


1288 


Diseases  and  Injuries  of  the  Abdomen 


Radical  Cure  of  Femoral  Hernia. — It  is  a  mistake  to  suppose  that  relapses  are 
less  common  than  after  operations  for  inguinal  hernia.  They  are  more  common 
in  an  adult.  Cheyne  ligates  the  neck  of  the  sac,  stitches  the  stump  to  the  ab- 
dominal wall,  dissects  out  a  flap  from  the  pectineus  muscle,  stitches  this  flap  to 
Poupart's  ligament  and  to  the  abdominal  wall,  and  thus  fills  up  the  crural  canal. 
Bassini  makes  an  incision  parallel  to  Poupart's  ligament,  ties  the  neck  of  the 
sac,  cuts  off  the  sac  below  the  ligature,  and  returns  the  stump  into  the  belly. 
He  attaches  by  deep  sutures  Poupart's  ligament  to  the  pectineal  aponeurosis 
jis  high  up  as  the  pectineal  eminence,  the  cord  or  round  ligament  being  drawn 
out  of  the  way.  Superficial  sutures  are  passed  between  the  pubic  portion  and 
the  iliac  portion  of  the  fascia  lata. 

The  operation  of  Fahricius  is  performed  as  follows:  An  incision  is  begun 
over  the  pubic  spine  and  is  carried  outward  for  5  inches  parallel  with  Poupart's 
ligament.  The  sac  is  exposed,  isolated,  and  opened,  its  contents  are  reduced, 
its  neck  is  ligated,  the  sac  is  cut  off,  and  the  stump  is  dropped  back  (Fig.  839). 


■f 

'<y 

Fig.  830      I';il)ri(ius's  operation  for  the  radical  cufl'  of  fcmcjral  hernia:   .Wck  of  sac  shown. 


Sac  cut  away. 
(Fowler). 


DuUed  line  shows  line  of  separation  of  Poupart's  ligament  and  fascia   lata 


An  incision  is  now  made  below  Poupart's  ligament  so  as  to  separate  this  struc- 
ture and  the  fascia  lata,  and  the  flap  of  fascia  is  turned  down  (Fig.  840).  The 
crural  sheath  and  the  vessels  are  retracted  outward.  The  surgeon  is  careful 
not  to  injure  the  obturator  artery  and  vein.  The  origin  of  the  pectineus  muscle 
is  sutured  to  Poupart's  ligament.  The  lower  stitches  include  the  periosteum 
of  the  horizontal  ramus  of  the  pubes  as  well  as  the  beginning  of  the  muscle 
(Fig.  841).  Care  must  be  taken  in  passing  certain  of  them  to  avoid  injuring 
the  deep  epigastric  vessels.  When  these  stitches  are  tied,  the  femoral  canal 
is  obliterated.  The  flap  of  fascia  lata  is  sutured  to  the  aponeurosis  of  the  ex- 
ternal oblique,  and  the  skin  is  sutured. 

The  best  operation  is  that  of  Moschcowitz  by  the  inguinal  route.  It  gives 
a  thorough  exposure  of  the  parts  and  enables  the  surgeon  absolutely  to  close  the 
femoral  ring.  The  incision  is  hke  that  for  inguinal  hernia  except  that  it  more 
nearly  reaches  the  pubic  region.  The  aponeurosis  of  the  external  oblique  is 
divided.  The  internal  oblique  and  transversalis  are  retracted  upward.  The 
lower  flap  of  the  external  oblique  is  retracted  downward.  The  round  ligament 
or  cord  is  held  aside.     The  transversalis  fascia  is  divided  and  the  peritoneum  , 


Treatment  of  Reducible  Hernia 


1289 


is  opened.     The  bowel  or  omentum  is  withdrawn  from  tlie  sac.     The  sac  is 
seldom  adherent  to  the  thigh  tissue  and  can  usually  be  pulled  up  with  its  contents; 


'W, 


L_, 


Fig.  840. — Fabricius's  operation  for  femoral  hernia:  Fascia  lata  turned  back,  exposing  crural 
sheath  and  origin  of  pectineus  muscle  (Fowler). 

SO  that  adhesions  between  sac  and  contents  can  be  separated.     If  the  sac  is 
adherent  in  the  thigh  the  incision  is  extended  on  to  the  thigh  and  the  sac  dis- 


FiG.  841 — Fabricius's  operation  for  femoral  hernia:  Crural  sheath  and  vessels  retracted 
and  kangaroo-tendon  sutures  applied  to  Poupart's  ligament  and  origin  of  pectineus,  ready  for 
tying.  Two  sutures  are  placed  in  position  to  approximate  the  pillars  o'f  the  external  ring 
(Fowler). 

sected  loose.  The  sac  is  tied  off.  The  femoral  canal  is  closed  by  suturing 
Cooper's  ligament  (which  covers  the  pectineal  line)  to  Poupart's  ligament. 
The  most  internal  suture  catches  Gimbernat's  ligament.     The  rest  of  the  wound 


1290 


Diseases  and  Injuries  of  the  Abdomen 


is  then  closed  (the  above  description  is  abl)reviated  from  the  admirable  article 
by    Seelig   and    Tuholske,    in    "Surgery,    Gynecology,  and  Obstetrics,  "  Jan., 

1914)- 

Operative   Treatment  of  Adherent   {Sliding)   Hernia  of  the    Ascending  and 

Descending  Colon. — My  personal  experience  consists  of  8  cases  of  right  and  2 
cases  of  left  inguinal  hernia.  The  sac  is  deficient  posteriorly  and  externally 
(see  page  1300).  In  order  to  restore  the  bowel  into  the  abdomen  many  opera- 
tors have  sought  to  force  up  the  adherent  intestine  to  the  external  ring,  and 
others  have  stripped  the  gut  from  the  subperitoneal  tissues  in  order  to  per- 
mit of  reduction.  The  first  plan  should  never  be  followed.  If  it  should  be 
employed,  sutures  will  fail  to  hold  the  bowel  up.  The  second  plan  is  risky 
and  may  be  followed  by  gangrene  of  the  bowel.  In  my  cases  I  followed  Weir's 
plan  ("Med.  Record,"  Feb.  24,  1900),  and,  after  dissecting  up  the  peritoneum 
on  each  side  to  a  little  above  the  internal  ring,  freed  the  bowel  from  its  bed 
and  covered  the  new  surface  with  the  peritoneal  flaps  (Fig.  842).  The  bowel 
was  then  restored  and  a  radical  cure  was  performed. 

Epiploitis  Following  a  Hernia  Operation. — This 
is  a  postoperative  inflammation  of  the  omentum 
due  to  ligation  of  that  structure.  The  condition 
was  pointed  out  by  Lucas-Championniere  in  1892 
(William  Hessert,  in  Surgery,  Gynecology,  and 
Obstetrics,  Sept.,  1916).  In  acute  cases  signs  of 
peritonitis  arise  a  few  days  after  operation  and 
suppurative  peritonitis  ensues.  Such  cases  are  due 
to  replacement  of  an  infected  stump.  In  most 
cases  trouble  does  not  begin  until  four  weeks  or 
more  after  operation,  when  pain  begins  and  is  ac- 
centuated by  motion  or  pressure.  Such  cases 
may  recover  but  usually  terminate  in  abscess.  In 
another  group  the  symptoms  come  on  insidiously 
and  late,  a  palpable  mass  develops  and  cancer  is 
suspected.  In  such  cases  there  has  been  an  in- 
flammatory growth  from  the  ligated  stump  and 
in  most  of  them  the  stump  has  been  tied  with  silk 
(see  Hessert's  illuminating  paper.  Ibid.). 
Irreducible  Hernia. — The  swelling  in  irreducible  rupture  presents  the  usual 
evidences  of  hernia,  imparts  an  impulse  on  coughing,  but  cannot  be  replaced 
in  the  abdomen.  Sometimes  a  portion  is  reducible  and  a  portion  is  irreducible. 
A  hernia  may  become  irreducible  because  of  the  size  of  the  mass,  because  of 
adhesions,  or  because  of  excessive  growth  of  omental  fat.  An  irreducible 
hernia  is  liable  to  be  bruised  and  to  cause  much  distress  and  pain,  and  is  always 
a  menace  to  life  because  of  the  danger  of  obstruction  and  strangulation.  It 
was  formerly  the  custom  to  support  a  small  irreducible  hernia  by  a  hollow, 
padded  truss,  but  now  operation  should  be  advised.  A  large  hernia  of  this 
variety,  if  operation  be  refused,  must  be  carried  in  a  bag  truss.  The  patient 
must  not  take  very  active  exercise,  must  keep  the  bowels  regular,  and  must  live 
upon  a  plain  diet.  Most  cases  of  irreducible  hernia  should  be  treated  by 
operation. 

Incarcerated  or  Obstructed  Hernia. — Obstruction  takes  place  by  the  dam- 
ming up  of  feces  or  of  undigested  food,  the  fecal  current  being  arrested,  but  the 
blood-current  in  the  wall  of  the  bowel  not  being  cut  off.  Incarceration  is  com- 
monest in  irreducible  hernia,  especially  umbilical  hernia,  and  during  the  exis- 
tence of  constipation.  The  hernia  enlarges  and  becomes  tender,  painful,  and 
dull  on  percussion;  pressure  may  diminish  it  somewhat  in  size.  It  remains 
irreducible,  but  still  presents  impulse  on  coughing.  The  abdomen  is  somewhat 
distended  and  painful;  there  are  nausea,  constipation,  and  not  unusually  slight 


Fig.  842. — Outline  of  per- 
itoneal lining  of  sac  utilized  as 
a  flap  to  cover  posterior  sur- 
face after  it  has  been  freed  by 
dissection  (Weir). 


Strangulated  Hernia 


1291 


vomiting.     Constitutional  disturbance  is  trivial  and  constipation  is  not  absolute, 
gas  at  least  usually  passing.     Vomiting  is  not  fecal. 

The  treatment  is  rest  in  bed  in  a  position  to  relax  the  belly,  an  ice-bag  over 
the  hernia  for  a  very  few  hours,  and  a  little  opium  for  pain.  Do  not  give  a 
particle  of  food  for  twenty-four  hours;  when  the  active  symptoms  subside  give 
an  enema,  and,  after  this  acts,  a  dose  of  castor  oil.  Do  not  employ  taxis,  as 
bruising  the  bowel  may  produce  strangulation.  If  improvement  does  not 
rapidly  occur,  operate.  Prompt  operation  saves  the  patient  from  the  danger 
of  strangulation  and  cures  the  hernia. 

Inflamed  Hernia. — Inflammation  of  a  hernia  is  local  peritonitis  due  to 
injury  of  an  irreducible  hernia.  The  mass  becomes  tender  and  painful,  and 
perhaps  heat  is  noted.  In  enterocele  much  fluid  forms;  in  epiplocele  the  mass 
becomes  hard.  The  hernia  cannot  be  reduced;  there  is  constipation,  often 
vomiting,  usually  elevated  temperature,  but  the  mass  still  shows  impulse  on 
coughing.  Vomiting  is  not 
fecal.  Some  gas  is  usually 
passed  through  the  bowels. 
Constitutional  symptoms  are 
slight. 

The  treatment  usually  rec- 
ommended is  rest  in  bed  with 
abdominal  relaxation,  an  ice- 
bag  to  the  tumor  for  a  few 
hours,  a  small  amount  of 
opium  by  the  mouth  if  pain  be 
severe,  an  enema,  and,  after 
this  acts,  a  saline.  In  an  in- 
flamed hernia  there  is  great 
danger  of  strangulation,  and 
operation  should  be  per- 
formed in  preference  to  rely- 
ing upon  the  conservative 
plan. 

Strangulated  hernia  is  a 
condition  in  which,  if  the 
hernia  contains  bowel,  not 
only  is  the  fecal  circulation 
arrested  and  gas  prevented  from  passing,  but  the  circulation  of  blood  in  the 
bowel  wall  is  also  arrested.  The  bowel  is  irreducible  and  obstructed,  and 
the  blood  ceases  to  circulate.  If  the  hernia  contains  omentum,  the  omental 
vessels  are  tightly  constricted.  In  both  bowel  and  omentum  gangrene  soon 
occurs,  but  sooner  in  bowel  than  in  omentum.  Strangulation  is  commonest 
in  old  inguinal  ruptures  in  active,  middle-aged  men,  and  is  more  frequent 
in  enteroceles  than  in  epiploceles.  It  is  most  common  when  the  hernial 
orifice  is  small  and  is  seldom  seen  in  large  ruptures.^  Strangulation  is  rare 
in  childhood.  Strangulation  is  much  more  dangerous  when  bowel  is  present 
in  the  sac  than  when  omentum  only  is  present.  If  in  a  subject  of  hernia  the 
abdominal  pressure  is  suddenly  increased,  as  by  a  violent  cough  or  a  muscular 
efifort,  the  hernial  orifice  is  dilated  for  a  moment,  more  intestine  or  omentum 
may  enter  the  sac,  and  if  it  does,  it  may  be  caught  and  constricted  by 
the  now  constricted  hernial  orifice  and  strangulation  begins.  Strangulation 
so  caused  is  called  elastic  strangulation.  A  sudden  increase  of  intra-abdominal 
pressure  mav  force  a  quantity  of  fecal  matter  into  the  herniated  intestine.  The 
sudden  entry  of  a  quantity  of  fluid  and  gas  into  the  herniated  coil  causes  fecal 
strangulation,  the  mechanism  of  which  is  obscure.  By  retrograde  strangulation 
1  Strangulation  developed  in  the  large  hernise  shown  in  Figs.  S16  and  843. 


Fig.  843. — Strangulated  umbilical  hernia  contain- 
ing nearly  all  the  intestines  and  part  of  stomach. 
Strangulation  under  bands  within  the  sac. 


129^ 


Diseases  and   Injuries  of  the  Abdomen 


we  mean  a  condition  in  which  the  end  of  a  loop  of  bowel  or  a  piece  of  omen- 
tum in  a  hernia  re-enters  the  abdomen  and  then  becomes  strangulated,  the  bal- 
ance of  the  hernia  not  being  strangulated.  Strangulation  may  be  due  to  active 
peristalsis  or  to  congestion,  and  it  may  arise  from  inflammation  or  from  incar- 
ceration. The  constriction  may  be  at  the  neck  of  the  sac,  in  the  outside  tissues, 
or  even  in  the  sac  itself.  In  an  hour-glass  hernia  the  constriction  may  be  in 
the  body  of  the  sac.  In  inguinal  hernia  a  tight  external  ring  is  a  common 
cause  of  strangulation  and  is  the  commonest  cause  in  children.  As  Coley 
shows,  the  neck  of  the  sac  is  very  seldom  the  cause  in  children.  Adhesions 
within  the  sac  may  cause  strangulation.  Spasmodic  contraction  of  the  tissues 
about  the  neck  of  the  sac  is  an  exploded  hypothesis.  The  obstructed  veins 
dilate  and  the  blood  in  them  ceases  to  move,  the  bowel  becomes  deep  bluish 
and  finally  black,  effusions  of  blood  occur  beneath  the  peritoneum,  and  the 
intestinal  wall  becomes  edematous.  Fluid  transudes  into  the  sac,  and  the 
fluid,  at  first  clear,  assumes  a  bloody  hue,  and  finally  becomes  foul.  The 
peritoneum  ceases  to  glisten,  becomes  dry  and  rough,  and  coated  here 
and  there  with  lymph.  Strangulated  omentum  undergoes  edema  and  hemor- 
rhagic infarction  and  thrombosis 
occur.  When  strangulation  once 
begins  the  hernia  swells,  a  furrow 
forms  on  the  bowel  at  the  seat  of 
constriction,  the  bowel  and  omentum 
below  the  constriction  become  deeply 
congested  and  edematous,  and, 
finally,  the  hernia  passes  into  a  state 
of  moist  gangrene  (Fig.  844).  The 
gangrene  may  be  in  spots  or  the 
entire  mass  may  be  gangrenous. 
The  mucous  membrane  may  be  gan- 
grenous when  the  serous  coat  looks 
fairly  sound.  When  gangrene  is 
once  established,  the  bowel  is  in 
danger  of  rupturing.  At  the  point 
of  constriction  there  may  be  a  line 
of  ulceration  or  of  gangrene  even 
when  the  balance  of  the  gut  looks 
fairly  safe.  A  strangulated  femoral 
hernia  becomes  gangrenous  more  rapidly  than  a  strangulated  inguinal 
hernia. 

Symptoms. — This  condition  is  sometimes  preceded  by  diarrhea  and  un- 
easiness or  pain  about  the  hernial  orifice.  When  strangulation  begins  the 
victim  is  seized  with  pain  in  and  about  the  hernia  and  with  violent  colicky 
pain  about  the  umbilicus,  and  the  paroxysms  of  colic  become  more  and  more 
frequent,  until  finally  the  pain  may  become  continuous.  The  hernia  is  found 
to  be  irreducible;  larger  than  usual,  tender,  painful,  dull  on  percussion,  without 
impulse  on  coughing,  and  the  skin  above  it  may  be  reddened.  Eructations  of 
gas  are  frequent,  and  generally  uncontrollable  vomiting  and  prostration  come  on. 
Vomiting,  as  a  rule,  is  an  early  symptom,  and  one  which  increases  in  severity. 
Occasionally  it  only  follows  the  swallowing  of  liquids.  Not  unusually  there  is 
retching  rather  than  vomiting.  In  rare  cases  vomiting  does  not  begin  for 
twenty-four  to  forty-eight  hours.  Vomiting  is  earlier  and  more  violent  when 
bowel  is  present  in  the  sac  than  when  the  hernia  is  purely  omental.  During 
the  course  of  a  strangulation,  vomiting  may  cease  for  a  day  or  more;  and  it  not 
unusually  ceases  toward  the  end,  when  prostration  is  profound.  The  early 
vomiting  is  due  to  reflex  causes;  the  later  vomiting  is  due  to  waves  of  peristalsis 
which   produce   regurgitation    (Macready's    "Treatise   on    Ruptures")-     The 


Fig,  844. — A  strangulated  coil  of  intestine 
after  the  strangulation  existed  for  a  considerable 
period  of  time.  The  color  has  become  almost 
black  and  the  peritoneal  surface  is  dull  and 
covered  with  flakes  of  fibrin.  The  constriction 
rings  are  deeply  sunken,  their  walls  markedly 
thinned,  relaxed,  and  dirty  gray  in  color.  Both 
constriction  rings  are  gangrenous  and  hemor- 
rhages are  observed  in  the  mesentery  (Sultan). 


Stranguhitcd  Hernia  1 29,^5 

vomiting  is  first  of  th-j  alimentary  contents  of  the  stomach,  next  of  mucus  and 
bilious  matter,  and  finally  of  the  contents  of  the  small  bowel  {fecal  or  stercora- 
ceous  vomiting).  Stercoraceous  vomiting  rarely  arises  until  strangulation 
has  lasted  forty-eight  hours,  and  may  not  appear  until  much  later,  "It  is 
seldom  met  with  in  inguinal,  more  often  in  femoral,  and  more  often  still  in 
obturator,  hernia"  (Macready,  Ibid.).  Prostration  is  a  marked  symptom  of  a 
strangulated  hernia,  and  it  increases  hour  by  hour  and  goes  on  to  collapse. 
Early  in  the  case  there  may  be  some  elevation  of  temperature,  but  later  it 
becomes  normal  or  subnormal.  The  pulse  is  small,  irregular,  rapid,  and  very 
weak;  the  extremities  cold;  the  face  becomes  Hippocratic.  Constipation  is 
absolute,  no  gas  even  being  passed,  though  in  the  very  beginning  there  may  be 
some  diarrheal  passages  from  below  the  constriction.  The  urine  is  scanty  and 
high  colored,  and  contains  only  a  small  amount  of  the  chlorids;  the  tongue  be- 
comes dry  and  brown;  the  thirst  is  torturing,  and  the  patient  often  has  an  im- 
perative desire  to  go  to  stool.  Pains  in  the  abdomen  and  in  the  hernia  become 
more  and  more  violent,  and  collapse  rapidly  increases.  When  gangrene  begins 
the  symptoms  apparently  lessen  in  violence;  there  is  a  delusive  calm.  Vomit- 
ing usually  ceases,  though  regurgitation  may  take  its  place;  hiccup  begins; 
the  pain  abates  or  disappears;  the  pulse  becomes  very  frequent,  feeble,  and 
intermittent;  collapse  deepens,  and  delirium  is  usual.  It  is  a  safe  clinical 
rule  that  in  strangulated  hernia  sudden  cessation  of  pain  without  the  relief  of 
constriction,  the  disappearance  of  the  lump,  or  the  use  of  opiates  means  that 
gangrene  has  begun.  In  some  cases  of  strangulation  there  are  muscular 
cramps  in  the  legs  (Berger).  In  children  convulsions  are  not  unusual.  In 
a  pure  omental  hernia  strangulation  produces  similar  but  less  decided  symptoms. 
It  may  be  that  only  a  portion  of  the  circumference  of  the  bowel  is  caught  and 
constricted  in  a  hernial  orifice  (see  Fig.  85 1,  a).  Such  a  condition  is  encountered 
occasionally  in  the  femoral  ring,  and  is  called  partial  enterocele  or  Richters 
hernia.  The  name  Littre's  hernia  is  often  wrongly  given  to  this  condition. 
WhatLittre  described  was  a  hernia  of  Meckel's  diverticulum  (see  Fig.  851,  b). 
In  a  strangulated  Richter's  hernia  constipation  is  rarely  absolute  and  often 
no  protrusion  is  discovered. 

Treatment. — In  treating  strangulated  Jiernia  place  the  patient  upon  his 
back,  bend  the  knees  over  a  pillow,  and  rigidly  interdict  the  administration  of 
food.  An  attempt  may  usually  be  made  to  effect  reduction  by  gentle  manipu- 
lation or  taxis.  In  applying  taxis  to  a  femoral  or  inguinal  hernia,  flex  and  adduct 
the  thigh  of  the  affected  side.  In  applying  taxis  to  an  umbilical  hernia  both 
thighs  should  be  flexed  upon  the  abdomen.  Always  lower  the  shoulders  and 
head  and  raise  the  pelvis,  and  accomplish  this  by  lifting  the  foot  of  the  bed 
and  placing  pillows  under  the  pelvis.  In  some  cases  raise  the  entire  body 
and  lower  the  head.  Grasp  the  neck  of  the  sac  with  the  fingers  and  thumb  of 
one  hand,  and  employ  the  other  hand  to  squeeze  the  hernia  and  urge  it  toward 
the  belly.  In  direct  inguinal  hernia  the  pressure  should  be  backward  and  a 
little  upward;  in  umbilical  hernia  it  should  be  backward;  in  oblique  inguinal 
hernia  it  should  be  upward,  outward,  and  backward;  in  femoral  hernia  it  should 
be  downward  until  the  hernia  enters  the  saphenous  opening,  and  then  "back- 
ward toward  the  pubic  spine"  (MacCormac,  in  Treves's  "  Manual  of  Surgery"). 
If  the  bowel  should  be  reduced,  it  will  pass  from  the  hand  with  a  sudden  slip 
and  enter  the  belly  with  an  audible  gurgle;  omentum,  when  reduced,  slowly 
glides  back  without  gurgling.  Taxis  is  never  to  be  continued  long,  and  it  is 
not  even  to  be  attempted  in  cases  of  great  acuteness,  in  cases  in  which  strangula- 
tion has  lasted  for  several  days,  in  cases  known  to  have  been  previously  irre- 
ducible, in  cases  associated  with  stercoraceous  vomiting,  or  in  inflamed  or 
gangrenous  herniae. 

If  taxis  fafls,  obtain  the  patient's  permission  to  operate.  Anesthetize; 
in  some  cases  try  taxis  again  upon  the  unconscious  patient  and  while  ether  is 


1294 


Diseases  and  Injuries  of  the  Abdomen 


being  dropped  upon  the  hernia  to  make  it  cold;  if  reduction  fails,  at  once  perform 
herniotomy.  Taxis  possesses  certain  dangers:  It  may  rupture  the  bowel; 
it  may  rupture  the  neck  of  the  sac  and  force  the  bowel  through  the  rent  into 
the  tissues  of  the  abdominal  wall;  it  may  strip  the  peritoneum  from  around 
the  hernial  orifice  and  force  the  bowel  between  the  detached  peritoneum  and 
the  abdominal  wall;  it  may  reduce  a  hernia  into  the  belly  when  the  bowel  is 
still  strangulated  by  adhesions;  it  may  reduce  the  hernia  en  masse  or  en  bloc. 
By  the  term  "reduction  en  masse"  we  mean  that  the  sac  has  been  separated 
and  dislocated  and  with  the  constricted  bowel  within  it  has  been  forced  through 
the  internal  ring.  By  " reduction  en  bissac"  is  meant  the  forcing  of  a  congenital 
hernia  into  a  congenital  pouch  or  diverticulum.  Reduction  en  masse  is  a  rare 
accident.  Corner  and  Howitt  ("Annals  of  Surgery,"  vol.  xlvii)  collected  137 
cases  of  reduction  en  masse  of  strangulated  hernia.  Of  these,  no  were  males, 
113  were  inguinal,  22  femoral,  and  2  obturator  hernia.  No  ventral  or  umbilical 
cases  are  recorded.  The  accident  is  a  very  dangerous  one. 
According  to  Corner  and  Howitt  (Ibid.),  the  mortality 
after  inguinal  reductions  en  masse  is  48  per  cent.,  and 
after  femoral  reductions,  72  per  cent.  Strange  to  say,  re- 
duction en  masse  can  occur  spontaneously.  The  subject 
most  liable  to  reduction  en  masse  is  an  elderly  person  with 
an  old  hernia.  In  acute  cases  the  small  bowel  is  the  viscus 
which  has  been  reduced.  In  subacute  and  chronic  reductions 
en  masse  the  omentum,  large  bowel,  or  bladder  has  been  re- 
duced (Corner  and  Howitt,  Ibid.).     Subacute  and  chronic 


^> 


Fig.  845. — Cooper's 
curved  herniotome. 


Fig.  846. — The  division  of  the  constriction  from  within  outward 
(Sultan). 


cases  may  happen  in  non-strangulated  hernia.  In  any  of  the  above  accidents  ob- 
struction may  persist  after  apparent  reduction  by  taxis.  Persisting  obstruction 
means  strangulation  or  peritonitis  and  calls  for  instant  laparotomy — in  most 
instances  through  the  hernial  aperture.  If  taxis  is  successful,  put  the  patient 
to  bed,  apply  a  pad  and  bandage,  allow  no  food  until  vomiting  ceases,  merely 
permit  him  to  take  a  little  hot  water  during  the  first  twenty-four  hours,  and 
keep  him  on  a  liquid  diet  for  several  days.  At  the  end  of  the  first  week  give 
solid  food.  Do  not  disturb  the  bowels  for  a  few  days,  but  if  they  have  not 
acted  when  four  or  five  days  have  elapsed  since  the  operation,  give  a  saline 
cathartic  followed  in  a  few  hours  by  a  purgative  enema.  There  is  usually  a 
spontaneous  movement  within  twenty-four  hours  after  reduction  by  taxis. 

Herniotomy. — If  there  has  been  stercoraceous  vomiting  the  stomach  must 
be  washed  out  before  giving  the  anesthetic,  and  during  the  administration  of 


Herniotomy  1295 

the  anesthetic  the  head  should  be  turned  upon  its  side.  In  most  cases  a  gen- 
eral anesthetic  can  be  given,  but  in  desperate  cases  it  is  not  justifiable  to  give 
ether  or  chloroform,  and  a  local  anesthetic  must  be  used  (infiltration  anesthesia). 
Wrap  the  patient  up  in  blankets.  In  most  cases  try  gentle  taxis  for  a  brief 
time  after  the  patient  has  been  anesthetized  and  while  ether  is  being  dropped 
upon  the  hernia  to  make  it  cold.  Never  try  taxis  if  stercoraceous  vomiting  has 
occurred.  If  taxis  fails,  at  once  sterilize  the  parts  and  operate.  Always  lay 
out  a  hernia  knife  (Fig.  845),  a  director  (see  Fig.  818,  a),  and  Murphy  buttons. 
During  the  operation  the  patient  lies  upon  his  back  with  the  shoulders  raised, 
the  surgeon  standing  to  the  patient's  right  side.  In  oblique  inguinal  hernia  it 
has  been  the  custom  since  the  days  of  Scultetus  to  raise  a  fold  of  skin  at  a  right 
angle  to  the  axis  of  the  external  ring  and  transfix  it,  the  wound  which  results 
being  extended  until  it  becomes  3  inches  in  length.  This  incision  possesses 
no  special  merit.  It  is  better  to  cut  from  without  inward,  and  to  make  the 
same  incision  as  for  the  performance  of  a  radical  cure  in  a  non-strangulated  case. 
The  superficial  tissues  are  divided,  the  aponeurosis  is  opened  as  in  Bassini's 
operation,  and  the  sac  is  reached.  In  most  cases  the  constriction  is  relieved 
as  soon  as  the  external  ring  is  nicked,  and  in  many  cases  fibrous  adhesions  will 
be  found  in  that  region,  gluing  the  sac  to  the  ring.  The  sac  must  be  identified; 
and  it.  is  known  by  the  fat  which  usually  covers  it,  by  the  fluid  within  the  sac,  by 
the  arborescent  arrangement  of  its  vessels,  and  by  the  fact  that  it  can  be  pinched 
up  between  the  finger  and  thumb  and  the  layers  rolled  over  each  other.  Should 
the  sac  be  opened?  It  may  not  be  actually  necessary  in  every  recent  case,  but 
if  there  is  any  doubt  as  to  the  condition  of  the  bowel  or  if  a  radical  cure  is  to 
be  attempted,  open  the  sac  and  be  certain  as  to  the  condition  of  its  contents.  As 
there  is  always  some  doubt  as  to  the  condition  of  the  contents,  and  as  a  radical 
cure  is  to  be  made,  make  it  a  rule  always  to  open  the  sac.  The  sac  is  opened 
and  the  contents  examined  for  fecal  odor  (which  is  not  unusual)  and  for  gangre- 
nous smell;  the  thickness  of  the  bowel  is  estimated  and  the  color  and  luster  are 
determined.  If  a  constriction  exists  at  the  neck,  it  is  nicked  with  a  hernia 
knife.  If  the  hernia  is  oblique  inguinal  and  is  caught  at  the  internal  ring,  nick 
the  constriction  upward  and  outward  or  directly  upward,  as  shown  in  Fig.  846. 
In  direct  inguinal  hernia  and  in  an  oblique  inguinal  hernia  caught  at  the  external 
ring  the  cut  is  made  upward  and  inward.  Always  pull  the  bowel  down  and 
examine  the  seat  of  constriction  to  see  what  damage  has  been  inflicted  at  that 
point.  If  the  serous  coat  glistens;  if  the  proper  color  comes  back  to  the  bovt^el 
wall  after  irrigation  with  very  hot  water;  and  if  there  are  no  spots  of  gangrene, 
restore  the  bowel  to  the  abdomen  and  do  a  radical  cure.  If  the  bowel  is  in  a 
doubtful  condition,  fasten  it  to  the  incision,  apply  a  dressing,  and  watch  the 
development  of  events.  If  the  bowel  is  gangrenous,  our  action  depends  upon 
the  condition  of  the  patient.  If  the  patient  is  in  good  condition,  resect  the 
gangrenous  portion  and  perform  end-to-end  approximation.  If  the  patient's 
condition  is  bad,  draw  the  gangrenous  portion  well  out,  anchor  it  to  prevent 
leakage  and  retraction,  make  an  artificial  anus,  and  at  a  later  period  perform 
anastomosis.  An  artificial  anus  can  be  made  by  the  method  of  Bodine  (see 
page  1262).  Unfortunately  in  these  cases  the  artificial  anus  must  usually  be 
made  in  the  small  intestine.  In  many  cases  in  which  there  is  some  uncertainty 
as  to  the  need  for  an  artificial  anus  prepare  the  bowel  for  the  opening,  but  do  not 
open  at  once,  because  the  bowel  may  recover  in  a  day  or  two,  when  it  can 
be  restored  to  the  belly,  or  it  may  slough  and  form  an  artificial  anus.  In  such 
doubtful  cases  fasten  the  bowel  to  the  belly  wall  with  sutures,  dust  it  with  iodo- 
form, dress  it  with  hot  antiseptic  fomentations,  and  await  future  developments. 
Gangrenous  omentum  requires  ligation  and  resection.  If  the  bowel  is  fit  to 
reduce,  push  it  just  inside  the  ring,  irrigate  the  parts,  suture,  and  perform  a 
radical  cure.  In  femoral  hernia  we  can  make  the  incision  i  inch  internal  to  and 
parallel  with  the  femoral  vessels  and  crossing  the  tumor  and  ligament  (Barker) ; 


1296 


Diseases  and  Injuries  of  the  Abdomen 


but  it  is  better  to  make  the  incision  of  Fabricius  for  radical  cure.  Divide  the 
constriction  by  cutting  upward  and  a  little  inward.  If  the  gut  is  found  gan- 
grenous or  in  a  doubtful  condition,  follow  Blake's  advice  ("Surg.,  Gynec,  and 
Obstet.,"  May,  1906J,  make  an  incision  at  the  edge  of  the  rectus,  draw  the 
affected  portion  of  gut  into  the  abdomen  and  out  of  the  incision,  and  either  re- 
sect, fix  it  under  or  out  of  the  incision,  or  wait  for  return  of  circulation,  as  may  be 
indicated  in  the  case.  To  draw  the  gut  out  of  the  femoral  ring  makes  so  much 
traction  that  return  of  circulation  may  be  prevented,  and  any  intestinal  opera- 
tion is  difficult  in  this  region  without  splitting  Poupart's  ligament.  I  greatly 
prefer  the  inguinal  incision  of  INIoschcowitz  to  any  crural  incision.     It  gives 

free  exposure,  makes  treat- 
ment of  bowel  and  sac  easier 
and  safer,  and  enables  us  to 
see  Gimbernat's  ligament  and 
recognize  an  anomalous  ob- 
turator artery  if  one  exists. 
It  is  a  perilous  thing  to  divide 
the  constricting  Gimbernat's 
ligament  by  touch  alone.  An 
anomalous  obturator  artery 
has  been  called  the  corona 
mortis.  The  radical  cure  by 
the  inguinal  route  is  described- 
on  page  1286.  In  umbilical 
hernia  make  a  slightly  curved 
incision  a  little  to  one  side 
of  the  middle  of  the  tumor, 
open  the  sac,  separate  ad- 
hesions, and  divide  the  con- 
striction by  cutting  upward 
or  downward,  and  sometimes 
also  laterally,  or,  better,  op- 
erate as  for  radical  cure  (see 
page  1286). 
After  an  operation  for  strangulated  hernia  put  the  patient  to  bed;  bend 
the  knees  over  a  pillow;  give  no  food  by  the  mouth  for  thirty-six  hours  (Mac- 
Cormacj,  only  allowing  hot  water,  and  every  sixth  hour  give  an  enema  of  salt 
solution  containing  brandy.  Abdominal  pain  and  tenderness  call  for  the  adminis- 
tration of  saline  cathartics  and  enemata  containing  turpentine  or  oil  of  rue. 
The  enema  ruta;  is  a  favorite  preparation  in  St.  George's  Hospital,  London. 
It  is  made  as  follows:  Take  16  oz.  of  an  infusion  of  camomile,  warm  it,  and  pour 
it  upon  3  dr.  of  confection  of  senna  (Sheildj.  If  there  is  no  abdominal  pain  and 
no  tenderness  the  bowels  need  not  be  disturbed  for  a  few  days;  but  if  at  the  end 
of  four  or  five  days  they  have  not  acted,  give  a  saline  cathartic  and  a  few  hours 
later  a  purgative  enema.  At  the  end  of  about  three  weeks  get  the  patient  up. 
If  a  radical  cure  has  not  been  attempted,  apply  a  pad  and  a  spica  bandage 
to  the  groin,  and  later  a  truss.  A  truss  should  not  be  worn  if  a  radical  cure  has 
been  made. 

Mortality. — Cases  of  strangulated  hernia  irreducible  by  taxis  will  practically 
all  die  without  operation.  The  mortality  following  operation  is  large;  it  is 
not  due  to  operation,  but  is  due  to  the  condition,  and  is  due  particularly  to 
delay  in  operating  or  to  forcible  antecedent  taxis.  Sultan,  from  a  total  of 
1429  herniotomies,  estimates  the  mortality  at  20.7  per  cent.  Estimating  the 
mortality  according  to  the  time  of  strangulation,  Henggeler  reaches  the  follow- 
ing conclusions:  The  mortality  of  cases  operated  upon  "the  first  day  after  the 
strangulation  is  8.09  per  cent.;  during  the  second  day,  22.2  per  cent.;  during 


Double  inguinal  rupture. 


Hernia  in  Childhood  1297 

the  third  day,  45.5  per  cent.;  during  the  fourth  day,  60  per  cent."  ("Atlas  and 
Epitome  of  Abdominal  Hernias,"  by  Dr.  George  Sultan.  Translated  and  edited 
by  VVm.  B.  Coley,  M.  D.).  Deaver  and  Ross  ("Annals  of  Surgery,"  191 5,  Ixi) 
had  a  mortahty  of  33.5  per  cent,  in  156  cases  and  umbilical  and  ventral  hernice 
showed  the  highest  mortality.  The  mortality  in  children  is  smaller  than  in 
adults.  In  Coley 's  12  cases  of  children  under  two  years  of  age  there  was  not  a 
death. 

Hernia  in  Childhood. — Umbilical  and  inguinal  herniae  are  extremely  common 
in  infants  and  children.  Femoral  hernia  is  very  seldom  seen  in  infants  because 
of  the  small  size  of  the  ring.  The  condition  is  rare  in  children.  It  is  an  inter- 
esting fact  that  if  one  conducts  a  careful  investigation  of  hernia  in  adults,  it 
will  be  found  that  but  5  or  6  per  cent,  of  them  have  suffered  from  the  hernia 
in  childhood.  This  fact  seems  to  demonstrate  positively  that  the  majority 
of  cases  of  hernia  in  childhood  are  recovered  from.  A.  J.  Ochsner  ("Jour. 
Am.  Med.  Assoc,"  Dec,  22,  1900),  in  commenting  upon  the  frequency  of  hernia 
in  childhood,  alludes  to  Malgaigne's  statistics.  Malgaigne  estimated  that 
during  the  first  year  of  life  i  child  in  every  21  has  hernia,  and  that  this  propor- 
tion is  maintained  until  the  age  of  sLx.  Then  it  diminishes  rapidly  until  the 
age  of  thirteen,  at  which  age  there  is  1  hernia  in  every  77  children.  It  is,  there- 
fore, obvious  that  75  per  cent,  of  all  hernise  in  children  of  six  years  will  heal 
spontaneously  before  the  age  of  thirteen.  Ochsner  states  that  95  per  cent, 
of  herniae  in  children  will  be  cured  without  operation.  He  points  out  that 
between  the  ages  of  thirteen  and  twenty  hernia  is  fairly  common  among  boys, 
but  very  rare  among  girls.  The  reason  for  the  tendency  to  cure  is  somewhat 
uncertain.  The  view  advocated  by  Thomas  C.  Martin  is  that,  as  the  pelvis 
broadens,  the  parietal  peritoneum  enlarges.  It  does  this  at  the  expense  of 
the  mesentery,  which  is  shortened,  and  the  internal  abdominal  ring  is  displaced. 
In  a  very  instructive  analysis  of  this  condition  Ochsner  shows  that  in  25  per 
cent,  of  cases  of  hernia  in  childhood  hereditary  weakness  exists;  that  the  con- 
dition is  commoner  among  the  poorer  classes  than  among  the  rich;  that  in  many 
cases  there  is  an  undescended  testicle;  and  that  the  chief  cause  is  an  excess  of 
intra-abdominal  pressure.  This  excess  of  intra-abdominal  pressure  may  result 
from  flatulent  distention  of  the  stomach  and  intestines,  the  product  of  bad 
.feeding;  constipation  and  straining;  straining  on  urinating,  due  to  the  existence 
of  phimosis;  vomiting,  or  cough.  He  thinks  that,  as  a  rule,  indigestion  causes 
flatulence  and  pain;  that  the  child  cries;  that  this  increases  the  pressure;  that 
the  mother  then  feeds  it  in  order  to  keep  it  quiet,  and  that  this  makes  it  worse. 
Strangulation  is  rare  in  childhood. 

A  hernia  may  be  overlooked  in  a  child.  In  childhood  a  hernia  may  make  a 
large  bulge  to-day  and  to-morrow  it  may  have  withdrawn  entirely.  We  cannot 
get  a  young  child  to  cough,  a  lump  may  fail  to  appear  even  when  the  child  strains 
or  cries,  and  hence  a  surgeon  may  deny  the  existence  of  a  hernia  which  has  been 
recently  in  the  scrotum.  Another  curious  fact  is  that  a  hernia  of  a  child,  when 
once  reduced,  may  not  "come  out"  again  for  weeks  or  even  for  months  ("A 
Treatise  on  Rupture/'  by  Jonathan  Macready).  Camper,  much  over  100  years 
ago,  pointed  out  the  difficulty  of  diagnosis  in  children. 

Treatment. — Strangulated  hernias,  irreducible  hernia,  herniae  with  very 
large  rings,  cases  in  which  trusses  fail,  and  cases  associated  with  reducible 
hydrocele  require  operation  (Ochsner).  Most  cases  are  curable  without 
operation,  the  ring  being  guarded  by  a  truss  of  rubber  or  a  pad  of  lamb's  wool. 
Ochsner  believes  that  many  cases  can  be  cured  by  keeping  the  child  recum- 
bent, with  the  foot  of  the  bed  raised,  from  four  to  six  weeks.  If  phimosis 
exists,  it  should  be  operated  upon, -and  any  other  causative  condition  should 
be  treated  (cough,  vomiting,  constipation,  flatulent  indigestion,  etc.).  An 
umbflical  hernia  can  usually  be  cured  by  the  use  of  a  cork.  The  cork  should 
be  I  inch  in  diameter  and  13^4  inches  in  length,  and  shaped  like  a  cone.  The, 
82 


1298 


Diseases  and  Injuries  of  the  Abdomen 


smaller  end  is  pushed  into  the  ring  and  the  cork  is  held  in  place  by  adhesive 
plaster.  In  two  weeks  a  smaller  cork  must  be  used,  and  in  six  or  eight  weeks 
it  can  usually  be  dispensed  with.  Radical  cure  operations  are  seldom  done 
before  the  age  of  four  (see  page  1276). 

Varieties  of  Hernia. — Direct  inguinal  hernicE  comprise  less  than  2  per  cqnt. 
of  cases  of  inguinal  herniae.  In  direct  hernia  the  contents  pass  out  through 
Hesselbach's  triangle  internal  to  the  deep  epigastric  artery.  They  enter 
the  inguinal  canal  low  down,  and  pass  outside  the  conjoined  tendon  or  force 
the  conjoined  tendon  before  them  or  split  through  the  tendon.  They  do  not 
enter  the  scrotum.  The  neck  of  the  sac  is  internal  to  the  deep  epigastric 
artery.     The  protrusion  is  globular  in  shape,  unless  it  emerges  around  the 

edge  of  the  tendon,  in  which  case  it 
is  pear  shaped.  The  coverings  of 
this  hernia,  when  it  passes  external 
to  the  conjoined  tendon,  are  the  same 
as  those  of  an  indirect  inguinal  hernia, 
except  that  the  transversalis  fascia 
instead  of  the  infundibuliform  pro- 
cess of  the  transversalis  fascia  is  one 
of  the  layers.  When  a  direct  hernia 
pushes  before  it  the  conjoined  tendon, 
its  coverings  are  skin,  superficial 
fascia,  intercolumnar  fascia,  con- 
joined tendon,  transversalis  fascia, 
subserous  tissue,  and  peritoneum. 

In  indirect  inguinal  hernia  the  con- 
tents pass  through  the  internal  ab- , 
dominal  ring  external  to  Hesselbach's 
triangle  and  external  to  the  deep  epi- 
gastric artery.  They  pass  down  the 
inguinal  canal  and  emerge  from  the 
external  ring;  and  may  or  may  not 
enter  the  scrotum  or  labium  {scrotal 
or  labial  hernia).  The  protrusion  ia 
pear  shaped.  The  neck  of  the  sac 
is  external  to  the  deep  epigastric 
artery.  Its  coverings  are  skin, 
superficial  fascia,  intercolumnar  fas- 
cia, cremaster  muscle,  infundibuli- 
form fascia,  subserous  tissue,  and 
peritoneum. 

Congenital  inguinal  hernia  is  a 
portion  of  bowel  within  an  unclosed 
vaginal  process.  The  bowel  in  congenital  hernia  has  one  layer  of  peritoneum 
in  front  of  it.  The  testicle  is  posterior  and  below  (Fig.  848,  b).  Always  re- 
member that  bowel  may  not  enter  the  sac  of  a  congenital  hernia  for  several 
months  or  longer  after  birth.  Congenital  hernia  conceals  or  buries  the  testicle; 
acquired  hernia  does  not.  If  a  vaginal  process,  open  above  and  closed  below, 
contains  a  hernia,  the  condition  is  called  hernia  into  the  funicular  process  (Fig. 
848,  c). 

If  the  funicular  process  is  closed  at  the  abdominal  end,  but  not  below,  a 
hernia  in  a  special  sac  may  descend  back  of  the  vaginal  tunic.  This  condi- 
tion is  known  as  infantile  hernia.  In  infantile  hernia  there  are  three  layers 
of  peritoneum  in  front  of  the  bowel — the  two  layers  of  the  vaginal  tunic  and 
the  one  layer  of  sac.     The  testicle  is  in  front  (Fig.  848,  d). 

If  the  tunica  vaginalis  is  closed  above  and  not  below,  and  a  hernia  pushes 


Fig.  848. — a,  Scrotal  hernia;  b,  congenital 
hernia;  c,  funicular  hernia;  d,  infantile  hernia; 
e,  encysted  hernia. 


Varieties  of  Hernia  1299 

down  the  vaginal  process  and  causes  it  to  double  on  itself,  the  condition  is 
known  as  encysted  infantile  hernia  (Fig.  848,  e). 

In  femoral  hernia  the  contents  descend  along  the  femoral  canal  to  the  inner 
side  of  the  vein,  and  the  neck  of  the  sac  is  at  the  femoral  ring.  The  neck  of 
a  femoral  rupture  is  always  external  to  the  pubic  spine;  the  neck  of  an  inguinal 
rupture  is  always  internal  to  the  pubic  spine.  Femoral  hernia  contains  omen- 
tum, but  seldom  intestine,  except  in  strangulated  cases.  It  used  to  be  said 
that  femoral  hernia  was  never  congenital.  Russell  and  Coley  show  that 
it  may  be  (see  page  1273).  Thirty  per  cent,  of  hernise  in  women  are  femoral. 
The  broad  female  pelvis  means  a  large  femoral  ring.  The  coverings  of  a  femoral 
hernia  are  skin,  superficial  fascia,  cribriform  fascia,  crural  sheath,  septum  crurale, 
subserous  tissue,  and  peritoneum. 

Occasionally  a  femoral  hernia  may  pass  in  front  of  the  vessels  {prevascnlar 
femoral  hernia).  Moschcowitz  operated  upon  such  a  case  ("Annals  of  Sur- 
gery," June,  191 2).  A  hernia  may  be  external  to  the  femoral  artery  (Hessel- 
hach's  hernia) ;  may  pass  through  an  opening  in  Gimbernat's  ligament  (Laicgier's 
hernia) ;  may  come  down  alongside  of  the  femoral  vein,  but  instead  of  emerging 
from  the  saphenous  opening  spread  into  thepectineus  muscle  {Cloquefs  hernia). 
Hernia  pectinea  is  beneath  the  pectineal  fascia  and  in  the  pectineal  muscle. 

Umbilical  hernia  may  be  congenital  (the  ventral  plates  having  closed  in- 
completely), infantile  (the  cicatrix  of  the  umbilicus  having  stretched),  or  ac- 
quired. An  acquired  hernia  may  be  through  the  opening  for  the  right  or  left 
umbiKcal  artery,  the  opening  for  the  urachus,  the  opening  for  the  umbilical 
vein,  or  through  the  center  of  the  umbilicus  when  Richet's  fascia  (the  thickened 
layer  of  transversalis  fascia  beneath  the  umbilicus)  is  thinned  or  destroyed 
(Moschcowitz,  in  "Annals  of  Surgery,"  May,  1915).  Far  and  away  the  most 
common  form  of  hernia  is  through  the  opening  for  the  umbiHcal  vein.  It  ap- 
pears at  the  upper  margin  of  the  ring.  Its  coverings  are  skin,  subcutaneous 
fat  only  in  the  upper  part,  thin  superficial  fascia,  thinned  transversalis  fascia 
and  peritoneum.     All  of  these  layers  are  fused  together  (Moschcowitz,  Ibid.). 

Ventral  hernia  is  a  protrusion  through  any  part  of  the  anterior  abdominal 
wall  except  at  the  umbilical  or  inguinal  regions.  A  ventral  hernia  may  be 
median  {hernia  of  the  linea  alba)  or  lateral.     The  treatment  is  radical  operation. 

Epigastric  hernia  is  a  form  of  ventral  hernia.  In  this  condition  there  is 
a  protrusion  of  the  peritoneum  in  the  space  bounded  by  the  ensiform  cartilage, 
the  ribs,  and  the  umbilicus.  The  sac  of  peritoneum  may  be  empty,  may  con- 
tain omentum,  or  omentum  and  bowel.  The  stomach  very  rarely  passes  into 
the  sac.  The  protrusion  is  usually,  but  not  invariably,  through  the  linea  alba. 
The  condition  may  Be  due  to  a  congenital  gap  in  the  transversaHs  fascia  or  to 
the  growth  of  a  fat  hernia.  This  condition  may  cause  abdominal  pain,  epi- 
gastric pain,  nausea  and  vomiting  after  eating  or  effort,  and,  according  to  Farrar 
Cobb  ("Annals  of  Surgery,"  Jan.,  1912),  chronic  diarrhea.  It  is  very  seldom 
strangulated.  In  some  cases  the  omentum  strangulates.  Moschcowitz  reported 
a  case  and  10  cases  in  literature  ("Surgery,  Gynecology  and  Obstetrics,"  1914, 
xix). 

Cecal  hernia  is  very  uncommon  in  women.  It  may  be  either  congenital, 
infantile,  or  acquired.  If  a  vaginal  process  is  open  the  cecum  may  readily 
enter  it,  it  may  be  drawn  in  by  the  plica  vascularis  as  the  testicle  descends 
(Wrisberg),  it  may  be  drawn  in  by  a  descending  testicle,  the  posterior  perito- 
neum over  which  has  formed  adhesions  to  the  cecum.  Most  acquired  cecal 
herniae  are  preceded  and  caused  by  hernia  of  the  small  gut,  but  they  may 
occur  alone.  In  the  simple  form  the  cecum  is  completely  covered  by  a  coat  of 
peritoneum  and  lies  within  the  sac.  Usually  there  is  a  complete  surrounding 
sac,  but  sometimes  the  sac  only  partially  covers  the  cecum  lying  in  front  and  to 
the  inner  side  of  the  bowel.  In  these  cases  the  cecum  is  on  the  posterior  and 
external  aspect  of  the  wall  of  the  sac.     The  appendix  may  be  in  the  sac,  outside 


I300 


Diseases  and  Injuries  of  the  Abdomen 


of  the  sac,  or  part  may  be  within  and  part  without.  If  the  sac  is  incomplete,  it 
means  that  we  have  one  of  the  i8  per  cent,  of  cases  in  which  the  cecum  is  not  com- 
pletely covered  with  peritoneum.  A  cecal  hernia  may  be  and  usually  is  right 
inguinal,  but  may  be  right  femoral,  left  inguinal,  or  left  femoral.  It  is  most 
common  in  advanced  life  and  is  frequently  irreducible. 

Hernia  of  the  appendix  may  occur  alone,  and  Merigot  de  Treigney  collected 
22  cases  of  it  ("These  de  Paris,"  1887).  In  17  the  hernia  was  inguinal;  in  5 
it  was  femoral.  I  operated  upon  a  case  of  appendicitis  in  which  the  inflamed 
appendix  was  the  sole  occupant  of  an  incomplete  right  inguinal  hernia  sac.  In 
some  cases  the  appendix  accompanies  the  cecum  into  a  hernia. 

Adherent  hernia  of  the  large  intestine  {sliding  hernia)  is  a  condition  first 
described  by  Scarpa,  in  which  the  sac  of  a  right-sided  hernia  contains  ascending 
colon;  of  a  left-sided  hernia,  descending  colon.  The  sac  is  complete  on  the  ante- 
rior, but  apparently  absent  on  the  posterolateral  aspect,  where  the  bowel  seems 

as  though  fused  to  it.  This  con- 
dition has  often  been  called  "hernia 
with  incomplete  sac."  A  commonly 
accepted   theory   is   that  because  of 


Fig.  849. — The    large    intestine   behind   the 
peritoneum   (Weir). 


Connectwe  t/ssue 
Fig.  850. — The  retroperitoneal  large  intes- 
tine in  a  cross-section  of  the  hernia  with  its 
incomplete  sac  (Weir). 


looseness  of  the  peritoneum  of  the  iliac  region  a  portion  of  the  large  bowel  slides 
into  the  hernia.  In  such  a  case  the  posterolateral  aspect  of  the  sac  is  absent 
(Figs.  849  and  850) .  In  a  right-sided  condition  the  descending  bowel  carries  with 
it  into  the  scrotum  a  fold  of  loosened  peritoneum,  just  as  in  the  descent  of  the 
testis  (Weir,  in  "Med.  Record,"  Feb.  24,  1900).  Sliding  hernia  of  the  ascend- 
ing colon  is  wrongly  called  sliding  hernia  of  the  cecum.  In  most  cases  of  slid- 
ing hernia  of  the  left  side  the  descending  colon  is  dragged  into  a  preexisting 
hernia  sac  containing  small  bowel,  omentum,  or  both.  The  large  bowel  is 
covered  with  peritoneum  except  posteriorly,  where  the  mesocolon  is  attached. 
This  form  is  nearly  always  irreducible  and  occurs  particularly  in  elderly  men. 
In  another  group  of  cases  the  large  bowel  makes  a  direct  inguinal  hernia  and 
the  sac  is  limited  to  the  anterior  surface  of  the  protruded  gut. 

In  this  edition  I  have  adopted  the  name  "adherent  hernia"  instead  of 
"sliding  hernia."  L.  J.  Ransohoff  ("Annals  of  Surgery,"  August,  1912)  seems 
to  demonstrate  that  the  condition  is  not  due  to  sUding  of  the  peritoneum,  and 
hence  is  not  a  sliding  hernia;  that  an  incomplete  sac  is  a  secondary  process,  the 
sac  having  been  complete  in  its  incipiency,  but  obliterated  posteriorly  "by 
secondary  adhesions  of  the  embryonic  type."  The  immobile  loop  of  intestine 
in  the  sac  has  been  originally  mobile;  "the  hernia  is  primary,  the  adhesions  sec- 
ondary" (Ransohoff,  "Annals  of  Surgery,"  Aug.,  191 2). 

In  properitoneal  hernia  the  sac  is  between  the  peritoneum  and  transversalis 
fascia.  This  form  of  hernia  is  sometimes  produced  by  making  taxis  on  an 
inguinal  hernia,  when  the  internal  ring  is  small  or  is  blocked  by  an  undescended 


Littre's  Hernia  1301 

testicle.  In  properitoneal  inguinal  hernia,  which  is  the  most  common  form, 
there  are  two  sacs,  one  in  the  scrotum,  the  other  parallel  with  Poupart's  liga- 
ment, and  as  one  sac  is  emptied,  the  other  distends  (Breiter,  of  Zurich). 

In  interstitial  or  interparietal  inguinal  hernia  the  hernia  sac  is  between  the 
transversalis  muscle  and  fascia,  or  between  the  external  and  internal  oblique 
muscles,  or  in  the  midst  of  the  fibers  of  the  internal  obUque  muscle,  or  be- 
tween the  external  oblique  muscle  and  the  transversalis  fascia,  the  internal 
oblique  and  transversalis  muscles  being  pushed  aside  (Sultan's  "Atlas  of  Ab- 
dominal Hernias"). 

In  superficial  inguinal  hernia  the  sac  is  between  the  aponeurosis  of  the  ex- 
ternal oblique  muscle  and  the  superficial  fascia.  This  variety  of  hernia  is 
always  congenital  and  the  testicle  is  invariably  misplaced. 

Obturator  hernia  passes  through  the  obturator  membrane  or  the  obturator 
canal,  and  is  felt  below  the  horizontal  ramus  of  the  pubes,  internal  to  the  femoral 
vessels.     The  obturator  nerve  is  pressed  upon  and  pain  arises  in  its  trajectory. 

Lumbar  hernia  is  a  very  rare  condition.  It  may  be  congenital,  traumatic, 
or  spontaneous,  and  may  follow  a  lumbar  abscess.  Braacz  collected  68  cases. 
It  occurs  through  the  triangle  of  Petit,  or  just  below  the  twelfth  rib  through 
the  superior  lumbar  triangle,  or  through  a  congenital  defect  in  the  aponeurosis 
of  the  latissimus  dorsi  muscle,  or  through  a  defect  near  the  triangle  of  Petit 
(Dowd,  in  "Annals  of  Surgery,"  Feb.,  1907).  A  lumbar  hernia  may  be  present 
at  the  edge  of  or  through  the  quadra tus  lumborum  muscles.  In  1738  Ravaton 
operated  upon  a  strangulated  lumbar  hernia. 

The  triangle  of  Petit  is  bounded  in  front  by  the  external  oblique,  behind  by 
the  latissimus  dorsi,  below  by  the  iliac  crest,  and  its  floor  is  formed  by  the 
internal  oblique.  The  superior  lumbar  triangle  (of  Grynfelt  and  Lesshaft)  is 
bounded  anteriorly  by  the  external  oblique,  posteriorly  by  the  iliocostal  muscle, 
above  by  the  serratus  posticus  inferior  and  the  end  of  the  twelfth  rib,  and  below 
by  the  internal  oblique.     The  latissimus  dorsi  overlies  it. 

Sciatic  or  gluteal  hernia  passes  through  the  great  sacrosciatic  foramen,  above 
or  below  the  pyriformis  muscle,  or  through  the  lesser  sacrosciatic  foramen. 

Pudenal  hernia  protrudes  into  the  lower  part  of  the  labium,  the  bowel  hav- 
ing descended  between  the  ischial  ramus  and  the  vagina. 

Perineal  hernia  presents  in  the  perineum,  between  the  rectum  and  the  pros- 
tate gland  or  between  the  rectum  and  the  vagina. 

Internal,  retroperitoneal,  or  intra-abdominal  hernia  include  hernia  into  the 
foramen  of  Winslow,  hernia  into  the  retroduodenal  fosses,  the  retrocecal  fossce, 
and  the  inter  sigmoid  fossa  (see  page  1 115),  and  hernia  into  the  lesser  peritoneal 
cavity  through  a  sht  in  the  transverse  mesocolon. 

Vaginal  hernia  is  associated  with  uterine  prolapse  or  ensues  upon  destruc- 
tion of  the  vaginal  wall. 

Richter's  hernia  (partial  enterocele  or  hernia  of  the  intestinal  wall,  Fig.  851, 
a)  was  described  by  Richter  in  1778.  He  called  it  "the  small  rupture."  It 
occurs  in  adults  only  and  is  most  common  in  women.  It  is  the  catching  of  a  por- 
tion of  the  circumference  of  the  bowel,  usually  a  portion  of  the  lower  part  of 
the  ileum.  It  is  usually  femoral,  but  may  be  inguinal,  and  even  epigastric  or 
obturator.  It  arises  usually  in  an  old,  reducible  hernia  (Royal  Hamilton  Fowler, 
"Am.  Jour.  Surg.,"  Jan.,  191 2).  Some  cases  are  due  to  adhesions.  It  may 
be  due  to  truss  pressure  on  an  incompletely  reduced  hernia  (Fowler,  Ibid.). 
Strangulation  of  a  partial  enterocele  may  not  completely  close  the  lumen  of  the 
gut.  There  may  not  be  stercoraceous  vomiting  or  absolute  constipation,  and 
the  protrusion  is  barely  perceptible  or  cannot  be  palpated. 

Littre's  hernia  is  hernia  of  Meckel's  diverticulum  (Fig.  851,  b).  It  was 
described  by  Littre  in  1700.  This  diverticulum  is  the  persistent  vitelline  duct 
and  comes  off  from  the  ileum  from  12  to  36  inches  above  the  ileocecal  valve. 
It  arises  from  the  convex  side  of  the  gut  and  rarely  has  a  mesentery  (see  pages 
iiiSand  1122). 


1302 


Diseases  and  Injuries  of  the  Abdomen 


Rokitansky's  diverticular  herniae  arc  due  to  separation  of  the  muscular 
fibers  of  the  bowel,  permitting  the  sacculation  of  mucous  membrane  and  peri- 
toneum. These  false  diverticula  may  be  no  larger  than  peas  or  may  be  larger 
than  walnuts,  and  there  may  be  scores  of  them  in  one  patient.  They  may  pro- 
duce no  symptoms  or  may  lead  to  peritonitis,  abscess  about  the  bowel,  perfora- 
tion, or  to  symptoms  of  intestinal  obstruction. 

Hernia  of  the  Bladder. — This  is  a  protrusion  of  a  portion  of  the  bladder 
wall  through  a  hernial  opening.  Eggenberger  adds  no  cases  to  Brunner's  182 
cases,  a  total  of  292  cases  ("Deutsch.  Zeitschr.  f.  Chir.,"  Oct.,  1908).     Most 

'-^Si  cases  are  instances  of  false 

A  hernia,  there  being  no  sac 
of  peritoneum.  The  pro- 
trusion may  or  may  not  be 
covered  with  peritoneum, 
and  in  most  cases  it  is  not 
so  covered,  but  lies  by  the 
side  of  a  hernial  sac  and  not 
inside  of  it.  Brunner's  table 
shows  only  5  cases  of  true 
bladder  hernia,  that  is,  of  in- 
traperitoneal hernia.  It  is 
most  frequently  met  with  in 
the  inguinal  region.  Brun- 
ner  describes  three  forms: 
(i)  Entirely  without  a  peri- 
toneal covering  (extraperito- 
neal) ;  (2)  partly  covered  with 
peritoneum  (paraperitoneal 
— the  commonest  form);  (3) 
completely  covered  with 
peritoneum  (intraperito- 
neal). The  bladder  may 
constitute  the  hernia,  or 
there  may  be  an  ordinary 
hernia  and  also  a  cystocele. 
In  an  inguinal  hernia  the 
bladder  will  be  internal  and 
somewhat  behind  the  other 
constituent  parts  of  the 
protrusion.  Hernia  of  the 
bladder  is  much  more  com- 
mon in  men  than  in  women. 
A  hernia  of  the  bladder 
may  become  strangulated. 
In  some  cases  a  diagnosis  of 
hernia  of  the  bladder  can  be  made  by  the  fact  that  the  protrusion  lessens  in 
size  when  the  patient  micturates,  and  increases  in  size  as  urine  gathers  or  when 
the  bladder  is  injected  with  fluid.  The  treatment  should  be  operative.  When 
the  bladder  is  exposed  it  is  replaced  if  possible  without  resection. 

Diaphragmatic  Hernia. — The  majority  of  cases  are  congenital  and  in  90 
per  cent,  of  them  there  is  no  sac.  The  hernia  may  pass  through  a  natural 
opening  or  through  a  gap  due  to  congenital  defect.  The  hernia  is  most  com- 
mon on  the  left  side,  and  the  stomach  is  the  organ  which  is  most  often  found  in 
the  hernia,  but  the  colon,  the  omentum,  the  small  intestine,  the  spleen,  liver, 
duodenum,  cecum,  pancreas,  or  kidney  may  be  found  (Cranwell,  "Rev.  de 
Chir.,"   1908,  No.   i).     Violent  traumatism  may  be  the  cause.     When  the 


Fig.  851. — A,  Diagrammatic  representation  of  Richter's 
hernia  of  intestinal  wall.  B,  Diagrammatic  representation 
of  Littre's  hernia,  which  is  a  hernia  of  Meckel's  diverti- 
culum (Sultan). 


Hernia  of  the  Uterus  1303 

stomach  passes  suddenly  through  the  left  side  of  the  diaphragm  there  will 
be  dyspnea,  cyanosis,  displacement  of  the  heart  to  the  right,  pain  in  the  upper 
abdomen,  thirst,  and  in  most  cases  rapid  death.  When  the  stomach  or  in- 
testine has  entered  the  left  side  of  the  thorax,  there  is  a  tympanitic  note  on 
percussing  over  that  area  of  the  thorax,  the  heart  is  displaced  to  the  right,  and 
the  side  of  the  chest  is  unduly  prominent.  The  upper  border  of  the  tympanitic 
area  does  not  move  with  respiration.  There  are  no  breath  sounds  audible  over 
the  tympanitic  area,  but  gurgling  is  heard.  In  250  cases  of  traumatic  dia- 
phragmatic hernia  collected  by  Leichtenstern  the  diagnosis  was  made  before 
death  in  but  5  cases.  The  :r-rays  are  of  value  in  diagnosis,  especially  if  the 
stomach  is  in  the  hernia.  Strangulation  of  a  diaphragmatic  hernia  produces 
severe  pain  in  the  upper  abdomen,  violent  vomiting^  constipation,  boat-shaped 
abdomen,  great  thirst,  rapid  wasting,  and  the  excretion  of  a  very  small  amount 
of  urea  (Mackenzie  and  Battle,  ''Lancet,"  Dec.  7,  1901).  Diaphragmatic 
hernia  may  be  confused  with  eventration  of  the  diaphragm,  an  unnaturally 
high  position  of  the  left  half  of  the  diaphragm,  with  ascent  of  the  viscera  of  the 
abdomen,  especially  the  stomach.  It  was  first  described  by  Petit  in  1790. 
Sailer  and  Rhein  reported  a  case  and  collected  12  others  ("Am.  Jour.  Med. 
Sciences,"  April,  1905).  J.  D.  S.  Davis  reported  5  cases  ("Trans.  Southern 
Surgical  and  Gynecological  Assoc,"  Dec,  1914).  The  physical  signs  of  even- 
tration are  practically  identical  with  those  of  diapTiragmatic  hernia,  except  that 
in  the  former  the  upper  border  of  the  tympany  moves  on  respiration. 

Treatment. — Open  the  belly  for  exploration.  If  a  hernia  be  found,  return  it 
to  the  abdomen;  open  the  chest  and  suture  the  diaphragm  from  above  (trans- 
pleural suturing).  Mackenzie  and  Battle,  Mikulicz,  Humbert,  and  others 
have  operated  for  this  condition. 

Hernia  of  the  Ovary. — The  ovary,  because  of  failure  of  descent,  may  re- 
main in  the  lumbar  region.  It  may  pass  into  the  inguinal  canal  or  labium 
majus  (inguinal  hernia);  into  the  gluteal  region  (gluteal  hernia);  into  the  region 
of  the  obturator  foramen  (obturator  hernia);  or  into  the  front  of  the  abdomen 
(ventral  hernia).  In  congenital  inguinal  hernia  there  may  be  ovary  alone, 
or  ovary,  tube,  omentum,  and  even  part  of  a  bicornate  uterus  (Garrigues). 
It  is  impossible  to  restore  a  congenital  hernia.  Acquired  hernia  may  follow  a 
fall  and  sometimes  it  can  be  restored.  A  femoral  or  crural  ovarian  hernia,  a 
condition  in  which  the  ovary  passes  to  the  front  of  the  thigh  below  Poupart's 
ligament,  is  never  congenital.  In  some  cases  a  herniated  ovary  can  be  re- 
turned within  the  abdomen.     Any  herniated  ovary  may  inflame. 

Treatment. — If  the  ovary  can  be  restored,  a  truss  will  probably  retain  it, 
but  even  in  such  a  case  operative  cure  is  better.  If  it  cannot  be  restored  or 
if  it  is  painful  or  undesirable  to  wear  a  truss,  operation  must  be  done.  Ex- 
pose the  ovary,  return  it  to  the  belly  if  healthy,  and  do  a  radical  cure  of  the 
hernia.     In  some  conditions  of  disease  remove  the  ovary. 

Hernia  of  the  Uterus. — This  condition  is  a  surgical  curiosity,  but  a  few 
cases  have  been  reported  (John  Howard  Jopson's  case  in  "Annals  of  Sur- 
gery," July,  1904).  The  hernia  may  be  umbilical,  ventral,  inguinal,  or  fem- 
oral. Hernia  of  the  unimpregnated  womb  may  be  congenital  or  acquired; 
impregnation  may  occur  when  the  uterus  is  herniated,  or  an  impregnated 
uterus  may  pass  into  a  preexisting  hernia  sac.  If  a  herniated  uterus  becomes 
impregnated  or  if  an  impregnated  uterus  becomes  herniated,  pregnancy  may 
go  on  to  term.  Multiple  pregnancies  predispose  to  uterine  hernia.  Ovarian 
hernia  may  precede  uterine  hernia,  or  hernia  of  omentum  adherent  to  the 
uterus  may  pull  that  organ  into  the  sac.  In  many  cases  congenital  anom- 
alies have  been  found  to  exist  (bicornate  uterus,  rudimentary  uterus,  shortness 
of  the  round  ligament,  imperforate  vagina,  etc.).  A  hernia  of  the  uterus  en- 
larges and  becomes  painful  during  menstruation,  and  a  vaginal  examination 
shows  that  the  uterus  is  absent  from  its  normal  position  and  that  the  direction 


1304  Diseases  and  Injuries  of  the  Rectum  and  Anus 

of  the  cervix  and  vagina  are  abnormal  (Jopson,  Ibid).  A  uterine  sound  can- 
not be  passed  at  all  or  can  be  passed  with  great  difficulty.  The  hernia  is  hard 
and  probably  pyriform.  If  impregnation  occurs,  there  are  the  ordinary  signs 
of  pregnancy  and  progressive  enlargement  of  the  hernia. 

Treatment. — Expose  the  mass  by  incision.  If  conditions  justify  such  a 
course,  return  the  uterus  and  adnexa,  if  they  be  present  (one  or  both  ovaries 
and  tubes  may  be  present),  to  the  abdomen  and  do  a  radical  cure.  If  the  uterus 
be  infected,  remove  it.  Jopson  in  his  case  removed  the  uterus  and  right  ovary 
and  fastened  the  uterine  stump  into  the  wound. 


XXIX.   DISEASES  AND    INJURIES  OF  THE  RECTUM  AND  ANUS 

Teratoids    and     Dermoids     in    the    Sacrococcygeal     Region. — In 

the  sacrococcygeal  region  there  are  many  opportunities  for  developmental 
error.  In  this  region  the  caudal  end  of  the  primitive  streak  must  undergo 
evolution  and  involution,  the  neurenteric  canal  must  form  and  disappear,  the 
anus  must  be  formed,  the  posterior  fissure  must  close,  the  sacrum  and  coccyx 
must  develop,  and  various  other  processes  must  go  on  correctly  and  uniformly 
if  complete  development  is  to  be  obtained.  As  Coplin  puts  it:  "Perfect 
evolution  of  the  tissues  embraced  in  this  part  of  the  body  is  beset  by  many 
narrow  escapes"  ("Publications  from  the  Laboratories  of  Jefferson  Med. 
College  Hospital,"  1906,  vol.  iii).  Fissures  and  clefts  may  fail  to  close,  frag- 
ments from  one  blastodermic  layer  may  be  lodged  in  another  layer,  groups  of 
cells  may  be  sequestered,  closing  clefts  may  include  tissue  elements,  and  parts 
that  should  normally  atrophy  may  do  so  late  or  not  at  all. 

In  order  to  understand  teratomata  and  dermoids  arising  in  the  rectal  region 
we  must  recall  some  facts  of  development. 

Early  in  embryonic  life  the  central  canal  of  the  spinal  cord  and  the  ali- 
mentary canal  are  continuous  around  the  caudal  end  of  the  notochord  by 
a  communicating  path  called  the  neurenteric  canal. 

When  the  anal  pit  undergoes  invagination  it  meets  the  gut  considerably 
in  front  of  the  region  where  the  neurenteric  canal  joins  the  gut.  The  portion  of 
intestine  between  the  anus  and  the  opening  of  the  neurenteric  canal  is  called 
the  postanal  gut.  The  postanal  gut  disappears  during  normal  development. 
If  it  persists  it  causes  tumor  formation. 

The  congenital  tumors  of  the  sacrococcygeal  region  are:  (i)  Tumors  of  the 
postanal  gut;  (2)  dermoids  back  of  the  rectum;  (3)  rectal  dermoids. 

According  to  Bland-Sutton,  tumors  of  the  postanal  gut  "are  composed  of 
closed  vesicles  lined  with  glandular  epithelium  and  contain  glue-like  fluid" 
("Tumors,  Innocent  and  Malignant,"  by  Sir  J.  Bland-Sutton).  These  tumors 
grow  to  a  large  size. 

Dermoids  back  of  the  rectum  often  contain  teeth,  may  attain  large  size, 
are  apt  to  mount  up  behind  the  peritoneum,  and  may  rupture  and  form  a  fistula. 
I  helped  Prof.  Keen  operate  on  such  a  case.  The  skin  over  the  mass  showed 
a  growth  of  hair,  there  was  a  gap  or  cleft  in  the  sacrum,  and  through  this  there 
was  a  clear  passage  from  the  rectum  to  the  skin.  This  sinus  closely  resem"  led 
the  trachea  in  structure. 

Dermoids  occasionally  grow  from  the  mucous  membrane  of  the  rectum  and 
are  apt  to  contain  an  abundant  growth  of  hair. 

Examination  of  the  Anus  and  Rectum. — There  are  four  positions  in 
which  we  may  place  the  patient  for  rectal  examination,  the  one  to  be  selected 
depending  upon  the  probable  local  difficulty.  These  positions  are  the  left 
lateral  prone,  the  knee-chest,  the  exaggerated  lithotomy,  and  the  squatting 
position.     The  knee-chest  position  is  desirable  if  the  sigmoidoscope  is  to  be 


Examination  of  the  Anus  and  Rectum 


1305 


used.  A  commonly  employed  position  is  the  left  lateral  prone  position  of  Sims, 
in  which  the  patient  lies  on  the  left  side,  the  chest  on  the  table,  the  left  arm  be- 
hind the  back,  the  knees  drawn  up,  and  the  pelvis  elevated  on  a  hard  pillow. 

\'ery  stout  people  should  be  placed  in  the  kncc-chest  position  or  exaggerated 
lithotomy  position,  as  the  rectum  cannot  be  seen  when  they  lie  on  the  side. 

A  squatting  position,  when  the  patient  is  placed  as  though  on  a  commode, 
is  best  adapted  to  cases  of  prolapse  and  hemorrhoids.  It  is  also  used  to  bring 
within  the  range  of  the  finger  strictures  or  new  growths  that  in  the  other  attitudes 
would  be  beyond  digital  reach. 

Sometimes  the  surgeon  is  able  to  pass  a  sigmoidoscope  upon  a  patient  in  the 
exaggerated  lithotomy  position  when  it  has  been  found  impossible  to  carry  the 
instrument  high  enough  with  the  patient  in  any  other  position. 

While  making  a  rectal  examination  the  patient  should  have  no  constriction 
about  the  abdomen,  such  as  corsets,  bandages,  or  tight  clothing. 

It  is  important  that  the  first  examination  be  made  when  no  cathartics  or 
enemata  have  been  administered,  so  that  the  condition  of  the  excretions  and 
secretions  may  be  noted.  By  such  first  examination  pus,  blood,  mucus,  or 
inspissated  fecal  matter  if  present  may  be  seen,  and  from  their  varying  char- 
acteristics, quantities,  and  locations  inferences  as  to  causation  may  be  drawn. 
After  these  observations  have 
been  made  an  enema  should 
be  given  and  the  anus  and 
rectum  be  well  cleansed. 
When  the  parts  have  been 
cleaned  and  the  bowel  washed 
out  the  anus  is  carefully  in- 
spected, the  anal  folds  being 
opened  during  the  process. 
By  inspection  the  surgeon 
can  notice  the  external  open- 
ing of  a  fistula,  external  piles, 
protruding  internal  piles, 
mixed  piles,  pruritus,  dis- 
charge from  the  rectum, 
eczema,  fissure,  tumor,  ulcer, 
condylomata,  abscess, 
whether  or  not  the  anus  is 
retracted  and  funnel-shaped 
or  protruding,  or  if  there  be 
parasites  on  the  anal  hairs. 

Next  the  thumbs  should  be  placed  on  either  side  of  the  anus  and  gently 
separated;  this  maneuver,  aided  by  a  bearing  down  effort  on  the  part  of  the 
patient,  will  often  cause  piles  to  protrude,  exhibit  fissures  and  polypi,  and  reveal 
the  condition  of  the  mucocutaneous  border. 

Next,  a  digital  examination  of  the  rectum  is  made.  The  nail  of  the  index- 
finger  is  filled  with  soap  and  the  finger  is  oiled  or,  better,  is  covered  with  a 
rubber  finger-tip  which  is  oiled.  The  digit  is  gently  inserted  through  the 
sphincter,  the  patient  being  asked  to  strain  lightly  during  its  insertion.  The 
finger  is  inserted  with  a  gentle  boring  motion  and  is  pointed  toward  the  um- 
bilicus until  the  sphincter  is  passed.  A  digital  examination  enables  the  sur- 
geon to  detect  an  ulcer,  a  polypus,  a  tumor,  a  stricture,  and  to  determine 
certain  points  regarding  the  condition  of  the  prostate  in  the  male  and  the 
uterus  in  the  female.  Non-indurated  piles  cannot  be  detected  by  the  finger. 
A  speculum  will  be  needed  to  discover  them  if  they  are  not  protruding. 

Next,  in  some  cases,  the  rectum  must  be  examined  by  means  of  a  specu- 
lum.    It  is  not  often  necessary'  to  give  ether.     ]\Iathews's  speculum  (Fig.  852) 


Fig.  85  2. — ^lathews's  self -retaining  rectal  speculum. 


i3o6 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


is  very  serviceable.  Sims's  duck-bill  speculum  is  a  valuable  instrument  for 
certain  cases.  The  speculum  is  warmed,  oiled,  and  slowly  introduced.  It  is 
first  directed  toward  the  umbilicus,  and  when  it  passes  the  sphincter  its  direc- 
tion is  gradually  altered  until  it  is  toward  the  promontory  of  the  sacrum. 
Illumination  is  obtained  by  direct  sunlight  or  by  a  forehead  mirror  and  an 
electric  light.  This  examination  will  extend,  confirm,  or  disprove  the  findings 
of  the  digital  examination;  ulcers,  hemorrhoids,  and  malignant  growths  can  be 


Fig.  853. — Brinkerhoff's  speculum. 

carefully  examined,  and  the  condition  of  the  rectal  mucous  membrane  can  be 
thoroughly  investigated. 

Marion  Sims  in  1845  demonstrated  the  ballooning  of  the  vagina  by  atmos- 
pheric pressure,  and  in  1870  Van  Buren  applied  this  method  to  the  rectum. 
Kelly  in  1895  put  forth  his  straight  tubes  and  described  in  detail  the  methods 
and  advantages  of  examination  by  them,  and  the  great  diagnostic  value  of 
ballooning  the  rect-um.  Kelly's  method  of  examination  is  shown  in  Fig.  856. 
The  tubes  are  shown  in  Fig.  857.  It  is  not  necessary  to  give  ether.  The 
patient  is  placed  in  the  knee-chest  position.     A  tube  containing   an    obtu- 


FiG.  854. — Martin's  speculum. 

rator  is  well  greased  with  vaselin.  "The  buttocks  are  drawn  apart,  and  the 
blunt  end  of  the  obturator  is  laid  on  the  anus,  which  is  also  coated  with  vaselin. 
The  direction  of  the  instrument  should  be  first  downward  and  forward,  and, 
when  the  sphincter  is  well  passed,  up  under  the  sacral  promontory.  The  moment 
the  speculum  clears  the  sphincter  ani  and  the  obturator  is  withdrawn,  air 
rushes  in  audibly  and  distends  the  bowel."  When  the  entering  instrument  is 
pressed  gently  against  the  sphincter  a  sharp  muscular  contraction  ensues.  If 
the  instrument  is  gently  and  slightly  withdrawn,  relaxation  occurs,  and  the 


Examination  of  the  Anus  and  Rectum 


1307 


moment  of  relaxation  may  be  seized  to  make  an  entry.  An  entry  so  made  is 
rapid  and  unresisted.  The  bowel  being  distended  with  air,  the  mucous  mem- 
brane is  plainly  seen  as  the  tube  is  slowly  withdrawn  and  the  electric  light  is 
reflected  into  the  speculum  by  a  forehead  mirror.     The  normal  mucous  mem- 


FiG.  855. — Cook's  operating  speculum. 

brane  is  dull  red,  like  the  nasal  mucosa,  and  the  blood-vessels  are  plainly  dis- 
tinguishable. The  Kelly  tube  must  be  used  with  great  care,  as  harm  may  be 
done  by  it,  and  the  longest  tube  should  be  used  in  exceptional  cases  only. 


Fig.  856. — Examination  of  the  rectum  by  reflected  light  (Kelly). 

I  use  with  the  greatest  satisfaction  James  P.  Tuttle's  pneumatic  proc- 
toscope (Fig.  858).  Dr.  Tuttle  describes  it  as  follows  ("Diseases  of  the  Anus, 
Rectum,  and  Colon"):  "This  instrument  is  composed  of  a  large  cylinder  (/), 


^o8 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


into  one  part  of  the  circumference  of  which  is  fitted  a  small  metaUic  tube  closed 
by  a  flint-glass  bulb  at  its  distal  end.     The  electric  lamp  {d)  is  fitted  upon  a 


Fig.  857. — Kelly's  rectal  specula. 


long  metallic  stem,  and  carried  through  the  small  cylinder  to  the  end  of  the 
instrument,  as  shown  in  the  illustration.     The  proctoscope  is  introduced  through 

the  anus  with  the  obturator  (a) 
in  position.  As  soon  as  the  in- 
ternal sphincter  is  passed  this 
obturator  is  withdrawn  and  the 
bayonet-fitting  plug  (b),  which 
contains  either  a  plain  glass 
window  or  a  lens  focused  to  the 
length  of  the  instrument  to  be 
used,  is  inserted  in  the  proximal 
end  of  the  instrument.  This 
plug  is  ground  to  fit  air-tight 
and  thus  closes  the  instrument 
perfectly.  The  plug  being  in- 
serted in  the  tube,  a  very  slight 
pressure  upon  the  hand-bulb 
will  cause  inflation  of  the  rectal 
ampulla  to  such  an  extent  that 
the  whole  rectum  can  be  ob- 
served and  the  instrument  can 
be  carried  up  to  the  promontory 
of  the  sacrum  without  coming 
in  contact  with  the  rectal  wall. 
Further  dilatation  will  show  the 
direction  of  the  canal  leading 
into  the  sigmoid,  and,  by  a  little 
care  in  manipulating  the  instru- 
ment and  keeping  the  gut  well 
dilated  in  advance,  it  can  be  carried  up  into  this  portion  of  the  intestine  without 
the  least  traumatism  of  the  parts.  If  any  fecal  matter  obscures  the  light  by 
being  massed  or  smeared  over  the  glass  bulb,  the  plug  can  be  removed,  and  a 


Fig.  858. — Tuttle's  pneumatic  proctoscope:  a, 
Obturator;  b,  plug  with  glass  window  closing  end 
of  tube;  c,  handle;  d,  cords  connecting  instrument  with 
battery;  e,  inflating  apparatus;  /,  main  tube  of  proc- 
toscope. 


Foreign  Bodies  in  the  Rectum 


1309 


pledget  of  cotton,  introduced  with  a  long  dressing  forceps,  will  wipe  this  off,  so 
that  the  plug  can  be  reintroduced  and  the  examination  continued  with  very 
slight  delay  or  inconvenience.  The  adjustable  handle  (c)  fits  on  the  rim  of  the 
instrument  and  thus  converts  it  into  a  Kelly  tube.  This  instrument  is  oper- 
ated with  an  ordinary  dry  battery  of  four  cells.  It  is  better,  however,  to 
have  a  battery  with  six  cells,  as  it  will  not  require  being  recharged  so  fre- 
quently." All  the  air  must  be  allowed  to«escape  before  the  instrument  is  with- 
drawn, otherwise  colic  may  develop. 

If  an  anesthetized  patient  is  placed  in  the  knee-chest  position,  the  sphincter 
can  be  stretched  by  the  fingers,  and  the  rectum  will  distend  with  air  and  can 
be  easily  examined.  The  fingers  are  introduced  as  suggested  by  Martin  (Fig. 
859)  and  the  rectum  becomes  visible  when  they  are  separated  (Fig.  860). 

Passage  of  Rectal  Tubes. — Some  have  asserted  that  soft  tubes  can  be 
passed  from  the  anus  through  the  sigmoid.  I  do  not  believe  this  can  be  done 
in  a  normal  rectum,  it  matters  not  in  what  position  the  patient  is  placed,  and 
whether  or  not  fluid  flows  from  the  tube  during  its  introduction.     A  soft  tube 


Fig.  859.  Fig.  860, 

Figs.  859,  860. — A  new  and  simple  method  of  proctoscopy  (Thomas  C.  Martin). 

always  coils  up  after  it  has  ascended  6  or  7  inches.  In  a  number  of  laparot- 
omies, desiring  to  locate  the  rectum,  I  have  had  an  assistant  pass  a  rubber  tube. 
It. would  never  ascend  above  the  rectal  dome  unless  I  aided  it  with  a  hand  in 
the  belly,  when  it  could  be  passed  through  the  sigmoid.  Fortunately  it  is  not 
necessary  to  give  high  enemas,  as  fluid  introduced  into  the  rectum  is  carried 
back  to  the  sigmoid.  If  we  wish  fluid  retained,  attempts  to  pass  the  tube  high 
up  will  cause  irritation,  and  irritation  will  lead  to  expulsion. 

Foreign  Bodies  in  the  Rectum. — It  is  not  at  all  unusual  for  hard,  un- 
digested articles  taken  with  the  food  to  lodge  in  the  rectum.  They  can  usually 
be  removed  through  a  speculum  by  means  of  forceps.  In  some  cases  ether 
must  be  given  and  the  sphincter  stretched;  in  others,  the  sphincter  must  be 
divided.  Sometimes  large  bodies  are  voluntarily  inserted  and  the  individual 
is  unable  to  remove  them.  Lewis  H.  Adler  ("Am.  Med.,"  July  20,  1901) 
removed  the  valve  of  a  steam  radiator  pipe  from  the  rectum.  The  small 
end  was  i3^^  inches  in  diameter;  the  large  end  was  2^^  inches  in  diameter. 
The  patient  had  been  in  the  habit  of  introducing  it  frequently  and  removing  it 
with  a  hook  of  galvanized  iron  wire.  A.  Marmaduke  Sheild  ("Lancet,"  Oct. 
12,  1 901)  reports  the  case  of  a  man  sixty  years  of  age  who  forced  a  gallipot  into 


13 1 o  Diseases  and  Injuries  of  the  Rectum  and  Anus 

the  rectum.  The  pot  was  2)2  inches  in  diameter  and  2^4  inches  in  height.  The 
patient  broke  it  trying  to  get  it  out.  Sheild  incised  the  sphincter  from  behind 
and  removed  the  article  by  means  of  obstetric  forceps. 

If  the  foreign  body  be  soft,  as  an  apple  or  a  potato,  a  hole  should  be  bored 
through  to  allow  the  air  to  pass  and  thus  relieve  the  suction.  It  can  then  be 
lifted  out.  If  the  body  be  of  wood,  screw  in  a  gimlet;  if  of  metal,  cut  with  strong 
forceps;  if  of  glass,  remove  as  Sheild  did  the  gallipot.  If  the  article  be  rough  or 
has  sharp  edges,  pack  gauze  all  around  it  as  a  first  step  to  protect  the  rectal  walls. 
In  a  case  in  which  a  boar's  tail  had  been  introduced,  large  end  first,  the  holding 
back  of  the  bristles  was  overcome  by  sliding  over  it  a  large-sized  rubber  catheter. 

Foreign  bodies  may  escape  into  the  sigmoid  and  necessitate  a  laparotomy. 
They  may  also  cause  periproctic  inflammation. 

A  remarkable  series  of  cases  of  foreign  bodies  in  the  rectum  may  be  found 
in  "Anomalies  and  Curiosities  of  Medicine,"  bv  George  M.  Gould  and  Walter 
L.  Pyle. 

Wounds  and  Injuries  of  the  Rectum. ^ — These  accidents  may  result 
from  fractures  of  the  pelvis,  most  often  from  fractures  of  the  sacrum,  from  the 
improper  use  of  enema  syringe  nozzles  or  tips,  from  gunshot-wounds,  stab- 
wounds,  foreign  bodies  introduced  by  the  patient,  and,  rarely,  from  digital 
examinations.  The  important  points  to  consider  in  these  wounds  are  whether 
or  not  there  is  penetration  of  the  entire  rectal  wall,  involvement  of  the  perirectal 
tissues,  or  peritoneum.  Slight  wounds  involving  the  mucous  membrane  only 
are  frequently  very  grave  from  the  fact  that  the  hemorrhage  is  constant  into  the 
rectum,  filling  back  into  the  sigmoid  and  often  followed  by  collapse  before  or 
when  the  blood  is  voided.  The  investigations  in  these  cases  should  always  be 
thorough  and  by  both  digital  and  visual  examination,  for  exact  diagnosis  is  of 
the  utmost  importance. 

If  the  peritoneum  has  been  lacerated,  laparotomy  should  be  performed  at 
once,  the  wound  in  the  bowel  repaired,  the  peritoneal  cavity  cleansed  and 
drained,  and  the  Murphy  treatment  for  general  peritonitis  instituted  (see 
page  1 162).  If  the  laceration  involves  the  perirectal  tissues  but  not  the 
peritoneum,  cut  down  on  the  side  of  the  bowel  that  is  injured  and  make  free 
drainage.  In  the  event  of  very  extensive  injuries  to  the  perirectal  tissues  the 
question  of  inguinal  colostomy  should  be  considered.  If  the  wound  involves 
only  the  mucous  or  submucous  coats,  dilate  the  sphincter,  arrest  hemorrhage 
by  suture  or  ligature,  and  follow  by  irrigation. 

Inflammation  of  the  Rectum  and  Sigmoid  (Proctitis  and  Sig= 
moiditis). — -These  conditions  may  be  acute  or  chronic,  simple  or  specific. 
The  simple  forms  are  acute  catarrhal,  atrophic  catarrhal,  and  hypertrophic 
catarrhal.  The  specific  forms  are  gonorrheal  catarrhal,  diphtheritic  catarrhal, 
erysipelatous  catarrhal,  dysenteric  catarrhal,  and  syphilitic  catarrhal  (Tuttle, 
"Diseases  of  the  Anus,  Rectum,  and  Colon"). 

Acute  Inflammation. — Acute  catarrhal  inflammation  may  be  caused  by  that 
class  of  incidents  which  are  apt  to  be  followed  by  ordinary  catarrh  of  the  respi- 
ratory passages  and,  in  addition,  errors  of  diet  or  sudden  change  or  temperature, 
as  sitting  on  a  cold  seat  when  overheated.  The  onset  is  sudden,  with  chill, 
general  malaise,  pain  and  discomfort  locally,  and  slight  fever.  There  is  a  sense 
of  fulness  and  weight,  with  often  a  burning  sensation  referred  to  the  rectum,  and 
at  times  tenesmus  with  frequent  desire  to  go  to  stool.  Pain  radiates  to  adjacent 
parts  and  there  is  bladder  irritability.  Patients  usually  prefer  to  be  in  the  re- 
cumbent posture. 

There  will  be  at  first  a  thin  fecal  discharge  followed  by  mucus  tinged  with 
blood.  Ulceration  soon  supervenes.  The  parts  are  hot,  dry,  and  swollen  in 
the  first  stages  and  digital  examination  is  very  painful.  Later  the  parts  are 
slimy  and  the  mucous  membrane  is  covered  with  tenacious  mucus  and  pus. 

Treatment. — First    remove   irritating   intestinal    contents   and   reduce   en- 


Peri-anal  and  Perirectal  Inflammations  131 1 

gorgement  by  lavage  and  saline  cathartics,  followed,  if  early  in  the  case,  by  irri- 
gations of  cold  water;  if  later,  by  hot  water.  A  useful  medicated  irrigation  is 
a  5  to  10  per  cent,  solution  of  the  aqueous  extract  of  krameria. 

Chronic  Inflammation. — In  chronic  proctitis  and  sigmoiditis  the  symp- 
toms are  similar  to  those  present  in  the  acute  forms  of  the  inflammation,  but 
less  severe  in  character.  In  addition  there  is  increased  secretion  of  mucus, 
flatulence,  and  marked  general  intestinal  disturbance. 

The  mucous  membrane  is  soft,  doughy,  and  thickened,  and  this  condition 
of  the  mucous  membrane  palpably  reduces  the  caliber  of  the  gut.  Through  the 
speculum  the  membrane  is  seen  to  be  edematous,  pale,  and  covered  with  secre- 
tion.    It  bulges  into  the  aperture  of  the  speculum  and  does  not  bleed  easily. 

Treatment  is  hygienic  and  dietetic,  with  antiseptic  and  astringent  irrigations. 

Atrophic  Inflammation. — The  atrophic  variety  of  inflammation  is  char- 
acterized by  long-continued  constipation,  dry  stools  covered  with  blood  and 
mucus.  There  is  such  pain  on  expulsion  of  feces  as  to  simulate  in  many  cases 
fissure  of  the  anus.  The  mucous  membrane  of  the  anus  ruptures  easily  when 
stretched  during  examination.  It  is  bright  red  and  shiny,  does  not  fill  the 
aperture  of  the  speculum,  and  bleeds  readily.  Ulceration  is  common  and  hem- 
orrhoids are  a  frequent  complication. 

Treatment  is  local  and  general.  Locally,  use  a  dilute  solution  of  nitrate 
of  silver  (i  :  2000),  hydrastis  (2  per  cent,  solution),  or  ichthyol,  applied  after 
the  rectum  is  emptied.     General  treatment  is  hygienic  and  dietetic. 

Peri=anal  and  Perirectal  Inflammations. — These  are  of  two  classes 
— circumscribed  inflammations  or  abscesses  and  diffuse  inflammations  that 
always  develop  pus.  The  circumscribed  variety  may  be  either  superficial  or 
deep.  The  superficial  variety  again  may  be  tegmentary,  subtegmentary,  or 
ischiorectal.  The  deep  variety  may  be  of  two  forms — retrorectal  or  superior 
pelvirectal.  It  is  important  to  note  that  right-sided  superior  pelvirectal  abscess 
may  be  confounded  with  appendicitis. 

The  diffuse  perirectal  inflammations  are  variously  classified,  but  the  par- 
ticular names  refer  only  to  the  degree  of  the  inflammatory  process,  which  may 
vary  from  ordinary  suppuration  to  gangrene. 

These  inflammations  travel  in  the  line  of  least  resistance,  wnich  is  upward, 
and  more  often  burst  into  the  bowel  than  externaUy.  They  may  follow  chilling 
of  the  region  or  external  traumatisms,  may  be  caused  by  perforation  of  the 
rectum  by  hard  fecal  masses,  or  by  the  direct  passage  of  bacteria  into  the  fossa 
through  a  fissure,  an  ulcer,  or  an  ulcerated  pile.  They  may  be  either  acute  or 
tuberculous.  In  many  cases  the  process  is  at  first  tuberculous,  and  secondary 
infection  with  pyogenic  bacteria  takes  place. 

The  symptoms  are  nearly  identical  with  those  of  abscess  elsewhere,  the  sweU- 
ing,  however,  being  brawny,  and  it  being  difi&cult  or  impossible  to  detect  fluctua- 
tion. Pain  in  the  groins  is  often  complained  of,  and  there  may  be  enlarged 
glands  in  these  regions.  Abscesses  commonly  result  in  fistula,  and  a  patient 
should  be  warned  of  this  tendency  before  operation  is  performed.  Superior 
pelvirectal  abscesses  generally  foUow  inflammation  of  some  pelvic  organ,  viz.: 
tubes,  urethra,  prostate,  and  the  symptoms  are  mainly  those  of  such  an  inflam- 
matory condition.  The  usual  tendency  of  the  pus  is  to  burrow  upward.  The 
presence  of  pus  is  indicated  by  the  symptoms  of  suppurative  toxemia,  which 
sometimes  simulate  tj^phoid  fever. 

The  treatment  is  instant  incision.  The  patient,  after  having  oeen  anesthe- 
tized, is  placed  in  the  hthotomy  position.  The  cut  should  be  parallel  to  the 
fibers  of  the  external  sphincter  and  well  outside  of  the  muscle  and  longer  than 
the  inflamed  area.  When  this  incision  is  made,  the  finger  should  be  introduced 
to  break  down  the  necrotic  septa  of  cellular  tissue.  Then  an  incision  should  be 
made  from  the  middle  of  the  first  cut  radiating  outward  and  opening  any  pockets 
external  to  the  original  focus.     Then  the  free  edges  of  the  cuts  are  pared  away, 


13 1 2  Diseases  and  Injuries  of  the  Rectum  and  Anus 

sacrificing  all  involved  tissue.  The  wound  is  irrigated,  the  sphincter  dilated, 
and  the  cavity  packed  with  iodoform  gauze.  If  a  fistula  is  found  opening  into 
the  rectum,  it  is  not  to  be  operated  on  until  after  the  wound  is  nearly  healed, 
only  a  small  fistulous  tract  remaining. 

In  cases  of  superior  pelvirectal  abscess  the  incision  should  be  made  at  right 
angles  to  the  fibers  of  the  levator  ani  muscle  to  facilitate  drainage.  In  these 
cases  tubal  drainage  is  used. 

Imperforate  Anus. — There  are  two  forms  of  this  condition.  In  one  form 
the  rectum  empties  into  the  bladder,  vagina,  or  urethra.  In  the  other  form 
there  is  no  rectal  opening  either  upon  the  surface  of  the  body  or  in  the  genito- 
urinary organs.  The  diagnosis  is  usually  at  once  apparent,  except  in  cases  in 
which  the  anus  looks  normal,  when  the  diagnosis  will  often  not  be  made  until 
symptoms  of  obstruction  arise. 

Treatment. — If  the  rectum  bulges  when  the  child  cries,  open  into  it  with 
a  knife  and  keep  the  opening  patent  by  inserting  a  plug  of  iodoform  gauze. 
In  cases  in  which  the  rectum  is  more  deeply  seated,  a  catheter  is  introduced 
into  the  bladder,  an  incision  is  made  from  the  anus  to  the  coccyx,  the  rectum 
is  sought  for,  and  when  found  is  sewed  to  the  anus  and  is  incised.  Keen,  the 
author,  and  others  have  performed  Kraske's  sacral  resection,  pulling  down 
the  rectum  to  the  anal  margin,  sewing  it  there,  and  incising  the  occluded  anus. 
If  the  rectum  cannot  be  found  or  cannot  be  pulled  down,  an  artificial  anus  must 
be  made. 

Fistula  in  ano  is  the  track  of  an  unhealed  abscess.  An  abscess  in  the 
anal  region  is  apt  to  refuse  to  heal  because  of  the  constant  movement  of  the 
parts  (produced  by  respiration,  coughing,  the  passage  of  gas,  defecation,  etc.). 
The  passage  of  feces  along  the  tract  will  keep  a  fistula  open.     If  a  tuberculous 


Fig.  86i. — Fistula  in  ano:  a,  Blind  external;  b,  blind  internal;  c,  complete  (Esmarch  and 

Kowalzig). 

ulcer  perforates  a  tuberculous  sinus  forms,  and  a  tuberculous  sinus  is  also  apt  to 
follow  a  cold  abscess  of  the  ischiorectal  fossa.  Fistula  is  often  associated  with 
phthisis  pulmonalis,  and  is  not  unusually  linked  with  piles,  cancer,  or  stricture. 
There  are  three  varieties  of  fistula — the  bhnd  external  (Fig.  86 1,  a),  the 
blind  internal  (Fig.  86 1,  b),  and  the  complete  (Fig.  86 1,  c).  The  external 
opening  is  usually  near  the  anus,  but  may  be  far  away,  and  there  may  be  only 
one  pathway  or  there  may  be  several  sinuses  and  openings.  In  a  healthy 
individual  the  external  orifice  is  small  and  a  mass  of  granulations  sprout  from 
if.  In  a  tuberculous  fistula  the  external  orifice  is  large  and  irregular,  with 
thin  and  undermined  edges,  shows  no  granulations,  extrudes  small  quantities 
of  sanious  pus,  and  the  skin  about  it  is  purple  and  congested.  In  a  fistula 
following  an  anal  abscess  the  internal  opening  is  just  above  the  anus,  between 
the  two  sphincters.  In  fistula  following  an  ischiorectal  abscess  the  internal 
opening  is  usually  near  the  anus,  but  may  in  rare  cases  be  above  the  internal 
sphincter.  A  sinus  may  run  up  under  the  mucous  membrane  from  the  internal 
opening.  In  a  horseshoe  fistula  the  internal  opening  is  usually  upon  the  posterior 
wall  of  the  bowel,  "and  from  this  a  tract  leads  into  the  ischiorectal  fossa,  not 
on  one  side  only,  but  upon  both.  Therefore  we  have  one  opening  into  the 
bowel  and  one  through  the  skin  on  either  side."^  In  some  cases  of  horseshoe 
fistula  there  is  no  internal  opening;  in  other  cases  there  are  two  openings.  In 
^"Diseases  of  the  Rectum,  Anus,  and  Sigmoid  Flexure,"  by  Joseph  M.  Mathews. 


Fistula  in  Ano  1313 

an  old  fistula  the  track  becomes  fibrous  and  cannot  collapse.  Two  or  more 
fistulae  may  exist  in  the  same  patient.  In  dealing  with  a  fistula  always  deter- 
mine if  the  condition  is  stationary  or  progressive. 

The  symptoms  of  a  complete  fistula  are  the  passage  of  feces  and  gas  through 
the  opening  and  the  flow  of  a  discharge  which  stains  the  clothing.  In  a  com- 
plete fistula  a  probe  can  be  carried  from  the  external  opening  into  the  bowel. 
After  a  time  incontinence  of  feces  is  apt  to  come  on,  repeated  attacks  of  inflam- 
mation thickening  the  rectum  and  destroying  its  sensibility.  From  time  to 
time  the  opening  will  block  and  new  abscesses  form.  In  examining  a  fistula 
use  Brodie's  probe,  as  its  flat  handle  enables  one  to  locate  the  direction  the 
bent  instrument  has  taken,  and  its  slender  shaft  will  find  its  way  through  a 
very  small  channel. 

Treatment. — In  treating  a  fistula  cleanse  the  parts,  as  cleanly  work,  though 
it  will  not  prevent  pus,  will  limit  suppuration.  The  external  parts  are  washed 
with  soap  and  water.  The  rectum,  which  must  be  empty,  is  irrigated  with 
warm  saline  solution.  Corrosive  sublimate  should  not  be  used  in  the  rectum 
because  it  is  irritant,  causes  a  flow  of  serum,  and  hence  lessens  tissue  resistance, 
and  is  rendered  inert  as  an  antiseptic  by  being  converted  into  sulphid  of  mercury. 
Anesthetize  the  patient  with  ether  unless  the  fistula  be  tuberculous,  in  which 
case  use  local  anesthesia,  spinal  anesthesia,  or  nitrous  oxid.  Ether  is  avoided 
in  such  cases  by  many  surgeons  for  fear  of  the  existence  of  a  pulmonary  focus. 
A  tuberculous  focus  in  the  lung  may  disseminate  after  inhalation  anesthesia. 
Place  the  patient  in  the  lithotomy  position.  If  operating  upon  a  complete 
fistula  the  usual  method  is  as  follows:  Pass  a  grooved  director  into  the  external 
opening,  carry  it  through  the  sinus,  make  it  enter  the  bowel,  bring  its  point 
out  externally,  and  lift  the  tissue  between  the  sinus  and 
the  surface.  If  the  director  ascends  above  the  internal 
opening,  the  opening  must  be  made  into  the  bowel  from 
the  summit  of  the  sinus.  If  there  is  no  internal  opening, 
make  one.  Incise  the  bridge  of  tissue  which  is  held 
up  on  the  director  (Fig.  862).  Cut  the  sphincter  at  a 
right  angle  to  its  fibers,  and  do  not  cut  it  more  than 
once  at  one  operation.  If  a  fistula  is  non-tuberculous, 
cut  with  a  knife.  If  it  is  tuberculous,  divide  the  tissues 
with  a  Paquelin  cautery  in  order  to  lessen  the  danger 
of  dissemination  of  the  infection.  Push  the  finger  to  pj^  862.— Operation 
the  depth  of  the  wound,  to  determine  that  the  sinus  for  fistula  in  ano  (Es- 
does  not  ascend  above  the  internal  opening.  Search  with  march  and  Kowalzig). 
a  small  probe  for  branching  sinuses,  and  if  any  are  found, 

slit  them  open.  Examine  carefully  to  see  if  there  is  a  sinus  beneath  the  mucous 
membrane  of  the  bowel,  and  if  such  a  sinus  is  found,  slit  it  up.  Curet  all  sinuses, 
and  if  they  are  very  fibrous,  clip  away  the  fibrous  wall  by  scissors.  Cut  away 
diseased  skin,  irrigate  the  wound  with  salt  solution,  pack  firmly  with  iodoform 
gauze  to  prevent  oozing,  and  dress  with  gauze  and  a  T-bandage.  The  packing 
is  removed  in  twenty-four  hours  unless  it  is  soiled  earlier,  in  which  case  it  is 
promptly  removed.  After  twenty-four  hours  the  wound  is  irrigated  and  packed 
lightly  with  gauze  to  its  full  depth.  This  dressing  should  be  repeated  every 
day  and  any  bridging  of  the  tissues  should  be  broken  down  by  a  probe.  If 
the  wound  becomes  sluggish,  it  is  stimulated  with  nitrate  of  silver  and  sodium 
iodid  is  given  in  small  doses  three  times  daily. 

The  bowels  should  be  moved  after  forty-eight  hours  by  enema.  The  diet 
should  be  light  and  fluid  for  the  first  few  days  after  operation,  and  the  bowels 
should  not  be  restrained  by  drugs.  Get  a  tuberculous  patient  out  of  bed  as 
soon  as  possible.  If  there  are  two  fistulae,  cut  one  through,  and  when  one 
wound  has  healed,  cut  the  other.  Some  straight  sinuses  can  be  extirpated 
and  the  parts  sutured,  primary  union  occasionally  resulting. 
83 


13 14  Diseases  and  Injuries  of  the  Rectum  and  Anus 

If  a  blind  external  fistula  does  not  heal,  every  sinus  must  be  incised,  and 
thickened  walls  must  be  cut  away  or  scraped  away. 

In  a  blind  internal  fistula  an  external  incision  is  made  to  convert  the  case 
into  a  complete  fistula,  which  is  then  treated  as  directed  above. 

In  horseshoe  fistula  more  than  one  operation  may  be  necessary  in  order 
to  avoid  cutting  the  sphincter  muscle  twice  in  one  operation,  a  proceeding 
which  would  probably  lead  to  fecal  incontinence.  One  side  alone  is  operated 
on  at  one  seance.  Sinuses  are  opened  and  scraped,  the  sphincter  is  divided, 
the  angles  and  edges  of  skin  are  trimmed  away,  and  the  wound  is  packed. 
When  the  wound  is  healed,  or  nearly  healed,  the  other  side  should  be  operated 
upon. 

Any  operation  will  fail  if  it  is  not  done  thoroughly.  Operative  failure  is 
common  after  fistula  operations.  The  operation  described  above  usually  gives 
excellent  results  in  simple  fistula.  It  gives  reasonably  good  results  even  when 
the  internal  opening  is  between  the  sphincters,  although  in  that  case  it  may  leave 
distinct  impairment  of  fecal  control.  If  the  internal  opening  is  in  and  above  the 
internal  sphincter,  the  operation  just  outlined  leaves  as  a  legacy  definite  loss 
of  sphincter  control  and  great  consequent  discomfort  (Mackenzie,  "Treatment 
of  Fistula  in  Ano"),  For  such  cases,  and  particularly  for  horseshoe  fistulas, 
Mackenzie  (Ibid.)  does  an  operation  which  does  not  mutilate  the  sphincter. 
He  dilates  the  sphincter;  finds  and  dilates  the  internal  orifice  of  the  fistula; 
lifts  the  mucous  membrane  around  it;  pares  it  in  the  direction  of  the  long  axis 
of  the  bowel;  trims  the  muscle  in  the  direction  of  the  circumference  of  the  sphinc- 
ter; sutures  the  muscle  with  catgut,  the  stitches  passing  at  right  angles  to 
the  fibers;  sutures  the  mucous  membrane  with  chromic  gut;  makes  a  flap  on 
the  side  involved,  the  flap  including  the  fistulous  tract  and  all  of  its  branches 
(in  a  horseshoe  fistula  he  makes  a  flap  on  each  side) ;  removes  all  scar  tissue 
from  the  rectal  wall  and  enfolds  the  wall  by  catgut  over  the  stitches  within; 
removes  all  of  the  fistulous  tracts  from  the  flap,  sutures  the  fat  with  buried 
sutures  of  catgut,  inserts  a  small  drain,  and  closes  the  skin. 

If  fecal  incontinence  results  from  an  operation  for  fistula,  remove  the  scar 
tissue  and  endeavor  to  suture  the  separated  muscular  fibers.  A.  W.  Mayo 
Robson  ("The  Practitioner"  Feb.,  1903)  performs  the  following  operation 
for  incontinence:  A  crescentic  incision,  from  J-^  to  ^4  inch  in  depth  and  taking 
in  about  one-half  of  the  circumference  of  the  bowel,  is  made  at  the  anterior 
border  of  the  anus.  The  middle  borders  of  the  incision  are  then  pulled  apart 
until  the  ends  of  the  cut  approximate  in  the  middle  line,  when  they  are  stitched 
with  deep  catgut  sutures  and  the  skin  is  sewed  with  silk-worm  gut,  the  immedi- 
ate result  being  an  incision  apparently  radiating  from  the  anus.  If  there  be  a 
large  defect  in  the  muscles  simple  suture  is  impossible.  The  attempt  to  bring 
down  adjacent  muscles  and  to  train  them  to  sphincter  function  is  futile.  To 
constrict  the  intestinal  tube  is  of  no  service  when  feces  are  soft.  Rectopexy 
is  useless.  Plastic  operations  upon  the  sphincters  have  been  devised  (Koerble, 
"Arch,  fiir  khn.  Chir.,"  1916,  cviii).  Should  an  operation  be  undertaken  for 
fistula  if  phthisis  exists?  Many  of  the  old  masters  said  no.  Mathews  sums 
up  the  modern  view:  In  incipient  phthisis  operate;  in  rapidly  progressive 
fistula  operate  whether  cough  exists  or  not;  if  much  cough  exists  do  not  operate 
unless  the  fistula  is  rapidly  progressive;  in  the  last  stages  of  phthisis  do  not 
operate. 

Pruritus  of  the  anus  is  a  symptom  and  not  a  disease.  It  may  be  due 
to  piles,  fissure,  seat-worms,  eczema,  nerve  disturbance,  kidney  disease,  gout, 
jaundice,  constipation,  inebriety,  the  opium-habit,  torpid  liver,  dyspepsia, 
alcohol,  tea-drinking,  vesical  calculus,  tobacco-smoking,  urethral  stricture, 
uterine  disease,  diabetes,  ovarian  trouble,  and  mental  disorder.  In  some  cases 
it  seems  to  be  a  pure  neurosis  and  no  special  causative  factor  can  be  recognized. 
It  is  vastly  more  frequent  in  males  than  in  females,  and  is  especially  common 


Fissure  of  the  Anus  131 5 

in  fat  men  who  sweat  profusely.  It  is  seldom  seen  before  the  age  of  thirty, 
except  in  children  suffering  from  thread  worms.  The  itching  comes  on  gradually 
and  usually  intermittently,  but  grows  progressively  worse  and  worse  until  it 
becomes  torturing.  In  many  cases  it  is  at  first  noticed  only  when  warm  in 
bed;  in  other  cases  it  exists  day  and  night.  A  violent  exacerbation  may  be 
excited  by  worry,  anxiety,  overwork,  dietary  indiscretion,  a  sudden  change 
of  temperature,  and  many  other  things.  The  itching  finally  becomes  an  un- 
bearable agony,  sleep,  except  in  snatches,  is  impossible,  the  appetite  disappears, 
the  strength  fails,  and  the  sufferer  may  become  a  nervous  wreck.  In  some 
cases  of  pruritus  the  anal  folds  are  edematous,  there  are  abrasions  here  and 
there  from  scratching,  the  area  is  white  and  moist  and  gives  origin  to  a  fine 
secretion;  in  other  cases  the  mucous  membrane  is  dry  and  fissured. 

Treatment. — In  every  case  first  of  all  make  a  careful  examination  to  find 
a  probable  or  a  possible  cause,  local,  reflex,  or  constitutional,  and  endeavor 
to  remove  this  supposed  cause.  Then  undertake  treatment  for  the  pruritus. 
It  is  very  important  to  prevent  constipation.  Kelsey  directs  that  the  parts 
be  cleansed  twice  a  day,  and  after  each  cleansing  the  following  ointment  be 
applied:  Menthol,  i  dr.;  cerat.  simp.,  2  oz.;  oil  of  sweet  almonds,  i  fl.  oz.; 
acid  carbolic,  i  dr.;  pulvis  zinc  oxid,  2  oz.  Mathews  commends  the  follow- 
ing mixture:  Chloral,  i  dr.;  gum-camphor,  l^  dr.;  glycerin  and  water,  each, 
I  oz.^  In  this  disease  a  "scarf  skin"  forms,  which  must  be  made  to  peel  off 
by  the  application  of  iodin,  pure  carbolic  acid,  corrosive  sublimate  (4  gr.  to 
I  oz.  of  cosmolin),  or  calomel  (2  dr.  to  i  oz.  of  cosmolin).  In  obstinate  cases 
paint  the  parts,  night  and  morning,  with  a  mixture  of  60  gr.  of  alum,  30  gr. 
of  calomel,  and  300  gr.  of  glycerin;  or  smear  with  an  ointment  composed  of 
\'2  part  of  oleate  of  cocain,  3  parts  of  lanolin,  2  parts  of  vaselin,  and  2  parts  of 
olive  oil  (Morain).  In  very  severe  cases,  in  which  the  skin  is  dry  and  cracked, 
apply  a  5  per  cent,  solution  of  eucain  to  the  abraded  portions  and  paint  the  en- 
tire surface  with  a  concentrated  solution  of  silver  nitrate.  It  may  be  neces- 
sary to  repeat  this  treatment  several  times  at  intervals  of  four  or  five  days. 
Adler  advised  us  to  apply  to  the  parts  the  day  after  the  silver  has  been  used 
unguentum  hydrargyri  nitratis  in  full  strength,  only  discontinuing  on  the  day 
a  fresh  application  of  silver  is  made,  and  the  next  day  resuming  the  applications 
of  ointment.  If  during  treatment  the  skin  becomes  sore,  use  calomel  ointment 
until  soreness  disappears.  Violent  attacks  of  itching  are  met  by  applying  hot 
water  and  black  wash  or  calomel  ointment.  This  plan  of  treatment  must  be 
pursued  for  some  months  (Lewis  H.  Adler,  Jr.,  ''New  York  and  Phila.  Med. 
Jour.,"  July  29,  1905).  I  have  used  this  plan  with  some  satisfaction.  In 
severe  and  protracted  cases  we  may  employ  the  .T-rays  twice  a  week  (J.  R. 
Pennington).  I  have  seen  their  application  productive  of  great  benefit  in  the 
worst  cases.  In  some  cases  we  employ  the  PaqueHn  cautery,  in  others  we 
resect  the  mucous  membrane,  as  in  Whitehead's  operation  for  hemorrhoids. 
Ball  divides  the  sensor}-  nerves  going  to  the  implicated  skin  and  has  obtained 
excellent  results.  H.  B.  Stone  ("BuU.  Johns  Hopkins  Hospital,"  1916,  xxvii) 
has  had  success  with  injections  of  alcohol.  He  anesthetizes  the  parts  by 
injecting  a  i  per  cent,  solution  of  novocain  or  a  i  per  cent,  solution  of  urea  hy- 
drochlorid  and  quinin.  A  general  anesthetic  may  be  given  instead  of  local  an- 
esthesia. The  needle  for  the  alcohol  is  carried  through  the  skin  vertically  and 
is  then  placed  horizontally  under  the  skin.  It  must  be  found  to  be  freely  mov- 
able from  side  to  side.  Alcohol  is  injected  beneath  the  area  involved.  The 
anal  canal  is  not  injected.     This  method  is  as  beneficial  as  operation. 

Fissure  of  the  anus  is  an  irritable  ulcer  at  the  anal  orifice  producing 
spasm  of  the  sphincter.  Pain  exists  because  twigs  of  nerves  are  exposed  upon 
the  floor  of  the  ulcer.  Fissure  is  caused  by  constipation  or  traumatism.  It  is 
usually  posterior. 

1  "Diseases  of  the  Rectum." 


13 1 6  Diseases  and    Injuries  of  the   Rectum  and  Anus 

The  symptom  is  violent,  burning  pain,  sometimes  beginning  during  defeca- 
tion, but  usually  at  the  end  of  the  act,  and  lasting  for  some  hours.  Consti- 
pation exists,  and  often  pruritus.  Examination  discloses  a  fissure,  usually  at 
the  posterior  margin,  running  up  the  bowel  j-^i  to  Yo  inch.  Piles  often  exist 
with  fissure. 

Treatment. — The  palliative  treatment  is  to  prevent  constipation,  to  wash 
out  the  rectum  with  cold  water,  and  apply  an  ointment  made  by  evaporating 
2  oz.  of  the  juice  of  conium  down  to  2  dr.,  and  adding  it  to  i  oz.  of  lanolin  and 
12  gr.  of  persulphate  of  iron.  Pure  ichthyol  frequently  promotes  heahng  unless 
the  edges  are  thick  or  the  base  indurated,  when  operation  must  be  done.  Many 
cases  are  so  sensitive  and  painful  to  the  touch  that  medication  and  examina- 
tion are  almost  impossible.  These  may  be  made  bearable  by  insufflations  of 
orthoform. 

Operative  Treatment. — Anesthetize  the  patient.  Thoroughly  cleanse  the 
parts.  Some  surgeons  advocate  operation  without  stretching  the  sphincter. 
It  has  always  been  my  custom  to  stretch  the  sphincter  for  fissure.  Stretching 
gives  us  room  in  which  to  work,  and  by  thus  paralyzing  the  muscular  fibers 
the  raw  surface  is  put  at  rest  and  paroxysms  of  pain  cease  to  occur.  In  order 
to  stretch  the  sphincter  the  patient  is  anesthetized,  the  surgeon's  thumbs  are 
inserted  into  the  rectum,  and  the  parts  are  stretched  slowly  until  the  thumbs 
touch  the  ischia.  After  stretching  the  sphincter  the  fissure  is  incised  through 
its  base  \'^  inch  deeper  than  the  deepest  part  of  the  ulcer,  extending  ^  :^  inch  above 
and  below  the  diseased  tissues,  so  that  the  healthy  muscular  fibers  at  either 
end  are  divided.  In  cases  in  which  the  ulcer  is  at  either  the  anterior  or  pos- 
terior commissure  a  V-shaped  incision  is  made,  the  apex  of  which  should  begin 
}4  inch  above  the  highest  point  of  the  ulcer  and  the  diverging  line  running 
close  to  the  sides  of  the  fissure,  but  in  healthy  tissue. 

A  search  is  made  by  a  probe  to  be  sure  no  pockets  exist.  Any  pocket  must 
be  opened  and  scraped.  The  floor  should  be  curetted  and  touched  with  the  solid 
stick  of  nitrate  of  silver.  If  there  are  redundant  edges,  exuberant  granulations, 
a  sentinel  pile,  or  a  polypus,  they  should  be  curetted  or  excised.  The  wound 
is  then  packed  lightly  with  gauze  and  the  patient  kept  in  bed  for  twenty-four 
hours. 

Hemorrhoids,  or  Piles. — There  are  three  varieties  of  varicose  tumors 
of  the  rectum,  namely:  external,  which  take  origin  without  the  external  sphinc- 
ter; internal,  which  take  origin  within  the  external  sphincter;  and  mixed  hemor- 
rhoids, which  are  a  combination  of  the  two. 

External  hemorrhoids  are  covered  with  skin.  Internal  hemorrhoids  are 
covered  with  mucous  membrane.  The  term  "external  hemorrhoids"  is  not 
strictly  accurate,  as  hemorrhage  does  not  occur  in  external  piles,  and  aU  ex- 
ternal piles  are  not  related  to  the  external  hemorrhoidal  veins.  An  external 
pile  may  involve  the  veins  of  the  skin. 

External  hemorrhoids  are  classified  as  thrombotic,  varicose,  inflammatory, 
and  connective-tissue  external  hemorrhoids  (Tuttle). 

Thrombotic  External  Hemorrhoids. — These  are  external  hemorrhoidal 
veins  fiUed  with  clot.  When  an  external  hemorrhoidal  vein  inflames  the  parts 
become  itchy,  painful,  and  swollen,  and  defecation  increases  the  pain.  The 
blood  clots  in  the  inflamed  vein  and  sometimes  the  vessel  ruptures. 

Symptoms  and  Treatment. — External  piles  of  this  variety  are  usually,  but 
not  always,  multiple.  Small  oval  tumors  appear  beneath  the  skin  or  the 
junction  of  the  skin  and  mucous  membrane.  They  appear  suddenly.  The 
parts  itch  and  pain,  defecation  increases  the  pain,  and  each  pile  increases 
rapidly  in  size.  When  the  vein  ruptures,  a  Uvid,  soft  enlargement  rapidly 
forms.  External  piles  of  this  variety  may  be  absorbed,  may  become  organ- 
ized into  a  scar,  or  may  suppurate.  These  piles  do  not  bleed.  In  treating 
external  hemorrhoids  some  surgeons  merely  use  remedies  to  combat  the  in- 


Internal  Hemorrhoids  1 3 1 7 

flammation.  An  old  plan  of  treatment  is  to  incise  the  blood-tumor,  turn 
out  the  clot,  and  pack  with  a  bit  of  iodoform  gauze.  Mathews  freezes  the 
part  or  injects  cocain,  catches  up  the  blood- tumor  with  a  volsellum,  excises 
the  tumor  and  the  tat^s  of  inflamed  skin,  dusts  the  part  with  iodoform,  and 
dresses  it  with  antiseptic  gauze.  The  bowels  should  not  be  allowed  to  move 
for  two  days.  Never  inject  external  piles  with  carbolic  acid;  it  causes  great 
inflammation,  violent  pain,  sloughing,  and  is  not  free  from  danger.  If  the 
patient  declines  operation,  order  rest,  a  non-stimulating  diet,  avoidance  of 
tobacco  (Mathews),  the  use  of  saline  purgatives,  injections  into  the  rectum  of 
cold  water  several  times  a  day,  sponging  of  the  anus  frequently  with  hot  water, 
and  the  application  of  hot  poultices.  As  the  acute  symptoms  begin  to  disappear 
use  extract  of  hamamelis  locally;  when  they  have  nearly  subsided,  apply  zinc 
ointment. 

Varicose  External  Hemorrhoids. — They  are  varicose  external  hemorrhoidal 
veins  and  are  visible  at  the  anal  margin  when  the  patient  strains.  They  rarely 
produce  pain  or  discomfort,  and  it  is  seldom  that  operation  is  necessary.  The 
bowels  should  be  moved  daily,  but  not  with  violent  purgatives,  and  after  each 
movement  cold  should  be  applied  to  the  anus,  while  the  patient  is  recumbent. 
Tuttle  advocates  the  use  at  night  of  an  ointment  containing  2  dr.  of  suprarenal 
extract  and  6  dr.  of  lanolin;  this  is  spread  on  cotton- wool,  which  is  applied  to 
the  anus  and  held  in  place  by  a  T-bandage. 

Inflammatory  Piles. — By  this  term  we  mean  edematous  inflammation 
of  the  anal  folds.  The  inflammation  may  be  due  to  a  traumatism,  the  pres- 
ence of  an  ulcer  or  fissure,  etc.  There  are  burning,  itching,  and  swelling  of 
the  anus,  which  are  aU  greatly  increased  by  defecation.  One  or  more  pear- 
shaped  swellings  can  be  seen  at  the  anal  margin. 

In  some  cases  medical  treatment  produces  cure.  This  treatment  consists, 
during  the  first  twenty-four  hours,  in  the  use  of  cold  and  of  rest  in  bed.  After 
this  period  heat  should  be  employed.  Tuttle  applies  gauze  soaked  in  a  25 
per  cent,  solution  of  boroglycerid  and  places  a  hot-water  bag  over  this.  He 
also  recommends  the  following  ointment,  to  be  applied  two  or  three  times  a 
day: 

I^.     Morphinae  sulph gr.  v-x; 

Ichthyol 3iv; 

Ung.  belladonnEe  \  .  aa   ^  i 

Ung.  stramonii     J 

Sig. — Apply  two  or  three  times  a  day. 

If  these  means  fail,  ether  is  given,  the  sphincter  is  stretched,  and  the  tumors 
are  cut  away. 

Connective-tissue  External  Hemorrhoids  (Skin  Tabs), — They  are  due 
to  hypertrophy  of  mucocutaneous  tissue  at  the  anal  margin.  Usually  they  re- 
sult from  acute  inflammatory  external  piles;  sometimes  they  arise  gradually  as 
a  result  of  chronic  anal  or  rectal  inflammation  or  irritation,  and  they  may 
be  due  to  varicose  or  thrombotic  external  piles  (Tuttle).  They  produce  no 
trouble  when  not  inflamed.  If  they  cause  serious  annoyance  the  treatment 
is  extirpation. 

Internal  hemorrhoids  are  varicose  tumors  of  the  internal  hemorrhoidal 
plexus,  and  are  found  internal  to  the  external  sphincter,  just  within  the  anus, 
and  they  prolapse  easily.  They  are  not  simply  varicosities,  but  new  tissue 
has  been  formed,  and  they  are,  in  reahty,  vascular  tumors.  They  are  covered 
with  mucous  membrane.  Capillary  piles  are  small,  sessile,  with  a  surface 
like  a  mulberry,  and  bleed  freely.  Children  are  not  very  liable  to  develop 
piles,  excepting  the  capillary  form.  Venous  piles  are  the  most  common  va- 
riety. They  extend  from  just  above  the  anal  margin  for  an  inch  or  more. 
They  are  purple  in  color,  soft,  irregular  in  outline,  and  are  usually  niultiple. 
They  bleed  when  irritated  by  hard  fecal  masses,  but  not  so  easily  as  the 


13 1 8  Diseases  and   Injuries  of  the  Rectum  and  Anus 

capillarv  piles.  Each  pile  is  composed  of  a  varicose  vein,  some  fibrous  tissue, 
and  a  few  arterial  twigs.  Arterial  piles  are  very  unusual.  They  are  large, 
smooth,  pedunculated,  bleed  easily  and  freely,  and  contain,  besides  a  distended 
vein,  arteries  of  some  size. 

Anything  producing  venous  congestion  in  the  rectum — constipation,  diver- 
ticulitis of  the  sigmoid,  diseases  of  the  rectum,  enlargement  of  the  prostate, 
pregnancy,  tumors  of  the  womb,  congestion  of  the  liver,  cirrhosis  of  the  liver, 
certain  diseases  of  the  heart  and  lungs,  sedentary  occupations,  relaxing  climate, 
and  stricture  of  the  urethra — may  cause  hemorrhoids. 

Symptoms  and  Treatment. — If  there  is  neither  bleeding  nor  protrusion  the 
piles  give  no  trouble.  The  first  symptom  is  usually  hemorrhage,  and  rectal 
examination  by  the  speculum  will  make  clear  the  condition.  After  a  time, 
during  defecation,  the  piles  protrude;  they  may  reduce  themselves  when  the 
patient  stands  up,  or  it  may  be  necessary  to  push  them  in.  Pain  does  not 
exist  in  uncomplicated  cases,  and  pain  during  or  after  protrusion  means  "abra- 
sion, fissure,  or  ulceration"  (Mathews). 

Palliative  Treatment. — This  will  not  cure,  but  it  will  give  great  comfort. 
Some  people  only  suffer  at  rare  times  when  the  liver  is  congested,  and  such 
subjects  will  not  submit  to  operation.  Remove,  if  possible,  the  cause  (alcohol, 
irritating  foods,  want  of  exercise,  etc.);  restrict  the  diet;  insist  on  regular  ex- 
ercise; give  a  course  of  Carlsbad  salt,  and  follow  this  by  the  administration  of 
bichlorid  of  mercury  (3-^4  gr.  after  each  meal).  Prevent  constipation  by  a 
nightly  dose  of  extract  of  cascara.  After  each  bowel  movement  wash  the  parts 
with  a  soft  sponge  soaked  in  cold  water,  and  syringe  out  the  rectum  with  cold 
water  and  dry  outwardly  with  a  soft  rag.  If  the  hemorrhoids  prolapse  after 
restoring  them  and  injecting  cold  water,  insert  a  suppository  containing  lo 
gr.  of  the  extract  of  hamamelis  and  use  another  suppository  at  bedtime.  A 
useful  suppository  for  prolapse  is  that  employed  by  Tuttle:  it  contains  5  gr. 
of  ichthyol,  5  gr.  of  tannic  acid,  3^3  gr.  of  ext.  of  stramonium,  ^  3  gr.  of  ext.  of 
belladonna,  and  10  gr.  of  ext.  of  hamamelis.  Bleeding  may  be  arrested  by 
suppositories,  each  containing  5  gr.  of  suprarenal  extract.  When  the  piles 
prolapse  and  inflame,  rub  Allingham's  ointment  on  the  parts  (2  dr.  each  of 
ext.  of  conium  and  ext.  of  hyoscyamus,  i  dr.  of  ext.  of  belladonna,  and  i  oz. 
of  cosmolin).  Mathews  uses  12  gr.  of  cocain,  i  dr.  of  iodoform,  ]4,  dr.  of  ext. 
of  opium,  and  i  oz.  of  cosmolin.  Grant  uses  an  ointment  containing  8  gr.  of 
morphin,  12  gr.  of  calomel,  and  i  oz.  of  vaselin.  A  small  quantity  of  this  is 
apphed  after  bathing  the  part  with  hot  water.  If  the  piles  are  protruding  and 
reduction  cannot  be  effected,  put  the  patient  to  bed,  give  a  h}^odermatic 
injection  of  morphin,  and  apply  hot  poultices.  If  reduction  cannot  soon  be 
effected,  divulsion  of  the  sphincter  must  be  practised  or  radical  operation  must 
be  resorted  to. 

Operative  Treatment. — Give  a  saline  the  morning  before  and  an  enema 
the  evening  before  the  operation,  and  wash  out  the  rectum  well  the  morning 
of  the  operation.  In  treating  by  injection  of  carbolic  acid  the  sphincter  should 
be  divulsed  while  the  patient  is  under  the  influence  of  nitrous  oxid  gas  unless 
the  pile  be  thrombotic.  "  Under  gas  muscular  relaxation  does  not  obtain  as  in 
the  use  of  ether.  Hence  dilatation  under  gas  can  be  more  rapidly  induced,  as 
we  have  the  sphincteric  rigidity  as  a  guide  in  knowing  exactly  how  much  force 
may  be  employed  in  the  individual  case"  (Lewis  H.  Adler,  Jr.,  in  "Jour.  Am. 
Med.  Assoc,"  Jan.  21,  1905).  The  surgeon  must  be  careful  not  to  tear  the 
parts.  The  tumors  are  drawn  out  or,  if  gas  has  not  been  given,  the  patientstrains 
them  out.  An  injection  is  given  by  a  hypodermatic  syringe  into  the  center  of 
the  pile,  and  as  each  pile  is  injected  it  is  pushed  into  the  rectum.  Only  one  or 
two  piles  are  injected  at  each  seance,  and  the  operation  is  not  repeated  for  one 
week  (Geo.  W.  Gay,  in  "Boston  Med.  and  Surg.  Jour.,"  Dec.  5,  1901).  The 
dose  for  oach  pile  is  i  or  2  min.  of  a  10  per  cent,  solution  of  carbolic  acid.     The 


Internal  Hemorrhoids 


1319 


injections  relieve  the  condition,  but  are  rarely  absolutely  curative  and  are  not 
without  danger,  and  may  produce  abscess,  sloughing,  hemorrhage,  phlebitis, 
pyemia,  stricture,  and  even  death  (W.  T.  Bull-Kelsey).  Dr.  Collier  F.  Martin 
("American  Medicine,"  August  27,  1904)  maintains  that  the  method  is  safe 
and  satisfactory.  He  injects  equal  parts  of  a  French  preparation  of  phenol  and 
distilled  water,  freshly  mixed  and  fdtered.  From  7  to  15  min.  are  injected  into 
a  pile  and  only  one  pile  is  injected  at  a  seance.  In  from  five  days  to  one  week 
another  injection  may  be  given.  Before  beginning  a  course  of  injections  the 
sphincter  is  stretched  while  the  patient  is  under  nitrous  oxid  and  oxygen.  It 
is  not  necessary  to  repeat  this  for  future  injections.  During  injection  a  special 
speculum  is  used.  The  pile  protrudes  into  the  speculum,  is  cleansed  with  a  i 
per  cent,  solution  of  creolin,  and  the  injection  is  thrown  into  the  most  promi- 
nent part  of  the  pile.  The  speculum  is  withdrawn  before  pulling  out  the 
needle.  This  maneuver  prevents  escape  of  injection  and  arrests  bleeding.  I 
seldom  employ  the  injection  treatment.  I  never  use  it  if  the  patient  consents 
to  the  clamp  and  cautery  operation  or  to  ligation.  The  clamp  and  cautery  is, 
in  the  great  majority  of  cases,  the  operation  of  choice.  It  requires  but  a  few 
minutes  to  do  it;  after  it  is  done  there  is  little  or  no  postoperative  pain,  in 
very  many  cases  retention  of  urine  does  not  occur,  and  the  patient  usually  is 
about  again  within  ten  days.     The  patient  is  anesthetized  and  the  sphincter 


Fig.  863. — Brick's  pile  clamp. 


is  carefully  and  thoroughly  stretched.  The  stretching  of  the  sphincter  is  very 
important.  It  gives  free  access  to  the  parts,  prevents  subsequent  spasm 
and  pain,  and  lessens  the  likelihood  of  venous  bleeding  after  operation.  The 
pile  is  caught  by  forceps  and  drawn  outside  of  the  sphincter.  Many  use  Smith's 
clamp.  It  is  applied  with  the  ivory  surface  against  the  mucous  membrane 
of  the  bowel.  I  use  the  clamp  devised  by  Dr.  J.  Coles  Brick  (Fig.  863).  From 
the  bite  of  Brick's  clamp  the  pile  cannot  slip,  as  the  blades  come  evenly  and 
firmly  together.  The  pile  is  cut  off  and  the  stump  is  seared  with  the  Paquelin 
cautery  at  a  dull-red  heat.  Pile  after  pile  may  be  thus  treated,  care  being 
taken  to  leave  some  mucous  membrane  at  each  side  of  every  pile.  If  this  pre- 
caution be  not  taken,  healing  will  be  slov/  and  stricture  will  result.  After  cau- 
terization is  complete  a  speculum  is  inserted  and  the  blades  are  widely  opened. 
Any  bleeding  points  are  at  once  ligated.  This  is  a  most  important  precaution. 
Packing  is  never  inserted.  I  formerly  used  it,  but  have  given  it  up.  It  is  of 
no  service  and  produces  severe  pain  and  edema.  The  treatment  from  this 
point  is  identical  with  that  advised  below  after  the  use  of  the  ligature.  Exci- 
sion is  preferred  by  AUingham.  He  stretches  the  sphincter,  holds  it  open  with 
a  retractor,  catches  up  the  pile,  cuts  it  off,  and  twists  the  bleeding  vessels.  Some 
prefer  to  pass  a  silk  or  catgut  suture,  cut  off  the  tumor,  and  tie  the  thread  \F\g. 
864).  Whitehead's  operation  (Fig.  865)  is  only  to  be  performed  in  severe  cases, 
when  the  piles  are  extremely  large  and  form  a  protruding  circular  mass.  Pri- 
mary union  is  rarely  secured.  When  first  introduced  the  operation  was  viewed 
with  favor,  but  experience  shows  it  is  sometimes  followed  by  disastrous  conse- 


I320 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


Fig.  864. — Extir- 
pation of  h  e  m  o  r- 
rhoids  (Esmarch  and 
Kowalzig). 


quences.^  Stricture  not  infrequently  arises  after  its  performance;  fecal  incon- 
tinence occasionally  results,  and  anal  anesthesia  with  inability  to  restrain  the 
passage  of  gas  is  common.  After  this  operation  the  anus  is  permanently  more 
or  less  moist.  The  entire  pile-bearing  area  of  mucous  membrane  is  dissected 
out  and  the  cut  margin  of  mucous  membrane  is  pulled  down  and  stitched  to 
the  surface.     The  sphincter  may  be  dilated  as  a  preliminary  measure. 

The  application  of  the  ligature  is  an  .easy  and  useful 
method.  It  is  not  so  rapid  as  the  cautery,  is  followed  by 
more  pain,  healing  requires  a  longer  time,  and  stricture  is 
more  common.  In  this  operation,  after  anesthetizing, 
stretch  the  sphincter  and  treat  each  hemorrhoid  separately. 
Catch  a  pile  with  a  pair  of  forceps  or  a  volsellum,  pull  it 
dowm,  and  cut  a  gutter  through  the  skin-margin  if  the  pile 
is  of  the  mixed  variety;  tie  the  small  piles  without  transfix- 
ing, but  transfix  the  large  piles;  tie  with  silk  (coarse  silk 
for  the  large  piles,  finer  silk  for  the  small  piles) ;  cut  off 
each  tumor  beyond  the  thread  and  cut  the  ligatures  short. 
Treat  the  other  piles  in  the  same  manner.  Irrigate  with 
hot  normal  salt  solution.  Do  not  insert  packing.  Place  a 
2-gr .  opium  suppository  in  the  rectum.  Apply  a  gauze  pad  and 
a  T-bandage  over  the  anus.  The  opium  locks  up  the  bowel?. 
The  patient  is  kept  on  a  light  diet  for  three  days,  at  the  end  of  which  time  a  saline 
may  be  given.  Just  before  the  bowels  act  remove  the  dressings  and  give  an  enema 
of  warm  water  or  of  glycerin  or  of  glycerin  mixed  with  olive  or  linseed  oil.  After 
the  movement  wash  the  parts  first  with  dilute  peroxid  of  hydrogen  and  next  with 
hot  salt  solution,  dust  with  iodoform,  and  apply  a  gauze  pad  over  the  anus.  Irri- 
gate daily  until  healing  is  complete.  After  the  tenth  day  examine  with  a  speculum 
to  see  that  the  Kgatures  have  come  away;  if  any  are  found  in  place,  remove  them . 

Prolapse  of  the  Rectum. — If  the  mucous 
membrane  be  prolapsed  the  condition  is  commonly 
called  prolapsus  ani;  if  the  entire  thickness  of  the 
rectal  wall  be  prolapsed,  it  is  commonly  called 
prolapsus  recti  (Fig.  866).  The  term  "prolapse  of 
the  anus"  is  an  incorrect  and  objectionable  one, 
and  we  should  designate  such  cases  prolapse  of 
tJie  rectal  mucous  membrane,  incomplete  or  partial 
prolapse.  If  all  the  coats  of  the  bowel  descend  the 
condition  should  be  called  complete  prolapse  or 
procidentia. 

Incomplete  Prolapse  (Partial  Prolapse). — In 
this  condition  the  mucous  membrane  of  the 
rectum  protrudes  from  the  anus.  In  normal  con- 
ditions the  membrane  protrudes  during  defecation 
and  at  once  retracts  when  the  act  of  defecation 
terminates.  In  the  condition  under  discussion  the 
mucous  membrane  remains  protruded  because  the 
submucous  tissues,  being  stretched  and  relaxed,  find 
it  difficult  or  are  unable  to  draw  the  mucous  mem- 
brane in  again.  In  this  condition  a  ring  of  mucous 
membrane  or  only  a  portion  of  its  circumference 
may  protrude.  It  is  particularly  common  in  early 
youth  and  in  old  age.  Prolapse  is  apt  to  occur 
from  excessive  straining  at  stool  and  is  commonest  in  feeble,  ill-nourished 
children.  A  polypus  may  be  the  cause.  Piles  and  worms  may  lead  to  prolapse. 
Straining  from  phimosis,  stone  in  the  bladder,  or  urethral  stricture  may  be 
'  Andrews,  in  "Mathew's  Medical  Quarterly,"  Oct.,  1895. 


Fig.  865.-5,  S,  The  lower 
circular  incision  along  Hilton's 
white  line;  M,  tube  of  mucous 
membrane  dissected  from  the 
sphincter;  B,  B,  dotted  line 
showing  the  place  for  the  up- 
per circular  incision  (Edmund 
Andrews). 


Incomplete  Prolapse  of  the  Rectum 


1321 


causative.  Its  development  is  favored  by  the  use  of  articles  of  food  which 
cause  frequent  movements  of  the  bowels.  If  an  individual  sits  a  long 
time  on  the  seat  of  the  closet  or  on  the  chamber  the  development  of  prolapse 
is  favored.  The  condition  comes  on  gradually  and  is  at  first  painless.  For 
some  time  it  reduces  itself  spontaneously  after  defecation,  but  reduction  be- 
comes more  and  more  difficult.  A  common  custom  of  sufferers  is  to  push  it 
by  the  fingers  above  the  grasp  of  the  sphincter.  Sometimes,  but  seldom,  it 
becomes  strangulated.  A  recent  prolapse  is  pink,  an  older  one  is  angry  red; 
one  which  is  tightly  caught  is  purple;  a  strangulated  one  is  deep  purple  and  soon 
becomes  black  from  gangrene.  If  the  prolapse  be  of  the  entire  circumference 
it  shows  radial  folds  of  mucous  membrane.  It  frequently  bleeds.  Prolapse, 
be  it  large  or  small,  tends  to  recur  again  and  again,  and  eventually  the  mucous 
membrane  inflames,  ulcerates,  or  sloughs.  Prolapse  of  all  the  coats  may  ensue 
(see  below).     The  condition  is  sometimes  confused  with  hemorrhoids,  but  in 


^^ 


Fig.  866. — Rectal  prolapse. 

prolapse  the  protruding  mass  is  circular  and  has  a  depression  in  the  center, 
whereas  hemorrhoids  are  distinct  masses.  Further,  hemorrhoids  are  very 
rare  in  children.  Hemorrhoids  often  exist  with  prolapse  of  the  mucous  mem- 
brane and  frequently  cause  it.  In  prolapse  of  the  mucous  membrane  there 
is  no  sulcus  between  the  sphincter  muscle  and  the  anterior  portion  of  the  pro- 
trusion; in  complete  prolapse  there  is. 

Treatment. — Palliative  treatment  forbids  straining  at  stool  and  amends 
an  improper  diet.  Phimosis  must  be  corrected;  stone  in  the  bladder  must 
be  removed;  stricture  must  be  dilated;  hemorrhoids  and  polypi  are  to  be 
removed.  Give  an  enema  of  cold  water  just  before  going  to  stool  in  order 
to  hurry  the  emptying  of  the  rectum.  If  prolapse  occurs,  the  protrusion 
must  be  bathed  with  cold  water  and  restored.  Constipation  must  be  pre- 
vented (enema ta  of  water  or  glycerin  may  be  used),  and  after  each  movement 
several  ounces  of  an  infusion  of  white  oak  bark  (i  ounce  of  quercus  to  a 
pint  of  water)  should  be  injected.  If  a  prolapse  is  caught  firmly,  paint  it 
with  cocain  and  adrenalin,  place  the  patient  in  the  knee-chest  position,  apply 


1322  Diseases  and   Injuries  of  the   Rectum  and  Anus 

hot  compresses,  grease  it  with  cosmoUn,  insert  a  finger  into  the  rectum,  and 
apply  taxis  around  the  finger  (Mathews).  If  this  fails,  cover  a  finger  with  a 
handkerchief  and  insert  the  wrapped  digit  into  the  rectum;  if  this  proves  futile, 
invert  the  patient  before  manipulation.  Do  not  give  a  general  anesthetic 
unless  it  is  imperatively  necessary;  the  vomiting  so  often  caused  by  ether  and 
chloroform  might  reproduce  the  prolapse.  After  reduction  apply  a  compress 
to  the  anus,  direct  that  it  be  worn  when  at  stool,  and  before  each  act  of  de- 
fecation give  an  injection  of  cold  water  containing  an  astringent  (tannin  or 
fluidextract  of  hydrastis).  Most  cases  in  children  can  be  cured  without  opera- 
tion. Some  cases  in  adults  and  obstinate  cases  in  children  may  be  treated 
by  painting  the  prolapse  with  fuming  nitric  acid,  greasing  it  with  olive  oil, 
and  restoring  it.  Some  cases  require  excision  of  the  mucous  membrane,  the 
divided  edge  of  this  membrane  being  stitched  to  the  skin.  In  other  cases  the 
protrusion  is  stroked  longitudinally  with  the  actual  cautery  and  restored. 
When  the  surgeon  comes  to  operate  for  recurring  prolapse,  it  will  often  be 
found  to  have  modestly  withdrawn  and  he  may  be  obliged  to  stretch  the  sphincter 
to  bring  it  into  view. 

Complete  Prolapse  (Procidentia). — In  this  condition  all  of  the  rectal  coats 
protrude.  There  are  said  to  be  three  degrees  of  this  condition.  In  the  first 
degree  the  prolapse  begins  at  the  anal  margin  and  its  outer  surface  is  continuous 
with  the  peri-anal  skin,  there  being  no  sulcus  between.  It  is  usually  a  conse- 
quence of  prolapse  of  the  mucous  membrane.  In  the  second  degree  (genuine 
procidentia)  the  prolapse  begins  on  a  level  or  above  the  level  of  the  lower  margin 
of  the  peritoneum  and  projects  out  of  the  anus.  In  the  third  degree  the  pro- 
lapse begins  at  the  origin  of  the  rectum  or  in  the  sigmoid,  and  is,  in  reality,  a 
protruding  intussusception.  Some  cases  come  on  suddenly.  The  prolapse  of 
the  first  degree  has  no  furrow  between  it  and  the  perianal  skin,  and  the  folds  are 
circular  instead  of  longitudinal.  It  is  usually  treated  as  is  prolapse  of  the 
mucous  membrane.  If  simple  methods  fail,  it  will  be  necessary  to  do  an  opera- 
tion to  lessen  the  size  of  the  anal  orifice.  In  prolapse  of  the  third  degree  the 
treatment  is  as  for  intussusception.  It  is  prolapse  of  the  second  degree  that  we 
consider  here.  It  is  more  common  in  adults  than  in  children.  There  are  many 
theories  as  to  its  causation.  Esmarch  regards  it  as  due  to  inflammation  of  the 
rectum,  which  spreads  to  all  the  coats  and  also  to  the  perirectal  structures.  An- 
other theory  (Jeannel's)  is  that  the  small  intestine  is  in  a  state  of  ptosis,  and  by 
falling  into  Douglas's  culdesac  presses  upon  and  causes  atrophy  of  the  levator 
ani  muscle.  The  most  probable  theory  is  that  the  condition  is,  in  reality,  her- 
nia (Waldeyer,  Zuckerkandl,  Moschcowitz).  Moschcowitz  ("Surg.,  Gynec, 
and  Obstet.,"  July,  191 2)  makes  a  powerful  argument  to  prove  that  the  intes- 
tine in  Douglas's  culdesac  causes  a  bulge  of  the  anterior  rectal  wall,  that  this 
bulging  part  of  the  wall  grows  larger  and  descends,  and  that  finally  the  entire 
circumference  of  the  rectum  is  dragged  down. 

Complete  prolapse  is  usually  preceded  by  chronic  constipation,  great  strain- 
ing being  necessary  to  effect  defecation.  Chronic  rectal  catarrh  is  also  a  com- 
mon antecedent. 

A  mass  sticks  out  of  the  rectum  and  there  is  a  purulent  discharge  which 
often  contains  blood.  The  protruding  mass  (which  is  seldom  over  6  inches  in 
length)  is  covered  externally  with  mucous  membrane  (which  may  be  normal, 
inflamed,  ulcerated,  or  bleeding)  and  is  lined  by  normal  mucous  membrane 
(Moschcowitz,  Ibid.).  The  opening  is  at  the  apex  of  a  canal  directed  back- 
ward. The  anterior  part  of  the  protrusion  is  much  larger  than  the  posterior 
part,  the  anterior  part  is  usually  tympanitic,  and  the  posterior  part  dull  on 
percussion  (Moschcowitz,  Ibid.).  There  is  a  deep  furrow  between  the  an- 
terior portion  of  the  sulcus  and  the  anal  margin.  The  furrow,  as  a  rule,  is 
about  I  inch  deep. 

Early  in  the  case  the  prolapse  is  reduced  spontaneously,  later  it  must  be 


Ulcers  of  the  Rectum  1323 

reduced  by  the  hand.  It  may  become  incarcerated  or  strangulated.  The 
protrusion  when  strangulated  becomes  gangrenous. 

Treatment. — In  children  the  condition  may  often  be  cured  by  the  methods 
used  for  prolapse  of  the  mucous  membrane.  If  a  prolapse  is  caught  tightly, 
apply  hot  compresses  to  reduce  swelling,  paint  it  with  cocain  and  adrenalin,  put 
the  patient  in  the  knee-chest  position,  and  reduce  as  described  under  partial  pro- 
lapse. General  anesthesia  is  undesirable  because  of  the  probability  of  vomiting 
with  consequent  straining.  After  reduction  apply  a  support.  Electricity  is 
used  by  some,  injections  of  astringents  under  the  mucous  membrane  by  others. 
Operation  is  necessary  for  prolapse  in  most  adults  and  in  some  children.  As  a 
preliminary,  hemorrhoids,  ulcerations,  etc.,  must  be  cured.  A  multitude  of 
operations  have  been  recommended.  Some  try  to  constrict  the  anal  opening 
(cauterization  by  the  actual  cautery,  nitric  acid  or  chlorid  of  zinc,  removing 
a  wedge-shaped  piece  from  posterior  rectal  wall  followed  by  suturing,  twisting 
the  rectum,  injections  of  paraffin  about  the  sphincter,  and  various  other  plans). 
Such  operations  are  entirely  inefficient.  Some  operate  on  the  bowel  higher  up, 
striving  to  increase  support.  Moschcowitz  also  mentions  "methods  which 
pay  particular  attention  to  the  fixation  apparatus  of  the  rectum."  One  plan 
is  to  operate  through  an  abdominal  incision,  fixing  the  sigmoid  to  the  abdominal 
wall — an  unphilosophical  operation  "because  the  distal  end  of  the  sigmoid  is 
fixed  to  the  sacrum,  and  pulling  can  have  very  little,  if  any,  effect  upon  the 
prolapse  of  the  rectum"  (Moschcowitz,  Ibid.). 

I  have  abandoned  the  operation  of  stitching  the  sigmoid  to  the  abdominal 
wall  (colopexy)  because  it  is  dangerous  thus  to  anchor  the  gut  and  because,  I 
believe,  it  alwa.ys  fails  to  cure.  Mikulicz's  operation  of  excision  of  the  pro- 
lapse has  elements  of  decided  danger,  but  may  cure  the  case.  I  apparently 
cured  i  case  this  way,  but  in  another  case  the  condition  recurred. 

Moschcowitz's  operation  is  the  most  reasonable  one.  The  abdomen  is 
opened,  the  rectum  is  held  taut,  and  the  culdesac  of  Douglas  is  obliterated  by 
silk  or  linen  sutures.     The  pelvic  fascia  is  included  in  the  sutures. 

Ulcers  of  the  rectum  are  divided  into  the  simple  traumatic,  the  syphilitic, 
the  tuberculous,  the  dysenteric,  the  gonorrheal,  and  the  malignant.  Simple 
ulceration  is  due  to  abrasion  with  fecal  masses  or  a  foreign  body,  the  abraded 
area  ulcerating.  It  may  follow  an  operation  for  piles  and  also  protracted  labor 
("Diseases  of  the  Rectum,"  by  ^\llingham),  and  is  apt  to  be  single.  The  base 
and  edges  of  a  simple  ulcer  are  neither  prominent  nor  hard  and  stricture  rarely 
forms.  Syphilitic  ulceration  is  a  tertiary  lesion  commonest  in  women.  There 
are  numerous  small  ulcers  of  the  mucous  coat  or  submucous  tissue,  but  little 
indurated,  with  sharp-cut  edges  which  are  not  undermined.  These  ulcers  fuse 
and  constitute  one  large  irregular  ulcer;  fibrous  tissue  forms  in  the  wall  of  the 
bowel,  induration  becomes  noticeable,  and  stricture  follows.  There  is  profuse 
discharge  and  fistulae  are  apt  to  form.  Such  ulcers  may  be  surrounded  by 
nodules  of  a  bluish  color.  In  many  cases  the  first  condition  is  stricture  due 
to  the  formation  of  masses  of  fibrous  tissue  in  the  rectal  walls,  and  ulceration 
occurs  secondarily.  In  syphilis  there  may  be  a  breaking  down  of  a  huge  gummy 
mass  or  of  multiple  gummata.  It  has  been  proved  by  the  microscope  that 
tuberculous  ulceration  may  arise  in  the  rectum.  Tuberculous  ulceration  pre- 
sents a  conical  ulcer  with  overhanging  edges  and  a  pale-red  base.  There  is 
some  mucous  discharge,  some  tenesmus,  and  a  little  pain.  Tuberculosis  is 
seldom  directly  responsible  for  stricture  (see  page  1325).  Dysentery,  catarrh, 
diabetes,  Bright's  disease,  neoplasms,  and  foreign  bodies  may  produce  ulcera- 
tion of  the  rectum. 

Sjrmptoms. — There  may  be  merely  uneasiness  about  the  rectum,  but  some- 
times there  is  severe  burning  pain  on  defecation,  and  perhaps  for  some  time 
after  the  act.  There  may  be  constipation  or  diarrhea;  the  patient  strains 
at  stool,  and  the  stools  may  contain  blood,  mucus,  or  pus.     As  a  rule,  there  is 


1324 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


diarrhea  on  rising  in  the  morning,  the  first  movement  consisting  of  blood  and 
mucus,  and  the  next  movement  being  fecal.  The  history  should  be  carefully- 
inquired  into;  tuberculosis  should  be  sought  for;  the  question  of  syphilis 
should  be  investigated.  A  digital  examination  enables  the  surgeon  to  feel  the 
ulcer,  and  an  examination  by  means  of  an  ordinary  speculum  or  an  electric 
proctoscope  brings  it  into  view. 

Treatment. — In  simple  ulcer  empty  the  bowel  by  the  administration  of 
a  saljne  cathartic,  wash  out  the  rectum  with  hot  water  after  the  saline  has 
acted,  introduce  a  speculum,  touch  the  ulcer  with  pure  carbolic  acid  or  silver 
nitrate  (40  gr.  to  i  oz.),  place  the  patient  in  bed,  restrict  him  to  a  liquid  diet, 
and  every  day  inject  iodoform  and  olive  oil  fio  per  cent.)  or  insufllate  iodoform 
into  the  rectum.  If  this  fails,  give  ether,  stretch  the  sphincter,  incise  the  ulcer 
through  its  entire  thickness,  and  cauterize  with  fuming  nitric  acid,  caring  for 
the  case  subsequently  as  we  would  a  patient  who  had  had  piles  ligated.  In 
tuberculous  ulcer  improve  the  general  health,  send  the  patient  to  a  genial  climate, 


Fig.  867. — Papilloma  of  anus  and  rectum. 

or  at  least  into  the  sunlight  and  fresh  air,  prevent  constipation,  give  nutri- 
tious food,  especially  fats,  wash  out  the  rectum  every  day  with  hot  water, 
and  insufflate  iodoform  or  inject  iodoform  emulsion.  Touch  the  ulcer  once  a 
week  with  silver  nitrate  (10  gr.  to  i  oz.j.  In  syphilitic  ulcer  give  antisyphilitic 
treatment  and  treat  the  ulcer  locally,  as  is  done  in  tuberculous  ulcer.  Dys- 
enteric ulcer  requires  injections  of  hot  water,  the  touching  of  the  ulcer  with  pure 
carbohc  acid,  insufflations  of  iodoform,  and  special  treatment  of  the  dysentery. 
Benign  Tumors  of  the  Rectum  and  Anus. — These  tumors  may  be  of 
the  connective,  epithehal,  or  muscular  tissue  type.  Of  the  first  there  are 
fibroma,  enchondroma,  lymphadenoma,  lipoma,  and  myxoma;  of  the  second, 
adenoma  and  papilloma;  of  the  third,  myoma  and  fibromyoma.  Many  benign 
tumors  appear  in  polypoid  form.  A  polyp  is  a  tumor  with  a  pedicle.  A 
polyp  may  be  a  fibroma,  myxoma,  myoma,  papilloma,  or  adenoma.  Papil- 
loma is  a  rare  growth,  usually  has  a  broad  pedicle,  but  may  have  no  pedicle. 
It  does  not  occur  in  childhood.  A  papilloma  bleeds  profusely  and  causes  a 
discharge  of  mucus.     A  polyp  causes  no  pain  unless  ulceration  occurs.     It 


Non-cancerous  Stricture  of  the  Rectum  1325 

causes  bleeding  and  mucous  discharge.  On  coming  from  stool  the  patient 
feels  as  though  the  rectum  still  contains  feces.  A  polyp  may  protrude  during 
defecation.  It  can  be  detected  by  digital  examination  and  can  be  readily  seen 
through  a  proctoscope.  There  may  be  one  polyp;  two,  several,  or  many  polypi. 
Polypi  are  most  common  in  children.  (See  Adler,  in  "Annals  of  Surgery," 
Dec,  1909.)  The  most  common  forms  of  tumor  are  the  myxoma,  hyper- 
trophied  solitary  follicles,  adenoma,  fibroma,  and  lipoma.  Myxoma  is  most 
common  in  children.  Fibroma  originates  in  the  connective  tissue  or  the  sub- 
mucosa  and  is  very  rare.  It  may  arise  at  the  upper  end  of  a  fissure.  It  has 
a  long  pedicle  and  may  become  very  large. 

Symptoms  of  tumor  are  dull,  aching  pain,  tenesmus,  frequent  defecation, 
and  sometimes  ulceration  of  the  mucous  membrane.  In  a  non-polypoid  benign 
tumor  there  is  absence  of  hemorrhages  and  of  mucous  discharges. 

Treatment. — Remove  the  tumor  after  dilating  the  sphincter.  In  tying  or 
snaring  off  polypi  it  should  be  borne  in  mind  that  the  peritoneum  may  be  in- 
vaginated  in  the  pedicle  and,  therefore,  no  traction  on  it  should  be  made  when 
operating.  Sessile  growths  are  dissected  out.  The  postoperative  treatment  is 
practically  the  same  as  for  hemorrhoids. 

Cryptitis  {Inflammation  of  the  Crypts  of  Morgagni). — These  crypts,  five  to 
ten  in  number,  are  situated  in  the  mucous  membrane  of  the  rectum,  about 
3  cm.  from  the  anus.  They  occasionally  become  packed  with  mucus  or  feces. 
There  is  quite  severe  pain  referred  to  the  site,  especially  after  defecation.  In 
this  condition  the  examination  of  the  anus  by  the  finger  is  extremely  painful. 
The  inflamed  crypts  may  be  detected  by  examination  through  the  speculum. 

Treatment. — Divide  the  afifected  crypts,  curet  away  any  granulations,  and 
allow  the  parts  to  heal. 

Non=cancerous  stricture  of  the  rectum  may  be  congenital  or  ac- 
quired. There  are  two  forms  of  acquired  stricture:  first,  stricture  due  to  ex- 
ternal pressure;  second,  stricture  due  to  primary  narrowing  of  the  rectal  lu- 
men.^ Stricture  due  to  external  pressure  is  very  rarely  complete,  and  may  be 
caused  by  bands  of  adhesions  or  a  tumor  growth.  The  second  form  may  be 
produced  by  syphilitic  tissue,  ordinary  inflammatory  tissue,  cicatrices  after 
operations,  sloughing,  tuberculous,  syphilitic,  or  dysenteric  ulceration,  rectal 
gonorrhea,  and  traumatism.  The  usual  seat  of  simple  stricture  is  from  i 
inch  to  1^4,  inches  above  the  anus.  The  deposit  may  be  limited  to  the  sub- 
mucous coat  or  all  the  coats  may  be  involved.  It  is  very  seldom  that  stricture 
arises  as  a  result  of  abrasion  from  fecal  masses  or  foreign  bodies.  It  may 
follow  an  operation  for  piles  if  considerable  tissue  be  removed,  and  is  an  occa- 
sional sequence  of  Whitehead's  operation.  A  perirectal  inflammation  may  be 
responsible.  Stricture  due  to  dysentery  is  extremely  rare,  and  no  case  has  ever 
been  reported  to  the  United  States  Pension  Office  (Peterson).  The  existence 
of  stricture  as  a  result  of  rectal  gonorrhea  has  not  been  positively  proved. 
A  majority  of  sufferers  from  rectal  stricture  have  labored  under  syphilis,  but 
it  is  not  probable  that  the  lesion  is  syphihtic  in  all  or  even  in  most  of  them. 
The  stricture  may  be  due  to  the  formation  of  fibrous  tissue  and  ulceration  may  or 
may  not  occur.  It  may  be  caused  by  the  contraction  and  healing  of  a  large 
ulcer.  Along  with  syphilitic  ulceration  comes  great  connective  tissue  hyper- 
plasia, a  hyperplasia  so  great  that  the  rectum  becomes  a  thick  rigid,  nodular, 
immovable  tube.  Most  cases  of  syphilitic  stricture  occur  in  women.  Some 
maintain  that  tuberculous  stricture  does  occur.  Mathews  dissents  from  this 
view  and  points  out  that  the  tendency  of  tuberculous  matter  is  to  break  down, 
and  before  the  rectum  can  form  a  stricture  from  tuberculosis  it  breaks  down 
from  ulceration.  Peterson^  says  a  large  proportion  of  the  victims  of  rectal  stric- 
ture die  of  phthisis,  and  that  one-third  of  so-called  syphihtic  cases  are  tubercu- 
lous.    It  may  begin  as  an  ulcer  or  as  an  infiltration  of  submucous  tissue. 

1  Reuben  Peterson,  in  "Jour.  Am.  Med.  Assoc,"  Feb.  3,  1900.  -Ibid. 


1326  Diseases  and  Injuries  of  the  Rectum  and  Anus 

Although  a  syphilitic  or  a  tuberculous  lesion  may  cause  rectal  stricture,  in  most 
cases  such  lesions  simply  expose  the  tissues  to  infection,  and  benign  rectal  stenosis 
results  from  the  infection.  Tuberculosis  may  cause  stricture,  but  does  so 
indirectly  rather  than  directly. 

The  symptoms  of  rectal  stricture  are  constipation,  pain  on  defecation,  strain- 
ing at  stool,  perhaps  the  presence  of  blood  and  mucus  in  the  stools,  an  open 
anus,  and  the  passage  of  stools  flattened  out  into  ribbons  if  the  stricture  be  low- 
down.  In  some  cases  there  is  fluid  diarrhea,  sohd  fecal  matter  being  retained 
above  the  stricture.  The  stricture  is  found  by  the  finger  or  by  the  soft-rubber 
bougie,  used  with  the  utmost  gentleness  and  care.  A  stiff  instrument  or  the 
rough  use  of  any  instrument  would  be  dangerous  and  might  rupture  the  rectum. 
In  s\-philitic  cases,  in  tuberculous  cases,  and  in  benign  cases  the  fibrous  thick- 
ening is  usually  in  the  submucous  coat,  and  in  syphilitic  and  tuberculous  cases 
the  mucous  membrane  is  apt  to  ulcerate.  It  is  said  that  complete  obstruction 
may  arise.  I  have  seen  obstructive  symptoms,  but  never  complete  obstruction 
in  rectal  stricture.     Distention  of  the  abdomen  and  cohc  are  very  usual. 

The  tratement  of  non-cancerous  and  primary  narrowing  of  the  rectal  canal 
is  rest,  non-stimulating  diet,  warm-water  injections,  mild  laxatives,  and  hot 
hip-baths.  Cocain  suppositories  may  be  needed.  Any  existing  disease  is 
treated.  Bougies  are  passed  every  other  day.  Use  a  soft-rubber  bougie, 
warmed  and  oiled,  and  introduce  it  gently.  If  the  method  of  gradual  dila- 
tation alone  be  employed  the  patient  must,  for  the  remainder  of  his  life,  pass  a 
bougie  from  time  to  time.  For  fibrous  strictures  forcible  dilatation  {drmlsiou) 
by  a  special  instrument  is  employed  or  incision  is  practised.  Incision  {proc- 
tototny)  may  be  either  external  or  internal.  In  internal  proctotomy  one  or 
more  incisions  are  made  from  the  rectum  through  the  stricture  down  to  healthy 
tissue,  the  first  cut  being  in  the  middle  line  posteriorly.  External  proctotomy, 
which  di\ides  the  sphincters,  is  apt  to  leave  incontinence  as  a  legacy.  Elec- 
trolysis finds  some  advocates,  but  on  what  grounds  it  is  difficult  to  see.  In 
some  cases  the  rectum  should  be  removed  by  Kraske's  resection,  the  sphincters 
being  spared  and  the  ends  of  the  gut  being  united.  In  incurable  cases  per- 
form iliac  colostomy. 

Cancer  of  the  rectum  is  the  cancer  of  the  bowel  most  often  met  with. 
According  to  Abbe  ("Keen's  Surgery'")  rectal  carcinomata  constitute  three- 
fourths  of  all  intestinal  tumors.  Its  growth  may  be  primarily  maUgnant  or 
may  arise  from  an  adenoma.  The  commonest  growths  are  composed  of  columnar 
cells,  and  may  be  either  soft  or  scirrhous.  In  cases  secondary'  to  epithelioma 
of  the  anus  ordinary  epithelioma  arises. 

In  most  rectal  carcinomata  the  cells  present  a  tubular  arrangement  sur- 
rounded by  a  more  or  less  plentiful  stroma  of  connective  tissue.  In  soft  tumors 
the  connective  tissue  is  scanty;  in  hard  tumors  it  is  plentiful.  The  softer  the 
growth  the  greater  its  malignancy  and  the  more  rapid  its  progress.  Scirrhus 
is  met  with  more  frequently  than  encephaloid.  Either  form  may  undergo 
colloidal  change.  Scirrhus  begins  as  a  nodule  in  and  under  the  mucous  mem- 
brane and  ulceration  is  late.     In  soft  cancer  ulceration  is  early. 

Sixty-five  per  cent,  of  cases  are  in  men.  Cancer  is  most  common  after  the 
age  of  forty,  but  it  not  unusually  occurs  before  the  thirty-fifth  year,  and  is 
sometimes  seen  as  early  as  the  twenty-fourth  year  or  even  earlier.  I  operated 
upon  a  man  of  twenty-seven  and  upon  another  of  thirty-one.  "Of  115  cases  of 
cancer  of  the  rectum  at  the  Rostock  Clinic,  4  occurred  in  patients  between 
fourteen  and  seventeen  years  of  age"  (Miles  Porter,  in  "'New  York  Med. 
Jour.,"  Feb.  10,  191 2).  Most  commonly  the  lower  margin  of  the  growth  is  on 
a  level  with  the  internal  sphincter.  Extensive  ulceration  occurs  in  the  growth 
and  may  also  occur  above  the  growth.  If  a  hard  ring  encircles  the  rectum 
the  lumen  of  the  tube  is  greatly  and  progressively  diminished.  In  cases  of 
diffuse  infiltration  the  lumen  is  not  greatly  lessened.     In  growths  involving  the 


'rrealniciU  of  ("ancer  of  the  Rectum  1327 

anus,  tlic  inguinal  glands  are  involved  and  also  the  glands  in  the  hollow  of  the 
sacrum.  In  growths  limited  to  the  rectum  proper,  the  glands  back  of  the  peri- 
toneum in  the  sacral  hollow  are  involved,  and  the  inguinal  glands  are  involved 
late  or  not  at  all. 

Symptoms. — In  the  beginning  and  for  a  considerable  time  after  there  are 
no  symptoms.  There  may  be  none  for  a  year  or  more.  Symptoms  begin  with 
ulceration  or  constriction.  The  symptoms  of  rectal  cancer  are  like  those  of  non- 
malignant  stricture,  except  that  the  pain  is  usually  greater  and  the  hemorrhage 
more  severe.  Constipation  is  apt  to  alternate  with  diarrhea.  The  diarrhea 
is  usually  in  the  morning.  Unfortunately,  in  many  cases  symptoms  are  long 
trivial;  in  fact,  pain  may  be  absent  until  the  disease  is  far  advanced.  Muco- 
purulent or  bloody  stools  are  often  thought  to  result  from  dysentery  or  hemor- 
rhoids, which  latter  condition,  however,  may  be  only  an  accompanying  con- 
dition of  rectal  cancer.  The  above  symptoms  may,  on  the  patient's  say-so, 
have  been  accepted  by  the  physician,  without  any  local  examination,  as  caused 
by  hemorrhoids.  The  patient,  again,  may  have  only  imagined  the  presence  of 
hemorrhoids,  since,  according  to  his  notion,  the  above  symptoms  must  result 
from  hemorrhoids,  with  which  condition  so  many  of  his  friends  with  like  com- 
plaints are  afflicted.  Loss  of  strength,  emaciation,  and  cachexia  are  generally 
noticeable  in  the  late  stages  only  of  rectal  cancer.  Tenesmus  becomes  unbearable. 
In  the  very  latest  stages  only  is  the  characteristic  odor  perceptible,  the  patient 
becomes  septic,  and  abscesses  attended  by  gangrene  may  form  (Ernest  Jonas, 
in  "Interstate  Med.  Jour.,"  No.  4,  1906).  The  finger  and  the  speculum  make 
the  diagnosis.  The  finger  and  speculum  must  be  inserted  most  gently  lest 
perforation  be  caused.  In  many  cases  of  cancer  the  anus  becomes  funnel- 
shaped  because  contraction  shortens  the  rectum  and  much  wasting  of  fat  occurs. 
In  rectal  cancer  metastasis  occurs  late.  The  most  favorable  cases  for  operation 
are  those  in  which  the  growth  is  small  and  movable.  Accurately  define  the 
extent  of  the  growth,  and  endeavor  to  make  out  if  it  has  invaded  the  cellular  tissue 
outside  of  the  rectum,  the  prostate,  the  bladder,  the  sacrum,  the  uterus  etc. 
Invasion  of  the  bladder  or  prostate  soon  causes  very  distressing  symptoms. 
Sooner  or  later  metastasis  occurs  to  the  liver.  If  unoperated  upon  cancer  of 
the  rectum  gives  a  prospect  of  life  of  from  one  to  five  years.  I  have  seen  nodules 
in  the  liver  three  months  after  the  first  symptoms  of  rectal  cancer  were  observed 
and  I  have  seen  a  man  aHve  six  years  after  symptoms  appeared. 

Treatment. — In  every  case  of  cancer  of  the  rectum  the  following  questions 
must  be  considered :  Shall  we  perform  a  radical  operation  in  hope  of  producing 
cure  or  at  least  greatly  prolonging  life?  In  what  cases  should  a  radical  opera- 
tion be  attempted?  It  is  the  proper  procedure  if  there  are  no  metastatic 
deposits,  if  the  patient  is  in  fair  general  condition  and  free  from  serious  organic 
disease,  and  if  the  cancerous  bowel  is  movable  and  not  fixed  by  dissemination 
to  adjacent  structures.  As  W.  Watson  Cheyne  ("Brit.  Med.  Jour.,"  June  13, 
1903)  says,  a  slight  adhesion  to  the  vagina  is  not  a  contra-indication,  because  this 
portion  of  the  vagina  can  be  readily  removed  with  the  diseased  rectum.  Some 
surgeons  wiU  not  attempt  radical  operation  if  they  cannot  pass  a  finger  through 
the  growth.  I  do  not  regard  high  position  as  forbidding  operation,  although, 
of  course,  it  makes  it  more  dangerous  to  life  and  less  promising  as  to  cure. 
Cheyne  is  of  the  same  opinion.  When  the  surgeon  is  first  called  to  a  case  of 
cancer  of  the  rectum  it  is  usually  found  to  be  so  far  advanced  as  to  be  inoperable. 
In  at  least  75  per  cent,  of  my  cases  radical  extirpation  was  impossible  when  I 
first  saw  the  case. 

If  a  radical  operation  be  determined  on,  the  next  question  to  answer  is, 
Shall  we,  or  shall  we  not,  perform  preliminary  colostomy}  If  the  cancer  is  very 
low  down,  involves  the  anal  canal,  and  is  to  be  removed  from  the  perineum, 
preliminary  colostomy  is  rejected  by  many.  I  beheve  that  even  in  such  cases 
it  should  be  done.     If  the  cancer  be  high  up  and  we  propose  to  attack  it  by 


1328 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


Weir's  method  or  the  Quenu-Mayo  method,  preUminary  colostomy  should 
not  be  done.  If  Kraske's  operation  is  to  be  performed,  I  believe  prelim- 
inary colostomy  is  usually  indicated.  It  enables  us  to  cleanse  the  area  upon 
which  operation  is  to  be  performed,  and  to  keep  the  wound  clean,  and  gives 
us  a  much  better  chance  of  obtaining  primary  union.  In  cases  in  which  the 
sphincter  is  retained  and  it  is  possible  to  anastomose  the  divided  ends  of  the 
gut  together,  colostomy  is  not  necessary;  and  if  an  artificial  anus  has  been 
made  in  such  a  case,  another  operation  will  be  required  to  close  it.  As  a  matter 
of  fact,  I  have  found  it  always  dilhcult  and  usually  impossible  to  suture  the 
divided  ends  of  the  gut  together  after  Kraske's  operation,  and  I  now  follow 
the  advice  of  Keen,  and  always  precede  Kraske's  operation  by  colostomy. 
The  abdominal  incision  necessary  to  reach  the  bowel  to  do  colostomy  may 
be  used  to  permit  of  exploration,  but  it  is  wiser  to  have  a  median  incision 
for  this  purpose.  I  consider  exploration  of  the  first  importance.  It  enables 
the  surgeon  to  examine  the  outer  surface  of  the  rectum,  to  detect  glandular 
involvement,  to  find  out  if  there  has  been  metastasis  to  the  liver,  and  to  de- 
termine with  certainty  whether  or  not  the  cancer  is  operable.  Several  times 
in  cases  of  small  and  apparently  operable  cancer  of  the  rectum  I  have  found 
on  opening  the  abdomen  extensive  glandular  involvement  or  unsuspected 
metastasis  to  the  liver,  and  once  I  found  another  cancer  4  inches  above  the  one 
to  which  attention  had  been  directed.     It  is  my  custom  to  make  a  median 

incision  for  exploration  and 
then  a  small  incision  through 
which  to  bring  out  the  gut  for 
colostomy.  A  large  abdominal 
incision  for  colostomy  is  ob- 
jectionable. I  strongly  object 
to  operating  at  all  on  rectal 
cancer  without  a  prehminary 
exploratory  operation.  If  rad- 
ical operation  be  rejected  (and 
about  three-fourths  of  the  cases, 
when  first  seen  by  the  surgeon, 
are  obviously  beyond  such  aid), 
palliative  treatment  is  desir- 
able. The  best  palliative 
treatment  is  th^  operation  of 
inguinal  colostomy.  If  this  be 
refused,  what  shall  be  done? 
One  plan  is  to  introduce  a  tube 
through  the  stricture  daily, 
wash  out  the  rectum  with  warm  water,  and  after  washing  inject  emulsion  of 
iodoform  (10  gr.  to  i  oz.  of  sweet  oil).  Injections  of  chlorid  of  zinc  (i  gr.  to 
I  oz.  of  water)  lessen  the  foulness  of  the  discharge.  The  bowels  are  opened 
regularly  by  laxatives,  and  if  the  growth  causes  obstructive  symptoms  it  is 
scraped  away  with  a  sharp  spoon.  Opium  is  given  to  relieve  pain.  The  ad- 
vantage of  this  plan  is  that  the  patient  does  not  suffer  from  the  unpleasantness 
of  an  artificial  anus.  Sooner  or  later,  however,  the  growth  gets  outside  of  the 
bowel,  and  terrible  pain  will  arise  from  involvement  of  the  sacral  plexus. 
W.  Watson  Cheyne  ("Brit.  Med.  Jour.,"  June  13, 1903)  would  restrict  palliative 
treatment  of  this  character  to  cases  in  which  fungating  masses  grow  from  one 
side  of  the  bowel. 

If  a  growth  encircles  the  bowel  and  produces  symptoms  of  obstruction, 
palliative  colostomy  should  be  performed.  This  operation  gives  great  comJort  to 
the  patient  and  allays  pain  by  intercepting  the  feces  before  they  reach  the  cancer. 
I  am  not  convinced  that  it  distinctly  retards  the  growth  of  the  cancer  or  notably 


Fig.  868. — Different  levels  of  resection  of  the  sacrum: 
K-O,  Kocher's  line;  B-0,  Kraske's;  B-H,  Hochenegg's; 
B-D,  Bardenheuer's;  R-S,  Rose's  (Mass.). 


Treatment  of  Cancer  of  the  Rectum 


1329 


prolongs  life.  Unfortunately,  colostomy  does  not  do  away  with  pain  if  the 
sacral  plexus  be  involved.  I  have  had  no  experience  with  radium  in  inoperable 
cancer  of  the  rectum  and  have  never  seen  the  .v-rays  produce  any  marked  or 
lasting  improvement.  Operative  treatment  includes  one  of  several  procedures. 
Excision  of  the  rectum  from  below  {Cripps's  operation)  is  practised  by  some  if  not 
more  than  3  inches  require  removal,  if  the  peritoneum  is  not  invaded,  and  if  the 
adjacent  organs  are  free  from  disease.  The  peritoneum  must  not  be  opened  in 
Cripps's  operation.  After  the  growth  is  removed  the  divided  rectum  is  pulled 
down  and  sutured  to  the  skin.  As  the  sphincter  is  sacrificed  the  condition  would 
be  dreadful  without  an  artificial  anus.  A  perineal  anus  without  a  sphincter  is 
vastly  more  distressing  than  an  inguinal  anus.  I  seldom  do  perineal  excision 
(it  does  not  permit  any  considerable  removal  of  lymph-glands).  When  of 
recent  years  I  have  done  it  I  have  preceded  it  by  exploratory  laparotomy  and 
the  formation  of  an  inguinal  anus.  In  some  cases  in  women  it  may  be  possible 
to  remove  a  low  growth  without  damage  to  the  sphincter  through  an  incision 
in  the  posterior  vaginal  wall.  Excision  of  the  rectum  after  excision  of  the  coccyx 
and  a  portion  of  the  sacrum  (Kraske's  operation,  that  is,  excision  of  the  rectum 
after  sacral  resection,  Fig.  868,  B-0)  is  a  procedure  which  permits  removal  of 
the  entire  tube,  portions  of  the  colon,  and  even  of  adjacent  parts.  The  peri- 
toneum is  opened  deliberately  in  this  operation,  and  is  subsequently  closed  with 
sutures  before  the  gut  is  opened.     The  glands  in  the  mesocolon  are  always 


Fig.  869. — Tying  off  the  tumor  through 
an  abdominal  incision  after  separating  peri 
toneum  from  sacrum  and  bladder  (Weir). 


Fig.  870. — Lower  end  of  rectum  everted 
through  the  anus  and  the  upper  end  of  bowel 
drawn  out  of  the  abdominal  cavity  (Weir). 


removed.  The  lower  end  of  the  upper  segment  of  bowel  is  fastened  in  the 
wound,  or,  if  colostomy  has  been  previously  performed,  may  be  closed.  In 
some  few  cases  in  which  it  is  not  necessary  to  remove  the  lower  end  of  the 
rectum,  the  two  portions  may  be  anastomosed  after  resection  of  a  part  of  the 
tube.  Kraske's  operation  may  be  done  by  an  osteoplastic  method,  the  bone 
not  being  removed.  It  is  well  to  precede  a  Kraske  operation  two  weeks  by  an 
inguinal  colostomy,  which  permits  of  cleansing  the  lower  bowel  of  feces  and 
lessens  the  chance  of  severe  wound  infection  and  delayed  healing  after  the  re- 
moval of  the  rectum.  Preliminary  colostomy  may  make  the  operation  of 
extirpation  more  difl&cult  by  fLxing  the  intestine,  and  thus  interfering  with  the 
necessary  drawing  down  of  the  gut  ("Operative  Surgery"  by  E.  H.  Taylor). 
If  the  growth  is  extensive  and  the  mesocolon  short,  it  may  be  best  to  perform 
right  inguinal  colostomy,  but  in  most  cases  left  inguinal  colostomy  is  preferred 
(Gerster).  The  colostomy  remains  open  during  the  patient's  life,  except  in 
those  rare  cases  of  Kraske's  operation  in  which  the  continuity  of  the  rectum  can 
be  reestablished  after  excision  of  the  growth.  In  such  cases  the  artificial 
anus  may  be  closed  some  time  after  resection  of  the  rectum. 

Robt.  F.  Weir  ("j\Ied.  News,"  July  27,  1901)  has  been  so  much  impressed 
with  the  difficulties  and  dangers  of  Kraske's  operation  in  a  case  of  high  car- 
84 


I330 


Diseases  and  Injuries  of  the  Rectum  and  Anus 


cinoma  that  he  now  employs  it  solely  in  cases  in  which  there  is  freedom  from 
disease  for  2  inches  immediately  above  the  anus  and  in  which  the  cancer  does 
not  extend  more  than  5  inches  above  the  anus.  In  high  cases  he  does  the  fol- 
lowing operation:  Open  the  abdomen  above  the  pubes,  separate  the  peritoneum 
so  that  the  bowel  and  "contents  of  the  sacral  curve"  are  liberated  behind 
nearly  "  to  the  tip  of  the  coccyx  and  in  front  of  the  edge  of  the  prostate."  The 
tumor  is  then  tied  off  with  tapes  (Fig.  869).  The  portion  of  the  rectum  bearing 
the  tumor  is  removed,  the  lower  end  of  the  bowel  is  everted  through  the  anus, 
and  the  upper  end  is  drawn  out  of  the  abdominal  incision  (Fig.  870).  The 
upper  end  is  then  caught  with  forceps  and  drawn  through  the  everted  lower  end 
of  the  rectum  (Fig.  871,  a).  The  ends  of  the  two  everted  portions  (Fig.  871,  b) 
are  sewn  together,  the  everted  bowel  is  replaced,  the  divided  peritoneum  is 
sutured  to  shut  off  the  peritoneal  cavity,  and  posterior  drainage  is  inserted 
(Fig.  872).  In  the  Quenu-Mayo  operation  the  object  is  to  remove  all  of  the 
diseased  glands  as  well  as  the  cancer  (Wm.  J.  Mayo,  in  "St.  Paul  Med.  Jour.," 
April,  1906).  The  patient  is  placed  in  an  exaggerated  Trendelenburg  position 
and  the  belly  is  opened  by  a  median  incision.  The  growth  is  studied  to  see  if 
it  is  removable,  and  a  search  is  made  for  enlarged  glands  which  might  cause  us, 


Fig.  871. — a,  The  upper  bowel  drawn 
out  through  the  everted  lower  end  of 
rectum;  b,  the  ends  of  the  two  portions  of 
the  rectum  sewn  together  (Weir). 


Fig.  872. — The  united  bowel  replaced 
with  posterior  drainage  and  the  divided 
peritoneum  so  sewn  together  as  to  shut  off 
the  general  peritoneal  cavity  from  the  pelvis 
(Weir). 


and  for  secondary  growths  which  would  cause  us,  to  abandon  the  operation. 
If  we  conclude  to  attack  the  growth,  pack  away  all  the  intestine  except  the 
sigmoid,  catch  two  clamps  across  the  sigmoid,  one  of  them  being  on  the  level 
of  the  sacral  promontory.  Divide  the  gut  between  them.  Free  the  mesosig- 
moid  by  lateral  cuts  and  bring  the  proximal  stump  out  of  the  belly,  Hgate  it, 
and  apply  a  purse-string  suture  to  invert  it.  A  gridiron  incision  is  then  made 
on  the  left  side  and  the  proximal  stump  is  pulled  through  it  and  is  sutured 
there.  Incisions  are  now  made  in  the  sides  and  in  front  to  Hberate  the  rectum, 
the  inferior  mesenteric  artery  is  tied  above  and  to  the  left  of  the  promontory, 
the  fat  and  glands  are  thoroughly  removed  from  the  sacral  hollow,  vessels 
being  tied  as  cut,  except  the  middle  sacral  and  middle  hemorrhoidal  vessels, 
which  are  tied  before  division.  The  area  is  now  packed  with  gauze  and  the 
patient  is  put  in  the  lithotomy  position.  The  rectum  is  packed  with  gauze, 
the  anus  is  sutured,  and  the  rectum  is  separated  from  the  prostate  and  urethra 
or  from  the  vagina  from  below  upward  to  just  above  the  levator  ani  muscle. 
An  assistant  presses  the  cancer-bearing  fragment  with  its  glands  down  from 
the  abdomen  and  the  surgeon  removes  it  from  the  perineum.  The  peritoneum 
is  sutured  within  the  abdomen,  room  being  left  for  a  small  drain  which  protrudes 
from  the  perineum.     The  perineal  wound  is  narrowed  by  sutures  and  the  wound 


Death-rate  from  Anesthetic  Agents  1331 

in  the  belly  is  closed.  In  twenty-four  hours  the  protruding  end  of  the  sigmoid 
is  opened  and  an  artificial  anus  is  thus  made. 

(See  Joseph  A.  Blake's  views  as  to  "The  Operation  of  Choice  in  Carcinoma 
of  the  Rectum,"  "New  York  Med.  Jour.,"  July  i,  1911.) 

The  mortahty  of  Kraske's  operation  is  from  12  to  15  per  cent.  Twenty- 
eight  per  cent,  of  Kocher's  cases  of  extirpation  of  cancer  of  the  rectum  remain 
well  from  three  to  sixteen  years  after  operation  (W.  W.  Cheyne,  "Brit.  Med. 
Jour.,"  June  13,  1903).  Charles  H.  Mayo  ("Annals  of  Surgery,"  Feb.,  1917) 
reports  753  cases  of  cancer  of  the  rectum.  Four  hundred  and  thirty  radical 
operations  were  performed  with  a  mortality  of  15.5  per  cent.  Before  19 13  the 
mortahty  was  17.7  per  cent.     During  1915  it  was  reduced  to  12.5  per  cent. 


XXX.  ANESTHESIA  AND  ANESTHETICS 


Anesthesia  is  a  condition  of  insensibility  or  loss  of  feeling  artificially 
produced.  An  anesthetic  is  an  agent  which  produces  insensibiHty  or  loss 
of  feeling.  Anesthetics  are  divided  into — (i)  general  anesthetics,  as  amylene, 
chloroform,  chlorid  of  ethyl,  ether,  bromid  of  ethyl,  nitrous  oxid,  and  bichlorid 
of  methylene;  (2)  local  anesthetics,  as  alcohol,  bisulphid  of  carbon,  carbolic 
acid,  ether  spray,  cocain,  eucain,  stovain,  ice  and  salt,  rhigolene  spray,  and 
ethyl  chlorid  spray. 

Anesthesia  may  be  induced  by  a  general  anesthetic  to  abolish  the  usual 
pain  of  labor  and  of  surgical  procedures;  to  produce  muscular  relaxation  in 
tetanus,  herniae,  dislocations,  and  fractures;  and  to  aid  in  diagnosticating 
abdominal  tumors,  joint  diseases,  fractures,  and  malingering. 

Ether  was  first  used  as  a  surgical  anesthetic  by  Crawford  W.  Long,  of 
Georgia,  in  1842,  but  he  did  not  pubHsh  his  cases  until  after  William  T.  G. 
Morton,  of  Hartford,  had  given  ether  in  public  in  1846.  The  ether  was  given 
to  a  patient  of  Dr.  Warren.  Dr.  W.  W.  Keen  says  ("Ether  Day  Address,"  191 5) 
"We,  who  are  accustomed  to  anesthesia,  can  hardly  appreciate  the  courage  of 
Warren  and  Morton  on  that  memorable  sixteenth  of  October,  1846.  Surely 
also  the  bravery  of  the  patient  himself  should  not  be  overlooked.  The 
name  of  Gilbert  Abbott  should  always  be  held  in  remembrance."  Horace  Wells 
gave  nitrous  oxid  in  1844.     Sir  James  Y.  Simpson  introduced  chloroform  in  1847. 

Death=rate  from  Anesthetic  Agents. — Sir  Frederic  W.  Hewitt  ("Anes- 
thetics and  Their  Administration")  combines  the  statistics  of  Julliard  and 
Ormsby,  with  the  following  result: 


Anesthetic 

Total  number  of 
administrations 

Total  number  of 
deaths 

Death-rate 

Chloroform 

Ether 

676,767 
407,553 

214 

25 

I  in    3,162 
I  in  16,302 

Hewitt  regards  the  St.  Bartholomew  Hospital  records  as  furnishing  the 
most  reliable  statistics  accessible.  He  takes  them  from  187  5-1 900.  The 
fatality  from  chloroform  was  i  in  1300;  from  ether  (and  gas  and  ether),  i  in  9319. 
It  is  to  be  noted  that  statistics  covering  many  countries  would  indicate  that 
chloroform  becomes  relatively  safer  in  warm  regions.  In  temperate  regions 
it  is  relatively  safer  (compared  with  ether)  in  summer  than  in  winter.  Hewitt 
is  of  the  opinion  that  ether  is  six  times  as  safe  as  chloroform.  Gwathmey 
("Jour.  Am.  Med.  Assoc,"  Nov.  23,  191 2)  collects  statistics  from  American 
sources.     In  157,453  administrations  of  ether  there  were  28  deaths  (about  i 


1332  Anesthesia  and  Anesthetics 

death  in  5623  administrations).  In  16,390  administrations  of  chloroform  there 
were  8  deaths  (about  i  death  in  2049  administrations). 

Hewitt  finds  that  during  the  last  forty  years  only  30  fatalities  are  recorded 
as  produced  by  nitrous  oxid,  and  he  thinks  several  of  these  should  be  excluded. 
It  is  practically  certain,  however,  that  many  deaths,  or  at  least  some  deaths, 
have  not  been  recorded. 

Seitz  collected  16,000  instances  of  anesthesia  by  chlorid  of  ethyl,  with  i 
death.  During  a  hospital  experience  of  twenty-eight  years  I  have  seen  anes- 
thetics (particularly  ether)  given  many  thousand  times.  For  five  years  I  gave 
ether  and  chloroform  for  Prof.  Keen.  I  have  witnessed  3  deaths,  each  of  which 
at  the  time  was  thought  to  be  directly  due  to  the  anesthetic,  and  i  of  them 
was  so  caused.  One  death  resulted  from  pouring  a  quantity  of  chloroform 
upon  an  Allis  inhaler,  the  bandage  of  which  had  been  saturated  with  ether.  At 
the  time  the  chloroform  was  poured  in  the  inhaler  the  patient  had  just  been 
struggling  and  consequently  was  breathing  deeply.  One  death  resulted  from 
giving  ether  on  a  thick  cone  made  of  several  towels  with  paper  between  the 
folds.  The  towels  were  saturated  with  ether,  the  patient  got  no  air  at  all,  and 
was  asphyxiated,  as  she  might  have  been  had  the  cone  been  wet  with  water 
only.  The  third  case  was  a  man  who  had  an  impacted  hip  fracture.  He  be- 
came cyanotic  under  ether  while  the  impaction  was  being  pulled  apart  and 
died.  The  death  was  supposed  to  be  due  to  ether,  but  necropsy  discovered 
fat  emboli  in  the  brain  and  lungs.  I  believe  that  for  a  huge  majority  of  surgical 
cases  ether  is  the  best  and  safest  general  anesthetic  and  that  other  general 
anesthetics  are  to  be  used  exceptionally  and  for  well-defined  reasons. 

Preparation  of  the  Patient. — Whenever  possible  prepare  a  patient  before 
administering  a  general  anesthetic,  and  prepare  him,  if  the  case  admits 
of  it,  during  two  or  more  days.  Heart  disease  is  not  a  positive  contra-indica- 
tion  to  surgical  anesthesia.  It  is  quite  true  that  anesthetics  are  dangerous 
to  people  with  fatty  hearts,  but  shock  is  also  dangerous,  and  the  surgeon 
stands  between  the  Scylla  of  anesthesia  and  the  Charybdis  of  shock.  Gallant 
truly  says  that  not  enough  attention  is  paid  to  the  "character  of  the  pulse 
and  action  of  the  heart  before  operation,  by  which  to  compare  its  work  during 
anesthesia,  and  after  the  operation  is  over,  and  this  neglect  leads  to  unneces- 
sary stimulation  and  overdriving  a  heart  which  is  doing  its  average  best."^ 
Always  examine  the  urine  if  the  nature  of  the  case  allows  time.  If  albumin 
be  found,  operation  is  not  contra-indicated,  but  the  peril  of  anesthesia  is  greater, 
and  certain  dangers  are  to  be  watched  for  and  guarded  against.  If  much 
albumin  is  present,  postpone  operation  except  in  emergency  cases.  If  sugar 
be  found,  the  danger  is  considerable,  as  diabetic  coma  occasionally  develops. 
The  percentage  of  sugar  does  not  determine  the  amount  of  danger.  Coma 
may  arise  when  only  a  little  sugar  is  present,  and  may  not  arise  when  there 
is  a  considerable  amount.  The  presence  of  aceto-acetic  acid  is  more  ominous 
than  is  the  presence  of  sugar.  Empty  the  intestinal  canal  by  purgation  a 
number  of  hours  before  anesthetization.  It  is  well  to  give  the  bowel  six  to 
twelve  hours'  rest  before  operation.  The  usual  custom  is  to  give  a  saline 
cathartic  the  evening  before  operation  and  an  enema  early  on  the  morning  of 
the  operation.  Frequently  the  nature  of  the  case  or  the  necessity  for  haste 
does  not  permit  of  preUminary  emptying  of  the  intestine  by  the  administration 
of  cathartics.  During  the  twenty-four  hours  preceding  operation  food  should 
be  taken  in  small  amounts  and  in  forms  easily  digestible.  During  a  day  or 
so  before  operation  there  is  usually  impaired  digestion,  and  no  undue  strain 
should  be  put  upon  the  stomach.  In  the  morning  allow  no  breakfast  if  the 
operation  is  to  be  performed  at  an  early  hour,  but  if  the  patient  be  very  weak, 
order  a  little  brandy  and  beef-tea.  If  the  operation  is  to  be  about  noon,  give 
a  breakfast  of  beef-tea  and  toast  or  a  little  consomme;  ticver  give  any  food 
1  "Medical  Record,"  Feb.  2,  1S99. 


Preparation  of  the  Patient  1333 

within  three  hours  of  the  operation,  but  brandy  is  admissible  if  stimulation  be 
required.  If  the  stomach  is  not  empty  at  the  time  of  operation,  vomiting  is  al- 
most inevitable,  and  portions  of  food  may  enter  the  windpipe;  if  the  stomach 
contains  no  food,  vomiting  is  far  less  likely  to  happen;  and  even  if  it  occurs  and 
vomited  matter  should  enter  the  windpipe,  it  may  do  little  harm,  as  it  consists 
chiefly  of  hquid  mucus.  In  cases  of  intestinal  obstruction  in  which  there  has 
been  stercoraceous  vomiting  there  is  much  danger  that  vomiting  will  occur  dur- 
ing anesthetization.  In  some  cases  of  intestinal  obstruction,  during  the  admin- 
istration of  the  anesthetic  and  during  the  anesthetic  state,  a  stream  of  stinking 
brown  fluid  may  flow  without  effort  from  the  mouth.  Vomiting  or  regurgi- 
tation of  stercoraceous  material  is  profuse,  sudden,  and  dangerous.  It  may 
flood  the  bronchial  tubes  during  inspiration  and  cause  death  by  suffocation. 
In  a  case  in  which  stercoraceous  vomiting  has  occurred  wash  out  the  stomach 
before  administering  the  anesthetic.  If  a  patient  with  intestinal  obstruction 
is  too  weak  to  permit  lavage,  a  local  anesthetic  should  be  used  instead  of  a 
general  anesthetic.  Vomiting  while  the  patient  is  under  the  influence  of 
an  anesthetic  is  dangerous  in  any  case,  because  of  the  great  cardiac  weakness 
which  precedes  and  follows  it.  If  a  patient  sleeps  well  the  night  before  an 
operation,  he  will  probably  take  the  anesthetic  better  than  if  he  sleeps  poorly. 
Effort  should  be  made  to  obtain  a  night's  sleep.  An  excellent  expedient  is 
a  hot  ammonia  bath,  followed  by  a  rub-down  with  weak  alcohol.^  It  may  be 
necessary  to  administer  trional  or  bromid.  About  fifteen  minutes  before 
giving  the  anesthetic  let  the  patient  drink  a  glass  of  hot  water.  Water 
protects  the  stomach  from  the  irritant  effects  of  any  anesthetic  which  may 
be  swallowed.  Before  giving  the  anesthetic  see  that  artificial  teeth  are  re- 
moved and  that  the  patient  does  not  have  a  piece  of  candy  or  a  chew  of  tobacco 
in  the  mouth.  Always  have  a  third  party  present  as  a  witness,  because  in 
an  anesthetic  sleep  vivid  dreams  occur,  and  erotic  dreams  in  women  may 
lead  to  damaging  accusations  against  the  surgeon.  Place  the  patient  re- 
cumbent. The  effort  should  be  to  place  him  in  as  comfortable  a  position  as  pos- 
sible if  this  position  be  consistent  with  operative  necessities.  Put  a  small  piUow 
under  him,  so  as  to  support  the  normal  lumbar  curve  and  prevent  postopera- 
tive backache.  See  that  the  clothing  is  loose,  particularly  that  there  is  no 
constriction  about  the  neck  and  abdomen.  Do  not  have  the  head  high  unless 
this  position  is  demanded  by  the  exigencies  of  the  operation.  The  anesthetist 
must  have  a  mouth-gag  and  a  pair  of  tongue  forceps  at  hand.  It  is  very 
wrong  to  say  that  a  mouth-gag  and  tongue  forceps  are  never  necessar}\  It 
is  quite  true  they  are  often  used  when  not'  needed,  but  this  does  not  justify 
us  in  being  without  them  when  they  are  needed,  and  they  may  be  needed  -very 
badly.  The  anesthetist  should  also  have  a  pair  of  artery  forceps  and  some  small 
gauze  sponges  with  which  to  swab  out  the  mouth  and  throat.  A  hypodermatic 
syringe  in  working  order,  and  solutions  of  strychnin,  atropin,  and  brandy  are 
to  be  in  an  accessible  place,  oxygen  must  be  ready  for  administration,  and 
it  is  well  to  have  an  electric  battery  adjacent.  Accidents,  it  is  true,  are  rare, 
but  they  may  happen  at  any  time,  and  hence  the  surgeon  should  always  be. 
prepared  for  them.  Any  danger  which  arises  must  be  met  promptly  and 
decisively,  or  action  will  be  of  no  avail.  As  Professor  Keen  says:  "  Every  case  of 
anesthesia  irrespective  of  the  method  employed  requires  unremitting  watchful- 
ness from  first  to  last"  (Ether  Day  Address  at  Massachusetts  General  Hospital 
Oct.  16, 1915).  Many  surgeons  give  a  hypodermatic  injection  of  morphin  a  short 
time  before  operation  to  steady  the  heart,  to  prevent  vomiting  during  anestheti- 
zation, to  shorten  the  stage  of  excitement,  to  prevent  rigidity,  and  to  aid  the 
bringing  about  of  insensibihty  with  very  little  of  the  anesthetic.  The  method 
has  been  tried  by  many  during  the  last  forty  odd  years.  It  is  used  in  drunkards 
(as  their  muscles  tend  to  remain  rigid  in  the  anesthetic  state),  in  those  whom  it  is 
1  A.  Ernest  Gallant,  "Med.  Record,"  Dec.  30,  1899. 


1334  Anesthesia  and  Anesthetics 

difficult  to  make  completely  unconscious,  in  neurotic  individuals,  and  in  badly 
frightened  subjects.  Epileptics  are  very  apt  to  clinch  the  jaws,  become  cyan- 
otic and  get  convulsions  when  anesthetized.  A  preliminary  injection  of 
morphia  lessens  their  liability  to  such  disorders.  Its  greatest  use  has  been  in 
operations  about  the  mouth  and  face,  for  in  these  procedures  an  anesthetic  has 
been  given  on  a  towel  or  inhaler,  has  been  of  necessity  given  intermittently,  and  a 
preliminary  dose  of  morphin  has  been  found  to  keep  the  patients  from  rousing 
during  the  intervals.  At  present  intratracheal  anesthesia  does  away  with  the 
need  of  morphin  in  operations  about  the  mouth  and  face.  There  are  objec- 
tions to  giving  morphin  before  anesthesia,  and  its  use  should  be  the  exception 
and  not  the  rule.  It  should  not  be  used  in  children,  in  cases  of  stupor,  or  in 
cases  in  which  the  respiratory  center  is  disordered.  It  depresses  respiration, 
lowers  temperature,  and  thus  perhaps  increases  operative  shock,  interferes 
with  the  pupillary  phenomena  of  anesthesia,  delays  awakening  from  the 
anesthetic  sleep,  adds  to  subsequent  abdominal  distention  and  headache,  and 
actually  favors  postanesthetic  vomiting.  Hewitt  ("Anesthetics  and  Their 
Administration")  says  that  several  recorded  fatalities  were  due  to  the  combina- 
tion. If  the  surgeon  determines  to  give  morphin,  he  gives  '  q  to^i  gr.  twenty 
minutes  before  the  anesthetist  begins  to  give  the  anesthetic.  Hewitt  (Ibid.)  says: 
''The  anesthetic  should  be  given  until  the  usual  signs  of  anesthesia  commence  to 
appear.  It  should  then  be  discontinued  for  a  few  moments  and  only  reapplied 
as  occasion  may  require.  As  little  as  possible  of  the  ether  or  chloroform  should 
be  subsequently  administered;  the  conjunctival  reflex  should  be  retained. " 
In  the  clinic  of  the  Jefferson  Hospital  the  elder  Gross  long  used  as  a  routine  the 
preliminary  administration  of  opium,  but  during  his  later  years  he  used  it  ex- 
ceptionally. His  successor,  the  younger  Gross,  used  morphin  hypodermatically 
exceptionally.  In  some  cases  we  may  anticipate  trouble  from  the  anesthetic. 
Cyanosis  may  occur  in  drunkards;  in  fat,  thick-necked  individuals  of  the  Major 
Bagstock  type,  who  are  short  of  breath  and  congested  in  appearance;  in  indi- 
viduals with  some  disease  of  the  lungs,  bronchi,  pharynx,  larynx,  or  trachea 
(empyema,  emphysema,  chronic  bronchitis,  croup,  cancer  of  the  larynx,  etc.); 
in  individuals  suffering  from  fatty  heart  or  valvular  incompetence.  Buxton 
points  out  that  an  individual  without  teeth  and  with  stenosis  of  the  nares  is  apt 
to  become  cyanotic  under  an  anesthetic,  because  the  lips  and  pillars  of  the 
fauces  are  drawn  in  like  valves  during  inspiration. 

Ether  and  Chloroform. — The  two  favorite  anesthetics  are  ether  and 
chloroform.  Only  the  very  best  ether  or  chloroform  should  be  used.  It 
is  a  good  plan,  in  order  to  lessen  bronchitis,  to  mix  with  ether  turpentine 
of  Pinus  pumilio  in  the  proportion  of  20  drops  to  6^2  oz.  (Becker,  in  "Cen.- 
tralbl.  f.  Chir.,"  June  i,  1901).  Chloroform  is  more  dangerous  than  ether 
in  general  cases,  though  it  is  more  agreeable,  less  irritant  to  the  lungs  and 
kidneys,  and  quicker  in  its  action.  Chloroform,  compared  to  ether,  is  relatively 
safer  in  warm  than  in  cold  countries.  In  fact,  in  the  tropics  it  is  a  matter  of 
considerable  difficulty  to  use  ether  because  of  its  great  volatility.  It  should, 
however,  be  noted  that  Squire  used  ether  successfully  when  the  temperature 
was  i2o°F.  in  the  shade  (''Lancet,"  vol.  i,  1913).  Chloroform  is  preferred  in 
campaigns,  because  less  is  required  and  transportation  is  easier.  Recovery 
from  chloroform  is  quicker  and  quieter  than  that  from  ether,  but  chloroform 
vomiting  lasts  longer  than  ether  vomiting.  Chloroform  may  induce  sudden 
and  even  fatal  syncope.  Hare's  experiments  on  animals  indicate  that  chloro- 
form may  kill  by  respiratory  failure  occurring  secondarily  to  failure  of  the  vaso- 
motor center;  but  certain  it  is  that  clinically  a  danger  of  chloroform  is  paralysis 
of  the  heart,  and  this  condition  may  come  on  so  rapidly  that  death  may  occur 
almost  before  an  attempt  can  be  made  to  save  life.  Heart  flutter  may  be  the 
cause  of  sudden  death.  Leonard  Hill  has  proved  that  most  chloroform  deaths 
that  take  place  after  a  considerable  amount  of  the  anesthetic  has  been  taken 


Ether  and  Chloroform  '      1335 

arise  from  paralytic  distention  of  the  heart.  Sudden  death,  when  inhalations 
of  chloroform  have  just  commenced,  may  be  due  to  the  irritant  vapor  acting 
on  the  nasal  mucous  membrane,  exciting  a  nasal  reflex,  and  powerfully  stimulat- 
ing cardiac  inhibition.  If  ether  produces  danger  it  does  so  usually  through  the 
respiration,  and  not  the  heart,  and  there  is  generally  time  to  undertake  resusci- 
tation, which  is  apt  to  be  successful.  Chloroform  is  preferred  to  ether  by  many 
surgeons  for  children  under  ten  years  of  age,  in  whom  ether  causes  a  great  out- 
flow of  bronchial  mucus,  which  may  asphyxiate;  for  people  over  sixty,  entirely 
free  from  myocardial  disease,  at  which  age  most  persons  have  some  bronchitis, 
and  ether  chokes  them  up  with  mucus.  Ether  also  irritates  the  kidneys, 
which  at  the  latter  age  are  apt  to  be  weak  or  diseased.  Personally,  I  give  ether 
even  to  infants  (if  they  are  free  from  bronchitis)  and  to  old  subjects  without 
marked  respiratory  trouble.  Chloroform  is  given  if  the  actual  cautery  is  to 
be  used  about  the  face,  neck,  or  mouth,  because  ether  vapor  may  take  fire 
and  chloroform  vapor  will  not.  Chloroform  is  preferred  for  labor  cases,  when 
moderate  anesthesia  only  is  required,  and  was  preferred  for  operations  on  the 
mouth  and  nose  before  the  advent  of  intratracheal  anesthesia.  In  cleft- 
palate  operations  chloroform  is  usually  preferred,  because  it  causes  but  little 
cough  and  salivary  flow.  In  ligation  of  a  large  artery  which  is  overlaid  by  a 
vein  ether  greatly  enlarges  the  vein,  but  this  is  no  real  embarrassment  to  an 
experienced  surgeon.  In  goiter  operations  ether  will  decidedly  enlarge  the 
veins.  Most  goiters  may  be,  and  many  should  be,  removed  with  the  aid  of 
local  anesthesia  only.  Chloroform  is  particularly  dangerous  when  there  is 
myocardial  disease,  and  is  apt  to  produce  cyanosis  and  embarrassed  respiration. 
In  valvular  heart  disease  chloroform  is  more  dangerous  than  ether,  and  even  in 
functional  heart  trouble  it  is  an  undesirable  anesthetic.  It  should  not  be  used 
in  those  who  smoke  or  chew  tobacco  to  excess,  or  who  overindulge  in  coffee  or 
alcohol.  Chloroform  is  more  dangerous  in  shock  than  ether.  A  patient 
in  dangerous  shock  requiring  operation  should,  if  possible,  have  the  nerves 
coming  from  the  part  injected  with  cocain  so  as  to  cause  the  "physiological 
block''  of  Crile  (see  page  289).  Chloroform  is  preferred  for  patients  with 
difficult  respiration  from  any  cause  other  than  heart  disease  (in  emphysema, 
bronchitis,  or  pulmonary  tuberculosis),  and  for  patients  with  kidney  disease. 
I  am  convinced  that  etherization  is  sometimes  responsible  for  a  latent  area 
of  pulmonary  tuberculosis  becoming  active.  Some  surgeons  do  not  use  ether 
in  abdominal  operations  because  they  beHeve  it  may  cause  persistent 
oozing  of  blood,  but  this  view  is  not  in  accord  with  the  author's  experience. 
Ether  is  the  best  and  safest  anesthetic  for  general  use.  It  is  much  safer 
than  chloroform  in  valvular  disease  and  functional  heart  trouble.  It  is 
dangerous  in  myocardial  disease,  but  not  nearly  so  dangerous  as  chloroform. 
In  valvular  disease  without  heightened  arterial  tension  it  is  reasonably  safe, 
but  in  valvular  disease  with  heightened  arterial  tension  it  is  dangerous.  Ether 
is  dangerous  when  atheroma  exists.  Both  ether  and  chloroform  may  induce 
changes  in  the  blood.  ^  In  practically  all  cases  they  produce  a  diminution  of 
hemoglobin  and  leukocytosis.  In  some  cases  they  produce  alteration  in  the 
shape  of  the  corpuscles.  These  changes  are  especially  marked  in  anemic  blood. 
Ether  produces  distinct  leukocytosis,  probably  toxic  in  origin.  Both  ether  and 
chloroform  seem  to  lessen  the  phagocytic  activity  of  leukocytes  and  hence  to 
lower  vital  resistance  (Ferguson,  in ''New  York  Med.  Jour.,"  May  11,  1912). 
These  blood  changes  indicate  that  prolonged  anesthesia  must  militate  against  re- 
covery from  a  severe  operation.  If  a  patient's  hemoglobin  be  below  30  per  cent., 
a  general  anesthetic  should  not  be  given.  During  the  state  of  anesthesia  the 
temperature  drops  from  i  to  3  degrees  or  more,  hence  the  patient  should  be 

^  See  the  author  on  the  "Blood-alterations  of  Ether-anesthesia,"  "Medical  News," 
March  2,  1895,  and  also  the  author  and  Kaltej^er  in  "The  Proceedings  of  the  American  Surgical 
Association  for  1901." 


1336 


Anesthesia  and  Anesthetics 


carefully  covered  during  the  operation.  The  question  as  to  the  effect  of  ether 
on  the  kidneys  is  much  disputed.  Most  surgeons  believe  that  it  tends  to 
cause  albuminuria  or  increase  existing  albuminuria.  Nitrous  oxid  is  very 
dangerous  when  there  is  vascular  degeneration,  and  it  may  induce  apoplexy. 
It  is  dangerous  if  the  air-passages  are  narrowed  as  by  a  goiter.  Ether  and  chloro- 
form lower  temperature  and  so  do  other  general  anesthetics.  The  patient 
responds  to  external  heat  and  cold  like  a  cold-blooded  animal  (Pembrey  and  Ship- 
way,  in  "Proc.  Roy.  Soc.  Med.,"'  1916).  This  dissipation  of  body  heat  is  a  danger 
and  calls  for  the  protection  of  the  patient  against  chilling  during  an  operation. 
In  giving  ether  or  chloroform  the  administrator  must  devote  his  undivided 
attention- to  the  task.  He  must  note  every  symptom,  must  order  or  carry  out 
proper  treatment  for  complications,  and  must  keep  the  operator  informed  as  to 
the  necessity  for  haste.  The  anesthetist  must  be  a  man  who  has  a  wholesome 
respect  for  ether  and  chloroform,  although  not  afraid  of  them. 

Can  an  anesthetic  be  administered  to  a  sleeping  person  without  waking 
him?  I  know  that  chloroform  can  be  so  given,  for  I  have  succeeded  in  giving 
it  to  a  child  without  breaking  the  slumber.  Probably,  in  most  cases,  an  attempt 
will  fail,  but  in  some  it  will  succeed.  Stone  ("Cleveland  ^Vled.  Jour.,"  Jan., 
1902)  reports  successful  administration  to  sleeping  children  and  also  the  chloro- 
forming of  a  resident  physician  while  asleep.  Paugh  (''Jour.  Am.  Med.  Assoc," 
Mav  18,  1901)  reports  three  successes  ^\dth  children.  Ether,  because  of  the 
irritant  nature  of  its  vapor,  would  be  more  apt  to  arouse  a  sleeper  than 
chloroform. 

Administration  of  Chloroform. — Chloroform  should  be  given  by  a 
highlv  trained  man  only.  In  fact,  safety  in  giving  chloroform  is  dependent  upon 
skill  and  experience  more  than  in  giving  ether.  No  one  should  think  of  allowing 
anyone  but  a  physician  to  give  chloroform.  The  most  dangerous  period 
is  when  the  patient  is  incompletely  anesthetized,  but  is  going  under.     Most 


Fig.  873. — Skinner's  mask. 


Fig.  874. — Junker's  inhaler. 


deaths  happen  at  this  time.  In  administering  chloroform  have  at  hand  a 
mouth-gag,  tongue  forceps,  artery  forceps,  small  gauze  sponges,  a  clean  towel, 
h>'podermatic  syringes  loaded  with  solutions  of  strychnin,  atropin  and  brandy, 
an  electric  battery,  and  a  can  of  oxygen.  Use  pure  chloroform  only.  The 
patient  should  be  recumbent.  The  erect  or  semi-erect  positions  are  dangerous 
in  chloroform  anesthesia.  The  Trendelenburg  position  is  admissible  (see 
page  1205).  No  special  inhaler  is  required,  but  the  drug  may  be  given  upon  a 
thin  towel,  a  napkin,  or  a  piece  of  lint.  The  mask  of  Skinner  (Fig.  873) 
is  very  useful.  Junker's  inhaler  (Fig.  874)  is  used  by  many  anesthetists.  In 
operations  about  the  face  Souchon's  instrument  is  serviceable.  Souchon's 
apparatus  is  so  arranged  that  chloroform  may  be  given  through  a  tube  which  is 
introduced  through  the  nose,  the  instrument  being  well  out  of  the  way  of  the 
operator.     Some  surgeons  cocainize  the  nares  before  giving  chloroform,  so  as 


Administration  of  Ether  1337 

to  prevent  the  supposedly  dangerous  nasal  reflex  (Rosenberg).  It  is  advisable 
to  smear  the  lips  and  face  (including  the  eyelids)  with  white  vaselin  to  prevent  blis- 
tering. The  chloroform  vapor  must  be  well  mixed  with  air.  The  chloroform  is 
sprinkled  on  the  fabric  from  a  drop-bottle.  Raise  the  napkin  well  above  the 
mouth,  add  5  drops  of  chloroform,  and  tell  the  patient  to  take  deep  and  regular 
breaths,  but  do  not  tell  him  to  breathe  forcibly.  Forcible  respiration  may  lead  to 
cessation  of  respiration.  Add  a  few  more  drops  of  chloroform,  and  when  the 
patient  grows  so  accustomed  to  it  that  he  or  she  does  not  choke,  turn  the  wet  part 
of  the  fabric  toward  the  face  and  place  it  near  the  mouth;  do  not  touch  the  mouth 
with  the  wet  lint,  because  it  will  blister.  If  the  drug  be  given  gradually,  struggling 
is  not  usually  violent  or  prolonged.  Never  pour  on  a  large  amount  at  one  time. 
Keep  the  lower  jaw  pushed  forv/ard  during  the  time  the  chloroform  is  being 
given.  Cough  and  vomiting  at  this  time  mean  that  the  vapor  is  too  strong. 
During  the  stage  of  excitement  do  not  suspend  the  administration  of  chloroform 
unless  respiration  becomes  difficult,  in  which  case  suspend  it  until  the  patient 
takes  one  or  two  respirations.  If  the  patient  struggles,  do  not  hold  him,  and  push 
the  administration  of  the  drug.  He  holds  his  breath  while  struggling,  and 
as  struggling  ceases  takes  full,  deep  breaths.  If  the  inhaler  be  saturated  with 
chloroform,  he  may  inhale  a  dangerous  amount  during  the  deep  respiration 
after  struggling.  Chloroform  given  in  considerable  amount  when  the  patient 
is  breathing  deeply  from  the  effects  of  ether  is  unsafe.  If  chloroform  is  given 
subsequent  to  anesthetization  by  ether,  it  should  be  given  gradually  and  well 
mixed  with  air.  When  the  patient  becomes  anesthetized,  give  just  enough  of 
the  drug  to  keep  him  so.  While  a  patient  is  taking  chloroform  hiccup  usually 
means  that  vomiting  is  about  to  occur.  If  vomiting  occurs  at  this  time  more 
chloroform  must  be  given  to  abolish  the  reflexes.  Deep  and  sighing  respiration 
and  repeated  swallowing  indicate  that  more  of  the  anesthetic  is  required.  Stop 
the  administration  or  give  very  little  when  shock  becomes  evident  or  when  there 
is  profuse  hemorrhage.  Chloroform  vapor  is  not  inflammable,  hence  it  is 
safer  than  ether  when  a  hot  iron  is  to  be  used  about  the  face  and  when  there  is 
a  lighted  lamp  or  a  stove  in  a  small  room;  but  the  presence  of  a  naked  gas-flame 
decomposes  chloroform  into  irritant  products  of  chlorin  (COCI3),  which  cause 
the  patient  and  the  surgeon  to  cough. 

Chloroform  and  Oxygen. — The  use  of  this  mixture  was  suggested  by 
Neudorfer.  •  Some  anesthetists  advocate  the  mixture  of  chloroform  and  oxygen, 
asserting  that  it  does  not  produce  spasm  of  the  glottis  or  muscles  of  respiration, 
that  it  does  not  produce  cyanosis  or  weakness  of  circulation,  that  it  does  not 
irritate  the  kidneys,  is  safer  to  life  than  pure  chloroform,  and  is  less  often 
productive  of  severe  and  prolonged  vomiting.  These  alleged  advantages 
are  probably  stated  with  rather  undue  emphasis,  although  I  do  believe  the  mix- 
ture has  less  tendency  to  produce  cyanosis  than  has  the  pure  drug,  does  not  so 
often  induce  vomiting,  and  is  somewhat  safer.  Hewitt  does  not  think  that  the 
method  offers  any  "special  advantages"  ("Anesthetics  and  Their  Administra- 
tion," by  Sir  Frederic  W.  Hewitt).  If  this  method  be  used,  a  bag  containing 
oxygen  is  attached  to  the  hand-bellows  attachment  of  a  Junker  inhaler,  and 
oxygen  is  forced  through  the  chloroform  and  flows  to  the  face-piece. 

Administration  of  Ether. — The  administration  should  not  be  intrusted 
to  a  novice.  The  anesthetist  should  be  one  of  your  most  trusted  men.  I  do 
not  believe  in  allowing  a  nurse  to  give  ether.  She  cannot  have  sufficient 
knowledge  to  observe  incipient  trouble,  to  anticipate  untoward  effects,  and  to 
at  once  do  the  correct  thing  when  difi&culty  arises  or  calamity  impends.  The 
moral  responsibility  and  the  legal  responsibility  demand  that  a  physician  give 
the  ether.  Usually  the  patient  is  recumbent  but  if  necessary  he  can  be  placed 
on  the  side,  prone,  semi-erect  or  in  the  Trendelenburg  position  (seepage  1205). 
Some  anesthetists  precede  the  administration  of  the  ether  by  causing  the  patient 
to  breathe  the  vapor  of  oil  of  orange.     The  patient  finds  it  pleasant  and  loses 


1338 


Anesthesia  and  Anesthetics 


some  of  his  apprehension,  and  the  oil  so  dulls  the  reflexes  of  the  air  passages  that 
when  ether  is  substituted  for  the  orange  it  is  "  taken"  more  easily  than  otherwise 
would  be  the  case.  Ether  is  best  given  from  a  partially  open  inhaler.  The  most 
satisfactory  appliance  is  AHis'sinhaler  (Fig.  875).  This  inhaler  secures  a  plentiful 
supply  of  air.  Before  being  used  the  metal  frame  is  scalded,  dried,  and  threaded 
with  a  clean  gauze  bandage.  The  end  of  the  frame  which  is  to  be  toward  the 
mouth  is  covered  with  one  layer  of  gauze.  The  frame  is  then  inserted  in  a 
clean  metal  case  and  the  case  is  wrapped  in  a  clean  towel.  The  drug  is  given 
drop  by  drop,  the  drops  following  each  other  in  regular  sequence.  This  is  known 
as  the  drop  method.  The  drop  method  is  the  safest  plan  and  the  most  com- 
fortable to  the  patient.  Instead  of  Allis's  inhaler  a  piece  of  gauze  or  an  Esmarch 
inhaler  may  be  used.  Some  surgeons  prefer  closed  inhalers.  The  Clover 
inhaler  (Fig.  876)  is  popular  in  England.  F  is  the  face-piece;  C,  a  reservoir  of 
ether  through  which  the  air-current  passes;  B  is  an  India-rubber  bag.  In  this 
apparatus  there  is  no  provision  for  the  entrance  of  fresh  air.     Rv  turning  the 


Fig.  875. — Allis's  ether  inhaler.  Fig.  876. — Clover's  portable  regulating  ether  inhaler. 

reservoir  C  on  the  tube  /  the  amount  of  current  passing  over  the  ether  can 
be  regulated.  When  this  apparatus  is  used,  the  ether  vapor  breathed  into  the 
lungs  is  expired  into  the  bag  and  is  rebreathed.  The  inhaler,  if  used  by  a 
skilful  man,  is  very  useful;  but  any  lack  of  watchfulness  or  skill  will  permit  of 
cyanosis,  and  the  very  young,  the  senile,  the  anemic,  and  feeble  are  best  anesthe- 
tized by  the  drop  method  described  above. 

An  admirable  detailed  account  of  anesthetization  by  the  closed  method 
will  be  found  in  Sir  Frederic  W.  Hewitt's  treatise  on  "  Anesthetics  and  Their 
Administration,"  and  in  Mr.  Dudley  W.  Buxton's  treatise  on  "Anesthetics, 
Their  Uses  and  Administration."  When  giving  ether,  have  at  hand  the  same 
drugs  and  appliances  as  when  chloroform  is  given,  and  keep  the  lower 
jaw  pushed  forward  during  the  administration.  When  using  Allis's  inhaler, 
take  every  care  that  none  of  the  ether  runs  through  on  to  the  face  and  into  the 
eyes.  If  it  does  it  will  irritate  and  perhaps  blister.  Even  the  vapor  irritates 
the  eyes,  and  boric  acid  solution  should  be  used  now  and  then  during  the  admin- 
istration to  flush  out  the  conjunctival  sacs.  It  is  wise  to  grease  the  face  and 
lips  with  vaselin.  Place  the  dry  inhaler  over  the  mouth  and  nose,  let  the 
patient  take  several  breaths,  that  he  may  gain  confidence,  begin  to  drop  ether 
into  the  inhaler,  let  the  patient  take  several  more  breaths,  and  so  on,  gradually 
increasing  the  rapidity  with  which  the  drops  of  ether  are  given.  If  he  tends  to 
struggle,  diminish  the  amount  of  ether  for  a  time,  but  do  not  hold  him.     Do  not 


The  Cotton  Process  Ether  i339 

tell  him  to  breathe  forcibly.  Forcible  breathing  is  liable  to  cause  a  cessation 
of  respiration.  Never  suddenly  add  a  large  amount  of  the  anesthetic:  it  causes 
coughing  and  often  vomiting.  When  the  patient  becomes  thoroughly  anesthe- 
tized, give  a  very  little  ether  as  often  as  is  required  to  maintain  unconsciousness. 
When  bleeding  is  profuse  or  shock  is  marked,  suspend  the  administration  of 
ether  or  give  very  little  of  it.  If  he  rolls  his  eyes  from  side  to  side,  if  the  respira- 
tions are  deep  and  sighing,  if  there  are  repeated  movements  of  swallowing,  more 
anesthetic  should  be  given  (Tarnowsky).  Hiccup  is  often  preliminary  to  vomit- 
ing, and  always  means  that  the  reflexes  are  returning.  If  a  hot  iron  is  to  be 
used  about  the  face,  remove  the  inhaler  and  fan  away  the  ether  before  bring- 
ing the  cautery  near.  Have  any  light  set  high  up,  as  ether  vapor  is  heavier 
than  air,  and  no  explosion  is  possible  until  it  reaches  the  level  of  the  flame.  If 
the  vapor  takes  fire,  cover  the  patient's  mouth  and  nose  with  a  towel. 

The  patient  should  be  kept  in  a  condition  in  which  he  feels  no  pain,  makes 
no  movement,  and  is  not  rigid.  In  this  condition  the  cutaneous  reflexes  are 
abolished,  the  breathing  is  regular  and  quiet,  the  color  is  good,  and  the  pupils 
react  to  light,  though  slowly.  Just  enough  anesthetic  must  be  given  to  cause 
the  patient  to  pass  into  this  condition  and  remain  in  it.  To  give  any  more 
is  to  poison  him.  The  amount  necessary  varies  witl^^||ie  individual  and  the 
operation,  and  requires  skill,  experience,  and  attennon  on  the  part  of  the 
anesthetist. 

The  old  idea  that  we  must  poison  a  man  into  dangerous  coma  has  been 
abandoned.  When  the  breathing  becomes  louder,  more  rapid,  or  spasmodic, 
it  means  that  reflexes  are  returning,  and  a  little  more  anesthetic  should  be 
given. 

The  Cotton  Process  Ether. — ^Dr.  James  H.  Cotton  of  McGill  University, 
after  many  careful  experiments  and  observations  has  published  some  novel  views 
upon  ether  ("Jour.  Canadian  Med.  Assoc,"  Sept.,  1917).  The  aim  of  the  manu- 
facturer has  been  to  make  ether  as  nearly  pure  as  possible.  The  process  of 
to-day  makes  purer  ether  than  that  made  years  ago,  yet  surgeons  often  feel  that 
patients  cannot  be  anesthetized  as  rapidly  as  in  former  days  and  that  primary 
anesthesia  is  more  difficult  to  obtain.  Cotton  believes  that  just  as  ether  ap- 
proaches to  purity  it  loses  more  and  more  of  its  anesthetic  power,  that  by 
removing  impurities  we  remove  a  valuable  element  and  that  perfectly  pure  ether 
is  not  an  anesthetic  at  all  but  only  serves  to  make  a  man  drunk. 

The  impurity  which  produces  anesthesia  is,  Cotton  believes,  a  gas  like  ethy- 
lene. Another  impurity  contains  an  unidentified  gas  which  produces  the  ordi- 
nary unpleasant  symptoms  which  so  commonly  fdilow  anesthesia  (vomiting, 
headache,  etc.) 

Cotton  makes  a  chemically  pure  ether  and  charges  it  with  the  desirable 
anesthetic  gas. 

Dr.  W.  G.  Huson,  Medical  Director  of  the  Dupont  Powder  Works,  says 
("Med.  Record,"  March  16,  1918):  "Dr.  Cotton  believes  that  perfectly 
pure  ether,  for  the  manufacture  of  which  an  entirely  new  process  had  to  be 
devised,  is  not  an  anesthetic  at  all,  but  produces,  upon  inhalation,  merely 
a  transitory  stimulation  similar  to  that  from  alcohol.  Commercial  anes- 
thesia ether  is  by  no  means  pure,  but  contains  two  sets  of  impurities,  one 
of  which  produces  the  anesthesia,  which  we  have  been  attributing  to  the 
ether  itself,  and  the  other  the  undesirable  after-effects,  which  have  been 
so  great  a  drawback  to  the  administration  of  ether.  He  then  proceeded 
to  charge  his  chemically  pure  ether  with  only  the  desirable  impurities,  going 
beyond  the  proportions  in  which  they  exist  in  ordinary  anesthesia  ether. 
When  this  was  done,  not  only  were  the  undesirable  after-effects  eliminated,  but 
it  was  found  possible  to  produce  an  entirely  new  type  of  anesthesia,  during  which 
the  patient  can  be  maintained  in  a  condition  in  which  all  sensation  is  abolished, 
but  in  which  he  is  perfectly  conscious,  can  carry  on  a  conversation  intelligently 


I340  Anesthesia  and  Anesthetics 

and  can  even  walk  about,  although  rather  unsteadily.  If  the  amount  adminis- 
tered is  reduced,  sensation  begins  to  return,  while  if  it  is  pushed,  the  condition 
passes  over  into  the  ordinary  surgical  anesthesia,  with  loss  of  consciousness  but 
without  any  intervening  stage  of  excitement." 

We  are  at  present  testing  out  the  Cotton  ether  in  Jefferson  College  Hospital 
and  feel  encouraged  to  hope  that  an  important  discovery  has  been  made  but 
it  is  too  early  to  speak  with  confidence. 

Ether  and  Oxygen. — This  mixture  is  useful  in  certain  cases  in  which 
respiratory  difficulty  exists,  particularly  in  empyema.  If  during  the  adminis- 
tration of  ether  cyanosis  tends  to  occur,  it  is  often  advantageous  to  give  oxygen 
with  the  ether.  The  process  of  anesthetization  by  ether  and  oxygen  is  some- 
what slower  than  by  ether  vapor  mixed  with  air.  It  can  be  given  by  insert- 
ing beneath  the  Allis  inhaler  or  pushing  deep  down  into  it,  from  above,  a  tube 
attached  to  a  reservoir  of  oxygen  and  from  which  a  stream  of  oxygen  emerges. 

Endotracheal  Insufflation  Anesthesia  (Intratracheal  Anesthesia) 
(Method  of  Meltzer  and  Auer). — A  flexible  elastic  tube  much  smaller  in  diameter 
than  the  trachea  is  carried  down  almost  to  the  tracheal  bifurcation.  When  air  is 
forced  in,  it  emerges  between  the  tube  and  the  trachea.  The  addition  of  ether 
vapor  to  the  air  mak^T the  maintenance  of  anesthesia  easy.  Ether  can  thus  be 
administered  by  means  of  a  tracheal  tube,  a  Wolff  bottle  to  contain  the  ether,  and 
a  foot-bellows.  I  have  had  it  given  in  this  way  a  number  of  times.  Elsberg's 
apparatus  (see  Fig.  656)  permits  of  the  most  desirable  method. 

The  patient  is  first  anesthetized  by  the  ordinary  method.  WTien  uncon- 
scious the  head  is  dropped  back  over  the  end  of  the  table,  and  the  tube  is  passed 
into  the  trachea  "under  the  guidance  of  the  eye  by  means  of  a  Jackson  direct 
laryngoscope"  (see  Fig.  630).  (See  Brewer,  in  "Keen's  Surgery,"  vol.  vi). 
In  this  form  of  anesthesia  the  stream  of  air  carries  off  ether  vapor  and  pre- 
vents accumulation  in  the  tubes. 

A  degree  of  anesthesia  necessary  to  maintain  muscular  relaxation  will  not  ap- 
parently cause  dangerous  symptoms.  If  the  ether  is  given  for  a  long  time  in  un- 
necessarily large  amounts  danger  may  be  reached,  but  it  is  attained  gradually 
and  not  suddenly  and  gives  warning.  If  there  should  be  an  ominous  fall  in 
blood-pressure  and  respiratory  failure,  cut  out  the  ether  vapor  and  use  the  ap- 
paratus for  artificial  respiration.  A  patient  remains  very  still  under  this 
method  of  anesthesia,  awakes  rapidly  from  it,  and  suffers  little  from  shock  and 
postoperative  vomiting.  Nitrous  oxid  and  oxygen  have  been  given  by  this 
method.  Meltzer  is  studying  chloroform  so  used  ("Keen's  Surgery,"  vol.  \d). 
In  operations  about  the  head,  mouth,  and  neck  insufflation  anesthesia  keeps  the 
anesthetist  out  of  the  operator's  way.  In  operations  about  the  mouth  the 
method  prevents  the  inhalation  of  blood  or  vomit.  In  goiter  operations  it  is  a 
safeguard  against  sudden  suffocation.  It  is  useful  in  brain  operations  especially 
cerebellar  operations.  In  intrathoracic  operations  it  serves  to  prevent  collapse 
of  the  lung.  After  the  operation  all  ether  vapor  is  driven  out  of  the  lungs  by  a 
stream  of  fresh  air.  Peck  ("Annals  of  Surgery,"  July,  191 2)  maintains  that  the 
insufflation  method  is  safe  if  certain  rules  are  carefully  followed.  ■  These  rules 
are  to  avoid  excessive  pressure  (which  might  rupture  air-cells),  to  be  sure  not  to 
spray  liquid  ether  into  the  tracheal  tube,  not  to  carry  the  tube  into  the  gullet, 
or  beyond  the  tracheal  bifurcation,  and  not  to  damage  by  rough  introduction. 

I  use  the  method  frequently,  find  it  extremely  useful  and  regard  it  as  safe. 
Meltzer  has  only  been  able  to  learn  of  4  or  5  deaths  during  the  application  of  the 
method  and  he  does  not  think  one  of  them  was  due  to  the  method.  One  was  due 
to  liquid  ether  being  allowed  to  run  into  the  tube;  another  to  rupture  of  the 
lung  brought  about  by  the  tube  being  pushed  down  too  far;  another  death  was 
due  to  the  tube  having  been  passed  into  the  gullet;  in  another  case  the  tube  was 
forced,  producing  cyanosis,  emphysema  and  death.  A  tube  with  a  safety- 
valve  and  scrupulous  care  would  probably  have  saved  these  lives.     (Abstract  in 


Rectal  Etherization  1341 

"  Surgery,  Gynecology,  and  Obstetrics,"  Jan.,  1915,  from ''Berlin  klin.Wochen.," 

1914.  ii-) 

Rectal  Etherization. — Pirogoff  suggested  this  method  in  1847  and  Roux 
employed  it  the  same  year.  The  method  is  recommended  by  some  for  operations 
upon  the  face,  tongue,  nasopharynx,  pharynx,  mouth,  larynx,  trachea,  thyroid, 
or  chest;  in  other  words,  in  cases  in  which,  were  the  ether  given  by  inhalation, 
the  operator  and  anesthetist  would  interfere  with  each  other.  It  is  useful  if  a 
patient  must  assume  a  prone  position  (as  in  laminectomy,  in  head  operations,  if 
bronchitis  exists  and  in  the  aged).  It  is  especially  useful  in  fat  alcoholics. 
It  does  not  cause  a  sense  of  suffocation,  the  stage  of  excitement  is  brief  and  strug- 
gUng  is  absent  or  trivial.  Rectal  anesthesia  causes  much  less  mucus  to  flow 
into  the  air-passages  than  does  inhalation  anesthesia.  Postoperative  nausea 
and  vomiting  are  less  common  than  after  inhalation  anesthesia.  A  badly 
frightened  patient  can  by  this  method  be  anesthetized  without  his  knowledge. 
It  is  contra-indicated  in  pelvic  operations,  if  there  is  irritation  or  inflammation  of 
the  intestines  and  in  laparotomy  because  gaseous  distention  of  the  gut  interferes 
with  work  and  necessitates  much  handhng.  Until  recently  the  following  rules 
were  laid  down  for  the  administration.  The  rectum  should  be  emptied  by  a 
purgative  enema  the  day  before  the  operation,  and  again  the  morning  of  the 
operation,  and  a  short  time  before  giving  the  ether  the  rectum  should  be  irrigated 
with  warm  salt  solution.  A  dose  of  laudanum  is  given  a  few  hours  before,  or 
an  injection  of  morphin  and  atropin  twenty  minutes  before  the  administration 
of  the  ether.  We  should  employ  an  apparatus  of  the  type  of  Buxton's,  which 
prevents  liquid  ether  from  passing  into  the  rectum. 

A  tube  containing  ether  is  set  in  a  vessel  containing  water  at  a  temperature 
of  i22°F.  The  ether  tube  is  joined  by  a  glass  tube  and  rubber  pipe  to  a  glass 
globe,  and  the  globe  is  connected  by  a  rubber  pipe  to  the  tip,  which  is  inserted 
into  the  rectum.  If  ether  vapor  condenses  into  liquid  in  the  glass  globe  the 
globe  should  be  at  once  emptied.  During  the  administration  abdominal  dis- 
tention occurs  from  unabsorbed  ether,  and  from  time  to  time  the  administra- 
tion should  be  suspended  temporarily  to  permit  the  gas  to  escape,  otherwise 
too  much  will  be  given  and  prolonged  stupor  and  postoperative  coUc  may 
result.  It  takes  much  longer  to  obtain  unconsciousness  by  rectal  administra- 
tion than  by  inhalation.  This  method  never  came  into  general  use.  It  was 
found  to  irritate  the  large  intestine,  to  produce  colic  in  many  cases,  and  some- 
times to  lead  to  protracted  stupor  ('''x\nesthetics  and  Their  Administration," 
by  Sir  Frederic  W.  Hewitt).  After  one  of  Baum's  cases  intestinal  hemorrhage 
occurred;  in  another,  gangrene  and  perforation  ("Zentral.  fiir  Chir.,"  March 
13,  1909).  Dudley  W.  Buxton,  however,  employed  it  in  many  operations 
about  the  face,  mouth,  and  larynx,  and  in  some  operations  for  empyema,  and 
commended  it.  James  T.  Gwathmey  ("  N.  Y.  Med.  Jour.,"  1913,  xcviii — 1914, 
xcix)  improved  the  method  greatly.  He  caUs  the  new  method  Oil-ether  Anes- 
thesia by  the  rectum.  The  mixture  used  consists  of  4  ounces  of  ohve  ofl  and  2 
ounces  of  ether.  One  ounce  is  given  for  each  20  pounds  of  the  patient's  body 
weight  but  not  more  than  8  ounces  are  to  be  given.  The  night  before  the  opera- 
tion compound  licorice  powder  or  castor  oil  is  given.  A  couple  of  hours  before 
the  injection  the  rectum  is  washed  out.  Forty  minutes  before  operation  a  h^-po- 
dermatic  injection  is  given.  It  contains  gr.  ^  4  of  morphin  and  gr.  ^  f  0  0  of  atropin. 
At  this  time  anesthetize  the  rectum  by  injecting  into  it  gr.  v  to  gr.  x  of  chloretone 
in  ether  and  olive  oil.  Twenty  minutes  before  operation  the  patient  is  placed  in 
the  Sims  position  and  the  mixture  of  oO.  and  ether  (which  has  been  well  shaken 
in  a  bottle  is  introduced  slowly  into  the  rectum  by  means  of  a  funnel  and  a  rubber 
catheter.  It  is  given  at  the  rate  of  an  ounce  a  minute.  In  5  or  6  minutes  the 
patient  should  be  unconscious  and  in  20  minutes  from  beginning  the  injection 
anesthesia  should  be  complete.  In  some  cases  anesthesia  is  not  complete  for  30 
or  40  minutes.     The  ocular  reflexes  must  not  be  abolished  and  stertorous  respira- 


1342  Anesthesia  and  Anesthetics 

tion  is  a  danger  sign  (W.  M.  Johnson  in  "N.Y.Med.  Jour.,"  I9i6,civ).  Gwath- 
mey  insists  that  respiration  should  be  smooth  and  easy,  without  stertor  and  with 
the  retention  of  eyehd  reflex.  If  danger  signals  arise  some  or  all  of  the  mixture 
is  withdrawn  by  lowering  the  tube.  At  the  termination  of  the  operation  the 
mixture  is  withdrawn  from  the  rectum,  the  rectum  is  well  washed  out  with 
cold  water  containing  soap  and  a  pint  of  cold  water  is  left  in  the  rectum  (Gwath- 
mey,  "N.  Y.  Med.  Jour.,"  1914,  xcix).  Sometimes  the  unconsciousness  is 
inordinately  prolonged.  In  some  persons  resistant  to  ether  it  is  necessary 
to  supplement  rectal  administration  by  inhalations  of  ether.  I  see  no  reason  to 
doubt  that  rectal  anesthesia  is  as  dangerous  as  inhalation  anesthesia.  It  is 
certainly  less  controllable.  It  is  useful  in  certain  cases  but  will  not  displace  the 
inhalation  method.  Intratracheal  insufflation  anesthesia  seems  to  have  nearly 
done  away  with  all  need  for  rectal  anesthesia. 

Intravenous  Etherization  (Infusion  Anesthesia). — This  method  was 
devised  by  Burkhardt,  of  Wiirzburg,  and  is  still  on  trial.  A  7}^^  per  cent, 
solution  of  ether  in  normal  salt  solution  is  employed  by  Rood  ("Lancet," 
March  23,  1912).  He  found  that  a  10  per  cent,  solution  causes  hemolysis  and 
a  5  per  cent,  solution  is  inadequate.  About  three-quarters  of  an  hour  before 
operation  he  gives  a  hypodermatic  injection  of  ig  gr.  of  morphin,  }ioo  gr-  of 
scopolamin  and  Hoo  gr.  of  atropin.  When  ready  to  operate,  a  vein  is  selected, 
exposed  and  opened,  and  the  cannula  is  introduced.  The  solution  is  warm. 
From  }-'2  to  i  pint  of  the  fluid  is  run  in  and  anesthesia  should  be  secured 
in  from  three  to  five  minutes.  Anesthesia  is  maintained  by  running  in  a  constant 
succession  of  drops.  If  anesthesia  becomes  too  deep  the  rate  of  flow  is  lessened, 
and  vice  versa.  This  method  of  anesthesia  keeps  the  anesthetist  out  of  the 
way  in  operations  on  the  head,  neck,  and  mouth.  It  is  claimed  that  it  enables 
us  to  measure  the  dose  of  anesthetic  much  more  accurately  than  does  the  respira- 
tory plan,  and  that  by  it  we  avoid  irritation  of  the  mucous  membrane  of  the 
respiratory  tract.  The  respiration  must  be  watched  just  as  carefully  as  in 
respiratory  anesthesia.  Rood  ("Brit.  Med.  Jour.,"  Oct.  21,  191 1)  has  had  136 
cases  and  no  bad  results.  It  would  seem  however,  that  there  must  be  elements 
of  danger,  ecchymoses  may  appear  on  the  back  and  buttocks  and  it  has  been 
stated  that  there  is  a  tendency  to  pulmonary  edema  ("The  Art  of  Anesthesia" 
by  P.  J.  Flagg). 

Hedonal  has  been  used  for  infusion  anesthesia.  It  was  suggested  byFederoff , 
of  St.  Petersburg.  Mr.  Page,  of  London,  has  reported  75  cases  ("Lancet," 
March  23,  1912).  He  uses  a  0.75  per  cent,  solution  in  normal  salt  solution  and 
gives  it  continuously.  Ward  ("Lancet,"  March  23,  1912)  has  reported  a 
death  from  it. 

Anesthetic  State  from  Ether  or  Chloroform. — The  inhalation  of 
an  anesthetic  produces  irritation  of  the  fauces,  often  some  cough,  a  profuse 
secretion  of  mucus,  acts  of  swallowing,  dilatation  of  the  pupils,  flushed  face, 
and  sometimes  struggling  (especially  in  children  and  in  drunkards).  If  at  the 
start  the  vapor  is  given  in  concentrated  form,  cough  will  be  violent  and  will 
cause  cyanosis.  If  the  anesthetic  is  given  gradually  the  cough  soon  ceases, 
the  respirations  become  rapid  and  often  convulsive,  the  pulse  becomes  fre- 
quent, and  the  patient  passes  into  a  condition  of  active  intoxication  with 
preservation  of  sight  and  touch,  loss  of  hearing  and  smell,  diminution  of  pain 
and  sensibility,  and  often  with  illusions  or  hallucinations.  In  this  stage  the 
patient  may  struggle,  and  while  efforts  are  being  made  to  hold  him,  cyanosis 
may  occur.  From  the  stage  of  excitement  just  alluded  to,  many  subjects 
(strong  men  and  drunkards)  pass  into  a  stage  of  rigidity  in  which  the  muscles 
become  firmly  fixed,  the  breathing  is  impeded,  the  respirations  are  stertorous 
and  the  face  is  bluish  and  congested.  Too  rapid  forcing  of  the  anesthetic 
tends  to  cause  rigidity,  and  a  skilled  anesthetist  endeavors  to  avoid  its  produc- 
tion, because  it  is  dangerous.     The  next  stage  is  one  of  insensibility;  the  pupils 


Treatment  of  Complications  1343 

are  contracted  and  react  sluggishly  to  light.  If  anesthesia  is  deep  the  con- 
tracted pupils  will  not  react  to  light;  if  anesthesia  is  profound  the  pupils  dilate, 
but  will  not  react  to  light.  The  conjunctival  reflex  is  gone;  the  lids  are  closed; 
if  the  arm  is  lifted  and  allowed  to  fall,  it  drops  as  a  dead  weight;  the  skin  is  cool 
and  moist  and  often  wet  with  sweat;  the  respirations  are  easy  and  shallow; 
the  pulse  is  slow,  and  there  is  complete  unconsciousness  to  pain.  The  loss  of 
conjunctival  reflex  is  the  usually  accepted  sign  that  the  patient  is  unconscious. 
In  a  young  child  this  reflex  is  soon  exhausted  by  touching  the  eye,  and  the  sign 
is  unreliable.  If  a  baby  is  to  be  anesthetized,  the  administrator  places  his 
finger  in  the  infant's  hand.  The  child  grasps  the  finger,  and  relaxes  its  grasp 
when  unconscious. 

Always  bear  in  mind  that  dilated  pupils  reacting  to  light  and  associated 
with  preserved  conjunctival  reflex  mean  that  anesthesia  is  not  complete;  that 
contracted  pupils  reacting  to  light  and  without  conjunctival  reflex  mean  mod- 
erate anesthesia;  that  contracted  pupils  not  reacting  to  light  and  without 
conjunctival  reflex  mean  deep  anesthesia;  that  dilated  pupils  not  reacting  to  light 
and  associated  with  lost  conjunctival  reflex  mean  dangerously  profound  anes- 
thesia. Sudden  dilatation" with  fixation  is  always  very  ominous.  The  pupillary 
phenomena  are  very  valuable  when  present,  but  unfortunately  they  are  absent 
at  some  stage  of  the  anesthesia  in  many  cases.  Inequality  of  the  pupils  is  not 
unusual  and  fbiation'of  one  pupil  or  of  both  may  occur.  A  preliminary  dose  of 
morphin  or  atropin  interferes  with  the  pupillary  phenomena.  Weak  pulse  and 
pallor  may  be  due  to  nausea,  but  always  require  instant  attention.  Vomiting 
may  be  due  to  forcing  strong  vapor  upon  the  patient,  but  may  also  be  due  to 
his  partially  emerging  from  a  state  of  insensibility. 

Watch  the  pulse  carefully  to  see  if  it  becomes  very  weak,  irregular,  ab- 
normally slow,  abnormally  fast,  or  if  it  suggests  a  fall  of  blood-pressure. 
Syncope  may  be  due  to  nausea,  shock,  hemorrhage,  or  the  giving  of  too  much 
of  the  drug.  Watch  the  respiration,  and  do  not  forget  that  the  chest  walls  and 
belly  may  move  when  no  air  is  entering  the  lungs;  hence  always  listen  to  the 
breathing.  Cyanosis  is  a  dusky  or  bluish  discoloration  of  the  skin.  This  condi- 
tion indicates  want  of  oxygen  in  the  blood.  The  individual  may  have  been 
cyanotic  or  predisposed  to  cyanosis  from  the  beginning;  cyanosis  may  be 
due  to  pressure;  to  cough  early  in  the  administration;  to  strugghng  during  the 
stage  of  excitement;  to  the  gathering  of  mucus  in  the  respiration  tract;  or  to  rigid 
fixation  of  the  respiratory  muscles.  It  may  also  be  due  to  obstruction  of  the 
air-passages  by  some  foreign  matter,  as  blood  or  vomit,  lodging  in  the  bronchial 
tubes,  windpipe,  larynx,  or  pharynx;  falling  back  of  the  tongue  {swallowing 
of  the  tongue);  closure  of  the  epiglottis;  or  to  the  glottis  being  pushed  against 
the  pharyngeal  wall  by  bending  the  head  forward.  Some  patients  with  occluded 
nostrils  may  fail  to  get  enough  air  because  of  closure  of  the  lips.  A  patient  may, 
while  taking  an  anesthetic,  lie  perfectly  quiet  and  appear  to  "forget  to  breathe. 
Ether  and  chloroform  mitigate  the  causal  mental  phases  of  shock,  but  neither 
drug  keeps  nerves  from  conveying  stimuli  and  each  produces  a  fall  of  blood- 
pressure,  chloroform  directly  by  its  action  on  the  vasomotor  center,  ether  by 
overstimulation  of  the  vasomotor  center  (Buxton,  in  "Proceedings  of  the  Royal 
Soc.  of  Med.,"  April,  1909).  Each  produces  a  fall  of  temperature.  Buxton 
heartily  condemns  the  once  common  belief  "that  evidences  of  shock  during  a 
surgical  operation  are  a  proof  that  an  insufficient  quantity  of  the  anesthetic  has 
been  given  and  that  the  symptoms  of  shock  can  be  abrogated  by  increasing  the 
depth  of  the  narcosis"  (Ibid.).  Heavy  anesthesia  by  ether  or  chloroform  pro- 
duces or  adds  to  shock.  Shock  is  manifested  by  deathly  paUor,  weak,  rapid,  and 
irregular  pulse,  slow  respiration,  cold  extremities,  and  a  drenching  sweat. 
Edema  of  the  lungs  occasionally  arises  during  or  after  anesthesia. 

Treatment  of  Complications. — Vomiting  due  to  too  much  anesthetic  is 
corrected  by  giving  a  few  breaths  of  air;  vomiting  due  to  incomplete  anesthesia  is 


1344  Anesthesia  and  Anesthetics 

amended  by  giving  more  of  the  vapor.  While  the  patient  vomits  hold  the  head 
over  the  edge  of  the  bed  or  table,  and  when  vomiting  ceases  separate  the  jaws  with 
the  gag,  and  wipe  out  the  vomited  matter,  mucus,  and  saliva.  Shock  is  treated  by 
diminishing  the  amount  of  the  anesthetic  that  is  being  given,  by  the  hypoder- 
matic injection  of  atropin  (atropin  is  particularly  useful  when  there  is  a  profuse 
sweat),  by  the  administration  of  hot  saUne  fluid  by  the  rectum,  by  surrounding 
the  patient  with  hot-water  bottles,  or  by  wrapping  him  in  hot  blankets,  and  by 
lowering  the  head,  of  the  bed.  Syncope  is  sudden  cerebral  anemia  and  is 
usually  due  to  a  reflex  cause.  A  tendency  to  syncope  requires  lowering  of 
the  head,  suspension  of  the  anesthetic,  and  hypodermatic  injection  of  strych- 
nin. In  extreme  syncope,  which  is  most  apt  to  occur  from  chloroform,  do 
not  wait  for  breathing  to  cease,  but  suspend  the  anesthetic,  lower  the  head 
of  the  bed,  open  the  mouth  with  the  gag,  catch  the  tongue,  and  make  rhythmical 
traction  while  an  assistant  is  making  sloio  artificial  respiration.  If  the  patient 
does  not  at  once  improve,  invert  him  completely,  holding  him  by  the  legs  and 
continuing  artificial  respiration  by  compressing  the  sternum  (Nelaton).  By 
continuing  artificial  respiration  the  blood  is  urged  on  through  the  heart. 
Give  hypodermatic  injections  of  atropin,  ether,  or  even  of  ammonia.  Put 
mustard  over  the  heart  and  spine.  Employ  faradism  to  the  phrenic  nerve  (one 
pole  to  the  epigastric  region,  the  other  to  the  right  side  of  the  root  of  the  neck). 
Let  fresh  air  into  the  room,  put  hot-water  bottles  around  the  legs,  apply  friction 
to  the  extremities,  wrap  the  patient  in  hot  blankets,  give  an  enema  of  hot  salt 
solution,  and  hold  ammonia  to  the  nose.  In  some  cases  of  anesthetic  poisoning 
direct  heart  massage  has  been  successfully  employed.  The  method  was  suggested 
by  Schliff  in  1874.  Frazier  was  operating  for  hydrocele  when  the  patient's 
respiration  ceased  and  his  pulse  disappeared.  Frazier  at  once  opened  the 
abdomen  and,  with  one  hand  on  the  chest  wall  and  the  other  against  the  dia- 
phragm, "massaged  the  heart  at  the  rate  of  15  to  20  movements  a  minute." 
In  about  two  minutes  cardiac  contractions  were  perceptible.  In  about  eight 
minutes  resuscitation  was  complete  ("Jour.  Am.  Med.  Assoc,"  May  20,  191 1). 
In  Conkling's  case  there  was  a  chest  wound  exposing  the  lung.  The  heart 
ceased  to  beat.  The  surgeon  grasped  the  heart  between  the  fingers  and  made 
compressions.  In  less  than  a  minute  he  detected  a  thrill,  and  in  a  few  seconds 
more  regular  pulsation  began  ("New  York  Med.  Jour.,"  Sept.  2,  1905).  In 
Sencert's  successful  case  an  operation  was  being  done  for  gall-stones  when 
collapse  occurred,  and  the  surgeon  stroked  and  kneaded  the  heart  through  the 
diaphragm.  In  a  case  recorded  in  the  "Brit.  Med.  Jour.,"  Nov.  18, 1905,  respira- 
tion and  pulse  had  ceased  three  minutes  when  the  abdomen  was  opened  and 
the  heart  was  kneaded.  Recovery  ensued.  Miiller,  of  Hamburg,  advocates 
exposing  and  opening  the  pericardium  to  perform  massage,  introducing  oxy- 
genated salt  solution  into  a  vein,  opening  the  trachea,  and  performing  arti- 
ficial respiration.  Frazier  ("Progressive  Medicine,"  March,  191 1)  publishes 
statistics  of  50  collected  cases.  These  figures  indicate  that  the  subdiaphrag- 
matic method  is  more  successful  than  either  the  direct  method  or  the  trans- 
diaphragmatic method.     The  table  is  as  follows: 

Successful 

Direct 2 

Transdiaphragmatic o 

Subdiaphragmatic 8 

10 

Leonard  Hill  holds  that  in  the  failure  which  arises  soon  after  administration  of 
chloroform  is  begun  the  trouble  is  due  to  vasomotor  paralysis  with  starvation 
of  the  nerve-centers.  In  such  a  case  he  applies  abdominal  compression  and 
inverts  the  patient,  making  artificial  respiration  at  the  same  time.     In  the 


Partially 

successful 

8 

Failures 
18 

Total 
28 

I 
5 

2 

6 

3 
19 

14 

26 

50 

The  Reaction  from  Anesthesia  1345 

failure  which  occurs  after  considerable  chloroform  has  been  taken  there  are 
paralytic  distention  of  the  heart,  fulness  of  the  venous  system,  and  loss  of 
the  compensations  for  the  hydrostatic  effects  of  gravity.  In  such  a  condition 
empty  the  distended  heart  of  venous  blood  by  raising  the  patient  into  an 
erect  position,  and  after  a  moment  place  him  recumbent  and  make  artificial 
respiration. 

Forgetting  to  breathe  is  met  by  removing  the  inhaler  and  waiting  a  moment; 
a  breath  will  usually  be  taken  soon;  but  if  it  is  not  taken,  somewhat  forcibly 
knead  the  structures  in  the  arm-pit.  If  this  fails,  open  the  mouth  and  pull 
forward  the  tongue;  this  causes  a  reflex  inspiration.  Cyanosis  is  practically 
not  encountered  when  oxygen  is  given  with  ether  or  chloroform.  Cyano- 
sis, if  slight  and  due  to  cough  or  struggling,  is  met  by  removing  the  inhaler 
while  the  patient  takes  a  breath  or  two  of  air.  If  position  is  responsible  for 
cyanosis,  correct  it.  In  empyema,  lying  upon  the  sound  side  may  produce  it. 
Obstruction  to  breathing  may  be  due  to  bending  down  the  head.  If  due 
to  stenosis  of  the  nares  in  a  person  without  teeth,  hold  the  lips  apart  with  a 
finger.  If  due  to  collection  of  mucus,  wipe  the  mucus  out  of  the  mouth  by 
means  of  bits  of  gauze  firmly  clamped  in  forceps;  raise  the  shoulders,  extend  the 
head  and  place  it  on  its  side  in  order  that  mucus  may  run  out  of  the  angle  of 
the  mouth;  and  give  a  dose  of  atropin  hypodermatically.  If  the  amount  of 
mucus  is  large  and  the  secretion  is  persistent,  it  may  be  necessary,  especially 
in  children,  to  empty  the  respiratory  passages  by  inverting  the  patient.  In 
cases  of  excessive  bronchial  secretion  we  fear  the  development  of  pulmonary 
edema  or  postoperative  bronchopneumonia. 

Dudley  W.  Buxton  points  out  that  duskiness  will  often  pass  away  if  ether 
is  removed,  one  or  two  inhalations  of  chloroform  given,  and  ether  then  continued. 
If  in  any  case  cyanosis  is  severe  or  grows  worse,  suspend  the  drug,  dash  cold 
water  in  the  face,  force  open  the  jaws,  pull  forward  the  tongue,  make  artificial 
respiration  until  a  breath  is  taken,  and  then  give  oxygen  for  a  time.  If  these 
means  fail,  stretch  the  sphincter  ani  and  bleed  from  the  external  jugular  vein. 
If  a  breath  is  not  now  taken,  do  tracheotomy.  In  respiratory  or  heart  failure 
forced  artificial  respiration  by  Fell's  method  is  of  great  value  (see  page  102 1). 
The  pulmotor  or  lungmotor,  if  at  hand,  enables  the  surgeon  to  maintain  regular 
artificial  respiration  for  an  indefinite  time  (see  page  977).  Swallowing  the 
tongue  is  corrected  by  pulling  the  tongue  forward.  If  it  tends  to  recur,  lay 
the  head  upon  its  side  or  keep  the  tongue  anchored  with  forceps.  Closure  of 
the  epiglottis  is  corrected  by  pulling  the  patient's  head  over  the  edge  of  the  table 
and  pushing  strongly  back  upon  his  forehead.  This  maneuver  lifts  the  hyoid 
bone,  and  with  it  the  epiglottis.  The  epiglottis  can  be  lifted  by  passing  a  spoon- 
handle  or  the  index-finger  over  the  dorsum  to  the  base  of  the  tongue  and  press- 
ing forward.  If,  in  obstruction  to  respiration,  the  above  means  fail,  make 
artificial  respiration  at  once  (see  page  974);  if  obstruction  continues,  perform 
tracheotomy). 

Edema  of  the  lungs  is  treated  by  instant  venesection,  the  inhalation  of  nitrite 
of  amyl,  and  the  administration  of  stimulants  and  nitroglycerin  hypodermat- 
ically. Sometimes  during  the  anesthetic  state  the  muscles  of  the  belly  become 
very  rigid,  a  condition  which  greatly  interferes  with  an  abdominal  operation. 
It  may  arise  during  cyanosis,  and  if  so  caused  is  amended,  as  cyanosis  abates 
under  proper  treatment.  In  some  cases  it  is  due  to  the  fact  that  sufl5cient 
anesthetic  has  not  been  given.  If  the  air-passages  are  obstructed  before  opera- 
tion, abdominal  rigidity  is  apt  to  arise.  In  some  cases  it  seems  impossible  to 
overcome  it  with  ether.  ^  In  such  a  case,  if  the  anesthetist  is  a  trusted  man, 
anesthetize  the  patient  with  gas  and  ether  and  then  give  chloroform  (Blumfield 
in  "Lancet,"  May  31,  1902). 

The  Reaction  from  Anesthesia. — When  ether  or  chloroform  is  given, 
a  considerable  quantity  is  swallowed  and  either  drug  irritates  the  stomach 
85 


1346  Anesthesia  and  Anesthetics 

and  creates  nausea  and  often  vomiting.  The  longer  the  operation,  the  more 
of  the  anesthetic  enters  the  stomach,  and  the  greater  the  habihty  to  subsequent 
vomiting.  At  the  termination  of  a  prolonged  operation  upon  an  adult,  if  the 
patient's  condition  admits  of  it,  and  if  the  nature  of  the  operation  does  not  forbid 
it,  I  like  to  have  a  stomach-tube  passed  and  the  stomach  well  washed  out  with 
warm  water.  The  washings  smell  strongly  of  the  anesthetic,  and  the  procedure 
greatly  lessens  the  severity  and  frequency  of  postoperative  vomiting  (Geo.  S. 
Brown,  in  "Surg.,  Gynec,  and  Obstet.,"  August,  1905).  After  the  administra- 
tion of  the  anesthetic  has  been  suspended  and  the  operation  has  been  completed 
the  temperature  is  usually  subnormal.  The  patient  must  be  watched  until 
consciousness  returns.  If  he  is  left  alone,  a  change  of  posture  may  lead  to 
arrest  of  feeble  respiration,  the  assumption  of  the  erect  position  may  cause  fatal 
syncope,  and  mucus  or  vomited  matter  may  block  the  air-passages  and  cause 
suffocation.  The  best  position  to  place  him  in  is  the  recumbent,  the  head 
being  level  with  the  body  or  somewhat  lower  and  the  side  of  the  face  resting 
on  the  pillow.  Shock  is  treated  by  ordinary  methods  (see  page  290).  The 
inhalation  of  oxygen  is  of  great  value  in  rousing  a  patient  from  the  state  of 
anesthesia,  and  will  often  prevent  vomiting.  If  vomiting  occurs,  the  head 
should  be  upon  its  side  or  should  be  held  over  the  edge  of  the  bed,  and  after  the 
spell  of  vomiting  the  mouth  must  be  wiped  clean.  The  face  should  be  washed 
with  cold  water  and  be  fanned  rather  actively.  It  is  the  routine  practice  of 
some  surgeons  to  administer  vinegar  by  inhalation  during  the  reaction  from  an 
anesthetic.  This  proceeding  sometimes  seems  to  prevent  vomiting.  Some 
patients  awake  from  anesthesia  as  from  a  quiet  sleep;  others  are  noisy,  turbulent, 
and  violent.  The  duration  of  the  period  of  reaction  varies  with  the  anesthetic 
used,  the  amount  given,  and  the  personal  tendencies  of  the  patient.  The 
patient  must  not  be  allowed  to  sit  up  for  several  hours  at  least.  No  food  is  to  be 
allowed  for  at  least  six  hours.  Unless  the  operation  has  been  upon  the  stomach, 
I  do  not  forbid  water,  but  allow  the  patient  to  drink  freely  of  hot  water.  This 
dilutes  any  irritant  material  in  the  stomach  and  dissolves  mucus,  and  if  vomiting 
does  occur  it  serves  to  wash  the  stomach  out.  All  fat  patients,  all  patients  with 
respiratory  difficulties,  or  in  whom  we  apprehend  respiratory  compHcations 
should,  if  there  is  no  contra-indication,  be  placed  in  a  sitting  or,  at  least,  a 
semi-erect  posture  as  soon  as  reaction  from  anesthesia  is  obtained.  If  this 
plan  is  followed,  ether-pneumonia  and  other  respiratory  troubles  will  very 
seldom  develop. 

After=effects  of  Anesthetics. — Vomiting. — I  am  convinced  that  in 
many  cases  postanesthetic  vomiting  is  due  or  is  largely  due  to  irritation  of  the 
stomach  caused  by  swallowing  considerable  quantities  of  an  irritant  anesthetic. 
The  liability  to  it  is  greatly  lessened  by  washing  out  the  stomach  before  the 
patient  leaves  the  operating  table,  and  allowing  the  patient  (in  suitable  cases) 
to  drink  freely  of  hot  water  as  soon  as  he  returns  to  consciousness.  Most 
patients  vomit  more  or  less,  but  if  the  man  has  been  drinking  hot  water  an  act 
of  vomiting  washes  out  his  stomach  and  he  may  not  vomit  again.  Violent 
vomiting  may  occur  in  spite  of  all  our  efforts,  and  may  persist  for  hours,  greatly 
exhausting  the  patient  and  doing  infinite  harm,  it  may  be,  especially  if  the  opera- 
tion has  been  upon  the  brain  or  an  intra-abdominal  structure.  If  vomiting  con- 
tinues, forbid  food  absolutely.  Very  hot  water  in  doses  of  a  teaspoonful  should 
be  given  at  frequent  intervals.  Drafts  of  hot  water  may  relieve  the  condition 
by  washing  out  the  mucus  from  the  stomach.  Other  remedies  which  may 
succeed  are:  inhalations  of  vinegar,  hot  black  coffee  by  the  mouth,  a  mustard 
plaster  over  the  stomach,  fresh  air  in  the  room,  small  pieces  of  ice  placed  in 
the  mouth  and  sucked,  small  doses  of  iced  champagne,  and  drop  doses  of  a 
3  per  cent,  solution  of  cocain  or  3-drop  doses  of  a  5  per  cent,  solution  of  eucain. 
The  best  remedy  for  persistent  vomiting  is  lavage  of  the  stomach.  Some 
persons,  as  Dudley  W.  Buxton  points  out,  suffer  greatly  from  nausea,  although 


Renal  Complications  1347 

there  is  little  or  no  vomiting.  In  such  cases  Buxton  uses  i  min.  of  tincture  of 
nux  vomica  in  a  teaspoonful  of  hot  water  every  ten  minutes  until  six  doses  have 
been  taken.  If  this  plan  fails,  he  gives  drop  doses  of  wine  of  ipecac  or  minim 
doses  of  dilute  hydrocyanic  acid.^ 

Vomiting  from  chloroform  is  usually  more  difficult  to  check  than  vomiting 
from  ether.  In  any  case  of  persistent  vomiting  examine  for  acidosis  (see  page 
1348). 

Backache. — This  is  a  very  common  and  often  a  very  distressing  consequence 
of  anesthesia.  It  is  complained  of  soon  after  consciousness  is  regained,  it  may 
persist  for  several  days,  and  it  is  a  not  uncommon  cause  of  wakefulness.  It 
is  usually  greatly  aggravated  by  turning  and  twisting,  and  by  attempting 
to  rise  up  from  the  bed.  The  pain  is  located  in  the  lumbar  and  sacral  regions 
and  is  often  accompanied  by  rigidity  of  the  lumbar  muscles.  Various  exolanations 
have  been  given  of  it.  One  view  is  that  it  is  due  to  renal  congestion.  Another, 
that  it  results  from  congestion  of  the  spinal  cord,  I  believe  that  the 
explanation  of  most  cases  is  that  given  by  John  Dunlop  ("New  York  Med. 
Jour.,"  July  ID,  1909),  viz.:  "The  patient  during  the  operation  lay  upon  a  flat 
table  without  support  to  the  lumbar  curve,  consequently  the  sacro-iliac  syn- 
chondroses were  strained.  The  backache  may  be  largely  prevented  by  placing 
a  small  pillow  so  that  it  will  support  the  lumbar  curve  during  anesthesia." 

Respiratory  disorders  are  more  often  noted  after  ether  than  after  chloro- 
form. Bronchitis  may  follow  or  bronchopneumonia  {ether-pneumonia).  Res- 
piratory difficulties  may  be  due  to  chilling  the  patient  by  bringing  him  from 
a  warm  operating  room  through  a  cold  hall  and  into  a  cool  bedroom.  Broncho- 
pneumonia is  especially  common  in  septic  patients,  and  may  be  due  in  some 
cases  to  septic  emboli  and  in  others  to  aspiration  of  septic  material  into  the 
bronchi  (cases  of  cancer  of  the  tongue  and  pharynx,  and  cases  with  stercora- 
ceous  vomiting).  They  are  treated  by  ordinary  methods.  If  chloroform  is 
given  when  a  gas-light  is  in  the  room  the  vapor  is  decomposed  and  certain 
highly  irritant  products  are  formed,  which,  when  inhaled,  produce  laryngeal 
spasm  and  possibly  bronchitis.  The  irritant  material  is  probably  COCI3. 
The  treatment  is  to  admit  fresh  air  freely  into  the  room,  and  to  have  the  patient 
inhale  vinegar  and,  later,  oxygen.  Ether-pneumonia  must  not  be  confounded 
with  postoperative  pneumonia,  described  by  Wm.  H.  Bennett.^  This  latter 
condition  may  arise  from  seven  to  fourteen  days  after  operation  in  robust, 
gouty  people,  and  is  usually  unilateral.  Some  cases  of  respiratory  disorder 
result  from  chilling  while  in  the  operating  room,  or  while  coming  from  it,  rather 
than  from  the  anesthetic.  If  the  patient  is  placed  in  a  sitting  position  or,  at 
least,  semi-erect  in  bed,  as  soon  as  he  reacts  from  the  anesthetic  the  danger  of 
serious  respiratory  disorder  will  be  at  a  minimum. 

Renal  Complications. — After  the  administration  of  an  anesthetic,  blood,  albu- 
min, sugar,  acetone,  or  diacetic  acid  may  appear  in  the  urine,  and  the  secretion 
may  become  scanty  or  even  be  suppressed.  It  is  usually  maintained  that  chloro- 
form is  less  apt  to  irritate  the  kidney  epithelium  than  ether,  but  there  has  been 
much  dispute  on  this  point.  If  casts  and  albumin  are  present  before  anestheti- 
zation, the  condition  may  be  rendered  worse  if  ether  or  chloroform  is  given. 
If  neither  casts  nor  albumin  are  present,  they  will  not  be  so  apt  to  appear  after 
taking  chloroform  as  after  taking  ether,  but  if  they  do  appear  after  chloroform, 
they  remain  longer  than  after  ether  (Legrain).  The  truth  of  the  matter  prob- 
ably is,  that  if  the  kidneys  are  healthy  a  small  or  moderate  amount  of  either 
drug  is  not  particularly  irritant;  but  if  the  kidneys  are  diseased,  a  small  amount, 
and  even  if  they  are  healthy,  a  large  amount,  of  either  drug  produces  decided 
renal  irritation.  Chloroform  is  less  irritant  because  less  chloroform  than  ether 
is  given  to  secure  and  maintain  anesthesia.     Scantiness  or  suppression  of  urine 

^  "Anesthetics,"  by  Dudley  W.  Buxton.  , 

-"Practitioner,"  December,  i8g6. 


134S  Anesthesia  and  Anesthetics 

may  be  due  to  operative  shock  rather  than  to  ether  or  chloroform.  If  the  urine 
becomes  somewhat  scanty  or  if  albumin  appears  in  it,  give  non-irritant  diuretics, 
diaphoretics  and  cathartics,  and  employ  proctoclysis.  The  treatment  of 
acidosis  is  set  forth  below.  If  the  urine  becomes  very  scanty,  use  hypoder- 
moclvsis.  If  postoperative  suppression  arises,  it  is  the  usual  custom  to  give 
intravenous  infusion  of  hot  saline  fluid,  but  I  am  doubtful  of  its  value.  Expo- 
sure of  each  kidney  in  the  loin  and  incision  of  its  capsule  to  relieve  tension  is 
justifiable  and  may  do  good. 

Acid  Intoxication. — This  condition  has  been  called  delayed  poisoning,  aceto- 
mcria,  a.nd  acidosis.  Acidosis  has  been  discussed  on  page  192.  Diabetic  coma 
is  due  to  acid  intoxication.  It  is  known  that  even  in  healthy  urine  there  may 
be  a  trace,  but  a  bare  trace,  of  acetone.  A  diabetic  individual  deprived  abso- 
lutely of  carbohydrates  is  apt  to  get  acetone  and  diacetic  acid  in  the  urine.  In 
such  cases  carbohydrates  cause  the  prompt  disappearance  of  the  acetone  and 
diacetic  acid.  Any  victim  of  a  wasting  disease,  of  fear,  of  alcohol,  of  shock  and 
any  person  who  is  underfed  may  have  acetonuria.  If  we  purpose  anesthetizing  a 
person  with  acetonuria  adopt  Bainbridge's  plan.  Purge  and  for  several  days 
before  operation  give  by  mouth  several  ounces  of  milk-sugar  a  day.  Render 
the  urine  alkaline  by  giving  bicarbonate  of  soda  by  mouth  and  by  rectum. 
Or  for  two  days  before  operation  give  twice  daily  retention  enemata  of  half  an 
ounce  of  glucose  and  half  an  ounce  of  bicarbonate  of  sodium.  (Quillian,  in 
"Annals  of  Surgery,"  1916,  Ixiiii).  Even  people  who  do  not  suffer  from  ace- 
tonuria or  diabetes  may  develop  acetonuria  after  anesthesia.  In  certain  cases 
in  which  dangerous  symptoms  arise  after  anesthesia  the  urine  shows  increased 
acidity,  may  contain  albumin  or  casts,  and  contains  acetone  bodies  (particu- 
larly j3-oxybutyric  acid),  diacetic  acid,  or  both  of  these  substances.  The 
blood  contains  an  excess  of  free  fat  and  shows  diminution  of  alkalinity.  Acid 
intoxication  is  very  much  commoner  after  the  administration  of  chloroform 
than  of  ether,  but  may  follow  the  giving  of  any  general  anesthetic.  It  may 
occur  in  individuals  whose  tissues  contain  areas  of  fatty  degeneration,  but  it 
also  occurs  in  those  entirely  free  from  degeneration;  in  fact,  children  par- 
ticularly suffer  in  this  way  after  the  use  of  chloroform.  The  actual  operation 
has  nothing  to  do  with  the  trouble,  and  sepsis  is  not  causative.  The  drug  used 
as  an  anesthetic  causes  acute  fatty  degeneration  of  the  liver  and  other  organs 
and  quantities  of  acid  bodies  are  formed  and  are  not  eliminated  and  these 
acid  bodies  are  directly  or  indirectly  responsible  for  the  symptoms.  Diacetic 
acid  and  |3-oxybutyric  acid  are  by-products  of  the  process  and  are  antecedents 
or  precursors  of  acetone.  The  symptoms  arise  after  the  patient  has  emerged 
from  anesthesia  and  reacted  from  shock.  There  is  persistent  vomiting  of  thin 
and  foul  fluid,  the  pulse  is  rapid,  there  is  dyspnea,  the  patient  is  extremely 
restless  and  much  excited,  there  may  be  delirium,  but  dulness  and  heaviness 
may  take  the  place  of  restlessness  and  excitement  and  coma  may  arise  .  Usually 
the  temperature  is  subnormal,  but  sometimes  there  is  elevated  temperature. 
In  many  cases  jaundice  arises.  There  is  an  odor  of  acetone  on  the  breath. 
Latent  cases  free  from  symptoms  usually  get  well.  Slight  cases  and  even  some 
grave  cases  recover,  but  most  of  the  grave  cases  die  in  from  one  to  five  days. 
A  knowledge  of  this  condition  explains  some  otherwise  inexplicable  deaths,  and 
also  some  cases  of  persistent  postoperative  vomiting  and  of  retarded  con- 
valescence. In  acid  intoxication  there  is  fatty  degeneration  of  the  kidneys,  of 
the  liver,  of  the  suprarenal  glands,  and  of  the  gastric  mucosa.  The  occurrence 
of  such  a  condition  is  an  impressive  admonition  that  a  surgeon  should  operate 
quickly,  that  as  httle  of  the  anesthetic  should  be  given  as  possible,  that  the 
urine  should  be  carefully  examined  each  day  after  operation  for  certainly 
several  days  and  that  chloroform  should  not  be  used  for  prolonged  adminis- 
tration.^ The  indication  for  treatment  is  to  saturate  the  patient  with  alkalis. 
Sodium  carbonate  is  usually  selected.     It  may  be  given  by  the  rectum,  by  the 


Postanesthetic  Paralysis  or  Narcosis  Palsy  i349 

mouth,  by  hypodermoclysis,  or  intravenously.  Rectal  administration  produces 
irritation  and  diarrhea.  In  acetonuria  without  clinical  symptoms  alkahnize 
the  urine  by  4  or  5  dr.  of  sodium  bicarbonate  daily,  given  by  the  mouth.  When 
the  urine  becomes  alkaline  it  is  to  be  kept' so.  When  symptoms  appear  give 
from  10  to  20  teaspoonfuls  a  day  by  the  mouth  and  give  glucose  and  bicarbonate 
of  soda  by  slow  proctoclysis.  If  symptoms  do  not  soon  disappear  give  the  drug 
intravenously.  Severe  acid  intoxication  is  treated  as  follows:  Encourage  skin 
activity  by  wrapping  the  patient  in  blankets  and  surrounding  him  with  hot- 
water  bags.  Give  carbonate  or  bicarbonate  of  sodium  intravenously,  and  a 
glucose  drip  into  the  rectum  (5  per  cent,  solution  of  anhydrous  glucose).  A  solu- 
tion of  bicarbonate  of  a  strength  of  from  3  to  5  per  cent,  is  used.  Labbe  gives 
from  I  to  2  liters.  If  the  patient  improves,  the  sodium  bicarbonate  is  again  given 
by  mouth.  Some  surgeons  give  citrate  of  sodium.  Drennan  gives  a  salt  of  cal- 
cium. Bevan  and  Farill  ("'Jour.  Am.  Med.  Assoc,"  Sept.  20,  1905)  reported  i 
case  and  collected  27  from  literature.  In  this  series  there  were  2  recoveries.  (On 
this  subject  see  Lewis  Beesly,  in  "Brit.  Med.  Jour.,"  May  19,  1906;  J.  A.  Kelly, 
in  "Annals  of  Surgery,"  Feb.,  1905;  A.  D,  Bevan  and  H.  B.  Farill,  in  "Jour. 
Am.  Med.  Assoc,"  Sept.  20,  1905;  Geo.  E.  Brewer,  in  "Transactions  Am.  Surg. 
Assoc,"  vol.  XX,  1902;  Labbe,  in  "Arch.  gen.  de  med.,"  Dec,  1911,  and  in 
"Presse  med.,"  Feb.  5,  1910;  Braun,  in  "Brit.  Med.  Jour.,"  Feb.  25,  1911; 
Geo.  W.  Crile,  in  "Annals  of  Surgery,"  1915,  Ixii;  A.  G.  Burnham,  in"  Am. 
Med.,"'  1916,  xi;  G.  W.  Quillian,  in  "Annals  of  Surgery,"  1916,  Ixiii;  J.  Harold 
Austin,  in  "Penn.  ]Med.  Jour.,"  Feb.,  191 7. 

Postanesthetic  Paralysis  or  Narcosis  Palsy. — Paralysis  may  arise  during 
anesthesia  as  a  result  of  cerebral  hemorrhage  or  embolism. 

It  sometimes  happens  that  when  a  person  has  come  out  of  the  anesthetic 
sleep  a  palsy  of  some  part  is  found  to  exist,  the  condition  being  peripheral  and 
not  central  in  origin.  Peripheral  narcosis  palsies  are  pressure  palsies  or  trac- 
tion palsies,  although  it  is  held  by  some  that  the  anesthetic  has  a  toxic  influence 
which  distinctly  lowers  the  capacity  of  the  nerves  to  sustain  pressure.  Certain 
it  is  that  palsy  sometimes  follows  what  seems  a  degree  of  pressure  inadequate 
to  cause  such  a  result.  Narcosis  palsies  may  be  due  to  pressure  of  an  extremity 
upon  a  table  edge  or  to  pressure  upon  nerves  by  placing  the  patient  in  certain 
positions.^  Such  palsies  are  most  common  in  the  upper  extremity  but  may 
occur  in  the  face  or  in  the  lower  extremity.  When  the  Trendelenburg  position 
has  been  employed,  the  flexures  of  the  knees  are  in  contact  with  the  edge  of  the 
table,  and  paralysis  of  one  or  both  external  popliteal  nerves  may  be  induced. 
When  the  patient  lies  upon  the  side  any  nerve  of  the  arm  or  forearm  may  suffer, 
but  the  circumflex  and  radial  are  most  liable  to  be  damaged.  When  the  arm 
is  elevated  to  the  side  of  the  head,  or  when  it  is  drawn  out  strongly  from  the 
body,  the  brachial  plexus  may  be  compressed  by  the  head  of  the  humerus  (Braun, 
in  "Deutsche  ]\Ied.  Woch.,"  1894).  When  the  arm  is  in  external  rotation  and 
is  dra\\Ti  backward  and  outward  the  median  nerve  is  stretched,  and  when 
the  forearm  is  flexed  and  supinated  the  ulnar  nerve  is  stretched  (Braun,  Ibid.). 
In  most  cases  the  paralysis  involves  muscles  supplied  by  the  brachial  plexus 
and  is  due  to  drawing  the  arm  upward  and  backward  over  the  head,  a  position 
which  may  squeeze  the  cords  -of  the  plexus  between  the  collar-bone  and  the 
first  rib.  Garrigues  shows  that  the  plexus  is  particularly  apt  to  be  squeezed 
when  it  is  stretched  by  the  head  being  drawn  to  the  opposite  side  or  being 
allowed  to  fall  back.-  According  to  Biidinger  the  mounting  up  of  the  clavicle 
squeezes  the  plexus  as  its  cords  cross  the  first  rib.  This  surgeon  thinks  that 
extreme  abduction  of  the  arm  may  squeeze  the  cords.  Molinari  (Abstract  in 
"Surgery,  Gynecolog}^,  and  Obstetrics,"  Feb.,  i9i4from  "Zentralb.  f.  d.  ges. 
Chir.,  u.  i.  Grenzgeb.")  says:  "  If  an  individual  is  upon  his  back  he  can  raise  his 

1  H.  J.  Garrigues,  in  "Am.  Jour.  Med.  Sciences,"  Jan.,  1897. 

2  Ibid. 


1350  Anesthesia  and  Anesthetics 

arm  forward  higher  than  the  shoulder  without  dragging  on  the  plexus.  When 
the  arm  is  drawn  backward  there  is  tension  of  the  plexus  over  the  head  of  the 
humerus  and  tension  becomes  extreme  when  the  upper  arm  is  rotated  inward 
and  the  head  is  turned  toward  the  opposite  side.  If  the  arm  is  now  raised 
to  a  vertical  position  the  tension  becomes  greater  and  soon  the  plexus  is  squeezed 
between  the  clavicle  and  first  rib." 

The  prognosis  is  good,  as  a  rule.  Slight  cases  are  soon  recovered  from; 
more  serious  cases,  in  which  degeneration  occurs,  may  not  be  recovered  from 
for  months.     The  treatment  is  that  of  any  pressure  palsy. 

Primary  Anesthesia. — Instruct  the  patient  to  count  aloud  and  hold 
one  arm  above  his  head.  Give  the  ether  rapidly.  In  a  short  time  he  becomes 
mixed  in  his  count  and  his  arm  sways  or  drops  to  the  side.  There  is  now  a 
•period  of  insensibility  to  pain  lasting  only  about  half  a  minute,  and  during 
this  period  a  minor  operation  can  be  performed.  The  patient  quickly  reacts 
from  primaty  anesthesia  without  vomiting  (Packard). 

Mixtures  are  used  by  some  because  of  the  belief  that  a  mixture  might 
eliminate  some  unpleasant  feature  or  some  danger  from  a  particular  anesthetic. 

Mixture  of  Ether  and  Chloroform. — This  may  be  used  in  varying  propor- 
tions.    Hewitt  at  times  employs  2  parts  of  chloroform  to  3  parts  of  ether. 

Vienna  mixture  contains  i  part  of  chloroform  and  3  parts  of  ether. 

Mixture  of  Alcohol  and  Chloroform. — All  the  chloroform  mixtures  produce 
the  effects  of  chloroform,  but  we  are  giving  the  drug  in  an  unknown  amount. 
It  was  believed  by  Sansom,  who  devised  this  mixture,  that  the  alcohol  prevents 
concentration  of  chloroform  vapor  by  retarding  evaporation.  When  used, 
I  part  of  alcohol  is  added  to  4  parts  of  chloroform. 

Nitrous  Oxid  and  Oxygen. — (See  page  1352). 

A.  C.  E.  Mixture. — This  mixture  was  originally  used  by  Harley  in  1864.  It 
is  often  valuable  in  cases  in  which  ether  cannot  be  given.  It  is  composed  of  i 
part  of  alcohol,  2  parts  of  chloroform,  and  3  parts  of  ether.  Its  action  is  sup- 
posed to  be  between  that  of  chloroform  and  ether.  The  objection  to  the  A. 
C.  E.  mixture,  as  to  any  mixture,  is  that  the  materials  do  not  evaporate  in  the 
ratio  in  which  they  are  mixed,  hence  an  uncertain  amount  of  chloroform  vapor 
is  being  inhaled  (Buxton).  This  mixture  is  given  by  some  from  a  Junker 
and  by  others  from  an  open  inhaler.  Plenty  of  air  should  be  given  with  it. 
The  anesthetic  acts  similarly  to  chloroform. 

Billroth's  mixture  contains  i  part  of  alcohol,  3  parts  of  chloroform,  and  i 
part  of  ether. 

Schleich's  Mixture  for  General  Anesthesia. — Schleich,  in  1895,  introduced 
a  new  anesthetic  agent  which  he  claims  is  safer  than  chloroform.  This  surgeon 
maintains  that  a  material  is  safe  as  an  anesthetic  only  when  almost  all  of  the 
amount  taken  in  at  an  inspiration  is  expelled  on  expiration.  The  anesthetic  is 
unsafe  in  direct  proportion  to  the  amount  absorbed;  and  the  lower  the  boiling- 
point  of  an  anesthetic,  the  less  is  absorbed,  hence  an  anesthetic  agent,  to  be  safe, 
should  have  a  low  boiling-point.  Schleich  make's  three  solutions.  The  first 
contains  (by  volume)  i}4,  oz.  of  chloroform,  ^  oz.  of  petroleum  ether,  and  6  oz. 
of  sulphuric  ether.  The  second  contains  i3^^  oz.  of  chloroform,  }^  oz.  of  pe- 
troleum ether,  and  5  oz.  of  sulphuric  ether.  The  third  contains  i  oz.  of  chloro- 
form, }/^  oz.  of  petroleum  ether,  and  2^^  oz.  of  sulphuric  ether.  No.  i  is  used 
for  light  anesthesia,  No.  2  for  medium  anesthesia,  and  No.  3  for  deep  anesthesia. 
The  anesthesia  can  be  given  from  an  open  inhaler  or  a  towel.  The  anesthetic 
state  is  quiet,  reaction  is  rapid,  and  vomiting  occurs  in  but  half  the  cases.  The 
superiority  of  this  new  anesthetic  has  not  been  proved.  It  sometimes  causes 
dangerous  symptoms,  and  has  produced  death.  Some  surgeons,  who  formerly 
approved  of  it,  have  abandoned  it.  It  will  certainly  not  displace  ether  or  chlo- 
roform. Schleich's  mixtures  are  now  seldom  or  never  used  in  the  United  States. 
Petroleum  ether  has  no  anesthetic  power,  and  Meltzer  shows  that  it  is  dangerous 


Chlorid  of  Ethyl  1351 

and  tends  to  paralyze  the  respiratory  muscles.  Willy  Meyer  ("Med.  Record," 
August  15,  1908)  believes  in  the  Schleich  principle,  but  substitutes  ethyl  chlorid 
with  a  boiling-point  of  59°  F.  for  the  petroleum  ether.  He  uses  17  per  cent, 
volume  of  ethyl  chlorid  with  S$  per  cent,  volume  of  the  molecular  mixture  of 
ether  and  chloroform. 

Ethyl  bromid  was  first  used  by  Nunneley,  of  Leeds,  in  1849.  It  was  re- 
introduced in  1882  and  again  in  1896.  It  is  still  sometimes  used  for  short  opera- 
tions. It  is  given  while  the  patient  is  recumbent.  The  unconsciousness  is 
obtained  in  from  one  to  three  minutes  and  is  rapidly  recovered  from,  and  there 
is  no  after-sickness.  The  unconsciousness  lasts  about  three  minutes.  Three 
drams  are  given  to  a  child,  and  6  dr.  to  an  adult.  A  towel  is  put  over  the  face 
and  the  entire  amount  is  poured  on  at  once,  and  as  soon  as  the  patient  is  uncon- 
scious the  towel  is  taken  away  and  no  more  of  the  drug  is  given  (Cumston). 
Even  if  consciousness  is  regained  too  quickly  to  suit  the  purposes  of  the  surgeon, 
it  is  not  safe  to  give  more  of  the  drug,  a  notable  objection  which  chlorid  of 
ethyl  does  not  possess.  Cases  have  been  reported  in  which  sudden  death  has 
followed  the  administration  of  this  drug,  and  it  should  not  be  given  if  there  is 
disease  of  the  heart,  lungs,  or  kidneys.^  Twenty-four  deaths  from  bromid  of 
ethyl  are  on  record  (Guadiana).  If  it  kills,  it  acts  like  chloroform.  It  may 
be  given  before  ether  to  prevent  unpleasant  effects,  but  it  is  usually  not  con- 
sidered proper  to  give  before  chloroform.  Zematski,  however,  has  used  it 
before  chloroform  in  2000  cases  ("Vratch,"  August  25,  1901).  I  know  of  2 
unpublished  deaths  from  it  in  Philadelphia.  1  never  use  it  and  regard  it 
as  unsafe.  The  drug  rapidly  deteriorates,  and  the  deteriorated  drug  is  very 
dangerous. 

Chlorid  of  ethyl  is  a  rapid  anesthetic  and  statistics  imply  that  it  is  a 
safe  one.  My  faith  in  it  has  been  greatly  shaken  by  knowledge  of  3  unpublished 
deaths  in  Philadelphia.  It  was  first  used  by  Heyfelder  in  1848.  A  committee 
of  the  British  Medical  Association  condemned  it  in  1880.  Carlson  and  Thie- 
sing  reintroduced  it  in  1895  (McCardie,  in  "Lancet,"  April  4,  1903).  It  may 
be  sprayed  upon  a  mask  covered  by  six  to  eight  layers  of  gauze,  so  that  the  drug 
will  not  evaporate  too  quickly  in  the  air.  Many  anesthetists  give  it  in  a  closed 
apparatus,  the  patient  respiring  into  and  from  a  rubber  bag.  I  believe  it  should 
be  mixed  with  air  and  that  concentrated  vapor  is  a  danger  to  the  heart.  The 
odor  of  the  drug  is  agreeable.  From  5  to  10  gm.  of  ethyl  chlorid  are  given  for 
a  short  operation  if  the  mask  is  used.  The  patient  must  always  be  recumbent 
when  taking  it.  Early  in  the  inspiration  the  pulse  and  respiration  become 
rapid.  When  unconsciousness  comes  they  should  be  normal.  The  anesthetic 
state  is  induced,  when  the  mask  is  used,  in  from  two  to  three  minutes, 
and  as  soon  as  it  is  obtained  the  patient  is  allowed  to  get  air.  If  the  closed 
inhaler  is  used  unconsciousness  is  obtained  more  rapidly.  Excitement  does 
not  precede  unconsciousness.  The  anesthetic  condition  lasts  from  one  to 
three  minutes,  and  it  is  recovered  from  rapidly,  usually  without  vomiting  or 
unpleasant  after-effects.  If  the  patient  recovers  too  rapidly  for  the  surgeon's 
purpose,  more  ethyl  chlorid  can  be  given.  It  is  to  be  noted  that  complete  mus- 
cular relaxation  does  not  occur,  in  many  cases  the  conjunctival  reflex  is  not 
completely  abolished,  and  often  the  pupils  do  not  dilate.  It  has  no  superiority 
over  nitrous  oxid,  except  as  to  cost  and  portability,  and  sometimes  it  fails  to 
produce  complete  unconsciousness.  A  large  dose  rapidly  given  is  dangerous, 
as  it  may  cause  cessation  of  respiration  and  spasm  of  the  diaphragm.  A  contra- 
indication to  its  use  is  any  respiratory  obstruction.  In  many  cases  there  is 
spasm  of  the  masseters.  Concentrated  vapor  administered  for  a  considerable 
time  lowers  the  blood-pressure,  induces  cyanosis  and  asphyxia,  and  would  even- 
tually cause  death  by  respiratory  failure  (McCardie,  Ibid.).  Lotheisser,  in  a 
study  of  2500  cases  of  anesthesia  by  this  agent,  reports  i  death.  Ware  col- 
1  See  Cumston,  in  "Boston  Med.  and  Surg.  Jour.,"  Dec.  20,  1894. 


1352 


Anesthesia  and  Anesthetics 


lected  12,436  cases,  with  i  death  ("Jour.  Am.  Med.  Assoc,"  Nov.  8,  1902). 
Seitz,  of  Konstanz,  collected  16,000  cases,  with  i  death.  Miller  ("Jour.  Am. 
Med.  Assoc,"  Nov.  23,  191 2)  estimates  that  there  is  i  death  in  13,365  ad- 
ministrations. It  is  perhaps  safer  than  chloroform,  not  nearly  so  safe  as  nitrous 
oxid,  and  not  so  safe  as  ether.  The  drug  is  used  for  a  brief  operation  or  exami- 
nation.    It  can  be  given  to  infants  a  few  days  old  with  reasonable  safety,  and  it 

has  been  administered  many  times  to 
the  aged.  When  it  kills,  it  acts  in  a 
similar  manner  to  chloroform.  I  have 
often  given  it  before  ether  to  prevent 
unpleasant  symptoms  and  to  hasten 
the  advent  of  anesthesia,  but  it  must 
never  be  given  before  chloroform.  Re- 
cently I  have  practically  ceased  to  ad- 
minister ethyl  chlorid. 

Nitrous  oxid  gas  may  be  used  to 
obtain  anesthesia  for  brief  operations. 
It  is  contra-indicated  when  high-blood 
pressure  indicates  vascular  degeneration, 
because  apoplexy  may  follow  its  ad- 
ministration. It  should  never  be  given 
when  the  air-channel  is  narrowed,  as  in 
Ludwig's  angina,  abscess  in  or  below 
the  tongue,  and  thyroid  enlargement 
(F.  W.  Hewitt,  in  "Lancet,"  July  20,  27, 
and  August  10, 1907).  This  gas  is  stored 
in  steel  cylinders,  in  which  it  is  lique- 
fied. The  gas  is  passed  into  a  rubber 
bag  (Fig.  877),  and  is  given  to  the  patient 
by  means  of  a  tube  and  a  mouth-mask, 
a  wedge  being  placed  between  the  pa- 
tient's molar  teeth,  and  the  nostrils 
l)eing  closed  by  the  anesthetist's  fingers. 
The  wedge  must  be  held  by  a  string, 
so  that  it  cannot  be  swallowed.  The 
patient  becomes  unconscious  in  about 
one  minute,  and  we  know  the  patient 
is  anesthetized  by  the  stertor  and  cya- 
nosis and  the  insensitiveness  of  the  con- 
junctivae. The  pulse  should  be  watched, 
and  if  it  flags  the  administration  must 
be  suspended  at  once.  The  striking 
phenomena  are  asphyxial,  stertorous  res- 
piration, cyanosis,  and  even  convulsions,  dilatation  of  the  pupils,  rapidity  of 
the  heart,  and  swelling  of  the  tongue.^  Muscular  relaxation  is  not  as  com- 
plete as  in  ether-anesthesia.  Slowing  of  the  heart  is  a  danger  sign.  If  nitrous 
oxid  causes  death,  it  does  so  by  asphyxia  or  by  asphyxia  and  cardiac  inhibition. 
A  person  rouses  very  rapidly  when  the  administration  of  nitrous  oxid  is  sus- 
pended. It  is  a  useful  plan  to  give  nitrous  oxid  first  and  follow  this  with  ether 
(see  page  1355).  By  this  method  the  patient  is  anesthetized  rapidly  and  pleas- 
antly with  the  nitrous  oxid,  and  the  anesthesia  is  maintained  by  the  ether. 

It  was  formerly  taught  that  nitrous  oxid  necessarily  produces  cyanosis,  be- 
cause the  gas  can  only  cause  anesthesia  by  partially  asphx-xiating  the  patient. 
We  know  this  is  untrue,  because  if  nitrous  oxid  is  mixed  with  oxygen  or  atmos- 
pheric air  anesthesia  is  obtained  without  cyanosis.     Nitrous  oxid  is  a  genuine 
1  See  Hewitt,  "Brit.  Med.  Jour.,"  Feb.  18,  1899. 


Fig.  877. — Hewitt's  nitrous  oxid  apparatus 


Nitrous  Oxid  Gas 


1353 


anesthetic  agent.  If  a  prolonged  administration  of  nitrous  oxid  is  desired,  pure 
nitrous  oxid  can  be  given,  a  breath  of  fresh  air  being  allowed,  from  time  to  time. 
By  this  method  Preston  has  anesthetized  many  patients,  the  duration  of  the 
anesthesia  being  from  ten  to  fifty  minutes.  A  better  plan  is  to  give  nitrous  oxid 
and  oxygen.  I  do  not  believe  it  is  wise  to  give  nitrous  oxid  even  with  oxygen 
over  thirty  minutes  because  of  the  destructive  effect  of  the  gas  on  hemoglobin. 
A  trouble  frequently  encountered  is  persistent  rigidity.  This  can  often  be 
prevented  by  a  preliminary  dose  of  morphin.  Postanesthetic  vomiting  is  rare 
(Teter,  on  "Thirteen  Thousand  Administrations  of  Nitrous  Oxid  with  Oxygen," 


Fig.  '  878. — Hewitt's  nitrous  oxid  an'd  oxygen  apparatus. 


''Jour.  Am.  Med.  Assoc,"  August  7,  1909).  Hewitt^  formulates  the  following 
views  as  to  the  use  of  oxygen  and  nitrous  oxid: 

"In  order  to 'obtain  the  best  form  of  anesthesia  oxygen  should  be  admin- 
istered with  nitrous  oxid  by  means  of  a  regulating  apparatus  (Fig.  878),  the  per- 
centage of  the  former  gas  being  progressively  increased  from  2  to  3  per  cent, 
at  the  commencement  of  the  administration  to  7,  8,  9,  or  10  per  cent.,  according 
to  the  circumstances  of  the  case.  The  longer  the  administration  lasts,  the 
greater  may  be  the  percentage  of  oxygen  admitted. 

"The  next  best  results  to  those  obtainable  by  means  of  a  regulating  appa- 
ratus for  nitrous  oxid  and  oxygen  are  to  be  secured  by  administering  certain 
1  "Brit.  Med.  Jour.,"  Feb.  18,  1899. 


1354 


Anesthesia  and  Anesthetics 


constant  mixtures  of  these  two  gases.  Mixtures  containing  5,  6,  or  7  per  cent, 
of  oxygen  are  best  for  adult  males,  and  mixtures  containing  7,  8,  or  9  per  cent, 
are  best  for  females  and  children.  The  next  best  results  to  those  last  mentioned 
are  to  be  obtained  by  means  of  mixtures  of  nitrous  oxid  and  air,  from  14  to  18 
per  cent,  of  the  latter  being  advisable  in  anesthetizing  men  and  from  18  to  22  per 
cent,  in  anesthetizing  women  and  children.  " 

Crile  uses  nitrous  oxid  and  oxygen  as  the  anesthetic  of  choice  for  many  opera- 
tions, even  major  operations.  He  believes  it  produces  less  shock,  less  nausea, 
and  less  lowering  of  vital  resistance  to  infection  than  does  ether.  He  insists 
on  the  necessity  of  having  a  highly  trained  administrator  and  of  keeping  the 
patient  pink  during  the  administration.     Respiratory  failure  is  met  at  once  by 

turning  off  the  nitrous  oxid  and 
substituting  pure  oxygen.  If  re- 
laxation is  impossible  (and  it  may 
be  in  a  very  muscular  subject), 
ether  is  given  until  relaxation  is 
attained  and  then  a  return  is 
made  to  nitrous  oxid  ("Trans- 
actions of  Southern  Surg,  and 
Gynec.  Assoc,"  1909).  Crilegives 
a  small  dose  of  morphia  and 
scopolamin  before  operation  to  pre- 
vent too  early  postoperative  appre- 
ciation of  the  "operative  trauma." 
The  Gwathmey-Woolsey  ap- 
paratus is  a  very  useful  one  for 
nitrous  oxid  and  oxygen  adminis- 
tration (Fig.  879).  When  the  op- 
eration is  to  be  brief,  when  there  is 
bronchial  or  pulmonary  disorder, 
or  when  nephritis  exists  nitrous 
oxid  with  oxygen  is  the  method  of 
choice.  I  agree  with  Baldwin  that 
it  is  not  free  from  danger  ("Med. 
Record,"  1916,  xc).  A  number 
of  deaths  have  been  reported 
(Baldwin  refers  to  over  thirty). 
The  method  is  expensive,  re- 
quires a  specially  trained  ad- 
ministrator, should  not  be  adopted 
as  a  routine,  and  should  not  be 
used  in  operations  requiring  more 
than  thirty  minutes. 
Bichlorid  of  Methylene. — The  composition  of  the  so-called  bichlorid  of 
methylene  is  a  matter  of  dispute.  Some  high  authorities  believe  it  to  be  a 
mixture  of  methyl  alcohol  and  chloroform.  It  rapidly  produces  unconscious- 
ness and  the  patient  returns  quickly  to  consciousness  when  the  administration 
is  suspended.  Some  surgeons  have  thought  highly  of  it,  and  claimed  that  it  is 
pleasant,  safe,  and  is  not  followed  by  vomiting  as  often  as  chloroform.  The 
weight  of  opinion  is  that  it  is  dangerous,  death  being  similar  to  death  from 
chloroform.     It  is  given  by  means  of  a  Junker  apparatus. 

Anesthetic  Successions. — Bromid  of  Ethyl  Followed  by  Chloroform  or 
Ether. — (See  page  1351.) 

Chlorid  of  Ethyl  Followed  by  Ether. — (See  page  1351.) 
Chloroform  Followed  by  Ether. — Chloroform  is  sometimes  given  until  the 
sensation  becomes  more  or  less  obtunded,  when  ether  is  substituted.     This  is 


Fig.  879. — Gwathmey-Woolsey  nitrous  oxid 
oxygen  apparatus  with  tanks  in  place:  O,  Regu- 
lating valve  for  oxygen;  O2,  oxygen  tank;  NiO, 
nitrous  oxid  tank. 


Nitrous  Oxid  Gas  followed  by  Ether  1355 

done  to  save  the  patient  from  the  unpleasant  sensation  of  etherization.  It  is 
a  practice  not  to  be  commended,  because  it  is  precisely  in  the  beginning  that 
chloroformization  is  most  dangerous. 

Ether  Followed  by  Chloroform. — When  the  patient  cannot  be  relaxed  or 
rendered  unconscious  by  ether,  or  when  some  other  complication  develops, 
it  is  common  practice  to  suspend  ether  and  substitute  chloroform.  If  the 
change  is  made,  chloroform  should  be  given  cautiously.  A  large  quantity  should 
never  be  poured  upon  the  inhaler  at  one  time.  The  change  should  never  be 
made  when  the  patient  is  struggling,  because  the  deep  respirations  which  attend 
or  follow  struggling  may  lead  to  the  rapid  inhalation  of  a  dangerous  dose  of 
chloroform  vapor.  Further,  as  Hewitt  points  out,  when  the  patient  is  deeply 
under  the  influence  of  ether  the  change  should  not  be  made  unless  it  is  impera- 
tively necessary. 

Nitrous  Oxid  Gas  Followed  by  Ether  (Gas  and  Ether). — This  very  valu- 
able method  was  suggested  by  Clover.  I  have  used  it  repeatedly  with  great 
satisfaction.  The  patient  is  made  unconscious  by  nitrous  oxid  and  is  kept 
unconscious  by  ether.  Thus  are  avoided  excitement,  struggling,  choking, 
and  the  very  unpleasant  sensations  induced  by  ether.  It  lessens  the  amount 
of  time  requisite  to  obtain  anesthesia  and  lessens  the  amount  of  ether  used. 
More  important  even  than  this,  the  method  is  safe.  It  is  more  satisfactory 
in  women  and  children  than  in  men.  In  very  muscular  men  and  in  very  stout 
elderly  men  it  should  not  be  used.  In  many  cases  nitrous  oxid  causes  a  flow 
of  mucus  from  the  respiratory  tract.  Because  of  the  frequency  of  this  hap- 
pening it  is  wise  to  precede  gas  and  ether  anesthesia  twenty  minutes  by  a  hypo- 
dermatic injection  of  morphin  and  atropin  (Van  Kaathov.en,  in  "Annals  of 
Surgery,"  Sept.,  1908),  or  of  atropin  alone.  Many  operators  first  anesthetize 
with  nitrous  oxid,  using  an  ordinary  dental  apparatus,  and  then  give  ether  on  an 
ordinary  inhaler.  The  anesthetist  must  bear  in  mind  that  ether  must  be  given 
gradually,  not  suddenly,  poured  on  in  large  amount.  Others  prefer  to  use  a  com- 
bined gas-and-ether  inhaler.    I  use  the  Gwathmey-Woolsey  apparatus  (Fig.  879) . 

Hewitt  ("Anesthetics  and  Their  Administration")  thus  describes  the  ad- 
ministration by  means  of  Clover's  portable  ether-inhaler  fitted  with  a  stop-cock 
and  a  detachable  gas  bag : 

"If  the  patient  be  lying  upon  his  back,  his  head  should  be  turned  to  one 
side.  The  face-piece  with  the  charged  ether  chamber  is  then  applied  during 
an  expiration.  Air  will  be  breathed  backward  and  forward.  When  the  res- 
piration is  seen  to  be  proceeding  freely,  and  the  face-piece  fits  well,  the  charged 
gas  bag  is  attached  to  the  ether  chamber.  Air  will  still  be  breathed,  but  not 
through  the  valves  of  the  special  stop-cock.  When  the  valves  are  heard  to 
be  working  properly  'gas'  is  turned  on,  and  is  likewise  breathed  through 
the  valves.  Three  or  four  respirations  (or  about  one-half  of  the  contents  of  the 
bag)  are  allowed  to  escape.  The  valve  action  is  now  stopped  by  turning  the 
tap  at  the  upper  part  of  the  stop-cock.  At  the  same  moment  at  which 
the  patient  begins  to  breathe  'gas'  backward  and  forward,  the  rotation  of  the 
ether  chambers  for  the  addition  of  ether  vapor  should  be  commenced.  The  ad- 
ministrator will,  in  fact,  find  that  he  can,  in  a  few  seconds  from  the  commence- 
ment of  the  administration,  rotate  the  ether  chamber  as  far  as  'i'  or  'i}-^.' 
Should  swallowing  or  coughing  arise,  he  must  rotate  more  slowly.  Respiration 
soon  becomes  deep  and  regular,  and  more  and  more  ether  may  be  admitted.  At 
about  this  juncture,  if  the  apparatus  has  been  fitting  the  face  well,  signs  of 
nitrous  oxid  narcosis  may  appear,  especially  in  those  who  are  quickly  affected 
by  this  gas.  Should  jerky  breathing  or  'jactitation'  arise,  one  full  inspiration 
of  air  may  be  admitted  at  the  air-tap.  It  should  be  remembered,  however, 
that  in  giving  'gas  and  ether'  by  this  method,  the  object  is  just  to  steer  clear  of 
the  clonus  and  'stertor'  of  nitrous  oxid  narcosis  and  gradually  but  increas- 
ingly to  mix  ether  with  the  gas. 


1356  Anesthesia  and  Anesthetics 

"In  muscular  and  vigorous  subjects  the  quantity  of  gas  above  mentioned 
will  be  found  to  be,  as  a  general  rule,  insufficient  to  lead  to  the  usual  signs  of 
deep  nitrous  oxid  anesthesia.  The  rotation  of  the  ether  chamber  should  be 
continued  till  the  indicator  points  to  '2,'  '3,'  or  'F.' 

"  The  mistake  that  is  most  commonly  made  is  that  of  admitting  air  too  soon. 
Should  air  be  given  during  the  first  half  or  three-quarters  of  a  minute,  the 
patient  will  partially  come  round,  hold  his  breath,  set  his  teeth,  and  give  a  good 
deal  of  trouble.  Duskiness  of  the  features  must  be  expected.  Speaking  gen- 
erally, air  should  not  be  allowed  until  the  patient  is  stertorous,  when  one  breath 
may  be  given.  In  this  manner  the  patient  will  continue  breathing  a  mixture 
of  nitrous  oxid,  ether,  and  air  till  the  usual  signs  of  deep  ether-anesthesia  appear, 
when  the  gas  bag  may  be  detached,  and  the  little  bag  ordinarily  used  with 
Clover's  inhaler  substituted." 

Hewitt  prefers  to  use  a  modified  Clover  inhaler,  which  permits  of  the  intro- 
duction of  ether  after  the  inhalation  of  nitrous  oxid  has  begun. 

Hypnotic  Anesthesia.- — It  is  well  known  that  Esdaile  in  India  did  numbers 
of  operations  upon  patients  in  hypnotic  anesthesia,  Cloquet,  as  long  ago 
as  1829,  amputated  a  breast  of  a  woman  who  was  held  free  from  pain  by  hyp- 
nosis. In  1 85 1  Guerineau  amputated  the  thigh  of  a  hypnotized  person  and 
there  was  no  sign  of  pain.  But  all  subjects  are  not  susceptible.  Even  sus- 
ceptible subjects  require  to  be  hypnotized  again  and  again  for  days  before  the 
operation.     The  method  has  its  own  dangers  and  has  been  entirely  abandoned. 

Scopolamin-morphin  Anesthesia. — This  method  has  been  enthusiastically 
praised  and  I  have  used  it  with  satisfaction  in  a  number  of  cases,  but  I  have 
grown  afraid  of  it.  In  a  patient  in  the  JefTerson  Hospital  dangerous  symptoms 
arose  after  a  dose  of  Hoo  gr.  of  scopolamin.  Ely  records  a  death  from  respira- 
tory failure  two  hours  after  the  administration  of  }'8  gr.  of  morphin  and  3^'ioo  gr- 
of  scopolamin  ("New  York  Med.  Jour.,"  Oct.  20,  1906).  A  number  of  deaths 
have  been  reported  following  its  use  and  there  are,  beyond  doubt,  unreported 
cases.  Four  deaths  in  2400  cases  were  certainly  directly  due  to  it  (H.  J.  Whit- 
acre,  in  "New  York  Med.  Jour.,"  March  31,  1906).  It  has  even  been  stated 
that  the  death-rate  is  i  in  100  ("Semaine  Medicale,"  Jan.  11,  1905).  Scopola- 
min is  chemically  identical  with  hyoscin  and  must  never  be  used  unless  fresh, 
as  it  decomposes  in  air  and  light.  If  given  without  morphin,  it  is  inefhcient. 
Large  doses  are  certainly  dangerous,  and  the  combination  should  never  be 
given  in  sufficient  amount  to  induce  surgical  anesthesia  unaided.  If  used  at  all, 
it  should  only  be  as  an  aid  to  local  anesthesia  or  to  general  anesthesia  by  ether  or 
chloroform.  I  have  used  it  as  an  aid  to  local  anesthesia  in  6  goiter  operations 
in  2  cases  of  removal  of  the  Gasserian  ganglion  and  in  several  prostatectomies. 
It  should  not  be  used  in  heart  disease  (Hayem) ;  in  persons  under  sixteen  or  over 
sixty  (Korff);  in  any  one  with  a  tendency  to  pulmonary  edema  or  with  any 
acute  condition  of  the  throat  which  interferes  with  respiration  (A.  C.  Wood,  in 
"American  Medicine,"  Nov.  11,  1905). 

It  produces  a  drowsy,  heavy  state  or  actual  sleep,  and  the  patient  can  be 
kept  unconscious  with  an  extremely  small  quantity  of  ether  or  chloroform. 
For  five  or  six  hours  after  the  operation  the  sleep  continues,  and  in  most  cases 
there  is  no  postoperative  vomiting. 

If  it  be  used,  a  mixture  is  freshly  made  containing  if  00  gr-  of  scopolamin 
and  l-Q  gr.  of  morphin,  and  this  is  given  hypodermatically  one-half  an  hour 
before  the  operation.  During  the  operation  the  sleep  may  be  maintained 
by  small  amounts  of  ether  or  chloroform.  If  symptoms  of  poisoning  occur, 
artificial  respiration  and  oxygen  inhalations  may  be  required,  external  heat  is 
needed,  and  nitroglycerin,  strychnin,  or  caffein  should  be  given. 

I  agree  with  Kochmann  that  we  are  not  as  yet  justified  in  reconimending 
this  method  of  anesthesia  ("Miinchener  medizinische  Wochenschrift,"  1905, 
No.  17).     The  Tubingen  Clinic  abandoned  it  after  thorough  trial. 


Hypodermatic  Injection  of  Cocain  Hyclrochlorate 


157 


Anesthesia  in  Obstetrics. — ^Light  ether  anesthesia  is  used  by  some,  light 
chloroform  anesthesia  by  others.  If  it  is  night  and  there  is  gas  lamp  or  candle 
light  be  sure,  if  ether  is  used,  that  there  is  sufficient  ventilation  to  prevent  an  ex- 
plosion, and,  if  chloroform  is  used,  to  prevent  the  decomposition  of  chloroform 
vapor  by  naked  flame  into  highly  irritant  gases.  Scopolamin-morphin  anesthesia 
was  introduced  by  Steinbuchel  in  1903.  In  1906  it  came  to  be  called  the  Frei- 
burg method  of  Gauss.  It  has  since  been  widely  and  most  improperly  ad- 
vertised as  ''twilight  sleep."  I  leave  the  discussion  of  its  merits  or  demerits 
to  the  obstetricians.  In  1S80  Klikowisch  began  to  use  nitrous  oxid  and  oxy- 
gen in  obstetrics.  Webster  took  it  up  in  1905.  He  gives  the  gas  during  the 
pains  and  withdraws  it  between  the  pains.  The  administration  is  begun  in 
the  second  stage  of  labor  when  the  pains  become  severe. 
It  is  said  to  increase  rather  than  to  arrest  expulsive 
contraction,  the  consciousness  is  retained  and  the  child 
is  not  injured. 

Local  Anesthesia. — In  every  case  requiring  oper- 
ation we  should  inquire  whether  local  anesthesia  should 
be  used  instead  of  general  anesthesia.  Many  really  exten- 
sive operations  can  be  done  under  the  former,  and  its  field 
has  been  greatly  broadened  by  the  knowledge  that  viscera 
innervated  by  purely  visceral  nerves  are  insensitive  and 
sensation  exists  only  in  those  which  receive  branches  from 
the  somatic  nerves  (K.  G.  Lennander,  in  "  ]\Iittheilungen 
aus  dem  Grenzgebeiten  der  ^Medicin  und  Chirurgie," 
1902,  Bd.  x,  Heft  I  and  2).  Lennander  shows  that  the 
parietal  peritoneum  is  sensitive  to  pain,  but  not  to  touch 
— ^that  the  intestine,  stomach,  edge  of  the  liver,  mesentery, 
gall-bladder,  urinary  bladder,  kidney  parenchyma,  lung, 
anterior  wall  of  the  trachea,  testicle,  and  epididymis  are 
insensitive,  though  the  coverings  of  the  testicle  and  epi- 
didymis are  sensitive.  My  experience  is  that  the  viscera 
may  be  cut,  sutured,  and  handled  without  any  severe 
pain  if  they  are  not  pulled  upon.  In  removing  an  ap- 
pendix the  only  pain  felt  will  be  when  the  meso-appendbc 
is  pulled  upon  or  adhesions  to  the  parietal  peritoneum 
are    separated.     The    advantages    of    operation   under 

local  anesthesia  are  freedom  from  the  danger  of  anesthetic  accidents,  blood 
changes,  and  postanesthetic  discomforts  and  dangers.  The  disadvantage  is 
the  knowledge  of  the  patient  as  to  what  is  taking  place.  He  may  become 
alarmed  and  turbulent,  and  may  thus  interfere  with  a  necessary  procedure  at  a 
\ital  moment.     There  are  many  methods  of  local  anesthesia. 

Freezing. — Ice  and  salt  may  be  used.  Take  I4  pound  of  ice,  wrap  it  in  a 
towel,  and  break  it  into  fine  bits;  add  }'g  pound  of  salt;  then  place  the  mixture 
in  a  gauze  bag  and  lay  it  upon  the  part.  The  surface  becomes  pallid  and  numb, 
and,  in  about  fifteen  minutes,  decidedly  analgesic.  A  spray  of  rkigolene  freezes 
a  part  in  about  ten  seconds.  It  is  highly  inflammable.  Ether-spray  anesthesia 
was  suggested  by  Benjamin  Ward  Richardson.  Chlorid  of  ethyl  comes  in  glass 
or  metal  tubes  (Fig.  880).  Remove  the  cap  from  the  tip  of  the  tube  and  hold 
the  bulb  in  the  palm:  the  warmth  of  the  hand  causes  the  fluid  to  spray  out. 
Hold  the  tube  some  little  distance  from  the  part,  and  let  the  fine  spray  strike 
the  surface.  The  skin  blanches  and  whitens,  and  is  ready  for  the  operation  in 
about  thirty  seconds.  Freezing  is  only  of  value  in  a  trivial  operation  and 
when  only  a  single  cut  or  stick  is  required. 

Hjrpodermatic  Injection  of  Cocain  Hydrochlorate. — Cocain  was  discovered 
by  Gaedeke  in  1855.  In  1884  Koller,  of  Vienna,  demonstrated  the  value  of 
cocain  as  an  analgesic  in  ophthalmic  practice.     In  1885  J.  Leonard  Corning,  of 


Fig.     S80.  —  Gebauer's 
ethyl-chlorid  tube.' 


1358  Anesthesia  and  Anesthetics 

New  York,  showed  that  cocain  when  appHed  to  a  mixed  nerve  in  man  aboUshed 
nerve  conduction,  as  it  was  aheady  known  to  do  in  the  lower  animals.  In  1885 
Halsted  and  Raymond  induced  anesthesia  in  the  nerve  distribution  by  inject- 
ing cocain  about  the  inferior  dental  and  lingual  nerves  (perineural  injection). 
This  was  done  before  pulling  a  tooth.  Schleich  introduced  infiltration  anes- 
thesia. Braun,  Van  Hook,  and  Matas  did  much  to  develop  local  anesthesia. 
A  tremendous  impetus  was  given  to  infiltration  anesthesia  by  Harvey  Cushing's 
report  on  herniotomy  under  local  anesthesia  ("Annals  of  Surgery,"  igoo,  vol. 
xxxi).  He  used  a  very  weak  solution  of  cocain  (i  :iooo).  Cocain  hydrochlo- 
rate  is  soluble  in  water,  but  should  not  be  boiled.  To  boil  it  impairs  its 
anesthetic  power.  A  tablet  of  the  drug  should  be  sterilized  by  dry  heat  and 
dissolved  in  sterile  water.  Always  bear  in  mind  that  cocain  is  sometimes  a 
decidedly  dangerous  agent.  There  are  a  number  of  deaths  from  cocain  on 
record.  The  urethra  is  a  particularly  dangerous  region,  and  so  is  the  face.  It 
is  undesirable  to  use  more  than  ^^  gr.  upon  a  mucous  surface,  and  to  inject 
hypodermatically  more  than  3^^  gr.  The  drug  must  not  be  injected  into  a  vein. 
Moderately  severe  cases  of  cocain-poisoning  are  characterized  by  great  tremor, 
restlessness,  pallor,  dry  mouth,  talkativeness,  and  weak  pulse.  In  dangerous 
cases  there  is  syncope  or  delirium.  Death  may  arise  from  paralysis  or  from  fixa- 
tion of  the  respiratory  muscles.  Cases  with  a  tendency  to  respiratory  failure 
require  the  hypodermatic  injection  of  strychnin.  In  cases  with  tetanic  rigidity 
of  muscles  hypodermatic  injections  of  nitroglycerin  or  inhalations  of  the  nitrite 
of  amyl  should  be  given.  In  cases  marked  by  delirium,  if  the  circulation  is  good, 
hyoscin  is  given.  In  any  case  stimulants  are  given,  a  catheter  is  used,  and  diuresis 
encouraged.  Cocain-poisoning  is  always  followed  by  a  wakeful  night.  Cocain 
should  not  be  used  in  any  considerable  amount  if  the  kidneys  are  inefficient. 
In  using  cocain  try  to  prevent  poisoning.  Because  of  the  dangers  inherent  in 
cocain,  have  the  patient  recumbent.  One  minute  before  giving  the  cocain 
administer  hypodermatically  i  drop  of  a  i  per  cent,  solution  of  nitroglycerin 
and  repeat  the  dose  once  during  the  operation.  In  operating  on  a  finger,  after 
making  the  part  anemic,  tie  a  tube  around  the  root  of  the  digit  before  injecting 
cocain,  and  after  the  operation  gradually  loosen  the  tube.  A  hot  solution  of 
cocain  is  more  efficient  than  a  cold  solution,  hence  hot  solutions  can  be  used  in 
much  less  strength  and  are  safer.  The  method  of  injection  is  as  follows:  A  sharp 
needle  is  held  at  an  angle  of  45  degrees  to  the  surface  and  is  pushed  into  the 
Malpighian  layer.  One  or  2  min.  of  a  2  per  cent,  solution  are  forced  into  the 
Malpighian  layer,  and  a  whitened  elevation  forms.  The  needle  is  withdrawn, 
at  the  margin  of  the  wheal  is  reinserted,  and  more  fluid  is  introduced,  and  so  on 
until  the  region  to  be  operated  upon  has  been  injected.  After  waiting  five 
minutes  the  operation  is  begun.  If,  after  cutting  the  skin,  it  is  necessary  to 
cut  the  subcutaneous  tissue,  inject  a  few  drops  of  a  i  per  cent,  solution  into  the 
tissue.  After  the  completion  of  the  operation,  if  a  rubber  band  has  been  used,  it 
is  loosened  for  a  few  seconds,  tightened  for  a  few  minutes,  again  loosened  and  re- 
adjusted, and  so  on  several  times  (Wyeth).  In  this  way  only  a  small  quantity 
of  cocain  is  admitted  into  the  circulation  at  one  time  and  toxic  symptoms  are 
prevented.  For  operations  upon  the  eye  a  i  to  4  per  cent,  solution  is  employed; 
I  drop  of  fluid  is  instilled  every  ten  minutes  until  3  drops  have  been  given. 
Rarely  use  over  a  10  per  cent,  solution  on  mucous  membrane,  although  in 
laryngeal  operations  a  20  per  cent,  solution  may  be  required.  For  the  nasal 
mucous  membrane  a  bit  of  wool  soaked  in  a  5  per  cent,  solution  is  inserted  or  a 
spray  of  4  per  cent,  solution  is  thrown  from  an  atomizer  into  the  nostrils.  In 
the  rectum,  vulva,  vagina,  and  uterus  use  a  5  per  cent,  solution;  in  the  urethra, 
a  4  per  cent,  solution,  and  in  the  bladder,  a  2  per  cent,  solution. 

Cocainization  of  a  Nerve-trunk. — Krogius,  Halsted,  and  Raymond  pointed 
out  that  if  cocain  be  injected  into  the  tissue  about  a  nerve-trunk  (perineural 
injection),  anesthesia  will  follow  in  the  area  supplied  by  the  nerve.     The  anes- 


Infiltration  Anesthesia  I359 

thesia  will  be  produced  in  five  minutes,  and  will  last  fifteen  minutes.  If  cocain 
be  injected  about  the  root  of  the  finger,  all  of  the  tissues  of  the  digit  will  become 
insensitive.  Injection  over  both  supra-orbital  notches  renders  the  middle  of 
the  forehead  insensitive.  Injection  over  the  ulnar  nerve  causes  complete  anes- 
thesia in  its  trajectory.     This  plan  is  extensively  used  in  Helsingfors. 

It  has  been  demonstrated  by  Crile  ('"Jour.  Am.  Med.  Assoc,"  Feb.  22, 
1902)  that  the  injection  of  cocain  into  a  nerve-trunk  (endoneural  injection) 
interposes  an  absolute  block  to  the  transmission  of  afferent  and  efferent  im- 
pulses and  greatly  lessens  operative  shock.  In  3  cases  I  employed  this  method 
to  secure  anesthesia  for  amputation  of  the  leg.  None  of  the  patients  felt  pain 
and  shock  was  trivial. 

In  two  amputations  of  the  entire  upper  extremity,  although  the  patient 
was  under  ether,  the  brachial  plexus  was  cocainized  to  minimize  shock  and 
shock  was  very  slight.  The  cocain  was  injected  directly  into  the  trunks  (en- 
doneural injection).  The  combination  of  local  anesthesia  and  general 
anesthesia  is  part  of  Crile's  anoci=association  operation,  a  plan  to  rule 
out  all  noxious  or  noci  influences  ("Jour.  Am.  Med.  Assoc,"  July  13,  1912). 
He  points  out  that  though  a  person  under  ether  is  without  feeling,  the  greater 
part  of  the  brain  is  still  awake,  nerve  impulses  still  reach  the  brain  and  cause 
functional  depression  and  morphological  alterations  in  the  brain  cells  (Crile's 
''Ether  Day  Address,"  1910).  He  would  prepare  a  patient  by  filling  him  with 
calm  confidence,  giving  him  morphin  and  scopolamin  previous  to  operation, 
administeiing  nitrous  oxid,  and  isolating  the  brain  from  the  field  of  operation 
by  infiltrating  the  region  with  1:400  solution  of  novocain.  At  the  conclusion 
of  the  operation  the  region  may  be  injected  with  the  hydrochlorid  of  quinin 
and  urea. 

Eucain  hydrochlorate  (/3-eucain)  is  not  entirely  nontoxic  but  is  far  safer  than 
cocain  used  in  full  doses,  and  in  many  cases  is  to  be  preferred  to  it.  It  is  in- 
jected in  the  strength  of  from  2  to  5  per  cent.  It  is  soluble  in  water  and  can  be 
boiled  without  destroying  its  properties,  and  hence  can  be  readily  rendered 
sterile.  It  occasionally,  though  rarely,  happens  that  the  injection  of  eucain 
causes  sloughing,  especially  at  the  extremities,  in  fatty  tissue,  in  tendon-sheaths, 
and  in  bursas.     It  can  be  used  on  mucous  membranes. 

Stovain. — This  agent  is  a  local  anesthetic  introduced  by  Fourneau.  It 
is  as  powerfully  analgesic  as  cocain,  is  only  one-third  as  toxic,  and  is  slightly 
germicidal.  It  is  dissolved  in  cold  water  or  salt  solution,  and  is  used  in  a  solution 
of  the  strength  of  0.5  per  cent.  Adrenalin  can  be  given  with  it.  (See  Son- 
nenburg,  in  "Deutsche  medicinische  Wochenschrift,"  March,  1905.) 

Quinin-urea  hydrochlorid  in  from  ^^  to  i  per  cent,  solution  causes  pro- 
longed local  anesthesia.  A  solution  of  i  per  cent,  is  too  strong — it  causes  the 
wound  to  heal  slowly  and  produces  induration.  The  drug  has  no  toxic  effect 
and  can  be  used  in  considerable  quantity;  it  lessens  bleeding,  and,  by  producing 
an  effect  for  many  hours,  lessens  postoperative  pain.  Quinin-urea  hydro- 
chlorid is  used  by  infiltration  (see  below-).  It  is  dissolved  in  water  or  normal 
salt  solution. 

Novocain  of  a  strength  in  solution  of  from  i :  200  to  i :  400  is  preferred 
by  some  surgeons.  It  may  be  given  alone  or  mixed  with  stovain.  It  is  given 
by  infiltration.  The  drug  is  soluble  in  water  and  the  solution  can  be  boiled 
without  being  unpaired  in  anesthetic  power.     It  is  one-sixth  as  toxic  as  cocain. 

Infiltration  anesthesia  is  in  most  instances  the  preferred  method  of  local  an- 
esthesia. It  is  a  term  used  to  indicate  a  form  of  local  anesthesia  in  which  the 
tissues  are  not  only  injected,  but  are  distended  decidedly  with  a  fluid  anes- 
thetic indifferent  in  nature.  It  is  called  terminal  anesthesia  because  the  anes- 
thetic acts  upon  the  terminal  branches  of  sensory  nerves.  It  is  called  regional 
anesthesia  because  the  fluid  injected  affects  a  particular  part  of  a  sensory  nerve 
in  its  course.     Infiltration  anesthesia  was  devised  by  Schleich,  of  Leipsic,  who 


1360 


Anesthesia  and  Anesthetics 


was  dissatisfied  with  cocain,  because  it  is  not  safe  and  sometimes  fails  to  produce 
complete  local  anesthesia,  owing  to  want  of  thorough  diffusion.  He  found  that 
salt  solution  (0.2  per  cent.),  if  injected  into  uninllamed  parts,  produced  anesthe- 
sia. To  obtain  this  anesthesia  the  part  must  be  distended  by  wide  infiltration. 
If  minute  quantities  of  cocain,  morphin,  and  carbolic  acid  are  added  to  the 
solution,  the  anesthesia  becomes  more  thorough  and  more  prolonged,  and  can 
be  obtained  even  in  inflamed  areas.     Schleich  uses  three  solutions: 

No.  I,  a  strong  solution,  which  is  used  in  inflamed  areas:  cocain  hydrochlo- 
rate,  3  gr. ;  morphin  hydrochlorate,  ^5  gr. ;  sodium  chlorid,  3  gr. ;  distilled  sterile 
water,  i^^  oz.;  phenol  (5  per  cent.),  2  drops. 

No  2,  medium  solution,  which  is  employed  in  most  cases:  cocain  hydro- 
chlorate,  1 3^^  gr. ;  morphin  hydrochlorate,  ^^5  gr.;  sodium  chlorid,  3  gr.;  dis- 
tilled sterile  water,  3^5  oz.;  phenol  (5  per  cent.),  2  drops. 

No.  3  is  the  weak  solution  used  to  infiltrate  extensive  areas:  cocain  hydro- 
chlorate, Y%  gr-;  morphin  hydrochlorate,  ^5  gr.;  sodium  chlorid,  3  gr.;  distilled 
sterile  water,  3^5  oz.;  phenol  (5  per  cent.),  2  drops. 

The  addition  of  adrenalin  chlorid  to  the  cocain  solution  is  an  advantage,  as 
it  retards  the  circulation  and  hence  favors  analgesia  and  lessens  bleeding  dur- 
ing the  operation.  A  satisfactory  fluid  for  infiltration  is  i  part  of  a  1:1000 
solution  of  adrenalin  chlorid  and  9  parts  of  a  0.5  per  cent,  solution  of  cocain 


Fig.  881. — The  syringe-point  stops  at  the  papillary  laver,  and  the  fluid  lodges  in  the  skin  itself 

(Van  Hook).' 

(Gangitans,  in  "Riforma  Medica,"  Sept.  9,  1903).  Eucain  and  adrenalin  are 
preferred  by  some.  Barker  uses  distilled  water,  100  gm.;  pure  sodium  chlorid, 
0.8  gm.;  jS-eucain,  0.2  gm.;  chlorid  of  adrenalin,  o.ooi  gm.  After  injecting 
Barker's  fluid  the  surgeon  waits  for  twenty  minutes  before  operating. 

The  injections  are  begun  in  the  skin,  not  under  it  (Fig.  881),  and  are  made 
one  after  another  until  the  area  to  be  operated  upon  is  surrounded  above,  below, 
and  on  all  sides  with  Schleich's  solution.  At  each  infiltrated  area  a  wheal 
forms  in  the  skin.  This  infiltration  can  be  made  painlessly  by  touchng  with 
pure  carbolic  acid  the  point  where  the  needle  is  to  be  inserted,  or  by  freezing 
this  spot  with  ethyl  chlorid.  After  infiltration  of  the  skin  with  the  cocain  solu- 
tion the  surgeon  waits  for  a  minute  or  two  and  then  operates;  incision  is  made, 
and  when  deeper  tissues  are  reached  they  are  infiltrated  before  incising  them. 
If  a  nerve  comes  in  sight,  touch  it  with  a  drop  of  pure  carbolic  acid.  Van 
Hook  says  that  the  anesthesia  obtained  by  this  method  is  due  to  artificial 
ischemia,  pressure  upon  the  tissues,  the  direct  action  of  the  drugs,  and  the 
lowered  temperature.^  The  method  is  very  efficient,  and  can  be  used  for 
operations  of  considerable  magnitude.  Matas  uses  a  special  apparatus  to 
infiltrate  the  tissues.  The  fluid  is  driven  by  compressed  air,  and  widespread 
or  massive  infiltration  is  produced. 

An  ideal  fluid  to  be  injected  should  be  isotonic  with  the  blood,  and  should 
contain  the  smallest  percentage  of  chemical  agent  necessary  to  render  the  part 
anesthetic.  The  solution  recommended  by  Dr.  James  Mitchell,  of  Washington, 
D.  C,  seems  to  meet  these  requirements  as  closely  as  practically  possible. 

»  "Med.  News,"  Nov.  16,  1895.' 


Infiltration  Anesthesia  1361 

Mitchell  uses  a  tablet  containing  ^^  gr.  of  cocain  and  34oo  gr-  of  adrenalin. 
The  tablets  are  dry  sterilized,  and  just  before  operation  are  dropped  into  cups 
containing  normal  salt  solution.  Two  strengths  of  solution  are  prepared:  one 
tablet  is  dissolved  in  a  cup  containing  50  c.c.  of  the  saline  solution,  one  in  a  cup 
containing  100  c.c.  The  stronger  solution  is  used  for  infiltrating  the  skin, 
blocking  nerves,  or  for  any  particular!}'  sensitive  area;  the  weaker  solution  is 
employed  for  general  infiltration  of  tissue.  As  Karl  G.  Lennander  (''Local 
and  Subarachnoid  (Spinal)  Anesthesia,"  in  "Keen's  Surgery,"  vol.  v,  page 
1054)  has  pointed  out,  "  Cocain  has  a  greater  affinity  for  the  sensory  than  for  the 
motor  nerves.  The  effect  of  cocain  in  a  certain  proper  concentration  upon 
peripheral  mixed  nerves  is  to  abolish,  first,  the  sense  of  tickling,  then  the  sense 
of  temperature,  thereafter  the  sense  of  pain,  and,  lastly,  the  sense  of  touch 
(pressure),  and  only  thereafter  the  motor  faculty,  which  may  remain  unaffected, 
although  all  the  modalities  of  sensation  have  been  paralyzed.  During  the  re- 
trogression of  poisoning  the  faculty  of  motion  is  the  first  to  return,  then  the  sense 
of  pressure,  next  the  sense  of  pain,  and  lastly  the  sense  of  temperature."  The 
addition  of  the  adrenalin  to  the  cocain  solution  is  an  advantage,  in  that  it  re- 
tards the  circulation  by  contracting  non-striped  muscle-fibers  in  arteries  and 
capillaries.  The  cocain  is  thus  localized,  its  anesthetic  action  prolonged,  and 
bleeding  diminished  during  the  operation.  I  do  not  believe  that  adrenalin  in 
any  way  modifies  the  toxic  action  of  cocain;  indeed.  Berry  ("Am.  Jour.  Med. 
Sciences,"  Nov.,  1905)  seems  to  prove  that  it  actually  increases  it.  With  the 
extremely  weak  solution  recommended  by  Mitchell  I  have  never  seen  the  slight- 
est physiological  action  of  cocain.  The  total  dosage  of  cocain  given  by  in- 
filtration should  not  exceed  i^  gr.  In  i  case  I  observed  superficial  sloughing 
of  the  skin  when,  by  an  operating-room  error,  three  tablets  had  been  dissolved 
in  50  c.c.  of  saline.  1  believe  the  slough  was  due  to  the  high  percentage  of 
adrenalin. 

The  field  of  operative  achievement  under  infiltration  anesthesia  has  broad- 
ened to  such  an  extent  that  it  is  difficult  definitely  to  limit  its  possibilities  when 
it  is  in  the  hands  of  one  skilled  in  its  use.  It  is  necessary  for  the  surgeon  oper- 
ating by  this  method  to  use  an  essentially  different  technic  from  that  com- 
monly employed  in  operations  under  a  general  anesthetic.  He  should  be 
calm,  equable,  content  to  wait,  and  patient  in  spite  of  delay.  He  must  be 
skilled  in  clean  operative  dissections,  and  accustomed  to  refrain  from  handling 
tissues  unnecessarily.  Failure  is  certain  if  the  operator  is  not  constantly  en- 
gaged in  this  kind  of  work,  for  he  must  have  learned,  above  all  things,  gentle- 
ness and  willingness  to  spend  plenty  of  time,  and  must  have  acquainted 
himself  accurately  with  the  sensibilities  of  the  various  tissues  encountered  in 
different  operative  fields.  For  the  occasional  operator  to  attempt  major 
operations  under  infiltration  anesthesia  is  to  court  failure.  The  patient  should 
be  informed  that  operation  is  to  be  a  matter  of  intelligent  co-operation,  and  in 
major  operations  it  is  wise  to  give  a  hypodermatic  injection  of  morphin  (i^  gr.) 
a  half-hour  before  beginning.  This  is  usually  sufficient  to  allay  the  appre- 
hension natural  in  one  about  to  undergo  an  operation.  A  tactful  assistant 
should  be  detailed  to  sit  by  the  patient's  head  and  engage  him  in  conversation, 
sponge  his  face,  administer  small  sips  of  water,  and,  in  other  words,  be  w'hat 
may  be  called  the  "psychic  '  anesthetist.  The  patient  should  not  see  anv  of 
the  preoperative  preparations;  instruments  should  be  carefully  excluded  from 
the  range  of  his  vision.  Needless  conversation  between  assistants,  nurses  and 
spectators  and  other  noise  should  be  avoided. 

The  special  instruments  required  are:  two  Record  syringes  of  2  c.c.  capacity 
and  one  of  5  c.c;  two  fairly  fine  needles  i^^  inches  in  length  and  two  coarser 
needles  2  inches  in  length;  a  pair  of  Mayo's  51^-inch  straight  dissecting  scissors 
with  keen  edges;  dissecting  forceps  with  teeth,  and  fine-pointed  artery  clamps. 
For  example,  let  us  take  an  appendectomy  in  a  patient  with  a  frank  tuberculosis 
86 


1362  Anesthesia  and  Anesthetics 

of  the  lung;  a  case  in  which  general  narcosis  would  cause  damage  and  might 
prove  fatal.  The  patient,  having  been  prepared  for  operation  (care  having  been 
taken  to  administer  morphin  a  half-hour  previously),  is  placed  upon  the  oper- 
ating table  and  made  as  comfortable  as  possible.  The  head  is  arranged  upon  a 
pillow,  the  arms  are  disposed  comfortably  at  the  sides,  and  a  folded  blanket  is 
placed  under  the  lumbar  spine.  The  patient's  wishes  may  be  consulted  as  to 
whether  he  desires  a  piece  of  gauze  placed  over  his  eyes  or  not.  Usually  the 
patient,  unless  addressed,  keeps  his  eyes  closed.  The  "  psychic  "  anesthetist  en- 
gages the  patient  in  conversation,  the  surgeon  must  show  full  confidence,  be 
cheerful,  and  endeavor  to  communicate  this  frame  of  mind  to  his  subject. 

The  easiest  method  of  approach  to  the  appendix  under  infiltration  anesthe- 
sia is  McBurney's  muscle-splitting  incision.  Begin  infiltration  by  taking  the  2 
c.c.  syringe  filled  with  the  stronger  cocain  and  adrenalin  solution.  Use  a  fine 
needle.  Pinch  up  a  small  piece  of  skin,  informing  the  patient  that  you  are  going 
to  stick  him  slightly  with  a  fine  needle.  Holding  the  needle  almost  parallel  with 
the  skin,  barely  insert  the  point  under  the  epidermis  and,  at  the  same  time, 
press  on  the  piston  of  the  syringe  so  as  to  obtain  an  infiltrated  spot  simultane- 
ously with  the  introduction  of  the  needle.  The  pain  caused  by  the  first  intro- 
duction of  the  needle  is  trivial  and  even  that  degree  is  absent  during  subsequent 
insertions.  A  small  wheal  is  produced,  the  integument  assuming  a  blanched, 
pig-skin  appearance.  From  the  center  of  this  infiltrated  circle  the  needle 
may  now  be  inserted  painlessly  to  its  full  length  in  the  skin  (not  under  the 
skin),  parallel  with  the  surface.  Do  not  insert  the  needle  too  deeply  at  this 
time.  As  the  point  of  the  needle  travels  the  solution  should  be  fed  from  the 
syringe.  Ordinarily  2  c.c.  of  solution  will  infiltrate  1I2  to  2  inches  of  skin. 
After  the  superficial  infiltration  a  coarser  and  longer  needle  should  be  used  to 
infiltrate  subcutaneous  tissues.  The  incision  may  now  be  carried  down  to 
the  aponeurosis  of  the  external  obUque.  Infiltrate  the  muscular  and  aponeu- 
rotic portion  of  the  external  oblique.  Make  a  spHt  in  the  aponeurosis  by  a 
knife  and  continue  by  Mayo's  scissors.  Gentle  clips  with  the  scissors  cause 
less  pain  than  knife  dissection.  Retract  carefully  the  aponeurotic  layer.  In- 
filtrate the  internal  obHque  and  spHt  it.  The  transversalis  and  peritoneum 
are  infiltrated  with  the  stronger  solution,  which  we  employ  at  this  point  for 
the  first  time  since  the  infiltration  of  the  skin.  These  layers  are  then  incised. 
Incisions  in  all  layers  of  the  abdominal  wall  must  be  of  ample  size  to  avoid 
unduly  strong  retraction.  Up  to  this  stage  the  patient  should  experience 
no  pain  unless  one  has  thoughtlessly  clamped  a  vein  without  previous  infil- 
tration about  it  with  the  stronger  solution.  The  visceral  peritoneum  may  be 
cut,  clamped,  burned,  and  stitched  with  impunity,  but  undue  traction  upon  the 
mesentery  immediately  causes  general  cramp-like  abdominal  pain  with  con- 
sequent rigidity  of  the  abdominal  wall.  The  appendix,  therefore,  is  sought 
for  by  gently  following  the  anterior  longitudinal  band  intra-abdominally  rather 
than  by  attempting  to  pull  the  cecum  out  of  the  abdominal  incision.  Once  the 
base  of  the  appendix  is  found,  the  rest  is  easy.  Traction  on  the  meso-appendix 
must  be  gentle,  and,  before  tying  it,  infiltrate  it  with  the  stronger  solution. 
The  crushing,  hgation  and  inversion  of  the  base  of  the  appendix  are  accompanied 
by  pain.  Occasionally  the  necessary  traction  on  the  mesocolon  will  cause  the 
patient  to  have  nausea,  which  is  reheved  as  soon  as  the  traction  ceases.  Suture 
of  the  abdominal  wall  now  follows  without  special  incident,  except  that  very 
small  rubber  tissue  drains  should  be  inserted  just  under  the  skin  at  one  or 
both  ends  of  the  incision  when  infiltration  anesthesia  has  been  used.  These 
drains  take  care  of  any  possible  oozing  that  may  occur  after  the  effect  of  the 
adrenalin  has  worn  off. 

By  the  use  of  infiltration  anesthesia  I  have  operated  with  satisfaction  in  the 
following  cases:  Tracheotomy,  tuberculous  glands  of  the  neck,  rib  resection, 
goiter,  drainage  of  a  cerebral  cyst,  ligation  of  the  thyroid  arter-ies,  gastrostomy. 


Bier's  Intravenous  Method  of  Local  Anesthesia  1363 

inguinal  colostomy,  typhoid  perforation,  abscess  of  the  lung,  chronic  and  acute 
appendicitis,  gangrenous  appendicitis,  appendicitis  in  the  interval,  appendiceal 
abscess,  jejunostomy,  radical  cure  of  inguinal,  femoral,  and  umbilical  hernia, 
strangulated  hernia,  incisional  hernia,  resection  of  the  bowel,  suprapubic  cystos- 
tomy,  extirpation  of  the  external  carotid  artery  (Dawbarn's  operation),  ligation 
of  the  femoral  artery,  cholecystostomy,  suture  of  fractured  patella,  amputation 
through  the  arm,  amputation  through  the  thigh,  amputation  of  the  leg,  removal 
of  stone  from  the  pelvis  of  the  kidney,  gastroenterostomy,  kidney  abscess, 
psoas  abscess,  varicocele,  hydrocele,  circumcision  and  large  numbers  of  minor 
conditions. 

Patients  after  abdominal  section  under  infiltration  anesthesia  very  rarely 
vomit  at  all,  never  have  as  much  postoperative  pain  as  those  who  have  been  under 
a  general  anesthetic,  and  seldom  have  backache.  Distention  of  the  bowel  is 
uncommon.  The  catheter  is  rarely  required,  and,  of  course,  the  blood  changes, 
renal  difficulties,  and  postoperative  pneumonias  are  much  less  frequent  than 
after  general  narcosis.  Infiltration  anesthesia  cannot  be  ignored  in  such  cases 
as  diabetes,  Addison's  disease,  sepsis,  advanced  Basedow's  disease,  diseases  of 
the  cardiac  muscle,  liver,  both  kidneys,  etc.  In  children  and  high-strung  in- 
dividuals infiltration  is  usually  impossible;  in  operations  for  extensive  malignant 
growths,  or  during  which  complete  muscular  relaxation  must  be  obtained,  this 
form  of  anesthesia  is  absolutely  contra-indicated. 

To  those  interested  in  infiltration  anesthesia  I  would  suggest  a  careful 
study  of  Spalteholz's  admirable  illustrations  of  nerves  (especially  those  of  the 
extremities),^  together  with  the  perusal  of  the  following  writings: 

H.  Braun:  "Die  Lokalanasthesie,  ihre  wissenschaftlichen  Grundlagen  und  praktische 
Anwendung,"  Leipzig,  1907.     (A  very  full  bibliography  accompanies  this  excellent  work.) 

Translated  by  Percy  Shields.     Lea  and  Febiger,  1914. 

Harvey  Gushing:  "Observations  Upon  the  Neural  Anatomy  of  the  Inguinal  Region  Rela- 
tive to  the  Performance  of  Herniotomy  Under  Local  Anesthesia,"  in  "Annals  of  Surgery," 
1900,  vol.  xxxi. 

Theodor  Kocher:  "Text-Book  of  Operative  Surgery,"  third  English  edition,  by  Harold 
J.  Stiles  and  C.  Balfour  Paul,  vol.  i,  page  16. 

Karl  G.  Lennander:  "Local  and  Subarachnoid  (Spinal)  Anesthesia,"  in  "Keen's  Surgery," 
vol.  V,  page  1045. 

James  F.  Mitchell:  "The  Production  of  Local  Anesthesia  for  Surgical  Purposes,"  in 
"American  Practice  of  Surgery,"  by  Bryant  and  Buck,  vol.  iv,  page  231. 

Carroll  W.  Allen:  "  Local  and  Region  Anesthesia."     W.  B.  Saunders  Co.,  iqi8. 

Arthur  Schlesinger:  "Local  Anesthesia."     Translated  by  F.  S.  Arnold.     Rebman  and  Co. 

Arthur  E.  Hertzler:  "Surgical  Operations  withLocal  Anesthesia."     Surgery  Pub.  Co.,  N.  Y. 

George  Hirschell:  "Text-book  of  Local  Anesthesia."  Translated  by  R.  E.  S.  Krohn. 
Wm.  Wood  and  Co. 

Bier's  Intravenous  Method  of  Local  Anesthesia. — This  plan  was  described 
by  Bier  at  the  German  Surgical  Congress  of  1908.^  It  permits  of  serious  opera- 
tions upon  the  limbs,  operations  for  which  ordinary  methods  of  local  anes- 
thesia would  prove  quite  inefl&cient.  Suppose  the  surgeon  intends  to  resect 
an  elbow-joint:  Mark  the  position  of  the  veins  on  the  asepticized  extremity. 
Apply  an  Esmarch  bandage  from  the  tips  of  the  fingers  to  well  above  the  elbow- 
joint.  This  is  the  expulsion  bandage.  A  thin  soft-rubber  band  is  applied 
around  the  arm  above  the  Esmarch  bandage,  the  bandage  is  removed,  and  a  like 
band  is  applied  below  the  elbow.  The  anesthetic  is  injected  into  a  superficial 
vein  of  this  bloodless  area  (the  basilic  or  cephalic) .  The  tissues  above  and  about 
the  vein  are  infiltrated.  The  vein  is  exposed,  the  syringe  of  the  cannula  is  in- 
troduced, and  ligatures  are  used  as  though  we  were  going  to  give  an  ordinary 
intravenous  injection  of  salt  solution,  except  that  the  cannula  is  pointed  to 

^"Hand  Atlas  of  Human  Anatomy,"  by  Werner  Spalteholz.  Edited  and  translated  by 
Lewellys  F.  Barker. 

2  Bier:  "Ueber  einen  neuen  Weg  Lokalanasthesia  au  den  Gliedmaassen  zu  erzeugen," 
"Arch.  f.  klin.  Chir.,"  1908,  Ixxxvi,  No.  4. 


1364  Anesthesia  and  Anesthetics 

the  periphery.  The  fluid  used  is  a  0.25  or  0.5  per  cent,  solution  of  nov^ocain. 
The  syringe,  containing  50  c.c  of  fluid,  forces  the  solution  downward  into  the 
veins  and  the  limb  swells. 

If  the  stronger  solution  is  used,  50  c.c.  are  enough;  if  the  weaker  solution  is 
used,  100  c.c.  will  be  required.  If  resecting  the  knee,  the  injection  should  be 
made  into  the  internal  saphenous  vein  using  twice  the  amount  advised  for  the 
elbow. 

After  injecting  the  strong  solution  operation  may  be  begun  at  once.  After 
injecting  the  weak  solution  we  should  wait  ten  minutes.  The  bloodless  area 
between  the  bands  becomes  anesthetic  very  promptly  after  the  injection — the 
bones  as  well  as  the  soft  parts.  The  peripheral  portion  of  the  limb  beyond 
the  area  between  the  bands  becomes  anesthetic  after  a  short  time  and  motor 
paralysis  may  follow.  Such  paralysis  is  eventually  recovered  from.  If  anes- 
thesia between  the  bands  is  not  attained  within  five  minutes  there  has  been 
some  failure  in  technic  (Bier,  "Edinburgh  Med.  Jour.,"  1910,  v.  No.  2).  The 
analgesia  is  entirely  satisfactory  and  passes  away  as  soon  as  the  band  is  re- 
moved. When  the  operation  has  been  completed,  wash  out  the  vein  with  salt 
solution  in  order  to  prevent  toxic  effects. 

By  this  method  the  anesthetic  passes  through  the  vein  walls  and  becomes  fixed 
in  the  tissues,  and  when  the  bands  are  removed  it  returns  very  gradually  to 
the  circulation,  hence  we  may  give  greatly  larger  doses  than  admissible  by  any 
other  method.  Adrenalin  should  not  be  given  with  the  novocain.  Toxic  symp- 
toms are  rare.  The  method  is  contra-indicated  in  arteriosclerosis.  (See  Carroll 
Smith,  in  "Jour.  Am.  Med.  Assoc,  "March  23,  1912;  P^ge  and  McDonad,  in 
"Lancet,"  Oct.  16,  1909;  Hitzrot,  in  "Annals  of  Surgery,"  1909,  vol.  i.) 

Anesthesia  by  Infiltration  with  Sterile  Water. — When  the  tissues  are  well  in- 
filtrated with  warm  or  cold  sterile  water,  anesthesia  ensues  promptly.  I  have 
not  found  it  as  complete  as  when  cocain  or  eucain  is  employed,  even  when  a  con- 
siderable amount  of  fluid  is  introduced.  Gant  uses  it  in  rectal  operations 
and  commends  it  strongly  ("New  York  and  Phila.  Med.  Jour.,"  Jan.  28,  1904). 

Spinal  Analgesia. — J.  Leonard  Corning  in  1885  discovered  that  cocain 
injected  between  the  spines  of  the  eleventh  and  twelfth  dorsal  vertebra  pro- 
duced analgesia  of  the  lower  limbs  ("New  York  Med.  Jour.,"  Oct.  31,  1885). 
From  this  observation  spinal  anesthesia  springs.  Bier  produced  complete 
anesthesia  of  the  entire  body  except  the  head  by  the  injection  of  a  small  amount 
of  cocain  into  the  subarachnoid  space  of  the  spinal  cord.  A  solution  of  cocain 
of  a  strength  of  from  0.5  per  cent,  to  i  per  cent,  is  used  by  some,  but  cocain 
cannot  be  boiled  without  impairment  of  its  anesthetic  power,  and  carbolic 
acid  must  be  added  to  it  in  small  amount.  Hence  cocain  so  prepared  is  not 
certainly  sterile,  and  the  carbolic  acid  added  may  induce  harmful  symptoms. 
(See  Neugebauer,  in  "Wien.  klin.  Woch.,"  1901,  Nos.  50,  51,  52.)  Some 
surgeons  use  a  solution  of  eucain  which  can  be  boiled,  but  it  is  not  so  rapid 
and  certain  as  cocain.  Some  use  tropacocain  (lUwicz).  A  solution  of  this  drug 
can  be  boiled,  is  less  poisonous  than  cocain,  and  somewhat  slower  in  action. 
Experimenters  tell  us  that  14,  to  i^^  gr.  of  cocain  may  be  given,  but  it  is  not 
wise  to  give  over  0.5  gr.  I  have  used  stovain  in  a  number  of  cases.  Some 
combine  it  with  adrenalin,  but  the  combination  is  not  desirable  in  the  sub- 
arachnoid space.  The  dose  is  i  c.c.  of  a  5  per  cent,  solution.  The  analgesia 
lasts  from  one-half  an  hour  to  an  hour  or  more,  and  was  followed  in  my  cases 
by  retention  of  urine.  Some  have  used  novocain  alone  or  combined  with 
adrenalin. 

A.  W.  Morton  ("Jour.  Am.  Med.  Assoc,"  Nov.  8,  1902)  takes  chemically 
pure  crystalline  hydrochlorate  of  cocain,  places  it  for  fifteen  minutes  in  a  dry 
temperature  of  300°  F.,  and  puts  it  in  sterile  tubes  until  wanted.  The  dose 
depends  upon  the  locality  in  which  he  wishes  to  induce  analgesia,  and  varies 
between   0.3   and  0.5   gr.     The  required  dose  is  placed  in  the  barrel  of  the 


Spinal  Analgesia  1365 

sterile  syringe  and  is  dissolved  in  cerebrospinal  fluid  drawn  into  the  syringe  for 
that  purpose.  I  now  follow  tlie  plan  of  Mr.  Arthur  E.  Barker.  He  believes 
that  the  specihc  gravity  of  the  fluid  containing  the  drug  plays  an  important 
part  in  its  localization  within  the  canal  ("Brit.  Med.  Jour.,"  March  16,  1912). 
He  uses  a  fluid  as  nearly  as  possible  isotonic  with  the  blood.  It  consists  by 
weight  of  5  parts  of  stovain,  5  parts  of  glucose,  and  90  parts  of  distilled  water. 
Adrenalin  is  never  added.  It  may  do  harm,  it  can  do  no  good.  This  fluid 
seeks  the  lowest  level  it  can  find  and  mixes  but  little  with  the  cerebrospinal 
fluid.     The  average  dose  is  i  c.c.  of  the  5  per  cent,  solution. 

The  syringe  used  is  of  glass  and  of  a  capacity  of  2  c.c.  The  needle  is  the 
hollow  one  of  Bier.  The  needle  must  be  sharp,  else  it  will  not  go  through 
the  dura.     Barker's  fine  blunt  cannula  goes  through  the  lumen  of  the  needle. 

The  fluid  to  be  injected  is  kept  in  sealed  Jena  glass  ampoules,  and  should  not 
be  more  than  a  week  or  two  old.  The  fluid  is  drawn  into  the  syringe  from  the 
ampoule.  The  patient  hes  upon  his  side  with  the  head  and  shoulders  well 
raised  and  with  the  back  curved.  The  back  has  been  previously  sterilized. 
The  dressings  are  removed  and  the  region  to  be  punctured  is  resterilized.  The 
spines  of  the  third  and  fourth  lumbar  vertebra  are  located,  and  the  needle  is 
entered  in  the  midline  beneatli  the  spine  of  the  third  or  fourth  lumbar  vertebra 
and  is  pointed  upward  and  forward.  The  surgeon  determines  that  he  has 
punctured  the  subarachnoid  space  by  lessened  resistance  and  the  appearance 
of  fluid  at  the  needle-opening.  The  injection  is  made  slowly,  the  needle  is 
withdrawn,  and  the  puncture  sealed  by  collodion.  In  performing  the  operation 
care  must  be  taken  to  prevent  the  escape  of  the  cerebrospinal  fluid. 

If  tlie  patient  remains  upon  the  side  the  nerve-roots  of  the  dependent  side 
are  rendered  analgesic  some  time  before  those  of  the  uppermost  side.  If  he  be 
turned  for  a  time  upon  the  other  side  the  nerve-roots  of  that  side  will  quicklv 
become  anesthetized.  To  turn  him  upon  the  back  mil  do  the  same  thing,  but 
less  rapidly.  If  he  is  placed  in  a  sitting  position  the  rectum  and  anus  are  quickly 
rendered  anestlietic. 

The  usual  position  for  operation  is  that  with  the  patient  on  his  back,  but  he 
may  perhaps  be  upon  his  side.  When  the  patient  is  placed  upon  his  back 
promptly  after  injection  the  anal  region  becomes  anesthetic  in  from  one  to  two 
minutes,  the  lower  extremities  in  from  three  to  sLx  minutes,  and  the  upper  ex- 
tremities in  from  fifteen  to  thirty  minutes.  The  anesthetic  condition  lasts  from 
one  to  three  hours  or  even  longer,  and  is  due  to  the  contact  of  cocain  with 
the  nerve-roots  (A.  W.  Morton,  "Jour.  Am.  Assoc,"  Nov.  8,  1902). 

After  cocainization  of  the  spinal  cord  surgical  operations  can  be  performed 
on  many  regions  without  causing  pain.  Among  the  operations  which  have 
been  performed  are  resection  of  the  knee,  resection  of  the  ankle,  osteotomy, 
amputation  of  the  leg,  amputation  of  the  thigh,  hysterectomy,  perforation  of 
gastric  ulcer,  intestinal  obstruction,  strangulated  hernia,  excision  of  bowel, 
acute  appendicitis,  gastro-enterostomy,  oophorectomy,  removal  of  ovarian 
cysts,  and  removal  of  the  rectum, - 

Spinal  analgesia  is  not  growing  in  popularity.  It  is  regarded  by  most 
surgeons  as  a  method  to  be  used  in  exceptional  cases.  It  should  never  be 
used  as  a  routine  procedure,  and  it  will  not  displace  ether  or  chloroform.  I 
see  no  occasion  in  the  eighth  edition  of  this  book  to  alter  the  view  which  I 
put  forth  in  the  seventh  edition.  By  it  analgesia  can  usuaUy  be  secured.  A. 
W.  Morton  (Ibid.)  used  it  673  times  without  a  faflure,  and  60  of  these  operations 
were  above  the  diaphragm.  If  w^e  desire  to  obtain  analgesia  of  the  upper  por- 
tion of  the  body  the  patient  must  be  placed  in  the  Trendelenburg  position  after 
the  fl^uid  has  been  injected.  j\Iost  operators  have  had  faflures,  especially  above 
the  diaphragm.  In  Sonnenburg's  1117  cases  there  were  78  utter  failures  ("Jour, 
de  Chir.,"  Oct.,'  1908).  Bier  says  that  faflures  occur  in  4  per  cent,  of  cases; 
Moynihan  says  in  14  per  cent. ;  Legueu  savs  in  one-seventh  of  the  cases.     In 


1366  Anesthesia  and  Anesthetics 

Barkers'  last  100  cases  there  were  3  failures.  No  one  should  attempt  it  who  is 
not  well  trained  in  aseptic  methods,  because  infection  of  the  cord  or  its  mem- 
branes will  prove  fatal.  Untoward  effects  are  common,  and  they  may  arise 
during  or  after  the  operation. 

Sonnenburg  had  them  in  193  out  of  1117  cases.  Among  the  untoward 
effects  reported  are  grave  collapse,  temporary  paralysis  of  the  abducens  nerve, 
of  the  facial  nerve,  of  the  hypoglossal  nerve,  meningitis,  retention  of  urine, 
chills,  elevation  of  temperature,  incontinence  of  urine,  persistent  paraplegia, 
pain  in  the  back  and  legs,  perhaps  lasting  for  weeks  or  even  for  months,  nau- 
sea and  vomiting  during  and  after  the  operation,  sweating,  overaction  of  the 
heart,  dimness  of  vision,  cramps  in  the  limbs,  dyspnea,  violent  headache,  invol- 
untary evacuation  of  feces,  and  cardiac  overaction.  Many  of  the  immediate 
symptoms  are  probably  due  to  the  absorption  of  the  drug  injected.  The  head- 
ache is  due  to  tension  and  is  relieved  when  some  cerebrospinal  fluid  is  with- 
drawn by  lumbar  puncture.  In  20  per  cent,  of  Barker's  cases  ("Brit.  Med. 
Jour.,"  March  16,  191 2)  there  was  more  or  less  transient  headache.  In  16.3 
per  cent,  there  were  nausea  and  vomiting. 

Headache,  vertigo,  weakness,  paresthesia,  neuralgia  may,  in  a  few  cases, 
persist  for  months  or  even  years  (Hohmeier  and  Konig,  in  "Archiv  fur  klin. 
Chin,"  Oct.  8,  1910). 

Whether  or  not  permanent  harm  ever  comes  to  the  cord  is  not  certain.  Bris- 
tow  ("Brooklyn  Med.  Jour.,"  1902,  xvi,  page  410)  reported  the  case  of  a  man, 
fifty-five  years  of  age,  on  whom  he  operated  for  hemorrhoids  after  spinal  cocain- 
ization.  An  examination  one  month  later  indicated  degeneration  of  the  pos- 
terior and  lateral  columns  of  the  cord  (spastic  lower  extremities,  ataxic  gait, 
increased  knee-jerk,  ankle-clonus,  and  inability  to  retain  urine).  Marx  ("New 
York  Med.  Record,"  Dec.  22,  1900)  states  that  i  case  in  his  experience,  after 
cocainization  of  the  spinal  cord,  developed  typical  locomotor  ataxia.  Dandois 
("Jour,  de  Chir.  Brux.,"  April-May,  1901)  reports  a  case  upon  which  he  had 
operated  for  traumatic  rupture  of  the  urethra.  Spinal  cocainization  was  em- 
ployed. Paraplegia  developed  and  lasted  two  months.  Several  cases  of  hemor- 
rhage into  the  subarachnoid  space  are  on  record.  Legueu  states  that  persistent 
paraplegia  and  persistent  incontinence  of  urine  may  arise  ("Rev.  de  Chir.," 
Oct.,  1908). 

Is  there  any  danger  of  death  from  spinal  analgesia?  If  the  operation 
be  not  performed  with  scrupulous  aseptic  care  it  is  very  dangerous.  Even 
when  performed  by  the  best  surgeons  death  may  occur.  Tuffier  places  the 
mortality  at  3  in  2000,  but  excludes  from  consideration  3  deaths  ("La  Presse 
Medicale,"  vol.  Iv,  1901,  page  190).  Reclus  finds  6  deaths  in  less  than  2000 
cases  (Address  before  the  Paris  Academic  de  Medicine,  March  19,  1901). 
Hahn,  in  1708  cases  collected  from  literature,  found  8  deaths  ("Mitt.  a.  d. 
Grenzgeb.  d.  Med.  u.  Chir.,"  1900,  iii,  337).  The  mortality  is  usually  supposed 
to  be  about  3  in  every  1000  cases.  Wm.  N.  Perkins  ("  New  Orleans  Med.  Jour.," 
Jan.-Sept.,  1902)  collected  2345  cases  with  16  deaths  or  i  death  in  146  adminis- 
trations. Strauss's  table  shows  46  deaths  in  22,717  cases  (quoted  by  Hardonin 
in  "Archiv  Generale  de  Chir.,"  August,  1908).  In  Barker's  2354  cases  there 
were  only  3  deaths  "  which  could  be  in  any  way  put  down  to  the  spinal  method 
of  anesthesia"  ("Brit.  Med.  Jour.,"  March  16,  1912).  Hohmeier  and  Konig 
("Archiv  fiir  klin.  Chir.,"  Oct.  8,  1910)  collected  2400  cases  of  spinal  anes- 
thesia: 12  deaths  were  due  to  it  directly,  4  of  them  died  of  paralysis  of  re  pira- 
tion;  7  of  the  fatal  cases  were  over  seventy  years  of  age.  One  victim  was  only 
t«hirty-two. 

Cocain  seems  to  act  like  a  toxin  on  the  pia  and  arachnoid.  Examination 
of  fluid  withdrawn  after  cocainization  shows  that  it  contains  polymorphic  leuko- 
cytes (Ravant  and  Aubourg,  in  "  Gaz.  Hebd.  de  Med.  et  de  Chir.,"  June  27, 1901). 

My  belief  is  strong  that  the  method  should  only  be  used  for  operations  below 


Dermatitis  Venenata  1367 

the  diaphragm,  and  I  hold  this  belief  in  spite  of  the  claim  of  Jonnesco  that  he 
.operates  with  the  aid  of  spinal  anesthesia  on  any  part  of  the  body.  It  is  most 
successful  in  operations  below  the  umbilicus.  I  very  seldom  use  it  for  opera- 
tions above  tliat  level. 

In  a  case  in  which,  because  of  heart  disease,  pulmonary  disease,  kidney 
disease,  or  some  other  condition  in  which  a  general  anesthetic  is  inadmissible, 
spinal  cocainization  is  justifiable.  It  should  be  reserved  exclusively  for  cases 
in  which  other  forms  of  anesthesia  are  positively  contra-indicated.  The  method 
should  not  be  employed  on  those  under  fifteen  years  of  age  or  on  the  subjects 
of  central  nervous  disease.  Barker  disapproves  of  spinal  anesthesia  in  "cases 
of  extreme  asthenia  due  to  carcinoma,  and  of  advanced  toxemia  depending 
upon  septic  peritonitis  or  obstruction,  especially  in  later  life"  ("Brit.  Med. 
Jour.,"  ^larch  16,  1912),  altliough  some  surgeons  regard  such  conditions  as 
particularly  demanding  spinal  in  preference  to  general  anesthesia. 

A  solution  of  Epsom  salts  has  been  used  by  Blake,  Haubold,  and  Willy  Meyer. 
It  was  discovered  (Meltzer  and  Auer,  "Am.  Med.,"  Nov.  25,  1905)  that  sub- 
cutaneous injections  of  salts  of  magnesium  produce  local  anesthesia.  The 
same  investigators  later  pointed  out  ("Med.  Record,"  Dec.  16,  1905)  that  sub- 
arachnoid spinal  injections  of  Epsom  salts  produce  widespread  and  complete 
anesthesia.  A  25  per  cent,  solution  is  used  and  i  c.c.  of  this  is  given  for 
every  25  pounds  of  body  weight.  After  three  or  four  hours  the  drug  causes 
paralysis  and  analgesia  of  the  legs  and  pelvic  region.  Sensation  and  motion 
do  not  return  for  from  eight  to  fourteen  hours.  Retention  of  urine  may  last 
two  days.  The  pulse  and  blood-pressure  are  unaffected,  but  the  respiration 
is  slowed.  Large  doses  would  endanger  life  by  respiratory  arrest.  In  view  of 
the  fact  that  in  some  cases  the  effect  of  the  drug  is  inordinately  prolonged,  it  is 
A^dse,  when  the  operation  is  completed,  to  puncture  the  theca  of  the  cord  again 
and  wash  it  out  with  salt  solution.  Guthrie  and  Ryan  ("  Amer.  Jour,  of  Phys.," 
August  I,  1 910)  deny  that  magnesium  salts  have  specific  anesthetic  properties 
and  claim  that  anesthesia  folllwing  their  injection  is  due  chiefly  to  asphyxia. 

Paravertebral  and  parasacral  anesthesia  was  devised  by  Sellheim  of 
Freiburg  in  1905.  He  injected  with  cocain  the  intercostal  nerves  just  after  their 
emergence  from  the  vertebral  column,  and  the  ilio-inguinal  and  iliohypogastric 
nerves  on  a  level  with  the  anterior  superior  spine  of  the  ilium. 

Braun  injected  the  sacral  ner^'es  just  as  they  emerged  from  the  sacral 
foramina. 

Novocain  is  much  safer  than  cocain.  Paravertebral  anesthesia  is  said  to 
be  successful  in  laparotomies  and  parasacral  anesthesia  on  vaginal  and  perineal 
operations.  In  certain  pelvic  operations  both  are  used.  I  have  no  experience 
in  the  method.  (It  is  fuUy  described  by  Kroenig  and  Siegel,  in  "Surgery, 
Gynecology',  and  Obstetrics,"  May,  1916.) 


XXXI.  DISEASES  OF  THE  SKIN  AND  NAILS 

Dermatitis  venenata  is  a  dermatitis  resulting  from  irritants.  It  may 
be  caused  by  wearing  garments  containing  arsenic.  A  common  cause  is  rhus- 
poisoning.  Rhus-poisoning  arises  from  the  poison-oak  (White,  Editorial  in 
"Jour.  Am.  Med.  Assoc,"  Aug.  5,  1906),  the  poison-ash,  the  poison-iw,  and 
some  other  species  of  sumach.  Actual  touching  of  the  plants  is  usually,  but 
not  always,  necessary.  Some  suffer  if  they  simply  come  near  them  as  the 
irritant  can  be  tarried  by  the  wind.  The  irritant  may  be  conveyed  by  tools, 
materials  or  insects.  The  smoke  of  burning  poison  plants  conveys  the  irritant. 
Some  people  are  immune  to  rhus-poisoning,  some  are  sHghtly  susceptible,  some 
are  more  strongly  predisposed.     It  is  beheved  by  some  that  toxicodendric  acid 


I  ^68  Diseases  of  the  Skin  and  Nails 

is  the  irritant  agent.  The  poison  isnot  bacterial,  is  not  gaseous,  is  not  volatile  and 
is  contained  in  the  resinous  sap  which  exudes  from  an  injured  plant  (McNair 
quoted  in  editorial  of  "Jour.  Am.  Med.  Assoc,"  Oct.  4,  1916).  The  condition  is 
most  apt  to  arise  when  the  skin  is  moist  from  perspiration. 

The  symptoms  are  burning,  itching,  redness,  and  edema  of  the  affected 
parts.  Vesicles  or  even  blebs  may  form.  The  hands  and  forearms  are  most 
apt  to  suffer,  but  any  part  may  be  attacked.  The  palms  seldom  suffer.  If  the 
penis  and  scrotum  suffer  from  rhus-poisoning  there  is  great  swelling  from  edema. 
The  fluid  of  a  vesicle  cannot  inaugurate  inflammation  on  sound  skin.  Usually 
a  vesicular  eruption  begins  between  the  fingers.  The  eruption  becomes  vio- 
lently inflammatorv,  and  in  the  form  of  fierce  red  edematous  inflammation 
spreads  widelv  over  the  body.  There  may  be  fever.  The  condition  usually 
begins  to  abate  in  from  three  to  six  days  and  desquamation  follows.      , 

When  one,  knowing  from  experience  that  he  is  predisposed,  feels  the  inaugu- 
ral itching,  he  should  at  once  apply  to  the  parts  a  i  per  cent,  solution  of  lactic 
acid  in  95  per  cent,  alcohol  (R.  F.  Ward,  in  "New  York  Med.  Jour.,"  Dec.  26, 

1908). 

The  treatment,  when  a  moderate  area  is  involved,  comprises  the  applica- 
tion of  cloths  wet  with  a  wash  of  lead-water  and  laudanum,  or  a  saturated 
solution  of  acetate  of  aluminum  (R.  F.  Ward,  Ibid.).  If  an  extensive  area  be 
involved,  apply  grindelia  robusta  (4  dr.  to  i  pint  of  water)  or  moisten  the 
surface  frequently  with  sweet  spirits  of  niter.  Oxid  of  zinc  ointment,  contain- 
ing 10  gr.  of  carbolic  acid  to  i  oz.,  gives  great  relief. 

Furuncle  (Boil). — (See  page  148.) 

Aleppo  Boil  {Endemic  Boil  of  the  Tropics,  Delhi  Boil,  Oriental  Sore,  etc.). — 
Papules  appear  upon  the  exposed  parts  of  the  body.  These  papules,  which 
ulcerate,  do  not  cicatrize  for  at  least  a  year,  and  leave  ineradicable  scars.  The 
condition  is  due  to  a  protozoan.  Man  is  infected  by  means  of  flies,  lice,  or 
other  insects.  The  Aleppo  boil  was  once  apparently  confined  to  India,  Arabia, 
Persia,  Egypt,  Algeria,  etc.  Of  late  it  is  said  to  have  appeared  in  Panama, 
the  Philippine  Islands,  and  Hawaii. 

Erysip>elas. — (See  page  219.) 

Erysipeloid. — (See  page  219.) 

Clavus,  or  Corn. — A  corn  is  a  tender  painful,  and  circumscribed  thickening 
of  the  epidermis,  and  is  commonest  over  one  of  the  joints  of  the  toes.  Hard 
corns  are  situated  on  exposed  parts  of  the  digits;  soft  corns  appear  between 
the  digits,  where  the  parts  are  kept  constantly  moist.  Corns  are  caused  by 
pressure. 

Treatment, — The  wearing  of  well-fitting  boots  will  usually  cause  a  corn 
upon  the  toe  to  disappear.  Soak  the  feet  often  in  water  containing  bicarbonate 
of  sodium,  dry  them,  and  apply  a  circular  corn-plaster  to  the  corn  to  take  off 
the  pressure  of  the  boot.  Another  method  is  to  touch  the  corn  with  iodin 
every  night  and  pare  away  the  hard  tissue  every  morning.  An  old  and  valu- 
able plan  is  to  paint  the  corn  every  night  and  morning  with  a  mixture  com- 
posed of  salicylic  acid,  40  gr.;  extract  of  cannabis  indica,  10  gr.;  and  collodion 
and  flexible  collodion,  of  each  2  dr.  After  several  days  of  the  treatment  soak 
the  parts  in  hot  water  and  scrape  away  the  mass.  Soft  corns  are  treated  by 
washing  the  feet  often  with  ethereal  soap,  drying,  gently  removing  the  sodden 
epithelium,  dusting  the  toes  and  between  them  wath  borated  talc,  and  placing 
absorbent  cotton  between  the  digits.  Incurable  soft  corns  require  the  removal 
of  the  skin  from  the  adjacent  sides  of  the  two  toes  and  suturing  the  toes  together 
(thus  converting  two  toes  into  one).  For  inflamed  corns  employ  rest  and  lead- 
water  and  laudanum,  and  let  out  pus  when  it  forms.  Remember  that  in  old 
persons  the  cutting  of  a  corn  may  cause  senile  gangrene.  In  the  inflamed  and 
painful  feet  of  a  person  who  has  corns  nothing  gives  so  much  relief  as  washing 
the  feet  with  ethereal  soap,  soaking  in  hot  water,  and  wrapping  the  feet  for  half 


Wounds  of  the  Thyroid  Gland  1369 

an  hour  in  cloths  wet  with  a  mixture  composed  of  linseed  oil  and  lime-^yater, 
each,  2  oz.,  and  spirits  of  camphor,  i  dr. 

Warts. — (See  page  432.) 

Onychia  is  inllammation  of  the  matrix  of  the  nail.  Syphilis  often  causes 
severe  onychia  which  requires  specific  treatment  (see  page  375).  Arunaround, 
or  paronychia,  is  suppuration  of  the  matrix  at  the  root  of  the  nail,  and  of  the 
skin  about  it,  of  traumatic  origin.  It  requires  incision,  trimming  away  of  the 
buried  edge  of  the  nail,  and  packing  with  iodoform  gauze  (see  page  814). 

Malignant  onychia,  which  is  inflammation  and  ulceration  of  the  entire 
matrix,  occurs  only  in  a  person  of  dilapidated  constitution.  This  condition 
requires  removal  of  the  entire  nail,  cauterization  of  the  matrix,  dressing  with 
iodoform  gauze,  and  the  internal  use  of  stimulants,  tonics,  and  nourishing  diet. 

Ingrowing  toe=nail  (see  page  169)  is  sometimes  due  to  lateral  hypertrophy 
of  the  edge  of  the  nail,  but  usually  to  forcing  of  the  soft  tissues  over  the  margin 
of  the  nail.  An  irritable  ulcer  arises.  The  condition  is  treated  by  splitting  the 
naU,  removing  the  ingrown  piece,  the  soft  tissue  at  the  margin  and  the  adjacent 
matrix,  and  dressing  antiseptically. 


XXXII.  DISEASES  AND  INJURIES  OF  THE  THYROID  QLAND^ 

The  thyroid  gland  is  an  essential  organ.  It  possesses  functions  of  the  first 
importance.  It  has  a  great  influence  upon  nutrition.  It  acts  by  means  of  its 
secretion,  which  is  an  iodothyroglobulin. 

An  excess  of  this  secretion  if  unneutralized  in  the  body  causes  hyperthy- 
roidism (see  page  1378).  A  diminution  of  this  secretion  causes  hypothyroidism 
(see  below).  If  there  be  a  very  small  thyroid  or  a  functionally  inactive  thyroid 
from  birth,  the  child  is  a  cretin  (see  below).  A  great  deal  of  the  gland  can  be 
removed  without  harm.  Charles  H.  Mayo  estimates  that  one-sixth  of  the 
gland  can  furnish  enough  secretion  for  the  body  needs  ("Illinois  Med  Jour.," 
Feb.,  1913).  The  older  a  person  is,  the  less  thyroid  is  apparently  needed  or, 
perhaps,  the  less  thyroid,  the  older  a  person  actually  is.  "According  to  Lorand, 
the  deferring  of  old  age  requires  the  continued  presence  of  some  of  the  thyroid 
throughout  life"  (Charles  H.  Mayo,  Ibid.).  The  thyroid  of  a  woman  is  apt 
to  enlarge  at  puberty  and  to  become  swollen  from  congestion  before  a  period  of 
menstruation.  During  pregnancy  or  at  the  menopause  the  thyroid  may  enlarge 
and  at  these  periods  women  are  apt  to  exhibit  symptoms  of  hypo-  or  hyper- 
thyroidism. Ovid  speaks  of  enlargement  of  the  neck  during  the  early  months  of 
pregnancy.  Charles  H  Mayo  (Ibid.)  points  out  that  increased  secretion  does 
not,  of  necessity,  cause  symptoms.  A  considerable  excess  maybe  neutralized 
in  the  body.  In  such  a  condition  a  shock  may  at  once  induce  symptoms. 
Entire  loss  of  the  thyroid  in  an  adult  causes  myxedema.  Kocher  pointed  out 
that  its  complete  removal  in  a  young  or  middle-aged  person  usually  causes 
operative  myxedema  {cachexia  strumipriva)  and  perhaps  tetany.  Removal  of 
the  gland  in  an  elderly  person  does  not  cause  these  curious  conditions.  Later 
knowledge  indicates  that  removal  of  the  thyroid  with  the  parathyroids  certainly 
produces  myxedema  or  tetany,  unless  aberrant  thyroids  exist  and  compensate. 
Removal  of  the  thyroid  without  the  parathyroids  does  not  induce  tetany,  even 
when  there  are  no  aberrant  thyroids.  The  thyroid  probably  furnishes  an 
internal  secretion  which  destroys  certain  toxic  products  of  metabolism.  It 
is  thought  that  the  parathyroids  furnish  an  antitoxin  to  poisons  formed  during 
digestion. 

Wounds  cause  violent  hemorrhage  which  is  difficult  to  arrest.  Ligatures 
may  cut  out  and  forceps  will  not  hold.  The  hemorrhage  is  arrested  by  suture- 
lA  valuable  recent  work  is  that  of  Andre  Crotti,  on  "Thyroid  and  Thymus." 


1370  Diseases  and    Injuries  of  the  Thynjid   Gland 

ligatures,  purse-string  sutures,  the  actual  cautery,  or  removal  of  the  bulk  of 
the  gland. 

The  thyroid  gland  may  be  absent  at  birth.  Congenital  atrophy  or 
congenital  hypertrophy  may  exist. 

Acquired  atrophy  leads  to  hypothyroidism  and  myxedema.  Hypothyroid- 
ism may  arise  during  any  process  destructive  of  the  cellular  acti\dty  of  the  thy- 
roid gland.  It  is  seen  not  unusually  in  women  of  from  twenty-five  to  forty  who 
have  borne  children.  It  sometimes  occurs  in  men.  The  patient  usually  grows 
fat,  is  sterile,  and  neurasthenic.  The  temperature  is  subnormal.  Complaint 
is  made  of  headache,  backache,  shortness /)f  breath  and  indigestion.  In  women 
amenorrhea  is  the  rule.  In  severe  cases  there  is  myxedema.  (See  Robert  L. 
Pitfield,  in  "New  York  Med.  Jour.,"  August  27,  1910.)  Myxedetna  is  a  condi- 
tion characterized  by  the  presence  of  a  firm  subcutaneous  swelling  in  the  face, 
neck,  and  limbs;  slow  speech;  mental  dulness,  and  subnormal  temperature. 
The  condition  is  identical  with  that  produced  by  removal  of  the  entire  gland. 

Cretinism  was  described  by  Paracelsus  early  in  the  seventeenth  centur)'. 
It  is  a  result  of  hypothyroidism.  It  is  a  form  of  infantilism  and  idiocy  due  to 
absence  of  the  gland  or  atrophy  of  glandular  elements  in  the  thyroid.  When 
atrophy  of  the  parenchyma  alone  exists  the  size  of  the  gland  may  be  actually 
increased.  The  body  is  dwarfed;  bone  development  is  very  defective,  the  face, 
neck,  and  extremities  resemble  those  parts  in  myxedema,  and  a  low  grade  of 
idiocy  exists.  Myxedema  and  cretinism  are  treated  by  the  internal  adminis- 
tration of  thyroid  extract.. 

Thyroid  Feeding  and  Grafting. — Hypothyroidism,  with  or  without 
myxedema,  is  greatly  benefited  by  thyroid  feeding  or  the  administration  of 
th>Toid  extract.  Some  experimenters  have  transplanted  thyroids  into  thyroid- 
ectomized  animals.  The  results  show  striking  but  temporary  improvement. 
Such  transplanted  material  eventually  disappears.  Experiments  have  been 
made  and  are  being  made  on  thyroid  grafting  in  the  treatment  of  cretinism  and 
myxedema.  Grafts  have  been  placed  under  the  skin,  in  bone  at  the  junction  of 
the  epiphysis  wdth  the  diaphysis,  in  the  spleen,  and  in  other  regions.  Encourag- 
ing cases  have  been  reported,  but  the  results  are  temporary. 

Congestion  of  the  thyroid  may  be  caused  by  violent  exertion,  prolonged 
eflfort,  febrile  maladies,  and  venous  obstruction.  It  is  treated  by  removing 
the  cause  and  applying  heat  locally.     Tracheotomy  may  be  required. 

Inflammation  of  the  thyroid  (acute  or  inflammatory  goiter)  may  be  in- 
duced by  a  septic  or  febrile  malady,  rheumatism,  tonsillitis,  muscular  strain 
causing  vascular  rupture,  a  wound,  or  contusion  of  the  thyroid.  Cases  due  to 
tv-phoid  bacilli  have  been  reported.  Usually  but  one  lobe  is  aflFected.  The 
ordinary  symptoms  of  inflammation  are  present  In  addition  there  are  dys- 
phagia, dyspnea,  venous  congestion  of  the  face,  epistaxis,  nausea  and  vomiting 
and  possibly  delirium.  It  may  terminate  in  resolution,  suppuration,  or  fibrous 
induration. 

Tuberculosis  of  the  thyroid  is  usually  a  part  of  general  miliar>-  tuber- 
culosis. It  is  very  seldom  that  a  local  caseating  focus  occurs,  but  such  cases 
have  been  reported. 

Syphilis  of  the  Thyroid. — Early  in  the  secondary-  stage  there  is  apt 
to  be  slight  and  painless  thyroid  enlargement.  In  the  tertiary  stage  gummata 
may  form. 

Tumors  of  the  thyroid  are  of  various  sorts.  Among  them  are  adenomata, 
cystic  adenomata,  sarcomata,  and  carcinomata.  Eight  cases  of  teratoma  are 
on  record  Cisabella  C.  Herb,  "Am.  Jour.  Med.  Sciences,"  June,  1906).  Malig- 
nant disease  is  unusual.  I  have  operated  on  but  2  cases:  i  of  cystic  carcinoma 
in  which  operation  was  rapidly  fatal,  and  i  of  round-celled  sarcoma.  The 
latter  patient  was  living  and  apparently  well  four  years  after  lobectomy. 
Malignant  disease  may  arise  in  the  normal,  but  is  more  apt  to  arise  in  a  goitrous 


Goiter 


1371 


thyroid.  In  over  50  per  cent,  of  the  reported  cases  there  is  a  history  of  ante- 
cedent goiter.  MaHgnant  disease  is  more  common  in  women  than  in  men  and 
is  very  seldom  met  with  before  the  age  of  thirty.  It  is  most  common  between 
forty  and  sixty.  One  should  always  suspect  malignant  disease  of  the  thyroid 
gland  when  the  growth  appears  rather  suddenly  in  a  patient  over  forty  years 
of  age.  If  the  growth  is  irregular  in  outline  and  is  accompanied  by  pain  and 
difficulty  in  swallowing,  the  diagnosis  becomes  reasonably  certain.  Later  in 
the  case  there  are  symptoms  due  to  pressure  upon  and  infiltration  of  the  nerves; 
the  growth  becomes  firmly  anchored  and  the  lymph-glands  adjacent  to  the 
thyroid  become  involved;  there  may  be  tracheal  bleeding,  and  perhaps  fever, 
and  eventually  cachexia  develops.  Sarcoma  or  carcinoma  may  occur  and  it  is 
seldom  possible  to  determine  clinically  with  which  we  are  dealing.  The  cancer 
may  be  a  scirrhus  or  an  epithelioma,  but  is  usually  an  adenocarcinoma.  A 
sarcoma  may  be  either  of  the  round 
cell  or  spindle  cell  type.  In  ma- 
lignant disease  of  the  thyroid, 
metastasis  occurs  early  in  a  great 
majority  of  cases,  the  lungs  being 
first  involved,  and  then  the  bones 
and  other  structures ;  though  it  has 
been  stated  that  in  adenocarcinoma 
the  lungs  are  likely  to  escape  and 
that  solitary  bone-metastasis  is 
not  infrequently  noted.  Sarcoma 
(Fig.  882)  may  involve  one  lobe, 
but  carcinoma  (Fig.  883),  even  at 
an  early  stage,  is  apt  to  involve 
both  lobes  (Berry,  "Diseases  of 
the  Thyroid  Gland").  These 
growths  soon  penetrate  the  gland 
capsule,  become  anchored  to  sur- 
rounding parts,  and  involve  the 
vocal  cords,  trachea,  and  even  the 
great  vessels  of  the  neck.  Malig- 
nant growths  if  not  cystic  are  apt 
to  be  hard  and  nodular  and  they 
grow  rapidly.  At  first  the  gland 
moves  with  deglutition,  but  later 

becomes  anchored  to  surrounding  parts.  In  malignant  disease  of  the  thyroid  it 
is  usual  to  find  difficulty  of  swallowing  and  paralysis  of  the  vocal  cord  on  the 
side  of  the  growth.  Malignant  disease  is  rapidly  fatal.  Many  die  within  six 
months  and  few  survive  over  eighteen  months.  Radical  operation  is  proper 
only  before  the  growth  breaks  through  the  capsule,  although  at  any  stage  it  may 
be  necessary  to  operate  in  order  to  prevent  suffocation. 

A  goiter^  is  an  enlargement  of  the  thyroid  gland  not  due  to  a  malignant 
tumor  or  to  inflammation.  Hippocrates  makes  no  mention  of  goiter.  Juve- 
nal and  Pliny  refer  to  it.  Juvenal  speaks  of  its  being  common  among  Alpine 
mountaineers  and  Pliny  states  that  certain  wells  seem  to  disseminate  the 
disease.  The  enlargement  may  affect  a  small  portion  of  the  gland,  one  lobe, 
both  lobes,  or  both  lobes  and  the  isthmus,  and  it  may  occur  either  sporadically 
or  endemically.  It  is  fcft-  more  common  in  women  than  in  men.  It  is  very  com- 
mon in  adolescent  girls.  It  may  exist  in  children.  Adenomata  may  even  be 
congenital. 

1  For  a  study  of  the  "Pathological  Anatomy  of  Goiter"  see  W.  C.  MacCarty,  in  "New 
York  State  Jour,  of  Med.,"  Oct.,  1912.  This  study  is  founded  on  2500  cases  from  the  Mayo 
Clinic. 


Fig.  882. — Sarcoma  of  thyroid  gland. 


1372 


Diseases  and  Injuries  of  the  Thyroid  Gland 


There  are  a  number  of  forms  of  ordinary  goiter.  The  most  common  is 
what  is  called  simple  or  parenchymatous  goiter  (Fig.  884).  In  this  condition  all 
portions  of  the  gland  enlarge,  and  the  goiter  is  consequently  bilateral.  It  does 
not  appear  first  in  one  lobe  and  at  a  considerably  later  period  in  the  other, 
but  each  lobe  is  enlarged  equally  or  nearly  equally.  Parenchymatous  goiter 
is  often  spoken  of  as  simple  goiter,  and  is  sometimes,  though  not  with  entire 
accuracy,  designated  hypertrophy  of  the  thyroid  gland. 

The  common  goiter  of  adolescence  is  "an  edematous  condition  of  the  gland 
due  to  watery  colloid"  (C.  H.  Mayo,  "Illinois  Med.  Jour.,"  Feb.  1913). 

Adenomatons  goiter  (Fig.  885)  is  a  condition  due  to  the  growth  of  encapsuled 
adenomata  in  the  thyroid  gland.  There  may  be  a  single  adenoma,  but  fre- 
quently there  are  multiple  growths.  One  or  both  lobes  may  be  involved.  The 
goiter,  however,  usually  seems  to  begin  in  one  lobe;  and  if  both  lobes  enlarge, 

one  generally  does  so  at  a  period 
distinctly  subsequent  to  the  en- 
largement of  the  other.  In 
some  cases  growth  seems  to 
originate  simultaneously  in  both 
lobes,  but  even  then  the 
growths  seldom  increase  equally. 
Adenoma  may  develop  in  a 
healthy  thyroid  gland,  but 
adenomatous  growth  is  usually 
associated  with  some  paren- 
chymatous growth. 

Cystic  goiter,  or  bronchocele, 
is  a  condition  in  which  the 
chief  mass  of  the  enlargement 
is  composed  of  a  cyst  or  of 
multiple  cysts.  When  cysts 
form,  the  thyroid  gland  is 
usually  hypertrophied  or  adeno- 
matous; occasionally,  however, 
cysts  form  in  a  non-hypertro- 
phied  thyroid.  The  great  ma- 
jority of  cysts  are  due  to  cystic 
degeneration  of  adenomata; 
some  are  formed  by  the  coalescence  of  overdistended  thyroid  vesicles,  and 
some  few  follow  blood-extravasation  into  the  thyroid  tissue.  The  liquefaction 
is  due  to  mucoid  or  colloid  degeneration,  and  the  fluid  of  the  cyst  is  sometimes 
clear  and  thin,  sometimes  viscid,  and  often  coffee-ground  in  appearance. 

A  fibrous  goiter  is  a  fibrous  induration.  It  is  likely  to  arise  in  old  broncho- 
celes,  which  may  actually  pass  into  a  calcareous  condition.  By  the  term 
malignant  goiter  is  meant  malignant  disease  of  the  thyroid  gland,  either  carci- 
noma or  sarcoma.  As  stated  above,  such  cases  are  not  really  goiters.  When 
hemorrhage  takes  place  into  a  goiter  the  condition  is  often  spoken  of  as  a 
hemorrhagic  goiter.  A  colloid  goiter  is  a  form  of  parenchymatous  goiter  in  which 
there  is  an  extremely  large  amount  of  colloid  material.  '  Exophthalmic  goiter  is 
discussed  on  page  1377.  A  simple,  or  an  adenomatous  goiter,  because  of 
degenerative  changes  or  overstimulation,  may  form  toxic  material  or  an  excess 
of  secretion  and  may  cause  symptoms  of  toxemia  (simple  toxic  goiter).  "These 
cases  may  have  all  the  nervous  svmptoms  and  heart  complications  of  a  bad  case 
of  Basedow's  disease  without  the  protruding  eyes"  (C.  H.  Mayo,  "Illinois  Med. 
Jour.,"  Feb.,  1913).  This  evolution  gives  rise  to  what  we  name  a  toxic  goiter 
and  the  French  call  a  Basedowified  goiter  (Morestin,  in  "Rev.  de  Chir.,"  Nov. 
10,  1899).     A  goiter  that  develops  with  great  rapidity  is  sometimes  called  an 


Fig.  883. — Cystic  carcinoma  of  thyroid  gland. 


Causes  of  Goiter 


137-3 


acute  goiter,  and  one  that  induces  marked  dyspnea  is  designated  a  suffocating 
goiter.  Syphilitic,  tuberculous,  and  amyloid  enlargements  are  extremely  rare, 
but  occasionally"  occur.  Further,  a  goiter  may  be  back  of  the  sternum,  that  is, 
substernal  or  retrosternal.  A  very  movable  goiter,  which  is  now  above  and  now 
below  the  sternal  notch,  is  called  a  wandering  or  diver  goiter.  A  goiter  within 
the  thorax  is  called  intrathoracic;  and  such  a  goiter  may  be  retrosternal,  retro- 
tracheal,  or  rctro-esophageal.  When  a  number  of  persons  in  the  same  region  are 
attacked  with  goiter  the  condition  is  frequently  referred  to  as  epidemic  goiter. 
When  the  condition  is  common  in  a  certain  district  it  is  called  endemic  goiter. 
When  a  person  living  in  a  district  in  which  the  disease  is  rare  develops  goiter, 
we  speak  of  the  condition  as  sporadic  goiter.  It  has  long  been  known  that 
accessory  or  aberrant  thyroids  exist.  The  term  ** aberrant"  is  better  than  "ac- 
cessory" because  in  some  reported  cases  the  thyroid  proper  has  been  absent  (V.L. 
Schrager,  in  "Surg.,  Gynec,  and  Obstet.,"  Oct.,  1906).  Aberrant  thyroids 
are  masses  of  tissue  composed  of  structure  identical  with  the  thyroid  gland. 


Fig.  SS4. — Parench}-matous  goiter. 


Fig.  8S5. — Adenomatous  goiter. 


and  distinct  and  separate  from  the  thyroid  gland  proper.  Median  aberrant 
thyroids  are  found  about  the  hyoid  bone  and  are  formed  from  remnants  of  the 
thyroglossal  duct.  Lateral  aberrant  thyroids  are  found  and  develop  from  the 
remains  of  the  lateral  anlages  of  the  thyroid  (Ibid.).  Aberrant  thyroids  vary 
in  number:  there  may  be  none,  one,  several,  or  chains  of  them.  An  aberrant 
thyroid  may  enlarge  with  the  thyroid,  may  not  enlarge  even  though  the  thyroid 
does,  or  may  enlarge  when  the  thyroid  proper  remains  normal.  I  recently  saw 
a  median  tumor  of  the  base  of  a  man's  tongue  which  on  removal,  proved  to  be 
composed  of  thyroid  tissue  (lingual  goiter).  Nearly  100  cases  are  on  record,  90 
per  cent,  of  them  in  women.  In  a  number  of  cases  myxedema  has  followed 
removal.  When  cachexia  strumipriva  does  not  develop  after  complete  thyroid- 
ectomy, the  patient  has  been  saved  by  enlargement  and  functionation  of  ac- 
cessory thyroids. 

Causes  of  Goiter. — It  is  known  that  goiter  is  extremely  common  in  the 
valleys  at  the  foot  of  certain  mountain  ranges  in  Switzerland,  southeastern 
France,  northern  Italy,  the  Austrian  Tyrol,  and  in  the  Himalayas  and  the 
Andes.  In  a  portion  of  England  it  is  so  common  that  it  is  referred  to  as  the 
Derbyshire  neck.  There  are  goiter  regions  in  Pennsylvania  and  in  other  parts 
of  the  United  States.  Endemic  goiter  has  been  kno-wn  since  the  fourteenth 
century.  It  seems  evident  that  the  disease  is  due  to  the  introduction  of  some 
poisonous  element  into  the  system;  but  what  this  element  is,  is  not  known. 


1374  Diseases  and   Injuries  of  the  'I'hyroid   (iland 

Some  writers  maintain  that  individual  liability  is  developed  by  habits  of  life; 
others  think  that  susceptibility  depends  upon  hygienic  surroundings;  and  some 
attach  great  importance  to  hereditary  influence.  The  prol)ability  is,  however, 
that  the  disease  is  due  to  the  existence  of  some  poisonous  substance  in  the 
drinking-water.  Some  observers  have  blamed  snow-water;  many  have  laid 
the  cause  of  the  trouble  at  the  door  of  water  impregnated  with  salts  of  lime; 
but  the  real  cause  has  not  been  demonstrated. 

Some  observers  believe  that  simple  goiter  is  due  to  bacteria  in  the  intestinal 
canal,  an  important  function  of  the  gland  being  to  save  the  body  from  poisons 
which  reach  the  blood  from  the  intestines,  an  excess  of  poison  or  certain  power- 
ful toxins  causing  the  gland  to  enlarge. 

The  ordinary  parenchymatous  goiter  of  adolescence  seems  to  be  a  work 
hypertrophy.  A  number  of  years  ago  I  suggested  the  view  that  the  gland  has 
undergone  such  an  enlargement  and  has  become  distended  with  colloid  material 
because  the  human  body  has  demanded  more  of  the  secretion  of  the  gland  than 
the  normal  gland  has  been  able  to  supply;  as  a  consequence,  the  normal  gland 
has  enlarged  its  capacity  and  increased  its  output. 

Signs  and  Symptoms  of  Goiter. — One  may  determine  that  a  growth  is  in  the 
thyroid  gland  or  is  connected  with  it  by  studying  a  number  of  facts.  A  goiter, 
as  a  rule,  follows  the  movements  of  the  larynx  and  the  trachea  during  deglutition, 
and  this  sign  may  be  obtained  in  the  great  majority  of  instances.  There  are, 
however,  rare  conditions,  such  as  hyoid  cyst,  in  which  a  movement  of  the  mass 
.takes  place  during  the  act  of  swallowing,  although  the  thyroid  gland  is  not 
involved.  Then,  again,  a  malignant  or  an  inflammatory  growth  of  the  thyroid 
usually  becomes  anchored  to  the  surrounding  tissues  and  does  not  show  this 
mobility.  Certainly,  however,  in  the  great  number  of  cases  an  enlarged  thyroid 
moves  with  the  larynx  and  the  trachea  during  swallowing. 

Goiters  vary  greatly  in  size.  Cases  in  which  the  goiter  was  as  large  as 
an  adult's  head,  and  some  cases  in  which  the  goiter  hung  in  front  of  the  breast- 
bone, and  reached  to  below  the  level  of  the  ensiform  cartilage,  have  been 
described.     A  very  large  goiter  may  have  a  stalk. 

When  the  entire  gland,  as  well  as  the  isthmus,  is'  enlarged,  or  when  the 
isthmus  alone  is  involved,  the  swelling  may  appear  to  be  in  the  median  line  of 
the  neck.  If  the  condition  begins  in  one  lobe,  the  growth  will,  for  a  time  at 
least,  be  distinctly  one  sided;  though  when  such  a  growth  has  attained  a  large 
size,  it  may  displace  the  windpipe  and  come  itself  to  the  middle  line  of  the  neck. 

A  goiter  of  any  considerable  size  pushes  the  sternocleidomastoid  muscle 
externally  and  anteriorly,  and  the  muscles  that  run  from  the  sternum  to  the 
hyoid  bone  and  to  the  thyroid  cartilage  overlie  the  front  of  the  growth.  The 
carotid  artery  is  displaced  externally  and  posteriorly.  The  relation  of  the 
jugular  vein  to  the  carotid  artery  is  usually  profoundly  altered.  The  artery, 
as  already  stated,  goes  externally  and  posteriorly,  while  the  vein  is  actually 
pulled  anteriorly  and  is  flattened  out  upon  the  side  or  the  anterior  surface 
of  the  goiter;  hence  the  vein  may  lie  to  the  inner  side  of  the  artery.  This 
curious  alteration  in  relationship  is  due  to  the  fact  that  the  common  carotid 
artery  has  no  branches,  and  therefore  is  pushed  externally  with  ease;  but  the 
internal  jugular  vein  receives  branches  that  lie  in  the  tumor,  pull  upon  the 
vein,  and  prevent  its  displacement  with  the  artery  (Liicke). 

Berry  alludes  to  the  fact  that  the  tumor,  unless  it  be  very  small,  usually 
reaches  the  upper  level  of  the  sternum,  and  frequently  passes  below  this  level; 
and  that  only  extremely  large  goiters  hang  in  front  of  the  sternum,  but  that  it 
is  not  at  all  unusual  for  prolongations  from  a  goiter  to  extend  for  quite  a  dis- 
tance into  the  mediastinum.  A  substernal  goiter  is  productive  of  very  dan- 
gerous symptoms  and  offers  many  difficulties  in  diagnosis.  A  goiter  will 
occasionally  wander,  now  appearing  in  the  neck  and  again  disappearing  behind 
the  sternum. 


Metastasis  of  Xon-malignant  Goiter  i375 

Some  goiters  are  said  to  pulsate.  This  takes  place  in  exophthalmic  goiter, 
the  vessels  of  the  goiter  pulsating  as  do  the  other  vessels  of  the  body;  but  in 
the  ordinary  simple  goiter  what  is  called  pulsation  of  the  goiter  is  usually  the 
transmitted  pulsation  from  the  carotid  artery. 

Some  of  the  most  important  symptoms  of  goiter  are  due  to  pressure  and  to 
the  displacement  of  Anatomical  structures.  Pressure  upon  the  veins  at  the 
root  of  the  neck  causes  great  enlargement  of  the  veins  above  the  goiter  and  in  it. 
Pressure  upon  the  recurrent  laryngeal  nerve  may  induce  characteristic  symp- 
toms (spasm  of  the  glottis  or  paralysis  of  a  vocal  cord),  but  the  dyspnea  of 
goiter  is  due  to  pressure  upon  the  trachea  and  not  to  interference  with  the 
recurrent  lar^mgeal.  Paralysis  of  a  vocal  cord  is  most  common  in  malignant, 
goiter,  but  the  records  of  the  !Mayo  Clinic  show  that  in  almost  one-fifth  of  all 
cases  of  goiter  there  is  paresis  on  even  paralysis  of  one  or  both  vocal  cords. 
Pressure  upon  the  cervical  sympathetic  may  cause  contraction  of  the  pupil  and 
narrowing  of  the  palpebral  fissure  (Berry).  Pressure  upon  the  cervical  plexus 
or  the  brachial  plexus  causes  paresthesia,  anesthesia,  or  paralysis  in  the  parts 
supplied  by  nerves  from  the  compressed  plexus.  Pressure  upon  the  larynx  and 
the  trachea  may  cause  very  great  displacement,  and  any  such  displacement  is 
productive  of  marked  dyspnea.  This  displacement  is  usually  to  the  side;  and 
it  may  cause  such  a  flattening  out  of  the  tracheal  rings  that  when  the  tumor 
is  removed  the  trachea  collapses  and  the  patient  perishes  of  suffocation. 

A  parenchymatous  goiter  usually  begins  insidiously  and  grows  slowly. 
It  occasionally  ceases  to  grow  for  a  considerable  period  of  time,  and  may  even 
shrink.  It  frequently  enlarges  temporarily  during  menstruation  or  pregnancy, 
and  occasionally  attains  an  enormous  size  by  changing  into  the  cystic  form. 
.\lterations  in  its  consistency  and  outline  may  be  due  to  the  development  cf 
adenomatous  masses,  A  goiter  may  at  any  time  give  rise  to  toxic  s\Tnptoms 
which  may  be  temporary  or  may  persist  (rapid  pulse,  palpitation,  tremor  and 
other  symptoms  of  Graves's  disease,  except  exophthalmus). 

In  making  a  diagnosis  between  the  different  forms  of  goiter,  one  should 
remember  that  a  fairly  symmetrical,  bilateral  growth  is  probably  parenchy- 
matous; if  it  has  been  symmetrical  from  the  start  the  probability  of  its  being 
parenchymatous  is  enhanced;  that  sudden  enlargements  are  produced  by 
hemorrhage;  that  cyst  formation  may  lead  to  very  great  enlargement,  and 
possibly  to  fluctuation;  that  if  a  non-malignant  goiter  induces  dyspnea,  it 
almost  invariably  does  so  by  pressing  upon  the  larynx  and  the  trachea,  whereas 
a  malignant  goiter  may  do  so  by  interfering  with  the  nerves  of  the  part  or  by 
infiltration  of  the  trachea;  that  a  non-malignant  goiter  very  rarely  produces 
difficulty  in  swallowing,  but  that  a  malignant  goiter  frequently  does  so;  and 
that  cough  often  exists  if  there  be  pressure  upon  the  larynx  or  the  trachea, 
such  a  cough  being  metallic  in  nature  and  unassociated  -v^-ith  impairment  of 
the  voice. 

In  any  goiter  there  may  be  cerebral  symptoms,  such  as  anemia,  S}Ticope, 
or  even  convulsions.  Rapidly  growing  goiters  are  often  fatal,  and  slowly 
growing  goiters  are  very  rarely  so.  A  malignant  goiter  grows  -v^-ith  great 
rapidity,  becomes  adherent,  infiltrates,  and  quickly  produces  metastases,  and 
both  sarcoma  and  carcinoma  produce  metastases  by  way  of  the  venous  system. 
A  goiter  may  grow  slowly  or  rapidly  during  pregnancy.  At  the  end  of  pregnancy 
it  may  disappear. 

Metastasis  of  Non-malignant  Goiter. — An  ordinary-  goiter  which  presents 
no  sign  of  being  malignant  may  suddenly  be  disseminated.  The  deposits 
are  apt  to  take  place  in  the  bones  and  in  the  lungs.  Tumors  have  been  re- 
moved without  any  thought  of  thxToid  trouble  being  responsible,  and  examina- 
tion has  shown  th}Toid  structure.  Patel  collected  iS  cases  of  th^Toid  metas- 
tasis (''Tumeurs  benignes  du  corps  th\Toide  donnant  des  metastases,"  '"Rev. 
de  Chir,"  No,  29,  1904).     The  bones  most  apt  to  receive  metastases  are  the 


1376  Diseases  and  Injuries  of  the  Thyroid  Gland 

bones  of  the  cranium,  the  lower  jaw,  the  vertebrae,  the  pelvis,  and  the  long  bones. 
In  4  of  these  18  cases  the  spine  was  affected.  Dercum  has  reported  a  case  of  thy- 
roid metastasis  to  the  spine  ("Jour,  of  Nervous  and  Mental  Dis.,"  Mar.,  1906). 
Colloid  goiters  are  particularly  prone  to  metastasis.  Some  surgeons  maintain 
that  if  a  metastatic  deposit  grows  and  destroys  bone,  the  primary  tumor  should 
be  regarded  as  malignant,  no  matter  what  histological  studies  indicate. 

Treatment  of  Goiter. — The  goiters  of  adolescents,  certain  nontoxic  colloidal 
goiters  and  parenchymatous  goiters  are  the  only  forms  amenable  to  medical 
treatment.  lodid  of  potassium  and  arsenic  internally  have  been  advised. 
An  ointment  of  red  iodid  of  mercury^  locally  is  advocated  by  some  writers.  It 
should  be  rubbed  in  while  the  goiter  is  exposed  to  the  direct  rays  of  the  sun. 
The  administration  of  thyroid  extract  may  do  much  good  in  a  case  of  parenchy- 
matous goiter,  but  it  is  useless  in  other  forms  of  the  disease.  It  should  be 
associated  with  the  local  use  of  tincture  of  iodin  or  ointment  of  red  iodid  of 
mercury.  Iodin  and  thyroid  extract  are  most  serviceable  in  the  goiters  of  ad- 
olescent girls.  Large  doses  of  iodin  are  unsafe.  Kocher  pointed  out  years 
ago  that  too  much  of  the  drug  might  cause  a  goiter  to  become  Basedowefied. 
McCarrison  ("Proceedings  of  the  Royal  Society  of  Medicine,"  Feb.,  1912) 
grew  cultures  from  the  feces  of  individuals  with  goiter.  He  prepared  a  mixed 
vaccine.  He  also  isolated  certain  bacteria  and  prepared  vaccines  from  them. 
Cases  of  goiter  were  treated  with  the  vaccines.  It  is  claimed  that  the  vaccines, 
especially  the  mixed  vaccine,  will  cure  recent  parenchymatous  goiter.  The 
vaccine  is  said  to  act  more  promptly  than  thyroid  extract.  In  times  past  it 
was  customary  to  treat  cystic  goiters  by  aspiration  and  injection  with  a  solution 
of  iodin.  Electrolysis  has  been  used  for  softer  goiter,  the  negative  pole  being 
pushed  into  the  growth,  the  positive  pole  being  applied  to  its  surface.  In 
many  cases  the  .T-rays  prove  of  benefit.  In  considering  the  propriety  of  opera- 
tion remember  that  a  goiter  which  begins  at  puberty  may  pass  away.  We 
should  operate  on  every  non-malignant  goiter  which  is  increasing  in  size  steadily 
or  rapidlv,  which  is  making  injurious  pressure,  which  is  causing  pain,  which 
is  interfering  with  important  nerves  or  which  is  actively  toxic.  Operation  is 
justifiable  even  if  there  is  not  pressure  because  the  mortality  is  very  small, 
and  it  saves  the  patient  from  the  possibility  of  malignant  change,  of  hemorrhage, 
and  of  inflammation.  Pregnancy  increases  greatly  the  risk  of  operation.  Abor- 
tion is  apt  to  follow.  I  used  to  operate  under  local  anesthesia.  There  is  less 
bleeding  under  local  anesthesia  than  under  ether.  It  is  a  great  advantage  to 
have  the  patient  conscious,  because  by  asking  him  to  speak  during  the  operation 
the  surgeon  can  tell  if  the  recurrent  laryngeal  nerve  is  being  approached  or 
touched.  Two  cases  of  violent  hemorrhage  in  conscious  patients  taught  me  a 
lesson.  Each  patient  was  conscious  that  something  was  wrong,  became  terri- 
fied and  uncontrollable,  and  greatly  increased  the  danger  and  difficulty.  I  now 
give  ether  (by  intratracheal  insufilation)  unless  there  be  very  high  blood-pressure, 
serious  tracheal  obstruction,  or  disease  of  the  heart,  lungs,  or  kidneys  (C.  H. 
Mayo,  "Illinois  Med.  Jour.,"  Feb.,  1913).  When  ether  is  to  be  given  I  precede 
its  administration  twenty  or  thirty  minutes  by  ^'e  gr.  of  morphin  and  H20  gr- 
of  atropin,  given  h^-podermatically.  In  some  cases  I  follow  Charles  H.  Mayo's 
plan  and  combine  local  anesthesia  with  light  general  anesthesia.  In  some  cases 
intraglandular  enucleation  is  performed,  in  other  cases  extirpation.  Occasionally 
these  two  methods  are  combined  (Bergeat).  Some  surgeons  advise  simple 
division  of  the  isthmus.  Ligation  of  the  thyroid  arteries  has  been  recommended. 
Exothyropexy  is  the  operation  of  exposing  the  thyroid  gland,  dislocating  it 
through  the  wound,  and  leaving  it  in  this  situation.  Exothyropexy  is  now 
almost  never  performed,  on  account  of  the  safety  of  the  operation  of  thyroid- 
ectomy.    Atrophy  of  the  gland  follows  exothyropexy.     Enucleation,  if  possible, 

1  This  ointment  consists  of  i  part  of  red  iodid  of  mercury  to  28  parts  of  vehicle  (white 
wax  and  almond  oil). 


Exophthalmic  Goiter  1377 

is  the  desirable  operation.  It  may  easily  be  employed  for  the  removal  of  a 
single  adenomatous,  colloidal,  or  cystic  area.  Thyroidectomy  (extirpation)  is 
employed  when  enucleation  is  impossible.  The  entire  thyroid  is  not  removed 
for  an  innocent  growth:  at  least  a  portion  of  a  lobe  is  left  behind,  otherw'ise 
operative  myxedema  will  probably  arise.  Unilateral  extirpation  (lobectomy)  is 
the  method  usually  chosen.  In  cancer  and  in  some  cases  of  sarcoma  complete 
extirpation  may  be  attempted  if  the  growth  be  movable.  If  it  be  immovable 
operation  is  useless.  The  operation  in  malignant  disease  will  occasionally 
prolong  life,  but  it  will  rarely  effect  a  cure.  In  malignant  disease  tracheotomy 
may  be  rendered  necessary  by  urgent  dyspnea.  The  operation  is  often  very 
diificult  because  the  growth  may  cover  the  trachea,  the  trachea  may  be  deviated 
a  considerable  distance  from  its  proper  position,  and  the  veins  may  be  very  large. 
After  the  performance  of  the  operation  it  is  usually  impossible  to  use  an  ordinary 
tracheotomy  tube,  and  in  such  a  case  Konig's  long,  flexible  tube  (Fig.  886)  is 
employed. 

Intrathoracic  Goiter. — Goiter  in  this  situation  causes  great  pressure  on 
the  veins  and  on  the  trachea  and  distention  of  the  veins  of  the  neck,  dyspnea 
and  cyanosis.  It  is  reached  by  dividing  the  manubrium  longitudinally  or 
dividing  the  entire  sternum.     Endotracheal  anesthesia  is  used. 

Endotracheal  Goiter.— 
Such  a  goiter  may  be  due  to 
misplaced  thyroid  tissue,  or  may 
be  a  prolongation  from  the  thy- 
roid gland.  Occasionally  the 
growth  is  situated  in  front;  but, 
as  a  rule,  it  is  attached  to  the 
posterior  surface  of  the  larynx  Fig.  8S6. — Konig's  tracheotomy  tube, 

or  trachea.     The  first  symptom 

is  dyspnea,  which  increases  and  becomes  very  severe.  An  examination  with 
a  laryngoscope  makes  the  condition  evident.  Endotracheal  goiter  is  much 
more  common  in  the  female  than  in  the  male.  It  is  believed  to  begin  usually 
at  about  the  age  of  puberty,  though  it  may  exist  for  a  long  time  unnoticed. 
In  some  reported  cases  the  patients  were  forty  years  of  age  before  having 
been  seen.  The  proper  treatment  for  an  endotracheal  goiter  is  the  performance 
of  a  preliminary  tracheotomy  and  then  extirpation. 

Exophthalmic  Goiter  (Graves's  Disease;  Basedow's  Disease;  Pulsating 
Goiter). — This  condition  was  first  described  by  Graves,  of  Dublin,  in  1835. 
It  is  a  condition  of  chronic  overactivity  of  the  gland  (h^-perthyroidism)  in  which 
the  secreting  structure  of  the  gland  is  increased  in  amount  by  h\'perplasia. 
The  increase  of  parenchyma  may  perhaps  be  general,  may  perhaps  be  in  sepa- 
rated areas  (C.  H.  INIayo,  "Illinois  Med.  Jour.,"  Feb.,  1913).  The  symptoms 
are  very  variable,  depending  upon  the  amount  and  nature  of  the  thyroid  secre- 
tion and  also  upon  the  nervous  tendencies  of  the  victim.  It  is  ten  times  more 
common  in  women  than  in  men,  and  is  most  common  between  the  ages  of  twenty 
and  forty.  It  may  arise  at  puberty  but  is  very  rare  in  children  under  ten  years 
of  age.  The  Mayos  operated  on  only  5  such  cases  in  8  years  ("St.  Paul  Med. 
Jour.,"  1914,  xvi).  It  has  been  stated  that  child-bearing  has  little  influence  in 
its  causation,  but  I  have  seen  the  development  of  it  in  a  woman  three  times  in 
three  different  pregnancies.  There  is  no  proof  of  heredity,  but  it  is  not  unusual 
to  find  more  than  one  member  of  a  family  with  it.  It  is  not  particularly  prone  to 
appear  in  ordinary  goitrous  families,  although  a  person  with  an  ordinary  goiter 
sometimes  develops  all  the  nervous  symptoms  and  heart  symptoms  of  Graves's 
disease  (see  page  1372,  Basedowified  Goiter).  It  may  arise  after  emotional  ex- 
citement or  depression,  fright,  shock,  hemorrhage,  or  an  acute  illness.  It  may 
develop  during  the  existence  of  locomotor  ataxia,  paresis,  epilepsy,  neurasthenia, 
hysteria  and  other  nervous  troubles,  and  abdominal  and  pelvic  diseases.     A 


137^ 


Diseases  and  Injuries  of  the  Thyroid   Gland 


shock  or  fright  does  not  cause  hypersecretion.  That  existed  before,  but  there 
were  no  symptoms  because  the  body  had  been  neutralizing  the  poison.  Shock 
develops  symptoms  by  abolishing  neutralization  (C.  H.  Mayo,  "Illinois  Med. 
Jour.,"  Feb.,  1913).  Crile  ("Am.  Jour.  Med.  Sci.,"  Jan.,  1913)  believes  that 
"  Graves's  disease  is  not  a  disease  of  a  single  organ  or  the  result  of  some  fleeting 
cause,"  that  it  originates  in  fear,  and  is  exicted  by  "some  stimulating  emotion 
intensely  or  repeatedly  given,  or  some  lowering  of  the  threshold  of  the  nerve 
receptors,  thus  establishing  a  pathological  interaction  between  the  brain  and 
thyroid."  Digestive  toxemia  is  thought  by  many  to  be  the  underlying  cause. 
It  is  frequently  associated  with  marked  anemia  the  result  of  excessive  vomiting. 
The  disease  is  a  toxemia  and  the  real  cause  of  the  symptoms  is  hypertrophy  of 

the  thyroid  and  excessive  secre- 
tion of  the  gland  {hyperthyroid- 
ism). This  view  is  rendered 
more  probable  when  we  recall 
that  a  condition  known  as  myxe- 
dema possesses  many  symptoms 
directly  opposite  to  those  of 
Graves's  disease  and  that  myxe- 
dema is  due  to  deterioration, 
great  diminution  or  absence  of 
thyroid  secretion,  and  the  un- 
opposed action  of  adrenal  se- 
cretion. The  administration  of 
thyroid  extract  to  an  individual 
may  produce  some  symptoms 
observed  in  exophthalmic  goiter 
and  partial  thyroidectomy  may 
improve  or  cure  Graves's  disease, 
lodothyroglobulin  is,  perhaps, 
the  poisonous  element. 

An  apparent  objection  to  this 
view  is  that  Graves's  disease  may 
exist  without  detectable  thyroid 
enlargement,  but  this  objection 
loses  force  when  we  recall  that 
the  thyroid  may  be  somewhat 
enlarged,  though  we  cannot  de- 
tect the  increase,  and  that  a  gland  may  be  diseased  even  when  not  enlarged.  It  is 
probable  in  exophthalmic  goiter  that  whether  or  not  there  be  an  excess  of  thyroid 
products  passing  into  the  circulation,  toxic  materials  of  some  sort  are  formed  in 
the  gland  and  are  taken  into  the  lymph  and  blood.  The  real  cause  of  exoph- 
thalmic goiter  is  not  positively  proved,  but  it  seems  probable  that  the  disease  is 
due  to  the  action  on  the  sympathetic  system  of  large  amounts  of  thyroid  mater- 
ial, of  some  poisonous  product  of  thyroid  activity,  or  of  some  toxin  the  thyroid 
fails  to  destroy. 

In  exophthalmic  goiter  the  vessels  of  the  gland  are  not  dilated — in  fact,  they 
are  "usually  smaller  and  less  numerous  than  in  a  parenchymatous  goiter  of  the 
corresponding  size"  (Berry,  on  "  Diseases  of  the  Thyroid  Gland")  but  the  vessels 
of  the  capsule  are  dilated.  The  surface  of  the  gland  is  smooth.  On  section,  the 
cut  surfaces  seem  solid  and  very  little  colloid  is  visible.  The  enlargement  is  due 
to  growth  of  the  glandular  epithelium,  either  general  or  in  localized  areas,  and 
this  epithelial  proliferation  may  be  induced  by  different  exciting  causes. 

In  many  cases  of  Graves's  disease  the  thymus  is  enlarged  by  hyperplasia. 
This  is  most  apt  to  be  the  case  in  young  subjects.  Status  lymphaticus  may  exist 
and  if  it  does  the  danger  of  operation  is  much  enhanced. 


Fig.  887. — Exophthalmic  goiter  and  total  blindness 
from  protrusion  of  eyes  (Hansell). 


Exophthalmic  Goiter  1379 

In  exophthalmic  goiter  the  lymphatics  within  the  lobules  are  usually  ob- 
literated, but  the  lymphatics  around  the  lobules  are  present  in  increased  num- 
ber and  are  of  exaggerated  size.  Sometimes  the  thyroid  becomes  fibrous,  and 
in  such  cases  myxedema  is  apt  to  arise.  In  a  typical  case  there  are  rapid  pulse 
or  tachycardia  and  protrusion  of  the  eyeballs  or  exophthalmus.  Some  suppose 
that  the  exophthalmus  is  due  to  a  collection  of  fat  back  of  each  eye,  but  the  varia- 
bility in  the  degree  of  protrusion  seems  to  contradict  this  view.  It  is  almost  cer- 
tainly due  to  involvement- of  the  sympathetic  system,  and  enlargement  of  the 
thyroid  gland  or  goiter.  Either  thyroid  enlargement  or  exophthalmus  may  be 
absent — in  fact,  in  some  rare  cases  both  are  absent.  The  pulse-rate  in  most 
cases  is  from  90  to  140.  Exophthalmus  is  present  in  at  least  80  per  cent,  of  cases. 
The  enlargement  of  the  thyroid  is  bilateral.  Unilateral  enlargements  are 
instances  of  Basedowified  goiter — that  is,  are  cases  in  which  toxemia  arises  in 
the  course  of  an  ordinary  goiter  (see  page  1372).  A  systolic  bruit  is  usually 
audible  over  the  thyroid  region,  and  the  large  vessels  at  the  root  of  the  neck 
pulsate  strongly  because  of  arterial  dilatation.  The  cardiac  symptoms  are  of 
great  importance.  Acute  cardiac  dilatation  occurs  during  tachycardia,  and  for 
a  time,  at  least,  disappears  as  tachycardia  abates.  Even  trivial  fatigue  brings 
on  temporary  dilatation.  Dilatation  may  become  permanent  (and  does  after 
one  year),  valvular  insufficiency  may  arise,  or  cardiac  hypertrophy  may  occur 
(Grocco,  in  "R.  Grit,  di  Clin.  Med.,"  Jan.  2,  1904).  Von  Graefe^s  sign  may  be 
present;  this  is  inability  of  the  lids  to  follow  the  eyes  in  looking  down.  Stell- 
wag's  sign  is  retraction  of  the  upper  lids.  The  lids  in  some  cases  cannot  be  com- 
pletely closed,  and  when  the  eyeball  is  suddenly  turned  up,  the  lid  and  brow  may 
fail  to  act  together.  Moehius's  sign  is  inability  to  maintain  the  eyes  in  conver- 
gence. In  some  cases  ocular  palsies  exist,  in  others  there  is  photophobia  or 
nystagmus.  Patients  may  suffer  from  neuralgia,  colic,  choreic  movements, 
tremor,  flushes  of  heat,  and  gastric  crises.  Tremor  is  practically  always  present 
when  the  arms  and  forearms  are  extended,  the  palms  of  the  hands  are  turned 
down,  and  the  fingers  are  spread  apart.  Widespread  tremor  is  apt  to  arise 
from  any  excitement,  shock,  or  surprise.  Dyspnea  often  exists  and  albuminuria 
and  polyuria  are  not  uncommon.  Hemoptysis,  hematemesis,  or  mental  dis- 
turbance is  sometimes  noted.  The  patient  is  usually  greatly  depressed  mentally, 
sometimes  is  excited,  and  may  have  outbreaks  of  violent  hysterical  excitement 
or  even  of  mania.  The  usual  expression  is  one  of  fright.  There  may  be  insom- 
nia, elevated  temperature,  excessive  sweating,  or  sudden  attacks  of  diarrhea. 
All  symptoms  are  increased  by  fear  or  fright.  Sugar  may  be  found  in  the  urine. 
Exophthalmic  goiter  is  sometimes  associated  with  osteomalacia.  This  fact  is 
important  in  connection  with  MacGallum's  observations  on  the  action  of  the 
parathyroids  in  controlling  calcium  metabolism.  Kocher  emphasizes  the  im- 
portance of  the  blood-picture.  In  nearly  all  cases  there  is  lymphocytosis. 
Halsted  ("Annals  of  Surgery,"  August,  1913)  says  of  his  cases:  "Almost  in- 
variably the  proportion  of  lymphocytes  was  increased,  once  being  as  high  as 
65  per  cent.  But  in  i  case,  the  most  serious  of  all,  the  total  percentage  of  lym- 
phocytes was  only  9."  Halsted  regards  enlargement  of  the  thymus  as  prob- 
ably responsible  for  the  lymphocytosis,  and  the  thymus  is  enlarged  in  at  least 
75  per  cent,  of  marked  cases.  After  operation  lymphocytosis  gradually  dimin- 
ishes (Halsted,  Ibid.).  The  duration  of  a  case  is  entirely  uncertain.  It  is 
usually  very  chronic,  with  remissions  or  actual  intermissions.  Sometimes  the 
patient  gets  entirely  well,  but  this  result  is  rare.  There  is  often  a  partial  cure, 
which  may  at  any  time  be  followed  by  a  renewed  outbreak.  Sometimes  the 
condition  passes  away  rapidly,  but  abatement  is  usually  gradual.  Some  cases 
get  progressively  worse  and  die.  Certain  cases  are  acute  and  these  are  apt 
to  result  fatally.  A  man  in  the  Jefferson  Hospital  died  in  five  weeks  after  the 
first  symptoms  were  noted.  He  was  delirious  for  several  weeks.  Another  case 
died  in  four  weeks  in  spite  of  ligation  of  the  two  superior  thyroids.     Very  grave 


1380  Diseases  and  Injuries  of  the  Thyroid  Gland 

cases  o£  exophthalmic  goiter  are  probably  often  associated  with  disease  of  the  thy- 
mus (Rehn).  C.  H.  Mayo  ("Illinois Med.  Jour.,"  Feb.,  1913)  says:  "While  the 
large  majority  of  cases  can  be  easily  diagnosed  from  the  nervous  symptoms, 
tachycardia,  goiter,  and  eye  symptoms,  there  are  a  few  cases  in  which  it  is 
difficult  to  diagnose  true  hyperthyroidism  from  pure  neurasthenia,  myocarditis, 
or  Bright's  disease,  as  well  as  a  few  cases  in  which  there  may  be  a  complication 
bv  affection  of  the  hv^^ophysis,  thymus,  or  adrenals."  Children  seem  to  suffer 
less  when  hypothyroidism  exists  than  do  adults. 

Treatment. — Thyroid  extract  does  harm.  Medical  treatment  in  a  severe 
case  should  comprise  rest  in  bed,  the  use  of  an  ice-bag  over  the  heart,  and  the 
administration  of  adrenalin.  When  the  patient  gets  about  again,  he  must 
avoid  alcohol  and  all  forms  of  excitement.  Gentle  exercise  is  desirable,  but 
never  violent  exercise.  Diet  is  to  be  nutritious,  but  non-stimulating.  Elec- 
tricity is  said  to  be  of  benefit.  Experiments  in  organotherapy  are  being  tried 
in  this  disease.  Thymus  extract  has  been  used.  Ballet  and  Enriquez  assumed 
that  the  thyroid  gland  furnished  an  antitoxin  to  certain  body  poisons,  that  an 
excess  of  thyroid  secretion  over  the  amount  required  to  neutralize  toxin  caused 
the  condition  known  as  Graves's  disease,  and  that  the  symptoms  of  Graves's 
disease  would  disappear  if  sufficient  toxin  were  administered  to  antidote  the 
excess  of  thyroid  secretion  (Hubert  Richardson,  in  "Am.  Medicine,"  August, 
1906).  The  two  observers  mentioned  above  obtained  blood-serum  from  thyroid- 
ectomized  dogs  and  injected  it  into  individuals  suffering  from  Graves's  disease 
and  claim  that  they  noted  improvement.  In  2  of  their  patients,  however,  tetany 
developed.  Lanz  has  used  the  milk  of  thyroidectomized  goats  instead  of  the 
serum  of  thyroidectomized  dogs.  The  serum  of  thyroidectomized  sheep,  pow- 
der made  from  the  dried  goiter  of  a  cretin,  and  the  powdered  flesh  of  the  thyroid- 
ectomized sheep  have  been  used  (Hubert  Richardson,  Ibid.).  What  is  known 
as  thyroidectin  is  the  dried  serum  of  an  animal  from  which  the  thyroid  gland 
has  been  removed.  John  W.  Rogers  and  S.  P.  Beebe  have  made  some  extremely 
interesting  studies  on  the  production  and  application  of  a  serum.  Rogers 
makes  two  sera,  using  one  or  the  other,  according  to  the  needs  of  the  case. 
One  serum,  called  the  normal  serum,  is  obtained  from  sheep  or  rabbits  after  inject- 
ing them  with  the  combined  nucleoproteins  and  thyroglobulin  of  healthy  thy- 
roids; the  other,  called  the  pathological  serum,  is  obtained  from  the  animals  after 
having  injected  them  with  combined  nucleoproteins  and  thyroglobulin  obtained 
from  the  thyroids  of  Graves's  disease.  In  i  severe  case  I  have  seen  rapid  im- 
provement and  apparent  cure  follow  the  use  of  Rogers's  serum.  The  value  of 
serum  treatment  is  as  yet  undetermined.  It  is  certainly  not  free  from  danger 
and  some  deaths  have  followed  its  use.  One  cause  of  diverse  results  after 
the  use  of  goat  serum  may  be  found  in  the  fact  that  some  of  the  animals  were 
probably  incompletely  thyroidectomized.  The  goat  possesses  aberrant  thyroids 
and  these  must  be  removed  as  well  as  the  gland  proper.  Beebe  and  Beveridge 
("N.  Y.  Med.  Jour.,"  Dec.  25,  191 5)  state  that  50  per  cent,  of  more  than  3000 
treated  were  cured  "in  the  sense  that  they  are  strong  and  able  to  meet  all  the 
demands  made  upon  them. " 

There  are  upon  the  market  three  preparations  to  combat  hyperthyroidism: 

1.  Thyroidectin  (or  thyreoidectin)  is  a  powder  made  from  the  dried  blood 
serum  of  thyroidectomized  animals.  It  is  given  in  5-gr.  capsules.  The  dose  is 
I  or  2  capsules  three  times  a  day. 

2.  Beebe's  serum  is  the  serum  of  thyroidectomized  animals. 

3.  The  antithyroidin  of  Moebius  is  the  serum  of  sheep's  blood,  the  animal 
having  had  its  thyroid  gland  removed  at  least  six  weeks  before  the  serum  was 
obtained. 

Jaboulay  of  Lyons  suggested  cutting  the  cervical  sympathetic  nerve  on 
each  side.  Jonnesco  of  Bucharest  suggested  bilateral  extirpation  of  the  cervical 
ganglia.     Bilateral  extirpation  of  the  cervical  ganglia  of  the  sympathetic  and 


Operations  on  the  Thyroid  Gland 


1381 


division  of  each  nerve  below  the  ganglion  have  been  employed,  it  is  alleged, 
with  benefit.  I  have  not  employed  the  operation  for  this  disease.  It  bene- 
fits exophthalmus,  perhaps,  more  than  does  thyroidectomy.  Ligation  of  the 
thyroid  arteries  may  do  good.  Its  chief  use  is  preliminary  to  thyroidectomy 
but  it  will  cure  exophthalmic  goiter  in  a  child.  Partial  thyroidectomy  is  the 
operation  commonly  employed  in  severe  cases;  it  cures  within  six  months  from 
50  to  75  per  cent,  of  the  cases  operated  upon.  One  lobe,  the  isthmus,  and  a 
portion  of  the  other  lobe  are  removed.  Some  cases  do  not  improve;  others 
improve  slowly  and  relief  is  only  partial.  It  is  the  operation  which  I  prefer. 
The  Mayos  have  obtained  a  splendid  series  of  results  from  this  operation. 
It  is  their  custom  to  apply  the  .v-rays  daily  for  several  weeks  and  then  to  operate. 
The  rays  produce  decided  but  temporary  improvement.  The  operation  is 
intracapsular  extirpation  of  one  lobe. 
Ether  is  given  to  most  cases  (by  intra- 
tracheal insuftlation).  In  some  cases 
thyroid  intoxication  follows  operation. 
In  other  cases  very  rapid  growth  follows 
incomplete  removal,  and  the  operation 
seems  actually  to  have  done  harm. 
Sudden  death  occasionally  follows  the 
operation.  The  removal  of  an  exoph- 
thalmic goiter  is  difficult ;  the  capsule  and 
blood-vessels  rupture  from  slight  force. 
Not  all  cases  should  be  operated  upon. 
(See  Operation  for  Exophthalmic  Goiter 


on  page  1385.)  The  .r-rays  frequently 
have  a  very  beneficial  effect  upon  the 
symptoms  of  exophthalmic  goiter.  They 
probably  destroy  some  of  the  secreting 
glandular  epithelium,  and  thus  diminish 
the  amount  of  the  thyroid  secretion  and 
alter  its  character.  They  also  induce  Fig. 
fibroid  changes,  and  80  per  cent,  of  cases 
are   relieved.      Frequently    they    cause 

great  improvement  and  occasionally  they  will  produce  a  cure.  In  one  case  the 
ic-rays  caused  such  atrophy  that  myxedema  arose  and  it  became  necessary  to 
administer  thyroid  extract.  Makenzie  reported  a  similar  case  ("Lancet,"  1916, 
cxci).  It  is  my  custom  to  use  the  rays  preliminary  to  operation  in  order 
to  decrease  the  vascularity  of  the  capsule,  to  lessen  the  amount  and. diminish 
the  toxic  quality  of  the  thyroid  secretion,  and  to  modify  the  various  symptoms. 
If  status  lymphaticus  exists  operation  is  decidedly  dangerous.  Enlargement 
of  the  thymus  without  status  lymphaticus  does  not  seem  to  increase  the 
danger  of  operation  to  any  decided  degree,  but  if  the  enlargement  be  great  it 
is  wise  to  precede  operation  by  the  administration  of  thymus  tablets  and 
exposures  to  the  x-rays. 

Operations  on  the  Thyroid  Gland. — The  removal  of  a  goiter  is  a  major 
operation  and  one  beset  with  difficulties  and  dangers.  Nevertheless  it  is  a  very 
successful  operation.  I  lost  a  case  of  supposed  adenomatous  goiter  which 
turned  out  to  be  a  metastatic  hypernephroma.  The  patient  died  from  second- 
ary hemorrhage.  I  lost  a  case  of  carcinoma  of  the  thyroid  and  a  case  of  simple 
adenoma.  My  mortality  in  ordinary  goiter  has  been  under  2  per  cent.  In  1 200 
cases  of  ordinary  goiter  the  Mayos  had  a  mortahty  of  i  per  cent,  following 
extirpation.  In  the  Mayo  Clinic  from  Jan.  i,  1907  to  Jan.  i,  19 18  there 
were  6668  thyroidectomies  for  simple  goiter  with  a  mortality  of  7  per  cent. 
Kocher's  mortality  is  0.4  per  cent.  Certain  anatomical  points  are  to  be  borne 
in  mind.     The  internal  jugular  vein  is  frequently  found  to  the  inner  side  of  the 


888. — Enucleation   of 
capsule  opened  (C.  H.  Mayo). 


cystic    goiter; 


1382 


Diseases  and  Injuries  of  the  Thyroid   (iland 


carotid  artery  and  lying  on  the  goiter  (because  the  vein  has  branches  which 
run  from  the  goiter  and  hold  the  vessel  against  the  thyroid).  The  recurrent 
laryngeal  nerve  ascends  along  the  side  of  the  trachea  back  of  the  gland,  and  is  in 
contact  with  the  esophagus. before  it  passes  through  the  cricothyroid  membrane. 
On  the  right  side  the  nerve  is  very  close  to  the  inferior  thyroid  artery,  some- 
times passing  over  it,  sometimes  under  it.  On  the  left  side  it  is  deeper  and 
not  so  near  the  artery.  The  parathyroids  are  behind  the  thyroid  and  usually 
behind  the  capsule. 

In  view  of  the  fact  that  one  or  both  recurrent  laryngeal  nerves  may  be 
paretic  from  pressure,  all  cases  should  be  examined  with  the  laryngeal  mirror 
before  the  operation  to  determine  this  point.  If  the  paresis  is  on  one  side 
only,  the  sound  vocal  cord  may  possibly  compensate  by  advancing  across  the 
midline.  In  such  conditions  the  paresis  may  be  first  observed  followdng  opera- 
tion, leading  the  operator  to  think  that  he  has  injured  a  nerve  (C.  H.  Mayo, 
in  "Surg.,  Gyn.,  and  Obst.,"  July,  1907). 

Intraglandular  Enucleation  (Socin's  Operation). — By  this  operation  an 
adenoma,  a  colloidal  area  or  a  cyst  of  the  thyroid  gland  can  be  removed,  the 
encompassing  glandular  tissue  being  left  in   place.     The  capsule  of  such  a 


Fig.    889.— Kocher's    transverse  incision         Fig.    890.— Isolating     the    accessory    veins 
exposing   the  muscles  and  median  veins  of  (Kocher). 

the  neck  (Kocher). 

growth  is  glandular  tissue.  The  operation  of  enucleation  is  not  suited  to  the 
removal  of  multiple  tumors  and  it  cannot  be  performed  for  parenchymatous 
goiter  or  exophthalmic  goiter.  Intraglandular  enucleation  is  performed  as 
follows:  The  thyroid  is  exposed  by  an  oblique  or  by  a  transverse  incision.  An 
incision  is  made  through  the  capsule  of  the  thyroid  gland  and  through  the  gland- 
ular tissue  until  the  cyst  or  sohd  tumor  is  reached.  As  a  rule,  the  tumor  can 
be  recognized  by  the  fact  that  its  color  differs  from  the  color  of  the  thyroid 
tissue.  The  tumor  is  turned  out  by  the  fingers,  a  special  scoop,  the  knife 
handle,  or  a  dry  dissector.  In  some  cases  a  cyst  can  be  most  easily  removed  if, 
after  exposure,  it  be  incised  and  emptied  and  its  wall  then  grasped  by  strong 
forceps.  A  solid  tumor  should,  if  possible,  be  removed  intact.  The  wound  is 
packed  temporarily  with  gauze,  the  edges  of  the  cavity  are  grasped  by  forceps, 
the  gauze  is  removed,  and  every  bleeding  point  is  carefully  ligated.  The  wound 
is  closed  by  three  lavers  of  sutures — "one  in  the  gland,  one  in  the  muscles,  and  a 
third  in  the  skin"  (James  Berry,  on  "Diseases  of  the  Thyroid  Gland").  If  the 
tumor  is  large,  drain  for  twenty-four  hours;  otherwise,  do  not  drain. 

Enucleation  is  a  very  successful  operation  if  performed  upon  properly 
selected  cases,  and  can  be  performed  rapidly,  but  the  arrest  of  bleeding  is 
often  tedious  and  troublesome. 


Operations  on  the  Thyroid  Gland 


1383 


Extracapsular  Extirpation. — This  term  means  removal  of  the  entire  gland 
[complete  thyroidectomy)  or  a  portion  of  the  gland  {partial  thyroidectomy)  with 
the  glandular  capsule,  the  operation  being  an  extracapsular  procedure.  Usu- 
ally but  one  lobe  is  extirpated  {lobectomy) ,  or  one  lobe,  the  isthmus,  and  a  por- 
tion of  the  other  lobe.  This  method  enables  the  operator  to  tie  the  chief 
vessels  before  he  cuts  them;  as  his  vision  is  not  abscured  by  bleeding,  he  can 
avoid  cutting  the  glandular  capsule  (which  would  provoke  copious  bleeding), 
and  he  keeps  a  safe  distance  away  from  the  recurrent  laryngeal  nerve. 

If  the  patient  suffers  from  grave  respiratory  trouble  with  myocardial  disease, 


J^=^ 


Fig.   8gi. — Exposure  of  veins  of  lower  end 
before  ligation  (Kocher). 


Fig.  892. — Dislocation  of  the  goiter  toward 
the  right  (Kocher). 


a  general  anesthetic  is  contra-indicated.  If  ether  is  used,  after  unconscious- 
ness is  obtained  the  ether  is  continued  by  intratracheal  insufflation.  The  patient 
is  placed  recumbent,  with  the  shoulders  a  little  raised  and  the  neck  laid  upon  a 
"sand-pillow  so  as  to  throw  the  head  back  as  far  as  is  consistent  with  comfort- 
able respiration. 

An  oblique  incision,  a  horseshoe-shaped  incision,  or  a  transverse  collar  in- 
cision (Fig.  889)  may  be  made.  I  usually  employ  an  incision  shaped  like  an 
incomplete  horseshoe,  the  convexity  being  downward.     Layer  by  layer  the 


A.carotis 


sternoclciio 
N.recurretis 

^Venathurfo- 
Videain/erior 


Fig.  894. 


-Ligation   of   the  inferior  thyroid 
artery  (Kocher). 


Fig.  893. — Isolation  of  the  superior  thyroid 
artery  and  vein  (Kocher). 

tissues  are  divided.  Vessels  are  carefully  tied  as  divided  or  before  division. 
The  muscles  which  run  from  the  sternum  to  the  hyoid  bone  may  in  some  cases  be 
separated,  but  the  extirpation  of  a  large  goiter  requires  transverse  division 
of  the  muscle  high  up.  The  capsule  of  the  lobe  is  exposed,  and  is  separated 
from  external  parts  (Figs.  8go,  891,  and  892).  The  upper  portion  of  the  gland 
is  cleared.  The  superior  thjo-oid  vessels  are  found,  tied  with  two  ligatures 
each,  and  divided  between  the  ligatures  (Fig.  893).  The  clearing  of  the  gland 
is  carried  on  toward  the  median  line  and  some  rather  large  veins  are  encountered 


1384 


Diseases  and  Injuries  of  the  Thyroid  Gland 


and  tied  (Fig.  895).  The  lower  portion  of  the  lobe  is  cleared  and  the  inferior 
thyroid  vessels  are  found.  Near  this  point  the  recurrent  laryngeal  nerve  lies 
and  may  be  located.  If  the  operation  is  being  done  under  a  local  anesthetic 
adjacency  to  the  nerve  is  readily  determined,  because  if  the  nerve  is  pulled 
upon,  or  if  it  is  pressed  upon  or  touched  by  a  blunt  instrument,  the  patient's 
voice  becomes  metallic.  A  deliberate  attempt  is  made  to  locate  the  nerve, 
and  the  patient  is  engaged  in  a  conversation  requiring  answers  while  the  sur- 
geon is  investigating.  The  lobe  is  lifted  from  its  bed  and  dislocated  from  the 
wound  and  the  inferior  thyroid  vessels  are  tied  close  to  the  border  of  the  gland  in 
order  to  avoid  the  recurrent  laryngeal  nerve  (Fig.  894).  The  vessels  are  tied  and 
cut  across  as  were  the  superior  thyroid  vessels.  The  isthmus  is  next  exposed, 
clamped,  ligated,  and  cut  across,  every  care  being  taken  to  prevent  colloid  from 
being  squeezed  into  the  wound  (Fig.  896).  After  dividing  the  isthmus,  any 
bleeding  point  is  ligated  and  the  stump  is  cauterized.  The  divided  muscles  are 
sutured  with  catgut,  a  drainage-tube  is  inserted,  and  the  superficial  wound  is 
closed  with  sutures  of  silkworm-gut  or  silk. 

Intracapsular  Extirpation. — This  operation  is  warmly  advocated   by  the 
Mayos.     The  preservation  of  the  posterior  portion  of  the  capsule  protects  the 


Fig.  895. — Isolation  of  the  venae  thy- 
reoideae  imae  (Kocher). 


Fig. 


'. — Isolation  and  clamping  of  the  isthmus 
(Kocher). 


recurrent  laryngeal  nerve  and  greatly  lessens  the  risk  of  injuring  the  parathy- 
roids. Ether  is  given  unless  there  is  grave  respiratory  difficulty  with  myocardial 
degeneration,  and  half  an  hour  before  administering  the  ether  the  patient  is 
given  a  hypodermatic  injection  of  ^4  gi"-  of  morpliin  and  Hoo  gr.  of  atropin.  The 
ether  is  continued  by  intratracheal  insufflation.  When  anesthetized,  the  patient 
is  placed  in  the  reversed  Trendelenburg  position  and  the  shoulders  are  elevated 
(C.  H.  Mayo,  in  "Surg.  Gyn.,  and  Obst.,"  June,  1907).  Kocher's  transverse 
collar  incision  is  made.  Muscles  are  separated  or  divided  as  in  ordinary  extra- 
glandular  extirpation.  If  the  ribbon  muscles  are  divided  the  cut  is  made  near 
their  upper  insertion  to  save  their  nerve  supply  and  prevent  the  muscle  scar 
from  being  in  line  with  the  skin  scar.  The  gland  is  elevated.  The  vessels  enter- 
ing and  leaving  the  raised  lobe  are  double  clamped  and  tied.  The  capsule  is 
incised  along  the  outer  side  of  the  gland,  is  pushed  back  with  gauze,  and  the  lobe 
is  drawn  toward  the  midline,  and  vessels  are  caught  by  forceps,  the  tissues  being 
grasped  in  line  with  the  midline  of  the  body  (C.  H.  Mayo,  Ibid.). 

Every  structure  bearing  any  resemblance  to  a  parathyroid  is  allowed  to 
remain.  The  isthmus  is  clamped,  divided,  and  closed  by  suture.  The  muscles 
and  skin  are  sutured.  Drainage  is  required  after  removal  of  large  growths,  a 
separate  incision  being  made  to  permit  of  it. 

Dangers  in  Goiter  Operations. — During  any  operation  for  goiter  sudden 
death   may  occur.     In   some   cases  a  general   anesthetic  is  responsible.     In 


The  Operation  for  Exophthalmic  Goiter  1385 

others  suflfocation  arises  from  pressure  upon  or  bending  of  the  trachea  or  collapse 
of  the  trachea  as  the  goiter  is  lifted  from  its  bed.  In  rare  cases  dangerous 
dyspnea  arises  from  irritation  of  the  laryngeal  nerves,  and  cardiac  inhibition 
may  be  induced  in  the  same  manner.  The  parathyroids  may  be  injured  or 
removed  and  tetany  may  result.  Rough  handling  and  flooding  the  wound 
with  colloid  may  be  followed  by  great  and  even  fatal  hyperthyroidism.  The 
trachea  or  esophagus  may  be  opened.  The  recurrent  laryngeal  nerve  may  be 
injured.  Air  emboHsm  seldom  occurs.  Reactionary  or  secondary  hemorrhage 
is  usually  due  to  slipping  of  the  ligature  on  the  superior  thyroid  artery  "caused 
by  including  a  piece  of  muscle"  (C.  H.  Mayo,  in  "Surg.,  Gyn.,  and  Obstet.," 
June,  1Q07). 

Acute  Thyroidism  (Hyperthyroidism). — When  colloid  from  the  thyroid 
is  squeezed  into  the  wound  during  the  operation  or  leaks  into  it  later,  it  is 
absorbed  and  may  produce  serious  symptoms  or  even  death.  This  is  most 
apt  to  happen  in  exophthalmic  goiter.  The  symptoms  always  appear  within 
forty-eight  hours  and  usually  within  twenty-four.  Sometimes  they  arise 
quickly  after  operation.  In  some  cases  in  which  this  happens  the  patient  never 
reacts  from  the  operative  shock,  but  develops  a  very  rapid  pulse  and  intense 
dyspnea,  and  dies  in  a  few  hours.  In  less  severe  cases  there  is  a  period  of  cir- 
culatorv  excitement,  dyspnea,  and  elevated  temperature  {thyroid  fever).  The 
surgeon  seeks  to  prevent  acute  thyroidism  by  limiting  leaking  of  colloid,  by 
cauterizing  the  stump,  by  washing  the  wound  with  adrenalin  solution,  by  sutur- 
ing the  capsule  over  the  raw  stump  of  the  gland,  and  by  inserting  drainage. 

The  Operation  for  Exophthalmic  Goiter. — The  operation  of  thyroidectomy  is 
not  to  be  performed  during  an  acute  exacerbation.  (See  Judd  and  Pemberton 
in  Surgery,  Gynecology,  and  Obstetrics,  March,  1916.)  To  do  it  then  will  very 
probablv  cause  death.  Delirium  is  a  contra-indication.  So  are  gastric  crises. 
The  operation  is  very  dangerous  when  there  is  great  cardiac  dilatation.  After 
the  disease  has  existed  one  year  it  is  highly  probable  that  marked  dilatation 
exists.^  Hence,  early  operations  are  much  safer  than  late  ones.  If  a  case  is 
seen  early,  and  if  the  .T-rays  (and  perhaps  serums)  fail  to  cure,  operation  should 
be  recommended.  In  any  case  with  serious  symptoms  the  surgeon  seeks  to 
modify  those  symptoms  before  thyroidectomy  by  means  of  rest,  the  ice-bag 
over  the  heart,  drugs,  the  .v-rays,  and  perhaps  serums.  If  under  this  treatment 
the  dangerous  symptoms  disappear  or  greatly  abate,  thyroidectomy  may  be 
performed. 

If  the  dangerous  symptoms  are  little  modified  or  not  modified  at  all  by 
medical  treatment,  prehminary  hgation  of  one  of  the  thyroid  arteries  is  indi- 
cated. Ligation  of  an  artery  will  not  cure  a  case,  but  will  probably  greatly 
improve  it.  The  operation  is  strictly  palliative  and  preliminary.  Tie  the 
right  superior  thyroid.  Wait  one  week.  If  the  symptoms  are  not  greatly 
improved,  tie  the  left  superior  thyroid  and  wait  a  while.  In  severe  cases  tie 
both  superior  thyroids  at  one  operation.  The  operation  is  done  under  infiltration 
anesthesia.  It  is  not  entirely  free  from  danger  and  may  cause  death.  Halsted 
("Annals  of  Surgery,"  August,  1913)  ties  one  inferior  thyroid  or  both  inferior 
thyroids.  He  says  that  by  the  inferior  operation  we  obtain  a  better  cosmetic 
effect,  leave  a  scar  largely  beyond  the  incision  which  will  subsequently  be  used 
for  lobectomy,  and  tie  vessels  which  are  larger  than  the  superior  arteries.  In 
I  of  his  cases  four  arteries  were  tied  in  4  operations  before  lobectomy.  C.  H. 
Mayo^  points  out  that  the  ligature  of  the  superior  thyroid  should  be  applied 
very  close  to  the  pole  or  should  actually  include  some  of  the  thyroid  tissue, 
"  so  that  a  reversed  circulation  in  anastomotic  branches  with  the  inferior  thyroid 
artery  may  not  occur." 

1  C.  H.  Mayo  in  "Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,"  Mayo  Clinic, 
1912;  Halsted,  "Annals  of  Surgery,"  August,  1913. 

2  "Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,"  Mayo  Clinic,  August,  1912. 


1386  Diseases  and   Injuries  of  the  'J'hyroid   Gland 

When  it  is  esteemed  safe  the  surgeon  prepares  to  perform  partial  thyroidec- 
tomy. In  most  cases  ether  is  given,  preceded  by  a  hypodermatic  injection  of 
morphin  and  atropin.  After  the  patient  is  anesthetized  by  ether  the  tracheal 
tube  should  be  introduced  and  the  unconsciousness  maintained  by  insuffla- 
tion anesthesia.  If  there  is  grave  cardiac  dilatation  and  we  determine  to  oj)- 
erate,  infiltration  anesthesia  is  relied  upon. 

At  the  operation  an  entire  lobe  (except  a  thin  slice),  the  isthmus,  and  a  por- 
tion of  the  other  lobe  should  be  removed.  The  more  of  the  gland  removed, 
the  better  the  prospect  of  cure  Halsted,  "Annals  of  Surgery,"  August,  1913). 
At  least  one-half  of  one  lobe  must  be  left  in  order  to  prevent  myxedema.  The 
parathyroids  are  protected  by  leaving  a  small  slice  of  the  posterior  portion  of 
each  lobe  (Halsted,  "Annals  of  Surg.,"  Aug.,  1913).  After  the  removal  of  one 
lobe  the  other  usually  undergoes  considerable  atrophy.  After  thyroidectomy, 
l^-mphocytosis  gradually  decreases,  and  an  enlarged  thymus  generally  disap- 
pears (Ibid.).  Thyroidectomy  may  cure  the  case;  it  may  greatly  improve  it; 
may  fail  or  nearly  fail,  or  may  cause  death.  Cure  is  gradual  and  may  be  at- 
tained after  several  months  only.  From  50  to  75  per  cent,  of  patients  are 
cured  by  the  operation.  Many  others  are  vastly  and  permanently  improved. 
Some  are  improved,  but  are  subject  to  temporary  relapses.  In  Halsted 's  39 
cases  there  was  not  a  death  from  operation. 

In  the  first  16  cases  operated  upon  by  the  Mayos  the  mortality  was  25  per 
cent.  At  present  the  factors  which  forbid  operation  are  recognized.  In  3709 
operations  for  exophthalmic  goiter  their  mortality  was  only  3  per  cent.  (Per- 
sonal communication  to  the  author).  They  have  had  278  consecutive  cases 
without  a  death,  a  truly  wonderful  record.^ 

The  elder  Kocher  ("Jour.  Am.  Med.  Assoc,"  April,  1910)  reports  upon  535 
partial  thyroidectomies  for  exophthalmic  goiter.  The  mortality  was  3.1  per 
cent. :  3  di^d  from  the  anesthetic,  and  now  his  clinic  uses  local  anesthesia  pre- 
ceded by  Crile's  plan  of  psychic  narcosis;  3  others  died  from  kidney  disease  which 
existed  at  the  time  of  operation.  Now  no  operation  is  recommended  in  his 
clinic  if  kidney  disease  exists.  There  were  3  thymus  deaths;  4  with  status lym- 
phaticus  died  suddenly  while  being  prepared  for  operation.  Such  patientsshould 
not  be  operated  upon  before  they  have  been  greatly  improved  by  medical  trea"t- 
ment.  Kocher,  like  Halsted,  says  that  the  degree  of  improvement  depends 
upon  the  amount  of  gland  removed.  In  such  cases  use  medical  treatment  and 
the  -T-rays  first.  If  this  plan  fails,  tie  one  or  more  of  the  th3n:oid  arteries  before 
doing  thyroidectomy. 

My  personal  experience  in  exophthalmic  goiter  is  small;  in  fact,  I  know  of 
no  one  in  Philadelphia  who  has  performed  any  great  number  of  operations  for 
it.  I  have  performed  thyroidectomy  for  exophthalmic  goiter  14  times,  with  2 
deaths. 

The  Parathyroid  Glands  and  Tetany. — (See  collective  review  in  "  Inter- 
nat.  Abstract  of  Surgery,"  May,  1915,  by  Eugene  H.  Pool).  These  glands  were 
discovered  by  Sandstrom  in  1880,  and  their  vital  functions  were  pointed  out  by 
Gley.     He  showed  that  removal  of  the  parathyroids  causes  tetany. 

The  parathyroids  are  brownish  red  and  are  larger  in  adults  than  in  infants. 
They  are  constant  in  man,  never  being  congenitally  absent. 

They  are  usually  four  in  number  and  are  ordinarily  placed  external  to  the 
thyroid  capsule.  In  some  cases,  however,  one  or  more  of  them  may  be  found 
embedded  in  the  thyroid  gland,  but  even  when  they  appear  to  lie  within  the 
thyroid  they  are  always  separated  from  it  by  a  capsule  of  connective  tissue. 

While  there  are  usually  four  parathyroids,  there  may  be  only  three,  or  there 
may  be  five,  six,  seven,  or  eight.  Accessory  parathyroids  may  be  found  over 
wide  areas.     One  was  discovered  by  Rogers  and  Ferguson  in  the  middle  of  the 

^C.  H.  Mayo,  in  "  Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,"  Mayo  Clinic, 
1912. 


The  Parathyroid  Glands  and  Tetany  1387 

posterior  portion  of  the  pharynx;  and  there  was  found  in  the  thorax  by  Ogle 
a  gland  that  was  partly  parathyroid. 

From  their  situation  the  parathyroids  are  divided  into  superior,  or  external, 
and  inferior,  or  internal.  Walsh  describes  these  glands  in  adults  as  being 
each  from  6  to  7  mm.  in  length,  3  to  4  mm.  in  breadth,  and  i}^  to  i  mm.  in 
thickness.  Each  of  these  glands  is  supplied  by  a  terminal  artery,  and  the 
supply  is  very  largely  obtained  from  the  inferior  thyroid  artery  or  from  the 
branch  of  anastomosis  between  the  superior  and  inferior  thyroid  vessels. 

If  the  parathyroid  glands  be  extirpated  from  an  animal,  tetany  usually 
develops  {experimental  tetany).  This  is  positively  the  case  in  dogs.  These 
glands  certainly  have  most  important  functions  in  the  metabolism  of  the  body. 
They  are  essential  for  normal  metabolism  (Mayo  and  McGrath,  in  "Annals  of 
Surgery,"  Feb.,  1912).  MacCallum  and  Voegtlin  ("Johns  Hopkins  Hosp. 
Bull.,"  March,  1908)  believe  that  damage  to  or  removal  of  them  causes  great 
changes  in  calcium  metabolism. 

Very  little  is  known  of  diseases  of  the  parath3'roid  glands.  A  few  cases  of 
tumor  have  been  reported,  each  being  an  example  of  either  work-hypertrophy 
or  adenoma.  One  of  these  cases  was  reported  by  the  author  in  "Surg.,  Gyn., 
and  Obst.,"  Jan.,  1909.  In  this  case  the  tumor  was  removed  under  the  im- 
pression that  it  was  an  adenoma  of  the  right  lobe  of  the  thyroid  gland.  The 
pathological  report,  however,  showed  it  to  be  a  parathyroid.  No  trouble 
of  any  kind  followed  the  operation,  though  at  a  later  period  enlargement  of  the 
opposite  side  of  the  neck  occurred.  This  has  been  let  alone  through  fear  that 
it  may  be  a  left  parathyroid.  In  spontaneous  tetany  histological  changes  have 
been  found  in  the  parathyroids  and  there  is  some  evidence  that  traumatism 
may  produce  functional  insufficiency. 

Some  persons  have  maintained  that  deficiency  of  parathyroid  secretion 
is  the  cause  of  paralysis  agitans,  but  this  idea  has  been  warmly  combated  and 
lacks  evidence.  Some  observers  believe  that  there  is  a  deficiency  of  parathy- 
roid secretion  in  exophthalmic  goiter. 

In  view  of  the  well-known  fact  that  removal  of  or  damage  to  the  para- 
thyroids may  result  in  tetany  {hypoparathyroidism) ,  provided  that  several  of 
these  glands  or  all  of  them  are  damaged  or  removed,  it  becomes  the  duty  of  the 
surgeon,  when  operating  for  goiter,  to  exercise  the  utmost  care  that  he  does  not 
remove  any  of  these  bodies.  The  safest  way  to  avoid  them  is  to  retain  the  pos- 
terior portion  of  the  capsule  of  the  thyroid  gland.  If,  during  operation,  any 
small  body  that  resembles  a  parathyroid  be  detected,  it  should  be  let  alone;  or 
if  such  a  body  has  been  accidentally  removed,  it  should  immediately  be  im- 
planted into  the  capsule  of  the  lobe  of  the  thyroid  gland  that  has  been  left  un- 
disturbed. It  is  highly  improbable  that  the  removal  of  even  both  parathyroids 
on  one  side  will  cause  tetany  if  there  are  two  normal  parathyroids  on  the 
opposite  side. 

On  account  of  the  possibility  of  the  development  of  tetany  the  question  of 
the  transplantation  of  parathyroids  from  animals  becomes  extremely  important. 
Halsted  has  made  some  very  valuable  experiments  upon  the  auto-  and  iso- 
transplantation  of  the  parathyroid  glands  in  dogs  ("Annals  of  Surgery," 
Oct.,  1907;  "Jour,  of  Experimental  Med.,"  vol.  xi.  No.  i,  1909).  He  has 
shown  that  if  the  parathyroid  be  transplanted  into  an  animal  with  normal 
parathyroids  failure  will  follow,  and  the  transplanted  glandule  will  disappear. 
If,  however,  there  be  parath}Toid  deficiency  in  the  animal  into  which  the  trans- 
plantation is  made,  the  glandule  will  attach  itself  and  grow.  He  obtained  the 
best  results  by  placing  the  parath}Toid  beneath  the  posterior  sheath  of  the 
rectus  muscle  of  the  abdomen.  Some  observers  have  placed  it  in  the  spleen; 
others,  within  the  peritoneum  and  in  various  other  regions. 

One  of  the  dogs  experimented  upon  by  Halsted  and  reported  upon  in  "Jour, 
of  Exper.  Med.,"  vol.  xi.  No.  i,  1909,  lived  in  perfect  health'"for  fifteen  months 


1388  Diseases  and  Injuries  of  the  Thyroid   Ghmd 

and  was  in  good  health  until  the  performance  of  the  final  operation,  at  which 
a  parathyroid  autograft"  was  removed.  The  dog  died  in  three  months  from 
hypoparathyroidism  (Ibid.,  No.  3,  1912). 

If  tetany  follows  thyroidectomy,  it  may  be  treated  by  the  intravenous, 
rectal,  or  stomach  administration  of  "a  5  per  cent,  solution  of  lactate  of  calcium 
(MacCallum  and  Voegtlin,  Loc.  cit.).  Von  Iselsberg  gives  parathyroid  tablets 
and,  if  these  fail,  practices  parathyroid  transplantation.  Beebe  and  Berkeley 
have  prepared  a  parathyroid  serum  which  they  claim  to  be  efficient.  Charles  H. 
Mayo  maintains  that  in  tetany  either  the  serum  or  the  calcium  lactate  should  be 
used,  in  the  hope  of  tiding  the  patient  over  until  parathyroid  glands  can  be  se- 
cured and  implanted  ("Annals  of  Surgery,"  July,  1909).  Human  parathy- 
roids are  preferable.  They  should  be  obtained  from  infants  which  died  during 
delivery  or  from  adults  killed  by  accident.  The  calcium  salt  may  be  given 
intravenously,  subcutaneously,  by  the  stomach,  or  by  the  rectum.  Joseph  H. 
Branham  ("Annals  of  Surg.,"  August,  1908)  has  reported  tetany  following 
thyroidectomy  cured  by  the  subcutaneous  injection  of  parathyroid  emulsion. 
The  emulsion  was  made  by  grinding  up  fresh  glands  of  beeves  in  a  mortar, 
and  then  pouring  400  c.c.  of  sterile  salt  solution  into  the  mortar.  The  prepa- 
ration was  filtered  through  sterile  gauze  and  was  administered  beneath  the 
patient's  breast. 

J.  Clarke  in  1815  and  S.  L.  Steinheim  in  1830  described  tetany.  The  name 
was  coined  by  Corvisart.  The  condition  has  been  described  in  association  with 
many  very  different  conditions  (pregnancy,  gastric  dilatation,  childhood).  It 
is  assumed  that  in  all  forms  of  tetany  there  is  impaired  secretion  of  the  parathy- 
roids because  of  damage  by  toxins  or  traumatism.  The  form  we  are  considering 
here  is  due  to  removal  of  or  injury  to  the  parathyroids  (Erdheims  designates  it 
tetany  parathyreopriva).     Cases  of  tetany  in  the  newborn  have  been  reported. 

When  tetany  begins  to  develop  in  a  patient  there  are  usually  headache, 
dizziness,  and  pain  in  the  extremities.  The  muscles  in  one  or  both  forearms 
and  hands  are  liable  to  be  affected.  The  hand  flexes  at  the  wrist,  while  the 
fingers  are  extended,  and  in  some  cases  the  forearm  flexes  at  the  elbow.  Now 
and  then  the  fingers  wall  flex  at  the  metacarpophalangeal  joints,  but  the  distal 
phalanges  will  remain  extended.  These  spasms  are  painful.  Similar  spasms 
may  occur  in  the  feet  and  toes.  In  most  severe  cases  the  trunk  muscles  and 
those  of  the  chest,  throat,  and  eye  may  be  involved. 

Trousseau,  years  ago,  showed  that  a  spasm  may  be  brought  on  in  the 
afifected  limb  by  pressing  upon  the  nerve-trunks  and  blood-vessels;  this  is 
called  the  Trousseau  sign.  Pressure  upon  the  facial  nerve  may  induce  the 
spasms,  and  it  is  called  Chvostek's  sign.  Erb's  sign  is  a  great  increase  in  the 
galvanic  irritability  of  the  motor  nerves.  Hoffmann's  sign  is  excessive  sensi- 
tiveness of  the  sensory  nerves.  Schultze's  tongne  sign  ("Miinch.  Med.  Woch.," 
Oct.  31,  191 1 )  is  said  to  be  invariably  present  in  adults  with  tetany.  If  the 
side  of  the  tongue  be  tapped  the  organ  responds  by  grooving  itself  on  that  side. 
If  the  tongue  be  lifted  by  a  spatula  and  the  dorsum  be  tapped  a  constriction  like 
a  waist  forms. 

Tetany  due  to  absence  of  the  parathyroids  will  inevitably  prove  fatal  if  not 
treated  actively. 

Before  we  understood  the  necessity  of  guarding  the  parathyroids  tetany  after 
goiter  operations  was  not  uncommon.  The  preservation  of  the  posterior  portion 
of  the  capsule  has  almost  abolished  this  peril.  In  3203  operations  on  the  thy- 
roid performed  at  the  Mayo  Clinic  in  St.  Mary's  Hospital,  Rochester  (up  to 
Dec.  I,  191 1)  there  was  but  i  case  of  tetany  and  the  symptoms  in  that  were 
slight  and  transitory. 


The  Thymus  Gland  1389 


XXXni.  THE  CAROTID  GLAND;  THE  THYMUS  GLAND 

The  Carotid  Body  or  Gland. — This  structure  was  discovered  by  Haller 
in  1743.  It  has  no  known  function.  It  is  about  the  size  of  a  grain  of  rice  and 
Hes  in  or  very  near  the  carotid  bifurcation,  being  adherent  usually  to  the  com- 
mon carotid,  occasionally  to  the  external  or  internal  carotid  by  the  ligament  of 
Mayer.  Tumors  may  form  in  this  little  body.  The  type  found  is  the  peri- 
thelioma. They  are  most  common  in  those  between  twenty  and  thirty  years  of 
age.  Such  a  tumor  grows  slowly,  is  hard,  is  movable  from  side  to  side,  but  not 
up  and  down,  and  is  lifted  with  each  beat  of  the  carotid  artery.  In  the  long  run 
it  tends  to  become  malignant.  As  the  tumor  grows  it  eventually  surrounds 
the  common  carotid  artery.  Dr.  Wagner  of  Wilkesbarre,  Pa.,  referred  to  me 
a  patient  with  rapidly  growing  .bilateral  tumors  of  the  carotid  bodies.  No 
operation  was  performed.  The  tumors  were  removed  postmortem  and  proved 
to  be  sarcomatous. 

Treatment. — Calhson  and  MacKenty  ("Annals  of  Surgery,"  191 3,  Iviii)  col- 
lected 54  operations.  Of  these  32  recovered  and  22  died.  Of  the  cases  which 
survived  3  had  hemiplegia  with  aphasia,  4  dysphagia,  i  constant  cough,  5  de- 
viation of  the  tongue,  4  eye  symptoms  and  4  facial  palsy.  Winslow  has  collected 
10  more  cases  ("Annals  of  Surgery,"  i9i6,lxiv).  Operation  on  an  advanced  case 
is  very  difficult,  will  probably  require  ligation  of  the  common  carotid,  and  will 
cause  grave  injury  to  important  nerves.  In  one  of  the  author's  patients  the  com- 
mon carotid  was  tied  and  the  patient  developed  laryngeal  palsy  and  hemiplegia. 
Early  operation  may  permit  of  removal  of  the  tumor  without  tying  the  common 
carotid  artery.  In  a  second  case  the  author  was  able  to  accomplish  this.  My 
first  case  led  me  to  agree  with  Reclus  that  these  tumors  should  be  let  alone 
unless  they  are  productive  of  dangerous  symptoms.  I  have  come  to  the  con- 
clusion that  the  time  to  operate  is  early,  long  before  there  are  dangerous  symp- 
toms. To  wait  for  obvious  malignancy  is  to  court  failure  or  disaster  (see 
the  author  in  "N.  Y.  Med.  Jour.,"  Feb.  7,  1914,  also  Callison  and  MacKenty, 
in  "Annals  of  Surgery,"  Dec,  1913). 

The  Thymus  Gland. — This  bilobed  ductless  gland  becomes  fully  developed 
toward  the  end  of  the  second  year  of  life.  From  that  period  it  remains  station- 
ary for  a  time  and  then  undergoes  retrogression.  At  puberty  retrogression 
becomes  rapid.  Finally,  the  gland  almost  entirely  disappears,  although  a  small 
vestige  of  it  usually  remains  through  life.  Studied  in  the  very  young  child,  it  is 
found  to  consist  of  a  thoracic  portion  and  a  cervical  portion.  The  chief  part  of 
the  gland  lies  directly  back  of  the  sternum  and  upper  four  costal  cartilages  of 
each  side  in  the  superior  and  anterior  mediastinal  spaces.  On  each  side  are  the 
pleura  and  lung.  Posteriorly  it  lies  upon  the  pericardium,  superior  vena  cava, 
innominate  vein,  and  pulmonary  artery.  The  two  lobes  from  the  gland  rise 
into  the  neck  in  front  of  the  trachea.  The  left  lobe  overlaps  the  common  caro- 
tid; the  right  lobe,  the  innominate  artery.  A  strand  of  fibrous  tissue  usually 
passes  from  the  lobe  which  ascends  highest  to  the  corresponding  lobe  of  the 
thyroid  gland.  The  lobes  of  the  thymus  receive  numerous  veins  from  the 
thyroids.  The  inferior  thyroid  artery  is  the  chief  source  of  arterial  blood.  The 
thymus  is  composed  of  may  lobules  separated  by  septa.  The  undegenerated 
thymus  contains  both  lymphoid  and  epithelial  structures. 

The  cells  of  the  reticulum  are  epithelial.  In  the  medulla  of  the  lobules  are 
the  concentric  corpuscles  of  Hassall  which  are  derived  from  the  epithelium 
of  the  reticulum.  The  small  thymic  cells  are  probably  lymphocytes.  In 
Hammar's  words:  "The  thymus  is  an  epithelial  organ  which  is  permeated  with 
lymphocytes"  (quoted  by  Charles  H.  Mayo  and  Bernard  F.  McGrath  in  their 
thorough  and  impressive  study  of  "The  Surgical  Importance  of  the  Thymus." 
See  "  Collected  Papers  by  the  Stafif  of  St.  Mary's  Hospital,"  Mayo  Clinic,  191 2). 


1390  The  Carotid   Gland;  the  Thymus  Gland 

The  function  of  the  thymus  is  as  yet  undetermined.  Some  believe  it  is 
merely  a  lymphatic  structure  and  furnishes  no  internal  secretion.  Others 
believe  that  it  furnishes  an  internal  secretion  of  great,  perhaps  of  essential, 
importance  in  development.  Some  observers  believe  that  the  thymus  de- 
stroys toxins,  and  that  deficiency  of  thymus  permits  the  accumulation  of  toxic 
matter  in  the  system.  These  studies  of  hypothymization  were  made  on  thy- 
mectomized  animals. 

Experiments  to  determine  the  result  of  excessive  thymus  function  (hyj^er- 
thymization)  are  peculiarly  contradictory,  unsatisfactory,  and  inconclusive. 
In  these  experiments  thymus  glands  have  been  implanted,  thymus  juice  has 
been  injected,  and  thymus  feeding  has  been  practised. 

Mayo  and  McGrath  (Ibid.)  conclude  "  that  the  thymic  function  is  concerned 
in  the  general  process  of  nutrition,  particularly  vi^ith  the  ossification  of  bone;" 
further,  it  is  probable  "that  the  thymus  and  the  chromaffin  portion  of  the 
adrenals  act  antagonistically  on  the  sympathetic." 

Although  the  thymus  should  have  practically  disappeared  between  the 
twelfth  and  twentielJi  year,  there  are  cases  in  which  it  fails  to  disappear  at  all. 
There  may  never  have  been  any  symptoms  to  suggest  persistence  and  the  gland 
may  be  discovered  at  a  necropsy.  It  is  known  that  the  thymus  persists  in  cas- 
trated animals  (Renton,  in  "Glasgow  Med.  Jour.,"  19 16,  Ixxxvi). 

The  thymus  gland  may  enlarge.  The  enlargement  is  most  usual  in  child- 
hood, but  if  the  thymus  be  persistent,  may  occur  much  later  in  life.  The  condi- 
tion is  hypertrophy  or  hyperplasia.  Enlargement  of  the  gland  may  be  met  with 
in  exophthalmic  goiter,  leukemia,  Hodgkin's  disease,  and  status  lymphaticus. 
It  may  produce  no  symptoms  whatever.  It  may  be  responsible  for  asthma  and 
for  sudden  death  {thymic  asthma  and  thymic  death).  Enlargement  may  some- 
times be  recognized  by  the  .v-rays — by  no  means  always. 

Infectious  and  wasting  diseases  in  children  may  cause  atrophy  of  the  thy- 
mus. The  gland  may  be  the  seat  of  hemorrhages,  inflammation,  tuberculosis, 
calcuH  formation,  and  necrosis  (in  diphtheria).  In  congenital  syphilis  the 
thymus  may  be  the  seat  of  gummatous  change  or  fibrosis. 

Dubois's  abscesses  occur  in  syphilis  of  the  thymus.  Many  spaces  form  and 
the  spaces  are  full  of  a  fluid  resembling  or  actually  pus. 

Enlargement  by  cysts  or  tumors  may  occur.  Innocent  tumors  (fibroma, 
myxoma,  and  adenoma)  are  rare.  MaUgnant  tumors  (carcinoma  and  sarcoma) 
are  more  common.  The  most  common  tumor  is  lymphosarcoma  (///y wo w<z). 
Spindle-cell  sarcoma  and  endothelioma  may  arise  (see  James  E wing  on  "  The 
Thymus  and  its  Tumors"  in  "Surgery,  Gynecology,  and  Obstetrics,"  April,  1916). 

Tumors  of  the  thymus  cause  the  symptoms  of  mediastinal  tumor  (cyanosis, 
dyspnea,  exophthalmus,  cough,  alterations  in  voice,  circulatory  disturbance). 
Metastases  are  often  early.  Such  a  tumor  may  be  rapidly  fatal  by  asphyxia. 
With  not  a  few  cases  of  thymus  tumor  myasthenia  gravis  has  been  associated. 
No  symptoms  are  reported  to  suggest  sympathetic  disturbance  of  the  chromaf- 
fine  system  (Ewing,  Ibid.). 

Status  Lymphaticus  (Status  Thy  miens;  Lymphatism). — This  condition  is 
associated  with  enlargement  of  the  thymus.     (See  page  249.) 

Operations  for  Thymus  Enlargement  or  Tumor. — (See  Ohver,  in  "Archiy. 
gen.  d.  Chir.,"  vi,  138,  191 2.)  Operators  have  removed  the  thymus  in 
goiter  operations  and  also  when  the  thymus  alone  has  been  enlarged. 

To  perform  exothymopexy  expose  the  thymus  by  an  incision  above  the 
sternum,  catch  the  gland  and  capsule  with  forceps,  draw  them  up  as  far  as 
possible,  and  suture  to  the  fascia.  This  operation  is  without  much  value.  A 
decompression  operation  can  be  done  by  resecting  the  manubrium.  It  does  not 
cure,  but  may  give  relief. 

Thymectomy  has  been  performed  a  number  of  times.  It  may  be  extracapsular 
or  intracapsular,  partial  or  complete.     In  42  reported  cases  there  were  15  deaths. 


Treatment  of  Wounds  1391 


XXXIV.  DISEASES  AND  INJURIES  OF  THE  LYMPHATICS 

Wounds,   Ruptures,  and   Occlusions  of  the  Left  Thoracic  Duct. 

— It  was  long  believed  that  wounds  of  any  part  of  the  thoracic  duct  were 
almost  certainly  fatal.  It  is  now  known  that  wounds  of  the  duct  at  the  root 
of  the  neck  are  rarely  very  dangerous  unless  the  duct  be  divided  close  to  the 
vein.  A  wound  of  the  duct,  as  the  result  of  an  accident,  is  rarely  seen  because 
the  adjacent  vital  structures  are  apt  to  be  injured  at  the  same  time  and  death 
rapidly  ensues.  Wounds  of  the  duct  or  of  its  large  branches,  occasionally 
but  very  rarely,  are  inflicted  during  surgical  operations.  Benetau  speaks 
of  12  cases  thus  inflicted;  in  8  cases  the  operation  was  for  tuberculous  glands, 
in  3  for  malignant  glands,  and  in  i  for  ligation  of  the  subclavian  artery.  One 
alleged  danger  of  wound  of  the  duct  is  entrance  of  air  into  the  adjacent  vein. 
This  is  said  to  have  happened  in  i  case.  As  a  rule,  the  short  end  of  the  cut  duct 
does  not  bleed,  the  duct  valves  preventing  hemorrhage.  In  Fullerton's  case, 
when  a  grooved  director  was  passed  along  the  stump  of  the  duct  by  way  of  a 
terminal  into  the  vein,  blood  at  once  appeared.  In  most  cases  the  injury 
is  not  recognized  at  the  time,  but  later,  when  white  fluid  escapes  from  the  wound. 
The  discharge  may  continue  or  may  cease  spontaneously.  If  it  continues,  there 
is  rapid  loss  of  flesh  and  strength.  I  assisted  Dr.  Keen  in  the  case  in  which  he 
did  recognize  the  wound  at  the  time  it  was  inflicted.  A  thin  fluid  was  observed 
flowdng  rhythmically  from  a  tear  in  the  duct.  It  is  to  be  remembered  that  the 
course  of  the  cervical  part  of  the  duct  is  very  variable  and  sometimes  the  duct 
lies  very  high  above  the  clavicle.  There  was  i  death  in  17  recorded  cases  (Dud- 
ley P.  .\llen  and  C.  E.  Briggs,  in  "  Amer.  Med.,"  Sept.  21,  1901). 

The  discharge  from  a  cut  duct  may  continue  to  leak — perhaps  a  pint  or 
more  flo\\ing  out  during  twenty-four  hours.  If  leakage  continues,  constitu- 
tional effects  wiU  sooner  or  later  become  evident.  In  Schoff's  case  ("Wien. 
klin.  Woch.,"  Nov.  28,  1901)  it  was  not  known  that  the  duct  had  been  injured 
until  the  stitches  were  removed  from  the  wound  in  the  neck.  The  wound  was 
found  distended  with  chyle  and  Schoff  packed  it  with  iodoform  gauze.  Fifteen 
days  later  the  patient  died  from  chylo thorax  and  pulmonary  compression. 

Rupture  of  the  thoracic  duct  or  of  the  receptaculum  chyli  may  occur  from 
traumatism  or  be  a  secondary  consequence  of  tuberculosis  or  carcinoma. 
Rupture  leads  to  death  by  starvation,  or  to  fatal  compression  by  the  exuded 
fluid  (Harvey  W.  Gushing,  in  "Annals  of  Surgery,"  June,  1898).  Occlusion  of 
the  main  duct  may  be  followed  by  rupture  of  the  receptaculum  chyli.  Gradual 
occlusion  by  a  tuberculous  or  inflammatory-  growth  may  not  produce  any 
serious  symptoms.  Gushing  assumes  that  in  such  a  case  the  lymph-current 
is  reversed  and  is  taken  up  by  the  right  thoracic  duct.  In  gradual  obstruc- 
tion masses  of  dilated  lymph-vessels  may  be  found,  particularly  in  the  thorax 
and  abdomen.  If  lymph-vessels  rupture,  chyle  flows  out  and,  according  to  the 
situation,  there  arises  ''  chvlous  ascites,  chvlothorax,  chyluria,  or  chvlous  diar- 
rhea" (Ibid.). 

Treatment  of  Woimds. — If  the  wound  in  the  neck  does  not  completely 
divide  the  duct,  and  if  the  duct  wound  is  discovered  at  the  time  of  operation, 
suture  the  duct.  Allen  sutured  the  duct  and  had  no  further  leakage.  Keen 
sutured  the  duct  and  recovery  followed.  If  the  duct  be  completely  divided,  fol- 
low Gushing's  advice:  "It  w-ould  seem  advisable  to  place  a  provisional  Ugature 
about  the  duct  on  the  proximal  side  of  the  wound,  and  to  control  the  leakage, 
if  possible,  by  a  gauze  tampon.  This  would  act  as  a  safety-valve,  and  allow 
chyle  to  escape,  if  the  pressure  in  the  duct  became  too  great  and  there  was 
difficulty  in  estabHshing  a  collateral  lymphatic  circulation.  The  patient 
meanw-hile  should  be  given  a  meager  diet.  If  the  leakage  should  become 
uncontrollable  and  threaten  starvation,  the  provisional  h'gature  should  be  tied, 


1392  Diseases  and  Injuries  of  the  Lymphatics 

with  the  hope  of  a  final  readjustment  of  collateral  circulation  or  trusting  in  the 
presence  of  some  anomalous  anastomotic  branch  which  might  suffice  to  carry 
the  lymph  into  the  venous  circulation"  (Ibid.).  Fullerton  tied  both  ends  of 
a  divided  duct  and  the  patient  recovered  ("Brit.  Med.  Jour.,"  June  i6,  1906). 
Deanesley  ("Lancet,"  Dec.  26,  1903)  inserted  the  divided  duct  into  the  in- 
ternal jugular  vein  and  sutured  it  in  place.  There  was  some  leakage,  but 
recovery  ensued.  After  ligation,  the  duct  on  the  proximal  side  of  the  ligature 
may  distend  greatly  and  may  actually  rupture.  When  a  wounded  duct  is 
leaking  the  patient  should  be  fed  exclusively  on  proteins.  The  diet  should 
be  scanty  and  the  patient  must  be  kept  absolutely  quiet  in  order  to  keep 
pressure  in  the  duct  at  as  low  a  level  as  possible  during  the  establishment  of 
a  collateral  lymphatic  circulation  (Fullerton,  Loc.  cit.J.  Nasaroff  (Abstract, 
in  "Surgery,  Gynecology,  and  Obstetrics,"  Jan.,  1914)  reported  a  case  of  injury 
to  the  duct  during  a  surgical  operation,  and  collected  62  others  from  literature. 
Most  cases  heal  after  prolonged  chylorrhea.  Tamponade  and  ligation  must 
be  considered  in  the  treatment. 

Lymphangitis  is  inflammation  of  lymphatic  vessels.  Reticular  or  capil- 
lary Ivmphangitis  (erysipeloid),  which  is  inflammation  of  lymphatic  radicles, 
is  seen  in  some  circumscribed  inflammations  of  the  skin.  It  is  apt  to  attack 
the  hands,  causing  redness  and  swelling,  fading  at  the  point  of  initial  trouble 
while  it  spreads  at  the  periphery;  it  is  caused  by  micro-organisms  derived 
from  decomposing  animal  matter  (see  page  219).  Erysipelas  also  causes  it 
(see  page  219).  Tubular  lymphangitis,  which  is  due  to  the  entry  into  the 
Ivmphatic  ducts  of  virulent  micro-organisms  or  toxic  materials,  is  seen  after 
the  infliction  of  dissecting  wounds,  septic  wounds,  snake-bites,  etc.  It  is 
announced  by  edema  and  by  minute,  hard,  red  streaks  running  from  the  wound 
up  the  extremity.      Suppuration  may  occur. 

Septic  or  infective  lymphadenitis,  or  inflammation  of  the  glands, 
may  follow  lymphangitis  or  may  be  due  to  the  deposition  of  infective  material, 
the  lymph-vessels  not  being  inflamed.  In  this  form  of  lymphadenitis  there 
are  pain,  tenderness,  and  swelling;  in  severe  cases  there  are  a  chill  and  a  septic 
fever.     Suppuration  may  arise. 

The  treatment  is  to  drain  and  asepticize  the  wound,  to  apply  iodin,  blue 
ointment,  or  ichthyol  over  the  glands  and  vessels,  and  to  employ  rest,  heat 
and  compression.  Internally,  milk-punch,  quinin,  and  nourishing  diet  are 
required.  If  the  glands  do  not  rapidly  diminish  in  size  after  disinfection  of  a 
wound,  and  if  they  are  in  an  accessible  region,  extirpate  them.  If  suppuration 
of  the  glands  occurs,  incise  and  drain. 

Acute  Ijrmphadenitis,  or  acute  inflammation  of  the  lymphatic  glands, 
may  be  due  to  tubercle,  syphilis,  glanders,  cold,  or  traumatism.  Suppura- 
tion may  or  may  not  occur.  In  inflammatory  lymphadenitis  there  are  pain, 
heat,  and  nodular  swelUng.     In  severe  cases  there  is  fever. 

The  treatment  is  to  asepticize  any  area  of  infection,  place  the  glands  at  rest, 
apply  heat  and  ichthyol  ointment,  or  inject  into  the  gland  every  day  5  minims 
of  a  3  per  cent,  solution  of  carbolic  acid  to  prevent  suppuration.  If  the  glands 
do  not  rapidly  shrink,  extirpate  them.  If  pus  forms,  evacuate  it,  drain,  and 
asepticize. 

Chronic  Ijmiphadenitis  is  almost  invariably  syphilitic  or  tuberculous.  It 
requires  constitutional  treatment  and  the  local  use  of  ichthyol,  iodin,  or  blue 
ointment.  If  these  remedies  are  not  rapidly  successful,  tuberculous  glands 
should  be  removed,  but  syphilitic  glands  rarely  require  such  radical  treatment. 

Lymphangiectasis  {varicose  lymphatics),  or  dilatation  of  the  lymphatic 
vessels,  is  due  to  obstruction.  It  may  be  congenital  (macroglossia;  lymphatic 
nevus,  see  page  420).  It  may  be  acquired.  Many  external  causes  may 
produce  obstruction;  for  instance,  the  removal  or  suppurative  annihilation  of 
a  considerable  group  of  lymphatics;  pressure  of  a  scar  or  of  a  new  growth  upon 


Lymphadenoma  1393 

Ivmph-vessels;  tuberculosis  or  neoplasm  of  a  group  of  glands.  In  many  cases  of 
external  pressure  upon  lymphatics  there  is  no  lymphangiectasis  because  the 
lymph  finds  other  channels.  In  fact,  it  has  been  proved  that  ligation  of  a  large 
lymphatic  trunk  is  not  of  necessity  followed  by  lymphangiectasis.  Even  when 
the  condition  arises  from  external  pressure,  it  is  usually  temporary,  although, 
particularlv  if  glandular  tumors  exist,  it  may  be  permanent. 

The  persistent  cases  are  usually  due  to  obstruction  within  the  ducts,  for 
instance,  endothelial  proliferation  as  a  result  of  chronic  lymphangitis,  or  re- 
current attacks  of  acute  capillary  lymphangitis  (erysipelas)  or  ordinary  acute 
Ivmphangitis;  or  tuberculosis  and  other  chronic  infections.  There  may  be 
such  a  condition  as  primary  intralymphatic  endothehal  proliferation  ("Med. 
Record,"  Sept.  6,  1902).  Blocking  with  filarial  worms  may  occur,  and  if  it 
does,  the  Ivmphangiectasis  is  usually  situated  in  the  pubic,  the  inguinal,  or  the 
scrotal  region,  or  on  the  inner  side  of  the  thigh.  There  are  two  forms  of  lymphan- 
gietasis:  the  varicose,  in  which  the  vessels  have  a  tortuous  outline,  like  vari- 
cose veins,  but  are  covered  only  with  surface  epithelium;  and  lymphatic  warts 
{lymphangioma  circumscriptum),  in  which  wart-like  masses  spring  up,  these 
masses  being  covered  with  epithelium  and  filled  with  lymph.  In  most  cases  of 
lymphangiectasis  there  is  considerable  hard  edema  {lymphedema).  Lymphan- 
giectasis sometimes  develops  in  an  upper  extremity  after  removing  the  axillary 
glands,  and  in  the  lower  extremity  after  removing  the  inguinal  glands.  Peri- 
odic attacks  of  pain  and  redness  occur  in  the  area  of  lymphangiectasis,  and  usu- 
ally at  such  times  fever  develops.  Rupture  of  the  dilated  vessels  causes  a  flow 
of  lymph  {lymphorrhea).  Infection  and  erysipelas  are  apt  to  occur;  perhaps 
again  and  again.  It  is  uncertain  whether  these  repeated  attacks  of  erysipelas 
cause  and  maintain  or  are  predisposed  to  by  lymphangiectasis. 

Treatment. — If  the  entire  area  can  be  removed,  it  should  be  extirpated. 
Maitland  ("Brit.  Med.  Jour.,"  Jan.  25,  1902)  shows  that  many  varices  are 
local  and  can  be  removed.  If  the  varices  are  only  partially  removed,  lymphor- 
rhea will  probably  develop. 

Lymphangioma  is  an  advanced  stage  of  lymphangiectasis  (see  page  420). 

The  treatment  in  mild  cases  is  to  pierce  each  vesicle  with  the  negative 
pole  of  a  galvanic  battery  and  to  pass  a  current.  In  severe  cases  destroy  the 
mass  with  the  Paquelin  cautery  or  excise  it  with  a  knife  or  with  scissors. 

Elephantiasis. — True  elephantiasis  (elephantiasis  Arabum)  is  chronic 
hypertrophy  of  the  skin  and  subcutaneous  tissues  following  a  lymphangi- 
ectasis produced  by  a  nematode  worm  (the  Filaria  sanguinis  hominis).  The 
disease  is  encountered  in  the  tropics  only.  Elephantiasis  of  the  scrotum  is 
called  lymph-scrotum.     Elephantiasis  of  the  leg  is  called  Barbadoes  leg. 

Spncrious  or  />^e^^o-elephantiasis  (Fig.  897)  is  hypertrophy  of  the  skin  and 
subcutaneous  tissue  due  to  chronic  inflammation  (for  instance,  in  a  leg  which 
possesses  an  ancient  ulcer,  or  in  the  scrotum  of  a  man  with  urinary  fistula). 

The  treatment  of  true  elephantiasis  is  massage  and  bandaging,  sometimes 
excision  of  the  deep  fascia  (Konboleon),  ligation  of  the  artery  of  supply,  extir- 
pation, or  amputation. 

Tuberculous  Glands. — (See  page  276.) 

Lymphadenoma  {Malignant  Lymphoma;  Eodgkin's  Disease;  Pseudo- 
leukemia).— Malpighi  in  1665  gave  an  outline  of  the  condition  which  Thomas 
Hodgkin  described  in  1832.  In  1865  Sir  Samuel  Wilks  gave  it  the  name  of 
Hodgkin's  disease.  The  term  "lymphoma"  is  used  loosely  to  designate  any 
persistent  swelling  of  a  lymphatic  gland  or  glands.  Lymphadenoma  means  a 
swelling  of  lymph-glands  or  lymphadenoid  tissue  due  to  endothelial  proliferation, 
is  progressive  in  character,  involves  group  after  group  of  glands,  is  associated 
with  anemia,  and  often  accompanied  by  secondary  growths  in  the  abdomi- 
nal viscera. 

This  disease    can  attack  persons  of  any  age  but  is  most  common  in  those 


1394 


Diseases  and  Injuries  of  the  Lymphatics 


under  forty,  and  affects  males  far  more  frequently  than  females.  Hereditary 
influence  is  not  apparent.  It  may  start  in  a  seemingly  robust  person.  In  many 
cases  the  disease  arises  slowly  in  apparently  healthy  glands,  and  exists  for  some  • 
time  before  it  takes  on  signs  of  malignancy  and  invades  distant  glands.  In  some 
cases  the  disease  comes  on  acutely  and  has  a  tendency  to  generalization  from 
the  start;  in  others  it  appears  to  remain  localized  for  many  months.  Some 
regard  the  condition  as  neoplastic,  others  as  inflammatory.  A  gland  enlarged 
from  irritation  or  from  tuberculous  disease  may  become  lymphadenomatous, 
and  tubercle  bacilli  can  sometimes  be  found  in  lymphadenomatous  glands.  Laz- 
arus asserts  that  the  disease  is  lymphosarcoma  and  the  tuberculosis  accidental. 
Musser,  Sternberg,  and  others  believe  that  tuberculosis  is  the  disease.  Some 
few  beheve  that  lymphadenoma  is  really  tuberculosis,  but  this  view  seems  to 
have  been  definitely  disproved.     Late  in  a  case  miliary  tuberculosis  is  apt  to 

arise.  A  diphtheroidal  bacillus  is 
regarded  by  some  as  causal  (Yates 
and  Bunting,  "Jour.  Am.  Med. 
Assoc,"  June  12,  191 5,  also  Cun- 
ningham, in  "Am.  Jour.  Med, 
Sciences,"  March,  1917).  Those 
who  believe  that  the  condition  is 
a  granuloma  due  to  infection  be- 
lieve the  point  of  entry  of  the 
bacilli  may  be  the  tonsil,  the 
sinuses,  the  teeth,  the  middle  ear, 
the  intestine  or  the  skin. 

That  the  disease  is  at  least 
similar  to  sarcoma  is  held  by 
many.  That  it  is  a  variety  of 
sarcoma  is  asserted  by  some.  In 
Hodgkin's  disease  Coley's  fluid 
(the  mixed  toxins  of  erysipelas  and 
Bacillus  prodigiosus)  causes  re- 
action as  in  sarcoma.  There  is  a 
form  of  tuberculosis  strongly  re- 
sembling Hodgkin's  disease,  but  I 
do  not  believe  that  the  two  pro- 
cesses are  identical.  The  gland- 
ular and  splenic  enlargements  are 
neoplastic  and  not  hyperplastic. 
The  new  tissue  formed  is  called 
lymphadenoid  tissue  and,  accord- 
ing to  Banti,  it  is  often  atypical,  tends  to  invade  glandular  trabeculae  and  cap- 
sules, sometimes  adjacent  tissue,  and  gives  origin  to  metastases. 

Leukemia  and  pseudoleukemia  are  closely  related,  and  both,  according  to 
Banti,  are  sarcoma.  In  leukemia  the  influence  that  stimulates  proliferation 
acts  chiefly  upon  the  bone-marrow;  in  Hodgkin's  disease,  upon  the  lymph- 
nodes  (Neumann,  quoted  by  Coley,  in  a  forceful  article  maintaining  that  Hodg- 
kin's disease  is  a  type  of  sarcoma,  "Trans.  Am.  Surg.  Assoc,"  1908). 

Sjrmptoms. — The  glands  in  the  neck  are  usually  involved  first,  especially 
the  glands  of  the  posterior  triangle,  but  the  disease  may  begin  in  the  axillary 
glands,  the  thoracic  glands,  or  the  intra-abdominal  glands. 

Two  or  more  regions  are  sometimes  involved  simultaneously  or  almost 
simultaneously. 

When  the  disease  begins  in  the  neck  it  affects  at  first  one  side,  and  after 
many  weeks  or  months  the  other  side  becomes  involved.  The  glands  are  at 
first  hard,  separated  from  each  other,  movable,  the  skin  moves  freely  over 


Fig. 


897. — Spurious    elephantiasis.      No    filarias 
found.     Born  and  lived  in  Philadelphia. 


Diagnosis  of  Lymphadenoma  1395 

them  and  they  may  remain  in  this  condition.  Later  the  large  glands  may 
weld  together  and  form  great  masses  upon  both  sides  of  the  neck  and  in  the 
axillae,  obstructing  respiration.  In  contradiction  of  the  general  view  it  is  certain 
that,  in  acute  cases  or  during  acute  exacerbations,  periglandular  structures  are 
invaded.     Great  subcutaneous  induration  may  occur. 

After  a  time  a  very  large  mass  may  break  through  its  capsule  and  infiltrate 
adjacent  structures,  and  in  very  rare  cases  the  skin  becomes  adherent  and 
finally  breaks.  Intrathoracic  symptoms  point  to  involvement  of  the  thoracic 
glands.     It  may  be  possible  to  palpate  enlarged  abdominal  glands. 

It  is  usually  held  that  there  is  no  distinctive  blood  picture.  Yates  and 
Bunting  (Ibid.)  insist  that  there  is  and  set  it  forth  as  follows: 

"There  are  two  distinct  types,  an  early  and  a  late,  showing  a  constant 
characteristic  increase  in  the  number  of  platelets  (unless  exhaustion  of  the  bone 
marrow  occurs)  with  abnormally  large  forms  and  either  a  relative  or  absolute 
increase  in  the  so-called  transitional  cells.  In  the  early  type  the  leukocytes 
are  usually  less  than  ten  thousand.  Very  early  there  is  a  moderate  increase  in 
the  basophils,  and  when  the  disease  is  well  established  the  eosinophils  are 
slightly  increased.  The  polymorphonuclear  neutrophils  remain  within  the 
usual  limits,  the  lymphocytes  at  or  slightly  above  the  normal.  The  late  type 
shows  a  leukocytosis  which  may  reach  one  hundred  thousand,  the  neutrophils 
are  relatively  increased  to  a  percentage  of  from  75  to  92  and  the  lymphocytes 
are  reduced  to  5  per  cent.,  frequently  even  less.  The  transitionals,  the  only 
other  cells  found  in  any  numbers,  are  usually  above  8  per  cent,  unless  the  leuko- 
cytosis is  very  high,  when  they  may  be  relatively  fewer,  but  still  exceed  the 
lymphocytes  in  number.  This  late  picture  is  a  result  of  the  intensity  of  the 
disease  rather  than  the  extent  of  involvement  and  is  usually  largely  dependent 
on  duration  for  its  development." 

The  spleen  is  enlarged;  the  thyroid  may  be  enlarged.  When  anemia 
becomes  marked  there  are  the  ordinary  symptoms  which  go  with  it,  viz.,  pal- 
pitation, breathlessness,  indigestion,  vertigo,  headache,  pallor,  and  sometimes 
epistaxis.  Without  obvious  reason,  the  glands  may  suddenly  increase  in  size 
or  rapidly  undergo  a  notable  but  temporary  diminution.  In  fact,  a  character- 
istic feature  of  the  disease  is  fluctuation  in  the  size,  consistency  and  movabihty 
of  the  glands  (Yates  and  Bunting,  in  "Jour.  Am.  Med.  Assoc,"  June  12,  1915). 
I  have  never  seen  secondary  pyogenic  infection. 

Distinct  attacks  of  fever  arise  at  times  in  many  cases,  and  ague-hke  par- 
oxysms may  occur.  During  the  existence  of  fever  the  glands  usually  increase 
rapidly  in  size. 

Diagnosis. — In  a  widespread  case  the  diagnosis  is  easy;  in  a  localized  case 
it  is  difficult.  True  tuberculous  glands  are  most  apt  to  appear  first  in  the 
submaxillary  triangle;  lymphadenomatous  glands,  in  the  root  of  the  neck  or 
in  the  occipital  triangle.  Tuberculous  adenitis  is  most  common  in  children. 
As  a  rule,  tuberculous  glands  caseate,  but  they  may  remain  localized  for  years 
if  caseation  does  not  occur.  The  tuberculous  glands  usually  soon  become 
adherent  and  immovable.  Lymphadenoma  is  most  common  after  twenty, 
rarely  remains  localized  for  more  than  a  few  months,  rarely  softens  unless  very 
large,  and  the  glands  are  separated  and  movable  until  a  huge  mass  forms. 
The  fluctuations  in  the  size,  consistency  and  movability  of  the  glands  and  the 
blood  picture  are  important  diagnostically.  Early  softening,  prolonged  limi- 
tation to  one  region,  and  absence  of  pronounced  anemia  in  a  person  under  twenty 
point  to  tubercle.  In  doubtful  cases  a  gland  should  be  removed  for  microscopi- 
cal and  bacteriological  study. 

In  widespread  tuberculous  lymphatic  involvement,  simulating  Hodgkin's 
disease,  fever  is  far  more  likely  to  be  present  than  in  Hodgkin's  disease.  La- 
Roy  ("Archives  Internat.  de  Chir.,"  1907,  vol.  iii)  says  that  tuberculous  glands 
are  but  little  improved  by  the  a;-rays  (a  statement  I  do  not  altogether  endorse), 


1396  Bandages 

whereas,  enlargements  in  Hodgkin's  disease  may  be  greatly  benefitted,  and  that 
in  tuberculous  conditions  there  is  no  particular  tendency  to  hemorrhage  and 
there  often  is  in  Hodgkin's  disease.  Coley  (''Trans.  Am.  Surg.  Assoc,"  igo8) 
shows  that  the  patients  with  Hodgkin's  disease  react  strongly  to  the  toxins  of 
erysipelas. 

Prognosis. — The  disease  is  almost  always,  if  not  invariably,  fatal.  Most 
cases  die  within  three  years,  some  die  within  two  months,  some  few  live  four 
or  five  years  or  more.  Acute  cases  die  as  a  rule  in  from  two  to  four  months.  In 
1 901  Fischer  could  not  find  a  single  authenticated  cure  on  record.  Yates  and 
Bunting  ('"Jour.  Am.  Med.  Assoc,"  June  12,  1915J  have  seen  two  recoveries, 
regarding  as  a  cure  five  years  freedom  from  evidence  of  the  disease. 

Treatment. — If  the  glands  are  localized  to  one  side  of  the  neck,  or  even 
to  both  sides  of  the  neck,  remove  the  tonsils,  put  the  teeth  in  order,  and  treat  any 
disease  of  the  nasopharynx.  In  any  other  region  seek  for  any  possible  portal  of 
bacillary  entry  and  apply  suitable  treatment.  Glandular  enlargements  localized 
to  certain  regions  should  be  extirpated  (see  Yates  and  Bunting,  in  "Jour. 
Am.  Med.  Assoc,"  March,  10.  191 7).  Early  removal  before  dissemination 
has  occurred  may  possibly  save  the  patient.  If  early  or  radical  removal  is 
not  possible,  do  not  operate,  but  treat  the  patient  with  nutritious  food,  tonics, 
course  of  arsenic,  the  mixed  toxins  of  erysipelas  and  the  Bacillus  prodigiosus, 
and  applications  of  the  .r-rays.  The  x-rays  are  thought  to  kill  causal  bacteria 
and  do  cause  fibrous  changes.  Coley  treated  2  cases  by  the  mixed  toxins. 
In  both  cases  the  lymphatic,  hepatic,  and  splenic  enlargements  entirely  disap- 
peared ("Surg.,  Gynec,  and  Obst.,"  August,  191 1).  Efforts  are  now  being 
made  to  obtain  a  curative  serum.  Beck  makes  nucleoprotein  serum  from  the 
glands  of  cases  of  Hodgkin's  disease.  Yates  and  Bunting  employ  a  vaccine 
(Ibid.).  My  experience  leads  me  to  agree  with  Holding  and  Brown  ("Jour. 
Am.  Med.  Assoc,"  March  3,  1917)  who  say  that  the  only  results  to  be  expected 
from  treatment  are  "temporary  ameliorations,"  that  the  .r-rays  and  radium 
should  be  used  after  operation  and  that  "a  Rontgen  examination  of  the  chest 
is  indicated  in  all  cases  before  an  extensive  surgical  removal  is  considered. 
This  will  save  many  patients  from  a  needless  operation." 


XXXV.  BANDAGES 

\  bandage  is  a  fibrous  material  which  is  rolled  up  and  is  then  employed  to 
retain  dressings,  applications,  or  appliances  in  contact  with  a  part,  to  make  pres- 
sure, or  to  correct  deformity.  It  may  be  composed  of  flannel,  of  calico,  of  un- 
bleached muslin,  of  plain  gauze,  of  gauze  infiltrated  with  plaster  of  Paris  or  soaked 
in  silicate  of  sodium,  or  of  gauze  wet  with  corrosive  sublimate  solution.  Un- 
bleached muslin,  which  is  the  best  material  for  general  use,  is  washed  to  remove 
the  sizing,  is  torn  into  strips,  and  the  edges  are  stripped  of  selvage.  One  end 
is  folded  to  the  extent  of  6  inches,  this  is  folded  upon  itself  again  and  again 
until  a  firm  center  is  formed,  and  over  this  center  the  bandage  is  rolled.  In  a 
well-rolled  bandage  the  center  cannot  be  pushed  out  of  the  roll.  A  roller  band- 
age is  di\dded  into  the  initial  end,  which  is  within  the  roll,  the  body  or  rolled 
part,  and  the  terminal  end,  which  is  free.  In  applying  a  bandage  the  outer 
surface  of  the  terminal  end  is  first  laid  upon  the  part. 

A  cylindrical  part  of  the  body  may  be  covered  by  a  circular  bandage,  each 
turn  exactly  covering  the  previous  turns.  A  conical  part  may  be  covered  by 
a  spiral  bandage,  each  turn  ascending  a  little  higher  than  the  previous  turn. 
As  each  turn  of  a  spiral  bandage  is  tight  at  its  upper  and  loose  at  its  lower  edge, 
the  reverse  was  devised  to  correct  this  inequality;  hence  a  conical  part  should 
be  covered  by  a  spiral  reversed  bandage.     To  make  a  reverse,  hold  the  roller 


Spiral  Bandage  of  the  Palm  or  Dorsum  of  the  Hand 


1397 


in  the  right  hand,  start  the  bandage  obliquely  upward  (do  not  have  more  than 
6  inches  of  slack),  place  the  thumb  across  the  fresh  turn,  fold  the  bandage  down 
without  traction,  and  do  not  make  traction  until  the  turn  has  been  carried  well 
around  the  limb.  A  projecting  point  is  covered  with  Jigure-of-&  turns.  The 
groin,  shoulder,  breast,  or  axilla  can  be  covered  by  figure-of-8  turns,  each  suc- 
ceeding turn  ascending  and  covering  two-thirds  of  the  previous  turn  and  form- 
ing a  figure  like  "  the  leaves  of  an  ear  of  corn."  Such  a  figure  is  called  a  "  spica." 
In  bandaging  an  extremity  the  peripheral  turns  should  be  tighter  than  the  turns 
nearer  the  body.  Never  apply  a  tight  bandage  to  the  leg  or  the  arm  without 
including  the  foot  or  the  hand  respectively.  In  firm  dressings  of  the  forearm 
and  arm  it  is  well  to  leave  the  ends  of  the  fingers  exposed,  and  use  them  as  an 
index  of  the  condition  of  the  circulation  in  the  part.  In  firm  dressings  of  the 
leg  and  thigh  leave  the  toes  exposed. 

Spiral  Reversed  Bandage  of  the  Upper  Extremity. — To  apply  this 
form  of  bandage  use  a  roller  2I/2  inches  wide  and  8  yards  long.  Take  a  circular 
turn  about  the  wrist,  and  a  second 
turn  to  hold  the  first;  pass  obliquely 
across  the  back  of  the  hand  to  the 
extremities  of  the  fingers;  ascend  the 
hand  to  the  root  of  the  thumb  by 
several  spiral  turns;  cover  the  wrist  by 
ascending  figure-of-8  turns;  ascend 
the  forearm  by  spiral  reversed  turns; 

cover  the  elbow  by  a  figure-of-8,  and  the  arm  by  spiral  reversed  turns;  end  the 
bandage  by  two  circular  turns,  and  pin  them  together  (Fig.  898). 

Spiral  Bandage  of  All  the  Fingers  (Gauntlet). — The  gauntlet  bandage 
requires  a  roller  i  inch  wide  and  3  yards  long.  Take  two  circular  turns  around 
the  ^\Tist,  pass  obliquely  across  the  wTist  to  the  root  of  the  thumb,  and  descend 
to  its  tip  by  spiral  turns;  cover  in  the  thumb  by  ascending  spiral  turns,  and  re- 
turn to  the  WTist.  Cover  successively  each  finger  in  the  same  manner,  and 
terminate  by  two  circular  turns  around  the  wrist  (Fig.  899). 


Fig. 


. — Spiral    reversed    bandage    of    thj 
upper  extremity. 


Fig.  899. — Gauntlet  bandage. 


Fig.  900. — Demigauntlet  bandage. 


Spiral  Bandage  of  the  Palm  or  Dorsum  of  the  Hand  (Demigaunt- 
let).— ^The  demigauntlet  requires  a  roller  i  inch  wide  and  3  yards  long.  This 
bandage  has  only  a  limited  value;  it  must  not  be  applied  tightly,  as  it  makes 
much  pressure  at  the  finger-roots,  but  leaves  the  fingers  free.  If  it  is  desired  to 
cover  the  palm,  supinate  the  hand;  if  to  cover  the  dorsum,  pronate  the  hand. 
Take  two  circular  turns  around  the  WTist,  sweep  around  the  root  of  the  thumb, 
and  return  to  the  point  of  origin.  Treat  each  finger  in  the  same  way.  End 
by  circular  turns  around  the -uTist  (Fig.  900). 


1398 


Bandages 


Spica  of  the  Thumb. — For  this  bandage  use  a  roller  i  inch  wide  and  3 
yards  long.  Start  at  the  wrist,  and  reach  the  tip  of  the  thumb  as  in  applying 
a  spiral  bandage  of  a  finger.  Make  a  series  of  ascending  figure-of-8  turns 
between  thumb  and  wrist,  each  ascending  turn  overlying  two-thirds  of  the 
previous  turn;  terminate  with  a  circular  of  the  wrist  (Fig.  901). 

Selva's  Thumb  Bandage  (Fig.  902). — ^Lay  the  terminal  end  of  the  bandage 
on  the  outer  side  of  the  second  phalanx  of  the  thumb,  near  the  base  of  the  pha- 
lanx. Carry  it  over  the  palmar  side  of  the  pulp  of  the  last  phalanx  to  the  inner 
side  of  the  second  phalanx.     The  surgeon  holds  this  turn  in  place  with  his  left 


Fig.  901. — Spica  of  the  thumb. 


Fig.  902. — Selva'b  thumb  bandage  applied. 


thumb  and  index-finger.  The  roller  is  returned  in  a  recurrent  manner  to  its 
place  of  origin,  overlaps  the  preceding  turn,  and  is  placed  as  much  as  possible 
on  the  dorsum.  The  roller  is  carried  over  the  dorsum  of  the  terminal  phalanx 
and  is  turned  around  the  tip,  the  loop  crossing  over  the  center  of  the  nail. 
Figure-of-8  turns  are  now  made  over  the  dorsum  of  the  hand,  over  the  palm, 
and  returning  to  the  terminal  phalanx,  and  an  ascending  spica  is  made.^ 

Spiral  Reversed  Bandage  of  the  Lower  Extremity.^ — Take  a  roller 
23^^  inches  wide  and  7  yards  long,  and  make  two  circular  turns  just  above  the 
malleoli,  and  an  oblique  turn  across  the  dorsum  of  the  foot  to  the  metatarso- 
phalangeal articulation;  make  a  circular  turn,  and  cover  the  foot  with  ascending 

spiral  reversed  turns;  return  to  the 
ankle  by  a  figure-of-8;  ascend  the  leg 
by  spiral  reverses;  cover  the  knee  by  a 
figure-of-8,  and  the  thigh  by  spiral  re- 
verses; terminate  by  two  circular  turns 
(Fig.  Qo^). 


Fig.    903. — Spiral  reversed  bandage  of  the 
lower  extremity. 


Fig.  904. — Method  of  covering  the  heel. 


Bandage  of  the  Foot  Covering  the  Heel  (A  merman  Bandage  of  the  Foot). 
— Take  a  roller  2^2  inches  wide  and  7  yards  long.  The  bandage  is  begun  as  a 
spiral  reversed  bandage  of  the  lower  extremity.  After  the  foot  is  well  covered 
by  ascending  spiral  reversed  turns,  carry  the  bandage  directly  around  the  point 
of  the  heel  and  return  to  the  instep;  from  this  point  carry  it  around  the  back  of 
the  ankle,  down  the  side  of  the  heel,  under  the  heel,  up  to  the  instep,  around  the 
ankle  in  the  opposite  direction,  down  the  opposite  side  of  the  heel,  and  under  the 

1  "Medical  News,"  Sept.  28,  1895. 


Borsch's  Eye- bandage 


1399 


heel  and  up  to  the  instep;  take  the  roller  to  above  the  malleoli,  and  end  by  a 
circular  turn  (Fig.  904). 

Bandage  of  the  Foot  Not  Covering  the  Heel  {French  Method).— Take 
a  roller  2 '  2  inches  wide  and  6  yards  long.  Make  a  spiral  reversed  bandage  of 
the  foot  and  a  figure-of-8  of  the  ankle-joint  (Fig.  905). 

Spiral  Bandage  of  the  Foot  Covering  the  Heel  {RihhaiVs  Bandage; 
Spica  of  the  Instep). — Take  a  roller  2 1-2  inches  wide  and  6  yards  long.  Apply 
as  a  spiral  reversed  bandage  of  the  lower  extremity  until  the  metatarsus  is  well 


Fig.  905. — Figure-of-S  bandage  of  the  ankle. 


Fig.  906. — Spica  of  the  instep. 


covered.  Carry  the  bandage,  parallel  with  the  margin  of  the  foot  (the  inner 
or  outer  margin,  according  as  to  whether  it  is  the  left  foot  or  the  right),  around 
the  posterior  aspect  of  the  heel,  along  the  opposite  margin  of  the  foot  to  cross 
the  original  turn  at  the  median  line  of  the  dorsum.  Make  a  number  of  these 
ascending  turns,  each  turn  covering  in  three-fourths  of  the  previous  turn; 
terminate  by  circular  turns  above  the  ankle  (Fig.  906). 

Crossed  Bandage  of  Both  Eyes  {Figure-of-S  of  Both  Eyes). — Take  a 
roller  2  inches  wide  and  6  yards  long.  Make  a  circular  turn  around  the  fore- 
head from  right  to  left,  a  second  turn  to  hold  the  first,  a  turn  downward  over 


Fig. 


907. 


-Crossed  figure-of-8  bandage  of 
both  eyes. 


Fig.  908. — Barton's  bandage  or  figure-of- 
of  the  jaw. 


the  left  eye,  under  the  left  ear,  round  the  back  of  the  neck,  and  upward  under 
the  right  ear  and  over  the  right  eye;  repeat  these  turns,  and  terminate  by  a  cir- 
cular turn  of  the  forehead  (Fig.  907). 

Borsch's  eye=bandage  is  convenient  and  useful  (Fig.  909).  A  narrow 
bandage  is  laid  upon  the  head,  in  its  anteroposterior  diameter,  in  such  a  manner 
that  its  anterior  end  will  hang  over  the  face  and  in  front  of  the  sound  eye.  A 
circular  bandage  is  applied  around  both  eyes,  and  over  the  narrow  bandage 
(a).  The  end  of  the  narrow  strip  is  lifted  and  pinned,  and  the  sound  eye  is 
thus  uncovered.  Of  course,  the  posterior  end  of  a  should  first  be  pinned  to  the 
circular  turn. 


I400 


Bandages 


Barton's  Bandage  (Figure-ojS  of  the  Jaw  and  Occiput). — Take  a  roller 
2  inches  wide  and  5  yards  long.  Place  the  initial  extremity  of  the  bandage  be- 
hind the  inion;  pass  over  the  right  parietal  bone,  across  the  vertex,  down  the  left 
side  in  front  of  the  ear,  under  the  chin,  up  the  right  side  in  front  of  the  ear, 
across  the  vertex,  and  across  the  left  parietal  bone  to  the  point  of  origin.  A 
turn  is  now  taken  forward  along  the  right  side  of  the  jaw  to  the  chin,  and  back- 
ward along  the  left  side  of  the  jaw  from  the  chin  to  the  nape  of  the  neck;  repeat 
these  turns,  and  pin  the  points  of  junction  (Fig.  go8).     In  Barton's  bandage  the 


Fig.  909. — Borsch's  eye-bandage:  A,  First  step;  b,  second  step. 

ear  lies  in  an  uncovered  triangle.  The  bandage  may  be  finished  by  circular 
turns  around  the  forehead.  Barton's  bandage  is  used  for  fracture  of  the  lower 
jaw. 

Gibson's  Bandage. — Take  a  roller  2  inches  wide  and  6  yards  long.  IVIake 
three  vertical  turns  around  the  head  and  the  jaw  in  front  of  the  ear;  reverse 
the  bandage  above  the  level  of  the  ear,  and  carry  it  horizontally  around  the 
forehead  and  head  three  times;  drop  the  bandage  to  the  nape  of  the  neck, 
and  take  three  turns  around  the  neck  and  jaw;  terminate  by  taking  from  the 


Fig.  910. — Gibson's  bandage. 


Fig.  911. — Oblique  or  crossed  bandage  of 
the  angle  of  the  jaw. 


nape  of  the  neck  a  half- turn  upward,  carrying  the  bandage  forward  to  the  fore- 
head, and  pinning  it  over  the  neck  and  over  the  forehead.  Pin  each  point  of 
junction  (Fig.  910).  Gibson's  bandage  is  used  for  fracture  of  the  lower  jaw. 
Crossed  Bandage  of  the  Angle  of  the  Jaw  {Oblique  Bandage  of  the 
Jaw). — Take  a  roller  2  inches  wide  and  6  yards  long.  Make  a  circular  turn 
around  the  forehead  toward  the  affected  side;  and  a  second  turn  to  hold  the 
first;  take  the  turn  to  the  back  of  the  neck;  carry  it  forward  on  the  sound  side, 
under  the  ear  and  chin;  now  make  a  series  of  turns  around  the  head  and  jaw, 


Velpeau's  Bandage 


1401 


in  front  of  the  ear  on  the  injured  side,  but  Ixick  of  the  ear  on  the  sound  side: 
these  turns  successively  advance  on  the  injured  side  only;  terminate  by  going 
backward  under  the  ear  of  the  sound  side  to  the  nape  of  the  neck,  and  then  by 
taking  two  circular  turns  around  the  forehead  (Fig.  911).  This  bandage  is 
used  for  fractures  of  the  ramus  of  the  jaw  and  for  holding  dressings  upon  the 
face  and  the  cranium. 

Spica  of  the  Groin  {Figure-of-8  of  the  Thigh  and  Pelvis). — For  one  groin 
the  roller  is  3  inches  wide  and  7  yards  long;  for  both  groins,  3  inches  wide  and 

10    yards    long.     Take    two  circular 
turns,  from  right  to  left,  around  the 


912. — Spica  of  the  groin. 


Fig.  913. — Spica  of  the  shoulder. 


waist,  then  down  over  the  front  of  the  right  groin,  around  the  back  of  the  thigh, 
up  over  the  front  of  the  right  groin,  around  the  waist,  down  over  the  front  of  the 
left  groin,  round  the  back  of  the  thigh,  up  over  the  left  groin,  and  around  the 
waist.  The  map  being  thus  laid  out,  the  turns  are  continued  upward,  each 
turn  overlying  one-third  of  the  previous  turn,  and  the  bandage  is  completed  by  a 
circular  turn  around  the  waist  (Fig.  912).     Pin  the  crossed  pieces. 

Spica  of  the  Shoulder. — Take  a  roller  2}^  inches  wide  and  7  yards  long. 
Make  a  circular  turn  and  several  spiral  re- 
versed  turns  around  the  upper  arm;  then, 
coming  from  behind  forward,  carry  the  band- 
age over  the  shoulder,  across  the  front  of  the 


Fig.  914. — Figure-of-8  bandage  of  the  elbow. 


Fig.  915. — Posterior  fiigure-of-8  of  both 
shoulders. 


chest,  through  the  opposite  arm-pit,  and  return  across  the  back  to  the  shoulder. 
Make  successive  and  advancing  turns  (Fig.  913). 

Figure-of-8  bandages  of  the  elbow,  both  shoulders  (posterior  figure-of-8), 
the  neck  and  axilla  are  shown  in  Figs.  914,  915,  a^d  916. 

A  figure-of-8  bandage  of  the  breast  is  shown  in  Fig.  921. 

Velpeau's  Bandage. — Take  a  roller  2,1^  inches  wide  and  10  yards  long. 
Place  the  palm  of  the  hand  of  the  injured  side  upon  the  shoulder  of  the  sound 
side,  interposing  cotton  between  the  arm  and  the  side.     Start  the  bandage  at 


1402 


Bandages 


the  axilla  of  the  sound  side  posteriorly,  carry  it  across  the  back  to  the  shoulder 
of  the  injured  side,  down  the  front  of  the  arm  and  under  the  arm  just  above  the 
elbow,  returning  to  the  point  of  origin;  repeat  this  turn,  but,  on  reaching  the 
axilla  the  second  time,  cross  the  back  and  pass  around  the  chest,  including  the 
arm;  keep  on  with  these  turns,  each  alternate  turn  going  over  the  injured 
clavicle,  each  alternate  turn  encircling  the  arm  and  the  body,  the  first  turns 
advancing  and  the  second  turns  ascending  (Fig.  917).  Pin  the  crossed  pieces. 
This  bandage  is  used  for  fracture  of  the  clavicle. 


Fig.  916. — Figure-of-8  of  neck  and  a.xilla. 


Fig.  917. — Velpeau's  bandage. 


Desault's  Apparatus. — This  apparatus  consists  of  three  rollers,  a  pad, 
and  a  sling.  Each  roller  is  2^^  inches  wide  and  7  yards  long.  The  pad,  which  is 
wedge  shaped,  is  inserted  into  the  axilla  with  the  base  up.  The  first  roller  is 
used  to  hold  the  pad  (Fig.  918).  The  second  roller  binds  the  arm  to  the  side 
over  the  pad.  This  pad  is  a  fulcrum,  the  shoulder  is  the  weight,  the  arm  is  the 
lever,  and  the  second  roller  of  Desault  corrects  the  inward  deformity  of  a  frac- 
tured clavicle  (Fig.  919).  The  third  roller  corrects  the  downward  and  for- 
ward displacement.     It  starts  in  the  axilla  of  the  sound  side  anteriorly,  crosses 


r^^ 


Fig.  918. — Desault's  bandage,  first  roller.       Fig.  919. — Desault's  bandage,  second  roller. 

the  chest  to  the  shoulder  of  the  injured  side,  runs  down  the  back  of  the  arm, 
around  the  elbow,  and  crosses  the  chest  to  the  point  of  origin,  forming  the 
anterior  triangle;  it  is  now  carried  through  the  axilla  of  the  sound  side  to  the 
back,  crosses  the  back  to  the  shoulder  of  the  injured  side,  runs  down  the  front 
of  the  arm,  around  the  elbow^  and  across  the  back  to  the  axilla  of  the  sound 
side,  forming  the  posterior  triangle  (Fig.  920).  The  formula  for  the  Desault 
bandage  is:  start  in  the  axilla  of  the  sound  side  anteriorly,  run  from  the  axilla 
to  the  shoulder,  from  the  shoulder  to  the  elbow,  from  the  elbow  to  the  axilla, 
and  pass  to  the  back;  from  the  axilla  to  the  shoulder,  from  the  shoulder  to  the 


Handkerchief  Bandages 


1403 


elbow,  from  the  elbow  to  the  axilla,  and  pass  to  the  front.     Pin  the  crossed  pieces 
and  hang  the  hand  in  a  sling  (Fig.  920). 

Recurrent  Bandage  of  the  Head. — Take  a  roller  2  inches  wide  and  6 
yards  long.  Make  two  circular  turns  horizontally  around  the  forehead  and 
head;  when  the  middle  of  the  forehead  is  reached,  catch  the  bandage,  take  a  half- 
turn,  carry  the  bandage  to  the  occiput,  let  an  assistant  catch  it,  take  a  half-turn, 
bring  the  roller  forward  to  the  forehead,  covering  a  portion  of  the  preceding 
turn;  continue  this  process  until  the  scalp  is  well  covered;  terminate  with  two 


Fig.  920. — Desault's  bandage,  third  roller.       Fig.  921. — Figure-of-8  bandage  of  the  breast. 


■circular  turns  around  the  forehead  and  head  (Fig.  922).     It  is  often  advisable 
to  take  a  turn  around  the  head  and  chin.     Pin  the  crossed  pieces. 

Recurrent  Bandage  of  a  Stump. — Take  a  roller  2  inches  wide  and 
6  yards  long.  Make  two  light  circular  turns  around  the  root  of  the  stump; 
make  recurrent  turns  covering  the  stump  as  is  done  in  covering  the  head;  take 
a  circular  turn  around  the  root  of  the  stump,  oblique  turns  to  the  top  of  the 


Fig.  922. — Recurrent  bandage  of  the  head.       Fig.  923. — Recurrent  bandage  of  a  stump. 

Stump,  circular  turns  around  the  top,  and  apply  an  ascending  spiral  reversed 
bandage  (Fig.  923). 

T=Bandage  of  the  Perineum. — Pass  the  transverse  part  around  the 
body  above  the  iliac  crests,  and  pin  it  in  front;  bring  one  of  the  tails  over  the 
dressing  and  up  between  the  genitals  and  the  thigh  of  one  side,  and  the  other 
tail  over  the  dressing  and  up  between  the  genitals  and  the  thigh  of  the  opposite 
side;  secure  these  tails  to  the  horizontal  band. 

Handkerchief  Bandages.— Take  unbleached  muslin  i  yard  square. 
The  muslin  folded  once  makes  an  oblong  bandage;  bringing  its  diagonal  angles 


1404  Plastic  Surgery 

together  makes  a  triangle  bandage;  a  cravat  is  formed  by  folding  a  triangle 
bandage  from  summit  to  base;  a  cord  is  a  twisted  cravat.  The  triangle  makes 
an  admirable  sling. 

Fixed  Dressings. — Plaster-of-Paris  Bandage. — Cover  the  extremity  with 
a  cotton  or  flannel  bandage  or  with  a  woolen  stocking.  Take  a  gauze  roller 
infiltrated  with  plaster  and  place  endwise  in  a  basin  of  tepid  water,  the 
water  covering  the  plaster.  When  bubbles  cease  to  arise,  squeeze  the  band- 
age and  apply  it  without  much  tension,  smoothing  out  each  turn  with  a 
moistened  hand.  As  each  bandage  is  taken  from  the  basin  drop  a  fresh  one 
into  the  water.  Apply  four  thicknesses  of  bandage,  and  finish  the  dressing 
by  sprinkling  dry  plaster  over  the  bandage  and  smoothing  it  with  wet  hands. 
The  ordinary  plaster  will  set  in  from  fifteen  to  thirty  minutes.  If  it  be 
desired  to  have  it  set  more  rapidly,  put  a  tablespoonful  of  salt  in  each  pint 
of  water  used;  if,  to  have  it  set  more  slowly,  pour  stale  beer  into  the  water  or 
add  a  solution  of  gelatin.  The  plaster  bandage  is  removed  by  sawing  it  down 
the  front  or  by  moistening  with  dilute  hydrochloric  acid  and  then  cutting  through 
the  moistened  line  with  a  strong  knife.  Gigli  has  devised  a  mode  of  application 
which  enables  us  to  remove  the  dressing  with  ease.  A  layer  of  cotton  is  placed 
around  the  limb.  A  piece  of  parchment  paper  which  has  been  wet  and  shaken 
out  is  placed  over  the  cotton.  A  cord  greased  with  vaselin  is  laid  upon  the 
paper  in  a  position  corresponding  to  the  line  through  which  we  shall  saw  when 
it  is  time  to  remove  the  plaster.  Apply  the  plaster  bandage  and  see  that  the 
ends  of  the  cord  project  beyond  the  bandage.  When  desiring  to  remove  the 
bandage  take  a  steel  wire,  make  nicks  on  one  side  of  it  by  means  of  a  file,  and 
attach  the  string  to  the  wire.  Pull  the  wire  under  the  bandage.  Attach  each 
end  of  the  wire  to  a  wooden  handle  and  saw  through  the  plaster.^ 

Silicate  of  Sodium  Dressing. — Protect  the  part  as  is  done  for  a  plaster 
bandage.  Bandage  the  limb  loosely  with  an  ordinary  gauze  bandage,  paint 
this  bandage  with  silicate  of  sodium,  apply  another  bandage  and  paint  it, 
and  so  on  until  six  layers  are  applied.  Gauze  bandages  are  better  than  or- 
dinary bandages  to  take  up  silicate  of  sodium.  Silicate  dressings  require 
from  twelve  to  eighteen  hours  to  dry,  and  they  are  removed  by  softening 
with  warm  water  and  then  cutting. 


XXXVI.  PLASTIC  SURGERY 

Plastic  surgery  includes  operations  for  the  repair  of  deficiencies,  for  the 
replacement  of  lost  parts,  for  the  restoration  of  function  in  parts  tied  down 
by  scars,  and  for  the  correction  of  disfiguring  projections.  Many  reparative 
operations  have  been  devised.  Among  them  are:  cheiloplasty,  or  the  construc- 
tion of  a  new  lip;  the  closure  of  a  cleft  in  the  palate,  the  lip,  or  the  penis;  the 
makmg  of  a  new  nose;  skin-grafting;  fascia  transplantation;  fat  transplantation; 
bone-grafting;  tendon-grafting;  grafting  of  muscle  or  tendon;  nerve-grafting; 
the  introduction  of  celluloid  or  metal  into  the  tissues  to  act  as  a  support;  the 
injection  of  paraffin  into  the  tissues  to  amend  a  depression;  the  diminution  in  the 
size  of  a  lip  or  a  nose;  the  amendment  of  protuberant  ears;  the  correction  of 
distortion  due  to  cicatrices;  excision  of  scars;  closure  of  congenital  sinuses  and  of 
fistulae;  and  removal  of  disfiguring  growths. 

Carrel  has  proved  that  autoplastic  transplantation  of  organs  can  be  accom- 
plished successfully;  that  homoplastic  transplantations  succeed  temporarily  only 
and  that  heteroplastic  transplantations  always  fail.  The  rapid  destruction  of 
the  heteroplastic  transplant  as  well  as  the  destruction  of  the  homoplastic  trans- 
plant is  due  to  the  invincible  tendency  of  the  organism  to  destroy  foreign  tissue. 
Transplantation  of  organs  is  useless  in  human  surgery  because  a  homoplastic 
/  "La  Semaine  Med.,"  Nov.  3,  1895. 


Skin-grafting  1405 

transplant  though  an  anatomical  success  does  not  functionate.  (Carrel  in 
"Med.  Press  and  Circular,"  1914,  xcvii.)  Lydston  has  apparently  proved 
that  a  transplanted  testicle  may  give  out  an  internal  secretion  for  a  sufficient 
length  of  time  to  place  an  individual  in  the  masculine  groove  and  to  remove 
him'  from  the  road  to  perversion. 

The  subject  of  plastic  surgery  is  very  extensive,  and  a  treatise  upon  it 
should  be  consulted  if  one  wishes  to  obtain  detailed  and  comprehensive  in- 
formation. 

A  plastic  operation  can  only  be  successful  after  lupus  when  the  disease 
has  been  cured.  It  is  useless  to  do  a  plastic  operation  during  active  syphilis, 
and  a  plastic  operation  for  a  syphilitic  loss  of  substance  is  to  be  performed 
only  after  the  patient  has  been  thoroughly  treated  and  the  disease  has  been 
apparently  cured.  The  first  step  of  a  plastic  operation  consists  in  making 
the  surfaces  which  are  to  be  brought  together  raw;  the  second  step  is  the  com- 
plete arrest  of  bleeding;  the  third  step  is  the  approximation  of  the  surfaces 
without  tension;  the  fourth  step  is  to  close  any  gap  from  which  tissue  may 
have  been  transplanted;  and  the  final  step  is  the  application  of  the  dressings. ^ 
The  following  are  the  methods  used:  - 

Displacement  is  the  method  of  stretching  or  of  sliding:  (i)  Approximation 
after  freshening  the  edges  (as  in  harelip) ;  (2)  sliding  into  position  after  trans- 
ferring tension  to  other  localities  (linear  incisions  to  allow  of  stretching  of  the 
skin  over  large  wounds) .  Interpolation  is  the  method  of  borrowing  material  from 
an  adjacent  or  a  distant  region  or  from  another  person:  (i)  Transferring  a  flap 
with  a  pedicle,  in  which  the  flap  is  put  in  place  at  once  or  gradually  by  a  series  of 
partial  cperations  (as  in  rhinoplasty,  when  a  flap  is  taken  from  the  forehead) ; 
(2)  transplanting  without  a  pedicle,  which  is  performed  by  placing  in  position 
and  by  fixing  portions  of  tissue  recently  removed  from  the  part,  from  another 
part  of  the  same  individual,  or  from  a  lower  animal  (as  replacement  of  the  button 
of  bone  after  trephining,  transplanting  a.  piece  of  bone  from  a  lower  animal  to 
remedy  a  bone  defect  in  a  human  being,  transplantation  of  fat  or  fascia,  or  the 
grafting  of  a  piece  of  nerve  from  a  lower  animal  or  from  an  amputated  human 
limb  to  remedy  a  loss  of  nerve  in  a  human  being) .  (See  "  Free  Tissue  Transplan- 
tations," by  I).  B.  Phemister  in  a  Collective  Review  in  "Intemat.  Abstract  of 
Surgery,"  Jan.,  1914.)  Retrenchment  is  the  removal  of  redundant  material 
and  the  production  of  cicatricial  contraction. 

Skin=grafting. — As  long  ago  as  1847  Dr.  Frank  Hamilton  partly  covered 
an  ulcer  with  a  pediculated  flap,  and  trusted  that  the  uncovered  portion  would 
be  healed  by  new  skin  from  the  flap.  Beck's  "  Ahdesive  plaster  method  for  the 
rapid  regeneration  of  skin  over  granulating  wounds"  will  undoubtedly  supersede 
some  of  the  skin  transplant  operations.  Beck  applies  "strips  of  plain  or  zinc 
oxide  adhesive  plaster  along  the  edges  of  the  granulating  wound"  and  leaves 
these  strips  in  place  for  twenty-four  hours  when  he  finds,  along  the  skin  margin, 
a  bluish-gray  border  of  epithelial  cells.  He  now  dresses  the  wound  with  dry 
gauze  for  twenty-four  hours  and  then  makes  another  application  of  adhesive 
plaster.  This  routine  is  followed  until  the  whole  granulating  surface  is  covered 
with  an  epithelial  growth  which  "serves  practically  the  same  purpose  as  a  skin 
transplant"  (Emil  G.  Beck,  "Annals  of  Surgery,"  March,  1919).  We  may 
graft  small  pieces  of  epithelium  taken  from  the  patient,  another  person,  or  one 
of  the  lower  animals,  or  may  graft  large  pieces  of  epithelium.  The  grafts 
should,  if  possible,  come  from  the  person  to  be  grafted.  The  epidermic  scales 
may  be  scraped  off  the  sound  skin  and  grafted.  Lusk  has  blistered  the  skin 
with  cantharides  and  grafted  portions  of  the  epidermis.  The  shavings  of  a  corn 
and  fragments  of  hair  roots  have  been  used.  The  best  plan  is  to  cut  off  and 
transplant  small  bits  of  epidermis. 

Grafts  may  come  from  another  person  or  from  a  lower  animal,  but  such 
1  "American  Text-Book  of  Surgery."  2  -^{^ 


1406 


Plastic  Surgery 


grafts  are  not  so  apt  to  grow  as  those  obtained  from  the  individual,  and  even 
when  they  do  grow,  fail  to  furnish  a  secure  cicatrix.  The  organism  always 
strives  to  eliminate  foreign  matter.  If  a  graft  must  be  obtained  from  another 
person,  the  closer  blood  relation  that  person  is,  the  better  the  chance  of  the  graft 
growing.  Before  taking  a  graft  from  another  person  be  certain  that  the  donor  is 
free  from  syphilis.  Frog-skin  furnishes  unsatisfactory  grafts.  Some  surgeons 
have  used  bits  of  sponge;  others,  the  skin  of  rabbits,  guinea-pigs,  or  pups.  Amot 
has  employed  the  lining  membrane  of  a  hen's  egg,  cut  in  strips  and  applied 
upon  the  wound  with  the  shell-surface  uppermost.  Small  bits  of  epidermis 
taken  from  a  recently  amputated  foreskin  or  leg  have  been  used.     Grafts  of 

fetal    membranes    and   of 
ovarian    cysts    have    been 
used.     Autoplastic    grafts 
,l^  ""^      should   be   used  whenever 

possible.  Homoplastic 
grafts  from  stern  necessity 
only.  Heteroplastic  grafts 
never. 

Reverdin's  Method. — 
This  operation  was  devised 
by  Reverdin  in  1869. 
Small  bits  of  epithelium 
are  used,  and  they  are 
taken,  preferably,  from  the 
person  himself.  The  sur- 
face to  be  grafted  should 
possess  healthy  granula- 
tions level  with  the  skin. 
Cleanse  the  skin  from 
which  the  grafts  are  ta 
come,  the  ulcer,  and  the 
skin  about  it,  and,  if  cor- 
rosive sublimate  be  used, 
wash  it  away  with  a  stream 
of  warm  normal  salt  solu- 
tion. Thrust  a  sewing- 
needle  under  the  epidermis 
to  raise  it,  cut  off  the  graft 
by  a  pair  of  scissors,  and 
place  the  raw  surface  of  the 
graft  upon  the  ulcer.  After 
applying  a  number  of 
grafts,  place  thin  pieces  of 
gutta-percha  tissue  over 
them  and  extending  beyond  each  side  of  the  ulcer.  These  pieces  of  gutta-percha 
should  be  so  arranged  as  to  have  distinct  intervals  between  them,  the  gaps 
permitting  drainage.  The  rubber  tissue  must  be  aseptic  and  moist  with  warm 
normal  salt  solution.  Dress  with  a  pad  of  aseptic  gauze  moistened  with  salt 
solution;  place  over  this  gauze  a  rubber-dam,  and  over  the  latter  absorbent 
cotton  and  a  bandage.  In  the  case  of  a  child  apply  a  light  silicate  bandage. 
If  the  grafted  area  be  very  extensive  or  if  it  be  in  the  lower  extremity,  put  the 
patient  in  bed.  In  forty-eight  hours  remove  all  the  dressings  except  the  gutta- 
percha tissue,  irrigate  with  normal  salt  solution,  and  reapply  the  dressings.  All 
signs  of  the  grafts  will  often  have  disappeared.  In  a  day  or  two  more,  at  the 
site  of  grafting,  there  should  appear  bluish-white  spots,  which  are  islands  of 
epidermis.     Each  graft  is  capable  of  forming  about  3^2  inch  of  cicatrix.     Graft- 


FiG.  924. — Injury  caused  by  crush  and  burn.  Healed 
by  granulation  in  eight  months.  Showing  condition  after 
removal  of  scar  of  the  palm,  which  has  been  repaired  by 
stitching  in  an  autoplastic  graft  (free  flap)  from  the  thigh 
(George  S.  Brown). 


Wolfe's  Method  of  Skin-grafting 


1407 


ing  also  stimulates  the  edges  of  the  ulcer  to  cicatrize  and  contract.  At  the  end 
of  seven  days  the  special  dressings  can  be  dispensed  with.  The  spot  from 
which  the  grafts  have  been  taken  is  dressed  anliseptically.  Reverdin's  method 
does  not  limit  cicatricial  contraction  to  any  great  degree,  and  the  new  skin  is  apt 
to  break  down. 

The  Ollier-Thiersch  Method. — Oilier  of  Lyons,  in  1872,  succeeded  in  trans- 
ferring large  pieces  of  epidermis.  In  1886  Thiersch,  of  Leipzig,  set  forth  the 
technic  practically  as  it  is  employed  to-day.  The  Ollier-Thiersch  method  is 
performed  as  follows:  Thoroughly  asepticize  the  ulcer,  the  surrounding  skin,  and 
the  site  from  which  the  graft  is  to  come  (the  inner  side  of  the  arm  or  the  thigh), 
and  wash  away  the  mercurial  preparation  with  normal  salt  solution.  Apply 
dressings  wet  with  salt  solution.  On  bringing  the  patient  into  the  operating 
room  remove  the  dressings  from 
the  ulcer,  scrape  the  ulcer  and  its 
edges,  irrigate  with  salt  solution, 

'  and  compress   to  arrest  hemor- 

'  rhage.    Grafts  are  then  obtained 

'  by  putting  the  prepared  skin 
upon  the  stretch  and  cutting 
strips  with  a  razor.  While  the 
razor  is  being  used  the  part  is 
constantly  irrigated  with  salt 
solution.  Mixter's  apparatus 
enables  one  to  perform  this  ope- 
ration with  great  neatness  and 
speed.  This  apparatus  consists 
of  a  knife  and  an  open  square 
with  sharp  points  on  the  under 
surface.  The  square  is  forced 
down  upon  the  front  of  the  thigh, 
the  epidermis  mounts  up  in  the 
opening  to  above  the  level  of  the 
metal  sides  and  the  grafts  may 
be  cut  with  ease.  The  graft 
contains  the  epidermis,  the  rete, 
and  part  of  the  true  skin.  In 
Halsted's  clinic  the  skin  of  the 
thigh  is  made  tense  by  pressing 
and  drawing  upon  it  with  a 
piece  of  asepticized  wood,  the 
wood  is  drawn  slowly  along, 
and  is  followed  closely  by  the 

sharp  catlin,  by  which  the  surgeon  cuts  long  grafts.  The  grafts  are  pressed 
into  place  upon  the  raw  surface,  and  each  graft  overlaps  a  little  the  edges  of  the 
wound  and  the  adjacent  grafts.  The  skin  wound  is  dressed  antiseptically,  and 
the  grafted  area  may  be  dressed  as  in  Reverdin's  method.  If  a  ring  of  aseptic 
gauze  be  made  to  encircle  the  limb  below  the  grafted  area,  and  another  ring 
above  the  grafted  area,  and  if  on  these  pads  little  strips  of  wood  wrapped  in 
aseptic  gauze  be  laid,  a  cage  is  made,  and  around  this  cage  the  dressings  may 
be  applied  (moist  chamber  plan)  (Fig.  926). 

Wolfe's  Method. — It  was  pointed  out  by  Wolfe  that  a  piece  of  skin,  com- 
prising the  entire  thickness  of  that  structure,  can  be  successfully  transplanted 
without  a  pedicle.  The  ulcer  is  extirpated  and  asepticized  and  bleeding  is 
arrested.  The  flap  is  cut  one-sixth  larger  than  the  surface  to  be  covered. 
Fat  is  kept  out  of  the  graft.  This  bit  of  tissue  is  laid  upon  the  wound,  the 
edges  of  the  graft  being  brought  against  the  edges  of  the  raw  area.     It  is  not 


Fig.  925. — Claw-hand  from  burn.  A  flap  with  a 
pedicle  was  taken  from  the  chest.  The  pedicle  was 
cut  on  ninth  day. 


1408 


Plastic  Surgery 


necessary  to  employ  sutures.  The  part  is  dressed  in  a  moist  chamber.  If  the 
graft  perishes,  remove  it. 

Subcutaneous    Injection    of    Paraffin    for    Prosthetic    Purposes. — 

The  principle  of  injecting  solidifying  oils  into  tissues  to  obtain  mechanical 
effects  was  first  laid  down  by  J.  Leonard  Corning  in  1891.  The  use  of  paraffin 
was  introduced  by  Gersuny  to  amend  the  deformity  of  a  saddle-nose.  It  has 
been  used  to  limit  incontinence  of  feces,  incontinence  of  urine  in  women,  to 
prevent  reunion  of  nerves  after  division,  as  a  counterfeit  testicle,  to  obliterate 
small-pox  marks,  to  narrow  a  hernial  ring,  to  correct  sinking  of  the  cheek  after 
removal  of  the  upper  jaw,  and  for  other  purposes  (Moszkowicz,  in  "Wien.  klin. 
Woch.,"  June  20,  1901).  Paraffin  is  not  toxic.  Its  injection  may  produce  some 
swelling  and  redness,  but  applications  of  cold  usually  control  inflammation. 
In  two  or  three  months  the  paraffin  becomes  hard  like  cartilage  and  encapsuled. 
It  is  questionable  whether  or  not  it  is  subsequently  destroyed  and  replaced  by 
granulation  tissue.     Sometimes  sloughing  takes  place  in  the  skin  above  it. 

Prepare  the  paraffin  as  follows:  In  Gersuny 's  clinic  solid  paraffin  is  mixed 
■with  liquid  paraffin.  The  melting-point  of  the  mixture  should  be  about  104° 
F.  It  is  rendered  sterile  by  boiling,  is  injected  by  a  warm  syringe,  and  as 
a  semisolid,  the  skin  having  been  first  warmed  by  a  hot  sponge.  After  in- 
jection it  is  molded  into  proper  shape.  It  sets  in  half  a  minute.  It  is  not 
wise  to  use  a  mixture  with  a  much  higher  melting-point,  because  it  would 
possibly  cause  thrombosis  in  veins.     There  are  difficulties  and  even  dangers 


Fig.  926. — Mayer's  dressing 


for  Thiersch's  method  of  skin-grafting  ("Amer.  Text-Book 
of  Surg."). 


in  the  use  of  paraffin  for  saddle-nose.  It  should  only  be  used  when  the  skin  is 
loose  and  elastic.  It  should  never  be  used  if  there  be  great  deformity,  because 
then  the  amount  required  would  surely  cause  dangerous  tension.  It  is  difficult 
to  prevent  the  injected  material  from  passing  down  the  sides  of  the  nose  and 
up  into  the  forehead.  Cases  of  embolism  causing  blindness  have  been  re- 
ported. The  skin  may  slough  if  the  injection  be  too  hot  or  if  it  produce  much 
tension. 

Paraffinoma. — This  term,  suggested  by  Delangre,  means  an  inflammatory 
new  formation  which  may  arise  in  the  submucous, or  subcutaneous  tissues 
about  a  depot  of  injected  paraffin.  It  may  or  may  not  ulcerate.  It  is  particu- 
larly apt  to  form  in  a  tuberculous  person.  The  swelling  is  marked  and  the 
disfigurement  great.  The  possibility  of  the  formation  of  a  paraffinoma  is  par- 
ticularly great  if  paraffin  be  used  in  the  subcutaneous  tissue. 

The  only  treatment  is  excision. 

Correction  of  Saddle=nose  by  the  Insertion  of  a  Plate. — Saddle- 
nose  is  a  condition  in  which  the  bones  and  cartilages  have  been  destroyed 
by  ulceration  or  collapsed  by  injury.  It  is  useless  to  attempt  correction  by 
skin-flaps  alone.  Paraffin  injections  (see  above)  may  be  used  in  the  less 
severe  cases.  In  a  bad  case  we  must  transplant  bone-flaps  or  insert  a  plate 
for  support.  The  bone-flap  operation  is  seldom  satisfactory  and,  of  necessity, 
creates  a  hideous  scar.  The  insertion  of  a  plate  may  give  an  excellent  result, 
although  the  future  is  always  uncertain.  In  2  cases  I  have  seen  sloughing 
occur  over  the  plate  months  after  the  operation.  In  i  of  these  cases  the  slough- 
ing was  due  to  a  blow  from  a  cow's  tail. 


Rhinoplasty 


1409 


The  plate  used  may  he  of  silver,  gold,  or  celluloid.  An  incision  is  made  to 
permit  the  insertion  of  the  plate.  I  agree  with  Leonard  P'recman  ("Annals 
of  Surgery,"  August,  1907)  that  the  incision  along  the  bridge  and  the  incision 
in  the  septum  below  the  tip  are  both  objectionable.  The  first  leaves  an  un- 
sightly scar  and  does  not  allow  for  stretching  of  the  skin.  The  incision  at  the 
tip  gives  unsatisfactory  access  to  the  tissues  requiring  separation  and  is  liable 
to  infection  from  the  nostril. 

The  best'  incision  is  Freeman's.  This  is  a  short  incision  across  the  root  of 
the  nose  between  the  eyes.  The  skin  is  undermined  along  the  bridge  to  the 
tip  and  along  the  sides.     The  undermined  skin  can  be  stretched  if  necessary. 

Rhinoplasty. — The  complete  operation  may  be  performed  by  trans- 
ferring a  flap  from  the  forehead.  This  is  known  as  the  Indian  operation. 
It  was  employed  for  centuries  in  India,  and  interest  in  it  was  awakened  in 
England  about  1820  by  Mr.  Carpue.  The  edges  of  the  defect  are  made  raw. 
A  model  of  the  desired  nose,  made  out  of  gutta-percha,  has  its  outlines  marked 
upon   the  forehead,  and  the  cut  is  made  ^4  inch  outside  of  the  outline,  so  as 


Fig.  927. — Indian  method  of  rhinoplasty.  Fig.  928. — Italian  method  of  rhinoplasty. 

to  allow  room  for  retraction.  The  flap  is  turned  down  and  sutured  in  place 
(Fig.  927),  care  being  taken  not  to  cut  off  the  blood-supply  from  the  pedicle. 
Plugs  of  gauze  or  tubes  are  inserted  to  support  the  flap. 

The  complete  operation  can  be  performed  by  the  Italian  method  (Taglia- 
cotian  method).  This  method  was  first  described  in  Tagliacozzi's  book, 
which  was  published  in  1597.  In  this  operation  the  flap  is  marked  out  on 
the  arm,  is  made  twice  the  size  of  the  desired  nose,  and  is  left  attached  by  a 
broad  pedicle.  The  nasal  surface  is  rendered  raw  at  proper  regions,  and  the 
flap  is  sutured  in  place,  the  hand  being  held  upon  the  head  by  a  special  appa- 
ratus (Fig.  928).  The  raw 'surface  upon  the  arm  is  dressed.  In  about  three 
weeks  the  flap  is  cut  loose  from  the  arm,  and  is  pared  and  corrected  as  may  be 
necessary. 

The  operations  for  harelip  and  cleft  palate,  and  plastic  operations  on  mus- 
cles, nerves,  tendons,  and  bones  are  considered  in  other  portions  of  this  work. 


89 


14 lo  Diseases  and  Injuries  of  the  Gcnito-urinary  Organs 


XXXVII.    DISEASES   AND    INJURIES   OF   THE  QENITO= 
URINARY   ORGANS 

Hematuria. — By  this  term  is  meant  the  voiding  of  bloody  urine  or  of' 
pure  blood,  the  blood  arising  from  any  portion  of  the  urinary  apparatus, 
and  the  condition  being  a  symptom  and  not  a  disease.  In  hematuria  the 
urine  contains  more  than  blood  coloring-matter;  it  also  contains  biood-corpus- 
cles.  The  condition  in  which  there  is  coloring-matter  only  is  called  hemoglo- 
binuria. Hemoglobinuria  may  arise  after  burns,  etherization,  and  after  taking 
urotropin,  and  during  various  fevers,  especially  in  malaria  (see  page  141 1). 
Hematuria  may  be  a  symptom  of  disease  or  of  injury  of  some  part  of  the  urinary 
system  (calculus,  acute  nephritis,  pyelitis,  renal  tuberculosis,  prostatic  en- 
largement, morbid  growth,  wounds  or  contusions  of  the  genito-urinary  tract), 
of  blood  disorganizations  (purpura,  scurvy,  variola,  leukemia,  or  anemia),  or 
of  metallic  poisoning  (mercury,  lead,  or  arsenic).  It  may  arise  during  typhoid 
fever,  in  the  beginning  of  an  acute  fever,  (especially  variola),  in  hemophilia,  in 
nephralgia,  in  malarial  fever,  and  in  kidney  infarction  resulting  from  endocar- 
ditis. It  may  be  caused  by  parasites  (Filaria  sanguinis  hominis  and  Bilharzia 
haematobia).  Some  drugs  are  renal  irritants  and  may  cause  hematuria  (can- 
tharides,  oil  of  turpentine).  Oxaluria  is  an  occasional  cause.  The  most  usual 
cause  of  renal  hematuria  is  stone.  The  color  of  the  urine  in  hematuria  may 
be  anything  between  a  light  pink  and  a  decided  black,  but  these  colors  may 
be  produced  by  agents  other  than  blood.  (See  Sollmann's  "Text-Book  of 
Pharmacology.")  Carbolic  and  salicylic  acids  make  urine  browTi  or  greenish 
black;  beet-root  and  sorrel,  the  color  of  blood;  methylene-blue,  green  or  blue. 
In  melanosis  and  splenic  fever  the  urine  becomes  brown.  Senna  and  rhubarb 
make  an  acid  urine  yellowish  brown  and  an  alkaline  urine  purple.  In  jaun- 
dice the  urine  is  yellow  or  green.  Coal-tar  products  may  make  it  blackish 
brown.  Picric  acid  makes  it  yellow.  Santonin  makes  an  acid  urine  yellow 
and  an  alkaline  urine  pink.  Logwood  imparts  no  color  to  acid  urine,  but  colors 
alkaline  urine  violet  or  reddish.  Trional,  sulfonal,  tar,  tannic  acid,  and  gallic 
acid  make  urine  brown.  Renal  hematuria  may  be  bilateral  or  unilateral. 
The  cystoscope  and  ureteral  catheterization  will  demonstrate  the  existence  of 
either.  The  commonest  cause  of  unilateral  hemorrhage  is  stone  but  it  can  be 
caused  by  pyelitis,  infarction,  a  neoplasm,  injury,  parasites,  nephritis,  or  tuber- 
culosis. Unilateral  pain  associated  with  unilateral  hematuria  is  very  signifi- 
cant of  an  unilateral  lesion. 

Tests  for  Blood. — Spectroscopic  Test. — Bloody  urine,  if  fresh  and 
diluted  with  water,  shows  the  two  absorption  bands  of  oxyhemoglobin.  The 
addition  of  ammonium  sulphid  causes  the  two  bands  to  give  place  to  the  band 
of  reduced  hemoglobin.  If  bloody  urine  stands  for  some  time  the  four  bands 
of  methemoglobin  are  discovered  (von  Jaksch). 

Heller's  Test.— Add  potassium  hydrate  to  the  urine  and  boil;  a  red  pre- 
cipitate of  earthy  phosphates  and  hematin  forms.  Throw  the  precipitate  upon 
a  filter  and  treat  it  with  acetic  acid;  a  red  solution  is  produced,  which  soon  fades. 

Rosenthal's  Test. — Take  the  precipitate  from  caustic  potash,  dry  it,  and 
test  it  for  hematin;  put  some  of  the  dry  sediment  on  a  slide,  add  a  crystal  of 
common  salt,  apply  a  cover-glass,  and  cause  a  few  drops  of  glacial  acetic  acid 
to  flow  under  the  glass;  warm,  but  do  not  boil.  Teichmann's  crystals  will 
appear  on  cooling. 

Stnive's  Test. — Test  the  urine  with  hydrate  of  potassium  and  add  acetic 
acid  in  excess;  a  dark  precipitate  forms,  which  will  yield  crystals  of  hematin 
when  treated  with  sal  ammoniac  and  glacial  acetic  acid. 

Almen's  Test  (Guaiac  Test). — Take  10  c.c.  of  urine  and  pour  upon  its  surface 
a  mixture  of  equal  parts  of  tincture  of  guaiac  and  old  oil  of  turpentine;  at  the 


Bleeding  from  the  Kidney-substance  141 1 

point  of  junction  of  this  lliiid  with  the  uruic  there  forms  a  white  ring  which 
turns  to  a  striking  blue.  If  a  man  is  taking  iodid  of  potash  his  urine  shows 
blue  in  the  guaiac  test. 

The  Benzidin  Test. — This  is  very  delicate.  If  this  reaction  cannot  be 
obtained  the  urine  is  certainly  free  of  blood.  Add  i  c.c.  of  glacial  acetic  acid 
to  10  c.c.  of  urine.  Add  to  the  mixture  one- third  of  its  volume  of  ether  con- 
taining a  few  drops  of  alcohol,  shake,  and  allow  to  stand.  The  ether  rises  to 
the  top,  is  taken  off  by  a  pipet,  and  is  put  in  a  test-tube  in  which  is  the  ben- 
zidin mixture  (0.5  c.c.  of  a  solution  of  benzidin  in  2  c.c.  of  glacial  acetic  acid  and 
2  c.c.  of  hydrogen  dioxid).  Blood  turns  the  reagent  green  or  blue  within  two 
minutes.  Later  the  color  changes  to  purple'.  (See  Holland's  "Medical  Chem- 
istry and  Toxicology.") 

Microscopical  Test.- — The  microscope  shows  numerous  corpuscles  except 
in  a  very  alkaline  urine,  when  but  few  corpuscles  may  be  found. 

In  hemoglobinuria — a  condition  sometimes  occurring  after  burns,  as  a  result 
of  large  doses  of  urotropin,  and  during  malaria,  acute  febrile  maladies,  metallic 
poisoning,  acute  alcoholism,  poisoning  by  mushrooms,  chlorate  of  potash,  coal- 
tar  products,  pyrogallic  acid,  and  naphthol — there  is  present  blood  coloring- 
matter,  which  is  showm  by  Heller's  test  and  by  Almen's  test.  The  spectro- 
scope shows  methemoglobin.  The  microscope  shows  no  corpuscles  or  only  a 
few,  but  discloses  masses  of  pigment.  Hemoglobinuria  does  not  occur  in  dis- 
eases limited  to  the  genito-urinary  tract. 

Determination  of  the  Source  of  the  Blood. — In  a  woman,  be  sure  that  the 
bloody  urine  is  not  due  to  a  mixture  with  menstrual  blood.  If  menstruation 
does  exist,  obtain  the  urine  for  examination  by  a  catheter.  The  three-glass 
test  may  he  of  service.  Blood  may  be  thoroughly  mixed  with  urine.  Renal 
blood  is  sure  to  be  mked.  Bladder  blood  may  or  may  not  be.  Blood  from 
the  urethra  comes  out  with  the  first  urine.  The  source  of  blood  may  be  deter- 
mined certainly  only  by  the  urethroscope,  cystoscope,  or  ureteral  catheter. 

Bleeding  from  the  Kidney=substance. — Bleeding  from  the  pelvis  of 
the  kidney  and  from  the  tireter  may  be  due  to  inflammation,  congestion,  con- 
tusion, stone,  vicarious  menstruation,  hemorrhagic  diathesis,  powerful  di- 
uretics, fevers,  purpura,  tumors,  catheterization  of  the  ureter,  etc.  Blood  is 
thoroughly  mixed  with  the  urine  and  no  sediment  forms  (smoky  urine).  The 
corpuscles  are  profoundly  altered,  are  devoid  of  coloring-matter,  and  show 
pale-yellow  rings.  The  severity  of  the  hemorrhage  is  measured  by  the  number 
of  the  corpuscles.  Von  Jaksch  states  that  the  diagnosis  between  renal  and 
ureteral  hemorrhage  rests  on  the  nature  of  the  casts  and  epithelium  present. 
From  the  pelvis  of  the  kidney  and  from  the  ureter  comes  small  epithelium, 
the  cells  from  the  superficial  layers  being  polygonal  or  elliptical,  those  from 
the  deeper  layers  being  oval  or  irregular.  In  hemorrhage  from  the  ureter  the 
cells  are  few;  in  hemorrhage  from  the  pelvis  they  are  plentiful  and  rest  upon  one 
another  like  "tiles  on  a  roof"  (von  Jaksch).  Cells  from  the  tubules  of  the 
kidney  are  small,  granular,  and  polyhedral,  have  large  nuclei,  and  are  often 
so  arranged  as  to  form  cylinders  (epithelial  casts) .  The  urine  during  and  imme- 
diately after  a  renal  hemorrhage  is  apt  to  be  acid  unless  alkalis  have  been 
administered,  unless  the  bleeding  has  been  severe,  or  unless  pus  is  present  in 
the  urine.  A  very  large  renal  hemorrhage  may  cause  the  passage  of  almost 
pure  blood.  In  renal  hematuria  there  are  aching  in  the  loin,  numbness  of  the 
corresponding  leg,  and  often  renal  colic.  The  use  of  the  cystoscope  enables 
the  surgeon  to  determine  if  the  hemorrhage  is  vesical  or  renal,  and  if  it  comes 
from  one  or  both  kidneys.  If  the  bladder  fluid  is  kept  clear,  the  blood  can  be 
seen  flowing  out  of  the  ureter  of  the  damaged  organ,  or  if  both  ureters  are 
catheterized  a  sample  of  urine  can  be  obtained  from  each  kidney.  Even  when 
skilfully  used  the  ureteral  catheter  is  apt  to  cause  slight  hemorrhage.  Hence, 
after  catheterization,  microscopical  hemorrhage  does  not  count  in  diagnosis. 


141 2  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Spontaneous   Hemorrhage  into  the  Kidney. — This  may  or  may  not  cause 

hematuria.  It  may  arise  during  nephritis  or  may  depend'  on  arterial  disease. 
No  lesion  may  be  discoverable.  If  accompanied  by  hematuria  it  is  classed 
as  essential  hematuria  (see  below).  The  bleeding  may  take  place  beneath  the 
capsule  or  through  a  tear  in  the  capsule  into  the  perirenal  tissue.  In  some 
cases  bleeding  begins  in  the  perirenal  tissue.  A  possible  cause  is  aneurysm  of 
the  renal  artery.  There  are  26  cases  of  this  condition  on  record  ("Lancet," 
Jan.  27,  191 2).  Spontaneous  hemorrhage  comes  on  suddenly  with  shock  and 
pain  in  the  loin.  There  may  or  may  not  be  hematuria.  A  mass  can  be  pal- 
pated. In  some  cases  the  skin  becomes  discolored.  Always  operate.  If 
hemorrhage  comes  from  perirenal  tissue,  excise  the  bleeding  tissue.  If  blood 
comes  from  the  kidney  it  is  usually  necessary  to  perform  nephrectomy.  In 
spontaneous  hemorrhage  blood  may  tear  its  way  into  the  peritoneal  cavity. 
(See  Article  by  Russell  S.  Fowler,  in  "Annals  of  Surgery,"  Dec,  191 1.) 

Essential  Hematuria. — In  this  condition  the  ureteral  catheter  reveals 
blood  from  one  kidney  only,  there  being  no  demonstrable  lesion  to  account  for 
the  condition.  Randall,  in  a  very  comprehensive  article,  draws  the  follow- 
ing conclusions  regarding  this  condition  ("Jour.  Am.  Med.  Assoc,"  Jan.  4, 

1913-) 

He  divides  essential  hematurias  into  three  groups:  (i)  Nephritis  with  con- 
gestion playing  the  leading  role.  (2)  Varicosities  of  vessels  of  renal  pelvis  result- 
ing from  some  extrinsic  condition  affecting  the  kidney  circulation.  (3)  Hemor- 
rhage due  to  rupture  of  capillaries  or  to  diapedesis  of  red  blood-corpuscles. 
In  each  of  these  conditions  congestion  probably  exists. 

I  believe  that  some  cases  are  due  to  unrecognized  papilloma.  Essential 
hematuria  is  sometimes  called  unilateral  hematuria,  an  unfortunate  name, 
as  many  cases  of  hematuria  which  do  not  belong  to  this  group  are  unilateral. 

Ureteral  Catheterism. — Catheterization  of  the  ureters  may  give  in- 
formation of  the  greatest  value.  It  enables  the  surgeon  to  obtain  the  urine 
from  one  kidney  unmixed  with  urine  from  the  other  kidney  and  uncontaminated 
by  material  from  the  bladder  or  urethra.  By  this  method  we  can  determine 
if  pus,  blood,  bacilli,  etc.,  come  from  the  ureter  or  kidney,  and  from  which 
ureter  or  kidney.  A  stricture  of  or  a  calculus  in  a  ureter  can  be  located;  hydro- 
nephrosis and  pyonephrosis  can  be  diagnosticated;  the  presence  of  both  kid- 
neys, if  either  kidney  is  diseased  or  if  both  are  diseased,  and  the  secretory 
capacity  of  each  kidney  in  a  given  time,  can  be  ascertained.  The  method 
is  also  employed  to  treat  various  conditions  cf  the  ureter  and  kidney. 

Kelly  impressed  upon  the  profession  that  the  ureters  in  women  could  be 
catheterized  when  the  patient  by  the  knee-chest  posture  permitted  the  atmos- 
pherical distention  of  the  bladder,  so  that  the  ureteral  orifices  could  be  inspected 
through  a  speculum.  Light  is  reflected  into  the  speculum,  a  forehead  mirror 
and  an  electric  light  being  employed.  It  may  be  necessary  to  dilate  the  ure- 
thra before  inserting  the  speculum.  It  is  rarely  necessary  to  give  a  general 
anesthetic.  Kelly  moistens  a  bit  of  cotton  wrapped  on  a  metal  rod  in  a  10 
per  cent,  solution  of  cocain,  introduces  it  just  within  the  external  urethral 
orifice,  and  holds  it  there  for  five  minutes  before  beginning  the  operation. 
When  the  ureteral  orifice  of  one  side  is  found  by  inspection  through  the  specu- 
lum, he  introduces  a  sterile  flexible  silk  catheter  lubricated  with  boroglycerid 
and  it  is  pushed  up  from  4  to  6  inches  in  the  ureter.  A  similar  tube  is  intro- 
duced into  the  other  ureter  and  the  separated  urines  are  collected  in  test-tubes. 
(See  Kelly's  "Operative  Gynecology.")  The  catheterization  of  the  ureters 
by  this  method  can  be  performed  by  a  dextrous  and  experienced  man  only; 
but  such  an  individual  can  do  it  with  ease  and  celerity;  as  practised  by  Kelly 
himself  it  seems,  until  one  tries  it,  the  perfection  of  ease  and  simplicity. 

Kelly  has  catheterized  the  ureter  in  man  by  inserting  a  straight  speculum, 
placing  the  patient  in  the  knee-chest  position  to  inflate  the  bladder  with  air, 


Segregation  of  Urine 


1413 


and  introducing  a  metallic  catheter.     (For  a  discussion  of  the  technic  of  cathe- 
terizing  the  ureters  see  Cystoscopy,  page  1447.) 

Segregation  of  urine  is  the  method  of  obtaining  urine  separately  from  each 
ureter  by  segregating  each  ureter's  supply  into  an  artificial  trough,  from  which 
it  is  drawn.  The  method  is  seldom  used  in  the  United  States  at  the  present 
time.  It  is  painful,  unreliable,  and  has  been  replaced  by  ureteral  catheteriza- 
tion. In  cases  in  which  the  ureters  cannot  be  found,  segregation  may  be  em- 
ployed. The  three  most  practical  segregators  are  Harris's,  Luys's,  and  Cathe- 
lin's.  Professor  Harris,  of  Chicago,  has  devised  an  instrument  (Fig.  929) 
which  in  some  cases  simplifies  the  problem  of  obtaining  unmLxed  urine  from 
each  ureter.  The  double  catheter  is  passed  into  the  bladder.  The  lever  is 
inserted  in  the  rectum  of  the  male  and  the  vagina  of  the  female.  The  lever 
is  fastened  to  the  perforated  frame  from  the  double  catheter.  The  double 
catheter  is  now  opened  in  the  bladder,  and  the  blades  of  the  instrument  are 
held  in  position  by  a  spring.  The  end  of  the  lever  in  the  vagina  or  rectum 
humps  up  the  floor  of  the  bladder  between  the  separated  ends  of  the  divided 
catheter,  and  forms  a  longitudinal  septum  or  watershed  between  the  ureteral 
orifices.     The  end  of  each  catheter  lies  in  the  bottom  of  a  pocket  to  the  side 


Fig.  929. — Harris's  segregator  fitted  for  use. 


of  the  watershed.  ''By  producing  a  very  slight  exhaustion  of  the  air  in  the 
vials  by  means  of  the  bulb  the  urine,  as  fast  as  it  escapes  from  the  ureters,  drops 
directly  into  the  ends  of  the  catheters  and  flows  at  once  into  the  vials,  right  and 
left  respectively."^ 

In  using  this  instrument  place  the  patient  flat  on  his  back  upon  a  table, 
the  thighs  and  legs  being  flexed,  and  the  feet,  hips,  and  head  being  on  the  same 
level.  Irrigate  the  bladder  thoroughly  with  sterile  water  and  have  150  c.c. 
of  fluid  in  the  bladder  when  the  blades  are  opened.  Leave  the  instrument  in 
place  for  thirty  minutes.  It  is  rarely  necessary  to  give  an  anesthetic.  In  some 
cases  cocain  must  be  used,  and  in  some  cases  of  painful  cystitis  ether  should  be 
given.  Harris  says  the  instrument  should  not  be  used  if  there  be  a  growth  of 
the  bladder  that  bleeds  easily,  if  the  bladder  be  contracted,  if  there  be  a  very 
large  prostate  or  a  vesical  stone. ^ 

In  catheterization  of  the  ureters  there  is  always  some  danger  of  carrying 
infection  upward  from  the  bladder,  and  sometimes  catheterization  is  impossible. 
It  is  impossible  if  great  quantities  of  blood  or  pus  make  the  urine  opaque,  or 
if  inflammation  of  the  bladder  wall  hides  one  or  both  ureteral  orifices.  The 
Harris  method  of  segregation  produces  considerable  pain,  but  is  free  from  this 

1  "Jour.  Cutan.  and  Gen.-Urin.  Dis.,"  May,  1899. 
-  M.  I.  Harris,  in  "Medicine,"  April,  1898. 


1414  Diseases  and  Injures  of  the  Genito-urinary  Organs 


danger.  As  a  matter  of  fact,  however,  Harris's  method  often  possesses  elements 
of  uncertainty,  because  the  septum  may  not  be  perfect  and  the  urine  from  one 
side  sometimes  contaminates  the  urine  from  the  other.  The  separator  devised 
by  Luys  in  1901  linds  some  warm  advocates  (Fig.  930).  It  causes  less  pain  and 
accomphshes  more  certain  results  than  the  instruments  of  Harris  or  Cathelin. 
Barringer  ("Am.  Jour.  Med.  Sciences,"  March,  1907)  points  out  that  "there 
are  certain  classes  of  cases  in  which  the  separator  cannot  be  used.  They  are 
the  following:  (A)  Those  in  which  the  bladder  capacity  is  less  than  20  c.c; 
(B)  those  in  which  the  urethra  is  not  penetrable  by  the  instrument;  and  (C) 

those  in  which  the  base  or  neck  of  the  bladder 
is  distorted  by  (a)  marked  prostatic  hyper- 
trophy; (b)  extreme  anteversion  or  anteflexion 
of  the  uterus;  (c)  certain  uterine  tumors;  and 
(d)  marked  cystocele."  Catheterization  of 
the  ureters  is  not  so  safe  as  separation,  is  far 
more  difficult,  but  gives  more  certain  results. 
Urethral  Hemorrhage.  —  In  urethral 
bleeding,  blood  appears  independently  of 
micturition,  or  blood  comes  out  first  and  is 
followed  by  clear  urine.  Urethral  hemor- 
rhage may  arise  from  acute  urethritis,  from 
an  inflamed  stricture,  from  the  passage  of  an 
instrument,  or  from  some  other  traumatism. 
It  may  be  due  to  a  polypus,  to  a  stone  in  the 
prostatic  urethra,  to  violent  or  prolonged  sex- 
ual effort. 

The  source  of  urethral  hemorrhage  can 
be  ascertained  by  the  use  of  the  endoscope 
or,  better,  by  means  of  the  cysto-urethroscope. 
Vesical  hemorrhage,  including  hem- 
orrhage from  the  prostate,  may  follow 
the  relief  of  retention  of  urine  (hence  do  not 
draw  off  all  the  urine  at  once  when  a  bladder 
is  distended),  may  be  due  to  stone,  inflam- 
mation, .  tumors,  etc.,  or  may  arise  from 
traumatisms,  instrumental  or  otherwise.  The 
color  of  the  urine  is  usually  bright  red,  but 
if  long  retained  in  the  bladder  it  becomes 
black  and  often  tarry.  The  reaction  is  alka- 
line. The  clots,  when  floated  out,  are  large 
and  without  definite  shape.  In  micturition  the  urine  is  clear  or  only  a  little 
colored  at  the  beginning,  but  becomes  darker  and  darker  as  micturition  con- 
tinues, and  as  it  ends  the  flow  may  consist  of  almost  pure  blood.  In  very 
small  vesical  hemorrhages  the  urine  may  be  smoky.  Crystals  of  triple  phosphate 
indicate  bladder  disorder.  The  microscope  shows  colorless  and  swollen  cor- 
puscles and  many  polygonal  cells.  Symptoms  of  bladder  mischief  usually 
exist,  but  cystoscopic  examination  or  exploratory  suprapubic  cystotomy  may 
be  required  for  the  diagnosis. 

Pain  in  Qenito=urinary  Diseases. — Pain  as  a  symptom  of  genito-urinary 
disease  may  be  found  at  some  point  distant  from  the  seat  of  lesion.  A  stone 
in  the  bladder  causes  pain  in  the  head  of  the  penis  just  back  of  the  meatus; 
stone  in  the  kidney  induces  pain  in  the  loin,  the  groin,  the  thigh,  and  the  testicle; 
inflammation  of  the  testicle  causes  pain  in  the  line  of  the  cord  in  the  groin.  In 
other  cases  of  genito-urinary  disease  pain  is  felt  at  the  seat  of  lesion,  as  in 
urethritis  and  prostatitis.  Pain  felt  before  micturition,  and  being  relieved  by 
the  act,  is  found  in  cystitis  and  in  retention  of  urine.     Pain  is  felt  during  mic- 


FiG.  930. — Luys's  separator:  a, 
The  composite  instrument  ready  for 
introduction ;  i  and  k,  discharge  tubes ; 
h,  screw  to  regulate  the  tension  of  the 
membrane;  b,  flat  middle  piece;  c  and 
d,  grooved  lateral  portions;  e,  tip 
uniting  the  parts;  g-f,  rubber  mem- 
brane, tense.  The  chain  is  not  visible 
in  the  figure  (Sahli). 


The  Determination  of  the  Excretory  Capacity  of  the  Kidneys   141 5 

turition-  in  inflammation  of  the  bladder,  prostate  and  urethra,  and  in  the 
passage  of  gravel  or  stone.  Pain  which  is  acute  at  the  end  of  micturition  is 
noted  in  stone  in  the  bladder,  in  trigonitis  or  urethrocystitis  (inflammation  of 
the  neck  of  the  bladder),  and  in  inflammation  of  the  prostate  gland.  The  pain 
caused  by  stone  in  the  bladder,  it  may  be  observed,  is  ameliorated  by  rest  and 
is  aggravated  by  exercise  unless  the  stone  be  encysted.  The  pain  caused  by 
acute  prostatitis  is  intensified  by  defecation  and  the  act  is  accompanied  by  the 
appearance  at  the  meatus  of  a  few  drops  of  starch-like  mucus. 

Frequency  of  Micturition. — Frequent  micturition  arises  from  irritation 
of  the  sensory  nerves,  from  phimosis,  contracted  meatus,  inflammations, 
very  acid  urine,  calculi,  urethral  stricture,  and  hyperesthesia  of  the  urethra. 
Frequency  of  micturition  may  be  due  to  spinal  irritability  from  concussion 
or  from  sexual  excess,  from  contraction  of  the  bladder  rendering  the  viscus 
unable  to  hold  much,  from  worry,  anxiety,  fear,  or  from  excessive  urinary 
secretion,  as  in  diabetes  or  in  the  first  stage  of  contracted  kidney.  Frequent 
micturition  exists  in  obstruction  by  enlarged  prostate  and  in  atony  of  the 
bladder  walls.  Hypersecretion  of  urine  plus  bladder  intolerance  is  known  as 
"nervousness  of  the  bladder,"  and  is  found  in  hysteria.  Frequency  of  mictu- 
rition increased  by  movement  is  observed  in  stone  and  tumor  of  the  bladder. 
Nocturnal  frequency  of  micturition  is  present  in  cases  of  enlarged  prostate 
and  atony  of  the  muscular  walls  of  the  bladder.  Frequency  of  micturition 
with  diminution  of  the  diameter  of  the  stream  suggests  a  constriction  of  the 
urethral  canal;  frequency  of  micturition  with  diminished  projectile  force  sug- 
gests a  posterior  stricture,  enlarged  prostate,  or  bladder  atony.  Slowness  of 
micturition  hints  at  enlarged  prostate,  atony,  or  urethral  stricture. 

Sir  Henry  Thompson s  diagnostic  questions  are  as  follows: 

"i.  Have  you  any,  and,  if  so,  what,  frequency  in  passing  water?  Is  fre- 
quency more  manifest  during  the  night  or  the  day?  Is  frequency  more  manifest 
during  motion  or  rest?     Does  any  other  circumstance  affect  it? 

"2.  Is  there  pain  on  passing  urine,  and,  if  so,  is  it  before,  during,  or  after 
the  act?  What  is  its  character — acute,  smarting,  dull,  transitory,  or  con- 
tinuous? What  is  its  seat?  Is  it  felt  at  other  times,  and  is  it  produced  or 
intensified  by  sudden  movements? 

"3.  What  is  the  character  of  the  stream?  Is  it  small  or  large;  twisted  or 
irregular;  strong  or  weak;  continuous,  remitting,  or  intermitting?  Does  it 
come  through  the  meatus,  or  partly  or  entirely  through  fistulas? 

"4.  Is  the  character  of  the  urine  altered?  What  is  its  appearance,  color, 
odor,  reaction,  and  specific  gravity?  Is  it  clear  or  turbid,  and,  if  turbid,  is 
it  so  at  the  time  of  passing?  Does  it  vary  in  quantity?  Are  the  normal 
constituents  increased  or  diminished?  Does  it  contain  abnormal  elements, 
as  albumin  or  sugar?  What  inorganic  deposits  are  found?  What  organic 
materials  are  met  with? 

"5.  Has  the  urine  ever  contained  blood?  If  so,  was  the  color  brown  or 
bright  red;  were  the  blood  and  urine  thoroughly  mixed;  was  the  blood  passed 
at  the  end  or  at  the  beginning  of  micturition,  or  did  it  come  only  with  the  last 
drops  of  urine;  or  was  it  passed  independently  of  micturition? 

"6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  permanent  or  transitory, 
and  for  the  occurrence  of  severe  paroxysms  of  pain  in  these  regions." 

The  Determination  of  the  Excretory  Capacity  of  the  Kidneys  in 
Health  and  in  Disease. — As  a  rule  marked  diminution  in  the  excretory  power 
of  a  kidney  means  anatomical  changes  but  this  inference  is  not  always  correct. 
Even  a  great  diminution  in  excretion  may  be  functional.  Hence  the  surgeon 
must  always  gauge  and  weigh  the  functional  findings  in  the  light  of  clinical 
evidence.  There  are  two  types  of  cases  in  which  the  surgeon  finds  renal  func- 
tional tests  of  the  greatest  value:  (i)  in  cases  in  which  kidney  disease  is  sec- 
ondary to  disease  of  the  lower  genito-urinary  tract  and  (2)  in  cases  in  which 


I4i6  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

such  tests  are  apphed  with  ureteral  catheterization  in  unilateral  and  bilateral  sur- 
gical maladies  (J.  T.  Geraghty,  in  "Bull.  Johns  Hopkins  Hospital,"  1915,  xxvi). 

The  Phloridzin  Test. — This  test  is  made  with  comparative  ease  and  may  aid 
the  surgeon  in  determining  whether  he  is  justified  in  performing  some  operation 
of  convenience.  It  enables  him  to  estimate  with  a  fair  amount  of  accuracy  the 
capacity  for  elimination  possessed  by  the  kidneys.  The  test  depends  on  the 
fact  that  the  healthy  epithelium  of  the  glomeruli  and  tubes,  when  stimulated 
to  activity  by  phloridzin,  forms  sugar  from  that  drug  and  thus  produces  tem- 
porary glycosuria.  When  the  epithelium  is  diseased,  little  or  no  glycosuria 
occurs.  The  test  is  applied  as  follows:  The  dose  is  about  5  to  10  mg.  of  phlorid- 
zin, according  to  the  body-weight  of  the  patient.  It  is  administered  hypoder- 
matically,  the  bladder  having  been  emptied  beforehand.  If  the  eliminating 
powers  of  the  kidney  are  at  a  healthy  level,  sugar  should  appear  in  the  urine 
within  half  an  hour  of  the  injection.  If  at  the  end  of  this  time  only  a  small 
amount  of  sugar  can  be  detected,  one  may  assume  that  the  kidneys  are  affected; 
and  if  no  sugar  can  be  found,  a  serious  renal  disease  may  be  assumed  to  exist. 

The  actual  standard  that  is  to  be  considered  as  the  normal  amount  of  sugar 
which  should  be  eliminated  after  the  administration  of  phloridzin  is  a  matter 
of  some  uncertainty.  It  is  usually  estimated  at  0.3  per  cent.,  a  less  amount 
of  sugar  than  this  being  taken  as  an  evidence  of  renal  difficulty  (Watson  and 
Bailey,  in  "  Report  of  Boston  City  Hospital  for  1902  ").  The  sugar  is  separated 
from  the  phloridzin  in  the  epithelium  of  the  glomeruli  and  tubules  of  the  cortex 
of  the  kidney.     The  drug  seems  to  be  entirely  harmless. 

It  is  because  phloridzin  is  acted  upon  by  the  kidney  epithelium  that  this 
test  is  better  than  the  methylene-blue  test.  The  latter  does  not  really  measure 
the  excretory  power  of  the  kidney  epithelium;  it  merely  shows  to  what  degree 
the  kidney  is  permeable  in  the  mechanical  sense.  Personally,  I  should  not 
be  disposed  to  set  aside  older  and  more  thorough  methods  of  urinary  analysis 
for  the  phloridzin  test,  although  I  believe  that  it  has  a  range  of  distinct  use- 
fulness. 

The  Methylene-blue  Test  {The  Method  of  Achard  and  Ca^/aigw) .— When 
methylene-blue  is  injected  hypodermatically  it  normally  is  changed_  into  a 
chromogen,  appears  in  the  urine  within  half  an  hour,  and  disappears  in  from 
thirty-six  to  forty-eight  hours.  If  the  blue  color  is  not  manifest  in  the  urine 
for  an  hour  or  more,  there  is  impairment  of  renal  permeability.  Only  50  per 
cent,  of  the  amount  ingested  is  removed  by  the  kidneys.  Accuracy  in  the 
test  is  not  possible  unless  the  amount  of  the  methylene-blue  actually  passing 
into  the  urine  in  a  given  time  be  determined.  The  dose  given  hypodermatically 
is  0.05  gm.  in  i  c.c.  of  sterile  water.  The  test  is  unreliable  and  the  blue  color 
may  appear  in  the  urine  in  half  an  hour  in  some  cases  of  marked  kidney  disease. 
At  its  best  the  test  only  indicates  the  freedom  of  mechanical  renal  permeability. 

The  Indigo-carmin  Test. — This  drug  should  be  largely  excreted  in  a  few 
minutes.  It  colors  the  urine.  It  is  an  unreliable  method.  It  will  show  func- 
tional failure,  but  there  may  be  no  functional  failure  even  in  organic  disease. 
In  many  cases  the  color  appears  as  quickly  in  urine  from  a  diseased  kidney 
as  in  urine  from  the  sound  organ. 

This  method  enables  us  to  recognize  functional  incapacity.  By  it  we  may 
forecast  uremia.  If  the  urine  be  collected  from  each  ureter  separately  we  can 
tell  the  capacity  of  each  kidney.  In  this  test,  if  color  does  not  appear  until 
after  twenty-five  minutes,  and  if  during  the  first  hour  less  than  30  per  cent,  of 
the  amount  introduced  is  excreted,  a  contemplated  surgical  operation  should 
be  postponed  or  abandoned. 

The  Phenolsulphonephthalein  Test. — This  is  the  most  reliable  one.  It 
shows  the  working  capacity  of  each  kidney.  The  drug  is  not  toxic.  It  is  given 
in  an  alkaline  solution.  A  hypodermatic  injection  of  6  mg.  is  administered. 
It  appears  in  the  urine  when  the  kidneys  are  normal  in  from  six  to  twelve  minutes. 


Cysts  and  Tumors  of  the  Kidney  141 7 

and  from  40  to  60  per  cent,  of  the  amount  given  is  excreted  during  the  first 
hour.  It  colors  urine  red  and  a  quantitative  estimation  can  be  made  by  means 
of  a  colorimeter.  When  the  color  first  appears,  and  how  much  of  the  drug  is 
excreted  in  the  first  hour,  must  be  noted. 

Cryoscopy  (Kordnyi's  Method).— Cry oscopy  is  the  determination  of 
the  freezing-point  of  a  liquid  and  the  comparison  of  this  with  the  freezing- 
point  of  distilled  water.  It  is  applied  particularly  to  blood  and  urine.  This 
method  is  complex  and  difficult  of  application,  requires  a  considerable  amount 
of  fluid,  and  is  not  regarded  as  very  valuable.  The  freezing-point  of  a  fluid 
depends  upon  the  number  of  molecules  it  contains.  The  freezing-point  goes 
hand  in  hand  with  molecular  concentration — great  concentration  gives  a  low 
freezing-point;  little  concentration,  a  high  freezing-point.  Cryoscopy  of  the 
blood  and  urine  is  used  to  determine  the  adequacy  of  renal  activity.  Normal 
blood  freezes  at  about  -0.56°  or  -0.57°  C.  Healthy  urine  freezes  between 
-0.9°  and  -2°  C.  In  renal  inadequacy  the  freezing-point  of  the  blood  is  lower 
than  normal  and  the  freezing-point  of  the  urine  is  higher.  It  is  held  that 
surgical  operation  is  contra-indicated  if  there  be  such  a  degree  of  renal  inactivity 
that  the  freezing-point  of  the  blood  is  at  or  below -0.6°  C.  and  if  the  freezing- 
point  of  the  urine  is  at  or  above  1°  C.  The  urine  is  obtained  from  each  kidney 
separately  and  is  compared  with  the  blood's  molecular  composition. 

Diseases  and  Injuries  of  the  Kidney  and  Ureter 

Infantile  Kidney — This  is  a  rare  anomaly  but  a  very  dangerous  one  if  a 
surgeon  operates  upon  the  other  kidney.  Even  when  ureteral  catheterization 
is  practised  a  clear  and  normal  urine  may  be  obtained  from  the  ureter  of  the  small 
kidney.  The  amount  of  urine  is  small,  the  percentage  of  urea  is  decreased  and 
functional  activity  is  impaired  (Geraghty  and  Plaggemeyer,  in  "Jour.  Am.  Med. 
Assoc,"  1 913,  Ixi).  In  some  few  persons  who  are  thin  the  it"-rays  will  demon- 
strate the  kidney  to  be  very  small.  Geraghty  and  Plaggemeyer  point  out 
that  pyelography  is  of  no  help  as  the  size  of  the  renal  pelvis  is  no  certain  index 
of  the  size  of  the  kidney  (Ibid.). 

Cysts  and  Tumors  of  the  Kidney. — Cysts  are  not  uncommon.  In  a 
case  of  congenital  cystic  kidney  both  kidneys  are  involved.  The  condition  is 
due  to  failure  of  fusion  between  the  excretory  and  collecting  tubes.  The 
cysts  are  numerous  and  are  separated  by  bands  of  atrophic  renal  structure. 
The  cyst-fluid  is  usually  clear  and  yellow  and  contains  urinary  salts.  In  some 
cases  it  is  colored  by  blood.  The  congenital  cystic  kidney  may  attain  a  great 
size.  It  is  a  strange  fact  that  these  kidneys  are  functionally  active  and  that  a 
person  who  has  them  may  live  well  into  adult  life  although  they  are  prone  to 
strike  work  suddenly,  a  cessation  which  causes  death  (see  Staehlin,  in  "Annals 
of  Surg.,"  1916,  xxx).  The  bilateral  nature  of  the  condition  forbids  nephrec- 
tomy. Cysts,  single  or  multiple,  bilateral  or  unilateral  may  arise  after  birth. 
Obstruction  of  the  renal  tubules  may  result  from  acute  parenchymatous  nephri- 
tis or  interstitial  fibrosis,  and  obstruction  may  produce  a  retention  cyst  or 
retention  cysts.  The  large  solitary,  serous  retention  cyst  is  an  uncommon 
disease,  most  often  encountered  in  males  and  in  adult  life  (Cunningham, 
"Surgery,  Gynecology,  and  Obstetrics,"  1916,  xxiii;  Staehlin,  Ibid.).  Hyda- 
tid cysts  may  form  in  the  kidney.  Tumors,  innocent  or  malignant,  may  arise 
in  the  kidney.  Among  the  innocent  tumors  are  fibroma,  lipoma,  angioma, 
and  adenoma.  Hypernephroma  of  the  kidney  arises  from  fragments  of  adrenal 
tissue  included  in  the  kidney.  Hypernephromata  were  thought  to  be  renal 
lipoma ta  until  1883,  when  Grawitz  showed  they  contained  adrenal  elements 
("Virchow's  Archiv.,"  xciii).  The  name  "hypernephroma"  was  suggested  by 
Birch-Hirschfeld  in  1896.  A  hypernephroma  may  arise  directly  from  the 
suprarenal    gland    or    it    may    arise    from    an    adrenal    "rest"    or    aber- 


I4i8  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

rant  gland.  Such  rests  may  be  met  with  in  the  substance  of  the  kidney, 
imder  the  renal  capsule,  in  the  perirenal  tissue,  in  the  testicle,  the  ovary,  the 
liver,  the  inguinal  canal,  the  mesentery,  among  the  spermatic  vessels,  in  the  broad 
ligament,  in  the  renal  plexus,  or  in  the  solar  plexus  (W.  W.  Keen).  The  term 
hvpernephroma  is  applied  to  any  growth  which  arises  from  adrenal  cells  "  whether 
the  growth  be  adenoma,  carcinoma,  or  sarcoma  in  type"  (Duffield,  in  "N.  Y. 
Med.  Jour.,"  May  i,  1909).  The  tissue  of  a  hypernephroma  is  identical  with  the 
adrenal  gland,  and  it  contains  fat  and  glycogen.  The  tumor  may  arise  at  any 
period  of  life  from  childhood  to  old  age.  The  commonest  decade  is  from 
50  to  60.  The  exact  nature  of  such  a  tumor  is  unsettled.  It  is  probably  an 
adenoma,  but  some  consider  it  to  be  a  sarcoma  and  others  a  carcinoma.  Some 
tumors  give  no  evidence  of  malignancy;  some  are  very  malignant.     A  malignant 


Fig.  931. — Sarcoma  of  kidney  with  metastasis  (Horwitz). 

Tiypernephroma  grows  rather  rapidly,  eventually  attains  a  large  size,  and 
is  sometimes  painful.  A  patient  in  the  Philadelphia  Hospital  from  whom 
J  removed  a  hypernephroma  complained  of  tenderness  in  the  left  side  and 
occasional  attacks  like  renal  colic  during  which  he  passed  bloody  urine.  The 
tumor  could  be  easily  palpated  in  the  left  loin.  The  kidney  was  removed  and 
resembled  a  huge  kidney  of  nearly  normal  shape,  but  nodular  in  outline.  Dr. 
Coplin  found  it  to  be  hypernephroma.  In  this  case  there  was  no  increase  of 
arterial  tension.  The  patient  died.  Another  case  was  a  woman  of  forty-five 
who  was  brought  to  the  Jefferson  Hospital.  She  had  suffered  from  pain  in 
the  loin  for  months.  It  was  paroxysmal,  but  lacked  the  radiation  of  renal  colic. 
Hematuria  appeared  long  after  the  pain  had  begun.  It  was  persistent,  but  small 
in  amount.  Palpation  detected  a  tumor  and  the  A;-rays  showed  enlarged  kid- 
ney. There  was  no  increase  of  arterial  tension.  Recovery  followed  nephrectomy. 
In  a  man,  aged  thirty-four,  in  the  Philadelphia  Hospital  there  were  attacks  of 


Nephroptosis,  Prolapse  of  the  Kidney,  or  Mobile  Kidney     1419 

severe  pain  referred  to  the  groin,  testicle,  and  loin.  The  bleeding  was  profuse. 
A  mass  was  palpal)le  in  the  right  upper  abdomen  and  loin.  Examination  of 
blood  showed  hemolysis,  but  there  was  no  hypertension.  The  growth  was  ex- 
posed in  the  loin.  Hemorrhage  was  so  violent  that  it  became  necessary  to  open 
the  abdomen  and  ligate  the  renal  pedicle.  The  kidney  was  removed  and  the 
patient  recovered. 

Very  malignant  cases  have  proved  fatal  within  six  weeks  after  symptoms 
have  been  observed.  Some  patients  have  lived  three  years.  A  hypernephroma 
of  malignant  nature  involves  adjacent  structures,  and  gives  rise,  after  a  time,  to 
metastases,  particularly  by  way  of  the  blood.  The  bones  are  most  liable  to 
metastatic  deposit,  but  such  deposits  may  occur  in  the  lungs,  liver,  and  other 
regions.  In  a  case  upon  which  I  operated  for  a  supposed  adenomatous  goiter 
the  condition  was  really  metastatic  hypernephroma.  Hypernephromata  are 
infinitely  more  common  in  the  kidney  than  anywhere  else.  The  treatment  is 
nephrectomy.  The  operative  mortality  of  hypernephroma  of  the  kidney  is 
from  1 2  to  15  per  cent.  The  earlier  the  operation  the  better  the  prospect  of  cure. 
One-third  of  the  cases  will  pass  the  three-year  limit  after  nephrectomy.  Sar- 
coma or  carcinoma  may  arise  in  the  kidney.  They  may  be  primary  or  secondary. 
Primary  sarcoma  is  far  more  common  than  primary  carcinoma.  Primary  sar- 
coma is  most  common  in  the  young,  and  may  reach  an  enormous  size  (Fig.  931). 
A  malignant  tumor  of  the  kidney  produces  hematuria,  the  urine  often  containing 
blood-casts  of  the  ureter,  kidney,  and  pelvis,  and  sometimes,  though  rarely, 
characteristic  cells.  Pain  is  often  present  in  the  loin  and  thigh,  and  there 
may  be  colic-like  attacks  when  clots  are  passing  through  the  ureter.  A 
tumor  can  usually  be  palpated.  Emaciation  is  decided  and  rapid.  Sarcoma 
of  the  kidney  is  a  rapid  growth  and  in  this,  as  in  all  rapidly  growing  sarco- 
mata, fever  is  not  uncommon  (Longhnane,  in  "Brit.  Jour.  Surgery,"  1914,  ii). 
In  some  few  cases  the  growth  is  bilateral.  Pyelography  with  a  10  per  cent, 
solution  of  coUargol  may  aid  in  the  diagnosis  (see  page  1455).  The  only 
possible  treatment  for  a  malignant  growth  is  early  nephrectomy.  In  some 
few  cases  an  innocent  tumor  can  be  removed  by  a  partial  nephrectomy.  A 
malignant  tumor  requires  a  complete  nephrectomy.  The  mortality  is 
considerable  (7  to  15  per  cent.)  and  rapid  recurrence  is  to  be  expected  in  80 
per  cent,  of  the  cases.  A  very  few  pass  the  three-year  limit.  In  making  a 
diagnosis  of  renal  tumor  use  the  cystoscope.  If  blood  is  coming  from  above 
the  bladder,  note  if  it  is  from  one  or  from  both  ureters.  Blood  from  both  would 
contra-indicate  nephrectomy.  Before  removing  a  kidney  it  is  necessary  to  be 
sure  that  the  patient  is  possessed  of  two  kidneys.  Note  if  urine  flows  from 
each  ureter,  or,  if  uncertain,  catheterize  the  ureters. 

Nephroptosis,  Prolapse  of  the  Kidney,  or  Mobile  Kidney. — There 
are  two  forms  of  this  condition:  (i)  Movable  kidney,  which  is  an  organ  freely 
moving  back  of  the  peritoneum,  either  within  the  cavity  of  its  fibro-fatty  capsule 
or  entirely  without  its  capsule  (this  condition  is  acquired);  and  (2)  floating  or 
-wandering  kidney,  an  organ  having  a  mesonephron  and  lying  within  the  peri-, 
toneal  cavity  (this  rare  condition  is  always  congenital).  Keen  states  that  there 
may  be  drawn  a  clear  theoretical  distinction  between  movable  and  floating 
kidney,  but  practically  there  is  no  rigid  line  of  demarcation,  as  a  movable 
kidney  may  have  as  large  a  range  of  movement  as  a  floating  kidney.  The 
kidney  is  normally  somewhat  mobile,  and  nephroptosis  is  considered  to  exist 
only  when  the  range  of  movement  exceeds  distinctly  what  is  normal.  Normally, 
on  inspiration  the  kidney  descends  about  ^^2  inch.  It  is  seldom  that  a  normal 
kidney  can  be  palpated  in  men,  but  in  most  women  the  right  kidney  can  be 
palpated,  and  in  some  women  the  left  organ  can  also  be  felt.  Harris  ("Jour. 
Amer.  Med.  Assoc,"  June  i,  1901)  describes  three  degrees  of  movable  kidney. 
In  cases  of  the  first  degree,  one-half  of  the  organ  can  be  distinctly  grasped  and 
the  kidney  can  be  made  to  recede.    In  cases  of  the  second  degree  both  hands 


I420  Diseases  and   Injuries  of  the  Genito-urinary  Organs 

can  be  brought  together  above  the  kidney.  In  cases  of  the  third  degree  the 
kidney  has  descended  as  low  as  the  pelvic  brim  or  has  moved  to  or  beyond  the 
umbilicus.  The  organ  may  drop  below  the  brim  of  the  pelvis,  may  cross  the 
vertebral  column,  or  may  reach  the  anterior  abdominal  wall.  When  a  movable 
kidney  becomes  fixed  in  an  abnormal  situation,  the  organ  is  spoken  of  a.sdislocated. 
Women  suffer  from  movable  kidney  more  often  than  men.  Kiister 
estimates  that  4.41  per  cent,  of  women  examined  in  general  surgical  practice 
have  movable  kidney.  Edebohls  finds  it  in  20  per  cent.,  and  Harris  in  56 
per  cent.,  of  cases  in  gynecological  practice.  In  about  one-half  of  the  cases 
it  gives  rise  to  little  or  no  trouble.  A  movable  kidney  is  found  in  the  great 
majority  of  cases  upon  the  right  side.  In  many  cases  it  is  bilateral,  the  right 
kidney  being  usually  the  most  mobile.  Splanchnoptosis  may  be  associated  with 
acquired  nephroptosis.  Floating  kidney  is  always  congenital.  Movability  of 
the  kidney  is  occasionally,  but  rarely,  found  in  children,  though  congenital 
cases  occur.  In  a  congenital  case  there  is  not  splanchnoptosis.  Tufi&er 
has  reported  3  cases  in  children  six,  nine,  and  ten  years  of  age  respectively, 
and  J.  Cromby  reported  18  cases  of  floating  kidney  in  children,  the  youngest 
patient  being  three  months  of  age  (quoted  by  Harris,  Ibid.).  Among  the 
assigned  causes  of  the  movable  condition  are  to  be  named  traumatism;  strains; 
abdominal-wall  laxity  from  pregnancy,  removal  of  a  tumor,  or  tapping  for 
ascites;  absorption  of  peritoneal  fat  from  wasting  disease  (Edebohls);  tight 
lacing;  uterine  displacements;  and  enteroptosis  leading  to  traction  on  the 
transverse  mesocolon.  The  condition  is  certainly  often  associated  with  ptosis 
of  the  other  abdominal  viscera  (enteroptosis,  gastroptosis,  etc.). 

Traumatism  is  rarely  the  immediate  and  essential  cause  of  a  true  movable 
kidney.  In  some  cases  patients  assert  that  pain  began  immediately  after  a 
blow,  an  attack  of  coughing,  violent  vomiting,  lifting,  straining  at  stool,  a 
fall,  or  in  parturition.  In  such  cases  the  kidney  may  have  been  mobile  before 
the  accident.  Again,  pain  is  not  proof  of  the  inauguration  of  movability.  It 
is  probable,  however,  that  traumatism  may  loosen  the  kidney  and  that  mobility 
may  subsequently  develop.  Gutterbock  says  that  a  kidney  in  normal  relations 
cannot  be  rendered  mobile  by  a  simple  fall  or  a  trivial  force.  Loosening  can  be 
induced  only  by  rupturing  surrounding  tissues;  and  if  this  happens,  symptoms  of 
a  distinct  nature  will  indicate  the  seat  of  injury.  Becher  and  Lennhoff  claimed 
that  there  is  a  connection  between  movability  of  the  kidney  and  the  length 
and  breadth  of  the  body.  They  have  laid  down  a  formula,  viz.:  Measure 
the  distance  from  the  suprasternal  notch  to  the  crest  of  the  pubes.  Divide 
this  by  the  smallest  circumference  of  the  abdomen.  Multiply  the  product  by 
100.  The  result  is  the  abdominal  index.  If  the  index  is  greater  than  75  there 
is  a  tendency  to  movable  kidney.  If  it  is  less  than  75  there  is  no  such  tendency. 
Harris  makes  out  a  strong  case  for  the  view  that  the  condition  is  due  to  the 
relation  existing  between  the  location  of  the  kidney  and  the  body  form.  He 
divides  the  body  into  three  zones:  The  upper  zone  contains  the  lungs  and 
heart.  The  middle  contains  the  liver,  stomach,  spleen,  pancreas,  and  the 
greater  part  of  each  kidney.  The  lower  contains  the  intestinal  canal  and  the 
lesser  part  of  each  kidney.  When  there  is  a  naturally  small  or  a  diminished 
capacity  of  the  middle  zone,  the  kidney  is  displaced  downward.  The  right 
kidney  is  pressed  upon  by  the  heavy  liver,  which  drives  it  down;  the  left  kidney 
is  pressed  upon  by  the  comparatively  small  spleen.  Hence  movable  kidney  is 
more  common  on  the  right  side  than  on  the  left.  The  upper  pole  of  the  kidney 
is  first  pushed  forward  and  then  the  entire  organ  descends  (M.  L.  Harris,  in 
"Jour.  Amer.  Med.  Assoc,"  June  i,  1901).  Harris  maintains  that  the  amount 
of  mobility  depends  upon  the  degree  of  contraction  of  the  middle  zone  and  upon 
internal  traumatisms  (lifting,  straining,  coughing,  etc.). 

Symptoms  of  Both  Forms. — There  may  be  no  discomfort  whatever,  or  the 
patient  may   be  a   confirmed   invalid.     The    usual   symptoms  are   epigastric 


Symptoms  of  Nephroptosis 


1421 


pain  (just  to  the  left  of  the  middle  line),  which  disappears  when  the  kidney 
is  replaced,  dragging  pain  in  the  loin,  and  paroxysms  like  nephritic  colic. 
Sudden  attacks  of  violent  pain  in  the  kidney  or  stomach  may  occur — attacks 
which  are  accompanied  by  nausea,  vomiting,  great  weakness  or  collapse,  vertigo, 
chills,  and  subsequently  elevated  temperature  (DiclPs  crises).  Dietl's  crises 
are  due  to  kinking  or  twisting  of  the  ureter  or  renal  vessels  or  to  inflammation 
of  the  kidney.  They  may  be  caused  by  physical  exertion  or  indiscretion  in 
diet  and  may  be  followed  by  hydronephrosis  or  strangulation  of  the  renal 
vessels.  A  few  years  ago  I  operated  upon  a  man  suffering  from  a  violent  and 
prolonged  crisis  and  found  a  twist  of  the  vessels  and  ureter.  In  a  Dietl's  crisis 
there  is  congestion  or  strangulation  or  both.  An  incomplete  or  temporary 
twist  of  the  renal  pedicle  may  induce  simply  pain  in  the  abdomen  and  loin, 
hematuria,  albuminuria,  and  cylindruria. 

The  question  as  to  whether  or  not  abdominal  pain  is  due  to  movable  kidney 
is  sometimes  in  doubt.  The  localization  of  the  pain  may  lead  us  to  suspect 
appendicitis.  Some  surgeons  think  that 
catarrhal  appendicitis  is  often  associated 
with  movable  kidney,  but  I  do  not  think 
the  association  is  common.  "Dr.  Kelly 
has  shown  us  how  to  solve  this  doubtful 
question  between  appendicular  pain  and 
the  pain  of  movable  kidney.  He  catheter- 
izes  each  ureter  separately,  and  introduces 
into  each  catheter  as  much  fluid  as  the 
renal  pelvis  will  hold  without  causing  pain. 
He  then  measures  this  fluid  from  each  side, 
and  determines  whether  it  is  in  excess  of 
an  estimated  average.  If  it  is  in  excess, 
he  is  sure  that  dilatation  has  begun.  He 
then  injects  the  kidney  again,  with  the  de- 
liberate purpose  of  producing  pain:  and  if 
the  patient  recognizes  this  pain  due  to  the 
distention  as  of  the  same  character  and  in 
the  same  position  as  that  which  he  has 
previously  felt.  Dr.  Kelly  assumes  that  the 
pain  has  been  due  to  the  kidney,  and 
not  to  the  appendix,  and  recommends  an 
operation  to  flx  the  kidney"  (the  author,  in 
"New^  York  Med.  Jour.,"  August  4,  1906). 
Usually  in  a  case  of  movable  kidney  there 
is  a  sense  of  a  moving  body  in  the  abdomen, 
and  the  patient  has  aggravated  indigestion,  often  accompanied  by  vomiting. 
Constipation  is  the  rule,  and  violent  attacks  of  cardiac  palpitation  are 
common.  ]\Iost  subjects  of  kidney  mobility  are  extremely  nervous — many 
of  them  hysterical  or  h\-pochondriacaI.  Persistent  vasomotor  paresis  causes 
cold  hands  and  feet  and  often  albuminuria.  Temporary  jaundice  is  not 
uncommon.  There  is  frequently  irritability  of  the  bladder.  Vertigo  and  in- 
somnia are  present  in  many  cases.  The  patient  cannot  sleep  when  lying  on 
the  sound  side  (Goelet).  In  women  the  sexual  organs  are  almost  invariably 
deranged,  and  menstruation  aggravates  the  pain  and  discomfort.  AU  the  s}Tnp- 
toms  are  intensified  by  exertion  and  are  modified  by  rest.  The  urine  is  normal 
except  after  violent  exercise,  when  it  may  contain  blood.  Splanchnoptosis  may 
also  exist,  and  if  it  does,  the  pulsations  of  the  abdominal  aorta  are  strongly 
noticeable  because  that  structure  is  bared  by  gastroptosis.  The  proof  of  the  exist- 
ence of  movable  kidney  is  the  finding  of  a  mass,  movable  on  respiration,  change  of 
position,  and  palpation,  shaped  like  that  organ,  pressure  upon  which  occasions 


Fig.  932. — A.  H.  Goelet's  method 
of  palpation  for  the  detection  of  a 
prolapsed  kidney. 


1422  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

no  sensation  or  causes  pain  or  a  sickening  feeling.     A  "lumbar  recess"  (Morris) 
may  sometimes  be  found,  and  percussion  over  the  loin  gives  resonance.     In  some 
cases  a  movable  kidney  can  be  readily  detected  when  the  patient  stands  up  but 
is  difficult  to  find  when  he  is  recumbent.     Franks'  method  of  examination  is  very 
satisfactory  in  most  cases  (Fig.  932).     The  patient  is  placed  recumbent.     If 
dealing  with  a  right  kidney,  the  surgeon  stands  to  the  right  side  and  pushes  four 
fingers  of  his  left  hand  in  the  loin  below  the  twelfth  rib,  and  rests  the  thumb 
lightly  in  front  just  below  the  ribs.     The  patient  takes  a  full  breath  and  holds 
it  a  moment,  and  just  before  he  empties  his  lungs  the  surgeon  presses  his  thumb 
up  deeply  below  the  ribs.     During  expiration  the  thumb  follows  the  liver,  and 
the  fingers  press  toward  the  front.     If  with  the  right  hand  the  kidney  can  be 
felt  entirely  below  the  left  hand,  the  case  is  one  of  movable  kidney.     If  such 
a  condition  is  detected,  press  hard  with  the  right  hand,  and  gradually  loosen  the: 
grasp  of  the  left  hand,  and  the  kidney  will  slip  between  the  fingers  and  ascend. 
A  normally  mobile  kidney  descends  so  that  its  lower  end  can  be  felt,  but  it  moves^ 
back  during  expiration.^     Goelet  uses  Kendal  Franks's  method  of  palpation,  but 
has  the  patient  stand,  with  the  weight  resting  on  the  leg  of  the  sound  side  and  with 
the  leg  of  the  impaired  side  slightly  flexed  and  resting  on  the  toes.     The  body^ 
leans  a  little  forward.     A  movable  kidney  must  not  be  mistaken  for  a  distended 
gall-bladder,  a  tumor  of  the  mesentery,  stomach,  or  omentum,  a  phantom  tumor, 
an  ovarian  tumor,  or  a  cancer  of  the  pancreas.     A  distended  gall-bladder  can  be 
pushed  upward,  but  not  backward,  and  not  downward  unless  the  liver  be  mov- 
able; it  is  extremely  tender,  and  cannot  be  pushed  out  of  reach.     A  kidney  can  be 
pushed  upward  and  backward — in  fact,  in  all  directions.     An  enlarged  gall- 
bladder can  always  be  palpated.     A  movable  kidney  which  is  not  enlarged 
can  be  felt  at  times  and  not  at  others  (Henry  Morris).     A  movable  kidney 
may  pass  between  the  examiner's  fingers,  and  if  pushed  into  the  loin,  it  tends- 
to  remain;  but  if  a  distended  gall-bladder  is  pushed  into  the  loin,  it  springs- 
out  as  soon  as  pressure  is  relaxed  (Henry  Morris) .     The  a:- ray  study  of  the  kidney 
pelvis  after  injection  with  collargol  is  known  as  pyelography  (see  page  1456). 
The  x-T2iy  picture  of  a  kidney  so  injected  is  a  pyelogram.     This  method  is  of 
the  highest  diagnostic  value.     It  will  always  show  a  displaced  kidney,  and  it- 
indicates  hydronephrosis.     One  picture  should  be  taken  with  the  patient  stand- 
ing, another  with  the  patient  recumbent..    It  is  important  to  remember  that 
in  about  one-half  of  the  cases  of  movable  right  kidney  the  left  kidney  is  also 
movable,  but  to  a  less  degree.     Appendicitis  is  thought  by  some  to  be  more 
frequent  in  individuals  with  movable  right  kidney  than  in  those  free  from  renal 
mobility.     Sometimes  a  movable  kidney  endangers  life,  rupture  of  the  kidney,, 
twisting  or  rupture  of  the  ureter,  or  strangulation  of  the  renal  vessels  occurring, 
the  ultimate  cause  of  death  being  nephritis,  uremia,  or  hydronephrosis. 

Treatment. — Mobile  kidney  is  treated  as  follows:  If  the  kidney  is  but 
slightly  mobile  and  there  are  no  local  symptoms,  the  treatment  should  be  non- 
operative:  (i)  The  rest  treatment  of  S.  Weir  Mitchell  may  be  tried;  it  often 
markedly  mitigates  the  symptoms,  iDut  does  not  seem  to  cure.  (2)  Mechanical 
support  should  always  be  tried.  The  most  satisfactory  mode  of  applying 
it  is  by  the  corset  recommended  by  Gallant  ("Am.  Jour.  Obstet.,"  July,  1901). 
This  corset  is  long  and  straight  in  front,  and  when  applied,  fits  firmly  over  the 
hips  and  lower  abdomen,  less  firmly  at  the  waist,  and  least  firmly  above. 

The  patient  lies  down,  a  pillow  being  under  the  buttocks  and  the  knees 
being  drawn  up.  While  in  this  attitude  the  corset  is  put  on  and  it  is  laced  in 
front  from  below  up.  If  the  attempt  to  apply  the  corset  develops  tenderness, 
keep  the  patient  at  rest  in  bed  until  it  can  be  applied  without  pain.  In  some 
cases  conservative  treatment  is  not  indicated;  in  others  it  fails. 

In  every  case  of  very  movable  kidney,  and  in  some  cases  in  which  mova- 
bility  is  not  great,  operation  is  indicated. 

i"Brit.  Med.  Jour.,"  Oct.  12,  1895. 


Treatment  of  Nephroptosis  1423 

•  *'In  a  case  in  which  the  kidney  exhibits  trivial  movability,  but  in  which 
the  range  of  mobiUty  is  found  to  be  gradually  and  certainly  increasing,  or  in 
any  case  of  kidney  movability  in  which  there  are  distinct  local  symptoms, 
operation  is  indicated.  The  distinct  local  symptoms  mean  the  beginning  of 
actual  harm  to  the  kidney,  and  the  progressive  increase  of  movability  means 
the  ultimate  attainment  of  a  wide  range  of  movement.  A  kidney  which  is 
widely  movable  may  at  any  time  twist  upon  the  ureter  and  the  renal  vessels; 
and  it  is  certain  to  suffer  from  partial  or  slight  twists,  probably  many  times 
repeated  in  the  twenty-four  hours,  even  if  a  severe  twist  does  not  occur.  A 
deduction  from  the  foregoing  statements  is  that  a  patient  suffering  with  neph- 
roptosis, even  when  the  mobility  is  slight,  should  be  examined  at  regular  inter- 
vals, to  note  whether  the  area  of  movement  is  extending,  or  whether  local  symp- 
toms have  arisen.  Three  local  symptoms  that  should  be  regarded  as  indications 
for  operation  are  severe  pain  in  the  renal  region,  distinct  tenderness  of  the 
kidney,  and  enlargement  of  the  kidney"  (the  author,  in  "New  York  Med. 
Jour.,"  August  4,  1906).  Billington  ("Brit.  Med.  Jour.,"  May  i,  1909)  for- 
mulates the  following  indications  for  operation: 

1.  When  renal  pain  is  so  severe  or  persistent  as  to  cause  serious  incon- 
venience. The  ordinary  dragging  pain  in  the  loin  is  not  an  indication.  Bil- 
lington refers  to  severe  pain  due  to  perirenal  inflammation,  ureteral  obstruction, 
or  impeded  venous  return. 

2.  When  there  are  harassing  and  depressing  gastric  and  colonic  troubles 
(gross  lesions  being  absent). 

3.  Cases  of  spinal  and  cerebral  neurasthenia. 

4.  Cases  of  lunacy.  Personally  I  do  not  operate  on  groups  3  and  4  unless 
there  are  signs  of  grave  renal  disaster. 

The  usual  operation  chosen  will  be  nephropexy,  very  seldom  nephrectomy, 
(i)  Nephropexy  is  the  operation  employed  in  most  instances  (see  page  1443). 
It  is  the  author's  experience  that  if  the  patient  has  had  marked  nervous  symp- 
toms for  a  long  time,  nephropexy  will  rarely  cause  them  to  pass  away  perma- 
nently, even  though  the  kidney  remains  firmly  anchored.  (2)  Nephrectomy 
is  necessary  in  very  rare  cases  only;  it  may  be  done  for  dislocated  kidney, 
when  grave  kidney  disease  exists,  or  when  nephropexy  has  failed  in  a  case  of 
great  severity. 

In  many  cases  of  this  trouble  no  operation  should  be  performed,  the  use 
of  Gallant's  corset  securing,  perhaps,  decided  or  complete  relief.  I  do  not 
operate  if  the  kidney  is  only  slightly  movable  and  if  there  are  no  local  symp- 
toms or  if  there  are  merely  the  general  symptoms  of  hysteria.  If  the  mobility 
is  slight  and  the  hysterical  and  neurotic  condition  is  pronounced,  anchoring 
the  kidney  will  not  cure  the  nervous  condition  In  these  nervous  cases,  asso- 
ciated with  prolapse  of  the  kidney,  there  is  usually  also  prolapse  of  the  other 
abdominal  viscera;  and  both  kidneys  are,  as  a  rule,  movable,  the  right,  how- 
ever, in  most  cases  being  decidedly  more  movable  than  the  left. 

If  there  is  but  slight  mobility  of  the  kidney,  but  the  range  of  movement  is, 
week  by  week  and  month  by  month,  increasing,  or  if  we  find  a  case  of  mov- 
able kidney  in  which  there  are  distinct  symptoms,  an  operation  should  be  per- 
formed. The  existence  of  definite  local  symptoms  means  beginning  harm 
to  the  kidney;  and  if  we  find  the  area  of  movement  gradually  increasing,  we 
know  that  eventually  it  will  become  extensive.  Any  widely  movable  kidney 
may  twist  the  ureter  and  the  renal  vessels,  producing  serious  trouble  or  even 
disastei:,  and  consequently  should  be  fixed  by  operation.  Even  if  a  severe  twist 
does  not  take  place,  the  kidney  is  bound  to  suffer  from  partial  or  slight  twists. 
Such  kidneys  will  eventually  become  hydronephrotic.  The  meaning  of  the 
term  "slight  mobility"  is  indicated  on  a  previous  page  (see  page  1419). 

One  is  not  unusually  in  doubt  in  cases  of  movable  kidney  whether  a  pain 
indicates  local  trouble  with  the  kidney  or  catarrhal  appendicitis,  because  the 


1424  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

pain  may  be  located  in  the  appendix  region.  Kelly,  of  Johns  Hopkins  Hospi- 
tal, has  shown  how  to  solve  this  problem  (see  page  142 1). 

There  are  many  operations  for  movable  kidney.  In  all  of  them  the  kidney 
is  exposed  in  the  loin.  Some  make  a  vertical  and  some  an  oblique  incision. 
Edebohls  makes  a  vertical  incision,  forces  the  kidney  out  of  the  wound,  incises 
the  fibrous  capsule  longitudinally,  turns  a  cuff  down  on  each  side,  and  applies 
sutures.  These  sutures  traverse  the  kidney  substance  and  the  fold  of  capsule 
on  each  side.  The  upper  suture  catches  the  periosteum  of  the  last  rib;  the 
other  sutures  catch  the  lumbar  fascia.  Drainage  is  not  required,  and  the  suture 
material  employed  is  kangaroo-tendon  or  chromicized  catgut. 

Some  surgeons  simply  pass  sutures  through  the  uncut  capsule  and  the 
kidney  substance  and  thus  fasten  the  kidney  to  the  lumbar  fascia.  Others 
split  the  capsule  and  pass  sutures  through  the  edge  of  the  capsule  and  the  wound 
edges,  but  not  through  the  kidney  substance. 

To  promise  success,  an  operation  ought  to  restore  the  kidney  nearly  to  its 
normal  position  and  fix  it  permanently  in  place.  It  is  undesirable  to  inflict 
damage  on  the  kidney  itself,  and  I  do  not  believe  in  any  operation  that  seeks 
to  obtain  fixation  by  passing  sutures  through  the  kidney  substance.  In  cases 
in  which  decapsulation  is  performed  the  kidney  will  grow  fast  without  any 
special  method  of  suturing. 

Most  of  the  operations  suggested  do  not  place  the  kidney  sufificiently  high 
up  to  get  it  into  a  fair  position.  Kelly's  operation  gets  it  higher  than  most 
of  them,  and  Goelet's  operation  gets  it  well  into  place.  In  many  of  the  suture 
operations  the  sutures  are  placed  in  the  convex  surface  of  the  kidney  or  the 
kidney  capsule,  and,  on  fixing  the  kidney  by  tying  the  sutures,  there  is  a  per- 
manent quarter  twist  of  the  ureter — a  condition  that  may  be  responsible  for 
great  pain.  This  may  be  obviated  entirely  by  the  ingenious  method  of  Goelet 
("Annals  of  Surgery,"  Dec,  1903).  I  believe,  however,  that  the  suture  opera- 
tions which  do  lift  the  kidney  well  up  toward  its  proper  place  and  in  which  the 
sutures  are  applied  on  the  posterior  surface  and  not  the  convexity,  tilt  the  upper 
pole  forward  into  a  permanent  and  perhaps  disastrous  position.  Such  opera- 
tions lift  the  kidney  from  below  its  midline  and  thus  fix  the  lower  half  of  the 
organ,  but  leave  the  upper  half  unfixed.  I  believe,  too,  that  in  many  cases  in 
which  kidneys  have  been  sutured  they  get  loose  again  and  that  the  best  opera- 
tion, after  all,  is  that  by  the  use  of  slings  of  iodoform  gauze  (see  page  1442). 

Injuries  of  the  Kidney. — Laceration  or  rupture  is  caused  by  falls  and 
by  blows  upon  the  back  or  the  belly. 

Symptoms. — In  some  cases  the  parenchymatous  structure  is  torn,  but  the 
capsule  is  not  torn,  and  in  consequence  urine  and  blood  are  not  extrava- 
sated  into  the  perirenal  connective  tissue  or  into  the  peritoneal  cavity.  In 
other  cases  the  parenchyma  and  capsule  are  both  torn  and  urine  and  blood 
are  extravasated  into  the  perirenal  tissues,  the  peritoneal  cavity,  or  both  of 
these  regions.  The  laceration  may  be  trivial,  may  be  considerable,  or  may 
tear  the  kidney  apart.  The  symptoms  depend  on  the  gravity  of  the  injury. 
A  slight  tear  without  involvement  of  the  capsule  may  produce  practically  no 
symptoms  at  all.  A  more  severe  injury  produces  shock,  and,  if  profuse  bleed- 
ing occurs,  the  general  symptoms  of  hemorrhage.  In  intraperitoneal  rupture 
there  is  profuse  and  usually  fatal  hemorrhage.  In  laceration  of  the  kidney 
there  are  lumbar  tenderness  and  severe  loin  pain  which  shoots  into  the 
testicle.  If  there  is  considerable  perirenal  bleeding  the  loin  will  be  full  and 
dull  on  percussion,  and  if  the  hemorrhage  is  large,  a  palpable  mass  will  form 
after  a  time  and  after  some  days  the  skin  will  become  discolored.  There  is 
usually  frequent  and  painful  micturition,  and  in  some  cases  suppression  of  urine. 
Hematuria  occurs  in  renal  laceration  unless  the  rupture  has  been  intraperitoneal 
or  the  ureter  has  been  torn.  If  the  rupture  has  been  intraperitoneal  there  are 
evidences  of  profuse  internal  hemorrhage,  abdominal  rigidity,  etc.  (Daniel  N. 


Laceration  or  Rupture  of  the  Kidney 


1425 


Eis^drath/'  Jour.  Amor.  Med.  Assoc./'  Oct.  25,  1902).  It  is  important  to 
remember  that  hematuria  can  arise  from  simple  renal  contusion,  and  that  even 
severe  kidney  damage  does  not  of  necessity  cause  bloody  urine.  If  there  be 
hematuria,  the  use  of  the  cystoscope,  catheterization  of  the  ureters,  or  the 
employment  of  Harris's  segregator  will  demonstrate  from  which  kidney  the 
blood  comes.  A  kidney  laceration 
may  be  followed  by  secondary  hem- 
orrhage, perirenal  suppuration,  hy- 
dronephrosis, or  pyonephrosis.  The 
force  of  the  injury  may  have  caused 
kidney  displacement. 

Treatment. — In  an  intraperitoneal 
rupture  laparotomy  should  be  per- 
formed. As  a  rule,  nephrectomy  is 
necessary,  but  it  may  be  possible  to 
arrest  hemorrhage  by  packing.  If 
the  shock  is  pionounced  and  if  there 
is  increasing  fulness  in  the  loin, 
whether  hematuria  exists  or  not, 
or  if  blood  comes  profusely  from 
the  ureter,  w^hether  or  not  there  is  much  shock  or  lumbar  fulness,  make  an  explor- 
atory lumbar  incision  and  stop  the  bleeding  by  packing  or  by  a  purse-string  suture 
(Figs.  933,  934),  or,  if  necessary,  perfoim  partial,  or  even  complete,  nephrectomy. 
Ordinarily,  after  a  kidney  injury,  when  there  is  not  great  shock,  increasing  lumbar 
swelling,  or  severe  hematuria,  treat  by  rest  in  bed  and  by  feeding  with  liquid 
food  or  by  nutritive  enemata  to  prevent  vomiting.  Opium,  tannic  acid,  or 
gallic  acid  may  be  used.  Apply  ice-bags  to  the  loin  and  to  the  side  of  theabdomen, 
and  after  bleeding  ceases  strap  the  loin  and  apply  a  binder.  If  large  blood- 
clots  in  the  bladder  cause  pain  or  retention  of  urine,  introduce  a  catheter  and  in- 


FlG. 


933- — Purse-string    suture   applied   to   a 
perforation  (after  Schacher). 


Fig.  934. 


-Showing  the  application  of  a  double  purse-string  suture  for  the  arrest  of  hemorrhage 
in  large  wound  (after  Schacher). 


ject  the  bladder  with  boric  acid,  or  use  the  tube  and  evacuator  of  a  Bigelow  ap- 
paratus. If  this  procedure  fails,  open  the^  bladder  by  a  suprapubic  incision  and 
drain. 

Results  of  Operation. — Up  to  1894  there  had  never  been  a  case  of  intra- 
peritoneal rupture  operated  upon.  During  the  following  seven  years  6  were 
operated  upon  and  all  recovered  (Daniel  N.  Eisendrath,  "Jour.  Amer.  Med. 
Assoc,"  Oct.  25,  1902).  Kiister  collected  47  cases  of  nephrectomy,  and  83 
per  cent,  recovered.  Keen  estimates  the  mortality  of  primary  nephrectomy 
for  rupture  at  20  per  cent.,  and  of  secondary  nephrectomy  at  38.5  per  cent. 
Without  operation  intraperitoneal  rupture  is  inevitably  fatal.  Of  extraperi- 
toneal ruptures,  70  per  cent,  recover  without  operation  (Eisendrath) .  Francis 
90 


1426  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


S.  Watson  (''Boston  Med.  and  Surg.  Jour.,"  July  16,  1903)  has  collected»66o 
cases  of  subparietal  injury  of  the  kidney.  The  following  statistics  are  of  interest: 
Treated  expectantly:  273  cases  with  81  deaths,  a  mortality  of  29.6  per  cent. 
Treated  by  operations  other  than  nephrectomy:  99  cases  with  7  deaths,  a  mor- 
tality of  7.7  per  cent.  Treated  by  nephrectomy:  115  cases  with  25  deaths,  a 
mortality  of  21.7  per  cent. 

Perforating  wounds  of  the  kidney,  if  purely  posterior,  do  not  involve  the 
peritoneum;  if  anterior,  they  do.  The  symptoms  are  escape  of  blood  and  urine 
from  the  wound;  hematuria  is  usual,  but  not  invariable;  pain  as  in  rupture;  the 
patient  may  be  unable  to  micturate;  and  nausea,  vomiting,  and  constitutional 
signs  of  hemorrhage  exist.  Traumatic  peritonitis,  perinephric  abscess,  or  gen- 
eral sepsis  may  ensue.  Confirm  the  diagnosis  by  exploration  with  the  finger 
after  operative  exposure.  Extraperitoneal  injuries  give  a  good,  and  intraperi- 
toneal a  bad,  prognosis. 

Treatment. — If  the  wound  of  the  kidney  be  extraperitoneal,  enlarge  the 
lumbar  wound  to  permit  of  drainage,  and  arrest  hemorrhage  by  packing  and 
hot  water  or  by  a  purse-string  suture  (Figs.  933,  934). 

Suture  of  the  Kidney. — The  tendency  of  any  suture  material  to  cut  through 
the  kidney  structure  is  great.     The 
following   simple   procedure  greatly 
lessens   this  danger:    Cut   the  ordi- 
nary catgut  roll  into  three  or  four 


Fig.  935. — Catgut  ring  cut  into  quarters 
to  be  inserted  under  the  suture  as  shown 
in  Fig.  936. 


Fig.  936. — Stellwagcp's   suture   of   kidney   to 
prevent  cutting  after  tying. 


parts,  as  shown  in  Fig.  935.  Slip  beneath  the  exposed  loops  of  the  purse-string 
suture,  as  shown  in  Fig.  936,  a  section  of  the  catgut  roll  consisting  of  a  series  of 
short  stiff  strands.  These  permit  fairly  firm  tying  of  the  suture-ligature  with- 
out cutting  of  the  kidney  structure  by  the  suture.  In  nephrotomy  the  same 
procedure  can  be  used  in  closing  the  kidney  wound. 

Asepticize  the  wound^  insert  a  drainage-tube  down  to  the  kidney,  dress  with 
sterile  gauze  and  make  frequent  changes  of  dressings,  keep  the  patient  in 
bed  and  on  a  low  diet,  and  give  gallic  acid  and  opium.  In  some  cases  neph- 
rectomy, partial  or  complete,  will  be  required.  In  intraperitoneal  wounds 
perform  an  abdominal  section  and,  as  a  rule,  remove  the  damaged  organ  (see 
Nephrectomy). 

Wounds  of  the  Ureters. — Rupture  from  external  violence  is  an  ex- 
tremely rare  accident.  Eisendrath  ("Jour.  Amer.  Med.  Assoc,"  Oct.  25, 
1902)  found  only  3  undoubted  cases  on  record.  A  rupture  or  wound  from  acci- 
dental violence  is  almost  invariably  associated  with  other  serious  injuries.  The 
ureter  may  be  wounded  accidentally  by  the  surgeon  during  the  performance  of 
an  abdominal  operation,  or  it  may  be  wounded  intentionally,  as  in  Morris's 


Symptoms  of  Renal  Calculus  1427 

case,  in  which  the  ureter  was  incorporated  in  a  malignant  growth.  There  is 
particular  danger  of  injuring  the  ureter  in  operations  upon  intraligamentary 
growths,  because  the  ureter  is  displaced  and  often  resembles  an  adhesion.  The 
rule  of  surgery  is  that  when  working  about  the  ureter  the  surgeon  neither  clamps 
nor  cuts  any  structure  without  a  careful  preliminary  examination  to  identify 
the  exact  position  of  this  organ.  Rupture  causes  severe  shock  and  extravasa- 
tion of  urine  around  the  kidney  or  into  the  peritoneal  cavity.  In  extraperitoneal 
rupture  a  palpable  mass  forms  in  the  loin.  When  the  ureter  is  divided  in  an 
operation,  a  flow  of  urine  is  seen. 

Treatment. — The  upper  three-fourths  of  the  ureter  can  be  reached  by  an 
extraperitoneal  incision,  which  is  a  prolongation  of  the  incision  for  lumbar 
nephrectomy,  running  from  the  twelfth  rib  downward,  and  forward  to  i  inch 
anterior  to  the  anterior  superior  spine  of  the  ilium,  and  then  parallel  to  Pou- 
part's  ligament  until  a  point  is  reached  above  the  latter 's  center  (Fenger). 
Israel's  incision  begins  at  the  anterior  edge  of  the  erector  spinae  mass,  one 
finger's  breadth  below  the  twelfth  rib,  is  taken  forward  parallel  with  the  rib  until 
it  reaches  the  line  of  the  rib's  tip,  and  is  then  carried  toward  the  middle  of 
Poupart's  ligament  until  the  line  for  ligation  of  the  common  iliac  artery  is 
reached,  and  is  then  taken  toward  the  middle  line  as  far  as  the  outer  border 
of  the  rectus  muscle.  The  lower  one-fourth  of  the  ureter  can  be  reached  by 
abdominal  section,  by  sacral  resection,  or  by  an  incision  like  that  for  extra- 
peritoneal ligation  of  the  ihac  vessels.  The  best  operation  to  reach  the  lower 
ureter  is  Gibson's  (see  page  1445).  If  it  seems  probable  that  the  ureter  is 
wounded  or  ruptured,  explore,  and  if  a  breach  in  the  ureter  is  found,  endeavor 
to  restore  the  continuity  of  the  tube.  A  longitudinal  cut  can  be  sutured  with 
fine  catgut.  If  the  ureter  is  cut  across  near  the  bladder,  implant  the  proximal 
end  into  the  bladder  and  ligate  the  distal  end  (Van  Hook,  Penrose,  Kelly).  If 
it  is  cut  above  the  bladder  portion,  perform  lateral  implantation  by  Van  Hook's 
method  (see  page  1447). 

A  longitudinal  wound  of  the  ureter  inflicted  during  an  abdominal  operation 
should  be  sutured,  but  if  the  duct  cannot  be  readily  reached,  simply  make  a 
posterior  incision  and  drain  with  rubber  tissue,  as  the  longitudinal  wound 
will  heal  by  granulation  if  no  sutures  are  inserted  (Van  Hook).  In  a  case 
of  transverse  division  perform  uretero-ureterostomy  or  vesical  implantation; 
or,  if  neither  of  these  methods  be  feasible,  make  a  urinary  fistula  in  the  loin  or 
perform  nephrectomy. 

Renal  Calculus  (Nephrolithiasis). — A  stone  in  the  kidney  is  formed 
by  the  precipitation  of  urinary  salts  upon  the  renal  epithelial  cells  and  the  gluing 
together  of  these  salts  and  cells  by  material  from  mucus  or  blood-clot,  this  mass 
serving  as  a  nucleus  on  which  accretion  takes  place.  Most  calculi  escape  when 
small,  as  gravel.  The  cause  is  said  to  be  highly  acid  urine,  which  induces  catarrh 
of  the  renal  tubes.  Such  high  concentration  of  urine  is  favored  by  a  sedentary 
life,  by  the  ingestion  of  much  alcohol  or  nitrogenous  food,  by  constipation,  by 
an  inactive  skin,  and  by  a  torpid  liver.  Infection  is  certainly  a  cause  in  some 
cases.  Any  obstruction  to  the  ureter  favors  stone  formation  by  producing  stasis 
and  stasis  leads  to  precipitation  and  favors  infection.  O.  S.  Fowler  ("Jour.  Am. 
Med.  Assoc,"  1914,  Ixii)  points  out  that  stones  tend  particularly  to  form  in 
the  lower  pole  -and  cites  this  as  evidence  that  renal  drainage  is  deficient  from 
that  portion  of  the  organ.  The  slaves  of  poverty  are  particularly  liable  to  calculi 
because  of  the  use  of  unsuitable  foods  and  the  formation  of  great  amounts 
of  nitrogenous  waste.  Males  suffer  more  often  than  females;  certain  loca- 
tions favor  the  development  of  the  malady,  and  a  family  tendency  sometimes 
exists. 

The  symptoms  of  stone  in  the  kidney  may  not  appear  for  years  after  the 
stone  forms,  but  generally  they  are  manifested  early.  There  may  be  no  pain. 
There  had  been  none  in  13  cases  out  of  23  which  came  to  autopsy  and  were 


1428  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

reported  by  Clark.  Usually  there  is  pain;  the  severity  of  the  pain  depending 
upon  the  roughness  and  movability  rather  than  upon  the  size  of  the  stone. 
A  fixed  stone  in  the  kidney  and  a  smooth  stone  in  the  pelvis  may  cause  little  or 
no  pain.  A  rough  stone  in  the  pelvis  causes  severe  pain  The  patient  usually 
complains  of  pain  in  the  loin,  and  sometimes  of  pain  in  the  iliac  region.  Deep 
percussion  over  the  kidney  causes  pain  in  the  loin,  even  when  pressure 
is  painless  (Jordan  Lloyd's  symptom).  Pain  is  aggravated  by  exercise  and 
pressure,  and  the  kidney  is,  in  most  cases,  enlarged.  The  urine  is  often 
somewhat  albuminous,  and  may  from  time  to  time  contain  blood.  Fre- 
quency of  micturition  is  noted  during  the  day,  but  seldom  when  at  rest  at 
night.     The  urine  may  be  purulent.     Nephritic  colic  is  due  to  the  washing  of 


037. — Stone  in  kidney. 


a  calculus  into  the  orifice  of  the  ureter,  which  it  blocks,  tears,  or  distends.  The 
pain  is  either  sudden  or  gradual  in  onset,  is  fearful  in  intensity  and  runs  from 
the  lumbar  region  down  the  corresponding  thigh  and  spermatic  cord  (the  testicle 
being  retracted),  and  ihto  the  abdomen  and  back.  There  are  nausea,  vomiting, 
collapse,  sometimes  unconsciousness  or  convulsions.  Frequent  attempts  at 
micturition  are  productive  of  pain,  but  of  little  urine.  Rectal  tenesmus  is 
common.  The  urine  is  often,  but  by  no  means  always,  smoky  from  blood. 
Blood  may  be  found  by  the  microscope  when  it  cannot  be  detected  by  the  naked 
eye.  In  rare  cases  fatal  hemorrhage  occurs.  Blood  is  present  in  about  one- 
half  the  cases.  After  a  time  the  pain  vanishes,  the  stone  having  passed  into  the 
bladder  or  having  fallen  back  into  the  pelvis  of  the  kidney.  Slight  attacks  of 
colic  occur  from  the  passage  of  small  stones  or  plugs  of  mucus.  A  calculus  re- 
tained in  the  kidney  eventually  excites  pyelitis,  pus  appears  in  the  urine,  and 


Treatment  of  Renal  Calculus  1429 

soreness  or  pain  exists  in  tlie  loin.  Kelly  says:  Even  if  jjus  k  found,  we  are  not 
always  sure  from  which  kidney  it  came.  Pain  or  swelling  may  point  to  one  side, 
but  we  are  not  sure  that  the  other  organ  is  not  also  affected.  The  cystoscope 
must  be  used.  Bloody  or  purulent  urine  may  be  seen  coming  from  one  ureter. 
If  able  to  pass  the  renal  catheter  into  one  ureter,  attach  a  syringe,  and  by  making 
suction  draw  out  any  pus  which  may  be  present.  In  renal  calculi  cases  this 
fluid  is  apt  to  contain  fragments  of  uric  acid.  By  using  a  renal  bougie  coated 
with  dental  wax  it  may  be  possible  to  make  scratches  on  the  instrument  when 
it  comes  in  contact  with  a  concretion.^  When  a  stone  is  impacted  in  the  renal 
pelvis  the  point  of  greatest  tenderness  on  pressure  is  below  the  last  rib,  at  the 
edge  of  the  erector  spinse  muscle.  In  septic  cases  there  may  be  chills  and  irregu- 
lar fever,  and  often  there  is  leukocytosis.  In  most  cases  a  stone  in  the  kidney 
or  ureter  can  be  skiagraphed.  Nephrolithiasis  may  cause  death  by  exhaustion, 
by  sepsis,  by  rupture  of  a  hydronephrosis,  or  by  amyloid  degeneration. 

Treatment. — For  the  gravel  of  the  uric-acid  diathesis  use  alkalis,  espe- 
cially the  liquor  potassii  citratis,  and  reduce  the  amount  of  nitrogen  in  the 
diet  to  a  minimum,  at  the  same  time  washing  out  the  organs  by  copious  drafts 
of  water.  Citrate  of  lithia,  given  in  the  water,  is  supposed  to  add  to  the  thera- 
peutic effect.  Some  surgeons  prescribe  natural  lithia  water.  Piperazin,  in 
doses  of  5  to  8  gr.  three  times  a  day,  is  highly  commended  by  some.  Exer- 
cise is  to  be  insisted  on.  When  gravel  is  phosphatic,  order  strychnin,  the 
mineral  acids,  and  rest  at  the  seaside.  When  oxalate  of  lime  is  found,  restrict 
the  diet,  use  the  mineral  acids,  recommend  travel  or  rest  amid  new  surroundings, 
and  give  an  occasional  course  of  sodii  phosphas,  3-^  dram  three  times  a  day, 
taken  in  a  natural  lithia  water.  Nephritic  colic  is  relieved  by  hypodermatic 
injection  of  morphin  and  atropin,  a  hot  bath,  diluent  drinks,  and  possibly 
the  inhalation  of  ether.  After  an  attack  watch  all  the  urine  passed  to  see  if 
a  stone  appears.  If  one  does  not  soon  appear,  use  the  cystoscope,  and  if  a  stone 
is  found  in  the  bladder,  wash  out  that  viscus  with  an  evacuator.  This  is  very 
important,  as  the  vesical  stone  may  fail  to  pass,  and  if  it  remains  in  the  bladder 
it  will  progressively  enlarge.  Further,  finding  it  proves  the  diagnosis  of  renal 
colic.  If  a  stone  impacts  in  the  ureter,  perform  the  operation  of  ureterolith- 
otomy. The  diagnosis  of  this  impaction  is  in  many  cases  aided  by  the  x-ray, 
but  is  sometimes  possible  only  after  exploratory  laparotomy.  If  the  symptoms 
point  to  stone  in  the  kidney,  always  take  a  skiagraph.  Take  a  skiagraph  of 
both  kidneys  for  comparison.  If  this  shows  a  stone  on  the  affected  side, 
if  medical  treatment  fails,  or  has  failed,  and  if  the  other  kidney  is  not  organically 
diseased,  operate  and  operate  early.  Delay  may  mean  disastrous  or  fatal  sepsis. 
The  danger  of  delay  is  greater  than  the  danger  of  operation.  If  in  doubt  in 
spite  of  the  skiagraph,  make  an  exploratory  lumbar  incision;  feel  the  surface 
of  the  kidney  with  the  finger,  sound  the  inside  of  the  organ  with  a  needle,  or 
open  the  organ  for  exploration,  and  if  a  stone  be  detected,  incise  the  kidney 
and  remove  the  stone.  Keen  is  of  the  opinion  that  operation  should  not  be 
performed  if  the  urea  is  below  i  per  cent.  If,  after  nephrolithotomy,  suppres- 
sion of  urine  occurs,  cut  into  the  other  kidney,  as  in  one-half  of  all  cases  a  stone 
will  be  found  lodged  there.  I  agree  with  Brewer  ("Med.  Record,"  March  20, 
1909)  that  "a  kidney  containing  one  or  more  calculi,  and  also  the  seat  of  an 
advanced  septic  process,  should  be  removed  if  the  opposite  organ  is  healthy. 
To  leave  such  a  kidney  is  to  invite  subsequent  trouble  from  recurrence  of  stone, 
pyonephrosis,  or  long  continued  sepsis."  I  agree  with  him  when  he  says: 
*'  It  is  also  often  safer  to  remove  a  kidney  with  multiple  calculi  embedded  in  its 
substance  than  to  inflict  the  trauma  necessary  to  remove  them,  as  alarming 
primary  or  secondary  hemorrhage  is  apt  to  occur."  In  a  case  of  my  own  a  most 
persistent  postoperative  hemorrhage  forced  me  to  perform  nephrectomy  to  save 
life.  If  each  kidney  contains  a  stone  or  stones  operation  is  perilous.  The  mor- 
1  Howard  Kelly,  in  "Med.  News,"  Nov.  30,  1S95. 


14,30  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

tality  of  operation  in  this  condition  is  at  least  30  per  cent,  and  fistula  is  apt  to 
result.  If  there  is  little  or  no  infection  operation  is  inadvisable,  otherwise  it 
must  be  done  in  spite  of  the  risk. 

Calculus  Impacted  in  the  Ureter. — A  ureteral  calculus  comes  from  the 
kidney,  sometimes  dropping,  but  more  often  being  forced,  into  the  tube.  A 
stone  may  be  arrested  at  any  one  of  the  points  of  constriction.  There  are 
three  points  of  constriction  in  the  ureter:  one  point  is  about  2  inches  below  the 
renal  pelvis,  another  is  at  the  pelvic  brim,  another  is  about  ^^  inch  from  the 
bladder  orifice  of  the  ureter.  The  highest  point  has  a  diameter  of  about }  7  inch, 
the  middle  point  a  diameter  of  about  34  inch,  the  lower  point  a  diameter  of  about 
\{o  inch.  A  small  stone  may  completely  block  the  ureter.  A  large  stone  may 
fail  to  block  it  completely  because  the  ureter  dilates  above,  the  stone  acts  as 
a  ball-valve,  and  urine  trickles  by. 

Symptoms.  —Attacks  of  violent  pain  of  the  nature  of  renal  colic  occur,  and 
not  unusuallv  there  are  rigor  with  the  attack  and  fever  after  it.  Such  an  attack 
may  be  followed  by  hematuria.  The  urine  should  be  examined  microscopically 
during  several  days  after  a  colic  to  see  if  it  contains  blood-cells.  Tenderness 
can  be  developed  at  the  point  of  impaction,  the  point  of  greatest  tenderness 
being  in  the  loin  below  the  level  of  the  kidney  or  in  the  iliac  region  (Perkins). 
In  stone  in  the  ureter  pain  is  not  developed  by  pressure  in  the  loin  at  the  level 
of  the  kidney.  If  a  stone  partly  obstructs  the  ureter,  the  urine  is  pale,  of  low 
specific  gravity,  and  free  from  albumin.  Impaction  near  the  bladder  causes 
symptoms  similar  to  stone  in  the  bladder  (Jordan  Lloyd).  These  symptoms  are 
frequent  micturition,  pain  at  the  seat  of  impaction,  pain  in  the  head  of  the 
penis,  and  bloody  urine.  If  a  stone  is  impacted  in  the  lower  end  of  the  ureter 
a  finger  in  the  vagina  or  rectum  will  find  tenderness  and  perhaps  will  feel  the 
stone.  In  a  woman,  a  stone  lodged  in  front  of  the  broad  ligament  may  be  felt 
by  a  finger  in  the  vagina.  Back  of  this  region  and  up  to  the  pelvic  brim  a 
stone  may  be  felt  by  a  finger  in  the  rectum.  A  cystoscopic  examination,  in 
unusual  cases,  may  show  a  portion  of  stone  projecting  from  a  ureter  (Kelly). 
Impaction  near  the  kidney  is  accompanied  by  hematuria  and  pyuria,  lumbar 
pain,  pain  radiating  into  the  groin,  thigh,  or  testicle,  and  retraction  of  the  tes- 
ticle. These  symptoms  are  identical  in  character  with  the  symptoms  caused 
by  stone  in  the  renal  pelvis.  Complete  obstruction  of  the  ureter  causes  hydro- 
nephrosis. Pyonephrosis  results  from  infection  of  a  hydronephrosis.  In  some 
cases  a  stone  acts  as  a  ball-valve,  plugs  the  ureter  for  a  time,  during  which  a 
lumbar  mass  develops,  and  then  allows  the  urine  to  flow.  A  copious  flow  of 
urine  is  accompanied  by  disappearance  of  the  lumbar  mass.  Complete  urinary 
suppression  may  follow  blocking  of  a  ureter  by  a  calculus.  If  a  ureteral  catheter 
tipped  with  wax  be  introduced,  a  calculus  will  make  distinct  scratches  upon  it 
(Kelly).  The  Cunningham  catheter  (see  Fig.  948,  e)  may  assist  in  detecting  a 
stone.  It  has  not  been  successful  in  our  hands  when  the  stone  has  been  im- 
pacted more  than  6  c.c.  above  the  ureteral  outlet.  This  catheter  may  also 
be   of  assistance  in  dislodging  the  stone. 

The  -T-rays  are  very  valuable  in  diagnosis.  A  pyelographic  study  of  the 
ureter  and  pelvis  may  give  material  assistance. 

Treatment. — During  a  painful  paroxysm  give  morphin  and  use  hot  packs. 
Belladonna  is  useful  by  inducing  relaxation  of  spasm.  The  ozonized  oil  of 
turpentine,  given  in  capsules  in  lo-min.  doses,  is  often  valuable.  It  was  em- 
ployed by  the  elder  Gross.  For  the  pain  Bransford  Lewis  ("Jour.  Am.  Med. 
Assoc,"  Jan.  29,  1910)  catheterizes  the  ureter  and  injects  into  the  renal  pelvis 
20  min.  of  a  I  per  cent,  solution  of  alypin  (monohydrochlorid  of  benzoyl). 
Alypin  is  a  powder.  It  is  soluble  in  water  and  is  to  be  sterilized  by  boiling 
for  not  over  five  minutes.  The  attack  may  terminate  and  not  return,  because 
the  calculus  passes.  If  such  an  attack  does  pass  away,  the  urine  should  be 
examined  after  everv  act  of  micturition  to  see  if  the  stone  has  been  voided  from  the 


Abscess  of  the  Kidney  143 1 

bladder.  After  a  day  or  two,  if  the  stone  does  not  appear,  use  the  cystoscope, 
perhaps  catheterize  the  ureter,  and  thus  discover  if  the  stone  is  in  the  bladder 
or  if  it  is  impacted.  If  the  stone  is  in  the  bladder,  use  the  Bigelow  evacuator 
to  effect  removal,  or  crush  the  stone  by  the  small  forceps  of  Bransford  Lewis 
or  by  the  forceps  of  Leo  Buerger.  The  stone  must  never  be  allowed  to  remain, 
as  it  will  surely  enlarge  and  cause  subsequent  trouble.  If  a  stone  is  found  im- 
pacted in  the  ureter  have  the  patient  drink  water  freely.  Sterile  olive  oil  may 
be  injected  into  the  ureter  through  a  ureteral  catheter,  or  the  ureteral  orifice 
may  be  dilated  by  a  suitable  bougie.  If  the  impacted  stone  is  very  near  the 
bladder  the  ureteral  orifice  may  be  slit.  Simple  catheterization  of  the  ureter 
may  be  followed  by  expulsion  of  the  stone.  If  in  spite  of  these  procedures  the 
stone  remains  impacted  in  the  ureter,  the  question  of  operation  presents  itself. 
An  impacted  stone  is  certainly  a  peril,  but  how  immediate  the  danger  is  it  is 
often  impossible  to  say.  In  some  cases  stones  have  remained  impacted  for  many 
years  without  doing  obvious  harm.  In  other  cases  the  kidney  has  been  rapidly 
destroyed.  The  stone  may  pass  after  having  been  retained  for  a  long  time, 
and  drinking  freely  of  water  favors  its  expulsion.  One  of  my  cases  had  long 
carried  a  retained  stone,  came  to  the  hospital  for  operation,  and  passed  the  stone. 
Sooner  or  later  a  retained  stone  will  lead  to  disaster  and  it  ought  to  be  removed 
by  operation  and  it  should  be  removed  early.  The  danger  of  delay  exceeds  the 
danger  of  operation.  It  will  cause,  if  retained,  thickening  or  ulceration  of  the 
ureter,  dilatation  of  the  ureter  above  it,  and  kidney  trouble  from  blocking  or 
sepsis.  A  lodged  stone  increases  gradually  in  size  and  other  stones  may  form 
above  it.  The  extraperitoneal  operation  is  to  be  chosen  in  most  cases.  Even 
when  the  stone  is  impacted  below  the  pelvic  brim,  it  is  usually  better  to  do  the 
extraperitoneal  operation  (see  Ureterolithotomy). 

Infections  of  the  Kidney. — Bacteria  may  reach  the  kidney  by  the  blood, 
by  the  lymph  and  by  any  of  the  lymphatics.  Mechanical  obstruction  favors 
infection  greatly.  So  does  inflammation.  Blocking  of  the  ureter  may  result 
from  stone  or  from  pressure  without.  The  gravid  uterus  may  obstruct  the 
ureter  and  this  may  be  an  explanation  of  that  common  lesion,  the  pyelitis  of 
pregnancy.  In  the  male,  enlargement  of  the  prostate  and  urethral  stricture 
interfere  with  kidney  drainage. 

Intestinal  inflammation  or  stasis  is  not  unusually  followed  by  kidney  in- 
flammation.    In  any  general  infection  the  kidneys  may  suffer. 

In  over  90  per  cent,  of  renal  infections  the  colon  bacillus  is  responsible  (Koll, 
"A  Collective  Review"  in  "Internat.  Abstract  of  Surgery,"  April,  1915).  Ac- 
cording to  Koll  (Ibid.),  next  in  order  of  frequency  is  the  Staphylococcus  pyogenes 
albus,  rarely  the  aureus;  the  Streptococcus  pyogenes;  the  typhoid  bacillus;  the 
gonococcus;  the  Bacillus  faecalis  alkahgenes;  and  the  pneumococcus. 

Gonococcus  infection  is  so  rare  as  to  be  a  surgical  curiosity. 

Staphylococcic  infection  comes  from  the  urethra.  These  bacteria  can  be 
found  in  one-fifth  of  healthy  male  urethras  (Koll,  Ibid.).  In  scarlatina  or 
tonsillitis  streptococci  may  reach  the  kidney  by  the  blood  and  cause  acute 
nephritis. 

One-fourth  of  all  typhoid  patients  have  typhoid  baciUi  in  the  urine  after  the 
third  week  of  the  disease.  These  organisms  may  continue  in  the  urine  for 
weeks,  months  or  several  years. 

Abscess  of  the  kidney  may  be  caused  by  traumatism,  by  calculus,  by 
stricture  of  the  ureter,  by  disease  of  the  bladder,  by  the  union  of  miliary  ab- 
scesses (tuberculosis),  by  pyemia,  and  by  certain  parasites. 

The  symptoms  are  pus  in  the  urine  (this  is  usual,  but  not  invariable), 
hematuria  in  traumatic  cases,  and  pain  running  into  the  groin.  The  urme 
in  most  cases  is  alkaHne.  Constitutional  symptoms  of  suppuration  exist,  the 
fever  being  far  higher  than  that  generally  encountered  in  renal  tuberculosis. 
The  bladder  should  be  examined  with  a  cystoscope  to  determine  whether  or 


1432  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

not  the  turbid  urine  is  flowing  from  the  ureter  and  to  identify  the  diseased 
side.     It  is  well,  if  possible,  to  catheterize  the  ureters. 

The  treatment  in  the  early  stage  is  rest,  morphin,  purgation,  anodynes, 
and  hot  fomentations.  In  some  cases  repeated  lavage  through  the  ureter  may 
cure.  When  the  diagnosis  is  clear,  and  lavage  fails  or  is  not  thought  desirable, 
incise  the  loin,  open  the  kidney  and  stitch  it  to  the  abdominal  wall,  or,  if 
the  organ  be  badly  damaged,  remove  it. 

Pyelitis. — ^Pyelitis  is  inflammation  of  the  pelvis  of  the  kidney.  It  may  be 
unilateral  but  is  usually  bilateral.  It  may  arise  by  a  descending  process  from 
nephritis,  by  an  ascending  process  from  a  ureteritis,  or,  in  very  rare  instances, 
by  spread  from  a  perinephric  inflammation. 

The  pelvis  of  the  kidney  is  predisposed  to  inflammation  by  irritation  and 
congestion.  Among  the  irritants  are  large  doses  of  sandalwood  oil  and  urotro- 
pin.  Cold  may  cause  congestion.  Highly  concentrated  urine  and  calculi  cause 
irritation.  Interference  with  drainage  of  urine  strongly  favors  infection  and 
aggravates  existing  infection.  Interference  with  urinary  drainage  may  be  caused 
by  a  stone  in  the  kidney,  ureter  or  bladder,  by  a  blood-clot  in  or  stricture  of  the 
ureter,  by  pressure  upon  the  ureter  from  without  (by  an  abdominal  tumor  or  a 
pregnant  uterus),  by  kinking  of  the  ureter  (in  movable  kidney),  by  vesical  pa- 
ralysis, by  urethral  stricture,  by  prostatic  enlargement,  by  ascending  tuberculous 
infection,  and  by  growths  in  the  calices.  In  rare  cases  trauma  is  responsible. 
Nephritis,  especially  the  chronic  interstitial  nephritis  of  the  gouty,  and  heart 
disease  predispose.  Perinephric  abscess,  malignant  disease  or  parasites  may  be 
responsible.  Intestinal  stasis  is  blamed  in  some  cases.  The  organisms  chiefly 
responsible  for  infection  are  pus  bacteria  and  colon  baciUi.  In  nine-tenths  of 
the  cases  arising  secondarily  to  bacterial  nephritis  colon  bacilli  are  responsible. 
In  most  ascending  infections  staphylococci  are  to  blame.  Gonococcal  infection 
almost  never  occurs.  Pyelitis  is  not  uncommonly  caused  by  the  exanthemata. 
If  infection  be  mild  a  catarrhal  inflammation  may  arise,  but  it  is  rare  and 
most  inflammations  are  suppurative.  A  pyelitis  is  greatly  aggravated  if  the 
ureter  becomes  blocked  with  pus  (pyonephrosis  or' pyelonephritis  follows). 

Pyelitis  may  lead  to  ulceration  and  ascending  pyelitis  frequently  causes 
parenchymatous  and  more  frequently  interstitial  nephritis. 

Symptoms. — Pain  in  the  loin,  which  may  be  severe  and  is  apt  to  have  acute 
exacerbations;  which  may  radiate  into  the  penis,  the  testicle  or  even  the  corre- 
sponding shoulder,  and  which  is  associated  with  tenderness  of  the  kidney.  The 
pain  is  increased  by  motion  (especially  by  cough).  The  output  of  urine  may 
be,  but  seldom  is,  diminished.  The  urine  is  acid,  and  contains  hyaline  casts, 
albumin  and  in  most  cases  numbers  of  pus-cells  or  even  obvious  pus.  It  may 
contain  blood.  In  catarrhal  cases  fever  may  be  slight  or  absent  but  in  puru- 
lent cases  there  is  certain  to  be  fever.  Chills  and  sweats  occur  in  many  cases. 
In  an  acute  case  the  kidney  is  seldom  enlarged.  If  pyonephrosis  occurs  the 
kidney  of  course  enlarges. 

In  acute  Bright's  disease  there  is  edema,  the  skin  is  dry,  the  urine  is  scanty 
and  contains  blood  and  there  may  be  convulsions.  In  pyelitis  the  urine  is 
usually  plentiful,  contains  pus,  albumin  and  bacteria,  seldom  contains  blood, 
there  is  no  edema,  the  skin  is  moist  and  convulsions  do  not  occur. 

In  grave  cases  a  chiH  is  followed  by  fever,  with  headache,  stupor,  dry  tongue 
and  usually  scanty  urine.  The  prognosis  in  catarrhal  cases  is  of  the  best  but 
in  severe  infections  is  extremely  grave.  Pyelitis  may  at  any  time  origiriate 
kidney  inflammation  (pyelonephritis).  When,  during  the  existence  of  pyelitis, 
the  ureter  becomes  blocked  the  condition  is  known  as  pyonephrosis  (page  143  S)- 

Treatment  depends  upon  the  course  or  the  severity  of  the  infection. 
Trivial  inflammations,  such  as  may  arise  during  an  exanthematous  fever,  re- 
quire merely  rest  in  bed,  liquid  diet  and  the  use  of  diluent  drinks.  In  a  more 
severe  case  give  morphia  if  the  pain  be  severe. 


Spontaneous  Perirenal  Hematoma  1433 

In  colon  infections  the  kidney  is  certainly  involved,  the  urine  almost  never 
sterile,  and  some  practitioners  use  an  autogenous  vaccine. 

If  the  urine  be  acid,  give  liquor  potassi  citratis;  if  alkaline,  give  benzoate  of 
ammonium  and  boric  acid  or  urotropin.  Gallic  acid,  eucalyptol,  and  small 
doses  of  copaiba  or  cubebs  are  recommended.  Venice  turpentine,  camphor,  and 
opium  may  be  given  in  pill  form.  Quinin  is  used  to  stimulate  the  patient.  If 
cystitis  exists  the  bladder  is  to  be  washed  out  every  day  with  boric  acid  solution 
(3  grains  to  the  ounce  of  water)  and  at  intervals  with  a  solution  of  nitrate 
of  silver  (i  to  8000).  In  some  cases  a  catheter  is  inserted  and  retained. 
Cups,  dry  or  moist,  and  hot  sand-bags  or  bran-bags  are  to  be  applied  to  the  loin. 
Alcohol  may  be  sparingly  administered.  Urotropin  is  a  useful  drug  if  the  urine 
be  alkaline.  Lavage  of  the  pelvis  by  means  of  the  hydrostatic  apparatus  shown 
in  Fig.  956  may  be  practised  and  is  often  most  useful.  For  lavage,  use  a  return 
flow  catheter;  first  wash  the  pelvis  gently  with  normal  salt  solution  or  sterile 
distilled  water.     Silver  nitrate  in  solution,  of  a  strength  of  /"loooO;  may  be  used. 

S.  B.  Dudgeon  and  A.  Ross,  of  London  ("Annals  of  Surgery,"  March,  1910), 
give  small  doses  of  autogenous  vaccine — 100,000,000  to  200,000,000  adminis- 
tered every  five  days.  Relapses  are  apt  to  occur.  If  pyonephrosis  develops 
perform  nephrostomy. 

Pyelonephritis. — This  is  a  septic  inflammation  of  the  kidney  which  is 
associated  with  or  secondary  to  pyelitis.  In  a  hematogenous  infection  (for 
instance  with  colon  bacilli)  the  nephritis  precedes  the  pyelitis  (E.  G.  Crabtree 
and  Hugh  Cabot,  in  "Jour.  Am.  Med.  Assoc,"  Feb.  24,  191 7).  In  an  ascending 
infection  the  pyelitis  precedes  the  nephritis. 

Some  restrict  the  term  pyelonephritis  to  the  ascending  form  of  renal  sup- 
puration and  call  the  descending  form  suppurative  nephritis.  The  causes  of 
pyelitis  and  pyonephrosis  are  the  causes  of  pyelonephritis.  The  calices,  the 
uriniferous  tubules  and  the  renal  parenchyma  are  involved  in  suppuration. 

Symptoms. — In  the  acute  form  the  symptoms  arise  suddenly.  There  is  a 
chill.  High  fever  follows.  Delirium  is  common.  Loin  pain  is  severe.  In  a 
short  time  the  patient  becomes  dull  and  drowsy,  stupor  comes  on  and  finally 
in  most  cases,  death.  Death  is  the  rule  in  from  one  to  two  weeks.  A  few  cases 
recover.  The  symptoms  "are  due  in  part  to  septic  intoxication,  in  part  to 
renal  insufficiency"  ("  Genito-urinary  Surgery  and  Venereal  Disease,"  by  Mar- 
tin, Thomas,  and  Moorhead).  In  chronic  pyelonephritis  the  chief  symptoms 
may  be  indicative  of  irritation  of  the  gastro-intestinal  tract,  in  fact  there  may 
be  no  sign  pointing  to  the  urinary  organs.  A  urinary  examination  and  a  blad- 
der study  are  of  course  imperative.  The  patient  suffers  from  indigestion,  flat- 
ulence, dry  mouth,  loss  of  flesh  and  strength  and  from  attacks  of  violent  diarrhea. 

Treatment. — A  liquid  diet,  diuretics,  diluent  drinks,  laxatives.  In  acute 
cases  dry  cup  over  the  kidneys.  Alcoholic  stimulation  is  required.  Martin 
gives  salol.     If  pyonephrosis  develops  open  the  kidney  and  drain  (nephrostomy) . 

Spontaneous  Perirenal  Hematoma. — Traumatism  is  the  common 
cause  of  a  hematoma  in  the  perirenal  tissues  (page  1424).  Spontaneous 
hematoma  is  a  rare  but  recognized  affection.  It  was  described  by  Wunderlich 
in  1856  under  the  name  of  spontaneous  apoplexy  of  the  capsule  of  the  kidney. 
In  most  of  these  cases  acute  or  chronic  nephritis  exists.  In  some  cases  the 
hematoma  is  under  an  unruptured  capsule.  In  some,  the  capsule  is  ruptured 
and  a  mass  is  palpable.  This*  mass  may  reach  up  to  the  diaphragm  and  down 
into  the  pelvis  and  even  to  the  median  line  of  the  body.  In  a  case  of  perirenal 
hematoma  a  cyst  may  form  {perirenal  hygroma). 

Lippens  ("Jour,  de  Clin.,"  1913,  xi,  i)  collected  23  cases  of  perirenal  hema- 
toma. He  found  records  of  two  bilateral  cases.  The  condition  is  much  more 
common  in  the  young  than  in  the  elderly  and  is  more  frequent  in  men  than  in 
women.  It  causes  sudden  and  violent  pain  in  the  loin,  with  symptoms  of  con- 
cealed bleeding,  and  the  formation  of  a  palpable  mass,  which  is  immovable, 


1434  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

tender  and  dull  on  percussion.  In  some  cases  violent  attacks  of  colic  occur 
during  a  number  of  months.  The  temperature  is  usually  elevated,  after  reac- 
tion from  the  initial  hemorrhage.  Without  operation  the  condition  will  be 
fatal  sooner  or  later. 

The  treatment  in  some  cases  is  incision  and  packing  with  gauze ;  in  some,  is 
nephrectomy.     The  earlier  the  operation  the  better  the  prognosis. 

Perinephritis  is  an  inflammation  of  the  perinephric  fatty  tissue  pro- 
duced by  cold,  febrile  disease,  slight  traumatism,  or  the  spread  of  inflammation 
from  another  part. 

The  symptoms  of  this  condition  are  rigidity  of  the  spine,  the  inclination 
being  toward  the  affected  side,  flexion  of  the  thigh,  pain  in  the  loin  and  iliac 
region,  and  often  pain  in  the  knee.  The  symptoms  resemble  those  of  hip-joint 
disease  in  the  second  stage.  Suppuration  may  or  may  not  take  place.  In 
some  suppurative  cases  the  condition  strongly  suggests  woody  phlegmon  (see 
page  147).  I  have  seen  one  case  in  which  there  was  severe,  unilateral  abdominal 
pain,  rapid  pulse,  elevated  temperature,  abdominal  distention,  a  mass  in  the  loin, 
and  compression  of  the  iliac  veins.  After  incision  and  drainage  necrosis  of  the 
kidney  was  found  to  exist  and  the  kidney  was  removed. 

In  another  case  the  kidney  sloughed  away  without  hemorrhage.  There  is  a 
chronic  form  in  which  masses  of  fibrous  tissue  develop. 

The  treatment  is  wet  cups  and  heat  to  the  loin,  rest,  purgation  by  salines, 
morphin  for  pain,  and,  after  the  acute  stage,  potassium  iodid  internally. 
In  a  lingering  case  an  incision  should  be  made.  It  will  frequently  be  followed 
by  cure.  Decapsulation  has  advocates.  If  suppuration  occurs  it  is  necessary 
to  incise  and  drain.     Necrosis  of  the  kidney  calls  for  nephrectomy. 

Perinephric  or  Perirenal  Abscesses. — An  abscess  in  the  perinephric 
fat  is  known  as  a  perinephric  or  perirenal  abscess.  There  may  or  may  not  be 
renal  involvement.  Primary  abscess  may  follow  a  chill,  may  develop  during  or 
after  an  acute  febrile  disturbance,  or  may  be  caused  by  pus  flowing  from  some 
other  part,  as  from  the  spine.  Slight  traumatisms,  by  producing  hemorrhage, 
make  the  perinephric  region  a  point  of  least  resistance  and  lead  to  abscess  of 
hematogenous  or  renal  origin.  The  causative  injury  may  be  produced  by  dig- 
ging, stamping,  coughing,  falling,  carrying  a  burden,  lifting  a  weigh":,  or  riding  on 
a  horse  or  on  a  jolting  wagon.  Consecutive  abscess  is  secondary  to  kidney  inflam- 
mation, suppuration,  calculus,  tuberculosis,  or  cyst.  Some  cases  follow  furun- 
culosis.  The  staphylococcus  is  the  organism  usually  found.  In  the  consecutive 
form  the  symptoms  may  be  masked  by  the  malady  to  which  perinephric  abscess 
is  secondary.  As  a  rule,  in  a  case  of  perinephric  abscess  there  are  found  the  con- 
stitutional symptoms  of  suppuration.  As  Dr.  Morris  Miller  has  shown,  there  is 
high  leukocytosis.  The  chief  local  symptom  is  a  deep  aching  and  paroxysmal 
pain  in  the  loin,  intensified  by  lumbar  pressure.  There  may  be  pain  in  the  iliac 
region  and  pain  in  the  knee.  Edema  of  the  corresponding  foot  and  lameness  are 
not  unusual.  The  thigh  is  often  drawn  up.  The  spine  is  rigid  and  inclined 
toward  the  diseased  side.  Edema  of  the  skin  is  usual,  but  fluctuation  is  not. 
An  exploratory  incision  will  settle  a  doubtful  diagnosis. 

The  treatment  is  to  lay  open  the  abscess,  wash  it  out,  and  drain.  The 
mortality  is  over  10  per  cent. 

Stricture  of  the  Ureter. — This  is  usually  at  or  near  the  termination 
of  the  ureter.  It  is  due  to  gonococcic  inflammation,  pyogenic  inflammation, 
or  tuberculosis.  The  symptoms,  as  Howard  Kelly  says,  are  at  first  those  of  a 
vesical  or  renal  inflammation.  The  diagnosis  is  made  by  the  ureteral  catheter. 
We  may  be  unable  to  introduce  it;  we  may  introduce  it  with  difficulty  and  find 
that  the  pelvis  of  the  kidney  is  distended  and  that  the  urine  obtained  is  slightly 
acid  or  even  alkaline,  much  lower  in  urea  than  the  urine  from  the  other  kidney, 
and  perhaps  contains  pus.  Stricture  of  the  ureter  causes  hydronephrosis, 
pyelitis,  pyelonephritis  and   pyonephrosis.     Great  care  must  be  exercised  in 


Pyonephrosis  or  Surgical  Kidney  1435 

the  examination  of  the  ureter  for  stricture,  and  we  know  of  cases  diagnosti- 
cated as  stricture  that  were  simply  spastic  contractions  or  deviations  in  the 
course  of  the  tube  resembling  stricture.  Some  urologists  have  regarded  the 
condition  as  quite  common,  but  we  do  not  beUeve  it  is  so;  in  several  of  the 
cases  so  diagnosticated  a  pyelographic  study  of  the  ureter  has  revealed  tortu- 
osities due  to  a  descended  kidney.  These  cases  will  often  have  greatly  enlarged 
pelves  and  many  of  them  suffer  from  mild  attacks  of  kidney  cohc.  Before 
arriving  at  a  diagnosis  the  Blasucci  catheter  should  be  used  and  a  pyelographic 
study  be  made. 

Treatment. — Dilatation  with  bougies,  resection  of  the  diseased  portion  and 
anastomosis,  resection  of  the  diseased  portion  and  implantation  of  the  sound 
end  into  the  bladder,  or  division  of  the  stricture  and  suture.  In  tuberculosis 
the  diseased  kidney  and  ureter  may  be  removed. 

Hydronephrosis  is  a  condition  of  the  kidney  resulting  from  an  impedi- 
ment to  the  outflow  of  urine  by  obstruction  in  the  ureter,  the  bladder,  or  the 
urethra,  the  cahces  of  the  kidney  becoming  overdistended  with  urine  and  the 
glandular  tissue  being  absorbed  by  pressure.  It  has  been  asserted  by  Albarran 
that  secretion  of  urine  ceases  in  a  kidney  whose  ureter  is  completely  blocked, 
distention  being  due  purely  to  congestion.  Hydronephrosis  may  be  congenital, 
due  usually  to  twisting  of  the  ureter  or  to  valve-formation  obstructing  the  ureter 
at  its  point  of  junction  with  the  pelvis  of  the  kidney,  the  valve  having  been  pro- 
duced because  the  ureter  passed  into  the  kidney  pelvis  at  an  unnatural  angle. 
Occasionally,  imperforate  urinary  meatus  produces  hydronephrosis  of  both 
kidneys. 

The  causes  of  the  acquired  form  are  the  pressure  of  pelvic  growths  or  preg- 
nancy, inflammation  or  tumor  of  the  bladder,  stone  in  the  bladder,  kidney,  or 
ureter,  twisting  or  kinking  or  stricture  of  the  ureter  of  a  movable  kidney, 
enlargement  of  the  prostate  gland,  and  stricture  of  the  urethra.  Acquired 
hydronephrosis  may  involve  both  kidneys,  all  of  one  kidney,  or  only  a  part  of 
a  single  gland. 

Symptoms. — Hydronephrosis  is  most  frequent  in  females.  When  a  lumbar 
tumor  is  absent  there  may  be  no  symptoms,  or  there  may  be  pain  in  the  back 
and  abdomen,  frequent  micturition,  a  persistent  or  intermittent  diminution  in 
urine,  or  even  occasional  anuria.  In  the  loin  may  be  found  a  mass  which  is 
dull  on  percussion,  which  shrinks  and  enlarges,  and  which  may  disappear  with 
a  large  urinarv-  flow.  Hydronephrosis  may  last  a  long  while  if  only  one  kidney 
be  involved,  but  death  is  not  far  distant  if  both  glands  suffer.  Death  occurs 
from  vu-emia,  from  pressure  on  adjacent  organs,  or  from  rupture  into  the  peri- 
toneal cavity.  The  diagnosis  is  aided  by  the  use  of  the  cystoscope,  by  catheter- 
izing  the  ureters,  and  by  pyelographic  study. 

Treatment  by  aspiration  may  possibly  cure,  but  the  operation  will  have  to 
be  done  repeatedly.  Tapping  on  the  left  side  is  performed  just  below  the  last 
intercostal  space;  on  the  right  side  the  tap  is  made  midway  between  the  last 
rib  and  the  crest  of  the  ihum.  Some  few  cases  have  been  cured  by  catheterizing 
the  ureter  (Pawlik).  The  proper  operation  in  most  cases  is  nephrotomy,  stitch- 
ing the  edges  of  the  cut  kidney  to  the  surface.  After  the  kidney  has  been 
opened,  explore  the  ureter  by  means  of  a  uterine  sound  or  an  elastic  bougie. 
A  healthy  ureter  will  permit  the  passage  of  an  instrument  of  the  size  of  from 
No.  9  to  No.  12  of  the  French  scale  (Fenger).  If  the  opening  of  the  ureter  into 
the  pehds  cannot  be  found,  open  the  peMs  or  open  the  ureter.  A  valve  should 
be  sHt  longitudinally  and  sutured  transversely  (Fenger).  If  a  permanent  sup- 
purating fistula  ensues  or  if  the  organ  is  found  extensively  damaged,  nephrec- 
tomy is  to  be  performed,  provided  the  other  kidney  is  in  reasonably  good 
condition. 

Pj'onephrosis  or  surgical  kidney  is  a  condition  in  which  the  pelvis 
and  the  cahces  of  the  kidney  are  distended  with  pus  or  with  pus  and  urine. 


1436  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

The  whole  kidney  may  be  destroyed.  This  condition  has  the  same  causes  as 
hydronephrosis,  for  it  is,  in  reality,  usually  an  infected  hydronephrosis.  In 
some  cases  the  inaugural  malady  is  pyelitis,  which  causes  blocking  of  a  ureter. 
Watson,  of  Boston,  has  reported  2  cases  associated  with  obHteration  of  the 
ureter  by  a  mass  of  fibrous  tissue  (stricture  of  the  ureter). 

The  symptoms  are  those  due  to  the  obstructing  cause  plus  pyelitis.  Pus 
may  be  constant  in  the  urine  in  incomplete  obstruction,  or  it  may  intermittently 
appear.  Bacilluria,  and  especially  colon  bacillus  infection  of  the  urine,  has 
a  strong  tendency,  unless  speedily  controlled,  to  cause  pyonephrosis.  Con- 
stitutional symptoms  of  suppuration  are  soon  manifest.  A  mass  like  the  tumor 
of  hydronephrosis  may  appear  in  the  loin.  If  only  one  kidney  be  involved,  and 
if  the  disease  be  due  to  blocking  of  a  ureter,  recovery  is  to  be  expected.  The 
diagnosis  is  rendered  more  certain  by  the  use  of  the  cystoscope  and  by  catheter- 
izing  the  ureters. 

The  treatment  in  the  early  stages  comprises  removal,  if  possible,  of  the 
cause  of  obstruction,  and  the  employment  of  measures  directed  to  the  cure 
of  the  pyelitis.  If  obstruction  is  not  complete,  palliative  measures  may  be 
employed  for  the  tumor.  If  fever  continues;  if  there  is  great  visceral  derange- 
ment; if  pain  is  severe  and  constant,  and  if  the  mass  continually  enlarges,  per- 
form nephrostomy,  stitching  the  organ  to  the  surface  if  possible,  or  removing 
it  if  it  be  hopelessly  disorganized  and  the  other  kidney  be  in  good  or  fairly  good 
condition. 

Chronic  Tuberculosis  of  the  Kidney. — This  condition  may  begin  in 
one  kidney,  no  other  area  of  infection  existing  in  the  body.  In  such  cases  the 
bacteria  have  been  deposited  from  the  blood  in  the  renal  tubules.  "From  these 
they  reach  the  surface  of  the  papillae  or  calyx  recess,  where  they  are  amassed  in 
sufficient  number  to  bring  about  a  tuberculous  lesion"  (Leo  Buerger,  in  "Inter- 
state Med.  Jour.,"  1914,  No.  11).  Even  when  the  bacteria  are  deposited  from 
the  blood  there  is,  in  most  cases,  an  imtial  focus  of  tuberculosis  somewhere  else 
in  the  body.  Primary  renal  tuberculosis  remains  for  a  long  time  a  local  disease, 
but,  unfortunately,  the  other  kidney,  sooner  or  later,  is  very  apt  to  become 
involved,  the  process  in  the  first  kidney  affecting  the  bladder  and  secondarily 
the  other  kidney.  The  important  point  is  that  tuberculosis  of  the  kidney  arising 
in  this  manner  is  at  first  a  unilateral  disease. 

Tuberculosis  of  the  kidney  is  seldom  a  primary  disease  and  usually  arises 
secondarily  to  tuberculosis  of  the  prostate,  bladder,  or  epididymis.  In  such  a 
condition  the  kidney  disease  is  always  bilateral.  Renal  tuberculosis  is  par- 
ticularly common  in  the  third  and  fourth  decades  of  life,  and  is  more  frequent 
in  males  than  in  females. 

Symptoms. — Renal  tuberculosis  of  arterial  origin  may  exhibit  no  symptoms- 
until  the  disease  is  far  advanced.  As  long  as  a  tuberculous  kidney  drains  pain 
is  absent.  When  the  urinary  passages  are  blocked  suddenly,  tension  ensues  and 
renal  colic  occurs.  If  the  blocking  be  gradual  pain  may  never  occur.  Renal 
tuberculosis  secondary  to  disease  of  the  bladder  or  prostate  always  presents, 
symptoms.^  A  very  common  symptom  of  renal  tuberculosis  is  the  sudden  onset 
of  polyuria  and  frequent  micturition.  The  patient  is  annoyed  day  and  night, 
and  in  some  cases  micturition  is  distinctly  painful.  Paroxysms  of  renal  pain  are 
not  unusual.  As  stated  above  there  may  be  no  pain.  Tenderness  may  be  ab- 
sent. The  urine  is  acid  and  may  contain  pus  or  blood.  Tubercle  bacilli  may 
be  found  in  the  urine  or  in  the  sediment  of  centrifuged  urine,  but  they  may  be 
absent.  Repeated  examination  should  be  made  before  it  can  be  stated  certainly 
that  bacilli  are  absent.  The  presence  of  bacilh  proves  the  diagnosis,  but  their 
absence  does  not  negative  it  (Willy  Meyer).  If  bacilli  are  not  found,  inject 
some  of  the  urinary  sediment  into  a  guinea-pig,  and  note  if  tuberculosis  arises 
in  the  animal.  Czerny  has  shown  that  in  cases  of  tuberculous  kidney  in  which 
1  F.  Tilden  Brown,  "New  York  Med.  Jour.,"  April  10,  1897. 


Operations  on  the  Kidney  and  Ureter  1437 

bacilli  are  not  fouiul  in  the  urine  the  administration  of  tuberculin  will  cause 
great  numbers  to  appear.  This  agent  will  also  cause  a  marked  febrile  reaction 
if  tuberculosis  exists.     The  urine  may  or  may  not  be  albuminous. 

In  many  cases  the  kidney  is  obviously  enlarged,  and  the  renal  area  is  fre- 
quently tender  and  occasionally  painful.  When  pain  and  tenderness  are  absent 
(silent  renal  tuberculosis)  the  diagnosis  is  often  missed.  The  patient  loses  flesh, 
and  there  is  nocturnal  fever  followed  by  sweating.  The  use  of  the  cystoscope 
furnishes  important  information.  It  shows  from  which  ureter  turbid  urine  is 
coming.  Catheterization  of  the  ureters  should  be  practised  by  some  one  who 
is  expert.  Always  examine  carefully  to  determine  if  one  or  both  kidneys  are 
involved,  if  the  bladder  is  diseased,  and  if  the  prostate  gland  or  seminal  vesicles 
are  tuberculous. 

Treatment. — Lumbar  nephrectomy  is  not  justifiable  in  the  very  beginning  of 
a  case,  because  such  a  patient  may  be  cured  by  a  combination  of  medical  and 
hygienic  treatment,  and  the  weakening  effect  of  the  operation  of  nephrectomy 
may  cause  the  other  kidney  to  develop  tuberculosis  rapidly.  Tell  such  a  patient 
to  lead  an  outdoor  life.  Brown  recommends  camp-life  in  the  Adirondacks 
during  the  summer,  and  sends  such  patients  south  during  the  winter.  If  a 
patient  cannot  go  to  another  climate,  urge  upon  him  the  necessity  of  practically 
living  out-of-doors  (see  page  255).  Insist  upon  the  taking  of  plenty  of. nutritious 
food.     Full  antituberculous  treatment  is  indicated  (see  page  257). 

If  the  kidney  is  markedly  enlarged;  if  there  is  profuse  hematuria;  if  the 
fever  is  high  and  persistent;  ii  only  one  kidney  is  involved,  if  the  other  kidney 
has  a  satisfactory  functional  capacity,  and  if  the  bladder  and  prostate  are  free 
from  disease,  perform  nephrectomy.  After  nephrectomy  for  tuberculous  kid- 
ney a  tuberculous  sinus  not'uncommonly  forms.  If  a  diseased  ureter  is  removed 
as  far  as  possible  at  the  operation,  if  an  open  ureteral  stump  is  injected  with 
5-10  minims  of  a  95  per  cent,  solution  of  carbolic  acid  (Mayo),  and  if  the  fatty 
capsule  is  removed  with  the  kidney,  a  tuberculous  sinus  will  seldom  form.  In 
cases  with  involvement  of  the  other  kidney  or  of  the  genito-urinary  tract  lower 
down,  or  in  which  the  functional  capacity  of  the  other  kidney  is  not  satisfactory, 
nephrectomy  is  not  justifiable,  although  nephrotom.^/  for  drainage  may,  for  a 
time,  greatly  benefit  the  patient. 

Operations  on  the  Kidney  and  Ureter. — Operations  for  Chronic  Neph- 
ritis.— In  1897  Mr.  Reginald  Harrison  advocated  puncture  of  the  kidney  to 
relieve  tension  in  cases  of  albuminuria,  and  in  1901  advocated  incision  of  the 
true  capsule  of  the  kidney  and  puncture  of  the  gland  to  accomplish  the  same 
purpose  ("Brit.  Med.  Jour.,"  Oct.  19,  1901).  Alexander  Hugh  Ferguson  in 
March,  1899,  reported  2  cases  of  interstitial  nephritis  cured  symptom atically 
by  decapsulation  and  multiple  punctures  ("Jour.  Am.  Med.  Assoc,"  March  11, 
1899).  Dr.  Geo.  M.  Edebohls  observed,  between  1892  and  1897,  that  in  certain 
cases  of  movable  kidney  with  albuminuria  the  albumin  and  casts  disappeared 
after  nephropexy.  Rose,  Wolff,  and  Ferguson  have  observed  the  same  fact. 
Harrison  believes  that  renipuncture  removes  the  symptoms  by  abating  tension, 
but  Edebohls  concludes  that  nephropexy  relieves  the  condition  and  possibly 
cures  it  by  establishing  vascular  adhesions  which  carry  on  additional  supply 
of  blood.  He  proposed  to  operate  for  Bright's  disease  in  1899  ("Med.  News," 
April  22.  1899).  Edebohls  deliberately  operated  for  chronic  nephritis  and 
claimed  8  complete  recoveries  from  chronic  Bright's  disease  ("Med.  Record," 
Dec.  21,  1901).  There  can  be  no  doubt  whatever  that  operation  is  sometimes 
followed  by  polyuria,  disappearance  of  edema  and  other  symptoms,  and  ap- 
parent cure.  But  in  some  cases  the  disappearance  of  symptoms  has  been  too 
rapid  to  permit  of  the  assumption  that  new  vessels  have  caused  it.  In  such 
cases  it  seems  much  more  probable  that  relief  of  tension  is  the  real  curative 
factor.  The  capsule  of  the  kidney  is  only  slightly  elastic,  and  tension  may  be 
brought  about  by  an  increase  in  the  blood-supply,  by  edema,  and  by  cell  pro- 


1438  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

liferation.  Increased  tension  causes  pain  and  perhaps  hematuria,  and  tension 
is  relieved  by  Harrison's  plan  of  incising  the  capsule.  Simple  incision  is  easier, 
safer,  and  probably  just  as  useful  as  stripping  the  capsule  off  of  the  kidney. 
Edebohls  advocates  decapsulation  and  says  that  the  polyuria  begins  about  the 
tenth  day  after  operation;  that  improvem.ent  begins  in  one  month  and  is  grad- 
ual; that  the  cure  is  due  to  vascular  adhesions;  that  the  adhesions  contain  more 
arteries  than  veins;  that  the  free  blood-supply  absorbs  exudate  and  products 
of  inflammation,  frees  the  tubes  and  glomeruli  from  pressure  and  constriction, 
causes  the  reestablishment  of  a  normal  circulation  and  the  regeneration  of 
epithelium  (Ibid.). 

The  exact  status  of  the  operation  is  not  as  yet  determined.  It  does,  how- 
ever, seem  to  be  proved  that  operation  is  in  some  cases  followed  by  apparent 
cure  or  great  amelioration  of  the  condition.  Whether  permanent  cure  is  ever 
thus  obtained  is  doubtful,  and  the  part  played  by  rest  in  bed  and  drugs  in  effect- 
ing an  improvement  must  not  be  lost  sight  of.  I  have  seen  no  case  of  genuine 
cure.  I  doubt  if  cure  is  ever  obtained.  Albumin  has  always  continued  present 
in  the  urine.  It  is  certain  that  the  operation  is  unjustifiable  unless  medical 
treatment  has  been  tried  and  failed,  unless  the  symptoms  are  growing  worse, 
and  unless  they  indicate  danger.  James  Tyson  ("Med,  Record,"  July  8,  191 1) 
sets  forth  dangerous  symptoms  as  follows:  Persistent  dropsy,  uremia  (violent 
headache,  convulsions,  or  coma),  excessive  amount  of  albumin  causing  anemia 
and  weakness,  anuria.  The  best  results  are  obtained  in  chronic  parenchy- 
matous nephritis  associated  with  marked  anasarca.  Pain  and  bloody  urine 
are  often  much  improved  by  incising  the  capsule.  Postoperative  suppression 
and  the  anuria  of  acute  infectious  diseases  may  be  favorably  influenced  by  the 
operation.  In  perinephritis  it  may  prove  curative.  *  An  important  fact  which 
Rovsing  maintains  and  Edebohls  proves  is  that  chronic  nephritis  may  be  for 
some  time  a  unilateral  disease.  (Read  the  views  of  Schmidt,  in  "  Med.  Record," 
Sept.  13,  1902;  of  Rovsing,  of  Copenhagen,  in  "  Mittheilungen  aus  den  Grenze- 
gebieten  der  Medicin  und  Chirurgie,"  vol.  x,  1902,  and  editorial  in  "Jour.  Am. 
Med.  Assoc,"  Jan.  11,  1902;  James  Tyson,  in  "Trans,  of  Amer.  Physicians,'^ 
191 1,  and  "Med.  Record,"  July  8,  191 1.)  Personally,  I  would  not  operate  in 
the  presence  of  grave  and  advanced  cardiovascular  disease.  Tyson  believes 
that  albuminuric  retinitis,  very  irregular  heart,  and  valvular  disease  forbid 
operation,  and  that  in  patients  over  fifty  the  operation  is  of  slight  value.  I 
believe  the  operation  has  its  highest  indication  in  an  acute  congestion  arising 
in  the  course  of  chronic  nephritis. 

The  operation  as  practised  by  Edebohls  may  be  done  on  both  kidneys  either 
at  one  sitting  or  in  two  seances.  In  some  cases  only  one  kidney  is  subjected  to 
operation.  Edebohls  takes  a  very  radical  view  and  would  operate  on  any  case 
free  from  incurable  complications,  if  an  anesthetic  can  be  given  and  if  the  life- 
expectancy  without  operation  is  not  less  than  one  month  ("Med.  Record," 
Dec.  21,  1 901).  Ether  is  given  or  nitrous  oxid  and  oxygen.  Lay  the  patient 
prone  with  an  air-cushion  under  the  belly  and  expose  the  kidney  by  a  vertical 
incision  at  the  edge  of  the  erector  spinae  mass.  This  incision  does  not  open  the 
sheath  of  the  muscle.  Remove  the  fatty  capsule  from  the  true  capsule,  con- 
tinuing the  dissection  around  each  pole  until  the  pelvis  of  the  kidney  is  reached. 
The  kidney  is  extruded  from  the  wound,  the  true  capsule  is  incised  along  the 
convex  border  and  around  each  pole,  is  separated  from  the  kidney,  and  is  cut 
away  close  to  its  junction  with  the  kidney  pelvis.  The  kidney  is  then  returned 
to  its  bed  of  fat  and  the  wound  is  closed  (Ibid.).  Edebohls  does  not  drain 
unless  there  is  considerable  edema.  He  reported  18  operations  without  a 
death.  In  9  of  the  cases  the  operation  had  been  done  more  than  one  year,  and 
8  of  them  were  said  to  be  cured.  Personally,  I  do  not  believe  that  the  operation 
can  really  cure  Bright's  disease.  It  cannot  restore  altered  connective  tissue 
and  epithelial  cells.     The  new  blood-supply  must  be  through  scar  tissue,  and 


Nephrotomy  i439 

we  have  yet  to  learn  that  such  a  blood-supi)ly  can  be  efficient.  The  operation 
should  be  restricted  to  acute  nei)hritis,  to  acute  exacerbations  in  chronic  cases, 
to  conditions  with  severe  renal  pain,  hematuria,  anasarca,  very  high  albumin 
percentage,  or  persistent,  and  notable  diminution  in  the  amount  of  urine  voided 
(Ertzbischoff,  in  "Ajchiv.  generales  de  Chirurgie,"  April,  1908). 

Nephrotomy  means  incision  into  a  kidney,  but  the  term  is  sometimes,  though 
wrongly,  applied  to  the  exploratory  exposure  of  the  kidney  without  incision  into 
the  organ.  When  the  kidney  wound  is  left  open  as  it  almost  invariably  is, 
the  operation  should  be  called  nephrostomy.  The  operation  is  employed  to 
evacuate  infectious  material,  relieve  tension,  permit  of  the  removal  of  a  calculus 
or  exploration  of  the  ureter,  and  for  diagnosis  of  renal  disease.  The  patient  lies 
upon  the  sound  side,  a  sand-pillow  or  a  cylindrical  air-bag  being  placed  under 
the  flank.  The  incision  is  made  3^  inch  below  the  last  rib  and  close  to  the 
outer  border  of  the  erector  spinas  mass,  and  runs  obliquely  downward  and  for- 
ward toward  the  iliac  crest  for  3  inches,  the  incision  being  enlarged  later  if 
required.  Divide  the  skin,  the  superficial  fascia,  the  fat,  the  external  oblique, 
the  posterior  border  of  the  internal  oblique,  and  the  outer  edge  of  the  latissimus 
dorsi.  This  incision  exposes  the  lumbar  fascia.  Push  aside  the  last  dorsal  nerve 
and  incise  the  lumbar  fascia,  when  the  perirenal  fat  will  bulge  into  the  wound. 
Two  distinct  layers  of  fat  exist.  Tear  through  this  fat  with  dissecting  forceps 
to  expose  the  kidney,  which  can  now  be  opened  while  it  is  forced  into  the  wound 
by  the  hand  of  an  assistant  making  abdominal  pressure.  In  some  cases  the 
kidney  can  be  brought  out  of  the  wound  for  exploration  and  operation.  In 
others  it  cannot.  When  it  cannot  be  drawn  out  it  is  brought  into  the  wound 
and  supported  by  means  of  a  pad  of  gauze  under  each  pole. 

Kocher's  incision  for  nephrotomy  is  begun  in  the  angle  between  the  sacro- 
lumbalis  muscle  and  the  twelfth  rib,  and  is  carried  downward,  forward,  and 
outward  to  the  axillary  line  (see  Fig.  285).  This  incision  divides  the  skin,  sub- 
cutaneous tissues,  lumbar  fascia,  the  latissimus  dorsi,  and  the  serratus  posticus 
inferior  muscles.     If  possible,  the  kidney  is  brought  out  of  the  wound. 

Edebohls's  method  enables  the  surgeon  to  explore  the  kidney  thoroughly 
because  this  organ  is  brought  outside  of  the  body.  It  is  not  suited  to  cases  in 
which  the  organ  is  much  enlarged  or  when  it  has  a  short  pedicle.  Its  best 
field  is  in  operations  for  movable  kidney.  The  patient  lies  prone,  with  a  large 
cylindrical  inflated  rubber  pad  beneath  his  abdomen.  A  vertical  incision  is 
made  close  to  the  border  of  the  erector  spinas  muscle,  from  just  below  the  last 
rib  to  just  above  the  Uiac  crest.  The  sheath  of  the  muscle  is  not  opened.  The 
fibers  of  the  latissimus  dorsi  are  separated  by  blunt  dissection.  The  iliohypo- 
gastric nerve  is  found  and  retracted.  The  transversalis  fascia  is  incised  and 
the  fatty  capsule  reached.  The  two  layers  of  the  fatty  capsule  are  torn  through 
and  the  kidney  exposed.  The  fatty  capsule  is  well  separated  from  the  kidney 
front  and  back.  The  patient  is  pulled  by  the  legs  toward  the  foot  of  the  table, 
the  pad  remaining  stationary.  This  change  of  position  brings  the  pad  beneath 
the  chest,  abdominal  respiration  takes  place,  the  kidney  is  forced  into  the  v^joiind, 
and  can  be  easily  withdrawn  and  thoroughly  examined.  In  many  cases  the 
lumbar  incision  does  not  expose  the  kidney  pedicle  enough  to  make  the 
surgeon  feel  that  he  can  readily  clamp  it  should  nephrectomy  become  neces- 
sary, and  in  any  operation  upon  the  kidney  nephrectomy  may  at  any  minute 
become  necessary.  Cutting  the  twelfth  rib  adds  to  the  exposure,  but  in  cutting 
it  the  pleura  may  be  opened.  Wm.  J.  Mayo  ("Annals  of  Surgery,"  Jan.,  1912) 
in  203  lumbar  operations  divided  the  twelfth  rib  51  times,  and  in  13  of  the 
operations  accidentally  opened  the  pleural  cavity.  In  not  a  case  did  the  lung 
coUapse  (probably  because  the  patients  lay  upon  the  abdomen  with  the  hips 
somewhat  elevated,  the  chest  being  fixed  by  the  position).  In  each  case  the 
torn  pleura  was  sutured,  the  stitches  including  tissue  of  the  diaphragm. 

Mayo  discovered  that  after  division  of  the  quadratus  lumftorum  muscle 


I440  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

and  the  lateral  arcuate  ligament  (which  binds  the  twelfth  rib  to  the  transverse 
process  of  the  first  lumbar  vertebra)  the  rib  can  be  lifted  out  of  the  way  and 
does  not  need  to  be  divided.  Mayo  now  operates  as  follows:  Beginning  over 
the  eleventh  rib  2^2  inches  external  to  the  spines  of  the  dorsal  vertebrae  make 
a  longitudinal  incision  3  inches  in  length.  From  this  point  carry  the  incision 
downward  and  forward  along  the  anterior  margin  of  the  quadratus  lumborum 
to  I  inch  above  the  crest  of  the  ilium;  then  carried  it  forward  parallel  to  the 
crest.  The  twelfth  rib  is  cleared  nearly  to  its  articulation;  the  pleura  is  pushed 
up  out  of  the  way.  The  erector  spinae  mass  is  retracted  toward  the  spine.  The 
costal  margin  is  raised  by  retraction.  A  wide  area  for  operation  is  exposed, 
the  kidney  can  be  brought  out  of  the  wound,  and  the  pedicle  can  be  seen  and 
reached. 

A  common  method  of  opening  the  kidney  is  to  make  a  longitudinal  incision 
through  its  convexity  sufficiently  large  to  admit  the  finger  into  the  renal  pelvis. 
This  incision  may  be  enlarged  if  necessary  until  the  kidney  is  split  in  half.  When 
the  operation  is  finished  close  the  kidney  wound  completely  by  means  of  a 
round  needle  and  catgut,  unless  drainage  is  necessary  or  packing  is  required. 
Another  popular  incision  is  placed  longitudinally  a  little  posterior  to  the  con- 
vex border.  This  goes  through  the  bloodless  zone  of  Hyrtl,  and  causes  less 
hemorrhage  than  the  incision  along  the  convexity.  Marwedel's  incision  is  a 
transverse  cut  at  the  middle  of  the  con\'ex  border  of  the  kindey  into  the  renal 
pelvis.  It  is  doubtful  if  this  incision  is  accompained  by  less  bleeding  than 
longitudinal  incision  of  the  convexity.  After  the  completion  of  our  work  on 
the  kidney  the  lumbar  wound  is  closed  completely  or  is  partially  closed  to  permit 
of  drainage. 

Operation  for  Stone  in  the  Kidney  by  Pyelotomy  or  Nephrotomy  (Pyelo- 
llthotomy,  Nephrolithotomy). — It  used  to  be  held  that  incision  of  the  pelvis  of 
the  kidney  is  far  more  apt  to  be  followed  by  fistula  than  incision  of  the  sub- 
stance of  the  kidney.  The  Mayos,  Bevan,  and  others  have  proved  that  this 
conviction  is  untrue.  In  many  cases  of  stone  pyelotomy  is  preferred  to 
neplirotomy.  It  is  used  for  single  stones  of  moderate  size  in  the  pelvis  and 
unaccompanied  by  suppuration.  When  we  have  a  large  branched  stone,  coral- 
shaped  stones,  multiple  stones,  and  stones  accompained  by  distinct  and  gross 
evidences  of  infection,  then  nephrotomy  should  be  preferred  to  pyelotomy 
(Bevan  and  Smith,  in  paper  read  before  the  American  Surg.  Assoc,  in  1908). 
in  both  operations  the  patient  is  placed  on  the  sound  side  with  a  sand-pillow 
or  cyhndrical  air-bag  under  the  flank.  In  both  cases  the  incision  recommended 
for  nephrotomy  is  used.  In  both  cases  the  kidney  is  lifted  into  the  wound  or 
brought  out  of  the  wound  so  that  it  may  be  satisfactorily  palpated.  In  both 
cases  bleeding  is  controlled  by  having  an  assistant,  if  possible,  grasp  the  pedi- 
cle with  his  lingers  or  with  a  pair  of  forceps,  each  blade  of  which  has  been 
covered  with  a  bit  of  rubber  tube,  while  the  surgeon  opens  the  pelvis  or  the 
kidney  tissue,  removes  the  stone,  and  explores  with  the  finger. 

Pydolithotomy. — Remove  the  fat  from  the  posterior  surface  of  the  pelvis  of 
the  kidney.  We  may  then  be  sure  that  no  aberrant  vessel  is  in  our  way.  The 
normal  vessels  are  all  in  front  of  the  pelvis.  The  posterior  wall  of  the  pelvis 
is  now  opened,  the  stone  is  extracted,  the  pelvis  explored,  the  cut  in  the  pelvis 
is  sutured  with  fine  catgut  sutures,  the  kidney  is  restored  to  place,  a  cigarette 
drain  is  introduced,  and  the  wound  in  the  loin  is  closed.  A  gauze  drain  should 
not  be  used  as  it  might  lead  to  the  formation  of  a  fistula. 

Nephrolithotomy. — The  methods  of  incision,  exposure,  and  opening  the 
kidney  are  described  on  page  1439,  under  Nephrotomy.  When  the  kidney 
has  been  opened,  loosen  the  calculus  with  the  nail,  and  remove  it  with  the 
finger,  with  a  scoop,  or  with  forceps.  After  removing  the  stone,  suture  the 
incision  with  catgut,  and  release  the  pressure  on  the  pedicle.  Hemorrhage 
will  usually  be  controlled,  but  sometimes  violent  bleeding  occurs.     If  in  spite 


Lumbar  Nephrectomy  1441 

of  this  plan  bleeding  occurs,  take  out  the  stitches  and  apply  pressure  and  hot 
water,  compress  the  bleeding  points  by  suture-ligatures,  and  close  again  by 
Stellwagen's  stitches  (see  Figs.  935,  936).  In  some  cases  plug  with  iodoform 
gauze,  suturing  the  gauze  in  place  within  the  kidney  by  fine  catgut  and  leav- 
ing it  until  it  loosens.  When  hemorrhage  ceases,  put  a  large  drainage-tube 
down  to  the  kidney.  Close  the  wound  in  the  muscles  and  integument  and 
dress  antiseptically.  The  dressings  must  be  changed  frequently  and  the  tube 
should  be  shortened  daily.  In  some  cases  nephrectomy  is  necessary  (see  page 
1429).  Formerly  in  these  cases  I  always  drained  for  a  time  and  removed  the 
kidney  secondarily,  believing  that  the  patient  would  gain  strength  in  the  in- 
terval and  stand  the  severe  operation  of  nephrectomy  better.  I  am  satisfied 
that  in  most  cases  this  view  is  wrong,  because  removal  of  a  kidney  bound  down 
by  adhesions  is  one  of  the  most  perilous  and  difficult  operations  of  surgery. 

Nephrectomy  is  the  removal  of  a  kidney.  There  are  two  methods  of 
nephrectomy — the  himbar  and  the  abdominal.  The  first  nephrectomy  (ac- 
cording to  Watson)  was  performed  in  1861  by  an  American,  Walcott.  The 
operation  was  transperitoneal  and  was  for  the  removal  of  a  cancerous  kidney. 
Simon,  in  1869,  performed  the  first  lumbar  nephrectomy  and  the  first  successful 
nephrectomy.  Before  performing  nephrectomy  ascertain  the  competence  of 
the  kidneys.  If  at  least  i  per  cent,  of  urea  is  not  being  excreted,  it  is  very  un- 
safe to  operate.  Be  sure  that  the  patient  possesses  two  kidneys.  Examination 
of  the  bladder  by  the  cystoscope  will  show  the  ureteral  orifices,  a  strong  indication 
that  both  kidneys  are  present.  Nevertheless,  when  we  reflect  that  a  horseshoe 
kidney  has  two  ureters,  the  proof  is  not  absolute.  Catheterization  of  the 
ureters  is  advisable  if  it  can  be  performed,  but  it  will  probably  require  a  special- 
ist to  perform  it.  Proof  absolute  of  the  presence  of  two  kidneys  consists  in 
feeling  both  of  them.  If  in  doubt  as  to  the  question,  and  if  uncertain  as  to  the 
ability  of  the  organ  which  is  to  be  left,  feel  each  kidney  during  the  operation 
before  removing  either,  or  perform  a  preliminary  exploratory  laparotomy. 

Lumbar  Nephrectomy. — The  patient  is  placed  on  the  sound  side  and  a 
pillow  is  placed  under  the  loin.  Several  incisions  have  been  proposed.  In 
many  cases  the  oblique  incision  is  first  made  to  permit  of  exploration.  This 
incision  is  begun  3^^  inch  below  the  last  rib  and  at  the  edge  of  the  erector  spinae 
muscle,  and  is  carried  downward  and  forward  toward  the  iliac  crest.  In 
some  cases  a  kidney  can  be  removed  through  this  cut.  In  other  cases  the  cut 
must  be  enlarged.  It  can  be  enlarged  by  extending  the  cut  downward.  Morris 
enlarges  it  by  adding  to  it  a  vertical  incision,  which  begins  i  inch  below  the 
origin  of  the  oblique  cut.  Konig's  incision  for  nephrectomy  consists  of  a 
vertical  cut  at  the  edge  of  the  erector  spinae,  carried  almost  to  the  iliac  crest, 
from  which  point  it  is  curved  forward  toward  the  umbilicus,  and  is  carried  to 
or  even  through  the  rectus  muscle.  After  thorough  exposure  Hft  the  kidney 
and  separate  it  from  the  peritoneum,  if  possible,  with  the  finger;  clamp  the 
pedicle;  pass  an  armed  aneurysm  needle  between  the  vessels  of  the  pedicle; 
ligate  in  two  places;  cut  between  the  threads,  and  arrest  hemorrhage  perma- 
nently by  ligation  of  each  vessel.  If  the  ureter  be  healthy,  ligate  it  with  silk 
and  drop  it  back;  if  it  be  foul  and  purulent,  scrape  it  with  a  sharp  spoon,  and 
inject  it  with  5-10  minims  of  a  95  per  cent,  solution  of  carbolic  acid  (Mayo), 
and  then  either  ligate  it  with  catgut  and  drop  it  back  or  sew  it  into  the  wound. 
If  hemorrhage  persists  from  the  wound,  plug  with  gauze.  Insert  a  drainage- 
tube  and  close  the  wound.  If  the  peritoneum  be  accidentally  opened,  close  it 
with  Lembert  sutures.  Kocher's  method  is  excellent,  and  enables  the  surgeon 
to  feel  the  opposite  kidney  before  removing  the  one  which  is  known  to  be  dis- 
eased. The  incision  is  begun  as  described  on  page  1439,  and  is  carried  for- 
ward so  as  to  expose  the  reflection  of  the  peritoneum  on  to  the  colon  in  the 
posterior  axillary  line  (see  Fig.  285).^  At  this  point  the  peritoneum  is  opened, 
1  Kocher's  "Text-book  of  Operative  Surgery." 
91 


144^ 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


and  the  surgeon's  hand  is  inserted  into  the  abdominal  cavity  to  feel  the  other 
kidney.  If  another  kidney  exists  and  it  is  found  to  be  healthy,  the  dis- 
eased organ  may  be  removed.  Brewer's  personal  statistics  show  53  cases  of 
nephrectomy  with  2  deaths,  a  mortality  of  3.8  per  cent.  ("Med.  Record,"  March 
20,  1Q09). 

Abdominal  nephrectomy  is  more  dangerous  than  the  lumbar  operation.  The 
position  is  supine.  The  incision  is  that  of  Langenbeck — 4  inches  in  length 
in  the  linea  semilunaris,  its  center  corresponding  to  the  umbilicus.  Open 
the  abdomen,  introduce  a  hand,  feel  the  kidneys,  and  if  both  show  serious 
disease,  do  not  perform  nephrectomy.  If  we  decide  to  remove  one  kidney, 
keep  the  small  intestine  away  by  pads,  push  the  colon  toward  the  umbilicus, 
incise  the  outer  layer  of  the  mesocolon,  and  bare  the  kidney.  Strip  off  the 
peritoneum  from  the  kidney  and  its  vessels,  and  ligate  the  vessels  by  passing 
strong  slik  through  the  center  of  the  pedicle  with  an  aneurysm  needle.  Ligate 
the  ureter  if  healthy,  and  divide  it.     If  the  ureter  be  septic,  fasten  it  in  an  open- 


FiG.  938. — Gauze  slings,  each  composed  of  two  pieces  sutured  together  with  fine  plain  catgut. 

ing  made  in  the  loin  by  cutting  down  upon  forceps  pushed  to  the  outer  edge  of  the 
quadratus  lumborum.  Stop  bleeding,  irrigate  the  belly  cavity,  and  dress  as 
usual,  employing  drainage  only  when  septic  matter  has  passed  into  the  peritoneal 
cavity  or  when  oozing  of  blood  is  persistent. 

Nephrectomy  in  Children. — The  operation  is  proper  in  certain  non-malig- 
nant troubles.  William  Jepson  (Jour.  A.  M.  A.,  Sept.  28,  19 10)  did  a  success- 
ful nephrectomy  for  a  congenital  cystic  kidney  on  a  patient  four  months  and 
fourteen  days  of  age.  Rovsing  did  it  successfully  for  congenital  hydronephrosis, 
the  patient  being  nine  months  old.  Roswell  Park  did  a  successful  nephrectomy 
for  congenital  cystic  kidney  on  a  child  twenty-three  months  of  age.  The  value 
of  nephrectomy  for  sarcoma  is  certainly  doubtful.  The  operation  never  really 
cures,  and  if  an  operative  recovery  is  obtained  the  disease  appears  after  a  time 
in  the  other  kidney.  Jessup  performed  nephrectomy  in  1 1  children  and  every 
case  died  within  two  and  one-half  years  of  the  operation.  The  operation  often 
prolongs  life  and  relieves  discomfort,  but  does  not  cure. 

Partial  Nephrectomy. — This  operation  may  be  performed  in  some  cases 
for   wounds,   cysts,  and  innocent  tumors.     After  removing  the  damaged  or 


The  Author's  Modification  of  the  Elder  Senn's  Operation       1443 


diseased  part,  bleeding  points  are  ligatcd  with  catgut.  The  wound  surfaces 
are  approximated  as  well  as  possible  by  catgut  sutures.  Drainage  is  intro- 
duced. The  value  of  partial  nephrectomy  in  some  cases  seems  certain,  and 
we  should  perform  it  when  possible  instead  of  the  complete  operation,  ^  except 
in  cases  of  malignant  disease. 

Renipuncture. — This  is  an  operation  devised  by  Reginald  Harrison  for 
the  relief  of  albuminuria  due  to  elevated  tension.  The  kidney  is  exposed  in 
the  loin,  the  capsule  is  incised,  and  punctures  are  made  in  the  kidney.  Simple 
incision  of  the  capsule  will  usually  relieve  nephralgia.  (See  Operation  for 
Chronic  Nephritis,  page  1437). 

Nephropexy  is  fixation  of  a  movable  kidney.  The  term  "  nephrorrhaphy," 
so  long  used  for  the  operation,  really  means  suturing  a  wound  in  the  kidney. 

The  Author's  Modification  of  the  Elder  Senn's  Operation. — Many  surgeons 
feel  that  it  is  not  desirable  to  pass  sutures  through  the  kidney  substance,  and 
I  have  entirely  abandoned  the  use  of  them  in  operations  for  movable  kidney. 
Urinary  fistula  has  followed  suturing. 
Again,  the  value  of  such  sutures  is  very 
doubtful.     The    kidney    is    a    very    soft 


Fig.  939. — Right  kidney  projecting  from  wound. 
Observer  standing  on  right  side  of  patient:  i  and 
2,  Slings  in  place,  with  sutures  external;  3.  skin  of 
the  back;  4,  upper  renal  pole;  5,  lower  renal  pole; 
6,  convex  border  of  kidney;  7,  external  surface  of 
kidney.  (Shngs  should  be  broader  than  those  ■ 
shown  in  illustration.) 


Fig.  940. — Right  kidney  restored  to 
place,  seen  from  in  front:  i  and  2, 
Slings  in  place,  sutures  anterior;  4,  upper 
renal  pole;  5,  lower  renal  pole;  7,  anterior 
surface  of  kidney.  (Slings  should  be 
broader  than  those  shown  in  illustra- 
tion.) 


organ,  and  if  it  be  suspended  by  sutures,  they  are  certain  to  cut  through.  In 
most  suture  operations  the  kidney  when  restored  is  not  placed  sufficiently  high 
and  has  its  ureter  and  vessels  looking  forward;  in  other  words,  there  is  a 
one-fourth  twist  in  the  ureter.  In  operations  like  Goelet's  and  Kelly's,  which 
raise  the  kidney  much  nearer  its  proper  level  and  which  do  not  twist  the 
ureter  and  renal  vessels,  the  upper  pole  is  not  anchored  and  tends  to  tilt  for- 
ward (see  page  1424).  The  operation  herein  described  fixes  the  kidney  without 
using  sutures. 

The  patient  lies  upon  his  abdomen,  Edebohls'  bag  being  placed  directly 
beneath  the  lower  abdomen.  A  vertical  or  slightly  oblique  lumbar  incision  is 
made,  the  perirenal  fat  is  exposed,  and  its  two  layers  are  torn  through  until  the 
kidney  is  reached.  The  fatty  capsule  is  thoroughly  stripped  from  the  entire 
organ.  The  kidney  is  brought  out  of  the  wound.  This  is  accomplished  by 
pulling  the  patient  toward  the  foot  of  the  bed,  so  that  the  pad  gets  under  the 

1  See  Oscar  Bloch,  in  "Brit.  Med.  Jour.,"  Oct.  17,  1896;  also  reports  of  Czerny,  Barden- 
heuer,  Tuffier,  and  Kiimmell. 


1444  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

ribs,  when  traction  on  the  fibrofatty  capsule  will  cause  the  kidney  to  emerge 
from  the  wound.  The  posterior  fatty  capsule  is  cut  away,  and  also  the  anterior 
fatty  capsule  up  to  the  hilum.  The  true  capsule  of  the  kidney  is  scarified. 
I  always  have  packing  prepared  by  suturing  together  with  the  finest  plain  catgut 
the  ends  of  two  pieces  of  iodoform  gauze.  Two  such  strands  are  prepared 
(Fig.  938).  One  piece  of  iodoform  gauze  is  placed  under  the  upper  end  of  the 
kidney,  and  another  piece  under  the  lower  end,  the  sling  in  each  instance  being 
directly  under  the  kidney  with  the  suture  line  external  and  not  in  front,  as  the 
kidney  protrudes  from  the  wound  in  the  back  (Fig.  939).  When  the  kidney 
is  replaced  the  suture  line  will  lie  in  front  (Fig.  940).  The  kidney  is  replaced 
and  will  then  lie  in  a  sling  composed  of  two  pieces  of  gauze,  the  ends  of  which 
protrude  from  the  wound.  Another  piece  is  placed  below  the  lower  renal  pole 
to  fill  up  the  space  which  always  exists  there  and  to  stimulate  granulation.  This 
space  below  the  kidney  is  a  frequent  cause  of  subsequent  loosening  in  most 


Fig.  y4i. — Ciiljjuii  s  incision  lor  oper- 
ations on  the  lower  ureter.  The  superficial 
incision  (C.  L.  Gibson). 


Fig.  g42. — Gibson's  incision  for  operations 
on  the  lower  ureter.  The  upper  flap,  consist- 
ing of  skin,  external  and  internal  oblique 
muscles,  is  retracted.  The  dotted  line  rep- 
resents the  line  of  incision  in  the  transversalis 
fascia  (C.  L.  Gibson). 


suture  operations,  because  the  kidney  hangs  in  it  unsupported,  as  a  bucket 
hangs  in  a  well.  Harris  recognizes  this,  and  in  his  operation  closes  the  space 
by  sutures.  Gauze  is  packed  in  over  and  about  the  kidney,  and  over  this  the 
two  long  slings  are  tied.  Several  sutures  of  silkworm-gut  are  inserted  to  close 
the  superficial  parts  and  the  lumbar  aponeurosis;  some  are  tied  and  some  are 
left  untied.  A  large  gauze  pad  is  placed  upon  the  abdomen  over  the  anterior  sur- 
face of  the  kidney,  and  the  lumbar  wound  is  dressed  with  gauze.  The  dress- 
ing and  gauze  pad  are  held  in  place  by  a  binder.  In  about  eight  or  ten  days 
the  gauze  should  be  soaked  with  dripping  salt  solution  during  half  an  hour  and 
the  packing  removed.  At  this  time  the  catgut  is  destroyed  and  the  gauze  can 
be  easily  pulled  out.  The  tied  sutures  are  cut  and  removed,  the  sutures  left 
unfastened  are  tied,  and  a  small  piece  of  gauze  is  inserted  as  a  drain  between  the 
granulating  surfaces.  If  a  continuous  piece  of  gauze  has  been  used,  ether  must 
be  given  before  removal  is  attempted.     Further,  in  the  old  operation,  a  large 


Gibson's  Incision  for  Operations  on  the  Lower  Ureter         144S 


wound  was  left  to  granulate  and  weeks  were  often  required  to  obtain  healing. 
In  this  operation  the  wound  is  usually  entirely  healed  in  from  eighteen  to 
twenty-one  days.  After  the  performance  of  nephropexy  the  patient  remains 
in  bed  for  three  weeks.  By  this  operation  the  kidney  is  placed  in  a  proper 
situation,  is  surrounded  with  granulations  which  are  converted  into  scar- 
tissue,  and  the  organ  becomes  encased  in  a  box  of  fibrous  tissue.  I  believe  that 
a  kidney  so  treated  will  probably  remain  fixed. 

If  a  kidney  has  been  decapsulated,  gauze  slings  should  not  be  placed  around 
it,  because  removal  of  them  might  lacerate  the  kidney.  After  decapsulation 
the  surgeon  rests  content  when  he  has  filled  the  space  below  the  kidney  with  a 
support  of  gauze. 

Ureterolithotomy. — If  the  stone  be  impacted  in  the  upper  two-thirds  or 
three-fourths  of  the  tube  it  may  be  reached  by  an  incision  from  the  twelfth 
rib  downward  and  forward  to  just  anterior  to  the  anterosuperior  spine  of 


Fig.  943. — Gibson's  incision  for  operations 
on  the  lower  ureter.  The  edge  of  the  rectus 
muscle  is  strongly  retracted  inward;  between 
it  and  the  cut  edge  of  the  transversalis  fascia 
the  peritoneum  is  exposed  (C.  L.  Gibson). 


Fig.  944. — Gibson's  incision  for  operations 
on  the  lower  ureter.  The  peritoneum  has 
been  pushed  upward.  The  ureter  is  lifted  out 
of  the  pelvis  and  brought  to  the  level  of  the 
external  wound  (C.  L.  Gibson). 


the  ilium  and  then  parallel  to  Poupart's  ligament  to  above  its  middle.  The 
peritoneum  is  stripped  up  as  in  extraperitoneal  ligation  of  the  iliac  vessels.  The 
ureter  adheres  to  the  peritoneum.     The  operation  is  strictly  extraperitoneal. 

Gibson's  incision  for  operations  on  the  lower  ureter  ("Amer.  Jour.  Med. 
Sciences,"  Jan.,  1910)  is  the  most  useful  for  reaching  and  amply  exposing  the 
lower  ureter.  Further,  it  enables  us  to  feel  and  accurately  to  operate  upon 
the  tube,  the  entire  operation  being  extraperitoneal.  Gibson  thus  describes 
his  operation: 

"The  skin  incision  runs  from  the  midline  about  a  finger's  breadth  above 
the  pubes,  horizontally  outward  nearly  parallel  to  Poupart's  ligament  at  first 
(Fig.  941),  and  curves  rather  sharply  upward  at  its  midpoint  to  end  about 
opposite  the  anterior  superior  spine  of  the  ilium.  This  incision  is  deepened 
in  the  same  line  through  the  aponeurosis  of  the  external  oblique  and  the  in- 
ternal oblique  muscle — the  latter  is  the  only  structure  which  suffers  any  real 
damage,  and  only  to  a  slight  degree,  for  the  lower  part  of  the  incision  runs 


1446  Diseases  and  Injuries  of  the  Cienito-urinary  Organs 

about  parallel  to  its  fibers,  cutting  only  the  ascending  leg  across  a  small  part 
of  these  fibers.  The  incision  stops  short  of  the  transversalis,  which  is  not  dis- 
turbed at  all.  With  efhcient  retraction  of  the  upper  flap  the  external  border 
of  the  rectus  muscle  is  identified  (Fig.  942)  and  the  fascia  of  the  transversalis 
is  now  divided  by  a  vertical  incision  close  to  and  parallel  to  the  rectus — that  is, 
at  right  angles  to  the  original  incision.  Two  retractors  are  now  inserted,  the 
outer  one  retracts  the  cut  edge  of  the  transversalis  outward,  the  other  (Fig. 
943)  pulls  the  rectus  muscle  well  toward  the  midline.  A  generous  space  is 
thus  obtained,  situated  well  toward  the  midline  (the  lower  part  of  the  ureter 
is  practically  in  the  midline  and  difhcult  of  access  by  other  extraperitoneal 
exposures).  The  floor  of  this  space  is  occupied  by  the  peritoneum.  The 
patient  being  in  a  complete  Trendelenburg  position,  the  peritoneum  is  easily 
and  gently  pushed  away,  and  a  free  access  to  the  pelvis  is  secured.  So  ample 
is  the  space  and  view  that  the  whole  hand  can  be  introduced  under  the  control 
of  the  eye.  The  ureter  is  released  from  its  surroundings  and  easily  brought 
to  the  level  of  the  wound"  (Fig.  944). 


Fig.  g4S. — Van  Hook's  method  of  ureteral  anastomosis. 

When  the  tube  has  been  exposed  it  is  opened  by  a  longitudinal  incision. 
The  stone  is  removed.  The  ureter  is  explored  by  means  of  a  sound  to  see  if  it  be 
patulous.  After  removing  the  stone,  close  the  wound  in  the  ureter  with  sutures 
of  very  fine  chromic  gut.  Deep  sutures  pass  through  all  the  coats  and  are  tied. 
Over  this  a  layer  of  superficial  sutures  is  inserted.  Close  the  tissues  about  the 
ureter  and  drain  by  rubber  tissue.  Never  drain  by  gauze.  To  do  so  will  cause 
a  urinary  fistula.  In  a  woman  a  stone  near  the  vesical  opening  can  be  reached 
by  a  vaginal  incision.  Stone  in^  the  vesical  portion  of  the  ureter  may  perhaps 
be  removed  by  aid  of  an  operating  cystoscope  or  by  forceps  after  the  perform- 
ance of  a  suprapubic  cystotomy. 

Judd  exposes  the  lower  two  or  three  inches  of  the  ureter  by  making  a  median 
incision  from  the  umbilicus  to  the  symphysis,  by  retracting  but  not  opening  the 
peritoneum  and  by  drawing  the  bladder  toward  the  median  line  ("Annals  of 
Surgery,"  1914,  lix). 

My  colleague.  Prof.  John  H.  Gibbon,  advocates  a  combined  intra-  and 
extraperitoneal  route  for  stones  anywhere  in  the  lower  two-thirds  of  the  ureter. 
The  peritoneal  incision  permits  of  exploration  and  exact  localization  of  the 
stone,  allows  the  surgeon  to  push  the  calculus  from  an  inaccessible  into  an 
easily  reachable  position,  and  makes  the  removal  vastly  easier.     The  stone 


Cystoscopy  1447 

is  removed  by  extraperitoneal  incision  of  the  ureter,  and  the  peritoneum  is  closed. 
(Gibbon,  in  "Annals  of  Surg.,  Gynec,  and  Obstet.,"  May,  1908). 

Uretero-ureterostomy  (Van  Hook's  Operation). — In  this  operation  ligate 
the  lower  end  of  the  divided  ureter  with  silk  or  catgut.  About  3-^  inch  below 
the  ligature  make  an  incision  in  the  long  axis  of  the  tube.  This  incision  is  in 
length  equal  to  twice  the  diameter  of  the  tube.  Each  end  of  a  piece  of  fine 
catgut  is  threaded  to  a  fine  needle.  This  thread  is  passed  through  the  upper 
end  of  the  ureter  (Fig.  945).  The  needles  are  made  to  enter  the  lower  end  of  the 
tube  through  the  door  made  by  the  surgeon.  They  are  pushed  through  the 
wall  of  the  ureter  3  2  i^^h  below  the  door  (Fig.  945).  Traction  upon  the  strings 
causes  invagination,  and  the  ligature  ends  are  tied.  If  the  operation  be  intra- 
peritoneal the  ureter  is  wrapped  about  with  peritoneum. 

Intestinal  Implantation  of  the  Ureters. — This  operation  may  be  employed 
in  exstrophy  of  the  bladder  and  in  vesical  cancer  in  which  it  is  necessary  to 
remove  the  bladder.  After  this  operation  there  is  danger  of  infection  of  the 
ureters  and  consequent  ascending  ureteritis  and  pyelonephritis,  and  the  presence 
of  urine  in  the  bowel  usually  causes  inflammation  of  the  rectum  and  incon- 
tinence of  urine  may  take  place. 

Maydl  asserts  that  a  piece  of  the  bas-fond  should  be  removed  with  the 
ureter,  and  implanted  with  it  into  the  intestine,  the  flange  hanging  free  in 
the  lumen  of  the  gut.  If  this  be  done,  the  relations  of  the  ureter  to  the  mus- 
cular coat  of  the  bladder  are  not  interfered  with,  stricture  is  less  likely  to  occur, 
ascending  infection  is  antagonized,  and  suppurative  conditions  arise  at  the 
margin  of  the  flange  rather  than,  as  in  other  methods,  directly  in  the  cut  ureter. 
Maydl  has  collected  the  records  of  14  cases  operated  upon  by  this  method, 
with  2  deaths.^  I  performed  it  twice,  with  i  death.  In  vesical  exstrophy 
Peterson  transplants  a  vesical  flap  containing  both  ureteral  orifices  into  the 
descending  colon. 

Cystoscopy  is  the  employment  of  the  cystoscope  for  the  study  of  the 
interior  of  the  bladder,  the  prostate,  the  ureteral  orifices,  and  the  appearance 
of  the  fluid  from  each  kidney. 

The  cystoscope  is  an  instrument  of  great  value  in  the  hands  of  a  skilful 
and  experienced  man,  but  is  practically  useless  when  employed  by  a  novice. 
All  of  my  cystoscopic  examinations  are  made  for  me  by  Dr.  Stellwagen  or  some 
other  expert.  In  using  a  cystoscope  the  mucous  membrane  may  be  burned  with 
a  hot  lamp.  This  causes  inflammation,  and  if  an  eschar  forms,  it  will  be  cast 
off,  exposing  a  granulating  surface.  Schmidt,  in  calling  attention  to  this 
injury,  speaks  of  the  condition  as  ulcus  cystoscopicum  and  says  that  it  is  in  the 
fundus,  has  the  shape  of  the  instrument,  and  heals  in  from  fourteen  to  twenty- 
one  days  ("Jour.  Amer.  Med.  Assoc,"  July  19,  1902). 

Cystoscopic  examination  of  the  bladder  owes  its  present  position  to  Messrs. 
Max  Nitze  and  Joseph  Leiter,  who  were  the  first  to  introduce  practical  in- 
struments: Nitze  in  1876  and  Leiter  in  1879.  The  great  obstacle  in  former 
years  was  the  danger  of  burning  the  mucous  membrane  by  overheating  of  the 
lamp.  The  invention  of  the  cold  lamp  by  E.  C.  Preston  eliminated  that  danger, 
and  was  a  great  step  forward.  Nitze  w^as  the  first  to  recognize  the  futility  of 
examination  by  reflected  light  and  constructed  an  instrument  with  the  light 
on  the  end  which  to-day  is  copied  by  all  of  the  modern  instruments. 

Cystoscopes  may  be  divided  into  several  types:  (i)  The  examining  instru- 
ment; (2)  the  instrument  carrying  ureteral  catheters  or  the  catheterizing  cysto- 
scope; (3)  the  operating  cystoscope.  They  aU  have  certain  mechanical  features 
in  common,  but  differ  in  their  construction  and  lens  arrangement. 

The  examining  instruments  are  of  two  fundamental  types — the  direct  and 
the  indirect.  In  the  direct  there  is  a  straight  telescope  with  a  series  of  wide 
angle  lenses  that  give  the  picture  of  the  bladder  in  front  and  slightly  to  the  side. 
^  Editorial  in  "Jour.  Amer.  Med.  Assoc,"  May  6,  1899. 


1448  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

In  the  indirect  the  lens  is  so  ground  and  set  as  to  enable  the  operator  to  look 
toward  the  prostate. 

Catheterizing  cystoscopes  are  also  of  two  kinds — the  direct  catheterizing 
and  the  indirect.  In  the  direct  catheterizing  cystoscope  the  catheters  are 
passed  directly  from  the  carrying  tubes  into  the  ureters.  In  the  indirect  cathe- 
terizing cystoscope  the  catheter  is  bent  or  directed  by  a  lever  on  the  end  of 
the  instrument  operated  by  a  thumb-screw  on  the  penile  end.  By  raising  or 
lowering  the  lever  the  angle  of  the  catheter  is  altered  to  facilitate  its  introduc- 
tion into  the  ureteral  orifice. 

It  is  obvious  that  the  bladder  should  be  distended  in  order  to  permit  of 
cystoscopic  examination.     For  this  purpose  air  and  water  have  been  utilized^ 


Fig.  946. — The  A.  C.  ^I.  I.  double  catheterizing  cystoscope. 

The  modern  tendency  is  in  favor  of  water  distention.  Some  of  the  operating 
instruments,  notably  that  of  Prof.  Lewis,  require  air. 

Water  as  a  dilating  medium  is  superior  to  air,  unless  operative  work  is  to 
be  done  through  the  instrument,  in  which  case  the  inevitable  hemorrhage  pre- 
cludes the  use  of  water.  The  air  instruments  show  but  a  small  field,  the  dis- 
tention causes  pain  and  is  often  followed  by  mild  cystitis. 

From  the  foregoing  it  is  plain  that  one  type  of  instrument  is  not  suited  to  all 
cases,  and  each  has  its  claim  to  practical  utility.  Some  cases  can  be  most 
readily  catheterized  by  the  direct,  while  others  are  only  reached  by  the  indi- 
rect, plan.  It  is  my  conviction  that  if  the  ureteral  orifices  are  normally 
placed,  the  direct  method  is  quicker  and  more  readily  learned  by  the  beginner. 


Fig.  947. — The  A.  C.  M.  I.  operating  cystoscope. 

Men  who  have  had  training  had  best  use  the  A.  C.  i\I.  I.  cystoscope  (Figs.  946^ 
947).  It  is  an  indirect  or  oblique  cystoscope,  but  has  a  corrected  image  field 
which  enables  the  operator  to  work  as  he  sees  and  not  the  reverse  (as  in  neces- 
sary with  the  uncorrected  image  field).  These  new  instruments  cause  less  pain 
than  direct  instruments,  and  give  a  very  wide  field.  When  from  any  cause  the 
ureteral  orifice  turns  backward  (which  only  happens  in  a  very  small  percentage 
of  cases)  the  indirect  cystoscope  is  indispensable,  it  being  practically  impossible 
to  reach  the  ureteral  orifice  by  the  direct  instrument. 

There  are  at  present  many  different  forms  of  cystoscopes  on  the  market, 
notable  among  them  being  the  Nitze,  Casper,  Tilden  Brown,  Cabot's  modifica- 
tion of  the  Tilden  Brown,  Buerger,  Albarran,  Bransford  Lewis,  and  the  so-called 
Universal.  The  universal  instruments  of  Bransford  Lewis  and  Tilden  Brown 
possess  features  of  great  practical  utility. 


Contra-indications  to  Cystoscopy 


1449 


Sterilization  of  Cystoscopcs  and  Ureteral  Catheters. — In  order  to  sterilize 
the  cystoscope  before  using,  place  it  for  five  minutes  in  a  solution  of  mercury 
oxycyanid  (1:1 000)  or  f ormaldehy d  ( i :  500) .  The  sterilizing  power  of  f  ormaldc- 
hyd  gas  is  not  to  be  relied  on.     Some 

operators  use  a  5  per  cent,  solution  of     ^ .    '^       ^  c      d      e  f       e 

phenol,  in  which  the  instrument  is  im- 
mersed for  twenty-four  hours,  after 
which  it  is  dipped  into  glycerin,  which 
both  neutralizes  the  phenol  and  lubri- 
cates the  tube.  The  mercury  oxy- 
cyanid solution  is  easily  used  and  is 
thoroughly  satisfactory.  Should  for- 
maldehyd  solution  or  formalin  gas  be 
used,  always  wash  the  instrument 
thoroughly  with  salt  solution  before 
using  to  prevent  irritation  by  the 
sterilizing  medium. 

Dr.  ]M.  P.  Willard,  of  San  Francisco, 
in  "Jour.  Amer.  Med.  Assoc,"  Octo- 
ber 4,  1913,  advocates  the  following 
method  for  sterilizing  ureteral  cathe- 
ters: The  ureteral  catheter  is  placed  in 
a  muslin  bag  2  cm.  wide  by  75  cm.  long. 
The  bag  is  enclosed,  with  the  catheter 
in  it,  in  paraffin  paper,  and  secured  by 
encircling  strips  of  adhesive  plaster. 
As  many  may  be  prepared  as  is  thought 
necessary.  The  package  is  placed  for 
twenty  minutes  in  an  autoclave  with  a 
pressure  of  8  to  10  pounds.  When  the 
catheter  is  to  be  used  the  paper  is  re- 
moved and  the  end  of  the  instrument 
is  exposed  by  pulling  back  the  linen 
bag  and  the  tip  of  the  catheter  is  en- 
gaged in  the  carrying  tube  of  the 
cystoscope.  As  the  catheter  is  fed 
through  the  cystoscope  the  linen  bag 
is  pulled  back;  in  this  way  the  fingers 
do  not  come  in  contact  with  the 
catheter. 

Ureteral  catheters  can  be  sterilized 
by  placing  them  in  an  open  shallow 
dish  containing  a  saturated  solution 
of  ammonium  sulphate  or  sodium 
chlorid  and  boiling  them  for  five  or 
ten  minutes.  The  following  precau- 
tions must  be  observed:  Each  catheter 
should  be  wrapped  in  gauze  and  the 
bottom  of  the  pan  covered  with  gauze. 
If  the  catheters  are  allowed  to  touch 
each  other  or  curl  upon  themselves  the 

shellac  coating  will  melt  and  ruin  the  instruments.  They  may  also  be  sterilized 
in  the  same  manner  as  the  cystoscope,  care  being  taken  if  formalin  has  been  used 
to  wash  away  carefully  the  germicide,  especially  from  the  lumen  of  the  catheter. 

Contra-indications  to  Cystoscopy. — The  bladder  must  hold  at  the  very  least 
50  c.c.  of  fluid.     If  it  holds  less  cystoscopy  is  useless.     Examination  is  either 


Fig.  948. — Different  tj-pes  of  ureteral 
catheters:  a,  Blasucci;  h,  return  flow  for  irri- 
gation; c,  Garceau;  J,  another  type  of  Blasucci; 
e,  Cunningham;  /,  olivary  tipped;  g,  .r-ra}- 
whistle  tip. 


I4SO  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

impossible  or  unsatisfactory  if  the  prostate  be  greatly  enlarged.  Contracted 
meatus  urinarius  and  stricture  of  less  caliber  than  No.  24  of  the  French  scale 
are  correctible  contra-indications.  Papillomata  and  other  tumors  and  foreign 
bodies  of  the  urethra  are  impediments.  In  acute  Bright's  disease  instrumenta- 
tion is  dangerous,  because  it  may  be  followed  by  suppression  of  urine.     The 


U^ 


"<'y» 


> 


Fig.  949. — Buerger's  rongeur  forceps  with  flexible  shank  for  use  with  Buerger's  operating 

cystoscope. 

following  are  further  contra-indications,  as  suggested  by  Follen  Cabot  and 
Henry  G.  Spooner,  in  "Med.  Record,"  July  11,  1903:  When  it  is  obvious  that 
operative  intervention  would  be  useless;  when  there  is  a  large  tumor;  in  acute 
cystitis;  in  tuberculosis  in  which  the  diagnosis  is  evident  without  the  cystoscope. 
In  women,  pelvic  adhesions  and  large  exudates  may  interfere  with  cystoscopy. 


Fig.  950. — Tilden  Brown's  cystoscopic  table  with  patient  in  position  for  examination. 

Technic  of  Cystoscopy. — The  patient  should,  if  possible,  be  carefully  sounded 
once  a  day  for  several  days  previous  to  the  cystoscopic  examination;  this  estab- 
lishes tolerance  of  the  urethra.  He  should  be  placed  upon  a  suitable  table, 
such  as  that  devised  by  Tilden  Brown  or  Bransford  Lewis,  as  shown  in  Fig.  950. 


Tcchnic  of  Cystoscopy  145 1 

The  urethra  is  cleaned  by  irrigation  with  salt  solution.  General  anesthe- 
sia is  rarely  necessary  provided  the  operator  is  gentle  in  his  manipulations. 
There  are,  however,  some  hypersensitive  urethras  which  it  is  necessary  to 
anesthetize.  Cocainization  of  the  urethra  will  usually  suffice.  This  is 
carried  out  by  instillation  through  the  Keyes-Ultzmann  syringe  or,  better, 
through  a  soft-rubber  catheter  into  the  posterior  portion  of  the  canal  of  i 
dram  of  a  4  per  cent,  solution  of  cocain.  Alypin,  placed  in  the  canal  at  the 
points  of  greatest  tenderness  by  means  of  Dr.  Lewis's  repositor,  answers  very 
well.  These  tablets  are  allowed  to  dissolve  in  the  urethral  mucus.  The  points 
of  greatest  tenderness  are  the  fossa  navicularis,  the  bulbo-membranous  junction, 
and  the  prostatic  urethra  about  the  verumontanum.  In  cases  complicated  by 
cystitis  preliminary  lavage  of  the  bladder  should  be  practised.  This  may  be 
given  through  the  cystoscope  sheath  or  through  a  soft-rubber  catheter.  If  the 
bladder  be  not  diseased,  it  is  merely  necessary  to  draw  off  the  urine.  After  the 
urine  has  been  withdrawn,  the 
cystoscope  sheath  should  be  firmly 
but  gently  held  in  place.  The 
thumb  of  the  left  hand  presses 
downward  while  the  index-finger 
presses  upward  on  the  under  sur- 
face of  the  sheath.  This  pro- 
cedure raises  the  beak  of  the  in- 
strument from  the  sensitive  trigone, 
where  most  of  the  pain  and  hem- 
orrhage are  produced  by  vesical 
tenesmus. 

In  regard  to  the  selection  of  the 
distending  medium,  the  operator 
may  use  sterile  water,  normal  salt 
solution,  boric  acid  solution,  or 
mercury  oxycyanid  solution 
(i  :  5000).  The  bladder  should 
be  moderately  distended  and,  if 
possible,  from  8  to  10  ounces  of 
fluid  are  allowed  to  remain  in  the 
viscus.  In  contracted  or  hyper- 
sensitive bladders  it  is  well  to 
elevate  the  hips  and  so  relieve  the  pressure  on  the  sensitive  vesical  neck  and 
trigone. 

The  temperature  of  the  distending  fluid  is  of  great  importance,  particularly 
if  there  be  difficulty  in  finding  the  ureteral  outlet.  If  this  is  the  case,  the  temper- 
ature of  the  fluid  should  be  about  60°  F.  This  enables  the  operator  to  see  a 
so-called  swirl  when  the  warm  jet  of  urine  mixes  with  the  cold  water  in  the 
bladder.  It  is  sometimes  advisable  to  give  methylene-blue  before  examining 
for  the  same  reason.     The  blue  stream  from  the  ureter  at  once  identifies  the  tube. 

After  the  bladder  has  been  fiUed  the  telescope  containing  the  catheters  is 
inserted  and  the  light  is  turned  on.  The  instrument,  then  held  in  the  median 
line,  is  pushed  gently  back,  well  into  the  bladder,  pressure  being  always  made  to 
keep  the  beak  from  impinging  upon  the  floor  of  the  viscus.  The  cystoscope  is 
now  slowly  withdrawn,  a  careful  watch  being  mantained  through  the  telescope 
for  the  intenireteral  bar  (Fig.  951).  This  structure  (there  has  been  much  ar- 
gument as  to  whether  this  structure  really  exists)  marks  the  posterior  border  of 
the  trigone.  The  examiner  has  still  another  guide  to  the  trigone  in  the  blood- 
vessels, which  in  a  general  way  run  anteroposteriorly.  There  is  a  distinct 
line  of  demarcation  between  the  fish-net  loop  arrangement  of  the  mucous 
membrane   of  the  sides  and  base  of  the  bladder  and  the  mucous  membrane 


Fig.  951. — The  interior  of  the  bladder,  show- 
ing arrangement  of  the  vessels  of  the  trigone: 
A,  B,  interureteral  bar. 


1452  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

in  the  trigone.  Fig.  951  gives  a  general  idea  of  the  vascular  arrangement. 
When  the  interureteral  bar  or  posterior  border  of  the  trigone  has  been  located, 
the  instrument  is  gently  and  slowly  moved  laterally,  so  that  the  border  of  the 
cystoscope  is  kept  in  the  field  until  the  end  of  the  bar  is  reached.  The  instru- 
ment is  then  held  stationary  for  a  moment  and  a  sharp  lookout  is  kept  for 
the  jet  of  urine  or  the  swirl.  The  ureteral  orifice  is  thus  indicated.  Should  the 
field  become  blurred  by  blood  on  the  lens,  or  should  the  solution  in  the  blad- 
der become  mixed  with  blood,  continuous  irrigation  must  be  kept  up  through 
the  cystoscope. 

The  Ureteral  Orifices. — As  before  mentioned,  the  ureteral  orifices  are  usually 
located  at  the  terminations  of  the  interureteral  bar,  and  occupy  the  basal  angles 
of  a  triangle  formed  by  the  vesical  outlet  and  the  base  of  the  trigone.  They  are 
usually  about  i  to  i}-^  cm.  from  the  median  line  and  about  2)^  cm.  from  the 
vesical  end  of  the  urethra.  They  are  recognized  as  small  slits  or  as  tubercles 
on  the  surface  of  the  mucous  membrane.  Their  position  is  not  always  the  same. 
Some  of  the  abnormal  positions  more  commonly  met  with  are  as  follows:  one 
ureter  closer  to  or  further  removed  from  the  median  line,  both  ureters  emptying 
into  the  bladder  close  to  the  median  line,  generally  about  one-quarter  or  one- 
half  the  length  of  the  bar.  Malposition  is  toward  the  vesical  outlet  and  in  some 
very  rare  instances  both  ureters  empty  on  the  same  side.  Sacculation  and  pocket- 
ing of  the  bladder  with  swelling  of  the  mucous  membrane  often  make  localiza- 
tion of  the  ureteral  orifices  difiicult.  It  is  then  that  the  administration  of 
methylene-blue  or  indigo-carmin  may  enable  the  investigator  to  locate  the  ure- 
ters more  readily. 

After  locating  a  ureteral  orifice  the  vesical  end  of  the  cystoscope  is  carried 
directly  over  the  opening  and  the  catheter  is  projected  against  the  opening, 
where  it  is  allowed  to  remain  for  a  moment  in  order  to  overcome  the  spasm 
of  the  sphincteric  muscular  fibers.  The  patient  is  instructed  to  hold  his  breath 
and  the  opening  is  carefully  watched  until  a  jet  of  urine  is  forced  through,  during 
which  act  the  catheter  is  gently  inserted  into  the  ureter.  The  passing  of  the 
urine  is  accompanied  by  dilatation  of  the  opening  and  greatly  facilitates  the 
passage  of  the  instrument.  After  the  catheter  has  passed  the  sphincter  muscle 
it  should  be  carried  up  the  canal  by  very  gentle  pressure.  The  practice  of 
passing  the  instrument  quickly,  so  commonly  resorted  to  by  the  novice  in  order 
to  gain  time,  is  pernicious,  and  almost  invariably  causes  laceration  and  hemor- 
rhage. Before  inserting  the  catheter  some  operators  prefer  to  coat  it  with 
parafiin  in  order  to  render  it  absolutely  smooth  and  further  to  assist  in  the 
detection  of  calculus.  This  is  not  necessary.  Any  instrument  with  an  im- 
perfect eye  should  be  discarded. 

The  round-pointed  catheter  should  be  used  wherever  possible,  as  with  it 
there  is  less  danger  of  injuring  the  delicate  mucous  lining  of  the  canal.  The 
sharp-pointed  oHvary  tipped  instrument  often  causes  blood  to  appear.  If 
possible,  insert  the  catheter  into  the  renal  pelvis,  for  then  hemorrhage  from 
trauma  is  less  likely  to  invalidate  the  examination,  and  spasm  of  the  ureter, 
with  sucking  of  the  mucous  membrane  into  the  eye  of  the  catheter,  will  not 
occur.  Having  finished  the  catheterization  of  one  side,  the  catheter  is  left  in 
place,  the  instrument  handle  is  swung  to  the  opposite  side  and  a  similar  pro- 
cedure is  carried  out.  Always  have  a  distinguishing  mark  upon  the  catheters. 
A  very  good  method  is  to  use  different  colored  instruments,  so  that  there  may 
be  no  confusion  after  withdrawal  of  the  cystoscope.  In  some  cases  only  one 
ureter  can  be  catheterized.  In  such  a  case  the  bladder  should  be  thoroughly 
washed,  and  the  other  catheter,  left  on  the  floor  of  the  bladder,  will  collect  the 
urine  from  the  uncatheterized  side  and  give  a  fair  idea  of  the  condition  of  that 
kidney. 

Removal  of  the  Cystoscope. — The  light  should  be  turned  off  and  a  small 
amount  of  fluid  allowed  to  escape  through  the  barrel.     The  lens  system  carry- 


Collection  of  the  Urine 


1453 


ing  the  catheter  is  then  loosened  and  gently  rotated  from  side  to  side  to  free 
the  catheters.  During  this  procedure  the  catheters  are  drawn  gently  backward, 
but  not  with  sufficient  force  to  cause  kinking,  and  the  lens  system  is  removed. 
Next  the  sheath  is  withdrawn  by  carrying  it  straight  up  over  the  abdomen. 
Collection  of  the  Urine. — The  protruding  catheters  are  carefully  wiped  with 
sterile  gauze  and  are  permitted  to  drain  into  separate  bottles  or  test-tubes, 
marked  respectively  right  and  left.  The  orifices  of  the  receivers  should  be 
plugged  with  sterile  absorbent  cotton,  which  will  collect  and  prevent  any  admix- 
ture of  urine  or  water  coming  from  the  bladder  by  capillary  drainage.  The 
bottles  should  also  be  held  in  such  position  as  to  prevent  such  capillary  drainage 
reaching  them.  With  regard  to  the  collection  of  the  samples,  there  are  certain 
precautions  that  should  be  observed:  (i)  The  samples  should,  if  possible,  be  col- 
lected in  three  separate  bottles  from  each  side,  allowing  each  set  to  remain  in 
position  a  definite  time,  generally  one-half  hour.  These  should  be  carefully 
watched  and  marked  first,  second,  and  third  haK-hours.  They  should  each  be 
examined  separately,  and  by  a  summation  of  the  examinations  the  opinion 
should  be  reached.  Almost  invariably  microscopical  blood  can  be  found  in  the 
urine  drawn  by  catheterization  of  the  ureters.     In  a  study  of  15  cases  of  normal 


Fig.  952. — Bulbs  and  bottle  for  distending  bladder  and  collecting  washings. 

ureters,  blood  not  being  present  before  catheterization  after  catheterizing 
with  the  greatest  care,  microscopical  blood  was  present  in  all  but  3.  The 
erythrocytes  are  usually  most  numerous  in  the  first  bottle,  gradually  diminish- 
ing, until  in  the  third  there  are  very  few  or  none.  Should  the  blood  increase 
in  amount  in  the  second  or  third  bottle,  it  is  an  important  clinical  fact. 

In  some  instances  one  or  both  catheters  faU  to  drain.  This  may  be  due  to  a 
bubble  of  air  in  the  instrument,  impinging  of  the  mucous  membrane  upon  the 
eye,  plugging  by  blood-clot,  mucus,  pus,  or  particles  of  gravel.  A  syringe 
is  then  essential.  The  blunt  hollow  needle  should  be  inserted  into  the  cath- 
eter and  suction  applied;  should  this  fail,  not  over  4  c.c.  of  sterile  normal  salt 
solution  may  be  injected  through  the  catheter.  This  procedure,  however,  must 
be  carried  out  very  gently,  because  of  the  danger  of  overdilating  the  renal  pel- 
vis and  thus  producing  colic. 

The  carrying  capacity  of  the  pelvis  of  the  kidney  is  uncertain.  Careful 
observations  indicate  that  there  is  no  definite  carrying  capacity  that  may  be 
called  normal.  The  range  of  difference  is  great  and  even  differs  at  certain 
times  in  the  same  kidney.  In  many  kidneys  it  is  about  8  to  10  c.c,  but,  on 
the  other  hand,  it  may  be  as  high  as  20  c.c.  and  stiU  be  normal.  It  would  seem 
as  though  the  blood-supply  of  the  organ  had  something  to  do  with  the  pelvic 


1454  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

capacity,  for  a  congested  circulation  means  distended  vessels,  and  they  prob- 
ably impinge  upon  the  pelvis.  Again,  the  question  of  producing  renal  colic 
by  overdilatation  of  the  pelvis  is  a  very  uncertain  guide  as  to  the  capacity,  for 
in  many  instances  the  ureteral  and  pelvic  musculature  is  sufficient  to  force  the 
fluid  down  the  ureter  with  the  catheter  in  situ  and  yet  produce  no  evidence  of 


Fig.  953. — I,  Scissors;  2,  tweezers;  3,  forceps;  and  4,  punch  for  use  with  the  Lewis's 

cystoscope. 

colic.  This  has  been  seen  in  many  instances  in  making  a  pyelographic  study 
by  means  of  a  solution  of  collargol,  which  is  much  thicker  than  urine  or  water. 

A  uropyknometer  is  used  for  taking  the  specific  gravity  of  small  quantities 
of  urine  removed  by  the  ureteral  catheter. 

The  Operating  Cystoscope. — The  most  practical  operating  cystoscopes  are 
Bransford  Lewis's  and  the  A.  C.  M.  I.  instrument  (see  Fig.  947).     These  instru- 


Fig.  954. — "Universal"  cystoscope  with  wire  snare. 

ments  greatly  facilitate  the  removal  of  small  portions  of  stone  and  foreign  bodies 
from  the  bladder  and  the  ureteral  orifices.  They  are  also  useful  for  making  ap- 
plications to  ulcerated  areas.  It  is  not  wise  to  remove  papillomatous  tumors 
by  them,  as  most  villous  papillomatous  growths  sooner  or  later  exhibit  the 
elements  of  malignancy  and  should  have  their  pedicles  removed  with  a  portion 
of  the  vesical  wall,  which  can  only  be  safely  done  after  suprapubic  cystotomy. 


Fig.  955. — Lewis's  repositor. 


We  have  succeeded  in  fulguration  of  intravesical  papillomata  of  a  benign  type 
by  means  of  the  high-frequency  current,  and  Prof.  Hiram  R.  Loux  has  had 
several  such  cases  that  have  remained  well  for  over  two  years. 

Practical  Value  of  Cystoscopy  and  Ureteral  Catheterization. — The  cysto- 
scope has  attained  a  very  important  position  in  the  surgeon's  armamentarium. 
It  undoubtedly  affords  the  best  method  of  establishing  an  accurate  diagnosis 
founded  on  pathological  findings.     By  it  one  is  enabled  to  determine  the  pres- 


Practical  Value  of  Cystoscopy  and  Ureteral  Catheterization    1455 

ence  and  character  of  cystitis,  stone,  foreign  bodies,  and  malformations.  With- 
out it  the  presence  of  ulcerations  could  merely  be  guessed  at  by  the  clinical 
history.  Its  greatest  field  is  in  the  early  diagnosis  of  the  cause  of  renal  and 
vesical  hemorrhages.  In  the  detection  of  renal  neoplasms  it  may  be  said  to 
have  revolutionized  surgery.  It  makes  possible  the  early  removal  of  such 
growths  before  malignancy  has  signed  the  patient's  death  warrant.  Cases  of 
prostatic  hypertrophy,  in  which  the  lobes  project  backward,  cannot  be  accu- 
rately diagnosticated  without  the  cystoscope;  with  it  the  parts  can  be  seen  and 
the  clinical  diagnosis  positively  confirmed.  It  makes 
possible  the  removal  of  small  foreign  bodies,  such  as 
stone,  pieces  of  cotton,  or  filiform  bougie  through 
the  urethra,  thus  saving  formidable  cutting  oper- 
ations. It  is  needless  to  mention  the  great  difficulty 
found  by  surgeons  in  former  years  in  determining 
the  source  of  symptomless  hemorrhage,  a  problem 
•  which  is  now  comparatively  easy  of  solution. 

Ureteral  catheterization  makes  possible  the  irri- 
gation of  the  ureter  and  pelvis  of  the  kidney  in  cases 
of  ureteritis  and  pyelitis. 

The  technic  of  lavage  is  as  follows:  The  gravity 
tubes  for  instilling  fluid,  shown  in  Fig.  956,  are 
carefully  sterilized  and  the  metal  nozzles  arranged 
so  as  to  fit  correctly  the  lumen  of  the  ureteral 
catheters.  It  is  always  necessary  to  make  certain 
that  the  nozzles  will  fit  and  that  they  and  the 
catheters  are  free.  This  should  never  be  neglected. 
It  has  been  found  on  several  occasions  that  one  or  the 
other  was  blocked,  and,  again,  any  particles  of  catheter 
or  other  material  that  might  form  a  nidus  for  stone 
formation  should  be  washed  out.  We  advise  the 
irrigation  to  be  done  by  means  of  gravity  in  pref- 
erence to  a  syringe,  as  the  fluid  may  be  delivered 
more  evenly  and,  so  to  speak,  may  be  "sneaked" 
into  the  pelvis  of  the  kidney.  This  gentle  trickle  of 
warmed  fluid  does  not  seem  to  excite  acutely  the 
musculature  of  the  ureter  and  pelvis;  in  consequence 
there  is  not  so  much  colic,  and  if  colic  occurs  it 
does  not  persist  so  long.  About  this  point  there 
has  been  some  difi'erence  of  opinion,  but  the  evidence 
is  in  favor  of  the  gravity  method  both  for  lavage  and 
pyelography. 

There  are  several  solutions  that  may  be  used. 
We  believe  that  normal  salt  solution  is  the  best  for 
mere  cleansing  purposes.  Saturated  solution  of 
boric  acid  may  be  used  if  a  mild  antiseptic  be  needed. 
Either  of  these  solutions  may  be  followed  by  the  different  silver  solutions  in 
strengths  calculated  to  suit  the  case  in  hand.  The  nitrate  of  silver  is  generally 
used  in  a  strength  of  i :  8000,  but  a  much  stronger  solution  may  be  resorted  to. 
In  the  clinic  of  Prof.  Loux  excellent  results  have  been  obtained  from  a  10  per 
cent,  solution  of  argyrol. 

The  catheters  are  passed  into  one  or  both  ureters  and  the  fluid  is  permitted  to 
pass  very  slowly  into  the  pelvis  or  ureter,  as  the  case  may  be.  Overdistention 
must  be  guarded  against,  and  a  safe  rule  is  not  to  allow  over  8  c.c.  to  be  used  at 
any  one  time. 

The  type  of  catheter  to  be  used  may  be  according  to  the  fancy  of  the  operator. 
There  is  at  present  a  very  excellent  two-way  pelvic  irigating  ureteral  catheter. 


Fig.  956. — Apparatus  for 
filling  pelves  in  pyelography; 
also  for  doing  lavage  of 
ureters  and  pelves. 


1456  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

or  the  single  tube  instrument  may  be  used  and  the  fluid  allowed  to  escape  after 
filling  the  pelvis.  This  procedure  should  be  repeated  until  the  return  fluid  is  clear. 
Should  hemorrhage  complicate  the  procedure,  an  irrigation  of  adrenalin  may  be 
used.     (This  has  been  known  apparently  to  cure  essential  renal  hematuria.) 

After  completion  of  the  irrigation  the  bladder  should  be  thoroughly  washed 
and  the  patient  put  upon  some  mild  genito-urinary  antiseptic,  of  which  there  are 
several.     Urotropin  is  the  one  usually  given. 

It  would  seem  a  wise  plan  to  irrigate  thoroughly  the  kidney,  pelvis,  and 
ureter  before  certain  surgical  operations.  When  a  surgeon  is  about  to  open  the 
kidney  in  the  presence  of  pus  or  infected  urine,  before  cutting  down  upon  the 
kidnev  it  is  well  to  wash  away  as  much  as  possible  of  the  purulent  matter  through 
a  ureteral  catheter  and  then  instil  some  nitrate  of  silver  or  collargol,  which  is  the 
silver  preparation  used  in  making  pyelographic  studies. 


Fig.  957. — .4,  Dilated  kidncN  pclw-  ,,,,.,  .  mh  .  .Jlari^'ol  solution;  B,  kink  in  ureter;  C, 
dilated  ureter  filled  with  collargol  solution;  D,  constriction  of  ureter;  E,  ureteral  catheter. 
(Taken  by  Dr.  W.  F.  Manges.) 

Irrigation  of  the  pelvis  and  ureter  has  become  a  rational  surgical  proced- 
ure and  in  many  cases  is  followed  by  a  marked  improvement  in  the  general  health 
of  the  individual,  making  operative  procedure  safer  and  not  complicated  by 
so  marked  a  toxemia.  In  all  cases  when  operative  work  is  to  be  done  on  a  kidney 
with  a  large  pus  sac  of  other  than  tuberculous  origin,  irrigation  of  the  pelvis 
by  means  of  one  of  the  milder  antiseptic  silver  solutions  would  seem  to  be  a 
proper  surgical  procedure.  It  is  especially  so  when  the  necessity  may  arise  for 
opening  the  peritoneal  cavity. 

A  differential  diagnosis  must  sometimes  be  made  between  gall-bladder  dis- 
ease, appendicitis,  and  movable  kidney  with  dilated  pelvis.  This  is  done  by 
determining  the  carrying  capacity  of  the  pelvis  by  means  of  the  injection  of 
salt  solution  and  by  making  a  pyelograph  (Fig.  957).  If  the  trouble  is  in  the 
kidney,  pain  caused  by  injection  of  salt  solution  will  be  similar  in  character  and 


Disinfection  of  Urethral  Catheters 


1457 


situation  to  the  pain  of  the  attaclcs.  As  a  rule,  in  movable  kidney  producing 
rnarked  symptoms  the  renal  pelvis  is  dilated.  When  the  trouble  is  due  to  the 
kidney  the  pain  mduced  by  the  distention  is  similar  to  that  from  which  the 
patient  has  suffered  (Howard  A.  Kelly).  If  a  stone  be  present  in  the  ureter 
the  .v-ray  picture  will  usually  reveal  it,  but  here  again  there  may  arise  doubt  as  to 
the  exact  course  of  the  canal.  Catheters  passed  into  the  ureters,  each  catheter 
with  a  lead  wire  in  it,  can  be  skiagraphed,  and  the  radiographer  will  be  able  to 
determine  the  exact  course  of  the  ureters.  Instead  of  a  catheter  containing  a 
wire  the  .v-ray  catheter  of  Eynard  may  be  used.  Fig.  958  shows  the  practical 
utility  of  such  manipulation.  Phleboliths,  fecal  masses,  appendoliths,  concre- 
tions, and  calcified  lymph-nodes  have  been  mistaken  for  ureteral  stone  even  after 
a  study  of  skiagraphs  (page  1618).  Appendices  have  been  removed  when  the 
source  of  trouble  has  been  impacted  stone  in  the  right  ureter.  In  3  cases 
seen  by  Stellwagen  appendectomy  had  failed  to  cure.  In  each  case  a  stone  was 
subsequently  removed  from  the  ureter  and  the  patient  cured.     An  impacted 


Fig.  958. — X-ray  photograph,  showing  the  course  of  the  ureters  by  wires  in  the  catheters. 
(Taken  by  Dr.  W.  F.  Manges.) 

Stone  in  the  ureter  may  often  be  dislodged  by  passing  a  catheter  into  the  ureter 
and,  if  possible,  beyond  the  stone.  Through  the  catheter  are  then  injected 
a  few  minims  of  sterile  olive  oil  which  act  as  a  lubricant  and  assist  in  the  passage 
of  the  stone.  Dilatation  of  the  ureteral  orifice,  by  leaving  the  catheter  in  situ 
or  by  passing  a  second  instrument  alongside  of  the  first,  will  often  cause  the 
stone  to  pass  into  the  bladder. 

Disinfection  of  Urethral  Catheters. — Metallic  instruments  are  cleansed 
by  boiling.  Soft-rubber  and  elastic  catheters  can  be  sterilized  by  mechanical 
cleansing  with  soap  and  water  and  by  boUing  for  five  minutes.  The  common 
custom  of  immersing  a  soft-rubber  or  elastic  catheter  for  five  minutes  in  a 
1:2000  solution  of  corrosive  sublimate  is  a  useless  waste  of  time,  as  such  a 
procedure  will  not  sterilize  an  infected  instrument.  Formalin  vapor  is  not  re- 
liable. A  catheter  coated  with  varnish  or  resin  cannot  be  placed  in  steam,  and 
cannot  be  boiled  in  water  if  it  be  allowed  to  touch  the  metal  of  the  boiler  or 
92 


145S  Diseases  and  Injuries  of  the  Gcnito-urinary  Organs 

another  catheter.  Woven  and  varnished  instruments  can  be  boiled  in  salt 
water  (3  drams  of  salt  to  i  pint  of  water),  provided  each  instrument  be  wrapped 
in  a  piece  of  gauze  so  that  it  cannot  touch  another  instrument  or  the  side  or 
bottom  of  the  metal  sterilizer.  This  plan  secures  the  m.ost  certain  sterilization. 
Catheters,  after  being  cleansed  mechanically  and  disinfected,  may  be  kept  ready 
for  use  in  a  glass  cylinder  containing  calcium  chlorid  (R.  W.  Frank,  in  "Berliner 
klin.  Woch.,"  No.  44,  1895).  By  this  plan  the  catheters  can  be  kept  straight. 
Some  prefer  to  keep  them  in  a  glass  cyhnder  containing  a  few  formalin  tablets. 
An  excellent  way  to  keep  sterile  catheters  clean  is  to  place  each  catheter  in 
an  individual  bag  of  linen  or  waxed  paper.  Stellwagen  boils  a  number  of 
rubber  condoms  at  the  time  he  boils  the  catheters.  When  the  instruments 
and  condoms  are  dry  he  encloses  a  curled  up  instrument  in  each  condom.  Be- 
fore using  catheters  which  have  been  in  formalin  vapor  they  must  be  washed 
in  sterile  water  or  salt  solution. 

Diseases  and  Injtiries  of  the  Bladder 

Retention  of  Urine  in  the  Male. — Retention  of  urine  is  not,  of  course, 
a  disease;  it  is  rather  a  result  of  one  of  a  number  of  different  diseases.  By 
this  term  is  meant  an  absolute  inabiUty  to  micturate  voluntarily.  The  re- 
tention may  be  complete,  not  a  drop  emerging,  or  it  may  have  been  complete, 
a  dribbling  setting  in  after  a  time,  due  to  paralysis  of  the  bladder,  which 
becomes  unable  to  contain  more  fluid,  expulsion  of  the  overflow  from  the  ureters 
being  produced  by  atmospherical  pressure.  This  condition  is  known  as  the 
engorgement,  the  overflow,  or  the  incontinence  of  retention.  There  may  be  re- 
tained urine  in  a  man  with  enlarged  prostate,  a  portion  only  of  the  urine  being 
voided.  This  is  not  retention,  and  the  urine  so  retained  is  called  residual  urine. 
Of  course,  true  retention  may  arise  in  a  person  with  enlarged  prostate.  Reten- 
tion may  be  caused  by:  (i)  Obstruction,  resulting  from  urethral  stricture, 
hypertrophied  prostate,  inflamed  prostate,  occluded  meatus,  impacted  calculus 
or  foreign  body,  urethral  tumor,  rupture  of  the  urethra,  perineal  abscess,  im- 
perforate prepuce,  congenital  phimosis,  tumor  of  the  penis,  tumor  of  the  pros- 
tate, prostatic  abscess,  abscess  of  the  penis,  ischiorectal  abscess,  and  pressure  from 
a  large  pelvic  tumor.  The  commonest  obstructive  cause  is  spasm  of  the  mem- 
branous urethra  arising  during  the  existence  of  stricture,  acute  gonorrhea,  or 
gleet.  In  some  cases  of  chronic  retention  there  is  a  spastic  sphincter.  This 
condition  is  not  uncommon  in  children  and  is  due  to  disease  of  the  saccal 
portion  of  the  spinal  cord.  (2)  Defective  ex  pulsion,  resulting  ivomimpsLirment 
of  the  nervous  apparatus  for  inducing  micturition.  Hysteria  is  a  rare  cause  in 
men.  We  see  retention  without  obstruction  after  vertebral  fractures  or  spinal 
concussion,  in  certain  diseases  of  the  spinal  cord,  sometimes  in  shock  and 
peritonitis,  often  in  the  continued  fevers  and  diseases  characterized  by  muscular 
wasting,  from  the  action  of  certain  drugs  (belladonna,  opium,  or  cantharides), 
and  after  certain  surgical  operations  upon  or  about  the  rectum.  The  last- 
named  form  of  retention  is  due  either  to  reflex  inhibition  of  the  expulsor  muscle 
or  to  reflex  stimulation  of  the  sphincter  vesicae,  causing  it  to  remain  firmly 
contracted.  Acute  retention  comes  on  suddenly  and  is  sometimes  the  first 
thing  that  causes  a  sufferer  from  urethral  stricture  to  seek  a  surgeon. 

Symptoms. — In  acute  retention  there  is  an  agony  of  desire  to  urinate,  the 
patient  making  acutely  painful  straining  efforts,  during  which  feces  are  often 
passed.  There  are  severe  pain  and  aching  in  the  abdomen,  thighs,  perineum, 
and  penis.  All  the  symptoms  rapidly  increase,  a  tjq^hoid  state  is  inaugurated 
eventually,  and  death  closes  the  scene  unless  relief  be  given.  If  retention 
is  from  time  to  time  alleviated  by  the  passage  of  a  little  water,  the  symptoms 
are  slower  in  evolution  and  are  less  intense,  and  the  case  is  said  to  be  chronic. 
Some  cases  of  gradual  onset  due  to  atony  are  verj-  insidious,  the  patient  feeling 


Treatment  of  Retention  of  Urine 


1459 


no  particular  pain  and  complaining  only  of  the  dribbling,  which  is  really  the 
overflow  of  retention,  and  is  not  a  sign  that  the  bladder  is  successfully  empty- 
ing itself.  In  any  case  of  retention  the  bladder  rises  above  the  pubes,  and  there 
is  found  a  pyriform,  elastic,  fluctuating  mass  in  the  hy{)ogastrium,  and  this  mass 
is  dull  on  percussion  and  gradually  enlarges  until  the  bladder  is  evacuated  or 
incontinence  sets  in.  The  flanks  give  a  clear  percussion-note,  and  the  tumor 
is  more  prominent  when  the  patient  is  erect  than  when  he  is  recumbent.  Long 
continuation  of  obstructive  disease,  producing  partial  retention  with  or  without 
attacks  of  complete  retention,  disorganizes  the  kidneys.  Acute  and  complete 
retention  may  induce  rupture  of  the  urethra  or  urinary  suppression.  ' 

Treatment  of  Retention  of  Urine. — Place  the  patient  upon  his  back  and, 
if  possible,  upon  a  hard  mattress.  If  the  bed  be  so  soft  that  the  hips  sink  down 
in  it,  put  an  ironing  board  or  some  other  support  beneath  the  mattress  at  the 
level  of  the  buttocks.  This  will  facilitate  catheterization.  Never  attempt 
to  use  a  catheter  when  the  patient  is  erect;  to  do  so  may  cause  serious  or  even 
fatal  shock.  Always  keep  the  patient  protected  from  cold.  Obtain  a  full 
history  of  the  case  and  always  make  a  gentle  rectal  examination  of  the  prostate; 
also  examine  the  external  genitalia.  Failute  is  often  traceable  to  a  lack  of 
thorough  examination.  It  is  evident  that  retention  due  to  prostatic  disturb- 
ance is  not  to  be  dealt  with  in  the  same  manner  as  retention  due  to  stricture, 
impacted  stone,  etc.  If  instrumentation  does  not  rapidly  succeed,  give  an 
anesthetic.  Be  sure  that  every 
instrument  is  aseptic,  and  irrigate 
the  urethra  before  and  after  instru- 
mentation. Grease  the  instru- 
ments with  liquid  cosmolin.  Pro- 
longed attempts  to  introduce  a 
catheter  and  excessive  instrumen- 
tation are  highly  dangerous,  es- 
pecially in  prostatic  cases.  Dread- 
ful damage  may  be  inflicted. 
There  is  no  operation  in  surgery 
that  requires  a  gentler  touch. 
Haste,  eagerness,  carelessness, 
roughness  are,  alike,  taboo.  If  a 
non-medical  person  knew  the 
facts  he  would  give  more  thought  in  the  selection  of  a  surgeon  to  relieve 
him  of  retention  of  urine  than  of  a  surgeon  to  amputate  his  leg.  A  surgeon 
with  retention  would  give  grave  thought  to  the  question.  When  the  instru- 
ment enters  the  bladder,  draw  off  but  half  of  the  urine,  withdraw  the  in- 
strument, wait  a  few  hours,  insert  it  again,  and  then  empty  the  bladder  and  wash 
out  the  viscus  with  warm  boric  acid  solution.  To  draw  off  all  of  the  urine  at 
once  is  dangerous,  because  the  sudden  relief  of  the  pressure  upon  distended  veins 
leads  to  bleeding  from  the  mucous  membrane  and  hemorrhage  into  the  bladder 
walls.  After  the  bladder  has  been  emptied  the  patient  is  wrapped  in  blankets,  a 
bag  of  hot  water  is  placed  against  the  perineum,  and  a  hot-water  bag  is  laid  upon 
the  hypogastric  region.  If  no  anesthetic  has  been  used,  he  is  given,  at  once  after 
the  operation,  a  suppository  of  opium  and  beUadonna.  If  an  anesthetic  has  been 
used,  he  is  given  the  suppository  when  he  recovers  from  the  effect  of  the  anes- 
thetic. Tablets  of  salol  and  boric  acid  are  administered  during  the  several 
days  which  immediately  follow  the  operation.  If  the  cause  of  retention  is 
organic  stricture,  try  to  pass  an  elastic,  olivary  pointed  catheter  (Fig.  959,  a). 
Do  not  use  any  force  until  the  neck  of  the  elastic  catheter  is  well  engaged  in 
the  stricture.  Then  an  experienced  operator  may  warily  use  a  certain  amount 
of  force,  but  never  an  amount  which  much  exceeds  the  slightest.  If  it  is  found 
impossible  to  pass  an  elastic  instrument,  make  an  attempt  to  carry  a  filiform 


Fig.  959. — a,  French  olivary  gum  catheter;  b, 
Mercier's  elbowed  catheter  (coude) ;  c,  Mercier's 
double-elbowed  catheter  (bicoude) ;  d,  curved  gum 
catheter. 


1460  Diseases  and  Injuries  of  the  Genito- urinary  Organs 

whalebone  bougie  into  the  bladder.  Fig.  960  shows  filiform  bougies.  If  the 
history  shows  that  the  man  has  long  had  an  organic  stricture,  do  not  waste 
time  with  the  gum  catheter,  but  at  once  j^roceed  to  use  the  liliform  bougie. 
On  this  bougie,  after  it  has  been  inserted,  Gouley's  tunnelled  catheter  can 
perhaps  be  threaded  (Fig.  961)  and  carried  into  the  bladder.  Instead  of  carry- 
ing in  the  catheter,  we  can  simply  leave  the  filiform  bougie  in  place  and  fasten 


V 


Fig.  960. — Points  of 
Gouley's  whalebone  guides 
(filiform  bougies). 


"'Lr^" 


Fig.  961. — Gouley's  tunnelled  catheter  threaded  on  a  filiform 
bougie. 


it.  The  filiform  bougie  will  act  as  a  capillary  drain,  and  in  a  few  hours  will 
empty  the  bladder  and  will  also  dilate  the  stricture.  Then  insert  another 
bougie  beside  the  first  and  so  on  for  several  days,  using  also  opium,  order- 
ing rest  in  bed,  and  making  no  attempt  to  dilate  the  stricture  forcibly  until  re- 
tention has  ceased  and  inflammation  has  subsided.  Perhaps  Phillips's  catheter 
(Fig.  965)  can  be  passed.  If  no  instrument  can  be  passed,  aspirate  above  the 
pubes   or   perform    cystotomy    (suprapubic    or  perineal).     In  spasmodic  stric- 


FlG.  962. — A-B-E  shows  the  proper  curve   (reduced  in  size)   for  unyielding  male  urethral 
instruments;  C-B-D  shows  an  improper  curve. 

ture  hold  a  good-sized  metal  catheter  firmly  against  the  area  in  spasm;  re- 
laxation will  occur  and  the  instrument  will  eventally  pass.  Fig.  962  shows 
the  proper  curve  of  a  metal  instrument.  An  individual  who  has  an  organic 
stricture  which  has  given  but  little  trouble  may  develop  attacks  of  re- 
tention because  of  inflammatory  edema  of  the  mucous  membrane  and  spasm 
of  the  urethral  muscles.  These  attacks  are  temporary,  and  an  instrument 
can  usually  be  inserted  when  employed  as  above  directed.     In  inflammation 


Fic.  963. — English  silk- web  catheter. 

give  a  hot  hip-bath  and  suppositories  of  opium  and  belladonna,  and  then  use 
a  hot  sand-bag  to  the  perineum  and  a  hot-water  bag  over  the  hypogastrium. 
If  these  fail  or  if  the  symptoms  are  urgent,  pass  a  soft  catheter.  In  the  occluded 
meatus  of  the  newborn  incise  with  a  tenotome.  In  a  congenital  cyst  of  the  sinus 
pocularis  pass  a  steel  bougie,  which  will  rupture  the  cyst.  In  complete  phimosis 
spUt  up  the  prepuce.  In  impacted  stone  try  to  pull  out  the  calculus  with  urethral 
forceps;  if  this  fails,  cut  the  urethra  or,  in  rare  cases,  push  the  stone  back  into 


Treatment  of  Retention  of  Urine 


1461 


the  bladder.  In  fecal  impaction  scrape  out  the  rectum  with  a  spoon.  In 
enlarged  prostate  the  rectal  examination  gives  information  as  to  the  type  of 
enlargement.  If  there  be  moderate  enlargement  of  the  middle  lobe  the  coude 
(Fig.  959,  b)  or  the  bicoude  catheter  (Fig.  959,  c)  will  probably  pass.  If  these 
instruments  fail,  try  the  overcurved  silver  catheter  of  Sir  Benjamin  Brodie. 
This  metal  instrument  has  a  large  curve  and  will  probably  succeed,  but  it  is 
a  dangerous  tool  and  one  capable  of  inflicting  grave  injury.  In  enlargement  of 
one  lateral  lobe  with  possible  deflection  of  the  urethra  and  valve  formation 
try,  in  order,  the  woven  silk  catheter  (Fig,  963),  the  Nelaton  catheter  (Fig.  964), 


Fig.  964.^Nelaton's  catheter. 

Strengthened  by  having  a  filiform  passed  in  its  lumen  nearly  to  the  beak,  and 
the  rat-tailed  silk  instrument.  In  enlargement  of  both  lobes  and  the  middle 
lobe  try  the  coude,  then  the  bicoude,  then  a  coude  and  a  bicoude  with  olivary 
or  rat- tailed  tips.  If  all  of  these  fail,  the  overcurved  metal  catheter  of  Brodie 
must  be  used  gently.  In  retention  from  expulsive  defect  use  a  soft  catheter 
(Fig.  964).  Cases  of  retention  after  catheterization  require  warmth,  confine- 
ment to  bed,  the  administration  of  laxatives,  free  action  of  the  .skin,  and  the  use 
of  such  drugs  as  salol,  boric  acid,  urotropin,  and  quinin  to  asepticize  the  urine. 


Fig.  965. — Phillips's  catheter. 

In  some  few  cases  no  instrument  can  be  inserted  in  the  bladder.  In  most  of 
such  cases  aspirate — which  may  be  done  several  times  if  necessary — and  in  a  day 
or  two,  when  swelUng  and  congestion  abate,  an  instrument  can  be  passed.  The 
parts  are  asepticized,  A  small  aseptic  trocar  or  aspirator  needle  is  pushed  into 
the  bladder,  the  trocar  or  needle  being  inserted  in  the  median  line,  just  above  the 
pubes,  and  taking  a  course  downward  and  backward.  After  the  completion 
of  the  operation  the  puncture  is  dressed  \vith  iodoform  and  collodion.  Only 
half  the  urine  is  withdrawn  at  a  first  aspiration.     Rectal  puncture  is  now 


1462  Diseases  and  Injuries  of  the  Cienito-urinary  Organs 

obsolete.  If  incision  he  necessary  in  retention,  the  perineal  route  is  usually 
chosen.  In  some  cases  the  operation  is  clone  with,  in  some  without,  a  guide.  In 
prostatic  retention  not  relievable  by  a  catheter,  make  suprapubic  drainage  or  do 
prostatectomy. 

Congenital  Defects  of  the  Bladder.  Exstrophy  of  the  bladder 
(ectopia  vesica:)  is  a  condition  of  defective  development  commoner  in  males 
than  in  females.  The  anterior  abdominal  wall  has  failed  to  close,  the  anterior 
wall  of  the  bladder  is  absent,  the  arch  of  the  pubes  has  not  developed,  epispadias 
exists,  and  in  many  cases  the  testicles  have  not  descended  into  the  scrotum. 
In  this  condition  the  posterior  wall  of  the  bladder  projects  into  or  beyond  the 
gap  in  the  abdominal  wall;  the  urine  constantly  flows  and  renders  the  condition 
of  the  patient  dreadful.  The  condition  shortens  life  and  only  30  per  cent,  of 
the  victims  live  beyond  the  twentieth  year,  death  being  due  to  pyelonephritis. 

The  only  treatment  which  offers  hope  is  operation,  and  operation  often 
fails.  If  possible,  operate  when  the  patient  is  about  five  years  of  age,  and  over 
rather  than  under  five.  Before  operation  the  ureters  should  be  catheterized  and 
the  urine  from  each  side  examined.  Pyelonephritis  of  both  sides  forbids  opera- 
tion. Various  operations  have  been  suggested  for  this  condition,  viz.:  covering 
with  skin-flaps;  implanting  the  ureters  into  the  bowel  (Maydl,  Albert,  Roux, 
Simon,  and  others);  division  of  the  posterior  ligaments cf  the sacro-iliac joints, 
bringing  the  arch  of  the  pubes  forcibly  together,  the  patient  wearing  a  support 
until  the  parts  become  firm,  when  the  greatly  narrowed  defect  is  closed  in  by 
integumentary  flaps  and  by  suturing  the  bladder  edges  (Trendelenburg's  opera- 
lion  or  synchondroseolomy);  osteotomy  through  one  ilium  or  both  ilia  instead 
of  separation  of  the  sacro-iliac  joints  (Berg's  operation),  or  after  extirpating  the 
bladder,  loosening  the  ureters  from  the  bladder,  drawing  them  down  and  at- 
taching them  to  the  end  of  the  penis  (Sonnenberg's  operation). 

A  bladder  closed  in  by  autoplasty,  by  Trendelenburg's  operation,  or  by 
Berg's  operation  is  never  really  continent,  although  when  the  patient  is  erect 
and  wears  a  light  compress  he  may  perhaps  be  able  to  hold  water  two  or  three 
hours.  The  above  methods  are  suited  to  young  children  and  are  far  safer 
than  ureteral  transplantation.  Tuffier  showed,  nearly  twenty  years  ago,  that 
transplantation  of  the  cut  ureters  into  the  bowel  was  certain  to  be  followed 
by  fatal  infection  of  the  kidney,  and  that  the  only  way  to  prevent  this  was  to 
retain  the  ureteral  orifices  which  contain  valves. 

Maydl  introduced  his  operation  in  1892.  He  implanted  the  trigone  with 
the  ureters  into  the  sigmoid  flexure,  extirpating  the  rest  of  the  bladder.  I 
have  twice  performed  a  modified  Maydl's  operation,  with  one  death  and  one 
recovery.  Buchanan  ("Surg.,  Gynecol.,  and  Obstet.,"  Feb.,  1909)  has  col- 
lected 80  cases.  In  this  collection  there  were  23  deaths  (28.7  percent.);  7 
died  of  peritonitis  and  9  of  pyelonephritis.  Bregenhem  in  1894  devised  extra- 
peritoneal implantation  of  the  ureters  and  a  portion  of  bladder  through  two 
separate  openings  into  the  rectum.  The  Makka's  operation  employs  the  cecum 
as  a  bladder  and  uses  the  appendix  as  a  ureter.  Of  course  it  cannot  be  done 
if  the  appendix  has  been  removed,  if  it  is  blocked  by  inflammation,  or  if  the 
cecum  is  anchored  by  adhesions. 

Diverticula  of  the  Bladder. — A  diverticulum  is  a  sac-like  protrusion  of 
a  p'art  of  the  bladder- wall  or  of  the  mucous  membrane  alone.  During  recent  years 
the  cystoscope  has  taught  us  that  diverticula  are  much  more  common  than  we 
once  thought.  Some  diverticula  are  congenital.  These  contain  a  muscular 
coat.  Among  congenital  conditions  is  the  hour-glass  bladder  and  the  double 
bladder  (G.  J.  Thomas,  in  "Surgery,  Gynecology  and  Obstetrics,"  Oct.,  1916). 
An  acquired  diverticulum  consists  of  mucous  membrane.  It  may  be  of  intra- 
uterine origin  (due  to  temporary  obstruction),  traumatism,  and  most  commonly 
to  urinary  obstruction.  One  diverticulum,  several,  or  many,  may  exist.  The 
form  most  commonly  seen  is  the  pocketed  bladder  from  chronic  urinary  ob- 


Rupture  of  the  Bladder  1463 

struction.  The  mucous  membrane  of  the  bladder  bulges  out  between  layers  of 
hypertrophied  vesical  muscle.  The  diagnosis  of  diverticulum  is  made  by  the 
.T-rays  and  the  cystoscope. 

In  most  cases  the  best  treatment  is  excision.  The  bladder  is  exposed, 
stripped  of  peritoneum,  opened,  the  diverticulum  packed  with  gauze,  dissected 
free  and  excised  and  the  wound  in  the  bladder  is  sutured  (Lower,  in  "Jour. 
Am.  ]Med.  Assoc,"  1914,  Ixiii).  The  various  operations  which  have  been  per- 
formed for  diverticula  are  set  forth  by  G.  J.  Thomas  (Ibid.). 

Diseases  and  Injuries  of  the  Bladder. — This  viscus  is  so  deeply  situated, 
and  the  abdominal  walls  are  so  elastic,  that  it  is  rarely  injured  when  empty. 
If  the  bladder  be  full  and  the  abdomen  tense — which  is  common  in  alcoholic 
intoxication — force  applied  to  the  abdomen  may  injure  the  bladder. 

Contusion  of  the  Bladder. — In  this  condition  there  are  noted  vesical  hema- 
turia, tenesmus,  severe  cystitis,  and  an  impediment  to  the  flow  of  water  because 
•of  clots.  Hemorrhage  may  be  very  severe  and  sepsis  may  arise,  even  causing 
death.  When  contusion  exists  retention  is  relieved  by  means  of  a  clean  soft 
catheter;  if  this  fails  because  of  occlusion  of  the  eye  of  the  catheter  with  blood- 
clot,  at  intervals  there  must  be  passed  through  the  catheter  from  a  fountain- 
syringe  a  solution  of  sodium  bicarbonate  in  cooled  boiled  water.  Gross's 
blood-catheter  can  be  used  or  the  evacuator  of  Bigelow  may  be  employed.  The 
patient  is  put  to  bed,  a  hot-water  bag  is  applied  to  the  hypogastrium,.  morphin 
is  administered  in  moderate  doses,  the  bladder  is  washed  out  several  times  a 
day  with  boric  acid  solution  or  a  solution  of  bicarbonate  of  sodium  to  disinte- 
grate and  remove  blood-clots,  and  the  urine  is  diluted  and  rendered  aseptic  by 
the  gastric  administration  of  salol,  boric  acid,  and  the  free  use  of  bland  fluids. 
Hemorrhage  usually  ceases  on  relieving  distention;  if  it  does  not,  some  more 
radical  measure  must  be  employed  (see  Hematuria). 

"Wounds  of  the  Bladder. — Besides  being  contused,  the  bladder  may  be 
injured  by  bullets;  by  stabs  or  punctures  through  the  abdomen,  the  vagina, 
or  the  uterus;  or  by  penetration  by  a  fragment  of  a  fractured  pelvic  bone. 
A  gunshot  wound  may  or  may  not  damage  bone.  The  greatest  danger  from 
a,  gunshot  wound  of  the  bladder  is  injury  to  the  peritoneum.  The  next  danger 
is  urinary  infiltration.  Infection  is  common  and  may  come  from  the  wound  or 
from  bacterial  urine.  Bazy  points  out  that  in  wounds  from  rifle  bifllets  there 
is  usually  urinary  retention  but  in  wounds  from  shell  fragments  there  is  a  free 
flow  of  urine  from  the  wound  ("Bull,  et  Mem,  Soc.  de  chir.  de  Paris,"  1916, 
xlii).  The  symptoms  of  such  conditions  are  those  of  rupture  of  the  bladder  {q. 
v.).  The  diagnosis  is  made  by  palpation,  the  .r-rays  and  the  cystoscope.  In 
an  int-aperitoneal  wound  at  once  open  the  abdomen,  suture  the  wound  in  the 
bladder  wall,  irrigate  and  drain  the  peritoneal  cavity,  and  drain  the  bladder 
by  means  of  a  retained  catheter,  perineal  section,  or  suprapubic  cystotomy. 
In  an  extraperitoneal  w^ound  drain  the  wound  by  a  tube,  and  drain  the  bladder 
by  a  retained  catheter,  perineal  section,  or  suprapubic  opening. 

Fistula  may  follow  the  injury.  The  wound  itself  may  become  fistulous  or 
a  collection  of  extravasated  urine  may  break  and  form  a  fistula.  The  fistula  may 
open  upon  the  abdominal  wall,  the  perineum,  the  scrotum,  the  buttock,  the  thigh 
or  into  the  intestine.     The  mortality  of  gunshot  wounds  is  said  to  be  25  per  cent. 

Rupture  of  the  bladder  occurs  in  three  forms:  (i)  intraperitoneal — a  rtip- 
ture  involving  the  peritoneal  coat;  (2)  extraperitoneal — a  rupture  of  a  portion 
of  the  bladder  not  covered  by  peritoneum;  and  (3)  subperitoneal — a  rupture 
of  the  mucous  and  muscular  coats,  the  urine  diffusing  under  the  peritoneal 
investment.  The  causes  are  of  two  kinds,  predisposing  and  exciting.  Pre- 
disposing causes  are:  distention  of  the  bladder;  drunkenness;  cystitis;  ulcera- 
tion; degeneration  or  atony  of  the  bladder-coats;  prostatic  enlargement,  and 
urethral  stricture.     Distention  o«!^  the  bladder  is  the  great  predisposing  cause. 


1464  Diseases  and   Injuries  of  the   Gcnito-urinary  Organs 

It  causes  the  bladder  to  rise  from  the  pelvis  and  so  become  exposed  to  a  direct 
blow,  it  places  the  organ  under  tension,  and  force  tends  to  rupture  the  weakest 
point.  In  about  one-third  of  the  cases  collected  by  Bartels  the  individual 
was  intoxicated  at  the  time  of  the  accident.  Drunkenness  predisposes  because 
a  drunken  man  is  very  liable  to  injury  and  is  apt  to  have  a  distended  bladder 
and  a  rigid  belly  wall.  Males  are  much  more  liable  to  rupture  then  females 
(10  to  i).  Most  cases  are  between  the  ages  of  twenty  and  forty.  Of  Besley's 
25  cases,  I  was  a  child  of  three,  i  a  man  of  forty-nine,  3  were  in  the  first  and 
second  decades,  5  were  between  twenty  and  thirty,  7  between  thirty  and  forty, 
6  between  forty  and  fifty,  and  in  2  the  age  is  not  given  (paper  before  Chicago 
Surg.  Soc,  Feb.,  1907).  The  condition  is  very  rare  in  children,  but  i  of  Bes- 
ley's cases  was  three  years  of  age,  and  King  recorded  the  accident  in  a  fetus 
with  imperforate  urethra. 

Exciting  causes  are:  obstruction  to  the  outflow  of  urine  (by  stricture  or  en- 
larged prostate) ;  external  violence;  falls  upon  the  feet  or  the  buttocks,  as  well  as 
upon  the  abdomen;  lifting;  straining  at  stool,  in  micturition,  or  during  partu- 
rition; and  the  forcing  of  injections  into  the  bladder.  A  distended  bladder  may 
be  ruptured  by  a  concussion.  The  most  usual  cause  of  the  injury  is  a  crush. 
The  mechanism  of  the  injury  is  in  dispute.  It  is  certain  that  the  bladder  must 
have  lost  its  elasticity  by  distention.  When  force  is  applied  to  fluid  (fluid  is 
incompressible)  the  bladder  tears  at  its  weakest  point.  The  weakest  point 
is  not  identical  in  all  individuals.  It  may  be  weak  anywhere  from  disease. 
The  most  common  site  of  the  tear  is  at  the  postero-superior  aspect,  but  it  may 
be  in  front,  at  either  side,  or  at  the  pubic  or  prostatic  ligament  (Staubenranch). 
The  mucous  membrane  or  the  peritoneum  may  give  way  first  and  the  tear  may 
be  anteroposterior,  oblique,  or  longitudinal.  Alexander  maintains  that  the 
most  usual  cause  of  the  injury  is  a  crush  which  forces  the  distended  bladder 
against  the  sacral  promontory,  but  Besley's  (Ibid.)  experiments  do  not  indi- 
cate that  this  is  correct.  A  common  complication,  especially  of  extraperitoneal 
rupture,  is  fracture  of  the  pelvis,  due  to  the  same  force  that  ruptured  the  bladder. 

Symptoms,  Diagnosis,  and  Treatment. — The  symptoms  are  not  always 
definite,  and  every  characteristic  one  may  be  for  a  time  absent,  the  patient 
seeming  in  some  rare  instances  of  extraperitoneal  and  intraperitoneal  rupture  to 
possess  the  power  of  retaining  his  urine  and  of  voiding  it.  As  a  rule,  however, 
there  are  found  some  or  all  of  the  following  symptoms,  following  an  accident 
or  occurring  during  the  progress  of  a  causative  disease:  severe  pain  in  the  blad- 
der and  in  the  suprapubic  region,  collapse;  inability  to  walk  or  great  difficulty 
in  walking;  excessive  desire  to  micturate,  but  inability  to  do  so  (sometimes  a 
little  pure  blood  or  bloody  water  is  squeezed  out  by  painful  effort) ;  a  catheter, 
when  used,  brings  away  pure  blood  or  a  very  little  bloody  urine;  the  catheter 
occasionally  slips  through  the  tear  into  the  cavity,  and  more  bloody  water  comes 
away.  In  some  reported  cases  clear  water  has  been  withdrawn.  If  a  measured 
amount  of  boric  acid  solution  is  injected,  it  is  improbable  that  all  of  it  can  be 
withdrawn  by  the  catheter,  although  in  some  cases  it  may  all  come  away  (Alex- 
ander in  "Annals  of  Surgery,"  August,  1901).  Injecting  fluid  fails  to  lift 
the  bladder  into  the  hypogastric  region  so  as  to  be  recognizable  on  percus- 
sion. In  a  patient  suffering  from  retention  of  urine  in  whom  rupture  occurs 
there  is  first  a  temporary  sense  of  relief  from  retention,  but  very  soon  severe 
hypogastric  pain  and  rectal  tenesmus.  In  intraperitoneal  rupture  reaction 
may  be  obtained  after  a  few  hours  or  a  number  of  hours.  The  evidences  of 
peritonitis  will  be  noted  soon  (rapid  pulse,  perhaps  vomiting,  rigidity,  disten- 
tion, obstruction  of  the  bowel,  elevated  temperature,  etc.).  Shock  in  vesical 
rupture  is  so  severe  that  death  may  ensue;  if  reaction  follows,  there  may  be 
delirium  and  often  septicemia;  extensive  infiltrations  of  urine  may  occur. 
In  intraperitoneal  niptnre  general  peritonitis  is  certain  to  arise,  but  its  appear- 
ance may  be  postponed  for  several  days  if  the  urine  be  healthy.     In  these  cases 


Symptoms  of  Atony  of  the  Bladder  1465 

the  extravasation  is  noted  as  a  simple  swelling,  probably  on  one  side  only. 
In  extraperitoneal  rupture  the  urine  may  infiltrate  the  perineum,  the  scrotum, 
the  thighs,  and  under  the  integuments  of  the  abdomen  and  the  back,  and  may 
soon  induce  sloughing.     In  subperitoneal  rupture  peritonitis  is  apt  to  arise. 

In  doubtful  cases  some  surgeons  pump  air  or  hydrogen  into  the  bladder. 
To  insert  air  a  bicycle  pump  can  be  used  (Brown)  or  a  Davidson  syringe  (Keen). 
Keen's  directions  are  to  insert  a  catheter,  empty  the  bladder  of  urine,  and  con- 
nect to  the  catheter  a  disinfected  Davidson's  syringe,  a  mass  of  absorbent  cot- 
ton being  fastened  over  the  distal  end  of  the  syringe.  Air  after  it  has  filtered 
through  "the  cotton  is  pumped  into  the  bladder;  an  unruptured  bladder  will 
rise  above  the  pubes  as  a  pyriform  tumor,  tympanitic  on  percussion.  A  rup- 
tured bladder  will  not  so  rise.  In  intraperitoneal  rupture  the  air  will  pass  into 
the  general  peritoneal  cavity  and  distention  will  occur.  In  extraperitoneal 
rupture  injection  will  produce  emphysema  of  the  extra  vesical  connective  tissue. 
On  removing  the  syringe  the  air  rushes  out  again  if  the  bladder  be  unruptured, 
but  little  if  any  comes  away  if  it  be  ruptured.  Alexander  considers  gaseous 
distention  unreliable,  and  claims  that  it  adds  to  shock  and  disseminates  infec- 
tion. His  rule  is  the  wisest  to  follow;  that  is,  in  a  case  of  suspected  rupture  of 
the  bladder,  make  a  suprapubic  incision  and  inspect  the  prevesical  space  for 
signs  of  extraperitoneal  rupture.  If  extraperitoneal  rupture  is  not  found,  open 
the  belly  and  explore. 

Treatment. — In  extraperitoneal  rupture,  after  incision  down  to  the  blad- 
der insert  a  drainage-tube.  In  intraperitoneal  rupture,  place  the  patient  in 
the  Trendelenburg  position,  expose  the  tear  in  the  bladder  by  abdominal  in- 
cision, and  suture  the  opening  in  the  viscus. 

Results. — Baron  Larrey  was  the  first  surgeon  to  state  that  a  wound  through 
all  the  coats  of  the  bladder  might  be  followed  by  recovery.  In  intraperitoneal 
ruptures,  if  operation  is  not  performed,  the  mortality  is  98  per  cent.  If  opera- 
tion is  performed  many  cases  recover.  Of  the  78  cases  collected  by  Dambriu 
and  Papin  in  1904,  34  died,  a  mortality  of  43  per  cent.  (Besley,  paper  before 
Chicago  Surg.  Soc,  Feb.,  1907).  Gala'ctionoff  (''Rovssky  Vratch,"  Nov.  12, 
1 910)  "reports  15  cases  operated  upon  for  intraperitoneal  rupture;  5  recovered 
(3  of  them  were  operated  upon  during  the  first  twenty-four  hours;  i,  after  thirty- 
sLx  hours,  and  i,  after  forty-eight  hours).  In  extraperitoneal  ruptirre  without 
operation  there  are  11  per  cent,  cures  and  with  operation  30  per  cent.  (See 
Daniel  X.  Eisendrath,  "Jour.  Amer.  Med.  Assoc,"  Oct.  25,  1902;  Samuel 
Alexander,  "'Annals  of  Surgery,"  Aug.,  1901.) 

Atony  of  the  bladder  is  a  condition  in  which  the  expulsive  power  of 
the  bladder  is  diminished  or  lost  because  of  impairment  of  muscular  tone. 
The  bladder  is  very  thin,  and  the  muscles  are  flaccid  and  often  the  seat  of  fatty 
degeneration.  Sometimes  the  viscus  is  very  large  and  sometimes  it  is  very 
small.     A  slight  degree  of  atony  is  physiological  after  middle  age. 

The  causes  are  senility,  distention  from  true  paralysis,  chronic  over  disten- 
tion from  obstruction,  and  acute  overdistention.  In  most  cases  there  is  obstruc- 
tion of  the  urethra.  In  that  rare  condition  known  as  idiopathic  atony  there  is 
no  evidence  of  obstruction.  Walker  ("Annals  of  Surgery,"  Nov.,  1910)  reports 
12  cases  of  idiopathic  atony.  He  says  the  patients  were  between  the  ages 
of  twentv-two  and  forty.  He  regards  the  condition  as  due  to  a  lesion  in  the  reflex 
centers. 

Symptoms. — In  atony  of  the  bladder  the  patient  passes  water  frequently 
(a  svmptom  probably  existing  for  some  years),  and  especially  at  night;  he  may 
even  do  so  while  asleep.  The  stream,  when  voluntarily  passed,  has  little  pro- 
jection, but  seems  to  drop  at  once  from  the  end  of  the  penis.  Residual  urine 
exists  for  years  and  may  at  any  time  set  up  cystitis,  and  retention  with  inconti- 
nence is  apt  to  occur.  This  condition  is  not  vesical  paralysis  resulting  from  a 
lesion  of  the  nervous  system. 


1466  Diseases  and  Injuries  of  the  (ienito-urinary  Organs 

Treatment. — In  treating  atony  of  the  bladder  measure  the  residual  urine: 
if  it  amounts  to  4  oz.,  use  a  soft  catheter  night  and  morning;  if  it  amounts  to 
6  oz.,  use  the  catheter  every  eight  hours;  if  it  amounts  to  8  oz.,  use  the  catheter 
every  six  hours  (J.  W.  White).  The  patient  should  be  taught  how  to  use  the 
catheter  and  how  to  keep  it  sterile.  (For  Methods  of  Disinfecting  Catheters 
see  article  on  page  1457.)  The  bladder  is  from  time  to  time  washed  out  with 
3  gr.  to  the  ounce  of  boric  acid  solution  at  a  temperature  of  100°  F.  Strychnin, 
electricity,  ergot,  and  urotropin  may  be  ordered. 

True  Paralysis  of  the  Bladder. — Vesical  paralysis  results  from  a  lesion 
of  the  nervous  system  causing  paralysis  of  the  motor  nerves  or  of  the  motor 
paths  from  which  they  are  prolongations  (fracture  of  the  vertebrae,  spinal  menin- 
gitis, syphilis  of  the  cord,  myeUtis,  and  hemorrhage  about  or  into  the  spinal 
cord).  A  traumatic  paralysis  comes  on  suddenly.  Hysteria  may  be  responsi- 
ble for  temporary  palsy.  If  the  detrusor  muscles  alone  are  palsied  there  is 
complete  retention  of  urine.  If  the  sphincter  is  paralyzed  the  uriiie  dribbles 
constantly.  Even  when  there  is  dribbling  a  quantity  of  urine  is  retained  below 
the  level  of  the  internal  meatus.  In  such  a  case  there  is  incontinence  with  partial 
retention  (the  overflow  of  Sir  Henry  Thompson).  If  the  patient  sits  down  or 
assumes  the  knee-chest  position  he  may  empty  the  bladder  by  contracting  the 
abdominal  muscles.  In  cases  of  real  retention  the  detrusors  may  be  temporarily 
paralyzed.  In  such  a  case  the  sphincter  may  finally  relax  from  fluid  pressure, 
and  atmospherical  pressure  or  contraction  of  abdominal  muscles  may  cause 
urine  to  dribble,  the  bladder  remaining  full  (the  overflow  of  retention  of  the  elder 
Gross).  In  some  cases  of  vesical  paralysis  there  is  retention;  in  some  cases, 
incontinence  of  urine.  If  the  sensory  as  well  as  the  motor  path  be  involved  in 
a  lesion,  the  patient  has  no  sensation  to  notify  him  of  dribbling  or  of 
retention. 

Treatment. — Treat  the  cause.  Employ  regular  aseptic  catheterization 
by  a  soft  instrument.  In  some  cases  the  bladder  may  be  subjected  to  faradism 
(one  electrode  in  the  bladder  and  one  in  the  perineum  or  on  the  abdomen  above 
the  pubes).  Kilvington  ("Brit.  Med.  Jour.,"  1907,  vol.  i)  pointed  out  that 
the  nerve-supply  of  the  bladder  and  rectum  is  from  the  second  and  third  and 
sometimes  also  from  the  first  sacral  nerves.  He  suggested  treating  some 
otherwise  incurable  cases  of  vesical  paralysis  by  anastomosing  a  nerve-root 
above  the  lesion  to  certain  sacral  nerves  below  the  lesion.  Bird  did  the  first 
operation,  but  it  failed.  Mills  and  Frazier  (see  page  972)  performed  intradural 
anastomosis  of  the  last  lumbar  nerve  to  the  third  and  fourth  sacral  nerves. 
The  patient  was  much  benefited  ("Jour.  Amer.  Med.  Assoc,"  Dec.  21,  1912). 
Foreign  Bodies  in  the  Bladder. — The  term  "foreign  body"  is,  at  best, 
a  poor  one,  since  a  stone  is  a  foreign  body.  The  term,  however,  is  generally 
used  to  designate  material  held  within  the  viscus  and  of  purely  extraneous  origin. 
There  has  been  a  great  variety  of  foreign  bodies  removed  from  both  the  male 
and  female  urinary  bladder.  We  have  seen  a  lead-pencil,  hair-pins,  a  willow 
twig,  a  glass  rod,  and  a  piece  of  chewing  gum  removed,  as  well  as  portions  of 
catheters  and  filiform  bougies.  For  reports  of  foreign  bodies  found  in  the 
bladder  the  reader  is  referred  to  text-books  upon  genito-urinary  diseases. 

Most  of  the  foreign  bodies  are  found  in  the  bladders  of  masturbators.  In 
them  the  glans  penis  or  the  clitoris  has  become  so  inured  to  friction  that 
they  must  seek  deeper  for  sensation,  consequently  men  resort  to  titillation  of 
the  verumontanum  and  posturethra,  and  women,  to  irritation  of  the  vesical 
neck.  The  object  used  to  stir  sensation  may  slip  from  the  grasp  and  pass  back- 
ward into  the  bladder.  The  careless  use  of  the  filiform  bougie  is  a  great  danger. 
Always  test  the  filiform  for  defects  and  for  tensile  strength  before  using  it. 
If  you  use  the  Gouley  catheter,  see  that  the  tip  through  which  the  filiform  must 
lace  is  not  sharp  or  square,  else  it  may  shear  off  a  portion  of  the  bougie  All 
foreign  bodies  sooner  or  later  induce  cystitis.     Every  foreign  body,  if  allowed 


Vesical  Calculus,  or  Stone  in  the  Bladder 


1467 


to  remain,  will  become  encrusted  with  urinary  salts  and  constitute  a  nucleus  for 
stone  formation. 

Diagnosis,  Symptoms,  and  Treatment. — Diagnosis  is  made  by  the  history, 
if  given  correctl)',  of  the  case.  The  stone-searcher,  the  .r-ray,  and  the  cysto- 
scope  are  most  useful  in  diagnosis.  The  symptoms  are  similar  to  those  of  stone 
in  the  bladder.  The  treatment  is  removal,  with  subsequent  care  of  the  resultant 
cystitis. 

Vesical  Calculus,  or  Stone  in  the  Bladder. — The  salts  normally  in  solution 
in  the  urine  may  become  deposited  as  calculi  and  may  be  imprisoned  in  any 
portion  of  the  urinary  tract.  The  commonest  primary  calculi  are  those  com- 
posed of  uric  acid,  urates,  calcium  oxalate,  and  fusible  phosphates.  In  80  per 
cent,  of  cases  primary  calcuH  are  composed  of  uric  acid  and  urates.  A  primary 
calculus  may  become  coated  with  another  material  (secondary  calculus). 
The  formation  of  uric  acid  and  urate  calculi  is  explained  under  Renal  Calculus 
(seepage  1427).    Vesical  calculi  are  usually  renal  calculi  that  have  passed  through 


Fig.  966. — Stone  in  bladder  shown  by  .v-rays. 

the  ureter  and  become  enlarged  by  new  accretions.  New  accretions  from  an 
alkaline  urine  will  cause  the  formation  of  a  secondary  phosphatic  stone.  Phos- 
phatic  calculi  may  be  formed  in  the  bladder  when  chronic  cystitis  causes  and 
maintains  an  alkaline  urine.  Uric-acid  calculi  are  smooth,  round  or  oval,  and 
hard,  but  easily  broken.  On  section  they  present  the  color  of  brick-dust  and 
are  marked  by  concentric  rings.  Their  nuclei  are  dark  by  comparison.  They 
are  soluble  in  dilute  potassium  hydrate  and  in  nitric  acid.  They  are  com- 
bustible and  leave  scarcely  any  ash.  Urate  of  sodium  and  urate  of  ammonium 
often  occur  together  in  stones,  and  these  calculi  are  not  in  rings,  are  not  so  hard 
as  the  uric-acid  stones,  and  are  fawn  colored  on  section.  Oxalate  of  lime  stones 
are  round,  with  many  projecting  nodes  like  the  mulberry,  hence  the  term  "mul- 
berry calculus."  They  are  very  hard,  and  section  shows  the  color  tobebrowTi 
or  green  and  that  they  possess  wa\y ,  concentric  rings.  This  form  of  calculus  is 
soluble  in  hydrochloric  acid.  The  so-called  fusible  calculus  of  the  early  \\Titers, 
which  is  composed  of  a  phosphate  of  magnesium,  ammonium,  and  calcium 


1468  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

{triple  phosphate),  constitutes  the  commonest  form  of  phosphatic  stone  and  of 
large  stone.  It  is  light,  soft,  smooth  and  white,  and  shows  no  laminae  on  sec- 
tion. Some  rare  forms  of  primary  stone  are  composed  of  xanthin,  cystin, 
indigo,  urostealith,  calcium  phosphate  or  calcium  carbonate,  or  blood  concretions. 

A  stone  having  layers  of  different  substances  may  be  formed;  for  instance, 
there  is  often  found  a  uric-acid  nucleus  surrounded  by  phosphates,  the  latter 
surrounded  by  some  uric  acid  or  urates,  and  these  again  by  phosphates.  In 
some  cases  oxalate  of  lime  alternates  with  uric  acid,  urates,  or  phosphates 
(Bowlby).  Bowlby  states  that  the  alternating  uric-acid  and  phosphatic  layers 
are  due  to  the  altering  reactions  of  the  urine;  that  when  the  urine  is  acid  uric 
acid  is  deposited  on  the  stone,  but  when  cystitis  makes  the  urine  alkaline  the 
stone  receives  a  phosphatic  coat. 

Anything  that  favors  the  formation  of  an  excessive  urinary  deposit  may 
cause  vesical  calculus,  and  among  such  causes  are  defective  digestion,  failure 
in  processes  of  oxidation,  excess  of  solids  and  nitrogenous  elements  in  the  diet, 
deficient  exercise,  etc.  If  to  the  urinary  condition  established  by  the  above 
factors  catarrh  of  the  genito-urinary  tract  is  added,  pus  or  mucopus  in  the  con- 
centrated urine  may  induce  stone.  Children  are  predisposed  to  uric-acid 
stones,  and  old  people  to  phosphatic  stones.  In  an  old  man  with  enlarged 
prostate  and  chronic  cystitis  a  stone  forms  rapidly  above  any  accidental  nu- 
cleus. The  nucleus  may  be  phosphate  crystals  glued  together  by  mucus, 
a  blood-clot,  uric-acid  gravel,  or  a  foreign  body.  Stone  is  rare  in  females 
because  of  the  shortness,  the  large  diameter,  and  the  ready  dilatability  of  the 
urethra.  Stone  is  very  rare  in  the  negro.  Gout,  rheumatism,  lithemia,  en- 
larged prostate,  vesical  atony,  urethral  stricture,  and  catarrhal  inflammation 
of  the  kidney,  the  ureter,  and  the  bladder  are  predisposing  causes. 

Symptoms. — In  not  a  few  cases  the  vesical  symptoms  are  antedated  by  an 
attack  of  nephritic  colic.  Hence  the  necessity  for  cystoscopy  after  renal  colic  if 
no  stone  has  passed  from  the  meatus,  and  the  removal  of  any  retained  stone  by 
the  evacuator  or  the  cystoscope.  The  severity  of  the  symptoms  of  stone  in  the 
bladder  depends  more  on  the  roughness  of  the  stone  than  on  its  size.  A  small, 
rough  calculus  will  produce  intolerable  anguish,  whereas  several  large,  smooth 
stones  will  cause  but  moderate  pain.  A  patient  with  stone  in  the  bladder  com- 
plains of  frequency  of  micturition,  particularly  in  the  daytime,  the  desire  being 
sudden,  uncontrollable,  and  invoked  or  aggravated  by  exercise.  This  symp- 
tom is  more  positive  in  youth  than  in  old  age.  Pain  of  a  sharp,  burning  char- 
acter is  experienced  at  the  end  of  micturition,  due  to  the  contraction  of  the 
empty  bladder  upon  the  stone  or  stones.  It  disappears  gradually  as  urine 
enters  and  distends  the  bladder.  The  usual  seat  of  this  pain  is  the  under  sur- 
face of  the  head  of  the  penis,  a  little  behind  the  meatus,  and  the  pain  may 
continue  for  some  time.  By  pulling  on  the  penis  to  relieve  this  pain  the  pre- 
puce of  a  child  may  become  pendulous.  The  pain  varies  in  severity,  being 
much  worse  during  an  attack  of  cystitis  and  after  exercise;  it  may  be  absent 
in  encysted  stone;  it  may  be  present  early  in  a  case,  but  almost  disappears  as 
a  case  progresses,  and  it  is  always  worse  in  the  young  than  in  the  old.  Stone 
in  chronic  cases  of  atony  and  in  cases  of  vesical  paralysis  causes  neither  marked 
pain  nor  frequency  of  micturition.^  In  a  case  of  enlarged  prostate  pain  pre- 
cedes the  act  of  micturition,  in  urethral  stricture  it  accompanies  it,  and  in  stone, 
as  already  stated,  \t  follows  it  (P.  J.  Freyer,  in  "The  Practitioner,"  Feb.,  1898). 
The  symptoms  maybe  somewhat  confused  by  the  co-existence  of  vesical  calculus 
and  prostatic  hypertrophy.  Attacks  of  cystitis  in  a  man  with  calculus  are 
spoken  of  as  attacks  of  stone.  When  a  stone  is  small,  it  may  during  micturition 
roll  into  the  urethral  orifice,  and  so  cause  a  sudden  interruption  of  the  flow  of 
urine,  the  stream  again  starting  when  the  patient  changes  his  position.  This 
symptom  is  seldom  met  with  and  is  particularly  rare  in  the  old,  the  stone  in  them 
^  ".American  Text-Book  of  Surgery." 


Stone  in  Females  1469 

dropping  into  the  sac  back  of  the  prostate  and  below  the  urethral  orifice.  Even 
if  this  symptom  occurs,  it  is  not  conclusive,  as  a  stalked  tumor,  a  blood-clot, 
or  a  mass  of  pus  or  mucus  may  block  the  urethral  orifice  and  cutoff  the  stream. 
Hematuria  may  or  may  not  be  noted;  it  is  most  usual  after  exercise,  and  occurs 
at  the  end  of  the  urinary  act,  the  first  urine  passed  being  clear,  the  later  urine 
being  blood- tinged,  and  at  the  end  of  the  act  some  drops  of  pure  blood  emerge.  It 
is  not  one  of  the  earliest  symptoms.  When  it  occurs  it  puts  the  patient  in  a 
great  fright.  It  does  not  appear  suddenly  and  profusely,  but  as  gradual  and 
trivial  bleeding  and  with  micturition.  Blood  appearing  between  acts  of  mic- 
turition comes  from  either  the  urethra  or  prostate  (P.  J.  Freyer).  The  bleed- 
ing from  a  bladder  tumor  is  profuse  and  the  urine  is  mixed  with  blood  and  blood- 
clots  and  tumor  fragments.  Bleeding  from  a  tuberculous  ulcer  of  the  bladder 
often  resembles  the  bleeding  caused  by  stone.  Pus  or  mucopus  will  be  observed 
if  cystitis  occurs  with  calculus  disease.  Priapism  occurs  in  some  cases.  Pain 
of  a  reflex  nature  may  be  felt  in  the  rectum,  in  the  perineum,  or  in  some  distant 
part. 

The  above  symptoms,  even  if  all  be  present,  do  not  prove  that  an  indi- 
vidual has  a  stone  in  the  bladder.  To  prove  the  presence  of  a  stone  the  object 
must  be  pictured  by  the  x-rays,  seen  through  a  cystoscope,  or  be  touched  by  a 


^ 


Fig.  967. — Thompson's  calculus  sound. 


sound.  Simple  touching  by  a  sound  is  not  sufficient,  the  contact  must  be  felt 
and  heard.  To  sound  a  patient,  have  the  bladder  well  filled  with  boric  acid 
solution  or  salt  solution,  and  place  him  recumbent,  with  the  knees  drawn  up. 
Never  sound  a  person  while  he  is  standing,  because  of  the  danger  of  syncope. 
In  an  ordinary  case  in  a  male  use  a  sound  with  a  very  slight  curve  (Fig.  967) ;  in 
a  man  with  hypertrophied  prostate  use  a  sound  with  a  short  and  decided  curve. 
The  caliber  of  a  stone-sound  is  No.  13  of  the  French  scale.  The  instrument 
is  carefully  boiled  and  anointed  with  yellow  liquid  cosmolin.  Examine  the 
entire  bladder  systematically,  and  don't  be  sure  a  stone  is  present  until  contact 
with  the  sound  is  both  heard  and  felt.  The  stone  may  be  difficult  to  find,  or 
it  may  elude  the  instrument  entirely  when  it  is  encysted,  when  it  rests  in  a  di- 
verticulum, when  it  is  fixed  to  the  roof  or  anterior  wall  of  the  viscus,  or  when 
it  is  crusted  with  lymph  or  blood-clot.  In  doubtful  cases  always  insist  on  a 
second  examination,  giving  ether  if  the  first  has  been  very  painful.  Occasionally, 
as  Freyer  pointed  out  in  1884,  a  small  stone  will  be  found  by  using  a  Bigelow 
evacuator,  the  current  causing  the  calculus  to  knock  against  the  tube.  In  many 
cases  stone  in  the  bladder  may  be  detected  by  means  of  the  x-rays  (see  Fig. 
966).  Use  the  cystoscope  in  all  cases  of  suspected  stone.  If  a  stone  is  fixed  in 
a  diverticulum  or  projects  from  the  ureter,  or  is  in  a  sac  back  of  the  prostate, 
it  may  be  missed  by  sound  and  evacuator  tube,  but  be  shown  by  the  x-rays 
and  the  cystoscope.  A  stone,  when  it  is  detected,  should  always  be  measured 
by  Thompson's  instrument,  an  arrangement  looking  something  like  a  small 
edition  of  a  lithotrite,  but  having  very  delicate  blades.  The  composition  of 
the  stone  is  assumed  from  an  examination  of  fragments  which  pass  through  the 
urethra  or  which  adhere  to  the  measure.  Remember  that  the  outer  layer  of  a 
calculus  may  be  soft  phosphate  and  the  inner  portion  may  be  the  harder 
uric  acid,  urate,  or  oxalate. 

Stone  in  Females. — Calculus  in  the  female  is  a  rare  complaint.  In  over  900 
patients  operated  upon  by  Freyer  for  stone  there  were  only  20  females.  Pain 
and  increased  frequency  of  micturition,  which  are  symptoms  of  stone  in  men 
and  women,  are  in  women  commonly  caused  by  other  conditions,  notably  by 
uterine  disease  and  displacement.     A  straight  sound  is  used  to  examine  a  female 


1470  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

for  stone.  If  the  surgeon  is  still  uncertain  after  sounding,  he  uses  a  cysto- 
scope  or  dilates  the  urethra  and  explores  the  bladder  with  his  little  finger. 

Stone  in  children  can  occur  at  any  age,  and  congenital  cases  have  been 
placed  on  record.  The  uric-acid  stone  is  most  common.  The  symptoms 
are  like  those  of  the  adult.  The  pain  causes  the  male  child  to  pull  at  the 
penis  and  the  prepuce  becomes  pendulous.  If  in  a  child  with  stone  the  stream 
of  urine  is  blocked  from  time  to  time,  the  child  strains  to  empty  the  bladder, 
and  after  a  time  a  hernia  may  form  or  prolaspe  of  the  rectum  take  place. 

Treatment. — In  people  predisposed  to  stone  (for  instance,  by  lithemia) 
the  physician  should  foresee  the  danger  and  antagonize  it.  Insist  on  the  urine 
being  kept  dilute  by  the  freest  use  of  water  and  of  milk,  and  reduce  to  a  minimum 
the  amount  of  alcohol,  meat,  sugar,  and  fat  which  is  taken.  Let  the  patient 
live  chiefly  on  green  vegetables,  salads,  bread,  fruit,  eggs,  fish,  poultry,  weak  tea 
or  coffee,  water,  milk,  and,  if  desired,  a  little  red  wine.  Continued  purging  does 
harm  by  concentrating  the  urine,  though  a  laxative  may  be  employed  when 
indicated.  Moderate  open-air  exercise  is  of  immense  importance,  sunshine 
and  fresh  air  being  Nature's  correctives  for  a  condition  of  imperfect  oxidation 
power.  If  the  urine  be  very  acid,  use  piperazin,  15  to  20  gr.  daily,  liquor  potassii 
citratis,  phosphate  of  sodium,  or  borocitrate  of  magnesium.  If  the  urine  be 
phosphatic  and  alkahne,  order  mineral  acids  and  strychnin,  or,  what. seems  to  be 
very  efficient,  urotropin.  Urotropin  is  given  in  5-gr.  capsules  four  times  daily. 
If  the  urine  be  filled  with  oxalate,  use  the  mineral  acids  with  an  occasional  course 
of  phosphate  of  sodium.  Travel  and  rest  at  the  seaside  or  at  some  spa  are  often 
of  service  in  all  forms.  Always  endeavor  to  prevent  cystitis,  and  treat  it 
promptly  when  it  does  occur.  When  a  stone  is  once  formed  it  is  an  idle  dream 
to  think  of  dissolving  it.  An  operation  must  be  done.  Some  very  small  stones 
may  be  crushed  in  view  through  the  cystoscope  by  one  of  the  several  intravesical 
forceps,  but  in  an  immense  majority  of  cases  a  very  much  more  formidable 
operation  is  required.  The  operation  selected  depends  upon  the  age,  the  state 
of  the  bladder  and  the  prostate,  the  dilatability  of  the  urethra,  the  kidney  con- 
dition, the  size  and  composition  of  the  stone,  and  the  number  of  calculi  present 
(see  Operations  on  the  Bladder). 

Bacteriuria  (see  page  143 1  et  seq.). — ^Most  urines  contain  bacteria  which 
soon  die.  If  the  bacteria  live  and  multiply  the  condition  is  called  bacteriuria. 
When  there  is  bacteremia,  bacilli  frequently  enter  the  urine.  Bacteremia  is  a 
common  cause  of  bacteriuria.  If  bacilli  are  present  in  numbers,  the  condition  is 
called  bacilluria.  The  variety  and  number  vary  greatly  in  different  individuals. 
In  typhoid  fever  typhoid  bacilli  are  found.  In  many  cases  of  nephritis  bacteria 
are  present.  In  pulmonary  tuberculosis,  vesical  tuberculosis,  and  renal  tuber- 
culosis, bacilli  may  be  found  in  the  urine.  In  some  cases  numerous  colon  bacilli 
are  found.  They  may  seem  to  do  no  harm;  they  may  cause  nephritis;  they  may 
cause  cystitis. 

If  a  urine  contains  bacteria,  inflammation  of  the  genito-urinary  tract  may 
or  may  not  exist,  but  even  if  it  does  not  exist  it  is  apt  to  occur  at  any  time. 
In  some  persons  the  urine  is  found  swarming  with  colon  bacilli.  Colon  bacilli 
are  capable  of  causing  a  very  severe  type  of  cystitis  and  nephritis.  Bacterial 
urine  explains  many  cases  of  urinary  fever  (see  page  1515). 

Cystitis. — Inflammation  of  the  bladder  is,  as  a  rule,  a  complication  of 
some  other  disease  of  the  genito-urinary  tract,  but  it  may  arise  after  exposure 
to  cold  and  wet.  Traumatism  from  a  catheter,  the  presence  of  a  stone,  the 
spread  of  a  urethral  inflammation,  pus  infection,  vesical  tuberculosis  or  cancer, 
and  the  use  of  such  drugs  as  cantharides,  turpentine,  alcohol,  urotropin,  and 
sandalwood  oil  in  large  doses  may  produce  it.  It  appears  not  unusually 
during  an  exanthematous  fever  or  in  conditions  of  vesical  paralysis;  it  often 
follows  retention;  frequently  accompanies  enlarged  prostate  and  urethral  stric- 
ture, and  sometimes  arises  from  concentration  of  urine  or  accompanies  bladder 


Treatment  of  Acute  Cystitis  147 1 

growths.  Acute  cystitis  causes  discoloration  and  swelling  of  the  bladder  walls, 
and  there  is  present  a  catarrhal  discharge  which  is  mixed  with  urinary  elements, 
serum,  mucus,  often  pus  and  epithelial  debris.  Ulceration,  sloughing,  or  false- 
membrane  formation  may  occur.  Chronic  cystitis  is  an  inllammatory  condi- 
tion always  due  to  bacteria.  We  frequently  speak  of  a  chronic  cystitis  as  due 
to  stone  in  the  bladder,  hypertrophy  of  the  prostate  gland,  or  tumor  of  the 
bladder.  These  conditions  do  not  cause  chronic  cystitis,  but  act  by  rendering 
the  bladder  vulnerable  to  micro-organisms.  Among  the  causative  organisms 
we  may  mention  the  Bacillus  coli  communis,  the  gonococcus,  the  Bacillus  tu- 
berculosis, the  Bacillus  typhosus,  the  Urobacillus  liquefaciens  septicus,  and  the 
various  pyogenic  bacteria  (Leonard  Freeman).  The  bacillus  aerogenes  lactis 
has  been  found  (Luetscher,  in  "Jour.  Clinical  Research,"  1914,  vii,  i).  These 
bacteria  may  gain  entrance  on  instruments  or  by  way  of  the  ureter,  urethra,  the 
lymph-vessels,  or  the  blood. 

In  chronic  cystitis  there  is  an  enormous  production  of  thick,  sticky  mucus 
and  the  urine  becomes  alkaline.  The  excessive  secretion  of  mucus  and  the 
great  number  of  bacteria  convert  the  urea  into  carbonate  of  ammonium,  and 
this  product,  being  irritant  to  the  bladder  walls,  makes  the  inflammation 
worse.  In  chronic  cystitis  the  bladder  is  contracted  and  has  very  thick  walls, 
and  the  mucous  membrane  is  thick,  edematous,  congested,  and  filled  with 
large  veins.  The  bladder  may  be  ulcerated  or  encrusted  with  urinary  salts. 
The  urine  contains  bacteria,  triple  phosphate,  pus,  blood,  and  mucus,  the 
blood  emerging  with  the  last  drops  of  urine.  Pyelitis  may  arise  as  a  result 
of  chronic  cystitis. 

What  was  formerly  called  inflammation  of  the  neck  of  the  bladder  is  an 
inflammation  of  the  vesical  trigone  and  of  the  posterior  urethra.  It  is  now 
usually  called  urethrocystitis  or  trigonitis. 

Symptoms  of  Acute  Cystitis. — Great  frequency  of  micturition,  with  the 
passage,  at  each  act,  of  a  very  small  quantity  of  urine;  the  desire  to  urinate  is 
almost  constant,  and  there  is  intensely  painful  straining  {tenesmus).  The 
pain  is  acute  and  scalding,  and  may  be  felt  in  the  head  of  the  penis,  above  the 
pubes  or  in  the  perineum;  it  often  runs  into  the  loins  and  the  thighs  and  radi- 
ates over  the  sacrum.  Pain  above  the  pubes  indicates  invoh^ement  of  the 
fundus,  and  pain  in  the  perineum  and  in  the  head  of  the  penis  points  to  in- 
flammation of  the  bladder  trigone.  The  urine,  at  first  clear,  loses  its  trans- 
parency, becomes  full  of  thick  mucus,  and  often  contains  a  little  blood  or  pus. 
The  patient  not  unusually  has  some  fever.  A  rectal  examination  causes  violent 
pain.  If  retention  arises,  there  will  probably  be  a  chill  and  high  fever,  and 
anuria  may  occur. 

Treatment. — In  treating  acute  cystitis  endeavor  to  remove  the  cause. 
By  allaying  an  irritation  or  removing  an  obstruction  the  bladder  will  often 
become  able  to  empty  itself  of  retained  urine,  which  causes  congestion  of 
the  bladder  and  thus  renders  infection  probable  or  may  be  itself  filled  with 
bacteria.  If  cystitis  arises  after  the  administration  of  cantharides,  put  the 
patient  in  bed  and  give  him  Hquor  potassii  citratis.  If  it  arises  after  the  use 
of  a  clean  sound,  order  rest  in  bed,  suppositories  of  opium  and  belladonna, 
diluent  drinks,  and  ammonii  benzoas  or  lupulin.  If  the  inflammation  is  septic 
(as  from  the  use  of  a  dirty  sound)  or  is  very  acute  put  the  patient  in  bed, 
keep  hmi  warm,  and  use  a  hot  sand-bag  to  the  perineum  and  hot  fomentations 
or  poultices  to  the  hypogastrium.  Urotropin  is  a  valuable  prophylactic  if  the 
urethra  or  bladder  is  to  be  subjected  to  instrumentation.  Hot  hip-baths  may 
be  used.  The  hips  should  be  elevated,  and  the  bowels  should  be  emptied  by  the 
administration  of  salines  and  by  glycerin  enemata.  An  exclusive  milk-diet  is  de- 
sirable. The  patient  should  drink  copiously  of  sweetened  water  containing  a 
few  drops  of  aromatic  sulphuric  acid  or  of  milk  of  almonds.  We  can  sterilize  the 
urine,  if  it  be  alkaline,  by  the  administration  of  urotropin,  giving  a  capsule  con- 


1472  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

taining  7}^  gr.  of  the  drug  three  times  a  day.  Others  remedies  which  may  be  of 
service  in  sterilizing  the  urine  are  quinin,  boric  acid,  salol,  borocitrate  ol  mag- 
nesium and  salicylate  of  sodium.  A  valuable  remedy  consists  of  15  gr.  of  sali- 
cylate of  sodium  and  15  gr.  of  benzoic  acid,  given  three  times  a  day  in  a  little 
chloroform  water.     If  the  pain  and  straining  still  continue,  order — 

P^.     Ext.  hyoscyami gr.  viij; 

Ext.  cannabis  indicse gr.  viij; 

Sacchar.  alba gr.  xlviij. — M. 

Div.  in  pulv.  No.  xxiv. 
Sig. — One  powder  every  four  hours. 
Or, 

I^.     Camphorae gr.  viij; 

Ext.  cannabis  indicae gr.  viij; 

Sacchar.  alba gr.  xlvij. — M. 

Div.  in  pulv.  Xo.  xx. 

Sig. — One  powder  every  three  hours  (Von  Zeissl.) 

The  two  most  active  agents  in  acidifying  alkaline  urine  are  the  acid  phos- 
phate of  sodium  and  the  benzoate  of  ammonium.  Boric  acid  not  only  acidifies 
urine  but  it  is  also  antiseptic.  Suppositories  of  extract  of  belladonna  are  of 
great  value.  Suppositories  each  of  which  contains  i  gr.  of  ichthyol  are  of  service, 
and  one  may  be  used  every  four  hours.  Opium,  unfortunately,  constipates; 
when  it  is  given,  secure  evacuations  by  the  use  of  glycerin  suppositories,  by  the 
administration  of  saline  cathartics,  or  by  the  employment  of  enemata.  If 
opium  is  necessary,  it  is  given  in  a  suppository  containing  i  gr.  of  powdered 
opium  and  l^  gr.  of  the  extract  of  belladonna  every  three  or  four  hours. 
Hypodermatic  injections  of  morphin  may  be  required.  Wash  the  bladder 
out  daily  with  warm  normal  salt  solution  or  warm  boric  acid  solution.  This 
can  be  done  through  a  soft  catheter  or,  better,  by  hydrostatic  pressure.  If 
retention  occurs,  use  a  soft  catheter.  If  much  blood  is  passed,  give  inter- 
nally the  tinctura  ferri  chloridi  and  blister  the  perineum.  In  acute  urethrocystitis 
{trigonitis)  the  instillation  of  solutions  of  nitrate  of  silver  (5  to  10  gr.  to  the  ounce) 
may  do  good.  A  very  acute  cystitis  is  rarely  arrested  within  a  week  or  ten 
days. 

Symptoms  of  Chronic  Cystitis. — This  condition  may  be  a  legacy  from 
acute  cystitis  or  it  may  appear  without  any  acute  precursory  phenomena. 
There  will  be  found  frequency  of  micturition,  but  not  so  great  as  in  the  acute 
form.  There  will  be  slight  tenesmus  and  moderate  pain  from  time  to  time, 
usually  radiating  toward  the  head  of  the  penis.  Constitutional  symptoms 
may  arise  when  kidney  damage  has  become  pronounced  or  sepsis  has  occurred 
from  absorption.  The  urine  is  ammoniacal,  fetid,  and  turbid;  it  is  filled  with 
viscid,  tenacious  mucus  or  with  mucopus;  it  contains  a  great  excess  of  phos- 
phates, and  occasionally  clots  of  blood.  The  condition  of  chronic  cystitis 
with  the  production  of  immense  quantities  of  thick  mucus  is  often  called 
chronic  catarrh  of  the  bladder.  Chronic  cystitis  may  eventuate  in  the  for- 
mation of  stone  or  in  the  production  of  serious  disease  of  the  bladder,  the 
ureters,  and  the  kidneys.     It  is  very  apt  to  cause  retention  of  urine. 

Chronic  Tuberculous  Cystitis. — Chronic  cystitis  may  be  due  to  tuber- 
culosis. Primary  vesical  tuberculosis  is  very  uncommon.  When  it  does 
occur  it  will  often  be  found  that  it  has  been  preceded  by  gonorrheal  infection  of 
the  bladder.  Most  cases  of  vesical  tuberculosis  are  secondary  to  renal  tuber- 
culosis or  to  tuberculosis  of  the  prostate,  seminal  vesicles,  or  epididymis. 
Some  cases  come  on  rapidly,  many  tubercle  bacilli  being  found  in  the  urine. 
Other  cases  come  on  more  gradually,  and  in  them  the  urine  may  contain  few 
tubercle  bacilH.  In  many  such  cases  no  tubercle  bacilli  are  found.  The  tuber- 
culous products  caseate  and  ulcers  form  or  fibrous  organization  takes  place. 
A  cystitis  for  which  no  cause  can  be  found,  and  which  is  accompanied  by  pyuria 
and  severe  and  lasting  pain,  is  possibly  tuberculous.     Pyuria  is  usually  present, 


Treatment  of  Chronic  Cystitis  1473 

but  in  some  cases  the  urine  is  perfectly  clear.  In  some  cases  the  patient  has 
painful  paroxysms  of  varying  duration  and  feels  well  between  the  attacks. 
Finding  tuberculosis  of  the  kidney,  prostate,  seminal  vesicle,  or  epididymis, 
increases  the  probability  that  tuberculous  cystitis  exists.  The  diagnosis  is 
made  by  the  cystoscope.  Tuberculous  ulceration  is  most  common  in  the 
trigone  and  about  the  inner  orifice  of  the  urethra.  A  tuberculous  ulcer  is 
small.  The  adjacent  mucous  membrane  is  not  inflamed,  but  contains  grayish- 
white  nodules  (Louis  E.  Schmidt,  "Jour.  Amer.  Med.  Assoc,"  July  19,  1902). 

Treatment  of  Chronic  Cystitis. — In  treating  chronic  cystitis  remove  the 
cause,  if  possible  (get  rid  of  a  stone,  evacuate  frequently  residual  urine,  dilate  a 
stricture,  and  remove  a  tumor).  For  chronic  cystitis  certain  remedies  are  taken 
by  the  mouth.  Water  is  drunk  in  large  amounts,  also  iron  spring- water  (Ma- 
rienbad,  etc.).  Diuretics  which  make  the  urine  alkaline  must  not  be  given  in 
association  with  urotropin.  Free  diuresis  by  such  waters  is  often  valuable 
but  we  must  choose  between  diuresis  so  obtained  and  urotropin  (J.  W.  T. 
Walker,  Abstract  in  "  Surgery,  Gynecology,  and  Obstetrics,"  from  "  Clin.  Jour.," 
191 5,  xliv).  Salol  and  boric  acid,  5  gr.  of  each  four  times  a  day,  are  very 
valuable.  Salol  in  fluidextract  of  triticum  repens  does  good;  so  does  chlorate  of 
potassium,  10  gr.  daily.  Either  borocitrate  of  magnesium,  quinin,  or  salicylate 
of  sodium  with  benzoic  acid  may  often  be  used  with  benefit.  A  valuable  combi- 
nation to  correct  alkalinity  and  to  exercise  an  antiseptic  action  consists  of 
benzoate  of  ammonium  and  boric  acid,  15  grains  of  each,  given  several  times  a 
day.  Alum,  tannic  acid,  uva  ursi,  copaiba,  cubebs,  buchu,  and  turpentine  have 
all  been  recommended,  and  possibly  may  be  of  some  benefit.  Urotropin  is  useful 
in  many  cases,  if  the  urine  be  alkaline.  This  drug  prevents  the  development  of 
bacteria  in  the  urine  (Nicolaier)  and  antagonizes  the  tendency  to  sepsis  and  urin- 
ary poisoning.  It  is  given  in  5-gr.  capsules,  from  four  to  six  being  given  daily. 
Alkaline  diuretics  must  not  be  given  if  urotropin  is  administered.  Colon  bacillus 
cystitis  is  treated  by  giving  sodium  benzoate  and  urotropin  internally.  In  ob- 
stinate cases  a  vaccine  should  be  made  and  given.  In  cases  of  chronic  cystitis 
(even  the  tuberculous  form)  Stellwagen  has  had  excellent  results  from  the  follow- 
ing capsule:  3  min.  of  creosote,  6  min.  of  oil  of  sandalwood,  i  min.  of  oil  of  cinna- 
mon, I  gr .  of  pepsin.  One  capsule  after  each  meal.  Whatever  remedy  is  used,  see 
that  the  bowels  move  once  a  day  and  that  the  skin  is  active.  Champagne  and 
beer  must  be  avoided.  If  residual  urine  gathers,  a  soft  catheter  must  be  regu- 
larly employed.  If  it  is  possible  to  introduce  a  catheter  of  considerable  size, 
catheterization  may  be  all  that  is  needed  in  the  case.  In  some  cases  of  chronic 
cystitis  the  retention  of  a  catheter  from  three  to  five  weeks  is  of  the  greatest 
service.  If  the  case  is  very  severe,  the  bladder  must  be  washed  out  daily  with 
peroxid  of  hydrogen  (25  to  40  per  cent,  solution),  nitrate  of  silver  (i :  8000),  boric 
acid  (5  to  10  per  cent.),  carbolic  acid  (i :  500),  corrosive  sublimate  (from  i :  20,000 
to  1:5000),  or  permanganate  of  potassium  (1:4000).  If  nitrate  of  silver  or 
permanganate  of  potassium  be  used,  first  rinse  out  the  bladder  with  distilled 
water.  If  any  other  agent  be  used,  first  wash  out  the  bladder  with  either  boiled 
water  or  normal  salt  solution.  The  daily  injection  of  a  2  per  cent,  solution  of 
ichthyol  may  prove  useful.  Collin  uses  a  i  per  cent,  solution  of  guaiacol  carbon- 
ate in  sterile  oUve  oil.  Some  surgeons  occasionally  employ,  at  intervals  of  a 
number  of  days,  strong  silver  solutions  (30  or  40  gr.  to  the  ounce).  If  a  strong 
solution  be  used,  after  the  drug  flows  away  wash  out  the  bladder  with  a  solution 
of  common  salt.  The  bladder  is  usually  washed  out  by  attaching  to  the  free  end 
of  a  soft  catheter,  the  other  end  of  which  is  in  the  bladder,  a  tube  which  is 
connected  with  a  graduated  bottle,  the  force  being  obtained  by  elevating  the 
reservoir  {fountain  irrigation).  The  bladder  can  be  irrigated  without  using  a 
catheter,  the  resistance  of  the  compressor  muscle  of  the  urethra  being  overcome 
by  the  pressure  of  a  column  of  water.  The  reservoir  is  raised  to  the  height  of 
6  feet.  The  patient  sits  in  a  chair.  The  tube  of  the  reservoir  has  upon  it  a 
93 


1474  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

clamp  to  control  the  flow,  and  in  its  end  a  large  bulbous  tip  which  will  fill  the 
meatus  (Valentine's  instrument).  The  tip  is  inserted  into  the  urethra,  the 
clamp  on  the  tube  is  loosened,  and  the  patient  is  directed  to  take  a  deep  inspira- 
tion. In  a  short  time  the  bladder  fills  with  water,  the  tube  is  removed,  and  the 
patient  empties  the  viscus  naturally.  In  some  cases  it  is  necessary  to  wait 
quite  a  while  for  the  column  of  water  to  tire  out  the  muscle.  If  the  fluid  will  not 
enter,  direct  the  patient  to  make  efforts  as  in  micturating,  the  pressure  of  the 
fluid  on  the  anterior  surface  of  the  cut-off  muscles  being  kept  up.  If  this  fails, 
direct  him  to  urinate,  and  then  the  surgeon  makes  another  attempt  to  get  the 
fluid  to  enter.     After  a  little  practice  a  patient  learns  how  to  admit  the  fluid. 

Chronic  trigonitis  is  treated  by  anesthetizing  the  bladder  locally  twice  a  week 
(by  means  of  novocain  or  alypin)  and  by  instilling  from  30  to  60  minims  of  a  2 
percent,  solution  of  nitrate  of  silver.  Direct  applications  of  a  5  per  cent,  solution 
can  be  made  through  a  Kelly  cystoscope.  If  a  cyst  forms  it  should  be  punctured. 
If  the  papillae  hypertrophy  they  should  be  curetted.  In  the  male  these  pro- 
cedures are  carried  out  through  an  operative  cystoscope,  in  the  female  through 
a  Kelly  tube  (H.  W.  E.  Walker,  in  "Med.  Record,"  1916,  Ixxxbc). 

If  the  cystoscope  discloses  tuberculosis  of  the  bladder  and  there  is  known 
to  be  tuberculosis  of  one  kidney,  cure  of  the  bladder  is  impossible  without 
preliminary  nephrectomy.  In  tuberculous  cystitis  collargol  may  be  injected 
once  a  day.  A  i  per  cent,  solution  is  used  and  it  is  allowed  to  remain  for  a 
long  time.  The  method  is  painless.  Collin  advises  the  instillation  of  30  min. 
of  the  following  mLxture  into  the  bladder  and  posterior  urethra:  5  gm.  of 
guaiacol,  i  gm.  of  iodoform,  100  gm.  of  sterile  oUve  oil.  About  30  min.  of  this 
are  injected  once  a  day.  Rovsing,  of  Copenhagen  (Meeting  of  French  Uro- 
logical  Assoc,  of  1910),  uses,  in  tuberculosis  of  the  bladder,  a  fresh  solution  of 
carbolic  acid  (3  to  6  per  cent.).  He  injects  from  25  to  50  c.c.  through  a  catheter, 
allows  it  to  remain  in  the  viscus  for  two  or  three  minutes,  lets  it  run  out,  and 
repeats  this  procedure  until  the  fluid  emerges  clear.  This  treatment  is  carried 
out  at  first  every  other  day.  When,  on  the  intervening  day,  the  urine  remains 
clear  the  interval  between  treatments  is  lengthened.  Rovsing  claims  to  have 
cured  28  cases  in  from  four  to  six  weeks.  During  treatment  he  makes  a  cysto- 
scopic  examination  every  other  week  to  determine  the  progress  of  the  case. 
The  injections  are  usually  very  painful  and  would  be  intolerable  without  a 
preliminary  injection  of  a  local  anesthetic  (25  c.c.  of  a  i  per  cent,  solution  of 
eucain).  Sometimes,  in  tuberculous  ulceration  of  the  bladder,  curetting  through 
a  cystoscope  is  useful.  In  other  cases  the  bladder  must  be  opened,  the  ulcer 
curetted,  and  the  viscus  drained. 

In  cystitis,  and  in  incrusted  cystitis  particularly,  injections  of  lactic  bacillus 
cultures  are  very  useful.  We  owe  this  knowledge  to  David  Neuman  of  Glasgow 
("Lancet,"  August  14,  191 5).  In  this  condition  bacteria  destroy  the  mucous 
membrane,  phosphates  are  deposited,  and  the  urine  is  very  bloody  and  ammoni- 
acal.  The  injections  are  made  after  the  estabhshment  of  suprapubic  drainage. 
Neuman  prepares  the  agent  as  follows  ("Lancet,"  Ibid.):  Dissolve  i  part  of 
sugar  of  milk  in  40  parts  of  sterile  water,  boil  it  for  ten  minutes,  allow  it  to  cool, 
add  one  tube  of  Oppenheimer's  lactogen  to  20  ounces  of  the  solution,  keep  it 
under  sterile  conditions  at  a  temperature  of  70°  F.  for  ninety-six  hours,  shaking 
occasionally.  Before  using  the  solution  of  bacilli  wash  out  the  bladder  with 
a  solution  of  permanganateof  potash,  beginning  with  a  strength  of  .025  per  cent, 
and  gradually  increasing  to  .1  per  cent.  If  there  is  a  great  quantity  of  mucus 
present  first  wash  the  bladder  with  a  solution  of  potassium  hydrate  (15  to  a  pint) 
then  with  sterile  water  until  the  fluid  is  neutral,  then  with  the  solution  of 
bacilli. 

The  lactic  bacilli   destroy  pyogenic  organisms. 

If  the  ordinary  methods  of  treatment  fail  to  cure  chronic  cystitis;  if  the 
bladder  resents  catheterization  and  irrigation;   if  in  spite  of  irrigation  the 


Symptoms  of  Tumors  of  the  Bladder  1475 

urine  does  not  become  clear;  and  if  there  are  evidences  of  infection  of  the 
patient  and  breaking  down  of  his  general  health,  drain  by  perineal  or  supra- 
pubic cystotomy  and  through  the  incision  wash  the  bladder  frequently  and 
thoroughly.  If  a  persistent  cystitis  is  due  to  stricture  which  dilatation  fails 
to  cure,  perform  external  perineal  urethrotomy  and  employ  perineal  drainage. 

Ulcer  of  the  bladder  may  be  due  to  injury,  cystitis,  tuberculosis,  malignant 
tumor,  or  gonorrhea.  A  form  of  ulceration  particularly  common  in  anemic 
women  is  a  solitary,  punched-out  ulcer  (Louis  E.  Schmidt,  "Jour.  Amer.  Med. 
Assoc,"  July  19,  1902).  Ulcers  may  be  single  or  multiple.  Some  are  non- 
indurated  and  superficial.  Some  are  indurated  and  deep.  Chronic  ulcers  are 
nearly  always  within  the  area  of  the  trigone.     Perforation  may  occur. 

A  perforation  may  occur  into  the  peritoneal  cavity  or  into  the  perivesical 
cellular  tissue.  In  the  former  case,  after  the  onset  of  marked  hematuria, 
there  are  shock,  abdominal  pain,  and  peritonitis.  In  the  latter  case  there  is 
extravasation  of  urine  or  abscess  formation. 

Tuberculous  ulcer  is  discussed  on  page  1474  and  cystoscopic  ulcer  on  page 
1447. 

Schmidt  (Ibid.)  points  out  that  gonorrheal  ulceration  is  apt  to  be  multiple, 
and  causes  severe  pain  and  bloody,  turbid  urine.  As  a  rule,  when  the  bladder 
is  ulcerated,  the  urine  contains  blood,  blood-clots,  or  tissue  debris,  but  the  urine 
may  be  clear  when  there  is  a  tuberculous  ulcer  or  solitary  ulcer. 

Diagnosis  is  usually  made  by  the  cystoscope.  In  some  cases  it  is  made 
by  exploratory  suprapubic  incision. 

Treatment. — If  there  is  one  ulcer,  or  if  there  are  a  few  ulcers,  curet  or  excise 
with  cutting  forceps,  through  an  operative  cystoscope  (Buerger),  use  irrigations, 
and  keep  the  urine  aseptic.  In  widespread  ulceration  perform  suprapubic 
cystotomy,  curet  the  diseased  mucous  membrane,  and  insert  a  drainage-tube. 
In  some  cases  of  malignant  growth  the  cautery  is  used  as  a  palliative  measure. 
Perforation  is  treated  as  is  rupture  of  the  bladder  (see  page  1465), 

Tumors  of  the  Bladder. — These  growths  are  usually  said  to  be  very 
rare,  but  in  Guyon's  statistics  they  are  found  to  constitute  3.9  per  cent,  of  aU 
cases  of  genito-urinary  disease.  They  are  almost  5  times  as  common  in  males 
as  in  females.  They  are  most  frequently  met  with  between  the  ages  of  fifty 
and  sbf ty,  although  myxoma  is  met  with  in  childhood  only  and  sarcoma  is  most 
common  in  the  young  (Lincoln  Davis  in  "Annals  of  Surgery,"  April,  1906). 
Persistent  vesical  irritation  may,  perhaps,  be  an  element  in  causing  tumor. 
Tumors  of  the  bladder  may  be  either  innocent  or  malignant,  the  latter  being 
the  commonest.  Innocent  tumors  which  may  arise  from  the  bladder  are 
papillomata  or  villous  tumors,  adenomata,  mucous  polypi  (myxoma ta),  fibrous 
polypi,  myomata,  and  angiomata.  A  myoma  may  attain  a  great  size  (even 
that  of  a  child's  head).  The  common  form  is  intravesical.  There  is  an  inter- 
stitial form  and  a  peripheral  form.  Papilloma  is  far  and  away  the  most  common 
form  of  innocent  tumor.  Cysts  may  also  arise.  Malignant  tumors  are  sar- 
coma (comparatively  rare)  and  carcinoma  (encephaloid,  rare;  epithelioma, 
common).  Munwes  ("Zeit.  f.  Urology,"  Nov.,  1910)  collected  107  cases  of  sar- 
coma. Sarcoma  begins  in  the  submucosa.  The  majority  of  bladder  carcino- 
mata  are  secondary  to  growths  of  the  rectum,  prostate,  or  uterus.  Adenocar- 
cinoma and  scirrhous  carcinoma  are  practically  always  secondary  to  rectal, 
prostatic,  or  uterine  tumors.  Papillary  cancer  and  epithelioma  are  not  un- 
usually primary  (JNIandlebaum,  in  "Surg., .Gynecol.,  and  Obstet.,"  1907).  Pri- 
mary carcinoma,  like  primary  sarcoma,  most  commonly  arises  in  or  near  the 
trigone.  Any  tumor  of  the  bladder,  innocent  or  malignant,  will  eventually  cause 
death  if  allowed  to  remain.     Papilloma  is  very  apt  to  become  cancerous. 

Symptoms. — The  innocent  tumors  rarely  cause  cystitis  or  irritation,  though 
by  obstructing  the  ureters  or  the  urethra  they  may  induce  disease  of  the 
kidneys.     Hematuria  is  almost  invariably  present  at  some  time  during  the 


147^  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

existence  of  a  bladder  tumor.  It  is  apt  to  be  profuse,  and  the  urine  contains 
blood,  blood-clots,  and  perhaps  fragments  of  tumor.  The  bleeding  is  intermit- 
tent, may  occur  even  when  the  patient  is  at  rest,  and,  except  in  malignant  dis- 
ease, is  seldom  preceded  or  accompanied  by  pain.  Bleeding  usually  occurs  at 
the  termination  of  micturition,  the  first  urine  being  clear  and  the  last  red  or 
clotted.  Often  hemorrhage  is  the  only  phenomenon  produced  by  a  papilloma 
or  a  mucous  pol\q3US.  Hemorrhage  may  occur  from  a  myoma.  Malignant 
tumors  cause  cystitis,  and  the  urine  contains  mucus,  blood,  and  pus.  The 
growth  may  become  crusted  with  salts  from  the  urine.  Cancer  is  decidedly 
and  often  horribly  painful.  In  malignant  disease  the  rectum  usually  becomes 
involved.  Hydronephrosis  may  be  caused.  Metastases  to  the  lungs  are  com- 
mon. Ulceration  may  occur  into  the  peritoneal  cavity  or  rectum.  A  malig- 
nant tumor  progresses  much  more  rapidly  than  an  innocent  growth,  although 
in  vesical  cancer  metastases  are  not  formed  so  early  as  in  some  other  regions. 
Innocent  tumors  are  felt  with  difficulty  with  the  sound,  but  malignant  tumors 
are  easily  felt.  In  some  cases  a  tumor  can  be  detected  by  a  bimanual  examina- 
tion (a  finger  in  the  rectum  and  the  fingers  of  the  other  hand  on  the  abdo- 
men). Make  a  careful  study  to  determine  whether  or  not  a  growth  has  in- 
filtrated the  prostate,  the  seminal  vesicles,  the  rectum,  or  the  perivesical  tissues. 
Bleeding  follows  the  use  of  a  sound.  There  may  be  difficulty  in  starting 
the  stream  in  micturition,  there  may  be  interruption  or  irregular  halts  in  the 
stream.  The  latter  condition  is  called  stammering  of  the  bladder.  The  urine 
should  be  examined  microscopically  to  see  if  it  contains  villi,  portions  of  fibroma, 
colonies  of  cancer-cells,  or  fragments  of  epithelioma.  A  cystoscope  should  be 
employed  in  order  to  reach  a  diagnosis.  If  the  urethra  is  too  narrow  for  the 
cystoscope,  this  channel  must  be  dilated.  If  there  be  profuse  bleeding  an  irrigat- 
ing cystoscope  must  be  employed.  In  doubtful  cases  exploratory  suprapubic 
cystotomy  is  advisable. 

Treatment. — Some  innocent  tumors  may  be  cured  by  high-frequency 
electro-coagulation.  This  method  is  very  valuable.  Some  use  the  Oudin,  some 
the  d'Arsonval  current.  Various  names  are  given  to  the  method  besides  the  one 
employed  above,  viz.:  dessication,  fulguration,  thermo-coagulation,  high- 
frequency  cauterization.  The  application  is  made  through  a  cystoscope.  In 
extensive  malignant  growths,  beyond  surgical  removal,  electro-coagulation  may 
be  used  to  arrest  bleeding  and  lessen  pain  (for  a  Collective  Review  of  this  method 
see  Henry  G.  Bugbee,  in  "Internat.  Abstract  of  Surgery,"  December,  1915). 
PapUlomata  are  particularly  amenable  to  this  treatment.  Recurrence  is  rare. 
Some  innocent  tumors  (for  instance,  peripheral  myoma ta)  are  treated  by  supra- 
pubic incision  and  removal  of  the  growth  and  a  portion  of  the  bladder  wall.  A 
papilloma  which  recurs  after  electrocoagulation  should  be  treated  by  excision  with 
a  portion  of  the  mucous  membrane  and  submucous  tissue  of  the  bladder  wall. 
The  perineal  operation  only  enables  the  surgeon  to  reach  and  remove  growths 
of  small  size,  pedunculated  growths,  and  growths  near  the  neck  of  the  bladder. 
(See  Operations  on  the  Bladder.) 

Among  the  operations  practised  for  malignant  disease  are  partial  cys- 
tectomy with  resection  of  one  or  both  ureters,  partial  resection  of  the  bladder 
wall,  removal  of  the  growth  without  resection  of  the  wall  (a  useless  procedure), 
curetting  (which  is  futile).  Complete  extirpation  of  the  bladder  {total  cystec- 
tomy) for  cancer  has  been  performed  by  Bardenheuer,  Heresco  and  others. 
Goldenberg  reported  26  cases,  with  a  mortality  of  over  60  per  cent.  It  is 
usually  done  in  two  stages,  in  the  first  operation  the  ureters  of  a  man  being 
transplanted  into  the  rectum,  the  ureters  of  a  woman  into  the  rectum  or  vagina. 
Heresco  prefers  skin  implantation  in  the  hypogastric  region,  because  the  ureters 
can  then  be  catheterized  and  the  pelvis  of  each  kidney  can  be  disinfected. 
About  three  weeks  later  the  bladder  is  removed.  The  adjacent  lymph-nodes 
along  the  internal  iliac  vessels  and  in  front  of  the  sacrum  must  be  removed  in  all 


Lateral  Lithotomy  1477 

cases.  The  space  left  by  removing  the  bladder  is  drained  through  the  perineum. 
The  surgeon  should  bear  in  mind  that  vesical  scirrhus  and  adenocarcinoma  are 
practically  always  secondary  growths,  and  if  he  cannot  remove  the  primary 
growth  he  should  not  extirpate  the  bladder.  The  complete  procedure  has  been 
carried  out  successfully  at  one  operation  (Tuffier  and  Dujarier,  "Rev.  de  Chir.," 
April,  1898).  Some  surgeons  prefer  preliminary  double  lumbar  nephrostomy; 
others  transplant  the  ureters  in  the  skin  surface.  The  operation  of  complete 
extirpation  is  of  questionable  value.  In  most  cases  it  has  proved  a  fatal  failure. 
Munwes  ("Zeit.  f.  Urology,"  Nov.,  1910)  reported  69  radical  operations  for 
sarcoma.     Only  3  patients  lived  for  more  than  a  brief  time. 

In  Rafin's  collection  of  30  cases  of  cancer  there  were  17  deaths.  One  case 
was  alive  five  years  after  operation,  i  fifteen  months,  and  i  seven  months  after. 
Watson's  table  of  25  cases  of  cancer  shows  14  deaths  and  only  2  of  the  survivors 
were  alive  and  free  from  recurrence  after  three  years. 

Complete  extirpation  should  be  employed  only  when  cancer  involves  the 
bladder  extensively.  I  agree  with  Berg  ("Annals  of  Surgery,"  Sept.,  1908),  that 
if  less  than  one-third  of  the  bladder  is  involved  the  operation  should  be  partial 
cystectomy  with  implantation  of  the  ureters  into  the  portion  of  bladder  remain- 
ing. The  surgeon  removes  the  anatomically  related  lymphatic  area  and  always 
bears  in  mind  that  vesical  adenocarcinoma  and  scirrhus  are  secondary  growths. 
Partial  cystectomy  saves  the  performance  of  the  fatal  operation  of  transplanting 
the  ureters  as  is  ordinarily  done,  or  the  questionable  operation  of  lumbar  neph- 
rostomy with  all  of  its  unpleasant  consequences.  In  Rafin's  collection  of  96 
cases  there  were  2 1  deaths  (a  mortality  one- half  that  of  complete  cystectomy) ; 
50  cases  were  traced — 5  were  well  over  three  years  and  16  over  six  months  (Berg, 
Ibid.).  Henry  Morris  lays  down  the  following  rule:  "When  an  infiltrating 
growth  is  felt,  per  rectum  or  per  vaginam,  or  with  the  sound,  to  be  involving  a 
large  surface  of  the  bladder  wall,  to  be  infiltrating  its  coats,  especially  in  the 
neighborhood  of  the  ureters  and  neck  of  the  bladder,  no  operation  whatever 
should  be  proposed  unless  the  hemorrhage  is  copious  or  the  symptoms  of  cystitis 
severe,  and  then  an  incision  for  palliative  purposes  only  should  be  made" 
(Treves's  "System  of  Surgery"). 

Many  surgeons  content  themselves  in  vesical  cancer  with  suprapubic  cystot- 
omy, removing  the  growth  and  a  portion  of  the  bladder  wall.  If  removal 
be  not  possible,  they  curet,  cauterize,  and  drain.  Radium  and  the  ^--rays  may 
be  of  service  to  prevent  recurrence  after  an  operation  for  cancer,  and  in  inoper- 
able growths.  After  cystotomy  for  irremovable  cancer  of  the  bladder,  radium 
is  sometimes  left  in  the  bladder  for  several  hours. 

Operations  on  the  Bladder. — Lateral  Lithotomy. — Lithotomy  is  the  re- 
moval of  a  stone  from  the  bladder.  Lateral  lithotomy  is  an  operation  which 
was  once  a  glory  of  surgery,  which  is  every  year  becoming  less  popular,  but 
which  is  still  at  times  employed  by  surgeons,  especially  for  stone  in  children. 
This  operation  should  not  be  performed  if  the  stone  is  over  2  inches  in  its  short 
diameter;  it  is  rarely  justifiable  if  the  stone  weighs  3  oz.  or  more  (Cage);  and  it 
must  not  be  performed  for  encysted  stone,  or  on  a  person  with  a  deep  perineum,  a 
narrow  pelvic  outlet,  or  an  enlarged  prostate.  For  one  week  before  the  opera- 
tion keep  the  patient  in  bed,  wash  out  the  bladder  daily  with  hot  boric  acid 
solution,  and  administer  salol  and  boric  acid  by  the  mouth,  5  gr.  of  each  four 
times  a  day.  The  night  before  the  operation  give  a  saline,  order  a  hot  bath,  and 
have  the  perineum,  the  scrotum,  the  buttocks,  and  the  inner  sides  of  the  thighs 
shaved,  cleansed  and  dressed  antiseptically.  In  the  morning  an  enema  is  to 
be  given.  At  the  time  of  operation  the  bladder  should  contain  several  ounces 
of  boric  acid  solution.  The  instruments  required  are  a  lithotomy  knife,  a 
straight  probe-pointed  bistoury,  a  grooved  staff,  a  stone-sound,  stone-forceps 
and  scoops,  a  tenaculum,  an  aneurysm  needle,  a  fountain-syringe,  curved 
needles  and  a  needle-holder,  hemostatic  forceps,  a  tube  with  chemise  (see  Fig. 
260),  a  Paquelin  cautery,  a  Clover  crutch,  and  a  lithotrite. 


1478  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

Place  the  patient  upon  his  back,  anesthetize  him,  and  find  the  stone  by 
sounding.  If  the  stone  is  not  discovered  by  the  sound  at  that  time,  do  not  oper- 
ate. Place  the  buttocks  so  that  they  project  beyond  the  edge  of  the  table,  intro- 
duce the  staflf  into  the  bladder,  flex  the  legs  and  thighs,  and  fasten  the  patient  in 
the  lithotomy  position  with  a  crutch.  During  the  first  incision  the  handle  of  the 
staff  is  held  toward  the  belly;  after  the  first  cut  the  staff  is  set  perpendicularly 
and  is  hooked  up  under  the  pubes.  An  incision  is  made,  starting  just  to  the 
left  of  the  raphe  of  the  perineum  and  I'^l^  inches  in  front  of  the  edge  of  the 
anus,  and  passing  downward  and  outward  to  between  the  anus  and  the  ischial 
tuberosity,  but  one-third  nearer  the  former  than  the  latter.  In  the  adult 
this  incision  is  3  inches  in  length.  The  first  incision  is  superficial  and  does  not 
reach  the  staff,  but  it  is  this  incision  which  may  cut  the  rectum.  After  making 
the  first  cut  the  nail  of  the  left  index-finger  feels  for  the  groove  of  the  staff,  the 
staff  is  hooked  up,  the  knife  is  entered  into  the  groove  and  is  pushed  into 
the  bladder,  and  as  it  is  withdrawn  the  wound  is  enlarged.  As  the  knife  enters 
the  bladder  there  is  a  gush  of  fluid.  The  finger  follows  the  knife  and  stretches  the 
wound,  the  staff  is  withdrawn,  and  the  stone  is  felt  for  and  extracted  with 
forceps.  Liston  showed  years  ago  the  value  of  keeping  the  finger  in  the  wound. 
This  maneuver  retains  some  water  in  the  bladder,  and  as  a  consequence  causes 
the  stone  to  rest  at  the  lowest  part  of  the  viscus,  and  when  the  forceps  are 
introduced  they  at  once  come  upon  the  stone.  In  withdrawing  the  stone  make 
traction  in  the  axis  of  the  pelvis,  and  do  not  rotate  the  calculus  until  it  is  entirely 
out  of  the  prostatic  urethra.  Wash  or  scrape  away  debris  or  incrustation  from 
the  wall  of  the  bladder,  see  that  no  other  stone  is  present,  syringe  out  the  viscus 
with  warm  salt  solution,  insert  a  tube,  apply  antiseptic  dressings  around  the 
tube,  and  put  on  a  T-bandage.  The  end  of  the  tube  which  is  external  to  the 
dressings  is  fastened  to  the  tails  of  the  T-bandage.  A  rubber  cloth  is  put  on  the 
bed,  under  the  body  and  legs,  and  the  patient's  buttocks  rest  upon  a  mass  of  old 
hnen,  the  scrotum  being  raised  on  a  pad.  The  knees  are  bent  over  pillows. 
Change  the  linen  as  soon  as  it  becomes  wet.  Remove  the  tube  in  forty-eight 
hours.  The  urine  begins  to  come  by  the  urethra  from  the  eighth  to  the  twelfth 
day.  In  children  the  incision  is  not  so  long,  it  is  dilated  by  forceps  instead  of  by 
the  finger,  and  no  tube  is  required.  In  lateral  lithotomy  the  prostatic  and  mem- 
branous portions  of  the  urethra  are  opened,  the  prostate  gland  is  partly  divided 
by  the  knife,  and  the  wound  is  dilated  by  the  finger.  One  objection  to  the 
operation  is  that  it  is  possible  to  cut  the  rectum,  and  another  is  that  inflam- 
mation may  occlude  the  ejaculatorv  ducts  and  cause  sterility. 

Suprapubic  Lithotomy. — This  operation  is  the  removal  of  a  stone  through 
an  opening  above  the  pubes.  It  is  in  many  instances  the  preferable  opera- 
tion. The  mortality  of  this  operation  is  higher  in  children  than  that  of  lateral 
lithotomy;  in  adults  and  in  individuals  beyond  middle  life  the  mortality  is 
decidedly  less  than  is  that  following  the  lateral  operation.  It  is  used  for  the 
removal  of  multiple  calculi,  for  very  hard  stones,  for  stones  above  2  inches  in 
their  short  diameter,  for  calculi  in  men  with  enlargement  of  the  prostate,  for 
foreign  bodies  incrusted  with  sediment,  when  the  perineum  is  deep,  when  the 
pehdc  outlet  is  narrow,  for  encysted  stones,  for  calculi  associated  with  a  vesical 
tumor,  and  when  the  urethra  will  not  permit  the  use  of  a  lithotrite.  Before 
doing  the  operation  determine  the  carrying  capacity  of  the  bladder  when  the 
patient  is  not  anesthetized.  This  gives  the  safe  limit  of  distention.  Under 
an  anesthetic  the  bladder  will  receive  3  or  4  more  ounces  than  the  safe  amount. 
The  patient  is  prepared  as  for  lateral  lithotomy,  except  that  the  pubes  are 
shaved,  and  the  lower  part  of  the  abdomen  and  the  upper  part  of  the  thighs  are 
disinfected.  During  the  operation  the  penis  is  kept  wrapped  in  a  piece  of  anti- 
septic gauze. 

In  performing  the  operation  place  the  patient  in  the  Trendelenburg  posi- 
tion.    It  is  necessarv  to  distend  the  bladder  and  raise  it  in  order  to  have  the 


Suprapubic  Lithotomy 


1479 


prevesical  space  uncovered  by  peritoneum.  In  most  cases  this  is  accomplished 
by  distention  of  the  bladder  and  the  Trendelenburg  position.  In  a  few  cases 
in  which  the  bladder  holds  very  little  fluid  a  rectal  bag  is  used  to  lift  the  bladder. 
If  a  rectal  bag  is  to  be  used  an  assistant  oils  it  and  pushes  it  (empty)  above 
the  sphincters.  It  is  filled  after  the  bladder  has  been  injected.  Draw  off  the 
urine  with  a  soft  catheter,  wash  out  the  bladder  with  a  solution  of  silver  nitrate 
(i  :  8000  to  I  :  5000),  and  inject  the  bladder  with  the  same  solution.  In  a 
child  under  the  age  of  five  inject  3  to  4  oz.;  in  an  adult  it  is  usual  to  inject  10 
to  12  oz.  Withdraw  the  catheter  and  tie  a  tube  around  the  penis  to  prevent 
the  escape  of  fluid.  After  injecting  the  bladder  with  fluid,  if  the  viscus  is 
not  well  lifted,  inject  the  rectal  bag  with  water  and  clamp  its  tube  with  for- 
ceps. In  a  child  inject  from  2  to  4  oz.  of  warm  water  into  the  rectal  bag;  in 
an  adult  inject  10  oz.  Bristow  suggested  the  injection  of  air  into  the  bladder. 
Some  surgeons  simply  inject  air  by  means  of  a  catheter  and  a  brass  syringe  or  a 
Davidson  syringe.  Air  injection  is 
not  recommended  if  fluid  can  be 
used.  In  operating  on  an  air-distended 
bladder  there  is  greater  danger  of 
trauma,  shock,  and  postoperative 
bleeding.  If  air  be  injected,  a  rectal 
bag  is  never  used,  and  the  patient  is 
placed  on  his  back  rather  than  in  the 
position  of  Trendelenburg.  The  best 
method  of  injecting  air  is  that  of  F. 
Tilden  Browm,^  by  means  of  a  bicycle 
pump.  A  catheter  is  introduced,  the 
bladder  is  washed  out,  the  catheter  is 
fastened  to  a  bandage,  the  bicycle 
pump  is  attached,  the  operation  is 
proceeded  with,  and  when  the  trans- 
versalis  fascia  is  exposed  the  bladder 
is  filled  with  air,  the  soft  catheter  is 
clamped,  and  the  bladder  is  opened. 
Make  a  3-inch  longitudinal  incision 
in  the  median  line  of  the  hypogastric 
region,  terminating  over  the  symphy- 
sis. When  the  prevesical  connective 
tissue  is  reached  push  it  up  wuth  a 
gauze-covered  finger  slowly  and  gently 
and  with  a  sweeping  motion.  In  close 
association  with  this  tissue  are  the 
prevesical  fat  and  peritoneum.  Any 
roughness    may    be    responsible    for 

disaster.  If  the  peritoneum  should  appear,  push  it  up.  Hold  the  wound  edges 
apart  by  retractors.  The  large  veins  are  seen,  giving  the  bladder  a  blue  color. 
Avoid  these  veins  if  possible,  but  even  if  they  should  be  cut  bleeding  will  usually 
cease  when  the  bladder  has  been  opened  and  the  rectal  bag  has  been  emptied  and 
removed.  Clamp  bleeding  vessels.  Pass  a  stay  suture  of  strong  silk  on  each  side 
of  the  contemplated  incision  in  the  bladder.  Catch  each  suture  by  a  hemo- 
stat  and  let  it  hang.  Open  the  viscus  in  the  middle  line  above,  and  cut  toward 
the  pubes.  Explore  the  bladder,  remove  the  stone  or  stones,  scrape  away 
incrustations,  ligate  bleeding  vessels  outside  the  bladder,  and  irrigate  the 
viscus  with  hot  saline  solution.  Introduce  a  double  tube  into  the  bladder,  and 
attach  to  its  external  end  a  long  tube  to  siphon  off  the  urine.  The  bladder 
can  be  drained  very  satisfactorily  by  a  siphonage  apparatus  (Fig.  968).  Suture 
^  "Annals  of  Surgerj^"  Feb.,  1897. 


Fig.  968. — Cathcart  drainage.  The  Y-tube 
is  of  glass  and  is  darkened  in  order  to  be  shown 
against  a  white  background. 


1480  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

the  muscles  and  fascia  at  the  upper  part  of  the  wound.  Dress  with  dry  anti- 
septic gauze  and  a  rubber-dam,  the  dressings  and  binder  being  spht  to  go 
around  the  tube.  Catch  the  urine  which  siphons  over  in  a  bottle  containing 
some  antiseptic  fluid.  Change  the  dressings  as  often  as  they  become  wet. 
Take  out  the  tube  in  four  or  five  days,  and  allow  the  wound  to  heal  by  granu- 
lation. The  patient  may  get  up  in  two  weeks.  Many  Continental  surgeons 
advocate  immediate  suture  of  the  bladder  after  incision.  Albert,  \'incent, 
Bassini,  DeVlaccos,  and  others  advocate  immediate  suture.  The  suture  ma- 
terial should  be  catgut.  After  suturing  a  catheter  is  kept  in  the  bladder  to 
drain  the  viscus.  Immediate  suture  may  be  employed  in  patients  of  any  age, 
but  should  not  be  used  if  the  urine  is  very  septic  or  if  pyelonephritis  exists. 
In  some  cases  the  attempted  closure  will  fail;  in  others  it  will  only  partially 
succeed;  in  others  it  will  prove  successful;  but  even  if  it  only  partially  succeeds 
it  will  tend  to  prevent  dissemination  of  urine  in  the  prevesical  cellular  tissue. 
The  chief  causes  of  death  after  suprapubic  lithotomy  are  septicemia,  secondary 
hemorrhage,  cellulitis,  peritonitis,  and  suppression  of  urine.  J.  W.  White  esti- 
mates the  relative  mortality  of  suprapubic  and  lateral  lithotomy  as  follows: 
In  children  the  suprapubic  operation  gives  a  mortality  of  12  per  cent.;  the 
perineal,  of  3  per  cent.  In  adults  the  suprapubic  gives  a  mortality  of  12  per 
cent.;  the  perineal,  from  8  to  12  per  cent.  In  old  men  the  suprapubic  gives  a 
mortality  of  25  to  30  per  cent.;  the  perineal,  30  to  40  per  cent. 

Crushing  of  the  Vesical  Calculi. — This  is  now  done  in  one  sitting,  the  old 
operation  of  Civiale,  which  required  repeated  crushings,  being  obsolete.  In 
every  case  of  suspected  stone  (as  before  stated)  the  cystoscope  should  be 
used. 

Contra-indications  to  Litholapaxy. — Papilloma,  malignant  tumor,  projecting 
prostatic  lobes,  encysted  stone,  and  diverticuli. 

Litholapaxy  {Bigelow's  operation,  or  rapid  lithotrity)  is  the  operation  for 
removing  a  stone  from  the  bladder  in  one  sitting  by  thoroughly  crushing  the 
stone  and  completely  washing  away  the  fragments.  This  operation  is  wonder- 
fully successful  if  done  by  an  expert.  Few  of  us  do  it  sufificiently  often  to  learn 
how  to  perform  it  with  great  rapidity,  certainty,  and  safety.  It  is  the  best 
operation  in  most  cases  if  performed  by  a  very  skilful  man.  It  is  the  opera- 
tion in  the  majority  of  cases  for  even  the  general  surgeon  to  select,  but  the 
general  surgeon  will  have  better  results  in  certain  difficult  cases  after  suprapubic 
lithotomy  than  after  litholapaxy.  Sir  H.  Thompson  says  this  method  is  suited 
to  29  cases  out  of  30.  Litholapaxy  should  be  employed  if  the  bladder  ^\ill 
hold  at  least  4  oz.  of  fluid  and  is  in  a  fairly  healthy  condition;  if  the  urethra 
is  tolerant  and  permits  freely  the  passage  of  instruments;  if  the  stone  is  not  too 
hard,  does  not  weigh  over  23^^  oz.,  and  is  not  over  2  inches  in  diameter.  It  is 
not  suitable  for  multiple  calculi,  for  large  and  hard  calculi,  for  encysted  stones, 
or  for  a  patient  with  marked  enlargement  of  the  prostate  gland,  with  vesical 
atony,  or  with  cystitis.  An  easily  dilatable  stricture  need  not  prevent  the  sur- 
geon doing  litholapaxy.  The  stricture  can  first  be  dilated,  and  later  Bigelow's 
operation  can  be  performed,  but  firm,  gristly  strictures  demand  a  cutting 
operation.  If  the  urethra  is  intolerant  to  instrumentation,  the  patient  being 
prone  to  febrile  attacks  when  it  is  attempted,  cut  instead  of  crushing.  An  in- 
dividual laboring  under  kidney  disease  will  do  better  after  this  operation  than 
after  cutting  (Cage).  In  diabetes,  locomotor  ataxia,  and  conditions  of  exhaus- 
tion patients  are  best  treated  by  Bigelow's  operation,  unless  cystitis  exists. 

The  Indian  surgeons  have  had  the  most  admirable  results  from  lithol- 
apaxy. It  has  often  been  claimed  that  such  results  were  due  to  racial  pecu- 
liarities of  the  patients  and  various  factors  regarding  their  habits,  diet,  etc. 
The  fact,  however,  that  some  of  these  very  surgeons  have  returned  to  England 
and  repeated  their  triumphs  in  London  shows  how  large  a  part  masterly 
dexterity  played  in  obtaining  success. 


Litholapaxy 


148 1 


J.  A.  Cunningham  ("Brit.  Med.  Jour.,"  Aug.,  1887)  reports  upon  10,073 
Indian  cases  of  litholapaxy.     The  mortality  was  3.96  per  cent. 

Cabot,  of  Boston,  in  116  cases  had  but  4  deaths,  and  2  of  these  were  due  to 
pneumonia. 

The  preparation  of  the  bladder  is  the  same  as  for  lithotomy.  Be  sure  to 
measure  the  stone,  and  to  ascertain  also  whether  a  lithotrite  can  readily  be 
introduced  and  manipulated.  The  instruments  required  are  a 
stone-sound  (see  Fig.  967),  lithotrites  (several  sizes,  Figs. 
969-971),  an  evacuating  bulb  and  tubes  (straight  and  curved. 
Figs.  972,  973),  soft  catheters,  a  glass  irrigator  to  inject  the 
bladder,  and  instruments  in  case  the  surgeon  is  forced  to  cut. 
The  patient  is  anesthetized  and  is  placed  upon  his  back,  a 
pillow  is  inserted  under  the  pelvis,  and  he  is  well  wrapped  up. 
The  urine  is  drawn  and  a  measured  amount  of  warm  boric 
acid  is  allowed  to  flow  into  the  bladder.  This  plan  is  better  than 
having  the  patient  retain  his  urine,  as  in  the  latter  case  there  is 


Fig.  969. — Bigelow's 
lithotrite. 


Fig.  970. — Thompson's 
lithotrite. 


Fig.   971. — Forbes's 
litlhotrite. 


no  certainty  as  to  the  amount  of  fluid  in  the  viscus.  It  is  well  to  introduce  at 
least  5  or  6  oz.  of  fluid,  if  possible.  If  the  bladder  will  not  hold  4  oz.  the  operation 
is  unsafe  (Thompson).  The  lithotrite,  preferably  the  instrument  of  Forbes 
(Fig.  971),  is  now  introduced  the  handle  being  gradually  raised  to  a  vertical 
position  as  the  penis  is  drawn  up  on  the  shaft,  but  not  being  depressed  until  the 
instrument  has  passed  by  its  own  weight  into  the  prostatic  urethra.  Thompson's 
plan  for  catching  the  stone  is  as  follows :  After  introducing  the  lithotrite,  let  its 


1482  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Fig.  972. — Bigelow's  latest  evacuator. 


lower  end  rest  for  a  few  seconds  on  the  bottom  of  the  bladder,  so  that  currents 
will  subside;  then  draw  back  the  male  blade,  wait  a  moment,  close  the  blades, 
and  in  almost  every  instance  the  stone  will  be  caught.     If  the  stone  is  caught, 

press  firmly  to  see  that  the  calculus  is  well 
held,  lock  the  instrument,  and  break  the  for- 
eign body  by  screwing.  When  resistance 
suddenly  ceases  the  stone  has  either  slipped 
or  has  been  crushed;  if  crushed,  the  blades 
should  have  been  felt  forcing  through  the 
stone  and  the  calculus  should  have  been 
heard  to  break.  When  resistance  ceases 
catch  and  crush  again  as  above  directed. 
Rapid  movements  with  the  lithotrite  are 
improper,  as  they  establish  currents  which 
are  apt  to  push  away  the  stone.  If  the  above 
maneuver  does  not  catch  the  stone,  see  if  the 
calculus  is  near  the  neck  of  the  bladder. 
Pull  the  instrument  close  to  the  vesical  neck, 
and  open  it,  not  by  pulling  the  male  blade, 
but  b)^  pushing  the  female  blade.  If  the  op- 
erator still  fails  to  catch  the  stone,  or  if,  after 
crushing,  a  large  fragment  knocks  against  the 
evacuator,  and  this  fragment  cannot  pass,  con- 
duct a  careful  search:  turn  the  blades  to  the 
right  side,  open,  and  close;  then  to  the  left 
side,  open,  and  close;  next  turn  the  point 
around  behind  the  prostate,  open,  and  close. 
After  catching  a  stone  with  the  lithotrite, 
turn  the  instrument  very  slowly,  so  as  to 
detect  the  catching  of  the  bladder  wall  if  it 
has  occurred,  and  crush  the  stone  in  the  middle  of  the  bladder  with  the  blades  up. 
After  crushing  several  times,  proceed  to  evacuate.  Fill  the  aspirator  with  warm 
saline  fluid.     Insert  an  evacuating  catheter,  its  point  being  in  the  center  of  the 


Fig.  973. — Thompson's  evacuator. 


Litholapaxy  in  Male  Children  1483 

bladder,  let  the  fluid  and  fragments  run  out,  and  attach  the  aspirator  to  the 
catheter;  turn  the  valve,  and  compress  and  relax  the  bulb  so  that  an  ounce  or 
more  of  fluid  is  forced  in  at  each  squeeze,  the  compression  coinciding  with 
expiration.  The  debris  falls  into  a  bulb,  and  the  pumping  is  continued  until 
the  fragments  cease  to  pass,  whereupon  the  point  of  the  catheter  is  pushed 
against  the  floor  of  the  bladder  and  another  trial  is  made.  If  fragments  which 
cannot  gain  exit  are  felt  knocking  against  the  tube,  withdraw  the  evacuator, 
crush  again,  and  again  use  the  aspirator.  When  no  more  debris  comes  away 
and  no  more  fragments  are  felt,  withdraw  the  tube  and  carefully  sound  the  blad- 
der. Keyes  advises  the  operator  to  seek  for  a  final  fragment  by  listening 
with  a  stethoscope  while  pumping  at  the  bulb  and  searching  the  bladder  with 
the  tube.  The  amount  of  blood  usually  obscures  a  cystoscopic  view.  This 
operation  will  rarely  occupy  over  forty  minutes,  though  Bigelow  has  protracted 
it  for  three  hours,  the  patient  recovering.  A  serious  complication  is  severe 
bleeding,  due  to  damage  done  with  the  instrument  or  to  the  presence  of  a  tumor 
which  easily  bleeds.  The  injection  of  moderately  hot  water  or  of  adrenalin 
solution  (i  :  10,000)  usually  checks  hemorrhage,  but  if  bleeding  is  dangerous  in 
amount  the  operation  of  litholapaxy  should  be  abandoned  and  suprapubic 
lithotomy  should  be  performed. 

If  clogging  of  the  lithotrite  with  fragments  occurs,  forcible  pushing  of 
the  blades  together  repeatedly  will  probably  amend  it;  but  it  will  never  happen 
if  the  surgeon  uses  a  proper  form  of  instrument.  A  lithotrite  with  a  fenes- 
trated blade  will  not  lock.  Forbes's  lithotrite  is  a  very  powerful  instrument, 
the  blades  of  which  will  not  lock.  If  the  blades  of  a  lithotrite  should  become 
forcibly  and  hopelessly  locked,  make  a  perineal  section,  clear  out  the  blades, 
■close  them,  and  then  withdraw  the  instrument. 

After-treatment. — Put  the  patient  to  bed,  apply  a  bag  of  hot  water  to  the 
hypogastrium,  and  give  him  a  hypodermatic  injection  of  morphin  as  he  re- 
covers from  ether.  Give  a  hot  hip-bath  every  night,  and  administer  liquor 
potassii  citratis  in  moderate  doses  every  day.  If  urethral  fever  occurs,  use 
quinin  and  morphin,  wash  out  the  bladder  several  times  daily  with  warm 
boric  acid  solution,  and  tie  in  a  rubber  catheter.  If  retention  occurs,  use 
the  catheter.  If  cystitis  appears,  treat  as  in  an  ordinary  case.  The  urine 
ceases  to  be  bloody  in  two  or  three  days,  and  the  patient  may  get  up  in  a  week. 
Before  the  case  is  discharged  cystoscopy  should  be  practised  to  be  certain 
that  no  fragments  of  stone  remain. 

Litholapaxy  in  Male  Children. — It  was  once  taught  that  a  child,  because 
of  the  small  size  of  the  bladder,  the  small  diameter  of  the  urethra,  and 
the  readiness  with  which  the  mucous  membrane  is  lacerated  by  even  slight 
violence,  is  a  poor  subject  for  crushing.  Lateral  lithotomy  is  known  to  be 
eminently  successful  when  performed  upon  children.  The  elder  Gross  did  this 
operation  upon  72  children,  with  only  2  deaths.  Keegan,  however,  has  per- 
suaded the  profession  that  rapid  lithotrity  is  perfectly  applicable  to  children. 
He  shows  that  the  bladder  of  a  child  of  even  less  than  two  years  of  age  is  quite 
large  enough  to  allow  the  surgeon  to  manipulate  an  instrument;  that  the  mucous 
membrane  is  in  no  danger  if  the  operator  is  careful,  and  that  the  urethra  is  by 
no  means  so  small  as  was  supposed.  The  urinary  meatus  must  often  be  incised, 
and  after  doing  this,  Keegan  states,  there  can  be  passed  in  a  boy  of  from  three 
to  six  years  a  No.  7  or  8  lithotrite  (English),  and  in  a  boy  of  from  eight  to  ten 
years  a  No.  10  or  even  No.  14.  It  is,  however,  just  to  state  that  the  operation 
is  more  delicate  than  a  like  procedure  on  older  persons,  and  Ihat  no  one  is  justi- 
fied in  doing  it  who  has  not  had  considerable  experience  in  adult  cases.  Further- 
more, it  should  be  noted  that  Keegan's  mortality  by  this  operation  has  been  4.3 
per  cent.,  while  Gross's  mortality  from  lateral  lithotomy  on  children  has  been 
under  3  per  cent. 

Special  points  relating  to  litholapaxy  on  male  children  are  as  follows :  use  well- 


1484  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

fenestrated  lithotrites;  have  a  stylet  to  punch  out  the  fragments  blocking  the 
evacuator;  and  crush  the  stone  to  a  line  mass.  There  can  usually  be  employed 
a  No.  8  lithotrite  and  a  No.  8  evacuating  tube  (English  scale). 

Perineal  Lithotrity  {Keith's  Operation). — This  operation  is  employed  by 
some  surgeons  in  dealing  with  very  hard  or  very  large  calculi  in  male  adults, 
or  in  cases  in  which  it  is  impossible  to  introduce  a  lithotrite  into  the  bladder. 
Keith's  operation  consists  in  opening  the  urethra  from  the  perineum,  passing 
a  lithotrite  through  the  wound,  into  the  urethra  and  along  the  urethra  into 
the  bladder,  and  crushing  the  stone,  introducing  an  evacuator  and  removing 
the  fragments.  In  Keith's  operation  the  incision  is  median  and  opens  the  mem- 
branous urethra.  In  very  large  stones  Milton  thinks  the  surgeon  should 
open  the  bladder  as  in  ordinary  lateral  lithotomy,  introduce  a  lithotrite  through 
the  incision,  and  crush  the  stone  before  extracting  it,  thus  avoiding  the  inflic- 
tion of  injury  upon  important  structures. 

Operation  for  Stone  in  Women. — If  the  stone  be  small,  give  the  patient 
ether,  place  her  in  the  lithotomy  position,  dilate  the  urethra  by  the  uterine 
dilator  until  it  admits  the  index-finger,  and  remove  the  stone  by  the  linger, 
the  scoop,  or  the  forceps.  If  the  stone  is  found  to  be  too  large  to  pass,  crush 
it  by  a  lithotrite  and  get  rid  of  the  debris  by  the  evacuator.  Large  stones 
(2  oz.)  may  require  suprapubic  lithotomy.  Vaginal  lithotomy  is  never  re- 
quired. If  done,  it  is  very  likely  to  leave  as  a  legacy  a  vesicovaginal  fistula. 
In  female  children  dilate  the  urethra,  crush  the  stone,  and  evacuate. 

Cystotomy  or  Cystostomy. — These  terms  mean  the  opening  of  the  bladder. 
If  the  opening  be  made  for  diagnosis  or  treatment  and  be  then  closed  or  allowed 
to  close,  the  operation  is  a  cystotomy.  If  the  wound  be  deliberately  kept  open 
it  is  a  cystostomy.  The  bladder  may  be  opened  for  drainage,  for  diagnosis,  for 
the  removal  of  stones  or  tumors,  or  for  the  treatment  of  ulcers.  This  opening 
may  be  done  by  (i)  a  suprapubic  cut  (as  in  suprapubic  lithotomy), (  2)  a  lateral 
perineal  cut  (as  in  lateral  lithotomy),  or  (3)  a  median  perineal  cut  (as  in  median 
lithotomy). 

The  operation  may  be  completed  in  one  sitting,  or  the  bladder  may  be 
only  exposed,  the  opening  of  it  being  delayed  for  several  days  until  it  becomes 
adherent  to  the  margins  of  the  wound  (Senn's  operation).  Senn's  operation 
prevents  infiltration  of  urine  into  the  prevesical  space,  and  it  is  advisable  to 
select  it  if  the  urine  be  very  foul. 

A  sinus  may  persist  after  suprapubic  cystotomy,  but  usually  the  wound 
heals  unless  it  be  kept  open  by  some  expedient. 

The  effects  of  suprapubic  drainage  are  very  beneficial  in  cases  of  chronic 
cystitis  associated  with  hypertrophy  of  the  prostate  gland,  the  urine  being  foul. 
Drainage  causes  the  urine  to  become  clear  and  the  mucous  membrane  of  the 
bladder  to  become  normal.  If  the  opening  be  made  as  a  permanent  drain,  there 
will  usually  be  incontinence,  as  the  new  channel  has  no  sphincter  action  (Dand- 
ridge).     Figures  977  and  978  show  tubes  for  prolonged  drainage. 

Suprapubic  Cystotomy  (or  Cystostomy). — The  operation  is  employed  to 
allow  the  surgeon  to  explore  the  bladder,  to  treat  an  ulcer,  to  provide  drainage, 
or  to  remove  a  tumor.  If  the  operation  be  for  calculi,  it  is  known  as  suprapubic 
lithotomy  (see  page  1478).  After  the  bladder  is  opened  its  interior  can  be 
illuminated  by  the  rays  of  an  electric  lamp,  which  is  fastened  with  a 
mirror  to  the  forehead  of  the  operator.  If  an  ulcer  be  found,  it  is  scraped  with 
a  curet  or  a  spoon.  Most  cases  of  tumor  require  suprapubic  cystotomy.  It  is 
true  that  a  small  smgle  growth  at  the  vesical  neck  is  accessible  by  median  cys- 
totomy, but  the  area  for  manipulation  is  very  narrow  and  the  growth  cannot 
be  seen.  Every  large  growth,  all  cases  of  multiple  tumors,  and  all  cases  of 
tumor  in  individuals  with  great  depth  of  perineum  or  with  enlarged  prostate 
require  suprapubic  cystotomy,  an  operation  which  allows  one  to  feel  and  to 
see  the  growth,  which  gives  room  for  manipulation,  and  which  permits  thorough 


Median  Cystotomy  (or  Cystostomy) 


1485 


exploration  of  the  entire  bladder.  The  patient  is  put  in  the  Trendelenburg 
position  if  water  distention  be  used,  but  is  placed  horizontally  if  air  distention 
be  employed.  After  opening  the  bladder  as  for  stone  (seepage  1479),  hold 
the  edges  of  the  incision  apart  by  means  of  a  speculum  (speculum  of  Keen 
or  Watson)  or  by  retractors,  and  reflect  the  electric  light  into  the  wound. 
Growths  when  seen  can  be  twisted  off,  a  pair  of  forceps  holding  the  base  and 
another  pair  being  used  to  twist,  but  after  removal  by  twisting  they  will  always 
recur  unless  the  base  and  the  mucous  membrane  about  the  base  be  removed. 
Broad  malignant  growths  may  require  partial  cystectomy.  Some  growths 
(as  inoperable  cancer)  are  removed  piece  by  piece  with  Thompson's  forceps  (Figs. 
974-976),  the  base  of  the  tumor  being  scraped.  Such  a  procedure  is  merely 
palliative.  Soft  growths  are  scraped  away  by  a  curet,  a  spoon,  or  the  finger- 
nail. If  bleeding  be  severe,  check  it  by  pressure,  by  hot  water,  by  a  i :  10,000 
solution  of  adrenalin  chlorid,  or  even  by  the  actual  cautery.     In  some  cases  the 


Figs.  974-976. — Thompson's  vesical  forceps  for  removing  growths  in  the  bladder;  for 
growths  close  to  the  neck  of  the  bladder,  with  separation  of  the  blades,  to  avoid  nipping  the 
neck  of  the  bladder. 

wound  is  allowed  to  heal  rapidly.  In  others  the  bladder  is  drained  for  a  con- 
siderable time.  In  some  it  is  kept  open  permanently.  Permanent  drainage  is 
desirable  in  some  cases  of  enlarged  prostate,  and  in  such  cases  Senn's  tube  (Figs. 
977  and  979)  or  Stevenson's  tube  (Figs.  978  and  980)  may  be  employed. 

Median  Cystotomy  (or  Cystostomy). — The  same  incision  is  made  in  the 
perineal  raphe  for  median  cystotomy  as  for  median  lithotomy.  A  grooved 
staff  is  introduced  and  is  hooked  up  under  the  pubes;  an  incision  is  made  into 
the  membranous  urethra,  and  is  extended  backward  for  ^  inch,  and  a  finger 
is  carried  into  the  bladder.  If  searching  for  a  growth,  find  it  by  the  finger. 
The  usual  rule  has  been  to  catch  it  in  Thompson's  forceps  and  twist  it  off. 
Such  an  operation  is  totally  inefficient.  Soft  growths  may  be  scraped  away. 
Stop  ^  bleeding  by  digital  pressure  or  by  injections  of  hot  water  or  adrenalin 
chlorid  (1:10,000).    Median  cystotomy  does  not  allow  anything  like  the  free- 


i486  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

dom  of  access  given  by  suprapubic  cystotomy,  and  the  latter  operation  is  the 
best  for  tumor  cases.     The  median  operation  may  be  used  for  drainage. 


Fig.  977.— Senn's  silver  tube. 


Fig.      978. — Stevenson's     suprapubic 
drainage-tube. 


Growths  in  the  Female  Bladder. — It  was  long  the  custom  to  dilate  the  urethra 
as  in  a  case  of  stone,  and  scrape,  twist,  or  pull  the  growth  away  or  ligate  it. 
This  plan  is  inefficient,  as  by  it  the  base  of  the  tumor  is  not  removed.     It  is 


Fig.  979. — Senn's  tube  applied.  The 
instrument  does  not  press  upon  the  sen- 
sitive neck  of  the  bladder. 


Fig.  980. — Stevenson'-  m,  clrain- 

age-tube  in  place  and  attached  to  a  receptacle 
for  urine. 


usually  best,  if  high  frequency  electro-coagulation  fails  or  will  evidently  be  use- 
less, to  perform  a  suprapubic  operation.  If  the  growth  is  large  or  if  there  are 
multiple  growths,  always  perform  suprapubic  cystotomy. 


Diseases   and    Injuries    of   the   Urethra,   Penis,   Testicle,   Prostate, 
Seminal    Vesicle,    Spermatic    Cord,    and    Tunica    Vaginalis 

Injuries  of  the  p)enis  and  urethra  may  arise  from  traumatism  to  the 
perineum  or  the  penis,  from  cuts  and  twists  of  the  penis,  from  the  popular 
"breaking"  of  a  chordee,  from  tying  string  around  the  organ,  from  forcing  rings 
over  it,  from  the  passage  of  instruments,  or  from  the  impaction  of  calculi.     Vio- 


Rupture  of  the  Urethra  1487 

lence  inflicted  upon  an  erect  penis  may  fracture  the  corpora  cavernosa.  The 
writer  saw  one  man  with  a  glass  rod  broken  off  in  the  canal,  he  having  been 
in  the  habit  of  introducing  it  at  the  dictate  of  morbid  sexual  excitement.  A 
patient  in  the  Insane  Department  of  the  Philadelphia  Hospital  pushed  over  his 
penis  a  ring  which  ulcerated  into  the  urethra.  These  injuries  are  treated 
on  general  principles. 

Perineal  Bruises. — If  the  perineum  be  bruised  without  rupture  of  the 
urethra,  the  perineum  and  scrotum  swell  and  become  discolored;  water  is  passed 
with  difficulty  because  the  extravasated  mass  of  blood  in  the  periurethral  tis- 
sues compresses  the  canal  more  or  less;  the  water  is  not  bloody;  and  there  is 
severe  pain  and  much  shock.  Some  authors  include  under  rupture  those  cases 
in  which  laceration  of  the  spongy  tissue  occurs,  without  involvement  of  the 
mucous  membrane  or  of  the  fibrous  coat,  but  they  are  prc^erly  contusions. 

Treatment  of  Bruises  and  Wounds. — Place  the  patient  in  bed  and  establish 
reaction,  and  when  reaction  is  complete  employ  opiates  for  the  relief  of  pain. 
Apply  an  ice-bag  to  the  perineum.  If,  notwithstanding  these  measures,  swell- 
ing continues,  introduce  a  silver  catheter  (No.  12  English),  tie  it  in,  and  make 
pressure  upon  the  perineum  by  a  firmly  applied  T-bandage  or  by  a  crutch  braced 
against  the  foot-board  of  the  bed.  Even  when  swelling  is  sHght,  retention  of 
urine  may  occur  from  projection  of  a  submucous  blood-clot  into  the  canal  of 
the  urethra.  In  some  cases  it  may  become  necessary  to  incise  the  perineum  and 
evacuate  the  blood-clot.  After  twenty-four  hours  have  passed,  if  hemorrhage 
has  ceased,  substitute  a  hot- water  bag  for  the  ice-bag,  and  empty  the  bladder 
every  6  hours  by  a  soft  catheter.  Occasionally,  though  rarely,  an  abscess  forms. 
Punctured  wounds  of  the  urethra  require  ordinary  dressings.  Incised  wounds  of 
the  urethra,  when  longitudinal,  are  closed  by  suture.  Healing  is  rapid  and  iU 
consequences  are  not  to  be  feared.  Stricture  does  not  follow.  When  the  wound 
is  transverse,  introduce  a  catheter,  suture  the  wound  over  the  instrument,  and 
remove  the  catheter  at  the  end  of  the  third  day.  If  a  catheter  cannot  be  in- 
troduced, employ  sutures,  but  at  the  first  evidence  of  extravasation  open  the 
wound,  and  if  drainage  is  not  free  perform  external  perineal  urethrotomy. 

Rupture  of  the  Urethra. — By  this  term  is  meant  a  lacerated  or  a  con- 
tused wound  of  the  urethra,  destroying  partially  or  entirely  the  integrity  of 
the  canal.  A  lacerated  wound  may  be  induced  by  fracture  of  the  cavernous 
bodies  during  erection,  the  symptoms  being  severe  hemorrhage,  intense  pain, 
retention  of  urine,  and  inability  to  pass  an  instrument;  infiltration  of  urine 
occurs,  and  gangrene  is  a  common  result.  The  writer  has  seen  i  case  of  rup- 
ture of  the  penile  urethra  due  to  a  man's  slipping  while  shaving,  the  penis  being 
caught  in  a  partially  open  drawer,  the  drawer  being  shut  by  his  body  coming 
against  it.  Rupture,  however,  is  almost  invariably  located  in  the  perineum, 
and  it  arises  when  the  urethra  is  suddenly  and  forcibly  pressed  against  the 
arch  of  the  pubes  by  a  blow,  by  a  kick,  or  by  falling  astride  a  beam  or  a  fence- 
raU  or  on  a  wagon  wheel.  Retention  of  urine  due  to  stricture  may  lead  to 
extravasation  of  urine.  The  lesion  of  urethral  rupture  consists,  in  some  cases, 
of  laceration  of  the  spongy  tissue  and  the  mucous  membrane,  a  cavity  being 
formed  which  communicates  with  the  canal,  and  which  fills  with  urine  during 
micturition.  In  other  cases,  not  only  the  spongy  tissue  and  the  urethral  mucous 
membrane  are  rent  asunder,  but  the  fibrous  coat  is  also  torn,  the  canal  opening 
directly  into  the  perineal  tissues,  in  which  forms  a  huge  cavity  that 
fills  with  blood  and  later  with  urine  and  pus.  The  urethra  may  be  torn  en- 
tirely across,  but  in  most  cases  a  small  portion  at  least,  of  its  circumference 
is  uninjured.  Rupture  never  occurs  primarily  and  alone  in  the  prostatic 
urethra.  Some  think  it  is  extremely  rare  in  the  membranous  urethra  unless 
due  to  pelvic  fracture.  I  believe  that  it  occurs  not  unusually  in  the  membran- 
ous urethra.  When  we  recall  that  this  is  the  fixed  portion  of  the  tube  we  should 
expect  rupture  here  rather  than  elsewhere.     It  is  very  unusual  in  the  penile 


1488  Diseases  and  Injuries  of  the  Genito-urinary  Organs 


urethra.     The  seat  of  rupture  in  the  great  majority  of  cases  is  in  the  region  of 
the  bulb.     Very  rarely  is  the  skin  broken. 

The  symptoms  of  rupture  of  the  fixed  urethra  are  considerable  pain,  ag- 
gravated by  motion,  pressure,  and  attempts  to  pass  water;  decided  shock;  in 
some  cases'  micturition  is  still  possible,  blood  preceding  and  also  discoloring 
the  stream,  for  some  blood  usually  runs  into  the  bladder;  retention  of  urine 
quickly  arises;  in  a  vast  majority  of  the  cases  retention  is  absolute  from  the 
very  first,  and  it  is  due  to  the  interruption  in  the  integrity  of  the  canal  and  to 
the  occlusion  of  the  channel  by  blood-clots.  Bleeding,  which  is  usually  free, 
lasts  for  several  hours,  some  little  blood  generally  appearing  externally  and 
much  being  retained  in  the  perineum,  inducing  progressive  swelling.  The 
presence  of  a  large  swelling  is  regarded  as  evidence  of  urethral  rupture.  The 
blood  which  is  effused  in  the  perineum  may  extend  under  the  fascia  to  the  penis 
and  scrotum.  The  swelling  soon  becomes  reddish,  purple,  or  even  black,  pressure 
upon  it  is  apt  to  cause  blood  to  run  from  the  meatus,  and  it  is  enlarged 
when    attempts   are   made    to    urinate.     After   a    time,  if  the   surgeon   does 

not  act,  the  urine  fills  the 
perineal  cavity  and  widely 
infiltrates,  and  there  ensue 
gangrene,  sloughing,  and  sep- 
sis, life  being  endangered  or 
fistulae  being  left  as  legacies. 
The  course  of  the  extra vasated 
urine  will  often  enable  one  to 
locate  the  seat  of  injury.  In 
rupture  of  the  membranous 
urethra,  if  uncomplicated,  the 
urine  remains  between  the  two 
layers  of  the  triangular  liga- 
ment until  a  channel  is  opened 
for  it  by  sloughing  or  by  the 
knife.  When  extravasation 
occurs  behind  the  posterior 
layer  of  the  ligament  the  urine 
finds  its  way  to  the  perineum 
in  the  neighborhood  of  the 
anus.  When  the  rupture  is 
in  front  of  the  anterior  layer 
of  the  ligament  the  urine,  directed  by  the  deep  layer  of  the  superficial  fascia, 
finds  it  way  into  the  scrotum  and  up  on  the  belly,  but  does  not  pass  into  the  thighs 
(Fig.  981).  A  contusion  is  distinguished  from  a  rupture  by  the  facts  that  in 
the  former  the  perineal  swelling  is  not  very  extensive  and  does  not  enlarge  on 
attempting  micturition,  while  in  the  latter  it  is  extensive  and  does  enlarge  on 
attempting  to  pass  water.  Furthermore,  contusion  does  not  cause  urethral 
hemorrhage,  while  rupture  does.  A  contusion  sometimes,  but  not  often,  prevents 
the  passage  of  a  catheter;  a  rupture  almost  always,  but  not  invariably,  does  so. 
The  mortality  from  severe  rupture  with  extravasation  is  about  14  per  cent. 
(Kaufman). 

Treatment. — In  some  very  rare  cases  it  is  possible  to  suture  the  urethra,  and 
this  procedure  should  be  carried  out  when  possible.  In  order  to  suture,  per- 
form suprapubic  cystotomy  and  also  make  a  perineal  section.  Find  the  pos- 
terior end  of  the  ruptured  urethra  in  the  perineum  by  passing  a  catheter  from 
the  bladder  into  the  urethra.  Suture  by  way  of  the  perineum  and  with  silk. 
The  sutures  pass  through  all  of  the  coats  of  the  urethra.  The  roof  of  the  canal 
is  sutured  first,  then  a  steel  sound  is  introduced  from  the  meatus,  and  the 
urethra  is  sutured  around  the  instrument.     The  sound  is  withdrawn  and  the 


Fig.  981.- 


-Rupture  of  the  urethra  and  extravasation 
of  urine. 


Symptoms  and  Treatment  of  Foreign  Bodies  in  the  Urethra    1489 

bladder  is  drained  by  Cathcart's  siphon  as  illustrated  in  Fig.  968  or  by  a  double 
tube.  In  recent  cases  of  ruptured  urethra  the  usual  treatment  is  as  follows: 
Immediately  perform  median  perineal  section  and  turn  out  the  clot;  trim  off 
lacerated  edges;  find  the  proximal  end  of  the  urethra,  pass  a  catheter  from  the 
meatus  into  the  bladder,  and  leave  it  in  situ  until  healing  has  begun  around 
it.  If  the  catheter  cannot  be  passed  from  the  meatus,  open  the  bladder  above 
the  pubes  and  find  the  proximal  end  of  the  torn  urethra  by  retrograde  cathe- 
terization. In  retrograde  catheterization  we  push  an  instrument  from  the 
bladder  into  the  wound  and  use  it  to  guide  a  catheter  from  the  meatus  into 
the  bladder.  When  rupture  occurs  back  of  a  stricture  it  is  a  good  plan  to  excise 
the  cicatricial  tissue.  In  cases  with  extravasation  make  a  median  incision  and 
numerous  transverse  cuts  to  secure  drainage  for  areas  of  retained  urine  or  pus. 
Then  at  once  perform  suprapubic  cystotomy.  Drain  suprapubically  and  from 
the  perineum  for  about  two  weeks,  by  which  time  sloughing  tissue  will  have 
separated.  Then  find  the  posterior  urethra  by  retrograde  catheterization  and 
do  a  perineal  operation  to  repair  the  damaged  urethra.  (See  Eugene  Fuller,  in 
"New  York  Med.  Jour.,"  Nov.  23,  1901.)  The  wound  is  packed  with  iodoform 
gauze,  and  the  bowels  are  tied  up  with  opium  for  a  few  days.  Some  surgeons 
strongly  disapprove  of  the  custom  of  retaining  the  catheter,  believing  that  the 
instrument  does  no  real  good,  as  urine  is  certain  to  get  between  the  catheter 
and  the  walls  of  the  urethra.  They  think  it  is  quite  enough  to  stuff  the  wound 
with  gauze,  the  patient  urinating  through  the  wound  for  the  first  few  days,  after 
which  time  a  catheter  is  used  at  regular  intervals.  Whatever  method  is  em- 
ployed, healing  will  require  from  six  to  eight  weeks,  and  the  patient  m-ust  during 
the  rest  of  his  life,  from  time  to  time,  introduce  large-sized  bougies. 

Foreign  Bodies  in  the  Urethra. — These  bodies  may  be  calculi,  bodies 
introduced  by  injury,  as  shot,  bone,  etc.,  bodies  entering  from  a  fistulous  opto- 
ing  into  the  rectum,  or  bodies  introduced  from  the  meatus,  as  broken  bits  of 
catheters,  straws,  pins,  etc. 

The  symptoms  and  treatment  vary  with  the  size  and  the  nature  of  the  body. 
Sometimes  there  are  almost  no  symptoms;  at  other  times  there  are  found 
great  pain,  retention  of  urine,  and  hemorrhage.  Examination  is  made  by  the  ure- 
throscope, by  feeling  carefully  with  a  finger  in  the  rectum,  and  by  searching 
very  gently  with  a  sound,  taking  care  not  to  push  the  body  back.  In  some 
cases  the  body  can  be  removed  by  aid  of 'the  urethroscope.  Employ  this  plan 
if  possible.  If  it  is  not  possible,  try  the  following  plan:  If  the  bladder  is  well 
filled  with  water  when  the  body  becomes  impacted,  inject  a  little  oil  into  the 
meatus,  close  the  lips  with  the  fingers,  and  direct  the  patient  to  attempt 
forcibly  urination,  the  surgeon  opening  the  meatus  when  the  urethra  is  widely 
distended,  the  foreign  body  being  often  forced  out.  If  this  maneuver  fails, 
and  the  foreign  body  be  impacted  in  the  pendulous  urethra,  prevent  its  back- 
ward passage  by  at  once  tying  a  rubber  tube  around  the  penis.  Try  to  squeeze 
the  body  out,  and,  if  unsuccessful,  endeavor  to  catch  it  with  a  wire  loop,  with 
a  scoop,  or  with  the  long  urethral  forceps.  If  these  methods  fail,  cut  down  upon 
the  body  and  remove  it,  dividing  any  existing  stricture.  If.it  be  lodged  just 
back  of  the  meatus,  incision  of  the  meatus  will  permit  extraction.  If  a  hairpin 
is  in  the  canal,  the  ends  of  the  pin  are  almost  always  pointing  to  the  meatus; 
to  prevent  them  catching  on  attempted  withdrawal,  the  penis  must  be  squeezed 
to  approximate  the  ends  of  the  pin,  and  when  they  are  adjacent  a  part  of  a  silver 
catheter  is  slipped  over  to  retain  them  in  this  position,  when  the  pin  can  be 
extracted.  If  this  fails,  drag  the  penis  against  the  belly,  by  rectal  touch  force 
the  sharp  ends  of  the  pin  out  through  the  integument,  cut  one  end  ofi",  and  then 
withdraw  the  other.  An  ordinary  large-headed  pin  is  forced  out  in  the  same 
way,  and  when  the  head  is  turned  externally  it  is  extracted  by  way  of  the 
meatus.  If  a  hard  or  sharp  foreign  body  be  lodged  in  the  prostatic  urethra,  do 
not  catch  it  with  an  instrument  or  try  to  drag  it  forward.  To  do  so  will 
94 


I490  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

be  apt  to  tear  the  membranous  urethra.  It  is  better  to  push  it  into  the  bladder 
and  remove  it  later  by  cutting  or,  if  it  be  a  stone,  by  crushing  (H.  Hartmann, 
in  "La  Presse  Med.,"  July  24,  1901).  If  a  lithotrite  loaded  with  fragments  be 
caught  in  the  urethra,  the  surgeon  must  perform  a  perineal  section,  to  enable 
him  to  clean  and  close  the  blades.  After  the  blades  have  been  closed  the 
instrument  may  be  easily  withdrawn. 

Urethrorrhea  is  not  urethral  inflammation,  but  is  a  condition  of  sensi- 
tiveness of  the  urethra  and  oversecretion  of  the  glandular  elements.  It  may 
be  due  to  masturbation,  sexual  excess,  and  also,  as  Sturgis  points  out,  to  with- 
drawal during  sexual  intercourse,  and  to  ungratified  sexual  passion.  A  drop 
or  two  of  transparent  mucus  is  found  at  the  meatus  in  the  morning,  and  a 
considerable  amount  may  flow  away  while  straining  at  stool  or  upon  the  dimi- 
nution of  an  erection.  This  flow  at  stool  is  often  called  defecation  spermat- 
orrhea. This  discharge  stains,  but  does  not  stiffen  linen  (Sturgis).  The 
discharge  contains  mucus,  mucous  corpuscles,  epithelial  cells,  but  no  gonococci 
or  pus  organisms.  The  patient  may  be  well  in  all  other  respects,  but  in  many 
cases  there  are  neurasthenic  symptoms,  sexual  weakness,  or  even  impotence. 
It  is  well  to  explain  to  the  patient  that  the  overaction  of  the  muciparous  glands 
is  Nature's  effort  to  facilitate  the  passage  of  the  fluid  of  the  orgasm  and  to 
alkalinize  an  acid  urethra  which  would  inhibit  the  activity  of  spermatozoids. 
Quacks  fatten  on  these  unfortunates.  This  condition  may  be  readily  distin- 
guished from  prostatorrhea  by  the  absence  of  Bottcher's  crystals  (see  page 
1524)  and  from  that  very  rare  condition,  spermatorrhea,  by  the  absence  of  sper- 
matozoids. 

Treatment.— In  an  uncomplicated  case  improvement  or  cure  will  follow 
the  abandonment  of  evil  habits  and  the  systematic  passage  of  steel  sounds. 
If  complications  arise,  they  must  be  treated. 

Urethritis,  or  Inflammation  of  the  Urethra. — Urethral  inflammations 
can  be  divided  into  two  classes:  (i)  simple  or  non-specific,  in  which  infection 
is  due  alone  to  pyogenic  cocci  (particularly  the  Bacillus  coli  communis  and 
the  Staphylococcus  pyogenes),  and  (2)  specific,  in  which  the  gonococcus  is 
present. 

Non-venereal,  non-specific,  pyogenic,  or  simple  urethritis  may  be  due  to 
several  causes,  such  as  traumatism ;  great  acidity  of  the  urine;  chancre  in  the  ure- 
thra; contact  with  menstrual  fluid,  leukorrheal  discharge,  the  discharge  from 
malignant  disease  of  the  uterus,  ordinary  pus,  or  acrid  vaginal  discharge;  the 
passage  of  instruments;  the  administration  of  irritant  diuretics;  strong  injec- 
tions; worms  in  the  rectum;  a  febrile  malady;  venereal  excess  and  masturba- 
tion; the  passage  or  impaction  of  foreign  bodies,  and  papillomata  of  the  urethra. 
A  temporary  and  mild  urethritis  sometimes  accompanies  early  syphilitic  erup- 
tions. Simple  urethritis  is  less  severe  and  prolonged  than  gonorrheal  urethritis, 
though  clinically  in  the  early  stage  the  physician  cannot  invariably  distinguish 
between  the  two  forms.  The  diplococci  of  gonorrhea  are  never  found  in  the 
discharge  of  simple  urethritis,  although  there  may  be  numerous  other  diplococci. 
In  medicolegal  cases  testimony  is  not  admitted  as  to  the  presence  or  absence  of 
diplococci,  as  judges  do  not  admit  that  their  presence  proves  or  their  absence 
disproves  gonorrhea.  In  the  non-specific  inflammation  pus  is  not  always 
present,  many  cases  stopping  short  of  pus  formation  after  a  varying  period  of 
catarrh,  but  any  catarrh  may  become  purulent.  A  simple  urethritis  may  be 
caused  or  may  be  prolonged  for  an  indefinite  period  by  the  presence  of  large 
amounts  of  oxalate  in  the  urine  or  the  existence  of  the  uric-acid  diathesis  (see 
Gouty  Urethritis). 

Treatment. — Seek  for  the  cause  and  remove  it.  Correct  any  abnormal 
condition  of  the  urine  by  means  of  suitable  diet,  drugs,  and  mode  of  life.  Mild 
astringent  injections  are  useful.  It  may  be  necessary  to  flush  the  urethra 
repeatedly  with  a  solution  of  silver  nitrate  (i:  8000). 


Examination  of  a  Patient  in  Whom  a  Urethral  Discharge  Exists  1491 

Traumatic  Urethritis. — The  onset  of  pain  in  traumatic  urethritis  is  coincident 
with  the  introduction  of  the  foreign  body.  The  discharge,  which  may  be  bloody, 
mucous,  mucopurulent,  or  purulent,  comes  on  within  twenty-four  hours. 

Treatment. — If  the  inflammation  be  slight,  px-escribe  diluent  drinks,  paregoric,- 
a  saline,  or  the  following: 

I^.     Tinct.  belladonna; f 3ss; 

Sodii  bromid 3  iv; 

Tinct.  opii  camphorat f  5  j; 

Syrupus  zingib f  5ss; 

Aqua;  destil q.  s.  ad.  f5vj. — M. 

Sig. — A  tablespoonful  every  six  hours. 

If  the  inflammation  be  severe,  put  the  patient  to  bed,  apply  hot  fomentations 
to  the  perineum,  give  diluent  drinks,  employ  suppositories  of  opium  and  bella- 
donna, and  watch  for  fever  and  other  complications. 

Gouty  Urethritis. — This  condition  first  manifests  itself  in  the  posterior  ure- 
thra, not  in  the  anterior,  as  does  clap.  Its  symptoms  are  great  vesical  irrita- 
bility; pain  on  urination;  discharge,  usually  scanty,  associated  with  uric  acid  in 
the  urine  and  perhaps  joint  symptoms  of  gout.  The  treatment  comprises  dieting 
and  the  usual  remedies  for  gout.  Purgatives  are  given  freely,  and  full  doses 
of  colchicum,  piperazin,  uro tropin,  or  the  alkalis;  hot  baths,  low  diet,  diluent 
drinks,  and  diaphoretics  are  indicated.  A  chronic  discharge  from  the  prostatic 
region  is  apt  to  linger;  for  this  there  is  nothing  better  than  the  usual  gouty 
remedies  and  saline  waters  with  copaiba,  cubebs,  or  sandalwood  oil.  In  many 
cases  it  is  necessary  to  flush  the  urethra  once  a  day  with  a  solution  of  silver 
nitrate  (1:8000). 

Eczematous  Urethritis. — Berkley  Hill  states  that  this  disease  is  very  obsti- 
nate, is  probably  associated  with  gout,  and  is  met  with  in  adults  of  full  habit  or 
who  are  beer-drinkers  and  who  have  eczema  of  the  surface  of  the  body.  He 
states  also  that  the  glans  penis  near  the  meatus  is  red  and  tender,  and  that  the 
interior  of  the  urethra  is  in  the  same  condition.  Pain  is  constant,  and  it  is 
aggravated  by  micturition.  The  discharge  is  scanty.  The  treatment  comprises 
injections  of  cold  water  or  irrigation  with  iced  water,  and  internally  the  adminis- 
tration of  arsenic  with  the  alkalis. 

Tuberculous  urethritis  is  due  to  a  tuberculous  ulcer,  which  is  most  apt  to 
be  seated  near  the  vesical  neck.  There  is  a,  little  pain  on  micturition,  but 
there  is  intense  pain  at  one  spot  on  passing  a  bougie.  The  discharge  is  slight 
and  at  times  bloody.  The  bladder  is  very  irritable,  and  severe  cystitis  arises 
and  persists.  The  treatment  includes  warmth,  nutritious  diet,  and  cod-liver 
oil,  curettement,  and  local  applications  of  iodoform  through  a  urethroscope, 
and  living  as  much  as  possible  out  of  doors.  The  climate  of  southern  California 
is  peculiarly  well  suited  to  these  cases.  The  bladder  is  washed  out  once  a  day 
with  boric  acid  solution.  Iodoform  emulsion  is  injected  daily.  Tuberculin 
may  prove  of  value.  After  a  time  the  surgeon  will  probably  be  forced  to  drain 
by  perineal  or  suprapubic  cystotomy  (see  Tuberculous  Cystitis,  pages  1472  and 
1473)- 

Pyogenic  Chancroidal  Urethritis. — This  condition  is  sometimes  seen  in 
association  with  chancroid  of  the  urinary  meatus. 

Pyogenic  Urethritis  of  Urethral  Chancre. — A  yrethritis  may  occur  in  this 
condition. 

Pyogenic  Syphilitic  Urethritis. — A  temporary  and  mild  urethritis  sometimes 
accompanies  early  syphilitic  eruptions. 

Examination  of  a  Patient  in  Whom  a  Urethral  Discharge  Exists. — 
Learn  accurately  the  history.  Obtain  some  of  the  discharge  and  examine  an 
unstained  slide  and  a  slide  stained  for  gonococci.  In  some  cases  take  cultures. 
Learn  the  amount  of  the  twenty-four-hour  urine  and  study  a  sample  chemically 


1492  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

and  microscopically,  being  sure  to  determine  the  amount  of  urea.  Learn  if 
the  discharge  discolors  or  stiffens  linen;  if  it  is  only  found  in  the  morning; 
if  it  simply  glues  the  lips  of  the  meatus  together;  if  it  is  seen  during  the  day; 
if  it  is  noted  particularly  or  only  after  sexual  excitement  or  straining  at  stool. 
Inquire  as  to  pain,  frequency  of  micturition,  passage  of  blood,  nocturnal  emis- 
sions, manner  of  urinating,  etc.  In  many  cases  insert  a  linger  in  the  rectum, 
feel  the  prostate  and  vesicles,  massage  them,  and  see  if  discharge  appears  at 
the  meatus  after  stripping  the  penis.  If  discharge  does  appear,  collect  a 
specimen  and  examine  it.  In  some  cases  it  is  necessary  to  pass  a  sound.  Care- 
fully cleanse  the  meatus,  glans,  prepuce,  and  urethra  before  passing  a  sound. 
Cleanse  the  meatus,  glans,  and  prepuce  with  a  i:  6000  solution  of  corrosive 
sublimate.  Irrigate  the  urethra  with  boric  acid  solution  and  fill  and  clean  the 
urethra  with  emulsion  of  iodoform  and  glycerin  (5  per  cent.),  and  after  using 
the  instrument  irrigate  again  with  boric  acid  solution  (Valentine's  method). 
Examine  the  urine  by  the  three-glass  test. 

The  Three-glass  Test  (Valentine's  Plan). — Take  as  many  3-oz.  tubes  as 
are  required  to  receive  all  the  urine  from  the  bladder.  The  first  tube  contains 
the  washings  from  the  anterior  urethra ;  the  second  and  other  tubes,  additional 
material  from  the  bladder;  the  last  tube  contains  material  expressed  from 
the  posterior  urethra,  prostate,  and  seminal  vesicles.  Examine  the  urine 
and  the  sediment  in  the  first  two  glasses  and  in  the  last  glass.  Note  particularly 
if  shreds  are  present.  The  shreds  of  gonorrhea  are  white  in  color  and  of 
variable  length,  and  float  in  the  urine.  They  are  composed  of  pus-corpuscles 
and  of  epithelial  cells  which  have  undergone  fatty  degeneration.  Some  of 
these  shreds  form  in  the  ducts  of  Cowper's  glands,  some  in  the  glands  of  Littre, 
some  in  the  prostatic  sinuses,  some  in  the  utricle,  some  in  the  folds  around 
the  verumontanum,  and  some  are  from  inflammatory  patches  along  the  entire 
length  of  the  urethra.  A  i  per  cent,  solution  of  methylene-blue  injected  into 
the  anterior  urethra  will  stain  the  urethral  shreds,  while  those  from  the  bladder 
will  not  be  stained  by  it. 

Gonorrhea  (Clap;  Specific  Urethritis;  Tripper;  Venereal  Catarrh). 
— Gonorrhea  is  an  acute  inflammation  of  the  genital  mucous  membrane, 
nearly  always  of  venereal  origin,  due  to  the  deposition  and  multiplication  of 
gonococci  in  the  cells  of  the  membrane  and  a  mixed  infection  with  the  cocci  of 
suppuration.  The  disease  is  inaugurated  by  gonococci.  After  a  few  days  or 
more  secondary  pyogenic  infection  develops  and  complications  may  result  from 
the  gonococci  or  from  the  bacteria  causing  the  mixed  infection.  The  disease 
attacks  with  the  greatest  ease  surfaces  covered  with  squamous  epithelium. 
The  gonococci  enter  into  and  multiply  in  the  superficial  epithelial  cells  and  pass 
between  the  deeper  cells,  where  they  lodge  and  multiply  as  the  superficial  cells 
are  cast  off.  The  pus  from  the  urethra  contains  epithelial  cells  with  gonococci 
on  or  inside  of  them,  and  also  pus-cells  with  gonococci  within  them  as  a  result 
of  phagocytosis.  Cultures  are  made  with  diflftculty.  Gonococci  do  not  stain 
by  Gram's  method,  but  stain  best  with  a  weak,  watery  solution  of  an  anilin 
dye.  These  bacteria  are  said  not  to  be  pathogenic  to  animals,  although  some 
observers  deny  this  assertion.  Gonorrhea  is  one  of  the  most  common  and 
widely  disseminated  diseases.  Probably  one-half  of  all  sterile  women  and  many 
sterile  men  have  been  rendered  so  by  this  disease.  It  is  responsible  for  not  a 
few  cases  of  abortion,  for  an  enormous  majority  of  female  pelvic  diseases,  and 
it  causes  many  cases  of  blindness  by  infection  of  children's  eyes  during  delivery. 

Gonorrhea  in  the  Male.- — In  the  male,  clap  begins  within  the  meatus  and 
fossa  navicularis  and  extends  backward  throughout  the  length  of  the  urethra. 
The  mucous  membrane  swells  and  becomes  hyperemic,  and  there  is  a  discharge, 
first  of  mucus  and  serum,  and  then  of  pus.  In  severe  cases  the  discharge  is 
bloody  (black  gonorrhea)  or  green.  For  a  week  or  more  the  inflammation 
increases,  then  becomes  stationary  for  a  time,  and  then  declines,  the  discharge 


Symptoms  of  Acute  Inflammatory  Gonorrhea  1493 

growing  less  profuse  and  thinner,  a  watery  discharge  lasting  for  a  considerable 
time.  An  ordinary  case  of  genuine  gonorrhea  lasts  from  six  to  ten  weeks,  and 
even  a  case  limited  purely  to  the  anterior  urethra  will  rarely  be  cured  within 
four  or  five  weeks.  During  the  acute  stage  the  entire  penis  swells  and  the 
corpus  spongiosum  becomes  infiltrated  with  inflammatory  exudate.  An  inter- 
esting fact  is  that  gonorrhea  may  induce  mild  septicemia  without  demonstrable 
complications,  the  condition  causing,  according  to  Thayer  ("  Amer.  Jour.  Med. 
Sci.,"  Nov.,  1905),  a  continued  fever  which,  perhaps,  lasts  a  number  of  weeks. 
In  true  gonorrheal  septicemia  the  blood  must  contain  gonococci  {gonococcemia) . 
In  the  case  recorded  by  Thayer  and  in  the  one  recorded  by  Blumer  and  Hayes, 
and  in  the  one  recorded  by  Stellwagen  ("Therapeutic  Gazette,"  April  16, 
1910),  cultures  were  obtained  from  the  blood.  Gonorrhea  may  produce  grave 
septicemia  with  systemic  complications.  It  tends  particularly  to  attack  serous 
membranes  or  other  endothelial  structures  (joints,  pericardium,  endocardium, 
pleura,  tendon-sheaths,  intima  of  vessels,  etc.).  Among  the  complications  are 
gonorrheal  arthritis,  myehtis,  poliomyelitis,  and  multiple  neuritis.  There  are 
3  cases  of  gonorrheal  myositis  on  record  (Martin  W.  Ware,  "Amer.  Jour.  Med. 
Sci.,"  July,  1901),  Phlebitis  may  arise.  Mild  endocarditis  may  arise  or  severe 
endocarditis  may  occur,  identical  symptomatically  with  ulcerative  endocar- 
ditis due  to  other  bacteria.  In  6  reported  cases  of  endocarditis  gonococci  were 
obtained  by  cultures  from  the  blood  intra  vitam  (Thayer,  Loc.  cit.).  Cerebral 
embolism  may  result.  Cerebrospinal  meningitis  can  occur  (fluid  obtained 
by  lumbar  puncture  contains  gonococci). 

Gonorrheal  rheumatism  is  discussed  on  page  723.  Gonorrheal  peritonitis 
is  rare.  Infection  of  the  peritoneum  through  the  blood  is  very  rare.  The 
majority  of  cases  of  gonorrheal  peritonitis  occur  in  w^omen  and  are  due  to 
direct  extension  from  the  Fallopian  tubes.  Gonococci  have  not  been  found  in 
the  exudates  of  cases  of  pleuritis  and  pericarditis  supposed  to  be  of  gonorrheal 
origin.  A  child  may  contract  gonorrheal  ophthalmia  during  delivery,  and  any 
person  may  develop  it  by  getting  gonococci  into  the  eyes. 

Symptoms  of  Acute  Liflammatory  Gonorrhea. — The  period  of  incubation 
of  gonorrhea  is  from  a  few  hours  to  two  wxeks.  The  usual  period  is  from  three 
to  five  days,  when  symptoms  of  the  prodromal  stage  or  stage  of  onset  begin. 
The  patient  notices  on  arising  a  drop  of  thin  fluid  which  glues  the  lips  of  the 
meatus  together,  and  he  feels  some  heat  and  itching  or  tickling  about  the  meatus 
or  in  the  na\dcular  fossa.  There  may  be  uneasiness  or  actual  pain  unconnected 
with  urination,  and  there  is  sure  to  be  scalding  pain  on  urination.  The  meatus 
is  red  and  swollen,  has  a  glazed  appearance,  may  be  covered  with  a  Httle  muco- 
pus,  and  the  lips  are  glued  together  by  the  discharge.  It  may  be  possible  to 
squeeze  out  a  drop  or  two.  Even  so  early  the  fluid  contains  gonococci.  The 
urine  appears  clear,  but  on  shaking  some  flakes  are  noted.  They  are  epithelial 
cells.  Within  forty-eight  hours  the  first  stage,  the  florid  stage,  the  acute  stage, 
or  the  stage  of  increase,  becomes  estabhshed.  The  meatus  is  now  red,  swollen, 
and  everted  {fish-mouth  meatus);  the  entire  glans  may  be  red  and  swollen; 
if  the  prepuce  is  long,  it  becomes  swollen,  reddened,  and  constricted,  and  in 
many  cases  very  edematous;  the  lymphatics  at  the  frenum  and  on  the  dorsum 
of  the  penis  may  be  red,  swoUen,  tender,  and  cord- like;  micturition  causes 
severe  pain  {ardor  urince),  which  is  due  to  distention  of  the  inflamed  urethra  and 
to  stinging  by  the  acid  urine.  Bumstead  thus  described  the  act  of  micturition 
in  acute  gonorrhea:  "During  the  act  the  patient  involuntarily  relaxes  the  ab- 
dominal walls,  holds  his  breath,  and  keeps  the  diaphragm  elevated  in  order  to 
diminish  the  pressure  on  the  bladder  and  lessen  the  size  and  force  of  the  stream '' 
("Venereal  Diseases,"  by  Robt.  W.  Taylor).  Because  of  the  narrowing  of  the 
canal  the  stream  of  urine  becomes  narrow,  weak,  twisted,  forked,  or  is  delivered 
in  little  bursts  or  drops.  Retention  may  result  from  spasm  of  the  muscles. 
When  the  acute  or  florid  stage  is  fuUy  developed,  the  entire  urethra  is  inflamed 


1494  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

from  the  meatus  to  the  triangular  Hgament;  there  is  constant  uneasiness  or 
actual  pain  in  the  penis  and  perineum,  increased  by  walking  and  by  sitting 
down  suddenly  or  carelessly.  Insomnia  is  common;  chordce  occurs,  especially 
when  the  patient  is  warm  in  bed.  By  "chordee"  we  mean  a  condition  of  pain- 
ful erection  in  which  the  penis  is  markedly  bent.  The  rigid- infiltration  of  the 
corpus  spongiosum  prevents  it  distending  to  accommodate  itself  to  the  enlarged 
corpora  cavernosa,  and  in  consequence  the  organ  curves.  There  is  frequent 
micturition,  with  tenesmus  and  a  profuse  creamy  discharge,  which  is  yellow, 
greenish,  or  even  bloody.  The  discharge  soils  and  stains  the  victim's  linen 
and  may  crust  upon  the  linen,  the  meatus,  or  the  glans.  The  commonest  com- 
plications of  this  stage  are  balanitis  (inflammation  of  the  mucous  membrane  of 
the  glans  penis),  balanoposthilis  (inflammation  of  the  surface  of  the  glans  and 
the  mucous  membrane  of  the  prepuce),  phimosis  (thickening  and  contraction  of 
the  foreskin,  so  that  the  glans  cannot  be  uncovered), and  paraphimosis  (catching 
and  fixation  of  the  retracted  prepuce  behind  the  corona  glandis,  with  such 
swelling  of  the  glans  and  prepuce  that  it  is  impossible  to  bring  the  prepuce 
forward  over  the  glans).  This  is  a  dangerous  condition  and  it  should  be  reduced 
at  once.  In  the  second  or  stationary  stage,  which  lasts  from  the  end  of  the  first 
to  the  end  of  the  second  week,  the  acute  symptoms  of  the  first  stage  continue. 
The  most  common  complications  of  this  stage  are  peri-urethral  abscess  or  phleg- 
mon (infection  of  a  urethral  gland  or  of  submucous  structures),  folliculitis 
(inflammation  of  the  follicles  of  Littre),  hemorrhage,  retention  of  urine  (which 
is  rare),  gonorrheal  arthritis,  lymphangitis,  and  diminutive  bubo  on  the  dorsum 
of  the  penis  {btibonulus) ,  solitary  and  painful  bubo  of  the  groin,  which  may 
suppurate,  Cowperitis  (inflammation  of  Cowper's  glands),  inflammation  of  the 
prostate  or  of  the  bladder,  gonorrheal  ophthalmia,  and  chordee  (painful  erection 
with  downward  bending  of  the  penis) .  In  the  third  or  subsiding  stage  the  symp- 
toms gradually  abate,  the  discharge  becoming  scantier  and  thinner,  and  finally 
drying  up.  This  stage  is  of  uncertain  duration,  and  in  it  there  may  occur 
epididymitis,  or  inflammation  of  the  epididymis.  Among  possible  complications 
we  may  mention  peri-urethral  abscess  or  phlegmon,  Cowperitis,  cystitis, 
prostatitis,  bubonulus,  folliculitis,  gonorrheal  arthritis  (see  page  723),  infective 
endocarditis,  tenosynovitis,  pyelitis,  purulent  ophthalmia,  perichondritis,  and 
peritonitis. 

Examination  for  Gonococci,— Every  urethral  discharge  should  be  examined 
for  gonococci  in  order  to  make  a  positive  diagnosis.  This  examination  is 
made  several  times  during  the  progress  of  the  case,  so  as  to  determine  when  the 
organisms  disappear.  Many  non-gonorrheal  conditions  are  due  to  cocci 
strongly  resembling  gonococci.  Free  pus  and  numerous  cocci  usually  mean 
gonorrhea.  So  do  complications.  The  examination  of  the  smear  is  not  abso- 
lutely conclusive.  Cultures  are  conclusive.  If  there  be  a  free  discharge,  fluid 
for  examination  can  be  easily  obtained.  If  the  discharge  be  scanty  or  occasional, 
have  the  patient  partially  empty  the  bladder.  Then  the  surgeon  massages 
the  prostate  and  urethra  and  smears  fluid  on  the  slide.  Then  the  patient 
empties  his  bladder  into  two  glasses.  Each  specimen  is  to  be  centrifuged 
and  examined  for  pus  (Keyes,  "Amer.  Jour.  Med.  Sci.,"  Jan.,  1912).  The 
taking  of  a  smear  and  its  examination  are  easy,.  Place  a  drop  of  discharge 
upon  a  cover-glass,  lay  another  cover-glass  over  this,  and  slide  the  glasses  apart. 
Dry  and  fix  the  slides  in  the  flame  of  an  alcohol  lamp.  Bring  the  cover-glasses 
in  contact  with  a  saturated  solution  of  methylene-blue  in  5  per  cent,  carbolic 
acid  water.  The  staining  material  is  allowed  to  remain  in  contact  with  the 
slides  for  five  or  ten  minutes,  the  glasses  are  washed  with  water,  are  then  placed 
in  a  solution  of  5  drops  of  acetic  acid  to  20  c.c.  of  water,  and  kept  there  "long 
enough  to  count  one,  two,  three  slowly,"  and  are  again  washed  with  water.  Ex- 
amination with  the  microscope  shows  the  gonococci  stained  blue.^  In  doubtful 
^  Schutz's  method,  as  set  forth  by  R.  W.  Taylor  in  his  work  upon  "Venereal  Diseases." 


Treatment  of  Acute  Gonorrhea  1495 

cases,  especially  when  the  microscope  fails  to  show  genococci,  make  cultures. 
Cultures  must  be  made  in  suspected  gonorrhea  in  a  child,  from  the  fluid  of  an 
inflamed  joint,  from  the  discharge  in  gleet  or  purulent  ophthalmia,  and  from 
the  blood  in  obscure  infections. 

Subacute  or  catarrhal  gonorrhea  develops  in  men  who  have  previously 
had  gonorrhea,  as  a  result  of  prolonged  or  repeated  coition  or  of  contact  with 
menstrual  fluid  or  leukorrheal  discharge.  There  is  profuse  mucopurulent 
discharge,  but  very  little  pain  on  micturition,  and  seldom  chordee  or  marked 
irritability  of  the  bladder. 

Irritative  or  Abortive  Gonorrhea. — In  this  disease  the  symptoms,  which 
are  identical  with  those  of  beginning  clap,  do  not  increase,  but  disappear 
within  ten  days. 

Chronic  Urethral  Discharges. — Chronic  lu-ethral  catarrh,  which  may 
follow  gonorrhea,  is  characterized  by  the  occasional  presence  of  a  drop  of 
clear,  tenacious  liquid.  This  discharge  becomes  more  profuse  as  a  result  of 
sexual  excitement  or  the  abuse  of  alcohol. 

The  persistence  of  a  small  amount  of  milky  discharge,  because  of  locali- 
zation of  inflammation  in  one  spot  or  the  production  of  a  granular  patch  or  a 
superficial  ulcer,  characterizes  chronic  gonorrhea.  There  is  some  scalding 
on  urination;  erections  produce  aching  pain;  there  are  pain  in  the  back  and 
redness  and  swelling  of  the  meatus.  All  the  symptoms  are  intensified  by 
sexual  excitement,  by  coitus,  by  violent  exercise,  or  by  alcoholic  excess. 

Gleet. — If  a  chronic  gonorrheal  urethritis  lasts  over  ten  weeks,  it  is  called 
gleet.  In  gleet  the  lips  of  the  meatus  are  stuck  together  in  the  morning,  and 
squeezing  them  discloses  a  drop  of  opalescent  mucopurulent  fluid  (the  morning 
drop).  During  the  day  the  discharge  is  rarely  found.  The  discharge  is  yellow 
or  has  a  yellowish  hue;  it  stains  the  linen  distinctly,  and  contains  pus  shreds,  epi- 
thelium, and  at  times  gonococci.  The  urine  is  clear  and  contains  pus,  gonor- 
rheal shreds,  and  comma-shaped  hooks.  The  discharge  is  not  obviously 
purulent,  and  contains  amyloid  corpuscles.  There  are  frequency  of  micturition, 
pains  in  the  back,  and  dribbling  of  urine,  and  a  bougie  may  find  a  stricture  of 
large  caliber,  or  at  least  will  discover  that  the  urethra  is  rigid  from  inflammatory 
infiltration.  A  discharge  may  be  maintained  by  chronic  prostatitis.  In  this 
condition  there  are  frequency  of  micturition;  a  sense  of  weight  or  dull  pain  in 
the  perineum;  diminished  projectile  force  of  the  stream  of  urine;  there  is  often 
a  tendency  to  sexual  excitement  and  premature  emission.  In  prostatorrhea  a 
milky  discharge  gathers  in  the  urethra  during  sleep  and  flows  during  muscular 
effort  or  while  the  patient  is  at  stool.  The  linen  is  stained  but  slightly  and  the 
lips  of  the  meatus  are  not  glued  together  on  waking.  There  is  a  history  of 
masturbation  or  sexual  excess.  The  condition  is  not  aggravated  particularly 
by  alcohol  or  sexual  intercourse.  In  chronic  anterior  urethritis  there  is  a  dis- 
charge from  the  meatus  or  sticking  together  of  the  lips  in  the  morning.  In 
chronic  posterior  urethritis  there  is  no  discharge  of  pus  from  the  meatus.  If 
the  three-glass  test  be  made,  it  will  be  found  that  in  a  case  of  chronic  anterior 
urethritis  only  the  first  portion  will  be  cloudy  and  show  shreds;  if  there  be 
posterior  urethritis  of  not  very  long  standing,  both  portions  will  be  a  little 
clouded,  the  first  containing  clap  shreds,  the  last  hook-shaped  shreds.  In  a 
very  chronic  case  neither  sample  will  be  cloudy,  but  the  first  portion  will  con- 
tain shreds.  In  gleet  the  rigidity  of  the  urethra  causes  the  retention  of  small 
quantities  of  urine  back  of  the  thickened  areas  after  each  urination.  This 
retained  urine  decomposes  and  adds  to  inflammation.  Indulgence  in  alcohol, 
sexual  excitement,  or  sexual  intercourse  aggravates  the  condition. 

Treatment  of  Acute  Gonorrhea. — General  Care. — Wash  the  hands  after  touch- 
ing the  parts  and  dry  them  on  an  individual  towel,  which  is  not  used  upon  the  face. 
Wear  a  suspensory  bandage.  Avoid  violent  exercise,  especially  bicycle  riding, 
and  also  exposure  to  dampness.     Moderate  exercise  is  allowable.     The  patient 


1496  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

must  not  only  refrain  from  sexual  intercourse,  but  must  not  permit  himself  to 
indulge  in  sexual  excitement,  and  must  not  drink  a  drop  of  liquor,  malt,  vinous, 
or  spiritous,  unless  he  be  a  heavy  or  a  regular  drinker,  in  which  case  we  should 
permit  the  moderate  use  of  a  well  diluted  rye  or  Scotch  whisky.  Some  men 
become  actually  ill  without  their  regular  daily  stimulants  and  such  men  should 
have  them  in  moderation.  Some  surgeons  permit  the  moderate  use  of  claret 
to  all  patients.  At  least  twice  a  day  wash  the  penis  for  five  minutes  in  a  cup  of 
warm  water  containing  i  dram  of  salt.  Passing  the  urine  while  the  penis  is 
immersed  in  warm  fluid  lessens  ardor  urinae.  Cut  a  small  opening  in  a  square 
piece  of  old  linen,  sUp  the  linen  over  the  glans,  catch  it  back  of  the  corona, 
and  bring  the  ends  forward  with  the  prepuce.  Never  permit  the  cotton  or 
linen  to  stick  fast  and  plug  up  the  lips  of  the  meatus.  If  the  lips  tend  to  become 
sealed  up,  grease  them  with  sterile  vaselin.  If  the  glans  be  completely  naked, 
pin  the  foot  of  an  old  stocking  upon  the  undershirt,  put  absorbent  cotton  in  the 
toe,  and  place  the  penis  within  this  bag.  Never  tie  or  fasten  any  material  about 
the  penis.  The  patient  should  drink  freely  of  plain  water  or  of  water  containing 
a  little  bicarbonate  of  sodium.  He  should  obtain  one  bowel  movement  every 
day. 

Diet  and  Instruction  List  (Dr.  T.  C.  Stellwagen,  Jr.). — Meats. — May  have 
white  meat  of  chicken,  boiled  fish,  lamb. 

Must  not  take  beef,  beef  steak,  veal,  pork,  liver,  kidney,  etc.;  nor  salt  fish, 
meats,  smoked,  canned,  or  potted  foods. 

Vegetables. — May  have  rice,  hominy,  string  beans,  fresh  peas,  spinach,  beans, 
baked  potatoes  (sweet  and  white) ,  lentils,  etc. 

Must  not  take  rhubarb,  tomatoes,  asparagus  (Guiteras's  rule.  See  Begg, 
in  "Phila.  Med.  Jour.,"  June  7, 1902),  lemons,  oranges,  limes,  or  peserved  fruits. 

Drinks.— 'Nothing  but  plain  water  and  milk. 

Must  not  take  alcoholic  beverages  or  carbonated  drinks. 

Must  not  take  salt,  spices,  condiments,  cheese  or  pickles. 

Desserts. — Only  of  the  simplest  kind,  made  from  milk  and  eggs,  and  take 
them  sparingly. 

General  Rules. — Put  on  a  suspensory  bandage  and  wear  it  in  conjunction 
with  a  piece  of  linen  or  a  bag  to  catch  discharges. 

Wash  the  hands  after  handUng  the  parts,  and  keep  the  fingers  away  from 
the  eyes. 

Keep  the  linen  from  contaminating  the  family  wash. 

Wash  the  organ  frequently  in  warm  salt  water  (i  teaspoonful  of  table  salt 
to  I  glass  of  water). 

When  urination  causes  burning,  immerse  the  organ  in  a  basin  of  warm  water 
and  allow  the  urine  to  flow. 

Keep  the  body  warm  and  free  from  chilling. 

Should  not  go  about  on  rainy  or  snowy  days  without  ample  protection. 

Should  go  to  bed  early. 

Must  not  take  cold  baths.     May  take  warm  ones. 

Should  not  eat  between  meals — it  is  unwise  to  overload  the  stomach. 

Should  drink  freely  of  plain  water  or  milk. 

Should  urinate  when  the  desire  comes. 

Should  keep  away  from  females  socially  and  sexually — and  any  other 
exciting  influences,  such  as  erotic  sights,  thoughts,  and  Uterature. 

Must  keep  bowels  loose. 

A  smoker  should  decrease  the  consumption  of  tobacco. 

Never  put  pieces  of  cotton  over  the  end  of  organ,  as  cotton  so  used  prevents 
the  free  drainage  of  discharge.  Should  the  lips  of  the  opening  seal  together, 
wash  clean  in  warm  salt  water  and  grease  with  vaselin. 

A  tea  or  coffee  drinker  may  have  a  small  amount  once  daily,  but  it  will  be 
better  not  to  partake  of  either. 


Treatment  of  Acute  Gonorrhea  1497 

Should  the  patient  be  using  an  injection  and  find  that  the  desire  for  urination 
becomes  frequent  at  night,  he  must  stop  the  injection  and  consult  his  physician. 

The  injection  is  never  to  be  forced  into  the  organ;  it  is  to  be  introduced 
gently,  and  the  bladder  is  to  be  empty  when  an  injection  is  given. 

Abortive  treatment  may  be  tried  if  the  case  is  seen  early.  The  use  of  strong 
solutions  of  powerful  germicides  has  been  abandoned  because  of  the  great 
pain  they  produce  and  the  inevitable  subsequent  crippling  of  the  urethra. 

Abortive  treatment  is  applicable  to  specially  selected  cases  only  and  even 
then  usually  fails.  It  should  never  be  used  after  the  gonococci  have  invaded 
the  submucosa,  but  only  during  the  prodromal  stage,  when  it  is  hoped  that  the 
germs  are  upon  and  not  in  the  mucous  membrane.  This  stage  usually  lasts 
but  a  few  hours,  usually  not  over  forty-eight.  The  patient  generally  presents 
himself  after  this  period  has  passed.  When  the  symptoms  as  described  in  the 
prodromal  period  prevail,  the  abortive  treatment  may  be  tried,  after  explaining 
to  the  patient  that  it  will  cause  some  pain  and  discomfort  and  in  the  end  may 
fail  or  even  aggravate  the  inflammation. 

Germicides  may  be  used  and  with  some  chance  of  killing  the  infection,  for 
as  yet  the  organisms  are  growing  upon  the  superficial  strata  of  epithelium 
much  as  a  sod  of  grass  upon  soil.  When  the  deeper  structures  have  been 
invaded  it  is  folly  to  attempt  to  abort  the  disease. 

The  abortive  method  advocated  by  White  and  Martin  and  which  has  proved 
successful  in  Prof.  Hiram  Loux's  clinic  in  a  limited  number  of  selected  cases  is  as 
follows:  After  urination  4  drops  of  a  4  per  cent,  solution  of  eucain  are  injected 
into  the  urethra,  after  which  2  drams  of  }'i  per  cent,  solution  of  protargol  are 
instilled  and  retained  for  three  minutes.  The  injections  are  repeated  every 
two  hours  while  awake. 

Each  time  the  bottle  is  half  emptied  it  is  replenished  with  sterile  water  to 
its  full  capacity,  until  the  end  of  the  third  day.  If  successful,  recovery  is  ac- 
complished in  about  seven  days.  Should  a  mucoid  discharge  persist  an  anti- 
septic astringent  injection  is  employed  to  complete  the  cure.  During  the  treat- 
ment the  patient  must  be  kept  at  rest.  The  diet  should  be  bland  and  light  and 
the  usual  balsamic  remedies  are  administered.  If  the  symptoms  become  hyper- 
acute, stop  the  treatment  at  once  and  give  a  sedative. 

Another  abortive  method  is  the  use  of  hot  retro-injections  of  corrosive  subli- 
mate solution  (i  :  20,000),  2  pints  being  run  through  the  urethra  once  a  day. 
If  in  seventy-two  hours  the  symptoms  are  not  greatly  improved,  abortive 
treatment  should  be  abandoned.  Recent  studies  render  it  almost  certain  that 
there  is  no  real  abortive  treatment.  Abortive  treatment,  to  be  efficient,  would 
have  to  be  carried  out  before  the  gonococci  penetrated  the  epithehal  cells; 
in  other  words,  would  need  to  be  instituted  before  the  distinct  symptoms  of 
the  disease  appear.  Janet  says  that  we  must  alter  our  conception  as  to  what 
constitutes  abortive  treatment,  and  he  doubts  if  a  case  of  true  gonorrhea  has  ever 
been  really  aborted. ^  The  method  of  irrigation  with  solutions  of  permanganate 
of  potassium  is  really  a  prophylactic  treatment.  .  Janet  apphes  his  treatment  as 
evidences  of  trouble  present  themselves,  and  before  acute  symptoms  appear, 
and  claims  that  in  most  persons  the  disease  can  be  arrested  in  from  eight  to 
twelve  days.     The  same  plan  of  treatment  is  useful  in  a  well-developed  case. 

Irrigation  in  Gonorrhea. — Irrigation  can  be  used  in  an  incipient  or  in  a  well- 
developed  case.  Janet's  method  is  as  follows:  An  irrigator  is  filled  with  a  warm 
solution  of  permanganate  of  potassium  (i  :  4000).  The  patient  after  emptying 
his  bladder  is  seated  upon  a  chair  and  his  sacrum  rests  upon  the  extreme  front 
edge  of  the  chair  (Valentine's  position).  The  reservoir  is  jouied  to  a  glass 
nozzle  by  a  rubber  tube.  The  nozzle  is  introduced  into  the  meatus,  and  the 
fluid  is  permitted  to  run  gradually  at  first,  with  full  force  later.  In  anterior 
trouble  the  fluid  is  allowed  to  run  out  of  the  meatus  by  the  side  of  the  nozzle. 
1  "Ann.  d.  mal.  d.  org.  gen.-urin.,"  1896,  p.  1031. 


1498  Diseases  and   Injuries  of  the  (jenito-urinary  Organs 

The  anterior  urethra  is  always  irrigated  first,  the  reservoir  being  2  feet  above  the 
chair. 

In  posterior  urethritis,  after  the  anterior  urethra  has  been  irrigated,  the 
reservoir  is  raised  from  6  to  7  feet  above  the  penis,  the  meatus  is  held  tight  about 
the  nozzle,  and  the  fluid  overcomes  the  force  of  the  compressor  muscles  of  the 
urethra  and  the  bladder  sphincter  and  enters  the  bladder.  If  the  muscles  do 
not  quickly  relax,  continue  the  hydrostatic  pressure  for  several  minutes,  when 
relaxation  will  usually  occur;  but  if  it  does  not  do  so,  tell  the  patient  to  breathe 
slowly  and  deeply,  and  to  make  efforts  at  urination  (Valentine's  plan).  When 
the  bladder  is  full  the  tube  is  withdrawn  and  the  patient  micturates.  This 
procedure  is  practised  once  or  twice  a  day  for  five  or  six  days,  or  even  longer, 
and  the  strength  of  the  solution  is  gradually  increased  up  to  i :  1000.  It  has  been 
claimed  that  after  one  or  two  weeks  of  this  treatment  gonococci  permanently 
disappear  in  the  majority  of  cases.  Figure  982  shows  the  ingenious  and  very 
useful  irrigator  devised  by  Ferd.  C.  Valentine,  of  New  York.  Valentine' 
has  constructed  the  table  shown  below,  which  is  of  use  to  a  practitioner  who 
wishes  to  employ  irrigations  with  permanganate  of  potassium  in  the  treatment 
of  acute  gonorrhea.  I  followed  the  method  set  forth  in  this  table  in  a  great 
number  of  cases,  and  regarded  it  an  extremely  useful  systematic  plan. 

First  day,  first  visit.  Anterior  irrigation 1 13000 

First  day,  7  p.  M.  Anterior  irrigation i :  4000 

Second  day,  9  a.  m.  Anterior  irrigation i :  3000 

Second  day,  7  p.  m.  Anterior  irrigation ; i :  4000 

Third  day,  9  a.  m.  Intravesical  irrigation i :  6000 

Third  day,  7  p.  m.  Anterior  irrigation i :  5000 

Fourth  day,  9  A.  M.  Intravesical  irrigation i :  5000 

■c       .-,    ■<  ( Intravesical  irrigation i :  sooo 

Fourth  dav,   7  p.  m.  <   .    .     •      •    •     .  •  ^ 

-      '  \  Anterior  irrigation i :  2000 

Fifth  day,       Noon.     Intravesical  irrigation i :  5000 

Sixth  day,       Noon.     Intravesical  irrigation i :  5000 

Seventh  day,  Noon.     Intravesical  irrigation i :  5000 

T7-  1^1    .  /  Intravesical  irrigation i :  sjooo 

Eighth  day,   9  a.  m.  <.,••.     .-^  -^ 

"  -^ '    ^  1  Anterior  irrigation i :  3000 

t?-  u*u  J  ^        J  Intravesical  irrigation i :  5000 

Eighth  day,    7  p.  m.  <   .    .     •      .    .     . -*  .•' 

^  ■"    '  I  Anterior  irrigation i :  2000 

Ninth  dav,     9  A.  M.  I  Intravesical  irrigation i :  4000 

'  '     ^  1  Anterior  irrigation i :  1000 

■kt;   ..-l  ^  „   ,,   J  Intravesical  irrigation 1 14000 

Ninth  day,     7  p.  M.  <    .    ^     .      .    .     ..."  ^ 

•^ '      '  1  Anterior  irrigation i :  1000 

Tenth  day,     9  a.  m.  i  Intravesical  irrigation 1:4000 

■"     ^  1  Anterior  irrigation i :  1000 

T^^4-u  ^„,  ^   w   J  Intravesical  irrigation i :  5000 

lenth  day,     7  p.  M.  <   .    .^    .      .    .     .,.''  -^ 

1.  Anterior  irrigation i :  500 

For  full  directions  regarding  this  method  see  Valentine's  book,  "The  Irri- 
gation Treatment  of  Gonorrhea."  If  a  stricture  exists,  it  is  not  advisable 
to  employ  this  treatment.  Excellent  results  can  be  obtained  by  irrigations 
with  fluid  containing  silver  nitrate  (i  :  12,000  to  i  :  8000). 

When  a  patient  is  treated  by  irrigation,  after  the  entire  subsidence  of  acute 
symptoms,  a  thin,  colorless  discharge  may  persist.  This  can  be  cured  by  the 
use  of  astringents.  Two  or  three  times  a  day  an  astringent  is  injected  by  means 
of  a  3'^-ounce  syringe.  Dalton's  formula  is  very  useful:  Zinc  oxid  and  lead 
acetate,  of  each,  3^^  to  3  gr. ;  tincture  of  catechu,  from  10  to  30  min.;  glycerin, 
from  }'2  to  I  dram;  and  water  to  make  i  oz.;  Ultzmann's  formula  is:  Zinc 
sulphate,  16  gr.;  pulverized  alum,  8  to  12  gr.;  carbolic  acid,  3  gr.;  and  water  to 
make  4  oz. 

Many  writers  oppose  the  irrigation  treatment,  claiming  that  it  increases 
the  liability  to  complications,  especially  prostatic  inflammation,  and  enhances 
the  danger  of  recurrence.  I  believe  in  the  method.  I  do  not  think  it  shortens 
'  "The  Irrigation  Treatment  of  Gonorrhea." 


Treatment  of  Acute  Gonorrhea 


1499 


materially  the  duration  of  the  disease,  but  do  believe  that  it  mitigates  its  inten- 
sity, makes  the  patient  much  more  comfortable,  and  quickly  causes  the  dis- 
charge to  become  mucopurulent.  That  it  increases  compUcations  and  the 
danger  of  reinfection  is  very  doubtful.  Much  of  the  trouble  which  has  fol- 
lowed its  use  has  been  due  to  raising  the  reservoir  to  too  great  a  height. 

Irritative  gonorrhea  will  subside  in  a  few  days.  The  above  directions  should 
be  followed,  and  the  anterior  urethra  should  be  washed  out  several  times  daily 
with  diluted  peroxid  of  hydrogen,  or  irrigated  once  a  day  with  a  hot  solution  of 
permanganate  of  potassium  (i  :  4000). 
In  catarrhal  gonorrhea  at  once  order 
injections  (i  gr.  to  the  ounce  of  sulphate 
of  zinc;  or  zinci  sulphas,  8  gr.,  plumbi 
acetas,  15  gr.,  water  8  oz.;  or  5  gr.  of 
sulphocarbolate  of  zinc  to  i  oz.  of  water; 
or  White's  prescription  of  i  dram  each 
of  acetate  of  zinc  and  tannic  acid,  8 
drams  of  boric  acid,  6  oz.  of  liq.  hydro- 
gen peroxid).  For  injecting  use  a  blunt- 
pointed  hard-rubber  syringe  of  a  ca- 
pacity of  3  or  4  drams.  Let  the  patient 
urinate  and  then  sit  on  a  chair,  his 
buttocks  hanging  over  the  edge ;  throw  a 
syringeful  of  the  solution  into  the  urethra 
and  let  it  run  out  at  once,  and  throw  in 
another  syringeful  and  hold  it  in  from 
three  to  five  minutes. 

In  ordinary  acute  gonorrhea  we  fol- 
low an  old  rule  when  we  order  balsams. 
The  common  custom  is  to  give  two 
capsules  three  times  a  day,  each  capsule 
containing  5  gr.  of  salol,  5  gr.  oleoresin 
of  cubebs,  10  gr.  balsam  of  copaiba, 
and  I  gr.  of  pepsin.  Clinical  observa- 
tion indicates  that  the  balsams  are  of 
distinct  value  in  gonorrhea.  When  used 
early,  the  discharge  tends  to  become 
mucopurulent  and  the  acute  symptoms 
usually  soon  begin  to  subside  (S.  Behr- 
mann  in  " Derma tologisches  Central- 
blatt,"  Berlin,  Nov.  and  Dec,  1901). 
Many  practitioners  will  not  use  balsams 
until  the  third  week.  Bacteriological 
studies  indicate  that  copaiba,  when  elim- 
inated in  the  urine,  has  a  certain  amount 
of  power  in  inhibiting  the  growth  of  gon- 
ococci,  but  that  cubebs  and  oil  of  sandal 
have  not  such  power.  Yet  oil  of  sandal 
is  more  useful  than  copaiba  as  a  remedy. 
Salol  is  distinctly  germicidal,  hence  it 
is  given   with   the  balsams.     In  a  case 

treated  by  balsams  an  astringent  injection  is  usually  employed.  The  injection 
is  used  two  or  three  times  a  day,  immediately  after  micturition.  As  the  inflam- 
mation subsides  the  strength  of  the  injection  should  be  gradually  increased. 
A  good  plan  is  to  order  an  8-oz.  bottle  and  8  i-gr.  powders  of  sulphate  of  zinc. 
Direct  the  patient  to  fill  the  bottle  with  water,  in  which  one  powder  is  dissolved; 
when  this  is  used  dissolve  2  powders  in  a  bottleful  of  water,  and  so  progressively 


Fig.  982. — -Valentine's  urethral  and  in- 
travesical irrigator:  a,  Board  with  attach- 
ments to  be  screwed  to  wall;  c,  open  collar; 
d,  puUey;  e,  cord;  /,  ring  to  suspend  perco- 
lator; g,  brass  rod;  h,  percolator;  i,  rubber 
tube;  j,  ring  for  fourth  finger;  k,  flange  to 
graduate  pressure;  /,  shield;  m,  ring  to 
suspend  shield;  n,  nozzle  attached. 


1500  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

increase  the  strength.  When  the  discharge  ceases  stop  the  injections  gradually. 
Whenever  a  syringeful  is  taken  from  the  bottle  a  syringeful  of  water  is  jjut  into 
the  bottle,  and  thus  pure  water  is  soon  obtained,  at  which  point  injection  is  dis- 
continued. If  a  simple  astringent  injection  causes  much  pain,  use  a  sedative 
injection — 2  drams  of  boric  acid,  8  gr.  of  aqueous  extract  of  opium,  and  8  oz.  of 
liquor  plumbi  subacetatis  dilutis.  I  have  had  about  as  much  success  with  the 
above  simple  method  as  with  the  most  complicated  of  plans.  Complication 
and  complexity  are  not  criterions  of  usefulness. 

Argonin,  which  is  a  combination  of  albumin,  silver,  and  an  alkali,  is  highly 
recommended  by  some  authors  as  a  local  remedy  for  gonorrhea  (Schafifer, 
Guthiel).  A  solution  of  this  material  is  non-irritant,  the  silver  is  not  pre- 
cipitated by  chlorids,  and  the  agent  destroys  gonococci.  It  is  used  by  injec- 
tion or  irrigation.  If  used  by  irrigation,  employ  a  i  :  500  solution  twice  a 
day.  If  used  as  an  injection,  employ  a  i  :  200  solution  six  or  eight  times  a 
day.  When  the  discharge  is  found  free  from  gonococci  and  remains  free  for 
three  days,  stop  the  argonin  and  use  an  astringent  injection. 

Protargol,  metallic  silver  combined  with  a  protein,  is  a  yellow  powder  solu- 
ble in  water,  the  solution  not  being  acted  on  by  light.  It  is  a  non-irritant 
germicide.  Neisser,  after  demonstrating  the  presence  of  the  gonococcus, 
administers  protargol  by  injection,  the  first  injections  being  of  a  strength  of 
0.25  per  cent.,  the  strength  gradually  increased  to  0.5  per  cent.,  and  finally 
to  I  per  cent.  In  the  beginning  he  orders  three  injections  a  day,  each  in- 
jection being  retained  from  fifteen  to  thirty  minutes;  after  several  days,  when 
the  symptoms  improve,  he  gives  only  one  or  two  injections  a  day,  and  these 
are  continued  for  ten  days  after  gonococci  disappear  from  the  discharge.  After 
protargol  is  abandoned  an  astringent  injection  should  be  used  for  a  time.  Some 
surgeons  use  a  i  :  1000  solution  of  protargol,  and  irrigate  the  anterior  urethra 
and  flush  the  bladder  twice  a  day.  A  silver  salt  used  by  many  is  argyrol, 
or  silver  vitelhn.  The  injection  used  at  first  may  be  of  a  strength  of  2  per  cent. 
The  drug  should  be  retained  in  the  urethra  four  or  five  minutes,  and  three  or 
four  injections  should  be  given  each  day.  The  strength  of  the  injection  can  be 
gradually  increased  to  5  per  cent,  or  even  more.  I  have  not  been  impressed 
with  the  value  of  this  preparation  except  in  the  earHest  stages  of  gonorrhea. 
Picric  acid  has  been  highly  commended  as  an  injection.  The  strength  of  solu- 
tion is  I  :  200,  and  it  is  to  be  retained  in  the  urethra  three  or  four  minutes  (de 
Brun's  method). 

Methylene-blue  internally  is  occasionally  of  service  in  gonorrhea.  A  cap- 
sule containing  i  or  2  gr.  of  the  drug  is  given  three  times  a  day.  It  makes  the 
urine  greenish  blue  and  occasionally  induces  strangury.  Urotropin  renders 
the  urine  sterile.     Salicylate  of  sodium  may  be  of  value  late  in  the  case. 

In  his  chnic  in  Jefferson  Hospital  my  colleague,  the  late  Prof.  Horwitz, 
introduced  the  following  plan  of  treatment:  A  capsule  containing  balsam  of 
copaiba,  oil  of  sandal,  and  methylene-blue  is  given  half  an  hour  after  each  meal: 

I^.     Methylene-blue gr.  xxx; 

Balsami  copaibae  1 --  f  5iss  __^i. 

Olei  santali  j 

Pone  in  capsulas  No.  xxx. 
Sig. — One  after  each  meal. 

The  patient  begins  at  once  to  take,  by  hand  injection,  a  10  per  cent,  solu- 
tion of  argyrol.     He  takes  it  three  times  a  day. 

At  each  daytime  injection  the  fluid  is  retained  in  the  canal  for  five  minutes. 
At  the  bedtime  injection  the  fluid  is  retained  for  fifteen  minutes.  At  first 
only  about  i  dram  is  injected  at  a  time,  but  as  the  urethra  becomes  accustomed 
to  fluid  distention  the  amount  is  gradually  increased,  until  finally  4  drams  may 
be  given. 


Treatment  of  Acute  Gonorrhea  1501 

When  the  stage  of  dedine  begins  (toward  the  end  of  the  second  week)  a 
combined  astringent  and  antiseptic  treatment  is  used. 

The  capsules  of  methylene-blue,  copaiba,  and  sandal,  and  the  injections 
of  argyrol  are  discontinued.  A  capsule  containing  oleoresin  of  cubebs,  oil 
of  sandal,  and  balsam  of  copaiba  is  given  before  each  meal,  and  a  capsule  of 
urotropin  is  given  after  each  meal.  An  injection  of  protargol  (^4  of  i  per  cent.) 
is  given  three  times  a  day.  This  remedy  is  germicidal  and  also  astringent. 
The  strength  is  gradually  increased  until  a  i  per  cent,  solution  is  used.  By  the 
end  of  the  fourth  week  the  patient  has  reached  the  terminal  stage.  Now 
capsules  of  sandal  and  salol  are  substituted  for  the  cubebs,  sandal  and  copaiba 
and  an  astringent  injection  is  ordered.  The  following  injection,  recommended 
by  J.  Wm.  White,  is  very  satisfactory: 

I^.     Hydrarg.  chlor.  corros gr-  M; 

Zinci  sulphocarbolas 5ss; 

Acidi  boraci 3  ij ; 

Acidi  carbolici njxv 

Boroglycerid  (25  per  cent.) f^ij; 

Aquae  destil q.  s.  ad.  f  5  vj. — M. 

Sig. — Inject.     Dilute  if  it  causes  much  pain. 

When  the  mucoid  condition  predominates  in  the  discharge  the  following  is 
useful : 

I^.     Zinci  sulph gr.  xv; 

Plumbi  acetati gr.  xxx; 

Glycerol  tannin  \  __   ,^. 

Hydrastin  (Lloyd's)  / ^^  ^  ^^^' 

Mucil.  acacise f  5iv; 

Aquae  destil q.  s.  ad.  f  0  vj. — M. 

Sig. — As  injection. 
The  formula  of  the  "injection  Brue"  is  as  follows: 

I^.     Plumbi  acetat gr.  xxx; 

Zinci  sulphat gr.  xvj; 

Ext.  krameriae  tl f  3iv; 

Tinct.  opii f  3  iij ; 

Aquae  destil q.  s.  ad.  f  o  vJ. — M. 

Sig. — As  injection. 

When  all  symptoms  of  clap  have  disappeared,  any  injection  in  use  is  gradu- 
ally diluted.  Whenever  a  syringeful  of  the  fluid  is  taken  from  the  bottle,  a 
syringeful  of  water  is  put  in.  When  the  fluid  becomes  pure  water  the  injec- 
tion is  discontinued.  Balsams  are  stopped  by  gradual  diminution  in  the 
number  of  daily  doses.  For  three  weeks  after  the  entire  disappearance  of  all 
symptoms  alcohol  is  forbidden  and  sexual  indulgence  is  prohibited.  Should  a 
relapse  occur  the  patient  is  at  once  placed  upon  treatment  as  for  the  acute 
stage,  and  when  the  stage  of  decline  again  ensues  he  is  placed  again  on  anti- 
septics and  astringents.  Relapses  are  caused  by  a  localized  lesion  or  lesions  in 
the  anterior  or  posterior  urethra,  hence  as  soon  as  all  acute  symptoms  subside 
an  endoscopic  examination  is  to  be  made  and  proper  treatment  is  to  be  applied 
to  any  localized  lesion.  If  during  the  treatment  of  gonorrhea  a  compliaption 
develops,  local  treatment  of  the  urethra  is  at  once  discontinued  and  constitu- 
tional treatment  suited  to  the  new  condition  is  prescribed. 

If  the  onset  of  gonorrhea  is  marked  by  violent  inflammatory  symptoms 
(chordee,  hemorrhage,  severe  pain,  swelling,  profuse  purulent  discharge), 
local  treatment  of  the  urethra  is  contra-indicated. 

If  the  invasion  is  hyperacute,  no  local  treatment  of  the  urethra  is  permis- 
sible until  the  disease  assumes  the  character  of  ordinary  gonorrhea. 

Not  unusually  gonorrhea  passes  into  a  low  grade  of  anteroposterior  ure- 
thritis that  proves  most  rebeflious  to  treatment.  This  condition  is  especially 
common  when  too  stimulating  a  treatment  has  been  used.     A  mild  astringent 


1502  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

injection  should  be  used  three  times  a  day.  Every  second  or  third  day  an  in- 
jection of  nitrate  of  silver  (1:4000)  should  be  given.  If  the  silver  salt  sets  up 
an  acute  inflammation  the  treatment  used  in  the  acute  stage  of  gonorrhea  is 
given  until  the  symptoms  abate. 

A  valuable  plan  in  rebellious  anteroposterior  urethritis  is  daily  irrigation 
of  the  anterior  urethra  with  a  warm  solution  of  permanganate  of  potassium 
(1:6000),  followed  by  the  passage  of  a  soft  catheter  and  the  filUng  of  the  blad- 
der with  a  like  solution.  The  patient  empties  his  bladder  after  the  catheter 
is  withdrawn  and  thus  flushes  the  entire  urethra  with  the  permanganate.  The 
strength  of  the  solution  is  gradually  increased  up  to  i :  2000. 

Weiss  used  corrosive  sublimate  (1:20,000)  in  the  manner  just  described. 
It  is  particularly  valuable  in  cases  of  bacterial  contamination,  the  gonococci 
having  disappeared. 

Treatment  of  Complications. — Ardor  urincB  is  relieved  by  urinating  while 
the  penis  is  immersed  in  hot  water  and  by  administering  alkaline  diuretics. 
Chordee  requires  a  bowel  movement  in  the  evening,  and  sleeping  in  a  cool 
room,  under  light  covers,  and  on  a  hard  mattress;  bromid  of  potassium  is 
given  several  times  daily,  and  a  considerable  dose  is  given  at  night;  it  may  be 
necessary  to  use  suppositories  of  opium  and  camphor  or  to  give  hyoscin.  Bala- 
nitis requires  frequent  washing  of  the  head  of  the  penis  and  prepuce  in  warm 
water,  drying  with  cotton,  and  dusting  with  borated  talc,  stearate  of  zinc,  or 
boric  acid  and  subnitrate  of  bismuth  (1:6).  Balano posthitis  requires  soaking 
in  hot  water,  and  injections  of  black  wash  under  the  prepuce  until  edema 
of  the  foreskin  subsides,  and  then  cleanliness  and  the  application  of  a  dry- 
ing powder.  Phimosis  requires  soaking  the  penis  in  hot  water,  and  injec- 
tions of  hot  water  beneath  the  foreskin,  followed  by  black  wash.  If  this 
fails,  circumcision  must  be  performed.  If  paraphimosis  occurs,  grasp  the 
head  of  the  penis  with  the  left  hand,  squeeze  the  blood  out,  and  try  to  push 
the  head  back,  while  with  the  right  hand  the  penis  is  pulled  upon  as  if  the 
surgeon  intended  to  lift  the  individual  by  the  organ.  If  this  fails,  cut  the 
collar  on  the  dorsum  with  scissors;  or,  what  is  better,  for  it  gives  free  expo- 
sure, incise  each  side  of  the  prepuce  between  the  middle  of  the  dorsum  and 
the  frenum.  Bubo  requires  the  application  of  iodin,  ichthyol,  or  blue  oint- 
ment, the  use  of  a  spica  bandage,  and  rest.  If  a  bubo  suppurates,  it  must  be 
opened  or  aspirated.  Acute  posterior  urethritis  is  treated  by  rest,  and  if  the 
symptoms  are  severe,  by  rest  in  bed.  If  the  balsams  do  not  irritate,  they  are 
given;  if  they  do,  they  are  withdrawn.  Urotropin  or  salol  is  given  and  the 
patient  is  placed  upon  a  milk-diet  with  orders  to  drink  largely  of  flaxseed  tea. 
Alkaline  fluids  do  harm  by  favoring  ammoniacal  decomposition  of  the  urine. 
Injections  and  irrigations  are  abandoned.  Pain  and  vesical  spasm  are  con- 
trolled by  suppositories  of  opium  and  belladonna.  If  retention  of  urine  occurs,, 
have  the  patient  urinate  while  in  a  hot  bath;  if  this  fails,  use  a  soft  catheter. 
Acute  vesiculitis  is  treated  as  is  acute  prostatitis.  Chronic  vesiculitis  is  con- 
sidered on  page  1522.  Pyelitis  is  treated  by  rest  in  bed,  hot  baths,  wet  cupping 
of  the  loin,  milk-diet,  diuretics,  the  taking  of  a  large  quantity  of  bland  liquid, 
and  the  administration  of  salol  or  urotropin,  and  in  some  cases  lavage  of  the 
kidney  pelvis-  through  a  ureteral  catheter  with  one  of  the  silver  preparations 
(1:15,000  of  nitrate  of  silver).  Folliculitis  is  treated  by  rest  and  the  apphca- 
tion  of  a  hot- water  bag  to  the  perineum  (if  that  be  the  part  involved).  If 
pus  forms  evacuate  by  incision.  Later  the  follice  may  be  dissected  out  or 
destroyed  by  cauterization.  If  the  follicle  opens  into  the  urethra  it  may  be 
cauterized  through  an  endoscope  Peri-urethritis  is  treated  by  rest  and  hot 
applications.  If  pus  forms,  an  incision  must  be  made.  If  the  abscess  is  per- 
mitted to  break  into  the  urethra,  rest  and  hot  fomentations  may  be  used,  but 
at  the  first  sign  of  urinary  extravasation  make  an  external  incision.  Cowperitis  is 
treated  in  the  same  way  as  peri-urethritis.     Gonorrheal  rheumatism  is  considered 


Treatment  of  Chronic  Gonorrhea  1503 

on  page  723.  A  cute  prostatitis  and  cystitis  require  confinement  to  bed,  a  milk-diet, 
the  use  of  diuretics,  hot  apphcations  to  the  perineum  and  hypogastrium  (bags 
of  hot  sand),  hot  sitz-baths,  suppositories  of  opium  and  belladonna  or  of 
ichthyol,  leeching  the  perineum,  the  discontinuance  of  balsams  and  injections, 
and  the  administration  of  urotropin  or  salol.  Heat  can  be  applied  by  means 
of  a  stream  of  warm  water  which  circulates  through  a  metal  instrument  intro- 
duced into  the  rectum.  Abscess  of  the  prostate  requires  instant  incision.  In  reten- 
tion of  urine  the  patient  should  try  to  pass  the  urine  while  in  a  hot  bath;  if  this 
fails,  a  soft  catheter  is  used.  After  relieving  the  bladder  put  the  patient  to  bed 
and  apply  hot  sand-bags  as  for  acute  prostatitis.  Chronic  prostatitis  requires 
cold  hip-baths,  cold-water  enemata,  deep  urethral  injections,  massage  of  the 
prostate,  plain  diet,  avoidance  of  alcohol  and  overexertion,  counterirritation 
of  the  perineum,  and  the  relief  of  stricture  or  phimosis.  Great  benefit  is  oc- 
casionally derived  from  passing  a  soft  bougie  covered  with  blue  ointment  or 
with  a  I  per  cent,  ointment  of  silver  nitrate.  If  epididymitis  arises,  put  the 
patient  to  bed,  abandon  injections,  shave  the  hair  from  the  groin,  leech  over 
the  cord,  elevate  the  testicles,  and  early  in  the  case  apply  an  ice-bag.  Give  a 
cathartic,  a  fever  mixture,  and  suitable  doses  of  bromid  of  potassium  and  mor- 
phin.  The  local  application  twice  a  day  of  20  drops  of  guaiacol  in  i  dram  of 
cosmolin  or  olive  oil  gives  relief.  When  swelling  lingers,  after  tenderness 
subsides  strap  the  testicle  with  adhesive  plaster.  A  lingering  case  is  benefitted 
by  the  internal  use  of  iodid  of  potassium  and  the  local  application  of  ichthyol. 
In  gonorrheal  ophthalmia  secure  a  watch-crystal  over  the  unaffected  eye,  put 
the  patient  in  a  darkened  room,  rub  the  infected  conjunctival  sac  with  cotton 
soaked  in  a  2  per  cent,  solution  of  silver  nitrate,  wash  out  the  affected  eye  re- 
peatedly with  hot  boric  acid  solution,  keep  the  pupil  dilated  with  atropin,  leech 
the  temple,  and  give  purgatives.     Always  send  for  an  ophthalmologist. 

When  is  Gonorrhea  Cured? — It  is  said  that  Ricord  declared:  "We  know 
when  clap  begins,  but  God  alone  knows  when  it  ends."  When  actual  discharge 
ceases  a  patient  considers  himself  cured,  and  yet  he  may  have  residues  of 
infection  which  are  liable  at  any  time  to  awaken  into  activity  and  produce  anew 
an  acute  condition.  Gonococci  are  frequently  retained  in  the  urethral  glands 
and  folhcles  or  in  areas  surrounded  by  indurated  mucous  membrane.  Gono- 
cocci may  linger  in  these  haunts  for  many  months,  some  say  for  years.  Keyes, 
however,  maintains  that  they  never  persist  in  the  male  urethra  over  three 
years  and  that  in  90  per  cent,  of  cases,  with  or  without  treatment,  they  dis- 
appear within  one  year  (Edward  L.  Keyes,  Jr.,  in  "Amer.  Med.  Sci.,"  Jan., 
191 2).  It  is  customary  to  consider  a  man  well  when,  after  he  has  been  without 
treatment  for  one  week,  shreds  and  pus  disappear  from  the  urine,  when  an 
examination  of  expressed  mucus  on  three  successive  days  fails  to  find  gonococci, 
and  when  there  has  been  no  discharge  for  ten  days.  Furthermore,  we  must  be 
sure  that  the  prostate,  Cowper's  glands,  and  the  seminal  vesicles  are  free  from 
disease.  Neyer  declare  a  man  well  under  three  months  from  the  start  of  the 
disease  unless  gonococci  are  positively  absent  from  the  urine  and  the  expressed 
discharge. 

If  a  patient  has  "no  morning  drop,"  has  been  apparently  well  for  three  or 
four  months,  has  no  pus  in  the  morning  urine  or  in  the  expressed  secretion  of 
the  urethra,  prostate,  and  seminal  vesicles,  we  can,  without  making  cultures^ 
afl&rm  that  he  is  well  (Keyes,  Ibid.). 

Keyes  also  maintains  that  a  man  with  a  "pearly  morning  drop"  who  passes 
a  urine  containing  pus-shreds,  but  who  has  no  free  pus  in  expressed  secretions, 
is  probably  free  from  gonorrhea. 

Treatment  of  Chronic  Gonorrhea  and  of  Chronic  Urethritis  Following 
Gonorrhea. — The  first  thing  to  do  is  to  determine  the  cause  of  the  prolonga- 
tion of  the  discharge.     Valentine's    list  of    causes  should  be  borne  in  mind 


1504  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

("Med.  Record,"  June  29,  1901).  They  are  as  follows:  (i)  Lack  of  treatment; 
(2)  misdirected  treatment;  (,^)  insuflicient  treatment;  (4)  overtreatment;  (5) 
infraction  of  dietetic  or  hygienic  regulations;  (6)  constitutional  disturbances; 
(7)  congenital  or  acquired  deformities  and  complications;  (8)  involvement 
of  the  urethral  adnexa;  (9)  marital  reinfection.  In  a  case  in  which  a  discharge 
persists  or  recurs  the  symptoms  and  general  condition  must  be  closely  studied, 


Fig.  983. — Bougie-a-boule. 

the  discharge  must  be  examined  microscopically,  the   condition   of  the  urine 
must  be  determined,  and  the  urethra  must  be  explored. 

Exploration  of  the  urethra  is  inaugurated  by  inspection  and  external  pal- 
pation. Palpation  detects  induration,  peri-urethritis,  follicular  abscess  or 
inflammation,  Cowperitis,  etc.  The  prostate  and  seminal  vesicles  are  ex- 
amined by  a  finger  in  the  rectum.     The  interior  of  the  urethra  is  explored 


Fig.  984. — Valentine's  urethroscope. 

by  a  soft  bougie-a-boule  (Fig.  983).  On  withdrawing  this  instrument  the 
shoulder  catches  in  any  contracture.  It  is  to  be  borne  in  mind  that  a  large 
steel  sound  can  often  be  introduced  with  ease  when  the  bougie-a-boule  makes  it 
evident  that  a  contracture  e.xists.  The  emergence  of  the  instrument  is  arrested 
by  a  patch  of  thickening,  a  granular  area,  a  zone  of  epithelial  proliferation,  a 
papilloma,  or  a  stricture.  In  fact,  anything  which  lessens  the  urethral  caliber 
interferes  with  the  withdrawal  of  the'bougie-a-boule.     It  does  not  do  to  con- 


Treatment  of  Chronic  Gonorrhea 


^505 


elude  that  stricture  exists  simply  because  some  lessening  of  caliber  is  appreciated. 
The  bougie-a-boule  finds  its  chief  use  in  exploring  the  anterior  urethra.  If 
introduced  into  the  deep  urethra  its  emergence  will  be  normally  checked  as  its 
shoulder  comes  against  the  posterior  layer  of  the  triangular  ligament. 

In  most  cases  the  diagnosis  is  only  certainly  determined  by  the  use  of  the 
urethroscope.  This  instrument  has  been  perfected  of  recent  years  and  is  now  an 
absolutely  essential  part  of  our  armamentarium.  I  have  long  used  Valentine's 
instruments  (Figs.  984-987).  Marks's  air-dilating  urethroscopes  (Figs.  988, 
989)  are  highly  satisfactory.     The  anterior  and  posterior  urethra  can  be  thor- 


FiG.  9S5. — Valentine's  urethroscopic  tube. 

oughly  examined  and  with  the  utmost  ease.  Before  inserting  a  urethroscopic 
tube  place  the  patient  recumbent  and  cleanse  the  foreskin,  glans,  and  anterior 
urethra  as  directed  in  the  section  on  Cystoscopy.  Insert  a  tube  which  readily 
passes  the  meatus,  first  cleansing  the  tube  and  obturator  by  burning  alcohol 
upon  them.  Carry  the  tube  to  the  anterior  layer  of  the  triangular  ligament. 
Withdraw  the  obturator  and  insert  the  light.  Turn  on  the  light,  mop  the  ure- 
thra with  bits  of  cotton  wrapped  on  a  stick,  and  slowly  withdraw  the  tube 
examining  the  urethra  as  its  walls  fall  together  back  of  the  retractino;  tube. 


Fig.  9S6. — Valentine's  obturator. 

After  withdrawal  of  the  tube  irrigate  the  anterior  urethra.  To  examine  the 
deep  urethra  carry  the  instrument  through  the  prostatic  urethra.  After 
the  examination  give  an  intravesical  irrigation. 

When  the  cause  of  a  discharge  is  once  determined,  rational  treatment  can 
be  instituted,  and  to  determine  the  cause  the  electric  urethroscope  is  indispen- 
sable. An  erosion  of  the  mucous  membrane  or  a  granular  patch  requires  touch- 
ing from  time  to  time  with  a  solution  of  silver  nitrate  (i  or  2  per  cent,  or  even 
much  stronger).     These  applications  are  made  through  the  tube  of  the  urethro- 


FiG.  9S7. — Valentine's  light  carrier. 


scope.  A  stricture  or  an  infiltration  is  treated  by  gradual  dilatation.  This 
combines  pressure  and  massage.  If  the  caliber  of  the  urethra  be  less  than  No. 
21  of  the  French  scale,  conical  steel  sounds  are  used  twice  a  week.  If  there 
be  much  hyperesthesia  they  are  retained  but  a  brief  time;  but  as  hyperesthesia 
diminishes  the  period  of  retention  is  lengthened,  until  an  instrument  can  be  kept 
in  place  without  causing  severe  suffering  for  ten  or  fifteen  minutes.  It  is 
not  desirable  to  use  cocain.  Its  use  is  not  free  from  danger  and,  further,  it 
obtunds  the  sensibility  so  that  undue  violence  may  be  used,  and  it  increases 
postoperative  inflammation.     Before  and  after  using  an  instrument  the  ure- 


1506  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

thra  must  be  cleansed   by   irrigation   with  salt  solution  or  permanganate  of 
potassium. 

When  the  urethra  becomes  tolerant  to  instrumentation,  a  special  dilator 
is  employed  to  act  particularly  on  the  area  of  disease.     If  in  the  beginning  of 


Fig.  988. — Marks's  air-dilating  urethroscope  for  examination  of  the  anterior  urethra. 

treatment  the  caliber  of  the  urethra  is  equal  to  or  greater  than  No.  21  of  the 
French  scale,  it  is  rarely  necessary  to  precede  the  dilator  by  the  use  of  conical 
sounds.  Figs.  990-993  show  various  dilators.  A  dilator  unless  of  a  very 
modern  type  should  be  inserted  in  a  sterile  rubber  cover  before  being  used, 
otherwise  it  will  cut,  tear,  or  pinch  the  urethra  when  closed  and  withdrawn. 


L....  .  .,: ■«■■  I  _._J 

Fig.  989. — Marks's  air-dilating  urethroscope  for  examination  of  the  posterior  urethra. 

Kollmann's  dilator  (new  style)  will  not  injure  the  mucous  membrane  and  can 
be  used  without  a  cover  (Fig.  990).  A  dilator  should  be  lubricated  with  lubri- 
chondrin,  synol  soap,  or  liquid  cosmolin.  If  a  two-bladed  dilator  be  used  at 
first,  a  four-bladed  dilator  must  be  subsequently  employed. 


Treatment  of  Chronic  Gonorrhea 


1507 


A  dilator  is  cleansed  by  scrubbing  its  blades  with  soap  and  water,  placing 
them  in  alcohol,  withdrawing,  and  burning  the  alcohol  retained  on  the  in- 
strument. 

The  following  rules  for  dilatation  are  of  the  first  importance  (Ferd.  C. 
Valentine,   in   "Med.    Record,"   June   29,    1901): 


Fig.  993. — -Kollmann's  anterior  dilator. 


Fig.  991. — Oberlander's  anterior  dilator. 


Fig.  992. — Kollmann's  anteroposterior  dilator. 


Fig.  993. — Oberlander's  anteroposterior  dilator. 

1.  The  first  dilatation  must  stop  at  that  point  at  which  the  first  resistance 
to  further  dilatation  is  felt  by  the  operator's  fingers  turning  the  screw  that 
separates  the  blades. 

2.  Dilatations,  if  done  by  a  novice,  must  in  the  beginning  of  treatment 
be  repeated  no  oftener  than  every  three  or  four  days. 


Fig.  994. — Kollmann's  gland  syringe. 

3.  Each  dilatation,  in  point  of  time,  must  reach  no  greater  duration  than 
two  minutes  over  that  of  the  preceding  session. 

4.  No  dilatation  must  exceed  one-half  number  (French  Charriere  scale) 
above  the  number  attained  at  the  next  prior  seance,  regardless  of  any  lack  of 
resistance  that  may  be  present. 

As  a  rule,  glandular  and  follicular  infiltrations  are  cured  by  the  use  of  the 
dilator.     If  they  are  not,  they  must  be  treated  through  the  tube  of  the  urethro- 


1508  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

scope.  The  interior  of  a  follicle  may  be  cauterized  by  a  heated  electric  wire, 
subjected  to  electrolysis,  fulgurated  by  the  Oudin  current,  or  touched  with 
a  3  per  cent,  solution  of  silver  nitrate.  A  thickened  crypt,  gland  follicle,  or 
an  area  of  induration  may  be  slit  by  a  knife.  A  polyp  can  be  removed  by  a 
snare,  the  cautery,  or  special  forceps.  In  a  chronic  inflammation  of  the  urethra, 
in  which  the  inflammation  is  superficial  and  in  which  the  glands  are  not  involved, 
irrigations,  urethral  and  intravesical,  constitute  the  best  treatment.  ("See 
Valentine's  treatise  on  "The  Irrigation  Treatment  of  Gonorrhea,  its  Local 
Complications  and  Sequels.") 

In  any  lingering  case  of  gonorrhea  examine  the  urine,  and  direct  suitable 
treatment  for  oxaluria,  lithemia,  or  phosphaturia,  if  any  one  of  these  condi- 
tions exists.  Such  morbid  states  of  the  urine  are  occasionally  responsible  for 
great  prolongation  of  the  inflammation.  In  some  cases  a  discharge  is  kept 
up  by  inflammation  of  the  seminal  vesicles  (see  page  1521). 

Gonorrhea  of  the  anus  and  rectum  occasionally,  though  very  rarely, 
occurs.  It  may  result  from  pederasty,  or  in  a  woman  from  a  flow  of  infectious 
material  from  the  genitalia  to  the  anus.  It  causes  severe  burning  pain,  aggra- 
vated by  defecation.  The  parts  are  red,  swollen,  and  tender.  The  discharge 
is  profuse,  being  at  first  cream  white,  and  then  thicker  and  greenish.  The 
diagnosis  rests  upon  the  history  and  the  finding  of  gonococci  in  the  discharge. 
The  disease  rarely  extends  above  the  anus.  I  have  seen  one  undoubted  case 
of  rectal  gonorrhea. 

Treatment. — If  the  anus  only  be  involved,  spray  it  several  times  daily  with 
peroxid  of  hydrogen,  wash  with  salt  solution,  irrigate  with  permanganate  of 
potash  (1:4000),  dust  with  talc  powder,  and  interpose  a  piece  of  iodoform 
gauze  between  the  inflamed  surfaces.  An  ulcer,  a  fissure,  or  an  excoriation 
is  touched  with  lunar  caustic.  If  the  rectum  becomes  involved,  secure  a 
daily  bowel  movement  and  irrigate  the  rectum  twic  a  day  with  boric  acid 
solution  or  permanganate  of  potassium  (1:4000). 

Gonorrhea  of  the  Mouth. — This  is  a  ver>'  uncommon  malady.  It 
occurs  in  infants  more  often  than  in  older  people.  Infection  in  infants  may 
take  place  during  birth  if  the  mother  has  gonorrhea.  The  symptoms  are 
those  of  violent  stomatitis.  The  diagnosis  is  suggested  by  the  condition  of 
the  mother  and  is  proved  by  finding  gonococci  in  the  discharges  from  the  mouth. 

Treatment. — -Wash  the  mouth  frequently  with  boric  acid  solution,  and 
swab  the  diseased  areas  at  intervals  with  a  10  per  cent,  solution  of  argyrol. 

Gonorrhea  of  the  Nose. — It  is  alleged  that  this  condition  can  arise, 
but  an  absolutely  authentic  case  does  not  seem  to  be  on  record. 

Gonorrhea  in  the  Female. — There  is  much  dispute  as  to  the  parts  in- 
fected. Some  observers  maintain  that  the  vaginal  epithelium  never  con- 
tains gonococci  and  that  gonococci  found  in  a  vaginal  discharge  have  come 
from  the  cervix  or  uterine  canal.  Beyond  a  doubt,  however,  when  young 
women  who  have  not  borne  children  contract  gonorrhea  the  vulva  and  vagina 
usually  suffer.  In  older  women  and  in  women  who  have  borne  children  the 
vaginal  tissues  are  altered  and  the  cells  are  not  nearly  so  prone  to  infection; 
hence  in  such  subjects  the  vagina  usually  or  at  least  often  escapes.  The  initial 
infection  is  in  many  cases  in  the  cervical  canal,  in  some  in  the  vulva  or  urethra. 
No  matter  what  part  has  been  first  attacked,  other  parts  usually  become 
quickly  involved  in  the  acute  process.  The  urethra  is  involved  in  almost  every 
case.  Chronic  gonorrhea  is  prone  to  linger  in  the  urethra,  in  the  glands  of 
Bartholin,  in  the  cervical  canal,  or  within  the  uterus  or  in  the  Fallopian  tubes. 
The  great  danger  of  gonorrhea  in  the  female  is  the  development  of  ascending 
infection  of  the  lining  membrane  of  the  uterus,  which  may  reach  the  tubes, 
ovaries,  and  peritoneum. 

When  infection  occurs  during  pregnancy  or  when  pregnancy  occurs  during 
infection  of  the  cervical  or  uterine  canal,  abortion  may  take  place.     Again, 


Gonorrhea  in  Female  Children  1509 

a  pregnant  woman  may  not  abort,  but  may  go  on  to  term  and  the  child  may 
receive  a  conjunctival  infection  during  delivery  and  rapidly  develop  purulent 
ophthalmia. 

In  some  cases  when  pregnancy  occurs  during  the  existence  of  gonorrhea 
the  disease  seems  to  pass  away,  and  yet  the  child  gets  conjunctival  infection 
during  delivery  or  tlie  mother  subsequently  develops  pus-tubes. 

Treatment. — Place  the  patient  in  bed  during  the  acute  stage  of  the  disease, 
give  hot  hip-baths,  keep  the  bowels  open  by  means  of  saline  purgatives,  insist 
on  a  fluid  diet  consisting  chiefly  of  milk,  and  flush  out  the  urethra  by  having 
the  patient  drink  considerable  quantities  of  water.  The  external  genital 
organs  should  be  sprayed  with  peroxid  of  hydrogen  every  two  or  three  hours, 
and  after  spraying  should  be  dried  with  absorbent  cotton  and  dusted  with  equal 
parts  of  starch  and  powdered  oxid  of  zinc,  or  mth  powdered  stearate  of  zinc. 
Pads  of  cotton  fixed  in  place  by  a  bandage  are  used  to  catch  the  discharge. 
If  urethritis  exists  in  this  stage,  we  may  give  alkalis,  balsams,  and  astringent 
urethral  injections. 

WTien  the  acute  symptoms  have  somewhat  abated  an  attempt  should  be 
made  to  prevent  ascending  infection  from  the  cervical  canal.  The  mucous 
membrane  of  the  canal  may  be  curetted  away  or  be  destroyed  by  pure  carbolic 
acid  or  nitrate  of  silver.  A  wiser  plan  is  to  paint  the  cervical  canal  daily  with 
iodin  or  a  10  per  cent,  solution  of  argyrol,  painting  the  vaginal  portion  of  the 
cervix  at  the  same  time  with  the  same  drug.  The  vagina  is  irrigated  twice 
a  day  wdth  a  warm  solution  of  permanganate  of  potash  (1:4000)  and  is  Hghtly 
packed  with  iodoform  gauze.  When  the  vulva  particularly  is  involved,  treat 
that  part  by  applying  acetate  of  aluminum  (2  per  cent.)  locally  or  paint  the 
vulva  with  silver  solution  (40  gr.  to  i  oz.).  If  the  vulvovaginal  gland  suppurates, 
open  it. 

If  vaginitis  exists  and  continues  in  spite  of  the  treatment  suggested  above, 
wash  out  the  vagina  every  two  hours,  first  with  i  pint  of  hot  solution  of  bi- 
carbonate of  sodium,  next  wdth  i  pint  of  hot  water,  and  finally  with  i  pint  of 
astringent  solution  (i  teaspoonful  of  lead  acetate,  i  teaspoonful  of  zinc  sulphate, 
I  teaspoonful  of  alum,  or  4  teaspoonfuls  of  tannin  to  i  pint  of  hot  water). 
As  the  attack  subsides,  use  vaginal  suppositories,  each  containing  5  gr.  of  tannic 
acid.  In  some  cases  apply  solutions  of  silver  nitrate  (1:200)  or  of  argyrol 
(10  per  cent.),  and  insert  tampons  of  ichthyol  (8  per  cent.)  moistened  with 
boroglycerid  (Le  Blonde). 

In  chronic  cases  of  urethritis  use  strong  solutions  of  silver  nitrate  and  irrigate 
the  urethra  and  bladder  with  silver  nitrate  (1:8000). 

For  uterine  gonorrhea  observe  the  same  general  management.  Swab  out 
the  uterus  with  tincture  of  iodin  or  nitrate  of  silver  and  insert  tampons  of 
iodoform  gauze. 

Gonorrhea  in  Children. — Male  Children. — This  disease  is  not  very 
common.  When  it  affects  children  under  twelve  it  is  usually  due  to  some 
abandoned  and  diseased  female  having  brought  the  child's  penis  in  contact  with 
her  sexual  organs.  It  may  result  from  introducing  infected  materials  into  the 
penis.  The  symptoms  are  similar  to,  but  more  acute  than,  those  met  with 
in  an  adult.  The  finding  of  the  gonococci  is  clinical  but  not  absolute  legal 
proof  of  the  existence  of  gonorrhea,  and  it  is  to  be  remembered  that  boys 
may  suft"er  from  catarrhal  urethritis  as  a  result  of  introducing  irritants,  from 
balanoposthitis,  or  from  overacid  urine.  Legal  proof  is  afforded  by  the  growth 
of  the  suspected  micro-organisms  on  artificial  blood-serum. 

The  treat7nent  consists  in  confinement  to  bed  during  the  acute  stage,  bland 
drinks,  Hght  diet,  etc.  Circumcision  is  necessary  if  phimosis  exists.  When  the 
acute  symptoms  subside,  injections  are  used  as  in  an  adult. 

Female  Children. — Gonorrhea  is  more  common  in  female  children  than 
in  male  children,  and  the  vagina  is  involved  as  well  as  the  vulva  and  urethra. 


1510  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

A  female  child  may  suffer  from  catarrhal  inflammation  of  the  vulva,  as  a 
result  of  the  contact  of  foul  urine,  of  feces,  of  the  presence  of  seat-worms,  or 
of  neglect  of  bathing.  In  such  a  case  the  vagina  and  urethra  escape.  Involve- 
ment of  the  vagina  and  urethra  strongly  suggests  gonorrhea.  A  recently  born 
child  or  a  young  infant  may  acquire  gonorrhea  directly  from  a  diseased  mother, 
or  indirectly,  by  pus  upon  linen,  from  the  mother's  fingers,  etc.  A  diseased 
nurse  may  infect  the  baby.  Older  children  who  have  ceased  to  nurse  may  get 
the  disease  from  infected  hnen,  bathtubs,  etc.,  and  may  by  these  means  infect 
child  after  child  in  an  institution.  Now  and  then  the  disease  arises  by  a 
man  or  woman  deliberately  bringing  the  child's  private  parts  in  contact  with 
his  or  her  own  diseased  organ. 

The  disease  is  acute:  the  urethra,  vulva,  and  vagina  are  usually  involved; 
the  discharge  is  profuse,  purulent,  and  often  bloody.  During  the  first  day 
or  two  the  discharge  exhibits  leukocytes  but  no  gonococci,  and  the  normal  flora 
of  the  urethra  disappear;  later  gonococci  appear  (Harmsen,  "Zeits.  f.  Hyg. 
u.  Infektionskr.,"  1906,  vol.  iii).  Microscopical  examination  of  the  discharge 
is  absolutely  necessary.  Dry  cover-slip  preparations  are  made  so  as  to  ob- 
tain clap  shreds  from  the  discharge.  An  attempt  should  be  made  to  obtain 
cultures.  The  gonococcus  is  very  difficult  to  maintain  in  culture;  it  must 
be  frequently  transferred,  and  it  grows  best  in  an  incubator  at  a  temperature 
of  36°  C.  No  attempt  is  made  to  grow  it  upon  ordinary  culture-media.  The 
finger  may  be  steriUzed  and  punctured,  blood  thus  obtained  being  smeared 
upon  ordinary  agar.  Upon  this  composite  material  growth  can  be  obtained. 
Animal  blood-serum  is  not  a  good  medium,  but  human  blood-serum  is  (Leh- 
mann  and  Neumann).  Human  blood-serum  is  obtained  by  opening  a  vein 
or  from  a  fresh  placenta. 

Lehmann  and  Neumann  ("Atlas  and  Principles  of  Bacteriology")  find 
the  following  a  satisfactory  medium:  Agar,  containing  i  per  cent,  peptone 
and  5  per  cent,  glycerin,  which  has  been  liquefied  and  cooled  to  50°  C,  is  mixed 
"with  one-half  its  volume  of  ascitic  fluid  or  the  fluid  from  ovarian  cysts." 
Plate  cultures  and  streak  cultures  should  be  made.  This  excessive  care  in 
proving  the  presence  of  the  gonococcus  is  imperatively  necessary  in  female 
children  because  of  the  medicolegal  questions  which  may  arise  in  such  a  case 
and  also  because  of  the  danger  there  is  of  the  case  infecting  other   persons. 

Surgeons  are  apt  to  be  doubtful  about  the  diagnosis  in  many  supposed 
cases  of  gonorrhea  in  female  children.  The  clinical  picture  may  simply  be 
that  of  catarrhal  vulvovaginitis;  it  may  be  that  of  gonorrhea.  The  finding 
of  the  gonococcus  is  regarded  as  conclusive  from  a  clinical  standpoint,  but  not 
from  the  legal  point  of  view.  Again,  as  Taylor  points  out,  in  some  cases  in 
which  the  clinical  evidence  and  microscopical  findings  seem  to  prove  the  exist- 
ence of  gonorrhea  no  proof  can  be  obtained  that  the  condition  is  of  venereal 
origin,  and  in  some  cases  in  which  everything  indicates  that  the  disease  ^be- 
gan as  a  catarrhal  vulvovaginitis,  a  condition  seemingly  identical  with  gonorrhea 
has  arisen.  Obtaining  a  culture  of  gonococci  is  conclusive.  The  treatment 
consists  in  taking  every  care  to  prevent  diffusion  of  the  infection  to  others  and 
to  the  patient's  own  eyes.  She  is  put  to  bed,  given  frequent  baths,  and  fed 
upon  milk,  etc.  Irrigations  of  bicarbonate  of  sodium  are  employed,  followed 
by  protargol  (1:5000,  according  to  White  and  Martin).  Later,  astringent 
injections  are  indicated. 

Treatment  of  Gonorrheal  Arthritis  and  Endocarditis. — In  a  communication  in 
the  "Jour.  Amer.  Med.  Assoc,"  Jan.  27,  1906,  pages  261-263,  Messrs.  Rogers 
and  Torrey  described  the  method  of  preparation  of  an  antigonococcic  serum 
for  the  treatment  of  gonorrheal  arthritis.  This  serum  in  its  present  form,  as 
manufactured  by  a  good  chemical  company,  seems  possibly  to  be  of  some  value 
in  the  treatment  of  gonorrheal  infections  of  joints,  tendon-sheaths,  and  allied 
structures.     Dr.  Thomas  C.  Stellwagen,  of  the  Genito-urinary  Department  of 


Stricture  of  the  Urethra  151 1 

Jefferson  Hospital,  has  used  the  material  in  a  series  of  26  cases  of  acute  and 
chronic  gonorrheal  arthritis  with  encouraging  results  ("Therapeutic  Gazette," 
April  16,  1910). 

Preparation  of  the  Serum. — To  quote  from  Messrs.  Rogers  and  Torrey's 
reports  (Loc.  cit.):  "Rabbits  were  first  used  exclusively  in  producing  the  serum. 
Although  a  very  potent  serum  may  be  obtained  from  these  animals,  it 
was  found  that  the  serum  itself  is  decidedly  toxic  for  some  individuals  and  may 
produce  a  rather  alarming  reaction.  In  order  to  obviate  this  serious  objection 
we  have  experimented  with  goats  and  sheep.  Similar  objectionable  properties, 
although  less  in  degree,  were  found  to  be  present  in  goat  serum,  but  from  sheep 
serum  they  seem  to  be  entirely  absent.  Accordingly  in  later  work  only  these 
animals  have  been  used.  They  should  be  full  grown,  uncastrated  males.  In 
immunizing  these  animals  it  has  been  found  advantageous  to  pursue  the  follow- 
ing plan:  The  first  inoculation  may  consist  of  the  twenty-four-hour  surface 
growth  from  18  square  inches  of  solid  culture-medium,  emulsified  in  about 
30  c.c.  of  physiologic  saline  solution,  and  heated  for  one-half  hour  at 
65°  C." 

In  Stellwagen's  studies  and  use  of  the  serum  it  was  found  that  the  best 
results  were  obtained  by  giving  the  injections  as  close  to  the  area  of  infection 
as  possible,  and,  further,  by  giving  them  every  day.  The  only  untoward  results 
noticed  were  now  and  then  an  eruption  of  wheals  or  urticaria  accompanied  by 
slight  headache  and  itching,  with  a  trivial  rise  of  temperature.  The  acute 
cases  generally  showed  marked  improvement  after  about  the  seventh  injection. 
The  serum  seemed  to  be  of  use  in  other  complications  also,  such  as  orchitis, 
prostatitis,  and  epididymitis.  Stellwagen  maintains  that  the  serum  is  a  valu- 
able adjunct  in  treatment,  especially  where  the  older  standard  remedies  are 
slow  to  produce  a  result.  The  great  claim  for  serum,  however,  has  been  in 
arthritis  and  other  synovial  infections,  in  which  it  seems,  perhaps,  to  have 
some  value. 

The  serum  must  not  be  confused  with  the  vaccine,  which  is  decidedly 
uncertain.  When  the  vaccines  were  used  in  the  venereal  clinic  of  the  Jefferson 
Hospital  they  did  not  produce  the  happy  results  that  other  clinicians  have 
claimed  for  them. 

Stricture  of  the  urethra,  or  narrowing  of  the  urethral  caliber,  is  divided 
into  inflammatory,  spasmodic,  and  organic.  The  so-called  inflammatory  or 
congestive  stricture  is  not  a  stricture,  but  is  an  inflammatory  swelling  of  the 
mucous  membrane. 

Spasmodic  stricture  does  not  exist  alone,  but  complicates  organic  stricture, 
a  hyperesthetic  urethra,  or  an  inflamed  bladder. 

Organic  stricture  is  a  fibrous  narrowing  of  the  urethra,  due,  as  a  rule,  to 
chronic  gonorrheal  inflammation  or  to  traumatism.  True  organic  stricture 
is  very  rare  in  children,  but  can  occur.  Abbe  reported  a  case  of  impassable 
stricture  in  the  deep  urethra  of  a  male  child  two  and  one-half  years  of  age, 
due  to  urethral  gonorrhea.  There  were  also  two  strictures  of  the  anterior 
urethra.  External  urethrotomy  was  performed.  Traumatic  strictures  occur 
in  the  bulbous  or  membranous  urethra,  and  are  due  generally  to  force  applied 
to  the  perineum,  the  urethra  being  squeezed  between  the  subpubic  ligament 
and  the  vulnerating  body.  Strictures  resulting  from  gonorrheal  inflammation 
occur  in  the  penile,  bulbous,  or  membranous  urethra.  Stricture  never  forms 
in  the  prostatic  urethra  except  as  a  result  of  traumatism.  Recent  non-traumatic 
strictures  are  soft  and  are  easily  distended.  Old  strictures  and  traumatic 
strictures  are  very  dense.  A  resilient  stricture  is  one  which  contracts  quickly 
after  dilatation.     The  nearer  a  stricture  is  to  the  meatus,  the  more  fibrous  it  is. 

A  congenital  stricture  is  congenital  narrowness  of  a  portion  of  the  urethra, 
usually  the  portion  near  the  meatus.  The  more  fibrous  a  stricture  is,  the  more 
it  narrows  the  urethra  and  the  less  dilatable  it  will  prove.     A  stricture  may  be 


1512  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

annular  (forming  a  ring  around  the  urethra),  tubular  (surrounding  the  ure- 
thra for  a  considerable  distance),  or  bridle  (when  a  band  crosses  the  urethra 
from  wall  to  wall).  A  stricture  of  large  caliber  will  admit  an  instrument  larger 
than  a  No.  15  French  sound.  A  stricture  of  small  caliber  will  not  admit  a  No. 
15  French  sound.  An  impermeable  stricture  will  not  admit  the  passage  of  any 
instrument.  "Impermeable"  is  more  or  less  a  relative  term.  A  stricture  may 
be  impermeable  when  an  anesthetic  is  not  used,  and  permeable  when  the  patient 
is  anesthetized,  or  may  be  impermeable  to  one  surgeon,  but  permeable  to 
another.  Impermeability  is  often  a  temporary  condition  due  to  spasm  or  to 
inflammatory  edema  about  an  organic  stricture. 

Symptoms  and  Results  of  Stricture. — There  is  usually  a  history*  of  repeated 
attacks  of  urethritis.  There  may  exist  a  chronic  discharge,  the  amount  of  which 
is  variable.  There  is  a  feeling  of  weight  in  the  perineum  and  soreness  of  the 
back,  and  frequency  of  micturition  is  complained  of.  Hypochondriacal  ten- 
dencies are  usual.  In  a  deep  stricture  there  is  difficulty  in  starting  the  stream 
in  micturition.  In  most  cases  the  stream  is  small,  twisted,  and  forked.  There 
is  often  interruption  or  "stammering"  of  the  stream,  and  it  dribbles  long 
after  the  conclusion  of  the  act,  so  that  the  penis  must  be  "milked"  before  it 
is  returned  within  the  clothing.  The  urethra  back  of  a  stricture  dilates,  a 
pouch  forms,  drops  of  urine  collect  and  decompose,  and  in  the  mucous  membrane 
or  the  parts  adjacent  there  results  a  chronic  inflammation  which  may  go  on 
to  ulceration  or  to  periurethral  abscess.  A  urinary^  fistula  follows  the  opening 
externally  of  a  periurethral  abscess.  Retention  of  urine  may  occur,  not  from 
actual  obliteration  of  the  tube  by  the  growth  of  the  stricture,  but  from  closure 
of  the  lumen  of  the  urethra  by  muscular  spasm  and  from  edematous  swelling  in 
the  neighborhood  of  the  stricture.  Edematous  swelling  may  be  due  to  cold, 
wet,  venereal  excitement,  the  use  of  alcohol,  overexertion,  etc.  Spasm  of  the 
muscles  results,  and  contact  of  the  urine  increases  the  spasm,  and  spasm  with 
edema  of  the  mucous  membrane  closes  the  urethra.  Spasm  may  exist  in  the 
urethra  itself  and  in  the  muscles  of  the  neck  of  the  bladder,  but  is  only  a  tem- 
porary condition.  In  old  strictures  the  bladder  is  hv'pertrophied  and  often 
fasciculated,  and  is  very  Uable  to  cystitis.  The  diagnosis  of  stricture  and  of 
its  location  is  made  by  the  use  of  exploratory  bougies.  In  this  examination 
the  author  follows  to  a  great  extent  Ramon  Guiteras's^  plan  which  is  as  follows: 
Have  the  patient  pass  urine  into  two  glasses.  Examine  the  urine  for  clap- 
shreds.  Cloudiness  in  the  first  glass  shows  that  urethral  discharge  exists. 
Cloudiness  in  the  second  glass  points  to  cystitis.  The  patient  is  placed  re- 
cumbent with  his  shoulders  elevated,  and  the  urethra  is  washed  out  with  warm 
salt  solution  or  boric  acid.  Bulbous  sounds  are  inserted,  beginning  with  No. 
15  French.  If  this  passes  with  ease,  take  a  larger  size  and  note  where  strictures 
are  situated  by  the  catch  on  withdrawal.  If  No.  15  does  not  pass,  use  a  smaller 
size.  Remember  that  the  posterior  layer  of  the  triangular  ligament  catches  a 
bulbous  instrument  on  withdrawal.  If  the  meatus  be  too  small  to  permit  of 
exploration,  divide  it  by  a  curved  bistoury,  cutting  from  within  outward.  After 
cutting  the  meatus  bleeding  is  arrested  with  styptic  cotton,  and  a  piece  of 
absorbent  cotton  is  tucked  into  the  cut.  After  each  act  of  micturition  the 
patient  inserts  a  fresh  bit  of  cotton,  and  after  three  days  the  urethral  examina- 
tion may  be  proceeded  with. 

Treatment. — A  stricture  of  large  caliber  in  the  deep  urethra  requires  gradual 
dilatation.  A  steel  bougie  is  introduced  every  fifth  day,  the  size  being  gradually 
increased.  Never  anoint  a  bougie  with  vaselin,  as  it  may  become  a  nucleus  for 
a  stone  in  the  bladder;  use  liquid  cosmolin,  glycerin,  synol  soap,  or  lubrichondrin. 
Before  passing  an  instrument  the  patient  urinates  and  his  urethra  is  washed 
out  with  salt  solution  or  boric  acid  solution.  Glans,  meatus,  and  urethra  are 
cleansed  as  directed  on  page  1492.  The  sound  is  rendered  sterile  by  boiling 
1  "Med.  Record,"  Nov.  14,  1896. 


Treatment  of  Stricture 


1513 


before  using.  Gradual  dilatation  can  be  effected  by  the  use  of  the  dilator  of 
Oberlaender,  the  tube  being  distended  to  the  extent  of  3  mm.  every  fifth  day.  If 
after  dilatation  there  be  urethral  spasm,  pain,  or  very  frequent  micturition, 
suspend  the  treatment  for  a  number  of  days  and  order  each  night  a  hot  hip- 
bath and  a  dose  of  paregoric.  During  gradual  dilatation  the  patient  should 
not  use  alcohol,  should  refrain  from  sexual  excitement,  should  avoid  cold  and 
damp,  and  should  take  internally  capsules  containing  boric  acid  and  salol. 


1) 


Fig.  995. — S.  W.  Gross's  ex- 
ploratory ureth.rotome. 


Fig.  996. — Maisonneuve's  ureth- 
rotome. 


Fig.  997. — Horwitz's 
modification  of  ^Maison- 
neuve's  urethrotome. 


It  is  rarely  necessary  to  dilate  above  No.  32  French.  After  the  surgeon  finishes 
treatment  he  teaches  the  patient  to  use  an  instrument  and  directs  him  to  pass 
it  once  a  month,  because  gradual  dilatation  rarely  cures  a  stricture,  and  if  dilata- 
tion be  permanently  abandoned  contraction  will  probably  occur.  Strictures  in 
the  pendulous  urethra,  if  soft,  are  treated  by  gradual  dilatation;  if  fibrous 
and  contractile,  by  internal  urethrotomy.  For  fibrous  stricture  in  or  near  the 
bidb  external  urethrotomy  should  be  combined  with  internal  division.     External 


1 5 14  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

urethrotomy  secures  drainage,  and  by  performing  it  we  greatly  lower  mortality. 
In  performing  internal  urethrotomy  prepare  the  patient  carefully;  for  several 
davs  before  the  operation  give  salol  and  boric  acid  by  the  mouth,  and  wash 
out  the  bladder  repeatedly  with  boric  acid  solution.  Be  thoroughly  aseptic 
\ncsthetize  the  patient.  Before  cutting  irrigate  the  urethra  with  warm  normal 
salt  solution,  and  after  cutting  irrigate  again,  pass  a  rubber  catheter  into  the 
bladder  and  tie  it  in.  These  precautions  will  prevent 
urethral  fever.  In  cutting,  insert  Gross's  urethrotome 
(Fig.  995)  back  of  the  stricture,  spring  out  the  blade,  cut 
the  stricture  on  the  roof  of  the  urethra,  close  the  blade, 
withdraw  the  instrument,  and  pass  a  full-sized  bougie. 

Stricture  of  the  meatus  requires  in- 
cision by  a  knife  and  the  use  of  a  meatus 
bougie  until  healing  is  complete. 
Strictures  of  small  caliber  in  front  of 
the  membranous  urethra  require  gradual 
dilatation  and,  if  this  fails,  internal  ure- 
throtomy or  divulsion.  Internal  ure- 
throtomy can  be  performed  with  the 
urethrotome  of  Maisonneuve  (Fig.  996) 
or  the  Otis-Wyeth  instrument  (Fig.  998). 
The  instrument  of  Maisonneuve  is 
shaped  like  a  sound,  has  a  groove  upon 
its  surface,  and  into  this  groove  a  shaft 
carrying  a  triangular  knife  can  be  in- 
serted. The  staff  is  screwed  to  a  guide, 
the  guide  is  carried  into  the  bladder  and 
the  staff  follows  it.  The  point  of  the 
staff  is  carried  to  the  prostatic  urethra 
and  the  guide  curls  up  in  the  bladder. 
The  penis  is  held  upon  the  stretch,  the 
blade  is  inserted  and  pushed  down 
through  the  stricture.  This  instrument 
cuts  the  stricture,  but  not  the  healthy 
urethra.  Stricture  within  i  inch  of  the 
meatus  is  divided  on  the  floor  of  the 
urethra.  A  deeper  stricture  is  divided 
on  the  roof,  except  at  or  near  the  bulbo- 
membranous  junction.  In  such  a  stricture 
the  roof  is  divided  by  internal  urethrot- 
omy and  the  floor  by  external  urethrot- 
omy. In  using  a  urethrotome  do  not 
overdilate  or  cut  deeply.  To  do  so  will 
cause  deformity  of  the  penis.  For  di- 
vulsion the  patient  is  prepared  as  for  in- 
ternal urethrotomy.  The  dilator  of  Gross 
(Fig  999),  or  divulsor  of  Sir  Henry 
Thompson  or  of  Goulev  (Figs.  1000,  looi)  is  introduced,  the  blades  are  separated, 
the  instrument  is  withdrawn,  a  large  bougie  is  passed,  and  a  catheter  is  tied  in  the 
bladder  Strictures  of  small  caliber  in  the  deep  urethra  are  seldom  permanently 
benefited  by  gradual  dilatation.  The  best  method  is  combmed  internal  and 
external  urethrotomy.  In  strictures  of  the  deep  urethra,  if  only  a  filiform  bougie 
can  be  introduced,  the  bougie  may  be  left  in  place,  and  in  a  day  or  two  another 
can  be  slipped  in  beside  it,  until  in  a  few  days  the  channel  becomes  permeable  to 
a  metal  bougie.  A  tunneled  catheter  can  be  slipped  over  the  fihform  bougie 
both  be  withdrawn,  and  a  metal  bougie  passed.     A  tunneled  and  grooved  statt 


Fig.  998. — Otis's  di- 
lating urethrotome. 


Fig.     999- — Gross 
urethral  dilator. 


Urinary  Fever 


1515 


can  be  carried  in  over  the  bougie  and  external  urethrotomy  performed. 
Thompson's  dilator  can  be  carried  in  over  the  filiform  and  the  stricture 
divulsed.  What  is  known  as  modified  rapid  dilatation  consists  in  first  dilating, 
as  described  above,  by  the  Thompson  dilator  and  then  introducing  the  powerful 
dilator  of  Gross  (Fig.  999)  to  distend  the  urethra  to  the  limit.  This  operation 
tears  and  lacerates  rather  than  dilates  and  has  been  practically  abandoned.  In 
impassable  stricture  of  the  deep  urethra  perform  external  perineal  urethrotomy 
without  a  guide  (the  operation  of  Wheelhouse). 

If  a  perineal  fistula  exists,  dilate,  divulse,  or  cut  the  stricture  and  retain 
a  catheter  in  the  bladder  for  forty-eight  hours.  After  this  period  dilate  the 
urethra  every  fourth  or  fifth  day  by  a  metal  instrument.  Every  morning 
and  evening  draw  the  urine  by  a  soft  catheter,  introduce  boric  acid  solution 


Fig.  iooo. — A  Thompson's  divulsor  maybe  carried  in  over  a  filiform  and  the  stricture  divulsed. 

into  the  bladder,  remove  the  catheter,  and  let  the  man  empty  his  bladder 
naturally.  A  part  will  flow  from  the  fistula  and  a  part  from  the  meatus.  Day 
by  day  the  quantity  which  comes  from  the  fistula  lessens,  and  finally  the  ab- 
normal opening  heals. 

Urethral  Fever. — Any  operation  upon  the  urethra  may  be  followed  by  a 
chill  owing  to  shock  (urethral  shock),  and  this  may  be  followed  by  a  nervous 
fever.  Urethral  fever  proper  is  sapremia  following  a  urethral  operation. 
The  condition  is  due  to  absorption  of  toxic  elements  which  may  be  in  the  urine, 
may  have  been  in  the  urethra,  or  may  have  been  introduced  from  without. 
It  usually  follows  the  first  urinary  act  after  operation.  It  begins  with  a  violent 
chill  and  presents  the  characteristics  of  a  septic  fever.  It  is  accompanied  by  a 
marked  tendency  to  urinary  suppression,  and  may  eventuate  in  septicemia 


Fig.  iooi. — Gouley's  divulsor. 

or  pyemia.  Urethral  fever  can  be  prevented  by  rigid  antisepsis.  If  this  fever 
should  arise,  a  catheter  must  be  tied  in  the  bladder,  the  bladder  and  urethra 
must  be  repeatedly  irrigated  with  aseptic  or  antiseptic  fluids,  and  the  patient 
must  be  given  antiseptics  and  stimulants  by  the  mouth. 

Urinary  Fever. — Sir  Benjamin  Brodie  pointed  out  that  the  withdrawal 
of  residual  urine  in  a  case  of  enlarged  prostate  may  be  followed  by  very  serious 
symptoms.  The  condition  is  spoken  of  as  urinary  fever,  and  was  said  to  be  due 
to  the  sudden  and  complete  emptying  of  a  bladder  which  had  become  accustomed 
to  retaining  permanently  a  considerable  quantity  of  urine.  Modern  studies 
prove  that  urinary  fever  is  due  to  infection  of  the  bladder  and  kidneys,  and  not 
simply  to  the  sudden  withdrawal  of  all  of  the  urine  from  the  bladder,  although 
such  a  procedure  leads  to  vesical  congestion  and  probably  favors  infection. 
The  bacteria  most  often  found  are  pyogenic  cocci,  colon  bacilli,  and  micro- 
organisms which  cause  putrefaction  and  decomposition  of  urea. 


i<i6 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


The  condition  does  not  arise  promptly,  suddenly,  and  violently,  as  does 
urethral  fever,  but  begins  rather  insidiously  after  several  days.  Mr.  C. 
Mansell  Moullin^  thus  describes  the  condition: 

"So  far  as  the  broader  features  are  concerned,  the  symptoms  that  present 
themselves  in  these  cases  are  remarkably  uniform.  They  do  not  begin  at 
once.  Nearly  always  some  few  days  elapse  before  there  is  anything  to  excite 
suspicion.  Then  the  urine  becomes  cloudy,  though  it  may  still  retain  its  acid 
reaction.     A  small  quantity  of  albumin,  more  than  can  be  accounted  for  by 


Fig.  I002. — -Syme's  grooved  staff. 

the  amount  of  pus  that  is  present,  makes  its  appearance.  Under  the  microscope 
there  are  a  few  hyahne  casts,  perhaps  a  blood-corpuscle  or  two,  numerous  pus- 
corpuslces,  and  myriads  of  bacteria.  The  specific  gravity  is  lower  than  it 
ought  to  be,  and  is  lower  than  it  was  before  the  catheter  was  used.  The  total 
amount  passed  in  the  twenty-four  hours  may  either  increase  until  it  is  as  much 
as  7  or  8  pints,  or  diminish  until  it  scarcely  reaches  20  oz.  There  is  seldom 
any  definite  rigor,  but  there  may  be  numerous  slight  chills.     The  pulse  grows 


Fig.  1003. — Wheelhouse's  staff. 

more  rapid  and  feeble.  The  tongue  becomes  red  and  dry.  There  is  complete 
anorexia.  Delirium  sets  in  at  night,  and  in  a  considerable  proportion  of  cases 
the  symptoms  rapidly  grow  worse  and  worse  until,  at  the  end  of  a  few  days, 
the  patient  sinks  into  a  semicomatose  condition  from  which  he  seldom  rallies. 
Postmortem  there  are  all  the  signs  of  recent  acute  cystitis  and  pyelonephritis. 
The  mucous  membrane  lining  the  pelvis  and  cahces  of  the  kidney,  the  ureters, 
and  the  bladder  is  swollen  and  stained  by  old  and  recent  hemorrhages,  and  here 
and  there  a  thin  layer  of  pus  is  adherent  to  it.     The  pelvis  and  the  ureters  are 


Fig.  1004. — Teale's  probe  gorget. 

dilated,  the  apices  of  the  pyramids  are  eaten  away,  the  cortex  is  shrunken  and 
hard,  the  capsule  is  adherent,  and  in  places  between  the  tubules  are  minute 
collections  of  pus  differing  in  shape  and  outline  according  to  the  anatomical 
arrangement." 

Treatment. — Aseptic  catheterization  is  necessary  if  we  would  avoid  urinary 
fever;  and  as  the  urethra  contains  some  of  the  causative  organisms,  the  prepuce, 
glans,  and  meatus  should  be  washed  with  soap  and  water  and  irrigated  with 

1"  Lancet,"  Sept.  10,  1898. 


Gibson's  Operation  for  Impermeable  Stricture  151 7 

boric  acid  or  permanganate  of  potassium  solution,  and  the  urethra  should  be 
irrigated  with  boric  acid  solution  or  permanganate  of  potassium  before  the  sterile 
catheter  is  introduced  to  draw  the  urine. 

If  urinary  fever  arises,  it  may  be  possible  to  control  it  by  frequently  irri- 
gating the  bladder  with  warm  normal  salt  solution,  solution  of  nitrate  of  silver 
(1:8000)  or  boric  acid  solution,  and  by  administering  stimulants,  diuretics, 
diaphoretics,  saline  cathartics,  urotropin,  salol  or  boric  acid,  quinin,  and  nutri- 
tious food.     In  severe  cases  perform  suprapubic  cystostomy  for  drainage. 

Perineal  section  is  external  perineal  urethrotomy.  There  are  three 
methods — the  operation  of  Syme,  of  Wheelhouse,  and  of  Cock. 

Syme's  Operation. — This  operation  is  employed  if  a  stricture  is  very  con- 
tractile, if  dilatation  fails  to  cure,  or  if  urethral  instrumentation  invariably 
causes  pronounced  urethral  fever.  The  patient  is  anesthetized,  Syme's  staff 
(Fig.  1002)  is  introduced,  and  the  surgeon  makes  an  incision  in  the  midline  of 
the  perineum  and  exposes  the  staff  just  above  the  shoulder  of  the  instrument. 
The  knife  is  carried  along  the  groove  and  divides  the  stricture.  A  catheter  is 
passed  into  the  bladder  from  the  meatus  and  is  retained  for  several  days,  and 
the  wound  is  dressed  antiseptically.  After  the  catheter  has  been  removed  it 
must  be  used  every  six  hours  until  the  urine  passes  by  way  of  the  meatus  only. 
During  the  rest  of  the  patient's  life  a  full-sized  sound  should  be  passed  at 
monthly  intervals. 

Wheelhouse's  Operation. — This  operation  is  employed  for  the  treatment  of 
impermeable  stricture.  Wheelhouse's  staff  (Fig.  1003)  is  passed  into  the  urethra 
until  it  blocks  on  the  stricture.  The  perineum  is  incised  down  to  the  staff 
and  in  front  of  the  stricture.  The  edges  of  the  cut  urethra  are  held  apart 
by  forceps,  the  surgeon  seeks  for  the  opening  through  the  stricture,  passes  a 
fine  probe  through  it,  divides  the  stricture,  carries  into  the  bladder  from  the 
wound  an  instrument  known  as  a  probe  gorget  (Fig.  1004)  to  dilate  the  canal 
and  furnish  a  solid  floor  to  facilitate  the  introduction  of  a  catheter.  With  the 
gorget  in  place  a  metal  catheter  is  carried  from  the  meatus  into  the  bladder. 
The  gorget  is  removed  and  the  catheter  is  tied  in  place.  After  three  or  four 
days  the  catheter  is  removed  and  is  then  passed  frequently.  The  perineal 
wound  is,  of  course,  dressed  antiseptically. 

Cock's  Operation. — This  operation  opens  the  urethra  back  of  the  stricture 
without  the  aid  of  a  guide  and  relieves  retention  of  urine.  The  surgeon  intro- 
duces into  the  rectum  the  index-finger  of  the  left  hand,  and  the  tip  of  the  finger 
is  rested  upon  the  apex  of  the  prostate  gland.  The  surgeon  incises  the  median 
line  of  the  perineum,  the  back  of  the  knife  being  toward  the  anus.  When 
the  point  of  the  knife  is  felt  to  be  near  the  finger  the  handle  is  lowered  slightly, 
the  blade  is  placed  a  little  obliquely,  and  the  urethra  is  opened.  A  catheter 
is  passed  into  the  bladder  from  the  wound  and  retained  for  a  time,  and  the  stric- 
ture is  subsequently  treated. 

Gibson's  Operation  for  Impermeable  Stricture  (C.  L.  Gibson,  in  ^'Med. 
Record,"  Aug.  6,  1910). — Open  the  posterior  urethra  by  Cock's  operation  (see 
above).  In  most  cases  it  is  now  possible  to  pass  a  small  urethrotome  from 
the  urethral  wound  forward.  If  this  can  be  done  the  deep  stricture  is  at  once 
divided.  If  it  cannot  be  done  a  filiform  is  passed  from  the  urethral  wound 
out  through  the  urinary  meatus.  This  maneuver  may  require  the  aid  of  a 
special  instrument  (Gibson's  retrograde  filiform  carrier).  The  straight  staff 
of  the  Fliihrer  urethrotome  is  threaded  over  the  filiform  bougie  in  front  of  the 
meatus.  It  is  pushed  back  until  it  passes  through  the  stricture,  when  the  knife 
is  inserted  and  "pushed  home."  This  trivial  cut  permits  the  passage  of  a 
large  urethrotome  (for  instance,  Otis's).  The  stricture  is  now  freely  divided 
(up  to  No.  30  French).  After  division  of  the  stricture  a  No.  30  French  steel 
sound  is  carried  from  the  meatus  into  the  bladder.  A  tube  to  drain  the  bladder 
is  introduced  through  the  wound. 


I^Ii 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


Epispadias  is  a  congenital  cleft  in  the  coqDora  cavernosa,  the  roof  of 
the  urethra  being  completely  or  partly  absent.  In  complete  epispadias  there 
are  absence  of  the  pubic  arch  and  exstrophy  of  the  bladder. 

Partial  epispadias  may  sometimes  be  remedied  by  a  plastic   operation. 

Hypospadias  is  a  congenital  cleft  in  the  floor  of  the  urethra,  the  meatus 
opening  on  the  floor  at  some  point  between  the  scrotum  and  the  end  of  the 
glans  penis,  the  channel  in  front  of  the  meatus  being  a  gutter  and  not  a 
tube. 

Hypospadias  of  the  glans  is  the  most  common  form.  In  this  condition 
the  urethra  has  no  floor  as  it  passes  beneath  the  glans,  the  site  of  the  urethra 
is  indicated  by  a  groove,  and  the  foreskin  is  absent  below.  Partial  hypo- 
spadias requires  no  treatment  except  possibly  dilatation  or  incision  of  the 
meatus.  People  who  suffer  from  it  are  very  prone  to  develop  chronic  urethral 
inflammation.     In  hypospadias  of  the  penis  the  ill-developed  cord-like  corpus 


Fig.  1005. 

Figs.  1005- 


FiG.  1006. 


riG.  1006. 
1007. — Beck's  operation  for  hypospadias, 


Fig.  1007. 


spongiosum  draws  the  penis  to  the  scrotum.  In  this  variety  of  the  deformity 
the  penis  is  very  short. 

In  complete  hypospadias  the  opening  of  the  urethra  is  back  of  the  scrotum 
in  the  perineum,  the  penis  is  dwarfed  and  bound  down,  and  looks  not  unlike 
a  clitoris,  the  scrotum  is  divided  into  two  portions,  a  gap  existing  between  them, 
and  in  many  cases  the  testicles  have  not  descended.  Such  individuals  are 
occasionally  mistaken  for  females.  In  the  penile,  complete  forms  of  hypo- 
spadias a  plastic  operation  should  be  performed  between  the  eighth  and  tenth 
years  of  age.  Such  an  operation,  unfortunately,  may  fail.  H}^ospadias 
is  rare  in  women,  but  it  may  occur.  In  such  a  case  the  urethra  opens  into  the 
vagina.  Figures  1005,  1007  show  the  ingenious  operation  successfully  prac- 
tised by  Carl  Beck  for  penile  hypospadias. 

Chancroid  {soft  chancre;  the  local  venereal  sore)  is  an  ulcer,  usually  of 
venereal  origin.  The  name  "  chancroid  "  was  introduced  by  Clerc,  who  believed 
that  a  soft  sore  resulted  from  inoculating  a  person  already  s^^philitic  with  the 


Chancroid 


1519 


products  of  a  hard  sore.  He  further  held  that  when  a  soft  sore  arose  the 
syphihtic  poison  lost  its  infective  properties,  and  "could  be  transmitted  as 
a  soft  sore  to  a  healthy  person,  and  not  cause  general  infection."^  The  chan- 
croidal ulcer  is  not  connected  with  the  syphilitic  poison,  but  is  developed 
by  inoculation  with  the  bacterium  of  Ducrey.  Until  recently  it  was  believed 
that  a  chancroid  was  not  produced  by  a  special  poison,  but  arose  after  in- 
oculation with  inflammatory  products  or  irritating  secretions.  It  seems  to 
have  been  proved,  however,  by  Krefting  and  Colombini  that  the  organism 
discovered  by  Ducrey  in  1889  is  the  real  cause.  This  organism  is  grown  on  a 
medium  of  fresh  blood  and  bouillon  or  in  "unmixed  human  blood."  (See 
Lincoln  Davis,  "Observations  On  the  Distribution  and  Culture  of  the  Chan- 
croid Bacillus,"  "Report  of  Research  Work,"  1902-03;  the  Division  of  Surgery 
of  the  Medical  School  of  Harvard  University.)  As  a  rule,  chancroids  are  of 
venereal  origin,  and  result  from  contact  with  other  chancroids,  pus,  mucopus, 
or  areas  of  ulceration.  A  chancroid  appears  soon  after  intercourse,  usually 
within  five  days,  always  within  ten  days.  It  is  first  manifested  by  a  pustule 
which  ruptures  and  discloses  an  ulcer.  This  ulcer  has  sharply  defined  and 
undermined  margins;  it  looks  "punched  out;"  the  base  is  gray  and  sloughy; 


Fig.  1008. — Buttonhole  perforation  of 
the  prepuce  following  phagedenic  chancroid 
(Horwitz). 


Fig.  1009. — Buttonhole  perforation  of 
the  prepuce  following  phagedenic  chancroid 
(Horwitz). 


the  discharge  is  profuse,  purulent,  foul  and  auto-inoculable,  and  causes  fresh 
chancroids  by  flowing  over  the  parts.  The  area  around  a  chancroid  is  red 
and  inflamed,  and  considerable  pain  is  apt  to  be  complained  of.  The  original 
chancroid  spreads  and  new  sores  appear.  The  edge  of  a  chancroid  is  rarely 
indurated  unless  caustics  have  been  used  or  there  is  mixed  infection  with  syphilis. 
Inflammatory  induration  fades  gradually  into  the  tissues,  but  the  induration 
of  a  hard  chancre  is  sharply  defined.  Fournier  says  that  a  chancroid  may  have 
a  hard  base  if  the  sore  is  located  in  the  sulcus  back  of  the  glans,  on  a  lip  of  the 
meatus,  or  on  the  lower  border  of  the  prepuce  of  a  man  with  phimosis,  or  when 
the  ulcer  is  inflamed.  The  surgeon  should  always  ask  if  the  sore  has  been  cau- 
terized and  how  it  has  been  treated.  When  a  chancroid  after  a  time  displays 
marked  and  sharply  outlined  induration  it  points  to  mixed  infection  with  chan- 
croidal and  syphilitic  organisms.  Chancroids  are  not  followed  by  constitutional 
symptoms,  but  are  apt  to  be  accompanied  by  painful  inflammatory  buboes 
which  are  prone  to  suppurate.  In  hospital  practice  about  30  per  cent,  of 
patients  with  chancroids  develop  buboes.  The  bubo  may  be  either  unilateral 
or  bilateral.     In  the  majority  of  cases  the  adenitis  of  chancroid  is  due  to  the 

1  "Syphihs,"  by  Alfred  Cooper. 


I^20 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


absorption  of  toxins  alone  and  the  pus  may  be  entirely  free  from  bacteria. 
Cases  have  been  reported  in  which  non-indurated  sores  were  followed  by  s^^hilis. 
It  is  probable  that  a  mixed  infection  existed,  and  that  induration  was  over- 
looked, because  a  papular  initial  lesion  was  beneath  the  chancroidal  ulcer. 
When  inflammation  in  chancroids  is  high,  a  rapidly  destructive  ulceration  known 
as  phagedena  may  arise  (Figs.  1008  and  1009),  but  this  process  is  more  common 
in  syphilitic  sores. 

Treatment. — Ordinary  cases  of  chancroid  are  treated  by  spraying  with 
peroxid  of  hydrogen,  drying  with  cotton,  touching  each  sore  first  with  pure 
carbolic  acid  and  then  with  pure  nitric  acid,  and  dressing  with  black  wash 
or  dusting  with  iodoform  or  with  calomel.  Every  few  hours  the  patient  soaks 
the  penis  in  hot  salt  water  (a  teaspoonful  of  salt  to  a  pint  of  water),  sprays  the 
sores  with  peroxid  of  hydrogen,  dries  with  cotton,  and  dresses  with  black 
wash  or  dusts  with  iodoform  or  with  calomel.  As  soon  as  granulation  begins 
the  sores  should  be  dressed  with  i  part  of  ointment  of  nitrate  of  mercury  to 
7  parts  of  cosmolin.  Mild  cases  do  well  without  cauterizing,  peroxid  of  hydro- 
gen being  frequently  used  and  a  drying  powder  being  employed.  In  chan- 
croids with  phimosis  slit  up  the  foreskin,  smear  the  raw  edges  of  the  wound 
with  pure  carbolic  acid,  and  treat  the  ulcers  by  cauterization.  A  regular  cir- 
cumcision usually  fails  because  of  infection  of  the  stitch-holes.  Phagedena 
requires  the  internal  use  of  iron,  quinin,  and  milk-punch,  and  the  local  use  of 
powerful  caustics  (bromin  or  nitric  acid  or  even  the  actual  cautery).  In  some 
cases  continuous  antiseptic  irrigation  is  valuable.  When  a  bubo  first  begins, 
order  rest,  apply  iodin  or  an  ointment  of  belladonna  and  ichthyol,  and  make 
pressure  by  a  spica  bandage  of  the  groin.  Some  surgeons  advise  the  injection 
of  20  to  40  min.  of  a  solution  of  carbolic  acid  (10  gr.  to  the  ounce),  but  I  have 
never  seen  any  benefit  from  it.  Some  inject  a  i  per  cent, 
solution  of  bichlorid  of  mercury,  but  the  proceeding  causes 
intense  pain.  Welander  recommends  the  injection  of  a 
I  per  cent,  solution  of  benzoate  of  mercury.  I  have  had 
no  experience  with  this  method.  If  the  bubo  persists,  though 
it  does  not  suppurate,  it  should  be  completely  excised.  If 
.  pus  forms,  several  methods  of  treatment  are  open  to  us: 
cumdsion°completed  aspiration,  injection  with  a  solution  of  carbolic  acid,  squeez- 
(Esmarch  and  ing  out  the  acid  and  injecting  10  per  cent,  ointment  of 
Kowalzig).  iodoform  and  glycerin,  and  sealing  the  opening  with  collodion 

(Scott  Helms).  Hayden  makes  a  puncture,  squeezes  out 
the  pus,  washes  out  the  cavity  with  peroxid  of  hydrogen,  and  then  with 
corrosive  sublimate  solution,  injects  warm  iodoform  ointment,  and  dresses 
with  cold,  moist,  corrosive  sublimate  gauze  to  set  the  ointment.  Otis, 
Fontain,  Perry,  and  others  commend  this  plan.  We  have  sometimes  found 
it  to  succeed.  If  the  above-mentioned  plan  fails,  if  it  is  not  used,  or  if  an 
ulcer  or  sinus  exists,  incise,  curet,  cauterize  with  pure  carbolic  acid,  cut  away 
hopelessly  infiltrated  skin,  and  pack  the  wound  with  iodoform  gauze.  In  some 
cases  it  will  be  necessary  to  extirpate  fragments  of  gland. 

Phimosis  is  a  condition  of  the  prepuce  that  renders  retraction  over  the 
glans  impossible.  It  is  usually  congenital,  but  it  may  arise  from  inflamma- 
tion. Congenital  phimosis  causes  retention  of  sebaceous  matter,  which  de- 
composes and  Ughts  up  inflammation  and  the  prepuce  is  apt  to  grow  fast  to 
the  glans.  Congenital  phimosis  may  induce  irritability  of  the  bladder,  incon- 
tinence of  urine,  prolapse  of  the  rectum,  and  various  nervous  symptoms. 

The  treatment  is  circumcision.  Asepticize  the  parts.  Grasp  the  foreskin 
and  the  mucous  membrane  by  two  pairs  of  forceps,  draw  the  prepuce  forward, 
catch  the  skin  (at  the  point  it  is  desired  to  cut)  horizontally  between  the 
arms  of  the  handle  of  a  pair  of  scissors,  and  cut  off  the  redundant  prepuce. 
Retrench  the  excess  of  mucous  membane  by  trimming  with  scissors  \'i  inch 


Acute  Vesiculitis 


1521 


Fig.  ioii. — Cancer  of  penis  (Horwitz). 


from  the  glans,  stitch  the  skin  to  the  mucous  membrane  with  catgut,  and  dress 
with  sterile  gauze  (Fig.  loio). 

Fracture  of  the  penis,  which  is  a  laceration  of  the  cavernous  bodies 
with  extravasation  of  blood,  occurs  occasionally  during  coition. 

The  treatment  consists  of  cold  and  bandaging  to  arrest  bleeding,  and  in 
some  cases  incisions  to  let  out  clot. 

Gangrene  of  the  penis  arises  from  phagedena,  from  tying  constricting 
bands  around  the  organ,  from  fracture  with  excessive  hemorrhage,  and  from 
paraphimosis.     If  extensive,  it  requires  amputation. 

Cancer  of  the  penis  (Fig.  loii) 
is  commonest  in  persons  with  phi- 
mosis. Penile  cancer  is  practically 
never  seen  in  Jews.  It  may  develop 
from  a  syphilitic  scar  or  ulcer  or 
from  venereal  warts.  I  have  seen 
one  case  of  Paget's  disease  of  the 
glans  penis.  Cancer  developed.  It 
has  been  claimed  that  contact  cancer 
of  the  penis  may  develop  as  a  result 
of  intercourse  with  a  woman  suffer- 
ing from  cancer  of  the  cervix  uteri. 
The  inguinal  glands  on  both  sides 
are  involved  early  and  the  deep 
glands  in  the  inguinal  canals  are 
usually  involved  (J.  H.  Cunningham, 
Jr.,  in  "Trans.  Am.  Assoc,  G.  U. 
Surgeons,"  1914).  In  a  limited 
epithelioma  of  the  foreskin  circum- 
cision is  performed  and  the  glands 
of  the  groin  are  removed;  if  a  well-developed  cancer  affects  the  glans,  ampu- 
tation of  the  penis  is  imperative  and  removal  of  the  inguinal  glands  is 
absolutely  necessary.  Certain  recent  superficial  cases  without  glandular  in- 
volvement may  apparently  be  cured  by  fulguration. 

Amputation  of  the  Penis. — Ricord  advised  cutting  off  the  organ  by 
a  single  stroke  of  the  knife,  making  four  slits  in  the  mucous  membrane  of  the 
urethra,  and  stitching  each  of  these  flaps  to  the  skin.  Treves  splits  the  skin 
of  the  scrotum  along  the  raphe,  separates  the  halves  of  the  scrotum  down  to  the 
corpus  spongiosum,  passes  a  metal  catheter  down  to  the  triangular  ligament, 
inserts  a  knife  between  the  corpus  spongiosum  and  the  corpora  cavernosa,  with- 
draws the  catheter,  cuts  the  urethra  across,  detaches  the  urethra  from  the  penis 
back  of  the  triangular  ligament,  cuts  around  the  root  of  the  penis,  divides  the 
suspensory  ligament,  detaches  each  crus  from  the  pubes,  slits  up  the  corpus 
spongiosum  )-^  inch,  stitches  its  edges  to  the  rear  end  of  the  scrotal  incision, 
introduces  a  drainage-tube,  ligates"  the  vessels,  and  sutures  the  wound. 

Seminal  Vesiculitis. — Inflammation  of  the  seminal  vesicles  is  due  to  the 
extension  of  a  gonorrheal  inflammation,  to  a  pyogenic  process,  or  to  tuberculosis. 
The  symptoms  vary  greatly  because  in  some  cases  the  vesiculitis  is  associated 
with  trigonitis,  in  others  with  prostatitis,  in  others  with  urethritis. 

Acute  vesiculitis  is  made  evident  by  frequent  and  painful  micturition, 
pains  in  the  anus,  rectum,  and  perineum,  and  possibly  the  hip-joint,  back,  and 
thighs.  The  cords  and  epididymes  are  painful  and  tender  and  epididymitis 
may  occur.  Defecation  and  micturition  are  excessively  painful.  There  may  be 
vesical  tenderness  and  tenesmus  and  even  retention  of  urine.  Persistent  and 
perhaps  painful  erections  may  take  place,  nocturnal  pollutions  are  common, 
and  in  some  cases  bloody  and  purulent  ejaculations  occur.  Rectal  examination 
detects  the  enlarged  and  tender  vesicles  external  to  the  lateral  lobes  of  the  pros- 
96 


1522  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

tate  and  on  a  higher  level.  Massage  of  the  vesicles  causes  pus  or  blood  mixed 
with  pus  to  enter  the  urethra  from  which  it  can  be  squeezed. 

Treatment. — Abandon  local  urethral  treatment,  and  treat  the  patient  as  for 
acute  prostatitis. 

Chronic  vesiculitis  may  result  from  the  acute  form  or  may  develop  in- 
sidiously in  an  individual  with  gonorrhea.  It  is  one  of  the  possible  causes  of 
a  chronic  urethral  discharge.  The  patient  suffers  from  imperative  and  frequent 
demands  to  micturate,  and  he  has  a  gleety  discharge  which  becomes  irregularly 
worse  and  better,  but  does  not  disappear.  In  many  cases  there  are  symptoms  of 
chronic  cystitis.  Micturition  is  frequent  and  painful,  the  cords  and  epididymes 
are  tender  and  painful,  urinary  retention  may  occur,  repeated  attacks  of 
epididymitis  are  noted  in  some  cases,  defecation  causes  pain,  and  pains  are 
complained  of  in  the  anus,  perineum  and  other  parts.  The  enlarged  and  tender 
vesicle  can  be  felt  through  the  rectum  and  massage  of  it  causes  mucopus,  which 
may  be  bloody,  to  enter  the  urethra.  Erections  are  at  first  frequent  and  pain- 
ful. In  most  cases  sexual  hypochondria  develops.  This  chronic  inflammation 
is  believed  to  persist  because  of  narrowing  of  the  duct  and  consequent  incom- 
plete drainage  of  the  vesicle.     In  chronic  seminal  vesiculitis  sooner  or  later  there 


Fig.  IOI2. — Dufaux's  prostatic  masseur. 

is  sexual  weakness,  nocturnal  emissions  occur,  and  the  semen  may  contain 
blood  and  pus.  Calculus  may  develop  in  a  vesicle.  Such  a  calculus  is  composed 
of  phosphate  of  lime. 

Treatment. — Treat  the  posterior  urethritis  by  ordinary  methods.  Use 
hot  rectal  enemata.  Milk  the  ducts  by  Fuller's  method  once  every  seven 
days.  During  massage  the  patient's  bladder  should  be  full.  He  leans  over 
a  chair-back,  the  knees  being  straight  and  the  body  at  a  right  angle  to  the 
thighs.  The  surgeon  covers  his  finger  with  a  rubber  stall,  anoints  it  with 
oil  or  synol  soap,  introduces  it  into  the  rectum,  and  makes  pressure  over  the 
pubes  with  the  fist  of  the  other  hand.  The  finger  comes  in  contact  with  the 
lower  half  of  the  vesicle;  it  makes  firm  pressure  for  a  moment  and  is  then  drawn 
slowly  toward  the  duct.  This  stroking  is  repeated  several  times.  The 
other  vesicle  is  treated  in  the  same  manner.  These  maneuvers  empty  the 
vesicles  and  hasten  the  resolution  of  inflammation.  In  many  cases  the  finger 
reaches  only  the  very  lowest  part  of  the  vesicle.  In  such  a  case  practice  massage 
by  means  of  Dufaux's  rubber  masseur  (Fig.  1012).  After  the  completion  of 
the  stripping  the  patient  should  micturate,  and  the  bladder  and  urethra  should 
be  irrigated. 

Tuberculosis  of  the  Seminal  Vesicles. — Primary  tuberculosis  is  very 
unusual.  As  a  rule,  there  is  evidence  of  antecedent  tuberculosis  of  the  testicle 
or  prostate  gland.  About  50  per  cent,  of  the  cases  occur  in  individuals  under 
forty  years  of  age.  The  diseased  vesicle  is  at  first  nodular  and  indurated, 
but  later  undergoes  caseation  and  softening.  Finally  the  disease  passes  through 
the  capsule  and  invades  adjacent  structures.  Dreyer  collected  36  cases  and 
found  that  in  34  of  them  the  lungs  were  involved. 

Tuberculous  vesiculitis  may  be  unilateral  or  bilateral.  In  unilateral  tuber- 
culous epididymitis  the  corresponding  vesicle  is  apt  to  become  diseased.  In 
bilateral  disease  of  the  testicles  both  vesicles  are  liable  to  become  victims. 
Peritoneal  tuberculosis  may  follow  tuberculous  vesiculitis.  In  very  unusual 
cases  spontaneous  cure  is  obtained  by  fibrous-tissue  formation.     On  palpa- 


Treatment  of  Acute  Prostatitis  1523 

tion,  a  tuberculous  vesicle  is  found  to  contain  here  and  there  hard  and  but 
slightly  tender  nodules. 

Treatment. — If  tuberculous  epididymitis  is  followed  by  tuberculous  vesicu- 
litis, it  is  justifiable  to  remove  the  vesicle  after  removing  the  epididymis  or 
testicle,  provided  the  prostate  and  other  parts  of  the  genito-urinary  tract  are 
free  from  disease  and  there  is  no  distant  lesion  of  tuberculosis.  If  both  tes- 
ticles or  epididymes  are  removed,  both  vesicles  can  be  extirpated.  If  a  vesicle 
or  both  vesicles  suffer  from  primary  tuberculosis,  operation  is  advised  by  some 
surgeons.     Reported  cases,  however,  do  not  seem  to  favor  operation. 

Kraske,  Schede,  and  Rydygier  have  removed  the  vesicles  after  preliminary 
resection  of  the  sacrum.  Zuckerkandl,  Diettl,  and  Schede  have  employed 
the  perineal  route.  Villeneuve  reached  them  by  way  of  the  inguinal  region. 
The  curved  perineal  incision  of  Zuckerkandl  is  the  method  usually  preferred. 
H.  H.  Young  makes  a  suprapubic  incision,  strips  the  peritoneum  from  the 
bladder,  and  reaches  the  vesicles  from  behind.  He  calls  it  the  suprapubic- 
retrocystic-extraperitoneal  method  (H.  H.  Young,  in  ''Annals  of  Surgery," 
Nov.,  1901).  For  a  Collective  Review  of  the  Surgery  of  the  Seminal  Vesicles 
see  John  R.  Caulk,  in  "Internat.  Abstract  of  Surgery,"  Nov.,  1915. 

Acute  Prostatitis. — Acute  inflammation  of  the  prostate  gland  may 
be  caused  by  inflammation  in  adjacent  structures,  the  use  of  instruments  or 
irritant  applications  in  the  deep  urethra,  injury  by  a  passing  or  impacted 
calculus,  various  infectious  diseases,  a  stricture  of  the  urethra,  but  particularly 
by  gonorrhea.  The  gland  enlarges  greatly,  the  prostatic  fluid  exudes  mixed 
with  blood  and  pus,  and  the  gland-ducts  become  distended  with  pus.  A 
distinct  abscess  may  form.  The  orifices  of  the  ejaculatory  ducts  become 
distended  and  filled  with  pus,  and  the  seminal  vesicles  or  epididymes  may 
also  suffer.  An  abscess  is  liable  to  form  in  the  cellular  tissue  outside  of  the 
prostate. 

Symptoms. — There  is  a  feeling  of  weight,  fulness,  or  soreness  in  the  peri- 
neum; a  persistent  pain  at  the  neck  of  the  bladder;  frequent  micturition,  pain 
being  present  and  becoming  most  severe  as  the  last  drops  are  voided;  perineal 
tenderness;  painful  defecation;  and  bulging  of  the  anal  mucous  membrane.  If 
a  finger  be  introduced  into  the  rectum,  it  causes  severe  pain  and  palpates  the 
enlarged  and  tender  gland,  unless  the  outlines  have  been  destroyed  by  periprosta- 
titis, in  which  case  there  will  be  felt  a  large,  boggy,  tender  mass.  (See  Henry  Morris 
on  "Injuries  and  Diseases  of  the  Genital  and  Urinary  Organs.")  These  symp- 
toms are  accompanied  by  distinct  elevation  of  temperature.  The  inflammation 
may  abate  without  suppuration,  but,  as  a  rule,  pus  forms,  the  temperature 
becomes  characteristic,  the  pain  becomes  pulsatile,  micturition  causes  agony, 
the  inflammatory  mass  is  felt  per  rectum  to  be  softening,  and  sometimes  the 
swollen  perineum  becomes  dusky  red.  Retention  of  urine  is  almost  certain  to 
occur.  The  abscess  may  rupture  into  the  urethra  or  the  rectum,  or  may  diffuse 
in  the  periprostatic  cellular  tissue  and  subsequently  may  open  in  the  perineum. 
Spontaneous  evacuation  may  be  followed  by  recovery  or  by  the  development 
of  annoying  or  dangerous  complications. 

Treatment. — Keep  a  hot-water  bag  on  the  perineum  and  three  or  four 
times  a  day  use  rectal  injections  of  hot  water.  Order  frequent  sitz-baths. 
Place  the  patient  on  a  milk-diet.  Leech  the  perineum.  Give  suppositories  of 
opium  and  belladonna  and  also  suppositories  of  ichthyol,  and  administer 
urotropin  by  the  mouth.  Retention  of  urine  is  relieved  by  a  soft  catheter. 
When  pus  forms  it  may  be  possible  in  some  cases  to  rupture  the  abscess  into 
the  urethra  by  the  passage  of  a  steel  sound.  If  this  can  be  accomplished  it  will 
be  fortunate.  Occasionally  a  specialist  may  succeed  in  opening  the  abscess 
through  an  operating  cystoscope.  Most  cases  require  to  be  cut  externally. 
What  is  known  as  the  houtojtniere  operation  is  the  method  of  choice.  The  patient 
is  placed  in  the  extreme  lithotomy  position.     The  index-finger  of  the  left  hand 


1524  Diseases  and  Injuries  of  the  Geni to-urinary  Organs 

is  introduced  into  the  rectum  and  carried  to  the  apex  of  the  prostate.  A  straight 
bistoury  is  entered  to  the  side  of  the  median  raphe  and  carried  into  the  abscess 
cavity,  and  the  opening  is  dilated  by  forceps.     The  urethrais  not  to  be  opened. 

Chronic  prostatitis  may  arise  from  stricture,  venereal  excess,  chronic 
cystitis,  or  stone  in  the  bladder,  but  gonorrhea  is  the  common  cause.  The 
prostate  is  usually,  but  not  always,  enlarged,  is  somewhat  softened,  and  the 
ducts  contain  pus  and  blood. 

Symptoms. — There  is  usually  a  mucopurulent  discharge  or  fluid  can  be 
obtained  by  massage  of  the  prostate.  There  is  a  feeling  of  weight  and  fulness 
in  the  perineum,  there  is  increased  frequency  of  micturition,  and  the  prostate 
is  very  sensitive  to  digital  pressure.  The  patients  are  neurotic,  frequently 
suffer  from  nocturnal  emissions,  and  have  but  feeble  power  of  erection.  The 
prostatic  urethra  is  extremely  hyperplastic.  All  the  symptoms  are  aggra- 
vated by  worry,  sexual  excitement,  or  violent  exercise.  x\n  abscess  may  form 
and  rupture  into  the  urethra. 

Treatment. — Tonics  and  nutritious  food  are  essential.  Intravesical  irri- 
gations with  nitrate  of  silver  solution  (i  :  8000)  do  good.  Massage  of  the 
prostate  is  useful.  Some  cases  are  benefited  by  touching  the  posterior  urethra 
through  a  urethroscope  tube  with  nitrate  of  silver  (3  gr.  to  the  ounce)  or  by 
injecting  by  means  of  Ultzman's  syringe  a  few  drops  of  silver  nitrate  solution 
(5  gr.  to  the  ounce).  Rectal  suppositories  of  ichthyol  may  be  ordered.  Blis- 
tering the  perineum  at  intervals  may  prove  of  service.  At  intervals  of  three 
or  four  days  a  full-sized  cold  steel  sound  should  be  gently  introduced.  If  an 
abscess  forms,  open  it  through  the  perineum.  Hot  or  cold  rectal  injections  of 
normal  saline  solution  are  useful. 

Prostatorrhea. — Just  as  overaction  of  the  glands  of  the  urethra  con- 
stitutes urethrorrhea,  so  overaction  of  the  glandular  apparatus  of  the  prostate 
constitutes  prostatorrhea.  Prostatorrhea  is  not  inflammatory,  although  the 
prostate  and  posterior  urethra  are  often  congested,  and  the  latter  region 
is  usually  hyperesthetic.  In  some  cases  urethrorrhea  exists  with  prostator- 
rhea. Prostatorrhea  is  produced  by  sexual  excess,  masturbation,  ungratified 
sexual  desire,  riding  a  bicycle  with  an  improper  seat,  and  sometimes  by  riding 
horseback.  The  condition  is  usually  accompanied  by  marked  neurasthenia, 
and  may  be  associated  with  spermatorrhea  and  impotence. 

The  patient  notices  a  milky  or  gray  discharge  after  straining  at  stool  {de- 
fecation spermatorrhea),  after  violent  exercise,  sexual  excitement,  or  a  bicycle 
ride.  The  discharge  also  gathers  in  the  urethra  during  sleep.  Examina- 
tion of  the  discharge  shows  it  to  be  prostatic  fluid,  although  spermatozoids 
are  sometimes  found.  It  is  not  purulent  and  contains  Bottcher's  spermatic 
crystals.  These  crystals  are  rhombic  prisms  and  terminate  in  fine  points 
or  rhomboid  margins  (Casper's  Geni  to- Urinary  Diseases  by  Bonney).  The 
composition  of  these  crystals  is  uncertain  but  Flirbringer  proved  that  they  are 
found  in  prostatic  fluid  only.  The  meatus  is  not  glued  up  in  the  morning  and  the 
linen  is  very  slightly  stained.  The  urine  is  clear  and  contains  small  comma- 
shaped  hooks.  Sexual  excitement  and  alcohol  do  not  appreciably  aggravate 
the  condition.  The  bladder  is  irritable,  and  there  is  frequency  of  micturition 
and  often  some  pain  in  the  head  of  the  penis  at  the  termination  of  the  act.  Noc- 
turnal emissions  may  occur. 

Treatment. — The  patient  should  correct  bad  habits.  If  there  be  urethral 
hyperesthesia  or  prostatic  congestion,  irrigate  the  bladder  and  urethra  once  a 
day  with  a  solution  of  silver  nitrate  (i  :  4000),  and  every  fourth  or  fifth  day 
introduce  a  cold  sound.  In  some  cases  the  occasional  instillation  into  the  pros- 
tatic urethra  of  a  few  drops  of  a  i  per  cent,  solution  of  jiitrate  of  silver  does  good. 

For  the  irritable  bladder  give  hot  hip-baths  at  night.  The  following  pre- 
scription is  of  service:  15  gr.  of  bromid  of  potassium,  \'2  dram  of  tincture  of 
hyoscyamus  in  )^  oz.  of  cinnamon-water,  three  times  a  day.  Hot  enemata 
are  of  service. 


Hypertrophy  of  the  Prostate  Gland  1525 

After  the  hyperesthesia  of  the  urethra  has  abated  and  nocturnal  emissions 
have  ceased,  the  neurasthenia  is  treated  by  cold  sponging  of  the  body  night 
and  morning,  the  continued  use,  at  intervals  of  several  days,  of  a  large-sized 
cold  sound,  irrigation  every  second  or  third  day  with  silver  nitrate  (i  :40oo), 
and.  the  administration  of  strychnin  and  other  tonics. 

Prostatic  Calculi. — Corpora  amylacea  are  present  in  the  prostate  with 
such  frequency  that  they  may  be  regarded  as  normal.  The  nucleus  of  one  of 
these  bodies  is  composed  of  inspissated  mucous  and  epithelial  cells  in  a  state  of 
degeneration.  About  the  nucleus  layers  of  albuminoid  material  form  which, 
under  the  microscope,  resemble  the  cells  of  starch.  In  youth  corpora  amylacea 
are  microscopic.  In  older  persons  they  are  visible  to  the  unaided  eye.  When 
small  they  cause  no  trouble.  When  they  enlarge  notably,  inflammation  arises, 
and  lime  salts  are  deposited  in  the  body.  These  true  prostatic  calculi  are 
multiple,  brown  or  black  in  color  and  are  commonly  faceted.  If  such  a  calculus 
ulcerates  into  the  urethra  urinary  salts  will  be  deposited;  they  will  enlarge 
greatly,  and  an  abscess  will  form. 

A  prostatic  calculus  may  arise  in  the  bladder  or  urethra  or  in  a  prostatic 
pouch.  After  prostatectomy  the  pouch  may  become  filled  with  a  mass  of  lime 
salts  and  urinary  salts. 

If  prostatic  calculi  cause  symptoms,  the  symptoms  are  those  of  chronic 
prostatitis  or  chronic  posterior  urethritis.  Perhaps  they  can  be  felt  by  a  finger 
in  the  rectum  or  by  a  metal  sound  in  the  urethra.  Some  are  visible  through  a 
urethroscope.     The  a;-rays  show  them. 

Treatment, — Removal  through  a  urethroscope  or  by  means  of  a  perineal 
incision. 

Hypertrophy  of  the  Prostate  Gland. — It  was  pointed  out  by  Mor- 
gagni  that  in  old  men  difficulty  of  micturition  is  due  to  obstruction  by  an 
enlarged  prostate  gland.  Enlargement  of  the  prostate  gland  may  be  brought 
about  by  different  forms  of  growth.  It  is,  as  a  general  thing,  a  senile  change, 
occurring  only  after  the  age  of  fifty,  and  being  most  likely  to  arise  after  the 
attainment  of  sixty  years.  It  is  very  rare  for  enlargement  of  the  prostate  to 
cause  symptoms  much  before  the  age  of  fifty  or  to  begin  after  the  age  of  seventy. 
Sir  Henry  Thompson  maintained  that  34  per  cent,  of  men  over  sixty  have 
prostatic  hypertrophy,  but  that  only  half  of  them  have  troublesome  symptoms. 
According  to  Freyer,  33  per  cent,  of  all  men  past  fifty-five  years  of  age  present 
some  enlargement  of  the  prostate. 

There  are  some  who  oppose  the  view  that  prostatic  enlargement  Is  essen- 
tially a  senile  change.  For  instance,  Dr.  L.  Bolton  Bangs  ("Jour,  of  Der- 
matol, and  Gen-urin.  Dis.,"  March,  1901)  maintains  that  the  change  is  not 
senile;  that  it  really  begins  early  in  life,  but  that  its  effects  do  not  become 
manifest  until  during  or  after  middle  age.  Lydston  asserts  that  it  begins 
during  the  third  decade  of  life,  but  the  gland  does  not  attain  sufficient  size  to 
cause  symptoms  till  beyond  middle  life.  Socin  and  Burckhardt,  as  a  result  of 
300  postmortem  examinations,  reached  the  following  conclusions:  Between  the 
ages  of  thirty- six  and  forty  the  gland  is  hyper trophied  in  13  per  cent,  of  cases, 
between  forty  and  fifty  in  25  per  cent.,  between  fifty  and  sixty  in  31  per  cent., 
between  sixty  and  seventy  in  56  per  cent.,  between  seventy  and  eighty  in 
50  per  cent.,  and  between  eighty  and  ninety  in  54  per  cent.  Undoubtedly,  the 
enlargement  begins  long  before  it  occasions  sufficient  obstruction  to  induce 
symptoms,  and  the  growth  progresses  very  slowly.  Guyon  and  the  French 
school  in  general  maintain  that  hypertrophy  of  the  prostate  gland  is  always  the 
result  of  arteriosclerosis,  affecting  not  only  the  prostate,  but  also  the  entire 
urinary  tract.  The  hypertrophy  that  ensues  affects  the  bladder  walls  notably, 
as  well  as  the  prostate,  because  of  distinct  growth.  Caspar  has  apparently 
demonstrated  that  Guyon's  view  is  not  correct.  He  has  shown  that  in  many 
cases  there  is  no  sclerosis  of  the  .prostatic  arteries,  and  that  frequently  there 


1526  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

are  no  sclerotic  changes  in  other  portions  of  the  urinar\-  tract.  Another  impor- 
tant point  made  by  Caspar  is  that  arteriosclerosis  tends  to  cause  degeneration, 
and  not  hypertrophy. 

Some  think  that  sexual  excess  is  a  cause  of  prostatic  enlargement;  some 
assert  that  antecedent  gonorrhea  is  the  cause,  but  it  seems  very  improbable 
that  either  is  causal.  Belfield  blames  altered  testicular  secretion;  Hawley 
believes  the  cause  to  be  altered  prostatic  secretion  and  the  "chemical  action 
of  pathological  proteins  resulting  from  irregular  metabolism  or  derived  from 
disintegration  of  the  secretion,  or  in  the  usual  action  of  tissue  enzymes"  ("Annals 
of  Surgery,"  Nov.,  1903). 

In  the  hypertrophied  prostate  there  is  an  excessive  production  of  fibrous 
tissue  and  of  ill-formed  glandular  tissue,  the  mass  constituting  a  fibro-adenoma. 
Fibro-adenoma  is  the  common  cause  of  enlargement  (W.  Bruce  Clarke).  Typ- 
ical adenoma,  according  to  Albarran  and  Halle,  is  found  in  14  per  cent,  of  the 
cases  ("Annales  des  Maladies  des  Organes  Genito-Urinaires,"  Feb.  and  March, 
1900).  Again,  in  not  a  few  prostates  there  is  no  real  enlargement,  but  there 
is  an  indurated  fibrous  mass  producing  obstruction.  Albarran  and  Halle  (Ibid., 
1898,  vol.  xvi)  point  out  that  in  an  enlargement  of  the  prostate  different  ele- 
ments may  usually  be  recognized:  soft  hypertrophy  of  the  gland;  indurated 
enlargement  of  the  glandular  elements;  fibrous  enlargement;  circumscribed 
tumor-masses;  distinct  fibromata  or  myomata;  or  adenofibromyomata.  The 
real  cause  of  the  various  forms  of  prostatic  enlargement  is  not  known.  Nearly 
10  per  cent,  of  cases  are  cancerous  (Oraison),  and  adenoma  is  apt  to  be  trans- 
formed into  cancer. 

All  the  lobes  may  be  enlarged  equally;  all  may  be  enlarged  unequally;  the 
enlarged  gland  may  surround  the  prostatic  urethra  like  a  horse-collar;  or  one 
lobe  only  may  be  enlarged.  Symmetrical  enlargement  of  the  entire  gland  is 
not  so  apt  to  produce  symptoms  as  is  non-symmetrical  enlargement.  In  some 
cases  the  chief  enlargement  is  into  the  bladder;  in  others,  into  the  urethra.  An 
enlarged  prostate  frequently  shows  a  circular  groove  about  it,  due  to  the  con- 
striction exerted  by  the  rectovesical  fascia  at  the  vesical  neck. 

The  bridge  of  prostate  which  joins  the  two  lateral  lobes  behind  the  urethra 
is  known  as  the  lohe  of  Home  or  the  middle  lobe,  and  a  comparatively  trivial 
enlargement  of  the  middle  lobe  may  cause  obstruction.  In  181 1  Sir  Everard 
Home  described  the  middle  lobe.  Prostatic  hypertrophy  causes  narrowing  and 
lengthening  of  the  urethra,  and  gives  this  tube  a  tortuous  course.  The  opening 
of  the  urethra  into  the  bladder  is  usually  pushed  to  a  higher  level,  and  there 
forms  behind  it  a  pouch  in  which  urine  collects.  The  urine  that  gathers  in 
this  pouch  is  known  as  residual  urine.  It  cannot  be  voluntarily  expelled.  It 
may,  therefore,  collect  in  large  quantity,  and  it  is  likely  to  decompose,  produc- 
ing cystitis.  Residual  urine  strongly  favors  calculus  formation.  The  mechan- 
ical resistance  to  the  expulsion  of  the  urine  causes  congestion  of  the  neck  of  the 
bladder  and  of  the  posterior  urethra  and  also  hypertrophy  of  the  muscles  of  the 
bladder.  In  consequence  of  the  hypertrophy  the  bladder  enlarges,  thickens, 
and  becomes  fasciculated.  When  this  takes  place,  micturition  becomes  very 
difficult  and  sometimes  impossible.  Enlargement  of  the  middle  lobe  inevitably 
blocks  the  flow  of  urine  and  causes  great  distention  of  the  bladder.  In  hyper- 
trophy of  the  prostate  gland  the  ureters  and  the  renal  pelves  and  calyces  may 
distend  and  surgical  kidney  may  develop. 

It  is  useful  to  divide  persons  with  prostatic  hypertrophy  into  three  groups: 
(i)  those  in  whom  there  is  no  obstruction  or  in  whom  the  urinary  symptoms 
are  very  trivial;  (2)  those  in  whom  there  are  residual  urine  and  disturbances 
of  urinary  function,  who  depend  upon  the  catheter  for  relief,  but  who  do  very 
well  by  this  method;  and  (3)  those  that  suffer  a  complete  breakdown  during 
the  period  in  which  the  catheter  is  depended  upon  (Orville  Horwitz,  in  "Phila. 
Med.  Jour.,"  Nov.  16,  1901). 


Treatment  of  Hypertrophy  of  the  Prostate  Gland  1527 

Symptoms. — In  90  per  cent,  of  the  cases  there  is  very  trivial  inconvenience, 
the  patient  merely  being  annoyed  somewhat  by  episodes  of  nocturnal,  and  less 
urgent  diurnal,  frequency  of  micturition.  During  the  day  when  the  man  is 
active  the  circulation  of  the  prostate  is  active  and  so  are  the  muscles.  At 
night,  when  in  bed,  there  is  venous  congestion  of  the  prostate  and  base  of  the 
bladder.  Hence  the  vesical  irritabiUty.  Again,  there  is  usually  polyuria  in 
cases  of  enlarged  prostate,  and  polyuria  is  most  marked  at  night.  The  stream 
of  urine  is  slow  to  start  and  falls  feebly  from  the  end  of  the  penis.  In  some  cases 
there  is  interruption  of  the  stream  (stammering).  The  last  drops  fall  entirely 
without  control.  If  the  patient  becomes  sexually  excited,  chilled,  or  worried,  or 
indulges  inordinately  in  the  pleasures  of  the  table  or  in  wine,  beer,  or  alcoholic 
liquors,  nocturnal  frequency  of  micturition  becomes  for  a  short  time  most 
harassing.  Very  early  in  a  case  the  bladder  can  be  completely  emptied.  In  10 
per  cent,  of  all  cases  the  bladder  becomes  unable  to  empty  itself  completely,  and 
residual  urine  collects.  Frequency  of  micturition  comes  on  during  the  day  as 
well  as  at  night;  the  patient  has  to  get  up  often,  several  or  many  times  from  his 
bed,  the  bladder  never  feels  empty;  and  cystitis  is  apt  to  arise.  This  is  known 
as  the  second  stage.  Guyon  calls  it  the  stage  of  "bladder  insuflSciency."  The 
urine,  at  first  acid  and  clear,  becomes  neutral  and  cloudy,  and  finally  ammoniacal 
and  turbid,  and  contains  bacteria,  mucopus,  precipitates  of  phosphates,  and 
blood.  Above  the  pubes  there  is  aching  pain,  soon  spreading  to  the  perineum, 
and  increasing  when  the  bladder  is  distended  and  during  micturition.  The 
rectum  becomes  irritable,  and  piles  form  or  prolapse  of  the  mucous  membrane 
occurs,  because  of  straining  in  micturition.  The  second  stage  may  last  a  year, 
two  years  or  several  years.  The  second  stage  passes  into  the  third  stage  in 
which  attacks  of  retention  of  urine  may  occur.  The  bladder  dilates  greatly. 
With  the  retention  there  is  usually  incontinence  (incontinence  of  retention). 
"With  this  overtaxed,  overdistended  bladder,  the  sphincter  relaxes  every  few 
minutes,  allowing  the  escape  of  a  few  drops  of  urine,  and  when  we  question  one 
of  these  old  men  about  his  urination,  asking  if  he  passes  water  frequently,  and 
he  says,  'Yes,  every  few  minutes' — that  always  means  an  overdistended  and 
dribbhng  bladder"  (H.  H.  Morton,  "N.  Y.  Med.  Jour.,"  Sept.  9,  1916).  In 
about  one-third  of  all  cases  we  can  make  a  diagnosis  by  rectal  palpation.  In 
enlargement  of  the  middle  lobe  alone  or  in  pure  intravesical  enlargement  rectal 
touch  will  fail  to  make  the  diagnosis  and  the  cystoscope  must  be  rehed  upon. 
The  bladder  becomes  thin  and  distended,  or  hypertrophied,  rigid,  and  fascicu- 
lated. In  rare  cases  true  incontinence  is  caused  by  the  median  lobe  growing 
toward  the  neck  of  the  bladder  and  preventing  closure.  The  health  breaks 
down  because  of  pain,  restless  nights,  indigestion,  and  disorder  of  the  bowels. 
The  urine  is  of  low  specific  gravity,  is  low  in  urea  and  there  may  or  may  not  be 
casts.  The  patient  becomes  somnolent  and  the  tongue  dry  and  parched  (uro- 
sepsis). The  kidneys  may  become  involved  (inflammation  of  the  pelves  or 
calices,  or  surgical  kidney)  and  suppression  may  occur.  Septic  fever  may 
arise.  Calculi  may  form  in  the  bladder.  Death  is  due  to  exhaustion,  suppres- 
sion of  urine,  or  septic  cystitis.  A  foul  catheter  is  the  usual  cause  of  septic 
cystitis,  but  micro-organisms  sometimes  enter  by  passing  along  the  urethral 
mucous  membrane. 

A  patient  should  be  examined  by  rectal  touch,  by  a  sound,  and  by  a  cysto- 
scope, if  possible;  the  amount  of  residual  urine  must  be  determined,  and  the 
condition  of  the  urine  is  to  be  carefully  studied.  The  presence  or  absence  of 
stone  should  always  be  determined.  After  an  examination  by  instruments  the 
patient  must  remain  in  bed  for  twenty-four  hours. 

Treatment. — There  is  no  known  method  of  preventing  prostatic  hyper- 
trophy. Many  cases  of  enlargement  are  treated  by  regular  catheterization, 
and  if  this  is  conducted  with  careful  cleanliness,  and  if  the  patient  rigidly  ad- 
heres to  hygienic  rules,  he  may  be  kept  comfortable  in  this  way  for  a  consider- 


1528  Diseases  and  Injuries  of  the  Geni to-urinary  Organs 

able  time.  Certain  cases  of  hypertrophy  of  the  prostate  gland  seem  to 
have  been  benefitted  by  radium  and  the  .i;-rays.  When  a  man  must  de- 
pend upon  a  catheter  to  empty  his  bladder  he  is  said  to  be  in  catheter 
life.  Alexander  has  formulated  several  sound  rules  as  to  when  cathe- 
terization is  the  proper  treatment.  He  says,  if  the  patient  is  intelligent 
and  dextrous,  if  cystitis  is  not  severe,  if  the  amount  of  residual  urine 
is  not  very  large,  if  obstruction  is  not  great,  if  the  bladder  retains  considerable 
expulsive  power,  and  if  catheterization  is  easy  and  painless,  we  are  justified  in 
relying  upon  this  simple  plan  of  treatment.  Prevent  cystitis  by  emptying  the 
bladder  each  evening  with  a  coude  catheter.  If  there  is  trouble  in  passing  the 
catheter,  strengthen  the  instrument  by  inserting  a  fiUform  bougie  as  a  stylet. 
It  is  very  seldom  that  a  metal  instrument  is  required,  but  if  it  is  necessary,  a 
catheter  with  a  large  curve  is  employed.  If  a  soft  or  semisolid  instrument  can 
be  passed,  teach  the  patient  how  to  clean  it,  how  to  use  it,  and  how  to  keep  it, 
but  never  permit  the  patient  to  use  a  metal  instrument  himself.  A  dirty  instru- 
ment may  cause  fatal  infection.  It  is  true  that  some  people  use  dirty  instru- 
ments for  long  periods  without  trouble,  but  in  most  cases  there  will  be  trouble 
if  it  is  attempted.  It  is  absolutely  necessary  to  use  perfectly  aseptic  instruments 
only.  Metal  instruments  are  sterilized  by  boiling  in  water.  Rubber  catheters 
can  be  cleansed  by  washing  with  soap  and  running  water,  wrapping  in  gauze, 
and  boiling.  After  sterilization  the  instruments  are  kept  ready  for  use  in  a 
glass  cylinder  which  contains  calcium  chlorid.^  The  cleansing  of  catheters  is 
discussed  on  page  1457.  If  there  are  3  oz.  of  residual  urine,  use  the  catheter 
at  night  only.  If  there  are  6  oz.,  use  it  night  and  morning.  If  there  are  more 
than  6  oz.  of  residual  urine,  add  one  more  catheterization  a  day  for  every  addi- 
tional 2  oz.  present  until  the  catheter  is  used  six  times  in  the  twenty-four  hours. 
It  should  never  be  used  oftener  than  this.  Gradual  dilatation  with  steel  sounds 
is  of  benefit,  but  forcible  dilatation  is  not  advisable.  The  sound  may  be  passed 
once  a  week.  Tell  the  patient  to  avoid  exercise,  cold,  damp,  sexual  excitement, 
and  the  use  of  alcoholic  liquors;  prevent  constipation  and  indigestion,  and  direct 
him  to  drink  milk  and  plenty  of  water.  A  hot  hip-bath  at  night  adds  to  his 
comfort.  Hot  enemata  are  of  value.  If  a  large  quantity  of  residual  urine 
exists,  or  if  cystitis  begins,  wash  out  the  bladder  daily  with  boric  acid  solution, 
or  normal  salt  solution,  or  nitrate  of  silver  (from  i  :  10,000  to  i  :  4000),  and 
give  urotropin  or  salol  and  boric  acid  by  the  mouth  (see  Cystitis,  page  1470). 
In  some  severe  cases,  if  a  large-sized  rubber  catheter  be  tied  in  the  bladder  for 
a  few  days,  great  relief  is  obtained.  Retention  of  urine  can  usually  be  relieved 
by  the  introduction  of  a  coude  catheter  strengthened  with  a  whalebone.  In 
exceptional  cases  a  silver. instrument  with  a  prostatic  curve  must  be  employed 
or  aspiration  must  be  practised.  Many  cases  occurring  among  well-to-do 
people  can  be  kept  comfortable  by  catheterization.  Some  surgeons  still  think 
that  only  when  this  fails  should  an  operation  be  performed.  Unfortunately, 
sooner  or  later  a  man  who  regularly  relies  upon  the  catheter  will  develop  cys- 
titis. A  poor  man  cannot  give  the  necessary  time  and  attention  to  make  cath- 
eter life  safe  and  operation  must  be  thought  of  in  him  sooner  than  in  others. 
If  the  symptoms  grow  constantly  worse,  if  the  suffering  becomes  severe,  if  the 
patient  cannot  empty  his  bladder  without  the  use  of  an  instrument,  if  cathe- 
terization is  painful  or  impossible,  if  the  patient  is  too  careless  or  ignorant  to 
trust  with  a  catheter,  if  only  a  catheter  of  very  small  size  can  be  introduced, 
if  attacks  of  obstinate  retention  occur,  if  there  is  persistent  or  recurring  cystitis 
or  hematuria,  if  there  are  signs  of  beginning  infection  of  the  kidney,  if  the  resi- 
dual urine  gradually  increases  in  amount,  operation  is  called  for.  Do  not  post- 
pone operation  until  the  patient  becomes  really  ill.  Give  palliative  measures 
a  reasonable  trial,  and  if  they  fail,  operate.  Before  determining  upon  any 
operation  make  a  cystoscopic  examination.  This  is  particularly  valuable  before 
a  Bottini  operation  and  before  a  perineal  operation.  It  shows  us  the  condition 
^  R.  W.  Frank,  in  "Berliner  klin.  Woch.,''  No.  44,  1895. 


Treatment  of  Hypertrophy  of  the  Prostate  Gland  1529 

of  the  bladder;  the  nature,  size,  and  situation  of  the  enlargement,  the  median 
lobe  if  present,  and  a  calculus  if  one  exists.  This  examination  may  determine 
the  form  of  operation  desirable.  Prostatectomy  is  not  to  be  regarded  as  a 
trivial  affair  certain  to  result  in  cure.  It  is  a  grave  procedure,  with  a  consider- 
able mortality,  which  may  be  attended  by  disastrous  comphcations  and  from 
which  unfortunate  consequences  may  arise.  I  agree  with  James  E.  Moore  that 
"it  is  altogether  too  grave  an  operation  to  be  resorted  to  as  a  routine  treatment 
for  every  enlarged  prostate,  and  i?  applicable  to  properly  selected  cases  only." 
The  operation  is  contra-indicated  if  there  is  advanced  disease  of  the  kidneys, 
and  if  it  is  performed  in  such  a  case,  fatal  uremia  is  to  be  expected.  Age  is 
not  in  itself  a  contra-indication  if  the  kidneys  and  cardiovascular  system  are 
sound.  An  occasional  sequel  of  prostatectomy  is  incontinence  of  urine  due 
to  injury  of  the  neck  of  the  bladder  or  to  the  nerves  of  the  part.  A  possible 
sequel  is  steriHty  but  age  has  rendered  most  of  the  subjects  practically  sterile 
before  operation. 

In  the  majority  of  cases  in  which  palliation  fails  the  operative  indication 
is  to  remove  an  obstructing  mass  and  to  depress  the  level  of  the  opening  from 
the  bladder  into  the  prostatic  urethra,  so  that  the  prostatic  pouch  is  aboHshed 
and  the  bladder  can  be  thoroughly  drained.  The  surgeon  chooses  between 
prostatotomy  and  prostatectomy.  Prostatotomy  is  usually  performed  by  the 
galvanocautery  (Bottini's  operation).  Prostatectomy  may  be  suprapubic  or 
perineal,  and  the  latter  may  be  by  enucleation  without  the  aid  of  sight  (as  in 
the  operations  of  NicoU  and  Alexander)  or  by  open  dissection  (as  in  Young's 
operation).  No  one  routine  plan  is  suitable  for  all  cases.  The  patient  should 
be  studied,  and  the  operation  chosen  which  is  safest  and  best  for  that  individual 
case.  The  surgeon  who  uses  one  method  only  must  wrong  many  patients,  and 
he  retains  consistency  at  the  expense  of  humanity.  It  was  formerly  beheved 
that  any  operation  of  total  prostatectomy  must  of  necessity  produce  impotence. 
This  we  now  know  need  not  be  the  case.  The  suprapubic  operation  is  probably 
less  likely  to  be  followed  by  this  than  is  the  perineal,  as  the  former  usually 
spares  the  ejaculatory  ducts.  Young's  perineal  operation  spares  the  ejacu- 
latory  ducts.  Destruction  of  the  ejaculatory  ducts  certainly  produces  sterility 
and  may,  but  does  not  of  necessity,  produce  impotence.  Willy  Meyer  ("Med. 
Record,"  Oct.  7,  1905)  points  out  that  impotence  may  be  caused  by  damaging 
important  nerves  or  blood-vessels  in  advancing  through  the  perineum,  and  also 
by  the  operation  producing  relaxation  of  the  verumontanum  and  prostatic 
urethra,  parts  necessary  in  the  reflex  for  erection. 

The  perineal  operation  is  as  safe  as  the  suprapubic  or  safer,  and  can  be 
rapidly  performed.  It  is  the  desirable  route  when  the  gland  can  be  palpated 
per  rectum,  and  does  not  mount  high  up  (when  the  finger  can  touch  the  upper 
margin  of  the  gland)  and  when  we  are  dealing  with  the  early  stages  of  soft 
hypertrophy.  Prolonged  drainage  should  be  perineal.  Permanent  drainage 
should  be  suprapubic.  According  to  Francis  S.  Watson  ("Annals  of  Surgery," 
June,  1904),  the  mortahty  in  203  cases  was  only  2.9  per  cent.  In  563  cases  of 
removal  through  the  perineum  by  dissection  the  mortality  was  5.5  per  cent. 
Young's  cases  in  this  group  number  150  and  his  mortality  was  4.6  per  cent.; 
the  mortality  of  Hartman  was  9  per  cent.;  of  Albarran,  4  per  cent.,  and  of  Mur- 
phy, 3.9  per  cent.  (Schachner,in"  Annals  of  Surgery,"  August,  1908).  In  190  cases 
of  blind  enucleation  through  the  perineum  the  mortality  was  4.7  per  cent.  (Ibid.). 

After  the  performance  of  the  perineal  operation  the  drainage  is  at  the  lowest 
part  of  the  bladder.  In  a  perineal  operation  every  effort  should  be  made  to  do 
as  Httle  damage  as  possible  to  the  urethra.  If  we  destroy  the  entire  prostatic 
urethra  the  operation  becomes  easy  and  rapid  and  Nature  rapidly  repairs  it, 
but  a  traumatic  stricture  may  follow  and  may  make  the  patient's  condition 
worse  than  at  first.  As  Moore  says,  we  must  destroy  a  portion  of  the  floor  of 
the  urethra,  but  we  can  preserve  the  roof  and  the  side  walls.     Another  point 


1530  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

in  the  perineal  operation  is  to  avoid  injuring  the  rectum.  A  tear  may  enter 
the  rectum,  or,  even  if  the  gut  has  not  been  torn,  sloughing  of  the  rectum 
resulting  in  recto-urethral  fistula  may  occur.  The  rectum  may  be  opened  be- 
cause the  surgeon  fails  to  stick  close  to  the  urethra  in  his  dissection,  and  slough- 
ing may  be  due  to  an  injudicious  use  of  the  retractors.  If  the  rectum  is  opened, 
it  should  be  at  once  sutured  with  catgut.  In  most  cases  it  takes  about  three 
weeks  for  the  wound  in  the  perineum  to  heal,  and  in  some  few  cases  a  perineal 
urinary  fistula  is  established.  Urinary  incontinence  may  follow  this  operation. 
By  simply  incising  the  prostate  gland  the  floor  of  the  urethra  may  be  lowered 
to'  the  level  of  the  floor  of  the  bladder.  Simple  incision  of  the  prostate  in  this 
manner,  or  by  Bottini's  method,  is  known  as  prostatotomy.  The  mortality  is 
small  and  the  rehef  is  often  great.  Prostatotomy  is  performed  on  old  and  ex- 
hausted patients  with  damaged  kidneys.  A  large  tube  should  be  worn  during 
the  healing  of  the  wound. 

The  suprapubic  operation  is  easier  than  the  perineal;  it  is  less  safe;  it  gives 
excellent  results  if  temporary  drainage  only  be  needed.  According  to  Watson 
("Annals  of  Surgery,"  June,  1904),  the  mortality  in  69  cases  was  8.6  per  cent. 
P.  J.  Freyer  reports  600  cases  varying  in  age  from  forty-eight  to  eighty-nine 
years.  There  were  47  between  the  ages  of  eighty  and  eighty-nine,  and  7  were 
seventy-nine;  most  of  the  cases  had  been  entirely  dependent  on  the  catheter 
for  periods  up  to  twenty-four  years.  "Nearly  all  were  in  broken  health  and 
many  apparently  dying  before  operation.  Few  were  free  from  one  or  more 
grave  complications,  such  as  cystitis,  stone  in  the  bladder,  pyelitis,  kidney  dis- 
ease, diabetes,  heart  disease,  chronic  bronchitis,  paralysis,  hernia;  and  in  a  few 
instances  there  was  malignant  disease  of  some  other  organ  than  the  prostate" 
("Archives  Internationales  de  Chirurgie,"  vol.  iv,  Fascic.  4,  1909).  In  these 
600  cases  there  were  37  deaths  in  periods  of  from  six  hours  to  thirty-seven  days 
after  operation,  a  mortality  of  6.15  per  cent.  Suprapubic  prostatectomy  is 
indicated  in  rather  young  subjects  in  whom  we  greatly  fear  impotence;  in  cases 
in  which  the  gland  is  placed  high;  in  cases  in  which  the  gland  is  not  palpable 
per  rectum,  but  is  causing  serious  symptoms,  and  in  which  the  hypertrophy  is 
recognized  by  the  cystoscope  (Meyer);  in  cases  in  which  there  is  a  middle  lobe; 
in  cases  in  which  cancer  exists,  or  in  which  calculus  complicates  the  case.  It  is 
the  most  useful  operation  when  the  gland  is  very  large  and  intravesical.  It  is 
not  a  suitable  method  if  the  bladder  is  markedly  contracted  or  if  the  belly  walls 
are  very  thick.  If  prolonged  drainage  (short  of  permanent  drainage)  is  re- 
quired, as  it  is  sure  to  be  in  cases  with  advanced  cystitis,  the  opening  is  better 
placed  in  the  perineal  operation.  If  when  a  suprapubic  operation  has  been  per- 
formed it  is  found  that  prolonged  drainage  is  indicated,  a  siphon  drain  (Fig. 
968)  may  be  used.  If  permanent  drainage  be  required  in  a  case,  the  suprapubic 
method  is  the  best.  After  a  suprapubic  cystotomy  has  been  performed  for 
drainage,  the  opening  may  be  kept  permanently  patent  by  the  retention  of  a 
tube  (Hunter  McGuire's  operation).  It  is  only  in  very  advanced  cases  or  in 
cancer  that  permanent  suprapubic  drainage  is  employed.  After  making  a 
suprapubic  incision  the  floor  of  the  urethra  cannot  be  brought  level  with  the 
floor  of  the  bladder  by  a  simple  incision  of  the  prostate  through  this  incision; 
it  can  be  brought  level  by  the  performance  of  prostatectomy  only.  In  the 
suprapubic  operation  the  structures  divided  are  less  important,  and  the  drainage 
is  less  conveniently  placed  but  better  than  in  the  perineal  operation.  Supra- 
pubic prostatectomy  inflicts  injury  upon  the  bladder,  it  may  gravely  damage 
the  sphincter  of  the  bladder,  and  is  sometimes  followed  by  incontinence  or  by 
inabihty  to  expel  urine  (John  B.  Murphy,  "Jour.  Amer.  Med.  Assoc,"  March 
29,  1902),  but  disturbance  of  control  is  less  common  than  after  the  perineal 
operation.  The  bladder  wall  may  be  seriously  torn,  and  if  such  a  wound  should 
be  inflicted,  it  ought  to  be  sutured  with  catgut.  In  this  operation  if  the  bladder 
be  contracted,  the  surgeon  must  exercise  great  care  to  avoid  injuring  the  peri- 


Suprapubic  Prostatectomy  1531 

toneum.  The  ureters  may  be  damaged  and  subsequently  become  obstructed 
from  contraction.  If  death  occurs  after  prostatectomy  it  is  due  to  shock, 
uremia,  sepsis,  or  postoperative  complications,  usually  pulmonary.  Schachner 
("Annals  of  Surgery,"  August,  1908)  uses  Watson's  figures  to  present  the  special 
dangers  of  each  operation.  The  figures  give  the  percentage  of  the  deaths  due 
to  shock,  uremia,  hemorrhage,  and  pulmonary  complications.  The  table  is 
.as  follows: 

Per  cent. 

Bottini 2.7  j 

Perineal  operations 35  -o  r  Uremia  (or  renal  insufSciency). 

Suprapubic  operations 34-°  J 

Bottini 52.0"! 

Perineal  operations i7-8^  Sepsis. 

Suprapubic  operations 8.6  I 

Bottini 5.0  I 

Perineal  operations 21 .4  ^  Shock. 

Suprapmbic  operations 3o-o  J 

Eottini. ».o     Postoperative  pulmonary  compli- 

Permeal  operations i7-or      cations 

Suprapubic  operations 22.0  J 

At  the  International  Urological  Congress  held  in  London  in  191 1  Young 
presented  the  records  of  484  cases  of  perineal  prostatectomy.  The  mortality 
in  simple  hypertrophy  (450  cases)  was  3.77  per  cent.;  34  cases  were  cancerous, 
and  of  these  2  died.  Zuckerkandl's  mortality  from  perineal  operations  was 
9.5  per  cent.,  from  suprapubic  operations,  18.7  per  cent.  ("Ann.  des  Mai.  des 
Org.  Gen.-Urin.,"  191 1,  ii).  Freyer  ("  Amer.  Jour,  of  Dermatology  and  Genito- 
urinary Diseases,"  191 2)  reports  1000  cases  of  suprapubic  prostatectomy  since 
1901.  The  average  age  of  these  cases  was  sixty-nine.  The  youngest  patient 
was  forty-nine,  the  oldest  was  ninety.  There  were  55  deaths  (a  mortality  of 
5.5  per  cent.).  Freyer's  mortality  in  his  first  100  cases  was  10  per  cent.,  in  his 
last  100  cases  it  was  3  per  cent.  This  proves  the  great  value  of  experience. 
The  less  training  a  man  has  had,  the  higher  will  be  his  mortality.  Prostatec- 
tomy is  distinctly  not  an  operation  for  a  juvenile  surgeon. 

Suprapubic  Prostatectomy. — Freyer's  Method. — The  bladder  is  washed 
out  through  a  catheter  with  warm  boric  acid  solution  and  is  then  filled  to  its 
previously  ascertained  capacity  with  the  solution.  The  nozzle  of  a  large  syringe 
filled  with  fluid  is  inserted  into  the  end  of  the  catheter.  This  keeps  the  bladder 
fluid  from  running  out  and  enables  the  surgeon  quickly  to  distend  the  viscus 
more  if  the  occasion  arise.  The  bladder  is  exposed  and  opened  in  the  midline 
and  in  an  area  free  from  veins  (see  Suprapubic  Cystotomy,  page  1484).  The 
incision  is  vertical,  is  made  toward  the  symphysis,  and  is  about  i  inch  in  length 
(it  can  be  enlarged  later  if  necessary).  If  any  calculi  are  found  they  are  at 
once  removed.  A  finger  is  placed  in  the  rectum  to  raise  up  the  prostate  and 
keep  it  steady.  The  finger  of  the  other  hand  is  introduced  into  the  bladder, 
and  by  means  of  the  fingernail  the  mucous  membrane  is  scratched  through  over 
*'the  most  prominent  portion  of  one  lateral  lobe,  or  over  the  so-called  middle 
lobe,  if  there  be  but  one  prominence"  (Freyer,  in  "  Archiv.  Internat.  de  Chir.," 
Fascic.  4,  1909).  This  portion  of  the  gland  is  covered  by  mucous  membrane 
only,  and  when  this  is  scratched  through  the  true  prostatic  capsule  is  reached. 
In  doing  Freyer's  operation  the  author  passes  the  finger  to  the  extreme  anterior 
limit  of  the  trigone,  so  that*  the  finger  is  really  within  the  urethra.  At  this 
point  he  splits  the  capsule  and  begins  the  enucleation,  being  careful  to  injure 
the  trigone  as  little  as  possible.  This  precaution  greatly  lessens  the  danger  of 
incontinence.  The  finger  is  kept  in  close  contact  with  the  true  capsule  and 
enucleates  the  gland  by  passing  first  posterior,  next  outside,  and  finally  in  front 
of  one  lateral  lobe. 

"The  finger  is  then  swept  in  a  circular  fashion  from  without  inward,  in 
front  of  and  to  the  inner  side  of  the  lobe,  detaching  this  from  the  urethra, 


1532 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


which  is  felt  covering  the  catheter,  and  pushed  forward  toward  the  symphysis 
between  the  lateral  lobes,  which  will,  as  a  rule,  have  separated  along  their 
anterior  commissure  in  the  course  of  the  manipulations.  The  other  lobe  is 
attacked  and  treated  in  the  same  manner.  The  finger  is  next  pushed  well 
downward  behind  the  prostate  and  the  inferior  surface  of  the  gland  is  peeled 
off  the  triangular  ligament.  When  the  prostate  is  felt  free  within  its  sheath 
and  separated  from  the  urethra,  with  the  finger  in  the  rectum,  aided  by  that 
in  the  bladder,  it  is  pushed  into  the  bladder  through  the  opening  in  the  mucous 
membrane,  which,  during  the  manipulations,  will  have  become  considerably 
enlarged"  (Freyer,  Ibid.).  The  prostate  is  removed  from  the  bladder  by  for- 
ceps. If  the  lobes  come  away  separately,  Freyer  believes  that  the  ejaculatory 
ducts  are  uninjured  and  remain  attached  to  the  urethra.  There  has  been  an 
active  controversy  as  to  whether  Freyer's  operation  does  or  does  not  destroy 
the  prostatic  urethra.  It  seems  certain  that  even  if  it  is  left  it  must  slough 
for  want  of  blood-supply.  In  my  operations  by  this  method  it  has  come  away 
with  the  prostate. 


Fig.  1013.  Fig.  1014. 

Figs.  1013  and  1014. — Showing  double-tube  drainage  for  suprapubic  operation.  Fig, 
1 01 3  was  taken  from  an  elevation  to  show  the  termination  of  the  drainage-tubes.  Fig.  1014 
shows  tubes  enlarged  in  separate  view. 

In  Freyer's  earlier  operations  he  sought  to  leave  the  urethra  and  accom- 
panying structures  behind,  but  he  is  now  convinced  that  the  prostatic  urethra 
may  be  torn  or  removed  without  ill  results.  Figure  1013  shows  the  drainage 
as  I  employ  it  after  suprapubic  prostatectomy.     Figure  1014  shows  the  drain. 

McGill's  Operation. — The  bladder  is  opened  by  a  suprapubic  Incision, 
the  edges  of  the  cut  bladder  are  sutured  to  the  abdominal  wound  with  catgut, 
and  the  interior  of  the  viscus  is  carefully  explored  by  the  finger  and  by  sight, 
an  electric  light  being  used  for  illumination.  If  a  sessile  growth  exists,  the 
mucous  membrane  is  incised  and  the  growth  enucleated  by  finger  or  a  curet. 
A  pedunculated  growth  is  cut  away  by  sharp-edged  forceps.  If  a  mass  pro- 
jects into  the  bladder,  an  incision  is  made  to  divide  it  into  two  portions  and 
each  half  is  enucleated.  Hemorrhage  is  arrested  by  irrigation  with  hot  salt 
solution  and  by  compression  with  gauze  pads.  In  some  cases  a  tampon  must 
be  inserted.     The  bladder  is  drained  for  several  davs  or  a  number  of  days.     As 


Bryson's  Operation  of  Suprapubic  Prostatectomy 


1533 


a  matter  of  fact,  a  dense  fibrous  prostate  cannot  be  enucleated  and  can  be 
removed  by  scissors  or  cutting  forceps  only. 

Fuller's  Operation, — Open  the  bladder  above  the  pubes;  have  an  assistant 
push  the  gland  up  by  means  of  a  fist  in  the  perineum.  The  gland  can  be  lifted 
by  two  fingers  in  the  rectum.  The  surgeon  makes  a  small  incision  through 
the  mucous  membrane  over  the  prostate,  enucleates  the  gland  by  means  of 
the  finger,  and  drains  through  an  incision  in  the  membranous  urethra,  as  well 
as  through  the  suprapubic  opening. 

Belfield's  Operation. — Belfield  performs  suprapubic  cystotomy,  makes  a 
perineal  cut  to  enable  the  finger  to  approach  the  prostate,  pushes  the  prostate 
up  toward  the  belly,  and  enucleates  it  from  within  the  bladder. 

Perineal  prostatectomy  is  less  bloody  than  suprapubic  prostatectomy. 
The  sphincter  of  the  bladder  is  not  damaged,  the  entire  prostate  can  be  brought  ■ 
into  view  and  removed,  and  perfect  drainage  is  obtainable  after  operation. 

Nicoll's  Operation. — Perform  suprapubic  cystotomy.  Then  incise  the  peri- 
neum doA\'n  to  the  prostate,  split  the  capsule  of  the  prostate,  insert  two  fingers 
of  the  left  hand  into  the  bladder,  and  push  the  prostate  into  the  perineum  so 
as  to  bring  it  within  reach.  Enucleate  the  gland  from  the  perineal  wound 
without  damaging  the  mucous  membrane  of  the  floor  of  the  bladder. 

Alexander's  Operation. — Alexander  makes  a 
suprapubic  incision  and  uses  it  for  the  same 
purpose  as  does  Nicoll,  but  he  also  opens  the 
membranous  urethra  on  a  grooved  staff.  After 
enucleating  the  gland  he  inserts  a  drainage-tube 
through  the  incision  in  the  membranous  urethra. 


Fig.  1015. — Tractor  introduced; 
blades  separated;  traction  made, 
exposing  posterior  surface  of  pros- 
tate. Incisions  in  capsule  on  each 
side  of  ejaculatory  ducts  (Young). 


Fig.  1016.- 


-Enucleation  of  lobes, 
sition  (Young). 


Forceps  in  po- 


In  a  very  thin  subject  it  may  not  be  necessary  to  perform  suprapubic  cys- 
totomy. Alexander  has  brought  the  gland  into  an  accessible  position  in  the 
perineal  wound  by  suprapubic  pressure,  and  Guiteras  has  done  so  by  making 
an  incision  in  the  linea  alba  and  inserting  two  fingers  into  the  prevesical  space. 
Syms  advocates  opening  into  the  peritoneal  cavity,  inserting  the  hand,  and 
pressing  the  prostate  into  the  perineum  without  opening  the  bladder  above 
the  pubes. 

Bryson's  Operation. — This  is  a  satisfactory  method  in  some  cases.  The 
bladder  is  irrigated  and  filled  w^th  warm  salt  solution.  A  grooved  staff  is  intro- 
duced and  a  median  perineal  section  is  made  to  open  the  urethra  just  in  front 


1534 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


of  the  apex  of  the  prostate  gland.  The  knife  is  pushed  back  in  the  groove 
of  the  staff  sufficiently  far  to  incise  the  ring  at  the  apex  of  the  prostate;  the 
forefinger  is  passed  into  the  prostatic  urethra  and  the  staff  is  withdrawn.  Then 
a  short  tear  is  made  by  means  of  a  blunt  instrument  into  the  mass  of  the  left 
lobe  and  the  finger  is  introduced  and  enucleates  the  lobe.  The  same  procedure 
is  carried  out  on  the  right  lobe,  and,  finally,  if  necessary,  on  the  middle  lobe. 
If  the  middle  lobe  requires  removal,  but  cannot  be  reached,  a  suprapubic  cut  is 
made  into  the  cave  of  Retzius,  two  fingers  are  inserted,  and  the  lobe  is  pushed 
within  reach  of  the  finger  below.  A  large  perineal  tube  is  introduced  for  drain- 
age, a  catheter  is  introduced  and  tied  in  place,  and  bleeding  is  arrested  by 
packing. 

Young's  Operation. — This  surgeon  frequently  operates  under  spinal  anes- 
thesia. He  places  the  patient  in  an  exaggerated  lithotomy  position  and  in- 
troduces a  sound.  In  thin  subjects  the  incision  is  in  the  raphe  and  is  carried 
close  to  the  anus;  in  short  individuals  the  incision  is  an  inverted  V.  He  in- 
cises the  recto-urethralis  muscle  transversely,  exposes  the  membranous  ure- 
thra, opens  it,  and  inserts  his  tractor  into  the  opening  in  the  urethra  (Fig.  1015). 


\^ 


Fig.  1017. — Young's  modification  of  Freudenberg's  instrument  for  prostatotomy  by 

galvanocautery. 

The  tractor  is  turned  180  degrees,  the  blades  are  opened,  and  traction  is  made. 
The  capsule  is  incised  on  each  side  of  the  ejaculatory  ducts  and  the  gland  is  re- 
moved by  blunt  dissection,  the  forceps  grasping  each  lobe  during  enucleation 
(Fig.  1016).  Ever}^  effort  is  made  to  save  the  urethra.  After  removing  the 
lateral  lobes  the  tractor  is  used  to  bring  a  middle  lobe,  if  one  exists,  into  the 
wound,  and  it  is  also  enucleated.     The  bladder  is  drained  for  about  one  week. 

Young's  punch  operation  was  devised  for  the  removal  of  small  prostatic 
bars  and  contractures  of  the  vesical  neck  involving  the  prostate.  Young 
reports  200  cases  with  no  mortality.  It  can  be  done  under  local  urethral  anes- 
thesia; 4  per  cent,  novocain  is  employed.  The  operation  is  performed  by 
means  of  a  special  prostatic  punch  devised  by  Young.  By  means  of  the  punch 
a  portion  of  the  offending  bar  is  removed. 

Bottini's  Qalvanocaustic  Prostatotomy. — Bottini,  of  Padula,  in  1874 
suggested  cauterizing  the  prostate  by  means  of  a  special  instrument.  He 
sought  to  bum  away  a  portion  of  the  gland  in  hope  that  the  contraction  of  the 
scar  would  cause  the  remainder  of  the  gland  to  shrink.  The  instrument  of  Bot- 
tini is  shaped  like  a  catheter,  and  carries  a  platinum  blade  which  is  heated  by 
an  electric  current.  Bottini's  early  instrument  was  not  satisfactory  and  the 
operation  never  became  popular  until  Freudenberg  improved  the  tools  in 
1897  (Fig.  1017). 

Bottini's  galvanocaustic  operation  is  performed  as  follows:  The  bladder 
should  be  emptied,  irrigated,  and  distended  with  air,  and  the  posterior  urethra 
must  be  anesthetized  by  instillation  of  cocain  or  eucain.     The  current  is  tried 


Bottini's  Galvanocaustic  Prostatotomy 


1535 


to  see  how  many  seconds  it  requires  to  heat  the  blade  sufficiently.  The  cur- 
rent is  broken,  the  instrument  is  introduced,  the  cooling  current  is  set  in  mo- 
tion, and  one  assistant  watches  this  and  nothing  else.  The  current  is  turned 
on  and  the  surgeon  waits  the  required  number  of  seconds  for  the  blade  to  become 


\   /' 


Fig.  1018. — Incisions  of  the  middle  lobe  (Young). 

red  hot  (twelve  to  fifteen  seconds),  and  then  turns  the  screw  at  the  handle,  and 
burns  a  groove  in  the  prostate.  A  groove  should  be  burned  toward  the  rectum, 
one  to  one  side,  and,  if  it  is  thought  desirable,  one  to  the  opposite  side.  No 
groove  should  be  burned  toward  the  pubes.     When  a  groove  has  been  burned, 


1^3  + 

Fig.  loig. — Different  incisions  of  prostate  gland  in  Bottini's  operation  (after  Young).     • 

the  blade  is  returned  into  its  sheath,  the  current  being  increased  while  doing 

so  in  order  to  keep  the  blade  from  adhering  to  the  tissue,  then  the  current  is 

shut  off.     After  withdrawing  the  instrument  it  is  not  necessary  to  introduce  and 

retain  a  catheter.     The  patient  is  confined  to  bed  twenty-four  hours  only,  there 

is  rarely  bleeding  or  fever,  and  the  results 

are  fairly  good.     The  scars  contract  and 

the  gland  atrophies.     During  the  period  of 

healing  a  steel  sound  should  be  passed 

from  time  to  time  (Bangs).     It  is  alleged 

that  fibrous  stricture  of  the  neck  of  the 

bladder  may  follow  in  some  cases.  ^ 

Bottini's  operation  is  the  procedure  to 
be  selected  for  a  sclerotic  prostate  and  for 
hypertrophy  in  a  feeble  and  aged  individual 
with  damaged  kidneys.  It  is  not  probable 
that  the  cautery  operation  will  ever  re- 
place prostatectomy.  The  best  instrument 
is  Young's  modification  of  Freudenberg's 
instrument  (Fig.  1017).  Figures  1018  and 
1019  show  various  methods  of  making  the 
cuts  as  advised  by  Hugh  H.  Young.  When 
there  is  a  distinct  and  pedunculated  median 
lobe  the  ordinary  plan  of  burning  fails  entirely;  but,  as  Young  shows  (Figs. 
1018,  1020),  if  an  oblique  cut  be  made  on  each  side  across  the  base,  this  lobe 

1  For  description  of  this  operation  see  Freudenberg,  in  "Berliner  klin.  Woch.,"  No.  46, 
1897;  and  Willy  Meyer,  in  "Med.  Record"  of  March  5,  1898,  and  May  12,  1900. 


Fig. 


1020. — Incising    the 

(Young). 


middle   lobe 


15^6  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

will  drop  out  of  the  way  and  quickly  atrophy.     Bottini's  operation  does  not 
gain  in  public  confidence. 

Castration  and  Vasectomy. — In  1886  Sanitzin  demonstrated  clinically 
the  shrinking  of  a  large  prostate  after  double  castration  (Hawley,  in  "Annals  of 
Surgery,"  Nov.,  1903).  In  1893  Ramm,  of  Norway,  performed  double  castra- 
tion in  order  to  cause  shrinking  of  an  enlarged  prostate.  In  1893,  after  a  long 
series  of  careful  experim£nts,  J.  William  White  recommended  the  operation  of 
bilateral  orchidectomy  for  the  treatment  of  prostatic  hypertrophy.  He  proved 
that  removal  of  the  testicles  causes  a  rapid  shrinking  in  an  enlarged  prostate. 
Much  of  this  shrinking  may  be  due  to  diminution  of  congestion  and  edema, 
but  true  atrophy  undoubtedly  occurs  in  the  glandular  elements.  Very  re- 
markable results  have  been  recorded.  In  some  cases  the  patients  become 
absolutely  comfortable  and  dispense  entirely  with  the  catheter.  Cystitis 
ceases,  and  desire  to  urinate  frequently  becomes  less  marked.  Unilateral 
orchidectomy  has  been  employed,  but  it  is  not  satisfactory.  In  1894  Mears 
suggested  ligation  of  the  spermatic  cord.  In  1895  Lauenstein  suggested  divi- 
sion of  the  spermatic  cord.  In  1896  Tilden  Brown  suggested  ligation  of  the 
vas.  Reginald  Harrison  in  1896  advised  section  of  the  vas.  Lennander  in 
1897  proposed  exsection  of  the  vas  deferens  (vasectomy).  It  is  slower  in  its 
results,  but  just  as  certain  as  castration.  In  spite  of  the  great  simplicity  of 
orchidectomy  the  mortahty  has  been  considerable  (from  11  to  18  per  cent., 
according  to  some  authors.  Socin  and  Burckhardt  say  16.2  per  cent.).  In 
several  instances  mental  disturbance  has  followed  the  operation.  Castration 
is  now  very  seldom  performed,  as  vasectomy  is  just  as  useful  and  is  safer. 
Vasectomy  is  valueless  in  cases  of  fibroid  prostate,  does  some  good  in  adenoma, 
but  is  most  valuable  when  the  prostate  is  generally  hypertrophied  and  prone 
to  great  congestion,  causing  violent  symptoms.  The  testicle  does  not  atrophy 
after  vasectomy,  mental  disturbance  does  not  occur  because  the  internal  se- 
cretion of  the  testicle  is  still  furnished  to  the  organism,  and  impotence  may  not 
develop,  though  sterility  must. 

Other  Methods. — Among  other  operations  which  have  been  suggested  are: 
ligation  of  the  vascular  elements  of  the  cord;  resection  of  all  the  cord  elements 
except  the  vas  and  its  artery  and  vein  [angioneurectomy,  proposed  by  Albarran 
in  1897);  parenchymatous  injections  of  cocaininto  the  testicles;  and  ligation 
of  both  internal  iliac  arteries.  Angioneurectomy  has  a  mortahty  or  5.5  per  cent. 
(Socin  and  Burckhardt). 

Selection  of  Operation  and  Residts. — The  relative  merits  of  these  various 
operations  alluded  to  above  are  in  dispute.  It  is  certain  that  many  cases  of 
prostatic  hypertrophy  can  be  kept  comfortable  by  aseptic  catheterism.  If 
this  procedure  fails,  or  for  other  reasons  must  be  abandoned,  or  if  the  surgeon 
decides  not  to  employ  it,  a  careful  study  of  the  case  should  be  made  before 
selecting  a  special  operation.  The  Bottini  operation  for  a  time  had  somewhat 
extensive  use.  Some  applied  it  to  almost  any  sort  of  case,  claiming  that  the 
operation  is  practically  free  from  danger.  Meyer  used  it  for  any  case  of  un- 
complicated hypertrophy,  but  if  the  prostate  was  very  large,  ligated  the  vasa 
deferentia  some  weeks  before  cauterizing  the  prostate,  in  order  to  lessen  the 
danger  of  thromboses. 

A  more  conservative  view  is  that  of  Eugene  Fuller,  who  doubts  the  perma- 
nence of  the  results  of  the  Bottini  operation,  fears  that  stenosis  of  the  vesical 
neck  may  follow,  and  would  restrict  the  operation  to  uncomplicated  cases  not 
of  a  grave  character,  and  in  which  the  bladder  has  not  been  seriously  damaged. 
It  is  the  operation  of  choice  if  the  prostate  be  fibrous.  It  is  the  preferable 
operation  if  the  patient  be  old,  debilitated,  or  the  victim  of  kidney  disease. 
Some  residual  urine  usually  remains  after  a  Bottini  operation.  In  over  10  per 
cent,  of  cases  no  benefit  follows.  Vasectomy  is  used  for  an  engorged  and  gener- 
ally enlarged  prostate.     It  may  do  great  good  or  may  fail  completely.     If  the 


Malignant  Disease  of  the  Prostate  Gland  1537 

urine  be  extremely  foul,  some  operation  permitting  drainage  is  advisable.  In  an 
adenomatous  prostate  in  which  enucleation  is  easy  we  should  prefer  the  perineal 
method.  In  other  cases  in  which  it  is  probable  enucleation  will  be  hard;  in 
cases  of  uncertain  diagnosis;  in  cases  in  which  a  calculus  may  exist;  and  in 
cases  in  which  the  middle  lobe  is  at  fault,  do  a  suprapubic  operation,  although 
sometimes  a  perineal  incision  may  be  made,  and  a  cut  be  made  in  the  prostate 
to  bring  the  floor  of  the  urethra  level  with  the  trigone. 

In  old  men  with  great  obstruction  and  \\-ith  serious  disease  of  the  bladder 
and  involvement  of  the  kidneys,  and  in  indi\-iduals  with  prostatic  cancer,  per- 
manent suprapubic  drainage  is  sometimes  the  most  useful  procedure. 

The  mortahty  from  Bottini's  operation  is  over  5  per  cent.  Young  had 
3  deaths  in  41  operations. 

Vasectomy  done  early  gives  a  mortahty  of  from  3  to  5  per  cent.  If  per- 
formed later,  the  mortahty  is  10  to  15  per  cent.  Socin  and  Burckhardt  estimate 
the  mortality  of  bilateral  vasectomy  as  S.t,  per  cent.  The  mortahty  of  bilateral 
orchidectomy  is  16.2  per  cent. 

The  mortahty  of  perineal  and  suprapubic  prostatectomy  has  been  con- 
sidered on  page  1529. 

Prostatic  Fibrosis. — This  condition  was  described  by  G.  J.  Guthrie  in 
1830.  He  caUed  it  a  bar  at  the  neck  of  the  bladder.  Enlargement  of  the  mid- 
dle lobe  is  not  the  bar,  it  is  h^-pertrophy.  Young  caUs  prostatic  fibrosis  a  median 
bar  formation.  Fuller  speaks  of  it  as  contraction  of  the  vesical  neck,  Earth 
designates  it  atrophy  of  the  prostate,  and  Guyon  names  it  vesical  prostatisme 
(see  the  elaborate  study  by  Alexander  Randall,  in  the  "N.  Y.  Med.  Jour.," 
Dec.  4,  and  11,  1915). 

The  entire  prostate  is  in  a  state  of  fibrosis  and  the  bar  forms  in  the  muscular 
tissue.  It  impairs  the  elasticity  of  the  vesical  neck  which  becomes  unable  to 
dilate  and  leads  to  the  gathering  of  residual  urine  and  the  symptoms  of  prostatic 
enlargement.  The  lobes  may  be  enlarged.  It  can  occur  in  persons  in  the 
forties. 

Treatment. — Some  practise  prostatectomy  but  the  patient  is  still  in  the 
age  of  virility  and  the  operation  is  difficult  and  dangerous.  Some  treat  it  by 
fulguration,  'some  by  applying  the  cauten,-  through  a  perineal  incision,  some 
foUow  Young,  and  remove  the  bar  by  means  of  a  punch  (see  page  1534)- 

Malignant  Disease  of  the  Prostate  Gland. — Primary  mahgnant  growths 
of  the  prostate  are  not  infrequently  encountered,  but  secondary  growths  are 
much  more  rare  than  primary  growths.  WTien  mahgnant  disease  does  occur 
it  is  usually  cancerous.  Secondary  cancer  of  the  prostate  finds  its  most  usual 
antecedent  in  cancer  of  the  rectum.  EpitheUoma  does  not  occiur.  Scirrhus 
occasionally  occurs;  but  the  most  frequent  form  is  encephaloid.  Carcinoma 
occurs  during  or  after  middle  age.  The  symptoms  are  those  of  urinarv'  obstruc- 
tion. A  hard,  nodular  mass  is  palpated  through  the  rectum.  Sarcoma  is 
ver\-  rare,  although  probably  not  quite  so  rare  as  has  been  thought.  Some 
cases  of  prostatic  tumor  obviously  inoperable  when  first  seen  by  the  surgeon  are 
probably  sarcomatous.  Roimd-celled,  spindle-ceUed,  or  mixed-celled  sarcoma 
may  develop.  Powers  says  there  have  been  but  31  authenticated  cases  of  pri- 
maiy-  sarcoma  reported  (''Annals  of  Surgery,"  Jan.,  1908).  According  to  Gib- 
son ("Jour.  Amer.  Med.  Assoc,"  April  23  1910)  there  are  on  record  36  abso- 
lutely authenticated  cases  of  sarcoma  of  the  prostate.  In  191 2,  Marcel  Descums 
was  able  to  coUect  41  positive  cases  and  Parmenter  has  recently  reported  a 
case.  Sarcoma  is  most  frequent  in  childhood,  but  may  occur  at  any  age.  _  It 
grows  rapidly,  is  usuaUy  soft,  and  causes  difficulty  of  urination  and  defecation 
and  pain  in  the  rectum'  and  perineum  or  pubic  region,  but  early  in  the  case, 
at  least,  there  is  seldom  residual  urine  (Powders,  Loc.  cit.).  In  some  cases  the 
chief  symptoms  are  rectal  (alternations  of  diarrhea  and  constipation  and  abdom- 
inal pains)  in  some  vesical  (frequency  of  micturition,  slowness  in  inaugurat- 

97 


1538  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

ing  the  act,  loss  of  projectile  power  and  dribbling).  A  mass  is  detected  by  rectal 
palpation  and  is  seen  through  a  cystoscope.  The  mass  may  be  soft,  suggesting 
abscess,  or  densely  hard.  No  real  cure  of  carcinoma  or  sarcoma  has  yet  been 
reported. 

Carcinoma  of  the  prostate  my  occur  at  an  earlier  age  than  ordinary  hyper- 
trophy of  the  prostate.  The  latter  does  not  become  evident  until  after  the  age 
of  fifty;  but  carcinoma  of  the  prostate  may  begin  at  any  time  after  the  age  of 
forty,  and  sarcoma  of  the  prostate  may  commence  in  early  youth. 

At  first  the  carcinomatous  growth  enlarges  slowly;  but  it  soon  begins  to 
grow  with  rapidity.  It  breaks  through  the  capsule  and  fungates  into  the 
bladder  or  into  the  urethra.  The  pelvic,  the  inguinal,  and  the  femoral  glands 
become  involved  early  in  the  course  of  the  disease.  It  is  unusual  to  find  great 
obstruction  to  urination  or  to  the  passage  of  a  catheter  at  an  early  period, 
but  later  both  these  conditions  are  noted.  Early  in  the  case  there  is  pain  only 
when  obstruction  to  urination  occurs;  later,  the  pain  in  the  neck  of  the  blad- 
der may  be  severe,  and  there  may  also  be  pain  in  the  loin  and  in  the  sciatic 
nerves.  Hemorrhage  usually  occurs.  In  the  beginning  the  hemorrhage  is 
trivial  and  intermittent,  but  when  fungation  exists,  large  hemorrhages  gen- 
erally take  place.  The  blood  is  usually  mixed  with  urine,  but  there  is  some- 
times a  large  hemorrhage  unassociated  with  micturition.  The  urine  is  not 
likely  to  contain  pus  or  any  large  quantity  of  mucus  unless  the  bladder  is  in- 
volved in  the  growth. 

When  the  prostate  gland  is  felt  by  means  of  a  finger  in  the  patient's  rectum, 
it  is  found  to  be  of  stony  hardness  and  to  be  firmly  anchored  in  place.  Regi- 
nald Harrison  points  out  that  an  ordinary  hypertrophied  gland  is  not  so  firmly 
anchored  as  a  carcinomatous  gland;  that  the  bowel  moves  over  it  with  free- 
dom; and  that,  although  it  is  firm  to  the  touch,  it  is  not  of  stony  hardness.  The 
patient  with  carcinoma  of  the  prostate  loses  flesh  rapidly  and  develops  dis- 
tinct cachexia,  and  metastatic  deposits  are  likely  to  form  in  the  vertebral  column, 
in  the  kidneys,  and  in  other  organs  and  structures. 

In  making  a  diagnosis  Harrison  insists  upon  the  value  of  the  cystoscope. 
He  says  that  in  cancer  one  does  not  find  much  intravesical  projection,  and 
that  what  projection  there  is  is  uneven  and  irregular.  In  an  ordinary  adeno- 
matous prostate,  on  the  contrary,  the  surface  is  smooth  and  rounded  and  pro- 
jects into  the  bladder. 

Treatment. — Radical  operation  is  out  of  the  question  in  these  cases.  Per- 
manent suprapubic  drainage  is  made  in  most  instances,  and  usually  gives  the 
patient  great  relief.  (See  "Remarks  on  Cancer  of  the  Prostate,"  by  Regi- 
nald Harrison,  in  "Brit.  Med.  Jour.,"  July  4,  1903.)     Radium  may  be  tried. 

Tuberculosis  of  the  prostate  gland  is  rarely  primary.  It  is  usually 
secondary  to  tuberculosis  of  the  kidney.  It  may  follow  tuberculosis  of  the 
epididymis.  In  the  majority  of  cases  of  tuberculosis  of  the  prostate  the  lungs 
are  involved  in  a  tuberculous  process  when  the  patient  is  first  seen  by  the 
surgeon.  The  disease  appears  particularly  between  the  ages  of  twenty  and 
thirty  years,  but  it  may  attack  elderly  men  and  even  the  aged.  It  begins  by 
the  formation  of  a  number  of  tuberculous  nodules  in  the  immediate  neighbor- 
hood of  the  prostatic  tubules.  These  nodules  caseate  and  run  together,  form- 
ing cavities  and,  eventually,  tuberculous  abscesses,  which  are  prone  to  rupture 
into  the  urethra.  In  very  rare  instances  a  large  tuberculous  abscess  ruptures 
through  the  perineum,  into  the  rectum  or  into  the  peritoneum. 

The  disease  occasionally  imdergoes  spontaneous  cure  through  fibrous 
tissue  formation  or  calcification.  The  tuberculous  process  is  liable  to  spread 
to  the  seminal  vesicles,  the  bladder,  the  ureters,  and  possibly  to  the  peritoneum ; 
and  in  some  cases  it  inaugurates  thrombophlebitis  and  pyemia. 

Symptoms. — The  patient  suffers  from  pain  during  micturition;  there  is 
frequent  micturition,  and  from  time  to  time  the  urine  contains  blood.     Attacks 


Retained  and  Malplaced  Testicle  1539 

of  cystitis  take  place,  and  weakness  and  loss  of  flesh  are  greater  than  is  com- 
mensurate with  any  ordinary  inflammation.  Tuijerculosis  of  the  prostate 
alone  is  said  not  to  cause  marked  hectic  fever,  but  when  adjacent  structures 
become  involved  the  temperature  is  definitely  elevated  and  becomes  charac- 
teristic. When  the  disease  has  advanced  there  is  not  unusually  urinary  in- 
continence, on  account  of  the  involvement  of  the  circular  muscular  fibers 
about  the  neck  of  the  bladder.  Commonly,  there  is  a  mucopurulent  discharge, 
or  mucopurulent  matter  may  be  obtained  by  massaging  the  prostate.  This 
matter  may  contain  tubercle  bacilli,  and  in  some  cases  the  urine  also  contains 
bacilli.  Early  in  the  course  of  the  case  rectal  examination  detects  some  enlarge- 
ment of  the  gland,  many  nodules,  and  tenderness;  later  in  the  disease  it  finds 
marked  enlargement  and  areas  of  softening. 

Treatment. — Early  in  the  case  Senn  recommends  parenchymatous  injec- 
tions of  iodoform  emulsion,  the  punctures  being  made  through  the  peri- 
neum. If  these  fail,  operation  must  be  considered.  When  one  takes  into 
account  how  rare  primary  tuberculosis  of  the  prostate  is,  one  is  impressed  with 
the  infrequency  with  which  a  radical  operation  should  be  attempted.  If 
there  is  absolutely  no  evidence  that  any  adjacent  organ  is  involved  or  that 
any  distant  focus  of  disease  exists,  it  is  justifiable  to  perform  perineal  pros- 
tatectomy. As  a  rule,  however,  the  only  surgical  operation  performed  con- 
sists in  making,  in  front  of  the  rectum,  a  curvilinear  incision  which  exposes 
the  prostate,  and  permits  the  surgeon  to  open  and  curet  caseous  foci.  If  an 
abscess  forms,  it  should  be  evacuated  by  means  of  a  perineal  incision  and 
cavities  should  be  curetted  and  packed  with  iodoform  gauze. 

When  a  patient  is  convalescent  after  an  operation  or  if  it  is  determined 
that  no  operation  is  advisable,  full  antituberculous  treatment  is  employed 
(see  page  255).  One  should  look  to  the  patient's  general  health,  administer 
uro tropin,  and  avoid  using  instruments  as  much  as  possible;  because,  as  Sir 
Henry  Thompson  has  shown,  instrumentation  irritates  the  prostate,  causes  a 
great  deal  of  pain,  and  makes  the  disease  worse  in  every  case. 

Retained  and  Malplaced  Testicle. — The  cause  of  non-descent  is  unknown. 
Certain  it  is  that  the  vaginal  process  is  not  a  factor  in  descent.  Some  think 
the  condition  is  a  reversion  to  type.  Buedinger  thinks  the  gland  is  restrained 
by  adhesions  the  result  of  fetal  peritonitis.  It  has  been  asserted  that  a 
short  mesorchium  is  responsible.  Eisendrath  ("Annals  of  Surgery,"  1916, 
kiv)  thinks  that  the  contributing  factors  are  deficiency  in  the  arching  fibers 
of  the  internal  oblique  and  a  weakness  of  the  conjoined  tendon  which  allow  of 
retraction  by  the  cremaster.  The  normally  descended  testicle  is  entirely  within 
the  scrotum.  In  i  person  of  100  there  is  either  undescended  or  ectopic  testis. 
In  80  per  cent,  of  individuals  the  testicles  have  descended  at  birth;  most  often 
it  is  the  right  testicle  which  fails  to  descend.  Sometimes  a  testicle  descends 
after  being  retained  for  months  or  even  years.  In  Keyes's  case  it  descended 
in  the  thirtieth  year.  Late  descent  usually  causes  hernia,  and  in  over  90  per  cent, 
of  all  cases  hernia  exists.  In  not  a  few  cases  of  non-descent  there  is  hjrpopitui- 
tarism.  The  testicle  may  be  arrested  in  its  passage  to  the  scrotum  {cryptor- 
chism,  single  or  double) ;  it  may  remain  in  the  lumbar  region ;  it  may  reach  the 
internal  abdominal  ring;  it  may  lodge  in  the  inguinal  canal;  it  may  emerge  from 
the  external  ring,  but  fail  to  enter  the  scrotum;  or  it  may  pass  into  an  unnatural 
position,  as  into  the  perineum  or  the  crural  canal  (ectopia  of  the  testis).  The 
failure  of  descent  may  be  unilateral  or  bilateral,  but  when  bilateral  the  degree  of 
descent  is  seldom  the  same  on  the  two  sides.  The  gland  may  be,  but  seldom  is, 
functionally  active.  When  retained  in  the  abdomen  it  never  has  the  power  of 
spermatogenesis.  Before  puberty  the  testicle  is  usually  normal,  but  after 
puberty  there  is  practically  always  more  or  less  atrophy.  In  about  i  case  out 
of  5  there  is  spermatogenesis  for  a  time.  A  retained  testicle  is  liable  to  attacks 
of  orchitis  amd  may  become  tuberculous,  carcinomatous,  endotheliomatous,  or 


I540  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

sarcomatous.  Coley  ("Annals  of  Surgery,"  1915,  Ixii)  reports  that  among 
59,235  cases  of  inguinal  hernia  admitted' to  the  N.  Y.  Hospital  for  Ruptured  and 
Crippled  there  were  found  737  cases  of  sarcoma  of  undescended  testicle.  In 
some  cases  mixed  tumors  form  (sarcocarcinomata).  See  case  of  Butt  and  Arkin 
("Jour.  Alumni  Assoc.  Coll.  Phys.  and  Surgeons,"  1915,  xvii).  If  both  testi- 
cles are  retained  one  or  both  may  become  the  seat  of  neoplastic  formation.  In 
some  cases  of  retention  torsion  of  the  cord  occurs.  In  most  cases  there  is  neither 
pain  nor  tenderness,  and  the  patient  presents  himself  for  treatment  because 
a  lump  has  appeared  in  the  groin.  In  some  cases  there  are  sudden  attacks  of 
violent  pain,  accompanied  by  nausea  (Rawling,  on  "Incompletely  Descended 
Testicle,"  in  "Practitioner,"  August,  1908).  A  testicle  in  the  inguinal  or  crural 
canal  or  in  the  perineum  is  far  more  apt  to  become  sarcomatous  than  one  re- 
tained within  the  abdomen.  Over  10  per  cent,  of  cases  of  sarcoma  of  the  testicle 
ar?  in  undescended  glands.  Russell  Howard  ("Practitioner,"  Dec,  1907), 
out  of  57  cases  of  undescended  testicle,  found  15.7  per  cent,  with  malignant 
disease.  In  double  cryptorchism,  in  which  the  testicular  function  has  been 
abolished,  there  is  delayed  union  of  the  bony  epiphyses  and  epiphyseal  frac- 
tures are  common,  and  there  may  be  excessive  growth  of  long  bones.  The  same 
liability  is  noted  in  those  subjected  to  castration  in  infancy.  When  such  a 
subject  reaches  manhood,  he  may  develop  some  disease  of  the  skeleton  which  is 
usually  seen  in  children  only  (Gross  and  Sencert,  "Rev.  de  Chir.,"  No.  11, 
1905).  In  operating  on  these  cases  we  usually  find  a  well-developed  gubernacu- 
lum  and  a  vaginal  tunic  extending  below  the  testicle. 

Treatment. — -If  one  testicle  is  undescended  at  or  after  the  eighth  year  of  life 
and  before  puberty,  if  it  lies  in  the  canal,  and  if  the  other  testicle  is  sound, 
the  former  should  be  removed  if  it  is  found  impossible  to  draw  the  gland  into 
the  scrotum.  Both  testicles  should  not  be  removed  from  a  child:  one  should  be 
placed  within  the  abdomen.  I  would  save  one  testicle  in  order  to  have  the  child 
certainly  enter  and  remain  in  the  masculine  groove.  Removal  of  both  testicles 
is  permissible  in  an  adult,  because  he  has  definitely  become  and  will  remain 
masculine,  and  undescended  or  ectopic  testicles,  in  an  adult  are  or  will  surely 
become  functionally  useless  and  menaces.  If  a  testicle  is  retained  in  the  abdo- 
men it  should  not  be  operated  upon  unless  it  causes  trouble.  Always  try  to  get 
a  retained  gland  into  the  scrotum  before  the  age  of  puberty.  If  it  is  retained 
after  puberty,  it  will  be  almost  certain  to  remain  so  or  become  functionally  useless. 
An  ectopic  testicle  should  be  restored  to  the  scrotum  if  possible;  if  not,  it  should 
be  removed.  Even  when  operation  is  performed  to  replace  the  testicle,  success 
is  seldom  enduring.  In  Rawling's  29  cases  only  4  were  permanently  successful. 
Other  operators,  however,  claim  better  results.  For  instance,  Broca  reports  79 
cases  traced  from  one  to  six  years,  and  in  3 1  of  them  the  result  was  perfect  and 
permanent.  The  method  I  employ  is  that  advocated  by  Coley,  viz.,  Bassini's 
incision  through  the  aponeurosis,  separation  of  the  cord  from  the  peritoneum  (it 
is  usually  in  the  posterior  sac  wall);  removal  of  the  vaginal  process,  the  cre- 
master  and  fibrous  adhesions  around  the  cord;  the  making  of  a  scrotal  pouch 
by  the  fingers,  closure  of  the  canal  as  in  hernia;  suturing  of  the  cord  to  the  pillars 
of  the  external  ring,  as  advocated  by  Dowd.  This  is  practically  Broca's  method. 
Bevan  operates  for  a  testicle  within  the  canal  by  separating  and  dividing  the 
vaginal  process,  removing  all  the  coverings  of  the  cord,  and  leaving  the  testicle 
suspended  by  the  vas  and  spermatic  vessels  only.  This  proceeding  gives  the 
testicle  a  very  wide  range  of  mobility.  A  pocket  is  made  in  the  scrotum  by 
means  of  the  finger,  the  testicle  is  placed  in  the  pocket,  and  remains  there 
without  suturing.  The  canal  is  now  sutured  as  in  a  Bassini  operation  without 
cord  transplantation.  There  is  a  certain  though  small  risk  of  gangrene  of 
the  testicle  after  Bevan's  operation.  I  believe  Bevan's  method  should  be  em- 
ployed in  the  more  severe  cases.  If  there  is  no  hernia,  operation  should  not  be 
performed  until  between  the  eighth  and  twelfth  years  of  life. 


Tuberculosis  of  the  Testicle  '  1541 

If  an  atrophied  testicle  can  be  moved  into  the  scrotum  it  might  be  proper 
to  take  a  text  from  a  remarkable  case  reported  by  Robert  T.  Morris  ("Jour. 
Am.  Med.  Assoc,"  Sept.  2,  1916).  A  boy  of  13  lost  both  testicles  as  a  result  of 
mumps.  The  scrotum  seemed  empty.  A  wedge-shaped  graft  was  secured 
from  the  testicle  of  a  hernia  patient  who  was  free  from  syphilis  and  tuberculosis. 
One  piece  of  the  graft  was  inserted  under  the  sheath  of  the  right,  another  under 
the  sheath  of  the  left  rectus  muscle  of  the  abdomen.  The  remainder  of  the  graft 
was  placed  in  the  scrotum.  As  the  graft  placed  in  the  right  scrotum  began  to 
disappear  the  vestige  of  testicle  began  to  enlarge.  About  a  year  later  another 
graft  was  inserted  into  the  right  scrotum.  It  was  then  seen  that  the  testicle 
appeared  normal  and  was  about  one-third  natural  size.  Evidently  the  graft 
stimulated  the  vestige  to  development.  Lespinasse  reports  the  case  of  a  man 
who  lost  both  testicles  and  the  power  of  erection.  A  graft  from  the  testicle  of  a 
live  man  restored  the  power  of  erection  ("Jour.  Med.  Assoc,"  19 13,  Ixi).  This 
is  a  new  principle  which  might  be  utilized  when  a  functionless  undescended 
testicle  is  drawn  into  the  scrotum. 

Orchitis  is  inflammation  of  the  testicle.  Actite  orchitis  may  foUow  cold, 
wet,  traumatism  or  epididymitis,  and  may  follow  or  develop  during  gout, 
mumps,  rheumatism,  or  a  specific  fever.  Mumps  seldom  attacks  the  testicle 
before  puberty.  Orchitis  before  puberty  may  be  due  to  tuberculosis  or  to  cord 
torsion.  The  testicle  is  round,  swollen,  tender,  and  very  painful,  the  scrotum 
is  red  and  swollen,  the  tunica  vaginalis  is  filled  with  fluid,  and  there  is  fever. 
Chronic  orchitis  results  from  the  acute  form  or  from  a  chronic  urethral  inflamma- 
tion, and  is  almost  always  combined  with  epididymitis.  Gonorrheal  orchitis 
is  rare  and  almost  certainly  results  in  sloughing  of  the  testicle. 

The  treatment  of  the  acute  form  consists  m  rest  in  bed  and  applications 
as  for  epididymitis  (see  page  1 545) .  The  chronic  form  requires  the  removal  of 
the  causative  lesion,  if  possible,  the  wearing  of  a  suspensory  bandage,  applica- 
tions of  ichthyol  or  mercurial  ointment,  and  the  administration  of  iodid  of 
jx)tassium  by  the  mouth.  Strapping  with  zinc  oxid  adhesive  plaster  may  do 
good.     Castration  may  be  required. 

Tuberculosis  of  the  testicle  may  perhaps  be  primary,  but  in  the  vast 
majority  of  cases  is  secondary  to  tuberculosis  of  the  kidney,  prostate,  bladder,  or 
seminal  vesicles.  As  Keyes  ("Annals  of  Surgery,"  June,  1907)  says,  careful 
examination  wiU  show  one  of  three  conditions — tubercle  bacilli  in  urine,  indura- 
tions in  the  prostate,  and  vesicles  or  "a  distinct  haze  in  the  urine  due  to  prostatic 
catarrh."  Tuberculosis  of  the  prostate  or  vesicles  exists  in  probably  one-half  the 
cases  (Barney,  in  "Boston  Med.  and  Surg.  Jour.,"  March  14,  1912).  In  about 
one-third  of  the  cases  there  is  evidence  of  tuberculosis  distant  from  the  genito- 
urinary organs  (especially  in  the  lungs  or  bones) .  Patients  with  tuberculosis  of 
the  testicle  are  nearly  always  sterile.  The  disease  may  be  preceded  by  pulmonary 
tuberculosis,  lymphatic  tuberculosis,  peritoneal  tuberculosis,  anal  fistula,  renal 
tuberculosis,  or  tuberculous  disease  of  bones  or  joints;  and  primary  tuberculosis 
of  the  testicle  may  be  followed  by  near  or  distant  tuberculous  lesions.  In  some 
cases  involvement  of  the  prostate  exists,  but  cannot  be  detected  {latent  tuber- 
culosis of  the  prostate) ;  in  other  cases  the  prostate  is  in  a  state  of  subacute  in- 
flammation. The  epididymis  is  usually  involved  before  the  testicle  and  early 
chronic  lesions  are  localized  there  for  some  time.  In  most  cases  the  bacilli 
reach  the  prostate  and  vesicles  by  way  of  the  blood,  and  reach  the  epididymis 
by  way  of  the  vas  deferens,  the  lesions  of  the  prostate  and  vesicles  developing 
first  or  remaining  latent.  In  some  cases  tuberculosis  of  the  kidney  or  bladder 
is  followed  by  tuberculosis  of  the  testicle.  The  spead  from  the  prostate,  vas, 
or  bladder  is  by  epithelial  infection.  There  is  no  evidence  confirmatory  of  the 
idea  of  ascending  infection  from  the  urethra.  In  a  child  with  an  open  vaginal 
process,  tuberculous  peritonitis  may  directly  cause  tuberculous  epididymitis. 
The  disease  begins  in  one  testicle,  but  in  the  vast  majority  of  cases  the  other 


1542  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

testicle  becomes  involved  after  a  few  weeks  or  months.  If  the  other  testicle 
remains  free  for  three  years  its  chance  of  remaining  free  is  good.  If  but  one 
epididymis  is  involved  the  testicle  may  not  be  affected  for  weeks  or  months. 
Von  Bruns  says  that  in  18  per  cent,  of  such  cases  the  testicle  is  not  involved 
for  six  months;  in  40  per  cent,  for  over  two  months  (''Archiv.  f.  klin.  Chir.," 
Bd.  63,  H.  4).  It  usually  comes  on  gradually,  but  it  may  begin  acutely,  as  I 
have  seen  in  two  instances  during  the  progress  of  tuberculous  peritonitis.  An 
acute  onset  or  an  acute  exacerbation  of  a  chronic  case  usually  means  mixed 
infection.  The  disease  may  follow  a  slight  injury  or" inflammation,  and  is  most 
common  in  young  men,  but  may  arise  at  any  age.  The  causal  influence  of  ante- 
cedent or  existing  gonorrhea  is  doubtful.  Some  maintain  that  sexual  excess 
predisposes.  There  is  often  a  family  history  of  tuberculosis.  A  chronic  case 
begins  by  swelling  of  the  epididymis.  Palpation  detects  one  or  two  or  several 
rounded  nodules,  or  a  diffuse  hardening.  In  the  latter  case  the  epididymis  is 
much  enlarged,  and  there  is  usually  a  slight  hydrocele.     Rectal  examination 


Fig.  102 1. — Obstructive  hyperemia  for  the  testicles.  The  ends  of  the  elastic  tube  are 
held  by  the  patient,  crossed.  A  piece  of  tape  is  placed  beneath  to  be  tied  by  an  attendant 
(Meyer  and  Schmieden). 

commonly  detects  nodules  in  the  prostate  and  vesicles.  In  a  few  cases  there 
are  frequency  of  micturition,  tenesmus,  hematuria,  and  seropurulent  fluid  can 
be  massaged  from  the  vesicles  and  prostate  and  milked  from  the  urethra.  In 
some  cases  bacilli  are  found  in  the  urine.  In  others  the  urine  is  hazy.  In 
about  80  per  cent,  of  cases  the  guinea-pig  test  will  prove  the  presence  of  bacilli. 
In  some  cases  the  urine  is  normal.  Sooner  or  later  nodules  appear  in  the  testicle. 
The  vas  is  always  swollen  and  may  or  may  not  be  palpable.  In  an  acute  case 
one  testicle  is  involved.  The  testicle  is  very  painful  and  the  epididymis  is  greatly 
swollen  and  smooth.  The  testicle  quickly  swells,  there  is  always  a  hydrocele, 
and  the  scrotal  skin  becomes  reddened.  In  a  few  days  the  acuteness  of  the 
symptoms  subsides,  but  suppuration  occurs  soon.  In  any  case  of  tuberculosis 
of  the  testicle  nodules  tend  to  soften  and  run  together.  After  a  time  the  skin 
may  become  red  and  adherent,  give  way,  and  expose  a  caseous  breaking-down 
epididymis  or  testicle.  Caseation  can  occur  without  mixed  infection,  but  in 
many  cases  in  which  softening  and  sinus  formation  occur  there  is  mixed  infec- 
tion.    The  duration  of  the  disease  is  uncertain;  10  per  cent,  of  the  100  cases 


Embryomata  1 543 

carefully  studied  by  Keyes  were  known  to  be  alive  ten  years  after  the  beginning 
of  the  trouble,  and  4  (and  not  one  of  them  had  been  operated  upon)  seemed  free 
from  tuberculous  lesions  anywhere.  One-third  of  the  cases  that  suppurated 
were  apparently  well  after  three  years  ("Annals  of  Surgery,"  June,  1907).  Ex- 
cept in  the  acute  cases  the  testicle  is  only  slightly,  if  at  all,  painful,  and  tenderness 
is  trivial.  In  one-sixth  of  the  cases  a  small  hydrocele  forms.  If  a  hydrocele 
exists  the  fluid  should  be  withdrawn  by  tapping  in  order  that  cultures  may  be 
made  from  it. 

Treatment. — Before  attempting  any  operation  try  Bier's  method.  The 
patient  is  placed  recumbent,  the  diseased  testicle  is  lifted  upward,  cotton 
batting  is  placed  around  the  neck  of  the  scrotum,  and  a  rubber  drainage-tube 
of  a  cahber  of  25  of  the  French  scale  is  wound  twice  around  and  fastened  with 
a  string  or  clamp.  If  both  testicles  are  fiiseased,  both  are  held  up  and  the  neck 
of  the  scrotum  is  embraced  by  the  tube  with  the  required  firmness  (see  Fig. 
102 1).  The  treatment  is  applied  for  two  or  three  hours  a  day  or  longer.  The 
patient  had  best  be  recumbent  during  the  application.  In  the  intervals  he  wears 
a  suspensory  and  gets  about.  During  the  use  of  Bier's  method  full  antitubercu- 
lous  treatment  is  required  (see  page  255).  If  a  cold  abscess  forms,  open  it  and 
dress  the  part  antiseptically.  Durante  injects  iodin  into  the  body  of  the  epidid- 
ymis once  a  month.  If  Bier's  treatment  fails,  consider  the  advisability  of  oper- 
ation. An  acute  case  requires  unilateral  castration.  If,  in  a  chronic  case 
the  disease  is  limited  to  the  epididymis  or  to  the  epididymis  and  vas,  resect 
the  epididymis  (epididymectomy)  and  the  vas  deferens.  If  the  testicle  is  dis- 
eased, orchidectomy  is  performed.  It  was  long  believed  that  orchidectomy  was 
useless  if  the  vesicles  and  prostate  were  involved,  but  Koenig  and  others  main- 
tain that  vesicular  and  prostatic  tuberculosis  improves  after  removing  the  dis- 
eased testicle  or  epididymis.  If  the  epididymis  of  each  testicle  is  involved, 
bilateral  epididymectomy  should  be  performed.  When,  both  testicles  are  dis- 
eased and  other  organs  and  structures  are  not  extensively  involved,  bilateral 
orchidectomy  is  performed  or,  better,  the  testicle  which  is  most  diseased  is 
removed  and  the  diseased  portion  of  the  other  is  extirpated.  Cumston  points 
out  that  when  the  testicle  is  diseased  the  disease  may  not  be  detectable  even 
on  operative  exposure.  Hence  in  doing  epididymectomy  he  splits  open  the 
testicle  to  see  if  it  be  diseased.  If  it  be  not  diseased  he  sutures  it  with  catgut 
and  removes  the  epididymis.  If  it  be  diseased  he  considers  the  advisability 
of  unilateral  orchidectomy  (Charles  Greene  Cumston,  in  "Annals  of  Surgery," 
June,  1909). 

In  many  cases  after  epididymectomy  sinuses  form.  They  may  remain  open 
for  months.  In  association  with  and  after  operation  employ  an ti tuberculous 
remedies,  order  a  nourishing  diet,  send  the  patient  to  a  good  climate,  and  insist 
on  an  open-air  life.  Tuberculin  may  prove  useful.  A  considerable  percentage 
of  unilateral  cases  are  cured  by  operation  (over  40  per  cent.).  Some  few 
bilateral  cases  are  cured. 

Cysts  and  Tumors  of  the  Testicle. — Innocent  tumors  are  very  rare;  in 
fact,  some  dispute  their  existence.  The  elements  of  a  testicular  growth  are  very 
complex.  A  majority  of  growths  is  unquestionably  malignant.  Some  are 
wholly  mahgnant.  Many  show  a  mingling  of  benign  and  mahgnant  elements. 
An  undescended  testicle  is  Hable  to  mahgnant  growth.  Even  growths  which 
are  not  malignant  in  the  beginning  have  an  irresistible  tendency  to  become  so. 
It  is  beheved  by  many  surgeons  that  fibroma  and  adenoma  can  arise  and  perhaps 
remain  for  some  time  benign.  Embryomata  are  at  first  benign,  but  tend, 
perhaps  after  years,  to  become  malignant. 

Embryomata. — H.  Morriston  Davies  ("Lancet,"  Feb.  17,  1912)  considers 
embl-yomata  to  be  "composite  tumors  containing  elements  derived  from  epi- 
blast,  mesoblast,  and  hypoblast."  They  are  "developed  in  the  body  of  the 
testicle"  and  not  in  the  epididymis,  though  that  structure  may  eventually  be 


I  S44  Diseases  and  Injuries  of  the  Genito-urinary  Organs 

involved.  Early  in  their  development  these  growths  are  benign,  but  any  or 
all  the  layers  may  become  malignant  (Nicholson,  in  "Guy's  Hospital  Reports," 
vol.  L\i,  1907). 

When  two  or  more  layers  become  "malignant"  a  mixed  tumor  is  the  result; 
when  hypoblast  alone,  the  tumor  assumes  the  character  of  a  columnar-celled 
carcinoma;  when  mesoblast  alone,  of  a  sarcoma  or  myxosarcoma"  (Davies, 
Loc.  cit.).  When  a  dermoid-like  growth  from  the  epiblast  becomes  malignant 
it  resembles  chorionepithelioma  and,  if  such  a  growth  arises,  the  mammary 
glands  may  enlarge.  Nicholson  (Loc.  cit.)  divides  embryomata  into  solid  em- 
bryomata  (which  often  contain  cysts  and  are  common)  and  cystic  embryomata 
or  dermoids  (which  are  very  rare.)  Many  surgeons  regard  sarcoma,  others 
carcinoma,  as  the  commonest  form  of  malignant  disease.  Endothelioma  may 
occur. 

Malignant  Disease  of  the  Testicle. — It  may  arise  from  an  embryoma  or 
may  be  malignant  from  the  start.  If  a  tumor  which  has  long  existed,  perhaps 
years,  begins  to  grow  rapidly,  we  may  assume  that  there  is  malignant  change 
in  an  embryoma.  It  is  seldom  possible  to  diagnosticate  the  form  of  a  malignant 
tumor.  Sarcoma  may  occur  at  any  age,  but  the  period  of  greatest  liability  is 
from  twenty  to  forty.  Sarcoma  is  usually  of  the  small  round-celled  variety  (the 
type  known  as  lymphosarcoma),  but  the  spindle-celled  growth  is  sometimes  seen. 
It  begins  in  the  mediastinum  of  the  gland.  The  other  testicle  soon  becomes  in- 
volved in  malignancy.  The  growths  disseminate  rapidly.  In  10  per  cent,  of 
cases  the  testicle  is  undescended.  Any  sarcoma  is  liable  to  sudden  increase  in 
si^e  because  of  hemorrhage. 

Nicholson  ("Guy's  Hospital  Reports,"  vol.  ki,  1907)  divides  carcinomata 
into  encephaloid  (which  is  commonest)  and  scirrhus  (which  is  rare),  and  regards 
so-called  columnar  carcinomata  as  teratomata.  Carcinoma  is  rare  before  the 
age  of  forty.  Davies  ("Lancet,"  Feb.  17,  191 2)  admirably  sums  up  the  clinical 
picture  of  malignant  disease  of  the  testicle.  I  have  utilized  his  article  exten- 
sively below.  The  tumor  may  attain  a  great  size  (that  of  a  cocoanut).  It  is 
usually  oval,  but  may  exhibit  a  few  rounded  projections  "due  to  the  presence 
of  degeneration  in  the  tumor  or  of  fluid  in  the  tunica  vaginalis."  Early  in  the 
development  the  growth  is  smooth  (except  for  the  projections  mentioned); 
later  it  breaks  through  the  tunica  albuginea  and  so  later  has  an  irregular  surface. 
The  epididymis  is  at  first  free,  but  sooner  or  later  becomes  part  of  the  tumor. 
The  consistence  of  malignant  tumors  is  very  variable  (may  be  hard,  elastic, 
soft,  or  fluctuating),  and  the  con^stence  of  a  tumor  may  vary  in  different  parts. 
In  most  cases  there  is  an  associated  hydrocele,  in  which  the  fluid  may  be  limited 
or  may  be  distributed  throughout  the  entire  sac.  The  hydrocele  may  be  trans- 
lucent, the  tumor  never  is.  Pain  is  seldom  severe  and  tenderness  seldom  acute 
in  the  testicle.  I  have  seen  terrible  agony  when  the  lumbar  glands  have  been 
involved.  The  tumor  when  raised  on  the  hand  feels  very  heavy.  The  cord 
becomes  enlarged  because  of  involvement. 

The  growth  finally  adheres  to  the  scrotum,  and  the  skin  reddens  and  gives 
way  and  fungation  occurs.  When  this  happens  there  is  severe  pain.  Sarcoma 
of  the  testicle,  unlike  sarcoma  in  most  other  regions,  causes  early  glandular 
involvement.  The  glands  along  the  renal  veins  are  especially  liable  to  in- 
vasion. Carcinoma,  of  course,  involves  glands.  The  inguinal  glands  are  not 
involved  unless  the  scrotum  be  attacked.  The  lumbar  glands  receive  the 
testicular  lymphatics.  Secondary  growths  are  early  and  widespread  and  are 
common  in  the  skin. 

Malignant  growth  of  an  undescended  testicle  causes  acute  pain  in  the  iliac 
fossa  and  later  a  mass  can  be  felt.  Such  symptoms,  in  one  whose  testicle  of  that 
side  is  not  in  the  scrotum,  at  once  suggest  the  cause. 

H.  M.  Davies  emphasizes  the  great  fatality  of  malignant  disease  of  the  tes- 
ticle; quotes  Chevassu's  collection  of  100  cases  treated  by  castration,  of  which  81 


Treatment  of  Epididymitis  1545 

died  of  malignant  disease  and  only  ig  were  cured,  and  insists  that  "early  diag- 
nosis and  the  removal  of  the  testicle  and  surrounding  fascia  and  the  glands  in 
the  lumbar  region  offer  the  only  hope  of  decreasing  so  appalling  a  mortality" 
C'Lancet,"  Feb.  17,  1912). 

Orchidectomy,  or  Castration  {Excision  of  a  Testicle). — Bilateral  cas- 
tration should  never  be  performed  without  deliberate  consideration.  It  often 
produces  grave  mental  disorder.  This  is  in  part  the  result  of  the  mental  de- 
pression attendant  on  knowing  that  the  highly  prized  glands  are  gone  for 
ever,  and  in  part  the  loss  to  the  organism  of  the  internal  secretion  of  the  testi- 
cles. A  boy  castrated  before  puberty  never  becomes  potent.  A  man  may  re- 
tain potency  for  a  considerable  time  after  castration.  I  removed  a  tuberculous 
kidney  from  a  man  who  had  been  castrated  by  my  colleague,  Dr.  Horwitz, 
two  years  before,  and  he  was  still  able  to  have  intercourse.  Unilateral  orchid- 
ectomy does  not  make  a  man  either  sterile  or  impotent  and  does  not  produce 
mental  disturbance.  In  orchidectomy  for  benign  disease  an  incision  is  made 
over  the  cord,  commencing  just  outside  the  external  ring  and  runing  down  over 
the  base  of  the  tumor.  Clamp  the  cord  and  divide  it  near  the  ring,  remove  the 
testicle,  ligate  the  spermatic  artery  alone,  and  then  ligate  the  entire  thickness 
of  the  cord.  The  cord  is  ligated  with  chromic  gut.  The  skin  is  sutured  with 
silkworm-gut.  Drainage  is  not  required.  It  is  often  advisable  to  remove  a 
considerable  amount  of  scrotal  skin.  Orchidectomy  for  malignant  disease  must 
be  a  much  more  radical  procedure.  After  the  cord  has  been  divided  and  the 
testicle  removed,  as  in  the  ordinary  operation,  the  incision  is  prolonged 
along  and  through  the  roof  of  the  inguinal  canal,  and  is  continued  in  the  same 
direction  to  a  point  a  little  above  the  anterior  superior  spine  of  the  ilium. 
The  incision  is  then  curved  and  carried  up  to  "the  costal  margin  at  the  level  of 
the  tenth  rib"  (Davies,  in  "Lancet,"  Feb.  17,  1912).  The  peritoneum  is 
exposed.  The  cord  is  traced  well  into  the  true  pelvis,  is  tied,  and  divided. 
The  fascia  over  the  iliacus  and  psoas  muscles  is  dissected,  "together  with  the 
contained  spermatic  vessels  and  lymphatics,"  and  the  glands  upon  "the  inferior 
vena  cava  and  aorta"  are  removed  (Davies,  Ibid.).  This  operation  was  first 
performed  by  Gregoire  in  1905.  Davies  did  the  thirteenth  operation  on  record 
(Ibid.). 

Epididymitis,  or  inflammation  of  the  epididymis,  is  usually  due  to  in- 
flammation of  the  urethra.  It  is  apt  to  occur  in  the  stage  of  decline  of  a  gonor- 
rhea, and  in  such  a  case  is  announced  by  a  notable  diminution  or  a  complete 
cessation  of  discharge.  It  may  result  from  the  passage  of  a  urethral  instrument, 
the  voiding  of  urine  which  contains  fragments  of  calculi,  or  as  a  complication 
of  prostatic  hypertrophy.  Acute  epididymitis  is  characterized  by  swellmg 
of  tJie  epididymis,  severe  pain  in  the  groin,  and  tenderness  over  the  posterior 
part  of  the  testicle.  The  pain  becomes  acute,  swelling  rapidly  increases,  and 
the  constitution  sympathizes.  The  swelling  is  due  partly  to  engorgement  of  the 
epididymis  and  partly  to  fluid  in  the  tunica  vaginalis  (acute  hydrocele) .  Chronic 
epididymitis  is  usually  linked  with  orchitis,  and  it  follows  an  acute  exacerbation 
of  a  chronic  urethral  inflammation. 

Treatment  by  aseptic  puncture  with  a  tenotome,  if  fluctuation  be  marked, 
wfll  relieve  tension  and  pain.  Hagner  makes  multiple  punctures  in  the  epididy- 
mis. Leeching  over  the  external  abdominal  ring,  the  use  of  an  ice-bag  early 
in  the  case,  elevation,  appHcation  of  guaiacol,  and  the  administration  of  laxatives 
and  opium  constitute  the  usual  treatment  in  the  acute  stage.  Apphcations  of 
guaiacol  over  the  cord,  epididymis,  and  testicle  seem  to  relieve  pain  and  dis- 
tinctly lessen  swelling.  Two  applications  a  day  should  be  made  for  one  week. 
At  each  appHcation  paint  the  scrotum  and  the  skin  over  the  external  ring  with  15 
drops  of  guaiacol  in  i  dram  of  glycerin  or  olive  oil.  Strapping  is  employed  as 
the  inflammation  subsides.  The  treatment  of  the  chronic  form  is  the  same  as 
that  for  chronic  orchitis. 


1546 


Diseases  and  Injuries  of  the  Gcnito-urinary  Organs 


Strangulation  of  the  Cord  by  Axial  Rotation. — In  nearly  one-half 
of  the  cases  the  testicle  is  undescended  or  only  partly  descended.  In  every  case 
there  is  a  long  mesorchium,  .and  if  a  normal  testicle  be  normally  placed  torsion 
of  the  cord  will  hardly  occur  (Chas.  L.  Scudder,  "Annals  of  Surgery,"  Aug., 
1901).  The  twisting  may  be  toward  the  right  or  toward  the  left.  The  symp- 
toms arise  suddenly,  and  usually  during  exertion.  In  some  cases  a  hernia  also 
exists.  When  the  rotation  occurs,  the  testicle  swells,  hemorrhages  take  place 
into  it,  and  gangrene  may  develop.  If  the  cord  of  an  undescended  or  par- 
tially descended  testicle  twists,  swelling  and  tenderness  are  noted  in  the  abdo- 
men or  groin.  If  the  swollen  testicle  is  in  the  scrotum,  the  gland  feels  nodular 
and  the  epididymis  is  found  to  be  anterior  instead  of  posterior,  as  it  is  in  a 
normally  placed  gland.  The  symptoms  are  sudden  pain,  vomiting,  moderate 
shock  and  a  swelling  in  the  groin  or  a  swollen  testicle  in  the  scrotum.  The 
swelling  receives  no  impulse  on  coughing.  The  symptoms  resemble  those  of 
strangulated  hernia,  but  are  less  violent,  and  the  bowels,  though  often  much 
constipated,  are  not  obstructed. 


Fig.  1022. — Hydrocele. 

Treatment. — An  incision  should  be  made,  and  if  the  twisting  has  been  recent 
and  the  testicle  is  not  gangrenous,  the  cord  may  be  untwisted  and  the  testicle 
fastened  to  the  scrotum  by  a  catgut  stitch.  If  the  testicle  is  gangrenous  it 
should,  of  course,  be  removed.  Scudder  tells  us  that  in  88  per  cent,  of  cases 
the  testicle  is  found  to  be  gangrenous.  According  to  Scudder,  there  are  32 
cases  on  record:  31  were  operated  upon  and  i  was  not,  but  all  recovered;  in  3 
the  testicle  sloughed  and  in  2  it  atrophied  ("Annals  of  Surgery,"  Aug.,  1901). 

Vaginal  hydrocele  {chronic  hydrocele)  (Figs.  1022  and  1024,  e)  is  a  collec- 
tion of  fluid  in  the  tunica  vaginalis  testis.  An  enlargement  of  the  testis  may 
cause  it  {secondary  hydrocele),  but  in  most  instances  the  cause  is  unknown  and 
no  signs  of  inflammation  exist  {primary  hydrocele).  The  fluid  is  albuminous, 
but  it  does  not  coagulate  spontaneously;  it  is  thin,  straw  colored,  and  may 
contain  crystals  of  cholesterin.  The  testicle  is  at  the  lower  and  back  part  of 
the  sac.  The  pyriform  mass  fluctuates,  is  translucent,  grows  from  below  up- 
ward, and  the  introduction  of  an  exploring  needle  permits  yellow  fluid  to 
flow  out.  Sometimes  a  hydrocele  has  an  hour-glass  shape.  This  is  the  hydro- 
cele ''en  bissac"  of  the  French.     In  this  condition  (Fig.  1023)  two  cavities  exist, 


Treatment  of  Vaginal  Hydrocele 


1547 


usually  but  not  invariably  communicating.     The  constriction  between  the  cavi- 
ties is  due  to  inflammatory  thickening. 

Treatment. — In  secondary  hydrocele  the  treatment  of  the  diseased  testicle  is 
the  essential  plan.  We  discuss  here  the  treatment  of  primary  hydrocele.  Simply 
tapping  the  sac  with  a  trocar  is  only  palliative;  air  must  run  in  as  fluid  runs  out, 
and  suppuration  may  occur,  which 
will  be  dangerous  without  drainage. 
Never  tap  a  rigid  sac.  The  injec- 
tion of  irritants  should  be  aban- 
doned, as  it  exposes  the  patient  to 
serious  danger  because  of  inflam- 
mation occurring  without  provision 
for  drainage.  A  good  plan  is  to 
incise  the  sac,  dry  its  interior  by 
bits  of  gauze,  swab  it  out  with 
pure  carbolic  acid,  pack  it  with 
iodoform  gauze,  and  dress  it  anti- 
septically.  The  packing  is  re- 
moved in  twenty-four  hours  and 
the  wound  is  allowed  to  close.  In 
most  cases  I  prefer  this  method. 
If  the  sac  is  rigid  and  will  not  col- 
lapse, either  stitch  it  to  the  skin 
and  pack  it  or  excise  a  large  portion 
of  its  parietal  layer  and  insert  a 
drainage-tube  {V olkmann' s  oper- 
ation). Another  plan  is  to  tap  the 
sac  with  a  trocar  and  cannula,  leav- 
ing the  cannula  in  place  as  a  drain 
for  some  days,  and  dressing  anti- 
septicaUy. 

Longuet's  operation  is  easy  and  is  advocated  by  many  surgeons.  It  is 
called  extraserous  transposition  of  the  testicle.  It  was  introduced  by  Longuet 
in  1898  ("Progres  Med.,"  Sept.  21,  1901).  Doyen  and  Winklemann  do  a  simi- 
lar operation.  Jaboulay,  too,  advocates  spHtting  the  sac  and  turning  it  inside 
out.     He  folds  it  around  both  the  testicle  and  cord  and  stitches  it  so  that  the 


Fig.  1023. — ^Hydrocele  "en  bissac."  This 
hydrocele  extends  up  the  cord  into  the  inguinal 
canal  and  to  the  internal  abdominal  ring  (Hor- 
witz). 


Fig.    1024. — Varieties   of  hydrocele:  a,  congenital;  b,   infantile;   c,  funicular;  d,  encysted; 

e,  vaginal. 


smooth  endothelial  surface  of  the  tunic  will  be  in  contact  with  the  raw  scrotal 
tissue.  It  will  adhere  to  the  scrotal  tissue  ("Keen's  Surgery,"  vol.  iv).  A 
local  anesthetic  is  injected  and  an  incision  2  inches  in  length  is  made.  The 
testicle  is  lifted  from  the  scrotum.  The  serous  and  all  the  other  coats  except 
the  skin  fall  together  behind  and  make  a  sheath  for  the  cord.  One  catgut 
suture  wiU  hold  them  behind  the  cord.     A  bed  is  made  for  the  testicle  beneath 


1548 


Diseases  and  Injuries  of  the  Genito-urinary  Organs 


the  inner  edge  of  the  skin  wound  by  tearing  with  the  fingers.  The  testicle  is 
rotated  on  its  long  axis  and  inserted  into  this  cavity.  The  testicle  rests  against 
the  scrotal  septum,  and  in  front  of  the  gland  is  the  cord  covered  by  the  tunic. 
The  skin  is  sutured  and  the  wound  is  dressed.  E.  Wyllys  Andrews  devised  the 
bottle  operation  ("Keen's  Surgery,"  vol.  iv).  The  unopened  tunic  (with  the 
testicle)  is  separated  from  the  scrotum  and  dislocated  through  the  scrotal 
wound.  A  small  incision  is  made  near  the  summit  of  the  funnel-like  prolon- 
gation of  the  sac  upon  the  cord.  The  sac  empties  and  then  resembles  a  bottle  or 
bag  with  a  small  opening  at  the  top.  The  testicle  is  squeezed  through  the 
opening.  When  this  is  done  the  sac  is  inside  out  and  the  edges  of  the  small 
opening  lie  closely  about  the  cord.  The  skin  is  closed  without  drainage.  In 
some  cases  after  doing  any  one  of  the  operations  which  turn  the  sac  inside 

out  a  large  tender  mass  forms,  com- 
posed of  swollen  testicle  and  thick- 
ened sac.  I  have  had  this  experience 
several  times.  In  such  a  case  it  is 
necessary  to  excise  the  thickened  sac. 
Congenital  hydrocele  (Fig. 
1024,  c)  is  hydrocele  through  an  un- 
closed funicular  process  into  the  tunica 
vaginalis.  If  the  pelvis  be  raised  the 
fluid  runs  back  into  the  peritoneal 
cavity,  from  which  it  originally  came. 
The  treatment  is  the  apphcation  of 
a  truss  to  obUterate  the  funicular  pro- 
cess, and  when  that  occurs,  if  the 
counterpart  of  an  infantile  hydrocele 
persists,  puncture  and  scarification  of 
the  walls  of  the  sac. 

Infantile  hydrocele  (Fig.  1024,  b) 
is  a  collection  of  fluid  in  a  funicular 
process  of  the  tunica  vaginalis,  the 
funicular  process  being  closed  above, 
but  not  below. 

The  treatment  is  to  puncture  the 
sac  and  to  scarify  the  sac  wall  with  a 
needle. 

Funicular  Hydrocele  (Fig. 
1024,   c). — The  funicular  process  is   closed  below,  but  is  open  above.     Rais- 
ing the  pelvis  causes  the  fluid  to  trickle  back  into  the  peritoneal  cavity. 
The  treatment  is  the  application  of  a  truss. 

Encysted  Hydrocele  of  the  Cord  (Fig.  1024,  d). — In  this  variety  the 
funicular  process  is  obliterated  above  and  below,  but  it  is  patent  between  these 
two  points  and  fluid  collects. 

The  treatment  is  the  same  as  that  for  infantile  hydrocele.  If  this  fails, 
incise  and  pack. 

Encysted  hydrocele  of  the  testicle  and  of  the  epididymis  may  occur.  Diffused 
hydrocele  of  the  cord  is  simply  edema  of  the  cord.  Hydrocele  of  a  hernia  is 
the  distention  of  a  hernial  sac  by  peritoneal  fluid. 

Hematocele  (Fig.  1025). — Vaginal  hematocele  is  blood  in  the  tunica  vaginalis, 
the  result  of  traumatism,  a  tumor,  or  the  tapping  of  a  hydrocele.  There  is  a 
pyriform  swelling  which  fluctuates,  but  which  gradually  becomes  firmer;  the 
scrotum  is  livid  and  the  testicle  is  below  and  posterior  to  the  tumor.  The  en- 
cysted form  of  hematocele  of  the  cord  is  a  hydrocele  of  the  cord  into  which  bleeding 
has  occurred.  The  diffused  form  is  due  to  extravasation  of  blood  into  the  cellu- 
lar substance  of  the  cord.     Encysted  hematocele  of  the  testicle  is  due  to  effusion 


I'iG.  1025. — Acute  hematocele  of  tunica 
vaginalis  the  result  of  traumatism  (Hor- 
witz). 


Treatment  of  Varicocele  1549 

of  blood  into  an  encysted  hydrocele  of  the  testicle.  Parenchymatous  hematocele 
is  extravasation  of  blood  into  the  substance  of  the  testicle. 

The  treatment  of  a  recent  case  of  vaginal  hematocele  is  to  put  the  patient  to 
bed,  support  the  scrotum,  and  apply  an  ice-bag  over  the  testicle.  If  the  swelling 
does  not  soon  abate,  incise,  irrigate,  and  pack. 

Varicocele  is  varicose  enlargement  of  the  veins  of  the  venous  plexus  of 
the  spermatic  cord.  The  veins  are  thickened,  lengthened,  dilated,  and  con- 
voluted. The  assigned  causes  are  straining,  cough,  constipation,  and  an  occu- 
pation requiring  prolonged  standing.  Some  believe  ungratified  sexual  desire 
is  a  cause.  Hereditary  predisposition  is  probable.  There  are  more  left-sided 
than  right-sided  varicoceles,  because  the  right  spermatic  vein  has  valves  and 
empties  into  the  vena  cava  at  an  acute  angle,  but  the  left  spermatic  vein  has 
no  valves  and  empties  into  the  left  renal  vein  at  a  right  anlge.  Varicocele  is 
a  very  common  condition.  The  elder  Senn  found  it  in  21  per  cent,  of  10,000 
recruits.  An  irregular  swelling  exists  in  the  scrotum  and  extends  up  the  cord. 
This  swelling  feels  hke  "a  bag  of  earth-worms;"  it  exhibits  a  slight  impulse  on 
coughing;  the  scrotal  skin  and  cremaster  muscle  are  attenuated;  the  testicle 
lies  at  the  bottom  of  the  swelling  and  is  softer  and  smaller  than  normal;  the 
swelling  diminishes  on  lying  down  and  increases  on  standing  or  on  making  pres- 
sure over  the  external  ring.  The  scrotum  is  pendulous  and  the  scrotal  skin  fre- 
quently contains  varicose  veins.  The  testicle  may  be  soft  and  shrunken. 
There  is  usually  some  discomfort,  aching,  or  dragging  in  the  testicle  and  the 
groin,  and  often  neuralgic  pain  in  the  cord.  There  may  be  no  discomfort  of 
any  sort.  A  large  varicocele  may  be  free  from  discomfort  and  a  small  varicocele 
may  produce  much  annoyance,  or  vice  versa.  There  are  sometimes  mental 
depression  and  hypochondriasis.  As  a  man  reaches  middle  age  a  varicocele 
usually  ceases  to  give  trouble. 

Treatment. — In  treating  varicocele,  reassure  the  patient:  tell  him  there 
is  no  real  danger  of  impotence;  order  cold  shower-baths,  correct  constipation 
and  indigestion,  give  occasional  tonics,  and  order  the  patient  to  wear  a  sus- 
pensory bandage.  If  the  testicle  is  undergoing  atrophy,  if  the  pain  and  the 
dragging  are  annoying,  or  if  the  mind  is  much  depressed,  operate. 

Operation  for  Varicocele. — Subcutaneous  ligation  is  no  longer  practised. 
The  open  operation  is  universally  employed. 

The  patient  is  placed  in  a  recumbent  position.  Local  anesthesia  is  very 
satisfactory.  A  fold  of  skin  is  pinched  up  over  the  external  ring,  and  the 
surgeon  transfixes  it  in  the  line  of  the  cord,  so  that  he  will  have  an  incision 
about  1 3^^  inches  long.  The  skin  and  fascia  are  cut  by  a  scalpel,  the  veins  are 
well  exposed,  and  the  cord  is  located  and  held  aside.  A  double  ligature  of 
strong  catgut  or  chromicized  gut  is  passed  under  the  veins  by  an  aneurysm 
needle.  The  threads  are  separated  i  inch,  tied  tightly,  and  the  ends  are  left 
long.  The  veins  between  the  ligatures  are  excised.  The  two  gut  ligatures 
are  tied  together  and  cut.  This  shortens  the  cord.  The  wound  is  sewed  up 
with  silkworm-gut. 

Bloodgood  points  out  that  it  is  well  to  avoid  dividing  the  genital  branch 
of  the  genitocrural  nerve  which  supplies  the  cremaster  muscle.  If  this  nerve 
should  be  divided,  the  cremaster  will  become  lax  and  return  of  the  varicocele 
will  be  favored.  Bloodgood  makes  the  incision  over  the  external  ring,  draws  the 
veins  up,  and  resects  them.  A  wound  so  placed  heals  more  certainly  and 
promptly  than  does  a  wound  of  the  scrotum.  Of  late  years  I  have  always 
followed  this  plan. 


^y 


Amputations 


XXXVIH.  AMPUTATIONS 

An  amputation  is  the  cutting  off  of  a  limb  or  a  portion  of  a  limb.  Re- 
moval of  a  limb  or  a  portion  of  a  limb  at  a  joint  is  known  as  "disarticulation." 
Amputation  may  be  necessary  because  of  the  existence  of  severe  injury,  of 
gangrene,  of  tumor,  of  intractable  disease  of  bones  or  joints,  of  ulcer  which 
will  not  heal,  of  traumatic  aneurysm,  etc.  A  re-amputation  may  be  required 
because  of  the  existence  of  a  defective  stump  or  disease  in  the  stump. 

Classification. — Amputations  are  classified  as  follows:  (i)  As  to  time 
of  operation  after  the  injury:  a  primary  amputation  is  performed  soon  after 
the  occurrence  of  the  accident — as  soon  as  the  sufferer  reacts  from  shock,  and 
before  he  develops  fever;  a  secondary  amputation  is  performed  some  time 
after  the  accident,  suppuration  having  supervened;  and  an  intermediate  ampu- 
tation is  performed    during  the  existence  of  fever,  but  before  the  develop- 


FiG.  1026.— Esmarch's  elastic  bandage. 


Fig.    1027. — Application  of  tourniquet. 


ment  of  suppuration.  (2)  As  to  the  situation,  where  the  bone  is  divided  or 
according  to  which  joint  is  cut  through.  (3)  As  to  the  form  and  situation  of 
the  flap. 

In  performing  an  amputation  maintain  rigid  asepsis;  completely  remove 
the  hopelessly  damaged  portion;  sacrifice  as  little  of  the  sound  tissue  as  possi- 
ble; prevent  hemorrhage  during  the  amputation,  and  carefully  arrest  it  after 
the  operation;  if  flaps  be  used,  have  enough  sound  tissue  in  the  flap  to  cover  the 
bone,  and  enough  skin  to  cover  the  muscles;  and  secure  drainage  at  a  dependent 
point.  In  mihtary  surgery  where  gas  gangrene  is  to  be  expected  (shrapnel,  con- 
dition of  soil,  etc.)  the  guillotine,  "chop"  or  other  flapless  amputation  may  be 
used;  in  civil  surgery,  however,  where  gas  gangrene  is  the  exception  rather  than 
the  rule,  flaps  should  always  be  employed. 

Hemorrhage  may  be  prevented  by  the  elastic  bandage  of  Esmarch  (Fig. 
1026).  Ordinarily  we  can  apply  this  bandage  from  the  periphery  to  well  above 
the  line  of  prospective  incision,  encircle  the  limb  with  an  elastic  band  (not 
the  thin  tube  shown  in  the  cut),  and  remove  the  bandage.  The  bandage 
and  band,  asepticized  before  using,  are  applied  to  the  limb,  which  has  been 
carefully  sterilized.  After  the  band  has  been  applied  the  limb  should  not 
be  freely  or  forcibly  moved,  because  of  the  danger  of  tearing  muscles  which 
are  firmly  fixed  by  the  compressing  band.  When  elastic  compression  has  been 
used  in  an  operation  the  surgeon,  after  removal  of  the  band,  should  be  very 
careful  to  tie  every  visible  vessel.     The  paralysis  of  the  small  vessels  induced  by 


Control  of  Hemorrhage  Following  Amputations 


:)3- 


pressure  often  prevents  bleeding,  and  unless  their  mouths  be  found  and  the 
vessels  be  tied  reactionary  hemorrhage  will  occur.  Reactionary  hemorrhage  is 
the  great  danger  after  the  use  of  the  Esmarch  bandage,  and  paralysis  or  slough- 
ing may  also  follow  its  employment.  If  there  be  an  area  of  suppuration  or  of 
gangrene  or  an  extra-osseous  malignant  growth,  do  not  apply  the  bandage  as 
directed  above.  One  bandage  can  be  applied  from  the  periphery  to  near  the 
lower  border  of  the  area  of  growth  or  infection,  and  another,  from  near  the 
upper  border  of  this  area,  up  the  limb.  If  the  bandages  are  applied  in  this 
manner  the  contents  of  the  diseased  area  ftumor-cells  and  fluid  or  septic  prod- 
ucts) are  not  squeezed  into  the  circulation.     In  cases  like  the  above  the  best 


Fig.  102S. — Petit's  spiral  tourniquet. 


Fig.  1029. — Charriere's  tourniquet. 


plan  is  to  hold  the  extremity  in  a  vertical  position  for  three  minutes,  lightly  strok- 
ing it  toward  the  body  with  the  hand,  and  then  apply  the  constricting  band. 
As  a  matter  of  fact,  this  plan  satisfactorily  empties  the  limb  of  blood,  and  it 
is  not  necessary  in  any  case  to  force  the  blood  out  by  elastic  compression. 
Some  surgeons  prefer  the  tourniquet.  Figures  1028  and  1029  show  two  forms  of 
tourniquet.  To  apply  Petit's  tourniquet,  place  the  plates  in  contact,  apply 
a  small,  firm  compress  over  the  arter\'  and  a  broad  thick  compress  over  the 
outer  surface  of  the  Umb,  buckle  the  tapes  around  the  limb  so  that  the  plate 
is  over  the  broad  pad,  and  tighten  the  tourniquet  by  separating  the  plates 


Fig.  1030. — Catlin,  long  knife,  and  saws  for  amputation. 

by  the  screw  (Fig.  1027).  When  a  tourniquet  is  apphed  to  arrest  bleeding 
during  transportation,  bandage  the  limb,  sew  the  compress  pad  to  a  bandage, 
and  place  the  plates  of  the  instrument  over  the  pad.  Monprofit's  all-metal 
tourniquet  may  also  be  used.  Signorini's  horseshoe  tourniquet  may  be  used 
upon  the  brachial  arter\-.  The  extended  use  (several  hours,  during  transpor- 
tation, etc.)  of  the  tourniquet  is  to  be  deprecated.  Frightful  gangrene  often 
followed  its  prolonged  apphcation  in  the  recent  hostilities.  In  hip-joint  and 
shoulder-joint  disarticulations  Wyeth's  pins  may  be  passed,  and  after  the  limb  is 
emptied  of  blood  the  band  can  be  fastened  above  them.  These  pins  prevent 
the  band  from  slipping. 

The  mstruments  and  appHances  required  for  amputation  are  Esmarch's 
apparatus  or  tourniquet,  amputating  knives  (Fig.  1030),  a  bone-knife,  scalpels, 


1552 


Amputations 


saws  (Fig.  1030),  a  lion- jaw  forceps,  bone-cutting  forceps,  a  periosteum-elevator, 
retractors  of  cloth  or  of  metal  (Monprofit 's),  dissecting,  hemostatic,  and  toothed 
forceps,  a  tenaculum,  an  aneurysm-needle,  a  probe,  scissors,  needles,  ligatures, 
sutures  of  silkworm-gut,  dressings,  bandages,  and  solutions.  A  cloth  retractor  has 
two  tails  for  the  thigh  and  arm  and  three  tails  for  the  leg  and  forearm :  it  is  made  by- 
taking  a  piece  of  musUn  or  of  linen  8 
inches  wide  and  1 2  inches  long  and  cut- 
ting tails  on  one  side  8  inches  in  length. 
Methods  of  Amputating. — 
The  transverse  circular  is  the  oldest 
method  of  amputating.  The  com- 
mon circular  incision  is  at  a  right 
angle  to  the  axis  of  the  limb.  Kocher 
considers  also  as  a  circular  incision 
an  oblique  cut  around  the  limb  if 
the  Hne  of  incision  "continues  in 
one  direction"  (  Kocher's  "Text- 
book of  Operative  Surgery,"  trans- 
lated by  Harold  J.  Stiles).  This 
method  is  called  the  oblique  circular 
amputation.  The  flush  circular 
method  makes  no  flaps  at  all.  A 
racket  incision  is  formed  by  adding  a 
longitudinal  cut  to  a  transverse  cir- 
cular cut.     If  the  edges  are  rounded. 


Fig.  103 1. — Amputation  of  arm  by  the 
circular  method  (Druitt). 


Fig.  1034. 
Figs.    1032-1034. — The   steps   of   a   transverse 
circular  amputation  (Kocher). 


the  lanceolate  incision  is  formed.  Rectangular  flaps  are  formed  when  two 
longitudinal  incisions  are  added  to  a  transverse  circular  cut.  If  the  corners 
of  a  rectangular  flap  are  trimmed,  rounded  flaps  are  formed.  The  three  last- 
mentioned  plans  are  considered  under  the  head  of  the  Modified  Circular  Ampu- 
tation (see  page  1554). 


Fig.  1035. — Circular  amputation :  Dissecting  up  the  skin-flap  (Esmarch). 

Transverse  Circular  Method  (Figs.  1031-1034). — The  surgeon  should  stand 
to  the  right  of  the  Umb  and  use  a  long  amputating  knife  which  cuts  from  heel  to 
point  (Fig.  1031).  After  an  assistant  has  retracted  the  skin  the  operator  divides 
the  soft  parts  by  a  series  of  circular  cuts.     He  does  not  cut  at  once  to  the  bone, 


Transverse  Circular  ^Method  of  Amputating 


:)oo 


but  divides  the  skin  and  subcutaneous  tissues.     At  the  retracted  edge  of  the 
first  cut  the  superficial  muscles  are  divided,  and  after  these  muscles  retract  the 


Fig.  1036. — Modified    circular    amputation:  Skin-flaps    and    circular    cut    through    muscles 

(Esmarch). 

deep  muscles  are  divided.  The  periosteum  is  incised  by  a  bone-knife  and  pushed 
up  by  an  elevator,  and  after  the  application  of  the  retractors  the  bone  is  then 
^^  sawed,  the  saw  starting  from  heel  to  point. 

A  periosteal  flap  can  be  made  to  cover  the 
end  of  the  bone,  but  it  is  not  wise  to  do 
so.  In  this  amputation  is  formed  a  cone 
whose  apex  is  the  bone  and  whose  base  is 
the  skin  edge.  Figures  103  2-1034  from 
Kocher,  show  the  steps  of  the  operation 
and  the  shape  of  the  resulting  stump.  In 
one  form  of  circular  amputation  [amputa- 
tion a  la  manchette)  the  retracted  skin  is 
cut  by  a  circular  sweep  of  the  knife,  a  cuflt 
of  skin  and  subcutaneous  tissue  is  freed 
and  turned  up,  and  the  muscles  are  cut 
circularly  at  the  edge  of  the  turned-up 
cuff  (Fig.  1035).  The  pure  circular  ampu- 
tation is  performed  on  the  arm  and  the 
thigh;  the  amputation  a  la  manchette  is 
performed  chiefly  through  the  wrist  and 
the  lower  forearm. 

If  there  is  more  sound  skin  upon  one 


Fig.  1039. 
Figs.  103 7-1039. — The  earl}-  steps  of  an       Fig.   1040. — Amputation   of  the  thigh  by  trans- 
oblique  circular  amputation  (Kocher) .  fixion  (Gross) . 

side  of  the  extremity  than  upon  the  other,  the  transverse  circular  incision  sac- 
rifices more  of  the  limb   than  is  necessary  and  the  obhque   circular  is  pref- 
98 


1^54  Amputations 

erable.  An  objection  lo  the  transverse  circular  incision  is  that  the  cicatrix 
lies  directly  at  the  end  of  the  stump  and  is  liable  to  cause  pain  when  subjected 
to  pressure. 

Flush  Circular  Method. — The  skin  and  superficial  fascia  are  divided  as 
in  an  ordinary  circular  amputation.  The  muscles  are  divided  transversely 
at  the  level  of  the  retracted  skin.  The  bone  is  sawed  through  at  the 
level  of  the  retracted  muscles. .  The  nerves  are  drawn  down  and  divided  and  the 
vessels  are  ligated.  The  wound  remains  open,  dressings  are  applied  and 
traction  on  the  skin  is  made  by  an  apparatus  like  that  of  Gci  ^on  Buck  for 
making  extension  in  hip-joint  fracture.  The  soft  parts  are  thus  drawn  gradually 
over  the  bone.  This  operation  has  been  practised  extensively  during  the  war. 
It  preserves  length  of  limb,  diminishes  the  danger  of  secondary  hemorrhage,  and 
because  of  the  clean  transverse  incision,  free  drainage,  open  wound,  and  accessi- 
bility to  disinfection,  lessens  the  danger  of  gas  gangrene,  tetanus  and  sepsis. 
Kelly  ("Brit.  Jour.  Surgery,"'  1916,  iii)  calls  it  the  "flapless  amputation,"  and 
Watson  (''Brit.  Med.  Jour.."  1916,  i),  the  ''flush  circular  method." 

Modified  Circular  Method. — In  this  operation  the  circular  skin-cut  may 
be  modified  bv  making  a  vertical  incision  to  join  the  first  wound,  the  muscles 
being  cut  bv  a  circular  sweep  (racket  incision)  or  by  making  two  vertical  skin 
incisions  (rectangular  flaps).  The  lanceolate  incision  is  made  by  rounding 
the  edges  of  the  flaps  which  result  from  a  racket  incision.  Liston's  modification 
consists  in  dissecting  up  two  short  semilunar  integumentary  flaps  and  in  dividing 
the  muscles  circularly  (Fig.  10.36).  This  is  known  as  the  "mixed  method.'' 
The  modified  circular  method  can  be  used  upon  the  thigh,  the  leg,  the  arm,  and 
the  forearm. 

Oblique  Circular  Method  (ElUptical  Method). — Mark  the  upper  and  lower 
ends  of  the  incision  as  shown  in  Figs.  103 7-1039.  The  lowest  incision  is  at  a 
right  angle  to  the  cutaneous  surface;  the  highest  incision  is  parallel  to  the  cuta- 
neous surface  (Kocher).  The  skin  and  fascia  are  divided  so  that  an  incision 
obhque  to  the  muscles  surrounds  the  limb.  The  distal  elliptical  portion  of 
skin  is  picked  up  and  drawn  toward  the  body  and  the  muscles  are  divided  to  the 
bone,  the  knife  being  held  transversely  (Figs.  1037-1039).  Kocher  points  out 
that  this  flap  increases  in  thickness  tow^ard  the  bone.  The  rest  of  the  muscles 
•  are  divided  on  a  level  w^th  and  in  the  direction  of  the  skin  edge.  The  periosteum 
is.  cut  transversely  and  is  treated  as  in  the  transverse  circular  operation.  The 
flap  of  muscle  and  integument  is  brought  over  the  wound.  This  method  stands 
midway  between  the  circular  operation  and  the  operation  by  a  single  flap, 
and  is  employed  particularly  in  certain  disarticulations. 

Flap  Method. — A  flap  may  be  composed  of  skin  only  or  of  both  skm  and 
muscle,  but  the  skin-flap  must  always  be  longer  than  the  muscle-flap,  so  that 
the  latter  will  be  covered  by  it.  A  flap  containing  much  muscle  heals  badly, 
but  the  ideal  flap  has  a  moderate  amount  of  muscle  (enough  skin  to  cover  the 
muscle  and  enough  muscle  to  cover  the  bone).  Flaps  may  be  single  or  double. 
Double  flaps  may  be  lateral  or  anteroposterior,  square  or  \J-sliaped,  equal  or 
unequal,  and  they  may  be  cut  by  transfixion  (Fig.  1040),  by  cutting  from  without 
inward,  by  dissection,  or  by  cutting  the  skin  from  without  inward  and  the 
muscles  b}^  transfixion. 

Racket  Method  (if  flaps  are  rounded,  is  known  as  the  "oval"  or  "lanceo- 
late" incision). — In  an  oval  amputation  the  incision  through  the  skin  and 
subcutaneous  tissue  is  an  oval  with  a  pointed  end  or  a  triangle;  and  the  other 
parts  down  to  the  bone  are  cut  from  without  inward.  When  a  longitudinal 
incision  down  to  the  bone  (see  Fig.  1052,  a-h)  extends  from  the  point  of  the  oval, 
the  operation  is  called  the  "  racket "  amputation.  If  the  longitudinal  cut  joins  a 
circular  cut,  the  operation  is  known  as  a  T-amputation.  The  oval  or  racket 
operation  is  performed  at  the  metacarpophalangeal,  metatarsophalangeal, 
and  shoulder-joints;  the  T-operation  may  be  performed  at  the  hip- joint. 


Completion  of  an  Amputation 


1555 


Completion  of  an  Amputation. — When  an  amputation  has  been  com- 
pleted,  tie  the  main  vessels,   pull   down  the   nerves  and  cut  them  high  up, 


«11 1;^  I 


Fig.  1041. — Showing  the  pattern  of  the  canton  flannel  extension  straps  used  for  the  purpose 
already  mentioned.  The  material  used  was  a  medium  weight  canton  flanhel.  (i)  The  broad 
piece,  with  extension  straps,  used  for  the  skin  traction  apparatus.  (2)  The  wooden  cross- 
piece  to  which  the  above  extension  straps  are  buckled.  (3)  Cloth,  with  webbing  extension, 
which  is  glued  to  the  forearm  in  the  overhead  extension  treatment  of  compound  fractures  of 
the  humerus.  (4)  Wooden  traction  piece  to  which  the  foregoing  webbing  is  buckled.  (5) 
Cloth  anklet  used  to  obtain  extension  on  the  foot  in  cases  where  the  wound  in  the  leg  was  low 
down  or  involved  the  ankle  joint.  The  horizontal  piece  is  secured  over  the  dressing  around 
the  ankle,  while  the  vertical  piece  turns  under  the  plantar  surface  and  is  afterwards  pinned 
to  the  horizontal  piece.  (6)  Cloth  extension  strap,  with  attached  webbing,  to  be  glued  to  the 
leg  in  the  application  of  the  Blake  splint.  (7)  A  double  extension  cloth,  the  ends  of  which  are 
glued  to  the  leg,  used  as  a  substitute  for  adhesive  plaster  in  the  application  of  a  Buck's  exten- 
sion (Fauntleroy). 

remove  the  periosteum  and  bone-marrow  for  a  distance  of  2  cm.     This  may  save 
the  patient  from  a  painful  stump.     It  is  bad  practice  to  cover  the  end  of  the 


Fig.  1042. — Showing  an  old  amputation  case  under  treatment  with  skin  traction  apparatus. 
This  case  improved  steadih^,  and  after  one  month  a  minor  plastic  operation  completed  the 
cure  (Fauntleroy). 

bone  with  periosteum.     Smooth  the  flaps,  gradually  loosen  and  finally  take  off 
the  constricting  band,  and  ligate  all  bleeding  points.     Apply  to  the  raw  surfaces 


1556 


Amputalions 


pads  wet  with  water  at  120°  F.,  and  make  compression  for  several  minutes. 
The  hot  water  arrests  capillary  bleeding.  It  also  restores  tone  to  some  vessels 
of  larger  size  which,  palsied  by  the  action  of  the  constriction,  have  been  open  but 
are  emitting  no  blood.  Tone  being  restored,  such  vessels  bleed,  and  can  be  seen, 
picked  up  and  tied.  Hemorrhage  from  the  medullary  canal  is  to  be  arrested  by 
antiseptic  wax.  Except  in  amputation  of  the  fingers  and  toes,  drainage  tubes 
are  necessary.     Take  two  tubes  and  fasten  an  end  of  one  to  an  end  of  the  other 


Fig.  io42(Z. — The  treatment  of  an  amputation  stump  Ijy  extension.  This  drawing  was 
sketched  from  a  case  of  direct  circular  amputation  through  the  thigh.  The  soft  tissues  and 
bone  were  cut  in  one  section  at  the  same  level.  In  order  to  bring  the  soft  parts  over  the  end 
of  the  bone  longitudinal  strips  of  strapping  were  placed  on  the  skin  and  supported  by  a  band- 
age. The  cord  passed  over  a  pulley  and  was  attached  to  a  light  weight.  The  effect  of  the 
extension  was  such  that  the  tissues  were  drawn  well  over  the  end  of  the  bone  and  a  good 
stump  resulted.  The  wound  contracted  until  a  comparatively  small  scar  remained,  which 
was  drawn  well  to. the  back  of  the  limb  (Hull). 

with  a  catgut  stitch  and  attach  the  point  of  junction  to  the  depths  of  the  wound 
by  a  suture  of  catgut.  When  the  time  comes  to  remove  the  tubes,  one  is  drawn 
out  from  one  side  of  the  flap,  the  other  from  the  other  side.  Were  one  tube  used 
removal  would  necessitate  dragging  one  free  end  first  within  and  then  all  the 
way  across  the  wound.  Sutures  are  now  to  be  inserted.  In  some  cases  the  deep 
parts  are  stitched  with  a  continuous  catgut  suture  and  the  superficial  parts  are 


Fig.  1043. — Cinematoplastic  amputation.     The  biceps  has  been  sutured  to   the  triceps  and 
a  rubber  tube  is  passed  through  the  loop  before  dressing  the  stump  (Ashhurst). 

closed  with  silkworm-gut;  in  other  cases  the  deep  parts  are  not  stitched  at  all, 
the  skin  alone  being  sutured  with  silkworm-gut.  Suture  of  opposing  tendon 
groups  prevents  atrophy  of  the  stump. 

Painful  Stumps. — A  painful  stump  may  be  due  to  neuromata.  Retrac- 
tion of  the  nerves  lessens  the  danger  of  neuromata.  If  neuromata  form,  excision 
is  necessary.  A  weight-bearing  scar  causes  pain  and  may  necessitate  re-amputa- 
tion. Periosteal  irritation  causes  pain.  This  is  prevented  by  removing  the 
periosteum  and  medulla  for  a  distance  of  2  cm.  If  irritation  exists  a  like  opera- 
tion should  cure  it. 


Disarticulation  at  a  Metacarpophalangeal  Joint 


1557 


Cinematoplastic  Amputations.— Vanghetti  devised  the  method  in  1898. 
The  plan  is  to  make  a  muscular  or  tendinous  loop  or  muscular  or  tendinous 
loops  at  the  end  of  a  stump,  so  that  the  movements  of  the  loops  can  be  applied  to 
move  an  artificial  hand.  It  is  not  performed  as  a  primary  amputation.  The 
stump  is  allowed  to  heal.     See  Fig.  1043. 


Special  Amputations 

Fingers  and  Hand. — In  amputating  the  thumb  and  index-finger  save 
everv  possible  scrap  of  tissue.  If  it  is  necessary  to  amputate  a  finger  above 
the  middle  of  the  middle  phalanx,  the  attachment  of  the  flexor  tendons  will 
be  cut  off  and  the  finger  will  be  liable  to  project  directly  backward,  so  that  it 
is  better  either  to  disarticulate  at  the  metacarpal  joints  or  to  stitch  the  flexor 
tendons  to  the  periosteum.  The  flexor  tendons  have  fibrous  sheaths  extending 
from  the  proximal  end  of  the  distal  phalanx  to  the  metacarpophalangeal 
articulations,  these  sheaths  being  thin  and  collapsible  opposite  the  joints,  but 
being  thick  and  rigid  opposite  the  shafts  of  the  bone.  The  fibrous  sheath  is 
known  as  the  theca,  and  when  it  is  cut  in  an  amputation  it  should  be  closed, 
otherwise  it  may  carry  infection  to  the  palm  of  the  hand.  The  theca  does  not 
exist  over  the  distal  phalanx,  and  it  is 
not  distinctly  visible  over  the  joint  be- 
tween the  distal  and  middle  phalanges. 
To  effect  closure  over  the  shaft  of  a 
bone,  strip  up  the  periosteum  and 
pass  catgut  sutures  vertically  through 
the  theca  and  the  periosteum  (Treves). 
In  amputation  of  the  fingers  and  the 
thumb  an  Esmarch  bandage  is  unnec- 
essary, though  pressure  may  be  made 
upon  the  arteries  at  the  wrist.  Only 
two   or  three   ligatures  are  necessary. 

Fig.  1045. — The  line  of  the  joints  in  the 
flexed  position  of  the  finger:  a,  Extensor  longus 
digitorum;  b,  interossei  and  lumbricals;  c, 
extensor  longus  digitorum  and  interossei;  g, 
interossei  and  lumbricals;  /,  flexor  sublimis; 
Fig.  1044. — Amputation  of  the  finger.  c,  flexor  profundus  (Kocher). 

Close  with  a  very  few  sutures,  so  as  to  favor  drainage  between  the 
stitches. 

The  distal 'phalanx  is  best  removed  by  a  long  palmar  flap  (Fig.  1044,  a). 
The  plamar  flap  (a)  is  marked  out  by  cutting  through  the  skin  and  subcu- 
taneous tissue.  The  incisions  are  next  carried  to  the  bone,  the  flap  is  dis- 
sected from  the  bone,  the  finger  is  strongly  flexed,  a  transverse  incision  (b)  is 
carried  across  the  dorsum  on  a  level  with  the  base  of  the  third  phalanx,  the 
soft  parts  are  pushed  back,  the  joint  is  opened,  the  lateral  hgaments  are  cut 
from  within  outward,  the  third  phalanx  is  forcibly  extended,  and  the  remaining 
structures  are  cut  from  below  upward.  Figure  1045  shows  the  lines  of  the  joints 
when  the  finger  is  flexed.  The  middle  phalanx  can  be  removed  by  the  same 
method  (Fig.  1044,  c).  The  proximal  phalanx  can  be  removed  by  a  long  palmar 
flap  or  by  a  long  palmar  and  a  short  dorsal  flap  CF\g.  1044,  d,  e). 

Disarticulation  at  a  metacarpophalangeal  joint  is  best  performed 
by  the  oval  method.  The  incision  upon  the  dorsum  (a)  is  begun  just  above 
the  head  of  the  metacarpal  bone,  is  carried  down  to  Iseyond  the  base  of  the 
phalanx,  and  involves  the  skin  only  (Figs.  1046  and  1047).  One  incision  sweeps 
around  the  finger  at  the  level  of  the  web,  going  through  the  skin  only  (b); 


:)D' 


Amputations 


the  finger  is  extended  and  the  palmar  cut  is  carried  to  the  bone;  each  lateral 
incision  is  carried  to  the  bone  while  the  finger  is  bent  in  the  opposite  direction, 
the  flaps  are  dissected  back  to  the  joint,  the  finger  is  strongly  extended,  the 
^joint  is  opened  from  the  palmar  side,  and  disarticulation  is  effected.  Cutting 
off  the  head  of  the  metacarpal  bone  improves  the  appearance  of  the  stump, 
but  weakens  the  hand,  hence  in  a  work- 
ingman  it  must  not  be  done  unnecessar- 
ily. If  it  be  necessary  to  remove  a 
metacarpal  bone,  the  incision  (c)  is  made 
from  the  carpometacarpal  joint. 

Amputation  of  the  thumb  through 


Fig.  1046. — A,  Disarticulation  of  a  meta-  > 
carpophalangeal  joint;  c,  amputation  of  a 
finger  wnth  the  metacarpal  bone. 


Fig.  1047. — Disarticulation  of  the  little 
finger  and  index-finger.  Disarticulation  of 
the  ring  finger  with  its  metacarpal  bone. 
Disarticulation  of  the  thumb  with  its  meta- 
carpal bone  (Kocher). 


its  distal  or  proximal  phalanx  is  performed  in  the  identical  way  employed 
in  amputation  of  a  finger.  Amputation  of  the  thumb,  with  a  portion  or  the 
whole  of  its  metacarpal  bone,  is  performed  by  the  oval  or  racket  incision 
(Fig.  1047). 

Disarticulation  at  the  wrist=joint  can  be  done  by  the  oblique  circu- 
lar method  (Fig.  1048)  or  by  a  double  flap.  In  the  double-flap  amputation  a 
dorsal  flap  is  made  by  carrying  a  semilunar  skin  incision  between  the  styloid 
processes;  the  skin  is  lifted,  the  wrist  is  forcibly  flexed,  the  joint  is  opened 


Fig.  1048.- 


-Disarticulation  of  the  middle  finger.     Disarticulation  at  the  wrist-joint, 
tion  through  the  forearm  by  the  oblique  circular  method  (Kocher). 


Amputa- 


by  a  transverse  cut,  and  a  long  semilunar  palmar  flap  which  includes  the  skin 
and  fascia  only  is  made  by  dissection.  Kocher  prefers  to  am;)Utate  by  an  oblique 
incision.  The  lower  end  of  this  incision  is  about  the  midde  of  the  palm  and 
the  upper  end  is  in  the  line  of  the  wrist-joint  (Fig.  1048).  "he  hand  is  strongly 
flexed,  the  extensor  tendons  are  divided,  the  posterior  liga  icnt  of  the  joint  is 
incised,  and  incisions  below  the  styloid  processes  divide  the  1: 
certain  tendons.  The  flexor  tendons  are  separated  from 
divided  so  as  to  remain  in  the  palmar  flap. 


jral  ligaments  and 
ihe  bone  and  are 


Disarticulation  at  the  Elbow  Joint 


1559 


Amputation  through  the  forearm  may  be  effected  by  the  oblique  circular 
method  (Fig.  1048),  the  circular,  the  modified  circular,  or  the  flap  operation. 
The  modified  circular  is  an  excellent  plan.  A  semilunar  dorsal  skin-flap  and  a 
semilunar  skin-flap  on  the  flexor  surface  are  made.  The  flaps  are  raised,  the 
muscles  are  cut  circularly  (Fig.  1049),  the  interosseous  space  is  cleared  by  the 
knife,  a  three-tailed  retractor  is  applied,  the  periosteum  is  pushed  up,  and  the 
bones  are  sawn  }  9  inch  above  the  flap.  In  sawing  the  bones,  start  the  saw  upon 
the  radius,  draw  it  from  heel  to  point,  make  a  furrow  on  the  radius  and  ulna, 
and  saw  both  bones  at  the  same 
time.  After  sawing,  cut  away 
any  irregular  edge  with  bone- 
pUers.  In  the  lower  third  Teale's 
amputation  may  be  done,  the 
dorsal  flap  being  the  long  one. 
In  Teale's   amputation  rectangu- 


FlG. 


1049. — IModified  circular  amputa- 
tion of  the  forearm  (Bryant). 


Fig.  1050. — Disarticulation  of  the  elbow-joint  by 
the  oblique  circular  method  (Kocher). 


lar  flaps  are  made.  The  long  flap  is  equal  in  width  and  length  to  one-half  the 
circumference  of  the  hmb  at  the  point  where  it  is  to  be  sawn.  The  short  flap  is 
equal  in  width  to  the  long  flap,  but  is  only  one-fourth  its  length.  The  two 
longitudinal  cuts  are  at  first  taken  only  through  the  skin,  but  the  two  transverse 
cuts  go  at  once  to  the  bone.  The  flaps  are  dissected  up  from  the  interosseous 
membrane  and  the  bone.  In  the  middle  or  the  upper  third  of  a  fleshy  arm 
two  semilunar  skin-flaps  can  be  cut  from  without  inward,  and  the  muscles  can  be 
cut  by  transfixion. 


Fig.  105 1. — Use  of  Wyeth's  pins  in  amputation  at  the  shoulder-joint.     The  acromion  is 

marked  by  a  black  line  (Keen). 

Disarticulation  at  the  elbow=joint  can  be  done  by  the  elliptical  method 
or  by  a  long  anterior  and  short  posterior  flap.  In  Kocher's  oblique  operation 
the  incision  begins  anteriorly  over  the  joint-Une  and  ends  posteriorly  a  hand's 
breadth  below  the  summit  of  the  olecranon  (Fig.  1050).  A  posterior'flap  which 
contains  the  integument,  the  insertion  of  the  triceps,  the  anconeus,  and  the 
periosteum^  is  dissected  up  until  the  posterior  surface  of  the  humerus  is  reached. 
The  joint  is  opened  anteriorly  by  a  transverse  incision,  and  the  radiohumeral 
articulation  is  opened  from  without  inward  (Kocher).  In  the  double  flap 
operation  the  forearm  is  partly  flexed  and  a  skin-cut  marks  out  a  long  anterior 


1560 


Amputations 


flap,  the  knife  being  entered  opposite  the  external  condyle  and  being  with- 
drawn I  inch  below  the  internal  condyle.  The  muscles,  which  are  bunched 
forward,  are  cut  by  transfixion.  A  posterior  semilunar  flap  is  made,  which 
separates  the  attachments  of  the  radius,  the  ulna  is  cleared,  and  the  triceps  is 
cut  at  its  insertion  (Bell).  Gross  advocated  sawing  through  the  olecranon 
and  the  inner  trochlear  surface. 

Amputation  of  the  arm  is  best  performed  by  marking  out  with  a  knife 
two  equal  semilunar  anteroposterior  flaps,  the  first  cut  being  carried  through 
the  skin  alone,  the  muscles  being  then  transfixed  with  a 
long  knife.  Teale's  method  is  shown  in  Figs.  496  and  497. 
The  circular  or  the  modified  circular  amputation  may  be 
performed. 

Disarticulation  at  the  Shoulder=joint. — In  this  oper- 
ation some  surgeons  use  Wyeth's  pins  to  hold  the  Esmarch 
band  in  place.  The  anterior  pin  is  entered  at  the  middle 
of  the  lower  margin  of  the  anterior  axillary  fold,  and 
emerges  i  inch  to  the  inside  of  the  tip  of  the  acromion. 
The  posterior  pin  is  entered  at  a  corresponding  point  on 
the  posterior  axillary  fold,  and  emerges  more  posteriorly 
than  the  first  pin  and  an  inch  to  the  inside  of  the  tip  of  the 
acromion.  After  the  extremity  Has  been  drained  of  blood 
by  the  Esmarch  bandage  or  by  stroking  and  a  vertical 
position,  the  Esmarch  band  is  applied  above  the  pins 
(Fig,  1051).  With  a  competent  assistant,  however,  the  pins  are  not  necessary, 
the  surgeon  dividing  his  main  vessels  as  the  last  step  of  the  operation,  and  the 
assistant  controHng  them,  before  they  are  cut  and  until  they  are  tied,  with  digital 
compression;  or,  the  main  vessels  may  be  ligated  as  a  preliminary  step. 

Larrey's  Operation. — In  this  method  of  shoulder-joint  disarticulation  the 
limb  is  held  away  from  the  side  and  an  incision  is  made  down  to  the  bone,  the 


Fig.  1052. — Ampu- 
tation at  the  shoul- 
der-joint :  a~b,  c-d, 
c-e,  Larrey's  opera- 
tion; f-g,  Dupuy- 
tren's  operation. 


Fig.  1053. — Disarticulation  at  the  shoulder- 
joint  by  Kocher's  method  (Kocher). 


Vic.    1054. — Removal    of    the    entire    upper 
extremity  (Kocher). 


incision  beginning  just  below  and  in  front  of  the  acromion  and  running  vertically 
for  4  inches  down  the  outer  surface  of  the  arm  (Fig.  1052,  a-b).  From  the 
center  of  this  incision  an  oval  incision  {c-d,  c-e)  is  carried  around  the  arm,  the 
inner  aspect  of  the  oval  reaching  as  low  as  the  lower  end  of  the  vertical  cuL 
The  oval  incision  at  first  involves  only  the  skin  and  subcutaneous  tissues.  The 
anterior  structures  are  divided  close  to  the  bone,  and  the  posterior  structures 
are  next  cut.     To  disarticulate,  cut  the  capsule  transversely  upon  the  head  of 


Amputution  of  the  Entire  Upper  Extremity 


I  ^6i 


the  bone;  while  the  arm  is  rotated  outward  cut  the  subscapularis,  and  while 
the  arm  is  rotated  inward  cut  the  supraspinatus  and  infraspinatus  and  the  teres 
minor.  Cut  away  any  tissue  holding  the  humerus  to  the  body,  hanging  nerves, 
capsule-fragments  and  tissue-shreds,  insert  a  tube,  and  sew  up  the  wound  ver- 
tically. Bell  advises  an  oval  incision  with  a  racket  handle.  Spence  used  an 
anterior  racket  incision. 

Kocher's  Operation. — Kocher  makes  an  anterior  lanceolate  incision  (Fig. 
1053).  The  incision  begins  over  the  clavicle  just  external  to  the  coracoid  proc- 
ess of  the  scapula,  and  is  carried  downward,  dividing,  as  it  advances,  the  ante- 
rior fibers  of  the  deltoid  muscle.  ''Bleeding  vessels  and  the  cephalic  vein  are 
ligatured.  In  the  upper  part  of  the  wound  the  acromial  branches  of  the  acro- 
miothoracic  artery  are  also  ligatured.  The  knife  is  carried  down  to  the  bone 
at  the  edge  of  the  deltoid  (only  the  upper  fibers  of  which  have  been  divided). 
The  capsule  is  divided  over  the  lesser  tuberosity  and  the  bicipital  groove. 
The  periosteum,  the  insertions  of  the  subscapularis,  pectorahs  major,  latissimus 
dorsi,  and  teres  major  are  detached  along  with  the  capsule.  The  capsule, 
along  with  the  insertions  of  the  supraspinatus,  infraspinatus,  and  teres  minor 
muscles,  is  also  detached  from  the  upper  part  of  the 
head  and  from  the  great  tuberosity.  The  head  of  the 
humerus  can  now  be  protruded  from  the  wound.  In 
cutting  down  over  the  surgical  neck  it  may  be  necessary 
to  hgature  the'  circumflex  arteries;  in  any  case  the  an- 
terior vessel  must  be  tied.  The  racket  incision  is  now 
completed  by  dividing  the  skin  circularly  at  the  level 
of  the  axillary  folds.  The  vessels  and  nerves  are  then 
easily  isolated,  the  former  being  ligatured  and  the  latter 
divided"  (Kocher's  "Text-book  of  Operative  Surgery," 
translated  by  Harold  J.  Stiles).  Kocher  cautions  us  to 
avoid  the  circumflex  nerve  which  supplies  the  deltoid, 
as  the  deltoid  is  the  muscle  of  the  stump. 

Dupuytren's  Operation. — In  Dupuytren's  shoulder- 
joint  disarticulation  a  U-shaped  flap  is  marked  out  by  a 
skin-incision  (Fig.  1052,  f-g).  If  the  amputation  is  to 
be  at  the  right  shoulder,  the  arm  is  carried  across  the 
chest;  the  knife  is  entered  at  the  root  of  the  acromion, 
follows  the  margin  of  the  deltoid,  and  is  withdrawn  at  the  coracoid  process, 
the  arm  being  gradually  abducted  and  pulled  off  from  the  chest.  If  the  left 
shoulder  is  to  be  amputated  the  procedure  is  reversed  (Treves).  The  knife 
next  cuts  through  the  deltoid  and  raises  a  flap  composed  of  this  muscle,  the 
shoulder-joint  is  exposed,  and  disarticulation  is  effected  as  in  Larrey's  method. 
The  knife  is  passed  down  back  of  the  bone  and  a  short  internal  flap  is  cut. 

Lisfranc's  amputation  is  by  transfixion  with  the  formation  of  an  an- 
terior and  a  posterior  flap,  and  can  be  performed  very  rapidly  by  a  skilful 
surgeon. 

Amputation  of  the  Entire  Upper  Extremity.— Berger's  Operation. 
— The  Interscapulothorac'.c  Amputation. — This  operation,  which  is  an  ampu- 
tation above  the  shoulder-joint,  was  described  by  Berger  in  1887.  By  it  are 
removed  the  arm,  the  scapula,  and  a  portion  of  or  the  entire  clavicle.  It 
is  occasionally  employed  in  cases  of  maUgnant  disease  and  of  severe  injury. 
The  operation  is  attended  with  profuse  hemorrhage,  and  as  a  prehminary  the 
subclavian  vessels  shoifld  be  hgated.  The  incisions  must  be  varied  according 
to  the  necessities  of  the  case.  In  this  operation  Berger  divides  the  clavicle  at 
the  junction  of  its  outer  and  middle  thirds,  and  resects  the  middle  third  of 
the  bone;  ligates  and  divides  the  subclavian  vessels;  cuts  the  anterior  flap; 
divides  the  brachial  plexus;  marks  out  the  posterior  flap;  and  completes  the 
operation  by  dividing  the  structures  which  hold  the  shoulder-blade  to  the  chest. 


Fig.  1055. — Removal 
of  the  whole  upper  ex- 
tremity. 


Amputations 


It  is  in  this  last  step  that  bleeding  is  profuse.     Figure  1055  shows  Berger's 
incisions  for  the  operation.     Figure  1054  shows  Kocher's  incisions. 

The  usual  procedure  of  tying  the  third  part  of  the  subclavian  artery  as  a 
preliminary  measure  possesses  certain  disadvantages.  The  artery  is  very 
deeply  situated  at  this  point,  is  in  close  relation  with  the  pleura,  and  is  covered 
to  a  considerable  extent  by  the  vein,  and  the  phrenic  nerve  is  very  near.  Le 
Conte  resects  the  entire  clavicle  before  tying  the  vessels.  He  maintains  that 
then  one  of  two  courses  may  be  taken:  The  veins  may  be  severed  first,  and 


Fig.  1056. — Amputation  of  the  toes  with 
and  without  the  metatarsal  bones. 


Fig.    105; 


-Lines    in  amputations  of  the 
foot  (Gross). 


afterward  the  artery  may  be  exposed  and  tied.  When  this  is  done,  the  amount 
of  blood  remaining  in  the  arm  is  lost.  The  procedure  that  he  selects  as  the 
best,  however,  is  to  expose  the  axillary  artery  as  high  up  as  possible,  and  place 
a  temporary  ligature  around  it;  then  elevate  the  arm,  empty  it  of  blood,  place 
a  permanent  ligature  around  the  third  part  of  the  subclavian  artery,  and 
divide  the  artery  in  this  portion  of  its  course  (Robert  G.  LeConte.  "Annals  of 
Surgery,"  Oct.,  1902).  If  the  scapula  be  involved  in  the  tumor,  the  mortality 
is  something  over  23  per  cent.  (Berger,  "Revue  de  Chir.,"  Aug.,  1905).  I  have 
twice  performed  the  operation  successfully  and  in  each  case  followed  LeConte's 
plan. 


Fig.  1058. — Lisfranc's  amputation:  First 
step  in  disarticulating  the  second  metatarsal 
bone  (Guerin). 


Fig.  105Q. — Lisfranc's  amputation: 
Second  step  in  disarticulating  the  second 
metatarsal  bone  (Guerin). 


Amputation  of  the  Toes  and  the  Foot. — Only  through  the  great  toe 
is  partial  amputation  performed,  and  it  is  eflfected  by  the  formation  of  a  long 
plantar  flap,  just  as  a  long  palmar  flap  is  formed  from  a  finger.  Amputation 
at  a  metatarsophalangeal  joint  is  performed  by  an  oval  or  racket  incision 
(Fig.  1056,  c,  c).  Amputation  of  a  toe  with  removal  of  its  metatarsal  bone  is 
shown  in  Fig.  1056,  a-b  and  d-e. 

Disarticulation  at  the  Tarsometatarsal  Articulation. — Lisfranc's 
Operation  {after  Treves). — In  order  to  amputate  the  right  foot  by  this  method 
begin  an  incision  on  the  outer  border  of  the  foot,  behind  the  tubercle  of  the 
fifth  metatarsal  bone;  carry  the  incision  forward  i  inch  and  sweep  it  across 


Disarticulation  at  the  Tarsometatarsal  Articulation 


1563 


the  foot  }'2  inch  below  the  tarsometatarsal  articulations;  bring  the  incision  to 
the  inner  edge  of  the  foot,  ^2  inch  in  front  of  the  articulation  of  the  tarsus 
with  the  first  metatarsal  bone,  and  carry  the  cut  straight  back  along  the  inner 
margin  of  the  foot  until  it  reaches  a  point  '^4  inch  above  the  articulation  of 
the  metatarsal  bone  of  the  great  toe.  A  very  short  semilunar  dorsal  skin-flap 
is  thus  formed.     Figure  1062  shows  the  flaps  as  cut  by  Kocher.     After  the  skin- 


FiG.  1060. — Anterior  in- 
tertarsal  disarticulation 
(Kocher). 


Fig.  106 1. — Chopart's  am- 
putation (Kocher). 


Fig.  1062. — Llsfranc's  am. 
putation  (Kocher). 


flap  has  been  dissected  back  for  3^^  inch  the  tendons  are  divided,  and  the  flap, 
which  now  contains  all  the  soft  parts,  is  dissected  back  to  above  the  joint.  A 
long  plantar  flap  is  cut,  reaching  from  the  origin  of  the  first  flap  to  the  necks 
of  the  metatarsal  bones.  The  skin-flap  is  dissected  up  until  the  hollow  behind 
the  heads  of  the  metatarsal  bones  is  reached,  when,  with  the  toes  in  extension, 
the  tendons  are  cut  across  and  a  flap  composed  of  all  the  soft  parts  is  dissected 


Fig.  1063. —  The  parts  after  Lisfranc's  am- 
putation (Bernard  and  Huette). 


Fig.  1064. — The  parts  after  amputation  by 
Chopart's  method  (Bernard  and  Huette) 


up  to  above  the  tarsometatarsal  joint.  Figures  1057  and  1062  show  the  line  of 
Lisfranc  at  the  tarsometatarsal  articulation.  The  joint  is  opened  from  the 
outer  side  according  to  the  following  rule:  in  separating  the  fifth  metatarsal  di- 
rect the  edge  of  the  knife  toward  the  distal  end  of  the  first  metatarsal;  in 
separating  the  fourth  metatarsal  direct  the  knife  toward  the  middle  of  the 


1564 


Amputations 


first  metatarsal;  in  separating  the  third  metatarsal  carry  the  knife  almost  di- 
rectly across.  The  separation  is  facilitated  by  bending  down  the  toes  and  the 
foot,  and  at  the  same  time  the  tendons  of  the  peroneus  brevis  and  tertius  are 
divided.  Open  the  joint  between  the  first  metatarsal  and  the  inner  cuneiform 
bone,  turning  the  knife  toward  the  middle  of  the  shaft  of  the  fifth  metatarsal, 
and  at  the  same  time  divide  the  tibialis  anticus  muscle.  Treves  says  that  in 
disarticulation  of  the  second  metatarsal  the  knife  is  to  be  held  as  a  trocar,  it  is 
to  be  thrust  between  the  base  of  the  first  and  second  metatarsal  bone  until 
the  point  strikes  bone  (Fig.  1058),  and  is  then  to  be  raised  to  a  perpendicular 
and  the  cut  is  to  be  made  toward  the  external  malleolus  to  sever  the  Hgament  of 
Lisfranc  (Fig.  1059).  Divide  any  remaining  ligaments,  and  also  the  tendon 
of  the  peroneus  longus  muscle.  The  skin-incisions  in  the  left  foot  are  begun 
on  the  inner  side,  and,  in  disarticulating,  the  tarsal  joint  of  the  great  toe  is  first 
opened.  Figure  1063  shows  the  parts  after  disarticulation  in  the  line  of  Lisfranc. 
After  Lisfranc's  amputation  a  patient  can  walk  with  very  little  limp. 

Hay's  Operation. — In  Hey's  method  the  incision  is  practically  the  same 
as  that  for  Lisfranc's  amputation.  The  four  external  metatarsal  bones  are 
disarticulated,  but  the  first  metatarsal  is  removed  by  sawnng  a  portion  of  the 
internal  cuneiform  bone.     Guerin  advised  sawing  all  the  bones  across.     Skey 

advised  the  division  of  the  head 
of  the  second  metatarsal.  Fig- 
ure 1057  shows  the  line  of  Hey. 
Anterior  Intertarsal  Dis= 
articulation  (Amputation  of 
"Forbes,  of  Toledo). — The  dis- 
articulation is  effected  between 
the  three  cuneiform  bones  in 
front  and  the  scaphoid  behind, 
and  the  cuboid  is  sawn  across. 
Figure  1057  shows  the  line  of 
Forbes.  The  incision  of  the 
soft  parts  is  as  for  Lisfranc's 
amputation  (Fig.  1060). 
Disarticulation  Through  the  Middle  Tarsal  Joint. — Chopart's 
Operation  {Posterior  Intertarsal  Disarticulation). — Make  a  transverse  incision 
through  the  skin  of  the  instep,  2  inches  below  the  ankle-joint,  cut  the  tendons 
and  muscles,  expose  the  tarsus,  and  make  on  each  side  a  small  longitudinal 
incision  reaching  to  below  and  in  front  of  the  corresponding  malleolus.  The 
flap  thus  formed  is  retracted.  The  plantar  flap  is  made  as  in  Lisfranc's  ampu- 
tation. The  flaps  as  made  by  Kocher  are  shown  in  Fig.  1061.  Open  the  as- 
tragaloscaphoid  joint,  then  the  calcaneocuboid  joint,  and  disarticulate.  Figures 
1057  and  1061  show  the  line  of  Chopart.  Figure  1064  shows  the  parts  after 
Chopart's  disarticulation.  Chopart's  amputation  seldom  gives  good  results. 
A  secondary  operation  is  usually  necessary. 

Subastragaloid  Disarticulation.^ — A  circular  incision  is  carried  around 
the  foot  at  the  level  of  the  middle  tarsal  joint  and  a  racket  incision  is  added  to 
it  running  below  and  posterior  to  the  tip  of  the  external  malleolus  (Fig.  1065). 
"The  joint  between  the  astragalus  and  scaphoid  is  opened  upon  the  dorsum, 
without  opening  the  calcaneocuboid  joint.  A  narrow  knife  is  then  passed  back- 
ward and  slightly  upward  beneath  the  head  of  the  astragalus  so  as  to  divide 
the  strong  interosseous  ligament  between  it  and  the  os  calcis.  The  soft  parts 
are  then  dissected  off  the  os  calcis,  first  from  its  upper  surface,  then  from  its  outer 
and  under  surfaces,  and  lastly  from  its  inner  and  posterior  surfaces.  The 
greatest  difficulty  is  met  with  at  the  inner  side  in  clearing  the  projecting 
sustentaculum  tali"  (Kocher's  ''Text-book  of  Operative  Surgery,"  translated 
by  Harold  J.  Stiles). 


Fig. 


1CO5. — Subastragaloid   disarticulation 
(Kocher). 


Amputations  of  the  Leg 


1565 


Fig. 


1066. — ^Lines  of  section  of  the  os  calcis  and  the 
bones  of  the  leg  in  Pirogoff's  amputation. 


Disarticulation  at  the  Ankle=joint. — Syme's  Method. — The  foot 
is  held  at  a  right  angle  to  the  leg,  and  a  skin-incision  is  carried,  from  just  below 
the  external  malleolus,  straight  across  or  a  little  backward  across  the  sole  to  a 
corresponding  point  on  the  oi)posite  side.  Do  not  take  this  incision  near 
to  the  inner  malleolus,  as  to  do  so  will  endanger  the  posterior  tibial  artery. 
The  incision  is  carried  to  the  bone,  the  flap  being  pushed  back  and  separated 
from  the  bone  by  means  of  a  strong  knife  and  the  thumb-nail  until  the  tuber- 
osity of  the  OS  calcis  has  been  reached.  The  foot  is  now  extended  and  a  trans- 
verse cut  is  made  across  the  dorsum,  joining  the  two  ends  of  the  first  incision; 
the  ankle-joint  is  opened,  the  lateral  ligaments  are  cut,  disarticulation  is  effected, 
and  the  foot  is  finally  completely  removed  by  severing  the  tendo  Achillis.  A  thin 
piece  of  bone  including  both 
malleoli  is  sawn  from  the  tibia 
and  fibula.  The  flap  is  per- 
forated posteriorly  to  secure 
drainage  (Fig.  496).  The  pa- 
tient will  be  able  to  walk  with 
very  little  limp. 

Pirogoff's  Method.  —  Flex 
the  foot  to  a  right  angle  with 
the  leg.  "Make  an  incision 
from  the  tip  of  the  internal 
malleolus  across  the  sole,  a  little 
in  front  of  the  long  axis  of  the 
tibia,  to  a  point  in  front  of 
the  apex  of  the  external  mal- 
leolus down  upon  the  bone."^ 
Dissect  the  flap  backward  from 
the  calcaneum  for  3>-^  inch,  but  do  not  dissect  the  flap  from  the  posterior  portion  of 
the  OS  calcis.  Join  the  extremities  of  the  first  incision  by  another  cut  which  reaches 
to  the  bone,  and  which  is  "3^2  inch  in  front  of  the  lower  extremity  of  the  tibia" 
(Bryant);  but  saw  off  this  bony  projection  obhquely  and  leave  it  adherent 
to  the  tissues.  The  saw  is  used  after  disarticulation  of  the  ankle-joint;  it  is 
passed  behind  the  astragalus,  cutting  downward  and  forward,  sawing  the  os 

calcis  obliquely,  and  leaving  a  considerable 
portion'  in  place  in  the  flap.  The  lower  ends 
of  the  tibia  and  fibula  are  well  exposed  by 
raising  the  anterior  flap  slightly;  the  sawing 
is  begun  anteriorly  just  above  the  articular 
surface,  and  is  completed  }''2  inch  above  the 
articular  surface  posteriorly.  The  lines  a  and  b 
(Fig.  1066)  show  the  sections  made  by  the 
saw.  The  sawn  surface  of  the  os  calcis  is 
brought  into  contact  with  the  sawn  surfaces  of 
the  tibia  and  fibula,  and  the  flaps  are  sutured. 
Amputations  of  the  Leg. — The  so- 
called  "point  of  election"  is  at  the  upper 
part  of  the  middle  third  of  the  leg.  Seventy- 
five  years  ago  Listen  advised  surgeons  not  to  amputate  in  the  lower  third  of 
the  leg  because  of  the  scantiness  of  the  soft  parts,  because  the  stump  is  apt 
to  ulcerate,  and  because  it  is  uncomfortable  in  an  artificial  leg.  These  views 
have  been  much  modified.  The  amputation  near  the  ankle  is  safer  than  the 
amputation  near  the  knee,  and  artificial  legs  are  now  made  which  may  be 
worn  with  comfort.  Binnie  ("Annals  of  Surgery,"  1914,  Ix)  maintains  that  in 
order  to  get  a  proper  stump  for  a  good  artificial  leg  the  lowest  point  considered 
^  "Operative  Surgery,"  by  Joseph  D.  Bryant. 


Fig.  1067. — Diagrammatic  repre- 
sentation of  amputation  of  the  leg 
after  the  method  of  Bier. 


1 506 


Amputations 


for  amputation  should  be  8  inches  from  the  ground  and  the  highest  point 
4  inches  below  the  lower  margin  of  the  patella.  The  circular  incision  seldom 
gives  a  good,  weight-bearing  stump  because  the  scar  is  over  the  end  of  the 
bone.  The  flap  method  should  be  used  if  possible.  The  removal  of  the 
periosteum  and  bone-marrow  for  a  distance  of  2  cm.  tends  to  prevent  a  painful 
stump.  In  amputations  of  the  leg  b}^  the  long  anterior  flap,  cut  through  the 
skin,  dissect  up  the  anterior  muscles  with  the  flap  and  cut 
all  the  posterior  tissues  with  a  single  transverse  sweep. 
Amputation  by  the  rectangular  flap,  Teale's  method,  is 
very  useful  (see  page  1559).  The  long  flap  is  anterior, 
and  is  in  length  and  breadth  equal  to  one-half  the  cir- 
cumference of  the  limb.  The  short  flap  is  one-fourth 
the  length  of  the  long  flap.  The  flaps  are  dissected  up, 
the  bones  are  sawn,  the  long  flap  is  turned  upon  itself, 
and  its  edges  are  sutured  to  the  edges  of  the  short  flap. 

Bier  suggests  a  plan  (Fig.  1067)  to  increase  the 
supporting  power  of  the 
stump  after  a  leg  ampu- 
tation. After  the  wound 
has  healed,  a  wedge-shaped 
piece  of  bone  is  removed 
above  the  level  of  the 
stump.  The  lower  extrem- 
ity is  turned  forward  and 
upward  through  an  arc  of 
90  degrees,  and  unites  in  this  position  (Zuckerkandl's  "Operative  Surgery"). 
Thus  the  medullary  cavity,  is  closed  and  the  skin  which  must  bear  pressure  is 
healthy  and  free  from  cicatrices;  and  as  the  muscles  are  still  attached  to  the 
bone,, they  do  not  undergo  atrophy. 

Sedillot's  leg  amputation  (Fig.  1068)  is  by  a  long  external  flap.     A  longi- 
tudinal incision  is  made  along  the  inner  edge  of  the  tibia,  the  tissues  are  drawn 


Fig.  T068.  —  Sedil- 
lot's amputation  of  the 
leg  (Wyeth). 


Fig.  1069.  —  Amputation  of 
the  leg  by  a  long  posterior  flap 
(Gross). 


Fig.  1070. — Kocher's  oblique  incision  for  disarticulation  at  the  knee-joint  (Kocher). 


toward  the  fibula,  a  knife  is  introduced  and  passed  to  the  outer  edge  of  the  tibia, 
just  touching  the  fibula,  and  is  brought  out  posteriorly,  thus  transfixing  the 
calf-muscles  and  cutting  an  external  flap.  A  convex  incision  is  made  on  the 
inner  side,  the  bones  are  cleared  and  are  sawn  i  inch  above  the  flaps,^  }i  inch 
more  being  taken  from  the  fibula  than  from  the  tibia,  and  the  tibia  being 
bevelled  anteriorly. 

Modified  Circular  Amputation  of  the  Leg.— Cut  semilunar  skin-flaps,  lay 
them  back,  and  cut  circularly  to  the  bone  at  the  edge  of  the  turned-up  flap. 
Another  method  of  modified  circular  amputation  is  by  adding  to  the  circular  cut 
a  vertical  incision  down  the  front  of  the  leg.     In  sawing  the  bones  of  the  leg  the 


Amputation  through  the  Femoral  Condyles 


1567 


surgeon,  who  stands  to  the  outer  side  of  the  right  leg  or  to  the  inner  side  of  the 
left  leg,  divides  the  fibula  first,  and  at  a  higher  level  than  the  tibia,  and  bevels 
the  anterior  surface  of  the  tibia.  In  sawing  the  left  fibula  the  saw  points  to  the 
floor;  in  sawing  the  right  fibula  it  points  to  the  ceiling. 

Amputation  of  the  Leg  by  a  Long  Posterior  and  a  Short  Anterior  Flap. — 
In  this  operation  a  posterior  U-shaped  flap  is  made  equal  in  length  and  breadth  to 
the  diameter  of  the  limb.  The  skin-incision  is  begun  i  inch  below  the  point 
where  the  bone  is  to  be  sawn,  and  behind  the  inner  edge  of  the  tibia,  and  is 
carried  to  a  point  posterior  to  the  peronei  muscles.  The  gastrocnemius  muscle 
is  divided  transversely  at  the  level  of  the  flap,  the  soft  parts  on  either  side  in 
the  line  of  the  flap  being  cut.  to  the  bone.  Through  these  vertical  cuts  the  mus- 
cles are  lifted  from  the  bones  and  are  divided  through  their  lower  part  by  cut- 
ting from  within  outward.  The  anterior  flap  is  formed  by  making  a  semilunar 
skin-flap  and  by  cutting  the  muscles  across  at  its  retracted  edge  (Fig.  1069). 

Amputation  of  the  leg  by  lateral  flaps  is  not  a  popular  operation,  as  it  offers 
too  much  encouragement  to  subsequent  protrusion  of  the  bone. 

Amputation  Just  Below  the  Knee. — The  seat  of  election  is  i  inch  below 
the  tuberosities.  No  muscle  is  needed  in  the  flap.  Cut  two  flaps  of  skin, 
equal  in  size  and  of  semilunar  shape,  these  flaps  beginning  anteriorly  2  inches 
below  the  tuberosity  of  the  tibia.     One  flap  is  antero-external  and  the  other  is 


Fig. 


1071. — Diagrammatic    representation 
of  Gritti's  operation. 


Fig.    1072. — Diagrammatic    representation 
of  Sabanejeff 's  operation. 


postero-internal.  The  flaps  are  pulled  up,  the  anterior  muscles  are  cut  as  high 
up  as  possible,  and  the  posterior  muscles  are  cut  through  the  middle  of  the  por- 
tion exposed  (Bell).     The  bone  is  sawn  i  inch  below  the  tuberosity. 

Disarticulation  at  the  Knee. — In  disarticulation  by  the  long  anterior  flap 
make  a  long  anterior  skin-flap,  incise  the  ligament  of  the  patella,  turn  up  a 
flap  containing  the  patella,  open  the  joint,  and  complete  the  disarticulation  by 
cutting  from  within  outward  and  downward.  The  knee  may  be  disarticu- 
lated by  means  of  a  long  anterior  and  a  short  posterior  flap.  Kocher  prefers 
the  oblique  incision  (Fig.  1070).  This  secures  an  anterior  flap.  The  leg  is  so 
held  that  it  makes  an  angle  with  the  thigh  of  135  degrees  and  "the  incision 
falls  in  the  continuation  of  the  long  axis  of  the  thigh"  (Kocher's  ''Text-book 
of  Operative  Surgery,"  translated  by  Harold  J.  Stiles).  The  posterior  part 
of  the  incision  is  opposite  the  line  of  the  joint  and  the  anterior  part  of  che  in- 
cision ends  four  fingers-breadth  below  the  tibial  tubercle. 

Amputation  through  the  Femoral  Condyles. — Syme's  Method  by  a  Long 
Posterior  Flap. — Carry  a  skin-incision,  with  a  very  slight  downward  curve  from 
one  condyle  to  the  other,  across  the  middle  of  the  patella.  Cut  down  to  the 
bone,  retract  the  flap,  and  cut  the  quadriceps  above  the  patella.  Insert  a 
long  kife  at  one  angle  of  the  wound,  pass  it  back  of  the  femur,  and  make  it 
emerge  at  the  opposite  angle,  cutting  a  posterior  flap  8  inches  long.  Retract 
the  posterior  flap,  clear  for  sawing,   and  section  the  condyles  horizontally. 


1^68 


Amputations 


In  Garden's  method  a  long  anterior  flap  of  skin  and  fat  is  cut,  all  other  soft 
parts  are  divided  transversely  and  the  bone  is  sectioned  through  the  base  of  the 
condyles.  The  patella  is,  of  course,  removed.  In  children  Buchanan  showed 
that  we  can  easily  separate  the  lower  femoral  epiphysis.  In  GriUVs  amputa- 
tion an  oblique  incision  is  made.  The  upper  end  of  the  incision  is  posterior  and 
just  above  the  condyles.  Its  lower  end  is  anterior  and  two  fingers'  breadth 
below  the  patella  (Kocher).  The  ligament  of  the  patella  is  cut,  the  flap  is  turned 
up,  the  femur  is  sawn  at  the  level  of  the  adductor  tubercle,  the  articular  face 
of  the  patella  is  sawn  off,  the  sawn  patella 
is  placed  upon  the  sawn  femur  and  the 
flaps  are  sutured  (Fig.  1071).  In  Stokes' 
atnputation  (which  is  really  a  supra- 
condvloid    amputation)    the  femur  is  di- 


FiG.  1073. — Amputation  of  the  thigh  (Bryant).  Fig.  1074.-  P;inc()a>t"s  aorta  tourniquet. 

vided  about  three-quarters  of  an  inch  above  the  condyles  and  the  sawn  patella 
placed  against  the  surface  so  formed.  In  Gritti's  amputation  the  remaining 
portion  of  the  patella  is  apt  to  be  pulled  forward  and  to  tilt.  Stokes's  oper- 
ation corrects  this  tendency  and  the  two  bone  surfaces  are  nearly  equal  in  size. 
Sabanejeff  makes  an  anterior  flap,  opens  the  knee-joint  from  behind,  saws  the 


Fig.  1075. — ^on  Esmarch's  aorta  tourniquet. 

condyles  at  their  broadest  part,  takes  a  bone-flap  from  the  anterior  portion  of 
the  tibia,  and  fastens  it  to  the  femur  (Fig.  1072). 

Amputation  of  the  Thigh. — In  amputation  high  in  the  lower  third  either  a 
flap  or  a  circular  operation  may  be  performed.  In  a  double-flap  operation  a 
semilunar  skin-incision  should  be  made  from  without  inward,  and  the  muscles 
should  be  cut  by  transfixion  (Fig.  1073).  In  the  lower  third  Teale's  flap  or  the 
long  anterior  flap  may  be  employed.  The  amputation  by  a  long  anterior  flap 
consists  in  making  a  lengthy  skin-flap,  reflecting  it,  cutting  the  anterior  struc- 


Disarticulation  at  the  Hip-joint 


1569 


tures  to  the  bone,  again  entering  the  long  knife  at  one  angle  of  the  incision, 
pushing  it  back  of  the  femur,  bringing  it  out  at  the  outer  angle,  and  cutting  the 
structures  behind  the  bone  directly  backward.  Bell  amputates  by  a  long  an- 
terior semilunar  tlap  and  a  short  posterior  flap.  In  am[)utations  in  the  upper 
two-thirds  of  the  thigh  the  best  plan  is  to  mark  out  equal  anterior  and  posterior 
semilunar  skin-flaps,  divide  the  skin  with  a  scalpel,  enter  the  long  knife  at  one 
angle  of  the  anterior  flap,  bring  it  out  at  the  other  angle,  and  cut  the  muscles 
by  transfixion.  Cut  the  posterior  flap  in  the  same  manner.  Some  surgeons 
prefer  a  long  anterior  semilunar  flap  and  a  short  posterior  semilunar  flap.  The 
purely  circular  amputation  is  not  adapted  to  the  thigh. 

Disarticulation  at  the  Hip-joint. — Various  methods  have  been  employed  to 
prevent  or  limit  hemorrhage  during  this  formidable  operation.  Abernethy 
used  digital  compression  of  the  external  iliac  artery  or  of  the  femoral  artery. 
This  is  an  extremely  tiresome  procedure;  the  finger  is  liable  to  slip;  and,  in  any 


Fig.  1076. — Macewen's  method  for  compression 
of  the  abdominal  aorta  ("American  Text-book 
of  Surgery"). 


Fig.  1077. — Posterior  flap  in 
author's  unusual  case  requiring 
hip-joint  amputation:  a—b.  The 
anterior  incision;  a-c-d,  the  ex- 
ternal incision  and  the  begin- 
ning of  the  posterior  cut. 


case,  compression  so  situated  fails  to  intercept  the  blood-current  in  a  number  of 
large  vessels. 

Various  other  methods  have  been  employed.  It  was  formerly  the  custom 
to  compress  the  aorta  by  means  of  an  abdominal  compressor  (Figs.  1074,  1075). 
A  tourniquet  is  very  likely  to  be  displaced  during  the  operation.  The  intention 
is  to  compress  the  artery  against  the  spine,  but  in  efl'ecting  this  the  circulation 
in  a  portion  of  the  intestine  may  be  impaired.  In  any  case,  as  Senn  says,  the 
circulation  is  cut  off  from  half  the  body,  and  the  patient  is  exposed  to  grave 
danger  from  "sudden  vascular  engorgement  of  important  internal  organs" 
(Senn).  Again,  an  abdominal  compressor  of  this  sort  does  not  arrest  venous 
bleeding.  A  number  of  years  ago  Davy  suggested  that  a  suitable  cylindrical 
piece  of  wood,  about  25  inches  long,  and  shaped  like  a  cone  at  the  end,  might 
be  introduced  into  the  rectum  and  used  to  compress  the  common  iliac  artery 
upon  the  pelvic  brim.  This  appliance  is  known  as  Davy's  lever.  It  is  apt 
to  slip,  and  may  do  serious  damage  to  the  rectum. 
99 


1570 


Amputations 


Some  surgeons  have  practised  preliminary  ligation  of  the  common  femoral 
artery  or  of  the  external  iliac  artery,  and  others  have  tied  the  vessels  while 
making  the  flaps.     I  employed  preliminary  ligation  of  the  common  femoral 

with  perfect  satisfaction  in 
2  of  my  4  cases  of  amputa- 
tion at  the  hip-ioint  for 
sarcoma  of  the  femur.  If 
any  form  of  compression  be 
used,  that  recommended  by 
Macewen,  of  Glasgow,  is  the 
most  successful  and  satis- 
factory (Fig.  1076).  The 
weight  of  the  assistant's 
body  is  throwTi  upon  the 
patient's  aorta  by  the  right 
fist,  placed  slightly  to  the  left 
of  the  umbilicus.  McBurney 
has  suggested  the  prevention 
of  bleeding  by  making  a 
small  abdominal  incision  and 
having  an  assistant  make  direct  digital  pressure  upon  the  iliac  artery.  I  em- 
ployed McBurney's  method  in  one  case  and  found  it  most  satisfactory.  In 
this  case  a  sarcoma  of  the  thigh  reached  up  so  far  that  no  band  could  be  ap- 
plied above  it   and  I   was  obliged  to  make  the  posterior  flap  shown  in  Fig. 


Fig.  107S. — Amputation  at  the  hip-joint:  Wyeth's  blood- 
less method. 


Fig.  1079. — Wyeth's  bloodless  amputation  at  the  hip-joint:  Cuff  of  skin  and  subcutaneous 
fat  turned  back,  muscles  divided  at  level  of  small  trochanter,  bone  partly  stripped,  and  large 
vessels  exposed  for  ligation. 

1077.  If  the  constricting  band  of  Esmarch  be  applied  by  the  ordinary  method, 
it  is  certain  to  slip.  It  may  remain  in  place  if  applied  as  a  figure-of-8  of  the 
thigh  and  the  pelvis,  but  even  then  it  is  uncertain. 

A  satisfactory  method  in  many  cases  is  Wyeth's,  in  which  the  constrictor 
is  held  in  place  by  the  preliminary  passage  of  two  steel  pins  (Fig.  1078).     Tren- 


Disarticulation  at  the  Hip-joint  1571 

delenburg's  method  consisted  in  passing  one  pin  and  winding  an  elastic  tube 
about  it.  Wyeth  applied  the  principle  and  greatly  improved  the  method. 
The  outer  pin  is  inserted  1^2  inches  below  and  a  little  internal  to  the  anterior 
superior  spine  of  the  ilium,  and  is  brought  out  just  back  of  the  great  trochanter. 
The  inner  pin  is  entered  i  inch  below  the  level  of  the  crotch  and  internal  to 
the  saphenous  opening,  and  it  emerges  i  ^  2  inches  in  front  of  the  tuberosity  of 
the  ischium.  A  sterile  cork  may  be  pushed  on  the  end  of  each  pin,  to  save  the 
surgeon  from  wounding  himself  upon  the  sharp  points.  A  cork  is  apt  to  come 
off  during  the  course  of  the  operation.  Because  of  the  insecurity  of  the  cork  I 
have  devised  pins  with  removable  points.  After  a  pin  has  been  passed,  the 
point  is  unscrewed  and  a  knob  is  screwed  on  in  its  place.  After  the  limb  has 
been  emptied  of  blood  by  holding  it  in  a  vertical  position  for  five  minutes  and 
stroking  it  from  the  periphery  toward  the  body,  the  constricting  band  is  fastened 
about  the  limb  above  the  pins. 

In  the  bloodless  method  of  Wyeth  (Figs.  1078,  1079),  after  passing  the  pins, 
draining  the  limb  of  blood,  and  applying  the  band  of  the  Esmarch  apparatus, 
the  amputation  is  proceeded  with.  The  hip  is  brought  well  over  the  edge  of 
the  table,  a  circular  incision  is  made  down  to  the  deep  fascia,  6  inches  below  the 
constricting  band,  and  is  joined  by  a  longitudinal  skin-cut  reaching  from 
the  band  to  the  level  of  the  circular  incision,  and  the  cuff  is  reflected  to  the 
level  of  the  lesser  trochanter.  The  muscles  are  cut  by  a  circular  sweep  at  the 
level  of  the  retracted  cuff,  the  capsule  of  the  hip-joint  is  opened  freely,  the  coty- 
loid ligament  is  cut  posteriorly,  the  thigh  is  bent  upward,  forward,  and  inward 
to  dislocate  the  head  of  the  bone,  and,  using  the  thigh  as  a  handle,  the  round 
ligament  is  incised  and  the  limb  removed.  After  ligating  the  vessels  and  intro- 
ducing drainage-tubes  the  flaps  are  sewn  together  vertically.  The  old  trans- 
fixion operation  is  practically  extinct.  A  T-amputation  may  be  employed.  It 
consists  of  an  external  straight  incision  down  to  the  bone,  starting  over  the  great 
trochanter,  down  the  outer  side  of  the  limb,  and  a  circular  incision  through  the 
skin  5  inches  below  the  constricting  band,  the  muscles  being  cut  by  a  circular 
sweep  at  the  level  of  the  retracted  skin.  This  method  affords  easy  access  to 
the  joint.  The  bloodless  method  of  Wyeth,  as  applied  to  the  hip-joint  and 
shoulder-joint,  is  a  notable  advance  in  the  art  of  surgery. 

Semis  Bloodless  Method. — The  elder  Senn  has  devised  a  method  of  prevent- 
ing hemorrhage  during  amputations  through  the  hip-joint.  He  makes  a  straight 
incision,  about  8  inches  in  length,  in  the  direction  of  the  long  axis  of  the  femur 
and  directly  over  the  center  of  the  great  trochanter.  This  incision  reaches 
about  3  inches  above  the  upper  margin  of  the  great  trochanter.  The  muscular 
insertions  are  divided  close  to  the  bone,  and  the  thigh  is  flexed,  strongly  ad- 
ducted,  and  rotated  inward.  The  capsular  ligament  is  divided  at  its  upper  and 
posterior  aspect.  While  the  thigh  is  brought  into  a  position  of  slight  flexion 
the  remaining  portion  of  the  capsular  ligament  is  cut.  Then  the  thigh  is  dis- 
located outward,  and  the  ligamentum  teres  is  cut.  If  this  cannot  be  accom- 
plished, the  head  of  the  bone  is  forcibly  dislocated  upon  the  dorsum  of  the  ilium. 
After  dislocating,  the  lesser  trochanter  and  the  upper  part  of  the  femoral  shaft  • 
are  cleared.  The  limb  is  now  brought  dowm  in  a  straight  line  with  the  body, 
the  thigh  is  slightly  flexed,  a  long  and  stout  pair  of  forceps  is  inserted  into  the 
wound  behind  the  femur  and  on  a  level  with  the  normal  situation  of  the  lesser 
trochanter,  and  the  instrument  is  pushed  downward  and  inward,  2  inches  below 
the  ramus  of  the  ischium  and  just  behind  the  adductor  muscles.  As  soon  as 
the  point  can  be  felt  under  the  skin,  an  incision  2  inches  in  length  is  made  upon 
it,  and  the  instrument  is  forced  through  the  opening.  The  tunnel  in  the  tissues 
is  enlarged  by  opening  the  forceps.  A  piece  of  rubber  tubing  ^4  inch  in  diam- 
eter and  4  feet  in  length  is  caught  about  the  middle  with  the  forceps  and  is 
withdrawn.  The  rubber  tube  is  cut  in  two  at  about  the  point  at  which  the 
forceos  have  held  it,  and  half  of  the  tube  is  used  to  constrict  the  anterior  seg- 


1572 


Amputations 


ment  of  the  thigh  (Fig.  1080)  and  the  other  half  to  constrict  ihe  remaining  por- 
tion of  the  thigh  (Fig.  1081).     Before  the  constricting  bands  are  tied  the  limb 


1 


Fig.  ioSo. — Senn's  method  of  performinf^  bloodle ss  amputation  at  the  hip-joint.  Disloca- 
tion of  head  of  femur  and  upper  portion  of  shaft  through  straight  external  incision.  Elastic 
constrictors  in  place,  the  anterior  one  tied  (Senn). 


Fig.  1081. — Elastic  constriction  completed  by  constricting  the  posterior  segment  of  the  thigh. 
Flaps  formed    including  all  the  tissues  down  to  the  muscles  (Senn). 

is  held  vertically  for  a  sufficient  length  of  time  to  make  it  practically  bloodless; 
the  amputation  is  then  completed  (Senn's  "Practical  Surgery"). 


Hypertrophy  of  the  Breast 


1573 


Other  Methods. — John  G.  Sheldon  ("  Amcr.  Med.,"  April  19,  1902)  has  modi- 
fied Senn's  method  as  follows:  He  disarticulates  the  head  of  the  femur  and 
frees  the  upper  part  of  the  femur  from  its  attachments.  He  then  introduces 
a  pair  of  long,  stout  artery-forceps  behind  the  femur  and  clamps  the  femoral 
vessels.  He  forms  the  flap,  removes  the  limb,  and  ligates  the  vessels.  In  this 
operation  the  surgeon  can  work  rapidly  and  can  make  a  flap  of  any  size  or  shape, 
and  is  not  hindered  by  a  constriction  apparatus;  but  this  method  does  not  cut 
off  the  bleeding  from  the  obturator  and  the  sciatic  arteries. 

Larrey     amputated     by     lateral 


flaps,  and  Liston  by  anteropos- 
terior flaps.  Forneaux  Jordan's 
method  consists  in  dividing  the  soft 
parts  low  down,  tying  the  blood- 
vessels on  the  face  of  the  stump, 
shelling  out  the  femur  from  the  soft 
parts,  and  disarticulating. 


Fig.  1082. — Keen  and  DaCosta's  method 
of  interilio-abdominal  amputation  (''Inter- 
national Clinics,"  vol.  iv,  13th  series). 


Fig.  1083. — Keen  and  DaCosta's  case  of 
interilio-abdominalamputation.  The  shaded 
portion  of  the  bone  was  removed  ("Inter- 
national Clinics,"  vol.  iv,  13th  series). 


Interilio-abdominal  Amputation. — This  very  formidable  operation  is  occa- 
sionally performed  for  sarcoma  of  the  ilium.  The  operation  was  first  performed 
by  Billroth  in  1891,  and  the  patient  died.  Prof.  Keen  and  1  collected  19  cases, 
including  i  of  our  own.  Five  of  these  cases  recovered  (W.  W.  Keen  and  J. 
Chalmers  DaCosta,  in  "International  Clinics,"  vol.  iv,  13th  series).  Our 
patient  perished  in  thirty-three  hours  from  suppression  of  urine  and  with  gan- 
grene of  the  parts  supplied  by  the  internal  iliac  artery.  J.  H.  Pringle  has  col- 
lected 43  cases  and  has  performed  the  operation  5  times  personally.  The  mor- 
tality in  the  series  was  58.1  per  cent.  Pringle  had  3  recoveries  out  of  5  cases, 
("Brit.  Jour.  Surgery,"  1916,  iv).  In  some  cases  the  entire  innominate  bone 
has  been  removed;  in  others,  portions  of  it  have  been  left.  In  our  case  we  made 
the  flap  shown  in  Fig.  1082,  tied  the  internal  iliac  artery  after  rolling  up  the 
peritoneum,  but  spared  the  external  iliac,  kept  the  femoral  in  the  flap,  and 
sawed  through  the  bones  as  indicated  in  Fig.  1083,  leaving  in  place  the  portions 
shown  in  white. 


XXXIX.  DISEASES  OF  THE  MAMMARY  GLAND 

Hypertrophy  of  the  Breast  (Fig.  1084). — This  is  a  rare  condition.  It 
may  affect  one  breast  or  both.  It  is  most  apt  to  appear  at  the  age  of  puberty, 
but  it  may  appear  in  childhood,  adult  life,  or  old  age.  The  breast  may  attain 
enormous  size.     In  Porter's  case  the  breasts  of  a  woman  of  thirty-seven  were 


1574 


Diseases  of  the  I\Iammar\'  Cilands 


so  very  large  that  they  were  carried  hung  upon  a  frame  ("Boston  j\Ied.  and 
Surg.  Jour.,"  March  3,  1892). 

These  very  large  breasts  are  not  composed  of  true  gland  tissue,  but  rather 
of  fat  and  connective  tissue  ("Diseases  of  the  Breast,"  by  A.  Marmaduke 
Sheild).  Hypertrophy  may  also  occur  in  the  male  breast.  In  some  cases  hy- 
pertrophy occurs  so  rapidly  as  to  merit  the  name  acute.  Such  cases  may  pre- 
haps  be  sarcomatous. 

Treatment. — Be  sure  it  is  hypertrophy  and  not  sarcoma,  adenoma,  or  lip- 
oma. Try  recumbent  posture,  dry  diet,  pressure,  and  iodid  of  potash  (Sheild, 
Ibid.).     If  these  means  fail,  amputation  is  the  only  recourse. 

Mammillitis  and  Fissure. — 
The  nipple  may  inflame  as  a  result 
of  injury,  but  the  condition  is 
rarely  encountered  except  in  a 
woman  who  is  nursing  a  baby. 
It  is  most  common  after  a  first 
pregnancy,  when  the  nipple  is  de- 
formed or  when  the  skin  is  deli- 
cate. The  nipple  is  slightly  injured 
during  nursing,  and  the  epithelium 
is  macerated  by  the  milk  and 
saliva.  If  the  inflammation  be  not 
arrested,  a  spot  excoriates  or  an 
irritable  ulcer  forms  (a  fissure).  A 
fissure  is  often  surrounded  by  an 
area  of  acute  inflammation,  and 
nursing  causes  intense  agony.  Be- 
cause of  the  pain  the  mother  is 
apt  to  extend  the  intervals  be- 
tween nursing,  and  as  a  conse- 
quence the  breasts  become  swollen 
with  retained  milk.  The  ulcer  not 
unusually  bleeds  when  the  breast 
is  taken  by  the  child.  Besides  the 
fact  that  a  fissure  causes  pain  to 
the  mother,  it  often  leads  to  grave 
trouble.  It  is  a  suppurating  area, 
and  as  such  may  lead  to  abscess  of  the  mother's  breast,  or  may  impair  the 
health  of  the  nursing  child. 

Prevention  of  Fissure. —  During  pregnancy  the  nipples  should  be  carefully 
attended  to.  They  should  be  washed  often  in  sterile  water  and  bathed  in 
alcohol,  and  if  retracted,  ought  to  be  drawn  out  repeatedly.  During  the  period 
of  lactation  the  nipples  are  washed  in  sterile  water,  dried,  and  dusted  with 
borated  talc  powder  as  soon  as  an  act  of  nursing  is  completed.  Washing  the 
nipples  regularly  with  the  following  solution  tends  to  prevent  the  formation 
of  a  fissure:  iodid  of  mercury,  2  gr. ;  alcohol,  1 1 9  oz. ;  glycerin  and  distilled  water, 
of  each  a  pint  (Lepage).  If  a  small  abrasion  appears,  order  the  woman  to 
wear  a  nipple-shield  during  nursing,  and  after  each  act  of  nursing  to  wash  the  part 
with  hot  sterile  water,  to  dry  it  and  to  dust  borated  talc  over  the  surface.  If 
a  fissure  forms,  wean  the  child  at  once,  and  dry  up  the  milk  on  both  breasts. 
It  is  useless  to  try  to  dry  it  up  in  one  breast.  Milk  may  be  dried  up  by  apply- 
ing ointment  of  belladonna  locally,  and  administering  iodid  of  potassium,  inter- 
nally; by  strapping  the  breasts  with  adhesive  plaster  (Parker);  or  by  applying 
to  the  nipples  six  times  a  day  a  5  per  cent,  solution  of  cocain  in  equal  parts  of 
glycerin  and  water  (Joise).  The  fissure  is  not  treated  by  ointments.  These 
preparations  are  septic,  prevent  drainage,  and  aggravate  maceration.     Wash 


Fig.  1084. — Hypertrophy  of  breast. 


Acute  Abscess  of  the  Breast  1575 

the  fissure  twice  a  day  with  peroxid  of  hydrogen,  dress  it  with  gauze  wet  in  boric 
acid  solution  (10  gr.  to  i  dram  of  water j,  and  cover  the  dressing  with  waxed 
paper.     If  the  fissure  resists  treatment,  touch  it  with  lunar  caustic. 

Acute  Mastitis  and  Abscess. — Acute  inflammation  of  the  breast,  as 
a  result  of  injury  of  the  breast  or  nipple,  may  occur  in  either  sex  at  any  time 
of  life.  Very  commonly  in  both  sexes  a  few  days  after  birth  the  breast  be- 
comes distended  with  a  material  which  in  reality  is  milk.  The  fluid  is  usually 
small  in  quantity.  The  process  is  physiological,  and,  as  a  rule,  ceases  spon- 
taneously (Guelliot).  If  it  lingers,  the  application  of  belladonna  ointment  wiH 
stop  secretion.  If  the  nurse  meddles  with  the  glands  and  tries  to  squeeze  out 
the  fluid,  acute  mastitis  is  apt  to  arise  in  one  gland,  or  occasionally  in  both. 
The  skin  of  the  breast  reddens,  the  gland  swells  and  becomes  tender  and  pain- 
ful, the  child  loses  its  appetite  and  becomes  feverish,  restless,  and  sleepless. 
Such  a  condition  is  treated  by  the  local  use  of  alcohol.  If  pus  forms,  the  local 
signs  and  constitutional  symptoms  are  aggravated.  Evacuate  the  pus,  dress 
with  hot  antiseptic  fomentations,  and  be  sure  that  the  child  is  well  nourished. 
Tonics  and  stimulants  are  indicated. 

A  condition  identical  with  the  secretory  activity  of  the  glands  of  the  new- 
born may  occur  in  either  sex  at  puberty.  The  methods  of  treatment  are  the 
same  in  both  cases.  As  a  matter  of  fact,  at  this  time  of  life  rarely  more  thaa 
one  lobule  inflames,  and  suppuration  is  most  unusual. 

Acute  mastitis  is  most  usually  met  with  in  a  woman  who  is  nursing  a  child, 
and  is  due  to  bacterial  infection.  Primiparae  are  particularly  liable  to  develop 
mastitis.  So  are  women  with  deformed  nipples.  In  most  cases  an  abrasion 
of  the  nipple  exists,  and  through  this  breach  of  continuity  bacteria  gain  entrance 
to  the  breast-tissue.  The  abrasion  may  be  so  slight  that  it  can  only  be  detected 
when  the  nipple  is  examined  through  a  magnifying-glass  (Marmaduke  Sheild). 
Streptococcic  infections  are  very  generally  due  to  inoculation  of  a  fissure  of  the 
nipple.  Bacteria  may  pass  up  the  milk-ducts,  coagulating  the  milk  and  pene- 
trating through  the  walls  of  the  acini.  Staphylococci  not  unusually  pursue 
this  route  in  reaching  the  breast-tissue.  Occasionally  causative  bacteria  reach 
the  breast  through  the  arteries  (in  septicemia  and  in  septic  wounds  of  the  genital 
organs) . 

Symptoms. — There  are  pain,  swelling,  and  tenderness  in  the  breast,  and  in 
most  cases  a  fissure  or  abrasion  exists.  There  is  a  febrile  condition.  Occa- 
sionally a  chill  ushers  in  the  attack. 

If  a  case  supposed  to  be  acute  mastitis  proves  utterly  rebellious  to  treatment 
the  suspicion  should  arise  in  the  surgeon's  mind  that  the  condition  is  acute  or 
inflamed  cancer  (carcinoma  mastitoides,  see  page  1586).  If  such  a  doubt 
arises,  a  piece  of  tissue  must  be  excised  for  microscopical  study. 

Treatment. — Order  the  patient  to  suspend  nursing.  The  physician  en- 
deavors to  arrest  the  secretion  of  milk.  Treat  the  nipple  as  advised  on  page 
1574.     Support  the  breast  and  apply  ichthyol  ointment. 

Mastitis  may  undergo  resolution;  it  may  terminate  in  organization  and 
induration;  it  may  eventuate  in  suppuration. 

Acute  abscess  of  the  breast  follows  acute  mastitis.  There  may  be 
but  one  area  of  suppuration,  or  multiple  foci  may  exist,  which  eventually  fuse. 
The  symptoms  of  mastitis,  local  and  constitutional,  are  greatly  aggravated. 
After  a  time  the  skin  becomes  dusky  and  edematous.  The  axillary  and  super- 
ficial cervical  glands  enlarge.  The  abscess  will  eventually  open  spontaneously 
at  one  or  more  points,  leaving  branching  fistulae.  A  superficial  abscess  is  situ- 
ated just  beneath  the  nipple,  and  pus  may  flow  from  the  nipple. 

An  intramammary  abscess  is  in  the  depths  of  the  gland.  There  are  often 
multiple  foci  of  suppuration.  Nodules  are  felt  in  the  gland,  pus  may  run  from 
the  nipple,  but  cutaneous  redness  is  late  in  appearing. 

Retromammarv  abscess  is  a  rather  rare  condition.     It  mav  occur  alone  or  be 


1:^76  Diseases  of  the  ^Mammary  Glands 

associated  and  connected  with  an  area  of  intramammary  suppuration.  It  may 
result  from  metastasis  or  from  caries  of  a  rib.  The  breast  is  lifted  up  by  the 
fluid  beneath  it. 

Treatment. — Open  a  superficial  abscess  by  an  incision  radiating  from  the 
nipple.  Treat  as  any  other  acute  abscess.  An  intramammary  abscess  should 
be  opened  by  a  radiating  incision,  and  pockets  of  pus  should  be  broken  into 
with  the  finger.  An  examination  is  made  to  determine  if  a  retromammary 
abscess  also  exists.  If  this  is  found  to  be  the  case,  an  incision  is  made  at  the 
point  of  junction  of  the  thorax  and  mammary  gland,  and  at  the  lower  border 
of  the  gland.  The  gland  is  raised  from  the  chest  wall,  the  pus  evacuated,  a 
drainage-tube  is  inserted,  and  a  few  sutures  are  introduced.  If  retromammary 
abscess  exists  alone,  make  the  last-named  incision  in  the  first  place. 

Chronic  Mastitis. — This  condition  may  be  present  in  only  a  portion 
of  the  breast,  or  may  attack  many  lobules  (lobar  mastitis).  The  ordinary 
form  may  arise  after  weaning  a  child,  or  may  be  due  to  a  blow,  to  the  pressure 
of  corsets,  or  to  numerous  slight  traumatisms.  It  may  occur  in  the  young, 
the  middle  aged,  or  the  old.  The  patient  has  slight  pain  at  times  in  the  gland. 
Examination  detects  a  firm,  elastic  area,  which  is  somewhat  tender  and  does 
not  possess  distinct  margins.  The  skin  is  not  adherent  to  the  mass  unless  sup- 
puration occurs.  If  the  mass  be  pressed  against  the  chest  by  the  surgeon's 
fingers,  it  becomes  evident  that  no  real  tumor  exists. 

Treatment. — Remove  any  cause  of  irritation.  Support  the  breast  by  a  spica 
bandage.  Apply  ichthyol  ointment.  During  the  night  employ  a  hot-water 
bag.     If  pus  forms,  treat  as  before  directed. 

Chronic  lobular  mastitis  is  a  condition  in  which  numerous  lobules 
become  indurated.  The  real  cause  of  this  condition  is  unknown.  It  may 
occur  at  any  age  after  puberty,  and  often  attacks  both  breasts.  Such  a  breast 
is  apt  to  be  painful,  especially  at  the  menstrual  periods;  it  feels  unnatural, 
solid,  and  careful  examination  detects  numerous  indurated  areas,  each  of  which 
is  of  small  size.  At  the  menstrual  period  the  breast  enlarges  and  new  nodules 
may  be  detected.  In  some  of  these  cases  violent  neuralgic  pains  are  present 
in  the  gland  \mastodynid).  Chronic  lobular  mastitis  is  apt  to  lead  to  cyst 
formation.  When  cysts  form  fluid  may  occasionally  discharge  from  the 
nipple. 

Treatment. — Support  the  breast  and  apply  ichthyol  ointment  or  belladonna 
ointment.  Examine  the  generative  organs  and  correct  any  existing  abnormal- 
ity. Improve  the  general  health  by  good  food,  tonics,  and  open-air  life.  In 
cases  in  which  multiple  cysts  are  known  to  exist  the  question  of  treatment  is 
uncertain.  There  seems  to  be  little  doubt  that  such  cases  tend  in  some  instances 
to  eventuate  in  cancer.  I  believe  that  the  proper  treatment  when  multiple 
cysts  exist  is  extirpation  of  the  breast. 

Tuberculosis  of  the  Mammary  Gland. — Sir  Astley  Cooper  in  1829 
wrote  on  '"  scrofulous  swellings  "  of  the  iDreast,  and  Velpeau  also  referred  to  them. 
Nevertheless,  Virchow,  in  his  treatise  on  tumors,  stated  that  the  mammary 
gland  was  not  subject  to  tuberculosis.  Durbar  first  proved  the  existence  of 
the  condition  by  histological  and  bacteriological  observations.  Primary  tuber- 
culosis of  the  breast  is  a  rare  condition.  If  we  are  to  judge  from  English  and 
American  literature,  it  is  a  very  rare  condition.  In  1902  Bindo  de  \'ecchi  was 
able  to  report  i  case  and  collect  77  from  literature  ("Extratis  della  Clinica 
Chirurgica,"  No.  8,  1902).  Braendle  in  1906  reported  11  cases  from  the 
Tubingen  clinic  ("Beit,  zur  klin.  Chir.,"  vol.  i,  1906).  Powers,  of  Denver, 
reported  4  cases  ("Annals  of  Surgery,"  Feb.,  1913).  About  80  cases  confirmed 
by  bacteriological  findings  and  histological  study  have  been  reported.  It  is 
seldom  that  both  glands  are  involved.  Tuberculosis  of  the  breast  may  be 
secondary  to  tuberculosis  of  the  skin,  of  related  glands,  of  the  rib,  etc.  It  may 
result  from  some  distant  tuberculous  lesion  of  bone,  of  joint,  of  lung,  etc.     It 


Treatment  of  Tumors  of  the  Nipple  1577 

may  be  a  part  of  general  miliary  tuberculosis.  We  consider  here  primary  or, 
as  Geissler  named  it.  solitary  tuberculosis,  tuberculosis  apparently  limited  to 
the  breast  in  an  individual  free  from  evidences  of  antecedent  tuberculosis,  and 
of  tuberculosis  elsewhere.  It  occurs  usually  in  those  of  excellent  general  health. 
The  route  of  infection  may  be  by  the  blood,  by  the  lymph-ducts,  and  perhaps 
by  the  lymphatics  from  the  skin  or  nipple.  The  lesion  begins  in  the  periacinous 
and  periductal  connective  tissue.  The  ducts  and  acini  become  involved  later. 
E.  M.  Von  Eberts  ("  Amer.  Jour.  Med.  Sci.,"  July,  1909)  states  that  there  is  no 
reported  case  before  the  age  of  puberty,  that  the  most  advanced  case  reported 
was  lif  ty-three  years  of  age,  that  maturity  of  the  gland  and  lactation  predispose, 
and  that  the  reported  cases  show  the  proportion  of  the  married  to  the  unmar- 
ried as  4  to  I.  It  is  vastly  more  common  in  women  than  in  men.  In  many 
cases  there  is  a  history  of  antecedent  inflammation  or  abscess  during  lactation. 
In  some  cases  there  is  a  history  of  traumatism.  There  are  two  forms  of  the  con- 
dition, and  in  each  form,  sooner  or  later,  degeneration  occurs,  and  fistulas  from 
a  cold  abscess  arise  (see  page  267);  these  forms  are  nodular  and  confluent  (von 
Eberts,  Ibid.).  In  the  nodular  form  a  nodule,  several  nodules,  or  many  nodules 
arise  in  the  glandular  tissue.  There  is  little  or  no  pain.  If  nodules  are  under 
the  nipple  retraction  may  occur.  The  condition  is  very  slow  in  progress  and 
a  year  or  several  years  may  elaspe  before  degeneration  occurs.  Degeneration 
results  in  cold  abscess  (see  page  262)  and  often  in  fistula  formation.  Schley 
has  pointed  out  that  cold  abscess  is  a  termination  more  common  in  the  confluent 
than  in  the  nodular  type  ("Annals  of  Surgery,"  1903).  In  the  confluent  form 
the  condition  develops  much  more  rapidly,  is  associated  with  pain,  is  most  apt 
to  arise  during  lactation,  is  particularly  prone  to  abscess  and  fistula  formation, 
and  is  liable  to  acute  exacerbation  from  secondary  pyogenic  infection.  The 
axillary  glands  are  found  enlarged  in  three-fourths  of  all  cases  of  primary  tuber- 
culosis. Cases  have  been  reported  of  carcinoma  and  of  adenoma  associated 
with  tuberculosis. 

Treatment. — In  a  very  slowly  developing  nodular  case,  in  which  it  is  certain 
lactation  will  not  arise,  it  may  be  considered  proper  to  treat  the  condition  with 
tuberculin,  etc.  (see  section  on  Tuberculosis).  In  the  confluent  form  and  in 
cases  of  the  nodular  form  in  which  tuberculin  treatment  has  failed,  or  in  which 
we  cannot  exclude  the  possibility  of  pregnancy,  the  breast  should  be  removed 
and  the  glands  and  fat  should  be  removed  from  the  axilla.  Most  of  the  cases 
recover  permanently  after  radical  operation  (Braendle,  of  Tubingen,  in  "Beit, 
zur  klin.  Chir.,"  1906,  Bd.  i).  Powers  ("Annals  of  Surgery,"  Feb.,  1913) 
advises  the  thorough  removal  of  the  breast,  pectoral  fascia,  and  axillary  contents, 
and  with  this  recommendation  I  am  in  accord. 

Cysts  and  Tumors  of  the  Nipple. — Tumors  are  rare  in  the  nipple, 
but  do  sometimes  occur.  The  following  growths  are  occasionally  seen:  fibroma, 
angeioma,  papilloma,  myxoma,  myoma,  and  epithelioma.  Sebaceous  cysts  of 
the  nipple  and  areola  are  not  very  unusual.  A  cancer  of  the  nipple  may  be 
a  primary  growth,  or  may  be  secondary  to  gland  cancer.  Primary  epithelioma 
of  the  nipple  presents  the  same  general  characters  as  epitheHoma  in  any  other 
part.  It  begins  as  an  indurated  area  in  the  areola,  or  an  excoriation  of  the 
nipple.  Ulceration  soon  occurs.  The  ulcer  is  irregular  in  outline,  has  hard 
edges,  and  furnishes  a  foul,  red,  sanious,  and  fetid  discharge.  The  mammary 
gland  becomes  infiltrated  at  an  early  period.  The  subclavian  glands  enlarge, 
and  later  the  axillary  glands.  Such  a  growth  must  not  be  confounded  with  a 
chancre  of  the  nipple. 

Treatment  of  Tumors  of  the  Nipple. — Innocent  tumors  are  to  be  excised 
and  the  breast  need  not  be  removed. 

Epithelioma  of  the  nipple  requires  the  complete  extirpation  of  the  breast, 
and  also  the  clearing  out  of  the  lymphatic  contents  of  the  axilla,  and  possibly 
of  the  subclavian  triangle. 


1578  Diseases  ot  the  Mammary  Glands 

Paget's  Disease  of  the  Nipple  (Malignant  Dermatitis). — Sir  James  Paget 
made  a  report  upon  15  cases  of  this  rare  disease  ("St.  Bartholomew's  Hospital 
Reports,"  vol.  x,  1874).  Over  thirty  years  previous  to  Paget's  paper  V'elpeau 
described  a  like  or  identical  condition  ("Lefon  orales  de  Clinique  Chirurgicale." 
1841).  It  is  a  rare  condition.  Only  about  150  cases  have  been  reported  (Jopson 
and  Speese,  "Annals  of  Surgery,"  August,  1915).  Paget's  disease  is  held  to  be  a 
peculiar  chronic  inllammation  of  the  epithelial  layer  of  the  nipple  and  areola 
occurring  in  women  beyond  middle  life,  and  is  regarded  as  a  not  unusual  pre- 
cursor of  epithelioma  of  the  nipple  and  of  duct  cancer.  Paget's  disease  is 
not  a  simple  eczema,  it  is  not  associated  with  the  usual  causes  and  attendants 
of  eczema,  either  local  or  constitutional,  and  is  not  cured  by  remedies  which 
control  the  ordinary  disease.  It  begins  in  the  cells  of  the  Malpighian  layer, 
which  grow  downward  but  do  not  invade  tissue  like  cancer  cells,  and  it  causes 
proliferation  of  cells  of  the  acini  and  milk-ducts. 

The  diseased  area  is  raw  and  red,  and  from  it  exudes  copiously  a  thick, 
yellow  discharge.  In  some  cases  inflammation  of  the  nipple  and  areola  is 
secondary  to  duct  cancer,  auto-infection  of  the  nipple  having  been  effected 
by  the  fluid  flowing  from  the  ducts  but  true  Paget's  disease  is  a  primary  affec- 
tion. Practically  always  cancer  follows.  In  rare  cases  squamous-celled 
epithelioma  arises  on  the  nipple  or  areola.  Commonly  duct  or  gland  cancer 
follows. 

Treatment. — Removal  of  the  entire  breast  and  clearing  out  of  the  axilla. 

Tumors  and  Cysts  of  the  Mammary  QIand. — These  tumors  may  be 
innocent  or  malignant.  Tumors  may  occur  in  childhood  (angeioma,  sarcoma, 
fibro-adenoma).     Malignant  tumors  are  very  rare  before  the  age  of  twenty-five. 

Innocent  Tumors  of  the  Mammary  Gland. — The  innocent  tumors  are: 
Periductal  fibroma,  fibrocystadenoma,  papillary  cystadenoma,  simple  adenoma, 
periductal  fibromyxoma,  myxoma,  angioma,  lipoma,  and  enchondroma.  It  is 
maintained  by  most  authorities  that  any  innocent  tumor  of  the  gland  may  and 
is  apt  to  become  malignant. 

Periductal  Fibroma,  Fibro-adenoma. — The  nomenclature  of  fibro-ade- 
nomata  is  in  a  state  of  great  confusion.  The  name  fibro-adenoma  was  given 
by  Cornil  and  Ranvier  to  the  same  sort  of  growth  which  the  younger  Gross 
called  a  fibroma,  Billroth  an  adenofibroma,  and  Sir  Astley  Cooper  a  chronic 
mammary  tumor.  It  is  doubtful  if  a  pure  fibroma  ever  occurs  in  the  mammary 
gland.  A  fibro-adenoma  consists  of  acini  surrounded  by  fibrous  tissue.  Each 
of  these  structures  proliferates,  but  the  fibrous  tissue  does  so  much  more  rapidly 
than  the  glandular.  Bloodgood  ("Amer.  Jour.  Med.  Sci.,"  Feb.,  1908)  says, 
"the  fibro-adenoma  microscopically  is  nothing  more  than  an  encapsulated  area 
of  normal  breast  tissue,  in  which  the  parenchyma,  in  the  early  stage  of  the 
tumor,  is  greater  in  amount  than  the  normal  breast.  Later  the  parenchyma 
undergoes  pressure  atrophy  and  the  tumor  may  become  calcified."  A  growth 
of  this  character  is  surrounded  by  a  capsule  and  is  movable.  It  is  firm,  elastic, 
lobulated,  superficially  situated,  and  of  slow  growth.  It  is  unassociated  with 
retracted  nipple,  glandular  enlargement,  adhesion  to  the  skin,  or  cachexia,  and 
may  occur  at  any  age  up  to  fifty,  but  is  most  common  between  twenty  and 
thirty  (Sir.  J.  Bland-Sutton).  Such  a  tumor  is  rarely  very  painful,  but  it  may 
be  tender  on  rough  handling  and  may  be  painful  at  the  menstrual  period.  As 
a  rule,  there  is  but  one  of  these  tumors  in  the  mammary  gland,  but  the  tumors 
may  be  multiple  in  one  gland,  or  one  or  more  may  exist  in  each  gland.  It  is 
not  very  common  for  sarcoma  or  carcinoma  to  arise. 

Periductal  Fibromyxoma. — It  is  most  common  in  young  women.  It  may 
be  multiple  in  one  breast  or  both.  It  is  an  encapsulated,  lobuled,  and  elastic 
growth,  which  is  seldom  painful,  is  usually  small,  and  often  remains  quiescent 
indefinitely  or  even  disappears.  It  may  enlarge  and  even  attain  a  great  size. 
When  it  enlarges  it  is  apt  to  become  cystic  and  sarcomatous. 


Simple  Adenoma  1579 

Treatment  of  Periductal  Fibroma  and  Fibromyxoma. — The  tumor  should  be 
extirpated.  If  a  supposedly  innocent  growth,  removed  by  a  limited  operation, 
has  been  really  the  seat  of  beginning  malignancy,  the  wound  will  soon  thicken 
after  healing  and  recurrence  will  be  rapid.  Halsted  has  shown  that  in  such  a 
case  re-operation,  however  extensive,  will  not  obtain  a  cure.  Hence,  it  behooves 
us  in  doubtful  cases,  if  we  err  at  all,  to  err  on  the  side  of  radicalism.  In  a  case 
recognized  as  doubtful,  when  the  growth  is  removed  a  frozen  section  should  be 
made  at  once  and  be  studied  then  and  there,  and  the  surgeon  should  suspend 
operation  while  he  waits  for  the  report.  If  the  report  shows  that  the  growth  is 
malignant,  at  once  remove  the  breast  radically  and  clean  out  the  axilla.  A 
tumor  known  to  be  innocent  may  be  removed  through  an  incision  made  along 
the  junction  of  the  mammary  gland  and  chest,  at  the  lower  margin  of  the  gland, 
as  Thomas  proposed,  or,  better,  at  the  edge  of  the  outer  hemisphere,  as  advo- 
cated by  Warren  ("Annals  of  Surgery,"  June,  1907).  The  incision  exposes 
the  fibers  of  the  great  pectoral  muscle,  the  gland  is  raised  from  the  muscle,  and 
its  posterior  surface  exposed.  Any  growth  is  exposed  by  an  incision  from  center 
to  periphery  and  this  incision  is  exploratory.  Warren  removes  an  innocent 
tumor,  a  cyst,  or  cysts  by  a  V-shaped  incision,  the  apex  of  the  V  being  at  the 
center  of  the  gland,  and  he  wisely  insists  that  the  tumor  is  not  to  be  dissected 
out.  Several  radiating  incisions  may  be  necessary  to  explore  a  cystic  breast. 
The  V-shaped  space  from  which  the  tumor  or  cyst  has  been  removed  is  closed  by 
a  double  row  of  catgut  sutures.  Incisions  for  exploration  seldom  need  to  be 
closed  by  suture.  The  gland  is  sutured  to  the  outer  edge  of  the  pectoral  fascia, 
and  a  row  of  sutures  is  inserted  through  the  deep  layer  of  the  superficial  fascia. 
Warren  calls  this  operation  plastic  resection  of  the  breast.  It  leaves  the  patient 
free  from  deformity. 

Fibrocystadenoma  or  cystic  adenoma  (adenocele)  is  a  rare  form  of  slowly 
growing  tumor,  which  is  apt  to  attain  a  large  size,  which  is  nodular  in  outline, 
hard  to  the  touch,  and  firmly  attached  to  the  mammary  gland,  but  mobile  upon 
the  chest.  A  cystic  adenoma  has  a  distinct  capsule.  This  form  of  tumor  is 
painless,  and  is  most  apt  to  occur  in  women  between  thirty  and  forty  who 
have  borne  children.  The  growth  is  adherent  to  the  skin,  but  the  cutaneous 
surface  is  not  discolored,  the  cutaneous  veins  are  not  distended,  the  axillary 
glands  are  not  enlarged,  and  the  nipple  is  not  retracted.  From  the  walls  of 
the  dilated  acini  papillomatous  growths  are  apt  to  arise  (intracystic  vegetations). 
The  growth  may  be  a  precursor  of  cancer. 

Treatment. — Radical  removal  of  breast  and  clearing  of  axilla. 

Papillary  Cystadenoma. — This  condition  is  often  called  villous  papilloma 
or  duct  papilloma.  There  is  much  more  epithelial  proliferation  than  in  the 
fibrocystadenoma,  and  the  warty  masses  project  into  the  cyst  cavities.  These 
growths  are  firm,  grow  slowly  and  painlessly,  and  seldom  fluctuate.  They 
do  not  adhere  to  the  skin,  attain  a  large  size,  or  cause  glandular  enlarge- 
ment. They  are  situated  near  or  under  the  nipple,  and  occur  particularly  in 
middle  life.  Discharge  of  serous  fluid  from  the  nipple  is  a  common  symptom. 
In  many  cases  there  is  a  bloody  discharge.  The  condition  tends  to  become 
cancerous. 

Treatment. — The  danger  that  duct  cancer  wifl  arise  is  so  great  that  the 
old  operation  of  excision  of  the  tumor  should  give  way  to  radical  removal  of  the 
breast.  In  any  duct  growth  with  a  serous  discharge  from  the  nipple  it  is  wise 
to  remove  the  breast  and  to  clear  the  axilla.  If  the  discharge  be  bloody  that 
radical  procedure  is  imperative. 

Simple  Adenoma. — This  is  a  very  rare  tumor.  It  occurs  in  young  and 
middle-aged  women.  It  is  soft,  nodular,  and  freely  movable.  It  does  not 
adhere  to  the  skin  and  does  not  cause  lymphatic  involvement.  It  consists 
of  glandular  acini  and  a  very  dehcate  stroma  of  connective  tissue.  It  tends 
to  become  cancerous. 


1580  Diseases  of  the  ^Mammary  Cilands 

Treatment. — Extirpation  of  the  tumor.  Touch  the  wound  with  chlorid  of 
zinc  solution  (10  gr.  to  the  ounce)  in  order  to  destroy  cells  which  might  lodge 
and  grow. 

Myxoma  is  a  rare  tumor,  and  only  occurs  in  a  person  of  middle  age  or 
beyond.  The  growth  is  solitary,  is  soft,  may  be  round  or  lobulated,  and  occa- 
sionally fungates.  The  nipple  is  not  retracted,  the  superficial  veins  are  not 
distended,  and  the  axillary  glands  are  not  enlarged. 

Treatment. — Removal  of  the  mammary  gland. 

Angioma. — This  form  of  tumor  is  very  rare.  It  may  arise  secondarily  to  a 
nevus  of  the  skin  (Sir.  J.  Bland-Sutton).  The  diagnosis  of  angioma  of  the  skin 
is  readily  made.  In  a  cavernous  angioma  of  the  breast  it  will  be  found  that 
the  tumor  can  be  lessened  in  size  by  pressure,  and  will  be  increased  in  size 
by  coughing,  laughing,  and  holding  the  breath.  Pulsation  may  be  detected 
and  a  bruit  may  be  audible. 

Treatment. — For  treatment  of  nevus  see  page  419.  If  a  cavernous  angioma 
exists  in  the  mammary  gland,  it  will  be  necessary  to  extirpate  the  gland. 

Lipoma  and  enchondroma  occasionally  occur  in  the  breast. 

Cysts  of  the  Mammary  Gland. — Involution  cysts  {cystic  degenera- 
tion of  the  mamma)  occur  in  women  who  are  approaching  the  menopause. 
Such  cysts  occur  earlier  in  those  who  are  sterile  than  in  those  who  have  borne 
children,  and  may  arise  after  chronic  mastitis.  The  parenchyma  of  the  gland 
undergoes  atrophic  change,  but  the  ducts  remain,  become  blocked  and  dilated. 
Numerous  small  cysts  form,  and  both  glands,  as  a  rule  sufiFer.  Villous  growths 
may  arise  in  the  walls  of  the  ducts.  In  some  cases  there  is  much  white  fibrous 
tissue  between  the  cysts  (cystic  fibroma). 

The  subjects  of  this  disease  are  often  nervous,  hysterical,  and  despondent. 
One  or  more  ill-defined  indurations  are  detected.  Frequently  there  is  a  history 
of  discharge  from  the  nipple  and  of  attacks  of  lancinating  pain  in  the  breast. 
Cystic  breasts  are  dangerous,  because  the  intracystic  vegetations  are  liable  to 
eventuate  in  duct  cancer.  One-fourth  of  these  cases  are  cancerous  when 
first   seen   (Speese,   quoted  by  Primrose  in   "Amer.  Jour.  Med.  Sci.j"  Jan., 

1913)- 

Treatment. — In  such  cases,  after  confirming  the  diagnosis  by  an  exploratory 
incision,  remove  the  entire  breast. 

Lacteal  cyst  (galactocele)  is  an  accumulation  of  milk  brought  about  by 
blocking  of  some  of  the  milk-ducts.  It  usually  arises  soon  after  the  delivery  of 
the  child,  but  may  not  be  noted  for  months  or  even  several  years  after  childbed. 
It  grows  rapidly  from  the  time  it  is  first  detected.  A  large  quantity  of  milk 
may  collect,  and  rupture  of  the  cyst  walls  may  occur,  the  fluid  passing  into 
the  glandular  connective  tissue. 

A  galactocele  is  rounded,  fluctuates  distinctly,  and  increases  in  size  during 
nursing.  There  is  little  or  no  pain.  In  some  cases  the  contents  of  the  cyst 
coagulate  and  a  solid  mass  is  formed. 

Treatment. — Incision  and  drainage. 

Hydatid  cysts  are  rare,  but  do  occasionally  occur.  There  are  2,3  positive 
cases  on  record  (Le  Conte,  in  "Amer.  Jour.  Med.  Sci.,"  Sept.,  1901).  A  small, 
hard,  movable,  and  painless  mass  appears  in  the  mammary  gland.  Usually 
it  gradually  increases  in  size,  but  it  may  grow  rapidly  for  a  time  and  then 
remain  apparently  almost  stationary  for  a  period.  If  rapid  growth  takes 
place  there  is  always  pain,  and  pain  is  usual  in  any  case  when  the  cyst  attains 
considerable  size.  Fluctuation  is  often  ateent  and  crepitation  is  never  ob- 
tained (Le  Conte).     Suppuration  is  apt  to  occur  and  sinuses  may  form. 

Treatment. — A  small  and  recent  cyst  may  be  extirpated.  If  the  cyst  is 
not  recent,  but  is  fairly  large  and  adherent,  incise,  evacuate,  and  pack  with 
gauze.  If  the  cyst  is  large  and  adherent,  but  is  surrounded  by  considerable 
breast  tissue,  partially  amputate  the  breast.     If  the  cyst  is  large  and  the  breast 


Sarcoma  of  the   Mammar}'   (iland  1581 

practically  destroyed,  or  if  the  nipple  adheres  to  the  cyst,  remove  the  mammary 
gland  (Le  Conte,  Ibid.). 

Malignant  tumors  of  the  mammary  gland  are  ten  times  more  com- 
mon than  innocent  tumors.  We  should  regard  every  palpal:)le  tumor  in  the 
gland  as  malignant  until  it  is  proved  to  be  innocent.  In  other  words,  we 
reverse  the  rule  of  jurisprudence.  We  regard  every  tumor  as  guilty  of  malig- 
nancy until  its  innocence  is  proved.  If  the  mistake  is  made  of  regarding  an 
innocent  tumor  as  malignant,  the  woman  loses  her  breast  needlessly.  If  a 
malignant  tumor  is  regarded  as  innocent  the  woman  loses  her  life  needlessly. 
"The  fact  that  malignant  degeneration  of  benign  growths  in  the  breast  is  of 
frequent  occurrence  is  obviously  another  convincing  argument  for  the  removal 


Fig.  1085. — Scirrhous  carcinoma  (J.  Collins  Warren). 


of  all  breast  tumors.  A  recent  study  of  Speese  showed  that  no  less  than  26 
per  cent,  of  the  cases  of  chronic  cystic  mastitis  (that  is,  that  form  of  'abnormal 
involution'  occurring  at  the  menopause)  examined  by  him  showed  malignancy. 
So,  too,  cyst  adenomata  are  found  associated  with  carcinoma,  the  frequency 
of  such  association  being  placed  by  some  authors  as  high  as  15  per  cent.  In- 
flammatory conditions  of  the  breast  resulting  in  mastitis  are  often  found  in  the 
early  history  of  cancer  cases.  All  these  facts  point  conclusively  to  the  frequent 
occurrence  of  malignant  degeneration  in  benign  growths  of  the  breast"  (A. 
Primrose,  Loc.  cit.). 

Sarcoma  of  the  mammary  gland  is  a  very  rare  growth  (not  over  3  per  cent, 
of  breast  tumors).     It  may  occur  at  any  age  from  puberty  to  old  age.     It  was 


1582 


Diseases  of  the  Mammarv  Glands 


long  thought  to  be  most  common  from  twenty  to  thirty-five  years  of  age,  but 
Rodman's  investigations  show  that  one-half  the  cases  occur  in  the  fifth  decade 
of  life  (Rodman  on  "Diseases  of  the  Breast").  The  growth  may  be  composed 
of  round  cells  or  spindle  cells.  The  spindle-cell  growth  is  the  most  common. 
Both  round  and  spindle  cells  may  be  present,  and  myeloid  cells  may  be  found. 
Myxomatous  change  may  occur.  Circumscribed  sarcoma  arises  usually  between 
the  ages  of  twentv  and  thirty;  it  is  firm  to  the  touch,  as  it  contains  much  fibrous 
tissue,  is  painless,  does  not  grow  very  rapidly,  glands  are  seldom  involved,  and 
there  is  no  cachexia.  The  nipple  is  not  retracted.  The  growth  may  adhere  to 
the  skin.  If  it  be  composed  of  giant  cells  or  spindle  cells  it  will  rarely  return 
after  extirpation  of  the  breast. 

Diffused  sarcoma  is  composed  of  small  round  cells,  arises  in  the  center  of 
the  breast,  and  grows  with  great  rapidity.  It  is  most  commonly  met  with 
about  the  age  of  thirty-five,  and  a  history  of  injury  can  often  be  elicited. 
The  tumor  is  soft,  some  parts  being  softer  than  others  because  of  cyst  formation. 
It  is  usually  mobile  upon  the  thorax,  though  it  soon  becomes  adherent  to  the 

skin.  The  tumor  reaches  a  very 
great  size,  and  soon  fungates 
through  the  skin.  There  is  little 
or  no  pain.  The  cutaneous  veins 
over  the  tumor  are  distended,  the 
nipple  is  not  retracted,  and  the 
axillary  glands  are  not  often  en- 
larged. Diffuse  sarcoma  is  apt 
to  recur  after  removal. 

Treatment.  —  Remove  the 
breast,  and  if  the  muscles  of  the 
chest  wall  are  infiltrated,  remove 
them.  The  axillary  glands  should 
be  removed  whether  they  are  en- 
larged or  not.  Operation  will  not 
cure  when  metastases  exist.  If 
the  case  be  inoperable,  we  can 
try  the  use  of  Coley's  fluid.  If 
the  toxins  of  erysipelas  fail  to 
arrest  the  progress  of  the  disease, 
keep  the  patient  as  comfortable 
as  possible  by  the  administration 
of  cocain  and  morphin. 
Endothelioma. — This  is  a  very  rare  tumor.  1  have  had  i  case  of  it.  The 
diagnosis  cannot  be  made  from  carcinoma. 
Treatment. — As  for  cancer. 

Carcinoma  or  Cancer  of  the  Mammary  Gland  of  the  Female  (Fig.  1085). 
— The  great  majority  of  mammary  tumors  arc  cancerous.  Cancer  is  due  to 
proliferation  of  the  epithelium  of  the  acini  (acinous  cancer)  or  of  the  ducts 
(duct  cancer). 

Acinous  cancer  is  vastly  more  common  than  duct  cancer.  Usually  there 
is  much  connective  tissue  and  but  little  parenchyma  in  the  growth  (scirrhous 
cancer).  In  some  cases  there  is  little  connective  tissue  and  much  parenchyma 
(encephaloid  or  medullary  cancer).  If  colloid  degeneration  of  the  parenchyma 
or  stroma  occurs,  the  growth  is  spoken  of  as  colloid  cancer. 

Scirrhus  (Figs.  1085  and  1086),  the  common  form  of  acinous  cancer,  is  almost 
as  hard  as  stone.  On  section  it  is  concave,  and  Sutton  says  "resembles  an 
unripe  pear."  The  tumor  is  without  a  capsule,  and  the  epithelial  cells  are 
surrounded  by  masses  of  fibrous  tissue.  Portions  of  tissue,  even  some  distance 
away  from  the  tumor  proper,  contain  foci  of  proliferating  embryonic  epithelial 


.  Fig.  1086.  —  Scirrhous  carcinoma  of  right 
breast  showing  retraction  of  nipple  (Dr.  Blanck's 
patient). 


Acinous  Cancer 


1583 


cells.  In  atrophic  or  withering  scirrhus  the  lihrous  stroma  contracts  and 
epithelial  cells  undergo  fatty  degeneration. 

Halsted  in  1898  described  adenocarcinoma.  It  is  the  initial  movement  in 
the  direction  of  unrestrained  e])ithelial  j)roliferation,  and  sections  of  the  tumor 
show  the  formation  of  tubular  acini.  The  most  characteristic  sections  resemble 
adenoma.  Adenocarcinoma  is  not  the  common  form  of  breast  cancer.  In 
the  common  form  the  proliferating  epithelium  attains  no  resemblance  to  gland- 
ular structure,  but  multiplies  irregularly  in  connective-tissue  spaces  or  lymph- 
spaces. 

Causes  and  Symptoms. — Scirrhus  is  more  common  among  women  who  have 
borne  children  than  among  those  who  have  not.  Heredity  is  manifest  in  only 
about  10  per  cent,  of  cases.  The  younger  Gross  found  it  in  i  case  out  of  9. 
Trauma  has  no  apparent  influence  in  producing  cancer.  The  disease  is  rare 
before  the  age  of  thirty-five,  and  is  most  common  between  forty-five  and  fifty. 
The  author  operated  for  scirrhus  of  the  breast  on  a  woman  only  twenty-seven 
years  of  age.     Henry  saw  a  woman  of  twenty-one  with  cancer.     It  is  frequently 


Fig.  1087. — Carcinoma  of  right  breast. 


Lesion  first  noticed 
was  made. 


six  months  before  photograph 


met  with  in  the  aged.  These  tumors  are  rare  in  the  negro  race.  A  hard  nodule 
is  found  in  the  breast,  usually  under  the  nipple,  but  possibly  far  away  from  it. 
The  growth  is  nodular,  and  is  immobile  from  the  beginning.  In  a  large,  fat 
breast  there  is  often  a  deceptive  sense  of  mobility,  because  some  of  the  breast 
tissue  moves  with  the  tumor.  The  cancer  may  have  been  present  for  a  con- 
siderable time  before  being  discovered.  Sometimes  widespread  lesions  develop 
from  a  small  or  an  undiscovered  breast  cancer  (pleural  effusion,  enlarged  glands 
of  the  neck,  disease  of  the  spinal  cord,  of  bones  of  the  skull  or  brain).  In 
obscure  lesions  of  bones  and  viscera  examine  the  mammary  glands,  because 
the  trouble  may  be  due  to  metastasis  from  an  undiscovered  carcinoma  of  the 
breast.  The  glands  of  the  armpit  always  and  soon  become  diseased,  the 
glands  above  the  clavicle  often  enlarge,  and'  the  arm  may  swell.  Growth 
may  arise  within  the  chest,  either  by  lymph  regurgitation  from  the  axillary 
and  subclavian  glands,  or  directly  through  the  chest  walls  to  pleura  and  lung 
or  to  mediastinal  glands.  Oelsner  and  Poirier  show  that  there  is  a  lymph 
tract  running  from  the  breast  to  glands  within  the  thorax,  passing  through  the 
great  pectoral  muscle  and  "  the  fourth  interspace  at  the  level  of  the  costochon- 


1584 


Diseases  of  the  Mammary  Glands 


dral  articulation"  (Primrose,  in  "  Amer.  Jour.  Med.  Sci.,"  Jan.,  1913).  "For- 
tunately, these  glands  are  not  frequently  involved,  a  circumstance  which 
may  be  accounted  for  by  the  atrophy  of  this  channel  in  senile  mammae,  in 
which  cancer  usually  develops  (Poirier)  "  (Primrose,  Ibid.).  Retraction  of  the 
nipple  is  present  in  over  one-half  of  the  cases.  It  occurs  when  the  growth 
is  near  the  nipple,  and  is  due  to  the  contracting  fibrous  tissues  of  the  tumor 
pulling  in  the  milk-ducts.  If  the  growth  be  far  away  from  the  nipple,  a  dimple 
is  apt  to  form  in  the  skin  of  the  breast  because  of  the  pulling  upon  the  sus- 
pensory fibers.  Neither  retraction  of  the  nipple  nor  a  cutaneous  dimple  proves 
the  existence  of  cancer.  One  or  both  may  be  noted  in  a  breast  containing  a 
scar  (from  a  wound  or  a  healed  abscess),  in  tuberculosis  of  the  breast,  and  in 
mammary  syphilis.  The  dimple  is  not  due  to  adhesion  between  the  tumor  and 
the  skin.  It  is  noted  even  when  the  tumor  is  far  away  from  the  skin.  It 
may  not  be  obvious  unless  the  gland  be  moved  to  and  fro  or  unless  the  skin 


Fig.  1088. — Recurrent  carcinoma.     Cancer  en  cuirasse. 

over  the  breast  be  pushed  in  various  directions.  When  this  is  done  it  becomes 
evident  that  the  skin,  at  a  certain  point,  is  held  inward.  The  dimple  is  a 
very  valuable  early  symptom. 

Glandular  carcinoma  in  the  axilla  soon  follows  the  appearance  of  a  scirrhus 
although  there  may  be  no  palpable  enlargement  for  a  considerable  time.  The 
glands  become  very  hard  and  adherent.  In  over  60  per  cent,  of  persons  the 
glands  of  the  axilla  are  felt  to  be  enlarged  when  the  patient  first  comes  for  treat- 
ment. Because  the  surgeon  cannot  feel  enlarged  glands  is  no  proof  that  they  do 
not  exist.  As  a  matter  of  fact,  the  glands  are  usually  involved  within  two 
months  of  the  beginning  of  the  disease,  but  the  involvement  can  rarely  be 
detected  externally  until  months  later.  Enlargement  of  the  axillary  glands  is 
followed  by  enlargement  of  the  glands  in  the  posterior  cervical  triangle  and  in 
the  mediastinum.  Herbert  Snow  has  shown  that  the  blocking  of  the  axillary 
glands  often  leads  to  regurgitation  of  lymph  containing  cancer-cells,  the  cells 
being  thus  deposited  in  the  head  of  the  humerus  and  in  the  thymus  gland.     Cancer 


Acinous  Cancer 


1585 


in  the  thymus  and  in  the  mediastinal  lymph-glands,  after  a  time,  causes  a  projec- 
tion of  the  sternum  (the  sternal  symptom).  When  the  axillary  lymphatics  are 
extensively  involved  the  arm  swells  from  obstruction  to  the  lymph-How  (lymphe- 
dema) or  pressure  upon  the  vein.     If  there  be  lymphatic  obstruction  the  skin  of 


Fig.  loSg. — Cancer  en  cuirasse. 

the  breast  becomes  pitted  and  resembles  pig  skin.  The  skin  is  actually  can- 
cerous or  soon  becomes  so  by  infiltration.  Each  pit  is  the  opening  of  a  sweat- 
gland.  The  sweat-duct  is  held 
down  by  contracting  fibrous  tis- 
sue. This  condition  is  termed 
peau  d'orange,  or  pigskin  saddle 
appearance.  The  tumor  usually 
grows  rather  slowly  unless  lacta- 
tion is  established,  when  it  grows 
with  frightful  rapidity.  As  it 
grows  it  infiltrates  adjacent  struc- 
tures (the  pectoral  fascia,  pectoral 
muscles,  subcutaneous  cellular  tis- 
sue, and  skin).  When  a  tumor  be- 
comes adherent  to  the  skin  the 
skin  becomes  congested  and  of  a 
dark  purple  hue.  When  the  skin 
is  destroyed,  an  ulcer  forms,  and 
around  this  ulcer  the  skin  becomes 
red  and  filled  with  cancerous  nod- 
ules, which  feel  like  shot  in  the 
skin.     Metastases  are  apt  to  occur 

in  the  bones,  liver,  brain,  pleura,  lung,  spine,  thymus  gland  and  rarely  the 
eye.  The  pleura  and  lung  may  be  attacked  by  direct  spread  of  the  growth 
through  the  chest  wall,  from  infected  rnediastinal  glands,  or  by  lymph  regurgi- 
tation from  the  axillary  and  subclavian  glands. 

Pain,  absent  at  the  start,  is  usually  present  later  in  scirrhous  carcinoma. 


Tig.  1090. — Recurrent  carcinoma  of  the  breast. 


1586 


Diseases  of  the  Mammary  Glands 


It  is  lancinating  and  neuralgic  in  character,  and  not  brought  on  or  increased 
by  handling.  It  ceases  if  colloid  degeneration  begins.  The  general  health 
is  usually  unimpaired  until  ulceration  takes  place,  when  cachexia  arises.  In 
1792  Howard  described  the  condition  to  which  Velpeau  called  particular  atten- 
tion in  1838  as  a  deep  cancer  of  the  integument  due  to  a  cancerous  state  of  the 
deep  cutaneous  lymphatics.  Velpeau  named  it  ligneous  cancer  and  also  cancer 
en  cuirasse  (Figs.  1088  and  1089).  The  cancer  en  cuirasse  of  Velpeau  is  a 
condition  in  which  the  lymphatic  vessels  of  the  skin  are  distended  because  of 
obstruction.  The  skin  thickens  as  in  elephantiasis.  The  blocked-up  lymph 
contains  cancer  cells  and  the  skin  early  becomes  nodular  and  cancerous.  In  most 
cases  the  condition  is  secondary,  but  primary  cases  have  been  reported.  The 
condition  may  arise  from  cancer  in  the  breast  or  may  follow  an  operation  for 
cancer  of  the  breast.  The  skin  of  the  chest  becomes  thick  and  rigid  like  a 
leather  cuirass.  The  growth  adheres  and  the  soft  parts,  after  a  while,  adhere  to 
the  chest  wall.  The  skin  is  very  extensively  invaded.  In  this  condition  the 
chest  wall  is  fixed,  respiration  is  difBcult,  temperature  is  commonly  somewhat 
elevated,  and  there  is  probably  a  pleural  effusion.  The  corresponding  upper 
extremity  is  usually  the  seat  of  great  swelling  from  hard  edema. 


I'k;.  1091. — Ulcerating  scirrhous  carcinoma. 


In  atrophic  or  withering  scirrhus  the  breast  becomes  very  small.  In  some 
cases  the  contraction  is  so  great  that  it  seems  as  though  the  mammary  gland 
had  been  removed.  The  duration  of  scirrhus,  when  left  to  run  its  course, 
varies,  but  the  disease  generally  produces  death  within  two  and  a  half  years. 
Occasionally  it  causes  death  within  a  year.  In  atrophic  scirrhus  the  patient 
may  live  for  m^ny  years. 

Duct  cancer  is  not  a  common  growth.  It  arises  from  the  duct  walls  in 
conditions  of  cystic  degeneration  of  the  mammary  gland.  The  tumor  is 
softer  than  the  acinous  growth  and  is  not  nodular.  There  is  no  pain,  no  re- 
traction of  the  nipple,  no  skin  dimple.  Serous  or  bloody  fluid  may  often 
be  squeezed  from  the  nipple.  A  duct  cancer  grows  and  infiltrates  less  rapidly, 
and  involves  adjacent  glands  later  than  does  an  acinous  growth. 

Cancer  beginning  in  an  outlying  lobule  of  the  breast  may  be  very  deceptive. 
Such  a  lobule  may  be  in  the  side  of  the  chest  in  the  axillary  line,  in  the  axilla, 
just  below  the  clavicle,  over  the  front  of  the  sternum,  or  over  the  lower  ribs. 

Carcinoma  mastitoides ,  acute  cancer,  brawny  cancer,  or  inflamed  cancer  is 
a  condition  originally  described  by  Volkmann  in  1875  under  the  name  of  wa^/^Vw 
carcinoma.     It  comes  on  almost  suddenly,  grows  very  rapidly,  causes  violent 


Treatment  of  Carcinoma  of  the  Mamniar}-  Gland  1587 

irritation,  and  hence  widespread  infiltration  ])y  small  cells.  The  condition 
resembles  inllammalion  (Edward  A.  Schumann,  in  "Annals  of  Surgery," 
July,  191 1).  In  this  condition  the  surgeon  cannot  make  out  the  outlines  of  a 
distinct  tumor,  but  the  entire  breast  is  hardened  and  enlarged,  and  the  skin 
of  the  breast  is  reddened,  infiltrated  and  edematous,  and  adheres  to  the  gland. 
There  is  often  pain  and  heat. 

Anatomically  related  glands  enlarge.  The  disease  is  most  apt  to  arise  late 
in  pregnancy  or  during  lactation  and  is  most  common  in  rather  young  women. 
It  may  be  limited  to  one  breast,  but  both  breasts  may  be  involved,  successively 
or  simultaneously.  The  nipple  may  or  may  not  be  retracted.  SHght  eleva- 
tion of  temperature  is  usual. 

There  is  rapid  metastasis,  profound  toxemia,  and  early  death.  Death 
occurs  in  less  than  a  year,  perhaps  in  a  few  weeks.  Billroth's  case  died  in  six 
weeks  after  the  discovery  of  the  cancer. 

Any  persisting  case  of  supposed  acute  mastitis  should  make  us  suspicious. 
In  suck  a  case  excise  a  piece  of  tissue  for  examination.  In  cutting  out  the  piece 
small  abscess  cav.t'es  may  be  discovered  even  when  the  condition  is  cancerous. 
Schumann  (Ibid.)  says  there  are  only  13  reported  cases  of  carcinoma  masti- 
toides.  Since  Schumann's  paper  Morris  Booth  Miller  reported  a  case  ("An- 
nals of  Surgery,"  May,  1913).  I  showed  a  case  to  the  class  at  Jefferson  Hos- 
pital in  the  winter  of  191 2-13.  The  w^oman  was  pregnant  and  both  breasts 
were  involved.  She  perished  miserably  a  few  months  after  the  onset  of  the 
disease  and  a  few  weeks  after  her  confinement. 

Cancer  of  the  Male  Breast. — This  condition  is  seldom  met  with,  though  I 
believe  it  to  be  more  common  than  is  generally  supposed.  I  have  seen  5 
cases  within  the  last  ten  years.  Each  patient  was  in  the  early  forties;  none 
complained  of  pain.  In  one,  the^breast  had  been  extremely  large  from  early 
years.  In  each  case  the  growth  was  indurated,  but  in  none  was  there  any 
retraction  of  the  nipple.  The  condition  in  each  patient  was  sirrchus  carci- 
noma. Warfield  has  collected  32  cases  from  literature  and  has  added  5  others 
("Bull,  of  Johns  Hopkins  Hosp.,"  Oct.,  1901).  The  patients  were  between 
forty  and  seventy  years  of  age;  8  gave  a  history  of  injury;  in  9  cases  there 
was  pain,  and  in  12  the  nipple  was  retracted.  Palermo  has  collected  750 
cases  of  tumor  of  the  male  breast  C'Semaine  Medicale,"  May  20,  1908)  and 
649  of  them  were  cancerous. 

Treatment  of  Carcinoma  of  the  Mammary  Gland. — The  treatment  is 
early  and  thorough  operation;  the  eariier  and  the  more  thorough,  the  better. 
The  older  surgeons  operated  simply  to  prolong  life  a  few  months;  the  modern 
surgeon  operates  with  the  hope  of  curing  the  patient.  The  mortahty  of  the 
operation  is  surprisingly  small.  It  is  certainly  under  2  per  cent.  Rodman's 
statistics  (2133  operations  performed  since  1893  by  twenty-one  American  sur- 
geons) show  a  mortality  of  less  than  i  per  cent.  I  have  personally  lost  5  pa- 
tients in  over  250  operations.  In  1878  Billroth's  statistics  showed  only  8  cures 
in  143  cases.  In  1896  W.  Watson  Cheyne  reported  12  cures  out  of  21  cases 
C57  per  cent.).  His  cases  now  show  54.8  per  cent,  alive  and  well  from  six  to 
thirteen  years  after  operation.  Depage's  statistics  show  that  48  per  cent,  of 
cases  passed  the  three-year  limit  ("Presse  Medicale,"  Oct.  21,  1908).  Green- 
ough,  Simmons,  and  Burney  consider  320  cases  operated  upon  radically  "  Annals 
of  Surgery,"  Jidy,  1907);  88  cases  passed  the  three-year  limit. 

E.  S.  Judd  ("Jour.  Ainer.  Med.  Assoc,"  April  27,  191 2)  pubHshes  the  fol- 
lowing statistics  from  the  Mayo  Clinic.  He  says:  "The  prognosis  as  to  the 
probability  of  a  cure  in  a  case  of  carcinoma  of  the  breast  will  depend — i,  on 
the  length  of  time  the  neoplasm  has  been  developing;  2,  on  the  degree  of  out- 
lying involvement;  3,  on  the  activity  of  the  gland,  which  will  be  determined 
by  the  age  of  the  patient  and  the  relation  to  a  period  of  lactation;  and,  4,  on 
the  thoroughness  of  the  removal  of  the  gland-bearing  fascia. 


1588  Diseases  of  the  Mammary  Glands 

"Data  Collected  from  the  Mayo  Clinic  on  518  Cases  of  Carcinoma  of  the  Breast, 
From  January  i,  1890,  to  January  i,  igoo: 

Average  age 55  years,  6  months. 

Oldest 75  years. 

Youngest 21  years. 

Number  of  cases  operated  on  over  ten  years  before: 

Alive  and  well 21  (23 . 5  per  cent.)- 

Dead 23 

Not  heard  from 45 

Total 89 

Number  of  cases  operated  on  over  five  years  before: 

Alive  and  well 74  (30  per  cent.)- 

Dead 76 

Not  heard  from 89 

Total 239 

Number  of  cases  operated  on  over  two  years  before: 

Alive  and  well 233  (44  per  cent.). 

Dead 134 

Not  heard  from 151 

Total 518" 

Bloodgood  ("  Amer,  Jour.  Med.  Sci.,"  Feb.,  1908)  sets  forth  Halsted's  statis- 
tics: "The  statistics  in  Halsted's  Clinic  up  to  the  present  time  show  that  among 
210  cases,  in  which  three  years  or  more  have  passed  since  the  operation,  42  per 
cent,  are  apparently  well.  If  we  consider  the  cases  in  which  the  axillary 
glands,  studied  microscopically,  showed  no  evidence  of  metastasis,  61  cases, 
or  85  per  cent.,  are  well.  In  cases  in  which  the  axillary  glands  showed  metas- 
tasis (no),  30  per  cent,  remained  free  from  recurrence  for  three  years.  When 
thf  glands  in  the  neck  showed  metastasis  (40  cases),  only  10  per  cent,  remained 
well  for  three  years.  In  all  of  these  groups  metastasis  has  been  observed  after 
an  interval  of  three  years  of  apparent  cure.  Such  late  metastasis  may  take 
place  up  to  eight  years  after  operation.  Excluding  these  cases  of  late  recurrence, 
the  number  of  definitely  cured  in  these  three  groups  is  reduced  to  75,  24,  and  7  per 
cent,  respectively,  or,  for  all  cases  together,  35  per  cent.  I  have  not  time  to  give 
the  facts,  but  there  is  evidence  to  indicate  that  when  the  microscope  fails  to 
demonstrate  metastatic  cancer  cells  in  the  lymphatic  glands  in  the  axilla,  this 
is  not  a  positive  proof  that  metastasis  has  not  taken  place,  and  for  this  reason 
and  others,  which  space  prevents  me  from  stating,  there  should  be  no  restriction 
in  the  complete  operation  for  carcinoma  of  the  breast."  It  will  be  observed 
that  of  these  40  cases,  with  involvement  of  neck  and  axilla,  only  4  passed 
the  three-year  limit.  If  they  had  not  been  operated  upon,  statistics  would 
have  been  bettered.  The  surgeon  who  would  not  operate  on  such  cases  would 
have  a  higher  percentage  of  cures  for  his  statistics,  but  he  would  have  sacrificed  to 
statistical  glory  these  4  cases.  If  there  be  the  slightest  doubt  of  the  diagnosis,  make 
an  exploratory  incision  before  making  the  incisions  for  the  removal  of  the  breast 
(see  Dawbarn's  remarks  on  the  deceptive  signs  given  by  thick- walled  abscesses, 
in  the  "Annals  of  Surgery," March,  1908).  A  frozen  section  can  be  made  and 
examined  m  a  few  minutes,  and  this  procedure  is  demanded  in  a  doubtful  case. 
If  the  mass  proves  to  be  cancer,  I  always  pack  in  a  piece  of  gauze  from  which  boil- 
ing water  has  just  been  squeezed  and  go  on  at  once  with  the  removal  of  the  breast. 
As  Dawbarn  shows,  this  method  seals  up  the  open  mouths  of  lymphatics.  A 
radical  operation  should  remove  the  breast  and  much  of  the  skin  above  it,  the 
pectoral  fascia,  the  pectoral  muscles,  the  fat  and  glands  of  the  axilla,  and  the 
fascia  over  tiie  serratus  magnus.  As  Cheyne  says,  remove  all  the  glands  along 
the  axillary  vein  and  lift  up  the  vein  at  the  apex  of  the  axilla  and  remove  the 


Halsted's  Operation  for  Carcinoma  of  the  Mammary  Gland    1589 

glands  and  fat  behind  it.  The  sheath  of  the  vein  should  always  be  removed. 
Cheyne  points  out  that  the  line  of  spread  must  be  traced  upward  along  the  ves- 
sels and  nerves  and  downward  along  the  external  respiratory  nerve  of  Bell 
("Lancet,"  March  12,  1904).  Cancer  of  the  male  breast  is  to  be  treated  exactly 
as  is  cancer  of  the  female  breast.  If  three  years  after  an  operation  there  has  been 
no  return,  we  regard  the  case  as  cured  (Volkmann's  Hmit).  As  a  matter  of  fact, 
recurrences  are  noted  after  five  years,  and  this  limit  should  be  used  instead  of 
three  years.  It  is  true  that  80  per  cent,  of  those  passing  the  three-year  limit 
remain  free  from  recurrence.  Over  90  per  cent,  of  those  passing  the  five-year 
limit  remain  free.  Coley  reported  65  cases  of  recurrence — 15  per  cent,  recurred 
after  three  years  and  6  per  cent,  after  fourteen  years.  Ransohoflf  collected 
10  cases  of  recurrence  during  the  seventh  and  eighth  years,  2  each  after  the 
ninth,  tenth,  eleventh,  twelfth,  and  fifteenth  years,  and  i  each  after  various 
intervals,  from  fifteen  to  twenty-five  years.  Martin  suggests  that  these  later 
so-called  recurrences  are  really  new  growths  in  persons  predisposed  to  cancer 
("Annals  of  Surgery,"  Oct.,  1908).     Certain  cases  are  unsuitable  for  a  radical 


Fig.  1092. — Halsted's  operation  for  carcinoma  of  the  breast:  The  first  incision. 

operation:  cases  in  which  metastases  exist;  cases  of  cancer  en  cuirasse;  cases 
with  mediastinal  involvement;  cases  where  axillary  involvement  is  very  great. 
Cheyne  would  also  rule  out  cases  in  which  large  glands  may  be  felt  above  the 
clavicle,  believing  that  in  such  cases  the  mediastinal  glands  must  be  cancerous.^ 
Operation  is  well-nigh  useless  for  carcinoma  mastitoides. 

Halsted's  Operation. — Halsted  performs  a  very  radical  operation.  He 
removes  suspected  tissue  in  one  piece,  and  thus  prevents  carcinoma  cells  from 
falling  into  the  wound,  for  it  is  well  known  that  if  such  cells  fall  into  the  wound 
they  may  grow  just  as  may  a  graft  of  healthy  epithelium.  The  neck,  shoulder, 
arm  to  the  elbow,  the  entire  surface  of  the  chest  down  to  the  waist,  both  breasts, 
the  axilla,  the  side  and  the  back  of  the  diseased  side  must  be  sterilized.  It  is 
necessary  to  have,  besides  scalpels  and  the  ordinary  instruments  for  an  opera- 
tion, a  great  number  of  hemostatic  forceps  (80  to  100).  Place  the  patient 
recumbent,  with  a  sand-pillow  under  the  shoulder  of  the  affected  side.  The 
shoulder  is  right  at  the  edge  of  the  table  and  a  nurse  holds  the  arm  from  the 
side,  keeping  it  at  a  right  angle  with  the  body.  Halsted's  operation  is  performed 
as  follows:-  The  skin-incision  is  made  as  shown  in  Fig.  1092,  and  is  carried  at 
once  through  the  fat.  The  triangular  skin-flap  (a,  h,  c)  is  turned  down.  The 
costal  insertions  of  the  great  pectoral  muscle  and  the  muscle  are  spUt  between 

1  See  "Objects  and  Limits  of  Operation  for  Cancer,"  by  W.  Watson  Cheyne. 

2  "Johns  Hopkins  Hosp.  Reports,"  vol.  iv;  "Annals  of  Surgery,"  Nov.,  1894. 


I590 


Diseases  of  the  Mammary  Glands 


the  clavicle  and  costal  portions  and  up  to  a  point  opposite  to  the  scalene  tuber- 
cle, and  at  this  point  the  clavicular  portion  of  the  muscle  and  the  tissue  over- 
lying it  are  cut  through  close  to  the  clavicle,  and  the  apex  of  the  axilla  is  at 
once  exposed.  The  cellular  tissue  under  the  clavicular  portion  of  the  muscle  is 
dissected  from  the  muscle,  and  the  splitting  of  the  muscle  is  continued  on  to  the 


Fig.  1093. — Halsted's  operation  for  carcinoma  of  the  breast:  The  mass  turned  down. 

humerus.  The  part  of  the  muscle  to  be  removed  is  cut  through  close  to  its 
humeral  insertion.  The  whole  mass  circumscribed  by  the  first  incision  (skin, 
breast,  areolar  tissue,  and  fat)  is  raised  with  considerable  force  in  order  to  put 
the  submuscular  fascia  on  the  stretch  as  it  is  stripped  from  the  thorax  close  to 
the  ribs.  It  is  well  to  include  the  delicate  sheath  of  the  pectoralis  minor  mus- 
cle. The  lower  and  outer  boundary  of  the  lesser 
pectoral  having  been  passed  and  exposed,  the 
muscle  is  cut  at  a  right  angle  to  its  fibers  and  a 
little  below  the  middle.  The  tissue  over  the  pec- 
toralis minor  muscle  near  its  coracoid  insertion  is 
divided  as  far  out  as  possible,  and  is  then  reflected 
inward  to  prepare  for  the  reflection  upward  of  this 
part  of  the  minor  muscle.  The  upper  portion  of 
the  minor  muscle  is  retracted  upward.  Some  sur- 
geons do  not  remove  the  lesser  pectoral  muscle.  I 
believe  it  should  be  removed,  because  the  axilla  can 
then  be  more  easily  and  rapidly  cleared.  The  re- 
moval of  the  muscle  does  not  impair  arm  move- 
ments, and  its  retention  leads  to  the  formation, 
when  healing  is  complete,  of  a  cord-like  band  in 
front  of  the  axilla.  (See  Douglas  Drew,  in  "Brit. 
Med.  Jour.,"  May  17,  1902,)  The  smah  blood- 
vessels under  the  minor  muscle  are  carefully  sepa- 
rated from  it,  are  dissected  out  very  clear,  and  are 
ligated  close  to  the  axillary  vessels.  Having  ex- 
posed the  subclavian  vein  at  the  highest  possible 
point  below  the  clavicle,  the  contents  of  the  axilla  are 
dissected  away  with  a  sharp  knife  and  the  vein  and  its  branches  are  stripped 
absolutely  clean.  The  loose  tissue  about  the  artery  and  the  nerves  should  also 
be  removed.  When  the  vessels  are  cleared,  the  axillary  contents  are  rapidly 
stripped  from  the  inner  walls  of  the  axilla  and  the  lateral  wall  of  the  thorax 
(Fig.  1093).  The  fascia  which  binds  the  mass  to  the  chest  is  cut  loose  from  the 
ribs  and  the  serratus  magnus  muscle.     Just  before  reaching  the  junction  of  the 


Fig.  1094. — The  younger 
Senn's  incision  for  amputa- 
tion of  the  breast. 


Halsted's  Operation  for  Carcinoma  of  the  Mammary  Gland    1591 


posterior  and  lateral  walls  of  the  axilla  an  assistant  draws  the  triangular  flap 
of  skin  outward  in  order  to  spread  out  the  tissue  which  lies  upon  the  subscapu- 
laris,  teres  major,  and  latissimus  dorsi  muscles.  The  operator  cleans  the  pos- 
terior wall  of  the  axilla  from  within  outward.  The  subscapular  vessels  are 
clearly  exposed,  and  are  caught  before  they  are  cut.  In  some  cases  the  sub- 
scapular nerves  are  removed,  in  others  they  are  permitted  to  remain.  Having 
passed  these  nerves,  the  mass  is  turned  back  into  its  normal  position  and  severed 


Fig.  1095. — Jabez  N.  Jackson's  incision 
for  removal  of  the  mammary  gland. 


Fig.  1096. — Alethod  of  approximating  flaps  after 
breast  amputation. 


from  the  body  of  the  patient  by  a  stroke  of  the  knife  from  b  to  c,  repeating  the 
first  cut  through  the  skin.  Every  bleeding  point,  however  small,  is  tied  with  fine 
silk.     From  60  to  100  ligatures  or  even  more  may  be  required. 

After  the  completion  of  the  operation  the  wound  into  the  axilla  is  closed  with 
a  subcuticular  stitch  of  silver  wire;  if  a  cut  has  been  carried  above  the  clavicle, 
it  is  closed  in  the  same  manner,  and  the  edges 
of  the  elhptical  opening  are  brought  nearer  to- 
gether by  a  purse-string  subcuticular  stitch. 
Thiersch  grafts  cut  from  the  patient's  thigh 
are  used  to  cover  the  gap.  Silver-leaf  is  placed 
over  the  wound,  this  is  covered  with  gauze, 
bandages  are  appHed,  and  the  dressing  is 
overlaid  by  a  plaster-of-Paris  bandage,  which 
includes  the  head,  neck,  chest,  and  arm.  The 
area  from  which  grafts  have  been  taken  is 
dressed  with  sterile  gauze  or  an  ointment  con- 
taining boric  acid. 

Formerly  I  did  not  open  the  subclavian 
triangle.  I  believed  that  these  glands  were 
involved  from  the  axillary  lymphatics  only, 
that  when  they  were  involved  the  mediastinal 
glands  were  sure  to  be  affected  (the  route  to 
them  being  more  direct)  and  that  operation  was  certain  to  be  useless.  When  the 
subclavian  glands  are  involved  from  the  axillary  lymphatics  this  is  true,  but  in 
some  cases  they  are  in volv  ed  by  way  of  the  direct  lymph  paths  from  the  mam- 
mary gland.  In  such  a  case  the  mediastinal  glands  may  be  free,  and  cleaning 
out  the  subclavian  triangle  may  save  the  patient.  I  always  open  the  subclavian 
triangle  and  clear  out  fat  and  glands  if  no  glands  or  only  a  few  small  glands 
have  been  palpable  before  operation.  If  there  be  a  large  glandular  mass  in 
the  triangle,  operation  is  useless.  I  always  open  the  triangle  if  the  tumor  of  the 
mammary  gland  is  in  the  upper  hemisphere,  or  if  I  discover  enlarged  glands 
at  the  apex  of  the  axilla,  whether  there  are  or  are  not  small  palpable  glands 


Fig.  1097. — Warren's  incision  for  re- 
moval of  the  mammary  gland. 


1592 


Diseases  of  the  Mammary  Glands 


above  the  clavicle.     An  .t-ray  examination  of  the  mediastinum  should  be  made, 
before  deciding  upon  operation  (see  page  i6i 2). 

The  Younger  Senns  Incision. — A  very  useful  incision  is  that  described 
by  the  younger  Senn,  and  shown  in  Fig.  1094.  The  breast  is  circumscribed 
bv  two  curvilinear  incisions  which  meet  above,  at  the  border  of  the  great  pec- 
toral muscle.  The  incision  is  continued  a  little  internal  to  the  outer  border  of 
the  muscle  to  about  i  inch  above  the  apex  of  the  axilla,  when  it  is  curved  out- 
ward in  the  deltoid  region,  and  terminates  at  the  level  of  the  apex  of  the  axilla. 
The  breast  is  removed  from  the  wall  of  the  chest,  and  is  then  suspended  by 
axillary  glands  and  fat,  which  are  removed  en  masse}  This  ihcision  gives  a 
free  exposure,  opens  the  axilla  from  in  front,  enables  the  surgeon  quickly  to 
locate  and  freely  to  expose  the  axillary  vein,  and  the  resulting  scar  does  not 
materially  limit  the  motions  of  the  arm. 


Fig.  1098. — Willy  Meyer's  operaiiun  fur  carcinoma  of  the  breast. 

since  1808. 


Skin  incision  as  practised 


Jackson's  incision  (Jabez  N.  Jackson,  "Jour.  Amer.  Med.  Assoc,"  March  5, 
1906)  is  shown  in  Fig.  1095.  The  axilla  is  entered  from  above,  a  quadrilateral 
flap  of  skin  is  raised,  and  is  subsequently  pulled  down  to  inclose  the  wound  (Fig. 
1096). 

Warren^ s  incision  is  shown  in  Fig.  1097.  It  enables  the  surgeon  to  close  the 
wound, 

Willy  Meyer's  Operation  ("Jour.  Amer.  Med.  Assoc,"  July  29,  1905). — 
For  the  last  few  years  I  have  been  performing  the  operation  devised  by  Willy 
Meyer.  I  consider  it  a  most  excellent  procedure,  with  distinct  points  of  super- 
iority over  other  plans.  We  owe  to  Gerster  the  principal  of  opening  the  axilla 
in  the  beginning  of  the  operation  in  order  to  prevent  the  diffusion  of  cancer 
cells  and  thus  diminish  the  chance  of  rapid  recurrence.  Gerster's  paper  was  pub- 
lished in  the  "Amer.  Jour.  Med.  Sci."  in  i888.  The  younger  Gross,  in  his  later 
^  See  the  younger  Senn  in  "Jour.  Amer.  Med.  Assoc,"  May  27,  1899. 


Meyer's  Operation  for  Carcinoma  of  the  Mammary  Gland    1593 

years,  used  to  open  the  axilla  first  when  there  was  an  axillary  mass,  but  he  did 
it  in  order  to  determine  in  the  beginning  of  the  operation  if  the  axillary  mass  was 
really  removable.  Willy  Meyer  emphasizes  the  value  of  his  procedure  in  les- 
sening hemorrhage.  In  Meyer's  operation  two  flaps  are  formed  by  the  skin- 
incision  (Fig.  1098) — a  lower  and  an  upper  flap.  The  incision  for  the  formation 
of  the  lower  flap  begins  at  the  point  of  insertion  of  the  great  pectoral  muscle 
on  the  humerus,  and  is  carried  downward  and  inward  3-^  inch  above  the  border 
of  the  muscle  and  parallel  to  it.  When  the  incision  reaches  the  base  of  the 
mammary  gland,  it  is  carried  along  the  lower  margin  of  the  gland,  and  it  ends 
over  the  sternum,  a  little  beyond  the  midline  (Fig.  1098).  The  lower  flap  is 
separated  and  turned  down,  a  quantity  of  subcutaneous  fat  being  allowed  to 
remain  attached  to  the  breast.  This  turning  down  is  carried  to  the  border 
of  the  latissimus  dorsi  muscle,  to  the  axillary  cavity,  and  to  the  chest  wall. 


Fig.  1099. — Willy  Meyer's  operation  for  carcinoma  of  the  breast.     Insertion  of  pectoralis 
major  muscle  exposed.     Operator's  left  index-finger  encircling  its  tendon. 

Meyer  then  directs  that  the  border  of  the  latissimus  dorsi  be  followed  down  to 
the  serratus  anticus  major,  and  upward  to  the  mass  of  fat  that  enters  the  bicipi- 
tal sulcus  of  the  arm.  The  fat  is  removed  from  the  anterior  border  of  the  muscle 
by  blunt  dissection.     This  anterior  lower  wound  is  then  packed  with  gauze. 

The  surgeon  next  forms  the  upper  flap  by  uniting  the  inner  and  outer  ends 
of  the  first  incision  with  another  incision  carried  along  the  upper  margin  of 
the  breast  (Fig.  1098).  In  this  flap,  as  in  the  other,  the  surgeon  leaves  as 
much  subcutaneous  fat  adhering  to  the  breast  as  he  can  spare  without  in- 
ducing the  danger  of  skin  necrosis.  This  upper  flap  is  raised  progressively 
untU  the  cephalic  vein  is  reached  and  there  is  exposure  of  the  lower  surface 
of  the  clavicle  with  the  sternoclavicular  articulation.  Meyer  directs  that  the 
tissues  covering  this  articulation  shall  not  be  disturbed. 

After  the  formation  of  these  two  flaps  the  next  step  in  the  operation  is  the 
division  of  the  tendons  of  the  two  pectoral  muscles  and  the  exposure  of  the 


1594 


Diseases  of  the  Mammary  Glands 


axillary  and  subclavian  veins.  Meyer  advises  that  the  cephalic  vein  be  fol- 
lowed up  until  the  insertion  of  the  great  pectoral  muscle  into  the  humerus  is 
found.  The  tendon  is  fully  exposed,  care  being  taken  to  bare  it  of  axillarj' 
fat.  The  arm  is  then  carried  a  little  nearer  to  the  side  to  relax  the  great  pec- 
toral muscle.  This  tendon  is  cut  off  close  to  the  humerus  (Fig.  1099).  The 
muscle  is  pulled  downward  and  inward  and  is  loosened  from  the  cephaUc 
vein.  It  is  then  cut  off  near  the  lower  border  of  the  clavacle  and  the  sterno- 
clavicular articulation.  It  is  necessary  to  divide  the  nerves  that  enter  the  pec- 
toral muscle,  and  all  the  vessels  that  come  into  view  are  divided  between  two 
clamps  and  tied. 

The  next  step  is  to  divide  the  tendon  of  the  lesser  pectoral  muscle  near  the 
<;oracoid  process  (Fig.  iioo).  Just  beneath  this  tendon  lies  the  subclavian 
vein.  The  surgeon  now  makes  a  transverse  division  of  the  fascia  over  the 
axilla,  and  thus  exposes  the  axillary  and  subcla\ian  \eins  f^Fig.  iioi). 


Fig.  iioo. — Willy  Meyer's  operation  for  carcinoma  of  the  breast.  Finger  under  tendon 
of  pectoralis  minor  muscle.  Above,  cut  surface  of  clavicular  portion  of  pectoralis  major 
parallel  to  clavicle  is  visible  (in  the  living  the  bellj^  of  the  pectoralis  major  is  not  so  thoroughly 
detached  from  that  of  the  pectoralis  minor.     It  is  done  here  to  show  the  latter's  tendon). 

Meyer's  third  step  is  to  split  the  axillary  fat  over  the  upper  portion  of  the 
latissimus  dorsi  up  to  the  ax'llary  vein,  "thus  dividing  it  from  the  mass  of  fat 
that  enters  the  sulcus  bicipitalis  brachii." 

Next,  the  axillary  and  the  subclavian  veins  are  followed  up  to  where  the 
subclavian  passes  below  the  clavicle,  and  every  vessel  that  evidently  must  be 
cut  is  divided  between  two  Ugatures  and  tied.  This  procedure  saves  a  great 
amount  of  hemorrhage.  Meyer  directs  us  to  be  careful  to  preserve  the  two 
superior  subscapular  nerves,  although  the  third  subscapular  must  be  sacrificed. 

The  next  step  in  the  operation  is  to  have  the  assistant  hold  up  the  mass  of 
partly  loosened  tissues  without  pulling  upon  them;  for  if  he  does  pull  upon 
them,  Meyer  truly  says,  he  is  apt  to  tear  off  pieces  of  periosteum  or  perichon- 
drium ;  and  such  bare  spots  are  liable  to  become  necrotic.  The  surgeon  now  cuts 
to   the   wall   of   the   chest,  being  careful   not    to   damage   the  great  serratus 


Meyer's  Operation  for  Carcinoma  of  the  Mammary  Gland    1595 

muscle.  Meyer  cautions  us  at  this  step  to  hold  the  blade  of  the  knife  horizon- 
tal; that  is,  "perpendicularly  toward  the  thorax."  "If  he  (the  surgeon)  should 
not  thus  turn  the  blade  of  his  knife,  but  cut  perpendicularly  downward  toward 
the  subscapular  muscle,  he  would  enter  the  fat  covering  and  enveloping  the 
nerves  and  blood-vessels  of  this  region,  thus  running  the  risk  of  unnecessarily 
causing  considerable  hemorrhage  and  of  injuring  the  subscapular  nerves.  In 
the  general  run  of  cases  this  region  need  not  be  explored;  only  in  very  advanced 
cases  did  I  find  a  few  infected  glands  in  this  area." 

The  pectoralis  major  muscle  is  now  divided  close  to  the  wall  of  the  chest, 
the  cuts  being  parallel  to  the  ribs,  and  almost  level  with  them;  and  the  mass 
being  gently  drawn  toward  the  sternum.     By  watching  carefully,  one   may 


Fig.  iioi. —  Willy  Meyer's  operation  for  carcinoma  of  the  breast.  Subclavian  and  axillary 
veins  fully  exposed.  So  far,  glands  and  fat  tissue  not  removed;  smaller  vessels  still  in  connec- 
tion with  main  trunks.  Finger  under  fat  toward  sulcus  bicipitalis,  its  nail  resting  on  axillary 
vein. 


see  the  perforating  arteries  and  veins  drawn  out  by  traction  oefore  cutting 
them,  and  may  usually  catch  each  of  them  with  two  clamps  and  divide  be- 
tween the  clamps.  If  this  be  impossible,  they  are  divided  and  quickly  picked 
up.  The  last  tissue  that  holds  the  mass  to  the  chest  wall  is  composed  of  the 
muscle-fibers  from  over  the  sternum.  These  are  divided  close  to  the  sternum 
(Fig.  1102).  The  final  steps  consist  in  tying  all  blood-vessels,  draining,  and 
suturing  the  wound.  The  draining  is  done  through  a  perforation  in  the  pos- 
terior flap.  It  may  be  tubal  or  by  gauze.  Gauze  has  the  advantage  of  restrain- 
ing oozing  of  blood. 

This  operation  has  noteworthy  merits.  It  can  be  performed  far  more  rap- 
idly than  any  other  method  that  I  have  ever  employed.  The  loss  of  blood  is 
comparatively  trivial,  because  in  this  operation  the  chief  blood-vessels  are  di- 
vided early,  are  cut  close  to  the  axillary  artery,  and  are  tied.     In  removing  the 


1596 


Diseases  of  the  Mammary   Gland 


mass  from  the  chest  wall  there  is  Uttle  bleeding,  except  which  comes  from  the  perfo- 
rating vessels,  hemorrhage  from  the  branches  of  the  axillary  being  entirely 
absent;  and  even  many  of  these  perforating  vessels  are  tied  before  being  divided. 
We  are  far  less  apt  by  this  method,  than  by  the  usual  plan,  to  milk  lymph  which 
contains  cancer  cells  into  the  wound,  or  in  aberrant  directions  through  the 
lymphatics.  As  Dawbarn  says,  the  squeezing  "of  the  breast  by  the  retractors 
during  its  oblation,  as  also  its  handling  when  separated,  save  for  its  attachments 
to  the  armpit,"  are  real  dangers  and  may  be  responsible  for  rapid  recurrence  of 
the  growth  ("Annals  of  Surgery,"  March,  1908).  The  drain  is  removed  in  from 
thirty  six  to  forty-eight  hours.  The  patient  is  placed  in  a  sitting  posture  on 
emerging  from  ether  and  is  allowed  out  of  bed  on  the  fourth  or  fifth  day. 


Fig.  1 102. — Willy  Meyer's  operation  for  carcinoma  of  the  breast.     Pedicle  of  mass  over  ster- 
num ready  to  be  cut  off. 


Stewart's  Operation  (Figs.  1103-1107). — My  colleague  Prof.  Francis  T. 
Stewart  removes  the  breast  by  a  transverse  incision.  He  attacks  the  axilla 
first.  The  incision  gives  free  exposure,  does  not  pass  into  the  arm  or  across 
the  axilla  ( in  either  of  which  regions  a  scar  may  impair  function,  or  press  upon 
vessels  or  nerves),  and,  with  the  aid  of  extensive  undermining  can  nearly  always 
be  closed  ("Annals  of  Surgery,"  August,  1915). 

Dressing  and  After-treatment. — After  operating  for  cancer  the  dressing  must 
be  wide  and  ample.  Fluffed  up  gauze  is  pushed  into  the  axilla  to  obliterate 
the  dead  space  and  the  arm  is  bound  to  the  side  for  forty-eight  hours.  When 
the  binding  is  removed,  the  extremity  is  placed  on  a  pillow  in  a  position  of  mod- 
erate abduction,  and  is  abducted  a  little  more  each  day.  If  the  incision  has  been 
placed  well  above  the  axillary  border  the  mobility  of  the  arm  will  be  such  that 
in  two  weeks  the  patient  can  place  the  hand  on  the  back  of  the  head.  Of 
late  I  have  been  placing  the  arm,  immediately  after  the  operation,  in  abduction 
(upon  a  pillow  or  a  triangular  splint  which  rests  upon  the  side).     This  is  un- 


Stewart's  Operation  for  Carcinoma  of  the  Mammary  Gland       1597 


&k_ i   .■.  .    

Fig.  1 103. — Primary  incision.     The  towels  which  should  be  attached  to  the  margins  of  the 
wound  are  not  shown  (Stewart,  in  "Annals  of  Surgery.") 


'**' 

^ 


'~'^i 


^liiMifi  i\T*^     ih 


ti.> 


Fig.  1104. — Dissection  of  axilla  (Stewart,  in  "Annals  of  Surgery.") 


I59S 


Diseases  of  the  Mammary  Gland 


Fig.  1 105. — The  lower  incision  is  made  after  evacuation  of  the  axilla  (Stewart,  in  "Annals  of 

Surgery.") 


Fig.  1106. — Combined  retention  and  coaptation  suture.  The  needle  is  inserted  a  couple 
of  inches  from  the  edge  of  the  wound  (A)  and  brought  out  at  a  corresponding  point  on  the 
opposite  side  (B).  It  is  then  reinserted  close  to  the  wound  (C)  and,  on  emerging  from  a 
corresponding  point  on  the  opposite  side  (D),  is  passed  through  the  loop  E.  When  the  suture 
is  tied  (F)  the  edges  of  the  wound  are  held  firmly  together  and  inversion  of  the  skin  does  not 
occur  (Stewart,  in  "Annals  of  Surgery.") 


Beatson's  Operation,  or  Double  Oophorectomy  i599 

necessary  if  the  incision  does  not  run  on  to  the  arm  but  is  in  front  and  above 
the  anterior  axillary  margin.  If  the  old  incision  in  the  axilla  be  used,  abduction 
and  all  other  plans  will  fail  to  prevent  decided  limitation  of  movement. 

Inoperable  Malignant  Diseases  of  the  Breast. — This  term  implies 
that  a  radical  operation  looking  to  cure  is  impossible.  The  conditions  in 
which  it  is  impossible  have  already  been  specified  (see  page  1589).  Even  if  the 
case  be  judged  inoperable  from  the  radical  standpoint,  it  may  be  wise  to  re- 
move the  mammary  gland,  in  order  to  free  the  patient  from  a  hideous,  ulcer- 
ating area,  \ioleni  pain,  or  harassing  hemorrhage. 


t'iG.  1 107. — Incision  closed  (Stewart,  in  "Annals  of  Surgery.") 

It  has  been  suggested  that  some  cases  inoperable  by  ordinary  methods  may 
be  subjected  to  removal  of  the  entire  upper  extremity  or  to  disarticulation  at 
the  shoulder- joint  with  some  prospect  of  cure.  My  own  view  is  that  when 
a  case  has  advanced  so  far  that  it  is  not  amenable  to  ordinary  operative  treat- 
ment, neither  of  the  above-mentioned  procedures  offers  any  reasonable  chance 
of  success.  If  the  pain  is  extremely  \dolent  in  an  inoperable  case,  the  surgeon 
may)  reheve  it  by  dividing  the  brachial  plexus,  or  perhaps  by  disarticulating 
at  the  shoulder-joint. 

Some  inoperable  cases  may  be  greatly  improved — for  a  time,  at  least — by  the 
use  of  the  .x--rays;  and  even  when  the  condition  is  not  benefited  in  other  ways, 
this  force  sometimes  mitigates  or  greatly  relieves  the  pain.  It  is  said  that  in 
some  cases  radium  is  more  efficient  than  the  .x-rays,  but  it  is  probable  that 
most  improvements  by  radium  could  have  been  obtained  by  the  .T-rays.  In 
cases  of  lymphatic  recurrence  it  is  ad\T.sable  to  administer  thyroid  extract 
during  the  .x-ray  course  (Woods,  in  "Brit.  Med.  Jour.,"  July  i,  1911). 

Beatson's  Operation,  or  Double  Oophorectomy. — It  has  been  pointed 
out  by  Sir  George  Thomas  Beatson  that  there  is  a  certain  similarity  between 
the  formation  of  cancer  in  the  mammary  gland  and  the  process  of  lactation. 
In  each  there  is  an  enormous  production  of  embryonal  epithehal  cells;  but 
in  lactation  the  epithelial  cells  undergo  fatty  degeneration,  and  in  cancer 
formation  they  do  not  do  so,  but  penetrate  into  the  tubules  and  the  acini  and 


i6oo  The  X-rays  in  Surgery 

infiltrate  the  gland  structure.  Beatson  further  points  out  that  when  a  lac- 
tating  cow  is  spayed,  it  continues  to  give  milk  indefinitely.  This  seems  to 
indicate  that  removing  the  ovaries  favors  the  fatty  degeneraion  of  the  epi- 
thelial cells.  This  operation  has  been  performed  in  cases  of  inoperable  carci- 
noma of  the  breast  in  the  hope  of  bringing  about  degeneration  in  the  tumor 
mass.  In  the  great  majority  of  cases  it  fails  utterly;  but  now  and  then  it 
secures  a  notable  improvement,  and  in  a  very  few  cases  outward  evidence  of 
the  disease  disappeared,  the  general  health  improved,  and  there  was  gain  in 
weight.  The  cure  is  apparent,  but  not  real.  The  improvement  is  only  tem- 
porary. Abbe  obtained  an  apparent  cure  in  2  patients.  It  was  at  first  thought 
that  the  operation  would  only  be  applicable  to  persons  that  had  not  passed 
the  menopause,  but  one  of  Abbe's  patients  was  over  seventy  years  of  age. 
Butlin,  however,  says  that  there  is  no  genuine  cure  secured  by  this  operation  on 
record,  and  Beatson  makes  the  same  statement.  The  operation  is  not  to  be 
considered  if  visceral  deposits  exist.  My  own  view  is  that  the  procedure  offers 
but  little  prospect  of  success,  but  that,  as  it  does  offer  some,  the  exact  facts 
should  be  placed  before  the  patient,  and  she  should  be  permitted  to  choose 
whether  or  not  she  wishes  the  operation  performed. 

XL.     THE  X=RAYS  IN  SURGERY.     RONTQENOQRAPHY; 

RONTGENOSCOPY;  RONTGENTHERAPY ;  RADIUM 

AND  RADIOTHERAPY;  ELECTROCOAGULATION 

(Dr.  George  E.  Pf abler  did  me  the  honor  to  rewrite  this  section.) 

History  of  the  Rontgen  or  X-rays. — In  1858-59  Gessler  obtained  violet, 
blue  and  red  colors  by  passing  alternating  currents  through  glass  tubes  of  low 
vacuum  {/-iooo  o^  3-n  atmosphere).  The  cathode  rays  were  discovered  by 
Hittorf  in  1869,  while  passing  an  induction  current  through  a  vacuum  tube. 
Crookes,  of  London,  greatly  improved  the  vacuum  tube  and  obtained  a  rare- 
faction which  left  in  the  tube  but  one-millionth  of  an  atmosphere.  This  last- 
named  observer  found  that  when  an  interrupted  current  of  high  potential  is 
passed  through  a  vacuum  which  is  nearly  perfect,  fluorescence  takes  place.  In 
Crookes's  tube  the  positive  electrode  is  placed  at  some  indifferent  point,  and 
the  current  at  the  negative  electrode  produces  what  is  known  as  the  cathode 
stream  or  cathode  rays.  These  do  not  flow  toward  the  positive  pole  unless  it 
be  in  direct  line  with  the  stream  of  rays,  but  are  thrown  directly  toward  the 
opposite  wall  of  the  tube,  and  at  this  point  a  phosphorescent  glow  is  detected. 

In  1895  William  Konrad  Rontgen,  of  Wurzburg,  while  making  a  study  of 
cathode  rays  as  developed  in  Crookes's  tubes,  discoveed  the  energy  which  he 
named  the  x-rays.  Both  Jackson  and  Lenard  were  on  the  very  eve  of  making 
the  discovery  a  year  before.  Rontgen  while  at  work  was  called  from  the  room 
and  laid  an  energised  vacuum  tube  upon  a  book.  Within  the  book  was  a  key 
placed  there  as  a  marker  and  the  book  rested  upon  a  photograph  plate  holder 
containing  plates.  He  returned  to  the  laboratory,  removed  the  tube,  took 
some  plates  for  a  camera  trip,  departed,  and  took  some  pictures  outside.  When 
he  developed  the  plates  he  found  the  picture  of  the  key.  By  reproducing  the 
conditions  he  made  the  discovery  (E.  E.  Burns,  in  "Popular  Science  Monthly," 
1908).  Rontgen  showed  that  at  the  wall  of  the  Crookes  tube  opposite  the 
negative  electrode  a  new  and  hitherto  unknown  energy  was  generated.  Be- 
cause of  the  uncertain  character  of  this  energy  he  gave  to  its  manifestation  the 
name  of  the  x-rays  or  unknown  rays.  Since  then,  in  honor  of  their  discoverer, 
these  rays  are  more  generally  known  as  the  Rontgen  rays,  and  from  this  root 
word,  Rontgen,  the  other  words  used  have  been  derived,  and  are  as  follows: 
Rontgenology,  the  science  of  the  Rontgen  rays;  Rontgenography,  the  photo- 
graphic efifect  of  the  Rontgen  rays;  Rontgenoscopy,  the  use  of  the  Rontgen 


The  Production  of  the  X-rays  1601 

rays  in  fluoroscopy;  R6ntgentherap>',  the  use  of  the  Rontgen  rays  in  the  treat- 
ment of  disease,  etc. 

Physical  Properties  of  the  Rontgen  Rays. — The  Rontgen  rays  or  x-rays 
are  a  form  of  ethereal  vibration  akin  to  light,  but  of  extremely  short  wave  length, 
and  belong  to  the  invisible  portion  of  the  light  spectrum.  They  have  been  re- 
fracted by  passing  through  salt  crystal,  but  in  practical  work  they  can  be  neither 
refracted,  reflected  nor  concentrated,  nor  deflected  by  a  magnet.  The  rays 
cannot  be  polarized,  travel  with  the  velocity  of  light,  and  cause  fluorescence  in 
certain  substances,  notably  in  the  tungstate  of  calcium  (Edison),  platinocyanid 
of  barium  (Rontgen)  and  the  platinocyanid  of  potassium.  The  rays  have  a 
marvellous  power  of  penetration,  and  move  in  a  straight  line  from  their  source 
until  absorbed.  The  rays  are  absorbed  by  the  substance  through  which  they 
pass  in  proportion  to  the  density  and  thickness  of  the  object.  The  density  is 
measured  by  the  atomic  weights  of  the  elements  composing  the  object.  For 
example,  aluminum  is  of  low  atomic  weight,  and  lead  of  high  atomic  weight. 
Therefore,  aluminum  is  relatively  very  transparent  to  the  x-rays,  while  lead  is 
very  opaque,  but  since  the  thickness  of  a  body  comes  into  consideration  in 
estimating  the  total  absorption  it  is  possible  to  have  a  layer  of  aluminum  so 
thick  that  it  will  cast  as  much  shadow  as  a  thin  layer  of  lead.  The  above 
physical  observations  are  of  practical  importance  because  it  is  possible  to  place 
a  pin,  or  other  dense  body,  on  or  near  the  surface  of  a  thick  muscular  portion 
of  the  body,  such  as  the  thigh,  and  while  in  itself  it  is  very  dense  it  may  not  be 
demonstrable  on  a  photographic  plate  or  fluorescent  screen  if  the  part  be  ex- 
amined in  one  position  only  and  the  pin  be  on  the  opposite  side  from  the  plate  or 
the  screen.  It  is  the  property  of  differentiation  of  tissues,  according  to  their 
density,  which  makes  the  Rontgen  rays  of  value  in  medicine  and  surgery.  The 
bones  are  relatively  opaque  as  compared  with  the  surrounding  soft  tissue  be- 
cause of  their  greater  density,  the  density  being  due  chiefly  to  the  calcium  salts. 
Even  soft  tissues  can  be  differentiated  if  there  be  any  variation  in  their  density. 
For  example,  the  heart  can  be  seen  clearly  because  it  is  surrounded  by  air  con- 
taining lung  tissue. 

The  Production  of  the  X=rays. — The  production  of  the  x-rays  depends 
upon  the  passage  of  a  high  tension  current  through  an  .x-ray  tube.  This 
high  tension  electric  current  may  be  generated  from  a  static  machine  which  is 
obsolete  because  impractical  or  from  an  induction  coil,  which  for  many  years 
was  used  almost  exclusively  and  is  still  used  for  small  outfits,  but  the  high  ten- 
sion transformer  is  more  efficient  and  is  now  most  generally  employed.  The 
high  tension  current  used  is  equivalent  to  about  25,000  to  100,000  volts.  In 
general,  diagnostic  work  from  50  to  60,000  volts  are  used,  and  in  deep  treatment 
approximately  90,000  volts  are  generaUy  used.  In  diagnostic  work  from 
5  to  100  milliamperes  of  current  are  used,  but  generally  about  30  miUiamperes. 
In  treatment  work  5  milliamperes  are  used  as  a  rule. 

The  x-ray  tube  consists  of  a  glass  bulb  from  which  all  but  about  one-miUionth 
of  the  air  has  been  exhausted.  It  contains  at  least  two  metal  terminals,  one 
called  the  cathode  and  the  other  the  target  or  anode.  There  are  two  main 
t^pes  of  tubes  in  existence  and  in  use  today;  the  gas  tube  and  the  Coolidge  tube. 
The  gas  tube  is  approximately  6  to  7  inches  in  diameter,  and  from  it  all  but  about 
one-millionth  of  the  atmospheric  air  or  other  gas  has  been  removed.  The  re- 
maining atoms  of  air  in  the  tube  are  essential  for  the  production  of  the  x-rays. 
Under  continued  use  these  remaining  atoms  of  gas  become  exhausted  and  it  is 
then  necessary  to  find  some  means  for  the  introduction  into  this  same  bulb  of 
other  molecules  or  atoms  of  gas,  and  for  this  purpose  is  attached  a  regulator 
which  is  a  device  for  introducing  a  smaU  quantity  of  gas  as  needed.  When  a 
high  tension  current  of  electricity  is  passed  through  one  of  these  tubes,  the  atoms 
of  gas  remaining  in  the  tube  are  di\dded  or  separated  into  their  corpuscles  or 
electrons,  and  those  electrons  are  propelled  from  the  negative  pole  or  cathode, 
101 


i6o2  The  X-rays  in  Surgery 

in  straight  hnes  from  the  surface  of  the  cathode  toward  the  target  or  anode 
of  the  tube.  The  cathode  of  the  tube  is  usually  cup-shaped,  and  therefore, 
as  these  electrons  are  propelled  in  straight  lines  from  the  surface,  they  become 
focused  upon  the  target  of  the  tube.  This  point  of  focusing  is  spoken  of  as 
the  focal  point,  and  the  impact  of  these  electrons  upon  this  target  is  the  cause 
of  the  production  of  these  ethereal  waves  which  are  similar  to  light,  but  of  much 
shorter  length  and  are  spoken  of  as  the  x-rays  or  the  Rontgen  rays.  When  the 
x-rays  coming  from  one  of  these  tubes  have  slight  powers  of  penetration,  they 
are  said  to  be  ''soft,"  and  the  tube  is  said  to  be  "low."  When  the  rays  have 
great  penetrative  power  they  are  said  to  be  "hard"  and  the  tube  is  said  to  be 
"high."  Between  these  two  extremes  we  speak  of  "medium  rays"  and  a 
"medium  tube."  Gas  tubes  are  objectionable  because  of  the  difficulty  in 
keeping  the  proper  amount  of  gas  in  the  tube,  and  thereby  in  keeping  the 
penetrative  value  of  the  light  constant.  The  impact  of  these  electrons  from 
the  cathode  terminal  of  the  tube  against  the  target  produces  great  heat.  This 
heat  causes  an  expulsion  of  gas  from  the  target  of  the  tube  and  this  increase  in 
the  amount  of  gas  in  the  tube  lowers  the  vacuum  and  produces  softer  rays. 
On  account  of  the  great  difficulty  in  keeping  the  rays  in  a  gas  tube  uniform  in 
penetrative  value  the  hot  cathode  tube  was  developed  by  W.  D.  Coolidge, 
and  is  now  generally  known  as  the  Coolidge  tube. 

It  was  found  that  when  a  metal  had  been  heated  to  a  white  heat  electrons 
were  given  off.  Therefore,  Coolidge  in  the  Research  Laboratory  of  the  General 
Electric  Co.  developed  a  tube  from  which  approximately  all  of  the  gas  had  been 
removed,  even  the  residual  gas  in  the  metal  terminals.  In  order  that  there 
might  be  electrons  in  the  tube  for  working  purposes,  he  introduced  a  tungsten 
filament  similar  to  the  filament  in  the  electric  hght  bulbs.  When  this  filament 
is  heated  to  a  white  heat  electrons  are  given  off,  and  by  regulating  the  amount 
of  heat  passing  through  this  filament,  just  as  the  amount  of  electricity  is  regu- 
lated as  it  passes  through  the  filament  of  the  ordinary  electric  light  bulb,  by 
means  of  a  rheostat,  the  degree  of  the  heat  of  the  filament  is  controlled  and 
therefore  the  number  of  electrons  given  off  are  controlled.  In  this  way  one  can 
compel  this  Coolidge  tube  to  produce  any  kind  of  penetrative  light  continuously, 
and  uniformly.  Its  chief  disadvantage  is  the  difficulty  of  bringing  these  con- 
verging electrons  to  a  sharp  focal  point.  The  second  disadvantage  is  that  this 
tube  produces  more  secondary  radiation  or  vagrant  rays  than  the  gas  tube. 
However,  because  of  its  convenience  in  handling,  and  its  constant  rays  it  is 
gradually  replacing  the  gas  tube  in  most  work.  It  has  entirely  replaced  the 
gas  tube  for  therapeutic  work.  In  therapeutic  work  the  sharp  focus  is  not 
essential  and  the  vagrant  rays  are  less  objectionable. 

Properties  of  the  X=rays. — The  four  great  properties  of  the  x-rays  which 
are  of  interest  in  surgery  are,  first,  the  effect  on  photographic  plates;  second,  the 
fluorescence  produced  in  certain  substances;  third,  secondary  radiation;  fourth, 
the  biological  effect,  or  its  curative  properties  in  various  diseases. 

The  photographic  effects  are  very  similar  to  those  of  light,  excepting  that 
the  x-rays  or  Rontgen  rays  have  the  power  of  penetrating  objects  which  are 
opaque  to  sunlight,  and  are  recorded  upon  the  plate,  in  inverse  proportion  to  the 
density  of  the  subject  through  which  the  rays  are  passing.  This  photographic 
effect  is  a  record  of  the  differentiations  of  the  various  densities  of  the  object 
under  examination.  For  instance,  the  greatest  effect  upon  the  photographic 
plate  will  be  shown  where  the  rays  have  to  pass  chiefly  through  air.  The  next 
greatest  effect,  or  amount  of  photographic  deposit,  will  be  shown  where  the  rays 
pass  chiefly  through  soft  tissues,  and  least  effect  of  all  through  solid  objects  such 
as  bone  or  metal.  With  great  skill  the  finest  kind  of  differentiations  can  be  made 
in  the  tissues  of  the  body,  such  as  the  tissues  of  the  head,  the  details  of  bone,  etc., 
and  the  soft  tissues  of  the  chest  and  abdomen.  Any  kind  of  photographic  plates 
can  be  used  but,   usually,  plates  are  specially  prepared  for  this  work,  and  are 


The  Biological  Effects  of  the  Rontgen  Rays  1603 

generally  doubly  coated.  They  are  developed  in  the  ordinary  manner.  They 
must  be  protected,  during  the  exposure  to  the  Rontgen  rays,  from  ordinary 
light  and  are  therefore  covered  with  a  black  envelope  and  then  an  orange  en- 
velope, or  are  [placed  in  an  aluminum  or  hber  casing,  "Kassette." 

Fluorescence. — The  .v-rays  ha\'e  the  proi)erty  of  causing  fluorescence  in  a 
number  of  substances,  but  those  most  commonly  used  are  barium  platinocyanide 
and  tungstate  of  calcium.  These  two  substances  become  fluorescent  under  the 
action  of  the  rays  but  of  course  must  be  seen  and  studied  in  a  dark  room,  or  at 
least  with  all  ordinary  light  shut  out  from  the  screen  by  means  of  a  hood  during 
the  course  of  the  examination.'  Upon  this  fluorescent  screen  the  same  sort  of 
dift'erentiation  of  tissues  can  be  seen  as  is  shown  upon  the  photographic  plate. 
For  instance,  with  such  a  fluoroscope  for  use  in  a  lighted  room,  or  with  a  fluores- 
cent screen  in  a  dark  room,  one  can  see  the  movements  of  the  heart,  the  move- 
ments of  the  chest,  the  movements  of  the  lungs  and  diaphragm.  One  can 
also  study  the  action  of  the  stomach  and  the  bowels.  It  is  of  especial  use 
in  the  study  of  movable  organs,  though  some  valuable  information  can  be 
obtained  in  the  localization  of  foreign  bodies,  and  in  the  setting  of  fractures. 
The  use  of  the  fluoroscope  is,  generally  speaking,  dangerous,  and  the  beginner 
must  be  especially  cautioned  against  burning  the  patient  from  too  much  ex- 
posure, but  especially  against  burning  his  own  hands  and  face.  There  is 
no  sensation  from  the  .v-ra}-s  and  one  can  do  great  damage  to  the  skin  of  the 
patient  or  the  operator  without  feeling  any  immediate  effects.  In  order  to 
do  good  fluoroscopic  work,  it  is  necessary  for  the  observer  to  be  in  a  dark  room 
for  approximately  fifteen  minutes  before  the  examination,  during  which  time  the 
retina  becomes  sensitive  to  the  faint  light,  for  this  fluorescent  effect  on  the  screen 
is  not  brilliant,  and  unless  the  retina  is  sensitive  much  detail  is  lost  and  accurate 
diagnosis  is  generally  impossible.  For  this  reason  patients  for  fluoroscopic  work 
should  be  sent  in  groups.  Fluoroscopic  examinations  are  generally  unreliable 
in  the  diagnosis  of  fractures  and  "line"  fractures  or  doubtful  fractures  are  often 
overlooked.     There  should  always  be  plates  made  when  a  fracture  is  suspected. 

Secondary  Radiation. — In  the  neighborhood  of  an  x-ray  tube  all  objects 
through  which  the  rays  pass  give  off  secondary  radiation.  The  secondary  radia- 
tion is  relatively  feeble,  probably  not  more  than  3^5  00th  of  the  value  of  the 
primary  radiation,  but  it  is  at  least  a  very  disturbing  factor  and  we  may  learn 
later  that  it  may  also  be  a  dangerous  or  harmful  factor.  The  air,  objects  in  the 
room,  human  bodies,  every  object  through  which  the  rays  pass  become  radio- 
active, and  give  off  these  secondary  radiations.  Therefore,  one  may  be  thor- 
oughly protected  from  direct  radiation  from  the  tube,  and  yet  not  sufficiently 
protected  against  the  secondary  radiation.  Up  to  the  present  time,  no  ill  effect 
has  been  observed  from  these  secondary  radiations,  excepting  that  they  tend  to 
fog  photographic  plates  and  give  or  render  more  obscure  the  fluorescent  image 
on  the  screen. 

The  biological  effects  of  the  Rontgen  rays  and  radium  are  especially  im- 
portant from  the  standpoint  of  physiology  and  therapeutics.  If  used  in  like 
quantities  and  qualities  the  effects  of  the  Rontgen  rays  and  radium  are  very 
similar,  and  probably  identical.  The  effect  of  the  rays  on  the  tissues  of  the  hu- 
man body  depends  first  upon  the  quantities,  secondly  upon  the  quahty  of  rays 
used,  and  thirdly  upon  the  sensibility  of  the  cells  under  exposure.  In  general,  a 
small  quantity  of  radiation  has  a  stimulating  effect  upon  the  cells  of  the  body 
and  even  upon  the  cells  of  growing  plants  (Albers-Schonberg)  but  very  quickly 
the  effect  passes  from  one  of  stimulation  to  destruction,  and  in  most  instances, 
when  the  rays  are  used  for  therapeutic  purposes,  it  is  the  inhibitory  or  de- 
structive effect  which  is  sought.  In  general  the  embryonic  cell  is  the  most 
sensitive  to  the  rays,  and  this  effect  is  due  to  the  chemical  or  actinic  action  of 
the  rays.  In  general,  the  glandular  cells  are  the  most  sensitive  of  any  in  the 
body  because  they  are  most  highly  specialized,  and  of  the  glandular  cells  the 


i6o4  The  X-rays  in  Surgery 

most  active  are  the  generative  cells  of  the  ovaries  and  testicles.  Next  to  these 
are  those  of  the  spleen,  the  thyroid  gland  and  thymus,  the  lymphatics  and  the 
liver.  Next  in  order  in  sensibility  are  the  tissues  of  the  body,  the  protective 
covering  of  the  skin  and  mucous  membrane,  the  connective  tissue,  the  lining  of 
the  blood-vessels,  and  probably  most  resistant  of  all  in  the  body  is  the  nervous 
tissue.  It  is  because  the  carcinoma  cell  approaches  the  embryonic  type  that 
it  is  more  sensitive  than  the  surrounding  tissues,  and  it  is  for  this  reason  that  the 
malignant  cells  in  the  body  yield  more  readily  and  become  effected  by  the  rays 
even  though  the  surrounding  tissues  show  little  or  no  effect.  If  it  were  not  for 
this  increased  sensibility  of  the  malignant  cells,  we  would  not  be  able  to  cause  a 
disintegration  or  disappearance  of  a  carcinoma  excepting  by  destruction  of 
the  entire  tissue.  This  specialized  effect  has  been  seen  by  almost  every  one 
who  has  had  the  opportunity  of  watching  the  therapeutic  action  of  the  rays. 
In  an  epithelioma  of  the  skin,  for  example,  one  notices  under  the  action  of  the 
rays,  which  are  appHed  at  intervals,  that  the  tumor  tissue  is  gradually  absorbed 
sometimes  without  breaking  down,  or  the  tumor  tissue  undergoes  degeneration 
and  disappears,  while  the  surrounding  skin  which  had  been  exposed  to  an  equal 
amount  of  radiation  shows  little  or  no  effect.  It  must  be  borne  in  mind  that 
the  action  of  the  rays  is  always  greater  on  the  surface  of  the  skin  excepting  in 
so  far  as  the  tissues  are  influenced  by  the  increased  sensibility.  Almost  50 
per  cent,  of  the  rays  are  absorbed  in  the  first  cm.  of  tissues.  It  is  therefore 
readily  understood  that  the  greatest  effect  will  be  shown  on  the  surface,  other 
things  being  equal,  but  because  of  the  greater  sensibility  of  certain  tissues,  such 
as  the  highly  sensitive  glandular  organs,  for  example  the  testicles  and  ovaries, 
it  is  possible  in  these  organs  to  produce  a  decided  inhibitive  or  destructive 
effect  without  showing  the  slightest  change  in  the  overlying  skin.  The  relative 
effect  on  the  overlying  as  compared  with  that  on  the  deeper  tissues  can  be  de- 
creased by  present-day  filtration  and  cross-firing.  This  filtration  was  begun, 
so  far  as  the  .r-rays  are  concerned,  in  1906,  at  which  time  Pfahler  argued  that 
if  the  greater  portion  of  the  rays  are  absorbed  in  the  first  cm.  of  tissue,  that  if 
one  introduce,  between  the  skin  and  the  tube,  tissue  resembling  the  skin  that  the 
greater  portion  of  the  rays,  which  would  otherwise  be  absorbed  by  the  skin,  would 
be  removed.  Therefore,  the  skin  would  receive  considerable  protection.  Ex- 
periments were  carried  out  with  the  skin  of  a  living  rabbit.  In  this  experiment 
he  exposed  an  area  on  the  back  of  the  rabbit  about  3  inches  in  diameter.  One- 
half  of  this  area  was  covered  by  a  layer  of  sole  leather.  As  a  result  of  the  ex- 
posure, which  was  given  sufficiently  long  to  produce  a  burn,  the  area  unpro- 
tected by  the  sole  leather  developed  a  slough  which  involved  the  entire  skin, 
while  the  area  protected  by  the  sole  leather  did  not  even  remove  the  hair.  This 
was  very  convincing  as  to  the  protective  value  of  filtration.  Since  this  time, 
however,  the  power  of  the  Rontgen  rays  has  been  increased  to  such  a  consider- 
able extent  that  Rontgenologists  now  use  from  2  to  6  mm.  of  aluminum  for 
filtration  and  thus  increase  the  value  of  the  deep  radiation. 

The  amount  of  exposure  or  treatment  that  can  be  given  over  any  area  of  skin 
is  spoken  of  as  a  ''skin  dose,^'  referring  to  the  limit  of  toleration  of  the  skin  to  a 
given  amount  of  radiation.  This  limit  of  toleration  is  indicated  by  an  erythema. 
Therefore,  the  dose  is  often  spoken  of  as  an  "erythema  dose."  An  "erythema 
dose"  not  only  produces  erythema  but  when  given  over  an  area  of  the  body  cov- 
ered by  hair  will  produce  epilation — "epilation  does."  The  amount  of  radiation 
that  can  be  given  to  the  deeper  tissues,  is  of  course  greatly  increased,  probably 
four  times,  by  means  of  filtration  through  6  mm.  of  aluminum.  It  is  advisable 
never  to  produce  even  an  erythema  of  the  skin  because  of  the  dangers  which  may 
develop  a  year  or  more  after  this  exposure.  Clinically  the  changes  to  be 
noticed  as  a  result  of  excessive  exposure  to  the  Rontgen  rays  or  radium  may  be 
divided  into  three  or  four  phases.  A  so-called  .v-ray  burn  is  not  really  a  burn 
in  the  sense  of  a  burn  produced  by  fire,  but  it  is  a  degeneration  of  the  skin. 


The  Biological  Effects  of  the  Rontgen  Rays  1605 

The  first  degree  of  an  x-ray  burn  or  dermatitis  consists  of  an  erythema 
indicated  by  general  redness  of  the  surface  of  the  skin,  with  epilation  in  hairy 
areas,  and  generally  this  erythema  comes  on  after  a  period  of  a  few  days  to  two 
or  three  weeks,  depending  upon  the  severity  of  the  exposure.  Generally  the 
erythema  may  be  looked  for  in  about  two  weeks.  It  has  the  appearance  of  an 
ordinary  sunburn,  and  disappears  in  about  the  same  length  of  time  as  an  ordinary 
sun  burn.  That  is,  the  erythema  disappears,  and  very  commonly  will  leave 
behind  a  pigmentation  or  tanning,  which  is  particularly  Hkely  in  a  dark  subject 
Blondes  show  this  erythema  effect  more  readily  than  brunettes,  and  a  slightly 
lesser  dose  can  be  given  to  blondes  than  to  brunettes.  A  severe  erythema  may 
disappear  completely  at  the  end  of  ten  days  to  two  weeks,  and  nothing  may  ap- 
pear again  for  a  year  or  two,  and  for  some  reason  not  yet  known  some  of  these 
patients  who  have  had  an  erythema  will  then  develop  a  telangiectasis  and  an 
atrophic  appearance  of  the  skin  over  the  area  previously  occupied  by  the 
erythema.  This  condition  is  due  to  an  arteritis  with  secondary  dilatation  of 
the  smaller  blood-vessels,  and  in  severe  cases  the  whole  area  may  be  covered 
by  a  spiderweb-like  distribution  of  fine  blood-vessels  through  the  skin. 

The  second-degree  burn  is  the  result  of  more  excessive  exposure  than  that 
necessary  to  produce  the- first  degree  burn,  but  less  in  extent  than  the  third- 
degree  burn.  It  is  likely  to  make  its  appearance  slightly  earlier — at  the  end 
of  a  week  or  ten  days — and  shortly  after  the  appearance  of  the  erythema, 
vesicles,  or  bullae  make  their  appearance.  The  entire  area  then  gradually 
desquamates  and  will  require  from  four  to  six  weeks  for  a  complete  heahng 
process.  These  cases  are  very  likely  to  be  followed  by  an  extensive  telan- 
giectasis after  a  year  or  two,  and  such  x-ray  burns  should  be  avoided.  They 
rarely  occur  in  these  days  when  filters  are  used  for  deep  treatment,  but  even 
through  any  amount  of  filtration  a  burn  of  any  degree  can  be  produced  if 
sufficient  radiation  be  given. 

A  third-degree  burn  occurs  as  the  result  of  very  excessive  exposure  and  in 
these  days  should  not  be  produced  on  any  account.  They  were  seen  in  the 
early  days  of  x-rays  when  instruments  produced  only  a  very  soft  radiation  all 
of  which  was  absorbed  in  the  superficial  skin.  For  instance,  one  patient  whom 
Pfahler  saw  had  been  examined  repeatedly  for  a  stone  in  the  kidney,  the  exposure 
had  been  excessive,  and  the  radiation  all  absorbed  in  the  superficial  layers  of 
the  skin  and  subcutaneous  tissues,  and  yet  not  sufiicient  radiation  had  passed 
through  the  body  to  produce  a  photograph  of  the  kidney.  This  exposure  was 
followed  by  a  deep  erythema  and  then  extensive  degeneration  of  the  skin  result- 
ing in  a  gray  ulcer,  with  indurated  edge,  extending  entirely  through  the  sub- 
cutaneous tissue  and  covering  an  area  about  four  by  six  inches  in  diameter. 
This  whole  area  sloughed  profusely,  but  showed  no  tendency  to  heal.  These 
third-degree  burns  are  extremely  painful,  show  little  or  no  tendency  to  heal, 
develop  into  a  foul,  sluggish  ulcer  which  may  never  heal,  and  which  is  apt  to 
change  from  an  ulcer  into  a  malignant  indurated  carcinoma. 

A  fourth  type  of  radiodermatitis  consists  of  a  degeneration  in  an  area  which 
has  been  treated  repeatedly  over  a  long  period  of  time,  say  a  year  or  more,  after 
which  there  is  a  general  sclerotic  leather-like  condition  which  may  last  for  several 
years  and  later,  as  a  result  of  deficiency  in  nutrient  vessels,  this  area  becomes 
necrotic,  very  painful,  and  like  the  third-degree  burn,  after  a  considerable 
period  of  time,  extending  over  six  months  or  a  year,  may  degenerate  into  true 
carcinoma. 

K  fifth  type  of  radiodermatitis  is  that  found  in  x-ray  workers,  in  those  who  are 
constantly  exposed  to  radiation  in  the  manufacture  of  x-ray  tubes,  or  physicians 
or  technicians  who  have  been  constantly  exposing  themselves  to  radiation  in 
the  course  of  examinations  for  medical  purposes.  This  dermatitis  found  in 
the  Rontgenologists  and  in  the  technicians  is  also  varying  in  its  effect.  Pfahler 
has  seen  physicians  who,  from  a  single  examination,  have  burned  their  hands  so 
as  to  lose  all  the  skin.     For  instance,  a  young  physician  with  a  portable  outfit 


i6o6  The  X-rays  in  Surgery 

attempted  to  set  a  broken  leg.  As  a  result  the  patient's  leg  was  burned  to 
the  third  degree,  his  own  hands  became  enormously  swollen  so  that  the  fingers 
were  almost  twice  their  normal  size,  all  the  skin  became  a  mass  of  blood,  and  he 
was  made  absolutely  helpless  for  a  period  of  several  months,  during  which  time 
the  skin  desquamated  and  again  healed.  This  is,  of  course,  the  acute  dermatitis, 
such  as  can  occur  from  any  excessive  exposure.  Generally,  the  exposures  to  the 
Rontgen  rays  in  the  Rontgenologist  produce  no  immediate  effect,  or  at  most 
only  a  slight  erythema  of  the  skin,  which  is  passed  over  or  given  no  particular 
attention.  After  several  years  the  skin  presents  an  atrophic  aspect  indicated 
by  a  glossy,  smooth,  lacquered  appearance.  There  then  develops  a  series 
of  keratoses,  or  crusts,  or  small  warts  over  different  parts  of  the  hand,  or  per- 
haps fissures.  These  warts,  fissures  or  keratoses  gradually  degenerate  into  true 
epitheliomata  and  generally  these  epitheliomata  are  of  the  squamous-cell  type, 
very  malignant,  tend  to  metastasize  and  to  recur,  and,  in  a  number  of  instances, 
have  led  to  the  death  of  the  Rontgenologist,  through  metastasis  to  the  axilla 
and  to  the  chest. 

Another  effect  of  the  Rontgen  rays  and  radium  which  is  of  interest  to  all 
operators  is  that  of  the  production  of  sterility.  This  may  be  produced  so 
gradually  and  without  any  knowledge  on  the  part  of  the  operator,  that  it  must 
be  especially  guarded  against.  Just  how  much  exposure  of  the  testicles  or 
ovaries  is  required  to  produce  sterility  has  not  yet  been  determined.  It  prob- 
ably varies  with  the  age.  It  does  not  produce  impotence.  This  fact  often 
deceives  the  operator  as  to  the  danger  of  this  effect.  Just  as  it  is  impossible  to 
tell  how  much  radiation  is  required  to  produce  sterility,  so  too  it  is  impossible 
to  know  when  sterility  has  been  produced  or  when  it  is  complete,  for  it  is  well 
known  that  a  number  of  cases  which  had  been  sterile  for  a  time,  again  have  be- 
come fertile,  both  in  men  and  women.  This  fact  can  therefore  serve  as  en- 
couragement to  those  who  may  have  been  temporarily  sterile,  but  it  should  not 
lessen,  to  any  extent,  the  precaution  that  every  beginner  should  take  to  provide 
protection  against  exposure  to  the  rays  by  every  means  possible. 

The  Treatment  of  Radiodermatitis. — The  treatment  of  radiodermatitis  should, 
first  of  all,  consist  in  its  prevention  by  the  appHcation  of  all  present  knowledge 
used  for  protection.  No  one  should  undertake  .v-ray  work  unless  he  has  learned 
to  protect  himself  and  his  patients,  and  .v-ray  work  should  not  be  undertaken 
unless  the  means  of  protection  have  been  provided.  There  should  rarely  be  a 
dermatitis  even  of  the  first  degree.  Accidents  will  happen,  however,  and  they 
happen  in  proportion  to  the  intelligence  and  care  used  in  the  treatment  or 
examination  of  a  patient.  We  must  keep  in  mind,  however,  that  there  are  cases 
in  which  occasionally  a  patient  will  present  an  erythema  even  though  only  the 
normal  amount  of  radiation  has  been  used.  For  the  first-degree  btcrn  or  ery- 
thema Dodd's  lotion,  or  "white  wash,"  may  be  used. 

Pulv.  zinc  oxid dr.  4 

Glycerin fldr.  i 

Phenolis min.  30 

Aq.  calcis  (fresh) fl.  oz.  8 

Sig:  Apply  locally  with  a  cotton  sponge. 

Pfahler  uses  this  wash  in  practically  all  cases  immediately  after  treatment,  and 
then  for  a  period  of  two  weeks  daily  following  the  exposure.  In  place  of  Dodd's 
white  wash,  any  soothing  application  such  as  is  used  for  sunburn  may  be  used. 
When  itching  and  burning  are  troublesome,  Engman  ("Interstate  Medical 
Journal,"  July,  1903)  recommends  the  following  preparation:  12  drams  of 
boric  acid,  i  ounce  of  zinc  oxid,  i  ounce  of  chalk,  i  ounce  subnitrate  of 
-bismuth,  i  ounce  of  olive  oil,  3  ounces  of  lime  water,  3  ounces  of  lanolin  and 
12  drams  of  rose-water.  The  powder  is  rubbed  in  a  mortar,  the  lanolin  is  added, 
the  olive  oil  and  lime  water  are  mixed,  and  are  slowly  added  to  the  powder  and 
lanolin.  The  mixture  is  stirred,  the  rose-water  is  added,  the  preparation  is 
beaten  into  a  creamy  paste.     If  itching  be  severe  i  to  2  per  cent,  of  carbolic 


The  Biological  Effects  ol"  llic   Ronlgen  Rays  1607 

acid  is  added.  The  paste  is  spread  on  several  thicknesses  of  gauze  and  the  gauze 
should  be  covered  with  rubber  dam. 

The  scrond-de^rcc  hum  is  treated  very  similarly,  but  by  all  means  protec- 
tion against  the  sun's  rays  or  heat  or  further  .v-ray  treatment,  is  to  be  considered 
first.  The  above-mentioned  protective  ointment  is  useful,  or  the  white  wash 
recommended  by  Dodd.  Occasionally  more  relief  is  obtained  by  the  constant 
application  of  normal  saline. 

A  third-degree  burn  is  a  serious  condition  and  is  truly  a  dangerous  process. 
Every  means  possible  should  be  used  to  bring  about  local  nourishment  and  com- 
fort. Sometimes  constant  application  of  normal  saline  will  give  comfort  enough 
to  bring  about  separation  of  the  sloughing  mass.  In  the  early  stages,  an  out- 
line of  treatment  such  as  follows,  may  give  good  results.  A  mixture  composed 
of  2  drams  each  of  zinc  oxide  and  bismuth  subnitrate,  \'2  dram  each  of  liquor 
potassi  and  liquor  plumbi  subacetatis,  2  drams  of  glycerine  and  sufficient  lime 
water  to  make  6  fluid  ounces.  This  mixture  may  be  applied  twice  daily  and 
will  relieve  much  itching  and  burning,  and  will  control  the  exudate.  It  should 
be  applied  over  a  considerable  area.  Generally  it  is  advisable  to  make  the 
patient  comfortable  by  whatever  local  applications  will  accomplish  this,  until 
there  is  a  distinct  limitation  in  the  process  and  until  there  is  neither  an  extension 
outward  nor  a  contraction  of  the  ulcer.  In  other  words,  when  the  process  has 
reached  a  standstill,  it  is  advisable,  if  at  all  possible,  to  excise  the  entire  area, 
and  then,  if  necessary,  to  do  skin-grafting  to  close  the  wound.  This  excision 
at  once  reheves  the  excruciating  pain,  and  also  eliminates  the  tendency  toward 
maUgnant  degeneration,  for  if  these  cases  are  allowed  to  continue  indefinitely 
they  tend  to  become  malignant.  One  must,  therefore,  not  wait  until  such 
malignant  degeneration  has  taken  place,  for  we  have  then  all  the  dangers  in- 
volved in  an  operation  upon  a  malignant  process. 

The  treatment  of  the  late  degenerations,  or  the  fourth  type  of  x-ray  derma- 
titis, is  very  similar  to  that  of  the  third.  One  can  coax  the  condition  into  a  heal- 
ing process  as  long  as  possible,  but  ultimately  an  excision  is  required,  and  if 
necessary  skin-grafting  should  be  done. 

In  the  fifth  type,  or  the  radiodermatitis  of  the  Rontgenologist,  treatment 
should  involve  first  of  all  a  cessation  of  exposure  to  the  Rontgen  rays.  As  soon 
as  warts,  keratoses  or  fissures  make  their  appearances  they  should  be  com- 
pletely destroyed.  Pfahler  recommends  very  strongly  the  destruction  of  these 
areas  by  the  high  frequency  spark  or  electrocoagulation.  This  destruction 
can  be  controlled  most  accurately,  and  the  superficial  layer  only  of  the  skin  re- 
moved, or  the  area  can  be  destroyed  as  deeply  and  as  extensively  as  may  be 
necessary.  This  destruction  is  followed  by  a  pronounced  reaction,  with  the  for- 
mation of  new  blood-vessels,  and  healthy  skin,  or  healthy  scar.  In  many  in- 
stances these  lesions  can  be  removed  without  even  leaving  a  scar,  and,  if  treated 
early,  dozens  of  them  can  be  removed  without  any  damaging  effect  whatever. 
If  they  are  allowed  to  continue,  and  especially  if  allowed  to  macerate  by  the 
application  of  ubber  finger  cots  and  rubber  dam,  which  is  used  to  keep  the  areas 
soft,  they  are  likely  to  degenerate  into  squamous-cell  carcinoma,  the  end  of 
which  no  one  can  predict. 

In  these  days,  if  all  the  principles  of  protection  are  applied,  no  more  exposure 
to  the  naked  tube  or  unfiltered  rays  should  be  necessary,  and  the  radiodermatitis 
of  the  Rontgenologist  should  be  a  thing  of  the  past.  Unfortunately  these 
precautions  will  not  always  be  taken,  for  there  are  always  men  who  con- 
sider themselves  immune  to  the  physical  laws,  and  they  will  find  out  to  their 
sorrow,  when  it  is  too  late,  that  they  have  not  used  all  the  protection  which 
science  provides.  If  epitheliomas  have  developed,  local  destruction  by  electro- 
coagulation should  be  considered.  Otherwise  excision,  amputation  of  the  finger 
or  the  surgical  removal  of  as  much  tissue  as  is  necessary  to  eliminate  the  dis- 
ease should  be  recommended,  for  unless  this  carcinomatous  tissue  be  completely 


i6o8  The  X-rays  in  Surgery 

removed  from  the  hand  there  will  likely  be  metastasis  to  the  axilla,  after  which 
the  chance  of  recovery  will  be  very  slim. 

The  Uses  of  the  Rontgen  Rays  in  Surgery. — This  subject  cannot  be 
discussed  fully  in  this  work,  and  only  such  facts  as  are  of  special  interest  to  the 
surgeons  will  be  considered.  Technical  details  will  be  omitted.  Those  who 
are  interested  in  the  practice  of  Rontgenology,  even  associated  with  surgery-, 
should  consult  the  special  books  written  upon  this  subject,  otherwise  much 
harm  will  result.  The  object  is  to  give  the  surgeon  the  essential  facts  so  that 
he  may  make  intelligent  use  of  the  Rontgenologist  for  the  good  of  his  patients. 
Not  only  is  it  impossible,  in  this  short  chapter,  to  discuss  the  technical  side  of 
the  subject,  but  it  is  impractical  even  to  consider  all  the  variations  at  one  time 
in  connection  with  diagnosis  and  the  treatment  of  the  various  diseases  under 
consideration.  The  Rontgen  rays  are  used  for  both  diagnosis  and  treatment 
of  surgical  conditions,  and  in  the  hands  of  skilled  and  trained  Rontgenologists 
great  assistance  can  be  given  to  the  surgeon  in  all  branches  of  surgery,  in  most  of 
the  chronic  diseases,  as  well  as  in  accidental  conditions.  In  the  hands  of  un- 
skilled men,  the  Rontgen  rays  are  capable  of  doing  much  harm  by  leading  to 
false  diagnosis,  or  to  improper  treatment.  The  general  practitioner  who  has 
not  been  trained,  or  made  a  special  study  of  the  subject,  can  do  himself  and  his 
patients  a  great  deal  of  harm. 

Diagnosis. — Diagnostic  studies  may  be  made  either  by  means  of  the  fiuoro- 
scope  or  by  Rontgenograms  (radiograph,  skiagraph,  x-ray  plate).  The  Edison 
fluoroscope  consisted  of  a  four-sided  box  tapering  from  the  top  toward  the  screen, 
the  top  being  open  and  arranged  so  that  it  will  fit  snugly  over  the  eyes  and  nose, 
and  the  bottom  of  this  box  is  covered  by  a  fluorescent  screen.  The  fluorescent 
screen  consists  of  a  layer  of  cardboard  covered  by  barium  platinocyanid  crystals 
or  by  tungstate  of  calcium.  In  order  to  see  an  image  on  the  fluorescent  screen 
it  is  necessary  that  all  dayhght  or  ordinary  light  be  eHminated  from  the  ob- 
server's eyes  and  the  screen.  Therefore  the  above  t\-pe  of  fluoroscope  is  essential 
when  one  attempts  to  make  a  fluoroscopic  examination  in  a  room  from  which 
the  hght  cannot  be  completely  excluded.  In  all  modern  hospitals  and  .r-ray 
laboratories  there  is  set  aside  a  room  which  can  be  completely  darkened,  and 
used  for  fluoroscopic  purposes.  In  this  room  there  is  usually  a  horizontal 
fluoroscope  and  a  vertical  fluoroscope.  The  horizontal  fluoroscope  consists  of  a 
table  with  a  top  which  is  transparent  to  the  .r-rays  and  underneath  this  table 
there  is  placed  an  .v-ray  tube  properly  attached  and  protected  by  means  of  lead 
glass,  lead  and  opaque  rubber,  so  that  only  the  beam  of  rays  which  is  essential 
for  the  fluoroscopic  examination  can  be  emitted,  all  other  rays  being  excluded. 
This  beam  of  rays  is  controlled  by  means  of  an  adjustable  diaphragm  so  that  one 
can  study  a  large  or  small  field  at  will,  the  smaller  the  field  under  observation 
the  sharper  the  detail,  and  the  more  satisfactory  will  be  the  results.  In  these 
fluoroscopic  rooms  there  is  supposed  to  be  a  vertical  fluoroscope  which  consists 
of  a  similar  apparatus  or  arrangement  as  the  fluoroscopic  table,  excepting  that 
it  permits  the  patient  to  stand  up  and  be  examined  in  a  vertical  position.  There 
are  many  modifications  of  these  arrangements.  The  fluoroscopic  examinations 
are  especially  useful  in  the  study  of  movable  organs.  Therefore,  this  method  is 
useful  in  the  study  of  the  movements  of  the  lungs,  the  heart,  the  diaphragm,  the 
stomach,  the  bowels,  the  hver,  the  spleen,  and  even  of  the  kidney  for  mobility. 
The  fluoroscope  can  also  be  used  in  the  study  of  fractures,  and  may  be  used  in  the 
setting  of  fractures,  but  great  caution  should  be  used  by  a  beginner  or  untrained 
operator  in  making  an  examination  of  this  kind,  because  it  is  in  the  setting  of 
fractures,  or  in  the  search  for  foreign  bodies,  that  serious  burns  have  most 
frequently  been  produced.  The  fluoroscope  is  also  useful  in  the  location  of 
metallic  foreign  bodies,  and  it  has  been  of  the  greatest  service  in  this  respect 
during  the  great  war  (see  pages  1619  to  1628).  Probably  the  greatest  field  of 
usefulness  of  fluoroscopy  in  civil  practice  is  in  the  study  of  the  gastrointestinal 


The  Rontgen  Rays  in  Diagnosis  1609 

tract.  This  subject,  together  with  the  locaHzation  of  foreign  bodies  will  be  dis- 
cussed in  more  detail  under  these  headings.  In  making  a  fluoroscopic  study  of 
the  hand,  for  example,  it  is  placed  between  the  tube  and  the  screen.  Usually  the 
tube  is  about  25  inches  from  the  screen.  The  hand  is  placed  immediately 
back  of  the  screen,  and  under  the  excitement  of  the  tube,  the  screen  becomes 
illuminated  brilliantly  outside  of  the  object,  and  one  can  see  clearly  the  outline 
of  the  bones  as  being  distinct  from  the  outlines  of  the  flesh.  One  can  see 
clearly  through  the  joints,  and  in  this  same  manner  one  can  study  the  organs 
within  the  chest,  and  some  of  the  organs  within  the  abdomen.  Rontgenograms 
are  usually  made  in  conjunction  with  the  fluoroscopic  examination,  if  a  fluoro- 
scopic examination  be  made,  and  in  the  great  majority  of  surgical  conditions 
the  Rontgenogram  alone  is  depended  upon  for  the  .v-ray  report. 

Rontgenography. — The  Rontgenogram  primarily  consists  of  a  photographic 
plate  which  is  protected  from  ordinary  light  by  means  of  an  envelope  of  black 
paper  covered  by  another  envelope  of  yellow  paper,  or  is  placed  in  an  aluminum 
case  which  protects  the  plate  thoroughly  from  light  and  through  this  covering, 
which  is  transparent  to  the  .v-rays,  the  object  under  examination  is  exposed  to 
the  .v-rays.  The  plate  is  then  developed,  washed  and  dried  as  an  ordinary  photo- 
graphic plate,  after  which  it  is  studied  by  placing  it  over  an  illumination  box  or 
by  holding  it  toward  the  northern  sky,  or  by  making  use  of  the  reflections  of 
a  sheet  of  white  paper.  It  is  not  advisable  to  depend  upon  the  light  from  an 
ordinary  electric  lamp,  or  candle,  or  gas  light,  for  many  delicate  shadows  and 
diagnostic  points  are  overlooked  in  so  doing.  These  Rontgenograms  are 
essential  in  the  study  of  most  of  the  obscure  conditions.  Accurate  diagnosis 
of  fractures,  of  all  lesions  of  the  bones  and  of  most  of  the  gastrointestinal  condi- 
tions demands  the  use  of  Rontgenograms.  and  fluoroscopic  examinations  alone 
cannot  be  depended  upon.  Rontgenographic  studies  are  probably  of  even 
greater  value  than  the  fluoroscopic  studies,  but  both  should  be  used  wherever 
it  is  necessar}',  and  every  laboratory  should  be  equipped  so  that  both  forirs  of 
study  in  a  case  can  be  used  at  will.  The  Rontgenogram  has  the  advantage  of 
being  a  permanent  record  which  can  be  studied  by  one  or  many,  and  can  be 
compared  with  future  pictures  of  the  part  under  examination,  gives  much  finer 
detail  and  in  general  gives  much  greater  accuracy  than  fluoroscopic  studies. 
Rontgenographic  studies  can  be  made  today  by  the  trained  Rontgenologist 
without  the  slightest  danger  to  either  the  patient  or  the  operator.  The  time  of 
exposure  varies,  of  course,  with  the  amount  of  energy  introduced  into  the  tube, 
but  any  part  of  the  body  can  be  recorded  on  the  Rontgenogram  in  from  ^foth 
to  10  seconds.  Most  exposures  are  made  in  from  i  to  5  seconds,  and  children 
can  be  Rontgenographed  instantaneously,  especially  when  one  uses,  in  conjunc- 
tion, the  intensifying  screen  which  increases  the  value  of  the  exposure  about  five 
or  six  hundred  per  cent.  The  intensifying  screen  has  the  objection  of  giving  less 
valuable  detail,  and  shows  some  grains  in  the  film,  especially  when  rapid  forced 
exposures  are  used,  but  when  time  is  the  important  element  it  offers  a  wonder- 
ful advantage. 

In  fractures  the  rays  enable  us  to  determine  the  nature  and  extent  of  the 
injurv,  the  amount  of  splintering,  the  degree  of  impaction,  the  relation  of  the 
fragments,  the  direction  of  the  line  or  lines  of  fracture,  the  variety  of  the  de- 
formitv,  the  existence  of  multiple  fractures,  the  extent  of  epiphyseal  separation 
or  dislocation  alone  or  with  fracture,  the  existence  of  ununited  fractures,  the  pres- 
ence of  callus  and  whether  the  callus  is  healthy  or  necrosis  is  taking  place 
in  the  fragments.  Probably  the  most  valuable  point  in  the  study  of  fracture 
is  the  record  of  the  position  as  shown  in  the  dressings.  There  is  some  advantage 
in  ha\-ing  Rontgenograms  of  all  fractures  before  setting,  but  in  cases  in  which 
the  diagnosis  of  fracture  is  positive  it  is  probably  more  economical  of  time, 
energv  and  money  if  the  fractures  are  reduced,  according  to  the  well-knowTi 
surgical  principles,  and  placed  in  splints  or  dressings  and  then  referred  to  the 


i6io  The  X-rays  in  Surgery 

Ronlgenologist,  and  examined  to  determine  whether  the  fragments  are  in 
satisfactory  position  or  not.  In  some  cases  it  will  be  found  of  great  advantage 
to  make  the  reduction  of  fractures  under  fluoroscopic  observation.  This  re- 
duction should  be  made  by  the  surgeon  and  Rontgenologist  conjointly,  and  the 
Rontgenologist  should  keep  in  mind  continually  the  dangers  both  to  the  patient 
and  to  the  operator  involved  in  this  procedure.  Both  the  surgeon  and  the 
Rontgenologist  should  keep  in  mind  the  fact  that  they  are  only  seeing  the  bone 
in  one  plane  and  that  the  observation  must  always  be  made  in  more  than  one 
plane  in  order  to  determine  the  actual  position  of  the  fragment.  This  great 
obstacle  it  is  hoped  will  be  overcome  shortly  by  the  use  of  stereo-fluoroscopy,  so 
ably  developed  by  the  late  Dr.  E.  W.  Caldwell,  and  almost  perfected  by  him 
at  the  time  of  his  death.  Patients  to  be  examined  for  the  position  of  the  frag- 
ments should  not  be  placed  in  a  metallic  spUnt  unless  the  metallic  splint  be 
made  of  aluminum,  for  the  examination  through  wire  and  other  metallic  splints 
is  most  unsatisfactory.  These  examinations  for  the  position  of  fragments  can 
easily  be  made  through  boards,  cardboard,  aluminum,  a  plaster  cast,  and 
celluloid  casts.  Adhesive  plaster,  leadwater  and  laudanum,  and  an  ointment 
of  mercury  and  belladonna,  which  are  frequently  applied  over  wounds,  often 
interfere  considerably  with  the  diagnosis  of  doubtful  or  line  fractures.  All 
doubtfid  cases  of  fracture  should  be  examined  before  dressings  are  applied.  In 
these  doubtful  cases  there  is  usually  no  deformity,  and  nothing  can  be  lost  in 
waiting  for  the  application  of  permanent  dressings  or  until  after  the  .v-ray 
examination  has  been  made.  All  fractures  should  be  examined  from  at  least 
two  angles,  and  when  possible  these  examinations  should  be  made  at  right 
angles.  Stereoscopic  plates  are  of  advantage  especially  in  the  neighborhood  of 
joints  and  about  the  head,  and  especially  when  the  patient  cannot  be  moved 
so  as  to  get  right-angle  plates.  Stereoscopic  plates  are  of  value  in  the  diagnosis 
of  fractures  of  the  skuU.  Fractures  of  the  spine  should  be  studied  if  possible 
from  both  an  anteroposterior  direction  and  in  a  lateral  direction.  A  lateral 
view  of  the  spine  cannot  always  be  made  satisfactorily,  especially  in  very  stout 
or  muscular  men,  but,  by  the  use  of  intensifying  screens  and  careful  technic, 
practically  all  can  be  demonstrated,  and  many  fractures  that  were  previously 
overlooked  because  they  gave  no  characteristic  symptoms  of  fracture,  are  now 
clearly  demonstrable  by  the  Rontgen  rays. 

Dislocations. — Dislocations  of  joints  can  generally  be  recognized  by  ordinary 
clinical  signs,  but  it  is  important  to  have  Rontgenograms  of  these  dislocated 
joints  to  show  the  exact  location  of  the  dislocated  bones  and  to  demonstrate 
any  associated  fracture  comphcating  the  treatment  and  the  results.  It  is  also 
important  to  make  Rontgenograms  after  the  reduction  to  prove  that  the  re- 
duction has  been  complete. 

Diseases  of  Bones. — In  most  diseases  of  the  bones  the  lesions  can  be  accu- 
rately demonstrated  by  the  Rontgen  rays  and  in  most  cases  a  definite  diagnosis 
can  be  made  by  this  means  alone,  but  in  all  cases  valuable  assistance  can  be 
rendered  to  the  surgeon  in  making  a  differential  diagnosis.  It  should  be  re- 
marked that  in  the  earliest  stages  of  acute  osteomyelitis  the  diagnosis  cannot 
be  made  by  the  Rontgen  rays.  Therefore,  a  negative  report  in  a  case 
suspected  of  being  acute  osteomyelitis  should  not  be  regarded  as  final  and 
if  the  diagnosis  cannot  be  made  by  clinical  means,  the  examination  should  be 
repeated  until  the  diagnosis  is  possible.  In  this  brief  chapter  it  is  utterly 
impossible  to  give  a  complete  description  and  illustration  of  the  various  diseases 
of  bone.  Whole  books  have  been  written  on  this  subject  alone.  The  leading 
characteristics  of  a  few  of  the  most  common  diseases  of  bone  will  be  mentioned. 

Tuberculosis  is  characterized  by  a  general  transparency  extending  outward 
from  a  joint  due  to  a  general  absorption  of  the  lime  salts,  and  commonly  asso- 
ciated with  some  destruction  of  the  joint  surfaces  of  the  bone. 

Myeloid  sarcoma  shows  a  central  destruction  of  the  bone  extending  outward 


The  Rontgen  Rays  in  Diagnosis  1611 

to  the  periphery,  and  sometimes  develops  to  the  extent  of  the  disease  breaking 
through  the  walls  of  the  bones  and  extending  into  the  surrounding  tissues,  with 
no  definite  line  of  dcmarkation  and  no  bone  sclerosis. 

Periosteal  sarcoma  shows  a  destruction  of  the  periphery  of  the  bone  with  an 
elevation  of  the  periosteum  and  a  tumor  formation  which  extends  into  the  soft 
tissues. 

Local  gumma  of  the  bone  resembles  somewhat  periosteal  sarcoma  but  it  is 
associated  with  more  actual  destruction  extending  from  the  surface  downward 
with  less  tumor  formation,  no  elevation  of  the  periosteum,  and  associated  with 
bone  sclerosis. 

Periostitis  is  indicated  by  a  slight  thickening  or  elevation  of  the  periosteum 
without  other  localized  destruction  of  the  bone. 

Osteomyelitis  is  indicated  by  localized  areas  of  destruction  of  the  bone  ex- 
tending sometimes  through  the  entire  shaft,  together  with  much  bone  sclerosis 
and  small  abscesses,  marked  thickening  of  the  periosteum  with  a  putty-like 
deposit  over  the  periosteum,  and  frequently  associated  with  sequestra. 

All  diseases  of  bone  can  be  demonstrated. 

Diseases  of  the  Joints. — All  diseases  of  the  joints  can  be  demonstrated  by  the 
Rontgen  rays  if  there  be  change  in  the  bony  structure,  exudate  into  the  joint 
spaces,  or  thickening  of  the  soft  tissues  about  the  joints. 

Fractures  of  the  Skull. — Fractures  of  the  skull  can  be  demonstrated  but  some- 
times a  number  of  negatives  are  required,  and  stereoscopic  plates  give  a  distinct 
advantage.  There  is  some  danger  of  diagnosing  ordinary  sutures  and  blood- 
vessel grooves  as  fractures,  and  this  should  always  be  kept  in  mind.  When  a 
number  of  negatives  are  made  they  should  be  made  from  different  angles.  Some- 
times a  fracture  is  found  on  the  side  opposite  to  the  injury. 

The  Jiasal  accessory  sinuses  and  the  mastoid  cells  can  be  clearly  demonstrated, 
and  the  pathological  processes  in  these  sinuses  and  cells  are  usually  demonstrated 
by  an  increased  opacity  due  to  exudate  or  tumor  formation,  or  are  indicated  by 
an  absorption  or  destruction  of  some  of  the  septa  or  all  of  the  various  sinuses. 

Intracranial  Lesions  and  Diseases  of  the  Bones  of  the  Head. — The  most  com- 
mon disease  of  the  cranial  bones  is  syphilis,  indicated  by  an  increased  porosity 
and  increased  thickening  of  the  tables  of  the  skull,  with  a  distinct  disturbance 
in  the  diploe.  Tu?nors  are  also  found  in  these  bones,  as  indicated  by  increased 
thickening,  porosity,  and  more  definite  localization  than  in  syphilis.  Osteo- 
tnyelitis  is  frequently  observed,  and  is  indicated  by  the  usual  characteristics  of 
osteomyelitis.  Intracranial  tumors  can  be  recognized  if  they  are  located  super- 
ficially and  cause  pressure  upon  the  bones  of  the  skull  so  as  to  cause  a  thinning, 
or  if  the  tumor  is  increased  in  density,  such  as  Pfahler  has  seen  in  gumma  and 
fibrosarcoma,  but  unless  the  tumor  causes  pressure  on  the  inner  table  of  the  skull, 
or  is  of  more  dense  structure  than  the  cerebral  tissues,  it  cannot  be  demon- 
strated. An  associated  sign  of  tumor  is  sometimes  found  and  is  indicated  by 
dilatation  of  the  meningeal  vessels  on  the  affected  side.  The  most  frequent  loca- 
tion of  tumors  demonstrable  by  the  rays  is  in  the  pituitary  region,  and  these 
are  indicated  by  a  distinct  increase  in  the  size  of  the  sella  turcica  and  partial  or 
complete  destruction  of  the  clinoid  processes,  or  associated  with  the  destruction 
there  is  a  marked  hypertrophy  and  elongation  of  the  posterior  clinoid  processes. 
At  times  tumors  in  the  pituitary  region  can  be  recognized  by  an  increased  den- 
sity probably  due  to  calcareous  deposit.  Just  as  these  tumors  cause  pressure 
upon  the  clinoid  processes,  there  may  be  pressure  on  the  floor  of  the  sella  turcica 
and  encroachment  upon  the  sphenoid  sinus.  Stereoscopic  plates  are  essential 
in  all  head  examinations,  and  will  give  additional  evidence  in  connection  with 
the  intracranial  tumors,  but  in  the  study  of  the  sella  turcica  it  is  always  advisa- 
ble to  make  a  very  small  localized  Rontgenogram  of  the  sella  turcica.  This 
increased  detail  gives  increased  information.  Internal  hydrocephalus  is  indi- 
cated by  deeply  marked  depressions,  corresponding  to  the  convolutions  of  the 


i6i2  The  X-rays  in  Surgery 

brain,  throughout  the  skull.  When  this  condition  is  due  to  congenital  syphilis, 
the  skull  sutures  unite  early.  When  it  is  due  to  internal  hydrocephalus  they  are 
apt  to  be  ununited  or  even  separated.  In  external  hydrocephalus  the  entire 
skull  is  deformed,  the  convolution  markings  are  not  nearly  so  prominent  and 
may  even  be  absent,  and  the  skull  sutures  are  separated. 

Intrathoracic  Surgical  Conditions. — Patients  suflfering  from  intrathoracic 
conditions  should  be  studied  both  fluoroscopically  and  Rontgenographically, 
and  generally  the  examinations  should  be  made  both  in  the  recumbent  and  ver- 
tical positions,  but  the  vertical  position  is  especially  important.  Pleural  effu- 
sion is  recognized  by  a  general  or  homogeneous  opacity  with  an  upper  level  more 
or  less  clearly  defined  by  the  transparent  lungs  above,  but  this  upper  line  is  rarely 
a  straight  or  horizontal  line  unless  there  be  free  air  above  it.  The  character  of 
the  fluid  cannot  be  recognized  definitely  by  the  x-ray.  One  can  form  some  esti- 
mate of  the  amount  of  fluid,  its  location  and  its  mobility.  Generally  if  the  fluid 
does  not  change  its  position  between  the  recumbent  and  vertical  position  it  is 
encapsulated.  The  encapsulated  empyema  has  been  especially  frequent  during 
the  recent  epidemic  of  influenza.  These  encapsulated  empyemas  may  be  located 
anywhere  in  the  chest,  but  a  rather  favorite  location  is  that  between  the  middle 
and  lower  lobe  on  the  right  side,  and  at  the  outer  side  of  the  base  of  the  chest  on 
both  sides.  If  the  pleural  effusion  be  great,  there  will  be  associated  a  displace- 
ment of  the  mediastinal  organs  toward  the  opposite  side.  Pneumothorax  is 
recognized  by  a  clear,  transparent  area  without  lung  markings,  together  with 
displacement  of  the  lung  tissue,  and  if  the  pneumothorax  be  great,  displacement 
of  the  mediastinal  tissues  toward  the  opposite  side.  Hydropneumothorax  and 
pyopneumothorax  are  recognized  by  the  opaque  fluid  below,  with  displacement 
of  the  lung  tissue  and  mediastinal  tissues,  and  especially  by  the  clear,  transparent 
area  above  the  level  of  the  fluid,  and  if  examined  fluoroscopically,  and  if  the 
patient  be  shaken,  this  fluid  can  be  seen  to  splash. 

Abscess  of  the  lung  is  recognized  by  a  localized  area  of  opacity  generally 
surrounded  by  more  or  less  inflammatory  or  less  dense  tissue,  but  the  positive 
diagnosis  of  abscess  will  depend  upon  its  central  location,  or  especially  upon 
the  finding  of  air  above  the  level  of  fluid  when  the  patient  is  in  the  standing 
position.  Gangrene  of  the  lung  is  recognized  primarily  by  the  odor,  and  its 
location  is  determined  by  the  finding  of  a  localized  area  of  consolidation  sur- 
rounded by  more  or  less  transparent  lung  tissue,  and  the  central  portion  of  the 
gangrenous  area  is  more  transparent,  thereby  giving  the  appearance  of  cavity 
formation. 

Malignant  Disease  of  the  Lungs. — Primary  carcinoma  of  the  lungs  is  extremely 
rare,  but  when  present  is  recognized  by  the  tumor  formation  usually  extending 
outward  from  the  mediastinum,  or  root  of  the  lungs. 

Metastatic  carcinoma  or  sarcoma  of  the  lungs  is  quite  common,  and  is 
especially  common  associated  with  carcinoma  of  the  breast  or  sarcoma  any- 
where. It  is  my  opinion  that  carcinoma  of  the  lungs  is  often  present  preceding 
the  operation  on  the  breast,  and  for  this  reason  a  careful  chest  examination 
should  always  precede  an  amputation  of  the  breast  (see  page  1592). 

Hydatid  cysts  are  recognized  by  the  dense  globular  areas  localized  in  the  lungs 
and  surrounded  very  definitely  by  clear  lung  tissue.  The  varying  degrees  of 
fixation  of  the  diaphragm  or  displacement  of  the  diaphragm  from  whatever 
cause,  can  be  demonstrated  by  the  x-rays. 

Mediastinal  Conditions. — Intrathoracic  goiter  can  be  demonstrated,  and  this 
is  important  preceding  operation  for  goiter. 

Enlarged  thymus  is  especially  demonstrable  in  children;  an  examination 
should  precede  operations.  Fortunately  enlarged  thymus  responds  marvel- 
ously  to  .x-ray  treatment. 

Mediastinal  tumors  of  all  varieties  can  be  demonstrated  as  to  their  extent, 
their  size,  and  their  degree  of  pressure  on  the  surrounding  organs. 


The  Rontgen  Rays  in  Diagnosis  1613 

Aneurism  of  the  arch  of  the  aorta,  its  size,  location,  and  degree  of  pulsation 
can  be  clearly  demonstrated. 

The  heart,  together  with  its  variation  in  size,  its  pulsations  or  its  position 
can  be  demonstrated. 

Enlarged  mediastinal  and  enlarged  peribronchial  glands  can  be  demonstrated 
and  are  of  importance  in  association  with  surgical  conditions  outside  the  chest. 
For  example,  in  Hodgkin's  disease  at  times  the  lymphatic  glands  may  only  be 
moderately  enlarged  externally,  but  may  be  much  enlarged  in  the  mediastinum, 
and  will  serve  as  a  guide  for  or  against  operation. 

The  Alimentary  Canal. — The  alimentary  canal  is  sometimes  studied  by  means 
of  the  introduction  of  gas,  either  naturally  or  artificially  introduced,  but  gen- 
erally these  studies  are  made  by  means  of  the  use  of  an  opaque  meal  consisting 
of  two  to  four  ounces  of  barium  sulphate  in  buttermilk  or  gruel.  There  are 
many  modifications  of  technic  and  this  study  in  itself  is  so  extensive  that 
volumes  have  been  written  on  this  alone.  (Carman  and  Miller,  "The  Rontgen 
Diagnosis  of  Diseases  of  the  Alimentary  Canal."  W.  B.  Saunders  Company.) 
Therefore  only  the  most  essential  points  of  interest  will  be  discussed.  A  barium 
meal  or  opaque  capsules  or  pills  are  observed  as  they  pass  through  the  entire 
gastro-intestinal  tract.  The  food  can  be  clearly  seen  passing  downward  through 
the  esophagus.     The  following  surgical  conditions  can  be  recognized. 

Diverticulum  is  recognized  as  a  pouch  on  the  side  of  the  esophagus  which 
becomes  distended  by  the  opaque  fluid  and  encroaches  upon  the  remainder  of 
the  esophagus,  obliterating  its  lumen,  thus  interfering  with  the  act  of  degluti- 
tion. The  size,  the  position  and  the  location  of  the  orifice  can  be  demonstrated, 
and  this  is  of  importance  to  the  surgeon. 

Strictures  of  the  esophagus  may  be  spasmodic  or  organic.  A  spasmodic 
stricture  is  complete,  is  usually  smooth  in  outline,  and  is  released  suddenly 
allowing  full  and  free  passage  of  the  fluid.  The  organic  stricture  is  permanent 
usually  presenting  an  irregular  border.  If  benign  the  walls  are  generally 
smooth ;  if  malignant  the  walls  have  a  jagged  appearance  or  there  is  a  serrated  out- 
line of  the  opaque  food.  It  is  of  importance  to  the  surgeon  to  know  the  size  of  the 
lumen,  the  location  of  the  tumor  and  the  amount  of  esophageal  dilatation  above. 

Cardiospasm  is  located  at  the  point  where  the  esophagus  passes  through  the 
diaphragm,  or  at  the  cardiac  end  of  the  stomach.  It  is  primarily  a  spasmodic 
stricture  of  the  esophagus.  It  therefore  presents  a  smooth  lower  border,  the 
obstruction  is  complete  even  to  fluid,  and  often  presents  enormous  dilatation 
above;  this  condition  may  exist  for  many  years  without  being  recognized 
either  by  the  patient  or  the  physician.  Pfahler  has  seen  the  esophagus  suffi- 
ciently dilated  to  hold  three  or  four  pints  of  fluid,  so  that  in  two  cases  the  patient 
was  sent  to  him  for  an  examination  of  the  stomach  because  the  attending 
physician  obtained  much  fluid  with  the  stomach  tube,  and  yet  could  not  obtain 
any  free  hydrochloric  acid. 

The  Sto7nach. — By  this  method  the  size,  outline,  position,  peristaltic  move- 
ments, rate  of  emptying  and  general  mobility  of  the  stomach  can  be  recognized. 

Pfahler  ("American  Quarterly  of  Rontgenology,"  Feb.,  1913)  groups  Ront- 
genological  evidences  of  gastric  ulcer  under  three  headings,  as  follows: 

"  I.  The  evidence  of  perforation:  {a)  A  projecting  shadow  outside  the  gastric 
shadow,  {h)  A  gas  bubble  lying  above  this  collection  of  bismuth,  (c)  Peri- 
gastric adhesions  or  involvement  of  other  organs,  {d)  A  palpable  tumor  con- 
nected with  the  stomach,  but  not  affecting  the  lumen,  (e)  The  above  may  be 
associated  with  either  an  organic  or  spasmodic  hour-glass  contraction  of  the 
stomach.  (/")  Retention  of  bismuth  or  barium  in  the  ulcer  after  the  remainder 
of  the  stomach  has  been  emptied,  {g)  Resistance  corresponding  to  the  projecting 
shadow. 

"  2.  The  evidence  of  irritation,  due  either  to  a  florid  ulcer  or  to  an  irritable 
scar  of  an  ulcer:  (a)  Spasmodic  contraction,     {h)  Retention  of  food  in  the  stom- 


i6i4 


The  X-rays  in   Surgery 


ach  after  six  hours,  (c)  Painful  pressure  point  corresponding  to  the  location 
of  the  ulcer,     (d)  Normal  outline  of  stomach. 

''3.  Secondary  effects  usually  associated  with  a  callous  ulcer:  (a)  Pyloric 
stenosis  and  gastrectasis.  (b)  Fixation,  (c)  Organic  contraction — hour-glass. 
(d)  Interference  with  peristalsis,  (e)  Reversed  peristalsis.  (J)  A  contracted 
lesser  curvature  with  retraction  of  the  pylorus  to  (he  left." 

Duodenal  Ulcer — Ninty-five  per  cent,  of  duodenal  ulcers  occur  in  the  first 
portion  of  the  duodenum  (Moynihan).  These  ulcers  cause  either  deformity  or 
spasm  in  this  first  portion  of  the  duodenum,  and  since  this  portion  of  the  duo- 
denum can  be  clearly  demonstrated,  and  presents  a  triangular  appearance  on 
the  fluorescent  screen  and  also  on  the  .v-ray  plate,  or  an  appearance  which  Cole 
has  likened  to  a  bishop's  cap,  it  is  therefore  commonly  spoken  of  as  the  "cap." 


m 


Fig.  iioS. — SumKali  shnwiii;^  perforating 
ulcer  at  the  middle  of  the  lesser  curvature, 
TOth  normal  first  portion  of  the  duodenum. 
Outline  of  the  bowel  showing  from  a  meal 
given  twenty-four  hours  previously  (Pfahler). 


P'lG.  1109. — Xormal  stomach. 
Duodenal  ulcer  shown  by  contrac- 
tions in  the  outline  of  the  first 
portion.  Compare  with  Fig.  1108 
f  Pfahler). 


When  this  first  portion  of  the  duodenum  or  cap  is  smooth  in  outline,  having  a 
definite  smooth  base  resting  on  the  pylorus,  and  the  walls  on  all  sides  are  smooth 
terminating  in  a  cone,  ulcer  is  considered  to  be  absent,  because  there  is  no  evi- 
dence of  either  indentation  or  deformity  such  as  ulcer  produces,  nor  contraction. 
We  believe,  therefore,  that  both  the  positive  and  negative  diagnosis  of  duodenal 
ulcer  can  be  made  in  approximately  95  per  cent,  of  the  cases  when  the  work  is 
done  by  a  Rontgenologist  skilled  in  this  line  of  work.  At  times  this  ulcer  is 
indicated  by  a  nitch  or  projection  outside  the  walls  of  the  stomach  which  indi- 
cates perforation.  At  other  times  there  is  a  retraction  or  shght  filling  defect 
on  one  or  the  other  walls,  and  this  filling  defect  persists  throughout  a  prolonged 
fluoroscopic  examination  and  is  shown  in  many  Rontgenograms  made  of  this 
section.  At  times  the  entire  duodenum  is  deformed  and  contracted.  In  all 
these  cases  the  evidence  presented  by  the  Rontgenologist  must  be  carefully  co- 
related  with  the  history  and  other  clinical  evidence. 

Diverticuli  of  the  duodenum  are  recognized  by  a  pouching  effect  extending 
outward  from  the  walls  of  the  duodenum. 


The  Rontgcn  Rays  in  Diagnosis 


1 615 


Adhesions  of  the  duodenum  can  at  limes  be  recognized  by  Lheir  effect  upon 
the  stomach  or  (kiodenum  in  drawing  them  definitely  out  of  place  or  in  some 
instances  by  causing  deformity  in  its  outline. 

The  small  bowel  presents  little  Rontgenological  evidence,  and  only  in  cases 
of  obstruction  or  definite  fixations  can  any  thing  abnormal  be  recognized. 
Obstruction  can  at  times  be  recognized  by  the  distention  with  gas  above  the 
point  of  obstruction. 

The  A  ppendix. — Unless  the  appendix  be  obUterated  by  exudate,  it  can  usually 
be  visualized  by  means  of  the  opaque  barium  buttermilk  meal.  It  is  demon- 
strable best  at  the  end  of  eight  or  twenty-four  hours,  but  at  times  it  can  be  seen 
for  days,  weeks,  or  even  months  after  the  Ijarium  meal  has  been  given.     An 


Fig.  1 1 10. — Normal  stomach.  Dilated 
duodenum.  Adhesions  drawing  the  duo- 
denum upward  and  to  the  right.  Gall-stones 
showing  between  the  duodenum  and  the 
liver  (Pfahler). 


Fig.  nil. — Extensive  carcinoma  of  the 
stomach,  indicated  by  the  filling  defects 
and  the  general  serrated  edges  (Pfahler). 


acute  appendicitis  seldom  demands  an  a;-ray  examination,  and  little  or  no  evi- 
dence can  be  found  in  acute  appendicitis  aside  from  filling  the  colon  and  deter- 
mining the  point  of  localized  tenderness  and  its  relation  to  the  bowel  or  other 
organs.  In  chronic  appendicitis,  the  symptoms  are  often  very  obscure  and  very 
often  point  more  strongly  to  the  stomach  than  to  the  appendix.  In  these  cases, 
the  -T-ray  study  is  of  most  importance,  and  the  evidence  of  chronic  appen- 
dicitis is  indicated  by  marked  localized  tenderness  over  the  appendix.  The 
appendix  is  only  partially  patulous.  It  is  likely  to  be  fixed.  It  may  be  dis- 
torted, or  may  be  located  retrocecally.  It  is  often  fixed  by  adhesions.  The 
cecum  is  usually  tender  and  more  or  less  fixed.  When  the  appendix  is  move- 
able, the  localized  tenderness  moves  with  the  appendix,  and  sometimes  this 
tender  point  can  be  moved  as  much  as  six  inches.  In  addition  to  determining 
the  presence  of  chronic  appendicitis  the  location  of  the  appendix  is  very  impor- 


i6i6  The  X-rays  in  Surgery 

taxit,  for  sometimes  the  appendix  is  found  up  at  the  Hver,  and  in  one  case  I  found 
it  surrounding  the  pyloric  end  of  the  stomach,  and  in  other  cases  it  may  be 
located  on  the  left  side  of  the  abdomen. 

The  Colon. — The  opaque  meal  referred  to  above  can  be  followed  throughout 
the  entire  colon,  and  normally  nearly  or  all  of  the  opaque  meal  will  have  passed 
out  of  the  intestines  in  about  24  hours.  In  intestinal  stasis  this  opaque  meal 
may  remain  in  the  colon  for  days  or  weeks.  When  the  colon  is  outlined  by  the 
opaque  meal  it  can  be  moved  about,  if  not  attached  by  adhesions,  within  a 
radius  of  a  few  inches  in  all  directions.  If  bound  by  adhesions,  it  cannot  be 
moved,  and  in  this  way  one  can  determine  such  conditions  as  Jackson's  mem- 
brane or  any  other  similar  condition  which  may  be  associated  with  extensive 
adhesions.  Obstruction  of  the  colon  can  be  recognized  by  the  stoppage  of  the 
barium  at  a  certain  point,  but  this  does  not  occur  unless  the  constriction  be 


Fig.  1112. — A  case  of  chronic  appendicitis.  The  appendix  elongated,  and  attached  in  the 
gall-bladder  region.  Cecum  directed  upward.  Symptoms  were  entirely  referable  to  the 
stomach  and  gall-bladder  (Pf abler). 

very  small.  Constrictions  of  the  colon  are  best  recognized  by  an  opaque  enema 
consisting  of  two  to  four  ounces  of  barium  sulphate  mixed  with  a  tumblerful  of 
kaolin,  and  two  to  three  pints  of  water.  This  mixture  is  distinctly  opaque  to 
the  x-rays  and  when  injected  into  the  rectum  it  can  be  traced  throughout  the 
entire  colon.  The  outl  ne  of  the  bowel  is  clearly  shown  and  if  any  constriction, 
indentations  or  filling  defect  be  present,  it  will  be  clearly  demonstrable.  Many 
precautions  must  be  taken  to  avoid  error  in  interpretation.  Carcinoma  of  the 
colon  is  best  demonstrated  by  means  of  the  opaque  enema.  If  carcinoma  be 
present  a  distinct  filling  defect  will  be  showm  and  this  filling  defect  is,  I  think, 
always  associated  with  a  considerable  amount  of  serration  in  the  region  of  the 
constriction,  such  as  is  produced  in  general  by  carcinoma.  It  is  possible  that 
an  opaque  meal  may  pass  entirely  through  a  constriction  caused  by  a  carcinoma 
and  yet  an  opaque  enema,  even  though  it  be  very  hquid,  may  not  pass  the 
constriction.  The  demonstration  of  carcinoma  of  the  colon  is  important,  not 
simply  for  the  fact  of  diagnosis,  but  also  to  determine  its  size,  its  position,  its 
adhesions  to  the  surrounding  structures,  and  at  times  even  the  evidence  of 


The  Rontgcn  Rays  in  Diagnosis  1617 

metastasis  can  be  demonstrated,  and  thus  an  unnecessary  exploratory  operation 
may  be  avoided. 

Diverticulitis  sometimes  gives  rise  to  symptoms,  resembhng  very  strongly 
those  of  carcinoma.  For  instance,  if  there  be  a  perforation  present  there  may 
be  a  large  inflammatory  mass  palpable  in  the  abdomen  through  the  abdominal 
wall,  and  there  may  be  associated  considerable  pain,  and  nearly  always  a  cer- 
tain amount  of  constipation.  There  may  also  be  a  passage  of  blood  and  mucous. 
These  point  strongly  toward  carcinoma,  but  carcinoma  and  diverticulitis  can 
be  easilv  differentiated  for  with  carcinoma  there  is  a  decided  filling  defect;  with 
diverticulitis  the  lumen  of  the  bowel  is  normal  unless  encroached  upon  by  pres- 
sure of  a  mass  on  the  outside,  in  which  instance  there  will  be  an  absence  of  the 
serration  which  is  found  in  connection  with  carcinoma.  In  addition  to  this,  one 
can  generally  demonstrate  the  opaque  enema  entering  the  pocket  or  pockets 
outside  the  line  of  the  bowel  wall.  This  can  be  demonstrated  at  times  by  the 
opaque  enema,  but  at  other  times  the  demonstration  can  only  be  made  positive 
after  sulhcient  time  has  elapsed  for  the  entire  bowel  to  have  emptied  itself. 
This  may  require  two  or  three  days,  or  a  week,  and  after  this  time,  with  the 
bowels  empty  of  the  general  opaque  enema,  the  little  pockets  of  retained  barium 
are  opaque,  making  the  diagnosis  positive. 

Each  case  must  be  studied  according  to  the  indications  present,  but  routinely 
Pfahler  (Jour.  Am.  Med.  Assoc,  Dec.  14,  1918,  vol.  71,  pp.  1951-1955)  orders 
for  the  patient  a  purgative  on  the  night  before  the  examination.  Then  have  him 
report  at  9  o'clock  in  the  morning,  without  breakfast,  at  which  time  about  six 
or  eight  plates  are  made  of  the  gall-bladder  region.  Then  the  esophagus,  stom- 
ach and  duodenum  are  studied  carefully.  If  nothing  be  found  abnormal  in  the 
stomach  or  duodenum,  he  is  then  allowed  to  eat  his  lunch,  and  then  return 
at  5.30  for  a  second  examination  at  which  time  the  stomach  is  nearly  empty, 
even  of  the  second  meal  he  has  taken,  and  the  opaque  meal  is  in  the  cecum 
and  ascending  colon.  At  this  time,  some  valuable  information  can  be  obtained 
with  regard  to  the  appendix,  the  mobility  of  the  cecum,  and  any  obstruction  if 
it  should  be  present  in  the  ileum.  Obstruction  in  the  ileum  is  an  extremely 
rare  occurrence  in  Pfahler's  experience.  If  there  be  any  suggestion  of  gastric 
ulcer  found  in  the  first  examinations,  the  patient  is  not  allowed  to  have  any 
food  for  a  period  of  six  hours,  at  the  end  of  which  time  he  is  again  examined. 
If  the  stomach  at  the  end  of  six  hours  shows  evidence  of  distinct  retention  and 
there  be  no  marked  ptosis  or  atony  of  the  stomach  present,  one  can  conclude 
that  the  retention  is  due  to  a  pylorospasm  which  is  some  evidence  of  gastric 
ulcer.     In  Pfahler's  experience,  this  six-hour  examination  is  rarely  needed. 

Examination  of  the  gall-bladder  is  of  value.  According  to  Pfahler,  Case, 
Cole  and  George,  gall-stones  can  be  recognized  if  the  work  be  carefully  and 
thoroughly  done,  and  from  eight  to  twelve  plates  are  made,  in  approximately 
50  per  cent,  of  the  cases  in  which  gall-stones  are  present.  In  addition  to  these 
there  is  suggestive  evidence  of  gall-stones  in  probably  25  per  cent.  more.  This 
evidence  may  consist  only  of  slight  mottling,  a  pressure  effect  upon  the  duo- 
denum in  the  gall-bladder  region  or  just  an  increased  density  localized  in  the  gall- 
bladder region,  or  evidence  of  adhesions  indicated  by  a  retraction  of  the  stomach 
and  duodenum  to  the  right.  These  findings  in  themselves  are  insufi&cient  to  make 
a  diagnosis,  but  when  associated  with  clinical  symptoms  referring  to  the  gall- 
bladder, and  when  by  Rontgenological  evidence  the  stomach,  the  duodenum, 
appendix  and  bowel  are  found  normal,  the  doubtful  evidence  above  referred  to 
is  of  some  distinct  value. 

The  Urinary  Organs. — In  a  study  of  the  urinary  organs  the  Rontgenologist 
should  be  able  to  determine  the  size  and  position  of  the  kidneys  in  a  normal 
subject  weighing  160  pounds  or  less.  In  larger  persons  only  the  best  skiagraphs 
will  show  the  outline  of  the  kidneys.  In  patients  under  160  pounds  renal  calculi 
from  the  size  of  a  No.  2  shot  to  the  largest  found,  whether  single  or  multiple,  in 
102 


i6i8  The  X-rays  in  Surgery 

one  kidney  or  both,  and  relatively  their  situation  in  the  kidneys  (except  in  stones 
composed  of  pure  uric  acid)  can  be  determined  in  Rontgenographs  of  the  best 
quality. 

Ureteral  calculi  are  suliject  to  the  same  display  as  renal  calculi.  The  course 
of  the  ureters  is  by  no  means  constant,  so  that  one  cannot  say  that  a  shadow 
lies  in  the  line  of  the  ureter  unless  this  line  be  determined  by  additional  means. 
However,  in  the  great  majority  of  instances  the  history  of  renal  colic;  a  point  of 
tenderness  on  deep  pressure;  the  presence  of  microscopical  quantities  of  blood 
in  the  urine;  the  fact  that  ureteral  calculi  are  almost  never  round,  but  oval  or  ir- 
regular, in  contrast  to  the  small  round  shadows  cast  by  phleboliths,  or  calcareous 
deposits  in  the  mucous  membrane  of  the  female  genitalia;  and,  the  mulberry 
appearance  of  calcified  lymphatic  glands,  are  sufficient  to  confirm  a  Rontgeno- 
graphic  diagnosis  of  ureteral  calculus  (see  page  1457).  Vesical  calculi  are  more 
apt  to  escape  notice  since  they  are  not  infrequently  composed  entirely  of  uric 
acid.  When  they  do  contain  more  dense  material  the  Rontgen  diagnosis  is 
usually  positive  as  to  size  and  number. 

In  the  past  few  years  great  progress  has  been  made  in  the  Rontgenographic 
study  of  surgical  conditions  of  the  urinary  organs  with  the  aid  of  ureteral 
catheterization  and  injection  of  solution  of  colloidal  silver,  argyrol,  potass 
iodid,  sodium  bromid.  The  study  demands  the  assistance  of  one  skilled  in  the 
use  of  the  ureteral  catheter,  and  this  part  of  the  subject  is  treated  of  in  another 
section  (see  pages  1452  and  1455). 

The  part  of  the  Rontgenologist  is,  to  be  prepared  to  make  Rontgenographs 
at  intervals  during  the  injection  and  with  the  patient  in  both  the  recumbent 
and  erect  postures  when  desired.  Manges  has  pointed  out  the  advantages  of 
making  these  examinations  fluoroscopically. 

The  points  of  information  gained  by  the  Rontgen  study  of  the  kidney  pelvis 
injected  with  collargol  {pyelography)  are:  the  position,  shape,  size,  and  the 
extent  of  mobility;  also  the  relation  of  the  kidney  pelvis  to  calculi  in  the  kidney^ 
ureter,  or  gall-bladder. 

The  normal  kidney  pelvis  will  hold  from  10  to  30  c.c.  of  the  solution,  and 
the  calices  are  sharp  in  outline,  branching  at  the  apices,  and  well  separated. 
The  hydronephrotic  kidney  may  hold  any  amount  above  this  to  500  c.c.  or  more. 
The  calices  are  less  separated,  the  apices  are  rounded  and  smooth,  and  all  the 
cahces  have  much  the  same  appearance.  The  pyonephrotic  kidney  may  hold 
small  or  large  quantities;  one  or  more  of  the  calices  may  be  involved,  and  the 
outline  is  irregular,  never  smooth,  as  in  hydronephrosis.  Tumors  involving 
the  kidney  produce  distortion,  but  usually  not  marked  enlargement  of  the 
pelvis  and  calices.  One  or  more  of  the  calices  may  be  long,  narrow,  and  irreg- 
ular in  outline.  Abscess  of  the  kidney  when  communicating  with  the  renal 
pelvis  permits  of  injection  with  collargol  solution,  and  shows  as  a  more  or  less 
large  shadow  external  to  the  shadow  of  the  renal  pelvis. 

The  mobility  of  the  kidney  may  be  shown  in  some  cases  by  skiagraphing 
the  injected  kidney  before  and  after  manual  displacement  of  the  organ,  but 
when  possible  the  exposures  should  be  made  with  the  patient  recumbent  one 
instant  and  erect  the  next.  The  change  must  be  made  quickly,  as  the  collargol 
promptly  leaves  the  unobstructed  pelvis.  A  stone  in  any  portion  of  the  kidney 
pelvis  will  be  included  in  the  shadow  of  the  injected  pelvis;  a  point  which  not 
only  serves  to  differentiate  stone  in  the  pelvis  from  stone  external  to  the  pelvis, 
but  shows  the  necessity  of  preliminary  Rontgen  examination. 

The  study  of  the  ureters  by  this  method  requires  that  the  ureters  be  filled 
to  their  maximum  capacity  throughout  their  entire  length  at  the  time  of  ex- 
posure. The  patient  may  be  placed  in  the  Trendelenburg  position  with  the 
ureteral  catheter  inserted  only  a  few  centimeters,  so  that  gravity  will  retain 
the  collargol  solution  in  the  ureter  and  kidney.  In  this  way  the  true  line 
of  the  ureter  and  diameter  of  the  lumen  will  be  shown.     In  a  case  of  hydro- 


The  Localization  of  Foreign  Bodies  1619 

nephrosis  due  to  ureteral  kink  associated  with  a  movable  kidney,  to  pressure 
from  without,  to  constriction  by  adhesions,  or  to  obstruction  within  the  ureter, 
there  will  be  shown  a  dilated  ureter  above  the  impediment  and  a  narrow  lumen 
below.  If  there  be  more  than  one  point  of  interference  the  ureter  will  show  a 
corresponding  number  of  areas  of  dilatation.  An  almost  completely  obstructed 
ureter  will  be  evidenced  by  the  presence  of  only  small  areas  of  collargol  shadow 
above  the  point  of  obstruction.  Here  again,  as  pointed  out  by  Fowler  and 
Stover  ("American  Quarterly  of  Rontgenology,"  Aug.,  1912),  skiagraphing  the 
patient  very  promptly  after  putting  him  in  the  erect  posture  will  often  show 
the  nature  of  the  kink.  Stone  in  the  ureter  may  be  positively  diagnosticated 
by  finding  that  collargol  will  enter  the  diverticulum  occupied  by  the  stone; 
by  noting  more  or  less  distortion  of  the  line  of  the  ureter  at  this  point  and 
dilatation  above,  if  the  stone  has  been  there  for  some  time  and  caused  obstruc- 
tion. A  stone  acting  as  a  "ball  valve"  in  the  ureter  will  be  associated  with 
dilatation  including  the  stone  shadow. 

Kelly  has  used  a  water  suspension  of  small  quantities  of  bismuth  subnitrate 
injected  into  the  bladder  and  stereo-Rontgenographs  to  show  the  presence  of 
and  extent  of  tumors  involving  the  bladder. 

In  addition  to  the  above  pathological  findings,  all  sorts  of  anomalies  and 
anatomical  peculiarities  of  the  urinary  organs  are  plainly  shown.  Kelly  and 
Lewis  prefer  an  emulsion  of  silver  iodid  to  collargol  for  pyelographic  study, 
but  the  latter  is  more  generally  used. 

The  ureteral  catheter  containing  lead  shows  the  course  of  the  ureter  less 
accurately  than  proper  injection  of  collargol,  but  does  have  the  advantage  of 
always  being  there  at  the  time  of  exposure. 

The  proper  preparation  of  the  patient  is  an  essential  requirement  in  any 
x-ray  study  of  the  urinary  organs.  This  consists  of  thorough  purgation  and 
abstinence  from  food  or  drink  for  at  least  six  hours  prior  to  the  examination. 

The  Localization  of  Foreign  Bodies. — This  subject  will  only  be  discussed 
from  the  standpoint  of  the  information  needed  by  the  surgeon,  and  not  from  the 
Rontgenologist's  standpoint.  Therefore,  technical  details  will  be  omitted. 
Only  the  principles  governing  the  various  methods  of  localization  can  be  dis- 
cussed, so  that  the  surgeon  will  understand  the  nature  of  the  information  which 
is  presented  to  him  by  the  Rontgenologist.  The  value  of  the  localization  will 
depend  on  the  skill  of  the  Rontgenologist  and  the  clearness  with  which  he  can 
present  the  information  to  the  surgeon. 

Characters  of  Foreign  Bodies.— M&ta]\iQ.  bodies,  such  as  bullets,  pieces  of 
steel  or  iron,  pins,  needles,  tin,  zinc,  brass,  etc.,  can  be  detected  in  any  portion 
of  the  body,  and  accurately  localized.  Fragments  of  stone,  granite,  marble  and 
lead  glass  can  be  localized  except  when  very  small  and  deeply  situated.  Drain- 
age tubes  and  iodoform  gauze  if  lost  in  a  sinus  or  cavity  can  be  demonstrated. 
Anthracite  coal,  glass  (other  than  lead  glass)  or  splinters  of  wood  are  difficult 
to  detect  unless  they  are  of  considerable  thickness,  are  not  superimposed  by 
bone,  and  are  imbedded  in  surface  structures,  so  that  the  body  can  be  brought 
close  to  the  sensitive  plate.  Sometimes  splinters  of  wood  or  other  transparent 
bodies  can  be  localized  because  of  metallic  dust  or  dirt  that  has  been  carried 
into  the  wound  by  the  foreign  body. 

The  Preparation  of  the  Patient. — The  clothes  should  always  be  removed  from 
the  part  to  be  examined,  and  when  at  aU  possible,  dressings  should  be  removed. 
In  fact,  satisfactory  localization  cannot  be  made  through  dressing,  and  when  a 
dressing  is  needed  it  should  be  at  least  no  more  than  packing  in  an  open,  bleed- 
ing wound.  When  practical,  the  skin  covering  the  part  to  be  examined,  should 
be  cleansed,  so  that  marks  placed  upon  the  skin  by  the  Rontgenologist  can  re- 
main there.  The  foreign  body  should  be  removed  as  soon  after  localization  as 
is  possible,  not  only  because  of  infection  which  is  likely  to  be  carried  into  the 
wound  by  the  foreign  body,  but  because  sharp-pointed  foreign  bodies,  such  as 


l620 


The  X-rays  in  Surgery 


needles  or  pieces  of  steel,  are  apt  to  be  moved  from  their  point  of  localization 
by  the  action  of  the  muscles  so  that  when  operation  is  attempted,  the  foreign 
body  cannot  be  found  at  the  point  at  which  it  was  originally  localized.  The 
manipulation  of  a  part  may  displace  the  foreign  body.  For  instance,  needles 
have  been  forced  out  of  the  tissues  of  the  foot  merely  during  the  process  of  scrub- 
bing and  preparing  the  foot  for  operation.  When  practical,  the  Rontgenologist 
should  be  present  at  the  operation,  but  in  all  instances,  there  should  be  sufficient 
cooperation  between  the  surgeon  and  the  Rontgenologist  to  permit  the  surgeon 
to  understand  thoroughly  the  markings  and  information  given  by  the  Rontgen- 
ologist in  each  particular  case. 


liG.   1 1 13.— Bullet  localized  by  Manges  by  means  of  stereoscope.     Removed  by  author. 

Choice  of  Methods  of  Localization. — The  method  of  choice  for  the  localization 
of  foreign  bodies  will  depend  first,  upon  the  character  of  the  equipment  in  any 
particular  hospital;  second,  the  form  or  character  of  the  foreign  body;  third, 
upon  its  probable  location,  and  fourth  upon  the  opportunity  that  the  Rontgen- 
ologist has  had  of  perfecting  his  technic. 

Preparation  of  the  Patient. — The  patient  should  always  be  examined  with  the 
part  in  the  position  in  which  it  is  likely  to  be  placed  during  operation.  That  is, 
if  the  patient  will  require  a  general  anesthetic  he  will  likely  be  in  a  recumbent 
or  supine  position. 

Principles  of  Localization  of  Foreign  Bodies. — The  .r-rays  move  in  a  straight 
line  from  their  source,  and  cannot  be  deflected.  Therefore  any  opaque  body  in 
the  path  of  these  rays  will  project  a  shadow  in  a  straight  line  between  the  source 
and  the  point  of  recording,  whether  the  shadow  be  recorded  on  the  photographic 
plate,  or  whether  it  be  observed  upon  a  fluorescent  screen.  Therefore,  for  pur- 
poses of  localization  of  a  foreign  body,  one  must  know  the  relation  of  the  source 
of  the  rays  on  the  target  of  the  .v-ray  tube  and  the  position  of  the  shadow  on  the 
fluorescent  screen  or  photographic  plate  in  relation  to  the  point  of  the  object 
under  observation.  The  central  ray  is  a  ray  passing  from  the  center  of  the 
target  through  the  center  of  a  foreign  body.  This  central  ray  should  if  possible 
be  made  vertical  to  the  plate  or  to  the  fluorescent  screen  in  one  position,  and  by 
closing  the  diaphragm  until  it  is  very  small,  under  fluoroscopic  study,  this  can 
easily  be  accomplished,  by  moving  the  tube  until  the  foreign  body  is  brought 
directly  in  the  center  of  the  small  field  upon  the  fluorescent  screen.     When  the 


The  Localization  of  Foreign  Bodies  162 1 

central  ray  has  been  made  to  pass  perpendicularly  through  the  center  of  a 
foreign  body  we  have  at  once  localized  the  foreign  body  in  the  two  vertical 
planes,  but  one  must  never  judge  the  position  of  a  foreign  body  from  any  single 
exposure  on  a  plate  or  screen,  for  its  depth  can  never  be  determined  by  such  a 
single  exposure.  If  the  part  under  examination  and  the  foreign  body  are  kept 
in  a  fixed  position  and  the  tube  be  moved,  the  shadow  of  the  foreign  body  will  be 
projected  at  a  different  point.  This  second  central  ray  also  passes  through  the 
foreign  body  and  at  the  point  where  these  two  central  rays  cross,  the  vertical 
ray  and  the  ray  of  displacement  will  give  the  depth  of  the  foreign  body.  All 
methods  of  localization,  therefore,  depend  upon  the  determination  of  this  depth 
point  and  the  variation  in  the  method  is  only  a  means  of  finding  the  point  of 
crossing  in  these  two  central  rays.  The  foreign  body  must  be  located  with 
reference  to  some  definite  landmark  placed  upon  the  skin.  This  landmark  is 
usually  made  by  means  of  some  indelible  ink.  If  the  photographic  method  of 
localization  be  used  this  landmark  can  be  recorded  by  placing  over  the  indelible 
mark  on  the  skin  an  opaque  body  such  as  a  pair  of  crossed  pins,  a  ring  or  a 
definitely  shaped  metallic  ball.  The  Rontgenologist  determines  the  relation 
of  the  foreign  body  to  the  landmark  on  the  skin.  It  is  important,  therefore, 
preceding  the  operation  and  during  the  operation  that  this  landmark  on  the 
skin  should  be  preserved.  It  is  the  duty  of  the  Rontgenologist,  so  far  as  is 
practical,  to  localize  the  foreign  body  in  relation  to  certain  anatomical  structures 
or  landmarks  so  that  if  the  skin  mark  be  lost  the  surgeon  can  find  the  foreign 
body  in  its  relation  to  the  bones  and  anatomical  structures. 

Methods  of  Localization. — The  methods  of  localization  may  be  divided  into 
two  great  groups;  the  fluoroscopic  and  the  photographic.  The  fluoroscopic 
has  the  advantage  of  speed,  and  therefore  during  military  operations  in  evacua- 
tion hospitals  where  patients  must  be  examined  in  the  shortest  period  of  time, 
the  fluoroscopic  is  the  only  practical  method.  It  has  the  disadvantage  of  being 
less  accurate  and  more  dangerous  to  the  operator  and  even  to  the  patient  if 
prolonged,  though  by  modern  technic  there  is  practically  no  danger  to  the  patient. 
No  technic  is  described. 

It  is  only  in  the  hands  of  an  amateur  Rontgenologist,  or  of  a  surgeon  who  is 
assuming  the  role  of  a  Rontgenologist,  that  the  fluoroscopic  localization  of 
foreign  bodies  is  a  danger  both  to  the  patient  and  to  himself.  In  this  group  of 
cases,  however,  extreme  accuracy  is  not  so  important  as  speed,  for  in  modern 
wars  the  projectiles  are  not  small  and  the  injuries  are  usually  great.  In  connec- 
tion with  the  Rontgenology  in  the  recent  world  war.  Col.  Case  very  aptly  says: 
"This  war  is  not  being  fought  with  bird-shot,  and  the  localizations  as  a  rule  to 
3^^  centimeter  will  be  entirely  satisfactory."  In  the  fluoroscopic  methods  of 
localization  of  foreign  bodies  every  precaution  for  the  protection  of  the  opera- 
tor, so  far  as  is  practical,  should  be  observed,  for  constant  exposure  of  the 
operator  to  the  rays  for  many  hours  of  every  day  is  bound  to  do  harm.  In 
all  fluoroscopic  methods  of  localization  the  Rontgenologist  should  first  make  a 
general  exploration  of  the  injured  portion  of  the  body  to  determine  the  num- 
ber of  fragments  or  foreign  bodies  present,  and  their  general  location  and  size. 
He  then  centers  the  tube  so  that  the  central  ray  passing  through  the  foreign  body 
is  vertical  to  the  fluorescent  screen.  The  diaphragm  controlling  the  beam  of 
rays  is  reduced  to  the  smallest  practical  size.  The  tube  is  moved  until  the 
foreign  body  is  brought  exactly  in  the  center  of  the  fluorescent  field.  A 
mark  is  then  made  upon  the  skin  of  the  patient  directly  over  the  point  of  exit 
of  the  central  ray.  This  can  usually  best  be  accomplished  by  passing  the 
pencil  directly  through  a  hole  made  in  the  screen  after  the  screen  has  been 
so  placed  that  said  hole  falls  directly  over  the  foreign  body,  or  the  Bowen  marker 
may  be  used  to  advantage.  We  then  know  that  in  the  position  in  which  the 
patient  is  lying  at  that  time,  the  foreign  body  is  in  a  direct  vertical  line  from  the 
point  marked  on  the  skin.     Its  depth,  however,  has  not  been  determined. 


1 62 2  The  X-rays  in  Surgery 

The  tube  is  then  moved  a  certain  distance,  according  to  the  method  used.  The 
displacement  of  the  shadow  of  a  foreign  body  in  relation  to  this  vertical  ray,  and 
in  relation  to  this  mark  on  the  skin  is  determined.  By  various  methods  the 
depth  of  a  foreign  body  is  then  obtained.  When  dealing  with  the  lingers  or  the 
extremities,  one  can  sometimes  mark  the  localization  of  the  foreign  body  as 
indicated  by  the  central  ray  in  one  position,  then  rotate  the  part  of  the  extremity 
at  right  angles,  and  determine  again  the  position  of  the  foreign  body  by  the 
vertical  ray  passed  at  right  angles  to  the  original  vertical  ray,  and  in  this  way 
the  depth  can  be  definitely  determined.  The  fluoroscopic  localization  of  foreign 
bodies  is  usually  done  in  a  darkened  room  with  a  tube  under  the  table,  the  top 
of  which  is  transparent  to  the  .r-rays.  In  the  army,  the  ordinary  army  stretchers 
are  usuallv  employed.  The  tube  under  the  table  is  capable  of  movement  in  at 
least  two  directions.  There  should  be  a  diaphragm  controlling  the  outlet  of  the 
rays  so  that  they  may  be  reduced  to  a  minimum.  The  excitement  of  the 
tube  should  be  usually  controlled  by  a  foot  switch.  In  this  way  the  amount 
of  exposure  can  be  reduced  to  a  minimum.  In  the  evacuation  hospitals  in 
many  instances  the  localization  of  the  foreign  body  was  combined  with  the 
operation,  the  surgeon  and  the  Rontgenologist  working  intermittently  with 
ruby  light  for  the  surgeon,  and  with  darkness  for  the  Rontgenologist.  When 
the  stereoscopic  fluoroscope  is  finally  made  practical  for  every-day  use,  the  com- 
bined operation  by  the  surgeon  and  Rontgenologist  for  the  removal  of  foreign 
bodies  will  probably  displace  all  other  methods.  The  stereoscopic  fluoroscope 
was  developed  by  Caldwell  almost  to  perfection. 

The  Rontgeno graphic  method  of  localization  has  the  advantage  of  accuracy 
and  safety,  at  the  expense  of  speed.  The  examinations  are  usually  made  in  a 
well-lighted  room  with  the  patient  lying  on  the  Rontgenographic  table  with  the 
tube  over  the  top  instead  of  underneath.  The  patient  is  fixed  in  a  definite 
position,  and  an  opaque  marker  is  placed  upon  some  part  of  the  skin  and  the 
relation  of  the  tube  to  this  mark  is  recorded.  Exposures  are  then  made  in  two 
different  positions.  If  the  height  of  the  opaque  mark  on  the  skin  from  the  sur- 
face of  the  plate  has  been  recorded,  the  positions  of  the  tube  can  be  determined 
by  cross  threads  and  then  with  the  same  cross  threads  leading  from  the  posi- 
tions of  the  tube  to  the  shadows  of  the  foreign  body  one  can  determine  the 
depth  and  the  exact  location  of  the  foreign  body  in  its  relation  to  the  skin  mark. 
By  this  method  the  patient  is  absolutely  safe  from  any  danger  of  exposure  to 
the  rays,  and  the  operator  is  out  of  the  field  of  the  rays.  The  plates  must  be 
developed,  washed,  dried,  and  then  the  calculations  made,  after  which  the  opera- 
tion can  take  place.  It  is  therefore  not  practical  where  the  removal  of  a  foreign 
body  must  be  made  within  an  hour  or  two  after  the  patient  reaches  the  hospital. 

Methods  of  Localization  Adopted  by  the  Surgeon  General's  Office  in  the  United 
States  Army  (U.  S.  Army  X-ray  Manual). — After  receiving  reports  of  both 
surgeons  and  Rontgenologists  abroad,  and  after  conference  with  Col.  James 
Case,  it  was  decided  to  adopt  and  provide  apparatus  for  seven  different  methods. 
They  are  as  follows: 

These  methods  can  only  be  described  briefly  so  that  the  surgeon  can  under- 
stand the  principles  involved,  and  in  a  general  way  have  an  idea  how  localiza- 
tions are  made,  but  the  space  allotted  to  the  subject  will  not  permit  a  detailed 
discussion  of  technic. 

The  Nearest-point  Method. — This  method  has  the  advantage  of  simplicity, 
great  speed,  with  a  fair  degree  of  accuracy.  The  method  consists  in  palpating 
under  fluoroscopic  observation  the  soft  tissues  surrounding  the  projectile.  The 
instrument  used  for  this  palpation  is  a  wooden  rod  a,bout  lo"  long  with  a  wooden 
screw  or  some  similar  piece  of  metal  at  each  end.  Under  the  screen  the  wood  is 
almost  invisible,  and  the  only  clearly  defined  shadow  is  that  cast  by  the  metal. 
By  the  movement  of  the  projectile  under  pressure  on  the  tissues  surrounding  it, 
and  the  amount  of  pressure  used,  the  operator  is  able,  with  care  and  ability, 


The  Localization  of  Foreign  Bodies  1623 

to  judge  what  point  of  the  skin  is  nearest  the  projectile  and  also  the  depth  of 
the  latter.  Obviously,  palpation  at  a  very  near  point  will  ordinarily  cause  much 
greater  movement  of  the  {projectile  than  will  palpation  at  a  more  remote  point. 
Likewise,  palpation  will  cause  greater  displacement  in  the  very  soft  tissues 
than  it  will  in  the  more  firm.  Skill  in  this  method  increases  with  continuous 
use,  and  a  sense  of  pressure  is  developed  that  proves  a  valuable  aid  to  speed 
and  accuracy.  To  the  beginner  in  this  method  it  is  recommended  that  he 
combine  with  palpation  the  principle  of  method  B.  by  shifting  his  tube  and 
observing  relative  displacement  of  the  projectile  and  the  palpating  stick.  The 
nearest-point  method  is  applicable  to  localization  of  projectiles  in  the  soft 
tissues,  the  extremities,  the  axilla,  scrotum  and  buttocks,  but  not  to  the  more 
vital  and  less  palpable  regions  of  the  head,  thorax  and  abdominal  cavity.  By 
practice,  one  becomes  accustomed  to  palpating  the  soft  tissues  around  the 
foreign  body,  and  by  what  is  termed  light  and  deep  palpation  to  determine  the 
depth  of  the  projectile  from  the  nearest  point  on  the  skin  surface.  Even  if 
the  foreign  body  cannot  be  displaced  by  pressure  with  a  palpating  stick,  this 
information  is  often  of  great  value,  showing  the  projectile  must  be  in  a  joint, 
against  a  bone  or  imbedded  in  deep  tissue.  An  indelible  mark  is,  of  course, 
placed  upon  the  skin  at  this  "nearest  point,"  and  a  statement  is  given  to  the 
surgeon  as  to  the  probable  depth  at  this  point.  This  method  is,  in  brief,  adapted 
to  localization  in  the  extremities  and  soft  parts  of  the  body,  under  advanced 
hospital  conditions  where  a  rapid  examination  of  the  patient  is  a  matter  of  great 
importance. 

The  other  methods  adapted  for  use  in  the  army  have  been  designated  in  the 
Army  Manual  by  letters  instead  of  by  the  names  of  those  responsible  for  theif 
development.  This  is  not  done  with  any  idea  of  discrediting  the  author,  or  of 
indicating  novelty,  and  for  the  sake  of  brevity  the  same  idea  will  be  carried  out 
in  these  paragraphs.     The  more  accurate  methods  are  as  follows: 

A.  Two-wire  double  tube  shift  method. 

B.  Parallax  method. 

C.  Tube-shift  method,  with  mechanical  triangulation. 

D.  Profondometer. 

E.  Hirtz  compass  with  accessory  devices. 

F.  Cannula  and  trocar,  with  harpoon. 

Method  A  (Strohl). — Briefly  the  method  consists  in  fixing  the  hole  in  the 
screen  directly  over  the  central  vertical  ray.  A  mark  is  then  made  through  the 
hole  upon  the  skin.  A  diamond-shaped  diaphragm  or  opening  on  the  top  of  the 
tube  box  has  a  small  wire  stretched  across  each  of  two  opposite  corners.  The 
tube  is  then  moved  either  right  or  left  in  the  line  connecting  these  two  corners, 
first  in  one  direction  until  the  shadow  of  the  wire  on  the  tube  box  coincides  with 
the  shadow  of  the  foreign  body.  The  tube  is  then  moved  in  the  opposite  direc- 
tion until  the  opposite  cross  wire  coincides  with  the  shadow  of  the  foreign  body. 
The  distance  between  these  two  displacement  shadows  is  then  measured  and 
the  depth  of  the  foreign  body  is  then  found  according  to  a  scale  which  is  furnished 
with  the  outfit.  Li  all  fluoroscopic  studies  it  is  an  advantage  to  mark  the  point 
of  entrance  and  the  point  of  exit  of  the  vertical  ray.  This  can  be  done  by  means 
of  the  skin  marker,  designed  by  Bowen,  which  can  be  pushed  under  the  part 
of  the  body  examined  until  the  entrance  of  the  vertical  ray  coincides  with  the 
shadow  of  the  foreign  body  and  similarly  pushed  under  the  screen  until  it  coin- 
cides with  the  exit  of  the  vertical  ray. 

Method  B. — This  method  utilizes  the  optical  principles  of  parallax  and  may 
be  carried  out  with  extremely  simple  apparatus,  although  a  more  elaborate 
device  has  been  provided  by  Jordon  and  by  Lane.  If  one  o'bserves  the  shadow 
of  a  projectile  upon  the  fluoroscopic  screen  while  the  tube  is  moving  and  the 
projectile  be  very  close  to  the  screen,  the  shadow  movement  for  a  given  tube- 
shift  will  be  very  slight,  and  the  part  of  the  body  removed  from  the  screen  or 


1624  The  X-rays  in  Surgery 

in  other  words,  the  greater  the  depth  the  greater  will  be  the  extent  of  the 
shadow  motion.  If  we  adjust  a  suitable  opaque  body  outside  of  the  patient 
until  the  shadow  moves  the  same  distance  for  a  definite  tube-shift  as  has  been 
moved  by  the  shadow  of  the  projectile  for  the  same  tube  displacement,  the 
auxiliary  body  must  then  be  in  the  same  plane  as  the  projectile  whose  depth  is 
sought.  For  this  purpose  one  may  use  the  stick  with  the  screw  in  the  end,  de- 
scribed under  the  nearest-point  method,  and,  for  example,  if  one  is  localizing  a 
foreign  body  in  the  thigh,  the  screen  is  placed  over  the  top  of  the  thigh,  the 
central  ray  found,  and  indelibly  marked  at  its  entrance  under  the  thigh  and  on 
top  of  the  thigh.  The  screw-head  of  the  stick  in  the  "nearest  point  method"  is 
then  held  in  the  same  vertical  plain  and  moved  upward  and  downward  until  it  is 
found  that  the  shadow  of  the  screw-head  moves  equally  with  the  shadow  of  the 
foreign  body.  This  necessarily  indicates  the  depth  of  the  foreign  body.  The 
apparatus  devised  for  this  method  of  localization  is  provided  with  three  hori- 
zontal arms,  one  of  which  passes  under  the  patient  and  is  fixed  in  the  position 
of  the  entrance  of  the  central  ray;  another  arm  is  adjusted  on  top  of  the  part 
under  examination  so  that  the  opening  in  the  end  corresponds  to  the  exit  of  the 
central  ray;  and  the  third  arm,  attached  to  a  vertical  post,  is  adjustable  in  this 
vertical  plain  so  that  when  the  depth  of  a  foreign  body  has  been  determined  its 
depth  from  above,  below,  or  laterally  can  be  read  off  from  a  scale  marked  on 
the  rods  and  vertical  posts. 

Method  C. — This  is  a  single  tube  shift  method  with  mechanical  triangulation. 
Fluoroscopically  one  again  locates  the  vertical  ray,  and  marks  its  entrance  and 
exit  on  the  part  under  examination.  The  exact  distance  between  the  target 
t)f  the  tube  and  the  fluorescent  screen  must  be  recorded.  The  tube  is  then 
moved  a  definite  measured  distance.  The  amount  of  movement  of  the  shadow 
of  the  foreign  body  is  then  recorded.  By  means  of  two  crossing  straight  lines 
drawn  upon  paper,  or  by  means  of  two  cross  strings  attached  to  the  wall,  or  by 
a  special  apparatus  with  adjustable  arms,  one  replaces  the  positions  of  the  tube 
and  the  two  shadows  on  the  screen  as  above  recorded,  and  at  a  point  where 
these  two  lines  cross  is  located  the  depth  of  the  foreign  body.  This  depth  is  then 
measured  on  the  vertical  post  or  vertical  string.  If  the  screen  be  not  in  direct 
contact  with  the  skin,  the  amount  of  separation  of  the  screen  from  the  skin  must 
be  subtracted  from  the  depth  as  above  determined. 

Method  D. — The  Profondometer  (Flint).  This  method  consists  effectually 
in  securing  three  lines  of  sight  through  the  part  under  examination,  each  of  which 
is  to  pass  through  the  projectile.  In  other  words,  on  the  fluoroscopic  table  the 
vertical  ray  is  marked  at  its  point  of  entrance  and  exit  as  previously.  The  part 
of  the  body  is  then  rotated,  and  another  line  of  entrance  and  exit  of  the  vertical 
ray  is  obtained  in  the  same  plane  as  before,  and  a  third  similar  line,  all  of  these 
lines  to  pass  through  the  foreign  body.  Two  pieces  of  flexible  metal,  such  as 
tin,  are  hinged  together  in  the  middle  and  then  moulded  around  the  part  of  the 
body  in  the  plane  indicated  by  the  skin  marks  and  made  to  conform  to  the 
shape  of  this  part  of  the  body.  The  skin  marks  are  transferred  to  this  metallic 
band.  After  removing  the  latter  from  the  body  they  may  be  laid  down  on  a 
card  or  a  sheet  of  paper,  and  by  bringing  the  overlapping  ends  to  the  original 
position,  a  tracing  with  a  pencil  will  show  the  outline  of  the  body  in  the  plane  of 
examination.  The  skin  mark  positions  are  then  transferred  to  the  diagram,  and 
we  have  an  approximate  duplicate  of  the  shape  of  the  body,  and  the  location  of 
the  external  skin  markings.  An  atlas  of  cross-sections  of  various  parts  of  the 
body  is  used  conjointly. 

Method  E. — The  Hirtz  compass  with  accessory  devices.  Twenty-seven 
pages  are  devoted  to  the  description  of  the  Hirtz  compass,  its  accessories  and 
its  use  in  the  U.  S.  Army  Manual,  or  the  x-ray  Manual,  and  a  careful  study  of 
these  twenty-seven  pages  is  recommended  to  any  who  intend  to  use  this  method 
of  localization.     Briefly  the  method  consists  in  finding  the  location  of  a  foreign 


The  Localization  of  Foreign  Bodies  1625 

body  fluoroscopically  by  one  of  the  first  three  methods  previously  described. 
The'  Hirtz  compass  consists  of  a  central  rod,  to  which  is  attached  three  adjust- 
able arms  standing  on  three  adjustable  legs,  or  rods  used  as  legs.  At  the  top 
of  the  central  rod  is  attached  an  arch,  and  at  the  outer  edge  of  this  arch  is 
attached  an  indicating  rod,  which  is  used  to  point  to  the  foreign  body.  After 
the  depth  of  the  foreign  body  has  been  determined  this  central  rod  on  the 
compass  is  adjusted  in  line  with  the  vertical  ray  passing  through  the  foreign 
bodv,  and  the  three  legs  on  tliis  Hirtz  compass  are  adjusted  so  as  to  conform 
to  the  shape  of  the  body,  and  three  marks  are  made  to  record  the  positions 
on  the  skin,  or  metallic  washers  are  attached  to  the  skin  at  the  point  where 
these  legs  touch.  After  careful  adjustment,  the  compass  is  fixed  in  position  and 
is  sterilized  to  be  replaced  on  the  skin  of  the  body  at  the  time  of  the  operation, 
and  it  gives  the  surgeon  the  advantage  of  using  the  arch  at  the  top  of  the  com- 
pass to  move  about  the  central  axis  through  360  degrees,  and  in  an  area  measured 
by  the  extent  of  the  length  of  the  arch  at  the  top  of  the  central  pin.  It  gives 
the  surgeon  the  advantage  of  choosing  many  points  for  his  incision,  and  always 
having  the  indicating  pin  directing  to  the  foreign  body  and  at  the  same  time 
indicating  its  depth  from  his  chosen  point  as  measured  by  the  indicating  rod. 
The  preparation  of  this  record  by  the  Rontgenologist  is  rather  compHcated. 
Its  use  bv  the  surgeon  is  simple.  If  any  of  the  adjustment  screws  become  loos- 
ened or  anv  of  the  arms  displaced  between  the  time  of  locaHzation  and  the  time 
of  operation,  all  the  work  is  lost,  or  must  be  repeated. 

Method  F.  Cannula  and  Trocar  with  Harpoon. — This  method  is  considered 
as  the  least  desirable  of  all  of  the  methods  adopted,  and  it  is  urgently  advised 
that  it  never  be  used  excepting  in  the  hands  of  an  operator  who  will  either  work 
under  the  direct  supervision  of  a  competent  surgeon  or  anatomist,  or  one  who 
has  acquired  that  degree  of  anatomical  knowledge  and  surgical  judgment  which 
would  permit  of  its  use  without  danger  to  the  patient.  The  method  conists 
in  finding  the  projectile  as  in  the  first  three  methods  described.  Then  hi  direct 
hne  with  the  vertical  ray,  and  never  at  an  angle  to  this,  a  trocar  is  inserted 
through  the  skin.  A  cannula  is  then  pushed  down  directly  in  the  line  of  the  ver- 
tical rav,  until  it  touches  the  foreign  body.  A  piece  of  piano-wire  bent  at  one 
end  in  the  form  of  a  hook  is  then  passed  into  the  cannula  until  it  passes  through 
the  opposite  end  against  the  foreign  body.  The  hook  then  catches  in  the  flesh, 
the  cannula  is  withdrawm,  the  piano-wire  is  bent  over  and  attached  firmly  to  the 
skin.  Tliis  serves  as  a  guide  to  the  surgeon  in  hunting  for  the  foreign  body. 
The  method  is  considered  dangerous  and  is  very  faulty  unless  the  cannula  be 
kept  absolutelv  perpendicular  and  in  direct  line  with  the  vertical  ray  passing 
through  the  projectile. 

Fluoroscopic  Assistance  During  Operation. — As  soon  as  stereoscopic  fluoros- 
copy (Caldwell)  becomes  practical,  it  is  likely  that  most  foreign  bodies  will  be 
removed  under  the  guidance  of  the  stereoscopic  fluoroscopy  At  present  the 
removal  of  foreign  bodies  under  the  guidance  of  direct  fluoroscopy  by  the  sur- 
geon is  not  usually  satisfactory  because  it  is  rare  that  the  surgeon  has  attained 
sufficient  skill  to  make  aUowance  for  the  distortion  due  to  obhque  rays,  and 
unless  the  surgeon  becomes  a  Rontgenologist,  or  the  Rontgenologist  a  surgeon, 
the  method  will  continue  to  have  many  objections.  In  all  instances  it  involves 
considerable  exposure  of  the  hands,  considerable  work  in  the  dark,  and  there  is 
always  the  risk  of  damaging  the  anatomical  structures. 

The  foUo^-ing  methods  may  be  used  for  combined  work.  First.  The  .v-ray 
work  may  be  done  in  the  surgical  operating  room,  thus  affording  the  surgeon  who 
operates  special  Hght,  which  may  be  extinguished  when  he  desires  to  examine 
fluoroscopicaUy.  Second.  The  patient  may  be  returned  to  the  .r-ray  room  when 
the  surgeon  requires  further  information.  Third.  The  Rontgenologist  may  be 
called  to  the  operating  room  for  temporary  assistance  in  pointing  out  the 
position  of  the  projectile.  Fourth.  The  operation  may  be  performed  with 
special  forceps  while  using  the  fluoroscopic  Hght  as  a  guide. 


1626 


The  X-rays  in  Surgery 


Depth  of  Anatomical  Landmarks  Beneath  the  Skin. — Metcalf  and  Keys- Wells 
have  published  the  following  table^  in  the  Lancet  of  May  27,  1916  for  the  pur- 
pose of  giving  surgeons  assistance  in  determining  the  exact  position  of  a  foreign 
body  in  relation  to  points  on  the  skeleton.  By  reference  to  this  table  the  sur- 
geon will  better  grasp  the  structure  to  which  a  certain  depth  will  lead  him  when 
the  depth  is  given  to  him  by  the  Rontgenologist,  as  measured  from  the  sur- 
face of  the  skin.  These  measurements  have,  of  course,  been  calculated  for  the 
average  soldier,  and  soldiers  are  generally  neither  very  fat  nor  very  thin.  This 
fact  must  be  borne  in  mind  in  considering  these  measurements. 


HEAD:  LATER.\LLY 

Incision 


Just  above  zygoma. 


Just  below  zygoma 

To  coronoid  process  or  condyle  of  mandible 

NECK:  ANTEROPOSTERIORLY 

Through  center  of  larynx 

3  cm.  to  side  of  center  of  larynx 


3  cm.  to  side  of  center  of  larjnx 

Through  middle  line  of  trachea  just  below  cricoid . 
3  cm.  to  side  of  center  of  trachea 


From  center  of  suprasternal  notch. 


NECK:  LATER.ALLY 
From  center  of  middle  of  neck 


From  center  of  middle  of  neck 

From  just  below  tip  of  mastoid  process . 


CHEST:  SUPERIORLY 
From  a  point  midway  between  root  of  neck  and  tip  of  acromion. 

From  a  point  midway  between  internal  and  external  extremitieS| 
and  just  behind  posterior  border  of  the  clavicle I 

CHEST:  ANTERIORLY 

From  center  of  lower  border  of  clavicle  backward  to  subscapular 
fossa  just  clear  of  ribs 

From  a  point  just  over  tip  of  coracoid  to  subscapular  fossa  back- 
ward     I 

From  a  point  2.5  cm.  external  to  sternoclavicular  joint  just  below 
clavicle 

From  a  point  2.5  cm.  external  to  sternoclavicular  joint  just  below 
clavicle 

From  a  point  5  cm.  external  to  sternoclavicular  joint  just  below 
clavicle  backward 

From  a  point  5  cm.  external  to  sternoclavicular  joint  just  below 
clavicle  backward 

From  a  point  S  cm.  below  center  of  clavicle 

CHEST:  POSTERIORLY 

To  supraspinous  fossa 2.5  cm. 

To  intraspinous  fossa 2  cm. 

To  transverse  process  of  7  th  cervical  vertebra 4  cm. 

To  pleura  level  of  7th  cervical  vertebra S  cm. 

To  anterior  level  of  body  of  7th  cervical 7.5  cm. 

To  transverse  process  of  12th  dorsal  vertebra 3.5  cm. 

To  pleura  level  of  12th  dorsal  vertebra I  S  cm. 

To  anterior  level  of  body  of  12th  dorsal  vertebra 8.5  cm 


DEPTH    OF     ANATOM- 
ICAL POSITION 

2.5  cm.  to  sphenosquamo- 
sal  suture. 

4  cm.  to  sphenoidal  bone. 
2.5  cm. 

5  cm.  to  body  of  vertebra. 
4  cm.  to  transverse  process 

of  cervical  vertebra. 
7.4  cm.  total  depth  of  neck. 
4  cm.  to  body  of  vertebra. 
4  cm.  to  transverse  process 

of  vertebra. 

3  cm.  to  posterior  border  of 
manubrium. 

4  cm.  to  transverse  process 
of  vertebra. 

6  cm.  to  body  of  vertebra. 
6  cm.  to  body  of  ist  cer- 
vical. 

5  cm.  to  apex  of  pleura, 
downward. 

5   cm.   to  apex  of  pleura, 
downward. 


7-5  cm. 
7-5  cm. 
3.5  cm.  to  ist  rib. 

2  cm.  to  pleura. 

3  cm.  to  ist  rib. 

4.5  cm.  to  pleura. 
5  cm.  to  pleura. 


^  These  depths  were  given  in  inches  in  the  original  table  but  were  converted  into  centimeters 
for  publication  in  the  United  States  .\rmy  .v-ray  Manual,  from  which  this  table  has  been  copied. 


The  Localization  of  Foreign  Bodies  1627 


ABDOMEN:  THICKNESS  OF  WALL  ERO.M  ERONT 


I  cm.  to  either  side  of  middle  line  just  above  umbilicus 

I  cm.  to  either  side  of  middle  line  just  below  umbilicus 

Just  internal  to  anterior-superior  spine  to  iliac  fossa 7.5  cm 

^lidway  between  anterior-superior  spine  and  pubic  crest  to  front  of 

acetabulum 

5  cm. 
ABDO.MEN:  THICKNESS  OF  W.\LL  ERO.M  SIDE 
On  level  of  tip  of  12th  rib  in  line  upward  from  anterior-superior 

spine 2.5  cm. 

ABDO-MEN:  THICKNESS  OF  W.ALL  ER0:M  BACK 

To  transverse  process  3d  lumbar 4.5  cm. 

To  anterior  level  of  body  of  3d  lumbar 1  11  cm. 

To  anterior  level  of  psoas  muscle 13  cm. 

HIP  AND  THIGH  FROM  FRONT  , 

8  cm.  below  anterior-superior  spine  to  head  of  femur 16  cm. 

8  cm.  below  anterior-superior  spine  to  neck  of  femur I  5-7  cm. 

15  cm.  below  anterior- superior  spine  (level  of  lesser  trochanter)  to 

front  of  femur 4  cm. 

To  greater  trochanter ;  1 1  cm. 

To  lesser  trochanter !  Q  cm. 

Brim  of  pelvis  2.5  cm.  in  front  of  sacroiliac  synchondrosis i  9.5  cm. 

To  anterior-inferior  spine 3  cm. 

To  spine  of  ischium 12.5  cm. 

To  ischial  tuberosity |  13  cm. 

To  anterior  surface  of  line  of  junction  of  ascending  ramus  of 

ischium  and  descending,  of  pubis 7  cm. 

HIP  AND  THIGH  FR0:M  BACK 

To  ischial  tuberosity 6  cm. 

To  spine  of  sacrum  on  level  of  posterior-superior  spines  of  ilia..      3  cm. 

To  sacral  groove 5  cm. 

To  head  of  femur 5  cm. 

To  great  trochanter 9  cm. 

To  lesser  trochanter |  7-5  cm. 

To  brim  of  pelvis  25  cm.  in  front  of  sacroiliac  SAmchondrosis. . .  .  1  10  cm. 

To  anterior- inferior  spine !  i.=>  cm. 

To  spine  of  ischium 5  cm. 

To  posterior  surface  of  junction  of  ascending  ramus  of  ischium  and 

descending  ramus  of  pubis n  cm. 


DEPTH    OF     ANATOM- 
ICAL POSITION 
2.5  cm. 
3  cm. 


Rontgeno graphic  Methods  of  Localizing  Foreign  Bodies, — There  are  really 
a  hundred  or  more  methods  of  localizing  foreign  bodies,  and  many  more  modifi- 
cations of  methods.  Only  two  or  three  of  the  simplest  and  most  practical 
methods  will  be  referred  to',  and  these  only  briefly  so  that  the  surgeon  or  surgical 
student  may  understand  the  principles  involved. 

(i)  Rontgeno  graphs  at  Right-angles. — This  method  can  usually  apply  to 
foreign  bodies  in  the  extremities,  and  the  position  of  the  foreign  body  is  usually 
easily  comprehended  by  the  surgeon.  An  opaque  marker,  such  as  a  pair  of 
crossed  pins,  or  a  metallic  ring,  is  placed  upon  the  skin  at  the  point  of  entrance, 
or  near  to  the  point  at  which  the  foreign  body  is  likely  to  be  foimd.  With  the 
patient  lying  upon  his  back,  or  the  extremity  lying  in  the  position  in  which  it  is 
most  likely  to  be  operated  upon,  a  plate  is  made  with  the  anode  or  target  cen- 
tered directly  above  the  opaque  marker.  The  fingers  or  the  extremity  is  then 
rotated  at  right  angles,  and  another  plate  made  in  the  same  plane.  Comparison 
of  the  two  will  usuallv  give  a  fairly  accurate  idea  of  the  location  of  the  foreign 
body,  and  if  a  record  has  been  mad'e  of  the  position  of  the  tube  in  relation  to  the 
plate  and  opaque  marker,  exact  measurements  can  be  made  by  the  Rontgenolo- 
gist and  the  exact  location  given. 

(2)  The  Single  Tube  Shift  Method.— T\r^s  is  simply  a  reduction  to  photography 
of  the  fluoroscopic  method  described  under  ''C."     It  consists  in  placmg  the 


1628  The  X-rays  in   Surgery- 

target  of  the  tube  directly  above  an  opaque  mark  on  the  skin  and  above  a  known 
mark  photographed  directly  on  the  plate.  The  tube  must  be  placed  at  a  defi- 
nite height  from  the  plate.  A  plate  is  then  made  in  this  position,  or  two  ex- 
posures may  be  made  on  the  same  plate.  Before  the  second  exposure,  the  tube 
is  shifted  a  certain  distance.  The  two  positions  of  the  tube  are  then  reproduced 
by  cross  strings  leading  to  the  shadow  of  the  fixed  marks,  and  a  second  pair  of 
cross  strings  from  the  positions  of  the  tube  lead  to  the  shadows  of  the  foreign 
body,  and  at  the  point  of  crossing  will  be  found  the  location  of  the  foreign  body 
in  relation  to  the  marks  on  the  skin. 

The  Localization  of  Foreign  Bodies  in  the  Eye. — This  involves  the  most  accur- 
ate localization.  A  knowledge  of  the  exact  position  of  the  foreign  body  is  neces- 
sary for  the  ophthalmic  surgeon  to  determine  whether  the  eye  can  be  saved  or 
not.  For  this  purpose  the  previously  described  methods  of  localization  are  too 
crude,  and  the  use  of  the  perfected  Sweet  localizer  or  the  more  simple  Sweet- 
Bowen  localizer  is  recommended,  and  for  the  use  of  these  special  skill  is  required 
of  the  Rontgenologist  and  a  familiar  knowledge  of  the  detailed  technic  which 
can  be  found  either  in  the  United  States  Army  .v-ray  Manual  or  in  the  articles 
written  by  Dr.  Sweet  or  Bowen. 

Rontgentherapy  in  Surgical  Diseases. — The  field  of  Rontgentherapy  is 
very  wide,  but  in  this  chapter  will  be  considered  only  those  diseases  which  are 
generally  treated  by  the  surgeon,  and  in  which  Rontgentherapy  has  been  found 
beneficial.  There  will,  therefore,  be  no  reference  made  to  skin  diseases  except- 
ing epitheliomata.  Reference  to  the  paragraph  of  this  chapter  on  the  biological 
effect  of  the  .v-rays  will  give  the  reader  an  idea  of  the  theory  of  the  action  of  the 
rays  on  the  various  diseases  under  consideration  and  wall  help  him  to  under- 
stand the  effects  produced. 

Malignant  Diseases. — Under  this  heading  may  be  included,  by  far,  the 
greater  number  of  surgical  diseases  in  which  Rontgentherapy  has  been  found 
beneficial.  The  Rontgen  rays  have  their  greatest  effect  upon  the  cells  which 
approach  the  embryonic  type,  or  those  of  recent  origin  or  rapid  growth,  and  least 
effect  upon  the  normal  tissue  cells  which  usually  make  up  the  surroundings 
of  the  malignant  tissue.  Much  experimental  work  and  much  microscopical 
study  have  been  done  upon  malignant  tissue  to  determine  the  effects  of  the 
Rontgen  rays  and  radium  rays.'-  Contamin  did  a  number  of  experiments  on  the 
tumors  growdng  upon  mice.  They  were  carcinoma  of  a  granular  type,  and  as  a 
result  of  these  observations  Contamin  drew  the  following  conclusions:  First, 
ihe  action  of  the  x-rays  is  the  greater  in  younger  and  more  actively  growing 
tumors;  secondly,  the  disappearance  of  a  large  tumor  caused  the  death  of  the 
animal  probably  from  intoxication.  The  disintegration  products  of  the  cells 
which  have  been  injuriously  affected  by  the  rays  are  eventually  absorbed  by 
the  body.     When  this  absorption  is  excessive,  it  leads  to  a  state  of  intoxication. 

Nogier,  Jaubert  de  Beaujeu  and  Contamin  removed  an  adenocarcinoma  from 
a  mouse.  It  was  then  exposed  to  the  .r-rays,  after  which  it  was  inoculated  into 
normal  mice  to  see  whether  it  would  grow.  Under  exposure  to  the  soft  rays, 
in  which  50  per  cent,  of  the  rays  were  absorbed  by  the  tumor,  these  inoculations 
gave  no  positives  or  "takes"  and  15  negatives,  while  the  controls  gave  14  posi- 
tive inoculations  and  one  negative.  The  authors  conclude  from  these,  and 
similar  observations,  that  the  action  of  the  rays  is  rather  to  hinder  the  subse- 
quent growth  of  the  tumors  and  to  prevent  their  "taking",  on  inoculation. 
This  is  quite  analogous  to  the  effect  of  radium  emanation  upon  the  cells  of  rat 
sarcoma  as  shown  by  Jensen.  In  many  cases  where  the  histological  features  of 
the  irradiated  tumors  were  under  investigation,  only  a  small  portion  of  the 
growth  was  exposed  to  the  rays,  the  remainder  being  protected  by  a  stout 
lead  screen.  In  one  tumor  examined  by  Contamin  only  a  small  area,  the  size 
of  a  pea,  was  so  exposed,  the  remainder  of  the  neoplasm  thus  showing  as  a  con- 
'  Radium,  A''-ray5  and  the  Living  Cell,  Cohvell  and  Russ. 


Rontgentherapy  in  Malignant  Diseases  1629 

venient  control.  Two  exposures  of  one  hour  were  given  on  two  consecutive 
days.  Four  days  after  the  first  irradiation  the  tumor  was  removed  and  pre- 
pared for  histological  examination.  The  non-irradiated  part  of  the  growth  pre- 
sented the  character  of  a  granular  carcinoma,  the  cells  having  comparatively 
little  cytoplasm,  and  the  nuclei  being  round  or  oval.  In  the  irradiated  area  the 
most  marked  change  was  the  formation  of  cavities  resembling  cysts  which  origi- 
nated in  the  center  of  cellular  masses  constituting  the  acini  of  the  growth. 
Their  walls  were  formed  by  the  neoplastic  cells  themselves  which  in  consequence 
of  the  pressure  exerted  upon  them  by  the  contents  of  the  cysts  had  become 
flattened  and  otherwise  more  or  less  distorted.  The  cyst  contents,  after  treat- 
ment with  the  usual  histological  fixing  agent,  presented  a  finely  granulated 
appearance,  while  in  the  larger  cysts  hemorrhages'  were  of  frequent  occurrence. 
In  addition  to  this  cystic  stage,  a  commoner  feature  was  the  marked  increase 
in  the  amount  of  stroma.  The  constituent  fibers  were  densely  packed  together 
and  in  addition  the  nuclei  of  the  connecting  tissue  cells  were  elongated  and 
abnormal  in  contour.  A  considerable  diminution  in  the  number  of  neoplastic 
cells  was  observed  and  those  which  survived  were  more  or  less  segregated  into 
small  groups  by  the  greatly  hypertrophied  stroma.  The  cell  groups  were, 
however,  observed  not  to  be  compact  but,  on  the  contrary,  here  and  there  were 
clear  spaces  and  islands  of  degenerated  cells.  Another  feature  of  the  cell 
groups  was  that  they  were  retracted  from  the  stroma  so  that  they  did  not  come 
in  contact  with  it,  a  condition  of  marked  contrast  to  that  obtained  in  non- 
irradiated  areas,  where  the  connection  between  the  neoplastic  cells  and  the 
stroma  was  remarkably  close  and  intimate. 

In  the  case  of  tumors  removed  eight  days  after  the  initial  radiation,  cysts 
were,  generally  speaking,  absent;  the  main  feature  was  the  enormous  increase 
in  the  stroma  and  the  consequent  subdivision  of  the  cell  masses  into  yet  smaller 
islets,  the  section  presenting  an  appearance  as  if  the  cells  were  undergoing 
strangulation  by  the  fibrous  tissue. 

If  the  mouse  bearing  a  tumor  be  exposed  to  x-rays,  the  tumor  excised  and 
subsequently  grafted  into  normal  mice,  then  after  slight  irradiation  the  grafts 
develop  into  tumors,  but  do  not  grow  so  quickly  as  the  untreated  tumor. 
With  longer  exposure  the  graft  may  remain  in  the  animal  for  weeks  without  show- 
ing any  signs  of  growth,  and  may  then  very  slowly  develop  into  a  tumor.  With 
still  more  prolonged  exposure  no  growth  at  all  takes  place. 

These  observations  become  a  strong  factor  in  favor  of  anteoperative  treat- 
ment. By  that  I  mean  treatment  just  preceding  the  operation,  the  x-ray  treat- 
ment to  be  followed  by  operation  in  a  few  days.  A  tumor  which  has  received 
a  lethal  dose  shows  no  histological  changes  if  it  be  examined  at  once.  That  is, 
a  few  hours  after  the  exposure,  but  if  it  be  left  in  the  animal  and  portions  be 
removed  on  succeeding  days  certain  degenerative  changes  begin  to  make  their 
appearance,  and  these  changes  are  quite  generally  well  established  by  the  fifth 
and  sixth  days,  the  time  depending  upon  the  type  of  tumor  and  the  amount  of 
radiation. 

Marie,  Clunet  and  Raulot-Lapointe  made  a  study  of  the  effect  upon  the 
heredity  of  the  characters  imposed  upon  tumors  when  they  are  exposed  to  the 
:r-rays.  The  mouse  bearing  the  tumor  (a  sarcoma)  was  exposed  to  a  strong  dose 
(30  H)  of  unfiltered  rays,  and  five  days  later  the  animal  was  killed  and  a  portion 
of  the  tumor  grafted  into  a  number  of  mice.  When  this  irradiated  graft  had 
grown  to  a  suitable  size,  a  mouse  with  the  tumor  was  treated  the  same  as  the 
first,  and  this  process  was  kept  up  for  twenty  months.  The  new  characters 
imposed  upon  the  tumors  were  found  to  consist  mainly  of,  first,  the  reduction  in 
the  number  or  percentage  of  successful  grafts;  second,  a  reduction  in  the  malig- 
nancy of  the  tumor;  third,  a  slower  rate  of  growth  and  certain  histological  fea- 
tures of  which  the  following  were  the  most  important :  (a)  the  presence  of  giant 
cells,  some  of  the  cells  being  as  much  as  four  or  five  times  their  original  diame- 


1630  The  X-rays  in  Surgery 

ter;  (b)  atypical  mitosis;  (c)  basophile  (giant)  cells,  having  multiple  nuclei. 
In  order  to  determine  whether  these  characteristics  would  be  transmitted 
through  a  number  of  generations,  even  if  entirely  removed  from  the  rays,  they 
took  one  of  these  tumors  and  grafted  it  onto  a  mouse,  and  when  it  had  attained 
sufficient  size  the  mouse  was  killed  and  a  section  again  grafted  onto  a  new  mouse, 
no  rays  being  applied.  It  was  found  that  there  was  a  tendency  on  the  part  of 
the  tumor  gradually  to  return  to  its  normal  condition,  but  even  in  the  sbcth 
generation  there  were  many  cells  showing  the  characteristic  abnormalities, 
(A),  (B),  (C),  produced  in  the  tumor  cells  by  the  previous  exposure  to  the  a--rays. 

Clunet  and  Raulot-Lapointe  treated  a  number  of  cases  of  carcinomata  and 
sarcomata,  and  at  various  stages  of  the  treatment  removed  portions  of  the 
growth  for  histological  study*.  As  a  result  of  observations  of  this  nature  upon 
nineteen  cases  of  squamous  cell  carcinoma  of  Malpighian  type  in  the  human 
subject  they  state  that  before  the  ultimate  disappearance  of , the  growth,  the  cells 
passed  through  at  least  five  successive  phases,  which  have  been  characterized  as 
follows:  (i)  The  latent  phase,  which  varies  from  sLx  to  fifteen  days  and  during 
this  time  no  cytological  changes  are  to  be  seen;  (2)  the  development  of  monstrous 
characters,  (a)  an  enlargement  of  all  parts  of  the  cells  which  may  be  increased 
in  diameter  as  much  as  two  or  three  times,  (b)  an  increased  number  of  atypical 
mitosis,  (c)  the  appearance  of  enlarged  nuclei,  markedly  chromophile;  (d)  the 
appearance  within  the  cells  of  forms  having  a  pseudoparasitic  character;  (3) 
keratinization  may  be  either  disseminated,  total  or  antipodal  (if  disseminated, 
each  cell  undergoes  keratinization  independently  of  its  neighbor  in  contrast  to 
those  effects  appearing  to  influence  all  cells  alike) ;  (4)  disintegration  and  phago- 
cytosis (the  disintegration  of  the  degenerating  cells  appears  to  be  caused 
mainly  by  the  polynuclear  cells  and  the  fibroblasts  of  the  stroma  which  are  in 
an  active  condition.  Macrophages  and  plasma  cells  appear  at  a  later  stage  and 
accumulate  around  the  vessels,  remaining  in  the  vicinity  long  after  the  disappear- 
ance of  the  malignant  cells.  At  the  periphery  of  the  keratinized  masses  plas- 
modia  are  sometimes  found,  simulating  the  type  presented  by  the  cells  of  the 
neoplasm,  but  they  are  rarely  found  in  great  numbers.  The  masses  of  degen- 
erate cells,  before  becoming  entirely  destroyed,  may  cease  to  give  color  reactions 
of  keratin,  and  remain  encapsulated  in  the  dermis  for  prolonged  periods) ;  (5) 
formation  of  the  connective  tissue  scar  (as  a  general  rule  this  is  not  brought 
about  by  the  formation  of  fibrous  masses,  but  the  tissues  assume  the  structure 
of  healthy  skin,  except  for  the  absence  of  hair  and  of  glands.  The  elastic  fibres 
are  also  less  numerous  and  more  attenuated  than  they  are  normally.  No 
neoplastic  masses  are  to  be  found  in  these  supple  scars  which  appear  to  be  quite 
healthy;  on  the  other  hand,  at  a  depth  below  the  skin,  cells  may  be  found  which 
have  been  acted  upon  by  the  a;-rays  but  are  not  yet  destroyed ;  such  cells  remain 
in  a  latent  condition  and  if  the  treatment  be  not  continued  they  give  rise  to  re- 
currences. They  are  distinguished  by  a  very  chromophilic  nucleus,  though  not 
pyknotic,  a  reduced  amount  of  protoplasm  and  an  avidity  for  basic  coloring 
material). 

Sarcoma. — Clunet  and  Raulot-Lapointe^  found  when  sarcomatous  growths 
are  exposed  to  x-rays  that  a  somewhat  similar  transition  in  the  cellular  character- 
istics occurs,  but  the  latent  phase,  during  which  no  changes  are  observable,  is 
very  much  shorter  than  in  the  other  types  of  malignant  growth  considered; 
instead  of  being  from  six  to  ten  days  it  is  generally  one  or  two  days. 

Of  a  spindle-cell  sarcoma  after  having  been  exposed  to  a  rather  small  quantity 
of  unfiltered  .x-rays  (9H),  their  description  is  as  follows:  "The  fibrosarcomatous 
zone  separating  the  granulation  tissue  from  the  normal  dermis  on  one  side  and 
from  the  pure  sarcoma  on  the  other  seems  to  show  that  at  a  certain  depth  the 
rays,  although  too  feeble  to  destroy  the  neoplastic  cells  of  the  connective  tissue, 
have  nevertheless  caused  a  profound  alteration  in  the  biological  evolution  of 
1  Radium,  X-rays  and  the  Living  Cell,  Colwell  and  Russ. 


Rontgentherapy  in  Malignant  Diseases 


1631 


these  cells;  the  rays  have  caused  the  cells  to  secrete  collagen  and  to  take  on  the 
morphological  characters  of  a  fibroma,  a  benign  tumor."  Dominici  found 
similar  changes  in  a  fibro-sarcoma  exposed  to  the  gamma  rays  of  radium  (Dom- 
inici, Archives  de  Medecine  Generale,  1909). 

These  and  other  experimental  and  pathological  studies  of  the  effects  of  the 
Rontgen  rays  upon  malignant  disease  should  convince  the  most  skeptical  of  the 
value  of  the  Rontgen  rays  in  the  treatment  of  malignant  disease.  The  evidence 
is  especially  convincing  when  taken  together  with  the  mass  of  clinical  observa- 
tions made  by  various  authors  upon  the  disappearance  of  malignant  disease. 

Skill  in  the  application  of  the  Rontgen  rays  for  therapeutic  purposes  is  no 
less  important  than  skill  in  the  application  of  surgery  in  the  treatment  of  dis- 


FiG.  1 1 14. — (a)  Sarcoma  of  the  neck  illustrating  the  manner  of  crossfiring  upon  this  disease. 
Patient  was  considered  inoperable.  Treatment  was  begun  March  26,  1914,  and  finished 
April  9,  1914.     There  has  been  no  treatment  since.     The  patient  has  remained  well  six  years. 

(b)  Photograph  made  October  23,  1915,  showing  complete  disappearance  of  the  tumor. 
No  damage  to  the  skin.  No  difference  from  the  normal  side  (Pfahler,  Jour.  Am.  Med.  Assoc, 
May  I,  1915,  Vol.  Ixiv,  pp.  1477-1485). 

ease  and  unless  one  keeps  in  mind  continually  the  object  to  be  obtained  and  pays 
the  most  careful  attention  to  all  details,  the  results  are  likely  to  be  disappointing. 
All  cases  of  malignant  disease  do  not  react  in  the  same  manner:  there  is  some 
difference  even  in  the  same  t^'pe  as  shown  microscopically.  The  results  obtained 
probably  depend  too,  in  part,  upon  the  general  resistance  and  power  of  reaction 
as  shoA;vTi  in  the  individual  patient.  In  a  general  way,  sarcomata  are  more 
responsive  to  .r-ray  treatment  than  carcinomata.  And  of  the  epithelioma, 
those  made  up  of  the  basal  cells  are  more  responsive  than  those  made  up  of  the 
spindle  cells. 

Lack  of  skill  in  the  use  of  Rontgentherapy  may  do  much  harm.  Harm  may 
be  done  by  insufficient  treatment  which  will  permit  the  disease  to  invade  the 
surrounding  tissues  and  extend  to  deeper  tissues  or  harm  may  be  done  by 
destroying  the  surface  of  a  growth  and  even  the  surrounding  health}'  skin 
without  destroying  the  deep  part  of  the  tumors.  At  times,  even  under  insuffi- 
cient treatment  the  surface  of  an  epithelioma,  for  example,  may  heal,  the 
ulcer  be  closed,  but  the  deeper  lying  cells  remain,  and  if  insufficiently  treated 
will  invade  other  tissues,   and  bring  about  a  recurrence  or  metastasis.     In 


1632  The  X-rays  in  Surgery 

this  respect  Ron tgen therapy  resembles  any  other  form  of  meddlesome  or 
insufficient  treatment  of  carcinoma. 

Harm  can  result  from  too  long  treatment.  In  these  cases,  of  which  many 
have  occurred,  .v-ray  treatment  has  been  applied  with  superficial  effect,  and, 
carried  over  a  long  period  of  time,  leads  to  the  development  of  telangiectasis, 
and  a  thick  fibrous  scar  tissue  with  secondary  degeneration  into  carcinoma. 
The  treatment  of  epithelioma  may  produce  a  severe  burn  indistinguishable 
by  the  untrained  from  the  original  carcinoma,  and  thus  treatment  may  be  pro- 
longed with  the  hope  of  controlling  the  carcinoma  and  conditions  made  worse. 
Harm  can  also  result  from  the  treatment  of  cases  which  are  not  suitable  for 
.T-ray  treatment. 

In  most  cases  treatment  can  be  combined  to  great  advantage  with  other 
forms  of  treatment  for  malignant  disease,  of  which  we  mention  first  surgical 
excision,  second  local  destruction  by  electrocoagulation,  and  third  the  additional 
application  of  radium  to  the  inside  of  cavities  while  the  rv-rays  can  be  applied 
externally.  Radium  and  .T-rays  should  not  be  used  at  the  same  time  or  within 
the  same  month  over  any  one  area  of  skin  or  mucous  membrane,  for  the  action 
of  the  two  agents  is  very  similar,  and  overdosage  is  likely  to  result. 

Epithelioma. — The  epitheliomata  involving  the  skin  can  nearly  all  be  cured 
by  skillful  treatment  with  the  Rontgen  rays,  and  when  combined  with  electro- 
coagulation (see  page  1637)  all  can  be  cured  if  treated  early.  Most  of  this 
group  of  epitheliomata  can  also  be  cured  by  excision,  and  unless  one  has  skill 
in  the  appHcation  of  Rontgentherapy  they  had  better  be  excised.  Of  the 
epitheliomata  the  basal-cell  variety  is  much  more  respondent;  the  squamous 
or  spindle-cell  epitheliomata  are  much  more  resistant  to  the  Rontgen  rays, 
as  well  as  to  any  other  form  of  treatment.  The  majority  of  the  epithelio- 
mata occurring  on  the  skin  are  of  the  basal-cell  type.  Those  occurring  on  the 
mucous  membrane  and  on  the  back  of  the  hand,  are  more  likely  to  be  of  the 
squamous-cell  type,  and  are  very  resistant  to  treatment.  Generally,  in  these 
cases,  I  believe  radiotherapy  alone  cannot  be  depended  upon,  but  should  either 
be  combined  with  surgical  excision,  or,  better,  electrocoagulation. 

The  advantages  of  the  Rontgen  rays  in  the  treatment  of  epithelioma  are  first, 
the  painless  applications;  second,  the  absence  of  deformity,  and  this  is  especially 
important  when  in  the  neighborhood  of  the  eyelid  or  the  side  of  the  nose.  The 
disadvantages  of  the  treatment  of  these  growths  by  radiotherapy  alone  are 
first,  the  slowness  of  the  result  to  be  obtained;  second,  the  inability  to  examine 
the  growth  microscopically.  In  the  treatment  of  recurrent  or  advanced  epi- 
thelioma the  keenest  judgment  and  the  greatest  skill  are  required.  In  these  cases 
generally  the  treatment  should  be  combined  with  some  other  form  of  treatment, 
either  with  surgical  excision  or  local  destruction  by  electrocoagulation.  The 
metastatic  glands  should  be  thoroughly  excised.  Surgical  excision  should  also 
be  used  when  the  disease  involves  the  neighborhood  of  vital  organs  or  nerves, 
such  as  at  the  angle  of  the  jaw  in  which  the  disease  is  liable  to  overlie  the  carotid 
vessels.  In  other  cases  where  the  disease  involves  areas,  overlying  structures 
which  are  less  vital  the  disease  can  be  destroyed  by  electrocoagulation  first, 
and  active  deep  Rontgentherapy  applied  immediately  after. 

Deep-seated  Malignant  Disease. — In  the  treatment  of  deep-seated  malig- 
nant disease,  the  Rontgen  rays  can  be  thought  of  chiefly  as  an  adjunct  to  surg- 
ical treatment.  When,  for  some  reason,  surgical  excision  is  impossible,  skillful 
application  of  deep  Rontgentherapy  is  undoubtedly  the  next  best  choice.  In 
the  treatment  of  deep-seated  malignant  disease  surgical  excision,  when  practical 
and  when  there  is  an  opportunity,  should  always  be  followed  by  Rontgentherapy. 

The  Treatment  of  Recurrent  and  Metastatic  Carcinoma. — There  is  a  great 
variation  in  the  results  obtained  from  the  treatment  of  recurrent  metastatic 
carcinoma,  and  at  present  no  one  can  decide  which  cases  will  respond  to  Rontgen- 
therapy, and  which  will  progress  under  treatment.     In  nearly  all  cases  treated 


The  Treatment  of  Recurrent  and  Metastatic  Carcinoma      1633 

there  will  be  some  improvement,  and  in  many  cases  the  local  evidence  of  disease 
will  disappear,  at  least  so  far  as  visible  evidence  is  concerned.  The  patient 
may  be  free  from  local  symptoms  and  in  some  of  these  cases  they  are  free  for 
a  year  or  more  when  the  disease  recurs  with  more  extensive  distribution. 
Generally  this  second  recurrence  is  uncontrollable.     In  some  cases  one  may 


Fig.  1 1 15. — A  case  of  carcinoma  involving  the  left  cheek,  the  alveolar  process  in  the  left 
upper  molar  region,  the  anterior  pillar  of  the  fauces,  the  posterior  two-thirds  of  the  inferior 
maxilla,  with  a  mass  of  metastatic  lymph  nodes  the  size  of  a  small  hen's  egg.  The  disease 
in  the  mouth  was  destroyed  by  electrocoagulation,  the  metastatic  glands  were  dissected  out, 
and  the  left  half  of  the  inferior  maxilla  resected  June  10,  191 5.  This  was  followed  by  radium 
applications  inside  the  mouth  and  x-ray  treatment  externally.  The  patient  is  still  well  May 
10,  1919  (Pfahler,  Jour.  Am.  Med.  Assoc,  November  18,  1916). 

{A)  Shows  area  destroyed  after  the  slough  has  separated. 

{B)  Rontgenogram  showing  the  destruction  in  the  jaw  by  carcinoma,  with  the  projection 
forward  of  one  of  the  molar  teeth. 

(C)  After  first  attempt  to  close  the  mouth. 

(Z>)  Showing  mouth  closed.     The  patient  is  a  traveling  salesman  and  is  at  work  daily. 


obtain  a  permanent  disappearance  or  cure.  In  general,  thorough  skillful 
application  of  the  Rontgen  rays,  or  Rdntgentherapy,  according  to  modern 
technic,  will  give  more  satisfactory  results  in  the  treatment  of  recurrent  carci- 
noma than  any  other  known  method.  Metastatic  carcinoma  may  be  made  to 
disappear  in  many  instances,  but  here  again  there  is  some  peculiarity  in  the 
nature  of  the  disease  which  will  cause  some  cases  to  yield  to  treatment  while 

103 


1^)34 


The  X-rays  in  Surgery- 


others  only  show  improvement  for  a  time  but  do  not  get  well.  Pfahler  has 
reported  four  cases  in  which  metastatic  carcinoma  of  the  spine,  secondary  to 
carcinoma  of  the  breast,  showed  a  complete  healing  of  the  lesions  which  had 
caused  total  destruction  of  one  or  more  of  the  vertebra,  and  the  patients  have 
remained  free  from  symptoms  for  from  one  to  two  years.  Metastatic  carcinoma 
of  the  spine  is,  however,  only  a  part  of  a  general  carcinomatosis,  and  sooner  or 
later  we  believe  that  the  patient  must  succumb  to  a  general  carcinomatosis, 
and  this  has  been  Pfahler's  experience  in  all  but  one  of  these  cases. 


Fig.  iii6. — Case  of  metastatic  carcinoma, 
probably  present  before  operation  for  carci- 
noma of  the  breast.  Patient  became  bedfast 
three  months  after  the  amputation  of  the 
breast.  Remained  in  bed  fifteen  weeks. 
Rontgenogram  was  made  March  17,  1918. 
In  four  months  the  patient  was  able  to  attend 
to  her  housework  with  the  support  of  a  brace 
(Pfahler). 


Fig.  1 1 17. — Same  case  as  Fig.  1 1 16.  Show- 
ing complete  recalcification  of  the  second 
lumbar  vertebra.  Rontgenogram  made 
March  17,  1919,  one  year  after  the  first, 
and  one  year  after  beginning  treatment. 
Patient  is  doing  all  the  general  housework, 
including  washing  and  ironing.  Is  wearing 
no  brace,  and  is  apparently  well  (Pfahler). 


Ante -operative  X-ray  Treatment. — It  has  been  shown  in  the  preceding  pages 
(see  pages  1628  to  163 1)  that  in  experimental  work  done  application  of  the 
Rontgen  rays  to  a  tumor  reduces  its  malignancy,  reduces  the  power  of  trans- 
plantation, and  causes  destruction  especially  of  the  more  actively  growing  cells. 
This  is  accomplished  when  skillfully  done  without  damage  to  the  healthy  tissues, 
because  of  the  hypersensibility  of  the  malignant  cells.  For  this  reason  Pfahler 
recommends  a  thorough  application  of  the  rays  preceding  operation.  Up  to 
the  present  time  no  ill  results  have  followed  this  ante-operative  application. 
The  wounds  heal  normally,  and  while  we  have  only  followed  this  method  for 
about  three  years,  and  are  therefore  unable  to  draw  definite  conclusions,  the  re- 
sults seem  to  justify  this  application. 


Rontgentherapy  in  Cervical  Adenitis  1635 

Boggs  and  Pfahlcr  have  each  recorded  cases  of  inoperable  carcinoma  of 
the  breast  made  operable  by  Rontgentherapy,  but  in  these  cases  the  treat- 
ment is  given  with  a  different  object.  It  is  given  with  the  idea  of  destroy- 
ing or  sealing  off  the  lymphatic  extensions,  and  causing  a  shrinkage  in  the 
growth  by  the  surrounding  fibrous  tissues  as  is  indicated  in  the  paragraph  on 
experimental  and  pathological  studies  of  carcinomatous  growths.  The  opera- 
tion is  then  done  with  the  idea  of  removing  the  fibrous  tissues  including  the 
encapsulated  malignant  cells.  This  prolonged  ante-operative  treatment  re- 
quires much  skill  and  good  judgment,  and  it  should  not  be  used  in  an  operable 
case.  The  ante-operative  treatment  which  Pfahler  believes  can  be  applied  to 
advantage  in  every  case  of  deep-seated  malignant  disease  requires  only  a  few 
days  during  which  a  thorough  course  of  treatment  can  be  given'  with  the  Cool- 
idge  tube  technic  in  which  the  disease  is  crossfired  upon  from  every  angle,  and 
all  the  outlying  lymphatic  areas  are  included  in  the  field  of  treatment.  If  the 
dose  be  carefully  measured  no  harm  can  result.  The  post-operative  treatment 
can  then  be  started  four  weeks  later. 

Post-operative  Rontgentherapy. — This  should  be  applied  in  all  cases  of 
malignant  disease.  It  should  be  applied  with  the  object  of  reaching  any  cells 
which  may  have  extended  beyond  the  palpable  growth  even  before  the  opera- 
tion, and  to  devitalize  any  malignant  cells  that  may  have  been  transplanted  or 
dissipated  or  disseminated  during  the  operation.  When  practical  it  can  be 
applied  to  advantage  in  the  open  wound  immediately  following  the  operation. 
This  is  generally  not  practical  for  various  reasons.  Therefore,  this  treatment 
should  be  given  as  soon  after  the  operation  as  is  found  practical  to  move  the 
patient  to  the  Rontgen  laboratory,  but  if  ante-operative  Rontgentherapy  has 
been  used,  and  full  doses  given,  it  must  not  be  repeated  in  less  than  four  weeks 
from  the  preceding  treatment.  This  treatment  should  be  given  from  every 
angle  possible,  and  over  every  area  to  which  the  disease  is  likely  to  have  extended, 
or  is  likely  to  extend.  The  amount  of  treatment  required  depends  upon  the 
amount  of  disease,  the  duration,  the  rate  of  growth,  but  generally,  in  a  breast 
case  for  example,  a  single  course  or  series  of  treatment  will  occupy  two  or 
three  different  days.  Such  a  course  of  treatment,  or  series  of  treatment,  should 
be  repeated  in  a  month,  and  repeated  at  intervals  of  a  month  or  more  from  three 
to  ten  times,  depending  upon  the  stage  of  the  disease  and  the  degree  of  malig- 
nancy at  the  time  of  operation.  In  abdominal  carcinoma  more  treatments  are 
usually  required,  first,  because  the  disease  is  more  deeply  situated,  and  secondly, 
because  the  lymphatic  distribution  of  the  disease  is  more  likely  to  be  extensive. 

Sarcoma  is  more  sensitive  to  the  Rontgen  rays  than  carcinoma,  and  unless 
one  is  quite  sure  that  the  disease  can  be  completely  excised  it  is  better  treated 
by  Rontgentherapy  than  by  excision,  but  it  is  likely  that  a  combination  of  the 
two,  ante-operative  Rontgentherapy,  excision  and  post-operative  Rontgenther- 
apy, will  give  the  most  satisfactory  results.  When  the  rays  are  depended  upon 
alone,  massive  dose  therapy  and  treatment  from  every  angle  possible  cannot  be 
urged  too  strongly. 

Cervical  Adenitis. — Cervical  adenitis  can  be  treated  successfully  by  Rontgen- 
therapy. These  lymph  nodes  are  more  responsive  the  earlier  the  appHcations 
are  made.  According  to  modern  technic,  the  applications  are  made  from  as 
many  angles  as  possible,  crossfiring  upon  the  disease,  and  this  is  done  once  a 
month.  If  the  treatment  be  begun  after  there  is  localized  tenderness  or  soften- 
ing, the  softening  process  will  be  hastened.  When  any  of  the  cells  become  sof- 
tened they  should  either  be  excised  or  drained,  or  probably  better  aspirated  and 
an  injection  of  the  following  solution  used,  as  has  been  recommended  by  Phender : 

Olive  Oil 70  parts 

Ether 3° 

Creosote 3 

Guaiacol i 

Iodoform 10 


1636  The  X-rays  in  Surgery 

In  some  cases  in  which  the  disease  has  persisted  for  sometime,  and  in  which 
there  is  much  fibrous  tissue,  the  nodes  may  not  disappear  completely  under 
Rontgentherapy,  but  they  may  become  calcified,  so  that  one  may  obtain  a 
complete  chain  of  calcified  lymph  nodes  as  a  result  of  this  treatment.  Therefore 
treatment  should  not  be  prolonged  too  much  with  the  hope  of  causing  a  com- 
plete disappearance.  This  calcification  shows  the  healing  process  for  we  well 
know  that  tubercular  lesions  heal  in  this  manner.  The  quickest  and  best 
method,  however,  is  complete  excision,  in  which  small  and  large  lymph  nodes 
are  removed,  and  this  should  be  followed  by  thorough  deep  Rontgentherapy. 
These  applications  should  be  made  two  or  three  times  at  intervals  of  a  month. 
This  is  usually  sufficient  to  prevent  other  glands  from  becoming  enlarged  as  so 
frequently  happens  after  an  operation  upon  this  area. 

Enlarged  lymphatic  glands,  from  whatever  cause,  can  be  made  to  disappea- 
under  skillful  "Rontgentherapy.  In  the  treatment  of  cervical  adenitis  by  Rontr 
gentherapy  a  dermatitis  should  always  be  avoided,  and  the  treatment  should 
never  be  carried  to  the  point  of  producing  a  reaction  in  the  skin  nor  continued 
too  long.  If  this  be  done,  there  is  very  likely  to  result  at  some  time  later, 
possibly  at  the  end  of  a  year  or  two  or  three,  a  telangiectasis,  together  with  an 
atrophic  scar-like  condition  of  the  skin.  A  dermatitis  is  always  hastened  by 
the  local  appUcation  of  other  agents  such  as  liniments,  poultices,  etc.,  so  that 
when  a  patient  is  sent  for  Rontgentherapy,  no  other  local  appHcation  should  be 
made  at  least  within  a  month  alter  Rontgentherapy.  Rontgentherapy  is 
usually  chosen  in  these  cases  because  it  is  supposed  to  produce  better  cosmetic 
results  by  preventing  unsightly  scars  which  sometimes  follow  surgical  excision, 
but  if  a  dermatitis  be  produced  the  end  result  may  be  worse  than  that  produced 
by  a  surgical  operation.  The  .T-rays  have  been  used  in  certain  infections  and 
George  G.  Ross  reported  a  case  of  facial  carbuncle  treated  by  them  (Annals  of 
Surgery,  July,  191 7). 

Exophthahnic  Goiter  or  Graves'  Disease. — The  thyroid  gland  is  especially 
sensitive  to  the  Rontgen  rays.  In  very  small  doses  there  is  the  possibility  of 
stimulating  the  thyroid  gland,  but  as  the  rays  are  appHed  in  modern  deep  ther- 
apy technic,  and  in  massive  crossfiring  doses  there  is  an  atrophic  action  upon 
the  cells.  The  secretion  of  the  glands  is  diminished,  the  secreting  cells  being 
the  first  to  be  affected.  Then  there  is  a  gradual  atrophy  of  the  gland  with  con- 
sequent diminution  in  its  size.  By  modern  technic  the  gland  is  treated  by  mas- 
sive doses,  crossfiring  from  two  to  six  different  directions,  or  fields  of  entry,  and 
this  series  is  given  about  once  a  month.  As  a  result  there  is  first  noticed  a  de- 
crease in  the  nervous  symptoms  which  can  sometimes  be  seen  at  the  end  of  a 
month,  but  almost  certainly  seen  at  the  end  of  two  months.  With  this  there  is 
a  decrease  in  the  pulse  rate  and  increased  weight,  and  gradually  there  is  a  reduc- 
tion in  the  size  of  the  gland  although  the  disappearance  of  the  thyroid  enlarge- 
ment and  of  the  exophthalmus  occurs  last.  It  usually  requires  from  six  to  twelve 
months  to  produce  a  cure.  The  pulse  rate  at  times  returns  to  normal,  but  gen- 
erally it  remains  slightly  above  normal,  either  due  to  some  permanent  damage  to 
the  heart,  or  because  the  treatment  has  not  been  carried  on  long  enough.  Gen- 
erally at  the  end  of  six  months  or  a  year  the  patient  has  been  restored  to  normal 
so  far  as  the  patient  can  recognize.  This  treatment  has  the  disadvantage  of 
slow  results  because  to  produce  results  one  must  wait  for  an  atrophy  of  the 
gland.  It  has  the  advantage,  however,  of  avoiding  the  shock  of  an  operation, 
and  can  be  appHed  especially  to  inoperable  cases,  or  it  can  be  applied  to  those 
cases  in  which  operation  has  not  brought  about  sufficient  results,  or  the  treat- 
ment can  be  applied  with  the  idea  of  reducing  the  secretion  and  preparing  the 
patient  for  any  later  operation.  By  operation  one  reduces  the  size  of  the  gland, 
thereby  diminishing  the  secretion.  By  Rontgentherapy  the  amount  of  secre- 
tion is  reduced  by  a  reduction  in  the  secreting  surface  or  secreting  area  of  the 
entire  ^rland. 


Electrocoagulation  in  the  Treatment  of  Malignant  Disease     1637 

Simple  goiter  should  not  be  treated  by  the  Rontgen  rays  until  after  a  care- 
ful sjtudy  has  been  made  as  to  the  etiology  of  the  enlargement,  for  in  many  cases 
the  enlargenent  of  the  thyroid  is  purely  compensatory,  and  in  such  instances 
either  operation  for  its  removal  or  treatment  by  Rontgentherapy  is  in  direct 
opposition  to  nature's  efforts  to  relieve  the  patient  of  other  more  serious 
conditions.  When  there  is  a  distinct  hypertrophy  of  the  thyroid  gland,  which 
cannot  be  accounted  for  by  the  theory  of  compensation,  and  operation  is  contra- 
indicated  it  can  often  be  treated  successfully  by  the  Rontgen  rays,  but  the 
results  obtained  will  be  more  satisfactory  and  more  prompt,  the  earlier  in  the 
stage  of  the  disease  the  apphcations  are  made.  Cystic  goiter  is  not  likely  to 
respond  to  Rontgentherapy  and  unless  there  be  some  contraindication  the 
patient  should  be  sent  for  operation  at  once. 

Fibroids  of  the  uterus  can  be  successfully  treated  by  Rontgentherapy,  just 
as  a  hypoplasia  or  tumor  formation  anywhere  in  the  body  can  be  reduced  by 
thorough  application  of  Rontgentherapy.  When  the  tumors  are  large  or  when 
there  are  no  contra-indications  they  had  better  be  removed  surgically.  Gener- 
ally the  cure  of  these  cases  is  followed  by  an  amenorrhea,  but  this  is  not  always 
necessary.  Pfahler  and  McGlinn  reported  a  case  in  which,  at  exploratory  opera- 
tion, it  was  found  that  removal  of  the  fibroid  would  mean  sacrifice  of  the 
uterus — an  operation  not  expedient  under  the  circumstances.  The  exact 
position  of  the  fibroid  having  been  determined,  the  abdomen  was  closed,  the 
a;-rays  were  confined  to  the  fibroid  area,  the  ovaries  being  protected,  and  the 
tumor  was  removed  completely.  At  no  time  did  the  patient  cease  menstruat- 
ing or  have  any  menstrual  disturbance.  At  the  proper  time  the  patient  was 
allowed  to  become  pregnant,  and  gave  birth  to  a  full-term  healthy,  normal 
child.  When  the  exact  location  of  the  fibroid  is  not  known,  or  where  it  is  so 
large  that  it  overlaps  the  areas  of  the  ovaries,  this  cannot  be  done,  and  an 
amenorrhea  must  be  expected  if  the  tumors  are  to  be  treated  with  success. 
The  treatment  extends  over  a  period  of  from  four  to  six  months,  and  the  series 
of  doses  crossfiring  upon  the  diseased  area  are  given  once  a  month.  During 
the  first  month  there  is  little  change.  During  the  second  month  there  is 
generally  a  diminution  in  the  size  of  the  tumor,  and  a  marked  reduction  in  the 
menstrual  flow.  Often  the  second  period  is  absent.  Generally  the  third  is 
absent.  The  treatment  is  usually  continued  even  after  an  amenorrhea  has  been 
produced  for  the  purpose  of  destroying  the  tumor  tissue.  These  results  can  be 
produced  without  placing  the  patient  in  the  hospital,  and  generally  she  can  be 
allowed  to  go  about  her  duties. 

ELECTROCOAGULATION  IN  THETREATMENT  OF  MALIGNANT  DISEASE^ 

This  consists  in  the  destruction  of  all  of  the  malignant  disease  by  means  of 
the  high  frequency  electric  current,  either  of  the  Oudin  or  d'Arsonval  type  of 
current.  It  differs  from  the  destruction  of  disease  by  the  thermocautery  in 
that  this  heat  is  generated  in  the  tissues  due  to  the  resistance  to  the  flow  of  the 
electricity  through  the  tissues,  instead  of  destruction  by  transmitted  heat  such 
as  appHes  to  the  use  of  the  thermocautery.  It  has  the  advantage,  therefore, 
over  the  thermocautery  of  producing  heat  at  a  much  greater  depth,  and  in  a 
more  graded  proportion.  It  appHes  the  principle  of  the  Percy  cautery  in  pro- 
ducing a  zone  of  tissue  in  which  there  is  sufi&cient  heat  to  destroy  malignant  cells 

1  Pfahler:  Electrothermic  Coagulation  and  Rontgentherapyin  the  Treatment  of  Malignant 
Disease.  Surgery,  Gynecology  and  Obstetrics,  December,  1914,  pp.  783  to  790;  The  Treat- 
ment of  Malignant  Disease  About  the  Mouth  by  Combined  Methods.  Jour.  Amer.  Med. 
Assoc,  Nov.  18,  1916,  Vol.  Ixvii,  pp.  1502-1508;  The  Treatment  of  Malignant  Disease  by 
Means  of  Deep  Rontgentherapy  and  Electrothermic  Coagulation.  Surgery,  Gynecology  and 
Obstetrics,  January,  1917,  pp.  14-29;  Deep  Rontgentherapy  and  Electrocoagulation  in  the 
Treatment  of  Mahgnant  Disease.  Interstate  Medical  Journal,  Vol.  xxiv,  No.  7;  The  Treat- 
ment of  Malignant  Disease  by  Combined  Methods.  Pennsylvania  Medical  Journal,  Febru- 
ary, 1919,  Vol.  xxii,  p.  307. 


1638  The  X-rays  in  Surgery 

but  not  normal  tissue  cells  beyond  the  area  of  actual  destruction  of  all  tissues. 
In  the  area  of  coagulation  all  tissues  are,  of  course,  destroyed.  The  method, 
therefore,  cannot  be  applied  in  the  region  of  blood-vessels  or  nerves  which  must 
be  saved  by  dissection. 

Technic  of  electrocoagulation,  according  to  Pfahler  is  somewhat 
similar  to  that  described  by  Nagelschmidt  and  Clarke  and  in  principle  is  identical. 
The  d'Arsonval  'current  is  used,  or  the  Oudin  current  may  be  used,  or  a  com- 
bination of  the  two.  When  the  d'Arsonval  current  is  used  an  instrument  is 
necessary  which  will  generate  from  1000  to  2000  milliamperes  [of  current.  The 
amount  of  current  will,  of  course,  vary  with  the  amount  of  destruction  of  tissue 
desired.  The  two  electrodes  are  used.  Sometimes  both  electrodes  are  used  lo- 
cally for  the  destruction  of  the  tissue.  In  many  instances,  or  in  most  instances, 
however,  the  disease  is  destroyed  by  a  pointed  electrode  and  a  pad  is  attached 
to  some  indifferent  portion  of  the  body  and  to  the  opposite  pole.  The  pad 
is  usually  placed  under  the  back  or  under  the  buttocks  or  over  the  abdomen. 
By  means  of  the  active  point  electrode  one  should  first  outline  carefully  the 
extent  of  the  diseased  tissue  which  is  to  be  destroyed.  If  the  growth  be  very  large 
it  is  advisable  to  use  both  electrodes  in  the  growth  itself  and  the  indifferent,  or 
blunter  electrode,  or  ball  electrode,  may  be  placed  in  the  central  portion  of  the 
disease,  and  the  point  electrode  is  used  to  surround  the  outside,  coagulating  the 
tissue  toward  the  central  electrode.  If,  as  is  usual,  the  area  of  disease  be  com- 
paratively small,  the  indifferent  electrode  may  consist  of  the  pad  placed  under 
the  buttocks  or  on  the  abdomen,  and  only  the  point  be  used  for  local  destruction. 
The  area  to  be  destroyed  is  coagulated  completely  until  it  is  entirely  white.  In 
this  destruction  one  must  realize  that  there  is  a  tremendous  heat  developed 
and  if  the  disease  is  destroyed  within  a  cavity  the  steam  from  the  cooking  of 
the  tissues  is  often  sufficient  to  scald  the  surrounding  mucous  membrane. 
This  must  be  especially  considered  when  one  is  destroying  disease  in  the  mouth, 
in  the  pharynx,  in  the  vagina  or  in  the  rectum.  Caution  in  this  respect  will 
save  the  patient  much  suffering,  and  much  unnecessary  delay  in  the  healing 
process.  After  the  area  is  thoroughly  coagulated,  the  destroyed  tissue  may  be 
cut  away  by  means  of  curved  scissors  or  a  knife,  or  it  may  be  curretted  away. 
One  must  always  be  as  sure  as  is  possible  to  destroy  the  entire  diseased  area,  for 
there  is  danger  of  rapid  extension  from  the  periphery  if  all  the  disease  be  not 
destroyed — unless  it  be  possible  to  control  this  tendency  by  deep  Rontgen therapy . 
The  tendency  to  the  increased  rate  of  growth  in  areas  not  removed  by  this 
process  or  by  operation  is  probably  due  to  the  increased  congestion  which  is 
brought  about  by  the  subsequent  reaction. 

Anesthetic. — The  destruction  of  tissue  by  heat  is,  of  course,  always  painful, 
and  large  lesions  are  more  painful  than  others.  The  degree  of  pain  also  varies 
with  the  individual  and  with  the  location  of  the  disease.  When  the  area 
selected  for  destruction  is  large,  the  pain  is,  of  course,  intense,  and  some  form 
of  general  anesthetic  is  always  necessary.  The  operation  is  generally  com- 
paratively short,  and  if  the  lesion  be  not  in  the  region  of  the  mouth,  nitrous 
oxid  may  be  used,  or  a  combination  of  nitrous  oxid  and  ether.  In  mouth 
cases,  however,  some  form  of  anesthetic  must  be  used.  Ether  is  objectionable 
because  of  some  danger  from  explosion,  no  matter  what  portion  of  the  body  is 
being  treated,  because  a  spark  may  be  drawn  from  any  part  of  the  body  during 
this  process.  Therefore,  ether,  and  the  ether  apparatus  must  be  completely 
removed  from  the  table  or  the  patient  during  the  process  of  actual  destruction 
or  electrocoagulation.  In  fact,  the  high  frequency  instruments  should  be  com- 
pletely detached  from  the  table  or  they  should  be  rendered  inactive.  Another 
objection  to  ether  in  mouth  cases  is  the  congestion  of  the  mucous  membrane, 
and  the  increased  amount  of  mucus  which  accumulates  during  the  process 
of  etherization.  This  increased  mucus  and  congestion  of  the  mucous  membrane 
interferes  with  vision,  and  the  mucus  carries  away  the  current  so  that  it  cannot 


Advantages  of  the  Treatment  1639 

be  strictly  confined  to  the  area  under  treatment.  When  the  condition  of  the 
patient  will  permit,  anesthesia  by  means  of  morphin  and  hyoscin,  or  the  com- 
bination of  morphin,  hyoscin  and  cactin  (Abbott)  may  be  used  successfully. 
When  necessary  ether  may  be  added  to  this  and  the  mucus  is  less  likely  to  collect 
in  the  mouth.  Even  when  ether  is  depended  upon  as  a  general  anesthetic,  the 
prehminary  administration  of  morphin  and  hyoscin  has  a  distinct  advantage, 
because  of  the  local  congestion.  Small  lesions,  such  as  moles,  warts,  and  epithe- 
homa,  may  be  removed  usually  by  1-ocal  anesthesia  by  the  injection  of  novocain 
or  any  of  the  local  anesthetics. 

Cases  Suitable  for  the  Combined  Form  of  Treatment. — (i)  Those  cases 
in  which  there  is  a  considerable  area  of  malignant  tissue  which  can  be  removed 
en  masse  without  danger  of  destroying  blood-vessels  or  nerves,  for  it  must 
always  be  kept  in  mind  that  all  tissues  are  destroyed  completely.  It  is  espe- 
cially valuable  in  the  destruction  of  epithelioma,  warts,  moles  and  birth-marks. 
(2)  Epithehoma  involving  the  lip,  cheek,  tongue  or  alveolar  process.  The 
method  seems  to  be  especially  useful  in  the  treatment  of  malignant  disease  of 
the  mucous  membrane.  (3)  Old  adherent  scirrhous  carcinomata  of  the  breast 
in  which  there  is  no  evidence  of  metastasis,  and  which  are  considered  inoperable 
by  surgical  means  because  of  the  involvement  of  the  intercostal  muscles.  At 
least,  Pfahler  has  treated  one  such  case  successfully.  Pfahler  has  treated 
approximately  50  cases  of  primary  epithelioma  of  the  lip  by  this  method  com- 
bined with  deep  Rontgentherapy  without  evidence  of  recurrence  or  metastasis. 

Disadvantages  of  the  Treatment. — (i)  There  is  complete  destruction  of 
all  the  tissue  between  the  two  electrodes,  when  the  two  electrodes  are  used  in 
the  area  diseased,  and  there  is  complete  destruction  of  all  tissues  including 
blood-vessels  and  nerves,  even  when  only  a  point  electrode  is  used  locaUy. 
Therefore,  there  is  no  chance  of  saving  the  blood-vessels  or  nerves  which  are  in 
close  proximity  to  the  disease.  In  the  destruction  of  disease  of  the  floor  of  the 
mouth,  and  of  the  alveolar  process  of  the  lower  jaw,  there  is  danger  of  destruc- 
tion of  the  periosteum  and  this  is  always  followed  by  necrosis  of  the  underlying 
bone.  This  very  frequently  involves  destruction  of  the  blood-vessels  and 
nerves  in  the  inferior  dental  canal,  to  be  followed  by  necrosis  of  the  entire  body 
of  the  bone,  very  annoying  later. 

Because  of  this  total  destruction  one  can  rarely  destroy  metastatic  glands, 
especially  in  the  region  of  the  parotid  vessels  and  in  the  axilla  and  supraclavicu- 
lar regions.  Here  a  careful  dissection  followed  by  deep  Rontgentherapy  must 
always  be  the  method  of  choice.  (2)  It  leaves  an  open  area  which  is  healed  by 
granulation,  but  at  times  this  healing  must  be  followed  by  a  surgical  plastic 
operation  to  close  the  mouth  or  to  correct  some  deformity.  (3)  A  very  serious 
objection  to  the  patient,  the  friends,  and  other  patients  in  the  hospital,  is  the 
odor  from  the  sloughing  tissues,  which,  of  necessity,  follows  such  destruction. 
This  can  be  partially  diminished  by  careful  removal  of  all  the  destroyed  tissue 
after  the  operation.  Such  removal  is  not  always  possible  and  at  best  there  must 
always  remain  a  layer  of  tissue  which  must  be  left  to  slough  away.  Dichlor- 
amin-T  may  be  used  to  control  part  of  this  disagreeable  odor,  but  in  the  region 
of  the  mouth,  or  where  there  is  much  secretion,  it  seems  at  times  that  the  com- 
bination of  the  secretion  with  the  dichloramin-T  produces  marked  irritation, 
and  therefore  must  be  eliminated.  Thorough  cleansing,  together  with  deodor- 
ants such  as  permanganate  of  potash,  must  be  used  until  the  slough  has  come 
away.  The  duration  of  this  sloughing  process  will,  of  course,  vary  with  the 
extent  of  the  tissue  destroyed,  but  it  generally  requires  from  two  to  four  weeks, 
after  which  the  healing  process  begins,  and  at  any  stage  during  the  healing 
process  when  healthy  granulations  are  present  skin  grafting  or  skin  trans- 
plantation may  be  done. 

Advantages. — (r)  There  is  complete  destruction  of  the  local  malignant 
disease.     (2)  This  is  accomplished  without  opening  the  blood-vessels  or  the 


1640  The  X-rays  in  Surgery- 

lymphatics,  and  it  is  behaved  that  this  method  of  treatment  is  less  Hkely  to  be 
fohowed  by  recurrence  or  metastasis.  (3)  The  wound  heals  with  a  smooth, 
soft  scar  which  resembles  skin  very  closely.  (4)  It  can  be  applied  to  surgically 
inoperable  cases  as,  for  instance,  to  the  adherent  scirrhus  carcinoma  of  the 
breast  (Pfahler,  Surg.,  Gyn.  and  Obst.,  Dec,  1914,  pp.  783-790). 

Deep  Rontgentherapy  applied  as  an  ante-operative  measure,  that  is,  immedi- 
ately preceding  the  operation,  and,  after  the  proper  interval,  following  the  opera- 
tion, has  the  same  advantages  as  described  previously  in  connection  with 
surgical  operations,  and  is  always  to  be  recommended  when  practical. 

FINSEN  LIGHT 

It  is  known  that  below  the  spectrum  of  red  light  are  heat  rays,  and  above 
the  spectrum  of  violet  light  are  short  violet,  actinic,  ©r  chemical  rays.  The 
short  violet,  with  the  indigo  rays  and  blue  rays,  constitute  the  Finsen  light. 
Ultraviolet  rays  cause  an  electrified  body  to  discharge,  excite  fluorescence  in 
certain  substances,  affect  a  photographic  plate,  and  are  bactericidal,  but  have 
Uttle  power  of  penetrating  tissues  and,  it  is  said,  do  not  inflame  tissues.  Ultra- 
violet rays  pass  readily  through  rock  salt  or  ice,  which  will  not  transmit 
heat  rays. 

Finsen  taught  us  to  use  these  rays  therapeutically.  He  first  obtained 
the  rays  from  sunlight,  intercepting  the  heat-rays  by  ice  or  rock  cr^-stal.  Later 
he  obtained  them  from  the  arc  light. 

Blood  in  part  prevents  the  passage  of  the  Finsen  light,  hence  in  using  the 
light  we  must  make  the  area  on  which  the  rays  are  to  act  nearly  bloodless. 
This  is  done  by  pressing  firmly  upon  the  part  with  a  rock  crystal  through 
which  water  passes.  The  rays  pass  through  the  crystal  and  the  water  ab- 
sorbs the  heat-rays.     These  rays  are  especially  serviceable  in  lupus. 

BECQUEREL'S  RAYS 

Becquerel  discovered  in  1896  that  uranium  and  some  of  its  compounds  give 
oE  a  radiation  similar  to  but  much  weaker  than  the  .v-rays.  Among  these 
radiant  substances  are  pitchblende,  radium,  and  uranium.  These  rays  are 
luminous,  actinic,  and  skiagraphic  (McFarland),  and  may  produce,  by  pro- 
longed action,  dermatitis  similar  to  .r-ray  dermatitis. 

RADIUM  RAYS 

Monsieur  and  Madame  Currie,  after  prolonged  research,  found  that  thorium 
and  certain  ores  of  thorium  and  uranium  (pitchblendej  are  radio-active,  pitch- 
blende being  more  strongly  so  than  uranium  itself.  The  conclusion  was  that 
pitchblende  contained  a  strongly  radio-active  element  and  that  it  was  not 
uranium.  In  1903  they  discovered  the  sources  of  radio-activity  to  be  two 
hitherto  unknown  elements,  radium  and  polonium  (Dawson  Turner,  in  "Brit. 
Med.  Jour.,"  Dec.  12,  1903). 

Turner  (Ibid.)  tells  us  that  radium  gives  off  a  radio-active  emanation  and 
three  kinds  of  rays  (alpha-rays,  beta-rays,  and  gamma-rays).  It  also  emits 
heat,  and  is  itself  at  a  higher  temperature  than  the  medium  in  which  it  rests. 
The  emanation  from  radium  is  a  luminous  gas,  which  can  be  condensed  by 
great  cold,  and  which  imparts  radio-activity  to  certain  bodies.  It  is  to  this 
gas  that  most  of  the  curative  effects  of  radium  can  be  attributed. 

Alpha-rays  consist  of  a  stream  of  positively  charged  gaseous  particles.  Tur- 
ner points  out  that  these  particles  are  each  about  twice  the  size  of  a  hydrogen 
atom,  travel  at  a  velocity  of  20,000  miles  a  second,  and  have  little  power  of 
penetration.  In  fact,  the  penetrating  power  of  the  alpha-rays  is  so  slight  that 
they  do  not  pass  through  the  glass  of  a  tube  (Robert  Abbe,  in  "Med.  Record," 
Oct.  12,  1907),     The  beta-rays  consist  of  particles  each  being  one  one-thou- 


Becquerel's  Rays,  Radium  Rays  1641 

sandth  the  size  of  a  hydrogen  atom  and  being  strongly  actinic.  These  rays 
are  said  by  Turner  to  resemble  cathode  rays  and  to  be  far  more  penetrating 
than  alpha-rays.  Gamma-rays  resemble  .T-rays  and  have  great  penetrating 
power  (Dawson  Turner,  Loc.  cit.).  According  to  Abbe  ("N.  Y.  Med.  Jour.," 
Feb.  10,  1912),  the  soft  beta-rays  and  the  alpha-rays  irritate  and  stimulate; 
the  hard  beta-rays  and  gamma-rays  destroy.  It  is  probable  that  radium 
also  generates  or  helps  to  generate  a  gas  called  helium,  which  has  no  action 
on  tissues. 

The  actions  of  radium  are  extraordinary.  A  man  entirely  blind  cannot 
perceive  light  when  radium  is  brought  near  him,  but  one  not  quite  but  almost 
blind  can,  and  one  quite  blind  to  form  but  with  retention  of  some  light  percep- 
tion can  actually  see  the  shapes  of  objects  near  a  screen  rendered  luminous 
by  radium.  Turner  tells  us  that  a  man  retaining  vision,  who  covers  his  eyes^ 
can  detect  radium  held  in  a  box  behind  his  head.  If  dry  seeds  before  plant- 
ing are  exposed  to  radium  rays,  sprouting  will  be  retarded  in  proportion  to 
the  time  of  exposure.  When  meal  worms  are  exposed  to  the  rays  "they  go 
on  living  as  meal  worms,  'veritable  Methuselahs,'  as  it  has  been  said,  while 
their  sisters  and  brothers,  unradiumized,  progress  for  generations,  completing- 
several  cycles  of  beetles,  eggs,  meal  worms,  etc."  (Abbe,  in  "Med.  Record," 
Oct.  12,  1907).  Radium  rays  are  germicidal,  but  act  very  slowly  and  feebly, 
Skiagraphs  can  be  taken  with  the  rays.  Water  and  other  materials  may  be 
rendered  radio-active  by  exposure  to  radium  rays.  Probably  certain  natural 
waters  have  subtle  powers  due  to  radio-activity.  On  the  tissues  radium  may 
act  to  produce  a  retrogressive  effect;  may  increase  self-digestion;  may  cause 
irritation  and  inflammation,  and  so  block  blood-vessels.  Severe  reaction  may 
result  in  ulceration.  On  a  tumor  radium  produces  inflammation,  first  of  the 
fiibrous  stroma,  then  of  the  tumor-cells,  or  a  primary  necrosis  (Sticker,  in 
"Presse  Medicale,"  May  18,  1912),  It  seems  to  have  a  selective  action  on 
cancerous  tissue.  Sometimes  a  spreading  eruption,  like  that  of  scarlet  fever,, 
follows  overaction.  Abbe  says  that  when  an  ulcerated  surface  is  treated 
or  when  a  tube  of  radium  is  inserted  in  a  wound  for  twenty-four  hours,  a  "specific 
toxemia"  frequently  arises.  "The  symptoms  will  be  headache,  chill,  gen- 
eral aching,  coated  tongue,  fever  up  to  from  103°  to  106°  F.,  and  an  occasional 
rash-like  scarlatina."  Some  hold  that  radium  acts  similarly  to  the  arrays 
and  that  the  .T-rays  can  do  anything  radium  can  do.  Other  observers  believe 
that  the  radium  rays  have  a  specific  action  and  can  accomplish  some  few 
things  impossible  to  the  ^*-rays. 

Radium  therapy  is  commanding  profound  and  widespread  public  interest. 
How  real  its  claims  are  and  how  great  its  future  is  to  be  we  can  only  guess. 
Sir  Frederick  Treves  bids  us  to  be  cautious  in  our  estimates,  although  he  thinks 
there  may  be  a  great  future  for  radium  therapy  in  surgery  ("Brit.  Med.  Jour.," 
Jan.  30,  1909).  It  has  cured  many  surface  carcinoma ta  and  sarcomata,  keloids, 
angeiomata,  moles,  pigmented  moles,  and  warts.  It  is  particularly  valuable  in 
lesions  about  the  face  when  it  is  desirable  to  avoid  scars;  in  lesions  of  the  nostril,, 
mouth,  and  other  cavities.  It  has  a  very  powerful  action  on  angeiomata.  Sa 
far  radium  has  been  used  chiefly  for  inoperable  cancer.  It  has  been  used  most 
advantageously  for  epithelioma  of  the  eyelid  (see  the  striking  cases  reported  by 
Abbe,  in  "Med.  Record,"  Oct.  12,  1907).  When  treating  a  surface  lesion  the 
rays  are  obtained  from  radium  bromid,  which  material  is  kept  in  a  hermetically 
sealed  platinum  or  lead  tube.  In  a  deep-seated  tumor  an  incision  may  be  made 
and  a  tube  of  radium  bromid  be  inserted  in  the  wound  and  allowed  to  remain 
for  forty-eight  hours.  Attempts  are  being  made  to  treat  internal  conditions 
by  the  inhalation  of  radium  emanations  or  by  the  administration  of  materials 
which  have  been  rendered  radio-active  and  contain,  so  to  speak,  radium  emana- 
tions in  solution.  Radio-active  water  has  been  tried  for  cancer  of  the  stomach. 
Treatment   by  radium  is  called  radium  therapy;  treatment  by  radio-active 


1642  The  X-rays  in  Surgery 

substances,  radiotherapy.  It  is  extraordinary  how  even  very  brief  appli- 
cations of  radium  may  be  followed  by  notable  changes.  In  one  of  Abbe's 
cases  an  epithelioma  of  the  forehead  disappeared  after  one  exposure  of  an 
hour's  duration.  Another  on  the  side  of  the  nose  disappeared  in  four  weeks 
after  one  exposure  of  an  hour's  duration.  A  cancer  involving  one-third  of  the 
upper  eyelid  entirely  disappeared  in  two  weeks  after  three  five-minute  expos- 
ures. After  an  exposure  no  changes  are  apparent  for  several  days  or  a  week. 
The  skin  at  the  site  of  application  then  begins  to  burn  and  itch  and  becomes 
reddened.     The  irritation  endures  for  about  two  weeks. 

Confusion  has  arisen  because  of  the  varying  strengths  and  amounts  used 
by  different  operators.  Bromid  of  radium  is  the  salt  usually  employed.  Abbe 
takes  as  a  standard  10  mg.  of  bromid  of  radium  and  tests  other  specimens 
by  this.  He  calls  the  10  mg.  of  strong  German  bromid  of  radium  "the  work- 
ing unit."  In  malignant  disease  the  best  results  have  followed  one  hour's  exhi- 
bition of  the  "working  unit"  to  small  growths  and  three  or  four  hours  to  large 
growths,  "with  an  interval  of  one  month  for  study  of  the  effect"  (Abbe,  Ibid.). 
Ischemia  favors  powerful  action  of  radium  rays. 

In  order  to  obtain  the  best  results  from  radium  heavy  "doses"  seem  to  be 
necessary,  and  heavy  "doses"  are  very  apt  to  burn  the  skin.  The  penetrating 
rays  are  the  gamma-rays,  and  in  order  to  make  them  reach  a  deep  growth  in 
sufficient  intensity  to  do  good  the  superficial  parts  are  endangered. 

So  far  radium  has  found  its  chief  use  in  inoperable  cases  and  in  superficial 
lesions.  Abbe  ("New  York  Med.  Jour.,"  Feb.  10,  1912)  says,  we  may  suppress 
the  short  rays  which  burn,  and  yet  use  the  deeply  penetrating  rays  by  placing 
a  considerable  amount  of  radium  in  lead  which  is  from  If  0  to  2  mm.  in  thickness. 

Macdonald  ("Brit.  Med.  Jour.,"  Dec.  9,  191 1)  uses  for  a  deep  growth  at 
least  250  mg.  of  bromid  of  radium  in  platinum  23^^  mm.  thick.  He  keeps  the 
tube  applied  from  twenty-four  to  forty-eight  hours.  In  some  cases  he  inserts 
the  tube  in  the  tumor  and  leaves  it  in  place  for  forty-eight  hours.  A  long 
application  is  not  to  be  repeated  for  five  or  six  weeks.  For  a  superficial  growth 
he  uses  radium  in  a  glass  tube  every  other  day  for  a  week. 

It  may  develop  that  radium  has  decided  power  in  preventing  recurrence 
after  operation.  In  some  few  cases  of  cancer  radium  may  convert  an  inoper- 
able into  an  operable  case. 

A  serious  bar  to  the  extensive  use  of  radium  is  its  immense  cost.  The 
little  there  is  in  the  world  is  in  the  hands  of  a  few  men  and  a  few  institutions. 
Altruistic  persons  in  many  lands  are  striving  to  give  greater  numbers  access 
to  the  supposedly  beneficient  influence  of  that  wonderful  element.  No  proc- 
ess ever  was  so  thoroughly  and  dramatically  advertised  as  the  radium  treat- 
ment of  cancer.  There  is  a  hideous  cruelty  in  the  newspaper  exploitation  of 
radium  therapy,  because  great  numbers  of  persons  who  are  victims  of  cancer 
have  been  caused  to  believe  that  they  could  certainly  be  cured  if  they  could 
gain  access  to  radium.  Such  hopes  cannot  be  realized.  Any  statement  that 
an  extensive  cancer  can  usually  or  even  often  be  cured  by  radium  is  a  stupid 
mistake  or  a  heartless  deception.  At  the  present  time  the  real  truth  of  the 
matter  is  being  slowly  and  carefully  studied  out  by  earnest  men  who  are  not 
seeking  profitable  notoriety.  There  is  little  evidence  at  present  that  radium, 
unless  it  be  in  certain  exceptional  cases,  has  greater  curative  power  than  the 
x-rays,  and  the  Coolidge  .r-ray  tube  may  remove  even  these  exceptional  cases 
from  the  radium  side  of  the  scale  (see  pages  1628  to  1631). 

Radium  can  be  appUed  advantageously  to  carcinoma  within  cavities,  such  as 
the  mouth,  esophagus,  bladder,  rectum,  and  vagina,  while  .T-rays  are  applied 
externally.  Radium  and  the  .r-rays  should  not  be  used  at  the  same  time  (see 
page  1632). 

Radium  has  been  found  of  value  in  the  treatment  of  carcinoma  of  the  uterus, 
of  uterine  fibroids,  of  uterine  hemorrhage  at  the  menopause  and  of  simple 
hypertrophy  of  the  prostate. 


Electricity  1643 


XLI.  INJURIES  BY  ELECTRICITY 

(Dr.  William  S.  Wadsworth  did  me  the  kindness  to  rewrite  the  section  on  electricity.) 

Electricity. — The  surgeon  meets  four  types  of  injury  by  electricity:  (i)  from 
currents  applied  for  therapeutic  purposes;  (2)  from  industrial  currents;  (3)  from 
lightning;  (4)  from  radiant  discharges — as  .T-ray  burns. 

To  understand  fully  the  effects  one  finds  in  the  body  would  require  not  only  a 
complete  knowledge  of  the  physics  of  electricity  but  an  equally  extensive  knowl- 
edge of  laboratory  and  clinical  physiology.  In  the  past  both  fields  have  been  so 
crowded  with  controversy — in  large  measure  due  to  the  overvaluing  of  some 
minor  part — that  even  at  present  it  is  hardly  safe  to  express  sane  conclusions 
on  the  subject;  but,  as  the  surgeon  cannot  wait  for  the  specialists  to  settle  their 
disputes,  he  must  accept  conclusion^  as  soon  as  they  are  sane. 

WTiile  nothing  is  to  be  ignored  there  are  certain  things  which  must  always  be 
kept  in  mind.  Electric  potential,  or  charge,  is  produced  by  a  vast  number  of 
processes  in  Hv-ing  bodies  and  electric  polarity  is  found  generally  where  metabolism 
is  active.  Whenever  produced  there  is  an  equal  amount  of  positive  and  negative 
electricity  and  these  charges  tend  to  go  together  and  to  neutralize  each  other. 

In  metals  and  other  good  conductors  this  reunion  takes  place  readily  but  in 
organic  tissues  we  find  insulation  preventing  the  equalization,  in  fact,  most  of  the 
best  insulating  materials  are  organic  bodies  and  this  is  not  accidental. 

We  find  then  the  body  developing  potential  and  polarity  and  at  the  same  time 
insulation  in  the  general  tissue  masses  and  we  find  specialized  properties  of  in- 
sulation and  conduction  in  the  nervous  system.  We  also  find  the  blood  acting 
as  a  good  conductor. 

All  the  active  tissues  of  the  body  are  converters  or  transformers  of  forces, 

and  heat  and  electric  potential  are  the  indices  we  have  for  measuring  metabolism. 

We  know  that  in  any  apparatus  where  electric  potential  is  produced  we  can 

produce  effects  by  passing  in  an  artificial  current  in  the  direction  opposed  to  that 

naturally  produced. 

We  know  that  the  action  of  the  heart  is  accompanied  by  electric  currents  and 
we  are  not  surprised  that  experimenters  have  been  able  to  show  conclusively 
that  moderate  currents  passed  into  the  heart  disturb  its  action,  causing  it  to 
cease  its  regular  beat  and  pass  into  fibrillation  and  finally  to  stop  entirely.  We 
know  that  all  muscular  and  nerve  action  is  accompanied  by  electrical  phenomena 
and  are  not  surprised  that  common  experience  and  laboratory  tests  show  that 
electric  currents  produce  profound  effects  on  both  nerves  and  muscles. 

We  know  much  about  the  effects  of  electricity  on  nerves  and  muscles,  a  little 
about  its  effects  on  the  blood  but  almost  nothing  about  its  influence  on  the  other 
tissues  of  the  higher  animals. 

We  are  forced  to  limit  our  considerations  largely  to  the  effects  on  nerves, 
muscles  and  blood,  not  because  such  effects  constitute  the  whole  but  because  of 
the  present  limitations  of  science.  Unfortunately,  serious  blunders  have  occurred 
in  the  surgical  use  of  electricity  because  what  was  already  known  of  normal  and 
abnormal  tissue  potential  and  of  the  response  to  artificial  potentials  and  currents 
by  normal,  abnormal,  and  repair  tissues  had  not  been  utilized. 

Specially  sad  have  these  blunders  been  in  :v-ray  work.  It  should  be 
remembered  that  the  human  body  is  a  vast  collection  of  histological  units  each 
of  which  is  a  sort  of  battery  having  its  minute  electric  qualities  of  charge,  re- 
sistance and  effect. 

WTiile  bodily  currents  and  potentials  are  small,  industrial  currents  are  relatively 
very  large,  so  that,  aside  from  the  great  outside  insulator  (the  skin) ,  they  readily 
overcome  the  internal  resistances  and,  forming  for  themselves  paths,  cause  very 
considerable  damage  to  the  tissues. 


1644  Injuries  by  Electricity 

This  damage  becomes  strikingly  apparent  when  it  affects  some  organ  on  which 
life  immediately  depends,  as  the  heart  and  central  nervous  system.  It  is  quite 
sensibly  apparent  when  we  get  a  shock.  It  is  clinically  important  when  we  find  the 
result  of  an  apparently  slight  contact  lasting  as  a  painful  and  incapacitating 
neuritis,  or  as  a  large  sloughing  area  about  a  slight  burn.  To  understand  the 
effect  of  artificial  currents  on  the  body  we  must  clearly  grasp  the  significance 
of  the  skin  as  an  insulator.  When  the  skin  is  dry  it  offers  a  high  resistance, 
which  is  raised  by  natural  or  other  oils.  If,  however,  the  skin  becomes  wet  by 
water,  or  any  other  fluid  of  lower  resistance,  such  as  perspiration  or  saline  solu- 
tion, the  power  of  resistance  of  the  skin  will  be  greatly  diminished — so  that 
very  low  currents  will  readily  enter  the  body.  This  diminution  in  skin  re- 
sistance is  not  so  common  after  a  superficial  wetting  as  it  is  when  the  fluid  has 
penetrated  deeply  into  the  cuticle.  Denudation  or  wounding  also  aids  in 
destroying  insulation.  Currents  on  entering  the  body  find  paths  through  the 
tissue  or,  more  readily,  along  blood  channels  and  along  nerves.  A  few  minutes' 
testing  with  a  "medical"  battery  will  give  one  much  valuable  insight  into  these 
matters.  If  the  current  finds  a  path  through  large  veins  to  the  heart  it  tends  to 
produce  marked  disturbance  leading  to  fibrillation  or  death  by  complete  arrest 
of  that  organ.  This  is  true  of  low  voltage  industrial  currents  whether  direct 
or  alternating. 

Very  high  voltage  direct  and  very  rapidly  alternating  currents  appear  to  have 
less  efifect  on  the  heart — which  explains  why  cases  of  survival  after  exposure  to- 
very  high  voltage  as  well  as  deaths  from  low  voltages  have  been  reported. 

In  general,  low  voltage  alternating  currents  are  more  dangerous  than  direct 
currents  of  the  same  voltage,  but  as  the  rate  of  alternation  increases  the  danger 
appears  to  become  less  until  no  fatal  results  follow  when  the  rate  of  alternation 
mounts  to  the  hundreds  of  thousands  per  second. 

We  have  spoken  of  potential  or  charge  and  flow  or  current.  There  are  two 
other  very  important  groups  of  electric  phenomena,  those  of  induction  atid  radiant- 
discharge. 

Wherever  there  is  either  stationary  charge  or  current  there  is  an  influence 
capable  of  inducing  in  near  objects  secondary  electric  charges  and  currents. 

Where  the  currents  passing  through  the  body  are  barely  powerful  enough  to 
get  through  we  may,  as  a  rule,  ignore  the  induced  currents  because  these  are  less 
than  the  primary,  but  where  the  currents  or  charges  are  very  large,  as  in  lightning, 
the  effects  may  be  very  great,  in  fact  may  result  from  currents  which  pass  not 
through  the  body  at  all  but  only  near  it. 

As  a  rule  low  currents  find  paths  rather  than  make  them,  while  high  currents 
often  make  actual  holes,  not  only  in  the  skin  but  in  the  tissues,  in  the  walls  of 
blood-vessels  and  in  the  case  of  very  high  currents,  as  lightning  bolts,  through 
bones.  Every  current,  no  matter  how  small,  tends  to  open  the  path  so  that  it 
flows  more  readily  after  such  path  has  been  established. 

Currents  require  substance  along  which  to  travel  in  their  paths.  They  also 
carry  substances  along  such  paths.  On  this  principle  depends  cataphoresis  and 
we  find  that  in  serious  industrial  accidents  there  is,  not  rarely,  a  metallic  im- 
pregnation of  the  tissues.  This  must  be  remembered  in  considering  the  burn 
which,  in  so  far,  becomes  a  poisoned  one. 

Currents  produce  heat  but  the  burns  are  usually  the  result  of  the  arc  produced 
at  the  point  of  contact  rather  than  by  the  heat  directly  resulting  fro.m  the  passage 
of  the  current.  Currents  also  produce  electrolytic  or  chemical  changes — the 
direct  current  being  regarded  as  most  effective,  but  in  the  tissues  there  are 
changes  which  must  be  recognized  even  though  we  must  wait  for  their  explana- 
tion— such  as  are  found  in  the  blood. 

The  effects  are,  in  general,  proportional  to  the  amount  of  current  and,  with 
qualifications,  also  proportional  to  the  voltage.  The  time  or  duration  of  the  flow 
is  a  very  important  factor  in  all  electrical  cases. 


Injuries  by  Artificial  Currents  1645 

In  considering  electrical  action  it  is  necessary  to  magnify  the  time,  for  great 
results  take  place  in  such  extremely  short  periods  that  we  can  hardly  conceive 
of  them  as  they  occur  unless  we  do  so  magnify  them.  Otherwise  we  will  not 
properly  realize  the  complex  nature  of  an  occurrence  which  takes  but  the 
minute  fraction  of  a  second,  such  as  a  stroke  of  lightning.  Nor  shall  we  properly 
appreciate  that  electricity  possesses  no  sense  of  geometry  but  seeks  its  path 
under  laws  of  attraction  and  repulsion  as  truly  as  does  the  trickle  of  water 
in  a  rain  storm. 

Injuries  by  therapeutic  currents  are  generally  to  be  studied  by  the  damage 
done  to  the  ner\-es  and  are  usually  of  a  trophic  type — rarely  we  have  severe 
thermal  or  mechanical  injuries.  Unfortunately  we  can  say  but  Httle  of  the  in- 
juries to  the  tissues  themselves  owing  to  the  dense  ignorance  of  the  whole  subject. 
Very  severe  damage  has  been  done  by  the  substances  forced  into  the  tissues  by  the 
cataphoretic  process — even  fatal  results  have  occurred;  fortunately  the  reck- 
lessness in  this  matter  has  largely  subsided. 

Injuries  by  Artificial  Cxirrents. — During  the  past  few  years  the  enormous  in- 
crease in  the  use  of  electricity  for  domestic  and  industrial  purposes  has  brought 
with  it  a  very  large  number  of  accidents  which  demand  the  attention  of  thesurgeon. 
In  spite  of  all  precautions  and  safeguards  this  class  of  cases  is  still  increasing. 
In  the  past  they  were  added  to  by  reason  of  the  ignorance  and  stupid  assurance 
of  the  so-called  practical  electricians ;  this  is  fortunately  being  corrected. 

WhUe  these  injuries  are  most  frequent  among  those  employed  about  electrical 
appHances  they  are  not  confined  to  this  class.  The  private  citizen  in  his  bath 
may  touch  with  his  wet  and  soapy  hand  a  charged  metal  light  socket,  the  butcher 
in  his  refrigerator,  the  confectioner  making  ice  cream,  the  lad  at  play,  the  pedestrian 
on  the  public  highway,  the  domestic  in  the  kitchen  or  laundry,  the  stenographer 
in  the  office.  These  and  other  similar  cases  have  occurred  with  serious  results 
in  our  own  experience. 

Most  industrial  currents  are  produced  by  dynamos  and  any  metal  or  other 
conductor  connected  either  purposely  or  through  accident  may  become 
dangerously  charged  and  cause  serious  or  fatal  accident.  Nearly  all  industrial 
currents  are  dangerous,  as  no  current  of  50  volts  or  over  is  safe.  Formerly  it 
was  supposed  that  the  resistance  of  the  human  body  was  very  high  but,  after  a 
sad  fist  of  fatalities  had  occurred,  it  was  concluded  that  under  certain  conditions 
the  skin  resistance  rapidly  disappeared.  Then  fatal  cases  from  low  currents 
were  recorded  as  due  to  heart  disease.  If  the  charged  metal  be  connected  with 
the  earth — "grounded" — the  current  will  seldom  leave  it  to  enter  the  body; 
this  suggests  the  procedure  of  grounding  a  charged  wire  where  the  current  can- 
not be  cut  or  the  person  removed  from  contact  with  it.  It,  however,  should  be 
remembered  that  this  is  a  dangerous  procedure.  Usually  the  person  receives  the 
current  in  one  of  two  ways,  either  he  touches  both  wires,  or  conductors,  and  then 
makes  a  double  contact  or  as  is  more  usual,  he  is  in  contact  with  one  wire  and  is 
grounded  by  touching  some  uncharged  conducting  material. 

With  low  voltages  fuU  contact  is  necessary,  as  such  currents  will  not  over- 
come the  resistance  of  the  air;  but  with  high  voltages,  the  current  may  jump 
or  spark. 

Ordinarily,  the  skin  resistance  is  sufficient  to  withstand  currents  up  to  200 
volts  but  with  skin  damp  with  perspiration  or  saline  solutions  the  ordinary  lighting 
currents  of  no  volts  are  dangerous  and  it  is  surprising  how  little  grounding  is 
necessary  to  produce  fatal  results.  We  daily  see  the  repair  men  on  the  trolley 
lines  handhng  live  wires  but  they  are  insulated  from  the  ground.  So  too  we  know 
that  firemen  come  in  contact  with  live  wires  but  their  rubber  boots  save  them  from 
serious  results,  though  they  are  frequently  severely  shocked.  Fortunately  the 
first  effect  of  the  current  is  to  cause  \iolent  muscular  contractions;  at  times 
these  throw  the  man  some  distance,  breaking  the  contact  thus  saving  his  life. 
Reports  from  the  large  industrial  plants  show  that  recovery  is  to  be  looked  for 


1646  Injuries  by  Electricity 

if  first  aid  be  promptly  rendered  and  artificial  respiration  quickly  instituted  and 
persistently  kept  up. 

At  the  point  of  contact  one  may  find  evidences  of  the  passage  of  the  current, 
such  as  minute  punctures — holes  or  wounds — burns,  or  simply  marks.  The  ef- 
fect may  vary  from  pallor  due  to  vasomotor  spasm  to  redness,  from  whiteness, 
as  of  cooking,  to  actual  charring  and,  at  times,  may  show  a  film  from  vaporized 
metal. 

It  is  usually  stated  that  constant  or  direct  currents  produce  shock  at  opening 
and  closing  only  but  it  should  be  remembered  that,  owing  to  muscular  action  and 
other  factors,  these  currents  often  practically  act  differently  and  that  burning 
and  electrolysis  may  be  severe.  There  is  some  debate  as  to  the  cause  of  respi- 
ratory failure  resulting  from  severe  electric  shock  but  it  is  quite  certain  that 
asphyxia  follows  the  arrest  of  respiratory  action  by  reason  of  spasm  of  the  mus- 
cles, also  that  this  spasm  produces  fatigue  which  persists  often  for  a  considerable 
time,  and  that  we  actually  do  find  true  nervous  respiratory  paralysis  in  cases. 
It  is  therefore  necessary  in  treating  such  cases  to  continue  the  artificial  respira- 
tion long  enough  to  allow  for  recovery  of  function  in  either  case  and  to  give  over 
only  when  it  becomes  clear  that  such  recovery  is  no  longer  to  be  hoped  for.  The 
hemolytic  action  of  electric  currents  must  be  remembered,  specially  after  pro- 
longed contacts  and  the  sequelae  of  such  hemolysis  expected  and  treated  when 
developed.  The  injury  to  the  peripheral  nerves  may  be  very  serious  and  may 
long  resist  treatment  and  must  be  considered  as  traumatic  lesions.  These  so 
often  complicate  severe  burns  that  they  should  be  expected  and  the  treatment 
should  be  adjusted  accordingly.  The  path  taken  by  the  current  cannot  be 
readily  diagnosed  from  the  position  of  the  contacts  but  something  may  be 
judged  from  these  contacts.  If  both  contacts  are  on  the  same  leg  one  would 
expect  the  heart  to  escape,  if  the  current  passed  from  one  hand  to  the  other  the 
chances  are  that  the  heart  has  suffered.  In  hand  to  leg  contact  there  is  un- 
certainty but  from  one  hand  to  the  leg  of  the  opposite  side  the  chances  are  less 
favorable.  If  one  of  the  contacts  is  on  the  head  the  chances  are  usually  bad. 
With  higher  voltage  the  danger  to  the  central  nervous  system  increases  rapidly. 

It  must  always  be  remembered  that  the  person  seldom  receives  the  full  charge 
from  the  wire  or  conductor — this  is  more  apt  to  be  the  case  if  the  skin  be  still  intact 
after  the  exposure. 

It  must  further  be  remembered  that  high-power  currents  may  force  a  path 
through  indifferent  tissues  avoiding  the  vital  organs.  Then  we  may  hope  for  re- 
covery but  we  must  expect  serious  local  effects  along  this  path  with  delayed  re- 
covery of  the  part  affected.  Usually  high-power  currents  acting  continuously 
give  fatal  results  and  the  exceptions  which  have  been  featured  in  the  literature 
seldom  show  insuperable  obstacles  to  careful  analysis  of  cause  and  effect.  The 
sequelae  depend  on  the  duration,  intensity,  type  and  amount  of  current  and  on  the 
location  of  its  application  and  its  path  in  the  body.  Usually  the  burns  are  slow 
to  heal,  tend  to  become  infected  and  often  show  the  trophic  changes  due  to  nerve 
lesions.  The  nerve  lesions  give  rise  to  all  degrees  of  anesthesia,  paralysis  and 
trophic  changes.  When  of  moderate  degree  we  often  find  profuse  local  sweat- 
ing, vasomotor  disturbances,  pain  and  various  forms  of  paresthesia,  such  as 
tingling,  formication,  etc.  Local  effects  naturally  vary  with  the  parts  affected 
being  unusually  serious  about  the  eye.  The  eye  also  suffers  from  the  exceedingly 
bright  light  of  the  arc  and  "flash  blindness"  is  quite  common  in  electric  plants. 

Treatment. — If  a  person  be  in  contact  with  a  live  wire,  the  first  thing  to  do 
is,  if  possible,  to  shut  off  the  current.  If  it  be  not  possible  to  shut  off  the  cur- 
rent, catch  a  portion  of  the  clothing  of  the  victim  and  pull  him  away  from  the 
wire,  but  do  not  touch  his  body  with  the  bare  hand.  If  a  pair  of  rubber  gloves 
can  be  obtained,  the  subject  can  be  moved  with  impunity  and  the  wires 
can  be  safely  cut.  If  it  be  not  possible  to  drag  a  person  away  from  electric  wires, 
an  individual  can  wrap  his  hands  in  dry  woolen  material  and  safely  lift  the  portion 


Treatment  of  Injuries  by  Artificial  Currents  1647 

of  the  body  in  contact  with  earth  or  wire,  and  thus  break  the  circuit  and  permit 
removal  of  the  body.^  A  dry  cloth  can  be  pushed  between  the  body  and  the 
ground,  and  the  body  can  then  be  removed  from  the  wires.  It  may  be  possible 
to  push  the  wires  away  by  means  of  a  dry  piece  of  wood,  or  to  cut  them  with 
shears  which  have  wooden  handles  and  which  are  perfectly  dry,  or  to  push  or 
draw  the  body  away  from  the  wire  by  the  employment  of  sticks  of  dry  wood. 
Spitzka  warns  us  to  be  careful  in  using  shears  "as  the  momentary  arc  formed 
between  the  separated  ends  may  blind  the  rescuers."  Treat  the  general  condition 
in  the  manner  set  forth  for  Lightning-stroke  (see  page  1649).  Raise  the  head 
a  little,  draw  the  tongue  forward,  and  tickle  the  epiglottis.  If  the  patient 
does  not  breathe,  place  him  prone  and  make  artificial  respiration  by  Schafer's 
method.  Artificial  respiration  may  be  carried  out  with  the  patient  supine  by 
Meltzer's  method  of  tracheal  insufflation  or  by  the  pulmotor  (see  "  Report  of  the 
Commission  on  Resuscitation  from  Electric  Shock,"  June,  1913).  Always  apply 
external  heat  ancimassage  over  the  cardiac  region.  If  facilities  are  at  hand  and  the 
victim  is  apparently  dead,  inject  at  once  adrenalin  and  salt  solution  into  a  large 
artery  (see  page  538).  While  any  heart  action  remains  there  is  a  chance  of  resus- 
citation. When  heart  action  and  respiration  are  present  the  prognosis  is  good. 
Very  severe  burns  may  be  caused.  The  author  has  dressed  many  electric  burns 
with  hot  fomentations  of  salt  solution  during  the  first  few  days.  This  facilitates 
the  separation  of  the  sloughs  and  seems  to  aid  the  weakened  tissues  in  resisting 
microbic  invasion;  after  sloughs  separate,  the  part  is  dressed  with  dry  sterile 
gauze.  Antiseptic  dressings  can  be  used  from  the  beginning,  but  they  often  fail 
entirely  to  arrest  the  sloughing.  Iodoform  produces  much  irritation  and  should 
not  be  employed.  Ointments  are  very  unsatisfactory.  When  the  dressings  are 
changed,  the  part  should  not  be  washed  with  corrosive  sublimate,  as  this  agent 
produces  irritation;  peroxid  of  hydrogen  should  be  employed,  followed  by  warm 
normal  salt  solution.  Sharpe  removes  sloughs  by  applying  the  following  mixture : 
2  parts  of  scale  pepsin,  i  part  of  hydrochloric  acid,  U.  S.  P.,  120  parts  of  distilled 
water.  This  mixture  is  washed  off  after  two  hours  with  peroxid  of  hydrogen. 
The  same  surgeon  treats  necrosis  of  bone  by  injecting  every  few  hours  a  3  per 
cent. ,  solution  of  hydrochloric  acid,  using  every  second  day  the  pepsin  solution, 
and  when  necrotic  areas  come  away,  packing  with  gauze.  When  repair  begins, 
the  raw  surface  should  be  covered  with  silver-leaf.  Skin-grafting  by  Reverdin's 
method  or  Thiersch's  method  is  rarely  successful.  In  some  regions  it  is  possible 
to  slide  a  large  flap  in  place  to  cover  a  raw  area  which  will  not  heal.  In  a  very 
severe  case  amputation  or  resection  may  be  necessary. 

In  New  York,  Pennsylvania,  New  Jersey,  and  several  other  states  electricity 
is  employed  to  execute  criminals  convicted  of  capital  offenses.  The  infliction 
of  death  by  electricity  is  popularly  spoken  of  as  electrocution.  It  is  beyond  doubt, 
in  the  words  of  Dr.  Spitzka,  "the  most  humane  method  of  executing  criminals." 
The  first  electrocution  in  New  York  was  in  Auburn  Prison  in  1890,  and  since 
then  over  100  criminals  have  been  executed  by  electricity  in  New  York  state 
alone.  Dr.  Spitzka  has  witnessed  36  electrocutions  and  made  autopsies  on 
27  of  the  victims  ("Jour.  Med.  Soc.  of  New  Jersey,"  1909).  The  apparatus 
used  is  "an  alternating  dynamo  capable  of  generating  2000  volts,  a  'death- 
chair'  with  adjustable  head-rest,  binding  straps,  and  adjustable  electrodes." 
(At  Trenton  a  2400- volt  current  is  taken  from  the  public  service  wire  and  lowered 
to  the  desired  tension  by  a  rheostat.)  The  notch  to  control  the  current  is  in  the 
death-chamber  and  the  dynamo  is  in  another  apartment,  communication  being 
had  by  electric  signals.  The  prisoner  (usually  without  fetters)  walks  in  when 
everything  is  ready  and  sits  down  in  the  chair,  and  his  arms,  legs,  head  and  chest 
are  strapped  to  the  chair.  An  electrode  moist  with  salt  solution  is  fastened  to  the 
head  and  another  to  the  bare  calf  of  the  leg.     The  head  need  not  be  shaved. 

1  See  the  directions  in  "Med.  Record,"  Dec.  28,  1895,  from  "Med.  Press." 


1648  Injuries  by  Electricity 

"The  application  of  the  current  is  usually  as  follows:  The  contact  is  made 
with  a  high  potential — 1800  volts — for  five  to  seven  seconds,  reduced  to  250 
volts  until  a  half-minute  has  elapsed;  raised  to  high  voltage  for  three  to  five 
seconds;  again  reduced  to  low  voltage  until  one  minute  has  elapsed,  when  it  is 
again  raised  to  the  high  voltage  for  a  few  seconds,  and  the  contact  is  broken. 
The  ammeter  usually  shows  that  from  7  to  10  amperes  have  passed  through  the 
criminal's  body. 

"A  second  or  even  a  third  brief  contact  is  sometimes  made,  partly  as  a  pre- 
cautionary measure,  but  more  to  abolish  completely  reflexes  in  the  dead  body. 

"The  time  consumed  by  the  strapping-in  process  is  usually  about  forty-five 
seconds  and  the  first  contact  is  made  a  few  seconds  later.  In  all,  about  skty 
to  seventy  seconds  elapse  from  the  moment  the  convict  leaves  his  cell  until  he 
is  shocked  to  death"  (Spitzka,  Ibid.). 

After  electrocution  the  temperature  of  the  body  rises  and  may  reach  129.5°  F. 
Dr.  Spitzka  finds  that  after  removing  the  brain  the  temperatur*  in  the  vertebral 
canal  is  often  over  120°  F.  The  brain  shows  capillary  hemorrhages,  arterial 
anemia,  and  venous  congestion.  In  some  of  Spitzka's  cases  sections  of  the  pons, 
oblongata,  and  spinal  cord  showed  areas  resembling  gaseous  emphysema,  which 
were  perhaps  caused  by  ''electrolytic  liberation  of  gas." 

In  electrocution  there  is  no  pain,  consciousness  is  at  once  abolished,  death 
is  certain,  and  resuscitation  is  impossible.  The  lurid  stories  about  criminals 
being  killed  by  the  necropsy  and  not  by  the  electric  current  are  nonsense. 

Injuries  by  lightning  occur  mostly  in  the  summer  months  and  are  more  fre- 
quently met  with  in  rural  districts  than  in  cities.  The  number  of  deaths  varies 
from  2  to  20  a  year  per  million  of  the  total  population.  It  is  impossible  to  say 
how  many  are  actually  injured  because  no  statistics  are  available  but  from  such 
experiences  as  the  great  storm  in  Gettysburg  during  the  militia  encampment  in 
1908,  when  3  were  killed  outright,  28  were  reported  as  seriously  shocked  but 
recovered  and  scores  were  more  or  less  seriously  affected  and  from  the  records 
of  many  other  instances  giving  similar  proportion,  we  conclude  that  at  least  five 
are  injured  to  one  killed. 

Lightning  which  is  the  discharge  of  atmospheric  electricity  varies  enormously 
in  phenomena  and  effects.  We  have  little  accurate  knowledge  regarding  the 
amount  of  electricity  contained  in  such  discharges  but  we  have  every  reason  to 
believe  it  is  very  great  as  compared  with  all  other  f  ormsof  electricity.  The  discharge 
or  "bolt,"  which  passes  from  a  cloud  to  the  earth  usually  appears  to  be  a 
direct  disruptive  spark  like  that  from  an  induction  coil  of  large  capacity. 

On  closer  study  we  find  this  simplicity  is  only  apparent  for  it  is  highly  complex, 
does  not  follow  straight  lines  but  seeks  out  a  path  with  relation  to  conductors 
and  the  attraction  of  other  primar}^  and  induced  charges  in  many  objects.  Further 
the  effects  are  not  limited  to  the  direct  line  or  actual  path  of  the  discharge  but 
extend  to  a  very  considerable  distance  by  producing  powerful  induction  effects 
in  proportion  to  the  enormous  potential  of  the  bolt.  In  order  to  understand  the 
action  of  lightning  we  must  recall  how  static  charges  not  only  accumulate  on  the 
surface  of  conductors  but  how  they  seem  to  sink  into  the  substance  of  non-con- 
ductors or  become  occluded  as  if  they  spread  over  the  multiple  surfaces  of  the 
component  particles,  as  they  certainly  do  in  such  objects  as  hair,  fur  and  clothing. 
The  discharge  is  not  over  surfaces  alone  but  goes  through  substance  also. 

We  then  can  realize  why  animals  become  sources  of  danger  during  storms, 
for  the  dry  hair  offers  aii  enormous  surface  for  electrical  accumulation  and  as 
soon  as  it  becomes  damp  enough  to  conduct  electricity  the  animal  becomes  more 
dangerous  than  an  equal  amount  of  metal.  In  a  similar  way  masses  of  damp 
hay  become  conductors  of  electrical  potential  and  are  often  struck. 

Trees,  with  a  corky  bark,  which  offer  an  enormous  surface  become  more 
dangerous  when  such  bark  becomes  damp  than  smooth  barked  trees.  This  has 
given  rise  practically  to  a  popular  belief  that  the  beech  is  safer  than  the  oak  in 
a  storm. 


Treatment  of  Injuries  by  Lightning  1649 

We  must  not  rest  content  with  classing  the  variations  of  lightning  as  freak 
performances  but  must  study  the  effects  in  the  light  of  scientific  accomplishment. 
Thus  the  effects  on  the  clothing  are  often  most  startling,  being  often  described  as 
explosive  in  type;  yet  when  we  recall  how  vast  is  the  surface  of  the  component 
fibers  and  how  hydroscopic  such  fibersarc  and  how  conduction  increases  with  damp- 
ness and  how  partial  conductors  develop  heat  in  proportion  to  the  current,  we  are  no 
longer  surprised  at  the  effects  but  are  enabled  to  judge  of  the  nature  and  path  of 
the  discharge  witli  some  degree  of  certainty.  This  will  help  us  greatly  in  our  diag- 
nosis and  prognosis  of  the  injuries  to  the  body.  It  will  also  help  us  to  understand 
why  two  persons  subjected  to  the  induction  effects  of  the  same  bolt  will  show  very 
different  markings. 

We  must  never  forget  that  electric  discharges  are  extremely  sensitive  to  the 
attractions  and  repulsions  of  electric  charges  and  that  they  induce  such  charges. 
It  must  further  be  recalled  that  what  we  observe  in  the  sky  on  a  large  scale  takes 
place  in  the  body  on  a  small  scale  and  that  as  one  discharge  is  thick,  intense  and 
straight,  another  is  notched  or  branched.  So  in  the  body  we  find  markings 
corresponding  to  all  the  types  seen  in  the  sky.  So,  too,  do  we  find  the  discharge 
from  the  body  meeting  that  from  the  sky.  In  one  case  the  mass  of  the  discharge 
is  so  great  that  it  is  uninfluenced  by  minor  object  charges  but  crashes  through  all 
obstacles;  in  another  case  a  smaller  charge  wanders  about  from  object  to  object, 
entering  a  window  or  door  and  playing  pranks  of  the  greatest  variety.  So  in  the 
body  the  heavy  charge  smashes  through  skull,  pulpifies  brain,  rushes  straight 
down  and  out,  while  the  milder  bolt  is  influenced  by  conditions,  wanders  and  may 
leave  with  only  local  effects.  In  this  way  cases  of  actual  stroke  have  recovered. 
Usually,  direct  strokes  are  fatal  when  they  pass  through  the  body  and  only  those 
passing  through  a  part  or  those  going  over  the  surface  or  those  passing  near 
furnish  the  cases  of  recovery.  When  death  occurs  it  is  usually  instantaneous 
so  that  when  any  sign  of  life  remains  there  is  hope,  but,  even  in  the  apparently 
hopeless  cases,  treatment  should  be  persisted  in. 

Persons  struck  while  in  open  fields  or  on  roads  are  apt  to  show  burns  indicat- 
ing that  the  bolt  passed  from  head  to  foot.  Persons  struck  while  under  trees 
often  show  induction  effects  only  but  may  show  that  the  bolt  or  part  of  the  bolt 
has  jumped  from  the  tree  to  the  body.  Arborescent  markings  are  purely  dis- 
charge phenomena  and  are  generally  due  to  induction  charges. 

What  has  been  described  as  return  stroke  and  has  been  supposed  to  be  due  to 
secondary  or  readjustment  discharge,  appears  generally  to  be  due  to  the  dis- 
charge of  induction  charges  immediately  following  the  primary  discharge.  The 
cause  of  death,  from  its  instantaneous  nature,  must  necessarily  be  due  to  the 
effects  on  the  nervous  system,  probably  destructive  effects  and  not  unlike  those 
produced  by  high  voltage  artificial  currents.  Tissue  effects  are  found  wherever 
the  bolt  has  passed  and  these  may  be  mechanical,  consisting  of  various  sized 
holes  or  considerable  wounds  or  they  may  show  the  explosive  type  indicating 
the  sudden  production  of  gases  or  vapor.  Very  frequently  we  find  burns, 
generally  superficial  but  not  rarely  severe,  and  at  times  very  severe.  Often  we 
find  a  combination  of  all  types — burning,  denudation,  actual  wounding  and 
markings.  The  eyes  often  suffer,  at  times  being  burned  and  at  others,  the 
optic  nerve  being  affected.     Frequently  we  find  only  a  temporary  flash  blindness. 

The  sequelae  include  nerve  lesions  similar  to  those  found  after  industrial 
injuries.  The  brain  is  more  apt  to  be  permanently  injured  but  may  exhibit 
anything  from  coma  to  intense  excitement.  Usually  unconsciousness  is  only 
brief  but  may  last  for  hours. 

Treatment  should  be  persisted  in  long  after  apparent  death,  for  cases  of  late 
recovery  are  recorded.  It  is  essentially  the  same  as  for  injuries  by  industrial 
currents  (see  page  1647)  and  includes  artificial  respiration  in  the  prone  position 
with  care  to  have  the  head  bent  well  back  so  as  to  free  the  throat;  maintenance 
of  temperature;  combating  of  shock  and  heart  failure  and  the  guarded  use  of 
electricity. 
104' 


INDEX 


Abadie's      treatment      of      war 

wounds  of  brain,  896 
Abb6's     method     of     intestinal 
anastomosis,  1253 
of  intracranial  neurectomy, 
861 
operation  for  esophageal 
stricture,  1065,  1066 
Abdomen,  contusion  of,  muscu- 
lar rupture  of,  1075 
gunshot  wounds  of,   1084 
injuries     and     diseases,     1073 
operations  on,  1204 
Abdominal    actinomycosis,    357, 
358 
aorta,  ligation  of,  563 
distention,     postoperative, 

1127 
esophagismus,  1068 
hernia,  1273 

index  in  movable  kidney,  1420 
nephrectomy,  1442 
operation,    hemorrhage    after, 

520 

in  insanity,  930 
rupture,  1273 
section,  1204 

after-treatment,  1209 
hemorrhage  in,  control,  51 S 
incision      in,      1206 
ligation     of     iliac     arteries 

after,  SS9 
suture  of  wound,  1208 
toilet    of   peritoneum,    1207 
type  of  pneumonia,   1148 
wall,  desmoid  tumors  of,  406 
simple     contusion     without 

injury  of  viscera,  1074 
wounds  of,  1082 
wounds  in  war,  loSs 
treatment,  326 
Abdominodorsal  tetanus,   228 
Abernethy's  _  method    of    infra- 
orbital neurectomy,  855 
of     ligating     external     iliac 

artery,  561 
of     neurectomy     of     infra- 
orbital nerve,  85  S 
of  _  preventing    hemorrhage 
in     amputation     at     hip, 
1569 
Aberrant     thyroid    gland,    1373 
Abortive  gonorrhea,  1495 
Abscess,  143 
acute,  152,  153 

retropharyngeal,  156 
symptoms,  153 
alveolar,  157,  1041 

treatment,  159 
appendiceal,  155,  1141 

treatment,  1214 
appendicular,  treatment,  160 
axillary,  15s 
Bezold's,  905 

treatment,  161 
Brodie's,  153,  569 
caseous,  153 
cheesy,  153 
chronic,  IS3,  260 
cold,  153,  260 
congestive,  260 
deep,  153 

drainage,  162 

Hilton's  method  of  opening, 

162 
treatment,  162 
diagnosis,  158 
diathetic,  153 
dorsal,    tuberculous,    266 

tuberculous,  treatment,  271 
Dubois's,  1390 
edema,  154 


Abscess,  embolic,  153,  218 
emphysematous,  153 
encysted,  153 
epiploic,  1088 
extradural,  906 
fecal,  IS3 
fluctuation,  158 
follicular,  153 
forms,  153 
hematic,  153 
iliac,    tuberculous,    267 
ischiorectal,  157 

treatment,  160 
lumbar,  tuberculous,  267 

treatment,  271 
lymphatic,    153,    260 
marginal,  153 
mediastinal,   tuberculous,   267 

treatment,  271 
metastatic,  153,  218 
migrating,  260 
milk,  153 
mushroom,  903 

of  antrum  of  Highmore,   156, 
988 
treatment,  160 
of  bone,  chronic,  569 

tuberculous,  treatment,  270 
of  brain,  154,  902 

from  ear  disease,  906 

treatment,  161 

types,  903 
of  breast,  157 

acute,  1575 

treatment,  161 

tuberculous,  267 
treatment,  271 
of  frontal  sinus,  989 
of  groin,  158 
of  hip,  711 

of  joints,  tuberculous,  267 
of  kidney,  143 1 
of  larynx,  157 

treatment,  161 
of  liver,  155,  1173 

pyemic,  11 74 
treatment,  1177 

traumatic,  11 73 
treatment,  1177 

treatment,  159 

tropical,  11 74 
treatment,  11 76 
of  lung,  156,  1028 

pneumotomy  for,  1029,  1040 

treatment,  160 

a:-ray  diagnosis,  1612 
of  lymphatic  glands,  tubercu- 
lous, treatment,  270 
of  mediastinum,  156 

treatment,  160 
of  neck,  deep,  155 

tuberculous,  267 
of  popliteal  space,  158 
of  prostate,  157 

in     gonorrhea,      treatment, 
1503 
of  quadratus  lumborum,  with 

caries    of   lumbar    and   last 

dorsal      vertebrae,      Treves' 

operation,  784 
of  rib,  tuberculous,  267 

treatment,  271 
of  scalp,  868 
of  spleen,  1203 
orbital,  157 

treatment,  161 
ossifluent,  153 
Paget's,  153 
palmar,  158,  812 
pericystic,  1083 
perigastric,  1098 
perinephric,  156,  1434 

1651 


Abscess,  perinephric,  treatment, 
161 
perirenal,  1434 
peri-urethral,     in    gonorrhea, 

1494 
pomtmg,  146,  152 
postauricular,  90s 
postpharyngeal,        treatment, 
272 
tuberculous,  266 
prognosis,  159 
prostatic,   treatment,   161 
psoas,      153 

caries    of   lumbar   and   last 
dorsal      vertebrae      with, 
Treves'  operation  for,  784 
tuberculous,  267 
treatment,  271 
pyemic.  153 
residual,  153.  263 

of  Paget,  276 
rest  in,  105 

retropharyngeal,      treatment, 
160 
tuberculous,  266 
scrofulous,  260 
secondary,  218 
shirt-stud,  162,  264 
spontaneous  evacuation,  152  . 
stercoraceous,  153 
strurnous,  153,  260 
subdiaphragmatic,  156 
subphrenic,    156,    1016,    1168 

treatment,  160,  1169 
superficial,  153 

treatment,  161 
sympathetic,      153 
thecal,  153 
treatment,  159 
tropical,  153 
tuberculous,  153,  260 
age  of  occurrence,  261 
albuminoid     disease     from, 

265 
contents,  261 
diagnosis,  265 
formation,  262 
in  various  regions,  266 
lardaceous      disease     from, 

265 
large,    treatment,    268,    271 
of  head  of  bone,  266 
pointing,  264 
prognosis,  266 
residual,  of  Paget,  265 
results,  26s 

secondary    infection    of,    by 
bacteria  of  putre- 
faction,   263 
of  suppurations,  263 
signs,  263 
situations,  261 
small  superficial,  treatment, 

268 
symptoms,  263 
terminations,  263 
treatment,  268 

general,  270 
wall  of,  262 

waxy  disease  from,  265 
tympanitic,  153 
urinary,  153 
verminous,  153 
von  Bezold's,  157 
wandering,  260 
Absorbent  cotton,  sterile,  prepa^ 

ration,  86 
Acapnia,  286 
Accessory  adrenals,  432 

thyroid  gland,  1373 
A.  C.  E.  mixture  for  anesthesia, 
1350 


l6s2 


Index 


Acetabulum,   fractures  of  brim, 
669 
of   fundus,    669 
Acetanilid,  35 
Acetate,  aluminum,  32 
Acetone  gas  in  warfare,  339 

odor  of,  192 
Acetonuria,  192 

after  anesthesia,  1348 
Achard  and  Castaigne's  test  for 

excretory  capacity  of  kidneys, 

1416 
Achillodynia,  411 
Achondroplasia,  564 
Acid,  boric,  32 

carbolic,  31 

hypochlorous,  36 

intoxication   after   anesthesia, 
1348 

picric,  36 
Acidosis,  192 

after  anesthesia,  1348 
Acinous   cancer  of   breast,    1582 
A.  C.  M.  I.  cystoscope,  1448 
Acne,  syphilitic,  374 
Aconite  in  inflammation,  116 
Acquired  syphilis,  361 
Acriflavine,  37 
Acromegaly,  582 
Acromion    process,   fractures  of, 

633 

Actinomyces  bovis,  356 
Actinomycosis,  356 

abdominal,  357,  358 

anthracoid,  358 

cutaneous,  357 

gummatous,  357 

intestinal,  357 

of  bone,  565 

of  brain,  910 

prognosis,  338 

pulmonary,  3S7 

treatment,  358 
Actol,  35 
Acupressure      in       hemorrhage, 

S08 
Acupuncture  in  aneurysm,  491 
Acute      obstruction,     intestinal 

1 1 1 1 
Adams'  large  saw,  778 

osteotomy    through    neck    of 
femur,  779,  780 
Adenitis,  tuberculous,  276 
cervical,  276 
*-ray    treatment,    1635 
Adenocarcinoma,  447 

of  breast,  1583 
Adenocele  of  breast,  IS79 
Adenoma,  434 

cystic,  434 

multiple,   of  Virchow,   iri6 

of  brain,  911 

of  breast,  i579 
Adenomatous  goiter,  1372 
Adherent  tongue,  1055 
Adhesion-dyspepsia,  1105 
Adhesions,  perigastric,  1104 
Adhesive     plaster     method     for 

skin    regeneration,     1405 
Adrenal  rest,  432,  1417 

hypernephroma  of,  14 17 
Adrenalin  chlorid  in  shock,  290 
Adrenals,  accessory,  432 

tuberculosis  of,  278 

tumors  of,  432 
Adynamic  fever,  103 
Aerial  bombs,  325 
Aerobes,  obligate,  26 
Aerobic  bacteria,  26 
Agglutination    test    in    tubercu- 
losis, 254 
Agglutinins,  45 

Agnew's  splint  in  transverse  frac- 
tures of  patella,  689 

treatment      of      fracture      of 
femur  in  upper  third,  680 
Agraphia  in  brain  tumors,  917 
Air-embolism,  212 

symptoms,  213 

treatment,  213 
Air-pressure,    positive    or    nega- 
tive,   operations   under,    1032 


Air-passages,   foreign  bodies  in, 

990 
Airol,  35 

Albee's     bone-graft     for    bone- 
cavities,  575 
in   intracapsular  fracture  of 

femur,  677 
in  Pott's  disease,  954,  968 
in  ununited  fracture,  782 
operation  in  osteo-arthritis  of 
hip,  730 
Albert's  disease,  411,  817 
Albuminoid  disease  from  tuber- 
culous abscess,  265 
Albuminous  expectoration,  103s 
Albuminuria  obstructing  repair, 
126 
of  secondary  syphilis,  377 
Alcohol,  32 

and     chloroform     anesthesia, 

1350 
for  boiling  catgut,  81 
in  inflammation,  120 
in  tuberculosis,  258 
injections      in'    neuralgia      of 
fifth  nerve.  856 
Alcohol-sublimate      method     of 
sterilizing  hands  and  forearms , 

73 

Alcoholic  coma,  88  r 

Aleppo  boil,  149,  1368 

Aleuronat  injections,  production 
of  hydrocephalus  by.  872 

Alexander's  method  of  perineal 
prostatectomy,  1533 

Alexin,  45 

Alexinsky's  treatment  in  avul- 
sion of  brachial  plexus,  843 

Alimentary    canal,    tuberculosis 

of-    273  .       .     a 

Alkaline  iodids  m  inflammation, 

119 
Alkaloids,  43 

AUingham's  method  of  intestinal 
anastomosis,  1250 
operation     for     hemorrhoids, 
1317 
Allis'  ether  inhaler.    1338 
method  of  nerve  suture,  853 
sign  in  intracapsular  fractures 
of  femur,  667 
in  traumatic   dislocation  of 
femur,  767 
treatment    of   fractures   in   or 
near    elbow-joint,     648 
Almen's  test  for  hematuria,  1410 
Alopecia,    syphilitic,    375 
Alpha-rays,  1640 
Aluminum  acetate,  32 

splint,  extempore.  638 
Alveolar  abscess.  157.  1041 
treatment,  159 
sarcoma,  425 
Amboceptor,  382 
Ambrine     treatment    for    burns 

and  scalds.  362 
Ambulant  erysipelas,  220 
Ambulatory  splint,  603 

treatment     of    fractures,    603 
American  bandage  of  foot,  1398 
Amotile  bacteria,  22 
Amputation,  1550 
a  la  manchette,  1553 
at  ankle,   1565 
Pirogoff's,  1565 
Syme's,  1665 
at  elbow.  1559 
at  hip.  1569 
Jordan's,  1573 
Larrey's,  1573 
Siston's,  1573 
Senn's,  1571 
Sheldon's,  1573 
T-,  1 57 1 

Wyeth's,  1570,  1571 
at  knee,  1567 
at  metacarpophalangeal  joint, 

1557 
at  metatarsophalangeal  articu- 
lation, 1562 
at  shoulder,  1560 
Dupuytren's,  1561 


Amputation     at     shoulder, 
Kocher's,  1561 
Larrey's,  1560 
Libfranc's.  1561 

at  wrist,  1558 

chop.    See  Guillotine. 

cinematoplastic,  1556,  1557 

circular,  flush,  1552,  1554 
modified,  1553,  1554 
oblique,  1552,  IS54 
transverse,  1552 

classification,  1550 

completion  of,  1555 

elliptical,  1554 

flap,  1554 

flapless,  1554 

Forbes's,  1564 

guillotine,      ISSO.       See     also 
Preface. 

hemorrhage  in,  1550 

in  compound  fractures,  indica- 
tions for,  605,  606 

in  gunshot  wounds,  310 

interilio-abdominal,  1573 

interscapulothoracic,       1561 

intertarsal,  anterior,  1465 
posterior,  1564 

lanceolate  incision,  1552,  1554 

Le  Conte's,  1562 

methods,  1552 

mixed  method,  1554 

of  arm,  1560 

of  fingers,  1557 

of  foot,  1562 

Chopart's,  1564 
Hey's.  1564 
Lisfranc's,  1564 

of  hand,  1557 

of  leg,  1565 

below  knee,  1566- 
Bier's   method,    1566 
by  lateral  flaps,  1567 
by  long  anterior  flap,  1566 
posterior    and    short    an- 
terior flaps,  1567 
by  rectangular  flap.  1566 
circular  modified,   1566 
point  of  election,   1565 
Sedillot's,  1566 
Teale's  method,  1566 

of  penis,  1521 

of  thigh,  1568 

at  upper  two-thirds,  1569 
Bell's.  1569 

of  thumb.  1558 

of  toes,  1562 

of  upper  extremity,  1561 
Berger's,  1561 

oval,  1554 

racket.  1552,  1554 

rectangular  flap,  1552 

rounded  flap,  1552 

special,  1557 

stump.     See  Stump. 

subastragaloid,  1564 

T-,1554 

Teale's,  of  forearm,  1559 

through     femoral      condyles, 
1567 
Garden's  method,  1568 
Gritti's,  1568 
Sabanejeff's,  1568 
Stokes's,  1568 

through  forearm,  1559 

through    middle    tarsal    joint. 
1564 
Amyelia,  941 

Amyloid   disease   from   tubercu- 
lous abscess,  265 
Anaerobes,  facultative,  26 

obligate,  26 
Anaerobic  bacteria,  26 
Analgesia,  spinal,  1364 
Anaphylaxis,  53 

Anastomosis,  aneurysm  by,  419, 
475.  496 

facio-accessory,  862 

faciohypoglossal,  862 

intestinal,      Abb6's      method, 
1253 
AUingham's    method,     1250 
by   Murphy's  button,    1248 


Inde; 


1653 


Anastomosis,     intestinal,     Con- 
nell's  method,  1251 
consideration    of    methods, 

1256 
end-to-side,  1247 
Frank's    coupler    for,    1249 
Gould      and      Harrington's 

method,  1249 
Halsted's  method,  1254 
Horsley's  method,  1254 
Kocher's  method,  1250 
Laplace's  forceps  for,    1251 
lateral,  1252 

Billroth's  method,  1247 
Laplace's      forceps      for, 

1255 
Senn's    method,     1253 
with  rings,  1256 
Maunsell's  method,    1249 
Moynihan's    method,     1250 
O'Hara's   forceps   for,    1252 
Robson's  method,  1250 
Senn's  method,  1247 
of  nerves,  849,  853 
vein-to-vein,  for  blood  trans- 
fusion, 531 
Anatomical   landmarks  beneath 
skin,    table    of,     for    x-Ta.y 
localization,  1626 
snuff-box,  S41 
tubercle,     272 
Anderson's    method    of    tendon- 
lengthening,  824 
Andrews'    bottle    operation    for 

hydrocele,  1548 
Anel's  operation  for   aneurysm, 

482 
Anemic  gangrene,  176 
Anesthesia,  133 1 

acetonuria  after,  1348 
acid  intoxication  after,  1348 
acidosis  after,  1348 
after-effects,     1346 
backache  after,   1347 
by  freezing,  1357 
closure    of  epiglottis  in,  treat- 
ment, 1345 
collapse  in,  heart  massage  for, 

1344. 
cyanosis  in,  1343 

treatment,  1345 
death-rate,  133 1 
delayed  poisoning  after,  1348 
endotracheal  insufflation,  1340 
forgetting  to  breathe  in,   1345 
hypnotic,  1356 
in  obstetrics,  1359 
infiltration,  1359 

with  sterile  water,  1364 
infusion,  1342 
intratracheal,  1340 
kidney     complications     after , 

1347 
local,  1357 

Bier's    intravenous  method, 
1363 
mixtures  for,  1350 
oil-ether   rectal,  Gwathmey's 

method,  1341 
oxygen  and  chloroform,  1337 
paralysis  after,  1349 
parasacral,  1367 
paravertebral,  1367 
preparation  of  patient,  1332 
prirnary,  1350 
pupillary  phenomena,  1343 
reaction  from,  134s 
rectal,  1341 
regional,  1359 
respiratory     disorders     after, 

1347 
shock  in,  treatment,  1344 
syncope  in,  1344 
swallowing  tongue  in,  1343 

treatment,  1345 
terminal,  1359 
vomiting  after,  1346 
treatment,  1343 
Anesthetic  mixtures,  1350 

successions,  1354 
Anesthetics,  133 1 
Aneurysm,  473 


Aneurysm,  acute,  475] 
Anel's  operation  for,  482 
aneurysmectomy,  482 
aneurysmorrhaphy,  484 
Antyllus'  operation  for,  481 
arteriovenous,    475,    493 

treatment,  495 
bilateral,  47s 

Brasdor's  operation  for,  484 
by  anastomosis,  419,  47s,  496 
causes,  476 

circular  angiorrhaphy,  488 
circumscribed,   475 
cirsoid,  419,  475,  496 
consecutive,  474 
constituent  parts,  477 
cylindrical,  475 
Delbet's  sign  in,  488 
diagnosis,  479 
diffuse,  474 

traumatic,  492 
treatment,  493 
dissecting,  475 
embolic,  475 

endo-aneurysmorrhaphy,    484 
false,  474 
forms,  474 
fusiform,  474 
gelatin  treatment,  479 
Goyanes'    operation    for,    488 
Halsted's  band  in,  489 

operation  for,  488 
Henle   and   Coenen's   sign   in, 

48?^   , 
Hunter's  operation  for,  482 
indications  for  suture  in,  487 
Korotkow's  test  in,  489 
Lexer's  operation  for,  488 
Lister's   tourniquet   in,    482 
Matas'    aluminium    band    in, 
486 

operation  for,  484,  485 

plan    for    testing    collateral 
efficiency  in,  488 
miliary,  475      . 

Moore-Corradi  treatment,  491 
Moschcowitz's     reaction     in, 

489 
needles,  Dupuytren's,  540 

Saviard's,  539 
of  bone,  475 
Pott's,  493 
Ou6nu   and    Muret's   sign   in, 

488 
Reid's  treatment,  481 
rest  in,  105 
ruptured,  474 

treatment,  492 
sacculated,  474 
secondary,  475 
Shekelton's,  475 
spontaneous,  474,  475 
Stewart's  test  in,  489 
Strongylus  armatus  in,  476 
Syme's  operation  for,  481 
symptoms,  477 
traumatic,  321,  474 

diffused,  474 
treatment,  479-493 

after  operation,  490 

by  acupuncture,  491 

by  amputation,  491 

by  distal  ligation,  483 

by  electrolysis,  491 

by  extirpation,  482 

by  injection  of  coagulating 
agents,  491 

by  introduction  of  wire,  491 

by  ligature  and  suture,  481 

by  manipulation,  491 

by  pressure,  480,  48 1 
true,  474 
tubulated,  474 
Tuffier  and  Hallion's  test  in , 

489 
Tufnell's  compress  in,  480 
varicose,  493 

symptoms,  495 

treatment,  495 
verminous,  475 
von  Frisch's  signs  in,  489 
Wardrop's  operation  for,  484 


Aneurysmal  varix,  493 
symptoms,  495 
treatment,  495 
Aneurysmectomy,  482 
Aneurysmorrhaphy,  484 
Aneurysmotomy,  481 
Anfjeiosarcoma,  426 
Angelic  scrofula,  249 
Angina,  Ludwig's,  199 

treatment,  200 
Angioma,  417 

capillary,  418 

cavernous,  418 

of  brain,  910 

of  breast,  1580 

simple,  418 

treatment,  419 
Angioneurectomy      for      hyper- 
trophy of  prostate,  1536 
Angiorrhaphy,  circular,  for  aneu- 
rysm, 488 
Angiosarcoma  of  brain,  910 
Animal  inoculations  in  diagnosis 

of  tuberculosis,  254 
Ankle,  disarticulation  at,  1565 

excision  of,  794 

Hancock's  method,  794 

traumatic  dislocations  of,  775 

tuberculosis  of,  717 
Ankle-joint  disease,  717 
Ankyloglossia  congenital,  105s 
Ankylosis,  739 

Baer's  treatment,  742  » 

bony,  739 

Chlumsky's  treatment,  742 

complete,  739 

extra-articular,  treatment,  743 

false,  from  fractures  in  or  near 
elbow-joint,  650 

faulty,  of  hip,  osteotomy  for, 
779 
of  knee,  osteotomy  for,  780 

fibrous,  739 

gonorrheal,  725 

Helferich's  treatment,  742 

Huguier  and  Murphy's  treat- 
ment, 742 

incomplete,  739 

intra-articular,  739 
treatment,  740 

Lexer's  treatment,  741 

Mikulicz's  treatment,  742 

Murphy's  treatment,  742 

stereo-arthrolysis  in,  741 

Tajdor's  treatment,  743 

temporomaxillary,  1041 

Thorn's  treatment,  743 

true,  739 

after    fractures    in    or    near 
elbow-joint,  650 

Tubby's  treatment,  743 

Verneuil's  treatment,  742 

Weglowski's  treatment,  741 
Anoci-association  operation, 

Crile's,  290,  1359 
Anodynes  in  inflammation,  117 
Anosacral  cysts,  959 
Anosmia,     ipsolateral,     917 
Antemortem  thrombus,  204 
Antenatal  tuberculosis,  246 
Ante-operative  a;- ray  treatment, 

1634 
Anthracoid    actinomycosis,    358 
Anthrax,  347 

bacillus  of,  in  blood,  349 

benign,  149 

carbuncle,  348 

diagnosis,  349 

edema,  348,  349 

external,  348 
treatment,  350 

forms,  348 

from  catgut,  80 

prevention,  350 

prognosis,  350 

Sclavo's  serum  in,  351 
Antibiosis,  27 
Antibodies,  45 

bacteriolytic,  45 
Anti-crotalus  serum,  347 
Antigen,  46 
Antipyretics  in  inflammation,  118 


1654 


Index 


Antisepsis,  64 

Antiseptic,  29 
chemical,  28 
gauze,  preparation,  85 

Antistreptococcic  serum  in  ery- 
sipelas, 222 

Antithyroidin    in    exophthalmic 
goiter,  1380 

Antitoxin,  tetanus,  52 

Antitoxins,  46,  48 

Antivenene    serum,    Calmette  s, 
346 

Antrum  of  Highmore,  abscess  of, 
156,  988 
treatment,  160 
empyema  of,  156 
sarcoma  of,  421,  423 

Antyllus'    treatment    for    aneu- 
rysm, 481 

Anuria,  postoperative,  293 

Anus,  artificial,  1127 

diseases  and  injuries,  1304 
examination  of,  1504 
fissure  of,  131 5 
gonorrhea  of,  1S08 
imperforate,  13 12 
inflammation,  pain  in,  99 
papilloma  of,  1324 
pruritus  of,  131 4 
tumors  of.  benign,  1324 

Aorta,     abdominal    ligation    of, 

«  thoracic,  operation  on,  504 
Apathetic  shock,  288 
Aphasia   in  localizing   brain   tu- 
mors, 917 

motor,   in  brain   tumors,    917 
Aplastic  lymph,  97 
Apnea,  973 

Apoplexy,  coma  in,  881 
Appendiceal  abscess,  155,  1141 
treatment,  12 14 

dyspepsia,  1 149 
Appendicitis,  X136 

acute,  in  typhoid  fever,  1 151 

Barker's  operation  in,  1212 

blood-count  in,  1149 

catarrhal,  1140 

chronic,  Bastedo'ssignin,  1 149 
symptoms,  1148 

cold  in.  1 1  S3.  1.1 54 

Davis'  incision  in,  1211 

Dawbarn's  operation  for,  1213 

diagnosis,  114s 

etiology,  1138 

following  childbirth,  1151 

foreign-body,  1139 

forms,  1 140 

fulminating.  1140 

gangrenous,  1 141 

hematuria  in,  1 147 

hepatic  infections  after,  1 144 

ice-bag  in,  ii53.  ii54 

in  children,  11 50 
treatment,  11 55 

in  pregnancy,  115° 
treatment,  11 55 

in     pulmonary     tuberculosis, 
iiSi 

irritans,  1148 

lymphatic      infections      after, 

"44 
McBurney's      operation       m, 
1214 

point  in,  1137.  ii43 

rule  in,  11 54 
morphine  in.  II54 
mortality  after  operations  in, 

1215 
obliterative,  1140,  11 48 
operation  for,  1210 
opium  in,  1154 
Parker's  operation  in,  12 14 
pathology,  1138 
prognosis,  1 144 
protective,  1138 
pseudo-,  148 
recurrent,  1 141 
simple  parietal,  1140 
stercoral,  1139 
suppurative,  1141 
symptoms  and  signs,  1141 


Appendicitis,  syncongestive,  1141 

terminations,  1144 

thrombosis  in,  206 

traumatic,  1139 

treatment,  1152 

tuberculous,  1151 
treatment,  IISS 

Weir's  operation  in,  12 16 

x-ray  diagnosis,  1615 
Appendicostomy,  I2'i6 
Appendicular      abscess,      treat- 
ment, 160 

colic,  1 139,  1 140 

lithiasis,  1139 
Appendix,  cancer  of,  1152 

concretions  in,  1138,  1139 

constipation  of,  1140 

hernia  of,  1300 

Morris'  method  of  palpating, 

1144 
x-ray  examination,  16 15 
Appendoliths,  1138 

mistaken    for    ureteral  stone, 
1457 
Apraxia,  918 
Arachnitis,  899 
Ardor  urinse  in  gonorrhea,  1493 

treatment.  1502 
Argonin  in  gonorrhea,  1500 
Argyrol.  36 
Aristol,  34 

Arm,  amputation  of,  1560 
carrying   function,   64S 

diagram,  646 
glass,  808 
lawn-tennis,  808 
spiral     reversed    bandage    of, 

1398 
Army-camp  empyema,  1018 
Arrow  wounds,  302 
Arsenic  cancer,  aa3 
Arsin  gas  in  warfare,  339 
Arterial     hemorrhage,     control, 

513 

hemorrhoids,  13 18 

pyemia,  218 

sedatives,     in     inflammation, 

"6 
transfusion    and    infusion    of 
saline  fluid,  538 
centripetal,    in    shock,    290 
Arteries,  gunshot  wounds  of,  497 
inflammation  of.  47 1 
ligation    of.     See    Ligation. 
wounds    of.    496 
Arteriocapillary    fibrosis,    472 
Arteriorrhaohy,     503 

Bickham's    method,     504-506 
circular,  505 
Gluck's  method,  506 
Halsted's  method,  506 
lateral,  505 
Lexer's  method,  507 
Murphy's  method,  505 
Payr's  method,  506 

tubes  in,  507 
Salomoni      and       Tomaselli's 
method,  506 
Arteriosclerosis,  472 
Arteriovenous    anastomosis    for 
blood  transfusion,  530 
for  prevention  or  treatment 
of  gangrene  of  legs,  202 
aneurysm.  475,  493 
treatment,  49s 
Arteritis,  471 
acute,  471 

Ford's  treatment,  472 
chronic,  treatment,  473 
Arthrectomy.  786,  787 
Arthritis,  702.  704 
acute  rheumatic,  726 

suppurative,  721 
compression  in,  no 
deformans,  727 
gonorrheal,  723 

treatment,  724.  isro 
gouty.  727 
hemophilic,  521 
infective,  720 
neuropathic.  731 
non-tuberculous,  719 


Arthritis  ossificans.  739 
pneumococcus.  725 
Poncet's  tuberculous,  704 
pyogenic,  721 
rest  in.  105 
rheumatoid.  727 
scarlatinal.  721 
syphilitic,  726 
traumatic,  720 
tuberculous,  70s 

fistula  in.  Beck's  treatment, 

708 
gelatiniform      degeneration 

in.  706 
night-terrors  in.  706 
operative  treatment,  709 
treatment,  707 
typhoid.  722 
Arthrodesis.  787 
Arthropathie  deformant.  395 
Arthropathies,  730 
Arthrooathv,  tabetic.  730,  731 
Arthroplasty  for  gonorrheal  an- 
kylosis, 72s 
Arthrospores.  25 
Arthrotomy  in  pyogenic  arthri- 
tis. 722 
Articular    rheumatism,  tubercu- 
lous. 276.  704 
Artificial  anus.  T127 

respiration,      974.     See      also 
Respiration,  artificial. 
Artillery    shell    gas    in    warfare, 
338 
shells.  322 
Asch  tube  in  nasal  fractures,  616 
Ascites    from    hepatic    cirrhosis, 

surgical   treatment,    1258 
Ascitic  peritonitis,  11 65 
Ascocpccus.  23 
Asemia,  918 
Asepsis.  64 
Aseptic  agents,  28 
peritonitis,  1x59 
Ashhurst's   method   of   exicision 

of  knee,  793 
Ashton's  gauze  pads,   87 
Asphyxia,  973 
local,  189 
smoke,  982 
traumatic,  1014 
Asphyxiating  gas'in  warfare,  338 
Aspiration    in    empyema,     1017 
of  joints,    785 
of  pleural  sac,  1035 
Aspirator  and  injector,  785 
Association,     phylogenetic     287, 

288 
Asthenic  fever,  103 
Asthma,  thymic,  1390 
Asthmatoid  wheeze,  992 
Astragalectomy,  79S 

by     subperiosteal     plan,     79s 
in  talipes,  832 
Astragalus,  excision  of.  795 
by  subperiosteal  plan,  79s 
traumatic  dislocations  of.  776 
forward  or  backward,  776 
lateral  and  rotary,  776 
Astringents  in  inflammation,  no 
Atheroma.  472 

Atheromatous  cystoma,  452,  454 
Atony  of  bladder.  I465_ 
Atrophy,     muscular,     ischem-c, 
with  contractures  and  paraly- 
sis, 805 
Atrophy  of  bone,  564 
fracture  in,  592 
of  muscles,  802 
of  thyroid  gland,  1370 
of      tongue,      indurative,      in 
tertiary  svphilis,  379 
Atropin  in  inflammation,  120 

in  shock.  292 

Auditory  nerve,  division  of,   for 

aural  vertigo.  862 

for   tinnitus   aurium,  862 

Auer  and    Meltzer's   method    of 

intratracheal  insufflation,  1033 

Aural  vertigo,  division  of    audi- 

nerytorve  for,  862 
Auricle,  cervical,  455 


Index 


165s 


Auscultation  in  examination  of 

esophagus,  1061 
Autogenous  vaccines,  55 
Auto-intoxication,  44 
Autotoxins,  24 

Autotransfusion    in    shock,    292 

Avulsion  of  brachial  plexus,  841 

Alexinsky's        treatment, 

843 
Frazier's  treatment,   842 
of  scalp,  300 
of  spine  of  tibia,  695 
Axilla    and    neck,    bandage    of, 
figure-of-8,  1401 
abscess,  155 
artery,  ligation  of,  544 


Babes'    tubercles  in  hydropho- 
bia, 352 
Babinski's  sign,  944 
Bacelli's  treatment   of    tetanus, 

234.  . 
Bacilli  in  blood  in  anthrax,  349 
Bacilluria,  1470 
Bacillus,  22 

aerogenes  capsulatus,  62 
botulinus,  62 
branching,  23 
coli  communis,  61 
comma,  22 
dichotomy,  23 
Eberth's,  63 
Frankel's,  61 
Koch's,  60 
leptothrix  forms,  23 
mallei,  60 
Nicolaier's,  59 
oedematis  maligni,  62 
of  Escherich,  61 
of  glanders,  5o 
of  malignant  edema,  62 
of  Neisser,  58 
of  tetanus,  59,  226 
pyocyaneus,  58 
pyogenes  fetidus,  58 
tuberculosis,  60,  238 

distribution,  239,  240 

extracellular  toxins,  243 

intracellular  toxins,  243 

products,  243 

resistance,  245 
ti-phoid,  63 
Welchii,  62 
Back,  litigation,  958 
saddle-,  950 
sarcoma  of,  430 
strain  of,  808 
Backache  after  anesthesia,  1347 
Bacteremia,  43 
Bacteria,  20 
aerobic,  26 
amotile,  22 
anaerobic,  26 
Brownian  movement,  22 
capsule,  21 
carriers,  41,  44 
chemical  composition,  25 
distribution  of,  40 
effect  of  bacteria  on,  27 

of  cold  on,  26 

of  heat  on,  26 

of  motion  on,  26 

of  radium  on,  26 

of  sunlight  on,  26 

of  x-rays  on,  26 
fission,  24 
forms,  22 
latent,  27 
life-conditions,  25 
motile,  21,  22 
multiplication,  23 
non-pathogenic,  21 
parasitic,  21 
pathogenic,  21 
products,  22 
pseudodichotomy,  23 
pus,  56 

putrefactive,  21,  63 
pyogenic,  56,  58 
segmentation,  24 
special  surgical,  56,  58 


Bacterial  protein,  43 

vaccines   in   treatment   of   in- 
fections, 54 
Bacterines,  54 
Bacteriology,  17 
Bacteriolytic  antibodies,  45 
Bacterium  coli  commune,  61 
drumstick,  25 
typhi,  63 
Bacteriuria,  1470 
Baer's  treatment  of  ankylosis,  742 
Bailey  and  Elsberg's  spinal  de- 
compression, 972 
Baillon  and    Mirieux's  reaction 

in  tuberculosis,  245 
Balanitis  in  gonorrhea,  1494 

treatment,  1502 
Balanoposthitis     in     gonorrhea, 
1494 
treatment,  1502 
Bald  patch,  syphilitic,  375 
Balkan    splint    in    intracapsular 

fractures  of  femur,  672 
Ballance's     mushroom    abscess, 

903 
Ballooning,  rectal,  11 19 
Ball- valve  gall-stones,  1189 
Balsams  in  gonorrhea,  1499 
Bandage,  88,  1396 

American,  of  foot,  1398 
Barton's,  1400 
Borsch's,  of  eye,  1399 
circular,   1396 

crossed,  of  angle,  of  jaw,  1400 
of  both  eyes,  1399 
of  eyes,  1399 
demigauntlet,  1397 
Desault's,  1402 
Esmarch's,  1550 

obstructive  hyperemia  with, 
in  inflammation,  122 
figure-of-8,  1397 
of  breast,  1403 
of  elbow,  1401 
of  eyes,  1399 
of  jaw  and  occiput,  1400 
of  neck  and  axilla,  1401 
of  shoulders,  1401 
of  thigh  and  pelvis,  1401 
French,  of  foot,  1399 
gauntlet,  1397 
gauze,  88 
Gibson's,  1400 
Hamilton's,  620 
hatidkerchief,  1403 
oblique,  of  jaw,  1400 
of  foot,  covering  heel,  1398 

not  covering  heel,  1399 
plaster-of-Paris,  1404 
recurrent,  of  head,  1403 

of  stump,  1403 
Ribbail's,  of  foot,  1399 
Selva's,  of  thumb,  1398 
spica,  1397 
of  groin,  1401 
of  instep,  1399 
of  shoulder,  140 1 
of  thumb,  1398 
spiral,  of  all  fingers,  1397 
of  foot,  covering  heel,  1399 
reversed,    1396 

of  lower  extremity,  1398 
of  upper  extremity,  1397 
T-,  of  perineum,  1403 
thumb,  Selva's,  1398 
Velpeau's,  1401 
in  fracture  of  clavicle,  631 
Barany  tests,  915 

in  brain  tumors,  915 
Barbadoes  leg,  1393 
Barker's  method  of  astragalec- 
tomy,  795 
of  excision  of  hip,  792 
of  spinal  analgesia,  1365 
needle  for    wiring  fracture   of 

patella,  690 
operation    for    dislocation     of 
semilunar     cartilages      of 
knee,  799 
in  appendicitis,  12 12 
osteotomy  for  talipes  equino- 
varus,  780 


Barker's  point,  866 

sharp-edged    irrigating    curet, 
270 

Barlow's  disease,  283 

Baron     Larrey's    disarticulation 
at  shoulder,  1560 
method  of  hip  amputation, 

1573 
on  wound  of  bladder,  1465 
on  frost-bite,  195 

Barthe  de  Sandfort's  paraflHn 
treatment  of  bums,  362 

Bartlett's  apparatus  for  reducing 
congenital  dislocations  of  hip, 
801 

Barton's  bandage,  1400 
fracture,  658 

Base  hospital,  32s 

Baseball-finger,  830 

Basedowified  goiter,  1372 

Basedow's  disease,  1377 

Bassini's   operation  for  femoral 
hernia,  1288 
for  oblique  inguinal  hernia, 
1280 

Bastedo's  sign  in  chronic  appen- 
dicitis, 1 149 

Bath,  hot-water,  in  inflamma- 
tion, 113 

Battle's  sign  in  basal  skull  frac- 
tures, 889 

Bayer's  treatment  of  bone-cavi- 
ties, 574 

Bayonet  wounds,  312 

Beads,  rachitic,  280 

Beatson's  operation  for  cancer 
of  breast,  1599 

Bechterew's  disease,  95s 

Beck's  adhesive  plaster  method 
for  skin  regeneration,   1405 
operation  for  epispadias,  15 18 
paste,  708 

treatment  of  fistula  in  tuber- 
culous arthritis,  708 

Becquerel's  rays,  1640 

Bed-sore,  172,  198 
treatment,   199 

Beebe's  serum  in  exophthalmic 
goiter,   1380 

Bees,  stings  of,  342 

Belfield's  method  of  suprapubic 
prostatectomy,  1533 

Bennett's  fracture,  664 

Benzidin  test  for  hematuria, 
141 1 

Benzin  bromid  gas  in  warfare,- 
339 

Berger's  amputation  of  upper 
extremity,  1561 

Berg's  operation  for  exstrophy 
of  bladder,  1462 

Berry's  operation  in  cleft-palate, 
1051  . 

Bertomier's  treatment  of  frac- 
tures in  or  near  elbow-joint, 
649 

Beta-eucain  anesthesia,  1359 

Beta-rays,  1640 

Bevan's  incision  for  surgery  of 
bile-ducts,  1263 

Beyea's  operation  for  gastro- 
ptosis,  1243 

Bezold's  abscess,  905 
treatment,  161 

Biceps,  dislocation  of  long  head 
of,  811      _ 
flexor       cubiti       or      tendon, 

rupture  of,  809 
long  head,  rupture  of,  809 

Bichat's  fissure,  864 

Bichlorid  of  mercurj',  30 

Bickham's  method  of  arterior- 
rhaphy,  504-506 

Bier's   amputation  of  leg,    1566 
hyperemia    in     inflammation, 
122 
in  tuberculosis,  260 
of  testicle,  1543 

Bigelow's  evacuator,  1482 
lithotrite,  148 1 
_  method  of  litholapaxy,    480 

Biggs'  apparatus  for  bunion,  822 


i6s6 


Index 


Bilateral  aneurysm,  475 
Bile-ducts,  cancer  of,  1192 

catarrhal      inflammation      of, 

1180 
diseases  and  injuries,  1170 
incisions    for    operations     on, 

1262 
inflammation     of.     croupous, 
1181 

suppurative,  1181 
rupture  of,  1082 
Biliary  fistula  after   cholecystos- 

tomy,  1266 
Billroth's     anesthetic      mixture, 

1350 
lateral  intestinal   anastomosis, 

1247 
method      of      gastro-enteros- 
tomy,  1230 

of  pylorectomy,    1222 
Bilocular  stomach,  lies 
Biological  theory  of  cancer,  439 
Bipp,  338 

treatment   of  compound  frac- 
tures, 607 

of  war  wounds,  338 
Bircher's  method  of  gastroplica  - 

tion,  1242 
Birth  paralysis,  brachial,  843 

operation  for,  863 
Bismuth  subgallate,  35 
Bites    and    stings     of     insects, 

342 
of  bot-flies,  343 
of  centipedes,  342 
of  chigger,  343 
of  cobra.  343,  345 
of  copperhead,  343 
of  Gila  monster,  347 
of  poisonous  lizard,  347 
of  poisonous  spider,  342 
of  rattesnake,  344,  34s 
of  reptiles,  342 
of  sand-flea,  343 
of  scorpion,  342 
of  snakes,  343 

symptoms,  344 

treatment,  34s 
of  tarantula,  34a 
of  tick,  342 

of  water  moccasin,  344 
Bladder,  atony  of,  1465 

calculus,  1467.     See  also  Stone 

in  bladder. 
catarrh  of,  chronic,  1472 
congenital  defects,   1462 
contusion  of,   1463 
diseases    and    injuries,     1458. 

1463 
congenital  defects,   1462, 
contusion  of,  1463 
diseases    and    mjuries,     1458, 

1463 
diverticula  of,  1462 
exstrophy  of,  1462 
fistula  of,  1463 
foreign  bodies  in,  1466 
hemorrhage  from  14 14 

control,  517 
hernia  of,  1302 
inflammation    of,     1470.     See 

also  Cystitis. 
insufficiency     of,     in     hyper- 
trophy of  prostate,  1527 
myoma  of,  i47S 
neck    of,    inflammation,    pain 

in,  99 
nervousness  of ,  1415 
operations,  1477 
papilloma  of,  147  s 
paralysis   of,    intradural   root 
anastomosis   in,    97  2 
true,  1466 
rupture  of,  1463 
sarcoma  of,  147  s 
sound,  1469  (Fig.  967) 
stammering  of,  1476 
stone  in,  1467 
tuberculosis  of,  278 
tumors  of,  1475 
ulcer  of,   147s 
wounds  of,  1463 


Blake-Keller       modification     of 

Thomas    traction    leg    splint, 

611 
Blake's     method     of     preparing 
silverized  catgut,  82 

on  nail  extension  in  fracture  of 
femur,  602 

splint   in   fractures   of   femur, 
682 

wound  of  bone  versus  fracture, 
586 
Blank-cartridge  wounds,  305 
Blasucci  catheter,  1449 
Blastomycetic     dermatitis,     20, 

359 
Blastomycosis,  359 

cutaneous,  359 

systemic,  359 

treatment,  360 
Blebs  in  fractures,  604 
Bleeders,  520 

Bleeding.     See  Hemorrhage. 
Blind  boil,  147 
Blindness,  flash,  1646 
Blindness,  mind,  918 

word,  918 
Blisters  in  inflammation,  114 
Block,  physiological,  286,  289 
Blood,   anthrax  bacillus  in,   349 

changes  in  cancer,  445 

determination     of     source,  in 
hematuria,  141 1 

extravasation  of,  in  fractures, 
594 

freezing-point    of,    determina- 
tion, 1417 

loss  of.  497.     See  also  Hemor- 
rhage. 

occult,    in   ulcer   of    stomach, 
1096 

transfusion,      528.     See     also 
Transfusion  of  blood. 
Blood-clot,  repair  by,  127 

Schede's,  in  bone  cavities,  S74 
Blood-count      in      appendicitis, 

1 149 
Blood-cyst,  284 

Bloodgood's  modification  of  Hal- 
sted's  operation  for  inguinal 
hernia,  1282 

operation  for  varicocele,  1549 
Bloodless    method    of    reducing 

congenital  dislocation  of  hip, 

799 
Blood-plaques,  94 
Blood-serum  in  hemorrhage,  51 1 
Blood-vessels,    diseases    and    in- 
juries, 459 

repair  of,  138 

tuberculosis  of,  273 
Blue  ointment  in  inflammation, 
II I 

pus,  146 
Bodies  in  joints,  loose,  744 

metachromatic,  21 

Negri,  352 
Bodine's     inguinal      colostomy, 

1262 
Boeckman's  method  of  prepar- 
ing catgut,  82 
Boil,  148 

Aleppo,  149,  1368 

blind,  148 

core,  148 

Delhi,  149,  1368 

endemic,  of  tropics,  149.  1368 

gum-,  157,  1041 

symptoms,  148 

treatment,  149 
Boiled  water,  32 
Boldt's  operating  table,  69 
Bombs,  aerial,  325 

incendiary,  325 

mortar,  325 
Bond's  splint  in  Colles'  fracture, 

661 
Bone,  abscess  of,  chronic,  569 
tuberculous,  treatment,  270 

actinomycosis  of,  565 

affections  of,  syphilitic,  376 

and    plate    holder,    bowman's 
combination,  614 


Bone,  aneurysm  of,  475 
atrophy  of,  564 

fracture  in,  592 
bolts    and    nut    driver,    Sher- 
man's, 614 
callus,  597 
cancellous,  hemorrhage  from, 

control,  514 
caries,  567,  S70 
comminution    of,    in    gunshot 

wounds,  304 
cystoma  of,  564 
cysts  of,  564 

diseases  and  injuries  of,  564 
typhoid,  572 

x-rays   in  diagnosis,    1610 
excision  of,  786 
felon,  815 

graft,  Albee's,  613.  782 
gumma    of,    x-ray    diagnosis, 

1611 
head   of,   tuberculous   abscess 

of,  266 
hypertrophy  of,  564 
inflammation  of,  566 
myeloma  of,  multiple,  586 
necrosis  of,  571 
acute,  567 
central,  571 
postfebrile,  572 
quiet,  572 
nodes  of,  568 
operations  on,  777 
ping-pong,  42s 
repair  of,  136 
riders',  568,  803 
skull,  diseases  and  malforma- 
tions, 869 
syphilis  of,  56s 
tertiary,  379 
transplantation  of,  137 
tuberculosis  of,  275,  565 

infiltrating  progressive,  566 
tumors  of,  564 
Bone-cavities,      Bayer's      treat- 
ment, 574 
bone-grafting  for,  574 
Dressman's  treatment,  574 
Neuber's  treatment,  574 
Schede's  treatment,  574 
Schleich's  treatment,  574 
Senn's  treatment,  574 
Sherman's  treatment,  574 
treatment,  574 

von  Mosetig-Moorhof's  treat- 
ment, 574 
Bone-drills,  Brainard's,  782 
Hamilton's,  782 
Richter's,  610 
Bone-grafting   after    partial   ex- 
cision of  lower  jaw,  799 
for  bone-cavities,  574 
in    intracapsular    fracture    of 

neck  of  femur,  677 
in  Pott's  disease,  954,  968 
in  ununited  fractures,  613.  782 
Bone-plates,  Halsted's,  609 

Lane's,  609 
Boot,     Gibrey's,  for    sprain    of 

ankle,  737 
Borborygmi,  1119 
Boric  acid,  32 

Borsch's  bandage  of  eye,    1399 
Bots,  343 
Bottini's     galvanocaustic     pros- 

tatotomy,  1534 
Bottle   operation  for  hydrocele, 

IS48 
Botulism,  62 
Bougie-^-boule,  1504 
Bougies,  esophageal,  1061 

Gouley's,  1460 
Bouton  de  Baghdad,  149 
Boutonniere  operation  in  prosta- 
titis, 1523 
Bovovaccination,  24S 
Bowlby's  arm  splint,  637 
Bow-legs,    830.     See    also    Genu 

varum. 
Boyer's  cyst,  818 
Brachial  artery,  ligation  of,  543 
birth  paralysis,  843 


Index 


1657 


Brachial  birth   paralysis,  opera- 
tion for,  863 
plexus,  avulsion  of,  841 

Alexinsky's       treatment, 

843 
Frazier's  treatment,  842  . 
paralysis,  843 
rupture  of,  841 
Bracketed  splint,  607 
Brain,  abscess  of,  154,  902.     See 
also  Abscess  of  brain. 
actinomycosis  of,  ©lo 
adenoma  of,  911 
angioma  of,  910 
angiosarcoma  of,  910 
cancer  of,  911 
cholesteatoma  of,  910 
compression  of,  878 

treatment,  881 
concussion  of,  87s 
contusion  of,  875 
cysts  of,  911 
diseases  involving,  870 

from    suppurative    ear    dis- 
ease, 90s 
gross,    Jacksonian    epilepsy 
from,      operative      treat- 
ment, 928 
enchondroma  of,  911 
endothelioma  of,  910 
fibroma  of,  910 
glioma  of,  910 
hernia  of,  898 
inflammation    of,    traumatic, 

899 
laceration  of,  875 
malformations  involving,  870 
operations  on,  930 

control    of    hemorrhage     in, 

935 
tapping  ventricles  in,  93s 
technic,  934 
osteoma  of,  910 
pearl  tumor  of,  910 
prolapse  of,  898 
psammoma  of,  910 
repair  of,  13s 
sarcoma  of,  910 
syphilis  of,  381,  382 
syphiloma  of,  910 
tuberculoma  of,  909 
tuberculosis  of,  275 
tuberculous  gumma  of,  909 
tumors    of,  Bdrdny's  tests  in, 
91S 
consecutive  bulging  in,  923 
Cushing's  decompression  in, 

924,  937 
diagnosis,  913 
exploratory     operation     in, 

922 
gummatous,  910 
initial  bulging  in,  923 
lesions     in     cortical     motor 

area,  917 
localization,  915 
palliative  trephining  in,  924 
symptoms,  911 
treatment,  922 
tuberculous,  909 
two-stage  ODeration,  923 
war  wounds  of,  891 
drainage,  895 
treatment,  893 
water  on,  901 
wounds  of,  890 

from  revolver  bullets,  896 
treatment,  897 
Brainard's  bone-drills,  782 
Brain-matter,    injections   of,    in 

tetanus,  235 
Brain-sand  tumor,  408 
Branchial  cysts,  455 
fistula,  455 
complete,  455 
incomplete,  455 
Branching  of  bacilli,  23 
Brandt's  method  of  gastroplica- 

tion,  1242 
Brasdor's    operation    for    aneu- 
rysm, 484 
Brass  wire,  preparation,  8s 


Braucr  and  Spengler's  modifica- 
tion of  Murphy's  apparatus 
for  artificial  pneumothorax, 
1036 

Braun's  method  of  gastro-enter- 
ostomy,  1231 

Breast,  abscess  of,  is7,  1575 
acute,  IS7S 
treatment,  161 
tuberculous,  267 
treatment,  271 
adenocarcinoma  of,  1583 
adenocele  of,  is 79 
adenoma  of,  1579 
angioma  of,  1580 
bandage  of,  figure-of-8,  1403 
cancer     of,     1582.     See     also 

Cancer  of  breast. 
cystadenoma  of,  1579 
cystic  adenoma  of,  1579 
degeneration  of,  1580 
cysts  of,  1577.  1578,  1580 
diseases,  1574 
snchondroma  of,  1580 
endothelioma  of.  1582 
fibro-adenoma  of,  1578 
fibrocystadenoma  of,  IS79 
fibroma  of,  1578 
fibromyxoma  of,  1578 
fissure  of,  1574 

prevention,  1574 
hydatid  cysts  of,  1580 
hypertrophy  of.  1573 
inflammation  of,  1575 
innocent  tumors,  1578 
involution  cysts  of,  1580 
lacteal  cysts  of,  is8o 
lipoma  of,  1580 
malignant  tumors,  1581 
myxoma  of,  rs8o 
sarcoma  of,  1581 
scirrhus  of,  atrophic  or  wither- 
ing, 1586 
tuberculosis  of,  273,  1576 
confluent,  1577 
nodular,  1577 
tumors  of,  1577,  1578 

Brewer's     operation     for     blood 
transfusion,   S3i 
tubes  for  direct  blood    trans- 
fusion, 531 

Brick's  pile  clamp,  13 19 

Bridge,  periosteal,  in  fracture, 
596 

Brilliant  green,  37 

Brinkerhofl's  speculum,  1306 

Bris6ment  forc6  in  ankylosis,  741 

Broca's  regional  terms  for 
craniocerebral  topography, 
864 

Brodie's  abscess,  153,  S69 
joint,  732 

Bronchi,  foreign  bodies  in, 
bronchoscopic   removal,    1002 

Bronchiectasis,  1029 
pneumotomy  for,  1040 

Bronchocele,  1372 

Bronchoscopy,  993 
direct,  996.  998 
for  removal  of  foreign  bodies 
in  trachea  and  bronchi,  1002 

Bronchus,  foreign  bodies  in, 
991 

Bronze  wire,  preparation,  8s 

Brophy's  operation  for  cleft- 
palate,  1052 

Brownian  movement  of  bacteria, 
22 

Brown's  cystoscopic  table,   1450 

method    of    injecting    air    in 

suprapubic  lithotomy,  1479 

Bruises,  perineal,   1487 

Brunonian  movement  of  bac- 
teria, 22 

Brunus'  reduction  in  shoulder- 
joint  dislocation,  7S7 

Brush-box,  glass,  71 

Brush-burn.  300 

Bryant's  extension  in   fractures 
of  shaft  of  femur  in  children, 
682 
splint  in  Pott's  fracture,   698 


Bryson's  operation   for  perineal 

prostatectomy,  1533 
Bubo,     chancroidal,     372,     15 19 

treatment,  is 20 
Bubo  in  gonorrhea,   treatment, 
1502 
indolent,  371 
pyogenic,  I  s8 
syphilitic,  371 
Bubonulus  in  gonorrhea,  1494 
Buchner    and     Nuttall's   theory 

of     immunity,     45 
Buck's  apparatus  in  intracapsu- 
lar   fractures    of    femur,    670 
Budding  fungi,  19 
Buds,  farcy-,  355 
Buerger's  rongeur  forceps,  1450 
Buffy     coat     of     inflammation, 

103 
Bullet.     See  also  Projectiles. 
DeNancrede  on,  308,  318 
Dumdum,  317 
explosive,  318 
Krag-Jorgensen,  314 
locating  with  fiuoroscope,  310, 
1619-1628 
with  skiagraph,  310,   1619- 

1628 
with  x-rays,  310,  1619-1628 
mushroom,  317 
pistol,     wound     from,     symp- 
toms, 308 
treatment,  308 
revolver,  wounds  from,  3S0 
soft-nose,  317 
Springfield,  314 
wounds,  rifle,  312 
Bullet-forceps,  309 
Bullet-probe,  Fluhrer's,  309 
Girdner's,  309 
Lilienthal's,  309 
N^Iaton's,  309 
Senn's,  309,  897 
Bullous  erysipelas,  220 

syphilid,  373 
Bunion,  822,  83S 

Biggs'  apparatus  for,  822 
Mayo's     operation    for,     780, 

822 
osteotomy  for,  780 
Burkhardt's    method    of    intra- 
venous    ether     anesthesia, 
1342 
Burns  and  scalds,  360 

ambrine  treatment,  362 
antiseptic  treatment,  363 
carton  oil  for,  363 
horse-serum  treatment,  363 
of  epiglottis,  364 
of  esophagus,  364 
of  glottis,  364 
of  pharynx,  364 
of  tongue,  364 
paraffin  treatment,  362 
picric  acid  treatment,  362 
symptoms,  360 
treatment,  361, 
Waterhouse's,  361 
brush-,  300 

liquid-fire,  in  warfare,  340 
warm  bath  in,  361 
x-ray,  1604,  1605 
treatment,  1606 
Burrs,  Hudson's,  931 
Bursas,  mseases  of,  801 
injuries  of,  801 

of    semimembranosus    muscle, 
822 
Bursitis,  817 
acute,  817 
chronic,  817 
gluteal,  817 
iliac,  817 
iliopsoas,  817 
infrapatellar,  821 
of    retrocalcaneal    bursa,     817 
olecranon,    817,    821 
subacromial,  819 

Codman's    treatment.     820. 

821 
Dawbarn's  sign  in.  819 
Monks'  treatment,  820 


1658 


Index 


Butcher's  method  of  exicision  of 
metatarsal  bone  of  great  toe, 
796 

Buttock,  sarcoma  of,  431 

Button  suture,  299 

Cabot  posterior  wire  splint,  6x2 
Cachectic,    gangrene,   multiple, 

176 
Cachexia,  cancerous.  436 
of  malignant  disease,  402 
strumlpriva  1369 
Calcareous   deposits   in   mucous 

membrane  of  female  genitalia 

mistaken    for  ureteral   stone, 

1618 
Calcaneus,  paralytic,  astragalec- 

tomy  in,  79s 
Calcium  chlorid  in  hemorrhage, 

Sii 
Calculus.     See  Stone. 
Callender's    strain-fracture,    S88 
Callous   leg   ulcer,    170 
Callus.  597 

bending,  599 

central,  598 

definitive.  598 

ensheathing.  598 
formation.  597 
intermediate.  598 

permanent,  598 

provisional,  598 

temporary,  598 
Calmette's     antivenene     serum, 
346 

ophthalmo- tuberculin  reaction 
in  tuberculosis,  253 
Caloric     tests     of     Barany     in 

brain  tumors,  916 
Cammidge's    reaction    in    pan- 
creatic diseases,  1196 
Camphor   in   chronic   leg   ulcer, 

166 
Cancellous  osteoma,  411 
Cancer,  434 

^deux,  401,  445 

alleged  increase,  440 

aquaticus,  198 

arsenic,  443 

biological  theory,  439 

blood  changes  in.  44s 

cachexia  in,  436 

chemotherapy  of,  450 

chimney  sweeps',  399,  445 

classification,  445 

colloid,  448 

conjugal,  401 

contact,  400,  44s 

contusion  as  cause,  437 

cuirass,  445,  1585.  IS86 

deep-seated,  x-ray  treatment, 
1632 

dissemination,  443 

distribution,  441 

electric  desiccation  in,  449 

electrocoagulation  in,  1637 

electrolysis  in,  450 

electrothermic  coagulation  in, 

•     449 

emboli,  444 

en  cuirasse,  443,  158s,  1586 

encephaloid,  447 

extension,  443 

from     congenital     pigmented 
mole,  451 

fulguration  in,  449 

glandular,  447 

hematoid,  447 

hereditary  influence  in,  441 

high-frequency  current  in,  449 

houses,  399,  442 

immunity  to,  441 

influence  of  diet,  442 

inoperable,     treatment,     449, 
1632-1634 

irritation  as  cause,  437 

Kangri,  437 

ligneous,  1586 

mastitoides,  1586 

medullary,  447 

melanotic,  445,  448 

metastases,  443 


Cancer,  mouse,  439 

eosin-selenium  in,  450 
of  appendix,  1153 
of  bile-ducts,  1192 
of  bladder,  1475 
of  brain,  911 
of  breast,  1582 
acute.  1586 
Beatson's      operation      for, 

IS99 
brawny,  1586 
cases  unsuitable  for  radical 

operation,  1389 
dressing  and  treatment  after 

operation,  1396 
duct,  1386 

Halsted's  operation,  1389 
inflamed,  1386 
inoperable,  1399 
Jackson's  operation,  1592 
Meyer's  operation,  1392 
pigskin  appearance  in,  1583 
•scirrhus,  1382 

atrophic      or     withering, 
1586 
Senn's  operation,  1392 
statistics      of      operations, 

1387,  1588 
sternal  symptom,  1383 
Stewart's      operation      for, 

1396 
treatment,  1387 
Warren's  operation,  1392 
*-ray  treatment,  1392,  1634 
of  colon,  x-ray  diagnosis,  161 6 
of  esophagus,  1067 
of  gall-bladder,  1192 
of  intestine,  1133 
of  kidney,  1418 
of  lip,  1033 

Grant's  operation  for,  1034 
of  liver,   1171 

of  lung,  x-ray  diagnosis,  1612 
of  male  breast,  1387 
of  pancreas,  1201 
of  penis,  1321 
of  prostate  gland,  1337 
of  rectum,  1326 

Cripps's  operation  for,  1329 
Kraske's  operation  in,  1329 
palliative      colostomy      in, 

1328 
preliminary     colostomy    in, 

1327 
Qu6nu-Mayo  operation  for, 

1330 
rest  in.  103 
treatment,  1327 
Weir's  operation  for,  1330 
of  spleen,  1203 
of  stomach,  1090 

coffee-ground  vomit  in,  1091 
contact.  1090 
scirrhus,  1090 
spheroidal  cell,  1090 
test-meal  in,  1091 
treatment,  1092 
of  testicle,   1543.  i544 
of  thymus  gland,  1390 
of  tongue.  1037 

Cheyne's  rule  in,  1060 
complete  removal  of  tongue 

in,  1039 
Kocher's  operation  for,  1039 
partial    removal    of    tongue 

in,  1039 
Whitehead's  operation    for, 
1060 
paraffin  worker's,  445 
parasite  theory,  439 
precancerous  stage,  438 
prevalence,  440 
recurrence  of,  after  operative 

removal,  443 
recurrent    and   metastatic,   x- 

ray  treatment,  1632 
regions,  442 
scirrhous,  447 
serum  reaction  in,  436 
sex  in,  441 

spontaneous       disappearance, 
444 


Cancer,  telangiectatic,  447 
theories  as  to  cause,  437 
Thiersch's  hypothesis  in,  438 
transmissibility,  400 
transplantation,  400 
treatment,  448 
x-ray,  443,  1605.  1606 
Cancerous  cachexia,  436 
cirrhosis  of  liver,  1171 
horn,  440 

stricture  of  esophagus,  1067 
ulcer,  true,  446 
Cancroid.  446 

ulcer,  171 
Cancrum  oris,  196 
Cannula  h  chemise,  318 

and  trocar  with  harpoon  me« 
thod     of    localizing    foreign 
bodies,  1623 
Cap,  duodenal,  1614 
Capillary  angioma,  418 
drain.  87 
embolism,  475 
hemorrhage,  control,  516 
hemorrhoids,  13 17 
Capsule  of  bacteria,  21 
Capsulorrhaphy     in    habitua 
shoulder-joint  dislocation,  759 
Caput  medusae,  469 
succedaneum,  867 
Carbolic  acid,  31 
gangrene,  200 

injection    in    hemorrhoids, 
1318 
in  tetanus,  234 
poisoning,  32 
Carboluria,  32 
Carbon  monoxid  gas  in  warfare, 

339 
Carbonic-acid    snow    in    nevus, 

420 
Carbonyl  chlorid  gas  in  warfare, 

338 
Carbuncle,  149 
anthrax,  348 
facial,  x-rays  in,  1636 
of  lip.  loss 
symptoms,  150 
treatment,  131 
Carcinoma,  434.     See  also  Can- 
cer. 
Carden's     amputation     through 

femoral  condyles,  1368 
Cardiolysis,  323 
Cardiorrhaphy,  462 
Cardiospasm,  1068 

x-ray  diagnosis,  1613 
Cardiovascular    degeneration, 

472 
Cargile  membrane,  86 
Caries,  367,  S70 
necrotica,  370 

of    lumbar    and    last    dorsal 
vertebrae,    with    abscess    in 
psoas  magnus  or  quadratus 
lumborum    muscle,    Treves' 
operation,  784 
of  rib,  excision  in,  796 
sicca,  366,  370 
spinal,    951.     See    also   Pott's 

disease. 
strumous,  370 
tuberculous,  370 
Volkmann's,  366 
Carotid    artery,    common,    liga- 
tion of,  330 
external,  ligation  of,  531 
internal,  ligation  of,  552 
body,  1389 

tumors  of,  1389 
triangle,  inferior,  343,  349 
superior,  345.  S49 
Carpal   bones,    traumatic    dislo- 
cation of,  763 
scaphoid,  fractures  of,  663 
Carphologia,  217 
Carpus,  fractures  of,  662 
Carrel- Dakin     treatment,     29St 
329 
after-care,  332 
apparatus  for,  329 
excision  of  wounds  for,  336 


Index 


1659 


Carrel-Dakin     treatment,     for 

penetrating  wounds,  332 

for  superficial  wounds,  331 

for     through-and-through 

wounds,  332 
improper  method,  333 
in  compound  fractures,  606 
in  gas  gangrene,  188 
introduction   of   instillation 

tubes,  331 
materials  necessary  for,  329 
of  gunshot  fractures,  61S 
preparing   wound   for    anti- 
septic, 330 
proper  method,  333 
reunion  of  wound,  334 
systematic  bacteriologic  ex- 
amination of  wound,  333 
Carriers,  bacteria,  44 
of  disease,  insect,  41 
typhoid,  44 
Carron  oil  for  bums  and  scalds, 

363 
Carry,  fire,  983 
Carrying  function  of    arm,   645 

diagram,  646 
Cartilages,    costal,    fractures  of, 
625. 
Malgaigne's  treatment,  625 
floating,  744 
.    loose,  728 

in  osteo-arthritis,  728 
semilunar,  of  knee,  dislocation 
of.  Barker's  operation 
for,  799 
traumatic,  773 
Caseation  in  tuberculosis,  236 
Caseous  abscess,  153 
osteitis,  570 
peritonitis,  ii6s 
pus,  146 
Castration,  1545 

for   hypertrophy   of   prostate, 
1536 
Casualty  clearing  station,  325  ■ 
Cataplasm  in  inflammation,  113 
Catarrh     of     bladder,      chronic, 
1472 
of    gall-bladder,    suppurative, 

1181 
urethral,  chronic,  1495 
venereal,  1492 
Catarrhal  cholecystitis,  1 180 
gonorrhea,  1495 

treatment,  1499 
inflammation,  96 

of    gall-bladder    and    bile- 
ducts,  1 1 80 
jaundice,  1780 
Catgut,  80 

in  anthrax,  80,  347 
in  tetanus,  80,  225 
method  of  tying,  83 
preparation,    Boeckman's  me- 
thod, 82 
boiling  in  alcohol,  81 
chromicized,  83 
Claudius'  method,  82 

Salkindsohn's      modifi- 
cation, 82 
corrosive  sublimate  method , 

82 
cumol  method,  81 
dry-heat  method,  82 
formalin  method,  82 
Johnston's    quick    method, 

83 
Kronig's  method,  81 
Senn's  method,  82 
silverized,   Blake's    method, 
82 
Cathartics  in  inflammation,  116 
Cathcart's  method  of  drainage  in 
suprapubic  lithotomy,   1479 
Catheter,  Blasucci,  1449 
Cunningham,  1449 
English,  1460 
French,  1459 
Garceau,  1449 
Gouley's,  1460 
Mercier's,  1459 
N61aton's,  1461 


Catheter,  Phillips's,  1461 

ureteral,  sterilization  of,  1449 
urethral,  disinfection  of,  1457 
Catheterism,  ureteral,  1412 
Catheterization   in  hypertrophy 

of  prostate,  1528 
Causalgia,  851 

Cautery,  actual,  in  hemorrhage, 
Sii 
in    inflammation,  115 
Cavernous  angioma,  418 
lipoma,  405 
lymphangioma,  420 
sinus,  infective  thrombosis  of, 
907 
Cecal  hernia,  1299 
Cecostomy,  valvular,  1260 
Celiotomy,  1204 
Cell-division  direct,  132 

indirect,  132 
Cell-proliferation    in    inflamma- 
tion, 94 
Cells,  epithelioid,  236 

giant-,  236 
Cellular    emphysema,   623 

fibroma,  406 
Cellulitis,  220,  223 
crab,  219 
diffuse,  146 
gangrenous,  223 
mild,  147 
treatment,  223 
Cellulocutaneous  erysipelas,  222 
Celluloid  thread,  8s 
preparation,  85 
Cementoma,  413 
Centipedes,  bites  of,  342 
Cephalic  tetanus,  228 
Cephalhematoma,  868 
Cephalocele,  870 
frontal,  870 
occipital,  870 
Cephalodynia,  802 
Cerebellitis,  899 
Cerebellopontile    angle,    tumors 

of,  920 
Cerebellum,  tumors  of,  919 
Cerebral     concussion,     rest     in, 
lOS 
hemorrhage,  883 
irritability  in   concussion,  876 
paralysis,     infantile,    epilepsy 
following,     operative    treat- 
ment, 928 
sinus,  hemorrhage   from,  con- 
trol, 51S 
tetanus.  227 
Cerebritis,  899 
Cerebrospinal  fluid,  970 

bacteriologic  study,  970 
chemical  study  970 
cytodiagnosis  of,  970 
Cervical    adenitis,     tuberculous, 
276 
x-ra.Y  treatment,  1635 
auricle,  45  s 
esophagostomy    for   stricture, 

1067 
fistula,       complete        median, 
I0S7 
incomplete  median,   1057 
congenital  lateral,  complete, 
4SS 
incomplete,  45s 
lymph-glands,  tuberculosis  of, 

276 
rib,  946 

excision  of,  797 
Chalk-stone,  727 
Chamber,  Sauerbruch,  1032 
Chancre,  368 

and    chancroid,    mixed    infec- 
tion, 370 
diagnosis,  370 
extragenital,  36S 
Hunterian,  369 
redux,  371 
relapsing,  371 
soft,  1 5 18 

syphilis  without,  369 
urethral,    pvogenic    urethritis 
of,  1491 


Chancroid,  1518 

and  chancre,  mixed  infection, 

370 
bubo  in,  372,  1519 
treatment,  1520 
treatment,  1520 
Chancroidal  urethritis,  pyogenic, 

1491 
Charbon,  347 

Charcot's  bed-sores,   acute,    199 
disease,  730,  731 

of  joints,  703 
fever,  1189 
intermittent     hepatic     fever, 

1184 
joint,  730,  731 
Charriere's  tourniquet,  1551 
Chauffeur's  fracture,  658 
Chauveau's  theory  of  immunity, 

45 
Chemical  antiseptics,  28 
Chemiotaxis,    negative,    22,    48. 
94  . 

positive,  22,  48,  94 
Chest,  concussion  of,  1021 
contusions  of,  1021 
treatment,  1022 
diseases  and  injuries,  1014 
wall,     plastic    operations    on, 
for  pulmonary  tuberculosis, 
103 1 
war- wounds  of,  1025 

treatment,  1026 
wounds  of,  1 02 1,  1023 

involving  diaphragm,  1025 
Cheyne's  operation  for  femoral 
hernia,  1288 
rule  in  cancer  of  tongue,  1060 
Chiene's   method  of  finding  fis- 
sure of  Rolando,  864 
Chigger,  bites  of,  343 
Chilblain,  365 

Childbirth,   appendicitis  follow- 
ing, 1 151 
Children,  appendicitis  in,  11 50 
treatment,  11 55 
hernia  in,  1297 

tuberculosis      of      mesenteric 
glands  in,  1135 
Chimney-sweeps'     cancer,     399, 

445 
Chlorazene,  39 
Chlorcosane,  40 
Chlorin  gas  in  warfare,  338 
Chloroform,    administration    of, 
1336 
and  alcohol  anesthesia,  1350 
and   ether  anesthesia,    1350 
anesthesia,  1334,  1342 
ether  followed  by,  1355 
followed  by  ether,  1354 
Chloroma    424 

Chlumsky's  treatment  in  anky- 
losis, 742 
Choked  disk  in  basal  skull  frac- 
tures, 889 
in  brain  abscess,  905 
compression,  879 
tumors,  912 
Cholangitis,  11 89 
infective,  11  S3 
suppurative,  11 84 
Cholecystectomy  for  gaU-stones, 
1192 
Langenbuch's,  1267 
Cholecystendysis,  1191 
Cholecystenterostomy,  1266 
for  gall-stones,  1192 
Murphy's  method,  1266 
Cholecystitis,  117  8 

acute  phlegmonous,  1182 
bacteriology,  11 79 
catarrhal,  1180 
croupous,  1181 
suppurative,  simple,  1181 
typhoid,  1 1 84 
Cholecystostomy,  1265 
biliary  fistula  after,  1266 
for  gall-stones,  1191 
two-stage,  1266 
Cholecystotomy,  1265' 
ideal,  1191,  1265 


i66o 


Index 


Choledochoduodenostomy,      in- 
ternal, 1270 
Choledocho-enterostomy,         for 

gall-stones,  1192 
Choledocholithotomy,  1268 
Choledocholithotrity,     for    gall- 
stones, 1 191 
Choledochostomy,  i2f:8,  1269 

for  gall-stones,  1191,  1192 
Choledochotomy  for  gall-stones, 
1191 

retroduodenal,  1270 

supraduodenal,  1268 
Cholelithiasis,  1185 
Cholesteatoma,  408 

of  brain,  910 
Chondrodysplasia,        hereditary 

deforming,  564 
Chondroma,  409 

ossifying,  410 

pelvic,  409 

treatment,  410 
Chondrosarcoma,  426 
"Chop"  amputation,  1550.    See 

also  Guillotine  and  Preface. 
Chopart's  amputation    of    foot, 

1564 
Chordee  in  gonorrhea,  1494 

treatment,  1502 
Chrome  ulcer  of  tanners,  164 
Chromicized  catgut,  preparation 

of,  83 
Chvostek's  sign  in  tetany,   1388 
Cicatrices,  131 

vicious,  131 
Cicatricial  stenosis  of  orifices  of 

stomach,  1102 
Cicatrization,  126,  130 
Cigarette  drain,  87 
Cinematoplastic     amputation, 

.1556,  1557 
Circulation,  retardation,  91 

reversal,     in    presenile     spon- 
taneous gangrene,  179 
Circumcision  in  phimosis,  1520 
Circumflex     nerve,     section    of, 

symptoms,  844 
Circumscribed  aneurysm,  475 
Cirrhosis     of     liver,      cancerous, 

1171 
Cirsoid  aneurysm,  419,  47s,  496 
Cisterna  magna,  drainage  of,  938 
Citrate  method  of  blood    trans- 
fusion, 536 

silver,  35 
Clamp  and  cautery  operation  for 
hemorrhoids,  13 19 

Brick's,  1319 

Freeman's,  783 

Moynihan's,  1237 
Clap,  1492 
Claret  stains,  418 
Clarke's  arm  splint,  637 
Claudication,     intermittent,      in 

presenile     spontaneous      gan- 
grene, 178 
Claudius    method    of    preparing 

catgut,  82 
Clavicle,    dislocations    of,     trau- 
matic, 750 

excision  of,  796 

fractures  of,  630 

Fox's  apparatus,  631 
Moore's  dressing,  631 
of  acromial  end,  632 
of  shaft,  630 
of  sternal  end,  632 
Say  re's  dressing,  631 
Velpeau's  bandage  in,  631 
Clavus,  1368 
Claw-hand,  846 
Cleanliness      in     inflammation, 

122 
Cleft-palate,  1045 

Berry's  operation  in,  1051 

Brophy's  operation.  1052 

Fergusson's      operation      for, 

I0S2 

operation  for,  1048 
Cloaca,  571 
Cloquet's  hernia,  1299 

tabatiere  anatomique,  541 


Clostridium,  25 

Clot,  passive,  476 

Cloth  retractor  for  amputation, 

1552 
Cloud  gas  in  warfare,  338 
Clove-hitch  knot,  747 
Clover's  ether  inhaler,  1338 
Club-foot,  831.    ^taaXso  Talipes. 
Club-hand,  831 
Coagulable  lymph,  127 
Coagulation  time,  mormal,  1268 
Coagulose  in  hemorrhage,  511 
Coal-gas  poisoning,  985 
Cobra,  bites  of,  343,  34s 
Cocain  hydrochlorate  by  hypo- 
dermatic injection,  1357 

with  urethral  sounds,  1505 
Cocainization     of     nerve-trunk, 

1358 
Cocain-poisoning,  fever  of,  141 
Coccus,  22 

Fehleisen's,  58 

pyogenic,  23 

wool-sack,  23 
Coccygodynia,  629 
Coccyx,  fractures  of,  629 

traumatic  dislocations  of,  766 
Cock's   method  of  perineal  sec- 
tion, 15 17 

reduction     of     shoulder-joint 
dislocation,  757 
"Cock-up"  wrist  splint  of  Jones, 

663 
Codivilla's    pin    for  fracture  of 

femur,  602 
Codman's     treatment     of     sub- 
acromial bursitis,  820,  821 
Coenen     and     Henle's     sign    in 

aneurysm,  489 
Cofifee-ground   vomit   of   gastric 

cancer,  1091 
Cohnheim's  inclusion  theory  in 

tumors,  398 
Coin  catcher,  1072 
Cold  abscess,  260 

effects  of,  360,  364 
on  bacteria,  26 

in  appendicitis,  1153,  1154 

in  inflammation,  107 
Coley's   dressing   in   oblique   in- 
guinal hernia,  1281 

fluid  in  sarcoma,  430 
Colic,  appendicular,  1139.  1140 

in  gall-stones,  1187 

intussusception,  11 14 

nephritic,  1428 
Collapse,  286 
Collargolum,  35 

Colles'  fractures,  658.     See  also 
Fractures,  Colles'. 

law  in  syphilis,  366,  394 
Colley's      operation      in      Volk- 

mann's  contracture,  807 
Collins's  incision  for  surgery  of 

bile-ducts,  1263,  1264 
Colloid  cancer,  448 

goiter,  1372 
Colloidal  silver,  35 
Colon,  ascending  and  descending, 
adherent   hernia   of,    opera- 
tive treatment,  1290 

bacillus,  61 

dilatation   of,  congenital  idio- 
pathic, II 56 

fibromatosis  of,  1156 

x-ray  examination,   1616 
Colopexy  for  prolapse  of  rectum, 

1323 
Colostomy,  1260 

inguinal,  1260 
Bodine's,  1262 

lumbar,  1262 

palliative,  in  cancer  of  rectum, 
1328 

preliminary,  in  cancer   of  rec- 
tum, 1327 
Colubrine  venom,  345 
Columnae  adiposae,  150 
Coma,  880 

alcoholic,  881 

determination  of  cause,  880 

diabetic,  191.  881 


Coma,  treatment,  193 

hysterical,  881 

Kussmaul's,  191 

of  opium-poisoning,  88r 

of  uremia,  881 

postepileptic,  881 
Comma  bacillus,  22 
Complement,  382 
Compound  fractures,   586.      See 

also  Fractures,  compound. 
Compression  in  aneurysm,  480 

in  hemorrhage,  508 

in  inflammation,  no 

of  brain,  878 
treatment,  881 

of  spinal  cord,  960 
Concealed  suppuration,  213 
Concentric  atrophy  of  bone,  564 
Concrete  pus,  145 
Concretions    mistaken    for  ure- 
teral stone,  1457 

in  appendix,  1138,  1139 

salivary,  1044 
Concussion,    cerebral,     rest    in, 
105 

of  brain,  875 

cerebral  irritability  in,   876 

of  chest,  102 

of  spinal  cord,  959 

shell,  323 
Condyloma,  375 

flat,  374 
Congenital  gangrene,  175 

syphilis,  transmitted,  393 

tuberculosis,  241 
Congestion    of    lung    by    recoil, 

1035 
Congestive  abscess,  260 
Conjugal  cancer,  401 

tuberculosis,  242 
Connective-tissue   tumors,   402 
innocent,  403 
malignant.  421 
Connell's    method    of    intestinal 
anastomosis,  1251 

suture,  1 218 
Consecutive  aneurysm,  474 
Constipation  of  appendix,    1140 
Constitution,  lymphatic,  249 
Consumption,      235.     See     also 

Tuberculosis. 
Contact  cancer,  400,  44s 

of  stomach,  1090 
Contagium  animatum,  18 
Continuous  suture,  298 
Contour    gunshot    wound,    307, 

1024 
Contra-indications    to     cystos- 
copy, 1449 

to  operation,  76 

to  radical  operation  in  cancer 
of  breast,  1589 
Contraction,    Dupuytren's,   828. 
See    also    Dupuytren's    con- 
traction. 

of  muscles,  810 
Contracture,   Volkmann's,   805 
Colley's  operation  for,  807 
Jones'  treatment,  806 
Contrecoup,  skull  fractures  by, 

885 
Contre-6preuve  of  the  Trendel- 
enburg test,  526 
Contused  wounds,  300 
Contusions,  284 

abdominal,   muscular  rupture 
from,  1075 
without   injury   of   viscera, 
1075 

of  bladder,  1463 

of  brain,  875 

of  chest,  1 02 1 
treatment,  1022 

of  head,  875 

of  lung,  1 02 1 

of  muscles,  807 

of  nerves,  850 

of  spinal  cord,  959 

symptoms,  28s 

treatment,  285 
Convalescent  hospital,  326 


Index 


1661 


Cook's  speculum,  1307 
Coolidge  tube,  i6or,  1602 
Cooper's  herniotome,  1294 

operation   for   ligation   of   ab- 
dominal aorta,  563 
reduction      of     shoulder-joint 

dislocation,  757 
rule  in  old  dislocations,  748 
treatment    of    dislocation    of 
lower  jaw,  749 
Coordination  center  of  Kroneck- 

er,  460 
Copaiba  in  gonorrhea,  1409 
Copper  wire,  preparation,  8s 
Copperhead,  bites  of,  343 
Coracoid    process,    fractures    of, 

633 
Coral  snake,  bites  of,  344 
Corn,  1368 
Coming's       method     of     spinal 

analgesia,  1364 
Corona  mortis,  1296 

veneris,  374 
Corpora   quadrigemina,    tumors 

of,  919 
Corpus     callositm,     tumors    of, 
918 
striatum,  tumors  in  or  about, 
918 
Corpuscle,  educated,  48 
Corradi-Moore  treatment  of  an- 
eurysm, 491 
Corrosive  sublimate,  29 

method  of  preparing  catgut, 

82 
poisoning,  30,  31 
Corset,     Gallant's,    in    movable 

kidney,  1422 
Costal  cartilages  and  ribs,  trau- 
matic dislocation,  763 
fractures  of,  625 

Malgaigne's     treatment, 
62s 
Costotome,  706 
Cotton  process  ether,  1339 

sterile  absorbent,  preparation, 
86 
Counterirritants,     inflammation 

in,  114 
Coup  de  fouet,  810 
Courvoisier's  law  in  gall-stones, 

1190 
Cowperitis  in  gonorrhea,  1494 

treatment,  1502 
Coxa  valga,  837 

Galeazzi's  treatment,  838 
vara,  837 
Coxalgia,   710.      See  also  Tuber- 
culosis of  hip. 
pain  of,  99 
Crab  cellulitis,  219 
Crab  wrist  splint  of  Jones,  663 
Cracked-pot  sound  in  skull  frac- 
tures, 886 
Cradle,  fracture,  670 
Crampton's  line,  560 
Cranial  nerve  paralysis  in  basal 
skull  fractures,  889 
pneumatocele,  869 
Craniocerebral  topography,  863 
Cranioschisis,  871 
Craniotabes,  279 
Craniotomy,  linear,  936 
Cranium.     See  Skull. 
Crawling  paralysis,  960 
Cred&'s  ointment  of  silver,  36 
Creolin,  32 

Crepitus  in  fractures,  594 
Cretinism,  1370 

Crile's    anoci-association    opera- 
tion, 290,  1359 
method  of  injection  of  saline 
solution  and  adrenalin,  538 
operation    of    blood    transfu- 
sion, 330 
Cripps's  operation  for  cancer  of 

rectum,  1329 
Crises,   Dietl's,  in  nephroptosis, 

1421 
Croupous  inflammation,  96,  97 
of     gall-bladder     and     bile- 
ducts,  1 1 81 


Crucial  ligaments  of  knee,  rup- 
ture of,  738 
Crural    nerve,    anterior,    section 

of,  symptoms,  847 
Cms,  tumors  of,  918 
Cry,  hydrencephalic,  902 
Cryoscopy,  141 7 
Cryptitis,  1325 

Cryptogenetic  septicemia,  214 
Cryptorchism,  1539 
Cuirass  cancer,  445 
Culture-tubes,  case  for,  159 
Cumol  method  of  preparing  cat- 
gut, 81 
Cuneiform  fractures,  389 

osteotomy,  777 
Cunningharn  catheter,  1449 
Cupping  in  inflammation,  106 
Cups,  dry,  106 

wet,  107 
Curdy  pus,  146 

Curet,   Barker's  sharp-edged  ir- 
rigating, 270 
Curling's  ulcer,  173,  1128 
Curvature,  spinal,  947 

angular,  931.    See  also  Poll's 

disease. 
anterior,  950 
anteroposterior,  930 
lateral,  94S 
posterior,  930 
Cushing's  cross-bow  incision  in 
brain  tumors,  923 
decompression    operation    for 

brain  tumors,  924,  937 
method  of  reaching  pituitary 
body,  940 
of  removing  Gasserian  gan- 
glion, 861 
on  management  of  war  head 

injuries,  893 
right-angled  suture,  121 7 
Cut  throat,  990 
Cutaneous  actinomycosis,  337 
blastomycosis,  339 
erysipelas,  219,  220 

prevention  of  spread,  221 
gangrene,  173 

reaction,   Noguchi's,   in  syph- 
ilis, 384 
tuberculin    reaction,     Moro's, 
234 
reaction,  von  Pirquet's,  234 
Cyanide  gauze.  Lister's  prepar- 
ation, 86 
Cylinder  gas  in  warfare,  338 
Cylindroma,  426 
Cyrtometer,   Horsley's,   863 
Cystadenoma  of  breast,  1379 
Cystectomy,  partial,  for  tumors 
of  bladder,  1476 
total,   for  tumors   of  bladder, 
1476 
Cystic  adenoma,  434 
of  breast,  1379 
degeneration  of  breast,  1380 
goiter,  1372 

kidney,  congenital,  141 7 
Cjsticotomy,  1191 
Cystitis,  1470 
acute,  147 1 

in     gonorrhea,     treatment, 
1503 
chronic,  1471,  1472 
treatment,  1473 
tuberculous,  1472 
fountain  irrigation  in,   1473 
incrusted,  treatment,  1474 
rest  in,  105 
tenesmus  in,  147 1 
treatment,  1471 
Cystocele,  1274 
Cystoma,  431,  456 

atheromatous,  452,  434 
mesoblastic,  452 
mucous,  432 
of  bone,  364 
traumatic  epithelial,  451 
varieties,  431 
Cystoscope,  A.   C.   M.   I.,   1448 
removal  of,  1432 
sterilization,  1449 


Cystoscope,  universal,  1454 
Cystoscopic  table.  Brown's,  1450 
Cystoscopy,  1447 

collection    of   urine    by,    1433 
contra-indications  to,  1449 
location  of    interureteral    bar 

in,  1431 
of  ureteral  orifices  in,   1432 
practical  value,  1434 
technic,  1430 
Cystostomy,  1484 

suprapubic,  1484 
Cystotomy,  1484 
median,  1483 
suprapubic,  1484 
Cysts,  436 

anosacral,  939 
blood-,  284 
bone,  364 
Boyer's,  818 
branchial,  433 
dentigerous,  412,  413 
dermoid,  453 

sequestration,  433 

traumatic,  434 

treatment,  433 
epithelial,  traumatic,  454 
from  softening,  437 
hydatid,  438 
lacteal,  437 
mesenteric,  1087 
milk,  437 

mucous,  456,  1044 
of  bone,  364 
of  brain,  911 
of  breast,  i377,  1578,  1580 

hydatid,  1380 

involution,  1380 

lacteal,  1580 
of  incisive  gland,  1044 
of  kidney,  1417 
of  liver,  11 71 

hydatid,  11 72 
of  lung,  hydatid,  A--ray  diagno- 
sis, 1612 
of  nipple  137  7 
of  sinus  pocularis,  congenital, 

treatment,  1460 
of  testicle,  1343 
of  vitello-intestinal  duct,  457 
oil,  457 
omental,  1087 
parasitic,  438,  1199 
retention,  456 
salivary,  437 
sebaceous,  436 
solitary,  409 
subhyoid,  1057 
thyroglossal,  1036 
thyrolingual,  1036 
urachal,  437 
vein,  470 
Cytodiagnosis    of   cerebrospinal 

fluid,  970 
Czerny-Lembert  suture,  121 7 
Czerny's     method     of     tendon- 
lengthening,  824 


DaCosta's  modification  .  of 

Senn's  nephropexy,  1443 

Dactylitis  in  hereditarv  svphilis, 
393 
tertiary,  380 

Dakin  on  dichloramin-T,  39 

Dakin-Carrel  treatment,  329. 
See  also  Carrel-Dakin  treat- 
ment. 

D  a  k  i  n-Carrel-Dehelly-DePage 
method  in  wounds,  37 
solution,  37 

Dakin's  solution,  formula  for, 
38 

Dalton's  formula  in  acute  gonor- 
rhea, 1498 

Daufresne's  solution,  formula, 
38  . 

Davaine's  treatment  of  anthrax, 
350  _ 

Davis'     transverse     incision     ir. 
appendicitis,  12  ir 
transverse   incision,    12 11 


i662 


Index 


Davy's  director,  781 

lever  to  control   hemorrhage, 

1569 
osteotomy  for  talipes  equinus, 

781    .  .         , 

Dawbam  s     operation     for     ap- 
pendicitis, 1 2 13 
rule  in  intracapsular  fractures 

of  femur,  670 
sign   in   subacromial    bursitis, 
819 
Dead  space,  66 
Deafness  in  syphilis,  376 

word-,  918 
Death  by  inhibition,  287 

thymic,  1390 
Debridement    in     gas    infection 

and  gas  gangrene,  187 
De  Cerenville's  pleural  epilepsy, 

1018,  1037 
D6collement  of  parietal  pleura, 

1040 
Decompression  for  heart  hyper- 
trophy, 525 
in  brain  tumors,  924,  937 
spinal,  972 

subtemporal,    in    basal    skull 
fractures,  889 
Decubital  gangrene,  176,  198 
Decubitus,  172,  198 
Defecation  spermatorrhea,  1524 
Defensive  protein,  45 
Deformity,      gardener's     spade, 
6s8 
gunstock,  64s 
Madelung's,  762 
silver-fork,  660 
Degeneration,       cardiovascular, 

gelatiniform,     m    tuberculous 
arthritis,  706 

of  muscles,  803 

pulpy,  of  synovial  membrane, 
275.  703,  70s 
De  Guise's  operation  for  salivary 

fistula,  1043 
De   Keating-Hart   treatment   in 

cancer,  449 
Delayed  union  in  fracture,  598, 

610 
Delbet's  operation  for  varix   of 
_  leg,  527 

sign  in   aneurysm,  488 
Delhi  boil.  149,  1368 
Delirious  shock,  288 
Delitescence     in     inflammation, 

97 
Delusions,  hypochondrial,  opera- 
tive treatment,  929 
Demarcation   line   in   gangrene, 

176,  i8r 
Demigauntlet  bandage,  1397 
De  Nancrede  on  cold  in  inflam- 
mation, 107,  108 

on  gangrene,  175,  176,  183 

on  projectiles,  308,  318 
Dental    nerve,    inferior,    neurec- 
tomy of,  856 
Dentigerous  cysts,  412,  413 
Deodorizers,  28 
Deipage's       modified      humerus 

splint,  638 
Depression  fracture,  588 
Derbyshire  neck,  1373 
Dermatitis,    blastomycetic,     20, 
359 

gangraenosa  infantum,  176 

of  nipple,  malignant,  1578 

venenata,  1367 
Dermatol,  3  5 
Dermoid  cysts,  453 

sequestration,  453    . 
traumatic,  454 
treatment,  455 

sublingual,  1056 

associated     with    sacrococcy- 
geal region,  1304 
De  Sanfort's  treatment  for  burns 

and  scalds,  362 
Desault's  bandage,  T402 

sign  in  intracapsular  fractures 
of  femur,  667 


Desmoid    tumors   of   abdominal 

wall,  406 
Diabetes  obstructing  repair,  126 

traumatic,  877 
Diabetic  coma,  191,  88r 
treatment,  193 
gangrene,  176,  191 

of  foot,  treatment,  193 
treatment,  194 
Diabetics,  operations  on,  78 
Diapedesis,  93 
Diaphoretics    in    inflammation, 

117 
Diaphragm,    chest    wounds    in- 
volving, I02S 
eventration  of,  1303 
rupture  of,  1022 
Diaphragmatic  hernia,  1302 
Diastasis  epiphyseal,  590 
Diathesis,  hemorrhagic,  520 
Diathetic  abscess,  153 
Dichloramin-T,  39 
in  leg  ulcer,  164 
wounds,  29s 
Dichlorethylsulphid  gas  in  war- 
fare, 339 
Dichlormethylether  gas  in  war- 
fare, 339 
Dichotomy  of  bacilli,  23 
Diet  in  inflammation,  120 

in  tuberculosis,  257 
Dietl's    crises    in    nephroptosis, 

1421 
Dieulafoy's     mucous     erosions, 
1095,  1096 
theory   of   etiology  of  appen- 
dicitis, 1138 
Diflfused  aneurysm,  474 

traumatic,  474 
Digestive  tract,  upper,   diseases 

and  injuries,  1040 
Digital  dilatation  of  pylorus  for 

cicatricial  stenosis,  1 219 
Digits,  supernumerary,  829 
Dilatation  in  urethral  stricture, 
gradual.  1513 
modified  rapid,  ISIS 
of  colon,  congenital  idiopathic, 

1156 
of  pylorus,  digital,  for  cicatri- 
cial stenosis,  1 2 19 
of  stomach,  acute.  1107 

Brandt's  operationfor,  1242 
chronic,  1106 
Dilator,  Gross's  urethral, _IS  14 
KoUmann's,  1507 
Oberlander's,  1507 
Dimple,  postanal,  942 
Dioxid  of  hydrogen,  33 
Dioxydiamidoarsenobenzol      di- 
hydrochlorid   in   syphilis,  391 
Diphenylchlorarsin   gas  in  war- 
fare, 339 
Diphosgen      gas      in      warfare, 

339 
Diphtheria,  traumatic,  188 
Diphtheritic    inflammation,    96, 

97 
Diplococcus,  22 

pneumoniae,  61 
Director,  Davy's,  781 

hernia,  1279 
Disarticulation,  IS50 

anterior  intertarsal,  1564 

at  ankle,  1565 

at  elbow,  1559 

at  hip,  1569 

at  knee,  1567 

at  metacarpophalangeal  joint, 

1557 
at  metatarsophalangeal  articu- 
lation, 1562 
at  shoulder,  1560 
at  wrist,  1558 
intertarsal,  posterior,  1564 
subastragaloid,  1564 
through    middle    tarsal    joint, 
1564 
Discission  of  pulmonary  pleura, 

1040 
Disease,  production  of,  by  micro- 
organisms, 43 


Disinfection,  29 

of  mucous  membranes,  78 
of  skin,  iodin  for,  77 
of  urethral  catheters,  1457 
Dislocations,  745 
congenital,  74s 
of  hip,  799 

Hoffa's  operation,  800 
Lorenz's    cutting    opera- 
tion for,  801 
method    of    reduction, 
799 
operation  for,  799 
reduction    by    means    o£ 
mechanical  appliances, 
801      . 
consecutive,  74s 
Monteggia's,  770 
N61aton's,  776 

occurring  with  fractures,  604 
of  femur,  internal,  628 
of  hip  in  typhoid  fever,  74s 
of  kidney,  1420 
of  long  head  of  biceps,  811 
of  muscles,  810 
of  semilunar  cartilages  of  knee. 
Barker's  operation  for,  799 
of  spine,  961 
of  tendons,  810 
of  ulnar  nerve  at  elbow,  850 
pathological,  74S 
spontaneous,  745 
traumatic,  74s,  746 
causes,  746 
compound,  748 
diagnosis,  747 
of  ankle,  775 

anteroposterior,  776 
lateral,  775 
upward,  776 
of  astragalus,  776 

forward  or  backward,  776 
lateral  and  rotary,  776 
of  carpal  bones,  763 
of  clavicle,  750 
of  coccyx,  766 
of  elbow,  759 

of  femur,  Allis'  sign  in,  767 
catching  up  sciatic  nerve 

during  reduction,  770 
central,  770 
downward  into  obturator 

foramen,  769 
internal,  770 
of  head  with  fracture  of 

shaft,  771 
on  dorsum  of  ilium,  767 
onto     border     of     sciatic 

notch,  768 
upon  pubis,  769 
of  fibula   at  superior  tibio- 
fibular articulation,   775 
of  hip,  anomalous,  770 
of  humerus,  752 
axillary,  754 
bloodless  reduction,  758 
Brunus'  reduction,  757 
Cock's  reduction,  757 
Cooper's  reduction,  757 
diagnosis,  755 
Erichsen's  signs,  754 
fracture  complicating,  758 
habitual,  758 

capsulorrhaphy  in,i  759 
Thomas'  operation,  759 
irreducible,  757 

McBurney's  treatment, 
758 
Kocher's  reduction,  755 
recurrent,  758 
reduction    by    extension, 

757 
laceration  of  axillary  ves- 
sels in,  758 
Smith's  reduction,  756 
subclavicular.  753 
subcoracoid,  753 
subglenoid.  754 
supracoracoid,  754 
symptoms,  754 
tearing  brachial  plexus  in, 
758 


Index 


1663 


Dislocations  of  humerus,  treat- 
ment, 755 
unreduced,  757 
of  knee,  771,  772 
backward,  773 
forward,  773 
inward,  773 
outward,  773 
of  mandible,  749 
of  metacarpal  bones,  764 
of  metacarpophalangeal  ar- 
ticulation, 764 
of  thumb,  764 
of  metatarsal  bones,  777 
of  patella,  772 
edgewise,  773 
inward,  773 
outward,  773 
of  pelvis,  76s 
of  phalanges,  777 
of  phalanx,  764 
of  radius,  761,  762 

and  ulna,  760 
of  ribs  and  costal  cartilages, 

765 
of  scapula,  751 
of    semilunar    cartilages    of 

knee,  773 
of  shoulder-joint,  Keetley's 
reduction,  756 
La     Mothe's     reduction, 
7S7 
of  sternum,  765 
of  tarsal  bones,  777 
of  ulna,  761,  762 
of  ulna  and  radius,  760 
of  wrist,  763 
old,  748 

pathological  conditions,  746 
subastragaloid,  777 
subspinous,  754 
symptoms,  746 
treatment,  747 
_a:-rays  in  diagnosis,  1610 
Displacement  in  plastic  sargery, 

140S 
Dissecting  aneurysm,  475 
Dissection- wounds,  341 
Distention     of     abdomen    after 

operation,  treatment,  11 27 
Diuretics  in  inflammation,  ii7 
Diver  goiter,  1373 
Diverticula,  intestinal,  II5S 
of  bladder,  1462 
of  esophagus,  1069 
Diverticular    herniae,     Rokitan- 

sky's,  1302 
Diverticulitis,  acute,  1155 
treatment,  1156 
chronic,  1156 

of  colon,  x-ray  diagnosis,  1617 
of  sigmoid,  1156 
Meckel's,  1114 
hernia  of,  130 1 
intestinal  obstruction  from. 

Diverticulum   of   esophagus,    x- 
ray  diagnosis,  1613 
pharyngeal,  455 

Divulsion     in     rectal     stricture, 
1326 
of    stricture  of   urethra,   1514 

Divulsor,  Gouley's,  1515 
Thompson's,  1515 

Dorsal  abscess,  tuberculous,  266 
treatment,  271 

Dorsalis  pedis  artery,  ligation  of, 
554 

Douche    in    inflammation,     1 1 1 
Scotch,  in  inflammation,  in 

Dowd     and     McBurney's    frac- 
ture-hook, 60s 

Downes'      method     of     electro- 
thermic  hemostasis,  512 

Doyen's  vasotribe,  502 

Drain,  cigarette,  87 
capillary,  87 

Drainage,  gauze,  87 
in  war  wounds  of  brain,  895 
of  cisterna  magna,  938 

Drainage-tubes,  87 
Senn's,  i486 


Drainage-tubes,        Stevenson's, 

i486 
Dressing  basins,  87 

first-aid,     for     war    wounds, 
327 
field,  in  war  wounds,  328 

Mayer's,    for    Thiersch    skin- 
grafts,  1408 

station,  advanced,  325 
field-ambulance,  325 
main,  325 

wounds,  294 
Dressings,  8s 

antiseptic,  66 

changing,  88 

dry,  67 

dry  antiseptic,  66 
aseptic,  66 

fixed,  1404 

impermeable  material  over,  87 

moist,  67 

protectives  for,  86 

silicate  of  sodium,  1404 
Dressman's  treatment   of  bone- 
cavities,  574 
Drift  gas  in  warfare,  338 
Drip,  Mc Arthur,  1266 
Drop    method    of    ether    anes- 
thesia, 1338 
Drop-finger,  830 
Dropsy,  703 
Drowning,  979 

treatment,  981 
Drummer's  paralysis,  8ro 
Drummond's     operation,      1258 
Drumstick  bacterium,  25 
Dry-heat    method   of   preparing 

catgut,  82 
Dubois's  abscess,  1390 
Dufaux's    prostatic        masseur, 

1522 
Dugas'    sign    in    dislocation    of 

shoulder-joint,  754 
Dumdum  bullet,  317 
Dunham's  treatment  in  fractures 

of  shaft  of  femur  in  children, 

682 
Dunn's    classification    of    pitui- 
tary gland  diseases,  921 
Duodenal  cap,  1614 
Duodenocholedochotomy,  1270 

for  gall-stones,  1192 

transdviodenal,  1270 
Duodenostorriy,  1244 

for  cancer,  1093 
Duodenum,  ulcer  of,  1128 

peptic,  1 128 
Dupuytren's  aneurysm  needles« 
540 

contraction,  828 

fracture,  658,  775 

method    of    disarticulation   at 
shoulder,  1561 

splint  in  Pott's  fracture,  697, 
698 

suture,  12 16 
Dura  mater,  hematoma  of,  900 
Duret's   operation   for   gastrop- 

tosis,  1243 
Dysenteric  ulcer  of  rectum,  1324 
Dyspepsia,  adhesion-,   1105 

appendiceal,  1149 


Ear,  affections  of,  syphilitic,  376 
disease,    brain    abscess    from, 

906 
suppurative,      brain      disease 

from,  905 
hemorrhage  from,  control,  517 
sign  in  erysipelas,  221 

Eberth's  bacillus,  63 

Eccentric  atrophy  of  bone,  564 

Ecchondroma,  409 

Ecchondroses,  409 

Ecchymosis,  284 

subconjunctival,  in  skull  frac- 
tures, 888 

Ecchymotic  mask,  1014 

]6olat,  303,  322 

Ecthyma,  gangrenous,  176 
syphilitic,  374 


Ectopia  of  testis,  1539 

vesicas,  1462 
Eczema      complicating       ulcer, 

treatment,  166 
Eczematous  urethritis,  1491 
Edebohls'  operation  for  chronic 
nephritis  1438 
for  movable  kidney,  1424 
Edema,  anthrax,  348,  349 
gangrenous,  acute,  184 
in  fractures,  604 
malignant,  341 

bacillus  of,  62 
of  glottis,  990 
of  larynx,  990 
Edematous  erysipelas,  220 

ulcer,  171 
Edison  fluoroscope,  1608 
Effusion,    pericardial,    operation 
for,  523 
pleuritic,  1014 
purulent,  163 
Ehrlich's    theory  of    immunity, 

46 
Elbow,   bandage   of,   figure-of-8, 
1401 
disarticulation  at,  1559 
dislocation  of,  traumatic,  759 

ulnar  nerve  at,  850 
excision  of,  788 
miners',  821 
tuberculosis  of,  718 
Elbow-joint  disease,  718 

fractures    in    or    near,     AUis' 
treatment,  648 
Bertomier's  treatment,  649 
false    ankylosis,    650 
false  ankylosis  after,  650 
in  young  children,  649 
Jones'  dressing,  649 
prognosis,  646 
treatment,  647 
true  ankylosis  after,  650 
Electric    currents,    artificial,    in- 
juries by,  1645 
therapeutic,      injuries      by, 

desiccation  in  cancer,  449 
Electricity,  injuries  by,  1643 

treatment,  1646 
Electrocoagulation,  1637 
advantages,  1639 
anesthetic  for,  1638 
combined    with    :x:-rays   cases 

suitable  for,  1639 
deep    x-ray    treatment    after, 

1640 
disadvantages,  1639 
in  cancer,  1637 
Pfahler's  technic,  1638 
Electrocution,  1647 

electrolytic   liberation    of   gas 
in,  1648 
Electrohemostasis      in      hemor- 
rhage, 512 
Electrolysis  in  aneurysm,  491 

in  cancer,  450 
Electrothermic     coagulation     in 

cancer,  449,  1637 
Elephantiasis,  1393 
Arabum,  1393 
pseudo-,  1393 
true,  1393 
Elevation    in    hemorrhage,    508 
Elsberg     and     Bailey's     spinal 
decompression,  972 
apparatus     for     intratracheal 
insufflation,  1034 
Embolic  abscess,  153,  218 
aneurysm,  47s 
gangrene,  176 
Embolism,  203,  207 
air-,  212 
symptoms,  213 

treatment,  213 

capillary,  475 

fat-,  210,  293 

symptoms,  211 

treatment,  212 

gangrene  from,  176 

treatment,  177 
of   mesenteric   arteries,    209 


1664 


Index 


Embolism  of  mesenteric  vessels, 
intestinal  obstruction  from, 
III" 
postoperative,  208 
pulmonary,  209 

occluding,  1027 
symptoms,  208 
treatment,  209 
Embolus,  207 
aseptic,  307 
bland,  207 
cancer,  444 
infective,  207 
occluding,  209 
septic,  257 
simple,  207 
toxic,  207 
Etnbryoma  of  testicles,  1543 
Emetics  in  inflammation,  118 
Emotional  fever,  142 
Emphysema,  cellular,  623 

gangrenous,  175,  184,  341 
Emphysematous  abscess,  153 

gangrene,  17s,  184,  341 
Empyema,  158,  1015 
acute,  1016 
chronic,  1017 
closed,  1016 
double,  1017 
excision  of  rib  in,  796 
in  army  camps,  1018 
localized,  10 16 
necessitatus,  1016 
of  antrum  of  Highmore,  156 
of  gall-bladder,  11 79,  1181 
acute,  1 182 
recurrent,  11 82 
of  mastoid,  905 
open,  1016 
partial,  1016 
pulsating,  1016 
total,  1016 
Emprosthotonos,  229 
Encephalitis,  899,  900 

chronic,  901 
Encephalocele,  870 
Encephalocystomeningocele,  871 
Encephaloid  cancer,  447 
Enchondroma,  409 
of  brain,  911 
of  breast,  1580 
Encysted  abscess,  153 
Endarteritis,  chronic,  472 

obliterative,  473 
End-bulbs,  134 
Endemic  boil  of  tropics,  149, 1368 

goiter,  1373 
Endo-aneurysmorrhaphy,    oblit- 
erative,     without     arterio- 
plasty,  484 
with    complete   arterioplasty, 

486 
with  partial  arterioplasty,  484 
Endocarditis,  gonorrheal,  treat- 
ment, 1510 
Endocardium,    tuberculosis    of, 

275 
Endospore,  25 
Endothelioma,  426 
of  brain,  910 
of  breast,  1582 
Endotoxins,  43 
Endotracheal  goiter,  1377 

insufflation  anesthesia,  1340 
End-to-end  arterial  anastomosis, 

SOS 
End-to-side  intestinal  anastomo- 
sis, 1247 
nerve  anastomosis,  853 
English  catheter,  1460 
Enlargements  of  spleen,  1203 
Enterectomy,  1245 
Enteritis,  rest  in,  105 
Enterocele,  1273 

partial,  1293,  1301 
Entero-epiplocele,  1274 
Enteroliths,    intestinal    obstruc- 
tion from,  1 1 14 
Enteroperitoneal    tuberculosis, 

1 134 
Enteroptosis,  1157 
Enterorrhaphy,  1216 


Enterorrhaphy,  circular,    resec- 
tion of  intestine  with,  1245 
Enterostenosis,    iiii.     See  also 

Intestinal  obstruction. 
Enterostomy,  1260 
Paul's  tube  for,  1261 
Stewart's  method,  1126 
Enucleation  in  goiter,  1376 
of  thyroid  gland,  intraglandu- 
lar,  1382 
Enzymes,  43 
Eosin-selenium  in  mouse  cancer, 

4.S0 
Epidemic  goiter,  1373 

parotitis,  1043 
Epidermization,  repair  by,  130 
Epididymectomy  for  tuberculo- 
sis of  testicle,  IS43 
Epididymis,    hydrocele    of,    en- 
cysted, IS48 
inflammation  of,  IS4S 
pain  in,  99 
Epididymitis,  154s 
compression  in,  no 
in  gonorrhea,  1494 
treatment,  1503 
Epigastric  hernia,  1299 
Epiglottis,    closure   of,    in   anes- 
thesia, treatment,  1345 
burns  and  scalds  of,  364 
Epilation  dose  of  .r-rays,  1604 
Epilepsy,  classification,  926 
essential  operative  treatment, 

926 
focal,     operative     treatment, 

926 
following     infantile     cerebral 
palsy,  operative  treatment, 
928 
idiopathic,     operative     treat- 
ment, 926 
with  local  onset,   operative 
treatment,  926 
Jacksonian,  915 

from    gross    brain    disease, 
operative  treatment,   928 
with  local   onset,   operative 
treatment,  926 
operative  treatment,  92s 
pleural,  1018,  1037 
posthemiplegic,  of  adults,  928 
reflex,     operative    treatment, 

926 
traumatic,  causes,  925 
operative  treatment,  927 
Epileptic      insanity,      operative 

treatment,  928 
Epiphyseal  separation,  590 
Epiphysis,  lower  radial,  separa- 
tion of,  662 
of  humerus,  lower,  separation 
of,  6so 
upper,  separation  of,  640 
Epiphysitis,  acute,  576 
Epiplocele,  1274 
Epiploic  abscess,  1088 
Epiploitis  following  hernia  opera- 
tion, 1290 
Epiplopexy,  1258 
Epispadias,  1518  1 
Epistaxis,  control,  si6 
Epithelial  cysts,   traumatic,   454 
odontoma,  412 
tumors,  innocent,  432 

malignant,    434.     See    also 
Cancer. 
Epithelioid  cells,  336 
Epithelioma,  171,  44s 
cylindrical-celled,  446 
exedens,  446 
of  nipple,  1577 
squamous-celled,  44s 
x-Ta.y  treatment,  1632 
Epulides,  fibrous,  406 
Epulis,  42s 

fibrous,  406 
Equinia,  354 
Erasion,  786,  787 

of  knee,  787 
Erb's  sign  in  tetany,  1388 
Erectile  tumors,  418 
Erethistic  shock,  288 


Erethistic  ulcer,  169 
Ergotism,  gangrene  from,  194 
Enchsen's     signs     in     shoulder- 
joint  dislocation,   754 
suture  for  angioma,  420 
Erratic  erysipelas,  220 
Erysipelas,  319 
ambulant,  220 
bullous,  220 
cellulocutaneous,  222 
cQmpression  in,  no 
cutaneous,  219,  220 

prevention  of  spread,  221 
ear  sign  in,  221 
edematous,  220 
effects  of,  on  sarcoma,  430 
erratic,  220 
erythematous,  220 
faucial,  220 
forms,  220 
law   of   centrifugal   maximum 

in,  220 
lymphatic,  220 
metastatic,  220 
migratory,  220 
mucous,  220 
neonatorum,  220 
phlegmonous,  220,  223 
puerperal,  220 
serum  in  sarcoma,  431 
simplex,  220 
streptococcus  of,  s8 
toxins  in  sarcoma,  430,  431 
treatment,  221 
typhoid,  220 
universal,  220 
venous,  220 
wandering,  220 
Erysipele  salutaire,  221 
Erysipeloid,  2ig 
Erythema   dose  of  a:-rays,    1604 

syphilitic,  373 
Erythematous  erysipelas,  220 
Erythromelalgia      in      presenile 

spontaneous  gangrene,   178. 
Escherich's  bacillus,  61 
Eserin  in  postoperative  obstruc- 
tion, 1 1 27 
Esmarch's  elastic  bandage,  15SO 

splint,  790,  792 
Esophageal  bougies,  1061 
forceps,  1072 
sounds,  1061 
bulbous,  1072 
Esophagismus,  1068 

abdominal,  1068 
Esophagoplication     for     cardio- 
spasm, 1069 
Esophagoscope,  1061 
introduction,  lOOS 
Esophagoscopy,  direct,  996 
for  foreign  bodies,  1013 
for  surgical  diagnosis,  10 12 
Jackson's    high-low     method. 
1007 
Esophagostomy,     cervical,     for 

stricture,  1067 
Esophagotomy,      external,      for 
foreign  bodies,  1072 
for  stricture,   1065 
Esophagus,  burns  of,  364 
cancer  of,  1067 
diverticula  of,  1069 

x-ray  diagnosis,  1613 
examination  of,  1060 
foreign  bodies  in,  1070 
injuries     and     diseases,     1040 
from  within,  1070 
from  without,  1070 
rupture  of,  spontaneous,  1070 
stenosis    of,    cicatricial,     1013 
stricture    of,    1062.     See   also 
Stricture  of  esophagus. 
Essential  hematuria,  1412 
Estlander's  method  of  thoraco- 
plasty, 1038 
Ether,  administration  of,  1337 
drop  method,  1338 
and     chloroform     anesthesia, 

1350 
and   oxygen   anesthesia,    1340 
anesthesia,  1334,  1342 


Index 


1665 


Ether      anesthesia,     chloroform 
followed  by,  1354 
followed      by      chloroform, 

I3S4 
intravenous,  1342 
nitrous    oxid    followed    by, 

I35S 
rectal,  1341 
Cotton  process,  1339 
inhaler,  Allis,  1338 

Clover's,  1338 
spray  anesthesia,  1357 
Ether-pneumonia,  1347 
Ethyl  bromid  anesthesia,  135 1 
chlorid  anesthesia,  1351 
spray  anesthesia,  1357 
Eucain   hydrochlorate    anesthe- 
sia, 1359 
Eupad,  36 
Europhen,  35 
Eusol.  36 

Evacuation  hospital,  325 
Evacuator,  Bigelow's,  1482 

Thompson's,  1482 
Eventration  of  diaphgram,  1303 
Ewald's    salol    test    for    motor 

power  of  stomach,  1107 
Excision,  786 

in  gunshot  wounds,  310 
of  ankle,  794 

Hancock's  method,  794 
of    astragalus,  795 

by  subperiosteal   plan,    795 
of  bones,  786 
of  cervical  rib,  797 
of  clavicle,  796 
of  elbow,  788 
of  half  of  lower  jaw,  798 
of  upper  jaw,  797 

by  median  incision,  797 
by     Weber's     incision, 
797 
of  head  of  radius,  789 
of  hemorrhoids,  1320 
of  hip,  792 

Barker's  method,  792 
by  anterior  incision.  792 
by  lateral  incision,  792 
Gross's  method,  793 
in  tuberculosis,  716 

Langenbeck's  method,  792 
of  joints,  786 
of  knee,  793 

Ashhurst's  method,  793 
by  anterior  semilunar  flap, 
793. 
of  lower  jaw,  partial,  799 
of  metacarpal  bones,  791 
of    metatarsophalangeal  artic- 
ulation _  of    great   toe,    795 
of  OS  calcis,  794 

subperiosteal  method,  795 
of  phalanges,  791 
of  pylorus,  1220 
of  rib,  796 
in  caries,  796 
in  empyema,  796 
of  scapula,  796 
of  shoulder,  787 

by  anterior  incision,  787 
by  deltoid  flap,  787 
Senn's  method,  788 
of  testicle,  1545 
of  wrist,  by  radial  incision,  790 
by  ulnar  incision,  790 
Lister's  method,  790 
Exclusion,  local  intestinal,   1257 
Excurvation  of  spine,  950 
Exfoliation,  571 

Exophthalmic  goiter,  1372,  1377 
antithyroidin  in,  1380 
exophthalmus  in,  1379 
Moebius's  sign  in,  1379 
.     operation  for,  1385 
Roger's  serum  in,  1380 
serum  treatment,  1380 
Stellwag's  sign  in,  1379 
tachycardia  in,  1379 
thyroidectin  in,  1380 
treatment,  1380 
v^on    Graefe's  sign  in,   1379 
.r-ray  treatment,  1636 
105 


Exophthalmos  in  brain-tumors, 

in  exophthalmic  goiter,  1370 

Exothymopexy,  1390 

Exothyropexy,  1376 

Exostosis,  41  r 

multiple,  41  r,  412 
subungual,  411 

Expectoration,  albuminous, 

I03S 

Experimental  tetany,  1387 

Exploration  of  urethra,  1504 

Exstrophy  of  bladder,  1462 

Extension,     Sayre's    double,     in 
knee-joint  disease,  718 
treatment  of  stumps,  1556 

Extensor  longus  pollicis  tendon, 
rupture  of,  810 
tendon,  rupture  of,  830 

Extirpation  in  goiter,    1376 
of    thyroid    gland,    extracap- 
sular, 1383 
intracapsular,  1384 

Extra-articular  ankylosis,  treat- 
ment, 743 

Extracapsular    fractures    of    fe- 
mur, 674 

Extracellular  toxins,  43 

of  tubercle     bacillus,  243 

Extracranial  operation  for  neu- 
ralgia of  fifth  nerve,  856 

Extradural  abscess,  906 
hemorrhage,  control,  514 
meningeal     hemorrhage,     884 

Extragenital  chancre,  368 

Extravasation,  284 

of  blood  in  fractures,  594 

Extremities,  local  tetanus  of,  228 

Exuberant      granulations,      130 
ulcer  of  leg,  168 

Exulceratio  simplex,   109s,   1096 

Eye,  affections  of,  syphilitic,  376 
bandage     of.     Borsch's,     1399 
crossed,  1399 
figure-of-eight,  1399 
foreign  bodies  in,  x-ray  locali- 
zation, 1628 
inflammation    of,   pain   in,  99 

rest  in.  lOS 
symptoms  in  hereditary  syphi- 
lis, 396 

Eyeball,  glioma  of,  424 

Pabricius'  operation  for  femoral 

hernia,  1288 
Face,  Hippocratic,  217 

injuries  and  diseases,  1040 
Facial  artery,  ligation  of,  553 

nerve,  section  of,  symptoms, 
848  i_ 

paralysis  extracerebral  opera- 
tion for,  862 
Facio-accessory  anastomosis,  862 
Faciohypoglossal      anastomosis, 

862 
Facultative  anaerobes,  26 

parasites,  21 

saprophytes,  21 
Fallopian    tubes,    inflammation 
of,  pain  in,  99 
tuberculosis  of,  278 
False  aneurysm,  474 
Farcy,  354 

acute,  35S 

chronic,  355 

diagnosis,  3SS 

treatment,  356 
Farcy-buds,  355 

Fascia,    plantar,    subcutaneous, 
fasciotomy  of,  824 

tuberculosis  of,  275 
Fasciotomy.     subcutaneous,     of 

plantar  fascia,  824 
Fat  hernia,  405,  1274 
Fat-embolism,  210,  293 

symptoms,  211 

treatment,  212 
Fat-necrosis  in  pancreatitis,  119S 
Faucial  erysipelas,  220 
Fauntleroy's  vein-to-vein  anas- 
tomosis for  blood  transfusion, 

531 


Fecal  abscess,  153 

accumulation,    intestinal    ob- 
struction from,  1 1 16 
fistula,   1 127 

impaction,  treatment,  1461 
incontinence    after    operation 
for  fistula,  treatment,    1314 
masses   mistaken  for  ureteral 

stone.  1457 
theory  of  tetanus,  226 
vorniting  in  strangulated  her- 
nia, 1293 
Fehleisen's  coccus,  58 
Fell-O'Dwyer  apparatus,  1021 
Felon,  158,  814 
bone,  815 
deep,  815 
elevation  in,  105 
painless,  815 
superficial,  815 
White's  treatment,  816 
Femoral  artery,  ligation  of,  557 
condyles,  amputation  through, 

1567 
hernia.     See   Hernia,  femoral. 
vein,    hemorrhage   from,   con- 
trol, 514 
Femur,   dislocation  of,   internal, 
628 
fractures    of,    666.     See    also 

Fractures  of  femur. 
head,  upper  epiphysis  of,  sepa- 
ration, 677 
incurvation  of  neck,  837 
infraction  cf  neck,  837 
neck    of,    ununited    fractures, 
783 
Freeman's     treatment, 
783 
osteoma  of,  409 
osteomyelitis  of,  chronic,  580 
osteotomy    through    neck    of, 
779 
Adams'  operation,  779, 

780 
with  osteotome,  779 
sarcoma  of,  427 
shaft  of,  osteotomy  below  tro- 
chanters, 780 
Gant's  operation,  780 
traumatic  dislocations  of,  766. 
See  also   Dislocations,   trau- 
matic, of  femur. 
Fenestrated  splint,  607 
Fergusson's  constipation  of  ap- 
pendix, 1 140 
operation  for  cleft-palate,  1052 
for  inguinal  hernia,  1284 
for  varix  of  leg,  527 
Fetal  rests  or  vestiges,  398 
Fetus,  parasitic,  453 

suppressed,  453 
Fever,  102,  293 
adynamic,  103 
aseptic,  127 

traumatic,  139 
asthenic,  103 
benign  traumatic,  139 
due  to    awakening    of  area  of 
pulmonary  tuberculosis,  141 
emotional,  142 
hectic,  141,  154 
hepatic,  141 
hysterical,  141 
inflammatory,  ro2 
intermittent  hepatic,  11 84 
leukocytosis,  103 
malarial,  142 
mercurial,  141 
neurotic,  141 
of  cocain-poisoning,  141 
of  iodoform  absorption,  141 
of  malignant  disease,  142 
of  morphinism,  141 
of  ptyalism,  141 
of  tension,  141 
postoperative  thermic,  143 
rheumatic,  726 
sthenic,  103 
suppurative,  140,  154 
surgical,  139 

essential  phenomena,  139 


i666 


Index 


Fever,  surgical,  scarlet,  142 
true,  140 

symptomatic,  102 

syphilitic,  143,  372 

thyroid,  143 

types,  in  inflammation,  102 

typhoid,  dislocation  of  hip  in, 
745    , 

urethral,  143,  ISIS 

urinary,  143,  151S 
Fibrinoplastic  peritonitis,  1165 
Fibrinous  pus,  14s 
Fibro-adenoma,  434 

of  breast,  1578 
Fibroblasts,  135 

in  inflammation,  94,  95 
Fibrocystadenoma      of      breast, 

IS79 
Fibrofatty  tumor,  403 
Fibroid  tumor,  recurrent,  426 

uterine,  415 

A;-ray  treatment,  1637 
Fibroma,  406 

cellular,  406 

hard,  406 

nasopharyngeal,  406 

of  brain,  910 

of  breast,  1578 

of  skin.  406 

soft,  406 

treatment,  408 
Fibromatosis  of  colon,  1156 

of  stomach,  1089,  1097 
Fibromyxoma  of  breast,  1578 
Fibrosarcoma,  425,  426 
Fibrosis,  arteriocapillary,  472 

prostatic,  1537 
Fibrospindle-cell  sarcoma,  425 
Fibrous  ankylosis,  739 

epulides,  406 

epulis,  406 

goiter,   1372 

odontoma,  413 

osteitis,  564 

tubercle,  237 
Fibula,  fractures  of,  696 
of  lower  third,  696 
of  upper  two-thirds,  696 

sarcoma  of,  429 

traumatic    dislocations    of,    at 
superior  tibiofibular  articu- 
lation, 775 
Field    ambulance    dressing    sta- 
tion, 32s 

dressing,  first,  in  war  wounds, 
328 

hospital,  32s 
Fifth  lumbar  vertebra,  variations 

in  lateral  process  of,  947 
Fifth   nerve,    neuralgia   of,    839. 

See    also     Neuralgia    of    fifth 

nerve. 
Figure-of-eight    bandage,     1397. 

See    also    Bandage,    figure-of- 
eight. 
Filamentous  fungi,  19 
Filarial  worms  as  cause  of  lym- 

phangiectasis,  1393 
Filterable  virus,  17 
Fingers,  amputation  of,  1557 

baseball-,  830 

drop-,  830 

jerk-,  829 

lock-,  829 

mallet-,  83a 

sarcorna  of,  spindle-celled,  423 

snapping-,  829 

supernumerary,  829 

trigger-,  829 

webbed,  829 
Finney's  method  of  gastroduo- 

denostomy,  1220 
Finsen  light,  1640 

in  tuberculosis,  260 
Fire  carry,  983 

St.  Anthony's,  219 
First-aid       dressing      for       war 

wounds,  327 
Fish-hook  in  esophagus,  1072 
Fish  stings,  343 

Fish-mouth    meatus,    in   gonor- 
rhea, 1493 


Fission  fungi,  24 
of  bacteria,  24 
Fissure,  intraparietal,  866 
of  anus,  13 IS 
of  Bichat,  864 
of  breast,  1574 

prevention,  1574 
of  Rolando,  864 
Fistula.  163,  174 
accidental.  1 127 
biliary,  after  cholecystostomy, 

1266 
branchial,  455 
complete,  455 
incomplete,  455 
cervical,     complete      median, 
1067 
incomplete  median,  1057 
congenital     lateral,    complete, 
455 
incomplete,  455 
fecal,  1 1 27 
in  ano,  1312 

fecal  incontinence  after  op- 
eration   for,     treatment, 
1314 
in        tuberculous        arthritis. 

Beck's  treatment,  708 
intentional,  1127 
of  bladder,  1463 
pancreatic,  1194 
perineal,  in  urethral  stricture, 

treatment,  1515 
pleural,  1016 
Fits,  habit,  928 
Flagella,  21 

Flail-joints  from  infantile  paral- 
ysis, 838 
Flap  method  of  neuroplasty,  853 
Plash  blindness,  1646 
Flat-foot.  833 

Gleich's  treatment,  83s 
Golding-Bird       and       Davy's 

treatment,  83s 
Goldthwait's     operation     for, 

833 
inflammatory,  833 
MuUer's    treatment,    83s 
Ogston's  treatment,  83s 
paralytic,  833 
Rugh's  treatment,   83s 
spurious,  833 
static,  833 

Stokes'  treatment,  835 
Trendelenburg's       treatment, 

835 
Whitman's  plate  for,  834 
Wilson's  treatment,  834 
Flesh,  proud.  130 
Flexion,  forced,   in  hemorrhage, 

509 
Floating  cartilages,  744 
hepatic  lobe,  11 78 
kidney,  1419 
■    liver,  1 177 

patella,  702 
Fluhrer's  aluminum  bullet  probe, 

309 
Fluorescence  of  x--rays,  1603 
Fluoroscope,  Edison,  1608 
examinations  with,  1608 
for   localizing   foreign   bodies, 

1625 
for  locating  bullet,  310,  1619- 

1628 
in  localizing  projectiles,  1621 
Focal  sepsis.  213 
Follicular  abscess,  153 
odontoma,  412 
compound.  413 
Folliculitis   in   gonorrhea,   treat- 
ment, 1502 
Fomentations.      antiseptic.      in 
inflammation.  112 
hot.  for  wounds.  301 
in  inflammation.  112 
Foot,  amputation  of,  1562 
bandage  of,  American.  1398 
covering  heel,  1398 
French,  1399 
not  covering  heel,  i399 
spiral,  covering  heel,  1399 


Foot,    club-,    831,         See    also 
Tali-pes. 
flat-,  833 

fractures  of  bones  of.  700 
gangrene    of,    diabetic,    treat- 
ment, 193 
golfer's,  836 
hollow,  835 
madura-,  20,  358 
trench,  340 
Foranien,    obturator,    traumatic 
dislocations  of  femur  down- 
ward  into,  769 
of  Winslow,  hernia  into,  1301 
Forbes's  lithotrite,  1481 

method  of  anterior-intertarsal 

disarticulation,  1564 
operation  for  hollow  foot,  83s 
Forceps,      bone-holding,      Lam- 
botte-Lowman's.  613 
Buerger's  rongeur,  1450 
bullet-,  309 

Halsted's  straight  artery,  500 
hemostatic,  curved.  500 

straight,  soo 
Hudson's,  932 

O'Hara's    for  intestinal  anas- 
tomosis, 1252 
Thompson's  vesical.  1485 
Ford's  suture,  298,  1217 
Forearm,    amputation    through, 
ISS9 
and  hands,  sterilization  of,  71. 
See  also  .Sterilization. 
Foreign      bodies,      appendicitis 
from.  1 139 
esophagoscopy  for,  1013 
in  abdomen,  1074 
in  air-passages,  990 
in  bladder,  1466 
in  bronchus,  991 
in  esophagus,  1070 
in  heart,  tolerance  to,  464 
in  intestines,  1088 
in  larynx,  991 
in  nose,  988 
in  pharynx,  992 
in  rectum,  1309 
in  stomach,  1088 
in  trachea,  991 

and      bronchi      broncho- 
scopic  removal,  1002 
in  urethra,  1489 
in  wounds,  removal,  294 
intestinal  obstruction  from, 

1 114 
localization    of.    Rontgeno- 
graphic  methods,  1627 
with  fluoroscope,  162s 
with     x-ray,      1619— 1628 
methods,  1624 
Formaldehyd,  36 
Formalin,  36 

injections     in     osteo-arthritis 

of  hip,  730 
method   of   preparing  catgut, 
82 
Formalin-gelatin,  36 
Formalin-glycerin    injections    in 
tuberculosis  of  hip,  7 IS 
in    tuberculous    arthritis, 
708 
in     ununited    fractures    of 
patella,  784 
treatment  in  synovitis,  703 
Formic  aldehyd,  36 
Fourth  of  July  tetanus,  224 

ventricle,  tumors  of,  919  • 

Fowler's      method      of     gastro- 
enterostomy, 1236 
method  of  pulmonary  decorti- 
cation, 1039 
operation  for  inguinal  hernia, 

1284 
position  in  peritonitis,  1163 
Fox's  apparatus  for  fractures  of 

clavicle,  631 
Fractura  acetabuli  perforans,  770 

perforata,  770 
Fracture  of  penis,  IS21 
Fracture-dislocations    of    spine, 
961 


Index 


1667 


Practure-dislocations    of     spine, 
paralysis  in,  962 

treatment,  964 

Watton's  method  of  reduc- 
tion. 96s 
Fracture-hook,  60s 
Fractures.  5S6 

ambulatory  treatment,  603 

Barton's,  658 

Bennett's,  664 

bent,  587 

blebs  in.  604 

by  contrecoup,  590 

capillary,  587 

chauffeur's,  658 

causes,  591 

Colics',  658 

Bond's  splint  in,  661 

Le\'is'  treatment,  660 

Maisonneuve's       symptom, 
660 

Moore's  treatment.  66 r 

Pilcher's  treatment,  661 

reversed.  658 

reversed   deformity  in,   660 

Robert's  splint  in,  661 

Storp's  treatment,  661 
comminuted,  589 
complete,  587 
complicated,  587 
conlplications,  596 

prevention   and  treatment, 
603 

composite,  589 
compound,  586,  597,  598 

bipp  treatment,  607 

Carre!- Dakin treatment,  606 

gunshot,  614 

indications  for  amputation, 
60s.  606 

primary,  587 

secondary,  587 

treatment.  60s 
compression  in.  no 
consequences.  596 
cradle  for,  670 
crepitus   in,   594 
cuneated,  589 
cuneiform,  589 
definition.  5S6 
deformity  in.  593 
delayed  union.  SPS 
treatment.  610 
dentate,  588 
depression,  588 
designation  according  to  seat, 

S9I 
diagnosis,  595 
direct,  590 
dislocations     occurring     with, 

604 
Dupu>-tren's,  6s8 
edema  in,  604 
en  rave,  s88 
en  V,  S89 
extracapsular,  591 
extravasation  of  blood,  S94 
faulty  union,  599 
fibrous  union.  600 
fissured,  587 

from  external  violence,  591 
from  hereditary  fragility,  S92 
from   muscular   action,    sgi 
from    violence,    direct,    sgi 

indirect,  591 
green-stick,  587 
gunshot,  614 
•    hair,  5S7 
Halsted's   plates    in,    609 
helicoid,  590 
hickory-stick.  587 
immovable  dressing  in,  602 
impacted.  589 
in  atrophy  of  bones,  592 
in   nervous   diseases,    592 
in  osteomalacia,  592 
in  rickets,  S92 
incomplete,  587 
indications     for     amputation 

in.  605,  606 
indirect,  590 
inflammation  in,  603 


Fractures,  intra-articular,  S9i 
intracapsular,  591 
intra-uterine.  590 
Lane's  plates  in.  609 
ligamentous  union,  600 
linear,  s87 
longitudinal,  588 
loss  of   function  in,   593 
massage  in,  602 
membranous  union,  600 
multiple,  589 
muscular  spasm  in.  60s 
non-operative  treatment, 
functional  result,   605 
non-union  in,  600 
obli:^ue.  588 

spiroide.  589 
of  acromion  process.  633 
of  bones  of  foot,  700 
of  both  bones  of  leg.  699 

compound.  700 
of  brim  of  acetabulum.  669 
of  carpal  scaphoid,  663 
of  carpus,  662 
of  clavicle,  630 

Fox's  apparatus,  631 
Moore's  dressing,  631 
of  acromial  end,  632 
of  shaft,  630 
of  sternal  end,  632 
Sayre's  dressing,  631 
Velpeau's  bandage  for,  631 
of  coccyx,  629 
of  coracoid  process,  633 
of    costal    cartilages,    625 

Malgaigne's      treatment, 
62s 
of  false  peh-is,  626 
of  femur,  666 

Blake's  splint  in,  682 
extracapsular,  674 
impacted,  67S 
Southam's  treatment,  675 
Hodgen's  splint  for,  681 
intracapsular,  666 
Allis'  sign  in,  667 
Balkan  splint  in,  672 
Buck's  apparatus  in,  670 
cause,  666 
Desault's  sign,  667 
diagnosis.  668 
examination  of  hip  in.  666 
Jones'     abduction    frame 

in,  672,  674 
Lagoria's   sign  in,    668 
prognosis,  669 
symptoms,  667 
"Thomas'  splint  in,  671 
treatment.  669 
Whitman's  treatment, 
673 
just  above  condyles,  684 
longitudinal,  686 
Mclntyre's  splint  in,  682 
near  knee-joint,  682 
of  base  of  neck,  674 
of  lower  part  of  lower  third, 

682 
of  middle  third.  681 
of  neck,  Albee  bone-graft  in, 
677 
in  children.  67s 
operative  treatment,   676 
of  shaft.  678 
in  children,  682 

Bryant's   extension, 

682 
Dunham's     treatment. 

682 
Jones'  abduction  frame 

in,  683 
Van     Arsdale's     splint 

in,  683 
Ware's   splint   in,    684, 

68S 
Wyeth's     dressing     in, 
683 
of  upper  extremity,  666 
part  of  lower  third,  681 
third,  680 
Agnew's  treatment,  680 
Smith's   splint   in,    680 


Fractures  of  femur,  separating 
either   condyle,  686 
separation  of  lower  epiphy- 
sis. 687 
of  upper  epiphysis,  677 
ununited.  599 
of  fibula.  696 

of  lower  third,  696 
of  upper  two-thirds,  696 
of  fundus  of  acetabulum,  669 
of  glenoid  cavity,  633 
of  great  trochanter,  677 
of  humerus,  633 

at  base  of  condyles,  64s 
at  external  condyle,  644 
at  head,  639 
at  inner  epicondyle,  644 
at  internal  condyle,  64s 
at  lower  extremity,  644 
at  middle,  641 
at  shaft,  640 

injury,    of    musculospiral 
nerve  in,  559 
complicating        dislocation, 

758 
in  or  near  elbow-joint.  564. 
See  also  Elbow-joint,  frac- 
tures  in   or    near. 
of  anatomical  neck.  634 
of  surgical  neck.  636 
of  upper  extremity,  634.  63s 
T-,  64s 
ununited,  598 
of  hyoid  bone,  622 
of  inferior  maxillary  bone.  620 
of  inner  malleolus,  69s 
of  lachrymal  bone,  617 
of  laryngeal  cartilages,  622 
of  leg,  694 
of  malar  bone,  619 
of  mandible,  620 
of  metacarpal  bones,  664 
of  metatarsal  bones,  701 
of  nasal  bones.  61  s 

Asch's  tube  in.  616 
Mason's  pin  in.  616 
of  patella,  687 

by  direct  force.  693 
comminuted,  693 
compound,  607,  693 
transverse,  687 

Agnew's  splint  in,   689 
and  badly  united,   694 
Barker's   method   of  wir- 
ing, 690 
open  operation  in,  692 
treatment,  689 
ununited,  wiring  in,  690 
of  pelvis,  626 
of  penis,  1321 
of  phalanges,  66s 

of  toes,  702 
of  radius,  6s4 

and  ulna  near  wrist,  662 
of  both  forearms,  6S7 
of  head,  6s4 
of  lower  extremity,  658 
of  neck,  65s 

of  shaft  above  insertion   of 
pronator  radii  teres,  656 
below    insertion    of    pro- 
nator radii  teres,  636 
of  ribs,  623 
of  sacrum.  629 
of  scapula,  633 
of  body,  633 
of  neck,  633 
of  spine,  633 
of  sesamoid  bones  of  thumb, 

66s 
of  skull,  630,  88s 
by  contrecoup,  88s 
Macewen's  sign  in,  88 7 
of  base.  887 

Battle's  sign  in,  889 
of  vault,  886 
trephining  for,  887,  930 
x-ray  diagnosis,  16 11 
of  spine,  961 
of  sternum,  62s 
of    superior    maxillary    bone, 
617 


1 668 


index 


Fractures  of  tibia,  694 

comminuted,  694 

compound  comminuted,  586 

oblique,  694 

of  lower  end,  695 

of  shaft,  69s 

of  upper  end,  694 

separation  of  lower  epiphy- 
sis, 696 
of  tubercle,  694 
of    upper    epiphysis,    69s 

transverse,  694 
of  true  pelvis,  627 
of  ulna,  650 

and   radius   near  wrist,   662 

of  coronoid   process,   650 

of  olecranon  fossa,  650 
process.    Murphy's  treat- 
ment, 652 
Pick's  treatment,  652 

of  shaft,  653 

of  styloid  process,  654 
of  vertebrae,  630 
of  zygomatic  arch,  619 
par  irradiation,  590 
pathological,  590 
periosteal  bridge,  596 
Pott's,  697 

Dupuytren's  splint  in,  697. 
698 

Heath    and    Selby's    treat- 
ment, 699 

Stimson's  splint  in,  698 
predisposing  causes,  591 
preternatural  mobility  in,  594 
radish-,  588 

recent,    operative    treatment, 
608 

simple,    operation    for,    781 
repair,  596 
rest  in,  105 
rupture  of  main  artery  in,  604 

of  main  vein  in,  605 
secondary,  590 
simple,  586 

repair  of,  596 
special,  615 
spiral,  590 
splinter-,  588 
spontaneous,  590 
sprain-,  588,  735.  746 
starred,  590 
Steinmann's  nail  extension  in, 

601 
stellate,  S90 

stereoscopic    plates    in    diag- 
nosis, 1610 
strain-,  588,  735 
suspension       and       extension 

frame  for,  613 
symptoms,  592 
toothed,  s88 
torsion,  590 
treatment,  600 
T-shaped,  589 
transverse,  588 
ununited,  590 

Albee's   operation,    782 

bone-grafting  in,  782 

Gussenbauer's  clamp  in,  613 

Lannelongue  and   M6nard's 
treatment,  61  r 

of  neck  of  femur,  783 

Freeman's     treatment, 
783 

of  patella,   operative  treat- 
ment, 784 

operative  treatment,  782 

treatment,  610 
varieties,  586 

of  displacement  in,  593 
versus  wound  of  bone  (Blake), 

S86 
vicious  union,  599 

osteotomy  for,  780 
treatment,  614 
V-shaped,  589 
wedge-shaped,  589 
willow,  587 
with  crushing  or  penetration, 

590 
x-ray  diagnosis,  596,  1609 


Fragilitas  ossium,  592 

idiopathic,  564 
FrambiEsia  tropica,  359 
Frame  for  suspension  and  exten- 
sion in  fractures,  613 
Jones'  abduction,  in  fractures 
of    shaft    of    femur    in 
children,  683 
in  intracapsular  fractures 
of  femur,  672,  674 
Frankel's  bacillus,  61 
Frank's    coupler    for    intestinal 
anastomosis,  1249 
method     of     examination     in 
movable  kidney,  1422 
Frazier's   treatment   of  avulsion 

of  brachial  plexus,  842 
Frazier-Spiller  m'ethod  of  intra- 
cranial neurotomy,  861 
Freeman's  clamp,  783,  784 

operation    for   ununited   frac- 
tures of  femoral  neck,  783 
Freezing  for  anesthesia,  1357 

treatment,  365 
Freezing-point   of   blood,    deter- 
mination, 141 7 
of  urine,   determination,    1417 
Fremitus,  hydatid,  458 
French  catheter,  1459 
Freudenberg's      galvanocautery 
for     prostatotomy.      Young's 
modification,  1534 
Freyer's   method   of   suprapubic 

prostatectomy,  1S31 
Friedrich's     operation     in    pul- 
monary tuberculosis,  1032 
Frohlich's  syndrome,  920 
Frontal  areas,  tumors  of,  917 
sinus,  distention  and  abscess, 
989 
trephining  of,  933 
Frost-bite,    gangrene   from,    195 
treatment,  196 
treatment.  196 
Fulguration  in  cancer,  449 
Fuller's    method    of   suprapubic 

prostatectomy,  1533 
Fulminating     appendicitis,  1 140 

gangrene,  184 
Fungi,  budding,  19' 
filamentous,  19 
fission,  24 
Fungous  ulcer  of  leg,  168 
Fungus  cerebri,  898,  899 
hsematodes,  423 
of  testicle,  278 
ray-,  20,  356 
Funicular  hydrocele,  1548 

process,  hernia  into,  1298 
Fiirbringer's  method  of  sterilizing 

hands  and  forearms,  72 
Furuncle,    148.     See     also    Boil. 
Furunculosis,  148 
Fusiform  aneurysm,  474 

Galactocele, 4S7,  1580 
Galeazzi's     treatment      of    coxa 

valga,  838 
Gallant's     corset     in      movable 

kidney,  1422 
Gall-bladder,  cancer  of,  1192 
catarrh  of,  suppurative,   ii8r 
catarrhal      inflammation      of, 

1180 
congenital  absence,  1262 
diseases  and  injuries,  1 170 
empyema  of,  11 79,  ii8r 

acute,  1 1 82 

recurrent,  1182 
healthy,  capacity,  1262 
incisions     for     operation     on, 

1262 
inflammation    of,     11 78.     See 

also  Choice jslitis. 
mucous  membrane  of,removal, 

1268 
rupture  of,  1082 
tenderness.  Murphy's  method 

of  palpating  for,  11 87 
Gall-stones,  1185 
ball- valve,  1189 
colic  in,  1 187 


Gall-stones,  Courvoisier'slaw  ia 
1 190 
Hamel's  test  for  jaundice  in, 

1189 
intestinal     obstruction     from, 

H14 
operations  for,  1 1 9 1 
prodromal  state  in,  1187 
Rothschild's  diet  in,  1 190 
symptoms,  1187 
treatment,  1190 
a:-ray   diagnosis,    1017 
Gait's  conical  trephine,  931 
Gamma-rays,  1640 
Ganglion,  814 

compound,  812 
Ganglioneuroma,  416 
Gangrene,  17s 
acute,  183 

amputation  in,  rules  for,  203 
anemic,  176 
carbolic  acid,  200 
causes,  17s 
chronic,  180 
classification,  175 
cold,  176 
congenital,  I7S 
constitutional,  175 
cutaneous,  I75 
decubital,  176,  198 
De  Nancrede's  anemic,  176 

definition,  176 

two  forms,  183 

views  on,  175 
diabetic,  176,  191 

of  foot,  treatment,  193 

treatment,  194 
dry,  17s,  176 
embolic,  176 

treatment,  177 
emphysematous,  175,  184 
foudroyante,  184 
from  ergotism,  194 
from  frost-bite,  19S 

treatment,  196 
fulminating,  184 
gas,  62,  184 

Carrel-Dakin  treatment, 
188 

debridement  in,  187 

in  war  wounds,  185 

treatment,  187 
gaseous,  17s 
glycemic,  176 
hospital,  17s 

treatment,  188 
hot,  176 
idiopathic,  176 

symmetrical,  176 
line   of   demarcation   in,    176, 

181 
microbic,  175 
mixed,  176 
moist,  17s,  183 

from  inflammation,  184 

of  limb,  183 

treatment,  184 
multiple,  176 

cachectic,  176 
of    leg,    arteriovenous  anasto- 
mosis   for   prevention   or 
treatment,  202 

puerperal,  202 
of  lung,  1029 

pneumotomy  for,  1040 

.r-ray  diagnoiis,  16 12 
of  penis,  1521 
postfebrile,  201 
Pott's,  180 
presenile  spontaneous,  177 

treatment,  179 
pressure,  176 
primary,  176 
Raynaud's,  176,  190 

treatment,  190 
reversal  of  circulation  in,    179 
secondary,  176 
senile,  180 

Moschcowitz's  method  of  de- 
termining viable  area  in, 
182 

prevention,  181 


Index 


1669 


Gangrene,  senile,  symptoms,  180 
treatment,  182 
special  forms,  188 
static,  176 
symmetrical,  188 
thrombotic,  176 
treatment,  177 
traumatic,  spreading,  184 
trophic,  176 
venous,  176 
Gangrenous    appendicitis,     1141 
cellulitis,  223 
ecthyma,  176 
edema,  acute,  184 
emphysema,  184,  341 
inflammation,  97 
masses,  198 
stomatitis,  196 
Gant's    osteotomy    of    shaft    of 
femur  below  trochanters,   780 
Garceau  catheter,   1449  . 
Gardener's  spade  deformity,  658 
Garel's  sign  in  abscess  of  antrum 

of  Highmore,  I57 
Gas,  338 

acetone,  339 

and  ether  anesthesia,  13SS 

arsin,  339 

artillery  shell,  338 

asphyxiating,  338 

benzin  bromid,  339 

carbon  monoxid,  339 

carbonyl  chlorid,  338 

chlorin,  338 

cloud,  338 

cylinder,  338 

dichlorethylsulphid,  339 

dichlormethylether,  339 

diphenylchlorarsin,  339 

diphosgen,  339 

drift.  338  ,     . 

electrolytic    liberation    of,    in 

electrocution,  1648 
gangrene,  62,  184 

Carrel-Dakin  treatment 

188 
debridement  in,  187 
in  war  wounds,  185 
treatment,  187 
hand  grenade,  339 
infection,  184 

debridement  in,  524 
lacrimator,  339 
mortar,  339 
mustard,  339 
oxychlorcarbon,  339 
phosgen,  338 
Gas  poisoning,  coal-,  985 
illuminating,  985 
treatment,  987 
poisonous,  338 
prevention,  339 
sneezing,  339 
sternutators,  339 
suflocating,  339 
tear,  339 
treatment,  339 
tube  for  :r-rays,  1601 
▼esicating,  339 
xylene,  339 
Gaseous  gangrene,  17S 

phlegmon,  184 
Gases,   shell,  in  warfare,  effects 

of,  treatment,  328 
Gasoline,  commercial,  37 
Gasserian     ganglion,     removal, 
858 
Cushing's  method,  861 
Hartley's  method,   859 
Horsley's  method,   861 
Gastrectomy,  complete,  for  can- 
cer, 1093 
partial,  for  cancer,  1093 
subtotal,  for  cancer,  1093 
total,  1224 
Gastro-anastomosis,  1242 
Gastroduodenostomy     by     Fin- 
ney's method,  1220 
Jaboulay's,  123S 
Gastro-enterostomy,  1227 

anterior,     Kocher's     method, 
1233 


Gastro-enterostomy,     Mayo's 
method,  1233 
Senn's  method,  1232 
Billroth's  method,  1230 
by  Murphy  button,  1236 
closing  pylorus  after,  1232 
complications  following,   1228 
for  cancer,  1093 
Fowler's  method,  1236 
Jaboulay's  method,  1231 
Lucke's  method,  1230 
Mayo's  method,  1240 
McGraw's  method,  1234 
peptic  ulcer  of  jejunum  after, 

1228 
posterior,  123S 
treatment  after,  1228 
vicious    circle    and   regurgita- 
tion after,  1229 
vomiting  after,  1229 

treatment,   1232 
von  Hacker's  method,   1231 
Wolfler-Lucke    method,    1230 
Walfler's  method,  1231 
Gastro-gastrostomy,  1242 
Gastrojejunostomy,  1227 
Gastropexy,  1243 
Gastroplication,  1242 
Bircher's  method,  1242 
Brandt's  method,  1242 
Gastroptosis,  1109 

Beyea's  operation  for,  1243 
Buret's  operation  for,  1243 
Ransohoff's    omentopexy    for, 
1243 
Gastroscopy,  direct,  996 

for  surgical  diagnosis,  1012 
Gastrostomy,  122S 
for  cancer,  I093 
for  esophageal  stenosis,  1067 
Kader's  method,  1226 
Senn's  method,  1227 
SsalDanajew-Frank       method, 

1226 
Witzel's  method,  1225 
Gastrotomy,  1224 
Gauntlet  bandage,  i397 
Gauze,  antiseptic, preparation,  85 
aseptic,  preparation,  86 
bandages,  88 
drainage,  87 

iodoform,  preparation,  86 
Lister's  cyanide,  preparation, 

86 
pads.  Ash  ton's,  87 
sterilized,  preparation,  86 
Gebauer's    ethyl    chlorid    tube, 

^357   .    , 
Gelatin  in  hemorrhage,  510 

injection,     tetanus    following, 

225 
treatment  in  aneurysm,  479 
Gelatiniform      degeneration     in 

tuberculous  arthritis,  706 
Gelatinous  polypi,  414 
Gelsemium  in  inflammation,  116 
Genito-urinary  diseases,  pain  in, 

1414 
operations    m    insanity,     930 
organs,   diseases  and  injuries, 
1410 
Genu  valgum,  830 

Ogston's  operation  for,  779 
osteotomy  for,  778 
varum,  830 
Germicide,  28,  29 
Gersuny's    technic    for    paraffin 
prosthesis  in  saddle-nose,  1408 
Giant-cell,  236 
sarcoma,  425 
Gibbon's     method     of     uretero- 
lithotomy, 1446 
Gibney's    method    of    strapping 

sprains  of  ankle,  737 
Gibson's  bandage,  1400 

incision     for     operations    on 

lower  ureter,  1444.  I44S 
operation      for      impermeable 

urethral  stricture,  1517 
valvular  cecostomy,  1260 
Gigli  saw  in  excision  of  head  of 
radius,  789 


Gig)i  saw  in  osteoplastic  resec- 
tion of  skull,  933 
Gila  monster,  bites  of,  347 
Gillette's  treatment  in  shoulder- 
joint  disease,  718 
Girdle  pain  of  tetanus,  230 
Girdner's       telephonic       bullet- 
probe,  309 
Glanders,  354 
acute,  3SS 
bacillus  of,  60 
chronic,  355 
diagnosis,  35s 
treatment,  356 
Glandular  cancer,  447 
Glass  arm,  808 
Gleet,  1495 
Gleich's   treatment  of    flat-foot, 

83s 
G16nard's  disease,  ii57 

sign,  II 78 
Glenoid  cavity,  fractures  of,  633 
Glioma,  417 
of  brain,  910 
of  eyeball,  424 
Gliosarcoma,  426 
Glottis,  burns  and  scalds  of,  364 

edema  of,  990 
Gloves,    preparation,   for  opera- 
tion, 74 
use  of,  73 
Gluck's      method     of     arterior- 

rhaphy,  506 
Gluteal  artery,  ligation  of,  561 
bursitis,  817 
hernia,  1301 

nerve,     superior,     section     of, 
symptoms,  847 
Glutol,  36 

Glycemic    gangrene,    176 
Goelet's  method  of  examination 
in  movable  kidney,  1422 
operation  for  movable  kidney, 
1424 
Goiter,  137 1 

acute,  1370,  1373 
adenomatous,  1372 
Basedowified,  I3'72 
causes,  1373 
colloid,  1372 
cystic,  1372 

differential  diagnosis,  137S 
diver,  1373 
endemic,  1373 
endotracheal,  1377 
enucleation  in,  1376 
epidemic,  1373 

exophthalmic,       1372,       i377. 
See  also  Exophthalmic  goiter. 
exothyropexy  in,  1376 
extirpation  in,  1376 
fibrous,  1372 
hemorrhagic,  1372 
inflammatory,  1370 
intrathoracic,  i373,  137  7 
lobectomy  in,  i377 
malignant,  1372 
non-malignant,  metastasis  of, 

^375  ^  .  - 

operations,    dangers    m,    1384 
parenchymatous,  1372 
pulsating,  i377 
retro-esophageal,  1373 
retrosternal,  1373 
retrotracheal,  1373 
signs  and  symptoms,  i374 
simple,  x-ray  treatment,   1637 
sporadic,  13  73 
substernal,  1373 
suffocating,  1373 
thyroidectomy  in,  1376 
toxic,  1372 
treatment,  1376 
wandering,  i373 

Golding-Bird  and  Davy  s  treat- 
ment of  flat-foot,  835 

Goldthwait's  operation  for  flat- 
foot,  833 

Golfer's  foot,  836 

Gonococcemia,  1493 

Gonococci,    examination  for,   m 
gonorrhea,  1494 


1670 


Index 


Gonococcus,  58 
Gonorrhea,  1492 
abortive,  1495 

treatment,  1497 
acute     inflammatory,      treat- 
ment, 1493 
treatment,  149s,  I499 
black,  1492 
catarrhal,  149S 

•treatment,  1499 
chronic,  149S 
treatment,  1503 
urethritis     following,    treat- 
ment, 1503 
complications,  treatment,  1502 
diet  list  in,  1496 
epididymitis  in,  1494 
examination  for  gonococci  in, 

1494 

in  children,  1509 

in  female,  1508 

instructions   to   patient,    1496 

irrigation  in,  1497 

irritative,  149s 
treatment,  1499 

of  anus  and  rectum,  1508 

of  mouth,  1508 

of  nose,  1508 

of  uterus,  treatment,  1509 

relapse  in,  treatment,  1501 

subacute,  149S 

when  cured,  1503 
Gonorrheal  ankylosis,  725 

arthritis,  723 

treatment,  724,  1510 

endocarditis,  treatment,  1510 

ophthalmia,      1346 
treatment,  1503 

orchitis,  1541 

peritonitis,  1493 

rheumatism,  723 

vaginitis,  treatment,  1509 
Gordon's  paradoxical  reflex,  944 
Gosselin's  fracture  en  V,  589 
Gould  and  Harrington's  method 

of  intestinal  anastomosis,  1249 
Gouley's  bougies,  1460 

divulsor,  15 15 
Gout,  chronic,  727 

rheumatic,  727 
partial,  729 

of  hip,  729 
progressive,  728 
Gouty  arthritis,  727 

urethritis,  1491 
Goyanes'     operation     for    aneu- 
rysm, 488 
Graft,   bone-,  574,  613,  677.  782, 
799,  954.  968 

omental,  1218 

skin-,  1405-7 
Grafting,  nerve-,  489,  853 

tendon-,  825 
Graham's    treatment    of    meta- 

tarsalgia,  837 
Granny  knot,  soi 
Grant's  operation  for  cancer  of 

lip,  1054 
Granulation,  edematous,  131 

exuberant,  130 

pale,  130 

repair  by,  128 

tissue,  153 

of  inflammation,  95 
Granuloma  fungoides,  427 
Gravel,  kidney,  1427 
Graves's  disease,  1377 
Gray  oil  in  syphilis,  388 
Gray's   solid    salt   treatment    of 

war  wounds,  337 
Grenades,  wounds  from,  324 
Green-stick  fracture,  587 
Gritti's    supracondyloid    ampu- 
tation, 1568 
Groin,  abscess  of,  158 

bandage  of,  spica,  1401 
Gross'    bristle    probang,    1072 

method  of  excision  of  hip,  793 

overflow  of  retention  of  urine, 
1466 

urethrotome,  1513 
Growths,  morbid,  397 


Growths,  new,  397 

Grynfelt  and  Lesshaft's  superior 

lumbar  triangle,  1301 
Guaiac  test  for  hematuria,  1410 
Guelliot's      tubulization      after 

nerve-suture,  853 
Guillotine  amputation,  1550.  See 

also  Preface. 
Guiteras'   method  of  diagnosing 

urethral  stricture,  1512 
Gum-boil,  157,  1041 
Gumma,  378 

bone,  x-vsly  diagnosis,   161 1 
tuberculous,  272 

of  brain,  909 
ulcer  of,  378 
Gummatous  actinomycosis,  357 
Gummy  pus,  146 
Gun,  machine,  wounds  from,  322 
Gunpowder,     black,     compared 
with    smokeless    powder,    313 
Gunshot  fractures,  614 

Carrel-  Dakin  treatment,  615 
compound,  614 
wounds,  303 

amputation  in,  310 

comminution  of  bone  in,  304 

contour.  307,  1024 

De  Nancrede  on,  308,  318 

entrance  wound,  303,  306 

excision  in,  310 

exit  wound,  304,  306 

explosive  effect  in,  304 

from  revolver,  305 

from  shotgun,  305 

from  sporting  rifle,  305 

hemorrhage    from,    control, 

.    S16      .       . 

in  civil  life,  304 

of  abdomen,  1084 

of  arteries,  497 

of  peripheral  nerves,  850 

of  pregnant  uterus,  1086 

of  skull,  penetrating,  891 

perforating,  891 
penetrating,  306 
perforating,  306 
tattooing  in,  307 
tissue  track,  306 
Wadsworth  on,  306,  307 
Gunstock   deformity,  645    (Fig. 

361) 
Gussenbauer's     clamp     in     un- 
united fractures,  613 
operation  for  esophageal  stric- 
ture, 1065 
suture,   1218 
Gut,  postanal,  943 
Guthrie's  rule  in  hemostasis,  512 
Gwathmey's  method  of  oil-ether 

rectal  anesthesia,  1342 
Gwathmey-Woolsey  nitrous-oxid 

oxygen  apparatus,  I3S4 
Gynecological  operations  in  in- 
sanity, 930 

Habit  fits,  928 

Hagedorn's  needles,  502 

Hair,    affections    of,    syphilitic, 

375 
Hair-ball,  1088 
Hallion    and     Tuffier's    test    in 

aneurysm,  489 
Hall's    method   of  artificial   res- 
piration, 976 
Hallus  valgus,  83s 

osteotomy  for,  780 
Wilson's  treatment,  83s 
varus.  835 
Halsted's  band  in  anuerysm,  489 
roller  for,  490 
hammer,  1269 
mattress  suture,  1217 
method  of  arteriorrhaphy,  S06 
of    intestinal     anastomosis, 

1254 
operation   for   aneurysm,    488 
for  cancer  of  breast,  1589 
for    inguinal    hernia,     1282 
plus  Bloodgood's 

method      of      trans- 
planting rectus,  1282 


Halsted's  packs,  87 
straight  artery  forceps,  500 
subcuticular  suture,  299 
suture,  66 
Hamel's  test  for  jaundice  in  gall- 
stones,  1189 
Hamilton's  bandage,  620 

bone-drills,  782 
Hammer,  Halsted's,  1269 
Hammer-toe,  836 

Terrier's  treatment,  836 
Hancock's  method  of  excision  of 

ankle-joint,  794 
Hand  amputation  of,  1557 
claw-.     846 
club-.  831 

grenade  gas  in  warfare,  339 
Handkerchief  bandage,  1403 
Hands    and  forearms,   steriliza- 
tion  of,    71.     See  also  Sterili- 
zation. 
Hanging,  981 
Harelip.  1045 

double,  Owen's  operation  for, 

1047 
Malgaigne's      operation      for, 

1046 
operation  for,  1046 
single,  Mirault's  operation  for, 
1047 
operation  for,  1046 
suture,  299 
Harpoon     with     cannula     and 
trocar     method    of    localizing 
foreign  bodies,  1625 
Harrington  and  Gould's  method 
of  intestinal  anastomosis,  1249 
Harrington's  solution.  31 
Harris'   method  of  nephropexy, 
1444 
segregator,  1413 
zones.  1420 
Harrison's    operation    for    albu- 
minuria, 1443 
Hartley's  method  of  removal  of 

Gasserian  ganglion,  859 
Haynes'   operation  for  drainage 

of  cisterna  magna,  938 
Head,     bandage    of,     recurrent, 
1403 
bones    of,    disease    of,    A:-ray 

diagnosis,  161 1 
contusion  of,  875 
diseases  of,  863 
injuries  of,  863,  874 

in  labor,  867 
tetanus,  228 
Headache,  congestive,  elevation 

in,  IDS 
Heart,     diseases     and    injuries, 
459 
foreign  bodies  in,  tolerance  to, 

464 
hypertrophy    of,     decompres- 
sion for,  525 
in  inflammation,  122 
injuries  of.  459 
massage     during    collapse    in 
anesthesia,  1344 
resuscitation    by    operation 
for,  526 
mortality  from  operations  on, 

463 
muscle,    tuberculosis    of,    274 
rupture  of,  459 
suture  of,  462 
tamponade,  460,  461 
wounds  of,  459,  460 
in  war,  464 
operation  for,  524 
symptoms,  461 
treatment,  461 
Heart-cavity,  tapping,  523 
Heat,  40 

effect  of,  on  bacteria,  26 
in  inflammation,  98,  112 
treatment     of     inflammation, 
no 
Heath  and  Selby's  treatment  in 

Pott's  fracture,  699 
Heberden's  nodes,  728 
Hectic  fever,  141,  154 


Index 


1671 


Hedonal      infusion     anesthesia, 

1342 
Heineke-Mikulicz's    method    of 

pyloroplasty,  1219 
Helferich's  treatment  in  ankylo- 
sis, 742 
Helicoid  fracture,  590 
Heliotherapy     in     tuberculosis, 
256 

in    tuberculous    arthritis,    707 
Helium,  1641 

Heller's  test  for  hematuria,  1410 
Hemangeiosarcoma,  426 
Hemangioma,  417 

treatment,  419 
Hematemesis,  control,  518 
Hematic  abscess,  153 
Hematocele,  1548 

of    speimatic    cord,    diffused, 
1548 
encysted,  1548 

of  testicles,  encysted,  1548 
parenchymatous,  1549 

of  tunica  vaginalis,  1548 

vaginal,  1548 
Hematoid  cancer,  447 
Hematoma,  284 

of  dura  mater,  900 

pulsating,  492 

serous,  321 

spontaneous  perirenal,  1433 
Hematomyelia,  959 
Hematuria,  1410 

Almen's  test,  1410 

benzidin  test,  1411 

determination    of    source    of 
blood  in,  141 1 

essential,  1412 

guaiac  test,  1410 

Heller's  test,  1410 

in  appendicitis,  1 147 

microscopic  test,  141 1 

renal,  141 1 

Rosenthal's  test)  1410 

spectroscopic  test,  1410 

Struve's  test,  1410 

unilateral,  1412 
Hemianopsia,  homonymous  lat- 
eral, 918 
Hemicellulose,  17 
Hemoglobinuria,  1410 
Hemolysin,  57 
Hemopericardium,  461 
Hemophilia,  520 

symptoms,  521 

treatment,  522 
Hemophilic  arthritis,  521 
Hemoptysis,  control,  518 
Hemorrhage,  497  _ 

actual  cautery  in.  Six 

acupressure  in,  508 

after  abdominal  operation,  520 

after  lateral   lithotomy,  con- 
trol, SI  7 

after    nephrolithotomy,    1429 

after  operation  in  obstructive 
jaundice,  498 

angiorrhaphy  in,  501 

arteriorrhaphy  in,  503 

blood-serum  in,  511 

calcium  chlorid  in,  511 

capillary  control,  516 

cerebral,  883 
_  meningeal,  882 

circular  arteriorrhaphy  in,  505 

coagulose  in,  511 

compression  in,  508 

concealed,   shock  and,   differ- 
entiation, 288 

consecutive,  519 

control  of,  in  brain  operations, 

935 
electrohernostasis  in,  512 
elevation  in,  508 
extradural,  control,  S14' 
meningeal,  882 

forced  flexion  in,  509 

from  artery,  control,  512 

from  bladder,  1414 

control,  517 
from  cancellous  bone,  control, 
S14 


Hemorrhage  from  cerebral  sinus, 
control,  515 

from  ear,  control,  517 

from  extremities,  control,  513 

from    femoral    vein,    control, 
S14 

from  gunshot  wounds,  control, 
S16. 

from   intercostal   artery,    con- 
trol, 514 

from    intestine,    control,    518 

from  kidney,  141 1 
control,  518 

from   leech-bite,    control,    517 

from    lung,    control,    518 

from    mammary    artery,    con- 
trol, 5 14 

from    nose,    control,    516 

from  palmar  arch,  control,  512 

from  pelvis  of  kidney,  141 1 

from   prostate   gland,    1414 
control,  S17 

from  punctured  wounds,  con- 
trol, S14 

from    rectum,    control,    S17 

from  stomach,  control,  518 

from  tooth  socket,  control,  515 

from  ureter,  1411 

from   urethra,    control,    517 

from    uterus,    control,    S18 

from  vagina,   control,   5 18 

from  varicose  vein,  control,  S16 

from  wounds,  286 
arrest,  293 

gelatin  in,  510 

Guthrie's  rule  in,   512 

in  abdominal  section,  control, 
51S 

in  amputation,  1550 

in  duodenal  ulcer,  1130 

in  pancreatitis,  11 96 

in  ulcer  of  stomach,  1096 

surgical   treatment,    iioo 
treatment,  1099 

into  kidney,  spontaneous,  1412 

intercurrent,  519 

intermediate,  S19 

intra-abdominal,  498,  1075 
control,  515 

intracranial,  882 
in  newborn,   884 
spontaneous,  882 
traumatic,  882 

intravenous  infusion  of  saline 
fluid  in,  536 

lateral  arteriorrhaphy   in,  503 

ligature  in,  499 

phleborrhaphy,  501 

primary  control,  513 
rules  for  arresting,  512 

reactionary,  519 

recurrent,  519 
control,  514       . 

secondary,  519 
treatment,  519 

serum  in,  511 

severe,  S14 

spinal    extrameduUary,    con- 
trol, SIS 

styptics  in,  S09 

subcutaneous,  498 

subdural  meningeal,  883 

suprarenal  extract  in,  511 

transfusion  of  blood  in,  530 

treatment,  499 

torsion  in,  507 

umbilical,  control,  517 

urethral,  I4I4_ 
Hemorrhagic    diathesis,    520 

disease,  520 

goiter,  1372 

infarction,  208 

osteomyelitis,  565 

sarcoma,  426 
serum  in,  523 

ulcers,  171 
Hemorrhoids,  469,  13 16 

AUingham's      operation      for, 
1319 

arterial,  13 18 

clamp  and  cautery  operation 
in,  1319 


Hemorrhoids,  capillary,  1317 

carbolic  acid  in,  1318 

excision  of,  1320 

external,  13 16 

connective-tissue,  1317 
thrombotic,  1316 
varicose,  1317 

inflammatory,  1317 

internal,  1316,  1317 

ligature  operation  for,  1320 

Martin's   treatment,    1319 

mixed,  13 16 

treatment,  operative,  1318 

venous,  1317 

Whitehead's    operation,    13 19 
Hemostatic    agents,    499 

forceps,  curved,  500 
straight,  500 
Hendrix  on  dichloramin-T,  39 
Henle     and     Coenen's     sign    in. 

aneurysm,  489 
Hepatic  duct,  drainage  of,  1268 

fever,  141,  1189 
intermittent,  1184 

infections    after    appendicitis, 

Hepaticotomy,  1270 
Hepaticostomy,  1270 
Hepatitis,  pain  in,  99 
Hepatopexy     in     hepatoptosis, 

1178 
Hepatoptosis,  1 177,  1178 
hepatopexy  in,  1178 
laparectomy  in,  1178 
Hereditary    deforming  chondro- 
dysplasia, S64 
syphilis,  366 
Heredity  in  tumors,  398 
Hernia,  1 133 
abdominal,  1273 
adherent,    of    ascending    and 
descending  colon,   opera- 
tive treatment,  1290 
of  large  intestine,  1300 
causes,  1274 
cecal,  1299 
cerebri,  898 
Cloquet's,  1299 
diaphragmatic,  1302 
director,  1279 
epigastric,  1299 
epiploitis  following  operation 

for,  1290 
fat,  405,  1274 
femoral,  1299 

Bassini's  operation  for,  1288 
Cheyne's      operation      for, 

1288 
Fabricius'     operation     for, 

1288 
Moschcowitz's       operation 

for,  1288 
pre  vascular,  1299 
radical  cure,  1288 
gluteal,  1301 
Hesselbach's,  1299 
hydrocele  of,  1548 
in  children,  1297 
incarcerated,  1290 
infantile,  1298 

encysted,  1299 
inflamed,  1291 
inguinal,  congenital,  1298 
direct,  1298 

radical  cure,  1286 
Ferguson's    operation    for, 

1284 
Fowler's  operation  for,  1284 
Halsted's      operation      for, 
I28r 
plus  Bloodgood's  meth- 
od   of    transplanting 
rectus,  1282 
herniotomy  in,  1295 
indirect,  1298 
interparietal,  1301 
interstitial,  1301 
Kocher's  operation  for,  1284 
Mace  wen's    operation    for, 

1278 
oblique,  Bassini's  operation 
for,  1280 


1672 


Hernia, inguinal,  oblique,  Coley's 
dressing  in,  1281 
internal,  1301 

intestinal  obstruction  from, 

intersigmoid     retroperitoneal, 

iiiS 
into     foramen     of     Winslow, 

1301 
into    funicular   process,    1298 
into  intersigmoid  fossa,    1301 
into     rectocecal     fossa,     1301 
into  retroduodenal  fossa,  1301 
intra-abdominal,  1301 
irreducible,  1290 
labial,  1298 
Laugier's,  1299 
Littr6's,  1293,  1301 
lumbar,  1301 
needles,  1279 
obstructed,  1290 
obturator,  1301 
of  appendix,  1300 
of  bladder,  1302 
of  brain,  898 
of  intestinal  wall,  1301 
of  linea  alba,  1299 
of  Meckel's  diverticulum,  1301 
of  muscles,  810 
of  ovary,  1303 
of  uterus,  1303 
perineal,  1301 
premonitory     uneasiness     in, 

I27S 
preperitoneal,  1300 
pudendal,  1301 
reducible,  1275 

Lannelongue's      treatment, 

1278 
treatment,  1275 
rest  in,  105 
Richter's,  1293,  1301 
retroperitoneal,  1301 
Rokitansky's         diverticular, 

1302 
sciatic,  1301 
scrotal,  1298 
sliding,  1300 

of  ascending  and  descending 
colon,     operative     treat- 
ment, 1290 
strangulated,  delusive  calm  in, 
1293 
elastic,  1291 
fecal,  1 291 

vomiting  in,  1293 
mortality  in,  1296 
reduction    en    bissac,     1294 
en  bloc,  1294 
en  masse,  1294 
retrograde,  1291 
taxis  in,  1293 
treatment,  1293 
traumatic,  1274 
tuberculosis  of,  1274 
umbilical,  1299 

Mayo's  operation  for,  1286 
omphalectomy  in,  1286 
radical  cure,  1286 
vaginal,  130 1 
varieties,  1298 
ventral,  1 299 
with  incomplete  sac,  1300 
Herniotome,  Cooper's,  1294 
Herniotomy  in  inguinal  hernia, 

1295 
Herxheimer's  reaction  in  syphi- 
lis, 389 
Hesselbach's  hernia,  1299 
Heterologous  tumors,  398 
Heurteloup's     scarificator,      107 
Hewitt's  nitrous  oxid  apparatus, 
1352 
nitrous    oxid-oxygen    appara- 
tus, 1 353 
Hexamethylenamin.     See     Uro- 

tropin. 
Hey,    internal    derangement    of, 

773  .     ,     . 

method  of  disarticulation  at 
tarsometatarsal  articula- 
tion, 1564 


Index 


Hibbs"      method      of      tendon- 
lengthening,  825 
operation  for   Pott's  disease, 
969 
Hickory-stick  fracture,  587 
High-explosive     shell     wounds, 
322 
shrapnel  shell  wounds,  322 
High-frequency  current  in  can- 
cer, 449 
High-low  method  of  esophagos- 

copy,  Jackson's,  1007 
Highmorc,  antrum  of.     See  An- 
trum of  Highmore. 
Hilton's      treatment      of      deep 

abscess,  162 
Hip,  abscess  of,  711 

disarticulation  at,  1569 
disease,  710 
quiet,  719 
dislocations      of,      congenital, 
799.     See  also  Dislocations, 

congenital,  of  hip. 
in  typhoid  fever,  74s 
examination    of,    in    intracap- 
sular fractures  of  femur,  666 
excision     of,     792.     See     also 

Excision  of  hip. 
gout  of,  partial  rheumatic,  729 
osteo-arthritis  of,  729 
osteotomy    for    faulty    anky- 
losis, 7  79 
traumatic  dislocation  of,  766. 
See   also   Dislocations,  trau- 
matic, of  femur. 
tuberculosis  of,  710.     See  also 
Tuberculosis  of  hip. 
Hippocratic  face,  217 

in     intestinal     obstruction, 
1118 
Hirschsprung's  disease,  1156 
Hirtz  compass  method  of  localiz- 
ing  foreign   bodies,    1624 
Hodgen's  splint  for  fractures  of 
femur,  681 
modified,  612 
Hodgkin's  disease,  1393 
Hoffa's  operation  for  congenital 

dislocation  of  hip,  800 
Hoffmann's  sign  in  tetany,  1388 
Hollow  foot,  835 
Homans'  description  of  tests  for 

varicose  veins,  526 
Home's  lobe  of  prostate,  1526 
Hook,  fracture-,  60s 
Horn,  456 

cancerous,     440 
wart-,  433 
Horsehair,  84 

preparation,  84 
Horse-serum  treatment  of  burns 
and  scalds,  363 
of  hemophilia,  523 
of  hemorrhage,  dosage,  511 
Horseshoe  fistula  in  ano,  13 12 
Horsley's  cyrtometer,  865 

method   of    intestinal   anasto- 
mosis, I2S4 
of  locating  Rolandic  fissure, 

86s 
Sylvian  fissure,  865 
of  removal  of  Gasserian  gan- 
glion, 816 
operation    for    chronic    spinal 

meningitis,  972 
wax  in  hemorrhage,  514 
Horwitz's   modification  of    Mai- 
sonneuve's         urethrotome, 

treatment  of  gonorrhea,   1500 
Hospital,  base,  32s 

convalescent,  326 

evacuation,  32s 

field,  32s 

gangrene,  175,  188 
treatment,  188 

stationary,  325 

war,    position    and    functions 
in  battle,  32s 
Hot-air     treatment     of     chronic 

synovitis,  703 
Hour-glass  stomach,   1103,   1243 


Housemaid's  knee,  818,  821 
Houses,  cancer,  399,  442 
Howard's    method    of    artificial 

respiration,  975 
Hudson's  burrs,  931 

forceps,  932 
Huguier    and     Murphy's    treat- 
ment in  ankylosis,  442 
Hull's  treatment  for  burns  and 

scalds,  362 
Humerus,   dislocations  of,  trau- 
matic,   752.     See   also    Dis- 
locations,  traumatic,   of  hu- 
merus. 
epiphysis    of,    lower,    separa- 
tion of,  650 
upper,  separation  of,  640 
fractures    of,    633.     See    also 

Fractures  of  humerus. 
osteoma  of,  410 
sarcoma  of.  428 
subluxation  of,  811 
Humoral  theor>'  of  immunity,  45 
Hunger-pain  in  ulcer  of  stomach, 
I09S 
of  duodenal  ulcer,  11 29 
Hunterian  chancre,  369 
Hunter's     operation     for     aneu- 
rysm, 482 
Huntington's        treatment        in 

tuberculosis  of  hip,  716 
Hutchinson's     knee     splint     in 
tuberculosis  of  knee,  717 
teeth,  396 
Hiiter's  sign,  809 
Hyaline  tubercle,  237 
Hydatid  cysts,  458 
of  breast,  1580 
of  liver,  11 72 

of     lung,     j:-ray    diagnosis, 
1612 
fremitus,  458 
moles  of  pregnancy,  414 
toxemia,  438,  1 172 
Hydrarthrosis  in  osteo-arthritis, 

728 
Hydrencephalic  cry,  902 
Hydrencephalocele,  870 
Hydrocele,  acute,  1543 
chronic,  1546 
congenital,  1548 
en  bissac,  1546 
funicular,  1548 
infantile,  1548 

of  epididymis,  encysted,   1548 
of  hernia,  1548 
of  neck,  452 
of    spermatic    cord,    diffused, 

1548 
encysted,  1548 

of  testicle,  encysted,  1548 

primary,  1546 

secondary,  1546 

vaginal,  1546 
Hydrocephalus,  872 

acquired,  872 

acute,  872,  901 

chronic  internal,  872 

congenital,  872 

external,  872 

internal,  872 

ventriculostomy  in,  874 
Hydrogen  dioxid,  33 

peroxid,  33 

rectal  insufflation  with,  1078 
Hydronephrosis,  457.  I43S 
Hydrophobia,  351 

Negri  bodies  in,  352 

spurious,  353 

tetanus    and,     differentiation, 
231 

treatment,  353 
Hydrophobic  tetanus,  228 
Hydrops.  457,  ii79 

articuli,  703 
Hygroma  of  neck,  453 

perirenal,  1433 
Hyoid    bone,    fractures    of,    622 
Hyperchlorhydria     in    ulcer    of 

stomach,  1094 
Hyperemia,  active,  89 
clinical  signs,  90 


Index 


1673 


Hyperemia,  Bier's,  in  inflamma- 
tion,    122 
in  tuberculosis,  260 
obstructive,       with       cupping 
glass,     in     inflammation, 
.123 
with     elastic     bandage,     in 
inflammation,  122 
Hyperesthesia  in  inflammation, 
102 
in  inflammation,  Ligat's  test, 
100 
Hypernephroma,  432 
of  adrenal  rest,  141 7 
of  kidney,  14 17 
Hyperostosis  cranii,  583 
Hyperpituitarism,  582,  921 
Hyperplastic   tuberculosis,    1134 
Hypersusceptibilit}'  to  serum,  54 
Hyperthymization,  1390 
Hyperthyroidism,  1378,  1385 
Hypertonic-saline    treatment   of 

war  wounds,  337 
Hypertrophic  stenosis  of  pylorus, 

congenital,  1103 
Hypertrophy  of  bone,  564 
of  breast,  1573 
of    heart,    decompression    for, 

525 
of  muscles,  802 
of  prostate,  1525 

catheterization  in,  1528 
of  middle  lobe,  1526 
operations  for,  1329 

cystoscopic     examination 

before,  1528 
impotence  after,  1529 
residual  urine  in,  1526 
symptoms,  1527 
of  thyroid  gland,  1370 
Hypnotic  anesthesia,  1356 
Hypnotics  in  inflammation,  117, 
Hypochlorous  acid,  36 
Hypochondrial  delusions,  opera- 
tive treatment,  929 
Hypodermoclysis  in  shock,  290, 

292 
Hypoparathyroidism,  1387 
Hypophysis  cerebri.     See  Pitui- 
tary gland. 
Hypopituitarism,  582 
Hypospadias,  1518 
Hypothyroidism,  1370 
Hysteria,  stigmata  of,  957 

tetanus     and,   differentiation, 

231 
traumatic,  957 
war,  958 
Hysterical  coma,  881 
fever,  141 
joint,  732 
paralysis,  957 

stricture  of  esophagus,  1068 
traumatic  monoplegia,  957 


Ice     and     salt    for    anesthesia, 

1357 
Ice-bag,  109,  no  (Fig.  53) 

use  of,  in  appendicitis,  11 53 
Ichorous  pus,  145 
Ichthyol  in  inflammation,  in 
Ideal  cholecystotomJ^  11 91 
Idiocy,  microcephalic,  869 
Idiopathic     atony     of     bladder, 
1465 
dilatation  of  colon,  congenital, 

1156 
epilepsy,  operative  treatment, 
926 
with  local   onset,  operative 
treatment,  926 
fragilitas  ossium,  564 
gangrene,  176 

symmetrical,  176 
tetanus,  possible  explanation, 
224 
Ileal  intussusception,  11 14 
Ileocecal  intussusception,  H14 
Ileocolic  intussusception,  1114 
Ileus,   nil.     See  also  Intestinal 
obstruction. 


Iliac  abscess,  tuberculous,  267 
arteries,  ligation  of,  559 

after    abdominal    section, 
559 
artery,    common,    ligation    of, 
559 
external,  ligation  of,  561 
internal,  ligation  of,  561 
bursitis,  817 
Iliopsoas  bursitis,  817 
Ilium,     dorsum     of,     traumatic 
dislocations  of  femur  on,   767 
Illuminating-gas  poisoning,   985 

treatment,  987 
Immunity,  44,  48 
acquired,  44 
active,  44 

Ehrlich's  theory,  46 
humoral  theory,  45 
natural,  44 
Nuttall  and  Buchner's  theory, 

45 
passive,  44 
retention  theory,  45 
to  cancer,  44 r_ 
Immunization,    incomplete, 

against  tetanus,  228 
Imperforate  anus,  13 12 
Impetigo,  syphilitic,  374 
Implantation  of  nerves,  849,  853 
of  ureters,  intestinal,  1447 
venous,  S06 
Incarcerated  hernia,  1290 
Incendiary  bombs,  325 
Incised  wounds,  296 
Incision    and    drainage    in    em- 
pyema, 1018 
in  inflammation,  106 
Incisive  gland,  cyst  of,  1044 
Incontinence      of      feces      after 
operation    for    fistula,     treat- 
ment, 1314 
Incurvation  of  neck  of  femur,  837 
Index,    abdominal,    in    movable 
kidney,  1420 
opsonic,  47 
Indian    method   of   rhinoplasty, 

1409 
Indigo-carmin  test  for  excretory 

capacity    of    kidneys,    1416 
Indolent  leg  ulcer,  169 
Induction    balance.     Bell's,    for 
locating  bullet,  309 
Graham  Bell's,  309 
Infantile  hernia,  1298 
encysted,  1299 
hydrocele,  1548 
kidney,  141 7 

paralysis,     cerebral,     epilepsy 
following,  operative  treat- 
ment, 928 
flail-joints  from,  838 
scurvy,  283 
Infarction,  207 
hemorrhagic,  208 
red,  208 
white,  208  '1 
Infected  wounds,  341 
Infection    by   protozoa,    63 
focal,  213 
gas,  184 

general,  thrombosis  in, 
intra-uterine,  28 
mixed,  28 
placental,  28 
primary,  28 
production      of,      by 

organisms,  42 
secondary,  28  1 
seminal    transmission, 
septic,  216 
treatment,    by   bacterial    vac- 

_  cines,  54 
vital   resistance   to,   49 
Infective  cholangitis,  11 83 
Infiltration  anesthesia,  1359 

purulent,  146,  222 
Inflammation,  89 
aconite  in,  116 
actual  cautery  in,  115 
acute,  96 

symptoms,  98 


206 


28 


Inflammation,  acute,  symptoms' 
constitutional,  102 
treatment,  104 

adhesive,  97 

alcohol  in,  120 

alkaline  iodids  in,  119 

anodynes  in,  1 17 

antiphlogistic  regimen  in,  120 

antipyretics  in,  118 

antiseptic      fomentations     in, 
n3 

arterial  sedatives  in,  116 

asthenic,  96 

astringents  in,  no 

atropin  in,  120 

Bier's    hyperemia    treatment, 
122 

bleeding  in,  105,  115 

blisters  in,  114 

blood-plaques  in,  94 

blue  ointment  in,  in 

buffy  coat,  ip3 

cataplasm  in,  113 

catarrhal,  96,  97 

cathartics  in,  116 

causes,  97,  98 

cell-proliferation,  94 

changes    in    perivascular    tis- 
sues, 94 

chronic,  96,  103 
causes,  104 
symptoms,  104 
tissue  changes,  104 
_  treatment,  122 

circulatory  changes  in,  89 

classification,  96 

cleanliness  in,  122 

cold  in  treatment,  107 

common,  96 

compression  in,  no 

contagious,  97 

counterirritants  in,  114 

croupous,  96,  97 

cupping  in,  106 

definitions,  89 

delitescence,  97 

depletion  in,  105 

derangement  of  secretions,  102 

diapedesis,  93 

diaphoretics  in,  117 

diet  in,  120 

diphtheritic,  96,  97 

discoloration,  loi 

disordered  function,  102 

diuretics  in,  117 

douche  in,  ni 

dry,  97. 

cold  in,  109 
heat  in,  113 

dynamic,  96 

elevation  intreatment,  104,  105 

embryonic  tissue,  95 

emetics  in,  118 

extension,  97 

exudation  of  fluids,  92 

fever  types  in,  102 

fibrinous,  97  , 

fibroblasts,  94,  95 

fomentations  in,  112 

gangrenous,  97 

gelsemium  in,  n6 

gouty,  elevation  in,  105 

granulation  tissue,  95 

healthy,  97 

heart  in,  122 

heat  in  treatment,  98,  no,  112 

hemorrhagic,  97 

hot-water  bath  in,  113 

hyperesthesia,  102 
Ligat's  test,  100 

hypnotics  in,  117 

hypostatic,  97 
ichthyol  in,  in 
idiopathic,  96 

impairment    of    special    func- 
tion, 102 
in  fractures,  60s 
in    non-vascular    tissue,    95 
incision  in,  106 
increased  irritability,  102 
tenderness,  102 

indifferent  tissue,  95 


i674 


Index 


Inflammation,  infective,  96 
interstitial,  97 
iodids  in,  ii8 
irritants  in,  1 14 
juvenile  tissue,  95 
latent,  97,  100 
lead-water  and   laudanum  in, 

108 
leeching  in,  106 
leukocytosis,  103 
lividity,  loi 
magnesium   sulphate  solution 

in.  III 
malignant,  97 
massage  in,  112 
mercury  in,  118 
migration,  93 

moist  gangrene  from,    184 
morbid     states     complicating 

remedies  for,  119 
multiple  puncture  in,  106 
muscular  rigidity,  102 
neuropathic,  97 
new  formation,  95 
new  growth,  97 
obstructive  hyperemia  in,  with 
cupping   glass,    123 

with    elastic    bandage,    122 
of  antrum   of   Highmore,   988 
of  anus,   pain  in,   99 
of  arteries,  471 
of    bladder,     1470.     See    also 

Cyslitis. 
of  bone,  566 

of   brain,    traumatic,    899 
of  breast,  1575 
of  crypts  of  Morgagni,   1325 
of  epididymis,  154s 

pain  in,  99 
of  eye,  pain  in,  99 

rest  in,  105 
of  Fallopian  tubes,  pain  in,  99 
of  gall  bladder,  1 178.     See  also 
Cholecystitis. 

and     bile-ducts,     catarrhal, 
1180 
croupous,  1 18 1 
suppurative,  11 81 
of      joints,      702.     See      also 

S_'noi)itis. 
of  Littr^'s  glands  in  gonorrhea, 

1494 
of  lymphatic  glands,  1392 
of  matrix  of  nail,  1369 
of  mucous  membrane,  96 

rest  in,  105 
of  neck  of  bladder,  pain  in,  99 
of  nerves,  838 
of  ovaries,  pain  in,  99 
of  pancreas,  1195 
of  pelvis  of  kidney,  1432 
of  prostate  gland,   1523.     See 

also  Prostatitis. 
of  rectum,  1310 

pain  in,  99 
of  sacro-iliac  joint,  pain  in,  99 
of  semilunar  cartilages,  703 
of  sigmoid,  1310 
of  tendon  sheaths,  811 
of  testicle,  1541 

pain  in,  99 
of  thyroid  gland,  1370 
of    urethra,     1490.     See    also 

Urethritis. 
of  uterus,  pain  in,  99 
of  veins,  466.     See  also  Phle- 
bitis. 
oscillation  in,  91 
pain  in,  98 
parenchymatous,  97 
peri-anal,  13 11 
perirectal,  131 1 
phlebotomy  in,  115 
phlegmonous,  97 
plastic,  92,  97 
poultice  in,  113 
pulse  in,  122 
puncture  in,  106 
purgation  in,  116 
purulent,  97 
redness  as  sign,  lOi 
referred  pain  in,  99 


Inflammation,  reflex,  97 

relaxation  in  treatment,  1 05 

resolution,  97 

rrest  in  treatment,  104 

scarification  in,  106 

Scotch  douche  in,  11 1 

sedative  poultice  in,   113 

serous,  92,  97 

silver  nitrate  in,  in 

simple,  96 

sorbefacients  in,  rro 

specific,  96 

stagnation  in,  91 

sthenic,  96 

stimulants  in,  120 

strychnin  in,  120 

subacute,  96 

suppurative,  96,  97 

swelling,  loi 

sympathetic,  97 
pain  in,  99 

tartar  emetic,  116 

tartar-emetic  ointment  in,  115 

temperature  in,  122 

tenderness  in,  99 

terminations,  97 

tincture  of  iodin  in,  1 1 1 

tonics  in,  120 

traumatic,  96 

treatment,  constitutional,  iiS 

tumefaction,  loi 

unhealthy,  97 

urine  in,  122 

vascular  changes  in,  89 

venesection  in,  115 

ventilation  in,  122 

veratrum  viride  in,  116 

wet  cold  in,  108 

with  threatened  suppuration, 
treatment,  114 

Wright's  views  on,  125 
Inflammatory  fever,  102 

hemorrhoids,  1317 
Infraction  of  neck  of  femur,  837 
Infra-orbital  nerve,  neurectomy 

of,  8ss 
Infrapatellar  bursitis,  821 
Infusion  anesthesia,  1342 

hedonal,  1342 
Ingestion  tuberculosis,  240 
Ingrowing   toe-nail,    1369 
Inguinal  colostomy,  1260 
Bodine's,  1262 

hernia.     See  Hernia,  inguinal. 
Inhalation  tuberculosis,  240 
Inhaler,  Allis's,  1338 

Clover's,  1338 

Junker's,  1336 
Inhibition,  death  by,  287 
Injuries  of  bones  and  joints,  564 

of  heart,  459 

of  joints,  734 

of  nerves,  840 
Innocent  syphilis,  367 
Innominate    artery,   ligation   of, 

548 
Inoculation       tuberculosis,      60, 

240,  241 
Inoculations,  protective,  so 
Insanity,   abdominal   operations 
in,  930 

epileptic,  operative  treatment, 
928 

genito-urinary    operations    in, 
930 

gynecological     operations    in, 
930 

non-traumatic,  operative  treat- 
ment, 929 

operative  treatment,  928 

postoperative,  908 

traumatic,     operative     treat- 
ment, 929 
Insects  as  disease  carriers,  41 

bites  and  stings,  342 
Inserts,  sflk,  825 
Insolation  sunstroke,  143 
Instep,   bandage  of,  spica,    i399 
Instruments,  sterilization,  75 

trays  for,  70 
Insufficiency  of  bladder  in  pros- 
tatic hypertrophy,  1527 


Insufflation  anesthesia,  1340 
intratracheal,  977 

Elsberg's      apparatus      for, 

1034 
Meltzer   and    Auer's  meth- 
od, 1033 
rectal,    with    hydrogen,     1078 
Intercostal    artery,    hemorrhage 
from,  control,  514 
neuralgia,  802 
Interdental  splint,  621 
Interilio-abdominal   amputation, 

1573 
Internal  iliac  artery,  ligation,  561 
Interparietal     inguinal     hernia, 

1301 
Interpolation  in  plastic  surgery, 

1405 
Interrupted  suture,  298 
Interscapulothoracic       amputa- 
tion, 1 56 1 
Intersigmoid  fossa,  hernia  into, 
1301 
retroperitoneal  hernia,  1115 
Interstitial  inguinal  hernia,  1301 
Intertarsal    disarticulation,    an- 
terior, 1564 
posterior,  1564 
Interureteral  bar  in  cystoscopy, 

1451 
Intestinal  actinomycosis,  357 
Intestinal         anastomosis.     See 
also  Anastomosis,  intestinal. 
diverticula,  1 1 55 
exclusion,  local,  1257 
implantation  of  ureters,    1447 
obstruction,  nil 
acute,  I  III 

symptoms,  1117 
chronic,  1112 

symptoms,  1119 
complete,  nil 
diagnosis,  11 19 
differential    diagnosis,    1123 
from  adhesions,  1112 
from   bands   and   abnormal 

openings,  11  is 
from     cicatricial     stricture, 

ni6 
from    embolism    or    throm- 
bosis       o  f        mesenteric 
vessels,    1117 
from  enteroliths,  1 1 14 
from  fecal  tumors,  1116 
from  foreign  bodies,  1114 
from  gall-stone,  11 14 
from  internal  herniae,    ins 
from  intussusception,   11 14 
from      Meckel's     diverticu- 
lum, 1115 
from  strangulation,  11 11 
from  tumors,  1116 

outside  of  bowel,  n  16 
from  volvulus,  11 12 
gradual,  nil 
partial,  1112 
postoperative,  1117 
prognosis,  1123 
pseudo-,  1 117 

reflex,  of  renal  origin,   1117 
stercoraceous    vomiting    in, 

1118 
treatment,  1123 
tympanites  in,  1118 
stasis,  chronic,  nio 
tuberculosis,     perforation     in, 

"35       .       , 
wall,  herma  of,  130 1 
Intestine,    cancer  of,    1135 
diseases   and   injuries,    1088 
foreign  bodies  in,  1088 
hemorrhage  from,  control,  518 
large,  adherent  hernia  of,  1300 

identification    of,    1079 
pseudo-obstruction     of,     niT 
resection  of,  with  approxima- 
tion   by    circular    enteror- 
rhaphy,  1245 
rupture    of,    pneumatic,    1077 
treatment,  1078 
without     external     wound, 
1076 


Index 


1675 


Intestine,  sarcoma  of,  1135 
small,    identification   of,    1079 
location  of  loop,  1079 

spasm  of.  1 117 

strangulation    of,    obstruction 

from,  iiii 
suture  of,  12 16 
tuberculosis  of,  274 

primary,  1 134 
tumors  of.   intestinal  obstruc- 
tion from,  1 1 16 
outside    of   bowel,   obstruc- 
tion from,  1 1 16 
ulcer  of,  1 128 
Intoxication,    putrid,    214 

septic,  214 
Intra-abdominal        emergencies, 
diagnosis.  1073 
hemorrhage.  498,  1075 
control,  5 IS 
Intra-articular  ankylosis,   treat- 
ment, 740 
Intracapsular  fractures  of  femur, 

666 
Intracellular  toxins,  43 

of  tubercle  bacillus,  243 
Intracranial  drainage  in  hydro- 
cephalus, 873 
hemorrhage,  882 
in  newborn,  884 
spontaneous.  882 
traumatic.  882 
lesions,   .v-ray  diagnosis,    161 1 
Intradermal  suture,  66 
Intraparietal  fissure.  866 
Intrathoracic  goiter,   i373.,   I377 
operations    under   positive   or 
negative   air-pressure,    1032 
Intratracheal    anesthesia,     1340 
insufflation,  977 

Elsberg's      apparatus      for, 

1034 
Meltzer  and  Auer's  method, 
1033 
Intra-uterine    fractures,     590 

infection,  28 
Intravenous  infusion     of     saline 
solution,  536 
local  anesthesia.  Bier's  meth- 
od. 1363 
Intubation    of   larynx,    99S 
Intussusception,     cecal,     1114 
colic,  1 1 14 
diverticular,  11 14 
ileal,  1 114 

ileo-appendiceal;  11 14 
ileocecal.  1 114 
ileocolic.  11 14 
intestinal     obstruction     from, 

1114 
operation  for,  1259 
retrograde,  11 14 
Intussusceptum,  11 14 
Intussuscipiens,  11 14 
Involucrum,  571 
lodid.  thymol,  34 
lodids,    alkaline,    in    inflamma- 
tion. 119 
with  mercury,  118 
lodin.  37 

for   disinfection  of  skin.   77 
tincture   of,   in  inflammation, 
III 
lodism.  119 

in  syphilis,  391 
Iodoform,  33 

absorption,  fever  of,   141 
emulsion  injections   in   tuber- 
culosis of  hip,  715 
in    tuberculous    arthritis, 
708 
gaui  .e,  preparation  of,   86 
injection        for       tuberculous 
abscess,  269 
to  prevent  tetanus,  234 
poisoning,  34 
Ipsolateral  anosmia,  917 
Iritis,  syphilitic,  376 
Irreducible  hernia,  1290 
Irrigation,  fountain,  in  cystitis, 

m  gonorrhea,  1497 


Irrigation  in  septic  wounds,  80 
of  kidney  pelvis.    1456 

Irrigator,   Valentine's,    1499 

Irritability,  increased,  in  inflam- 
mation, 102 

Irritants    in    inflammation,     114 

Irritative   gonorrhea,    1495 
treatment,  1499 

Ischemia.  00 

Ischemic  muscular  athropy,  with 
contractures  and  paralysis, 
805 
myositis,  805 
paralysis,  805 

Ischiorectal  abscess,  IS7 
treatment,  160 

Isohemolysins,  437 

Issy-les- Moulineaux    method   of 
treating  burns  and  scalds,  362 

Italian   method   of   rhinoplasty, 
1409 

Itrol,  35 

Ivy-poisoning,  1367 


Jaboulay's         gastroduodenos- 
tomy,  123s 
method      o  f      gastro-enteros- 

tomy,  123 1 
operation  for  hydrocele,   1547 
Jacket,  plaster-of-Paris,  in  Pott's 

disease,  953 
Jacksonian  epilepsy,  915 

from   gross   brain    diseases, 
operative  treatment,  928 
with  local   onset,   operative 
treatment,  926 
Jackson's    high-low    method    of 
esophagoscopy,  1007 
instruments   for   direct  laryn- 
goscopy, bronchoscopy,  and 
esophagoscopy,  996 
method  of  laryngoscopy,   996 
bronchoscopy,        esopha- 
goscopy    and    gastros- 
copy,  996 
operation  for  cancer  of  breast, 

1592 
veil,  IIII 
Jacob's  reduction  of  dislocations 
of     semilunar     cartilages     of 

knee,  774 
ulcer,  171,  446 
Janet's   method  of  irrigation  in 

gonorrhea,  1497 
Jarisch-Herxheimer's       reaction 

in  syphilis,  389,  392 
Jaundice,  catarrhal,  11 80 

in    gall-stones,     Hamel's    test 

for,  1 1 89 
obstructive,  hemorrhage  after 
operation  in,  498 
Jaw   and    occiput,    bandage    of, 
figure-of-eight,  1400 
angle  of,  bandage  of,  crossed, 

1400 
bandage  of,  oblique,  1400 
injuries  and   diseases,    1040 
lower,  excision  of  half,   798 

partial,  799 
lumpy,  357 
necrosis  of,  1041 

phosphorus,  1042 
osteosarcoma  of,  423 
upper,  excision  of  half,  797 

by  median  incision,  797 
by     Weber's     incision, 
797 
Jaws,  closure  of,  1040 
Jejunostomy,  1244 
for  cancer,  1093 
Jejunum,  peptic  ulcer  of,  follow- 
ing  gastro-enterostomy,    1228 
Jerk-finger,  829 
Johnston's  method  of  preparing 

catgut,  83 
Joints,   abscess   of,   tuberculous, 
267 
affections    of,    syphilitic,    376 

trophic,  730 
aspiration  of,  785 
Brodie's,  732 


Joints,  Charcot's,  730,  731 
disease  of,  703 
diseases  and  injuries  of,   564, 
702 
a;-ray  diagnosis,  1611 
excision  of,  786 
false,  600 
flail-,  from  infantile  paralysis, 

838 
hysterical.  732 
inflammation     of,     702.     See 

also  Synovitis. 
injuries  of,  734 
loose  bodies  in,  744 
neuralgia  of,  733 
operations  on,  777 
sacro-iliac,   sprain  of,  738 
strumous.  705 
syphilis    of.   tertiary,   380 
tuberculosis  of,  27s,  703 
wounds  of,  734 
Jones'      abduction      frame      in 
fractures     of    shaft    of 
femur  in  children,  683 
in  intracapsular  fractures 
of  femur,    672.    674 
dressing    for    fractures    in    or 

near  elbow-joint.  648 
extension  splint,  639 
modification  of  Thomas'  arm 

splint,  642 
nasal  splint,  617 
reduction    of    dislocations    of 
semilunar   cartilages    of   fe- 
mur, 775 
traction  spUnt,  642 
treatment     of     metatarsalgia, 
836 
of  Volkmann's  contracture, 
860 
wrist  splint,  663 
Jonnesco's     method    of    sympa- 
thectomy. 854 
Jopson  on  erysipeloid.  219 
Jopson    and    Speese  on  Paget's 

disease  of  nipple.  1578 
Jordan's  method  of  amputation 
at  hip,  1573 
of  support  in  Pott's  disease, 

953 
Judd's  incision  for   exposure   of 

ureter,  1446 
Jugular  vein,  thrombosis  of,  205 
Junker's  inhaler,  1336 
Jury-mast,  953 
Justus'  test  for  syphilis,  382 

Kader's     method     of    gastros- 
tomy, 1226 
Kangaroo-tendon,  83 
preparation.  83 

Truax's  method,  83 
Kangri  cancer,  437 
Karyokinesis,  132 
Katzenstein's  operation  for  ser- 
ratus  palsy,  752 
for  varix  of  leg,  527    . 
Keen's   operation   in   torticollis, 

829 
Keetley's  reduction  in  shoulder- 
joint  dislocation,  756 
in   traumatic   dislocation  of 
femur  upon  pubis,  769 
Kehr's  sign  in  splenic  rupture, 

1202 
Keith's     method    of    lithotrity, 

1484 

Keller's   operation   for   Tarix   of 
leg,  527 

Kelly's     method    of    examimng 
rectum,  1306,  1307 
operation  for  movable  kidney, 

1424 
speculum,  1308 

Kelly-Welch   method  of  steriliz- 
ing   hands    and   forearms,    72 

Keloid,  407 

spontaneous  or  true,  408 

Kernig's  sign  in  acute  leptomen- 
ingitis, 901 

Keys- Wells  and  Metcalf 's  table 
for  ;i;-ray  localization,  1626 


1676 


Index 


Kidney,  abscess  of,  1431 

calculus  of,  1427 

referred  pain  in,  99.  1428 
operation  for,  1440 

cancer  of,  1418 

colic,  1428 

complications  after  anesthe- 
sia. 1347 

congenital  cystic,  1417 

cysts  of,  141 7 

diseases   and  injuries,    1417 

dislocated,  1420 

excretory  capacity,  in  health 
and  disease,  1415 

floating,  1 41 9 

gravel,  1427 

hemorrhage  from,  control,  518 

hemorrhage  into,  spontaneous, 
141  2 

hypernephroma  of,  1417 

infantile,  1417 

infections,  1431 

injuries  of,  1424 

laceration  of,  1424 

mobile,  1419 

operations  on,  1437 

pelvis   of,    hemorrhage    from, 
1411 
inflammation,  1432 
irrigation  of,  1450 

perforating  wounds  of,  1426 

prolapse  of,  1419 

repair  of,  138 

rupture  of,  1424 

sarcoma  of,  1418 

surgical,  143  s 

suture  of.  1426 

tuberculosis  of,  278 
chronic,  1436 
silent,  1437 

tumors  of.  1417 

wandering,  14 19 
Kidney-substance,     hemorrhage 

from,  1411 
Kilvington's  operation  for  pa- 
ralysis of  bladder,  972 
Kimpton-Brown  method  of  in- 
direct blood  transfusion,  533 
Kissing  ulcer  of  stomach,  1095 
Klemperer's      test      for      motor 

power    of   stomach,    1 107 
Klumpke's     paralysis,     843 
Knee,  ankylosis  of,  faulty,osteot- 
omy  for,  780 

crucial  ligaments  of,  rupture 
.of,  738 

dislocation  of  semilunar  carti- 
lages of.  Barker's  operation 
for,  799 

erasion  of,  787 

excision  of,  793 

Ashhurst's  method,  793 
by  anterior  semilunar  flap, 
793 

fractures  of  femur  near,  682 

housemaid's,  818,  821 

knock-,  830.  See  also  Genu 
valgum. 

semilunar  cartilages  of,  trau- 
matic   dislocations,    773 

subluxation  of,  773 

synovitis  of,  rest  in,  405 

traumatic  dislocations  of, 
771. 

See  also   Dislocations,  trau- 
matic, of  knee. 

tuberculosis  of,  716.     See  also 
Tuberculosis  of  knee. 
Knock-knee,     830.     See    also 

Genu  valgum. 
Knot,  clove-hitch,   747 

granny,  501 

reef,  501,  540 

surgeon's,  soi 
Kocher's    incision    for  nephrot- 
omy, 1439 
for    surgery    of    bile-ducts, 
1263,  1264 

method    of    anterior    gastro- 
enterostomy, 1233 
of  disarticulation  at  elbow, 
ISS9 


Kocher's  method  of  disarticula- 
tion at  shoulder,  1560, 
1561 
at  wrist,  1558 
of     intestinal     anastomosis, 
1250 
operation  for  cancer  of  tongue, 
1059 
for  inguinal  hernia,   1284 
reduction     in     shoulder-joint 
dislocation,  755 
Koch's  bacillus,  60,  238 

circuit  as  proof  of  microbe  as 
cause   of   disease,   42 
Kollmann's  syringe,  1507 
Konig's     incision    for    nephrec- 
tomy, 1441 
tracheotomy  tube,  1377 
Koranyi's  method  of  cryoscopy, 

1417 
Korotkow's     test    in    aneurysm, 

489 
Krag-Jorgensen  bullet,  314 
Kraske's  method  of  preventing 
spread  of  cutaneous  erysipe- 
las, 221 
operation  in  cancer  of  rectum, 
1329 
Kronecker's  coordination  center, 

460 
Kronig's    method    of    preparing 

catgut,  81 
Kronlein's    method    of    cerebral 

localization,  866 
Krukenberg    tumor,    444 
Kussmaul's  coma,  191 
Kyphosis,  950 


L.\BIAL  hernia,  1298 

Labor,  head  injuries  in,  867 

Laborde's    method    of    artificial 
respiration,  977 

Lacerated  wounds,  300 

Laceration  of  brain,  87S 
of  kidney,  1424 
palsy,  843 

Lachrymal    bone,    fractures    of, 
617 
glands,  lymphoma  of,  1044 

Lacing  lobe,  11 78 

Lacrimator  gas  in  warfare,   339 

Lactate,  silver,  35 

Lacteal  cysts,  457 

Lagoria's    sign   in    intracapsular 
fractures  of  femur,  668 

Lambotte-Lowman's    bone-hold- 
ing forceps,  613 

Lambotte's     operation     for     en- 
teroptosis.  1159 

Laminectomy,  968 
in  Pott's  disease,  955 

La   Mothe's  reduction  of  shoul- 
der-joint dislocation,   7S7 

Landerer's  dry  method  of  opera- 
tion, 80 

Lane's  bands,iiio 

plates   in  fractures,   609 

Langenbeck's    incision    for    ab- 
dominal nephrectomy,  1442 
method  of  excision  of  hip,  792 

Langenbuch's    cholecystectomy, 
1267 

Lannelongue       and        M6nard's 
treatment    of     ununited    frac- 
tures. 611 

Lannelongue's  operation  in   mi- 
crocephalus,  869 
treatment  of  reducible  hernia, 
1278 

Lannier-Hackerman    area,    1069 

Laparectomy      in     hepatoptosis, 
1178 

Laparotomy,  1204 

Laplace's   forceps   for   intestinal 
anastomosis,  1251 
lateral      intestinal     anasto- 
mosis. 125s 

Lardaceous  disease  from   tuber- 
culous abscess.  265 

Larrey's    method  of  amputation 
at  hip,  1573 


Larrey'smethod  of  disarticulation 
at  shoulder.  1560 
on  wound  of  bladder.  1465 
on  frost-bite,  19s 
Laryngeal     cartilages,     fracture 

of,  622 
Laryngoscopy,  direct,  996,  997 
Laryngotomy,  quick,  99s 
Laryngotracheotomy,  995 
Larynx,  aVjscess  of,  157 
treatment.  161 
benign  growths,  removal,  998 
diseases  and  injuries,  990 
edema  of,  990 
foreign  bodies  in,  991 
intubation  of,  995 
operations  on,  993 
papilloma  of,  removal,  998 
war  wounds  of,  990 
wounds  of,  990 
Latent  bactena,  27 
tuberculosis,  241 
Lateral  process  of  fifth  lumbar 
vertebra,  variations  in,  947 
sinus,  infective  thrombosis  of, 
205 
Laudable  pus,  145 
Laugier's  hernia,  1299 
Lautenschlager's      sterilizer.     85 
Lavage  of  ureter.  145  s 
Lawn-tennis  arm,  808 

leg,  810 
Leather-bottle  stomach,  1089 
Le  Conte's  amputation  of  upper 
extremity,  1562 
on  dichloramin-T,  39 
on  hydatid  cyst  of  breast.  1580 
on  rectal  insuflBation  of  hydro- 
gen, 1078 
Le  Dentu's    tendon-suture,    824 
Lee  an  dichloramin-T,  39 
Leech,  artificial,  107 
Leech-bite,     hemorrhage     from, 

control,  517 
Leeching    in    inflammation,    106 
Le   Fort's   tendon-suture,    824 
Leg,  amputation  of,  1565 
Barbadoes,  1393 
bow-,     830.     See     also     Genu 

varum. 
fractures  of,  694 
of  both  bones,  699 
compound,  700 
gangrene      of,      arteriovenous 
anastomosis    for    preven- 
tion or  treatment,  202 
moist,  183 
puerperal,  202 
lawn-tennis,  810 
milk-.  169,  204,  467 
riders',  808 
spiral    reversed    bandage    of, 

1398 
ulcer  of,  164.     See  also  Ulcer 

of  leg. 
varicose    veins    of,    527.     See 
also  Varix  of  leg. 
Legg's  disease,  719 
Leiomyoma.  414 
Lejars'  tendon-suture,  824 
Lembert[s  suture.  1216 
Leontiasis  ossea,  583 
Leptomeningitis,  899 
acute.  900 
chronic,  901 
primary,  900 
secondary,  900 
Leptothrix  forms  of  bacilli. 

23 

Le  tour  de  poignet,  640 
Leukocytes,      ameboid      move- 
ments, 93 
stages  of  migration,  93 
Leukocytosis,  48 

in     inflammation,      103 
Leukolysin,  56 
Leukomains,  44 

Lever,  Davy's,  to  control  hemor- 
rhage, 1569 
Levis'  splint,  66r 

for  dislocation  of  phalanges, 
765 


Index 


1677 


Levis'  treatment  of  Colles'  frac- 
ture, 660 
Lewisohn's    citrate    method    of 

blood  transfusion,  536 
Lewis's  repositor,  1454 

treatment    of    impacted    ure- 
teral calculus,  1430 
Lexer's      method     of     arterior- 
rhaphy,  507 
operation    for   aneurysm,    488 

in  torticollis,  829 
treatment    of    ankylosis,    741 
Lichen,  syphilitic,  374 
Ligation  in  tabatiere.  541 
of  abdominal  aorta,  563 
of  anterior  tibial   artery,   554 
of  arteries  in  continuity,   539 
of  axillary  artery,  544 
of  brachial  artery,  543 
of    common     carotid    artery, 
550 
iliac  artery,  559 
of   dorsalis   pedis   artery,    554 
of  external  carotid  artery,  551 

iliac  artery,  561 
of  facial  artery,  553 
of  femoral  artery,  557 
of  gluteal  artery,  561 
of  iliac  arteries,  559 

after   abdominal   section, 
559 
of  inferior  thyroid  artery,  548 
of  innominate  artery,  548 
of  internal  carotid  artery,  552 
iliac  artery,  561 
pudic  arterj',  562 
of  lingual  artery,  552 
of  occipital  artery,  553 
of  popliteal  artery,  556 
of  posterior  tibial  artery,  555 
of  radial  artery,  540,  541 
of  sciatic  artery,  562 
of  subclavian  arterj',  545 
of  superior  thyroid  artery,  552 
of  temporal  artery,  553 
of  ulnar  artery,  542 
of  vertebral  artery,  547 
Ligat's  test  for  hyperesthesia  in 

inflammation,  100 
Ligature  and  suture,  80 
for  hemorrhage,  499 
operation     for     hemorrhoids, 

1320 
suture-,  SOI 
Light  carrier,   Valentine's,    1505 

Finsen,  1640 
Lightning,  injuries  by,  1648 

treatment,  1649 
Ligneous  cancer,  1586 

phlegmon,  147 
Lilienthal's      bullet-probe,      309 

operating  table,  68 
Limb,  avulsion  of,  300 

war  wounds  of,  treatment,  327 
Line,  Crampton's,  560 

McKee's,  560  _ 
Linea  alba,  hernia  of,  1299 
Linear  osteotomy,  777 
Lingual  artery,  ligation  of,   552 
Linguiform   lobe   of  liver,    11 78 
Lip,  cancer  of,  i053_ 

Grant's  operation  for,  1054 
carbuncle  of,  1055 
Lipoma,  403 
cavernous,  405 
diffuse,  404 
nevoid,  419 
of  breast,  1580 

of    submaxillarj'    region..    404 
telangiectodes,  405 
treatment,  405  _ 
Liquid  fire  bums  in  warfare,  340 
Liquor   formaldehydi,    36 

puris  of  pus,  144 
Lisfranc's  method  of  disarticula- 
tion at  shoulder,  1561 
at  tarsometatarsal  articu- 
lation, 1562 
Lister's  cyanide  gauze,  prepara- 
tion, 86  _ 
method   of   excision   of   wrist- 
joint,  790 


Lister's   oiled-silk  protective  for 
wounds,  86 
tourniquet   in   aneurysm,    480 
Liston's   method  of  amputation 
at  hip,  1 573 
■  method   of   tracheotomy,   994 
Lithiasis,      appendicular,      1139 
Lithiomercuric  iodid,  3  i 
Litholapaxy,  1480 

in  male  children,  14S3 
Lithotomy,  1477 
lateral,  1477 

hemorrhage    after,    control, 
S17 
suprapubic,  1478 
Lithotrite,  Bigelow's,  148 1 
Forbes's,  148 1 
Thornpson's,  1481 
Lithotrity.  perineal,  1484 

rapid,  1480 
Litigation  back,  958 
Littre's  glands,  inflammation  of, 
in  gonorrhea,  1494 
hernia.  1293.  1301 
Liver,     abscess    of,     155,     ii73- 
See  also  Abscess  of  liver. 
cancer  of,  1171 
cirrhosis  of,  cancerous,  1171 
cysts  of,  1 17 1 

hydatid,  11 72 
diseases  and  injuries,  11 70 
floating,  1 177 
lobe   of,   floating,    1178 
lacing,  1 178 
linguiform,  11 78 
movable,  11 77 
repair  of,  138 
rupture  of,  11 70 
syphilis  of,  11 72 
tuberculosis  of,  274 
tumors  of,  11 71 
wounds  of,  1 1 70 
Lizard,   poisonous,  bites  of,   347 
Lloyd's     symptom     in     kidney 

stone,  1428 
Lobectomy,  1383 
in  goiter,  1377 
Lobular  mastitis,   chronic,    1576 
Local  anesthesia,    1357 

Bier's  intravenous  method, 
1363 
Lock-finger,  829 

Lockjaw,  224.     See  also  Tetanus. 
Longevity,  effect  of  syphilis  on, 

367 
Longitudinal  fractures,  588 

sinus  syndrome,  892 
Longuet's   operation  for  hydro- 
cele, 1547 
Lordosis,  950 

in  tuberculosis   of  hip,    712 
Lorenz's    cutting    operation    for 
congenital  dislocation  of  hip, 
801 
method  in  tuberculosis  of  hip, 
71S       .  .  . 

of  reducing  congenital   dis- 
locations of  hip,  799 
Loreta's  operation  for  cicatricial 
pyloric    stenosis,     12 19 
stenosis  of  stomach,  1103 
Loretin,  35 

Lowman-Lambotte's  bone-hold- 
ing forceps,  613 
Ltowman's  combination  bone  and 

plate  holder.  614 
Lucke's    method    of    gastro-en- 

terostomy,  1230 
Ludloff's   sign   in   separation   of 
epiphysis  of  small  trochanter, 
678 
Ludwig's  angina,  199 

treatment,  200 
Luetin  reaction  in  syphilis,  384 
Lumbago,  801 

Lumbar  abscess,  tuberculous,  267 
treatment,  271 
and  last  dorsal  vertebra, 
caries  of,  with  abscess  in 
psoas  magnus  or  quadratus 
lumborum  muscle,  Treves' 
operation,   784 


Lumbar  colostomy,  1262 
hernia,  1301 
nephrectomy,  1441 
plexus,  847 
puncture,  969 

in    hydrocephalus,    873 
technic,  970 
triangle,  superior,  of  Grynfelt 

and  Lesshaft,  1301 
vertebra,    fifth,    variations   in 
lateral  process  of,   947 
Lumpy  iaw,  357 
Lung,  abscess  of,  136,  1028 

pne  u  mo  t  o  m  y  for.   1029, 

1040 
treatment,  160 
«-ray  diagnosis,  161 2 
cancer     of,     .r-ray     diagnosis, 

1612 
congestion  of,  by  recoil,   1035 
contusion  of,  1021 
diseases  and  injuries,  10 14 
gangrene  of,  1029 

pneumotomy    for,    1040 
.r-ray  diagnosis,  161 2 
hemorrhage   from,   control, 

518 
operations  on,  1032 
protrusion  of,  1023 
rupture  of,  1022 
Lungmotor,     artificial    respira- 
tion by,  979 
Lupus,  272 
exedens,  272 
hypertrophicus,  272 
syphilitic,  378 
vulgaris,  272 
Luxatio  erecta,  754 
Luxations,  746.     See    also    Dis- 
locations. 
Luys's  separator,  1414 
Lymph.  92 
aplastic,  97 
coagulable,  127 
scrotum,  420 
Lymphadenitis,  acute,  1392 
cervical,  tuberculous,  276 
compression  in,  no 
chronic,  1392 
infective,  1392 
septic,  1392 
Lymphadenoma,  1393 
Lymphangiectasis,  420,  1392 
from  filarial  worms,  1393 
varicose.  i393 
Lymphangioma.  420,  1393 
cavei"nous.  420 
circumscriptum,  1393 
Lymphangitis,  1392 
capillary,  1392 
reticular,  219,  1392 
tubular.  1392 
Lymphatic  abscess,  153.  260 
constitution,  249 
erysipelas,  220 
glands,    abscess    of,    tubercu- 
lous,   treatment,    270 
inflammation   of.    1392 
tuberculosis  of,  276 
infections    after    appendicitis, 

1144 
ne\ais,  420 
scrofula.  249 
thrombosis,  204 
tissue,  repair  of,  138 
vessels,  inflammation  of,  1392 
warts,  1393 

Lymphatics,  diseases  and  injur- 
ies of,  1391 

■   varicose.  1392 

Lymphatism.  249,  1390 

Lymphedema,  1393 

Lymph-glands,  cervical,  tuber- 
culosis of.  276         _ 

Lymph-nodes,  calcified,  mis- 
taken for  ureteral  stone,  1457. 
1618 

Lymphoma,  403 
malignant,  1393 
of   laclirymal    glands,    1044 
of   salivary    glands,    1044 

Lymphorrhea,  1393 


1678 


Index 


Lymphosarcoma,  424 
of  testicle,  1544 
of  thymus,  1390 

Lymph-scrotum,  1393 

Lysins,  bacteriolytic,  45 

Lysol,  36 

Lyssa,  351 


Mac  Cormac's  method  of  meas- 
uring for  truss,  1276 
Macewen's  method  of  prevent- 
ing hemorrhage  in  amputa- 
tion at  hip,  1570 
operation    for    genu    valgum, 
778 
for  inginal  hernia,  1278. 
suign  in  skull  fractures,   886 
suprameatal  triangle,  866,  936 
Machine  gun,  wounds  from,  322 
Macroglossia,  420 
Maculae,  syphilitic,  373 
Macular  syphilids,  373 
Maculopapular  syphilids,  373 
Madelung's  deformity,  762 

operation  for  varix  of  leg,  527 
Madura-foot,  20,  358 
Maggots  in  wounds,  343 
Magnesium  sulphate  in  tetanus, 
-    235.  .     , 

injections,    spinal,    anesthe- 
sia by,  1367 
saturated    solution,    in    in- 
flammation, III 
Maisonneuve's  symptom  in  Col- 
ics' fracture,  660 
urethrotome,  1513 

Horwitz's  modification,  1513 
Makka's  operation  for  exstrophy 

of  bladder,  1462 
Malar  bone,  fractures  of,  619 
Malaria,  fever  of,  142 
Male  breast,  cancer  of,  1587 
Malformations  involving  brain, 

870 
Malgaigne's  operation  for  hare- 
lip, 1046 
pads,  720 

treatment  of  fractures  of  cos- 
tal cartilages,  625 
Malignant  disease,  cachexia  of, 
402 
fever  of,  142 
edema,  341 

bacillus  of,  62 
pustule.  347.  348 
Malingering,  958 
Mallein  in  diagnosis  of  glanders, 

355 
Malleolus,    inner,    fractures    of, 

69s 
Mallet-finger,  830 
Malleus,  354 

Malplaced    testicle,    1539 
Mammary  artery,  internal,  hem- 
orrhage  from,   control,   514 
gland.     See   Breast. 
Mammillitis,  iS74 
Mandible,  dislocations  of,  trau- 
matic, 749 
fractures  of,  620 
Mannkopf's    sign    in   spinal   in- 
juries, 956 
Maragliano's  serum    in  tubercu- 
losis, 259 
Marchant's  operation    for  hepa- 

toptosis,  1 1 78 
Marginal  abscess,  153 
Marie's    disease,    582,    585,    732 
Marjolin's  ulcer,  171.  44s 
Marks,  mother's,  418 

1309 
Marks's  urethroscope,  1506 
Marmorek's   serum  in  tubercu- 
losis, 259 
Marriage  in  syphilis,  391 
Marsupialization,  459,   1172 
Martin's  bandage  for  leg  ulcer, 
168 
method  of  examining  rectum, 

1309 
speculum,  1306 


Martin's   treatment    of    hemor- 
rhoids, 13 19 
Marwedel's  incision  for  nephrot- 
omy, 1440 
Mask  ecchymotic,   1014 

Skinner's,  1336  * 

Mason's    pin    in    fractures     of 

nasal  bones,  616 
Massage  in  fractures,  602 
in  inflammation,  112 
of  heart  for  collapse  in  anes- 
thesia, 1344 
resuscitation  by,   operation 
for,  526 
Mastitis,  acute,  1575 
cancer,  1586 
chronic,  1576 
lobular,  1576 
Mastodynia,  1576 
Mastoid,  empyema  of,  90s 
suppuration,     operation     for, 
936 
Mastoiditis,  90s 

Matas'      aluminium      band      in 
aneurysm.  486 
operation  for  aneurysm,  484, 

48s 
plan     for     testing     collateral 
efficiency  in  aneurysm,  488 
Mathew's  rectal  speculum,  1305 
treatment  of  external  throm- 
botic     hemorrhoids,       13 17 
Maunsell's  method  of  intestinal 
anastomosis,  1249 
operation  for  intussusception, 
1259 
Maxillary  antrum.     See  Antrum 
of  Highmore. 
bone,  inferior,  fractures  of,  620 
superior,    fractures    of,    617 
Maydl's      inguinal      colostomy, 
1260 
operation     for     exstrophy     of 
bladder,  1462 
Mayer's    dressing    for    Thiersch 

skin-grafts,  1408 
Mayo    Robson's    operation    for 

meningocele.  871 
Mayo's     method     of     anterior 
gastro-enterostomy,   1233 
of  gastro-enterostomy,  1240 
of  nephrotomy,  1440 
of  pylorectomy,  1222 
operation  for  bunion,  780,  822 
for  umbilical  hernia,  1286 
for  varix  of  leg,  527 
osteotomy   for  hallux  valgus, 
780 
McArthur  drip,  1266 
McBurney  and  Dowd's  fracture- 
hook,  60s 
McBurney's        duodenocholedo- 
chotomy,  1270 
method  of  preventing  hemor- 
rhage in  amputation  at  hip, 
IS70 
operation  in  appendicitis,  12 14 
point    in    appendicitis,     1137, 

1143 
rule  in  appendicitis,  1154 
treatment    of    traumatic    dis- 
locations of  humerus,  7s8 
McCurdy's    operation    in    torti- 
collis, 829 
McGill's  method  of  suprapubic 

prostatectomy,  1532 
McGraw's     method    of    gastro- 
enterostomy, 1234 
Mclntyre's    splint    in    fractures 

of  femur.  682 
McKee's  line,  560 
Meatus,    fish-mouth,    in    gonor- 
rhea, 1493 
of   newborn,    occluded,    treat- 
ment, 1460 
Meckel's      diverticulum,      11 14 
hernia  of,  1301 
intestinal  obstruction  from, 
1115 
Median   nerve,  section  of,  symp- 
toms, 84s 
Mediastinum,  abscess  of ,  156 


Mediastinum,   abscess  of,   treat- 
ment, 160 
tuberculous,  267 
treatment,  271 
conditions  of,  Ar-ray  diagnosis, 

1612 
surgical  invasion  of,  1073 
Medulla,  tumors  of,  919 
Medullar  sarcoma,  425 
Medullary  cancer,  447 
Megacolon,  true,  1156 
Melanosis,  448 
Melanotic  cancer,  44s,  448 
growth,  45 1 
sarcoma,  424,  425 
Melon-seed  bodies,  813 
Meltzer  and   Auer's  method   of 
endotracheal      insuffla- 
tion anesthesia,  1340 
of   intratracheal    insuffla- 
tion, 1033 
Membrane,  Volkmann's,  262 
Membranous  peri-enteritis,  11 11 
M6nard       and       Lannelongue's 
treatment    of    ununited    frac- 
tures, 611 
Meningeal    hemorrhage,     extra- 
dural, 882 
subdural,  883 
Meningitis,  899 

chronic        spinal,        Horsley's 

operation  for,  972 
otitic,  90s 

tuberculous,  273,  901 
Meningocele,  870,  941 

spurious,  871 
Meningomyelocele,  941 
Mercier's  catheter,  1459 
Mercurial  fever.  141 
Mercury  bichlorid.  29 
in  inflammation,  118 
in  syphilis,  386 
M6rieux  and   Baillon's  reaction 

in  tuberculosis,  245 
Mesenteric    arteries,     embolism 
of,  209 
rupture  of,  1082 
cysts,  1087 

vessels,    embolism    or    throm- 
bosis    of,     intestinal    ob- 
struction from,  II 17 
thrombosis  of,  205 
tuberculosis  of,  in  children, 
1135 
Mesoblastic  cystoma,  452 
Metacarpalbones,  excision  of,  791 
fractures  of,  664 
traumatic  dislocation  of,  764 
Metacarpoohalangeal    articula- 
tion, dislocation  of,  764 
joint,  disarticulation  at,  ISS7 
of  thumb,   traumatic  dislo- 
cation. 764 
Metachromatic  bodies,  21 
Metal  retractor  for  amputation, 

1552 
Metastasis  in  sarcoma,  422 
Metastatic     abscess,     153,     218 

erysipelas,  220 
Metatarsal    bone    of    great    toe, 
excision  of,  796 
bones,  fractures  of,  701 

traumatic     dislocations    of, 
777 
Metatarsalgia,  836 

Graham's  treatment,  836 
Jones'  treatment,  836 
Metatarsophalangeal      articula- 
tion  of  great   toe,  excision  of, 
795 
Metcalf   and   Keys-Wells     table 

for  a:-ray  localization.  1626 
Methylene    bichlorid  anesthesia, 

1354 
Methylene-blue     in     gonorrhea, 
1500 
test  for  excretory  capacity  of 
kidneys,  1416 
Meyer's  operation  for  cancer  of 
breast,  1592 
treatment    of    presenile   spon- 
taneous  gangrene,    179 


Index 


1679 


Microbes,  17,  19 

as    cause    of    disease,    Koch's 
circuit  as  proof,  42 

saprophytic,  21 
Microbic  gangrene,  17s 
Microcephalic  idiocy,  869 
Microcephahis,  869 
Micrococcus,  22 

gonorrhoeee,  58 

pyogenes,  56 
tenuis,  57 

tetragenus,  57 
Microdactyha,  803 
Micro-organisms,  17 

infection  or  disease  production 
by,  42 
Microphyta,  19 
Microzoaria,  19 

Micturition,  frequency  of,   1415 
Migrating  abscess,  260 
Migration  of  leukocytes,  94 
Migratory  erysipelas,  220 
MikuHcz's  bags,  88 

disease,  1044 

treatment  of  ankylosis,  742 
Milian's   ear  sign  in  erysipelas, 

221 
Miliary  aneurysm,  475 

tuberculosis,  acute,  278 
Milk  abscess,  153 

cysts,  457 
Milk-leg,  169,  204,  467    • 
Milzbrand,  347 
Mind-blindness,  918 
Miners'  elbow,  821 
Mingazzini-Poerster      operation 

in  tabes,  971 
Missile.     See  Projectiles. 
Mitchell's  solution  for  infiltration 

anesthesia,  1360 
Mixed  infection, 28 
Mixter's    treatment    of    esopha- 
geal stricture,  1064 
Mobile  kidney,  1419 
Mobilization    of   thorax   in   pul- 
monary   tuberc^ilosis,     103 1 
Moebius's    antithyroidin    in  ex- 
ophthalmic goiter,  1380 

sign    in    exophthalmic    goiter, 
1379 
Moist  gangrene  from  inflamma- 
tion, 184 
treatment,  184 
Molds,  19 
Mole,  406 

congenital  pigmented,   cancer 
from,  45 1 

hydatid,     of    pregnancy,     414 
•  Mollifies  ossium,  581 
Molluscum  fibrosum,  407 
Monarticular    rheumatism,    729 
Monks'    method    of  identifying 
small    and  large  intestines, 
1079-1082 

treatment   of  subacromial 
bursitis,  820 
Monococcus,  22 

Monoplegia,      hysterical      trau- 
matic, 957 
Monprofit'smetal  retractor,  1552 

tourniquet,  1 551 
Monteggia's      dislocation,      770 
Moore-Corradi      treatment      of 

aneurysm,  491 
Moore's  dressing  for  fractures  of 
clavicle,  631 

treatment  in  Colles'  fracture, 
661 
Morbid  growths,  397 
Morbus  coxae  710 
senilis,  729 

coxarius,  710 
senilis,  705 
Morgagni,     crypts    of,     inflam- 
mation, 1325 
Morison's  operation,  1258 

treatment     of     war     wounds, 
338 
Morning  drop  in  gonorrhea,  1495 
Morphea,  408 

Morphin  in  appendicitis,  1154 
Morphinism,  fever  of,  141 


Morris'    measurement    in    intra- 
capsular fractures  of  femur, 
668 
method  of  palpating  appendix, 

1 144 
rule  in  operation  for  bladder 
tumors,  1477 
Mortar  bombs,  325 

gas  in  warfare,  339 
Mortification,      175.     See     also 

Gangrene. 
Morton's  disease,  836 

Graham's  treatment,  836 
Jones'    treatment,    836 
method    of    spinal    analgesia, 
1364 
Morvan's  disease,  815 
Moschcowitz's    method  of  deter- 
mining viable  area  in  senile 
gangrene,  182 
operation  for  femoral  hernia, 
1288 
for  prolapse  of  rectum,  1323 
reaction     in     aneurysm,     489 
Mother's  marks,  418 
Motile  bacteria,  21,  22 
Motion,  effect  of,  on  bacteria,  26 
Mouse  cancer,  439 

eosin-selenium  in,  450 
Mouth,  gonorrhea  of,  1508 
injuries  and  diseases,  1040 
preparation  for  operation,  78 
M  o  u  t  h-to-mouth    insufflation, 

975 
Movable  liver,  1177 
Moynihan's  clamp,  1237 

method      of      gastro-enteros- 
tomy,  1237 
of    intestinal     anastomosis, 
1250 
Mucous  cystoma,  452 
cysts,  456,  1044 
erysipelas,  220 

membranes,    affections   of,    in 
syphilis,  37S 
disinfection  of,  78 
inflammation  of,  96 

rest  in,  105 
of  gall-bladder,  removal  of, 

1268 
wounds  of,  299 
patches  in  syphilis,  375 
polypi,  414 
Mulberry  calculus,  1467 
Muller's  law  in  tumors,  397 
treatment  of  flat-foot,   835 
Multilocular  cystic  tumors,  412 
Mummification    in    senile    gan- 
■  grene,  181 
Mumps,  1043 

Muret  and  Qu6nu's  sign  in  aneu- 
rysm, 488 
Murphy    and    Huguier's    treat- 
ment  in   ankylosis,    742 
Murphy's    button     method    of 
g  a  s  t  r  o  -enterostomy, 
1236 
of  intestinal  anastomosis, 
1248 
formalin-glycerin  treatment  in 
synovitis,  703 
in    tuberculous    arthritis, 
708 
method  of  arteriorrhaphy,  505 
of        cholecystenterostomy, 

1266 
of  nerve-suture,    853 
of  palpating  for  gall-bladder 
tenderness,  11 87 
treatment    of    ankylosis,    742 
of    fractures     of  .olecranon 

process   of  ulna,   652 
of  peritonitis,  1162 
of     ununited     fractures     of 
patella,  784 
Murray's  operation  for   ligation 

of  abdominal  aorta,  563 
Muscles,  atrophy  of,  802 
contractions  of,  810 
contusions  of,  807 
degeneration  of,  803 
diseases  of,  801 


Muscles,  dislocations  of,  810 

hernia  of,  810 

hypertrophy  of,  802 

injuries  of,  801 

operations  on,  823 

ossification  of,  local,  803 

repair  of,  135 

rupture  of,  808 

strains,  808 

syphilis  of,  804 

trichinosis  of,  804 

tuberculosis  of,  275 

tumors  of,  804 

wounds  of,  807 
Muscular     atrophy,     ischemic, 
with        contractures       and 
paralysis,  80s 

rheumatism,  801 

spasm  in  fractures,  605 
Musculocutaneous     nerve,     sec- 
tion of,  symptoms,  844 
Musculospiral   nerve,   injury  of, 
in   fractures   of  shaft    of 
humerus,  641 
section  of,  symptoms,  844 
Musculus  sardonicus,  229 
Mushroom  abscess,  903 

bullet,  317 
Mustard,  36 

gas  in  warfare,  339 
Myalgia,  801 
Mycetoma,  20,  358 
Mycosis,  20,  427 
Myelocele,  941 
Myeloid  sarcoma,  425 
Myeloma  of  bone,  multiple,  586 
Myiasis,  343 
Myoblasts,  136 
Myoma,  414 

of  bladder,  1475 

treatment,  415 

uterine,  415 
Myositis,  infective,  802 

ischemic,  80s 

ordinary,  802 

ossificans,  803 
progressiva,  803 
traumatica,  803 
Myxedema,  1370 

operative,  1369 
Myxoma,  413 

of  breast,  1580 

treatment,  414 
Myxosarcoma,  414,  426 

of  orbit,  426 


Nail    extension    in     fractures, 

Steinmann's,  601 
Nails,    affections    of,   syphilitic, 
375 
diseases  of,  1367 
inflammation  of  matrix,   1369 
ingrowing,  169 
Narcosis  paralysis,  1349 
Nasal  bones,  fracture  of,  615 
fracture  of,  Asch's  tube  in, 
616 
Mason's  pin  in,  616 
Nasopharyngeal  fibroma,  406 
Nearest-point  method  of  localiz- 
ing foreign  bodies,   1622 
Neck,  abscess  of,  deep,  155 
tuberculous,  267 
and  axilla,  bandage  of,  figure- 

of-8,  1401 
Derbyshire,  1373 
hydrocele  of,  452 
hygroma  of,  453 
region  of,  anatomy,  549 
sarcoma  of,  421,  422,  423 
triangles  of,  545,  549 
anterior,  549 
posterior,  549 
Necrosis,  163 
of  bone,  571 
acute,  567 
central,  571 
postfebrile,  572 
quiet,  572 
of  jaw,  1041 

phosphorus,  1042 


i68o 


Index 


Needles,  aneurysm,  Dupuytren's, 
540 
Barker's,  for  wiring  fracture  of 

patella,  690 
Hagedorn's,  502 
hernia,  1279 

Saviard's  aneurysm,  539 
Negri  bodies,  352 
Neisser's  bacillus,  58 

treatment  of  acute  gonorrhea, 
ISOO 
N61aton's  bullet-probe,  309 
catheter,  1461 
dislocation,  776 
treatment     of    dislocation    of 
lower  jaw,  749 
Neoplasms,  397 
Xeosalvarsan  in  syphilis,  391 
Nephrectomy,  1441 
abdominal,  1442 
for  movable  kidney,  1423 
in  children,  1442 
lumbar,  1441 
partial,  1442 
Nephrite      toxique     appendicu- 

laire,  1147 
Nephritic  colic,  1428 
Nephritis,     chronic,     operations 

for,  1437 
Nephrolithiasis,  1427 
Nephrolithotomy,  1440 
Nephropexy,  1423 
Nephroptosis,  1419 
Nephrorrhaphy,  1443 
Nephrostomy,  1439 
Nephrotomy,  560,  1439 

for  renal  calculus,  1440 
Nerve-grafting,  849,  853 
Nerves,  anastomosis  of,  849,  853 
contusion  of,  850 
diseases  of,  838 
implantation  of,  849,  853 
inflammation  of,  838 
injuries  of,  838,  840 
lengthening  of,  849 
operations  on,  851 
peripheral,     gunshot     wounds 

of,  8so 
pressure  on,  850 
primary  suture,  849 
repair  of,  133 
secondary  suture  of,  849 
section  of,  840 
symptoms,  841 

anterior  crural,  847 
in  brachial  plexus,  841 
in  circumflex,  844 
in  external  popliteal,  848 
in  facial,  848 
in  great  sciatic,   847 
in  internal  popliteal,  848 
in  median,  845 
in  musculocutaneous,  844 
in    musculospiral,    844 
in   obturator,    847 
in  plantar,  848 
in  posterior  thoracic,  843 
in  radial,  844 
in  small  sciatic,  847 
in  suprascapular,  844 
in  ulnar,  845 
transplantation  of,  849 
tuberculosis  of,  273 
wounds  of,  840 
punctured,  850 
Nerve-suture,  851 
k  distance,  853 
AUis'  method,  853 
Murphy's  method,  853 
secondary,  852 
tubulization  after,  853 
Nerve-trunk,    cocainization     of, 

1358 
Nervous  system,  syphilis  of,  376, 

Nervousness  of  bladder,    1415 
Neuber's    operation    for     bone- 
cavities,  574 
Neuralgia,  839 
intercostal,  802 
of  fifth  nerve,  839 

Abba's  operation  in,   861 


Neuralgia  of  fifth  nerve,  alcohol 
injections  in,  856 

extracranial  operation 
for,  856 

Frazier-Spiller  operation 
in,  861 

osmic  acid  injection  in, 
856 

removal  of  Gasserian  gan- 
glion for,  858.  See 
a\so  Gasserian  ganglion. 

Rose's    neurectomy     for, 

r  •    ■     *S7 
of  joints,  733 

of  stumps,   Senn's  treatment, 
840 
Neurasthenia,  traumatic,  956 
Neurectasy,  854 
Neurectomy,  854 

intracranial,    Abb6's   method, 

861 
of  inferior  dental  nerve,  856 
of  infra-orbital  nerve,  855 
of  supra-orbital  nerve,   855 
Neuritis,  838 
multiple,  838 
optic.     See   Choked  disk. 
Neurofibroma,  416 
Neuroma,  416 
central,  851 
false,  416 
lateral,  850 
malignant,  416 
plexiform,  416 
terminal,  851 
traumatic,  416 
treatment,  416 
true,  416 
Neuroparalytic  ulcer,  172 
Neuropathic  arthritis,  731 
Neuroplasty  by  flap  method,  853 
Neurorrhaphy,     851.     See     also 

Nerve-suture. 
Neurotic  fever,  141 
Neurotomy,  854 

intracranial,        Frazier-Spiller 
method,  861 
Nevolipoma,  40s,  419 
Nevus,  418 

lymphatic,  420 
venous,  418 
Newborn,    intracranial     hemor- 
rhage in,  884 

meatus    of,    occluded,     treat- 
ment, 1460 
tetanus  of,  227 
New  growths,  397 
Nicolaier's  bacillus,  59 
NicoU's    method    of    suprapubic 

prostatectomy,  iS33 
Night-cries  in  tuberculous  arth- 
ritis, 706 
Nipple,  cysts  of,  i577 
epithelioma  of,    1577 
malignant  dermatitis  of,  1578 
Paget's  disease  of,  1578 
tumors  of,  iS77 
Nitrate  of  silver,  35 
Nitrous  oxid  anesthesia,  1352 

followed    by    ether,    1355 
gas  anesthesia,  1352 
oxid-oxygen   anesthesia,    1352 
Noci  influences,  287 
Nodes,  Heberden's,  728 

of  bone,  568 
Noguchi's  cutaneous  reaction  in 

syphilis,  384 
Noli  me  tangere,  171 
Noma,  196 
pudendi,  196 
symptoms,  197 
treatment,  197 
vulvae,  196 
Non-pathogenic  bacteria,  21 
Non-traumatic   insanity,   opera- 
tive treatment,  929 
pneumothorax,  1019 
Normal  coagulation  time,  1268 

saline  solution,  32 
Nose  and  antrum,  diseases  and 
injuries,  988 
foreign  bodies  in,  988 


Nose,  gonorrhea  of,  1508 
hemorrhage  from,  control,  516 
injuries  and  diseases,  1040 

Nosophen,  35 

Novocain  anesthesia,  1359 

Nucleins,  40 

Nussbaum's  treatment  of  cuta- 
neous erysipelas,  222 

Nuttall    and    Buchner's    theory 
of  immunity,  45 

Oberlander's  dilator,  1507 
Obligate  aerobes,  26 

anaerobes,  26 

parasites,  21 

saprophytes,  21 
Obliterative  appendicitis,  1 140 

endarteritis,  473 
Obstetric     depressions    of    skull, 

890 
Obstetrics,     anesthesia   in,    1357 
Obstruction,  intestinal,  1 1 1 1 

postoperative,  1127 
Obstructive     jaundice,     hemor- 
rhage after  operation  in,  498 
Obturator     foramen,     traumatic 
dislocations  of  femur  down- 
ward into,  769 

hernia,  1301 

nerve,   section  of,   symptoms, 
847 

Valentine's,  1505 
Occipital  artery,   ligation  of,  553 

lobe,  tumors  of,  918 

triangle,  545.  549 
Occiput    and    jaw,    bandage    of, 

figure-of-eight,  1400 
Occlusions  of  left  thoracic   duct, 

1391 
Ochsner's    operation   for   esoph- 
ageal stenosis,  1066 
Odontoma,  412 

composite,  413 

epithelial,  412 

fibrous,  413 

follicular,  412 
compound,  413 

radicular,  413 

treatment,  413 
O'Dwyer's    method    of    intuba- 
tion of  larynx,  99s 
Ogston's    operation    for    knock- 
knee.  779 

treatment   of   flat-foot,    835 
O'Hara's    forceps   for   intestinal 

anastomosis,  1252 
Oidiomycosis,  359 
Oidium  albicans,  20 
Oil  cysts,  457  , 

Oil-ether   rectal  anesthesia, 

Gwathmey's  method,  1342 
Olecranon  bursitis,  817,  821 
(Ollier-Thiersch  method  of  skin- 
grafting,  1407 
Omental  cysts,  1087 

graft,   1 218 
Omentopoxy,     Ransohoflf's,     for 

gastroptosis,  1243 
Omentum,  great,  torsion  of,  1088 
Omphalectomy  in  umbilical  her- 
nia, 1286 
Omphalospinous  line,  1143 
Onychia,  1369 

malignant,  1369 

syphilitic,  375 
Oophorectomy,    double,    for   in- 
operable cancer  of  breast,  1599 
Opeiating     table,     Boldt's     69 

Lilienthal's,    68 
Operation,  contra-indications,  76 

r'langers   of   purgation    before, 
76 

during  shock,  293 

Landerer's  dry  method,   80 

on  diabetics,  78 

preparation,  67 
of  gloves,  74 
of  mouth,  78 
of  patient,  75 
of  rectum,  78 
of  urethra,  78 
of  vagina,  78 


Index 


1681 


Operation,      preparation,      sur- 
geon's, 70 

prevention    of    shock    in,    289 

surgeon's  clothes   for,    70 

time  of  day  for,  78 
Ophthalmia  gonorrheal,  1346 

treatment,  1503 
Ophthalmo-tuberculin    reaction, 
253 
in  tuberculosis,  253 
Opisthotonos,  229 
Opium  in  appendicitis,  1154 
Opium-poisoning,   coma  of,    88r 
Oppenheim's  reflex,  944 
Opsonic  index,  47 
Opsonin    estimation    of    Wright 

in    diagnosis    of    tuberculosis, 

254 
Opsonins,  46,  47 
Optic  neuritis.     See  Choked  disk. 

thalamus,  tumors  in  or  about, 
918 
Oral  sepsis,  214 
Orange  pus,  146 
Orbit,  myxosarcoma  of,  426 
Orbital  abscess,  157 
treatment,  i6r 
Orchidectomy,  1545 

for    tuberculosis     of    testicle, 
1543 
Orchitis,  1541 

gonorrheal,  154 1 
Oriental  sore,  149,  1368 
Orrhotherapy,  Si 
Orthopedic  surgery,  826 
Orthotonos,  229 
Os  calcis,  excision  of,  794 

osteophyte  of,  410 
Oscillation   in  inflammation,    91 
Osgood-Schlatter  disease,  737 
Osmic    acid    injection  for    neu- 
ralgia of  fifth  nerve,  856 
Ossification  of  muscles,  local,  803 
Ossifluent  abscess,   153 
Osteitis,  566,  567 

caseous,  570 

deformans,  583 

fibrous,  564 

pearl  workers',  567 
Osteo-arthritis,  727 

of  hip,  729 
Osteo-arthropathie  hypertrophi- 

ante  pneumique,  585,  732 
Osteochondritis  deformans  jure- 
nalis,  719 

dissecans,  730 
Osteocopic  pains  in  syphilis,  376 
Osteogenesis   imperfecta,    564 
Osteoma,  410 

cancellous,  411 

of  brain,  910 

of  femur,  409 

of  humerus,  410 

treatment,  482 
Osteomalacia,  581 

fractures  in,  593 
Osteomyelitis,  575 

acute  infective,  575 

x-Tays  in  diagnosis,  1610 

chronic,  580 
of  femur,  580 

hemorrhagic,  565 

of  tibia,  chronic,  579 

of  vertebrae,  acute,  94S 

pyogenic,  575 

symptoms,  578 

treatment,  579 

tuberculous,  275,  565 

*-ray  diagnosis,  1611 
Osteoperiostitis,  566 

acute  diffuse,  567 

diffuse,  s68 

syphilitic,  376 
Osteophyte,  411 

of  OS  calcis,  410 

of  retrocalcaneal  bursa,  411 
Osteoplastic  periostitis,  568 

resection  of  skull,  933 
Osteopsathyrosis,  592 
Osteosarcoma,  426 

of  jaw,  423 
Osteotome,  778 
106 


Osteotomy,  777 
cuneiform,  777 
for  bent  tibia,  7  79 
for  bunion,  780 
for  faulty  ankylosis  of  hip,  779 

of  knee,  780 
for  genu  valgum,  778 
for  hallux  valgus,  780 
for    talipes    equinovarus,    780 

equinus,  781 
for  vicious  union  of  fractures, 

780 
linear,  777 
of     shaft     of     femur     below 

trochanters,  780 
through  neck    of    femur,    779 
Adams'  operation,  779, 

780 
with  osteotome,  779 
Otis's  urethrotome,  1514 
Otitic  meningitis,  905 
Ovaries,  hernia  of,  1303 
inflammation,  pain  in,  99 
tuberculosis  of,  278 
Owen's     operation     for     double 

harelip,  1047 
Oxycephaly,  912 
Oxychlorcarbon  gas  in  warfare, 

339 
Oxygen    and    chloroform    anes- 
thesia, 1337 
Ozena,  syphilitic,  379 

Pachon's  test  in  aneurysm,  489 
Pachymeningitis,  899 
externa,  899 
interna,  900 

haemorrhagica,  900 
Packs,  87 

Halsted's,  87 
Pads,  87 

gauze,  Ashton's,  87 
of  Malgaigne,  720 
Pagenstecher    thread,     prepara- 
tion, 85 
Paget's  abscess,  153,  276 
disease,  44s,  583,  S84 

of  nipple,  1578 
residual  abscess,  276 

tuberculous  abscess,  265 
Pain,  girdle,  of  tetanus,  230 
in      genito-urinary      diseases, 

1414 
in  inflammation,  98 
of  anus,  99 
of  epididymis,  99 
of  Fallopian  tubes,  99 
of  neck  of  bladder,  99 
of  prostate,  99 
of  pyelitis,  99 
of  rectum.  99 
of  sacro-iliac   joint,   99 
of  testicle,  99 
of  uterus,  99 
referred,  99 
sympathetic,  99 
in  movable  kidney,  1431 
in  wounds,  285 
of  coxalgia,  99 
of  hepatitis,  99 
physiognomy  in,  loi 
sympathetic,  99 
Painful  stumps,  1556 
Painting  of  tuberculous  abscess, 

264 
Palate,    cleft-,     1045.     See    also 
Cleft-palate. 

hard,  closure  of  clefts  in,  1051 
soft,   operation  for  suture  of, 
1050 
Palmar  abscess,  158,  812 

arch,   hemorrhage  from,   con- 
trol, 512 
psoriasis,  374 
Palsy.     See  Paralysis. 
Pancoast's   tourniquet,    1568 
Pancreas,  cancer  of,  1201 

diseases    of,    Cammidge's    re- 
action in,  1 196 
displacement  of,  II9S 
inflammation  of,  ii95 
injuries  and  diseases,  1192 


Pancreas,  tuberculosis  of,  274 

tumors  of,  1201 

wounds  of,  during  operations 
on  stomach  and  spleen,  1 194 
Pancreatic  calculi,  1199 

cysts,  ri99 

fistula,  1 194 
Pancreatitis,  119S  ' 

acute,  1 196 

chronic,  1198 

fat-necrosis  in,  rrgs 

forms,  1196 

hemorrhage  in,  1196 

subacute,  1198 
Pannous  synovitis,  706 
Pantophobia,  352 
Papillitis.      See  Choked  disk. 
Papillo-edema.     See  Choked  disk. 
Papilloma,  432 

of  anus,  1324 

of  bladder,  147S 

of  larynx,  removal,  698 

of  rectum,  1324 
Papular  syphilids,  373 
Paquelin  cautery,  512 
Paracentesis  auriculi,   523 

pericardii,  523 

thoracis,  1034 
Paraflin      prosthesis,      subcuta- 
neous, 1408 

treatment  of  burns  and  scalds, 
362 

worker's  cancer,  44s 
Paraffinoma,  1408 
Parallax    method    of    localizing 

foreign  bodies,  1623 
Paralysis,   brachial  birth,   843 
operation  for,  863 
plexus,  843 

crawling,  960 

crossed,  919 

drummer's,  8ro 

facial,  extracerebral  operation 
for,  862 

hysterical,  957 

in    brain    compression,    880 

in  Pott's  disease,  954 

in  spinal  injury,  962 

infantile      cerebral,      epilepsy 
following,  operative  treat- 
ment, 928 
flail-joints  from,  838 

ischemic,  803 

Klumpke's,  843 

narcosis,  1349 

of     bladder,     intradural     root 
anastomosis  in,  972 
true,^  1466 

of  cranial  nerves  in  basal  skull 
fractures,  889 

postanesthetic,  1349 

pseudohypertrophic,  802 

Volkmann's,  805 
Parah'tic   calcaneus,    astragalec- 
tomv  in,  795 

flat-foot,  833 

rabies,  353 
Paranoia,   operative     treatment, 

929 
Paraphimosis  in  gonorrhea,  1494 

treatment,  1502 
Paraphlebitis,  466 
Parasacral  anesthesia,  1367 
Parasites,  facultative,  21 

obligate,  21 

submicroscopic,  17 
Parasitic  bacteria,  21 

cysts,  458 

fetus,  453 

theory  of  cancer,  399,  439 
Parasyphilitic  lesions,  382 
Parathyroid  glands,  1386 

tetany  after  removal,   1386 
Paratrimma,  199 
Paravertebral    anesthesia,     1367 
Parenchymatous   goiter,    1372 

hematocele  of  testicle,  1549 
Paresis,      operative     treatment, 

929 
Parietal  lobe,  tumors  of,  918 

pleura,    d^coUement   of,    1040 
Parietocolic  sinus,  1168 


1 682 


Index 


Parker's   operation   in   appendi- 
citis, 1214 
Paronychia,  815,  1369 

syphilitic,  375 
Parotid  gland,  concretion  in  duct 

of,  1044 
Parotitis,  1043 
epidemic,  1043 
sympathetic,  1043 
Parthogenesis,  21 
Passive  clot,  476 
Pasteur's  anti-anthrax   vaccina- 
tion for   animals,   348 
treatment   of   rabies,   353 
vibrion  septique,  62 
Pastpointing  reaction  of  Bdrdny 

in  brain  tumors,  915 
Patella,  floating,  702 
fractures     of,     687.     See    also 

Fractures  of  patella. 
traumatic    dislocation  of,   772 
edgewise,  773 
inward,  773 
outward,  773 
Pathogenic  bacteria,  21 
Patient,   preparation  for  opera- 
tion, 75 
Paul's     tube    for     enterostomy, 

1261 
Payr's      method       of       arterior- 
rhaphy,  506 
tubes  in  arteriorrhaphy,  507 
Pearl  tumor,  408 
of  brain,  910 
workers'  osteitis,  567 
Peau  d'orange,  1585 
Peduncle,  middle,  tumors  of,  919 
Pelvis    and    thigh,    bandage    of. 
figure-of-eight,  1401 
false,   fractures  of,  626 
fractures  of,  626 
of  kidney,   hemorrhage  from, 
1411 
inflammation,  1432 
traumatic      dislocations      of, 

76s  ^    ^ 

true,  fractures  of,  027 
Pemphigoid  syphilid,  373 
Penetrating     gunshot      wounds, 

306 
Penis,  amputation  of,  1521 
cancer  of,  1521 
diseases  and  injuries,  i486 
fracture  of,  1521 
gangrene  of,  1521 
Peptic  ulcer  of  duodenum,  11 28 
of  jejunum  following  gastro- 
enterostomy, 1228 
of  stomach,  1094.     See  also 
Ulcer  of  stomach. 
Perforating  gunshot  wounds,  306 
sigmoiditis,    treatment,    1156 
ulcer,   172 
veins,  test  for,  526 
Perforation,   acute,   in   duodenal 
ulcer,   1 130 
in  intestinal  tuberculosis,  113S 
in  ulcer  of  stomach,  1090 
operation    for,     iioi 
Perforative  peritonitis,  1161 
Perhydrol,  33 

Peri-anal  inflammation,  13 11 
Peri-arteritis,  473 
Pericardial     effusion,     operation 
for,  523 
sac,  tapping  of,S23 
suppuration,  523 
Pericardiotomy    in    pericarditis, 

466 
Pericarditis,  46s 
treatment,  466 
Pericardium,  tuberculosis  of,  275 
wounds  of,  460 
symptoms,  461 
treatment,  461 
Pericystic  abscess,  11 83 
Perienteritis,  membranous,  nil 
Perigastric    abscess,    1098 

adhesions,    1 104 
Perineal  fistula  in  urethral  stric- 
ture, treatment,  1515 
hernia,  1301 


Perineal  prostatectomy,  1529, 
1 533-  See  also  Prostatec- 
tomy, perineal. 

section,  1517 

Cock's  method,  1517 
Syme's  operation,  1517 
Wheelhouse's  method,  1517 
Perinephric  abscess,  156,  1434 

treatment,  161 
Perinephritis,  1434 
Perineum,    bruises  of,    1487 

T-bandage  of,  1403 
Periosteal  bridge  in  fracture,  596 
Periostitis,  566 

chronic,  568 

of   tertiary   syphilis,   379 

osteoplastic,  568 

simple,  acute,  567 

suppurative  dental,  157 

*-ray  diagnosis,  161 1 
Peripheral        nerves,      gunshot 

wounds  of,  850 
Perirectal  inflammation,   13 11 
Perirenal  abscess,  1434 

hematoma,  spontaneous,  1433 

hygroma,   1433 
Perithelioma,  426 
Peritoneum,    diseases   and   inju- 
ries of,   1 159 

pseudomyxoma  of,  414 

toilet      of,      after     abdominal 
section.   1207 

tuberculosis  of,  274,  1165 
Peritonism,  1075 
Peritonitis,  acute,  1159 

ascitic,   1165 

aseptic,   1159 

caseous,  1165 

fibrinoplastic,  1165 

forms.  1 160 

Fowler's  position  in,    11 63 

gonorrheal,  1493 

Murphy's    treatment,    1162 

perforative.  1161 

pneumococcus,  1168 

proctoclysis  in,  11 63 

septic  diffuse,  1161 

suppurative,       circumscribed, 
1 1 60 
treatment,  1 164 
diffuse,  1 161 

treatment,  1161 

tuberculous,  1165 
acute,   1 166 
chronic,  ii6s 
treatment,  1167 
Peri-urethral  abscess,   in  gonor- 
rhea, 1494 
Peri-urethritis      in      gonorrhea, 

treatment,  1502 
Permanganate      of      potassium, 

37 
Pernio,  365 

Peroneus  longus  and  brevis  mus- 
cles, tendons  of,  subcutaneous 

tenotomy    of,    823 
Peroxid  of  hydrogen,  33 
Perthes's  disease,  719 
Pes  cavus,  83s 

planus,  833.    See  aXso  Flat- fooU 
Petechia,  284 
Petit,   triangle  of,   1301 
Petit's  tourniquet,  ISSI 
Petrosal    sinus,  infective  throm- 
bosis of,  907 
Pfahler's    technic    in    electroco- 
agulation, 1638 
Phagedena,    198,   371.    IS20 

sloughing.  188 
Phagedenic  ulcer,  171 

of  leg,   164 
Phagocytes,  47,  48 
Phagocytosis,  48 

artificial  stirnulation,  49 
Phalanges,  excision  of,  791 

fractures  of,  C65 

of  toes,   fractures  of,  702 

traumatic  dislocations  of,  777 
Phalangette,  dropped,  830 
Phalanx,  traumatic  dislocations 

of,  764 
Phantom  tumor,  1121 


Pharyngeal  diverticulum,  455 
Pharynx,    burns   and   scalds    of, 
364 
foreign  bodies  in,  991 
Phelps'   operation,  for    varix    of 

leg,  527 
Phillips's  catheter,  1461 
Philogenetic  association,  287,  288 
Phimosis,   1520 

complete,  treatment,  1460 
in  gonorrhea,  1494 
treatment,  1502 
Phlebectasia,       468.     See      also 

Varix. 
Phlebitis,  466 
acute,  466 
chronic,  468 
infective,  466 
plastic,  466 
postoperative,  467 
symptoms,  467 
treatment,  468 
Phlebolith,  204,  457,  470,  1618 
Phleborrhaphy,  502 
Phlebosclerosis,  468 
Phlebotomy,  528 

in  inflammation,  115 
Phlegmasia   alba  dolens,  204,  467 
Phlegmatic  scrofula,  249 
Phlegmon,  gaseous,  184 
ligneous,  147 
of  tendon-sheaths,  812 
peri-urethral,     in     gonorrhea, 

1494 
woody,  147 

treatment,  148 
Phlegmonous  cholecystitis 
acute,   1 182 
erysipelas,  220,  222 
suppuration,  146 
Phloridzin      test    for     excretory 

capacity   of  kidneys,    1416 
Phosgen  gas  in  warfare,  338 
Phosphatic  calculus  in  bladder, 

1468 
Phosphorus  necrosis  of  jaw,  1042 
Phthisis,    235.     See    also  Tuber- 
culosis. 
Physiognomy   in  pain,    loi 
Physiological  block,   286,   289 
Physostigmin  salicylate  in  post- 
operative obstruction,  1 1 27 
Pick's   rule   in  fractures  of  olec- 
ranon process  of  ulna,  652 
Picric  acid,  36 

treatment    for    burns    and 
scalds,  362 
Pilcher's     treatment    in    Colles' 

fracture,  661 
Piles,       469,       1316.     See       also 

Hemorrhoids. 
Ping-pong  bone,  42s 
Pins,  Codivilla's,  for  fractures  of 
femur,  602 
Mason's,  in  nasal  fracture,  616 
Trendelenburg's,  1571 
Wyeth's.     for    amputation   at 
hip-joint,       1571       (Figs. 

1078  and  1079) 
at  shoulder,    1560  (Figs. 
1051) 
Pirogoff's  amputation   at  ankle, 

1565 
Pistol  bullet,  wound  from,  symp- 
toms, 308 
treatment,  308 
Pitchblende,   1640 
Pituitary  body,  Cushing's  method 
of  reaching,  940 
disorders  of,  Dunn's  classifi- 
cation, 921 
methods  of  reaching,  939 
tumors  of,  921 
Pituitrin,  920 
action  of,  921 
in  shock,  292 
Placental  infection,  28 
Plantar     fascia,    fasciotomy     of, 
subcutaneous,  824 
nerves,  section  of,  symptoms, 

848 
psoriasis,  373 


Index 


1683 


Plantaris  muscle,  rupture  of,  810 
Plaster-of-Paris    bandage,     1404 
jacket   in    Pott's   disease,   9S3 
Plastic  exudation,  92 
inflammation,  92 
operations   on   chest   wall  for 
pulmonary         tuberculosis, 
1031 
phlebitis,  466 
surgery,  1404 
Pleura,     diseases    and    injuries, 
1014 
operations  on,  1032 
parietal,  decollement  of,  1040 
pulmonary,  discission  of,  1040 
tuberculosis  of,  273 
Pleural   epilepsy.    1037 
fistula,  1016 
sac,  aspiration  of,  103S 

exploratory     puncture     of, 
1034 
Pleurectomy,  total,   1039 
Pleuritic  effusion,  1014 

epilepsy,  1018 
Pleuritis,  rest  in,  105 

traumatic,  102 1 
Pleurodynia,  S02 
Pleuropneumolysis,       thoracico- 
plastic,  with  subcostal  apicoly- 
sis,  1032 
Pleurosthotonos,  229 
Plexiform  neuroma,  416 

sarcoma,  426 
Plexus,  brachial,  a\'ulsion  of,  841 
Alexinsk>''s  treatment,  843 
Frazier's  treatment,  842 
paralysis,  843 
rupture  of,  841 
lumbar,  847 
sacral,  847 
Plummer's  test  for  diverticula  of 
esophagus,  1069 
for    stenosis    of    esophagus, 
1064 
Pneumatocele,   cranial,   869 
Pneumectomy      in      pulmonary 

tuberculosis,  103 1 
Pneumococcic   septicemia,    1168 
Pneumococcus,  61 
arthritis,  725 
peritonitis,  1168 
Pneumolysis,      interpleural,     in 
pulmonary  tuberculosis,   1032 
Pneumonia,      abdominal     type, 
1 148 
ether-,  1347 
postoperative,  1347 
traumatic,  1022  ' 

Pneumopericardium,  461 
Pneumoperitonitis,  1160 
Pneumothorax,  acute  traumatic, 
1020 
artificial,  1031 

in  pulmonary  tuberculosis, 
1031 
operation  for,  103S 
non-traumatic,  1019 
Pneumotomy    for    abscess    and 
gangrene  of  lung,  1040 
for  lung  abscess,  1029 
in     pulmonary     tuberculosis, 
1030 
Point,    McBurney's  in  appendi- 
citis, 1137,  1143 
Pointing,  abscess,  146,  152 
Points  douloureux,  Valleix's,  100 
Poisoned  war  wounds,   340 
Poisoning,    anesthetic,    heart 
massage  in,  1344 
carbolic  acid,  32 
coal  gas,  98s 
cocain-,  fever  of,  141 
corrosive  sublimate,  30,  31 
delayed,  after  anesthesia,  1348 
illuminating-gas,  985 

treatment,  987 
iodoform,  34 
ivi^-.  1367 
rhus-,  1367 
sausage,  62 

strychnin-,  tetanus    and,    dif- 
ferentiation, 231 


Poison-oak,      dermatitis      from, 

1367 
Poisonous  gas  in  warfare,  330 
Poliomyelitis,    flail-joints    from, 

838 
Polonium,  1640 
Polydactylism,  829 
Polypi,  gelatinous,  414 

mucous,  414 
Polyuria,  traumatic,  877 
Poncet's     method     of     tendon- 
lengthening,  825 
rheumatism,  276 
tuberculous  arthritis,  704 
Pons,  tumors  of,  919 
Popliteal  artery,  ligation  of,  556 
nerve,     external     section     of, 
symptoms,  848 
internal,   section   of,   symp- 
toms, 848 
space,  abscess  of,  158 
Portal  pyemia,  218,   11 74 
Port-wine  stains,   418 
Postanal  gut,  943,   1304 

sinus,  942 
Postauricular  abscess,  90s 
Postepileptic  coma,  881 
Postfebrile  gangrene,  201 

necrosis  of  bone,  572 
Posthemiplegic        epipepsy        of 

adults,  928 
Position,  Trendelenburg's,    120s 
Positive      pressure      apparatus, 

1033 
Postoperative  anuria,  293 
embolism,  208 
insanity,  90S 

obstruction,  treatment,  1 1 27 
phlebitis,  467 
pneumonia,  1347 
rise  of  temperature,  139 
thermic  fever,  143 
thrombosis,  206 
Postpharyngeal    abscess,    treat- 
ment, 272 
tuberculous,  266 
Potassium  permanganate,  37 
Pott's  aneurysm,  493 
disease,  951 
Albee's  bone-graft  in,   954, 
96S 
bone-transplant  in,  934 
forcible  correction  of  angu- 
lar deformity  in,  955 
gradual  correction  of  angu- 
lar deformity  in,  954 
Hibbs'    operation    for,    969 
Jordan's  method  of  support 

in,  9S3 
laminectomy  in,  9SS 
paralysis  in,  954 
plaster-of-Paris     jacket     in, 

953 
treatment,  953 
fracture,  697.     See  also  Frac- 
tures, Pott's. 
gangrene,  180 
puffy  tumor,  868 
Poultice  in  inflammation,  113 
Pox,     36s.     See     also     Syphilis. 
Precancerous  stage,  438 
Precentral  sulcus,  865 
Precipitins,  45 

Prefrontal  region,  tumors  of,  917 
Pregnancy,  appendicitis  in,  1150 
treatment,  ii55 
following  childbirth,  iisi 
hydatid   moles   of,    414 
Presenile  spontaneous  gangrene, 

177 
Pressure      apparatus,      positive, 
1033 
gangrene,  176 
stasis,  1014 
Preventive  inoculations. 
Primary  infection,  28 
Primitive  tubercle,  236 
Probang,   Gross'   bristle. 
Probe  gorget,  Teale's,  15 16 
Process,  lateral,  of  fifth  lumbar 

vertebra,  variations  in,  947 
Procidentia  of  rectum,  1322 


50 


1075 


Proctitis,  13 10 

Proctoclysis  in  peritonitis,   1163 

in  shock,  290,  292 
Proctoscope,  Tuttle's,  1308 
Proctoscopy,    Martin's   method, 

1309 
Proctotomy   in   rectal   stricture, 

1326 
Profeta's  law  in  syphilis,  366 
Proflavine,  37 

Profondometer  method  of  local- 
izing foreign  bodies,  1624 
Projectiles,  314 

culminating     point,     317 
danger  zones,  316,  317 
De  Nancrede  on,  308,  318 

drift  of,  3  IS 
explosive  effect,  320 
influence  of  air-resistance  on, 
31S 
of  gravity  on,  315 
initial  velocity,  315     , 
mechanics,  315 
motion  of  translation,  315 
movement  of  rotation,  315 
muzzle  velocity,  31s 
point  of  first  catch  for  cavalry, 
317 
for  infantry,  317 
power  of,  to  wound,  317 
remaining  velocity,  31s 
resistance     encountered,     318 
sectional  density,  31s 
small,      nature      of      wounds 

inflicted  by,  318 
spin  of,  3 IS 
trajectory  of,  315 
velocity,  315 

wind  contusion  from,  321 
Proapse  lof  anus,  1320 
of  brain,  898 
of  kidney,  1419 
of   rectal    mucous   membrane, 

1320 
of  rectum,  1320 
complete,  1322 
incomplete,  1320 
Prolapsus  ani,  1320 
Prone    method    of  artificial  res- 
piration. 976 
Propagating  thrombus,  204 
Properitoneal  hernia,  1300 
Prostate,  abscess'of,  IS7 

in     gonorrhea,     treatment, 
IS03 
cancer  of,  IS37 
hemorrhage  from,  1414 

control,  S17 
hypertrophy     of,     IS2S.     See 
also    Hypertrophy    of    pros- 
tate gland. 
inflammation    of,     1S23.     See 

also  Prostatitis. 
malignant  disease  of,  IS37 
sarcoma  of,  IS37 
tuberculosis  of,  278,  IS38 
latent,  1541 
Prostatic  abscess,  treatment,  161 
bar,  1537 
calculus,  1525 
fibrosis,  IS37 
masseur,  Dufaux's,  1522 
Prostatectomy,  1529 
perineal,  1529,  IS33 

Alexander's  method,  IS33 
Bryson's  method,   1S33 
McGill's  method,   1532 
Young's       method,       1534 
suprapubic,  1530,  1531 
Freyer's  method,  1531 
Fuller's  method,  1533 
Nicoll's  method,  1533 
Prostatitis,  1523 
acute,  1523 
chronic,  1405,  1524 
in  gonorrhea,  treatment,  1503 
pain  in,  99 
Prostatorrhea,  1495,  1524 
Prostatotomy,  1529,  iS30 

Bottini's  galvanocaustic,  1534 
Prosthesis,    paraflan,    subcutane- 
ous, 1408 


1 684 


Index 


Protargol,  36 

in  gonorrhea,  1500 
Protective  inoculations,  $0 
Protectives  for  wounds,  86 
Protein,  bacterial,  43 

defensive,  45 
Protonuclein,  40 
Protozoa,  infection  by,  63 
Protrusion  of  lung,  1023 
Proud  flesh,  130 
Pruritus  of  anus,  13 14 
Psammoma,  408,  427 

of  brain,  910 
Pseudo-appendicitis,  1148 
Pseudo-arthrosis,  600 

in  ankylosis.  741 
Pseudodichotomy  of  bacteria,  23 
Pseudo-elephantiasis,  1393 
Pseiidohypertrophic       paralysis, 

802 
Pseudoleukemia,  I393 
Pseudomyxoma   of  peritoneum, 

414 
Pseudo-obstruction  of  intestine, 

1117 
Psoas  abscess,  153 

caries    of   lumbar    and    last 
dorsal       vertebrae      with, 
Treves'  operation,  784 
tuberculous,  267 
treatment,  271 

muscle,  strain  of,  808 
Psoriasis,  palmar,  374 

plantar,  374 
Psorosperm,  4.01 
Psorospermosis,  401 
Ptomains,  44 
Ptyalism,  118 

fsver  of,  141 

in  syphilis,  389 
Pubis,    traumatic   dislocation   of 

femur  upon,  769 
Pudendal  hernia,  1301 
Pudic   arterj',    internal,    ligation 

of,  S62 
Puerperal  erysipelas,  220 

gangrene  of  legs,  202 
Pulmonary    actinomycosis,    357 

decortication,  1039 

embolism,  209 
occluding,  1027 

pleura,  discission  of,  1040 

tuberculosis,  273 

appendicitis  in,  1151 

fever   due   to   awakening   of 

area  in,  141 
surgical  treatment,  1030 
Pulmotor,    artificial    respiration 

by,  977 
Pulpy  degeneration,  275 

of  synovial  membrane,  703, 
705 
Pulsating  empyema,  1016 

goiter,  1377 

hematoma,  492 
Pulse  in  inflammation,  122 
Puncture    in    inflammation,    io6 
multiple,  106 

lumbar,  969 
technic,  970 

of    pleural    sac,    exploratory, 

1034 
Punctured  wounds,  301 

of  nerves,  850 
Purgation  before  operation,  dan- 
gers, 76 

author's  views  on,  76 

in  inflammation,  116 
Purulent  effusion,  163 

infiltration,  146,  222 
Pus,  144 

aseptic,  144 

bacteria,  56 

blue,  146 

caseous,  146 

concealed,  213 

concrete,  145 

consistence,  14S 

constituents,  144: 

curdy,  146 

fibrinous,  14s 

forms,  14s 


Pus,  gummy,  T46 

healthy,  145 

ichorous,  14S 

laudable,  14s 

malignant,  145 

orange,  146 

red,  146 

sanioiis,  145 

scrofulous,  146 

serous,  146 

spurious,  144 

stinking,  14s 

tuberculous,  146,  236 

watery,  14s 
Pustular  syphilids,  374 
Pustule,  malignant,  347,  348 
Putrefaction,  29,  41 

bacteria  of,  63 
Putrefactive  bacteria,  21 
Putrid  intoxication,  214 

suppository,  215 
Pyelitis,  1432 

in  gonorrhea,  treatment,  1502 

inflammation   in,    pain   of,    99 
Pyelography,  td22,  1618 
Pyelolithotomy,  1 440 
Pyelonephritis,  1433 
Pyelotomy,  1440 

for  renal  calculus,  1440 
Pyemia,  213,  218 

arterial,  218 

portal,  218,  ri74 

streptococcus  of,  58 

symptoms,  218 

treatment,  219 
Pyemic  abscess,  IS3 
of  liver,  1 174 
treatment,  1177 
Pylephlebitis,  septic,  207 
Pylorectomy,  1220 

Billroth's  method,  1222 

for  cancer,  1093 

Mayo  method,  1222 
Pylorodiosis,  12 19 
Pyloroplasty,  1219 
Pylorus,  closing  of,  after  gastro- 
enterostomy, 1232 

dilatation      of,      digital,      for 
cicatricial  stenosis,  12 19 

excision  of,  1220 

stenosis  of,  hypertrophic  con- 
genital, 1 1 03 
Pyonephrosis,  1432,  143S 
Pyogenic  arthritis,  721 

bacteria,  56,  58 

bubo,  158 

chancroidal     urethritis,     1491 

coccus,  23 

osteomyelitis,  S7S 

syphilitic  urethritis,  1491 

urethritis.  1490 

of    urethral    chancre,    1491 

QUADRATUS  lumborum,  abscess 
of,  with  caries  of  lumbar  and 
last  dorsal  vertebrae,  Treves' 
operation,  784 

Quadriceps  extensor  femoris  ten- 
don, rupture  of,  810 

Qu6nu     and     Muret's     si^n     in 

aneurysm,  488 
,Qu6nu-Mayo  operation  for  can- 
cer of  rectum,  1330 

Quilled  suture,  299 

Quincke's  lumbar  puncture,  969 
technic,  970 

Quinin-urea  hydrochlorid  anes- 
thesia, I3S9 

Rabic   tubercle,   352 
Rabies,  351 

paralytic,  353 

symptoms,  352 
Rachischisis,  941 

partial,  941 
Rachitic  rosary,  280 
Rachitis  278.     See  also  Rickets. 
Radial   artery,   ligation   of,     541 

nerve,   section    of,  symptoms, 

844 
Radicular  odontoma,  413 


Radiodermatitis,  1604 

treatment,  1606 
Radiotherapy,  1642 
Radio-ulnar      articulation,      in- 
ferior,   traumatic    dislocation, 
762,  763 
Radish-fracture,  588 
Radium,  1640 
action  of,  1641 
effect  of,  on  bacteria,  26 
in  rabies,  354 
in  treatment,  1641 
sterility  from,  1606 
therapy,  1641 
Radius    and    ulna,    dislocations 
of,  traumatic,  760 
excision  of  head,  789 
fractures    of,    654,     See    also 

Fractures  of  radius. 
lower  epiphysis  of,  separation, 

662 
traumatic  dislocations  of,  761. 
762 
Railway  spine,  956,  957 
Ransohofif's  omentopexy  for  gas- 
troptosis,  1243 
operation      for     discission     of 

pulmonary  pleura,  1040 
tongs    for    fracture  of  femur, 
602 
Ranula.  1044 
Rapid-fire  gun,  322 
Rattlesnake,  bites  of,  344,  34s 
Ray-fungus,  20,  356 
Raynaud's  disease,  188 
treatment,  190 
gangrene  176 
treatment,  190 
Reaction,    Cammidge's,    in  pan- 
creatic diseases,  1196 
Jarisch-Herxheimer,  in  syphi- 
lis, 389,  392. 
luetin,   in   syphilis,   384 
M6rieux     and      Baillon's,     in 

tuberculosis,  245 
Moschcowitz's,    in   aneurysm, 

489 
Noguchi's  cutaneous,  in  syphi- 
lis, 384 
ophthalmo-tuberculin,  in  tub- 
erculosis, 253 
serum,  in  cancer,  436 
tuberculin,  cutaneous,  Moro's, 

254 
Wassermann,   in   syphilis,  384 
Reactionary     hemorrhage,     Si9 
Receptaculum  chyli,  rupture  of, 

1391 
Rectal       anesthesia,       oil-ether, 
Gwathmey's  method,  1342 
ballooning,  11 19 
ether  anesthesia,  141 
insufflation     with     hydrogen, 

1078 
mucous    membrane,    prolapse 

of,  1320 
speculum,  Brinkerhoff's,  1306 
Cook's,  1307 
Kelly's,  I3c8 
Martin's,  1306 
Mathew's,  1303 
Sims's,  13 16 
tubes,  passage  of,  1309 
Rectitis,  intractable,  rest  in,  105 
Rectocecal    fossa,    hernia    into, 

1301 
Rectum,    cancer   of,    1326.     See 
also   Cancer   of  rectum. 
diseases   and   injuries,    1301 
examination  of,  1304 
foreign  bodies  in,  1309 
gonorrhea  of,  1508 
hemorrhage  from,  control,  S17 
inflammation  of,  13 10 

pain  in,  99 
Kelly's  method  of  examining, 

1306,  1307 
Martin's    method   of   examin- 
ing. 1309 
papilloma  of.  1324 
preparation  for  operation,    78 
prolapse  of,  1320 


Index 


1685 


Rectum,    prolapse   of,  complete, 
1322 
incomplete,  1320 
stricture     of,     non-cancerous, 

1325 
tumors  of,  benign,  1324 
ulcer      of,       1323.     Sec      also 

Ulcer  of  rfctum. 
wounds  and  injuries,  1310 
Recurrent      appendicitis,      1141 

hemorrhaRe,  519 
Red  pepper  grains,  357 

pus,  146 
Redressement   in  ankylosis,   741 
Reducible  hernia,  1275 

treatment,  1275 
Reef  knot.  501,  540 
Reflex,      Gordon's     paradoxical, 
914       . 
Oppenheim's,     944 
Regimental  aid  posts,  325 
Repional  anesthesia,  1359 
Regurgitation  after  gastro-enter- 

ostomy,  1229 
Reid's  method  of  treating  aneu- 
rysm, 481 
Relapsing  chancre,  371 
Renal.     See  Kidney. 
Renipuncture,  1443 
Repair,  125 

albuminuria    obstructing,    126 
by  blood-clot,  125 
by    cicatrization,     126,     130 
by  epidermization,  130 
by  first  intention,  126 
by  granulation,   128 
by  second  intention,  128 
by  third  intention,  131 
diabetes  obstructing,  126 
of  blood-vessels,  138 
of  bone,  136 
of  brain,  135 
of  kidney,  138 
of  liver,  13S 

of  lymphatic  tissue,  138 
of  muscles,  135 
of  nerves,  133 
of  skin,  138 
of  spinal  cord,  135 
of  spleen,  138 
of  tendons,  136 
of  testicle,  138 
Repositor,  Lewis's,  1454 
Reptiles,  bites  and  stings,  342 
Resection,  786 
of  intestine,  124s 

with  approximation  by  cir- 
cular enterorrhaphy,  1245 
of  rib,  796 

of  skull,  osteoplastic,  933 
Residual  abscess,  153,  263 
of  Paget,  276 
urine,  1458 

in     prostatic    hypertrophy, 
1526 
Resistance,  vital,  to  infection,  49 
Respiration,   artificial,   974 

by     intratracheal     insuffla- 
tion, 977 
by  lungmotor,  979 
by  pulm.otor,  977 
Hall's  method,  976 
Howard's  method,  975 
Laborde's  method,  977 
mouth-to-mouth       method, 

975 
prone  method,  976 
Schafer's    method,    976 
Respiraton,'  disorders  after  anes- 
thesia, 1347 
organs,  surgery  of,  973 
Rest,  adrenal,  432 

hypernephroma  of,  1417 
fetal,  398 

treatment  for  wounds,    295 
of  tuberculosis,  257 
Resuscitation  by  heart  massage, 

operation  for,  526 
Retained  testicle,  1539 
Retention  of  urine,  1458 
acute,  1438 
chronic,  1458 


Retention     of    urine,    complete, 
1458 
from     defective     expulsion, 
1458 
treatment,  1461 
from  obstruction,  1458 
in     gonorrhea,      treatment, 

1503 
incontinence  of,  1458 
treatment,  1459 
theory  of  immunity,  45 
Retention-cysts,  456 
Reticular  lymphangitis,  219 
Reticulated  tubercle,  237 
Retractor,  cloth,  1552 
metal,  1552 
Monprofit's,  1552 
Retrenchment  in  plastic  surgerj', 

140S 
Retrocalcaneal  bursa,  inflamma- 
tion of,  817 
osteophytes  of,  411 
Retroduodenal  choledochotomy. 
1270 
fossa,  hernia  into,  1301 
Retro-esophageal     goiter,      1373 
Retroperitoneal  hernia,  1301 
Retropharyngeal  abscess,  acute, 
156 
treatment,  160 
tuberculous,  266 
Retrosternal  goiter,  1373 
Retrotracheal  goiter,  1373 
Reverdin's      method      of      skin- 
grafting,  1406 
Revolver  bullet  wounds,  305 
of  brain,  896 
treatment,  897 
Rhabdomyoma,  414,  425 
Rheumatic  arthritis,  acute,   726 
fever,  726 
gout,  727 
partial,  729 

of  hip,  729 
progressive,  72S 
torticollis,  801 
Rheumatism,  acute,  726 

articular  tuberculous,  276,  704 
chronic,  726 
gonorrheal,  723 
monarticular,  729 
muscular,  801 
Poncet's,  276 
syphilitic,  376 
Rheumatoid  arthritis,  727 
Rhigolene       spray       anesthesia, 

I3S7 
Rhinoplasty,      Indian     method, 
1409 
Italian  method,  1409 
Rhoads'      method     of     tendon- 
lengthening,  824 
treatment     of     dislocation     of 
clavicle,  751 
Rhus-poisoning,  1367 
Ribbail's  bandage  of  foot,    1399 
Ribs,  abscess  of,  tuberculous,  267 
treatment,  271 
and     costal     cartilages,     trau- 
matic dislocation,  764 
cervical,  946 

excision  of,  797 
excision  of,  796 
in  caries,  796 
in  empyema,  796 
fractures  of,  623 
resection  of,  796 
in  empyema,  1018 
Rice  bodies,  813 
Richter's    bone-drill,    610 

hernia,  1293,   1301 
Rickets,  278 
acute,  2S0 
causes,  278 
evidences,  279 
fractures  in,  592 
late,  280 
lesions,  2S0 
prevention,  280 
scur^'-y,  279,  283 
treatment,  280 
Rider's  bone,  56S,  803 


Rider's  leg,  808 

Riesman's  congestion  of  lung  by 

recoil,  103S 
Rifle  bullets,  wounds  from,   312 
symptoms,  321 
treatment,  326 
sporting,  wounds  from,  305 
Ring-.around,  815 
Ringer's  treatment  of  cutaneous 

erysipelas,  222 
Risus  sardonicus,  227 
Riziform  bodies,  813 
Roberts'    splint   in    Colles'    frac- 
ture, 661 
Robson's  incision  for  surgery  of 
bile-ducts,  1263,  1264 
method    of    intestinal    anasto- 
mosis, 1250 
operation  for  fecal  incontinence 
after  operation   for    fistula, 
1314 
Rodent  ulcer,  171,  446 
Rogers   and    Torrey's    antigono- 
coccic   serum   in  gonorrheal 
arthritis,  15 10 
serum  in  exophthalmic  goiter, 
.1380 
Rokitansky's  diverticular  hernias, 

1302 
Rolando's    fissure,    864 
Rontgen    rays,    1600.     See    also 

X-rays. 
Rontgenographic  method  of  lo- 
calizing   foreign  bodies,  1622, 
1627 
Rontgenography,  1600,  1609 
Rontgenology,  1600 
Rontgenoscopy,  1600 
Rontgentherapy,      1601,      1628. 

See  also  X-rays  in  treatment. 
Rosary,  rachitic,  280 
Rosenthal's  test  for  hematuria, 

1410 
Roseola,  syphilitic,  373 
Rose's  neurectomy  of  fifth  nerve 

for  neuralgia,  857 
Ross,   carbuncle  of  face  treated 
by  x-ray,  1636 
classification     of     subphrenic 

abscess,  1168 
on  Ludwig's  angina,  199 
on  fracture  of  humerus,  636 
Ross  and   Deaver  's  statistics  of 
acute    intestinal   obstruction, 
1123 
Ross     and    Stewart    on    sprain 

fractures,  7  35,  746 
Ross     and     'Wilbert     on    sprain 

fractures,  735 
Rotation  test  of  Bdrdny  in  brain 

tumors,  915 
Rothschild's  diet  in  gall-stones, 

1190 
Rouleaux  formation,  91 
Round-celled  sarcoma,  424,  425 
Rugh's    splint    for    Volkmann's 
contracture,  806 
treatment  of  fiat-foot,  835 
Runaround,  1369 
Rupia,  syphilitic,  374,  378 
Rupture,  abdominal,  1273 

muscular,      from      abdominal 

contusion,  1075 
of     biceps     flexor     cubiti     or 

tendon,  809 
of  bile-ducts,  1082 
of  bladder,  1463 

extraperitoneal,  1465 
intraperitoneal,  1464 
subperitoneal,  1465 
of  brachial  plexus,  841 
of   crucial   ligaments   of  knee, 

738 
of  diaphragm,  1022 
of     esophagus,     spontaneous, 

1070 
of     extensor     longus     pollicis 

tendon,  810 
of  gall-bladder,  1082 
of  heart,  459 

of  intestines,  pneumatic,  1077 
treatment,  1078 


i686 


Index 


Rupture   of   intestines    without 

external  wound,  1076 
of  kidney.  1424 
of  left  thoracic  duct,  1391 
of  liver,  1 170 

of  long  head  of  biceps,  809 
of  lung,  1022 

of  mesenteric  arteries,  1082 
of  muscles,  808 
of  plantaris  muscle,  810 
of  quadriceps  extensor  femoris 

tendon,  810 
of  receptaculum  chyli,  1391 
of  sinus,  884 
of  spleen,  1201 

Kehr's  sign  in,  1202 
of   stomach    without   external 

wound,  107s 
of  tendons,  808,  811 
of  urethra,  1487 
Ruptured  aneurysm,  474 
Russ's        coaptation        traction 
splint,  664 

Sabanejeff's   amputation 
through      femoral      condyles, 
1568 
Sacculated  aneurysm,  474 
Sacral  plexus,  847 
Sacrococcygeal  region,  teratoids 
and      dermoids      associated 
with,  1304 
tumors,  942 
Sacro-iliac  disease,  710 

joint,  inflammation  of,  pain  in, 
99 
sprain  of,  738 
tuberculosis  of,  710 
relaxation,  738 
Sacrum,  fractures  of,  629 
Saddle-back,  9S0 
Saddle-nose,    correction,    by    in- 
sertion of  plate,  1408 
paraffin  prosthesis  in,  1408 
Saline  infusion,   intravenous,   in 
shock,  290 
solution,  32 

arterial  transfusion  and  in- 
fusion, 538 
intravenous  infusion,  S36 
Salivary  concretions,  1044 
cysts,  457 

glands,   injuries  and   diseases, 
1040 
lymphoma  of,  1044 
wounds  of,  1042 
Salivation  in  syphilis,  389 
Salol  in  gonorrhea,  1499 

test  for  motor  power  of  stom- 
ach, 1 107 
Salomoni         and         Tomaselli's 
method  of  arte.riorrhaphy,  S06 
Salt    treatment,    solid,    for    war 

wounds,  337 
Salvarsan  in  syphilis,  391 
Salter's    local    intestinal    exclu- 
sion, I2S7 
Sand  flea,  bites  of,  343 
Sandf  ort '  s treatment  of  bums,3  6  2 
Sanguine  scrofula,  249 
Sanious  pus,  145 
Santorini's  musculus  sardonicus, 

229 
Sapremia,  214 
symptoms,  215 
treatment,  215 
Saprophytes,  21 
facultative,  21 
obligate,  21 
Saprophytic  microbes,  21 
Sarcinae,  23,  24 
Sarcoblasts,  136 
Sarcocele,  syphilitic,  376 
Sarcoma,  421 
alveolar,  425 
black,  425 
Coley's  fluid  in,  430 
effects  of  erysipelas  on,  430 

of  suppuration  on,  430 
erysipelas  serum  in,  431 

toxins  in,  430,  431 
fibrospindle-cell,  425 


Sarcoma,  giant-cell,  425 

hemorrhagic,  426 

medullar,  425 

m»ilanotic,  424,  425 

metastasis,  422 

multiple  cutaneous,  428 

myeloid,  425 

«-ray  diagnosis,  1610 

of  antrum,  421,  423 

of  back,  430 

of  bladder,  1475 

of  brain,  910 

of  breast,  1581 

of  buttock,  431 

of  femur,  427 

of  fibula,  429 

of  humerus,  428 

of  intestines,  113S 

of  kidney,  1418 

of  neck,  421,  422,  423 

of  prostate,  IS37 

of  sternum,  427 

of  stomach,  1093 

of  testicle,  I544 

periosteal,      x-ray      diagnosis, 
1611 

plexiform,  426 

round-celled,  424,  425 

spindle-celled,  424 
mixed,  425 
of  finger,  423 

tel,angiectatic,  426 

treatment,  428 

varieties,  424 

a:-ray  treatment,  1630,  163S 
Sarcomatosis,  422 
Sardonic  smile,  229 
Sauerbruch  chamber,  1032 
Sausage  poisoning,  62 
Saviard's  aneurysm  needle,  539 
Saw,  Adams,  77S 

Gigli,  789,  933< 
Sayre's  double  extension  in  knee- 
joint  disease,  718 

dressing      for      fractures      of 
clavicle,  631 

jury-mast.  953 

knee  splint  for  tuberculosis  of 
knee,  717 

plaster-of-Paris  jacket,  953 

splint   in   tuberculosis  of   hip, 

714 
Scalds,  360.     See  also  Burns  ana 

scalds. 
Scalp,  abscess  of,  868 

avul'^ion  of,  300 

dangerous  area,  868 

diseases  of,  868 

wounds,  874 
Scaphoid,    carpal,    fractures    of, 

663 
Scapula,     dislocation    of,     trau- 
matic, 751 

excision  of,  796 

fractures     of,    633-     See    also 
Fractures  of  scapula. 

wing-like,  843 
Scarification     in     inflammation, 

106 
Scarificator,  108 
Scarlatina,  arthritis  after,  721 
Scarlet  fever,  surgical,  142 

red  in  leg  ulcer,  165,  170 
Scars,  131 
Schafer's    method    of    artificial 

respiration,  976 
Schede's     method     of     thoraco- 
plasty, 1038 

operation  for  varix  of  leg,  527 

treatment    of    bone    cavities, 

574    ,         ,  , 
Schimmelbusch  s  sterilizer,  74 

Schizomycetes,  20 
Schlatter's  sprain  or  disease,  737 
Schleich's     anesthetic     mixture, 
1350 
infiltration  anesthesia,  1359 

solutions  for,  1 360 
treatment     of     bone-cavities, 

574 
Schultze's  sign  in  tetany,  1388 
Sciatic  artery,  ligation  of,  562 


Sciatic  hernia,  1301 

nerve,     catching     up,     during 

reduction     of     traumatic 

dislocation  of  femur,  770 

great,  section  of,  symptoms, 

847 
small,  section  of,  symptoms, 

847 
stretching  of,  855 
notch,    traumatic    dislocation 
of  femur  onto  border  of,  768 
Sciatica,  840 
Scirrhous  cancer,  447 
of  breast,  1582 

atrophic    and    withering, 
1586 
of  stomach,  1090 
Sclavo's  serum  in  anthrax,  351 
Scoliosis,  948 
Scopolamin-morphin  anesthesia, 

1356 
Scorbutic  ulcer,  173 
Scorbutus,  281.     See  also  5c«n'y. 
Scorpion  bites,  342 
Scotch  douche  in  inflammation, 

III 
Scrofula,  248 
angelic,  249 
lymphatic,  249 
phlegmatic,  249 
sanguine,  249 
Scrofuloderm.  272 
Scrofulous  abscess,  260 

pus,  146 
Scrotal  hernia,  1298 
Scrotum,  lymph-,  420,  1393 
Scurvy,  281 
gums  in,  282 
infantile.  283 
prevention.  283 
rickets.  279,  283 
treatment,  283,  284 
Sebaceous  cysts,  456 
Secondary  infection,  28 
shock,  287 
syphilis,  372 
Section  of  nerves,  840.     See  also 

Nerves,  section. 
Sedatives,  arterial,  in  inflamma- 
tion, 116 
Sedillot's     amputation     of     leg, 

1566 
Segmentation  of  bacteria,  24 
Segregation  of  urine,  1413 
Selby  and  Heath's  treatment  in  ' 

Pott's  fracture,  697 
Selva's  thumb  bandage,  1398 
Semilunar  cartilages,  inflamma- 
tion of,  703 
of     knee,      dislocation     of. 
Barker's  operation  for, 
799 
traumatic  dislocations  of, 
773 
Semimembranosus  muscle,  bursa 

of,  822 
Seminal    transmission    of    infec- 
tion, 28 
vesicles,   tuberculosis   of,    278, 

1522 
vesiculitis,  1521 
acute,  IS2I 
chronic,  1522 
Semple's      theory      of    tetanus, 

224 
Senile  gangrene,  180 
prevention,  181 
symptoms,  180 
•     treatment,  182 
Senkungsabscess,  260 
Senn's      bloodless      method      of 
amputation  at  hip,  1571 
bullet-probe,  309.  897 
drainage  tube,  i486 
injection  syringe,  269 
method     of     anterior    gastro- 
enterostomy, 1232 
of  excision  of  shoulder-joint, 
788 
method  of  gastrostomy,  1227 
of     intestinal     anastomosis, 
1247 


Index 


1687 


Senn's  method  of  lateral  intes- 
tinal anastomosis,  1253 
of    nephropexy,     DaCosta's 

modification,  1443 
of  preparing  catgut,  82 
operation  for  cancer  of  breast, 
IS92 
for  fecal  fistula,  1260 
treatment     of     bone-cavities, 

574 
of  neuralgia  of  stumps,  840 
Separator,  Guy's,  14 14 
Sepsis,  focal,  213 

oral,  214 
Septic  infection,  216 
intoxication.  214 
peritonitis,  diffuse,  1161 
wounds,  341 

irrigation  in.  So 
Septicemia,  213,  214 
cryptoge'netic,  214 
pneuraococcic,  1168 
streptococcus  of,  58 
true,  216 
Sequestration  dermoid  cysts,  453 
Sequestrectomy,  573 
Sequestrum,  571 
superficial,  S7i 
Serous  hematoma,  521 
inflammation,  92 
pus,  146 
Serpiginous  ulceration  in 

syphilis,  371 
ulcers,  in  tertiary  syphilis,  578 
Serum,  anti-crotalus,  347 

antistreptococcic,    in    cutane- 
ous erysipelas,  222 
antitoxin,    in     tetanus,      232, 

233 
Beebe's,        in       exophthalmic 

goiter,  1380 
Calmette's  antivenene,  346 
diagnosis  of  syphilis,  382 
disease,  54 

erysipelas,  in  sarcoma,  431 
horse,    for   burns    and    scalds, 
363 
dose  of,  for  hemorrhage,  511 
in  hemophilia,  523 
hypersusceptibility  to,  54 
injections,    untoward    effects, 

S3  ,  ,     . 

Maragliano's   m  tuberculosis, 

259 
reaction  in  cancer,  436 
Rogers's,      in      exophthalmic 

goiter,  1380 
Sclavo's,  in  anthrax,  351 
Serum-therapy,  51 
Sesamoid      bones      of      thumb, 

fractures  of,  665 
Sex  in  cancer,  441 
Shekelton's  aneurysm,  47s 
Sheldon's  method  of  amputation 

at  hip,  IS73 
Shell  concussion,  323 

gases    in    warfare,    effects    of, 

treatment,  328 
high-explosive,  322 
shock,  958 
shrapnel,  322 

high-explosive,  322 
wounds,  32 

treatment,  328 
Sherman's   bone   bolts    and    nut 
driver,  614 
treatment    of    bone    cavities, 
574 
Shirt-stud  abscess,  162,  264 
Shock,  286 

adrenalin  chlorid  in,  290 
apathetic,  288 
atropin  in,  292 
autotransfusion  in,  292 
causes,  287 

centripetal    arterial    transfus- 
ion in,  290 
concealed     hemorrhage     and, 

differentiation,  288 
Crile's     anoci-association     op- 
eration, 290 
delayed,  288 


Shock,  delirious,  288 
diagnosis,  288 
erethistic,  288 

from  rifle-bullet  wounds,  321 
hypodcrmoclysis  in,  290,  292 
in  anesthesia,  treatment,  1344 
intravenous  saline  infusion  in, 

290 
local,    from    gunshot    wounds, 

337   „ 
noci  influences,  287 
operation  during,  293 
philogenetic  associations,  287, 

288 
pituitrin  in,  292 
prevention,  in  operations, 

2S9 
proctoclysis  in,  290,  292 
secondarj',  287 
shell,  958  , 
strychnin  in,  292 
symptoms,  288 
torpid,  288 
treatment,  290 
war,  340,  958 
Shoemaker's   symptom   in   ulcer 

of  stomach,  1099 
Shotgun,  wounds  from,  305 

treatment,  305 
Shoulder,     bandage     of,     figure- 
of-8,  1401 
spica,  1401 
disarticulation  at,  1560 
excision  of,  787 

by  anterior  incision,  787 
by  deltoid  flap,  787 
traumatic  dislocation  of,  752. 
See   also    Dislocation,    trau- 
matic, of  humerus. 
tuberculosis  of,  718 
Shoulder-joint  disease,  718 
Shrapnel  shell,  303,  322 
high-explosive,  322 
Sialodochitis,  1044 
Sialolithiasis,  1044 
Sigmoid,  inflammation  of,  1310 

diverticulitis  of,  1156 
Sigmoiditis,  13 10 

perforating,  treatment,  1156 
Sign,     Allis's,     in     intracapsular 
fractures  of  femur,  667 
in  traumatic  dislocation  of 
femur,  767 
Babinski's,  944 
Bastedo's,    in  chronic    appen- 
dicitis, 1 149 
Battle's,   in  basal  skull  frac- 
ture, 889 
Chvostek's,  in  tetany,  1388 
Dawbarn's,     in     subacromial 

bursitis,  819 
Delbet's,  in  aneurysm,  488 
Desault's,      in     intracapsular 

fractures  of  femur,  667 
Dugas',      in      dislocation      of 

shoulder-joint,  754 
ear,  in  erysipelas,  221 
Erb's,  in  tetany,  1388 
Erichsen's,    in    shoulder    dis- 
location, 754 
Garel's,  in  abscess  of  antrum 

of  Highmore,  157 
G16nard's,  1178 
Henle  and  Coenen's,  in  aneu- 
rysm, 489 
Hoffmann's,  in  tetany,  1388 
Hutcr's,  809 
Kehr's,     in     splenic     rupture, 

1202 
Kernig's,      in      acute      lepto- 
meningitis, 901 
Lagoria's,      in      intracapsular 

fractures  of  femur,  668 
Ludloff's,     in     separation     of 
epiphysis      of     small      tro- 
chanter, 678 
Mace  wen's,  in  skull  fractures, 

886  ... 

Mannkopf's,  in  spinal  injuries, 

9S6 
Moebius's,     in    exophthalmic 
goiter,  1379 


Sign,  Ou6nu  and  Muret's,  in  aneu- 
rysm, 488 
Steilwag's,     in     exophthalmic 

goiter,  1379 
Stiller's,   in  enteroptosis,   1x58 
Trousseau's,  in  tetany,  1388 
von  Frisch's,  in  aneurysm,  489 
von  Graefe's,  in  exophthalmic 
goiter,  1379 
Silicate  of  sodium  dressing,  1404 
Silk  inserts,  82s 

ligature  and  suture,  83 
preparation,  84 
Taifs,  &3 
Silkworm-gut,  84 
preparation,  84 
Silver,  35 
citrate,  35 
colloidal,  35 
Credo's  ointment,  36 
lactate,  35 
leaf,  35 

protective  for  dressings,  86 
nitrate,  35 

in  inflammation,  in 
wire,  preparation,  8s 
Silver-fork  deformity,  660 
Silverized  catgut,  82 
Simon's  multiple  cachectic  gan- 
grene. 176 
Simpson's   method    of    acupres- 
sure in  hemorrhage,  508 
Sims's  speculum,  1306 
Sinus,  174 

cavernous,     infective     throm- 
bosis of,  907 
cerebral,     hemorrhage     from, 

control,  S15 
frontal,  distention  and  abscess, 
989 
trephining  of,  933 
lateral,    infective    thrombosis 

of,  205,  907 
longitudinal,  syndrome,  892 
parietocolic,  1 168 
petrosal,  infective  thrombosis 

of,  907 
pocularis,  cyst  of,  congenital, 

treatment,  1460 
postanal,  942 
rupture  of,  884 
Sinuses,  thyroglossal,  1056 
thyrolingual,  1056 
treatment,  174 
Sinus-thrombosis,  infective,  906 
Skene's    method    of    controlling 

hemorrhage,  512 
Skiagraph     for    locating    bullet, 

310,  1619,  1628 
Skin,    depth    of   anatomic   land- 
marks beneath,  1626 
diseases  of,  1367 
syphilitic,  372 
disinfection  of,  iodin  for,  77 
dose  of  x-rays,  1604 
fibroma  of,  406 
regeneration,  adhesive  plaster 

method,  1405 
repair  of,  138 
tabs,  1 3 17 
tuberculosis  of,  272 
Skin-grafting,  140S 

Ollier-Thiersch  method,  1407 
Reverdin's  method,  1406 
"Wolfe's  method,  1407 
Skinner's  mask,  1336 
Skull,     bones     of,    diseases    and 
malformations,  869 
fractures    of,    630,    885.     See 

also  Fractures  of  skull. 
gunshot  wounds  of,  penetrat- 
ing, 891 
perforating,  891 
obstetric  depressions  of,  890 
operations  on,  930 
osteoplastic  resection  of,  933 
Sleep,  twilight,  1357 
Sleeping  sweats  in  tropical  liver 

abscess,  1175 
Slocum  and  Whiting's  method  of 
sterilizing  hands  and  forearms, 
73 


1 688 


Index 


Sloiighing,  198 

phagedena.  188 
Smith's  dressing  basin.  87 

head-rest    for    operations    on 
cerebellum,  040 

reduction      of     shoulder-joint 
dislocation,  756 

splint    in    fracture    of    upper 
third  of  femur,  680 
Smoke  asphyxia,  982 
Smokeless  powder  as  compared 

with  black,  313 
Smoky  urine,  141 1 
Smothering,  973        . 
Snake-bites,  343 

symptoms,  344 

treatment,  34s 
Snake-venoms,     differences     in, 

Snappmg-finger,  829 
Sneezing  gas  in  warfare,  339 
Snuff-box.  anatomical.  541 
Sodium  chlorid  solution,  32 
citrate  method  of  blood  trans- 
fusion, 536 
Soft-nose  bullet,  317 
Solitary  cyst,  409 
Solution,  Dakin's.  formula,  38 
Dufresne's,  formula,  38 
Harrington's,  31 
saline.  32 
Whiting's,  37 
Sonnenberg's   operation   for   ex- 
strophy of  bladder,  1462 
Sorbefacients    in    inflammation, 

no 
Sore,  bed-,  172,  198 
treatment,      199 
Oriental,  149,  1368 
splint-.  198,  806 
venereal,  local.  1518 
Sounds,  conical  steel,  in  urethral 
stricture,  1505 
esophageal,  1061 
Thompson's  calculus,  1469 
urethral,  cocain  with,  1505 
Southam's    treatment    in    extra- 
capsular fracture  of  femur,  67.5 
Space,  dead,  66 
Spasm,  intestinal.  1117 
Spasmodic    stricture  of  esopha- 
gus. 1068 
torticollis,  827 
Spectroscopic     test     for     hema- 
turia, 1410 
Speculum,  Brinkerhofl's,  1306 
Cook's,  1307 
Kelly's,  1308 
Martin's,  1306 
Mathews's  1305 
Sims's.  1306 
Spencer's    apparatus    for    intra- 
venous saline  infusion.  537 
Spermatic   cord,   hematocele   of, 
diffused,  1548 
encysted.  1548 
hydrocele  of,  diffused,   1548 

encystic,  1548 
strangulation    of,    by    axial 

rotation,  1546 
varix  of,  469 
Spermatorrhea,  defecation,  1524 
Sphacelus,       175.  See      also 

Gangrene. 
Spica  bandage,  1397 
of  instep,  1399 
of  shoulder,  1401 
of  thumb,  1398 
Spider,  poisonous,  bites  of,  342 
Spina  bifida,  941 
occulta,  941 
operation  for,  968 
ventosa,  275,  566 
Spinal  analgesia,  1364 

caries,    951.     See    also    Pott's 

disease. 
cord,  concussion  of,  959 
contusion  of,  959 
compression  of,  960 
injuries  in  war,  959 
membranes  of,  tuberculosis 
of.  275 


Spinal   cord,   regeneration  after 
injury.  967 
repair  of,  135 
syphilis  of,  382 
tumors  of.  943 

intramedullary.  943,  944 
treatment.  94/ 
wounds  of,  959 
decompression,  972 
hemorrhage,     extramedullary, 

control,  5 IS 
ligaments,  injuries  of,  956 
meningitis,   chronic,  Horsley's 

operation  for,  972 
muscles,  injuries  of,  956 
theca,  puncture  of,  969 
Spindle-celled  sarcoma,  424 
mixed,  425 
of  finger,  423 
Spine,     congenital     deformities, 
941 
curvature    of,    947.     See    also 

Curvature,  spinal. 
curves  of,  947 
dislocations  of,  961 
excurvation  of,  950 
fracture- dislocations  of,  961 
paralysis  in.  962 
treatment,  964 
Walton's  method  of  reduc- 
tion, 96s 
fractures'  of.  961 
operations  on,  968 
railway.  956,  957 
surgery  of,  941 
tumors  of.  943 

extramedullary,  943 
typhoid.  946 
Spirillum,  22 

Spirochaeta  pallida,  64,  366 
Splanchnic  tetanus,  228 
Splanchnoptosis,  1157 
Spleen,  abscess  of,  1203 
cancer  of,  1203 
diseases  of,  1201 
enlargements  of,  1203 
injuries  of.  1201 
operations      on,      wounds      of 

pancreas  during,  11 94 
repair  of,  138 
rupture  of,  1201 

Kehr's  sign  in,  1202 
tuberculosis  of,  274 
tumors  of,  1203 
wandering,  1 204 
wounds  of,  1 201 
Splenectomy,  changes  after,  1272 

total,  I  27 1 
Splenic  fever,  347 
Splenopexy,  1204,  1273 
Splenoptosis.  1204 
Splenorrhaphy,  1203 
Splint,  abduction,  in  subacrom- 
ial bursitis,  821 
Agnew's,    in    transverse    frac- 
tures of  patella,  689 
ambulatory,  603 
anterior  angular,  648 
Balkan,  in  intracapsular  frac- 
tures of  femur,  672 
Blake's,  in  fractures  of  femur, 

682 
bracketed,  607 
Bryant's,    in    Pott's    fractxire, 

693 
Bond's,  in  Colles'  fracture,  661 
Bowlhy's  arm,  637 
Cabot,  posterior  wire,  612 
Clarke's  arm,  637 
Depage      modiiied      humerus, 

638 
Dupuytren's,    in    Pott's    frac- 
ture, 697.  69S 
Esmarch's.  790.  792 
extempore  aluminum.  638 
fenestrated,  607 
hard-rubber,  6i8,  619 
Hodgen's,    for     fractures     of 
femur,  681 
modified.    612 
Hutchinson's   knee,    in   tuber- 
culosis of  knee,  417 


Splint,  interdental,  621 
internal  angular,  635 
Jones'  extension,  639 
nasal,  617 
traction,  642 
wrist,  663 
Levis',  661 

for  dislocation  of  phalanges, 
76.S 
Mclntyre's,     in     fractures    of 

femur,  682 
Roberts',   in    Colles'    fracture, 

661 
Rugh's,   for  Volkmann's  con- 
tracture. 806 
Russ's     coaptation     traction, 

664 
Sayre's,  in  tuberculosis  of  hip, 
714 
knee,  in  tuberculosis  of  knee, 
717 
Smith's,   in  fracture  of  upper 

third  of  femur,  680 
Stimson's,   in  Pott's  fracture, 

608 
Stromeyer's,     in     elbow-joint 

disease,  419 
Thomas'  arm,  637 

Jones'  modification.  642 
in  leg  fractures.  671,  672 
in  tuberculosis  of  hip,  714 
traction  leg,  611 

Blake-Keller    modifica- 
tion, 61 1 
triangle,  641 

Van    Arsdale's   triangular,   in 
fractures  of  shaft  of  femur 
in  children,  683 
vulcanite,  621 

Ware's,    in  fractures   of   shaft 
of   femur   in   children,    684, 
6S5 
Watson's  plaster-of-Paris,  794 
Splinter-fracture,  588 
Splint-sore,  198.  806 
Spondylitis,  deformans,  739,  955 
rhizomelique,  956 
syphilitic.  379 

tuberculous,     951.     See     also 
Pott's  disease. 
Sponges.  87 

Spontaneous  aneurysm,  474 
Sporadic  goiter,  i373 
Spore  formation,  25 
Sporotrichosis,  20 
Spots,  syphilitic.  373 
Spra!?ue  hot  drs'-air  apparatus  in 

chronic  synovitis,  704 
Sprains,  735 

of  sacro-iliac  articulation,  738 
Schlatter's,  737 
treatment,  736 
Springfield  bullet,  314 
Spurious  elephantiasis,  1393 
hydrophobia,  353 
meningocele,  871 
pus,  144 
Squamous- celled  epithelioma,  445 
Ssabanajew- Frank     method     of 

gastrostomy,  1226 
Stab  wounds,  302 
Staff,  Syme's  grooved,  15 16 

Wheelhouse's,  15 16 
Stagnation  in  inflammation,  91 
Stains,  port- wine,  418 

claret,  418 
Stammering  of  bladder,  1476 
St.  Anthony's  fire.  219 
St.    Nicholas  Hospital,  Issy-les- 
Moulineaux,      treatment      of 
burns,  362 
Staphylococci,  22 
Staphylococcus  albus,  56 
aureus.  56 
cereus  albus,  57 

flavus.  57 
citreus,  56 

epidermidis  albus,  57 
fiavcscens,  57 
pyogenes  albus,  57 
aureus,  56 
citreus,  57 


Index 


1689 


StaphylorrhaDhy.  1050 
Rtarck's    position    for    examina- 
tion of  esophagus,  10(11 
Stasis,  chronic  intestinal,  11 10 

pressure,  1014 
Static  flat-foot,  833 

gangrene,  176 
Station,  casualty  clearing,  32.'; 
dressing,  field  ambulance,  325 
main.  325 
Stationary  hospital.  325 
Status  lymphaticiis.  249.  1300 
retrogressive  form.  249 
thymicus.  1390 
Stave  of  thumb.  664 
Steinmann's    nail    extension    m 

fractures.  601 
Stellwagen's    suture    of    kidney. 

1426 
Stellwag's  sign   in  exophthalmic 

goiter.  1379 
Steno's  duct,  wounds  of.  1042 

stone  in,  1044 
Stenosis,  cicatricial,  of  orifices  of 
stomach.  11 02 
of  esophagus,  cicatricial,  1013 
Ochsner's       operation      for 
1066 
of  pylorus,   cicatricial,   digital 
dilatation  for.  1219 
hypertrophic,        congenital, 
1 1 03 
Step-mother,  815 
Stercoraceous  abscess,  153 

vomiting,  11 18 
Stercoral  appendicitis,  1139 

ulcers,  1 1 16 
Stereo-arthrolysis    in    ankylosis, 

741 
Stereoscopic  plates   in  diagnosis 

of  fractures,  1610 
Sterile    water    infiltration    anes- 
thesia, 1364 
Sterility  from  .r-rays,  1606 
Sterilization,  29 

of  cystoscope,  1449 
of  hands,  71 

and   forearms,    alcohol-sub- 
limate method,  73 
Furbringer's  method,  72 
mechanical,  71 
Slocum      and     Whiting's 

rnethod,  73 
Weir-Stimson  method,  72 
Welch-Kelly    method,   72 
of  instruments.  75 
of  ureteral  catheter.  1449 
of  urethral  catheter,  1457 
Sterilizer,  Lautenschlager,  85 
portable,  75 
Schimmelbusch's.  74 
Sternocleidomastoid     muscle, 
open    division,    for    wry-neck, 
823 
Sternum,  fracture  of.  625 
sarcoma  of,  427 
traumatic,    dislocation  of,  765 
Sternutators,  gas,  in  warfare,  339 
Stevenson's     bag     for     inguinal 
colostomy,  1261 
drainage-tube,  i486 
Stewart's     method     of     enteros- 
tomy, 1 1 26 
operation  for  cancer  of  breast, 

1396 
test  in  aneurysm,  489 
Stifling,  973 

Stigmata  of  hysteria.  957 
Stiller's     sign     in     enteroptosis, 

1 158 
Stillman's  operation  to  prevent 
contraction  after  partial  exci- 
sion of  lower  jaw,  799 
Still's  disease.  729 
Stimson-Wier    method  of    steril- 
izing hands  and  forearms,  72 
Stimson's   splint  in  Pott's  frac- 
ture. 698 
Stimulants  in  inflammation.  120 
Stings  and  bites  of  insects,  342 
Stings  of  bees,  342 
of  fish,  343 


Stings  of  wasps,  342 
Stinking  pus,  145 
Stokes's    supracondyloid    ampu- 
tation, 1568 
treatment    of   flat-foot,    835 
Stomach,  bilocular,  1105 
Stomach,    cancer  of,    1090.     See 
also  Cancer  of  Stomach. 
cicatricial  stenosis  of  orifices, 

1102 
dilatation  of,  acute,   1107 
Brandt's  operation  for,  1242 
chronic,  1 106 
diseases  and  injuries,  1088 
fibromatosis  of.  i8og.  1097 
foreign    bodies    in.    1088 
hemorrhage  from,  control,  518 
hour-glass,    1105,   1243 
leather-bottle,  1089 
operations  on,  12 18 

wounds  of  pancreas  during, 
1 194 
rupture   of,    without    external 

wound.  1075 
sarcoma  of.  1093 
test     for     absorptive     power, 
1107 
for  motor  power,  1107 
tuberculosis  of,  274 
ulcer  of,  1094.     See  also  Ulcer 

of  stomach. 
volvulus  of,  1089 
x-ray  examination,  16 13 
Stomach-reefing,  Brandt's  opera- 
tion, for  dilated  stomach,  1242 
Stomatitis,  gangrenous,  196 
Stone,  chalk-,  727 
in  appendix,  1138 

mistaken  for  ureteral  stone, 
I4S7 
in  bladder,  1467 
attacks  of,  1468 
crushing  in,  1480 
in  children,  1468,  1470 
in  female,  1469 
mulberry,  1467 
operation    for,    in    women, 

1484 
phosphatic,  1468 
rest  in,  105 
treatment,  1470 
in  gall-bladder.  1185 
in  intestine,  obstruction  from, 

1114 
in  kidney,  1427 

inflammation  in,  pain  from, 

99 
operation  for,  1440 
a:-ray  diagnosis,  1618 
in  pancreas,  1199 
in     parotid     duct      (Steno's), 

1044 
in  prostate,  1525 
in  sublingual  duct.  1044 
in  subraaxillarj'  gland.  1044 
in  ureter,  impacted,  1430 
in  urethra.  1489 

impacted,  treatment,  1460 
in  vein.  204,  470 

mistaken  for  ureteral  stone, 
1437, 1618 
salivary,  1044 
sound,  Thompson's,  1469 
Stony  lymph-nodes  mistaken  for 

ureteral  stone,  1457,  1618 
Storp's     treatment     in     Colles' 

fracture.  661 
Stovain  anesthesia,  1359 
Strain,  muscular,  808 
of  back,  808 
of  psoas  muscle,  808 
Strain-fracture,  588 
Strangulated    hernia.     See    also 

Hernia,  strangulated. 
Strangulation.       intestinal      ob- 
struction from,  1 1 II 
Streptobacillus,  23 
Streptococcus,  22 
articulorum,  58 
lanceolatus,  61 
of  erysipelas,  58 
of  pyemia,  58 


Streptococcus  of  septicemia.  58 
pyogenes,  57 

mahgnus,  58 
septicus,  58 
Streptrotrichosis,  356 
Stretching   of  sciatic   nerve,   855 
Stricture,     cicatricial,    intestinal 
obstruction  from,  iri6 
of  esophagus,  1062 

Abbe's  operation  for,   1065, 

1066 
cancerous,  1067 
cicatricial.  1062.  1063 
compression,  1064 
fibrous,  1062 
forcible  dilatation,  1065 
gradual   dilatation.   1064 
Gussenbauer's         operation 

for.  1065 
hysterical.  1068 
Mixter's  treatment.   1064 
spasmodic,  1068 
Symonds's  treatment,  1065 
treatment,  1064 
A;-ray  diagnosis,  1613 
non-cancerous,  1325 
of  ureter,  1434 
of  urethra,  1511 
congenital,  15 11 
divulsion  for,  15x4 
impermeable,  15 12 

Gibson's     operation     for, 

inflammatory,  15 11 
organic,  15 11 

perineal     fistula     in,     treat- 
ment, 1515 
results,  1512 
spasmodic,  151 1 

treatment,  1460 
symptoms,  1512 
treatment,  1512 

Gibson's     operation     for, 
■   n    ^517  • 
inflammatory,  1511 
organic,  15 11 

perineal    fistula    in,     treat- 
ment, 1S15 
results,  1 5 12 
spasmodic,  1511 

treatment,  1460     • 
symptoms.  1512 
treatment.  15 12 
urethrotomy  in.  1513 
Stromeyer's     splint     in     elbow- 
joint    disease.    719 
Strongylus     armatus     in     aneu- 
rysm. 476 
Strumous  abscess,  153,  260 
caries,  570 
joint,  70s 
Strychnin  in  inflammation,    120 

in  shock,  292 
Strychnin-poisoning,         tetanus 

and,    differentiation,    231 
Stump,    bandage    of,    recurrent, 
1403 
extension    treatment,     1556 
neuralgia     of,     Senn's     treat- 
ment, 840 
painful.  1556 
Struve's  test  for  hematuria.  1410 
Styptics    in   hemorrhage,    509 
Subacromial     bursitis,     819 

Codman's    treatment,    820, 

821 
Dawbam's  sign  in,  819 
Monts'  treatment,  820 
Subastragaloid      disarticulation, 
1564 
traumatic  dislocations,    777 
Subclavian    artery,    ligation    of, 
545 
triangle,  545.  550 
Subcutaneous  connective  tissue, 
tuberculosis    of,    273 
hemorrhage,  498 

control,  517 
tenotomy  of  tendon  of  tibialis 

anticus    muscle,    823 
wounds,  healing,  132 
Subcuticular  suture,  66,  299 


1690 


Index 


Subdiaphragmatic   abscess,    156 
Subdural       meningeal       hemor- 
rhage, 883 

ubgallate    of    bismuth,    35 
Subhyoid  cyst.  1057 

sublimate-alcohol   method    of 

sterilizing     hands     and     fore- 
arms, 73 
Sublingual  dermoid,  1056 

duct,  stone  in,  1044 
Subluxation   of  humerus,   811 

of  knee,  773 
Submaxillary    gland,    stone    in, 
1044 

triangle,  545,  549 
Submental   triangle,    545.    549 
Submicroscopic  parasites,  17 
Subphrenic    abscess,    156,    1016, 
1168 
treatment,  160,  1169 
Subsultus  tendinum,  216 
Subungual  exostosis,  411 
Suffocating  gas  in  warfare,  339 

goiter,  1373 
Suffocation,  973 
Suffusion,  284 
Sulcus,  precentral,  865 
Sulphur  grains,  357 
Sunlight,    eflfect  of,   on  bacteria 

26 
Sunstroke,    insolation,     143 
Superficial    abscess,     treatment , 
161 

sequestrum,  571 
Supernumerary    digits,    829 
Suppository,    putrid,     215 
Suppuration,  56.  143 

concealed,  213 

effects  of,   on  sarcoma,  430 

mastoid,    operation  for,   936 

pericardial,    523 
operation  for,  523 

phlegmonous,  146 

signs.  146 

symptoms,  146 

threatened,   treatment,    114 
Suppurative    appendicitis,    1141 

arthritis,  acute.  721 

catarrh   of   gall-bladder.    1181 

cholangitis,  1184 

cholecystitis,  simple.  1181 

fever,  140,  154 

inflammation,  96 

of     gall-bladder     and     bile- 
ducts,  1 181 

peritonitis,  circumscribed, 

1 160 
diffuse,  1 161 

thecitis,  158 
Supraduodenal  choledochotomy, 

1268 
Suprameatal    triangle    of    Mac- 

ewen,  866 
Supra-orbital      nerve,       neurec- 
tomy of,  855 
Suprapubic  cystostomy,    1484 

cystotomy,  1484 

lithotomy,  1478 

prostatectomy,      1530.      1531. 
See       also       Prostatectomy, 
suprapubic. 
Suprarenal    extract     in    hemor- 
rhage. 511 
Suprascapular  nerve    section  of, 

symptoms,  844 
Surgeon    in    war,    requirements, 
310 

preparation      for      operation, 
70 
Surgeon's  knot,  501 
Surgery,  war.  310 
Surgical  fevers,  139 

essential  phenomena,  139 
true,  140 

kidney,  1435 

scarlet  fever,  142 

tuberculosis,  235 
Suture,  ^  distance,  842,  850 

and  ligature,  80 

button.  299 

Connell's,  1218 

continuous,  298 


Suture,  Cushing's   right-angled, 
1217 
Czerny-Lembert,  1217 
Dupuytren's,  1216 
Erichsen,  for  angioma,  420 
Ford's,  298.  1 2 17 
GussenVjauer's,  1218 
Halsted's,  66,  299 

mattress,  1217 
hare-lip.  299 
interrupted,  298 
nerve-    851.     See   also    Nerve- 
suture. 
of  heart,  462 
of  intestine,  1216 
of  kidney.  1426 
primary,  of  nerves,  849 
quilled.  297 
removal,  88 
secondary,  131 

of  nerves,  849 
subcuticular,  299 
tendon-,    824.     See   also    Ten- 
don-suture. 
twisted,  299 
Wolfier's,  1218 
Suture-ligature,  501 
Suturing    clean    wounds,    295 
Sweats,     sleeping,     in     tropical 

liver  abscess.  1175 
Sweet  on  dichloramin-T,  39 
Swelling    in    inflammation,     loi 

white,  275,  705,  716 
Sword  wounds,  312 
Sylvester's    method   of   artificial 

respiration,  97s 
Symbiosis.  27 

Syme's     amputation     at     ankle, 
156s 
grooved  staff,  1516 
method  of  amputation 

through  femoral  condyles, 
1567 
of  excision  of  scapula,   796 
of  perineal  section,  15 17 
operation   for   aneurysm,    481 
Symmetrical  gangrene,    188 
Symonds'  treatment  of  esopha- 
geal stricture,  1065 
Sympathectomy,  854 

Jonnesco's  operation,  854 
Sympathetic  abscess,  153 

parotitis,  1043 
Symptomatic  fever,  102 
Synchondroseotomy,  1462 
Syncongestive  appendicitis,  1141 
Syncope  in  anesthesia,  1344 

local,  189 
Syncytioma  malignum,  448 
Syndactylism,  829 
Syndrome,  Frohlich's,  920 

longitudinal  sinus,  892 
Synovial     fringes,     inflamed,    in 
traumatic  arthritis,  720 
membrane,     pulpy     degenera- 
tion of,  275,  703,  70s 
ynovitis.  702 
acute  simple,  702 
chronic,  703 
compression  in,  no 
pannous.  706 
of  knee,  rest  in,  105 
rest  in,  105 
subacvite,  702 
traumatic,  702 
tuberculous,  chronic,  706 
Syphilis  of  liver,  1 1 7  2 

of  thyroid  gland,  1370 
Syphilitic    ulcer  of  rectum   1323 

urethritis,  pyogenic.  1491 
Syphiloma  of  brain,  910 
Syringe,  Kollmann's.  1507 

Senn's  injection,  269 
Syringomyelocele.  941 
Systemic    blastomycosis,    359 
Syphilids,  372 
bullous,  373 
macular,  373 
maculopapular,  373 
papular,  373 
pemphigoid,  373 
pustular,  374 


Syphilids,    secondary    and    ter- 
tiary,   diffferentiation,    374 
tuberculous,  374 
Syphilis,  365 
acquired,  366 

chancre,  368.     See  also  Chan- 
cre. 
Colles'  law  in,  366,  394 
congenital  transmitted,  393 
deafness  in,  376 
definition,  365 
diet  in,  386 
duality  theory,  369 
effect  on  longevity,  367 
forms  of  eruption,  373 
general,  372 

care  in,  386 
gray  oil  in,  388 
hereditary,  366,  393 

at  birth,  394 

dactylitis  in,  395 

diagnosis,  396 

eye  symptoms  in,  396 

Hutchinson's  teeth  in,  396 

natiform  skulls  in,  395 

tardy,  393 

treatment,  396 
history,  365 
in  animals,  365 
infection  in  utero,  394 
initial  lesions,  369 
injection  treatm.ent,  387 

dangers,  388 
insontium,  367 
intermediate  period,  377 
iodids  in,  390 
iodism  in.  391 
Jarisch-Herxheimer's  reaction 

in,  389.  392 
Justus'  test  for,  382 
luetin  reaction  in,  384 
marriage  in,  391 
mercur>'  in,  386 
neosalvarsan  in,  391 
Noguchi's  cutaneous  reaction 

in,  384 
of  bone,  565 
of  brain,  381,  382 
of  innocent,  367 
of  muscles,  804 
of  nervous  system,  376,  381 
of  spinal  cord,  382 
osteocopic  pains  in,  376 
period,  368 

intermediate,  368 
incubation,  368 
symptoms.  368 

of  secondary  incubation,  368 
symptoms,  368 

of  teitiary  symptoms,  368 
prevention,  384 
primary,  368 

treatment,  385 
Profeta's  law  in,  366 
ptyalism  in,  389 
reminders,  366,  377 
rules  of  inheritance,  394 
salivation  in,  389 
salvarsan  in,  391 
secondary,  372 

albuminuria  of.  377 

complications  in,  treatment, 
390 

treatment,  386 
scrum  diagnosis,  382 
Spirochaeta    pallida    in    diag- 
nosis, 384 
stages.  368 
tertiarj',  377 

dactylitis  in,  380 

indurative     atrophy     of 
tongue  in,  379 

lesions  of,  379 

of  bones,  379 

of  joints,  380 

periostitis  in,  379. 

serpiginous  ulcer  in,  378 

skin  diseases  in,  378 

treatment,  390 
transmission.  366.  367 
treatment,  abortive,  38s 

medical,  386 


Index 


1691 


Syphilis,  tuberculosis  and,  367 
unity  theory,  369 
visceral,  381 

Wassermann's  test  in,  382 
without  chancre,  369 
Syphilitic  abscess,  153 
acne,  374 

affections  of  bones  and  joints. 
376 

of  ear,  376 

of  eye,  376 

of  hair,  37s 

of  mucous  membranes,  37S 

of  nails,  375 

of  testes,  376 
alopecia,  375 
arthritis,  726 
bald  patch,  37s 
bubo,  371 
condyloma,  37s 

flat,  374 
ecthyma,  374 
erythema,  373 
fever,  143,  372 
gumma,  378 
impetigo,  374 
iritis,  376 
lichen,  374 
lupus,  378 
maculae,  373 
mucous  patches,  375 
onychia,  3 IS 
osteoperiostitis,  376 
ozena,  379 
paronychia,  37s 
periostitis,  376 
phthisis,  381 
rheumatism,  376 
roseola,  373 
rupia,  374,  378 
sarcocele,  376 
skin  diseases,  372 
spondylitis,  379 
spots,  373 
ulcer  of  leg,  165 
warts,  375 
Syphiloderm,  372 

TABATiiiRE  anatomique  of  Clo- 
quet,  S41 
ligation  in,  541 
Tabes  mesenterica,  276,  1135 
Mingazzini-Foerster  operation 
in,  971 
Tabetic  arthropathy,  730,  731 
Table,  Boldt's  operating,  69 
Lilienthal's  operating,  68 
Metcalf   and  Keys-Wells,  for 
a;-ray  localization,  1626 
Tache  c6r6brale,  901,  902 
Tachycardia     in     exophthalmic 

goiter,  1379 
Tait's  silk  for  ligatures,  83 
Talipes,  831 

astragalectomy  in,  832 
calcaneovalgus,  832 
calcaneovarus,  832 
calcaneus,  831 
equinovalgus,  832 
equinovarus,  832 

Barker's  osteotomy  for,  780 
equinus,  831 

osteotomy  for,  781 
subcutaneous      tenotomy      of 

tendo  achillis  in,  823 
valgus,  831,  832 
varus,  831,  832 
Talma's  operation,  1258 
Tamponade,  460 

heart,  461 
T-amputation,  1554 

at  hip,  1571 
Tanner's  ulcer,  164 
Tarantula  bites,  342 
Tarsal  bones,  traumatic  disloca- 
tions of,  777 
joint,    middle,    disarticulation 
through,  1564 
Tarsometatarsal        articulation, 

disarticulation  at,  1562 
Tartar  emetic  in  inflammation, 
116 


Tartar   emetic   ointment,  in   in- 
flammation, IIS 
Tattooing    in    gunshot    wounds, 

307 
Taxis     in     strangulated    hernia, 

1293 
Taylor's  treatment  of  ankylosis, 

743 
T-bandage  of  perineum,   1403 
Teale's  amputation  of  forearm, 
1559 
of  leg,  1566 
probe  gorget,  1516 
Tear  gas  in  warfare,  339 
Teeth,  Hutchinson's,  396 
Telangiectasis,  418 
Telangiectatic  cancer,  447 

sarcoma,  426 
Temperature    in    inflammation, 
122 
postoperative  rise,  139 
Temporal  artery,  ligation  of,  553 
Temporomaxillary         ankylosis, 

1041 
Temporosphenoidal  lobe,  tumors 

of,  918 
Tenaculum,  501 

Tenderness  in  inflammation,  99 
Tendo      achillis,      subcutaneous 

tenotomy  of,  823 
Tendon,    extensor,    rupture    of, 

in  mallet-finger,  830 
Tendon-grafting,  825 
Tendon-lengthening,  824 
Anderson's  method,  824 
Czerny's  method,  824 
Hibbs'  method,  825 
Poncet's  method,  825 
Rhoads'  method,  824 
Tendon-sheaths,      inflammation 
of,  811 
phlegmon  of,  812 
tuberculosis  of,  278 
Tendon-suture,  824 
Le  Dentu's,  824 
Le  Fort's,  824 
Lejars',  824 
Tendon-transplantation,  825 
Tendons,  diseases  of,  801 
dislocations  of,  810 
inflammation  of  sheaths,  811 
injuries  of  801 
operations  on,  823 
repair  of,  136 
rupture  of,  808,  811 
wounds  of  811 
Tenesmus  in  cystitis,  147 1 
Tenosynovitis,  811 
Tenotomy,  823 
open,  823 
subcutaneous,  823 
of  tendo  achillis,  823 
of  tendon  of  tibialis  anticus 
muscle,  823 
of  tibialis  posticus  muscle, 
824 
of     tendons     of     peroneus 
longus  and  brevis  muscles, 
823 
Tension,  fever  of,  141 
Teratoids  associated  with  sacro- 
coccygeal region,  1304 
Teratoma,  453 
external,  453 
internal,  453 
Terminal  anesthesia,  1359 

neuroma,  851 
Terrier's  treatment  of  hammer- 
toe, 836 
Tertiary  syphilis,  377 
Test,    agglutination,    in    tuber- 
culosis, 254 
Almen's,  for  hematuria,  1410 
benzidin,  for  hematuria,  1411 
constriction,    for    perforating 

veins,  526,  527 
for  varicose  veins,  S26 
guaiac,  for  hematuria,  1410 
Heller's,  for  hematuria,  1410 
indigo-carmin     for     excretory 

capacity  of  kidneys,  1416 
Justus',  for  syphilis,  382 


Test,  Korotkow's,  in  aneurysm, 
489 
methylcne-blue,  for  excretory 

capacity  of  kidneys,  1416 
microscopic,     for    hematuria, 

1411 
Moschcowitz's    for    collateral 

adequacy,  182 
Pachor's,  in  aneurysm,  489 
phloridzin,    for   excretory    ca- 
pacity of  kidneys,  1416 
Plummer's,     for     stenosis     or 
diverticula     of     esophagus, 
1064 
Rosenthal's,     for     hematuria, 

1410 
spectroscopic,  for  hematuria, 

1410 
Stewart's,  in  aneurysm,  489 
Struve's,  for  hematuria,  14 10 
Trendelenburg's     for      varix, 

526,  527 
tuberculin,     in     non-tubercu- 
lous, 244 
Tuffier      and      Hallion's,      in 
aneurysm,  489 
Testicle,  affections  of,  syphilitic, 
376 
cancer  of,  1543,  I544 
cysts  of,  1 54  3 
ectopia  of,  1539 
embryoma  of,  1543 
excision  of,  1545 
extraserous  transposition,   for 

hydrocele,  1547 
fungus  of,  278 
hematocele  of,  encysted,  1548 

parenchymatous,  1549 
hydrocele  of,  encysted,  1548 
inflammation  of,  1541 

pain  in,  99 
lymphosarcoma  of,  1S44 
malignant  disease  of,  1544 
malplaced,  1539 
repair  of,  138 
retained,  1539 
sarcoma  of,  1544 
tuberculosis  of,  278,  1S41 
tumors  of,  1543 
undescended,  1539 
Test-meal  in  gastric  cancer,  1091 
Tetanus,  224 

abdominodorsal,  228 
acute,  symptoms,  229 
antitetanic  serum,  232 
antitoxin,  52 

serum  in,  232,  233 
Bacelli's  treatment,  234 
bacillus  of,  59,  226 
brain-matter  in,  235 
carbolic  acid  in,  23  s 
catgut  in,  80,  225 
cephalic,  228 
cerebral,  227 
chronic,  230 

deposited    from  blood  in  aii- 
_  aerobic  area  of  wound,  224 
diagnosis,  230 

differential,  230 
dolorosa,  227 
fecal  theory,  226 
following     gelatin     injection, 

22s 
following  vaccination,  225 
Fourth  of  July,  224 
girdle  pain,  230 
head,  228 

hydrophobia  and,  differentia- 
tion, 231 
hydrophobic,  228 
hysteria    and,    differentiation, 

231 
idiopathic,    possible  explana- 
tion, 224 
local,  228 

of  extremities,  228 
magnesium   sulphate   in,    235 
mortality,  229 
of    incomplete   immunization, 

228 
o£  newborn,  227 
postoperative,  225 


1692 


Index 


Tetanus,  prevention,  iodoform 
injections  for,  234 

prophylactic  injection  in,  228 

prophylaxis,  231 

Sample's  theorj'  of,  224 

splanchnic,  228 

spores,  60,  226 

strychnin  poisoning  and,  dif- 
ferentiation, 231 

symptoms,  229 

tetany    and,     diflferentiation, 

231 
treatment,  231 
Tetany  after  removal  of  para- 
thyroid glands,  1386 
of      thyroid      gland,      1369 
Chvostek's  sign  in,    1388 
Erb'ssign  in,  1388 
experimental,  1387 
Hoffman's  sign  in,  1388 
parathyreopriva,  1388 
tetanus    and,     differentiation, 

230 
Trousseau's  sign  in,  1388 
Tetracoccus,  23,  24 
Thalamus,    optic,    tumors   in   or 

about,  918 
Theca,   spinal,  puncture  of,  969 
Thecal  abscess,  153 
Thecitis,  811 
acute,  811 
chronic,  813 
non-suppurative,  811 
suppurative,  158,  812 
traumatic,  813 
tuberculous,  812 
Thermic     fever,     postoperative, 

143 
Thiersch's  hypothesis  m  cancer, 
438 
solution,  32 
Thiersch-Ollier  method  of  skin- 
grafting,  1407 
Thiery's  treatment  of  burns  and 

scalds,  362 
Thigh,  amputation  of,  1568 
and  pelvis,  bandage  of,  figure- 
of-8,  1401 
Third  ventricle,  tumors  of,   919 
Thomas'  arm  splint,  637 

Jones'  modification,  642 
operation  for  habitual   shoul- 
der-joint dislocation,  759 
in  leg  fractures,  671,  672 
in  tuberculosis  of  hip,   714 
traction  leg  splint,  611 

Blake-Keller    modifica- 
tion, 611 
Thompson's      calculus       sound, 
1469 
diagnostic   questions    on    mic- 
turition, 141S 
divulsor,  15  IS 
evacuator,  1482 
.    lithotrite,  1481 

overflow  of  urine,  1466 
vesical  forceps,  1485 
Thoracic    aorta,    operation    on, 
564    , 
duct,  left,  occlusions  of,   139 1 
rupture  of,  1391 
wounds  of.  1391 
nerve,    posterior,    section    of, 
symptoms,  843 
Thoracicoplastic  pleuropneumo- 
lysis  with  subcostal  apicolysis, 
1032 
Thoracoplasty,  1038 
Thoracotomy.  1036 
Thorax,      mobilization      of,      in 
pulmonary  tuberculosis,   103 1 
Thorium,  1640 
Thorn's  treatment  of  ankylosis, 

743 
Thread,  celluloid,  85 
preparation,  85 
Three-glass  test  of  urethral  dis- 
charge, 1492 
Throat,  cut,  990 
Thrombo-angiitis  obliterans, 

177.  178,  473 
Thrombogen,  521 


Thrombokinase,  521 
ThrombophleV:>itis,  infective,  466 
Thrombosis,  203 
causes,  203 
gangrene  from,  176 

treatment,  177 
in  appendicitis,  206 
in  general  infections,  206 
in  typhoid  fever,  206 
infective,  of   cavernous   sinus, 
907 
of  lateral  sinus,  20s,  907 
of  petrosal  sinus,  907 
lymphatic,  204 
of  jugular  vein,  205 
of  mesenteric  vessels,  20S 

intestinal  obstruction 

from,  1 1 17 
postoperative,  206 
sinus-,  infective,  906 
symptoms,  205 
treatment,  207 
Thrombotic      external      hemor- 
rhoids, 1316 
gangrene,  176 
Thrombus,  203 
antemortem,  204 
mixed.  204 
primary,  204 
propagating,  204 
red,  204 
secondary,  204 
spreading,  204 
white,  204 
Throttling,  981 
Thrush,  20 

Thumb,     amputation    of,     1558 
bandage  of,  Selva's,  1398 

spica.  1398 
metacarpophalangeal  joint  of, 

dislocation,  764 
sesamoid    bones    of,    fractures 

of,  66s     . 
stave  of,  664 
Thymectomy,  1390 
Thymic  asthma,  1390 

death,  1390 
Thymol  iodid,  34 
Thymoma,  1390 
Thymus  gland,  1389 
cancer  of.  1390 
enlargement  of,  1390 
lymphosarcoma  of,  1390 
Thyroglossal  cysts,  1056 

sinuses,   1056 
Thyroid  artery,  inferior,  ligation 
of,  S48 
superior,  ligation  of,  5S2 
fever,  143,  138S 
gland,  aberrant,  1373 
accessory,  1373 
atrophy  of,  1370 
congestion  of,  1370 
diseases   and   injuries,    1369 
enucleation  of,  intraglandu- 

lar,  1382 
extirpation    of,    extracapsu- 
lar, 1383 
extirpation      of,      intracap- 
sular, 1384 
feeding  of,  1370 
grafting  of,  1370 
hypertrophy  of,  1370 
inflammation  of,  1370 
operations  on,  1381 
removal     of,     tetany    after, 

1369 
syphilis  of,  1370 
tetany   after  removal,    1369 
tuberculosis  of,  273,  I370 
tumors  of,  1370 
wounds  of,  1369 
Thyroidectin     in     exophthalmic 

goiter,  1380 
Thyroidectomy,  complete,  1383 
in  goiter,   1377 
partial,  1383 
Thyroidism,  acute,  138s 
Thyrolingual  cysts,  1056 

sinuses,  1056 
Thyrotomy    for    foreign    bodies 
in  bronchus,  993 


Tibia,  avulsion  of  spine,  69s 
bent,  osteotomy  for,  779 
fractures   of,   694.     See   Frac- 
tures of  tibia. 
osteomyelitis  of,  chronic,   579 
Tibial  artery,  anterior,   ligation 
of,  SS4 
posterior,    ligation    of,    555 
Tibialis  anticus  muscle,  tendon 
of,   subcutaneous  tenotomy 
of,  823 
posticus     muscle,     tendon   of, 
subcutaneous  tenotomy   of, 
824 
Tic   douloureux,   839.     See   also 

Neuralgia    of  fifth    nerve. 
Tick  bites,  342 
Tinnitus     aurium,     division     of 

auditory  nerve  for,  862 
Toe,  great,   metatarsal  bone  of, 
excision  of,  796 
metatarsophalangeal  articu- 
lation of,  excision  of,  795 
hammer-,  836 
Toe-nail,    ingrowing,    169,    1369 
Toes,   amputation   of,    1562 

phalanges  of,  fractures  of,  702 
Toluene  -  parasulpho-  chloramin, 

39 
Tongs,  Ransohoff's,  for  fracture 

of  femur,  602 
Tongue,   adherent,    lOSS 
burns  and  scalds  of,  364 
cancer     of,      1057.     See     also 

Cancer  of  tongue. 
complete  removal,  for  cancer 

I0S9 
indurative  atrophy  of,  in  terti- 
ary syphilis,  379 
injuries   and   diseases,    1040 
partial    removal,    for    cancer, 

I0S9 
swallowing   of,    in   anesthesia, 
1343 
treatment,  1345 
tuberculosis  of,  1056 
Tongue-tie,  1055 
Tonics    in    inflammation,    120 
Toothache,    elevation   in,    105 
Tooth-socket,  hemorrhage  from, 

control,  SIS 
Torek's  operation  in  pulmonary 

tuberculosis,  1032 
Torpid  shock,  288 
Torsion  in  hemorrhage,  507 
of   great   omentum,    1088 
Torticollis,  826 
acute,  826 
chronic,  826 
congenital,  827 
Keen's  operation  in,   829 
Lexer's  operation  in,  829 
open  division  of  sternocleido- 
mastoid   muscle   for,    823 
rheumatic,  801 
spasmodic,  827 
Tourniquet,  application  of,    ISSO 
Charriere's,  issi 
Esmarch's,  isSi 
impromptu,  509 
Lister's,  in  aneurysm,  480 
Monprofit's,  1551 
Pancoast's,  1568 
Petifs.  ISSI 
Signorini's,  iSSi 
von  Esmarch's,  1568 
Toxalbumins,  43 
Toxemia,  43 

hydatid,  458,  1172 
Toxic  goiter,  1372 
Toxins,  43 

extracellular,  43 
intracellular,  43 
Trachea,    diseases    and    injuries, 
990 
foreign  bodies  in,  991 

bronchoscopic      removal, 
1002 
operations  on,  993 
war  wounds  of,  990 
Tracheal  cartilages,  fractures  of, 
622 


Index 


1693 


Tracheobronchoscopy,    993 
Tracheotomy,  993 

high.  994 
Transfusion,     arterial     centripe- 
tal, in  shock,  290 
of  saline  fluid,  538 
of  blood,  528 

Brewer's  operation  for,  531 
by  arteriovenous  anastomo- 
sis, 530 
Crile's    operation,    530 
direct,  530 
Fauntleroy's       vein-to-vein 

anastomosis  for,   531 
Kimpton-Brown       method, 

533 
Lewisohn's   citrate   method, 

536 
in  hemorrhage,  530 
indirect,  530 
Transplantation  of  bone,    137 
of  nerves,  849 
tendon-,  825 
Transposition  of  testicles,  extra- 
serous,   for  hydrocele,    IS46 
Trauma,    relation   of,    to    tuber- 
culosis, 247 
Traumatic  abscess  of  liver,  11 73 
treatment,  1177 
aneurysm,  321,  474 
diffuse,  492 

treatment,  493 
appendicitis,  1139 
arthritis,  720 
asphyxia,  10 14 
dermoid,  454 
diabetes,  877 
diffused  aneurysm,  474 
diphtheria,  188 

dislocations,     745,     746.     See 
also  Dislocations,  traumatic. 
epilepsy,  causes,  92s 

operative  treatment,  927 
epithelial  cystoma,  451 

cysts,  454 
fevers,  139 
aseptic,  139 
benign,  139 
septic,  139 
true,  140 
hernia,  1274 
hysteria,  957 

inflammation  of  brain,   899 
insanity,  operative  treatment, 

929 
intracranial    hemorrhage,    882 
monoplegia,  hysterical,  957 
neurasthenia,  956 
neuroma,  416 
pleuritis,  102 1 
pneumonia,  1022 
pneumothorax,  acute,    1020 
polyuria,  877 
spreading  gangrene,   184 
thecitis,  813 
urethritis,  1491 
Trays,  instrument,  70 
Trench  foot,  340 

warfare,    wounds   in,   327 
Trendelenburg's     operation     for 
exstrophy  of  bladder,  1462 
for  varix  of  leg,  527 
pin    for   hip-joint   disarticula- 
tion, 1 571 
position,  1 205 

test  for  varicose  veins,  526-527 
treatment   of   flat-foot,    83s 
Trephine,    conical,    Gait's,  931 

Hudson's,  933   (Figs.  S9I-594) 
Trephining,     decompressive,     in 
brain  tumors,  937 
for  fractures  of  skull,  887,  930 
of  frontal  sinus,  933 
palliative,  in  brain  tumors,  924 
Treponema  pallidum,  64 
Treves'    method    of    excision    of 
scapula,  796 
operation  for  caries  of  lumbar 
and    last    dorsal    vertebrse, 
with  abscess  in  psoas  mag- 
nus  or  quadratus  lumborum 
muscle,  784 


Treves'  treatment  of  perforating 

ulcer,  173 
Triangle,   carotid,    inferior,    545, 
549 
superior,  545,  549 

occipital,  S4S,  549 

of  election,  545,  549 

of  necessity,  545,  549 

of  neck,  545,  549 
anterior,  549 
posterior,  549 

of  Petit,  1301 

splint,  641 

superior   lumbar,    of    Grynfelt 
and  Lesshaft,  1301 

suprameatal,  of  Macewen,  936 

subclavian,  545,  550 

submaxillary,  545,  549 

submental,  545,  549 

suprameatal.  866 
Trichina  spiralis,  804 
Trichiniasis    of    muscles,   804 
Trichinosis  of  muscles,  804 
Trichobezoar,  1088 
Trichomycetes,  22 
Trigeminal  neuralgia,  856.     See 

also    Neuralgia    of  fifth   nerve. 
Trigeminus,  sensory  root,   Fraz- 

ier-Spiller    method    of    intra- 
cranial neurotomy  of,  861 
Trigger-finger,  829 
Trigonitis,  1471 

chronic,    treatment,    1474 
Tripper,  1492 
Trismus,  229 

nascentium,  227 

neonatorum,  227 
Trocar    and   cannula   with  har- 
poon    method     of     localizing 

foreign  bodies,  1625 
Trochanter,  great,  epiphysis  of, 
separation,  678 
fractures  of,  677 

small,     epiphysis    of,     separa- 
tion, 678 
Trophic  gangrene,  176 

joint  afife'ctions,  730 

ulcer,  172 
Tropical  abscess,  153 
of  liver,  11 74 
treatment,  11 76 
Trousseau's  sign  in  tetany,  1388 
Truax's     method    of    preparing 

kangaroo  tendon,  83 
True  septicemia,  216 
Tubby's  treatment  of  ankylosis, 

743 
Tubercle,  236 

anatomical,  272 

bacilli,  products,  243 

diffuse,  236 

fibrous,  237 

hyaline,  237 

painful    subcutaneous,    406 

primitive,  236 

rabic,  352 

reticulated,  237 
Tubercular  syphilids,  374 
Tuberculin,  243 

BE.,  244 

dangers  from,  245 

in    prognosis    of    tuberculosis, 
25s 

in   treatment   of   tuberculosis, 
258 

OJ.,  244 

reaction,    cutaneous,     Moro's, 

254 
von  Pirquet's,  254 
in  non-tuberculous,  244 
in  tuberculosis,  252 
ophthalmic,  Calmette's,  253 
TO.,  244 
JR.,  244 
Tuberculoma  of  brain,  909 
Tuberculosis,  23s 
acute  miliary,  278 
agglutination  test  in,  254 
alcohol   in  treatment,  258 
animal  inoculations  in  diagno- 
sis, 254 
antenatal,  246 


Tuberculosis,     appendicitis     in, 

IISI 
bacillus  of,  60,  238 

distribution,  239,  240 

extracellular    toxins,    243 

intracellular    toxins,    243 

products.  243 

resistance,  24s 
Bier's  treatment.  260 
blistering   in  diagnosis,    254 
bovine,     communicability     to 

man,  239 
caseation  in.  236 
congenital,  241 
conjugal,  242 
diagnosis,  251 
diet  in.  257 
disseminata,  272 
enteroperitoneal.  1134 
familial  infection.  242 
ferer  from  awakening  of  area 

in,  141     . 
Finsen  light  in.  260 
heliotherapy  in.  256 
hereditary    predisposition    to, 

241 
hyperplastic,  1134 
immunity  to,  245 
incidence,  237 
ingestion,  60,  240 
inhalation,  240 
inoculation,  60.  241 
intestinal,  perforation  in,  1135 
latent,  241 

lesions,  243 
local  treatment,  259 
Maragliano's  serum  in,  259 
Marmorek's  serurn  in.  259 
massage  of  focus  in  diagnosis, 

254 
of  adrenals,  278 
of  alimentary  canal,  273 
of  ankle,  717 
of  bladder,  278 
of  blood-vessels,  273 
of  bone,  275,  565 

infiltrating  progressive,  566 
of  brain,  275 
of  breast,  273,  1576 

confluent,  i577 

nodular,  1577 
of  cervical  lymph-glands,  276 
of  elbow,  718 
of  endocardium.  275 
of  Fallopian  tubes,  278 
of  fascia,  275 
of  heart  muscle,  274 
of  hernia,  1274 
of  hip,  7iO_ 

amputation  in,  716 

complications,  713 

diagnosis,  712 

excision  in,  716 

Huntington's         treatment, 
716 

intra-articular  injections  in, 
715      . 

lordosis  m,  712 

Lorenz's  method,  715 

positions  in,  712 

prognosis,  713 

resection  in.  716 

Sayre's  splint  in,  714 

symptoms,  710 

Thomas'  splint  in.  714 

treatment.  714 

weight-bearing  and  fixation 
treatment.  715 

Wyeth's  apparatus  in,  714 
of  intestines,  274 

primary,  1134 
of  joints,  27s 
of  kidney,  278 

chronic,  1436 

silent,  1437 
of  knee,  716 
of  liver,  274 

of  lymphatic  glands,  276 
of  mesenteric    glands    in  chil- 
dren, 1 135 
of  muscle,  275 
of  nerves,  273 


1694 


Index 


Tuberculosis  of  ovaries,  278 
of  pancreas,  274 
of  pericardium,  275 
of  peritoneum,  274,  1165 
of  pleura,  273 
of  prostate,  278,  1538 

latent,  1541 
of  sacro-iliac  joint,  710 
of  seminal  vesicles,  278,  1522 
•  of  shoulder,  718 
of  skin,  272 

of  spinal  cord  membranes,  275 
of  spleen,  274 
of  stomach,  274 
of    subcutaneous     connective 

tissue,  273 
of  tendon-sheaths,  278 
of  testicle,  278,  1541 
of  thyroid  gland,  273,  I370 
of  tongue,  1056 
of  urethra,  278 
of  uterus,  278 
of  vertebrEE,  7 10 
of  wrist,  719 
open-air  treatment,  256 
predisposition  to,  246 
primary  focus  in,  243 
prognosis,  254 
relation  of  trauma  to,  247 
rest  in  treatment,  257 
routes  of  infection,  240 
serum  treatment,  259 
surgical,  23s 

treatment,  1030 

special  methods,  260 
syphilis  and,  367 
syphilitic,  381 
treatment,  255 

tuberculin  test  in  diagnosis,  252 
in  prognosis,  25s 
in  treatment,  258 
ulcerosa,  272 
verrucosa,  272 
Wright's    opsonin    estimation 

in  diagnosis,  254 
«-rays  in  diagnosis,  252,  1610 
Tuberculous    abscess,    153,    260. 
See  also  Abscess,  tuberculous. 
adenitis,  276 
appendicitis,  1151 
treatment,  1 155 
articular  rheumatism,  276,  704 
arthritis,  705 

Poncet's,  704 
articular  rheumatism,  704 
caries,  570 

chronic  synovitis,  706 
cystitis,  chronic,  1472 
gumma,  272 

of  brain,  909 
meningitis,  273,  901 
osteomyelitis,  275,  565 
peritonitis,  1 165 
acute,  1 1 6s 
chronic,  11 66 
treatment,  1167 
pus,  146,  236 
thecitis,  812 
ulcer  of  leg,  l6s 

of  rectum,  1323 
urethritis,  1491 
Tube-shift   method  of  localizing 

foreign  bodies,  1623 
Tubulated  aneurysm,  474 
Tubulization  after  nerve-suture, 

853 
Tubulocysts,  457 
Tubulodermoid,  453 
Tuffier's  decoUement  of  parietal 

pleura,  1040 
Tuffier    and     Hallion's    test    in 

aneurysm,  489 
Tumefaction    in    inflammation, 

lOI 

Tumors,  397 
adrenal,  432 
brain-sand,  408 
causes,  397,  398 
classes,  397 
classification,  402 
Cohnheim's  inclusion  theory, 
398 


Tumors,  connective-tissue,  402 
innocent,  403 
malignant,  421 
erectile,  418 
fibrofatty,  403 
fibroid  recurrent,  426 
heredity  in,  398 
heterologous,  398 
inflammation  as  cause,  399 
injury  as  cause,  399 
innocent,  402 

epithelial,  432 
Krukenberg,  444 
malignant,  402 

epithelial,     434.     See     also 
Cancer. 
mixed,  426 
MuIIer's  law,  397 
multilocular  cystic,  412 
of   abdominal    wall,    desmoid, 

406 
of  bones,  564 
of  brain,  909.     See  also  Brain, 

tumors  of. 
of  carotid  body,  1389 
of  corpus  callosum,  918 
of  intestine,  1135 
of  liver,  1171 
of  muscles,  804 
of  pancreas,  1201 
of  spinal  cord.  943 

intramedullary,  944 
treatment,  944 
of  spine,  943 

extramedullary,  943 
of  spleen,  1203 
of  thyroid  gland,  1370 
of  vertebrae,  942 
parasitic  theory,  399 
pearl,  408 
phantom,  1121 

physiologic  activity  as  cause, 
399 
decline  as  cause,  397 
Pott's  puffy,  868 
sacrococcygeal,  942 
transmissibility,  4od 
Virchow's  law,  397 
Tunica  vaginalis,  hematocele  of, 

1548 
Tuttle's  proctoscope,  1307,  1308 
Twilight  sleep,  1357 
Two-wire      double     tube     shift 
method    of    localizing    foreign 
bodies,  1623 
Tympanites     in     intestinal     ob- 
struction, 1 1 18 
Tympanitic  abscess,  153 
Typhobacillosis,  278 
Typhoid  arthritis,  722 
bacillus,  63 
bone  disease,  572 
carriers,  44 
cholecystitis,  1184 
erysipelas,  220 

fever,    acute    appendicitis    in, 
nsi 
dislocation  of  hip  m,  74s 
thrombosis  in,  206 
spine,  946 

ulcer,  perforated,  1132 
vaccination,  51 

Ulcer,  163 
acute,  163 
cancroid,  171 
chrome,  of  tanners,  164 
chronic,  163 
classification,  163 
complications    of,    treatment, 

166 
compression  in,  no 
Curling's,  173,  1128 
eczema     complicating,     treat- 
ment, 166 
edematous,  171 
erethistic,  169 
gummatous,  378 
healthy,  168 
hemorrhagic,  171 
irritable,  169 
Jacob's,  171.  446 


Ulcer,  Marjolin's,  171,  445 
neuroparalytic,  172 
of  bladder,  1473 
of  duodenum,  1 128 

acute  perforation  in,  1130 
hemorrhage  in,  1130 
hunger-pains  in,  11 29 
treatment,  1131 
x-rays  in  diagnosis,  1614 
of  intestine,  11 28 
of      jejunum,      peptic,      after 

gastro-enterostomy,  1228 
of  leg,  acute,  164 

acute,  treatment.  164 
callous,  170 
chronic,  165 
treatment,  165 
Unna's  dressing,  166 
exuberant,  168 
fungous,  168 
indolent,  169 
inflamed,  164 
Martin's  bandage  for,  168 
phagedenic,  164 
syphilitic,  i6s 
tuberculous,  165 
varicose,  168 
of  rectum,  1323 
dysenteric,  1324 
simple,  1323 
syphilitic,  1323 
tuberculous,  1323 
of  stomach,  1094 
acute,  1095 
chronic,  1095 
hemorrhage  in,  1097 

surgical  treatment,  iioo 
treatment,  1099 
hunger-pain  in,  1095 
indurated,  1095 
kissing,  1095 
latent,  109S 
non-indurated,  1095 
occult  blood  in,  1096 
perforation  in,  1098 

operation  for,  iioi 
surgical  treatment,  iioo 
symptoms,  109S 
x-ray  diagnosis,  1613 
painful,  169 
peptic,  of  duodenum,  1120 

of  stomach,  1094 
perforating,  172 
phagedenic,  171 
rodent,  171,  446 
scorbutic,  173 
serpiginous,  in  syphilis,  371 

in  tertiary  syphilis,  378 
stercoral,  1 116 
trophic,  172 
true  cancerous,  446 
typhoid,  perforated,  1132 
varix  complicating,  treatment, 

167 
Vesigne's,  172 
Ulcus  cystoscopicum,  1447 
Ulna  and  radius,  dislocations  of, 
traumatic,  760 
fractures    of,    650.     See    also 

Fractures  of  ulna. 
traumatic  dislocation  of,  761, 

762 
artery,  ligation  of,  542 
nerve,    dislocation,   at   elbow, 
850 
section  of,  symptoms,  845 
Ultzmann's     formula     in     acute 

gonorrhea,  1498 
Umbilical   hemorrhage,    control, 
S17 
hernia.       See  Hernia,  umbili- 
cal. 
Undescended  testicle,  1539 
Unilateral  hematuria,  1412 
United    States    Army    methods 
of  x-ray  localization  of  foreign 
bodies,  162a 
Universal  cystoscope,  1454 

erysipelas,  220 
Unna's   dressing  for  chronic  leg 

ulcer,  166 
Urachal  cysts,  457 


Index 


1695 


Uranium,  1640 
Uranoplasty,  1051 
Uremia,  coma  in,  881 
Ureter,     calculus     impacted     in, 
1430 
catheter,  sterilization,   1449 
diseases     and     injuries,     1417 
hemorrhage  from.  141 1 
intestinal    implantation,    1447 
lavage  of,  1455 
operations  on,  1437 
stricture  of,  1434 
wounds  of,  1426 
Ureteral  calculi,  x-ray  diagnosis, 
1618 
catheters,       sterilization      of, 

1449 
catheterism,  1412 
orifices,  location  of,  in  cystos- 
copy. 1452 
Ureterolithotomy,  1429,  1445 
Uretero-ureterostomy,  1447 
Urethra,  bleeding  from,  control, 
.517 
diseases  and  injuries,  i486 
exploration  of,  1504 
foreign  bodies  in.  1489 
hemorrhage  from,  control,  517 
inflammation    of,     1490.     See 

also  Urethritis. 
preparation  for  operation,   78 
rupture  of,  1487 
stricture    of,    151 1.     See    also 

Stricture  of  urethra. 
tuberculosis  of,  278 
Urethral      calculus,      impacted, 
treatment,  1460 
catarrh,  chronic,  1495 
catheter,  disinfection  of ,  1457 

sterilization  of,  1457 
chancre,     pyogenic    urethritis 

of,  1491 
dilator.  Gross's,  1514 
discharge,  chronic,  1495 
examination  in,  1491 
three-glass  test  of,  1492 
fever,  143.  1515 
hemorrhage.  1414 
sounds,  cocain  with,  1505 
Uretnritis.  1490 

acute     posterior,     treatment, 

1502 
chronic,   following   gonorrhea, 

treatment.  1503 
eczematous,  1491 
gouty,  1491 
non-specific,  1490 
non-venereal,  1490 
pyogenic.  1490 
chancroidal,  1491 
of  urethral  chancre,  1491 
_  syphilitic,  1491 
simple,  1490 
specific,  1492 
traumatic,  1491 
tuberculous,  1491 
Urethrocystitis,  1471 
Urethrorrhea,  1490 
Urethroscope,  Marks's,  1506 

Valentine's,  1504 
Urethrotome,  Gross's,  15 13 
Maisonneuve's,  15 13 
Otis's,  1514 
Urethrotomy   in   urethral    stric- 
ture, 1514 
Urinary  abscess,  153 
fever,  143,  1515 
tract,  x-ray  examination,  16 17 
Urination,    frequency    of,     141S 

slowness  of,  141S 
Urine,  bacteria  in,  1470 

collection   of,    by    cystoscopy, 

1453 
engorgement,  1458 
freezing-point    of,    determina- 
tion, 1417 
in  inflammation,  122 
overflow,  1458 

postoperative  suppression,  293 
residual,  1458 

in     prostatic     hypertrophy, 
1526 


Urine,   retention  of,    1458.    See 
also  Retention  of  urine. 

segregation  of,  1413 

smoky,  141 1 
Urosepsis  in  prostatic  hypertro- 
phy, 1527 
Urotropin    before    head    opera- 
tions, 930 

in    basal    skull   fractures,    889 
Uterus,  fibroid  of,  415 

x-ray  treatment.  1637 

gonorrhea  of,  treatment.  1509 

hemorrhage      from,      control, 
S18 

hernia  of,  1303 

inflammation,  pain  in,  99 

myoma  of,  415 

pregnant,  gunshot  wounds  of, 
1086 

tuberculosis  of,  278 

Vaccination,  50 
bovo-,  24s 
Pasteur's,     anti-anthrax,     for 

animals,  348 
tetanus   following,    225 
typhoid,  SI 
Vaccine  therapy,  54 
Vaccines,  autogenous,  S5 

bacterial,      in     treatment     of 
infections,  54 
Vagina,  hemorrhage  from,  con- 
trol, 5x8 
preparation  for  operation,  78 
Vaginal  hematocele,  1548 
hernia,  1301 
hydrocele,  1546 
Vaginitis,  gonorrheal,  treatment, 

1509  _ 
Vagolysis  for  cardiospasm,  1069 
Valentine's  irrigator,  1499 
light  carrier,  1505 
obturator,  15  OS 
rules  for  dilatation  in  chronic 

gonorrhea,  1507 
three-glass     test     of     urethral 

discharge,  1492 
treatment  of  acute  gonorrhea, 

1498 
urethroscope,  is 04 
urethroscopic  tube,  1505 
Valleix's  points  douloureux,   100 
Valvular  cecostomy,  1260 
Van     Arsdale's     treatment      of 
sprains,  737 
triangular    splint     in    frac- 
tures   of    shaft    of    femur 
in  children,  683 
Van   Hook's  method  of  uretero- 
ureterostomy, 1447 
Variations     in     lateral    process 

of  fifth  lumbar  vertebra,  947 
Varicocele,  469,  1549 

Bloodgood's      operation,     for, 

1549 
open  operation  for,  1549 
Varicose  aneurysm,  493 
symptoms,  495 
treatment,  49s 
external  hemorrhoids,  13 17 
lymphangiectasis,  1393 
lymphatics,  1392 
ulcer  of  leg,  168 
vein,    hemorrhage   from,    con- 
trol, 516 
veins,    468.     See    also   Varix. 
Varix.  468 

aneurysmal,  493 
symptoms,  49s 
treatment,  49s 
complicating  ulcer,  treatment, 

167 
of  leg.  Delbet's  operation  for, 
S27 
Fergusson's    operation    for, 
^527 
Katzenstein    operation    for, 

527 
Keller's   operation   for,    527 
Madelung's    operation    for, 

527 
Mayo's   operation   for,    S27 


Varix  of  leg,  operation  for.  526 
Phelps'    operation    for.    S27 
Schede's  operation  for,  527 
treatment,  470 
Trendelenburg's     operation 
for,  S27 
of  spermatic  cord,  469 
tests  for,  526 
Varnish,         Whitehead's.         for 

wounds,  300 
Vascular  system,  operations  on, 

523 
Vasectomy    for   hypertrophy    of 

prostate,  1536 
Vasotribe,  Doyen's,  S02 
Veil,  Jackson's,  11 11 
Vein  cyst.  470 

Veins,     inflammation     of,     466. 
See  also  Phlebitis. 
perforating,  test  for,  S26 
varicose.  468.     See  also  Varix. 
wounds  of,  497 
Vein-stone.  470 
Vein-to-vein      anastomosis      for 

blood   transfusion.    53 1 
Velpeau's  axiom  in  fractures,  601 
bandage,  1401 

in  fractures  of  clavicle,   631 
Venas  comites.  S39 
Venereal  catarrh,  1492 
sore,  local,  1518 
warts.  433 
Venesection,  S28 

in  inflammation,  115 
Venom,  colubrine,  345 

viperine.  34S 
Venous   circle,   470 
vicious,  470 
erysipelas,  220 
gangrene.  176 
hemorrhoids.  13 18 
implantation,  506 
nevi,  418 
Ventilation  in  inflammation,  12?- 
Ventral  hernia.  1299 
Ventriculostomy   in   hydroceph- 
alus, 874 
Veratrum    viride    in    inflamma- 
tion, 116 
Vermiform  appendix.     See   Ap- 
pendix. 
Verminous  abscess,  153 

aneurysm.  47  s 
Verneuil's    treatment    in    anky- 
losis, 742 
Verruca  necrogenica,  272 
Vertebra,  fifth  lumbar,  variations 

in  lateral  process  of,  947 
Vertebras,  fractures  of,  630 
osteomyelitis  of,  acute,  94s 
tuberculosis  of,  710 
tumors  of,  942 
Vertebral  artery,  ligation  of,  547 
Vertigo,  aural,  division  of  audi- 
tory nerve  for,  862 
Vesical._     See  Bladder. 
Vesicating  gas  in  warfare,  339 
Vesiculitis,  seminal,   1S21 
acute,  1521 
in     gonorrhea,      treatment,. 

IS02 
chronic,  1522 
Vesigne's  ulcer,  172 
Vestiges,  fetal,  398 
Vibrio,  22 

Vibrio  n  septique  of  Pasteur,  62 
Vicious      circle      after      gastro- 
enterostomy, 1229 
Vienna    mixture  for   anesthesia, 

.1350 
Villous  papilloma,  433 
Viperine,  venom,  345 
Virchow's  disease,  583 
law  in  tumors,  397 
multiple  adenoma.  1116 
sign  in  late  syphilis,  379 
Virus,  filterable,  17 
Visceral  syphilis,  381 
Visceroptosis.  1157 
Vischer's  case  for  culture-tubes, 

.159 
Vital  resistance  to  infection,  49 


1696 


Index 


Vitello-intestinal  duct,  cysts  o£, 
457 

Volkmann  5  canes,  566 
contracture,  805 

Colley's  operation   for,    807 
Jones'    treatment,    806 
membrane,  262 
operation  for  hydrocele,   1547 

Volvulus,  intestinal  obstruc- 
tion from,  1 112 
of  stomach,  1089 

Vomiting  after  anesthesia,  1346 
after  gastro-enterostomy, 

1229 
after  gastro-enterostomy, 

treatment,  1232 
coffee-ground,  in  gastric  can- 
cer, 1 09 1 
fecal,   in  strangulated   hernia, 

1293 
in  anesthesia,  treatment,  1343 
stercoraceous,  11 18 

von  Bezold's  abscess,  iS7 

von  Esmarch's  tourniquet,  1568 

von  Frisch's  sign  in  aneurysm, 
489 

von  Graefe's  sign  m  exophthal- 
mic goiter,  1379 

von  Hacker's  method  of  gastro- 
enterostomy, 1 23 1 

von  Mosetig-Moorhof's  treat- 
ment  of   bone-cavities,    574 

von  Nussbaum's  treatment  of 
cutaneous  erysipelas,  222 

von  Oppel's  operation  for  threat- 
ened senile  gangrene,   180 

von  Pirquet's  cutaneous  tube»- 
culin  reaction  in  tuberculosis, 
■254 

Vulcanite  splint,  621 

Vulva,  noma  of,  196 


Wadsworth  on  gunshot  wounds, 
306,  307 
on  injuries  by  electricity,  1643 
Walton's  reduction   of   fracture- 
dislocation  of  spine,  964 
Wandering  abscess,  260 
erysipelas,  220 
goiter,  1373 
kidney,  1419 
spleen.  1204 
War     hospitals,      position     and 
functions  in  battle,  325 
hysteria,  958 
shock.  340,  958 
surgery.  310 
wounds,  311 

abdominal,  1085 

treatment,    326 
bipp   paste   treatment,  338 
Carrel-Dakin         treatment, 
329.     See      also      Carrel- 
Dakin  treatment. 
first-aid  dressing  for,  327 
first  field  dressing,  328 
Gray's  solid  salt  treatment, 

337 
hypertonic-saline  treat- 

ment, 337 
in  trench  warfare,  327 
local  shock  from,  337 
Morison's  treatment,  338 
of  brain,  891 

drainage  in,  895 
treatment,  893 
of  chest,  I02S 

treatment.  1026 
of  heart.  464 
of  larynx,  990 
of  limbs,  treatment,  327 
of  spinal  cord,  959 
of  trachea,  990 
poisoned.  340 
treatment.  326 
Wright's   treatment.    337 
Wardrop's    operation    for   aneu- 
rysm. 484 
Ware's     splint     in     fracture     of 
shaft    of    femur,    in    children, 
684,  68s 


Warfare,  gas  in,  338.     See  also 

Gas. 
Warren's  operation  for  cancer  of 
breast,  1592 
for  fibroma  of  breast,  1379 
Wart-horn,  433 
Warts,  432 

lymphatic  1393 

syphilitic,  375 

treatment,  433 

venereal,  433 

villous,  433 
Wash  stand,  70 
Wasps,  stings  of.  342 
Wassermann's    test    in    syphilis. 

382 
Water,  boiled.  32 

moccasin,  bites  of.  344 

on  brain.  901 
Waterhouse's  treatment  of  burns, 

361 
Watson's  plaster-of-Paris  splint, 

794 
Waxy  disease  from  tuberculous 

abscess,  265 
Weavers'  bottom,  822 
Webbed  fingers,  829 
Weber's   incision  for  excision  of 

half  of  upper  jaw,   797 
Weglowski's  treatment  of  anky- 
losis, 741 
Weir's    operation   for    cancer    of 
rectum,  1330 
in  appendicitis,    1216 
Weir-Stimson   method  of  steril- 
izing hands  and  forearms.  72 
Welch-Kelly     method    of   steril- 
izing hands  and  forearms.  72 
Welch's  bacillus.  62 
Wens,  456 

Wharton's  duct,  stone  in,  1044 
Wheelhouse's    method    of    peri- 
neal section,    1517 

staff,  1516 
Wheeze,   asthmatoid.  992 
White  swelling,  275.  716 
Whitehead's   operation  for  can- 
cer of  tongue,  1060 
for  hemorrhoids,  13 19 

varnish  for  wounds,  300 
White's  injection  in  acute  gonor- 
rhea, I  501 

treatment  in  catarrhal  gonor- 
rhea, 1499 
of  felon,  816 
Whiting  and  Slocum's  method  of 

sterilizing  hands  and  forearms, 

73  .      _ 
Whiting's  solution,  37 
Whitlow,  814 

Whitman's    plate    for    flat-foot, 
834 

treatment      in      intracapsular 
fractures  of  femur,  673 
Wilks'  verruca  necrogenica,   272 
Willard's    method    of    sterilizing 

ureteral  catheters,  1449 
Willow  fracture.  587 
Wilson's       flat-foot       correction 
screw.  834 

treatment    in    hallus    valgus. 

Wind  contusion  from  projectiles, 

321 
Wing-like  scapula,  843 
Winslow's  foramen,  hernia  into, 

1301 
Wire,  brass,  preparation.  85 

bronze,  preparation.  8s 

copper,  preparation.  85 

silver  preparation,  85 
Witzel's  method  of  gastrostomy, 

1225 

Wolfe's  method  of  skin-grafting. 
1407 

Wolfler-Lucke  method  of  gastro- 
enterostomy, 1230 

Wolfler's      method      of    gastro- 
enterostomy, 1 23 1 
suture.  1 2 18 

Word-blindness,  918 

Word-deafness,  918 


Worms,     filarial,     as    cause     of 

lymphangitis,  1393 
Wounds,  284,  28s 
arrow,  302 
blank-cartridge,  305 
bringing   about    reaction,    294 
Carrel-Dakin  treatment,  295 
clean,  suturing  of,  295 
cleansing,  294 
closure,  204 
constitutional  condition  after, 

286 
contused,  300 
dichloramin-T  in,  295 
dissection-,  341 
drainage,  294 
dressing,  294 

changing,  29s 
foreign  bodies  in,  reiioval,  294 
from  bayonet,  312 
from  grenades,  324 
from  rifle  bullets,  312 

symptoms,  321 

treatment,  326 
from  revolver  bullet,  30s 
from  small  projectiles,  318 
from  swords,  312 
gaping  or  retraction  of  edges, 

286 
gunshot,  303.     See  also  Gun- 
shot wounds. 
healing.  132 
hemorrhage  from.  286 

arrest.   293 
hot     fomentations     for,     301 
in  war,  311 
incised,  296 
infected,  341 
lacerated,  300 
local  phenomena,  28s 
loss  of  function  in,  286 
maggots  in,  343 
of  abdominal  wall,  1082 
of  arteries.  496 
of  bladder.  1463 
of  brain,  890 

from  revolver  bullets,  896 
treatment,  897 
of  chest,  1021,  1023 

in  war,  1025 

treatment,  1026 

involving  diaphragm,  1025 
of  heart,  459,  460 

operation  in,  524 

symptoms,  461 

treatment.  461 
of  joints.  734 
of  left  thoracic  duct.  1391 
of  liver.  1 170 
of  mucous  membranes,  299 
of  muscles,  807 
of  nerves,  840 

punctured,  850 
of  pancreas  during  operations 

on  stomach  and  spleen,  1 194 
of  pericardium,  460 

symptoms,  461 

treatment,  461 
of  rectum,  1310 
of  salivary  glands,  1042 
of  scalp.  874 
of  spinal  cord,  959 
of  spleen,  1201 
of  Steno's  duct,  1042 
of  tendons,  811 
of  thyroid  gland,  1369 
of  ureters,  1426 
of  veins,  497 

perforating,  of  kidney,  1426 
pistol    bullet,    symptoms,    308 

treatment,  308 
protectives  for,  86 
punctured,  301 

hemorrhage    from,    control, 
S14 
rest  treatment,  29s 
septic,  341 

irrigation  in,  80 
shell,  322 

treatment.  328 
stab.  302 
subcutaneous,  healing,  132 


Index 


1697 


Wounds,  treatment,  293 
constitutional,  296 
war,      311.     See      also       War 
wounds. 
Wooden  phlegmon,  147 

treatment,  148 
Wood's  rule  in  fractures  of  true 

pelvis,  627 
Wool-sack  coccus,  23 
Wool-sorters'  disease,  347 
Wright's  method  of  treating  war 
wounds,  337 
of     estimating    coagulation 
time,  1268 
opsonin    estimation    in    diag- 
nosis of  tuberculosis,  254 
views  on  inflammation,  125 
Wrist,    disarticulation    at,    1558 
excision  of,  790 

Lister's  method,  790 
radial  incision  for,  790 
ulnar  incision  for,  790 
splint,  Jones's,  663 
traumatic  dislocation  of,  763 
tuberculosis  of,  719 
Wrist-joint  disease,  719 
Wry-neck,  826.     See  also  7'orti- 

collis. 
Wyeth's   apparatus  in  tubercu- 
losis of  hip,  714 
bloodless  method  of  amputa- 
tion at  hip,  1570,  IS7I 
dressing   in  fractures  of  shaft 

of  femur  in  children,  683 
handles   for   Brainard's   bone- 
drills,  782 
pins  in  shoulder-joint  amputa- 
tion,  ISS9,  1560 
in      hip-joint     amputation, 
IS71  (Figs.  1078,  1079) 

Xanthoma,  405 
X-rays,  1600 

biological  eflfects,  1603 
bums,  1604,  1 60s 
treatment,  1606 
cancer,  443,  1605,  1606 
effect  of,  on  bacteria,  26 

on  glandular  cells,  1603 
epilation  dose,  1604 
erythema  dose,  1604 
107 


AT- rays  fluorescence  of,  1603 
focal  point,  1602 
history,   1 600 
in  diagnosis,  1608 

of  acute  osteomyelitis,  i6ro 
of  appendicitis,   161S 
of  bone  diseases,  1610 

gumma,  1611 
of  cancer  of  colon,  1616 

of  lungs,  1612 
of  cardiospasm,  1613 
of    constrictions    of    colon, 

1616 
of  diseases  of  cranial  bones, 

1611 
of  dislocations,  1610 
of    diverticulitis    of    colon, 

1617 
of     diverticulum  of  esoph- 
agus,  1 61 3 
of  duodenal  ulcer,  1614 
of  fractures,  596,  1609 
of  fractures  of  skull,  161 1 
of  gall-stones,  1617 
of  gangrene  of  lung,  1612 
of  gastric    ulcer,  1613 
of  hydatid  cysts  of  lung,  16 12 
of  intracranial  lesions,  161 1 
of  joint  diseases,  161 1 
of  lung  abscess,  16 12 
of    mediastinal     conditions, 

1612 
of  myeloid  sarcoma,  1610 
of  obstruction  of  colon,  16 16 
of  osteomyelitis,  1611 
of  periosteal  sarcoma,  161 1 
of  periostitis,  161 1 
of  renal  calculi,  1618 
of    stricture    of    esophagus, 

1613 
of  tuberculosis,  252,  1610 
of  ureteral  calculi,  1618 
in  examination  of  alimentary 
canal,  1613 
of  appendix,  1615 
of  colon,  1616 
of  stomach,  1613 
of  urinary  tract,  1617 
localization  of  foreign  bodies, 
1619-1628 
methods,  162 1 


X-rays  in  surgery,  1600 
in  treatment,  1628 

before  operation,  1634,  1635 
combined  with  electrocoagu- 
lation,  cases  suitable  for, 
1639 
deep,  following  electrocoagu- 
lation, 1640 
of  cancer,  1628 

dangers  in,  1631 
of  carbuncle  of  face,  1636 
of  cervical  adenitis,  1635 
of  deep-seated  cancer,  1632 
of  epithelioma,  1632 
of  fibroids  of  uterus,  1637 
of  Marjolin's  ulcer,  172 
of  recurrent  and  metastatic 

cancer,  1632 
of  sarcoma,  1630,  1635 
photographic  effects,  1602 
physical  properties,  1601 
production,   1601 
properties,  1602 
secondary  radiation,  1603 
skin  dose,  1604 
sterility  from,  1606 
tubes  for,  1601 
uses  in  surgery,  1608 
Xylene  gas  in  warfare,  339 

YKVfS,  359 
Yeasts,  19 

Young's     method     of     perineal 

prostatectomy,  IS34 

modification  of  Freudenberg's 

instrument     for     prostato- 

tomy,  1534  _ 

punch  operation  on  prostate, 

1534 
treatment    of    dislocation    of 
lower  jaw,  749 

Zinc  chlorid  in  delayed  union  of 
fractures,  611 

sulphate  in  gonorrhea,  1499 
Zone  of  election  of  pathological 

processes,  577  , 

Zones,  Harris's,  1420 
Zooglea  masses,  23 
Zygomatic    arch,    fractures    of, 

619 


COLUMBIA  UNIVt  hiSI  i  M  iiirtHhlto  iiibi.bU) 

RD31  D11  1919  C.1 

Morlcrii  '->i<iv'\i  (umummI  ;iiifl  (iperative  / 


2002104520 


